DEP/DUA/1/15/13 (Normalised version)

Robert Dunneval

(1777-1778)

---

Robert Dunneval

A patient who after being but short time under care dismissed cured.

Yet must own that at loss to say not only how far we had much merit in removal but even what disease was.

And must acknowledge that began trial on a supposition which afterwards great reason to suspect ill founded.

That most threatening symptoms to which this patient subjected were of nervous kind could admit of no doubt.

Yet among class of Neuroses must own at loss to say to what particular genus should be referred.

Of four orders pointed out by Dr Cullen as referred to this general class could refer it only to head of spasmi.

Affection beginning in abdomen & propagated gradually to fauces gives evident indication of an inordinate motion.

Farther to be observed that in fauces gives sense of strangulation.

This well known to be case with the globus hysterica.

And with those considering that circumstances as pathognomonic of hysteria affection would probably obtain that denomination.

To this supposition however cannot help thinking that there are differences

Is somewhat against supposition of hysteria that patient a male.

For although with these the disease sometimes occurs yet is very rare.

And at least not exposed to causes most frequently exciting it, that is state of uterus.

From sex then some presumption against this supposition.

But still greater difficulty from age of patient

With females indeed sometimes does occur at commencement of menstrual.

Or rather at time when should appear but when notwithstanding evolution of uterus flow prevented.

But when does take place with males usually not till later in life.

And from oldest & most accurate practitioners cannot learn that have observed it so early.

To all this may farther add that far from considering globus hysteria as pathognomonic

To be considered merely as a spasmodic affection propagated through course of alimentary canal.

And hold that this may arise in other cases besides hysteria.

Have often seen it where no other [symptoms] of this affection present.

And indeed this pretty much the case in instance now before us.

Although at the same time must be allowed that not only symptom.

And in loss of power of motion with effect of senses have symptoms not unfrequently occurring in hysteria.

Yet these no more the characteristic of this than of other nervous diseases.

And upon whole disposed to reject supposition of hysteria.

If reject supposition of hysteria will next occur as subject of consideration how far can consider it as referring to affection of all other most nearly resembling it.

At least in external appearance.

This is Epilepsy.

To this not same objections as in other case.

Is an affection often occurring even at earlier periods of life.

And then too from very inconsiderable irritation.

Affection of senses still more in favour of this than of the other supposition.

And indeed may even be considered as some objection to the supposition that vision unimpaired.

Have likewise another particular giving difficulty in continuation of fits.

Are told that will sometimes last for two or three hours together.

Which if exclude consequences of fit is at least uncommon with Epilepsy.

Especially with that occurring in young subjects.

If therefore representation accurate this rather against supposition.

But besides these still another circumstance giving difficulty.

That is appearance of the disease.

Besides affection of senses & dyspnoea, Epilepsy still more particularly marked by convulsive agitation of muscles.

No such affection however said to occur with this patient.

And in as far as motion affected was by loss not by involuntary or inordinate affect.

From all these considerations then should I own have great doubts, in considering [disease] of this boy as strictly Epilepsy.

At same time know no other affection of nervous kind to which can with greater propriety be referred.

And must own was disposed to consider it as of this nature.

Epilepsy in infancy however not same terrible disease as at later periods of life.

And even at 7^th year which the age of our patient may be induced by irritation not afterwards capable of giving rise to it.

And which at same time of transitory nature.

In this way not unfrequently an affection from worms in intestinal canal.

And in case before us several circumstances leading to supposition that affection derived origin from thence.

Of this indication from pain so frequently seated about umbilical region.

Still more from its being attended with looseness & gripes.

And especially from these affections being conjoined very irregular appetite.

Sometimes considerably impaired sometimes morbid keenness.

This last circumstance in particular often the attendant of worms.

And these more frequent at early periods of life than afterwards.

From all circumstances taken together disposed to think, that Nervous affection here occurring was consequence of worms in intestines.

From this view of case was disposed to form a prognosis rather favourable as otherwise

And hoped that by removal of worm affection might be overcome.

Event of case however has not verified this conjecture.

And recovery of patient has taken place without any reason for believing that disease originates from this cause.

Patient indeed after came under our care discharged some worms of ascarides kind

But these which in general merely situated about extremity of rectum can hardly be supposed to have induced his affection.

