DEP/DUA/1/32/17 (Normalised version)

William Davidson

1783

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William Davidson June 18^th 1783.

With regard to affection to which this patient subjected must own am somewhat at a loss.

Have not in former practice met with many instances which could be considered as corresponding to present.

Perhaps however would have thought disease less singular if proper opportunity had been afforded of examining it.

But never happened that patient attacked with any of fits while we saw him at the Dispensary.

According however to account given us disease consisted principally in an affection of Respiration.

And this return in fits particularly frequent during the night.

These however always but of short continuation

And while attacked without any manifest cause so also spontaneously terminated.

If this description perfectly accurate disease of present patient does not exactly correspond to any of affections of Respiration or order of [illegible] as have been called, with which am acquainted.

But in its nature seems to [appearance] most nearly to fits of Asthma.

And perhaps may view it as being a peculiar modification of that disease.

But whether of this kind, or not, can be little doubt that to be looked upon as being principally a nervous affection.

And as depending on an inordinate action induced in some of the organs concerned in function of Respiration.

Of this abundant evidence from transitory nature as well as from frequent recurrence.

And if farther proof wanting afforded in evident connection with other inordinate action

Particularly dry cough & singultus with which this patient is at times also affected.

While these we are told never attended either with expectoration or vomiting.

A circumstance serving to show that these inordinate actions of diaphragm more effect of peculiar irritability than of any local irritation

Not impossible that difficulty of [respiration] or Asthma affection itself, which here occurs, also immediately dependant on an inordinate action of diaphragm.

For on all hands allowed that diaphragm an organ principally concerned in that function.

But at same time many other parts also, from affect of which, such difficult fits of respiration as, here take place, may be supposed to proceed.

Thus may be induced from [constriction] either at extreme branches of bronchea or at larynx.

Of situation some judgement might be formed both from appearance during fits & likewise from feelings of patient.

But as had never opportunity of seeing fits & as infant totally incapable of describing feelings would be improper to offer any conjecture on the subject.

Can only therefore state it as my opinion, that this affection of respiration consequence of inordinate action in some of respiratory organs.

Here however to be observed, that although this the principle, yet not only affection to which patient subjected.

Besides these fits, is subjected also to some degree of constant dyspnoea.

And this we are told during whole course of complaint attended with hoarseness.

Not improbable therefore that in case of these, are to look for origin of other [affection].

And that the inordinate action giving alarming fits, depends on peculiar state at Larynx giving hoarseness.

But besides these, still another circumstance also mentioned in history of this case.

And not improbable that with this also, different parts of affection already mentioned have connection.

Eruption viz of red pustules on different parts of body.

That with cutaneous eruption asthmatic affections, often connected undeniable.

Every one much conversed in treatment must have met with many instances of this kind.

Nothing even more common than to observe fits of difficult respiration from sudden case of Psora.

And instances upon record where Psora & Asthma have alternated with each other.

Still more common & less surprising to observe connection with other eruptions.

Accordingly with great propriety that among other species of Asthma Mr Sauvages has enumerated as one the Exanthem

While however on this ground suggest it at least as possible circumstance that such connection may take place yet think it more probable that [altogether] unconnected.

For in first place this tendency to eruption of much older date than other affection.

Had always prevailed to greater or lesser degree.

Had never been observed either alternating with asthmatic affection or increasing in proportion to its severity.

And as far as I could observe was nothing different from what every day to be met with in infants of that age who in other respects enjoy best health.

Here then inclined to look upon this as a part of affection free from danger & even hardly deserving attention.

But with regard to prognosis in [other] parts of complaint was formerly & still am more doubtful.

Would be, by no means surprised, if from fit of difficult respiration, suddenly arising to great height should be even unexpectedly cut off.

And as long as subjected to frequent returns of it cannot consider him as free from danger.

At same time after continuation which has now had this less to be apprehended than at first.

No reason for suspecting that future fits will be more violent than what have already passed.

Grounds even for hoping that may be slighter.

At least this observed to be case with a disease in some [respects] [illegible] Croup

Very generally first attack most severe

And but rarely that child falls victim to it who survives first fit.

Upon whole then hopes of this case rather favourable than otherwise.

And for these hopes better foundation when consider relief patient has had since came under care.

At same time after long continuation which has already had very speedy recovery hardly to be looked for.

And from reports inserted in Register¹ have no reason to flatter ourselves that progress to recovery uniform or [unintrusive].

Aggravation of affection however probably to be considered as consequence of very unfavourable weather which has of late taken place.

And while distressing to invalids in general may expect that will be particularly so to those labouring under affection of Respiration.

Although patient had already arrived at 17^th year of age yet hitherto no appearance of menstrual discharge.

And although period of commencement not exactly fixed yet at a medium is before time of life now mentioned.

