DEP/DUA/1/14/15 (Normalised version)

James Hutton

(1777)

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James Hutton.

That this patient subjected to disease evident from slightest attention even to appearance.

In emaciated habit had evident indication of some cause giving exhaustion of general system

And from apparent mode of respiration little doubt in fixing this cause to be in breast.

Although at same time description of patient would seem to lead to different supposition.

For according to his account was affected about fortnight before came under care with severe vomiting of blood.

Might therefore lead to suspicion then cause of affection rather in stomach than lungs.

That is that principle part of affection rather Haematoma than Haemoptysis

Here however to be observed that between these two, patients not always very accurate in distinction.

Are apt to [comprehend] under term of vomiting almost every preternatural discharge by mouth.

And here particular room for deception when by action of vomiting expectation of blood promoted.

That blood here in reality discharged by expectoration evident from mixture still appearing in what spit up from lungs by coughing.

Presumption therefore that supposition of patient as to discharge by vomiting a mistake.

Especially when consider that Haematoma a very rare affection.

And very generally occurs only as symptom of other complaints.

Would here then be disposed to consider evacuation of blood as wholly Haemoptysis.

And this the rather probable from other complaints with which here conjoined.

Particularly from cough.

Cough may indeed be conjoined with Haematemesis as well as with any other affection.

But by no means a symptom peculiar or characteristic of it.

On contrary is an universal concomitant of Haemoptysis.

And must indeed be an universal symptom of every disease, where matter lodged in breast.

To be observed however that cough occurring in Haemoptysis takes place in very different state.

Sometimes mere short tickling cough without any severity.

And to be considered as proceeding from no other cause than irritation which blood occasions in air vesicles.

This perhaps most common state of cough.

And hence in some of best definitions is characterised by title of tussicula.

Where haemoptysis with this state of cough disease may be considered as affect either of peculiar determination to lungs or of general plethoric habit.

And haemorrhage occurring always to be viewed as of active kind.

That is as depending on action of blood vessels themselves, being augmented & giving rupture. Not on rupture proceeding from other causes & consequential discharge from ordinary action.

In that case besides state of cough this affection also distinguished by other marks of plethoric habit.

Particularly by flushing of countenance general florid state of complexion sense of weight & oppression & especially by what may be called haemorrhagic disposition.

That is tendency to evacuation of blood by other places as well as by vessels of lungs.

All such appearances however whatever may have formerly been case at present at least wanting in instance before us.

And cough distinguished here both by frequency & severity.

To be remembered however that discharge of blood may take place by lungs from active as well as passive haemorrhage.

And that among other causes inducing rupture of vessels violent cough to be justly enumerated.

Occurs therefore as question of some importance whether haemorrhage of this or former kind.

And must own that from state of cough together with present condition of habit am disposed to view it now at least, whatever may have formerly been case as of passive kind.

True indeed that besides Dyspnoea, which may be considered as consequence of air vesicles being filled with other matters, patient complains also of pain of breast.

Which perhaps to be considered as one of strongest marks of increased action or what has been called haemorrhagic affect giving rise to increased discharge.

But to be remembered that pain as well as cough of different kinds.

And not improbable that pain here occurring merely consequence of oppression & general uneasiness.

Particularly as not remarked that attended with heat, an almost constant [concomitant] of peculiar increased action.

But although from these considerations would view haemorrhage as at present of passive kind yet would not infer that has been always so.

For with beginning in [different] state may have given rise to debilitated condition of vessels.

And may have even been origin of fixed cause producing cough.

Of this some presumption from continuation of affection

And from extent of haemorrhage giving appearance of vomiting.

Yet when consider cause of affection as far as that obvious may perhaps conclude that from beginning of same nature as at present.

But inquiry respecting original state now perhaps immaterial.

As treatment unquestionably to be accommodated to present condition.

And respecting this another question of greater importance claiming attention.

Whether viz can consider present patient as subjected to Phthisis.

Have formerly had occasion to point out these different causes as giving origin to Phthisis.

Catarrh Tubercle & Haemorrhage.

Wherever therefore haemoptysis exists reason to dread Phthisis as consequence.

And in a disease which makes progress so imperceptible symptoms giving any indication of it particularly to be attended to.

In case before us some particulars perhaps to be considered as favourable supposition of Phthisis.

And may be imagined that is in consequence of ulceration or vomica originating from this cause that cough supported for so long time & with such severity.

State of expectation also may be considered as giving some countenance to supposition.

And may be imagined that yellow viscid matter expectorated is of purulent nature

Here must be owned that subjected to [difficulty] from want of proper diagnosis between pus & mucus.

Well known however that both particulars mentioned as described pus in present instance yellowness & viscid, are strictly properties of mucus.

Latter even more the property of mucus than of purulent matter.

And here some at least of more common marks of pus wanting.

Particularly foetid smell & taste.

