DEP/DUA/1/38/41 (Normalised version)

Margaret Hislop

(1785-1786)

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Margaret Hislop.

Respecting disease of this patient must own that a good deal at a loss.

Circumstance which led her to apply for our assistance was haemorrhage from nose.

But though this to her most alarming yet to be doubted whether most important part of affection.

For long prior to any appearance of Epistasis had been subjected to a pulmonary affection.

And that we may venture to assert if not of alarming, at least of distressing nature.

But before saying anything of this part of affection may be proper to give opinion of former.

And here first question that presents [itself] is whether Haemorrhage of active or passive kind.

For in these cases treatment very different.

First in general requires evacuation, latter astringent

Here several circumstances which would argue its being of former nature.

Patient indeed not at period of life when haemorrhage most common.

This may be placed from 15 to 25 years.

But active haemorrhage by no means [entirely] confined to that period.

And when consider that only at 35 year cannot look upon her as passed prime of life.

But besides this to be remarked that complexion rather florid than other

And that with pulse quicker than natural standing also observed harder.

In these particulars have what commonly consider as marks of predisposition to haemorrhage

And this at least somewhat in favour of being of active kind.

But other particulars against supposition

Bleeding takes place only in consequence of such violent exertions as may be supposed to produce rupture.

For has occurred merely during course of cough which has attacked her with great severity.

And as thus occurring only to small quantity at a time.

A circumstance affording evident proof that is not affect of increased impetus but of rupture.

May however be observed that even most violent cough, will not in ordinary cases, give rise to haemorrhage from nose.

Hence then may infer that produces this affect only, in consequence of predisposition to haemorrhage here existing.

Upon whole then, would view haemorrhage as being affect of certain plethoric state of habit.

But as immediately depending, not on increased action, which gives active haemorrhage, but on rupture from violent agitation.

In this view of it, though that part of complaint most alarming to patient yet neither disposed to consider it, as most important nor what shall find most obstinate

In both these respects her pectoral complaints more an object of attention.

These not only of longer standing but in nature even more alarming.

For here also some room to doubt whether catarrhal or Phthisis.

While however in case last treated was inclined to opinion of Phthisis, here again, am disposed to look upon affection as merely catarrhal.

In this case indeed symptoms described not dissimilar to those of hectic fever.

Shivering fits succeeded by heat, sweating & headache.

And with these, considerable permanent quickness of pulse.

But here, these febrile attacks, not of that regular kind, which commonly marks hectic fever.

While at same time, long continuation of the disease, as well as winter exacerbation & cause by which induced all favour idea of being merely catarrhal.

And may also be added that patient rather past consumptive period.

For at least most generally before 25.

Here however must add, that in all these circumstances no security.

Phthisis, a very [insidious] disease, often making considerable progress before known.

Present complaint, though not yet Phthisis may in no long time, degenerate into that state.

And should not be surprised to find, that she yet falls victim to catarrhal Phthisis if be not already subjected to that disease

But upon whole as disposed to view Pectoral affection as being originally catarrhal & still continuing merely in that state, & as consider haemorrhage to be as it were accidental, prognosis may be more favourable.

Even supposing severity of cough to continue, hope that latter by removal of disposition to haemorrhage, may cease.

And this the rather to be expected, if can do anything to remove of cough.

In this way many attempts may be made.

But am I own very doubtful how far in present circumstance can do much with advantage or success.

For to be observed that several particulars much against patient.

Especially season of year, for well known that in consequence of cold, disease has as it were winter exacerbation.

But employment during winter no less against her than state of weather.

For occupation by which supports herself, is that of carrying water.

So that is at same time exposed to action, both of cold, & wet.

Very doubtful therefore, whether this will not have more influence, in supporting cough than any thing we can do in removing it.

This however no objection against trial

And may at least perhaps be able to free her, from circumstance [most] alarming to her, haemorrhage from nose.

This indeed, if conjecture as to cause well founded, very much depends on violence of cough.

And therefore to be obviated, by means employed for mitigating catarrh.

But have supposed it in some degree also to depend on Haemorrhagic tendency.

Hence, in consequence of removal of this, less chance of return.

Especially if at same time impetus of circulation through head diminished.

Was with these intentions then, that had recourse to practice, first directed for this patient.

Begun, you will observe, by directing for her the Cream of Tartar to extent of tea spoonful about ℥i twice a day.

This in removal of disposition to haemorrhage, have often found highly serviceable.

And may I think consider it as operating both from action as refrigerant, & evacuant.

For can be no doubt that immediate affect of action on stomach, is of former kind.

That excites there, a sense of coldness, extended over whole system.

And that, if does not always diminish celerity of pulse, has at least very generally affect of diminishing impetus of circulation.

With these consequences, at same time operating as evacuant, in different ways.

First & most obvious operation, is that of exciting discharge by stool.

