DEP/DUA/1/34/26 (Normalised version)

Donald Budge

1784

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Donald Budge April 3^d 1784

Disease of this patient very distinctly marked.

Could have no doubt in considering him as subjected to an intermittent fever.

And that too of the most common the Tertian type.

Not however in most regular form.

For consists entirely of cold & hot without sweating fits.

This though somewhat anomalous yet not a very uncommon appearance.

When occurs always supposed to indicate [ Ass] [complete] apyrexia or freedom from fever.

Hence therefore an appearance somewhat unfavourable.

Another circumstance which may be considered of same kind, was cough with which paroxysm attended.

Cough though by no means a common symptom with fits of intermittent yet cannot be represented as very rare.

And when does occur very generally highly distressing to patient.

Particularly during cold stage.

In case before us however a singularity seems to have taken place.

For occurred only during hot stage

And with that spontaneous termination.

Hence then though not an occurrence of cold stage yet evidence of its [connection] with the intermittent.

And perhaps equally difficult to explain how should be [connected] with [either].

But if one to be accounted for as some have supposed from constriction of surface & determination of blood inwards, other again may be ascribed to irritation given by increased impetus

Must however be remarked that [these] are effects constantly occurring in every intermittent

While again cough either in hot or cold stage but rarely takes place.

Hence then, with causes mentioned above, if these have any influence, some peculiar disposition must be conjoined.

And I own as connected with intermittent at whatever stage of paroxysm may occur am inclined to look upon it as indicating a peculiar irritability.

Especially occurring in the lungs.

And in this point of view, as well as from immediate distress which it occasioned, an occurrence rather unfavourable.

Besides these still another occurrence of same kind to be mentioned.

That is anticipation which fits have had since commencement of disease

When first began, paroxysm about nine in the morning.

But when came under our care attacked about three hours earlier.

Such varieties in attack by no means uncommon.

And indeed more frequently the case that hour of attack changes than that remains steady during whole course of disease.

But while the postponement of fits always considered as a favourable circumstance anticipation again constantly viewed in opposition [illegible]

Hence then, while disease evidently a Tertian intermittent, the three peculiarities pointed out, anticipation of fits, cough during hot stage & want of sweating stage were all unfavourable.

Besides these particulars in symptom of disease itself, other particulars also leading to similar conclusions might be mentioned.

Season of year somewhat against speedy recovery.

Intermittents need hardly observe prevented principally during spring & autumn.

And of these two the former [imagine] upon whole most favourable.

But attacking early in spring apt to run on to greatest length

And particularly distressing to patients during easterly winds prevailing so much at that season especially during months of April & May.

From these nothing more common than to observe formal recurrence of disease even after complaint overcome.

Still oftener return of distressing symptoms as growing headache or the like

Hence then here reason to expect such affection.

To all these another particular to be added viz age of patient.

Was only you will observe in his 12^th year.

[A] circumstance not [proposing] having much influence on nature of disease

But whether that most effective mode of cure not so readily employed in early life or from any other circumstance no doubt that then more difficult to remove than at more advanced age

Hence then from all these particulars taken together reason to apprehend obstinacy of present case.

At same time in opposition to all of them might be observed that disease was a tertian intermittent.

An affection which while in this country at least, very rarely dangerous at same time generally admits of cure

And even when cannot be effected by medicine is often even consequence from single circumstance of change of season

Here therefore had reason to hope though not for speedy yet for successful termination.

And this the rather as we possess a remedy which in cure of intermittents operates with as great if not greater success than any remedy we are acquainted with for any other disease.

Need hardly observe that remedy to which here allude is Peruvian Bark. the efficacy of which against intermittents of this country at least now confirmed by many years experience.

For a long time past however what has been used as best bark is quilled pieces of pale kind.

Of late however a very different opinion has prevailed & now generally received.

That viz the Red Peruvian Bark which is in much larger pieces, of coarser appearance, & of stronger sensible qualities both with respect to bitterness & astringency is much more efficacious.

And this opinion now I apprehend incontestably proved both by experiment & observation.

From these considerations then naturally led to make trial of it in present case

But prior to its use directed you will observe the employment of an Emetic.

In this had two intentions in view. Was first & indeed principally meant for evacuation of contents of stomach.

As by this hoped that bark would have better opportunity of acting with effect.

