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

John Hook

(1776-1777)

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John Hook

In all probability subjected to a disease of which too frequent examples in this country.

And which in by much greatest number of cases has fatal termination.

I mean Phthisis pulmonalis.

Phthisis one of those affections in nature highly insidious.

Seldom fails to deceive patient.

Even to very last stage entertaining hopes of speedy recovery.

And has seldom least suspicion of being subjected to an affection vulgarly considered to be certainly fatal.

But not merely patient that deceived here

This frequently often likewise the case with Physicians.

And disease has often made very great progress before least suspicion of it.

In some few instances circumstances the contrary of these.

as expect from the lungs.

And have appearance giving presumption of Phthisis where in reality does not occur.

Here think it necessary to observe that present case not altogether without doubt.

From merely catarrhal affection greater part of symptoms with which patient at present affected will often arise.

And but rarely that Phthisis subsists for so long time without having made more progress.

Particularly in those instances, where, as is probably case with present patient, it is not affection of tubercle but consequence of catarrh.

Patient not affected with those feverish exacerbations which in advanced state of phthisis often so distinct as greatly to resemble intermittent.

Nor does he seem to have constant quickening of pulse

May farther add that no certainty of matter expected being purulent.

And indeed probable that large proportion of it mucus

To be regretted that no certain test by which pus can be distinguished from mucus

Or by which can be determined where any proportion of pus in matter expectorated.

Common marks from sinking in water from smell in burning, & from application of acids all liable to fallacy.

If any certain mark could be fallen upon would often be very useful as affording a diagnosis of this affection.

Not indeed that could infer absence of phthisis where no evidence of pus.

But might with confidence conclude existence of Phthisis where pus discovered.

And consider such a mark to be one of those [disid] not unattainable.

In present instance however no such evidence.

From all circumstances now mentioned consider present to be case where not entirely without grounds for doubt.

Yet from many other particulars very strong presumption

And in numberless instances not [hath] the evidence where disease has even approached nearly to conclusion.

Presumption even from cough alone.

Especially after continuation for so many months

Greatly corroborated by fixed pain of side.

And by being of such nature as to be aggravated by coughing.

Besides these presumption at least of purulent expectoration.

And state of pulse with morning sweats show even advanced condition of hectic fever

To these superadded all other common although not essential symptoms.

A transparency of albuginea hectic [flow] of countenance & cleanness of tongue.

This last an almost constant attendant of purulent expectoration.

And indeed were not this the case would here probably find tongue in different state

Whole taken together therefore can leave very little room for doubt.

And not only look upon patient to be Phthisic but consider disease as having already made very considerable progress.

Although at same time must be allowed that retains more strength than common even after much shorter continuation

This however by no means sufficient to give any hopes of favourable termination

And own that in present case entertain very faint hopes.

Though progress of disease hitherto but slow can by no means conclude that will continue so.

And even in space of very few weeks may terminate fatally.

Perhaps even in shorter time

If goes on even at former rate hopes hardly more flattering.

And little probability that patient will outlive commencement of summer.

Would by no means however represent his case as one where no possibility of recovery

Am even inclined to think that has better chance for it than if same symptoms without expectoration of pus.

For although many circumstances unfavourable to healing of any ulceration in lungs yet certainly may happen & has happened.

And unquestionably better chance where opportunity for free discharge of pus than when lodged in Vomicae

And perhaps of all phthisis these most incurable where no proper suppuration.

As for example where cough & hectic fever the product of tubercle yielding merely sanies.

Should he even recover then may still be more effect of nature than of any medicine which we can employ.

But own that is even more than look for from conjoined influence of both.

While however able to attend us must still attempt something for recovery.

In treatment of this disease attempts made to cure by aid of medicine.

Still more however by regimen.

But from treatment of this last kind patient in great measure precluded by circumstances in life.

May indeed as easily reach a milk or vegetable diet as of other substances less proper.

But here cannot think of proposing change of climate sea voyage or the like.

Nor even of enjoining any exercise but on foot.

And that perhaps from bodily exertion required rather pernicious as otherwise.

Whatever aid therefore can be afforded to this patient must be by means of medicine.

In beginning of Phthisis before any proper local affection much may be done by diminishing general inflamed diathesis.

By occasioning derivation from lungs to other parts particularly surface.

And by mitigating tickling cough.

With these views small bleeding at proper intervals repeated emetics & antiphlogistic regimen often very serviceable

Present patient however considered to be too far advanced for this treatment

And view him as having already open ulceration in breast.

