DEP/DUA/1/33/20 (Normalised version)

James Marshall

(1783-1784)

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James Marshall January 10^th

From history of this patients case will observe that principal symptoms were borborygmi, flatus & acid eructation.

But above all pains in abdomen

Can be little doubt in referring most if not all these symptoms to same cause.

To uncommon collection of wind in alimentary canal.

And can have no hesitation in considering it as an example of that affection to which greater part of nosological¹ & practical writers have given name of flatulentia.

Flatulentia indeed not considered as a genus by every systematologist.

And particularly has no place in system of Dr Cullen.

Cannot however represent him as having omitted it.

But has [comprehended] it under his genus of Dyspepsia.

In my opinion however these genera are conjoined with impropriety.

No doubt indeed that symptoms of flatulence & stomach complaints often [connected]

And that very apt mutually to induce each other.

But at same time, may & frequently do exist separately.

Many symptoms of Dyspepsia wanting in most cases of Flatulentia

And on the other hand often stomach complaint to great degree where little or rather no uneasiness from flatulence at least in intestinal canal.

Accordingly in case before us though some, yet but inconsiderable conjunction.

For although acid eructation, yet neither Anorexia, nausea, vomiting nor pain of stomach.

While again chiefly marked by borborygmi & severe pain over whole abdomen but particularly about umbilicus.

Hence therefore notwithstanding frequent conjunction yet as well entitled to be considered as separate genera, as occasioning flatulence, & permanent tympanites.

On these grounds then with view to distinction from Tympanites on one hand & Dyspepsia on other, give to this affection name of Tympanites.

But although uncommon [extrication] of air, immediate cause of principle symptoms yet for understanding nature of affection, necessary to have in view cause from whence this arises.

That very generally depends on want of due tone in alimentary canal.

Which however commonly conjoined with disposition to inordinate action

And indeed on such action not only the borborygmi, but the pain also in part depends.

For although principally, yet not entirely the effects of distension.

But in whatever manner this as well as other symptoms may be produced can be no doubt that affection itself no less common than troublesome.

May however add, that more troublesome than dangerous.

And although not always in our power to remove, yet can in most instances at least relieve this affection.

True indeed that after once induced apt to be again renewed from slight causes. Yet entertain hopes of favourable conclusion.

Or at least of such remission that patient may be dismissed from farther attendance.

This the rather to be expected from relief which has already been observed to have since came under our care.

For as will observe from reports though some supervening symptoms had occurred yet was at one time, almost entirely free from those mentioned in history of case.

Since that indeed, has again been subjected to recurrence.

An event to which reason to [apprehend] will again be subjected on future remission.

And that the rather as diet, from rank in life, more spare & consisting more of farinaceous matter, than suited for his affection.

But at same time, to measures already employed am inclined to attribute relief which patient has experienced since came under our care

By same practices similar & even more permanent benefits may be obtained.

Or if in this disappointed others may be adopted to improve advantages derived from it.

Here for immediate ease of patient is in general first objective to bring about expulsion of wind, both by increasing action & by removing obstructions to it.

But of no less consequence to employ such measures as will increase tone of intestinal canal & to remove causes weakening it.

Was with view of fulfilling these intentions, that had recourse to practices here directed.

Began treatment you will observe by directing for patient, a mixture of Rhubarb & Magnesium.

To first of these articles, was in some degree led on general principle of juvantia.

For will observe, that before came under our care, had been in habit of employing it.

And particularly with the good effect of obviating costiveness.

As answering even this intention then, had reason to expect, both that would remove obstruction to passage of flatus, & increase tendency to that expulsion.

But besides this from astringent [qualities] unquestionably operates as increasing tone of intestinal canal.

While by bitterness, must at least have some effect, in destroying acid a cause very much weakening tone.

From symptoms of acid eructation however hardly imagine, that would be product of this effect to sufficient degree

Hence you will observe was led to conjoin Rhubarb with Magnesium.

Which of all the absorbents where acid to be destroyed, & at same time discharge by belly promoted, is unquestionably the best.

This combination directed you will observe, to be taken in Peppermint water.

An article not merely employed as a [illegible], but with view also to active powers.

For no doubt, that has powerful & immediate influence, as tending to expulsion of wind, at least as far as lodged in stomach.

While therefore Rhubarb & Magnesium source of more permanent benefit from this [expected] that patient would derive immediate relief

In these views expectations to certain degree at least were not disappointed.

For use attended with considerable relief both from acidity & flatulence.

Had however but little effect in moving belly.

And still a good deal distressed from wind which seemed principally lodged about inferior part of intestinal canal.

From this led to direct in conjunction with medicine formerly employed the use of Pill Foetid cum Aloe.

A formula consisting of equal parts of Aloes, Assafoetida & Soap.

And from which with patients labouring under flatulence have seen most remarkable benefits derived.

For while aloes move belly, Assafoetida which has some effect in this way has also powerful influence as removing spasmodic strictures, by which both flatus & excrement retained.

Under these medicines patient soon obtained very considerable relief

And after short continuation was almost entirely free from all symptoms with which affected when came under care.

But at this time were informed of a new occurrence which considered as deserving some attention.

Discharge viz of some ascarides by stool.

These indeed from account given, but few in number & apparently not product of any uneasy symptoms.

Worms particularly ascarides often lodged in intestines without producing any bad affects

And this might probably have been case with our patient.

From what cause now manifested by discharge cannot pretend to say.

Not improbable however that in some degree consequence of Foetid pill.

For assafoetida well known to have very powerful influence in killing & expelling all worms.

And is one of those anthelmintics active powers of which carried through whole intestinal canal.

Hence reaches even rectum where ascarides commonly situated.

This therefore additional reason for continuing use.

Though principally led to persist in employment with view to expulsion of flatulence & obviating costiveness.

And as reason to presume that more ascarides still remained directed against these a more powerful medicine.

Use viz of injection of Lime water.

From situation of ascarides, very generally merely at rectum, most anthelmintics rendered [effete] before can reach them.

Hence then, those articles in general best effects, which immediately applied

And of all injections I have tried, have found none more efficacious or more safe than lime water.

How far had here any good effect cannot pretend to say.

Not improbable that before commencement of use whole had been discharged.

For since began employment none have been observed.

But after intermission of Magnesium & Rhubarb again subjected to considerable return of pain

From this therefore led to [direct] repetition.

While from absence of symptoms of ascarides, lime water omitted.

Under use of this medicine pains from flatulence again considerably diminished.

But from employment in conjunction with pills, had now in general five or six loose stools every day.

Here however to be observed that while with patient subjected to flatulence, constipation to be [dreaded] severe purging no less so

For has unquestionably very considerable tendency to weaken tone of intestines.

And never fails to leave patient worse than before.

Omitting foetid pills therefore, have now directed continuation of Magnesium & Rhubarb alone.

And under use hope that patient may soon be in situation to be dismissed.

If this however not the case, shall endeavour to strengthen tone by vegetable bitters & aromatics.

The infusion amarum, Tincture Aromatic Elixir [ Saer]. or the like.

But in this must be much directed by circumstances in which shall hereafter find patient.

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Explanatory notes:

1) Nosology is the branch of medical science dealing with the classification of diseases. Individuals referred to in the case notes as nosologists were commonly those who had published nosological, or classificatory, medical texts.