Such nervous exhaustion, when it is the result only of overwork, speedily disappears when the presence of excessive demands upon the nervous energies is taken off. If such exhaustion continues as a chronic ailment, there is evidence that there is a perpetuating cause which should be sought for and removed. These conditions of nervous weakness are, in females, often attended by relaxation of some of the pelvic muscles and ligaments; uterine deviations result, and perhaps act as secondary causes. These secondary causes, themselves symptoms, are frequently treated during months and years with results too well known to the medical profession. CHOREA. We enter upon a brief examination of an extremely interesting subject, one which might well demand a most careful and extended review. It is proposed, however, in this place, only to call attention to the bearing of some of the most characteristic features of the disease upon the subject of its etiology and treatment. Notwithstanding the assertion of many learned writers that, as all cases of chorea are chronic, there can properly be no distinction of acute and chronic forms, it is well known that while recovery takes place in the great majority of cases of chorea in from two to four months, there remains a certain proportion of cases in which the complaint, resisting all medical treatment, continues many years or a lifetime. The distinction made by Sée of common and chronic chorea, would therefore seem a practical one. A fact, now recognized by those most familiar with the common form of chorea, is that under almost all circumstances recovery takes place within a few weeks after the onset. Hence, a great variety of remedies have been supposed to be nearly or quite specific; and cases are reported cured by cathartics, by bleedings, by vermifuges, and cold shower-baths, as well as by vegetable tonics, iron, strychnia, arsenic, chloral, and almost numberless so-called remedies. It is an interesting fact that, in defiance of such means as are mentioned in the first part of the foregoing list, recovery takes place almost as soon as under the more rational tonic treatment. In the chronic form, however, there are no specifics; neither cathartics nor tonics do much if any good, and the patient is doomed to years of suffering and perhaps to death, for death not infrequently comes to the relief of these unfortunate sufferers, while the physician consoles himself with the unfounded dictum that the disease, being based upon chronic lesions of the brain or spinal chord, is therefore incurable. That anatomical lesions of the brain or of the cord are sometimes coincident with chronic chorea it is true, but that there is necessary or causative relation. between the two conditions has not been shown. Indeed, it is much more probable that the anatomical lesions of the brain and cord are among the results of chorea or of the irritation causing it, and that they are not in in any respect the original sources of irritation. In considering the interesting fact that so many cases of "chorée vulgaire" recover under so many radically different methods of treatment, the age of the patients, and the circumstances attendant upon the period of life at which the great majority of cases occur, must be regarded as an important factor in explanation of the circumstance. Dr. P. H. Pye-Smith found that of 136 choreic patients at Grey's Hospital,* 106 were between the ages of six and fifteen, and 62 of these were between the ages of six and ten. In other words, nearly half were at the age when children enter schools, and nearly all were children of school age. Researches of the author of this essay prove that the majority of cases of chorea occur among children who are hypermetropic. If we consider that the strain upon the muscle of accommodation in these hypermetropic children is, during the first years of school-life, an unusual one, and that the attending confinement and possibly impure air of schools may aggravate the effect of the excessive demand upon the accommodation in delicate children, it will not be difficult to see that great nervous disturbance may result. Now, upon the advent of decided symptoms of chorea, the child is, in the great majority of instances, at once removed from school. The strain upon the overtaxed accommodation is relieved, and in the space * "Grey's Hospital Reports," third series, xix, p. 341. of a few weeks, as soon as time has been allowed for the overtaxed muscle to regain its tone, the child recovers from chorea, in defiance of medicines or possibly assisted by them. An important symptom of chorea may also be directly explained on this hypothesis. It is well known that widely dilated pupils, reacting feebly in response to the influence of light, constitute a very characteristic feature of this complaint, and it has also frequently been observed that on the termination of chorea the dilatation of the pupils disappears. Dilatation of the pupils is not always, but, as a rule, associated with enfeebled accommodation, and may be regarded as indicating weakness of the ciliary muscle in proportion to the degree of mydriasis. An example is found in paralysis of the third nerve, when the pupil is widely dilated and accommodation nearly or quite suspended. Returning to the condition of the pupil in these choreic children, a great proportion of them are hypermetropic. They have not been accustomed to the continued act of accommodation, and when sent to school or put to any other close work where a very marked and continued effort to maintain accommodation is required, the ciliary muscle experiences fatigue and finally exhaustion, its action is considerably enfeebled, and with it the action of the sphincter pupilæ. The widely dilated pupil is the signal which tired Nature gives as a warning to discontinue overwork of the exhausted muscles. If the signal passes unheeded, the whole nervous system surrenders. When the child is withdrawn from school, or other employments which require the use of the eyes at close range (for many of these children are from among the poor, who demand a certain amount of labor even from the very young), the wearied muscle gradually regains its contractile power, and the pupil returns to its normal state. Hence we may justly reverse the statement made above, that the dilatation of the pupil disappears on the termination of chorea, and say that with the proper contractile power of the ciliary muscles nervous quiet is restored. In reply to this line of argument may be adduced the fact that many children and even adults with dilated pupils do not have chorea. To which, again, it may be replied that not all similar causes, acting upon different individuals, produce like effects. It has been stated that observations have shown that the majority of cases of chorea occur among hypermetropic children. Of 118 cases examined in private practice Simple hypermetropia existed in......... 78 5 Myopia, unequal in the two eyes, in..... 6 11 Associated with these conditions in a considerable number of the above cases, more or less muscular disability was found. Insufficiency of the lateral recti muscles, with no marked degree of refractive error, existed in five. |