DEP/DUA/1/18/02 (Normalised version)

Elizabeth Mill

(1778-1779)

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First Patient Elizabeth Mill a female in 23^d year of age.

With regard to affection to which this patient subjected must own that am not without very considerable difficulty.

Have however selected this case as subject of lecture as probably affording an example of affection where have never before had occasion to treat.

I say probably only for here conjecture which am to offer is by no means without difficulty

Affection to which I allude that disease to which Dr Heberden has given title of Angina Pectoris.

And to which he has been first to call attention of medical practitioners.

That this disease not of modern date may I think be fairly presumed.

Yet till described by Dr Heberden probably confused with other affections or passed under general title of pain of breast.

Of late however by him pointed out as separate & distinct genus of disease

+ whose system if not the most accurate at least the most [complete]

And since his description many cases communicated to public by oldest & most eminent practitioners which had long since fallen under their care.

Particularly by late Dr Wall of Worcester Dr Smith & Dr McBride of Dublin Dr Haygarth of Chester & several others.

How far all of them have with propriety followed Dr Heberden title of Angina Pectoris is I think matter of doubt.

Perhaps with view to future introduction into nosological¹ systems might be better distinguished by title of Pectoralgia or some similar [composite].

In present nosological systems even those of Sauvages & Sagar + no genus, description of which, nearly approaching to that of Angina Pectoris except the Cardiogmus.

Of Cardiogmus according to these nosologists essential constituent is pain referred to region of heart.

This pain however then attended with palpitation of heart affection of pulse deliquium [anima] & like.

These symptoms sufficiently serve to distinguish it from Angina Pectoris of Dr Heberden.

And evidently point it out as being a very different genus.

Of Angina Pectoris or Pectoralgia many descriptions now to be found in different works.

But most accurate those of London Medical Transactions.

Particularly first article of third volume where have a case of this disease drawn up by patient himself from own feelings, & communicated to Dr Heberden.

May in general observe that this affection consists in temporary acute pain of breast returning at no regular periods.

This pain while it lasts so severe as necessarily to cause suspension of action.

Patients for example when walking obliged to stop.

And to support themselves by any object that near them.

Pain thus occurring chiefly seated in Thorax.

In several cases however has been observed to extend to neighbouring parts.

And particularly frequently affects with great severity the biceps muscles sometimes of one, sometimes of both arms.

In other cases has begun in biceps & from thence propagated to breast.

At commencement of disease attacks of pain but of short duration & at considerable intervals from each other.

In process of time however become more frequent, & more severe.

Till at last in greater number of cases patient falls suddenly a victim to affection.

These then characteristics of the disease, which has been called by Dr Heberden Angina Pectoris & which I would distinguish by term of Pectoralgia.

To description here given can be at no loss to see strong similarity in case before us

Our patients principle complaint also a violent pain commencing at sternum & extending to back.

Is not indeed said to extend so low as biceps muscle.

But are told that to a considerable degree affects shoulders.

And this in many of most distinctly marked cases of Angina Pectoris utmost extent to which has gone.

That severity of pain in our case very great cannot be matter of doubt.

For goes even to such length as to excite profuse sweating.

Here then have at least what hitherto considered as great characteristic of Angina pectoris

But on this ground cannot I imagine give positive judgement.

For in present form of disease, some circumstances, which create doubts with respect to this affection.

And some which may be thought to give countenance to other suppositions.

Cannot indeed rank either extension of pain to biceps muscle of arm or origin from thence, among pathognomonic of disease without which cannot be said to occur.

Yet at least a frequent symptom.

And here wanting to corroborate supposition.

Other instances of Angina Pectoris observed solely in Men.

Our patient a Female

But from some other particulars still greater difficulty.

Pain in case before us does like Angina Pectoris return in fits.

In all history of that affection which I have seen patient represented as perfectly easy [unless] while during fit.

But our patient although at some times much more severe pain than at others, never entirely free.

From this then reason for presuming existence of some local cause.

While on contrary in cases of Angina Pectoris examined by most accurate anatomists [particularly] Mr John Hunter no local affection whatever discovered.

Patient before us at early period of life viz twenty third year.

Angina Pectoris however in all cases that I have read has occurred only in advanced age.

