DEP/DUA/1/17/03 (Normalised version)

Peter McDougall

(1778)

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Peter McDougall.

Respecting affection to which this patient [subjected] several questions may be started to which cannot give any positive [answer]

First & most urgent symptom when came under our care affection of alimentary canal.

These affections to some degree appeared under form of vomiting.

For this we are told, in particular was frequent occurrence with him after taking food.

But still more distressed by looseness.

This complaint not like former occurring only at times.

Was to such degree of violence that in space of twenty four hours often even 20 watery stools

And while thus a very frequent discharge subjected also to other distressing symptoms evidently connected with it.

Particularly gripes & borborygmi.

In these affections then such manifest lessening of natural functions as may reasonably conclude to constitute an affection of very threatening nature.

And from circumstances of increased discharge by belly should at first be inclined to look for affection under head of [alimentary] fluxus.

Under that title however those affections only comprehended in which looseness occurs as an idiopathic disease.

That is where depend on state of intestinal canal itself.

Well known however that such circumstances not less frequently take place as symptomatic than as idiopathic

Or in other words depending not on morbid condition of alimentary canal but of other parts.

In this manner in particular is frequent consequence of suppuration at different parts.

And perhaps no symptoms more common at termination of Phthisis than colliquative diarrhoea.

Before therefore considering to what particular Genera may be referred first occurs as question [whether] idiopathic or symptomatic.

In favour of each supposition some arguments may be argued.

Is somewhat in support of being idiopathic that no circumstance in nature or appearance of discharge which may not arise from that source

Still farther that besides mere discharge there occurs also other affection of alimentary canal.

Where colliquative diarrhoea induced by Phthisis is at least but rare to observe that at same time accompanied with vomiting.

This indeed will sometimes happen in [consequence] of severe fits of coughing.

But although patient affected with cough vomiting does not then principally occur.

Is particularly remarked to happen after meals.

From this then may conclude that arises in consequence of stimulation even from ordinary aliments.

And that by means of peculiar irritability a convulsive action of stomach occasioning rejection of food, occurs from stimulants which otherwise would produce no effect.

When therefore thus grounds for presuming irritable state in stomach greater reason for supposing that may extend to other parts of intestinal canal.

And thus consider vomiting as being in favour of supposition that the looseness is idiopathic.

Still more corroborated however from other affections of alimentary canal.

Gripes indeed equally occur whether diarrhoea idiopathic or symptomatic.

And may either arise from peculiar [stimulation] uncommon sensibility, or inordinate action.

Often even from combining affects of all taken together.

Can hardly therefore be considered as arguing any peculiar state of alimentary canal.

But besides gripes affections of patient attended also with borborygmi.

And farther to be remarked that [from] discharge of wind relief afforded.

In this then consider us as having evident indication of debilitated & irritable state.

In existence of wind have evidence of this condition as giving rise to extrication of it

And in relief which expulsion affords have evidence of unease being induced even by slight stimulation.

From all circumstances then presumption of morbid condition in alimentary canal itself.

And on this ground should be inclined to pronounce frequent loose stools to which patient subjected as being at least in some degree idiopathic

If to be considered as such can be no doubt that must be referred to genera of Diarrhoea.

According to best [systems] could be referred only either to this head or to that of Dysentery.

But while every symptom here occurring such as frequently accompanies former, many of most [essential] of latter wanting.

No reason to suspect that arose from [continuation]

Almost certain evidence that incapable of being communicated by this means.

For during whole time that occurred with present patient no other of family subjected to it.

But what to be considered as still stronger circumstance than any of these was without fever.

Hold [primary] fever to be essential & necessary character of that disease which would [denote] dysentery.

And accordingly inclined to think that with greater propriety referred to tribe of contagious febrile diseases than any other.

While characteristics of Dysentery thus absent no symptoms in nature of [illegible] discharged which can occur as objection to diarrhoea.

At least if this general term taken in most extensive & perhaps may add most proper sense

These arguments however in support of idiopathic diarrhoea do not afford sufficient evidence that solely from this cause.

And if even to consider affection of alimentary canal as solely referred to this head yet no doubt that patient also subjected to other symptoms

Becomes then first necessary to consider how far a complication of diseases here take place.

And how far any other affection here existing can be supposed to have share either as supporting or augmenting diarrhoea.

This may observe frequently the case where looseness yet in great measure depends on state of intestines.

And will not be [refused] that in present case several very alarming symptoms.

At same time such as afford strong [indication] if not certain evidence of an affection of most dangerous tendency

Besides complaints of which have already spoken patient we are told affected also with severe cough.

And this cough accompanied with some degree of constant fixed pain in left side.

