THE 
RATIONAL TREATMENT 
OF 
CHOREA, 
BY 
JOHN VAN BIBBER, M.D.*, 
BALTIMORE, 
Reprinted from The American Journal of NeuroloM 
for May, 1884. 
NEW YORK: 
STEAM PRESS OF INDUSTRIAL PRINTING COiMPANY, 
Stettiner, Lambert & Co., 
Nos. 129 & 131 Crosby Street, near Houston St. 
1884. THE RATIONAL TREATMENT OF CHORDA 
BY 
JOHN VAN BIBBER, M.D., 
Baltimore, Md. 
The latest articles and studies on chorea that have ap- 
peared in the current medical journals do not, in any way, 
refer to a most important factor in the treatment of this 
disease. 
In the light of an extended experience in the manage- 
ment of chorea, this general omission seems very singular, 
and I have determined again at this time to refer to the 
results of my study of this peculiar nervous affection. I 
say again, for in a paper read before the Medical and Chi- 
rurgical Faculty of Maryland in 1878, and printed in the 
Transactions of that year, I suggested a treatment for cho- 
rea which, though it had been proposed before, had made 
little or no impression on the profession, and, it must be 
added, the effort seems to have passed unnoticed, or has 
been entirely forgotten, for the treatment does not prove 
to have invited either praise or opposition, no place being 
given to it in the many suggestions made since then, in 
the journals, for the treatment and cure of St. Vitus’ dance. 
Within the past year chorea has been remarkably pre- 
valent in Baltimore, and though I will not go so far as 
to say it has been epidemic, or could be so, still I am as- 
tonished at the number of cases brought to my notice. In 
private and dispensary practice I have seen not less than 
eighty-six (86) cases of this disease during the last year, 
and both in abridging the duration of an attack, and mak- 2 
JOHN VAN BIBBER. 
ing the cure more permanent, my success has been so 
encouraging that 1 am led to believe that this effort should 
be made to introduce a valuable method of treatment into 
general notice. 
Most of these cases were of a well-marked and severe 
type, and man)’ of them had proved obstinate under other 
medical treatment, and while the long list of remedies 
usually used in chorea had been uselessly exhausted, the 
patients remained as hopelessly jerky and restless as they 
were when they commenced to test the whole gamut of 
a therapeutic treatment. It must not be inferred from 
this assertion that the plan to be suggested is efficient 
without the use of drugs, or will be recommended as cura- 
tive without their aid. This is far from the purpose of this 
article, the chief aim of which is to call attention to the 
fact that chorea cannot be treated by drugs alone, and 
that the best results can only be obtained by a combination 
of medical regimen and proper physical care. But this last 
element requires much careful attention on the part of the 
physician, and much tedious monotony on the part of those 
who nurse the patient, and hence the prospect of popularity 
for this recommendation is dim and uncertain. Yet it 
nevertheless deserves serious consideration, for in my 
hands it has proved in many obstinate cases the best and 
most reliable means of bringing about recovery. 
To select an example of the information which can be 
obtained from various authors in regard to the treatment 
of St. Vitus’ dance, I will refer to Reynolds’ System of 
Medicine. I find the chapter on chorea is full and inter- 
esting. It contains a graphic description of the disease, 
diagnosis, and pathology. In regard to treatment it con- 
tains the usual long list of remedies of more or less value, 
devotes much space to advocating the beneficial effects of 
exercise and regulated movements, and even goes so far 
as to recommend dancing. A single paragraph of a few THE RATIONAL TREATMENT OF CHOREI. 
3 
lines refers to the fact that in bad cases the “recumbent 
position ” is a necessary part of treatment. 
Now, this is in my experience the most important factor 
in the management of all cases of chorea. In the article 
just referred to, Dr. Radcliffe dwells at length upon the 
fact that exercise, gymnastics, and regulated movements 
are most beneficial in this disease, while on the other hand, 
my success in the rest treatment leads me to be equally 
positive in my belief-that the most rational, efficient, and 
proper treatment for all cases of chorea is rest. It will be 
hard to reconcile views so utterly at variance with each 
other, and I feel tempted to strengthen my opinion with 
some corroborative testimony. In a report of the service 
at the Evelina Hospital (Lancet, February ioth, 1883), Dr. 
Goodhart relates a case of chorea major which was treated 
alone by rest and massage, and though he questions the 
cure by an interrogation, I look upon th£ success as an 
evidence of my theory. The following is an abstract of 
the report: E. L., girl, twelve years. Admitted Septem- 
ber 19th. Seven weeks ago it was noticed that her arms 
were constantly twitching and she was unable to be quiet. 