In Angina pectoris pain has been especially remarked to occur in afternoon.

With our patient occurs equally at every time of the day.

In cases of Angina pectoris occurring to most eminent practitioners no other symptoms whatever besides affection of breast.

But in case of our patient several other affections also.

And these such as indicate disease of very different nature.

Is frequently troubled with nausea, sickness & vomiting.

And at times much uneasiness from distensions of stomach by wind.

In these indications of an affection which am inclined to consider as one of most common to which people of all ranks subjected.

What formerly viz passed under general title of stomach complaint the Ventricle [Act] [illegible]

But what now with greater propriety [received] by modern nosologists among distinctly marked genera of disease under title of Dyspepsia.

Whatever be nature of that part of affection first mentioned that this patient subjected to Dyspepsia symptoms can I apprehend be matter of no doubt.

And may even be question how far pain of breast may not have originated from this source.

Well known that flatulence in alimentary canal by inducing distension giving [spasms] often cause of very violent pain.

And although the most frequently seated in stomach yet may at times have place in oesophagus as well as often have in intestinal tube.

To this supposition some countenance given in cause to which the affection is referred.

Are told that all complaints had origin in consequence of drinking quantity of cold small beer when very hot.

Influence of cold on human system both as removing & inducing disease unquestionably very great.

And although at present cold applied in different forms justly ranked among most fashionable remedies yet perhaps difficult to say to what different affections may not at times give origin

This supports argument in support of supposition that pain may depend on local affection.

But to this again frequent returns with so great severity occurring as strong objection.

Is particularly observed to operate as cause of disease when body pre heated which according to account given was case with our patient.

In this situation have known it induce many different affections of general system.

Even violent nervous disorders of convulsive [kind]

Of all other parts however has chance of acting most immediately on stomach.

From this therefore some farther countenance to supposition that in present case whole complaint may originate from stomach.

Yet to this supposition great difficulty unquestionably occurs from constancy of pain in breast.

And upon the whole, of three suppositions which have thrown out viz Angina Pectoris Local affection in some of Thoracic viscera & Dyspepsia, am still most inclined to first.

And whatever reason may afterwards have for adopting different opinions at [present] at least disposed to look upon it as complex [case]

And consider it as case of Angina Pectoris or Pectoralgia united with Dyspepsia to no very high degree

After these suppositions respecting name of disease or rather diseases to which patient subjected next come to offer conjectures as to Prognosis.

And here may observe that some parts of complaint with regard to which under little apprehension.

In dyspeptic affection see nothing very threatening.

Stomach ailments although very distressing often exist to much greater degree & for much greater length of time than has yet happened to our patient without proving fatal.

Besides is one of those complaints which [although] may not readily admit of radical cure

Can at least in most cases be kept moderate.

And grounds I think to hope that in case before us by aid of proper medicines this may be effected.

If therefore, as among other suppositions have thrown out, disease entirely a stomach ailment whole affection may in no long time be in great measure, if not entirely removed.

If this however the case, must own, shall be agreeably disappointed.

And if on contrary foundation for supposition of Angina pectoris may look for unexpected & fatal termination.

For if examine most of history of this affection will find that patients seemingly in perfect health, suddenly cut off within space of few minutes from very [severe] fit.

And if excepting practices tried in Dublin by that very eminent practitioner Dr. Smith & since more fully confirmed by justly celebrated Dr McBride no method of treatment, hitherto found of any avail.

Even on supposition of Angina Pectoris however from following treatments which they have pointed out some chance of success.

Yet at same time from frequently fatally terminating grounds for apprehending the worst.

And if in place of what strictly to be called Angina Pectoris disease depends on any local affection of Thoracic viscera prospects of success not more favourable.

Patient indeed, may in that case hold out for great length of time.

And may even at last be cut off by some supervening affection.

Upon whole however with regard to this case am in hopes that shall be able to mitigate stomach complaint.

But apprehensive that affection of breast will in end prove fatal to her.

This however am hopeful may not happen during period for which continues under our care.

And although may sometimes be aggravated sometimes diminished yet that in reality will be little altered under care.

But how far this conjecture which may indeed be considered as in great measure random one well founded hereafter better able to judge.

