Playing The Fool

Playing The Fool

He was in his early sixties, a retired maths teacher, unmarried, below average height, fastidiously dressed. His greenish, checked tweed suit matched his shirt and a tightly knotted maroon tie matched the handkerchief in a breast pocket which also held two ballpoint pens. We shook hands. He sat down. I had already made up my mind that he wasn’t playing the fool but that’s what his General Practitioner had suggested in a brief referral letter.

‘Tell me about your symptoms,’ I asked. He had brought a hard backed diary with him and opened this to read the entries he’d made. These were long and meticulously detailed so I’ll summarise. For six months he’d been experiencing odd sensations in his legs. Muscle throbbing and twitching, tingling and transient cramps. The symptoms, intermittent at first, had become more frequent. At first he could ease them by standing and stamping his feet and he demonstrated this to me. This manoeuvre had helped for a while, but then he’d had to jog on the spot to get relief, and more recently he’d had to dance.

‘They’re coming on now doctor,’ he said, while I was still ruminating on this information.

‘Can you show me what you do exactly?’ I said. He didn’t need a second invitation and placing his diary and pens on my desk, he stood and began to dance in the consulting room. He held his upper body rigid, arms and hands tight to his side, and began quick, precise stepping movements of his feet and legs. He kept it up for a few minutes, jigging around the small room. During the performance the out-patient clinic nurse, alerted by the rhythmic percussion of his brown brogues on the pine-wood floor came in, closing the door to the waiting area carefully behind her and watching the performance open-mouthed with arms crossed. His pace eventually began to slow.

‘They’ve gone,’ he said as he sat down again. ‘But they’ll be back in a few hours.’

‘How often do you have to dance?’ I asked.

‘Three or four times a day. It’s very embarrassing.’

‘And if you don’t dance?’

‘I have to. I can’t bear not to. The throbbing and spasms just get worse and worse. I can’t sit. I can’t stand or walk. I have to dance.’

I examined him thoroughly but could find no neurological or muscular abnormality. His spine and legs were entirely normal. His reflexes were a little brisk but there was nothing else to find.

The only diagnosis I could reasonably suggest was that he had a severe case of ‘restless legs syndrome’. However, as he continued to sleep well, wasn’t anxious about anything other than his legs, didn’t smoke and already took regular exercise there was little I could suggest by away of a sensible medical intervention. I arranged some blood tests and a spinal scan in view of the brisk reflexes, but wasn’t expecting to find any abnormality. I was just playing for time as all medics do now and then.

The test results were normal, but when he returned to the clinic the symptoms were getting worse.

During our second interview his dancing began again and various nurses and junior doctors came in to watch the ‘performance’. Some shook their heads slowly, mouth's open; others grinned or frowned in puzzlement; a student had to leave the room with her hands covering her face.

We discussed his case, at the multidisciplinary team meeting, that afternoon. There was an even split. Half the staff thought he was playing the fool or had a psychological disorder, the other half a muscle problem. A senior physiotherapist suggested exercise therapy and muscle stretching techniques.

Four weeks passed, but when I next saw him it was obvious the stretching techniques hadn’t worked. He was unshaven, his fingernails dirty, his brogues unpolished. Various stains had ruined his tweed suit. He was wearing a canvas splint on his wrist. He’d tripped and hurt it while ‘dancing’ the day before and attended the emergency department.

‘I can’t go on like this,’ he said, close to tears and now described electric shock sensations in his legs and a feeling as if water was trickling down his shins. People were laughing at him in the supermarket when he danced. He’d had to cancel his annual fishing trip to Scotland with friends and he’d given up his crown green bowling and was having so much difficulty tending the allotment he’d run for thirty years he was thinking of giving that up as well.

I decided to refer him to our local neurologist.

‘She’s the most brilliant colleague I have,’ I said. ‘If anybody can help it’ll be her.’

A few weeks later I received a summary of that consultation.

Dear B.

Thank you for requesting a second opinion on this fascinating case which you have called ‘dancing legs syndrome’. He was a most delightful man and we had a long chat and I thoroughly examined him and like you could find no evidence of any serious physical problem whatsoever. Interestingly his symptoms recurred toward the end of our interview and as you have described he began to dance around the consulting room. I let his Michael Flatley/Riverdance routine go on for about ten seconds, then shouted:

‘STOP!!’ as loudly as I could manage and he immediately stopped and sat down. He mentioned that as soon as I shouted the symptoms eased. As this also established his dancing legs were under voluntary control we agreed that all he needs to do is tell himself firmly to stop dancing and hopefully we have a solution to the problem. Many thanks again for a fascinating referral.

I saw the patient for a final follow up a few weeks later.

‘How are you?’ I said, noting his previous smartness had returned. A new tweed suit, a tightly knotted blue tie and matching handkerchief. Clean shaven again, his brogues polished.

‘Much better doctor. Your colleague was so very kind. The symptoms have almost gone and I’ve got back to bowls and I’m keeping my allotment. I’m so grateful.’

‘You still get the symptoms occasionally then?’

‘Yes but when I feel them coming on all I have to do is stand up and say ‘STOP!’ to myself. I don’t need to shout it out. I just say it to myself. The symptoms go away. The neurologist told me it’s all a question of mind over matter.’

We shook hands. I never saw him again.