DEP/DUA/1/20/11 (Normalised version)

Robert Winter

(1779)

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Two next cases Robert Winter & Nelly Davidson exhibit examples of affections which I am disposed to consider rather as [illegible].

And in symptoms of the two cases at least very great similarities.

Is however with me a matter of doubt whether in reality to be considered as of same nature.

And at least certain that differ very essentially from each other in point of degree.

Case of Robert Winter the first in order is of the two by much most slight.

Symptoms of this patients case but few in number.

Yet reason to think that all of them not connected with each other.

Principle complaints in case, & those [indeed] which led to our selecting him as subject of observations here were vertigo & tinnitus aurium.

In these have affections of different [senses] indeed, yet in some respects of similar nature.

This at least case in as far as both consist in Hallucinations or deception.

And give to patient representations of action of impression in reality not present.

Besides this well known that frequent concomitants of each other as either [preceding] attendance or following other disease.

Hence then although often take place separately yet when to be met with in complaints of same patient may conclude that are connected.

While however look upon these two as symptoms of same affection cannot hold this opinion with respect to [another] complaint to which patient subjected that is pain between shoulders.

This latter we are told had been at least for some time before came under our care a constant affection.

And particularly severe on motion.

May from this then presume that totally an affection of muscles or of parts about joints.

While other symptoms before mentioned had now continued for space of several years to this latter had been subjected only for few days.

Might justly I think consider it either as consequence of parts being overstrained or of some Rheumatic affection in [consequence] of cold

And to both one & other patient much exposed from his profession that viz of house carpenter

Here attended with no appearance from which could be led to consider it as alarming

And whether either one or other view the most proper was inclined to look upon it as slight & temporary affection hardly claiming attention.

This however could not be asserted with respect to other part of his disease

For although had continued for several years without giving great distress yet were upon increase [hard].

And perhaps in every case unless where cause well known to be of transitory nature, should be considered as what may at least be incurable or even dangerous.

With regard however to this part of affection must acknowledge myself very much in dark.

And while at loss what name to affix to complaint have still more difficulty in being able to conject from what cause proceeds.

With respect to name may observe that in system of Mr Sauvages the Hallucinationes or deception of senses constitute a particular order of diseases in one of most important classes.

And not only those of hearing & seeing but likewise of taste, touch & smell subjected to what may be called deception.

That is independent of other morbid affections give idea of presence of bodies which really absent or represents bodies present as possessing qualities which totally imaginary.

This however in case of these latter senses very rarely if ever observed unless as consequence of some other affection.

Hence even Mr Sauvages himself has considered deception of taste smell & touch as merely accidental or symptoms of other [diseases]

Not only Sauvages however but most other nosologists¹ have formed distinct [genera] of deception of sight & hearing.

And accordingly in their systems find those of Vertigo & Syrigmus.

Or at least have employed terms of similar importance for expressing such [collections] of symptoms.

But while Dr Vogel on one hand has carried number of affections of senses much beyond Sauvages. Dr Cullen on other has as far retrenched number.

And neither among affections of senses nor indeed in any other part of system does he give place to Vertigo as genus.

Here must own that am in great doubt whether in this respect should consider him as in right or not.

Can be no doubt that in by much greatest number of cases in which [occurs] to be reckoned merely symptom.

And perhaps in every instance better denominated from cause inducing vertigo than from vertigo itself, at least where [that] cause can be discovered.

Vertigo however in many cases principle & in some only symptom where yet patient to be considered as in very great distress

And although cause sometimes may be ascertained yet in others very obscure

Where can trace affection either to inordinate action of muscles intended for motion of whole eye, or of particular parts of it as crystal lens perhaps with greatest safety considered as instance of partial convulsions.

But besides this as had very lately occasion to remark same sensation in reality occurs when see nothing of external object from eyes being shut.

Body itself & objects on which placed are felt as being in state of motion.

That is [there] occurs vertigo tadus as well as vertigo visus.

In these cases must consider cause of affection as neither seated in sensorium or at least acting immediately on brain [with] intervals of organ of sense

In such instances disease perhaps better denominated by term vertigo than any other.

At least where this occurs as only or even as principal symptom.

This however can hardly be said to be case in instance before us.

For tinnitus aurium of same standing & to equal degree distressing to patient.

Hence then equally a claim to be denominated Syrigmus according to Sauvages or Paracusis accord to Dr Cullen.

And cannot be denied that the deception of hearing which has been denominated tinnitus or susurrus more frequently occurs as a depending on fault of external organ that is as idiopathic [affection] than vertigo.

Perhaps then, following Sauvages would with greater propriety bestow upon it the appellation of Syrigmus vertigo than any other.

Although must at same time [allow] that case before us does not correspond with definition which he has given of that particular species of this genus.

Here however hold it to be matter of much less importance to us in as far as respects future practice in case, accurately to ascertain name than nature.

And with regard to this, must here observe, that can offer no [conjecture] which even to myself appears to have much probability.

From affection occurring at once both in sight and in hearing should be led rather to refer it to sensorium than to any disease in organs of sense.

And this opinion corroborated when consider that both augmented from same causes.

Particularly from augmentation in consequence of head being inclined forwards a cause may readily suppose would affect brain

And which probably produces that affection principally from alteration in state of circulation

But another particular mentioned in case which may be supposed to give some difficulty with regard to this supposition.

That is alteration of disease from state of weather.

Are informed that in moist & [wet] weather complaint always worst.

This state of [atmosphere] cannot suppose to have any immediate effect on local affection within the Cranium

May perhaps be matter of doubt how far this does not entirely depend on imagination of patient.

