DEP/DUA/1/20/07 (Normalised version)

William Hamilton

(1779)

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William Hamilton.

Case of this patient exhibits a [set] of symptoms which in my own practice have not frequently had occasion to see

Yet which correspond very exactly with an affection described by greater part of practical writers.

Here indeed there occur some symptoms which are no uncommon attendants of great variety of different affections.

This particularly the case with respect to frequent vomiting.

But while this so frequent in various affections in other parts of complaint have a set of symptoms much more material & alarming.

In accessions to which is described as having been for first time subjected on 5^th of May have such an affection of senses both externally & internally, as would naturally lead us to look for this cough among those affections which general considered as more immediately depending on Nervous power.

That is on connecting medium [between] sentient & corporeal parts of system by [intervals] of which they mutually act upon each other.

And of different orders referred to this class is at least chiefly characterised as falling under head of Comata.

That is abolition of senses, which indeed necessarily attended with cessation of power of voluntary motions.

Some as Dr Cullen have reduced all diseases referred to this head to very few genera.

For in his system two only comprehended under it viz Apoplexy & Palsy.

If however to be thus few in number must be taken in very extensive sense.

And must own that inclined to think that other nosologists¹ have done [better] in increasing number of genera.

According to Dr Cullen affection of this patient would necessarily fall under head of Apoplexy.

Can however be no doubt that it by no means corresponds to what generally known by that appellation

But whether sitting or even standing erect remains in situation in which attacked.

And when again in system of Mr Sauvages compare it with history of Catalepsy has very exact resemblance.

That disease characterised by sudden abolition of sense & of power of voluntary motion.

And chiefly distinguished from others having same symptoms by patient [retaining] [illegible] whatever it is in which attacked.

Paroxysms of this affection in general described as preceded by some symptoms.

But particularly by dullness or torpor both of mind & of body.

And for most part also as seems to have been case with our patient with some degree of headache.

While these symptoms however to such degree as to give no particular alarm patient suddenly seized with paroxysm.

Is deprived of all sense & of all power of motion.

If patient in recumbent posture not surprising that should lie still.

Does not as in Epilepsy or indeed in Apoplexy which still greater resemblance to present affection fall to the ground.

In this then evidence of retention of power of action at least to certain degree

Appears still capable of resisting force of gravity which otherwise would necessarily operate & which solely to be considered as cause of fall of patients in diseases [mentioned]

But besides this in what described by authors as most perfect catalepsy have still farther evidence of some degree of muscular action.

For if body or limb put into any particular position retains situation given.

Here then evidence that although influence of will has ceased, what may be called tonic power of muscles still [remains]

And this power also without any disposition to inordinate action.

For neither attended with any manifest motion nor with resistance to change of situation by external force.

How far latter of these particulars was case with patient before us cannot say.

For in none of attacks to which subjected does the experiment of giving any particular position to aim for [ex] [seem] to have been tried.

And indeed had circumstances now deserted been wanting have still sufficient similarities to peculiarities of this disease

For during first attack of patient was in erect posture & remained in that situation till moved from it.

Soon after changed to horizontal one [are] told that fit ceased.

In this also consider us as having general similarity to Catalepsy.

For by most authors attacks as have now described represented as of short duration.

In greater number of cases without medical aid fits terminate in few minutes

And is represented as a rare instance when attacks continue for space of hour.

Recovery happens in manner similar to awaking from sound sleep.

And patients totally insensible of every thing said or done around them.

Preceding headache usually in some degree removed

And patients not only free from complaint but even fitter for ordinary action of life than before attack.

When paroxysm however thus ends are by no means to consider disease as terminated

For while affection of nervous kind is at same time reduced to class of chronic disease

And as is case with epileptic fits patient subjected to returns at irregular periods.

Continuation of affection indeed as well as manner in which the disease terminates must be regulated by many different circumstances

Particularly by cause from which the [disease] excited & means used for removal.

Hence then should affection with our patient be already finally terminated is nothing inconsistent with ordinary cases.

And in circumstances now mentioned as well as what before taken [notice] of [have] exact resemblance to this disease.

With our patient paroxysm after [usual] continuation had terminated in sound sleep.

A conclusion by no means infrequent with almost every nervous affection attacked by paroxysms.

And upon awaking from this had remembrance only of those transactions which had preceded fit.

Affection thus occurring not confined to single attack.

