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NATIONAL LIBRARY OF MEDICINE




         Bethesda, Maryland 
/ 
 
AN
&ttt»gttrrtr< #te&ttttftat
ON
CHOREA  SANCTI VITI,
SUBMITTED TO THE EXAMINATION
HONORABLE ROBERT SMITH, PROVOST,
AND OF THE
MEDICJIL PROFESSORS ANB $EGEJYT8
UNIVERSITY OF MARYLAlS$)yv t
FOR THE DEGREE OF
DOCTOR OF MEDICINE.
BY ERNESTUS A. DUNKEL
   OF BALTIMORE, MARYLAND.
" Mobilitas ipsa nimia esse potest,
""Probe disting-uendum est hanc inter et vigorem."
                   GREGORT.
    Baltimore:
PRINTED BY JOHN WANE,
 XO. 22, NORTH GAT-STREET.
      1815. 
 
               TO




Dr. GEORGE A. DUNKEL,




  This Essay is respectfully and gratefully




    inscribed, as an humble tribute of




       Filial Affection  and kindness, for




         the many favors  and benefits




           which have been conferred on




             His Son and Pupil,




                   THE AUTHOR. 
              TO




1 HE MEDICAL PROFESSORS,




  Of this  University, this Essay is also





    offered, as a testimony of gratitude,




      for the many marks of attention




        which have been shewn to  '




