DEP/DUA/1/27/09 (Normalised version)

Elizabeth Turnbull

(1781-1782)

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Elizabeth Turnbull

Case of this patient can hardly I think be represented, as being, like last, of complicated nature.

At same time may without hesitation assert that no less difficult.

And unquestionably a much more rare occurrence.

Disease at present at least consists almost entirely in affection of muscles of neck.

In consequence of this sudden & frequent alteration of position of head, not only without intention but even contrary to efforts of will.

When this affection first began besides inordinate motion here mentioned another circumstance arguing more general affection of system.

Profuse sweating viz occurring from slightest cause.

That these not altogether unconnected with present affection may at least be presumed from commencement at same time.

Yet more probable that both proceeded from same cause than that in any degree connected with each other as cause & effect.

Accordingly find that removal of one no influence on other.

But whether any connection or not has now for long time been free from sweatings.

And affection of muscles of neck only disease now to be considered.

With regard to this must own am by no means without difficulty either as to name or nature.

And must set out with observation that have not before in practice met with any instance exactly similar.

Distortion indeed of position of head by no means a rare occurrence to be observed in [commencing] life.

And accordingly in writings of practical authors often described under title of Capit obstipum, Obstipitasi. Torticollis etc.

In all instances however which have ever before seen, head fixed in position.

And that even when appears in most simple form, as when effect of cold & has name in this country of crick in the neck.

Here however position by no means fixed

And although but momentarily yet so contorted as to give very great inconvenience.

Although however have not before met with this affection in my practice yet several instances nearly similar at least to be found on record, as described by eminent practitioners.

Particularly in writings of Bonetus & of Tulp.

Besides these as case also very exactly similarly described by Mr Sauvages as treated by him.

And accordingly has given it a place in his system under title of Obstipitas spasmodica.

Of this affection have little doubt in considering present case as an example

But while give it that name are by no means equally sure with regard to nature.

And in particular possible to conceive such a complaint arising from affection of muscles on either side of head.

In instance before us head uniformly drawn to right side.

Often found that such motion, independent of power of volition, effect merely of weakness of [antagonising] muscles.

And accordingly often fixed distention to one side from paralysis of opposite.

As even that degree of sheathing to which muscles subjected in body a stimulation to contraction where power of antagonism removed.

But at same time difficult to conceive that such weakness should instantly come & go in manner here described.

And this not only supposition on which involuntary motion here taking place may be explained.

Well known that muscles in natural state possess disposition to contraction on application of stimulation

This property which has been called irritability may suffer either increase or diminishment.

And when former of these takes place involuntary contraction excited by very trifling causes

Not merely by external stimuli but even by internal as stimulation of circulation or like.

Is from such morbid irritability [that] most pathologists at least are disposed to explain those [particular] convulsions seizing lips, eye lids or other muscles about face.

Think it therefore more probable that inordinate motion in present instance from this than from any other cause

While therefore give it name of Obstipitas Spasmodica would consider it as depending on peculiar morbid irritability of muscles of right side of pectoral.

And although from particular part affected entitled to appellation of obstipation yet in reality to be considered as particular modification of Convulsio

From observations now offered as to name & nature of disease will readily [conclude] that with respect to Prognosis must be very doubtful.

As have never before met with instances of affection under present form can in no degree judge from former experiences

Nor is much aid in this way to be derived from cases related by others.

For these so few in number that can hardly be supposed to warrant any general conclusion.

Yet as far as they go would at least lead us to entertain favourable hopes of cure.

For while some, apparently at least removed by measures employed, others after measures used in vain, ceased of themselves.

From nature of disease also rather favourable opinion than otherwise.

True indeed that inordinate actions falling strictly under head of convulsion often very obstinate.

Yet upon whole in general less obstinate than Epilepsy or even hysteria.

And unquestionably less dangerous than either of these affections.

Upon whole then here reason to hope, if not for speedy cure at least for opportunity of trying different medicines.

