This section is from the book "Materia Medica And Therapeutics Inorganic Substances", by Charles D. F. Phillips. Also available from Amazon: Materia medica and therapeutics.
Manson affirms that he has cured seventy-two cases of chorea by giving iodide of potash. Bardsley and Gibney make similar statements, but many of these cases would probably have come to a natural termination after six or seven weeks' rest, even without iodine. We are still much in the dark as regards the nature of chorea, and from a rational point of view iodine can only be recommended for it as likely to influence a scrofulous, rheumatic, or syphilitic taint.
The varying results obtained in the treatment of chorea must be connected with its varying pathology, which is not yet well understood. I have seen a few patients recover rapidly under treatment by bromide, but the majority are too anaemic or asthenic to bear it well; hence, it is not surprising that Dr. R. Reynolds found it even prejudicial in some cases.
Dr. Ramskill tried fully the potassium salt, "and with strong prejudice in its favor," but without satisfactory result. Camphor bromide is said to have acted better (British Medical Journal, i., 1877), but has not done so in my experience.
The emetic action of antimony has been utilized for the relief of chorea, and the influence of the remedy has been explained as reflected through the vagus nerve to its central origin in the medulla, inducing sedative effects in that part (Ringer). Boulay and others have recorded successful cases from the use of nauseating doses (Bulletin de Therapeutique, v., 52-4, London Medical Review, 1861), and Dr. West recommended it, but I cannot consider it a desirable treatment, nor is the evidence in its favor very strong. Comparing it with arsenical treatment in twelve cases in Parisian hospitals, only half the number were reported cured by antimony, and some of these lasted long enough at least for natural recovery (fifty-eight days); whereas of eleven cases treated by arsenic all got well (M. Long). Of course, in comparisons of this kind we must make some allowance for the tendency of chorea to recover under judicious management, independently of medicine, but the general evidence in favor of arsenic much outweighs that in favor of antimony.
From the time of Girdlestone, 1806 - (London Medical and Physiological Journal), there has been a large accumulation of evidence as to the value of arsenic in chorea. Reese, of New York, in 1840, describes cures in two hundred children under 6 to 8-min. doses of Fowler's solution twice daily. Rayer corroborates his results (Union Medicale, 1847).
Romberg calls it "the foremost remedy," when given in sufficient doses (Klin. Ergebnisse, 1856), and records severe cases - one of eight years' duration, rebellious to many other medicines, but cured in two months by arsenic; and another patient had been unable for six months to stand or speak, having such violent choreic movements, yet recovered after two months of treatment with 4 min. of Fowler's solution thrice daily. The well-known names of Aran, Henoch, Steiner, and Barthez may also be cited as authorities in the same direction; and continental work with regard to it is fully summarized in the thesis of M. Gelle ("Hopital des Enfants," Paris, 1860). He quotes cases where improvement was manifest within eight days, three days, and even forty-eight and thirty-six hours respectively, but concludes that from five to eight days is an average period. He gives also several cases equal in severity to those of Romberg, and expresses similar conclusions - viz.: that some failures of the remedy may be expected in neurotic, sanguineous subjects, but very great success in the lymphatic, chlorotic, and cachectic. M. Aran urges the rapid attainment of a full dose rather than a long-continued small one (Sydenham Society's Year Book, 1859). Dr. Steiner, on the other hand, commences with 1 min., and considers 8 min. should be the maximum daily dose: within fourteen days he expects improvement.
Among English observers there is a large preponderance, though by no means a consensus of opinion in favor of arsenic as the best remedy for chorea. Gregory, Babington, and many others have all written to this effect. Dr. Radcliffe fully agrees as to the efficacy of the medicine, but, having been obliged sometimes to discontinue it on account of gastric disturbance, he adopted its hypodermic use, and in some cases, especially of localized choreic action, with signal benefit; thus, in a woman in whom the neck-muscles were affected, and who was not relieved by a long trial of sedatives, 1 to 12 min. of Fowler's solution were injected locally, and, before the fourth injection, improvement had taken place. He recommends dilution with half water; in some cases he has preferred the en-dermic use of the remedy on a blistered surface ("Reynold's System," vol. ii.). Schmidt has also practised hypodermic injection with success (Wiener Med. Woch., 1871, No. 44). Dr. Anstie records the severe case of a girl who had been treated in hospital with camphor, cod-liver oil, bromides, and zinc, also with succus conii in the dose of many ounces daily, yet without relief, and who recovered under 3 to 5-min. doses of Fowler's solution: he used at the same time ether spray to the spine, but this application has not proved itself of such power as he then thought it (Practitioner, June, 1874), and therefore I do not believe that it much influenced the result. Dr. Ringer considers arsenic as by far the best remedy in simple chorea; he remarks that failure may be owing to small-ness of dose; also that children above five years of age bear nearly as much as adults, and that girls seem to require more than boys. Dr. Eustace Smith and others have also specially noted the tolerance of choreic children for arsenic, and the necessity of full doses to secure success (British Medical Journal, i., 1875). In my own practice, for upward of twenty-five years, I have seldom known arsenic fail to cure simple chorea, although many of my cases were severe and of long duration, and quite incapacitated for the ordinary duties of life - 3 to 10 min. of Fowler's solution thrice daily has been the dose usually prescribed by me, but I have frequently observed no permanent good effects follow until the development of some of the slighter physiological symptoms.
