DEP/DUA/1/21/04 (Normalised version)

Jean Clerk

(1779-1780)

---

Jean Clerk.

Several of symptoms such as very frequent.

And have selected this and next that may have opportunity of contrasting as arise from different causes.

Often as occurring though distressing not dangerous.

This however cannot say is case at present.

Principle symptom Palpitations.

And these occurring with much greater severity at some times than others.

But never entirely wanting.

And not only obvious to feel but even to sight.

Felt principally in region of Heart itself

But from thence propagated upwards till manifestly appears above sternum.

From these circumstances then no room for doubt that very different disease from temporary & transitory palpitations from other causes.

And here may without hesitation pronounce that depends on local affection.

How far heart itself affected matter of doubt

Not uncommon to have distressing palpitation with great enlargement.

This however more rare occurrence at least than aneurism of ascended Aorta.

Of this miserable affection in my own practice have met with three instances.

Two of these as present females other male

All of them advanced in life.

And before saw them disease had made much greater progress than in present case

In man in particular not merely [pulsation] above & below Sternum.

But that bones split or destroyed almost their whole length.

And very large [pulsating] tumour formed in place

This long in hopes would have terminated in suppuration & anxious to have it opened.

At length probably from rupturing inwardly gave almost instant death

Would not however from this assert that although present of same nature will have similar termination.

For in present instance progress very inconsiderable.

And if goes on in slow manner hitherto done may continue for many years.

During this patient may be cut off by some other disease.

But symptoms of aneurism affection, not only complaint.

Is distressed likewise with Borborygmi & sense of ball moving about in abdomen.

This even like Globus hysteria rises to throat.

And although nothing like Hysteria fits yet may justly consider these as Hysteria symptoms.

Or at least as arising from weak & peculiarly irritated state of alimentary canal.

Would not positively assert that these in no degree effect of Aneurism.

But at least did not occur in any other cases I have met with.

In one instance indeed attended dissection of patient where from aneurism of aorta had probable affection of alimentary canal.

There however circumstances very different from present.

A man for several months subjected to violent stomach complaints.

Particularly constant rejection of food by vomiting & violent constipation.

For these complaints was long treated in Royal Infirmary¹.

And were suspected, as afterwards appeared to be case, to proceed from scirrhous pylorus.

No suspicion however entertained of aneurism nor any symptoms indicating it.

At length after trial of many remedies to no purpose died from mere want.

Among other remedies may observe that some months before death had swallowed two pistol bullets, with view to removal of obstruction.

These never observed to be either discharged by stool or rejected by vomiting.

Dr Jackson who had attended him after leaving hospital obtained permission for examination

And at his desire was present at the dissection

Upon dissection bullets found in stomach.

And very little altered from 2 months

Passage at pylorus almost entirely shut up by scirrhous tumour.

In so much that balls could not possibly pass.

But besides this discovered also another unexpected morbid appearance.

A large tumour viz on Spine.

An aneurism of Aorta descended extended from diaphragm to where gives off [ coclia] artery.

No rupture however either of this or any other vessel had occasioned death.

But by bulk had pushed diaphragm rather higher & stomach lower than natural.

And while from compression had probably induced scirrhous at pylorus, had still more considerable affect on bones.

Vertebrae to which applied so soft that cut by dissecting knife.

Both stomach & aneurisma now in possession of Dr Monro.

Here mention case as affording evidence of aneurism inducing disease of alimentary canal.

As showing the affect which has, probably from pulsation, on bones.

And above all demonstrating that aneurisms of largest vessels may exist where yet no certain evidence of them.

In case before us however am inclined to consider stomach complaint now mentioned as totally unconnected with it.

And look on this affection of alimentary canal as being very different disease.

Some symptoms however with which more difficulty.

Particularly obtuse pain in left hypochondria region & loins.

In former in particular complains of very severe pain to touch

And although somewhat doubtful as to nature look upon it rather as connected with aneurism than hysteria affection.

This still more manifestly case with irregularity of pulse & pains of arms.

These observed only severe when pulse very violent.

And when with fixed disease, increase of action from particular accident.

This then idea of nature of different complaints with which patient affected.

And from opinion now given prognosis cannot be favourable.

Although aneurism may not prove fatal yet can have no hopes of [removal]

Nor can even expect alleviation.

Principle view in selecting to exhibit example of disease not frequently occurring.