But while product of this effect hoped also that might induce more complete paroxysm.

And that thus more perfect apyrexia might be obtained.

Is in this manner probable that Emetics sometimes even of themselves are means of complete cure in Intermittents.

But whether on this principle or not with regard to general utility there can be no doubt.

In case before us indeed may seem extraordinary that Emetic should be so useful when cathartic accused of doing so much mischief.

For you will observe that according to history of case to these commencement of present disease is attributed.

Before he fell ill had taken we are told a dose of salts, which operated very briskly.

And to this, as intermittent succeeded soon after on exposure to cold, his mother inclined to attribute his complaint.

That salts here were really product of bad effects would be very far from denying.

For no doubt that causes of intermittent act most powerfully when body previously debilitated

But at same time, that neither purging, bleeding, or any other evacuation to a great degree, will of themselves give intermittent is undeniable.

These if not always, are at least very generally an affect of action of effluvium of marshes.

And hence abundantly apparent not only why they are epidemic at certain seasons but likewise why are in great measure endemic to certain countries.

To this general cause therefore intermittent in present instance was in all probability to be attributed.

And utmost effect of salts if had any effect whatever was merely that of giving ordinary cause of disease a greater latitude for action.

But such an affect in no degree I apprehend to be feared from Emetic.

For although also considered as belong to tribe of evacuants yet operation of a very different nature.

And have by no means same influence in producing inanity & debility.

In case before us if not product of good consequences may safely at least venture to say that had no bad effects

For brisk operation by which full evacuation of the stomach obtained was product of no inconvenience.

And probably cooperated in some degree in producing operation of bark which afterwards employed.

Immediately after paroxysm to which use of Emetic had been [premised] began patient with Red bark.

And this directed to be employed in manner in which think that bark in general most successful.

That is gradual introduction in doses of ℥p. Jii or ℥i at short intervals.

But that might see how far cure could be obtained from small quantity ordered to extent of ℥i only.

And is I think, in but few instances if ever that from smaller quantity cure can be expected.

Here after previous use of the Emetic was taken in manner directed without any inconvenience.

And from time that use begun, had not at succeeding report any return of paroxysm.

In this situation however considering unfavourable circumstances which had before been stated reckoned it improper immediately to intermit use.

Ordered therefore an additional half ounce to be taken in more gradual manner

And was in hopes that by this complete cure would be effected.

When however during space of another week continued free from any return of fits thought farther use unnecessary.

At same time however could not consider patient as in state of perfect health

For thought that was affected with some swelling both in legs & belly.

Such swellings of the dropsical kind by no means an infrequent consequence of Intermittent.

And bark has often been accused as cause inducing them

That in some cases may have had such effect would not deny.

And indeed such swellings in my opinion often to be considered as effect of cure.

For where, as termination of each paroxysm, sweating before very considerable gives rise to obstruction of accustomed evacuation.

But is in this way only, that in my opinion ever produced it.

And here could not suppose that proceeded from any such cause.

For paroxysm you will observe did not terminate in sweating fit.

Here therefore as far as swelling took place was inclined to consider it as mere affect of weakness.

And hoped that by recruited vigour of system from absence of disease, might soon be completely overcome

To aid this however from strengthening tone of stomach & likewise as a substitution for bark directed use of Infusion Amarum.

From some accident however was not called for.

And during time when taking no medicine his paroxysms returned.

Now you will observe came back under different type that viz of Quotidian.

A circumstance on recurrence of disease by no means uncommon.

Affection however in other respects apparently more favourable than before

And fits so slight that hoped might have been stopped by bitter infusion alone.

In this however were disappointed.

For notwithstanding employment continued regularly subjected to paroxysms & these even assumed former type that viz of Tertian.

Now conclude therefore that again necessary to have recourse to bark.

But in place of giving it even so fast as had formerly done now directed that should be thrown in in manner still more gradual.

And with view of increasing activity conjoined it with a mineral tonic the Sal. Chalybeate adding ℥i of this to ℥p of red bark.

This directed to be taken only to quantity of tea spoonful thrice a day.

And am in hopes that by [means] of it may again obtain as considerable [remission] as before.

If this the case by persisting a little longer in use hope that radical cure may be affected.

If not future measures will be [according] to circumstances in which shall find patient