Would then consider this mark of Phthisis affection at least to be wanting.

And from circumstance of viscidity of mucus alone may perhaps explain severity & continuation of cough.

Farther to be observed that other characteristics of Phthisis here wanting.

Though breathing affected yet not observed particularly laborious on either side.

Though pain of breast yet not fixed to any particular spot.

And although pulse quick yet not with those regular accessions which distinguish hectic fever.

Besides even circumstances of continuation may be considered as an objection to phthisis.

Had now been liable to Haemorrhage for space of three years.

If however phthisis affection had occurred when haemorrhage greatest, may conclude that ere this time patient would have been cut off.

And well known that haemorrhage may very frequently occur from lungs without inducing phthisis.

For this last consequence of ulceration & suppuration succeeding rupture of vessels

And is rather to be considered as proceeding from depraved habit of lungs than follows as necessary consequence.

For when such habit does not exist rupture naturally healed up by first [intermission]

From all these circumstances then disposed to consider present patient as not yet at least subjected to Phthisis.

And on this supposition chance of recovery unquestionably better than should otherwise suppose

Must however upon whole view present case as of very dangerous tendency.

Is so in every instance even the slightest

But particularly so where has continued for so long a time.

After this has been case can hardly expect to prevent return even from slightest accident.

And utmost to be looked for is I apprehend to give temporary relief to patient.

Am much afraid that by this affection or consequences patient will yet be cut off.

And even supposing at present free from Phthisis may yet soon occur.

Is however our objective here to take such measures as may serve to remove present complaint.

General principles on which this to be affected must in great measure turn on condition of [patient]

Even where haemorrhage of passive kind & quantity of blood in system not morbidly augmented is yet sometimes necessary to diminish impetus of circulation.

For even in ordinary impetus have a cause capable of supporting haemorrhage.

And from reduction below natural standard other remedies will operate with greater success

Where however state of general impetus such as to preclude any measures with this view may yet be necessary particularly to diminish impetus at lungs.

And that either by restraining action of vessels there or by promoting determination to other parts.

With different intentions now mentioned, blood letting refrigerant cathartics, blisters, issues, sedative emetics & various other articles, are according to circumstances employed with advantage.

In some cases however none of these practices admissible.

Particularly case where patient as in instance before us much exhausted.

Then farther diminishment of impetus even [allowing] augmentation of it should be demonstrated by [increased] quickness of pulse, not to be attempted by evacuants

Utmost then to be done, is to endeavour to moderate it by use of refrigerants.

Great objective of cure must then be the constriction of bleeding vessels.

And the removal of every circumstance which can give rise to fresh rupture.

Was on these principles then that chiefly expected to afford temporary relief to this patient.

Put chief dependence here on such a medicine as thought would have some chance of producing constriction of vessels.

With this intention might have employed many different astringents.

But consider none as preferable to Infusion Rosarum.

Not indeed from any great efficacy which it derives from Roses.

Although these it must be allowed do possess an astringent quality.

And enter this formula to such extent that may expect utmost affects which capable of producing.

But must be allowed that possesses other vegetable astringents still more powerful.

And consider chief efficacy of this medicine as arising from Vitriol acid entering composition.

While however exhibits an astringent [wished] also to employ in same formula a means of alleviating cough.

And was with this intention that here united Infusion Rosarum with Mucilage of Gum Arabic Simple Syrup & Hysop water.

These articles of themselves would have formed mucilaginous mixture.

And although conjoined with astringent yet do not think that power would be diminished as lubricating & sheathing parts against irritating stimulation

Hoped therefore that by this means [severe] cough which considered as chief [cause] giving [former] rupture might be mitigated.

But while these expectations from this [prescription] did not think it advisable to trust to it alone.

And although could not here venture on evacuation as means of restoring impetus of [circulation] yet with pulse at 100 consider something as necessary with this intention.

With this view then had recourse to nitre as a refrigerant.

And that might sit more easily on stomach combined it with Gum Arabic.

From which also expected some good effects as demulcent.

Former of these medicines seems in great measure to have been attended with desired affects

For after use for some time cough not only mitigated but had no return of bloody expectoration

Latter prescription however did not seem to have had much affect on state of circulation.

And as patient imagined that had affect of producing gripes thought it advisable to limit it

During continuation of mixture for about fortnight lungs remained perfectly free from spitting of blood.

Still however cough at times severe & particularly so at bed time.

While therefore saw no farther immediate occasion for pushing astringent reckoned means of mitigating cough still more necessary.

And was with this intention that throwing out Infusion Rosarum substituted a proportion of an opiate viz Tincture Thebiaca

What affect of this prescription however have not yet learned.

But hope may have had some influence as diminishing cough.

And if this the case at least better chance that will not be subjected to return

This however can hardly I imagine be expected.

But if does return unless circumstances changed shall probably have again recourse to same measures as formerly.