On May 18 the rheumatism was so much better that the salicylate was stopped and Fowler's solution of arsenic was given instead. The chorea had also become better. The arsenic was continued in increasing doses, and the case convalesced steadily. On June 26 he was able to return to his home in Maryland entirely well.
He remained well until July, 1884, when he had a slight attack of chorea, which was preceded for about a week by rheumatism. The cardiac murmur, which was almost absent after recovery from the first attack, was now heard again, but faintly.
Scarlatina is sometimes the forerunner of an attack of chorea. Other diseases, whooping cough or measles, may also be the immediate cause of an attack of chorea, but it is generally in cases where there is a predisposition to the disease.
The connection between pregnancy and chorea is of great interest. Barnes12 has collected 58 cases, and Bodo-Wenzel13 has added 8 more, making 66 in all. Of 51 of these patients, 31 were primiparæ, and in the majority of cases the ages were between twenty and twenty-three years. Four cases which came under my own personal observation were all young primiparæ, and were between the second and fourth months of gestation when the disorder began. The affection usually appears in the first half of pregnancy. It may cease before the eighth month or may continue to the end of gestation. Sometimes it persists after delivery. It does not necessarily occur in patients who have had the disease in childhood, but from the above cases it would seem that an attack in one pregnancy would tend to its recurrence in another. Of the 66 cases, 14 had had chorea in previous pregnancies. Sometimes the chorea appears only at the time of labor.
12 Obstet. Transactions, vol. x. p. 147.
13 Ziemssen's Cyclopædia, loc. cit., p. 428.
The immediate cause of chorea in pregnancy, when a cause can be found, is most often fright or rheumatism. In two of my own cases the patients were unmarried. Of the 66 cases of Barnes and Wenzel, fright is named as a cause in 7, and in 7 more rheumatism and endocarditis are stated to have preceded the attack.
Climate has been supposed to have a marked influence upon chorea. It was thought to be less frequent in warm than in cold regions; but Hirsch denies this, and Weir Mitchell14 states that it does not appear to exist to any less extent in the southern than in the northern portion of this country.
14 Loc. cit.
Season, according to Mitchell,15 largely affects the production of chorea. He has gone to great pains to collect statistics on the subject. He shows that the majority of attacks in his cases occurred in spring. This agrees with Wicke,16 who found that among 35 relapses, 13 were in spring, 12 in winter, 9 in autumn, and 1 in winter. On the contrary, Hammond17 found 54 attacks in the six months from October to March, and but 28 in the remainder of the year. Gerhard18 in a study of 80 cases found that of 68 attacks, 39 occurred in spring, 10 in summer, 7 in autumn, and 12 in winter. In Mitchell's cases a study was made of 170 attacks. In the spring and summer months there were 115 attacks against 55 in the winter and autumn months. This observer does not find that rain or dampness has any notable effect in causing the disease, but that the influence of storms is probably great.