DEP/DUA/1/17/03 (Transcript version)

Peter McDougall

(1778)

---

Peter McDougall.

Resp. affect to which this patient [subj.] sever. quest. may be started to which can not give any pos. [aswer.]

First & most urg sympt. when came under our care affect of alim canal.

These affect to some degree appeard under form of vomiting.

For this we are told, in partic was freq. occurr. with him after taking food.

But still more distressd by looseness.

This compl. not like formr occurr only at times.

Was to such degree of viol that in space of twenty four hours often even of 20 wat. [stool]

And while thus a very freq. disch. subj also to othr distress. sympt evid connected with it.

Partic gripes & borborigmi.

In these affect then such manif les. of natur funct. as may reason concl. to constit an affect of very threat nature.

And from circum of encreased disch by belly should at first be inclind to look for affect undr head of [alim] fluxus.

Under that title howevr those affect only compreh. in which loosness occur as an idiopath disease.

That is where dep. on state of intest canal itself.

Well known however that such circum not less freq. take place as sympt. than as idiopath

Or in othr words dep. not on morbid condit of alim canal but of othr parts.

In this manner in partic is freq. conseq. of suppurat. at diff. parts.

And perhaps no sympt more common at termin of Phthisis than colliq. diarrh.

Before therefore consid to what partic Gen. may be referrd first occurrs as quest [wheth] idiopath or symptom.

In fav of each suppos. some argt. may be argued.

Is somewhat in support of being idiopat that no circum in nature or appear of disch. which may not arise from that source

Still farther that besides mere disch there occurrs also other affect of alim canal.

Where colliq diarrhea induced by Phthis is at least but rare to observe that at same time accomp with vomiting.

This indeed will sometimes happen in [conseq] of severe fits of coughing.

But although patient affect with cough vomiting does not then prin occurr.

Is partic remarkd to happen after meals.

From this then may concl. that arises in conseq. of stim even from ordin alim.

And that by means of pecul irritab. a convuls. action of stom occas. reject of food, occurrs from stim which otherwise would prod no effect.

When therefore thus ground for presum irritab. state in stom greater reason for suppos. that may extend to other parts of intest. canal.

And thus consid vomiting as being in fav of suppos. that the looseness is idiopath.

Still more corrob. however from othr affect of alim canal.

Gripes indeed equally occur whether diarrhoea idiopath or symptom.

And may either arise from pecul. [stim] uncom sensib, or inordin action.

Often even from comb. affects of all taken togeth.

Can hardly therefore be consid as arguing any pecul. state of alim canal.

But besides gripes affect of patient attended also with borborygmi.

And farthr to be remarkd that [from] disch of wind relief afforded.

In this then consider us as having evid indicat of debilit & irritab. state.

In exist of wind have evid of this condit as giving rise to it extricat of it

And in relief which expuls affords have evid of uneas. being induced even by slight stim.

From all circum then presumpt of morbid condit in alim canal itself.

And on this ground should be inclind to pron. freq. loose stools to which pat subj as being at least in some degr. idiop

If to be consid as such can be no doubt that must be referrd to gen of Diar.

Accord to best [syst.] could be referrd only either to this head or to that of Dysen.

But while every sympt here occuring such as freq. accomp former, many of most [essent] of latter wanting.

No reason to susp that arose from [cont]

Almost certain evid that incapab of being commun by this means.

For during whole time that occurred with pres patient no other of family subj. to it.

But what to be consid as still strong circum than any of these was without fever.

Hold [prim] fever to be essent & necess charact. of that disease which would [denot] dysent.

And accord inclined to think that with greater prop referrd to tribe of contag febr. diseases than any other.

While charact. of Dysent thus absent no sympt in nature of [illegible] disch. which can occurr as obj. to diarrh.

At least if this gener. term taken in most extens & perhaps may add most prop. sense

These argt howevr in support of idiopath diarrhea do not afford suff. evid that solely from this cause.

And if even to consid affect of alim canal as solely refer. to this head yet no doubt that patient also subj to other sympt

Becomes then first necess to consider how far a compl of dis here take place.

And how far any othr affect here exist. can be supp. to have share either as support. or augm diarrh.

This may observe freq. the case where looseness yet in great meas dep. on state of intest.

And will not be [refused] that in pres. case sever very alarm sympt.

At same time such as afford strong [indi] if not certain evid of an affect of most danger tendency

Besides compl. of which have already spoken patient we are told affect also with severe cough.

And this cough accomp. with some degree of const. fixd pain in left side.