But perhaps a more general & permanent affect from it, is that of operating as diuretic.

And in both ways, must have affect of diminishing impetus of circulating fluids & of course haemorrhagic disposition.

Besides which still farther tendency to diminish disposition to haemorrhage by nose, from giving determination to other parts.

And accordingly, in this way Cream of Tartar & indeed similar cathartics & diuretics, often useful even in catarrh.

For in that disease, increased quantity of mucus discharged, very much connected with determination to lungs.

But with view of preventing epistaxis from giving determination to other parts, expected still more from another practice.

The application viz of blister which directed at same time to be put between shoulders.

And which advised should afterwards be kept open by Epispastic ointment.

That the application of blister, very powerful influence, in augmenting circulation through part undeniable.

And this necessarily followed, by diminishment in neighbouring vessels.

Especially the case, where not only discharge at first, but after by proper means continued.

Accordingly an issue, has with great propriety been termed by a late elegant writer Dr Simson of St. Andrews quase nova glandula

And in all instances where situation of part will admit of it & where wish for change of determination, possess few means more effective for accomplishing end.

Thus reason to hope that as giving determination to superficial vessels of back, might tend both to prevent return of epistaxis & to alleviate catarrh.

How far these remedies product of good consequences here mentioned cannot perhaps very positively say.

But some, at least, of those consequences, have in reality taken place

For while in obvious operation were attended with effect expected, ever since began use has had no return of Epistaxis.

And at same time, as farther mark of diminishment of determination to head, has also been free from headaches with which before affected.

Has also less florid complexion, & less quickness of pulse, two of principal marks of haemorrhagic disposition.

Some reason therefore to hope, that while have obtained at least temporary [relief] less danger of return.

But if from practices employed this change produced on disposition to haemorrhage cannot at least say so much with respect to catarrhal affection.

For at last report, cough you will observe, still continued with very great severity.

And still attended with cold & hot fits, sweating & other circumstances giving some suspicion of hectic fever.

With view however, of still counteracting it, both Cream of Tartar & Issue might have been continued with advantage.

But from finding issue inconvenient to her, had allowed it to heal

And, so far skinned over, that discharge could not be renewed without fresh application of blister.

This however was desirous at least of delaying for a little.

And therefore with continuation of Cream of Tartar directed use of Thebaic Pills.

This practice, I must acknowledge, I reckon a doubtful one.

And consider it as nearly equal [chance] whether be followed with good, or bad affect.

Have not unfrequently used it in former cases, sometimes with advantage, sometimes with the contrary.

Here need hardly observe that intention in view, is to diminish frequency of cough, by taking off affects of irritation.

And little doubt that from this frequent irritating cause rendered more considerable.

For by frequent agitation in coughing secretion promoted.

But on other hand if secretion continued without cough, still [more] consequences may be expected.

For then accumulation in lungs inducing distressing dyspnoea must necessarily occur.

Accordingly observed by many of those long subjected to such affections, that never in worse health than when cough wanting

For in that case, habitual secretion & deposit into lungs still continues, without however being discharged.

But if, with diminishment of cough, at same time corresponding diminishment of secretion could not fail to be product of best consequences.

And this, was in hopes, might be consequence of employing at same time, the Cream of Tartar & Thebaic pill.

From doubtful affect of opium however, have here directed it only in small dose.

To quantity viz of grain s morning & evening.

For to this extent enters each grain V of Pill Thebaic.

Accordingly to affect of this quantity will be regulated in future measures.

If has affect of alleviating cough without any farther inconvenience, may continue or increase it.

And perhaps by persisting in use, may do as much for patient as expect.

For during winter season & while continues employment of carrying water can hardly expect that will remain free from return.

Indeed, in this disease, where situation of patient will admit of it, more advantage from avoiding winter, than from all other remedies put together.

And this mode of cure naturally indicated by periodic relief in this climate, during summer months.

Where change of climate unattainable, [some] same advantage from keeping home during winter.

But where, as with our patient, necessarily exposed to cold, remedy given to very great disadvantage.

If from this or other reasons, shall seem advisable to alter present course, have thoughts of trying a remedy in which am inclined to think advantages of two now used in some degree conjoined.

The remedy to which now allude is Vinum nicotiana.

Made by infusing ℥i of dried leaves of Tobacco with pound i. of Wine.

This remedy need hardly observe lately recommended to attention of practitioners by Dr Fowler of Stafford as a cure for dropsical affections.

And in cases which he relates has unquestionably from diuretic power been attended with best consequences.

With power as diuretic however manifestly combined also a narcotic quality.

Thus may infer that in some degree to expect from it advantage both of Cream of Tartar, & Opium.

On this ground have of late had recourse to it, in several instances of chronic catarrh.

And I think with manifestly good affect.

But whether shall have recourse to this, or some other practice, must depend very much, on situation in which find our patient.