15. The treatment is simple. Purgatives are useless, if not injurious. As early as possible, large injections of water should be used. If these fail to reduce the intestine, air should next be thrown into the rectum by means of a bellows or other contrivance, until the abdomen is greatly distended. If the repeated use of air and water is unsuccessful, we should soon desist from active treatment, and endeavour to sustain the patient's strength till the bowels are reopened by sloughing. Opiates should be given to relieve pain and keep in check the serous inflammation, and, when the abdomen is tender, poultices may be employed; but, further than this, our reliance must be on nutritious diet and stimulation.

147 N. 49TH ST., NEW YORK.

ART. II.—Remarks on Chorea, with Notices of some Allied Disorders. By JAMES J. LEVICK, M. D., one of the Physicians of the Pennsylvania Hospital.

THE involuntary, grotesque, but in some instances distressing, symptoms of chorea are too well known to need description in this place. Almost all writers on this disease quote the following graphic description of Sydenham

"St. Vitus' dance. This is a kind of convulsion which attacks boys and girls, from the tenth year to the time of puberty. It first shows itself by limping or unsteadiness in one of the legs, which drags. The hand cannot be steady for a moment. It passes from one position to another by a convulsive movement, however much the patient may strive to the contrary. Before he can raise a cup to his lips he makes as many gesticulations as a mountebank, since he does not move it in a straight line, but has his hand drawn aside by spasms until by some good fortune he brings it at last to his mouth. He then gulps it off at once, so suddenly and so greedily as to look as if he were trying to amuse the lookers on."-The Works of Thomas Sydenham, M. D., translated by R. G. Latham, M. D., etc. Syd. Soc. Ed., London, 1850, vol. ii. p. 257.

Among the symptoms in choreic patients not generally recorded, but which I have sometimes observed, are a tendency to fall down stairs, a disposition to hide in holes and closets, from which they can with difficulty be extricated (Fleischmann), and as a premonitory symptom prolonged insomnia.

While separately the causes of chorea are numerous, they may all, I believe, be classed under one head, that of irritations affecting a highly sensitive nervous organization. These causes may be predisposing or determining, congenital or acquired, centric or eccentric. By congenital it is not meant to be asserted that the specific disease, chorea, is transmitted from parent to child, but that the peculiar nervous organization which favours its development under the usual exciting causes is so. This peculiar diathesis shows

itself in an unusual delicacy of nervous organization which is generally associated with a feeble muscular frame. I believe, although I have never seen it so recorded, that the marriage of relatives, especially of first cousins, is highly favourable to the development of this disease, and am familiar with an illustration of this in a large family the children of first cousins, almost all the members of which are more or less choreic, some of them strikingly so. In their case the irregular manifestations of nervous force in the muscular system appear to have taken the place of the impairment of cerebral function which often attends the offspring of such marriages, as the subjects of it are possessed of unusual intellectual attainments. Returning to the proposition that irritation to the nervous system is the exciting cause of chorea, we may consider the commonly received causes of this disorder.

Fright is universally admitted to be one of the most common, if not the most frequent cause of chorea. M. Guersent, however, says it is not the fear which causes the chorea, but the disposition to this malady which causes the child to be so easily affrighted.

Fright I believe acts in two ways in producing the phenomena of chorea. In the first place by directly disturbing the nervous force, as a blow on the forehead or the poison of malaria would do; and secondly by affecting the action of the various emunctories so that the depurative processes are not healthfully performed, and toxæmia is thus developed. No one can be ignorant of the influence of our emotional system on the functions of the various organs. Arrest of the secretion of the gastric juice, of the menstrual flow, the sudden development of jaundice, convulsions and even death in children at the breast, all have followed sudden fright or violent anger. Hence chorea may be developed immediately or remotely. Romberg reports a case coming on a few hours after fright, while Gull reports an interval of nine months to have elapsed before the manifestation of the disease.1

Rheumatism as a concomitant, and, as it is believed, a provocative of chorea, has long been recognized. Dr. Addison and Dr. Bright have especially called attention to this as an exciting cause of chorea. The belief has been expressed that in almost every instance there is mitral disease in chorea. The authorities quoted are of great weight, but after a careful observation of many cases of chorea during the last ten years it has not happened to the writer to find this association a frequent, much less a constant one. Bellows murmurs referable to anemia and their temporary occurrence, from, as I believe, a sort of choreic spasm of the columnæ carneæ

