DEP/DUA/1/39/24 (Normalised version)

David Shank

1786

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David Shank. March 25^th 1786.

When formerly spoke of this patients case pronounced it peculiar modification of Chorea or Convulsivo strictly so called.

And during course of attendance have had no reason to alter opinion.

For disease has all along subsisted very much under same form as described in register¹.

And indeed under same form which have before seen it on former occasions.

For this patient as will observe indeed from history in register already oftener than once under care.

First a patient at Collegium Casuale² in February 1781.

And then disease according to account given us but of few months standing

Then also delivered in lecture same opinion respecting it.

Does not indeed exactly correspond with definition given of Chorea by some of nosologists³.

Particularly with those making separate genus, as Dr Cullen of Chorea from Convulsivo.

Has not even those [illegible] of [illegible] resembling Buffoon, introduced into most definitions.

This however I consider as by no means essential.

For even in majority of instances which I have seen, though in other respects exactly corresponding to definition & agreeing with no other disease, that wanting.

In other instances where has occurred not present in every fit.

Still however must consider all fits as essentially the same.

And may readily therefore suppose absent either altogether or for length of time.

But in present instance more near [resemblance] to definition of Chorea than to any other disease.

He indeed considers that affection as in general confined between 10 & 14 years.

And though our patient now at 19^th yet commenced within period mentioned.

Hence may be considered as proof that this part of definition by no means universally holds.

Here may be strictly said that the motus convulsion is exparte [volunt].

For while remains at work [without] change of place almost never attacks him.

On contrary no sooner effort to walk than almost certainly affected with it.

And then may particularly observe another circumstance mentioned in his definition, one foot viz rather drawn after him than [raised].

This however does not occur more on one side than other.

Sometimes right, sometimes left limb particularly affected.

Often even both, as had particular opportunity of seeing at visit on Saturday last when contrast so far extended that head also drawn back.

And if had not been supported would in all probability have fallen to ground.

In these inordinate actions then occurring in voluntary muscles of legs & arms have I apprehend essential characteristic of disease

While sufficiently distinguished from Epilepsy by total want of any abolition or even disorder of mental faculties.

For even during course of fit itself these unimpeded.

And after has ceased patients [instincts] as well as ever.

Distinguished again from hysteria by there being no affection of alimentary canal.

Though tongue at times contracted yet nothing like globus hysteria.

And none of other symptoms either in state of mental faculties, or bodily functions, which attendant of that disease.

These however only complaints to which can be considered as having [resemblance]

At least if except convulsive of Dr Cullen & consider that as separate disease.

But to his definition of convulsive it exactly corresponds.

For here no one will deny that [there] occurs, musculorum contraction clonica abnormis citra soporem.

And indeed this must take place in every instance of Chorea, as defined by Dr Cullen.

Hence cannot help thinking that he has done wrong in making too general.

Do not indeed deny that not in every instance of convulsive all these symptoms occur which he has described in [definition] of chorea.

But on other hand, as in case before us, so many of these symptoms occurring as to give more exact resemblance to this [disease] than to any other.

And as in case before us [always] with these other symptoms take place not mentioned in this definition.

Thus while in Dr Cullens definition convulsive motion considered as entirely confined to extremities, would appear that no muscle of body not at times affected.

Very generally trunk of body often head also drawn backwards.

And in most instances, tongue [affected]

At least during fit unable to speak.

And then has, as he expresses it, sense of tongue being tied.

But if in this peculiarity have no less so in frequency & in short duration of fits.

At least in all instances I have before seen, never met with any where, so frequent occurrence.

For if does not remain at rest, almost innumerable in course of day.

While however thus remarkable for frequency no less so for short duration.

For very rarely, that continues even for space of minute.

Commonly even go off in very few seconds.

While however in these respects peculiar modification, also with particular symptoms.

Among these may mention as perhaps most alarming, shooting pain with which affected under sternum.

This indeed am disposed to consider as an involuntary contraction of muscles of diaphragm analogous to what occurs in muscles of limbs, & other parts.

A conjecture the rather rendered probable, by affection of respiration which induces.

At same time, of this no certainty.

And to be observed, whether is so or not, that affected with it, not merely on attack of proper fits, but also at other [times]

And as giving interruption to an important vital function, hard to say, what may be consequence of severe or long continual attack.

Though hitherto but of short continuation, yet cannot pretend to tell, how soon may become much longer.

And if affects diaphragm at one time, may affect heart at another producing consequences still more immediately [alarming]

Besides this painful sensation another peculiarity to be marked in present case is prickling sensation with which affected.

