Chorea





This twitching affection, so familiar that it need not be described

particularly, is sometimes classed as a pure neurosis, sometimes as a

nervous disease with perhaps some organic basis and sometimes is

placed among the ailments related to rheumatism and attributed to some

pathological condition of the circulation.





Etiology.--Two elements must be considered in the problem of the

etiology of the disease--the predisposition and the direct

occasion. The affection occurs particularly in nervous children who

are made to occupy their intellects too much while their muscular

systems are kept quiet for long hours. Often a preceding running down

in weight is noticed, though sometimes the child only fails to

increase in weight as it should in proportion to its growth. It occurs

quite frequently among chlorotic girls just before or about the time

of puberty. Anemia generally seems to predispose to it, but the

affection may occur among children who seem to be in excellent

physical health, though usually a distinct nervous heredity is found.





Immediate Causation.--Fright is one of the most frequent immediate

causes or occasions of the development of chorea. Mental worry of any

kind may have the same effect. Scolding has produced it; a sudden

grief has seemed to be the occasion; a slight injury, and still more,

a severe injury, or a surgical operation, even a slight one, may be

the forerunner of it.





Pathology.--No definite lesions have been found to which the disease

can be attributed, though a careful search has been made for them.

Endocarditis is an extremely common accompaniment. It is probably

present in three-fourths of the cases that have come to autopsy. Osler

found it in sixty-two out of seventy-three cases in the literature.

The association of the affection with rheumatism is insisted on by the

French and English particularly, and certainly in a considerable

number of cases there is a history of preceding or coincident

rheumatism, that is, an acute rheumatic arthritis. Often these attacks

are concealed under such names as "growing pains" or "colds in the

joints" but it is not hard to elicit a history of a red and swollen

joint with some fever. In children mild cases may occur of genuine

acute rheumatism with the involvement of but a single joint and that

not severely. These mild forms are often found in the history of cases

of chorea.



It seems likely that the heart affection is often responsible for the

symptoms and it is probably through the endocarditis that whatever

connection there is between chorea and rheumatism exists.



All the elements in the disease point to the influence of the mind

over it. The predisposition is caused by over-use of the mind at a

time when many claims are being made on the nervous system because of

the growth of muscles. There must, as a rule, be a pathological basis,

natural or acquired, that is, something that tends to produce a defect

in the circulation, but even without this certain children suffer from

the affection. If the patient is an object of solicitude or of

curiosity at home or at school, the symptoms rapidly become worse. At

any time the consciousness of observation makes them worse. The

symptoms do not occur during sleep, or at times when the patient's

mind is much occupied with some absorbing interest. They lessen just

to the degree that the patient's own attention is not called to them

or the consciousness not allowed to be concentrated on them. Chorea

often occurs in bright, intelligent children and always seems worse in

them.





Treatment.--The story of the therapeutics of chorea in recent years

strongly confirms the idea of the place of mental influence in the

cure of the disease. We have had a whole series of remedies,

introduced with a promise of cure by distinguished authorities, used

for a time with apparent success by many physicians, and then

gradually falling into innocuous desuetude. It was recognized that any

remedy would have to be used over a rather prolonged period, at

least from five to ten weeks. It was appreciated, also, that the

patient must be kept quiet, both in mind and body, emotional

disturbances especially being avoided, that all physical functions

have to be set right and that the nutrition particularly must be

corrected if in anything it is abnormal. Where all this is done

patients recover without any remedy quite as promptly in most cases as

with any of the supposed specifics. Expectant treatment, supplemented

by symptomatic treatment, has proved in many institutions to give

excellent results without the necessity of troubling the patients with

more or less dubious drugs. It was important that the patient should

be given certain medicine and impressed with the idea that this

medicine was expected to do them good, a suggestion automatically

emphasized at every dose, but it is probable that few men of

considerable clinical experience now hold the notion that we have any

genuinely curative remedy for chorea, though we have certain tonic,

alterative remedies which, in conjunction with the setting of the mind

at rest, help to put the patient in a condition where the affection is

gradually overcome.



The most important object in the treatment of chorea must be its

prevention or its early recognition, and its immediate treatment; then

there is little likelihood of relapses and, above all, the condition

does not last long. Children who have had an attack of acute articular

rheumatism or who have suffered from growing pains or any other of the

rheumatic simulants of childhood should be watched carefully during

their growing period and at certain critical times in early life. They

should be especially regarded immediately after being sent to school.

The first sign of involuntary twitchings should be taken to mean that

the children are overborne and a period of rest from anxiety and study

and over-exercise should be afforded them. Of course, all this

watchful care must be exercised without attracting the little

patient's attention, or the very purpose of the care will be defeated

and the mind disturbed.



Rest does not mean that patients should be kept absolutely in bed even

after chorea has frankly developed, but that there should be hygienic

rest. Long hours of sleep, interesting occupations without much

exercise, a period of lying down in the afternoon, but, above all,

such occupation of mind with simple pleasant things as keeps their

attention from themselves. Visitors should not be allowed to see them;

above all, they should not be conscious objects of over-solicitous

care on the part of father and mother or the relief of symptoms will

be delayed and the condition will be made worse. As a rule, children

do not worry about themselves nor their physical ailments, but they

can be made to do so by seeing the over-anxiety of others. A good

nurse of sympathetic nature with power to interest the child, is

better than its mother for a constant companion, though family life,

the playing with brothers and sisters and the regular routine of home

is the best possible mental solace and occupation. Grandmothers are

useful adjuvants in the treatment late in the affection. At the

beginning their over-solicitude nearly always does harm.





Habit Following Chorea.--In certain nervous children after the chorea

itself has subsided there remains a habit of twitching that often is

almost more intractable than the chorea itself. This is particularly

likely to be manifest in children who have an unfortunate nervous

heredity or in those whose nervous systems have been impaired by

preceding infections disease as anterior polio-myelitis, syphilis or

one of the forms of meningitis. Occasionally it is seen in children

without nervous heredity, but they are usually children surrounded by

solicitous relatives, made the centre of pathological interest and

constantly fussed about. The habit is not surprising and would remind

the observant physician of the whoop that by habit sometimes clings to

children in any cough that they may have for months after they have

had whooping cough. Often it will be found that these children are

capricious eaters, that they take tea and coffee, that their diet

instead of being the simple nutritious food that they should have

consists of many things that their mothers obtain to tempt their

appetites and that the children can really have anything they crave

for and get it much oftener than is good for them. To continue any

form of presumedly specific treatment in these cases does no good. If

arsenic is used over long periods, or any of the salicylates because

of the supposed connection of chorea and an underlying rheumatic

diathesis they will certainly do harm. The patients' diet can be

regulated, nerve stimulants of all kinds must be denied them, and

their appetites must be brought into order by the proper care of a

nurse who will not yield too readily to their caprices, and then the

solicitous environment must be changed. These cases represent a good

many of the so-called prolonged choreas and are really habits or tics

due to concentration of mind and a certain hysterical tendency to

continue to attract attention which may be noted.





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