This disease appears oftener in children. It is characterized by irregular, involuntary twitching or contraction of the muscles. Authors recognize the liability of these cases to develop endocarditis.

Etiology

Children are oftener affected between five and fifteen years of age than at any other age. It is said to be rather rare among negroes and the native races of America. The reason for this is that only neurotic temperaments develop the disease. It is a disease of civilization. Putrefaction, with systemic infection by the toxins absorbed from this putrefaction, is the exciting cause. No one would believe that negroes and aborigines are less liable to putrefactive processes than the type of children who develop chorea; but when they develop enough toxin poisoning to cause a nervous temperament to develop chorea, these lower types will develop convulsions, paralysis, tuberculosis, scrofula, rheumatism, and kindred affections. Authors usually recognize a causal relationship between rheumatism and chorea. The basis on which chorea. rests is the same as that on which rheumatism rests. If a child does not develop rheumatism, it will be because it has not enough of the gouty diathesis, and the toxin poisoning will manifest in some other way. A child of a gouty diathesis will certainly develop rheumatism instead of chorea. The neurotic temperament will develop chorea and not rheumatism. In cases of chorea presenting a complication of arthritis there will be found the gouty diathesis, with a decided neurotic tendency. In all cases that I have seen of this nature the painful affections of the neurotic temperament have been more on the order of neuralgia than rheumatism. In some cases the affection has presented a state of neuritis rather than rheumatism. I have not seen a true inflammatory type of rheumatism complicating chorea, or vice versa.

Endocarditis, which is common in these cases, is an early development of inflammation due to toxin in the blood. Unless the cause is controlled, the disease will extend to the arteries, developing arteritis. Then, if the condition continues without interruption, there is nothing impossible about embolism, convulsions, and paralysis as the sequel of the diseased condition of the endocardium and the inside membrane of the arteries. It is not strange that, preceding chorea, such diseases as scarlet fever, measles, whooping-cough, and chicken-pox develop. As regards a tendency for the disease to develop in certain families, there is no question but that families of the neurotic type are subject to this and other nervous affections. Children are high-strung and easily excited. Too frequently mothers have no self-discipline, and their influence on children is to drive them into such diseases, rather than to steer them clear of chorea as well as other nervous affections. Children of this temperament find musical education very hard on their nerves, The strain of taking the lessons is often quite enough to develop chorea in decided types of this temperament. Such children are easily worried. They come to grief with lessons. They are hurt very badly by criticism. If teachers find fault with them, or scold them, or give them bad marks, it means indigestion and a day of nervousness--probably a headache. The average schoolteacher is unfit to take care of children of this type. Indeed, such children should be sent to institutions where they can have the proper feeding, and where they may be understood and disciplined in keeping with their needs. So far as the mind is concerned, these children belong to the brightest and most active. If their physique will hold up, they can outstrip all other classes. Very nervous children are liable to be thrown into chorea by a shock or an injury of any kind, or a surgical operation.

For the purpose of commenting on it, I shall give a part of a paragraph from Osler: "There are instances without endocarditis and without, so far as can be ascertained, plugging of cerebral vessels; and there are also cases with extensive endocarditis in which the histological examination of the brain, so far as embolism is concerned, was negative."

These facts are explained when it is recognized that children have been brought into a high state of toxin infection from decomposition in the bowels, and this infection has gone to such an extent as to create inflammation of the lining of the arteries as well as of the heart. A case might escape developing endocarditis, yet there would be sufficient inflammation in the arteries to furnish the emboli required to develop the infarctions necessary to account for the disease.

Symptoms

There are mild and severe types. The severe types are sometimes called maniacal. In mild cases the affection of the muscles is slight. Speech is not necessarily interfered with to any great extent, and the general health, so far as the appearance of the child is concerned, would pass for being all right; but no physician will recognize a child with ever so slight choreic development as a normal or healthy child. There is always indigestion, creating gastro-intestinal irritation sufficient to account for the unsteadiness of movements and the involuntary movements which such children develop. I am persuaded to believe that children who are kept largely on fruit and vegetables, with cereals, are more inclined to develop the lighter forms of this disease. The more severe types require the more toxic poisoning that comes from putrefaction of animal proteins. Children who have the mild type are pronouncedly nervous, and they are accused of having the fidgets. They have crying spells, and frequently scream out in the night. Some of them walk in their sleep. Stuttering, stammering, and awkwardness in speech are mild types of chorea.

The extreme or severe cases--those that are called maniacal--have truly a terrible disease. This disease develops more often in grown people or adults than in children. It first begins in the hands and arms; then the face is affected, and subsequently the legs. The movements are confined to one side. It is then called hemi-chorea. It is thought that it is more often developed on the right than on the left side. Its decidedly prominent symptom is muscular weakness. There will be a visible dragging of the legs, or limping, and a tendency for falling forward. Patients will took as if they were going to fall, but they save themselves. Sometimes there is a dragging of one leg. In some cases there is extreme paresis. These cases have a regular but rapid pulse.

Treatment

When children begin to develop signs of chorea, they should be taken from their studies and put to bed. The first few days they should not have anything to eat. Then for a few days they should be fed nothing but fruit morning, noon, and night. After the first week of fasting and fruit, then two fruit meals should be given each day, with a combination salad and one or two cooked, nonstarchy vegetables for the dinner. Nothing else is to be given until the choreic symptoms have entirely disappeared. But it is cruel to allow these children to stay out of bed. They must be kept there until they are well. Cases that have been allowed to develop extreme types may require a long time in bed before they get control of themselves; but they certainly should not be allowed to go out, unless they are carried either in the arms or in a go-cart. They are not to be allowed to use their limbs. After the child has been restored, it is necessary for the family to change its mode of living. Indeed, such families should employ a physician to go into the home and see what is wrong. I often think it would be a good thing for a physician to go and board for an entire week with such families, eating at the same table and learning all their peculiarities. No doubt there will be a great deal to do by way of straightening out the psychology of such a family. They are to be taught poise. Certainly they must be well balanced in the treatment of nervous children, or cures will not come to stay. After such children have been restored, they ought never to be given meat, eggs, fish, or any other animal foods, except very sparingly: eggs and lamb or chicken once or twice a week. Perhaps cheese and milk will take the place of meat or fish. A dish of cottage cheese at a dinner, or an ounce or two of ordinary commercial cheese, or an egg or two, not more than twice a week in the dinners. The other dinners should be built around one decidedly starchy food, such as baked potatoes, either Irish or sweet, or a dish of navy beans, butter beans, corn bread, whole-wheat bread, etc. The rest of the dinner will be one or two cooked, nonstarchy vegetables and a dish of salad. These children should always have a dish of salad with the dinners, whether they eat anything else or not. The severely chronic cases--those that have become organized, so to speak--may be improved by correcting their lives, and they may not. It stands to reason, however, that if they are put on the proper lines, they will certainly do better than where they are living wrongly each day. Incorrect living cannot help but make even a bad case worse, whereas correct living certainly ought to modify the worst cases and do them a certain amount of good. There is no special treatment for them, except to teach them to live normally.