DEP/DUA/1/38/65 (Normalised version)

Betty Lindsay

1785

---

Betty Lindsay. 14^th January 1785.

Affection of this patient consists almost entirely in severe pains.

And these seated in different parts of body.

Chiefly however in head, left arm & right leg.

In these places also pains not constant.

Or at least much more severe at some times than at others.

From situation as well as nature then can have no hesitation in [conviction] as of Rheumatic kind.

Do not indeed it is true particularly affect the joints.

But though joints most common seat of Rheumatic pains by no [means] confined to these alone.

And especially often seated in head.

While also to be observed that although pain in other parts, yet joints not exempt.

Hence then from situation no presumption afforded that rather of venereal than of Rheumatic kind.

For must be allowed that among other circumstances distinguishing Rheumatism from venereal pains, is observed that while former affects joints, latter chiefly in middle of bones.

But besides this, with venereal pains, in most cases a local affection to be [detected] about middle of bones.

And very generally also other symptoms of Syphilis.

Of these however in present case not slightest suspicion.

But besides this what may be considered as affording incontrovertible proof of absence of Syphilis during greater part of disease has been nursing healthy child.

Idea of Rheumatism also corroborated by cause to which affection traced.

Began from exposure to cold which if not only at least most common cause of Rheumatism.

And that exposure during puerperal state when well known, that system most susceptible of injury from cold.

Upon whole then no hesitation in pronouncing affection to be Rheumatism.

Here however no symptoms of any considerable inflammatory disposition.

No marks of any local inflammation.

And indeed after affection had now subsisted for space of two years, which the case before came under our care was hardly to be expected.

Even then indeed from renewal of causes [running] of inflammation & as it were recurrence of disease

But very generally long ere that period has degenerated into other state.

Not unfrequently even into the paralytic.

This however could not be said to occur in case before us.

But at least so much loss of muscular power in limbs affected, that there had evidently occurred, a considerable degree of the atonic condition.

Pains however still manifestly augmented as soon as became hot in bed.

A circumstance which consider as great characteristic of irritable state

And which indeed to be considered as affect of increased impetus on parts possessing high degree of irritability.

While again in paralytic state of Rheumatism from all heat some alleviation takes place.

Upon whole then consider this as case of Rheumatism passing from irritable to atonic state.

And indeed in some degree palate of natures of both.

As to prognosis must own am now rather more doubtful than when patient came under our care.

For at that time, hoped that should be able to do good deal, if not in removal, at least in alleviation of affection.

Disease indeed had been of such standing, that could not look for very speedy recovery.

But at same time even spontaneous mitigation of severity had occurred.

For much less violent when came under our care than had formerly been.

And although of long standing yet as far as could learn, no proper remedy tried either for alleviation or removal.

Hopes however which then entertained have not I own been fully answered

For although partial remission at one time obtained yet have again returned with former severity.

This however when consider severity & inconstancy of weather by no means surprising.

For thus almost constantly exposed to cause renewing affection.

And indeed at this season, such a return of affection, under circumstances much more favourable than that of our patient would not have been wondered.

After however trial already made hopes of speedy removal cannot now be very sanguine.

Especially as no reason to hope that weather soon more favourable.

For though may not have return of severe frost, yet reason to look for weather still more distressing to Rheumatic pain

What viz. cold rainy & inconstant.

And indeed perhaps no season when Rheumatism more severe than spring.

Although however thus continuation & recurrence of disease yet still hope for alleviation.

In accomplishing this, from idea given of affection, two great objectives to be aimed at.

The removal viz of morbid irritability in parts on which pain may be considered as principally & immediately depending.

And the removal of atonic state, with which parts affected which while it probably has great influence in augmenting & supporting irritability, is to be considered as immediate cause of loss of strength, which has occurred.

With view to accomplishment of these ends, have had recourse to remedies here employed.

Began by directing for her, use of Extract of Hyoscyamus.

Hyoscyamus or Henbane one of those articles, which belongs to natural order of Luridae or Solanaceae, as have been called.

An order comprehending greatest part of narcotic vegetables.

And like many others of same tribe, possesses to no inconsiderable degree sedative power of allaying pain.

Indeed no article perhaps, if we expect [illegible] itself, or in other words opium, has in this way more influence.

Accordingly with this intention, employed by earliest practitioners.

And particularly celebrated by Dioscorides who may be considered as first writer of [illegible] on Materia Medica.

But notwithstanding this characteristic, had fallen at least much into disuse.

Particularly after free introduction of opium, which must be allowed in general at least more powerful.

Of late however, employment of this article revived.

And attention of practitioners particularly called to it by Dr Stork of Vienna.

From this as well as from other narcotic vegetables according to his account most surprising affects to be obtained.

For my own part, am I own, very far from giving credit to what Dr Stork says respecting his favourite medicine.

Yet as little agree with those who allow him no merit.

And even allowing all he has said to be fiction, is yet I think, entitled to thanks, from having called attention to articles of very active nature.

Among others, have for my own part no doubt, that on different occasions have seen best affects from Hyoscyamus.

Many things indeed respecting this article consider as yet to be ascertained by future experience & careful observation.

Particularly for ascertaining circumstances in which agrees with Opium & circumstances in which differs

In some degree to promote this end, an experimental inquiry concerning this article proposed by Harveian Society¹ as prize question for this year.

And flatter myself with hopes that may afford no unimpeded addition to dissertation on subject of opium at present under consideration.

