DEP/DUA/1/16/03 (Normalised version)

William Kay

(1777-1778)

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William Kay.

Principle part of affection to which this patient subjected by no means rare.

Yet is at least uncommon at so early a period of life.

Especially when attend to first comment.

Here although several symptoms no question that most material part of affection is bloody expectoration.

Of five nosological¹ systems circumstances of expectoration of blood alone reckoned sufficient to constitute a disease

And to this affection have universally given the name of Haemoptysis.

Of these two consider absence of acute fever as an essential [constituent] of disease

And for this [restriction] at least some [foundation]

For certain that in particular febrile affections example peripneum bloody sputum occurs when not proper haemoptysis.

But on other hand in system of Dr Cullen haemoptysis as well indeed as all other haemorrhages ranked among febrile affections.

And for this arrangement also some apparent reason.

For in some instances of active haemorrhage febrile affection distinctly marked.

And in others although all symptoms not obvious yet often quick & hard pulse.

At same time can by no means consider presence of fever as essential to Haemoptysis.

And that too even when haemorrhage [occurring] is of active kind.

Still less however when is merely passive

In instance before us an example of Haemorrhage where symptoms of Pyrexia cannot by any means be said to take place.

Is then on these considerations that look upon disease as best defined where neither presence nor absence of fever considered as necessary constituent

And in this light consider definition of Linnaeus & Vogel as having preference to those of Sauvages & Sagar on one hand, & Cullen on other.

Considering bloody expectoration as only essential constituent of the affection no hesitation in [pronouncing] existence here to considerable degree.

For here not merely slight appearance of blood in sputum which may come from vessels of Trachea.

But is we are told at times discharged even to extent of one or more pounds.

And seldom continues free from it for more than space of month.

Often even intermission not more than week or two.

In these different particulars of recurrence & quantity of discharge no great singularity.

And with age at which patient is now arrived that viz of fourteen cannot be considered an uncommon affection

Although at same time much more frequent somewhat later in life.

But present patient who yet but 14 years of age has been subjected to it for space of 8 years.

With him then example of occurrence at [much] more early period of life than common.

And that too without having been originating affection of any particular accident.

From which may I think justly infer that tendency to this affection particularly strong.

And of all species enumerated by Mr Sauvages most exactly resembles what directed under [title] of habitualis.

In which disease does not take rise from any particular accident as violent concussion wound tubercle or like but where merely affection of peculiar state of pulmonary vessels & of condition of fluids in these

And this species of Haemoptysis particularly marked as attended with other symptoms occurring in present case.

Our patient for example has to very high degree the florid complexion attending that species of haemoptysis.

With him even so strong as often to approach to purple hue.

Is affected also with pain of side, cough & dyspnoea.

Circumstances in which certain indication of local determination to lungs giving irritation.

While at same time am disposed to consider sickness at stomach & headache as consequences of general plethoric state.

Thus then view all symptoms to which patient subjected as constituting only one disease

And to that would give name of haemoptysis.

As consider bloody discharge as constituting principle & most dangerous part of his affection.

Yet view it ultimately as being affection of peculiar plethoric habit.

And of particular state of lungs in consequence of which discharge by superabundant quantity more readily affected by that outlet than any other

This then idea of nature of affection to which patient subjected when came under care

And with which according to account given us had been affected for several months before.

With this opinion respecting nature of affection prognosis cannot be favourable.

Notwithstanding continuation of disease indeed has not hitherto induced those sequels which most to be dreaded.

Evacuation has not hitherto proceeded such length as to give rise to marks of inanity

Or at least if otherwise would have done so influence has been fully counteracted by disposition in system to plethora state.

Neither on other hand does the frequent rupture seem, on any occasion, to have [been] succeeded by purulent expectoration.

While at same time does not appear that hitherto many remedies tried for [removal] of this affection.

Cannot therefore represent it as having already obstinately resisted different means of cure.

Yet must own do not consider all these circumstances as giving foundation for great hope

Haemoptysis in every instance to be considered as a dangerous affection.

Is especially so where occurs at early period of life.

Much to be dreaded also when subjected to frequent returns.

And especially when these so much affect of constitution as to take place even without exciting cause.

May also remark that during continuation which has already had in place of mitigation has increased in violence

And from this great reason to believe that such a state of vessels of lungs indeed that even notwithstanding use of medicine will prove obstinate.

Hence then great reason to [apprehend] that sequel already mentioned although yet no certain indication of them, will at last take place

Even some presumption indeed that has already taken place But if not dangerous at least that will hereafter occur

Should not then be surprised here to find that haemorrhage extended to such length that patient at last cut off by inanity.

