fatiguing machines which up to this plicating the tissues of the joint itself to time have been in common use. But this any serious extent; by phlegmonousinflamoperation will not succeed if there be any mation of the cellular tissue around the abnormal union between the tarsal bones, joint, by long inaction, the limb being kept or at the ankle-joint, and only partially if in the flexed position, by goutor rheumatism there be any deformity in those bones them. -in fact, by any cause capable of inducing selves, though a new position may do much rigidity in the soft parts around the artilo remedy this. Properly used, it is estab- culation. This rigidity may affect only the lished that it is applicable to all ages and tendons destined to move the leg upon the both sexes, since it has been performed thigh, or it may be accompanied by a si. with equal success from early infancy to milar condition of the ligamentary tissues. ffty, in women as well as men. A month, In a certain number of cases the contracor two months, will commonly suffice for a tion has seemed to depend principally or cure, that is, for the patient to walk on the almost entirely on the resistance offered by sole of the foot ; a longer time will of course the tendons of the hamstring muscles, be necessary to dissipate the more pro- and in these cases the section of one or minent traces of the deformity. It is true more of these tendons offers a probable that some of the patients who have been cured remedy for the disease. But before we by it miglit have been cured without it, by resort to operation, we must be satisfied means of the machines of Scarpa and others, that the anchylosis is extra-capsular, and or by enveloping the limb in plaster of that the tendons and not the ligaments Paris: but then this operation is so simple, are principally affected: some persons are $o free from pain, so easy, and so exempt of opinion, that even if the ligaments be from danger,its results are so prompt,socom. affected, we ought not to hesitate in attackplete, that unless there be great objections ing them; but before I advise you to on the part of the patient, it should be apply a cutting instrument to the ligagenerally substituted for the different ap- ments about the knee-joint, I should like paratuses wbich were almost exclusively to support my advice by experience. employed up to the present day.

Michaelis applied his "partial section” It must not, however, be supposed that to this disease, but he has not described his because the mechanical has ceased to be mode of operating. Stromeyer, Dieffenthe principal method of treatment, it is bach, Dural, Little, Liston, and no doubt therefore to be entirely abandoned; its many others, as well as myself, have em. value is little less because it is made to ployed this operation, with varying and play the part of an auxiliary. It is still an more or less complete success. Lutens also indispensable element, so much so, that the employed it, but his operation did not conperfection of those apparatuses and the sist of a subcutaneous section ; he fairly cut exactitude of their application are in many his way out through tendons and integu. cases a sine quâ non of a perfect cure, and ment, making a large wound. In none of the insufficiency of mechanical means is the cases published in the These of Duval, an occasional source of failure of the ope- amounting to seven, did the patients exceed ration. The power of mechanical means, the age of 35; the respective ages being associated with section, in the reduction of eleven, twelve, six, two, twenty, thirtythese deformities, has scarcely any limits, five, and twenty : the disease which prowhen the osseous surfaces are not con. duced the condition being respectively, tinuous, and the moral courage of the pa- phlegmonous inflammation, with abscess tient seconds the care of the operator. around the knee joint; the second, a simiSill, I do not bold out to you the section of lar affection, consequent upon local injury; the tendo achillis as an exclusive method, the third, paralysis, consequent on menin. preferable in all cases to every other. The gitis; the fourth, suppurative inflammation priuciple to be kept in view in the appli. around the joint; the fifth, severe subcucation of mechanical means, whether before taneous inflammation; the sixth, paor after section, rests on the same basis; the ralysis; the seventh, supurative iniam. centres of motion of the apparatus must mation. Lutens' case was a consequence correspond to the centres of motion of the of inflammatory action, succeeding to condisplaced joints, and its action must be tusion. Dr. Little's case had succeeded exactly opposed to the action of the re- " to caries and suppuration around the tracted muscles.

joint.” My case succeeded to rheumatism. In fact, it does not seem to me material

what caused the condition; if we find that The same causes which produce retrac- the hamstring muscles evidently prevent tion of the foot may produce retraction of further extension, if we can flex the leg so the leg, but there are other causes by which far as to assure ourselves that true anchythe fernoro tibial region may be affected. losis does

not exist, and there be nothing Retraction in this region may be brought about the joint, at the time, to contra-inabout by disease around the joint, not im- dicate operation, we may, ordinary exten

