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a good omen. Have had no hemorrhage to speak of in a single case. I think Credés method the best one for the expulsion of the secundines. I never give ergot until the contents of the uterus have been expelled, and then usually give a teaspoonful. I sometimes give quinine when the pains are inactive, and I nearly always leave a few doses to be given during the puerperal state. Have never had a case where the temperature was above 102° F. I have had two or three bad cases of abortion come under my jurisdiction.

Generally speaking I like the practice of obstetrics very well, although I rather make a special study of pediatrics. I think, however, that the two branches would make a very good combination where a doctor does not care to do a general practice.

Success to the BRIEF.

I get a great many good points from its columns.

[Written for the MEDICAL BRIEF.] Treatment for Chronic Ulcers of the Leg.

BY E. BRUCE WENNER, M. D., Philadelphia, Pa.

I noticed an article in the April number of the BRIEF, by Dr. Ira A. Marshall, on the same subject. I have no fault to ind with his experience and treatment whatever. I simply wish to give to the profession my extremely successful treatment in this unyielding affection.

I also noticed an inquiry in the same journal, by Dr. R. S. Blair, as to the successful treatment of the same trouble, therefore trust it may be of service to him.

About six years ago I was called to see an aged lady, suffering much pain, had a large ulcer on the outside of left leg, just above the ankle. Leg swollen, and black and blue half way up to the knee. She had been to the different doctors of the neighborhood, but failed to be cured. I had experiences with nearly all kinds of ointments, and dry antiseptic dressings, in treating such ulcers, and succeeded fairly well in healing them in some cases, but the result was not permanent, and the treatment, therefore,

unsatisfactory to me. On account of the severe inflammatory condition of this case, I persuaded her to let me cut the indurated edges of the ulcer, and let the blood out by pricking the surrounding surface. Accordingly, I placed her foot into a spacious vessel, containing warm water, to facilitate the flow of blood, and, with a thin, narrow blade, cut a number of openings into the edge of ulcer, and then very rapidly punctured the congested leg in six or eight different places, by running the blade in from a quarter to a half inch. The blood began to flow in streams, and I let it flow until it stopped voluntarily. After bleeding ceased, washed the parts with sterilized water, and dressed with iodoform, bichloride, or iodoform gauze, cotton, and bandage.

Returned in three days, and found congestion all gone, ulcer much smaller, no pain, color quite natural, and a much pleased patient. She said she had rested better the last two nights than for many weeks. I repeated the same treatment once a week, and had a complete and permanent cure in three and a half weeks. I have used the same treatment ever since, in all chronic ulcers of the legs, with the same result in all cases. I have never since had one ulcer to return. The operation, if done quickly, is not very painful, but very effective.

Gentlemen, try this, and you will not be sorry. I have come to the conclusion that so long as the parts are so very much congested from the great amount of blood present in the surrounding tissues, it is almost impossible to heal the ulcer. The patient's general condition must be considered also. Tonics, fresh air, and moderate exercise add to the prevention of a return of the ulcer, no doubt.

[Written for the MEDICAL BRIEF.] Albumen Test.

BY J. M. ADAMS, Urinary Analyst, Etc.. Watertown, N. Y.

The most sensitive test for albumen in urine, is found in treating with an exceedingly dilute aqueous solution of formaldehyde. It exceeds all other tests yet discovered.

[Written for the MEDICAL BRIEF.]



M. A., M. D., EDIN., M. R. C. P. LOND., Senior House Physician to the National Hospital for Paralysis and Epilepsy, Queen Square, London, Eng.

Chorea is a commonplace disease. So many excellent descriptions of chorea have been written in medical text-books that it may seem well nigh impossible to invest with interest so threadbare a subject. This paper, therefore, must be considered merely as a supplement to the classical descriptions of chorea, not by any means as a substitute for them. The following remarks are founded on clinical observations, and the statistical references in this paper are based on notes of cases personally observed. I have taken the first twenty cases which happened to come under my observation during the past twelve months, and these cases are not selected for their peculiarities, but were recorded indiscriminately as they came under observation. Yet they are sufficiently numerous, I think, to justify us in emphasizing certain points in the symptomatology of the disease which have hitherto, perhaps, been inadequately recognized.

