DEP/DUA/1/16/08 (Normalised version)

Andrew Donaldson

(1777-1778)

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Andrew Donaldson.

Symptoms to which this patient affected but few in number.

And at same time what you will not find constituting disease in most nosological¹ systems.

When indeed patient came under care was affected with cough, dyspnoea & pain of breast.

And these consider even without fever as of themselves sufficient to constitute catarrh.

At least in that state which in [contradiction] to acute is I think best characterised by title of chronic catarrh.

Besides these symptoms however patient at time of admission affected with another still more distressing to him.

That was hoarseness with which affected.

Change of voice so considerable that could [scarcely] be heard to speak.

And then with tone which if compared with any ordinary voice totally [illegible]

But at same time such as in morbid state very frequently occurs.

And while other affections removed this part still remains.

Might then I apprehend be considered even at time when came under care as constituting greatest part of affection.

In some systems particularly those of Linnaeus & Vogel this symptom introduced as characterising an affection under title of [illegible] or Remat.

Does not however as genus enter those either of Sauvages. Cullen or Sagar.

Not perhaps room for much surprise that does not enter system of Dr Cullen.

As has evidently been his objective as far as could properly be done to reduce number of genera.

And indeed has pointed it out as falling under two others.

Catarrhus & Paraphonia.

With former hoarseness a symptom frequently occurring in combination with others.

And under latter he [comprised] every instance of depraved of sound of voice.

In this light however must view the later genus as by much too extensive.

And as comprehending affections in nature very little similar to each other.

Power viz of common ideas by language.

While at same time neither to be considered as constant symptom of catarrh, nor is it in every case attended with other catarrhal affections.

If however from these considered to be conclusion that should have had place in system of Dr Cullen still more surprising that has not entered two others.

But especially that of Mr Sagar.

Who in last edition of his system to which gives [pompous] title of Filum Ariadnaeum ad Lectulos Aegrorum, has described upwards of 2000 species.

Is indeed very improper multiplication of genera, to consider as such every trifling symptom.

Yet apprehend ought always to give genera appellation where [distinctive] affect even of one function.

And in cases of hoarseness, manifest [affection] occurs of that function by which of all others human species most essentially characterised from other parts of animal creation.

From these [differences] considering them [conclude] that raucedo or Raucitas should constitute genus of disease.

And to this affection consider present patient as subjected.

But after giving this name to disease may perhaps be expected that should next say somewhat of nature.

Here however would necessarily be carried into very extensive & very intricate field.

Doctrine viz of Human voice.

A subject concerning which Physician writers by no means altogether agreed.

Some viewing it as entirely wind instrument

Others consider it as to certain degree at least a string instrument.

And look upon human voice as in great measure formed by vibration of cords.

Into this controversy however although not foreign to present inquiry cannot here propose to enter.

May only remark that whether human voice wind or string instrument, no doubt that much affected by state of solids.

Particularly by different degrees of moisture or dryness

And want of due secretion in particular frequently [remarked] as cause of that rough & [obscure] tone constituting hoarseness.

In this manner probably is, that attends that, dry state of surface of Trachea commonly occurring from inflammation in incipient Catarrh

In same way also may be affect of want of due secretion from other causes.

And in all probability of different morbid conditions producing alteration in state of those solids chiefly concerned in first formula of voice.

In this way probably is that often [occurs] as symptom at latter stages of phthisis

Need not observe that when then does take place is universally considered as very unfavourable appearance

From what particular circumstance proceeds in case before us considered as very obscure.

From connection with pectoral complaint stated in case may here perhaps be question whether does not occur as consequence of Phthisis.

But to this unsurmountable objection that pectoral complaint now much [abated], almost entirely gone.

And that although affection of several years standing, yet none of threatening symptoms of phthisis, have ever occurred.

For such a supposition then very little foundation

Yet when consider that catarrh here preceded & has accompanied [hoarseness] can hardly look upon them as altogether unconnected.

