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Tous les autres exempiaires orlginaux sont fllm6s en commen^ant par la premiere page qui comporte une empreinte d'Impression ou d'iilustration et en terminant par la dernlAre page qui comporte une telle empreinte. Un dee symboles suivants apparaTtra sur la derniAre image de cheque microfiche, selon le cas: le symbole — »> signifie "A SUIVRE", le symbole V signifie "FIN". Les cartes, planches, tableaux, etc.. peuvent dtre fllmte A dee taux de rMuction diffirents. Lorsque le document est trop grand pour dtre reproduit en un seul clich«, il est fllm« d partir de i'angle sup^rleur gauche, de gauche d droite, et de haut en bas. en prenant ie nombre d'Images ndcessaire. Les diagrammes suivants illustrent la mdthode. 1 2 3 4 5 6 *^\i!l €^ fitvvM-^A-' 7^ 1"" ^^^/\JCUU ' *" ' "^ ' Pe x^ G^C.g! A PECULIAR FORM OF FAMILY "TIC CONVULSIF" WITH iNOCTURNAL EXACERBATIONS AND EPILEPTIC ATTACKS. BY F. G. FINLKY, M.D., Assistant Profi'ssor of Medifiiio and Associate I 'lofessor of Clinical Medicine, MctJill Univ I'sity'; Physician to the Montreal (Jeneral Hospital. {Bepriuted from the Montnal Mtdiritl Journal, March, 1897.) \ / ^ fiY.-eu. f" Cn. ■? '. y PECULIAR FORM OF FAMILY "TIC CONVULSIF " WITH NOCTURNAL EXACERBATIONS AND EPILEPTIC ATTACKS.' HY F. G. FiNi-EY, M.D., Assistant Professor of Medicine and Associate Professor of Clinical Medicine, McGill University ; Physician to the Montreal General Hospital. The two following cases occurred in brothers and are recorded as presenting some unusual features : Case 1. Jean Degan, aged 23, a French Canadian, was admitted to the Montreal General Hospital for twitching movements in the hands in December, 1896. Family History. The patient's mother states that she suffered from chorea in childhood. She also gives an indefinite history of insanity previous to the patient's birth. A matei-nal uncle is affected by " nervousness " manifesting itself by following out any sudden order ; if told *^^o " strike " or " to drop " anything he does so at once. A brother (case II) is affected in a somewhat similar way to the patient, and all the members of the family appear dull and some- what stupid. The patient's birth was normal, not requiring forceps. He suffered from measles at 12 y(;ars of age. Although he attended school for four years he is quite illiterate. Previous to the onset of the convulsive movements, was affected in a similar way to his uncle, and if given an}' sudden command was obliged to carry it out. On one occasion he rendered a little girl insensible by a blow on the clieso at the suggestion of a mischievous individual. His present trouble came on six years ago. On returning from the lumber camp his friends noticed that his arms and hands were affected with shaking mo\ jments. In June, lcS94, he had a fit, and during the present year there have been three similar seizures. The attacks are preceded by irritability, indistinctness in speech and dulness of hearing. They are marked by sudden rigidity of the body, lasting several minutes, but not accom- panied b}' biting of the tongue, involuntary micturition, or cyanosis. One attack occurred at night in bed. The twitching movements are much diminished for several days following a fit. ' Read before the Montreal Medico-Chirurgical Society, January 1.5th, 1897. Present Condition. The patient is dull and stupid. He speaks intelligibly but it is impossible to obtain a clear account of his illness horn him. He is of good muscular development, 5 ft. 4 in. tall. Every few seconds a single twitching movement of one or other side of the mouth or a similar single contraction of the fingers of one or other hand is observed. The movements are slight in degree and are apparently unaffected by his attention being drawn to them. In addition to these twitching movements, marked jerking mco- ordinate clonic movements are induced in attempting to perform any action. In attempting to pick up a piece of paper, he hovers over it for a few seconds, his hand swaying to and fro, and then suddenly pounces down and picks it up with a grasping, clumsy movement. When asked to button his ;?hirt, these movements are often so marked that it is impossible for him to do so. They vary, however, consider- ably in intensity from day to day. He can convey a cup of water to his lips, occasionally, however, spilling a little from twitching of the hantl. In attempting to touch the fore-fingers together, the twitching becomes so marked that he usually fails to do so. During sleep both the twitching and the jerking incoordinate movements continue, and are, indeed, much increased. He is also restless when sleeping and throws himself quickly from side to side of the bed. He occasionally utters a guttural, grunting sound when asleep, but has had no evidence of ecliolalia or coprolalia during his waking houi\s. The motor power tested by the dynomometer shows there is slight diminution, 20 to 22, instead of 25 to 80. Sensaticm is unaffected. The knee jerks are increased. The pupils react well to light and accommodation. The optic disc is normal and there is no nystagmus. There is some deafness in both ears, the watch being heard at three inches only. Dr. J. J. Gardner reports a double chronic catarrhal otitis media. There is an eruption of scabies