In these will not be refused that have two of most frequent symptoms of Phthisis Pulmonalis.

But at same time often occurs to considerable degree where no Phthisis.

And where Phthisis present in other cases either wanting or at [utmost] present but to slight degree.

Without other concurrent circumstances therefore less dependence to be put upon them.

And even after all where presumption corroborated by many particulars will sometimes turn out to be mistaken.

While at same time from insidious nature of disease will often even prove fatal where many of principle & most common symptoms have never appeared.

From these considerations then judgement must always be very uncertain.

But besides cough & pain of breast here several particulars corroborating presumption.

Patient not indeed affected with any obvious difficulty of breathing.

A circumstance at least often occurring particularly where large vomica in lungs.

Then also seldom that patient can sleep unless laid on affected side.

As respiration must necessarily be carried on by sound lobes.

And these more free latitude for action where parts forming cavity in which are contained not prevented from motion by [pressure] [from] weight of body.

Although however [such] affections of [breathing] wanting yet cannot be considered as any strong objection to existence of Phthisis.

And perhaps restless state during night to be considered as in some measure affect even of respiration less free [than] natural.

Supposition of Phthisis however much more corroborated by feverish attacks to which patient subjected.

Was affected even from time that came under care with a feverish paroxysm returning every day.

Pulse indeed, at time when [case] taken, not above natural standing.

And although most frequently the case in Phthisis that is constantly accelerated yet by no means uncommon to find it at times in ordinary condition.

While such periodic febrile [accepted] as occurring in case of our patient with his other symptoms with greater probability to be considered as hectic than any thing else.

Supposition of Phthisis still farther corroborated by cause to which affection attributed & symptoms with which attended at commencement

Patient ascribes all present affections to cold.

A cause more frequently inducing Phthisis especially at his period of life than any other.

Farther to be observed that at commencement was subjected to bloody discharge by mouth from coughing

If this to be considered as Haemoptysis [unquestionably] to be looked upon as one of great [illegible] of suppuration in lungs.

And indeed tubercle, that is Scrofula. simple catarrh, & Haemoptysis, three great sources from whence Phthisis Pulmonalis arises.

Here however may be some [doubted] [were] bloody discharge in reality from lungs.

And gives at least some presumption to contrary that at same time there took place also discharge of blood by stool.

This however will sometimes even happen where entirely from breast

As after brought to mouth in part again swallowed.

But whether this origin of bloody stools or not presumption that in some degree at least from lungs when considered that discharged by coughing.

But still strong evidence of what took place at that time from what has since happened.

Patient not many weeks ago affected with return of bloody expectoration.

And then without any manifest discharge by stool entirely coughed up.

While at same time succeeded by copious expectoration of matter which according to description has at least many of marks of purulent discharge.

Particularly in colour taste and odour.

Have not indeed as yet had opportunity of trying this matter according to more certain test than these afford.

That viz discovered & [proposed] by my late [ingenious] & worthy friend Mr Darwin.

And for which not many weeks ago he obtained prize medal of Aesculapian Society¹.

If heaven permit me is my intention to take some future opportunity of attempting publicly to delineate a character which did honour not only to this [illegible] of medical education but even to age in which we live

Of this admirable young man therefore shall at present only observe that has taught medical world on what grounds a certain diagnosis may be formed between purulent & mucous expectoration by aid either of Caustic Alkaline Lixivium or of [Vitiated] Acid.

While both even in diluted state, keep mucous in perfect solution do not exert same [property] on pus.

From trials with several other patients have now no doubt as to accuracy & certainty of this test.

At least when performed with due degree of attention.

Had [such] trial been already [made] with matter coughed up by present patient might with more confidence have now [seemed] whether does or does not expectorate pus.

And on this ground shall soon have present opinion drawn from appearance & other circumstances either corroborated or refuted.

But even independent of certain evidence of purulent expectoration, in various other particulars mentioned have strong presumptive proof of existence of Phthisis.

On whole then look on present patient as labouring under complication of diseases.

Long before came under our care [supposed] that vomica or collection of purulent matter existed in breast.

But besides this consider alimentary canal to have been in peculiarly weak & irritated state

From this weakness & irritation would explain most urgent symptoms at time when came under our care.

Particularly flatulence. vomiting & [looseness]

Consider these symptoms however as having been then supported by purulent absorption

And now look upon him as being subjected to hectic fever from [same] cause

While at same time from rupture of vomica would explain Haemoptoe to which has lately been subjected as well as cough & state of expectoration which still continues.

After this opinion of nature of case need say but little either of prognosis or of intended practices.

Were patient subjected to complaint of alimentary canal alone might have reason to fear that disease would be tedious but could not hold it to be highly dangerous.