                  THE AUTHOR. 
        INTRODUCTION.
  AS the laws of the institution, in which I have imbibed
the principles of Medical Science,  make it obligatory to
write, publish and defend a dissertation, any apology for
obtruding my juvenile production upon the  world would
be superfluous.  Among  the great diversity of subjects
that  have presented themselves to my mind, during my
state of probation, none appeared more worthy of inviting-
attention than Chorea Sancti Viti.
  From the great diversity of opinion that has existed con-
cerning the causes  and theory  of Chorea as well as from
the variety of cures which have been proposed, I was in-
duced to select it as the subject of an Inaugural disserta-
tion.  I was  also urged by another motive, which was thai
I might bring into more general notice, a remedy which has
been recently employed with the greatest success.
   Chorea, commonly called chorea Sancti Viti derives its
name from *«*. a dance, and from a supposed resem-
blance to the gesticulations performed  by certain fanatics,
before the shrine of Saint Vitus.
  This disease, so formidable in modern times, must
haveoccurredformerlyless frequently, and in amuch mild- 
                          6
ei i.m ai than at this day, since Sydenham, whose practice
was very extensive, met with but five cases, which ap-
pear to have been of a lowT grade, when compared with those
related by Hamilton  and other  eminent authors.  This
opinion,  is strengthened by the silence of Boerliave,  who
makes no mention of it in his aphorisms, andithe declara:
tion of Doctor Henry Buyzen, of Haerlem, who translated
Sydenham with annotations.   He says he never saw a  per-
fect case of chorea, but observes that Plater and Tulpius
have given an accurate description of it.
 Chorea has been confounded with Scelotyrbe, and is treat
ed of by Sauvage under the name of Scelotyrbe chorea viti;
but from the description of Scelotyrbe, left  us by  the
ancients, I am induced  to believe that they are distinct
diseases.  Galen describes it as  a  species of paralysis of
the legs, which renders  the person afflicted by it, unable
to walk in a straight line, crossing the left foot  over the
right,  or the right over the left or both alternately -,  and
sometimes raising his feet, as if he were ascending a great
acclivity.
   Chorea generally attacks young persons of both sexes.
It has  been supposed that girls  are more liable to it than
boys -,  as they are of more delicate  frames there is proba-
bly some foundation for this remark.   Dr. Potter of this 
                       .  7
I'niverf.j<y,sMpp^"(i?-.that :.*f those attacked by chorea, two
thirds are girls.  It appears, from what different authors
have said on the subject, that children are most liable to
an attack of chorea, from the fifth to the fourteenth year of
their  ages.   Dr. Hamilton  has related two instances, of
which one was sixteen and the other eighteen years of age.
Dr. Heberden saw a person who had it in her  twentieth
year.
   Sydenha m, in  his Schedula Monitoria de  nova febris
                   i
ingressu, thus  describes chorea—•< Chorea  sancti viti
convulsionis  est  species, qu» utplurimum pueros puel-
lasve a decimo  setatis anno, ad  pubertatem usque  inva-
dit;  primo se prodit claudicatione quadam vel  potius ;
instabilitate alterutrius cruris, quod a;ger post se trahit
fatuorum more ; postea inmanu  ejusdem lateris cernitur,
 quam,  hoc  morbo affectus,  vel pectori, vel alii  alicui
 parti adplicitam,  nullo pacto potest continere in eodem
 situ, Vel hor» momento,   scd in alium situm,  aliumque
 locum convulsione quadem distorquebitur, quicquid segei*
 contra nitatur.   Si vas aliquod  potu repletum in manus
 porrigatur, antequam illud ad os  possit  adducere, mille
 gesticulationes, circulatorum instar, exhibebit; cum oiiim
 poculum recta linea ori  admovere  nequeat, deducta a
 spasmo manu, hue illuc aliquam diu versat, donee tan- 
                          8
dcm forte fortuna illud labris proprius apponens, liquore
derepente in os injicit, atque avide haurit; tanquam mi
sellus id  tantum ageret,  ut dedita  opera,  spcctantibus
risum moveret."
  Doctor Francis Home  seems to have copied Syden-
ham's description of the disease.   « Chorea sancti viti,
says Home, est et alia convulsionis species chorea sancti
viti nominata, ubi crus claudicatione,  et brachium cjus-
dem lateris convulsione corripiuntur."
  Doctor CuUen, in his genera morborum class the se-
cond Neuroses,  Order the third Spasmi, and forty-eight
Genus,  Convulsio, thus defines chorea—" Musculorum
contractio, clonica, abnormis, citra soporem."
  Doctor Davidge, in his description  of chorea, in his
Nosologia Methodica, has  improved  upon Cullen. In
his  second class Neuroses and fifth  genus, he says—