RETRACTION OF THE LEG.

sion failing, make the section of the ham. ly more difficult or dangerous than the string tendons.

biceps—the artery, vein, and nerves, are 100 The operation is performed in the fol. deep-seated to be in danger. The internal lowing manner:- the patient lies on the saphena vein and nerve run some risk, bal abdomen, with the thigh extended ; the they are easily avoided. Unfortunately, surgeon places himself on the side of the when we have done all this, we may find that tendon he is about to cut. If he be about the tendon of the membranosos requires to to divide the biceps, he makes his puncture be divided. Placed nearthe posteriorsurface on its outside, if the inner tendons, the and inner border of the femur, towards its puncture must be made on their inner side. termination, it is necessary that the instru. The knife is passed under the tendon, or ment, carried between its posterior surface between it and the integuments, and when and the tendons we have mentioned, should it has arrived on the other side of it an be so held as to divide the mascle from assistant extends the leg so as to make the within outwards and forwards, about an muscles very tense; the cutting edge is then inch above tbe inner condyle. If we use turned towards the tendon, and, by means a blunt-pointed knife there will be little of a slight sawing motion, rapidly divides risk of injury to the popliteal vessels and it. Supposing we are operating on the nerves; and if we find that any resisting biceps, the operation is now finished, the portion still remains, it must be divided. knife is removed, and the little wound As soon as the operation is completed, exdressed. If the inner hamstring tendons tension may be increased considerably; are to be divided, the operation is not so but I prefer leaving the limb at rest for easy; we may have to cut the tendon of three days, wben extension may be comthe gracilis, the sartorius, the semi-tendi- menced by means of such an instrument as nosus, one after another; and this is scarce. the following, which I employed in my case,

Extension should be slowly made, and the the surgeon divides those only which prerevolutions of the screw should not exceed vent extension of the leg. two daily, and even that, in some cases, may be more than the patient can bear. WRY NECK, CAPUT OBSTIPUM, OR TORIn most cases it will be found that exten

TICOLIS, sion may be carried to its extreme limits may be produced by several causes; but within six weeks; sometimes it may be the most common would seem to be a reaccomplished in half that time; in others, traction of one or more of the muscles of as in one of Duval's cases, many months the neck, usually, the sterno-mastoideus. may be necessary for the purpose. It is The idea which long existed that wry not wise to make pressure over the patella, wry neck was always the consequence of because patients usually complain of it, anchylosis, or some other affection of the and it has interfered with the progress spine, has had much influence in the treat. of the cure. If there be anchylosis at the ment of this affection ; despairing of cure, knee-joint, the section of these tendons palliatory measures were alone employed. must not, of course, be attempted, nor, in. In the present day, we seem to be precipi. deed, unless the flexion be exempt from tated into the opposite exaggeration : luxation -upless, in fact, the infirmity be many practitioners maintain that wry owing to a retraction of the muscles. In neck is always owing to muscular retracthis point of view, flexion of the leg has tion. A midway course between these disnot been sufficiently studied to enable us cordant opinions is the one you must fol. to determine whether one of the hamstring low : some cases of wry neck are untendons more than the other has a tendency doubtedly owing to changes brought about to become thus affected. However, this is gradually in the relation of the articulating not a difficulty in the operation, because surfaces of certain of the vertebræ of the

neck; others are as certainly owing to ex- disease is convulsive, or spasmodic, which aggerated muscular action alone; and, may be permanent. unfortunately, in a given case, it is difficult Treatment.—These deformities, when deto say whether the deformity is owing to pendent upon muscular contraction, and que or the otber. A cicatrix and chronic when there is no spinal disease, will somedeep-seated inflammation of the tissues of times give way to counter-extension conthe neck may also produce the disease. tinued for some weeks, but the benefit is

