DEP/DUA/1/37/19 (Normalised version)

James McGregor

1785

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James McGregor February 26. 1785.

In case of this patient an example of an affection of which cannot say that have before met with any instance.

At least by no means certain that this the case.

And when patient came under our care, symptoms with which affected, by no means sufficient certainty to characterise disease which here suspect.

From examining case as introduced into register¹ may consider him as subjected to three different sets of symptoms.

In cough, dyspnoea & pain of breast as described in register have pectoral symptoms of considerable severity.

And these indeed, particularly the uneasiness from lying in bed in a horizontal posture, were most distressing complaint.

Next to these may point out as a morbid condition in general at least very little connected with what here described the peculiar state of his surface.

Were informed that over his whole body had very lately acquired as it were new skin.

That cuticle in most parts of it had fallen off under form of furfuraceous scales.

That in some parts had come off in very large portions.

And indeed when case taken was in such a state in palms of hands that had reason to believe, that in day or two would come off from each in one entire piece.

Where thorough desquamation had occurred parts appeared red & tender.

But in no other way in diseased state.

In this then had at least what might be considered as an uncommon occurrence.

Especially when occurring over whole body.

And may be considered as constituting a very different affection from pectoral complaint with which may safely venture to assert at least very rarely united.

But besides these, in present case still also another occurrence & that too not a little alarming.

Swelling viz of abdomen which here occurred.

When patient indeed came first under our care was not very considerable.

And chiefly observed when lying in bed, probably from pressure on abdomen which thus took place.

But in progress of attendance here became soon more considerable.

In so much that gave considerable [tension] to clothes formerly containing him with ease.

And probably that from pushing the diaphragm upwards had considerable share in inducing difficulty of breathing.

At same time from pain in breast, felt on motion in horizontal posture had reason to believe, that some other cause concern.

Upon whole however no doubt that in this case three different sets of symptoms.

And these too often at least occurring unconnected with each other.

Here therefore first question is, whether are to view them as having any mutual dependency or not.

Whether any of them connected together as cause & affect.

Or whether in any degree originating from one common cause.

Evident that on proper solution of these questions just idea of nature of disease must depend & proper plan of cure must be founded.

For former conjecture on this subject however, must attend to origin of affection & preceding circumstances.

Are told in history of case that all symptoms began nearly about same period.

That when came under our care had been of about four weeks duration.

That all of them succeeded as consequence of febrile affection to which then subjected.

And that this fever attended with general redness of whole surface.

Here then natural to consider whether this could be any disease of which present symptoms common sequel.

In the efflorescence here described have at least what may be considered as description of the appearance, in scarlatina.

No mention indeed of any sore throat a very common occurrence in that disease

But an occurrence by no means essential.

And indeed very generally the least remarked where efflorescence the greatest.

While again well known that in such cases of Scarlatina, desquamation of cuticle very common consequence.

Often furfuraceous scales for long time discharged from whole surface.

Sometimes from hands in particular cuticle known to come off in one entire piece under form of glove.

But if presumption that, desquamation of cuticle, here consequence of Scarlatina, may also suspect same, with regard to dropsical symptoms.

For well known that dropsy one of most common sequels of disease.

While often gives swelling of abdomen, produces also watery effusion into other cavities.

In particular often remarked to induce hydrothorax, or even hydrops pericardii.

And in this manner sometimes even cause of sudden death.

Here then a natural suggestion to consider, how far affections of breast here occurring are any indication of water in that cavity.

Or how far, this a cause from which these symptoms may be explained.

With regard to diagnosis of water in chest, is universally allowed to be very difficult.

Is thought to be particularly characterised by fluctuation discovered on percussion or shaking

By irregularity of pulse.

By inability to sleep unless in an erect posture, or when stooping forwards.

And by sudden starts from sleep, with sense of suffocation, palpitation or tendency to deliquium Animi.

But these, in general only symptoms of advanced stages, & of considerable degree.

And certain that often takes place when none of these observed.

While equally certain, that often gives rise to such pectoral symptoms, as here occur.

Cough an almost [invariable] attendant of every instance of hydrothorax.

Same may be observed with respect to pain of breast.

At least though not always severe pain, yet seldom wanting under some one form or other.

In affection of breathing again have both most constant & most distressing symptom of the disease.

And particularly in uneasiness in horizontal posture.

Hence then, though cannot be said that in this case, had diagnosis of hydrothorax, yet not improbable that exists.

And if be present, may readily presume, that is cause of all pectoral symptoms which here occur.

If then had certainty of previous existence of Scarlatina, might look upon all affections here occurring, as sequelae.

And indeed that whole arose from some one common cause, the rather probable from all beginning at same time.

