DEP/DUA/1/15/06 (Normalised version)

George Fife

(1777-1778)

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George Fife.

Little hesitation in pronouncing that disease of this patient somewhat of complicated nature.

For evidently effected with symptoms between which in ordinary cases at least no connection

And what renders it very probable that no connection in present instance is that affections of very different duration.

Of these however that of longest standing the least considerable.

When came under our care by much most considerable part of disease the affection of back.

Chief complaint frequent attacks of very violent pain there.

But from progression no doubt that [seat] of this pain in cavity of abdomen.

And that even derived origin from an affection of intestinal canal.

While at same time of that transitory nature which serves to show that no fixed affection.

And in greater part of nosological¹ systems at least might with strict propriety get name of Colica.

In system of Mr Sauvages to genus of colica numerous species referred.

Of all these however no doubt of reducing present case to head of colica flatulent.

For that arises from wind sufficiently demonstrated from local but temporary swelling moving from one place of abdomen to another.

Although however thus characteristic of colica according to nosological arrangement would hardly in judging from general history give it that appellation.

For with respect to duration at least very different from what usually case in Colica

With our patient seldom of that continuation occurring in colica

And attacks much more frequent than with those even habitually disposed to colic.

Have therefore some scruple² in giving it that appellation in common acceptation.

And perhaps may in such cases conduct practice with greater safety from view of nature than name.

Have already observed that consider pain to be more immediately effect of wind in intestines.

From distension which gives suppose spasmodic affection to be induced.

And from air thus confined [circumstantial] swelling.

While at same time by progressive motion of spasmodic affection swelling changes [place]

And from contraction on one hand & distension on other pain excited.

Taking this view of case however still recurs as question by what means wind here generated.

This would presume to depend on two circumstances.

Torpor of bowels giving rise to [removal] of feculent matter.

And atonic condition admitting of extrication

Is somewhat at least in favour of this supposition that patients belly particularly bound.

And that when most costive [symptoms] to highest degree.

This then short view of scientific name & of nature of affection.

But besides this of some consequence to every one engaged in practice to be acquainted also with vulgar names.

And in this respect case before us gives room for a remark.

When patient came under care his own account was that was afflicted with windy gravel.

A term which in this part of country at least will often have occasion to hear.

And which must seem to you very absurd if with gravel connected idea of complaint from calculus.

Term gravel however promised employed wherever either affection of urine, or even without that pains resembling nephritic ones.

Both one & other however readily product of wind in bowels.

And is to such affections that vulgar appellation now mentioned has been [given]

From our account then would seem to have been not improperly bestowed in present case

Thus far of most material part of complaint.

But besides this in history of case another particular also mentioned perhaps little connected with former.

That is gross foetid expectoration.

From this however are told neither affected with cough nor with Dyspnoea.

Circumstances which I must own create some doubt as to nature.

Although said to be gross & foetid little reason to presume that any other than mere mucus.

For here no indication of any internal suppuration or proofs of affect of it.

And that mucus will put on not only appearance but smell also of pus can admit of no doubt.

As discharged from mouth however may be [furnished] from different sources.

May fall down upon throat from different cavities surrounding nose

May be brought up by inverted motion of gullet from stomach.

Or which of all most common may be brought from lungs.

Hence question from which of these sources here arises.

To supposition of descent from [illegible] may be objection that in order to this course voluntary effort necessary.

To supposition of [coming] from lungs objection that without cough or Dyspnoea.

And somewhat in favour of stomach being source that patient subjected to other affection of alimentary canal.

Yet very rarely that as comes from stomach of consistency & odour here [mentioned]

On whole then still inclined to supposition that is from lungs.

But may observe that is a part of complaint from which hitherto little inconvenience.

And has not therefore been subject of practice.

Unless puts on different appearance shall not probably think of paying much attention to it

Hence at present not subject of farther remarks either in prognosis or practice.

With respect to prognosis am disposed to consider disease of present patient as in great measure free from danger.

At least whatever may be finally event hope that will be so as long as continues under our care.

Of affections of alimentary canal indeed many in end proving fatal.

Yet is only in consequence of general [extremity] of system

And of this at present at least no indication

While however consider it as not threatening danger am far from thinking that will be easily removed.

