(3) Those arising from corporeal causes (chorea naturalis). This last case, according to a strange notion of his own he explained by maintaining that in certain vessels which are susceptible of an internal pruriency, and thence produced laughter, the blood is set into commotion in consequence of an alteration in the vital spirits, whereby are occasioned involuntary fits of intoxicating joy, and a propensity to dance. The great physician Sydenham gave the first accurate description of what is to-day called chorea, and hence the disease has been named "Sydenham's chorea." So true to life was his portrayal of the disease that it has never been surpassed by modern observers.
The disease variously named palmus, the jumpers, the twitchers, lata, miryachit, or, as it is sometimes called, the emeryaki of Siberia, and the tic-convulsif of La Tourette, has been very well described by Gray who says that the French authors had their attention directed to the subject by the descriptions of two American authors—those of Beard upon "The Jumpers of Maine," published in 1880, and that of Hammond upon "Miryachit," a similar disease of the far Orient. Beard found that the jumpers of Maine did unhesitatingly whatever they were told to do. Thus, one who was sitting in a chair was told to throw a knife that he had in his hand, and he obeyed so quickly that the weapon stuck in a house opposite; at the same time he repeated the command given him, with a cry of alarm not unlike that of hysteria or epilepsy. When he was suddenly clapped upon the shoulder he threw away his pipe, which he had been filling with tobacco. The first parts of Virgil's aeneid and Homer's Iliad were recited to one of these illiterate jumpers, and he repeated the words as they came to him in a sharp voice, at the same time jumping or throwing whatever he had in his hand, or raising his shoulder, or making some other violent motion. It is related by O'Brien, an Irishman serving on an English naval vessel, that an elderly and respectable Malay woman, with whom he was conversing in an entirely unsuspecting manner, suddenly began to undress herself, and showed a most ominous and determined intention of stripping herself completely, and all because a by-standing friend had suddenly taken off his coat; at the same time she manifested the most violent anger at what she deemed this outrage to her sex, calling the astonished friend an abandoned hog, and begging O'Brien to kill him. O'Brien, furthermore, tells of a cook who was carrying his child in his arms over the bridge of a river, while at the same time a sailor carried a log of wood in like manner; the sailor threw his log of wood on an awning, amusing himself by causing it to roll over the cloth, and finally letting it fall to the bridge; the cook repeated every motion with his little boy, and killed him on the spot. This miryachit was observed in Malaysia, Bengal, among the Sikhs and the Nubians, and in Siberia, whilst Beard has observed it in Michigan as well as in Maine. Crichton speaks of a leaping ague in Angusshire, Scotland.
Gray has seen only one case of acute palmus, and records it as follows: "It was in a boy of six, whose heredity, so far as I could ascertain from the statements of his mother, was not neurotic. He had had trouble some six months before coming to me. He had been labeled with a number of interesting diagnoses, such as chorea, epilepsy, myotonia, hysteria, and neurasthenia. His palmodic movements were very curious. When standing near a table looking at something, the chin would suddenly come down with a thump that would leave a black-and-blue mark, or his head would be thrown violently to one side, perhaps coming in contact with some adjacent hard object with equal force, or, while standing quietly, his legs would give a sudden twitch, and he would be thrown violently to the ground, and this even happened several times when he was seated on the edge of a stool. The child was under my care for two weeks, and, probably because of an intercurrent attack of diarrhea, grew steadily worse during that time, in spite of the full doses of arsenic which were administered to him. He was literally covered with bruises from the sudden and violent contacts with articles of furniture, the floor, and the walls. At last, in despair at his condition, I ordered him to be undressed and put to bed, and steadily pushed the Fowler's solution of arsenic until he was taking ten drops three times a day, when, to my great surprise, he began to improve rapidly, and at the end of six weeks was perfectly well. Keeping him under observation for two weeks longer I finally sent him to his home in the West, and am informed that he has since remained perfectly well. It has seemed to me that many of the cases recorded as paramyoclonus multiples have been really acute palmus."
Gray mentions two cases of general palmus with pseudomelancholia, and describes them in the following words:—
"The muscular movements are of the usual sudden, shock-like type, and of the same extent as in what I have ventured to call the general form. With them, however, there is associated a curious pseudomelancholia, consisting of certain fixed melancholy suspicious delusions, without, however, any of the suicidal tendencies and abnormal sensations up and down the back of the head, neck, or spine, or the sleeplessness, which are characteristic of most cases of true melancholia. In both of my cases the palmus had existed for a long period, the exact limits of which, however, I could not determine, because the patient scouted the idea that he had had any trouble of the kind, but which the testimony of friends and relatives seemed to vouch for. They were both men, one thirty-six and one thirty-eight years of age. The pseudomelancholia, however, had only existed in one case for about a year, and in the other for six months. One case passed away from my observation, and I know nothing of its further course. The other case recovered in nine months' treatment, and during the three years that have since elapsed he has been an active business man, although I have not seen him myself during that period, as he took a great dislike to me because I was forced to take strong measures to keep him under treatment, so persistent were his suspicions."
