According to Guinon, isolated contraction of one sternomastoid, whereby the head is rotated and inclined once or twice or several times consecutively, to the usual accompaniment of facial contortions, is very frequently to be noted. If there occur simultaneous contraction of the platysma, its fibres will be seen to line the cervical integuments longitudinally from the chin to the infraclavicular fossa. Synchronous involvement of the two sternomastoids will flex the headand approximate the chin almost to the sternum, but more commonly there is only a slight forward inclination of the head exactly similar to a gesture of assent. Extension and lateral deviation are less generally encountered.
According to Guinon, isolated contraction of one sternomastoid, whereby the head is rotated and inclined once or twice or several times consecutively, to the usual accompaniment of facial contortions, is very frequently to be noted. If there occur simultaneous contraction of the platysma, its fibres will be seen to line the cervical integuments longitudinally from the chin to the infraclavicular fossa. Synchronous involvement of the two sternomastoids will flex the headand approximate the chin almost to the sternum, but more commonly there is only a slight forward inclination of the head exactly similar to a gesture of assent. Extension and lateral deviation are less generally encountered.
Extreme variability characterises the exciting causes of these tics. It has been remarked more than once that insecurity of the headgear the subject happens to be wearing ought to be blamed; instead of readjustment with the hand, a little toss of the head will make the hat sit properly, and one need not search further afield for the germ of the patient's tic. We have been able to trace this mode of inauguration quite as conspicuously in young men as in young women. Prohibition of unstable head coverings and resort to exercises of immobilisation suffice for the tic's correction in early cases.
A not infrequent accessory symptom—viz. elevation of the corresponding shoulder—may have a similar origin in peripheral excitation connected with the patient's clothing. To escape the annoyance of a high and narrow collar, or, on the other hand, to experience an agreeable sensation by rubbing the skin, it is a very simple and a very easy matter to lean the head on the shoulder, and to raise the latter at the same time. The automatic reproduction of this gesture eventually ends in the formation of a tic which removal of the collar entirely fails to suppress. The first therapeutic indication, nevertheless, is to interdict the wearing of the unsuitable collar, and to recommend the adoption of others softer and more ample. Whatever be the opinion one holds on the mechanism of tic, the influence of peripheral stimuli is, according to Pierre Marie,[77]very considerable, and it is his invariable practice, in the case of youthful subjects, to impress on the parents the desirability of payingspecial attention to their children's clothing, and of discarding any article that is either stiff or heavy.
In one of our cases, a girl A., suffering from a nodding and rotatory tic of the head, examination of the cervical region revealed the existence of a line of cicatrices along the margin of the sternomastoid, the vestiges of a previous operation for a severe tuberculous adenitis. Some nerve filaments entering the sternomastoid and trapezius had no doubt been cut, since these muscles presented a minor degree of atrophy, and the irritation arising therefrom, as well at that due to dragging on the adhesions between the cicatrices and the underlying tissues, had been the starting-point of a motor reaction primarily convulsive and involuntary, but eventually habitual and automatic, and therefore, with the subsidence of the excitation, a tic.
In one of our cases, a girl A., suffering from a nodding and rotatory tic of the head, examination of the cervical region revealed the existence of a line of cicatrices along the margin of the sternomastoid, the vestiges of a previous operation for a severe tuberculous adenitis. Some nerve filaments entering the sternomastoid and trapezius had no doubt been cut, since these muscles presented a minor degree of atrophy, and the irritation arising therefrom, as well at that due to dragging on the adhesions between the cicatrices and the underlying tissues, had been the starting-point of a motor reaction primarily convulsive and involuntary, but eventually habitual and automatic, and therefore, with the subsidence of the excitation, a tic.
In another case[78]a month's systematic treatment served to curtail to a noteworthy extent spasmodic head movements resembling those one makes to get rid of a fly.
From another point of view, some of the tics of this class are merely the exaggeration of certain functions destined for the expression of the ideas of affirmation and negation. The nod of the head with which little G. used to punctuate his "yes's" was logical enough, but he soon began its repetition irrespective of his topic of conversation, and even when saying "no"—a veritable tic of affirmation.
Numbers of people are in the habit of emphasising their words with those to-and-fro movements of the head that we call gestures of approval. Now, if the gesture be strictly appropriate to the thought present in the mind, it cannot be identified with the tics. On the other hand, its execution may be inopportune, in which case, provided the form remain normal, it is merely a stereotyped act, and must exhibit the additional features of abruptness and exaggeration ere it rank as a tic.
It is chiefly among the mentally infirm, such as idiots and imbeciles, that the phenomenon of salutation occurs, and as its rhythm is an element which is foreign to most ordinary tics, it is not likely to be confounded with them.
These conditions apart, however, there is one highly specialised clinical type that merits separate study—viz. mental torticollis.
The medical world has long been familiar with various kinds of permanent or intermittent torticollis presumably unconnected with muscular, articular, or osseous lesions of the neck, and been as long divided on the question of their tabulation.
Instances of this affection, bearing such widely differing names as "hyperkinesis of the accessory of Willis," "spasmodic torticollis," "functional spasm of the neck muscles," "rotatory tic," etc., have abounded in medical literature ever since the days of Duchenne of Boulogne, Trousseau, and Charcot. Some twelve years ago now, the term mental torticollis was applied by Brissaud[79]to a type of convulsion of the neck musculature whose association with psychical disturbances justified its description as a tic, and his opinions have been abundantly confirmed by later observation.
As a matter of fact, mental torticollis is a tic which the patient can ordinarily curb by some procedure of his own invention. It has itsraison d'êtrein his mental imperfection. To obviate misunderstanding, we must premise that the latter term is not synonymous with mental alienation. It merely signifies that lack ofmental balance, to whatever extent, that is patent in all sufferers from tic.
From the motor aspect the tic under consideration may be characterised as a functional disorder, consisting in the ill-timed, inapposite, unceremonious, and exaggerated repetition of the function of head rotation. Notwithstanding the large number of muscles involved, the various modifications of movement possible, and the consequent complexity of clinical types, each individual case is recognisable as a tic. Let but momentary cessation of the muscular spasm be effected, and the torticollis disappears without leaving a trace. Instantaneous and total prevention is in practically every case attainable by resort to some subterfuge, however vehement be the patient's contortions.