It will be convenient to arrange our discussion of the subject under several headings, viz.: Etiology and Pathology, Symptoms, Complications and Treatment.


Chorea has a clinical, rather than a pathological, existence. Very little is known with regard to its essential pathology. Various appearances have been described in autopsies on fatal cases, amongst which may be mentioned general hyperemia of the brain, occlusion of arterioles by thrombosis or by embolism, extravasation of blood round minute vessels in the brain and spinal | cord. But one insurmountable objection to our acceptance of any of these as the essential cause of the disease lies in the fact that any, or all, of these changes may be entirely absent, and the brain, spinal cord, and nervous system in general, may appear abso

lutely normal, so far, at least, as our present methods of investigation enable us to judge. The nature of the choreic movements points undoubtedly to their origin from an irritable condition of the nerve cells of the motor cortex of the cerebral hemispheres, and, as we shall see, the frequency with which the symptoms are confined to one side of the body still further corroborates such a hypothesis. We seem driven to regard the disease as a functional, rather than a structural disorder of the nerve cells. There can be little doubt that some molecular and chemical changes in the nerve elements must underlie all socalled "functional" disorders, but the exact nature of such changes is a problem as yet unsolved. If it is to be solved, it will probably be by the physiological chemist rather than by the histologist. It appears to be not improbable that the disease may be due to a toxin.

Clinically, a history of rheumatism or of scarlet fever, or a family diathesis towards rheumatism is very common, and should be inquired for in every case of chorea. Out of twenty choreic patients, in seven there was a previous history of rheumatic fever in the patient; in four there was a strong family history of rheumatic fever, and in the remaining nine there was no history of rheumatic fever in the patient, or the patient's family; but out of these nine, two had mitral stenosis (which proved fatal in one case); five had mitral regurgitation, and only two had no valvular affection of the heart.

Another fairly common antecedent is fright or shock to the nervous system. Out of twenty cases, five gave a history of fright or shock. Of these five, one patient had had rheumatic fever, another died of mitral stenosis, and the other three bad all of them signs of mitral regurgitation. One little patient is said to have acquired the disease by imitating another child afflicted with chorea, but it is doubtful whether this is to be considered as the sole cause. Another patient, an adult, developed violent chorea after a quarrel with her landlady. The presence of worms in the intestinal canal has been believed to cause some cases of the disease by

reflex irritation, but in our series of cases, the only case of chorea in a child with a tape-worm, occurred in a patient who had previously had an attack of rheumatic fever. The probability, therefore, is, that in many cases, shocks and irritations to the nervous system only precipitate an attack of chorea in a constitution which is already rheumatic. Two of the twenty patients were pregnant-primi gravidæ. One of these, however, had had repeated attacks of chorea before, the other had previously suffered twice from rheumatic fever.

Chorea is essentially a disease of childhood, being common between the ages of five and fifteen years. In our twenty cases, eighteen came on between the fourth and the fifteenth year, five of which (a large proportion), occurred at the fourteenth or fifteenth year. This, of course, refers only to first attacks of chorea. After fifteen years of age, chorea is much less common as a primary attack, although second and third attacks are not uncommon after the age of fifteen. In our series of cases the earliest one occurred in a child aged four years, and the latest age of a first attack was twenty-four years. One old lady, it is true, had a second attack at the age of sixty, but she had suffered from chorea fifty-five years previously, at the age of five.

The female sex is much more liable to this disease than the male. Out of twenty cases, sixteen occurred in females, and only four in males. The proportion being thus four females to one male. This is a little more than the average proportion, which is commonly stated at about three females to one male.


The onset of the disease is more or less gradual, usually taking a day or two to develop, before anything abnormal is noticed about the child. The patient is often fretful and more irritable in temper than usual. Then restless, wriggling movements are observed in the face or limbs. The symptoms gradually increase in severity, and in. fully developed cases they may be classified into several groups, viz.:

(a) Irregular involuntary movements.

(b) Incoördination on voluntary exertion.

