DEP/DUA/1/34/10 (Normalised version)

Mary Manuel

1784

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Mary Manuel February 28^th 1784

With regard to disease to which this patient subjected am I own very much at a loss.

None of symptoms indeed to which subjected can be considered as uncommon.

But assemblance in many respects very peculiar.

This particularly the case, both with regard to origin of pain, & manner in which propagated.

And also with regard to termination in [sickening] & vomiting, not of ordinary contents of stomach but of very acid liquid.

As well as from sickness being attended not only with sense of flushing & heat but of trembling over whole body.

But in this case a circumstance still more extraordinary than any of these

Remission & exacerbation viz for alternate [months]

For according to her own account at least after these symptoms have continued for space of month, disappeared during succeeding month & again returned with former violence.

And this we are told has not happened merely for one or two periods but for space of 12 months past.

In these different particulars will readily be admitted that several singularities take place.

And that have not distinctly marked characteristics of any particular disease as described by nosological¹ or practical writers.

Yet may be observed that none of the symptoms which do not frequently accompany Hysterical affections

And that course & combination in no respect more singular than frequently takes place in that disease, which well known to be an affection putting on almost infinite variety of appearances.

Was then of opinion that this patients disease to be considered as an example of an hysteria affection.

And notwithstanding periodic attacks under form of paroxysms was yet rather inclined to view it as consisting in what might be called hysteria symptoms than in proper hysteria fits.

This supposition of disease not a little corroborated by two other circumstances.

viz age of patient, & connection with menstrual discharge.

Is at that period of life when hysteria very common.

Hence more grounds for presuming this affection, than if occurred either at earlier or at later periods.

But a circumstance still more remarkable in connection with menstrual discharge.

Need not here observe how much hysteria connected with state of that organ.

This so much the case that has even given name to the affection.

But without supposing as was once prevailing opinion that all hysteria symptoms from the uterus, can be no doubt that very much connected with state of menstrual discharge.

And that very much affected by regularity both as to time & quantity.

In present case however were informed that intervals uncommonly long

While at same time discharge itself both scanty & irregular.

While also observed that during flow all complaints are considerably alleviated.

From this circumstance am inclined to think that may perhaps even explain remission & exacerbation for alternate months.

This may be connected with more liberal or scanty menstrual.

At least this discharge is without doubt often subjected to such varieties.

And if, during even scanty flow, evacuation removes symptoms, may conclude that by very copious discharge will be suspended for some time.

Must however admit that this opinion entirely conjecture.

And cannot pretend to say, that has been discovered by observation, that discharge more copious, prior to remission than at other times.

Perhaps therefore may with greater safety & no less truth, refer this alteration to those intricate laws of nervous system which regulate many periodic motions.

The agency of which readily discovered although not easily explained.

But whatever cause of those regular periodic exacerbations & remissions, yet look upon this as an additional proof that disease of patient, a hysteria affection.

And at least highly probable, that if not dependant on state of menstrual is yet somehow [connected] with it.

On this idea of disease prognosis cannot be very favourable.

Would not indeed be understood to mean, that here any symptoms indicating danger.

But reason to fear that affection may prove obstinate.

For this very commonly the case with such affections

And although apparently removed for short time yet soon again return.

Here however the rather reason to fear obstinacy from being connected with state of menstrual.

For till this discharge brought to natural state a constant cause supporting it will continue to act.

And when such irregularity as here described occurrence not easily removed.

Hence then shall not be very greatly disappointed if not even able to afford her considerable relief.

But if circumstances of obstructed menstrual in some respects unfavourable on other hand gives more grounds to hope for cure.

For if hysteria symptoms induced or even supported by this cause on restoration of due menstrual may entirely cease.

And if that the case less chance of future return, than if two affections altogether unconnected, & hysteria more especially depended on irritated state of system.

Although thus however chief hopes of radical & permanent cure, yet, consider hysterical symptoms themselves as being first object claiming attention in treatment.

And here with view to removal wished to make trial of Zinc.

Need hardly observe that some years ago, calx of Zinc introduced as a remedy against epileptic affections by late Dr Gaubius of Leyden.

Extolled it as a remedy of great efficacy

Since that time however results of experiments of those who have tried it so different that very opposite opinion entertained with regard to it.

And some who even look upon it as of little or rather no efficacy.

Result of my experience however leads me to very different conclusion.

Am far indeed from considering it as a remedy which will succeed in every instance of Epilepsy.

