The constant movement seems to cause wonderfully little muscular fatigue. In ordinary cases, if the movements are not exceptionally violent the general health is but little affected. The child may complain of gid diness and headache, but appetite is usually good, and the digestive functions are well performed, although the bowels may be costive. In bad cases appetite is often capricious and digestion impaired, and partly for this reason, partly from the difficulty in feeding the patient and the want of sleep, nutrition may suffer and the child become pale and thin.
The urine has always a high specific gravity at the height of the dis ease, and contains abundant urea and phosphates.
The mental condition may vary, according to the severity of the dis order, from mere depression or irritability to taciturnity, obstinacy, vio lence of disposition, or even furious delirium. In the milder cases intelli gence does not appear to be enfeebled, and although the patient often has a silly vacant expression, this is no more than can be accounted for by the child's own feeling of helplessness, and her consciousness that her contor tions and grimaces may be the subject of ridicule.
The temperature in chorea is normal unless the complaint be compli-. cated with a rheumatic attack, or be symptomatic of organic disease of the nervous centres.
Weakness of the muscles has already been referred to as an essential symptom of the disorder, but as a rule it is insignificant, and may not be noticed without special inquiry. Sometimes, however, the muscular weak ness assumes great prominence, and may even throw all the other symp toms into the shade. Thus a form of the disease is sometimes met with in which a paralysis or paresis of one or more limbs is the only symptom complained of. For instance, a little girl is said to have gradually lost the use of her arm. The band hangs down and is evidently very weak. The patient may perhaps by a great effort of will be able to raise it, but when she tries to grasp with the fingers the pressure is very feeble. The leg of the same side is sound, and there is no paralysis of the face or tongue. Sometimes the other arm is also weak, although to a less degree. In other cases the paralysis involves the leg as well as the arm of one side, but the face and tongue always escape. In all these cases, although to a casual
glance there may appear to be no movement at all, careful inspection will usually discover occasional slight twitches—faint clonic spasms—in the affected limb or on the sound side. Sometimes this is all that can be noticed, and the muscular power returns after a time without the occur rence of any confirmed disorder of movement. In other cases the clonic spasms become more and more marked as the paresis improves, so that when the power of the affected limb is almost restored the motor disorder is at its height.
There is another form of muscular' weakness which occurs later, and sometimes remains as a permanent condition after the disease has passed off. It affects the muscles which have been previously implicated, and is probably due to degenerative changes in the spinal cord. The muscles remain weak and become wasted, and perhaps contracted.
The state of the heart in chorea is very interesting. In a large propor tion of cases, at least of those occurring in young chiklren,•a mitral mur mur becomes developed in the course of the illness. This murmur may disappear as the symptoms of motor disorder decline, or may remain as a permanent condition. The temporary murmurs are often very variable in intensity ; coming and going ; heard with some beats of the heart and not with others. These • are probably due to some irregular action of the papillary muscles of the heart, the consequence of clonic spasm similar to that which takes place in the voluntary muscles of the body. Temporary murmurs, when not thus interrupted, may be the result of anfemia—a condition in which the blood is watery and the tissues of the heart relaxed, so that the left ventricle is dilated and the mitral orifice is insufficiently closed by its valve. In these cases there is often a basic pulmonary mur mur. We cannot say positively that a murmur has disappeared until we have examined the chest after exertion as well as when the heart is quiet. It is important, therefore, before pronouncing an opinion, to excite the heart's action by making the child run round the room. If the heart-sounds after this exercise still remain clear, we can say decidedly that the murmur has gone. Temporary murmurs are much more common in girls than in boys.