DEP/DUA/1/17/04 (Normalised version)

Margaret Gray

(1778)

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Margaret Gray.

Case of this patient evidently of complicated nature.

And while some parts of affection at time when came under our care very manifest, others with regard to which had from beginning & still have very great difficulty.

This particularly the case with most urgent part of complaint.

Pain viz which from shoulder of right arm shoots downwards in such manner as to affect whole of that limb.

Here according to description given us pains chiefly seated in joint.

And these neither swelling inflammation nor any other appearance to which can be referred as cause.

Although evident morbid appearance wanting yet not impossible that may depend on some local & topical cause.

While however no indication of such must be led rather to conjecture that is to be accounted for on some other footing.

And that depends more on state of nerves themselves than on any [particular] cause giving painful impression to these

For hold that all pain must ultimately depend on certain impression communicated by nerves to sensor.

And that such must ultimately be referred to one of two general sources.

Either cause acting on nerves or condition of nerves acted upon

When therefore no evidence of former, that is peculiar cause, whether in way of [chance] or mechanical stimulation, of distension, contraction or like naturally led to latter supposition.

And must ascribe pain to peculiar state of extremity of nerves in part to which referred.

Such consider to be very generally the case in that disease known by title of chronic or perhaps as many with greater propriety be styled the atonic rheumatism.

May naturally then occur as question how far pain here is of that kind.

In favour of this supposition several [arguments] may be adduced

Yet at same time if really [chronic] rheumatism is at least with peculiar circumstances

This however will more particularly [appear] from examination of different arguments for & against such a supposition.

Is somewhat at least in favour of supposition of Rheumatism that pain situated in one of large joints.

In these indeed cannot be refused that pain may arise from other causes.

Particularly sprains or the like.

But well known that of all parts of the system the large joints more especially seat of Rheumatic affections.

Hence when other causes not obvious this at least more readily suspected.

Here also to be observed that pain chiefly seated in joints propagated in course of muscles

A circumstance not always occurring in rheumatism nor entirely peculiar to it.

Yet so frequent & so much peculiarity that enters best definitions.

And particularly used as mark for distinguishing rheumatism from pains with which in many other respects agrees those viz from Gout.

Taken therefore in conjunction with other circumstances serves at least to corroborate supposition.

And besides what already mentioned of situation of pain may mention as [illegible] increase of this pain on motion.

This indeed it must be allowed, takes place also, with pain of joints from other causes.

Particularly when occurs not merely as consequence of white swelling or other cause giving obvious disease but when has proceeded from sprain.

This case however excepted is but very rarely at least that pain on motion of joint continues for such length of time, from any other cause except Rheumatism.

When therefore consider that here patient not exposed to any cause giving spasms serves at least strengthen presumption.

But besides these a circumstance on which perhaps still more to be rested is the augmented severity of pain from heat in bed.

This indeed not a particular which in all stages & every instance of Rheumatism uniformly occurs.

But while some other particulars mentioned in common to pain from Rheumatism & from other causes this in great measure peculiar to Rheumatic affections.

And when occurring may I apprehend in some degree at least be considered as [pathognomonic].

Not here our business to inquire either into causes on which depends or at what stages of the disease more especially [occurs]

Sufficient to give presumption of Rheumatism that such an occurrence manifestly does take place

May only in general way observe that seldom occurs during first period of inflammatory stage

And while some disposed to consider it as peculiar to state purely chronic others look upon it as characteristic of intermittent state between the acute & chronic.

Perhaps of the two this most frequently the case.

Yet am fully persuaded that may occur also where Rheumatism advanced to chronic state

And indeed if present instance Rheumatic affection have here example of it.

For in diminished heat have mark of chronic condition advanced to even greater height.

Lastly as farther circumstance in favour of Rheumatism may mention account given of progress of affection.

Are informed in history of case that this pain of no less than four years [continuation].

And that then commenced with pain not only in shoulder now affected but also in most other large joints.

Particularly in knees & ankles.

From this description then little doubt that at least commenced as Rheumatism.

And although chronic Rheumatism may occur without [acute] having preceded yet unquestionable that most frequently begins in that state.

From all these [arguments] then taken [together] grounds for presumption that pain here of the Rheumatic kind.

And must own should have little difficulty in giving this opinion with some degree of confidence were there not other circumstances which in some measure occur as objections to the supposition.

Of these then shall [next] take short view.

Here then to be observed that pain in case of our patient fixed to particular joint.

This however very rarely the case with chronic Rheumatism.

Especially in those instances where follows as immediate [sequela] of acute.

And where as was case with our patient this acute Rheumatism extended over whole system.

Fixed & partial situation then must occur as some objection to supposition of [pain] being [here] of Rheumatic kind.

To this may perhaps also add place in which situated.

Had affection been here in hip joint long continued would have been less surprising

For hold that genera of disease which have obtained name of Lumbago. Ischias etc are no other than Rheumatic affections.

And under these forms have frequently occasion to observe disease remains for long time with great obstinacy.

That large joints of superior as well as inferior extremities are frequently also seat of Rheumatism cannot be denied.

