DEP/DUA/1/16/12 (Normalised version)

Patrick Trotter

(1777-1778)

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Patrick Trotter.

A patient with regard to whose case as at present under care little room for doubt

And which indeed had in no long time favourable termination in our hands.

Most obvious symptom of disease [consists] in swelling.

And this occurring in several different parts of body.

But particularly in parts most [dependent] after an erect posture.

From this circumstance together with nature of swelling as bearing impression of finger could be no doubt that depends on water.

And that this water lodged in cellular membrane

Such an affection by no means an infrequent occurrence.

And well known to constitute a genus of disease which has entered every system.

In these indeed distinguished by different appellations of anasarca, [Phlegmatic] Leucophlegmatic etc

But without entering into distinctions which consider as unnecessary & even improper [pronounce] present to be case of Anasarca.

And besides characteristic symptoms other [symptoms] here occurring are at least the [common] concomitants of this affection.

This particularly case with regard to affection of breathing & scarcity of urine.

These indeed not uniformly or invariably attendants of Anasarca.

Yet very rarely that either one or other or even both wanting.

First difficulty of breathing a necessary consequence wherever affection extended to breast.

And no doubt that without proper hydrothorax or effusion in cavity of breast lungs as well as other parts subjected to anasarca affection.

Wherever disease of any very great extent water deposited in cellular membrane there as well as in other parts of system.

Often even reason to suspect that such effusion occurs among first symptoms.

And indeed when has once taken place less ready exit unless by absorption than from most other parts of system.

Second circumstance scarcity of urine frequently exists even as cause [inducing] the affection

And when this not the case very rarely that does not soon follow as consequence.

For fluid which ought to be discharged in this way is deposited in cellular membrane.

And circular mass depends even of usual proportion of watery part.

In this manner also are to account for uncommon inclination for fluids which here occurs.

While at same time from general diseased state of system appetite for solid food diminished.

May here then view, not only scarcity of urine, & difficulty of breathing, but also thirst & want of appetite as symptoms of anasarca.

These however not only symptoms mentioned in case.

And some other particulars with regard to which greater difficulty.

This particularly case with respect to cough.

Perhaps may also add with [regard] to pain of side.

This last circumstance indeed patient ascribes to agitation in coughing

And cannot be refused that from severe cough such pains often excited.

Yet in many cases consequence of some fixed local affection.

And when [such] exists as giving rise to cough pain more readily excited.

Here therefore naturally falls to be [inquired] from what cause cough arises.

Had I known nothing farther of this patient than as last under care should I own have considered cough as merely [consequence] of irritation given to lungs by effused water.

But had formerly occasion to treat this patient when laboured under pectoral symptoms without anasarca appearance.

And then also was subject of lecture

Now then comes to be question of some importance whether are to look upon cough as at that time, proceeding from water, effused in breast, or now to consider anasarca as arising from cause then [inducing] cough.

Or whether the two complaints to be viewed as totally unconnected.

Can be no doubt that cough often consequence of anasarca affection of lungs.

And that deposit of water there may take place before in other parts of system.

Farther often occurs without other obvious symptoms of anasarca.

Is at least then not impossible that incipient state of affection for which at present came under care formerly cause of cough.

Some of you may remember that in observations on case of this patient last summer had great difficulty as to nature.

Did not then indeed entertain suspicion of disease in any degree depending on dropsy.

Chiefly divided in opinion whether to be considered as catarrhal or phthisic.

To first strong objection that was without such expectoration as to give indication of augmented secretion by lungs.

And was somewhat in favour of [latter] that besides cough & pain of breast patient then affected with other symptoms commonly attending Phthisis.

Particularly quickness of pulse & profuse sweating during the morning.

From these then imagined that some presumption of tubercle

Yet to this supposition also some objections

Particularly from age of patient, from want of other appearances of scrofula etc.

Inclined then to hope that local affection existing was at utmost but inconsiderable.

And that cough principally supported by peculiar irritation of lungs.

From this as well as debility [illegible] was then led to make trial of Peruvian bark.

Under that medicine cough soon so far mitigated & other symptoms entirely, removed that dismissed him. At least in tolerable Health

At same time without being satisfied that lungs really in sound state.

Now as already observed may be some doubt how far opinion [then] delivered was not a mistaken one

Yet must own that from several [particulars] am inclined to think that no anasarca of lungs then existed.

If so was at least singular that patient for so great length of time should have no other dropsical appearance.

Still more that cough should be without difficulty of breathing.

And lastly had it then depended on this cause would not have yielded in manner which did to medicine employed.

Consider then first conjecture as still more probable.

And disposed to think that then produced & still supported by some local affection of breast.

In this view then may have some share as inducing the anasarca.

But reckon it more probable that this connected with disposition to sweat which patient formerly had & which still in some degree continues.

Nothing more apt to induce anasarca than checking profuse discharge by surface.

And this very ready to happen where with tendency to sweat patient at same time affected with cough.

This then opinion respecting connection of different parts of affection in present case.

And have now given sentiments as to nature of affection to which subjected.

