DEP/DUA/1/17/10 (Normalised version)

Helen Alexander

(1778)

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Helen Alexander.

Respecting real nature of this case am at loss to form any decisive or certain opinion.

Symptoms with which she is affected such as may proceed from different causes.

And circumstances in the case which would lead us to entertain different suppositions.

Chief complaint to which she is subjected is severe pain of bowels.

Pain in intestinal canal may it is well known arise from causes in nature very different & even in great measure opposite.

If however cannot here say what the cause is, some circumstances at least, from which may say what is not.

That here does not proceed from any fixed cause, may with great confidence be inferred from two particulars.

First from not being a constant affection but recurring only at particular times

And secondly from not being fixed to any particular part, but being sometimes more especially seated at one part of intestinal canal sometimes at another.

From all these particulars at least some probability that patients own conjecture with respect to cause well founded.

That affection viz the consequence of wind in intestines.

And this farther corroborated by sensation of ball rising from bottom of abdomen to throat.

This indeed a symptom very frequently occurring in another affection.

And while obtains denomination of globus hysteria, is by many considered, as being pathognomonic that disease

Must however own that can neither look upon it as being a symptom essential to hysteria nor can I look upon presence of it as a certain evidence of presence of that affection.

Is to be considered merely a propagation of a spasmodic affection from under to superior part of alimentary canal.

And view as only connected with hysteria in as far as is consequence of irritated state of intestinal canal.

A condition which although very frequent in Hysteria may yet occur without it.

And besides where no very great irritability, such inordinate action may sometimes be consequence of peculiar stimulants.

And of none more frequency than that which arises from distension by wind.

In this circumstance then do not consider [us] as having evidence of any other affection.

But look upon it as corroborating proof at least of supposition that pain the affect of flatulence.

Although however flatulence immediate cause both of pain & of motion giving sense of ball yet are to look upon cause of disease as depending on circumstances giving rise to extrication of air

And this at least very generally the consequence of a peculiarly debilitated state.

Such I own at first my opinion respecting disease of this patient.

And am still inclined to look upon it as being not least probable supposition.

Yet must be admitted that same [phenomena] may be explained on other principles.

And that since this patient came under our care appearances have taken place giving countenance to a different supposition.

Not long after began attendance here, patient discharged by stool a large worm of lumbricus kind.

From this however not only presumption of others but also grounds for conjecture that these may give origin to all other parts of affection

Where worms present in intestines many disposed to look upon them as cause, of almost every affection which can take place.

And can be no doubt that frequently product even of most anomalous symptoms.

What here occur very common consequences of presence.

On these grounds then, many who would have no hesitation in considering present to be a worm case.

And that may yet prove to be so, not impossible.

At same time however am far from thinking that such a conclusion by any means fully warranted.

Although worms product of many symptoms yet may also exist where variety of symptoms from other causes.

And may often even be considered as symptoms of other affections.

Particularly of affections of intestinal canal from debilitated state of which, together with concomitant secretion [illegible] more readily afforded.

From same cause also thus giving rise to generation of worms, other symptoms as those occurring in present case may also originate.

But if worms sometimes occur as symptom of other affections so much more frequently make appearance in consequence of them.

And by diseases of different kinds when otherwise would be retained in intestinal canal are discharged.

This particularly the case with respect to febrile complaints.

And am convinced that in many of those cases termed worm fevers, worms do not induce fever but in reality discharged as consequence.

Of this sufficient evidence both from other [causes] to which fever can be in such cases traced & from [genius] which fever puts on.

Thus never more frequently appears than in course of worst cases of Typhus.

And in this light fever may be considered as a remedy for worms not merely of lumbricus kind, but as cure for Taenia also.

At least not many years ago had occasion to treat one case of Typhus in which this [happened]

A girl subjected to such a fever with many of most malign symptoms.

Particularly Haemorrhage. Petechial eruption. Vibices & frequent foetid involuntary stools.

In this situation will not doubt that considered her as in utmost danger.

And had no hesitation in referring complaint to contagion to which had been exposed.

During course of affection however from which at length happily recovered discharged complete Taenia of considerable lengths.

And here I apprehend no room for doubt that cure affected by supervening disease.

From such instances then sufficient evidence that can neither consider presence nor discharge of worms as by any means alone affording evidence that cause of symptoms.

And must own that from different circumstances of case before us am inclined to think that here either unconnected with complaint, or occurred in consequence of them.

In support of this opinion to circumstances already mentioned some others may be added.

Particularly [ease] of patient in morning when stomach & upper part of the intestinal canal mostly empty

Where worms in intestines contrary of this at least most frequently the case.

At that time gripes & other symptoms usually the most severe.

Another circumstance rather against supposition of worms is bound state of belly.

