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Acute Chorea.

Problems:

Synonyms.—St. Vitus's or St. Anthony's Dance; Sydenham's Chorea.

Definition.—An acute disease affecting children mostly, and characterized by irregular, involuntary, and clonic spasms of the muscles, a tendency to endocarditis, a variable amount of psychical disturbance, and a liability to recurrence.

Etiology.—Among predisposing causes may be mentioned age, sex, and race.

Age.—The disease occurs most frequently between the ages of five and fifteen, puberty being especially favorable to its development.

Sex.—Of five hundred and fifty-four cases reported by Osler, seventy-one per cent were in females, and twenty-four per cent in males, the ratio rising still higher in females after puberty.

Race.—It is peculiarly a disease of the white races, rarely ever occurring among the colored races.

Heredity.—An effort has been made by some to show a hereditary tendency in the disease, but the fact that only about ten per cent of all choreic patients can show a family history of chorea, makes this quite a doubtful etiological factor.

Rheumatism.—The same may be said of rheumatism, and though English statistics show quite a large per cent of rheumatism in chorea, the history of other countries does not bear out the same conclusions, and it is probable that where the two are found in the same patient, it is a coincident.

Endocarditis.—Some observers claim endocarditis as a cause, due to the lodgment of vegetations from the valves in the cerebral vessels. In the large majority of cases, however, it is the result rather than the cause.

Infectious Diseases.—Scarlet fever, whooping-cough, pyemia, puerperal fever, and gonorrhea have preceded the disease, but it is very doubtful if they have any significance as an etiological factor.

Reflex irritation, while a possible cause, has probably been overrated, though, in one of my cases, the release of an adherent clitoris was followed by a rapid cure, where medication had failed.

Pregnancy frequently is the exciting- cause, in one of a neuropathic temperament.

The cause, then, is elusive, and in children of a nervous temperament may arise from fright, shock, mental or emotional excitement.

Pathology.—No constant or characteristic lesion has been found, the pathology still being obscure. Some believe a functional disturbance of the centers that control the motor apparatus is the chief lesion, while others believe the lesion to be embolic, and still others the result of infection.

Symptoms.—In the beginning the affection is generally unilateral, though both sides are soon involved. It usually begins with slight involuntary twitching of the muscles of the hands or face. It is noticed that the child spills liquids when attempting to drink or pass them at the table, or that he lets articles drop, and this being attributed to carelessness, he is often scolded or punished, which only aggravates the disease. This twitching or rather jerking of the muscles, extends to the shoulders, which are twisted or raised in a jerky manner. The involuntary movements may extend to the leg, making locomotion in severe cases quite difficult.

In the more severe cases, the child presents a pitiable appearance; there is batting of the eyes and jerking of the mouth, the hands are almost in a constant spasm, the legs jerk irregularly, and the child is unable to feed or dress himself, and many times is even unable to walk. The child's disposition seems completely changed, becoming cross, peevish, and with sudden outbursts of anger, especially if corrected for his seeming carelessness.

In severe cases his speech is affected, articulation being so difficult that often no attempt is made to talk. Generally the involuntary movements cease during sleep, though in the most pronounced cases the rest is disturbed even in sleep. Occasionally nocturnal incontinence occurs.

The appetite becoming impaired, the child frequently becomes weak and anemic, and where endocarditis occurs, a blowing murmur may be heard in the apex region.

As a rule, there is no fever unless complications exist.

Diagnosis.—Few diseases present more characteristic symptoms than chorea, and the laity generally diagnose the disease even before the physician is consulted. The peculiar twitching and jerking of the muscles of the face and hands, extending to other parts of the body, is apparent to every one, and the diagnosis becomes very easy.

Prognosis.—This is favorable in the large majority of cases, though there is a tendency to one or more relapses. The disease runs from four to ten weeks, though sometimes it may linger three or four months.

Treatment.—The child should be dealt with kindly, and little attention paid to his contortions; for this reason he should be removed from school as soon as recognized, that he may be saved the pain of thoughtless laughter and remarks by fellow playmates.

The diet should be nourishing though easily digested.

In the way of medication, there are a few remedies that have proven of great value.

Macrotys.—Where there is muscular soreness, whether due to acute rheumatism or muscular contraction, macrotys will give good results. From a half to one dram of the specific medicine added to four ounces of water, and a teaspoonful given every two or three hours, will not disappoint.

Gelsemium.—Where the child is extremely nervous, gelsemium will be the better agent.

Cypripedium.—This agent has been used quite successfully by Eclectics for this troublesome affection. A broad, puffy tongue is the special symptom. It should be given in quite tangible doses, ten to fifteen drops every two hours.

Physostigma, scutellaria, avena, cannabis, hyoscyamus, and like remedies, should be used.

Dr. Webster speaks highly of the use of the tonic faradic or secondary current of electricity.

Should there be no improvement in a carefully selected medication, the clitoris should be examined for adhesions, and released when present. I seriously object to subjecting young girls to any unnecessary examinations, and since many of these cases yield to medication, I should only resort to this measure when other means failed. After treating a severe case of chorea in a girl of twelve, for two weeks without any improvement—in fact, there was rather an increase in the severity of the symptoms—I found a very tightly adherent clitoris, the release of which was followed by speedy relief. One could hardly believe so great a change as took place within twenty-four hours; but since these are exceptional cases, do not examine every girl that has chorea, till other measures fail.


The Eclectic Practice of Medicine, 1907, was written by Rolla L. Thomas, M. S., M. D.



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