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CHOREA 
 
ON CHOREA 
 
 AND OTHER ALLIED MOVEMENT DISORDERS 
 OF EARLY LIFE 
 
 BY 
 
 OCTAVIUS STURGES, M.D. 
 
 FELLOW OF THE ROYAL COLLEGE OF PHYSICIANS 
 
 PHYSICIAN TO THE WESTMINSTER HOSPITAL 
 
 ASSISTANT-PHYSICIAN TO THE HOSPITAL FOR SICK CHILDREN 
 
 LONDON 
 SMITH, ELDER, & CO., 15 WATERLOO PLACE 
 
 1881 
 
 iAll rights reserved'^ 
 
TO 
 
 D^ JOHN ABERCROMBIE 
 
 MEDICAL REGISTRAR TO THE HOSPITAL FOR SICK CHILDREN 
 
 '§^15 '^oxk is gnscribeb 
 
 IN RECOGNITION OF THE SOURCE WHENCE MUCH OF 
 
 ITS MATERIAL IS DERIVED 
 WITH THE GOOD WISHES OF HIS FELLOW-LABOURER 
 
 THE AUTHOR 
 
PREFACE 
 
 The object of this book, a portion of which has already 
 appeared in medical journals, is to place before the reader 
 such an account of Chorea, and of the theories which 
 prevail concerning it, as shall enable him to form some 
 judgment as to the nature and suitable treatment of a 
 disorder which is not very common in ordinary practice, 
 yet subject to so many varieties that the study of a few 
 examples gives no adequate conception of its true cha- 
 racter. 
 
 The first and chief part of the work is occupied with a 
 description of Chorea and of the several hypotheses which 
 have been provided to explain it ; the rest is devoted to 
 an examination of these theories in the light of admitted 
 facts, together with an account of that particular view of 
 the pathology and management of the affection which a 
 full consideration of its phenomena seems to suggest. The 
 Appendices, referring to a large number of cases which 
 have been under my own observation and treatment, claim 
 to furnish some of the evidence upon which the conclusions 
 of the book are founded. 
 
 In expressing dissent from all anatomical explanations 
 of Chorea, it has been necessary to refer to many eminent 
 
vi PREFACE. 
 
 authorities who have attempted to reach its structural basis. 
 In so doing I must not be understood as setting up my 
 own opinion against accepted doctrines of pathology. The 
 failure, or at least the ambiguity, of morbid anatomy in 
 this particular is not denied, and in calling attention to 
 it I have only given utterance to what is generally ad- 
 mitted. If it should be thought that too much space is 
 occupied with such controversy, the apology must be that 
 the subject in its present stage cannot be otherwise dealt 
 with, and that it would be absurd to discuss the treatment 
 of Chorea until we have come to some agreement as to its 
 nature. 
 
 My purpose throughout has been to show that Chorea, 
 no less than the many smaller movement transgressions 
 which resemble it, is a disease of function due in large 
 measure to preventible causes ; that the nature and cir- 
 cumstances of children render them apt subjects for such 
 a disorder ; and that, while it is beyond reasonable ex- 
 pectation that the course of childhood should be kept 
 altogether out of its reach, we are not without guidance 
 as to the sort of training and management which affords 
 the surest protection against its attacks, and the best 
 material for its cure. 
 
 85 WiMPOLE Street : 
 October 16, 188 1. 
 
CONTENTS. 
 
 INTRODUCTION. 
 
 PAGE 
 
 The Place in Nature of Functional Nervous Disease . . . . . i 
 
 CHAPTER L 
 
 GENERAL DESCRIPTION OF CHOREA. 
 
 Pedigree — Definition — Parts affected — Degrees of severity — Mental involve- 
 ment — Temperament — ^Age — Sex — Adult and senile chorea — Geographical 
 distribution — Causes — ^Varieties — Progress — Paralytic symptoms — Re- 
 currence — Connection with heart disorder — Sequelae . . . . ii 
 
 CHAPTER II. 
 
 CONNECTION OF RHEUMATISM WITH CHOREA. 
 
 Analysis of 177 cases — Comparison with other statistics — Conclusions in 
 reference to rheumatic connection, (i) from statistics, (2) from general 
 considerations 32 
 
 CHAPTER III. 
 
 THE HEART SYMPTOMS OF CHOREA. 
 
 Facts for explanation — The comparative frequency of heart disturbance in 
 chorea of different ages — The heart symptoms referred to endocarditis — 
 to a sympathy on the part of the heart with the muscular disorder — 
 Difficulties in the way of both hypotheses — Conclusions .... 44 
 
 a 
 
viii CONTENTS. 
 
 CHAPTER IV. 
 
 CHOREA AS A FATAL DISEASE. 
 
 PAGE 
 
 Recorded examples of fatal chorea — Age and sex in relation to fatality — Exciting 
 causes — Morbid anatomy — Conclusions 72 
 
 CHAPTER V. 
 
 THE PATHOLOGIES OF CHOREA. 
 
 Connection with rheumatism — with spinal meningitis — with pericarditis — 
 with enfeebled nutrition — The embolic theory of chorea — Vascular and 
 nervous changes — Disturbed nutrition of cerebral ganglia — Altered states of 
 blood — Chorea a functional disturbance — Continental opinion — Sum- 
 mary ............. 82 
 
 CHAPTER VI. 
 
 THE PATHOLOGIES OF CHOREA IN THEIR APPLICATION. 
 
 Clinical conditions to be satisfied — Symptoms of embolism compared with 
 those of chorea — The direct evidence in favour of the embolic theory — Peri- 
 vascular degeneration of brain and cord as a cause of chorea — Hypothetical 
 explanations — Chorea ascribed to temporary trophic changes — Application 
 of such theories — The ataxy of chorea 96 
 
 CHAPTER VII. 
 
 CHOREA A FUNCTIONAL DISEASE. 
 
 The parts selected by chorea — Its varieties and modifications — Its form in 
 relation to its cause — Alliance to hysteria and emotion — Manner of pro- 
 gress and of recurrence no 
 
 CHAPTER VIII. 
 
 CHOREA A FUNCTIONAL DISEASE {c07ltinucd). 
 
 Some objections considered — The duration of chorea in relation to its cause — 
 Duration at various ages — Chorea in association with structural lesions — 
 The effects of chorea to be distinguished from its cause — Chorea incom- 
 patible with structural disiase — Various modes of expressing existing 
 knowledge in reference to the pathology of chorea 124 
 
CONTENTS. IX 
 
 CHAPTER IX. 
 
 THE TREATMENT OF CHOREA. 
 
 PAGE 
 
 Indications to be fulfilled — Removal of source of irritation in young children — 
 Rest — Signs of debility as indications for treatment — Change of place — 
 Drug remedies — Treatment of acute chorea — Chronic chorea — Conva- 
 lescence • 13^ 
 
 CHAPTER X. 
 
 THE PREVENTION OF CHOREA. 
 
 Development and direction of childish movement — Allowance for emotional 
 
 movement — The therapeutics and morals of movement .... 142 
 
 APPENDIX A. 
 
 Abstracts of Cases illustrating some of the Associations of 
 Chorea :— 
 
 1. Heart disturbance preceding chorea 151 
 
 2. Choreic heart disturbance following fright . . . . .152 
 
 3. Chorea in a youth following rheumatic endocarditis . . . 152 
 
 4. Chorea with hemiplegia. Remarks . . . . . . 153 
 
 5. An example of the rapid transitions of chorea . . . .156 
 
 6. Violent chorea in an adult. Remarks on treatment . . . 158 
 
 7. Chorea of imitation. (Dr. Brabazon.) 163 
 
 8. Chorea with muscular paresis and heart murmur in a youth . . 164 
 
 9. Chorea of the hand following muscular exertion .... 165 
 
 10. Chorea changing from left to right side, joint affection succeeding. 166 
 
 11. Hemichorea in a young woman ....... 167 
 
 12. Chorea in middle life from mental shock . . . . .168 
 
 13. Chorea with general muscular paresis. Benefit of mechanical 
 
 support 169 
 
 14. Chronic chorea with incontinence of urine, &c. Improvement under 
 
 discipline .......... 171 
 
 15. Chronic chorea in a boy of eleven ultimately fatal .... 172 
 
 APPENDIX B. 
 TABLE A. 
 
 132 consecutive cases of chorea, showing its rheumatic connec- 
 tion, state of heart, exciting causes, limbs affected, &c. . 175 
 
 TABLE B. 
 
 45 consecutive cases illustrating the same points as Table A, but 
 
 IN older subjects 187 
 
 INDEX 
 
 195 
 
Erratum. 
 Page 147, line i,for hopeless ;'^ai/ helpless 
 
INTRODUCTION. 
 
 THE PLACE IN NATURE OF FUNCTIONAL NERVOUS DISEASE. 
 
 There exists in some quarters a disposition to discredit — and 
 even to deride — the reference of disease, and especially of nervous 
 disease, to functional causes. * Functional or unsubstantial 
 diseases,' it has been said, * are flitting before the microscope 
 like ghosts at sunrise. Nervous disorders, the most evasive of 
 all, are becoming tangible.'^ I am not about to dispute this 
 assertion, but rather to ask what it means. Functional disorder 
 of some degree, I suppose, everyone must admit, inasmuch as 
 the elements of such disorder are to be met with universally. 
 Granting that there is a wide difference between ordinary 
 emotional spasm and hysteric convulsion ; or between the 
 temporary fidgetiness of shyness and the long-enduring agitation 
 of chorea, yet still there is a region intervening which is occupied 
 by muscular disorder of an equivocal kind. The question is, 
 what degree of such disorder is to justify the anatomist in making 
 search for its material expression? No one will answer any 
 degree of it whatever, since that would be to include the whole 
 of mankind, and would involve the absurdity of making disease a 
 universal possession. We are entitled to ask, therefore, how far 
 and in what manner that orderly action of the voluntary muscles 
 which hypothetically represents health may be departed from 
 before disease becomes ' tangible ; ' if indeed we may not ask 
 
 * The Art and Science of Medicine. Introductory Address at St. George's 
 Hospital, by Dr. Dickinson. 
 
 B 
 
2 CHOREA. 
 
 yet further upon what authority any particular method of 
 muscular conduct is insisted on rather than another as being its 
 proper pattern, all declensions from which are to be regarded as 
 morbid. 
 
 No one will deny, I suppose, that the several conditions of 
 consciousness find a ready and accurate expression in the move- 
 ments and attitudes of the body. So peremptory, indeed, is this 
 union between the mind and the muscles that the term * voluntary ' 
 commonly given to the latter is only partially applicable. It is 
 true that the more violent gestures get subdued and toned down 
 by education, and that custom and imitation supply a certain 
 number of conventional and meaningless movements, yet the 
 muscles are not the less expressive on that account. We are 
 seldom deceived as to the nature of emotion on account of the 
 effort of repression which is used. On the contrary, we can see 
 and measure the force of both. 
 
 The monotony and uniformity of civilised life tend of course 
 to reduce these motor phenomena to a minimum. The full 
 display of passion or emotion is rare, and when it occurs the 
 sympathy of the observer is so far enlisted as to divert attention 
 from the mere muscular condition apart from what it expresses. 
 Thus the several modes of response to as many different states of 
 consciousness, the spasm of horror, the restlessness of embarrass- 
 ment, the tremor of fear and sudden disaster, violent and dis- 
 composing as they are physically considered, pass without notice, or 
 are noticed only for the meaning they convey, just as the movements 
 of the tongue and lips are not considered in themselves or apart 
 from the words they utter. What would be really surprising would 
 be the absence of these several emotion movements, or still more, 
 the expression of any one emotion by means of muscular move- 
 ments such as we are accustomed to associate with another. Thus 
 while many phenomena of movement which are involuntary and 
 disabling are readily accepted as amongst the natural endow- 
 ments of the individual no less than are the acts which arc 
 
INTRODUCTION, 3 
 
 voluntary and deliberate, yet must it be provided that each of 
 these shall have its proper motive. Anger excites spasm, fear 
 tremor, mental embarrassment restlessness, and so on. A tremor 
 with no particle of fear or dismay to justify it, a rigid spasm with 
 no sensation of anger or suspense, a restlessness of the limbs with 
 the mind at rest — these are conditions which require a separate 
 explanation. The ordinary laws of emotion movement do not 
 provide for them. Some extra and separate motive must be 
 sought for. 
 
 But while thus ascribing to emotion a great variety of mus- 
 cular phenomena, it is necessary to remember that this particular 
 motive extends over a wide range including even in some individuals 
 the ordinary conditions of existence. In some temperaments and 
 at some periods of life the most common incidents will suffice to 
 provoke emotion. Familiar illustration of this is seen in child- 
 hood, whose ordinary movements indicate a ready and constant 
 yielding of this kind. Again, the spasmodic movements and 
 involuntary gestures of youth are due to such nervous exaltation 
 as is with them habitual, and, indeed, proper to that stage of 
 physical development. And we may say generally that what oc- 
 casions emotion in one, with its accompanying bodily disablement, 
 will brace and nerve another to his fullest capacity. We cannot 
 say beforehand how or when emotion phenomena will be excited. 
 We know only that, while different individuals are variously re- 
 moved from emotion, there is no one altogether beyond its reach; 
 and that the response to such emotion is by means of particular 
 movements, spasms, and palsies common to all mankind. 
 
 But we need not confine ourselves to emotion alone, we may 
 consider as well the ordinary movements of intelligence, those 
 muscular acts by means of which we are always expressing during 
 our waking hours the common current and transitions of thought 
 and sentiment. Such movements, although of the same insti- 
 gation as the emotional, are so directed and governed by the will 
 as to subserve the purposes of intelligence. The period of life 
 
 B 2 
 
4 CHOREA, 
 
 when these movements are the most precise and orderly is that of 
 early middle age, when the muscular frame, while it maintains 
 stillness without obvious restraint, exhibits at the same time by 
 the disposition of the limbs and features the ability to move with 
 alertness, and to use the muscles for intelligent expression without 
 surrendering them to spasm or palsy. He is manifestly the best 
 upon whom this self-imposed control sits the easiest. Rare any- 
 where, such composure is hardly to be looked for until such time 
 as the comparative calm of middle life has been reached. And 
 what always finds place in such a deportment, side by side with 
 the various sentiments that are animating it, is the continual, 
 watchful presence of self-control, a control of which the highest 
 exercise is seen in the power to maintain a vigorous, capable, un- 
 constrained stillness of the whole frame. 
 
 This rare perfection of muscular government, I say, is the 
 end and outcome of a lengthened training having for its object 
 not so much to direct the movements as to restrain them. The 
 limbs which are thus disposed have but lately emerged from a 
 condition of continuous, impotent movement where they have 
 been swayed about under an influence lower than the reason yet 
 overpowering it. Even now, if anything should occur to disturb 
 the even balance of the mind the restless, motiveless movement 
 of the earlier time would reappear.^ The best and fullest power 
 of control, indeed, never becomes altogether spontaneous and 
 self-acting. It is not only easily overborne by passion and 
 
 ^ It will be seen in the sequel that familiar and widely recognised facts such as 
 these are expressed with great variety of phrase. Thus, for example, Professor 
 Bain speaks of a 'central spontaneous energy or activity as a fundamental and per- 
 manent property of the system.' ' The active display of the muscles,' he says, ' is 
 most usually and abundantly brought into play by the stimulus of our various 
 feelings, yet is there no reason for supposing that dead stillness would be main- 
 tained if outward prompting were withheld.' He further speaks of the restless 
 activity of childhood as ' only to be accounted for by a central fire that needs no 
 stirring from without.' — See Bain on The Emotions and Will, Part. II. Chap, I. 
 What I desire of the reader throughout this discussion is that he will separate 
 facts from expressions, and not accept any technical paraphrase or generalised 
 statement of phenomena in the light of new knowledge. 
 
INTRODUCTION, 5 
 
 emotion, but its constant exercise is so difficult and irksome that 
 any occasion for being rid of it is readily taken advantage of 
 Herein we have one of the uses of laughter, that half-voluntary 
 spasm which in many states of mind affords welcome relief from 
 complete muscular order. Again, the best deportment will seek 
 relaxation by means of a variety of distortions, stretchings and 
 grimaces so soon as these may be indulged in without obser- 
 vation. Such acts are proportioned, as everyone knows, not to 
 the mere bodily fatigue, but rather to the degree of constraint that 
 has been called for, extreme ceremonial or extravagant gravity 
 needing a larger measure of such relief than the common busi- 
 ness of life. It is easy to see that the circumstances may be 
 such as to make the natural craving for this kind of indulgence 
 quite irresistible, insomuch that it has to be yielded to in public 
 as well as in private, and gets noticed and stigmatised as disease. 
 
 And along with this careful control of movement in the 
 presence of others and its relaxation afterwards, we have to con- 
 sider the obedience that we owe to a conventional code of conduct. 
 Although, as we have seen, there can be no actual uniformity of 
 muscular response, but each of us must act after his own prompt- 
 ing, yet is there a strict pattern set up for general imitation. 
 Whoever errs from that pattern, as by too ready or too violent a 
 display of movement or of spasm, soon finds that these extra acts of 
 his, which would be accepted and allowed if appearing upon proper 
 occasion, subject him to express notice, and (during the tutored 
 period of life at least) to rebuke or ridicule ; and, inasmuch as 
 muscular obedience is more difficult when it is thus observed 
 upon and mistrusted, and the loss of confidence in movement is 
 an extra incentive to error in movement, we have here conditions 
 which must tell directly on the side of disorder. 
 
 It thus appears that muscular response varies very widely with 
 the individual, the time of life, and the circumstances. We can 
 give no stricter account of it than this : that it will be such or such, 
 according as the conditions in their different associations combine 
 
6 CHOREA. 
 
 to make it. With certain methods of movement and of spasm, as- 
 cribed generally to emotion, we cannot say beforehand what is the 
 material which each individual will find sufficient for emotion, the 
 very same cause which disables one bracing up another to his best 
 response. With certain conceptions regarding the voluntary muscles 
 as obedient agents of the will, and moving only at its bidding, we 
 find, in fact, that their natural and untrained state is one of con- 
 stant movement, which is so imperative that the best discipline, 
 far from controlling it absolutely, serves rather to disguise its 
 necessity by giving it some show of purpose. With a certain ideal 
 pattern as to the demeanour which is the fittest, we never actually 
 attain such demeanour ; it is not even approached except by long 
 and careful training, and the effort that holds it is always ready to 
 escape. With certain aids to orderly muscular conduct provided 
 by the public sentiment, we perceive that, after a while, the pre- 
 servation of a set attitude becomes intolerable, and that the help 
 which outside observation gives at first to order and stillness, it 
 gives at last to disorder and involuntary movement. I am not 
 asking now how much, or how little, of muscular disorder actually 
 arises from this wide reach of emotion, or this infirmity of control 
 over movement, or this disturbing influence of having to conform 
 to a pattern ; I only say that we have here the elements of dis- 
 order — material out of which it is inevitable that disorder should 
 spring and grow. Yet to what degree such disorder may spread 
 under the most favouring conditions, or what particular pheno- 
 mena of so-called disease may be thus accounted for, is a separate 
 question. 
 
 And while we thus perceive that the muscular control is 
 variously evaded at the successive periods of life, and take it for 
 a law that the novelty of childhood, the access of new passions in 
 youth, and the monotony of old age should each in turn serve to 
 produce the characteristic movements and attitudes of those 
 periods, it is easy to see besides, how, in a community like ours, 
 the several causes of muscular disobedience and disorder should 
 
INTRODUCTION, 7 
 
 press unequally at different ages. It is to be observed, especially, 
 how the motor infirmities of early life get confirmed and intensi- 
 fied by the treatment they meet with. Thus, for example, the 
 natural restlessness of childhood is directly fostered in having to 
 bear the additional strain of observation and rebuke. The pre- 
 vailing methods of education, which are designed to repress 
 movement, serve, in fact, only to disfigure it. The attempt to 
 enforce stillness of the body at the same time that the mental 
 capacity is being tasked, does direct violence to the natural laws 
 of movement The emotional period of young women is similarly 
 beset by the tax that is put upon it in the readiness of others 
 sometimes to ridicule, and sometimes to pity, emotional displays 
 which might fitly pass without notice. 
 
 And this extra and artificial strain, which is thus put upon 
 youth in general, might perhaps be still further defined as ope- 
 rating with its utmost force at certain stages of development anci 
 under certain social conditions. There is a time in every child- 
 hood when the desire for movement is the most active and the 
 least within control ; there is also a time when, by our conven- 
 tional rules of education, the penalties that are put upon move- 
 ment are the most severe. The nearest coincidence of these two 
 periods, both of which may be fixed approximately, ought to indi- 
 cate the age when the frequency of movement disorder is the 
 greatest Similarly, at a somewhat later period of life, with the 
 fuller control of movement which age naturally brings, we should 
 expect a comparative calm, until upon reaching puberty a new 
 source of disturbance would have to be encountered. Thus, not 
 only might we predict that the factors of movement disorder, 
 which we see so variously combined, must appear every now and 
 then in such combination as to bring disorder into special promi - 
 nence ; we might go further, and indicate particular periods of 
 life and states of society whose conditions are such as to favour 
 this combination. 
 
 Such conclusions, as I have said, must be brought to the test 
 
8 CHOREA. 
 
 of facts. Is the disorder which we thus prefigure actually found; 
 and does it attach by preference to the periods here indicated ? 
 Are its apparent causes of a mental or a material kind ? Does it 
 prevail more or less according to the social condition, or every- 
 where alike ? Are the particular muscles it affects such as emotion 
 selects, or such as structural disease selects ? Is the actual search 
 for its material cause successful or unsuccessful ? The answer to 
 such questions involves the investigation of the several diseases 
 which, rightly or wrongly, have been classed as functional ; and 
 does not concern us now. It is evident, at least, that such an 
 investigation may be undertaken free from any antecedent objec- 
 tion, and that functional disease, although necessarily beyond the 
 field of the microscope, is not ' unsubstantial ' in the sense of 
 being unreal. 
 
 But the varieties of muscular conduct are not confined to the 
 circumstances of youth, or the special urging of emotion. We 
 have to take into account, besides, such deformities as arise from 
 inherited and acquired tricks and habits, from the natural ten- 
 dency of human beings to copy one another, and from modifica- 
 tions in the use of the muscles which spring from their frequent 
 employment in some particular way. Innumerable movement 
 disorders are of this origin. Take any man or woman out of 
 the crowd, and how many will be found the involuntary acts and 
 spasms which contact with the world has produced or exaggerated; 
 how many movements are purposeless and imitative ; how com- 
 plete is the transition, in gesture, and demeanour, and manner of 
 response, under observation and in solitude — when inspirited and 
 dispirited — anxious or assured. In all these varieties of move- 
 ment response, which is to be regarded as the normal and healthy 
 one ? I do not say, which is the most convenient and useful — 
 for, however precise the definition may be from that point of view, 
 that is mere matter of sentiment and convenience, and has no 
 right to be heard in the question — but which is the proper healthy 
 pattern ? Is it that in which the muscular response is the quickest 
 
INTRODUCTION. 9 
 
 and readiest, the state of body always verging upon spasm and 
 ready to exhibit emotion by means of the most violent convulsion ; 
 or is it that in which the muscles are under full command and 
 no expression is allowed to escape except such as the will and 
 judgment approve, the rarest and least attainable of all human 
 conditions ? 
 
 The full significance of such considerations as the foregoing 
 will be best seen by observing how the case stands with the most 
 sensitive muscles of all, namely, those of the face. If only the 
 principle be admitted that there is nothing special in the move- 
 ments of the face muscles excepting in their alacrity of response, 
 and that a mental impression of whatever kind needs only to be 
 deepened a little to make its motor response spread from the 
 features to the limbs, we shall see then, in the study of this 
 particular region, that spasm, and paralysis, and numerous acts 
 of disobedience on the part of the muscles are part of the daily 
 life of everyone ; that, indeed, the precise conduct of the muscles 
 can only be predicted by a knowledge both of the will that informs 
 them and of all the circumstances in which they are placed ; that 
 to speak of the normal condition of the muscular system is to 
 speak without precise meaning. 
 
 Any example taken from some more restricted field, with a 
 view to illustrate this position, might no doubt be so used as to 
 misrepresent it. Yet, keeping within the strict terms of the 
 comparison, we may say of the muscular system, as of any system 
 of mechanism, that so long as it remains competent its conduct 
 will vary with its adjustment, and that such variation is the test of 
 its integrity. The most approved clock for present service is the 
 one whose minute-hand occupies precisely an hour in making the 
 circuit of the dial ; but the best clock is the one that is most 
 obedient to its regulator, moving quicker or slower accordingly. 
 
 But, while we are thus compelled to admit motor disorder as 
 a necessary ingredient of life, we do not admit it indefinitely. 
 There are the muscular phenomena of functional origin — spasm 
 
K) CHOREA. 
 
 or tremor, or palsy — and there are the very same conditions due 
 to substantive disease ; nor would it be difficult to point out, in 
 general terms, the different associations of the two. I am con- 
 cerned at present, however, only to show that there is a place in 
 nature for functional nervous disease ; my next object will be to 
 make out the claim of a particular affection to occupy that place. 
 There is in the mind of each of us a certain pattern of muscular 
 capacity and muscular control, as it ought to be, and there is the 
 larger and less definite pattern which comprehends the actual 
 range of muscular conduct under all circumstances. It is because 
 these patterns are not co-extensive that we need the service of 
 such a word as functional disease to express the difference between 
 them, and occupy the ground which the narrower of the two leaves 
 uncovered. 
 
TI 
 
 CHAPTER I. 
 
 GENERAL DESCRIPTION OF CHOREA. 
 
 Pedigree — Definition — Parts affected — Degrees of severity — Mental involvement — 
 Temperament — Age — Sex — Adult and senile chorea — Geographical distribu- 
 tion — Causes — Varieties — Progress — Paralytic symptoms— Recurrence — Con- 
 nection with heart disorder — ^Sequelse. 
 
 In attempting to give some account of the history and relations of 
 chorea, I deem it unnecessary to describe the various dancing 
 epidemics from which it takes its name. Chorea for us begins 
 with its definition by Sydenham. It may, indeed, at first sight 
 seem strange that a movement extravagance of the middle ages, 
 having its origin in pious fervour, finding its subjects amongst the 
 emotional and the credulous, and its cure in some supernatural 
 agency, should have transmitted its name to a purely muscular 
 commotion of children to which the patients are often themselves 
 indifferent, while they are but ill-furnished with that religious 
 sentiment which provided both the cause and the cure of the 
 ancient disorder. 
 
 It is remarkable that every epidemic of the kind of which we 
 have any account grew and spread out of material of its own pro- 
 viding. It was never that with the decline of the disorder the 
 terror subsided ; it was always the converse of this. The epidemic 
 disappeared as soon as it ceased to inspire the terror or attract 
 the attention, which was one of its essential factors. In other 
 words, the gesticulations and dancing (although in great measure 
 involuntary) had the strength taken out of them when the popular 
 tribute to their reality was withdrawn. So long as the priests' 
 
12 CHOREA. 
 
 exorcism or pilgrimage to shrines was held to be necessary, so 
 long, to the great annoyance of their victims, the muscular con- 
 tortions flourished and spread ; but they could not survive 
 neglect It will be seen from Hecker's account of these popular 
 seizures that they did not decline from want of subjects, but from 
 a change in the public sentiment The patients who came latest 
 were discredited. They were not impostors any more than the 
 others, except so far as the knowledge that they would be so ac- 
 counted tended to make them so. The same affection, that is to 
 say, neither more nor less real than at first, had lost the necessary 
 element of public sympathy. 
 
 The current of opinion changes, but men and women remain 
 the same. There is ample evidence in the experience of the pre- 
 sent as well as in the dancing and jumping manias of the past, 
 that conscious convulsive seizures need external support for their 
 perfect exhibition. Wanting this, the explosive violence of their 
 discharge (to adopt the language of current pathology) is di- 
 minished. Thus, while the example of others suffering, and the 
 knowledge that bystanders are disturbed and impressed, combine 
 to make the circumstances most favourable for the development 
 of such epidemics, the knowledge that the particular symptoms 
 will be recognised only to be discredited, and that those who yield 
 to them are neglected or despised, make the circumstances most 
 favourable for their suppression.^ 
 
 VVe are not too readily to assume that the chorea we are 
 now to consider is altogether different from the epidemics of old. 
 
 1 Upon this subject, in reference not only to popular movement distortions, but 
 also to witchcraft and modern miracles, I would refer the reader to Lecky's His- 
 tory of Rationalism in Europe (vol, i. p. 89, et scq.), where it is well shown that 
 the belief in all such phenomena, genuine alike on the part of performer and ob- 
 server, required for their due exhibition the joint operations of the two. They 
 resulted from ' a general predisposition to see Satanic agency in life which grew from 
 and reflected the prevailing modes of religious thought, and declined only when 
 those modes were weakened or destroyed." With all the distinctive features of our 
 present chorea, we shall find in the sequel, if I am not mistaken, that this affection 
 in many of its modes is largely influenced from without. 
 
GENERAL DESCRIPTION. 13 
 
 The very same form of muscular derangement that Hecker de- 
 scribes is with us still, in such dwarfed dimensions as the altered 
 circumstances permit. Its motives and methods of cure are the 
 same now as formerly, and if it is less common or less contagious, 
 the reason is to be found in the wider spread of education. But 
 the healthier public sentiment which has overwhelmed in neglect 
 and contempt, together with witchcraft and sorcery, the various 
 movement extravagances due to ecstacy and fanaticism, has 
 brought into greater prominence the muscular disorder of child- 
 hood which we now call chorea. The first mention of chorea 
 indeed as a disease peculiar to children coincides with the 
 time when the growing influence of education had acquired 
 strength enough to deprive the popular epidemics of their neces- 
 sary motive. Along with this change the disorder ceases to be 
 regarded from the old point of view, and descends to a different 
 class of subjects. The notion of demoniacal possession is 
 abandoned, and attention is rather directed to such features of the 
 malady as tend to link it with ordinary disease. It is due to a 
 materies morbi in the blood, to the lodgment of fibrinous clots in 
 the brain, to a new development of articular rheumatism. Such 
 altered attitude of the observer makes an alteration as well in the 
 thing observed. Chorea has changed its shape for reasons which 
 we can partly explain, yet some of the old hneaments are still 
 discernible. The motor disorder which now plagues our children 
 still clings to the same sex as of old, it chooses by preference the 
 same temperament, and is apt to be aroused by precisely the 
 same causes. 
 
 Of the many attempts that have been made in our own day 
 to define chorea^ none can be regarded as altogether successful It 
 has been described as 'an irregular convulsive action of the 
 voluntary muscles,' but it is not necessarily convulsive, and not 
 always confined to the voluntary muscles ; as ' a tremulous, ir- 
 regular, and ludicrous movement,' but there is nothing of tremor 
 
14 CHOREA, 
 
 about it, and not much that is ludicrous. Sydenham's com- 
 parison of chorea to the feats of Merry Andrew is familiar to 
 everyone. The more modern definitions are confessedly faulty 
 and inadequate. In the latest treatise upon the subject Pro- 
 fessor Ziemssen declares that it is only possible as yet ' to aim at 
 a definition.' In his own description he is chiefly careful to dis- 
 criminate between true chorea and the so-called chorea major ; 
 the latter as he believes being 'the product of hysteria or of 
 genuine psychoses and cerebral maladies.' ^ By true chorea he 
 understands ' a neurosis of which the seat (as it seems) may some^ 
 times be the brain alone, sometimes the entire nervous system ; 
 characterised by incessant twitchings or jerks of groups of muscles, 
 which are sometimes spontaneous and sometimes excited by 
 voluntary impulse, which occur almost exclusively in the waking 
 state, and are accompanied by a more or less developed psychi- 
 cal disturbance.' It may be questioned whether such definition 
 really pictures the affection to anyone not already familiar with 
 it. To ordinary observation, at all events, chorea consists in an 
 exaggerated fidgetiness. It is an extravagant exaltation of that 
 continual unrest which is the natural characteristic of child- 
 hood. Its movements, that is to say, resemble the emotional, the 
 same muscles being affected in the same kind of way. Chorea, 
 therefore, may be imitated as emotion may. But up to a certain 
 point only; extreme chorea, like extreme emotion, is beyond imi- 
 tation, for there belongs to both a degree of spasm and dis- 
 tortion which can never be assumed, or only partially and for a 
 moment. 
 
 Consistently with this comparison the muscles of the vpper 
 part of thi body are much more often affected than the rest, and 
 the hands suffer most of all. The thoracic muscles seldom escape 
 altogether, but it is only exceptionally that their concern in the 
 disorder is a prominent feature. Tlio lower limbs arc never 
 
 ' Zicinsscn's Cycl., vol. xvi. p. 418. 
 
GENERAL DESCRIPTION. 15 
 
 affected alone, although they may be the first attacked. * In the 
 chorea of elder children and of grown-up girls the face is almost 
 always concerned. The more disturbed limbs, or those in which 
 disturbance lasts the longest, become eventually weakened, the 
 loss of power being sometimes very obvious. Certain groups of 
 muscles indeed may appear to be altogether disabled. Thus the 
 hand may hang from the wrist, and even for a while be incapable 
 of full extension, or, less commonly, the arm or the leg muscles 
 may become relaxed and motionless. Complete paralysis, how- 
 ever, is rare, and, as a very general rule, there is neither failure of 
 nutrition, loss of tactile sensibility, nor alteration in the muscular 
 response to the induced or continuous current 
 
 Chorea is commonly more marked on one side than on the 
 other, and not seldom it affects one hand, or one anii, in especial.^ 
 For reasons that will presently appear, much stress has been laid 
 upon chorea confined to the arm and leg of one side, so-called 
 hemicJiorea. M. See, in 154 cases, found chorea confined to the 
 left side, or 7nore marked there, in 97. But this is obviously not 
 to the point, since it fails to distinguish hemichorea in any accu- 
 rate sense. Dr. Pye Smith, however, found 33 out of 150 confined 
 to one side. For myself, I cannot recall a single case of chorea 
 of any severity continuing throughout its course limited to one 
 side of the body and including both arm and leg. That chorea 
 commonly begins in one side, we all admit ; that it may continue 
 confined to a single limb until it gradually disappears, we may 
 admit also ; but a violent chorea of one side, in which the other 
 side in no degree shares, is, I believe, almost unknown. 
 
 The speech defects of chorea are of many kinds and degrees. 
 Sometimes speech will be rendered difficult and uncertain owing 
 to imperfect command of the respiration, causing occasional 
 
 ^ So Romberg, Sydenham Society's Trans., p. 56, with which my own obser- 
 vation accords. 
 
 2 Compare with the statements here given the figures quoted in Appendix B, 
 in reference to the starting-place of chorea. 
 
i6 CHOREA. 
 
 arrests in speech, or the words to be violently jerked out.* At 
 other times there is difficulty in setting the vocal apparatus going ; 
 the answer to a question will be delayed, as though the other 
 muscles were so busy as to leave no place for speech. In extreme 
 cases of this kind, the lips will be seen to move, but the attempt 
 to utter word or sound will go no further. Another kind of speech 
 disorder arises from imperfect muscular co-ordination, and is seen 
 best in the elder patients, giving to their words that indistinctness 
 and confusion of syllables which is characteristic of drunkards. 
 These speech disorders are in no constant relation to the choreic 
 disturbance elsewhere, and, with severe chorea, speaking may be 
 little or nothing affected. But where speech difficulty occurs, it 
 is commonly an early symptom, and may be the very first. That 
 it may be rightly appreciated, it is well to bear in mind that 
 speech chorea, like chorea in other parts, is a muscular disorder. 
 Aphasia, or any other form of misuse or disuse of speech due to 
 cerebral defect, and not to faulty working of the apparatus of 
 speech, is not met with — or, certainly, is very rarely met with ^ — 
 in chorea. 
 
 Defects of deglutition^ less common than those of speech, follow 
 much the same rule. It is not that the power of deglutition fails 
 (although even this may occur), but that, in severe cases, there is 
 first the difficulty of food reaching the mouth, and next the diffi- 
 culty of its being dealt with by the tongue and lips. 
 
 The body temperature is almost always slightly raised at first, 
 in the more violent attacks ; but, with remarkable uniformity, // 
 tends to fall below the normal afterwards. It will be easily under- 
 stood that in the utmost severity of the choreic paroxysms trust- 
 worthy observation upon this point is impossible. The highest 
 temperature I have succeeded in taking was ioo-6 ; the lowest, 
 
 ' Ziemssen, loc. cit. p. 436, has called particular attention to the various laryn- 
 geal defects of chorea. My friend and colleague, Dr. de Havilland Hall, has 
 made many attempts to inspect the larynx in cases of children with marked speech 
 chorea ; but for obvious reasons this is a task of much difficulty. 
 
 '■* See case 14, Appendix A. 
 
GENERAL DESCRIPTION. 17 
 
 95 "8. Contrary to the opinion of Ziemssen {loc. at p. 440), that 
 the body temperature is not changed even in severe cases, I be- 
 lieve it to be very rare for the normal heat to be maintained, 
 although the variations are not considerable. The pulse is com- 
 monly quickened, it is often variable, and sometimes uneven or 
 distinctly irregular. During severe paroxysms it may exceed 120. 
 The state of the circulation, however, will come for separate con- 
 sideration presently. 
 
 The degree of severity of chorea may be well measured by ob- 
 serving the patient's posture in bed. One effect of the continual 
 working of the arms and shoulders is to push the body low down 
 in the bed, thus drawing the head from the pillow, and bringing 
 the whole frame into a horizontal plane. At the same time, the 
 patient remains constantly on the back, so as to allow full play 
 for the extravagant limb movements. Lying thus, the reckless 
 disposition of the arms in their short intervals of rest is charac- 
 teristic. They remain, so to speak, where they fall ; the flexed 
 arm and wrist lying over the chest, or the limb hanging down 
 loosely over the bed-side. 
 
 With its prone position and the depression of the head and 
 shoulders chorea thus comes, by an accident, to resemble enteric 
 or typhus fever. . In the worst cases, indeed, when the violent move- 
 ment has given place to prostration, this resemblance of posture 
 is complete. It may be added that in severe chorea, as in fever, 
 the position in bed from day to day — a little higher, or a little 
 lower — is a valuable indication of the progress to better or worse. 
 
 In the commonest form of chorea — that, namely, which is 
 found amongst young children, and is of long duration but 
 moderate degree — two varieties are to be recognised. In the 
 one, the patient's movements are at their worst when he is 
 conscious of observation, and at their best when he is left to 
 himself In the other, there is a considerable power of control 
 when the effort is made ; but without it, as when at play, or in 
 simple muscular acts, the unsteadiness and disorder become very 
 
 c 
 
1 8 CHOREA. 
 
 apparent. This latter variety is by far the more untractable of 
 the two. 
 
 Yet, even in severe chorea, it is less true to say that the child 
 cannot be still than that it is unable to maintain stillness. By an 
 effort and for a moment movement can be stopped wholly or 
 partially. And it is curious to notice the effect produced by 
 making appeal to the child's understanding. If, for instance, he 
 is invited not to be still, but to move to the utmost, it will com- 
 monly happen that the character of the movement is for the time 
 altered, and probably diminished. Similarly, attention directed to 
 a particular limb serves, in a measure, to quiet that particular 
 part. 
 
 Notwithstanding the inconvenience of chorea, young children 
 take it very composedly. They eat and sleep well, and are in no 
 way mentally disturbed : the mental disturbance comes later. 
 Thus, it is common to find after the age of ten that at the first 
 onset of the affection, or even before it, the child becomes fretful, 
 or capricious, or passionate. It is easy to understand that with 
 these elder children the temper is continually tried by the disobe- 
 dience and riot of the voluntary muscles. At a later period still 
 — at and after puberty — the ceaseless agitation of the limbs, in 
 spite of the will, produces a state of mind little short of terror. It 
 is at this time of life exclusively, so far as I know, that chorea 
 becomes blended, in various degree, with delirium and acute 
 mania. The utmost mental disturbance of the children concerns 
 the temper and the degree of intelligence. 
 
 It may be true, perhaps, that chorea tends in a measure to 
 blunt the mental acuteness ; but in judging of this we are to 
 remember that the instruments of intelligence are themselves 
 impaired, that failure in act tends to produce infirmity and 
 distrust of will, and that the facial deformity of chorea often 
 so disguises the natural expression that it is no longer a fair index 
 of the mind. Added to all this, the motor disorder so far occupies 
 the attention that it is difficult and irksome to direct it elsewhere. 
 
GENERAL DESCRIPTION. 19 
 
 Some authors have laid much stress upon the independent 
 variation of two separate elements of chorea, namely, the muscular 
 restlessness and the ataxy. It is pointed out that children with 
 but little restlessness may yet show marked want of muscular 
 consensus, and the converse. It will suffice, in this place, to 
 admit that the fact is so ; its explanation must be sought when 
 we come to consider the pathology of the affection. 
 
 As regards the kind of person most liable to chorea, indepen- 
 dently of the question of age, or sex, or of predisposing diseases, 
 it is enough to say that of those who have wTitten with authority 
 upon the subject some have chosen the dark children, and some the 
 light. All have agreed, however, that susceptible and ' nervous ' 
 individuals are especially liable, although none believe that chorea 
 is limited to these. ^ The attempt to connect anaemia with chorea 
 I believe to depend on erroneous or too limited observation.^ 
 
 The favourite age of chorea is between six and fourteen or 
 fifteen. Its period of dangerous and sometimes fatal severity is 
 from thirteen to about twenty-three. Of See's 191 cases, 151 
 fell between six and fifteen years of age ; only 1 1 w^ere under six, 
 and 12 over twenty-one. In Dr. Pye Smith's^ 136 cases, 106 were 
 between six and fifteen. In 71 cases of Dr. Dickinson's, treated 
 at the Hospital for Sick Children, 42 were under ten years.* In 
 177 consecutive cases under my own care, 96 were under that 
 age. 
 
 It is thus necessary to amend Sydenham's statement, giving the 
 limits of chorea between ten years old and puberty. It is rather 
 from the period of second dentition to about twelve or thirteen 
 that it prevails, and then suddenly declines. Yet it must be added 
 that the most formidable examples of the affection occur at the 
 
 ^ See Appendix B, in reference to the large proportion of whooping cough in 
 choreic subjects. 
 
 ^ It has been obser\-ed that choreic children in larger proportion than others 
 have large pupils, but I know of no reason for this, and have no accurate data con- 
 cerning it. 
 
 ' See Guy's Hospital Reports, 1873. 
 
 * Med.-Chir. Trans., vol. iix. p. 30. 
 
 C 2 
 
20 CHOREA. 
 
 time of puberty. If, indeed, such cases were eliminated, the 
 actual mortality of the disease, small as it is, would be very greatly 
 reduced. 
 
 Chorea occurs to girls more than twice, but so??iethi?ig less than 
 three times, as often as to boys} This sex difference is the least 
 among the little children and the greatest amongst the elder ones, 
 but it never disappears. The statement that there is no sex dis- 
 parity under nine years of age is certainly an error. The statistics 
 of many authors upon this point are in substantial agreement. 
 M. See, in 531 cases, had 393 females, and 138 males; a pro- 
 portion of 2*8 to I. Dr. Hughes has 73 females to 27 males ; a 
 proportion of 2*5 to i. Dr. Dickinson, 50 to 21 ; a proportion 
 of nearly 2-4 to i. Dr. Peacock, 66 to 26 ; or 2-6 to i. My own 
 tables give 99 to 33 — exactly 3 to i — for the Children's Hospital ; 
 and 35 to 10, or 3*5 to i, for the Westminster Hospital. That 
 there is a somewhat less inequality in the younger children — yet 
 no approach to equality — appears probable from the fact that of 
 
 21 children under eight years, of Dr. Dickinson's table, 13 were 
 girls and 8 boys ; while of 40 children under the same age of 
 my own, 28 were girls and 12 boys. Of the exact proportion of 
 the sexes at the age of puberty, I cannot speak ; but there is 
 undoubtedly a very large preponderance of young women. A 
 severe form of chorea at the approach or completion of puberty 
 in girls, is a not very uncommon occurrence ; while the same 
 thing in youths is certainly very rare. 
 
 Cases have been reported of chorea occurring to infants at the 
 breast, and even at the hour of birth ; but I know of none such. 
 
 Wc have yet to notice a form of the disorder, which, although 
 slower, less varied, and more nearly rhythmical than ordinary 
 chorea, may properly be called by that name. In the very rare 
 occurrence of chorea for the first time in old age, the patients are 
 usually weakened in intellect or actually demented. Less rare, 
 but still uncommon, is . the persistence into adult life of a chorea 
 
 * See Appendix B. 
 
GENERAL DESCRIPTION: 2i 
 
 that began in childhood ; here, too, there is commonly some 
 degree of mental impairment. Both these forms of the disorder 
 may be regarded as incurable. Professor Charcot, who has called 
 especial attention to senile chorea, has no anatomical pathology 
 for it. He regards it as a merely emotional disease, and quotes 
 examples from the Salpetriere Asylum to show its origin in dis- 
 tressing events and violent passions, as well as the mental feeble- 
 ness that goes along "with it.^ 
 
 Along with this adult chorea, mention may here be made of 
 the various muscular tricks and twitches acquired early in life, 
 and which, as the common observation of everyone will admit, 
 cease to be curable when youth has passed. There is hardly an 
 individual of middle life to be met with who has not some habit 
 of the kind, which only needs to be exaggerated or extended to be 
 accounted chorea. These movement infirmities concern chiefly 
 the face, head, and shoulders ; and the jerking or twitching of these 
 parts is often strictly rhythmical. ^ The equality of the intervals is 
 seen best when the individual is walking, by their leaving time 
 always for the same number of steps. Such disorder is of course 
 more or less noticeable according to its seat and extent, and is 
 more readily accepted and overlooked in the old than in the 
 young. There is another form of rhythmic movement which is 
 intimately associated with hysteria and with young women, to 
 which M. Charcot has given the name of 'rhythmic chorea.' In 
 this affection, the arm and leg of one side may be alternately 
 flexed and straightened ^ for a considerable period, or the head 
 may be set shaking, and continue to move with constantly in- 
 creasing rapidity, to the utter exhaustion of the patient. These 
 
 ^ ' On Chorea in Old People.' Lectxire by Professor Charcot, Medical Times and 
 Gazette, March 9, 1878. See also, in reference to post-mortem appearances, 
 ' Cases of Choreic Convulsions in Advanced Age, ' by Dr. Macleod. — Jourit. MeJital 
 Science, July 1881. In Appendix A, case 12, is an example of chorea occurring 
 to a man in middle hfe, intelligent and unemotional, and with no history of any 
 previous attack. 
 
 2 In reference to the natural tendency of over-movement in adults to become 
 rhythmical, see Medical Times and Gazette, Septembe 28, 1878. 
 
 3 British Medical Journal, vol. i. p. 224. 
 
22 CHOREA. 
 
 latter examples of perverted movenient are intimately connected 
 with perverted mind, and belong properly to the subject of hysteria. 
 
 As regards the geographical distribution of chorea., although we 
 have no statistics to offer, it is known that the prevalence of the 
 disorder varies very greatly in different parts of the world. Over 
 the continent of Europe, or, so far at least as medical observa- 
 tion extends, chorea is nowhere very uncommon. It is a familiar 
 disorder, at all events, in France, Germany, Austria, Italy, and 
 European Russia, as well as in the United States of America. 
 But there are other quarters of the globe where it is believed to 
 be far less common. In Northern India I am informed it is very 
 rarely met with, and in Bombay, I learn from a Parsee gentlem.an, 
 a student of the Grant Medical College, that in the Jamsetjee 
 Hospital for natives, where there are 500 beds, he saw, during 
 three years' attendance, only a single case. Dr. Hughlings Jack- 
 son mentions, on the authority of an African medical man, that 
 the affection is very rare among negroes. Dr. Livingstone makes 
 no mention of chorea amongst the diseases he encountered during 
 his travels. It is curious to notice that in countries where extra- 
 vagant movements and contortions are practised in connection 
 with religious rites, this movement disturbance of childhood, which 
 takes its popular name from a mediceval superstition similarly 
 allied to religion, should be rare.' 
 
 There is no evidence to show that chorea as such is heredi- 
 tary ; yet, inasmuch as the temperament which exhibits it most is 
 often inherited, it is probable that in certain families the affection 
 should appear with unusual frequency in successive generations. 
 
