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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

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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