DEP/DUA/1/38/43 (Normalised version)

Ann McNicol

1785

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Ann McNicol November 26^th 1785.

Respecting disease of this patient there is I think no room for doubt.

Can have no hesitation in considering principle part of disease, & indeed what led her chiefly to apply for our assistance, as being an affection of Rheumatic kind.

In this disease, must indeed be allowed, that diagnosis not always an easy matter.

For in some instances distinction in particular, between gout & rheumatism, very difficult & uncertain.

But in other instances, occur each so distinctly marked, that very little room for doubt.

And in case before us sufficient to observe, that patient is a female & one of labouring poor.

That disease neither preceded nor attended by any affection of alimentary canal

And that is, & has been through whole course, seated in larger joints.

But although affection principally of Rheumatic kind yet not entirely without complexity.

For besides this, subjected also to catarrhal symptoms.

Particularly cough & pain of breast.

These latter symptoms as ascribed, & probably with justice, to late exposure to cold.

And reason, I think, to conject that to same cause, are also to attribute other parts of affection

For well known, that Rheumatism, very generally the affect of cold.

And that to action of cold, Women particularly in rank of life, of our patient, who cannot afford any keeper are very much exposed during nursing.

Which has then the rather affect, as often necessarily exposed to cold when [previously] sweating.

At same time must be observed that upon whole, duties of nursing cannot be considered as unhealthy.

For except during pregnancy has been remarked, that no equal period, of life, during which fewer deaths.

Yet will readily be allowed, that neither pregnancy, nor nursing [exima] from disease

But may at least in some degree lead us, to more favourable prognosis.

For in place of being any cause of alarm, should, from this circumstance, consider patient as in less danger.

But independent of this circumstance, neither affection can be considered as of dangerous tendency.

Rheumatism indeed a painful & distressing disease.

But even in very worst cases, terminates rather in lameness, than in death.

And in present instance, is not of such a violent nature, as to threaten either of these terminations.

While catarrh again, although very distressing to her, may be considered as but of recent date.

And is subject of daily observations, that after such continuation, as has here taken place, has often gradually declined, without use of any remedy.

May therefore, I think, by aid of proper medicine, reasonably hope for favourable conclusion, to both affections.

At same time must be observed, that both season of year, & occupation of nursing, not a little against speedy recovery either from catarrh or Rheumatism.

While by both circumstances, are at least somewhat restrained in use of those remedies which might otherwise employ with greatest prospect of success against those affections

Hence then cannot be much disappointed if notwithstanding remedy employed, should continue for some time.

Yet hope that by these, favourable termination, will at least be forwarded & promoted.

In Rheumatism, treatment very much varied, according to circumstance of case.

And particularly by state of disease at the time.

When come to treatment of Rheumatism in practical course shall endeavour to describe & point out, four different conditions of this disease.

States viz of Inflammation of Irritability of Atonia & of Paralysis.

But without here entering into particulars, shall only observe that consider disease of our patient, as in second of these states, viz of Irritability.

This sufficiently marked, by absence of fever & of weakness & insensibility characterising other stages.

And by transitory swellings, pain on motion, & on slightest impression the attendants of this state.

In this state of the disease, there seems to exist in pained joints, a peculiar irritability.

And by this means, constant disposition both to renewal of inflammation, & to painful sensation from slightest impression on diseased part, even any slight increase of [impetus], in circulation.

Hence then cure chiefly to be accomplished by removal of this disposition, & by obviating influence of impression on part.

This to be chiefly accomplished from diminishing irritability itself, or from counteracting its affects.

And at same time, from supporting determination of fluids, from diseased to sound parts.

For each of articles separately I had before often used in rheumatic cases. To this combination

Is I apprehend on these principles that may look for good affects from the internal remedies, which here directed for this patient.

Combination viz of Opium & Calomel.

At same time must acknowledge, that where here directed it, employed it, rather on recommendation of those, who have used it very extensively, & with great success & on some experiences which have had of good affects from it in my own practice, than on confidence, founded on any theory respecting mode of action.

To this remedy, or at least to this combination + I had first recourse on recommendation of Dr Hamilton of Lyme Regis.

On this subject will find a paper of his inserted ninth volume of Medical Commentaries of this place, published about 10 months ago.

There he candidly delivers the [results] of eighteen years experience in the use of this medicine.

And it appears, that in a variety of affections, particularly in inflamed diseases of most violent & dangerous tendency, was product of best affects.

Among others, employed in Rheumatic cases even in those of acute & inflamed kind, with greatest imaginable success.

Here however, must own that have neither ventured implicitly to follow Dr Hamilton in diseases in which he has used it, nor in mode of administering.

In very acute inflammatory affections particularly those of Pleuritic & Peripneumonia kind hardly I think time, for slow operation of Mercury.

At least have never in these, from expectation of relief by other means, ventured to delay attempting relief of patient by superadding to bleedings the immediate [illegible] of blisters.

Neither have I given it, in so short space, to extent Dr Hamilton directs.

For to some of his patients, five grains of Calomel, with one of Opium, given every six hours.

And with effect of producing obvious operation sometimes in way of purging, sometimes of sweating, Saliva Diuresis.

And even in cases, where no obvious operation, yet very speedy & considerable relief.

In this mode of practice, success of which, I am inclined to think, he has fairly represented I have not however I own implicitly followed him.

But from beginning, was disposed to think, that many advantages might result from this combination.

That from use of the Calomel some of inconvenient results from opium would be obviated.

Particularly affect of binding belly often distressing to Rheumatic patients

Was inclined to think also that opium, while had immediate affect of relieving pain, & diminishing irritability would at same time obviate some of inconveniences & aid operation of Calomel.

Particularly that would prevent its running off by stool, & determine influence, more to surface.

For on this principle, as well as on affects in restoring equable circulation, & remove obstruction, am disposed to explain benefit which often experience from Calomel in Rheumatism cases

This article employed by itself, I heed hardly observe, long held by some, in highest esteem in Rheumatic affections, of chronic kind.

Indeed one of most eminent practitioners in London, has I am told asserted, that in this affection never knew any other remedy succeed, never knew Calomel fail.

And although, for my own part, can by no means say so much in praise of that medicine, yet have often observed product of best affects.

These considerations then, led me to follow Dr Hamilton in employing combination of Calomel & Opium in cases of Rheumatic kind in part.

And I think, have often used it with very great benefits.

And that too without any other obvious operation than the exciting gentle diaphoresis probably supporting constant increase of insensible perspiration.

But in combination, have by no means followed always same proportion.

Regulating proportion by condition of patient.

Here condition of disease, which suppose to be in state of irritability, joined to circumstance of patient being a nurse, seemed to indicate, more sparing use of Calomel & more free of opium.

Accordingly in Pills here directed, [double] quantity of latter to former.

But besides this had recourse also to opium externally with view to immediate action, on pained parts.

For is I apprehend, from sedative affect of opium, that are almost entirely to explain, relief derived from external application of Anodyne Balsam.

Am in hopes, that from these remedies, patient will soon derive very considerable relief.

And inclined to think, that may not merely counteract Rheumatism, but also Catarrhal affection.

And on this account have directed nothing particularly, with that view.

If this practice succeeds, to wish, probably only other measure employed will be, giving patient few doses of Bark.

If not, future practice must be very much regulated by state in which shall find patient after due trial has been made.