DEP/DUA/1/37/44 (Normalised version)

Mally Newall

1785

---

Molly Newall April 9. 1785

Respecting disease of this patient in several particulars little room for doubt

And even different names which might with propriety be affixed to it.

Symptoms in her case the most distressing were difficulty of respiration & difficulty of deglutition

And these in some instances arose even to a distressing degree.

Affection of first constitutes a genus which among nosological¹ & practical writers known by name of dyspnoea.

While last again difficulty viz of deglutition is the great characteristic of dyspnoea.

To both these diseases then might consider this patient as here subjected.

And although each may arise from variety of causes yet here no doubt that both to be attributed to same cause.

And that cause too a manifest one.

For on inspection of fauces tonsils appear so much increased in size as almost totally to obstruct passage downward.

To this enlargement then could have no doubt in attributing these symptoms.

Such symptoms every day consequence of affection of same parts in Cynanche or Angina.

There however both progress & symptoms very different.

From state of active inflammation is attended with high degree of acute & pungent pain.

And as in other cases where that state takes place in very short time terminates either by resolution or suppuration.

While during its continuation very generally attended with fever.

In present case however not only free from pain but also of much longer continuation.

Had commenced according to account given us, no less than twelve weeks, before came under our care.

During that period had gradually increased & as far as could learn at least in whole of that time, no symptoms of fever.

Is indeed true that commencement of disease, said to have been attended with a febrile affection.

And that too accompanied with eruption which from appearance supposed to be measles

But whether this really the case or not very uncertain.

At any rate, febrile affection may be considered as having preceded that of throat.

And disease evidently very different from ordinary cases of Cynanche.

Here when consider conjunction of eruption & of swelling of throat, may perhaps be stated, as no improbable supposition that present affection to be considered as sequel of Scarlatina.

For while in that disease [redness] often similar to measles so also affection of throat very generally concomitant.

And while internally affected in different ways, often external tumours, such as occurred in present case, remaining for great length of time.

Hence then in appearance at least nothing giving difficulty to this supposition.

During present course have already had occasion to treat of another patient whose disease had also appearance of being sequel of Scarlatina.

Case viz of James McGregor, which there occurred, very complicated [illegible] of cuticles with dropsical symptoms.

There however stated as objection to idea of Scarlatina, that disease did not then prevail as epidemic.

Or at least that had neither met with it in my own practice in Edinburgh at this time, nor heard of its occurrence to others.

And have not, in former practice, met with what could be called sporadic instances of that disease.

In present case then, same objection also occurs.

But whether swelling consequence of scarlatina, or of any other cause here evident that was immediate cause, both of difficulty of respiration & deglutition.

And these were at least most distressing, & alarming symptoms in this case.

Here however cannot I think consider this swelling as cause of all symptoms

For besides affection already described for space of several years, laboured under pain of side.

Had at times been affected with headache, at times with violent cramps in her upper extremities.

And at times also had discharged worms

All these affections as evidently apparent from commencement & other circumstances unconnected with disease of throat.

And most of them was disposed to consider as of little consequence.

For some, as for example worms, had not in any degree been observed, for some years.

Others as cramps of extremities seldom to such height as to be considered in light of a disease although a [destructive] symptom

While headache here, seemed to be merely transitory & symptomatic affection.

And pain of side now not worse than had been for years before.

Consider therefore first affection as being here alone subject of practice.

And of this only therefore, reckon it necessary to speak with regard to Prognosis.

Here however in speaking of prognosis cannot have recourse to what have myself seen in former practices.

For must here observe, that in present instance, the greatest enlargement takes place that have ever met with.

At least, of a nature in any degree permanent.

For when affect of accidental inflammation as in cynanche is for most part very temporary.

And very soon terminates either by resolution or suppuration.

Here however, from long continuation, such an event not to be expected.

And after gradual increase for such length of time, hard to say to what height may [arrive]

Instances described by authors, where said to be product of most alarming symptoms.

Accordingly, operation in their nature even dangerous proposition for removal or [ob] consequence.

Thus while some have advised [extraction], others have recommended bronchotomy, with view of preventing suffocation.

How far cases may occur, where these necessary will not pretend to say.

Would only observe that am inclined to think, that neither will be requisite in present instance.

And hope, that soon affection so much removed, that no farther assistance will be necessary.

Of this I think grounds to entertain hope, from favourable change which has already occurred.

At same time, I do not from this imagine that disease will soon be entirely removed.

For as affection slow in increase, so have also reason to believe, that will be in decline.

And may even happen that never completely removed.

For many instances, where such swelling once induced always continues.

This however may happen, without any inconvenience whatever.

And accordingly, even most superficial observation must show, that tonsils not of any fixed size.

But that with [difference] individually, considerable variety being sometimes larger, sometimes smaller.

Even on supposition however that formerly small, & that were now to remain of largest size, yet if no lesion of [ Rep] or deglutition hardly to be considered as remaining diseased

When however applied for assistance here, size such that both affected to very considerable degree.

Became therefore an objective of great importance to diminish them.

After these ceased, yet still desirable that should be reduced to ordinary & moderate size.

For while continually enlarged from every accidental cause, augmenting size, were exposed to danger of recurrence of symptoms.

Was with intention then, of producing such diminishment, that had recourse to practice at first employed in this case.

Began you will observe, by directing for patient, the use of a refrigerant cathartic electuary consisting of Cream of Tartar, with small proportion of Jalap, as adjuvant & of Cassia as corrigents.

By this hoped to diminish inflamed tendency, & give determination to intestinal canal.

From this imagined, that would have some tendency, to reduce swelling

Or at least that would aid operation of other medicines, used with that intention.

But at same time, had recourse you will observe, to an astringent gargle.

And on this, as immediately diminishing swelling, put much greater confidence.

For here, seemed evidently to be of soft & spungy kind, depending on relaxation.

As an astringent had here recourse to the infusion rosarum.

An article which though derived its name from roses has in reality its efficacy from vitriol acid.

Here however imagined, that as prepared by stated formula of Pharmacopoeia² would not be sufficiently strong of acid.

Directed therefore an additional proportion by which rendered as astringent as could easily bear.

And this addition the rather necessary as to give some degree of viscidity, combined with Infusion Rosarum, an equal quantity of mucilage of Gum Arabic.

Under these medicines, swelling soon somewhat diminished.

And very considerable relief, both in respiration & deglutition.

Since began use, however, diminishment has not continued uniformly.

For about end of last month, had again some return.

And at same time also, observed to discharge some ascarides.

Concluded however, that swelling would soon again subside & thought it sufficient to persist in use of gargle.

And for ascarides had recourse to injection of Lime water.

Which as producing expulsion of these worms from alimentary canal, consider as safest & most affective practice [with] which am acquainted

Of efficacy in this way already example during this course

From these injections, a considerable number of ascarides were discharged.

And since that no more have been seen.

Reckoned farther continuation therefore, unnecessary.

Under use of gargle, swelling of tonsils, also, somewhat diminished.

And at last report both respiration & deglutition pass free & easy.

Am in hopes, therefore, that from short continuation of use, patient may be in condition to be dismissed.

If in this however disappointed may have recourse to other gargles of [illegible] or bracing kind.

Particularly to alum, or Peruvian bark

And latter may be used under form of spirit tincture at least in diluted state.

For by spirits, parts increased in size from such relaxed condition, sometimes brought to natural state.

With these practices also, as an additional means of increasing power, scarification, may be conjoined.

And trust that under use of some of them, affection may be removed

Am however inclined to hope that none of them will be necessary.

And that from article at present used disease may soon be overcome

---

Explanatory notes:

1) 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.

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.