From the above quotations and remarks, though they represent an ample experience, we must not conclude that the value of this remedy is equally acknowledged by all. The counter-claims of iron, of zinc, of belladonna, etc., are urged by some observers, and the natural tendency to cure of the malady under favorable conditions is still more strongly insisted upon by others. Vogel, the distinguished Russian professor, classes arsenic with "a number of empirical remedies that are more praised than curative." Dr. Wilks attributes much more importance to rest (British Medical Journal, ii., 1876), and my colleague, Dr. Sturges, includes arsenic among a number of other "useless medicines" ("Lectures on Chorea," 1876). In estimating the value of any remedy, we are constantly met by the difficulty of proving how far we have affected the course of nature; this difficulty is not greater with the present medicine than with others, and even allowing that chorea will recover with proper rest, food, and management, yet I am clearly of opinion that arsenic will promote, and quicken, and confirm the cure. I cannot affirm that it will always, of itself, and in despite of circumstances, control the disease. Judging from private practice and from hospital in-patient records, a large number of cases recover while taking arsenic, either far more quickly than is consistent with the ordinary course of the malady, or (making the contrast more striking) recover after many powerful remedies have been tried without effect under equal conditions. The ordinary duration of a chorea well managed, but without medicines, has been stated as six to eight weeks; if it continues three months Jaccoud considers it chronic, almost incurable, yet we have already quoted and have seen many cases that improved within two or three days, and recovered within three to five weeks, and we have quoted also cases of cure after a duration of many years. A certain proportion of cases of chorea are connected with embolism, and these were excluded by Dr. Anstie from the range of the beneficial action of this drug, but from what we know of its value in cerebral congestions, we should think it often appropriate even in such serious conditions. In markedly anaemic patients we might prefer iron, or at least combine it; and if sexual excitation were present, as in the case of some girls at puberty, we might substitute bromides or antispasmodics; acute rheumatic symptoms would also modify the treatment, but with these exceptions we must consider arsenic a most valuable agent in all varieties of the malady.
Rodolfi has recorded cases of chorea treated by lime chloride, 7 to 15 gr. in twenty-four hours, and finds it suitable for all cases provided that there is no "cerebral hyperaemia;" improvement began at once, and cure resulted in about sixteen days (Medical Times, i., 18G9). Aperients were also given, and, as Jaccoud remarks, belladonna was combined with the lime, so the results must be held doubtful.
In nerve-disorder with sleeplessness, and in infantile convulsion, Dr. Hammond has found the bromide of calcium more readily taken and more effective than that of potassium, and I can to some extent verify his observations.
Although preparations of copper are not now much used in this affection, I can refer to some very good results from the sulphate in my own experience, and especially in cases connected with taenia and other intestinal worms. I think it well worthy of use in cases where there is even a suspicion of their existence; it will aid their expulsion if present, and in any case act as a good nervine tonic. I have seen permanent good results from 1/4 gr. given three times daily, though sometimes this dose needs to be gradually increased.
When this disorder is dependent upon anaemia, iron is clearly indicated, and may prove of great service, as it did in the hands of Elliotson, who used large doses of oxide (Medical Times, i., I869, p. 136). Sir T. Watson recommends the carbonate. Many cases occur about the time of commencing puberty, and others evince obscure rheumatic symptoms: and in these also iron is useful, but it often acts better when taken in conjunction with arsenic.
There is much evidence as to the value both of oxide and sulphate of zinc in this malady, more perhaps in favor of the latter; it requires to be given in gradually increasing doses up to 15 to 20 gr. (Barlow). In recording many cases, all of which derived some benefit, Mr. Marsh, of the Children's Hospital, remarks that no definite indication for the sulphate could be verified, but that a harsh, dry skin became soft during its administration (Lancet, ii., 1871); it was well borne. In chorea affecting strumous children, I can speak well of the iodide of zinc. Dr. Barlow was the first to recommend it (Medical Times, ii., 1857).