DEP/DUA/1/31/32 (Normalised version)

Robert Don

(1782-1783)

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Robert Don.

In history of this patients disease many different symptoms are mentioned.

And must own that with regard to affection not altogether without doubt.

These symptoms what on many occasions attendant on different diseases.

And may here be altogether unconnected with each other.

Pains in hypochondrium may be merely effect of flatulence.

Those of back may be of Rheumatic kind.

While affection of inferior extremities, which evidently of paralytic kind, may be consequence of cause by which that disease in general produced.

And may be effect either of nerves at origin or of torpor in fluid

But am here rather inclined to a different conjecture.

And consider whole symptoms to which is subjected as being connected.

View which have of this case is that all of them depend on affection of spine.

Not however extending through whole course but existing at one or at [utmost] a few vertebrae.

Particularly among lowest of dorsal vertebrae, where pain chiefly fixed, & curvature took place.

In what manner affection of those should produce pain in opposing abdominal viscera not readily explicable.

But that does give rise to affection of these have already had occasion to see in more than one instance

But particularly in case of a joiner to whom disease proved fatal

There first & most distressing symptom such a pain in region of hypochondrium as here took place.

Soon however followed both by fixed pain in back, paralytic affection of limbs & various other distressing symptoms.

And in no long time patient fell victim to the disease.

Upon dissection discovered that cause of all these symptoms a caries or dissolution of one of dorsal vertebrae.

A circumstance which from similar history had been suspected before death of patient.

Founding therefore on such history may at least venture to say that affection of dorsal vertebrae whatever way in which happens does produce pain referred to abdominal viscera.

And that should do so is at least no more surprising than that inflammation of kidney should give rise to lesion of stomach.

Not improbable that may here be effect of inflammation excited in [illegible] lining part & propagated along [continuing] membrane.

But whether this explanation just or not, would at least on grounds now mentioned consider affection of vertebrae as a cause from which pain in hypochondria, here described may arise.

And that such an affection in some degree at least took place with our patient reckon probable from other affections.

But particularly from situation & nature of pain referred to inferior dorsal vertebrae.

This pain as described, [referred] to vertebrae & attended with sense of burning heat.

Such feelings indeed cannot be supposed to arise from any affection of bone.

But by such affect that diseased condition on which most readily explained will infallibly be induced & supported.

And that this the case may with some degree of probability be inferred from curvature which is [obligated] to [take] to obtain ease as well as from pain which induced by attempts to take erect posture.

While these symptoms had continued with more constancy & for greater length of time than could be supposed to happen from affections of Rheumatic kind.

But of all occurrences in present case that which gave greatest countenance to suspicion now thrown out was affection of legs.

These though hardly in what could strictly be called paralytic state had yet lost very considerably both of power of sense & motion.

This however well known to be every day consequence of affection of spine.

And indeed must unavoidably arise wherever from thence affection of spine [illegible]

This however often even consequence of vertebrae merely having position changed.

And accordingly paralysis where curvature marked by projection of one or few of spinal [processes].

This however could not be said to be case in present instance.

For although curvature yet this chiefly if not entirely from voluntary [effort]

And did not depend on great alteration of position of a few, but on slight alteration of position of several.

Is however in former way that compression or injury chiefly given to spinal marrow.

And accordingly where paralysis from one or two changing place often spontaneously cured from others taking same course

As by this means arch as it were, through which spine marrow should pass, is increased.

Whereas with projection of few [turned] out of direction at an angle.

Hence also even largest distortion of spine, without any symptoms of paralysis in parts below.

But besides change of position in vertebrae spine at marrow may be [impaired] by affection of these in other respects.

And such suspected here to have occurred, from conjunction of pain of back as described in history of case, with torpor, numbness, & diminishment of power of legs.

On such a morbid affection as have already observed imagine that all symptoms mentioned in case may be explained.

And this the rather suspected from resemblance in many different particulars to causes which have formerly had occasion to treat

With this idea of disease notwithstanding favourable changes of appearance which have of late taken place, cannot entertain very sanguine hopes of speedy cure.

For nature of affection such that even where recovery takes place must be work of time.

And in majority of instances which I have had occasion to treat, especially in those, where vertebrae more diseased in other respects than displaced, [complaint] has been fatal.

This particularly happened in case to which have already alluded, which in circumstances more resembling present than any other I have met with.