Was seen by two medical men, but in spite of treatment 
grew rapidly worse. Patient was so bad when admitted 
that the sides of the bed were padded in order to keep 
her from injury. Was ordered to bed and to be kept as quiet 
as possible ; only one attendant was allowed to be with her. 
Full diet and massage for twenty minutes twice daily. 
October 7th; had improved much. October 14th; could 
talk better and feed herself. October 26th ; was well 
enough to be discharged. 
In some remarks on this case, Dr. G. says: “ Thirty- 
four days after admission patient was quite well. May 
this be said to be due to massage, to rest in bed, or to iso- 
lation from friends and relatives, or to all three combined? 
She never had any medicine.” Personally, this question 4 
JOHN VAN BIBBER. 
is, I think, very easily answered by my own experience of 
the past year with the rest treatment, and 1 select from 
my note-book several cases which will indicate the value 
of rest and massage as curative agents in this special class 
of nervous disease. 
E. YV\, age fourteen, well developed, no rheumatic his-, 
tory. Had been under medical treatment for nine weeks 
when 1 first saw her. Had been advised to go out as 
much as possible, to take violent exercise, etc., etc. Worse 
now than at any time during sickness. After walking, or 
any exercise or excitement, is always more restless. Per- 
sistent insomnia. Saw this patient on December 28th, 
1883. Ordered her at once to bed, to be kept as quiet as 
possible, and free from all excitement, to see no strangers, 
and to have only one person in room with her. Massage 
three times daily, and whenever very restless; diet liberal. 
December 30th. Decided improvement; restlessness 
much reduced, talks more distinctly ; same treatment con- 
tinued with addition of tonic before eating. Sol. Fowleri, 
gtt. xv., and Sued conii 3 iij. daily. 
January 4th. Much improved ; sleeps well and appetite 
very good. 
January 14th. Patient is now allowed to sit up for a 
few hours daily, and on January 21st is allowed to take a 
short walk and pronounced cured. 
H. G., boy, eleven years, was brought to office February 
1st, with well-marked case of chorea. Has been under 
treatment for six weeks. The doctor ordered him to be 
out in the air all day, to walk far and play hard. The boy 
himself objected, but this was not allowed, and his mother 
forced him out each day. Under this treatment he has 
been gradually getting worse. Ordered patient to bed 
immediately on return home. To be kept free from all 
excitement, no children to be allowed in the room, slow 
and gentle massage three times daily. Treatment same as THE RATIONAL TREATMENT OF CHOREA. 
5 
last case, with addition of 1 ss. Sp. frumenti each P.M. In 
three days the improvement was marked, and on February 
9th was almost free from facial grimaces; can talk much 
better, and muscles of arm and leg are quieter in every 
way. Patient does not object to bed, feels so much more 
comfortable that he is willing to stay in one room a month 
if it is necessary. 
February 25th. Report good, and so much improved 
that he is allowed to sit up, and on 28th goes out, cured. 
N. H., girl, thirteen. Had been quite sick with inter- 
mittent fever, and during convalescence was noticed to be 
irritable and restless. In ten days well-marked chorea was 
developed, and I saw her October 8th, about two weeks 
after the commencement of attack. Movements of extre- 
mities were unceasing, and sleep was much disturbed. 
Ordered same treatment as in preceding cases, with addi- 
tion of quinias sulph. and substitution tinct. cinchona flav. 
for ordinary tonic. Massage has very soothing effect upon 
this patient, and she asks to be manipulated all the time. 
October 12th. Has much improved, but on 13th had a 
chill, after which she became worse. Up to 23d patient 
had several bad days, clearly owing to the malarial com- 
plication ; and after this date she steadily improved, and 
was allowed to go out on November 5th. 
These are cases in private practice where any special 
directions in regard to care and nursing can be faithfully 
carried out, and in which one would naturally expect bet- 
ter results than in dispensary cases. But although among 
the poorer classes the element of quiet in conjunction with 
rest is almost impossible, still I have found this treatment, 
even when modified by circumstances, to be of great value. 
Patients that have resisted all forms of treatment finally 
succumbed to power of rest and massage. Of the fifty- 
three (53) cases seen at dispensary for nervous diseases 
during the last year, all of them were placed under this 6 
JOHN VAN BIBBER. 
treatment, and though this number includes many severe 
cases of chorea major, the success has always been encour- 
aging- 
The limits of this article prevent me from giving fur- 
ther details qf* ca$es, and Twill now come to the discus- 
sion of the plan of treatment which has been advocated. 
