DEP/DUA/1/16/06 (Transcript version)

John McInnes

(1777-1778)

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At least of the two more freq. to have [such] pains aggrav. when first heated in bed than [other]

John McInnes

History of this patient [case] affords example of a disease simple & uncomp.

For I appreh. that little room of quest that all sympt here occurring in [real] parts of same affect.

And indeed sympt although appear in affect of very distant parts of body are of no great variety.

Princip affect pains in diff. parts of body.

But princip if not entirely conf to joints.

These pains cheifly remarkab. on exertion or motion of joint.

And on attempts to motion appears that do not possess same facilit of action of formerly.

With this pain patient least affected while in bed.

While although This in some respects a peculiarity as shall afterwards observe

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Yet probab. to be consid merely as conseq. of want of exert. at that time

But during ease in this situat anoth partic of a diff nature discov.

Observed that parts affected not of same heat with others.

That is not here same tend to free circulat on surface.

And such in partic, moder. temper. in bed is apt to induce.

These diff sympt of pain rigid & want of heat of joints for space of sever. months before patient came under care seem to have constit sole affect.

Few days indeed before admitted on our list had observed dimin of quant of water & flatul.

Neither one nor other of these sympt have to great degree

Nor as far as can learn were they prod of any great inconven.

In so much that with regard to dimin of water was even doubtful.

And flatul. to some degree well known to arise even from slightest irregul of diet

Both affect therefore in as far as did exist may here consid as of little import

And viewd disease even at time when patient came first under care as solely consist of first set of sympt.

Follows then that should say what name to be affixed to this compl.

Of five nosol. writers will with strict prop. fall under defin of Rheum as given by four of them.

In all these defin howevr affect very vague & general.

And besides Rheum even in most extrem sense would apply also to other affect.

While disease thus under genus so vague may farther observe that cont also such sympt as would likewise lead us to refer it, to other gener.

Thus for ex. in situat of pain of in lumb. verteb & about hip joint togeth with stooping post & lameness have charact of two gener of Lumbago & ischias as def. by Mr Linnaeus some of Nosolog. partic Sauv.

Have no doubt howev that has here multip gen without reason

And that these to be consid as in no respect diff. from his Rheum unless in situat.

Under which indeed from vague defin of Rheum might readily have been [comp.]

For in general [defins] this affect. doler diuturnus in partic carnosa artuum.

But besides Rheum many othr inst of doler diut affect limbs.

And situat here fixed upon viz [illegible] carnos a circum which would rather tend to mislead as otherwise

Affect much more accur. describd in defin given by Dr Cullen.

These also as in some others disting from pains of other kinds by situat.

That viz affects articulat.

And when thus put more exactly applic than as affect of limbs.

For in many inst as in case before us affect not conf. to extrem but exists also in artic in other parts trunk of Bod.

Cannot however be refused that besides rheum pains, other pains also often arise from articul.

These however general. entirely conf. to joint.

While on other hand those of rheum kind prop. from thence in tract of muscles

From this circum chiefly it is that by rheum affect motion imped.

Whereas in other cases if is impeded cause obvious.

And very rarely if ever that affect of more than one joint at time.

While on contrary as case with pres patient in Rheum commonly affect of [illegible]

Here also as in definit of Dr C. patien disease consisted entirely in affect of larger [join]

A circum by which perhaps more than any other pains of Rheum disting from those of Gout.

And although not [a] univ yet a gener occurr.

In all these partic then pres affect very exact resemb. to defin of Rheum

But to be observed that besides [these] other sympt also introd into [defit].

And here resemb. wanting.

Besides all circum already mentioned two other enter [defin] of Dr Cullen.

Remarked that Rheum an affect commonly at least arising from obv. [extr] cause

And this also one of cheif sympt by which to be disting from gout

Especially in cases where other circum giving doubt as to judgem. which should form from seat

If however disease here affect of obv. accid escaped attent of patient.

But besides that this might read. happen, to be observed that in defin alluded to is ment. merely as common occurr.

Must however be allowed that gives slight diffic.

But if from this any [disagrem] with defin. still greater from anoth circum.

These disease ranked in class of Pyrex. & under order of Phlegm.

And besides this arrang. pyrex introd as constant sympt of the affect.

With our patient however no reason for concl. that pain arises from active inflam

[Most] of those sympt charact that state here evid absent.