Where these present in intestines from constant irritation increasing action usually a contrary condition.

Or at least if not looseness peculiar appearance in stools.

And but very rarely happens that accompanied with bound state

While at same time the [illegible] [illegible] an almost constant symptom not only in Dyspepsia but in other affections where debilitation of intestinal canal

A farther argument may be drawn from continuation of complaint.

Before came under our care had subsisted for space of several years.

And during that as far at least as could learn no worms had been discharged.

Nor had any of most common symptoms of worms then existed.

May presume however that both circumstances would have taken place had worms been cause of affection.

While on other hand by no means [illegible] common for such an affection of alimentary canal as here suppose to be of that [continuation].

And during even much longer time to remain either stationary, or subjected to different changes being sometimes more, sometimes less severe.

Being in this manner principally affected by accidental occurrences.

From all circumstances taken together then reckon it most probable that the disease originates from a debilitated state.

That by this means both uncommon [removal] of food, in intestines, & latitude given for extrication of air.

And in consequence of air part [illegible] origin given both to pain & to that motion which gives sensation of ball [propelled] to throat

But although this the opinion which inclined to adopt of the disease, would not pretend to affirm that worm which has been discharged a solitary one.

And indeed but seldom that one lumbricus only.

There may therefore be yet also, others although product, of none of present symptoms.

May hereafter be multiplied & increased in intestines & may give rise to many different morbid appearances.

Hence then, even occurrences of such cannot be considered as [refutation] of present sentiments.

And may hereafter with propriety lead both to prognosis & practices different from what at present disposed to follow.

Of these however according to present sentiments next to speak.

And here may observe that this view would lead us to consider present affection as not threatening immediate danger

Sometimes indeed from stomach ailments foundations laid for most obstinate affections.

And for complaints of different kinds which at last have fatal termination.

Thus for example not unfrequently induces dropsical complaint by which patient at last cut off.

But in instance before us, no threatenings of this kind.

And although complaint distressing yet gives no indication of any very considerable affection of system.

Unless therefore in consequence of some unexpected turn shall not I own be here very apprehensive of danger.

On contrary would even hope that by aid of proper remedies complaint if not removed may be yet to considerable degree alleviated.

And that may leave us if not entirely at least in great measure free of affection.

Yet when consider duration of complaint this not to be suddenly expected.

And indeed such affections of viscera even when treatment soon begun are in nature obstinate.

And often more to be affected by diet than by medicine.

Hence patients often wearying of medical assistance trust recovery to proper management.

Especially after affection in some degree mitigated.

This may not improbably be case with patient of whom now speak.

Especially if conjectures as to nature of complaint well founded.

But if other opinion suggested as to nature of the complaint be the real one prognosis ought not to be more unfavourable.

True indeed that worms the cause of many of most threatening & dangerous symptoms

And in some cases proves even suddenly fatal as inducing Epilepsy, catalepsy etc.

These however on whole but very rare instances

And in by much greater number of cases, symptoms which they induce may be considered rather as troublesome, than dangerous.

May farther add that in this country seldom of long continuation.

At least but rarely that cases occur in their nature so obstinate as to resist long remedies which can employ against them.

If therefore from future occurrences be led to [adopt] this opinion may yet hope for more speedy termination.

On different idea however practice has hitherto almost solely proceeded.

And on this also is present intention to continue cure.

On supposition that disease the affect of debilitation of intestinal canal great objective in cure must be the restoration of due vigour.

And this to be affected not more by use of such means as tend give additional tone, than by avoiding such as are capable of augmenting debility.

Of these none more considerable than superabundant acidity in intestines, & bound state of belly.

Of former no evidence in instance before us.

But latter manifestly present & that too to no inconsiderable degree.

Hence then here an objective of some consequence to obtain regular state of discharge by belly.

Yet from this alone progress to cure but inconsiderable.

While at same time from cathartics producing any great evacuation must look rather for aggravation of complaint as otherwise.

With use therefore of gentle laxatives here led to conjoin tonics either to system in general or to alimentary canal in particular.

These then general principles on which attempts hitherto made to cure have proceeded.

And on these intend still farther to [continue] endeavours for recovery of patient.

This however will more particularly appear in making few remarks, on medicine already used, & on these which have it in view hereafter to employ.

When patient came first under care put her on use of Tincture Amarum or as formerly called Elixir Stomachicus.

In this medicine several active articles from vegetable kingdom have place.

Consists of one of most agreeable & pure of bitters conjoined with warm aromatic.

As consisting of these articles has had place in four successive editions of Edinburgh Pharmacopoeia¹

And has always been held in considerable esteem.

Now indeed preparation somewhat varied from what formerly employed.