There however to be remarked that somewhat against supposition of preceding scarlatina, that generally appears as an epidemic disease.

And for my own part, have neither of late met with any instances of it in my own practice nor heard of occurrences in that of others.

While at same time, have never on any former occasion, met with what could be called sporadic instances of that disease.

From these circumstances then, must [acknowledge] that here grounds for doubt.

At same time seems to me at least most probable supposition that here there occurred either scarlatina, or some similar febrile affection, where analogous efflorescence on surface, & analogous condition of subcutaneous vessels, as consequence.

That from this condition of surface & vessels there occurred in first place that desquamation of cuticle so remarkable in present case.

[That] from influence on state of discharge there was producing the dropsical symptoms.

And that while effusion of water into cavity of abdomen gave obvious swelling there, that into cavity of chest, gave pain of breast, dyspnoea & cough.

While not improbable that headaches as well as occasional haemorrhage from nose were consequence of interrupted circulation.

Thus then, notwithstanding very different [sets] of symptoms here occurring, seemed to me probable, that whole originated from one common cause.

And from view now given of the disease, may readily conclude that not a little doubtful respecting prognosis.

From particular appearance on surface indeed had nothing to fear.

For no reason to doubt, that desquamation which had already made very considerable progress would go regularly on, & would soon have favourable termination.

But much more grounds for alarm with respect to dropsical symptoms.

Dropsy from any cause & even when appears under slightest form often proves both obstinate & dangerous disease.

And few cases of it, where there [particularly] more to be apprehended, than where deposited in chest.

While also to be added that hydrothorax as sequel of scarlatina, has often proved suddenly fatal.

Here then such an event would not I own have surprised me.

At same time, had no less reason to expect a favourable conclusion.

And after termination in recovery which has now in reality taken place, any farther observations on prognosis, may be considered as altogether superseded.

How far this recovery the effect of medicine employed is I own with me matter of some doubt.

Highly probable, that some parts of disease, in which recovery took place by what may be called natural progression.

This particularly the case with respect to desquamation of cuticle, & recovery of sound state to skin.

Hence, with view to this affection, no measures whatever were taken.

Began practice you will observe by directing application of blister, to pained part of breast.

And by advising discharge from thence to be supported by means of Epispastic ointment.

In this had in view, not only alleviation of pain of breast, but also of affection of breathing.

For suspected both, to depend on water.

And hence although consider blister as powerful outlet yet did not think that was alone to be trusted to.

Accordingly had also recourse to Cream of Tartar but as gentle purgative & diuretic.

To this added as corrigent with view of counteracting uneasiness at stomach a small proportion of powder of Cassia.

And as adjuvant particularly with view to purgative operation a proportion of powder of Jalap.

In operation of blister were not disappointed.

But whether from want of proper application or from some other circumstance running not afterwards supported.

While at same time, Cream of Tartar, in quantity to which taken, no obvious operation, either in moving belly, or producing diuresis.

Hence then could not be surprised that at succeeding report, cough dyspnoea & pain of breast should continue as before.

Desquamation of cuticle indeed as might have been expected had natural course.

But more urgent symptoms continued as before.

Did not however seem necessary immediately to repeat blister.

But with view to farther diuresis, directed use of Squill pills.

Effect however even of these not considerable.

Had however, under use, very considerable remission, both of pain of breast & dyspnoea.

While however from this inferred diminishment of water in cavity of chest, seemed to be greater, in abdomen.

For swelling of belly increased.

From this therefore considered more powerful purgative as requisite.

And in place of small proportion of Jalap, before employed now ordered what in our pharmacopoeia² styled Composite powder

Consisting of two parts of Cream of Tartar to one of Jalap.

Here in preparation, will observe, article directed to be pounded, not separately, but together.

And imagined that from this activity very much increased.

As far however, as my own experience goes, have not been able to observe this.

And accordingly ordered to extent of ℥i for dose, that is to quantity of Ji of Jalap.

And from this, not more affect, than could have wished.

That attended with good affect, may infer from swelling of belly, as well as all other symptoms, being diminished.

While at same time desquamation of cuticle seemed now to be complete.

And only inconvenience from tenderness of skin, particularly in parts from which last thrown off the feet.

This so much case that even unable to walk.

Highly probable however, that [contributed] not a little to cure.

For dropsical symptoms, succeeding scarlatina, seem to be principally if not entirely affect, of obstructed perspiration, arising from state of surface.

Accordingly when skin recovers natural condition, very generally remarked to cease.

But whether from this, or from evacuant employed was so well that farther attendance or farther use of medicine seemed unnecessary.

Patient therefore dismissed free from affection.

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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) 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.