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Hysterical chorea versus neurosyphilis.

Case 14. (De Massary and Du Sonich, April, 1917.)

There were various complications in the case of a lieutenant (nervous tic in childhood; travel 23 to 30), who was at Antwerp during the period of mobilization. He was taken there by the Germans; was a prisoner in their hands for 55 days; and succeeded under great strain in escaping.

He then entered his regiment, and, passing the examinations, was made an adjutant, and went to the front, March, 1915. He stayed ten months in the Verdun region, under heavy bombardment, and in June was bowled over and buried by a 210. He seemed to be fearless, getting no sensation from shell-bursts except a griping sensation in the bowels.

However, his character had altered in the direction of irritability; and by the end of January, 1916, he had to be evacuated for the first time from the front, for general weakness, with the diagnoses: neurasthenia, neuralgia, dyspeptic troubles, great general fatigue, marked depression. In fact, at Narbonne he was asked no questions for several days on account of his obvious depression. He was given ice-bags for violent headaches, complete rest in bed, cacodylate and sodium nucleinate. In two weeks he was up and about.

At this time appeared choreiform movements, which reached their maximum in two or three days, whereupon he was sent, March 4, 1916, to the neurological centre at Montpellier. Here W. R. positive! Neosalvarsan on the second injection (0.45 and 0.60) yielded a strong reaction, with fever, delirium, vomiting, and then jaundice.

About a month later, he was given twenty more intravenous injections, whereupon the choreic movements now decreased, and July 15 he was given convalescence for three months. October 15 he went back to his dépôt cured; and October 20, on request, went to the front. He was potted and under machine-gun fire at times during the next three months, but the choreic movements did not reappear. January 1 he left the trenches as the division went into billets. January 8, suddenly, without any emotional cause, he began to “dance” again. Accordingly, he was evacuated for the second time, January 10, 1917, with the diagnosis: choreic movements, especially on left; evacuate to special centre.

At Royallieu, a lumbar puncture showed a slight lymphocytosis. The headache improved. He was evacuated January 24, 1917, to Val-de-Grâce, with a diagnosis: Recurrent chorea; first attack followed commotio cerebri, nervous depression, inequality of pupils, various pains, contracted in the army. Another W. R. was positive. Twelve intramuscular injections of oxygen cyanide were given, besides baths. He was then sent to Issy-les-Moulineaux with a diagnosis of tic. He showed choreiform movements affecting the legs alone. When sitting, legs extended and flexed, the knees would abduct, then adduct; the thighs flexed. When standing, flexor movements were produced alternately on the left and the right, the knee being raised high, sometimes striking the patient’s hand. In walking, the thigh and lower leg flexion was always out of proportion to the required step. There was thus a sort of saltatory chorea limited to the legs. The reflexes so far as they could be tested were normal save that the left pupil was fixed to light and accommodation; the right pupil was sluggish to light but accommodated normally. Leucoplakia of the cheeks; nocturnal headaches; and pains resembling lightning pains in arms and legs. Lumbar puncture, March 26, showed blood-stained fluid, and the puncture was followed by headache, vomiting, and slow pulse. The fluid showed a slight lymphocytosis; W. R. negative.

It is clear that a diagnosis limiting itself to the leg trouble would probably content itself with “hysterical chorea.” The lieutenant said that when he saw people “dance” he did have a tendency to imitate them; and when he was cured of that, he did not want to go to Lamalou because he would see the ataxic patients there and might fall back into his “dancing.” However, in view of the pupillary inequality, the lymphocytosis, the leucoplakia, the W. R., and the initial neurasthenia and depression found in the very first hospital in which he was examined, we probably should be entitled to consider that general paresis played a part in the chorea.