CONGENITAL TORTICOLLIS Torticollis does not occupy a uniform position among the deformi ties. The larger portion are undoubtedly congenital, but there are a number of eases in which it is only a secondary or part manifestation of other affections.
Nevertheless it may be discussed here from a uniform point of view, considering that the pathological anatomy, symptomatolog,y, and treat ment are the same in all cases.
Etiology.—Heredity, which I have observed in a case of mother and son, and the frequent simultaneous occurrence of other anomalies, such as dislocation of the hip, deformities of the shoulder-blade, or hare lip, point to the probability of incomplete or abnormal development in many cases. At the same time, numerous observations favor the assumption of a considerable influence being exercised by mechanical intra-uterine and inflammatory processes and adhesions (Petersen, Volker).
On the other hand, the traumatic explanation of a tear in the st onto cleidomast oid muscle during delivery is supported by many observations. Animal experiments throw no light upon the matter, since the head of animals develops under different static conditions. Von Mikuliez and Nader attribute the development of torticollis to t he interstitial chronic myositis which has followed the trauma and which leads to cicatricial change in the muscle.
Again, other cases are positively known where no torticollis devel oped from a distinctly palpable hTmatoma caused by forceps delivery (personal observation).
The transfer of micro-organisms by the blood has been held respon sible for the infection, but this has never been demonstrated. "forti coins has also been noticed to develop at later age following the injury of a muscle (Bouvier, V. EISPISberg, v. BillrOt 11).
It would appear, therefore, that the coincidence of various factors is necessary to occasion the cicatricial degeneration of the muscle. The location of the lesion, pressure on the nutrient artery, and injury to the nerves are in all probability factors in the case.
Torticollis occurring after birth may likewise be of widely different origin.
As a matter of course, in later life other injuries to the bony and muscular parts of the neck may cause the characteristic attitude of the head. Ifigh-seated deformity of the vertebral column, unilateral tuber culous foci of the cervical vertebra., infectious or suppurating processes
in the vicinity of the vertebral column or of the sternocleidoinastoid muscle, otitis with glandular swelling, may from the position of the head due to the pain cause a subsequent cicatricial fixation and lead to torti collis. Thus, occipital periostitis, suppuration of glands by the side of or underneath the sternocleidomastoid may cause this deformity. I have observed a case of "pediculus in which the torticollis that had existed for six months immediately disappeared with h the removal of the "exciting factor." Rheumatic processes as well a spastic affec tions of the sternocleidomastoid on a neurogenic basis may likewise lead to the same clinical symptoms.
The symptoms can be explained anatomically by the unilateral shortening of the sternocleidomastoid and by analysis of its function. Any further changes have resulted secondarily by adaptation to the changed conditions of growth.
The head is rotated toward the sound side and deflected toward the affected one. In this position it is fixed in so far as an increase of deflection and torsion is possible, but a decrease of the same is not likely (Figs. 21a, 21b, 21c).
These two cardinal symptoms may differ in intensity according to which portion of the muscle is shorter, the sternal (torsion) or the clavic ular (flexion).
The head appears deflected toward the sound side owing to the contiguous lateral scoliosis of the cervical vertebra, while the unilateral traction produces a facial asymmetry. According to the investigations of Witzel, Milo, and Barn, all the cranial bones participate in the scolio sis, the cause of which is supposed to be the unilateral traction as well as the disturbance of the muscular balance. No doubt we have here to deal with an adaptation of growth conditions to change static founda tions. In facial scoliosis the eves and ears are not in a horizontal line and the position of nose and mouth is oblique. The resulting lateral curvature of the vertebral column leads to further compensatory scolio sis of the vertebral column, conformably to the natural requirements of its structure and function tFig. 2.1f b).