DEP/DUA/1/28/02 (Normalised version)

William Stark

(1781-1782)

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William Stark.

Case of this patient so distinctly marked as to remove all room for doubt with regard to nature

While health in other respects good affection consists principally in pains.

And these especially affect joints particularly larger ones of lower extremities as knees & ankles.

While from pain in loins & lower part of back may conclude that article at head of femur also affected.

And in latter of these situations viz back is observed to be particularly distressing.

Severe pain in back indeed often a symptom of other diseases.

And particularly with patients far advanced in life observed to proceed from Calculus of Kidney.

Here however no grounds for presuming that in any degree connected with such an complaint.

All other symptoms of calculus as affection of stomach & like entirely wanting.

And had even never observed any affection of urine.

Besides this remarked that pain much aggravated on motion particularly on getting into erect posture.

A circumstance evidently demonstrating connection with muscular action

And very rarely if ever observed to occur in calculus affections.

From this then joined to pain in large joints put beyond all doubt.

But supposing disease to be Rheumatism still for conduction of successful practice another [qualifier]

In what stage viz here suppose Rheumatism to be.

Have already had occasion to observe that four different states of this disease each requiring particular attention in practice

These in heads of lecture have termed states of Inflammation. Irritation. Atonia & Paralysis.

With patient advanced to 70^th year first in high degree hardly to be expected.

And if had existed at commencement could hardly be imagined that would have continued till time that patient came under care

For before applied for our assistance had subsisted for space of 12 months

During that period not surprising that should have passed stage of irritability & proceeded to atonia with manifest tendency to paralysis.

That this the case evidently apparent I think from due attention to symptoms.

For pains now no longer aggravated by heat of bed.

A symptom almost invariably occurring while stage of irritability remains.

On contrary atonia & even paralysis as long at least as pains continue, most certainly characterised by their being increased by cold & alleviated by heat.

Besides this atonia stage farther [indicated] by great weakness.

For patient even when free from pain incapable of muscular action.

Or when exerted from mere weakness considerable pain immediately renewed.

If these however circumstances indicating atonia some others pointing out tendency to Paralysis.

This particularly the case with respect to coldness of extremities of which patient complains.

For in most instances at least a forerunner of insensibility.

This then idea with respect to state of this patients Rheumatism when came under care

Here however to be observed that mean this to apply to affection only in general way.

For when many different parts affected with Rheumatism not to be supposed that all in same state at same time.

Even possible to conceive that may have all different stages subsisting in body at once.

More frequently however combination merely of those [nearest] to each other.

And this appears to have been case in present instance with respect to Atonic & Paralytic.

With this idea of disease will readily conclude that could form no very favourable opinion of prognosis.

Nothing indeed in case indicating approach of danger.

And indeed Rheumatism one of those affections which upon whole is seldom dangerous.

When proves so is in general only in second way from constitution being ruined & worn out by disease.

Of this however although patient advanced in life no appearance in present case.

For except pain & inability to motion still usual appetite & health in other respects.

Here however if no reason for being greatly alarmed, equally little grounds to hope for speedy cure.

Affection already of considerable continuation & had made great progress.

But what still more unfavourable advanced age of patient.

Hence then but little reason to hope that should soon obtain speedy or considerable alleviation.

Still less that affection could be completely & entirely removed.

At same time nothing to prevent employment of practices with either of these views.

And no doubt that in cases [equally] unfavourable great benefit when not expected has been obtained.

From opinion given of disease was led to imagine that benefit might here be reaped from stimulating topical application.

And as pains now always alleviated by heat while manifest tendency to coldness had recourse to one of tribe of rubefacient.

As such ordered Liniment Volatile.

An article in some degree deriving activity from [properties] of Camphor.

But still more from Volatile Alkaline Spirit.

And this indeed if applied without oil would produce actual vesicles.

Even with some tender skins has this affect when two parts of oil to one of Spirit [common] [proportion].

But in most cases, in this state excites only sense of heat & slight topical inflammation.

And this the utmost here intended.

For when product of this effect have in such instances often seen it attended with best consequences.

But besides this external medicine had [recourse] also to one taken internally.

I mean the Volatile Elixir Guaiacum.

This medicine long used in Rheumatism in different forms.

But under that of Volatile Elixir & in large doses chiefly introduced by Dr Dawson

Fully persuaded that in such cases as present where Rheumatism tends to Paralysis have often seen best effects from it.

But have seldom found that patient able to bear it, at first at least to extent that he recommends

Often in particular intentions entirely frustrated from its moving belly.

Hence then always necessary to begin with smaller doses at least than he has ordered.

Besides this in management another caution necessary.

From immediate action of Spirit on mouth & fauces great inconvenience often produced.

Hence then in every case necessary that should be taken diluted.

And whether in pure state or in composite with other articles always to be exhibited in pretty large draught of some mucilage diluent, Water gruel. Infusion Liniment etc.

But besides this have in general also thought it of advantage to employ it in [previous] state of combination with some demulcent.

