DEP/DUA/1/42/33 (Normalised version)

George Donaldson

(1787-1788)

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George Donaldson at 29

Disease of this patient formerly pronounced an example of that disease generally known by name of Ischias.

An affection no less frequent than often highly distressing & obstinate.

During treatment of this case have had no reason to alter Sentiment.

Formerly expressed opinion of obstinacy of case & doubts with respect to recovery.

And these must acknowledge in no degree removed by anything that has since occurred.

For must be acknowledged that hitherto at least have made no progress to recovery.

And although little hesitation in giving name of Ischias, yet not without doubts as to [nature]

For while chief characteristic of this disease severe pain, occupying thigh & leg, yet this pain may arise from very different causes.

According to this genus several different species are referred.

In nosology of Sauvages will find that has enumerated ten different species.

And most of these too on authority of accurate observations.

Not a few of them even subject of daily observations.

Can be no doubt that pathology of these different species considerably diverse.

Thus can hardly suppose that same morbid affect cause of pain in Ischias, Intermittent Syphilis Venereal etc

But without entering into pathology of other species may only observe that in present patient example of Ischias Rheumatism

Or in other words a Rheumatic affection particularly seated in left thigh & leg.

Rheumatism a disease which whether occurring in local or general manner, often during course considerable variety in nature.

And requiring with view to successful practice that these varieties should be distinguished from each other.

In practical course shall attempt to point out distinguishing marks of four different states of it.

Those viz of inflammation or irritability of atonia & of paralysis.

A distinction the rather necessary as to each, particular modes of cure more especially adapted.

At present however out of place to enter into these.

May only observe that disease of present patient has evidently passed first state that viz of Inflammation.

Of this sufficient evidence, from period of continuation from state of pulse & absence of other febrile symptoms.

But of being still in state of irritability may infer from aggravation on heat of bed.

A circumstance strongly characterising that state.

And indeed following as consequence of additional impetus which circulation thus acquires, being able to excite pain in consequence of action on very irritated parts.

Of irritable state also a farther evidence in case obtained by hard labour during course of day.

For while this tendency to aggravate state attended with inflammation on one hand & atonia on other often tends to give at least temporary diminishment of morbid irritability.

On these grounds then consider this affection as example of Ischias Rheumatic in state of irritability.

And is on this idea of the disease that treatment hitherto directed has proceeded.

Began you will observe by directing for patient a mixture of which active basis the Oleum Terebinth.

This article long in use in this affection even among vulgar in this country.

Perhaps indeed more than [among] regular practitioners.

Has particularly been a remedy prescribed by Farriers.

And as directed by them at least while sometimes product of cure, in other has had bad effect, sometimes even fatal consequences.

For particular account of some facts of this kind may refer you to paper published about fifty years ago in medical essays of this place by late Mr Stedman of Kinross.

But has by no means been confined to vulgar only.

Was employed by celebrated Dr Cheyne as will observe from treatise on gout¹ with success in own case when laboured under inveterate ischias.

But always considered as somewhat dangerous & never extensively employed.

Of late however highly extolled by Dr Hume & by him a good deal used in Royal Infirmary² at this place

For account of it refer you to his volume of Clinical Experiments.

Mixed up with Honey in form of Linctus. Ol. ℥ii. to Mel. ℥i.

And this taken to extent of tea spoonful m & vesp.

Though not always yet in majority of cases found it successful.

And that too in general at least with but little inconvenience to patient.

As to mode of operation, those who have employed it most, differ in opinion

Some consider it as operating merely from influence on stomach, & as exerting general stimulating power of essential oils.

Others again attribute effects to influence as diuretic.

And in this way at least has in general obvious operation.

While third set consider its action as depending on peculiar stimulation exerted in diseased part.

And to this again a peculiar sensation excited in part some time after [action] seems to give countenance.

Am inclined to think that may be some truth in all these conjectures.

Am however inclined to attribute its influence chiefly to operation as stimulating diuretic.

But not very material in what manner operates provided really product of effects alleged.

And had here recourse to it not so much on any experience of my own as on authority I have just mentioned.

As being however a medicine of considerable activity did not wish to try it in large dose.

And indeed by some extent of dose limited to ten or twelve drops.

In place of Honey diffused it in mucilaginous mixture aiding union by addition of sugar.

Introduced the Oleum Terebinth to extent of ℥i in ℥VI

That is about ten or twelve drops in ounce.

This quantity our patient directed to take daily.

And although after being taken excited for some time rather disagreeable sense of heat in stomach, yet no great inconvenience.

And particularly no vomiting or sickness.

Followed however by obvious operation of exciting considerable discharge of urine.

And attended also with considerable alleviation of pain.

Still however of such severity during night as almost entirely to deprive him of sleep.

But hope that by continuation this might be overcome.

And as wished to see effect without having recourse to any other medicine directed merely that should persist in employment.

From farther use diuretic effect although not increased was however continued.

And at same time imagined that during day at least could walk with more ease than before.

Still however pain particularly in night as severe as before.

And by this almost constantly deprived of rest.

Seemed necessary therefore to employ something with view of procuring sleep.

And as most effect article, at least in generality of cases had recourse to Opium.

Gave it under form of Pill Thebaic one of most convenient & best modes of exhibiting.

As aromatic with which united often operates as corrigent.

These directed to extent of grains X - 1 of Opium.

A full dose with those unaccustomed to article - grain 30 of Liquid Laudanum.

In effect of these however our expectations were not answered.

For nights still continued as sleepless as before.

And only effect seeming to arise from them, that of inducing, remarkable drowsiness through day.

And on this account patient had of himself deserted use of them

In this situation, though still as necessary as before, thought it better to vary prescription than to persist in employment

And accordingly to Pill Thebaic substituted the Pill extract Hyoscyamus.

In every five grains of this mass one of extract of Hyoscyamus enters.

And in this extract have, next to opium, most powerful sedative with which I am acquainted as allaying pain & inducing sleep.

Directed here to extent you will observe of grain ii viz X of pill.

And that might better secure operation during night directed their being [taken] early in evening.

While with view to pains which still continued severe directed that should persist in Oleum Terebinth

To this the rather encouraged as still continued to produce diuretic effect

But this not of much longer continuation.

For at succeeding report, found that augmented discharge of urine had ceased.

While at same time, pains more urgent than ever.

In so much that now confined to house & indeed almost entirely to bed.

In this situation seemed requisite either to increase dose of Oleum Terebinth or to desert use.

And as large doses, sometimes attended with inconvenience while at same time had already been used for several weeks without any material benefit chose latter plan.

In its place therefore have now had recourse to an article from which have lately been informed that in some cases of Ischias very great benefit has been obtained viz Powder of Cicuta.

This directed to extent of grain V ter de die.

And with view of promoting diuresis as well as keeping belly open conjoined with some powder of Cream Tartar.

With this have directed continuation of Hyoscyamus.

And to give it fair chance have directed it to extent of grain iii, at still earlier period.

According to effect obtained from these future practice will be directed.

But not improbable that may have recourse to measure formerly suggested of blister & issue.

And I own now less hopes than formerly of being able to do much good to this patient

At same time many other practices which may still be tried with some hopes of success.

And I have known several instances where Ischias had obstinately resisted [every] mode of cure that could be thought of for several years, & [where] afterwards complete spontaneous recovery.

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Explanatory notes:

1) George Cheyne, An essay on the gout, with an account of the nature and qualities of the Bath waters. Intended for the benefit of Richard Tennison (1720).

2) The Royal Infirmary of Edinburgh, established in 1729.