And if shall be able to affect former will have some reason to ascribe it to medicines employed.

For although has not of late increased in violence yet has continued with great obstinacy for considerable length of time

And during that has resisted several powerful remedies.

Upon whole then have rather selected patient with view of giving trial to different medicines than from hope of being able by any of them to effect cure.

To measures which have in view with this case however, must acknowledge that here directed rather on empirical or random footing than in any other way

From idea given of disease indeed great objective to be aimed at is removal of morbid irritability or uncommon disposition to action of muscles on right side of neck.

And as accomplishing this intention both over system in general & at particular parts many medicines may be employed with some prospect of success.

Will perhaps however imagine that mode of cure here employed, Electricity viz. but ill suited for that purpose.

At least much more frequently used with very opposite intention.

That viz of restoring sense & motion to parts deprived of it.

With this intention, have often I think seen it attended with best effects

At same time am also [persuaded] not merely from reason but observation that may likewise be of great [utility] in counteracting & removing depraved state of Nervous power.

Into grounds of opinion on this subject however cannot at present propose to enter.

But for some view of these may refer you to Volume of Medical cases published some time ago¹.

From thence will understand the principles on which expect success.

And may now add that some experience of use in such cases has furnished me, although will not venture to say with certain evidence, at least with additional proof of conjecture.

But besides my own supposition as to power of electricity here led to it on another & what with me, is I must own a stronger ground.

Successful employment viz in a similar case by a practitioner on whose accuracy I can depend.

Case to which I now allude treated by Dr Gray of the British Museum one of best [electricians] in Britain.

There also disease consisted in affection of muscles of neck.

Was not indeed in its circumstances similar to ours as consisted of inordinate action.

But although constantly laid to one side reason to presume that depended on increased force of contraction in [muscles] of that side to which inclination took place not from weakness of antagonism.

In this case Dr Gray thought of trying electricity in a manner which is I believe peculiar to himself.

Or at least for my own part have not met with it in any of treatises on this subject & was unacquainted with it till had pleasure of conversation with him.

Had considered it as applicable in four different ways. Shocks. Sparks Pencil & Insulation.

Mode of application in these different ways long known & now generally understood.

But besides these, Dr Gray has introduced practice of making electrical fluid pass through a part, from its form immediately communicated between negative & positive sides of jaw applied to prime conduct of a machine in action.

This most nearly approaching to electrical stream or pencil. – But different.

And perhaps better distinguished by title of electric current than any other appellation

To this mode of application Dr Gray had recourse with his patient.

And found that while electrical stream passed through muscles, [although] patient no feeling whatever from thence could with ease hold head erect.

But if drawn off in another direction even unknown to patient head soon again drawn into former position.

By continuation however gradually acquired power of holding it longer erect.

Particularly for some time after came from wheel.

At length by proper continuation, interval gradually protracted till disease cured.

This case then some encouragement to use in instance before us.

And accordingly have ordered it in same manner.

Since first directed patient has attended with tolerable regularity.

Cannot however say that hitherto great progress made in cure

At same time is at least no worse since commenced use of it.

Shall therefore wish to continue it, till has had full & fair trial.

If however after this appears that insufficient to combat affection two other measures to which have thought of having recourse either in conjunction or in succession.

First of these applications of Aether & Laudanum to affected muscles of neck.

And second a combination of Calx of Zinc & Valerian taken internally.

To both these proposals led from effects which have seen derived from them as allaying tendency to inordinate action in other cases.

If in this instance shall have occasion to employ them may hereafter take opportunity of speaking of them at more length.

But not impossible that farther observations of case may lead us to alter both opinion of nature & plan of cure.

Hence then such remarks at present unnecessary.

And what already said will sufficiently explain present views & intention.

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Explanatory notes:

1) Andrew Duncan, Medical cases, selected from the records of the Public Dispensary at Edinburgh : with remarks and observations : being the substance of case-lectures, delivered during the years 1776-7 (1778).