DEP/DUA/1/39/06 (Normalised version)

Peggy Malcolm

(1785-1786)

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Peggy Malcolm. February 11^th.

In history of this patients case many different symptoms enumerated.

And perhaps some room for doubt whether whole can be considered as connected or not.

Am however upon whole inclined to former opinion.

And although by no means corresponding to definition of Hysteria as entering system of nosologists¹ yet as already said when formerly spoke of case consider whole as being peculiar modification of hysteria.

In history before us the first symptom mentioned is at least one of most common in hysteria cases.

And that too most distinctly marked.

Sense viz of ball forming in side & rising upwards in alimentary canal.

Need hardly mention that this so common in hysteria cases as to have obtained denomination from that affection.

Well known by title of Globus Hysteria.

In that case indeed, often rises even to throat, producing sense of suffocation.

But with our patient comes no farther than stomach giving sickness & unease.

This however in no degree alters essential nature.

For equally to be considered as same inordinate action taking place in alimentary canal.

And no real difference in extent to which propagated.

This symptom some consider as being in hysteria even a pathognomonic.

That is a symptom always occurring wherever this disease is present & not taking place in any other affection.

To this opinion must own that would by no means subscribe.

May I apprehend be even present where disease cannot with propriety be styled hysteria.

And I have no doubt often wanting where yet Hysteria is present.

But notwithstanding this is at least a symptom always giving strong presumption of this affection.

And where present sufficient grounds for considering disease as of hysteria kind unless another complaint distinctly marked.

This however cannot be said to be case in present instance.

For after globus hysteria symptoms mentioned, also affection of alimentary canal.

Particularly distension of abdomen flatus borborygmi & acid of stomach.

These indeed it is true are symptoms often taking place where hysteria cannot be said to be present.

Are common attendants of every instance of dyspepsia.

And occur also not only in tympany affection but even in cases of simple flatulence.

Well known however frequently to occur as hysteria symptoms.

And indeed some of [them] unavoidable consequences of that peculiar irritability of alimentary canal which one of principal morbid conditions in every hysteria affection.

Hence then tends rather to corroborate than invalidate opinion of disease.

But besides these still a third set of symptoms here take place

Flying pains viz in different parts of body

These also need hardly observe may depend on various causes.

Such pains perhaps more frequently of Rheumatic kind than any other.

And not impossible that though other symptoms hysteria this may here be case.

Is no objection to supposition of rheumatism that chiefly distressing during night.

Nor that without febrile symptoms.

For although, at commencement of rheumatism, often fever & in general constant pain, yet this by no means case in after periods.

Even in state of irritability however, seldom of that flying nature here reported.

Seldom that arrives at that stage, without passing through inflamed state

Seldom that cannot be traced to action of preventing cold.

None of these circumstances however hold in present instance.

Hence therefore rather inclined to suspicion, that pains of some other kind.

And to increase suspicion to be remarked, that affects places, which not commonly seat of Rheumatic pains, viz Side & Back

While, as far as can learn at least, joints entirely free

Among other particulars, to be considered as symptom of hysteria flying pains may justly be enumerated.

In so much, that by some also, supposed to give pathognomonic of disease.

Thus Dr Sydenham disposed to consider as such, a peculiar pain of head, which accordingly denominated, Clavus hysteria.

Hysteria pains are especially remarked to be very [acute], & at same time transitory

And much more affecting head or trunk, than extremities.

Hence, may with considerable probability, view these also, as hysteria symptoms

Even viewing case however as entirely an instance of Hysteria, yet some difficulty as to prognosis.

At least difficult to say, whether shall be able to overcome it, or not.

May however consider it, as not even of dangerous nature.

For well known, that hysteria affections in general much more alarming than dangerous

And even where symptoms much more numerous & distressing, than in present case, yet often successfully terminates

While at same time, hard to say, under what forms may not sometimes appear.

Of this diversity have very lately even had some strong instances.

Am in particular at present attending a case with Dr Cullen where appears under form of cough.

This cough while patient awake almost incessant.

At least have never of late observed an interval for above two or at utmost three minutes at times.

And while constant when awake, may also add, that sleeps very little

Seldom indeed above four or five hours, in space of 24^hr

And then rather in day than night.

In this distressing state has patients affection now continued for no less than space of 7 weeks.

And that as may readily suppose notwithstanding use of various [remedies]

Has taken opium in course of 24 hours to extent of grain XII in solid state & 200 [gt] of [Liquid] Laudanum

And that without smallest remission

While at same time, such affect of disease, that no more sleep when takes opiate to this extent than when wants it.

Bleeding, blistering & bathing both with warm & cold water, as well as whole tribe of nervous medicines, Musk. Camphor. Castor, Assafoetida, have had fair trial, with equally little affect.

[What] will be event of this case, dare hardly venture to say.

At same time, do not pretend to [affirm] that have certain or indubitable proof, its being entirely hysteria.

Yet very extraordinary that should have subsisted so long without alarming symptoms or even fatal consequences.

And no less so that even during short interval which patient has is in apparently easy state

While unless during concussion of coughing no affection of circulation.

While these circumstances much in favour of opinion of its being hysteria affection are by no means only ones.

For patient a female, who though young, has for considerable time, been subjected to hysteria under different forms.

And particularly during course of last summer regular hysteria fits, which at length overcome by cold bathing.

After considerable interval, of apparent good health, present cough took rise immediately after violent emotion of mind from fright.

Has been, during whole course, without smallest particular of expectoration.

And is at same time, with such peculiar sound, that cannot consider it as ordinary cough.

