1847]

Dr. Hughes on Chorea.

109

perforation at that part: and, further, from the fact that there was seen, at the inspection of the body, a thick layer of old lymph, in part detached from the peritoneum, over the opening, allowing of an escape through it, but which, during its super-position, as regarded the opening, would have as completely prevented any occurrence of the kind.”

VIII. The article on certain " Appearances in the Stomach after Death," by Mr. Wilkinson King, is written in such a strange pedantic style as to be scarcely intelligible. Our readers would not thank us, we are sure, for any extracts and we therefore at once proceed to notice the "Digest of 100 cases of Chorea, treated in the Hospital," by Dr. Hughes.

Of these 100 cases, 73, or nearly three-fourths, occurred in females. The greater nervousness of constitution in girls and their consequent greater susceptibility to all external impressions, and especially to one principal exciting cause of the complaint, Fright, will partly account for this very marked preponderance. The changes, too, induced in the female system on the approach, and from irregularities, of the catamenial secretion, may have something to do with it.

In three of the cases, the sudden suppression of the menses, resulting from fright, is mentioned as the immediately-exciting cause of the attack. "I believe," says Dr. H. it will be found that females who have passed the age of puberty are rarely affected with chorea, unless they be troubled with some irregularity of the periodical function of the uterus, or unless the complaint be clearly connected with rheumatism, or with disease of the brain or spinal-marrow."

Age. Of the 100 cases, 33-11 in males and 22 females-occurred at or below the age of ten years; 45-11 in males and 34 in females-between ten and fifteen; and 22-5 in males and 17 in females-above the latter age. Above eighteen years of age, the number of males affected was the same as that of females, viz. 4. It may be also worthy of notice that the two youngest patients, aged five and six, were males. As to the alleged exciting causes, it is difficult to speak with any degree of confidence. 31 cases are referred to fright; and 8 to rheumatism, simple or complicated. We extract the remarks of our author on the connection of Chorea with Rheumatic Affections.

"The connection between the two diseases has been often noticed; and the frequent occurrence of spasmodic affections with pericarditis, which, in the great majority of cases, is of a rheumatic origin, has been particularly illustrated by Dr. Bright, and, more recently, by Dr. George Burrows. It appears at least doubtful whether, in most of such cases, there exists anything more than a sympathetic affection of the spinal marrow; seeing that after the removal of the rheumatic affection the chorea is usually curable by the same remedies which are found available in cases of chorea having a different origin. There are, however, some exceptions, in which the membranes of the cord seem to be inflamed and thickened, and in which local depletion, counter-irritation, and the continued action of mercury, appear to be the means more especially calculated to remove the complaint, which, in such instances, is often very rebellious.

66

Among the fifty-eight cases in the table in which, after inquiry, either no exciting cause could be ascertained, or a particular cause of the complaint is mentioned, eight are enumerated as having their origin more or less directly in

rheumatism. This number, amounting to nearly 14 per cent., may be, perhaps, regarded as a fair average." P. 376.

In some of the cases of rheumatic complication, there was Pericarditis present.*

Treatment, mode and duration of.-With respect to the latter point, it would seem that, in an immense majority of the cases, the patients were under treatment for from three weeks to two months. We shall now briefly notice the results of the principal modes of practice that were tried.

To trust entirely, or even mainly, to the use of Purgatives, in conjunction with good diet, and, it may be, wine also, as some have advised, is a practice that cannot be favourably spoken of. There is a form of tonic aperient however, which may often be used with very great advantage, more especially in the weak, ill-fed children of the poor. This is a cold infusion of Rhubarb (3ss. sliced) in port wine (3viij); two or three table-spoonfuls may be given thrice a day.

"The effect of this medicine, together with good diet, is often very remarkable; not only upon the disease for which it is prescribed, but also upon the health, strength, and general appearance, of the little patients. It must be, however, acknowledged that, while it improves the general health, it sometimes fails in curing the complaint." P. 383.

We need scarcely say that the state of the bowels must be carefully attended to in every case of Chorea, without exception; as the irritation of unhealthy secretions, worms, &c. is well known to aggravate every spasmodic disease. But this is a very different thing from following the purgative plan of treatment.

Mineral Tonics.-Different practitioners have given a marked preference to different sorts, and different preparations, of this class of remedies.

