DEP/DUA/1/11/18 (Normalised version)

Robert Robertson

(1776-1777)

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Towards close of last Clinical Lecture entered upon case of Robert Robertson.

Observed that although many circumstances of this patients disease evident

Yet that not altogether without grounds for doubt

No grounds for suspecting any mistake with regard to bloody discharge.

This told has frequently happened to very considerable extent particularly in mornings.

Giving presumption therefore of accumulation in stomach during night.

Besides this great probability at least of very considerable purulent discharge.

That really discharges pus by the mouth may be inferred both from colour taste & smell.

Still more from quantity at once discharged

Are told, that even since came under care has vomited up a matter with every appearance of pus even to extent of pound at a time.

Matter to such extent with strong foetid & disagreeable taste could hardly be supposed anything else but pus.

May with certainty infer then that here purulent & bloody discharge on vomiting

But discharge of these matters not merely in way of vomiting.

Certain that blood also discharged by expectoration on coughing.

That is that comes from cavity of chest.

Strong presumption also that from same source discharge of pus.

For on coughing expectorates a matter with usual appearance of pus in colour smell & taste

And has farther been found to answer to common test that viz of sinking in water.

All these marks however must be allowed do not amount to certainty

And have already oftener than once had occasion in these lectures to regret that an easy & certain test for distinguishing pus from mucus as expectorated from lungs had not been discovered.

The rather regret this as am persuaded that by a little industry & attention, with no great degree of chemical knowledge such a test may be discovered.

Am in hopes that in short time this question may be proposed as subject on which any student at this place may exert his ingenuity.

And if that ingenuity excited with success may be the means of obtaining to him if not adequate at least honourable compensation.

Although however difficulty in distinguishing when pus, when mucus expectorated in many other cases can be very little in present.

For besides ordinary marks strong probability from its being accompanied with bloody discharge

Still stronger from suddenness & extent of the discharge on vomiting.

From these different particulars then led at least to one conclusion respecting nature of the disease.

Strong presumption that somewhere a large abscess

Difficulty however respecting situation.

May naturally conclude it in neighbourhood of part where complains of fixed pain.

That is about lower extremity of Sternum.

Would therefore give presumption that suppuration in Lungs.

And of all the viscera there perhaps most frequently seat of suppuration.

While at same time on such a supposition see why blood & purulent matter discharged by expectoration.

This supposition however not altogether without difficulty

Unquestionably some objection to it from quantity at once discharged.

Seldom that any vomica in Lungs continues at once to extent of pound.

At least if this the case might expect to find before rupture much greater difficulty of breathing than in present instance.

But if difficulty from quantity not less from mode of discharge.

Are told that evacuated to greatest extent by vomiting.

This however means of discharging more immediately the contents of stomach.

At least presumption therefore of coming from thence.

Natural to think therefore of some other supposition than that solely confined to lungs

Difficulty may be [solved] on supposition that more than one abscess.

One may exist entirely in thorax, another communing with stomach.

Yet if this in reality case a rare occurrence.

With greater probability may be supposed that one abscess so situated as in consequence of adhesion & erosion to have communion both with lungs & stomach.

Perhaps still more probable explanation of difficulty from supposing mistake on part of patient.

Not improbable that matter seeming to be discharged from stomach by vomiting in reality expectorated from lungs during act of vomiting

And that computation of patient respecting quantity higher than ought to be.

Or mistake may even be of an opposing nature

And notwithstanding seat of pain all matter seeming to be discharged by expectoration may really be wrought up from stomach by oesophagus.

And merely discharged during forcible effects by coughing.

Yet must own reckon this conjecture less probable than former

But at same time where so many possible suppositions will at least be allowed that grounds for doubt.

Thus far of nature of affection.

Of Prognosis must observe that am [affecting] less grounds for uncertainty respecting termination.

Great reason I think to apprehend that will terminate fatally.

Few instances of internal suppuration ending in any other manner.

Those in lungs particularly fatal.

And here every reason for presuming that affection by no means inconsiderable.

Would not however from this mean to represent case as totally irrecoverable.

Have already often remarked that some [chance] from free discharge of pus.

And disease in proportion to continuation does not hitherto seem to have much affected constitution of patient.

Gives therefore presumption that not here readily absorbed

Besides from description of matter every reason to think that what here discharged well digested pus.

Certain however that from this as lodged in different parts of system no remarkable inconvenience

Either is not capable of being absorbed or if absorbed not same tendency to produce hectic fever as putrid sanies.

Need not surprise us therefore that here no great degree of hectic fever.

And that patient still continues to possess vigour which from occurrence of this would soon be lost.

Yet many circumstances in internal suppuration even of mildest kind very unfavourable to healing

Particularly where extent of affection such as great reason to fear in present case.

Must therefore own that favourable conclusion of present case is more than expect

And from progress being hitherto slow cannot infer that will continue so.

Hard to say how soon pus formed may degenerate from present to more vitiated state.

In that event progress of affection may afterwards be as rapid as has hitherto been slow.

Yet better chance of slow progress than if from beginning evident appearance of vitiated pus

May hope therefore that better opportunity of trying what can be done by aid of medicines

Yet must own that in present case much at loss even respecting general plan of cure

And particularly divided in opinion whether best chance of success by what would call trusting to natural or attempting artificial cure.

Healing of ulcers work rather of nature than art.

Is probably consequence of peculiar inflammation to which unless in particular diseased state greatest tendency.

Where purulent matter formed however & has no existence this cannot take place.

But after rupture of abscess & discharge have at least all that chance of healing which power of system can give.

To this have hitherto trusted in present case.

And during time that patient has been under care have done little else but looked on.

Had indeed recourse here to a blister since converted into an issue.

But of principles on which expected benefits from it need not say anything after what have already observed of other phthisis cases.

Had recourse to Cream of Tartar on presumption that purulent matter in alimentary canal.

By gently moving belly wished to discharge downwards what not evacuated by vomiting.

And ordered vomit with view of supporting & promoting expectoration.

But trusted cure of ulceration to natural progress of [adhesive] inflammation.

In this plan will yet probably persist for some time.

Continued issue & purgative & repeating emetics at due intervals.

If under this management hectic symptoms do not appear may entertain some hope of natural tendency to cure.

But if these supervening purulent discharges continue will be proper at least to make some trial towards giving disposition to heal.

And present a case in which may I imagine have some expectation from Peruvian Bark

While at same time may make trial without much hazard.

If this fails have thoughts of putting patient on use of Gum Myrrh.

A remedy of which can say nothing from my own experience.

But which am told Dr F. of London thinks he has found very serviceable in Phthisis complaints.

By time these trials made probably more distinct idea of patient’s complaint.

And may perhaps be thence induced to alter plan in manner which do not expect.