DEP/DUA/1/32/13 (Normalised version)

Alexander Stuart

1783

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Alexander Stuart. June 12^th 1783.

In history of this patients affection but few symptoms mentioned.

And these evidently indicate a catarrhal affection.

An affection to which he has been subjected for many years.

And which probably not a little aggravated by profession which he follows that viz of flax dresser¹.

His affection we are told both now & formerly under form of cough & dyspnoea.

These however by no means exactly [proportionate] to each other.

Rather indeed observed to alternate.

For formerly much more subjected to Dyspnoea with less cough.

Whereas at present again when came under our care, cough severe dyspnoea less considerable.

But under whatever form affection always worst during winter.

A circumstance almost constantly happens with regard to such catarrhal affections.

And in all probability proceeding from want of due circulation on surface in consequence of constriction.

Accordingly by warm & even temperate or steady climate almost universally removed.

But besides season have already hinted that in case of present patient something also dependant on occupation.

From trade of flax dresser air which he breathes must contain large quantity of dust.

Not wonderful that such extraneous matters should often give obstruction to passage into air vesicles.

And accordingly with this profuse dyspnoea a very frequent complaint.

Nor is it at all surprising that dyspnoea thus induced should occur more readily in winter than summer

For in former case increased secretion of viscid mucus to which more readily attached.

This then idea as to nature of affection to which present patient subjected.

And in my opinion very little room for doubt with respect to it.

Here indeed as in every case where cough to any considerable degree some grounds at least for being apprehensive of Phthisis.

For while no disease equally dangerous more common in this country is also an affection appearing in different forms.

And has often even made very considerable progress before suspicion.

If however any expectation of being able to combat it must attempt cure at commencement.

In present case however no grounds for suspecting Phthisis.

Age of patient, state of [pulse] & duration of disease all strong objections to it.

May indeed [be] held as a circumstance somewhat suspicious that immediately before came under care rapid emaciation took place

This it must be allowed always alarming.

Particularly when conjoined also with rapid loss of strength.

Had lately occasion to treat a case of Phthisis terminating fatally [where] almost no other symptoms.

Or at least where disease with these symptoms alone had made very considerable progress before either cough dyspnoea hectic paroxysms or even quickness of pulse.

Such cases however very rare.

And in that instance both age, habit & family of patient gave grounds to suspect Phthisis

Here therefore notwithstanding cough, occurrence of Phthisis if had taken place would have been still more extraordinary.

And that no tendency of this kind now beyond all doubt established by termination.

For in no long time after came under our care terminated favourably.

And for present at least patient free from his affection.

From this circumstance observations respecting prognosis may be considered as [imprudent].

May only remark that from all circumstances, age of patient state of complaint season of year & like had hopes of favourable termination.

At same time did not expect that would have taken place so suddenly.

And may also add that am doubtful how far will be found permanent.

Probable indeed that unless from accidental or imprudent exposure to cold will continue free from it for summer season.

But have reason to dread recurrence during succeeding winter.

Prevention of future returns however a matter but little connected with cure of affection when present.

And much more to be brought about by regimen than medicine.

And hence very much dependent on conduct of patient himself.

Was therefore entirely with latter intention, removal of affection viz that practices here directed.

How far conducive to this end is next our business to inquire.

Here you will observe began practice by directing for our patient the use of an Emetic.

From this need hardly observe that principal intent was the unloading breast

For no doubt that emetic the most immediate, perhaps may also add most powerful expectorant with which yet acquainted.

In catarrhal affections also often of use by giving determination to surface

For even, by [momentarily] affecting in this way, from action of vomiting, permanent circulation [there] often restored.

How far on these principles operation of emetic here to be entirely expected will not pretend to say.

But at least probable, that were principal source of change for better, which took place.

And at least certain that while emetic attended with all obvious operation that could have wished, affection at succeeding report found to be very much relieved.

This however I am inclined to think in part also to be attributed to pills

For at first report, was you will observe directed to use of Pill Scillitica.

To these pills, while squills give name, are also to be considered as most active article.

Gum Ammoniacum, Cardamom seeds & Extract of Liquor indeed enter [composition] in still larger proportions.

But none of these articles of any great activity.

Particularly in small quantity to which can here be taken.

And while cardamom seeds used merely as corrigents, Gum Ammoniacum as well as Extract of Liquor may be considered as intended merely to give form.

Active powers therefore to be viewed as entirely dependent on Squills.

And in this mode of exhibiting can I think be no doubt that Squills very powerful.

May seem somewhat singular that Squill pills, which have long had place in Pharmacopoeia² of almost every College were rejected from last edition of that of Edinburgh³.

This however did not proceed from any idea of want of efficacy.

But because squills a medicine which when in state of pills apt to suffer from being kept.

Was therefore thought that by want of formula, [Physicians] more [illegible] of having them freshly made.

And that also more latitude in [varying] preparation of squills according to circumstances of case.

But these reasons by no means sufficient for rejection.

For Squills pills a medicine so much in demand that for convenience must be kept ready made.

And so much [prescribed] by patients for themselves, unacquainted with composition that some fixed standard must be followed.

Accordingly although no place in last Pharmacopoeia were always kept in shops as prepared by edition of 1756.

And may farther add that fixed standard need in no degree prevent any practitioner from varying preparation as he pleases in extemporizing prescription.

Hence then College in present edition of Pharmacopoeia have I think with propriety restored formula for Squill pills.

According to this formula near a grain of powder of Squills in every five of mass.

And this quantity you will observe directed for our patient twice a day.

Squills taken to this extent have very generally effect of increasing secretion by kidney.

With our patient such a change not indeed at first obvious.

But from short continuation of use not only augmentation of urine, but also opened belly.

And can be little doubt that from both derived benefit.

For my own part, [however] am fully persuaded, that active parts of squills, taken into circulation act on [ excreter] by lungs as well as kidney.

And that therefore justly entitled to characterisation of expectorant.

On this footing then would explain in part at least, that benefit [which] seemed to derive from them.

For in no long time dismissed free from his affection.

And have little doubt that was in great measure to be attributed to remedy employed.

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Explanatory notes:

1) A worker who separated the coarse part of flax or hemp with a hackle in preparation for the spinner.

2) An official publication containing a list of medicinal drugs with their effects and directions for their use. The Royal College of Physicians of Edinburgh's Pharmacopoeia was first published in 1699.

3) Royal College of Physicians of Edinburgh.