DEP/DUA/1/11/09 (Normalised version)

William Walker

(1776-1777)

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William Walker.

Complaint distinctly marked.

One of several patients under our care affected with haemorrhaging.

And may here remark that for so limited number of patients very considerable variety under care.

In one already mentioned bloody vomiting.

In present bloody expectoration.

In next to be mentioned Fergusson bloody stools.

In case of Johan Scott Menorrhagia or excessive discharge of menstrual blood.

In case of William Knight probably Haematuria or bloody urine.

And lastly in Jane Allen example of bloody discharge by gums & nose & may even say tendency to bloody discharge by surface.

All these in some measure referable to class of haemorrhagia.

And thus may be considered as having general affinity.

In many respects however do not agree

And not only gives diseases to which different names affixed, but attended even with very different degree of danger & requiring different treatments

To disease of present patient can have no doubt in affixing name of Haemoptysis or Haemoptoe.

This affection characterised by one symptom.

viz Discharge of blood from lungs.

Blood may be evacuated by spitting when comes from other parts as Gum fauces & even Stomach

But then easily sensible that not from lungs.

And indeed when comes from breast, its arising from thence as in case with present patient can be sensibly felt.

For most part fixed pain in breast.

And if not as in present instance at least at commencement violent cough, most commonly some slight ticklishness.

Besides these some nosologists¹ have introduced also into definition of this disease other symptoms. Particularly Flushing & Dyspnoea

Were these even essential might observe that not wanting in present instance.

May remark however that do not consider them as necessarily constituents of every case.

Latter chiefly attendant only where the haemorrhage considerable.

And where blood accumulated & coagulated in breast.

Former a very common attendant indeed where idiopathic haemoptysis of active kind

Particularly where affection of plethora.

But does not even generally occur where haemorrhage passive.

Or where as in instance before us has been affect of accident.

For little doubt that with this patient first derived origin from stroke in breast.

That vessels thus brought to diseased state have never again recovered former condition.

And that accordingly fresh rupture induced by agitation of coughing in consequence of catarrhal affection.

This then brief view of opinion respecting name & nature of this disease.

As to probable event must own that much at loss to speak with certainty.

Would fain hope that patient may get better of present attack

Or rather that already in some measure terminated.

Yet own suspicion with regard to future consequences.

And disposed to consider him as now very liable to future attacks from slight accidents

Probability is that these in end may prove fatal to him.

Where this disease not to such extent as to be fatal by itself usually terminated by phthisis.

And should not be astonished to learn that this hereafter case with present patient

Such termination however do not imagine that any danger of witnessing at present.

On contrary unless from some fresh accident may soon be dismissed.

And will even perhaps depend on accident if has ever any such occurrence in future

In treatment of this patient’s affection first & greatest objective is discharge of blood.

And here would naturally occur that prevention to be expected on two principles.

By diminishing force propelling blood.

And by increasing resistance to passage.

Force propelling blood in such a case as present may be considered as of two kinds.

The constant impetus of circulation.

And accidental occurrence giving uncommon impetus

Example in present case cough.

This indeed in some degree necessary for expulsion of accumulated blood in breast.

But at same time suspect it to have been first cause exciting the Haemorrhage.

During continuation therefore will always have tendency to support it.

And even after has ceased to renewal.

Other circumstances indeed which may also in some measure have same affect.

Example loudness & much speaking, violent exercise

While these however can be avoided cough will occur contrary to every effort.

Hence is here principally accident claiming attention.

In present case therefore principal objectives were

1 To diminish momentum of blood.

2 To mitigate cough.

3 And to contract ruptured vessels.

These views will readily explain to you meaning of prescription

Employed nitre here as a refrigerant.

And of all substances taken into alimentary canal has perhaps greatest effect in diminishing impetus of blood.

Had recourse to blisters & paregoric elixir with view of mitigating cough.

And employed infusion rosarum as an astringent.

Not so much indeed from virtue which suspect to be communicated by roses.

As from vitriol acid.

Although not to be doubted that latter also of astringent quality.

From these remedies patient already seems to have obtained considerable relief.

In so much that part of plan already discontinued.

And now reckon it chiefly necessary to guard against return.

Both by endeavouring as far as possible to strengthen vessels.

And to mitigate remaining cough.

Am hopeful that in present case will be necessary to employ no other remedy.

And as already observed that may soon dismiss patient from any future attendance.

If cough should remain obstinate however may be necessary to do more than merely trust to paregoric Elixir.

Besides mucilaginous & demulcent medicines may be necessary to have recourse to second blister.

Or support drain from neighbourhood of breast for considerable time by issue or seton.

This probable treatment of case even on supposition of continuation of cough provided the haemoptoe does not return.

If however is again attacked with that complaint will require other measures.

With this view may have recourse to use of lancet, & to cooling purgative.

At same time enjoining every other part of a refrigerant plan.

With these may at same time employ even more powerful astringents than formerly.

May employ other vegetables of this tribe as Tormentil & Bistort.

May have recourse to other minerals as alum

But upon whole should trust more to increased doses of vitriolic acid.

May however be necessary for us to prosecute none of these measures.

And may soon even be led to others which do not at present foresee.

Yet what now suggested are the measures which think there is greatest reason to apprehend may be necessary.

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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.