Permanent murmurs are in all cases, probably, the result of endocar ditis, which may be due to coincident rheumatism, or may arise in the course of the illness without rheumatic taint.
The choreic disorder runs a chronic course, but in the large majority of cases ends in complete recovery. Its progress is, however, often un equal, and the child may be better and worse again several times before control over muscular movement is completely restored. After all in voluntary spasm has subsided, a certain abruptness of executing voluntary acts may continue for a time before all traces of the disorder pass away. Relapses after an interval of months or years are very common.
The duration of chorea varies greatly. If left to itself it lasts from one to two months, seldom longer, although cases are recorded in which mus cular disturbance has continued through life. As a rule, the disease can be greatly influenced by treatment. When the complaint passes off, recov ery in most cases is complete. Sometimes, however, the mind remains more or less enfeebled ; the patient becomes slovenly, careless, and dirty in her habits, and may even drift into a state of permanent weakness of mind. 111 other cases the contrary happens, and the intellect seems bright ened by the attack. Sometimes, although fortunately very rarely, some of the affected muscles undergo atrophy and contraction.
Death from the disease is very uncommon in children, but it sometimes occurs from the violence of the disease, the patient being worn out by want of sleep, insufficient nourishment, and muscular exhaustion. Death is usually preceded by delirium and coma. In the bad cases the chafing of the skin produced by constant friction becomes a source of great dis comfort, and may induce an attack of fatal erysipelas.
Diagnosis.—In a well-marked case of chorea the absence of monotony and rhythm in the movements, their abruptness and variety, their com plete independence of the will, and their occurrence in spite of all efforts to restrain them, make mistake impossible. The cases which begin with paresis, and in which the muscular movement is a subordinate and insig nificant feature, are less immediately recognisable. In such cases careful observation is often required to ascertain the existence of muscular spasili. According to Dr. Gowers, whenever a child of the choreic age suffers from gradual loss of power in the arm, and presents no weakness of face, tongue, or leg, the disease is invariably chorea. If the nature of the com plaint be suspected, we must look for confirmatory evidence, and slight oc casional spasm will be usually detected in the weak arm or in the sound one.
Prognosis.—The immediate prognosis is almost always favourable, and very severe cases in children under twelve years of age seldom do other wise than well. The worst cases are seen in girls who have menstruated, and it must be remembered that the catamenia sometimes appears at a very early age.
The influence of the disease upon a child's future life has also to be considered. If the patient have strong neurotic tendencies derived from inheritance, we may feel less sanguine than we other wise should be as to the after-effects of the illness. In such cases much will depend upon the moral influences which may be brought to bear upon the child. The form of the complaint in which muscular weakness is the prominent and early symptom, seldom passes into very severe general chorea, but it often proves an obstinate ailment and difficult of cure.
Treatment.—Chorea is a disease which is decidedly influenced by treat ment in the wider sense of the word, as distinguished from mere drug giving. Our first care should be to see that the muscles are spared all un necessary exertion ; and that the child is kept as quiet as possible in bed. We should then attend to all the bodily functions—see that the bowels are regularly relieved ; that any worms present in them are re moved ; that the skin and kidneys act well ; that the diet is regu lated with a proper proportion of animal and vegetable substances ; and that the child does not take too much farinaceous matter or sweets. In most cases the subjects of chorea are anemic and weak, with flabby mus cles ; not unfrequently the skin is dry and acts imperfectly. To re store the skin to its natural condition the body should be oiled all over at night, and in the morning the child should be thoroughly washed with soap and hot water. After a few days the normal softness and suppleness of the skin will be restored. A cold douche may be then added to the treatment. If the child be not weakly, the douche may be given after her ordinary bath as she sits in the warm water. In the case of a weakly child it is better to separate the ordinary washing from the invigoratino. douche. The patient may take her usual bath in the evening, and in the morning the douche may be given as the child sits in hot water, after complete preparation of the skin by vigorous shampooing (see Introduc tion). In this process the shampooing, besides preparing the skin to resist the shock of the cold water, seems to have a directly beneficial effect upon the muscles.