If exercise and regulated movements are found to give 
the best results on the physical side of the treatment for 
St. Vitus’ dance*, we should be loyal to this rule, for the 
care of the patient is less irksome, and the responsibility 
in the case is reduced to a minimum. 
But, on the other hand, if by experience, if by the en- 
couragement of good results, we find that rest curtails the 
disease, renders recovery more permanent, and makes the 
patient much more comfortable during the attack, 1 think 
the views so long entertained by the majority of the pro- 
fession should be modified, if not absolutely changed. 
Now, it has been my experience that to place a choreic 
child in the best possible condition, to secure rest and 
quiet, to insure an avoidance of all external irritation, and 
to invite sleep whenever that sedative influence can be 
brought about, is a matter of the utmost importance, and 
the greatest possible aid to the action of various remedies. 
It is impossible to -expect sedatives, except in injurious 
doses, to quiet the constant turmoil of the body which al- 
ways exists in bad cases of chorea, and which is always 
increased by exercise or excitement of any kind. For 
each movement or effort brings on a succession of irregu- 
lar and exaggerated muscular twitchings, and these so 
irritate and exhaust the patient, that a state bordering 
upon frenzy is brought about. The effort to reduce this 
frenzy to a minimum, and by quiet and absence of excite- 
ment to induce repose, is certainly a rational one, and I 
have often found that those who are in charge of choreic THE RA TIONAL 7REA TMENT OF CHOREA. 
7 
children agree with me that walking or exercise of any 
kind invariably makes them worse. 
It seems difficult to believe that regulated movements 
or calisthenics could have been recommended as a means 
of cure for a disease which clearly demands restand quiet 
as the two essential points to be sought for and obtained. 
In a patient suffering from chorea, any voluntary move- 
ment excites and brings on a series of exaggerated mo- 
tions, both in the muscles directly concerned in the 
action and in other parts of the body. Thus, forced exer- 
cise in such cases must be a species of torture, and the 
sum of unnecessary and irregular movements amounts to 
a general condition of clonic spasm which, I am quite 
sure, must needlessly prolong the duration of the attack. 
Indeed, I sincerely hope that the semi-homoeopathic sys- 
tem of movements curing movements will be now entirely 
abandoned ; for whatever may be our idea of the pathol- 
ogy of chorea, the fact still remains that there exists a 
certain irritability of the nerve centres which produces 
the most prominent symptom of the disease. To reduce 
this irritability is the first indication ol a wise treatment, 
and I cannot see how this is to be accomplished by ex- 
citement or violent exercise. Entire freedom from all 
external distractions and prolonged rest in bed are the 
best means of reducing this irritability, and these sooth- 
ing influences make the patient less difficult to manage, 
and more amenable to treatment. 
I have purposely omitted until the end of this article to 
give in detail the method adopted by me in the manage- 
ment of St. Vitus’ dance, for I am anxious to place it be- 
fore Lhe profession with as much emphasis as possible, 
and I know that often the last part of an article is read 
when the rest of it may be neglected. An effort must be 
made to induce others to give the rest treatment a fair 
and impartial trial, and I am sure one case treated after 8 
JOHN VAN BIBBER. 
the following method will convert the most ardent cham- 
pion of the exercise or gymnastic treatment from a grave 
and cruel error. 
As the factor of the first importance in this method of 
treatment is rest, the patient should be confined to bed in 
a quiet and moderately-lighted room, and this seclusion 
must be so guarded that it cannot be disturbed, and so 
supplemented that it cannot produce weakness. 
Massage by slow and gentle gradations will gradually 
give the patient ample passive exercise, and this should 
be rigidly carried out at least three times each day. Any 
momentary excitement can be lulled by these manipula- 
tions, and the attendant will soon learn that this is the 
best means of controlling the restlessness which always 
makes its appearance in the afternoon. When sleep does 
not come naturally to the patient, some means to produce 
it will be employed, but not until the slowly repeated 
massage has been given a fair and thorough trial. This 
amount of passive exercise will improve the appetite, and 
thus it will be possible to give nourishment frequently and 
in ample quantity ; and if the manipulations are carried 
out with care and assiduity, the torpor of the bowels is 
prevented, and no ill effects can result from a prolonged 
confinement in bed. It will be found best to have the 
patient in charge of one attendant, whose duty it will be 
to prevent all unnecessary conversation, and to protect 
the patient from all causes of excitement, and who will 
carry out each detail of the treatment with honesty and 
precision. 
As an aid, therefore, to any medical treatment, this sys- 
tem of rest is invaluable, for it places the patient in the 
best possible condition to be affected by drugs, and being 
as quiet as the circumstances will allow, the element of 
habit, which is by no means to be forgotten, is rendered 
every day less powerful.