Is affected you will observe with a peculiar prickly sensation over whole body

But particularly in palms of hands.

According to description he gives, more nearly resembling what called sleeping of part, than anything else.

This sensation every one must have felt, & not unfrequently met with, in different diseases.

Have particularly remarked it as an symptom both preceding & accompanying paralytic affections of particular parts.

[And] to paralysis, at least in certain parts of body, would here seem to be tendency.

For in general, motion of lower extremities rather imperfect.

But in cases to which I allude, prickling both permanent & entirely confined to [particular] parts

Here however, sensation extended over whole body & by no mean constant.

Hence then even in its nature singular.

But is no less so, that conjoined with chorea.

At least, in any former instance of that disease, which have had occasion to treat, have not met with anything similar.

Is indeed not uncommon, that a peculiar sensation in chorea, felt in muscles previous to being affected.

And by this, during course of fit, where muscles affected in succession, patient able to tell in what particular part inordinate motion will next occur.

But this very different from pricking sensation here described.

And indeed matter of doubt [whether] connected with convulsive motion or not.

But when consider that of same duration that have disappeared & reoccurred together, probably at least in favour of connection.

Besides these as still another peculiarity may mention circumstance just alluded to disappearance & recurrence of affection.

Patient now subjected to this complaint for space of several years.

And during that period though imagined that medicine sometimes employed with advantage yet observed in disease as it were regular course.

First attacked him in cold weather of winter 1780-1.

And though free from it during warm weather in summer & autumn, yet again returned in winter.

In this manner, has continued ever since

Ceasing whether medicine employed or not in summer & recurring during winter

Hence presumption that relief more from season than medicine.

But whether so or not, in this particular may be considered as exhibiting another great singularity.

At least, in my own practice, have never before seen any instance of it.

Nor do I observe that mentioned by any of those, who have written most accurate history of disease.

On contrary, as far as I am able to recollect, majority of instances I have, seen during summer.

Thus then some observations on name of disease and on peculiarity.

But in such a case, with view to prognosis, as well as practice, may be expected that should say [something] of nature

Here however must acknowledge [illegible] very much at loss.

And indeed this case with regard to nervous affections in general.

Concerning most, if not all these, almost utmost length that can go is to say that depend on Nerves.

For till nature of nervous fluid, if such a fluid [may] exist at all, be ascertained in state of health, can say nothing of morbid change to which subjected.

Not wanting some indeed who think they solve every difficulty with respect to it, by telling us that Chorea is a disease of debility.

But hardly any one I think, who bestowing [momentary] [reflection], can have any doubt that this a mere cloak for ignorance.

Indeed I know no term which has of late been more employed for this purpose.

At the same time know none the fallacy of which more easily detected by even slightest consideration

Even allowing could be clearly demonstrated that in every case of Chorea debility present yet would by no means follow, that connected as cause & affect.

Might be merely concomitant affects of same cause.

Or what certainly often case, debility consequence not cause of disease.

And where debility occurs, in 19 of 20 instances this certainly case.

Indeed hardly possible to conceive, long continuation of any disease without inducing some degree of debility.

And accordingly after disease itself overcome, debility still as great, [sometimes] even greater than ever.

But by no means case, that in every instance of Chorea, debility can be said to exist.

In by much greater number of instances, that I have seen, this by no means happened.

Present patient evidently more strong & robust, than thousands of others, without slightest mark of disease.

While indeed inordinate actions take place is necessary incapacitated, from voluntary action.

But at all other times, is abundantly capable of strong exertion.

And every function, whether vital, natural or animal, goes on without mark of slightest affect.

But if thus appears that chorea where no debility, so on other hand thousands of instances of debility, where no Chorea.

As already observed hardly any disease of long continuation, as consequence of which, [debility] does not ensue

Yet will any one pretend to say that debility thus induced gives rise to Chorea.

Is but poor subterfuge to allege that Chorea effect only of particular degree of debility

In that disease from state of health which has preceded attack can distinctly mark, gradual decline of powers, gradual diminishment of energy of every function [whether] vital, natural or animal till death ensues.

Are there not every day examples of patients passing from state of [highest] health & vigour, to greatest imaginable extreme of debility, without slightest appearance of it.

This daily exemplified in cases of Dropsy.

But for my own part at least among 100 of Dropsy patients have never once seen Chorea occur.

Besides this will any man pretend to say, even in those cases where Chorea accompanied with debilitated, state all patients same degree of it.