(c) Weakness of the affected muscles. The irregular involuntary movements are quite sui generis. They are of a twisting, wriggling, and tossing type. Face, trunk, and limbs, indeed, all the voluntary muscles of the body, may be affected; but the choreic movements, in the majority of cases, affect one side of the body earlier and more severely than the other, and may often remain confined entirely to one side. In our experiences the left side is far more commonly affected than the right. Out of the twenty cases referred to, no fewer than twelve were either wholly leftsided or affected, the left arm distinctly more than the right; five were bilateral, affecting both sides apparently equally, and in only three were the movements right-sided, either entirely or preponderatingly. Of these three right-sided cases one was in a left-handed boy (which still further strengthens the opinion as to the greater frequency of left-sided chorea in ordinary righthanded patients); and another case occurred in a patient who had received a severe electric shock from a dynamo in his right hand, five days before the movements commenced in the right hand. It is interesting to observe that in ordinary, right-handed patients, the choreic movements usually (though not invariably) begin on the left side. A similar preponderant left-sided distribution of "functional" paralysis, motor or sensory, in right-handed people, and of right-sided "functional" paralysis in left-handed people, has also been observed in other "functional" diseases, such as paralysis agitans, hysterical hemi-anesthesia, etc.

The commonest starting point for the movements is in the hand. Once begun, the movements are quite characteristic. They may vary in degree from the slightest restlessness of the fingers to the wildest and most violent irregular movements of the whole limb. The affected joints in arms and legs are impetuously flexed, extended, rotated, or circumducted. The eyes roll about restlessly. The patient makes peculiar foolish grimaces, sometimes shutting his eyes, sometimes showing his upper teeth.

The jaws may open and shut irregularly, the tongue may be moved in various directions, and not infrequently it is bitten by a sudden, involuntary snap of the teeth. In some cases we have seen the soft palate move irregularly and involuntarily. Respiration is often jerky, and irregular; the action of the diaphragm is often overshadowed by that of the intercostal and extraordinary muscles of respiration. Sometimes the intercostals and diaphragm contract alternately instead of synchronously.

In severe cases the limbs may be thrown about so violently, that the patient may fall out of bed, or may bruise or cut the bony prominences of his arms, legs, or head, by knocking them against surrounding objects. So much for the involuntary movements, which are always irregular, not rythmical.

Voluntary movements are always impaired when involuntary choreic movements are going on. The irregular, spontaneous movements of chorea are very little under the control of the will. But sometimes, in mild cases, no spontaneous movements are seen, and it is only on voluntary exertion that the chorea is evident. A good test for slight cases of chorea is to make the patient hold up both hands, for a few seconds, above his head, with the fingers outstretched. This usually succeeds in bringing out a few irregular wriggling movements of the fingers on the affected side; or, make the patient squeeze your hand, and you will find the choreic grasp to be sudden, spasmodic, jerky, and ill-sustained. If the grasp be compared on the two sides, in a case of hemi-chorea, it will be found that the grasp on the choreic side, though more sudden, is yet actually weaker than the grasp on the unaffected side. Also, in picking up objects, the patient makes a sudden dash for the object, and often drops it after securing it. Sometimes, on the other hand, the patient has a difficulty in letting go an object promptly when he wishes to do so. Thus, in feed. ing himself he often drops his cup, and may scatter his food about the table with his knife and fork.

In the lower limbs, besides the involuntary wriggling movements, similar to

those observed in the arms, we may find the gait peculiarly altered. In walking the knees may suddenly give way, causing the patient to fall down.

Articulation is often very jerky and indistinct, and, in bad cases of chorea, the speech may be quite unintelligible, or the patient may only speak in a whisper, or he may refuse to speak at all. In the latter case a mental element is superadded, which is not infrequent in severe cases of chorea.

A considerable degree of muscular weakness is common in chorea. In some cases it may be so severe that the patient is unable to raise a limb from the bed, although slight, restless movements are seen going on irregularly in the weakened limbs. Such cases, where the weakness is out of all proportion to the choreic movements, have been termed "paralytic chorea."