" Impuberes ouriusque sexus,  ut  plutmum  intra  deci-
mum et decimumquartum getatis annum adorientes, mo-
tus  convulsivi exparte  voluntarii, plerumque alterius
lateris,  in  brachiorum et nanuum et pedum motu, his-
trionum gesticulationes referentes, in gressu, pedem al
temm ssepius trahentes quam attollentes."
   Doctor Hamilton, of Edinburgh,  thus  describes the
symptoms of chorea :— 
                          9
  " The approaches of chorea are slow.  A variable and
often a ravenous appetite, loss of usual vivacity and play-
fulness, a  swelling  and hardness  of the lower belly in
most cases, in some a lank and soft belly, and in gene-
ral, a constipated state of the bowels, aggravated as the
disease advances,  and slight* irregular involuntary  mo-
tions of different muscles, particularly of the face, which
are thought to be the effect of irritation, precede the
more violent convulsive motions which now attract the
attention of the friends of tbe patient. These convulsive
motions vary : the muscles  of the  extremities and face,
those moving the lower jaw, the head and trunk of the
body,  are  at different times, and in different instances,
affected by it.  In this state, the patient does not walk
steadily; his gait resembles a jumping or starting; he
sometimes cannot walk, and  seems palsied 5 he cannot
perform the  common and necessary motions with the af-
fected arms.  This convulsive motion is more or less vio-
lent, and is constant, except during sleep, when, in most
instances, it ceases altogether.  Although different mus-
cles are sometimes  successively convulsed, yet in  gene-
ral, the muscles affected in  the early part of the disease,
 remain  so during the course of  it.  Articulation is now
 impeded,  and is frequently  suspended—Deglutition is 
                          10
also occasionally  performed  with  difficulty.  The eye
loses its lustre and intelligence ; the countenance is pale,
and expressive of vacancy and langour :  and these cir-
cii ^stances give the patient a  fatuous  appearance.  In-
deed there is every reason to believe, that when the dis-
ease has subsisted for some time, fatuity to a certain ex-
tent, interrupts the exercise of the  menial faculties.
   « Fever, such as arises in marasmus, is  not  a neces-
sary attendant on chorea; nevertheless, in the  advanc-
ed periods of the  disease, flaccidity and wasting of the
muscular flesh take  place,  the consequence of constant
irritation, of abating appetite, and  impaired digestion,
the common attendants of protracted chorea, and which,
I doubt not may,  in  some  instances,  although  contrary
to the opinion that chorea is not fatal, have been the fore-
runners of death."
   Doctor Stoll, in relating a case  of chorea, states none
of the symptoms  that are  here  enumerated by  Doctor
Hamilton, except  the convulsive motions; there being
no previous disorder of the functions  of  the  body, the
patient's  appetite  remaining  undiminished  throughout
the whole, course ofwhe disease. 
                         a
                  DIAGNOSIS.
  Chorea is easily distinguished from  other diseases—
Vov  although all the spasmodic and  convulsive diseases
have symptoms in common with each other, yet the con-
vulsions of the muscles  of the legs, arms, and in fine, of
the whole body, accompanied by difficult deglutition, and
the other symptoms  already mentioned,  will render it
impossible  to commit an  error in forming a diagnosis.
In  the last stage of hydrocephalus intcrnus, there is
sometimes a convulsive  motion of the leg  and  arms, re-
sembling very much the gesticulations of chorea.   " In
one case," says Willan on hydrocephalus internus, "there
was paralysis of the right side ; in two others, the irre-
gular motions of the limbs, called the dance of Saint  Vi-
tus, took place at the second alteration of the pulse,  and
 continued till within a day or two of the patient's death."
   Hydrocephalus  internus  is a  symptomatic  affection,
 ue consequence of inflammatory action, and runs its
 course in a short time, and generally terminates fatally.
 Chorea is long continued, and  seldom  terminates unhap-
 pily.  Pyrexia [recedes  as well as accompanies hydro-
  ephalus internus in itsjirst stage; in chorea there is
 very seldom any fever. 
                         48
                    CAUSES.
   The causes  of  chorea may be  arranged  under Wo
heads-—Predisposing and Exciting.
           I—PREDISPOSING  CAUSE.
   That the predisposing  cause  is  increased mobility,
scorns to be conceded by all the authors who have written
on the subject.  It will not be difficult to shew, that Dr.
Hamilton's successful  practice does  not militate in the
least against this theory.
            II—EXCITING CAUSES.
