A system of practical medicine. By American authors. Vol. 4

by Unknown

The PROGNOSIS is unfavorable. Of Sir James Y. Simpson's 28 cases, only 6 recovered; 2 cases observed by Wiltshire terminated unfavorably.

In the entire absence of knowledge of the pathology of the disease, TREATMENT is empirical. Chloroform, the narcotics, curare, and nitrite of amyl are the remedial agents usually employed.

CHOREA.

Chorea occurs in pregnancy as an accidental complication or as the direct result of that state. It is a rare disorder of pregnancy. Spiegelberg has observed 3 cases; Barnes has collected 56 cases; Fehling²⁷ brings the number up to 68; altogether, 84 cases are on record.

²⁷ Lehrb. d. Geburtshülfe, 1882, p. 239.

ETIOLOGY.—The investigations of Robert Barnes show that where chorea arises in pregnancy in the large majority of cases there is a history of chorea in childhood, acquired predisposition prior to pregnancy, or hereditary "nervous diathesis predisposing to chorea." The connection between rheumatism, endocarditis, and chorea is a well-established fact. The precise nature of this relation is unknown. Hughlings Jackson has constructed the theory of "embolism of the small branches of the middle cerebral artery supplying the structures near the corpus striatum." Robert Barnes²⁸ calls attention to the following facts, which invalidate this ingenious theory: "(1) The frequent recovery of choreic patients; (2) the occasional immediate cessation of choreic fits upon delivery; (3) the progressive character of the disease during pregnancy, convulsions increasing in severity, and the gradual development of mania in some cases; (4) the fact that embolism is rare during pregnancy." In the absence of any definite cause, Spiegelberg refers a large number of these cases to the class of reflex neuroses. All the elements essential to a reflex neurosis are present. We have (1) a predisposition to chorea, inherited or acquired; (2) inanition of the central nervous system incident to the hydræmic state of the blood in pregnancy; (3) various potential peripheral irritants in connection with the sexual organs. Intense emotions, terror and the like, may act as exciting causes.

²⁸ Obstetric Medicine and Surgery, London, 1884, p. 379.

COURSE AND SYMPTOMS.—Chorea usually makes its appearance in the course of the first half of pregnancy, and continues until the beginning of labor. Sometimes choreic attacks are witnessed during parturition. In only 3 out of the 84 recorded cases the disease continued after the puerperium. Primiparæ are more frequently affected than multiparæ. The disease is liable to recur with succeeding pregnancies, entirely disappearing in the intervals. The choreic movements are the same as in the non-gravid woman affected with the disease. They are usually bilateral. As in chorea in the non-gravid state, transitory albuminuria and glycosuria may be observed. The increase of urates and phosphates in the urine is interpreted as the result of nervous excitement and muscular activity. Pregnancy is interrupted in about one-half the cases. The child may be born alive and affected with the disease.

PROGNOSIS.—Out of the 84 cases, 23 terminated fatally as the result of complications. Mania, loss of memory, grave cerebral and spinal lesions are occasionally traceable to the chorea of pregnancy. The prognosis with reference to the child is unfavorable, from the tendency to the premature interruption of pregnancy.