DEP/DUA/1/15/03 (Normalised version)

Violet Mathews

(1777-1778)

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Violet Mathews.

Respecting disease to which this patient subjected little room for doubt.

Is evidently subjected to an affection no less common than it is dreadful.

In different systems however has received different appellations

Yet can be no doubt that this patient subjected to a disease which in some systems title of Cancer in others of Carcinoma.

Yet in System of Sauvages may perhaps with strict propriety give it yet a different [appellation].

Mr Sauvages has formed general class of diseases under title Dolores.

To this class from shooting pains with which patient affected would naturally be disposed to refer her affection

This class according to situation of pain divided into different orders.

And of all these disease of present patient could alone belong to order of external pain

Under this order find a genus distinguished by title of Mastodynia.

A word of Greek derivation expressing pain of Mamma.

To this genus Mr Sauvages has referred no less than ten different species.

And under each has described very minutely affections of breast different in essential particulars from each other.

In so much that may I think with justice say that this genus does not include natural combination.

Under this genus however a species described under title of Mastodynia Cancerosa to which no doubt in referring affection of present patient.

And indeed in history of affection there delivered have all symptoms of present case.

Here as in that affection the tumour hard red & unequal.

But besides general appearance characterised also by pains.

These from description given by patient are in her case of acute Cancerous kind.

Such however described by Sauvages as distinguish Mastodynia Cancerosa

And such indeed universally allowed attendants of Cancer in breast.

In this affection then investigation by nosological¹ system of Mr Sauvages leads to direct & positive conclusions respecting disease.

And shows how far even artificial methods may be serviceable for this purpose.

For can be little doubt that a genus consisting of painful affection of breast [form] by no means a natural assembly.

And much less affinity between these than between cancers situated in different parts of body.

For although situation varied nature & tendency of disease the same.

And in great measure to be combatted by same remedies.

Adopting cancer as genus chief difficulty of distinguishing it from scirrhous.

And principally to be done by presence of pain.

For other marks from [inequality] of tumour from varicose veins about basis etc though general yet not constant.

In case before us however still farther demonstration of cancerous tendency.

And perhaps the mark of all others the most to be relied upon.

That is affection of axillary glands in consequence of disease of breast.

In our patient has now subsisted for considerable time.

And even where [cancin] pains do not occur serves as ground for distinguishing cancer from mere scirrhous.

For can be no doubt that is affection of absorption of matter from sore.

And that this matter acting on other glands is inducing on these a similar state.

From every circumstance then no doubt that this affection strictly to be called cancer.

Yet perhaps cancer placed in contra distinction to scirrhous on an imprudent foundation.

And cannot help adopting the opinion of an ingenious Gentleman Dr Hopkins whose inaugural Dissertation on this subject considered to be one of most accurate & judicious [performed] on cancer that scirrhous, cancer & carcinoma to be considered merely as progressive stages of same affection.

And must own give his definition of this affection preference to that of any of the nosologists.

Yet not to be refused that many scirrhous which never become cancer in common acceptance.

That is affection stops as it were at first step

And on contrary has sometimes apparent beginning from second or even third stage, without others having preceded.

Yet excepting nosologists almost every authority has conjoined two last.

In this disease two conditions to [appearance] at least opposite pointed out by most practical authors. occult & open cancer.

With patient before us although disease of several months continuation no doubt that still in former of these states.

Yet must consider nature & tendency to be same as if already ulcerated.

Real nature of cancer however a matter much more difficultly investigated than presence in cases where occurs

While at same time on proper knowledge of this rational plan of cure must in great measure proceed.

Into this subject however foreign to present course to enter at any length

When humoural pathology prevailed supposed to depend on morbid state of general mass of fluids.

And will find many not in other respects to be reckoned humoural pathologists who still contend for this doctrine.

In so much that frequently affects their practice.

Am so far however from being of this opinion that led to believe that where such a state of fluids does occur is consequence not cause of affection.

Do not deny that cancer may be hereditary or constitutional affection.

But even then suppose that principle cause at least depends on solids

Hold it to be at first affection of peculiar inflammation or if may be allowed more general term, peculiar action of vessels in part.

This suppose to give rise to stagnation & effusion in part.

And stagnated matter often assumes coagulated state giving peculiar hardness of swelling & difficulty of resolution.

Forms even confused solid mass in which organ structure in great measure destroyed.

