A system of practical medicine. By American authors. Vol. 5

by Unknown

DIAGNOSIS.—The only diseases for which chorea may be mistaken are paralysis agitans and disseminated sclerosis. The former occurs only in adult life, and the tremor is of a regular rhythmical character. In the latter the tremor occurs only on voluntary effort, and is also more regular than the movements of chorea. There are forms of congenital sclerosis seen in children which closely resemble chorea. Here the duration of the disease and the association of contractures with it distinguish it from chorea.

Hysterical subjects have a form of chorea which can only be differentiated from the true disorder by noting the general hysterical character of the case and the result of treatment, which strongly influences the will-power of the patient.

PROGNOSIS.—In the great majority of cases this is favorable. If the disease occurs in childhood and is without complications, recovery generally takes place spontaneously after a few weeks. Should the movements be violent and continuous, so as to interfere with sleep and the taking of food, or should there be any complication, such as acute rheumatism or cardiac disorder, then the prospect of recovery is not so good.

The prognosis as to relapses should be given with caution. If in a child, it is possible that there will be a return of the disease after a longer or shorter interval. It is not likely to recur until after several months, usually at about the same season the following year. As the child grows older the intervals become longer, and it may safely be asserted that after puberty is passed and bodily development completed there will be no more returns of the affection.

The cure is usually complete. It must be remembered, however, that for some time after an apparently complete cure there may be slight inco-ordination of movements, particularly in the arms and the face. These are shown in the unnecessary haste in making uncertain motions or in slight grimaces, or if excited an awkwardness in the use of the fingers.

Death is a rare termination in uncomplicated cases, especially in children. The fatal cases are generally when acute rheumatism has been associated with the chorea or when there has been a fracture or an injury as a complication.

In Sée's statistics there is a mortality of 5.7 per cent. in 158 cases in the Children's Hospital. In adults, and more particularly in pregnant women, death is more common. Wenzel's cases referred to above gave a mortality of 27.3 per cent.

The cause of death in chorea may be from the intensity of the disease, and in this case the symptoms are generally violent from the outset, increase to an extreme extent, and then collapse and coma come on. The movements may cease when the collapse occurs, but they may continue to the last, growing gradually less until death.

TREATMENT.—A vast number of remedies have been popular in this disease from all ages. The medicine which is most generally depended upon at the present day is arsenic. It is advised by most writers, and in my own experience is decidedly the most reliable remedy for chorea which we know. The best way to administer it is in the form of Fowler's solution, and it should be given in large doses. I have given the bromide of arsenic, but did not find it superior to Fowler's solution. The amount of arsenic which can be safely borne by children with chorea is surprising to those who have not had experience in its administration. The medicine should be given in gradually increasing doses until the toxic effects are well marked or until the patient is convalescing. In a child of six years three drops may be given to begin with, three times a day. One drop additional should be added to the dose each day, and the child soon acquires a remarkable tolerance of the drug. As much as twelve or fifteen drops at a dose is borne by a child of eight years. If vomiting or much œdema of the face occurs, the medicine should be stopped for a day or two, and then the original dose should be taken, to be again increased as before.

Seguin recommends that the patient should begin again with the dose at which tolerance ceased. For instance, if vomiting occurred after a dose of nine drops, he stops the medicine for a day, and begins again with eight drops. I have found that sometimes this causes vomiting again, and I think it preferable to resume the medicine with a small dose.