DEP/DUA/1/34/14 (Normalised version)

James Lundie

1784

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James Lundie February 6^th 1784

Case of this patient somewhat doubtful.

Affection chiefly marked by severe cough & pain of breast.

These however well known to be symptoms of different affections.

And particularly to be chief characteristics of both Catarrh & Phthisis pulmonalis.

In pain of breast however which here takes place a peculiar occurrence.

For according to his description [consists] rather in sense of stricture than anything else.

In this however nothing peculiar characterising either of these or any other affection.

Nor can we consider it as in any respect singular that during cough pain not felt

For may reasonably suppose that by agitation to which patient subjected this sensation for the time not attended to.

But when consider that sensation most strong preceding the cough may from thence conclude that from this irritation the cough immediately arises

And from this circumstance joined to want of expectoration am I own inclined to fear that affection more important & dangerous than catarrh.

Is indeed true that have not here all those symptoms which usually occur in Phthisis.

Pulse in particular not affected.

For while of [middling] strength in point of Number does not exceed 80.

Whereas in Phthisis patients even at early stages of the disease seldom under 100.

Besides this other remarkable symptoms of Phthisis also wanting.

Patient not affected with shivering with hot fits or with flushings

No night sweats or other hectic symptoms.

Although however all these wanting must still remark that Phthisis a very insidious disease

And that often [subsists] for a long time & has made very considerable progress before [known] to exist.

And when this duly considered from urgency of cough & pain of breast.

But too much grounds for suspecting that affection.

Of this affection also some suspicion from origin of disease

For began we are told under a form somewhat different.

Was first affected with severe headache succeeded by profuse sweating

Probably depending on some slight febrile accession.

Soon after this however returned to work.

And from that period dates commencement of cough.

Probably the consequence of exposure to cold air when surface in very sensible state.

A cause frequently observed to induce not only catarrhal affections but more serious pectoral complaints such for example as Pleurisy Peripneumonia & the like.

Here then reason to presume that pain to which has been so long subjected may be somewhat of similar nature

Or at least that depends on fixed & local cause.

From continuation as well as fixed seat of pain another conclusion also may be drawn

May infer that if Phthisis exists is neither of tuberculous nor catarrhal kind.

For in both these affections not in general at least limited to any particular spot of lungs.

But extended over many parts.

Here on contrary may presume that suppuration rather under form of large vomica.

And that disease of that kind which would term the ulcerous Phthisis.

From state of expectoration however may conclude that this vomica not yet ruptured.

And from this probably to account for absence of many of the Phthisis symptoms.

But if conjecture well founded a [rupture] may soon be looked for

And in that case, farther evidence of nature of disease will be afforded by purulent expectoration.

If this series of symptoms shall occur prognosis will be as little doubtful as disease.

And at least great reason to dread that patient will fall victim to the affection.

Is indeed true, that in some instances of Phthisis recovery does take place.

And this more the case in instances of ulcerous than of tuberculous consumption.

At same time however even from slightest, recovery but rare.

And therefore I own, under great apprehension that notwithstanding all we shall be able to do, patient will fall victim to affection.

Principle chance of recovery is, that our idea respecting nature of disease a mistaken one.

And that both cough & pain to be accounted for in some other manner than from abscess.

On this supposition however & on idea of Phthisis, treatment has hitherto principally proceeded.

And although must acknowledge that am acquainted with no practices, from which much success to be expected, yet different measures which may be tried with at least some chance of success.

Here, on supposition of abscess, prospect of cure in some degree depends on purulent matter already collected being discharged.

And after discharge has taken place on ulcer being healed by means of adhesive inflammation.

With measures suited to these intentions however must be conjoined, on many occasions at least, practices directed [against] accidental occurrence.

Particularly with view of obviating unquestionable symptoms & of counteracting effects of purulent absorption.

These different intentions, will explain practices to which as will observe from register¹ have had recourse with this patient.

Began you will observe by directing for him the use of an Emetic.

From concussion thus induced, on supposition of vomica, had reason to think that rupture & free discharge might be induced.

And had also some grounds for hoping that by derivation to surface might, somewhat relieve breast.

Accordingly though no purulent [discharge] was consequence of use, yet cough somewhat alleviated.

Still however continued to be very distressing to him.

And as one of most urgent symptoms seemed to require some immediate means of alleviation.

Was with this intention, that had recourse to Mucilage mixture combined with Cicuta

Former well known in many cases to have very considerable influence as lubricating fauces & thus taking off irritation.

While latter again, probably operates as counteracting affects of irritation

That is by narcotic power renders influence of irritation less considerable.

Probably on this principle that are to explain operation in cases of Chin cough.

And since introduced against that complaint has been used in many other cases of severe cough with considerable [advantage]

While this however employed as means of alleviating cough had recourse to another remedy for obviating costiveness.

Was with this intention, you will readily suppose that had recourse to powder of Cream of Tartar & Sulphur.

From this were not disappointed in obtaining operation wished for that viz of keeping belly gently open.

But cannot say so much of the affect of mixture with Cicuta

When first began use indeed [thought] that pain of breast somewhat alleviated.

A consequence, if at all to be attributed to it, probably resulting from sedative affects

But had not the same influence on cough

For this continued with equal severity as before.

And without alleviation of cough, thought that had affect of exciting vomiting.

At same time belly now so open that nothing aiding discharge seemed for present at least to be necessary.

On these accounts gave up use of both medicines

And had recourse to practices directed with other intentions.

Now found that much affected with difficulty of breathing.

Which while may be supposed to have arisen from increased size of vomica, may also have in part at least proceeded from some degree of inflammation surrounding it.

As counteracting this had recourse to blister

And with view of supporting [determination] from breast directed that discharge should be continued under form of issue.

But besides this had now farther evidence of what seemed to me to be affects of purulent absorption.

For though frequency of cough diminished yet strength very much impaired.

Considering this as affect of purulent absorption had recourse to use of Gum Myrrh.

An article which of late has with some practitioners had considerable [illegible] in Phthisis

And of which, I own, am from my own experience inclined to entertain very favourable opinion.

For most particular account of use may refer you to a treatise lately published by Dr Simmons on Consumption².

Among those supposing it useful, operation indeed has been differently explained.

For my own part am inclined to look upon it as chiefly useful where vomica ruptured and expectoration of purulent matter, has taken place.

And am disposed to explain affects from influence as promoting adhesive inflammation.

In same manner as has long been esteemed useful when applied externally to ulcers of different kinds, under form of Tincture or like.

A very different opinion however is [contended] for by Dr Simmons.

He again considers influence as depending on antiseptic power.

Or rather on affect, which has, as counteracting purulent matter absorbed.

And was I own, on this ground, that had here recourse to employment.

If patient really subjected to the disease we suspect & if persists in use for sufficient length of time shall from thence at least be able to determine how far Dr Simmons opinion well founded.

In some cases, from employment, inconvenience arises as tending to produce looseness.

Hitherto however with present patient has had no influence in this way.

But cannot say that either from blister, or powders, much benefit has yet been derived.

This however to be expected only, from trial for some length of time.

And if no circumstances occur [leading] to alter opinion of disease, or indicating other practices shall wish to persist in use both of issue & Gum Myrrh.

Or perhaps even discontinue former, to go on with latter alone.

And if after fair trial shall found unsuccessful future measures must be accommodated to situation in which shall then find patient.

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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) Samuel Foart Simmons, Practical observations on the treatment of consumptions (1780).