The course is not always regular. In some cases the disease gradually reaches a crisis, remains stationary for a few days, and then by degrees declines; in others there are exacerbations. The patient will seem to be almost well, and then become very much worse for a time. Relapses are not infrequent, and are generally caused by fright or excitement.
The recurrence of attacks of chorea is well known. A child who has had the disease one year may have it a second or third year. It is most likely to recur in the spring. Some cases have as many as five attacks, but as puberty approaches the attacks are lighter, and finally cease. Of 282 cases to which I have referred, 198 were first attacks, 47 had had chorea twice; 23 were in their third attack, 8 in the fourth, and 3 in the fifth attack.
TERMINATION.—The disease in most instances terminates in complete cure, but sometimes there is nervousness or want of co-ordination remaining for a time. Rarely the inco-ordination or a certain quickness in movement becomes permanent.
Death is a rare termination of chorea except in pregnancy. If it does occur, it is usually from some complication. In pregnancy the mortality is great. Of 64 cases collected by Wenzel, 18 died. In Philadelphia, in seventy-four years from 1807 to 1881, there have been but 64 deaths from chorea; of these, 38 were under twenty years, and 26 over that age.
Hutchinson reports a fatal case in a boy of twelve years.26 After complaining of headache and rheumatic pains for several days, choreic movements began. They soon became general and very violent. At the end of two weeks he was admitted to the Pennsylvania Hospital. At this time the patient was so extremely convulsed that it was impossible to keep him in bed without tying him. The movements continued but little abated, and the child died in two days.
26 Philadelphia Med. Times, vol. vi. p. 535.
Another case of unusual interest is reported by Hunt.27 The patient, a man of twenty-nine years, had suffered from chorea of the face and arms for years. In consequence of a fall on the pavement he fractured the left humerus. The movements were immediately exaggerated, and in spite of a carefully adjusted splint it was impossible to keep the arm at rest. The fragments were in a state of constant movement, and the points of bone threatened to penetrate the skin. The skin was so much excoriated that it was determined to dispense with the splint and attempt to keep the limb at rest by the administration of morphia hypodermically in half-grain doses three times daily. This failed to keep the arm quiet, and the seat of fracture became greatly inflamed. No form of appliance or medication succeeded in keeping the arm at rest, and the patient finally sank and died from exhaustion on the tenth day after admission to the hospital. The post-mortem examination revealed no gross lesion of the brain or cord. No microscopic examination was made of the brain.
27 Pennsylvania Hospital Reports, vol. ii.
MORBID ANATOMY AND PATHOLOGY.—In a disease so seldom fatal as chorea it is not surprising that there have been but few post-mortem examinations made. In the earlier autopsies, before the microscope was extensively used, but little of value was recorded. Sée, who collected 84 cases in which post-mortem examinations were made, reported that in 16 no changes were found in the nervous system. In 32 there were lesions in the brain and nervous centres, usually softening and tuberculosis, and in the remainder inflammatory changes in the serous membranes. In 29 there were evidences of heart disease. Sée considered that but few cases of death in chorea were caused by inflammatory diseases of the heart, but that the majority should be referred to nervous excitement and anæmia.
Ogle28 in a report of 96 cases of chorea mentions 16 which were fatal. Post-mortem examinations were made in all of these. Cardiac lesions were found in 13. In 10 of these deposits were found upon the valves, and in 3 there was some change in the pericardium. He speaks of having noted congestion of the nervous centres six times, and softening of the cord once.