There is no rigidity nor tonic spasm. The muscles may become tender to press ure. There is usually some muscular weakness or paresis, which, in occasional cases, becomes extreme ("paralytic cho rea"). The tendon-reflexes are normal. Trophic disorders are not the rule, but erythema, herpes zoster, or chloasmic blotches may be occasionally seen.
The movements are rarely general at first. They begin in the upper ex tremity, or the face, or, rarely, in the lower extremity. They spread over the corresponding half of the body, and finally attack the opposite side. In 144 cases studied, the onset was general in 25 cases only and hemilateral in 111 cases. G. Oddo (Revue de Med., Jan. 10, 1901).
There is always some disorder, usually a. general dulling of tactile temperature and muscular sense. In the early stages pain is frequent, but in later stages this gives place to well-marked analgesia. Pricklin5 formication, and other pars thesite are common.
In uncomplicated cases the pupillary reactions are normal.
Psychical abnormalities are the rule. These vary from the slight irritability, weakness, and altered disposition com monly seen in early stages to marked I intellectual impairment with loss of memory, confusion of ideas, inability to concentrate attention, and grave emo tional disorder of a melancholic cast. Occasionally a generalized outburst of acute insanity or delirium will occur, giving rise to the clinical subdivision "chorea insaniens." Chorea an infectious disease. Like all other infectious diseases, its toxic prin ciple may give rise to insanity with hal lucinations, modified in form according to individual peculiarities. lhe onset of the insanity is, like all insanities of toxic origin, sudden, and its progress acute or subacute. Usually there is no parallel ism between the choreic inovements and the mental symptoms; but it is to be noted that, while chorea generally occurs in patients about 15 years of age, mental disturbance is generally found in choreic patients of 19 years of age. P. J. Milibius (Miinchener med. Woch., Dec, 20, 27, '02).
A true aphasia has been noted in a few instances, usually associated with a right hemichorea.
Along with the nervous symptoms above described in detail there are, in most cases, some evidences of disorder of the general bodily functions. Fever is present at some stage, usually early, in a majority of cases. When slight and
maniacal chorea is present a tempera ture of 103° to 104° F. is often noted. A decided rise is usual in cases show ing complications, such as rhenmatism, pericarditis, or endocarditis.
The renal function is, in mild uncom plicated cases, normal. In the severe cases and in almost all febrile cases al buminuria exists, and the amount of urea excreted is in excess of the normal. In maniacal chorea there is, as a rule, a dis tinct nephritis.
Cardiac irregularity with abnormal rapidity of action is not infrequent, and of all the complications of chorea, peri carditis and endocarditis are most often seen, the latter, especially, occurring, ac cording to Osler, in quite one-half of all cases. Cardiac murmurs, due to the en docarditis and also in some instances to impoverished blood, are common. A true amemia—diminution in hwmoglo bin-percentage and in number of red and white corpuscles—is often noted.
In a limited number of cases symptoms of gastro-intestinal disorder occur, the symptoms being those shown in cases of autoinfection. .
Since chorea occurs by preference in children of neurotic heredity, the psy chical, physiological, and anatomical stigmata of degeneracy in greater or less prominence are often added to the symp toms above detailed.
Three grades of the disease are de scribed: The mild, in which there is little disturbance of general health, no complications, and only moderately-well marked choreic movements; the severe, in which fever, mental disorder, and other complications are present, and the inco-ordinate clonic spasms more severe and continuous, with well-pronounced muscular weakness; and the violent "chorea insaniens," characterized by rapid onset and progress, violent and con tinuous chorcoid spasm, with fever and delirium, terminating not infrequently in death.
Motor symptoms in chorea arranged in five clinical groups: 1. Cases in which there is at some stage absence of the mo tions when at rest. 2. Cases in which tbe movements are less when the child is at rest, but are aggravated by volun tary movements. 3. Cases in which the severe choreiform movements disappear during voluntary movements. 4. Cases in which voluntary exertion does not in fluence the movements. 5. Cases present ing at different stages more than one of the above types. Weir Mitchell and J. H. W. Rhein (Phila.. Med. Jour., Ja.n. 22, '93).