Nosologies² indeed have differed much [where] want of appearance of menses at proper period or even obstruction after have once appeared strictly to be considered as disease or not.

Yet universally allowed that from both one & other cause an almost infinite diversity of symptoms of most anomalous & troublesome nature may arise.

While however want of menses is often observed as cause of many diseases is also frequently remarked as consequence of [other]

Here then a question of some importance to determine whether in present case are to consider it as cause or consequence of other affection

For probable at least that unless from one or other of these circumstances would have already appeared

Here must observe that of the two inclined rather to latter opinion.

Is indeed true that in this case no disease seems to have occurred till about time that menstrual flux might have been expected.

But on other hand to be observed that affection did not begin with those appearances which usually indicate diseases from want of menses.

And to be remarked that although in course, symptoms much diversified yet at commencement of all cases very much the same.

Very general if not universal indication of partial congestion in uterine vessels occurring at regular periods.

And not unfrequently of general plethora as succeeding such partial congestion.

To these might also add pains in region of uterus very generally occurring to certain degree & in some instances, with even great severity.

At present from exhausted appearance of patient without any other cause of obstruction could as little expect [illegible] as in last stage of Phthisis.

And as far as we can learn this condition of habit has existed as early as any of obvious symptoms.

That is took place as soon as menstrual flux could have been expected.

Farther to be observed that although obvious ulceration but for about 18 months yet reason to presume that disease much earlier in habit

And that really existed prior to usual period of appearance of menses.

From all these considerations then am inclined to consider scrofula as being here original disease

And to this from exhaustion of habit would refer want of menses at period of life when otherwise might have been expected.

As well indeed as extenuated habitual tendency to looseness, quickness of pulse & other symptoms, indicating hectic state.

From this view of nature of disease cannot be disposed to give very favourable prognosis.

And from influence which it has had on the habit as indicated by last mentioned symptom reason even for being afraid

Well known that scrofula sores even when entirely situated in gland or soft parts without any affection of bones are always obstinate.

In present case, from situation, although no certainty, yet reason to apprehend that this may be the case

And while disease well known obstinately to resist artificial remedies patient has already passed that period of life at which natural cure principally occurs.

But if from these particular reason to fear obstinacy so other symptoms induced give grounds to apprehend fatal tendency.

For after absorption from scrofula sores gives rise to hectic fever whether these sores seated in lungs or elsewhere are never without danger.

Upon whole then reckon it most probable that this patient will at length fall victim to affection.

Yet on other hand recovery even from present situation cannot be thought extraordinary.

And of this greater prospect from change for better which seems to have taken place since patient came under our care

How far however this has in any degree been consequence of medicine which patient has taken since that time cannot with confidence propose to say.

Before this patient came under our care had employed a practice from which perhaps more frequently than any other material benefit obtained in Scrofula.

That is cold bathing conjoined with the drinking of Sea water.

These practices however although frequently beneficial can by no means be represented as successful in every case

Nor can they be considered as always admissible.

Former, perhaps both, particulars to be avoided where Scrofula affects lungs.

And in every case propriety of prosecuting them to be determined by [affect]

How far in the instance before us, proper opportunity for forming such a judgement was afforded by trial made cannot pretend to say.

But was at least opinion of patient that all her³ affections aggravated during use.

And although some grounds perhaps for conjecture that opinion of effects proceeded from aversion to it, yet in this situation thought it advisable to try another practice at least for some time.

On commencement of treatment of this case began with use of extract of Aconite

Was here exhibited as conjoined with Soap & Extract of Gentian intended with no other view, than to give proper form.

Of principles on which suppose the Aconite to operate, or of grounds on which suppose that may be useful in Scrofula need not now make any observations.

Sentiments on this subject have already had opportunity of stating to you when treated of case of Donald Robertson.

Here only may observe that in each pill extract introduced to extent of grain s.

And of these one directed to be taken every morning & evening.

To this extent however seemed to be more than patient could easily bear.

Or at least she herself disposed to ascribe to it both gripes & increase of looseness.

In this situation even on presumption of its being cause of these symptoms thought it advisable to diminish dose.

But after finding that single pill borne with ease again ordered two in the day.

And to this the rather led as sores during use of her medicine had put on more favourable appearance.

While this continued to be the case shall be desired not only of persisting in use but even of pushing it to greater extent than before.

And if under this course patient gets rid of affection will I own consider it as strong instance of efficacy of the medicine.

If proves ineffective in place of using any farther measures at this place is my intention again to recommend to her the use of Sea Bathing.

And from greater warmth of season may now perhaps be able to bear it with less inconvenience than formerly.

And was with view to answering this intention that had recourse to Valerian.

Of this article sensible qualities strong & peculiar.

