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 (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]).