DEP/DUA/1/44/43 (Normalised version)

Margaret Calder

(1788)

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Margaret Calder at 11. N^o24

When formerly spoke of case of this patient expressed uncertainty with respect to it.

And after has now been under care for considerable length of time, as little certain with respect to it as formerly.

Then however observed that all symptoms mentioned in history such as frequently arise from worms.

And that this suspicion corroborated by worm formerly discharged.

Still I think grounds for entertaining same conjecture.

And that too, although of late appearance very much varied.

For perhaps no cause of disease symptoms resulting from which more varied than worms.

Indeed hard to say to what symptoms may not give rise.

From this however readily concluded that great difficulty in diagnosis.

For all same symptoms may unquestionably arise from other causes.

And that too even although worms at same time exist in alimentary canal.

While on other hand certain that worms often exist there without [inducing] any symptoms whatever.

And hence some led to conclude that to be considered as product of no disease whatever.

But for my own part, am inclined to think that equal errors in both ways.

Am very far from believing, that those symptoms commonly considered as diagnostic of worms, do not still more frequently arise from other causes.

At same time well persuaded that worms in intestines may be product of great variety of symptoms.

But that these not to be considered as mere effect of presence.

That are consequence only of peculiar condition of system at time & of peculiar action which worms exert.

And hence results that remarkable variety in appearances arising from them.

And accordingly great difficulty in distinction.

Where however such appearances as these taking place in present case, & at same time worms discharged strong reason for presuming that worms have been cause of symptoms.

And in cases even more doubtful the directing treatment in some degree to worms, is at least allowable

At same time however proper that treatment also on other views of disease should not be neglected.

Is then on these grounds, that practices hitherto employed in present case have been directed.

Began you will observe by prescribing for this patient the use of Semen santonica mixed with same proportion of Rhubarb.

In former of these articles worm seed or worm [crud] as commonly called, have what with many a very favourable anthelmintic.

A seed brought from Mediterranean, the product of a plant of genus Artemisia.

And accordingly of same genus, with the worm wood, & some other of the indigenous vegetable bitters of this country.

On what principle operates in producing death or expulsion of worms a subject of much doubt.

Some consider it as entirely affects of bitterness.

But bitters in general by no means that poison to worms which once suspected.

And other bitters much stronger, less of anthelmintic power.

Has been ascribed to power as increasing tone of intestinal canal, & thus augmenting force of expulsion.

But this no less exceptional.

Stronger tonics not product of equally good effects.

For my own part inclined to suspect that in some degree operates on mechanical principle.

And that probably like Cowhage, operates at least to certain extent, from impression it gives to surface of worms.

For principle if not only success when given in form of powder.

And this always of rough & disagreeable feel.

But whatever principle of operation may be am persuaded that in many instances have seen it employed with best effect.

Particularly against lumbricus.

For to expulsion of Taenia, whether lata or cucurbitina, seems to be inadequate.

While again like other articles taken by mouth, in general effete before reaches ascarides.

For these commonly seated, near extremity of intestinal canal.

And accordingly best acted upon by articles immediately applied under form of injection.

Even in case of these last however often useful.

And at same time one of easiest & safest anthelmintics that can be employed.

For not only no commotion disorder or general uneasiness of system, not only no bad effect on intestinal canal, but tending even to strengthen it.

Accordingly very often at least begin with use.

And although others may afterwards be found necessary, yet in general has effect of producing discharge of some worms.

Most frequently perhaps employed alone

Or at least cathartic only subject to use.

Here however combine it with a proportion of Rhubarb.

In this need hardly observe that have an article operating both as a laxative & stomachicae.

But besides these [properties] by many also esteemed an useful anthelmintic.

Was particularly reckoned such by the late Sir John Pringle.

And although for my own part have seldom employed it with this intention yet know one practitioner of this city who is frequently in habit of using it.

And he informs me with best success.

Imagined then that on these grounds might expect benefit from employment of small quantity of it in present case.

That might in some degree increase both stomachicae & anthelmintic power of santonica.

And that might tend also to augment power of expulsion.

In these effects not altogether disappointed at least.

For after began use of this medicine, some ascarides observed to be discharged.

But after this, did not attend us for several weeks.

By which use of medicine necessarily interrupted.

When again returned, found that for some time before, no worms had been observed.

And at that time, those symptoms indicating them most, were absent.

While was then particularly distressed with pain & distension of abdomen.

This I imagine might most readily be obviated by [some] carminative medicine.

As reason to presume that pain proceeded from distension & that distension immediate effect of wind.

With view to expulsion then, had recourse to Tincture Aromatic.

And to bring this to state of proper dilution, in place of water, employed the Infusion Amarum.

An article from which expected some additional effect, as tending to strengthen tone of bowels.

This however but little influence as removing pain or swelling.

