DEP/DUA/1/16/06 (Normalised version)

John McInnes

(1777-1778)

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At least of the two more frequent to have [such] pains aggravated when first heated in bed than [other]

John McInnes

History of this patients [case] affords example of a disease simple & uncomplicated.

For I apprehend that little room of question that all symptoms here occurring in [reality] parts of same affection.

And indeed symptoms although appearing in affection of very distant parts of body are of no great variety.

Principle affection pains in different parts of body.

But principally if not entirely confined to joints.

These pains chiefly remarkable on exertion or motion of joint.

And on attempts to motion appears that do not possess same facilities of action of formerly.

With this pain patient least affected while in bed.

This in some respects a peculiarity

Yet probably to be considered merely as consequence of want of exertion at that time

But during ease in this situation another particular of a different nature discovered.

Observed that parts affected not of same heat with others.

That is not here same tendency to free circulation on surface.

And such in particular, moderate temperature in bed is apt to induce.

These different symptoms of pain rigidity & want of heat of joints for space of several months before patient came under care seem to have constituted sole affection.

Few days indeed before admitted on our list had observed diminution of quantity of water & flatulence.

Neither one nor other of these symptoms have to great degree

Nor as far as can learn were they product of any great inconvenience.

In so much that with regard to diminution of water was even doubtful.

And flatulence to some degree well known to arise even from slightest irregularity of diet

Both affections therefore in as far as did exist may here consider as of little importance

And viewed disease even at time when patient came first under care as solely consisting of first set of symptoms.

Follows then that should say what name to be affixed to this complaint.

Of five nosological¹ writers will with strict propriety fall under definition of Rheumatism as given by four of them.

In all these definitions however affection very vague & general.

And besides Rheumatism even in most extreme sense would apply also to other affections.

While disease thus under genus so vague may farther observe that contained also such symptoms as would likewise lead us to refer it, to other genera.

Thus for example in situation of pain in lumber vertebrae & about hip joint together with stooping posture & lameness have characteristics of two genera of Lumbago & ischias as defined by some of Nosologists particularly Sauvages.

Have no doubt however that has here multiplied genera without reason

And that these to be considered as in no respects different from his Rheumatism unless in situation.

Under which indeed from vague definition of Rheumatism might readily have been [comprised]

For in general [definitions] this affection doler diuturnus in particular carnosa artuum.

But besides Rheumatism many other instances of doler diuturnus affect limbs.

And situation here fixed upon viz [illegible] carnosa a circumstance which would rather tend to mislead as otherwise

Affection much more accurately described in definition given by Dr Cullen.

These also as in some others distinguished from pains of other kinds by situation.

That viz affects articulation.

And when thus put more exactly applicable than as affection of limbs.

For in many instances as in case before us affection not confined to extremities but exists also in articles in trunk of Body.

Cannot however be refused that besides rheumatic pains, other pains also often arise from articulation.

These however generally entirely confined to joint.

While on other hand those of rheumatic kind [propelled] from thence in tract of muscles

From this circumstance chiefly it is that by rheumatic affection motion impeded.

Whereas in other cases if is impeded cause obvious.

And very rarely if ever that affection of more than one joint at time.

While on contrary as case with present patient in Rheumatism commonly affection of [illegible]

Here also as in definition of Dr Cullen patients disease consisted entirely in affection of larger [joints]

A circumstance by which perhaps more than any other pains of Rheumatism distinguished from those of Gout.

And although not [a] universal yet a general occurrence.

In all these particulars then present affection very exact resemblance to definition of Rheumatism

But to be observed that besides [these] other symptoms also introduced into [definition].

And here resemblance wanting.

Besides all circumstances already mentioned two other enter [definition] of Dr Cullen.

Remarked that Rheumatism an affection commonly at least arising from obvious [external] cause

And this also one of chief symptoms by which to be distinguished from gout

Especially in cases where other circumstances giving doubt as to judgement which should form from seat

If however disease here affect of obvious accident escaped attention of patient.

But besides that this might readily happen, to be observed that in definition alluded to is mentioned merely as common occurrence.

Must however be allowed that gives slight difficulty.

But if from this any [disagreement] with definition still greater from another circumstance.

These disease ranked in class of Pyrexia & under order of Phlegmatic.

And besides this arrangement pyrexia introduced as constant symptom of the affection.

With our patient however no reason for concluding that pain arises from active inflammation

[Most] of those symptoms characterising that state here evidently absent.

No swelling obvious redness or sense of heat.

