To these propositions may be added a fourth—viz. Choreic movements may be the result of a peripheral irritation, or, in other words, may be reflex.
Hysterical rhythmical chorea is a form of chorea in which involuntary movements are systematized into a certain order, so as to produce in the parts of the body which are affected determinate movements which always repeat themselves with the same characters. The movements are strikingly analogous to the rhythmical movements, as those of salutation, which often occur in the second period of the hystero-epileptic attack. Rhythmical chorea should undoubtedly be arranged among the manifestations of grave hysteria. An account of an interesting case of this kind is given in a lecture by Wood, reported by me in the Philadelphia Medical Times for Feb. 26, 1881.
As Charcot has shown, rhythmic chorea is usually of hysterical origin, although it may exist without any of the phenomena which usually characterize hysteria. In these cases the movements imitated are according to a certain plan; thus, they may be certain expressive movements, as some particular form of dancing or the so-called saltatory chorea. They may be, again, certain professional or trained actions, such as movements of hammering, of rowing, or of weaving. Charcot speaks of a young Polish girl in whom movements of hammering of the left arm lasted from one to two hours, and occurred many times in a day for seven years. He has also given an account of another case, a patient with various grave hysterical manifestations, who would have a pain and beating sensation in the epigastrium, accompanied by a feeling of numbness. The right upper extremity would then begin to move; this would soon be followed by the left, and then by the lower extremities; then would follow a succession of varied action, complex in character, but in which rhythm and time and correct imitation of certain intentional and rational movements could readily be recognized. The attacks could be artificially induced in this patient by pulling the right arm or by striking on the patellar tendons with a hammer. During the whole of the attack the patient was conscious. In another patient rhythmical agitations of the arm, the movement of wielding a hammer, were produced in the first stage; then followed tonic spasms and twisting of the head and arms, suggesting a partial epilepsy; finally, rhythmical movements of the head to the right and left took place, the patient at the same time chanting or wailing.79
79 Charcot's lectures in Le Progrès médical for 1885.
In the following case an hysterical jumping chorea was probably associated with some real organic condition or was due to malarial infection. The patient was a middle-aged man. During the war he received a slight shell wound in the back part of the right thigh, and from that time suffered more or less with numbness and some weakness of the right leg. He was of an active nervous temperament. About three months before coming under observation he had without warning a peculiar attack which, in his own words, came on as if shocks of electricity were passed through his head, back, limbs, and other parts of the body. In this attack, which lasted for fully an hour, he jumped two or three feet in the air repeatedly; his arms, legs, and even his head and eyes, shook violently. He was entirely conscious throughout, but said nothing except to ask for relief. His wife, who was present, stated that at first he was pale, and afterward, during the attack, he became almost turgid under the eyes. Attacks appeared to come at intervals of seven and fourteen days for a time, so that his family physician surmised that there might be some malarial trouble, and prescribed for him accordingly. They soon, however, became irregular in character, and did not occur at periodical intervals. After the attacks he would lie down and go to sleep; he did not, however, pass into the condition of stupor that is observed after a grave epileptic seizure. His sleep seemed to be simply that of an exhausted nervous system.
Hysterical tremor is of various forms and of frequent occurrence: a single limb, both upper or both lower extremities, or the entire body may be affected. In a case of hystero-epilepsy, which will be reported in the next article, the patient had a marked tremor of the left arm, forearm, and hand, which was constant, but worse before her attacks; it remained for many months, and then disappeared entirely. Caraffi80 reports the case of an hysterical girl of eighteen, anæsthetic on the right side and subject to convulsive attacks, who fell on the right knee and developed an arthritis. At the Hôpital Beaujon service of Lefort and Blum she presented herself with the above symptoms, aphonia, and an uncontrollable tremor of the right lower extremity, and trophic disturbances of the same. Immobilization of the limb was tried without benefit, and Blum then stretched the sciatic, with complete relief of the tremor and of the troubles of sensibility and of nutrition.
80 L'Encéphale, June, 1882.
Hysterical contracture, like hysterical paralysis, may assume a variety of forms: it may be hemiplegic, monoplegic, paraplegic, alternating, or local, as of the ocular muscles, the facial or neck muscles; laryngeal, pharyngeal, or œsophageal; of the fingers or of the toes.
Richardson81 records the case of a young lady who saw in India a religious devotee with his leg flexed upon his body and fastened there. In a few hours she was found with her leg in a similar position, and this contracture remained until after she had been taken to London; then it disappeared as suddenly as it came. Conscious purpose could not have maintained the leg in such a position for an hour.