And most frequently at least catarrh gives rise to hoarseness from affection of state of secretion

While secretion increased by [some] parts of mucus membrane may yet be diminished by others

And notwithstanding state of expectoration may be [want] of usual moisture at larynx.

This what am disposed to conject is cause of hoarseness in present case.

Give this opinion however not as founded on what by any means strong evidence but as what considered to be most probable.

Thus then conjecture as to name & nature of affection next Prognosis.

And here must own hopes by no means sanguine.

Do not indeed think that any reason for apprehending danger from present case.

Or that will even be more distressing to patient than is at present.

For as already remarked do not here consider it as in any degree connected with Phthisis

And this perhaps only condition in which to be looked upon as dangerous affection.

In some instances indeed change of noise from natural state still greater than that occurring with present patient.

And such may here possibly take place

Yet when consider that for some time past has not been upon increase think it more probable that will not now be [aggravated]

At least without farther recurrence of affection by which first ushered in.

And here we are told now easier than have been for some time past.

Unless therefore fresh exciting cause may hope that catarrhal affection will continue more moderate.

And now state of weather may at least be expected to be such that [course] of catarrh less common.

From this however can hardly flatter ourselves with hopes of mitigation of [hoarseness]

While change on catarrh this if at all very little diminished.

And has already in some degree subsisted for space even of several months.

Known however that although frequently a transitory affection, yet that when does not soon yield often even continues for whole remainder of life.

In such cases to be apprehensive that [change] induced in state of solids chiefly [concentrated] in [vomiting]

Particularly in head of Trachea or Larynx

And when such takes place delicate [illegible] & [illegible] necessary for particular [sounding] as well as in other cases of instrument fitted for sound may never again be restored.

On these grounds then must own that very doubtful respecting recovery from hoarseness where has been of long continuation.

Although at same time in 98 of 100 recent cases, may with confidence foretell that will be very soon terminated.

Would not however be understood to say that consider every long continuing case as being affection of irredeemably diseased condition of solids

Or as depending on loss of condition [where] cannot again be restored.

For instance unquestionably to be met with [where] voice perfectly recovered after long continued hoarseness

And when this happens as frequently [occurring] with out any manifest cause as follows as affect of medicine.

Upon whole then if present patient speedily recovers is more than expect.

And should it take place think it [probable] that will rather happen, by some spontaneous [change] in system, than by any thing we are able to do

While however patient continues attending will afford us opportunity for trial of different [practices]

Both those commonly employed & [such] also as from observations now thrown [out] respecting nature of affection may be [suggested]

This naturally leads us to remark on practice here.

And here with regard to treatment of present case must own greatly at loss respecting general principles on which to proceed.

Have indeed given it as what reckon most probable conjecture that affect of want of due secreting nature serving to lubricate Larynx

Have already however had occasion to [remark] that besides this may arise from several other causes.

Particularly from different changes in condition of solids themselves.

And sometimes even presumption that is effect rather of augmented or vitiated secretion than of deficiency.

In such circumstances then general principles of cure must be very different.

But have at least begun treatment on that supposition which reckon the most probable.

Where from want of secretion attempts to combat will necessarily proceed on one of two principles.

To be removed either by restoration of natural secretion or by introduction of what will serve to [compensate] [want].

Of these, however first in such case not readily affected.

Chiefly to be affected by stimuli

And these may either act as immediately applied to [excretory] or as entering circulation

That in both ways state of secretion here may be altered have no doubt

Yet of means by which to be affected [some] inconvenient others not to be depended on.

And besides this in slight cases [from] short time alone soon return to natural condition.

Articles most generally employed then such as intended to afford [confirmation] of want

And with this view chiefly are those of lubricating nature.

Particularly mucilaginous & oily medicines.

Principles now pointed out will at least explain intention in greater part of practices here employed.

Began treatment of this case by ordering emetic for patient.

This however intended rather against catarrhal affection than with view to hoarseness.

