DEP/DUA/1/18/03 (Normalised version)

Susan Paul

(1778-1779)

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Susan Paul.

At a very early period of life affected with symptoms apparently alarming & which can have no doubt in considering as belonging to tribe of Nervous affections.

At least of such nature evidently are most urgent parts of complaint.

These consist of fits, in which occurs total loss of faculties of sense & motion.

And according to account given us such fits continue from five to fifteen minutes without any convulsive agitation.

Among numerous list of Nervous affections occurs as question to which present case belongs

In two circumstances loss of sense & motion have characteristics of several genera.

But particularly according to system of Dr Cullen of Syncope & of Apoplexy.

In former however with suspension of sense & motion there occurs also temporary cessation of Respiration & circulation.

From these circumstances therefore naturally led to refer case before us to latter.

Symptoms however in other respects but ill correspond with general history of Apoplexy as delivered by greater part of practical writers.

And particularly nothing of Apoplexy [illegible] reckoned so much a characteristic symptom of affection.

Besides in every respect a much more slight disease.

Will find however that under apoplexy of Dr Cullen several different genera of other nosological [complaints]

Particularly Carus, Cataphora, Asphyxia Catalepsis, Extasis. & several others of Mr Sauvages.

Can be no doubt that system of Dr Cullen very great merit in simplifying nosology & reducing number of genera.

Yet perhaps in some cases has with this view gone too far.

And in my opinion present [extensive] genus affords example of it.

Here indeed cannot say that in case before us any exact resemblance to those genera as defined by other nosologists¹ comprehended under apoplexy as defined by Dr Cullen

At least according to representation given us by parents of this patient.

Most near resemblance however to Extasis or Catalepsis of Mr Sauvages.

In these as well as in Apoplexy or Epilepsy strictly so called notwithstanding abolition of senses pulse & respiration [continue]

But neither [illegible] nor other symptoms of former nor convulsive agitation of latter.

Although therefore some of characteristics here wanting as for example retention of position into which body put, yet may consider it as belonging to that affection.

Under both these genera which indeed very little different from each other several species enumerated.

Particularly under head of Catalepsis.

And among others one denominated under title of Catalepsis verminosa.

Can be little doubt, that if really belongs to this genus, to be considered as of that species.

For besides that other causes absent here, worms manifestly present.

If then attacks such as represented to us would be disposed to affix to it this name

If again notwithstanding account fits really attended with convulsive agitation would [fall] to be referred to Epilepsy. And can be no doubt that both Catalepsis Syncope & Epilepsy frequently depend on worms as exciting cause

But if during loss of sense & motion there occurs also privation of Respiration & Circulation would fall under genus of Syncope.

And here also would refer it to Syncope verminosa.

This then opinion as to name of disease from investigation by nosological arrangements

And have no doubt in asserting that as leading to accurate investigation Nosologies of utmost utility.

Yet cannot consider it as applicable in every case.

And in many with view to cure must investigate rather cause then name of disease

Of this kind I apprehend is case now before us.

Is well known that worms in alimentary canal product of great variety of symptoms & these often of most anomalous nature.

Here however have almost all those symptoms which, where there even no evidence of worms by discharge, yet considered to afford proof of presence in intestinal canal.

At least to these descriptions given by patient so exactly corresponded as to leave no ground even for suspicion

Particularly pain of belly with considerable swelling.

But still more grinding of teeth starting in sleep & awaking with frequent [cries].

These circumstances alone although by no means certain diagnostics, yet considered to give strong suspicion of worms.

And here this suspicion put beyond all doubt, by actual discharge.

True indeed from actual presence of worms, cannot infer that cause of all symptoms

For not unfrequently appears rather as consequence than as cause of disease

But besides symptoms pointed out as [characterising] them can be [no] doubt, that often induce various affections of Nervous kind.

Particularly Epilepsy, Catalepsy etc.

May therefore without hesitation conclude that are cause of all symptoms in case before us.

And that our patients affection may be in general viewed as worm case.

Here also equally little doubt that worms for which are to treat patient, of the ascarides kind.

After this view of case then next Prognosis

And here I apprehend judgement to be directed rather by attention to cause than to appearance.

Obvious symptoms loss viz of sense & motion would lead to form most unfavourable opinion.

Yet may be observed of Nervous affections in general that more dangerous in appearance than in reality.

And in case before us, if cause can be removed, great reason to expect, that all appearances will cease.

Am inclined however to hope that if patient, or rather parents shall follow directions given them this may be effected.

Do not indeed consider removal of worms from intestinal canal as being in every case a matter easily affected

And among, three different kinds of worms, most common source of disease from lodgement in intestines, Ascarides with which our patient affected.  Though more easily removed than Taenia less so than lumbricus.

Of former kind which in this country at least a much more rare occurrence have example in another patient also selected as subject of lecture.

In case viz of Binny Wood in which probably shall have opportunity of trying some of new medicines lately so much celebrated against that affection those viz of Dr [ Herber] & of Madame Nouffer

If these however so successful against that species of worm should a [illegible] [present] that may be so against ascarides.

And while nothing in present case which would lead to supposition that will be particularly obstinate well known that every day removed, even by common anthelmintics.

Upon whole then led to conclude that by proper attention patient may entirely get rid of worms.

But if opinion of disease be not a mistaken one conclusion that will from this be freed not only from Nervous affection, but also of grinding of teeth pain of belly & all other Symptoms

When however consider that great variety of Anthelmintics already employed not to be imagined that will be speedily affected.

And this the rather as unacquainted with others already employed without success.

In treatment however of all worm cases great objective in view is removal from system.

And this to be expected on one of two principles either

By inducing such a state of action as will expel them, even although retain native vigour.

