DEP/DUA/1/22/13 (Normalised version)

William Gray

(1779-1780)

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William Gray.

Have already hinted that consider this patient, as well as last Archibald Campbell to be subjected to Phthisis.

Of this however have not at least same degree of certainty.

Yet from several circumstances consider it as more probable than any other supposition.

And if really the case exhibits very different example of Phthisis from last mentioned.

While referred former to vomica [am] inclined to think that this again product of tubercle.

Here may among other circumstances remark, striking disparity in progression of two cases

One brought to fatal period even in space of few months

Other has subsisted already for years.

And patient still in such a state that cannot be said to threaten immediate danger.

+ And little doubt that dyspnoea affection of this matter loading air vesicles of lungs & small branches of Bronchia

In both cases with dyspnoea considerable degree of expectoration

But great reason to presume that matter expectorated very different.

Have already had occasion to point out circumstances from which led to conclude former to be purulent.

Here again from difference of circumstances, would conclude this to be mucus.

Patient not affected with that fixed pain at any part of thorax which commonly case in vomica.

Matter neither foetid, smelly, disagreeable taste, nor appearance of mixture of blood.

And although tongue moist, yet without that peculiar cleanness & rawness, which the attendant of purulent expectoration.

But besides all these tests another & perhaps still stronger mark afforded

Have had opportunity of trying the matter expectorated by this patient with test proposed by late ingenious Mr Darwin in treatise mentioned last lecture.

And have found that this expectorated matter by aid of a little agitation completely & entirely dissolved in caustic alkali.

While this however universally allowed to be case with mucus, will find from Mr Darwin’s 32 Experiments that by no means holds of pus.

Found latter fluid incapable of being dissolved by caustic alkaline lixivium of ordinary or even of double strength.

And that too although much agitation employed with view to forwarding solution.

This experiment he observes, he repeated five different times, with same event.

Must therefore conclude that very little room for deception.

And on this ground, corroborating other circumstances would conclude that matter here expectorated entirely mucus.

From this may naturally be suspected that complaint in place of being phthisis, entirely catarrhal.

And that suspicion strengthened by two other circumstances.

Continuation viz of disease, & aggravation during winter.

Although sometimes happens yet but rarely that patients subjected to Phthisis for years.

While again aggravated during particular [seasons] especially winter much more common with catarrh when in chronic state.

To these may also perhaps add age of patient.

Already in 34^th year, past period when phthisis most common.

And at same time verging to that when patients most affected with chronic catarrh

These circumstances it must be allowed are all in favour of supposition of catarrh

And as here expectoration not purulent are necessarily led to conclude that catarrh in some degree takes place.

Yet at same time other circumstances which would lead to belief that Phthisis also occurs.

At an early period of life long continued cough always a suspicious circumstance.

This [suspect] here corroborated by quickness of pulse.

Still more by hectic flushings, night sweats & exhausted habit.

But to all these, another circumstance to be added, giving still stronger grounds for suspicion.

That is evident marks of scrofula, appearing in [scars] under chin.

From every circumstance of case reason here to presume that Phthisis [from] tubercle.

And well known that of this the most frequent if not indeed only origin is scrofulous habit.

From all these circumstances taken together then too much reason to apprehend that this patient subjected to tuberculous consumption.

And although consider Phthisis as here complicated with catarrh yet look upon former as by much most important & dangerous part of affection.

Is objective therefore principally to be regarded both in prognosis & in measures for cure.

Here indeed if affection only catarrh patient may either have complete [recovery] or may not at least fall victim to the affection although subjected to it for many years.

But if really Phthisis chance much against him.

And although may hang out for present & even another winter, yet if not in end cut off by disease notwithstanding all remedies which we can employ, is more than I expect.

Here, supposing affection to proceed from tubercle, most important objective in cure would be, removal of that morbid condition

What called tubercles, appear from dissection to be small indurated tumours usually of whitish colour, which may have seat at any part of lungs.

And often even to be found there in great numbers.

Evident from situation that cannot possibly admit of removal by operation.

Alone to be expected by action of absorbency, & renewal of circulation.

Well known that in this way many obstinate indolent tumours at length [dissolved].

And as long as circulation through them continues this at least possible.

But not infrequent, that vessels being entirely obliterated, these become as it were an inorganic mass.

And if sometimes happens, in other cases, is a frequent occurrence in Scrofula tumours in general, but particularly in tubercules of lungs.

Here then not surprising that the [obtaining] removal by resolution always difficult, often perhaps impossible.

Where cannot be accomplished next objective as far as able, to counteract effects [also] remaining.

