DEP/DUA/1/38/45 (Normalised version)

Robert Lamb

1785

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Robert Lamb. November 26^th 1785.

History of this patients complaint does not in my opinion afford certain diagnostic of any particular disease

Has indeed many of those symptoms, which known to arise from presence of worms, particularly of lumbricus, in intestinal canal

Such for example as pains of belly, & picking of nose.

Of same kind also may reckon delirium during sleep, starting, & grinding of teeth.

And may also rank among these, tenesmus, & frothy or slimy stools.

That all these symptoms frequently arise from presence of worms in alimentary canal, cannot admit of doubt.

But at same time, often arise also from other causes.

Probably may be affect of any material giving peculiar irritation, to intestines.

Perhaps even, of very irritable state of intestinal canal, when acted upon merely by ordinary stimuli, to which unavoidably exposed.

In many cases then, from symptoms alone, diagnosis impossible.

For even where worms discharged, may yet arise, from other causes.

At same time, where no objection to use of anthelmintics, these perhaps, afford most certain diagnosis.

For if from use, some worms discharged may conclude with at least considerable probability, that these, or others still remaining, have been cause of symptoms.

Where on contrary no worms appear gives at least stronger presumption, that originates from other causes.

On this ground, though at first supposition of lumbricus now different opinion of this case.

+ Am inclined to think that few ascarides observed to be discharged little or no connection with his present disease

And consider it as arising from weak & irritable state of intestinal canal.

To which as very generally indeed happens in such instances a vitiated secretion operates as more powerful stimulant is superadded.

To this affection, unless when arises to such height as to induce Diarrhoea do not know any proper name in system of nosology¹.

For gastrodynia, an affection characterised by pain of belly principal & indeed [most] distressing symptom which here occurs is yet a very different affection as described in nosological systems.

But if right as not nature of the disease, name less material.

For is on knowledge of principle morbid affect here occurring, that successful treatment must be founded.

And on this idea of the affection am I own disposed to look for favourable termination.

Not indeed that can be alleged in no instances to prove fatal.

Sometimes is merely forerunner of incurable diarrhoea.

Sometimes, where no discharge takes place, gives rise to Tabes or Atrophy proving fatal.

But of none of these termination does there seem at present to be any threat

And in greater number of instances, even where symptoms worse than with present patient, by aid of proper remedy, due condition of intestinal canal may be restored.

Hope therefore that in no long time, may be able to dismiss him free from affection.

Or at least, in such a [illegible], that from proper management respecting diet exercise & the like remaining symptoms may of themselves gradually disappear.

After what already said concerning nature of disease almost unnecessary to add anything, respecting general plan of cure

This must consist in unloading intestinal canal, of those matters, acting as peculiar stimulants.

In removing morbid irritability, in consequence of which, more affected by irritating cause.

And in restoring to its moving fibres, due degree of tone & vigour.

These general intentions, will abundantly explain practices, to which have had recourse with this patient.

Remedy indeed with which first began viz the Calomel, directed in some degree with a different intention as before [trusted].

Or at least, while intended that should operate, as evacuant of alimentary canal, wished also, by this means, to determine whether any lumbricus present in intestines or not.

Power of Calomel as an anthelmintic medicine, long ascertained by very extensive experience.

And in manner in which here given doses viz of single grain at intervals of two days no less safe than efficacious.

While at same often also thus operates as powerful evacuant of alimentary canal.

But with view to both intentions to use of Calomel thought that a purgative might with propriety & advantage be superadded.

For this purpose, had recourse to a mixture of Tincture of Jalap, & Syrup Simple

A mixture for introduction of which, we are indebted to the Sutton Inoculators.

And which, even with youngest infants, I have found to operate, with equal certainty & ease as a cathartic.

Especially as not disagreeable to taste, & can be thrown in, by small doses in such manner as to secure operation.

not even any of ascarides

From these medicines, while no worms discharged + & thus at least strong presumption, that none existed, there took place very free discharge in way of catharsis.

From this therefore conclude that intestines sufficiently unloaded, & that what chiefly remained to be done, for accomplishing cure, was the removal of morbid irritability & restoring of tone.

By restoration of tone however proper condition of sensibility often also restored.

Hoped therefore that here both ends might be accomplished by use of Rhubarb.

An article combining laxative & astringent power.

And where does not disagree with patient, often in such cases product of best affects.

To render it more [palatable] a circumstance necessary to be [consisted] with infant Vinum Infusion of Rhubarb here united with Syrup Simple

Or finally if any more ascarides discharged of which whether cause of affection or not at least desirable that should be freed, will have recourse to injection of Lime water, most powerful & safest cure with which I am acquainted

And as suspected that swelling of belly was affect of flatulence diluted it with Syrup Cinnamon Water

Adding at same time a proportion of Mucilage both with view to tickling cough, & with intention of lubricating intestines

Under this medicine complaint though not removed, now considerably alleviated.

And hope that from continuation, patient may soon be in condition to be dismissed

If however violent return of gripes, may combat it with small proportion of Laudanum.

If marks of accumulated sordes in intestines may alternate it with purgative.

Or if more powerful astringent shall seem requisite may substitute Infusion Japonica or Gum Kino.

But in choice of these, if any necessary must be directed by circumstances at the time

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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.