But if [suspicion] of absence of phlegm from these particulars, certainly from many others, of absence of Pyrexia.

Here not smallest appearance of any febrile affection.

Must either therefore look upon introduction of pyrexia into definition as [improper] or conclude that our patient not affected with Rheumatism

That Rheumatism in certain state with [greater] propriety ranked among inflammatory diseases cannot be denied.

Unquestionably evidence of inflammation both in causes symptom & cure.

While at same time febrile affection present also to very high degree.

In this state however disease seldom continues for many weeks.

And with termination of fever all indications of inflammatory affection at same time ceased.

Still however pains occupying same place, and if not similar in nature are so at least with regard to course in which propagated.

Such pains not like formerly [constant] & severe while obvious local affection continues

But suffer very considerable remissions & returns chiefly on particular accidents.

Particularly apt to be excited by change of temperature whether by action of heat or cold & by motion.

In such a state constitutes the affection [which] in most practical systems known by title of chronic rheumatism.

And consider it as it were as more advantageous stage of same affection.

That complaint now described most commonly consequence of former cannot be [refused].

Yet in other cases such pains arise where no evidence of active inflammation or acute fever has preceded.

And whether consequence of former or not can be little doubt that whatever [source] of symptoms in other particulars nature of affection essentially different.

This not more manifest from diversity in particulars already mentioned than from cure.

May be question then how far acute & chronic Rheumatism should not in reality be considered as different genera of disease.

From every circumstance attending former reason to conclude that pain & indeed all other symptoms proceed from inflammatory affection of parts.

While in latter equal reason for presuming that pain which occurs is consequence of spasms.

And that this again immediate effect of atonic state both of muscular fibres & vessels of part whether induced by preceding inflammation or by any other cause.

If however this opinion as to nature of affection well founded while term Rheumatism appropriate to former had [better] distinguish [latter] by some [appellation] [expressing] of pain at joints or rather of extremity of muscles or ligaments

Such for example as arthralgia desmalgia etc.

But after numerous terms invented by late nosologists as expressing names of diseases will naturally be thought that farther multiplication of terms to be avoided.

And must own that think should in general be endeavour rather to [rebranch] than to increase number of genera terms.

But whether here introduce new term or not of great consequence that should attend to distinctions.

In many cases however this extremely difficult.

Which indeed necessarily consequence of one being so frequently sequel of other.

From this must unavoidably happen that during part of progression hard to say to which head ought rather to be referred.

In extremes however from circumstances already mentioned distinction sufficiently [easy].

For most part may be done by [continuation] of disease alone.

Strong presumption at least that of inflammatory kind when but of short duration.

And that of atonic when as in instance before has continued for months.

But as in some [cases] atonic condition may occur in first instance & in others inflammation may be excited at late period [farther] necessary to have [diagnostic] in symptoms.

May chiefly infer presence of latter where pain not long fixed to particular part but suddenly moving from one joint to another.

Where when attacks with greatest severity at same time attended with obvious swelling.

Where with this swelling there occurs evident redness of pained parts.

But above all where pain attended with quickness of pulse, heat, thirst, & other febrile symptoms.

May chiefly conclude case to be atonic or pain not from inflammation but spasms when symptoms already mentioned swelling redness & fever are absent.

When pains do not as it were occur spontaneously but immediately excited by some particular cause heat, cold, or motion.

But above all when pained parts do not retain heat of rest of system. When cannot be made to sweat & when assume wasted appearance.

In case before us have if not all at least by much greater part of these symptoms.

And thus then may be considered as affording example of pure chronic rheumatism

Or of that affection not in inflamed but atonic state.

Thus then have given opinion as to name & nature of this patients disease when came first under care

If had been at that time to deliver sentiments respecting termination should I own have given it as opinion that disease would prove very tedious

Many circumstances in case by no means favourable.

Well known that after continuation for some length of time becomes often a very obstinate affection.

In place merely of state of atonia there occurs even insensibility of part.

And what takes place at first under diminishment of motion ends in total loss.

With our patient before came under care disease had subsisted to considerable degree for space of several months.

And besides this two other particulars from which reason to dread course already mentioned.

viz Age of patient & obstinacy with which affection resisted remedies already employed.

Patient had already nearly arrived at fiftieth year.

And while in advanced age less disposition to inflammation greater to all affections depending on want of tone & sensibility.

This manifested, even where no [proper] [illegible] in shaking of head & hands & other unsteady motions

From this then to be concluded that at least an unfavourable period for cure.

