DEP/DUA/1/35/28 (Normalised version)

Janet Duff

1784

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Janet Duff. July 9^th 1784.

Respecting disease to which this patient subjected am I own in several respects very doubtful.

And while different conjectures may be formed with regard to principal symptoms probable that all do not arise from same source.

Thus some of them considers probably with justice as consequences of Intermittent.

While others again existed long prior to her being subjected to that affection.

This particularly the case with respect to symptom most distressing to her when came under our care viz Pain of side.

Had been evidently subjected to it for space even of several years.

While intermittent again had existed only few weeks before.

Hence pain of side both in nature & cause different from other symptoms.

And here with respect to nature much at loss to form any positive opinion.

From having been so long & so much fixed to a particular part, grounds for suspecting some local affection.

And [besides] more [integral] different viscera in which may be supposed to be placed.

Thus circumstances of situation may be considered as favouring idea of its being placed in kidney.

And well known that this viscus is from different causes a very frequent source of obstinate & excessive pain.

But where kidney to any degree diseased may reasonably expect an affection of urine.

And this indeed an almost unavoidable [consequence] of disease of that organ.

[Hence] then as discharge here in natural state, strong presumption against pain originating from that cause.

While seat by no means so strictly defined that may not have situation in other viscera.

And here cause to which pain originally attributed would lead to different supposition.

Patient herself, has to greater or lesser degree been sensible of this pain from time of a delivery about six years ago

And ascribes origin to injury which sustained on that occasion.

This well known to be a frequent cause of pain.

And although may produce it from affection of many different parts, yet chiefly led to suspect either uterus or appendix.

And here situation such that not improbably may be in left ovary.

Which indeed rather to be suspected than uterus itself as has [never] [been] attended with affection of menstrual.

This therefore conjecture as to seat [which] disposed to think the most probable.

And the rather so when consider how often morbid affections in different ways take place in these organs.

This however at utmost to be offered as conjecture only.

And the rather so as no obvious [enlargement] of that viscus detected by [external] examination.

Such a change however in general the [attendant] of fixed pain arising from that source.

And notwithstanding presumption of viscus may merely depend on affection of integumentary

And that too rather in way merely of increased sensibility than of any proper local disease.

But whatever cause of pain, would appear that of late considerably emaciated

And on any idea of it this may be supposed to occur as consequence of intermittent

But particularly favourable to idea of local affection in ovary.

For well known that nothing a more common consequence of intermittent than obstruction & scirrhous of viscera.

And many instances of affection of Ovary as well as others.

Where therefore diseased state had previously existed this may readily be supposed to be increased.

But whatever original cause of pain of side or of increase since other affection commenced this by no means only symptom to which subjected.

Of the others if not all at least greatest part dated only from attack of intermittent.

May therefore with greater confidence be assigned to that cause.

And especially as many of them well known to be consequences & [concomitants] of Intermittent

This may particularly be observed with respect to weakness vertigo & headache.

Weakness a necessary consequence indeed of almost every disease.

But in an especial manner of those of febrile kind.

And of all fevers none perhaps producing so great degree of permanent debility as intermittent.

Towards close of many fevers indeed debility to still more considerable degree than intermittent.

But there as far as my observation goes recovery of strength takes place more rapidly.

And accordingly intermittent more frequently than other fevers observed to induce dropsical affections.

If however thus consider weakness as consequence of fever may view also in same light Headache to which subjected.

For well known, that of all symptoms of intermittent, none more general, few more distressing.

And while is an almost uniform attendant of paroxysm so also a very frequent consequence of the disease.

In so much that none more liable to frequent headaches from slight causes than those once subjected to intermittent

Many who from this origin subjected to headaches on every easterly wind.

Many with whom return in regular & periodic manner under same form, as intermittent itself.

And indeed, thus often considered as remaining intermittent, though all other symptoms removed.

Hence then by no [measure] singular, that should here [take] place.

Nor one we even to wonder at occurring to such extent as to render her [sometimes] incapable of standing.

To headache, vertigo to which subjected is I think entirely to be referred.

For one well known to be very frequent concomitant, & affect of other.

Thus [then] appears that many symptoms which may with considerable probability at least, be traced to intermittent.

