A system of practical medicine. By American authors. Vol. 5

by Unknown

During the course of the disease there may be exacerbations, and sometimes after convalescence has seemed established there are relapses.

Recovery is gradual, and as the abnormal movements cease the mental condition improves, and the patient regains his health without any traces of the disease remaining.

We will now consider some of the symptoms separately. First, as to disturbances of motion. As before remarked, the disorderly movements occur soon after the general restlessness is seen. They most commonly begin in one upper extremity. The hand is thrown into various positions, the fingers are flexed and extended or separated, and all of the movements occur with great rapidity. In a day or two the whole arm is affected, and then the leg of the same side is involved in the jerkings and twitchings. In many cases the facial muscles are contorted, the mouth is pursed up or opened wide, and then quickly twisted into some other shape. If the patient is told to put out his tongue, it is protruded after a moment's hesitation, and then suddenly retracted, the jaws coming together with a snap. A smacking sound is made with the lips quite often, and words are uttered involuntarily. The movements may remain confined to one side of the body, constituting what is called hemichorea. This is quite common, and the right side is rather more frequently involved than the left. There is so great difference of opinion among authors on this point that it is probable that one side is affected about as often as the other. Of 252 cases which I have examined, 69 were right and 43 left hemichoreas. Gerhard²⁰ found in 80 cases of chorea that 32 were unilateral; of these 20 were right and 12 were left. Sée, however, found that in 97 of 154 cases the movements were either confined to the left side or were more marked on that side. He states that in his experience the proportion between left and right hemichorea is as 37 to 27. Pye-Smith in 33 cases of unilateral chorea found 15 on the right and 18 on the left side. Many cases which begin as hemichorea soon become general.

²⁰ American Journal of Med. Sci.

The disease reaches its greatest severity in about two weeks, and if the case is a bad one we find by this time all of the voluntary muscles are in constant movement. At this time the French name for chorea, folie musculaire, is most appropriate. Patients are often unable to walk or to sit up, and sometimes they may be thrown from the bed by violent spasmodic movements of the trunk. Strange as it seems, patients rarely complain of fatigue, notwithstanding the violent muscular exercise. This is probably because each set of movements is of short duration and is constantly changing its seat.

As a rule, the movements cease completely during sleep or under an anæsthetic. Sometimes occasional twitchings of muscles are seen in sleep, and in rare instances we are told by the parents of a child with chorea that the movements are as active in sleep as in the waking hours.

The movements of chorea occur either while the limbs are at rest or under the influence of voluntary effort. This fact has been pointed out by Mitchell and by Gowers. In some cases the movements are most marked when the patient is at rest. If a directed effort is made to use the member for a time, the choreic movements are suspended. For example, a patient may be able to carry a glass of water to the mouth without spilling a drop, while a moment before the hand may have been performing a continual dance. I have often observed that while the limb to which the whole attention has been directed in performing some movement has been steadied, the other limbs become violently agitated.

In another class of cases the movements are comparatively slight when the part is at rest, but when a motion is attempted the disorder of the muscles is so much increased that it is almost impossible for the act to be completed. The patient is told to pick up some small object: he throws the hand out toward it, and it is jerked away before he can grasp it. He again puts the hand forward, reaches the object, and the fingers open and shut and sprawl over the article before it is taken up. Sometimes it cannot be grasped at all. This has been called choreic ataxia, but it is only one type of the cases commonly seen.

This brings us to the influence of the will on the movements in chorea. There are some cases, as mentioned above, in which the movements may be controlled by the will for a brief period, but they will sooner or later return. In other cases it is quite impossible for the patient to check the movements at all, and one frequently sees in a case of hemichorea the sound hand used to grasp the other, so as to control the movements. We have referred to this because of Niemeyer's opinion that corporeal punishment would shorten an attack of chorea.