DEP/DUA/1/28/12 (Normalised version)

Robert Carfrae

(1781-1782)

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Robert Carfrae.

Case of this patient not attended with so many peculiarities as that last considered.

But in most important particular hold it to be of same nature.

For here also little doubt in viewing disease as being Rheumatism.

When came under care principle uneasiness from pains in larger joints particularly knee

And these pains also as in former case aggravated by warmth in bed.

Were now neither constant nor attended with any febrile symptoms.

In this case likewise therefore consider affection as being in state of irritability.

To which as appeared from history of affection transition had now taken place from previous state of active inflammation.

At least at commencement so violent that obliged to keep bed.

After that however considerable mitigation of affection.

But before he came under our care probably from some accidental circumstance, was again somewhat aggravated.

In this state of affection however saw nothing which could be considered as alarming.

Disease indeed one of those which although often long distressing seldom fatal even by consequences.

And when proper opportunity of treating it in early stages & with patient in other respects healthy perhaps few more under power of medicine.

Here however every circumstance very favourable.

Hoped therefore that in no long time complaint might be considerably alleviated if not entirely removed.

At same time although complete removal should for present be obtained would not from thence pronounce patient altogether freed from affection.

For well known that where Rheumatism has once taken place to considerable degree very apt to be again renewed from slight causes.

Particularly from every change of weather

In so much that many thus affected become as it were living thermometers during future life

This however at present at least had no reason to apprehend would be case with present patient.

And in no long time expected that by aid of proper remedies should be able to dismiss him.

With view of obtaining this, had here recourse to a medicine, which of late years has been very much used in such complaints

And which in many instances have myself employed I think with great success

I mean the Volatile Elixir of Guaiacum

Of Guaiacum in Rheumatism had very lately occasion to make some observations when treated of case of James Grinlay.

But in place of being employed in substance form there used, here employed Volatile Elixir.

In this state besides Guaiacum, the menstruum also employed a very active article.

For here recourse had to Spirit Salt Ammoniac Vinos.

An article of such activity that can be given to no great extent even when taken merely by itself.

And accordingly for long time was common practice to exhibit this Elixir merely in doses of few drops.

Of late however very large doses, even to quantity of half an ounce or upwards have been exhibited in Rheumatism with great success.

For introduction of this practice are indebted to Dr Thomas Dawson of London.

And to his treatise entitled cases of acute Rheumatism & Gout may refer you for more full account of it.

Here would only observe that in this practice have frequently followed him with great success.

And that too although not given to extent which he has gone.

For must here observe that even in smaller doses product of much inconvenience from heat excited by immediate action both on mouth, fauces, & stomach.

And that too even when involved & sheathed as was here the case with vegetable mucilage.

In so much that still farther requisite that should be taken in draught of water gruel or some such other fluid

And that after taken effects on fauces & stomach should be farther countered by washing mouth & fauces & by diluting in stomach.

By these precautions inconvenience which would otherwise result even from quantity to which here used may be very much if not altogether obviated.

In this manner then Elixir exhibited to our patient to extent of ℥ii. for dose at bed time.

But besides this prescribed also at same time another medicine viz Peruvian Bark.

This have often before employed in cases of Rheumatism.

But have chiefly had recourse to it only late in the disease.

And rather against stage of atonia than of irritability.

But of late have been informed by a very judicious practitioner & accurate observer Dr Palmer of Peterborough, that he employed much earlier with great advantage.

Even in what may be considered as inflamed state.

That is employed it even in very commencement of disease as soon as remission of [patient] can be obtained.

And particularly after this effected by copious sweating.

As soon as sweating ceases recourse instantly had to Peruvian Bark.

And according to his account with best effects in preventing return of pain

And tendency of disease to pass from inflamed to any other state entirely prevented.

Thus necessity of frequent sweatings by which patient very much exhausted, entirely superseded

Of this practice for my own part have not hitherto had much experience.

But in any trials which have made have seen no inconvenience from it.

And am now disposed to think that apprehensions which some entertained from use of Peruvian Bark where tendency to inflame diathesis by no means well founded.

But whatever may there by case trials which have made of Peruvian Bark in way here mentioned seems to me to have been attended with good consequences.

And on this ground here directed it for present patient.

From hopes that if given in commencement of affection may prevent irritability stage, if employ when that already exists may be useful in combating it.

And with view of having farther experience of effects of Peruvian Bark in early stages of Rheumatism

While Elixir of Guaiacum taken at bed time, Bark given during former part of day.

By this means expected that would daily immediately succeed use if not of forming sweat at least of gentle diaphoresis.

And that by this means advantage obtained from Elixir might be secured.

In obvious operation of Elixir were not disappointed

For learnt at next report, that dose taken in evening had generally produced during night a gentle sweat.

While at same time had no influence in exciting looseness.

An affection not unfrequently taking place from large doses.

And when does take place in general inconvenient sometimes even hurtful to patient.

Had also satisfaction of finding that from regular use of bark suffered no inconvenience.

While at same time whether from medicine or otherwise pains very considerably mitigated.

In this situation then & presuming not without probable evidence, that by course on which patient put, complaint mitigated could have no hesitation in directing continuation.

And now with continuation of Elixir directed bark to double quantity that had before employed it.

To extent viz of ℥ii in day.

After these medicines given however saw nothing more of patient

Cannot therefore with confidence say what were future effects.

At same time think it more probable that patients desertion proceeded, from having no more occasion for assistance than from any other cause.

But even supposing this not to have been case, yet still present instance affords example, that Bark in substance may be given early in Rheumatism not only without inconvenience but even with apparent advantage.