Attempts to heal this therefore must now be great objective.

Evident therefore that if is to be effected principle part of work must be operation of nature.

All that can expect from art merely to aid this.

Or to prevent bad effects of it on system while continues

Have no doubt that hectic fever in phthisis is the product of absorbed pus.

And that purulent discharge at particular part may be diminished by determination to other parts.

Particularly if from these also discharge occurs.

Such for example as issues or setons

How far these afford any outlet from mass of circulatory fluids, for absorbed purulent matter will not pretend to say.

Certain however that such a matter may be thrown off by some excretion.

Often evident marks of it in sediment of urine.

Should therefore reckon it as probable that may find exit by purulent discharge as any other.

These were considerations which in this case directed me to use of issue.

And whether on these grounds or not apprehension will not be doubted that often afterwards considerable relief.

Present patient even observes that all his complaints aggravated when the running diminished.

Can be no doubt therefore that while strength will bear it ought to be continued.

Is accordingly intention to do so.

This however rather palliative than anything else.

And with same intention also prescribed a mucilaginous mixture.

By which hoped to diminish frequency of cough & in some measure promote expectoration.

But remedy which was principally desirous of trying in present case was the Mercury.

Mercury a remedy which as far as I know has not been much used in Phthisis

Nor can I say anything of it from my own experience.

While at same time doubtful respecting principles on which may be of service

Is however a medicine of which some of first practitioners in Kingdom have high opinion in Phthisis. Particularly Sir John Pringle.

Cannot help thinking that on such authority deserves trial.

Not improbable that may have good effects from action as deobstruent.

And if can thus resolve tubercle may be radical cure to disease.

May also conceive it in such a case as suppose present to be, to be useful on other principles.

Well known that frequently serviceable in treating obstinate ulceration, besides those of Venereal kind.

Probably from acting as peculiar stimulation & inducing proper suppurative inflammation.

But whatever principal, effect to be determined by experience.

And if under use of it present patient recovers will I own have much higher opinion of it, than at present have from anything that have yet heard.

Should it even fail in present case will not reckon it unworthy of trial in other.

And must own that even doubtful, how far will in present instance have it in power to give fair trial.

Have here put patient on same formula which have known Sir John Pringle use in some cases.

And which I believe he commonly employs in Phthisis.

Although at same time should I own have greater confidence in common Mercurial pill.

As there while Mercury rendered active by same means are more secure of [competent] [trial]

But whatever may do in other cases, wish as have already said to continue formula already prescribed with present patient.

Particularly if see any evidence of its producing affects of mercury as introduced into system.

Cannot from use of this medicine expect any sudden or immediate benefit.

And should reckon it very unsafe to charge system with Mercury to great extent.

Is therefore from considerable continuation that have any reason to look for benefits

If therefore no evident prejudice wish to persist in use for some length of time, even allowing that shall not be able to discover from it any good effects.

May indeed soon be obliged to desist from it in consequence of supervening looseness or such other symptoms.

But if this does not happen more than probable that present case will not afford opportunity for trial of any other medicine.

If should have thoughts of making trial here of inspiration of resin smoke.

From some late cases published in different newspapers has been recommended as having had very wonderful affects.

And do not I own consider it as impossible that application of such substances in form of vapour may have produced that inflammation which is accompanied with disposition to heal

Have myself known it tried in one instance only.

There however had evidently bad effects

And from producing great increase of cough was soon obliged to be discontinued.

Have heard also same account of this practice from others.

And am I own very suspicious that were we to give it trial would soon be obliged to discontinue it

At same time must observe that consider it to be in some respects no unpromising medicine.

By no means unreasonable to suppose that from application to ulcer in lungs some tendency to healing may be produced.

And unless that of smoke or vapour no other manner in which application can be made.

If patient benefits by neither of these & if state of symptoms will allow of it have some thoughts of trying cicuta in this case.

On no other principle however than merely to give some chance in what reckon a desperate case.

And as has certainly affect in giving disposition to heal to other ulcers of very bad tendency may perhaps likewise to those of lungs.

On this foundation also have sometimes been disposed to think that Mezereon might be tried in some Phthisis cases.

But apprehensive that have already suggested more than shall have any opportunity of putting in practice in present case.

And not improbable that soon shall have no other view here but to obviate symptoms.

Such for example as colliquative Diarrhoea or like often known to occur towards close of such affections.

And indeed will find that by much greater part of Practitioners, in phthisis once confirmed make no attempts to radical cure.

But confine attention solely to mitigation of urgent symptoms.