1 A curious case of chorea cured by fright is recorded by Dr. Hughes (in Guy's Hospital Reports, vol. iv., N. S., 1846, p. 36). A girl who had been cured of a former attack of chorea had a return of her complaint. She was going to the hospital to apply for readmission, but on her way was much alarmed as she passed over London Bridge by a person being run over. She, however, pursued her course. On her arrival at the hospital, both she and her mother were surprised to find that the complaint had left her. She remained well.

15. The treatment is simple. Purgatives are useless, if not injurious. As early as possible, large injections of water should be used. If these fail to reduce the intestine, air should next be thrown into the rectum by means of a bellows or other contrivance, until the abdomen is greatly distended. If the repeated use of air and water is unsuccessful, we should soon desist from active treatment, and endeavour to sustain the patient's strength till the bowels are reopened by sloughing. Opiates should be given to relieve pain and keep in check the serous inflammation, and, when the abdomen is tender, poultices may be employed; but, further than this, our reliance must be on nutritious diet and stimulation.

147 N. 49TH ST., NEW YORK.

ART. II.-Remarks on Chorea, with Notices of some Allied Disorders. By JAMES J. LEVICK, M. D., one of the Physicians of the Pennsylvania Hospital.

THE involuntary, grotesque, but in some instances distressing, symptoms of chorea are too well known to need description in this place. Almost all writers on this disease quote the following graphic description of Sydenham:

"St. Vitus' dance. This is a kind of convulsion which attacks boys and girls, from the tenth year to the time of puberty. It first shows itself by limping or unsteadiness in one of the legs, which drags. The hand cannot be steady for a moment. It passes from one position to another by a convulsive movement, however much the patient may strive to the contrary. Before he can raise a cup to his lips he makes as many gesticulations as a mountebank, since he does not move it in a straight line, but has his hand drawn aside by spasms until by some good fortune he brings it at last to his mouth. He then gulps it off at once, so suddenly and so greedily as to look as if he were trying to amuse the lookers on."-The Works of Thomas Sydenham, M. D., translated by R. G. Latham, M. D., etc. Syd. Soc. Ed., London, 1850, vol. ii. p. 257.

Among the symptoms in choreic patients not generally recorded, but which I have sometimes observed, are a tendency to fall down stairs, a disposition to hide in holes and closets, from which they can with difficulty be extricated (Fleischmann), and as a premonitory symptom prolonged insomnia.

While separately the causes of chorea are numerous, they may all, I believe, be classed under one head, that of irritations affecting a highly sensitive nervous organization. These causes may be predisposing or determining, congenital or acquired, centric or eccentric. By congenital it is not meant to be asserted that the specific disease, chorea, is transmitted from parent to child, but that the peculiar nervous organization which favours its development under the usual exciting causes is so. This peculiar diathesis shows

itself in an unusual delicacy of nervous organization which is generally associated with a feeble muscular frame. I believe, although I have never seen it so recorded, that the marriage of relatives, especially of first cousins, is highly favourable to the development of this disease, and am familiar with an illustration of this in a large family the children of first cousins, almost all the members of which are more or less choreic, some of them strikingly so. In their case the irregular manifestations of nervous force in the muscular system appear to have taken the place of the impairment of cerebral function which often attends the offspring of such marriages, as the subjects of it are possessed of unusual intellectual attainments. Returning to the proposition that irritation to the nervous system is the exciting cause of chorea, we may consider the commonly received causes of this disorder.

Fright is universally admitted to be one of the most common, if not the most frequent cause of chorea. M. Guersent, however, says it is not the fear which causes the chorea, but the disposition to this malady which causes the child to be so easily affrighted.

