DEP/DUA/1/16/14 (Normalised version)

William Gray

(1777-1778)

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William Gray

Respecting disease of this patient according to representation given of symptoms can I think be no room for doubt.

Affection almost solely consists in discharge of blood by anus.

This indeed an occurrence in more than one genus of disease.

To some degree takes place both in diarrhoea & in dysentery.

More especially however constitutes genus of disease by itself which in system of [illegible] universally known by title of Haemorrhois.

This indeed as well as Haemorrhagia [taken] in most extensive sense may be understood to mean every discharge of blood.

But long [peculiar] appropriated to that discharge which takes place from vessels of rectum by anus.

And accordingly on these titles of Arterae & Venae haemorrhoids has been bestowed.

In some instances state of discharge of blood may be such that difficult to distinguish whether strictly haemorrhois or whether belongs to either of two other genera.

For in some instances Haemorrhage attended with several of more common symptoms of [the] diseases.

But in present instance this not only not the [case] but state of discharge also such as evidently points out difference.

For here extent of discharge alone sufficient to evince nature.

And not merely discharged by effort to stool but runs without any [propulsion] to action in full stream

And in same manner as would do from rupture of vessels in other parts of body.

In this situation then can be no hesitation in referring it to order of Haemorrhage.

And there from situation as little doubt that belongs to this genus.

When however give it name of Haemorrhage may naturally be asked how far corresponds with definition of that [effect] as given by nosologists¹.

In greatest part of practical systems this affection divided into blind & bleeding piles.

And no doubt that both depend on affection of same vessels.

May even farther add that one frequently prelude to other

Yet as exist nature & even treatment essentially different.

[Cannot] help thinking therefore that with great propriety Mr Sauvages has divided them into two different genera.

Confining Haemorrhage to cases where discharge of blood

And distinguishing cases of tumour by general [appellation] of marisca.

While however give mention for this view at loss to consider why has referred Genera of Haemorrhage to order of Alvi flexus rather than of Sanguis fluxus

For my own part disposed to consider it as with much greater propriety referred to last than to first.

But independent of arrangement definition such as readily applicable to present case.

Essential part of definition consists in fluxus [cruris] expodice.

Has indeed added prosentibus tuberculis [rulris] durin dolorificus [cut] [usdem] in recto [latantibus].

Although therefore no external appearance in present case can occur as no objection.

And indeed in almost every instance of dissection after death by Morgagni & others some local affection always discovered.

At same time by no means in every instance of proper Haemorrhois that hard & painful tumours discovered.

Perhaps therefore definition of other nosologists [particularly] Linnaeus & Sagar where this circumstance not [introduced] less [exceptional].

But if find fault with definition of Sauvages as containing too many circumstances same objection much more applicable to that of Dr Cullen.

Definition of Dr Cullen indeed very accurate description of Haemorrhois in some states.

Especially if include under one genus both Marisca & Haemorrhois of Sauvages.

Have already however given reasons why think that should rather be considered as distinct genera.

Definition of Dr Cullen chiefly applicable to Marisca

And that too merely in incipient state.

Are not therefore to consider it as any objection to referring present case to Haemorrhois that [no] patient not affected with pain of head or vertigo.

Besides these in case before us [there] does not even occur pain of loins, about anus or any external appearance of disease

From this however mean merely to infer that many symptoms in the definition which by no means take place at every period of affection.

And that absence of all these affords no objection to pronouncing present a distinctly marked instance of Haemorrhois

And that too to excessive degree.

If account not exaggerated must own that [excepting] two instances have never seen disease to greater height.

And from event in both these little reason to look for favourable termination in present.

For under hands of most eminent practitioners neither cured.

One of them an officer in Army who died few years ago had opinion of most [eminent] practitioners not only in Britain but in France & in Holland.

And although great variety of remedies tried yet excessive discharge of blood nothing mitigated.

On contrary under all medicines used affection rather increased as otherwise.