This device, whatever it be, may be called the "efficacious antagonistic gesture," of which the simple placing of the index finger on the chin may be cited as an example. Its field of operation is not limited to mental torticollis, and we shall have opportunities of observing its working in greater detail in other tics; but in the former affection the constancy of its occurrence and the facility of its detection combine to enhance its diagnostic value.
We hasten to remark, however, that conditions other than those we have just mentioned are capable of producing convulsive movements in the muscles of this region. In addition to such osseous, articular, and muscular alterations as may determine a more or less permanent torticollis, certain nervous lesions are apt to be succeeded by the development of the spasmodic form, no longer as a tic, but as a true neck spasm, the due recognition of which may be a matter of no little perplexity.
Confining our attention for the present to torticollis tic—the mental torticollis of Brissaud—we notice, in thefirst place, that it affects either sex indifferently. The age of our youngest patient was eighteen, though in a case of Raymond and Janet's the disease made its appearance four years earlier. A hereditary neuropathic or psychopathic factor is invariable, but similar heredity is the exception. Paternal alcoholism has been quoted by Guibert as a possible predisposing cause, also a rheumatic diathesis (Bompaire), family trembling (Feindel), hereditary stammering (Noguès and Sirol), nervous and mental disease in the parents (Feindel and Meige). One of Oppenheim's patients had a peculiarly sinister family history: the grandparents were related by blood, one being a diabetic as well, and the other a lunatic; the mother was nervous, and the sisters either epileptic or psychically abnormal. This case was characterised by the existence of generalised tics in childhood, and by the development of torticollis soon after marriage.
Among personal antecedents may be noted hysterical attacks (Sgobbo), emotional unrest (de Buck[80]), migraine (Brissaud), neuralgia (Bompaire), irritability, eccentricity, caprice, absentmindedness, neurasthenia (Brissaud and Meige[81]). Other favouring circumstances are moral shook, intense and prolonged emotion, remorse, preoccupation (Bompaire, Sgobbo, Brissaud and Meige, Grasset). Purely extraneous causes seem sometimes to be the starting-point; for instance, toothache and dental inflammation (Souques[*]), pain in the neck from carrying heavy loads (Amussat[*]), chill (Legouest, de Buck, Guibert[*]).
[*] Cited by BOMPAIRE,Thèse.
At the Congress of Limoges a case was reportedby Lannois where the onset of torticollis in a young girl was determined by an overpowering impulse to gaze at a little papilloma on her nose. The extirpation of the growth was followed by an amelioration of symptoms that amounted substantially to a cure.
Mental torticollis consecutive to anthrax of the neck has been described by Briand.
Other conditions that have been invoked as possible causes are the intoxications and infections, alcoholism, saturnism, mercury poisoning, typhus, pneumonia, paludism, etc. Oppenheim has signalised the reappearance, after several months of respite, of a torticollis secondary to an attack of influenza. Overwork, accident, occupation, have in their turn been suggested. In some cases, as a matter of fact, it does seem that the last is of some import, since the incidence of the torticollis is to a certain extent on those muscles that have been actively employed in the pursuit of a profession, and they thus acquire a sort of functional hyperkinesis.
Graff's[82]case of clonic convulsive contractions of the left splenius, left deep rotators, and right sternomastoid, occurred in an individual obliged, when carrying heavy loads, to maintain his head in a fixed position to the left, and unable thereafter to turn it to the right.
In some quarters no little importance is attached from the pathogenic point of view to the actual state of the muscles, and in particular to atrophy or hypertrophy of the sternomastoids. Féré holds that sometimes unilateral atrophy may occasion abnormal contraction of the opposite muscle, but such muscular changes are, in our opinion, much less likely to be the cause than the consequence of reiteration of movement or conservation of attitude. Legenmann's case was one oftonic and clonic convulsion of the right sternomastoid where there was a cartilaginous tumour in the left.
The rôle played by ocular affections, by troubles of vision and of accommodation, in the genesis of wryneck is frequently no insignificant one, and it is curious how often patients attribute the mischief to the strain of overwork in bad light. Strabismus (Walton) and ocular palsies (Nieden) have also been known to lead to lateral deviation of the head and permanent torticollis. There has been described a varietyab aure læsa.
Albeit these factors have a share in determining the gesture and attitude adopted by the patient, the resulting torticollis is not of necessity mental. That which, according to Romberg, is provoked by compression of supraclavicular nerve filaments is unmistakably a spasm.
To establish the diagnosis of mental torticollis, the existence of those psychical anomalies that are common to all who tic must first be substantiated, and then must one essay the reconstruction of its mechanism. The inquiry may at first prove fruitless, of course, but continuation of the search can scarcely fail to elicit tokens of mental infantilism. In pursuance of this quest we shall find ourselves face to face with the "big baby," the personification of childishness, obstinacy, and caprice; we shall encounter the peevish, the sulky, the whining; we shall see how their impotence in presence of their tic turns their nonchalance to profound despair, how their failure to adapt themselves to their malady convicts them remorselessly of volitional imperfection. The utter weakness of their will, according to Déjérine, justifies their being ranked as neurasthenics; but in the latter class of case obsessional ideas are both fugitive and fluctuating, whereas mental torticollis is dependent on a fixed idea of peculiar tenacity.
There can be no doubt that such patients, however undimmed their intellectual powers may remain, ultimately fail before the everlasting obsession of their disease, and if in some cases interest in daily life and work continues unabated, a multitude of others become indifferent and apathetic, and sink into a state of physical and moral infirmity.
To retrace the steps in the evolution of mental torticollis is a task not always easy of accomplishment. Very commonly the affection supervenes as the sequel to the unhindered repetition of a once voluntary purposive act, a repetition become tyrannical through volitional debility. One or two extracts from published cases will serve to illustrate the truth of our contention.
