Another case recently brought before the Neurological Society of Paris by Marie and Guillain[175] serves even better to illustrate the intricacies of diagnosis.
The patient was a man of fifty-eight, who for years had exhibited certain movements apparently of an athetoid nature. His head was extended and rotated to the right synchronously with elevation and eversion of the left shoulder, then it passed into flexion. Except for a few odd movements of the tongue, the face conserved immobility. In the arms the localisation of the contractions was mostly proximal, though there were alternating flexion and extension movements of the fingers which suggested athetosis. Flexion, inversion, and adduction of the thighs also occurred. The recti abdominis were similarly involved.
Under the influence of emotion the movements were increased, but they could not be inhibited by an effort of attention. Their rate was too slow for chorea. Ordinary voluntary movements were performed without apparent trouble; the patient was able to dress himself, and to drink without spilling the liquid. Diminution of the knee-jerks was noticed, with what seemed to be an extensor response. Slight scoliosis of the vertebral column and a misshapen right foot recalled Friedreich's ataxia. There was nothing to justify a diagnosis of hysteria.
This curious condition dated from the year 1874, when the patient had a febrile attack, in the course of which pain and tingling appeared in the toes of the right foot, followed by involuntary movements of the same member. Analogous symptoms were not long in appearing in the left arm. Two months later the condition had become general, but from that time no special modification took place.
In the subsequent discussion it was remarked by Souques that the case resembled one recorded by Chauffard[176] as Friedreich's disease with athetotic attitudes, where the patient was a child with club foot, diminution of the knee-jerks, and generalised athetotic movements.
Notwithstanding our inability to assign a definite nosographical position to examples of this kind, we think it desirable to make some reference to them, in the hope that further observations will aid in their diagnosis. They at least remind us that convulsions occurring in the course of organic disease may be simulated by the manifestations of certain motor neuroses.
TICS AND CHOREAS
A. Sydenham's Chorea
It would be difficult to find a better description of chorea minor than that given originally by Sydenham himself:
The dance of Saint Guy, chorea Sancti Viti in Latin, is a sort of convulsion whose incidence is greatest, in both sexes, between the age of ten and puberty. Its onset is characterised by weakness of one limb, which the patient drags behind him, and soon the arm of the same side is affected in the same way. He finds it impossible to maintain the same position of the arm for two consecutive moments, however great be his efforts to attain this object. Before he can bring a full glass to his lips he makes innumerable gestures and antics, as the convulsive moments of the limb deviate it from one side to the other, until at length he has piloted the glass opposite his mouth, when he empties it at a gulp.