SPASMODIC TORTICOLLIS.—DIFFERENT FORMS OF 
SPASM AFFECTING THE MUSCLES OF 
THE NECK. 
A Clinical Lecture: Delivered at the Philadelphia Hospital, 
By Charles K. Mills, M.D., 
Neurologist to the Philadelphia Hospital; Professor oj Diseases of the Mind and 
Nervous System in the Philadelphia Polyclinic. Reprinted from the 
University Medical Magazine, 
February, 1890. 
SPASMODIC TORTICOLLIS.—DIFFERENT FORMS OF 
SPASM AFFECTING THE MUSCLES OF 
THE NECKj. 
A Clinical Lecture Delivered at the Philadelphia Hospital, 
By Charles K. Mills, M.D., 
Neurologist to the Philadelphia Hospital; Professor oj Diseases of the Mind and 
Nervous System in the Philadelphia Polyclinic. 
IyOCAiv spasmodic affections are of practical importance since many of them 
are curable though often difficult to cure ; and this morning the first case to 
which your attention will be called is one of the most interesting of these disor- 
ders—a form of spasm of the muscles supplied by the spinal accessory. Many 
examples of local spasmodic affections have come under my observation, 
among them, in addition to accessorius spasm, cases of spasm affecting 
the ocular muscles, the orbicular palpebrarum, and the superior auricular or 
attolens aurem ; general facial tic, masticatory or trigeminal spasm, and spasm 
of the splenius capitis. Besides these, I have, of course, seen many instances of 
local spasm in the limbs. Erb briefly describes several forms of spasm of indi- 
vidual muscles in the neck, including spasm of the obliquus capitis inferior, and 
of the deep muscles of the neck, besides those forms to which reference has just 
been made. 
Case I.—M. B., aged 24, in the Autumn of 1887, was thrown from a wagon, lighting on 
her head and back. She was much stunned, but was not unconscious, and walked home. 
From the time of this accident she often suffered severely with pain in the occipital region, 
more marked on the leftside ; but she had no other inconvenience from her injuries until 
April, 1888, when now and then her head began to be drawn downward to the left, and her 
face upward to the right. These attacks of spasm became more and more frequent and soon 
almost continuous. She has been treated with medicines and counter-irritants without any MILLS, SPASMODIC TORTICOLLIS. 
2 
marked improvement. The spasm is brought on by walking, excitement, or by pressure 
in the left occipital region. She has a spot of great tenderness about one inch to the left and 
a little above the occipital protuberance, and pressure here will bring on the spasm or 
increase its violence. 
With this history let us carefully examine our patient. Notice the position 
of her head. It is not always easy to decide upon the muscle or muscles 
affected in a spasm of this character. A paresis or paralysis of the muscles of 
one side may simulate spasm of the muscles of the other. It is of great impor- 
tance, because of the possibility of surgical interference, to decide what muscles 
and nerves are affected. The spasm here seems to be in the sterno-cleido-mas- 
toid and probably also the trapezius muscles of the left side, as shown by the posi- 
tion of the head and face, and in the swelling and hardness of these muscles when 
the spasm occurs. The left side of the head is pulled down and to the left, while 
the face is turned upward and to the right; probably, but not certainly, the 
trapezius takes part in the spasm. In a paper1 written by me some years since 
the effect of spinal accessory spasm is spoken of as follows :— 
“The direction given to the face and head is deserving of brief attention. The sterno- 
cleido-mastoid muscle, acting singly, draws the head toward the shoulder and clavicle of 
the same side, while the chin and face are carried toward the opposite side, away from the 
affected muscle. When both muscles act together the face and head are bent forward 
towards the breast. The bulky trapezius has several sets of fibres, which tend to produce 
movements in different directions. The upper fibres draw the shoulder upward and back- 
ward, the middle directly backward, and the lower backward and downward. When the 
trapezius is spasmodically affected, usually the head is pulled backward and toward the 
side attacked while the shoulder is raised and the scapula drawn inward. The lower fibres 
are vanquished by the others when all are acting by the same stimulus. It happens rarely 
that the middle and lower fasciculi are chiefly affected, in which case the scapula is rotated 
and fixed firmly. If the sterno-cleido-mastoid and trapezius muscles are attacked coinci- 
dently with spasm, the movements already described as belonging to each muscle are com- 
bined or alternate.” 
The head here is pulled somewhat backward toward the side affected while 
the face goes toward the other side. The case then is clearly one of spasm in 
the domain of the spinal accessory nerve. It is clonic, or perhaps rather an 
admixture of clonic and tonic spasm, the contraction sometimes persisting. 
