DEP/DUA/1/33/08 (Normalised version)

Daniel Frazer

(1783-1784)

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Daniel Frazer November 29

Affection to which this patient subjected very distinctly marked.

Can have no doubt in asserting that as principle part of complaint at least he labours under an intermittent Fever.

And when came under our care at least observed very exactly the Quartan type

But from history of case you will observe this had by no means been form from commencement.

On first attack, now no less than seven months ago, appeared under quotidian form.

From this, after complete remission for short time, probably effect of change of climate, passed to Tertian type.

And from this not long since had transited to Quartan its form when came under our care.

These transitions as well as sameness of cure in all intermittents in my opinion affords strong evidence, that cannot with propriety be considered as different genera of fever.

But that all modifications of intermittent merely to be viewed as species or rather perhaps varieties only, of one genus.

These symptoms however, constituting regular intermittent by no means only ones to which this patient subjected.

Another very distressing affection, to him is diarrhoea.

When came under our care, had you will observe seldom less than 12 stools in 24 hours.

And these attended not only with gripes & tenesmus, but with discharge also of bloody & slimy matter.

From all these symptoms taken together, this looseness would by many be considered as entitled to appellation of Dysentery.

And especially as cannot be said to be without fever.

Here however can hardly view it as example of epidemic putrid dysentery such [so] often rages in Camps & [Armies] & is effect of peculiar contagion.

Or at least, if in this state at commencement may reasonably infer that influence of contagion has now long since ceased.

And that symptoms now remaining to be considered merely as sequel of that affection incapable of giving contagion

But whether originally putrid & contagious dysentery or not, can be little doubt that from beginning connected with intermittent.

For not only did attack take place at same time, but diseases manifestly marked to alternate with each other.

During fit of intermittent, little affected with looseness.

But as soon as that ceases, stools become frequent.

This connection between intermittent & dysentery of warm climates very remarkable.

And of such, you will observe disease of our patient was product.

Has been mentioned, by almost all the accurate writers, on that [affection] particularly Dr Cleghorn

And indeed reason to believe that in great measure product of same cause.

In so much, that not wanting some, who consider them, merely as different modification of same disease.

But without going so far as to adopt that opinion, can yet have no doubt, that both often product of miasma or exhalation from marshes.

And that therefore most frequent when rains & heat conjoined.

Is however in general remarked that while weather warmest, tendency to intermittent prevails most strongly.

And as becomes somewhat cooler dysenteries in proportion become more frequent.

Often however, as in case before us conjoined at same time in same person

And indeed according to account of our patient, this was the case with many others on board the same fleet, & in similar situation with himself.

Here therefore have no doubt in considering intermittent & dysenteric affections, as deriving origin from same cause.

But besides these, history of this patients case, contains also third set of symptoms.

Affection viz of right hand.

While strength in general very much impaired, in this limb power of motion more particularly so.

And with diminishment of power of motion parts also appeared somewhat wasted.

From these circumstances can have little doubt in considering this as an affection of paralytic kind.

But manifestly with some peculiarities.

For here you will observe much more, an affection of motion, than of sensation.

For excepting finger & thumb, sensation in parts affected unimpeded.

Is indeed true that sense & motion, not unfrequently remarked to be separately affected.

Sometimes even total loss of one while other unimpaired.

Sometimes one part of body affected with loss of sense, another with loss of motion.

But much more frequently, affected nearly in same proportion.

Want of this however not only peculiarity in case before us.

For while Palsy in general with diminishment of heat, this affection would seem to have been accompanied, with increase of it.

For a preternatural sense of heat we are told, in whole hand.

But while loss of heat a much more common symptom this cannot be said never to occur.

In my own practice have before met with more than one instance of it.

And have particularly observed it in other cases where power of motion more affected, than that of sense.

Or in other words, where paralytic affection, more in nerves leading to [muscular] fibres, than in subcutaneous.

