DEP/DUA/1/11/22 (Normalised version)

William Knight

(1776-1777)

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William Knight.

Case of this patient in all probability a complicated affection.

First symptoms mentioned in case would indicate local affection of some abdominal viscera.

One of principle complaints constant acute pain of epigastric region.

And respecting cause no room for doubt.

A tumour felt there inclined towards left side

On pressure of this pain augmented

Yet evidently not an affection of abdominal [integumentary]

Otherwise should discover both local rising & probably also change of colour.

To which of viscera to be referred not clear.

From seat some grounds for suspecting stomach

And this suspicion corroborated by two circumstances.

viz Frequent nausea & loss of appetite.

Farther to be observed that scirrhous of stomach no infrequent occurrence.

Sometimes affecting pylorus sometimes cardiac

An affection occurring at earliest as well as latest periods of life.

This supposition however not altogether without difficulty

For patient not affected with vomiting

Which if not constant is at least very frequent symptom of that affection.

And affection of stomach not only possible supposition

May depend on diseased state of part of chest or spleen.

Or even notwithstanding situation on an affection of liver.

Upon whole however equal if not greater probability of affection of stomach than any other viscus

And can by no means think that vomiting to be considered as an attendant symptom unavoidably necessary

When happens must be considered as consequence of an affection of nerves on [interm] surface.

These however may be but little if at all affected where scirrhous or tumour external.

Would then entertain this conjecture respecting local affection.

This from account given us seems to have been first & is perhaps still principle part of complaint.

At present however by no means only one

Other symptoms mentioned in case at least not immediately connected with this.

As such may mention, flatulence tinnitus aurium & sense of ball rising to throat threatening suffocation.

Would not contend that these have in no degree derived origin from disease already mentioned.

Certain however that in by much greater number of cases in which occur take place without any such local affection.

Daily example with hysterical girls.

And merely affection of debilitated & irritable state.

Presumption therefore is that in present case the two affections totally unconnected.

But besides these probably subjected to still another affection.

State of urine in morbid condition in different ways.

This discharge we are told takes place in uncommonly small quantity.

And gave such description of colour that induced to desire him to bring some for examination

As far as could judge from appearance had evident mixture of blood.

Very exactly resembling what mentioned by Mr Vogel in definition of Haematuria.

Urina exquisite permixto sanguine perfunditur, ut ea quasi dilutus & tenuis sit sanguis.

Could have no reason in this case to suspect any deception.

Patient to gain nothing by it which could be of any use to him.

And of some of other complaints most unquestionable evidence

That here however mixture of blood took place not merely from colouration & appearance.

Appeared still more manifestly from sediment.

For on being allowed to stand some time deposited grimous black coloured sediment.

Which perhaps stronger test of mixture of blood than even appearance.

As serving to point out particular matter on which colour depends.

Besides other affection therefore must conclude that patient also labours under Haematuria of Nosologists¹.

This indeed by some as Dr Cullen not ranked among genera.

But considered always as symptom.

This opinion however can by no means adopt.

May be indeed true that most frequently a haematuria of passive kind.

Yet even admitting it to be always so can see no reason, why passive haemorrhage should not constitute & give name to disease as well as active.

Besides cannot suppose that bloody discharge from kidneys always to be reckoned symptom.

Nothing peculiar in this organ which could be supposed to prevent haemorrhage.

Vessels as liable to have action increased & as tender as most others in body.

Discharge of blood takes place also to as great quantity.

In so much as to endanger life from inanity

Can have no doubt therefore in concluding haematuria a genus as done by Sauvages Vogel & Linnaeus

And next occurs as question whether bloody discharge here of active or passive kind.

Whether depends on kidneys ureter or bladder.

In solving first little to guide judgment.

May be observed however, that if expect thirst, no febrile symptoms.

And that no sense of augmented impetus at any particular part.

Presumption therefore that of passive kind.

While at same time from scarcity of urine may conclude that depends on kidney

This then idea respecting this part of patient’s complaint.

How far connected with other parts difficult to say

Should not readily suppose that any dependency on flatulence occasioning sense of suffocation.

Not that wind in intestines may not affect kidney

But will give merely a temporary affect.

Or at least one with remarkable remission & exacerbation.

For such supposition therefore present in its nature too permanent.

More reason to suspect that may be connected with tumour & pain in epigastric

To this indeed situation of tumour some objection

But from place where felt cannot possibly determine extent.

