Fonsart and Bourdon have reported teno-synovitis, involving both the extensors and flexors of the fingers and toes. In many cases peritonitis, peri-metritis and metritis have been observed. It is not only after normal labor at term that puerperal rheumatism may manifest itself, for Peter has reported a fatal case which followed an abortion at three months.
The prognosis is rendered grave, of course, by the tendency to suppura tion already alluded to, and the outlook is more serious in proportion as the disease has developed rapidly after labor. But, although the prog nosis is more favorable in the cases occurring later than the tenth or twelfth day after labor, it is still very serious, for, in these cases, the arthritis tends to chronicity, and the termination by transformation into strumous arthritis is frequent. In the most favorable cases, anchylosis is the rule. This is not always the result, and in one case which we ob served at the clinic, the patient recovered without suppumtion of the articulations and without anchylosis.
Treatment. —This is often inefficacious. Quinine seems to have yielded the best results, thus far, but large doses must be used, as twenty-three grains per diem, and must be continued during the whole course of the disease. The treatment should not be suddenly but gradually suspended.
Revulsives and narcotics are only uncertain palliatives.
Chorea.
Chorea may occur during pregnancy or after labor, but is infinitely more common during utero-gestation, and this relation between chorea and pregnancy had been already noted in the eighteenth century when Borsieri advised the use of quinine. • disease is rare, for Mosier, in 1862, had only been able to collect twenty cases. Barnes, in 1869, collected fifty-six, and Fehling, in 1874, sixty-eight cases. Schroeder and Spiegelberg consider it as very rare. The latter has only seen two cases, in a very large practice. Among 1600 patients, observed by ourselves at the clinique, we only discovered two cases, and we have recently seen our third case in a woman after labor.
Primiparous authors agree on this point. Scanzoni, Dreyssig, Schneider, Bezold, Wirke, Bodo, Wenzel, Sieckel, Chorea, is, therefore, most frequent between 20 and 25 years.
3. anstitution.—There is no uniformity. Sometimes the women are feeble, small and delicate, and sometimes are robust and strong.
4. Heredity.—Romberg has only quoted one case in which this cause can be really assumed.
5. Previotte Chorea.—Mosler saw, among his twenty-one cases, five who had had previous attacks. This was noted by Senhouse Kirke, Eliscrhe and Fehling, fifteen times among thirty-three primiparw. Barnes reports nine out of his ftfty-six cases. Spiegelberg, without giving statistics, in sists on this point and the same is true of Franck and Duncan, whose patients had had chorea either during infancy, as in the preceding cases, or during previous pregnancies. Chorea may, however, appear suddenly during the second or third pregnancy, or as a relapse, having existed during a first or a second pregnancy. Again, it may not appear until
after labor whether at or before term. Pregnancy may commence during an attack of chorea, as in a case of John Hirks.
Among the seven multiparte cited by Mosier, the previous pregnancies had been normal in three, and in two there bad already been chorea during the first pregnancy. In the other cases there had been vertigo, intense headache, and marked anEemia.
6. Emotions, as anger, fright, mental trouble, delirium.
. Rheumatism.—Spiegelberg insists on rheumatism, combined with cardiac affections. In some cases, albuminuria or glycosuria has been noted. In many cases the cause isnot discovered, and Spiegelberg regards these cases as reflex neuroses, which, given a predisposition on the patient's part, suddenly develop under the influence of inadequate nutrition of the nervous centres by impoverished blood or under the influence of peri pheral irritation of the genital system. It is, in fact, not rare to find choreic patients poorly nourished, feebly developed and antemie. Barnes, Copland, Roger, St.° and Chambers also mention rheumatism, and Ogle embolism.
Period of Development.—Chorea may appear at any stage of pregnancy and after labor, but it is particularly in the earlier part of pregnancy that it is most often observed. It then persists, generally, until the be ginning, or even to the end of labor. More rarely, it yields before labor, and more rarely still (only three times out of Spiegelberg's sixty-nine cases) does it persist during the post-puerperium. In our own case, the chorea did not appear until three weeks after labor. On the day follow ing her confinement the patient, a multipara who had been four times pregnant, was seized with a left crural neuralgia which resisted quinine, injections of morphia and vesicatories for twenty-one days. On the twenty-second day, after a severe annoyance, the patient was. attacked by left hemichorea of a typical character, involving the whole left side, more marked in the upper extremity and involving the muscles of the face. This attack disappeared at the end of thirteen days and gave place to genuine hysterical attacks, which were repeated two or three times daily, at first, but which are nevertheless now diminishing. There is now only one daily hysterical attack, and this is less violent, although accompanied by very plain erotic sensations, which lead to free secretion of the vulvo vaginal gland, and they have tended, ever since their diminution, to be replaced by an incessant hysterical cough. Bromides, valerian, cold douches and chloral have been, hitherto, absolutely powerless, and the same has been true of quinine, arseniate of iron, etc. We may add that the patient has had an intense catarrhal metritis for some years, and an ulceration of the cervix for which she is now being treated. She had an attack of chorea in her infancy, but not in her other pregnancies.