DEP/DUA/1/23/09 (Normalised version)

John Coarser

(1780)

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John Coarser.

Case of this patient of doubtful nature

But not without some threatening appearance.

Principle complaint severe pain of side

Has now continued with obstinacy & fixed to particular part for space of 6 months.

Grounds therefore for presuming some fixed cause

Such continuation indeed not uncommon for affections of rheumatic kind.

And although these principally confined to joints, yet affect also attack of muscles at other parts.

Among these not unfrequently seated in intercostal.

And here also greater probability as extended to shoulder.

But if such pain in some instances from bounder of thorax still more frequently from internal parts.

Particularly observed to arise from affection of lungs, or surrounding membrane pleurisy

And not only from inflammation of these, as in some acute affections but also from suppuration.

Hence fixed pain attendant of abscess of lungs or membrane whether under form of Vomica or Empyema.

And of this here the rather [presumed] from three circumstances.

Cough viz State of pulse & Respiration.

Former of these has continued for equal length of time with other symptoms

May indeed, it is it true, arise from variety of causes.

Is consequence of every irritation to lungs.

And more frequently indeed, of other irritations such as that of mucus, than of any fixed cause.

But among others may be consequence also of tubercule & vomica.

And of this here probably the rather as cannot ascribe it to mucus.

For unless in morning when some accumulation during night, cough not attended with expectoration.

With other circumstances then frequency severity & dry cough gives countenance to cause from which have suggested that pain may arise.

And this I think still farther corroborated by state of pulse.

For here to be observed that very considerably quickened above natural standing.

In so much that 108 pulses in minute.

With this celerity indeed, cannot be said that patient subjected to hectic fever.

For none of those fits of cold or heat by which marked.

Yet quickness shows constant irritation

And perhaps even may add debility & irritable state

Hence then also favours supposition.

But if presumption from cough & pulse, still more from state of respiration.

To these three might add also another circumstance

Cause viz to which complaint [illegible]

Is ascribed to action of cold.

This indeed a cause which may produce great variety of affections

And therefore little foundation for positive conclusion.

Yet may at least say that a probable cause of affection here [supported].

And certainly affords no contradiction to supposition.

This are told interrupted or short, & laborious.

Circumstances serving to show that that free motion of lungs impeded.

And indeed more frequently consequence of space which should be occupied by air, being filled with other matters, than from any other cause.

Upon whole then may I think conclude that abscess of considerable size, either in lungs or surrounding membrane is a cause from which all symptoms, to which patient at present subjected may be explained.

Still however cannot speak with great confidence.

For circumstances which alone can give certain evidence still wanting.

Actual discharge viz of purulent matter.

Hence then can at present suggest it only as supposition, which to me at present appears more probable than any other.

Supposing such vomica or abscess to exist yet still would not at present say that patient subjected to Phthisis.

For consider not merely possibility of purulent absorption from lungs but actual affects as producing hectic fever, to be essential constituents.

And such as far at least as have been able to learn, has not yet taken place.

This however not to be considered as any objection to supposition.

For in every other part of system can observe large collection of purulent matter without hectic.

And in many cases is only in consequence of rupture & of accession of external air, that hectic [induced]

This particularly manifested in case of Psoas abscess – under muscle at upper part of thigh

These though certainly of large collection of matter, yet may subsist for considerable time [without] any hectic symptoms

But soon after opening, hectic occurs, which in general fatal.

How occurrence from admission of air to be explained matter of some difficulty.

Yet two circumstances may be mentioned which seem to operate & which probably principle [concerned].

Action of air, from stimulating extremity of vessels, probably affect of increased absorption.

Thus greater quantity of purulent matter taken up than before.

But besides this probably also still greater influence as producing [different] matter.

For in place of thick, white coloured pus, at first discharged soon assumes more thin bloody & sanies appearance.

Hence then both from increase in quantity of absorption, & change of matter hectic accession, may be induced.

Thus may understand why in present case, where abscess if exists yet entire, are wanting.

Although therefore patient not at present subjected to Phthisis yet if supposition well founded in greatest danger of it.

Hence then when consider nature of that disease, on idea of present affection, prognosis cannot be favourable.

If Phthisis shall occur most probably will terminate in death.

But may yet observe, that Phthisis here to be expected of the purulent or ulcerous [kind]

Which although more dangerous than catarrhal, is at least less certainly fatal than tuberculous.

Besides although abscess already formed yet purulent matter collected may be removed without rupture.

And hence without accession of air, [vitiated] matter.

For well known that [content] of abscess of considerable size, taken up entirely by [absence]

Thus then even supposing conjecture well founded case not desperate.

And if as it first hinted shall turn out that pain merely of Rheumatic kind not even dangerous.