Athetosis was first described by Hammond in 1871, who gave it the name because it was mainly characterized by an inability to retain the fingers and toes in any position in which they might be planed, as well as by their continuous motion. According to Drewry "athetosis is a cerebral affection, presenting a combination of symptoms characterized chiefly by a more or less constant mobility of the extremities and an inability to retain them in any fixed position. These morbid, grotesque, involuntary movements are slow and wavy, somewhat regular and rigid, are not jerky, spasmodic, nor tremulous. The movements of the digits are quite different from those attending any other disease, impossible to imitate even by the most skilful malingerer, and, if once seen, are not likely to be forgotten. In an athetoid hand, says Starr, the interossei and lumbricales, which flex the metacarpo-phalangeal and extend the phalangeal joints, are affected; rarely are the long extensors and the long flexors affected. Therefore the hand is usually in the so-called interosseal position, with flexion of the proximal and extension of the middle and distal phalanges. The athetoid movements of the toes correspond to those of the fingers in point of action. In a great majority of cases the disease is confined to one side (hemiathetosis), and is a sequel of hemiplegia. The differential diagnosis of athetosis is generally easily made. The only nervous affections with which it could possibly be confounded are chorea and paralysis agitans. Attention to the twitching, spasmodic, fibrillary movements, having a quick beginning and a quick ending, which is characteristic in Sydenham's chorea, would at once exclude that disease. These jerky movements peculiar to St. Vitus's dance may be easily detected in a few or many muscles, if moderate care and patience be exercised on the part of the examiner. This form of chorea is almost always a disease of childhood. So-called post-hemiplegic chorea is, in the opinion of both Hammond and Gray, simply athetosis. The silly, dancing, posturing, wiry movements, and the facial distortion observed in Huntington's chorea would hardly be mistaken by a careful observer for athetosis. The two diseases, however, are somewhat alike. Paralysis agitans (shaking palsy), with its coarse tremor, peculiar facies, immobility, shuffling gait, the 'bread-crumbling' attitude of the fingers, and deliberate speech, would be readily eliminated even by a novice. It is, too, a disease of advanced life, usually. Charcot, Gray, Ringer, Bernhardt, Shaw, Eulenberg, Grassel; Kinnicutt, Sinkler, and others have written on this affection."
The following is the report of a case by Drewry, of double (or, more strictly speaking, quadruple) athetosis, associated with epilepsy and insanity: "The patient was a negro woman, twenty-six years old when she was admitted into this, the Central State (Va.) Hospital, in April, 1886. She had had epilepsy of the grand mal type for a number of years, was the mother of one child, and earned her living as a domestic. A careful physical examination revealed nothing of importance as an etiologic factor. Following in the footsteps of many of those unfortunates afflicted with epilepsy, she degenerated into a state of almost absolute imbecility.
"Some degree of mental deficiency seems usually to accompany athetosis, even when uncomplicated by any other degenerating neurosis. Athetoid symptoms of an aggravated character, involving both upper and both lower extremities, had developed previous to her admission into this hospital, but it was impossible to find out when and how they began. She had never had, to the knowledge of her friends, an attack of 'apoplexy,' nor of paralysis. The head was symmetric, and without scars thereon. The pedal extremities involuntarily assumed various distorted positions and were constantly in motion. The toes were usually in a state of tonic spasm,—contracted, and drawn downward or extended, pointing upward, and slightly separated. Irregular alternate extension and flexion of the toes were marked. The feet were moved upon the ankles in a stiff and awkward manner. During these 'complex involuntary movements,' the muscles of the calf became hard and rigid. The act of walking was accomplished with considerable difficulty, on account of contractures, and because the feet were not exactly under the control of the will. The unnatural movements of the hands corresponded to those of the lower extremities, though they were more constant and active. The fingers, including the thumbs, were usually widely separated and extended, though they were sometimes slightly flexed. The hands were continually in slow, methodic, quasi-rhythmic motion, never remaining long in the same attitude. In grasping an object the palm of the hand was used, it being difficult to approximate the digits. The wrist-joints were also implicated, there being alternate flexion and extension. In fact these odd contortions affected the entire limb from the shoulder to the digital extremities. When standing or walking the arms were held out horizontally, as if to maintain the equilibrium of the body. The patient's general physical health was fairly good. She frequently complained of headache, and when she was exceedingly irritable and violent all the athetoid movements would be intensified. Speech was jerky and disordered, which gave it a distinctive character. The special senses seemed to be unimpaired, and the pupils were normal, except when an epileptic attack came on. Death occurred in January, 1895, after an obstinate attack of status epilepticus." Paramyoclonus multiplex is a condition of chronic muscular spasm affecting the trunk, occasionally the muscles of the face, abdomen, or diaphragm. The muscles affected are usually in the trunk and in the limbs, and not in the toes and hand; occasionally the movements are tonic as well as clonic; the degree of spasm varies greatly, and according to Gray may sometimes be so violent as to throw the patient down or out of the chair.
Saltatoric spasm is an extremely rare condition, first observed by Bamberger in 1859. The calf, hip, knee, and back-muscles are affected by clonic spasm, causing springing or jumping movements when the patient attempts to stand. The disease is transient, and there are no mental symptoms.
Progressive muscular atrophy has been observed as far back as Hippocrates, but it is only in recent times that we have had any definite knowledge of the subject. It is divided into four types, the hand type (causing the griffin-or claw-hand, or the ape-hand); the juvenile type (generally in the muscles of the shoulder and arm); the facial type; and the peroneal type. Generalized progressive atrophy leads to a condition that simulates the appearance of a "living skeleton."