DEP/DUA/1/15/14 (Normalised version)

Margaret Anderson

(1777-1778)

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Margaret Anderson.

Of case of this patient have not been able to form any very decisive opinion.

When came first under our care appearance of symptoms somewhat different from what are at present.

And whether of precisely same nature am much at loss to say.

At that time attacks of affection apparently in form of paroxysm.

And consists chiefly in palpitation of heart.

With this attacked with great violence three or even sometimes four times in course of day.

Palpitation unquestionably consists in an inordinate action of heart.

Is however a change from natural [standing] which may arise from different causes.

Most commonly however referred to one of two

May depend either on an affection merely nervous in which way often a symptom with hysterical girls.

Or may arise from an actual local affection either influencing course of blood into heart or altering state of sensibility.

Of this last kind example in inflammation of heart itself, polyps of large vessels etc

Here then to determine or perhaps rather to conject only from circumstances to which is to be ascribed.

And in giving name some question whether should be derived from cause inducing palpitation or from palpitation itself.

Here to be observed that some circumstances favouring supposition of affection arising from inflammation of heart itself.

Besides palpitations affection attended also with severe sense of pain.

And with very considerable degree of heat.

These however well known to be constant attendants of inflammation.

And among symptoms of carditis palpitation universally ranked.

May farther be added that cause [undeniably] such as might be supposed to give rise to this affection.

Was we are told consequence of having hurried herself much in walking.

From which presumption that both considerably heated & suddenly perhaps [imposed] [cold].

Yet although some circumstances in favour of this supposition liable to much strong objections.

Carditis very generally attended with other symptoms than here occur.

Were patient subjected to that disease pain & heat would not as is here the case occur only at times but be constant.

Is also strongly marked by peculiar anxiety difficult respiration inequality of pulse & syncope.

But above all constantly accompanied with very great degree of fever.

These symptoms however which undoubtedly essential to disease in our case totally [absent]

For although considerable quickness of pulse yet without heat or febrile anxiety.

Hence whether from local affection or not have at least very little room for suspecting that derived origin from this cause.

From sex of patient some presumption afforded that might be merely a nervous [affection]

And well known that palpitation a frequent occurrence with hysterical patients.

To this supposition however nothing giving countenance in other symptoms.

Cause inducing it not such as should have suspected to give rise to hysteria.

Patient not formerly subjected to hysteria complaint.

And greatly past period of life at which most frequently occurs.

Hence then disposed to consider this supposition also as rather improbable.

Among other causes of palpitation has been said to arise from gout.

And no doubt that well vouched instance at least where has alternation with attacks of gout

To this supposition some objection from sex of patient

Is with females a disease but rarely occurring.

Yet supposition in some degree probable from all symptoms which have pointed out as indicating inflammation.

Still more from an [after] occurrence which took place soon after patient came under care

And which indeed happened nearly about same time when affection of patient most considerably relieved.

That was particularly painful in left foot attended with very considerable swelling.

This well known to be common seat & appearance of gout when most distinctly marked.

And upon whole of three suppositions I have mentioned disposed to consider this as most probable.

Must however at same time observe that as palpitation an affection from gout, is also from rheumatism.

Of this at least had once occasion to observe a very striking instance.

Disease indeed there much more threatening than with our patient.

Case to which I allude was that of a Clinical patient treated in Royal Infirmary¹ about 14 years ago

These symptoms began with every [appearance] of cardites.

But particularly marked by great palpitation.

After however of some continuation, & when patient thought in greatest danger had very unexpected conclusion.

Many of larger joints became affected with the painful inflammation & swelling distinguishing acute rheumatism.

And to common treatment of this disease all the symptoms soon yielded.

On these grounds the learned Professor who then gave lecture [showed] no doubt in pronouncing that affection to which patient subjected was of the Rheumatic kind.

In present case however this by no means clear.

And although some instances of gout which may be readily distinguished from Rheumatism yet others where even greatest difficulty.

And whether here suppose pain connected with palpitation or not may be stated as question of some importance from what cause arises.

Particularly whether are to look upon it as of gouty or rheumatic kind.

Present one of those doubtful instances where presumptive arguments may be brought for both sides

And perhaps by farther progression of disease only that certain determination can be formed.

Age of patient more period for gout than for Rheumatism.

And part principally affected viz foot more seat of Gout than of Rheumatism.

But on other hand to be observed that parts here affected which seldom seat of Gout

Example trunk of body.

Gout seldom observed to affect more than one part at time.

But with our patient has existed with considerable severity in different parts at once.

Farther presumption of Rheumatism from sex.

And upon whole must own that most disposed to favour that supposition.

Taking it for granted then that complaint of present patient originates from Rheumatic affection still some difficulty as to name to be given.

