DEP/DUA/1/20/13 (Normalised version)

Donald Robertson

(1779)

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Donald Robertson.

Disease of this patient in some respects very distinctly marked.

Yet in others not altogether without doubt.

Most obvious part of disease consists in tumours under ears & in some measure below skin.

These though now of considerable size & of several months continuation neither painful nor discoloured.

This slow progress if not peculiar to scrofula tumours is at least with these very common.

And when observed that similar tumours with several of relatives & that these after long continuation at last came to suppuration may conclude that present patients constitution liable to scrofula from hereditary disposition.

Upon whole then little hesitation in pronouncing tumours below ears & under chin to be of scrofula nature.

But this although most obvious not most distressing part of affection.

Has for still longer period been subjected to considerable unease from pains in abdomen.

These have subsisted we are told now for space of about 12 months.

And now attended with several other symptoms

Particularly with picking of nose when awake grinding of teeth during sleep & want of that quiet [rest] which at his period of life so common.

These well known to be symptoms frequently attending presence of worms in alimentary canal.

Particularly so when accompanied with [another] circumstance here also observed.

That is state of patients appetite.

In general bad though at times rather keen as otherwise.

Such irregularity well known frequently to proceed from worms.

In so much that by no means a rare occurrence to find with this disease a voracious appetite.

But from all these taken together by no means what can be called certain proof.

Nor would this be case were they even accompanied with several others.

Such for example as swelling of upper lip or septum narium, glairy stools or like.

In present case notwithstanding concurrence of [symptoms] which here take place have little hesitation in pronouncing that no worms.

Pain of abdomen well known may arise from diversity of causes.

While grinding of teeth & picking of nose though frequent attendants of worms yet as arising from them are only effect of peculiar irritation in intestines.

And may also proceed from similar irritation from any other cause.

Still less dependence to be put on state of appetite.

But besides this continuation of symptoms strong objection to supposition of worms.

Pains have now [subsisted] during course of 12 months.

And during all this period no worms observed to be discharged.

This however could hardly suppose to have happened had these been present in intestines for so long time.

And especially as has on different occasions taken purgatives.

To all this to be added that much more satisfactory explanation on a different hypothesis

Supposition viz that depends on [cause] similar to what has given rise to tumours in inferior part of face.

Though scrofula most frequent there yet well known that no part of body which may not affect.

And in many of those instances where patients fall victim to it is in consequence of affecting the mesenteric glands

Then has termination by that affection often fatal at early period of life the tabes mesenterica

Where mesenteric glands affected even before any proper hectic fever have all other symptoms which occur in present case.

And here tendency to fever although not great is yet manifest.

Observed that exacerbation of symptoms occurs towards evening.

Is then affected not only with [increase] of pain but also with augmented heat.

And strong presumption at least that while these consequences of fever paroxysms are to refer also to same cause want of rest during the night.

Upon whole then, from symptoms referred to abdomen with which this patient affected.

From evident affection in other parts of body manifestly of scrofula nature.

And lastly from disease to which his relatives have been subjected indicating hereditary constitution have evidence amounting at least to high probability that mesenteric glands are here affected.

Would then look upon all symptoms to which this patient is subjected as in reality belonging to one disease

And consider him as subjected to Scrofula.

From these sentiments respecting nature of disease cannot entertain very favourable opinion as to termination.

If we except cases where scrofula affects lungs none perhaps more generally fatal than [where] affects mesenteric glands

And in cases where does not prove fatal is yet well known how far in every instance an obstinate affection.

Where does admit of cure is for most part consequence rather of natural [change] in constitution than of medical aid.

In instance before us then can neither look for expedient cure nor can we promise that will not prove fatal.

While at same time cannot propose trial of any medicine upon which can place any great confidence.

Am however inclined to think [that] at this period of scrofula some practices with view to resolution of tumours which deserve trial.

Was with view to such that [selected] present patient.

And have at least some hopes that these may alleviate if not remove complaint.

Respecting general principles on which cure of scrofula to be directed must acknowledge that am much at loss.