   Any of  the depressing  passions, particularly   fear,
tainted food, impure air, propensity to imitation, denti-
tion, or any irritating matter in the intestinal canal, are
capable of producing the  disease.  Of the first of these
causes, Stoll relates a remarkable  case.  A child,  five
years of  age, was thrown from a carriage with her pa-
rents, was very much frighted, and was soon after seized
with chorea.  Doctor Monro the  younger,  was the  first
who observed that chorea was sometimes produced by
dentition.  He saw a girl, nine years of age, labouring
under chorea ; he perceived that the gums of one side
were inflamed and swollen, and three molar teeth mak-
ing their  way with difficulty through the gums.   The
gums were cut with a scalpel,  chorea vanished, and the 
                          13
 teeth soon appeared.  The disease returned in  a short
 time; three molar teeth on the opposite side were making
 their way ; he had recourse again to the scalpel;  chorea
 ceased, and never returned.  Many examples of the like
 might be brought forward, but these are sufficient to an-
 swer our purpose.
                    PROGNOSIS.
   The prognosis is  generally favourable, more particu-
 larly if  the disease is not very severe, and is not  of long
 continuance.  It  seldom remains after the person has
 attained  the age of  puberty, and it very seldom recurs
 after that period.   But  when neither nature, nor the
 changes which the human system undergoes at  the age
 of puberty, nor the skill of the physician, can counteract
 the violence of the  disease,  fatuity  and the violent con-
 vulsions  remain during life, as is exemplified in  the fol-
 lowing melancholy case, related by Doctor Thomson,  in
 his inaugural dissertation :—" Miserum, annorum prope
 triginta, agricolse filiumjnuper apud  Hawick, in provin-
 cial Roxburgh, vidi  hoc modo plexum.   Quasi equitabat,
 sed pars sell* posterior formam semicircularis,  ad lum-
 bos, attigit.   Pedes ad stapites, genua ad sellae cingulas
 et partes pendulas,  frsenum  ad  manum unam, et flagel-
' lum ad alteram, alligata fuerunt.  Caput,  oculi, facies, 
                         14
os,  lingua, brachia, crura,  et  c»r  us  totum, perp-tuu
movebantur.  Corporis summa inacies; fatuitas in vultu
depicta;  vox debilis continue fere prolata, cum loquendi
conatibus, quos  tamen intelligere non potui. Vota et
mentis pathemata, si aliquid  mentis pevstitir, signis non
verbis enuntiavit.   Hoc modo vectus equum per i< "um
impulsit;  morbi causa, historia, et progressus  mihi ig-
nota sunt."
       OF THE METHOD OF CURE.
  Sydenham, in his indications of cure, says, « As this
disorder  appeal's to me to proceed from some humour
thrown upon the nerves, which by  its irritation, occa-
sions such preternatural  motions. I conceive that *hc
curative  indications are to be  directed,  first, to lessen
those humours by bleeding and purging, and secondly,
to strengthen the nervous system.  To answer these, I
use the following method :—I order seven ounces of blood
to be taken away from the  arm, or such  a quantity,
whether more or less, as best suits  the age of the pati-
ent ; on the next day  I give half, or a little more, of a
common  purging potion,  according to his age, or  his
being easier or  harder to be purged, and in the evening
an  anodyne draught.  I order the purge to be thrice re-
peated, with the  interposition of a  day between  each 
                         15
time of taking it, and the opiate to be given always in
the evening after the operation."   On the intermediate
days he prescribed tonics and julaps.
  Doctor Home says,  " Sanatur hie morbus repetita
ven»sectione et purgatione,  cum antiepilepticis et robo-
rantibus viz Cort Peruviano, chalybeatis, et Balneo fri-
gido.  Confert  musculis  convulsione  affectis  admovere
secundo quoque die cucurbitulas siccas."
   Cullen and Brown depended upon tonics for the cure
of  this disease.
   Doctor Maximilian Stoll, in the case before mentioned,
which occurred about the middle of November, first at-
tempted the cure  by purgatives and emetics ; he then
gave the flores zinci, but with as little  effect—He then
discontinued their use, and directed that the sixth part
of  a  grain  of belladona should be  taken every fourth
hour.  On the  second day, he  saw symptoms of amend-
ment, and increased the dose.   In six days  she could
sit up alone, and within eight  days she could stand and
walk  a  little.   About the  last of December,  she could
run about as usual,  but had not perfectly recovered the
 use of her arms, as she could not feed  herself.   Some-
 time after this  she was seized with an intermittent fever: 
                          16
bark was administered, and on the ninth of January she
