DEP/DUA/1/23/09 (Transcript version)

John Coarser

(1780)

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John Coarser.

Case of this patient of doubtful nature

But not with out some threat app.

Princip compl. severe pain of side

Has now cont with obstin & fixd to partic part for space of 6 months.

Ground therefore for pres. some fixd cause

Such contin indeed not uncommon for affect of rheum kind.

And although these prin conf. to joints, yet affect also attack of muscles at other parts.

Among these not unfreq seated in intercost.

And here also greater probab as extended to shoulder.

But if such pain in some inst from bounder of thorax still more freq from intern parts.

Partic obs. to arise from affect of lungs, or surround memb. [pleur]

And not only from inflam of these, as in some acute affect. but also from suppurat.

Hence fixd pain attend of ulcer abscess of lungs or memb. whether under form of Vomica or Empyema.

And of this here the rather [presum] from three circum.

Cough viz & State of pulse & Respirat.

Former of these has contin for equal length of time with other symp

May indeed, it is it true, arise from variety of causes.

Is conseq of every irrit to lungs.

And more freq indeed, of other irrit such as that of mucus, than of any fixd cause.

But among others may be conseq also of tubercule & vomica.

And of this here probab. the rather as cannot ascribe it to mucus.

For unless in morning when some accumul during night, cough not attended with expect.

With other circum then freq sev. & dry cough gives count. to cause from which have sugg. that pain may arise.

And this I think still farther corrob. by state of pulse.

For here to be obs. that very consid quickend above natur stand.

In so much that 108 puls in min.

With this celerity indeed, cannot be said that patient subj to hec. fever.

For none of those fits of cold or heat by which markd.

Yet quickness shews const. irrit

And perhaps even may add debilit state & irritab. state

Hence then also fav suppos.

But if presumpt. from cough & pulse, still more from state of respirat.

To these three might add also another circum

Cause viz to which comp. [illegible]

Is ascribd to action of cold.

This indeed a cause which may prod great variety of affect

And therefore little foundat for pos. conclus.

Yet may at least say that a possib probab cause of affect here supp.

And cert. affords no contrad to suppos.

This are told interrupt or short, & laborous.

Circum serving to shew that that free motion of lungs impedd.

And indeed more freq conseq of space which should be occup by air, being filld with other matters, than from any other cause.

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Upon whole then may I think conclude that abscess of consid size, either in lungs or surround memb. is a cause from which all sympt, to which patient at pres subj. may be explaind.

Still however cannot speak with great confid.

For circum which alone can give certain evid still wanting.

Actual disch viz of purul. matter.

Hence then can at pres suggest it only as suppos, which to me at pres appears more probab. than any other.

Suppos such vomica or abscess to exist yet still would not at pres say that patient subj to Phthis.

For consid not merely possib of [purul] absorpt from lungs but actual affects as prod hectic fever, to be essent. constit.

And such as far at least as have been able to learn, has not yet taken place.

This however not to be consid as any obj to suppos.

For in every other part of syst. can observe large collect of purul matter without hectic.

And in many cases is only in conseq of rupture & of access of extern air, that hectic [induc]

This partic manif in case of Psoas abscess. – under musc at upp part of thigh

These though cert. of large collect of matter, yet may subsis for consid time with any hectic sympt

But soon after opening, hectic occurs, which in gener. fatal.

How occurr from admiss of air to be expl. matter of some diffic.

Yet two circum may be ment which seem to oper. & which probab. prin concern.

Action of air, from stim extrem of vessels, prob affect of encr. absorpt.

Thus greater quant of purul. matter taken up than before.

But besides this probab also still greater influ as prod diff matter.

For in place of thick, white colourd pus, at first disch soon assumes more thin bloody & sanies appear.

Hence then both from encrease in quantity of absorp, & change of matter hectic access, may be induced.

Thus may understand why in pres case, where abscess if exist yet entire, are wanting.

Although therefore patient not at pres subj to Phthis yet if supp well founded in greatest danger of it.

Hence then when consid nature of that disease, on idea of pres affect, progn cannot be fav.

If Phthisis shall occurr most probab will termin in death.

But may yet observe, that Phth here to be expected of the purul or ulcer [kind]

Which although more danger than catarrh, is at least less cert. fatal than tuberc.

Besides although abscess already formd yet purul mattr collected may be rem without rupt.

And hence without access of air, [vitiat] matter.

For well known that cont of abs of consid size, taken up ent. by [absen.]

Thus then even suppos conj well founded case not desperate.

