DEP/DUA/1/34/02 (Transcript version)

William Courage

1784

---

Wm Courage Febr 14^th. 1784

With regard to disease of this patient when came under care patient first app for assist was I own much at loss.

And although has now been under care for sev. weeks still in same situat.

Nay circum which have since occurrd, have in my opin, tended rather to encr. diffic than illust [nature] of affect.

When first app for assist. most [distr] sympt. consisted in pecul [pricking] pain under left mamma.

Const. of this pain as well as encr. on coughing or even on inspir. gave reason to believe that dep on some local affect, & that too even [within] the thorax.

And this may be thought not a little corrob. by freq. cough.

A sympt almost necess arising from any topic affect within the breast.

In all these partic nothing extr.

But in progr. & contin of pain something singul.

Before he came under our care was of a months durat.

A circum very uncomm with [thor] pains ushered in with coldness [shiver] & fever.

These whether of pleurit or [peripn]. kind in general very soon termin either in resolut or suppurat.

But if attack thus uncommon progr still more so.

For during whole space of month has been subj to daily febr. attacks

And never as far as we at least have had opport of obs. entirely free from praeternat celerity of pulse.

But at same time small & easily compress.

From these circum then, as well as contin, cannot look upon it as concomit of active inflamm.

While at same time at loss what other idea to form of it.

Diffic still farther augm by progr.

For when pain first began was chiefly seated under sternum.

And in part now affected then felt only slight uneasiness.

This however grad encr. [while] that under stern. had prop. dimin.

And at end of five days had entirely left him, [&] contin to be subj only to pain under mamma mamma

What nature of this pain may be must own cannot, with any certainty pretend to say

But was then disp to suspect that depended on some intern supp.

And that, although active inflam which had preceded, chiefly seated under sternum, yet had there been termin by resolut while in pres sit. only had come to suppurat.

Was inclind to consider daily febrile access as being of hectic kind.

And to view patient as lab. under Phthisis. Pulmon.

Consid him as subj to that species of it, which in [contradistinc] to tubercul & catarrhal would term the ulcerous.

And where disease effect of abscess of some consid size & at one partic part of lungs.

Here indeed true that had by no means all sympt with which this species of Phthisis attended.

But to any obj from this circum suffic answer from insid nature of the disease.

For well known to be one of those affect which makes consid progr where very little ground for susp. it.

And freq. even in cases where in end proves fatal much fewer sympt of it, than with pres. patient.

This then conjec with regard to symp when came first under care.

And hoped that by careful attent should soon be able to determine whether well founded or not.

During course of attend howevr as have already remarkd in place of being removed rather augm.

For while no circum eithr confirm or refut opin. othr partic have occurrd which may give conten to diff supp.

This partic the case with respect to disch of worms.

Without any of those sympt commonly consid as indic pres of these & prior to empl of any remed for expuls. sever. lumbrici disch.

And here may occur as quest. how far whole sympt. may not have proceeded from this cause.

That worms capab of prod [almos] infin variety of diff morbid app. cannot I think be denied.

Indeed hard to say to what affect they may not at times give rise.

And no sympt in hist of pres. case which have not a diff times produced.

But even this circum joind to actual pres. by no means cert. evid that are cause of pres compl.

For certain that often lodged in alim canal when prod of almost no sympt whatever.

And that often supposed to be cause of diseases where merely [disch] in conseq of such affect taking place from some othr cause.

Partic happens that disch by occurr of febrile compl.

Prob. from encreasd & morbid [heat] rend situat uneasy.

While therefore can by no means agree with those who consid them as never being cause of disease, can as little adopt the opin of others who look upon them as prod of every sympt where happen to app.

And in inst before us am I own rathr disp to consid expuls as conseq of the disease, than pres as cause of sympt.

At same time evid which has now been afforded of pres in alim canal a circum claiming attent both in progn & pract.

If whole sympt depends on worms may soon look for fav termn

But if as am still disp to susp. greatest part of sympt conseq of supp. within breast, may consid disease as of most danger. tenden.

And reason to fear that notwith any efforts which are capab of empl. will in end prove fatal.

In pres. state of uncertainty howevr can offer only what to be consid as but vague conject.

And from this circum also cannot lay down any determin plan of cure.

But in pract empl. must be chiefly guided by attend to [juv] & [illegible].

Was chiefly on this footing that when pat. first app. for assist had recourse to a blister.

On whatever prin may operate can be no doubt that has remark influ in allev. affect of breast.

And partic when these app. under form of fixd pain.

Probab. that benefite in a consid degree the affect of change in mode of circulat.

And that on same prin. is [usef] even where suppurat within the chest.

But whether thus advant or not in [these] cases very generaly empl & app with advant.

These then reasons for having recourse to it in pres inst.

But besides this directed also at same time anoth med.

A mixt viz of flower of Sulph & powder of Cream Tart.

From this had chiefly in view the keeping belly gently open.

From which in all affect of the breast very great benef is obt.

And indeed in obstin catarrh affect. very few remed from which pat. derive more consid relief.

Upon suppos then that pectoral affect here wholy catarhal might have been highly benef.

And in [any] view of disease [reasn] to hope that might be useful.

In obv affects of both these remed were not disapp.

For while blister rose well & prod free disch. powder also kept belly gently open.

Under use of these med, the pain of breast seemd to be somewhat mitig.

But still contin to be much distr. with cough.

And though free from vomiting was even more than formerly affected with sickness at stomach

Imagind however that by contin of gentle disch. these sympt might be mitig.

And I own did not then suspect as cause of this sickness, a circum which there is since reason to inferr, may at least have had share in inducing it.

Pres. viz of Lumbrici in alim canal.

Directed therfore that should contin with Cream of Tart & Sulph [illegible]

During use several lumbrici were disch by stool.

Not improb. that this disch in some degree affect of laxat [pow] in the article empl.

But at least equal reason for suppos. that worms disch in [contin] of daily febrile access.

Whethr however from one or other cause, or whether indep of both a quest of much less import, than that already stated whethr viz worms cause of othr sympt.

This I own then came with me to be a matter of some doubt.

But as have already said am rather inclind to susp. that merely accid compl. & that disease depends on cause deeper seated & more [dan]

Notwith this suppos however must still be consid as obj of conseq to remove lumbrici.

By this have at least chance of freeing him of some part of compl.

And if compl. removal obt, best able to determine how far had any share in inducing or support affect.

On this acct omitting remed formerly empl. pract. now you will obs. directed to lumbrici.

With intent of expelling these the remed to which had recourse the Sem. Santon.

This need hardly observe long celeb. as an anthelmint.

If to judge of virtues from sensib qualit should consid it as very little diff from othr veget bitters.

And these univ allowed to possess some degree of anthelm power.

But as far as I can judge from my own exper. powers of Sem Santon in much greater degree than in prop to bitterness.

And indeed from affects which have freq. obs to result from use look upon it as one of best & safest anthelm we can employ.

Rather howevr affect in killing than in expelling worms.

Hence in general propr to to use a Cathart should be subj.

And as such have here [orderd] the Pulv. Jallap comp.

From conj influ of these expect that worms if pres will be expelld.

And from situat in which shall then find patient, pract must be regulated.

For must [own] so far doubtful that cannot lay down any fixd plan of cure.