DEP/DUA/1/30/12 (Normalised version)

Francis Cruickshank

1782

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November 30^th 1782

Francis Cruikshank.

Disease to which this patient subjected an intermittent of Quartan type an affection rather uncommon if original growth of this country.

For intermittent of any kind, no very common affection in Edinburgh.

And under that modification which has name of Quartan much more rare than either Tertian or Quotidian.

But as informed from history her disease product of a county where intermittents & even Quartan ones of most common occurrences.

That viz of Kent.

A county which as abounding with marshes, also remarkable for intermittents.

And is as thus imported only that have ever observed them here in my own practice.

In circumstances of present quartan as far as learn from history of case nothing peculiar.

Unless perhaps be considered as such that hot fits not succeeded by sweating.

This however in intermittents of every form by no means uncommon.

And is particularly so when these of long standing.

With our patient however you will observe had already subsisted for space of 18 months.

Accordingly not surprising that should already have induced very great weakness general exhaustion of system & other marks of diseased habit.

During continuation, for such a length of time, very common for it, not only to show different anomalous appearances but to pass through every type which intermittents commonly at least observed to put on.

Perhaps therefore rather surprising that did not now exist with more uncommon appearance & that had not already reduced constitution to still greater state of weakness & exhaustion.

This indeed in some degree to be explained when consider that during period which has been mentioned did not continue without interruption.

Had at one period from use of proper remedies been apparently completely removed.

But during course of march to which subjected from occupation of husband that viz of soldier again returned.

This also no uncommon accident with intermittents

And that too even when no particular cause can be assigned for it.

Probably however although not obvious, that often connected with changes in state of weather.

The rather to be inferred as in many instances evidently see this to be case.

Thus very frequent occurrence for relapses to take place from prevalence of easterly winds particularly with hazy weather.

When thus easily renewed then, cannot seem very extraordinary if brought back by those causes to which here attributed.

Action viz of Cold & fatigue.

Have no doubt that either may have had this effect.

At same time must be admitted that exercise a tendency to forward cure & prevent return.

While again disease often checked by cold as well as by warm weather

And accordingly much more frequent during vernal & autumn seasons, than in summer or winter.

Hence then not impossible that may have proceeded from some other cause connected with march escaping observation.

Such for example as peculiarly moist atmosphere prevailing easterly winds, or even exhalation of marshes.

But whatever cause, returned here under same

A circumstance if not altering mode of treatment at least in some degree affecting prognosis.

In intermittents in general indeed prognosis may for most part be favourable.

For now acquainted with remedies from proper administration of which, can in by much greater number of instances accomplish such cures.

And even when these neglected intermittents notwithstanding fatalities in warmer climates, & other seasons yet rarely of themselves mortal here.

Sometimes however, without proving fatal to patient yet continue with considerable obstinacy.

Are particularly apt to do so, when originate in those situations where intermittents most common.

And although hold, that in all various types, nothing essentially different in nature & that merely modifications of same affection yet no doubt that some of these more obstinate than others.

Of all types quartan well known to resist means of cure with great obstinacy.

From these two circumstances then, situation in which affection originates, & type which had from beginning, had reason to be apprehended that present disease could not soon be removed.

And this the rather, as from having already subsisted for very considerable length of time, as it were more rooted in [constitution]

For no doubt, that unless from change of season or some other circumstance more easily removed at commencement than any other time

Here however although disease of long continuation yet could hardly be said that had resisted any powerful modes of cure

For excepting small quantity of Bark does not appear than any practices tried.

From this therefore at least greater reason to hope, that from proper administration of this most useful remedy successful cure might be accomplished.

Into principles on which Peruvian Bark operates in intermittents, any inquiry would in some degree be foreign to [business] in this place.

And indeed after all that has been said & written on subject nothing in my opinion offered that can be considered as by any means satisfactory.

Whatever mode of operation is yet an undeniable fact, that good Bark properly exhibited in most instances furnishes us with successful mode of cure.

But in accomplishing cure both these circumstances choice of Bark & mode of exhibiting of great consequence in practice.

With respect to former indeed, the Physician in general does very little.

For contenting himself with prescribing bark leaves choice entirely to Apothecary.

By this means however can be no doubt that efficacy of prescription often disappointing.

Choice therefore a subject well meriting attention.

And this the rather to be mentioned as reason to believe, that hitherto practice in general very much in wrong in this particular.

Has long been a practice at Apothecaries hall, in London, from whence the quality of medicine bought, to sort bark according to supposed value.

And have uniformly given preference to what they denominate the quilled bark

That is smallest pieces rolled up in form somewhat resembling quills.

And these unquestionably the advantage of being at least the cleanest Bark

For much more free from [effete] or adhering matters on external surface

From such often altogether impossible to free larger masses.