1. To escape the pain of a dental abscess on the right side, of only four or five days' duration, the patient had acquired the habit of turning the head to the right and maintaining it so for as long as possible at a time. Very shortly after the healing of the abscess, the head commenced to move involuntarily towards the same shoulder (Souques[83]).2. Occipital neuralgia and pain in the neck led the patient to try various positions to allay the agony, in the course of which he found that rotation to the right brought transient relief. By dint of repetition the movement became involuntary (Brissaud and Meige[84]).3. In this case the subject used to spend the whole evening inert, arms folded, without reading or working, tilting his head forwards or backwards to rediscover a "cracking" in his neck from which he suffered—a proceeding that gradually developed into a tic (Brissaud and Meige).4. A schoolgirl was dissatisfied with the place allotted to her in the schoolroom, and pretended that she felt a draught on her neck coming from a window on her left. The initial movement was an elevation of the shoulder as if to bring her clothes a little more closely round her neck, then she commenced to depress her head and indicate her discomfort by facial grimaces, and these eventually passed beyond voluntary control (Raymond and Janet[85]).5. In order to deceive his friends, the patient assumed a forcedattitude of gaiety when really sick at heart, by inclining his head, raising his shoulders, and arching his back, and at the end of a few months a bantering remark revealed the surprising fact that he could not correct the position (Raymond and Janet[86]).6. A woman used to pass the day sewing or knitting at her window and amusing herself from time to time by pensively looking out into the street. Not long afterwards she noticed how much more pleasant it was to allow her head to turn to the right, and how troublesome it was to keep it straight. At length she found this impossible, except with the aid of her hands (Sgobbo[87]).7. Worried by severe occipital pains, an individual became so concerned to find they were being replaced by a feeling of great weakness, that he let his head rest by inclining it now and then to the left, an act which he is certain was the cause of his torticollis (Feindel[88]).One further instance may be cited from Séglas,[89]where a neurasthenic lady, fifty years old, had been for three years a martyr to vague pains which finally settled in her neck, and asserted themselves on the slightest exertion. She sought to mitigate her sufferings—a veritable topoalgic obsession—by leaning her head on her shoulder, and the desire thus to procure alleviation gradually became irresistible and the movement unconscious.
1. To escape the pain of a dental abscess on the right side, of only four or five days' duration, the patient had acquired the habit of turning the head to the right and maintaining it so for as long as possible at a time. Very shortly after the healing of the abscess, the head commenced to move involuntarily towards the same shoulder (Souques[83]).
2. Occipital neuralgia and pain in the neck led the patient to try various positions to allay the agony, in the course of which he found that rotation to the right brought transient relief. By dint of repetition the movement became involuntary (Brissaud and Meige[84]).
3. In this case the subject used to spend the whole evening inert, arms folded, without reading or working, tilting his head forwards or backwards to rediscover a "cracking" in his neck from which he suffered—a proceeding that gradually developed into a tic (Brissaud and Meige).
4. A schoolgirl was dissatisfied with the place allotted to her in the schoolroom, and pretended that she felt a draught on her neck coming from a window on her left. The initial movement was an elevation of the shoulder as if to bring her clothes a little more closely round her neck, then she commenced to depress her head and indicate her discomfort by facial grimaces, and these eventually passed beyond voluntary control (Raymond and Janet[85]).
5. In order to deceive his friends, the patient assumed a forcedattitude of gaiety when really sick at heart, by inclining his head, raising his shoulders, and arching his back, and at the end of a few months a bantering remark revealed the surprising fact that he could not correct the position (Raymond and Janet[86]).
6. A woman used to pass the day sewing or knitting at her window and amusing herself from time to time by pensively looking out into the street. Not long afterwards she noticed how much more pleasant it was to allow her head to turn to the right, and how troublesome it was to keep it straight. At length she found this impossible, except with the aid of her hands (Sgobbo[87]).
7. Worried by severe occipital pains, an individual became so concerned to find they were being replaced by a feeling of great weakness, that he let his head rest by inclining it now and then to the left, an act which he is certain was the cause of his torticollis (Feindel[88]).
One further instance may be cited from Séglas,[89]where a neurasthenic lady, fifty years old, had been for three years a martyr to vague pains which finally settled in her neck, and asserted themselves on the slightest exertion. She sought to mitigate her sufferings—a veritable topoalgic obsession—by leaning her head on her shoulder, and the desire thus to procure alleviation gradually became irresistible and the movement unconscious.
Multiplication of examples is unnecessary. It is abundantly evident from the above that the repetition of a deliberate and voluntary functional act, co-ordinated and systematised, is the first step in the genesis of mental torticollis.
The mere memory of a frequently repeated movement, especially if the latter occur in the prosecution of one's avocation, may determine the type of torticollis, as in Grasset's "post-professional colporteur tic," to which reference has already been made.
In the case of one of our patients, N., the prolonged and almost exclusive use of certain muscles in thecourse of his business decided their involvement in the condition of practically permanent torticollis with which he was afflicted, and which was due to strong contraction of the right trapezius and sternomastoid. It appeared that for eighteen years he had been a cutter in a linen draper's, where it had been his duty, for hours at a stretch, to cut rolls of stuffs with a large and heavy pair of scissors, and in the execution of this work the right arm was extended, the hand firmly pressed on the table, the shoulder elevated, the head rotated and inclined to the left.
We cannot do better in this connection than recall the cases referred to by Brissaud[90]when directing attention for the first time to this variety of tics of the neck.
Here is a patient with energetic contraction of the muscles which depress the head on the neck. She holds her head in her hands to inhibit the movement, and succeeds. And she is quite convinced that the force requisite for rectifying the vicious attitude is not simply the power of her will acting on the muscles concerned, but the strength of her hands. She has unconsciously doubled her physical personality; her hands obey her will, her neck does not. At least, this would appear to be the key to the situation, for it can be well understood how much easier it would be to readjust the position by action of the antagonist cervical muscles than by the hands. The contraction, moreover, is entirely painless. It is a trivial act of obsessional insanity, provoked by some or other insignificant psychomotor hallucination.Take this next man, who also must needs keep his head straight by means of his hand—obviously no irritation of the spinal accessory can be accused of originating the mischief, else would he be unable himself to replace his head. It is merely the idea that is urging him to its rotation. Try by force to prevent him from twisting his head round, or try to twist it against his will, and the difficulty of the thing will be at once comprehended. Or try to pull your own two hands apart to see which is the stronger, and you will never succeed, for the simple reason that abstraction of the will is impossible. One hand can prevail over the other only if both consent; the left cannot be in ignorance of what the right is doing. A "partial" or "local" will is inconceivable; there cannot be one for the head and another for the arm.Here is a third patient, presenting an identical muscular spasm. He is content to apply two fingers to his chin to overcome the otherwise irresistible bend of his head to the right. Such has been the situation for the last five years. No line of treatment has made any impression on this neurosis, to which two factors contribute, though one cannot say which predominates—an unconscious, imperious, motor impulse, and a conscious though ill-informed volition, powerless to arrest the convulsions by simple and normal media, and obliged to resort to a puerile artifice, to a sickly sort of deceit. The opposition furnished by two fingers only cannot be of any avail, yet, however feeble be the succour, the patient's imagination is thereby appeased.Such (adds Brissaud), fashioned in the same mould, are the "mentals" of whom I have been speaking. Recollect the ungovernable impulse they feel to execute a convulsive movement that their will might thwart; remember, therefore, at the same time, their volitional enfeeblement.