And whatever be nature of impression which gives to nerves, that has powerful influence as allaying inordinate motions, particularly those arising from mobility abundantly confirmed by experience.

Do not indeed pretend that in own practice have always succeeded with it.

And that too even when given in very large doses.

This however do not consider as sufficient foundation for disregarding it as medicine.

For in other instances have found it I think, attended with manifest good consequences.

And have particularly observed benefits from it in hysterical or nervous headaches.

Here therefore wished to give it by itself fair & full trial

And with this view begun by ordering it to patient to extent of Jii [bis] indies.

This quantity as much as imagine stomach of patient at first able to bear.

Was however intention, particularly if any encouragement to persist in use, to increase both quantity of dose, & frequency of repetition.

Or at any rate to persist regularly in employment if not [restricted] by other [measures].

For space of week was employed without any inconvenience.

But at same time without any benefit.

And urgency of headache in particular such that gave very great distress to patient.

In this situation thought it more advisable to have recourse to some medicine with a view of mitigation of symptoms than to trust to increase of Valerian.

For another week then directed Valerian in former quantity, & with a view to radical cure.

While at same time directed for patient a mixture of Volatile Elixir of Guaiacum with Laudanum [Liquid].

In this formula, combined will [observe] what hold to be very active stimulant with most powerful sedative of Materia Medica.

From this combination was by no means intention to obtain at same time both stimulating & sedative effects

For that hold to be impossible.

But have already remarked that both from stimulating & sedative impressions Hysteria fits anticipated & Hysteria symptoms counteracted.

And look upon combination of stimulant & sedative as not so much destroying affect of each other as altering & modifying impression.

Accordingly find that while opium combined with cantharides, though pain lessened yet vesicles excited.

And that opium again combined with Volatile Alkali, in some habits whereby itself constantly producing tendency to delirium has affect of inducing sleep, without such consequences.

Upon whole then consider these [contents] as altering nature of impression yet still giving strong or powerful impressions

And from practice in some cases have been disposed to think that from such combination impression more to be obtained than either from stimulant or sedative by itself.

Was here therefore desirous of putting opinion to test of farther trial.

Effect to be wished for was from immediate action on nerves of stomach

Directed exhibition therefore on sugar rather than any menstruum.

As thus conveyed into system in most concentrated & active state.

While at same time free from danger of [precipitation] of Guaiacum from menstruum.

What has been effect however of this prescription have not learned

And as patient has so long deserted us not hardly talk of other plans should present be found ineffective.

May only in general observe that conceive this to be case in which something may be expected from external application of Aether. Wards Volatile Essence or like

And from internal use of Tonics as Peruvian Bark. Cinchona [illegible] or Salix alb.

And if resumes attendance to some of these shall probably have recourse

Pain however & uneasiness in latter way depend very much on [illegible] of epispastic ointment employed.

And from some equal effect with much less distress to patient than from others.

With same proportion of cantharides will act much more mildly when reduced to very fine powder.

But have still milder & with many habits no less effective ointment in what formed by extracting active parts of cantharides by boiling.

And in this manner Unguent Epispastic mitius of Edinburgh Pharmacopoeia⁴ is prepared.

Where by this means discharge can be supported have it at least in more constant & uniform manner than by blister repeated [at] some intervals.

And [considering] benefit which patient at first received should have rather wished for it in present case.

But as in this disappointed though it more advisable for short time to try some other measures than have immediate recourse to second blister.

Was then with view of relieving symptoms by promoting expectoration that has recourse to Squill pills.

These indeed considered as in some measures adverse to this affection from tendency which have to increase secretion.

But this more than counterbalanced by their promoting excretion.

And from fluid being discharged before acquires viscid form absorption of [these] parts, cough much less distressing.

Is chiefly on these principles that would account for benefit from Squill pills in such affections.

And in many cases have seen patient derive very great advantage from use

As far however as trials yet go this has not been the case

For at last report found that cough of patient rather aggravated as otherwise

From this however was not disposed immediately to intermit pills.

On contrary supposing aggravation from some accidental cause & that more to be expected from squills if given to greater extent ordered dose to be doubled.

Unless however from this course derives very great benefit shall not think of trusting to it alone.

But shall either conjoin it with repetition of blisters, or endeavour either by means formerly employed or other measures to support permanent discharge.

And am in hopes that under this course affection will be alleviated if not removed.

But if other measures necessary for promoting expectoration shall probably employ emetic.

Or if blister in no degree diminishes discharge may have recourse to astringent.

In these particulars however must be directed by future occurrences.

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Explanatory notes:

1) References are made throughout the case notes to a dispensary patient register. However, no evidence has been found that this register survives.

2) 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.

3) At this point in the case note the gender of the patient changes to female, suggesting that two different patient records have accidentally been combined by the author.

4) 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.