DEP/DUA/1/44/21 (Normalised version)

Kath Hastie

(1788)

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N^oI Kath Hastie.

Formerly observed that disease of this patient might be said to consist entirely in affection of vision.

But at same time that suspected it to be somewhat of complicated nature.

As however, since that, have not had opportunity of seeing patient no circumstance has occurred, either to confirm or alter opinion.

Still therefore, must speak of it, only from history in register¹.

When patient applied for assistance, on membrane of left eye, there was obviously very considerable degree of inflammation.

Hence then could have no hesitation as to existence of that species of ophthalmia, which title of Ophthalmia membrane.

And not impossible that this only disease to which subjected.

For of such inflammation, diminishment of vision & intolerance of light necessary consequences.

Very frequently also gives exquisite pain

Sometimes immediately referred to eye, sometimes deep seated.

Not unfrequently even, giving rise to delirium

And that too of Phrenitic kind.

Here then, deep seated pains in temple, may have been entirely consequence of ophthalmia.

But besides these, another circumstance mentioned in case.

Uncommon dilation viz of pupil.

And at same time want of that free contraction, which action of light should induce.

In these circumstances, need hardly add, that have evidence of diminished sensibility of optic nerve, or its expansion the retina.

That this should occur combined with intolerance of light, rather singular.

And I own, do not recollect any former instances, in which observed it.

Uncommon redness of eye indeed, no infrequent attendant of Amaurosis.

But then is without pain, or any unease from light, & probably mere affect of relaxed state of vessels.

In present case however, ophthalmia most considerable, & most urgent part of affection.

And if doubt with regard to either, is with respect to Amaurosis.

Though at same time, when consider want of contraction of pupil, am inclined to think, that this considerable share in producing diminishment of vision.

And probably also, with this, deep seated pain in temple connected.

For with amaurosis such pains in temples, over eyes, or referred to still more internal parts of head, common symptom

Commencement also of affection, somewhat in favour of idea of Amaurosis.

For began we are told, like mist or fog before the eye.

In some cases indeed, amaurosis like other affections of paralytic kind, makes instant attack.

In so much that there occurs at once, total loss of vision, in one or both eyes.

But more frequently begins in gradual manner.

And particularly sometimes with appearance of fog before eyes, prevents vision.

Sometimes of muscae volitantes as have been called, or small bodies appearing floating in air before eye.

But which need hardly add, in reality do not exist there, [any] more than fog or mist.

[Hence] then disposed to consider patient, as subjected to complication of affection of vision.

A certain degree viz both of Ophthalmia & of Amaurosis.

But whether patient in reality subjected to this combination, or to one of these diseases only, can yet be little doubt as to cause of affection.

Lesion of vision we are told, succeeded a fever.

And as no other manifest cause, can have little doubt, in considering this, as origin of present affection.

For hardly any disease, of which fever has not at times operated both as cause, & cure.

A necessary consequence of that very great commotion & agitation, which induces in system

And among others while sometimes relieves, still more frequently induces affection of eyes.

Such sequel, in general distinguished, by title of dregs of fever.

And at one time explained from deposit of morbid matter on particular parts.

But since fall of humoural pathology this explanation rejected.

And although some instances, where strong reason to believe that these sequelae depend on condition of fluids, yet more frequently to be attributed, merely to state of [living] solids, or condition of nerves of part.

And this perhaps universally case when affects eye.

Not even excepting instances where gives rise to Ophthalmia Scrofula.

A consequence by no means infrequently observed to result from fever.

Here seem to have acted, not only on condition of moving fibre, but also on sentient nerve.

And this last, by no means a rare case.

[At] least every day occasion to observe after fever, what may be called nervous weakness of eye.

That is pain & unease from exertion, for any length of time.

And even incapable of exertion, to any extent.

Often also affected with muscae volitantes.

Sometimes with perfect loss of vision or complete amaurosis.

Here then, suppose fever to have operated in both ways mentioned.

To have left condition in [membrane] of eye liable to be affected by inflammation.

And to have induced diminishment of sensibility in nerve.

With this view of nature of disease, prognosis cannot be very favourable.

At same time, rather reason to expect obstinacy, than danger.

And even obstinacy not to be [apprehended] of every part of affection.