This must entirely turn on knowledge of what properly to be called proximate cause of affection.

And with regard to this are still very much in dark.

May observe however than when in state of ulceration must be immediate objective in cure to heal that ulceration.

And when in state of tumour to obtain resolution of it.

In latter of these conditions is case before us.

Disease as far at least as is obvious still entirely consists in swelling of Lymphatic Glands

And as far as mesenteric glands affected probable that these also in same situation

This enlargement notwithstanding hardness can hardly suppose to depend on increase of solids.

But to be considered as principally if not entirely effect of congestion of fluids & obstruction to passage.

To be best overcome then by removal of such obstructions.

This may be affected on many different principles.

But chiefly either by relaxing vessels through which passage is to be made

Or by increased force impelling contents.

In as far as am acquainted with operation of medicine here employed was on last of these principles, that chiefly expected success.

At same time however must observe that induced to give it a trial rather on experience of others & on my own observations of its affects, than on any principle whatever.

Only remedy hitherto employed with this patient the Extract of Aconite.

This need not observe introduced into modern practice on authority of Dr Stork

Long ranked among list of Narcotic vegetable poisons.

With this power however seems also to possess effects of operating as a peculiar stimulant.

From these qualities may conclude it of efficacy in various diseases.

And accordingly on authority of Dr Stork recommended in many different affections.

Particularly in cases of obstinate Rheumatic pains.

But besides these has recommended it also in cases of scirrhous tumours even where approach to cancerous nature

Effects in this way Dr Moffatt late an eminent practitioner in New England informed me that thinks has such confirmed in different cases.

And particularly from employment of extract of plant as growing in that [climate] & pressure by insolation without any evaporation from heat of fire

How far either of these circumstances much effect cannot pretend to say.

Yet some probability at least that while heat of climate gives additional activity to plant, from slow evaporation these qualities more effectively retained.

To this gentleman not only indebted for this account of new England extract but has also furnished me with some of extract itself.

And this extract have formerly employed in several cases.

In some of these has I think been attended with very considerable effects

Although cannot represent it as equally successful in all yet have seen so much of good effects as to induce to future trial.

Present patient has now been on use of this medicine for near space of month

And although cannot say that has had very remarkable effect, yet now consider him as in many respects better than when came under care.

May even assert that progress to recovery has been more considerable than I expected.

And this I infer not only from change in obvious swelling but also from relief from pains of belly.

These changes accompanied with another circumstance giving grounds for still more favourable judgement that is more regular appetite.

Here indeed can by no means [represent] it as beyond doubt that these changes consequence of medicine.

May have happened & indeed, [such] alterations often do happen, independent of any obvious cause

Besides this to be observed that since patient came under our care has been subjected to more brisk febrile accessions than had before occurred.

And well known that while fever in some instances a cause inducing obstruction & scrofula swellings, in others as effective in removing them.

To this then not impossible that relief patient has already received is to be attributed.

Yet am rather disposed to look upon it as consequence of medicine.

And to view this even as cause by which febrile [accession] if not induced at least augmented.

Hence will observe that on [occasion], though did not interrupt use of pills, yet diminished quantity.

But as feverish symptoms now gone have again returned to use to same extent as before

Have not yet had opportunity of learning what effect now produce

But unless from some very particular occurrence shall be unwilling to alter plan.

If by continuation shall be able to dismiss patient free from complaint or with disease much alleviated will I own strengthen good opinion as to efficacy of medicine.

If ineffective some other measures which may at least be tried.

And if in any cases success to be look for from saline mineral waters is I think in such as present.

Or at least if these any effect as washing out Lymphatic Glands is chiefly to be expected when disease in those of Mesenteric

Should present course then disappoint [expectations] proper next to put patient on use of solution of Salt soda or Salt Polychrest by way of artificial mineral water.

And if farther measures necessary shall recommend him to use of Sea Bathing & salt water so as to excite gentle catharsis

But shall be much better [placed] if can find him in such situation [here] may be dismissed after use of present [medicines] [illegible]