For at succeeding report, these continued nearly as before.

And while no more worms observed, belly at same time remarked to be bound.

This latter circumstance imagined might contribute not a little to support of pain

Hence with continuation of mixture directed an aloetic pill with view of obviating it.

While this had effect of opening belly, was at same time accompanied both with mitigation of pain & some [discharge] of worms.

These as formerly, now also appeared to be entirely of ascarides kind.

And although still suspected that pain principally from flatulence, yet imagined that might tend in other respects to [support] complaint.

Hence while directed continuation of former practice thought some measures also necessary for expulsion of these.

With this intention, advised injection of lime water.

This as far as I can judge from my own experience, hold to be one of best remedies in ascarides.

Not indeed that there are not many other articles perhaps more effective in killing.

But this I have found, very generally sufficient for purpose.

While at same time, one that may be injected with perfect safety.

And when activity somewhat [blunted], by mixture with milk, may be injected even with youngest subjects.

Is not however, from single injection, that can expect removal of it.

For while some so situated, as to survive action, others probably not in a condition to be acted upon.

That is, exists merely in form of ova involved in mucus.

Hence for obtaining complete removal repeated injections become necessary.

Accordingly under continual use of these a considerable number of ascarides discharged.

And symptoms upon whole considerably relieved.

While at same time under this relief discharge of worms almost entirely ceased.

But while in this situation, patient attacked, with an [apparently] new, & more alarming affection than had before been subjected to.

Fits viz of a peculiar kind.

Appeared chiefly under form of inordinate muscle action.

But had hardly any resemblance either to Epilepsy or hysteria fits.

Begin with contraction in hands analogous [to] that which constitutes cramp.

But consisting chiefly in severe pain referred to belly & head.

Which however probably entirely effect of inordinate action of muscular fibres.

And here was inclined to suppose that inordinate action chiefly in alimentary canal.

From this supposition inclined to hope that might be able to combat it by united powers of Vitriol acid, & Opium.

Of latter effects as allaying inordinate action so well known, that need say nothing with respect to it.

But if am not much deceived [influence] of former also in this way very considerable.

And particular example in use in cases of singultus

Have seen these of most obstinate & distressing nature immediately relieved by this article.

And that too even where opium previously employed had failed.

From these considerations then here led to combination of Spirit Vitriol ten. & Tincture Thebaic.

And employed as excipient to give form a simple mucilaginous mixture.

From this however after repeated trials were disappointed in desired effect.

For after use for some days found at last report, that attacks continued nearly as before.

And particularly that now occurred at almost regular period every night.

viz about ten o’Clock.

Although no worms now observed to be discharged, still suspected that these might be cause of present symptoms.

For little doubt that have given rise to fits of different kinds.

Thus well authenticated cases of these induced both epileptic & cataleptic affections

Imagined therefore that some benefit might be derived from producing death or expulsion by lime water injection.

Accordingly directed repetition of these.

Was however unwilling to trust to these alone.

And whatever might be cause of fits imagined that might have some chance of obviating them from employment of opium in larger dose.

Wished however to see effects alone without any other active articles.

And accordingly ordered it under form of Pill Thebaic.

These directed to extent of ten grains that is one of opium.

And this reckoned sufficiently large dose for girl in 11^th year unaccustomed to opium.

This dose directed to be taken about two hours before usual accession of it.

As by this hoped that would have best chance of anticipating it.

For action on system in any form requires some length of time.

But particularly so when under form of pills of slow solution.

Hence then expected that should have action to fullest extent at time of usual attack.

But although thus interruption of fits yet if worms cause, relief can at utmost be temporary only.

Or at least constant danger of relapse as long as worms continue.

And in that case, effect may only be, to put off period of accession for some time.

If however from lime water injection not only discharge of worms but also freed from fits, & mitigation of affection in other respects may look for more permanent cure.

And in order completely to remove [effect] will only be necessary to continue them.

Shall however be disposed to direct this without opium

As thus best able to determine whether [mere] temporary suspension in consequence of sedative.

If from the lime water no worms discharged, will not yet afford evidence, that these are not cause of disease.

For though common at extremity of rectum, yet sometimes much higher in intestine.

And may be here so situated that injection cannot reach them.

This therefore may lead to trial of some anthelmintic taken by mouth.

And after what have already [been] used, have some thoughts of trying Calomel.

Subject to use employed of some brisk cathartic.

As thus chance not only of destruction & expulsion of worms but also of contents of alimentary canal of every kind.

For no doubt that besides worms different irritating causes, there, will give rise to various, & often very anomalous appearances.

If neither from these, radical cure, nor from opium, even temporary relief, shall probably have recourse to some other of most powerful antispasmodics.

And particularly may make trial of Aether.

But at same time in a case so anomalous & doubtful as present future practices must be very much regulated by future occurrences