 To sum up, then, the ascertained facts in regard to chorea ; 
 we find its favourite time of life included between the time of 
 
 * How far chorea may be influenced by social position is a question of much 
 interest, but also of much difficulty. I Ijclieve the fact to be that chorea as z. fully 
 developed and recognised disease is very much commoner with the poor, while 
 among the well-to-do we have as many or more examples of commencing chorea, 
 which due care and timely relief succeed in arresting at that stage. We must 
 speak of this presently. 
 
GENERAL DESCRIPTION. 23 
 
 second dentition and that of puberty ; its favourite sex is the 
 female ; the temperament that invites it most is the sensitive and 
 emotional ; it is apt to increase in severity as it decreases in 
 frequency, little children suffering quite commonly, yet hardly 
 ever with a fatal result, whilst of the few instances of adult chorea 
 a notable proportion have died. Further, the disorder is but little if 
 at all hereditary, and more common in highly civilised countries 
 than in other parts of the world. So much is certain ; what is to 
 follow is to some extent involved in controversy. The exciting 
 causes of chorea, its clinical and pathological associations, com- 
 mon sequelae and modes of progress or of cure, furnish so much 
 material out of which every student of the disorder would obtain 
 a sanction for his own conceptions as to its real nature. It is 
 impossible to proceed with the further study of the subject free 
 from the bias of some hypothesis or other which will interpret and 
 select facts which are equivocal in its own interest. I shall endea- 
 vour in this place to give the commonly received opinions upon 
 the points just enumerated, and with this to conclude a general 
 account of the clinical aspect of the affection which shall be free 
 as far as possible from matters of speculation and difference. 
 
 Be the exciting cause of chorea what it may, there is cfm- 
 monly a distinct i7iterval hetween cause and effect. It s pro- 
 bable that such interval is really shorter than it appears, inasmuch 
 as the disorder is seldom observed at its very commencement. 
 Dr. Hughes ^ made special inquiry into this point in 26 cases. 
 He found that in 13, or exactly half of these, this interval was o 
 not more than a week, in 2 of the 26 it was between one and two 
 weeks, in 3 it exceeded two weeks, and in 8 there was no ap- 
 preciable interval. Thus in all but five the attack followed its 
 presumed cause either immediately or within a week, the latter ■ 
 being the commoner event. 
 
 The ijiimediate exciting causes of chorea are variously stated 
 by different authors. It is certain and universally admitted that 
 
 ^ Guy's Hospital Repoj-ts, 1846, p. 380. 
 
24 CHOREA. 
 
 fright and mental disturbance are prominent amongst these causes. 
 Certain also that various kinds of pain, rheumatic and other, 
 headache, joint pain'^, and the like, precede and accompany the 
 affection whether as cause or not. Again, the convalescence of 
 children from acute disease, scarlatina, measles, rheumatism, is some- 
 times disturbed by the appearance of chorea. This liability seems 
 to attend especially the recovery from acute rheumatism. But in 
 what proportion of cases this occurs, and whether or not this lia- 
 bility holds good apart from heart disease, are matters of contro- 
 versy to be discussed presently along with the whole question of the 
 relationship between chorea and rheumatism. It may be stated, 
 however, as amongst the facts which are beyond dispute, that be- 
 tween chorea and heart disease, whether rheumatic or not, there 
 is during childhood a distinct connection. There remain a not 
 inconsiderable number of cases whose immediate origin is un- 
 certain, where there has been neither rheumatism nor heart 
 affection, nor acute disease. No hypothesis as to the pathology of 
 chorea can be accepted which does not take account of this class. 
 A child is at first supposed to be careless or awkward, and pre- 
 sently is discovered to be choreic. The affection in this kind is 
 often prolonged but seldom violent. We may thus recognise, 
 without however comprehending chorea in its entirety, three 
 degrees of the affection : First, the obstinate, but not severe 
 muscular restlessness of little children, of very obscure origin, 
 gaining little by treatment but recovering at length as it were 
 spontaneously. Secondly, the severe and sometimes fatal chorea 
 of puberty, due often to some obvious mental disturbance, and, 
 in the case of girls at least, never with certainty separable from 
 some such cause. Thirdly, the rare and incurable chorea of the 
 adult, distinct in many respects from the childish affection, being 
 more spasmodic, rhythmical and uniform, and having no con- 
 nection whatever, as I believe, with heart disease. If we add to 
 these a small but distinct class of cases curiously associated with 
 acute rheumatism and endo- and pericarditis, very early assuming 
 
GENERAL DESCRIPTION. 25 
 
 the form of uncontrollable and often fatal spasm, we shall have 
 embraced the chief varieties of the disease. To these points we 
 shall presently return. ♦ 
 
 The progress of chorea is very irregular and its duration un- 
 certain. Recovery is commonly gradual and apt to be inter- 
 rupted. In some rare cases it has suddenly disappeared after 
 mental shock. The rule of the affection according to my own 
 observation is this ; that after a longer or shorter duration signs of 
 improvement will commence, but that this amendment is not 
 continuous, but subject to interruption and relapse. Slight 
 trouble or excitement, or physical pain, the sight of other children 
 suffering similarly, or temporary indisposition short of serious 
 illness, are among the common causes of such relapse. But when 
 recovery has reached a certain point it becomes henceforth rapid 
 and continuous. It must be added that when chorea first comes 
 under formal medical treatment it commonly gets worse, while, 
 apart from disturbing causes, rest in bed, especially with the 
 younger children, will commonly make it better. 
 
 The duration of chorea is too variable to admit of any general 
 statement. Dr. Hillier and Drs. Gray and Tuckwell have fixed 
 ten weeks as the average. It is seldom recovered from under six 
 weeks, and, as has been already mentioned, in the case of very 
 young children, it may linger for many months. It is not easy 
 indeed in any individual instance to assign its precise limits, for it 
 is seldom discovered quite at the first, and, owing to the nature of 
 its subjects, it declines very gradually, not into absolute steadiness, 
 but into such comparative quiet as still leaves the shadow of the 
 old disorder. Honest observers, therefore, of the very same 
 series of cases of chorea, might differ widely in their account of its 
 duration. 
 
 To these statements regarding the progress and duration of 
 chorea, something must be added in regard to occasional and ex- 
 ceptional symptoms. One curious and rare incident of the affection 
 is the intervention of general or localised muscular weakness. The 
 
 > 
 
26 CHOREA. 
 
 chorea, that is to say, will moderate in respect of the violence of 
 the movements, but there will supervene, along with the failure of 
 muscular consensus, a distinct /^55 of power on the pa7't of individual 
 muscles^ the general health meanwhile being maintained, and the 
 bodily weight even increasing. Other things being equal, such 
 chorea is not more dangerous, although it is longer than the ordinary 
 form. In such cases, I think, the decreasing violence of the 
 movement as an augury for good is hardly lessened by the ob- 
 servation of this particular symptom. 
 
 It is not uncommon for choi-ea to recur, although two, and still 
 more three recurrences are rare. M. See had 37 recurrences among 
 158 cases. Dr. Dickinson in 71 cases has 18 second attacks, 4 
 third attacks, and i fourth attack. In my own 177 there are 38 
 which were second attacks, 10 third attacks, 3 fourth attacks, and 
 I in which the precise number of attacks was uncertain. 
 
 In the chorea of pregnancy and of puberty it is common to find 
 that the same disturbance has happened in childhood. Thus Dr. 
 Barnes ^ in 66 choreas in pregnancy had 14 of this kind. My 
 belief is that the severe chorea of puberty would also show a large 
 proportion who had suffered earlier attacks, but the numbers at 
 hand are insufficient for the purpose of proving this. 
 
 Heart affection in cofinection luith chorea will be considered in a 
 future chapter. I would confine myself now to a simple statement 
 of what passes current upon this matter, as well as of what I shall 
 presently attempt to prove. It is universally admitted that a sys- 
 tolic apex murmur is a common symptom in the chorea of child- 
 hood. Ziemssen speaks of this murmur as of purely functional 
 origin, due, as he believes, to the action of the capillary muscles. 
 Upon d priori grounds he considers that change in the valvular 
 sound * is more likely in chorea than in any other affection.' He 
 asserts (I believe with perfect accuracy) that there is commonly 
 * no increase in the second pulmonary sound, no enlargement of 
 the right ventricle, nor any other sign of increased tension demon- 
 * Obstetrical Trans., vol. x. p. 147. 
 
GENERAL DESCRIPTION. 27 
 
 strable in the system of the pulmonary artery.'^ At the same time 
 he recognises ' the residual consequences of an old endocarditis ' 
 as sometimes contributing to produce murmur. It is occasionally 
 hard to decide, according to the same authority, whether the mur- 
 mur be anatomical or purely functional, and he instances ansemia, 
 chlorosis, and acute rheumatism as exhibiting ' functional disturb- 
 ances of the mitral quite as obscure as does chorea.' In all this 
 I venture to concur, and still further would desire to recognise 
 a ' chorea of the heart,' which Ziemssen describes without adopt- 
 ing the description, 2 consisting of' irregularity of rhythm audible 
 while the disease is at its height, but neither before nor after.' 
 
 The opinion I have been led to form upon this subject, and 
 which I shall seek to justify presently, is as follows : — Accepting the 
 views just stated as to the frequency and character of cardiac mur- 
 mur and the absence of signs indicating enlargement or change of 
 any kind in the heart cavities, I would insist, too, upon the cardiac 
 symptoms of chorea as being special and unique, a part of the 
 disease itself, coming and going with it, and exhibiting in many 
 instances not only murmur, but marked unevenness of rhythm 
 and even irregularity of action. This cardiac implication is not 
 more frequent in severe than in moderate chorea, and follows no 
 other rule than that it is more common in children than in adults. 
 The irregularity of the heart is in no direct relation to that of 
 the respiration, and seldom gives rise to any subjective symptom. 
 Such description applies only to that functional disturbance of the 
 heart to which all young choreic subjects are liable, although many 
 escape it. We are to remember at the same time that there is at 
 least this connection between chorea and endocarditis, that the 
 disturbance of the heart which begins with an attack of chorea, 
 
 ^ Loc. cit. p. 440. 
 
 2 Ziemssen speaks of arhythmia of the heart as 'certainly very rare,' and 
 quotes Romberg's assertion that he could discover no abnormal variation in the 
 movements of the heart in spite of continued observation. Accelerated action of 
 the heart is the utmost he admits. These points will be found discussed in 
 Chap. III. 
 
28 CHOREA. 
 
 and exhibits at first no more than uneven or irregular rhythm, may 
 presently develop a mitral murmur, without trace of rheumatism 
 past or present, a murmur which shall . not only present all the 
 physical signs of endocarditis, but which after death shall be found 
 to depend upon fibrinous deposit. 
 
 It has been mentioned already that the chorea of later life, and 
 especially that of puberty, is commonly associated with more or 
 less of nervous exaltation. In young women hysteria is often com- 
 bined with it. The two affections may occur alternately, or they 
 may be so intimately blended that the one name seems as appro- 
 priate as the other. The same sort of sympathy is further illus- 
 trated by examples of choreic movement in girls being replaced by 
 tremor or insensibility, or even prolonged immobility.^ The loss of 
 will control is further shown in a still rarer modification by Dr. 
 Handfield Jones, who mentions a case where certain words escaped 
 involuntarily, and to the evident mortification of the patient.^ 
 
 Among the rare associations of chorea is delirium, rising in some 
 instances to such violence as to assume the character of mania. 
 This symptom will sometimes accompany, and sometimes alternate 
 with, or replace chorea, reminding us of a similar conduct on the 
 part of epilepsy. Such nervous implication is confined to the 
 chorea of puberty, pregnancy, or early adult life, thus adding 
 another distinctive feature to the disorder as seen at this period.^ 
 
 1 Dr. H. Jones, Functional Nervous Diseases, p. 362, sq. A child (aged six) has 
 lately been under my care recovering from chorea, who exhibited remarkable fixity 
 of attitude, inasmuch as that she would maintain for a considerable time any 
 posture, however inconvenient, in which she was placed. Thus she would remain 
 quite motionless with both arms extended and the head thrown back ; and at 
 ordinary times, although not actually cataleptic, was, to use Dr. Jones' words, 'un- 
 naturally still,' even for an adult. Moreover, when set to walk she seemed to want 
 spontaneity, would soon stop, and only after repeated halts and several biddings 
 get round the table. Other similar examples are quoted in the Medical Times 
 and Gazette, ' Motor Disorders," October 19, 1878. 
 
 2 The occurrence of painful points, or points painful upon pressure, ought 
 probably to be mentioned in this place, but I have no observations of my own 
 on the subject. See Ziemssen, loc. cit. p. 435. 
 
 ' See further references to such cases in Chapter IV, A good example of the 
 kind quoted by Dr. Bradbury, of Cambridge, will be found in the British Medical 
 
GENERAL DESCRIPTION. 29 
 
 It is not uncommon in the violent chorea of adults to find that 
 whenever by a strong exertion of the will the overmovement is 
 violently resisted, the effect of such effort presently appears in the 
 form of emotional agitation. I have conversed with adult patients, 
 who, after their recovery, still retained a vivid impression of the 
 state of mind which they described as compelling them to surren- 
 der themselves as by a sort of choice to movement rather than 
 emotion. 
 
 In evidence of the hysteric alliance of chorea, its i77iitatwe ten- 
 dency is sometimes quoted. And that the disorder is sometimes 
 spread in this way there can be no doubt. Thus Bucheteau ^ 
 relates that in the course of five days after the admission into hos- 
 pital of a girl suffering from most intense chorea, eight patients 
 already in the ward contracted the disorder. Dr. West has ob- 
 served instances of a similar contagion. It must be admitted, 
 however, that this mode of conveyance is rare. In many instances, 
 and probably in that just quoted, it is not so much that the disease 
 is directly imitated as that it spreads by the intervention of terror 
 produced by the sight of it. 
 
 From this aspect of chorea in association with various functional 
 nervous disturbances, we might proceed to consider its connection 
 with structural diseases of the brain and spinal cord. Chorea is 
 sometimes followed by hemiplegia, sometimes it leaves a permanent 
 contraction of the flexor muscles of the wrist, and sometimes such 
 oscillatory movement as is met with in disseminated sclerosis. 
 Again, convulsion or tremor has been seen to alternate with chorea, 
 and epilepsy ^ has both preceded and followed it. Of such phe- 
 
 Journal, June 10, 1876, the patient being a young man, and the chorea, which 
 was ultimately recovered from, originating in fright. 
 
 1 Dr. H. Jones, loc. cit. p. 350. 
 
 2 Out of a large number of" cases of epilepsy. Dr. Gowers found but twelve who 
 had had chorea, and in only four of those did the fits begin at the time of the 
 chorea. In eight cases epilepsy existed before the chorea. In the small number 
 of instances where the fits immediately succeeded the chorea, he thinks it probable 
 that ' the impaired nutrition of the motor centres may have left a predisposition to 
 further disturbance.' I think, on the contrary, that the exceptional character of 
 
30 
 
 CHOREA. 
 
 nomena we shall speak more particularly presently. "WTiat I have 
 to insist upon here is that they are all in the highest degree excep- 
 tional We are absolutely forbidden therefore from attributing any 
 such meaning to them as they might justly bear were they of com- 
 mon occurrence in chorea. What is called ' choreic hemiplegia ' 
 is not only very rare, it is seldom complete or enduring. In some 
 alleged instances of the kind, the evidence of chorea is very defec- 
 tive, w^hile in others it is evident that the preceding affection was 
 not chorea but tremor. ^ A form of paralysis far commoner than 
 hemiplegia is that temporary loss of power on the part of a par- 
 ticular group of muscles which has been just noticed. The 
 occurrence of such lesion can never escape notice, for it serves in 
 a marked manner to disfigure the characteristic aspect of chorea. 
 Apart from such exceptional instances, what we have to consider 
 now, — what we see ninety times out of a hundred, is the condition 
 I began by describing, a restlessness of the limbs and faces of chil- 
 
 the occurrence argues strongly against any such predisposition. See Gower's 
 ' Lectures on Epilepsy,' Lancet, vol. i. 1880, p. 355. 
 
 ^ In the three cases of choreic hemiplegia related by Dr. Todd [Nervous 
 Diseases, p. 312, et ^eq.) and often quoted, the chorea in th* first (a boy of nine) 
 was not ' hemichorea, ' nor was the paralysis complete ; the patient was nearly well 
 in eight days. The second was a girl of eighteen, who after right-sided chorea 
 appeared uneasy in her right foot, had feeble grasp with that hand, and sensations 
 of numbness in the right arm and shoulder, symptoms not unusual in one of her 
 age and sex. The third case is that of a child of five taken ' with a trembling 
 motion of both arms,' suddenly followed by right hemiplegia, observed only by the 
 mother, lasting only two or three days, and succeeded by right-sided chorea. This 
 last case, therefore, is the only one in point as showing a connection between 
 chorea and hemiplegia of the same side. 
 
 As contrasting with hemiplegia, some examples of my own may be here shortly 
 quoted, illustrating that temporary or partial loss of power which is not very 
 uncommon in chorea. A boy aged nine, with very chronic chorea, is observed one 
 morning when being washed to have the left shoulder drooping, and is found on ex- 
 amination to have lost power incompletely (and, as it proved, very temporarily) 
 of the muscles that raise the shoulder. A girl aged about ten with severe chorea 
 is unable to extend the right hand when the arm is raised. As an example of 
 more permanent changes, a girl of six gets in addition to her chorea habitual 
 flexure of one arm, with tendency to tremor therein. Another girl, aged ten, after 
 many months of chorea, develops while under observation such contractions of the 
 flexors of the left arm as to keep the hand firmly bent at the wrijt, after the 
 manner of so-called athetosis. 
 
GENERAL DESCRIPTION. 31 
 
 dren easily borne and not affecting the health ; involuntary more or 
 less, changeful with the emotions, apt to influence the action and 
 rhythm of the heart ; moving the upper limbs in preference to the 
 lower, sometimes limited to a particular set of muscles, but other- 
 wise seldom strictly confined to one side of the body ; liable to 
 recur during the period of childhood and youth, while after that 
 time it is often replaced by hysteria, which mixes with it more and 
 more intimately as puberty is approached ; an affection of very 
 uncertain duration and uneven progress, yet almost always (in the 
 case of children) recovering completely without entailing any 
 further disorder or infirmity. Such, in fact, is a general sketch of 
 chorea, the object of the present chapter. Its exceptional phe- 
 nomena are neither to be overlooked nor overestimated, and will 
 be considered in their place. 
 
 In what follows we are to examine in detail the various re- 
 lationships and asserted modes of origin of chorea ; to consider 
 the theories that have been propounded to explain it, and to offer 
 for acceptance some such hypothesis in regard to its pathology as 
 an unbiassed review of the facts may seem to justify. 
 
CHOREA, 
 
 CHAPTER 11. 
 
 THE CONNECTION OF RHEUMATISM WITH CHOREA. 
 
 Analysis of 177 cases of chorea — Comparison with other statistics — Conclusions in 
 reference to rheumatic connection, (i) from statistics, (2) from general con- 
 siderations. 
 
 In Appendix B will be found two series of cases of chorea, 
 the one consisting of 132 examples furnished by the Hospital 
 for Sick Children, the other of 45 furnished by the Westmin- 
 ster Hospital. The question of the rheumatic origin and associa- 
 tions of chorea was made a special object of inquiry in the first 
 series, where the cases are taken consecutively, with no sort of 
 selection, and where, moreover, the entries are not mine, but 
 those of successive Medical Registrars at the Hospital for Sick 
 Children during the five years over which the record extends. 
 For these reasons, although the two series tell substantially the 
 same tale, I would direct the reader's attention more especially to 
 the first and larger series. It will be seen, at the place just re- 
 ferred to, that the 132 cases are arranged in three consecutive sets 
 of 51, 49, and 32 respectively; and, although there is no real 
 break between one series and the next, it may give the clearest 
 impression of the question at issue if the facts in regard to 
 rheumatism are stated separately for each of the three. It appears 
 thus, that, of the 51 cases (14 boys and 37 girls), acute rheuma- 
 tism was in the history of only i, and rheumatism in the history 
 of only 6 — doubtfully as regards 3, if not 4, of these ; in 3 the 
 facts could not be ascertained. Of the second series of 49 cases 
 (13 boys and 36 girls), 4 had had acute rheumatism (i of them 
 
RHEUMATIC CONNECTION, 33 
 
 shortly before the choreic attack) ; 6 had probably had rheuma- 
 tism ; 2 were doubtful ; and in i the facts were not known. Of 
 the third series of 32 cases (6 boys and 26 girls), 2 had had 
 rheumatic fever ; 7 rheumatic pains ; and i was uncertain. Thus, 
 the whole 132 cases give 7 who have had rheumatic fever ; 14 to 
 1 6 who have had pains probably rheumatic ; 6 who were doubtful, 
 and 5 where the facts were not ascertained. 
 
 The precise accuracy of this account cannot of course be 
 guaranteed ; but if the facts be stated in somewhat different form, 
 we may assert, precisely and certainly, that of the 5 1 cases of the 
 first series there are 39 with positive evidence against any rheu- 
 matic connection whatever ; of the 49 of the second series, 35 
 with such evidence ; and of the 32 of the third series, 22 — 97 
 cases, that is to say out of 132, were free from any rheumatic 
 association. In other words, chorea has nothing to do with rheu- 
 matism in three-fourths of the cases. 
 
 And when we come to inquire what is the nature of the 
 association, it will appear that of this small proportion of cases 
 having a rheumatic history there are very few where the chorea 
 springs from the rheumatism in such manner as to make the one 
 seem to be the direct consequence of the other. In perhaps 6 out 
 of the 132, or i in 22 — 2 of these 6 being cases of acute rheuma- 
 tism — this direct relationship may appear to exist. 
 
 Allowing a considerable margin for error, the conclusion to be 
 drawn from these numbers is not doubtful. It would appear from 
 them, so far as children are concerned, that chorea in the great 
 majority of cases, say in three-fourths of them, is apart from rheu- 
 matism altogether ; and further, that chorea, as the direct and im- 
 mediate consequence of rheumatism, is a rare event. It will not 
 be denied that 132 cases, taken consecutively, and where pains were 
 taken in regard to this particular point, afford weighty material to 
 be put in evidence upon the question at issue. But the particular 
 conclusion arrived at may be resisted on several grounds. It may 
 be said that a too rigid definition of rheumatism has been adopted, 
 
 D 
 
34 CHOREA. 
 
 which excludes proper examples of it. The symptoms of rheuma- 
 tism, it will perhaps be urged, occur to children with special modifi- 
 cation, and are, on that account, easily overlooked. It may be 
 added that these statistics are in direct conflict with others, the 
 balance of testimony being, on the whole, in favour of an intimate 
 connection between chorea and rheumatism. 
 
 There is a further contention which will be best considered 
 separately. It is that of some physicians who, while admitting 
 that rheumatism is hardly excessive among choreic children, yet 
 still maintain the rheumatic association in virtue of their kindred. 
 I would say a word or two upon each of these points. 
 
 As regards the definition of rheumatism^ the account of the 
 patients has usually been accepted. In some few cases there have 
 been joint pains of no specified character, without redness, or 
 swelling, or definite illness. In these, the occurrence of rheuma- 
 tism was held to be doubtful, and the cases are so recorded, and 
 have been included in the above enumeration. 
 
 As to the peculiar character of childish rheu7?iatis7n, it is true 
 that many authorities lay stress upon the evanescent character 
 of the joint affection in these subjects, and the great frequency 
 with which the heart is attacked.^ Accepting this observation 
 without reserve, it seems obvious to remark that the original 
 assertion of the connection between chorea and rheumatism had 
 reference to the limb pains and joint inflammation of the latter 
 disease as we see it at all ages more or less. If this latent form 
 of rheumatism is now to be substituted and the absence of any 
 history of rheumatism to be explained accordingly, we not only 
 make all former statistics worthless, but virtually admit, by raising 
 this new plea, that the original assertion as to the connection 
 
 1 Side by side with the statement that the joint impUcation of rheumatism in 
 childhood may be slight and evanescent, may be put the observations of M. 
 Bouilly upon a febrile condition of children involving the joints called by him ' the 
 fever of gp"owth,' and which, although unconnected with rheumatism, would in all 
 probability be mistaken for it. See Bouilly, Journal Ue Midecine et de Chirurgie, 
 December 1879. 
 
RHEUMATIC CONNECTION. 35 
 
 between chorea and rheumatism has broken down. And, more- 
 over, if it be by inflammation of the heart and pericardium rather 
 than by joint pains that childish rheumatism shows itself, it will 
 be safest to connect chorea, not with the rheumatic poison (which 
 is a vague thing at best), but with endocarditis and pericarditis.^ 
 It must be remembered, besides, that the more we succeed in 
 making rheumatism a common disease amongst children, the 
 more we must expect to meet with examples of it in any collec- 
 tion of subjects whatever, whether of chorea or any other affection, 
 unless, indeed, which no one pretends, the one disorder excludes 
 the other. 
 
 The statement that the results just quoted are at variance with 
 general testimony, and that, upon the whole, the rheumatic con- 
 nection of chorea is supported by statistics, is one which need 
 not be accepted immediately. Of continental opinion it may be 
 enough to say that the French and the Germans are very much 
 at issue upon this point. Trousseau, as is well known, always 
 insisted upon the intimate union of the two affections, reckoning, 
 however, as evidence of rheumatism any traces of by-past endocar- 
 ditis. M. See finds chorea and rheumatism coinciding in 6 1 out of 
 128 cases ; in only 32 of these, however, 01 one-fourth, were the 
 rheumatic signs decisive. M. Roger has disposed of the question 
 summarily, and in language which renders the labour of taking 
 percentages superfluous. He believes that ' chorea and rheuma- 
 tism are one and the same affection under two forms.' On the 
 other hand, Romberg lays no stress upon rheumatism as allied to 
 chorea, and declares his dissent from the views of English writers 
 in this respect ; while Steiner, of Prague, records 252 cases, only 
 4 of which occurred during the course of acute rheumatism. 
 
 1 Senator, in his lengthy monograph upon rheumatism, alludes to the risk of 
 heart disease amongst the young, and adds: 'This' (i.e. the heart disease, and 
 not the rheumatism) ' is not unfrequently followed by chorea, especially when the 
 mitral is the affected valve.' This one sentence contains the only allusion to 
 chorea. So little do the historians of rheumatism respond to those of chorea upon 
 this subject. — Ziemssen, vol. xvi. p. 57. 
 
 £> 2 
 
36 CHOREA. 
 
 The most recent statistics of our own upon this subject are 
 those of Dr. Dickinson, in vol. lix. ' Medico-Chirurgical Trans.' ; 
 of Dr. Owen, in the 'St. George's Hospital Reports,' vol. ix. ; and 
 of Dr. Peacock, in the eighth volume of the 'St. Thomas's Re- 
 ports.' There are also the often-quoted cases of Dr. Hughes in 
 the 'Guy's Hospital Reports.' These last, however, owing to their 
 date, and other circumstances which I shall mention presently, 
 seem to require separate consideration. Dr. Dickinson's cases 
 refer to the same hospital, and include the same ages as my own 
 (from two to twelve). In 71 cases, as many as 10 are doubtful 
 (they are 7narked as 9, but a tenth case is described in the same 
 terms) as to their antecedents. There remain 61, in 42 of whom 
 rheumatism is absent ; 19, at the most, had rheumatism some- 
 where in their history, and in 7 of these it immediately preceded 
 the chorea. Two hundred and three cases (these and my own) 
 thus furnish 139 wholly free from rheumatism, 21 without history, 
 and perhaps 43 who had rheumatism somewhere in their lives, in 
 12 or 13 of whom this affection might be regarded as cause, or part 
 cause, of the chorea. 
 
 These numbers refer to a child's hospital where the utmost 
 age is twelve. General hospitals, where there is no such age 
 limitation, may be expected to yield a larger proportion of rheu- 
 matism, inasmuch as with the larger aggregate of years there is 
 more time for accumulating disease. In two tables of the model 
 medical reports of Dr. Owen, of St. George's Hospital, will be 
 found a collection of 50 cases, 22 of whom were over twelve years 
 old. Of these 50, 34 were without rheumatism, 3 were too 
 doubtful to be reckoned, and 13 had rheumatism in their 
 histories, in 4 of these last immediately preceding, and pre- 
 sumably causing, the chorea. Adding, therefore, this third list, we 
 get 253 cases, which yield 173 wholly free from rheumatism, 24 
 doubtful, and 56 who had rheumatism somewhere in their lives, 
 of whom 16 or 17 had the rheumatism in immediate connection 
 with the chorea. 
 
RHEUMATIC CONNECTION. 37 
 
 In Dr. Peacock's tables, dealing with 92 cases, only a portion 
 of whom were children, there are as many as 24 or 26 who had 
 had rheumatism at some time or other, the rheumatic symptoms 
 having immediately preceded the chorea in 7; 53 or 54 were known 
 not to have had rheumatism ; and the remainder are variously 
 accounted for.^ The percentage of rheumatism, therefore, is 
 higher in these than in the other tables, yet still the number of 
 the rheumatic is only just over a fourth of the whole. 
 
 There remain for consideration the statistics of Dr. Hughes, 
 in the 'Guy's Hospital Reports ' of 1846 and 1855. It is neces- 
 sary to observe of these tables that they were not constructed 
 exclusively from cases under the author's own observation, and 
 that there is no constant purpose pervading them. In many 
 instances rheumatism is not even alluded to. The first series, 
 indeed, is founded upon the supposition, no longer tenable, that 
 the existence of cardiac murmur deposes directly in favour of past 
 rheumatism. We read, therefore, that while 8 cases only had 
 their origin, 'more or less directly," in rheumatism, 'there were 
 only 15, out of the 104 where inquiries were made on the subject, 
 in which the patients were both free from cardiac murmur and 
 from a previous attack of rheumatism.' Such a statement would 
 not diifer very widely from the general experience. Some sort of 
 cardiac disturbance is very common with the younger children. 
 This observation, however, can no longer be accepted as deter- 
 mining the question of the proportion of rheumatism. In Dr. 
 Hughes' second series of cases, rheumatism finds place in the 
 notes of but 58 out of 209. It so happens that in this casual 
 mention the positive fact of its presence is noted 30 times, and 
 the negative fact of its absence 28 times, or about half and half. 
 But, it is surely unfair to suppose that these numbers at all 
 represent the actual proportion of rheumatism in the whole body 
 
 * From the elaborate character of Dr. Peacock's report I find it difficult to 
 summarise it, and would refer the reader to the paper itself, which deals with 
 many other points of interest besides the one here discussed. 
 
38 CHOREA. 
 
 of cases. A small number of examples thus brought together, 
 with a view to illustrate the rheumatic origin of chorea, at 
 a time when such origin is devoutly believed in, will be certain 
 to give undue prominence to that connection. It is only by taking 
 a number of examples consecutively, over a long period, that this 
 disturbing element of choice can be eliminated. Where this is 
 done, the results, as I have shown, are not very various, and 
 non-rheumatic chorea is exhibited in overwhelming excess of 
 the rheumatic, the percentage of the former var>'ing from 75 to 85. 
 But it is said the rheumatism with which chorea is associated 
 appears in the families rather than in the patients themselves. 
 It is impossible, of course, to test this position with any accuracy. 
 Rheumatism is to be found in every family in thp kingdom if we 
 do but seek far enough, nor can anyone say what is the proper 
 normal amount of it. I have noted the point in 73 of my own 
 cases, restricting inquiry to the immediate family, that is, to 
 parents, brothers, and sisters. The result is as follows : Rheuma- 
 tism is in the family history in 19 out of the 73 ; 9 of these 19 
 have themselves had rheumatism, and 10 have not. In i or 
 perhaps 2 of these 9 personally rheumatic patients rheumatism 
 was probably the direct cause of the chorea, and in i rheumatic 
 fever was the direct cause. I do not quote these figures as con- 
 clusive, or even wholly reliable. So far as they go, and are 
 accepted, they do not confirm the assertion that choreic children 
 have, as a rule, near relatives who are rheumatic. We may well 
 hesitate to believe a doctrine to which the statistics of rheumatism 
 give no support. At any rate, if rheumatic parents transmit their 
 morbid peculiarities to their children, they may be trusted to 
 transmit first of all a liability to rheumatism. We are thus 
 brought back to consider the question as regards the children 
 themselves, since it is certain that if these are choreic in excess, 
 they must still more be rheumatic in excess. 
 
 There is reason to believe, from the figures that have been 
 quoted, allowing sufficient room for error : — 
 
RHEUMATIC CONNECTION. 39 
 
 I St. That the proportion of chorea showing antecedent rheu- 
 matism does not exceed 25 per cent, of the whole number where 
 children up to twelve years old are taken (viz. 20 per cent, in my 
 own 132, and at the rate of something under 26 per cent, in Dr. 
 Dickinson's 71) ; and somewhere between 26 and 28 per cent, 
 where there is no age limitation (viz. 26 per cent, in St. George's 
 50, and 26 or 28 per cent, in Dr. Peacock's 92). 
 
 2nd. That the number of instances where rheumatism, in 
 whatever form, is wimediately connected with the chorea is very 
 small ; being 4 per cent, in my own cases, 7 in Dr. Dickinson's, 
 and from 7 to 8 in Dr. Peacock's and in Dr. Owen's (St. George's). 
 
 3rd. That in the great majority of cases of chorea occurring in 
 children supposed to have been rheumatic, the immediate exciting 
 cause of the chorea is no other than that which suffices to produce 
 the same affection in other children who have never been rheu- 
 matic. 
 
 It is obvioue that by no method of argument can these conclu- 
 sions be made to tell in favour of that intimate connection between 
 chorea and rheumatism which some contend for. Let us say, for 
 example, that 100 instances of chorea yield 25 with a history of 
 antecedent rheumatism. Of these there must be a certain number 
 representing the proper proportion of rheumatic subjects, which 
 we might expect to find in 100 individuals. What this number 
 should be we know not. Suppose that, on an average, only 5 per 
 cent, of our countrymen get rheumatism in childhood. We have 
 then 20 out of 100 choreic patients charged with rheumatism in 
 excess of the proper number. But physical pain is a well-recog- 
 nised cause of chorea, so that of the cases that arise immediately out 
 of rheumatism (from 5 to 8 per cent, as we have seen;, some may 
 be accounted for, not because of the rheumatism as such, but 
 because of the pain that attends rheumatism. This would still 
 further reduce the number. 
 
 The excess of rheumatism, then, in chorea would seem to be 
 represented, at the utmost, by something between 15 and 20 per 
 
40 CHOREA, 
 
 cent. — an excess too small to be adduced in support of any 
 intvnate alliance between the two, but nevertheless needing to be 
 accounted for somehow. The question, in fact, comes to this : 
 whether to believe that rheumatism confers this extra liability to 
 suffer from chorea, not immediately, but at some future and it 
 may be distant period ; or else to believe that the excess of 
 rheumatism is only apparent, and due to the fact that rheumatism 
 shares with chorea both heart disturbance and limb pains, so that 
 symptoms which properly belong to the one affection are easily 
 attributed to the other. If the first supposition be adopted it will 
 be necessary to insist (for here the evidence of statistics is 
 decisive) — first, that the rheumatism which predisposes to chorea 
 is seldom connected with it in point of time, a clear interval 
 occurring between the disappearance of the cause and the arrival 
 of the effect ; and secondly that the rheumatic children who 
 become choreic require the very same immediate incentive to the 
 disorder as do other children — namely, alarm or mental excite- 
 ment or nervous shock. If the second supposition be adopted, 
 the prevalent belief in the connexion of rheumatism and chorea 
 depends upon faulty observation and is sufficiently explained by 
 the circumstances ; while in the lessening proportion of rheumatism 
 in our later statistics we see the operation of that still recent 
 knowledge which discriminates between the heart affection of 
 chorea and that of bygone rheumatism. 
 
 But it is not by statistics alone that this question must be 
 settled, nor do the bare figures give a complete representation of 
 the relationship of chorea to acute and chronic rheumatism 
 respectively. With the special liability of choreic children to 
 joint and limb pain as well as to valvular heart murmur, we may 
 well accept a much larger proportion of rheumatism than is actually 
 credited to chorea without becoming convinced of any real 
 connection between them. The prevalence of such a belief is 
 easily accounted for without assuming its truth. The case is 
 somewhat different with acute rheumatism. The instances in 
 
RHEUMATIC CONNECTION. 4 
 
 which severe and sometimes fatal chorea arises in the course ot 
 this disease are so striking and so similar that notwithstanding the 
 comparative rarity of the conjunction it is difficult to resist the 
 conclusion that the one affection actually gives rise to the other. 
 Such examples, although too few to affect perceptibly statistical 
 tables, are yet numerous in the aggregate. If, indeed, we were to 
 exclude the commonest form of chorea and look only to adult 
 patients the proportion of instances where chorea occurred as the 
 immediate sequel of acute articular rheumatism with endocarditis 
 would not be excessively small. ^ And not only so, but the 
 sequence may be different, and in the course of chorea, or imme- 
 diately on recovery from it an attack of acute rheumatism may 
 supervene. On the other hand, and lest any should think that this 
 connection is other than rare, let it be considered that in a disease so 
 familiar to hospitals as acute rheumatism many physicians of experi- 
 ence have never seen this association, no one would think of antici- 
 pating it, and the voluminous records of rheumatism hardly make 
 mention of it. Further material will be adduced in the course of 
 this treatise, upon which the reader will be invited to form his own , 
 judgment upon this matter ; in the meanwhile, the following 
 conclusions seem to be justified by a full consideration of the 
 facts : — 
 
 I St. Acute rheumatism with heart implication, although rare 
 in the history of chorea, occurs in such association with it as to 
 justify the assumption of some direct relationship. The combina- 
 tion, however, is so exceptional that it hardly affects the question 
 of the origin of ordinary childish chorea. 
 
 2nd. Chronic or subacute rheumatism, although mentioned 
 
 1 Mention may be made in this place of 22 cases of chorea recorded by myself 
 many years ago, when Medical Registrar at St. George's Hospital, and not en- 
 tered elsewhere in this book, having as many as three examples of the connection 
 we are discussing. One was a boy of nine, who got chorea when recovering from 
 acute rheumatism with pericarditis ; another was a girl of sixteen, who got acute 
 rheumatism in the course of severe chorea ; the third was a girl of ten, who had 
 acute rheumatism and chorea concurrently. 
 
42 CHOREA. 
 
 in the histories ot patients more often than the other, is so 
 difficult of identification, so often disconnected as regards time, so 
 seldom seen unequivocally in actual company with chorea, and so 
 easily imputed upon insufficient grounds, that the asserted influence 
 of the rheumatic diathesis, or indeed any real connexion between 
 rheumatism and chorea cannot be established. 
 
 But there is more to be said in regard to those examples of 
 chorea to which I have alluded as occurring in immediate con- 
 nexion with acute rheumatism, and in virtue of which it may be ne- 
 cessary to admit that the one disease actually gives rise to the other. 
 In most of these the subjects are not children, but young adults 
 in whom violent and often fatal clonic convulsion (whether chorea 
 or not) arises immediately out of acute articular rheumatism, or 
 interrupts or may even precede it. Such symptoms cannot be 
 dissociated from the other phenomena of the disease which they 
 accompany. They furnish examples, along with those of acute 
 delirium and the various forms of cerebral embolism, of the several 
 nervous accidents to which the condition of the blood during acute 
 rheumatic fever gives occasion. In their origin, therefore, no less 
 than in their character and choice of subjects, these convulsions 
 are to be kept distinct from the chronic disorder of childhood 
 which we are now discussing. 
 
 It is not to the present purpose to notice other arguments of 
 statistics which are opposed to this asserted connection. These are 
 to be found, as I believe, in the time of life, the sex, and the geogra- 
 phical distribution of chorea and rheumatism respectively, as well 
 as in the fact that while students of chorea are earnestly contend- 
 ing for an alliance of this kind, the students of rheumatism, with 
 their far richer material and ready recognition of complications 
 and sequelae, give no encouragement to such proposals. The 
 doctrine of the rheumatic origin of chorea, however, is too firmly 
 rooted in this country to be much disturbed by such considera- 
 tions. We no longer seek to verify this connection, but are rather 
 occupied in constructing some plausible explanation of it Mean- 
 
RHEUMATIC CONNECTION. 43 
 
 while the two most prominent and unquestionable facts in regard 
 to the causation of chorea pass unregarded : the fact that alarm 
 or mental disquiet is its commonest, and, it may be, its constant 
 cause, and the fact that female children are in overwhelming 
 proportion its favourite subjects. 
 
44 CHOREA. 
 
 CHAPTER III. 
 
 THE HEART SYMPTOMS OF CHOREA. 
 
 Facts for explanation — The comparative frequency of heart disturbance in chorea 
 of different ages — The heart symptoms referred to endocarditis — to a sympathy 
 on the part of the heart with the muscular disorder — Difficulties in the way of 
 both hypotheses — Conclusions. 
 
 It is now generally admitted that there are certain heart symptoms 
 proper to chorea apart from those which are due to its association 
 with acute rheumatism or with anaemia. It is admitted as well 
 that cardiac apex murmur is, more often than was at first believed, 
 the sign of a functional disorder on the part of the valvular appa- 
 ratus ; the precise nature of this defective action has been in great 
 measure elucidated, and it has been repeatedly shown both in 
 chorea and other conditions that such murmurs are temporary and 
 innocuous. With this double advance of knowledge, both in re- 
 gard to the natural history of the disease in question, and the 
 pathology of the heart, we may consider the cardiac symptoms of 
 chorea from a new standpoint, with a clearer and more just appre- 
 hension than heretofore of the facts involved, and fuller and more 
 definite material for their discussion. In what is to follow I pro- 
 pose to investigate the present state of opinion as to the nature 
 and significance of the cardiac phenomena of chorea. To place 
 such opinion side by side with the actual facts of the case, and 
 upon this review, to consider whether by means of any existing 
 hypothesis, or of any modification or combination of hypotheses, 
 the question at issue finds reasonable solution. 
 
 The heart symptom of chorea chiefly discussed amongst us is 
 systolic murmur. In regard to the rate and rhythm of the heart, 
 
HEART SYMPTOMS. 
 
 45 
 
 as well as the precise seat of the bruit, there are, as we shall see, 
 doubts and differences ; but all observers allow that a soft systolic 
 murmur is apt to arise in the course of chorea, independently of 
 rheumatism or of anaemia, which is variable in tone, disappearing 
 and reappearing, often influenced by posture and' by exercise, most 
 audible in the majority of instances at the left apex, productive of 
 no sensation of its own, and indicated by no outward sign of dis- 
 turbed circulation. ^ Between this cardiac murmur and the choreic 
 restlessness there is no equality or parallelism. No particular 
 manner or degree of mismovement, and no particular temperament 
 of patient is especially liable to this heart affection. The choreic 
 murmur comes and goes secretly and without notice, there is no 
 recognisable law of its occurrence, and when auscultation has dis- 
 covered it, neither treatment nor prognosis is greatly influenced by 
 the discovery. 
 
 But while these symptoms on the part of the heart, in their 
 physical characters, limited duration and freedom from injurious 
 consequences, remind us most of the so-called functional murmurs, 
 yet they have a near relationship to substantive disease. This is 
 not matter of inference, but of direct observation. There is no 
 fact of chorea better established than this : that in the majority of 
 fatal cases — dying either in the course of chorea or shortly after- 
 wards — a fibrinous bead-like fringe is found edging the mitral 
 valve, and occasionally the aortic valve also.^ That this condition 
 is the effect rather than the cause of the chorea, we are compelled 
 to assume, in the numerous instances where murmur has gradually 
 developed in the course of the muscular disorder. There are 
 others, however, and especially those which arise out of acute 
 rheumatism (be they few or many), where the sequence is different, 
 
 * Such is the general description. Dr. Walshe, however, insists upon the 
 regularity of action, and Dr. George Balfour asserts that the murmur ' while it 
 lasts is constant and unchanging.' See Walshe, Diseases of Heart, p. 89 ; Balfour, 
 Diseases of Heart, p. 166. 
 
 2 ' Pathology of Chorea,' Dickinson, Med.-Chir. Trans., vol. lix. See Chap. 
 IV. ' On Fatal Cases of Chorea.' 
 
^6 CHOREA. 
 
 and the cardiac murmur, from immediately preceding the chorea, 
 may be taken to indicate an endocarditis which is certainly not the 
 consequence and may possibly be the direct cause of the chorea. 
 
 But although endocarditis, upon this showing, seems to be 
 connected with chorea in a double relationship, both as its cause 
 and its product, there are obvious difificulties in the way of ad- 
 mitting it at all. If endocarditis is really at the origin of chorea, 
 why do the physical signs which should announce it so often lag 
 behind, and why are they in themselves so equivocal and without 
 the usual accompaniments and results of valve inflammation ? If, 
 on the contrary, endocarditis is not the origin of chorea, but arises 
 out of it, by what sort of agency is this accomplished, and why 
 does not chorea, in virtue of this association, lay the foundation of 
 organic heart disease as acute rheumatism does ? Two conflicting 
 doctrines are thus offered for our acceptance, neither of which we 
 can wholly accept, and neither wholly reject. It is certain on the 
 one hand that cases of chorea which happen to die (whether from 
 the severity of the disorder or otherwise) very commonly exhibit 
 a fringing of recent lymph on the mitral valve ; it is not less 
 certain on the other that the non-fatal cases (that is of course 
 the vast majority) very rarely exhibit valvular disease in later 
 life. It is certain that both the auscultation signs and the 
 subsequent history of chorea murmur correspond most closely with 
 the dynamic murmur of young women ; it is not less certain that 
 chorea prefers children rather than young women, and shows after 
 death the actual material of endocarditis. 
 
 Such are the difficulties which meet us at the outset in en- 
 deavouring to explain the cardiac symptoms of chorea, and it is 
 obvious that the account I have just given in regard to these 
 symptoms does not contain the key to the solution. There still 
 remain, however, other factors of the problem, some which are 
 differently interpreted by different observers, and some which per- 
 haps have not as yet received their due share of notice. Thus, for 
 example, there is the character of the heart's rhythm, which some 
 
HEART SYMPTOMS. 47 
 
 report to be irregular, and others undisturbed ; and there is the 
 further question as to the mode of incidence of cardiac phenomena 
 in chorea in respect of age. It may be that the discrepancies 
 which appear at present in regard to the precise characters and 
 relative frequency of heart disturbance will disappear when we 
 come to compare patients of similar age. We know, for instance, 
 that the liability to such disturbance is in no direct relation to 
 the violence or the particular method of the choreic attack ; but 
 we do not know that it has no direct relation to the age of the 
 patient. Again, we know that choreic murmur may occur inde- 
 pendently of any marked change in the cardiac rhythm ; but we 
 do not know that this is so at all periods of life, or that disturbed 
 rhythm is not the rule rather than the exception in young children. 
 In what follows I propose to consider the characters and the 
 frequency of cardiac disturbances in young children as contrasted 
 with those who are older ; to compare actual observations upon 
 these points with the more general statement of authors ; and, by 
 the help of this comparison, and the material it will require, to 
 consider what hypothesis serves best to reconcile phenomena which 
 at first sight seem to be conflicting. I take for this purpose, as 
 before, the following : — 
 
 1. Dr. Dickinson's seventy-one cases (not 70 as stated) ap- 
 pended to his paper in the fifty-ninth volume of ' Medico- Chirur- 
 gical Transactions,' and referring to children treated at the Great 
 Ormond Street Hospital. 
 
 2. One hundred and thirty-two cases of children treated by 
 myself at the same hospital, but at a late stage of their dis- 
 order. 
 
 3. Thirty-nine cases of older children and young adults under 
 my charge at the Westminster Hospital. ^ 
 
 4. Fifty cases similar to the last recorded by Dr. Owen in the 
 ninth volume of the ' St. George's Hospital reports.' 
 
 1 See Appendix B. The last six cases of the second series were added later, 
 and are not reckoned above. 
 
48 CHOREA. 
 
 These four groups represent respectively, as will be seisn more 
 particularly in the sequel — 
 
 (i.) Young children from 2 to 12 observed at an early period 
 of their disorder. 
 
 (2.) Young children of similar age observed at a later period 
 of their disorder. 
 
 (3.) Older children with a few adults. 
 
 (4.) Older children, with a considerable proportion of young 
 adults. 
 