Reckon it however still more probable that from frequent rupture of vessels of lungs ulceration will in end occur.

And, that from purulent absorption patient may at last fall victim to hectic fever.

But although look upon this to be most probable termination am far from considering it as certain.

Disease may admit even of complete cure.

Or even if this cannot be affected may yet be so far mitigated as not to be attended with fatal consequences.

And some instances at least, although [indeed] but rare ones, are to be met with, of patients subjected to this disease to considerable degree even for greatest part of long life.

A Gentleman who lives in this neighbourhood & who is very considerably advanced in life affords perhaps one of most striking examples of case now mentioned.

From this then may at least infer that case not altogether desperate.

And that while patient inclined to continue under care may even try other measures than with mere view of mitigating symptoms.

Treatment of this & similar cases [naturally] referable to two heads.

Measures viz to be taken while discharge [present].

And measures during interval with view of preventing return.

Where excessive evacuation and of long continuation reason to apprehend that may prove even suddenly fatal.

For in same manner as other haemorrhages may give rise to convulsions or deliquium terminating even in death.

In such cases then must attempt to restrain flow either by diminishing cause giving impetus by which expelled.

Or by increased resistance to passage [have] ruptured vessels.

When however as suspect to be case with present patient discharge in effect of plethora such measures totally inadvisable.

For then evacuation to be considered as [salutary]

And by giving check to course worse consequences may be induced.

Hence [then] nothing farther to be aimed at than follows in consequence of means of preventing return.

Or at utmost can venture only to restrain discharge by removal of causes supporting it.

Hence then consider great objective of cure in present instance to rest on prevention of return.

And where as suppose to be case with our patient haemorrhage of active kind depending on plethora different objectives to be aimed at

Must endeavour as far as able

1 To prevent recurrence of plethoric state

2 To avoid causes increasing [amount] of blood in general.

4 To avoid circumstances giving uncommon momentum at lungs.

And to support free circulation on surface

Is chiefly on these grounds that would explain principle part of practices already [employed] or hereafter to be employed with this patient.

Although at same time some measures also taken from apprehension that already tendency to Phthisis affection.

And not impossible that if frequent returns of bloody expectoration may afterwards have recourse to others as means of increasing resistance to passage of blood by lungs.

Especially if, which at least highly [presumed], from continuation of disease indication of general plethora entirely removed.

When patient first came under care had been free from bloody expectoration for space of ten days only.

Had reason to hope therefore that [still] [some] interval for trial of means with view of preventing return.

Might with this view have had recourse to various means of preventing plethora.

Particularly to [different] evacuants.

And from none more certain or immediate affect than from blood letting

But although influence powerful yet but temporary

And in end occasions even afterwards greater disposition to renewal of same state

From this circumstance then unless where appearance urgent seldom consider it as being an advisable remedy.

Same objection does not indeed in general occur to cathartics.

And hold cathartics of refrigerant kind to be among most powerful means of counteracting tendency to plethora.

But here natural catharsis had occurred without aid of medicine.

And while this at least continues, use of these superseded.

Was then from such considerations that at commencement of treatment had recourse to nitrous powders alone.

This employed principally with view of obtaining from it considerable affects as momentum of circulation.

And by this means prevents impetus by which fresh rupture of vessels in lungs produced.

Among neutral salts many which have what may be called refrigerant quality.

That is from [solution] in mouth a sense of cold is excited.

While from action on stomach & other parts of alimentary canal produce general sensation of cold over whole system.

And at same time gives rise general affect of sedatives to [sanguine] system very manifestly diminishes momentum of blood.

Such then would naturally occur as [apparent] in present case.

Especially as besides indication of augmented impetus at extreme vessels from general [fluid] here also very considerable quickness of pulse.

Never [remained] below [100] sometimes even at 120.

Of all neutrals however none from which have ever observed more powerful affects in this way than from nitre

And accordingly in such cases is in very frequent use among practitioners in general

In my own practice have I think in such instances found it product even of best effects.

Was intention therefore to continue it to considerable extent at least for some length of time.

And if Haemoptysis did not return at usual period to go on with it till [that] period past.

Is a medicine which in common practice is exhibited in different forms.

Not unfrequently given in way of mixture

And in this [rate] action most immediate.

Yet has at least most remarkable affect as exciting cold when solution takes place in system itself.

On this account therefore consider it in such circumstances preferable to give it in [substance].

Here directed in form of powder combined with Gum Arabic.

From which as demulcent hoped for some good effect as mitigating cough.

And probable that this operated at [least] [as] exciting cause [recovery] haemoptysis

On use of this medicine patient continued for space of two weeks.

And during that period appearance rather favourable as otherwise.