Particularly to have given pains in umbilical region.

Now therefore disposed to consider conjecture on which founded prognosis & began treatment as being erroneous.

And therefore inclined to think that plan of cure at first begun not accommodated to disease of patient.

And that in reality had no effect in bringing about that relief which patient obtained in our hands.

Am however inclined to think that medicines here employed had no inconsiderable influence in cure

This however will more particularly [appear] from considering practice.

Began treatment as have already observed on supposition that affection arose from worms.

And on this supposition concluded that removal of fits would be effected by expulsion from system.

This to be brought about on one of two principles.

By diminution of power in consequence of which worms keep place

Or by increasing efforts of system for expulsion of contents of alimentary canal.

On this general principle explain action of all anthelmintics.

Some suppose produce effect by killing or sickening worms.

Others by increasing peristaltic motion of intestinal canal.

And by many substances both powers [possessed] in conjunction.

Hence then number & diversity of anthelmintics.

As being efficacious both from affecting worm & acting on system are many mercurial [preparations]

That mercury a poison to many individuals of animal creation cannot be doubted

Even in crude state alleged to kill Worm

And to commend power of doing this to simple water.

Lately contended in France that water in which Mercury boiled one of safest remedies against lumbricus.

But whether influence goes so far or not can be no question that is property of many of saline preparations.

And in calomel one which while generally answers this purpose has also tendency to operate as cathartic.

Has even been alleged of Calomel that operates in no other way but as cathartic.

And that is a mercury preparation very rarely if ever entering system.

Of contrary of this doctrine however have seen many striking facts.

And persuaded that under proper [management] is a mercurial preparation which will as [readily] enter system as most others.

Yet no doubt of disposition to act on intestinal canal.

And in this way only here requisite.

Did not however wish that [action] as cathartic should be immediate.

For had this been case could have exerted little influence on worm

Gave it therefore to extent of one grain only & that at bed time.

In this way chance of gradual solution & continuing for some length of time in [illegible]

For a well known fact that operation of purgative retarded both by state of [rest] & by warmth of surface.

And thus many purgatives taken at [night] do not operate till morning.

Expected then that would thus have full effect on worms if present.

And that next morning would have influence also as cathartic.

Patient at such age that even single grain of Calomel might be supposed to operate as purgative.

For even with adults in small quantity has sometimes this affect.

But must be allowed that operation as purgative uncertain.

Did not therefore [choose] to trust to this alone.

And especially as wished that in this case brisk catharsis should occur.

With this view had here recourse to Jalap.

A purgative which till of late years disposed to consider as too violent for children.

And which undoubtedly to be considered as in general a cathartic rather drastic as otherwise

In formula however in which have exhibited have never found it product of uneasy consequences.

And has always at same time fully answered intentions where brisk Catharsis [necessary]

For introduction of present formula are indebted to Sutton inoculators.

Long before these times indeed Tincture of Jalap an article of Pharmacopoeia¹.

But were first who introduced conjunction of it with syrup.

And who in this state with [freedom] exhibited it to infants.

In this form consider it as one of most effective & easiest taken purgatives with which am acquainted.

Purgative powers of Jalap known to reside in resinous part.

And fully extracted by weak ardent spirit here employed as menstruum.

In this state alive even in small bulk

While at same time syrup effect covers taste perhaps also mitigates [action]

And from being thrown in by small doses frequently repeated operation can be obtained to any extent without doing too [much]

From this then conclude that if vital power of worms diminished by former medicine would now be expelled.

And from conjoining operation if obtains no other affect would at least be satisfied whether worm in intestines or not.

In operation of these medicines in as far as had occasion to look for any action on system were not disappointed.

Bolus retained without inconvenience till morning & in conjunction with cathartic had then brisk operation.

But without any appearance of discharge of worms from intestinal canal.

From this then became more doubtful respecting conjecture.

And resolved at least for some time to intermit plan which had begun.

In place of immediately aiming at radical cure wished to attempt mitigation of symptoms

And during this hoped that might be more certainly able to ascertain [cause]

As means of mitigating or rather of anticipating fits had here recourse to aether.

This medicine as employed against Epilepsy had occasion to mention on Saturday last in case of Peter Drummond.

