Early, without exact date, 6; late, 3; unknown, 6.
Our three cases appeared as follows : Twice during pregnancy, at the fourth and the sixth month, and once, twenty-two days after labor.
In Fehling's fifty-five cases, chorea began in tho first half of pregnancy in thirty-nine instances. In only three did the chorea persist during the puerperium. In only twenty-nine cases did pregnancy reach full terna.
vary according as the chorea appears slowly or sud denly. If the inception is gradual, the friends of the patient, or the patient herself, first perceives involuntary movements of the limbs or of the face, and in some cases, such as Kiwisch, Scanzoni and Romberg have observed, there is also head-ache, vertigo, a queer facial expression, ex cited speech, and, rarely, excitement of the whole psychical system. Then these movements grow marked, and the chorea is progressively de veloped. At other times, the chorea begins rapidly, the incoordination of the movements is marked and rapidly extends to several parts of the body.
Among the twenty-one cases of Mosier, the disease began in the right arm alone, twice; in the left arm and leg, twice; in the legs only, twice. The attacks returned at a fixed time. In four cases the disease began in the face, and, in one case, in the tongue muscles.
When the attack is sudden, several parts of the body are simultane ously involved, as the face, limbs and tongue. There are evening exacer bations, delirium and insomnia (llelfft). In the majority of cases, the chorea is bilateral (Mosier, Fehling, Barnes). In sixteen of Mosler's cases, the disease affected besides the limbs, the face, the eyes, the tongue, and the muscles of the neck and trunk. Speech was affected. But even in these cases, the chorea is not always of equal intensity in all parts of the body, and the movements are now violent, now quite slight. In many cases there seem to come crises or exacerbations of the disease. Almost always, save in two cases of Franck and Ingleby, the movements ceased during sleep, but often-times the sleep is disturbed, and ac companied by night-mare. The patients talk aloud and are restless.
The movements reappear in the moniing when the patients awaken, and sometimes it is the reappearance of the movements which puts an end to sleep (Scanzoni). There are, sometimes, diurnal remissions, of which Mosier has noted four distinct cases. Hand has observed an aggravation of the movements under the influence of movements of the child and of vaginal touch. Often, the chorea is accompanied by epileptiform con vulsions and hysterical fits which seem to return at fixed hours (Mosier, Dancan). One of Duncan's patients, and ono of our own, had ulceration of the cervix. Other complications are headache, sharp pains in one limb, cardiac and renal diseases. Generally, there is little or no fever, no digestive difficulties and no disorder of the intellect. In a case of Lever, however, there was weakening of the memory and the intelligence seemed impaired at the time of the crises.
Course, Duration and influence of chorea upon pregnancy is very marked. Abortion or premature labor are common. The sooner the chore,a begins, the greater the chances that preg-nancy will end before full term.
Among twenty-one cases, Mosier observed four abortions, at four, five and six months. In three eases, the chorea had lasted three, four and five months, for it began in the first month. In three cases it disap peared immediately after abortion. Once, it lasted six weeks after labor (Romberg).
In three cases there was premature labor, twice at the beginning of the ninth month and once in the seventh. The chorea bad persisted, in one case, nine months, in one case five, and, in one, only one month. In three cases the chorea e,eased abruptly. Once (Aran), the patient had a still-birth and died delirious the next day.
Barnes, recapitulating his fifty-seven cases, reaches the following results: In five cases of Mosier, the chorea continued until the end of preg nancy; in three cases, from the third to the tenth month, and once, from the fourth to the tenth.