But can hardly from this circumstance look on formula at present employed as preferential to that which had place in Pharmacopoeia published about commencement of present century.

And both now & then Cochineal introduced with no other intention than to give colour.

This medicine chiefly intended to operate as stimulation to stomach.

And thus from increasing action promotes digestion.

Has also similar affect on intestinal canal.

Hoped therefore that might here be in some degree means of restoring that vigour which supposed wanting.

While at same time in as far as tendency to acidity, diminishing tone would have influence in counteracting it.

For as well as absorbent bitters also are from experiments found to neutralize acid.

From this medicine expected also some influence as tending to expulsion of wind.

And no doubt that as inducing immediate action, this affect in some degree consequence of every stimulation to intestinal canal.

Yet from this [medicine] could hardly expect that escape of wind would be facilitated from removal of spasms [retaining] it.

While at the same time could not look for any influence from it as moving belly.

And have already observed that the obviating costiveness here a matter of very great consequence.

At least if brought about without any evacuation from general system.

From these considerations then, here led to conjoin with use of Tincture Amarum employment of pills from which expected these affects.

With the Assafoetida given as an antispasmodic combined the aloes as a purgative.

And was principally with [intention] of giving form that to these two articles added the Soap.

Both aloes & assafoetida which hold to be articles of great use & considerable activity more frequently exhibited in form of pills, than in any other state.

And both the foundation of formulae in [Pharmacopoeia]

One basis of Pill Gummos.

Other of Pill Aloetic etc

From [experience] am conjoining that advantage to be had from each separately may be combined by conjunction.

And cannot help thinking that [as] conjoined might with propriety constitute fixed formula in [Pharmacopoeia]

Distinguished for example by title of Pill Foetid. Aloetic. or like.

These pills directed to be given to extent of grain X at bed time

From which hoped that should both obtain regular discharge of faeces & ready expulsion of wind.

And must own that from continuation of this course for due length of time expected alleviation or even cure of affection.

In employment of these medicines however soon interrupted by an occurrence of which have already spoken.

Discharge viz of worm of the lumbricus kind by stool.

How far this the affect of these medicines may perhaps be matter of doubt.

Yet several of these which at least reputedly anthelmintics

And besides tendency which all cathartics must have to expulsive power of killing or at least diminishing vital power of worms, is unquestionably to some degree excited both by vegetable bitters & by Assafoetida.

But even supposing that had this affect yet consider Tincture Amarum & Pill Foetid. Aloetic. as at utmost but weak anthelmintic.

And although still of opinion that not to be considered as a worm case yet imagined that others might remain.

And when present hard to say what affection they may induce or support.

These then sufficient reason with me for resolving, to interrupting at least, plan began & to take immediate measures for expulsion of worms

With this view had recourse to a Mercurial preparation viz Calomel with view of killing them & to Jalap, as purgative for discharging them from intestines whether dead or alive.

Former considered to be one of most [active] & most certain anthelmintics in common use.

While look upon latter to be one of most affective purgatives where [illegible] powerful discharge wanted.

But although Calomel regularly taken & although Jalap operated briskly yet no more worms observed.

From this then at least some [presumption] that no more existed.

And as no urgent symptoms at least which could suppose to proceed from this, was unwilling farther to interrupt plan of cure.

But especially to prosecute [measures] [which] according to idea I had of affection must tend to augment it.

By this then led at least to return to use of medicine on former principle.

And indeed varied rather formula than active article of the composition.

In place of Tincture Amarum substituted Infusion Amarum

And for in some measure supplying [spirit] menstruum, added Tincture Aromatic.

With view to moving belly still continued the Aloes.

But in place of employment in solid state gave it as dissolved by weak spirit menstruum.

And in order to obtain still farther affects of tonic gave it as combined with Rhubarb.

From this then expected both to obviate circumstances having tendency to augment the affection & to remove causes.

How far however [has] in any degree answered these intentions, have not been able to learn.

But unless from aggravation of complaint or from [new] occurrences should be disposed to persist in use

And as conjoined with proper regimen & due exercise may be product if not of radical at least of temporary cure.

Or may afford such relief to patient that shall consider farther attendance as unnecessary

If however in this disappointed & at same time no reason for altering opinion of disease may try other tonics

But particularly Chalybeate. Peruvian Bark or the cold baths.

Taking care however to employ also such means as will have affect of obviating costiveness.

But if opinion of disease shall turn out to be a mistaken one, may lead to practices very different from any of which can at present be aware.

And according to circumstances may be yet be led to have recourse to Anthelmintic or to practices directed on principles not more corresponding to those which have now laid down.

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Explanatory notes:

1) An official publication containing a list of medicinal drugs with their effects and directions for their use. The Royal College of Physicians of Edinburgh's Pharmacopoeia was first published in 1699.