Here is a patient with energetic contraction of the muscles which depress the head on the neck. She holds her head in her hands to inhibit the movement, and succeeds. And she is quite convinced that the force requisite for rectifying the vicious attitude is not simply the power of her will acting on the muscles concerned, but the strength of her hands. She has unconsciously doubled her physical personality; her hands obey her will, her neck does not. At least, this would appear to be the key to the situation, for it can be well understood how much easier it would be to readjust the position by action of the antagonist cervical muscles than by the hands. The contraction, moreover, is entirely painless. It is a trivial act of obsessional insanity, provoked by some or other insignificant psychomotor hallucination.
Take this next man, who also must needs keep his head straight by means of his hand—obviously no irritation of the spinal accessory can be accused of originating the mischief, else would he be unable himself to replace his head. It is merely the idea that is urging him to its rotation. Try by force to prevent him from twisting his head round, or try to twist it against his will, and the difficulty of the thing will be at once comprehended. Or try to pull your own two hands apart to see which is the stronger, and you will never succeed, for the simple reason that abstraction of the will is impossible. One hand can prevail over the other only if both consent; the left cannot be in ignorance of what the right is doing. A "partial" or "local" will is inconceivable; there cannot be one for the head and another for the arm.
Here is a third patient, presenting an identical muscular spasm. He is content to apply two fingers to his chin to overcome the otherwise irresistible bend of his head to the right. Such has been the situation for the last five years. No line of treatment has made any impression on this neurosis, to which two factors contribute, though one cannot say which predominates—an unconscious, imperious, motor impulse, and a conscious though ill-informed volition, powerless to arrest the convulsions by simple and normal media, and obliged to resort to a puerile artifice, to a sickly sort of deceit. The opposition furnished by two fingers only cannot be of any avail, yet, however feeble be the succour, the patient's imagination is thereby appeased.
Such (adds Brissaud), fashioned in the same mould, are the "mentals" of whom I have been speaking. Recollect the ungovernable impulse they feel to execute a convulsive movement that their will might thwart; remember, therefore, at the same time, their volitional enfeeblement.
Brissaud's earliest observations were followed at no long interval by various articles, first of all the thesis of his pupil Bompaire,[91]then others in collaboration with ourselves. The more recent publications of Lentz,[92]Sgobbo, Noguès and Sirol, Raymond and Janet, Séglas, Etienne Martin, etc., may be mentioned, as well as a contribution by Grasset,[93]notable alike for the case it contains and for the author's interpretations.
The view that considers of prime importance the psychical phenomena of this affection has received general confirmation. We have seen protracted cases of "spasm of the accessorius" cured, exactly as with the tics, by widely differing therapeutic agents. In numerous instances, according to Oppenheim, torticollis is not consecutive to any peripheral or central change in the nervous system, but rather indicates irritability of nerve centres. It is probable that the kinæsthetic centres in the cortex for the neck muscles are the seatof the lesion, and that their congenital and hereditary imperfection fixes the form the convulsion will take.
These and similar facts are well calculated to corroborate the opinion that mental torticollis is nought else than a form of tic. The subjects of the disease are satisfied of two things—that no one and no circumstance can hinder their torticollis from asserting itself, and that their own antagonistic gesture is the sole efficacious preventative at their command. The attempt to put the displacement right evokes acute pain and stimulates opposition on their part. They prefer the display of considerable resistance to the renunciation of their satisfaction in their tic, and follow up any momentary restraint by a riot of inco-ordination, in recompense for the brief sacrifice they have made to preserve immobility.
The muscular contraction that deviates the head may be either clonic or tonic, bringing it to one side by a series of convulsions and allowing it to resume its original position in the intervals, or forcing it to maintain a vicious attitude for hours. Innumerable variants may occur, indeed are the rule, even in the same patient. In short, though mental torticollis may generally be classed as a tic of attitude, it matters but little whether the adoption of the attitude or the attitude adopted constitutes the tic. They are simply two successive phases in the same abnormal muscular act. The most elementary movement is rotation of the head; it may equally well be inclined on one shoulder, or be both inclined and rotated to one side, or it may be inclined in one direction and rotated in the other. There may be accompanying elevation of the shoulder, or the act may become a much more complex one, involving neck, shoulder, and arm.
Each and all of the neck muscles may take a share in the torticollic movement, but some are more commonlyaffected than others, in particular the sternomastoid, whose contraction may either be isolated,[94]or modified by trapezius, splenius, levator anguli scapulæ, etc., of the same or the contralateral side. It is frequent to find the head inclined to one side and rotated to the other by the action of the sternomastoid, or displaced backwards and slightly turned to the side of the contraction by means of the splenius. If the sternomastoid and homolateral trapezius are acting together, torsion of the neck is very pronounced and the skin over that area is deeply lined.[95]It may happen that the head is rotated and inclined to the same side, as in Grasset's case, where the curious combination occurred of clonic convulsion of left trapezius and pectoralis major with right pectoralis major and sternomastoid. In the same patient the left arm was pressed against the trunk and the right extended posteriorly.