At same time however cannot be supposed to possess any medical virtue

This circumstance however, desire to have clean bark, has probably misled practitioners in a more important particular.

For now reason to believe that bark in this clean state, less powerful than the other.

At least of this strong presumption from late treatise on the subject by Dr Saunders of London¹.

Has lately published some observations on superior efficacy of Red Peruvian Bark.

A considerable quantity of Peruvian Bark captured in Spanish ship from Lima, in large flat pieces, having coarse appearance & red colour.

This from repeated trials found to be of superior efficacy to what formerly reckoned best.

From several circumstances thinks it probable that this obtained from trunks of old trees.

While again quill bark from smaller branches not arrived at maturity.

But whatever cause of apparent difference, if former of superior efficacy has [ascribed] a matter of great importance in practice.

That he is really in the right as to its superior virtue, cannot pretend to say, from any facts that have fallen under own observations.

But since publication of Dr Saunders observations two circumstances have been mentioned to me

One is that some years ago, a considerable quantity of Bark, in large flat pieces & of red colour was imported into this city, by a Merchant directly from Spain & sold to several surgeon apothecaries here in hands of all whom found to be peculiarly efficacious.

The other is that a druggist in this city, was very famous for bark of remarkable efficacy, who I am informed was always supplied with Bark of this kind.

Happened to have a relation, who was the British Consul at Lisbon, by whose means he was supplied with it from that port in place of receiving it from London

What sent him however as best bark was in large [pieces] of more deep red colour than quill bark.

And indeed somewhat remarkable that in Spain, this Bark, always reckoned best, though Quill most esteemed in England

These circumstances then seem to me to remove any doubt, which may arise from supposition of peculiarity in Bark used by Dr Saunders.

And not only corroborates his observations but also his conjecture as to cause of difference.

That one viz from Trunk other from branches.

And if this really the case should naturally suspect that former most efficacious.

At same time, but fair also to observe that in opinion of some, what called red Peruvian Bark, is product of different tree from Cinchona officinalis.

On this subject therefore, farther observations & inquiry yet wanting.

But what has been now said may at least serve if not to diminish [illegible] of Quill Bark at least to remove prejudice against Bark of coarser appearance in larger masses & of deeper red colour.

In cure of intermittents while much depends on choice of Bark something also to be attributed to mode of administration.

In one particular almost all practitioners agreed, viz that most efficacious in substance.

But while some advise that should be exhibited in considerable quantity immediately before the fit others as strenuously contend, that should thus be exhibited immediately after it.

For my own part have never been able to see peculiar advantage of either.

And of opinion that exhibited with more success & greater ease to patient, when thrown in by small quantities as dose of the ℥p [Jiis] or ℥i, at short intervals during whole intermittent.

By this mode of administration as far as bark really efficacious without any danger of sickness at stomach, vomiting, or other inconvenience to patient may obtain full effects.

Was in this manner that directed for present patient.

With regard to particular kind of bark employed can say nothing as [purchased] in state of powder.

Effects however show that in [power] of quality was not defective.

For after began use had only one fit.

And before taken to extent of ℥ii had obtained at least evident suspension of disease for some time if not complete cure.

Still however after having already suffered one relapse thought it improper to trust to this.

Ordered therefore continuation till ℥ip more should be taken.

By this means not only freed from any [danger] of return but had health also improve in other respects.

This particularly indicated both by remarkable change in appearance for better & by uncommon keenness of appetite.

Might now therefore I apprehend [without] any hazard have dropped medicine.

And was I own more with view of obtaining attendance for another week than with any other intention, that ordered continuation of medicine.

But at end of this period as free from every mark of affection was dismissed.

Here therefore unnecessary to have recourse to any other, than common mode of cure.

And such always entitled to first trial before having recourse to any practices less common or in way of experiment.

When however ordinary practices fail not only proper but necessary to try other means.

And as suspected that a quartan fever already of long continuation, which was product of fenny country, might have resisted power of best bark which could here obtain had in view trial of medicine which have never yet [employed]

One viz still kept a secret in the hands of the preparers with regard to composition of which therefore can say nothing

Medicine to which I allude sold in London under title of infallible tasteless ague drops.

And has of late acquired very high character in [Lincoln] & some other of those counties where [observed] intermittents the most common.

Said even to have succeeded in many cases where Bark has failed.

Although therefore, still what some would, entitle a quack medicine, reckon it entitled to trial.

Of this no one can have any doubt, who consider that bark itself when in hands of Jesuits & sold under title of Pulveris [Palr.] was in same situation.

Have therefore taken care to [provide] shop with some of it.

And not improbable that before close of present session, shall yet have some proper opportunity of [trying] it

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Explanatory notes:

1) William Saunders, Observations on the superior efficacy of the red Peruvian bark, in the cure of fevers (1783).