As far as my observation goes by much greatest part of these incurable either by this or any other means.

If therefore succeeds in any cases of Epilepsy may I think be looked upon as a very valuable acquisition.

Of this however am very firmly persuaded from what have had occasion to see in practice.

But if has succeeded in some instances of Epilepsy, have found it attended with best effects in many more cases of Hysteria.

How here acts am I own at a loss to say.

The most common opinion however is that operates by tonic power.

And that from increase of tone & vigour of muscular fibres these less liable to be subjected to inordinate action

Whether however this operates as affecting condition of muscular fibres themselves, or as affecting nervous power a matter of great doubt.

Of two however am I own [most] disposed to latter opinion.

And am inclined to think, that independent of increase of tone, has influence in diminishing irritability by change in Nervous power.

And that produces this affect from peculiar impression which gives to nerves in stomach.

But whether any foundation for this conjecture or not, hold it to be one of those articles, by which tendency to inordinate action very much diminished

And as such had recourse to it with present patient.

Where Zinc employed however can be exhibited only in small doses.

And hence some additions requisite to give proper form.

In case of present patient employed with this intention the Magnesium Alba.

To which chiefly led from prevailing acid in stomach.

And by destroying this hoped that one of most urgent symptoms the vomiting might be counteracted.

While however had thus recourse to Zinc directed also you will observe the employment of another medicine.

The elixir viz of Aloes & Rhubarb or as commonly called the sacred Elixir a name which has obtained from high opinion of virtues.

Although however cannot look upon it as justly entitled to this appellation yet unquestionably a very useful remedy.

Particularly beneficial where wish to brace the stomach & at same time keep belly open.

Here besides these intentions had also another in view from use.

The promoting viz a free & regular menstrual discharge.

For can be no doubt that purgatives in general some influence in this way.

But is particularly the affect of the aloetic purgatives.

And probably the consequence of that peculiar power which they possess of stimulating the rectum in particular.

For effect of this communicated to neighbouring parts & especially to uterus.

Under these medicines patient soon obtained very considerable relief.

And although far from certain is yet at least probable that this the consequence of practices employed.

Attacks to which subjected soon became less frequent.

And with this relief, vomiting & sourness at stomach also very considerably abated.

In so much that for space of fortnight almost entirely free from vomiting.

At our last visit however found that this symptom had in some degree returned.

At the same time had also occasion to remark that period for which menses absent had been now [inconveniently] long.

For had seen nothing of discharge for space of nine weeks.

This therefore, especially as what held to be hysteria attacks now much less distressing to her, consider to be an object claiming particular attention.

And with one where strong indication of plethoric habit might easily [induce] all other symptoms to which now continues to be subjected.

On this account therefore resolved at least for short time to discontinue calx of zinc

And to try in conjunction with the Elixir some more powerful Emmenagogue.

As such you will observe here directed employment of Electricity.

Electricity of late years highly extolled as means of restoring menstrual discharge

And although unquestionably not suited to every case yet upon whole few [articles] more powerful.

Is in my opinion chiefly fitted for those cases where menses absent from want of due action in uterus.

When this the case has in [comm] instances good effect by restoring due power of action.

And in this way influence over uterus in same way as has over other muscles in state of debility arising even to total paralysis.

In this way renders uterus [suspended] of action when natural stimulation is applied.

But if in some cases operates on this footing in others more immediately so as instantly inducing action

Power of electricity as an immediate stimulant to muscular action well known to be very great.

Has influence, not only during life but even some time after death.

This particularly exemplified in case of animals [nearly] killed by hanging, drowning or like.

After muscles have ceased to be affected by any other stimulation yet whole thrown into convulsions by an electric shock.

In this manner then am inclined to think that often operates as inducing immediate action of uterus.

And thus menstrual discharge after being long obstructed sometimes restored as immediate consequence of shock.

Was chiefly in this way that here expected benefit from it.

And if attended with desired affect flatter myself that patient may be soon in condition to be dismissed.

If however after continuation for a week shall be found to fail, with continuation of shock shall probably also direct continuation of insulation & sparks.

Because while former most effective means of inducing immediate action, these again best fitted, for restoring power of action.

If neither way successful must own am at loss to think what other measures can here be taken with much prospect of success.

And shall be disposed to accommodate practice to circumstances in which shall then find patient rather than to any views which at present have with respect to this case

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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.