DEP/DUA/1/15/02 (Normalised version)

George Drummond

(1777-1778)

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George Drummond.

This patient subjected to an affection of which must own never before saw an example.

And must acknowledge myself greatly at loss both with regard to name & nature of the complaint

Little hesitation however in saying that disease a complicated one

That is considering constant pains to which has been for long time subjected to have no connection with periodic involuntary motions, which constitute greater part of affection & that with regard to which greatest difficulty.

Pains in haunches we are told of long standing.

And probably merely of rheumatic kind.

An occurrence very frequent in this country with people of lower class at advanced period of life.

And indeed when consider state of their habit & vicissitudes of weather by no mean surprising.

This then what I consider as most probable conjecture.

But at same time must observe that to this part of disease have hitherto paid very little attention.

For consider other affection as most urgent & most material part.

And at same time what to be treated & cured as perfectly unconnected with present pains.

Here must acknowledge at loss to which of two [fin] great classes of Dr Cullen to refer it.

Pyrexia or Neuroses.

Of first have here to certain extent at least almost all symptoms.

Yet to definition no very exact resemblance.

In case before us indeed, not only cold & hot but even sweating fits.

Cold however as is said to be case in Pyrexia does not usher in heat.

For both subsist in different parts at same time.

To general characteristics of Neuroses still stronger resemblance.

But here also as class defined by Dr Cullen at least some difficulty.

That here there occurs great mark of class lesion of [sense] but still more of motion can admit of no doubt.

While at same time as far as we can discover at least no local affection produced either

But after what already observed cannot say that disease here sine pyrexia.

This however am far from considering as a sufficient objection to supposition of belonging to that class.

Fever indeed not to be considered as a constituting of class of Neuroses.

Yet its being present does not exclude occurrence of these.

Not unfrequently attends both as concomitant & preceding affection.

In some cases even as a consequence.

For with certain constitutions fever excited by every disturbance to system.

If suppose it to belong to Neuroses will naturally look for it among spasmodics

If to fevers among the intermittent.

And indeed principally divided in opinion whether to look upon it as referable to genus of convulsions or chorea as has been more [usually] called.

Or to consider as particular modification of intermittent

When attend to general histories of both many circumstances favouring each supposition.

Of all affections of nervous kind seem to [approach] most nearly to general [history] of Chorea St Vitus as described by that accurate writer Dr Sydenham.

To him refer such of you as wish to consider it more particularly for general history of this affection.

Besides short account in Processus integri¹ will find it particularly described in tract entitled Schedula monitoria de novae febris ingress²

Sufficient to observe that those involuntary motions of legs & arms particularly confined to one side occurring with our patient make principle part of disease as described by Sydenham.

Nor do I consider it as a great objection to supposition that disease of Sydenham [seemed] to occur principally from ten years of age till puberty.

For although then most common [cannot] be considered as peculiar to that period of life

Have never during time that have bestowed attention on [practice] of medicine seen in instances of Chorea but once.

Then also attacked a man advanced in life.

Though not so old as our patient had passed fifty

With him indeed [appearance] by no [means] same as with present patient.

Attack of fits not as in this case preceded by involuntary eructation.

Nor did occur at regular & stated period

Attacks instant & but of short duration

Attended however to remarkable degree with those [ridiculous] [contortions] particularly in drinking, described by Dr Sydenham.

Cannot however suppose that in every case appearance the same.

Was lately consulted in conjunction with another Physician of Edinburgh by a practitioner about thirty miles distant where appears very different.

Was of a boy about 11 years of age.

And principle affection involuntary motion & [dis]

At same time chiefly confined to one side

Practitioner, who sent us the case, a man of accuracy & judgement had no hesitation in pronouncing it to be chorea.

And we readily disposed to agree with him in opinion.

There however motion rather [fec] than of convulsive kind.

Patient slept easily & quietly during whole night.

But motion began as soon as awakened.

And continued without interruption during whole time that was not asleep.

From these instances then evident that this a disease putting on different appearances

And although not exact resemblance in every particular, yet gives strong presumption that present an example of it.

Will then seem strange to you that should entertain any suspicion of its being a disease so opposite in appearance as intermittent.

But of this also many circumstances giving at least some presumption.

