380 GENERAL NEUROSES, OF UNKNOWN ANATOMICAL ORIGIN. 



by volition, but take place against the will of the patient, his con- 

 sciousness meantime being perfectly unclouded. These movements go 

 on not only at times when the patient does not intend to move, but 

 also when he moves voluntarily. In the latter case, as the voluntary 

 motion is complicated by the involuntary, the proposed action of the 

 patient either is frustrated or carried out imperfectly or awkwardly. 

 The involuntary movements of chorea are distinguished from the more 

 simple and monotonous jerking muscular contractions of epileptic or 

 hysterical attacks, by a great degree of variety, and by a sort of com- 

 bination which imparts the aspect of design to the motions. A cursory 

 and superficial observer would be much more apt to overlook and mis- 

 take the former than the latter. 



In most instances the disease begins very gradually, and is not 

 recognized for some time. It may be noticed, perhaps, that the sick 

 child drops and breaks things a good deal ; that it does not sit still ; 

 that it writes badly, or makes more mistakes than usual in playing on 

 the piano, and it is accordingly scolded or punished that it may be 

 more careful and correct its awkwardness. The poor child often 

 does not know what it has done, and, in consequence of the unjust re- 

 proaches, becomes either depressed and sad, or else grows irritated and 

 perverse. The restlessness of the muscles, meantime, becomes more 

 and more apparent. The acts of awkwardness become more frequent, 

 and are grosser than ever. The child misses in reaching for its tum- 

 bler, pricks itself with its fork, or makes extraordinary grimaces. The 

 morbid character of this condition often becomes apparent to the minds 

 of its relatives quite suddenly, and without the occurrence of any 

 special change in the symptoms. It is much more unusual for the dis- 

 ease to develop suddenly, and from the outset to present the remark- 

 able symptoms which characterize St. Vitus's dance in its later stages. 



In pronounced chorea, the utmost variety of motions follow each 

 other, in a manner so manifold and grotesque that the term " insanity 

 of the muscles," which has been applied to it, seems quite appropriate. 

 In the face, the eyebrows are alternately contracted and separated, 

 the forehead wrinkled and smoothed, the eyelids rapidly winked, and 

 now and then are fast closed for a moment. The eyes roll hither and 

 thither, the mouth is successively pursed up, closed, then suddenly 

 opened and shut, now spreading into a smile, now drawn down as if 

 to weep, while the tongue is often and suddenly thrust forward. The 

 head itself is turned, now forward, now backward, now sideways ; the 

 shoulders are raised and sunken. The upper extremities are flourished 

 about. In the elbows, hands, and finger-joints, flexion and extension, 

 pronation and supination, abduction and adduction, alternate with 

 one another. Similar movements, which, however, usually are of less 