Yet upon whole, though at present nothing very urgent am disposed to fear the worst

With respect to cure from opinion which at present inclined to adopt little I think now to be done.

Supposing abscess to exist cure of all symptoms to be effected by removal of pus, & by coalescence or heating of [containing] parts.

Latter of these entirely dependent on operation of system.

And probably would soon follow [could] former be affected.

This again to be brought about either by artificial or natural outlets.

In case before us, no circumstances indicating any probability of discharge externally.

Even from cavity of chest indeed purulent matter discharged from external [opening]

Yet very rarely that anything in this way can be attempted unless when some mark in integumentary [directing] to place where opening to be made.

But here in state of uncertainty such an operation as [illegible] of Thorax not to be dreamt of.

And in as far as to be discharged by artificial opening, can be only, by rupture into air vesicles of lungs & consequential expectoration.

Such rupture often happens in consequence of mere distension & erosion.

And when this not of itself sufficient, may be forwarded by any circumstances giving concussion or agitation of system.

Often by such artificial openings alone that discharge of abscess can be obtained.

But when can be entirely taken up by absorption & thrown off by excretion from what already said must appear [pressure] made.

For this freed from danger & inconvenience arising from accession of air.

In instance before us then, was inclined to look upon it, as [preferable] practice to see what could be done in this latter way.

And during measures for this purpose, imagined that circumstances might occur giving higher probability.

Hence then could with greater confidence afterwards attempt to aid rupture, by means giving concussion.

These intentions will explain practice already employed & which have afterwards in view unless change opinion as to nature of disease

Began treatment of case by application of blister to pained parts

From this on different grounds expected some advantage.

Supposing affection not of nature suspicious but entirely of Rheumatic kind, still a very applicable remedy.

For well known, that in different states of that affection product of advantage.

And in this case perhaps even more serviceable than if conjecture well founded.

Here however directed as means of promoting absorption on supposition of abscess.

As answering this intention operates on two footings.

Both viz by evacuating & stimulating power

Well known that increase of absorption is effect of evacuants in general.

But particularly of those combining with evacuation, a stimulating power.

And independent of reasoning known from undoubted experience that this a consequence from blisters.

Perhaps not very material here, that should have been applied as near as possible to pained parts.

For unquestionably capable of evacuation at least in some degree, from system in general.

And as little doubt that stimulating effects also extended over whole.

But still latter in particular more considerable in neighbouring parts.

And to these more especially propagated.

As promoting absorption indeed, more powerful evacuation might have been employed.

But to these situation of patient, & apprehensions with regard to [consequential] Phthisis occurred as strong objections.

Upon whole then thought no measures here better calculated for removal of purulent matter collected by natural outlets than [separate] blisters

But besides this useful also as changing determination.

For from augmenting circulation in part to which applied diminished determination to lungs

Hence well known that benefits from them in variety of pneumonic affections.

Consider them therefore as well entitled to trial in present instance.

Application of first blister seemed to have good effects.

For pain of breast, as well as dyspnoea very considerably diminished.

From this therefore encouragement at least to future trials.

Practice however of repeated blisters requires some interval.

[And] in mean while was necessary that should not appear inactive.

Especially as patient notwithstanding relief, still subjected to distressing cough.

Was rather however as placebo than anything else, that had here recourse to mucilage mixture.

For although may be highly useful where irritation at fauces, yet little to be looked for where cough supported, as supposed to be case with this patient, by fixed irritating cause in lungs.

Ultimately therefore removal to be expected only by removal of abscess.

Still however mucilage mixture might not merely give some satisfaction to patient & attendance, but also take off some irritation.

While at same time a practice from which nothing to be apprehended.

And which could be supposed in no degree to interfere with blisters.

To repetition of these therefore is intention to have recourse every ten or 14 days

And some grounds for expectation that may at least facilitate discharge of purulent collection by natural outlets.

If in this however in end disappointed & if no reason to alter conjecture as to nature of disease must next aim at artificial discharge.

With this view no means more likely to produce rupture of Vomica from concussion, & afterwards to promote expectoration, than Emetic.

To these therefore repeated at proper intervals, if no circumstance occurs to [illegible] use shall next have recourse.

And if should not produce rupture will still be means of promoting absorption also.

Hence may be useful with same intention as blisters.

These then measures on which according to present idea of disease should place great confidence.

May however occasionally employ others, with view of obviating particular symptoms.

These however must be entirely [accommodated] to occurrences, of which in no degree aware.

Of these therefore can say nothing at present.

Nor indeed of future plan of treatment provided reason to alter opinion of nature of disease.

As in that case must be accommodated to sentiments afterwards adopted.