Freud describes a peculiar form of motor disturbance under the name of ehoreatic paresis. This differs from the usual form of cerebral infantile palsy by the later occurrence of the disease—after the third year of life, instead of in earlier infancy—by the fact that the motor disturbances manifest themselves at once, and by the absence of spasms, epilepsy or idiocy. In a single case, which was examined post mortem (Landouzy), an old tuberculous nodule was found in the lenticular nucleus.
Cerebral hemiplegia is not always strictly unilateral. In otherwise typical hemiplegic cases rigidity and exaggeration of reflexes, without any distinctly recognizable paralysis, are frequently seen in the leg which is apparently not involved. Such cases form the connecting link between hemiplegia and the second main group of cerebral infantile palsy—ecrebral diplegia. In the latter the palsy does not exhibit the hemiplegic type; there is either a paraplegia, or all four extremities are attacked. The following varieties are dis tinguished after Freud: (a) General rigidity.—This manifests itself in rigidity of the entire muscular system. The rigidity is noted in earliest infancy' and interferes with the necessary manipulations in bathing and dressing the child. Later it is noticed that the child is slow about learning to sit up or walk, and there is a peculiar crossing of the legs when it first attempts to walk (due to great tension of the adductors). The arms are closely pressed to the trunk and flexed at the elbow; the forearms are in pronation, flexed at the wrist; and the fingers are folded, producing a characteristic "devo tional or praying" attitude (Freud). The back is rigid, the abdomen hard and retracted, the legs in extreme extension, the feet spastic and in a position of pes equinus. The rigidity' is extremely pro nounced in the entire body and is much more prominent than the paralysis, which is often very slight. The reflexes, which are difficult to elicit on account of the impossibility of inducing relaxation, are everywhere greatly' exaggerated. Some times touching the lips, tongue or oral mucous membrane elicits reflex movements of the muscles of the jaw, simulating sucking or masticating movements L)ppenheini's eating reflex). Strabismus and dysarthria are frequent concomitants. The children are easily frightened, especially by sudden loud noises. On the other hand, epilepsy and idiocy are usually absent; although one is very apt, on account of the sluggish movements, slow step and (lull expression of countenance, to do the patients the injustice of mistaking them for idiots. This form of cerebral infantile palsy is particularly; apt to follow
birth injuries and corresponds to the original Little's disease.
A special form of this general rigidity is seen in nticrocephalic rigid ity in which the skull is diminished in size and there is a high grade of idiocy in addition to the muscular rigidity, which is very marked (see above, microcephalus).
Sometimes the general rigidity is only slight when the child is at rest; but it makes its appearance at once when the child is uncovered, frightened, or hears a loud noise. This condition is called paroxysmal rigidity.
(b) Paraplegic rigidity.—In this form of cerebral diplegia the lower extremities only are rigid and exhibit the same peculiarities as in the cases of general rigidity. The chilcl is very slow in learning to walk and the crossing of the legs at the first attempts is very marked. Paraly sis in these cases also is very slight. The artns exhibit at most a slight rigidity and exaggeration of reflexes. The intelligence is normal and convulsions do not occur. On the other hand, strabismus is practi cally constant. Paraplegic rigidity is observed chiefly in prematurely born children. Opinions are still divided on the question whether this form of spastic paralysis is really due to a cerebral lesion or depends on arrested development of the motor tracts in the spinal cord only (v. Gehuchten). Owing to the frequency of strabismus, however, most authors are inclined to assume a lesion in the cerebral cortex in this form of spastic paralysis also.
(c and d) When in this form of rigidity the paralytic phenomena are more pronounced, Freud employs the terms bilateral hemiplegia and paraplegic paralysis, according as both arms and legs or the legs only are involved. The paralysis in these cases may be of unequal degree on the two sides; but in every case the involvement of the hands is very striking, just as in unilateral hemiplegia. The two sides of the face may also be involved, so that the child presents a peculiar, masklike, immobile expression of countenance. Strabismus, convul sions and dementia occur in these forms of cerebral infantile palsy. The cause of these rare disturbances is sought in grave lesions of the brain occurring either before or after birth.