DEP/DUA/1/38/67 (Normalised version)

Joseph Begbie

1786

---

Joseph Begbie January 21. 1786

Respecting disease of this patient, when had formerly occasion to mention case expressed great doubts & anxiety.

And though now for considerable time under our care yet that doubt very little remains.

Still I own much at loss what idea to form even of most manifest & distressing part of complaint.

Of these first mentioned in his case is pain of right breast.

This while fixed to particular place is of dull & obtuse kind.

Is aggravated both by full inspiration & by coughing.

And last we are told a circumstance by which sometimes much harassed.

When to this added the unhealthy & emaciated appearance of patient may be considered as giving some suspicion of Phthisis

For that disease as have often had occasion to observe at commencement insidious.

And frequently has subsisted even for long time where fewer symptoms giving suspicion than even in present case.

But here I own am inclined to hope that not of this kind.

Has not that quickness of pulse which at least commonly attendant of Phthisis

Has never as far as can learn been affected with accession of hectic kind.

And with pain here occurring [though] fixed & obtuse yet some circumstances which would lead to consider it, as of same nature with other pains to which subjected.

For also affected you will observe with severe shooting pains in back & loins.

And these as well as pain of breast, are we are told most severe in bed.

While at same time augmented also on pressure.

From these circumstances then should rather be disposed to consider them as of rheumatic kind.

And to look even on pain of breast, as more consequence of affection of muscles & integumentary than of thoracic viscera.

While however disposed to view these of rheumatic kind somewhat doubtful whether this case also with headache.

For though headache often from Rheumatism yet may arise also from other causes.

And well known to be in many instances a nervous affection arising from symptoms within other parts, especially stomach.

In case before us however affection of stomach occurs to very great degree

These indicated not only by want of appetite & increased thirst, but also by distension of stomach, flatus, borborygmi etc

And no less probable that headache connected with these, than with pain of Rheumatic kind.

Especially as not like other pains observed to be augmented in bed.

Have then I own been inclined to consider headache as chiefly of nervous kind.

While look upon affection of alimentary canal as consequence of atonic & irritable state of its muscular fibres.

Great general weakness to which subjected as well as want of sleep, may be looked upon as necessary consequence of other affections.

Especially when consider that these have supervened to long continued affection of acute kind.

And when reflect that appetite so bad, that system neither [recruited] from these nor during present [properly] supported.

Whether these conjectures as to different parts complaint well founded or not, yet here at least little doubt that disease of complicated nature.

And hence hopes of speedy recovery cannot be very sanguine.

Nay cannot consider case as by any means free from danger.

For if pulmonary affects from diseased condition of lungs, in all probability will prove fatal.

Nay even though this not the case may terminate in death from mere exhaustion & debility.

But this at least less probable.

And if conjecture well founded as to affection of breast not being Phthisis here no reason for much alarm.

And am I own disposed to view affection rather as what will prove obstinate & distressing than dangerous.

In practice here from doubtful as well as complex nature of affection could hardly propose to myself any general plan of cure.

Have I own hitherto chiefly directed remedy to particular symptoms.

And see little reason to expect that shall hereafter be able to conduct practice on any different plan.

Began by directing for this patient the use of an Emetic.

This I consider as in some degree indicated by condition of appetite.

From aversion to food, as well as great thirst, had reason to suspect that stomach loaded.

And if this the case in consequence of free evacuation might expect both that appetite would be improved & other symptoms mitigated.

As an Emetic here had recourse to powder of Ipecacuanha.

This I own am inclined to consider both as most safe & most certain Emetic with which we are yet acquainted.

And when given in substance to extent of Ji or so for dose, very generally [product] of desired effect.

Though larger doses, taken without any danger of violent vomiting yet this will in general be found sufficient.

And where smaller would answer yet from this no reason to dread too much.

For as soon as begins to act, have reason to infer, that superabundant quantity will be thrown off.

Hence while abundantly certain is at same time more moderate in operation than Emetic Tartar or indeed most other Emetics

From use here were not disappointed at least in obvious operation.

But cannot say that attended with any remarkable affect on complaint.

For appetite still continued as bad as before.

And pain continued with usual severity.

From this led to think of some remedy more particularly adapted to them.

And imagined, that if remedy employed such as could obviate costiveness to which patient subjected might have good effect in promoting appetite.

For no doubt that constipation often a cause of anorexia.

Remedy to which had here recourse a powder [composed] of equal parts of Gum Guaiacum & Cream of Tartar.

To this composition have of late in Rheumatism cases very frequently had recourse in practice.

And is you will observe introduced among formulae most frequently in use in Dispensary under title of Pulveris Guaiacum composite.

The Guaiacum given in variety of forms has long been in use with Rheumatic patients.

Often fashionable in form of Volatile or spirit Tincture.

Often employment acted upon by watery menstruum as in decoction of woods.