Yet may without hesitation [affirm] that instances of such obstinate pain at joint of [illegible] very rarely to be met with.

And if present entirely Rheumatism must add that is only instance I have ever met with where severe pain in shoulder of such continuation

To these peculiarities in present case may add as third constancy & uniformity of pain.

Are indeed told that pain aggravated by motion.

And that particularly severe during night.

From these circumstances have drawn argument in favour of Rheumatism.

But besides being varied from these causes Rheumatism also to very great degree affected by state of weather.

Such varieties particularly manifested when [assumes] chronic state.

In so much that from returning pain greatest part of Rheumatic patients can even [foretell] changes.

With our patient however no circumstance of this nature has ever been observed.

And may therefore justly consider it if not as objection to Rheumatism at least as [peculiarity].

To these circumstances may perhaps add as still farther peculiarity the continuation of free motion

Not indeed same tendency to collection of cretaceous matter about joint as in cases of Gout.

Yet here also even such after disease of long continuation frequently do occur.

And where these do not occur yet with atonic state of muscular fibres rigidity in ligaments takes place.

From either one or other however motion cannot fail to become difficult.

And this should naturally have expected even at much earlier period of disease.

Lastly some objections even from insensibility & coldness.

Is indeed true that these common symptoms of Rheumatism in most chronic condition.

And that chronic Rheumatism often even degenerates into Paralysis.

Yet loss of heat & sense rather to be viewed as proper paralysis than Rheumatic symptoms

And pure paralysis in incipient state not unfrequently accompanied with even very acute pains.

From these circumstances then, some room to doubt as to nature of affection.

And give grounds for suspicion that may be pure paralysis.

To this indeed must at same time be observed that many objections occur.

Particularly that pain ushering in paralysis rather of transitory than constant nature.

And present merely enumerated among circumstances giving some grounds for suspicion or [showing] peculiarity.

Upon whole then appears that from several circumstances some difficulty as to this part of patients complaint.

Yet cannot help thinking that from arguments first adduced supposition of its being a Rheumatic affection the most probable.

And to me seems no unreasonable supposition to explain peculiarity here from accident mentioned in case

Stroke viz received on right shoulder from fall at time of Rheumatism.

From sensible extremities of nerves being then in morbid state no doubt that from such injury greater pain excited than at any other time.

And although not a general occurrence yet may conceive that from injury in this manner even permanent morbid condition in sensible extremities may occur.

Thus far then have delivered sentiments respecting first & what must now at least view as principle part of affection.

That this affection not attended with symptoms of Gonorrhoea.

That [accommodated] with common concomitant of Leucorrhoea pain of loin & back.

Besides this however present patient affected also with other complaints.

At least this to no inconsiderable degree the case when came under our care.

And although have for some time disappeared yet not improbable that may soon again return.

These complaints at same time such as constitute an affection often very obstinate & very troublesome with women.

What I allude to is the viscid [mucous] discharge from the Vagina.

This need hardly observe is principle symptom occurring in Leucorrhoea.

Takes place indeed also in other affections particularly in Gonorrhoea.

And distinction between the two when [reason] to suspect veracity of patient often [extremely] doubtful.

In present case however several concurring circumstances which can leave little grounds for doubt.

When consider that not principle disease for which patient came under care of different nature

That evidently connected with menstrual flux

That had continued for much longer time in one state than Gonorrhoea ever known to do without changing form.

And lastly that since came under our care had yielded to medicines used with [intention] of removal of Leucorrhoea have if not certain at least probable evidence of that affection.

Viewing then different parts of patients disease as being of nature now mentioned next come to be questioned how far in any degree [communicate] with each other.

That this may be the case not improper

Yet must own can discover no circumstances indicating connection.

And when consider that diseases commenced at different times.

That independently of each other subjected to changes.

That while at present one has almost [entirely] ceased other has even increased in violence.

And that rheumatism not remarked by any authority as product of Leucorrhoea can I apprehend have little difficulty in pronouncing that are totally unconnected.

After this view of different parts of affection to which patient subjected when came under our care & to which indeed still subjected next to speak of Prognosis.

And here can with no degree of confidence give favourable opinion.

One part of her complaint indeed, as have already observed, has either spontaneously ceased or yielded to medicines employed.

Yet even of this can by no means trust that has obtained permanent or complete cure.

While on other hand affection of arm since came under our care rather aggravated

And that too notwithstanding employment of various remedies which on suppositions [mentioned] might be supposed to have had influence in removal of it.

When to this circumstance add [continuation] which has already had can have little hopes of recovery.

Yet must at same time observe that nothing which threatens imminent danger.

And should consider it as singular were patient ever to fall victim to this complaint.

Yet although hold that neither to be considered as a dangerous disease nor to be easily cured, am far from asserting that will continue statically in present situation.

Look upon it as most probable that pain will be soon less severe, but that same time sensibility also will diminish.

And shall not be surprised to find it terminating in total Paralysis.

While however patient continues to attend us must not only take what measures we can to prevent this but also to removal of affection.

Come next then to remarks on practice.

In this have in part had in view both affections.

But by much greatest number of remedies employed, directed against pain of shoulder.

