Torticollis, or Caput obstipum (the permanent crooked position of the head, which consists of bending of the head to one side, rotation to the opposite side, with the chin raised and the back of the head lowered, corresponding to the action of the sterno-cleidomastoid muscle of one side), occurs in two essentially different forms from the point of view of medical gymnastics and massage. In one form, which is generally found as truly congenital or acquired during birth, the head is somewhat fixed in the above faulty position, with the power of only slight movement from its faulty resting position. The latter depends in most cases on changes in the muscles, which are by degrees associated with corresponding shrinkings and tightenings of ligaments as well as changes in shape of cartilage and bone, as is always the case with deformities produced by changes in muscles.

The muscular change consists of a permanent shortening of the sterno-cleido-mastoid muscle of one side; this may have arisen during foetal life owing to faulty position of the foetus as a so-called intra-uterine deformity due to gravity, in which case the ligaments and bony parts will have undergone corresponding changes of shape during the growth of the foetus, or during birth by rupture or other severe injury, with consequent shrinking of the sterno-cleido-mastoid muscle of one side. This explanation of torticollis, which was formerly accepted, cannot be so often valid as was generally stated; on the contrary, this mode of origin must be uncommon, as everyday experience teaches us that a ruptured muscle in healing becomes longer, not shorter. A similar faulty position of the head may also arise as necessary compensation to a severe scoliosis, or as a habit deformity in people with strabismus, who can only avoid troublesome double images by some such position of the head. A similar position arises as a paralytic deformity in unilateral paralysis of neck muscles. Further, this deformity may arise by contracture of other soft parts, as of scar tissue after burns or other severe injuries.

The other form of torticollis is that most often met with in adult patients, the spasmodic form, caused by clonic cramp in the sterno-cleido-mastoid muscle of one or sometimes both sides, generally combined with cramp in the upper part of trapezius and other muscles supplied by the upper cervical nerve roots.

The indications for treatment are essentially different in these different forms. In that form commonly met with in children, the ordinary torticollis, the faulty position must be corrected, which cannot generally be done without operation under an anaesthetic. The shortened sterno-mastoid may be divided, or partly or wholly removed along with other soft parts. In certain cases, especially when the patient is treated quite early, it should be possible to restore the head to its normal position by manual correction alone with suitable bandages; this, however, seldom or never takes place in practice, so that medical gymnastic treatment as a rule is not begun till the surgical treatment is ended. After correction or a certain degree of over-correction has been obtained by means of one or other operation a fixation apparatus is applied. If this can be easily taken off the medical gymnastic treatment is begun a few days after the operation, in other cases, three or four weeks after the operation, as soon as the apparatus is removed. The treatment consists of correcting movements towards the side opposite to that of the original faulty position, and of exercising the sterno-cleido-mastoid of the opposite side. One-sided head movements are therefore given, and, after the action of the sterno-cleido-mastoid of the healthy side has been developed to its greatest extent, symmetrical movements are practised, till the head movements have become in all respects as normal as possible. This methodical exercise of the healthy, unshortened, and pathologically unchanged muscle is a very important factor, and this naturally holds good not only for the treatment of torticollis, but of all muscle contractures. It may therefore be well to speak here in greater detail of this condition. One might suppose that when the action of a contracted muscle and hence the hindrance to the working of its antagonists have been removed, these muscles would at once begin to exert their effect on the joint concerned, and the patient would himself by degrees exercise the power of performing the corresponding movements, hitherto impossible owing to the contracture. Medical gymnastic treatment ought therefore to be unnecessary. This, however, is by no means the case, since the antagonists of a contracted muscle also undergo changes. On the one hand they atrophy owing to disuse, and this atrophy may be so great that the effect of contraction of the muscle is almost nil; on the other hand, the patient has by degrees lost the habit of voluntary impulses, having found for a long time that they did not produce the desired effect, and has thereby lost what might be called the functional connection between the will and the function of the muscle in question. The working power of such muscles, which has thus been lost or reduced to a minimum, is more surely and quickly restored by means of methodical exercise than without it. Further, one must lay great stress on a specially important factor, which is that normal mobility is not easily restored after correction of a contracture. The permanent faulty position due to shortening of muscle often oversteps the limit of flexion used in ordinary movement, and for this reason the antagonists are often considerably lengthened. Since in general a muscle in contraction cannot shorten more than a certain proportion of its length, the fact must also be considered that, even if a lengthened muscle contracts, its effect on the corresponding portion of the skeleton is unsatisfactory. With continued exercise a muscle should by degrees recover a medium length, and possibly also the power to contract to a greater proportion of its total length than formerly. The medical gymnastic exercise of muscles after correction of a contracture is therefore a very important part of treatment, without which the latter seldom leads to the desired result. In connection with this question it must be added that sometimes even the most energetic gymnastics fail to restore the muscles to effective function. The orthopaedist must then have recourse to extreme operative measures, such as shortening of muscle or tendon, as preparatory operations to treatment by exercise. Thus, in severe cases of torticollis, by a preliminary shortening of the lengthened muscle of the healthy side satisfactory function has been restored to it, without which the result of a torticollis treatment cannot be satisfactory. We may state the following as a quite general rule : Exercise by gymnastics must be used as after-treatment in every case in which one has by orthopaedic operation, cutting or otherwise, changed the position of contracture of a joint, however caused. As orthopaedic interference is generally of this kind, one can easily understand how indispensable medical gymnastic treatment really is in this special branch of medicine.

