DEP/DUA/1/44/23 (Normalised version)

Betty Johnston

(1788)

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N^o2. Betty Johnston at 40.

In case of this patient as formerly observed distinctly marked instance of Cynanche.

For here all great characteristics of the disease, pain of throat, difficulty of deglutition & of respiration.

Under this genus however, both nosological¹ & practical writers have comprised several different species

And some of these not in my opinion with strict propriety referred to this genus.

Such for example as Cynanche malign an affection always arising from peculiar [continuation].

And which I think ought by itself to constitute separate & distinct genus.

But without saying anything of other species may remark that species to which our patient subjected sufficiently manifest.

For upon inspection of tonsils & [uvula] such a degree of manifest swelling that could have no doubt in pronouncing a case of Cynanche tonsillaris.

Or as named by others of Angina [Infection].

And in symptoms with which here attended nothing peculiar.

For is if not universally at least very generally case that this affection involved & accompanied with brisk febrile accession.

Patient also as will observe from history had before been subjected to repeated attack of this affection.

And is unquestionably one of those diseases to which there exists with some people uncommon disposition.

In so much that never fails to be induced by every imprudent exposure to cold.

And sometimes even as occurred in present instance takes place without any manifest cause.

These probably tending to increased action such that induced by causes entirely escaping observation.

And in after treatment of affection this condition may naturally be supposed to claim some attention.

While however inflammation subsists [must] have different objective in view.

Here first objective naturally presenting itself is to obtain resolution of inflammation & to stop [progress]

For on some occasions gives not merely difficulty of deglutition but such difficulty of respiration, that an opening into trachea [below] becomes necessary.

And is chiefly as a remedy in this affection that operation of Bronchol, proposed & practised.

That operation however at least if disease [illegible] treated very seldom I believe necessary.

In so much that have not only never had occasion to direct it in my own practice but have never even heard of an instance, in which performed in this City for 20 years past.

And I believe equally uncommon to other parts.

For very generally before such difficult respiration as to render this operation necessary terminates in suppuration.

This however when it can be done a termination also to be avoided.

For before takes place, patient subjected to great degree of pain, & when occurs, troublesome & inconvenient.

Hence then endeavours naturally directed to obtain termination by resolution.

Omission of blood letting either general or topical.

+ At Edinburgh volatile Liniment by addition of Alkaline water, to Camphor oil.

Camphor some benefit in Rheumatic cases.

But none here where intended to operate as strong rubefacient applied to blister

And was chiefly with this intention that the various practices here directed were recommended.

Directed you will observe the application of Volatile Liniment to the fauces externally.

Of this article need hardly observe that active basis is volatile Alkaline or Ammonium

And hence by London College now more properly styled Liniment Ammoniac.

Indeed in their Pharmacopoeia² two different kinds are introduced.

Liniment Ammoniae simply so called & Liniment Ammonia Tortius.

Former made with one part of Spirit of Hartshorn, or Aqua Ammoniae in aerated state to three of oil.

While latter not only with larger proportion but also with Caustic Volatile Alkaline or Aqua Ammoniae purae.

In either condition however operates as very active & immediate rubefacient.

And where skin tender, excites even very considerable vesicles.

Is chiefly on these principles I apprehend that to explain benefits derived from it in this disease.

For by augmentation of circulation on surface balance between that & internal parts soon changed.

And thus impetus at affected part diminished.

These even immediately & readily obtained without having recourse to [stronger].

And of some consequence to avoid even that degree of pain, which actual vesicles produce.

This indeed chief reason for preferring volatile liniment to proper blister.

Though at same time has also an advantage from suddenness of operation.

But whatever principle of operation can be no doubt that often advantageously employed in bringing about resolution of inflammation in Angina or Cynanche tonsillaris.

And since recommendation of late Sir John Pringle, who as informed us in Army diseases was first led to use on authority of Dr Young of this place has been very common practice.

But while employed this outwardly had recourse to an internal application of a different kind.

A gargle viz consisting of equal parts of Infusion Rosarum & Mucilaginous Gum Arabic.

The latter intended merely to give form & viscidity to the medicine, so as to lead to more ready [attachment].

While former, which to be considered as active basis of this medicine, possesses to considerable degree both astringent & refrigerant power.

And although derives name from roses yet as prepared both by London & Edinburgh³, active principle depends on vitriol acid which contains.

This acid in concentrated state a powerful means of inducing inflammation.

But when properly diluted, from astringent power serves to diminish increased action in parts to which applied.

And few affections against which more frequently used under form of Infusion or Tincture Rosarum than angina.

But in conjunction with these two here directed also a third practice.

The use viz of brisk refrigerant cathartic

And as such, though it must be allowed not one of most agreeable, yet as one of most certain & cheapest [directed] Glauber Salt or Soda Vitriolata.

By this hoped to facilitate & increase influence of other medicines from giving determination to intestinal canal.

And at same time to obviate costiveness to which subjected.

From all these medicines however could not obtain end in view.

For although had obvious operation wished for, yet this did not prevent inflammation of throat from terminating in state of Suppuration

Accordingly a few days afterwards from rupture of abscess formed considerable discharge of purulent matter took place.

And as happens in ordinary phlegm soon restoration of parts to sound state.

Whether from medicine here employed inflammation moderated & suppuration of course less considerable will not pretend to say.

But at least for a case terminating in suppuration that termination as favourable & as expedient as could be looked for.

And with this disease for present at least considered as terminated.

Have however already remarked that with this patient, there was as it were constituent disposition to this affection.

And where that the case, is unquestionably an objective of importance to combat it.

Particularly with these, who from situation in life, cannot be supposed capable, of avoiding exposure to occasioning causes.

Of these none as have already hinted more common than exposure to cold.

And on this account always proposed to enjoin defence against [application] part to neck.

Is probably on this footing that to account for a nostrum if it may so be called, recommended by that celebrated practitioner late Dr Ward.

At least if had in reality [those] good effects which some allege.

To those habits liable to Cynanche Dr Ward recommended the wearing a bit of black crape round neck below shirt & next to skin.

If this any effect can hardly suppose any other than that of giving additional heat & supporting free perspiration.

But whether operates on this or any other principle am acquainted with some people who place very great confidence in this mode of prevention.

Who assure me that though before very liable to sore throats, since have had recourse to this have had no return.

That this however may have proceeded from other causes do not doubt But at same time the practice as being both [easy] & [illegible] may perhaps be considered as not [unworthy] of trial.

Must however own that should be disposed to place equal confidence in anything else affording equal defence against cold.

And besides this general recommendation advised also to present patient another practice.

Use viz of gargle constituting of cold watery infusion of bark acid by vitriol acid.

This directed with view to its Tonic & astringent power.

And can be no doubt that from thus diminishment irritability of muscular fibre, tendency to increase action diminished.

Accordingly in some cases have I think directed it with manifest advantage.

But how far present patient will give it fair trial very doubtful.

And if even does in all probability we shall not know event of it.

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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.

3) Royal College of Physicians of London and Royal College of Physicians of Edinburgh.