DEP/DUA/1/42/37 (Normalised version)

Duncan Stewart

(1787-1788)

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Duncan Stewart at 77.

In case of this patient as formerly observed have a decided example of Cancer.

And that too whether [consider] extent, appearance state of discharge, or pain with which attended evidently of worst kind.

And attempts hitherto made to cure of no effect.

Nor can even be said to have had any influence as mitigating pain or alleviating other symptoms.

Hence no reason to alter former opinion that will prove fatal.

And that event am now inclined to consider as not far distant.

For patient not only now entirely confined to bed, but even there can enjoy no rest.

Reason therefore to presume that constitution soon worn out.

And that from supervening febrile accession, convulsions, syncope, or like will be cut off.

For in all these ways, patients fall victims to this disease.

But although under our care disease has made usual progress yet prospect of recovery little better then, than at present.

For must be allowed that Cancer long & justly ranked among [opprobrium] medicine.

As little acquainted with cure, on an empirical, as on dogmatic footing.

For of nature of this affection, in my opinion at least, no proper or satisfactory account has yet been given.

Evidently however see it existing in two states.

Those viz distinguished by appellation of occult, & open cancer.

And perhaps may even add to these a third.

That viz of scirrhous.

For although cannot be alleged that every scirrhous degenerates into Cancer, yet certain, that not unfrequently a transition from one state to the other.

And wherever severe pains arise from a hard indolent tumour & skin over it becomes corrig. may consider it as passing into state of cancer.

For these evident consequences of cancer virus as it may be called generated at part.

Cannot indeed adopt opinion of those who suppose that disease of particular part produced from Cancer virus [existing] in mass of fluids.

But no doubt that a peculiar matter generated at part.

Of this undeniable evidence even previous to any ulceration from affection of other glands induced in consequence of abscess.

And from certainty that disease induced in these partakes of same nature.

To matter thus generated as to ascribe many of worst symptoms.

Particularly want of disposition to heal, severe pain, & sense of excessive heat.

For anything we know, this [separate] in no degree consequence of [pab].

For while cancer exists in one part, separate & secret from others, in perfectly sound state.

Hence necessarily led to attribute form of cancer virus, to peculiar depraved action in vessels of part.

But how this depraved action induced or in what it consists do not pretend to say.

Even this conjecture however perhaps not altogether without use in practice.

For leads us to consider cancer as being at first at least a local disease

And as affecting system only by [illegible] generated at the part.

Hence grounds for expecting that by complete removal at sufficiently early [period] cure may be obtained.

Not indeed to be expected that operation will remove virus already introduced into the system.

But this consequence only of delay. And where by means of it complete removal can be effected, does more than all other modes of cure put together.

Am therefore of opinion that ought never for a moment to be delayed in expectation of cure by other means.

But different circumstances from which becomes inadmissible.

There remains only to attempting cure by other means.

In these circumstances recourse had to various remedies, which recommended as have sometimes been attended with success.

Particularly Cicuta, [ Verruc], [ Aeg], & [ Onan].

All these readily admit to be articles of very considerable activity.

And that may have succeeded in some cases am far from denying.

But can have no doubt in asserting that from many of them success but a rare occurrence.

And have reason to suspect that to some of them particularly Cicuta recourse had before patient came under care

From this led here to make trial of another medicine of late in some esteem.

viz the Belladonna or Deadly Night shade the Arop. Belladonna of Linnaeus the Solan. [Furios] of some other Botanists

This article need hardly observe long ranked among most virulent poisons.

And from accidental use of different parts particularly berries, even to small extent fatal consequences have often ensued.

Notwithstanding this however now for a considerable time in use as medicine.

And especially as employed both externally & internally in cases of Cancer.

With this intention long used externally in Britain as apparent from writings of Ray & others.

And some well vouched instances [which] in this way remarkable success.

Particularly one not long since published in Medical Commentaries by Dr Graham of Stirling.

And in this way though not always innocent yet reason to believe is one of most powerful [resolv] with which yet acquainted.

From external Physicians probably passed to internal use.

And in this way about beginning of present century employed under form of weak watery infusion by Junker Degnerus Timmerman etc.

In 1739, a treatise written professedly with respect to it by Dr Oetinger at Halle.

De Belladonna, tanquam specifico in Cancro, imprimis occult¹.

In 1754 another by Dr Lambergen Lectio inauguralis sistens ephemeridem persanati Carcinomatis².

But in consequence of these never came into general use.

And while in some instances failed of producing cure, product of alarming consequences.

Were however sufficient to show that in particular instances might be employed with impunity & with advantage.

Very lately again recommended to attention of Physicians in a treatise published at Gottingen by Dr Munch.

Dissertatio medica sistens Obvervationes practicas circa usum Belladonna in Melancholia Mania & Epilepsia³.

By this treatise has of late [come] into some fashion both in these diseases & also in cases of Cancer.