Well known that intermittents put on very various appearances.

And when this true [genus] of disease, makes appearance as it were, under form of various spasmodic affections.

In so much that particular tribe of intermittent formed of those, spasmis & motibus convuls stipata.

And may observe that intermittent [here] appears under shape of asthma Hysteria tetanus & even Epilepsy.

Do not indeed know of any instance on record of appearing under form of chorea

But this certainly not more [illegible] than other forms which has assumed.

And undoubtedly instances of occurring even as partial affection.

Which if present an intermittent would here appear to be in some measure the case

If however difficulty from appearance thus in some measure removed many circumstances in favour from other particulars

Gives some presumption that patient of aguish constitution.

Last year at same time a quotidian

And frequently before subjected to intermittent.

Well known however that with such constitutions many symptoms from intermittent where does not really appear.

Particular periodic headaches etc.

Stronger reason then for presuming it origin of other affection.

Supposition corroborated by period of attack

Well known that in spring & autumn complaints of intermittent kind most prevalent.

Those subjected to such periodic returns seldom pass a season without some inconvenience.

And at this very time last year patient subjected to a quotidian.

Probably augmented by third circumstance mode of attack

Did not, like most nervous affections, immediately commence in present state.

In many of these most dreadful [appearances] even on first attack.

Particularly case with Epilepsy.

And to Epilepsy simple convulsions of which Chorea one of most common [species] has in many respects resemblance.

Do not indeed contend that attack of this never gradual.

But at least more rarely so than affect from intermittent where in constitution.

A circumstance still more favourable to supposition of intermittent than any yet mentioned is [regularity] of accession.

After once formed occurred regularly at a particular hour every second day.

And in this respect might be said to observe regular tertian type.

Well know however that tertian often converted into Quotidian.

Quotidian into continual.

And when now present patient has come to have daily attacks is same type as formerly

But besides regularity of attack appearance also of aguish tendency in the intermission.

For at least for some time after disease formed a regular pyrexia.

And if has at last come to continual is no more than often happens.

In phenomena during fit also many circumstances giving appearance of intermittent.

At begin of accession local heat & cold.

Such feelings however very common in intermittents

Corroborating the supposition that these succeeded by heat of some permanency.

And if not universal at least extended over affected side.

Lastly this hot paroxysm often terminates in sweating.

Which by no means least favourable circumstance to supposition of intermittent.

And upon whole disposed to consider this as of the two the most probable supposition.

Yet far from being so certain that can speak with much confidence.

And must conclude with repeating doubts with which first set out.

Own however that shall be disappointed if turns out an affection different both from Intermittent & Chorea.

As thus uncertain respecting nature of the disease must be also doubtful with regard to prognosis.

And in this doubtful state not without apprehensions.

Intermittents in general indeed in present state of medicine [much] under command.

Since introduction of bark & proper method of exhibiting it [ascertained] these seldom prove mortal.

This however still sometimes the case

And particularly so when attacks old people with whom in some measure habitual.

Especially if assumes such type that no proper intermission for use of this remedy.

Even from intermittent then [here] dangerous.

And as being an intermittent peculiar in nature that danger augmented.

On supposition of chorea also cannot be free from apprehensions.

Yet nervous affections of convulsive kind in general less dangerous than threatening.

And if this supposition well founded will I imagine be rather tedious than dangerous.

Yet upon whole though considered as [ticklish] case am in hopes of cure

And on supposition of intermittent think that may not even prove very tedious.

Of which some presumption from relief formerly obtained by remedy on which put patient when came first under care.

Hope that patient therefore may recover under our hands.

And even not entirely without expectation that this may soon take place.

Yet if otherwise not greatly disappointed.

General plan of cure here has hitherto chiefly proceeded on supposition that basis of affection at least is an intermittent

[But] principally on which cure of intermittent to be conducted not here our business to enter

These must in great measure [turn] on theory given of disease.

And with respect to this physicians by no means agreed.

Perhaps notwithstanding subject being lately so much laboured still room for doubt.

But whatever opinion of proximate cause of the disease cure naturally resolves itself into two great objectives.

Treatment viz of paroxysms while continue & the prevention of return.

If these modes necessary when paroxysms of ordinary appearance still more so when as in present case conjoined with uncommon appearance.