Hyoscyamus as employed for medical purposes especially when taken internally given under different forms.

But of various parts of plant, leaves almost alone in use.

And these contrary to what is case with respect to Cicuta have a much more strongly narcotic [smell], than seeds.

Were formerly given, chiefly in powder or infusion.

But now principally employed under that of extract.

Or more properly of succus [inspissation]

For in our Pharmacopoeia² at least, is not an extract prepared from decoction of dry herbs, but merely inspissation of recent juice.

In some modern Pharmacopoeias indeed, a preparation somewhat [different].

Thus in Pharmacopoeia Suecica after inspissation has proceeded certain length, a proportion of powder of leaves added.

And perhaps as in case with our extract of Cicuta, gives a mass fitter for form of pills.

But in this, in medical virtues, probably very little difference, from mere inspissated juice.

Which in appearance as well as quality more nearly approaches opium than any other preparation.

For has in strong, nay may even say in concentrated degree narcotic [smell] of plant

And to this in general at least narcotic powers are proportional.

To This extract in cases of Rheumatism in state of irritability have often before had recourse.

And not without very considerable advantage.

Particularly as allaying severity of pain & especially those aggravations occurring from warmth in bed.

Imagine therefore that might here be product of [similar] affect.

And that might give to patient quiet & refreshing nights.

Here employed it under form of what call Pill ex Hyoscyamus.

Where united merely with such a proportion of bread as to give proper form & enters to quantity of one grain in every pill of grain V

This dose have in general found even with adults sufficient both for alleviating pain & procuring sleep.

At least on first employment.

For to be observed that in consequence of [habitual], affects of Hyoscyamus as is case with opium are diminished

And that like opium energy is as it were [suspended] by violent pain.

Hence to these two, circumstances dose to be proportional.

But whether from under dose, or from some other cause, found this inadequate to removal of pain or to procure rest.

Accordingly at succeeding report augmented to double quantity.

Even from this no great influence.

And although some mitigation of pain yet little rest during night.

Thought therefore that no inconvenience from still farther augmentation.

Accordingly directed to extent of grain XV of mas bis indies

That is six grains of Extract in the day.

But suspecting that irritability might be supported by want of tone had here also recourse to another remedy.

The use viz of Peruvian Bark.

Respecting the affects of this article as a tonic practitioners in general at least very much agreed.

Is common opinion, that in generality of cases, is one of most powerful & best articles which can employ internally with that view.

And of advantage to be reaped from it even in early stages of Rheumatism have already had occasion to speak.

Observed that even in inflamed stage of disease after remission of pain obtained nothing more powerful in preventing return

And hence might be considered as well suited, for a case of the affected part of nature of both irritation & atonia.

Especially where reason to believe that former very much dependent on latter.

Here therefore ordered to extent of ℥i twice a day.

While this medicine employed in conjunction with former they seemed to be product of best affects

For pains not only considerably mitigated but quiet sleep during night.

In this situation of symptoms, perhaps did wrong, in ordering Hyoscyamus to be omitted.

But now at least no urgent necessity occurred for employment.

And imagined that by continuation of bark alone remains of disease might be removed.

Was unwilling therefore to persist in use of medicine which any danger of rendering habitual to patient

And well known, that from frequent use of opium, affect not only lost, but continuation, rendered even necessary for patient.

Wished therefore at least for space of week to see in what situation would remain without it.

And imagined, that want in some degree compensated, by directing Bark thrice a day.

But unfortunately happened, that in place of one only, both medicines were in great measure intermitted.

For when next saw her here, powder we were told had occasioned sickness at stomach.

And from this circumstance few of them had been taken.

While at same time again considerable augmentation of pain.

But whether, from want of former medicine From uncommon severity of weather or from some other cause will not pretend to say.

In this situation however thought it inadvisable to persist in use of Bark.

For although vomiting from use an uncommon occurrence & probably here proceeded from some other cause, yet while this opinion of patient could not suppose that would regularly take it.

As she herself, disposed to ascribe return of pain, to want of pills, naturally thought of repeating these.

Especially as afforded better opportunity of judging how far former relief to be attributed to employment.

For if same affect again followed use was at least rendered highly probable.

If by means of pills, have again remission of pain, shall not think of giving up use so soon.

But will at least persist in employment in diminishing dose.

And if pain aggravated before relinquished use, shall probably augment it still farther.

Notwithstanding vomiting also is my intention on another remission to have again recourse to Peruvian Bark.

And from combining influence, with milder weather, yet hope, that in no long time, patient may be in situation to be dismissed.

If this however not the case future practices must be accommodated to circumstance.

May have recourse to external application of Unguent Terebinth cum Opio.

May if can obtain it, make trial of the Rhododendron.

Or may employ Calomel with Opium

But at present farther suggestions superficial as even these perhaps never employed.

---

Explanatory notes:

1) The Harveian Society was founded 12th April 1782. The idea came from Andrew Duncan senior who had also been behind the setting up of the Aesculapian Club and the Edinburgh Medico-Chirurgical Society.  Duncan envisioned a larger club than the restricted Aesculapian to take over the running of the prize essay competition which had started in 1777 and to run an annual festival to commemorate renowned medical figures.

2) An official publication containing a list of medicinal drugs with their effects and directions for their use. The Royal College of Physicians of Edinburgh's Pharmacopoeia was first published in 1699.