DEP/DUA/1/17/08 (Normalised version)

Elizabeth Robertson

(1778)

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Elizabeth Robertson.

Case of this patient formerly subject lecture during course of last summer

Was then a Dispensary patient for [complaint] in every respect similar to present.

And as remarks offered in her case are delivered in selection which have published¹, [shall] not again repeat here my sentiments on this subject.

May only in general observe that had formerly little hesitation in referring affection to head of Lepra.

And that of all species consider it as most nearly resembling that described by Mr Sauvages under title of Lepra Graecorum.

From continuation of same appearance am still led to entertain same opinion.

And look upon affection to be simple & uncomplicated.

Or at least consider all other symptoms as consequence of diseased state at surface.

That this should give rise to headache shivering & such other affections by no mean surprising

As well known how much general condition of habit connected with state of surface.

May indeed be here some question respecting Amenorrhea.

That this in no degree concerned as [cause] of the disease is beyond all doubt from late period at which occurred.

That may indeed here take place totally unconnected with it is very possible.

Yet must be observed that no other known cause to which can be ascribed.

That in perhaps more [instances] takes place as symptom than as idiopathic disease

That particularly apt to occur from [chronic] affections of long continuation.

From all these particulars then taken together probable that here a symptom of the Lepra.

And that could health of patient be perfectly restored flow would return [without] any other remedies.

Must however be admitted that no certain grounds for such a conclusion.

And that therefore with respect to this part of prognosis cannot speak without some degree of doubt.

Considering it however, which am at present disposed to do, as merely symptom view Lepra here as principle, if not sole object of attention.

And must own that expectations by no means great of obtaining favourable termination of this affection.

Disease very generally in its nature obstinate.

And here occurs with every appearance which can tend to give evidence of such a condition.

To this may farther add that has [already] from experience been found to resist most powerful medicines.

Previously to her being last our patient at Dispensary had been under care of many different practitioners.

And from account given had tried to considerable extent several of most powerful medicines.

Particularly Mercury to such degree as to affect mouth.

At Dispensary during last summer various other articles tried.

Especially vitriol acid & Mercury externally.

These indeed had affect of producing in great measure total removal of eruption.

But that this removal temporary only is sufficiently demonstrated by present affection.

And has now again returned probably without any other exciting cause than season of year.

May therefore I apprehend hope that by change of season alone would again be mitigated.

And by aid of proper medicine this may be at least accelerated.

Hope therefore again to dismiss patient at least apparently cured of this affection.

Yet am very suspicious that will neither be radical nor permanent.

From this however flatter myself that many of other symptoms for time at least will be removed.

Particularly headaches faintness etc.

And perhaps even Amenorrhea.

Should this not be case cannot at present say whether under our care shall reckon it necessary to make it object of treatment or not.

In this particular must be entirely regulated by circumstances.

And should patient even under our care seem freed from other affections, may yet think it proper to dismiss her leaving [recruitment] of system to proper diet, & from this source hoping for restoration of menstrual flux

More probable however that in such a situation should think of trying something with this intention

And of numerous tribe of Emmenagogues after system recruited should think chiefly of employing such remedies as [would] either produce determination to uterus or renew disposition to action.

But without thinking of measures with this view present object of attention must be cutaneous affection

And here as formerly [observed] greatly at loss respecting general principles on which to be [cured]

Extent however of affection & recurrence at particular season still leads me to view it as more consequence of general state of fluids than of any local cause

Such for example as condition of sebaceous glands, of bulb of hair or of extreme vessels.

Yet considered as affection of general mass [this] [again] may be induced by state of discharge by [surface]

And as affecting this nothing more powerful than condition of [superficial] vessels.

Perhaps then radical cure still ultimately to be affected by restoring to these due state of action & such condition as to admit of [illegible] discharge.

How far this theory may lead to [illegible] plan of cure will not pretend to say.

Am however inclined to think that is by support of regular excretion by surface, that here to look for prevention of return of affection

Must at same time [however] [acknowledge] that still as formerly medicines chiefly employed rather on empirical than any other footing.

Have already observed that present patient tried with several of most active.

And besides what used by other practitioners when last at the Dispensary had taken both vitriol acid & mercury to considerable [extent].

But although with apparent relief yet [without] producing radical cure.

This then consider as sufficient reason for at least first giving trial to other medicines.

And consider present as case from which might at least in some measure be able to judge of efficacy of a remedy of late highly celebrated against such affections.