And either to prevent separation of [illegible ] sanies giving hectic fever, or although separated to prevent action on system.

More frequently happens however that none of these intentions can be accomplished

And that must content ourselves merely with endeavouring to obviate symptoms.

Where however circumstances of the case will admit of it, something at least to be attempted in first way.

And is with view to resolution of tubercles, that have here had [recourse] to repeated Emetics.

These, have long with different intentions, been advised against Phthisis

And several principles, on which may I imagine expect benefits from them.

In case before us hoped, for some effect from them, as unloading lungs & determination to surface.

But chiefly determined, to persist in use, from accounts which have lately heard, of use now made, by some practitioners in London of Emetics, in other cases of Scrofula

Have been told that by frequent employment even largest & most indolent scrofula tumours happily resolved.

Not indeed suited for this during inflammation stage.

But after inflammation gone while indolent tumour remains often of great service in removal.

And that practice, some analogy at least, in use that has long been made of them in a particular glandular swelling that of testicles

On what principle there operates hard to say.

But probable that affection in part at least depends on giving increased action to whole vascular system, both sanguiferous & absorbent.

But whatever principle of operation, success in certain states of that affection, confirmed by experience.

And analogy alone a circumstance sufficient to encourage to use, in similar cases.

On this foundation then, consider present as an instance where merits fair trial.

And with this intention, patient has now for space of month taken sometimes one, but in general two vomits every week.

Cannot however say that from these have derived any manifest advantage.

On contrary affection rather more distressing to him.

And whatever may be influence in other cases now begin to be apprehensive, that shall not find it, adequate to cure in present.

Hitherto have employed this practice almost alone

Principally that might be able to judge how far by itself, had effects

Of late indeed, with view to dyspnoea, have ordered application of blister to breast

But although disposed to place some confidence in issues, in such cases, this merely employed as temporary measure.

And if do not find some change at next report, neither intended to support drain nor to push use of emetic any farther

Here propose next, to try a practice which for my own part at least, have not hitherto used in Phthisis.

Nor do I observe it mentioned by any of latest writers - viz Cicuta.

Need not observe that has of late been highly celebrated against scirrhous & even cancerous tumours.

Has been extolled also as highly advantageous in cases of open cancer.

And for my own part, although do not consider it as universally successful, yet have good opinion of it, even in these.

Of late also have used it much in cases, both of scrofula tumours & ulcerations & I think with advantage.

On these grounds is I think naturally suggested in such a case of Phthisis as present.

But here do not propose to employ it alone.

Have thought, that power as discutient, in many instances increased, from combination with Calomel.

To Mercury indeed objected in cases of scrofula that induces suppuration.

But still doubtful whether this a good or bad affect.

Of discutient power of mercury in such cases however, some practitioners, particularly Sir John Pringle very high opinion.

After finish with Emetics therefore next propose to give this fair trial.

And if find it successful shall be disposed to consider it as strong proof of efficacy.

Perhaps however even should recovery occur, credit may be given it without [reason]

And that not merely as may be mistaken respecting disease.

For may observe, that patient will naturally at this season of year, be put in way of another remedy of late extolled.

What I allude to, a Spanish practice extolled by Dr Simmons in treatise on consumption¹

The Banos de Tierra or Earth Bath.

This practice consists in burying patient up to chin in fresh earth, or in pit dug for that purpose.

In this situation continue for

& repeated at intervals.

Is particularly celebrated in cases of consumption

Dr Simmons mentions several instances of efficacy.

And imagine, that good effects to be accounted for from effluvia of Earth absorbed

And from being carried into circulation correcting morbid state of fluids on which hectic depends.

Recommend, therefore that trial should be made of it during warm months in the country.

How far practice really advantageous, future experiments must determine.

May only observe that very analogous with what long employed, with delicate & weakly children in this country following the plough.

And not even uncommon to lay them in newly made furrow.

Have not at present in view a trial of this practice with present patient.

But may observe that is by occupation a Gardner.

At this season therefore as far as heat will permit will be employed in digging up ground.

And therefore hard to say, how far if recovery should take place may not be attributed to that cause.

Here however must observe that although can say nothing either for or against virtues, yet should not expect any great benefits from it in such a case as present.

Although may be useful in relieving hectic fever yet should not expect from it the removal of tubercles.

Still therefore in as far as advantage may be obtained presumption at least in favour of Cicuta with Mercury.

Besides this might suggest also other measures to be employed if what now mentioned unsuccessful.

But as no opportunity of trying these at least during present course hold it to be unnecessary.

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Explanatory notes:

1) Samuel Foart Simmons, Practical observations on the treatment of consumptions (1780).