Particularly towards inferior parts of abdomen.

Not improbable therefore that from this tumour some degree of compression on kidneys.

But respecting this, at utmost, can only conject

And from every view of case must pronounce it a complicated affection.

On this ground prognosis can be by no means favourable.

Especially with patient in many respects in most unfavourable circumstance.

Complaint already of very considerable duration.

And has resisted whatever medicine hitherto employed

Besides, medicine when taken cannot have every advantage.

Patient both aged & indigent.

And state of stomach by no means well suited for retention of such as in any degree nauseous.

Farther from many excluded.

As while may seem useful for one part of symptom by no means so for others.

On these different considerations then little hope of speedy cure by aid of medicine.

And no reason to look for favourable natural termination.

On other hand how far threatening of immediate danger a matter of doubt.

From continuation which disease has already had should not be inclined to fear worst

Yet reason to apprehend that even severity of some symptoms might prove suddenly fatal

Particularly to be dreaded from affection of urine.

No reason indeed to be afraid of very great discharge of blood.

But scarcity of urine may soon be converted into total ischuria.

Especially if as some reason to suspect be effect of compression on kidney.

But even suppose increase of tumour may yet take different turn

And patient may hold out under it even for very considerable time.

Yet little probability that state of health will admit of regular attendance here.

And were he even to give regular attendance would probably be followed by no great degree of advantage.

Shall however briefly point out plan of cure which would here be chiefly inclined to follow

Great objective in this affection take to be removal of tumour in abdominal viscera.

And perhaps little varied whether stomach or any other viscus.

In former instance indeed more immediate application

But perhaps after all chief relief to be expected from entering system.

Removal of such complaints well known to be particularly obstinate.

And no remedy yet discovered on which dependency can be absolutely put

Among most powerful may justly rank Cicuta & Mercury.

And in present case chief expectation from these

Patient however by no means in proper situation for use of either.

Reckoned it of more consequence therefore to attempt in first instance alleviation of symptoms.

And particularly as most urgent to increase quantity of urine.

With this intention had recourse to the nitrous powders

United however with considerable proportion of Gum Arabic

By this means hoped that in first instance might less affect the stomach.

And farther that might act as demulcent as thrown off by urinary passages.

Besides this ordered also friction with camphor oil to pained part.

But without any other view than that of affording temporary relief.

These intentions however not answered.

Nor I own did this by any means surprise.

From having found indeed that from nitrous powders no uneasiness at stomach might have increased dose.

But must still with respect to some of complications at least have been doubtful medicine.

Wished rather therefore to try here what might be effects of Uva Ursi.

A remedy not many years ago introduced with very high character against complaints of urinary passages even against calculus.

Certain however that although may give ease in calculus cases no influence in removing stone

And now chiefly employed where reason to suspect ulceration [relaxation] or similar affection of kidney

Must own that from all I have seen of it could never think that desired characteristics which has obtained.

In situation of this patient however seemed to have some peculiar advantage.

For could never suspect it of any effect as increasing morbid irritability or laxity of [illegible] [illegible]

On contrary from sensible qualities should presume it a medicine of service against these.

For on whatever principle influence on urinary passage to be explained little doubt that as acting upon stomach will exert astringent power.

Thus then expected that might be of some service with double intention.

And proposed at least trial for space of a week

According to affects was intention to regulate future conduct.

And if patient shall again be able to visit us still mean to do so.

If from first trial any benefits shall persist in use in increased dose without any additions.

If sits easily in stomach with continuation of scarcity of urine mean to try combining with some of quickest diuretics.

Particularly with dulcified spirit of Nitre.

At same time while gives no inconvenience continue friction with Camphor oil.

If these means of alleviating symptoms shall fail may have recourse to others.

In which however rather to be directed by circumstances than by any general plan.

If however any considerable mitigation of symptoms obtained shall next direct attention to tumour

And with this view give at least trial to use of Cicuta.

Should this be found not to disagree may continue use even when attended by no remarkable effects.

For from perseverance alone that can expect any benefit [frequenting] an affection of so long standing

If patient unable to bear it might perhaps think of giving trial to Mercury.

At same time much to be doubted whether could be pushed to such extent as to give any hopes of cure.

And must conclude, as have before observed, that present a case in which expectations of being serviceable to patient very faint.

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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.