DEP/DUA/1/24/07 (Normalised version)

Alexander Hastie

(1780-1781)

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Alexander Hastie

With regard to disease of this patient not without difficulty both as to name & nature.

At same time only distressing symptoms in case both obvious & common.

Although some evident swelling of legs yet principal complaints those of breast.

Consisting of great dyspnoea & severe cough.

After what said of last case Mary Ainslie will naturally occur that here great similarity.

And both unquestionably may be affect of mucus

This the rather probable when consider cause from which immediately arose.

Exposure viz to cold when body [previously] much heated.

But while affection may be considered as catarrh & depending on mucus, other causes from which may also arise.

And here chiefly divided in opinion whether from mucus or water.

While former may be cause of symptoms many circumstances favouring latter supposition.

Well known that from water either in cellular membrane of lungs or in cavity of chest all these symptoms may arise.

And here unquestionable evidence of dropsical affection to certain extent in obvious swelling of legs.

This, from appearance – from effect of pressure – & from increase by erect posture manifestly of anasarca kind.

And gives at least some presumption that dropsical affection may exist also in other places.

But certain evidence of dropsy not only presumption of its being cause of cough & dyspnoea.

Here will observe that notwithstanding severity of cough very little discharge by expectoration

And from this want of evidence of mucus presumption of water

Presumption heightened by increase of dyspnoea in horizontal posture.

And still more by breathing being more difficult when lies on right than on left side.

As farther evidence may add also state of urine.

For as is in general case in dropsy, both scanty & high coloured.

Lastly may add as additional circumstance appearance of patient

For had very much of pale leucophlegmatic look, which so common in Dropsical affections.

Upon whole then strongly disposed to consider disease as dropsical affection of lungs.

But supposing it such, still another doubt.

Whether viz Anasarca of lungs or proper hydrothorax.

Is no evidence particularly of former that anasarca of legs.

For this well known to be seldom wanting in hydrothorax.

While again in anasarca respiration little affected by posture & equally difficult on both sides.

But may here be objection to supposition of Hydrothorax that some of those symptoms wanting which pointed out by practical & nosological¹ writers as characteristic of Hydrothorax.

Particularly no affection of pulse neither in way of intermittent, or irregular.

No sudden starting from sound sleep with palpitation.

And no evident fluctuation within thorax.

That all these when occurring are strong symptoms of hydrothorax no one will deny.

Yet may with confidence venture to assert that disease may occur even to such degree as to prove fatal when entirely absent.

Of this lately met with very [striking] instance

Not long ago attended in conjunction with another Physician & Surgeon of this place a patient in whose case no suspicion of hydrothorax.

After a tedious illness which put on different appearances complained of pain in breast.

But this without either dyspnoea or cough.

Pulse full strong & regular.

And no inconvenience from sleeping in horizontal posture.

While not smallest indication of dropsical symptoms in any other part of system.

In that case much more than in present what are reckoned the [diagnostics] of the disease wanting.

Yet in situation I have mentioned patient died very suddenly.

And upon opening body very large collection of water found in left side of Thorax.

When related this case to a very able surgeon at this place Mr [Andrew] Wood was informed that a similar instance had occurred to him.

At least none of common symptoms of hydrothorax & no suspicion before death

But on dissection very large collection of water found in cavity of chest.

From all this would not deny that diagnostics of hydrothorax proper.

Have no doubt that where present indicate existence of the disease

Yet from absence cannot conclude that patient free from the affection.

And from all circumstances of present case taken together cannot help thinking that more reason to suspect disease to be Hydrothorax than any other affection

With this opinion of nature, prognosis must at least be doubtful.

For in general ranked among the most dangerous forms of dropsy.

And when consider function which must or at least may be [disturbed] from water in breast this by no means surprising.

At same time even when exists as most distinctly characterised do not look upon affection as incurable.

And am inclined to believe that often to certain degree takes place & removed where not distinctly marked.

In present instance from want of most distressing symptoms may conclude that has not proceeded to very great height.

And on present occasion at least has not been of very long duration.

For when patient first applied here ailment had continued only a few weeks

Are indeed it is true informed that [during] former winter subjected to similar symptoms.

But even this also rather in favour of patient.

For recovery at that time gives now some grounds for hopes.

Upon whole then though consider affection as dangerous yet not without prospect of recovery.

At same time must observe that patient now in worse situation than at last report.

And dyspnoea in particular so far increased that for two weeks past unable to attend us.

Is also not in favour of patient that not very attentive in following directions given him.

Hence then at least less chance of benefits from what we can direct.

And should not be surprised were affection to have fatal termination & that too in sudden manner.

