DEP/DUA/1/21/30 (Normalised version)

Thomas Coots

(1779-1780)

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Thomas Coots

Symptoms of affection, when came under our care few & distinctly marked.

While at same time characteristic of disease by no means uncommon.

Yet if consider progress before came under care not without singularities.

And independent of all singularities useful on another account.

Afforded example of removal of an obstinate affection by a very powerful remedy.

And one too which although of late fashionable yet still perhaps not so much used at this place as ought to be.

But before practice first nature of disease

And here no difficulty in referring to genus of Paralysis.

Affection entirely local & confined to very small part of system viz right hand.

And there neither total loss of sense nor of motion.

But both very considerably impaired.

And particularly in two of fingers which retained almost no degree of sensibility.

Even to these however that peculiar sensation referred which called sleeping of part.

And this although by no means certain proof yet some evidence that nerves from part still capable of conveying impression made on extremities.

Affections of this nature, consisting principally in diminishment of sense & motion, in the system of nosologists¹ constitute great variety of different genera.

Distinguished from each other not only by function of which lesion occurs, but also by degree, situation, & other particulars.

Hence different genera of Paralysis [ Hem] Paraplegia. Paraplexia etc.

All these however ultimately to be considered as very much the same.

And whatever modifications no doubt that to be ascribed to nervous power.

And whether loss or diminishment of sense or motion, or of both [ultimately] referred to lesion of function immediately depending on [nerves]

Without aiming therefore at distinctions of no use in practice apprehend that all best denominated by general title of paralytic affection.

To present disease then from characteristic symptoms no difficulty in giving this name

While however little foundation for diversity in name must observe that essential & useful difference from cause of affection

For on this circumstance both practice & prognosis very much depend.

Not so much indeed from particular remote cause as from peculiar morbid state in nervous power on which more immediately depends.

And here particularly impaired state of function depending on nerves, may be referred to one of two great causes.

In place therefore of term collapse consider that of Torpor as here more proper.

Either to morbid change in state of fluid conveyed by nerves, or to [change] in nerves themselves independent of the condition of fluid.

First of late [distinguished] by title of Palsy from Collapse, last Palsy from [illegible]

To both designations however some objections

For collapse should I apprehend be entirely referred to state of sentient principle.

Or rather to particular state of connection between sentient & corporeal part of system.

While again many instances of dependence not on nervous fluid but on nerves themselves, not properly from compression.

As for example when induced by acting erosion etc.

Apprehensive therefore that may with greater advantage take more general view.

And consider every instance of paralysis as depending either on torpor of nervous power or on causes tending to obstruct its passage through nerves [depending] on nerves themselves.

This distinction I have already remarked of use both in prognosis & practice.

And palsy from one or other causes, may occur, in every different genus to be considered as subdivision of this affection

With regard however to particular cause to which to be referred can by no means in every instance arrive at certainty.

And in many hardly even probable conjecture

This good deal case in present instance.

For affection had beginning in way very different from what common.

Commencement of present affection was we are told from great swelling of hand & arm which happened about six months before came under our care.

What particularly nature of the swelling cannot now even conject.

But according to description which he gives not attended with that heat or redness which concomitants of inflammation.

For this affection was treated in the London hospital.

And would appear from practices there employed that whatever might be opinion of nature [expected] terminated in suppuration

For with this view according to information of our patient poultices frequently repeated were continued for great length of time.

And patient himself seemed disposed to ascribe insensibility induced as much to these, as to the disease itself.

For was not one of original symptoms of disease but occurred only during use of these

That this a possible circumstance do not deny.

Well known that long continuing moisture with gentle warmth does induce such a state of extremity of nerves that sensibility very much diminished.

When however consider how rarely this occurs from poultices perhaps more probable that was consequence of original disease.

Here however, which ever supposition adopt must still consider the paralytic affection as depending on action on nerves at [extremities]

And as not arising from obstruction during course, or affection at origin.

Was evidently not connected with any general state of torpor.

From this however would not be understood to infer, that consider it as depending on nerves themselves not on fluid.

For may here observe that by condition of extremity of nerves, & of course by [illegible] communicated from these extremities, fluid very much affected.

This affect however not general but often entirely confined to fluid in particular nerves, state of whose extremities altered.

For hold that brain to be considered not as one but collection of secreting organs.

And that thus morbid state of torpor or mobility in nervous fluid may exist in particular parts independent of others

Thus then partial paralysis from this cause as well as from diseased state of particular nerve either at extreme origin or through any part of course

From these observations will readily understand opinion as to pathology of this patients affection.

Consider paralysis as here arising from torpor in fluid of those nerves leading to part in which this affection appeared.

This torpor supposed again to proceed from peculiar state of action in those parts of brain from whence these nerves have origin.

And this change of action is I imagine affect of want of usual impression from extremities the consequence of alteration in [these] either from morbid swelling or application of [illegible]

From this view of nature of this affection was from beginning inclined to entertain hopes of favourable termination.

And perhaps is somewhat in favour of our conjecture that this has occurred.

But whether this case or not, the occurrence of favourable termination now [supersedes] farther observations on prognosis.

With regard to practice after what have already said as to nature of disease, need add nothing of general [intentions] of cure.

As supposed torpor from want of due action proceeding from want of impression at extremities, were naturally to look for removal by giving impression.

And hold that action at particular part of brain may be increased by [impression] made on extremities of nerves terminating in such [parts]

With view of giving stimulation many different articles might have been employed.

And of these great variety in common use in Paralysis.

Thus recourse frequently had with advantage to friction with flower of mustard seed, with volatile liniment, to blisters etc.

And among many different articles employed for our patient imagined that more relief from blisters than from other practices.

These however hitherto found inadequate to affection.

From this then determined to have recourse to another & still more powerful stimulant

viz Electricity.

And while has advantage of penetrating deeper & thus affecting nerves to which blisters cannot be applied is also a stimulating application which can be more [regularly] continued & more frequently repeated.

Electricity for purpose of medicine employed in various ways.

And according to mode of application effects varied.

Into all these cannot now propose to enter.

May only observe that independent of differences between negative & positive electricity four principle ways in which exhibited.

Insulation or electrical fomentation - The electrical stream or pencil directed into any part.

The drawing sparks from part, & the giving electric shocks.

Of all these what seemed best adapted in case of our patient was electric sparks.

Affords much more considerable stimulation than what arises simply from insulation.

Much less distressing than what proceeds from shocks.

And while these exerted on system in general this almost entirely confined to affected part.

This practice from commencement appeared to have best effects.

From very first trials patient sensible of very considerable relief.

From such appearances however may [observe] that cannot in every case promote cure.

For often recovery to certain extent & can be made to go no farther.

Present instance however not of [this] obstinate nature.

For after no long continuation was dismissed entirely free from his affection.

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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.