DEP/DUA/1/28/13 (Normalised version)

Mary Walker

(1781-1782)

---

Mary Walker

In history of this patients case many circumstances singular.

At same time nature of affection to which subjected sufficiently obvious.

And am much afraid that shall find it very obstinate, if not incurable

First symptom mentioned in case sense of soreness

This however in such a state that could hardly be esteemed pain.

And at same time not augmented even by considerable pressure.

But if peculiar in this sensation not less so in limits.

Entirely confined to left side of head

And that too as if exactly divided

Not merely confined to external parts

But extended also to gums of left side

And even exactly affecting left side of tongue

Such a limit of affection although [sometimes] occurring yet not frequent in practice.

When does take place commonly a symptom in paralytic complaints.

Such a peculiar & limited sensation will not I believe find mentioned by practical authors as an attendant of paralysis.

But that here connected with such an affection cannot be doubted when consider other symptoms also occurring.

For in these parts muscular power also lost

This apparent in difficulty of moving tongue

But still more in motion of eye lids

Over these power of will has entirely ceased.

In so much that utmost efforts incapable of opening left eye.

This however not consequence of [any] [forced] contraction.

For without any [resistance] to external force easily raised.

And when raised remain even for some time in that state till fall by gravity.

And exertion of power of will no more influence in shutting eyes closed, than in opening them.

Would appear therefore that affection extended to all muscles intended for motion of eye lids.

Similar affection also extended to muscles moving the eye itself.

But besides this interior parts also by no means exempted

And have very obvious & remarkable affection in state of pupil.

When eye lids opened by external force pupil appears remarkably dilated.

In efforts to distinct vision incapable of being accommodated to purpose.

And suffers very little if any [perceptible] contraction on exposure even to strong light.

Such a state seldom occurs while retina retains sensibility.

And most commonly indeed concomitant of [perfect] amaurosis.

For whatever may be mode of connection no doubt that pupil principally contracted from stimulation of light acting on retina

Hence then, when, retina in state of insensibility not surprising that stimulation usually giving contraction, should lose influence.

Dilation however cannot here be ascribed to that cause

For when eyelids opened by external force appears that by no means entire abolition of sense of vision.

Can then see & distinguish with tolerable accuracy all surrounding objects.

At same time must be admitted that vision also considerably impaired.

And this therefore to be added to other symptoms.

Besides these many other symptoms also enumerated in history of affection.

Particularly want of appetite bound state of belly, quick & weak pulse & obstructed menstrual.

These however am disposed to view as being here merely symptoms.

And as arising from what may be held to be primary disease in same manner as they do from many other affections.

If however to look upon symptoms first mentioned as constituting primary affection yet still at loss what name should most properly be affixed to it.

1) writers should consider patient as labouring under complication of diseases

For according to them one disease constituted by affection of sense another by that of motion.

One in affection of eye another in that of tongue.

One from being exactly limited to left side in perpendicular direction.

Another from being now at least principally if not entirely confined to head alone

Yet can be no doubt that affection now same when confined to head as when extended through whole of left side

No doubt that affection both of tongue & eye from same cause.

And that want of motion in eye lids & pupil, strictly to be considered as part of same affection with impeded vision.

Here then most distinct idea of nature of disease from viewing whole as belonging to one genus.

And most [just] idea conveyed of it by considering patient as subjected to partial paralysis.

When however give it this appellation do not mean to represent as being an instance of paralysis partialis of Dr Cullen.

For according to his definition palsy confined entirely to affection of motion

Here however consider affection as comprising both abolition & diminishment either of sense or motion.

And although these sometimes separate yet must be allowed that more frequently conjoined even as part of same disease

Of this paralytic affection as have already observed held other symptoms here occurring as being symptomatic.

And well known that often [produced] in this manner from many different [causes]

Here however may suggest it as supposition not altogether improbable that some of them to be considered even as parts of same disease.

Such an idea may particularly be entertained with regard to bound state of belly & want of menstrual discharge.

For latter as well as former of these am of opinion that muscular action in organs is requisite.

