DEP/DUA/1/36/04 (Normalised version)

Robert Fisher

(1784-1785)

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Robert Fisher November 12^th

With respect to disease of this patient several different suppositions may I think be entertained.

From perusal of history of case however, can have no doubt in asserting that circumstance most distressing to him is pain & other affections of head.

And these nosologists¹ & indeed practical writers have in general considered as characteristic of a particular genus.

Nay by some considered as marking several genera

As for example the Cephalgia Cephalalgia Hemicrania and like.

But to avoid unnecessary & perpetual [multiplication] of genera, whole may I think with propriety be referred to one head.

And to genus of Cephalea as distinguishing this affection would refer disease of present patient.

Cephalea however while not unfrequently an idiopathic disease still oftener what may be called a symptomatic affection.

Thus frequently consequence of rheumatism of the integumentary.

Often of affections of the nervous kind as of Hysteria.

And in many instances the effect of stomach complaint thus producing what will find described in last volume of London Medical Observations by Dr Fothergill under title of sick headache.

But if Rheumatism, Nervous, & Stomach headaches be very frequent, those from intermittent fever, still more so.

And nothing more common, than in cases where intermittent itself no longer remains to find patient still very much distressed with aguish headache.

In case before us indeed cannot be said that headache occurs as a sequelae of intermittent

But at the same time that of this kind when consider symptoms with which attended & circumstances with which occurs cannot I think admit of doubt.

From this view of nature of affection are naturally led to favourable prognosis.

For even intermittents themselves in this part of country at least seldom an obstinate or dangerous disease.

And still less to be dreaded from mere headache depending on this cause.

Although however less alarming than intermittent, yet in some cases no less obstinate

And perhaps even more apt to frequent recurrence.

For although intermittents very liable to do so at certain seasons of year, yet aguish headaches apt to return at every season.

And particularly when wind from east.

A circumstance which while has very remarkable affect, in renewing & aggravating every symptom of intermittent, has peculiar influence on aguish headache.

In so much that some of those long subjected to it never fail to have return of it in that case.

Hence therefore after all that can do shall perhaps be able to affect rather temporary than radical cure.

With present patient however, from former state of health have no reason to suspect that disposition to intermittent is very strong.

And hitherto at least has not been long subjected to it.

May therefore hope for complete cure.

And to this indeed reason to believe that already considerable progression

An event which am I own inclined very much to attribute to practices here employed.

From idea given of disease will naturally be concluded that [should] here expect cure from same remedy employed to counteract intermittent.

And this you will observe was the practice to which had here recourse

Began by directing for this patient the use of an Emetic.

These by some condemned in intermittents from idea that operate as a debilitating or a deranging power.

But without any regard to ridiculous [theory] any one who attends to facts can have no doubt that are of most material service.

And indeed that in many situations without premising use, cure of intermittent by other means far from safe.

On what different principles may here operate will not pretend to say.

But whatever may be affects in other respects certainly useful as unloading stomach.

Which in this disease often oppressed by viscid, mucous, bilious or other matters.

Hence then exclusion of other effects at least an useful preparation for exhibition of Bark.

But in headaches even of aguish kind, great reason to believe that pain very much depends on Stomach.

For consent between stomach & head well known to be very great.

Here then in exhibition of emetic had principally two objectives in view.

The removing viz a cause of it, by cleansing stomach.

And the preparation for successful exhibitions of other medicines.

If disease of patient had appeared under form of pure intermittent, should probably have had recourse, to use of Bark alone.

For no doubt that in great majority of cases, at least affords most safe, easy & expedient cure.

And not improbable, that even here bark alone would soon have produced complete cure.

But in place of that, employed a combination which have of late often used, & I think in certain modifications & against certain symptoms of intermittent, with peculiar success.

A mixture viz of equal parts of powder of bark, & valerian.

Valerian has long & in my opinion deservedly, had high character among tribes of nervous medicines.

And in many headaches, particularly those which are concomitants of hysteria affections, used with success.

From the [results] of many observations am inclined to think that as combined with bark more to be expected from it than from either separately.

From use of this combination to extent of an ounce after previous free operation of Emetic patient found [himself] much better.

Was now entirely free, not only from headache & vertigo, but also from hot & cold fits.

In this situation, thought it unnecessary to push it farther.

And wished at least to see, how far quantity thus taken adequate to cure.

Resolved therefore on intermission of bark & valerian, at least for course of a week.

But although patient no longer affected with headache yet not free from every symptom of disease.

And now complains of gripes with flatulence.

This led me, as means of strengthening alimentary canal, & of expelling wind, to direct a mixture of Infusion Amarum & Tincture aromatic.

Which while tended to obviate these symptoms might also, I hoped, operate as a cheap substitute for Bark.

For no doubt, that combines two of most remarkable qualities, bitterness & aroma.

And accordingly, even of itself, is successful in removing slight intermittents.

Hope therefore that may here both counteract affection of alimentary canal, & secure benefit from medicine previously employed.

If this the case, shall reckon farther attendance of patient, unnecessary.

But if, which perhaps not a less probable supposition, headache shall return, shall again have recourse for second time, to use of former medicine.

Unless circumstances of case shall lead us, to form different idea of the disease.

And in that case, future practices must be accommodated to opinion which then entertain.

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Explanatory notes:

1) Nosology is the branch of medical science dealing with the classification of diseases. Individuals referred to in the case notes as nosologists were commonly those who had published nosological, or classificatory, medical texts.