DEP/DUA/1/18/09 (Normalised version)

Mary Burnet

(1778-1779)

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Mary Burnet.

Disease to which this patient subjected in great measure an obvious one.

At least can evidently see here a diseased state in those parts to which refers her affection.

And can have little hesitation in referring disease to one of two genera.

Gout or Rheumatism

Here however several circumstances by which rendered in some measure doubtful whether are to consider it as a Gouty or as a Rheumatic affection.

In many instances these affections appear in such manner that distinction between them sufficiently manifested.

Yet no doubt that principle symptoms of each, viz pain & swelling of article precisely the same.

And that disease often in such form that extremely difficult to say to which [should] be referred.

Of this nature hold present instance to be an example.

For distinction between Rheumatism & Gout recourse had to age of patient.

Rheumatism most frequently a disease with [young] & vigorous.

Gout most generally an affection with those advanced in life

From age of patient then presumption rather in favour of gout.

Rheumatism for most part proceeds from obvious cause.

And in general may be traced to great or imprudent exposure to cold.

Gout on other hand seldom referred to any accidental circumstance.

Our patient however acquainted with no cause to which affection can be referred.

This therefore also in favour of Gout.

In third place may observe that the two diseases often distinguished by situation

A circumstance which has accordingly entered best definitions.

Rheumatism very generally in larger joints as shoulders, knees etc.

While gout almost constant in smaller ones particularly articles of feet & hands.

Latter however evidently situation of disease with our patient

This circumstance therefore also in favour of gout.

But if age, situation of pain & want of obvious cause, on one side, many more circumstances on other.

At head of these may mention sex of patient.

Is at least but rarely that gout attacks females.

While with these Rheumatism as frequent as with men.

Gout in by much greater number of cases is disease of rich & indolent rather than of industrious poor.

And for most part [seminal] of affection [transferred] from father to son

In this way however present patient no claim to it.

Is product of full living, high [seasoned] & luxurious diet.

Circumstances from which present patient can be supposed exposed to no danger.

Besides may farther observe that present case even in symptoms does not correspond with gout.

For besides severity & situation of pain Gout very generally attended also with other symptoms.

Particularly with sickness at stomach & other affections of alimentary canal.

Is a disease not constant in [possession] but returning in fits & at intervals.

All such appearances however here wanting.

And excepting pains of joints is free from every other morbid affection.

Hence then appearances here wanting which should naturally expect in Gout.

But farther appearances present which should not expect.

Patient affected with pains in several different places at same time.

This however very rarely if ever case with respect to Gout.

Attack in one place almost certain symptom of cessation in others.

Farther to be added that although pain principally in hands sometimes also in shoulders.

A circumstance at least very rarely occurring in any Gouty affection.

Lastly may remark that with our patient pain manifestly aggravated by heat of bed.

A circumstance which while characteristic of certain state of Rheumatism does not occur in gout.

When all circumstances taken together then presumption of Rheumatism be much stronger.

And although more rarely than Gout has often also even commenced in advanced age.

Although frequently from obvious causes, yet in some instances, that cause escapes observation.

And indeed hardly to be imagined that a patient in situation of ours & at this season of year could escape exposure to causes from which most frequently arises

Though commonly in large joints yet sometimes even as most distinctly marked, affects these which usual seat of Gout.

But even this not entirely case with our patient.

For with her, not only affects wrists but those places also in which Rheumatism most common, Shoulders.

On these grounds then conclude [affection] to be of Rheumatic kind.

And although no certainty, must still consider presumption as strong.

But before leaving [inquiry] as to name & nature of disease another question occurs

To what species viz of genus of Rheumatism are to refer it.

In system of Mr Sauvages will find that has enumerated no less than fourteen different species.

Of these however greater part merely symptomatic affections.

+ Into any inquiry respecting differences of these do not at present propose to enter.

As for example pains occurring from worms hysteria scurvy etc.

Were we here to arrange it according to his system would refer it to third species, Rheumatism Arthritic.

At least no doubt that of all species he describes has most near resemblance to this.

But hold Rheumatism strictly so called to be, by no means an affection, admitting of variety, which Mr Sauvages supposes.

And am inclined to think that most useful distinction is into acute & chronic or perhaps as may be more properly called atonic state of this affection.

For sentiments on this subject may refer you to medical cases¹ which published last summer.

Here sufficient to observe that while look upon acute Rheumatism to be effect of active inflammation consider Chronic as depending on atonic state of same parts principally induced by that inflammation.

Evident therefore that in these different states practices must be much varied.

While one to be overcome by evacuation other to be chiefly combated by tonics.

Is then a distinction of greatest consequence in practice.

And for most part sufficiently obvious.