In these will not be refused that have two of most freq. sympt of Phth. Pulm.

But at same time often occurr to consid degree where no Phthisis.

And where Phthis pres in other cases either wanting or at [utm] pres. but to slight degree.

Without othr concur circum. therefore less dep. to be put upon them.

And even after all where presumpt corrob. by many partic will sometimes turn out to be mistake.

While at same time from insid nature of disease will often even prove fatal where many of princip & most common sympt have nevr appeard.

From these consid then judgem must always be very uncert.

But besides cough & pain of breast here sever. partic corrob. presumpt.

Patient not indeed affected with any obvious diff. of breathing.

A circum at least often occurring partic where large vomic in lungs.

Then also seldom that patient can sleep sleep unless laid on affected side.

As respirat must necess be carried on by sound lobes.

And these more free latit for action where parts forming cavit in which are cont. not prev from motion by [press] [from] weight of body.

Although however [such] affect of [breathin] wanting yet other sympt cannot be consid as any strong object to exist of Phthisis.

And perhaps restless state during night to be consid as in some meas. affect even of respirat less free [than] natur.

Suppos of Phthisis however more much more corrob. by feverish attacks to which patient subj.

Was affected even from time that came under care with a fever. parox. returning every day.

Pulse indeed, at time when [case] taken, not above natur stand.

And although most freq. the case in Phthisis that is unif & regul constantly acceler. yet by no means uncommon to find it at times in ordin condit.

While such period febrile [accep] as occur with in case of our patient with his other sympt. with greatr probab. to be consid as hectic than any thing else.

Suppos of Phthis still farthr corrob. by cause to which affect attrib & sympt. with which attended at commen

Patient ascribes all pres. affect to cold.

A cause more freq. inducing Phthisis especially at his period of life than any other.

Farther to be observd that at commen was subj to bloody disch by mouth from coughing

If this to be consid as Haemoptys. [unques] to be looked upon as one of great [illegible] of suppurat in lungs.

And indeed tubercle, that is Scroph. simple catarrh, & Haemopt, three great sources from whence Phth. Pulm. arises.

Here howevr may be some doubt [were] bloody disch in reality from lungs.

And gives at least some presumpt to contrary that at same time there took place also disch of blood by stool.

This however will sometimes even happen where entirely from breast

As after brought to mouth in part again swallowed.

But whether this origin of bloody stools or not presumpt that in some degree at least from lungs when consid that disch by coughing.

But still strong evid of what took place at that time from what has since happened.

Patient not many weeks ago affected with return of bloody expector.

And then without any manif disch by stool entirely coughd up.

While at same time succeeded by cop. expector. of matter which accord to descrip has at least many of marks of purul. disch.

Partic in colour taste and odour.

Have not indeed as yet had opport of trying this matter accord to more certain test than these afford.

That viz discov & prop. by my late [ingen] & worthy friend Mr Darwin.

And for which not many weeks ago he obt. prize medal of Aescul. Society.

If Heaven permit me is my intent to take some fut. opport. of attempting pub. to delin a charact. which did honour not only to this [illegible] of med educat. but even to age in which we live

Of this val admir young man therfore shall at pres. only observe that has taught med world on what grounds a cert. diagn. may be formd between purul & mucous expect. by aid either of Caust Alk [Luxiv] or of Vit Acid.

While both even in dilut state, keep mucous in perf. solut. do not exert same prop on pus.

From trials with sever othr patient have now no doubt as to accur & certainty of this test.

At least when performed with due degree of attent.

Had [such] trial been already [made] with matter coughd up by pres. patient might with more confid have now [seemd] whethr does or does not expect. pus.

And on this ground shall soon have pres. opin drawn from appear & other circum either corrob or refuted.

But even indep. of cert evid of purul expect., in various other partic mentiond have strong presumpt evid proof of exist of Phthisis.

On whole then look on pres patien as lab. undr complic of disease.

Long before came under our care [suppos] that vomica or collect of purul. mattr existed in breast.

But besides this consider alim canal to have been in pecul weak & irrit state

From this weakness & irrit would expl. would expl. most urg. sympt at time when came under our care.

Partic flatulen. vomiting & [looseness]

Consider these sympt however as having been then supported by purul. absorpt

And now look upon him as being subj to hectic fever from [same] cause

While at same time from rupture of vomica would expl. Haemoptoe to which has lately been subj. as well as cough & state of expect which still cont.

After this opin of nature of case need say but little either of prognos or of intended pract.