was perfectly restored to health.
  Doctor Coxe, of Philadelphia, in the Medical Repo-
sitory, has  related the case of a girl nine years of age,
whose  body was affected  with convulsions.  He gave
calomel,  bled and blistered her, without any change be-
ing produced ;  he then salivated her, which did uot an-
swer any good purpose,  and he finally was obliged to
have recourse to tonics;  and although the disease was
strengthened by long habit, the girl was completely cured
by their use in one and twenty days.
  Doctor James Hamilton, dissatisfied with  the method
of cure that had been pursued since the time of  Syden-
ham, introduced a new theory and mode of cure, which
it may be proper to relate.  " Notwithstanding, says the
Doctor, the  employment of these remedies (tonics) chorea
has  been found a  tedious disease;  experienced prac-
titioners  having admitted  that it has continued for many
months, nay, for years,  terminating only,  on some oc-
casions, about  the  age of puberty.   This confession is
not  much in favour of the modem practice, or of the
doctrine on which it rests.   I now  began  to  desert a
practice  in which I had lost confidence, and to consider
chorea in a  different light from that in which it bad been 
                         17
commonly  viewed.  I conceived that the debility and
spasmodic motions, hitherto so much  considered, might
not be the leading symptoms  of the disease, but might
depend  upon previous and increasing derangement of
health, as indicated by irregular appetite  and constipa-
tion of the bowels.  If my conjectures  were well found-
ed, the first and principal object of practice would be to
remove  the constipated state of the, bowels.  In pursu-
ance of this obi: t, I  began to try the  effects of purga-
tive medicines,  given  regularly in moderate doses."
  He used purgatives so liberally, that the foecal matter
discharged in ten days,  nearly equalled the weight of
the body of his extenuated patient.  The Doctor  sup-
poses, that by the use of purgatives, chorea can be cured
in a fortnight;  and yet he soon after narrates two cases
which proved  more  obstinate.  " Four or five weeks
elapsed, says he, before  I could pronounce them in the
way of recovery."  This practice of continued purging,
may  be insisted on in  hospitals, but  would not, I am
persuaded, be submitted to in private practice.
  Doctor Thomas AV. Smith,  of Loudon couifty,  Vir-
ginia, in September,  1807, transmitted to Doctor Coxe,
of Philadelphia, a description  of four cases of chorea. 
                          18
 In the first case previous to the Doctor's being consult-
 ed, bleeding and purging had been employed for some
 time, without producing any change in "~~ ^itient's situa-
 tion.  When he was called  in, he  prescribed  various
 toni:s,  which in two  months  restored  the  patient to
 health.   In  the three other cases which came  under his
 observation, the patients were cured  in a few weeks by
 the exhibition of tonics.
   The successful treatment of the  three following cases
 will shew that we possess a remedy which  appears to
 possess advantages over all other tonics.  It is powerful,
 pleasant,  and  cheap.  If Doctor  Sydenham  had been
 acquainted with its virtues, he unquestionably  would not
 have considered it necessary to prescribe an electuary of
 seven articles,  and a medicated wine of twelve; nay, 1
 am convinced,  that if Doctor  Hamilton had experienced
 its efficacy in the cure of chorea, he would have prefer-
 red it to his methodus curandi.
  "John Wigart,  a dutch  gardiner, on the Pratt Street
road, requested me on the fourteenth of May, 1808, to vi-
 sit his daughter about ten years old.   He informed me that
she had been grievously afflicted with Saint Vitus's dance
for nine weeks, and that in his opinion, she was becoming
worse instead of better.   I saw her on my first visit, in a 
                         19
most piteous condition, all the muscles of voluntary mo-
tion  appeared incessantly agitated.  I requested her to
shew me her tongue,  she thrust it out, but it was in an
instant retracted involuntarily.  She appeared conscious
of tile difficulty she must encounter to comply with my
request,  but by the sudden exertion of the will, she ac-
complished  it, by opening her mouth and protruding her
tongue at one effort.   I met the attending Physician in
consultation for several days,  when finding no symptoms
of amendment, I suggested to him the propriety of chang-
ing the remedies which had been given for so long atime»
without  the least perceptible benefit and mentioned  the
Arsenite of Potash as an excellent tonic.  He appeared
shocked at  the proposition,  and unhesitatingly  declared
himself opposed to the exhibition of Arsenic in any  form.