Three days after first was attacked with second paroxysm of similar nature

Both these had occurred previously to his coming under our care.

And since that has been subjected to third attack of same kind.

In almost every circumstance then have the characteristics of this affection.

And whether we attempt investigation of name by nosological system – by general history of affection or by single pathognomonic symptom of patient remaining fixed in state of insensibility in posture in which attack occurs can have no doubt in giving it appellation of Catalepsy.

This however a disease which indeed like every other may occur either in most simple state or as complicated with other affections.

And here may be some question whether such complication does not take place.

Most frequently conjoined with Hysteria

To this at such early period of life cannot expect to find any disposition.

And in symptoms no traces of appearance which can be considered as having any resemblance to it.

Yet must be observed that in affection of muscles here taking place there seems to be something peculiar.

Are informed that in first fit head found to be turned round to right shoulder.

This indeed may suppose to have been consequence merely of accidental position at the time.

And observed even that if patient attacked with fit of catalepsy when in act of laughing or of crying continued still to [express] at least by muscles of face same passion.

And change afterwards induced not when particular passion first giving rise to it ceases, but when fit terminates.

From such accidents then not impossible that particular position of head here to be accounted for.

Yet when take along with this the position of eyes should rather I own be inclined to different supposition.

And should suppose that both the one & the other in some measure effect of inordinate action.

Hence then look on present case as not entirely of most simple nature.

But as having some tendency to convulsions perhaps to epilepsia.

Have thus then stated grounds of opinion with respect to name of disease to which this patient subjected.

But in many cases the ascertaining this of no great consequence as to cure.

And particularly so where ignorant of nature of affection.

For to this, not merely to name, the treatment must always be accommodated.

And with regard to present affection as well indeed as to all of nervous kind, must be acknowledged, that still much in the dark.

Only know that is by [interval] of brain that sentient & corporeal parts of system mutually affect each other.

And that from certain condition of this organ both one & other materially affected.

Presumption at least that is from inducing peculiar state of action in this organ that mind capable of exciting motion in body.

And that on other hand from similar or at least analogous actions impression on body excites sensations in mind.

With this opinion respecting influence of brain am led to think that on certain state of action all the phaenomena of this affection may be explained.

This condition however may be induced from various causes

And according to particular causes operating treatment best adapted for removal of affection must be accommodated.

Causes may probably sometimes exist in brain itself.

Well known however that in other instances is affect of irritating [causes] acting on remote parts.

Thus for example not unfrequently affect of irritation of worms in alimentary canal.

These well known to be capable of giving these very different impressions.

And from some particular impressions can readily conceive such a sensation to be induced as will give rise to that action of the brain on which catalepsy depends.

Thus then can understand how same appearance the product of different remote causes on removal of which however, cure of affection, must in great measure, if not entirely depend.

In instance before us, some circumstances which gave grounds at least for suspicion that irritation producing accession was in alimentary canal.

First accession ushered in by vomiting.

And although second took place without any such occurrence yet afterwards subjected to frequent vomiting.

Of all [causes] of irritation in alimentary canal none more frequent than worms.

And these well known to be often cause of disease at that period of life at which present patient is.

From this then was inclined I own to suspect that to worms symptoms of present patient to be attributed.

Since came under our care however several circumstances concurred in diminishing probability of that conjecture.

Affection if has not entirely left patient has at least suffered very considerable remission.

This has happened without any worm being observed to be discharged.

And during time that patient has been under our care no other symptoms of this have occurred.

These however in no degree diminish the probability that did arise from some other irritation in alimentary canal.

And of this continuation of tendency to vomiting gives I think at least some presumption.

With such idea as to cause of present case may form a prognosis as favourable as nature of affection will admit of.

And must certainly consider it as less threatening than if any grounds for supposing local affection of brain.

From considerable interval which has now taken place may even I think presume that affection already entirely gone

And if no farther symptoms of disease shall soon dismiss patient.

Especially as from place of [residence] in neighbourhood readily opportunity of knowing if any return of affection.

Here however may observe that [although] much longer interval than has yet taken place should occur; will not be surprised at return of affection.

May either continue merely in form in which has already occurred or may degenerate into an affection both more obstinate & more dangerous.

What in this way chiefly to be dreaded is occurrence of Epilepsy.

And not infrequent that this tedious & alarming affection ushered in, by other diseases of nervous kind.

If however sometimes degenerates into other affections, more frequently the case, that catalepsy admits of complete cure by removal of cause.

