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.