Tics and Their Treatment

Among personal antecedents may be noted hysterical attacks (Sgobbo), emotional unrest (de Buck80), migraine (Brissaud), neuralgia (Bompaire), irritability, eccentricity, caprice, absentmindedness, neurasthenia (Brissaud and Meige81). 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 reported by 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's82 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 of tonic 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 variety ab 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 (Souques83).

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 Meige84).

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 Janet85).

5. In order to deceive his friends, the patient assumed a forced attitude 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 Janet86).

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 (Sgobbo87).

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 (Feindel88).

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 the course 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 Brissaud90 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.

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 seat of 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 commonly affected 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 of retrocollis, as in a case recorded by Brissaud, or procollis, 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 instructive case 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.

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 synchronous and 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.

The spasmodic movements sometimes spread to the shoulder, arm, and trunk, and, in one of our cases, to the leg. 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 Guillain97:

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.