DEP/DUA/1/44/31 (Normalised version)

Alexander Paterson

(1788)

---

Alexander Paterson at 39 N^o6^th

When this patient came under our care disease consisted entirely in affection of knee.

But since that subjected to a supervening affection. Pain of breast, cough & dyspnoea.

These however merely a catarrhal affection which inclined to consider as of no great consequence.

And although some practices may be necessary for counteracting it, yet still consider, affection of knee not only, as primary complaint but as that deserving most attention.

And in this, as formerly observed some singular occurrences.

Is indeed by no means rare to meet with cases where long continued & violent pain from knee.

And this also, as indeed must necessarily be case, accompanied with diminished power of motion.

Of this daily examples in that [modification] of scrofula which has name of white swelling of knee.

And likewise where both less obstinate & less severe in cases of Rheumatism.

But in both one & other a disease obvious.

In former large & considerable swelling essential characteristic.

And in latter not only does this occur but in general also some degree of similar affection of other joints.

Here however no appearance whatever of disease in joint itself.

And only obvious affect some apparent wasting of limb below.

Hence then differs at least from ordinary appearance of rheumatism as affecting that joint

And besides this, has not as far as we can learn had common progression of that disease.

Never appeared under acute form.

Has not like most rheumatic pains been subject to exacerbation & remission.

But has now uniformly continued for space of three years.

And during all that time has gradually increased in violence.

From these different considerations then would not pretend to give positive judgement of this case.

And not impossible that may depend on some local affection of joint of which entirely ignorant.

But at the same time though thus differs from ordinary Rheumatism cases some to which more nearly appears.

Particularly that modification which often seated in hip joint & has name of Ischiadicus.

For there also disease often continues long [obstruction] fixed in one part without any affect of other.

There also without obvious swelling.

And there, as in present instance, often wasting of parts below.

While at same time, in this case as in Rheumatism in general, at least in certain stages of progression, not only aggravated from motion, but also from action of cold.

On these grounds then prognosis formerly given, that consider it as obstinate Rheumatic affection could not look for speedy cure.

But at same time entertain hopes that in end should be able at least to alleviate if not entirely to remove it.

And since patient under care no reason to alter opinion, or to entertain more or less favourable expectation.

On this idea also treatment of case hitherto directed.

Here however to be observed that under name of Rheumatic affections differing very much from each other, are comprehended.

And require very different nay even in some respects, opposing modes of treatment.

Chief of these morbid affection, shall [after] in practical course endeavour to describe under titles, of stages of inflamed irritability atonia & paralysis.

Here however would be foreign to business to enter into distinguishing marks of each.

May only observe that very manifestly is neither in state of inflammation nor of paralysis

And if Rheumatism must view it as being either in state of irritability or atonia

Perhaps as in progress from one to other & partaking in some degree of nature of both

In these cases several different intentions of cure, which a practitioner will naturally have in view.

But cure chiefly to be expected by altering condition of nervous power in part.

And by counteracting effects of morbid sensibility.

While in many instances, both one & other, not a little effected, by increasing tone of moving fibres in part.

Is with these intentions, that remedies [hitherto] employed have chiefly been directed.

Began you will observe by directing for patient the internal use of Hyoscyamus

This article though recommended by ancients particularly Dioscorides & Celsus, as means of alleviating pain had fallen very much into disuse.

And for revival as well as introduction of several other useful articles [are] indebted to Dr Stork of Vienna.

Since publication of his treatise to De Strammonio Hyoscyamus & Aconitum¹ has been in very frequent use.

And accordingly has now a place in most modern pharmacopoeia² of Europe.

Is perhaps singular that not admitted by London College.

And that too although several of their own members have committed to the public [imp] observations respecting advantage derived from it.

For my own part after pretty extensive experience for several years, am inclined to consider it as a very valuable medicine.

Extract of Hyoscyamus properly prepared though not equally powerful with Opium yet product of many of best effects.

And particularly those of allaying pain & inducing sleep.

Is besides this free from some of inconveniences of which opium produces.

For some habits with whom that valuable medicine disagrees very much from [affecting] head.

And with whom every practice [commonly] employed for counteracting narcotic effects proves of no avail.

Besides this opium often also [inconvenient] from influence as binding belly.

Hyoscyamus on contrary tends rather to move belly than otherwise.

From these considerations then often [inclined] to give it even in preference to opium with view of obviating pain.

And among other diseases in which pain most distressing symptom have frequently employed it with success in Rheumatism.

On these grounds then directed it, to present patient.

