DEP/DUA/1/24/09 (Normalised version)

Andrew Hutton

(1780-1781)

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Andrew Hutton

In this patients case a set of symptoms very frequent at this season of year.

Complaints in many respects similar to those occurring in case of Margaret [Ainslie]

Consists principally of cough, dyspnoea & pain of breast with copious expectoration.

These we have already observed a set of symptoms in common both to Catarrh & Phthisis Pulmonalis.

And here only doubt with regard to disease, is, to which genus should be referred.

With regard to first evidence that cannot be considered as acute or febrile catarrh since has already continued for space of several months.

Can as little [style] it Catarrh senilis when consider that patient yet only in 12^th year.

Yet even with present patient may be what would call chronic catarrh.

Or what in vulgar language of this country commonly called sitten down cold.

Instances similar to present where no suspicion of Phthisis, point out propriety of distinguishing by particular name.

But here I must own not without doubt

For in this case many circumstances leading to suspicion of Phthisis affection.

In matter expectorated indeed neither taste nor smell indicates purulent [appearance]

And can be no doubt that by much greater part merely mucus

At same time have had no opportunity of determining whether any mixture of pus.

This however may exist to some degree though principal part mucus

But in Phthisis besides purulent expectoration should also meet with hectic fever.

And cannot be said that this formally exists in present instance.

Have no accounts at least in history of case of periodic shivering succeeded by heat.

Nor is patient in any degree affected with colliquative sweats or diarrhoea.

But these well known to be symptoms only in advanced stages.

And phthisis one of most insidious diseases which practitioners have to treat.

Has often made very considerable advances before any suspicion of it.

And in this instance patient by no means entirely free from febrile symptoms

Heat indeed as in general observed nearly about natural standard.

And no affection of discharge by stool or urine.

But appetite impaired, thirst augmented & pulse considerably accelerated.

To these febrile symptoms still another circumstance to be added giving grounds for alarm.

That is pain of breast.

In instances of chronic catarrh, even where cough very severe this symptom commonly entirely wanting.

And when does occur is in general only consequence of severe fits of cough.

But here besides being aggravated from coughing constantly exists.

Is not indeed so much confined to any one spot as to give evidence of inflammation or suppuration there.

But from whole middle region of breast extended particularly to left side.

Such generally diffused pain particularly occurs in one species of [illegible]

And indeed in some measure [serves] to distinguish it from others.

For here may observe that proper treatment of disease requires distinction into species.

And as shall afterwards more fully endeavour to show in practical lectures three species

These distinguished by appellation of ulcerous catarrhal & tuberculous.

In first pain fixed to particular part

In latter no pain

While catarrhal with diffused pain or rather general soreness of breast.

But besides this distinguished also by state of expectoration.

In ulcerous at times at least [large] & evidently purulent discharge.

In tuberculous for most part dry cough or at least very little expectoration.

Hence then if any Phthisis in present instance no doubt as to being catarrh

And from circumstances already mentioned must own am apprehensive that this is the case.

Nor can I observe any circumstance in complaint that can be considered as objection to it.

Affection indeed seems to have begun under different form.

That viz of Rheumatism.

And this, as is indeed in general the case consequences of an obvious cause.

Exposure viz to action of cold when much heated.

For when consider that this by much most common cause, no reason to imagine that fatigue to which subjected operated in any other way than as heating body.

But after continuation of Rheumatic for few weeks was succeeded by pneumonic affection.

Although symptoms represented as from beginning very much same yet have little doubt that at first under form of mere catarrh.

Now however from all circumstances taken together inclined to think that if has not already degenerated into Phthisis strong reason to presume that on verge of it.

In this situation Prognosis cannot be very favourable.

For if conjectures well founded from mere name of disease most practitioners disposed to pronounce it fatal.

Must own however cannot look upon every instance even where phthisis the best characterised as incurable.

And of all species recovery most frequent from that to which suppose present patient subjected

Is also farther in favour that [disease] has not yet made any very great progress.

No symptoms have occurred of very threatening or alarming nature.

Besides this consider period of life also as in his favour.

For in early age constitution [unquestionably] best able to weather diseases.

And has not yet arrived at period when inflammatory affections apt to [rise] to greatest height.

Hence then do not consider him as without chance of recovery.

At same time no instance of Phthisis in which can be surprised at fatal termination.

And this most probable conclusion of present case.

Yet at least prospect that shall not soon happen.

And during that period from circumstances mentioned have greater reason to entertain hopes from remedies employed.

In catarrhal Phthisis of which have alleged that consider this case as instance suppose purulent separation not from any abscess or tubercule but from inflamed internal surface.