And last in all probability from excessive Haemorrhage was seized with Paralysis of inferior extremities.

Although however loss of blood [astonishingly] great did not die from it.

But was cut off by fever at time of his death epidemic in county where resided.

Other [patient] to whom I allude whose [case] equal in violence to present a Clergyman in North of Scotland.

With him also discharge very frequent and to excessive extent.

Has consulted most eminent practitioners at this place & followed our directions with utmost punctuality but without deriving from these the smallest benefit.

My advice with regard to cure first taken about twelve months ago.

And have suggested several measures when put in practice.

But must add that have not been in smallest degree more successful than those whose opinion before taken.

And disease upon whole rather still increases as otherwise.

In so much that not long before last heard from him discharge at one time so excessive that fainted during course.

Was informed however very lately by a Gentleman in neighbourhood of place where he resides that still alive.

And that not even reckoned in more dangerous situation than was several years ago.

From these cases Prognosis that would [draw] with regard to present is that notwithstanding extent will probably not soon at least prove fatal to patient.

Or if does will rather happen as inducing some other affection than from Haemorrhage

At same time however patients may unquestionably be cut off by immediate loss of blood from Haemorrhaging vessels as well as from any other.

But must own think that here less reason to suspect this than in two instances already mentioned.

For with this patient appears at least no great degree of debility [induced]

And from peculiar paleness of countenance state of pulse or other particulars no strong indication of inanity.

On contrary not long ago when [working] seen to have occasional haemorrhage by mouth probably from lungs.

And well known that in haemorrhages in general if system does not [sink] under evacuation becomes capable of [preparing] greater quantity of blood than filled for own expense.

Thus from natural evacuation as well as from habitual bloodletting even plethora induced.

From these considerations then less disposed to be alarmed although patient discharged every day for weeks without intermission to extent of several [ounces]

And shall not be surprised to find that continually affected with it, for several years more without any bad consequences.

At same time must own that had patient even continued under our care should have entertained no hopes of cure.

This should have been inclined to conclude not only from extent but from several other circumstances.

Particularly from duration of affection.

Had continued before came under care for no less period than space of 16 years

Age also much against recovery.

For patient had already passed his 60^th year

A period at which reason to apprehend that suppression of habitual evacuation might prove [as] suddenly fatal.

Even from attempts to cure therefore perhaps greater hazard than from disease.

And must own that on this account was not much [illegible] that patient [deceived] us.

Had he however thought proper to continue under our care & to submit to measures proposed different practices which might have been used.

Of these therefore as well as of measures which in reality tried shall now offer few remarks.

Here first question occurring in practice was whether discharge to be stopped or not.

Often happens that haemorrhage particularly of active kind to be considered as salutary.

And that serve to free system from what otherwise pernicious.

Such inconvenience however or dangerous [consequences] never more manifest than from obstruction of accustomed evacuation.

In as far therefore as with prudence to be restrained must at same time be [compensated].

And in proportion as this evacuation diminishes others less distressing to patient to be augmented

By this means even while morbid state of supply to system continued, may yet be product of no inconvenience.

And even from change in condition of [evacuation] preternatural supply furnished to system may cease.

Which such attention bestowed with view of counteracting bad consequences from [stopping] discharge next to be inquired by what means that may be affected.

This chiefly to be aimed at on two principles.

First by diminishment of causes giving rise to escape of blood from vessels.

And secondly by increasing resistance to passage

Causes giving rise to escape of blood here which must be aim to diminish referred to two [heads]

1 General impetus of circulation.

Or impetus at rectum in particular.

And this last again affected either by stimulation increasing action of vessels.

Or by causes external to vessels propelling blood through them.

Such for example as muscular action in discharge of urine & faeces or even position of body.

These different particulars lead rather to attention [managed] in regimen than to use of many [medicines].

Was however with such views what few medicines here employed were directed.

First & indeed principle remedy used a gentle refrigerant cathartic

By this had in view diminishment of [impetus] of circulation in general & in vessels of rectum in particular.