Or be merely consequence of effect which state of weather has on his spirits.

Instances often met with where complaint not only thought to be aggravated from this cause but where are supposed although entirely absent.

Independent of this however peculiar impression given by moist state of atmosphere, may as communicated to brain, affect even that morbid condition on which suppose symptoms of case to depend.

Not however from impression made on optic or [acoustic] nerves themselves, but on surface in general.

And impression thus communicated may afterwards affect these senses in particular, from morbid state being principally at origin of nerves, subservient to these senses.

From this supposition then, with regard to cause of affection, have I think most full explanation of phenomenon.

At same time cannot represent it as supported by many circumstances giving great probability

With this uncertainty respecting nature of disease cannot give confident judgement as to termination.

Supposing it to depend on affection within cranium may yet admit of cure.

If this however really the case cannot consider it as without danger.

And the rather as of late has been considerably augmented.

Would not therefore surprise me, if found it terminating in other affection, dependant on deprived state of nervous power.

On one hand from increase of irritation some reason to dread occurrence of general [complaint]

On other from augmentation of [compression] may terminate in partial paralysis.

And fear present depraved state may [given] diminution, or even total loss of senses, at present affected.

Nay in one way may induce Epilepsy & in other apoplexy.

And from either fatal termination may be induced.

Consider it however as more probable that will be tedious than dangerous affection

And instances by no means rare where without any other alteration than merely aggravation of such affection, have continued [during] even greatest part of life.

Such then may be case in instance before us.

And especially to be expected as patient has already passed 60^th year of age.

But while from these particulars reason to fear that case will be tedious still more grounds for it from continuation which has already had.

After subsisting for several years & during that time suffering increase cannot now look for sudden or complete cure.

Upon whole then little expectation that shall be of much service to patient.

Yet imagine that may at least make some trials for recovery without aggravating [complaint]

And am not without hopes that may even be able to dismiss him with affection alleviated.

If however should under care obtain complete cure, must own that more than expect.

At same time not surprising

From opinion formerly stated as to [nature] of this patients affection cannot lay down any rational or probable plan of cure.

If, as suppose, local affection really exists within brain, know not how to be removed or combated.

Were we indeed acquainted with nature, some measures, from which might expect more than others.

Yet while ignorant whether cause of irritation or compression practices must be in great measure at random.

And not impossible even that may [illegible] require removal of particular condition of certain parts of brain whence nerves of senses now principally affected derive origin than of either.

Consider cure therefore as rather to be regulated by attending to [illegible] & [Sedentary] than on any other footing.

And in this way, one circumstance mentioned in history of case claiming at least some attention.

Observed that complaint particularly aggravated when head kept dependent

From this might conclude that whatever cause was at least augmented from determination to the part.

And therefore some grounds to hope for alleviation from derivation from head.

This first led me to application of Blister between shoulders.

And from this was intention to have supported discharge for some length of time by means of issue ointment.

What would have been effect of such derivation if had got fair trial cannot say.

But here in discharge both from Blister & issue were somewhat disappointed

For according to account of patient even at beginning was by no means considerable.

And as reason to apprehend that during work, from motion fretting Blistered [parts], would be uneasy to him had less grounds to hope for proper continuation.

If however did not relieve principle affection, under use got at least rid of pain between shoulders.

From which I think additional presumption that solely rheumatic.

Even with view to Vertigo & Syrigmus however although first application not successful yet wished to observe effect from farther continuation.

And with this intention patient still [directed] to go on with issue ointment.

But thought that would be losing time to trust to this alone.

Had therefore recourse also to use of Valerian.

Of powers of this article as having effect on nervous system from action on stomach [have] already had occasion oftener than once to state opinion.

Is by [instantaneous] power employed as remedy with some of brute creatures.

Particularly with those well known to be most liable to affections of nervous system example Cats.

By them indeed eaten with great [avidity] in state of health.

And immediately when taken seems to produce a state of [exhilaration] or intoxication in some degree similar to what in human species is effect of strong liquors [acting] on stomach.

Is indeed true that even to greatest extent in which generally used at least with human race, not product of obvious operation.

And from this some led to look upon it as of no efficacy.

May however be observed that obvious operation wanting with many of most powerful medicines with which are acquainted.

And from effects which have often observed from Valerian, in morbid cases am inclined to think very favourably of it.

During use for space of week, patient thought that Vertigo somewhat diminished.

After this however from irregularity in attendance, was discontinued for some length of time.

Although therefore now near month since prescribed, do not consider it as having had by any means fair trial.

And in hopes that patient will now attend us more regularly have again put him upon use of it.

If from continuation, complaint suffers considerable alleviation is utmost that look for.

And shall be very well pleased to be able to dismiss him in such state.

If however complaint aggravated, with any symptoms of determination to head, shall consider farther evacuation as necessary notwithstanding age of patient.

And with view to determination from head may have recourse to cathartics at proper intervals.

Or may again employ issue excited by applying Blister to head itself.

And drain from thence perhaps less [illegible] when at work than between shoulders.

Besides these another measure also which have some thoughts of trying in present case.

That is the use of electricity

Can be no doubt that influence as increasing nervous power at particular parts often very great

And even supposing cause of disease to be seated within brain, yet by [illegible] drawn from neighbourhood of eyes & ears some chance of affecting origin of nerves leading to these organs of sense

Consider it therefore as in this case at least deserving trial.

At same time shall be better pleased if found not to be necessary.

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Explanatory notes:

1) Nosology is the branch of medical science dealing with the classification of diseases. Individuals referred to in the case notes as nosologists were commonly those who had published nosological, or classificatory, medical texts.