But of all formulae which I have tried, am inclined to consider present as one of cheapest, most convenient & best.

From conjoining with Cream of Tartar while influence as diaphoretic not diminished, has in general less affect as healing.

While at same time, has in general, effect of keeping belly gently open

Imagine therefore that might here be useful both against Rheumatic complaints & affection of alimentary canal.

While however employed this, directed also at same an external application with view to immediate action of pained parts.

To unguent Terebinth, as is called in Dispensary practice, a composition formed by rubbing, with hogs lard, a proportion of Oil Terebinth, directed addition of proportion of Tincture Thebaic.

The Unguent Terebinth in simple state, often employed as substance for Camphor oil.

And though not applicable in every case, yet not a few, where answer same purpose.

Particularly where, skin unbroken, & deep seated pain to be combated.

Where does answer is a much cheaper medicine, a circumstance always to be regarded in Dispensary practice.

But as the Unguent Terebinth by itself a cheap substitute for Camphor oil, so with addition of Tincture Thebaic, here ordered, furnish substance for Anodyne Balsam.

An article which need hardly observe often successfully used for combating severe pain.

And was with this intention that had here recourse to substances ordered.

In expectations from this however, as well as from powders, were somewhat disappointed.

For notwithstanding use of both, pains nothing alleviated.

And while powder had effect of gently moving belly, imagine also that occasioned some unease at stomach.

While at same time informed that from distress during night, patient could enjoy very little rest.

From these considerations then determined to employ powder less frequently & at same time to give an anodyne [medicine] at bed time.

But in place of using opium by itself, here conjoined it, you will observe, with two other medicines.

Equal parts viz of Opium Camphor & Assafoetida.

From first had in view the obviating pains in general & procuring sleep.

Camphor again employed, with view to headache in particular.

And may here observe, that by many practitioners, particularly by Dr Hope, has been found in cases of nervous headache, product of best effects.

And this, if am not mistaken, have seen confirmed by my own experience in such cases.

With view again to distension of stomach & flatulence directed the Assafoetida.

This I need hardly observe one of the most powerful of carminatives.

And here consider distension of alimentary canal with wind as being cause not only of many of stomach ailments, but also in some degree, of dyspnoea.

For by such distension, free descent of diaphragm is prevented.

On different grounds expect that from these pills, patient might derive some benefit.

And in this expectation whether conjecture as to nature of affection well founded or not, am inclined to think, not altogether disappointed.

At least, at succeeding report, both breathing relieved & slept better.

In this situation was natural to hope for still farther benefit, from continuation of medicine.

Accordingly directed to persist in employment as before.

But a circumstance occurred, by which this interrupted.

For at succeeding report were informed, that from use of powders, was affected not only with sickness, but vomiting.

This I own was inclined to consider, as rather uncommon.

For although from these powders, have often seen brisk catharsis, yet do not recollect any former instances, where occasioned vomiting.

At least, if we except those cases, where vomiting consequence also of every other medicine.

For in some instances condition of that viscus such, that by everything touching it, vomiting excited.

Here therefore, should I own be disposed to ascribe it, rather to condition of stomach than effect of medicine.

Time indeed, at which taken, rather unfavourable.

For no doubt, that many medicines have this effect, when taken on empty stomach in morning though no influence if taken later in day.

Perhaps also, dose of preceding evening had some influence in this way.

For will observe that besides Camphor & Assafoetida, took in pill at bed time to extent of grain is of Opium.

And this well known to be an article, which though first effective, to quiet & allay action, yet after operation over, with many leaves stomach in [painful] irritated state.

In so much that though opium product of best effects during night, yet often succeeding morning sickness & vomiting even spontaneous.

But whether these circumstances, any influence in inducing vomiting or not, its occurrence from Guaiacum powder an objection to continuation of use.

Since that therefore, have continued him, with use of Pills of Opium Camphor & Assafoetida alone.

But during use, quantity as is indeed requisite with opium, has been gradually [increased]

So that now takes two pills 3 de die

That is between 7 & 8 grains of opium.

Cannot decidedly say, that from this course, patient has derived any great benefit.

For very possible, that all change for better which has taken place, may have occurred without medicine.

And indeed, as have already remarked, uncertainty as to nature of affection, now little less than at first.

But at same time during use at least, very considerable mitigation of affection has in different respects taken place.

Unless therefore led to it by some particular occurrence shall probably [think] of persisting for some time longer in use.

At same time, am unwilling to render habitual to patient, opium to extent here given.

Unless therefore pain urgent & watchfulness great, shall probably both diminish dose, & frequency of repetition.

While at same time, have recourse to some stomachic bitter, with view to strengthening tone of alimentary canal, & to improve appetite.

But in these particulars, must be very much directed, by situation of patient at the time.

And where so great uncertainty as to nature of case, difficult to form even probable conjecture with regard to practices which may be necessary.