There are other instances where it would be more accurate to speak ofretrocollis, as in a case recorded by Brissaud, orprocollis, the two sternomastoids contracting synchronously, as in another case due to Duchenne of Boulogne. The extreme degree of flexion induced in this way was neutralised immediately by supporting the head; the adoption by the patient of a reclining position sufficed to inhibit the tic's manifestation.
Intensity and frequency of movement, duration and deformity of attitude, all alike may vary in the same individual at differing times. Solitude, tranquillity, and repose favour the diminution and even the entire disappearance of spasmodic movements which fatigue, anxiety, and emotion are prone to exaggerate. An instructivecase in point is one of van Gehuchten's,[96]the subject being a labourer twenty-five years old, in whom a tic of the right arm and right sternomastoid of seven years' continuance disappeared whenever the patient was by himself, to burst out afresh as soon as he was conscious of being observed.
Distraction is a valuable sedative. A patient of ours used to pass the day in twisting his head round with ever-increasing violence, while at night, amid the smiling gaiety of the theatre, hours slipped by without his betraying the least suspicion of his malady.
Occupation, on the other hand, may provoke the condition. Duchenne has a reference to a case where rotation of the head to the right commenced whenever the subject started to read, and ceased only with the laying down of the book. In one of our cases the head kept turning whenever and as long as the two hands were simultaneously engaged in some pursuit. If one hand was disengaged, there was no torticollis.
As a general rule, excitement invites or increases movement, whereas sleep frustrates it, and after a good night's rest several minutes or even an hour or two may elapse ere the convulsions reassert themselves.
Acute pain is rarely met with in the disease we are considering, but sensations of discomfort, of tension, of strain in the muscles, form a common subject of complaint.
By way of example may be cited the case of one of our patients:
L. is eighteen years old, and has been suffering from torticollis for the last six weeks. The chief movement is abrupt rotation and very slight inclination of the head to the right, and the muscles principally concerned are the left sternomastoid and the right splenius. The head is sunk between the shoulders, of which the right one is elevated synchronously with the rotation, and remains so as long as the latter persists.The displacement is effected by a moderately brisk muscular contraction that rotates the head to the right on its vertical axis, and succeeding contractions only serve to accentuate the deviation or to maintain it when the head is beginning to revert to its original position. There are none of those upward or downward oscillations, those hesitating, tentative little jerks that some patients make before assuming a fixed torticollis attitude. In L.'s case the duration of the wryneck is exceedingly variable; sometimes the head returns spontaneously to its place, and deviates afresh immediately after, but its periodicity changes with the days, and even with the minutes.The torticollis is accompanied by a rather disagreeable sensation, a feeling of fatigue in the muscles concerned, of "dragging" in their bellies as well as at their insertions. The site of this sensation is over the left sternomastoid, on the right half of the posterior aspect of the neck, and deep in the right shoulder, whereas the upper parts of the trapezii, the left half of the neck and its anterior surface, and the right sternomastoid, are areas that are free from pain.Here, further, as in all cases of the same nature, the subjective sensations differ from day to day, and moment to moment. It is just as perplexing to localise these pains exactly as to fix the topoalgia of a neurasthenic. The lack of precision of the answers is no doubt explicable by the variability of the muscular contractions.Emotion, apprehension, the presence of strangers, tend to intensify the spasm, which tranquillity and rest will attenuate. On the other hand, the most trivial incident—a sudden noise, an unexpected question, the act of swallowing saliva, of putting out the tongue, etc.—will reawaken the latent torticollis; any surprise, any movement, or even the idea of a movement, suffices for its ebullition.Under the influence of the will, particularly after a time of rest, the head may sometimes reoccupy the mid position spontaneously, a result unfailingly obtained by distraction also, as when the patient is hearkening thoughtfully to her father's conversation. On her "bad days," however, the use of even considerable force fails alike to hinder the head's turning and to effect its replacement. That is to say, the resistance offered by the torticollis to reduction may at one moment be nil, at another, feeble, or forcible, or even insuperable.
L. is eighteen years old, and has been suffering from torticollis for the last six weeks. The chief movement is abrupt rotation and very slight inclination of the head to the right, and the muscles principally concerned are the left sternomastoid and the right splenius. The head is sunk between the shoulders, of which the right one is elevated synchronously with the rotation, and remains so as long as the latter persists.
The displacement is effected by a moderately brisk muscular contraction that rotates the head to the right on its vertical axis, and succeeding contractions only serve to accentuate the deviation or to maintain it when the head is beginning to revert to its original position. There are none of those upward or downward oscillations, those hesitating, tentative little jerks that some patients make before assuming a fixed torticollis attitude. In L.'s case the duration of the wryneck is exceedingly variable; sometimes the head returns spontaneously to its place, and deviates afresh immediately after, but its periodicity changes with the days, and even with the minutes.
The torticollis is accompanied by a rather disagreeable sensation, a feeling of fatigue in the muscles concerned, of "dragging" in their bellies as well as at their insertions. The site of this sensation is over the left sternomastoid, on the right half of the posterior aspect of the neck, and deep in the right shoulder, whereas the upper parts of the trapezii, the left half of the neck and its anterior surface, and the right sternomastoid, are areas that are free from pain.
Here, further, as in all cases of the same nature, the subjective sensations differ from day to day, and moment to moment. It is just as perplexing to localise these pains exactly as to fix the topoalgia of a neurasthenic. The lack of precision of the answers is no doubt explicable by the variability of the muscular contractions.
Emotion, apprehension, the presence of strangers, tend to intensify the spasm, which tranquillity and rest will attenuate. On the other hand, the most trivial incident—a sudden noise, an unexpected question, the act of swallowing saliva, of putting out the tongue, etc.—will reawaken the latent torticollis; any surprise, any movement, or even the idea of a movement, suffices for its ebullition.
Under the influence of the will, particularly after a time of rest, the head may sometimes reoccupy the mid position spontaneously, a result unfailingly obtained by distraction also, as when the patient is hearkening thoughtfully to her father's conversation. On her "bad days," however, the use of even considerable force fails alike to hinder the head's turning and to effect its replacement. That is to say, the resistance offered by the torticollis to reduction may at one moment be nil, at another, feeble, or forcible, or even insuperable.
