DEP/DUA/1/34/02 (Normalised version)

William Courage

1784

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William Courage February 14^th. 1784

With regard to disease of this patient when patient first applied for assistance was I own much at loss.

And although has now been under care for several weeks still in same situation.

Nay circumstances which have since occurred, have in my opinion, tended rather to increase difficulty than illustrate [nature] of affection.

When first applied for assistance most [distressing] symptom consisted in peculiar [pricking] pain under left mamma.

Constancy of this pain as well as increase on coughing or even on inspiration gave reason to believe that depended on some local affection, & that too even [within] the thorax.

And this may be thought not a little corroborated by frequent cough.

A symptom almost necessarily arising from any topical affection within the breast.

In all these particulars nothing extraordinary.

But in progression & continuation of pain something singular.

Before he came under our care was of a months duration.

A circumstance very uncommon with thorax pains ushered in with coldness [shivering] & fever.

These whether of pleuritic or peripneumonia kind in general very soon terminate either in resolution or suppuration.

But if attack thus uncommon progression still more so.

For during whole space of month has been subjected to daily febrile attacks

And never as far as we at least have had opportunity of observing entirely free from preternatural celerity of pulse.

But at same time small & easily [compression].

From these circumstances then, as well as continuation, cannot look upon it as concomitant of active inflammation.

While at same time at loss what other idea to form of it.

Difficulty still farther augmented by progression.

For when pain first began was chiefly seated under sternum.

And in part now affected then felt only slight uneasiness.

This however gradually increased [while] that under sternum had proportionately diminished.

And at end of five days had entirely left him, [&] continued to be subjected only to pain under mamma

What nature of this pain may be must own cannot, with any certainty pretend to say

But was then disposed to suspect that depended on some internal suppuration.

And that, although active inflammation which had preceded, chiefly seated under sternum, yet had there been terminated by resolution while in present situation only had come to suppuration.

Was inclined to consider daily febrile accession as being of hectic kind.

And to view patient as labouring under Phthisis Pulmonalis.

Considering him as subjected to that species of it, which in [contradistinction] to tuberculous & catarrhal would term the ulcerous.

And where disease effect of abscess of some considerable size & at one particular part of lungs.

Here indeed true that had by no means all symptoms with which this species of Phthisis attended.

But to any objection from this circumstance sufficiently answered from insidious nature of the disease.

For well known to be one of those affections which makes considerable progress where very little grounds for suspecting it.

And frequently even in cases where in end proves fatal much fewer symptoms of it, than with present patient.

This then conjecture with regard to symptoms when came first under care.

And hoped that by careful attention should soon be able to determine whether well founded or not.

During course of attendance however as have already remarked in place of being removed rather augmented.

For while no circumstance either confirming or refuting opinion other particulars have occurred which may give countenance to different supposition.

This particularly the case with respect to discharge of worms.

Without any of those symptoms commonly considered as indicating presence of these & prior to employment of any remedy for expulsion several lumbricus discharged.

And here may occur as question how far whole symptoms may not have proceeded from this cause.

That worms capable of producing [almost] infinite variety of different morbid appearances cannot I think be denied.

Indeed hard to say to what affection they may not at times give rise.

And no symptoms in history of present case which have not a different times produced.

But even this circumstance joined to actual presence by no means certain evidence that are cause of present complaint.

For certain that often lodged in alimentary canal when product of almost no symptoms whatever.

And that often supposed to be cause of diseases where merely [discharged] in consequence of such affection taking place from some other cause.

Particularly happens that discharged by occurrence of febrile complaint.

Probably from increased & morbid [heat] rendering situation uneasy.

While therefore can by no means agree with those who consider them as never being cause of disease, can as little adopt the opinion of others who look upon them as product of every symptom where happens to appear.

And in instances before us am I own rather disposed to consider expulsion as consequence of the disease, than presence as cause of symptoms.

At same time evidence which has now been afforded of presence in alimentary canal a circumstance claiming attention both in prognosis & practice.

If whole symptom depends on worms may soon look for favourable termination

But if as am still disposed to suspect greatest part of symptoms consequence of suppuration within breast, may consider disease as of most dangerous tendency.

And reason to fear that notwithstanding any efforts which are capable of employing will in end prove fatal.

In present state of uncertainty however can offer only what to be considered as but vague conjectures.

And from this circumstance also cannot lay down any determined plan of cure.

But in practices employed must be chiefly guided by attendance to [ juv] & [illegible].

Was chiefly on this footing that when patient first appeared for assistance had recourse to a blister.

On whatever principle may operate can be no doubt that has remarkable influence in alleviating affections of breast.

And particularly when these appeared under form of fixed pain.

Probable that benefit in a considerable degree the affect of change in mode of circulation.

And that on same principle is [useful] even where suppuration within the chest.

But whether thus advantageous or not in [these] cases very generally employed & apparently with advantage.

These then reasons for having recourse to it in present instance.

But besides this directed also at same time another medicine.

A mixture viz of flower of Sulphur & powder of Cream Tartar.

From this had chiefly in view the keeping belly gently open.

From which in all affections of the breast very great benefit is obtained.

And indeed in obstinate catarrhal affections very few remedies from which patient derives more considerable relief.

Upon supposition then that pectoral affection here wholly catarrhal might have been highly beneficial.

And in [any] view of disease [reason] to hope that might be useful.

In obvious affects of both these remedies were not disappointed.

For while blister rose well & produced free discharge powder also kept belly gently open.

Under use of these medicines, the pain of breast seemed to be somewhat mitigated.

But still continued to be much distressed with cough.

And though free from vomiting was even more than formerly affected with sickness at stomach

Imagined however that by continuation of gentle discharge these symptoms might be mitigated.

And I own did not then suspect as cause of this sickness, a circumstance which there is since reason to infer, may at least have had share in inducing it.

Presence viz of lumbricus in alimentary canal.

Directed therefore that should continue with Cream of Tartar & Sulphur [illegible]

During use several lumbricus were discharged by stool.

Not improbable that this discharge in some degree affect of laxative [powers] in the article employed.

But at least equal reason for supposing that worms discharged in [continuation] of daily febrile accession.

Whether however from one or other cause, or whether independent of both a question of much less importance, than that already stated whether viz worms cause of other symptoms.

This I own then came with me to be a matter of some doubt.

But as have already said am rather inclined to suspect that merely accidental complaint & that disease depends on cause deeper seated & more [dangerous]

Notwithstanding this supposition however must still be considered as object of consequence to remove lumbricus.

By this have at least chance of freeing him of some part of complaint.

And if complete removal obtained, best able to determine how far had any share in inducing or supporting affection.

On this account omitting remedies formerly employed practice now you will observe directed to lumbricus.

With intention of expelling these the remedy to which had recourse the Semen Santonica.

This need hardly observe long celebrated as an anthelmintic.

If to judge of virtues from sensible qualities should consider it as very little different from other vegetable bitters.

And these universally allowed to possess some degree of anthelmintic power.

But as far as I can judge from my own experience powers of Semen Santonica in much greater degree than in proportion to bitterness.

And indeed from affects which have frequently observed to result from use look upon it as one of best & safest anthelmintics we can employ.

Rather however affect in killing than in expelling worms.

Hence in general proportional to use a Cathartic should be [subjoined].

And as such have here [ordered] the Pulveris Jalap [compound].

From conjoining influence of these expect that worms if present will be expelled.

And from situation in which shall then find patient, practices must be regulated.

For must [own] so far doubtful that cannot lay down any fixed plan of cure.