When however are farther of opinion that vomica formed in lungs not only has given rise to purulent expectoration but also to hectic fever must hold him to be in most immediate danger

But rarely happens that from such a state patients ever do recover.

And indeed my opinion at present is that this patient cannot hold out for many weeks longer.

Yet in prognosis as to period of event of Phthisis much more liable to error than as to event itself.

When Phthisis distinctly marked will at least seldom be wrong in pronouncing that event will be fatal.

Yet where patient seems to last degree exhausted will often hang on for long time

While in other cases progress of Hectic symptoms extremely rapid.

And patient even while considerable vigour yet remains cut off much sooner than could have been expected.

Wherever prognosis given then must not lose sight of such occurrences.

Yet must own that shall be inclined to consider it as exemplifying such a case if patient holds out much longer.

When thus speak of termination however would not yet be understood to mean that consider it as certainly fatal.

Although many circumstances against the healing of ulcer of lungs yet not impossible.

And perhaps reason why this event does not more frequently take place depends rather on condition of ulcer than situation.

From this circumstance not only less disposed to heal but in place of mild pus yields matter more readily inducing hectic fever.

Ulceration however of mild kind may occur in lungs, as well as in other places.

And whatever condition of ulceration chance of healing unquestionably better when from rupture of vomica free discharge allowed to matter than where entirely pent up & can be removed only by absorption.

Is then on this ground that consider patient as not altogether without chance of [recovery]

Yet must own that if does occur is much more than I expect

And should it happen must I imagine be much more ascribed to powers of nature than to any medicine which we can employ.

While however patient remains under our care some measures may be taken if not as means of curing at least of alleviating [complaint]

Of these then as well as of practices already employed shall next offer few remarks.

When patient came first under our care not in every respect same evidence of Phthisis as at present.

And whether did or did not exist at that time viewed severe looseness as the circumstance from which greatest danger to be apprehended.

This considered as depending on debilitated & irritated state of alimentary canal

But before employing astringent thought first of thoroughly evacuating irritating causes

And of endeavouring to restore inordinate action by means of sedatives.

Was with these intentions that had here recourse first to dose of Glauber Salt & then to anodyne draughts.

These medicines had apparently at least some good effects.

And from time that began them looseness very considerably diminished

Still however symptoms remained indicating evident affection of alimentary canal.

Particularly much sourness at stomach & great unease from wind.

Considering both these as [illegible] affects of want of due tone had recourse [illegible] Tincture e Kino as an astringent.

This Gum Resin a vegetable astringent of which frequent use made since paper respecting it published by Dr Fothergill in London Medical observations

Of late have myself frequently employed it & with best affects.

Of all forms hold that of Tincture to be preferred.

And indeed this substance so far of resinous quality that readily & completely dissolved in weak Spirit.

In this respect then better qualified for exhibition in form of Tincture than another vegetable astringent the Succus Japonica.

This however also the basis of a Tincture

But while Tincture Japonica with addition of Cinnamon the Tincture e Kino without any addition.

This then the rather an inducement for me to direct it for present patient in conjunction with the Tincture Aromatic.

From this operating as carminative in consequence of stimulation to stomach hoped that might be freed from unease depending on wind.

From this medicine looseness so far ceased that thought continuation of the Tincture e Kino unnecessary.

And reckoned it sufficient to persist in use of the Tincture Aromatic alone.

Soon however a return of looseness led me to renewal of former prescription.

And with this, increase of hectic fever led me to direct [enjoining] still another measure.

That was employment of Peruvian Bark.

Has indeed been much subject of dispute how far in any case of Phthisis Peruvian Bark can be exhibited with [advantage]

Is unquestionably in many cases an objection to it that gives check to free expectoration.

And where free discharge of purulent matter from lungs can be no doubt that gives best perhaps only chance of recovery.

At same time certain that as [counteracting] hectic fever arises from absorption of pus from other parts of system has often best affects

And for my own part little doubt in asserting that from altering state of action of vessels producing alteration of condition of discharge.

In cases then where even most certain evidence of vomica, if as was the case with our patient, no expectoration & yet high degree of hectic fever cannot consider it as improper

And from use here, appearances were even somewhat flattering.

For after continuation to extent of about half an ounce a day for space of about eight days

These febrile accessions very considerably abated.

In this situation substituted to bark use of Infusion amarum.

And if operation of bark as is commonly supposed depends on action as bitter & astringent may from this at least reap some good affects

But while patient on this course, [appearance] much more [threatening] took place

For during remission both from hectic fever & looseness was attacked with [return] of bloody expectoration.

This, from subsequent state of discharge by cough, am inclined to think, was consequence of bursting of vomica.

