DEP/DUA/1/42/43 (Normalised version)

Archibald McPhail

(1787-1788)

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Archibald McPhail at 50

When spoke of case of this patient at time of admission expressed doubts with regard to it.

Observed that different suppositions might be entertained with regard to it.

But chief difficulty was whether to view it as being merely a catarrhal affection or an example of Hydrothorax.

Must indeed be admitted that had never all ordinary characteristics of that disease.

But well known that Hydrothorax an affection often occurring where even less marked than in present instance.

Since came under our care no circumstance has taken place either to confirm or refute former conjecture.

Still therefore continue in same state uncertainty as before.

But whatever affection may have been, now at least considerably easier.

And this I think, have probably grounds to conclude has been affect of medicine employed.

On either supposition respecting disease, thought some advantage might be obtained from a gentle laxative & diuretic.

Was with this intention that at first directed Powder of Cream of Tartar, in which well known that both these powers are combined.

This taken to extent a tea spoonful twice a day.

To this quantity had effect of gently moving belly.

And at same time some relief of Dyspnoea.

Thus far then apparently good effects.

But not observed to have any influence in increasing quantity of urine.

And with complaint so urgent wished to try some more active medicines.

As such had here recourse to pills of Digitalis.

Digitalis Purpurea or Fox Glove long held to be active & even deleterious vegetable

Belongs to tribe of Solanaceae or Luridae [comprehending] most of vegetable poisons.

And indeed contains very few articles which are not of active nature.

This as well as many others long in some degree employed.

But although entered Pharmacopoeia¹ of different colleges till of late but little in use.

And within these few years has been employed for purposes very different from those for which before used.

I mean for operation as diuretic.

First remarkable case with which I am acquainted a patient labouring under distinctly marked Hydrothorax treated by Dr [Wilkin] of Birmingham & Dr Darwin of Derby.

And to former of these gentlemen are particularly indebted for knowledge we have acquired of its use.

Has published a treatise professedly on subject containing many important cases & many useful observations.

Since that use in Britain has been very common.

And while sometimes product of astonishing good effects, in others accused of having done much mischief.

Must indeed be allowed that when overdosed very violent in operation.

Exciting not only sickness at stomach but vomiting also very [difficultly] allayed.

Must also be allowed that these effects sometimes occur unexpectedly.

Either from very slight increase of dose or even from continuation of dose which patient had before taken without any inconvenience.

Probably depends on state of stomach at time.

From this circumstance with some practitioners very strong prejudice to use.

For my own part however, though have sometimes seen vomiting & sickness from use, yet have never met with any affect in this way in any degree alarming.

While at the same time have [often] seen it prove very useful & powerful diuretic.

Am convinced that for obtaining effect in this way, not necessary to push it to such extent, as to excite vomiting or even sickness.

On contrary that by occurrence of [these] frequently disappointed of succeeding diuresis.

Not even necessary to employ it in such manner as to have much affect on pulse.

For may observe that in this way has remarkable influence as rendering circulation slower.

And indeed know no medicine, belonging to tribe of sedative which has even equal effect in that way.

In so much that from 70 observed to fall to fifty & even under.

For avoiding these consequences particularly sickness & vomiting is best exhibited in small doses & in substances.

As thus acts more gradually on stomach & better chance of being introduced into system.

On these accounts in my own practice prefer much pills formed of dry powder to common form of infusion.

And under formula of pills seldom exhibit it to greater extent than single grain.

Must be allowed that uncertainty in operation as well as other diuretics.

And effect not always immediate.

Yet from some continuation of use more than by increased dose end in view will often be obtained.

This appears to have been much case in present instance.

For during course of first week no obvious diuresis appeared.

And as no obvious influence either in producing sickness at stomach or vomiting might have been thought that should have ventured on increase of dose.

But in affection of patient at this time nothing remarkably urgent.

For although still consider dyspnoea & irregularity [of] pulse yet less necessary to rise to erect posture during night.

Imagined even that in this situation might omit powder of Cream of Tartar.

To which some objection occurred both as carrying more quickly through intestinal canal & might render it in some degree uncertain if diuresis ensued whether entirely effect of digitalis.

Directed therefore continuation of Digitalis alone & to extent only of grain as before.

In expected diuretic effect were not disappointed.

For at succeeding report found discharge of urine very considerably augmented

And at same time affection of [breathing] much relieved.

Now indeed complains of considerable sickness at stomach.

But encouraged by relief obtained this did not prevent me from persisting in use of digitalis.

Nor did I even intermit use, from being informed at succeeding report that during course of week had been repeatedly affected even with vomiting

Trusted that this merely accident & would soon abate.

And this confirmed by subsequent report

For has since that gone on for several weeks with same dose of digitalis, without any inconvenience whatever

And while supports increased discharge of urine symptoms have now for a considerable period continued uniformly [easier]

Unless therefore some change takes place, shall reckon farther continuation unnecessary.

Upon whole though cannot as have already said make any positive assertion respecting this case, yet at least some probability that affords example of Hydrothorax in which Digitalis employed with advantage.

And have at least seen that from this article diuretic effect may be obtained without any inconvenience to patient.

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Explanatory notes:

1) 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.