Hence also difficult tendency to suppuration.

But even this operates as cause supporting depraved action.

And from this both the pain & separation of a peculiar fluid sometimes discharges externally, but always in part taken up by absorption.

Thus the affection of other glands particularly those in course of absorption.

And thus general affection of system [horripil] shivering & other febrile appearances by which patients cut off.

From this view of the disease will readily imagine that not disposed to favourable prognosis.

Cancer notwithstanding pompous assertions of empirics & even of some regular practitioners in by much greater number of cases terminate fatally

And great reason to fear that this will happen with regard to present patient.

Disease indeed hitherto has not had very rapid progression.

Although of above two years continuation has not yet degenerated into ulcerated state.

Nor does it at present show any manifest signs either of this or of great absorption.

Would hope therefore that may at least have opportunity of trying effects of different medicines.

Yet must own that look upon it to be a very unfavourable case for expecting much from medicine.

Even slow progression against speedy cure.

From firm attachment size & other circumstances is not in condition that can be removed.

And from long continuation in present state less chance that proper circulation through it can be renewed.

On whole then suspect much that patient will leave us no better than when came under care.

This however not to deter us from at least trying most likely means of cure.

In all diseases of nature of present where affection merely local cure may proceed on one of two principles.

To be aimed at either by entire removal of diseased part or by restoration of that part to sound state.

No dispute that operation in as far as can be successful affords chance of most expedient cure.

Yet propriety of operating in any case of cancer among surgeons subject of much dispute.

While some contend for propriety of early operation.

Others condemn it in every case.

And advocates for both sides contend that founded opinion, not merely on reasoning but observations.

Those who are favoured of the operation contend that when diseased part can be [completely] removed patient not only speedily cured but as little chance of future cancer as if never subjected to it

Those on other hand who condemn it tell us that almost every patient on whom operation performed, afterwards cut off by cancer in internal viscera.

And that symptoms to which subjected of most excruciating kind.

In so much that have been told by one of oldest & most attentive practitioners in this city that was firm resolution never to operate on one of them.

Must however own that as far as my observation goes can by no means agree with him.

Know several people still alive once afflicted with cancer who if not operated upon in all probability long since dead.

And cannot help thinking that on principles respecting nature of disease which can hardly be controversial propriety of operating at early period may be defended.

Into the general question however not here particular our business to enter.

And [sufficient] upon whole to say that am friend to operation.

Becomes however a second question how far such circumstances occur in case before us.

And here must own that think operation not to be ventured upon.

To this independent of other circumstances consider fixed state of tumour to be an unsurmountable objection.

For hold that operation only to be performed where can be means of entirely removing the diseased part.

Here even swellings under axilla would give some difficulty.

But much greater from [firm] attack to bones of chest.

And indeed little doubt that in several places insinuates itself between ribs.

Although therefore where consider operation advisable would recommend that should not be a moment delayed [treatment] to other means of cure yet in present is in [second] way alone that can have any expectation.

Here therefore endeavour to be employed to restore as far as we are able a sound state to diseased parts.

And this to be brought about.

1 By removal of obstruction in vessels.

2 By absorption of [effused] fluids.

3 By restoring due condition & proper action to diseased parts.

Two first intentions however will often be accomplished if can fulfil last.

For by restoration of due condition & action to vascular system in [patient] absorption promoted & circulation renewed.

And perhaps renewal of circulation is of all other means most powerful for removal of obstructions.

An end indeed very difficult to accomplish.

And probably shall never be able to discover effective means of doing it.

Yet I apprehend is on this principle [then] as far as have any affect are to account for operation of different vegetables formerly [esteemed] poisons now recommended for cure of this affection.

Is I imagine on this ground that are to account for good effects of Cicuta Hyoscyami Aconitum & Belladonna.

From all these plants can observe evident narcotic powers & at same time effects as peculiar stimuli.

And I apprehend on these [properties] [action] in scirrhous & cancer may be accounted for.

Am fully aware indeed that many who of opinion that no good effect ever obtained from Cicuta.

And for own part am very far from considering it as by any means entitled to high character Dr Stork gave it.

Yet that has active powers evident from obvious operation.

And that these powers have been product of good effects at least in some cases even of cancer is I think confirmed by observations.

Have even in my own practice see instances where am persuaded that from use of Cicuta good effects obtained.