And particularly whether should consider it as particular species of Rheumatism or of Palpitation.

As have already observed genus of palpitation adopted by most Nosologists².

And under it Mr Sauvages the most [celebrated] of them has comprehended several species.

Among other one distinguished by title of palpitatio arthritis.

On same footing may I apprehend established another by denomination of palpitatio Rheumatism.

And this name might perhaps have been disposed to attribute to affection had symptoms with which came under care been more permanent.

Still however would I apprehend have been naming disease, rather from appearance than nature.

For although chiefly marked by this symptom yet [genus] of affection to be considered as of Rheumatic kind.

And although means may be occasionally employed for obviating [symptoms] of palpitation yet radical cure to be aimed at by removal of Rheumatism.

Without therefore being more minute in name would consider it even in most anomalous state as Rheumatism in particular form.

May however here occur as objection that symptoms not such as enter definition of Rheumatism in nosological systems.

Practitioners however have long distinguished between two different states of this disease vizr. acute & chronic.

And these probably not more different from each other in symptoms than in nature

May be question how far should not be distinguished by different names.

But circumstances of one being so frequently [sequel] of other has led to bestowing upon them the same term.

And indeed often intermediary states [partake] in some measure of symptoms of both.

This seems to have happened in instance before us.

In obvious inflammation or swelling together with quickness of pulse had symptoms of acute.

Yet general absence of febrile affection & pains commonly without external appearance led to think that inclined most to latter.

With this view of nature of affection do not I own consider it as threatening great danger.

Rheumatism even when most violent is more a painful than dangerous disease.

And in acute state perhaps few affections more under command of medicine.

When however degenerates to chronic often a very tedious disease.

And even after seemingly cured patients from vicissitudes of weather subjected to returns even for life.

Particularly the case with old people

From all circumstances then can hardly look there for expedient cure.

And indeed even opinion that free from danger rested on no very certain foundation.

Rheumatism although not highly dangerous as affecting joints, may yet be attended with greatest danger as affecting vital organs.

Besides have already hinted some circumstances giving presumption, that disease may be Gout

And if this the case well known that attacks of different organs attended with great danger

Should then return of affection prove even suddenly fatal will not be altogether [unexpected]

Yet disposed to hope that for present at least severity over.

And that even in no long time patient may be in condition to be dismissed.

But hardly expect that during whole course of winter will be entirely free from pain.

In treatment of this case have proceeded pretty uniformly on plan on which first began.

First prescription intended with view of obviating an urgent symptom.

Second as means of radical cure.

When patient came under care had not formed any very decisive opinion respecting nature of fits of palpitation.

But from whatever cause, whether merely nervous or from more fixed local affection imagine that might at least be counteracted by means allaying inordinate motion.

And was with that intention that had recourse to aether.

From even commencement of use had apparently good effects.

For by being taken previously to paroxysm these mitigations in violence shortened in duration & rendered less frequent.

During use however a circumstance occurred removing ambiguity as to course

Or perhaps should rather say giving grounds for more probable conjecture.

That was severe pain on left foot attended with swelling.

As from this led to conclude that palpitation either from Rheumatism or Gout practices directed accordingly.

And here accommodated to disease as in [intermittent] state between acute & chronic.

Or to use different language between [inflamed] & atonic condition.

For consider first as depending on state of inflammation induced in particular parts of system.

Last as arising from peculiar irritated condition depending on atonia.

First then to be combated by evacuation [particularly] blood letting & sweating.

Last by means most affective [tracing] Peruvian Bark cold bathing or like.

But for intermediate cases consider those remedies as best suited which possess some degree of stimulating & evacuating powers in conjunction.

Was on these grounds that here determined to use of Guaiacum.

A remedy active part of which consists in resinous gum.

And which in whatever form exhibited, long deserved ranking among stimulated diaphoretics.

Of all formula however perhaps most powerful that of volatile elixir.

And in a Volume of cases of Rheumatism & Gout lately published by Dr Dawson of London is extolled as a most effective remedy both against rheumatism & gout.

Dr Dawson cannot be considered as introducer of this medicine.

But was at least first who gave it freely to great extent.

And increased dose from not many drops to extent even of ounce at time.

Since his publication have employed it in both affections for which recommended it.

In gout think have given it with advantage

In Rheumatism have found it product of most manifest good effects.

With present patient has not had that obvious operation which expected.

Yet think that has been here attended with advantage

And hope by continuation to overcome affection

At present therefore no immediate thought of altering plan.

And should this fail must own at loss to say what plan should next [illegible]

But in all probability change will only be requisite from alteration of affection.

And in that case future practices determined by circumstances then occurring.

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Explanatory notes:

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

2) 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.