In a third instance we meet with many of the symptoms already noted among those who tic:
X. is a well-developed boy of fifteen, but there is something peculiar about his physiognomy which defies analysis. If his mother's statements can be trusted, he is intelligent, quick, witty, sound in judgment, and blessed with an excellent memory. From the very first he has been eccentric, timid, and hypersensitive, and is to-day as tender-hearted and affectionate to his people as ever. He has various little "manias" of his own; he must have a knife, fork, and spoon for himself, and cannot take his food in comfort if they have been set before some one else. Each morning he dresses himself with extreme deliberation, then comes down to breakfast, of which, however, he will not partake unless he has touched all the door handles on his way. This little matter has developed into an obsession. His loathing of cold water is so pronounced that his morning toilet is rather a stormy proceeding, and as he is too old to be washed by his mother, the inevitable result is that his face and hands are never clean. At school he is both attentive and docile, finding pleasure in his study of the classics, but evincing a perfect passion for German. Anything German is a source of ineffable joy, so much so that he hugs his dictionary with childish exuberance. He listens deferentially to his teachers, but takes no note of what he hears. In German, Greek, and Latin he is at the head of his class, whereas in history and mathematics he is at the foot.
The "nervous movements" for which he has been brought to the consulting-room consist of a series of gesticulations akin both to tic and to chorea. Some are much more frequent than others, meaningless gestures executed spontaneously, one might almost say unconsciously. As he walks to school with his books under his left arm, his right hand roams over his person; and in the class-room the movements are repeated. At table he rubs his back against the chair, and alternately flexes and extends his right leg. Apart from these "habit tics," he exhibits actual twitches of his muscles generally, and evidence of the consequent disturbance of his movements is furnished by a glance at his untidy bedroom, his disarranged books, his blotted papers, his slovenly clothes. When he goes out with his parents, he is never at their side, but lounges along in his own way, then suddenly hurries to regain his place by them, falling back again and occupying himself by crossing his legs, knocking his ankles together, shrugging his shoulders, grimacing, etc. All the movements can be arrested for a time by an effort of the will. At any one's behest he can maintain tranquillity for a minute, but the strain is too severe, and the muscular dance recommences sooner or later.
The movements are highly variable in type and degree, nor can the mother specify the date of their appearance. It is only during the last three years that her attention has been more particularly drawn to them, and their increasing gravity occasions her some anxiety. The boy has become the laughing-stock of his companions at school, hence he limits his stay there to the actual hours of his classes.
Three years later the choreic symptoms vanished. X. is to-day a stalwart youth, though still timid and eccentric. It is evident that in his case the variable chorea has been but an episode in adolescence, to be added to the numerous stigmata of degeneration enumerated above.
Notwithstanding its slow evolution (says Brissaud), the neurosis, in so far as it was a disorder of motility, seems to have completely disappeared. The importance of this for prognosis is fundamental, but from the point of view of diagnosis it is no less significant, seeing that the nature and form of the movements suggested chronic or Huntington's chorea.
A case described by Gilles de la Tourette[139] as disease of the tics seems really to have been one of variable chorea.
A woman of twenty-two, who had never been very strong, had an attack, at eight years, of involuntary movements of face and arms which prevented her feeding herself, and at the hospital a diagnosis of chorea was made. Two months later cessation of the movements allowed of her return to school, but a second attack followed after two years, and a third a year later. At the time of observation she was in the throes of her sixth relapse. Every one who had seen her considered the condition as chorea.
Tourette, however, was dissatisfied with the diagnosis. There was no suggestion of its being Sydenham's chorea, or hysterical chorea, still less of its belonging to Huntington's variety. According to the author, the muscular twitches were amorphous and indefinite, and characterised by extreme variability in form, expression, and intensity.
In our opinion the clinical picture is that of variable chorea, and we are confirmed in our opinion by a consideration of the patient's mental condition.