DEP/DUA/1/24/01 (Normalised version)

Robert Hamilton

(1780-1781)

---

Gentlemen.

Have already delivered two lecture introductions to this course.

In these have endeavoured to state & explain nature of business both with respect to Practice & Lectures.

Shall not now occupy any part of time by resuming observations then offered.

May refer those who had not opportunity of hearing them to general view of business of Collegium Casuale¹ subject to History of Lectures on Theory & Practice².

From that view will at least form some idea of plan on which business to be conducted.

With respect to utility of course may only observe that shall be much disappointed if do not derive [such] [insight].

And to those who honour me with attendance hope also may be of product [some] advantage.

Without farther preliminaries then shall begin general view of some of first cases.

Speaking of each in order in [which] stand in register³.

First in order of list Robert Hamilton

Respecting disease to which subjected little room for doubt.

Is sufficiently marked in state both of obvious swellings & ulceration.

May without hesitation pronounce affection Scrofula Swellings seated in those glands which of all others Scrofula most frequently attacks.

Slow progress to ulceration, length of time for which continued in ulcerous state, & condition of discharge from them, leaves no room to doubt that of this nature.

With these symptoms at any age & with any habit should pronounce this to be the disease.

But in present case still [farther] corroborative evidence.

Patient at that early stage of life when appearance of Scrofula in this form most frequent.

And has those external marks in habit, with which most frequently occurs Fine Florid complexion & soft smooth skin.

Here may observe that besides most considerable swelling & ulceration, upper lip & septum [middle] of nose also affected.

In these at least when case came under our care considerable swelling.

This appearance the rather [noticed] as by some held diagnostic of a very different disease.

Presence viz of worms in alimentary canal.

In instance before us however no other symptoms from which should suspect this.

Appetite nothing peculiar.

Neither affected with gripes glairy stools nor any other of common symptoms.

Or even that worms may not sometimes induce it.

And must own this a diagnosis in which for my own part disposed to put very little confidence.

Would be far indeed from denying that where takes place worms are never present.

But in greatest part of worm cases which have had occasion to treat no such appearance.

And on other hand have frequently seen it present where no worms.

Particularly so in instances of Scrofula.

And where present with worms is [most] commonly where they affect Scrofulous habits

Even in such cases then still inclined to look upon it as Scrofula symptom

And as having connection with worms in no other way than accidental combination.

Here however as already remarked no reason for presuming such combination.

And therefore notwithstanding presence, view [case] as simple instance of Scrofula.

Or even that worms may not sometimes induce it.

With respect to what shall be termed very great uncertainty.

No reason indeed to apprehend fatal consequences.

At least with disease in present form.

But scrofula an affection in which, have it not in power to do great deal by aid of medicine.

And often when appears slight, of great obstinacy

Frequently even happens that where least appearance most danger of fatal termination.

Particularly observed that in cases, where scrofula in family, in those with least external appearance most apt to affect lungs.

And in this way more frequently fatal than any other.

To period of life at which this most frequently happens, patient not yet arrived.

Hence then can neither venture to say that shall be able to cure disease nor to speak with any confidence of duration or [termination]

Yet in as far as judgement can be given case rather favourable as otherwise

And age as well as constitution of patient affords opportunity for trial of different practices.

As affording such have selected case as subject of treatment in this place

Here however must set out with observation that very much at loss to say on what general principle cure to be conducted.

But without pretending to thorough knowledge of nature, certain morbid conditions which may be considered as indicative.

These particularly are the tumours especially of glands.

The ulceration in which tumour often terminates.

And the general state of system, as well that which precedes disease, as which accompanies or is induced by it.

Here though some ulceration at present at least by no means [constant]

And whatever may have been original faculty in state of system has not at least suffered in any considerable degree from effects of disease.

Consider removal of tumours then in first instance at least, as principle object of attention.

Where such swelling & hardness takes place natural size to be recovered only by removal of that matter producing enlargement.

And this principally effected by restoration of free circulation through part.

Or by [abstraction] of matter, through channel of Lymph vessels.

These principles will in some measure explain to you intention in practices already employed here.

Mean with view of affecting [these] ends, or at least of attempting [removal] of swellings, to try patient with course of Emetics & Cicuta in conjunction.

Use of course of Emetics in scrofula is as far as I know but lately introduced.

Have indeed in general been advised in this affection, by [practitioners] where disease accompanied with viscid sordes in stomach as means of obviating symptoms

But not with view to radical cure.

Of late however have been informed by a correspondent in London that very much used with that intention, by some of practitioners there.

And particularly with view of obtaining resolution of indolent swellings.

By whom first introduced do not know.

But I think, some principles on which benefit to be expected from

Especially from influence which have on circulation from agitation induced by action

And from affect as augmenting action of absorbent system.

But independent of doubtful principles supported by analogies in practice.

At least one kind of glandular [swelling] in which often used with affect of [discussing] with great advantage.

That is swelled testicles.

After active inflammation over in cases where their remains indolently enlargement often of great service.

On these footings then some grounds for hope in scrofula.

And cannot help considering this practice as rational & meriting trial.

At same time cannot yet say anything in support of it on more certain footing of experience.

In cases in which have hitherto directed such a course did not find benefit looked for.

This however inclined in some measure to attribute to want of fair trial

And not improbable that disappointment in present instance may originate from same cause.

For must be allowed that a course of emetics by no means a pleasant mode of cure

And less chance of being persisted in, with scrofula, as in this affection mankind in general not yet taught by experience to place confidence in them.

Is partly at least on this account that here conjoined with Cicuta

For from obvious operation at least not same distress or inconvenience.

But besides this am inclined also to think that from conjunction benefit may be derived.

Of introduction of this remedy into modern practice need say nothing.

May only observe that since first recommended by Dr Stork succeeding practitioners have formed most opposite opinions

By some extolled, by others considered as totally inefficacious

For my own part in as far as can judge from experience I have had [disposition] to think favourably of it.

Not indeed as a remedy capable of producing cure in every case of cancer.

But as often attended with good affects both in this, & other complaints.

In none have I observed it more so than in Scrofula.

And although unquestionably essentially different in some particulars yet perhaps between cancer & Scrofula greater analogy than is in general imagined.

From this analogy & from experience which have had of affects rather than any theory as to mode of operation had here recourse to it.

And not without hopes that proper continuation may be product of good affects.

In producing this emetic repeated every eight or ten days may I think cooperate

On this course therefore, unless some reason shall occur for altering is intention to continue patient for some length of time.

And thus at least shall be able to judge whether adequate to cure in present instance.

If swellings diminished or removed may yet reckon it necessary to put patient on course of Peruvian Bark with view of strengthening system, & preventing return.

If fails, may have yet recourse to trial of some other of those medicines lately celebrated.

Such for example as Sal. Soda Burnt Sponge, or Burnt [leather]

But probably with no better [success]

Still however may afford us opportunity for such trials.

And if none efficacious patient may again in spring season resume practice more to be depended on than either Sea Bathing.

---

Explanatory notes:

1) A term used in the 1700s in Leiden, Padua and elsewhere to describe clinical teaching, using demonstrations of outpatients.

2) Andrew Duncan, Heads of lectures on the theory and practice of medicine (1781).

3) References are made throughout the case notes to a dispensary patient register. However, no evidence has been found that this register survives.