Here however must also observe that since had occasion to treat that patient an important improvement has been made in method of cure in this affection by Mr Pott of St. Bartholomews Hospital.

Need hardly observe that practice to which here allude is use of issues in such complaints.

On this subject different publications have of late appeared both by Mr Pott himself who has repeatedly published on subject & also by other practitioners.

Particularly Dr John Jebb of London.

When last in London about two years ago was carried by Dr Jebb to see several patients labouring under this disease who were at that time under care of Mr Pott.

Cure solely trusted to issues on each side of the spine as near as possible, to seat of distortion or other disease.

Here cannot pretend to say that every one of those cases afforded decisive example in favour of the practice.

Some with whom issues long employed seemed to have derived very little benefit.

Others though affection much alleviated had yet derived no farther relief than often happens where issues not employed.

Yet was with these exceptions from whole of cases taken together was convinced that the practice an advantageous one.

And was chiefly with view of having opportunity of exhibiting trial that here selected this patient as subject of treatment for Collegium Casuale¹.

For I apprehend no one can entertain any doubt that it is upon facts not upon reason, that [illegible] opinion of importance of any practice to be founded.

At same time no less satisfactory than useful to form even probable conjecture as to mode in which any remedy operates

With regard to use of issues in this affection must own cannot pretend to say how effect to be explained

Yet am inclined to think that there are two principles on which effects may in some degree be accounted for.

May conceive them here useful as diminishing determination to affected part.

Can be no doubt that issues as augmenting flow in vessels of part in which inserted have tendency to diminish it in neighbouring ones.

And thus variety of diseased [states] either induced or supported by this flow may be counteracted.

But besides this probably also [illegible] as affording outlet to particular matter.

Especially to matters of acrid kind which if retained would operate as corrosives & even solvents of bones.

In what manner such fluids [shall] be formed from [common] mass of blood is indeed difficult to conceive.

But that in many cases they are formed undeniable.

Whether from peculiar action of vessels from peculiar fermentation or from whatever other cause immaterial.

Exemplified in cases of cancer of syphilitic virus & many others.

But whether benefit of issues [there] to be explained or not yet that are beneficial for my own part have no doubt.

And on this ground directed employment in present case.

At same time however had recourse also you will observe to another remedy the pill Foetid cum Aloe.

These even supposing affection of stomach entirely symptomatic yet thought might be of some use as producing temporary alleviation.

And whatever nature of affection had yet reason to hope that from obviating costiveness good effects might be obtained.

Cannot however say that here product of desired effect.

For although kept belly gently open yet had not effect of [relieving] pain.

While at same time from an accidental circumstance the insertion of the issues was for some time delayed.

In this situation had recourse to external application of anodyne balsam as immediate means of relieving pain.

This we were informed attended with desired effect.

But with relief of pain numbness of [external] still continued.

Still therefore the use of issues seemed as necessary as before.

Were accordingly inserted & have now been attended with tolerable free discharge for more than a month

During that time, has not only [continued] very free from pain, though Balsam omitted, almost as soon as issues began to have effect, but complaint in other respects also [considerably] alleviated.

On affection of legs indeed sudden change could not be looked for.

But even this according to reports which he has given considerably alleviated.

While at same time local pain in back such that can now walk with much less curvature.

These therefore circumstances encouraging us to persist in use of issues.

And I own entertain hopes that by means of use complete cure may be obtained.

Although this the case will not indeed be decisive proof of advantage of issues against curvature or other affections

Because cannot pretend to say that disease so distinctly marked as to remove all doubt.

But considering that as most probable supposition shall be inclined to look upon it as an instance of efficacy of Mr Pots practice.

Notwithstanding however present apparent relief symptoms may again be aggravated.

And if in progress of disease symptoms shall occur corroborating opinion of nature, while at same time issues found ineffectual must own at a loss to think what other practices can be tried with any prospect of success.

In situation of our patient where effect of spinal marrow without obvious distortion of spine itself natural cure hardly to be expected.

And although may give him chance of trial of Cicuta or Mezereon yet shall probably have mortification of seeing him fall victim to disease

But while on supposition of progress of affection, such an even to be dreaded on other hand not impossible that by continuation of disease may appear that of a different nature from what at present suppose.

In that event however practices afterwards to be employed must be accommodated to idea which then entertain of nature of affection.

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Explanatory notes:

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