Or by diminishing that power in consequence of which capable of retaining place in alimentary canal, while other inanimate matters discharged.

And indeed without such diminution of vigour expulsion very generally extremely difficult.

And that even where action of intestinal canal increased to great degree.

For most part therefore most expedient cure where both practices conjoined.

And where after use of medicines acting as poison to worms or weakening vital power [purge] superadded.

These general principles equally applicable to removal of ascarides as of other kinds of worms.

And indeed substances poisonous to all very much the same.

Some kinds must be allowed more difficultly acted upon than others.

This particularly case with Taenia.

And although in some instances yet perhaps but rarely that removed by ordinary [illegible].

Hence introduction of particular remedies with this intention.

Ascarides however very far from being difficultly deprived of life

In so much that die in short time after expelled from body.

Probably in consequence either of action of air, or from want of that heat to which accustomed in intestines.

While however opposite of Taenia with respect to power of retaining life during continuation in system furnished with another & that too very strong defence

For most part entirely situated [about] rectum

By this means medicine even of most active quality, before can reach them, must be subjected to action of whole tract of intestinal canal.

And thus those in nature even most active often rendered perfectly [effete].

Besides this from small size easily lodged in plicae of intestines.

Thus active matters in rectum may pass without any prejudice.

From these reasons then most readily combated by matter in fluid form

And by these matters when immediately introduced into rectum, from being exhibited in way of injection.

On these principles then will be at no loss to understand, meaning of practices already directed for this patient or hereafter to be employed.

Have begun practice here by directing for this patient injection of lime water

Of how long standing this practice is against ascarides do not know.

Must however observe that in great measure new to me

And till within two years past have never employed it.

Lime water indeed long considered to be among best of substances noxious to worms.

And this not merely on general vague belief but determined by experiments.

Particularly by some lately made at this place by a Gentleman of great industry & ability Dr Fowler now Physician at Stafford.

According to his experiments while worms live without inconvenience for several days together in pure water, are strongly [illegible] immediately on being put into lime water, & in half an hour perfectly dead.

Thus then anthelmintic power although not so great as that of some other substances, at least very considerable.

While at same time has advantage of being a substance which may be taken to considerable extent either by mouth or in way of injection without either inconvenience or hazard.

In former way however could expect little from it against ascarides.

As from acid in stomach & circumstances to which subjected in alimentary canal must be rendered totally effete before can [reach] part of intestines in which situated

Used in injection, however, opportunity of immediate action with full activity.

And in this way since period mentioned have often directed it, with very great success, in many different instances.

Do not however pretend to say that in every case produces immediate cure.

Probably from smallness of worms & plicae of intestines no injection can at one time be applied to all of them.

And besides this probable, that many in state of ova which will soon afterwards become worms.

In this state however may presume that not liable to be destroyed by substances afterwards proving noxious to them.

Thus then can easily understand why repeated use of injections for some length of time requisite

To all this may farther be added that cannot here by any means obtain same thorough immersion as in earthen or glass vessel.

Even admitting activity therefore to be very great can still see why may not always be sufficient for cure.

From what have seen of affects however am persuaded that where does [fail] will more frequently arise from want of proper administration than from want of activity

And as look upon it to be one of safest consider it as in general deserving [first] trial.

Mean therefore not to direct any other remedy for this patient, till affects of lime water glyster first fairly tried.

Unless perhaps gentle cathartic by mouth with view of promoting expulsion of worms either killed, or so far debilitated, as to be less capable of retaining place in system.

If however these measures unsuccessful many others to which may have recourse.

And among numerous tribe of Anthelmintics great variety which may be employed in way of [injection]

But is in this way only I apprehend that can expect much affect from them.

Among others solution of different saline [substances] particularly alkaline salts may be employed.

Such for example as Sal. Absinthe

And from many experiments particularly those of Dr Fowler appears that this a very powerful anthelmintic.

From this perhaps may understand reason why employed by Dr Herrenschwand as part of his composition for cure of Taenia

These united with Gamboge in larger proportions than safe to introduce into rectum in way of injection.

Particularly with a subject so young as that at present under our care.

Yet cannot help thinking that some instances in which a proportion of Gamboge dissolved in a fluid to be used in way of injection might be employed with success.

But besides these many other common practices to which might here have recourse

Example injection of oily matters, of oil impregnated with Camphor, of bitter vegetable infusion of mineral waters, particularly those in which principle ingredient a Hepar Sulphuris.

These long in common use & no doubt frequently successful.

Yet before having recourse to any of these, if opportunity of giving fair trial to practices already recommended & if this [illegible] successful mean to have recourse to a practice hitherto little if at all used against worms.

That is use of Aether.

Aether some years ago given in Royal Infirmary² to considerable extent to an epileptic patient with whom various anthelmintics before tried without affect.

And while apparently answers purpose for which intended of anticipating fits, had at same time affect of producing discharge of worms.

By this means patient received not only temporary relief but radical cure.

This [fact] led Dr Fowler to trial of anthelmintic power of Aether.

And found that in this way had more remarkable affect than any medicine before employed.

To employment however against worms as taken by mouth, strong objection undoubtedly occurs.

For probable that activity solely exerted in stomach.

And that hardly to be considered as even making way into intestinal tube.

Is but in few cases therefore that can thus suppose it capable of reaching worms.

But as used in way of injection against ascarides would have opportunity of immediate action.

And with this view may be added in smaller proportion to any other injection.

Such for example as Lime water.

Before any other trials therefore this the next practice to which mean to have recourse

But even this may not probably be necessary.

For if lime water properly used may be sufficient for producing complete cure

And for removal even of all distressing symptoms with which patient at present affected.

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Explanatory notes:

1) 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.

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