From all these circumstances then have little hesitation, in agreeing in opinion with other two Gentlemen in considering it as strong example both of obstinacy of Hysteria, & variety of forms, which will put on.

Have at present also another patient in private practice whom attended with Mr Gard an Apothecary here in which [also] both obstinacy & peculiarity of disease apparent.

In that case there takes place a convulsive affection somewhat resembling, though by no means same, with singularity.

With this notwithstanding trial of various remedies has continued affected ever since beginning of January.

These mention as being cases singular & obstinate.

Where however still inclined to consider affection, as more alarming than dangerous.

But in our patient this cannot be said to be case.

And may add that where least alarming & mostly in common form often most tedious.

Hence then shall not be surprised if in present instance baffles all attempts to cure.

But at same time, if do not entirely remove, may at least entertain hopes of alleviating affection.

And even complete recovery, in short time, could not be considered as singular.

For while hysteria thus obstinate in some cases, in others readily yields to proper remedy.

Principal, on which cure conducted, in such cases, somewhat varied according to circumstances

During violent attacks, under whatever form may appear, first objective to mitigate these.

And often also, symptoms even not very urgent, which require to be obviated.

Such for example as constipation flatulence or like.

But in every case, an objective to remove irritability of habit with which disease at least very much connected.

Was on these grounds, that had with present patient, recourse to practice here employed.

Began you will observe, by directing for her, the pill Foetid cum Aloe.

By these hoped, that should not only obviate costiveness, but also alleviate borborygmi.

And with latter, imagine that flying pains, might be not a little connected.

While from free discharge of wind, hoped also, for removal of distension of abdomen.

Thus then imagined that might mitigate some of most distressing symptoms.

And by this means better opportunity afforded, for action of remedy intended to remove irritated state.

With this view when formerly spoke of patient mentioned that was my intention, to make trial of Zinc.

And this accordingly you will find prescribed for her, at succeeding report.

This article as a remedy in affections of nervous kind, first introduced among regular practitioners by Dr Gaubius.

And to his [a dversariorum]², where treats of it under title of Luna fixata Luddemanni may refer you, for particular account of introduction.

May only here observe that since his recommendation of it, as a remedy in Epilepsy has been much used both, in that & other similar affections.

And very different opinions formed of effects obtained from it.

Some, from frequent disappointment & want of obvious operation, disposed even to consider it as of no efficacy.

But for my own part judging from experience which have had, cannot help entertaining different opinion.

Allow indeed, that even in large doses, unless where excites sickness at stomach no obvious operation.

And this affect consider as in no degree connected with powers as medicine.

On contrary inclined to look upon it as product of inconvenience without any advantage.

And therefore that dose never to be pushed to such extent as to produce any affect in this way.

But want of obvious operation no proof of want of efficacy.

For this also case with respect to Peruvian Bark, Mercury & some others of most powerful remedy, in instances where decidedly product of best affects.

Hence this at least no good grounds of objection.

That in diseases in which most employed often fails, am far from [denying]

But this also in common to it with medicines confessedly powerful.

In Epilepsy in particular, through cure effected in some cases, yet majority of instances incurable.

This therefore, is we may likewise observe no proof of inefficacy.

These particulars the rather mention as [inclined] to think, that with many practitioners, has of late fallen into undesirable contempt.

For my own part, judging from experience, I have had, have been led to conclusion that have often seen it product of good affects.

More indeed in cases of Hysteria, than of Epilepsy.

In hysteria affections, nearly similar to present, much deceived, if have not seen it product of best effects.

Hoped therefore that might be useful in this case.

And gave it conjointly with valerian, an article of which also am inclined to think favourably, in such complaints.

Here however employed rather with view of giving form, than any other intention.

For from quantity of Ji bis indies, much could not be expected.

From this formula however, patient had at first, not only sickness at stomach but vomiting.

But whether this affect of Zinc or of Valerian, had hopes that would be of no long continuation.

For in few days, vomiting gone & sickness much diminished.

This therefore led me to direct continuation of use.

As from continuation only that benefit to be expected.

While persisted in powders however ordered quantity of aloetic pills to be doubled.

For from five grains no influence even in moving belly.

In affect from these however even with increased dose, almost as much disappointed as before.

For still no influence in moving belly.

And consider as better to vary purgative than farther augment quantity.

Accordingly in place of these directed pill extract Colocynth cum Aloe.

Which though perhaps less fitted for cases of flatulence, unquestionably more powerful purgative.

Though costiveness however continued, yet had some mitigation of affection in other respects.

And this I own was inclined to hope might be affect of powder.

But these we were told still [occasioned] sickness at stomach.

And this, as already observed consider as in no degree [concomitant] with efficacy.

Was however unwilling to diminish calx of Zinc.

And resolved at least to try, [how] far sickness might be prevented by change of formula.

In place therefore of Valerian substituted equal quantity of Pulveris Cretacea.

To this the rather led from sourness at stomach with which patient affected.

Since began this formula cannot indeed say that sourness at stomach overcome by the absorbent.

But are told, at least that now, no sickness from powders.

While at same time hysteria symptoms much diminished particularly the globus with which has not of late been affected

Pill ex Colocynth have also desired affect of keeping belly moderately open.

These therefore at least inducement to continue in present course till shall see fully affects of it.

And am even in hopes, that patient may be in condition to be dismissed, [without] use of any other remedy.

But if this not the case, future practice, must be directed by occurrence.

And even while continue course, particular symptoms, such for example as sourness at stomach, which may require being obviated.

But practice employed for these must be adapted to 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.

2) Hieronymus David Gaubius, Adversariorum varii argumenti (1771).