Some patients affected with mental torticollis seem to have lost the sense of position of their head, others evince a want of precision and assurance in the execution of different limb movements. Speaking generally, it may be said that downward movements of the arms are less good than upward ones, and that their synchronousand symmetrical action is accomplished with greater ease than is the operation of one only.
The debut of mental torticollis is usually insidious. Whether head or shoulder be implicated first, the incipient motor reaction is infrequent, inconsiderable, and transitory. Little by little its frequency increases and its duration lengthens, till the end of a few months sees the torticollis established.
It may happen that the onset is so stealthy that it eludes the subject's own notice, and attention is called to his peculiar attitude by the members of his circle. Not seldom the earliest localisation of the condition in a particular muscle is abandoned in favour of some other, and resumed at a subsequent stage. Occasionally the torticollis passes from right to left, or vice versâ; occasionally, too, the clonic variety may give way to the tonic after a few weeks or months.
It has been already remarked that at the outset the tic is infrequent, and may depend for its manifestation on certain predetermined circumstances, as, for instance, the exercise of the faculty of writing. Such was the case with S., with P., and with N.
N. was a patient forty-eight years old, with a left torticollis dating back twenty months. His account of its origin was to the following effect: for some years he had been employed in a commercial office, where from seven in the morning to eight at night he was occupied in writing, head and body being turned to the left. At the beginning of 1900, consequent on a succession of troubles, he noticed that his head was twisting round to the left in an exaggerated fashion while he was writing, and the rotation gradually began to assert itself at other times, when he was reading, or eating, or buttoning his boots. Even apart from any other act, the rotatory movement soon became incessant, continuing while he was on his feet, but vanishing completely if he lay down or if the head was supported. At present he has the greatest difficulty in writing, for his head at once deviates violently to the right.
N. was a patient forty-eight years old, with a left torticollis dating back twenty months. His account of its origin was to the following effect: for some years he had been employed in a commercial office, where from seven in the morning to eight at night he was occupied in writing, head and body being turned to the left. At the beginning of 1900, consequent on a succession of troubles, he noticed that his head was twisting round to the left in an exaggerated fashion while he was writing, and the rotation gradually began to assert itself at other times, when he was reading, or eating, or buttoning his boots. Even apart from any other act, the rotatory movement soon became incessant, continuing while he was on his feet, but vanishing completely if he lay down or if the head was supported. At present he has the greatest difficulty in writing, for his head at once deviates violently to the right.
The spasmodic movements sometimes spread to the shoulder, arm, and trunk, and, in one of our cases, to theleg. Should the condition be advanced, it is frequently complicated by choreiform or athetotic movements in the limbs, or by irregular and arhythmical tremors.
A case of this nature was shown at the Neurological Society of Paris by Marie and Guillain[97]:
The patient, forty-nine years of age, was suffering from muscular spasms that kept turning his head first to one side and then to the other. Fixation of the head between the hands assured a few moments' respite, but the convulsions were quick to reappear. The left hand was constantly being brought up to the face in the endeavour to procure immobility, while the arms were the seat of abrupt jerking movements intermediate between tremor and chorea.The various reflexes were normal; stimulation of the sole of the foot evoked a flexor response on either side, and no symptom of hysteria was forthcoming. The disease had made its appearance in 1879, when, without discoverable motive, the head had commenced to tremble and to work round to the left. Section of the tendon of the sternomastoid did not impede the development of the affection, which two years ago increased in intensity, when the above-mentioned movements in the arms were superadded. The likelihood seemed to be that they were of the same nature and origin as the torticollis itself.
The patient, forty-nine years of age, was suffering from muscular spasms that kept turning his head first to one side and then to the other. Fixation of the head between the hands assured a few moments' respite, but the convulsions were quick to reappear. The left hand was constantly being brought up to the face in the endeavour to procure immobility, while the arms were the seat of abrupt jerking movements intermediate between tremor and chorea.
The various reflexes were normal; stimulation of the sole of the foot evoked a flexor response on either side, and no symptom of hysteria was forthcoming. The disease had made its appearance in 1879, when, without discoverable motive, the head had commenced to tremble and to work round to the left. Section of the tendon of the sternomastoid did not impede the development of the affection, which two years ago increased in intensity, when the above-mentioned movements in the arms were superadded. The likelihood seemed to be that they were of the same nature and origin as the torticollis itself.
In reference to this communication, the following remarks were offered by Professor Brissaud:
It is true of all forms of functional hyperkinesis, that the indefinitely prolonged repetition of the same act leads finally not merely to muscular hypertrophy, but to a ceaseless over-activity of contraction in all the muscles affected. That this hypertrophy and hyperexcitability depend on some organic central lesion is not the necessary sequel. A purely functional exasperation may entail visible augmentation of movement, the cause of which is not central, but lies in the external manifestation of muscular over-activity.
It is true of all forms of functional hyperkinesis, that the indefinitely prolonged repetition of the same act leads finally not merely to muscular hypertrophy, but to a ceaseless over-activity of contraction in all the muscles affected. That this hypertrophy and hyperexcitability depend on some organic central lesion is not the necessary sequel. A purely functional exasperation may entail visible augmentation of movement, the cause of which is not central, but lies in the external manifestation of muscular over-activity.
The antagonistic gesture is, in some instances, contemporaneous with the wryneck, although more usually it is not in evidence until months or years after the distortion has become inveterate.
Mental torticollis is characterised by remarkable chronicity. We have seen cases of ten or fifteen years' duration and more. Temporary remissions have been known, however, and alternations with other tics or with psychical affections. At the Congress of Limoges, the following case was reported by Briand:
As the result of a bicycle accident, a young man developed a torticollis which ordinary treatment was sufficient to cure, and it remained in abeyance until he entered a government school, when its place was taken by a tic of the shoulder, with twitching of the mouth and eye. At the approach of the annual vacation the tic disappeared, and the torticollis, for some simple reason or other, became obvious again. The latter had once more been got under control by the time the holidays were over, but on the patient's re-entering school the shoulder tic again manifested itself, and this sequence recurred several times. A permanent cure was eventually effected, but he continued as psychasthenic as ever.
