DEP/DUA/1/12/04 (Normalised version)

Janet Jardine

(1776-1777)

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On Saturday last dismissed from attendance Janet Jardine.

When came under care doubtful as to nature of affection.

Symptoms neither urgent nor distinctly marked.

Some however respecting which could hardly be mistaken.

Of these gave sufficiently distinctive account.

And others which patient herself could not so easily see obvious to our examination.

From all however taken together no distinct Genus.

And indeed was inclined to look upon it as complicated affection.

Patient herself suspected that all symptoms proceeded from worms.

And in this supposition was disposed to agree with her

At least several particulars favouring such conjecture.

Had not here it is true some of most common symptoms indicating worms.

And several others present which do not frequently induce

Example Cough, soreness of breast & scanty expectoration.

And among others may even enumerate sneezing.

May however observe that know no symptoms wanting which consider as essential.

Unacquainted with any affections which worms constitute & uniformly produce.

At one time only affection severe gripes & glairy stools.

At another characterised only by [ nidor.] [illegible] & [illegible] various or peculiar.

In third case after probably being long in alimentary canal without any inconvenience will at once occasion convulsions catalepsia & all trains of most dreadful nervous symptoms.

In fourth will exist for long time where no other grounds for suspicion but grinding of teeth during sleep & peculiar itchy sensation at point of nose

These perhaps of all other symptoms most seldom absent.

Hence by some considered as essential characteristic

Especially when conjoined with swelling of upper lip.

Which indeed some practitioners consider even of itself, as without any other mark infallible diagnosis of present worms.

As far as my own observation goes however must own am of different opinion.

And in this opinion by no means singular.

Far from meaning to deny that these common symptoms.

Two former as already observed generally present.

Of latter from own observation can say little

Yet on credit of others will not refuse that this also a common symptom.

Can neither allow however that any one uniformly present in every case.

Nor that when all occur together to be considered as certain evidence of existence of worms.

Have seen more than one instance where other symptoms of worms without any one of these three marks.

And where certain evidence of nature of affection by cure on removal of worms.

On other hand these symptoms will unquestionably proceed from other causes.

May institute for example where with infants grinding of teeth during sleep and itchy sensation at nose the affects of dentition.

And after exists to high degree on cutting a tooth will entirely disappear.

And that too though patient never either before or after observed to discharge worms.

Last symptom swelling viz of upper lip perhaps still more frequently occurs without worms.

And indeed to form any judgement from it should have previous acquaintance with patient.

For with some even natural appearance such that should suspect it to be highly swelled.

But even increase of natural size as well as of septum nasi a common symptom of other affections

In so much that by Dr Cullen introduced into definition of scrofula

And that too even without use of [word] plerumque which in definition often employed.

Would seem therefore that considers it as an essential characteristic.

And certainly will not be supposed that in every case of scrofula worms present.

But fair however to observe that can by no means totally adopt idea of Dr Cullen.

At least as I would explain it.

That is cannot consider swelling of lip & nose as constant symptom of scrofula more than of worms

Yet will not I dare say be refused by anyone that are a frequent appearance.

And have no hesitation in asserting that have often seen them present in scrofula where no worms.

Upon whole then must conclude with observation that no symptom the invariable attendant of worms in alimentary canal.

And perhaps even may venture to assert that none which may not at times induce.

At least no doubt that are cause of an almost infinite variety of anomalous appearances.

Remains then to say by what circumstance induced to this conjecture as to cause of present symptoms.

Was led to presumption solely from two circumstances.

1 Sensation of which patient complains at point of nose viz peculiar tickling.

This as already observed although not constant yet a frequent symptom.

Still more however by 2d viz Worm discharged a few days before came under care.

Where this the case certain evidence that have been present.

And strong presumption that others still remain

Does not follow however that are cause of symptoms

But very generally either this the case or worms discharged in consequence of a supervening disease.

Often unquestionably the affect of febrile complaint.

But in this case other symptoms such as could have no influence in that way.

Was therefore disposed to view them as consequences.

And certainly none which worms have not in other instances been observed to induce.