For with acute state there is very generally present considerable degree of fever.

While very little if at all [concomitance] of atonic.

When chronic has advanced to last stage, parts cold & stiff.

And indeed in good measure in same situation as in Paralysis.

Then little if any remains of swelling and no obvious inflammation.

While at same time pains in place of being augmented by heat are [retained] by it.

And chiefly violent from exposure to cold.

From this description however some difficulty may be supposed to arise.

For while want febrile symptoms of acute Rheumatism characteristics of chronic also absent.

Here pain though without inflammation still with considerable swelling.

And while fever absent, several of effects augmented, not by cold, but by heat.

To be observed however that in this affection accurate or precise limits betwixt two states cannot be fixed.

Occurs as it were, imperceptible [gradation] from one to other.

And at such intermittent state case of our patient seems to have been when came under care.

Would then pronounce disease to be a Rheumatic affection, still partaking in some measure of nature of acute, but evidently verging to atonic state.

From this view led to more favourable prognosis than if were to pronounce it Gout.

For although both affections unquestionably obstinate yet of the two Rheumatism least so.

And while but rarely that either has by itself terminated in death yet most frequently happens of Gout

Both one & other often at last fatality be consequence.

Of such tendency however no appearance in instance before us.

Am upon whole hopeful therefore that patient may soon get better of present attack.

But even allowing this to be affected can hardly look upon it as perfect cure.

For after being once severely subjected to this disease great disposition to return.

And that too even from very slight causes.

While these at same time so frequent in this country that hardly to be avoided.

Do not therefore expect, that patient, after period of life, at which now arrived will ever get entirely free of affection.

Reckon it probable that will be more or less subjected to it from different accidents during whole remaining part of life

And am in hopes, that for present at least may be able, soon to dismiss her free from complaint.

With this view according to idea given of disease two great objectives to be aimed at

The removal of inflammatory affection as far at least as such a state still [remains]

And secondly the restoration to parts that degree of tone, & condition of sensibility of which deprived by former inflammation.

In this case then cure neither to be entirely adapted to acute nor chronic.

For by liberal use of evacuation resolve [inflammation] have chance of increasing loss of tone.

This then must necessarily occur as objective to evacuation, most common in [illegible], blood letting & sudorific.

On other hand by most powerful tonics, as cold bathing & bark, should here be in danger of augmenting inflammation.

Such case as present then to be considered as suited for intermediary practice.

And as such ought chiefly to employ medicine conjoining some degree of evacuation with stimulatory power.

And is I apprehend on these principles that great advantage often derived from Electricity, Mercury & Guaiacum.

But in place of employing any of these have made this case subject of trial of another remedy.

And one [too] which till within these few months has never I suppose been employed in this country for medical purposes.

viz Rhododendron.

Under this general term in Systema Naturae² of Mr Linnaeus will find six species described under different trivial names.

Plant however which here employed not referred to any of these.

Is a native of mountains of Siberia growing higher up than region producing trees, & near borders of snow by which summits are in general covered.

Is a small hardy shrub which among inhabitants has name of Chie or Tea probably as are in practice of drinking an infusion of it, in same manner as China do with their Tea

In reality however is a very different plant

First examination in a way of botanical investigation by Mr Pallas of Petersburg [illegible].

Finds it to possess all marks characterising the genus of Rhododendron.

But at same time must be reckoned new species.

And accordingly Mr Pallas has distinguished it by title of Rhododendron Chrysanthemum.

How far has different sensible qualities or medical virtues from other species probably not yet ascertained by sufficient examination.

But besides employment as common drink is considered, also by Siberians as being a very powerful medicine.

And is the great remedy which they employ in Gouty & Rheumatic affections.

For that purpose exhibited it in form of strong infusion, made by warm digestion.

Upon ℥ii of dried Shrub consisting of mixture of leaves & stalks poured about ℥X of boiling water

Whole put into an earthen vessel & closely [illegible] up.

Then placed in heat of oven for space of night.

And after this [preparation], the water thus impregnated Is taken next morning for a dose.

Obvious operation of this medicine is said to be the exciting general heat over system.

This heat accompanied with degree of intoxication same as arises from use of spirit liquor

These affects however seldom we are told continue for more than few hours.

And then terminated by two or three loose stools.

But besides these general effects [which] probably consequence of action on the alimentary canal others more particular.

And especially confined to affected parts

Patients complaint soon after has taken dose of uneasy but at same time very peculiar sensation at affected part.

And with this sensation these parts also affected with singular sense of [prickling] or vermiculation.

This however as well as former affections also but of short continuation.

But when ceases pain with which parts formerly affected found to be greatly diminished.

And by repetition of dose, at proper intervals, is soon entirely removed.