From state of expectoration reason to think that cough supported by mucus accumulated in breast

Well known that with view of promoting [discharge] of such nothing more affective than concussion given by emetics.

Besides which as determination to surface often also has affect of preventing fresh accumulation.

These then principle objectives in view from this prescription.

But besides this imagined also that [might] exert some affect on hoarseness itself.

And that on general principle of concussion.

For by this means some chance of restoration of circulation where deficient.

And thus renewal of secretion.

Emetics however, it must be allowed, not a remedy, in common use for such an affection.

And accordingly was not disposed to put great confidence in it.

Besides this therefore prescribed also common oily mixture.

In which, by aid of Alkali, oil united with water and thus brought to state of diluent.

By this means sits at least easily on some stomachs, which otherwise would reject it.

And when does so unquestionably few more powerful means of lubricating fauces.

But even in this state of dilution many stomachs, particularly those little accustomed to oil which will not bear it.

Becomes therefore necessary to begin use at least, with small doses.

And by commencing in this manner may reap advantage of which by employing it to greater extent at once, would be disappointed.

With present patient answered so far at least as to occasion no inconvenience [from] affection of stomach.

While at same time in operation of emetics were not disappointed.

From neither however was condition of voice in any degree altered.

Yet affection in other respects somewhat mitigated

And both cough & dyspnoea considerably [reduced].

By this then at least encouraged to farther trial.

And while ordered repetition of emetic directed oily mixture to greater extent.

But, while from these other affection [eases], still no influence on hoarseness.

And after imagined that had made sufficient trial for determining whether would be affective resolved to change oily mixture for another demulcent.

And with this view had recourse to spermaceti.

In this changed from vegetable oil to [animal] oil

For Spermaceti, notwithstanding different suppositions entertained with regard to it unquestionably to be viewed as peculiar animal fat.

Has then, in state of proper division generally lubricating quality of other oils.

But besides affect on parts to [which] immediately applied which probably sole influence of vegetable oils, [seems] farther to act as [illegible] at [excretion].

In present instance however neither in one way nor other did produce any change for better.

At least while cough continued easier yet hoarseness nothing diminished.

From such fruitless trials then lead to conclude that in this case was not from demulcent that patient to be cured.

From this then lead to trial of medicine of very different nature.

That is use of electricity.

From this trial must own entertained no sanguine hopes of success.

Yet was not merely a random trial without any intention in view.

Have already observed that among other causes of hoarseness am inclined to think that may arise from affect of solids.

And thought it not impossible that if did not proceed here, from paralytic state of parts, might at least be affect, of somewhat approaching to it.

Wished therefore to try how far any affect in removing it from augmented nervous energy, & capable of action, in parts of Larynx, by which voice first modified.

Although now however continued for some length of time has not been product of desired affects

And if do not soon see influence shall be led to despair of benefit from it.

Without some apparent affect also shall not think of prosecuting much farther, other medicines on which patient at present put.

Electuary viz of Sulphur & Florentina Iris.

To this led rather from what have heard of affects than from knowledge of principles on which acts.

Orrice however a vegetable of acrid & powerful nature.

And shall be very happy if any can suggest to me any remedies which in obstinate cases of [illegible] kind have seen successful.

And has at least been supposed to exert influence on state of secretion by mucous gland at breast.

From use with present patient however have not hitherto reaped much affect.

But although, which now very probable does fail yet have thoughts of trying some other remedies with same intention.

And may probably try how far as [allowed] [secretion] good affect from squills combined with mercury.

But before this shall probably first try affects of more immediate application to [diseased] [patient]

With this view have thoughts of [directing] for patient inspiration of vapour impregnated with vegetable acid.

If this abortive may perhaps also try in same way inspiration of Aether.

Or may order it [externally] to that part of throat at which suppose disease to be chiefly seated.

Besides these might suggest [other] [practices] to which may also have recourse.

But must own that if from these no benefits shall be very apprehensive of being of any [use]

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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.