Cannot however say, that present instance affords any example of benefits to be reaped from it

But before taking notice of effects may be proper to observe, that while this medicine directed internally, had at same time recourse also to an external application viz Unguent Terebinth cum Opio.

This formed by dissolving opium to extent of ℥p. in double that quantity of Oleum Terebinth.

And by uniting these by means of [illegible] with two ounces of Hogs Lard.

In this manner forms very penetrating & at same time very powerful anodyne ointment.

Is in many respects analogous to anodyne balsam so well known in [practice]

While at same time both a much cheaper medicine & also some other advantages

Particularly as from unctuous nature [admits] of longer application

And in many instances of local pains have employed it with best effects.

From these practices therefore not without hopes of some benefit.

And by first account received from patient these hopes were encouraged.

For after using them for space of week thought pain somewhat diminished.

And at same time imagined that could walk with more facility than before.

A consequence which in some degree inclined to attribute to relaxing effects of ointment.

But still more to mitigation of pain.

For aggravation of pain from motion a sufficient cause for preventing walking with freedom

And ease in walking perhaps best test of diminishment of pain.

In this situation naturally encouraged to persist in use of medicine.

And as imagined that good effects of Hyoscyamus might be increased from augmenting dose, ordered pills to be taken to extent of ten grains every morning & evening.

That is two grains of extract at each dose.

For every five grain pill contained one of Hyoscyamus.

This dose even from [commencement] should have by no means esteemed large one.

And at same time opium like Hyoscyamus & indeed almost whole [tribe] of Narcotic medicines has influence very much diminished from habit.

Concluded therefore that without any inconvenience & with some [prospect] of advantage might have been increased.

But had not at least [effect] of giving any additional relief of pain.

For at succeeding report found that no farther abatement had taken place.

And although still continued to walk with more ease than before yet slept worse during night.

While at same time was much affected with pains in belly.

These consequences he himself was disposed to attribute to increased dose of medicine.

And not impossible that conjecture may have been well founded.

For with all the narcotics effects [all] from very trifling circumstances.

And accordingly not uncommon to observe opium in place of inducing sleep gives rise even to watchfulness.

While certain that with some Hyoscyamus considerable influence as stimulating bowels.

Not improbable then that may have produced effects here suspected.

At same time no less probable that these may have arisen from some other accidental circumstance.

But at any rate consider it as sufficient reason for diminishing dose of pills.

Even with diminished dose however, found that at succeeding report, these symptoms rather aggravated than otherwise.

And as still ascribed them to pills thought it unnecessary to persist in use.

From this therefore led, to drop also external application & to adopt another mode of cure.

Use viz of Electricity.

This I need hardly observe, one of most powerful agents on human system.

And when topically applied is unquestionably most penetrating stimulant yet discovered.

For no doubt that active [fire] makes way through parts.

But any particular account of action would be foreign to present case.

Sufficient to observe, that when employed under form of sparks, a most powerful agent, both in restoring lost & diminished morbid sensibility.

And that a most active means of renewing circulation through obstructed vessels & restoring activity of moving fibre in general.

On these grounds I apprehend it is that to account for benefits from it in cases of Rheumatism.

And in such particulars in atonic state verging to paralysis often employed with very great benefit.

In not a few cases of this kind have I think employed it with great [advantage].

And besides this have also used it with great benefit in some cases of anomalous pains.

Where reason to believe that acted as removing morbid sensibility of affected part.

On these grounds then led to direct it in present instance.

But since use first directed, from different accidents has been but little employed.

After first using it thought pain of knee considerably diminished.

But before had opportunity of repeating it seized with an accidental catarrhal affection.

By this confined to house for some time.

And although now able to come abroad yet when last visited us these symptoms still distressing to him.

Seemed therefore necessary to do [something] with view to mitigation of these.

And with this intention ordered composite powder of Cream of Tartar to extent of Tea spoonful twice a day.

This consists of equal parts of Cream of Tartar & Soap.

And often useful in such affections, both as promoting discharge by belly & increasing urine.

For by free discharge in either way [some] relief to breast.

With view however to affection of knee which will probably prove most obstinate.

And if patient can be made to continue with tolerable regularity shall wish to give it fair trial before having recourse to any other practice.

If these necessary choice regulated by situation in which shall find patient at the time.

---

Explanatory notes:

1) Anton von Störck, Libellus, quo demonstratur: stramonium, hyosciamum, aconitum non solum tuto posse exhiberi usu interno hominibus, verum et ea esse remedia in multis morbis maxime salutifera (1762).

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.