And not improbable that affection here taking place the consequence of that muscle action being impaired.

But whether to explain in this way or not cannot look upon these as unconnected affections.

Nor, notwithstanding diversity of symptoms, [which] may arise from Amenorrhea am disposed to consider them, as having any [illegible] in inducing or even supporting the affection.

This have little doubt in attributing as patient herself disposed to do, to living in cold & damp situation.

At least in former practice have met with many instances of paralytic affections which could be distinctly traced to this cause.

And where at same time no reason to suspect any other.

In such affections distinction most important in practice is to determine whether arises from affection of Nervous fluid or merely of condition of that fluid.

This is of Nerves themselves.

And when last the case whether that affection at extremity of nerves at origin, or in course

In forming even probable conjecture however although disease very distinctly marked often very great difficulty.

Yet can see no circumstance leading to suspicion of affection of nerves either at extremities or in course

While from headache, vertigo & various others, grounds for presuming affect at origin.

At same time cause to which complaint attributed equally ready to induce such affection as any other.

This then conjecture which disposed to entertain as to nature & cause of present affection

And from this idea of disease [cannot] have very sanguine hopes of speedy recovery

Would not indeed represent compression at origin of nerves as giving in every case an incurable paralysis.

But instances where depends upon [compression] are upon whole less within power of medicine than where arises from torpor of Nervous fluid

And of all different kinds of compression, that at origin of nerves as being farthest out of reach is upon whole least easily removed.

But besides these particulars from considering case itself circumstances no less unfavourable.

Affection has now subsisted for considerable length of time & in some respects at least to high degree

Power for example of moving eye [lash] not partially merely, but totally lost.

That is no efforts which capable of exertion have any effect.

And in this state have continued for many months, notwithstanding use of various practices.

Since came under our care have tried several powerful means.

At least what have found so in other cases.

But from none of them can we be said to have derived even temporary alleviation.

Must own therefore that entertain no sanguine hopes.

And am apprehensive, that after every trial which can make, shall be obliged to dismiss patient, in no better situation than when came under care.

Still however in present state of affection at least, nothing alarming.

And although inclined to think, that may prove incurable, yet do not look upon it as dangerous.

Nay, notwithstanding what have said, would not even represent it as beyond period of natural cure.

Although of late, no change for better, yet symptoms at first much more considerable than at present.

And then extended even through the whole of left side.

From that state however spontaneous recovery took place to present condition.

And although progression to natural cure has been for some time suspended, yet may again be renewed.

Particularly if any accidental commotion in system as febrile affection, or like should take place.

Situation therefore by no means such as should lead us to [relinquish] future trials

And besides practices to which recourse has already been had, many others which may be used at least with some prospect of success.

When first came under care, from supposition that compression at origin of nerve, might depend on serous effusion though no practice promotes indeed more relief than drain from neighbourhood of head, under form of blister & issue.

This therefore the first practice here directed.

But besides this had at same time recourse also to another medicine.

Use viz of Camphor.

Influence of this singular substance on Nervous energy, unquestionably very considerable.

From peculiar impression which gives to nerves of alimentary canal, effect extended over whole system.

And among other affects is sometimes I think very useful in paralysis.

In some cases, in which have myself lately employed it, have been disposed to think, that have seen very material benefits from it.

Although therefore am far from looking upon it as adequate to cure in every instance, yet consider it as well meriting trial in obstinate cases

Here directed under form of pills as most convenient way of exhibiting it, to any considerable extent.

These made with extract of Gentian which used with no other intention than to give form.

And directed to be taken, at beginning, to extent of ten grains in day.

From blister & issue had not that operation which expected.

For discharge at first but inconsiderable & could be supported only for short time.

From use of pills as had reason indeed to expect no obvious operation arose.

And at same time were taken regularly, without any inconvenience.

After continuation for eight days was herself disposed to think that symptoms somewhat alleviated.

Not only considering headache as somewhat diminished but thought also that vision less impaired.

While to us appeared that when pupil exposed to action of light was somewhat less distended than before.

Change however, in any of these particulars, so inconsiderable that could not speak with certainty.

