DEP/DUA/1/12/01 (Normalised version)

David Wilson

(1776-1777)

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On Saturday last dismissed from attendance David Wilson.

A patient of whose case have hitherto said nothing

As not having reached in order of admission.

Now will afford subject for but few remarks

Neither in nature singular nor important.

Nor any room for doubt respecting it.

While at same time simple & uncomplicated.

That patient affected with Haemorrhage could admit of no doubt.

May indeed be thought that has not every characteristic of this disease as defined by some

Thus patient when came under care no complaints of headache vertigo or pain about loins

Nor could we even learn that had ever been affected with such symptoms.

These however according to Dr Cullen characteristic of affection

And even put in such manner that ought to conclude should [constituents] be present.

By few nosologists¹ however so many symptoms reckoned essential.

And present case corresponds at least very exactly to definition of Sauvages.

Words are fluxus cruentus, expodice, vel recto mariscis ruptis obsito.

Besides bloody discharge & tubercles here also pain by some considered as characterising the affection.

For may even be remarked that neither one nor other of symptoms mentioned by Sauvages to be considered as essential.

Often indeed as in present instance both conjoined

But in some cases no tumour in others no discharge

Has led to distinction into [illegible] & aperture internas & externas.

Depends however not on any essential difference in nature but merely on situation & condition.

In one of these situations no external haemorrhage

In other no discharge.

In present therefore no doubt in pronouncing that were of external kind & at same time [operative]

No doubt that this complaint in general from affection of haemorrhoidal vessels.

Has been disputed however whether the haemorrhage immediately proceeded from artery or veins.

+ Morgagni from dissertation contends Haemorrhoides nihil esse aliud quam varices venarum ani

And whether the tumour the effect of effusion into cellular membranes or enlargement of veins.

Most common opinion however that both haemorrhage & tumour from veins.

And perhaps most generally true.

Corroborated both by dissertation of Morgagni.

And by attending to habits usually subjected to haemorrhage.

Chiefly affects those labouring under venous plethora

Or at least such as arrived at that period of life when this condition most frequent.

Not to be refused however that many circumstances favouring [opinion] of effusion.

To be observed that frequently no inconsiderable pain

This however a circumstance not arising from distension of veins.

Besides dissertation also in support of [opinion] of effusion.

And have demonstrated lodgement of blood in a receptacle formed of cond. cellular membrane.

To be remarked also that discharge sometimes very great.

And evidently preceded by increased impetus & tendency to haemorrhage over whole system

Opinion favoured even by some of dissertation of Morgagni.

In one case observes.

Extremum intestinum intus varicosis venarum nodis meguale maforem exhis perattente inspiciens miratus sum, cum ipso qui non modico aleoquin distendebatur sumquinis grumo, non nisi termissima sanguifera vascula communicare, ut evidens esset aliguarn perexilem venam in cam fuisse amplitudinem dilatalam.

More probably effects of effusion than of extraordinary dilation which thus astonished Morgagni.

In such cases then strong presumption that from arteries.

Would appear then that in these respects cases may differ essentially in nature

And such a distinction often of consequence in cure

Naturally occurring as question then to which kind present case to be referred.

Know no circumstances in instance before us from which can form certain judgement.

Yet must own that disposed to consider it as venous affection.

Discharge of blood only to slight degree.

And seems to happen principally if not entirely from pressure as on discharge of faeces by stool.

Not attended with any marks of increased impetus

Nor accompanied with any considerable degree of pain.

All these objections against supposition of haemorrhage being arterial

While idea of being venous confirmed by period of life at which patient has arrived.

Thus then have stated sentiments respecting disease with which patient affected.

After termination which has already had need add nothing of prognosis.

Disease indeed previous to admission of some duration

Yet no circumstances indicating what could be reckoned any great degree of violence.

Little grounds therefore for entertaining doubt of favourable termination which soon took place.

Would not however be from this understanding to mean that patient radically cured.

Well known that those once subjected to this complaint very liable to recurrence.

And no improbable event with present patient.

Yet when dismissed free from pain swelling & bloody discharge.

And without some exciting cause may continue so

In treatment of this case found it necessary to do very little.

And here may observe that haemorrhage one of these affections respecting cure of which often great doubt.

In many cases particularly where habit to be considered as salutary discharged.

And in most instances some danger from sudden checking even when inconsiderable.

Particularly, as was observed with present patient, when have in florid complexion proof of plethora.

Remedy therefore to be regulated by appearance of disease.

And where nothing very urgent perhaps best plan to do but little.

Especially where no reason to apprehend that by neglect danger of disease becoming habitual.

Cases indeed of this affection calling for immediate use of most powerful remedies.

These sometimes necessary with view of obviating violent inflammation.

Sometimes for restraining excessive discharge of blood

As by evacuating in this way patient may be cut off either by inanity or some supervening disease

In former case impetus at rectum to be diminished by general & topical bleeding.

By Antiphlogistic purgatives, & by emollient application.

In latter must attempt to induce [constitution] of vessels by different astringents whether externally or internally employed.

In instance however which had here occasion to treat saw no necessity for either.

Although suspected haemorrhage from vein & considered it as passive yet extent by no means so great as to require such a doubtful medicine as astringents.

Although some evidence of plethoric disposition yet neither general effect of habit nor local inflammation requiring diminishment of impetus.

From these considerations therefore reckoned it sufficient to obviate principal exciting cause of haemorrhage.

This took to be state of discharge by belly.

Put patient therefore on use of a gentle refrigerant purgative.

From which hoped that should not only remove compression but produce also gentle depletion of system.

Which together with daily labour in which must be engaged & if not low at least moderate diet which probably utmost that his circumstance could afford, hoped would be sufficient for removal of plethora.

In this expectation would appear were not disappointed.

And from time that began electuary which gently loosened belly had no more of bloody discharge

But besides during continuation of it pain & external swelling gradually diminished.

In so much that at last report considered him so far well as to judge farther attendance here unnecessary.

Might indeed have continued for week or two longer on list.

As thus better able to judge how far cure completed

But for this purpose would have been required at least for sake of form to have persisted in use of some medicines.

While however consider nothing as better suited for nature of complaint than electuary on which had put him, was unwilling to continue even that any longer.

For from rendering purgative habitual the inconvenience produced by no means small.

Consider it therefore as preferable method to recommend it to patient to return upon recurrence of his complaint.

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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.