TREMOR AND TREMOR-LIKE MOVE MENTS IN CHOREA. By DR. J. H. WALLACE RHEIN, Philadelphia. Chief of Clinic for Nervous Diseases, St. Agnes' Hospital; Medical Electrician to Orthopedic Hospital and Infirmary for Nervous Diseases; Instructor in Neuropathology, Polyclinic Hospital; Bacteriologist to Elwyn Training School for Feeble Minded Children. WITHIN the last few months I have seen a few cases of chorea which presented some unusual and novel features. We are accustomed to think of the movements of chorea as awkward, incoördinate and irregular. The affected limbs are agitated in a most capricious and fantastic manner, in fact it is the irregularity of the movements which has been always considered as characteristic of the malady, so much so indeed that the older writers spoke of the jactitations, as an insanity of the muscles. In the cases just referred to, details of which will be given later, the muscles are not agitated in the manner just described. In some the movements have assumed a rhythmical character, while in others a true tremor was present which either replaced or accompanied the usual clonic movements. The case that first led to this brief study was seen at the dispensary for nervous diseases at the St. Agnes Hospital. The patient, a girl of thirteen years, presented herself for the relief of a tremulousness in her right hand, which she had noticed for a year back. A careful study revealed the presence of a tremor not alone of the right hand, but of the head and of the hand on the left side. There was no tremor in the lower limbs, but instead irregular inconstant motions, quite typically choreiform. At once it was suspected the child was suffering from chorea and the other symptoms together with the subsequent history confirmed this diagnosis. The family history was negative. She had suffered from scarlet fever at six years of age from which she had recovered entirely. In early childhood she had measles, diphtheria and whooping cough, but never rheumatism. four years of age after an attack of acute indigestion she had a number of spasms, lasting off and on for twenty-four hours, but has had none since. She had not yet reached menophania. She was anæmic, had daily head-aches, was emotional and thin. Her appetite was fair, the tongue coated, the bowels regular and she suffered from indigestion. There was no nystagmus or loss of power. The knee jerks were slightly increased, equal on both sides, but there was no clonus. A soft systolic murmur was heard at the base of the heart. Her pupils reacted normally and there existed a slight degree of hypermetropia. The tremor was rhythmical and fine, and as before stated involved both arms and hands and to a slighter extent the head. The tremor was about the same on both sides, there being seven vibrations per second on the right, six on the left. When voluntary muscular effort was attempted, the tremor became slightly more rapid and a trifle larger. It was not constant during muscular inaction; the interval of rest being only a few seconds. It seems a. plausible theory that the tremor had for its origin the same cause as the chorei-form movements observed in the legs, and this is confirmed by the, subsequent history of the case. When the patient was placed in bed and given the usual treatment for chorea, both the tremor and the chorei⚫form movements disappeared entirely. (See tracing.) In the second case, a girl of eleven years, the movements were vibratory and rhythmical and very suggestive of a large tremor. They were distinctly more like a tremor than like the movements of chorea. They occurred about four times a second and were not continuous. Intentional effort, such as lifting a spoonful of water, or taking a glass of water in the hand, made little or no difference in the character of the tremor. They were not present during sleep and were only slightly controlled by efforts of the will. The vibrations on the left side were large and occurred four times a second; on the right side much smaller but synchronous with than on the left. Voluntary muscular acts and voluntary restraint had practically no effect upon the motions. The general appearance was typical of chorea. She had the facies choreica; her physical condition was fairly good though her digestion and appetite were poor; the bowels were irregular and she was restless in her sleep. The knee jerks were capricious; there was no loss of muscular power. A low hypermetrophic astigmatism existed and there were slight remains of the pupilary membrane. Otherwise the condition of the eyes was negative. This was her first attack of chorea and began in February of this year, after an emotional disturb ance. The family history is negative. The patient has had measles and chickenpox but no rheumatism or scarlet fever. Otherwise the previous health of the patient had been good until the onset of the present trouble, which dated five weeks prior to her applying for treatment. As she was an out patient at the clinic, it was not discovered whether she eventually recovered entirely or not. Under the usual treatment for chorea she improved immensely and then disappeared from observation. (See tracing.) The third case, a girl of thirteen years of age, presented movements very like those described in the last case. The family history was negative. She herself suffered from measles in early childhood but had never had scarlet fever or rheumatism. At eleven years she suffered from an attack of appendicitis. The present attack began in Oct., 1894, two months prior to her applying for treatment and was her first attack. The movements were left sided, coarse and rhythmical, resembling as in the last case the tremor of disseminated sclerosis. During rest or muscular inaction it was often absent, but when she attempted to drink a glass of water or perform a similar fine muscular act, the tremor became at once very much worse. other symptoms of disseminated sclerosis. There were no |