But some, & these too what have succeeded only to that disease, with regard to which greater room for doubt.

This particularly the case with regard to catarrhal symptoms to which subjected.

Is affected we are told, every morning with severe coughing.

And this attended with great sickness, & heaviness, or sense of weight in chest.

Seldom however with any expectoration.

This symptom may or may not arise from intermittent.

And difficult to determine which [symptoms] the most probable.

That coughs very frequently both attendants & consequences of intermittent, will not be denied.

Connection with that disease, in many instances distinctly proved from being attendant of paroxysm only.

And by no means a rare occurrence to observe them remaining after other symptoms

Here then date of this symptoms periodic returns every morning, & its not being accompanied with expectoration all in favour of connection with intermittent

But on other hand to be observed, that if cough sometimes from this [cause], much more frequently from others.

And at least equal reason for supposing that may be merely accidental catarrh.

Especially as with that disease [after] of any standing cough in general most frequent in morning.

Thus then appeared that with regard to different parts of affection much room for doubt.

But whatever view take of it, affords example of complicated, probably of obstructive [disease]

At same time prognosis both with regard to danger & obstinacy, must depend much on particular cause of symptoms.

And on supposition of [truth] of different conjectures, must be led to very different opinions as to event.

Thus if pain of side an affection merely of integumentary may be soon removed

If again, arises from any fixed affection of viscera as ovaries utmost that can expect is mitigation

And probably notwithstanding utmost efforts though temporary relief, will yet in end increase in violence.

Nay from augmentation of affection, [although] at present nothing alarming need not even be surprised at fatal conclusion.

This however the part of present patients affection, giving most grounds for alarm.

All symptoms which are mere consequences of intermittent, may in no long time, even without interposition of art, be removed by operation of system itself.

While again reason to hope, that this removal, may be not a little forwarded by the remedy which known to be so successfully employed in combating intermittents.

By these means if cough a consequence of intermittent may be overcome as well as others.

If from any other cause may yield in same manner as similar catarrh.

And nothing in present appearance at least which can lead us to dread that either particularly obstinate or dangerous.

As prognosis so practice also varied by complicated nature of affection & uncertainty with regard to it.

And if any truth in conjecture offered, different parts of affection, must be combated in different ways.

And indeed attempts to cure [hitherto] employed, rather directed to particular parts, than on general plan.

When came under our care, most urgent symptom, was pain of side

Of this from whatever cause might proceed, had some chance of obtaining mitigation, by external application of Anodyne Balsam.

Of this article need hardly observe that active principle depends on opium which contains.

For although besides [ardent] Spirits, the menstruum used, Camphor & essential oils also enter composition yet these by themselves form a very different medicine.

Opium the power of which as allaying pain, or in other words as sedative, has long been known, produces of this effect wherever applied.

And particularly seems to be increased in proportion to sensibility of part on which acts, as appears from effect as acting on stomach.

But has more especially influence on pain from particular parts, when acting on nerves on surface nearest to [these]

And thus also avoids inconvenience from action on alimentary canal as binding belly or like.

By this then & particularly by degree of costiveness already subsisting led to application externally, in present case.

While however employed this medicine externally, had at same time recourse to another internally.

Use viz of composite powder of Cream of Tartar consisting of equal parts of that article, & flower of Sulphur.

This expected, would have effect at least, of obviating costiveness.

And thus imagined, that headache might be alleviated.

But looked for still more advantage from it as counteracting cough.

For in affections of catarrhal kind, very generally product, of considerable benefit.

After continuing on these medicines for some time, pain of side became much easier.

An affect which could have little doubt in attributing to application of Anodyne Liniment

After this mitigation obtained thought it improper to persist in use at least without intermission.

As should thus be deprived of benefit from it as afterwards producing mitigation if necessary.

But as cough still continued persisted in use of Cream of Tartar.

If however alleviation of that symptom [also] obtained is next intention to have recourse to Peruvian Bark, with a view to [weakness] vertigo & headache.

And if pain of side continues, or returns shall probably have recourse to Cicuta.

In these particulars however must be very much directed by circumstances, [hereafter] occurring, which may either tend to confirm present conjecture, or lead to other suppositions.