Since that have chiefly trusted chance of recovery to free discharge of what reckon purulent matter.

Have indeed continued him on use of a mixture containing some proportion of Infusion Rosarum.

This in some measure intended as gentle astringent to prevent [fresh] effusion of blood from ruptured vessels.

A circumstance which if occurred to any considerable degree in present situation of patient might prove even suddenly fatal.

But must at same time add that medicine principally meant as placebo.

And is I must own, with me great doubt, whether any thing farther than mere alleviation of symptoms now to be attempted

Now without paying much attention to state of alimentary canal must consider morbid condition of lungs as great [indication].

And indication of cure which ought chiefly to endeavour to fulfil, is the healing of the ulcer.

This perhaps chiefly to be affected first by endeavouring to obtain free discharge of stagnant pus.

And then by inducing such a state of action of vessels as will give adhesive inflammation.

How far these ends in any degree to be effected by art must own think very uncertain.

Can however be little doubt that with first intention that viz of promoting expectoration service sometimes derived from emetic.

And probably is in great measure on last footing, that to account for benefit from setons and issues

And indeed persuaded that [these] operate also on other principles.

Yet inclined to think that as diminished impetus at breast altered state of action of vessels.

In present instance however have had recourse neither to one nor other of these

Must own, consider patient as too much debilitated, for bearing agitation of emetics.

And in exhausted & emaciated condition doubtful of propriety of any evacuant.

Particularly so of such as debility most in proportion to quality of evacuation.

This however especially case with every purulent discharge.

And is from this circumstance that even strong indication of exhaustion the facies Hippocratica appearing so soon in Phthisis affection.

From these different considerations then though consider them as often of service, yet think that not always admissible.

And in many cases imagine that cure to be trusted to operation of nature aided by aliment, nutritious yet not stimulating

While at same time patient to be placed in such situation as will promote appetite & aid influence of this regimen

Is on these principles that would account for good affects from milk diet country air & gentle exercise.

These measures as far as patients circumstances would admit of it have here enjoined.

Is common practice in Phthisis to [enjoin] even most [illegible] diet.

And while strong inflammatory tendency for prevention of farther suppuration is often proper

Yet must own am inclined to think that frequently pushed too far.

And that support of vis vitae² [requires] nutritious aliment.

This not only indicated by apparently [exhausted] state, by also by natural cravings of patient

Often strong desire for nutritious aliments.

And may by way remark that such cravings when not founded on [preconcluded] opinion seldom misled.

This so much the opinion of a late celebrated team of medics at this place Dr Monro Senior that laid it down as rule never to refuse patient in any disease what expressed strong desire for [providing] could assign no reason.

These then grounds on which are I imagine to aid & regulate natural cure of Phthisis

Endeavouring only to obviate by artificial means such urgent symptoms as may occur

In present case however have proceeded one step farther

Have directed for patient use of Gum Myrrh

After what lately said by learned Dr Fothergill against healing balsam in Consumptive cases this practice may perhaps be [deemed] a bad one

And can by no means venture to assert that will be serviceable to patient.

Yet must own that on principles laid down entertain some hopes from it.

Was first [induced] to use this medicine in such cases as present on footing merely [empirical]

That was from being told that much employed in Phthisis by Dr George Fordyce & he imagines with advantage

Have of late given it in several cases which at last had fatal termination.

And which, as suspect of present, would I am convinced have had that fate [although] had never been given.

In one case however in which used it patient very unexpectedly recovered from internal suppuration

Whether owing to medicine or not cannot positively pretend to say.

Yet this has led me both to consider use as deserving farther trials & to think how to be explained.

Is with intention of such trial that have ordered it for present patient.

And if he recovers shall be [inclined] to attribute much to it whether can explain operation or not

On this subject however if cannot do much am at least inclined to conject.

Need not then observe that Myrrh long a celebrated application against ill conditioned ulcers when used externally.

Then chiefly used in form of Tincture

And can be no doubt that by means of his application state of discharge often changed & ulcer afterwards healed.

This then gives presumption that Myrrh acts as peculiar stimulant to vessel.

And if has this affect on immediate topical application may exert same influence when after entering circulation again collected at extreme vessels.

These then grounds by which led to use

Here however extremely doubtful whether shall be able long to continue it.

But if obliged to discontinue present plan have thoughts of doing nothing farther in this case than merely attempting to palliate.

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Explanatory notes:

1) More commonly known as the Aesculapian Club rather than the Aesculapian Society, this is a medical dining club founded in 1773 by Andrew Duncan. The stated objective of the club is to encourage professional connections between physicians and surgeons through convivial gatherings.

2) From Latin, meaning vital force or strength of life.