 (i.) In Dr. Dickinson's table the number has to be reduced 
 to 69, on account of two cases with the ages omitted. The 
 children are all young. There is in fact but one, a girl, as old as 
 13, and but 3 as old as 12 ; the youngest is 3, the next youngest 
 are two of 5 ; the ages most largely represented are 10 and 11 
 Taking the 69 cases, with a view to ascertain the incidence of 
 heart affection at different ages, it will be found that of the 21 
 children who are 8 years old and under, only 4 are free from heart 
 affection, 3 of these being of the age of 8 ; while of the 48 children 
 above 8 years old, there are 17 free from heart disorder.^ If, how- 
 ever, we state the numbers somewhat differently, classing the 
 children of 8 amongst the elder ones, we shall then find that in 1 1 
 children under 8, there is but one free from heart affection, while 
 in 58 of 8 years old and over, there are at least 19 free from any 
 abnormality of cardiac action which can fairly be reckoned. ^ As 
 regards irregularity, the 69 cases give 20 such examples, 12 of ir- 
 regularity alone and 8 of irregularity together with murmur. Of 
 the 21 children 8 years old and under, there are 5 with hearts 
 
 • Of the 17 children of eight and under having heart disturbmce, as many as 
 five had had acute rheumatism, to which therefore the heart conchtion might be 
 referred. On the other hand^ of the 31 children over eight having henrt disturbance, 
 as many as six had had previous attacks of chorea ; to which period, therefore, 
 rather than to the age retorded, the date of the heart disturbance might be referred. 
 
 * I have made these calculations from the tables themselves (to which I refer 
 the reader), and they do not precisely correspond with Dr. Dickinson's own sum- 
 mary (on p. 34 of his paper). This latter, however, has reference not to the ages of 
 the patients, but to the several causes of the chorea. 
 
HEART SYMPTOMS, 49 
 
 irregular only, and 3 with irregularity together with murmur. Of 
 the 48 children over 8 years old, there are 7 with hearts irregular 
 only, and 5 with irregularity together with murmur, 
 
 I take next a second group of children from the same hospital 
 who were under my own charge, having been received from one 
 or other of my colleagues. The ages are still between two and 
 twelve, as in the first group, but the children come under observa- 
 tion at a later stage of their disorder ; the great majority were 
 chronic cases, some few were convalescent. The total number 
 of these patients was 132 (appearing as 137, from 5 of them having 
 been twice admitted). The age distribution is as follows : — 
 
 12 years old are only 2 
 
 1 1 years old are 24 
 
 9 and 10 years old 47 
 
 8 years old and under (36 of these being under 
 
 eight) ..... 59 
 
 132 
 In the whole 132, 47 (more than a third) have heart murmur 
 or irregularity. The 59 children of eight and under have 24 
 examples of heart disorder ; the 72 children over eight have 23 
 such examples. In other words, the proportion of heart disturb- 
 ance is about 40 per cent, in the younger children, and about 32 
 per cent, in the older ones. 
 
 Again, if we take the extremes of age in both directions, that 
 is to say, if we compare the 26 children of eleven and twelve (the 
 oldest we have to do with) with 36 who are imder eight, we have 
 9 of the former having heart disorder against 16 of the latter, the 
 actual percentage of heart disturbance being thus somewhat 
 greater in the younger than in the older children. Of cardiac 
 irregularity, as apart from murmur, not including mere unevenness 
 of rhythm, there are but 9 examples, 6 of these referring to the 
 little children. 
 
 These cases, therefore, representing the same ages as Dr. 
 Dickinson's, but referring to a later stage of the affection, yield a 
 
 E 
 
50 CHOREA. 
 
 much diminished proportion of heart disturbance of whatever 
 kind. It is a little over a third, whereas in the former table it is 
 over two thirds. And what is still more remarkable, irregular 
 action of the heart, largely represented in Dr. Dickinson's list, 
 hardly appears in mine, and is almost confined to the younger 
 patients. 
 
 It thus appears probable, taking these two tables as they 
 stand, and comparing them together, first, that the heart affection 
 of chorea is not less but more marked in early than in later child- 
 hood ; secondly, that observation of the disorder at a late period 
 discovers less heart disturbance than at an earlier, and especially 
 that cardiac irregularity, a distinguishing feature of the chorea of 
 early childhood, is found at the beginning rather than at the end 
 of the attack. 
 
 Such, I say, are the conclusions to be drawn from a bare 
 enumeration, and so long as we confine ourselves to children the 
 majority of whom are not over ten, they are conclusions which 
 need no correction. But when we enlarge the view and admit 
 older children and adults ; in other words, when we go from 
 children's hospitals to general hospitals, we can no longer accept 
 the mere figures without some attempt at adjustment on account 
 of disparity of age. Thus, for example, all other things being 
 equal, the greater the age the larger the proportion of heart dis- 
 turbance independent altogether of chorea. We have to consider 
 besides, that in comparing childhood with adolescence, in respect 
 of the signs we are discussing, we have to encounter at the 
 later period those functional murmurs (variously named, and 
 attaching especially to young women) which, although they be 
 altogether distinct from chorea as such, are not in practice dis- 
 tinguishable from it. Add to this that the older the patient the 
 greater the probability that the chorea is not the first, but the 
 second or the third attack, and the heart disturbance therefore 
 but a revival of what has occurred in childhood, according to the 
 well known law of the disorder to repeat itself. Such cases 
 
HEART SYMPTOMS. 51' 
 
 illustrate in fact the liability of early childhood in respect of heart 
 sympathy : they are taken to illustrate the hability of the more 
 advanced age at which the patient comes under notice. Again, 
 some account must be taken of the previous occurrence of acute 
 rheumatism, which is likely to appear in larger proportion in the 
 histories of the older patients than of the younger, and to con- 
 tribute its share of heart murmurs which are not choreic but 
 rheumatic. It would be quite unfair, I say, to attempt the com- 
 parison we are now about without making allowance for discrepan- 
 cies of this kind ; without providing, that is to say, for the fact 
 that the younger the child the more likely the heart disturbance 
 to be part of the chorea, the older the child the more likely to be 
 accidental or contributed. Moreover, in any exact computation as 
 to the age-incidence of heart disturbance, it would be necessary of 
 course to exclude from the comparison anaemic and chlorotic girls, 
 as well as those who in earlier childhood had had either chorea or 
 acute rheumatism. In the case of such children as we have been 
 considering, all of them young, the correction necessary on this 
 account would not amount to much, and we need not stay to 
 make it ; but in the case of the older patients we are now coming 
 to, it makes a very wide difference. It would be altogether delu- 
 sive and misleading to place the old and the young side by side 
 with the view to an even comparison in respect of heart sympathy 
 in chorea. Numerical equality between the two classes, or any- 
 thing near an equality, would indicate, without doubt, that the 
 heart was more often implicated in the chorea of the young than 
 of the less young. 
 
 How the figures stand in these respects with older patients, 
 and how large a correction is needed for such reasons as have 
 been mentioned, will be seen from the examples of chorea which 
 remain to be quoted, viz., the 39 of Westminster Hospital and the 
 50 of St. George's Hospital. In the 39 Westminster cases 19 are 
 twelve years old or over, 5 of them being young women. In the 
 50 cases reported by Dr. Owen in the ' St. George's Hospital 
 
 E 2 
 
52 
 
 CHOREA. 
 
 Reports,' vol. ix., of two following years, as many as 27 are twelve 
 years old and over, 1 1 of these being young women and 6 young 
 men. We have thus in the four series of cases now rehearsed a 
 constant rise in the ages of the patients. Dr. Dickinson's are the 
 youngest, and the St. George's cases are by much the oldest, the 
 Westminster series standing midway, and my own children's 
 hospital cases differing from Dr. Dickinson's more in the duration 
 of attack than in age of subject. 
 
 The 39 Westminster cases are distributed as follows : — 
 
 13 years and over (two being young women) . 15 
 
 12 years old 4 
 
 1 1 years old 5 
 
 9 and ten years old 9 ] 
 
 8 years old and under 6 
 
 39 
 
 Of the whole number, 13 would have to be excluded, 5 on account 
 of acute rheumatism at some earlier period, and 8 on account of 
 previous attacks of chorea. The remaining 26 are made up of 
 19 who have no cardiac disorder, and 7 who have either murmur 
 or irregularity. Of the 19 who have their hearts free, 15 are over 
 eleven years old ; of the 7 who have cardiac murmur or irregu- 
 larity, only I is over eleven. 
 
 In the two tables of cases of St. George's Hospital there are 
 15 examples of heart disturbance in 50 cases, 10 of these 15 are 
 found among the 27 cases over twelve years old ; only 5 are 
 found among the 23 cases under that age. Upon this showing, 
 it would seem that cardiac symptoms in chorea are not more rare 
 but much more common after twelve years old than before. 
 Upon examination, however, of 10 individuals exhibiting heart 
 murmur and over twelve years old, it appears that 4 of them have 
 had previous attacks of chorea, i had pericarditis while in hospital, 
 I developed murmur just after acute rheumatism, and 2 were 
 weakly girls, aged fourteen and fifteen respectively. There are 
 tl\us 8 of the 10 whose murmurs are accounted for apart from 
 
HEART SYMPTOMS. 53 
 
 chorea altogether. We get but too properly choreic murmurs 
 in 2 7 choreic patients of ages ranging from thirteen to eighteen, 
 as large a proportion, I am disposed to think, as will be commonly 
 found at that period. 
 
 There is indeed considerable difficulty in fixing the time of 
 life when the liability to heart disturbance in chorea finally ceases. 
 The evidence already adduced shows, I think, that childhood is 
 particularly liable to it, and that irregularity of rhythm distin- 
 guishes this earliest liability, whether with or without systolic 
 murmur. It is also generally agreed that the rare chorea of ad- 
 vanced life has little connection with heart disturbance. But of 
 the middle period our knowledge is far from precise. For it so 
 happens that at the very time when, with the progress of develop- 
 ment, the frequency of cardiac murmur in chorea is obviously 
 lessening, there comes a period of life (and especially with young 
 women) when the precise significance of the symptom we are 
 discussing is hardly discoverable. Murmur may be choreic or 
 (so-called) anaemic. It would seem impossible at such time to 
 determine with any approach to certainty the proper liability of 
 the heart in connection with chorea. We know only that so 
 soon as this interval of obscurity has passed, and, with the com- 
 pletion of adult life, the indications furnished by the heart are 
 again trustworthy, cardiac sympathy in chorea is hardly recog- 
 nisable. 
 
 From the facts now adduced several conclusions seem to 
 follow. Heart symptoms in chorea occur most frequently during 
 a period which is included between two years of age and about 
 seven or eight. The age of greatest liability to choreic heart 
 disturbance thus nearly coincides wdth the age of greatest liability 
 to chorea. Again the abrupt decline in the liability to chorea, 
 which occurs at about fifteen, corresponds with a similar decline — 
 if it be not rather a cessation — in the disposition of the heart to 
 share in the disorder of the voluntary muscles. 
 
 It has been already observed that irregular cardiac action, 
 
54 CHOREA. 
 
 either alone or preceding, or accompanying the murmur, is a 
 pretty frequent feature in the younger children of Dr. Dickinson's 
 table. In my own children of similar age, but in a later stage of 
 chorea, it is much less common. In the Westminster cases, 
 where the patients are older, it is also rare, and in the St. George's 
 cases, older still, irregularity hardly occurs. This particular 
 symptom in the younger subjects is often the single sign of the 
 heart's affection. I believe, although I cannot show by tables, 
 that there are very few little children, if there be any, in any early 
 stage of chorea, who do not exhibit a marked unevenness or 
 inequality of cardiac rhythm. Such unevenness will sometimes 
 develop into murmur and sometimes not, murmur which is 
 almost always variable with the child's position, sometimes best 
 heard over the pulmonary cartilage rather than at the apex,^ apt 
 to come and go, and often finally lost sight of before the chorea 
 itself has disappeared. The second pulmonary sound is seldom 
 accentuated or doubled. 
 
 These statistics in regard to the age-incidence of the heart 
 symptoms of chorea enable us to render a fuller account than 
 heretofore of the particular phenomena. Dr. Walshe's assertion 
 that the cardiac action is regular must be limited to the older 
 subjects, or to the later stages of the disorder. Dr. Bristowe's 
 statement that the greater number of choreic patients have some 
 cardiac defect, irregularity amongst the rest, must be qualified by 
 adding that this large proportion refers to children, and that ir- 
 regularity as a sign of heart disturbance is almost confined to 
 them. 
 
 ' The fact of mitral regurgitation being most audible in this situation, is well 
 explained by Naunyn, as reported by Rosenstein (Ziemssen's Cyclopcrd., vol. vi. 
 p. 122). He points out that the second intercostal space, close to the left edge of 
 the sternum, coincides with the point of the left auricular appendix, which winds 
 round the pulmonary artery and lies in front of it. Now with the abnormal current 
 of blood flowing towards the auricle, we can easily understand, says Rosenstein, 
 ' how the sound should be conducted to the spot mentioned better than to- 
 wards the apex, more especially in cases where the appendix is long enough to lay 
 its point against the anterior wall of the thorax.* 
 
HEART SYMPTOMS. 55 
 
 Thus the several factors of the problem with which we have 
 to deal summarily stated are these : — 
 
 1. In the course of the chorea of childhood the heart is apt to 
 become irregular or uneven, and its first sound to be followed by 
 apex murmur, which is variable in pitch, influenced by posture, 
 seldom audible in the axilla or at the angle of the scapula, and 
 which disappears along with or shortly after the chorea, the heart 
 and the circulation suffering no injury. 
 
 2. This liability on the part of the heart, to what, from its 
 signs, would seem to be a functional disturbance, is independent 
 of the violence or method of the chorea, but dependent upon the 
 age of the patient, the younger children being the most, and the 
 elder the least liable, while beyond childhood there is little if any 
 liability of the kind. 
 
 3. These heart signs of chorea — acute rheumatism being ex- 
 cluded — give rise, as a general rule, to no symptoms whatever 
 affecting the health or comfort of the child. They make no ap- 
 parent difference to the prospects of recovery or the structural in- 
 tegrity of the heart. Nevertheless, choreic children having this 
 murmur and happening to die, either with or shortly after recovery 
 from chorea, very commonly exhibit a beading of recent lymph on 
 the mitral valve. 
 
 Such, I say, are the chief statements which statistics seem to 
 warrant. I will venture to add another, which, so far as I know, . 
 has never been statistically reckoned, but which no one will gain- 
 say. It is, indeed, the most constant of all the heart symptoms 
 of chorea, and met with at a later age than the rest I mean the 
 acceleration of the heart and pulse. ^ 
 
 1 Ziemssen says ' cases of arhythmia are certainly very rare, and there is hardly 
 anything published about it. ' On the other hand, he regards acceleration of the 
 action of the heart as common, and acceleration of the pulse as quite constant, 
 although, as he believes (I am convinced erroneously), the bodily heat is not 
 changed even in severe cases. — Ziemssen's Cyclopced. art. Chorea, p. 436. 
 
 The heart symptoms mentioned in the text are not the only ones to be met 
 with in chorea. I have heard presystolic murmur and both accentuation and 
 doubling of the second sound, and this in cases where there was sufficient evidence 
 
56 CHOREA. 
 
 Now there are two hypotheses of the heart phenomena of 
 chorea, each of which has special regard to certain of the facts 
 just mentioned, although neither is able to reckon with them all. 
 The two are in a sense mutually antagonistic, inasmuch as what 
 the one rejects the other prefers. Both theories have their sup- 
 porters in this country. The one asserts that the heart symptoms 
 of chorea are due to endocarditis, the precise relationship of the 
 muscular disorder to the valve inflammation being variously in- 
 terpreted. The other asserts that the cardiac signs are intrinsic, 
 a part of the chorea itself That there is some evidence in favour 
 of each of these views we have already seen. The task before us 
 is to reconcile them. 
 
 To the belief that the heart murmur of chorea is due to endo- 
 carditis I know of nothing in the actual clinical symptoms that 
 can be opposed. Our information in regard to the physical signs 
 of endocarditis per se is, indeed, vague enough,' while the pro- 
 bability of its occurrence in chorea is directly favoured, as we 
 have seen, by post-mortem evidence. The distinction between 
 organic and functional heart murmurs, founded on hard and fast 
 lines as to the transmission of the bruit, is of doubtful validity. 
 * A well-pronounced functional murmur,' says an excellent ob- 
 server,^ ' may be as diffused and transmitted as an organic' ' A 
 systolic apex murmur,' says Dr. Bristowe, ' is a positive proof of 
 
 that the heart disturbance was purely choreic. But I am not able to say at present 
 to what ages these exceptional signs chiefly attach, or what is their proportion to 
 the commoner symptoms. 
 
 ' ' There are few diseases,' says Rosenstein, ' the presence of which is diagnos- 
 ticated so arbitrarily as that of original acute and subacute endocarditis.' He 
 proceeds to point out the necessity of ' proving the existence of other symptoms in 
 addition to the mere murmur, especially intensified second sound in the pulmonary 
 artery, the localisation of the murmur, or transverse hypertrophy of the cardiac 
 volume.' — Rosenstein, art. Endocarditis, Ziemssen's Cyclopccd., vol. vi. Dr. 
 Bristowe says : ' If in the progress of any of those diseases of which endocarditis 
 is a common complication, we detect a recent cardiac murmur, and if further 
 observation proi.'e<; this to be a permanent phcnomcJion, we cannot reasonably doubt 
 that endocarditis is present." — Bristowe, Theory arid Practice of Medicine, and 
 edition, p. 522. 
 
 2 Dr. Nixon in Dublin Journal of Med. Science, vol. iv. p. 575. 
 
HEART SYMPTOMS. 57 
 
 regurgitation.' We have, indeed, just as much evidence, so far 
 as physical signs are concerned, of endocarditis in the course of 
 chorea as we have of it in many instances of acute rheumatism. 
 In both cases ahke a soft and not conveyed murmur may be 
 proved, in the event of death, to depend upon valve deposit, and 
 in both alike (I do not say to a like extent), when death does not 
 so intervene, the murmur has been found to disappear. In frank 
 recognition of these facts. Dr. Wilks expresses the belief that all 
 mitral systolic murmurs associated with chorea are organic ; and 
 Dr. Sansom,^ in a short summary of the prevailing opinions upon 
 the subject, admirable for its conciseness, arrives at a like con- 
 clusion. 
 
 But when this much has been granted and endocarditis is 
 admitted, how much are we the better? What is the mode of 
 origin and what is the sequel of such endocarditis? It is but 
 exchanging one difficulty for another. For we have to suppose, 
 upon this hypothesis, not only that endocarditis may arise in and 
 out of chorea, and that the younger the child the greater the pro- 
 bability of this event, but also that cardiac irregularity sometimes 
 precedes and sometimes takes the place of regurgitation, whilst 
 none of the injurious after consequences which attend endocarditis 
 in its other relations are found to ensue here. In face of such 
 grave objections, we are forced to admit that, although physical 
 signs do not contradict it and post-mortem evidence may seem to 
 be directly in its favour, the theory of choreic murmur (not to 
 speak of the other signs) which invokes endocarditis is too difficult. 
 It is inconsistent with all that we know of that inflammation in its 
 various pathological relations ; and apart from these we know 
 remarkably little about it. 
 
 It is in fact by virtue of this vague know^ledge that endocarditis 
 maintains its hold in this connection. A form of heart inflamma- 
 tion special to chorea, and having a history and mode of termina- 
 tion of its own, is a creation of too shadowy a kind to be easily 
 
 1 Sansom, Diseases of the Heart, p. 89. 
 
58 CHOREA. 
 
 dealt with. But so soon as anything definite and within reach of 
 investigation is alleged in regard to it, when, for instance, it is 
 said (as Trousseau, Bouillaud, Roger, and other French authors 
 say) that the endocarditis of chorea is in fact rheumatic, although 
 the rheumatic element is itself latent, we have a distinct yet 
 still but partially tangible issue. Of the relationship between 
 chorea and rheumatism I need not speak in this place. I have 
 endeavoured to show elsewhere that although real it is rare and 
 exceptional, and both Walshe and Hayden are of the same 
 opinion. However this may be, no one will refuse to admit that 
 the cardiac symptoms of chorea are observable someiifnes when 
 there is no open rheumatism either past or present. Now if in 
 all such instances we are to say, in the first place, rheumatism is 
 actually present, but after a secret and ineffable manner, and in 
 the second place endocarditis is the consequence of that rheuma- 
 tism, but it is an endocarditis which is exceptional in commencing 
 after the chorea has begun and disappearing along with it, we 
 account for the facts no doubt, but after a fashion which rather 
 begs the question than provides for it. 
 
 We are thus compelled to regard the heart symptoms of 
 chorea, taking them in their entirety and not by arbitrary selection 
 « — the early irregularity, the variable mitral murmur, the very fre- 
 quent acceleration of heart and pulse with frequent fluctuations in 
 the rate of both — as being altogether special and peculiar. They 
 are signs of the heart's sympathy with the voluntary muscles, and 
 are seen most at that early time of life when the antecedence of 
 acute rheumatism is the least probable. The heart suffers, by 
 whatever mechanism or nervous influence, part and parcel with 
 the rest of the muscular system, or rather it is apt to suffer. Such 
 a conclusion, I say, in some sense or other, seems self-evident, 
 and is indeed involved in the statement that the heart symptoms 
 of chorea are met with in no other association. 
 
 Obvious and inevitable as it may be, it is far from being easy 
 of application. For if it be granted, in the words of Dr. Walshe, 
 
HEART SYMPTOMS. 59 
 
 ' that the apex murmur of chorea is plausibly ascribable to dis- 
 ordered action of the muscular apparatus connected with the valve,' 
 why does not the same disordered action extend to the ventricular 
 walls ? It may be answered (although Dr. Walshe does not admit 
 as much) that in young children there is both disorder of rhythm 
 and regurgitation ; but the answer is insufficient. These two 
 signs do not commonly concur nor do they vary together. And it 
 is not young children alone that we have to consider, but the elder 
 patients as w^ell ; and in these latter, while murmur is not infre- 
 quent, any marked irregularity of cardiac rhythm is certainly rare. 
 Thus we have to suppose that the fibres of one and the same 
 muscle are acting regularly as regards the ventricular wall, but 
 irregularly as regards the papillary muscles. ' We should be forced 
 to admit,' say Dr. Hayden, ' that whilst the greater portion of the 
 length of certain muscular fibres contracts with perfect order and 
 regularity, the remaining and smaller portion of the same fibres act 
 spasmodically and out of harmony with the former. ' ' No physio- 
 logist,' he adds, ' bearing in mind the unity of nerve centres and 
 the community of nerve distribution enjoyed by both portions of 
 the same fibres, would admit such a doctrine.' ^ 
 
 There are other objections equally formidable. It is not in 
 the nature of chorea to dissever the normal combinations of 
 muscular movement. It stirs the very same muscles that are 
 employed by purpose or emotion, and moves them in a similar 
 way, only less precisely and with less definition. Apart from 
 anatomical considerations, therefore, a choreic spasm of the heart, 
 which should select the papillary muscles and leave the cardiac 
 walls, would be untrue to the pattern of chorea elsewhere. And 
 again, if this choreic conduct of the heart be but an extension of 
 the same disorder which affects the other muscles (an extension, 
 as Dr. Kirkes points out, to which there is no parallel in any 
 other involuntary muscular organ), the most violent and general 
 chorea ought to exhibit this cardiac disturbance the most. But it 
 
 ^ Diseases of Heart and Aorta, p. 268. 
 
6o CHOREA. 
 
 is not so. On the contrary, the violent chorea of puberty has 
 seldom either cardiac murmur or cardiac irregularity, while the 
 chorea of the young child, which is very rarely violent and is 
 sometimes rather a paresis than a disorder of movement, exhibits 
 both these forms of heart affection very often. And even if these 
 difficulties should be overcome or the ground of some of them 
 disputed, it would still, I think, be hard to understand how the 
 great centre of circulation and (in one sense, at all events, within 
 the experience of everybody), of emotion should become the seat 
 of a mismovement at all resembling the choreic contortions of the 
 visible muscles without giving rise to sensations of grave disquiet, 
 sensations, be it remembered, which, so far as young children are 
 concerned, the favourite subjects of such cardiac disorder, are 
 conspicuously absent. 
 
 It would thus appear that both the hypothesis which supposes 
 endocarditis to be the cause of choreic murmur and the hypothesis 
 which supposes an extension of the muscular infirmity to the heart 
 to be the cause of it are fallacious. Both theories commit us to 
 too much. And if, in this strait, we have recourse to vaguer ex- 
 pressions having regard to the ' impoverishment ' or ' vitiation ' of 
 the blood, we neither provide an adequate explanation nor allege 
 a demonstrable cause. But while thus compelled to abandon one 
 position after another, we must beware lest by too precipitate a 
 retreat we quit ground which it is essential to hold. We may even 
 venture so far upon the assured facts of the case as to make some 
 sort of stand and to affirm something. If the views just announced 
 cannot be held in their entirety they must be held with some modi- 
 fication or other. There is no alternative. Part of the perplexity 
 arises, as has been shown, from a consideration of the harmlessness, 
 variability, and limited duration of the choreic murmur. But if 
 these facts are in themselves secure we may rely upon them to force 
 at least this conclusion, that the conduct of the heart in chorea is 
 similar to its conduct in anaemia. Whatever explanation, therefore, 
 applies best to the precise mechanism of the so-called functional 
 
HEART SYMPTOMS. 6 1 
 
 or dynamic murmur cannot be altogether foreign to the circum- 
 stances of chorea. 
 
 It is now generally admitted that the murmurs once called 
 haemic, anaemic, and by similar names, implying dependence on 
 some blood change, are much more often than was at first supposed 
 produced by actual regurgitation, due to a temporary defective 
 action on the part of the mitral valve. Such murmurs are to be 
 heard in purpura, in anaemia, in the general muscular relaxation 
 due to nervous strain, in epilepsy, as well as in typhus, and 
 enteric fever, and even in simple pyrexia. This dynamic mitral 
 bruit may, by exception, be harsh and far-sounding, audible in 
 the axilla and even at the lower angle of the scapula, yet never- 
 theless by its ultimate disappearance give ample proof that what- 
 ever may befal the valve during its continuance (and there is some 
 reason to believe that a material change actually occurs) is not 
 abiding or permanently mischievous. So much, I think, is gener- 
 ally admitted. The question for us now is, whether the same 
 explanation of the mechanism of this murmur which applies to its 
 association with the conditions just mentioned applies also to its 
 association with chorea. 
 
 No one, so far as I know, has more ably discussed this subject 
 than Dr. Nixon. ^ His exposition of the various ways in which 
 dynamic apex murmur may arise, and of ' the perfect unity and 
 correspondence in action of the fibres of the walls of the ventricles 
 and of those which are connected with the valves, which is needed 
 in order to ensure complete closure,' suggests to him the inquiry 
 whether this nice correspondence of movement might not be so 
 disturbed by altered nutrition or innervation as to render such 
 closure for awhile defective. The tremor of the voluntary muscles, 
 which is apt to follow upon their violent exercise, is adduced as 
 being analogous to this disordered cardiac action. Dr. Nixon con- 
 cludes that functional mitral murmur results from ' this want of 
 correspondence between the fibres of the ventricle, which obliterate 
 
 1 Dublin Journal of Medical Science, vol. Iv. p. 572, &c. 
 
62 CHOREA. 
 
 the cavity, and those which close the valve ; ' an altered function 
 due, as he believes, ' to some defect in the vital power or condition 
 of the heart itself, which leads either to atony of the papillary muscles 
 or derangement in the rhythm of their movement.' In the further 
 observations of the same author as to the means of separating this 
 murmur from the organic, he alludes to its changeable character, 
 alteration or even disappearance with the upright posture, and the 
 absence (in most instances) of accentuated or double second 
 sound. Thus, in all its essential features, the murmur which Dr. 
 Nixon describes corresponds with that of chorea ; and, except in 
 cases of temporary debility, aucemia and certain conditions already 
 particularised, commonest in the female sex, it is seen in no other 
 connection. 
 
 Dr. Hayden, assenting in part to these views, would attribute 
 the dynamic murmur not so much to a want of correspondence 
 between muscular fibres as to atony or parietal debility of the walls 
 of the left ventricle.^ Weakness and relaxation of the papillary 
 muscles, he admits as a possible cause of mitral regurgitation. 
 Spasm, or irregular action of the same muscles, he does not admit 
 as a possible cause of it. This regurgitant murmur, ' caused by 
 atony and partial yielding of the walls of the left ventricle at the 
 acme of systole,' Dr. Hayden has long associated with anaemia, 
 purpura, and excessive use of tobacco. His later observations lead 
 him to include chorea and fatty heart in the same category. 
 
 But the latest and least reserved expression of the opinion that 
 dynamic murmur is in fact dependent on muscular paresis is that 
 of Immermann.* ' The muscular tissue of the heart,' says he, 'owing 
 to the altered state of the blood, is easily fatigued, and this lia- 
 bility to premature fatigue extends to the papillary muscles con- 
 nected with the auriculo-ventricular valves. After any undue 
 exertion of the cardiac muscle a temporary paresis of the musculi 
 papillares ensues. In conscfiuence of this the valve flaps intrude 
 
 ' Hayden, loc. ctt. p. 274. * Ziemssen's Cyclop., vol. xvi. p. 399. 
 
HEART SYMPTOMS. 63 
 
 into the auricles with every ventricular contraction, that is, a 
 transient functional insufficiency of the tricuspid and mitral valves 
 is established. As the organ regains its normal energy these grow 
 fainter and ultimately disappear.' He goes on to describe the 
 fatty degeneration of the papillary muscles which sometimes en- 
 sues upon simple anaemia, and which explains both the occasional 
 permanence of these murmurs and their occurrence in connection 
 with fatty heart. 
 
 It will be admitted, I think, that both the time of appearance 
 and precise manner of the choreic murmur, as well as its mode of 
 origin and duration, varying intensity and limitation to the period 
 of youth, are all nicely provided for in the hypotheses just re- 
 hearsed. If only it be granted that the heart's disorder is really a 
 sympathy with the muscular disturbance, an inexact and precarious 
 correspondence between the ventricular contraction and that of 
 the papillary muscles would seem to serve for chorea even more 
 than for the conditions to which Dr. Nixon applies it. Still better, 
 and without making any assumption as to the heart's sympathy, 
 might we admit the doctrine of partial paresis of the valve appa- 
 ratus, and insist that the excessive muscular movement of chorea 
 is the precise condition w^hich, upon the hypothesis, should give 
 rise to murmur such as we hear in token of fatigue on the part of 
 the heart Adopting either of these views, we might say with 
 Ziemssen that ' change in the valvular sound is a priori more likely 
 in chorea than in any other affection.' ^ 
 
 But the matter is not so easily settled. Let it be granted that 
 the choreic murmur is due to a functional disorder on the part of 
 the mitral and probably also of the tricuspid valves, by means of 
 which a temporary and variable regurgitation is permitted (and I 
 think so much of admission is inevitable), we have to ask, in the 
 next place, why this regurgitation, whether it be due to faulty adap- 
 tation of the several parts of the heart to one another, or to the 
 paresis of fatigue, is not in harmony with the other symptoms ? 
 
 ^ Loc. cit. p. 440. 
 
64 CHOREA. 
 
 If the murmur betokens a sympathy on the part of the heart with 
 the disordered action of the other muscles it ought to appear when 
 chorea is the most generalised ; if, on the other hand, it betokens 
 a fatigue paresis it ought to appear when the chorea is most vio- 
 lent and prolonged. But it does neither. The sympathy of the 
 heart (if it be rightly so called) goes not with the manner or the 
 degree of the chorea, but, as has been shown, with the age of the 
 patient. And, moreover, we should be taking a very partial view 
 of the subject were we to limit the heart symptoms to cardiac 
 murmur. This, we have seen, is but one, and not even the 
 chief, symptom of choreic heart disturbance. There is besides the 
 unevenness or inequality which belongs especially to early child- 
 hood, and, most constant of all, there is the accelerated pace of 
 the heart. Moreover, we have not merely to account for the 
 presence of these additional signs, we have to fit them into their 
 places, and to show why the heart, seldom failing to share the 
 muscular disorder in one way or another, exhibits this mode of 
 disturbance or that according to the age of the subject. We may 
 accept either account of the mechanism of dynamic murmur, and 
 without much violence apply it to suit the circumstances of chorea: 
 that is a little gain no doubt. But when that is done there remain 
 these other symptoms, which, unlike valvular murmur, can com- 
 pare with nothing to be found in other analogous conditions, unless 
 indeed the cardiac unevenness and its acceleration remind us of 
 what is sometimes met with in hypochondriacs and hysterical 
 women, the least promising subjects to throw light upon obscure 
 places in pathology. 
 
 It would seem then that to understand the conduct of the 
 heart in chorea we must look to chorea itself and the modifications 
 it exhibits at various ages. Here is an affection which both in 
 absolute frequency and in its tendency to implicate the heart, 
 attaches itself to young children most of all, to older children some- 
 what less, to adults hardly at all. At each of these periods chorea, 
 both in the limbs and at the heart, shows itself after a particular 
 
HEART SYMPTOMS. 6$ 
 
 manner. If, then, the action of the heart in this disorder is 
 throughout in real harmony with that of the voluntary muscles, the 
 clue to the secret we are in search of must be sought in the special 
 characteristics of those periods of Hfe to which chorea especially 
 attaches — characteristics, that is to say, in which they differ from 
 infancy on the one hand and adult life on the other. If the reader 
 is not already wearied by the length of this exordium and the some- 
 what circuitous path he has had to pursue, I would venture in such 
 space as remains to take a final survey of the subject from this 
 point of view. 
 
 I would observe, in the first place, that the chorea of the post- 
 infantile period is the immediate successor of the muscular spasm 
 or convulsion of the infantile period. At an age varying with the 
 ' forwardness ' of the child, the one Hability takes the place of the 
 other. The very same material cause (as for example, intestinal 
 irritation, or the troubles of dentition) will excite convulsion in 
 infancy, and chorea a little later. Again, the chorea of early child- 
 hood will sometimes commence with convulsion, or the two affec- 
 tions may alternate, the same limbs being affected in both cases. 
 Little, of course, can be certainly known as to the actual sensations 
 of the child at this early age, or of the mode in which physical 
 pain gets mentally interpreted \ but it depends probably in some 
 measure upon the degree of completeness of such interpretation 
 whether the response shall be by way of convulsion or by way of 
 chorea. However this may be, the general muscular restlessness 
 of the young child which passes for chorea is not only in close 
 union with spasm in the way just mentioned, it often bears a direct 
 resemblance to it in form. There is an universal unsteadiness in 
 which the muscles of the abdomen and of respiration share as well 
 as the diaphragm and larynx. This generalised chorea which thus 
 succeeds to convulsion is, so to speak, the simplest form of the 
 disorder, without variety, so far as the movements of the several 
 parts of the body are concerned, and without any mental admix- 
 ture. It is an aggravation of the natural unsteadiness of child- 
 
66 CHOREA. 
 
 hood, an universal and equable overmovement or mismovement 
 extending to all those regiens which it is the nature of chorea as a 
 motor disorder to affect, and it is this merely. There is no inco- 
 ordination, for the muscles have not yet learnt to act together ; 
 there is no distinction between the movement of one part and 
 another, for the several muscular uses are not yet differentiated, 
 and the limbs are stirred indifferently without method or purpose. 
 Such general, featureless agitation of the body is the proper re- 
 sponse to a source of irritation which appeals to no one part in 
 particular and has no mental representation. 
 
 With maturer age, the bodily movements become varied and 
 definite, and each department of the muscular system sets about 
 its separate business. And as with movement, so with mismove- 
 ment. The chorea of later life is a definite deformity, which 
 alters and disfigures the natural carriage in this way or that 
 according to its seat. It selects those muscles which are the 
 readiest to respond to emotion, and moves them as they are 
 wont to be moved by the passions and employments of life. Thus 
 the choreic distortion of the face is one thing, of the legs another, 
 of the arms another ; and this separateness becomes the more 
 distinct as the individual grows and his individuality, as it is 
 called, becomes more and more marked. The mismovement of 
 chorea betrays the age of its subject, no less than does the natural 
 movement ; and, as life goes on, chorea becomes more and more 
 distinctly localised. In its latest form it is a partial disobedience 
 or misconduct of certain muscles, rendered inveterate by habit, 
 and incorporated, as it were, with the rest of the bodily move- 
 ments. 
 
 My conjecture is that the conduct of the heart in chorea is in 
 strict accordance with these successive modes or differentiations 
 of the muscular disorder. The heart sympathises with chorea, in 
 one way or another, throughout life, or at any rate until that late 
 period is reached when the affection is both rare and difficult to 
 identify. Not to speak, for a moment, of the valvular murmur, 
 
HEART SYMPTOMS. 67 
 
 the choreic heart is unrhythmical or irregular in early childhood,^ 
 accelerated in youth, and left undisturbed in old age. Thus, the 
 earliest period of heart sympathy, that of cardiac irregularity, with 
 or without acceleration, corresponds with that chorea which is a 
 purely motor disorder, the earliest transition from infantile convul- 
 sion, and differing from it mainly in the character of the movement, 
 and the implication of the emotional centres ; but resembling it in 
 its exciting cause, wide range, and conformity everywhere to a single 
 pattern. In the heart, as well as the limbs, in the tongue, the speech, 
 the diaphragm, in all the parts, in fact, accessible to emotion, yet 
 without any mental representation of emotion, the choreic disturb- 
 ance of little children is a purely motor disorder, excited very often, 
 like the earlier convulsion, by a material irritation. 
 
 In like manner, the cardiac acceleration of youthful chorea, 
 with or without murmur, corresponds with that form and period 
 of the affection when the several muscular movements have been 
 differentiated, and there is no longer a single and uniform re- 
 sponse, but each department of the body liable to chorea responds 
 after its own manner to a disorder which is now first mentally 
 apprehended and intimately connected with emotional exaltation. 
 As to the limbs, there is no longer a mere restlessness impartially 
 distributed, but complicated disorder of movement, in which 
 paresis and inco-ordination are variously blended, and which 
 selects, by well-marked preference, those muscles which are the 
 readiest exponents of emotion. And as to the heart, in place of 
 disturbed action and rhythm, there is the proper emotional 
 response with which everyone is familiar in his own person — an 
 acceleration, namely, and often knocking impulse as well. 
 
 Now, at both the periods we are now considering, in child- 
 
 1 Ziemssen's suggestion as to ' the influence of restless muscular action upon 
 aortic pressure and the working of the heart ' {loc. cit. p. 437), fails to apply, I am 
 convinced by repeated observation, in explanation either of the heart's irregularity 
 or of its rate. It is. indeed, at once negatived by the admission that the heart 
 disturbance of chorea is in no direct proportion to the violence of the muscular 
 disorder. 
 
 F 2 
 
68 CHOREA. 
 
 hood and in youth, both with cardiac irregularity and cardiac 
 acceleration, we have, or we may have, apex murmur. It has 
 been shown already that for such murmur no other explanation 
 applies except the functional one ; and indeed, in the case of 
 choreic patients, at that time of life when the so-called anaemic 
 murmur is common, I know not how it is to be determined 
 whether valve defect is due to chorea or to anaemia. The 
 same causes may operate in both cases, and the explanation of 
 Dr. Nixon of faulty adjustment of valve and ventricle may serve 
 for both. But there are still the children to be considered ; and, 
 if we are still to apply the argument that the heart symptoms of 
 chorea are in constant harmony with the rest of it, it is necessary 
 to remember that there is another element in chorea besides those 
 that have been alluded to. I mean paresis. 
 
 The real character of this choreic paresis has been somewhat 
 obscured, I venture to think, by the prominence that has been 
 given to those examples of it which have chanced to affect one 
 side of the body only. I would only remind the reader, in this 
 place, of what has been said before in reference to that strictly 
 localised paresis which mixes with choreic restlessness in children. 
 Sudden both in its access and departure, it may be recognised 
 especially in a droop of the wrist, or a falling of one shoulder, or 
 feebleness of grasp of one hand. It selects this part or that, 
 according to no known rule, and may in some instances show so 
 prominently as to give the patient the appearance of paralysis 
 rather than of chorea. Now, all that can be said of choreic 
 paresis, as we see it in the limbs, may be said as well of choreic 
 murmur, as we hear it at the heart. Both are characteristic of 
 childish, or, at least, youthful chorea ; both are sudden in their 
 development, variable in degree, and apt to come and go 
 without any other corresponding change in the character of the 
 disorder. 
 
 If, then, weakness and relaxation of the papillary muscles be 
 admitted as a possible cause of mitral regurgitation, and if a 
 
HEART SYMPTOMS, 69 
 
 debility of this kind may arise temporarily, from tobacco-smoking 
 or nervous exhaustion, much more should it arise in chorea, 
 where — apart from muscular fatigue — there is a special liabiUty 
 to paresis extending, as it would seem, to all the muscles which 
 the disease is able to effect ; and observe that this relaxation on 
 the part of the papillary muscles, which is common both to 
 anaemia and chorea, and productive of regurgitation in both, is 
 not of the same origin in the two cases, nor always accompanied 
 by precisely the same signs. In anaemia it gives rise to an equable 
 murmur, which only ceases with the gradual recovery of the 
 patient ; but in chorea it is (or it often is) a variable and incon- 
 stant murmur, which hardly repeats itself precisely for two con- 
 secutive beats, and which appears and disappears without apparent 
 cause, as does the similar paresis of the voluntary muscles, with 
 which indeed, as I have repeatedly noticed, it may be strictly 
 synchronous, both in its time of arrival and duration. Moreover, 
 with a murmur having this origin, we are rid of the difficulty which 
 attaches to the doctrine of a fatigue paresis, and would require 
 that the valvular defect should be in direct relation to the dura- 
 tion and severity of the chorea ; which would associate it, there- 
 fore, not so much with childhood, as with that violent form of 
 chorea which is commonest at a later period of life. 
 
 Yet still the old objection will recur. Whence comes it that a 
 temporary paresis of the valve apparatus is found to be associated 
 after death, if not with endocarditis, at all events with a deposit 
 of recent lymph on the edges of the mitral valve? That this 
 appearance does not represent a true inflammation of the endo- 
 cardium is rendered probable by its bead-Uke arrangement, and 
 limitation to the margin, rather than the auricular surface of the 
 valve. There is never ulceration ; and, where time has been 
 allowed to elapse between the chorea and death, the valve is 
 found to be in a normal condition. Only in cases where death 
 supervenes either in the course of the chorea or very shortly after- 
 wards is this appearance met with, and in these not always. There 
 
70 CHOREA. 
 
 is ample clinical and post-mortem evidence that it is neither 
 lasting nor injurious.^ Mindful of this strict limitation of the 
 facts to be interpreted, and of the necessity, in the last resort, of 
 reaching a solution upon the principle of exclusion, the question 
 suggests itself whether an imperfect closure of the mitral orifice, 
 or rather such uncertain action of the valve segments as closes it 
 at one time, but not at another, might not, at the approach of 
 death, and when, with the flagging action of the heart, fibrine is 
 very readily deposited — so determine the seat and method of 
 such deposit as to produce, at the edge of the valve, the bead-like 
 appearance that we see ; the condition which immediately precedes 
 death being one of the essential factors of the occurrence. 
 
 It may be said, indeed, that whatever is true of the dynamic 
 murmur of chorea must apply equally to the same murmur in 
 anaemia and elsewhere. But of the post-mortem appearances 
 of simple anaemia we know absolutely nothing. There is, how- 
 ever, a disease having a striking likeness to chorea in respect of 
 its preference for the female sex, near connection with hysteria 
 and with mental emotion, and apparently anomalous blending of 
 functional with organic disturbance. In exophthalmic goitre we 
 have at first acceleration of the heart and afterwards mitral mur- 
 mur, a murmur which sometimes wholly disappears with the com- 
 plete recovery of the patient, and sometimes is the precursor of 
 organic mitral disease. 
 
 In conclusion, I would briefly recapitulate the facts which it 
 has been the object of this paper to establish, together with the 
 hypothesis which they seem to support. The facts are that in 
 chorea the heart is apt to sympathise with the voluntary muscles 
 
 ' See Chap. IV. p. 78. The suggestion in the text is in fact that of Dr. Dic- 
 kinson. ' The beads,' he writes, ' are usually confined to the inner surface of the 
 mitral valve and arranged along the attachment of the thin edge, where a line of 
 minute but abrupt prominences is presented to retrograde blood, but an arrange- 
 ment of more gradual slopes to blood flowing normally. Thus possibly the collection 
 of fibrine is the consequence not the cause of the regurgitation.' — Pathology of 
 Chorea, loc. (it. p. 37. 
 
HEART SYMPTOMS. 71 
 
 at all ages up to the adult period, this sympathy being shown as 
 well by dynamic murmur as by accelerated action, unevenness of 
 rhythm, and, not seldom, the excited impulse common in hysteria, 
 the particular manner of response being dependent upon the age 
 of the patient. The hypothesis is that these several modes of 
 heart affection correspond with as many modifications of chorea, 
 which are exhibited not in the heart only but in the voluntary 
 muscles as well ; these several regions sharing jointly, each in 
 its own degree and after its own manner, in a disorder the area 
 of whose influence is co-extensive with that of ordinary emotional 
 disturbance ; and, particularly, that in all such variations the 
 motor element of the affection is represented mainly by in- 
 equality and unevenness of cardiac rhythm, the emotion element 
 by acceleration, and the paresis element by dynamic murmur. 
 
72 CHOREA 
 
 CHAPTER IV. 
 
 CHOREA AS A FATAL DISEASE. 
 
 Recorded examples of fatal chorea — Age and sex in relation to fatality— Exciting 
 causes — Morbid anatomy — Conclusions. 
 
 The pathology of chorea needs to be discussed upon a wider 
 basis than that which is offered by morbid anatomy ; nevertheless, 
 no survey of the disorder can be considered complete which fails 
 to take into account the evidence to be derived from fatal cases. 
 The review of a sufficient number of examples of this sort, apart 
 from any direct discovery of morbid change, cannot fail to be of 
 service in exhibiting the age, sex, and temperament most liable to 
 succumb to such attacks. We shall be thus assisted in separating 
 from one another a highly dangerous form of convulsion, and that 
 far commoner motor disorder which, whether violent or not, has 
 little or nothing of danger about it, and probably recovers best 
 without active medical interference. 
 
 Yet with this obvious service to be got from the study of 
 fatal chorea, its occurrence is so exceptional, that no single observer 
 from his own experience can do more than contribute a very 
 small share of the material necessary for the purpose of drawing 
 any general conclusions. Thus, Dr. Hughes, in so large an 
 hospital as Guy's, was able to collect from all the records by 
 various hands, which had been preserved during more than thirty 
 years, only eleven fatal cases. Dr. Dickinson, from a similar re- 
 cord at St. George's, extending over thirty-three years, collected 
 sixteen such cases, while the large field of observation offered by 
 the Hospital for Sick Children during fifteen years furnishes but 
 
AS A FATAL DISEASE 73 
 
 six. These examples, it must be understood, include those dying 
 with chorea as well as those dying of it. Although it is not always 
 easy to distinguish between these two classes, it is certain, as 
 will presently appear, that the cases of death attributable directly 
 to chorea fall very far short of the numbers just given. It must 
 be added that many of the earlier records are very defective, that 
 there is no uniform plan of tabulation, and that with different ob- 
 servers different points of interest have received mention. On 
 the whole, it may be said that if all the recorded accounts of 
 fatal chorea in this country which are fairly complete and readily 
 accessible were put together, the total number would not be large, 
 and that in a considerable proportion of these the immediate 
 cause of death and the choreic disorder would be found in very 
 remote and uncertain connection. 
 
 Such being the facts of the case, I have thought it of interest 
 to bring together 80 cases of death in connection with chorea, 
 or at least with convulsions resembling and called chorea. They 
 are made up as follows : — {a) 3 cases (quoted by Dr. Bright), 
 Med.-Chir. Trans., vol. xxii. ; {b) 11 cases (Dr. Hughes), Guy's 
 Hospital Reports, 1846 (first series) ; {c) 7 cases (from same 
 source), 1855 (second series) ; [d) 34 cases (Dr. Tuckwell), 
 Bartholomew's Hospital Reports, vol. v. ; {e) 22 cases (Dr. 
 Dickinson) Med.-Chir. Trans., vol. lix. ; (/) 3 cases (Dr. 
 Peacock), St. Thomas's Hospital Reports, vol. viii. 
 
 With these references and the frequent mention I shall have 
 to make of each of these eminent authors no one can quote 
 against me on their behalf the line that Virgil wrote on the palace 
 gate. The present object is to bring together under one point of 
 view a body of evidence derived from many sources without ad- 
 mixture of extraneous matter. Of the conclusions to be drawn 
 from such evidence the reader will judge for himself. 
 