Concerning the special technique of the after-treatment of this form of torticollis one need not speak here; every medical gymnast, who understands the indication for treatment in each special case, easily finds the movements that are necessary; the technique of medical gymnastics is, moreover, dealt with elsewhere in this book. Neither can it be necessary in what follows to mention in each case the great importance of massage for the stretching of contracted soft parts, restoration of healthy circulation, removal of exudations and haemorrhages into the tissues which are often to be found after orthopaedic treatment, etc. These are matters involved in the general use and importance of massage, and are discussed in detail in another part of the book. Although somewhat outside the subject, one may here mention that in the after-treatment in question faradisation of the muscles is often used along with treatment by gymnastic exercises. The value of this simple remedy is again receiving recognition, after a period of neglect due to reaction against the reckless over-estimation of the value of electricity, which followed its introduction into therapeutics.

The other chief variety of torticollis, the clonic, spastic form, or, as it is often called, "accessorius cramp," which is generally met with in adults, is an affection much harder to cure. As in the case of many other forms of clonic cramp, the varied operative treatment which has been proposed and made use of in these cases, from simple division of single muscles, tendons, and nerves to the more extensive resection of whole muscles, nerves and nerve plexuses, has been on the whole very unsatisfactory, and in too many cases devoid of result. Severe cases of clonic torticollis have rightly been reckoned amongst the most hopeless pathological conditions. Since they may also be reckoned among the affections most painful and depressing to patients, and frequently compel recourse to serious operations which are not without risk, one welcomes all the more gladly the experience in recent times of the use of gymnastics alone in this affection. Even in very severe cases good results have been obtained by such treatment, and it is at the present time ordered even by surgeons.

The medical gymnastic treatment, which in these cases plays a somewhat large part, is purely treatment by exercise, and does not consist of mechanical methods applied to peripheral parts, but more, as in educational gymnastics, of methodical, central, i.e., voluntary exercises. Since it is a fact that operative methods, which have by degrees been carried higher and higher up the motor path towards the centre, but never reach higher than the cervical roots, have often proved to be failures, and since it is also a well-known fact that these cramps are generally influenced to a great extent by psychical causes, one has every reason to assume that the cause of these cramps is to be sought in the psychic centres. The medical gymnastic treatment of this condition starts with the assumption that exercise of the centres is the aim in view. The technique of the treatment is therefore in some ways that of educational gymnastics. The patient must under direction and supervision practise control of the jerking movements, and also practise fully controlled and co-ordinated symmetrical movements. If the affection has been of long duration and has already produced a certain degree of permanent faulty position, corrective movements are of course suitable; they must, however, be performed with great caution, since experience shows that they may greatly increase the painful jerkings; for a similar reason resistance is not given, or at least very little, in the performance of exercises. In regard to the technique, it is worth remembering that in these cases, as in all other therapeutic exercises for cramps, ataxy and the like, it is very useful to let the patient practise before a looking-glass. By studying his movements in a looking-glass the patient often learns much more quickly to control them, i.e., to repress the involuntary and to perform the voluntary muscular contractions, than by ordinary gymnastic exercises done to command. It is stated - and quite recently the statement has come from a distinguished surgical source (Professor John Berg amongst others) - that by such a procedure good results have sometimes been obtained even in very severe cases, and that the result has often been obtained wonderfully quickly.