At same time have never seen any instances where reason to suspect that continued use of it attended with bad effects.

Particularly never heard it accused of precipitating progress of the disease.

A circumstance often affect of other measures especially external applications.

Wish therefore, hoping for some good effects from narcotic & stimulating powers to give it fair trial in present case

Active properties of Cicuta reside in different parts of plant in various degrees.

And from these may be extracted by & exhibited in different forms

Of all parts leaves most commonly in use

And from these virtue extracted first by expression of recent juice & then by evaporation of watery part [impressed] to form of extract.

Where thus [cant.] prepared, perhaps one of best & most commodious forms

And easily divided into proper dose by being formed into pills.

For this purpose powder of leaves themselves to be preferred to any other.

Of all parts of plant however few less active than leaves.

From account given of deleterious effects would seem that root most virulent.

But has not as far as I know been employed in medical practice.

Seeds while less active than root more so than leaves.

Of this evidence at least in having more powerful narcotic effects.

And as far as my observation goes is chiefly when producing some degree of vertigo that cicuta attended with good effects.

On this account therefore in general disposed to give preference to extract of seeds.

Or at least to have recourse to this after extract of leaves used for some time.

For in administration of cicuta hold that objective to be aimed at is to throw it in to such extent that affect sensibly felt.

In this manner then mean to give it trial for some length of time with present patient.

And to avoid every external application except merely defending part & preserving  gentle warmth

Is with this intention that have directed her to cover mamma with soft fur.

If this course successful with patient will I think be strongest instance I have yet met with of efficacy of Cicuta.

But although should fail will not on that account be disposed to pronounce the medicine as useless one.

Shall not even think of desisting from trials of stimulating narcotic.

But before dropping cicuta have thought of giving it conjoined with some other of that tribe.

For this purpose have thoughts of uniting it with the Atropa Belladonna or deadly night-shade.

This particularly on authority of Mr Vogel told has frequently succeeded where Cicuta failed.

And if from internal use no success have thoughts of trying at same time external application of leaves of latter.

If these measures abortive must own shall lose hopes of cure here from tribe of Vegetable poisons

There is however a mineral poison which has of late been recommended in this affection as more powerful than any of these.

That is Arsenic.

This in cases of open cancer long recommended as an external application.

And supposed to operate as removing the part by corrosion.

This practice probably first introduced by some empiric.

And according to Dr McBride is probably remedy long kept secret in family of Plunkets in Ireland.

In prescription which he gives Arsenic formed into mass with other articles is applied to two drams.

From sulphur indeed in composite power may be very considerable weakened.

Application of arsenic externally of late [directed] by several regular practitioners.

And a surgeon of eminence in this city informs me that has often used it with considerable success.

On his authority once ventured to employ it to a open cancer in Royal Infirmary².

In his formula however one grain of the arsenic only enters.

And of this mass I ventured only on application of about one fourth at a time

This patient some time after cut off by [horriss] & shivering, succeeded by violent fever.

And has by some been said that he died in consequence of the application.

Will not pretend to affirm positively that this not the case

At same time when consider that arsenic here used to very inconsiderable extent.

That death did not happen till considerable time after used

That patient affected with none of those symptoms which arsenic when operates as poison induces purgation. vomiting. or convulsions.

And that cut off by symptoms fever so frequently putting period to cancerous affections can see no foundation for the accusation.

Arsenic however in this manner applicable only in cases of open cancer.

But very lately are told that has been given with success not only externally but internally also.

For this practice are I believe indebted to Mr Le Febure of Paris.

At least only author who as far as I know has written upon subject.

The original treatise will not easily [meet] with at this place

But will find an analysis of it in a late number of medical commentaries.

There however necessary to observe that at end of formula an omission of words French weight.

This medicine tried by one practitioner at this place.

But without any good affects.

From this however do not think that by any means warranted to conclude against it.

And in a desperate case after other measures had failed should I own be disposed to take chance it affords.

May therefore be ultimate resource with this patient.

But after measures already proposed before having recourse to it have thoughts of trying another medicine of which I own have very high opinion.

That is electricity.

Of this shall at present say nothing as will naturally fall to be mentioned when speak of two other patients at present under care.

And indeed doubtful whether present patient will remain so long under care to give [opportunity] of trying it

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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.

2) The Royal Infirmary of Edinburgh, established in 1729.