For reason to hope, that inflammation here, might in no long time yield to ordinary remedies.

But affection of nervous kind, often much more obstinate.

And indeed this so much the case, with insensibility of optic nerve, that by many, amaurosis held to be an incurable disease.

And in reality often proves so, notwithstanding every effort of most able practitioners.

Weakness of sight however, & even muscae volitantes after fever, often spontaneously disappears on recovery of strength.

Hence here then, no reason for despair, even of natural cure of both affections.

At same time, reason to hope, that might be readily aided by artificial means.

In practices hitherto employed these entirely directed to Ophthalmia or inflammation affection.

In combating this, great objective is, to remove increased action in vessels of eye affected.

And this not more effectively accomplished by any means, than by diminishing impetus at eye, from changing mode of circulation.

With these intentions no remedy more successful than topical bleeding, & blisters near affected eye.

To neither however had recourse in present case.

With regard to bleeding did not think that urgency of case required it.

For neither, great pain nor heat.

And consider it as unfavourable, to state of paralysis, which here supposed to exist.

This indeed not an objection to blister

For these as well as other stimulants, often had recourse to in affections of nervous kind where insensibility occurs.

But here wished to see whether after inflammation removed, there remained any other affection of eye.

And in place therefore, of an article which might operate on both affections, chose to confine practice, to what might be supposed to operate, on inflammation alone.

With this intention had recourse to topical application of a saturn solution.

The Saccharum Saturnine, as formerly very improperly [styled], the Sal Plumbi of Edinburgh College² or as still more denominated by that of London in last pharmacopoeia³, the Plumbi acetas dissolved in water.

That lead in saline state possesses a very high degree of sedative power, is of not universally at least very [generally] [illegible].

And indeed demonstrated by influence both as inducing, & as combating diseases.

Seems however to act solely on nerves or sensible fibres to which immediately applied.

Thus while even a small quantity taken internally will induce Colic [illegible], no such effect arises even from most copious external application.

As for example when most extensively applied to greater part of surface accidentally burnt or scalded.

There however has effect of giving immediate mitigation of pain.

In so much that to patients in most excruciating torture affords [inexplicable] ease

In same manner also mitigates inflammation of eye.

Accordingly in daily use in cases of ophthalmia membrane.

To obtain full advantage however requires frequent & continual application.

Is not sufficient that eyes washed once or twice a day.

Should be applied six eight or ten times

And at each application, bathing continuously for some length of time.

Often even advantage from constant application during night.

By using it viz, under form of cold poultice, with crumb of bread, enclosed in linen, over affected eye.

By this alone, distressing inflammation, in some instances overcome.

And hoped that might here be product of desired effect.

But in this case directed also internal use of small quantity of Cream of Tartar.

This intended to operate as a gentle laxative, & at same time refrigerant.

Thus by diminishing impetus of circulation, & at same time giving permanent determination to intestinal canal, often considerably alleviates inflammation of eyes.

Here however had not effect wished

And as notwithstanding Saturn solution, some degree of inflammation still continued, thought it necessary to employ a more active purgative.

As such, directed for this patient, two doses of Soda Phosphorus each to extent of an ounce, dissolved in eight ounces of warm water.

Of this purgative, for my own part, have hitherto no experience.

But has of late become highly fashionable in London as cooling laxative, & as possesses many peculiar properties.

Here shall only observe that [characteristic] given is That has very little taste when dissolved

That this taste by no means disagreeable.

That occasions no disgust when taken.

That excites no nausea or sickness

That gives no uneasy sensation or irritation to Stomach

And that operates in most gentle [manner] when taken to extent of ounce medicine dose.

By employing in present case, wished to see how far this characteristic well founded.

But hoped also might have some influence in combating inflammation.

If by removal of this affection entirely ceases other practices will be unnecessary.

And may conclude that if any degree of amaurosis has ever existed was at [utmost] but very slight.

If however after removal of inflammation want of ready contraction of pupil & diminishment of vision remains, must endeavour to restore sensibility of Nerves.

And with this view as formerly suggested nothing promises more success than electricity.

To trial of this therefore is my intention to have recourse.

But, as even this perhaps, not requisite, unnecessary at present to suggest any farther measures.

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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) The Royal College of Physicians of Edinburgh, established in 1681.

3) 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.