on the skin and evidence of a small quantity of fluid in the left pleura ; a small encysted collection of fluid is present in front of the left side of the chest, displacing the apex impulse upward to the third space in the anterior axillary line. A trace of albumen was present in the urine during a stay of some weeks in the hospital, but no casts. On January 18th, at night, he had several convulsive attacks, described by Dr. Ewan, who witnessed them, as follows : The onset is mai'ked by clonic spasmodic flexion or extension of one or moi'e fingers of one or both hands, followed by flexion or extension of the wrists, jerking forward of the shoulders, and, lastly, a general clonic I: I 8 I spasm of the muscles of the trunk and legs ; the back became slightly arched. These attacks shook the bed, and wore followed by twitch- ing of the mouth and closing of the eyes. Later on in tlie night he had three attacks, in which the arms were thrown wildly aV»out and pounded on the bed or table. The eyes remained open and staring and the jaw closed ; the extremities were somewhat stiff'. There was slight flushing of the face, followed- by pallor, but no incontinence of urine or biting of the tongue. The attacks lasted about half an hour and were accompanied by sounds like the yelping of a dog. Case II. — Alex. Began, aet. 20, first noticed shaking of the hands five or six years after an attack of inflammation of the lungs. Some months later he Vjcgan to suflfer from fits, the first coming on when being teased and tickled. These fits are chieHy nocturnal and occur with varying frequency at intervals of a week, or, again, of a month. During the fits he loses consciousness, froths at the mouth, passes urine and once bit his tongue. Present Condition. Intellectually ho is brighter than his brother, but is also somewhat dull. When at rest, there is no motor affection, The twitching movements in the hands and face, noticed in the brother, arc here absent when awake, but he presents precisely simihir jerky and incoordinate movements cm attempting any action, such as buttoning his clothe.s. During sleep, however, the twitching movements have been observed on a few occasions. The tongue presents distinct jerky and tremulous movements. Owing to this, the speech is somewhat indistinct, but not syllabic. The motor power and sensation are normal. The knee jerks are diminished and brought out with difficulty. The special senses are normal. There is no nystagmus and no albumen in the urine. The diagnosis of tic is based in the first case on the char, teristic twitching movements in the face and hands. In the second, these movements are much less pronounced, and were only observed when carefully watched for and at night. The movements present in both cases are of two forms, the one consisting of twitching movements in thr face and hands, occnring when at rest at intervals of a few seconds ; the second form is brought (»ut by action and marked by jerking and incoordinate movements, which continue as long as the action is kept up. The diagnosis of tic is based on the former, although in the second case these movements were so slight as to be almost pas.sed unnoticed. The simihirity of the second form of movement, jerky and inco- ordinate, was so marked in both cases as to at once susfffest the identical character of the disease. / Another feature of tic observed in the first cose was the history given of being obliged to follow out any quick command, and it is interesting to note that a simiiiU' condition existed in a maternal uncle. The exacerbation of the movements during sleep was well marked in both cases, and both the single clonic movements like tic and the incoordinate irregular movements were then seen to best advantage It is very generally recognized that the movements of tic and other spasmodic affections are lessened or absent during sleep, and although cases are recorded in which they continue, yet this is so unusual as to throw some doubt on the diagnosis. It is now pretty generally admitted that tic and the allied condition of para- myoclonus are manifestations of the neuropathic subjects, and a few instances are recorded in which several mombers of a family have been so affected. Unverricht for instance records a famil}'' in which a brother and four sisters were affected with para- myoclonus (Die Myoklonie, Wien 1891) and Earald also refers to a somewhat similar incidence {Berl. Klin Woch. 1888, M. 51). In Unverricht's family the children suffered from epileptic attacks in early life. These gradually lessened in frequency and disappeared and later on the spasmodic movements came on. In both the above cases the epileptic attacks followed the onset of the convulsive movements, and in view of the neurotic family history may be looked upon as expressions of heriditary nervous degeneration. Although these cases are classified as " Tic," the features of this disease are quite subordinate to the other symptoms. In the first case the clonic movements about the face and hands are sufficiently characteristic, but in the second, they were only observed during sleep and when specially looked for. As Raj'mond remarks (Clinique des Maladies du Systeme Nerveiix, Paris, 1896), numerous cases of tic occur in which the symptoms do not conform to any well define