 The points I propose to examine concern the age and sex and 
 common exciting cause of fatal chorea, together with its most 
 obvious morbid associations. It will be seen immediately that 
 
74 CHOREA 
 
 only a proportion of the 80 cases are given in such detail as to be 
 dealt with in all these respects. Thus, Dr. Tuckwell's account 
 is no more than a short summary occupying one paragraph of his 
 paper just quoted. Dr. Hughes's first series is described by him- 
 self as ' very meagre and imperfect ; ' Dr. Bright's 3 cases, although 
 so often quoted, are not altogether in point ; in one there was 
 trismus and tetanic spasm, and in a second paroxysmal attacks 
 described as hysteric. In the several enumerations now to be 
 made, therefore, while 80 will be the extreme number dealt with, 
 smaller numbers will have to serve in regard to particular points 
 where the information is defective. With such deduction the 
 cases available in all respects will not exceed 30, but 30 in the 
 circumstances of this disorder is a large number, it is the gleaning 
 of a very wide field, the sum of fatality out of many thousand 
 examples of chorea extending over a long period of years. 
 
 Taking in the first instance the gross number 80 as repre- 
 senting so many individuals dying in connection with chorea, 
 the most striking point of all to those who are in the habit of 
 regarding chorea as a child's affection is the large proportion 
 of adults and the small proportion of children. Of the 80, 
 48 are over thirteen years of age, and the ages of two are not 
 stated. Excluding Dr. Tuckwell's numbers, where further par- 
 ticulars are not given, we have in 46 fatal cases 27 who are over 
 thirteen and nineteen who are under that age. Of the 27 over 
 thirteen, as many as 23 may be said to have died of chorea. Of 
 the 19 children, 10 at the utmost died of it, the youngest of these 
 being a girl of seven (No. 19 in Dr. Dickinson's table, loc. cit). 
 Or, again, excluding Dr. Hughes's first (and defective) series, we 
 should have, out of a total of 35, 20 fatal cases over the age of 
 thirteen, of whom 16 died apparently of chorea ; and 15 under 
 thirteen, of whom only seven died ai)parently of chorea. We 
 thus establish the fact, making large allowance for error (which 
 from the nature of the material cannot be wholly excluded,) that 
 the mortality of children directly from chorea is exceedingly small, 
 
yiS A FATAL DISEASE. 75 
 
 and that seven is the youngest age at which it is known as a fatal 
 disease in a very extensive review. We find also, as we should 
 expect in view of the comparative commonness of chorea in 
 children, that the proportion dying with chorea but not of it is 
 greater with them than with adults. 
 
 But next in regard to sex. In 46 fatal cases (again exclud- 
 ing Dr. Tuckwell's) 34 are females and 12 males. Of the 34 
 females 8 only were children, the youngest (mentioned above) 
 seven years old, and one described only as 'a child.' As many 
 as 26 were young women, 11 of whom, there is good evidence to 
 show, died of chorea. Of the 1 2 males 9 were adults and only 3 
 young boys. These latter are made up as follows : i is in Dr. 
 Hughes's first series (No. 6), i is in Dr. Dickinson's table (No. 
 14), and died of heart affection 'without return of chorea,' and i 
 is a case of the late Dr. Fuller's (No. 9, Case 15, Append. A.) that 
 died under my own observation as then Medical Registrar at St. 
 George's Hospital, after five months of almost persistent convul- 
 sion. These three boys were each eleven years old. It does not 
 appear upon the evidence before us that chorea is ever fatal to 
 males at an earlier age than this, nor have we more than one out of 
 the three whose death is immediately attributable to this disorder. 
 The puberty age, then, is the age of fatal chorea. If we take 
 forty-six as representing the total number of persons dying in this 
 connection, thirty-five would be at or a little above the age of 
 puberty, and twenty-five of these young women. ^ We are thus 
 led to associate fatal chorea with the disturbing incidents of a 
 critical period of life. And the more so inasmuch as in those in- 
 stances where exciting causes are actually discovered and recorded 
 (but a small proportion, it must be remembered, of the whole 
 number), there is frequent mention of some special excitement of 
 those parts and organs which in the plan of nature are properly 
 over-active at this particular time. Thus Dr. Hughes, in his 
 
 ' There is but one elderly person on the list, a woman aged fifty four, who had 
 had chorea for four years. — Dr. Dickinson, loc. cit., No. 15. 
 
76 CHOREA 
 
 second series of cases, finds the genital organs unusually excited 
 in three of the four cases examined, while in Dr. Dickinson's table 
 out of nine dying directly of chorea, and with causes assigned, 
 there are three in whom these causes are distinctly sexual. 
 
 And not only does fatal chorea attach peculiarly to the emo- 
 tional sex and the emotional time of life, there are but few 
 instances of it out of the few fully detailed cases which constitute 
 our entire material in this matter where mental excitement does 
 not concur with the bodily over-movement. Such mental dis- 
 turbance embraces all varieties, from the hysterical to the 
 maniacal. Here again, therefore, a distinction appears between 
 the fatal chorea of adolescence and the non-fatal chorea of child- 
 hood. The latter, even in its greatest violence, is commonly quite 
 apart from emotion. The disorder acquires this mental admix- 
 ture at the same time that it reaches what may be called its 
 dangerous age. It will be perhaps better in this place to cite 
 instances rather than to quote figures. The condition to which I 
 am alluding is manifested by particular incidents. Thus in a case 
 related by Dr. Hughes (first series, loc. cit. p. 390), a man of 
 twenty-five, with violent and ultimately fatal chorea, was ' sensibly 
 hurt and shed tears when the bystanders observed that he could 
 restrain the movements if he pleased.' In a second case, by the 
 same author (second series, p. 250), that of a girl of eighteen, the 
 symptoms ' which were at first slight were suddenly aggravated by 
 fright caused by a patient in the same ward, and she became 
 almost maniacal.' In a third instance (from the same series, p. 
 251), a girl of sixteen, where ' there was unusual excitement of 
 the generative organs,' the symptoms at first * partook of the 
 character of hysterias, the patient appeared strange in her move- 
 ments, and fancied that others were laughing at her.' In a fourth, 
 a boy of sixteen, ' supposed to be addicted to secret vice, his early 
 movements excited the derision of his comrades. Their conduct 
 depressed him much, and he went suddenly into a fit, after which 
 violent and universal chorea supervened.' In all three of Dr. 
 
AS A FATAL DISEASE. 77 
 
 Peacock's fatal cases mental excitement is a prominent feature. 
 In one of the very few cases that are recorded of chorea fatal as 
 early as ten (Dr. Dickinson, loc. cit. p. 2), it is related of the child 
 (and some will probably regard the relation as trivial), that a little 
 friend of hers had lately died of chorea, she had watched and 
 imitated the movements, and when she recognised them in her 
 own person made sure that she should meet the same fate. If it 
 be remembered from how small a number of examples these 
 instances are taken, even these few quotations will be allowed to 
 have weight in showing the common habit of fatal chorea. I think 
 it may be said, indeed, not only of fatal chorea but of chorea that 
 at any part of its course threatens to be fatal (a comparatively large 
 number), that amongst the symptoms that give alarm nervous ex- 
 altation (so to speak) is generally one. 
 
 But while the emotional origin of chorea is thus apparent, as 
 well as the direct influence of mental causes in determining its 
 fatal issue, it is not to be doubted that fatal chorea arises in some 
 instances in immediate connection with acute rheumatism. The 
 evidence upon this point now before us is to the following effect : 
 — Out of thirty-two fatal cases dying with chorea, and reported 
 with sufficient fulness to be available (viz., seven of Dr. Hughes', 
 second series, twenty-two of Dr. Dickinson's, and three reported 
 by Dr. Peacock), seven had a rheumatic origin. Selecting out of 
 the thirty-two eighteen who died directly of chorea (viz. , five of 
 Dr. Hughes', ten of Dr. Dickinson's, and all three of Dr. Pea- 
 cock's), we get three — a male and two females, all adults — where 
 the fatal disorder was of rheumatic origin. These numbers corro- 
 borate the conclusion arrived at upon independent grounds 
 (Chap. II. p. 41) — viz., that acute rheumatism, although having 
 but a small share in chorea, is nevertheless veritably associated 
 with it, and especially with its fatal form at the puberty age. 
 
 Coming now to the morbid associations of chorea in so, far as 
 they are revealed post mortem, the evidence before us fully bears 
 out the belief expressed by the late Dr. Kirkes in 1863, 'that 
 
78 CHOREA 
 
 further experience would still more positively demonstrate that an 
 affection of the left valves of the heart with the presence of 
 granular vegetations upon them is an almost invariable attendant 
 upon chorea, under whatever circumstances the chorea may be 
 developed.' The singular accuracy of this description, the need 
 of 'almost,' and the justice of applying the observation to chorea 
 of whatever origin, and not limiting it (as some would do even 
 now), to rheumatic chorea, or even to chorea fatal as such, will 
 be seen in what is now to be said. Out of all the cases in which 
 the condition in question is especially mentioned I can find but 
 five where the heart valves and pericardium are reported healthy, 
 one of these being an elderly woman. Wherever the heart is 
 affected the mitral valve is affected ; the aortic valves are implicated 
 often, the pericardium sometimes. This heart affection occurs 
 equally in those that die in connection with chorea, and in those 
 that die directly of it. Thus, of Dr. Dickinson's twenty-two 
 there are, as I reckon, twelve dying with^ but not of^ chorea ; of 
 these ten have mitral valve vegetations, and two have not. Of 
 the ten dying of chorea seven have vegetations, and three have 
 not. In Dr. Peacock's three cases, all dying of chorea, two have 
 vegetations, and one has not. The valve deposit, which for short- 
 ness I thus name, may be either old or new, and variously con- 
 nected with the mitral valves on their auricular side. The condition 
 would seem to be an accident of the disease it accompanies, 
 having but little apparent connection with its fatal result. It so 
 happens that of the five cases just mentioned as being the only 
 examples of chorea occurring with perfectly healthy heart, all 
 save one, the old woman, are typical instances of deaths in and by 
 chorea. Three were girls at about the puberty age (Nos. i, 5, 
 and 8 in Dr. Dickinson's table), and one is a girl of Dr. Peacock's, 
 aged twelve (St. Thomas's Reports, vol. viii. p. 29). 
 
 With the exception of this observation in regard to the heart 
 and pericardium, there is little to be gathered in the material now 
 before us as to the morbid anatomy of fatal chorea. I need not 
 
AS A FATAL DISEASE. 79 
 
 again refer to Dr. Dickinson's investigations as to the minute 
 nervous changes in seven of the cases here mentioned, nor to those 
 of Dr. Tuckwell upon embolic plugging, in the paper above quoted. 
 Speaking generally, it must be said that the state of the brain and 
 cord is not described in sufficient detail to be instructive. In 
 a large proportion the brain, in a few the cord, is described as 
 'congested.' In the case of the boy to whom I have alluded as 
 the single example of the kind in my own experience or in these 
 tables, it was observed that ' the grey matter of the cord was altered 
 and yellow in patches,' but there was no minute examination. 
 
 How far the foregoing particulars may serve to fortify or dis- 
 turb pathological doctrines I do not now inquire. Their practical 
 teaching is obvious. We are justified upon this evidence in look- 
 ing upon severe chorea at the puberty age, especially in connec- 
 tion with sexual excitement or with acute rheumatism, as a 
 dangerous disorder apt to terminate fatally. It is true that we do 
 not number many fatal cases, but it is also true that we do not 
 meet with many, whether fatal or otherwise. The condition of 
 such patients is the more precarious when, as is commonly the 
 case, there is emotional as well as motor disorder. Such nervous 
 exaltation, which is commonly altogether absent in the more 
 familiar chorea of childhood, is with these both the sign and the 
 source of danger. They are in a state of extreme sensitiveness, 
 and lay hold of trivial circumstances to aggravate their disquiet. 
 The smallest incident, the conduct of bystanders, undeserved 
 reproach or ridicule, or even the sight of a patient affected *like 
 themselves, will often have its immediate prejudicial influence 
 in a degree which those who have little experience of this kind 
 of convulsion (whose actual title to the name of chorea, as 
 Dr. Bright's cases show, is often far from obvious), will find 
 it difficult to believe. The question cannot but suggest itself, 
 whether in these circumstances we address our treatment suffi- 
 ciently to this mental state. 
 
 But the facts before us have this further teaching. If we 
 
8o CHOREA 
 
 exclude puberty, chorea of whatever violence is hardly dangerous 
 to life. If we exclude both puberty and the female sex, chorea 
 of whatever violence is not dangerous at all. Now violent chorea 
 is by no means uncommon with boys. Thousands of examples 
 of it must be comprehended within the period we are now review- 
 ing. And yet in all that time, and from so many fields of obser- 
 vation, we get but one boy, aged eleven, dying of chronic chorea 
 after five months, and probably with sclerosis of the cord. Chorea 
 therefore, we may say, extremely rarely fatal in young girls, is 
 practically speaking, never fatal in young boys. If we add to this, 
 what will not be denied, that permanent disablement from chorea 
 is very uncommon, and that there is no treatment that even pre- 
 tends to avert such after-effects, we get a strong argument in 
 favour of leaving childish chorea alone. It will be further 
 strengthened by a perusal of the valuable papers, published in 
 'The Lancet' of November i8, 1876, by Drs. Tuckwell and 
 Gray, upon ' The Expectant Treatment of Chorea,' 
 
 The conclusions ^ to be derived from the foregoing review may 
 be expressed as follows : — 
 
 1. Chorea, regarded as a disease of itself fatal, belongs almost 
 exclusively to puberty, and especially to female puberty ; its im- 
 mediate exciting cause having distinct reference, in many instances, 
 to conditions of unusual sexual excitement 
 
 2. Besides the operation of sexual causes mental disturbance 
 has to be reckoned ; not fright only, but worry, anxiety, and 
 despondency also, while the force and influence of such impressions 
 is to be seen in the course as well as in the origin of fatal chorea. 
 
 3. Acute rheumatism appears as a cause of fatal chorea in but 
 a small proportion of cases ; yet the association, infrequent as it 
 is, is distinct and unquestionable. 
 
 4. Chorea in its fatal, no less than in its non-fatal forms, shows 
 
 1 I had intended to supply an Appendix to this Chapter, setting forth in detail 
 the figures upon which the main conclusions are based, but have refrained from 
 doing so because the material in that shape would occupy much space. The de- 
 ductions here insisted on stand out so clearly that the more general statement of 
 the text will probably be thought sufficient. 
 
AS A FATAL DISEASE. 8i 
 
 strong preference for the female sex at all ages. Children, how- 
 ever, very rarely die of it, and boys, practically speaking, never. 
 
 5. Mental excitement, in varying degree (although not amongst 
 the symptoms of ordinary chorea), is met with in so large a pro- 
 portion of its fatal examples that we are justified in regarding this 
 concurrence as of bad augury. 
 
 6. ' Vegetations,' new or old, on the auricular surface of the 
 mitral valves, with or without similar deposit on the aortic valves, 
 and sometimes with pericarditis, are met with in the great majority 
 of cases dying of, or with, or shortly after, chorea. This condition, 
 however, does not, as a rule, contribute directly to the fatal issue ; 
 it is found equally amongst those that die with and those that die 
 of chorea ; and in some of the most marked and typical cases of 
 fatal chorea the valves of the heart have been found absolutely 
 healthy. 
 
 7. There is no other post mortem condition, except that which 
 concerns the heart, occurring with sufficient frequency or unifor- 
 mity to be regarded as characteristic of fatal chorea. 
 
82 CHOREA. 
 
 CHAPTER V. 
 
 THE PATHOLOGIES OF CHOREA. 
 
 Connection with rheumatism — with spinal meningitis — with pericarditis — with 
 enfeebled nutrition — The embolic theory of chorea — Vascular and nervous 
 changes — Disturbed nutrition of cerebral ganglia — Altered states of blood — 
 Chorea a functional disturbance — Continental opinion — Summary. 
 
 I PROPOSE to set down in this place, in something like chrono- 
 logical order, a short summary of the several hypotheses as to the 
 pathology of chorea which have been put forward since the time 
 that the disease was first accurately described. 
 
 The connection of rheumatism with chorea was first asserted 
 at the beginning of this century. Dr. Bright mentions that in the 
 * Syllabus of the Practice of Medicine,' published at Guy's Hos- 
 pital in 1802, 'rheumatism is distinctly mentioned as one of the 
 existing causes of chorea.' He adds that in later editions of the 
 same work, as in that of 1820, chorea is said to alternate with 
 acute rheumatism, 'but through what organ or by what interven- 
 tion it occurs is not conjectured.' In the following year, and 
 independently, as he expressly asserts, of these earlier observa- 
 tions, Dr. Copland drew attention to the rheumatic origin of 
 chorea, upon the evidence of a case which he quoted of rheumatic 
 pericarditis and disease of the membranes of the spine, with which 
 chorea alternated. This change from rheumatism to chorea he 
 sought to explain by ' metastasis from the joints to the membranes 
 of the spinal cord.' 'In nearly all the cases,' he writes, 'there 
 has been a marked disposition of the rheumatic inflammation to 
 
PATHOLOGIES. 83 
 
 recede from the joints and attack the internal fibro-serous mem- 
 branes, as those of the cerebro-spinal axis and the pericardium.' ^ 
 
 A more precise reference to the pericardium in association 
 with chorea occurs in the paper by Dr. Bright, from which I have 
 just quoted, on ' Cases of Spasmodic Disease accompanying Affec- 
 tions of the Pericardium' (Med.-Chir. Trans., vol. xxii.). In this 
 communication the author dissents from the conclusions of Dr. 
 Copland, connecting chorea with spinal meningitis, and expresses 
 his belief that a much more frequent cause of chorea is pericarditis, 
 ' although in some instances the coverings of the cerebro-spinal 
 mass might be implicated. ' From the inflamed pericardium, as Dr. 
 Bright supposed, 'an irritation was communicated to the spinal 
 cord,' of which irritation convulsive movement was the consequence. 
 
 It is to be remarked, however, that Dr. Bright's cases, as des- 
 cribed by himself, are illustrations of spasmodic disease rather than 
 of chorea. In one of them there were epileptic seizures and tetanic 
 spasm \ in another the spasms put on the ' character of most vio- 
 lent convulsions,' 'more violent,' it is added, 'than is almost ever 
 seen in chorea.' Both these cases were fatal. In some of the 
 other examples 'there might be doubt,' as Dr. Bright admits, 'of 
 the correctness of the diagnosis.' What this paper seeks to make 
 out is indicated by its title — the connection, namely, between vio- 
 lent and often fatal muscular spasm and pericarditis, the patients 
 not being children, but young men and women. 
 
 In order to show how little such views found acceptance in 
 this country, and how vague and indefinite was the pathology of 
 chorea more than ten years later, Dr. Todd's opinion may be next 
 quoted. 'It is easier,' says this physician (in lectures published 
 in 1854, but delivered some time before), ' to say what chorea is not, 
 than to describe what its essential nature is. We may regard it as 
 a disease which depends upon a debilitated state of the system, 
 which does not in any way arise from an inflammatory or hyper- 
 semic state of any part of the great nervous centres or of other 
 
 ^ See Copland's Z??V/zo«ar)/, art. 'Chorea.' 
 G 2 
 
84 CHOREA. 
 
 organs. Almost without exception, in those cases which terminate 
 fatally, we fail to detect any morbid alteration which physiologi- 
 cally could give rise to the phenomena.' ' If I were to refer to 
 any particular part, it would be to that which may be regarded as 
 the centre of emotion. The remarkable frequency with which the 
 attack has been traceable to fright as its cause points clearly to 
 this part of the brain as the priijiuin movens in the production of 
 choreic convulsions. The chain of phenomena would then be as 
 follows : first, a peculiar diathesis ; secondly, a more or less en- 
 feebled nutrition ; thirdly, a strong mental impression which dis- 
 turbs the centre of emotion, and through it deranges the action, 
 more or less, of the nervous system and of a corresponding portion 
 of the muscular system.' ' 
 
 It was eleven years after Dr. Bright's paper, namely, in 1852, 
 when the reality of the connection between rheumatism and chorea 
 had been recognised by text books as well as the occurrence, in 
 the latter affection, of systolic murmur, that Dr. Kirkes wrote 
 his celebrated essay, destined to exercise an important influence 
 upon pathology, ' On some of the principal effects resulting from 
 the detachment of fibrinous deposits from the interior of the heart 
 and their mixture with the circulating blood.' ^ Towards the end 
 of this paper, in the form of an incidental remark, occurs the pas- 
 sage which may fairly be regarded as the origin of what is now 
 called the embolic theory of chorea. ' I would suggest,' writes 
 Dr. Kirkes, ' that many functional disorders of the nervous 
 system, especially chorea, may be thus explained [i.e. by cerebral 
 embolus]. The frequent existence of a cardiac murmur in chorea, 
 and the presence of warty vegetations on the valves of the heart 
 so commonly found in fatal cases of the disease, are in favour of 
 such a view.' Of the numerous modes of application of this re- 
 mark it is impossible to speak in detail. With the knowledge of a 
 frequent concurrence of chorea and valvular murmur, coupled 
 
 1 Todd's Clinical Lectures, ' Nervous System,' p. 442. 
 ' Med.-Chir. Trans., vol. xxxv. 
 
PATHOLOGIES. 85 
 
 with the very general belief in some connection between chorea 
 and rheumatism, it was certain, even if Dr. Kirkes had failed to 
 make this special reference, that the phenomena of embolism 
 would be made use of, sooner or later, on behalf of a disorder 
 sorely in want of explanation. 
 
 Of the development of this doctrine, and the mode in which 
 it is now expressed, Dr. Hughlings Jackson may be taken as the 
 exponent. 'I suppose,' says this pathologist, 'that the excessive 
 movements occurring either in chorea, or in epilepsy, or epilepti- 
 form seizures, are produced by discharges of grey matter, which, 
 except for great instability from over-nutrition (not better nutri- 
 tion), is healthy. We cannot expect to discover, with our present 
 means of research, the alterations in grey matter on which exces- 
 sive discharges depend.' ' My opinion is,' he goes on, ' that the 
 direct pathological state leading to instability of grey matter, pro- 
 ducing choreal movements, is increased quantity of blood in the 
 periphery of the capillary district embolised.' ' Of course,' he 
 adds, ' this opinion is hypothetical, and so is every one's opinion 
 as to the nature of lesions insusceptible of anatomical demon- 
 stration.' ^ As regards the seat of these lesions, Dr. Hughlings 
 Jackson, following Russell Reynolds, fixes upon the corpus 
 striatum, insisting that there is frequently disease of that 
 part of the brain which superintends the movements of the 
 tongue in uttering syllables. He asserts, moreover, ' the frequent 
 one-sided nature of the movements of the limbs, and their often 
 dying out into definite hemiplegia^ (words which I venture to 
 italicise), 'as pointing to disease at or near the corpus striatum.'^ 
 
 It has not escaped Dr. Hughlings Jackson that the special 
 character of choreic movement as contrasted with the convul- 
 sion of epilepsy needs some apology. ' The elaborateness of the 
 movements,' he says, ' is strong warrant for the inference that the 
 changes causing them must be seated in the brain and not in the 
 
 ^ British Medical Journal, Dec, 23, 1876. 
 2 London Hospital Reports, 1864 
 
86 • CHOREA. 
 
 cord ; and he thinks it ' most probable that the convolutions are 
 the parts diseased.' 
 
 From views thus mainly hypothetical we may turn to those of 
 Dr. Dickinson, arrived at directly from post-mortem evidence, 
 and which, in the opinion of their opponents, only fail when the 
 attempt is made to apply them to the actual symptoms of the 
 disease in question.^ It is impossible in this summary to re- 
 produce an adequate account of the facts upon which Dr. Dickin- 
 son depends for his conclusions. These facts are based mainly 
 upon a minute examination of seven fatal cases of chorea, or, as 
 I should prefer to describe them, fatal cases with chorea, in three 
 of them at least the choreic movements being of no great severity.^ 
 The morbid changes, described as remarkably constant in kind 
 and place, are thus summed up by the author. '- In place the 
 changes affected both brain and cord. As regards the two sides 
 of the body they were either exactly symmetrical or tended to be 
 so. The parts of the brain most amenable lay between the base 
 and the floor of the lateral ventricles in the track of the middle 
 cerebral arteries ; the substantia perforata, corpora striata, and 
 the beginning of the Sylvian fissures. In kind the changes were 
 all connected with vascular disturbance. The injection was gene- 
 ral to all the vessels, most marked in the arteries ; when the sources 
 of haemorrhage could be determined they were always arterial ; 
 the degenerations were usually periarterial, and the spots of 
 sclerosis similarly placed. The first visible change would seem 
 to be the injection or distension of the arteries, succeeded by 
 
 1 Med.-Chir. Trans., vol. lix. p. 15, 'On the Pathology of Chorea.' 
 
 2 Thus in Case i, a girl of ten, the child is described as restless and sleepless, 
 her movements much increased on the 21st, on which evening, ' after acute pains 
 in the lumbar region, she somewhat unexpectedly died ; ' there were vegetations on 
 the aortic as well as the mitral valves. In Case 5, a boy of eleven, the use of the 
 limbs and the power of speech were slowly restored, and the boy was sent into 
 the country convalescent. There ' his heart symptoms became more pronounced, 
 without any return of those of chorea." He died of his heart disease. In Case 6, 
 a girl of thirteen, ' the symptoms were not apparently threatening, and the chorea in 
 particular obtamed little attention.' She too died suddenly and had both mitral 
 and aortic disease. — Vide loc. cii., pp. i «t seq. A similar remark will apply to some 
 of the fatal cases of chorea by other authors. See e. g. H. Jones, loc. cit. p. 560. 
 
PATHOLOGIES. 87 
 
 extrusion of their contents to the irritation and injury of the sur- 
 rounding tissue. 
 
 ' Of the cord no region was exempt ; but perhaps the cervical 
 and dorsal regions were usually more affected than the lumbar.' 
 Both white and grey ' shared in the vascular distension. This 
 condition, however, was usually most marked in the vessels be- 
 longing to, or in connection with the lateral part of the grey 
 matter about the root of each posterior horn. This was also the 
 chosen situation of the more definite and special changes.' In 
 commenting upon these changes as a whole, the writer observes : 
 * The nature and steps of the morbid process are open to view, 
 hypersemia, exudation, and its consequences, but not so the 
 causes in which the series has taken origin. Arterial repletion 
 seems mainly concerned in the development of the disease.' 
 
 As regards embolism, the author remarks not only upon the 
 absence of any signs of such impaction, but upon the constancy 
 with which the changes repeated themselves in certain portions, 
 and the equality with which they affected both sides of the body 
 as conclusive objections to that hypothesis. 
 
 'The results,' says Dr. Dickinson in conclusion, 'in muscular 
 excitement rather than in paralysis or loss of sensation, may be 
 associated with the character of the lesions, which are points of 
 irritation rather than planes of section, and as such calculated to 
 produce irritation rather than paralytic effects, not so much to cut 
 off, as unnaturally to excite nervous function.' The author alludes 
 to the similarity between the morbid changes of chorea and those 
 of diabetes, and he concludes with a bold attempt to bend clinical 
 observation into some compliance with the demands of morbid 
 anatomy. ' Every period of life has its own regions of nervous 
 susceptibility ; in childhood the motor ; in adolescence the 
 emotional ; in advancing years the mental, and coevally, or 
 nearly so, that part of the nervous mechanism which instigates 
 glycosuria. Much the same mental impression may make a child 
 choreic, a girl hysterical, or a man diabetic. And thus both in 
 
S8 CHOREA. 
 
 external origin and in the nature, though probably not in the site 
 of the organic changes, we see resemblances and alliances be- 
 tween nervous disorders which in their symptoms betray little 
 similarity.' * 
 
 In noticing these observations of Dr. Dickinson the advocates 
 of embolism maintain that the condition just described is not in- 
 compatible with that theory. ' The local periarterial softenings,' 
 Dr. H. Jackson suggests, 'account for the choreal paresis,' while 
 the cerebral changes described are not very unlike those producible 
 by embola, regard being had to size of arteries plugged.' He 
 admits at the same time that the embolic hypothesis supposes the 
 cord to be unconcerned in the irregular movements of the disease, 
 and that, as a matter of fact, the absence of embolism is much 
 more common than its presence. 
 
 Dr. Bastian,^ supporting in some respects the conclusion of 
 Dr. Dickinson, and relying with him upon anatomical evidence, 
 agrees with Dr. Hughlings Jackson in attributing chorea to a 
 disturbed nutrition in the corpora striata and adjacent parts. In 
 place of embolism, however, he would put thrombosis. He points 
 out that the production of multiple minute thromboses ' might 
 easily give rise to minute vascular injections,' but is careful to add 
 that ' other hypersemias, more or less secondary in their duration 
 and mode of origin, may easily be confounded post mortem with 
 those which are hypothetically supposed to lie at the root of chorea.' 
 support of this opinion he refers to three cases of his own, where, 
 with hyperaemia of the ganglia at the base of the brain, and 
 especially the corpora striata, occlusions were found in the small 
 vessels of these parts.^ He sums up his view of the etiology and 
 pathology of chorea: 'I look (certain rare cases excepted), to an 
 altered and often anaemic blood state as its predisposing cause in 
 individuals of a certain age and nervous temperament. Secondly, 
 I look to the initiation in such individuals of a disturbed nutrition 
 
 ' Loc. cit. p. 39. ^ British Medical Journal, Jan. 20, 1877. 
 
 ^ Ibid. July 13, 1877, P- 38- 
 
PATHOLOGIES. 89 
 
 in the corpora striata and adjacent parts of the brain, tending to 
 issue and often actually issuing in what may be called a subacute 
 inflammation of these centres, often characterised in part by the 
 production of multiple minute thromboses.' ^ 
 
 In harmony with these views, so far as regards locating chorea 
 in the corpus striatum and optic thalamus, and in partial agree- 
 ment with them as accepting capillary embolism of these parts 
 and of their vicinity as one of its causes, we may notice next the 
 opinions of Dr. Broadbent which have especial weight owing to 
 their wide acceptance both in England and Germany. In addi- 
 tion to embolism of the regions just named, Dr. Broadbent * 
 would recognise many other sorts of disturbance of nutrition of 
 the cerebral ganglia, ' as, for instance, peripheral influences arrest- 
 ing the reflex process, direct lesions of the ganglia due to fright or 
 to mechanical lesions,' as possible causes of chorea. ' The pro- 
 cesses of chorea are in fact such as weaken the force of the nervous 
 apparatus without destroying its structure. Hence the weakness 
 of the muscular force and diminished sensibility so common in 
 chorea. Hence also its frequent termination in paralysis.' To 
 the condition of system of which chorea is the consequence. Dr. 
 Broadbent gives the name of 'delirium of the sensory motor 
 ganglia of the brain. ' 
 
 Having thus reached, in our search after the anatomical basis 
 or material of chorea, the point at which it is affirmed that the 
 nervous apparatus is weakened., but not destroyed, and that the 
 condition of the nervous ganglia concerned is best described by 
 such a word as delirium., we may fairly conclude that anatomical 
 hypothesis has pretty well exhausted itself. But when physical 
 changes are lost sight of, there still remains a wide field of 
 conjecture, if not of research. We leave the tissues, and make 
 appeal to the blood. 
 
 Variously expressed by various authors, and favoured in part 
 
 1 British Medical Journal, Jan. 20, 1877. 
 
 2 Ibid. April 17-24, 1869. 
 
90 CHOREA. 
 
 by some of those I have just quoted, the doctrine which connects 
 chorea with an altered condition of the blood finds perhaps the 
 frankest and most unreserved statement at the hands of Dr. John 
 Ogle, with whom Dr. Hammond, of New York, fully agrees.^ It 
 may be objected that the hypothesis does not so much account 
 for the origin of chorea as for its consequence. Recognising the 
 frequent occurrence of fibrinous deposits on the heart's valves in 
 chorea, Dr. Ogle ^ is led to regard these ' as results of some ante- 
 cedent condition of the blood, common also to the choreic condi- 
 tion.' In rheumatism and in anaemia, ' conditions both of them 
 associated with chorea,' Dr. Ogle observes, ' an excess of fibrine in 
 the blood, which renders it very prone to be precipitated.' ' May 
 not this hyperinosis,' he asks, ' be the explanation of the coinci- 
 dence alluded to ? Speculation might suggest that the fibrinous 
 deposits arise from some interference with the degree of solubility 
 of the fibrine induced by the presence of some ununited elements 
 within the blood, produced by the excessive muscular action and 
 other functional disturbance which exists in the choreic state," this 
 being not in any way related to this state as a cause, but as a 
 consequence.' 
 
 From conjectures like these the transition is easy to a pathology 
 of chorea which makes no attempt at exact anatomical descrip- 
 tion, but refers, in terms which, although general and inexact are 
 yet sanctioned by physiological use, to altered cerebral nutrition and 
 abnormal conditions of nerve discharge. Among the most striking 
 and satisfactory of such hypotheses is that of Dr. Barnes, who has 
 been led to consider chorea in its connection with pregnancy. 
 ' The condition upon which the latent disposition to chorea de- 
 pends,' he says, 'is some change of nutrition or of structure of the 
 nervous centres, unimportant under the ordinary conditions of life, 
 but liable to be called out into renewed activity linder that special 
 increase of central nervous development which is the constant at- 
 
 * Y\.z.vnTS\Gw<}i on Diseases of Nervous System, p. 614. 
 ' British and Foreign Med.-Chir. Rev.,]aX\. 1868. 
 
PATHOLOGIES. 91 
 
 tendant upon pregnancy.' ^ The chorea of puerperal women Dr. 
 Barnes believes to be almost always a revival of the same disease 
 in childhood, having pregnancy for its immediate exciting cause, in 
 virtue of ' the exalted central nervous irritability ' of that condition, 
 which is thus ' a test of the soundness of the nervous system.' 
 
 As nearly in accord with these views, I may allude next to 
 the opinions of Dr. Handfield Jones ; and here, even more than in 
 the previous instances, comes the difficulty of doing justice to the 
 author in such curtailed statement as the present design necessi- 
 tates. The following quotation, however, gives in Dr. Jones's own 
 words a summary of his opinion. For its illustrations I must refer 
 to his well-known work.^ 
 
 * The view which I take of the pathological events in chorea 
 is the following. The motor centres especially, and also not 
 unfrequently the intellectual, emotional, and sensory, in persons 
 of weak organisation, fall into a state of paresis, either in conse- 
 quence of a shock or more gradual injury, or of some toxic matter 
 in the blood, or of peripheral irritation, all of which may generate 
 the same peculiar condition. The paresis in all these parts may 
 take the form of hyper-excitability or of paralysis, the former being- 
 much the more frequent. The nerve exhaustion, aggravated more 
 or less by the jactitation, involves the vaso-motor nerves of the 
 cerebral and spinal arteries especially, and conditionates relaxation 
 of their muscular walls as well as impairment of the tone of the 
 capillaries and haemorrhage. These, however, are of course not 
 necessary events, even in fatal cases. Occasionally actual inflam- 
 mation of the nerve-centres results from the hyperaemia. Pulmonary 
 congestion and consolidation may be produced in the same way, 
 and possibly, in some instances, valvular lesions of the heart. 
 This view, that chorea is essentially a functional disorder of the 
 motor centres, is in harmony with its frequency in children and 
 females, whose motor apparatus is more prone to be weak and 
 
 1 British Medical Journal, Dec. 9, 1876. 
 
 2 Functional Nervous Disorders, p. 361 et seq. 
 
92 CHOREA. 
 
 irritable, with its affinities to epilepsy, hysteria, paralysis, and 
 insanity.' 
 
 As for the connection between chorea and rheumatism, it 
 seems to Dr. H. Jones to be best explained by regarding the 
 motor disorder in just the same light as we do delirium, to which 
 it has much affinity. ' In typhoid we have an intestinal lesion, 
 and commonly delirium ; but we do not assume a connection 
 between these, but consider the specific poison to give rise to 
 both. In rheumatic fever we have also often a lesion (cardiac) 
 and delirium, both as co-products of the cause of rheumatism, not 
 one as the cause of the other. If we substitute motor disorder for 
 intellectual, why need we change our view ? ' 
 
 In this brief statement it still remains to notice some of the 
 theories and researches of continental pathologists. Yet any de- 
 tailed account of these may be excused after the admission of 
 Ziemssen, that 'the sum of knowledge of the pathologico- 
 anatomical changes of chorea is so small that it is scarcely of 
 consequence to attempt to explain it." It is admitted that 
 England and France have been the chief contributors both to 
 the statistics and pathology of the affection, while in Germany the 
 observations of English pathologists upon the embolic origin of 
 chorea and its connection with endocarditis have attracted more 
 attention than any investigations of their own. It is due, how- 
 ever, to the high authority of certain continental observers now 
 to be named that their contributions to this subject should shortly 
 be referred to. 
 
 Rokitansky, in 1857, asserted the occurrence in chorea of 
 interstitial connective-tissue growth in the central nervous system ; 
 and Steiner, ten years later, confirmed the observation in a single 
 case, and so far as it concerned the spinal cord. He found also, 
 in two cases, serous effusion within the spinal canal, and in one, 
 hcemorrhage at the upper part of the cord at the exit of the nerves. 
 Similar changes, so far as the cord is concerned, together with 
 
 ' Ziemssen, loc. cit. p. 460. 
 
PATHOLOGIES. 93 
 
 hypersemia of the medulla and spots of softenings, have been now 
 repeatedly met with. Yet it is to the brain, rather than the cord, 
 that continental observers, upon considerations of physiological 
 necessity, have chiefly looked to discover the structural basis of 
 chorea.^ The cerebral changes, it is asserted, affect the brain 
 cortex and grey substance of the great basic ganglia ; but their 
 precise character is far from being exactly stated, and is made to 
 rest rather upon clinical facts than direct observation. As with 
 the cord, the brain changes are said to include interstitial hyper- 
 plasia, with regressive metamorphosis of nerve elements, some- 
 times confined to one hemisphere or its great ganglia, and some- 
 times diffused over the whole brain, preferring the grey substance, 
 and extending always to the cord, and even the peripheral nervous 
 system. 2 
 
 Again, Charcot has recorded some observations upon cases of 
 hemichorea after hemiplegia, in which cicatrices were found at the 
 posterior end of the optic thalamus, and (in two cases) of the 
 anterior corpus quadrigeminum of the affected side. In other 
 instances, where hemiplegia followed chorea, the same observer 
 found a blood clot as large as a nut in the posterior half of the 
 optic thalamus. In accepting the evidence of such cases, however, 
 we are clearly transgressing the proper limits of our subject, and 
 complicating the pathology of chorea with that of paralysis. 
 
 A similar objection applies to many of the other quoted cases, 
 where it will be found that the chorea is combined with some other 
 affection, as with mania or encephalitis. It is admitted, indeed, 
 by Ziemssen and others — and I shall presently quote instances of 
 this kind — that ' chorea may occur as a transitory phenomenon in 
 
 * Ziemssen. Cycl. , loc. cit. 457 et seq. * 
 
 2 As regards the latter, the observations of Elischer may be quoted. He found 
 the changes just described for the cord equally marked in the peripheral nerves, 
 the connective tissue between nerve bundles being greatly developed, and the 
 medullary sheaths of the nerve fibres tumefied, while their axis cylinders had dis- 
 appeared. The nerves examined (the median and sciatic), seemed to the naked 
 eye abnormally small and flat. 
 
94 CHOREA. 
 
 the course of cerebral lesion, and presently give way to other and 
 severer disturbances.' * It is misleading to adduce the post- 
 mortem appearances in such cases by way of evidence of the 
 changes attending chorea. 
 
 Lastly, experiments have been made upon animals by Chau- 
 veau and others,^ and it has been shown that the muscular 
 twitchings of dogs persist after section of the cervical cord, 
 and, further, that these may be produced or increased by mechani- 
 cal irritation of the posterior columns. Thence it is concluded 
 that the limb-twitching depends on the cord, and not on the brain. 
 But such information is not in point, for the simple reason that 
 this canine affection is not really chorea, or at all like it. 
 
 In reviewing the several observations and conclusions which 
 have now been enumerated, it is easy to see that the theories in 
 reference to chorea which have successively gained acceptance 
 represent so many attempts to accommodate this particular 
 affection with the pathological doctrines of their day. When first 
 emerging from the obscurity of humoral pathology, chorea, in 
 virtue probably of the pain that often attends it, is found in some 
 sort of alliance with rheumatism. Presently, upon the observation 
 of its occasional association with acute rheumatic arthritis, the 
 prevalent belief in metastasis is appealed to, and the muscular 
 disorder is accounted for by an inflammation transferred from the 
 joints to the spinal cord. Next, and following the researches of 
 Marshall Hall upon the functions of the cord, we find the prin- 
 ciple of reflex irritation made use of to explain the dependence of 
 chorea upon pericarditis. At a still later period, and when further 
 observations of the heart symptoms of chorea had made the appli- 
 cation easy, comes the discovery of embolism, both to explain the 
 cardiac disturbance and to satisfy those phenomena of the disease 
 which better study had shown to depend upon the brain rather 
 than the spinal cord. 
 
 ' See for example Case 4 in Appendix. 
 2 Arch. -Gen. de Mdd., March, 1866, 455. 
 
PATHOLOGIES. 95 
 
 But while the pathological history of chorea has been one of 
 revolution, its clinical history (in so far as the two may be 
 separated) has been one of almost continuous progress ; and it 
 has come to pass with the gradual accumulation of facts, that, 
 while precise and definite hypotheses have been found faulty and 
 insufficient, the only adequate pathology of chorea hardly goes 
 further than to translate its symptoms into physiological language. 
 We have mere definitions of the disorder which are unassailable, 
 which venture nothing and explain nothing ; but what is wanted is 
 some explicit statement of the anatomical conditions on which 
 chorea depends which may be brought into harmony with its 
 actual phenomena. 
 
96 CHOREA. 
 
 CHAPTER VI. 
 
 THE PATHOLOGIES OF CHOREA IN THEIR APPLICATION. 
 
 Clinical conditions to be satisfied — The symptoms of embolism compared with 
 those of chorea — The direct evidence in favour of the embolic theory — Perivas- 
 cular degeneration of the brain and cord as a cause of chorea — Hypothetical 
 explanations — Chorea ascribed to temporary trophic changes — AppUcation of 
 such theories — The ataxy of chorea. 
 
 I TURN then once more to chorea itself, and would place side by 
 side with it the several hypotheses which have just been enumer- 
 ated. No theory can be finally accepted which fails to satisfy all 
 the conditions of the problem. There are certain features of 
 chorea which are obvious and beyond dispute, as that it is a child's 
 disease, that it prefers the female sex, that it is apt to recur, that 
 it affects the arms, hands, and face more often than the legs, that it 
 is more often both sided than one-sided, that complete recovery is 
 the common rule, and death or any permanent disablement the 
 rare exception and so forth. Whether, therefore, it be alleged that 
 embolism, or thrombosis, or perivascular softening, or * disturbance ' 
 in some motor centres, or ' toxic influence ' is at the root of chorea, 
 each of these conditions needs for its justification to be brought 
 into relation and harmony with the known symptoms of the dis- 
 order it professes to explain. 
 
 Now, if this comparison be fairly made I think it will appear : — 
 
 I St. That there is no morbid condition as yet anatomically 
 
 described which, so far as we have independent knowledge of it, 
 
 is capable of producing symptoms at all similar to those of chorea. 
 
 2nd. That the hypotheses which, apart from demonstration, 
 
 really provides the best for the actual phenomena of chorea, do 
 
APPLICATION OF PATHOLOGIES. 97 
 
 not in fact present any distinct picture of a definite morbid 
 change. 
 
 3rd. That having regard to the special characters of chorea, it 
 is difficult to conceive of any morbid condition whatever, anato- 
 mically demonstrable, calculated to produce it, or indeed com- 
 patible with it. 
 
 I. The morbid anatomy of chorea, or as much of it as has 
 survived, begins, as we have seen, with its association with endo- 
 carditis,^ an association soon to be supplemented and explained 
 by the observations of Dr. Kirkes upon embolism in 1852. 
 Taking, therefore, this, the most concise and ingenious of all the 
 theories having a purely anatomical basis, we may inquire, in the 
 first place, whether embolism, so far as we have independent 
 knowledge of it, is capable of producing symptoms at all similar 
 to those of chorea. 
 
 Now, the ordinary symptoms and course and cause of embolic 
 obstruction are known. Making allowance for great diversity in 
 the response to cerebral injury, as well as for modifications due 
 to the extent, size, and site of the plugging, our actual information 
 under these headings may be summed up generally as follows : — 
 {a) For sympto7ns : a sudden vertigo or an acute head pain, with 
 faintness or sickness ; a more or less complete hemiplegia ; im- 
 paired intelligence and sensation ; and, if the hemiplegia be right- 
 sided {as it most often ts\ either aphasia or inability to utter 
 articulate sounds, (d) For course : a gradual but interrupted 
 decline, or an incomplete and precarious recovery ; nutrition 
 
 1 In speaking of the several anatomical conditions which have been definitely 
 described as representing the material expression of chorea, it is unnecessary to 
 refer again to doctrines which are now abandoned. Yet the observations of Dr. 
 Bright in 1841 upon the connection between pericarditis and chorea have this 
 singular value ; they point to a connection which, although different in form from 
 that which Dr. Bright asserts, is really implied in the evidence which his paper 
 affords. There is reason to believe, as we shall presently see, that severe and 
 fatal choreic convulsion is sometimes in direct relationship with endocarditis. It is 
 in the highest degree probable that Dr. Bright's cases, although referring expressly 
 to pericarditis, are in fact illustrations of this connection, inasmuch as the endocar- 
 dium and the pericardium commonly suffer inflammation together. 
 
 H 
 
98 CHOREA. 
 
 changes in the muscles of the affected side ; a special liability to 
 recurrence of the first fit ; often a fatal termination by way of 
 coma. Such or such like clinical features of embolic cerebral 
 obstruction are accounted for by reference to its morbid anatomy. 
 Its usual seat, mainly determined by the distribution of the 
 middle cerebral artery, is the left rather than the right side of the 
 brain, while secondary softening is an early consequence of the 
 original accident, {c) For cause : the conditions which belong tD 
 degeneration ; to endocarditis ; to acute rheumatism ; and to the 
 ]:)uerperal state. In other words conditions belonging to advanced 
 life, or to the time between puberty and middle age. 
 
 Such, I say, is the general description of cerebral plugging, so 
 far as it has been observed clinically and anatomically ; and if the 
 account have reference to minute embolism, we have but to add 
 that there is often active delirium, high temperature, and a train of 
 symptoms, rapidly fatal, which resemble most specific fever.* 
 How far does all this apply to chorea ; to a disease confined 
 almost to childhood; favouring the female sex ; preferring the left 
 side rather than the right ; seldom sudden in its access ; hardly 
 ever exhibiting aphasia, high temperature, vertigo or sickness ; 
 jjroducing no special wasting of the affected muscles ; implying 
 little danger to life or limb, and apt to disappear at that precise 
 period of life when, with the greater frequency of endocarditis and 
 the setting in of degenerative changes, the liability to embolism 
 and thrombosis is largely increased ? Putting together all that we 
 know of the plugging of cerebral vessels, large or small, in its 
 symptoms, associations and subjects, it is directly opposed to all 
 that we know in respect of chorea. ^ If it could be shown that 
 this particular morbid condition was constantly present in chorea, 
 
 ' See, for example, two cases of cerebral embolism reported by Dr. Dickinson, 
 Britixh Medical Journal, May 21, 1881, p. 795. 
 
 - The connection of chorea with acute rheumatism and with child-bearing 
 may be alleged to the contrary. But the rheumatic connection, as I have endea- 
 voured to show elsewhere, is rare, and in its nature peculiar ; while the chorea of 
 child-bearing, as Dr. Barnes has pointed out, is almost always but the revival of 
 a former chorea in childhood. 
 
APPLICATION OF PATHOLOGIES, 99 
 
 the observation would offer a new difficulty ; we should still have 
 to look elsewhere for the structural basis of the disorder. 
 
