DEP/DUA/1/38/69 (Normalised version)

Helen Smart

1785

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Helen Smart. January 28^th 1785.

Circumstance which chiefly led this patient to come under our care a severe headache.

This as have already has occasion to observe by some considered as merely symptom

But for my own part from frequency as well as importance think may justly be considered as genus of disease.

And this view taken by most nosological¹ & practical writers.

Hence then little hesitation in pronouncing an instance of Cephalea.

But for proper conditions of success practice must go somewhat farther.

For no doubt that headache from various causes.

As indeed already occasion to remark when treated of case of John Montgomery.

In present instance not altogether I think without ambiguity.

Very little doubt that in some instances headache affect of state of circumstance in head.

Has affect probably both as acting on integumentary of head & even on brain itself.

Accordingly in some instances with severe headache sense of impulse [with] very distinctly marked.

This have often felt in my own case.

Am often subjected to very severe headaches.

And not unfrequently can in these cases [numerate] pulse as excited as by application of finger to artery at wrist.

This too I may observe will happen where impetus of circulation in other respects not increased.

Where pulse neither quicker nor stronger than natural.

For no doubt that in consequence of local state of action impetus may be partly augmented.

And from this cause, am convinced that headache often arises even where does not go to such height, as to produce evident sense of pulsation.

Here some suspicion that headache may have origin from this cause.

For at least one circumstance in case giving countenance to it.

That is frequent haemorrhage from nose to which patient subjected.

For many years we are told had been liable to frequent returns of Epistaxis.

And this also an affection well known to arise in many instances from increased impetus.

Here therefore not improbable that both headache & haemorrhage from same cause

But in such cases haemorrhage seldom merely in small quantity.

This however has always happened with regard to bleeding from nose in present instance.

Hence therefore no less probable, that merely affect of peculiar tendency of vessels, & entirely of passive kind.

Besides this another circumstance against supposition of connection.

Though headache of long standing, yet haemorrhage from nose much longer.

Hence then at least not improper to inquire how far [presaging] of other causes.

And among these may remember that headaches very frequent from affection of stomach.

This so much the case, that subject expressly treated [off] even by some of first writers.

This in 6^th volume of London Medical Observations & Inquiry long passage by Dr Fothergill on what he terms [sick] headache

Which he considers as being always effect of indigestion often of impropriety with respect to diet.

And which, whether from that cause, or from state of stomach itself, may always view as example of what Mr Sauvages calls the Cephalgia stomach.

In case before us appears to me most probable that affection of patient of this kind.

For here stomach complaint little less urgent than headache itself.

Is affected not only with flatus & borborygmi but with much sickness at stomach.

These symptoms also of same standing with the headache.

Hence good reason for presumption that are connected.

And this accordingly opinion I formerly [gave] of case & still apt to hold.

At same time, cannot say, that circumstances have since occurred, by which more confirmed.

On contrary of late though stomach complaint much easier yet headache greatly aggravated.

And two now mention, by no means only suppositions, which may here be entertained.

Patient you will observe a female at that period of life when hysteria or nervous affection very frequent.

And well known that not a few headaches, occurring too with particular severity & obstinacy, from this source.

Hence then even this no improbable supposition.

But may at least be observed that here no other nervous symptoms, [as] are commonly called.

And am I own still inclined to supposition of its being example of Cephalgia stomach.

On this idea of disease cannot look upon it as being a dangerous affection.

And indeed perhaps every instance of Cephalgia to be considered as rather obstinate & distressing than dangerous.

But perhaps Cephalgia stomach to be considered as one of most obstinate.

Or at least most liable to recur.

For this as already observed the consequence of every irregularity with regard to diet.

And even slight transgression in this way with those of very weak stomachs apt to have considerable affect.

From this circumstance then, joined to long continuation, before came under our care, could not entertain hopes of speedy termination

But at same time both for alleviation & removal something to be expected from medicine.

And in such cases still more from regimen particularly diet.

In latter way however with Dispensary patient have it in our power to do very little.

At utmost can merely give general directions.

And when our patient servant as case with present have it not in power, even with utmost inclination, to carry regularly into execution.

Without this however medicine can in general be but of little avail.

For affects more than counteracted by impropriety in diet

While however in this respect gave directions to patient to avoid causes tending either to support or increase affection have recourse to those medicines by which hoped that vigour of stomach might be restored & digestion promoted.

But prior to this directed use of an Emetic

For though frequent vomiting tends to weaken stomach, yet from fully emptying this viscus both removes cause of disease & paves way for other medicines.

For this not to be expected while stomach loaded with viscid sordes & with that acrid fluid giving cardialgia.

Here as Emetic employed Ipecacuanha.

Which as already have had occasion to observe hold in all such cases to be best safest & most certain.

And accordingly in effect not disappointed.

But from free operation did not obtain any relief of complaint.

An affect which however may by way observe in such cases not unfrequently follows even mere evacuation of stomach.

And when does take place affords at least corroborating evidence of cause of Headache

Here after emetic had recourse to a mixture consisting of equal parts of bitter & aromatic tincture & of Peppermint Water

Need hardly observe that common tribe of what called stomachic medicine consists of bitters & aromatics.

And particularly of those in which bitterness & aromatic conjoined.

Among all medicines of this kind have found few answer better than present form.

Which for basis of bitter tincture formerly termed stomachicus elixir has generally one of purest & strongest of vegetable bitters

And of aromatic, has Cinnamon & Cardamom seeds, two of most [qualified] & least heating of that tribe.

From use of this medicine seemed in no long time to derive very considerable advantage.

For at succeeding report found that both headache, and stomach ailment, were considerably relieved.

Though at same time still subjected to severe returns of both

This however naturally great encouragement to persist in use.

Accordingly directed merely continuation

And after persisting in employment for another week in both respects affection much mended.

Had no return during that time of severe headache.

And appetite much mended an evident symptom of more ready digestion.

Still however had at times uneasiness from wind.

A circumstance from which might infer that tone & vigour of stomach not thoroughly restored.

Even this however hoped might be soon accomplished by continuation of medicine.

And expected that by persisting in use might now soon obtain cure.

On this subject our patients expectation went perhaps even farther.

For after this did not again make application at Dispensary for course of some weeks.

And during that interval, use of medicine of course entirely omitted.

This irregularity the affect of relief obtained & of imagining that no farther medicine now necessary.

But in this appears that had judged with too much precipitation.

For was again obliged to return to attendance in consequence of severe action of affection

And that too both under form of headache & stomach complaint

This as far as could learn at least our patient could not trace to any obvious cause.

Probably however as much affect of some irregularity with respect to diet as of want of medicine.

At same time by continuation of medicine might possibly have been prevented.

But whether this case or not from affects which appeared to be derived from it now inducement to repetition.

And again in short time seemed to be attended at least with some advantage.

For as soon as began use affection of stomach somewhat alleviated with return of appetite.

Notwithstanding this however headache still violent.

From this therefore led to imagine that whatever formerly cause might now be more affection of Nervous kind

Accordingly thought of having recourse to trial of some medicine with that intent

And as such here directed Camphor.

An article, which as formerly had occasion to observe, often employed in such cases with great success.

Of from this combining benefit shall endeavour to obtain more regular trial.

And by persisting in employment hope that patient though not radically cured may soon be in condition to be dismissed.

And by due caution, in avoiding what disagrees with stomach, may continue at least tolerably easy.

But if this not the case future practice must be regulated by situation in which shall find her.

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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.