Were patient subj. to compl. of alim canal alone might have reason to fear that dis would be ted. but could not hold it to be highly danger.

When howevr are farther of opin that vomic formd in lungs not only has given rise to purul. expect. but also to hect. fever must hold him to be in most imm. danger

But rarely happens that from such a state patients ever do recov.

And indeed my opin at pres. is that this patient cannot hold out for many weeks longer.

Yet in prognos as to period of event of Phthis much more liab to error than as to event itself.

When Phthisis distinctly markd will at least seldom be wrong in pron that event will be fatal.

Yet where patient seem to last degree exhausted will often hang on for long time

While in other cases progress of Hectic sympt. extremly rapid.

And patient even while consid vig. yet remains cut off much soonr than could have been expected.

Wherever progn given then must not lose sight of such occurr.

Yet must own that shall be inclind to consider it as exempl. such a case if patien holds out much longer.

When thus speak of termin howevr would not yet be understood to mean that consider it as cert. fatal.

Although many circum against the healing of [ulcer] of lungs yet not imposs.

And perhaps reason why this event does not more freq take place dep. rather on condit of ulcer than situat.

From this circum not only less disp to heal but in place of mild pus yeilds matter more readily induc. hectic fever.

Ulcerat however of mild kind may occurr in lungs, as well as in other places.

And whatever condit of ulcerat chance of healing unquest better when from rup of vomica free disch allowed to matter than where entirly pent up & can be removed only by absorpt.

Is then on this ground that consid patient as not altog without chance of [recov]

Yet must own that if does occur is much more than I expect

And should it happen must I imag. be much more ascribd to powers of nature than to any med which we can employ.

While however patient remains under our care some meas. may be taken if not as means of curing at least of allev. [com]

Of these then as well as of pract. already employd shall next offer few remarks.

When patient came first under our care not in every respect same evid of Phthis as at pres.

And whether did or did not exist at at that time viewd severe looseness as the circum from which greatest danger to be appreh.

This consid as dep. on debilit & irrit state of alim canal

But before employing [astrin] thought first of thoroughly evac irrit causes

And of endeav. to rest. inordin action by means of means of anod. sedatives.

Was with these intent that had here recourse first to dose of Glaub. Salt & then to anod. draughts.

These med had appar at least some good effect.

And from time that began them looseness very consid dimin

Still howevr sympt remaind indic evid affect of alim. canal.

Partic much sourness at stomach & great uneas. from wind.

Consid both these as [illegible] affects of want of due tone had recourse [illegible] Tinct e Kino as an astring.

This Gum Resin a veget astring which of which freq. use made since paper resp it pub by Dr Foth. in Lond Med [observ]

Of late have myself freq. employd it & with best affects.

Of all forms hold that of Tinct to be preferrd.

And indeed this sub. so far of resinous quality that readily & completely dissolved in weak Spt.

In this respect then better qualif for exhib in form of Tinct than anoth veget astring the Succus Japon.

This however also the basis of a Tinct

But while Tinct. Japon with addit of Cinnam the Tinct e Kino without any addit.

This then the rathr an inducemt for me to direct it for pres. patient in conj with the Tinct. Aromat.

From this operat as carmin in conseq. of stim to stomach hoped that might be freed from uneas. dep on wind.

From this med loosness so far ceased that thought cont of the Tinct e Kino unnecess.

And reckond it suff. to persist in use of the Tinct. Aromat. alone.

Soon however a return of looseness led me to renewal of former prescrip.

And with this, encrease of hectic fever led me to direct [enjoin] still anoth meas.

That was employm of Peruv. Bark.

Has indeed been much subj of disp how far in any case of Phth. Per. Bark. can be exhib with [advant.]

Is unquest in many cases an obj. to it that gives check to free expect.

And where free disch of purul. matter from lungs can be no doubt that gives best perhaps only chance of recov.

At same time certain that as [counteract] hectic fever aris from absorpt of pus from other parts of syst. has often best affect

And for my own part little doubt in asserting that from altering state of action of vessels prod alter of cond of disch.

In cases then where even most certain evid of vomica, if as was the case with our patient, no expect. & yet high degree of hectic fever cannot consid it as improp

And from use here, appear were even somewhat flatter.

For after cont to extent of about half an ounce a day for space of about eight days

These febrile access. very consid abated.

In this situat subst to bark use of Inf amar.

And if operat of bark as is commonly supp. depends on action as bitter & astring may from this at least reap some good affects

But while patient on this course, [appr] much more [threating] took place

For during remiss both from hectic fever & looseness was attacked with [return] of bloody expect.