And after these remarks on prognosis come next to give account of intended plan of cure.

On view given of case two affections here occurring as claiming attention in treatment.

Those viz of breast & of stomach.

With respect to first all knowledge of disease which have yet acquired not sufficient to conduct to any rational plan of cure.

Different hypotheses indeed offered with regard to it.

And that not less in what respects seat than nature of affection.

Thus while Dr McBride supposes it disease of heart Dr Haygarth contends that depends on affection of mediastinum.

To both dissection after death gives some countenance.

Yet in still greater number of cases no morbid appearance whatever.

Probable therefore that neither uniformly affected.

And perhaps may even be sometimes entirely seated in other organs.

At least where no morbid appearance nothing to ascertain the contrary.

Want of any determined local affection has led very generally to supposition that disease of spasmodic kind.

And indeed, to this, manner in which fit commenced & ceases serves equally to give countenance.

Yet as far as practice goes medicines of Antispasmodic, or nervous kind, do not seem to be successful.

Only practitioner who has had success in this affection Dr Smyth of Dublin.

Account of his method of treatment will find in edition of Dr McBrides introduction to Theory & Practice of medicine published at Dublin last year.

He too considers immediate cause of pain & sense of strangulation as being affects of spasm.

But supposing this spasm induced by peculiar acrimony of fluids.

Hence led to conclude that [rational] cure to be aimed at by alteration & evacuation

With this view in one case at least has tried issues & antimony with success.

And whether look upon theory as well founded or not must still consider [same] practice as deserving future trial

Is then on this authority & on supposition of angina pectoris that have already prescribed for patient an antimony medicine.

Here indeed must observe that have not employed same antimony as used by Dr Smith.

He used antimony wine of Dr Huxham [while] I have had recourse to Antimony in crude [state]

Can be no doubt that former much more active than latter.

Yet long disposed to think that if [wished] for [alternative] affects most conveniently had from antimony in form here prescribed.

Very rarely that not sufficiency of acidity in stomach to render it active.

While at same time rendered [active] in so gradual manner that rarely subjected to looseness, vomiting, or even nausea [which] other preparations very apt to occasion.

These then reasons for giving trial in first place to this medicine.

And if find it product of any remarkable affect on pain shall give it to greater extent & persist in use without addition of any other medicine.

If however does not soon produce manifest change for better, shall have recourse to issue

And must own am inclined to suppose that on this more than antimony good consequences in Dr Smyths case depended.

If these remedies of no affect at a loss to think what shall next have recourse to with view to this part of affection.

Upon supposition at least that no such change in appearance as to lead to alter opinion with regard to name of disease

For in Angina Pectoris as have already observed consider us as having no sufficient knowledge of disease to lead to rational cure.

May only observe that on supposition of [being] affection of spasmodic kind dependent on peculiar sensibility inclined to think that trial may be made with safety & even advantage of Electricity.

If from observing future progress of disease shall discover to be of different nature from what at present suspect may be led to other practices.

But with regard to these cannot at present pretend to make any conjecture.

Thus far then have spoken of [intention] in practice with regard to principle part of complaint.

Have remarked however that besides this patient also affected with stomach ailment.

And for this may be supposed that should also have recourse to medicine.

Here however must own that should be sorry to interrupt or disturb operation of remedies for other affection.

Unless therefore for obviating urgent symptoms shall avoid doing any thing with this intention.

If however either acidity flatulence or constipation give great unease will necessarily be led to employ means for temporary relief.

And is with view to first of these that have already had recourse to Gummi Pills

Into composition of these several active articles of Gummy kind enter.

But article on which put principle [reliance] in present case the Assafoetida.

This consider to be a very powerful antispasmodic of stimulant kind.

And from such powers frequently product of good affects as obviating flatulence.

This especially to be expected when conjoined with another medicine of same kind as in these pills with Oleum Succini.

Hope therefore that from these patients may derive benefit.

But if this complaint tolerably easy [shall] think even of omitting these.

Principally that may be able to determine with greater certainty how far remedies already mentioned have influence on first part of affection.

But may conclude with observing [that] in case where so much in dark must speak either of present or future plans of cure with great uncertainty.

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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.