And that this in reality case abundantly appeared from disease having resisted many of most powerful remedies as administered by skilful practitioners.

Must own therefore was apprehensive that during patients continuing under care disease would be aggravated.

And had very little expectation that in short time should have been able to dismiss him free from complaint.

Event however in this respect much more favourable than expectation.

And now only remains to consider how far measures to which here directed had any share in producing that affection.

From what said of nature of affection may be concluded that here general principles of cure must be very different from what are in acute rheumatism.

In many respects may even be considered as opposite.

In that case consider morbid state to be combatted as being merely an inflammatory affection.

Hence then requires same means of cure as in other inflammatory affections.

But particularly brought about by bloodletting & by profuse sweating.

These in some instances indeed may to certain extent be admissible in atonic rheumatism.

But to by much greater number of cases are by no means suited.

On contrary great reason to suspect that very profuse bloodletting used to overcome inflammatory state often means of inducing atonic.

Of this on other hand to expect cure by restoring to parts natural sensibility & due vigour.

For with atonia at earlier periods at least rather [deprived] than diminished sensibility.

And from removal of this parts less apt to be subjected to those spasmodic affections from which suppose pain principally to arise.

Hence then chiefly to look for cure from medicine altering condition of sensibility and augmenting tone.

All medicines altering condition of sensibility referred to two great classes.

Those viz of Stimulant & Sedative.

In last unquestionably most immediate means of counteracting morbid sensibility.

Effect however unless [illegible] to very great extent for most part temporary only.

While afterwards affection rather augmented.

Hence then preferable in general to be given to stimulate.

By these may induce both alteration in condition of Nervous fluid at part & in common between affected part & [sensor].

Thus in as far as tone depends on state of nervous power means of restoring it.

And here conceive them to operate on same principle as in paralytic affections to which [indeed] atonic state of Rheumatism may be conceived as being as it were an [illegible]

Appears then on what footing stimulation calculated for this affection as depending on condition of nervous [inflammation] at part.

But here atonic state connected with peculiar laxity both of vessels in part & of moving fibres.

And former in particular often induced by degree to which [streaked] during preceding inflammation.

Is then on this ground that while [main] benefit from stimulation not less from such articles as tend to brace parts

And thus whether by action on them as simple or as moving fibres natural condition restored.

These then general principles on which I imagine that can expect to overcome this affection by use of stimulants & tonics.

To be observed however that while these well adapted to Rheumatism in purely atonic state must necessarily be prejudicial while inflammatory tendency remains.

Hence then while disease in progression from one state to other greatest [illegible] respecting treatment.

And then chiefly to be overcome by such medicines as combine some degree of evacuation with stimulatory power.

Have already however observed that consider disease of this patient when came under care as having arrived at purely chronic state

Imagined therefore that hope of success alone from stimulants & tonics.

And from circumstances already pointed out expectations from these by no means high.

Some of them particularly cold bathing one of most powerful tonics had here already been tried to no purpose.

Besides this however several others both externally & internally from which some chance

And particularly among tribe of stimulants.

Externally to pained parts could have recourse to application with Camphor Oil of Turpentine & Vitriol acid

Internally to Mercury, Mezereon Aconite. Arnica and the like.

Had however I own greatest hopes from use of Electricity.

And was intention in this case, to have given fair trial pushing to utmost extent which patient could bear.

But previous to beginning use resolved to see what in this case could be [derived] from volatile Elixir of Guaiacum.

A remedy which of late years chiefly on authority of Dr Dawson of London [have] used in many instances.

And I think with very great success.

From what have seen however am now inclined to think that much more depends upon menstruum than on Guaiacum.

For here menstruum employed is Spirit of Sal Ammoniala.

And this which well known to be very powerful stimulant often given to great extent.

But on whatever activity may principally depend obvious effects in general are slight degree of Diaphoresis & catharsis.

Hence then may be considered as in some measure combining evacuation with stimulating powers.

And thus suited for intermittent cases.

With present patient produced obvious affect in both ways already mentioned but to very moderate degree.

From commencement of use however pains very greatly diminished.

And from no very long continuation even entirely freed from them.

In this situation as he himself thought farther attendance unnecessary had no objection to his being dismissed.

And am in hopes that unless from exposure to cold or some other existing cause, aid which has obtained may be permanent

Yet should he ever return again subjected to complaint will still be disposed to consider present as strong instance of efficacy of medicine.

And then perhaps before employing any other again recourse to it.

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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.