Continued at least free from any return of spitting of blood.

And although [celerity] of pulse but little diminished yet skin [cooler] than before

While at same time less appearance of that florid complexion indicating augmented impetus at extreme vessels.

Thus far then seemed to have [effect]

But while in this respect relief of symptoms in other particulars where nothing [diminished].

And both cough & Dyspnoea if any thing rather augmented.

By this led to suspect that [diminishing] repeated haemorrhage there might have taken place effusion inflammation or even local suppuration in breast.

Imagined therefore that some advantage might be derived from [determining] circulation to neighbouring parts.

And was with this intention that directed application of blister to be converted into issue.

This imagined might without any inconvenience be conjoined with nitrous powders.

And that upon whole affects would rather [cooperate] than obstruct each other.

While however with copious & free discharge from blister comes relief of cough & dyspnoea appetite much impaired.

And this he suspected to be affect of powders.

As therefore no return of expectoration of blood, & as continued seemed less necessary [thought] of intermitting use.

And to this the rather induced from another circumstance.

State viz of expectoration which now took place.

From this some presumption that ulceration in breast had already in reality taken place.

For although abatement of cough & dyspnoea yet still considerable quickness of pulse

And matter expectorated to considerable extent which in some respects at least resemblance to pus.

Had appearance of pus in consistency & colour.

And was something in favour of supposition that contained slight mixture of blood.

From all these taken together [indeed] am far from thinking that have evidence of purulent expectoration.

And must own that still rather disposed to be of contrary opinion.

Yet here thought it not improper to have recourse to remedy of which have already spoken as [aid] in other Phthisis [cases]

Use viz of Gum Myrrh.

A remedy of good effects of which in [cases] of ulceration of breast, inclined to have favourable opinion.

And that both from some trials [which] have made on other occasions & still more from observations of a practitioner on whose observations am disposed to lay great stress

Yet of effects wish to be more fully satisfied by future experiments.

If therefore in present instance should afterwards have evidence that ulceration really existed, would I thought afford opportunity of trying effect.

And had at least better chance of doing good from having been begun early

If on contrary expectoration although with mixture of blood merely mucous would at least do no harm.

These then the considerations by which first induced to use of Myrrh & still [propose] to continue it.

Since begun use found symptoms so much relieved that did not bestow proper attention to supporting discharge by issue

And indeed this a practice to continuation of which from pain occasioning patients can seldom be induced.

During continuation however with Myrrh alone although cough & dyspnoea much mitigated has had some return of the Haemorrhage

By this induced again to return to use of nitre.

And now intention to give both Myrrh & nitre in conjunction

In this course if no particular reason for altering it shall wish to persist for some length of time.

And during this shall endeavour to pay attention to all circumstances by which can ascertain real nature of [expectorated] matter.

If evidence of purulence & at same time patient under this course gets rid of distemper may I think be considered as example of efficacy of myrrh.

But from what already said of progress will readily conclude that whether purulent or not, recovery by means of this is more than expect.

At same time future treatment which may be necessary must be much regulated by circumstances.

If bloody expectoration shall again return in excessive degree may have recourse besides refrigerant to evacuative particularly cooling cathartic & blood letting.

And at same time enjoining, the [avoiding] with utmost care every circumstance accelerating circulation as stimulating diet, bodily motion or like

While by these endeavour to diminish [force] by which blood expelled may also consider it even as expedient to take some measures for increasing resistance.

And with this intention may have recourse to astringent either from Vegetable or Mineral Kingdom.

As belonging to first may employ roses, succus japonica or gum Kino.

And as belonging to last may have recourse to Alum or to Vitriol acid in more pure state.

Of these vegetable & mineral astringents different combinations in the Pharmacopoeia of College of Edinburgh².

Particularly in Pulveris Stypticus & Infusion Rosarum.

In one Alum united with Gum Kino

In other Roses with Vitriol acid.

But besides this other combinations also might be suggested.

And cannot help thinking that infusion of succus japonica as well as of roses might be advantageously united with Vitriol acid.

If any astringent here employed shall probably first have recourse to this formula

Reckon it however less probable that will be necessary to alter measures with view of checking excessive haemorrhage than of countering influence of suppuration.

If this shall seem necessary some circumstances in present case which might lead to trial under cautious management of Peruvian Bark.

At same time with regard to measures to be taken in consequence of future occurrences can at present form only vague conjecture.

And shall be better satisfied if can [dismiss] patient without trial of any other medicine than already begun.

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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.

2) An official publication containing a list of medicinal drugs with their effects and directions for their use. The Royal College of Physicians of Edinburgh's Pharmacopoeia was first published in 1699.