And to mark as far as can, progress of affection for some time.

If therefore when patients attendance terminated, this part of affection no worse, is utmost that can expect.

In removal also of other complaints can expect to do very little

For such hysteria symptoms often more difficult to cure than formed disease.

And with other more dangerous affections to which patient subjected cannot venture to employ some of most powerful remedies.

Here therefore must be merely content with attempts to alleviate.

Or at utmost employ only for radical cure measures from activity of which no danger to be apprehended.

And if from such, alleviation or temporary removal of affection, is more than expect.

From these remarks on prognosis observations on general plan of cure in great measure superseded.

For at such can hardly be said here to have aimed.

Chief objective to produce some alleviation of affection of alimentary canal.

And, as wished for attendance of patient, that might view progress of principal affection, was necessary that should not seem to be entirely inactive.

With these views first prescribed the Pilulae Foetid cum Aloe.

Under this title no formula in Pharmacopoeia²

In many instances however have found it both convenient & useful.

Consists of equal parts of Aloe Assafoetida & Soap formed into mass with Simple Syrup.

Each pill then contains nearly as much aloes as in pill aloetic.

And as much Assafoetida as in [Pill] [Gummo].

On Assafoetida however [supporting] activity of these latter, very common in practice, to depend

But pill [Gummo] very little influence in moving belly.

And with bound belly affections connected with flatulence always increased.

Hence then in cases where this state, in general employ it in preference to [Pill] [Gummo]

And often I think with best affects.

While from Antispasmodic affect of Assafoetida counteracting tendency to inordinate action, from Aloe costiveness is obviated.

But soon after these pills directed for her menstrual appeared.

During menstrual flux is common with women not only to attend to food & other circumstances in regimen, but to avoid all medicines.

And unless where urgent necessity [illegible] is perhaps proper.

Had patient taken them during this discharge, from stimulation of aloes, might have been increased.

And that probably without inconvenience.

But as in her case flux natural, [sustained] nothing from delay.

When began use not at first attended with any remarkable effects in moving belly.

And after continuation for eight days, all symptoms nearly in same state as before.

Afterwards however influence as cathartic more than could have wished

And on this account have diminished frequency of exhibition.

In place of every day now only once every third night

And hope that to this extent may reap from it affects of Assafoetida as obviating Borborygmi

And of Aloes as counteracting costiveness.

Besides these however with view to alleviation of hysteria symptoms have had recourse also to another medicine.

A combination viz of Calc of Zinc with Valerian

Is from former that chiefly entertain expectations.

Lately only introduced into practice against affections of Nervous kind.

Particularly recommended by Dr Gaubius in Epilepsy.

Opinion now held however of efficacy very ambiguous.

But this not surprising when consider that Epilepsy often altogether incurable.

And as far as can learn where this has failed other remedies employed without [affects].

No objection to use that in these cases given to great extent without obvious operation.

For same also might be alleged against Peruvian Bark & many other powerful articles

In my own practice have met with instances of Epilepsy where reason to believe that produced complete cure.

But still more frequently have found it beneficial in Hysteria.

Suppose it to act as tonic, giving vigour to debilitated & irritated system.

As having this affect in present case may prevent tendency, in alimentary canal to inordinate action

And thus at least producing alleviation of some of symptoms.

From valerian also must own that in cases of inordinate action, have good opinion.

Use made of it by some of brute creatures, particularly Cats, in convulsive diseases points it out as remedy to Human Species.

True indeed on our systems has not same influence as on theirs.

Yet not from this to conclude it without effects.

And in many instances where have employed it, used with manifest advantage.

For this purpose have at present employed Pill Gummo.

If these also distressing to patient must vary for some other.

To obtain full effects however larger doses required.

And here principally employed to give form to the Calc of Zinc, by itself small.

If this course had been product of temporary relief or even of no inconvenience should not be in hurry to alter it.

For here much at loss to think what can be employed with greater probability of success.

As from many modes of cure recommended against hysteria symptoms are in great measure precluded by principal affection.

As however found to disagree with patient have recourse to some others as means of temporary relief.

shall probably in that case employ aromatic & bitters.

But as already observed do not from any practice, expect material benefits.

And chief objective in view is to mark progress of disease, as far at least as such may occur during attendance.

---

Explanatory notes:

1) The Royal Infirmary of Edinburgh, established in 1729.

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.