DEP/DUA/1/17/04 (Transcript version)

Margaret Gray

(1778)

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Margaret Gray.

Case of this patient evid. of complic nature.

And while some parts of affect at time when came under our care very manif, other with regard to which had from begining & still have very great diffic.

This partic the case with most urgent part of compl.

Pain viz which from shoulder of right arm shoots downwards in such mannr as to affect whole of that limb.

Here accord. to descript given us pain cheifly seated in joint.

And these neither swelling inflam. nor any othr appear. to which can be referrd as cause.

Although evid local morbid appear wanting yet not imposs that may depend on some local & topic cause.

While however no indicat of such must be led rathr to conject that is to be accounted for on some othr footing.

And that depends more on state of nerves themselves than on any [partic] cause giving painful impress. to these

For hold that all pain must ultim depend on cert. impress commun by nerves to sensor.

And that such must ultim be referrd to one of two gener. sources.

Either cause acting on nerve or condit of nerve acted upon

When therefore no evid of former, that is pecul cause, whether in way of [chance] or mechan stim, of distens, contract or like naturally led to lattr suppos.

And must refer ascribe pain to pecul state of extrem of nerves in part to which referrd.

Such consider to be very gener. the case in that disease known by title of chronic or perhaps as many with greatr prop. be stilld the aton. rheum.

May naturally then occurr as quest how far pain here is of that kind.

In fav of this suppos sever [argt] may be adduced

Yet at same time if really [chron] rheum is at least with pecul circum

This however will more partic [appear] from exam of diff argts for & against such a suppos.

Is somewhat at least in fav of suppos of Rheum that pain situat in one of large joints.

In these indeed cannot be refused that pain may arise from other causes.

Partic sprains or the like.

But well known that of all parts of the syst. the large joints more espc. seat of Rheum affect.

Hence when othr causes not obv. this at least more readily susp.

Here also to be observd that pain chief. seated in joints propag in course of musc

A circum not always occurring in rheumat. nor entirely pecul to it.

Yet so freq. & so much pecul. that enters best defin.

And partic used as mark for disting rheum from pains with which in many other respects agrees those viz from Gout.

Taken therefore in conj. with other circum serves at least to corrob. suppos.

And besides that what already mentiond of situat of pain may mention as [illegible] encrease of this pain on motion.

This indeed it must be allowd, take place also, with pain of joint from other cause.

Partic when occurs not merely as conseq. of white swelling or other cause giving obv. disease but when has proceedd from sprain.

This case howevr excepted is but very rarely at least that pain on motion of joint cont for such length of time, from any other cause except Rheum.

When therefore consid that here patien not exposed to any cause giving spasm serves at least strength. presumpt.

But besides these a circum on which perhaps still more to be rested is the augm severit of pain from heat in bed.

This indeed not a partic which in all stages & every inst of Rheum unif. occurrs.

But while some other partic mentiond in common to pain from Rheum & from other causes this in great meas. pecul to Rheum. affect.

And when occurring may I appreh. in some degree at least be consid as [patha].

Not here our business to inquire either into causes on which dep. or at what stages of the disease more espc. [occr.]

Suff. to give presumpt of Rheum that such an occurr manif. does take place

May only in gener. way observe that seld occurrs during first period of [inflammation] inflam stage

And while some disp to consider it as pecul to state purely chron. other look upon it as charact of interm state between the acute & chron.

Perhaps of the two this most freq. the case.

Yet am fully persuadd that may occur also where Rheum advan to chron. state

And indeed if pres. inst an examp Rheum affect have here example of it.

For in dim heat have mark of chron condit advanced to even greater height.

Lastly as farther circum in favour of Rheum may mention acct given of progr. of affect.

Are informed in hist of case that this pain of no less than four years [cont].

And that then commencd with pain not only in shoulder now affectd but also in most othr large joints.

Partic in knees & ancles.

From this descript then little doubt that at least commen as Rheum.

And although chron Rheum may occurr without [acute] having preceded yet unquest. that most freq beg. in that state.

From all these [argt] then taken [togth] ground for pres. that pain here of the Rheum kind.

And must own should have little diffic in giving this opin with some deg. of confid were there not othr circum which in some degree measure occur as obj to the suppos.

Of these then shall [next] take short view.

Here then to be observd that pain in case of our patient fixd to partic joint.

This however very rarely the case with chron. Rheum.

Especially in those inst where follows as immed [sequela] of acute.

And where as was case with our patient this acute Rheum extended over whole syst.

Fixed & partial situat then must occurr as some obj. to suppos. of [pain] being [here] of Rheum kind.

To this may perhaps also add place in which situated.

Had affection been here in hip joint long cont. would perhaps have been less surp

For hold that gener of disease which have obt name of Lumb. Ischias &e are no other than Rheum affect.

And under these forms have freq. occas to observe dis rem. for long time with great obstin.