And in most obvious part of affection, produced no alteration for the better.

For still as totally deprived of power of moving eye lids, as ever, unless by external force.

In this situation however, had at least encouragement to continue course

And as former dose of Camphor, product of no inconvenience augmented to grains XV in day.

But after persisting in use for space of another week, could not say that had gained any material advantage.

Or that prospects of future benefit such, as to lead us to persist in use, in place of making other trials.

Still indeed, [apparent] disease of pupil & affection of vision, seemed less than at first.

But during course of 2^d week though quantity of Camphor increased had made no progress.

Now therefore thought of trial of electricity

On which I own, when properly administered, have more depended in paralytic affections than on any other practice [with] which yet acquainted.

And same time am fully convinced also that will by no means succeed in every case.

Hence therefore if no apparent advantage, after due trial, not to be persisted in, to neglect of other practices.

Here therefore wished to employ it in state of considerable activity at first.

And on this account directed both sparks & shocks.

Was I own from former that in this case chiefly expected benefits.

Both from immediate impression as stimulant to affected muscular fibres, & from communication of that impression from extremities to origin of affected nerves

But besides this wished also to have effect of general concussion to system.

Which from few practices more effective or extensively obtained than from slight electric shocks.

After continuing in both ways mentioned for space of 8 days no apparent change

Had not even effect of inducing motion of paralytic muscles at the time.

Nor was vision immediately after employment anything different from what had been before

Such temporary relief will often take place in cases where yet inadequate to cure.

And when occurs, although no grounds for confident expectation of recovery is yet always inducement to continue.

Here as have already observed encouraging circumstances of this kind entirely wanting.

Still however thought that use of electricity not to be [deserted] without farther trial.

For if in some cases, has given [flattering] expectation at first, where yet in end failed, in others has succeeded where at first no good effects.

Ordered therefore continuation for another week.

But besides electrical sparks, ordered also application of volatile liniment, to all affected parts as more permanent stimulant.

And while electricity employed at midday, this used morning & evening.

Had not however that effect as rubefacient which expected.

To Spirit Corm Cerv. therefore, substituted still more powerful stimulant Vitriol Aether

And in place of Camphor oil, was combined with Camphorated Spirit of Nitre.

From this application at first considerable sense of heat excited.

And by continuation induced even external soreness of parts to which applied

But neither from this, nor from continuation in electricity, in conjunction with it, could it be said that any advantage had been obtained.

Soreness excited, now became an objection to farther external application of so pungent a stimulant as Aether.

While after trial of electricity for upwards of month without any good affect now despair of deriving any advantage from it.

This therefore was also omitted.

In this situation before trial of other practices, thought of again trying effects of issue

And as belly bound wished to see at least, what would be consequence of producing free discharge.

For to be observed that by spontaneous evacuation in this way unexpected cure sometimes obtained.

With this latter intention had recourse to composite powder of jalap.

In which have unquestionably a very active purgative.

In obvious operation of both these medicines expectation fully answered.

For while free discharge from blister & issue, cathartic also operated briskly.

From neither however, was any advantage derived.

In this situation had no encouragement to persist in repeated use of purgatives.

And from continuation of these, inconvenience as exhausting patient to be apprehended.

Nothing however to be apprehended from persisting in use of issue.

And with this also directed, at last report, the employment of another evacuant from neighbourhood of seat of disease.

The use of viz of an Errhine.

Of good effects of this remedy in paralytic cases have in my own practice little experience.

But by some has been highly recommended.

And said even attended with success where palsy in most remote extremities.

Wished therefore to give trial in this case both as evacuant & as giving concussion to system.

If any appearance of benefits may repeat use.

But unless this the case nothing I imagine to be expected from persisting in it.

And shall next think of having recourse to trial of some other medicines.

If such shall be found necessary is my intention here to have recourse to the Arnica Montana.

At least if shall be able to procure.

And if entitled to high character given it by some may be attended with good effects

But if this either cannot be obtained or unsuccessful only other article which in present situation of patient to me appears to promise much advantage is Mercury [Composite]

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.