DEP/DUA/1/22/15 (Normalised version)

Helen Brown

(1779-1780)

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Helen Brown.

When selected this case at some loss with regard to it

Consider it however as exhibiting a [collection] of symptoms which do not every day [occur]

And had some suspicion that affords example of an affection not very common.

Here, most remarkable part of affection consists in dyspnoea.

Respiration according to account given us never without difficulty

But particularly so, on certain exertions & on certain posture.

Is especially increased during action necessary for going up hill.

That so much case, that are told, is then at times deprived of breath altogether.

A certain evidence that strongest voluntary efforts necessary for continuation of this action.

And therefore that liable to interruption when mind concerned & occupied, with other exertions.

But if difficulty on such action, still more from change of posture.

This so much case that incapable of breathing in horizontal position.

And therefore during whole course of night can sleep only when erect.

From these conditions then, naturally led I think to seek for dyspnoea here from fixed cause.

That is not so much from defect or morbid state of action in moving powers, as from uncommon resistance which these have to overcome.

Such resistance however may be of very various kinds.

And of this conjecture to be formed only from concomitant circumstances.

Was in hopes that during course of attendance such circumstances might here [occur] as to give if not certain at least high probability.

Since this patient however under our care have seen very little of her

Still left therefore in same state of doubt as before.

Here may observe that dyspnoea with these symptoms, by no means an uncommon affection, at age at which our patient arrived, from accumulation of mucus in breast.

And this also, not unfrequently consequence of that cause to which affection of our patient here attributed, viz cold.

Of this kind by much greater part of those cases of difficult respiration in old people which even by practitioners termed Asthma, although indeed, with great [impropriety]

But against such a supposition in this instance an unsurmountable objection.

For when mucus accumulated in Bronchia never fails to give cough & viscid [expectoration]

Here however neither cough nor any expectoration of mucus.

And for most part has very slow advance

But besides this other causes also

May proceed either from other fluids impeding enlargement of lungs or from solids.

Here however when consider that disease of no very long continuation, that has had comparatively rapid progression, & that much aggravated by an horizontal posture probable that [not] of latter kind.

For in dyspnoea from affect of solids, difficulty of breathing not increased from horizontal posture but from lying on one or other side.

Besides mucus lungs liable to compression either from water or from blood

Latter of these fluids particularly, this affect as contained within varicose aneurism or distended blood vessels.

And of such a cause may be thought that here some presumption from palpitation at heart.

But for most part this attended with some [rupture] at least of small vessels giving bloody expectoration.

And in general pulse subjected to irregularity

To all these circumstances farther to be added that is at least a much more rare cause, than compression from water.

Water in chest may give dyspnoea, either from existing in state of Anasarca of lungs, or of Hydrothorax

Here however could not suppose it of former kind, as patient no other anasarcous symptoms.

And as that dyspnoea in general attended, both with cough, & watery expectoration.

While again not aggravated by change of posture.

Next then to consider how [far] [probability] that this affection depended on water within cavity of chest.

In systems of Nosologists¹ Hydrothorax [variously] defined.

But in most, symptoms introduced as essential to the disease which do not here occur

In all great characterising symptoms is difficulty of breathing increased by horizontal posture.

And this according to account given us here occurs to very great degree.

But to these symptoms Mr Sauvages has added peculiar paleness of countenance, with swelling of hands and feet.

Of first of these can hardly judge from want of former acquaintance.

But if alleged that may be present, yet oedemata swelling of legs & feet [unquestionably] [abates]

Nor is patient affected with that peculiar stupor in either arm, which he seems to consider as characteristic of the disease.

This indeed though an occurrence very distinctly marking the affection does not enter into definition of others.

Particularly has no place in definition of Dr Cullen.

And for this unquestionably good reason since by no means always present.

Dr Cullen however has introduced another symptom which he again considered as a [pathognomonic] or essential symptom

That is sudden starting from sleep with peculiar uneasy sensation & remarkable palpitation

To this cannot be alleged that this patient subjected.

And if be a symptom always occurring in hydrothorax disease unquestionably does not here take place.

But even in my own practice, have met with more than one instance, where after death certain evidence of Hydrothorax, & where this appearance did not yet take place.

Besides in case before us frequent palpitation observed to occur.

And in thirst to which patient subjected while moist tongue have at least a common dropsical symptom.

To this may add as farther [presumptive] circumstance, pains of which complains at inferior part of Thorax

Proper pain indeed not marked among symptoms of this affection.

But sense of uneasiness & weight then in general attends it even from commencement.

And indeed may be considered as necessary consequence of weight of water upon diaphragm

Upon whole then from all circumstances taken together was inclined to suspect that patient subjected to Hydrothorax.

Yet from circumstances which have now [stated] cannot deliver this opinion without doubt.

And could only expect here from future opportunity of examining patient & from marking progress of disease to form decisive opinion.

Whether however shall now have such opportunity extremely doubtful.

And rather so, as although have not seen patient, learn that symptoms are upon whole aggravated.

From this circumstance joined to opinion of disease, prognosis cannot be favourable.

Hydrothorax occurring even in most favourable circumstances always dangerous.

But particularly so when takes place very late in life.

Notwithstanding any measures which could have taken [grounds] I think to apprehend that patient would have fallen victim to [it]

If however should again return to attendance here different measures which might at least be tried.

Here unquestionably first & principal objective to be aimed at in, cure is removal of water

And although often more difficultly effected than in some other cases, yet to be attempted at on some general principles.

[If] [however] doubts as to artificial opening into cavity containing water, in other cases, still greater in this.

And particularly till absolute certainty of presence of water by distinct fluctuations, could never be thought of.

Here therefore may be considered as [entirely] reduced to attempting cure, by natural [outlets]

At least by removing water in first instance from cavity of breast by absorbents

But after thus taken up may be as it were artificially discharged.

And in practice, few modes of cure found more effective than application of Blister.

Where strongest reason to suspect disease have in particular best effects from application to chest.

To this practice therefore was intention to have had recourse with present patient

Began therefore by directing Blister in hopes that might both promote absorption from Breast and discharge of water after [absorption]

But notwithstanding severity of affection would seem that to this practice patient [herself] very averse.

And accordingly was not applied.

With use of Blister here directed also Cream of Tartar to extent of ℥i every morning.

From this had principally in view the obviating costiveness to which patient subjected.

And hoped that while had effect of gently opening belly might also both in some degree mitigate thirst, & increase quantity of urine.

Under this medicine, was intention to [continue] patient regularly, while employed blister at short intervals.

And during this course, hoped that affection might have been removed

If this however had not been case & if from progression of disease certain evidence that not been mistaken as to nature of it, two other remedies to which had [view] of giving trial in succession.

viz Digitalis purpurea & the Melampodium or Helleborus niger.

First of late introduced in dropsy & has been found particularly successful in hydrothorax from evacuating both as cathartic & diuretic.

Latter rather [revived] than introduced particularly by Mr Bacher of France.

And under form of his Pilulae Tonicae should here have thought of employing it.

Must however at same time observe, that if have yet opportunity of trying either, consider case as unfavourable.

With patient at 70^th year of age much freedom cannot be used with [active] medicines.

And if again returns to attendance shall wish to give first trial to blisters & Cream of Tartar as before proposed.

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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.