That large joints of super. as well as infer extrem are freq. also seat of Rheum cannot be denied.

Yet may without hesit [affirm] that inst. of such obstin pain at joint of [illegible] very rarely to be met with.

And if pres. entirely Rheum. must add that is only inst. I have ever met with where sev pain in should of such cont

To these pecul. in pres. case may add as third const. & unif of pain.

Are indeed told that pain aggrav by motion.

And that partic severe during night.

From these circum have drawn argt in fav of Rheum.

But besides being varied from these causes Rheum also to very great degree affected by state of weather.

Such variet partic manif when [assum] chronic state.

In so much that from return pain greatest part of Rheum patients can even [foretell] changes.

With our patient however no circum of this nature has ever been observd.

And may therefore justly consid it if not as obj to Rheum at least as [pecul].

To these circum may perhaps add as still farther pecul the cont of free motion

Not indeed same tenden to collect of cretaceous matter about joint as in case of Gout.

Yet here also even such after disease of long contin freq. do occurr.

And where these do not occurr yet with atonic state of musc. fibres rigid in ligam takes place.

From either one or other however motion cannot fail to become diffic.

And this should naturally have expectd even at much earlier period of disease.

Lastly some obj even from insensib & coldness.

Is indeed true that these common sympt of Rheum in most chron. condit.

And that chron Rheum often even degen into Paralys.

Yet loss of heat & motion sense rather to be viewd as prop. paral. than Rheum symp

And pure paralys in incip state not unfreq. accomp with even very acute pains.

From these circum then, some room to doubt as to nature of affect.

And give ground for suspic that may be pure paralys.

To this indeed must at same time be observd that many obj. occurr.

Partic that pain ushering in paralys rathr of transit than const nature.

And pres. merely enum among circum giving some ground for susp. or [shewing] pecul.

Upon whole then appears that from sever circum some diff as to this part of patients compl.

Yet cannot help thinking that from argt first adduced suppos of its being a Rheum affect the most probab.

And to me seems no unreas suppos to expl pecul. here from accid mentiond in case

Stroke viz receivd on right shoulder from fall at time of Rheum.

From sensib extrem of nerves being then in morbid state no doubt that from such injur greatr pain excited than at any other time.

And although not a gener. occurr yet may conceive that from injur in this manner even perm morb condit in sensib extrem may occurr.

Thus far then have deliv sentim respecting first & what must now at least view as prin part of affect.

That this affect not attended with sympt of Gonnor.

That evid [accom] with common concom of Leucor pain of loin & back.

Besides this howevr pres. pat affected also with other compl.

At least this this to no inconsid degree the case when came under our care.

And although have for some time disapp. yet not improb. that may soon again return.

These compl. at same time such as constit an affect often very obstin & very troublesome with women.

What I allude to is the viscid [muc] disch from the Vagin.

This need hardly observe is princip sympt occurring in Leucorrh.

Takes place indeed also in other affect partic in Gonnorrh.

And distinct between the two when [reasn] to suspect verac of patient often [extremely] doubtful.

In pres. case howevr sever. concurring circum which can leave little ground for doubt.

When consid that not prin disease for which patient came undr care of diff natur

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That evid connected with menst flux

That had cont. for much longer time in one state than Gonnor. ever known to do without changing form.

And lastly that since came under our care had yielded to med used with [inten] of remov of Leucorrh. have if not cert at least probab. evid of that affect.

Viewing then diff parts of patients dis as being of nature now ment. next come to be quest. how far in any degree comm with each other.

That this may be the case not improp

Yet must own can discov. no circum indic connect.

And when consid that dis. commen at diff times.

That indep of each other subj to changes.

That while at pres one has almost [entrly] ceased othr has even encreasd in viol.

And that rheum not remarkd by any other author as prod of Leucorr. can I appreh. have little diffic in pron. that are totally unconnected.

After this view of diff parts of affect to which patient sub when came under our care & to which indeed still sub. next to speak of Prognos.

And here can with no degree of confid give fav. opin.

One part of her compl. indeed, as have already observd, has either spont. ceased or yielded to med employd.

Yet even of this can by no means trust that has obt perm or complete cure.

While on other hand affect of arm since came under our care rathr aggrav

And that too notwith employm of various remed. which on suppos. [ment] may might be supp. to have had influ in remov. of it.

When to this circum add [cont.] which has already had can have little hopes of recov.

Yet must at same time observe that nothing which threat. immin danger.

And should consider it as singular were patient ever to fall vict. to this compl.

Yet although hold that neither to be consid as a danger. dis nor to be easily cured, am far from asserting that will cont. stat in pres. situat.

Look upon it as most probab. that pain will be soon less severe, but that same time sensib also will dim.

And shall not be surprized to find it termin in total Paral.

While howevr patient cont to attend us must not only take what meas we can to prev this but also to remov of affect.

