CHOREA. 381 



active character, are observed in the lower extremities. The muscles 

 of the trunk also take part in the general restlessness, so that the spi- 

 nal column is inclined either forward, backward, or sideways ; some- 

 times in one direction, sometimes in another. If the patient be lying 

 in bed, he often is tossed upward, or toward the foot of the bed, or is 

 even pitched out of it. In the worst forms of chorea, the patients are 

 quite unable to sit upon a chair, but immediately slide off from it to 

 the ground. This morbid restlessness grows all the more intense and 

 general, if the patients pay attention to it, especially if they know that 

 they are being watched. Sometimes it is stronger upon one side than 

 upon the other, or is chiefly confined to one or more limbs. The mus- 

 cles of the larynx and those of respiration but seldom take part in the 

 disease, and the sphincters and the muscles of the pharynx probably 

 never do so. Owing to the constant motion, it is difficult for the pa- 

 tients to go to sleep ; when once asleep, however, the muscular twitch- 

 ing ceases. Occasional exceptions to these rules are now universally 

 ascribed to dreams of movement, ever since Marshall Hall originally 

 suggested the idea. 



Nearly all the motions of the body, with exception of those of 

 respiration and deglutition, are seriously embarrassed by this restless- 

 ness of the muscles. The articulation becomes indistinct, as the inten- 

 tional movements of the mouth and tongue are accompanied by others 

 which are unintentional. In eating, the fork misses the lips ; in drink- 

 ing, the beverage is spilt, so that a patient often has to be fed. Some 

 of them have great difficulty in offering their hand, others are unable 

 to dress and undress themselves. Even in slight cases all occupations 

 requiring delicacy of manipulation become impossible, as, even in 

 walking, the feet only touch the ground by a circuitous route, and, as 

 the entire body is constantly making superfluous and irregular move- 

 ments, there is something very remarkable and characteristic in the 

 gait of the patient. 



The other functions and the general health suffer comparatively 

 little. It is easy to comprehend why the patient should be dispirited, 

 sensitive, and wilful, when we consider that for weeks he has not been 

 master of his motions, and that he has been constantly taunted about 

 the mistakes he makes. Not unfrequently the grimaces of the pa- 

 tient are so at variance with his actual humor, or so unsuitable to the 

 subject of conversation, as to give him a foolish, imbecile look, although 

 his mind is quite sound. When of long duration, however, the accu- 

 racy of judgment seems really to be impaired, and other intellectual 

 disorder arises. Sometimes, but not always, there is complaint made 

 of headache and pain in the back. Although, strange to say, there i? 

 ao especial fatigue of the muscles, the joints of the limbs are some- 