In any instance I have formerly met with however, has rather been sense of heat than real increase

At least increase could not be detected by Thermometer.

This remarkably the case with a paralytic patient which had occasion to treat about 7 years ago.

Had lost entirely power of moving both legs, though sufficient sensibility when touched, or otherwise injured.

But with this, complained of constant sense of burning heat in soles of feet.

These however, to feeling of others not warmer than natural.

Nor could thermometer by longest continuation & most careful application be raised above natural standing of heat.

And this, though no trials have yet been made, I suspect to be also case with present patient.

Consider it therefore as an example of partial paralysis, under form of peculiar modification, which though not very frequent is yet sometimes at least observed to take place.

From view now given, of various affections to which patient subjected, prognosis cannot be very favourable.

Must indeed be allowed, that few diseases, which more certainly admit of artificial cure, than intermittents in this climate at least, & in this part of country.

Nay at season to which year now advanced, autumn intermittents, as well as vernal ones during summer, often cease of themselves.

But without waiting in expectation of natural cure, very rarely happens that in this part of country at least, any intermittent resists sufficient quantity of good Peruvian Bark.

Although therefore this affection with our patient product of warmer climate where the disease much more obstinate & dangerous yet reason to hope that Bark may now overcome it.

This however after repeated trials have not yet been able to accomplish.

Hence then incontestable evidence that intermittent peculiarly obstinate.

And no doubt that from continuation even, here may prove fatal.

Particularly after exhausted & debilitated state to which patient already reduced.

But besides intermittent here, also very great danger to be apprehended from looseness.

Since treatment began is indeed considerably abated.

But still to such extent that must weaken very considerably by evacuation.

And after long continuation which has now had, reason to [apprehend] that, even topical effect of intestines may have taken place.

If not may at least conclude highest degree of weakness.

Hence then, even if successful in removing intermittent not surprising if should fall victim to this affection.

At same time nothing which can lead us to infer very immediate danger from either.

And hopeful that by proper measures both may yet be successfully removed.

With regard even to paralytic affection more doubt.

For no question that these even when appear most slight, yet often irrecoverable.

Hence then shall not be surprised if find it, to resist every effort.

But on other hand when consider condition to which patient reduced, by long continuation of disease, not impossible that merely consequence of present state.

And that if other affections can be overcome will even cease of itself.

At any rate, as these most urgent, will naturally be first object of attention.

And accordingly to these endeavours hitherto have been solely directed.

Began practice, you will observe, by ordering for this patient, an Emetic.

And as such had here recourse to Ipecacuanha.

Which with view of obtaining full vomiting & of completely emptying stomach, [reckon] by much most convenient & certain.

Taken to quantity of Ji dose here ordered, seldom disappointed in obtaining from it these effects.

While at same time, neither in this, nor larger doses have ever seen it product of any inconvenience.

Indeed probable that even to quantity of Ji whole does not act.

But that by vomiting first excited greatest part of it expelled before has had any influence

Some accordingly have advised exhibiting even in small doses

And undeniable, that even from few grains vomiting may be excited with most adults.

But slowness of operation & long continued sickness which induces, an objection to it.

And much better to lose few [grains] of Ipecacuanha, than expose patient to [illegible] inconvenience.

From operation of Emetic in this case had several objectives in view.

Imagined that might be serviceable both with view to Intermittent, & Dysenteric affections.

In cases of looseness, no doubt that the affection often supported by matter passing downwards from stomach

Accordingly by complete rejection of these, speedily & effective termination.

This particularly observed by Dr Sydenham, who indeed goes so far as to say, that most instances of fever, where Emetic neglected at commencement, succeeded by troublesome looseness.

Besides this often useful in looseness as giving determination to surface.

Have effect of renewing circulation there which afterwards freely & readily supported with increase of cuticle discharge

But if much employed in dysenteric affections, still more in intermittents.

There even when of obstinate nature, have by repeated use of Emetics, been completely overcome.