Here suppose pus yielded in same manner as from inflamed state of cutaneous vessels induced by blister followed by application of issue ointment or like.

Such a state then extended to greater or lesser degree is morbid condition to be removed.

Hence in this species of phthisis intentions of cure different from what are in others.

State now mentioned particularly supported by impetus of circulation at lungs.

Becomes therefore principal objective in cure to diminish this impetus.

And several measures by which as giving determination from lungs this may be in some degree affected.

But in most instances becomes also necessary to diminish general impetus.

By these means cause may be so far counteracted that natural condition of superficial vessels from which discharge afforded may be restored by operation of system itself.

But where these ineffective attempts to cure may be made by endeavouring to strengthen tone.

From these general indications will better understand practices already [employed] & which hereafter in view in this case.

Of measures therefore already taken come next to offer few remarks.

Here will observe that mode of cure principally employed with this patient a course of Emetics.

To these the rather led as hoped to derive benefit from them whether disease as suspected was really Phthisis or only catarrhal.

On either supposition expected that might be serviceable as unloading lungs.

Expected that in this way should at least remove immediate cause of dyspnoea.

For can be no doubt that expectoration more immediately promoted by action of vomiting than by any other means

But besides thus affording temporary relief, expected still more as altering state of separation at surface of lungs.

For unquestionably an effect of emetics that give very powerful determination to surface.

This an effect both from nausea which excites & from action of vomit after induced.

And perhaps few means more powerful as diminishing impetus at lungs than determination to surface.

And when by operation of emetic, [circulation] through superficial vessels renewed, will frequently continue, till occurrence of some cause again altering [distribution].

Accordingly from repetition of emetics & proper intervals have in such cases I think seen very considerable advantage.

Hoped therefore that might have similar effect in present instance.

And from consequences of operation have I think reason to believe that [expectation] not altogether disappointed.

Obvious operation at least such as could have wished

For without distressing patient, both had effect of producing free & brisk vomiting.

And consequence was that both cough & breathing much relieved.

Whether therefore had effect of producing determination from lungs or not had at least reason to conclude that had removed, cause of these [symptoms]

But when consider that with this alleviation expectoration also diminished gives presumption of latter effect.

Here however would be improper to ascribe alleviation entirely to emetics.

For besides these another medicine also employed.

A mucilage mixture viz with addition of a proportion of a sedative.

This however rather meant with intention of not appearing to patient & mother to be inactive than with view of any material benefit

At least expected nothing from it as tending to radical cure of disease

But while engaged attention of patient imagined also that might be of some benefit as diminishing frequency of cough.

Particularly in as far as depended on irritation at fauces.

Here vinegar added to mixture was meant only with view of giving [agreeable] acid taste.

While hysop water with no other intention than to give form.

From mucilage expected that power of irritating causes might be diminished, in consequence of lubricating fauces.

And imagine that opium under form of Tincture Thebaic might in some degree take off tendency to inordinate action.

Respecting operation of opium indeed different opinions entertained.

Yet no one who has in least degree attended to effects in practice can deny that most powerful means of allaying inordinate action.

And therefore in sense in which term sedative taken by every author, of any note is most powerful one.

Upon these articles then have reason to look for some effect.

And probable that mixture some share in producing alleviation of cough.

With this opinion, in situation in which found patient at succeeding report, thought repetition of emetic at that time unnecessary.

Resolved therefore to intermit use for short interval.

And to continue patient with [mixture] alone, at same time directing to diet & medicine which might best [correspond] in cure.

Under this course, for some time affection seemed to be much alleviated.

But on such favourable appearance, where suspicion of Phthisis can by no means put dependence.

And accordingly at last report some of symptoms again very considerably aggravated.

Were attended even with circumstances rather more alarming than formerly.

Frequent returns viz of shivering fits which but too often prelude of hectic fever, & other hectic symptoms.

In this situation have again had recourse to the Emetic.

And if from repetition any prospect of success shall still reckon it advisable to persist in course already begun

If however urgency of cough with copious expectoration, shall reckon it necessary to have recourse to blister.

And with view of protracted good effects to be obtained shall order drain to be supported under form of issue.

In such case also as present may I think expect good effects from use of refrigerants.

And with this intention, may here make trial of remedy of late highly extolled & I think very useful in such instances of Phthisis viz Lemon juice.

Or may employ with same intention, nitre either in powder or solution.

There are also circumstances in case from which may be led to hope for advantage from Peruvian Bark.

But if necessary to have recourse to these measures shall afterwards more fully explain intention in view.