As the result of a bicycle accident, a young man developed a torticollis which ordinary treatment was sufficient to cure, and it remained in abeyance until he entered a government school, when its place was taken by a tic of the shoulder, with twitching of the mouth and eye. At the approach of the annual vacation the tic disappeared, and the torticollis, for some simple reason or other, became obvious again. The latter had once more been got under control by the time the holidays were over, but on the patient's re-entering school the shoulder tic again manifested itself, and this sequence recurred several times. A permanent cure was eventually effected, but he continued as psychasthenic as ever.
In another of Briand's cases torticollis alternated with astasia-abasia, a sort of "mental paraplegia." The patient could not walk at all without crutches, or without a littleminerve, which he used either to steady his gait or to keep his head straight.
No doubt facts such as these just given are rather uncommon, but there is abundant reason for considering mental torticollis one of the most tenacious and intractable of all tics.
The rarity of isolated involvement of the thoracic muscles, and the frequency of their inclusion in tics of the neck and limbs, arise from the fact of their insertion into the bones of the extremities, and consequently conditions affecting them will be dealt with in another place. Omitting for the present all reference to the muscles of respiration, we have to consider only the vertebral and abdominal groups. These pass into activity in the rhythmical salutation and balancing movements so common among idiots, movements bearingthe most intimate analogies to the tics, though their peculiarity of rhythm justifies their separate classification.
Tonic contractions that find expression in attitude tics of the body are generally associated with tonic tics of the neck and limbs, and in some cases of mental torticollis the deformation they produce is extensive.
The material part played by the abdominal muscles in the function of respiration explains their implication in respiratory tics. A curious case of this kind has been published by Pierre Janet[98]:
A woman thirty-two years old had been afflicted for three years with a respiratory tic that consisted in imitating with the lips the neighing of a horse, and with a still more extraordinary tic of the abdominal parietes. She appeared to "swallow her stomach"; in other words, her abdomen, prominent enough in its ordinary state, was flattened and retracted, and the skin so stretched and dragged upwards that the umbilicus approached the costal margin. Just as it seemed to be disappearing, to be "swallowed," relaxation of the abdomen slowly took place, and this procedure was repeated ten or twelve times a minute. Pressure on the epigastrium inhibited the abdominal movement, but was accompanied by immediate renewal of the neighing, whereas with the relief of the pressure the sequence of events was inverted.
A woman thirty-two years old had been afflicted for three years with a respiratory tic that consisted in imitating with the lips the neighing of a horse, and with a still more extraordinary tic of the abdominal parietes. She appeared to "swallow her stomach"; in other words, her abdomen, prominent enough in its ordinary state, was flattened and retracted, and the skin so stretched and dragged upwards that the umbilicus approached the costal margin. Just as it seemed to be disappearing, to be "swallowed," relaxation of the abdomen slowly took place, and this procedure was repeated ten or twelve times a minute. Pressure on the epigastrium inhibited the abdominal movement, but was accompanied by immediate renewal of the neighing, whereas with the relief of the pressure the sequence of events was inverted.
In the upper extremity tics may affect the various muscles of the shoulder, arm, or forearm. Shoulder tics are of frequent occurrence, and often owe their origin to the discomfort of a tight sleeve or of a badly fitting collar. They are generally a concomitant of neck tics, in particular of mental torticollis.
In this connection we may recall the case of O., and supplement it by a description of another—viz. young J.
This boy J. had always been "nervous," and affected with "nervous movements" of face or limbs. At the age of thirteen years, when playing in the house one day, he knocked himself against an opendoor and bruised the shoulder near the outer end of the left clavicle. Three or four days later all pain and discolouration had vanished, and the child's movements were perfectly unimpeded again. His tics continued as before.Two months after this little accident was over and forgotten, it was remarked that at the seat of the contusion there was a slight swelling, quite painless and scarcely even uncomfortable, but disquieting enough to the parents and thought to require applications of neapolitan ointment and the actual cautery. This line of treatment effected no alteration in the local condition, but it had other far-reaching consequences, for the boy noticed the anxious interest aroused by the singular exostosis, and began to devote attention to it himself. From the moment that his parents manifested their apprehension by words of pity and by solicitous examination, his tics developed a preference for the left shoulder, though continuing to exhibit themselves in the face and the right arm. He would unexpectedly elevate or depress his shoulder, would shrug it forwards or brace it back, accompanying the performance with inclination of the head or abduction of the upper extremity. He was very positive as to the painless nature of his affection; his sole complaint was of a certain stiffness in the joint, and at the thought of it came an impulse to move the shoulder which there was no resisting. The twitching would disappear for a time for no fathomable reason, and reappear again. By the exercise of a little circumspection he could temporarily overcome it, and during sleep it subsided entirely.The facts—duly controlled and confirmed by the parents—that involuntary shoulder movements preceded not merely the application of the counter-irritants, but the accident itself, and that the unique difference lay in the similarity of his shoulder tic to all his other tics before the trauma, and in its marked preponderance in degree and frequency after, especially subsequent to the treatment, are of weighty diagnostic significance. Plainly the injury and its sequelæ did not exert any causative influence on the tic, and while it is conceivable that the clavicle may have been cracked and an exostosis ensued, we must repeat that the pre-existence of the movements in question negatives the possibility of their being attributable to nerve irritation from a periosteal overgrowth. The only effect which the accident and its consequences had was to intensify the patient's preoccupation and to determine the incidence of the tic.By the month of October, 1900, the latter was at its height, and had reached a state where differentiation of the movements and of their muscular counterparts was attended with no little difficulty. They could be resolved into four principal groups, whereby the shoulder was raised, lowered, advanced, or drawn back, respectively. The first of these presented no unusual feature except that with it the head was commonly inclined to the same side; but the act of depression was rather peculiar, inasmuch as it was achieved by a sudden contraction of the inferiormuscles of the scapula, together with the pectoralis, which drew the humeral head downwards, elongated the capsule, and stretched the deltoid fasciculi over it. The space thus left between the separated articular surfaces was partly filled in by the neighbouring ligamentous and muscular structures. Anterior or posterior projection of the shoulder took place at the expense of an actual subluxation, the head of the humerus bulging under the pectoral or the scapular muscles. Each and every movement was accompanied by articular cracking, sometimes so insignificant as scarcely to be pathological, to which, nevertheless, the boy attached extravagant importance and devoted methodical investigation.Ordinary arm movements were, without exception, unimpaired, nor was any bony malformation discoverable. The two shoulders were practically symmetrical, though the upper border of the trapezius on the left side was, if anything, thickened and more prominent than its fellow, and the same applied to the left scapular muscles. Horizontal extension of the left arm revealed a slight tremulousness, quite distinguishable from pathological tremor and from fibrillary twitching, and wholly comparable to what is seen when, by reason of a fracture or otherwise, a limb is for a certain length of time prevented from executing movements of extension.