No swelling obv redness or sense of heat.

But if [suspicion] of absence of phlegm from these partic, certainly from many others, of absence of Pyrexia.

Here not smallest app. of any febrile affect.

Must either therefore look upon introd of pyrex into definit as [improp] or conclude that our patient not affected with Rheum

That Rheum in certain state with [greater] prop. ranked among inflam. diseas. cannot be denied.

Unquest evid of inflam both in causes sympt & cure.

While at same time febrile affect pres also to very high degree.

In this state however disease seldom cont. for many weeks.

And with termin of fever all indicat of inflam affect at same time cease.

Still however pains occupying same place, and if not simil in nature are so at least with regard to course in which propag.

Such pains not like former [const] & severe while obvious local affect cont

But suffer very consid remissions & return cheifly on partic accid.

Partic apt to be excited by change of tempr. whether by action of heat or cold & by motion.

In that such a state constit the affect [which] in most pract systems known by title of chron. rheum.

And consider it as it were as more advan stage of same affect.

That compl. now describd most commonly conseq. of formr cannot be [refused].

Yet in other cases such pains arise where no evid of active inflam or acute fever has preceded.

And whether conseq of former or not can be little doubt that whatever [source] of sympt in other partic nature of affect essent. diff.

This not more manif from diver. in partic already mentiond than from cure.

May be quest then how far acute & chron. Rheum should not in reality be consid as diff gener of disease.

From every circum attending formr reason to conclude that pain & indeed all other sympt proceed from inflam affect of parts.

While in latter equal reason for pres. that pain which occurrs is conseq. of spas.

And that this again immed effect of atonic state both of muscul. fibres & vessels of part whether induced by preced inflam or by any other cause.

If however this opin as to nature of affect well founded while term Rheum approp. to former had [better] disting [later] by some [appellat] express of pain at joints or rather of extrem of muscles or ligam

Such for ex as arthralgia [illegible] desmalgia &e.

But after num term invented by late nosol. as express. names of diseases will naturally be thought that farther multip of terms to be avoided.

And must own that think should in gener. be endeav. rathr to [rebranch] than to encrease numb of gener. terms.

But whether here introd new term or not of great conseq. that should attend to distinct.

In many cases however this extremely difficult.

Which indeed necess. conseq. of one being so frequently sequel of other.

From this must unavoid happen that during part of prog hard to say to which head ought rather to be referrd.

In extremes however from circum already mentiond distinct suff. [ease].

For most part may be done by cont of disease alone.

Strong presumpt at least that of acute inflam kind when but of short durat.

And that of atonic when as in inst before has cont. for months.

But as in some inst [cases] aton condit condit may occurr in first inst & in others inflam may be excited at late period [farth] necess to have diagn in sympt.

May cheif inferr pres of latter where pain attended with swelling of joints not long fixd to partic part but sudden moving from one joint to anoth.

Where when attacks with greatest sever. is at same time attended with obvious swelling.

Where with this swelling there occurs remarkab. evid redness of paind parts.

But above all where pain attended with quickness of pulse, heat, thirst, & other febrile sympt.

May cheif concl. case to be atonic or pain not from inflam but spasm when sympt already mentiond swelling redness & fever are absent.

When pains do not as it were occurr spontan. but immed excited by some partic cause heat, cold, or motion.

But above all when paind parts cannot acquire do not retain heat of rest of syst. When cannot be made to sweat & when assume wasted appear.

In case before us have if not all at least by much greater part of these sympt.

And thus then may be consid as affording example of pure chron. rheum

Or of that affect not in inflam but aton. state.

Thus then have given opin as to name & nature of this patients disea when came first under care

If had been at that time to deliv sentim respecting termin should I own have given it as opin that disease would prove very ted

Many circum in case by no means favourable.

Well known that after contin for some length of time becomes often a very obstin affect.

In place merely of state of aton. there occurrs even insensib. of part.

And what takes place at first under dimin of motion ends in total loss.

With our patient before came under care disease had subsisted to consid degree for space of sever. months.

And besides this two other partic from which reason to dread course already mentiond.

viz Age of patient & obstin with which affect resisted remed already empl.

Patient had already nearly arrivd at fiftieth year.

And while in advanced age less disp to inflammat. greater to all affect dep on want of tone & sensib.