"While one regards Arsenic as a specific for true chorea, another cures nearly all his cases with the sulphate or the oxide of Zinc; and another considers the sulphate or carbonate of Iron as an almost infallible remedy. This may perhaps arise, in a great measure, from habit. It is possible that all may be nearly equally efficacious. I have seen each of these, and many other remedies, occasionally cure the complaint; and I have seen them all occasionally fail. I have seen zinc cure after arsenic and iron had failed; and iron cure after zinc had failed. Iron sometimes acts with excellent effect, and with great rapidity, after zinc has been administered for weeks, and in large doses, without any, or scarcely any, impression being made upon the disease. It also frequently acts exceedingly beneficially in improving the general health, and completing the cure, after that has been, in a great measure, effected by the administration of zinc."

P. 385.

According to Dr. Hughes' experience, Arsenic is not so useful as other

* Whenever there is any tendency to Chorea or other Spasmodic affections, the debilitation of the system has invariably a tendency to aggravate the complaint. There cannot, we think, be a doubt but that the condition of the circulating fluids has a good deal to do, if not with the induction, at least with the persistance, of Chorea. As far as we know, medical writers have not yet ascer tained with sufficient precision whether cardiac or vascular murmurs are generally present or not, independently of any rheumatic complication; and whether, if present, they subside as the patient gets well.-Rev.

1847]

Dr. Hughes on Chorea

111

mineral medicines; but he has not used it in many cases. Iron is especially well suited to chlorotic females, to girls approaching the period of puberty, and to anæmic children. It was usually given in the form of the sulphate with extract of gentian, the sesqui-oxide, and the compound steel mixture. Zine was more largely administered than any other metallic preparation, and usually in the form of the sulphate. "Beginning with one or two grains three times a day, it has usually been gradually increased by a grain to each dose at each visit twice or thrice a week; or by adding one grain daily to the whole quantity taken in the day. It has been given either in the form of pill or in solution. The dose has been increased up to thirtysix grains three times a day. It has not often caused sickness. The stomachs of some persons, however, appear unable to bear it even in small doses; and in others the organ rebels against its increase after a certain number of grains has been attained."

"In seven of the forty-five cases iron had previously failed; the zinc was given together with iron in one, and together with the administration of electricity in five cases. In two cases the zinc was given in the form of oxide." P. 387.

Electricity. The effects of this remedy in Chorea are sometimes remarkable. Occasionally it will effect a cure, and this too rapidly, after a great variety of remedies has been tried in vain; in other instances, it does harm rather than good. "The cases in which it appears to be more especially applicable are those occurring in young women, in whom the disease assumes somewhat of an hysterical character, and those protracted cases in boys in whom other remedies have been tried ineffectually, and in whom the disease is dependent upon no obvious source of irritation, and has an injurious effect upon the general health instead of being affected by it."

Shower Bath.-Dr. Hughes rather oddly remarks that he is not able to judge of the influence of this remedy, when employed alone in the treatment of Chorea. Who would ever be so mad as to do this?-except indeed some of your French experimentateurs, determined at all hazards to dress up some statistical table or another, in the way of a report !

Shower bathing is certainly not suited to all cases. Much will depend upon the circumstance whether the young patient likes it or not, and also whether a feeling of general warmth is induced after its use. It is therefore to be regarded as a mere auxiliary, but never as the principal remedy. Results. Of the 100 cases, the general result was—

Of the 3 fatal cases, one occurred in a young woman,

and was accompanied with suppression of the menses; in another, death was the result of an attack of Pericarditis, in a girl 16 years of age; and in the third, which occurred in a man, 25 years old, the malady appears to have been connected with disease (although not extensive or well-marked) in the cerebro-spinal axis.

The last patient occurred in Dr. Hughes' practice at the hospital, about two years ago. Without any obvious cause, the patient became affected with twitchings in both hands; in the course of a few days, these irregular movements extended to the arms; next to the face, and organs of articulation; then to the legs and to the trunk; so that, when admitted, he was in a lamentable state of jactitation in every part of the body. The mouth, eyes, trunk and limbs were twisted and turned in every possible direction, without a moment's cessation. The motions and contortions were so violent as to throw him out of bed, even though boards were put at the side for his protection. He was all this while perfectly sensible; nor was there paralysis of any part. Tonics and generous diet were ordered. He did not sleep a wink during the night, being in a state of constant and violent motion the whole time. Next day, he was much exhausted; and, as the convulsive movements continued as severe and incessant as ever, it was manifest that, unless sleep could be procured, he could not last long. Opium was given repeatedly, but with no effect. He died about 40 hours after admission into the hospital.