Then at least more requisite to attend to paroxysm itself

And to use such remedies as may [mitigate] violence of particular symptoms.

For in ordinary intermittents, paroxysms in general left to natural course.

At least doing nothing farther than attending to management during [sweating]

In present case appearance such that with some patients in private practice would have been under absolute necessity of doing great deal during every paroxysm

And perhaps with some advantage might have had recourse to various antispasmodics both of stimulant & sedative nature.

Particularly volatile spirits as of first kind & opiates as of second.

But from these utmost that could have obtained would have been temporary relief

And some even might have had affect of rendering prevention of return of paroxysms still more difficult.

Hitherto therefore attention totally confined to that object.

And is with this view that have used both, emetics, Peruvian Bark & Zinc.

Of good effects of emetics in intermittents need say nothing.

Particularly as prelude to use of Peruvian bark

Of themselves from general [concession] of system when given before paroxysms sometimes effect of anticipating.

In every case from cleansing stomach gives bark better opportunity of acting

For no doubt that influence depends on action of alimentary canal, not as introduced into circulatory system.

In both ways then here expect [serviceable] from the emetics.

But by repetition had in view chiefly their being useful on first principle.

With this view indeed will perhaps think that ought to have employed stronger emetics.

Certain that emetics very powerful in operation have been employed with success.

A Physician whose practice indeed very singular. Dr Marryat a work of his Art of healing prescribes an emetic alone sufficient to remove any intermittent.

His emetic indeed a very strong one

And must own should be very shy in venturing upon it till saw it exhibited.

Orders no less than eight grains of Tartar Emetic & as much blue vitriol to be mixed together.

Divided into three doses one taken early every morning in a glass of water.

This no doubt must occasion severe [action] in vomiting.

And probably with view of augmenting strain Dr Marryat prohibits patient from drinking

If therefore account of success well founded shows efficacy of concussion in intermittents.

But must own that consider both success & even safety of practice as requiring confirmation.

And if to be tried rather in a distinct intermittent [than] in a doubtful affection as present.

These considerations then induced me to employ Ipecacuanha only.

But besides this had recourse here to another medicine.

A conjunction viz of Peruvian Bark & Calx of Zinc.

Respecting action of Peruvian Bark in intermittents many different opinions entertained.

And perhaps greatest number of practitioners disposed to consider it as specific with action of which unacquainted.

Certain however that by use of aromatic bitters & astringents intermittents cured where no bark employed.

Certain at same time that bark possesses these qualities

May with probability infer then that operates on same principles.

And is on these also that would explain use in other affections

Particularly in nervous diseases depending on augmented irritability.

For by increasing tone diminishes disposition to action.

With Peruvian Bark here conjoined as means of improving powers the Calx of Zinc.

A medicine for introduction of which into practice we are indebted to Dr Gaubius of Leyden.

And of which as tonic & in consequence of that as antispasmodic must own have high opinion.

From this then whether disease modification of intermittent or proper Chorea may I think expect good effects.

And if again obtain by means of it temporary intermission shall not think of so soon discontinuing use as did formerly.

If however not even temporary relief what now ordered must own will [reckon] it necessary to alter plan.

And with this view unless some circumstances indicating contrary have thoughts of trying antispasmodics more strictly so called.

Particularly Opium & Volatile Alkaline.

And these according to circumstances may either use separately or conjoined.

If these also fail must own that should here wish to make trial of electricity.

A remedy which on authority of Mr Sauvages is said in some cases to have made instant cure.

But patient must be in state [somewhat] different from present before can have it in power to exhibit it.

And perhaps unnecessary now to [suggest] farther practices in a case so doubtful

For is very far from being improbable that new occurrences may lead us entirely to alter both opinion of disease and plan of cure.

Case next in order referred to this day [illegible]. Must take the [opportunity] of [intermitting]

To Gentlemen who have formerly been my pupils at lectures & again honour with attendance on this or other course – that proper to deliver to them at lecture on Wednesday next at 7 o’Clock evening

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Explanatory notes:

1) Thomas Sydenham, Processus integri in morbis ferè omnibus curandis (1693).

2) Thomas Sydenham, Schedula monitoria de novae febris ingressu (1686).