All cases of torticollis are by no means of this character. It is important to 
study closely the muscles affected, in view of the fact that operations both mus- 
cular and neural are often resorted to in these cases. Spasm of the platysma, 
splenius and possibly other muscles of the neck may simulate spinal accessory 
spasm. 
Not long since, at the Polyclinic, a patient presented himself for treatment 
in whose case it was somewhat difficult to decide as to whether the spasm 
chiefly affected the right sterno-cleido-mastoid or the left splenius capitis. The 
chin did not turn upwards to the left as is the case in spasm of the right sterno- 
cleido mastoid, but rather outward. In spasm of the splenius capitis the chin 
is directed rather toward the corresponding side. Dr. John B. Roberts per- 
formed a partial myotomy of the left splenius capitis, subsequently keeping the 
head in position by a plaster of Paris bandage. Still later, no improvement re- 
Am. Jour. Med. Sci., October, 1877. MIRES, SPASMODIC TORTICOEEIS. 
3 
suiting, the splenius capitis was thoroughly divided, but the result was still 
unsatisfactory. The patient improved under the administration of gelsemium. 
A brief account of this case has been published by Dr. Charles B. Williams in 
the Medical News, November 16, 1889. The failure of operation in this case 
did not, however, prove that the splenius capitis was not the affected muscle, as 
such operations not infrequently fail, although the local diagnosis is correct. 
It might be well to give from Erb1 the diagnostic symptoms in spasm 
of the splenius capitis :— 
‘ ‘ In this affection the head is drawn backward towards the affected side, the chin 
is somewhat depressed and directed towards the corresponding shoulder, and at the spot 
where the splenius appears beneath the anterior border of the trapezius a hard roll can be 
felt. (The diagnosis of this form of spasm of the trapezius is founded on the fact that in this 
last the head is rotated toward the opposite side. In spasm of the sterno-cleido-mastoid 
the chin is raised and rotated toward the opposite side, while the mastoid process is drawn 
forward and downward.) This spasm is for the most part of a tonic character (with remis- 
sions and occasional spasmodic contractions (Erb), or appears in the form of a permanent 
contracture (Duchenne).” 
The swelling of the muscle spoken of above could be felt in the case 
treated by Dr. Roberts and myself. In spasm of the obliquus capitis inferior, 
according to the same authority : 
“Since the action of this muscle when in a state of spasm causes horizontal rotation 
of the head, the head is either rotated intermittently (tic rotatoire), or (where the spasm is 
tonic in character) persistently around its vertical axis, without any elevation of the chin 
or depression of the mastoid process. Clonic spasms of this muscle are a very burdensome 
evil, the patient being obliged to fix the head or to replace it in its natural position with the 
hands if he wishes to look at a fixed object or to speak. He may also be observed to cor- 
rect the oblique position of the head with the hand when walking.” 
A neurasthenic patient, for many months under my care, whenever much 
excited or depressed was liable to violent attacks of tic rotatoire. Her head 
would be rotated horizontally with great rapidity and force, the spasm some- 
times being simply this form of motion, and at others accompanied by a rapid 
spasmodic crossing of the arms, and occasionally by movements of the legs and 
body. I have known this distressing rotatory spasm to be kept up for three 
hours. During the attack the patient remained clear-headed, and, considering 
the violence of the movement, comparatively placid. Sometimes the spasm 
could be stopped or abated by forcibly holding the head ; at other times this 
procedure would lead to greater violence of action in the trunk and limbs. The 
patient would sometimes converse during the continuance of the spasm, the 
rotation diminishing a little while she was talking. Strong mental impressions 
were very effective both in inducing and stopping the spasm. When it had once 
occurred it had a tendency to recur about the same time the following day ; and 
this could often be prevented by giving a nerve tonic or other medicine, with a 
positive assertion that it would prevent the attack. Cases of this kind, however, 
due to general nervous impression, are very different from the form of per- 
sistent local spasm in our patient. A local irritative lesion of some kind is 
Ziemssen’s Practice of Medicine, Vol. ix, p. 329. MITTS, SPASMODIC TORTICOTTIS. 
4 
doubtless here present, and must be remedied or removed before we can hope 
for an abatement or cure of the affection. 
