In exceptional cases the symptoms do not come on in this insidious way, but begin with some suddenness as a consequence of fright or other shock to the nervous system. But however the disorder may have begun, when fully developed the symptoms are the same. The power of the will. to control muscular action appears to be completely lost, and we find spontaneous spasmodic movement, incoordination of voluntary movement, and a certain degree of muscular weakness.
In a marked case nearly all the voluntary muscles of the body seem to take their share in this disorder of movement. The child is never quiet. First one group of muscles, then another, contract in a jerky spasmodic manner which is very characteristic. Volition is evidently not concerned in their production. They occur not only without the influence of the will, but in spite of it. The face is curiously worked, as if the muscles were attempting, but unsuccessfully, to simulate all the passions of the mind. The eyebrows are suddenly bent into a frown ; but it is not anger. The mouth expands abruptly into a smile ; but conveys no im pression of mirth. The eyelids are opened widely ; then quickly squeezed together ; the eyes are rolled upwards, downwards, and from side to side ; the cheeks twitch, and the angles of the mouth are contorted with strange grimaces. The head is jerked backwards and forwards, and then pulled suddenly down to one side. The arm may be thrown abruptly forwards by a peculiar movement of the shoulder ; the hand and wrist are violently pronated, then as suddenly supinated, and the fingers work convulsively. Sometimes, by a strong efibrt of the will, the hand may be kept quiet for a few seconds, but soon, with a convulsive jerk, it is thrown again into motion. The lower limbs, although less violently affected, are not inac tive. They are thrown one over the other, or are suddenly drawn up and again extended.
Sometimes the muscles of the trunk may be affected, and spasmodic contractions of the respiratory muscles may take place ; or the patient may be suddenly jerked upwards from the bed, or even thrown out of it upon the floor. In the worst cases the child has a wild, frightened look, or sometimes a half-dazed expression ; speech may be impossible, and even memory may appear to be almost lost.
In the milder cases an effort to execute a voluntary act increases the contractions ; and even the exertion of standing makes control of the' muscles more difficult. The more completely the child is at rest, the
quieter she becomes. The movements are also increased by mental emo tion and nervousness, so that the child is always at her worst when observed ; and no doubt, as Dr. Sturges suggests, the consciousness of failure increases her helplessness. During the height of the complaint the ungovernable eccentricity of movement makes the commonest actions difficult or impossible ; for an attempt to direct any special group of muscles is immediately frustrated by violent contractions of antagonistic groups, so that the patient does anything but what she wishes. The child can only speak indistinctly ; she cannot button or tie her clothes, or perform any act in which accurate co-ordination of movement is required. For this reason it is often quite impossible for her to feed herself, as she can no longer guide the spoon or fork to her lips. Even when fed by the nurse, mastication may be difficult from irregular movements of the tongue ; and sometimes the contractions of the gullet are interfered with in the process of swallowing. In bad eases natural sleep is almost impossible. Even in a milder form of the complaint the child finds a difficulty in going to sleep ; but when she does at last sleep the movements cease.
Sometimes sensory disturbances can be noticed. Painful spots may be found in the course of the nerve-trunks in the affected parts ; there may be tenderness on pressure over the spinous processes of the vertebrae ; or the child may complain of hypermsthesia or anaesthesia of the skin. Occa sionally sight is impaired.
The choreic movements are not always general ; sometimes they are limited to one-half of the body (hemichorea). In these cases either side may be attacked ; but even in hemichorea, according to Dr. Broadbent, muscles bilaterally associated in their action are affected to some extent on the two sides. When the disorder is unilateral, the muscular weakness, which is seldom completely absent, is more easy to recognise, as we have in the sound side a standard of comparison. When sensation is impaired in hemichorea, it is impaired on the same side of the body as that on which the muscles are affected. This fact is relied upon by Dr. Broadbent as a proof that the seat of the disease is not in the cord ; for if it were so, sensation would be impaired on the side opposite to the affected muscles.