DEP/DUA/1/46/36 (Normalised version)

Janet Sutherland

(1789)

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N^o 11^th Janet Sutherland at 34.

Case of this patient, which as will observe from history read, consisted chiefly in cough, dyspnoea & viscid expectoration, consider as example of catarrh.

And have since had no reason to alter opinion.

Must indeed be allowed that same symptoms are also ordinarily constituents of Phthisis.

And that Phthisis in many instances makes considerable progress before distinctly marked.

But at same time many circumstances in present case against that supposition.

Patient particularly has already passed consumptive period.

Has none of that quickness of pulse which at least very general attendant of Phthisis

Nor is she affected with hot or cold fits, which so great characteristic of hectic fever.

Has nothing also of emaciation, loss of strength colliquative sweats or other common attendants of Phthisis.

Tongue continues either in natural state or whiter than natural.

An evident proof that matter expectorated free from mixture of purulence.

Nor do we observe in eyes that pearly appearance & want of red vessels so common in Phthisis.

Probably an indication of want of due impression at extreme vessels.

menses indeed said to be irregular.

And this it must be allowed not uniformly occurs with Phthisis patients.

But at same time irregularity or obstruction of menses by no means, a Phthisis symptom.

While also a frequent occurrence in many other affections.

And indeed hardly any disease of which may not be symptom.

There is indeed one circumstance mentioned in history which may lead to supposition of Phthisis injury viz done to breast, and consequential morbid affection of lungs.

Severe hurt viz which [received] by a fall.

This it may be conceived produced local inflammation terminating in vomica or abscess of lungs.

But had this been case [train] of symptoms would have been very different from what here described.

Should have expected constant fixed pain referred to particular spot in breast.

And patient able to sleep only on pained side.

As free respiration only when [unaffected] side not compressed.

And finally on bursting of vomica should have expected copious & evident discharge of mucus.

Thus then appears that hardly any circumstance here giving suspicion of Phthisis.

While at same time, every ordinary characteristic of chronic catarrh a disease not infrequent even at age of 34.

While however what have seen of case since last spoke of it, tends to confirm former opinion of nature, cannot say the same as to Prognosis.

For then expressed hope that as disease of no long standing might soon be able to overcome it.

Must however acknowledge that hitherto have hardly made any progress in cure.

And probable that cold & unsteady weather has done more in supporting the affection, than remedy we have employed in removing it.

Must be allowed that in this affection nothing of equal consequence with guarding against influence of cold.

This indeed abundantly apparent from periodic return of disease here, during winter season, & periodic relief, in summer months.

Indeed no mode of cure perhaps of equal consequence in this complaint with passing winter in warm & steady climate

In my opinion is much more in such catarrhs than in Phthisis that ever does any good.

Indeed am inclined to think that reputation of South of France, & other similar climates in cure of Phthisis has entirely arisen from catarrh being mistaken for Phthisis.

For cannot be doubt that there tubercules equal tendency to suppurate as here.

And that suppuration when induced gives equally acute hectic.

Accordingly in distinctly marked tuberculous Phthisis as great a proportion die who go abroad as who remain at home.

That is very nearly the whole.

In catarrh however where disease solely affect of augmented secretion at breast very great benefit from that state of [almost] allowing free circulation on surface.

And next to change to warm & steady climate, the keeping here within doors in warm & comfortable house.

With [lower] class however both one & other of these equally unattainable.

And utmost we can do is to endeavour to counteract effects of cold by proper clothing.

At same time avoiding much exposure particularly to night air.

But while this essential to cure, as tending to counteract & prevent [causes], supporting & aggravate the affection sometimes also may be done by aid of medicine.

And various articles which as answer different intentions, may here be product of some good effect.

With this patient had in first place you will observe recourse to an Emetic.

And as most certain means of obtaining full vomit employed Ipecacuanha in powder.

The action of vomit I need hardly observe is one of best expectorants we can employ.

Next at least to coughing is unquestionably best means of producing discharge from lungs.

And where fruitless cough for great length of time well known that [supervening] vomit facilitates expectoration.

Thus then expected that at least for time would unload breast.

But besides discharging mucus already secreted, has also tendency to diminish future secretion.

For no doubt that gives though temporary only, yet very considerable determination to surface.

And free circulation [thus] begun in extreme vessels, often afterwards supported by their own action.

Particularly if by [proper] warmth future constriction of superficial vessels is prevented.

Thus then no uncommon practice here to have recourse even to repeated emetics.

And some with whom to prevent very distressing dyspnoea are even essentially necessary.

But at same time must own that consider habitual use as a bad practice.

For though temporary relief yet from frequent repetition have effect of weakening tone of stomach.

And thus product of inconvenience in many different ways.

Reckoned it therefore preferable to employ other articles with view to continuing advantage thus obtained.

And among others is of great consequence to prevent long stagnation of mucus in breast

For thus not only greater quantity to be expectorated but increased viscidity.

Hence the advantage of articles promoting more frequent expectoration.

And this property I am inclined to think possessed by some substances carried to lungs in course of circulation.

Among these Squills have long & I think very justly been considered as one.

No more difficulty in conceiving that should [reach] [excretion] here than those of urine.

On all hands however allowed that act on later.

And I think no less strong evidence of action on former.