Fright I believe acts in two ways in producing the phenomena of chorea. In the first place by directly disturbing the nervous force, as a blow on the forehead or the poison of malaria would do; and secondly by affecting the action of the various emunctories so that the depurative processes are not healthfully performed, and toxæmia is thus developed. No one can be ignorant of the influence of our emotional system on the functions of the various organs. Arrest of the secretion of the gastric juice, of the menstrual flow, the sudden development of jaundice, convulsions and even death in children at the breast, all have followed sudden fright or violent anger. Hence chorea may be developed immediately or remotely. Romberg reports a case coming on a few hours after fright, while Gull reports an interval of nine months to have elapsed before the manifestation of the disease.1

Rheumatism as a concomitant, and, as it is believed, a provocative of chorea, has long been recognized. Dr. Addison and Dr. Bright have especially called attention to this as an exciting cause of chorea. The belief has been expressed that in almost every instance there is mitral disease in chorea. The authorities quoted are of great weight, but after a careful observation of many cases of chorea during the last ten years it has not happened to the writer to find this association a frequent, much less a constant one. Bellows murmurs referable to anemia and their temporary occurrence, from, as I believe, a sort of choreic spasm of the columnæ carneæ

1 A curious case of chorea cured by fright is recorded by Dr. Hughes (in Guy's Hospital Reports, vol. iv., N. S., 1846, p. 36). A girl who had been cured of a former attack of chorea had a return of her complaint. She was going to the hospital to apply for readmission, but on her way was much alarmed as she passed over London Bridge by a person being run over. She, however, pursued her course. On her arrival at the hospital, both she and her mother were surprised to find that the complaint had left her. She remained well.

and their tendinous chords, causing irregular action of the auriculo-ventricular valves, are not unfrequent, but a persistent endocardial murmur due to mitral disease is certainly not often met with in choreic patients as we see them in our American hospitals. That the irregular movements of chorea are not confined to the extremities is well known. Romberg relates an instance where the diaphragm, the intercostals, and other muscles of respiration were spasmodically affected in a case of chorea. Spasm of the glottis is also related, and it has been even suggested that stammering is but an instance of chorea of the organs of speech. Dr. Pepper, of the University of Pennsylvania, informs me that he has known incontinence of urine to interchange with chorea of the external muscles, and conversely.

While thus expressing the belief that mitral disease is by no means a constant association of chorea, I do not doubt that the irritation of rheumatic toxæmia in a person predisposed to chorea may be a determining cause of that disease, and that this too may act directly or indirectly, on the peripheral or ganglionic structure, or involve disorganization of the spinal membranes or substance. Hence the very marked difference in the intensity with which the symptoms of chorea show themselves. Thus, it may affect the intercranial structure, producing symptoms more serious even than those of chorea. Mesnet, in an essay on certain cerebral accidents which developed themselves in the course of rheumatism, mentions a case of chorea occurring with articular rheumatism with symptoms of rheumatic meningitis, as well as cases of rheumatic disorder of the brain associated with more general convulsive movements, disturbance of all the principal functions, and proving mortal in a few hours; this last by Stoll is called rheumatic apoplexy. M. Vegla quotes three such cases.3

Coley mentions a case of chorea in which a translation of rheumatic irritation to the fibrous coat of the spinal marrow produced fatal meningitis. In a number of cases reported by Hughes, eight out of fifty-eight had their origin in rheumatism. Dr. Hughes thinks it is probably only a sympathetic irritation of the spinal marrow. Dr. Watson thinks, in some cases of chorea with coincident rheumatic cardiac disease, that some morbid condition of the spinal marrow might have arisen simultaneously with the cardiac inflammation, or that the cardiac disease might have been an eccentric exciting cause of the disorder of the muscles; or that it may be from a diseased blood causing articular cardiac disease and spinal disorder. This

1 Romberg (Disorders of the Nervous System, translated by E. M. Sieveking, M. D., etc., p. 53 et seq., vol. ii.) has rarely found chorea with disease of the heart. Archives Générales de Médecine, tome vii. 5 série, p. 704.

3 Ibid., tome ii. 5e série, Paris, 1853.

Pract. Treatise Diseases of Children. By James M. Coley, Philadelphia, 1846. Guy's Hospital Reports, vol. iv. N. S., 1846, p. 36, et seq.

6 Lectures on the Principles and Practice of Physic, by Thomas Watson, London.