Spasm in the domain of the spinal accessory nerve may be due to at least 
half a dozen differently situated irritative lesions, namely : (i) A lesion in the 
spinal cord anywhere above the fifth or sixth cervical segment; (2) An intra- 
spinal but extra-medullary lesion—of membranes, bone or nerves—in the upper 
portion of the vertebral canal ; (3) A lesion of the oblongata or floor of the 
fourth ventricle ; (4) A lesion of the main trunk of the accessory nerve as it 
passes downward to the sterno-cleido-mastoid and trapezius muscles ; (5) A 
lesion of any of the nerves which anastomose with the spinal accessory and are 
closely connected with it in the spinal cord ; (6) A lesion of the cortical centres 
which preside over lateral deviation of the head. 
I cannot go into an elaborate discussion of the position of the lesion in 
this case, but dismissing with a few words the consideration of its possible posi- 
tions, I will direct attention briefly to what seems to be the most reasonable 
assumption. It is not at all probable that we have either an intra-spinal or 
pons-oblongata lesion. Associated symptoms of such an affection are absent ; 
such, for example, as an involvement of the nerves and muscles of the upper 
limbs, respiratory and cardiac phenomena, etc. 
It is well known that the physiologists have defined areas in the brain 
cortex which are known to preside over movements of the head. Ferrier, 
Beevor and Horsley, and Horsley and Schafer particularly, have studied these 
centres. According to Beevor and Horsley the head moves in one of the fol- 
lowing modes or in combinations of the same : (a) Simple horizontal rotation 
to the opposite side. (£) Rotation with elevation of the muscle, (y) Rotation 
with abduction of head to the (opposite) shoulder. These observers also found 
that although movements of the head and eyes are usually simultaneous, that 
this is not always the case, and that by irritation of certain isolated cortical 
areas movements of the head alone could be produced. It follows that from 
cortical irritation we may have a monospasm in the form of involuntary move- 
ments of the head either with or without simultaneous action of the eyes. The 
traumatism may have caused the rupture of intra-cranial vessels at any position 
within the skull, scattered small hemorrhages being of somewhat frequent occur- 
rence in violent concussion of the head without fracture. In this patient, how- 
ever, we have positively no symptoms or indications of a lesion of the brain 
cortex unless it is the spasm. Most forms of cortical monospasm—of Jacksonian 
epilepsy, in other words—occur as occasional, although it may be frequently 
repeated, attacks of local spasm, in which, while the spasm usually begins with 
a signal symptom in one part, it just as commonly radiates until a number of 
muscles are involved in a serial order. The phenomena in this case are not 
those of a cortical epilepsy with this signal or initiatory symptom and succes- 
sion of spasmodic movements, due, when present, to the radiation of the irrita- 
tive impression from the seat of lesion to neighboring districts of gray matter 
in the brain rind. We have here a persistent, or, at least, a persistently recur- 
ring spasm always strictly confined to the same muscles. The view of cortical 
irritation must not, however, be overlooked in these cases, and in time we will MITTS, SPASMODIC TORTICOTTIS. 
5 
probably obtain exact points for the differential diagnosis of lesions situated in 
the half-dozen different places to which I have referred. 
It is highly probable that the spasm in this case is due either to direct 
lesion of the accessory nerve, or to reflex irritation from some anastomosing 
sensory nerve. 
A view of the causation of this spasm has suggested itself to me, one 
which may give the clue to its proper explanation and treatment. This is, that 
the spasm is reflex and in this particular case due to injury and subsequent 
inflammation of either the major or minor occipital nerve. If this be a correct 
supposition, then treatment, whether counter-irritative or operative, should be 
directed to the nerves which are the source or focus of irritation rather than the 
motor nerves which transmit this irritation to the muscles affected by the spasm. 
Both the occipitalis major and minor have close connections with the spinal 
accessory nerve, and are also topographically in close relation, the former with 
the trapezius and the latter with the sterno-cleido-mastoid muscles. Both the 
sterno-cleido-mastoid and the trapezius muscles have their main nerve supply 
from the second and third cervical segments. The occipitalis major nerve is the 
internal branch of the posterior division of the second cervical nerve; and the 
occipitalis minor also arises from the second cervical nerve. The occipitalis 
major nerve pierces both the complexus and trapezius muscles near their cranial 
attachments. The occipitalis minor in its course curves around the posterior 
border of the sterno-mastoid, and then ascends along the posterior border of 
that muscle for some distance. Both of these nerves are, therefore, closely con- 
nected both inside and outside of the spinal canal with the nerve supply to the 
sterno-cleido-mastoid and trapezius, and, as well as having some direct anatomi- 
cal relations with the muscles themselves, possibly supply them with some fila- 
ments. The motor nerve supply from the occipital nerves is also such as to show 
how their irritation might give rise directly or by anastomosis to varying spas- 
modic phenomena. The posterior division of the second cervical nerve, from 
which the major occipital originates, supplies the inferior oblique muscle ; and 
the external branch of the major occipital joined by the external branch of the 
posterior division of the third cervical nerve, supplies the complexus, splenius 
and trachelo-mastoid muscles. 