Is even said that for obtaining complete cure, seldom necessary to use it above two or three times.

For [relation] which have now given you, of operation & affects of this medicine, am indebted to ingenious & industrious friend Dr Guthrie of Petersburg.

And if wish for more full account may refer you to a letter of his which have published in last [number] of Medical Commentaries.

But besides sending this information of medicine, has transmitted to me also small parcel, that may have opportunity of trying effects at this place.

Is in such situation that cannot show you, any species which a Botanist would consider as a good one

And indeed must remark that parcel which Dr Guthrie has [sent] me has been dried with very little attention.

A circumstance which although does not remove may yet very considerably diminish its medical virtues.

From fragments however, which have here brought may have some idea of [figure] of plant.

And hope that by trial even in present state shall be able to form some judgement of virtues.

Is with this intention that have [ventured] to prescribe it to present patient.

And may venture to say that as far as trial has hitherto gone in favour.

Here will observe that have not ventured to exhibit it to extent to which said to be given in Siberia.

For with every medicine with effects of which am not acquainted from experience reckon it better to lose time, than to run any risk

In place therefore of two drams venture upon exhibition of it only to extent of ℥p.

Cannot seem strange then that from this did not observe all affects described by Dr Guthrie

And here in particular neither heat, signs of intoxication, vertigo, or loose stools.

That is produced none of effects which would ascribe to action on primae viae.

But had no small satisfaction in finding that had evidence of influence as entering system.

This evinced by peculiar feeling excited in diseased part.

For patient of her own accord gave very particular account of same feelings mention in Dr Guthries letter.

In few hours after dose taken had numbness or insensibility in pained parts giving peculiar uneasy sensation & succeeded by prickling or vermiculation.

[Circumstances] which can suppose present patient to have been capable of describing [only] from her own feelings.

But with these obvious affects has had also in some measure at least same good effects on the disease as the Siberians allege.

For after two first doses pain not only very considerably diminished, but motion of joints which before much impeded in great degree restored.

And as proof of this informed us that had been able to put on her own clothes which had not done for space of 7 weeks before

In this situation was I own in hopes that by continuation of medicine disease would soon be removed.

But in succeeding week, during which time took two more doses complaint rather aggravated.

This however patient herself ascribed to fresh exposure to cold which probably the case.

Did not therefore look upon it as any discouragement in former plan of cure.

But from another circumstance was led in some measure to [alter] plan.

Found that if persisted in use of [Infusing] whole stock of Rhododendron would soon be exhausted.

In place therefore of watery menstruum by which considerable share of efficacy probably lost had recourse to plant in substance.

In this way have hitherto ventured on it only to extent of few grains for dose

And while thus not product of signs of intoxication still excites peculiar feeling at pained parts.

And besides appearances mentioned by Dr Guthrie our patient farther observes, that these parts in particular observed to sweat during night.

Am still therefore in hopes, that without any farther alteration than small increase of dose, may be able to produce complete cure.

If this however not the case shall notwithstanding desire of saving medicine have again recourse to infusion.

And before desist from employment have thoughts of pushing it as far as patient capable of bearing.

Will however be much better placed if can dismiss her cured after having [used] only few scruples³ in way of powder.

What now said will explain to you intention in practice & future expectations in this case.

May however be expected that should offer some conjecture as to theory of action.

Will however be soon enough to say any thing on this subject when effects confirmed by more certain & more numerous observations.

And may here observe that besides present have used this remedy also in another case.

There however have not found it attended with same affects.

Case of that patient indeed in many respects peculiar.

And although principle part of affection consists in pain confined to one side of head & hip joint which suspect to be rheumatism yet by no means certain as to nature of case.

With her powder of Rhododendron no effects in producing ease of pain or vermiculation at pained parts.

Nor has it had any influence in moving belly.

But as suspects that has considerable [illegible] vertigo to which however before subjected have omitted use.

And indeed consider trial from beginning as by no means a fair one.

Have little doubt however that besides present shall soon have opportunity of trying it in other cases of distinctly marked chronic Rheumatism.

And must own that from case of present patient am inclined to look upon it as useful addition to Materia Medica⁴.

Will hold this opinion should it even fail with present patient.

In that event as already suggested may have recourse to Electricity or Guaiacum

But before using any other shall wish to give very full trial to present.

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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) Carl Linnaeus, Systema naturae per regna tria naturae :secundum classes, ordines, genera, species, cum characteribus, differentiis, synonymis, locis (1735).

3) A unit of weight equal to 20 grains, used by apothecaries and physicians.

4) Latin term referring to the body of collected knowledge about the therapeutic properties of any substance used for healing (i.e., medicines).