This boy J. had always been "nervous," and affected with "nervous movements" of face or limbs. At the age of thirteen years, when playing in the house one day, he knocked himself against an opendoor and bruised the shoulder near the outer end of the left clavicle. Three or four days later all pain and discolouration had vanished, and the child's movements were perfectly unimpeded again. His tics continued as before.
Two months after this little accident was over and forgotten, it was remarked that at the seat of the contusion there was a slight swelling, quite painless and scarcely even uncomfortable, but disquieting enough to the parents and thought to require applications of neapolitan ointment and the actual cautery. This line of treatment effected no alteration in the local condition, but it had other far-reaching consequences, for the boy noticed the anxious interest aroused by the singular exostosis, and began to devote attention to it himself. From the moment that his parents manifested their apprehension by words of pity and by solicitous examination, his tics developed a preference for the left shoulder, though continuing to exhibit themselves in the face and the right arm. He would unexpectedly elevate or depress his shoulder, would shrug it forwards or brace it back, accompanying the performance with inclination of the head or abduction of the upper extremity. He was very positive as to the painless nature of his affection; his sole complaint was of a certain stiffness in the joint, and at the thought of it came an impulse to move the shoulder which there was no resisting. The twitching would disappear for a time for no fathomable reason, and reappear again. By the exercise of a little circumspection he could temporarily overcome it, and during sleep it subsided entirely.
The facts—duly controlled and confirmed by the parents—that involuntary shoulder movements preceded not merely the application of the counter-irritants, but the accident itself, and that the unique difference lay in the similarity of his shoulder tic to all his other tics before the trauma, and in its marked preponderance in degree and frequency after, especially subsequent to the treatment, are of weighty diagnostic significance. Plainly the injury and its sequelæ did not exert any causative influence on the tic, and while it is conceivable that the clavicle may have been cracked and an exostosis ensued, we must repeat that the pre-existence of the movements in question negatives the possibility of their being attributable to nerve irritation from a periosteal overgrowth. The only effect which the accident and its consequences had was to intensify the patient's preoccupation and to determine the incidence of the tic.
By the month of October, 1900, the latter was at its height, and had reached a state where differentiation of the movements and of their muscular counterparts was attended with no little difficulty. They could be resolved into four principal groups, whereby the shoulder was raised, lowered, advanced, or drawn back, respectively. The first of these presented no unusual feature except that with it the head was commonly inclined to the same side; but the act of depression was rather peculiar, inasmuch as it was achieved by a sudden contraction of the inferiormuscles of the scapula, together with the pectoralis, which drew the humeral head downwards, elongated the capsule, and stretched the deltoid fasciculi over it. The space thus left between the separated articular surfaces was partly filled in by the neighbouring ligamentous and muscular structures. Anterior or posterior projection of the shoulder took place at the expense of an actual subluxation, the head of the humerus bulging under the pectoral or the scapular muscles. Each and every movement was accompanied by articular cracking, sometimes so insignificant as scarcely to be pathological, to which, nevertheless, the boy attached extravagant importance and devoted methodical investigation.
Ordinary arm movements were, without exception, unimpaired, nor was any bony malformation discoverable. The two shoulders were practically symmetrical, though the upper border of the trapezius on the left side was, if anything, thickened and more prominent than its fellow, and the same applied to the left scapular muscles. Horizontal extension of the left arm revealed a slight tremulousness, quite distinguishable from pathological tremor and from fibrillary twitching, and wholly comparable to what is seen when, by reason of a fracture or otherwise, a limb is for a certain length of time prevented from executing movements of extension.
[Beating or striking tics (the patient using his own fist against himself) arise from the attempt to alleviate some insignificant pain or irritation; but tics of this kind are in their turn the exciting cause of local discomfort, and so of fresh tics. In spite of the obviousness of this, it is often difficult to convince the patient that his movements are prior, not consecutive, to the unpleasant sensations.[99]]
Finally, tonic tics of the upper extremity find expression in attitudes that vary with the localisation of the contraction. We have already had occasion to observe this, which is an almost constant phenomenon in mental torticollis, in the case of young J., in Madame T., and in N., where, it will be remembered, the all but permanent elevation of the right shoulder seemed traceable to the habit of cutting stuffs with a pair of large scissors.
Scratching movements are infinite in their variety, and since the co-operating muscles vary in each case, the question of muscular localisation is of secondary interest.
The object in view in the act of scratching is relief from some such source of cutaneous irritation as a pimple, an abrasion, a burn, the bite of an insect, etc., and so long as the cause persists, the function is being rationally exercised; but to persevere mechanically, involuntarily, immoderately, in the absence of pruritus or of other paræsthesiæ, is a sign that the functional act is growing into a tic. Innumerable tics are thus developed, and they are intimately associated with biting tics.
S. passes his hand every instant over his forehead, O. over his eyes, T. over her lips, P. over his moustache, young J. over his budding whiskers, etc., etc. These elementary tics are scarcely more than stereotyped acts, and may maintain the semblance indefinitely, though there is also the likelihood of their becoming immeasurably more pronounced.
M. scratches his lips with his nails till they are bleeding; E. suffers from a facial tic, and scrapes at his forehead and temples to such an extent that his complexion is perpetually blooming with a crop of little bleeding excoriations; in some places, as a result of ceaseless rubbing and tapping, the skin is thickened and discoloured—a condition that might be known as "scratchers' corns." Madame W. used to tear at her toe nails with her fingers whenever she had retired for the night; and at the present time, as a result of incessantly passing a fine gold chain between the pulp of her fingers and the nails, she has succeeded in half detaching the latter from their bed.
A case reported by Raymond and Janet[100]is one of unusual severity.