He had never used it, lie said, nor would he consent to the
 employment of it in this case ; fortunately for our patient,
 he soon discontinued his visits, and left me at liberty to
 pursue my  plan. I put her immediately upon the use of it:
 She commenced with it on the second of June and had im-
 proved so much by  the fourteenth, that I did not see her
 again till the twenty sixth, and then found her still im-
 proving : She took the medicine a considerable time after
 all the symptoms had ceased, with the intention of pre 
                           20
venting their recurrence.  She did not take a single pur-
gative after shebegan to take the arsenite of potash, but she
had taken them repeatedly before, as well* as tonics and
antispasmodics.  In this case there was no appearance of
fatuity, nor of gastric affection, her  tongue was not
furred, and she did not complain of her head."
  « On the sixteenth of July 1811, I was desired  to visit
the same girl afflicted with another violent attack of chorea.
She  was  now at the house of her brother-in-law  beyond
Saint Mary's  College.   She had been ill a fortnight or
more.  This attack appeared to me more distressing than
the former: Her sister whose constant attendance upon
her appeared necessary, had placed her bed upon the floor
from an apprehension of her falling from the bed if it were
left on the bedstead.  The house was small and low, the? e
was  but one room in it, of course, at this season of the
year, she could not but suffer from the heat.  The firs
day she took a purgative powder of rhubarh and Sulphate
of Potash.  On the seventeenth, she began to take the Arse-
nite  of Potash; on the eighteenth she took 01. Ricini;
On the twenty fourth she had another deobstruent, on the
twenty sixth I bled her—on  the  fifth and twelfth  of  Au-
gust  she  took  deobstruents.  She was now so well re-
 stored, that I did not visit her any more.  In this attack
 there were no symptoms of fatuity observable," 
                         21
  « Sometime after this a hoy five or six years of age* was
seized with chorea in the same quarter, and placed under
the care of a dispensary Physician.   As no symptoms of
amendment appeared, his mother becoming impatient call-
ed in another Physician, who, as I was afterwards inform-
ed by her, considered his case hopeless; but told  her  she
                               i
might as a dernier resort, have his head blistered and get
him bled.   He had, I suppose,  adopted the theory of Dr.
Cove.   He now became my patient,  the' Arsv nite of Pot-
ash which had, in two attacks of a higher grade of this
disease, so satisfactorily fulfilled the. hopes I entertained
of its efficacy, with an eccoprotic occasionally,in the short
space of two weeks, restored him to health.   He however
continued to take it some time after, in  order to guard
against a relapse."
  The above cases of chorea are extracted from  the note
book of my Father.
  Doctor Potter, professor of the Theory and Practice of
Medicine in  this University, stated in his lecture on this
disease, the particulars of a case cured by the Arsenite of
Potash, after three months duration,  and another that had
recently appeared.
  With respect to its modus operandi, I may be asked, how
doc.? it effect a cure ? I should answer, by  exciting and 
                          22
 sustaining actions sufficiently powerful Jo subdue the nmr-
 bid actions produced and supported by debility.  Its tonic
 power is excelled by no medicine, that has been employed
 in the cure of chorea.   Its pleasantness and great activity
 in small doses, are advantages, wiiich are possessed  by
 few of the remedies, commonly arranged under the class
 of tonics.  Bark, the preparations of  Iron  and  Zinc,
 Electricity, Cold Bath, and Valerian, have severally been
 recommended by different writers,  and either seperately
 or combined have sometimes succeeded in effecting a cure,
 although it must be  acknowledged that the disease has
 generally baffled the efforts of the Physicians who have re-
 commended them.  If there be  any other remedy,   with
 winch we are acquainted, except the Arsenite of Potash,
it is to be derived from a change of air,  exercise and the
interruption of former habits   and associations, by re-
moving the patient into a scene entirely new.
  Although I may not have suitably met the importance of
the subject, I have endeavoured to do it all the justice in
my power, under the  circumstances in which I have been
placed.   It now remains forme todojusticeto my feelings,
by expressing my gratitude, to all the  Professors of this
 institution, under whose auspices I have prosecuted my
studies in search of medical knowledge. 
 
 
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