What we have said, in speaking of mus- often only partial—the deformity is only cular retraction generally, and the destruc- partially removed. I know at this moment tion of equilibrium, perfectly applies here. iwo patients, in whom the deformity bas On one side a muscle may be paralyzed, succeeded to scarlet fever, and has been on the other, its power may not be in- treated in every conceivable way short of creased ; yet wry neck may be the conse. section, and with very little benefit. quence: or, on one side, the power is ab. Within a few years, Recamier has pronormal; on the other, is exaggerated— posed a method of treatment, which, in from this may result wry neck; it may such cases, in his hans, has succeeded very succeed to rheumatism, to neuralgia, to well, and which he terms massage. It conscarlet fever. When caused by rheu sists in making sudden jerks, to the extent matism, and treated early, it is often cured the muscle will allow, in the direction to by counter-irritation, local bleeding, or reduce the deformity. In many cases, in etbollients; but when it is of nervous a comparatively very short space of time, origin, or has succeeded to chronic inflam. the muscular contraction is overcome, and mation, it will not yield to such means. the head restored to its proper situation ; The muscle most coinmonly contracted is but the pain attending the practice is often the sterpo.cleido mastoid-more particu- very severe. He has also employed, with larly its sternal attachment, or, to speak considerable success, a method which conmore correctly, the sterno-mastoid, for sists in a sort of shampooing of the affected there can be no question that the functions muscle. of tlie sternal portion are distinct from the In the treatment of this deformity we clavicular; the first is especially the motor find that surgeons long ago resorted to the of the head; the other is essentially a section of the sterno.cleido mastoid muscle. muscle of respiration. In wry neck it has Among the early operators are Isacius Miheen usually the fashion to consider it as nius, mentioned by Tulpius, (Observat. dependent upon a retraction of the sterno- Medic., 1641; Roonhuysen, (Heilkuren cleido mastoid muscle, whilst it is the sterno. Nürnberg, 1674); Meekren, (1688); Blamastoid alone which is usually and primarily sius, 1677; Sharp, 1739, Cheselden, 1740; affected; it is tbis portion, therefore, par. Goocls

, 1757; but, after his time, the ope. ticularly, which it is necessary to attack in ration was not, so far as I know, resorted treating the affection, Still it is not only to until 1822, by Dupuytren. the sternal portion of this muscle which In 1822, a case of ihis deformity was most be occasionally attacked; it may be presented to Dupuytren at the Hotel Dieu. necessary to act upon the clavicular portion, “ Massage” and topical relaxants were or even the clavicular portion of the tra- tried without effect, when that celebrated pezius; examples of ihis are given by surgeon determined to make a section of Gooch, Sharp, Stromeyer, and others. the sternu-cleido-mastoid muscle, which was Out of the thirty seven cases mentioned by in a state of permanent retraction. To Dieffenbach (Berlin Medic. Zeilung. 1838, avoid an unsightly cicatrix at the internal No. 27), in twenty-foar the whole musclé border of the inferior attachment, he made was affected, so that in so large a propor. a small puncture, through which he passed lion of his cases the section of both attach. a narrow blunt-pointed bistoury, flat, bements of the muscle was necessary. hind the muscle: when it fairly included

There are two kinds of deformity to the muscle, be turned the cutting-edge towbich the term wry neck has been attached; wards it; and cut through its fibres, passin the one the head is rotated ; in the ing towards the skin, without wounding other, it is simply inclined. The rotation it. The head was quickly restored to its occurs from the bealthy side, the muscle of proper position, and there was no draw. that side being hard, projecting, and often hack. In 1833, Professor Syme performed painful ; spontaneous motion of the head the operation in a child of six months: the is impossible ; in fact, to reduce the head wound was excessively small, the cure im. to its proper position, considerable force is mediate and complete. Now, the operanecessary, and, as soon as the 'orce is re- tion of Dupuytren was chronicled in 1823, mored, ibe head returns to its former posi- in Germany, in Ammon's Parallele (Leiption. There is a variety of this deformity zig); near the same time in England, hy which has an intermitent character, and, Mr. Averill, in his Operative Surgery; by io these cases, there is usually no vertebral Froriep, of Weimar, in the same year; by discase; there is another in which the Graese and Walthier in 1821; by Diefen

bach in 1830 : and yet, in 1838, we find off your guard, and the operation must not two eminent French surgeons, one of whom be lightly undertaken. Its deeper surface did not perform the operation before 1836, is in immediate relation with the subclavian the other before 1837, strongly supporting artery and vein, the internal jugular rein, their several claims for inventing the ope- and carotid artery; its superficial surface ration.