 But we have still to inquire upon what ground of actual obser- 
 vation this doctrine of vascular plugging in chorea depends. ' I 
 am aware,' says a very candid and fair advocate' of this belief, 
 ' that the morbid anatomy of chorea is not considered to lend 
 much support to the attractive hypothesis of embolism.' Drs. 
 Wilks and Moxon have never met with microscopic emboli in any 
 instance. In one case where, together with chorea, hemiplegia 
 had followed embolism, ' there were no discoverable emboli in the 
 small vessels.' These authors are unable, indeed, to recognise 
 any constant morbid appearance after death in chorea. Similarly 
 Dr. Gowers and Dr. Ferrier have failed to discover emboli after 
 diligent search. It is not too much to say that instances of minute 
 embolism in association with chorea are conspicuous by their 
 rarity. Cases of the kind, as those of Dr. Broadbent and of Dr. 
 Tuckwell,^ are quoted over and over again, but it is admitted 
 that they conflict with the general experience. ' I have never 
 seen an instance,' says Dr. Dickinson, ' in which the well-known 
 blocking [of embolism] as found after death, has been conjoined 
 in life with choreic symptoms ' {loc. cit. p. 36). If this theory of 
 vascular plugging is to be established, it must be, as Dr. S. 
 Mackenzie admits, 'upon evidence of a clinical and physio- 
 logical nature.' Where is such evidence to be found ? It would 
 appear, on the contrary, that the condition of minute vascular 
 plugging, whether of embolism or thrombosis, is both insufficient 
 theoretically, so far as our knowledge goes, to account for the 
 special phenomena of chorea and, as a matter of fact, only excep- 
 tionally met with in connection with it. 
 
 The same may be said in part of the nervous changes pointed 
 out by Dr. Dickinson, and shortly described in the last chapter. 
 
 1 Dr. S. Mackenzie, British Medical Journal, Dec. 23, 1876. 
 
 2 Medical Times and Gazette, 1875, P- 4^2 ; British and Foreign ^edico- 
 Chirurgical Review, 1867 ; St. Bartholomew's Hospital Reports, vol. v. 
 
 H 2 
 
lOO CHOREA. 
 
 Although this condition, consisting in spots of perivascular de- 
 generation distributed symmetrically throughout the brain and cord, 
 was found wherever it was looked for (not only in chorea, but in 
 diabetes as well), it is obviously not the kind of change we are 
 seeking, and, being found, it is impossible, without a revolu- 
 tion in physiolog}', to reconcile with it the actual phenomena of 
 chorea. How can these degenerated spots, symmetrically arranged, 
 affecting the cord as well as the brain, and tending to ultimate 
 <iestruction of nerve-substance, be compatible with a disorder 
 which is transitory and often one-sided, and which almost always 
 leaves the functions of the cord unimpaired ? How, indeed, can 
 those who appeal exclusively to anatomy to explain disease be 
 content with but one set of changes for affections so diverse as 
 disseminated sclerosis, diabetes, and chorea? 
 
 The difficult)' has been felt and expressed. And accordingly, 
 in place of a pathology^ which claims to have the direct sanction of 
 anatomical observation, we are offered hypotheses which have been 
 expressly framed to meet the conditions of the case, and which, while 
 still insisting in part upon a physical chane;e, eke out the rest by 
 means of some of those general expressions imputing blame to 
 the blood or the vessels which are so ready of service where de- 
 monstration fails. Thus, for example, we have Dr. Bastian's 
 doctrine of chorea as being due to ' disturbed nutrition ' of the 
 corpora striata, ' issuing often in sub-acute inflammation of those 
 centres, and characterised in part by the production of minute 
 multiple emboli, a condition originating in an altered state of 
 blood.' ^ Now, so far as the anatomical part of this description is 
 concerned. Dr. Bastian himself calls attention to the scantiness of 
 its direct evidence, and to the possibility of confounding what 
 * lies at the root of the disease with other hyperaemias more or less 
 secondary' in duration and mode of origin.' And for whatever is 
 beyond such description, there are many difficulties in the way of 
 accepting what is asserted in any definite sense. ' Disturbed 
 
 ' British Medical Journal, p. 67, 187^ 
 
APPLICATION OF PATHOLOGIES. loi 
 
 nutrition,' indeed, is hardly a tangible expression, while any theory 
 of chorea which needs the supposition of a blood-change is at 
 once negatived by clinical facts. Chorea attaches to no special 
 blood-state ; it occurs to the plethoric as well as the anaemic ; and 
 all the ' blood-poisons ' that we know of serve rather to remove 
 than to excite it. Even in the case of acute rheumatism, which 
 would seem at first sight to give shelter to some such theory, it is 
 not until the active febrile stage of that disease has disappeared 
 that the chorea comes. 
 
 And so by degrees, with the gradual substitution of hypothesis 
 for observation, we come at last to theories which are all hypo- 
 thesis, a mere writing out of the symptoms of chorea in technical 
 phrase, where, although some morbid change or other is still im- 
 plied, no attempt is made to reconcile the actual phenomena with 
 any definite localised lesion. It is felt, indeed, that this task of 
 reconciliation becomes the more perplexing just in proportion as 
 anatomical description becomes the more explicit. It is easy to 
 accommodate chorea to general expressions of altered nutrition 
 and disturbed nerve centres ; it is most difficult to accommodate 
 it, even in theory, to any morbid condition whatever that we have 
 actually seen, and of which we know the common course and 
 issue. 
 
 Take for example the opinions of Dr. Hughhngs Jackson, 
 already quoted upon this subject. *The great elaborateness of 
 the movements in chorea ' has led this author to the conclusion 
 that the convolutions are the parts diseased. But if the character 
 of the movements requires this assumption, what shall be said of 
 their seat and variableness? With the supposition of diseased 
 convolutions we are not only led to expect aphasia, mental dis- 
 turbance, and ' head symptoms,' we have also to face the fact that 
 very limited injury to certain regions of the cortex, whether irrita- 
 tive or destructive, will produce either spasm or paresis, and never 
 chorea. In the list of cases which Dr. Ferrier has collected, there 
 is not one which lends the slightest support to the behef that the 
 
I02 CHOREA. 
 
 movements characteristic of childish chorea are among the conse- 
 quences of any brain lesion as yet described or produced. But 
 the disparity does not stop with the character of the movements ; 
 it extends to the particular muscles implicated in the two cases. 
 In cortical lesions the leg and the arm are usually affected together, 
 while in the few instances of exception, it is the leg that is affected 
 first. It is notorious that in chorea the two hands or the arms and 
 shoulders are far more commonly affected than one side or one leg. ' 
 
 It thus appears that the pathology of chorea which really takes 
 into account and satisfies the actual phenomena of the disorder, 
 does so in fact by eluding anatomical description altogether. It 
 may borrow its phrases ; it is not restricted to what they imply. The 
 gist of the explanation lies always in some convenient expression 
 which we are bound to accept, but which is so little definite as to 
 advance us nothing in actual knowledge. And in the last resort 
 the trammels of anatomy are broken through, and the condition 
 of the corpus striatum in chorea is described as one of delirium. 
 
 2. It is this that I mean in saying that the hypotheses which 
 provide the best for the actual phenomena of chorea do not in 
 fact present any distinct picture of a definite morbid change. 
 Take, for instance, the late Dr. Todd's description already quoted, 
 which refers chorea to a 'debilitated state of the system, which, 
 with the aid of a peculiar diathesis, produces a more or less en- 
 feebled nutrition, leading, upon adequate cause, to a disturbance 
 of the centre of emotion.' Or take Dr. Handfield Jones's ^ state- 
 ment (I do not profess to give it in full, but only with reference to 
 the point in question), that the ' motor or emotional centres fall 
 into a state of paresis.' Or take the several beliefs variously ex- 
 pressed of some ' toxic influence,' or of some * eccentric irritation.' 
 It would be impossible, I say, to deny the occasional relevancy of 
 each of these descriptions ; but how much are we the better for 
 them ? They are in fact but translations of what we see and know. 
 
 ' See Appendix B. Analysis of Tables, p. 193. 
 • Functional Nervous Disorders, p. 361. 
 
APPLICATION OF PATHOLOGIES. 103 
 
 Wherever the voluntary muscles are beyond control, we may reason- 
 ably impute blame to the region which presides over movement. 
 Wherever there is over-emotion, we may credibly ascribe it to a dis- 
 turbance of the centre of emotion. Similarly, we may have ' toxic 
 matter' and 'peripheral irritation,' and each of these in its own 
 way may generate this same ' peculiar condition ' which we call 
 chorea. But observe that whenever these wholly metaphysical 
 accounts of morbid influence and irritation can be brought fairly 
 into the light, whenever they assign some definite pathological 
 state, such as anaemia or some specified poison, then at once they 
 can be met and confuted. 
 
 But it may be said the lesions of chorea are real enough, but 
 from their nature ' they are not susceptible of anatomical demon- 
 stration.' ^ The symptoms are transitory and paroxysmal, and death 
 comes too late to find any trace of them. In this respect, it may be 
 urged, the disorder resembles epilepsy and other convulsive or spas- 
 modic diseases, the nature of which must be investigated at the time 
 and in the working. It must be answered that the actual physical 
 conditions upon which the paroxysms of epilepsy or of nervous 
 asthma immediately depend, if not known, are at least being hope- 
 fully sought for. Take the epileptic fit, for example. There are 
 the materials to work with in the pallor of the face, the condition 
 of the retinal vessels, the definite methods by means of which the 
 fit may be produced or averted, and its frequent dependence upon 
 direct mechanical pressure or the retention of particular elements 
 of disintegration. And not only in disease but at will, by the drain 
 of blood, by section of one of the lateral columns of the cord, or 
 by irritation of the cerebral cortex, we can obtain epilepsy. What- 
 ever the modus operandi^ whether the brain be anaemic or hyper- 
 semic, or first one and then the other, there is ample evidence of 
 a profound vascular change of some sort. The symptoms and 
 associations of epilepsy are definite and invariable. It has a recog- 
 nised place in the category of diseases. Very different is the 
 
 1 Dr. Hughlings Jackson, British Medical Jou7-nal, Dec. 23, 1876. 
 
104 CHOREA. 
 
 position of chorea. There is no known means of producing it 
 artificially, and no known disease which (to say the least) is habi- 
 tually associated with it; while as regards the condition of the cere- 
 bral circulation during the indefinite time that chorea drags on, we 
 have proof, upon every test that can be applied, that there is no 
 change of the kind that we are in the habit of recognising as 
 morbid. 
 
 And even when anatomical expressions are abandoned, and 
 recourse is had to more flexible language ; when it is said, for in- 
 stance, that the excessive movements in chorea are due to the 
 same agency as those of epilepsy, namely, to * discharges of grey 
 matter, which, except for great irritability from over-nutrition, is 
 healthy,' the course is not made much clearer. The same expla- 
 nation can hardly be made to serve both for chorea and epilepsy. 
 The explosive discharge by means of involuntary spasm (which is 
 epilepsy) is quite different from that continuous restlessness and 
 feeble consensus of the higher muscles seen in chorea, which is 
 without spasm, and not wholly involuntary ; which never occurs in 
 sleep or without consciousness, and indeed intelligence ; which no 
 manipulation can produce ; which is almost unknown with certain 
 races of mankind, and never seen in the lower animals. ' 
 
 Let it be granted, however, that ' an increased access of blood 
 to a district which is embolised but otherwise healthy,' is, by what- 
 
 ' Even could it be established, which it cannot, that choreic movement is a 
 symptom of cerebral disease at all analogous to epileptiform spasm, we should 
 have next to inquire whether the mode of onset and the sequel corresponded in 
 the two cases. The fact is, that there is no such correspondence, but a marked 
 contrast. This is enforced by the very same authority from whom I am now 
 quoting — namely, Dr. Hughlings Jackson. Epiletiform seizures indicative of local 
 brain disease begin in the thumb and index finger of one hand ; the over-movement 
 of chorea is in all the fingers, and generally of both hands. In the epileptiform 
 seizure the lower part of the face is most affected ; in chorea the upper part of 
 the face generally. In epilepsy aphasia is common, and especially with affection 
 of the right side ; in chorea there is never aphasia, and the speech defect is in no 
 relation to the side affected. After epilepsy there is exaggerated knee jerk on the 
 side that was convulsed ; after chorea there is nothing of the sort. — See Dr. H. 
 Jackson on ' Epifeptiform Convulsions from Cerebral Disease,' Medical Section, 
 International Medical Congress, 1881. 
 
APPLICATION OF PATHOLOGIES. 105 
 
 ever agency, the cause of chorea, is such a condition really com- 
 patible with the phenomena it professes to satisfy? I maintain 
 that it fails, both in respect of embolism and in respect of increased 
 access of blood. Our knowledge of cerebral embolism assures 
 us that grey matter thus improperly nourished soon disintegrates 
 and softens. Allowing, therefore, that this form of embolism 
 would give rise to chorea first, it would give rise to paresis after- 
 wards. Chorea would not be the recovering disease which we 
 see ; it would be intimately allied with paralysis. Else the hypo- 
 thesis which provides embolism as the cause of chorea, must 
 provide something besides which shall presently dispose of such 
 embolism. 
 
 But further, and apart from this difficulty, upon what ground 
 is the hypothesis based that hyperemia of grey matter occasions 
 chorea ? In the many forms of intracranial growth, syphilitic, tuber- 
 cular, and sarcomatous; in aneurism; in meningitis; in the changes 
 which precede softening ; in the reparative processes after corti- 
 cal haemorrhage, a localised hypersemia of grey matter may be 
 assumed to arise at some time or other. The symptoms of these 
 several conditions, as is well known, present the greatest variety. 
 They include almost every kind of nervous disturbance except 
 chorea : spasm, whether tonic or clonic, ' limited to the distri- 
 bution of a single motor nerve or implicating a group of muscles 
 on one side of the body ; ' emotional disorders resembling hysteria 
 so closely as to be often mistaken for it ; incoherence, mania, 
 delirium, obstinate vomiting, acute pain, aphasia, but never (or 
 hardly ever)^ chorea. Especially is it to be remarked in the case 
 of meningitis, a disease which both involves hyperasmia of grey 
 matter and has children for its favourite subjects, that with all the 
 variety in its symptoms (coinciding probably with a correspond- 
 ing variety in the order of sequence of the morbid changes) 
 
 * I make this reservation in view of those individuals who have already suffered 
 chorea in childhood, and with whom, as is well known, many provocations, and 
 cerebral disease amongst the rest, will serve sometimes to revive the same affec- 
 tion. — See Case 4, Appendix A. 
 
io6 CHOREA. 
 
 chorea has no place. There is nothing more remarkable, I think, 
 in the general conduct of chorea than the way in which it keeps 
 irself separate, not only from all those brain diseases which 
 imply active trophic change, but from all active disease whatever. 
 3. And it may be contended generally, not merely that all the 
 morbid conditions hitherto described fail to account for the 
 phenomena of chorea, but further, that it is difficult to conceive of 
 any morbid condition whatever, anatomically demonstrable, which 
 is at all calculated to produce it. We have seen already by what 
 course of reasoning the locality of the chorea change has been 
 referred to the convolutions. But suppose we place it there, by 
 what further supposition can any material defect of a tangible 
 kind (more distinct and demonstrable, I mean, than ' mal-nutrition ' 
 or 'trophic disturbance ') be assigned to this region of which it may 
 be reasonably affimied that it is calculated to provoke chorea? 
 Look again at the actual facts, look especially at the points in 
 which the chorea of every day differs from the chorea that is 
 really wanted to satisfy anatomical theories. The brain cortex has 
 by this time been injured and irritated by disease and experiment 
 in a great variety of ways. It may be assumed that every kind 
 of response of which it is capable has been elicited from 
 it. It has been shown by the experiments of Dr. Ferrier and 
 others that certain defined areas of the cerebral hemispheres 
 have special endowments, insomuch that their stimulation 
 is followed by particular movements or groups of move 
 ments.^ Thus we get complex movements of the several limbs 
 like those of climbing or swimming, or walking ; extension move- 
 ment of the hand and arm ; the combined movement of head, 
 eyes, and pupils, which gives the attitude of surprise ; and so on, 
 each of these movements being, so to speak, under command of 
 the operator, and producible always so long as the particular 
 centre is structurally uninjured. Moreover, these several centres 
 
 ' See Ferrier, On the Localisation of Drain Injuries. 
 
APPLICATION OF PATHOLOGIES. 107 
 
 of movement being all near together, and all included in that 
 area of the brain which is in relation through the corpus striatum 
 with the motor tract, movements of these various parts are apt to 
 be variously conjoined, or the one kind of movement to precede 
 or follow the other, just as the stimulation of one centre gets com- 
 municated to the next. ^ And from movements of a precise and 
 definite kind which result from the earliest stimulation of a par- 
 ticular motor centre, we pass on to a corresponding spasm, and 
 from that to a paresis, these several gradations corresponding with 
 increased irritation and the production eventually of structural 
 injury. It must be added that the earliest of these results, that 
 of combined movement, is chiefly known to us in experiment, 
 while the later consequences, spasm and paresis, are amply illus- 
 trated in cerebral disease. 
 
 Now, suppose some lesion or other of an irritative kind affect- 
 ing the convolutions to be so situated as to concern some one or 
 other, or some group of these motor centres. Upon the foregoing 
 data, what consequence might be reasonably expected to happen ? 
 Surely that the earliest impression of such irritation should be 
 seen in some definite muscular movement, or in a combination of 
 movements corresponding with the propinquity and relative posi- 
 tion of the several motor centres, the leg and lower part of the 
 face suffering with the arm, the head and neck with the eyes so 
 as to give a particular expression, and so on. Or if the irritation 
 were limited to one centre, we should expect (arguing from every 
 irritation of the kind that we know of) that it would at length 
 produce spasm and paresis : that we should have for this par- 
 ticular motor centre at first extravagant movement strictly 
 localised, presently spasm or tremor of increasing violence, and 
 at last paralysis, just as the nerve deterioration proceeded. 
 
 1 For the purposes of the argument the facts of localisation are here taken as 
 established. I would refer the reader, however, to a paper by Dr. Brown-Sequard, 
 read at the Medical Congress {Lancet, Aug. 6, 1881), entitled ' Experimental Facts, 
 showing that the admitted facts relating to paralysis of cerebral origin, and to the 
 physiology of the so-called motor tract, must be rejected.' 
 
io8 CHOREA. 
 
 How far do the facts of chorea correspond with such expecta- 
 tion? I have already alluded to the anomalous and irregular 
 manner in which the several parts of the body are implicated, the 
 most sensitive and intelligent muscles being the most liable to 
 attack ; but what is more noteworthy still, is the character of the 
 movements. Chorea does not consist in the frequent repetition 
 of any one muscular act, or exaggeration of any particular bodily 
 expression. Still less is it spasm. Choreic muscles are restless 
 and jerky and indeliberate, they combine so badly that the inten- 
 tion of particular movements, whether of the tongue or the limbs, 
 is not apparent, while, so far as the special muscles of expression 
 are concerned, it is not the look of surprise that we see or of any 
 other emotion, but mere vacancy. Chorea is, in fact, not absolute 
 but relative disorder. The movement which is proper to the child 
 would be accounted chorea in the man or woman. The move- 
 ment which is fitting and convenient for one limb or feature would 
 be chorea in another. Nay more, the movement which we learn 
 to accept from one man we should call choreic in another. True, 
 such examples as these fail to represent extreme chorea, but it is 
 not extreme chorea that we at present want, but the common 
 metJwd of the disorder. 
 
 But there is another element of chorea much insisted on by 
 those who are in search for its physical basis — namely, ataxy. Here, 
 again, we have but to watch the thing itself to see at once how this 
 word fails to apply to chorea in the same sense as it applies to the 
 progressive disease which depends upon degenerative changes in 
 the cord. A single example will serve better than any general de- 
 scription to make this clear. I take the instance of a girl of twelve, 
 shortly described in Case 5 of the Appendix. Ataxy is very marked 
 in this patient, but it is in the arms and speech muscles, and not in 
 the legs. When directed to clap her hands together, she moves 
 the two arms with a jerk, but in such manner as not only to fail 
 of her purpose but to conceal the existence of any purpose what- 
 ever. And the more so, that there is no deliberate direction of 
 
APPLICATION OF PATHOLOGIES. 109 
 
 the eyes towards the arms, or to the place where the hands should 
 meet. The movement is sudden and reckless and wholly abor- 
 tive. So it is in the next attempt and the next. At last, however, 
 by a sudden jerk, as if resolving to anticipate the perverted work- 
 ing of more deliberate will, the act is performed to perfection, the 
 . palms meeting quite accurately, while with this unexpected success 
 subsequent movements of a similar kind are much improved. 
 Every one will admit the contrast between this and progressive 
 ataxia. The cautious and painful way in which an ataxic sets 
 about any combined movement, the careful manner in which, with 
 the help of the eyes, the hands are moved towards one another, yet 
 just fail to meet, or meet by a happy chance, not fully, as in the 
 other case, but with their sides touching, all this is as characteristic 
 of the disease as is its progressive character, implication of the organs 
 of special sense, preference for the lower extremities, and limita- 
 tion almost to adult males. Add to this (if more needs to be 
 added) that the ill consensus of choreic muscles is a very variable 
 and intermittent affection. In the case just mentioned, with the 
 confidence of success the arms very quickly regained their full 
 use. Upon a mental disquiet, however (occasioned by an incau- 
 tious comparison of her complaint, in the girl's hearing, with de- 
 moniacal possession), the ataxy returned temporarily, together with 
 the full violence of the original disorder, and such extreme diffi- 
 culty in mastication and deglutition that for some twenty-four 
 hours she could hardly be got to swallow. All these symptoms, 
 however, subsided in the course of a day or two with the quieting 
 of the mind, and the girl eventually became absolutely steady. 
 
 I should be content almost to rest the whole case upon one 
 such example as this, upon any example, indeed, in which the cause 
 and course and termination and exact manner of chorea are faith- 
 fully and fully set down. If morbid anatomy will serve at one 
 point, it will fail upon a complete review, and can only be main- 
 tained by having regard to certain isolated symptoms at a particu- 
 lar period of their development. 
 
,10 CHOREA 
 
 CHAPTER VII. 
 
 CHOREA A FUNCTIONAL DISEASE. 
 
 The parts selected by chorea — Its varieties and modifications — Character of its 
 
 ataxy Its form in relation to its cause — Alliance to hysteria and emotion — 
 
 Manner of progress and of recurrence — Objections. 
 
 Morbid anatomy thus failing to account for chorea, we are led to 
 consider the question of its pathology from a different point of view. 
 jMay not chorea be looked upon as a functional disorder, a motor 
 disturbance which is as much beyond the reach of anatomical 
 demonstration as are the various passions and emotions which, like 
 it, distort and coerce the body in a great variety of ways ? This 
 functional hypothesis will, no doubt, be rejected by some as a 
 mere evasion of the difficulty, and I have already given such answer 
 as I can to that preliminary objection. Assuming, however, that 
 we may properly recognise certain varieties in the exercise of the 
 muscular functions apart from material disease, the question still 
 remains whether or not the phenomena of chorea are to be included 
 amongst these varieties. We have seen that anatomical theories 
 are faulty and inadequate. How far can any functional hypo- 
 thesis take their place ? It will need to be tested like the rest in 
 the light of the facts, by considering, that is to say, the character 
 of the choreic movement, its subjects, causes and associations. 
 
 It has been urged in the preceding chapter that the movements 
 of chorea, in their method and mode of distribution over the body, 
 together with the rarity of spasm or of i)aralysis, give no warrant 
 whatever for assuming the existence of any definite morbid change. 
 In their variety and half voluntariness such movements would 
 
A FUNCTIONAL DISEASE. iii 
 
 seem, as we have seen, to have their source in the cerebral convo- 
 lutions ; yet not in convolutions diseased or disturbed in any of 
 the ways which anatomy can discern. The limbs become subject 
 to chorea in the order of their use as intelligent instruments, and 
 not as they would do upon any assumption of injury or irritation 
 of a motor centre. Thus, untaught muscles, and such as have 
 never been employed as the agents of intelligence, never suffer 
 chorea ; while, further, the more complex the muscular employ- 
 ment, the higher the place, so to speak, in the intellectual scale of 
 any particular limb or group of muscles, the greater the liability 
 in this respect. The arms suffer chorea much more than the legs, 
 the hands much more than the arms, and the face (so soon as 
 sensitiveness begins to settle there) more than any other part of 
 the body. 
 
 Chorea thus indicates the withdrawal or infirmity of controlling 
 power over certain parts of the frame, and w411 be seen, cceteris 
 paribus^ first and most in those muscles which are by nature (or, 
 it may be, by some special acquirement) the most unruly. Its 
 precise manner, at whatever age it may occur, is due to this : that 
 the muscles concerned, having been educated more or less per- 
 fectly in certain kinds of movement, are suddenly thrown back in 
 their education by some nervous shock which renders them restless 
 and unruly, while the operation of the will no longer sufficing to 
 regulate the limbs, tends rather to disfigure the movements it seeks 
 to arrest. Yet the child thus disturbed does not return altogether 
 to the method of infantile movement. There still lingers some 
 memory of order, and the simpler uses of the muscles in their 
 acquired conjunction are in a measure retained. But the capacity 
 for stillness, which ought to develop pari passu with the acquisition 
 of purposive movement, is enfeebled. Intelligent movement is 
 for the while embarrassed, disfigured, and overborne by emotion 
 movement It is not lost, and under favouring circumstances 
 will assert itself. A sudden access of determination or confidence, 
 an effort which is purely mental, will bring the limbs for a moment 
 
112 CHOREA 
 
 to order and quiet. But the habitual condition is one of weak 
 restlessness when there should be quiet, and of exaggerated mis- 
 directed movement when some muscular act is required. 
 
 Hence it is that the deformity of chorea and its spasmodic 
 character appear more and more as life goes on. In early child- 
 hood the over-movement is easily concurred in and hardly deform- 
 ing, but in adult life, the will being in active opposition, the disorder 
 exhibits a corresponding distortion and spasm. ^ 
 
 We are thus led to consider chorea as being no absolute thing 
 susceptible of one general description like spasm, or tremor, or 
 paresis, or any other of the clinical signs of nervous disease. It 
 varies with its subjects. The child who has not yet acquired the 
 full use of its voluntary muscles, whose movements are undecided 
 and featureless, is the proper and, indeed, the only subject of that 
 irregular and variable commotion which the books seek to describe. 
 The mismovement is but an exaggeration of the natural movement 
 of that time of life ; a mere restlessness which is without character 
 or rhythm. But when chorea comes to the adult, his fixed habits 
 of moving will impart to the disorder a distinct method ; the 
 affected limbs, that is to say, are jerked about after a manner that 
 may be described. The mismovement is more or less rhythmical, 
 or there is a recurrent twitching of certain muscles m a constant 
 order. And as life goes on, chorea presents these characters more 
 and more, insomuch that we might guess with some accuracy the 
 age of a choreic person without the aid of the features. 
 
 And along with these several modifications of chorea, regard- 
 ing it as a motor disorder, there are others which concern its 
 mental or psychical associations. In these respects chorea not 
 only varies with the age and temperament ; it is affected visibly 
 
 ' Apart from chorea this same law is of universal application. Thus when, as 
 often happens, the face muscles pass beyond control so as to express sentiments 
 which it is desired to conceal, there results from this conflict a localised chorea, a 
 chorea which has many degrees from the slight facial disorder which indicates that 
 some restraint is being put upon the features to the absolute distortion of face which 
 occurs when some violent passion is to be concealed. 
 
A FUNCTIONAL DISEASE. 113 
 
 by passing events, and may be of one form to-day and another 
 to-morrow. In any moderate chorea, as was mentioned at first, 
 if the attention of the child be expressly called to a particular 
 limb, and she be bidden either to increase or to modify in any 
 stated way the movement of that part of the body, the effect of 
 such observation will always be to alter for a while the character 
 of the restlessness. Similarly, the holding of one Hmb, in the 
 moderate cases I am speaking of, will have the effect of transfer- 
 ring the over-movement to other parts of the body ; the restraint 
 is never actively resisted. 
 
 The mental or psychical connection is seen still further in the 
 ataxy of the affection. It is to be remembered, indeed, so far as 
 anatomy is concerned, that morbid changes in the cerebral cortex 
 do not provide for ataxy at all. But what I would notice here is 
 that the ataxy of chorea, like its over-movement, is of that kind of 
 which we get the pattern — I do not say the degree — not in struc- 
 tural disease, whether cerebral or spinal, but in the many condi- 
 tions of mental excitement and perplexity to w^hich all mankind 
 are liable. A choreic child may fail utterly in some muscular act 
 one day which it will accomplish easily the next. The very same 
 purpose which cannot be accomplished when set about deliberately 
 will be performed accurately on a sudden and without premedi- 
 tation. Again, the observation of others has the effect sometimes 
 of aggravating and sometimes of controlling choreic ataxy ; or it 
 may have both these effects at different times in the same subject. 
 In addition, therefore, to the very obvious distinction between 
 the ill consensus of choreic muscles and the progressive ataxy of 
 disease of the cord already alluded to in the last chapter, there is 
 the further difference that the former is directly influenced by 
 psychical causes. 
 
 It has been urged by Dr. Gowers that the ' inco-ordination of 
 chorea is distinct from mere inability of the will to still the mus- 
 cles,' and he thence argues that the independent variation depends 
 on a morbid condition of distinct and perhaps separate regions. 
 
 I 
 
114 CHOREA 
 
 But it is to be remembered that muscular co-ordination and the 
 power of muscular stillness do not commonly vary together. There 
 are many habitually restless individuals who will at once bring 
 their muscles into order when employed on some familiar task. 
 There are others, still and reposeful so long as they do nothing, 
 yet painfully wanting in co-ordination when set to work. In so 
 far, therefore, as chorea may properly be said to depend upon a 
 mere exaggeration of defects which we all exhibit in some degree 
 or other, the particular manner of its ataxy, as contrasted with 
 its restlessness, is just what we might expect. 
 
 A further argument in favour of the functional hypothesis of 
 chorea may be drawn from the observation of its actual starting 
 place.' In young children, the hands (one or both, but the right 
 much more than the left) are in a large number of instances the 
 parts first disturbed. Now it is obvious that in childhood there is 
 no member of the body more heavily taxed than this. Consider- 
 ing the modern requirements of education, the hand of the child 
 may be said to be habitually overstrained. And accordingly, 
 without obvious nervous shock or previous rheumatism, we get 
 hand chorea in children, an affection almost limited to them, and 
 the cause of which is regarded as very obscure. All such examples, 
 however, receive their explanation, if we will accept the doctrine 
 that the work and competition of school may furnish occasion 
 for mental disturbance which finds expression in the part most 
 exercised. 
 
 Other examples may be quoted which tend to show that, along 
 with the general law which makes the muscles of the highest en- 
 dowment the most liable to chorea, there is a tendency on the 
 part of those muscles which are the most directly beset or embar- 
 rassed to suffer the disorder first and most. The operation of this 
 principle is seen generally in the successive modifications which 
 chorea undergoes at the several periods of life, the limbs often 
 suffering alone in childhood, and so long as they are freely made 
 
 ' See Appendix B. 
 
A FUNCTIOiYAL DISEASE. 115 
 
 use of, in emotional expression ; while at a later stage, when the 
 face comes to be a conscious index of the feelings, it is the facial 
 muscles which are the most disturbed. It is seen also, indi- 
 vidually, when the particular event or catastrophe which occasioned 
 the chorea happens to concern a particular group of muscles. A 
 boy of eleven \vas much alarmed by an explosion of gunpowder, 
 which slightly scorched his face, and was followed by choreic 
 twitching of the eyelids. A girl of eight and another of ten, having 
 accidentally pinched the fingers of one hand, became choreic in 
 those fingers. A boy of eight gets chorea of the hand in which 
 he was holding the reins of a runaway horse. A girl of eleven, 
 stooping to pick up, as she thought, her brother's cap, found 
 to her great alarm that she had seized a dead rat : she became 
 choreic in the offended hand (the right), and so markedly that, 
 although the general chorea which followed was not severe, this 
 one member for a long time after could by no effort be kept still. ^ 
 Similarly I have noticed repeatedly chorea originating on the 
 side whence the alarm comes. A boy frightened by a dog jump- 
 ing up at him gets chorea on the side of the dog's approach ; a 
 girl frightened by a man suddenly starting out upon her in the 
 dark gets chorea of the side exposed, and so forth. A very large 
 number of cases would of course be needed to verify the hypothe- 
 sis which these examples would appear to illustrate ; but I think 
 the number might be found, while the principle itself is no other 
 than that of which we have familiar knowledge, in the after 
 agitation of muscles which have been strongly excited, and their 
 
 ^ I mention only cases of my own. There are many others. Ziemssen relates a 
 case of violent chorea of the legs reaching great height in a few hours, occurring in 
 a boy, owing to fright, from a gun being fired behind him when he was gathering 
 hops. — Cycl. vol. xiv. p. 432. 
 
 It is to be observed of these instances and of others like them, where chorea is 
 caused by some grave terror, that, contrary to what may be regarded as the rule of 
 of the disease, there is hardly an interval between cause and effect. I would refer 
 to the table of cases in Dr. Dickinson's paper, pp. 30 and 31, Med.-Chir. Traits., 
 vol. lix., where will be found six instances of chorea due to sudden terror and imme- 
 diately following it. 
 
 I 2 
 
no CHOREA 
 
 tendency to recall the violent movements or spasm of the moment 
 of passion. 
 
 And observe that in the most violent chorea the muscles still 
 maintain their accustomed concert. The muscular over-movement, 
 except for its exaggeration and disregard of the will, is the same 
 as the natural movement. Putting aside the paresis which is 
 sometimes conjoined with chorea, it is not true to say (as has 
 been said) that it will select certain muscles out of a group, and 
 move them after a manner of which mere will is incapable. That 
 this conjoint action of the muscles remains intact is shown espe- 
 cially in this, that in those parts of the body where the several 
 muscular uses are most distinctly differentiated, there, in exact 
 proportion to the degree and perfection of such differentiation, do 
 we find a more or less perfect separateness of choreic movement. 
 Thus, for example, the hand and the fingers are concerned in 
 many tasks in which the arm takes no direct share. And the 
 hand and the fingers are often choreic without the arm. On the 
 contrary, the simple movements of the foot are commonly those 
 w hich it shares with the leg. Foot movements alone are as rare 
 as foot chorea alone. It is the same in regard to the two sides of 
 the body. Movement of one arm is common enough, without 
 need or suggestion of movement in the other ; but the movement 
 of one leg almost implies movement of the other. Accordingly, 
 chorea of a single arm is very common, and chorea of a single leg 
 is very rare. But most of all do we find this rule exhibited in the 
 face. One-sided chorea of the face is the exception ; one-sided 
 l)aralysis of the face is the rule. 
 
 But we have yet to consider chorea in its connection with 
 mental disturbance, hysteria, delirium, and mania.' Ziemssen, 
 indeed, is content to refer 'the deterioration of intellect to 
 
 ' It is sometimes asserted that there is a connection between chorea and epi- 
 lepsy (p. 29). I have already alluded to that pathology which would ascribe the 
 phenomena of both affections to a common cause. That epilepsy does not as a fact 
 predispose to chorea may, I think, be safely admitted upon the evidence of the 
 tables in Appendix B, where there is no single instance of the kind. 
 
A FUNCTIONAL DISEASE. 117 
 
 slight anatomical changes in the central apparatus of the 
 nervous system.' But such an explanation, indefinite as it is, will 
 not serve. For there is both more and less than deterioration of 
 intellect to account for. Thus many patients with severe chorea 
 escape cerebral symptoms altogether ; the Hability to such symp- 
 toms is governed by the age ; and the mental disturbance, varying 
 independently of the motor, is of all degrees, from slight emotional 
 display to acute mania. Any account, then, of the mental pheno- 
 mena of chorea which shall connect these invariably with its motor 
 disorder is contrary to the facts. What has to be explained is this : 
 that chorea in the child is usually a purely motor disorder ; that men- 
 tal disturbance comes to mix with it at and after the time of puberty, 
 and that the two sometimes combine and sometimes alternate. 
 
 This gradual intrusion of the emotional element, the transmu- 
 tation, so to speak, wholly or partially with the progress of life, of 
 a motor into a mental disorder, is a phenomenon which finds ample 
 illustration in other affections, and especially in hysteria. In the 
 hysteric fit there is often a sudden and complete transition from 
 the sighs and tears which first announce it to the violent convulsion 
 which at once dissipates it, or else is again exchanged for emotion. 
 At one time the hysteric fit will be purely motor, a convulsion or 
 relaxation of the whole frame ; at another it will be purely emo- 
 tional, a burst of laughter or of weeping, or of these two combined . 
 It seems, indeed, to be matter of indifference as to which of these 
 modes of relief shall be employed. ^ 
 
 1 In later life, and when chorea is almost impossible, these emotional displays 
 become painful and difficult. Tears and laughter and spasm no longer come 
 readily as convenient avenues for feeling. Yet there is still a motor equivalent, or 
 exchange for emotion, w^hich is not less obvious to those that look for it than 
 chorea or hysteria. It consists not in over-movement or spasm, or any of the violent 
 muscular displays which are associated with early life, but in some shght over-ten- 
 sion or relaxation of certain muscles, in a less erect posture of the body, an immo- 
 bihty or changed expression of the face, or, it may be, an alteration of the whole 
 carriage. Changes like these, I say, are less striking than the others, but they are 
 more abiding, as is the state of mind that provokes them ; and at any time they 
 may attain a degree of prominence which shall secure for them the equivocal name 
 of disease. 
 
ii8 CHOREA 
 
 But the manner in which the voluntary muscles are put to use, 
 both to express and take the place of emotion, is best seen in 
 childhood. Childish grief is actually dispelled by means of move- 
 ment, and conversely any violent bodily exercise will always bring 
 children to the verge of emotion. A little child, reserving as long 
 as possible the motor expression of its grief, will suffer acutely in 
 mental respects ; presently a slight quivering of the body, with 
 catching of the breath, and irregular or perhaps suspended respi- 
 ration, will indicate the approach of the required relief, which will 
 come at last in the violent convulsion which we call sobbing, 
 together with free movement of the limbs, and soon perfect mental 
 serenity. In such familiar facts of our nature, as it seems to me, not 
 only do we find the real clue to the various ways in which the mental 
 phenomena of chorea associate themselves with its motor disorder, 
 we learn besides why mere restlessness should be the particular 
 mode of such disorder almost exclusively in early life. 
 
 From considerations such as these, suggested by the method 
 and movements of chorea, we may pass on to those which concern 
 its progress and mode of development. Chorea is usually sepa- 
 rated from its exciting cause by a distinct interval. In many 
 instances, however, this interval is more apparent than real, and 
 arises from the fact that the disorder is of very gradual develop- 
 ment, and fails at the first to attract notice. Yet so soon as it is 
 once recognised, whether by its subject or by those about him, it 
 rises at once into prominence. From this point its progress and 
 duration are extremely variable. Sometimes the patient's first 
 consciousness of his infirmity coincides with the height of the 
 disorder, and after a short interval when both the disease and its 
 treatment have become familiar, the over-movement begins to 
 decline. In some severe cases with the elder patients it will thus 
 moderate with remarkably rapidity. With very young children, 
 however, the course of chorea from the time of its first recognition 
 is one of continual ups and downs, dependent upon trivial circum- 
 stances of health, and spirits, and occupation, until at last and quite 
 
A FUNCTIONAL DISEASE. 119 
 
 suddenly an unusual improvement is noticed, from which time 
 the progress to recovery proceeds rapidly and continuously. Yet 
 even now this favourable progress may at any time be arrested by 
 a mental shock, and the patient thrown back to his worst state, or 
 it may be to worse than that.^ This uneven progress, with the 
 striking manner in w^hich the first distinct sign of amendment 
 becomes the foothold for further recovery, is among the many 
 characteristics of chorea testifying to its real nature. Not less 
 pertinent towards the same end is the long-enduring chorea of 
 young children, where the patients are both indifferent to their 
 disorder and incapable of applying the effort or attention necessary 
 for its cure. 
 
 But w^e are to notice further that as life progresses the time 
 presently comes when we are finally secured against chorea. As 
 with experience and use the voluntary muscles acquire variety, so 
 do they acquire stability, and thereupon lose the infirmity of child 
 hood. They become less and less subject to chorea, not because 
 they have escaped any of those liabiUties to embolism and nervous 
 deterioration which are said to produce it, for these liabilities are 
 every year on the increase, but because variety of employment 
 implies muscular accuracy and obedience. Thus there is nothing 
 which so certainly removes the individual from the influence of 
 chorea as education and culture. The more nicely adjusted are 
 the several uses of the higher muscles, or, if the phrase be pre- 
 ferred, the more distinctly differentiated the functions of the 
 cortical centres, the greater is the power of control. 
 
 And not merely does age with its fixed uses deliver the body 
 from the assaults of chorea, but further, the several departments 
 of the muscular system escape from it one by one in the order of 
 their education. Thus, for example, the higher employment of 
 the fingers in writing, sewing, and the like, are neither self-taught 
 nor self-evident. There is nothing in the natural wants of child- 
 hood to suggest the way to them or to recommend their employ- 
 ^ See, for instance, Case 5, Appendix A. 
 
120 CHOREA 
 
 ment. Yet after a while the time comes when these intricate 
 movements are performed as readily and automatically as any. 
 They become then as fixed and unvarying as the rest of the mus- 
 cular habits. I write on this page with as little thought, except 
 at this instant, of the complicated shapes I am forming, as I shall 
 presently give to the movements of my legs in walking down Bond 
 Street. And now, with the hand and fingers brought under the 
 very same subjection as the lower limbs, they are protected, or in 
 large measure protected, against chorea. 
 
 And what is true of the hand is true also after its manner of 
 other parts. So long as the tongue or the face or the speech 
 muscles are being taught and gathering experience, so long do we 
 hold precarious possession of those parts of our bodies. But 
 when long use and constant repetition have made the higher 
 bodily movements, each in its proper turn, as natural and spon- 
 taneous as the movements of the legs in walking, we begin to hold 
 them with something like the same security. And at last with 
 the completion of the muscular education, a stage which is never 
 reached except in company with superior intelligence and mental 
 stability, chorea becomes altogether impossible, be the pathological 
 conditions what they may. Overstrain, fatigue, and other in- 
 fluences directed against the voluntary muscles do not cease to 
 be injurious, but the nature of the response is different. Just as 
 the overworked hand of the school-girl suffers chorea, so the over- 
 worked hand of the law-writer suffers palsy or trembling. 
 
 Agam, what hypothesis except the functional one can be made 
 to provide for a disorder which is recurrent as chorea is, recovering 
 perfectly time after time ; and at last, when adult life is reached, 
 finally disappearing, the signal for this departure being nothing 
 else in the world but the departure of childish ways and the sub- 
 stitution of new modes of response to nervous impressions ? And 
 observe that during the time that this liability to recurrence con- 
 tinues, it is not the same muscles that arc implicated in successive 
 attacks, but rather those which are similar when regarded as in- 
 
A FUNCTIONAL DISEASE. I2i 
 
 tellectual instruments. The manner of the repetition does not 
 accord with any notion of disturbed nerve-centres influencing 
 particular groups of muscles ; it accords with the more assured 
 observation that intellectual and emotional expression makes use 
 of different muscles at different ages. Thus the recurrence of 
 a childish chorea in adult life will not necessarily be an exact 
 repetition of it, although in obedience to exactly the same 
 law. The muscles which at the time are the most sensitive are 
 again the muscles which suffer. A further principle is involved 
 in the case of chorea happening repeatedly to the same side, if 
 not to the same limb. The fact may seem at first sight to need 
 some anatomical explanation, but no one will deny that muscular 
 failures and inco-ordination of whatever kind are long retained and 
 easily recalled. In the articulation of certain words and the per- 
 formance of certain manual and facial acts the same infirmity of a 
 particular group of muscles will appear again and again, however 
 long and complete the interval between one attempt and the next. 
 To say that the muscles remember, and that the same muscles 
 are repeatedly disturbed owing to the repetition of an old impres- 
 sion is, I am aware, only to say that the first impression has 
 wrought some change or other in the brain, but it is a change to 
 which at present no material conception attaches. 
 
 To these arguments, drawn from the nature of the choreic 
 disorder, its variations with age and with the mental condition, as 
 well as the manner in which it originates, progresses and recurs, 
 others may be added having reference to its exciting cause and 
 favourite subjects. Of the immediate causes of chorea there is 
 none than can be put into comparison with fright. And not only 
 in actual frequency does it stand first, it is superior to all th^ 
 others in the manner of its association with the disease it occa- 
 sions. We are invited to accept rheumatism as the cause of 
 chorea, whatever the interval separating the two ; and as a matter 
 of fact, as I have shown, they are seldom actually consecutive. 
 But in the case of fright there is often no interval whatever. Now, 
 
122 CHOREA 
 
 if it be admitted that fright is an efficient cause of chorea, as no 
 one can for a moment doubt who reads the records of it, it is at 
 least highly probable that other forms of mental disturbance 
 operate in the same way.^ In such cases the provocations to 
 chorea that lie in the way of children in their schooling and un- 
 equal association with others older and stronger than themselves 
 are very numerous. I do not suppose that mental disturbance is 
 always the cause of chorea, yet if that were so we should hardly 
 expect it to appear in a larger proportion of cases than we find. 
 Children suffer from many terrors which they cannot explain,^ 
 both sleeping and waking ; and apparently spontaneous chorea is 
 probably not more frequent than that sudden and causeless change 
 of disposition which young girls sometimes exhibit at an age when 
 there are no developmental changes to account for it. 
 
 And the associations of chorea need the same interpretation as 
 do its other characters. There is no condition which is so inti- 
 mately connected with it as hysteria. The two affections, although 
 properly separate, have so much in common that the very same 
 symptoms which we should call chorea in the child we often call 
 hysteria in the woman ; while not seldom the motor and the emo- 
 tional infirmity are so combined that we see in the same subject 
 now one and now the other the more prominent.^ 
 
 ' Just as the particular movements of chorea are confined to the human race and 
 need for their display a wider range and complexity of movement than other animals 
 enjoy, so are its causes similarly limited, depending as they do upon superstition, a 
 quick apprehension of danger, mental application and reflection, and other condi- 
 tions beyond the reach of brutes. 
 
 - Pondering these matters in a crowded thoroughfare, I witnessed an incident 
 so apposite to my thoughts that I am induced to relate it. 
 
 A man in charge of a child in a perambulator was looking in at a shop window 
 when a passing dog put his nose into the child's face, causing it to scream with ter- 
 ror. The man, hearing the cry, looked round to see what had happened, but not 
 until the dog, finding his attentions unwelcome, had disappeared round the corner. 
 Now, supposing this child became choreic, no one but myself and the dog could 
 guess at the cause. 
 
 '^ It is interesting to notice the attitude of pathological anatomy towards hysteria 
 as contrasted with chorea. The following is from Jolly's article on Hysteria in 
 vol. xiv. of Zicmssen's CyclopcEdia, p. 488 :— ' That some alteration in the 
 nature of the nervous system must be at the foundation of its altered function can- 
 
A FUNCTIONAL DISEASE. 123 
 
 For such reasons as these I am content for the present to 
 regard chorea as a disorder of function. Some structural basis it 
 has no doubt, Hke all other movement, orderly and disorderly, 
 mental or bodily ; but in its ordinary dress it displays none of 
 those symptoms which we have succeeded so far in associating 
 with any material morbid process whatever. If it is to be grouped 
 with other disorders it must be with those which, like it, are tran- 
 sient and recoverable, and w^hich attach themselves in turn to each 
 period of life. To explain or rather to classify chorea I would 
 look beyond it. Especially I would look to that multiform dis- 
 order whose physical basis has yet to be sought, and which at the 
 next epoch of life, when in its turn the emotional part becomes 
 unduly prominent, is apt to arise in the same sex and the same 
 temperament, and upon similar incentive in strict parallelism with 
 this motor disorder of children. 
 
 not be doubted. But whether we are to expect that these changes affect the struc- 
 ture of the nerve elements, or only have reference to its chemical and molecular 
 constitution, cannot yet be stated. It is quite as possible that the microscope may 
 at som.e time give us information concerning the nature of this condition, as it is 
 that no information m.ay be derived from this source. One can, therefore, in the 
 meanwhile only discover the basis of hysteria in an "abnormal" condition of the 
 nervous system, which can only be determined by its symptoms.' Thus we have, as 
 at present advised by pathological anatomy, a dehrium of the corpus striatum to 
 account for chorea, and an abnormal condition of the whole nervous system to 
 account for hysteria. 
 
124 CHOREA 
 
 CHAPTER VIII. 
 
 CHOREA A FUNCTIONAL DISEASE — {continued). 
 
