My dear Charles,

I have some difficulty in answering your letter of yesterday.² The circumstances of the case are so far peculiar (especially those you state in this letter) that on present knowledge I can hardly hazard an opinion as to their cause & exact import.

That there is a cause of physical irritation present, affecting at times the brain & nervous system, must be deemed certain. The intermittent nature of the attacks, & the freedom from obvious disorder between, may be fairly admitted in proof that the cause is transient in kind; & therefore, as I trust, not depending on any organic disease.³

Though I know (& I believe told you) that worms are often a cause of very irregular symptoms in young Children, yet I cannot readily suppose, that at the age of eleven, Ascarides should be capable of producing the peculiar effects you have described to me. Still it is important to bring the treatment to act upon this ascertained fact; & to remove what would add to irritation of nerves, if not producing it.

If the Salt injection should not be of avail, one including Castor Oil might be used, to clear the Rectum of these worms—Or other injections still might be suggested, if these fail of effect.

Does he pick or rub his nose or lips frequently? Irritation from Ascarides often shews itself in this way. Even without reference to Ascarides, I should consider that the use of Enemas, small in quantity but somewhat stimulating to the mucous membranes of the Rectum, would tend to relieve the irritation elsewhere.

Without going further at present, I would ask that if you come to Town again, you would let me have the satisfaction of seeing you—to talk further as to the details of the case, upon having of which I should desire to put questions more minutely than can be done or answered by letter.

Ever yours affect^ly | H Holland

It is important, (as far as may be possible) to ascertain the state of the Heart action, during the attacks