DEP/DUA/1/19/09 (Normalised version)

Elizabeth Gray

(1778-1779)

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Elizabeth Gray.

Case of this patient though less complicated than that of last yet not altogether to be reckoned a simple affection.

And in some respects symptoms of a similar nature.

At least principle part of affection also consists in severe pains of joints.

Here however as far at least as account of patient to be relied upon no suspicion of Lues.

May perhaps however occur as matter of doubt whether affection Rheumatic or Gouty.

Especially when know, how nearly in many respects these two diseases resemble each other.

And as pain in present case principally affects neighbourhood of foot which at least most common seat of gout.

But however difficult diagnosis may be in some instances several circumstances in present which afford high probability if not absolute certainly respecting affection.

Presumption of Rheumatism both from age & sex of patient.

Is a female who although sometimes are at least but rarely subjected to gout

Is not passed that period of life [most] addicted to Rheumatism nor arrived at age when gout most common.

Pain here affects several joints at same time with manifest disease as appears from swelling.

This however very rarely the case with gout.

But what of all others most decisive circumstance in present case is cause from which the affection arose.

While patient as far as could learn had no hereditary title to gout, was not of that rank in life from which disposition most readily acquired.

Was at same time in a situation much exposed to cause by which of all others Rheumatism most frequently induced cold

And accordingly are told that from manifest action of this cause to high degree present case distinctly marked to originate.

With regard then to nature of pains can hardly think that here any room for doubt.

And this to be considered as principle part if not whole of complaint.

Besides this indeed will remark in case that for four months menses have been [absent]

And every reason to presume that this rather occurs as diseased condition, than from any of those causes in consequences of which should be naturally wanting.

But still may occur either as an idiopathic or symptomatic effect.

If view it as of former kind must esteem it a separate disease.

But if consider it as of latter is to be reckoned only a part of her Rheumatic affection

And must own that am inclined to this opinion.

Not less certain that obstruction of menses causes many affections than that is consequence of many others.

And indeed for proper symptoms of this as well as of other discharge general health of system is in some measure requisite.

Here however obstruction did not commence till several months after pains very severe

Since obstruction has taken place no symptoms have supervened which can be attributed to that cause.

From these circumstances then may readily look upon it as merely consequence of general state of system which pains have induced.

And this supposition the more probable when consider that patient has now arrived at that period of life when menstrual discharge affected by slight accidents.

From this idea then of this part of affection becomes hardly an objective either in Prognosis or Practice.

Am inclined to think that by removal of other part of complaint & restoration of general health will soon be restored.

At least, unless from this accident has entirely left patient in which [case] any means for restoration highly improper as want will be product of no inconvenience.

As to other & more important part of complaint cannot speak with very great confidence respecting conclusion.

Rheumatism unquestionably one of those affections which of itself seldom fatal.

And with our patient has not [hitherto] induced any symptoms so far affecting constitution that have any reason speedily at least to apprehend such a termination.

On contrary disease so far alleviated for present as even gives hopes that patient may soon be in such [situation] as to require no farther aid at this place.

But here to be observed that disease of our patient has already continued for space [almost] of 12 months almost without interruption.

After such continuation although diseased parts may still at times be subjected to inflammation yet must be principally [suspected] from atonic state induced.

But after this condition has taken place is not only difficult to remove but renewed by even most slight causes.

Reason therefore to dread that present relief which patient has obtained will not be permanent.

And will not surprise me to see her soon again from any slight accident as bad as has ever hitherto been.

Am however in hopes that from proper management & [medicine] disease may be so far combatted that for present at least may dismiss her free from complaint.

At same time present season of the year when may look for sudden vicissitudes of temperature more unfavourable than [summer] or even than steady cold weather in winter

This inconvenience however to be combated as far as possible by proper treatment

With regard to general plan of treatment have already observed that think practice to be totally conducted on supposition of affection being purely of Rheumatic kind.

This disease however well known at different stages to require very different & in some measures even very opposite practices.

During inflamed state resolution most speedily & affectively to be obtained by free use of [evacuation] particularly by bloodletting & Sudorifics

But when after inflammation gone disease supported by relaxed & atonic condition of parts must remove it by restoration to these natural vigour & sensibility.