Viewed disease for which here to be treated as anasarca.

Yet consider lungs as not altogether sound.

And imagined that from this source affection had arisen.

After patient already dismissed [observations] on Prognosis may seem unnecessary.

Yet when consider that has already been twice under care & that may again return will perhaps be expected that should even have view to this.

And here must own that even when dismissed patient as cured was far from considering him as restored to perfect health.

Viewed Dropsy indeed for which came under our care as being completely removed.

And although one of these diseases very apt to return yet without some accident, am hopeful that may continue free from it.

Yet when last dismissed was by no means free from cough.

And must own still consider lungs as being in diseased state.

To what affection may give rise hard to say.

Am even disposed to think that patient will never get entirely free from this complaint.

And that of course will never enjoy perfect health

Of Treatment of this patient when last under care very little to be said.

Consider effusion of water into cellular membrane to be morbid condition which had to combat.

And where can be done always esteem it preferable that this should be evacuated by natural [emanation].

Of these although unquestionably there are others more ready, yet may venture to affirm that know no more safe outlet than [illegible]

Unquestionably debilitation less than any other mode of evacuation.

Seemed therefore particularly proper in such a case as that of present patient.

For here dropsy not simple occurrence but complicated with other affections

And these also of most debilitating, probably of most dangerous tendency.

Besides this farther indication in present case by scarcity of urine.

Which while sometimes originating cause must in every instance be cause supporting the affection.

From all these considerations then here [determined] to use of diuretics.

And as such had recourse to Colchicum

Is [natural] in some places of Britain but more frequently cultivated as flower in Gardens

Colchicum but very lately introduced into practice as medicine.

Was long considered as a poisonous substance.

And little doubt that in large doses affects are deleterious.

Yet as well as other poisons promises perhaps greater success than articles possessing less active qualities.

Amidst trials therefore of different poisons made by Dr Stork naturally occurred as one.

From these trials found it a very powerful diuretic.

And as such several years ago recommended in a treatise [professedly] on that subject.

If justly entitled to characteristics he gives of it would indeed be valuable acquisition.

For hold that a certain diuretic a very powerful article in cure of disease.

In operation however of all before in use were often disappointed.

And thus as far as I have seen not infrequently also case with the Colchicum

Yet no question that in many instances examples as in case before us product of desired affects

And probable that frequently fails both from improper dose & from improper mode of administration.

Only preparation employed by Dr Stork was the oxymel of Colchicum.

And this made by first extracting [virtue] of recent root by Vinegar.

In this state now introduced into some of modern pharmacopoeias¹.

Particularly Dispensary Pharmacopoeia [Brunswick] published during course of last year, one of most elaborate works yet extant of subject of Pharmacopoeia

As [have] however found to disagree with many people Edinburgh College² have entirely rejected oxymel as form of medicine.

And no doubt that in as far as [having] merely intended to cover taste same advantage may be derived from sugar

Have therefore substituted the Syrup.

Colchicum a formula equally well suited to every constitution & better adapted to some

To this formula then had here recourse.

At same time inclined to think that probably others under which Colchicum may be more certain in operation.

Analogy of this substance in several respects to squills would naturally suggest use in form of pills.

And of these, a preparation rather of dry [than] recent root.

Have little doubt in asserting that in this form of all others most certain of operation of Squills.

And some presumption that same may also be case with Colchicum.

Must however acknowledge that have never tried these pills.

And indeed supposed noxious qualities of root perhaps some objection to its being used in solid state.

Now however appears that this quality not so great in it as once imagined.

And of late with best affects exhibited in much larger doses than formerly ventured upon.

But although large doses have of late been given not only without prejudice but with manifest advantage yet hold that in every case should begin use with small quantity.

And if these fail may afterwards be gradually increased.

For in some instances where has not deleterious affects, will yet give great unease as affecting Intestines

And in this way have known it to induce not only looseness but even gripes tenesmus, & bloody stools.

Must however allow that there the Oxymel of Colchicum was employed.

And not impossible that symptoms may have been in some measure effect of colic pains induced by Honey.

Here began patient with Syrup Colac. to extent of half ounce in day.

In this quantity produced manifest [increase] of discharge by urine.

And as product of no uneasiness with view of augmenting & supporting evacuation increased quantity to six drams.

In this state discharge by urine [mass] affect in diminishing swellings.

Was unwilling therefore that from [attempting] to [precipitate] cure consequences should be [induced] which might interrupt plan

On this account therefore while swellings continued to diminish, resolved not to push it farther

And events [showed] that not necessary.

For with continuation of Diuretics swellings soon entirely disappeared

And except remaining cough patient free from all symptoms with which affected when came under care

In this situation reckoned it unnecessary for him to continue medicine, or even attend at Dispensary.

And accordingly dismissed at least cured of Dropsical complaint.

If however conjectures which have hazarded well founded not improbable that may again be our patient.

And even great reason to fear that may yet fall victim to affection either under form which lately had or some other

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Explanatory notes:

1) 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.

2) The Royal College of Physicians of Edinburgh, established in 1681.