Do not indeed adopt opinion of those who suppose that have power of cutting or dissolving phlegm already [secreted]

But have in many cases at least appearance of doing so, from matter expectorated being afterwards much less viscid.

This however consequence only of being expectorated before viscidity obtained.

Thus effect in augmenting secretion, [unquestionably] unfavourable in this disease, more than counterbalanced by more speedy excretion.

Accordingly with many subjected to chronic catarrh, Squills pills a habitual & as it were a family medicine.

While however thus desirous of preventing accumulation in breast, wished also to diminish secretion.

And as means of effecting this wished to give augmented determination to some other part.

This also indeed, in some degree an effect of the Squills.

For from augmented determination to Kidney diminished that to lungs.

Accordingly from diuretics in general benefits in this complaint.

But besides what thus obtained wished also to do something farther by inducing nerves, & what might be called, artificial discharge.

For this purpose directed the application of a blister to the breast, afterwards to be converted into an issue.

Need hardly remark, that thus very considerably augmented discharge, through part in which situated.

And that too, much greater than in proportion to mere quantity of matter discharged.

For not to consider discharge by issue as a discharge of putrid matter

An issue to use language of a late elegant writer may justly be considered Nova quasi glandula.

And as consistency in [peculiar] separates in same manner as in case of other glands a very considerable proportion of blood both brought to it & carried from it.

Thus gives considerable change in balance of circulation.

And by augmenting flow to one part tends to diminish it to others.

Is I apprehend on this ground that highly useful in many diseases.

And particularly beneficial when discharge can be instant, near the part from which wish determination to be made.

In case of lungs however having as it were circle by themselves, this almost unattainable.

At least many places equally near.

Accordingly from circumstance of conventional drain here often [inserted] from back from arm or from leg.

But whatever may be principle on which to be explained cannot help thinking that have seen peculiar benefits by drain from breast.

And discharge from thence obtained even with less inconvenience than from most other places.

Here therefore consider it as [desirable] preference.

On these different grounds then expected that benefits might be reaped from practices here directed

Cannot however say that expectations by any means answered.

And that too although weather by no means so unfavourable for such complaints as we generally have in this country.

For in as far as winter marked by frost & snow have hitherto we may almost entirely escaped it for this season.

And in point of temperature have had climate of Italy or Spain rather than that of North of Scotland.

Such a season then might have expected, if did not aid, would at least not have counteracted medicine.

But whatever might be cause benefit from practice employed by no means so great as in such circumstances should have expected.

At first indeed thought all her symptoms considerably relieved

And after emetic & blister was in particular much less distressed both with cough & dyspnoea.

This relief however but temporary only.

And at succeeding report though dyspnoea still moderate, yet cough very severe.

While mucus so viscid, that [expectoration] accomplished only with great difficulty.

And this too although issue continued to have free discharge.

This aggravation however considered as effect of some accidental exposure to cold.

And hoped that by continuation of practice the wished for relief might be obtained.

But to intended plan patient herself do not do justice.

For allowed issue to heal up.

And must be admitted that such drains though often advantageous are yet always troublesome & not unfrequently painful.

Issues particularly so at commencement.

And must also be confessed, that have effect of debilitating more than in proportion to quantity discharged.

Hence then, could here hardly [entertain] hopes, that should be able to induce patient to persist in use.

And by directed repetition, should probably have obtained no other effect than that of desertion from farther attendance.

In place therefore of repetition of Issue had here recourse to another practice from which hoped more immediate relief might be obtained.

The use viz of Opium.

This article in cases of chronic catarrh is I must allow a very precarious one.

In some cases have seen it do much good in others much mischief.

Can be no doubt that more effective than any other article we possess [allays] irritation to inordinate action.

And while thus diminished frequency of cough, also removed a cause of augmenting secretion.

For no doubt that by frequent concussion & agitation of lungs mucus secretion is augmented.

On these principles are probably to explain benefit sometimes reaped from it in this affection.

But whatever may be principle, unquestionable that in some cases has very considerable & very salutatory affect.

In others however from influence as suspending cough without diminishing secretion tends to augment accumulation in chest & of course increase dyspnoea.

Nay in some instances even reason to believe that has thus given rise to suffocation.

Hence therefore great cautions always requisite in employment.

And are chiefly to judge of propriety of persisting in it from effects.

In my opinion cases in which chiefly advantageous those in which cough the effect of irritation.

And where increased mucus secretion is very much effect of concussion.

From presumption that this the case with present patient then here ventured on trial.

Began however with small quantity only, half a grain viz the proportion contained in five of Pill Thebaic.

And with this quantity of opium at night directed continuation of Squill pills to extent of ten grains in morning.

Under this course has now continued for some weeks.

Cannot however sat that with any considerable advantage.

For although symptoms sometimes better sometimes worse yet no permanent change.

At last report found that [illegible] the Opium, had from frequency of cough slept ill in the night.

And that during day much affected with sickness probably in consequence of squills.

If these symptoms continue shall probably rather think of deserting present plan than augmenting quantity either of one or other medicine.

And in place of what now employ Vinum Nicotiana.

At same time not improbable that domestic situation of this patient, with respect to exposure to cold, more than sufficient to counteract anything we can do for her.

And that till we get still warm & more steady weather all our efforts in vain.