DEP/DUA/1/18/04 (Normalised version)

Elizabeth Anderson

(1778-1779)

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Third Patient Elizabeth Anderson.

Evidently affected with complication of diseases

And at least some room for doubt how far different parts any connection with each other.

Most obvious part of disease tumour of considerable size immediately on Sternum at its upper part.

Externally no change in colour or appearance of integumentary.

While at same time so hard to feel, & so much fixed in situation, that cannot consider it as having any tendency to suppuration.

From this however patient affected with constant & violent pain.

And particularly on any circumstance giving motion of parts, especially of bones example [illegible]

This tumour we are informed not a spontaneous occurrence but affection of particular [accident]

A stroke viz on part where now appears

From all these circumstances then taken together must endeavour to determine nature of this tumour.

Well known that from severe strokes to any part of system increased action of vessels induced.

And that from this inflammation with all its consequences pain [effused], tumour etc

Nature & tendency of inflammation however much varied according to nature of part in which situated

And from this circumstance in particular, consequences whether in resolution, suppuration, scirrhous, or like, very much affected.

For these, with several other particulars [although] not so commonly occurring, to be ranked among sequelae of inflammation.

And although several consequences which may occur to many different parts, yet some peculiar to certain parts.

From this circumstance then inquiry into nature of part affected of some consequence.

And here from progression as well as appearance cannot suppose it a cutaneous affection.

From fixed situation & hardness can neither believe it to be affection of gland nor of cellular membrane.

Nor indeed can we easily suppose it to depend on [enlargement] of any softer solids

Among all genera of tumours in best nosological¹ systems, particularly that of Mr Sauvages from appearance, as well as other circumstances can be referred only to one of two Exostosis or Condyloma

Of these genera latter no place in system of Dr Cullen unquestionably an improvement on that of Mr Sauvages

While to his definition of exostosis affection before us very exactly corresponds.

Tumor durus ossi insidens.

According to this definition will observe that every exostosis not be viewed as affection of bone itself.

And in present case as in many other instances, am inclined to think that rather an affection of periosteum.

From sentiments however with regard to use of periosteum, & format of bone, hold that from this source a real bony tumour may be formed.

And is chiefly from state of this part that varieties in exostosis produced.

Although indeed must also be admitted, that much affected by cause.

And from this source in system of Mr Sauvages several different species of exostosis as Scrofula Scorbutic. Syphilitic etc

Of any such cause in present case no suspicion.

While at same time from severity of pain, does not correspond with exostosis benigna of Sauvages.

And of all his species most exact resemblance to what calls exostosis supria.

Am inclined then to give this name to first part of affection to which patient subjected.

And to view it, in its nature as depending on a diseased state of the periosteum [induced] from injury given by the blow.

But although this most obvious may be some doubt whether looked upon as most considerable part of affection.

For besides this subjected to frequent attacks of vertigo & tinnitus aurium.

And these we are told to such degree as frequently to deprive her of vision

In these can hardly be considered as having characteristics of any affection.

For occur as symptoms of many different diseases very little connected with each other.

Both vertigo & [illegible] indeed, [received] as genera into system of Mr Sauvages.

In this however apprehend that has multiplied genera with impropriety.

And that even where these symptoms do not occur with others, must still have regard to cause.

In account given by our patient [nothing] particularly to direct us with respect to this

From laboured respiration however was led to imagine that might arise from distension of alimentary canal by flatulence.

Both because from occurrence of this breathing often affected from lungs being pressed upwards.

And because well known to be a circumstance from which vertigo often arises

In this supposition, somewhat [confused] by other particulars.

Especially by other sensations which flatulence excites

That this part of affection in no degree consequence of other evidenced from being of much earlier date.

And probable even that aggravation lately taking place rather from some accidental circumstance than in any measure arising from supervening affection.

This leads us in prognosis to speak of each separately.

And indeed according to opinion given one may admit of total removal or considerable alleviation while other either nothing diminished or increased in violence.

Of the two affections to which our patient subjected am most alarmed with respect to tumour on sternum.

See no reason indeed for imagining that bad consequences will soon arise from it.

Yet on other hand from hard & fixed nature cannot hope for speedy removal.

And difficult to say in what way may yet terminate.

Have however at least some chance that may be able to artificial means to obtain resolution of it.

In that case by progress to recovery as gradual as increase has been, may at length be completely removed

If however in this disappointed which by no means improbable may possibly degenerate into state of insensibility.

And tumour may continue for whole remainder of life without either pain or any other inconvenience than arises merely from bulk.

Have however some reason for apprehending still worse termination

From continuation & severity of pain consider [us] as still exposed to danger of terminating in suppuration.