 Some objections considered — The duration of chorea in relation to its cause — 
 Duration at various ages — Chorea found in association with structural lesions — 
 The effects of chorea to be distinguished from its cause — Chorea in its ordinary 
 form as a child's disease incompatible with structural disease — Various modes of 
 expressing existing knowledge in reference to the pathology of chorea. 
 
 Against such arguments as those of the last chapter certain ob- 
 jections are raised, some of which I have already mentioned, and 
 some which, at the risk of being wearisome and of some necessary 
 repetition, I would briefly notice in this place. They may be 
 classed thus : — 
 
 1. Chorea is an enduring affection which often does not even 
 commence until its supposed cause has ceased to operate. 
 
 2. Chorea occurs in connection with paralysis, convulsion, and 
 other similar phenomena indicative of cerebral or nervous lesions, 
 if not uniformly, yet too often to admit of the supposition that 
 the connection is accidental ; while, added to this, chorea ending 
 in death actually exhibits definite morbid changes, endocarditis 
 as a very general rule ; nerve changes, such as minute emboli and 
 softening, in an aggregate too large to be neglected. 
 
 I. As regards the duration of chorea the facts are these. It 
 is apt to be much lengthened out in young children, is of some- 
 what shorter duration in those that are older, while at the puberty 
 age, or when connected with pregnancy, it is severe but not long. 
 In later life and in old age it is a permanent, incurable disorder. 
 
 Now, if the account I have given of the circumstances which 
 attend chorea be a true one, these several modes of it are not un- 
 
A FUNCTIONAL DISEASE. 125 
 
 accountable. In childhood, as we have seen, the muscular system, 
 disturbed by some nervous shock, degrades from the orderly 
 movement which education was developing towards the aimless 
 irrepressible movement of infancy. And if this be so, what is the 
 probability of an immediate restoration ? From what source is 
 that extra power of control to come which will enable the child 
 suddenly to quell such a disorder as this ? From nothing that I 
 can think of except that gradual strengthening of the will which 
 comes naturally with development. Children do not immediately 
 recover from chorea ; young children, unable or unwilling to make 
 an effort on their own behalf, retain the disorder for a considerable 
 time, yet they all recover eventually, while the circumstances pro- 
 moting or retarding their recovery clearly indicate its mental 
 dependence. The growing power of the will together with the 
 natural decline of childish restlessness are pledges for ultimate 
 relief. 
 
 In the chorea of grown-up girls and young women the condi- 
 tions are somewhat different. There is a disturbance of mind as 
 well as of body. Both are on the side of disorder. The mus- 
 cular agitation provokes and maintains a corresponding emotional 
 excitement. Yet such chorea, although severe, is not often pro- 
 longed. Excited sometimes by pregnancy, and sometimes by the 
 arrival of the catamenial period, it also, like the other, has 
 security for its ultimate cure in the temporary character of the 
 conditions to which it owes its origin. The chorea of the puer- 
 peral state, indeed, as Dr. Robert Barnes has pointed out, has for 
 its subjects women who have already suffered chorea in childhood, 
 and in whom the occurrence of pregnancy so elevates the emo- 
 tional element as to render their power of control once more, and 
 for the while, inadequate. 
 
 It is otherwise when we come to consider chorea in adult life 
 and in old age. But the same reasoning applies to these as to 
 the others. Chorea may persist with the advance of years, be- 
 cause the childish mind persists, and that extra will-command 
 
126 CHOREA 
 
 which we expect with the natural development, and to which we 
 look always for the cure of chorea, never comes. Or otherwise 
 chorea may happen when life is already advanced, but only to those 
 who are intellectually weak, or who from age have come to share 
 the infirmities of childhood. But come as it may, it is obvious 
 that the chorea of adult life has not the same hope of recovery as 
 that of an earlier period. There is no reinforcement of will-power 
 to be expected. The disorder has gained ascendency over the 
 individual at his best, and there is nothing in the man's future as 
 in the child's likely to dispossess it. 
 
 2. But it is said chorea occurs in connection with hemiplegia, 
 convulsion, and endocarditis,^ symptoms which appear to depend 
 (and indeed in the fatal cases are commonly found to depend) 
 upon definite structural lesions. The statement must be ad- 
 mitted, but it is incomplete. We have to add that chorea occurs 
 much more often without these accompaniments than with them. 
 And further that the circumstances of these exceptional cases 
 forbid our accepting them as illustrations of the pathology of 
 chorea /(?r se. Chorea as a rule occurs by itself In its common 
 form it is a temporary affection of childhood which neither wastes 
 the muscles nor paralyses them, and which disappears when 
 childish habits have subsided, leaving no trace behind. But we 
 need not stop here. Let us consider the actual significance of 
 those examples in which chorea and paralysis are so associated as 
 to appear due to a common cause. ^ All such examples in respect 
 of the evidence they furnish of morbid change have this fatal ob- 
 jection, that they exhibit not chorea merely, but chorea disfigured 
 owing to its combination with something else. These additional 
 symptoms furnish, it is true, extra material for determining the 
 precise sort of lesion in each particular case ; they do not help 
 towards determining the pathology of chorea, nor can they be ac- 
 
 ' In so far as the question concerns the heart, I must refer the reader to Chapter 
 III. 
 
 * See, for instance, Case 4, Appendix A, \\ iih tlie remarks there appended. 
 
A FUNCTIONAL DISEASE. 127 
 
 cepted as illustrating it.^ We are in fact in this dilemma, that so 
 long as chorea exists alone it furnishes of itself no sufficient 
 ground for asserting any such morbid change as anatomy would 
 recognise ; while so soon as other symptoms are superadded, these 
 so complicate the matter as to make the proper post-mortem 
 signs of the simple affection extremely difficult of separate re- 
 cognition. 
 
 We know, indeed, perfectly well that brain lesions of whatever 
 kind do not, as a rule, exhibit chorea at any part of their course, 
 and conversely, that chorea implies no appreciable liability to 
 cerebral disease. Nay more, the nervous symptoms, such as 
 sickness and partial convulsion, so readily excited in young 
 children, are but seldom seen in connection with chorea. Yet 
 with all this it is perfectly consistent with the hypothesis I am 
 advocating, that the first signal of a trophic brain-change in a 
 child or predisposed person should appear in that exaltation of 
 movement which we call chorea, just as it may appear in that 
 emotional exaltation which we call hysteria. The actual fact is, 
 as has been said, that all the morbid conditions of the nerve 
 centres that have been recognised are much more often without 
 chorea than with it, yet any disturbance, even such as is not 
 directly cerebral, may revive or even produce chorea. 
 
 But while we properly insist upon keeping the pattern of 
 simple chorea distinct and separate, there is reason for believing 
 that this purely functional disorder may of itself in some rare 
 instances so affect the nerve centres as eventually to involve other 
 parts of the body besides those at first concerned ; or otherwise 
 (although the pathology of senile chorea gives little support to 
 such a view), 2 that the long continuance of motor disturbance may 
 ultimately give rise to actual structural deterioration of the centre 
 on which such movement depends. It is difficult, without the aid 
 
 1 See, for example, Dr. Tuckwell's cases, Med.-Ckir. Review, Oct. 1867, and 
 Bartholomew's Reports, vol. v. 
 
 2 See Charcot on Chorea in Old Age, Med. Times and Gazette, March g, 1878. 
 
I2S CHOREA 
 
 of some such hypothesis to account for facts like the following. 
 Chorea beginning in one arm may be presently seen in the leg of 
 the same side ; one-sided chorea may be converted into con- 
 vulsion or hemiplegia of the same side, or the converse may 
 happen ; a choreic limb may eventually become distorted owing 
 to contraction of the flexor muscles. 
 
 Again, although the functional hypothesis seems sufficient, as 
 has been said, to cover most of the examples of permanent chorea, 
 it does not account for them all. Chorea may commence in a 
 child with the ordinary symptoms, and go on indefinitely until 
 the patient is eventually worn out and killed by persisting clonic 
 convulsion.' In such instances, both in the duration and the 
 gradually altering character of the affection, we seem to recognise 
 a purely functional disorder at first, and something more than a 
 functional disorder afterwards. The pathology of such cases is 
 confessedly obscure and it can serve no purpose to speculate about 
 them. Yet the more we lay stress upon the few instances of 
 chorea having such issues as these, the more we bring into pro- 
 minence that general law of the disorder which exhibits it as a 
 harmless and temporary affection, wanting in all those symptoms 
 which imply irritation or destruction of nervous structure. 
 
 And when all the instances of chorea ending in death and 
 associated with structural changes have been eliminated, by how 
 much do we diminish the sum of the affection ? The movement 
 derangement of ordinary chorea endures for a while and then dis- 
 appears. That is the short account of the disorder on which we 
 have to build ; the condition of the living patient supplies all the 
 material for analysis we are ever likely to possess, and this in so 
 absolute a sense that the event of death, which alone could give 
 us access to more, would at the same time impart such an 
 element of exception as to forbid our drawing conclusions from 
 that particular case. 
 
 Let us return once more to consider what this chorea of child- 
 
 ' See Chapter IV. p. 75, and Case 15, Appendix A. 
 
A FUNCTIONAL DISEASE. 129 
 
 hood really is, an affection without paralysis and without spasm, 
 and often with no disturbance whatever of the general health. The 
 symptoms are not those of disease but of exalted function, and 
 their recurrence many times in the same subject and the same 
 limbs with no ultimate harm, gives conclusive proof that these re- 
 peated visitations are not destructive. Chorea, in a word, for its 
 full development requires the service of a brain and cord 
 structurally uninjured, and so soon as textural injury intrudes it 
 will alter its proper form, and give room to some one or other of 
 the recognised symptoms of nervous disease. 
 
 It remains only to consider how such conclusions as these 
 may best find expression. There is an ample vocabulary now at 
 the disposal of everybody, by the use of which it is easy to bring 
 many ill-understood nervous conditions within physiological range. 
 Impaired nutrition of nerve-centres ; disruption of the normal re- 
 lations between such centres ; excessive, defective, or misdirected 
 nervous discharge by cells of some particular part of the brain 
 cortex, these and similar expressions^ in so far as they have a pre- 
 cise meaning, may find ample justification some day. For the 
 present I venture to doubt whether such phrases advance us much 
 in any knowledge of chorea which may be put to practical use. Far 
 more is accomplished, I believe, towards that end by directing 
 attention to the near alliance of chorea with those emotional dis- 
 turbances of which both the origin and the remedy are universally 
 known. This done, we may await with patience whatever new 
 light the future is destined to throw upon the structural basis of 
 recovering diseases of this class, satisfied that no information of 
 the kind will ever discredit that rational method of treatment 
 which applies to all functional nervous disturbance and has the 
 sanction of the common experience. 
 
I -,o CHOREA, 
 
 CHAPTER IX. 
 
 THE TREATMENT OF CHOREA. 
 
 Indications to be fulfilled — Removal of intestinal or other irritation in young chil- 
 dren — Rest — Signs of debility as indications for treatment — Change of place — 
 Drug remedies — Treatment of acute chorea — Chronic chorea — Convalescence. 
 
 The foregoing inquiry, with its negative rather than positive con- 
 clusions, will have missed its main object unless the great princi- 
 ple of conduct which it has been intended to enforce has been 
 made apparent. Yet while I am content that what has been 
 written should stand by itself to be judged and applied by the 
 reader, I am unwilling either to disappoint those who are in the 
 habit of turning first to the end of a book for some account of its 
 practical conclusions, or to give a handle to the statement that it is 
 consistent with the whole scheme of this work that the chapter 
 upon treatment should be left out. I proceed, therefore, without 
 waiting to describe the old methods of cure or entering into 
 details unsuited to those I am addressing, to consider the indica- 
 tions for treatment, the particulars of such treatment, and the pro- 
 phylaxis or way of avoiding chorea. 
 
 In discussing the treatment of any disease the actual limit of 
 reasonable expectation in that respect is apt to be disregarded. 
 There is always a yearning towards some such curative effect as 
 if deliberately expressed would often be seen from the nature of the 
 case to be impossible. By a wholesome preservative instinct we are 
 unwilling to concur in disease in any degree whatever, or to say of 
 any treatment, short of that which would rid us at once of what is 
 
TREATMENT. 131 
 
 felt as intolerable, that it is enough. And so in regard to chorea. 
 No one who has studied its history will deem it reasonable to 
 expect that such an affection can be suddenly arrested. All 
 experience and all analogy tend to show that recovery must be 
 gradual, and that the object of treatment is to bring it about as 
 rapidly and securely as possible. And the same study of the dis- 
 order will certainly bring the further conviction that the time 
 necessary for recovery cannot be precisely stated, depending as it 
 does upon the age, temperament, and aptitude for treatment of the 
 patient. The utmost reasonable expectation, I say, in regard to 
 chorea is that under our methods it should begin to mend, and 
 ultimately altogether recover, and that this should apply to the 
 severe cases as well as the less severe. 
 
 Now, the precise nature of the task before us is of this 
 kind ; it is not so much to check movement as to regulate it. By 
 medicinal means it is possible no doubt to obtain a partial and 
 temporary stillness, but this is only a rough counterfeit of that 
 stability we have to seek. The actual ' indications ' of treatment 
 are not to be met in that way. Muscular stillness and ready con- 
 sensus in movement can only be obtained by developing that 
 power of self-direction which is naturally feeble in childhood. The 
 main object to be kept in view is to stimulate self-confidence. 
 Instead of being openly mistrusted and having attention called to 
 their defects, which is the inevitable result of any formal and sys- 
 tematic treatment, these patients need encouragement and easy 
 allowance. The great principle which underlies this method of 
 cure — for so, as I believe, it deserves to be called — is familiar to 
 everyone. It is the principle which makes success easier when 
 some degree of it has been already attained, which makes the 
 knowledge of help being at hand almost as good as help rendered, 
 which makes the confidence of others a distinct reinforcement to 
 self-reliance, which makes moral support material support. Possunt 
 quia posse videntur. 
 
 The first need of chorea is rest. Even a moderate chorea in 
 
 K 2 
 
132 CHOREA. 
 
 its early stage needs to be kept in bed. The diet should be 
 liberal but not unrestricted, and in the case of young children one 
 meat meal daily is sufficient, the rest being made up with milk, 
 milk puddings, whole meal bread, weak tea and coffee, (Sec. There 
 is an erroneous notion in some quarters that choreic children can 
 hardly be overfed.^ 
 
 What remains concerns almost solely the mental or moral 
 treatment of the patient, and will vary with the age, tempera- 
 ment, and intelligence, as well as with the degree and kind of 
 chorea, and the time it has lasted. In the case of young children 
 careless of their infirmity, who are able to control their limbs but 
 prefer to be restless, choreic movement must be taken for a sign 
 either of some nervous overstrain, or it may be of some material 
 irritation. The presence of undigested food or of round worms is 
 associated with such chorea often enough to make necessary special 
 inquiry upon these points, and to commence treatment with 
 moderate purgation, and it may be to employ santonin as well. 
 That done and the condition of the gums ascertained, these chil- 
 dren, carefully guarded against undue excitement, must be left 
 to their own natural recovery, which is likely to be slow, but 
 almost certam (in the absence of mental defect) to be complete. 
 Not good but harm is done by any open notice ; and there are 
 many indirect means of encouraging bodily quietness which will 
 naturally occur to every sensible mother or nurse. Confidence as 
 to the result, and patience to wait for it, without injuring the 
 child's health with drugs or its temper by scolding, are, I believe, 
 
 * It is a common direction of the books in regard to the treatment of chorea 
 ' to improve the general health of the patient,' and a common statement of theirs 
 that the general health of choreic children is usually impaired. Such is not my 
 own experience ; but however this may be, it is surely unnecessary to say that if the 
 child show sign of illness that sign is not to be disregarded, be there chorea or not. 
 I may go further and say that no child exhibiting chorea ought to be altogether 
 removed from medical inspection, and that while the general principles of its 
 treatment might, in my opinion, be very widely taught to parents with very great 
 advantage, they are not safe to be trusted to make the best application of such 
 knowledge to particular cases. 
 
TREATMENT. 133 
 
 the two main rules of conduct in chorea happening at this early 
 period of life. 
 
 With the older children it is somewhat different. Some of 
 these will too readily concur in their bodily mismovements ; others 
 again are needlessly distressed by them, and some have lost for 
 so long the proper muscular use that they have to be taught 
 afresh. With but one principle in view, each of these classes, it is 
 obvious, will require a separate treatment. At the outset, or 
 rather on our first introduction to a case of recent moderate 
 chorea, the main consideration is to establish a fitting relationship, 
 if I may so speak, between the child and its disorder, sometimes 
 neglecting the bodily mismovement, sometimes even approving it, 
 and sometimes taking special precautions to set the mind at rest 
 in regard to it. It is seldom at this early stage that any direction 
 to the patient to control over-movement is of service. Muscular 
 propriety is never so difficult to preserve as when care is taken 
 about it with the knowledge that it is being overlooked, and the 
 apprehension that failure will entail some kind of penalty. There 
 is no nicer point, I believe, in the whole scheme of treatment than 
 to know exactly when to make direct appeal to the child's own 
 volition so as to ensure that its first active exercise of will shall 
 meet with the success which is to strengthen, and not the failure 
 which is to enfeeble it. The observation of the disorder will be 
 continually teaching how much its progress depends upon trivial 
 circumstances of its own providing, how well-bestowed praise or 
 some special motive to be quiet, or the attention pleasantly 
 arrested, wall procure a quite sudden amendment, and how by the 
 help and encouragement of this progress a fresh step is made 
 towards recovery. 
 
 We have further and specific guides to treatment in the condi- 
 tion of individual muscles, in the body temperature, the sounds of 
 the heart, and the state of the circulation. Muscular paresis, or 
 debility, is, as we have seen, often associated with chorea and often 
 the sequel of it. The temperature of the body after the first week 
 
134 CHOREA. 
 
 is apt to be habitually subnormal. The rate of the pulse may 
 undergo frequent variations; the impulse of the heart may be short, 
 knocking, and abrupt, and the closure of its auriculo-ventricular 
 orifices from time to time incomplete. All such signs indicate the 
 need of tonic remedies, and the best of such remedies, at a 
 comparatively late stage of the disorder, is change of place. The 
 special benefit which children derive from pure air, and especially 
 from sea and mountain air, is here combined with that change of 
 associations and surroundings which is best fitted to break the mono- 
 tony of the complaint. But while change of place, if adopted at the 
 proper time, is commonly beneficial, there are other and more 
 violent changes which are commonly injurious. New companions, 
 strange attendants, life rendered either irksome or exciting are so 
 many hindrances to the natural course of recovery. What we 
 seek is an even life without monotony, employment which shall 
 give interest without fatigue, the repeated promise of recovery, 
 and notice of every improvement. 
 
 It has been said already that the progress of chorea is not 
 accurately described by saying that it gets gradually worse and 
 then as gradually better. Very commonly there is a period — a 
 day or an hour — of which we can say that in it the disorder is got 
 under, not finally vanquished but mastered for the time. And in 
 this uneven course many incidents occur of which we may avail 
 ourselves for the service of the patient. Thus the power of walk- 
 ing, which may be completely lost even with moderate chorea, is 
 often regained very quickly, and not by slow degrees, as with the 
 other limbs. Of such improvement the child should have the full 
 benefit in being allowed extra freedom for pleasurable exercise. 
 
 And here it is impossible to disregard the plain teaching of 
 nature as to the bodily circumstances which serve to strengthen or 
 relax that muscular control which is always variable. Hunger and 
 fatigue and passing illness act upon the frame like emotion and 
 passion. Everyone knows at what time and under what con- 
 ditions his own muscular control is at the best or at the worst. 
 
TREA TMENT. 135 
 
 and there are very few who do not exhibit some sort of facial or 
 speech disobedience when their time for food is delayed, or there 
 is some worry of business. The imperfect nutrition upon which 
 this condition depends is capable of very certain and obvious 
 relief, and food is a more direct and immediate remedy for it than 
 any medicinal agent. 
 
 Of the incidental ills of chorea there is none more striking than 
 its sudden limb and joint pains, acute, fugitive, apt to be worst at 
 night, the wrists being their favourite seat. I believe that local 
 applications are here of slight benefit, and that the best treat- 
 ment is that which applies to hysterical pains. 
 
 As regards medicinal tonics, although of course these are often 
 appropriate in chorea as in other affections, I desire simply to 
 express my belief that they are of no other or higher value to 
 choreic children than to others.^ A similar statement would not 
 apply altogether to aperient medicine. It is of peculiar import- 
 ance, as I believe, in this affection to pay particular attention to 
 the character and frequency of the alvine discharge, and to secure, 
 by means of the simplest drugs, a regular action on the part of 
 the bowels. 
 
 But there is more to be said about drugs than this. It is im- 
 possible to ignore the fact that many competent observers have 
 given testimony in no doubtful terms in favour of certain drug 
 remedies for chorea. Thus, for example, Dr. Begbie states that 
 he has ' never known arsenic fail to cure the malady in an experi- 
 ence of thirty years.' How is it, that with all ordinary sources of 
 error excluded — incompetent knowledge, the mistaking of recovery 
 for cure, the mere habit of boasting and so forth — the very same 
 preparation of arsenic should be uniformly curative in one set of 
 instances and uniformly inert in another ? In common with many 
 
 ^ I have been misunderstood by Dr. Strange, in his ' Notes of One Hundred 
 Cases of Chorea,' [British Medical Journal, July 30, 1881), as well as by others in 
 this matter. It is only of specific remedies for chorea that I am doubtful, and 
 Dr. Strange admits that no such remedy is Hkely to be found ; ' we must ring the 
 changes, ' he says, ' upon the so-called nervine tonics.' 
 
136 CHOREA. 
 
 physicians I have repeatedly used arsenic with at best but slight 
 effect. Yet not Dr. Begbie alone, but others as little likely to be 
 misled have found it of the highest value. A similar statement 
 would apply to sulphate of zinc, to certain preparations of iron, to 
 conium and other agents. Why, I say, should the very same drug 
 have virtue from the hands of one and no virtue at all from the 
 hands of another? What makes the difference ? It cannot be the 
 drugs ; it must be the hands. Faith, I am persuaded, makes the 
 great, the real virtue of these medicaments, whether in chorea or 
 other affections allied to it. Arsenic, or anything else, doubtfully or 
 tentatively given with no expression of opinion as to the result, is 
 one thing ; and arsenic given with a confident anticipation of cure 
 and much keenness in detecting and proclaiming the earliest 
 signal of benefit is another thing. We have here, in fact, under 
 cover of the drug, the very image of the treatment I am now 
 advocating. And this, which is the only possible conclusion from 
 the facts, is but a modern illustration of what is more grossly 
 shown in the early history of chorea. Only a proportion, it is to 
 be feared, would now be cured by exorcism or visiting the shrine 
 of a saint, yet we know that it was by such methods that the old 
 epidemics were allayed and that the popular sentiment was as 
 potent to cure as to cause choreic disorder. It may be objected 
 that the imagination of childhood is too immature to be affected 
 by such impressions as these. Chorea, however, is not an in- 
 fantile affection ; its chief subjects, children of eight years old and 
 upwards, are the most impressionable of mortals, they reflect at 
 once the temper and the spirit of those around them,^ and while 
 
 ' Those who suppose children slow to reflect impressions produced upon their 
 elders by causes which the childish mind cannot be supposed to comprehend may 
 profitably read Wesley's Journal as to the effect of the revival preaching of his 
 day. ' I heard,' reports an eye witness, 'many cry out, especially children, whose 
 agonies were amazing. One of the eldest, a girl of 10 or 12, was in violent con- 
 tortions of body. Among other children who felt the arrows of the Almighty, I 
 saw a sturdy boy about 8, who seemed in his agony to struggle with the strength 
 of a grown man. I observed besides one little girl deeply convinced, and a boy 
 nine or ten years old,' &c. &c. See Lecky's England in the Eighteenth Century, 
 vol. ii., p. 583, seq. 
 
TREATMENT. 137 
 
 they have enough intelligence to understand what is expected of 
 drug treatment, are sufficiently credulous to believe that the 
 result will accord with the expectation. 
 
 But if it be true that drugs confidently administered are of 
 real efficacy in chorea, what becomes of the statement that 
 medicinal treatment is useless. We ought rather to say that the 
 operation of drugs is not of the precise kind that the patient is 
 picturing to himself, and probably as much as this may be said 
 of medication in general. Only, if this hypothesis be the right 
 one, the desired result may be obtained as well by harmless drugs 
 as by those that are harmful. It often happens, as has been said, 
 that the health of the patient will of itself suggest the use of 
 some tonic, and if not, the aqua cainphorce, of the British Pharma- 
 copoeia has been employed with such excellent results that there 
 is the fullest justification for expressing confidence in it. 
 
 No other principles than these apply as I believe to that acute 
 form of chorea of which we have examples in Cases 5 and 6 of 
 Appendix A. The vital power of such patients begins to fail 
 early, and it fails very rapidly. The violent and ceaseless move- 
 ments, the utter want of sleep, the inability sometimes to swallow, 
 sometimes to get food fairly into the mouth, it may be even the 
 very measures designed for relief concur to produce this result. 
 We are face to face with a very grave juncture. Two points 
 especially demand patience, judgment and dexterity. One, the 
 protection of the patient from injury during the violent jactitations, 
 the other the procurement of food and sleep. As regards the 
 first, ample room and scope should be given, not on a narrow bed, 
 but on the floor of a mattress-covered room or perhaps better, 
 for the sake of attendance, on an arrangement of wide beds side 
 by side and foot to foot. Grateful help may be given from time 
 to time by holding the hands or the arms, or by tightening a sheet 
 over the body (as in Case 13), but any continuous or forcible 
 restraint, or coercion of any kind against the expressed wish of 
 the patient, is certainly to be avoided. The movements are always 
 
138 CHOREA. 
 
 to be represented to the patients as being in themselves curative, 
 and when this has been sufficiently impressed, as little notice as may 
 be is to be taken of them. There is ample evidence in the fore- 
 going pages of the highly excited and sensitive nervous condition 
 which almost always accompanies these violent motor paroxysms. 
 I am convinced that an array of force, direct opposition, expres- 
 sions of entreaty or dismay, the presence even of sympathising 
 relatives, are as hurtful here as in hysteria or mania, while on the 
 other hand words of encouragement and a natural demeanour on 
 the part of the attendants are of direct help to the patient Re- 
 peated observation of such result has, indeed, led me to regard 
 chorea like hysteria and catalepsy as the product not of one but 
 of two. The cataleptic or hysteric fit derives an essential part of 
 its material from the presence and sympathy of spectators. It is well 
 known that many nervous phenomena displayed by weak-minded 
 and, in every sense, unfortunate young women, whatever their precise 
 explanation, have to be elicited by means of abdominal pressure 
 applied by the hand of one of the opposite sex. And similarly, 
 although of course not to the same degree, chorea maybe stimulated 
 or repressed by the conduct it meets with on the part of the on- 
 lookers. ^ 
 
 The sudden and serious vital depression which these patients 
 often exhibit must be promptly met by precisely the same means 
 as apply when similar symptoms threaten in enteric fever or 
 pneumonia. Alcohol is sometimes necessary at this stage. But 
 as prevention is better than cure, the great aim should be to 
 administer timely nourishment in sufficient quantity. This busi- 
 ness of feeding is often extremely difficult and laborious. Yet it 
 must always be remembered that the ability to swallow, like all 
 the other symptoms, is subject to frequent variation. The nurse 
 
 * In mentioning so often chorea in its relationship to hysteria, and certain fea- 
 tures which are common to both, I must not be understood to imply that the two 
 affections are but different forms of one disease. The radical difference between 
 them at the only period of life when they can by possibility be mistaken the one for 
 the other, is pointed out in some remarks appended to Case 6, Appendix A, p. i6i. 
 
77?^^ TMENT. 
 
 139 
 
 must watch her opportunity. I have never known an instance 
 where skill and patience were finally baffled, but I have known 
 them severely tried. The question of nutrient enemata may well 
 have to be entertained. 
 
 There is then the question of sleep. How long is the patient 
 to be suffered to remain utterly sleepless ; by what means may 
 sleep be best procured ? At the beginning of such an attack as 
 we are speaking of very little sleep can be expected ; the best 
 means towards it consists I believe in successful feeding at 
 frequent intervals with good beef tea, milk, jelly, eggs, &c. The 
 disorder only admits of snatches of troubled sleep. But if two 
 days should pass with no such relief I give from 20 to 30 grains 
 of chloral, with about half the quantity of bromide of potas- 
 sium (the patient being an adult, as is commonly the case) 
 at sleeping time. This failing (and whether it will fail or not is 
 soon seen) a quarter of a grain of morphia may be introduced 
 hypodermically. If even a few hours' sleep should be procured by 
 such means, that must for the while suffice ; it would be objection- 
 able in my view to repeat either chloral or morphia at regular 
 intervals. Necessary from time to time as they may be for 
 obtaining sleep, they are never for an instant to be looked upon 
 as curative, or indeed, apart from their special purpose, free from 
 objection. 
 
 These acute cases do not long remain in one stay. The 
 real remedy to be confidently and continuously relied on is 
 food and all the conditions of rest. There is, indeed, a question 
 to which no dogmatic answer can be given. Is it lawful to give 
 alcohol with a view to procuring some of its narcotising effect ? 
 My own opinion is that where there are signs of typhoid sinking 
 together with insomnia, and other remedies are either not applic- 
 able or have been found to fail, then over a short time and for 
 this specific end we are justified in pushing alcohol to this degree, 
 whether the affections be chorea or pneumonia. In the adminis- 
 tration both of food and of direct sedatives, it is important to have 
 
140 CHOREA. 
 
 regard to the natural habits of the patient ; to give food at the 
 usual meal time, and narcotics at the usual sleeping time. 
 
 In such severe cases as we are now considering, the real pinch 
 of the moral treatment is fully felt. It has more than the disease 
 to overcome. In the use of drugs every fatal case is supposed to 
 occur in their despite — every recovering case is due to their 
 agency. In the use of such methods as I am describing every 
 fatal case has been left to perish, and every recovery is spontane- 
 ous. Add to this that moral encouragement and support are 
 neither mysterious remedies nor capable of much diversity ; but 
 there is absolutely no end to drugs, and the real feebleness of 
 purpose which appeals to one after the other is easily made to 
 appear fertility of resource. 
 
 Chorea, as we have seen, will sometimes prove a very tedious 
 and lingering affection, getting better and worse by turns, suffering, 
 it may be, sudden relapse with acute, transient pains in the joints 
 and limbs, and sometimes, in boys as well as girls, violent hysterical 
 outbreaks. The most suitable treatment for such patients is 
 certainly not that which a general hospital is able to provide. 
 What they want is rest and quiet, and the gentle stimulation of 
 fresh pure air ; they have to endure instead the disturbing and 
 not seldom distressing incidents of ward life, the sight of others 
 affected like themselves, confinement within doors and a hospital 
 atmosphere. On the other hand, I can speak with the confidence 
 of experience, of the service of such treatment as has just been 
 advocated. Examples of chronic chorea sent from the Great 
 Ormond Street Hospital to Cromwell House, Highgate, get 
 rapidly and sometimes almost suddenly well. For the past five 
 years this has been accomplished in almost every instance without 
 the aid of medicine, a result that affords perhaps the strongest 
 evidence that can be adduced not only of the efficacy of the treat- 
 ment in question, but of the real nature of the disorder. 
 
 It hardly needs mention that this system of treatment, like 
 every other, is more or less efficacious according to the subject 
 
TREATMENT. 141 
 
 acted upon. With children naturally deficient in intelligence, 
 and in those who in the course of the disorder fall into a semi- 
 fatuous condition, moral persuasions and inducements may 
 altogether fail from wanting the material upon which to operate. 
 In some such instances (and Case 14 of Appendix A is a 
 good illustration of the kind), it is necessary to make use of such 
 means to rouse and stimulate the patient to exertion as would be 
 highly injurious at an early stage of the affection. Chorea, no 
 doubt, like hysteria, may fall into a state of self-contentment and 
 apathy which needs to be broken in upon by some method designed 
 to convince the patient that his condition is not a desirable one. 
 This stimulation of the will, however, is only needed in exceptional 
 and chronic cases. 
 
 As regards the treatment of convalescence, it has been said 
 already that it is generally a lengthy process. For a considerable 
 time after apparent recovery much care is necessary lest the child 
 should be exposed to any influence similar to that which occa- 
 sioned the first attack. Too early return to school, the resump- 
 tion, when still physically weak, of manual labour, even a sudden 
 recalling of all the circumstances of the seizure by being brought 
 back to the same place may revive a chorea which has disappeared 
 for weeks. Choreic subjects, indeed, are always in need of some 
 extra care and help ; and if the disposition which attaches to them 
 with comparatively few exceptions be but recognised in time, we 
 may do far better than curing chorea, we may avoid it altogether. 
 
142 CHOREA. 
 
 CHAPTER X. 
 
 THE PREVENTION OF CHOREA. 
 
 Development and direction of childish movement — Allowance for emotional move- 
 ment — The therapeutics and morals of movement. 
 
 This brings me to speak in the last place of the nature and 
 service of that judicious training of children which shall best 
 secure them not only from the assaults of chorea, but from other 
 movement disorders as well, which are far more common, hardly 
 less disfiguring, and more likely to be permanent. 
 
 If the movements of the body may be regarded as a reliable 
 index and exponent of the working of the mind, we may make 
 larger use than we do of this relationship in educational training. 
 Viewed from the physical side each period of life has its own 
 defect and need of help. There is a time when the bodily 
 movements are changeful, excessive, and ill-directed ; another 
 time when they are tumultuous and spasmodic ; and again another 
 time when they become tardy and habitual. Such phenomena, 
 rightly regarded, are plain revelations of mental conditions which 
 appear in no other way. Thus, for example, the character of 
 childish movement is the chief, and for a time, the only indication 
 of the character of childish mind. The necessity for movement is 
 a natural defect of childhood, and observation or attempts at 
 suppressal do not remove, but aggravate it. It is only by ignoring 
 such plain facts that education is made to consist in a strict 
 oversight of children with a view to keeping them still. Such 
 attempts are as hurtful to the bodily as to the mental training. 
 In both apparent success is delusive, and so soon as direct 
 
PREVENTION. 143 
 
 control is withdrawn some extravagant movement or paroxysm of 
 passion is apt to follow. Children, it is well known, are never 
 really kept still by command and watching, and never, there- 
 fore, where this system prevails, escape rebuke, and the further 
 injury to their tender consciences which arises from their believing 
 that they are altogether sinful and that to do well is not in them. 
 
 That confidence in movement which is so backward in 
 children needs to be invited by trust and allowance. What is 
 really wanted is not that they should be kept still, which is a task 
 beyond their years, but that they should learn to move with 
 motive, that their limbs should be regarded as instruments 
 awaiting employment and having many uses, simple and complex. 
 They will learn to use, as they will learn to still, first one depart- 
 ment of the body and then another in an order which nature 
 herself dictates. Simple and graduated limb exercises, such as 
 may appeal to the sympathy of children by having some fun and 
 variety ; withdrawal of their minds from the mere contemplation 
 of their bodies ; ready praise for muscular dexterity ; freedom 
 from the rigors of church and sermon ; such are amongst the 
 means of childish education which the observation of every 
 healthy child born into the world would seem to teach. 
 
 There is no period of Hfe when attention to these points is so 
 imperatively called for as that of childhood, for there is none 
 when mere tricks of movement are so readily caught, or when 
 muscular incontrol stands so nearly related to what is arbitrarily 
 called disease. 
 
 And in the further progress of education up to the time of 
 youth and passion, we are never to forget that muscular use is a 
 continual appeal to the mind. The growing flexibility of the 
 voice, the nicer adjustment of the body to even trivial service 
 the fuller power to co-ordinate and to discriminate accurately 
 between one kind of movement and another, all this implies a 
 discipline addressed to the mind as well as to the limbs, and by 
 these means invading new territories of thought. How much is 
 
144 CHOREA. 
 
 lost in mere physical respects by want of such education is well 
 seen in the voice and face and gesture of young men and women 
 of the neglected classes in their converse with each other. No 
 movement of theirs is well-directed or accurately accomplished. 
 Their muscles in wanting variety want power, and from having 
 few uses are the feebler and the more imperfect in such uses as 
 they have. We notice, therefore, although their fancies are 
 nimble enough, how vague and shadowy is the expression of 
 them, how easily they fall into spasm, their uncontrolled and in- 
 expressive features, imperfect power of articulation, and meaning- 
 less gestures. 
 
 The best testimony to the truth of these principles is to be 
 found in the fact that the parents of the poorer and least educated 
 classes find their children the victims of chorea in large excess 
 over the rest of the community. The treatment of these children 
 in being compelled to painful stillness during school hours, and 
 suffered to run wild during the rest of the day, is in both respects 
 injurious. The natural defect of that time of life gets unfairly 
 put upon at one time and directly encouraged at another. And 
 accordingly, setting aside the instances of chorea brought about 
 by sudden alarm or mental shock, we find young children among 
 the poor quite commonly falling into this disorder from no 
 other cause than that which is furnished by their daily habit 
 
 of life. 
 
 It is to be remembered at the same time that while neglect in 
 the intelligent use of the muscles leaves them disobedient, inexact 
 and unready, a too close attention to their conduct makes them 
 over-sensitive and uneasy. In the case of growing girls, for 
 example, extravagant and inexpressive movement is the precise 
 reflection of newly aroused passions and indistinct mental im- 
 pressions. Such natural response of the muscles, if left to itself, 
 will work its own remedy, and may claim some little allowance 
 upon consideration of the circumstances. Too often, however, it 
 is aggravated by open notice and rebuke, and thus (as the history 
 
PREVENTION. 145 
 
 of all nervous weakness testifies) the strongest possible incentive is 
 given to its further development. 
 
 We see about us young persons of highly mobile tempera- 
 ment responding with their limbs and faces to joy, and sorrow, 
 and pain, and fear. We observe that the measure of this re- 
 sponse grows continually with its exciting cause, and that, after a 
 while, movement becomes involuntary and aimless. We know, 
 both of ourselves and of others, that the power of the will to 
 control the limbs is not absolute but relative. And yet, with ail 
 this knowledge, when our children, as yet imperfectly trained in 
 movement, under whatever pressure of excitement, lose sight for 
 a while of order and method in moving, we begin at once to call 
 names and to speak of some material change in the brain or 
 spinal cord \ as though want of confidence and distrust, or that 
 insecurity of self-control which is the common inheritance, should 
 have some anatomical equivalent. 
 
 The remedy which is needed for these emotional young per- 
 sons is partly to allow, as with the children, what is in the course 
 of nature, with no surprise and no superfluous attention, and partly 
 to make appeal, not directly to the mind (which in its present 
 mood is little open to such appeals), but to the muscles. Ordered 
 and intelhgent movement under the form of some game or ex- 
 ercise requiring judgment as well as dexterity, will occupy the 
 limbs and through them employ the mind. In the case of young 
 men these requirements are amply met in many ways ; but with 
 girls, where the need is much more pressing, there are but few 
 pastimes which combine a sufficient variety of exercise with 
 reasonable interest. 
 
 And here, even more than with the children, the security 
 which arises from confidence is immediately apparent in the 
 movements. Just as the preacher or actor, or public speaker 
 gains fluency and power almost on a sudden so soon as he is 
 assured of popular favour, insomuch that his later performance 
 seems separated from the earlier by a distinct interval, so is it 
 
 L 
 
146 CHOREA. 
 
 with the progress of physical training. We find young women 
 made confident and easy in movement when once they have 
 learnt that these graces are attributed to them. On the other 
 hand, the expectation of failure once aroused by one or two ex- 
 periences of the kind puts new difficulties in the way of success 
 and may soon shut out all prospect of it. It is thus that both 
 success and failure starting from the same level soon create an 
 atmosphere of their own, and each maintains its place in virtue of 
 its surroundings. 
 
 Similar principles hold good when the period of youthful 
 emotion and spasm gives place to the pondering and immobility of 
 advancing age. What moves the body moves the mind. To the 
 melancholic and the hypochondriacal, to the vast body of persons 
 who are self-tormentors, it is quite vain to speak of changing the 
 current of the thoughts. It is the sorest part of their malady that 
 these thoughts are beyond control. Yet except with the most 
 hopeless, bodily exercise in some degree or other is always pos- 
 sible. The body may be stirred when it would be altogether im- 
 possible to act directly upon the mind. If the reality and in- 
 timacy of the union I am insisting on is once taught and believed 
 as a veritable law of nature, everyone not absolutely insane might 
 be induced to make movement of his muscles on behalf of his 
 mind. 
 
 Lastly, there is a moral teaching as well as a practical use in 
 the observation of mind and body in their mutual relations. It 
 is to be feared that there is much self-deception as to the cha- 
 racter of this connection. We do but conceal ourselves a little 
 and for a little while.* If this fact were generally recognised, many 
 small acts of seeming would be abandoned owing to their cer- 
 
 ■ If, indeed, we look to that portion of the community which has the least re- 
 spect for convention we see at once how little it answers its purpose. It is impos- 
 sible to gain the confidence of a child without real sympathy. On this account 
 made-up people avoid children, and are, indeed, afraid of them. This character- 
 istic of childhood is sometimes quoted as proof of a rare sagacity or instinct. It 
 seems more probable, however, that the actual insight of the child, here as else- 
 where, is inferior to our own, and that it is only in candour that he excels. 
 
PREVENTION. 147 
 
 tainty of failure. So abjectly hopeless are we in this respect that, 
 with all the aid of crowded streets and shop windows, no man 
 ever succeeded in so simple a stratagem as making another be- 
 lieve that he was unconscious of his neighbourhood when passing 
 im without notice. And yet we think, when in direct intercourse 
 with our fellows, to pass off sham regard or sympathy, well know- 
 ing of ourselves that we should at once detect such counterfeits. 
 Conventional usages do not really hide the sentiments, but we agree 
 together to pretend that they do. 
 
 But the muscles which are so feeble at concealment are ready 
 at help. No discipline addressed to the body with the view to 
 regulate its movements and enforce order fails to convey the same 
 message to the mind. An upright carriage and direct gaze will 
 compel a like bearing within. It is no mere figure of speech that 
 we use in speaking of those who lean to dishonesty or stoop to 
 meanness. Thus physiognomy (which need not be confined to 
 the face, although there, of course, is its chief seat and index), is 
 a more searching science than it would be quite convenient to 
 admit. The union between mind and body, whether harmonious 
 or not, is never dissoluble. And it is properly so intimate that no 
 conflict can be secret or enduring. The voice of suppressed 
 emotion is really expressing it. The tongue of false congratulation 
 or pretended regard actually stammers. The face of hypocrisy is 
 known and has been drawn. There is but one way of cringing 
 or fawning. The utmost that the will can do, and this only for 
 a while, is to rob these attitudes of their due proportions. It is the 
 same with sincerity. Amid all the strife of opinion and specu- 
 lative belief, directness of purpose bears a physical impress which 
 finds instant and universal recognition. It proclaims its title of 
 nobility unquestioned, however simple the mind or faulty the 
 judgment. 
 
 I- 2 
 
APPENDIX A. 
 
 ABSTRACTS OF CASES ILLUSTRATING SOME OF THE 
 
 ASSOCIATIONS OF CHOREA REFERRED 
 
 TO IN THE TEXT. 
 
ABSTRACTS OF CASES. 
 
 The following Abstracts of Cases, quoted in the order of their occur- 
 rence, are intended to illustrate some of the characteristics of chorea — 
 e.g.^ its connection with rheumatism and endocarditis ; dependence on 
 emotional causes; cardiac and paralytic symptoms ; limitation to one 
 side of the body ; occurrence in adult life ; together with various 
 methods of treatment. The object has been not to give a full account 
 of a certain number of cases, but to direct attention to particular 
 points of interest in each. The selection having thus been made 
 partly with a view to exhibit remarkable symptoms and anomalous 
 modes of origin of chorea, cannot be taken as a general picture of the 
 disorder such as would be afforded by a like number of examples 
 taken consecutively, as in Appendix B. With the exception of a case 
 borrowed from Dr. Brabazon as a more striking example of its kind 
 than I could myself quote, and of one which is extracted from the 
 post-mortem book of St. George's Hospital, all the patients were under 
 my own care, and all but three at the Westminster Hospital. 
 
 Case I. — Heart Disturbance arising in a child while under obser- 
 vation in hospital without distinct evidence of Rheumatis^n^ and 
 shortly followed by General Chorea. 
 
 Alfred G., aged lo, was admitted into the Children's Hospital under 
 the care of Dr. Gee, July i8, 1880, with an account of six months' loss 
 of flesh, and cough, pain in left side and loss of appetite for the last 
 fourteen days. Neither his parents nor he had had rheumatism. The 
 heart sounds were natural. Three days after admission he had some 
 tenderness and pain over the right sterno-clavicular articulation. 
 Temperature, however, had not risen over 100°. There was now audi- 
 ble over upper sternum a well-marked (basic) diastolic murmur. In 
 the course of the next week his temperature became normal, and no 
 
152 CHOREA, 
 
 fresh symptoms appeared. But now the heart's action was irregular 
 and ' tumbling,' the murmur persisting as before. The boy, appear- 
 ing well as to his general health, was sent to the Convalescent Hospital 
 at Highgate. There, while under my care, he got toothache. The 
 action of the heart became thumping, and much accelerated. With 
 this, a restless movement came on which soon developed into a general 
 chorea. His parents, seeing him at this time, and alarmed at his ap- 
 pearance, insisted on taking him away, and he was thus unfortunately 
 lost sight of. 
 
 Case 1 1. — Heart Disturba?ice following fright^ with paiti ?wt 
 identified as rheu??iatic^ and very slight and transient Chorea. 
 
 Emma D., aged lo, was admitted May 29, 1878. A month before 
 she had been much alarmed by being bitten in the hand by a dog. 
 Two weeks after she complained of pain in her knees. On admission 
 there was still pain, but neither redness, tenderness, nor swelling of 
 joints. For three days her night temperature was raised, and there 
 was slight choreic movement of arms and hands. A soft systolic apex 
 bruit was audible. As the pyrexia disappeared this soft bruit de- 
 veloped into a loud blowing mitral murmur. 
 
 [These two cases are samples of many where the heart symptoms 
 preceding the development of chorea are connected with local pains 
 and slight pyrexia, both of short duration, but giving some colour to 
 the belief that both cardiac murmur and chorea are of rheumatic 
 origin.] 
 
 Case III. — Chorea followi?ig Acute Rheumatism and 
 Endocarditis^ and without obvious nervous cause. 
 
 George H., 13, a shop boy, pale, slightly built, and tall for his age, 
 was admitted into Westminster Hospital, October 20, 1880, with 
 marked chorea of hands, mouth, eyes and tongue, the head and legs 
 being less affected. There was but little muscular inco-ordination. Pulse 
 was 90, temperature normal. The heart's impulse was visible over a 
 large area in normal position ; there was a thrill perceptible of vary- 
 ing distinctness, and a blowing systolic apex murmur which was con- 
 ducted. to axilla and left vertebral groove. Pulmonary second sound 
 accentuated. 
 
 This boy was stated to have been strong and well till about a month 
 before admission, when he had acute rheumatism affecting most of the 
 joints. He was laid up for twelve days and attended by Mr. Lattey 
 
ABSTRACTS OF CASES. 153 
 
 of Kensington ; he had praecordial pain together with the physical 
 signs of endocarditis. Recovering as was believed from this attack, he 
 went back to his business at Richmond. Three days later he was 
 again attacked with joint pain, this time attended with choreic move- 
 ment. There had been no previous rheumatism and none of his 
 family had had rheumatism. No mental cause of any kind could be 
 made out. The boy throughout was cheerful and composed. There 
 was nothing of significance in his history except that his paternal 
 grandfather had died insane. 
 
 The boy was kept in bed, but no active medicinal treatment was 
 adopted. In less than a week he had recovered fair use of legs. His 
 full recovery was somewhat retarded by a painful whitlow, but within 
 three weeks of his first admission he was almost steady. He was re- 
 markably cheerful and unemotional. 
 
 [In an instance such as this, where the rheumatism and the endo- 
 carditis are unquestioned, and where there is no room for supposing 
 any nervous upset, it is hardly to be doubted that there is some real 
 connection between the acute disease (whether rheumatism or endo- 
 carditis) and the subsequent chorea. This boy affords an example 
 (more strikingly exhibited in Case 8) of chorea following acute rheu- 
 matism, not immediately but where the patient too early in his conva- 
 lescence is sent back to his ordinary work.] 
 
 Case IV. — Chorea with Hemiplegia. 
 