The report of the dissection is as follows:

"Head: a small quantity of blood was spread thinly over the arachnoid, on both sides of the vertex ; but it was doubtful if this might not be the result of violence in removing the calvarium. The edge of the fornix on the right side was much softened; and the surface of the third ventricle tumid, red and soft. No other morbid appearance was observed in the brain. Spine: the rachidean fluid vas opaque, yellow, and largely coagulable by heat, and the medulla, upon section, was thought to be softer than natural. Chest: evidence existed of slight pleuritis and pneumonia. The blood was thick, dark, and fluid. Patches of ecchymosis existed below the attached pericardium and the endocardium. The lining of the aorta was dyed by the fluid blood, and its root sprinkled with atheroma." P. 392.

Whether our readers will agree with Dr. Hughes in regarding this anatomical inspection as "especially valuable," we leave to themselves to decide. The case is a remarkable one of fatal Choreic Convulsions. A priori, we should certainly expect the Spinal Marrow to have been the seat of the chief pathological changes: but, alas! morbid anatomy throws but little, if any, light upon too many of the Neuroses.

IX. CASES AND OBSERVATIONS IN MEDICAL JURISPRUDENCE. BY Alfred Taylor, F.R.S.

As Mr. Taylor has so deservedly acquired a high reputation for skill in medico-legal enquiries, more especially in those which relate to Death from Poisoning, and as, most unfortunately, instances of this description seem to be on the increase each successive year, it is highly necessary for medical men to be fully prepared for the performance of those duties which moral,

1847) Mr. Taylor's Cases in Medical Jurisprudence.

113

as well as legal, justice requires of them. This can only be done by having their attention frequently drawn to the narratives of the more important cases as they occur. We shall therefore briefly notice those which Mr. Taylor has recorded in this paper.

1. The first case is one of fatal Poisoning from Sulphuric Acid. The sufferer was an infant, only four months old. The medical man first called gave magnesia and carbonate of soda in frequently-repeated doses. Subsequently lime-water with breast-milk was administered; then nitrate of potash in combination with the compound tragacanth powder. The infant survived 25 days. Great praise is due to the skilful treatment of the surgeon in attendance, Mr. Tatham of Wandsworth. Perhaps it would have been better, if chalk had been administered in place of magnesia and soda, as the sulphuric acid forms soluble aperient salts with these bases; and the diarrhoea thereby induced might prove troublesome.

On dissection, no distinct morbid appearances were discoverable in any part of the alimentary tube.

The matter, that was at first rejected by vomiting, was of a glairy grumous nature, thick, and of an almost black colour. This was subsequently analyzed by Mr. Taylor, and shewn to contain distinct traces of sulphuric acid, by testing it with a salt of barytes, the white precipitate so formed being insoluble on the addition of nitric acid. With respect to the physical appearances of the vomited matter, Mr. Taylor observes that the acid "must have been evidently taken in a concentrated form, from the dark and carbonized appearance of the matter ejected.* It is only concentrated vitriol which thus chars and decomposes blood, mucus, and other organic substances; and by this action it becomes itself decomposed and partially lost."

The report drawn up by Mr. Taylor was for the use of the Wandsworth magistrates. The person upon whom suspicion fell, was a servant girl in charge of the child. The sulphuric acid had been obtained for the preparation of blacking. That the infant had perished from the effects of this most corrosive poison, somehow given to it, could not be disputed, after the convincing medical and chemical evidence adduced; but, then it was argued by the prisoner's counsel, that the oil of vitriol had been administered, in mistake, for aniseed water, by the mother of the child, and not by the servant. The jury, being not satisfied of the guilt of the latter, acquitted her.

Mr. Taylor enters upon a lengthened examination of the various circumstances connected with the medical and chemical evidence of the case, to shew that it could not have been the mother who had accidentally administered the poison. The facts and reasonings which he adduces must satisfy, we should think, every reader.

2. The next case reported is one of Profuse Salivation, following the use of small doses of Calomel in Nephritis, and proving fatal. The case occurred about twelve months ago at Reading, and the party inculpated

"I place these words in italics, as the defence set up was that the acid was taken in so diluted a state, as not to have the power of carbonizing sugar! See Mr. Tatham's evidence, p. 417."

NEW SERIES, NO. 1X.-V.

I