Particularly tickling cough, soreness of breast, & other symptoms appearing catarrhal.

Had indeed somewhat more doubt respecting yellowness of eyes.

Especially as conjoined with high colour of urine

And particularly when found that gave yellow tinge to linen.

These consider as certain evidence of presence of bile in circulatory system.

And although no marks of total want in alimentary canal yet was disposed to look upon it as affect of obstruction.

Imagined that might proceed from sordes in duodenum obstructed mouth of ductas com Choledochus.

Well known that such sordes almost continual attendants of worms.

And that is great nidus in which hatched & supported

Probably in some measure generated by themselves.

Thus then consider worms & cause of obstruction as not unconnected.

This idea of disease when patient came under care

After observation however did not confirm opinion.

And presumption at least that depended less on worms than was then inclined to believe.

For although medicines employed which might both have killed & expelled yet none appeared

And principal symptoms indicating them vizr tickling at nose gradually diminished.

While at same time very little continuation either of cough or of pain at breast.

Other symptoms however rather increased than diminished

Particular yellow tinge of eyes & high colour of urine.

Was still more inclined therefore to view jaundice as principal part of complaint.

But still as depending rather on sordes in primae viae than any other cause.

On every view of case then could not consider it as of dangerous nature.

Even on supposition of worms looked for favourable termination.

Had still greater expectations however from circumstances giving presumption that no other than at first discharged.

And that principal if not only complaint to be combated was slight jaundice.

In this termination now appears that were not [disapproved]

For symptoms of jaundice as well as others have now left her.

Would not however pretend to say that perfectly cured.

For supposing conjecture right may soon again be subjected to such returns of sordes as to give fresh [compression]

And although symptoms of worms have disappeared yet may still be present in alimentary canal.

Or nidus may yet remain [continuing] ova from which may be generated.

But farther all conjectures may be entirely wrong

And whole symptoms may have arisen from some other cause, of which although action suspended yet cause itself not removed.

Cannot help thinking however that more probable not only that conjecture well founded but that relief which patient has obtained will be of some permanence.

Treatment of this case as far as went proceeded entirely on idea given of nature.

At commencement disposed to consider worms as principal affection.

And as chiefly requiring treatment.

Yet before exhibiting any medicine with this view thought it advisable to evacuate stomach

Both as action of anthelmintic afterwards given would thus be more powerful.

And as by agitation had some chance of removing sordes or other obstructions to biliary duct

From these circumstances directed first Ipecacuanha to such dose as hoped might produce brisk vomiting

Afterwards Calomel as one of easiest & most effective of the anthelmintics killing worms.

And lastly composite powder of Jalap as brisk purgative.

By which worms either killed or in languished state might be expelled.

Or if none present intestines freed from sordes & mercury thoroughly evacuated.

In obvious operation of these medicines were not disappointed.

At least both emetic & purgative operated well

And Mercury given in such manner that no obvious operation to be expected.

Would however appear that either no worms or that killed none.

For although symptoms disappeared yet no others observed either in natural stools or during operation of purgative.

Concluded it therefore unnecessary at least at that time to push attempt against worms any farther.

And as still remains of symptoms of jaundice took this rather to be objective claiming attention.

With this view thought of pushing farther the emetic.

Especially as from continued disagreeable taste in mouth still some presumption of foul stomach

Although indeed a common symptom in jaundice from state of saliva

And with present patient saliva as well as urine might unquestionably have been affected.

Consider it however as more probably affect of sordes in stomach, since disease neither to high degree nor of long standing.

And saliva seldom affected early in the complaint.

On these grounds then directed use of repeated doses of Ipecacuanha.

And from events would seem attended with good affects.

According to account of patient by one of these discharged a quantity of coagulated dark coloured matter.

At same time with very disagreeable taste

Whether this matter rather coagulated bile, than as patient suspected blood, & whether had before given obstruction to duct will not pretend to say.

But after evacuation patient considerably relieved

And yellowness with every other symptom of jaundice soon left her.

Reckoned it unnecessary therefore that should continue attending here.

And am hopeful that relief she has received may be permanent.