DEP/DUA/1/13/13 (Normalised version)

Forbes Richardson

(1777)

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Forbes Richardson.

Case of this patient furnishes example of what I reckon a very singular affection.

Must own that have never before met with any case which could be said very nearly to resemble it.

Nor can I assign place for it in any Nosological¹ system.

Without therefore attempting to give any name to disease must try how far can give any probable conjecture as to nature.

Evident that affection, whatever nature may be, is totally a local one.

Confined entirely to left hand.

And there marked merely by one symptom that is pain.

For contraction of fingers & loss of motion as far as we can learn to be considered as solely consequence of this.

While at same time no tumour, ulceration, inflammation, or any other obvious cause from which can suppose pain to arise.

Well known however that all pain the consequence of impression communicated from sentient extremities of nerves to origin.

And that impression varied by many different circumstances.

Particularly by state of sentient extremities & by condition of Nervous fluid

With these in certain conditions force of impression either totally taken off or greatly diminished.

While on other hand by contrary state influence equally augmented.

In so much that impression usually [give] no sensation will produce even excruciating degree of pain.

From supposition therefore of such a change in state of nervous power may I apprehend account for singular affection in case before us.

Patient affected with excruciating pain on irritation afforded even by most gentle touch or slightest attempt to motion.

And complains even of constant pain probably from that irritation which must ever be afforded by circulation & such other causes.

But while such supposition would afford some solution for phenomenon is still farther corroborated by cause inducing the affection.

Can I apprehend be no doubt that patient right in conjecture in attributing disease before us to stroke

This although not so violent as to occasion any wound produces such pain as to prevent use of flexor muscles of fingers.

And with continuation of this pain sensitivity in short time arose to present height.

In so much that dreads the least approach towards his hand even in most gentle manner.

Can I apprehend be upon whole then little doubt that by stroke though no wound producing an injury done to subcutaneous nerves

And that from this disease to be considered as solely originating.

Would then upon whole consider case of present patient to be one of those anomalous affections of Nervous kind to which no name can be given.

And which characterised rather by peculiarity than by any particular symptoms.

To this disease as already observed have never seen anything very similar.

Yet in case of Janet Wilson one of our clinical patients during winter had an affection which to me seemed in nature somewhat to resemble it.

There indeed from seat of affection gave that genus of disease which nosologists distinguished by title of Dysphagia.

But had I apprehend an instance of difficult deglutition totally arising from increased sensibility.

And from this also constant pain as in case before us & excruciating pain on being touched by solids as in action of swallowing

Have heard of case still more similar mentioned by Dr Hunter of London in Lectures.

There without any evident diseased state pain similar to present arising from second joint of thumb.

And on slightest touch most excruciating sensation induced.

There the affection resisted almost infinite variety of means of cure.

And even the division of nerve leading from thumb, had no other affect but to produce change of seat.

Then pain began not at thumb as before but immediately above where incision had been made

What at length fate of this case do not know.

Were we however to form any conjecture as to termination of present from what saw of that of Janet Wilson would dispose us to favourable judgement.

And own that do not here see anything which can very greatly alarm.

Consider patient although in very distressing yet not as in highly dangerous situation.

And indeed nervous affections in general often more terrible than really dangerous.

At same time in anomalous cases judgement should never be pronounced with very great confidence

And hard to say what turns may sometimes suddenly take.

Am sorry however to observe that whatever may be future progress of this disease we shall probably have but little opportunity of observing it.

For has now discontinued his attendance & have not been able to learn where he lodges.

If however shall be able to discover place of residence shall reckon it worthwhile to attend to disease even although may not be able to prevail upon him to trial of medicine

Yet must own that without artificial cure am disposed to think affection will be very tedious.

Before came under our care had continued with very little alteration for space of 12 months

And during that time had resisted use of various remedies.

Not improbable that all our attempts in no degree more fortunate.

Had he however continued with us should at least have given fair trial to different medicines from which I apprehend something might have been expected.

Here will naturally occur to you from what said of nature of disease that consider great objective in cure to be restoration of proper sensibility to Nerves.

Sensibility of nerves where no obstruction to intercourse with [sensors] considered as depending on two circumstances.

On state of sentient extremities & on condition of Nervous fluid.

And as suppose brain to be not strictly speaking one only but a great number of secreting organs imagine that fluid may be morbidly altered in one nerve while not in another.

Am disposed also to think that from action on extremities of any nerve state of secretion furnishing it with fluid may be altered.

As impressions on extremities communicated to origin

On these principles then consider increased sensibility here occurring as dependant on both circumstances.

Perhaps more on change in state of nervous fluid than in sentient extremities.

[And] least that this took place with regard to Dr Hunters case was manifest from uneasiness remaining after Nerve cut.

And from arising above incision.

Supposing this therefore cause of augmented sensibility proper state to be restored only both by action of condition of Nervous fluid & on sentient extremities.

Those who heard observations offered on case of Janet Wilson will not be surprised that with these intentions should have had recourse to electricity.

Especially as those disposed to imagine that produces so good affects.

Will at first sight indeed seem odd that should here have employed for diminishing morbid sensibility what known to be so powerful an agent in augmenting or restoring it where diminished or lost.

Hold however that these affects in consequence of its altering state of secretion.

And that by analogous alteration will restore it to natural condition when otherwise affected.

But whatever be principle of action am persuaded from facts that electricity capable of diminishing morbid sensibility.

And on these grounds directed it to present patient.

With a case however where from slight accident exquisite pain induced was necessary to begin with utmost caution.

On this account began by directing for patient the electricity [fomentert]

That is the more charging of system with electric [force]

In this state hold that operates as stimulant to whole.

But does not affect any part so immediately as if either shocks given or sparks drawn from thence.

Was on this account therefore that at same time ordered trial should be made if patient able to have sparks drawn from extremities of fingers of left hand.

This almost contrary to expectations found he was able to bear.

For although excited some pain yet but of short continuation.

After short use of electricity in this manner had appearance of some progress in cure.

For although pain from touch still continues yet was able somewhat to move his fingers.

At this time however our electricity machine met with accident which necessarily gave interruption to cure.

And was not again got out of hands of workmen so soon as could have been wished.

During this period patient called several times without being electrified.

And after repeated disappointments at last forsook us.

Must own however that was very sorry both on his on account of [fair] trial which had in view that lost sight of him.

And if ever fall in with him again provided disease in same situation shall persuade him to fresh trial of electricity.

Of other plans however which might afterwards to followed should this prove abortive, unnecessary to say anything.

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Explanatory notes:

1) Nosology is the branch of medical science dealing with the classification of diseases. Individuals referred to in the case notes as nosologists were commonly those who had published nosological, or classificatory, medical texts.