Before chiefly [used] under form of infusion.

But by Dr Munch, recommended with greater propriety in that of powder or pills [formed] from the powder

For by this means most certain that activity not destroyed by action of heat.

While slow & gradual infusion is as it were formed in stomach.

To this formula therefore had here recourse.

Mass formed by means of soap divided into pills each containing 1 grain of Belladonna.

From activity of medicine was necessary that should be employed with great caution.

Directed therefore only a single pill at bed time.

While this taken internally, was necessary to employ some topical treatment.

And with this intention directed ulcer to be dressed with Saturnine Ointment.

Which while a soft & gentle [application] has at same time more than almost any other ointment effect of cooling parts.

An effect which from intolerable sense of heat with which patient [diseased] here particularly necessary.

But at same time, could expect nothing from it as tending to radical cure of affection.

And if under this course change for better had been induced could attribute it only to Belladonna.

On Belladonna patient continued for week.

And as not product of any sensible operation had reason to conclude [that] might be increased.

This the rather necessary as [some] continuation in every respect as before.

Directed therefore continuation to triple former quantity. three grains a day.

One in morning & two at bedtime

Still however no sensible operation of any consequence.

At least utmost effect he could perceive slight sickness from every dose.

Was indeed now more affected than formerly with general flushings heat & dryness of mouth.

But this no more than might naturally be expected in progression of disease.

And indeed is very commonly by violent febrile accession that patient cut off in Cancer.

And with patient in situation of ours with pulse almost permanently above 100, such to be expected.

But while no inconvenience from medicine had as little influence on sore.

And pain in particular continued as violent as ever.

In this situation then nothing to deter from still farther augmentation.

Could not however propose to increase with same rapidity as before.

Especially as from the two grains some sickness at stomach.

Merely ordered therefore two grains for each dose.

From this quantity thought pain somewhat mitigated for an hour or two after taken.

But whether this effect of medicine or not was both inconsiderable & but temporary.

Now however complains nothing of sickness.

Hence directed even dose to be augmented to three grains.

Though slight diminishment of pain yet no change in condition of [sore]

And was even more than ever affected with distressing sense of heat.

To counteract or at least to mitigate this, besides continuation of Saturnine ointment directed careful lotion with Saturnine solution.

But after fair trial without effect.

And whether former mitigation of pain effect of Belladonna or not now appears that quantity taken inadequate to that effect.

For pain more severe than ever.

Besides therefore increasing dose of medicine to three grains twice a day, directed also an opiate at bed time.

But as at same time taking another very remarkable narcotic would have been imprudent to begin with large dose

Directed therefore grains XV of Pill Thebaic containing Opium grain i s.

This indeed may be considered as sufficient dose at commencement.

But to be remembered that our patient under influence of severe pain.

And certain that in that condition not only born with impunity in large doses, but such doses requisite for producing any effect.

Indeed hard to say to what [extent] from influence of pain & habit may not be pushed.

Have from indubitable authority been informed of one case in which Liquid Laudanum taken to extent of ℥IV ter de die.

A quantity sufficient to kill 20 people in state of health unaccustomed to use.

Have no doubt therefore that might at first have directed it with impunity to much greater extent.

But for reasons already given reckoned it necessary to begin with prudence.

While at same time am fully convinced that benefit of Opium often lost from being overdosed as well as underdosed.

Have now however directed it to double quantity.

Substituting to Pill Thebaic a pill of Opium alone.

This if not product of desired effect shall probably increase even to double quantity.

Must however again repeat that am no friend to habitual use of large doses of opium.

For whether answers intent of producing [term] mitigation of pain or not very generally [illegible] constitution in other respects.

And where [proposition] of continuation being requisite for some length of time, should I think seldom exceed five or six grains.

And from this often more benefit than from double or even triple quantity.

But while increase opium shall also probably still farther increase Belladonna

Giving it perhaps to extent of ten or twelve grains in day

But that quantity should be [illegible] to exceed

And indeed must be confessed that little encouragement to persist in use from any appearance of change to better.

But see no change that can be made with any prospect of success.

And after begin use wish to give it here fair trial.

Must however observe that failure of success in this instance will not lead me to any conclusion against it.

And on other hand extent to which here borne without obvious [opposition] no rule for other [cases].

For may infer that effect of Belladonna as well as of opium [counteracted] by severe pain to which patient subjected.

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Explanatory notes:

1) Ferdinand Christoph Oetinger, Dissertatio inauguralis medica, de belladonna, tanquam specifico in cancro, imprimis occulto (1739).

2) Tiberii Lambergen, Lectio Inauguralis Sistens Ephemeridem Persanati Carcinomatis (1754).

3) Johann Heinrich Münch, Dissertatio inauguralis medica sistens observationes practicas circa usum belladonnae, in melancholia, mania, et epilepsia (1783).