Case of Severe Chorea. By Dr. Barclay, Medical Registrar to St.
George’s Hospital.—A very severe case of this disease has just been
brought to a successful termination, some few particulars of which may
be found worthy a place in the Medical Times and Gazette. ■ For some
days the issue in life or in death was exceedingly doubtful; and the
means employed, with beneficial results, being somewhat unusual in the
treatment of this disease, available suggestions maybe derived from their
detail to guide others in the management of similar instances.
The two principal remedies used at the time when the disease took a
favourable turn, and to which we are, therefore, disposed to look as those
by which its progress was checked, were the inhalation of chloroform
and the employment of large suppositories of quinine. The former agent
now holds the first place in temporarily allaying nervous irritability and
suspending muscular action; but its effects are also not merely tempora-
ry; sleep commonly follows on recovery from the immediate stupefac-
tion ; and in how many instances may not the physician say, “ if he
sleep he shall do wellI” But it is not the troubled dream of narcotism
or quasi intoxication that fulfils the function of “Nature’s soft nurse.”
If natural sleep does not follow on the cessation of the artificial dose,—
if the drug, whatever it may be, does not serve merely as the first pro-
vocative of a “ balmy sleep,” which is prolonged without artificial aid,
the object of the physician will be frustrated, and the patient will awake
unrefreshed by his slumbers, and, perhaps, not uninjured by the conges-
tion of the brain which always attends in greater or less degree the ac-
tion of narcotics. On this circumstance depends the very varying success
which has attended the use of chloroform in states of extreme nervous
irritability—mania, delirium tremens, and chorea; in each of which it
has been employed at times with apparent advantage, while at others its
effect has been null, or even, perhaps, pernicious. It is true that,
as its effects are more transient, at the same time that they are more de-
cided than those of any other narcotic, it may be ventured on in those
doubtful cases bordering on inflammation, where, in all probability, a
certain degree of congestion already exists, and where we should not feel
justified in giving opium or even morphia experimentally, and, there-
fore, there is less limit to the cases in which its effects may be tried; yet
while we know that we can for a time allay pain, annul consciousness,
and calm irritability, we cannot be certain that we shall succeed in ob-
taining a natural, sleep, and, therefore, can be by no means certain, even
when no congestion exists, that its action will be curative.
Along with the calm of the narcotic, and, in fact, to give full force to
its action, it was necessary to support the system, and restore its exhaust-
ed energies, by the administration of a tonic. Large doses of quinine
have of late been so frequently given, with alleged benefit in some in-
stances, and apparently without prejudice in all, that nothing need be
said except with reference to the mode of administration, which was here
in the form of suppository : tonics and sedatives, taken into the stomach,
had failed of quieting, and restoring disordered function; and, in such
cases, it always demands consideration, whether perverted assimilation
may not prevent their entering the circulation in such a manner as to
produce their normal effects on the system. Dr. Wilson is con’stantly
in the habit of noticing this circumstance in the depraved states of sto-
mach of habitual drunkards, and attempting to reach the nervous system
by another channel, which may not offer the same obstruction to its ab-
sorption. With this view, opium, in the form of suppository, is fre-
quently ordered in delirium tremens with the best effects.
The consideration, too, of the absence of the menstrual flux, the evi-
dence of periodical congestion of the generative organs, was not without
its importance in determining this application of the remedy. The cata-
menia had been regular up to that time, and the decided exacerbations
of the symptoms occurred just when their return was expected. Two or
three days had passed without any appearance of the sort, and the symp-
toms were gradually increasing in severity wheri this remedy was em-
ployed. It may be remarked, however, that, up to the period of her
convalescence, the function was not restored.
Susan II—, aged 16, was admitted into St. George’s Hospital, under
the care of Dr. Wilson, on February 23, 1853. She had been in ser-
vice, and had been much worried by illness in the house, and over-work.
No. other cause was known for the occurrence of the symptoms of chorea,
which had been gradually supervening during a fortnight or three weeks
before her admission. She had had no rheumatism, and the heart was
healthy. When received into the hospital, the spasmodic movements
were not by any means violent, nor very constant; but there was great
distortion of feature, especially when she attempted to speak. She was
ordered a strong purgative, and then directed to have six minims of
Fowler’s solution in pimento water, three times a day. The bowels were
rather loaded, and much inclined to be costive, and the purgative was
repeated on two or three occasions. She continued taking the arsenical
solution until the 11th of March, and seemed, under its influeuce, to be
gradually becoming quieter and steadier. She was rather out of sorts
that day, and the arsenic was left off for a day or two.
The spasmodic movements now began to be more frequent and severe,
and she was obliged to lie in bed. The sesquioxide of iron was given
in doses of two scruples three times a day without benefit. Her nights
became disturbed, and she used to scream out a good deal during the
day. Seclusion had rather a calming effect upon her; and the bed was
screened off from the rest of the ward, during which she used to have oc-
casional short slumbers; but, for the most part, she was very restless;
the expression of her face was rather wild, and the spasmodic movements
constant and severe.
On the 17th, the bowels having been well purged, she was ordered to
have a third of a grain of tartar emetic every three hours, and half a
grain of acetate of morphia at night. This produced no sickness, and
seemed partially to calm her; it was continued a second day, at intervals
of four hours. She had no sleep that night, and was evidently no bet-
ter ; without being very violently tossed about, there was excessive rest-
lessness and desire of movement; her face was much distorted, and the
expression wild, and almost maniacal; and, as she sat upon her bed,
with her legs drawn up under her, and her hair in wild confusion about
her face, she looked much more like a proper inmate for Bedlam, than
a person suffering simply from chorea, and the more so, because of her
constant cries; but the nurse satisfied herself that she was free from de-
lirium, and perfectly conscious on all occasions.
She had now passed the catamenial period, with no return of the men-
strual flux. Her nights were sleepless, and a quarter of a grain of mor-
phia was given every three hours to six times, but without benefit. She
seemed to be gradually becoming exhausted by the constant jactitation
and want of sleep. Wine had been given; yet the tongue was becom-
ing dry and brown, the lips covered with sordes, and the pulse quick
and feeble. Her aspect was distressed, and she was tossed about very
violently by the spasmodic movements of the disorder.
On the 21st she was directed to inhale chloroform, and to have a sup-
pository, with two grains of opium at onpe, and a draught with four
grains of camphor, and some chloric ether every two hours. The first
inhalation quieted her, but she awoke almost immediately after the first
effects had passed off; it was not repeated till night, and, in the mean
time, eight grains of quinine in suppository were ordered every hour for
six times. She had some sleep after the second inhalation, and it was
repeated the following forenoon. She was decidedly quieter, and the
draughts and the suppositories, which had not been all given with per-
fect exactness, although very frequently during the night, were conti-
nued at intervals of four hours. The chloroform inhalation was again
repeated on the evening of the 22d. She slept pretty well after it
through the night, and fell asleep naturally next morning, waking up to
have her dinner, and almost immediately going to sleep again, and con-
tinuing to dose all day. From this time she continued to improve
rapidly. She was still a little odd-looking in the face, and restless jacti-
tations lasted for some time; but she gradually became steadier. On the
4th April she was ordered Griffith’s mixture, and on the 15th was dis-
charged recovered.—London Medical Times and Gazette.