Chorea

“ He believes the history of chorea to be this: “Owing to emotional disturbance, sometimes stopping of various vessels of the brain, or sometimes the presence of organic disease, there is an altered condition of the ganglionic cells throughout the nerve-centres. If the cause is removed and the altered condition of the nerve-cells goes only so far, it remains what we call a functional disease. If it goes so far that the cells show alteration, we have an organic disease of the nervous system.” ”

“ It is true that changes in the intensity of the symptoms seem to confer a remittent character on the affection, but there is nothing at all comparable to the sudden and unexpected waxing and waning of the form of chorea at present under consideration. None of the pathological attributes just mentioned concerns variable chorea, which, in addition, differs from Sydenham's chorea in two points—the multiplicity of the types of movement, and the fact that the patient can voluntarily check his involuntary actions. ”

“ 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. ”

“ Her mother was frightened by seeing a case of chorea some time before the child was born. The movements were observed at birth, and have continued always. The patient was brought to my clinic at the Infirmary for Nervous Diseases, and her condition noted as follows: The movements are general and continuous; the arms and legs are in constant motion, and the mouth is perpetually grimacing; there is tremor of the tongue when it is protruded; volitional efforts increase the movements; during sleep they cease entirely; tendon reflexes are normal; there is no paralysis ”

“ Occasionally sulkiness results from some special form of nervous disease. It may be an initial symptom of that strange malady of childhood, chorea. A child affected with chorea is restless, uneasy, and weak in muscular control. Muscles of the face twitch, the child has difficulty in using his hands, and, in later stages of the disease, the arms and legs make random, involuntary movements. ”

“ It was the female portion of the community that suffered most. Anything offensive to the mind re-acted convulsively on the body, causing a sort of chorea, which it was attempted to distinguish or divide into two distinct forms of the disease, called mental and physical chorea. ”

“ The cause of death in chorea may be from the intensity of the disease, and in this case the symptoms are generally violent from the outset, increase to an extreme extent, and then collapse and coma come on. The movements may cease when the collapse occurs, but they may continue to the last, growing gradually less until death. ”

“ In a variety of instances, there is the irritable temper which accompanies chorea in the human being, and most certainly when the disease has been extensive and confirmed.
Chorea, neglected or improperly treated, or too frequently pursuing its natural course, degenerates into
paralysis agitans
. There is a tremulous or violent motion of almost every limb. The spasms are not relaxed, but are even increased during sleep, and when the animal awakes, he rises wilh agitation and alarm. There is not a limb under the perfect control of the will; there is not a moment's respite ”

“ Social condition has little or no effect on the production of chorea, but it is more common in cities than in the country. Indeed, everything which increases the excitability of the nervous system during development adds to the tendency to the disease. ”

“ Although there are several recorded cases of human chorea in which lesions of the spinal ganglionic cells have been found, we cannot believe that this can be a constant lesion in chorea. The disease is too transient in many cases, and presents too many variations and anomalies, for the cord to be always the seat of the diseased condition. ”

“ In the healthy child teething can cause no such effect. Both these manifestations, the convulsions and the bronchorrhœa, are starvation neuroses. In such children many other trivial conditions may weaken the controlling mechanism.
In older children chorea, whatever be its cause, is evidently connected with the developmental process. The beneficial effects in chorea of absolute rest in bed and forced feeding are a matter of common observation. Dysphagia as a neurosis in children is uncommon. ”

“ As during the years from four to eight there is great danger that overemphasis of the activities of the accessory muscles will sow the seeds of chorea, or aggravate predispositions to it, now again comes a greatly increased danger, hardly existing from eight to twelve, that overprecision, especially if fundamental activities are neglected, will bring nervous strain and stunting precocity. ”

“ A large majority of the cases of chorea occur in females and at the period of life when the nervous system is subjected to unusual requirements. In these cases the "Favorite Prescription" effects a gradual restoration of nervous energy, and improvement in the tone of the nerve centres, and by its direct effect upon the circulation in the ovarian region, eliminates the most potent causes of debility. In young people, we usually advise a dose of three drops for each year of the age. ”

“ It is often rife in one district a long consecutive time. Facts like this must certainly be regarded as pointing to a condition of the blood as one, at least, of the causes of this terrible disorder. This condition of the blood may react upon the nerves, and maintain in them a particular morbid state. Chorea seems also to depend primarily on the state of the blood, and is indirectly curable by medicines which, like Iron and Quinine, improve its condition. In a weakly and strumous child it may be brought on by a sudden fright which would not affect one of a good constitution. ”

“ The involuntary movements of chronic chorea, like those of Sydenham's chorea, are illogical, but they are combined in a co-ordinate manner—that is to say, certain functionally associated muscular groups act simultaneously as for a particular end: the patient shrugs his shoulders, closes his fists, cracks his fingers, utters cries, he swallows, sniffs, sucks in his breath, makes the sound of kissing, etc, in all of which actions orderly participation of the musculature in a foreordained way is evident. Slight twitching of individual muscles and parts of muscles also occurs. ”

