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

David Shank

1786

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David Shank. March 25^th 1786.

When formerly spoke of this pat. case pronoun. it pecul. modif of Chorea or Convuls. strictly so calld.

And during course of attend have had no reason to alter opin.

For disease has all along subs. very much under same form as descr. in regist.

And indeed under same form which have before seen it on formr occas.

For this pat. as will obs. indeed from hist in regist. already oftener than once under care.

First a patient at Col. Casuale in Febr. 1781.

And then disease accord. to acct given us but of few months stand

Then also deliv in lect same opin resp. it.

Does not indeed exactly corresp. with defin given of Chorea by some of nosol.

Partic with those making separ. genus, as Dr C. of Chorea from Conv.

Has not even those [illegible] of [illegible] resemb. Buffoon, introd into most defin.

This however I consid as by no means essent.

For even in major of inst which I have seen, though in other resp. exactly corresp. to defin & agreeing with no other disease, that wanting.

In other inst where has occurred not pres. in every fit.

Still however must consider all fits as essent the same.

And may readily therefore supp abs. eithr altog or for length of time.

But in pres inst more near [resem] to defin of Chorea than perhaps to any other disease.

He indeed considers that affect as in gener. conf. between 10 & 14 year.

And though our pat. now at 19^th yet comm. within period ment.

Hence may be consid as proof that this part of defin by no means univ holds.

Here may be strictly said that the motus convuls. is exparte volunt.

For while remains at work [without] change of place alm. never attack him.

On contr. no sooner effort to walk than almost cert. affected with it.

And then may partic obs anoth circum ment. in his defin, one foot viz rather drawn after him than [raisd].

This however does not occurr more on one side than othr.

Sometimes right, sometimes left limb partic affected.

Often even both, as had partic opport of seeing at visit on Satur. last when contrast so far extend that head also drawn back.

And if had not been supp. would in all prob. have fallen to ground.

In these inord actions then occur. in volunt. muscles of legs & arms have I appreh. essent charact of diseas

While suff. disting from Epilep by total want of any abolit or even disorder of ment. facul.

For even during course of fit itself these unimp.

And aftr has ceased patient inst as well as ever.

Disting again from hystr. by there being no affect of alim canal.

Though tongue at times contr. yet nothing like glob. hyster.

And none of othr sympt. either in state of mental facul, or bodily funct., which attend of that disease.

Where These however only compl. to which can be consid as having [resem]

At least if except convuls of Dr Cullen & to consid that as separ disease.

But to his defin of convuls. it exactly corresp.

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

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

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

Do not indeed deny that not in every inst of convul. all these sympt occurr which he has describd in [defin] of chorea.

But on other hand, as in case before us, so many of these sympt occur as to give more exact resemb. to this [disea] than to any other.

And as in case before us [alw] with these other sympt take place not ment in this defin.

Thus while in Dr Cullens defin convuls. mot. consid as entirely confined to extrem, would app. that no muscle of body not at times affec.

Very gener. trunk of body often head also drawn backwards.

And in most inst, tongue [affec]

At least during fit unable to speak.

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

But if in this pecul. have no less so in freq. & in short durat of fits.

At least in all inst I have befr seen, never met with any where, so freq. occur.

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

While however thus remark for freq. no less so for short durat.

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

Commonly even go off in very few seconds.

While howevr in these respects pecul. modif, also with partic sympt.

Among these may ment as perh. most alarm, shooting pain with which affected under stern.

This indeed am dispos. to consid. as an invol. contract of muscles of diaph analog. to what occurs in muscles of limbs, & other parts.

A conject the rather rend probab, by affect of respir which induces.

At same time, of this no cert.

And to be obs, whethr is so or not, that affected with it, not merely on attack of prop. fits, but also at other [tim]

And as giving interrupt to an import. vital funct., hard to say, what may be conseq of severe or long contin attack.