And when this happens, which at least not very rare occurrence in such cases often product of caries in bone itself.

From this however there never fails to arise obstinate & painful ulceration sometimes even death itself.

Yet if such to be consequence of present tumour will not probably happen soon.

And entertain hopes that may be able to dismiss patient in second situation mentioned.

That is with alleviation if not removal of pain although tumour should still continue.

On supposition that other parts affection Vertigo, Tinnitus aurium etc the consequence of flatulence imagine that less to be dreaded than from affection of breast

And inclined to hope that by proper means tending to expulsion of flatulence return of attacks may be prevented.

Still however even on this supposition reason to fear that may be liable to renewal from slight irregularities.

And if conjecture as to origin a mistake one may find it, much more difficult to combat, or alleviate than expected.

May even be forerunner of some of most distressing affections of Nervous kind.

Such for example as Epilepsy.

If this the case may yet turn out to be most material part of disease.

But from length of time, for which has continued in present form, as well as from opinion of cause, inclined to hope more favourable.

And expect that shall be able if not to remove at least to relieve this part of affection.

Practice here requisite for different parts of complaint very little correspondence

On supposition that Vertigo etc consequence of flatulence attempts to counteract must be directed with view to two different objectives.

The prevention of general or [extrication] of air in the alimentary canal.

Or expulsion after is extricated.

Is in latter of these ways than can here look for most immediate relief.

While former most affective means of radical cure.

Rather however to be brought about by regulation of diet & by general conduct of life than by medicines strictly so called.

And was chiefly with intention of operating on latter principle that had here recourse, to Pill Gummos

These pills composed of equal parts of [ Gabban]. Myrrh & Assafoetida.

From all these articles but especially last derives stimulating & antispasmodic power.

And to this some addition made by [illegible] succinate article by which mass formed.

Since began this medicine whatever may be principle on which has operated, patient has at least obtained considerable relief.

And if affection continues so far alleviated shall not soon think of having recourse to other measures.

May even desist from present measures [confining] attention entirely to affection of breast.

But if in place of this shall again be aggravated or put on different form hard to say to what measures may think it necessary to have recourse.

Have thoughts however of trying some of mineral tonics with view to removal of an irritable state.

And with this intention should be disposed to put greater confidence in Cuprum Ammoniala under form of Pill Caeruleae than any other.

But to this measure am hopeful will not be necessary for us to have recourse.

If however should have thus little difficulty with one part of disease no grounds for expecting that other will yield in no short space of time.

Or that even if brought to termination, that termination will be so favourable.

Here however should at least be first aim, in cure to obtain if can resolution of the tumour.

And if this not to be affected to alter condition of sensibility in such a manner as to mitigate pain.

Am in hopes, that both these intentions may in some measure be answered, by that mode of cure which have prescribed for this patients use, viz of Electricity.

Of principles on which Electricity as [used] for medical purposes operates do not at present propose to speak.

May perhaps hereafter have some more favourable opportunity of stating to you my sentiments on this subject.

Will however find some view of them in the Volume of Medical cases² which I published last summer.

Particularly in observations on a case of Dyspnoea treated with success by means of electricity at this place.

On principles there laid down hold that may be no less useful as counteracting morbid sensibility than as restoring sensibility when lost.

And in as far as is a means of renewing circulation in obstructed vessels look upon it as a remedy which may be powerful in removal of tumours.

At least while vessels there continue [in] such a state as to admit of possibility of renewal of circulation.

In neither way however have affects been yet determined by sufficient experience.

And this an additional reason for trial in instance before us.

Unless therefore from some unforeseen occurrence shall be unwilling to adopt any other practice till this has had full trial.

For such trial however since use first directed weather has been particularly unfavourable.

And that both for attendance of patient and for obtaining effects of electrical machine in manner that would wish.

Hitherto therefore very little has been done in this way.

Is however intention, besides drawing sparks from part, the only way in which have hitherto employed it, to direct also shocks in such manner that will pass through the tumour

And if patient submits to cure with proper perseverance am in hopes that may be product of good effects.

If in this however disappointed may have recourse to topical application either of stimulant or sedative kind.

Particularly friction with unctuous substance, combined with camphor or mercury, with view to resolution of tumour.

Or application of Hemlock or Saturn preparation, with view to mitigation of pain.

And if notwithstanding these both size & pain increased, Cicuta or Mercury may be used internally.

But after failure of electricity must own should not be disposed to put much confidence in any of these.

And after that has had proper trial shall be satisfied if can dismiss patient even with alleviation of pain.

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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) 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).