DEP/DUA/1/36/13 (Normalised version)

Robert Moulray

1784

---

Robert Moulray. December 4^th 1784.

Disease to which this patient subjected by no means distinctly or certainly marked.

At same time but too much reason to apprehend that subjected to a disease no less frequent than dangerous viz Phthisis Pulmonalis.

And this the rather to be dreaded as well known to be a disease in its nature very insidious.

Hence has often made considerable progress even arriving at what may be called last stage before certainty of existence.

In case before us patient subjected to many of those symptoms which most common attendants of this affection.

As such may mention the cough dyspnoea & pain of breast

May mention also as symptoms no less common, the quickness of pulse, shivering fits & colliquative sweats.

For while former symptoms in common to Phthisis & Catarrh, latter again characteristic of hectic fever peculiar to Phthisis.

But although from this collection of symptoms may assert that Phthisis often exists, where less distinctly marked yet here other circumstances to create doubt.

This particularly case with respect to situation of pain.

Is seated you will observe not properly in the breast but at pit of stomach

And there gives sensation of pressure on parts seeming to push them upwards

Hence then some grounds for inferring than an abscess may be formed rather below than above the diaphragm.

Another circumstance giving some doubt is frequent vomiting to which patient subjected.

This indeed it is true not unfrequently does arise from cough.

But here would appear that something farther.

For not only does vomiting ensue on severe fits of coughing, but even constant inclination to it.

In so much that are told nothing retained in stomach for any length of time.

This therefore would argue irritation deep seated if not entirely below lungs.

To these circumstances may be added as another particular giving doubt, state of expectoration & state of tongue.

Cough of this patient dry & bound as is styled.

And no appearance of any discharge having mixture of purulence.

Tongue you will observe of white colour.

But wherever purulent expectoration in any degree takes place well known to put on very different appearance.

Accordingly in Phthisis very generally happens that tongue uncommonly red.

Often from being deprived of natural covering has resemblance to piece of new flesh.

Not unfrequently even in an ulcerated state.

Hence then from this circumstance consider us as having certain evidence that no purulent expectoration.

Or in other words that although vomica exists in lungs is still entire.

And this I own is idea I am inclined to form of the disease.

For none of circumstances mentioned which may not be explained on supposition that there here occurs a large vomica still unburst deep seated in lungs.

And this supposition the more probable as there such abscesses more common than in other neighbouring parts.

This however suggest only as what to me seems most probable conjecture.

But notwithstanding this uncertainty with regard to disease have I own but little concerning prognosis.

And here I think but too much reason to dread that disease will in no long time have fatal conclusion.

For if such vomica exists whether above or below diaphragm equally dangerous.

And symptoms which have already taken place of most alarming nature.

Under colliquative sweats & diarrhoea patient cannot subsist long.

And loss of strength which has already taken place so considerable that do not I own again expect to see him at the Dispensary.

One circumstance indeed which consider as giving him some chance of recovery.

That is the bursting of vomica in such manner as to give opportunity for free discharge of matter.

No doubt that at least better opportunity of recovery when this case than when continues shut & only outlet by absorption.

For on bursting opportunity at least afforded for adhesive inflammation.

But on other hand, bursting in place of leading to recovery may hasten fatal conclusion.

For well known that this often consequence of opening large abscesses.

Particular example in case of Psoas suppuration.

Where before opening, hectic fever but very inconsiderable, has been found rapidly to increase.

Probably consequence of change in state of matter from access of air.

And of sarnies or ichor fluid being now observed in place of bland pus.

Same also well known not unfrequently to happen, on rupture of vomica of lungs.

Hence then on any view of matter hopes of recovery here at utmost but very faint.

And I confess that what consider as principal chance of patient is that entirely mistaken with regard to nature of disease.

And if this the case cannot even pretend to guess whether more or less danger than now represented.

But on idea which entertain concerning nature of disease & on opinion delivered of prognosis need add but little with regard to practice.

Am I own disposed to think that if cure at all to be affected must be by operation of system itself.

And by natural progression, of proper adhesive inflammation after rupture of vomica & discharge of matter.

In forwarding these ends however in situation of present patient am inclined to think that very little can be done.

Might indeed employ emetic with view to rupture of vomica as first step towards cure.

But this practice should esteem very hazardous.

And in present weakened state of patient especially if rupture took place, conclusion might be immediately fatal.

Hence then utmost here left in my opinion to palliate

And is with that view that have had recourse to practices here employed.

At first you will observe directed for patient a mixture consisting of powder of cicuta & of liquor.

This medicine employed in hopes of obtaining from it some affect in obviating cough.

And although latter article, the liquor, from abounding with mucilaginous & [saccharine] parts, in general considered as a demulcent yet here principally employed as an [excess] & to give form

Was on narcotic power of Cicuta that put principal dependence.

May indeed occur that in this way, could have obtained more certain & powerful affects from opium either in solid state [or] in that of Liquid Laudanum.

But to opium here tendency which has to induce sweating seemed to me to be an objection.

For patient already exhausted with colliquative sweats to great degree.

And influence of opium which has very powerful effect in relaxing the surface as increasing these well known.

That from Cicuta very considerable affect may be obtained as allaying cough is I think incontestably proved.

For introduction with this intention indebted to Dr Butter, who recommended it as infallible specific in cases of Pertussis.

But although by repeated experience found that in this was mistaken, yet from same experience discovered that useful in all coughs.

And accordingly in many instances where thought that objection occurred to opium have had recourse to Cicuta as means of [alleviating] cough.

And if my observations not mistaken has in many such cases been attended with advantage.

Cannot however say that this was the case in present instance.

Seemed indeed to have [some] good affect in settling stomach.

Or at least while was itself [retained] without inconvenience seemed to him, that less affect with vomiting than before.

Cough however nothing diminished in severity.

And if vomiting somewhat alleviated seemed now to be more affected with another & no less distressing complaint looseness.

As alleviating this could expect nothing from Cicuta.

And as only means of obtaining such relief seemed necessary to have recourse to opium

To avoid however inconvenience from more excessive sweats during night directed it in morning.

And that might have better [chance] of action on inferior part of alimentary canal employed in solid state.

Of these medicines patient was you will observe continued use at last report.

And if have affect of alleviating can I own expect nothing more from them.

But even with this intention am afraid will not long be [illegible] as I own inclined to consider death of patient as at no great [distance]

If however should happen otherwise, future attempts to palliate must entirely be directed to circumstances at the time.