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

And if affects diaph at one time, may affect heart at anoth prod conseq still more immed [alarm]

Besides this painful sensat. anoth pecul. to be marked in pres case is prickling sensat with which affect.

Is affected you will obs. with a pecul. prickly sensat. over whole body

But partic in palms of hands.

Accord. to descript he gives, more nearly resemb. what calld sleeping of part, than any thing else.

This sensat every one must have felt, & not unfreq. met with, in diff. dis.

Have partic remarked it as an affect sympt. both preced & accomp. paralyt affect of partic parts.

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

For in general, motion of lower extrem rathr imperfect.

But in cases to which I allude, prickling both perman & entirely conf. to [part] parts

Here however, sensat extended over whole body & by no mean const.

Hence then even in its nature singul.

But is no less so, that conj. with chorea.

At least, in any former inst of that disease, which have had occas to treat, have not met with any thing simil.

Is indeed not uncommon, that a pecul. sensat in chorea, felt in muscles prev to being affected.

And by this, during course of fit, where muscles affected in success, patient able to tell in what partic part inord. motion will next occurr.

But this very diff from pricking sensat here descr.

And indeed matter of doubt [wheth] connected with convuls mot. or not.

But when consider that of same durat. that have disapp. & recurd together, prob. at least in fav of conn.

Besides these as still anoth pecul. may ment. circum just alluded to disapp. & recurr of affect.

Patient now subj to this compl. for space of sever. years.

And during that period though imagind that med sometims empl. with advant. yet obs. in disease as it were regul course.

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

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

In this manner, has cont ever since

Ceasing whether med empl or not in summer & recurring during spring winter

Hence presumpt that relief more from season than med.

But whether so or not, affect in this partic may be consid as exhibit. anoth great singul.

At least, in my own pract, have never before seen any inst of it.

Nor do I obs. that ment by any of those, who have written most accur hist of disease.

On contrary, as far as I am able to recollect, maj. of inst I have, seen during summr.

Thus then some observ. on name of disease and on pecul.

But in such a case, with view to progn, as well as pract, may be xpected that should say [somethin] of nature

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

And indeed this case with regard to nerv. affect in gener.

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

For till nature of nerv fluid, if such a fluid [may] exist at all, be ascert in state of health, can say nothing of morb. chang. to which subj.

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

But hardly any one I think, who best. mom [reflx], can have any doubt that this a mere cloak for ign.

Indeed I know no term which has of late been more empl. for this purp.

At the same time know none the falacy of which more easily detected by even slightest reflex considerat

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

Might be merely conconm affects of same cause.

Or what certainty often case, debilit conseq. not cause of disease.

And where debilit occurrs, in 19 of 20 inst this certainly case.

Indeed hardly possib to conceive, long contin of any disease without induc some degree of debilit.

And accord after disease itself overcome, debilit still as great, [sometm] even greater than ever.

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

In by much greatr numb of inst, that I have seen, this by no means the case happend.

Pres. pat. evid more strong & robust, than thous. of others, without slightest mark of disease.

While indeed inordin actions take place is necess incap, from volunt action.

But at all othr times, is abund capab. of strong exert.

And every funct, whether vital, natur or animal, goes on without mark of slightest affect.

But if thus app. that chorea where no debilit, so on othr hand thousands of inst of debilit, where no Chorea.

As already obs. hardly any disease of long contin, as conseq of which, [debl.] does not ensue

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

Is but poor subrtf. to alledge that Chorea effect only of partic degree of debilit

In that disease from state of health which has preceded attack can distincty mark, grad decline of powers, gradual dimin of energy of every funct [whethr] vital, nat or animal till death ens.

Are there not every day exampl. of pat. pass. from state of [highes] health & vigour, to greatest imag extreme of debilit, without slightest app. of it.

This every daily exempl. in cases of Dropsy.

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But for my own part at least among 100 of Drop. pat. have nevr once seen it Chorea occur.

