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In the current nomenclature Saint Vitus' dance or chorea (from the Greek χορεíα for dance) has been largely displaced by the eponym Sydenham‘s chorea. The exchange occurred recently, although the association of the saint and his dance had a long evolution. It attested to the durability of the cult of Saint Vitus in which the early notions of the dance underwent differentiation by physicians centuries later.
The legend and tradition
According to hagiographic texts, Saint Vitus or Guy was born during the third century in Sicily, southern Italy.1 2 He came from an illustrious family and against the wishes of family and teachers he became a Christian. During a brief career Vitus was said to have performed numerous miracles.3 On one occasion he cured the paralysis of the hands of his tormentors. On another, his father lost his sight on seeing angels in front of his son. Vitus prayed for him, whereupon his father regained his vision. In another episode the saint relieved the son of the emperor Diocletianus of his demons, by laying his hands over the head. These miraculous feats contributed to the making of Vitus’ later reputation as the patron saint of neurological disorders. It was the same Diocletianus who had Vitus, still a boy, put to death in 303. Vitus' iconography included many depictions of him, inside or holding a boiling cauldron, the symbol of his martyrdom. Afterwards his relics were transported to Paris and Prague. His cult grew with the establishment of many chapels of Saint Vitus throughout Europe. Veneration of the saint appeared particularly strong among the Germans, Czechs, and Slavs who sought his cure of hydrophobia and other illnesses.4
The association with chorea
The healing power of the saint's relics was thought to be especially efficacious for the sick with “unsteady step, trembling limbs, limping knees, bent fingers and hands, paralysed hands, lameness, crookedness, and withering body”.3 5 The signs and symptoms in this grouping mimicked the movements of a dance, and thus the linkage of Vitus and his dance acquired a popular coinage. As the clinical features were heterogeneous, Saint Vitus' dance (also known as triste mal) became an umbrella term for an assortment of conditions with movement disorder. The association was further enhanced during the middle ages when outbreaks of dancing mania and other delirious behaviour struck Europe. Pieter Brueghel the Elder in 1564 depicted the mania of Saint Vitus' dance in a well known print entitled “Procession of the Possessed”, reproduced in Schechter.6 The explanation of these historical events remains unclear. Whether they represented mass hysteria, epidemic infection, or food poisoning has not been resolved. The identification of these epidemics with the present day Sydenham's chorea is also problematic. However, the dance did undergo a process of differentiation. In the 16th century Paracelsus designated Saint Vitus' dance as “chorea naturalis”. He recognised that the loss of emotional stability and voluntary motor control was central in the course of the disease.7 A century later Sydenham, in 1686, clarified the kinetic disturbances: “ . . .Saint Vitus' dance is a sort of convulsion which attacks boys and girls from the tenth year till they have done growing. At first it shows itself by a halting, or rather an unsteady movement of one of the legs, which the patient drags. Then it is seen in the hand of the same side. The patient cannot keep it a moment in its place, whether he lay it upon his breast or any other part of his body. Do what he may, it will be jerked elsewhere convulsively . . ..”6
Sydenham also described rheumatic fever with its articular manifestations, but he failed to connect it with the chorea. The failure was due in part to the fact that Sydenham and his colleagues did not have a clear idea of the visceral involvement in rheumatic fever. The lack of an auscultation method undoubtedly hampered Sydenham in making the diagnosis of rheumatic carditis. It remained for Richard Bright in 1831 to make the linkage: “The instances of the combination and alteration of rheumatism and chorea are very numerous; and though I doubt not, in some cases the coverings of the cerebrospinal mass may be and are implicated, yet I believe that the much more frequent cause of chorea, in conjunction with rheumatism, is the inflammation of the pericardium. The irritation probably is communicated thence to the spine . . ..”6
We have here the chorea, the peripheral, and systemic manifestations of rheumatic fever grouped together for the first time. Others, notably See in 1850, also articulated the urinary view, that the chorea, carditis, and the articular features were all components of the rheumatic fever.6 Bright could not be faulted for a misguided notion of the disease pathogenesis, for it was not until the 1930s that the infectious process in rheumatic fever was elucidated by the work of A F Coburn, among others.8 The cerebral lesion of chorea and its relation to the damage in other organs remain unresolved issues. Nevertheless, we have advanced far in our understanding of Saint Vitus' dance, or in modern usage, Sydenham's chorea.
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