is traversed by blaments of the cervical The operation is now performed in the plexus, by the external jugular rein. Oiber following manner:-The patient is either veins creep along its inserior extremity: laid on a table, or sits in a chair; the head When the primary obstacle to the redacis slightly flexed, so as to admit of the tion of the deformity is destroyed, all our knife more easily passing between the in. difficulties are not usually removed. The tegument and the muscle. The surgeon passive retraction of other muscles must be having placed himself in front or at the overcome; and this is to be done by me. side of the patient, with the right hand, if chanical ineans, which are to be used as it be the left side, the left if it be the right, soon as the little wound is cicatriscd, he makes, if we follow the plan of Guerin, about the third day. The head and neck a puncture at the external border of the having been long maintained in an abnor. sternal attachment of the mastoid muscle, mal position, all the inuscles of the neck, at six or eight lines above the sternum. not only those of the affected but those of The instrument is then passed on its fat, the healthy side, have suffered changes immediately before the muscle, until it of relation and dimension. These circumreaches its internal border; he then turns stances show evidently, that a mechanical the edge towards the muscle, and carefully consecutive treatment is almost as indis. cuts through it, passing towards the deeper pensable as the surgical operation. The seated parts. If it be right to relax the duration of mechanical treatment is variinteguments while the knife is gliding be- able, depending upon the time and the ex. neath the skin, they, as well as the muscle, tent of the deformity. Some days will must be made tense at the moment of sec. often be sufficient to make an apparently tion. As the knife is acting upon a dense perfect reduction, but many weeks are often tissue, the absence of resistance clearly in- necessary to really complete it, dicates when the section is completed. It is hardly necessary to make a compa

For the clavicular portion the puncture rison between the present and former modes must be an inch, or an inch and a half, of treating.wry neck. As far as concerned more externally, and a little nearer the the former operations, either the integuclavicle. As this portion is larger than the ment was included in the transverse inci. other, the bistoury must be carried deeper sion, or a longitudinal incision was made from without inwards. This tendon, which in the course of the fibres of the muscle; a is as frequently divided from its internal to director was then passed under it, and its its exterual border, as from its cutaneous fibres incised on the director. These two to its deep surface, is less surrounded than modes differ much in principle and in the the sternal portion with blood vessels. If, mode of execution. In the transverse sec. instead of thus diriding the muscle, corn. tion, the operation was long, fatiguing, and mencing by its cutaneous surface, we pre. painful. Similar inconveniences attend fer cutting from its posterior to its cutane- ihe second operation; the obstacles 10 ous surface, it will be more convenient, but raising the muscle upon the director, and not indispensable, to puncture the integu- to pass the director throngh the opening, ments on the inner edge of each tendon; are considerable. The iminediate results and, when the puncture is made, I think of these two operations are relative to the it most prudent to use a blunt pointed tine and the difficulty of the operation, knife, so as to more surely avoid wounding the pain which is suffered, and the extent the vessels of this region: afterwards, cuts of the wound. Considerable inflammatory ting towards the cutaneous surface by a action has been developed, bas extended to short sawing motion. As soon as the ien. the throat and surrounding parts; the cica. don is cut through, a depression between trix is unsightly; it interferes with the the extremities is very evident. The head employment of mechanical means, causes can then, usnally, be brought to its proper the muscles to adhere to the skin, and thus position. The accidents which have been seriously interferes with extension. As to experienced are not severe; the ecchymosis the definitive results they are not more adis often considerable; nervous excitement vantageous: the reduction is incomplete; has been occasionally seen; and, in one case a certain rotation and inclination of the of Guerin's, something like the penetration head remains, because proper mechanical of air into veins; but the symptoms were means could not be promptly applied. not pressing. The little wound is usually This proves how indispensable is the con. soon cicatrised, and suppuration very rarely secutive mechanical treatment, and shows

But the absence of serious acci. very clearly the advantages of the operation dents so far, though Dieffenbach himself at present employed. has operated fifty times, must not put you Other muscles of the neck have been cut