Decoction viz of inner bark of Elm Tree [Ulmus] has not a place in present edition of Edinburgh Pharmacopoeia².

But was introduced into all former editions.

And still retained in other modern Pharmacopoeias published since that of Edinburgh.

Formerly however held in no very high estimation

Inner or rather middle bark, the part most in use possesses slightly astringent taste

And chiefly employed externally on supposition of possessing [illegible] quality.

Of late however introduced also for internal use.

And particularly very highly recommended by Dr Lyssons of Bath as a remedy against cutaneous affections.

On this subject will find a paper in the 2^d Volume of London Medical Transactions.

Since that time has been used by several other practitioners.

And particularly in Medical Memoirs of London Dispensary³ will find several cases in which Dea Ulmi attended with best affects

Found successful not only against other cutaneous affections but even in [apparently] [illegible] cases of Lepra.

From these facts have of late been induced to trial of it in several instances

And in most of these I think with manifest advantage.

These therefore sufficient grounds for having recourse to employment in present case.

And is intention to give it with this patient a full & fair trial.

If after measures already taken be found successful must own that will not only confirm but increase opinion which already [entertained] of it.

And should it even prove ineffective here will still consider it as being a remedy of efficacy.

For although unequal to complete cure has already had in present instance very considerable efficacy.

If by means of it radical cure obtained must rather be looked for as gradual work than to be brought about suddenly.

Is then from this reason that hitherto have made little alteration in dose with which at first began.

In extent to which here given while manifest diminution of eruption yet no obvious [operation] from decoction.

Nor indeed has this been case in other instances in which have employed it.

In one [case] indeed imagined that [increased] quantity of urine.

At same time doubtful whether this might not be in some measure affect of watery part of decoction.

For this doubt the rather a foundation since present patient inclined to think that with her has had contrary affect

Or at least that during use quantity of urine has been rather diminished as otherwise.

At same time this may be either mere supposition of patient, or entirely unconnected with any effect from medicine.

And at any rate is in present state no objection to continuation of use.

Is therefore intention to persist in employment & if disease shall either again increase or if cure even shall seem to become [static] to augment both quantity & strength of Decoction.

If from [eruption] speedily disappearing [neither] measure should seem necessary will yet wish to continue use for some time after apparent cure.

But in place of this perhaps rather more probable that from use of this medicine shall in end be disappointed.

And that will be necessary for us to [attempt] cure by aid of some other.

For this purpose have thoughts of next employing another medicine likewise which has not place in Pharmacopoeia.

That is Oenanthe crocata or Hemlock dropwort

This vegetable long ranked among [list] of poisonous plants.

And that in reality possesses active [power] may without hesitation be inferred from [illegible] quality.

Till very lately however has not been employed for medical purposes.

And then [introduction] rather [intent] than be [dangerous]

In late Volume of Philosophical Transactions a paper by Dr Poult where [juice] of root of Oenanthe used for water [illegible] produced most remarkable cure in an obstinate cutaneous affection.

Do not know that since publication of this case same substance has been given to [same] [extent]

But other preparations of plant which may be supposed less violent in effects have been tried in several cases at this place.

Particularly an infusion of leaves.

And while used with apparent success in some affections where obstructed menses occurred has been observed to restore flow.

In so much that one of most eminent practitioners of Edinburgh dispensary to consider them as very powerful emmenagogue.

This then as additional reason for thinking of employment in present case.

And was chiefly with view to trial now mentioned that selected present instance as subject of lecture here.

If these fail, other measures that may be recommended.

Such for example as living entirely or principally on particular kinds of Vegetable food

Especially on Turnips.

For by liberal use of these in some obstinate cases cure certainly has been effected.

On presumption also that connected with debilitated state of [external] vessels may recommend use of cold or sea bathing.

And if eruption once [removed] from this [perhaps] as much as any measure reason to hope for prevention of return.

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Explanatory notes:

1) Andrew Duncan, Medical cases, selected from the records of the Public Dispensary at Edinburgh : with remarks and observations : being the substance of case-lectures, delivered during the years 1776-7 (1778).

2) An official publication containing a list of medicinal drugs with their effects and directions for their use. The Royal College of Physicians of Edinburgh's Pharmacopoeia was first published in 1699.

3) John Coakley Lettsom, Medical memoirs of the General Dispensary in London, for part of the years 1773 and 1774 (1774).