This manif, even where no prop. [illegible] in shaking of head & hands & other unsted motions

From this then to be concluded that at least an unfav. period for cure.

And that this in reality case abund appeard from disease having resisted many of most powerf. remed as admin by skilful pract.

Must own therefore was appreh. that during patients contin under care disease would be aggrav.

And had very little expect. that in short time should have been able to dismiss him free from compl.

Event howevr in this respect much more fav than expectat.

And now only remains to consider how far meas to which here directed had any share in prod that affect.

From what said of nature of affect may be concluded that here general princip of cure must be very diff from what are in acute rheum.

In many respects may even be consid as opposite.

In that case consider morbid state to be combat as being merely an inflam affection.

Hence then requires same means of cure as in other inflam affect.

But partic brought about by bloodletting & by prof. sweating.

These in partic cases some inst indeed may to certain extent be admiss in aton rheum.

But to by much greatr number of inst cases are by no means suited.

On contrary great reason to suspect that very prof bloodletting used to overcome inflam state often means of inducing atonic.

Of this on other hand to expect cure by restoring to parts natural sensib & due vig.

For with atonia at earlier periods at least rather depr than dimin sensib.

And from remov of this parts less apt to be affected subj to those spasm affect from which suppose pain prin to arise.

Hence then cheifly to look for cure from med altering condit of sensib and augm tone.

All med altering condit of sensib referrd to two great classes.

Those viz of Stim & Sedat.

In last unquest most immed means of counteracting morbid sensib.

Effect however unless [illegible] to very great extent for most part tempor. only.

While afterwards affect rather augm.

Hence then prefer. in general to be given to stimul.

By these may induce both alterat in condit of Nerv. fluid at part & in common between affected part & [sensor].

Thus in as far as tone dep on state of nerv. power means of rest. it.

And here conceive them to operate on same prin as in paralyt affection to which [indeed] aton state of Rheum may be conceivd as being as it were an [illegible]

Appears then on what footing stim calcul for this affect as depend on condit of nerv. infl. at part.

But here atonic state connected with pecul. laxity both of vessels in part & of moving fibres.

And former in partic often induced by degree to which [streaked] during preced inflam.

Is then on this ground that while [man] benefite from stim not less from such artic as tend to brace parts

And thus whether by action on them as simple or as moving fibres natural condit restored.

These then gener prin on which I imagine that can expect to overcome this affect by use of stim & tonics.

To be observed however that while these well adapt to Rheum in purely aton. state must necess. be prejud while inflam tendency remains.

Hence then while disease in progr from one state to other greatest [illegible] respecting treatment.

And then cheifly to be overcome by such med as comb. some degree of evac with stim power.

Have already however observed that consid disease of this patient when came under care as having arrived at purely chronic state

Imagined therefore that hope of success alone from stim & tonics.

And from circum already pointed out expect from these by no means high.

Some of them partic cold bath one of most powerful tonics had here already been tried to no purpose.

Besides this howevr several others both external & intern from which some chance

And partic among tribe of stimul.

Externally to paind parts could have recourse to applic with Camphor Oil of Turp & Vitriol acid

Internally to Mercury, Mezer Aconit. Arnica and the like.

Had however I own greatest hopes from use of Electricit.

And was intent in this case, to have given fair trial pushing to utmost extent which patient could bear.

But prev to beginning use resolvd to see what in this case could be [deriv] from vol. Elix of Guaiac.

A remed which of late years cheifly on authority of Dr Daws of London [have] used in many inst.

And I think with very great success.

From what have seen howevr am now inclind to think that much more depends upon menst than on [Guaiac].

For here menst employd is Spt of Sal Ammon.

And this which well known to be very powerful stimul often given to great extent.

But on whatever activ may princip depend obv. effects in general are slight degree of [Diapn] & cathar.

Hence then may be consid as in some meas. comb. evac with stim powers.

And thus suited for interm cases.

With pres. patient prod obvious affect in both ways already mentiond but to very moder. degree.

From commen of use howevr pain very greatly dimin.

And from no very long contin even entirely freed from them.

In this situat as he himself thought farther attend unnecss. had no obj to his being dismissd.

And am in hopes that unless from expos. to cold or some other exist cause, aid which has obt may be perman

Yet should he ever return again subj to compl. will still be disp to consid pres as strong inst of effic of med.

And then perhaps before employing any othr again recourse to it.