And accordingly as in present instance have often given it with equal parts of Mucilage of Gum Arabic.

Must however acknowledge that this or any other addition of watery fluid an inelegant formula.

For separation & precipitation of resinous part of Guaiacum necessary consequence of watery addition.

Still however virtues not altered.

In [obvious] effects of these medicines not altogether disappointed.

External application of liniment indeed did not produce effect expected.

For neither sensible heat nor inflammation.

This may have arisen from different causes

Perhaps from fault in medicine more probably from fault in application.

At same time am inclined to suspect that in some degree also affect of insensibility.

But although no obvious operation, yet still thought, that must necessarily [have] some influence.

And from Elixir had all evident affects which wanted.

For excited slight diaphoresis without moving belly.

Under these medicines however no alleviation of pain.

But still expected that by longer continuation might be obtained.

And in this not altogether disappointed

For at succeeding report informed that pain somewhat alleviated at least in back.

This then some encouragement to still farther continuation.

And as no inconvenience from Elixir to give fairer trial augmented dose.

Now ordered both morning & evening.

And while ℥ii taken at former of these periods ℥p at latter.

To this extent however induced considerable looseness.

Became necessary therefore either to diminish dose or desert use.

And as pains still to same degree as before determined on latter.

In this trial then appeared that Elixir of Guaiacum unsuccessful.

But although inadequate to present case yet no general objection to medicine.

And even here under different administration might still have succeeded.

At same time from want of success as here employed had evidence of obstinacy of the disease.

In this situation resolved on trial of a medicine but lately known in this country.

Viz. Rhododendron Chrysanthemum.

This article but very lately introduced into practice of medicine at least in this country.

And very little published with regard to it

Rhododendron Chrysanthemum a plant growing in Siberia unknown to Linnaeus & not described in his writings.

First accurate description in botany [illegible] by Professor Pallas of Petersburg.

Who has found that while belongs to genus Rhododendron is also a new species.

And to distinguish it from others, has given it name Chrysanthemum.

Has long it seems been in use among the Siberians who give it name of Cheii

And while employ weak infusion as an article of diet use stronger as medicine.

And said with greatest success in arthritic & rheumatic affections.

For short account of virtues refer you to letter of Dr Guthrie of Petersburg published in 7^th volume of Medical Commentaries.

And to that gentleman am indebted for what here used.

Shall only observe that Siberians use it in form of infusion.

℥ii of dried shrub infused [with] ℥VIII Ag. Cal.

Kept in [stone] vessels in warm situation during night

This quantity taken next morning for dose

Excites heat with some degree of intoxication

But besides this singular degree of uneasy sensation in parts before pained.

And this attended with vermiculation or prickling in these.

But in few hours these effects disappeared.

And then said commonly to produce one or two loose stools.

After this patient greatly relieved from disorder.

And from repetition of medicine for two or three times complete cure.

This account however given by Dr Guthrie not from own experience but from account given of it.

That might be tried in this county sent small parcel of it to Royal Infirmary¹ & Dispensary of this place.

In former of these charities has chiefly been employed by Clinical Physicians.

And will find account of some cases in which used published by Dr Home.

Instances in which I have employed it more favourable to report of medicine.

Has not indeed [been] successful in every instance.

But in one in particular very great effect & attended with peculiar prickling at pained joints.

And upon whole as far as fair trials yet made have gone, am [inclined] to think very favourably of it.

Soon found however that by employing several drams on each patient quantity would soon be exhausted.

Resolved therefore with view of [illegible] trials till should obtain fresh supply to use it in substance.

In which state might unquestionably experience more activity from smaller quantity.

From several trials have found that powder even in small doses has very considerable effect.

Particularly as exciting sense of heat & giving some degree of confusion of head.

While at same time not disappointed in obtaining wished for effects.

On these grounds then consider it as at least deserving trial in present [case]

Here powder of Rhododendron ordered to quantity of three grains for dose to be taken every morning & evening.

Was merely to give more considerable formula that here combined with small quantity of Pulveris Cretacea.

As taken in this manner was product of no inconvenience.

But after use of it are informed that considerable sense of heat over whole body.

And that this especially observed in ankles where pain most severe.

But what of still more consequence in these parts in which chiefly felt pain very much diminished.

This then sufficient to encourage to farther trial.

And after persisting in use for space of another week although parts formerly affected very weak yet pains still [farther] diminished.

Since that have heard nothing more of patient.

And from what have often found to be case in other instances inclined to [illegible] [illegible] to having no more occasion for assistance.

But whatever may now be state of complaint appears at least that during use of Rhododendron very considerable alleviation of pain

And had no doubt in attributing alleviation to medicine employed.

Consider present case then as affording additional evidence of advantage to be derived from this medicine.

At same time from what already said in prognosis particularly respecting age etc of patient am far from thinking that disease completely cured.

Little probability however that shall see more of him during present course.

And if does return circumstances then to be accommodated to state of affection at the time.

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Explanatory notes:

1) The Royal Infirmary of Edinburgh, established in 1729.