Come next then to remarks on pract.

In this have in part had in view both affections.

But by much greatest numb of remed employd, directed against pain of shoulder.

This however will more partic appear when come to speak of them in order in which exhib

Began by direct for patient a mixt. in which united simple Elix of Guaiac with Tinct of [Catharid].

To these also added Simple Syrup & common water

But with no othr intent than to give formulae.

Was on two former artic that consid effic of med as solely resting.

First the Guaiac meant solely with view to affect of arm.

Need not observe that under diff forms has long been used with great [illegible] in Rheum cases.

And perhaps no forms more effic than those in which unit. with Spir. Menst.

Used in solid state from [illegible] [illegible] of resin, than gummy [nature], not sol. in Stom.

And from same reason with most watery menst. cannot be unit with out much diff

Where Gum itself attempt to be conj to water, is rathr diff by aid of viscid or mucil matters, than any thing else.

In Decoct. Lign indeed virtues of [Guac] extracted by mere watery menst.

But there, prop of Guaiac entering it but very inconsid.

And prob. to be prin consid as mere diluent.

Of those prep of Guaiac formd by spir menst. two enter Pharm which in freq. use.

The simple & Volat Elix.

Of late, latter highly extold in Rheum by Dr Daws of London.

And in my own pract have in many inst used it with great advant

Still however consid it as matter of doubt whether advant reapt from that formul. not rather to be ascribd to menst. than to [Guac]

And unquest in cases where stim requis. advant may be expectd from this.

Especially when exhib to great extent to which now given.

And accord in some inst have seen I think manif advant from Vol. Aromat. Spt.

But in others also, think that have derivd good effects from Simp Elix.

With trial of this therfore resolvd to begin

Espec. as imag. that less risk of any bad affect, than with resp. to other parts of pat. compl.

With use of Guaiac however with view to Leuccorrh. joind small prop of Tinct [Cath].

A remed of which some in this affect, have very high opin.

And which supposed to operate as [pecul.] stimul. to uterus.

That this may be the case do not deny.

Yet know no partic phaenom by which confirmd.

And from my own exper. can say very little of its effic.

But whatever may be power must yet admit that with our pat. had no prop trial.

And on recur of Fl. Alb. to consid extent had recourse to a med with regard to affects of which, was less doubt.

That was the use of Alum.

This one of those states in which the vitriol acid as an astring may be exhib with not least advant.

And consid this disease to be gener at least affects of relax. hold that no remed more powerful than astring.

Accord in pres. inst although pushd to no very great extent seemd to be prod of best affect.

And after last menst flow not even slightest return of it.

Would not howevr from this assert [thus] to be consid as completely removed.

But should it again return may reas. entert hopes of advant from remed already success. employd.

Have by no means howevr been equally success. in comb. othr & more matter. [form] of compl.

With this view before commen of pres course beside remed already ment, had tried Elect Blist, & Vol. Elix of Gua [with] affect.

And when introd into pres. [regis.] had begun put her with on use of Mercur. Pil.

From these howevr pushd even to extent of touching mouth, no manif advan.

And must own am now very doubtful whether shall be able to be of any serv.

Still however some pract, which may at least be tried.

And among these have now directed one to which in simil inst. have not before had recourse.

That is the Extract of Hyosciam

Need not observe that this remed first introd into pract by Dr Stork of Vienna

And by him extold as of highest utilit in many diff affect.

In hands of othr pract power has not been found prod of same benef.

Yet from many concur. testim appear to consid degree to exert sedat influ.

And at same time to prod this affect without binding belly.

But while exerts influ as narcot veget, is supposed as well as [cicut] & some other of same tribe to be of penet. & resolv. natur.

On these prin then have been induced to give trial in pres. case.

And that rather on authority of a Gent. lately a pract in New Eng. who informs me that in some cases of obst. pains has often employd it with very great success than from observ of Dr Stork.

Dr Moffat, the gentleman to whom I allude inclind to think that extract of [Hyos.] prep. in a clim such as that of New Eng. may be more powerf. than what prep in this country.

And in some meas. to determ this by trial has sent me small parcel of extract prep. [there].

Is his extract which at pres. using with this patient.

And if find it prod of no bad affect shall give it as fair trial as am able.

Should it succeed after attempts already abort. must own will give me much higher opin of this med than have before had

Should it fail am greatly at loss to think what can next try with any prop. of success.

Have thought howev of at least trying how far full dose of anod. will have influ as giving tempor. allev. of pain.

And if intern use of little service may see what can be deriv. from it extern

May have also recourse externally to stim ointment.

Partic to oil of Turpent & Vitriol acid in this form.

May again employ Mercur either for frict externally or in some othr form intern

And must indeed observe that know few med more effic in obstin Rheum cases than Calom.

Yet after all very appreh that shall dismiss patient not beter than found her.