The question of the influence of nervousness in the production of the disease naturally suggests the etiologic significance of psychic trauma tism. Although such a traumatism often occurs in the history of choreic children in the form of fright, grief of some kind, or mental or psychic overexertion in school, but little importance is usually attached to these factors in the literature. This may not be altogether justified, since when the disease is well developed, we usually consider complete bodily and psyehic rest as the most important factor in the recovery.
From what has been said, it appears that the diagnosis of chorea minor is usually easy and sometimes can be made at the first glance. Of the di.seases which must be considered in the differential diagnosis, hereditary chorea (chronic progressive, or Huntington's chorea) is excluded at once by-the fact that it develops at a later age than childhood. So-called eleetrical chorea (see page 334 ) is characterized by the fact that the lightning-like eonvulsions are confined to certain symmetrical groups of muscles (particularly of the neck, shoulder girdle and arm), while the rest of the muscles eseape altogether.
Intra- and extra-uterine organic disease of the brain may, under certain conditions which we do not know, terminate in a eondition of muscular unrest closely resembling chorea, instead of the muscular rigidity of the extremities, which i.s a much more frequent result.. Sim ilarly, the movements which accompany every intentional movement in many forms of congenital rigidity of the limbs may exhibit a certain resemblance to choreic movements. The primary disease in both classes of eases is at once revealed by a systematic examination.
The museular unrest and the twitching, jerking movements and grimaces indulged in by neuropathic children from shyness, and par ticularly when they know that they are observed, are more apt to be confounded with chorea minor, and this mistake is not uncommon in general medical practice.
A single examination is not always enough to make the distinction absolutely clear, especially if the history is confused and misleading and it is stated that. the movements began at a certain definite date, when, as Et n)atter of fact, they were only accidentally noted for the first time by the attendants at that particular time. If one ean succeed in diverting the child's attention and fixing it on some other subject, these movements usually disappear, while choreic movements persist. Some assistance is derived from the objective examination, inasmuch as the passive movements in neuropathic children are more apt to be accom panied by heightened muscular tone—they are unable to relax their muscles; while, on the other hand, a pronouneed hypotonia is the rule in chorea. The greater the neuropathic condition, the more persistent
may the movements become (ehork) variable des degenere)s, Brissaud). These cases merge without, any sharp lines of division into the large group of maladie des ties. Hysteria may also produce similar clinical pictures.
The prognosis of genuine chorea minor has been .stifficiently dis cussed.
The treatment of chorea offers a wide field for medical art, but it should be remarked at the outset that a.s yet we have no specific remedy, and it is probable that our methods of treatment have but little influence on the duration of the disease. On the otlaer hand, we are rather more able to modify the intensity of the irritative symptoms.
In spite of their specific action in articular rheumatism, the salicy lates and antipyrin appear to have as little distinct influence nn chorea as on the development of cardiac affections, and are accordingly- suitable only when ehorea is associated with rheumatic or cardiac symptoms. In such a ease the drug tnay be given in doses of 1 gram (15 grains) to a child from five to six years old; and of about 2 grams (30 grains) a day', to one between 10 and 12 years of age (Filatow).
The remedy enjoying by far the greatest popularity is arsenic, in the form of potassium arsenite, Fowler's arsenical solution, or arsenious acid.
As Fowler's solution contains one per cent. of potassium arsenite, the dose of two to five drops, which is usually ordered for a child, three times a day in ascending doses, contains 0.015 Gm. (1 gr.) of arsenie„ which is but little below the official maximum dose of 0.02 (d gr.); nevertheless, quantities considerably in exeess of this are given by many authors, for example, Comby, Filatow and others. As arsenious acid in large doses is said to be better borne than Fowler's solution, Comby orders an aqueous solution of arsenious acid, 1:1000, mixing 10 grams, (24 drams), with six tablespoonfuls of water on the first day, and directing that a tablespoonful be taken every two hours. After eaeh dose the child drinks a little milk; on the second day, 15 grams (3i drams); on the third (lay, 20 grams (5 drams) of the solution are given; and so on until on the seventh clay, the daily amount is 40 grams (10 drams) of thc solution. After the eighth day the closes are reduced at the same rate, so that in the period of two weeks the child consumes 0.350 grams (51 grains) of arsenious acid.