Is perhaps one of most powerful of tribe of Nervous medicines with which [are] yet acquainted.

And has an almost immediate action as counteracting inordinate motion whether taken internally or applied externally.

Seemed therefore to be as proper a medicine as could here have recourse to.

But besides powerful influence in this way had here from use of Aether another intention in view.

On supposition that former conjecture might not be entirely without foundation imagined that might here be of service as tending to radical cure if worms present.

Aether indeed has not I believe been professedly employed as anthelmintic.

But not many months ago, as I have been informed, some evidence afforded that had such affect.

A patient with epileptic affections admitted into Royal Infirmary².

There as in present instance suspected that Epilepsy proceeded from worms.

And various anthelmintics tried.

From these however no effect in curing disease.

And afterwards with view of mitigating severity recourse had to Aether.

Effect of this was that worms discharged & patient recovered.

From this circumstance alone then some presumption that Aether a powerful anthelmintic.

But in present case proceeded on less doubtful authority.

Since that time a Gentleman whose [presence] [prevents] from bestowing upon him those [encom] which think he well deserves has made various experiments with view of ascertaining the composite power of anthelmintics.

These experiments which demonstrate equal judgement & industry ascertain comparative power not only of various reputed anthelmintics but of many other articles as affecting & killing worms.

Of all substances tried none found of same activity with Aether.

While some of stronger did not produce death by application even for days Aether even when diluted with water killed the worms in space of very few days.

And that too when very considerably diluted.

Wherever therefore can be applied there is I apprehend very little reason to doubt that may be considered as a powerful anthelmintic.

True indeed that from great volatility of Aether action perhaps more upon stomach than any other part.

But even there worms frequently lodged.

And from case already mentioned have even I think presumption that activity extended to some portion of intestines.

These then sufficient motives for inducing me in present instance to give aether preference to other antispasmodics.

On use of Aether patient continued for space of fortnight.

And although did not entirely remove pains of belly yet seems to have effectively prevented return of fits.

In so much that from time of beginning use had never any return.

In what manner here operated must own am somewhat at loss to say.

Reckon it however probable that good effects arose from influence as anticipating fits.

Certain at least that did not proceed from action as anthelmintic.

For during employment no appearance of any worms discharged.

And from this circumstance together with relief at same time obtained farther evidence that first conjecture a mistaken one.

Even all this however did not consider as certain evidence.

And although free from fits had still at times threatening & [complained] of pain of belly.

In this state ordered diminution of Aether & at same time prescribed for him a mixture the principle active constituent of which [illegible] of Chamomile flowers.

This article also one of tribe of anthelmintics hitherto supposed of considerable powers.

And from experiments to which have already alluded appears that not void of activity.

Yet by no means so considerable as once imagined.

Was however in some measure with this view that here directed it.

But still more as a bitter & by that means a Stomachicus.

Here however seemed at least to have different operation.

And indeed an affect which have never before observed from use.

That is considerable catharsis.

At least looseness ensued which patients mother ascribed to this cause.

During this looseness was I own somewhat contrary to expectation that worms appeared.

These however as far as could judge from description merely of ascarides kind.

And if that the case can hardly suspect that were either cause of pain about umbilical region or of fits.

For seat of ascarides very generally if not universally merely about extremity of rectum.

Not impossible however that in this particular mother of patient may have been mistaken.

And that what according to her description we conclude to be ascarides may in reality have been small lumbricus.

If this the case, notwithstanding circumstances mentioned to contrary first opinion may have been well founded.

But whatever may have been nature of these, under course mentioned patient got so far free of complaint that thought farther attendance unnecessary.

Not impossible indeed especially if last supposition ill founded that may have return of affection.

But in that case will probably again apply for aid.

And according to circumstances then occurring future practices will be directed.

May then conclude this case with observation that if from beginning had suspected ascarides would have ordered injection of aether diluted with water.

Is practice which I apprehend may be had recourse to without any hazard.

And if equally destructive of these as of lumbricus [promises] to be highly [efficacious]

---

Explanatory notes:

1) An official publication containing a list of medicinal drugs with their effects and directions for their use. The Royal College of Physicians of Edinburgh's Pharmacopoeia was first published in 1699.

2) The Royal Infirmary of Edinburgh, established in 1729.