Sensory Phenomena.-These are not referred to in the text-books with the emphasis which their frequency merits. True, in most cases of chorea, the patient does not complain of numbness, pain, or any other abnormal feeling, but if sensation be carefully tested in every case of chorea, it will be found that a certain proportion of patients show a degree of blunting of sensation on one side of the body (seven cases out of twenty in our series). This hemianesthesia, when present, always occurs on that side of the body on which the choreic movements are best marked. The hemi-anesthesia of chorea is very slight in degree, and can only be detected by comparing corresponding points on opposite sides of the body. If this be tried, many patients will be found to perceive light touches and pricks more acutely on one side than on the other, and the boundary of this area of blunted sensibility will always be found to be exactly in the middle line of the body. Sometimes the trunk and limbs are alone involved in the hemi-anesthsia, the face and scalp escaping.

As to reflex action: the superficial reflexes are occasionally diminished on the hemi-anesthetic side. The only other point worthy of note in this connection is the "choreic knee-jerk," which is demonstrable in some cases of the disease, not in all. When present,

it differs from the healthy knee-jerk, in that when the patellar tendon is tapped, instead of producing a brisk contraction of the quadriceps extensor, followed at once by a sudden relaxation, the knee is suddenly extended to its full extent, and remains so for a second or two, the foot and toes of the extended limb meanwhile exhibiting irregular wriggling movements. In very severe cases of chorea, with much mental dullness, the sphincter may be uncontrolled, the patient passing urine and feces into the bed. The duration of the disease is very variable. An ordinary case of moderate severity usually lasts six or eight weeks, but some cases may last six months or more. Moreover, the disease tends to recur again and again. It is not uncommon for a patient to have four, five, or six attacks.


Of these, by far the most important is valvular heart disease, generally of the neutral orifice. We have already seen that many cases of chorea occur in patients who are already rheumatic, and we know that rheumatism is the commonest cause of valvular heart mischief. But even where there is no previous history of rheumatism, a large proportion of choreic patients exhibit well-marked valvular disease. As we have already seen, in our own series of cases, out of twenty cases there were nine in which no history of rheumatism was obtainable. Yet no fewer than five of these nine had neutral regurgitation, two had neutral stenosis, and in only two was there no valvular affection of the heart. Four other cases in which there was an actual previous history of rheumatism showed no cardiac abnormality. The majority of cases of chorea, then, show some evidence of cardiac affection. It is extremely rare to find a patient with a second or third attack of chorea in whom the heart has not become affected. Moreover valvular disease may be quite distinct at the second attack of chorea in a patient in whom it was quite absent during the first attack, and this without any rheumatic fever in the interval between the two attacks of chorea. It is, therefore, certain that chorea may produce valvular heart disease in the absence of an

attack of rheumatic fever, and this fact is held by some authorities to support the theory of the essentially rheumatic nature of chorea.

Some cases of chorea are sometimes accompanied by mental dullness, which may amount to acute dementia. In one of our cases the patient was silent and apathetic for four weeks, passing urine and stools in bed, and requiring to be fed by nasal tube, for she did not swallow food even when placed in her mouth. Yet this patient, after passing through a stage of mild delusions, ultimately recovered completely, as most cases of post-choreic insanity do.

Subcutaneous rheumatic nodules are found in some choreic children, the nodules varying in size from a pea downwards. Their commonest distribution is along the subcutaneous borders of the ulna and tibia, and around the elbow and knee-joints. One child in our series had a painful contracture of the palmar fascia, probably rheumatic in origin, and clearing up under appropriate remedies.


The first and most important thing to secure for every choreic patient is rest, physical and mental. The child must be taken away from its lessons and put to bed. Even in mild cases, rest in bed should be insisted on, for several weeks at least, and when the patient is ultimately allowed to get up, it should only be for a short time each day at first, gradually lengthening the time which he is allowed to spend out of bed. In severe cases, where the choreic movements are very violent, the patient must be prevented from falling out of bed, or from hurting himself. In bad cases the patient must be laid on a mattress in the corner of a room, and the corners of the room, into which the mattress fits, should be padded with cushions or pillows to prevent the patient from knocking himself against the walls. How long are we to keep a choreic patient in bed? It will be found advantageous to keep him at rest in bed until the choreic movements of the fingers, on holding out the hands horizontally in front of him, are very faint. In some cases in private practice it is difficult to convince the patient's friends

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