The spinal portion of the accessorius nerve, after giving several branches 
to the sterno-mastoid during its passage through this muscle, joins in its sub- 
stance with branches from the second cervical, which also supply this muscle. 
“ Beneath the trapezius it joins with the third and fourth cervical nerve to form a sort 
of plexus, from which fibres are distributed to the muscle, and in the occipital triangle 
between the two muscles it j oins with the second and third cervical nerves and assists in the 
formation of the cervical plexus.” (Gray). 
The great occipital nerve supplies the skin corresponding with the upper 
part of the occipital bone and adjoining part of the scalp. The small occipital 
supplies the skin behind the ear, and this area is directed in a pointed shape 
towards the crown of the head. 
The history is that our patient was thrown from a wagon and landed on 
her head and back, after which accident her trouble began. It is clearly, then 6 
MIIyLS, SPASMODIC TORTICODDIS. 
of traumatic origin. As we examine by pressure the back of her head we cause 
no pain in the mastoid region, nor in the back of the neck, but pain is elicited 
by pressure at a point already mentioned to the left and above the occipital pro- 
tuberance, the spasm being at once precipitated by this procedure. By exam- 
ining an atlas of the cutaneous nerve supply, as, for instance, that of Heiberg, 
it will be seen that the place of greatest tenderness in this patient is in the area 
of distribution of the occipitalis major nerve, or about the border line between 
the occipitalis major and minor districts. It is likely that we have here some 
local inflammatory trouble involving the sensory nerves, whatever other tissues 
may be included in the disease. This being the case, it will be easily compre- 
hended what an intense source of reflex irritation such a lesion may be. One of 
the main objects of treatment should be to subdue this local inflammation. 
In all probability this patient can be cured, but the task is by no means 
easy. It will require great perseverance both on her part and that of the phy- 
sician, at least such has been my experience in other cases. Operation has been 
frequently resorted to for such cases and most frequently without success. In 
October, 1888, Dr. F. X. Dercum reported three cases of spinal accessory spasm 
unsuccessfully treated by excision of the nerve, and at the same Fine I 
reported another unsuccessful case. The accessory nerve has been cut, resected 
and stretched by many surgeons, occasionally with success but more often with 
failure. The muscles affected have sometimes been severed, but again most 
frequently without success. In fact this patient had her sterno-cleido-mastoid 
muscle cut some months since without any relief. The operation that would 
seem to offer the most hope of success in this case, if surgical procedure is 
resorted to at all, would be excision of the portions of the occipitalis major or 
minor nerves, which are apparently diseased, and if the course of treatment on 
which she is now placed does not succeed this operation will be performed. 
Treatment by electricity offers some hope, but is not commonly successful. The 
best method is the direct application of a moderately strong galvanic current to 
the nerve supplying the muscles affected by the spasm ; by preference, the anode 
or positive pole over the nerve, and the cathode to some indifferent part. The 
best text books on electro-therapeutics and nervous diseases, however, contain 
directions as to the various methods of using electricity. Massage and gym- 
nastic treatment have been highly lauded. 
The patient seems to be improving, although she is far from well, 
on the following course of treatment: Internally she is taking the fluid extract 
of gelsemium. The treatment was begun by the administration of five drops 
three times daily, increasing the dose one drop daily, until now she is taking 18 
drops three times a day, and is just beginning to experience physiological 
effects from the drug. Gelsemium of the shops is an uncertain preparation, but 
the drug is an efficacious anti-spasmodic if the particular specimen used is 
reliable. Iodide of potassium, grains 10, and bichloride of mercury, grain 1-32, 
and the compound sumbul pill have also been given. This pill, which contains 
arsenious acid, sulphate of iron, asafcetida, and extract of sumbul, is a powerful 
nervine and general tonic. Three times a week the actual cautery has been 
used, the burns being made by a small olive-shaped cauterizer, heated to MILLS, SPASMODIC TORTICOLLIS. 
7 
whiteness, and applied to the back of the neck and the left occipital region. 
Small superficial burns are to be preferred and have been used. The actual 
cautery is one of the most successful forms of treatment for this and 
similar forms of local spasm. It probably acts in a two-fold manner—as a pow- 
erful counter-irritant, and as an equally powerful counter-reflex. The salicy- 
lates interna1 ly. and hypodeimic injections of morphia and atropia locally, are 
also valuable therapeutic measures.