In treatment of this case on supposition that conjecture as to cause of affection well founded, [indication] [obvious].

Here can only look for cure of disease from removal of water

And indeed could hardly from any other measure expect permanent relief of symptoms

Even by this however could not expect what may be called radical cure.

For after water removed often tendency to fresh deposits.

In such instances therefore measures also requisite for prevention of farther affection.

But of these few at least of such nature that any tendency to produce immediate evacuation.

And hence before any attempts in this way in general at least becomes necessary that evacuation first produced.

With view to this intention measures employed in this case almost solely directed

First measure to which had here [recourse] was application of blister.

And this may observe a measure on which in cases of hydrothorax more dependence than almost any other.

Need not observe that affords artificial outlet for the water.

True indeed that from application in such cases as present discharge not direct.

But while gives vent for discharge at same time increases action of absorbance.

And by this means not only artificial discharge but chance also of uncommon evacuation by natural emunctories.

Accordingly blisters a very common remedy in this affection.

And from repetition to different parts of chest at short intervals often very [surp] cures.

Was intention therefore with present patient to have recourse to such repetition as occasion might require.

From first blister as much [benefit] derived as could reasonably have expected.

For while product of free discharge both cough & dyspnoea considerably relieved.

And notwithstanding distance of situation reckon it also not improbable that ought in some measure to ascribe to it removal of swellings of legs.

Is indeed true that had here recourse to another measure from which such consequences might have been expected.

I mean Spirit Nitri Dulcified.

This in my opinion, one of the easiest & most expedient diuretics which has yet place in Materia Medica².

Do not indeed represent as powerful or certain in operation where others fail.

Nor as producing in consequence of operation very copious discharge.

But in general at least to extent of twenty drops for dose once or twice a day very considerable affects.

And although not to be ranked among most powerful yet will sometimes succeed where others generally reckoned more active have failed.

Besides seldom distressing to patient as inducing nausea, sickness at stomach etc.

Hence then a remedy to which where diuretic indicated am very much disposed to have recourse.

And in present instance expected benefits from it on several footings.

Hoped that while blister promoted absorption of water, would tend to discharge

Expected that by copious diuresis absorption would be still farther promoted.

And imagined that might have influence as counteracting strangury affect sometimes arising from blisters.

How far was of any use with latter of these intentions perhaps matter of doubt.

Patient however not affected with strangury

An occurrence however which might very readily have happened without Spirit Nitri.

But if any influence in this way were at least disappointed of effects in other.

For in consequence of use no obvious increase of urine.

At this however, after trial for space of eight days, neither surprised nor disappointed.

And although inclined to consider both removal of swelling of legs & alleviation of dyspnoea as affect of blister, yet necessary to delay repetition for few days.

And in mean while thought could not do better than continuing Spirit Nitri.

Now however directed augmentation of dose from 20 to 30 drops.

And as means of still farther aiding operation advised also another diuretic.

Use viz of Squills in form of pills.

Diuretic power of squills is I may say universally admitted.

And by many held as most certain & powerful article referred to class.

Hoped therefore that in conjunction with former article might produce desired effects.

But besides this expected benefits also on another footing

Am persuaded that secretory organs of urine not only ones on which squills act after entering circulation.

Have I think undeniable evidence of exerting same influence on those of lungs.

And imagined that might here tend to relieve pneumonia symptoms from promoting discharge by expectoration.

Hoped then that should soon see good affects of this course.

Since Nitre increased however & squills prescribed, patient has never been present at [reports] here

Am sorry to say that this has proceeded from inability to attend

And from visiting him at his own house have had mortification to learn that neither Squills nor Spirit of Nitre any influence as increasing urine.

This however am inclined to suspect has in some measure proceeded from inattention or aversion to medicine on his own part.

But whether regularly taken or not most distressing symptoms of patient aggravated since last saw him here.

And although no return of swelling of legs, yet very much distressed with cough & dyspnoea.

In this situation have ordered repetition of measures with which began & which indeed had in view if attendance had been continued.

Application viz of blister.

But must own am very doubtful how far this direction will be complied with.

If however patient does follow advice hope that will be attended with some benefits.

And shall still be disposed to advise repetition at proper intervals.

But during these in place of Spirit of Nitre & squills to which now expresses aversion, have thoughts of employing with nearly same intention the Cream of Tartar.

And if shall prove properly diuretic may expect advantage.

If not many other measures from which at least probable chance of alleviation to which may have recourse

But with uncertainty of patients attendance unnecessary at present to suggest any thing farther.

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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.

2) Latin term referring to the body of collected knowledge about the therapeutic properties of any substance used for healing (i.e., medicines).