Perhaps no part of system to which more difficult to restore tone when lost than alimentary canal.

And especially so when has subsisted for any length of time.

With this patient, already manifested to considerable degree, for space of two years

Must therefore own do not expect that shall be able to free him from it.

Yet hope that may be able at least to alleviate his complaint.

Particularly by counteracting & preventing accidents which would serve to augment them.

In this & similar complaints great objective in cure unquestionably is to restore due sensibility & vigour to alimentary canal.

And this to be effected.

1^st By such remedies as tend to increase these powers in intestinal tube.

2. By avoiding & counteracting all accidents serving to weaken sensibility & vigour.

With first of these intentions various remedies of tribes of stimulants, tonics, & astringents employed.

And will have effect either as acting on system in general or on alimentary canal in particular.

But greater part of medicine most powerful in latter way [exception] on second principle mentioned.

That viz of augmenting causes serving still farther to weaken tone.

Of these no one perhaps more powerful than bound state of belly.

Which while effect of want of due sensibility operates as powerful cause of atonia.

As thus distension of bowels both by feculent matter & wind.

On this account therefore internal use of astringents or even tonics seldom advisable.

And what chiefly to be relied upon are those acting on system in general.

Such for example as cold bathing or [exercise]

Former indeed not hitherto much in use with this intention.

But in many cases may I apprehend be employed with safety and advantage.

Latter hold to be best remedy which in such cases can employ.

Especially where circumstances of patient will admit of his taking exercise freely in open air.

And perhaps in this manner horse back preferable to most other modes

Rank in life of our patient however does not admit of any such recommendation

Must therefore be content with enjoining exercise on foot as far as can conveniently be taken.

And to endeavour to give opportunity to natural powers of system to restore tone as much as possible.

With this view [then] chief endeavour must be counteracting such circumstances as to support the affection.

Is entirely on this footing that only remedy which have hitherto employed has been used.

Have already observed that chief circumstance aggravating the affection is bound state of belly.

And in consequence of this distension of intestines by wind produced spasmodic stricture retaining it.

These then symptoms chiefly to be had in view.

And to be obviated by supporting regular peristaltic motion, & by removal of spasms

Is on these intentions that have here put patient on a medicine consisting of aloes & assafoetida.

First intended to act as purgative, second as antispasmodic and consequently carminative.

That is, in this manner discharges wind.

In choice of purgative in such complaints as present great difficulty.

For while constipation worst effects, bad consequences also from looseness.

And although from frequent stools immediate ease yet in end aggravates affections

For most part even followed by still greater constipation.

In such affections therefore a great [desire] to discover a purgative by which belly may be kept easy or at utmost gently open.

And what fulfils this intention with one will by no means succeed with another.

Is often requisite therefore after one purgative has failed to try another.

And when can find one suited to constitution of patient will have more effect in alleviating symptoms than any other remedy which can employ.

In case of present patient chose to begin with use of aloes.

Which of all purgatives perhaps best accommodated to cases of habitual costiveness.

And with present patient seems to have answered to wish.

By this means while belly kept open pain greatly relieved.

And returns of severe fits particularly less frequent.

Which perhaps in some degree to be ascribed to antispasmodic effects of Assafoetida.

As from this retention of wind in great measure prevented.

Thus far then [endeavours] in present case have succeeded.

And am I must own very doubtful whether shall be able to be of much farther service to him

By continuing course on which have put him may I hope be kept [easy]

And by avoiding flatulent aliment will at least cease to be exposed to causes aggravating atonia of bowels.

Hence better opportunity for system even of itself recovering natural state.

Especially if patient can at same time enjoy benefits of exercise & free air.

But besides this may perhaps also do something towards restoration of due tone by internal medicines.

And with this intention may add to present course the use of bitters conjoined with aromatics.

At same time, do not imagine that farther practice on this case will afford much instruction

And has I apprehend already afforded example of benefits to be reaped in such circumstances from obviating tendency to constipation & to spasmodic affections.

In this situation then shall not be unwilling to dismiss him.

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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) A unit of weight equal to 20 grains, used by apothecaries and physicians.