 Caroline C, a domestic servant, 21 years of age, was admitted 
 into hospital in a condition of grave prostration, with a temperature 
 of 102°, a drying tongue, and an extensive but superficial sore over 
 the sacrum. When put to bed it was observed that the face was in 
 violent and continual movement, the tongue likewise being very un- 
 steady and protruded with difficulty. The patient was confused in 
 mind and unable to give any connected account of herself. She an- 
 swered questions, however, more or less pertinently, but with great 
 difficulty of utterance of the choreic kind. She moaned and cried out 
 so as to disturb the ward, and her arms were restlessly thrown about. 
 There was extrem.e tenderness above the elbows, the girl crying out 
 upon slight touch. The urine was of high specific gravity (1030), and 
 contained at first a trace of albumen. Large bronchial rales w^ere 
 heard over the chest ; the heart-sounds very feeble and indistinctly 
 heard. 
 
 The account of the patient, derived chiefly from her mother, was 
 
154 CHOREA, 
 
 shortly this : that in childhood she had twice had chorea, severely 
 affecting both face and limbs, and that in December last, while in ser- 
 vice, she was laid up with rheumatism, apparently acute. Getting 
 better of this, in about a month she was sent home. After six weeks' 
 holiday she returned to her place and had now to carry a sick mistress 
 daily up and down stairs, a service which she felt to be beyond her 
 strength. She now began to suffer leg pains, and complained of weak- 
 ness of the knees. A month before her admission she travelled with 
 her employers from Brighton to London. After this journey, and 
 while sitting at tea, she suddenly lost all power in the legs, and was 
 carried to bed. The history at this period becomes obscure, the patient 
 having little recollection of the time. It appeared, however, from the 
 account of the woman who had attended her, that she had complained 
 of pains in the limbs, with cough and restlessness, and had shown 
 much agitation of the muscles of the face. 
 
 The further progress of the patient need only be noted in so far 
 as it concerns the relationship between the chorea and the paralysis. 
 After two days' residence (during which, although not actively delirious, 
 the patient was continually crying out, answering away from the purpose, 
 and passing motions in bed, the bowels at the time being very loose) 
 the extreme restlessness of the face became less. There now suddenly 
 occurred a paralysis of the left orbicularis palpebrarum, and with this 
 a complete lax paralysis of the right arm. There was no alteration in 
 sensation, the early tenderness of the arms having disappeared. The 
 tongue was still choreic, the pupils equal and active. Temperature 
 io2-8° ; pulse 102. The aspect and posture of the patient still indicated 
 great bodily weakness. The bronchial signs remained ; respiration 
 between 35 and 40. The heart-sounds becoming more audible, a loud 
 whirring systolic murmur was heard at the base, having certain pecu- 
 liarities as to place which need not here be dwelt on. 
 
 After a week of this condition, during which diarrhoea continued at 
 intervals, no control was exercised over bladder or rectum, and, with 
 an improved mental condition, the prostration was so extreme that 
 brandy had to be given, the patient began to mend. The arm slowly 
 recovered power, remaining for some time obviously weaker than the 
 other. The orbicular paralysis also disappeared by degrees. The 
 face and tongue, as has been mentioned, began to get steady when 
 the palsy appeared, but it is to be observed of the tongue that it suffered 
 a distinct relapse lasting but a few hours. On the tenth day after ad- 
 mission all signs of paralysis had disappeared, and the patient's natural 
 
ABSTRACTS OF CASES. 155 
 
 manner, which was quiet and unexcitable, had returned. She was 
 still very weak, with temperature over 100°, and pulse 120, The bron- 
 chitis still continued, and there were some special physical signs at 
 the left apex indicative of commencing phthisis. With the final disap- 
 pearance, however, of the nervous symptoms, and the progress of re- 
 covery so far that the girl was able to get up during a part of the day, 
 the case comes to an end for the purpose for which it is related. 
 
 [For full remarks on this case I must refer to a clinical lecture re- 
 ported in the ' Lancet,' September 6, 1879, fi'O"^ which the following 
 short extracts are taken. 
 
 Observe first, that the chorea anticipates the paralysis. By how 
 long a time it precedes it is not quite clear. Having already had chorea 
 twice, it is not remarkable that, with the incentive of overwork, and in 
 convalescence from acute rheumatism, the same affection should re- 
 turn. It need not be denied that both the chorea and the arm paralysis 
 which shortly followed it point to one and the same cerebral lesion. 
 Nevertheless, the order of events must be kept in view, and it is this : 
 facial chorea gives the first warning of cerebral change, incoherence 
 of mind, pyrexia, and general prostration announce its actual advent ; 
 presently arm paralysis appears, which taken together with the valve 
 disease and rheumatic history, contributes something to determine the 
 character of the injury. We must keep the phenomena in that order. 
 
 But, further, iMisface chorea takes the form of a ge7ieral a7id extre7ne 
 restlessness, which is noticed first while the patient is still sensible, 
 and not acutely ill ; and, having stopped once, it is suddenly revived 
 again for a short time, and then finally ceases. Moreover, there 
 is nothing partial or one-sided about it ; it affects the whole face. Of 
 itself, therefore, this symptom would in no way help to determine the 
 precise place of the supposed brain lesion. With paralysis of the right 
 arm arising from embolus or extravasation, we should have expected 
 rather a paralysis, or spasm, of the right lower facial region. We get 
 neither one nor the other, but the gradual subsidence of an already 
 existing facial chorea (the occurrence of which we may well accept in 
 virtue of the patient's early history and extreme susceptibility in this 
 respect), with a paralysis of the upper ^^sirt of the face on the left side. 
 
 Let it be assumed that we have in this instance some anatomical 
 change in the corpus striatum or in the neighbouring convolutions 
 which are in fact ' the same centre raised to a higher power represent- 
 ing the same muscles in more intricate combinations ; ' let it be 
 embolism of minute vessels, or thrombosis, or any other pathological 
 
156 CHOREA. 
 
 event calculated to produce an immediate trophic change. When 
 did that particular event occur? In what relation does it stand to the 
 chorea ? This girl is ill and weak, and feels herself overworked, her legs 
 fail, she has twice already had chorea, and now again the face is found 
 to be restless. Yet she manages to travel in attendance upon her 
 employers a journey of fifty miles. Reaching home she suddenly loses 
 power, her face becomes more restless, and soon she is compelled to 
 keep her bed altogether. When admitted into the hospital she is 
 pyrexic, delirious, and in a state of dangerous prostration, and pre- 
 sently becomes paralysed in the right arm and upper part of the face 
 on the left side. Now, on the supposition of embolism or extravasa- 
 tion, or any like event, it is to these later symptoms and to this period 
 that such event must be referred, and not to the chorea which pre- 
 ceded them all. The facial chorea, which was a revival of former 
 choreas (happening under circumstances well calculated so to revive 
 it), was obviously anterior, not indeed to a cerebral change of some 
 kind or other, but certainly to that period when such change had 
 issued in any lesion like those we are here contemplating. And not 
 only is the chorea anterior to the condition which is said to produce 
 it, it fails to correspond with it in regard to its seat ; for this is not 
 limited to a particular group of muscles but distributed over the face. 
 It is a return of that form of chorea which the girl had already suf- 
 fered twice, and which any other kind of illness might have revived 
 as well.] 
 
 Case V. — An Exa7nple of Chorea^ exhibiting rapid transitions 
 and dependence on mental Condition. 
 
 Elizabeth D., aged 12, was admitted on the first occasion for 
 chorea brought on by fright on being threatened with corporal chastise- 
 ment ; the movements, which were not severe, commenced in the 
 left leg and extended to the arm and hand. After a short residence in 
 hospital she was discharged nearly well, but returned after three weeks' 
 worse than at first. This second attack had followed upon a blow. 
 The child walking carelessly had struck her head violently against a 
 lamp post. The movements now concerned the hands, head, and 
 face, there was likewise much restlessness of the tongue and difficulty 
 in speech. She improved considerably after four days in bed, and, 
 now allowed to be up for part of day, could move about with ease and 
 comfort. 
 
 Two days later, a week after admission, and a few hours after she 
 
ABSTRACTS OF CASES. 157 
 
 had been much disturbed by the news of the serious illness of her 
 father, she complained of pain in the right arm, wept, refused her 
 food, and occasionally vomited. All the movements were now much 
 increased ; the face and right side being the most agitated, and 
 speech very difficult. Night temperature was 100°, the pulse not 
 frequent. Her position, lying low down in the bed, with restless work- 
 ing of the mouth and eyeballs, frequent upward jerking of the chin 
 or flexure of a leg, while the arms, less actively disturbed, lay loosely 
 by her side, or with the knuckles of the flexed hand resting on the 
 chest, indicated at a glance a severe degree of chorea. In attempting 
 to clasp her hands together she would make movements quite distant 
 from her purpose, but once or twice, as by a sudden jerk, succeeded in 
 bringing the palms accurately together. The same sort of intermittent 
 co-ordination was observable in other movements. She was unable to 
 maintain a grasp, and much arm-agitation was occasioned by attempts 
 to take food. Here, indeed, was the main difficulty. It was only 
 after much patience and many trials that food could be swallowed, 
 attempts at deglutition being often followed by general spasm. She 
 was acutely sensitive, readily shed tears when noticed by strangers, 
 and had the usual emotional exhibitions of crying and laughing com- 
 mon in hysterical women. These symptoms continued for three days, 
 at the end of which time, owing probably to the inadequate amount of 
 food taken no less than to the muscular exertion, she was much 
 weakened, and ominous signs of sinking began to threaten. Brandy 
 \vas now given, and by a sudden spasmodic effort, similar to that 
 which impressed all her movements, she succeeded in swallowing 
 a few gulps of it. Upon this she slept more soundly than she had 
 done for some time, and was still sleeping when suddenly awakened 
 by a street band. Thereupon the muscular agitation returned with 
 almost maniacal vigour. The girl screaming and crying, but unable 
 to utter words. This fit spent itself in about an hour, and the patient, 
 much exhausted, again slept. From this the improvement was rapid 
 and continuous, and the difficulty in swallowing almost disappeared, 
 yet she was still quite unable to perform the movements of walking. 
 The walking power was almost suddenly regained ; on February 10, 
 a month from time of admission, she was convalescent. 
 
 [This case speaks for itself, in its rapid transitions, emotional admix- 
 ture, variable power of co-ordination, early appearance of alarming 
 prostration, difficult management and response to treatment. In some 
 of these respects it may be compared with the one to follow. 
 
158 ChOREA. 
 
 I need only append the following note by the sister of Harpur 
 Ward, who most carefully and judiciously directed the nursing of the 
 child : — ' All through her illness the girl has been fearfully sensitive. 
 We had to be most careful how we talked in her hearing. A mis- 
 understood word would bring on difficulty of speech.'] 
 
 Case VI. — Violent Chorea in an Adult ^ rapidly recovering. 
 
 Marian R., aged 20, a fair-haired, healthy girl, living at home in 
 training to become a governess, was admitted into the Westminster 
 Hospital under my care, June 22, with severe chorea. She had had 
 three previous attacks — the first, occurring at 13 when studying 
 with the view to teaching, was due immediately to fright caused by a 
 boy throwing a dead kitten in her face. She immediately began to 
 twitch the facial muscles, and became ' excitable ' and ' nervous.' Five 
 or six months before this she had complained of what were called 
 ' growing pains,' wherein her legs and joints were affected but not red 
 or swollen. The second and third attacks occurred near together 
 two years after the first, and when she was 1 5. They were both of mild 
 character, and little could be remembered of them. The girl had 
 been healthy in childhood, but apt to walk in her sleep. The family 
 history was of a negative kind, and especially wanting in any par- 
 ticulars of rheumatism or nervous disease. 
 
 At the end of March of the present year (1880) the patient was in 
 bed for a week for supposed rheumatism. Some fortnight later, when 
 still feeling the effects of this illness, she was much alarmed by having 
 to spend a night in the same house with a woman who was subject to 
 fits of insanity, and who associated the patient with her delusions. 
 Yxom. that time up to her admission the girl felt 'as if going mad,' had 
 visions of rats and mice, was always worse towards night, and feared 
 to sleep alone. She would occasionally ramble in her talk, and fore- 
 told that she would presently have St. Vitus's dance. The actual 
 attack commenced thirteen days before admission, and had been 
 getting worse daily. 
 
 On admission the patient was found to be the subject of violent 
 chorea affecting chiefly the face, speech, and upper part of the body. 
 A loud systolic bruit was audible at the heart's apex. On being put 
 to bed the movements became much aggravated, and towards evening 
 were so energetic that she was kept in bed with difficulty. Mr. 
 Davies, house physician, gave her two doses of bromide of potassium 
 
ABSTRACTS OF CASES. 
 
 159 
 
 with chloral during the night, but she got barely two hours of dis- 
 turbed sleep. On the following day (June 23), at the time of the usual 
 visit the jactitations were extreme, so as to require constant watching 
 and holding. She spoke indistinctly, and was fed with difficulty. 
 The pulse was now 108 and intermittent, tongue natural. Hearing 
 and sensitiveness were acute. As evidence of this, she was es- 
 pecially disturbed by overhearing a whisper to the effect that her 
 father was not to see her. At times she had some delusions in re- 
 ference to those about her, but these had always a basis of reality, 
 and she was easily recalled to herself She reached her worst on the 
 night of this second day, and remained in the same critical condition 
 till the afternoon of the third day (the 24th), when it was thought 
 necessary to place her in an isolated ward. 
 
 It is not easy to convey in words the exact violence of choreic 
 agitation. It must suffice to say that from the evening of the 22nd to 
 the morning of the 25th, this girl required the active service of one or 
 more nurses to keep her in bed and prevent her doing herself injury. 
 The jactitation of arms and body was more than of the legs. There 
 was no emotional excitement at this time, but much anxiety and ap- 
 prehension. When almost at the worst, and desiring to see her 
 mother, she was able so far to control her hand for a moment as to 
 write a few legible words. It was observed also that whenever the 
 violence of movement somewhat relaxed, she would snatch the op- 
 portunity to employ her hands to some purpose of the moment. She 
 could also offer her hand to be held accurately and without divergence, 
 and was partially steadied for a while by such means. Throughout, so 
 far as observation was made, she retained such imperfect power of con- 
 trol as enabled her to moderate her movements for a moment when so 
 bidden, but their violence was heightened by such efforts. The pulse 
 was now 120, the temperature could not be taken at the full strength 
 of the paroxysms, but immediately before (on the 23rd) it was 99°. 
 
 So soon as the case had actually assumed the degree of violence 
 that it threatened from the first, it was resolved to attempt no specific 
 or experimental treatment, but to direct attention to removing all 
 removable discomfort ; to supplying food ; and to the procuring during 
 night time of a sufficient amount of sleep by the help, if necessary, of 
 such narcotic as might prove the best. With this threefold object 
 several mattresses, bounded by pillows and bolsters, were placed on 
 the floor of the room to which she had been removed in such manner 
 as to form a capacious bed ample enough for the patient to lie at 
 
i6o CHOREA. 
 
 length in any direction and to fling her limbs about without injury. 
 She had already had repeated doses of morphia subcutaneously without 
 effect, and on the morning of the third day (the 24th), some hours 
 before her removal to the separate ward, had been given thirty grains 
 of chloral. She got, however, only short snatches of sleep, was fed 
 with extreme difficulty owing, not to any impairment of deglutition, 
 but to the violence of movement, and her strength was beginning to 
 fail. It was now decided to suspend all medicine whatever during the 
 day, but that, if absolutely sleepless during the night, a hypodermic 
 injection of a quarter of a grain of morphia should be given. Three 
 ounces of brandy were ordered in addition to such liquid food as 
 she could be got to swallow. She was left almost free and unre- 
 strained as regards movement, with the assurance that she might 
 throw herself about without fear of injury and that such agitation was 
 not in itself evil but rather to be suffered as working out the cure. 
 This same night, in pursuance of the plan described, she was injected 
 with a quarter of a grain of morphia, but was restless and sleepless, 
 although less violent. On the 25th the agitation had moderated 
 considerably but increased towards evening. That night the sleeping 
 draught consisted of thirty grains of chloral, a dose which (without 
 absolute occasion) was repeated on the night of the 26th. 
 
 For in fact the morning of this, the fifth day, saw the end of the 
 chorea in its violent and threatening form. The patient had slept for six 
 hours. She now for the first time exhibited emotional excitement in 
 tears and lamentations, the hands and arms, heretofore violently 
 agitated and still unruly, being now employed to some extent in 
 giving expression to these feelings. This hysterical state lasted only 
 for the day. The girl was brought back to the general ward with but 
 slight chorea affecting chiefly the hands. It was now for the first 
 time possible to judge of the patient's aspect and bearing. She 
 appeared to be an intelligent girl, cheerful and contented. During 
 convalescence she had for two days pain with some tenderness in the 
 left wrist and back of the hand. On the 27th, the sixth day from 
 admission, she was up and about, some choreic restlessness being 
 still perceptible, but to such slight degree as to make it unnecessary 
 to keep her much longer an in-patient. The cardiac murmur still 
 continued, although much softer and less distinct than at first. 
 
 [The points for consideration in the case concern its distinctive 
 characters ; method of progress and recovery ; and response to 
 treatment. 
 
ABSTRACTS OF CASES. i6i 
 
 Here was obviously a chorea due to mental disturbance in a 
 predisposed person and with the interval so often observed between 
 the exciting cause and the actual outbreak of muscular disorder. At 
 such an age, as I have said, chorea is in many respects quite different 
 from the chorea of childhood ; it is more severe ; it is almost always 
 mixed with some mental disturbance and it occasionally ends fatally. 
 The violence of muscular movement observed in this particular 
 instance could hardly have been exceeded. Yet it exhibited, as in my 
 belief it does always, an element of voluntariness. The girl could 
 remain comparatively still for a second or two when so bidden, an 
 increased, violence of movement following such effort. We are to 
 observe, however, how differently exercised is this volition from that 
 which is seen in hysteria. In the short intervals of partial quiet this 
 girl would seize the opportunity to perform a muscular act which she 
 had strongly in mind {e.g.-, writing a few words to her mother), making 
 such use of her fingers as was possible between her paroxysms. The 
 hysteric, on the contrary, occupies the same periods in relaxation and 
 self-regard. She shows no similar anxiety to get w^ork out of her 
 muscles in their lucid intervals. There is further a strong contrast 
 between the distress which the choreic shows at the sight of her 
 disorder and the mental concurrence which attends the hysteric convul- 
 sion. Thus, whatever the alliance between the two affections, the differ- 
 ence between them is obvious. The muscles are in conflict with the 
 will in the one case and in some sort of agreement with it in the other. 
 
 It is to be observed further how, in its utmost severity, the disorder 
 of chorea keeps itself clear of spasm. At no time could it be said in 
 the present instance that any particular limb or set of muscles was in 
 true convulsion. Looking at these patients on the whole, as common 
 observers do, the amount of their disorder seems hardly to be 
 surpassed, but looking at one limb only or one set of muscles, its 
 movement is seen to be neither convulsive, nor repeating, nor even 
 continuous. The arm, for instance, is flung about now in this direction 
 and now in that, with a half-recklessness which is always under some 
 sort of command, and which is considerably modified for the short 
 time that attention can be centred on that particular part. Anyone 
 who will hold the hands of a violent choreic for a short time will 
 recognise this diversity of movement. This same absence of spasm is 
 seen further in the grimacing of the face, while the measure of volition 
 is shown in the rarity with which the tongue gets severely bitten or 
 the faeces discharged, as happens so commonly in epilepsy. 
 
 M 
 
1 62 CHOREA. 
 
 It has been observed of these patients, as happened in the present 
 case, that the chorea increases in violence on the patient's first admis- 
 sion to hospital. There is much in the nature of the disorder to make 
 it probable that removal from home with the restraints of hospital and 
 observation of strangers may be in part responsible for such result. 
 Chorea, I believe, at its beginning and in its common form is best 
 treated by rest at home, a quiet and even life and no open notice. But 
 it is with chorea beyond this stage that we are now to deal. And in a 
 case like the present, when, together with mental exaltation, the jacti- 
 tations are of such strength as to need the most watchful coercion, one 
 cannot but reflect upon the moral and physical effect of such restraint. 
 The mode in which chorea culminates is not so vtxy different now and 
 in the old time. With less of gross and naked superstition the subjects 
 and the provocatives of the disorder remain the same. And so proba- 
 bly do the remedies. With no actual belief in demoniacal possession 
 ihere is still present to the minds of these patients a mysterious and 
 unseen agency which takes the place of the will, and which, it is often 
 feared, will presently disorder the reason. The distress and demoralisa- 
 tion which chorea commonly excites in its adult subjects are well worthy 
 of attention. There is the widest difference between them and young 
 children who, having no deliberate will and but little experience of 
 muscular conduct, are ready to concur in any kind of movement. 
 These elder patients, as in the present instance, often believe they are 
 going mad ; their friends often ask whether the complaint will ' not 
 go to the brain.' In such circumstances, as mentioned in the text, 
 it is no small thing to give the body the amplest opportunity of move- 
 ment without fear of injury, and to give the mind the best support that 
 ran be devised by representing the movements as having a curative 
 design. In extreme chorea this can only be accomplished by the 
 method that was here followed, room for movement and no discourage- 
 ment to moving; abolishing the pain of physical restraint and allaying 
 in great measure the apprehension and even terror which the move- 
 ments themselves excite. And the marked change which ensued upon 
 these measures was very striking. The violence of movement left un- 
 checked soon spent itself, just as a high sea gradually dwindles on a 
 shelving shore, but rises into greater commotion when some direct 
 obstacle opposes it. 
 
 While the course of the chorea in the present instance was marked 
 throughout, as it so often is with adults, by great sensitiveness and 
 anxiety, it was only when the muscular disorder began to decline tha 
 
ABSTRACTS OF CASES. 163 
 
 the hysterical symptoms appeared. We see precisely the same sequence 
 in hysteria itself. During the height of hysterical spasm emotion is in 
 abeyance, the convulsion ceases and the patient breaks into tears or 
 laughter. Thus, notwithstanding the very re d distinction between 
 these disorders which has been already mentioned — the distinction, 
 namely, that the choreic woman is dismayed and distressed at what 
 has come upon her, while the hysteric surrenders herself willingly to a 
 spasm which is in itself a relief — there is an obvious alliance between 
 the two. Choreic patients are mostly hysterical. Chorea will invite 
 hysteria. The chorea of childhood may become the hysteria of woman- 
 hood. It may even be difficult to decide whether to call a restless 
 movement by one name or the other. 
 
 A word as to drug treatment. Drugs were pretty freely used at the 
 first and were wholly inefficacious ; the improvement set in when they 
 were stopped and when bodily freedom and moral support were sub- 
 stituted. I do not propose to draw large conclusions from a single 
 case, but I ask whether, supposing this favourable change (which was 
 both earlier and greater than is customary in chorea) had coincided, 
 not with the suspension of drugs, but with the change from one drug 
 to another, we should not have heard a great deal of the virtue of 
 drug-treatment and been charged with unreasonable scepticism for 
 expressing any doubts upon the subject ? 
 
 Case VII. — -The Chorea of Imitation and Sympathy. 
 
 The following case is related by Dr. Brabazon, physician to the 
 Bath Mineral Water Hospital, in a paper upon the treatment of chorea 
 with the Bath mineral waters, published in the ' British Medical 
 Journal,' May 15, 1880 : — 
 
 ' The patient, a girl aged 18, was admitted to hospital for chronic 
 rheumatism and amenorrhcea. She was a stout healthy-looking girl. 
 Her home was in the quiet village of Wrington, in Somersetshire, her 
 mode of life and general surroundings were most unsensational. There 
 happened to be in the same ward with this girl a child suffering from 
 chorea, but not of an exaggerated type. After being in hospital about 
 a month this girl was suddenly seized with chorea in its most severe 
 form. In attempting to walk, she knocked herself black and blue 
 against furniture or whatever came in her way ; she could not hold a 
 cup in her hands, or feed herself, and, at night, was sometimes jerked 
 as it were out of bed. Her facial contortions and grimaces were 
 
 M 2 
 
1 64 CHOREA. 
 
 horrible to behold. No votaiy of St. John, no disciple of St. Vitus, no 
 victim of tarantism could have proved a more perfect specimen of 
 "Chorea Sancti Viti " of the middle ages. It became necessary to 
 isolate this girl completely from her fellows, some of whom, in accord- 
 ance with the history of the disease, would in all probability have been 
 similarly affected, and the Mineral Water Hospital would have been 
 assimilated to an asylum for " jumpers " or " shakers," This patient 
 was placed in a room by herself, with one attendant, the room being 
 so padded and arranged that she could not injure herself. Mr. Cop- 
 pinger, the Resident Physician, has favoured me with notes of the 
 case. I should mention that in this, as in all the cases which I have 
 seen, the thoracic movements were bilateral. The medical treatment 
 employed was bromide of potassium and chloral hydrate in full doses at 
 night. When the symptoms were most violent, six leeches were ap- 
 plied to the inside of the thighs ; and, after a time, when the acute 
 symptoms had subsided, she had tincture of belladonna, perchloride of 
 iron, and a reclining bath daily at 100° Fahr. This was palpably a case 
 of acute chorea, induced by morbid sympathy, in a female at the age 
 of greatest nervous susceptibility, and under circumstances of func- 
 tional derangement adapted to aggravate the symptoms. I think 
 there could be no better example than this of a case of acute chorea, 
 and no case better suited to form a link in the chain of connection 
 between the epidemics of the middle ages and the sporadic cases of 
 the present. It also bears out to some extent the theory of Dr. Sturges 
 as regards this and other analogous diseases, regarded by him as 
 simply an affection of function.' 
 
 Case VIII. — Chorea after Cotivalesceiice from Rheumatism with 
 emotio7ial adtnixtiire^ delusiojis, c^c. Relapse. Muscular Paresis 
 occurring together with mitral murmur. 
 
 William L., a healthy-looking youth, aged 16, a railway porter, 
 admitted April 7, 1881. After an attack described as acute rheu- 
 matism (and for which he kept bed two days, and remained at home 
 by the fire for fourtcecn days longer), this youth, on convalescing, 
 was put to new and harder cmi)l()ymcnt as a railway porter. He kept 
 at this, although feeling overdone, until a fortnight before his ad- 
 mission, the jomt pains not wholly leaving him. He then, while still at 
 work, had an hysteric fit, crying and kicking, on recovery from which 
 
ABSTRACTS OF CASES. 165 
 
 both hands were found to be choreic. Next day the legs were af- 
 fected, then the head, and in a week's time the speech was difficult. 
 The pains increased as the chorea appeared. 
 
 On admission there was choreic movement of both hands, and 
 some dragging of the left leg. The hands worked awkwardly, and 
 their grasp was insecure, the right hand being the worst. There was 
 much speech difficulty, and the face was vacant, partly no doubt from 
 muscular fault, although besides the youth was wanting in intelligence. 
 The heart sounds were at this time normal. 
 
 After about three weeks' residence, getting about, feeding himself 
 with difficulty, this boy had a severe attack of general chorea with 
 frequent shrieking and temporary delusions ; as that his brother had 
 met with an accident on the railway. With this attack the wrists be- 
 came painful and tender, and, on the partial subsidence of the pain, 
 the right wrist dropped, insomuch that for a while the hand could 
 hardly be raised into line with the arm, the grasp was likewise very 
 feeble. Along with this a systolic murmur appeared most audible at 
 the base or over the right auricular region. In two days and quite 
 suddenly the wrist power returned, and the cardiac murmur dis- 
 appeared. 
 
 The boy remained in hospital for some time longer, able to get 
 about, and in good general health, but still unsteady, especially when 
 the hands were employed. He was ultimately made an out-patient. 
 
 [This case illustrates the occasional alternation of joint pains (in 
 this instance probably rheumatic), with chorea ; also the occurrence 
 of a distinct paresis of certain muscles along with an equally distinct 
 cardiac murmur, both symptoms being temporary (See Chapter III. 
 p. 69). The exciting cause of chorea in this instance was a not un- 
 common one, the overstrain of harder work than the youth was accus- 
 tomed to when imperfectly recovered from rheumatism. The hysteric 
 fits and mental aberration are also noteworthy.] 
 
 Case IX. — Choreic Moveinent of the Hand following Partial 
 Paralysis of the Arm after heavy lifting. Chorea changing side. 
 
 George C, aged 14, a healthy boy, kitchen -help at an hotel, ad- 
 mitted April 15, 1 88 1, stated that four weeks before he had lost 
 power in the right arm after carrying heavy trays. A week after this 
 loss of power, and first brought to his notice from his letting a cup 
 fall, the boy got choreic movement in the right arm and hand. He 
 
1 66 CHOREA. 
 
 had had no rheumatism or previous illness. Heart was natural. 
 During time of his residence this boy got passing attack of pyrexia, 
 in which he exhibited general restlessness, which for a few days 
 threatened to pass into severe chorea. It was short-lived, however, 
 and on its subsidence left him unsteady in the affected arm as well 
 as in the face. He was made out-patient when still imperfectly re- 
 covered. 
 
 This youth was admitted a second time, with chorea now most on 
 left side. 
 
 [This case shows the association of chorea with that functional 
 paralysis which arises from fatigue of certain muscles, the subject, as 
 the subsequent history showed, having a predisposition to chorea. 
 The seat of the chorea on the second admission affords one of the 
 many exceptions to the rule that subsequent attacks of the disorder 
 are repetitions of the first.] 
 
 Case X. — A Moderate and Partial Chorea of Left Side follow- 
 ing rhemnatisni converted., upo?i the ocairrence of fright {jnore 
 than three jnonths after the rheumatism) into Violent General 
 Chorea., in ivhich the right side was most affected. Succeeding 
 7oi?it affection. 
 
 Louisa P., aged lo, a delicate-looking lean child, had had rheu- 
 matism five months before admission, followed (after a clear interval 
 of three weeks) by twitching movements of the left arm and leg. 
 This disorder continued up to a week before admission {i.e. for 
 about three months), the child getting about as usual. She was now 
 greatly alarmed by being beaten by some boys in the street. The 
 movements thereupon became general and violent, and worst on the 
 right side. Chorea was still severe on admission, insomuch that for 
 the first three weeks she had to keep her bed. She made good 
 gradual recovery, and was fairly steady in about five weeks. 
 
 When on the way to recovery this child happened to fall on her 
 right elbow. The joint next day became swollen, red, and tender, 
 and was put up in splint in flexed position. The swelling and redness 
 shortly subsided ; the elbow joint, however, remaining stiff and the 
 arm constantly maintaining a position of rigid flexure, the patient was 
 referred to Mr. Macnamara. It was found that under chloroform the 
 joint movements were normal, as they appeared to be also in sleep. 
 Mr. Macnamara was of opinion that the elbow-joint was perfectly 
 
ABSTRACTS OF CASES. 167 
 
 healthy. The rigidity, nevertheless, persisted. Considerable force, 
 nmet by continuous and unvarying resistance, served to flex the fore 
 arm partially ; the girl giving utterance to pain the while, but with- 
 out any hysterical manifestation. By the time these symptoms had 
 developed, the chorea had disappeared, and the child's general health 
 was good. Not only could the arm be easily flexed during sleep, but 
 the condition improved so rapidly upon the promise to the child that 
 she should go home when the joint was well that, although the ex- 
 treme resistance to flexure and other signs were anomalous, the 
 symptoms generally coincided best with so-called hysteric joint. 
 
 [The case is introduced to show how a slight localised chorea 
 may be aggravated to severe and general chorea by nervous shock. 
 It shows also, like the last, that chorea in its second attack may 
 change its side. Further, the joint affection which arose in the course 
 of convalescence is a good illustration of the sort of symptoms which 
 cause chorea to pass as rheumatic upon ver>^ dubious grounds.] 
 
 Case XL — Left Hemichorea implicating lower part of left 
 face, left hand, and left foot in a young pregnant wo?nan newly 
 married, a month after rheumatic attack. 
 
 Jane C, aged 21, ironer, four months married, and in third month 
 of pregnancy. Two and a half months before admission she had had 
 pains, swelling and tenderness in the small joints of both hands and 
 the left foot, for which she kept bed a week. Five weeks before ad- 
 mission {i.e. something over a month from supposed rheumatism and 
 when in good health) suddenly, and from no apparent cause, she felt a 
 twitching or turning outwards of the left hand, the left foot soon par- 
 ticipated, and the left corner of the mouth had downward twitch. 
 These movements were very perceptible on admission, although not 
 violent. The woman had never had chorea, and, except for headache 
 and neuralgia, knew of no previous illness. There was no rheumatism 
 or neurosis in her family history. A variable systolic bruit was 
 audible between apex and base of the heart, sometimes loud, some- 
 times quite lost. The patient improved in a few days, and left the 
 hospital after a fortnight's residence, nearly steady. 
 
 [Here was a strictly one-sided affection, involving both face and 
 hand, and foot, in just such manner as irritation of a motor centre 
 would, and without the slightest participation of the right side. If 
 hemichorea at all, then a very perfect and complete hemichorea, 
 
i6S CHOREA. 
 
 pointing to a definite seat of irritation. Yet it was not a continuous 
 restless movement, but an occasional twitching, without muscular in- 
 co-ordination. If the term chorea is to be restricted to the cha- 
 racteristic form of the child's affection, this case would not be an 
 example of it. Yet in its occurrence during pregnancy, partial control 
 by the will, the state of the heart, and the complete recover)', its near 
 alliance to chorea is obvious ; while the exception which it offers in 
 its mode of distribution over the body to the common rule of that 
 affection is very significant.] 
 
 Case XII. — Chorea in Middle Life occasioned by mental shock. 
 
 James S., aged 38, a wire-worker, intelligent and unemotional, 
 with no history of chorea, syphilis, or rheumatism, either personal 
 or in his family. He had enjoyed good health up to three years ago, 
 when he lost a child by death. He then became unsteady in the left 
 arm, and soon in left leg and left side of face. Eighteen months ago, 
 on the death of his wife, the chorea became general. He was for 
 two months in St. Thomas's Hospital, and afterwards at Guy's. In 
 the latter hospital he had an attack of acute illness described as 
 rheumatism, and lasting two months. On recovery the limb move- 
 ments became somewhat less. 
 
 The patient is in good general health, and least unsteady when 
 employing his hands holding a book or turning over leaves. He is 
 .even able for a while to work at his trade. The choreic affection oc- 
 cupies the limbs, face, and speech muscles. In the limbs it is seen 
 most in movements of extension, giving to his gait as he walks a 
 curious spring for each step. The heart's action is regular except 
 that with some beats there is marked prolongation of the first sound. 
 When lying in bed the movements are almost confined to the upper 
 limbs. The pulse is 94, temperature habitually subnormal, a little 
 over 97°, rarely reaching 98°. 
 
 The patient remained in hospital for about two months, and im- 
 proved unquestionably in his command of speech and power of 
 walking. His own estimate, however, as to the measure of his re- 
 covery exceeded that of other observers. His poverty and pre- 
 carious mode of living previous to admission made him so far a 
 favourable subject for treatment, and such progress as he made 
 towards recovery was due no doubt to improved nutrition from better 
 living. As already mentioned, he was always best when his hands 
 
ABSTRACTS OF CASES. 169 
 
 were employed, and when discharged he beHeved himself well enough 
 to resume his employment. 
 
 [This case affords an example of the very rare occurrence of 
 chorea to a man of middle life, and not excitable or notably feeble 
 in intellect, from the operations of causes similar to those which pro- 
 duce the disease in childhood. It is the more remarkable as he had 
 not suffered chorea in early life. As regards rheumatism, the patient 
 was certamly without it until after the chorea had become confirmed 
 and general. The exact nature of the attack in Guy's Hospital de- 
 scribed as rheumatism could not be made out owing to the man's 
 infirmity of speech. For the same reason this case cannot be quoted 
 to negative the statement that no grown man of full, mental capacity 
 ever yet suffered chorea. The degree of intelligence through all the 
 difficulties in the way of expression could not here be estimated, and 
 there was no evidence as to his condition in this respect when first 
 attacked. He was not conspicuously emotional, was fairly educated, 
 and fond of reading.] 
 
 Case XIIL — Severe Chorea with Muscular Paresis ; variable 
 ataxy ; extreme agitation of the hand ; benefit to be derived fro?n 
 mechanical support and muscular exercise. 
 
 Annie M., aged 12, an intelligent and tractable child, lean but of 
 healthy aspect, was brought to hospital with rather severe chorea of 
 about three weeks' duration. The affection was first noticed from 
 her dropping her glass while drinking. The over-movement was 
 now general, but affected the right side chiefly. Both hands were 
 very unsteady, and the right could not be fairly extended from the 
 wrist, but habitually drooped more or less. She was quite unable 
 to stand, or walk, or move the legs in any desired direction. The 
 girl had never had rheumatism, and the attack (which was the first) 
 was attributed to falling downstairs or, perhaps, to toothache and 
 extraction. There was neither chorea nor rheumatism in the family 
 history. The heart was slightly uneven in action and the first sound 
 prolonged. 
 
 The choreic movement soon became much worse, so as to require 
 special watching. With the full consent and concurrence of the child 
 means were employed mechanically to restrain the limbs. A sheet 
 wide enough to cover the whole trunk was stretched over her and 
 tied round the bed. This was applied and removed at her pleasure, 
 
170 CHOREA. 
 
 and by its aid she got sleep and soon improved in steadiness. But 
 now with the lessening of the more active agitation a general mus- 
 cular weakness became apparent. The girl lay low in bed, and the 
 inability to stand was now due rather to want of strength than want of 
 steadiness. The rhythm of the heart had become irregular. There was 
 no appreciable wasting. It now became a nice question whether her 
 condition might be best met by rest in bed or by directing such use 
 and exercise of the muscles as was possible. In the belief that the 
 paresis was parallel to that met with in hysteria, and with a view to test- 
 ing that opinion, the girl was directed to be up for a few hours daily. 
 In the course of a fortnight she was able to walk with some support, 
 dragging the legs somewhat, but showing no misdirection. The face 
 was still unsteady, and, as at the first, words were uttered with difficulty 
 and in jerks ; but the stress of the disorder was now chiefly in the 
 right hand, which was utterly choreic, and unable either to be still or 
 to make any attempt at grasping. 
 
 In pursuance of the same plan that had succeeded with the general 
 disorder, this hand was now bandaged down on a straight splint, the 
 child concurring in this as readily and indeed eagerly as in the case 
 of the sheet. For the first week of this treatment the hand could be 
 felt with the fingers wriggling about under their bandage. After this 
 the hand became rapidly steadier. She was able first to hold a 
 pencil, and soon to write : the return of nvritiiig power being noted 
 to a day a?td eveti to aft hour, while once regained (as in the case 
 of walking), it was veiy soon regained completely. The girl was in 
 hospital altogether about three months, the first fortnight of that time 
 showing a severe degree of chorea, and the rest of it being occupied 
 with recovery which, although slow on the whole, was rapid and 
 almost sudden in its main incidents. 
 
 [Besides the points for notice already alluded to in the text of this 
 work, this case may be quoted amongst others to show the benefit of 
 restraint. The mechanical aids to steadiness which were given to this 
 girl, if they did not quicken recovery (and I am not certain that they 
 did), were yet grateful to the patient, and were applied only in so far 
 as they were so. Restraint which is not directed and qualified in 
 this way, restraint which is sternly ordered by the doctor without con- 
 sulting the patient, is more likely to do harm than good, and sometimes 
 does very serious harm. But with the patient's concurrence, and with 
 a clear understanding that it may be used and disused at will, me- 
 chanical restraint may sometimes be made use of, on and off, with 
 
ABSTRACTS OF CASES. 171 
 
 manifest advantage, even in cases more violent than the present. 
 Another point of interest concerns the treatment of the general paresis 
 of chorea and the need of stimulating the muscles to exertion. The 
 rapid transitions of the disorder, and especially the quick recovery of 
 the use of the fingers shown in the present case, are highly character- 
 istic features.] 
 
 Case XIV. — Chronic Chorea with Tncoiitinence of Urine., 
 emotional attacks ajid temporary Heart Disturbance. Condition 
 of fatuity succeeding. Improvement with discipli?ie. 
 
 Samuel S., aged 13, a fresh-coloured healthy schoolboy, of blunt 
 intelligence, had pains in the left thigh ten months before admission, 
 shortly followed by choreic movement of the same side. The present 
 is a second attack of three weeks' duration, affecting the left arm and 
 especially the face (the forehead and eyebrows being in constant 
 movement). There is no apparent cause for this second attack. The 
 case, never violent, was extremely obstinate. It was marked by three 
 notable incidents : incontinence of urine ; emotional or hysterical 
 attacks ; and great variability in the character of the heart's action. 
 The incontinence continued more or less throughout his stay. The 
 emotion was exhibited on the occasion of a sudden death in the 
 ward, when the boy had a fit of crying and sobbing with much increase 
 in the choreic movement. The heart, at first regular and without 
 obvious murmur, became for a while irregular or uneven, and de- 
 veloped a variable murmur which exercise made louder, and was 
 post diastolic in time, and heard best just above and within the apex 
 impulse. 
 
 After many variations this boy fell into a half fatuous state, 
 where, as will be seen from the description, it was extremely difficult 
 to estimate the precise mental condition. The muscle movements, 
 moderate but general, were greatly aggravated on moving, and he was 
 quite unable to walk or stand. He lay habitually on the back, low in' 
 the bed, constantly grimacing, and passing urine involuntarily. When 
 addressed he would sometimes merely grin, and sometimes make an 
 effort at speech, never getting out more than a word. He took food 
 well, but wasted somewhat. His temperature was habitually sub- 
 normal, between 97° and 98°, pulse very variable, ranging from 96 to 
 below 70. 
 
 When this boy had been over three months in hospital it occurred 
 
172 CHOREA, 
 
 to Dr. Donkin (who then had charge of the ward and to whom is due 
 the full credit of this treatment) to make trial of moral persuasions to 
 exertion more forcible than had hitherto been employed. The patient 
 was with some difficulty got out of bed, and unavailing attempts were 
 made to get him to stand with the help of some support. This failing, 
 a faradic current of some strength was applied, much to the patient's 
 dismay. The next day he stood, and from that time made continuous 
 and rapid progress, no further severity of urging being called for. 
 The face unsteadiness in lessened degree persisted, but in other re- 
 spects the boy was almost well three weeks from the commencement 
 of the active treatment. 
 
 [The lesson of this case, so far as treatment is concerned, speaks 
 for itself. Yet, though it yielded rapidly to moral suasion applied at 
 the right time, it was truly a case of chorea as evidenced by the con- 
 tinual movement of the face no less than of the limbs, by the speech 
 difficulty and the condition of the heart. The variability of the pulse 
 and subnormal temperature were further signs which could not be 
 mistaken. What the treatment accomplished was to break the 
 monotony at the time when the aftection, no longer active, had left a 
 stupid boy without the vigour to bestir himself unless strongly roused. 
 Such treatment is only to be commended for such cases, yet its 
 success in this instance is one of the many illustrations we have had 
 to consider of the points of contact between chorea and hysteria. 
 It need hardly be added that faradism has no specific effect, and 
 that any other application equally disagreeable would be equally 
 effectual.] 
 
 Case XV. — Chronic Chorea in a boy of eleven^ ultitnately 
 
 fatal 
 
 [The following case was under the care of the late Dr. Fuller 
 at St. George's Hospital, in 1864, and reported by myself, then 
 Medical Registrar, the post-mortem examination being performed 
 by Dr. Dickinson, then Curator of the Museum.] 
 
 Leopold L., aged 1 1, admitted July 13, 1864. The boy had before 
 been an in-patient, and was discharged improved, but on returning 
 home his disorder at once returned. At the time of his second ad- 
 mission it had lasted three months. No cause could be traced. The 
 patient was well nourished, of dark complexion, and not unhealthy 
 aspect. The chorea was general but at the first not extreme. He 
 
ABSTRACTS OF CASES. 173 
 
 was given iron and sulphate of zinc, the latter up to five grains for a 
 dose, and for a short time improved. This early amendment, how- 
 ever, not continuing, he was ordered strychnia with iron, and morn- 
 ing shower baths. At the end of five weeks from his admission his 
 state had become distressing. He got little sleep, had wasted much, 
 the tongue was frequently bitten, and the skin scratched with the 
 finger nails. 
 
 The liquor arsenicalis was now given in five minim doses, thrice 
 daily ; many other drugs followed, particulars of which it is unneces- 
 sary to insert, since none exercised the slightest beneficial effect. The 
 symptoms progressed without interruption, the skin was excoriated, 
 the tongue bitten, and bed-sores began to threaten. At this ad- 
 vanced period of the disease it is noted, ' There seems a strange 
 mixture of temper with the disease, rendering it difficult to discri- 
 minate between the two. His most violent paroxysms may be 
 controlled for awhile by speaking sharply to him.' Ten days be- 
 fore his death he was tied down, and, to prevent further injury from 
 his scratching, the hands were secured. So he lay like one possessed, 
 struggling and kicking, the mouth and tongue deeply ulcerated, and 
 the body lacerated and bleeding wherever his fingers could reach it. 
 He died September 17, after over two months' residence, and more 
 than five months' duration of chorea. 
 
 Post-Morte7?i Examination. ^ 
 
 The body was much emaciated, and the skin rubbed ofT the 
 prominences of the back ; the hair was worn off the back of the scalp, 
 and under its skin was a collection of pus ; the lips were scored with 
 fissures. The brain^ both grey and white, was injected, the ventricles 
 natural. 
 
 The cord showed on its surface large vessels distended with 
 blood. On section in various situations, its appearance was not un- 
 natural ; but on closer inspection portions of the grey matter seemed 
 duller and more yellow than natural, particularly towards the upper 
 part. External to the membrane were much distended veins lining 
 the vertebral canal. No microscopic examination was made. 
 
 The heart at the inner edge of the mitral valve showed a line of 
 soft beads of lymph easily detached. The left ventricle was con- 
 tracted. 
 
 1 This case is referred to in Dr. Dickinson's paper, Med. Clin. Trans., vol. 
 lix., and included among the 22 fatal cases he has collected. 
 
174 CHOREA. 
 
 The kidneys were congested. Other organs natural. 
 
 [Although incomplete in some respects, I am induced to select this 
 case for quotation in this place, owing to its extreme rarity. Chorea 
 in a chronic form occurring to a boy of this age, and persisting up 
 to the time of death, 710 extra symptoms supervening^ but the disease 
 fnaintaifiing its proper characteristics to the very end^ is, as I think 
 Chapter IV. tends to show, an excessively uncommon event. There 
 was no trace of paralysis, no known rheumatic connection, and no 
 cerebral symptoms beyond those of temper. Compare Case by Dr. 
 Peacock, St. Thomas's Hospital Report":^ vol. viii. p. 29.] 
 
APPENDIX B. 
 
 TABLE A.1 
 
 132 CONSECUTIVE CASES OF CHOREA, SHOWING ITS 
 
 RHEUMATIC CONNECTION, STATE OF HEART, 
 
 EXCITING CAUSES, LIMBS AFFECTED, &c. 
 
 1 In the composition of this table I am indebted to notes furnished me, at the 
 time the patients respectively came under my care, by several successive Registrars 
 of the Hospital for Sick Children, during the five years the work has been proceed- 
 ing. The present Registrar, Dr. Abercrombie, has supplied the largest portion ; 
 Dr. Garlick the next largest. 
 
176 
 
 CHOREA. 
 
 SUB-SERIES I. 
 
 
 
 
 If previous 
 
 If Rheumatism 
 
 If Rheuma- 
 
 No." 
 
 Name 
 
 Age 
 6 
 
 Whooping cough 
 
 previously 
 
 tism 
 in family 
 
 I 
 
 Charlotte O. 
 
 Whooping-cough 
 
 Rheumatism 
 
 
 2 
 
 Anne N. 
 
 II 
 
 ., 
 
 
 
 
 3 
 
 Henry R. . 
 
 9 
 
 
 
 
 
 
 4 
 
 Albert S. . 
 
 7 
 
 Whooping-cough 
 
 
 
 
 5 
 
 Fanny P. . 
 
 10 
 
 
 
 
 Swelling of wrists 
 
 
 6 
 
 Emma R. . 
 
 61 
 
 Whooping-cough 
 
 and ankles 
 
 
 7 
 
 Ellen C. . 
 
 8 
 
 ,, 
 
 No Rheumatism 
 
 
 8 
 
 Amy A. 
 
 8 
 
 II 
 
 ? Rheumatism 
 
 
 9 
 
 Rosa R. 
 
 7 
 
 
 
 
 
 
 10 
 
 Arthur W. . 
 