This, from subseq. state of disch by cough, am inclind to think, was conseq. of bursting of vomica.

Since that have cheifly trusted chance of recov. to what reckon free disch of what reckon purul. mattr.

Have indeed cont. him on use of a mixt cont. some prop. of Inf. Rosar.

This in some meas. intended as gentle astring to prev [fresh] effus of blood from rupt. vessels.

A circum which if occurrd to any consid degree in pres situat of patien might prove even suddenly fatal.

But must at same time add that med princip meant as placebo.

And is I must own, with me great doubt, whether any thing farther than mere allev of sympt now to be attempted

Now without paying much attent to state of alim canal must consider morb. condit of lungs as great [indicans].

And indicat of cure which ought cheif to endeav to fulfill, is the healing of the ulcer.

This perhaps cheifly to be affected first by endeav to obt free disch of stagn. pus.

And then by inducing such a state of action of vessels as will give adhes. inflammat.

How far these ends in any degree to be effected by art must own think very uncert.

Can however be little doubt that with first intent that viz of prom. expect service sometimes deriv from emet.

And probab is in great meas on last footing, that to acct for benef from setons and issues

And indeed persuaded that [these] operate also on other princip.

Yet inclined to think that as dimin impet at breast alter state of action of vessels.

In pres. inst however have had recourse neither to one nor other of these

Must own, consid patient as too much debilit, for bearing agitat of emetics.

And in exhaust & emaciated condit doubtful of prop. of any evac.

Partic so of such as debilit most in proport to quality of evac.

This howevr especially case with every purul. disch.

And is from this circum that even strong indicat of exhaust. the facies Hippoc. app. so soon in Phthis affect.

From these diff consid then though consider them as often of service, yet think that not always admiss.

And in many cases imagine that cure to be trusted to operat of nature aided by alim, nutrit yet not stimul

While at same time patient to be placed in such situat as will promote appetite & aid influ of this diet regim

Is on these princip that would acct for good affects from milk diet country air & gentle exercise.

These meas as far as patient circum would adm of it have here enjoind.

Is common direct pract in Phthisis to [enjoin] even most [illegible] diet.

And while strong inflam. tendency for prevent of farther [supper] is often prop

Yet must own am inclind to think that freq. pushd too far.

And that support of vis vitae [require] nutrit alim.

This not only indic by appar. [exhaust] state, by also by natur cravings of pat

Often strong desire for nutrit alim.

And may by way remark that such cravings when not founded on [preconcud] opin seldom misled.

This so much the opin of a late celeb. team of med at this place Dr M. Senr that laid it down as rule never to refuse patient in any dis what expressd strong desire for prov. could assign no reason.

These then grounds on which are I imagine to aid & regul. natur cure of Phs

Endeav only to obviate by artif means such urg. sympt as may occurr

In pres. case howevr have proceeded one step farther

Have directed for patient use of G. Myrrh

After what lately said by learnd Dr Fother against healing balsam in Cons. cases this pract may perhaps be [deemed] a bad one

And can by no mean venture to assert that will be serviceable to patient.

Yet must own that on prin laid down entert some hopes from it.

Was first [induced] to use this med in such cases as pres. on footing merely [empyr]

That was from being told that much employd in Phthisis by Dr G. Fordyce & he imagines with advant

Have of late given it in sever cases which at last had fatal termin.

And which, as suspect of pres., would I am conv. have had that fate [although] had never been given.

In one case howevr in which used it patient very unexpectedly recov from intern [supp]

Whether owing to med or not cannot posit pretend to say.

Yet this has led me both to consid use as deserv. farther trials & to think how to be expl.

Is with intent of such trial that have ordered it for pres. patient.

And if he recov shall be [inclind] to attrib much to it whether can expl. operat or not

On this subj. howevr if cannot do much am at least inclined to conject.

Need not then observe that Myrrh long a celeb. applic against ill condit ulcers when used externally.

Then cheifly used in form of Tinct

And can be no doubt that by means of his applic state of disch often changed & ulcer afterwards heald.

This then gives presumpt that Myrrh acts as pecul stim to vessel.

And if has this affect on immed topic applic may exert same influe when after entering circul. again collected at extrem vessels.

These then grounds by which led to use

Here howevr extremly doubtful whether shall be able long to cont. it.

But if obliged to discont pres plan have thoughts of doing nothing farther in this case than merely attempting to palliate.