This however will more particularly appear when come to speak of them in order in which exhibited

Began by directing for patient a mixture in which united simple Elixir of Guaiacum with Tincture of Cantharides.

To these also added Simple Syrup & common water

But with no other intention than to give formulae.

Was on two former articles that consider efficacy of medicine as solely resting.

First the Guaiacum meant solely with view to affection of arm.

Need not observe that under different forms has long been used with great [illegible] in Rheumatic cases.

And perhaps no forms more efficacious than those in which united with Spirit Menstruum.

Used in solid state from [illegible] [illegible] of resinous, than gummy [nature], not [soluble] in Stomach.

And from same reason with most watery menstruums cannot be united without much difficulty

Where Gum itself attempted to be conjoined to water, is rather diffused by aid of viscid or mucilage matters, than any thing else.

In Decoction Lignum indeed virtues of Guaiacum extracted by mere watery menstruum.

But there, proportion of Guaiacum entering it but very inconsiderable.

And probably to be principally considered as mere diluent.

Of those preparations of Guaiacum formed by spirit menstruum two enter Pharmacopoeia¹ which in frequent use.

The simple & Volatile Elixir.

Of late, latter highly extoled in Rheumatism by Dr Dawson of London.

And in my own practice have in many instances used it with great advantage

Still however consider it as matter of doubt whether advantage reaped from that formula not rather to be ascribed to menstruum than to Guaiacum

And unquestionably in cases where stimulation requisite advantage may be expected from this.

Especially when exhibited to great extent to which now given.

And accordingly in some instances have seen I think manifest advantage from Volatile Aromatic Spirits.

But in others also, think that have derived good effects from Simple Elixir.

With trial of this therefore resolved to begin

Especially as imagine that less risk of any bad affects, than with respect to other parts of patients complaint.

With use of Guaiacum however with view to Leucorrhoea joined small proportion of Tincture Cantharides.

A remedy of which some in this affection, have very high opinion.

And which supposed to operate as [peculiar] stimulant to uterus.

That this may be the case do not deny.

Yet know no particular phaenomena by which confirmed.

And from my own experience can say very little of its efficacy.

But whatever may be power must yet admit that with our patient had no proper trial.

And on recurrence of Fluor Albus to considerable extent had recourse to a medicine with regard to affects of which, was less doubt.

That was the use of Alum.

This one of those states in which the vitriol acid as an astringent may be exhibited with not least advantage.

And considering this disease to be generally at least affects of relaxation hold that no remedy more powerful than astringents.

Accordingly in present instance although pushed to no very great extent seemed to be product of best affects.

And after last menstrual flow not even slightest return of it.

Would not however from this assert [thus] to be considered as completely removed.

But should it again return may reasonably entertain hopes of advantage from remedy already successfully employed.

Have by no means however been equally successful in combating other & more material [form] of complaint.

With this view before commencement of present course besides remedies already mentioned, had tried Electricity Blister, & Volatile Elixir of Guaiacum [without] affect.

And when introduced into present [register]² had put her on use of Mercurial Pills.

From these however pushed even to extent of touching mouth, no manifest advantage.

And must own am now very doubtful whether shall be able to be of any service.

Still however some practices, which may at least be tried.

And among these have now directed one to which in similar instances have not before had recourse.

That is the Extract of Hyoscyamus

Need not observe that this remedy first introduced into practice by Dr Stork of Vienna

And by him extolled as of highest utility in many different affections.

In hands of other practitioners power has not been found product of same benefits.

Yet from many concurrent testimonies appears to considerable degree to exert sedative influence.

And at same time to produce this affect without binding belly.

But while exerts influence as narcotic vegetable, is supposed as well as cicuta & some others of same tribe to be of penetrating & resolving nature.

On these principles then have been induced to give trial in present case.

And that rather on authority of a Gentleman lately a practitioner in New England who informs me that in cases of obstructive pains has often employed it with very great success than from observations of Dr Stork.

Dr Moffatt, the gentleman to whom I allude inclined to think that extract of Hyoscyamus prepared in a climate such as that of New England may be more powerful than what prepared in this country.

And in some measure to determine this by trial has sent me small parcel of extract prepared [there].

Is his extract which at present using with this patient.

And if find it product of no bad affects shall give it as fair trial as am able.

Should it succeed after attempts already abortive must own will give me much higher opinion of this medicine than have before had

Should it fail am greatly at loss to think what can next try with any prospect of success.

Have thought however of at least trying how far full dose of anodyne will have influence as giving temporary alleviation of pain.

And if internal use of little service may see what can be derived from it externally

May have also recourse externally to stimulating ointment.

Particularly to oil of Turpentine & Vitriol acid in this form.

May again employ Mercury either for friction externally or in some other form internally

And must indeed observe that know few medicines more efficacious in obstinate Rheumatism cases than Calomel.

Yet after all very apprehensive that shall dismiss patient not better than found her.

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Explanatory notes:

1) An official publication containing a list of medicinal drugs with their effects and directions for their use. The Royal College of Physicians of Edinburgh's Pharmacopoeia was first published in 1699.

2) References are made throughout the case notes to a dispensary patient register. However, no evidence has been found that this register survives.