Evidently [apparent] both from state of [voluntary] actions, & condition of other functions, that very different degrees of vigour.

Will any one pretend to say that same patient same degree of vigour during whole course of [disease]

Thus with present patient disease has now subsisted for greater part of four years.

And can there be a doubt that during this period, from thousands of different accidents, must have been [sometimes] to greater, sometimes to lesser degree in vigour or debilitated state?

Yet during all these varieties, disease uniform nay stated in periods

Thus then present case as well as general history of disease affords abundant refutation of this doctrine.

Undeniable that many instances of Chorea without any mark of debility.

That in number instances of other affections every possible degree of debility without any symptoms of Chorea.

And that both when compare together different patients labouring under Chorea & same patient at different periods of disease, have evidence of infinite variety of different degree both of debility & vigour.

If this however case [unnecessary] to add that hypothetically supposing a certain degree of debility cause of Chorea a manifest absurdity

On refutation of this doctrine have perhaps bestowed, more time than ought to have done.

And indeed for my own part, I hardly consider it as either requiring or deserving refutation.

But will I hope be [some] apology, that same reasoning, equally applicable to various other diseases where those who either think themselves much wiser than every body else or at least venture to tell the world that they think so, shelter their ignorance under term of debility.

From what said would only conclude that every thing we yet know as to cause of disease, carries us no length, in forming any proper prognosis.

And on this subject can alone judge from former experience, & observations.

If to judge of present case from other instances of Chorea, which have had occasion to treat, opinion as to termination would be favourable.

For at least greater part of these whether from affect of remedy employed or operation of system itself, had favourable termination.

But from what has already happened in present instance cannot venture to give such an opinion.

For disease has already subsisted with obstinacy even for space of years.

Or at least, though not uniform during that period, has continued for greater part of time

Besides this, is as have already [seen] attended with some peculiar circumstances.

Particularly with sense of prickling, not unlike that, which often precedes paralytic affections.

And with shooting pain under sternum affecting respiration which have already hinted probably from affection of diaphragm.

Hence then can neither flatter ourselves with hopes of speedy termination nor freedom from danger.

At same time season of year now approaching at which affection has had even spontaneous termination on former occasions.

Have therefore at least some reason to hope, that independent of use of remedy same may again occur.

This however does not prevent us from opportunity at least of trying different [practices]

And here from what already said will readily conclude that have recourse to these rather on footing of former experience than from pretended knowledge of nature of affection.

When this patient first under care began treatment by having recourse to Calx of Zinc.

A remedy which in some other instances have I think used with very great advantage.

But here after trial for some time & to considerable extent found ineffective

Had then recourse to Cuprum Ammoniala another article which have often employed & I think with advantage in cases where [inordinate] action of voluntary muscles.

Even in some cases of Epilepsy, if not much mistaken, with affect of complete cure.

And under use, at that time patients complaint very much alleviated.

But this it is to be observed happened at that season of year when as since remarked, tendency to spontaneous temporary recovery.

Probably therefore relief as much [affect] of season as of remedy.

Still however this no reason why should not give it again trial

Accordingly began treatment by prescribing cuprum under form of Pills to extent of grain s twice a day.

Have gradually increased it till now takes six grains in day

And even from this quantity is not affected with any sickness.

Under use of this medicine very little change has taken place on affection.

For although sometimes [appears] alleviated sometimes [diminishment] of prickly yet upon whole affection much as before.

Concluding therefore that cure not to be affected by this alone have since had recourse to Zinc.

And here mean to try these two remedies in conjunction.

For has been said that patient bears as much of both taken together as of either separately.

Is intention then to persist in use till shall have had fair trial.

And to increase dose while bears it without any inconvenience.

As however already observed expectation of cure by no means sanguine.

If fails many other practices which may at least be tried.

And as a means of allaying inordinate action might naturally think of opium.

For on all hands admitted that in this way very powerful influence.

Here however symptoms indicating tendency to paralysis may perhaps be considered as some objection.

[For] however much practitioners may dispute whether to be considered as stimulant or sedative yet no one as far as I know has advised it in that complaint.

On contrary very generally considered as prejudicial.

But notwithstanding this shall here perhaps give it trial particularly as conjoined with Camphor

And if this also unsuccessful [future] practice regulated by circumstances

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Explanatory notes:

1) References are made throughout the case notes to a dispensary patient register. However, no evidence has been found that this register survives.

2) A term used in the 1700s in Leiden, Padua and elsewhere to describe clinical teaching, using demonstrations of outpatients.

3) 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.