Besides this will any man pretend to say, even in those cases where Chorea occurs accompan with debilit, state all pat same degree of it.

Evid app. both from state of [volun] actions, & condit of othr funct, that very diff. degrees of vigour.

Will any one pretend to say that same pat. same degree of vigour during whole course of [diseas]

Thus with pres. patient disease has now subs. for greater part of four years.

And can there be a doubt that during this period, from thousands of diff accid, must have been [sometim] to greater, sometimes to less degree in vigour or debilit state?

Yet during all these varieties, disease unif. nay stated in periods

Thus then pres. case as well as general history of disease affords abund refut of this doctrine.

Unden. that many inst of Chorea without any mark of debilit.

That in numb. inst of other affections every possib degree of debilit. without any sympt of Chorea.

And that both when compare together diff pat. lab. under Chorea & same pat. at diff periods of disease, have evid of infin variety of diff degr. both of debilit & vigour.

If this however case [unnecss]. to add that hypoth suppose a certain degree of debilit cause of Chorea a manif absurdity

On refutat of this doctrine have perhaps best, more time than ought to have done.

And indeed for my own part, I hardly consider it as either requir or deserv. refut.

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

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

And on this subj. can alone judge from formr exper, & observ.

If to judge of pres. case from other inst of Chorea, which have had occas to treat, opin as to termin would be fav.

For at least greater part of these whether from affect of remed empl. or operat of syst itself, had fav. term.

But from what has already hap. in pres. inst.  cannot venture to give such an opin.

For disease has already subs. with obstin even for space of years.

Or at least, though not unif. during that period, has contin for sev. years for greater part of time

Besides this, is as have already [seen] attended with some pecul. circum.

Partic with sense of prickling, not unlike that, which often prec. paraly affect.

And with shooting pain under stern affect respirat. which have already hinted prob. from affect of diaph.

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

At same time season of year now approach at which affect has had even spont. termin. on form occ.

Have therefore at least some reason to hope, that indep. of use of remed. same may again occurr.

This however does not prev. us from opport at least of trying diff. [pract]

And here from what already said will readily concl. that have recourse to these rather on footing of former exp. than from pretend knowl. of nature of affect.

When this pat. first under care began treatm by having recourse to Calx of Zinc.

A remed which in some other inst have I think used with very consid great advant.

But here after trial for some time & to consid extent found ineffect

Had then recourse to Cupr. Am. anoth artic which have often empl. & I think with advant. in cases where [inord] action of volunt musc.

Even in some cases of Epilep, if not much mist, with affect of compl. cure.

And under use, at that time pat. compl. very much allev.

But this it is to be obs. happ. at that season of year when as since remarkd, tend to spont temp recov.

Prob. therefore relief as much [affec] of season as of remed.

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

Accord. began treat. by prescr. cupr. under form of Pills to extent of gr s twice a day.

Have grad encr. it till now takes six gr in day

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

Under use of this med very little change has taken place on affect.

For although somtimes app. allev. sometimes dimin of prickly yet upon whole affect much as before.

Concl. therfore that cure not to be affected by this alone have since had recourse to Zinc.

And here mean to try these two remed in conjunct.

For has been said that patient bears as much of both taken togeth as of either separ.

Is intent then to persis in use till shall have had fair trial.

And to encr. dose while bears it without any inconven.

As however already obs. expect of cure by no means sanguine.

If fails many othr pract which may at least be tried.

And as a means of allaying inordin action might natur. think of opium.

For on all hands admitted that in this way very powerf. infln.

Here however sympt indic tend to paraly. may perhaps be consid as some obj.

[For] howevr much pract may dispute whethr to be consid as stim or sedat. yet no one as far as I know has adv it in that compl.

On contrar very gener. consid as prejud.

But notwith this shall here perhaps give it trial partic as conj with Camph

And if this also unsucess [futur] pract. regul. by circum