Particularly in those instances where arises from any irritation in alimentary canal.

Taking this therefore to have been case in present instance, hope that is now removed.

And that patient as free from affection as if had never be subjected to it.

And here must acknowledge that this recovery very little if in any degree to be attributed to the measures which we employ.

For in treatment of this case have had recourse to none of the remedies generally employed against catalepsy or from which on idea given of disease should expect benefits.

On idea given of affection cure must turn on prevention of that state of action in brain on which suppose disease to depend.

In as far as this depends on any cause acting immediately on brain itself am inclined to think that no effective measures by which prevention can be obtained.

But when arises from irritation acting on distant parts of system as for example on alimentary canal different principles on which may be counteracted.

In many cases irritating cause may be entirely & effectively removed.

And in others though still continues yet influence may be counteracted.

For impression produced as much consequence of peculiar sensibility at part as of acting [causes]

Hence then on both principles many different practices had recourse to

And in some instances at least with success.

Measures for removal of irritation must be accommodated to particular cause on which depends.

Where proceeds from worms recourse had to anthelmintics.

Where affection of sordes in stomach or intestines benefit from emetics & cathartics.

And where consequence of peculiar stimulation from acidity, removed by absorbents.

For counteracting influence of irritating causes may have recourse to such measures as render nervous power less capable of communicating impression.

Or such as render extremity of nerves less susceptible of impression.

First of these intentions often to be answered by means of sedatives & antispasmodics

Last by means of tonics, from which in consequence of additional vigour to [part] less liable to be affected to high degree by any stimulation.

On these general principles should probably have attempted cure in case of present patient.

But when first came under care attention more immediately engaged by other symptoms.

Then to very considerable degree affected by severe vomiting.

Although therefore was then inclined to suspect that catalepsy arose from worms, yet reckoned it first necessary to obviate this symptom.

For otherwise no reason to hope that anthelmintic would be so far retained as to be product of any effect.

Was principally then as counteracting this symptom that had recourse to Liquid Laudanum

Employed as a [vehicle] the distilled [water] of Mint, of itself often used as Antispasmodic.

And added as corrigent the Spirit of hartshorn.

Than which know no addition which better counteracts that distressing [conf]. sometimes resulting from opiate medicines.

Particularly when given in under dose so as not to excite full effects of anodyne in producing sleep.

But besides being corrigent hoped also that Alkaline spirit from peculiar stimulation might be means of obviating return of fit.

And indeed in spasmodic diseases of [infants] few remedies more highly celebrated.

This medicine however whatever may have been effects in other ways does not seem to have answered principle intention.

For during use of it, although vomiting not so severe as before yet patient continues to be frequently affected with it.

And when ceased seemed rather to have occurred spontaneously than from the medicine.

In this state still considered every measure as inadmissible which could have much tendency to renew vomiting.

While at same time as attacks both less frequent; & probability of existence of worms diminished, could at least without hesitation still farther delay the trial of Anthelmintic.

On presumption that might [illegible] from [illegible] [illegible] in stomach was inclined rather to use of an absorbent.

And that with this might have farther benefits from opening belly, employed Magnesium.

Was in some measure to increase purgative powers that conjoined with it a small proportion of Rhubarb.

But still more from hopes that by increasing tone of alimentary canal might remove morbid sensibility.

After commencement of these vomiting in some measure again returned.

This however could hardly I think ascribe to medicine

For as happened principally after taking food may suppose it effect of stimulation from this cause on stomach with peculiar sensibility.

Consider it therefore as rather an [inducement] to continuation of medicine as otherwise.

And especially as during [use] no farther return of it.

If under this medicine vomiting shall cease, will reckon any farther practices unnecessary.

If continues shall be inclined to expect removal rather by strengthening tone of stomach than on any other principle.

And for this purpose have thought of employing the Succus Japonica.

If without vomiting fits return notwithstanding what have said as to circumstances now arguing against supposition of worms shall consider a trial of some anthelmintics as necessary.

And for this purpose will [probably] have recourse to Calomel.

If no worms shall next attempt cure by means of tonics of antispasmodic kind.

And may employ Zinc combined with Valerian, or the Pill Caeruleae.

Am however in hopes that future measures will not be necessary either with view to Catalepsy or Vomiting.

And that patient may be dismissed from farther attendance at least till recurrence of some symptoms.

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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.