Still oftener however used as preparative for employment of Peruvian bark.

Particularly as unloading stomach, & thus allowing bark, better opportunity of acting.

And was principally with this intention that here employed it.

For will observe that at same time, directed also that article.

That Peruvian Bark most effective cure for intermittents with which yet acquainted allowed on all hands.

Many disputes however both as to choice of bark & best mode of administration

For a long time past however, in this country, at least preference, given to small quilled bark of fine appearance & light colour.

But since a late publication by Dr Saunders of London, a different opinion entertained.

And notwithstanding opposition & arts of many dealers & apothecaries many practitioners now direct to give preference to bark of much coarser appearance in larger pieces & of much redder colour.

In so much that to distinguish it from quilled, has now got name of Red Peruvian Bark.

To opinion of its superior efficacy must own that am very much disposed to be inclined both from sensible qualities & likewise from several trials in way of Pharmaceutical experiments.

But in actual practice have had few opportunities of making proper comparative trial.

Intended therefore to give trial to effects in present case.

From obstinacy indeed, even if should fail, cannot conclude against it.

But if succeeded would be strong evidence of efficacy.

And especially if this effected by employment to small extent only.

Was on this account, that when first prescribed it, limited quantity to extent of ℥i.

By this quantity of ordinary bark common vernal intermittents of this climate will in general be overcome.

Some however think it preferable that whole should be thrown in, within as short space as possible before fit.

While others contend, that peculiar advantage from exhibition within very [short] time, immediately after fit.

For my own part, after having made many different trials have never been able to discover propriety or advantage of either practice.

In both ways, often overloads the stomach, so much, that rejected by vomiting.

In my own practice therefore prefer introduction by small doses, as most certain way, obtaining full effect with least inconvenience.

Accordingly here ordered in doses of ℥i every hour, till whole taken.

By this means patient uninterrupted under influence, & would also have full [time] to act

Besides Emetics & Bark a third article also ordered for this patient.

Use viz of Pill Thebaic.

Of these need hardly observe that principle active article is Opium.

Gets form & consistence of mass by means of Extract of Liquor.

While one of most grateful of vegetable aromatics the Pepper Jamaica added as Corrigent.

On opium thus corrected activity of this article may be supposed totally to depend.

And into each pill of grain V opium enters to extent of grain s.

By this medicine what I had [chiefly] in view was restraining looseness.

And whatever disputes may be entertained with regard to action of opium no one can doubt, that as diminishing morbid action of alimentary canal has that effect to very great degree.

Here however was apprehensive that by sudden check to discharge which had so long subsisted, dropsical symptoms might be induced.

Thought it advisable therefore, to begin with small quantity

And this directed at bed time, as of most consequence to patient, that should not be disturbed with looseness during night.

From use of these medicines, cannot say that all wished for effects have been obtained.

Vomit indeed operated well.

And as far as could aid subsequent use either of bark, or opium, had probably full effect.

But from use of Bark & Opium, though these articles continued & quantity increased have not been able entirely to remove either intermittent or looseness.

Both however particularly latter now much less distressing to him.

And hopeful that by continuation of Pill Thebaic may be entirely overcome.

Reason also to presume that from Red Bark already taken may be freed from returns of Intermittent.

For has now had, within space of few weeks, upwards of ℥IV

And if this does not completely stop fits, shall at present despair of accomplishing it by this remedy.

If still subjected to returns, will without regard to intermittent, for short time, direct attention more especially to looseness.

And by more frequent repetition of the opiate, as well as by use of astringents, will endeavour to get it completely removed, that may try for intermittent [some] other practice.

And with this intention, if it shall be necessary, may have recourse with this patient, to tasteless ague drops a remedy much celebrated in some parts of England.

Or may try Alum, or even Blue vitriol, combined with Aromatics.

But these am hopeful may be found unnecessary.

And that by plan already instituted cure may be accomplished.