Hence then, at that period chiefly to be looked for from use of tonics.

And is in this state that benefit to be derived from Peruvian Bark & cold bathing.

From [these], in condition of Rheumatism now described under prudent management have often I think seen best effects.

Would by no means however represent them as always suited to the disease after marks active inflammation disappear.

That is local swelling & redness [attended] with fever

Between this a pure atonic state these [intervals] [intermit] condition in some measure partaking of nature of both.

And after atonia has taken place there is from [illegible] [illegible] to state of Paralysis attended not merely with loss of tone but with wasting of moving solids.

These then require remedies operating in still different manner from any of former.

And are to be combated by articles combining in some measure an evacuatory power with [those] of peculiar stimulus.

On these principles it is that benefits here to be expected from Guaiacum Mercurial Electuary, warm bathing & many other articles recommended in Rheumatism cases.

These then general outlines of my sentiments respecting practice in this affection.

With regard to case before us consider it as having arrived at second stage now described.

After having subsisted for twelve months could not possibly consider it as so long supported by uniformly continued state of active inflammation.

While at same time symptoms still remained indicating disposition to this.

For as such must consider both feverish symptoms & transitory swellings of joints to which patient subjected since came under our care.

These considerations then determined me to make trial in this case of Rhododendron an article of affects of which have already spoken.

Besides opinion which I have adopted respecting it from account given by Dr Guthrie & from case of Mary Burnet have met also with some other facts which incline me to think favourably of it.

With a view of having as much effects with as little expense as possible directed it at first to be employed in substance.

When taken to extent of gr V [m] & [vesp] had in her opinion some effect as exciting gripes

This however an affect which in no other instances have heard mentioned as resulting from it.

And if was really the cause of gripes, that was not from stimulation to intestines as cathartic, appeared from belly being very bound.

Reckon it much more probable that gripes arose from constipation induced from some other cause, than from the Rhododendron

But while in present instance had no other obvious operation, pains with which patient had been affected were nothing mitigated.

In this situation, while with view to Rheumatism increased dose of Rhododendron [ordered] also an aloetic pill as means of obviating costiveness

Without use of this purgative however discharge by belly returned to natural state

And from gripes then disappearing was [rendered] still more probable that [these] consequences of costiveness.

But still increasing dose of other medicines had no affect as removing pains.

From this then led to vary form & gave it in that of watery infusion the state in which employed with success by the Siberians.

From commencement of use pains were somewhat mitigated.

But this relief not permanent for very week after had some return.

Since that however have again very considerably diminished.

But in this fluctuating state can hardly say that freedom from pain which patient enjoyed at last report was to be ascribed to this medicine.

Cannot be here contended that benefits derived from it either very manifest or very considerable.

Yet for my own part am inclined to think that was of service.

And can at least venture to assert that was not product of any bad affects.

But after trial for so many weeks thought it unnecessary to persist farther in use.

In state of patient however at that time did not think that measures to be immediately discontinued.

For without means of counteracting affection thought that great reason to dread return

And of all remedies which have ever used against chronic Rheumatism have in my own practice found none more generally successful.

Although at same time can by no means agree with an eminent London Practitioner who asserts that has never found any other medicine succeed & has never found Calomel to fail.

In those circumstances had recourse to a practice which have not before tried.

Use viz of Mercury immediately applied to affected joints

Mercury indeed has long been a very common remedy in Rheumatic affections particularly in very last stages when tendency to Paralysis.

Then however exhibited only internally.

And intended to act on affected parts as affecting system in general.

Here however had immediately recourse to friction on affected parts.

A practice which am informed now [employed] frequently at London & said to be attended with best effects.

As have already [observed], for my own part have hitherto had no experience of it.

But must own from theory am inclined to think favourably of it.

And disposed to imagine that may reap from it full advantage of Mercury taken internally without same inconvenience.

From this then led to give it trial in present instance.

And after disease for present at least so far overcome use it with some hopes of success.

If however proves ineffectual many other measures to which may have recourse.

Particularly, to use of Elixir of Guaiacum.

Of which I own have in this affection very high opinion.

If this also fails may recommend Electricity Peruvian Bark or Cold Bathing.

But in this must be directed by circumstances of disease at time.

Which probably will be in some respects at least different from what are at present.