It should be added here that IIeubner was also impressed by the peculiar character of the choreic motor disturbances and was led to say that "the pathologic irritation to which these movements owe their origin, cannot be referred—or at least exclusively referred—to those regions of the brain which are generally called the motor regions, i.e., the anterior central convolution and the pyramidal tract." Mode of Onset.—The motor disturbance in chorea usually- begins gradually. Spontaneous movements first make their appearance, and disturb the child's muscles, either when they are at rest or during a purposive movement.
The child is unable to sit still, wriggles, makes faces, drums on the tabie with its fingem, picks at its clothes, shuffles its feet, drops things on the floor and breaks them, etc. These involuntary movements, as well as the movements which accompany every intentional movement that requires the slightest exertion, render the patient ridiculous, an object of general derision. Quite frequently the children are not only teased, but punished for misbehavior, until the true state of the case is finally recognized by some intelligent parent or teacher. Sometimes the physician is the first to give the true explanation.
The pathologic nature of the motor disturbances, however, at once becomes clear when the disease is well developed. The child is then in a condition of constant unrest; the play of features is exceedingly lively and variable; and the greatest variety of emotions are expressed in the most exaggerated manner, in rapid succession and without any reference to the particular mood that the child may be in at the time. The tongue and all the muscles that take part in the act of speech are affected by the disturbance, and a characteristic change is observed in the speech. A few syllables or words are pronounced properly; sud denly the voice drops to a barely perceptible whisper or ceases alto gether while the child is trying to pronounce several words, and in its vain attempts to speak it indulges in a number of more or less droll, fantastic or even alarming gestures. When the obstacle has been over come, a few words are again pronounced correctly, or nearly correctly, and so the comedy goes on until the child bursts into tears and gives up the attempt at conversation, the futility of which has a most depressing influence.
The breathing is affected in the same way, and often becomes sighhag and interrupted.
The child is unable to perform the smallest movements with the extremities, for the motor impulse gets off the track and reaches muscles which it was never intended to set in motion. Thus, for example, instead of opposing the thumb as the child may have intended to do, it may flex the hand or spread out the fingers, or perform some other similar movetnent utttil suddenly the desired movement is performed, apparently by accident. When, after laborious attempts, the child has finally succeeded in assuming the desired position, it is unable to maintain it more than a few seconds, and has to begin all over again.
At first the child still retains the power of sitting, walkhag, standing, etc.; but at the height of the disease these static functions are impossi ble on account of the instability of the movements. The gait is uncer tain, and the child not only stumbles but even falls down when it attempts to stand or take a few steps, unless it is supported. Even in bed the movements which accompany every spontaneous intentional muscular action become so marked in severe cases that the patients fling them selves about on the bed in a state of what the French call "folic museu lairc," and often sustain abrasions or even serious contusions, or fall out of bed.
Objective examination in pronounced eases of chorea usually shows a very marked diminution of the muscle tone (Bonhider). Tbus, during the attempt to raise the ehild by the shoulders the shoulder girdle goes up to the level of the ears. In the extremities also the un controlled swaying movements induced by passive walking are quite conspicuous. Normally there is no diminution of gross motor strength.
Paresis, whether mild or severe, is quite rare in choreic patients. Before the appearance of the choreic movements paresis may develop gradually in the form of monoplegia or hemiplegia and may for a long time dominate the clinical picture (limp chorea or ehoree molle); or they may develop in the extremity or side of tbe body which had been the seat of choreic movements and replace these movements; and as they disappear the chorea may again assert itself (paralysie de la chor4e). There is no sharp division between the two forms (Rindfleisch). The prognosis of paretic chorea is always favorable.