 8 
 
 1 
 
 
 
 vj 
 
 II 
 
 John W. . 
 
 7 
 
 — 
 
 
 
 
 
 Hi 
 
 12 
 
 Henry P. . 
 
 7 
 
 — 
 
 - 
 
 '■n 
 
 13 
 
 Amelia B. . 
 
 7 
 
 — 
 
 — 
 
 
 14 
 
 Alfred M. . 
 
 10 
 
 — 
 
 
 
 ''Z* 
 
 15 
 
 Florence B. 
 
 6 
 
 
 
 
 
 
 16 
 
 Louisa S. 
 
 9 
 
 Whooping-cough 
 
 Very doubtful 
 
 '■J 
 
 17 
 
 Susannah M. 
 
 7 
 
 , , 
 
 ? Rheumatism 
 
 I. 
 
 18 
 
 George P. . 
 
 6 
 
 — 
 
 
 
 c 
 
 
 19 
 
 Agnes D. 
 
 8 
 
 Whooping-cough 
 
 
 
 
 
 20 
 
 Alice H.^ . 
 
 II 
 
 ,, 
 
 
 
 
 21 
 
 Martha C. . 
 
 9 
 
 ,, 
 
 
 
 
 22 
 
 JaneC. 
 
 9 
 
 — 
 
 — 
 
 
 23 
 
 Sarah C. . 
 
 9 
 
 Wh oopi n g-cou gh 
 
 
 
 
 24 
 
 Amy D. 
 
 5 
 
 ,, 
 
 
 
 
 25 
 
 Beatrice P. . 
 
 6 
 
 — 
 
 — 
 
 
 26 
 
 Ruth E. . 
 
 4 
 
 — 
 
 — 
 
 
 27 
 
 Walter N. . 
 
 9i 
 
 
 
 
 
 
 28 
 
 Herbert B. . 
 
 7 
 
 Whooping-cough 
 
 
 
 
 29 
 
 Anne O. 
 
 10 
 
 ,, 
 
 
 
 
 30 
 
 John B. 
 
 8 
 
 II 
 
 
 
 
 31 
 
 Mary II. . 
 
 8 
 
 ,, 
 
 
 
 
 32 
 
 Emma K. . 
 
 10 
 
 ,, 
 
 
 
 
 33 
 
 Anne F. 
 
 II 
 
 
 
 
 
 
 34 
 
 Alice D. 
 
 II 
 
 Whooping-cough 
 
 
 
 
 35 
 
 Marv H. . 
 
 8 
 
 
 
 
 
 Z^ 
 
 Alice M, . 
 
 lO 
 
 .. 
 
 
 
 
 37 
 
 Rose G. 
 
 9 
 
 II 
 
 
 
 
 38 
 
 Florence E. 
 
 9 
 
 ,, 
 
 
 
 
 39 
 
 Charles B. . 
 
 9 
 
 
 
 ? Subacute 
 
 
 ' This mark indicates throughout that the point in question is not referred to in il. 
 notes of the case. 
 
 '^ Right hand choreic constantly against all control. 
 
ILLUSTRATIONS. 
 
 177 
 
 SUB-SERIES I. 
 
 Heart 
 Condition 
 
 2nd or 
 
 Part of Body 
 
 
 
 
 3rd 
 attack 
 
 where 
 Commenced 
 
 Supposed Cause 
 
 Result 
 
 Remarks 
 
 Mitral regurg. 
 
 
 Twitching face 
 
 — 
 
 Well 
 
 
 " 
 
 
 
 
 Rapid Im- 
 
 
 >i 
 
 
 
 
 provement 
 
 
 — 
 
 
 — 
 
 No cause, ' gradual, 
 father insane 
 
 Nearly well 
 
 
 — 
 
 
 — 
 
 No cause, emotional 
 
 WeU 
 
 
 Mitral dist. 
 
 
 Began in right 
 hand 
 
 — 
 
 ,, 
 
 - 
 
 Mitral regurg. 
 
 2nd 
 
 — 
 
 No cause 
 
 1 J 
 
 
 — 
 
 
 Began in hands 
 
 — 
 
 II 
 
 
 — 
 
 
 In left hand 
 
 — 
 
 II 
 
 
 Syst. Murmur 
 
 
 In left side 
 (? hand) 
 
 No cause 
 
 i-i_ 
 
 
 — 
 
 
 — 
 
 Fright 
 
 f 1 
 
 
 — 
 
 
 Left side 
 
 1 J 
 
 II 
 
 
 Murmur 
 
 
 Right side 
 
 No cause 
 
 
 
 Mitral Mur. 
 
 
 ,1 
 
 After measles 
 
 )> 
 
 
 — 
 
 2nd 
 
 Right side 
 (both attacks) 
 
 No cause 
 
 II 
 
 
 Mitral regurg. 
 
 
 Right side 
 
 ,, 
 
 II 
 
 
 — 
 
 
 Right hand 
 
 After ' low fever ' 
 
 1 1 
 
 
 — 
 
 
 Right side 
 
 Harsh treatment 
 at school 
 
 
 
 Syst. murmur 
 
 4th 
 
 Right arm ? 
 
 Fright, overtaxed 
 at school 
 
 1 1 
 
 
 — 
 
 
 — 
 
 Fright 
 
 ,, 
 
 
 — 
 
 
 Left arm 
 
 Fright at school 
 
 II 
 
 
 — 
 
 2nd 
 
 i f 
 
 Overwork at school 
 
 1 1 
 
 
 Irregular 
 
 
 
 No defined cause 
 
 
 
 ,, 
 
 
 Genl. twitching 
 
 — 
 
 , , 
 
 
 — 
 
 
 Right hand 
 
 Fright 
 
 J , 
 
 
 
 
 2nd 
 
 Left leg 
 
 I St attack fright 
 
 Not improved 
 
 
 Regular 
 
 
 Left arm & leg 
 
 None (nervous) 
 
 Well 
 
 
 
 
 Both hands 
 
 Death of brother 
 
 In statu quo 
 
 Stupid 
 
 
 
 Fingers & face 
 
 Fright, sunstroke 
 
 Well 
 
 
 
 
 Hands 
 
 Pinching right hand 
 
 jj 
 
 
 
 3rd 
 
 Left hand & side 
 Left side 
 
 None 
 
 1 1 
 
 
 
 
 Right hand 
 
 Fright 
 
 Well 
 
 
 
 2nd 
 
 — 
 
 — 
 
 Improved 
 
 See 31 
 
 Murmur 
 
 
 — 
 
 ? A fall 
 
 Well 
 
 
 Regular 
 
 
 Right hand 
 
 Very studious, 
 
 
 
 
 
 and leg 
 
 ? cause 
 
 1 1 
 
 
 — 
 
 
 Left hand 
 
 Worms 
 
 • 1 
 
 Nervous 
 
 Regular, mur- 
 mur variable 
 
 
 Hands 
 
 No cause 
 
 1 1 
 
 , 
 
 1 • No cause ' denotes none ascertained after full enquiry. 
 N 
 
ijS 
 
 CHOREA. 
 
 SUB-SERIES I— CO}} tin tied. 
 
 No. 
 
 Name 
 
 Age 
 
 If previous 
 Whooping-cough 
 
 If previous 
 Rheumatism 
 
 If Rheumatism 
 in Family 
 
 40 
 41 
 
 John B. 
 Gertrude W. 
 
 4 
 
 Whooping-cough 
 
 
 
 
 
 42 
 
 Emma S. . 
 
 8 
 
 ,, 
 
 
 
 Ul 
 
 43 
 
 Jane S. 
 
 7 
 
 " 
 
 
 
 
 
 hi 
 
 44 
 
 Fanny F. 
 
 II 
 
 " 
 
 
 
 
 
 45 
 
 Louisa A. . 
 
 12 
 
 
 
 
 
 46 
 47 
 
 jMary F. 
 Maria N. . 
 
 9 
 loj 
 
 
 Whooping-cough 
 
 
 
 Rheumatic fever 
 
 a 
 
 48 
 49 
 
 John B. 
 Frederick M. 
 
 9 
 10 
 
 •• 
 
 
 
 
 
 
 y. 
 
 50 
 
 Katharine S, 
 
 6 
 
 ,, 
 
 
 
 
 ^r 
 
 Louisa J. . 
 
 12 
 
 >» 
 
 
 
 
 52 
 
 Emma R. . 
 
 II 
 
 •• 
 
 
 
 
 SUB-SERIES II. 
 
 No 
 
 
 Age 
 
 If previous 
 
 If previous 
 
 If Rheumatism 
 
 
 
 Whooping cough 
 
 Rheumatism 
 
 in Family 
 
 X 
 
 Marion R. . 
 
 5 
 
 Whooping-cough 
 
 
 
 
 
 2 
 
 Henry M. . 
 
 9 
 
 ,, 
 
 
 
 — 
 
 3 
 
 Jane C. 
 
 10 
 
 
 
 
 
 — 
 
 4 . 
 
 Eleanor B. . 
 
 5 
 
 Whoopi ng-cough 
 
 ? 
 
 — 
 
 5' 
 
 Florence E. 
 
 9 
 
 ,, 
 
 
 
 — 
 
 6 
 
 Charlotte G. 
 
 10 
 
 ,, 
 
 
 
 — 
 
 7 
 
 lilizabeth L. 
 
 8 
 
 > > 
 
 
 
 — 
 
 8 
 
 Amelia G. . 
 
 II 
 
 »i 
 
 
 
 Father rh. 
 
 9 
 
 Hannah C. . 
 
 II 
 
 , , 
 
 
 
 
 
 10 
 
 Richard G. . 
 
 II 
 
 
 
 
 
 
 II 
 
 Alice W. . 
 
 6 
 
 ^ J 
 
 
 
 Father rh. 
 
 12 
 
 Eliza L. 
 
 8 
 
 1 ^ 
 
 
 
 
 
 13 
 
 Katharine S. 
 
 10 
 
 , , 
 
 
 
 
 
 14 
 
 Ernest James T. . 
 
 8i 
 
 ,, 
 
 
 
 
 
 15 
 
 Christina A. 
 
 10 
 
 — 
 
 
 
 — 
 
 16 
 
 Elizabeth F, 
 
 8 
 
 
 
 Rheumatism 
 
 
 
 17 
 
 Elizabeth P. 
 
 TO 
 
 
 
 
 
 
 
 ' 18 
 
 Henry M. . 
 
 8 
 
 Whooping-cough 
 
 
 
 
 
 1 Habitual flexure of right wrist developed ; said to have been palsied ou that side ; 
 
 no distmct account. 
 
ILL US TEA TIONS 
 
 179 
 
 SUB-SERIES I — contimied. 
 
 Heart 
 Condition 
 
 2nd or 
 
 3rd 
 attack 
 
 Part of Body 
 
 where 
 Commenced 
 
 Supposed Cause 
 
 Result 
 
 Remarks 
 
 Regular 
 
 
 Hands 
 
 No cause 
 Fright 
 
 In statu quo 
 
 Well 
 
 Nervous 
 
 ,, 
 
 
 Legs and arms 
 
 No cause 
 
 ,, 
 
 Nervous 
 
 Uneven systolic 
 
 
 Twitching arms 
 
 
 
 Stupid 
 
 apex murmur 
 
 
 for 3 years 
 
 1 ) 
 
 " 
 
 
 
 
 
 
 Iridectomy four 
 
 
 
 Twitchinc of 
 
 
 
 years ago, twitch- 
 
 Regular 
 
 
 eyes and face 
 
 Fright 
 
 1 71 statzc quo 
 
 ing and awkward 
 
 
 
 
 
 movements ever 
 
 
 
 
 
 
 smce 
 
 , 
 
 
 — 
 
 No cause 
 
 Well 
 
 A stupid child 
 
 
 2nd 
 
 — 
 
 >' 
 
 .. 
 
 
 " 
 
 2nd 
 
 Hands 
 
 " 
 
 " 
 
 
 Mitral murmur 
 
 
 — 
 
 Fright 
 
 Improved 
 
 
 Regular 
 
 
 — 
 
 No cause 
 
 Well 
 
 
 J, 
 
 
 Hands 
 
 Overwork at school 
 
 
 A clever child 
 
 
 
 Hands and legs 
 
 No cause 
 
 
 
 SUB-SERIES II. 
 
 Heart 
 
 Condition 
 
 2nd or 
 
 Part of Body 
 
 
 
 
 3rd 
 
 where 
 
 Supposed Cause 
 
 Result 
 
 Remarks 
 
 attack 
 
 Commenced 
 
 
 
 
 Regular 
 
 
 Left arm & leg 
 
 
 
 Well 
 
 Mental defect ? 
 
 
 
 Right side 
 
 A fright 
 
 
 
 
 2nd 
 
 — 
 
 — 
 
 
 
 
 
 — 
 
 - — 
 
 
 
 
 3rd 
 
 — 
 
 Fright 
 
 
 See No. 38 
 
 
 2nd 
 
 Limbs and face 
 
 No cause 
 
 
 
 
 
 ,, 
 
 ? Fright 
 
 
 
 Syst. murmur 
 
 
 Left side 
 
 Being run over 
 {i.e. fright) 
 
 
 
 — 
 
 
 Limbs gene- 
 rally affected 
 
 Over study 
 
 
 
 Regular 
 
 2nd 
 
 Right side 
 
 No cause 
 ? Fright 
 
 
 
 
 
 — 
 
 No cause 
 
 
 
 It 
 
 2nd 
 
 Facial & general 
 
 ? a fall 
 'Brain fever' (3atks.) 
 
 
 See No. 50 
 
 Irregular 
 
 
 — 
 
 Over study 
 
 Taken out 
 by friends 
 
 
 Syst. murmur 
 
 
 Right hand 
 
 Rheumatism 
 
 Well 
 
 
 Regular 
 
 
 Rt. hand & arm 
 
 Over fatigue 
 
 Improved 
 
 
 " 
 
 2nd 
 
 — 
 
 No cause 
 
 Well 
 
 
 N 2 
 
I So 
 
 CHOREA. 
 SUB-SERIES W— continued. 
 
 No." 
 
 Name 
 
 Age 
 
 If previous 
 Whooping-cough 
 
 If previous 
 Rheumatism 
 
 If Rheumatism 
 in Family 
 
 19 
 
 Henry B. . 
 
 II 
 
 Whooping-cough 
 
 
 
 
 
 20 
 21 
 22 
 
 Annie E. 
 Edith T. . 
 Helen K. . 
 
 II 
 9 
 9 
 
 " 
 
 
 
 Rheumatism 
 
 
 Father 
 
 
 
 23 
 
 Arthur W. . 
 
 10 
 
 ,. 
 
 
 
 
 
 24 
 
 Edward F. . 
 
 7 
 
 ,, 
 
 Rheumatism 
 
 Mother 
 
 25 
 
 Alfred G. . 
 
 7 
 
 >, 
 
 — 
 
 — 
 
 26 
 
 Sarah B. . 
 
 9 
 
 ,, 
 
 
 
 Sister 
 
 27 
 
 Arthur C. . 
 
 II 
 
 ,, 
 
 Rheumatic fever 
 
 
 
 28 
 29 
 30 
 
 Rose L. 
 Louisa J. . 
 Anne G. 
 
 7 
 9 
 2 
 
 
 
 Whooping-cough 
 
 
 
 
 Rh. Just before 
 
 
 
 
 31 
 
 Hannah B. . 
 
 9 
 
 ,, 
 
 Rheumatism 
 
 
 
 32 
 33 
 34 
 
 35 
 
 1 36 
 37 
 
 Sydney P. . 
 Annie P. 
 Albert H. . 
 
 Anne P. 
 
 Mary Anne D. . 
 Elizabeth H. 
 
 6 
 
 9 
 II 
 
 3 
 
 9 
 11 
 
 
 
 
 
 Whooping-cough 
 
 
 
 
 
 Redness or swell- 
 ing, feet & hands 
 
 
 
 
 
 
 
 Mother & father 
 
 
 
 Mother's 
 
 family 
 
 
 
 
 
 38 
 
 Annie G. 
 
 10 
 
 >> 
 
 Rheumatism ^ 
 
 
 
 39 
 
 Margaret M. 
 
 7 
 
 .. 
 
 
 
 
 
 40 
 
 Annie C. 
 
 10 
 
 '• 
 
 
 
 
 
 41 
 
 Lydia H. . 
 
 7 
 
 
 
 
 
 
 
 42 
 43 
 
 Eleanor W. 
 James F. 
 
 6 
 8 
 
 Whooping-cough 
 
 
 
 
 
 
 
 44 
 
 Olive T. 
 
 4 
 
 
 
 Rheumatic fever 
 
 Family 
 
 45 
 46 
 
 47 
 43 
 
 Florence F. 
 Edward S. . 
 
 William B. . 
 
 Elizabeth R. 
 
 8 
 9 
 
 6 
 
 9 
 
 Whooping-cough 
 
 Rheumatism 
 
 
 Pain in joints, no 
 swelling or redness 
 
 
 
 
 
 
 49 
 
 Ellen B. . 
 
 10 
 
 .. 
 
 
 
 
 
 50 
 
 Jane L. W. 
 
 7 
 
 ? Whooping-cough 
 
 Father rh. 
 
 Sister 
 
 SI 
 
 Horonce M. 
 
 7 
 
 Whooping-cough 
 
 
 
 
 
 ^ Hands and knees swollen 14 days, but did not keep bed. 
 
ILL USTRA TIONS. 
 
 i8i 
 
 SUB-SERIES \l— continued. 
 
 {Heart 
 Condition 
 
 2nd or 
 
 3rd 
 attack 
 
 Part of Body 
 
 where 
 Commenced 
 
 Supposed Cause 
 
 Result 
 
 Remarks 
 
 Syst. murmur 
 (at first) 
 
 2nd 
 
 — 
 
 Frightened by horse 
 
 Well 
 
 
 Regular 
 1 1 
 
 
 General 
 Hands 
 
 No cause 
 
 Over study 
 
 No cause 
 
 No cause. In ist 
 
 > > 
 
 
 Mitral regurg. 
 
 2nd 
 
 General 
 
 attack fright, dog, 
 on side affected 
 
 »> 
 
 
 Irregular 
 
 
 — 
 
 — 
 
 ... 
 
 
 
 
 
 
 Developed chorea on taking 
 
 Aortic regurg. 
 
 
 ■~- 
 
 •^ 
 
 cold at Cromwell House ; 
 was taken out by friends 
 
 Mitral 
 
 2nd 
 
 Legs 
 Right hand 
 
 No cause 
 Fright, horse run- 
 
 Well 
 
 
 ' ' 
 
 
 
 ning away with him 
 
 J i 
 
 * 
 
 Regular 
 
 
 Left hand 
 Left side 
 
 No cause 
 
 1 i 
 
 
 »> 
 
 
 General 
 
 ? Rheumatic fever 
 
 Falling down and 
 
 breaking a jug 
 
 
 
 
 
 Arms 
 
 No cause 
 
 i» 
 
 
 [[ 
 
 2nd 
 
 Left side 
 
 Fright 
 
 Improved 
 
 
 ,, 
 
 
 Left hand 
 
 No cause 
 
 Well 
 
 
 Syst. murmur 
 
 
 Right arm & leg 
 
 ? Rheumatism 
 
 » » 
 
 
 Regular 
 
 
 General 
 
 Fright 1 
 
 ,, 
 
 
 Mitral murmur 
 
 
 Right hand 
 
 No cause 
 ? Rheumatism, has 
 
 » » 
 
 
 Regular 
 
 2nd 
 
 Left arm (not 
 
 complained of pain 
 
 
 
 (uneven) 
 
 
 leg) 
 
 in left side since so- 
 called rheumatism 
 
 >> 
 
 
 Mitral 
 
 2nd 
 
 Left side 
 
 General (began 
 in right hand) 
 
 Fright (both attacks) 
 
 >> 
 
 Begun with lan- 
 
 Uneven 
 
 
 ? 
 
 >> 
 
 guor and extreme 
 nervousness 
 
 Regular 
 
 3rd 
 
 General (began 
 in right arm) 
 
 Fright, dog jump- 
 ing up right side 
 
 Improved 
 
 
 Syst, murmur 
 
 
 General 
 
 No cause 
 
 Well 
 
 
 Regular 
 
 2nd 
 
 Hands 
 
 »» 
 
 >) 
 
 
 Syst. murmur 
 
 
 General 
 
 ? Rheumatism 
 
 >> 
 
 Appearance of 
 mere shyness 
 
 Not regular 
 
 
 ,, 
 
 Fright 
 
 Improved 
 
 
 Regular 
 
 
 Left hand 
 
 ) > 
 
 WeU 
 
 
 Aortic obstn. 
 
 
 Right hand 
 
 No cause 
 
 11 
 
 
 Mitral murmur 
 
 2nd 
 
 Left leg 
 
 
 
 >» 
 
 
 ist sound thick 
 at apex 
 
 2nd 
 
 Right side 
 
 Fright (on right side) 
 
 II 
 
 
 Not quite reg. 
 
 3rd 
 
 Left side most 
 
 After fall — ist at- 
 tack fright 
 Contending for 
 
 ) 1 
 
 
 Mitral murmur 
 
 
 Left arm & face 
 
 school prize, much 
 excited thereby 
 
 Improved 
 
 
 ^ Ascertained at Highgate, 
 
1 82 
 
 CHOREA. 
 
 SUB-SERIES III. 
 
 
 
 Age 
 
 If previous 
 
 If previous 
 
 If Rheumatism 
 
 No. 
 
 Name 
 
 Whooping-cough 
 
 Rheumatism 
 
 in family 
 
 I 
 
 J ane B. 
 
 II 
 
 Whooping-cough 
 
 Rheumatic pains 
 
 Father 
 
 2 
 
 Madeline P. 
 
 II 
 
 — 
 
 
 
 
 
 3 
 
 Emily W. . 
 
 6 
 
 Whooping-cough 
 
 
 
 
 
 4 
 
 Florence P. 
 
 II 
 
 
 
 — 
 
 — 
 
 5 
 
 Alice J. 
 
 II 
 
 Whoopin g-cough 
 
 
 
 
 
 6 
 
 Elizabeth S. 
 
 7 
 
 
 
 Rheumatic pains 
 
 Father 
 
 7 
 
 John B. 
 
 II 
 
 Whooping-cough 
 
 Pains 
 
 Mother 
 
 8 
 
 Rosa R. 
 
 10 
 
 ,, 
 
 
 
 
 
 9 
 
 Jesse M. 
 
 9 
 
 >> 
 
 Rheumatic pains 
 
 Father 
 
 lO 
 
 Lihan H. . 
 
 7 
 
 ,, 
 
 
 
 
 
 II 
 
 Alfred B. . 
 
 10 
 
 ,, 
 
 
 
 
 
 12 
 
 Edwin C. . 
 
 7 
 
 ,, 
 
 
 
 
 
 13 
 
 Sidney P. . 
 
 7 
 
 ,, 
 
 
 
 
 
 14 
 
 Eliza S. 
 
 10 
 
 ,, 
 
 Rheumatic fever 
 
 Father& mothe 
 
 15 
 
 Ellen M. . 
 
 II 
 
 ,, 
 
 
 
 
 
 16 
 
 Elizabeth R. 
 
 II 
 
 > > 
 
 Rheu ma tic fever 
 
 
 
 17 
 
 James M. . 
 
 10 
 
 
 Rheumatic pains 
 
 Mother (rh.fvr.) 
 
 18 
 
 Margaret P, 
 
 8 
 
 » I 
 
 
 
 Mother's sister 
 
 19 
 
 Phoebe B. . 
 
 II 
 
 ,, 
 
 Rheumatic pains 
 
 
 
 20 
 
 Caroline W. 
 
 II 
 
 ,, 
 
 
 
 
 
 21I 
 
 James F. 
 
 8 
 
 > 1 
 
 
 
 
 
 22 
 
 Florence S. . 
 
 8 
 
 .. 
 
 
 
 
 
 23 
 
 Agnes D. . 
 
 II 
 
 - 
 
 
 
 
 
 24 
 
 Elizabeth C. 
 
 10 
 
 ,, 
 
 
 
 
 
 25 
 
 Louisa R. . 
 
 9 
 
 ,. 
 
 
 
 Mother (rh.fvr.) 
 
 26 
 
 Marianne H. 
 
 9 
 
 " 
 
 
 
 >« 
 
 27 
 
 Catherine S. 
 
 8 
 
 ,, 
 
 
 
 
 
 28 
 
 Louisa J. . 
 
 9 
 
 it 
 
 
 
 Father 
 
 29 
 
 Mary B. . 
 
 5 
 
 
 
 Rheumatic pains 
 
 
 
 30 
 
 Robert L.i . 
 
 9 
 
 
 
 
 
 
 
 31 
 
 Emily P. . 
 
 8 
 
 
 
 
 
 
 
 32 
 
 Florence W. 
 
 8 
 
 Whooping-cough 
 
 
 
 Mother 
 
 33 
 
 Alice T. 
 
 6 
 
 1 » 
 
 
 
 
 
 34 
 
 Anne T. 
 
 9 
 
 •• 
 
 
 
 
 
 1 Got 
 
 sudden (very tempor 
 
 ary)p 
 
 aralysis of muscles 
 
 f left shoulder, Jan 
 
 uary 22, 1881. 
 
 Abstract : 
 
 1st series . 52 [less i (No. 35) admitted twice] . .51 
 
 2nd series . 51 [less 2 (Nos. 5 and 13) admitted twice] 49 
 
 3rd series . 34 [less 2 (Nos. 21 and 28) admitted twice] 32 
 
 "137 132 
 
ILLUSTRATIONS, 
 
 183 
 
 SUB-SERIES III. 
 
 Heart 
 
 Condition 
 
 2nd or 
 3rd 
 
 Part of Body 
 where 
 
 Supposed Cause 
 
 Result 
 
 attack 
 
 Commenced 
 
 
 
 Mitral murmur 
 
 2nd 
 
 
 
 Fright 
 
 Well 
 
 .. 
 
 2nd 
 
 Left side 
 Right hand 
 
 Fright (both attacks) 
 No cause 
 
 1 1 
 
 Regular 
 
 
 Right side 
 General 
 
 Nothing entered 
 
 " 
 
 Mitral murmur 
 
 
 Hands 
 
 for these six 
 
 , , 
 
 Regular 
 
 4th 
 
 General 
 Left arm 
 
 under this 
 heading 
 
 Improved 
 Well 
 
 Mitral 
 
 
 General 
 
 Fright 
 
 ,, 
 
 Irregular 
 
 
 Arms and legs 
 
 No cause 
 
 — 
 
 Regular 
 
 
 General 
 
 ,, 
 
 W^ell 
 
 " 
 
 2nd 
 
 Arms 
 General 
 
 School examination 
 Rheumatic fever 
 
 •• 
 
 Mitral 
 
 2nd 
 
 , 1 
 
 No cause 
 
 ,, 
 
 Regular 
 
 3rd 
 
 Left side 
 
 Fright 
 
 1 1 
 
 y 1 
 
 
 General 
 
 No cause 
 
 II 
 
 
 3rd 
 
 
 No cause — ist 
 
 1 1 
 
 " 
 
 " 
 
 from fright 
 
 
 ,, 
 
 
 J 1 
 
 No cause 
 
 1 1 
 
 Mitral 
 
 
 ,, 
 
 J J 
 
 J, 
 
 Regular 
 
 3rd 
 
 Hands 
 
 Fright from blow 
 
 ,, 
 
 Soft m. at apex 
 
 
 General 
 
 Fright 
 
 ) 1 
 
 Not quite reg. 
 
 2nd 
 
 >. 
 
 ist fright, 2nd scold- 
 ing at school 
 
 1 1 
 
 Regular 
 
 3rd 
 
 II 
 
 2nd and 3rd attacks 
 fright 
 Fright 
 
 )i 
 
 Irregular 
 
 3rd 
 
 II 
 
 ist fright, 2nd and 
 3rd unknown 
 
 Improved 
 
 Regular 
 
 3rd 
 
 .. 
 
 ist fright, 2nd and 
 3rd unknown 
 
 Well 
 
 5> 
 
 2nd 
 
 Left side 
 General (face 
 
 No cause 
 
 " 
 
 Syst. murmur 
 
 
 most affected) 
 
 " 
 
 II 
 
 Regular 
 
 
 Face & left side 
 
 I! 
 
 1 J 
 
 >i 
 
 
 General 
 
 , , 
 
 ,, 
 
 • 1 
 
 3rd 
 
 Right side only 
 General (hands 
 
 ist fright, 2nd un- 
 known, 3rd schoo 
 
 " 
 
 Irregular 
 
 
 and right side 
 most) 
 
 Fright 
 
 II 
 
 Regular 
 
 
 General 
 
 School punishment 
 
 ,, 
 
 Remarks 
 
 See 43 
 
 See 29 (2nd series); 
 
1 84 - CHOREA 
 
 ANALYSIS OF TABLE A, 
 
 I. Age and Sex. 
 
 Total number, 132. Boys, 33 ; girls, 99 ; \\z.. 
 Of twelve years olcl : 2 girls. 
 Ten and eleven years old : 10 boys, 34 girls. 
 Nine years old : 7 boys, 20 girls. 
 Eight years and under : 16 boys, 43 girls. 
 
 2. Previous Attacks of Chorea. 
 
 and attacks, 27. 
 3rd ,, ic* 
 4th „ 3. 
 
 3. [a] Antecedent Whooping-cough in Choreic Children^. 
 
 The point was ascertained in 120 cases. 
 
 Of 28 boys, 4 had not had whooping-cough ; i.e. i in 6. 
 
 ,, 92 girls, i6 had not had whooping-cough ; i in 5-8. 
 
 [b) Antecedent whooping-cough in three independent series of cases of 132: 
 each, taken consecutively without reference to particular illness : — 
 
 In ist series, 27 of 105 had not had whooping-cough ; 27 no record. 
 In 2nd series, 31 of no had not had whooping-cough ; 22 no record. 
 In 3rd series, 33 of 104 had not had whooping-cough ; 28 no record. 
 
 Hence it appears that 2 in 12 choreic children are with6ut history of whooping- 
 cough, whilst 2 in 5 non-choreic children are without such history. Who&ping- 
 cough has thus more than twice the frequency in the choreic over ike non~choreic. 
 
 4. Rheumatic Connection. 
 In the ist Sub-series of 51 cases : — 
 
 1 had had rheumatic fever previously. 
 
 2 ,, ,, rheumatism previously. 
 4 were doubtful as to- this point. 
 
 3 were not ascertained. 
 
 In the 2nd Sub-scries of 49 : — 
 
 4 had had rheumatic fever. 
 
 6 had probably had rheumatism. 
 2 were too doubtful to reckon. 
 I was not ascertained. 
 
ANALYSIS OF TABLE A. 
 
 185 
 
 In the 3rd Sub-series of 32 : — 
 
 2 had had rheumatic fever. 
 
 7 ,, ,, pains, probably rheumatic, 
 
 I was not ascertained. 
 
 Hence 132 cases give 7 who have had rheumatic fever, 
 
 14 or 15 who have had pains, probably rheumatic ; 
 6 that were doubtful, 
 5 not ascertained. 
 
 In 73 cases where that point is noted rheumatism is in \he family history of 19 ; 
 of these 19, 9 have themselves had rheumatism, 10 have not. Of these 9 who have 
 rheumatism, both themselves and in their famihes, rheumatism might have been 
 the immediate cause of chorea in 2, and rheumatic fever in i (No. 14. Sub- 
 series 3). 
 
 [The above is as exact an account of the rheumatic connection as the facts 
 admit of ; precise accuracy cannot be insisted on. See p. 33.] 
 
 5. Exciting Cause. 
 Of the 132 cases : — 
 
 Supposed exciting cause not entered in 
 
 Not to be ascertained in ... . 
 
 Rheumatism exciting cause in . . . 
 
 Rheumatic fever exciting cause in 
 
 Fright or sudden shock in . 
 
 Some nervous strain, school discipline, hard lessons, &c., in 
 
 Previous illness in 
 
 20 
 
 45 
 4{?3) 
 
 2(?I) 
 
 39 (? 2) 
 
 18 (?2) 
 4 
 
 [The figiu-es within the brackets denote proportion of doubtful cases under- 
 each heading.] 
 
 Hence it appears that of the 112 cases of which the exciting cause is presum- 
 ably known, 57 or 53 ( say one half) have their origin in some notable nervous 
 shock. 
 
 6. Implication of the Heart. 
 Of the 132 cases : — 
 
 No report as to heart condition in 13.^ 
 
 In 2 cases of twelve years old there was heart defect in none. 
 
 In 44 cases of ten and eleven years old there was heart defect in 16 (murmur in 
 13, irregularity in 3). 
 
 In 27 cases of nine years old there was heart defect in 3 (murmur in 2, irregu- 
 larity in i). 
 
 In 59 cases of eight and under there was heart defect in 26 (murmur in 16, 
 irregularity in 10). 
 
 Hence, in 132 cases there is heart defect in 45, the largest proportioji of such 
 defect appearing with the yoimgcst children. 
 
 1 In the majority of these, if not all, it may safely be assumed that there was 
 no heart defect, and that express note of the heart was therefore not entered. 
 
CHOREA. 
 
 Place of Origin of the Chorea as regards the Several 
 
 Groups of Muscles. 
 Of the 132 cases : — 
 
 No report as to place of origin in ... . 
 Chorea ' general ' from the first in ... . 
 Chorea commenced in a particular group of muscles 
 (whether or not becoming general after) in . 
 
 24 
 36 
 
 69 to 72 
 
 Locality of first onset distributed as follows : — 
 Right side ...... 
 
 Left side 
 
 13 times 
 
 15 .. 
 
 ( ' Side ■ signifying generally arm and leg, but sometimes the arm only). 
 
 Both hands 10 (or 11) time 
 
 ,, arms twice 
 
 ,, legs Once 
 
 Right hand 10 time 
 
 Left hand 4 •. 
 
 Right arm 3 1. 
 
 Left arm 6 , , 
 
 ,, leg Once 
 
 Right leg o 
 
 Face 4 time 
 
 Hence, taking sides of the body (whether arm, leg, or both chor was rigfit- 
 sided in 26, left-sided in 26 ; taking upper limbs against lower, occupied the 
 upper in 36 ( hand or hands in 25, arm or artns in 11), t lower in 2. 
 
TABLE B. 
 
 45 CONSECUTIVE CASES OF CHOREA ILLUSTRATING 
 
 THE SAME POINTS AS TABLE A, BUT IN 
 
 SOMEWHAT OLDER SUBJECTS. 
 
1 88 
 
 CHOREA. 
 
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192 CHOREA. 
 
 ANALYSIS OF TABLE B. 
 
 I. Age and Sex. 
 
 Total number, 45. Boys, 10 ; Girls, 35. 
 Over thirteen years : 3 boys, 7 girls. 
 Twelve and thirteen years : 2 boys, 12 girls. 
 Ten and eleven years : 2 boys, 9 girls. 
 Nine years old : i boy, 3 girls. 
 Eight years old and under : 2 boys, 4 girls. 
 
 2. Previous Attacks of Chorea. 
 
 Second attacks : 11 
 Several previous attacks : i 
 
 3. Rheumatic Connection. 
 
 Had had rheumatic fever, 4 
 
 ,, ,, rheumatism, 5 
 Were doubtful, 11 
 
 4. Exciting Cause. 
 
 Rheumatism exciting cause in 2 
 Fright, or sudden nervous shock, in 2 
 Exciting cause, absent in 15 
 
 5. Implication of the Heart. 
 
 No report as to heart in 21 ' 
 
 Of the 10 cases over thirteen years old there was heart defect in 4 
 Of 14 cases twelve and thirteen years old ,, ,, ,, 4 
 
 Of II cases ten and eleven years old ,, ,, ,, 4 
 
 Of 4 cases nine years old , , , , , , i 
 
 Of 6 cases eight years old and under ,, ,, ,, 3 
 
 Hence, in 45 cases there is heart defect in 16. 
 
 ' In the majority of these, if not in all, it may safely be assumed tliat there was 
 no heart defect, and that express note of the heart was therefore not entered. 
 
ANALYSIS OF TABLE B. 
 
 193 
 
 Place of Origin of the Chorea as Regards the Severat 
 
 Groups of Muscles. 
 Of the 45 cases : — 
 
 No report as to place of origin in 2. 
 Chorea general from the first in 5, 
 
 ,, commenced in a particular group of muscles in 38. 
 
 Locality of first onset distributed as follows : — 
 
 Right side 
 
 • 4 
 
 Left hand 
 
 
 Left side 
 
 • 4 
 
 Right arm . 
 
 
 Both hands 
 
 . 8 
 
 Left arm 
 
 
 ,, arms 
 
 . 2 
 
 ., leg 
 
 
 ., legs 
 
 . I 
 
 Right leg . 
 
 
 Right hand 
 
 • 4 
 
 Face 
 
 
 Two were examples of spasmodic twitching of head and shoulders. 
 
 RESULTS FROM THE TWO TABLES TAKEN TOGETHER. 
 
 X, Age and Sex. 
 
 Total number, 177. Boys, 43 ; Girls, 134. 
 Over thirteen years : 3 boys, 7 girls. 
 Twelve and thirteen years : 2 boys, 14 girls. 
 Ten and eleven years : 12 boys, 43 girls. 
 Nine years old : 8 boys, 23 girls. 
 Eight years old and under : 18 boys, 47 girls. 
 
 2. Previous Attacks of Chorea. 
 
 Second attacks : 38 (more than one-fifth). 
 Third attacks : 10. 
 Fourth attacks : 4. 
 
 3. Rheumatic Connection. 
 
 Had had rheumatic fever, 11. 
 
 ,, ,, pains probably rheumatic, 20. 
 Were doubtful, 17. 
 Not ascertained, 5. 
 
 4. Exciting Cause. 
 
 Rheumatism, acute or not, appeared to be exciting cause in 8 (4 of 
 
 these doubtful). 
 Previous illness, exciting cause in 4. 
 Fright or some nervous shock or strain, exciting cause in 85 — nearly 
 
 haif (4 of these doubtful). 
 Exciting cause not to be ascertained, 60. 
 ,, ,, not entered, 20. 
 
 O 
 
194 
 
 CHOREA. 
 
 5. Place of Origin as Regards the Several Groups of Muscles. 
 
 Of tlie 177 cases : — 
 
 Place of origin not entered or not known in 26. 
 
 Chorea general in 41. 
 
 Commenced in particular group of muscles in no. 
 
 Locality of first onset distributed as follows : — 
 
 
 Right side . . 17 
 
 Left hand 
 
 • 5 
 
 Left side . . 19 
 
 Right arm 
 
 . 4 
 
 Both hands . 18 (or 19) 
 
 Left arm 
 
 . 10 
 
 ,, arms . . 4 
 
 ,. leg 
 
 2 
 
 legs . . 2 
 
 Right 1^ 
 
 I 
 
 Right hand . . 14 
 
 Face 
 
 . 9 
 
 Five cases indefin 
 
 ite or anomalous. 
 
 
 Hence, in 151 cases {i.e. excluding 26 not known) : 
 
 Chorea was both sided in 65 (or 66). 
 ,, ,, in the face in 9. 
 ,, ,, one sided in 72. 
 ,, ,, indefinite or anomalous in 5. 
 
 Chorea affected the upper limbs in 55. 
 
 ,, ,, the lower limbs in 5. 
 
 ,, ,, the right hand 14 times, against the left 
 hand c^ times ; but the right arm only 4 times, against 
 the left 10 times. 
 
 Of all parts of the body, chorea began most often in both hands ; while in either 
 one or both hands it began in 38 instances, i.e. in more than a quarter of the 
 total number whose place of commencement was known. 
 
INDEX. 
 
 ACtr 
 
 ACUTE chorea, 17 
 in connection with acute 
 
 rheumatism, 42 
 
 treatment of, 137 
 
 case of, 158 
 
 Adult chorea, 21 
 
 cases of, 158, 168 
 
 Age of chorea, 19 
 
 Age-incidence of heart symptoms in 
 
 chorea, 54 
 Age of fatal chorea, 75 
 Alcohol in treatment of chorea, 138 
 Anaemic murmurs simulating choreic, 53 
 Ancient chorea, 12 
 Aperients, use of, in chorea, 135 
 Aphasia, absence of, in chorea, 16, 98 
 Arsenic in treatment of chorea, 136 
 Associations of chorea, 28 
 Ataxy of chorea, 108 
 case illustrating, 157 
 
 BARNES on the pathology of chorea, 
 90 
 Bastian on the pathology of chorea, 88 
 Bouilly on the ' fever of growth,' 34 
 Bright on rheumatism as cause of chorea, 
 
 82 
 — on pericarditis as cause of chorea, 83 
 Bristowe on cardiac murmurs, 56 
 Broadbent on the pathology of chorea, 8g 
 Bucheteau on imitative tendency of chorea, 
 
 29 
 
 DUR 
 
 CAUSES, exciting, of chorea, 23, 76 
 tables of, 176 
 
 statistics of, 185-193 
 
 Change as treatment in chorea, 134 
 
 illustrations of benefit of in chorea, 
 
 140 
 Charcot on chorea of old age, 21 
 — on morbid anatomy of hemichorea, 93 
 Chauveau, experiments on dogs, 94 
 Chronic chorea, treatment of, 140 
 
 case of, 171 
 
 Convalescence in chorea, 141 
 
 DEBILITY, treatment of, in chorea, 
 133 
 Definition of chorea, 13 
 Deglutition, defects of, 16 
 Delirium in chorea, 28 
 Delusions in course of chorea, case illus- 
 trating, 164 
 Dickinson on age in chorea, 19 
 
 sex in chorea, 20 
 
 recurrence of chorea, 26 
 
 rheumatic connection of chorea, 36 
 
 heart symptoms in chorea, 48 
 
 mitral reflux in chorea, 70 
 
 fatal chorea, 'j'j 
 
 the morbid anatomy of chorea, 86 
 
 Diet in chorea, 132 
 Donkin, treatment of chorea by, 172 
 Drug treatment in chorea, 135, 163 
 Duration of chorea, 25 
 
196 
 
 INDEX. 
 
 EMB 
 
 EMBOLIC theory of chorea, 78, 84 
 Emotion exchanged for movement 
 in chorea, 117 
 
 — likeness of, to chorea, 14 
 
 — symptoms prominent in fatal chorea, 
 
 76. 79 
 
 cases illustrating, 156, 164, 171 
 
 Endocarditis with chorea, 46, 56 
 
 case of, 153 
 
 Epilepsy, connection with chorea, 29, 
 
 ti6 n. 
 Exciting causes of chorea, 23 
 tables illustrating, 176, 193 
 
 FACE, chorea of, 15 
 cases of, 155, 171 
 
 statistics of, 194 
 
 Family histor}' of rheumatism in chorea, 
 
 38 
 
 statistics of 185 
 
 Fatuity succeeding to chorea, case of, 
 
 171 
 Fatal chorea, illustrations of, 73 
 
 case of, 172 
 
 Feeding, difficulty of, in acute chorea, 138 
 cases illustrating, 157, 
 
 160 
 Ferrler on localisation of brain Injuries, 
 
 106 
 Freedom from restraint in chorea, 160 
 Fright, as cause of chorea, 23 
 
 — frequent occurrence of, 43 
 
 — statistics of, 185, 192, 193 
 
 GEOGRAPHICAL distribution of 
 chorea, 22 
 Gowcrs on epilepsy in chorea, 29 
 
 mco-ordination in chorea, 113 
 
 Gray and Tuckwell on duration of chorea, 
 25 
 
 HAND affection in chorea, 114 
 cases of, 165, 169 
 
 Hayden on heart symptoms of chorea, 55 
 
 MOR 
 
 Heart affection in chorea, 26, 44 
 
 cases of, 151 
 
 at various ages, 66 
 
 in connection with paresis, 69 
 
 case of, 164 
 
 — post mortem in chorea, 78 
 Hemichorea, 15 
 
 — case of, 167 
 Hemiplegia with chorea, 29 
 
 case of, 153 
 
 Hughes on sex in chorea, 20 
 Hypothesis as to heart signs in chorea, 
 
 70 
 Hysteria in connection with chorea, 28 
 
 — distinction from chorea, 161 
 
 — cases of in male, 164, 171 
 
 IMITATIVE tendency of chorea,'^29 
 case illustrating, 163 
 
 Immermann on dynamic murmur, 62 
 Incontinence of urine in chorea, 171 
 
 JACKSON, Hughlings, on pathology 
 of chorea, 85 
 joint pains associated with chorea, 40 
 
 cases illustrating, 165, 166 
 
 Jones, Handfield, on the pathology of 
 chorea, 91 
 
 K 
 
 IRKES on embolism as cause of 
 chorea, 78, 84 
 
 LIMBS selected by chorea, in 
 — order of affection of, 114 
 — upper compared with lower in chorea, 
 186, 193 
 
 MACKENZIE, Dr. S., on pathology 
 of chorea, 99 
 Mechanical support in treatment of 
 
 chorea, 169 
 Morbid anatomy of chorea, 86 
 
INDEX. 
 
 197 
 
 MOR 
 
 Mortality of chorea, 72 
 
 Muscular strain as cause of chorea, 165 
 
 N 
 
 ARCOTICS in acute chorea, 139 
 Nixon on dynamic murmurs, 61 
 
 OBJECTIONS to functional hypo- 
 thesis of chorea, 124 
 Objects of treatment in chorea, 131 
 Ogle, John, on the blood in chorea, 90 
 Old age, chorea in, 21 
 Over-stillness in childhood, 28 
 Owen on rheumatic connection of chorea, 
 36 
 
 PAINS associated with chorea, 40, 
 135 
 Paresis, muscular, in chorea, 15 
 
 cases of, 165, 169 
 
 — cardiac in chorea, 68 
 Peacock on sex in chorea, 20 
 
 rheumatic connection of chorea, 36 
 
 Pericarditis as cause of chorea, 83 
 Poor, prevalence of chorea in children of, 
 
 144 
 Pregnancy, chorea in, 26, 90 
 
 case of, 167 
 
 Progress of chorea, 25, 134 
 Puberty, chorea of, 19, 75 
 
 cases of, 152, 164, 165 
 
 Pulse in chorea, 17 
 
 P3^e-Shiith on parts affected in chorea, 
 
 15 
 
 on age of chorea, 19 
 
 RECOVERY of chorea, 177 
 Recurrence of chorea, 26 
 
 significance of, 120 
 
 Rest in treatment of chorea, 131 
 Rheumatic connection of chorea, 32 
 
 tables illustrating, 176 
 
 statistics of, 193 
 
 Roger on connection of rheumatism with 
 chorea, 35 
 
 • WHO 
 
 Rokitansky on morbid anatomy of chorea, 
 
 92 
 Rosenstein on diagnosis of endocarditis, 
 
 56 
 
 SANSOM on the heart symptoms of 
 chorea, 57 
 S6e on rheumatic connection of chorea, 
 
 35 
 
 parts affected by chorea, 15 
 
 sex in chorea, 20 
 
 recurrence of chorea, 26 
 
 Senator on heart disease in connection 
 
 with chorea, 35 v. 
 Side affected in chorea, 15 
 
 — changing from left to right, case of, 
 166 
 
 — statistics as to, 177, 193 
 Speech defects in chorea, 15 
 case of, 171 
 
 Steiner on rheumatic connection of chorea, 
 
 35 
 morbid anatomy of, 92 
 
 TEMPERAMENT in chorea, 19 
 Temperature lowered in chorea, 16 
 Todd, cases of hemiplegia in chorea, 30 
 — on pathology of chorea, 83 
 Tonic treatment of chorea, 134 
 Training of children, 143 
 Treatment, illustrations of, 157, 159, 169, 
 
 171 
 Trousseau on the rheumatic connection 
 
 of chorea, 35 
 Tuckwell on fatal chorea, 74 
 
 VARIATIONS, rapid, in chorea, case 
 illustrating, 156 
 Violent chorea, case of, 158 
 
 WEST on imitative tendency of cho- 
 rea, 29 
 Whooping-cough, large proportion of, in 
 chorea, 176 
 
198 
 
 INDEX. 
 
 WHO 
 
 Whooping-cough, statistics as to, 184 
 Wilks on mitral systolic murmur in 
 chorea, 57 
 
 YOUNG children, chorea in, 24 
 treatment of, 132 
 
 Youth, physical education of, 143 
 
 ZIE 
 
 ZIEMSSEN, definition of chorea, 14 
 — on arhythmia of heart in chorea, 
 
 55 «• 
 heart action in chorea, 67 
 
 mental disturbance in chorea, 117 
 
 pathology of chorea, 14, 92 
 
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