And if as it first hinted shall turn out that pain merely of Rheum kind not even dangr.

Yet upon whole, though at pres. nothing very urg. am disp to fear the worst

With respect to cure from opin which at pres incl. to adopt little I think at pres now to be done.

Suppos abscess to exist cure of all sympt to be effected by removal of pus, & by coalles or heating of cont. parts.

Latter of these entirly dependent on operation of syst.

And prob would soon follow [could] former be affected.

This again to be brought about either by artif or natural outlets.

In case before us, no circum indic any probab of disch externally.

Even from cavity of chest indeed purul matter disch from extern [open]

Yet very rarely that any thing in this way can be attempted unless when some mark in [integ] [direct] to place where open to be made.

But here in state of uncert. such an operat as [illegible] of Thor. not to be dreamt of.

And in as far as to be disch by artif open, can be only, by rupt into air vesic of lungs & conseq expect.

Such rupture often happens in conseq of mere distens & eros.

And when this not of itself suff, may be forwarded by any circum giving concuss or agit of syst.

Often by such artif open alone that disch of abscess can be obt.

But when can be entirely taken up by absorb. & thrown off by excret. from what already said must appear [press] made.

For this freed from dangr & incon arising from access of air.

In inst before us then, was inclind to look upon it, as [pref] pract. to see what could be done in this latter way.

And during meas for this purp., imagind that circum might occur giving higher probab.

Hence then could with greater confid afterwards attempt to aid rupt, by means giving concuss.

These intent will expl. pract already employd & which have afterwards in view unless change opin as to nat of dis

Began treatm of case by applic of blister to paind parts

From this on diff grounds expected some advant.

Suppos affect not of nature susp. but entirely of Rheum kind, still a very applic remedy.

For well known, that in diff state of that affect prod of advant.

And in this case perhaps even more serviceable than if conj well founded.

Here however directed as means of promot absorpt on suppos of abscess.

As answering this intent operates on two footings.

Both viz by evac & stimul power

Well known that encrease of absorpt is effect of evac[ants] in gener.

But partic of those combining with evac, a stimul power.

And indep of reasoning known from undoubted exper. that this affect a conseq from blisters.

Perhaps not very matter here, that should have been applied as near as possib to paind parts.

For unquest capab of evac at least in some degree, from syst. in gener.

And as little doubt that stimul effect also extended over whole.

But still latter in partic more consid in neigh. parts.

And to these more especially propag.

As promot absorpt indeed, more powerful evac might have been employd.

But to these situat of patient, & appr. with regard to conseq. Phthis occurd as strong object.

Upon whole then thought no meas. here better calcul. for remov. of purul matter collectd by natur outlets than [sep.] blisters

But besides this useful also as as changing determin.

For from augm circulat in part to which applied dimin determ to lungs

Hence well known that benef from them in variety of pneum affect.

Consid them therefore as well entit to trial in pres. inst.

Applic of first blister seemd to have good effect.

For pain of breast, as well as dyspnoea very consid dimin.

From this therefore encour at least to future trials.

Pract however of repeated blisters requires some interv.

[And] in mean while was necess that should not appear inactive.

Espec as patient notwith relief, still subj to distress. cough.

Was rather however as placebo than any thing else, that had here recourse to mucil mixt.

For although may be highly useful where irrit at fauces, yet little to be lookd for where cough supp, as supp to be case with this patient, by fixd irrit cause in lungs.

Ultim therefore remov. to be expect only by remov of abscess.

Still however mucil mixt. might not merely give some satisf. to patient & attend, but also take off some irrit.

While at same time a pract from which nothing to be appreh.

And which could be supp. in no degree to interfere with blisters.

To repet of these therefore is intent to have recourse every ten or 14 days

And some ground for expect that may at least facilit disch of purul collect by natur outletts.

If in this however in end disapp. & if no reason to alter conject as to nature of disease must next aim at artif disch.

With this view no means more likely to prod rupt of Vom from concuss, & afterw. to prom expect, than Emet.

To these therefore repeated at prop interv, if no circum occurrs to [illegible] use shall next have recourse.

And if should not prod rupt. will still be means of prom absorp. also.

Hence may be useful with same intent as blisters.

These then meas on which accord to pres idea of disease should place great confid.

May however occas employ others, with view of obviat partic sympt.

These however must be entirely [accom] to occurr, of which in no degree aware.

Of these therfore can say nothing at pres.

Nor indeed of future plan of treatm provided reason to alter op of nature of disease.

As in that case must be accom to sentim afterwards adopted.