These in some degree necessary affects of evacuation occasioned by purgative but especially as occurring from vessels of intestinal canal.

But besides these affects, expected still farther service as preventing accumulation of faeces in rectum.

By this means, not only an irritating [cause] removed but also that strong action otherwise requisite prevented.

Is I apprehend on these general principles that great benefit derived from cathartics in this affection to be explained.

But whatever principles of operation no doubt that in many instances are even means of complete cure.

And where this not to be obtained yet serve very greatly to mitigate symptoms.

As cathartic in this affection many different articles may be employed.

Should always however be such as operate gently without inducing gripes or tenesmus.

As answering these purposes great benefits often derived from flower of Sulphur.

In general however requires that [should] be rendered somewhat [illegible] in operation by addition

And with this view nothing perhaps answers purpose better than Cream of Tartar.

Cream of Tartar basis of purgative employed with this patient.

But here in place of combination with Sulphur directed Lenitive electuary.

From this in consequence of Senna introduced into it, expected more affect as purgative than could be had from sulphur at least to moderate extent.

And from prunes entering composition looked for more as demulcent.

Formula of lenitive electuary now much altered from what was in last edition of Edinburgh Pharmacopoeia²

And in some particulars especially with respect to simple not a little [improved]

And probably now also a more active medicine when Senna introduced into it in substance, than in former state of infusion.

Yet in one particular unquestionably worse

Formerly could be kept in sound state for considerable length of time.

Now serves little other [purpose] than as extemporary prescription.

For in few days entirely spoilt.

And would seem that thick syrup prepared from the Senna a more affective preservative for pulp of prunes than Syrup of Pale Roses which now directed to be used.

When consider therefore doubts as to [illegible] in which may be found in shops perhaps now less efficacious medicine than formerly

With our patient however purgative fully answered expectations.

Had affect of keeping belly gently open.

And bloody discharge at least considerably diminished.

While this case however without inconvenience, thought that something farther might be done with view of increasing resistance to discharge.

And was with this intention that directed a gentle astringent injection.

By this hoped that relaxed & ruptured vessels might be corrigent & braced up.

Must indeed be allowed that this not without hazard.

Yet where preceded & accompanied with uses of purgative considered it as a measure at least promising some success.

And which on that account ought to be risked

Patient himself however of a different opinion.

At least so far disliked practice that after one injection given although product of no inconvenience refused to submit to any more.

And accordingly gave up attendance here

Whether to his prejudice or not, will not [pretend] to say.

Yet must allow that if had been of any considerable service to him more than expected

May however add that although regular practitioners dare not venture on strong astringents yet no doubt that sometimes employed by empirics with success.

And greatest part of [this] [nostrum] consists of such

At present a man in neighbourhood of this city very famous for cure of bleeding piles.

This does by immediate application of a substance to affected parts, which has affect of exciting sense of burning heat.

And probably acts in some measure as an escharotic [Caustic]

Thus stopping [extremities] of bleeding vessels in same manner as if burnt with hot iron.

This substance, I am told, nearly of [consistency] of an ointment.

And that may be immediately applied to parts is pushed through a small reed introduced into extremity of rectum.

On what article principle activity depends have not heard.

But reckon it not improbable that may be from vitriol acid.

Yet [whatever] principles no doubt that in some instances has succeeded.

Was [consulted] by a Gentleman not many weeks ago who had now put himself [into] this mans care & is to try his remedy.

Patient I mention affected with Haemmorrois nearly under same form as present but not indeed to same height

Had affection however to so great extent as obliged him to give up good appointment in the Navy.

And particularly anxious for recovery that may again resume former employment.

After therefore trying for some time the measures which I had directed without success has put himself under care of man I have mentioned.

And must own not without some [curiosity] to know event of trial

Cannot help however [entertaining] suspicion that if disease be cured, patient may be killed by it.

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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.