“ PARALYSIS.—Not infrequently in chorea there is paralysis to a greater or less extent. It is generally one-sided, and most often involves the upper extremity. The limb affected is the one in which the movements were most violent. The arm may hang entirely powerless or it may be only enfeebled, and feeling to the patient like a dead weight. The paralysis always recovers with the chorea or soon after. ”

“ Chorea, tonic spasms, paresis and paralysis are on the contrary habitually late manifestations and often seem to be sequelæ determined by toxin poisoning of the nerve centers, or degenerations of their structure. Choreic movements may be confined to the head, or a limb, or they may affect the whole body. Tonic spasms often affect the neck, turning the head rigidly to one side. ”

“ One never sees in chorea a succession of similar movements, but though a patient be suffering from several tics, each of them is reproduced always in the same fashion. Unilaterality of distribution is more common in chorea than in tic; in other words, chorea, more or less, follows anatomical lines in the regions it affects, whereas the incidence of tic is physiological. ”

“ Pregnancy favors the occurrence of chorea, a circumstance explicable by the increased irritability of certain nerve centres characteristic of the pregnant woman. The chorea of pregnancy occurs for the most part in primiparæ, it is commoner in young than in older pregnant women, and appears especially in the early months of pregnancy. ”

“ In the latter cases the disease generally excites some hysterical symptoms.
This affection differs from chorea. The patient has no difficulty in keeping the affected limbs steady, if not called upon to exert them, and in general exertion is irksome and painful. Like chorea, however, it is always attended with a constipated condition of bowels. The evacuations, also, are uniformly hard, scybulous, and dark coloured. ”

“ A woman of twenty-two, who had never been very strong, had an attack, at eight years, of involuntary movements of face and arms which prevented her feeding herself, and at the hospital a diagnosis of chorea was made. ”

“ It is of the greatest value in bad cases to place the patient in bed and keep him there until the symptoms improve. John Van Bibber of Baltimore has treated a number of cases of chorea successfully by keeping them secluded in a darkened room. Such an extreme degree of isolation is not often necessary, and it might make a child more nervous.
In children the patient should always be taken from school and kept from exciting play. Plenty of fresh air and wholesome food should be [p. 456] insisted upon. Change of air to the mountains or to the seashore often effects a cure in a short time. ”

“ 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. ”

“ 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. ”

“ He especially noted the existent cases and studied the notes on the old cases of the peculiar form of chorea his father and grandfather had had in their practice. ... (H) is father had classified these cases. ... ”

“ Other diseases act directly upon the brain and nervous system, as leptomeningitis, pachymeningitis, sclerosis, capillary aneurisms, embolisms, cerebral hemorrhage, tumors, disease of arteries, syphilis, caries, exostosis, abscess, internal otitis, sunstroke; still others by disturbances in the cerebral circulation, as diseases of the heart and kidneys; others by vitiating the blood circulating in the brain, as in the acute stage of febrile disorders; others in some general unknown way, as chorea, hysteria, epilepsy, gout, rheumatism, malaria, pneumonia ”

“ Aretæus defines cholera to be a retrograde movement of the matters in the body upon the stomach and intestines, consisting of a discharge upwards and downwards of bile, which, if the disease proves fatal, becomes black; and, at the same time, the extremities are cold, with profuse sweats, pulse small and dense, constant straining to vomit, and tenesmus. He also makes mention, among the symptoms, of spasms and contractions of the muscles in the legs and arms, borborygmi, tormina, and syncope. ”

“ To say the truth however, it does not appear that Cholera is a very proper name for it; for it seems much more a disease of the blood than of the bile. It is by no means always accompanied with disorder in the bowels, but it is as if a man’s life blood were suddenly poisoned; as if it were choked up so that it could not flow freely, and therefore there is a great feeling of weight and pressure about the heart and chest. The powers of life seem palsied, the legs and belly become cold and cramped, and the pulse so weak that you can scarcely feel it. ”

“ In those rare cases, called “cholera sicca,” in which no purging takes place, the intestines have been found distended with the excretion peculiar to the disease, 11whenever an examination of the body has taken place after death. In all the cases of cholera that I have attended, the loss of fluid from the stomach and bowels has been sufficient to account for the collapse, when the previous condition of the patient was taken into account, together with the suddenness of the loss, and the circumstance that the process of absorption appears to be suspended. ”

“ The loss of water from the blood causes it to assume the thick tarry appearance, so well known to all who have opened a vein in cholera. The diminished volume of the blood causes many of the symptoms of a true hæmorrhage, as debility, faintness, and coldness; while these effects are much increased by its thick and tenacious condition, which impedes its passage through the pulmonary capillaries, thereby reducing the contents of the arteries throughout the system to the smallest possible amount, as indicated by the small thready pulse. ”