DEP/DUA/1/42/29 (Normalised version)

James Ritchie

(1787-1788)

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James Ritchie at 8.

Formerly observed that case of this patient not without doubt.

That symptoms such as occur in commencement of several different diseases.

While could not be considered as characteristic of any one.

Chief affection a complaint of febrile kind.

But of irregular type.

And at same time chiefly characterised by distressing headaches.

These well known to be appearance with which acute hydrocephalus often attended.

And often for some time no other appearance.

But here may be thought that suspicion corroborated by other particulars.

Particularly by state of sleep during night.

For while sleeps little that sleep also disturbed by frequent starting.

If therefore should in end turn out to be that affection, could not be said that appearance at commencement uncommon or anomalous.

And certain that often subsists for some time where even less grounds for suspicion.

But if some circumstances in favour of supposition others against it.

Particularly wants one of most common symptoms the vomiting.

This as may conclude from variety of circumstances a common symptom of [ opp.] brain.

And unquestionably one of most frequent at commencement of Hydrocephalus

Particularly as returning at intervals of two or three days

If vomiting a common symptom of Hydrocephalus bound state of belly no less so.

This however you will observe also absent here.

To these objections to suppose a third also to be added drawn from progression.

Here more slow than in much greater number of instances of acute Hydrocephalus.

Before came under our care had subsisted for fortnight.

Ere then however might have expected commencement of 2^d stage.

Particular slowness of pulse.

These particulars then consider as rendering supposition rather improbable.

And besides to be remarked as already said, that while symptoms of patient such as often occur in hydrocephalus take place also in other diseases.

Particularly such febrile affections often consequence of worms in alimentary canal.

And with many would be considered as not a little in favour of presumption of these that patient affected with grinding of teeth during sleep.

That this a very frequent symptom from worms not to be denied.

But at same time judgment would be very erroneous if to infer these present wherever this symptom occurs.

Well known to take place even in disease last mentioned.

And among other particulars to increase difficulty in distinguishing in some cases between symptoms from worms & hydrocephalus.

But besides that not diagnosed some supposition many of principal marks of worms here wanting.

When these present very generally principal part of affection severe gripes.

And in place of appetite being impaired commonly even voracious.

While with worms in general discharge of glairy stools.

And seldom that symptoms from worms of long continuation without some of them being discharged.

On these grounds then conclude that still stronger objection to supposition of worms than of hydrocephalus.

But worms & hydrocephalus by no means only affections giving rise to such febrile affects as that occurring in present case

[These] not unfrequently arise from even very trifling irritation in alimentary canal

And then particularly attended with diminished appetite & with grinding of teeth

Then also fever particularly marked by headache as leading symptom.

And then especially slow & lingering suffering exacerbation & remission.

Of these there suppose then conclude this to be most probable.

And accordingly on this supposition treatment of patient has hitherto proceeded.

Begun you will observe by directing use of an Emetic.

In this had chiefly in view unloading the stomach.

A means of removing irritation from one & indeed most essential part of alimentary canal.

For unquestionably most sensible as giving affect of system in general.

But besides matters accumulated in stomach pass downwards

And thus exert as it were action on whole tract of intestinal canal.

Hence from evacuation of stomach benefit here to be expected on different principle.

And indeed indicated by want of appetite.

But even supposing conjecture as to nature of case not well founded, yet still might here expect some benefit from use.

For without pretending to say how happens certain that in many febrile affections from concussion of Emetic best effects may be obtained.

Strong reason to presume that in commencement of fevers from contagion even in plague itself Emetics have sometimes cut short the disease.

And not unfrequently same effect even at after periods.

Some indeed consider these affects as following only from use of Antimony Emetic.

And look on James Powder. Tartar Antimony as like as possessing peculiar & as it were specific power.

This opinion however as far at least as can judge from my own observations am inclined to consider as ill founded.

And am persuaded that no other effect results from them, than consequence of obviating operation particularly as Emetic.

And this effect of producing full vomit may with greater certainty & with more safety be obtained from Ipecacuanha.

Need hardly remark that this Emetic very rarely fails, very rarely produces more effect than wanted.

Both one & other however frequent consequence of the Antimony Emetic.

Particularly those which in state like James Powder not soluble in water

And which for solution in alimentary canal require acid or liquor of stomach.

Accordingly with one condition of stomach, although taken to great extent, product of no effect.

With another even in small doses product of very violent effects.

In so much that in some instances, especially at early periods of life, have seen very violent effects from use.

And on this account am I own disposed very generally to give preference to Ipecacuanha over antimony emetic.

Ipecacuanha though more slow in operation will yet have effect when exhibited even in small doses.

And taken even to great extent seldom if ever product of excessive vomiting

For operates from being subjected to infusion, or rather perhaps warm digestion in stomach.

And as soon as infusion sufficiently active for exerting action of vomiting the superfluous quantity it may be allowed expressly expelled by action of vomiting.

In this manner would account for moderation & regulation as may be called of operation.

But whether this conjecture well founded or not certain that effects, by no means proportionate to quantity taken

That while from small dose seldom disappointed in operation large one almost never observed to do too much.

And from these circumstances look upon it as being upon whole much preferable to any other Emetic with which yet acquainted

While directed emetic prescribed also a combination of Magnesium & Rhubarb.

Of these articles neither can be considered as possessing any great degree of activity.

Yet both separately & conjoined often of very great service.

Particularly in affections of alimentary canal of infants.

No doubt that many of these affections the consequence of superabundant acid.

And in Magnesium have a most powerful agent for destruction of acid.

In many cases has advantage over almost every other [from] tendency to open belly.

A consequence probably of its rather neutralising than destroying acid.

This laxative power not a little increased by addition of Rhubarb.

Which while operates as purgative in first instance tends afterwards to strengthen tone of intestines.

Accordingly from this combination in [variety] of affections of infants depending on condition of alimentary canal have I think seen best effects.

With present patient Emetic product of wished for effect in inducing full vomit.

And after this several of symptoms, particularly distressing headache considerably relieved.

While in every other respect appears much better.

A circumstance in some degree at least corroborating opinion, that conjecture as to nature of disease well founded.

Still however some symptoms [remain].

And while slight febrile [exacerbation] at night, Magnesium had no effect in moving belly.

Directed therefore its continuation in increased dose.

But whether in this operates according to intention or not, am hopeful, that will be necessary to do little more for this patient.

If however in this disappointed future measures must be accommodated to state in which shall find him.