DEP/DUA/1/24/05 (Normalised version)

James Ingram

(1780-1781)

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James Ingram.

Disease to which subjected consists of but few symptoms.

And these of such nature that can leave no room for doubt as to complaint.

That in affection of this patient an example of Haemoptysis evident from bloody expectoration.

To be observed however that [mere] bloody discharge from lungs may [arise] from very different causes.

And particularly that may depend upon haemorrhage either of active or passive kind.

Determination of this question of consequence both in prognosis & practice

And although sometimes very easy matter yet others where cannot arrive at certainty.

This I think some reason for pronouncing to be case in present instance.

For though pulse affected, not such increase of velocity or force as is the common attendant of active haemorrhage

While again if fever at all [existed] but very inconsiderable.

For appetite natural & free from thirst

But on other hand passive haemorrhage seldom commences without obvious cause

And in instance before us patient unacquainted with any accident which could induce it.

Had received no external injury

And all the coughing which was affected no more than tussicula which attends every instance of [activity].

If therefore of passive kind must have depended on some local erosion of vessels at some part of lungs.

And this by no means impossible.

At same time consider supposition of its being of active kind as more probable.

Patient not past that age when such might be expected.

Pulse evidently that peculiar [hard] feeling which so much the concomitant of increased impetus.

Heat of skin above natural standing

And if other febrile symptoms less considerable than might have been expected to be remembered that Haemorrhage but to slight degree.

While then consider affection as Haemoptysis look upon Haemorrhage to be of active kind.

Any farther inquiry respecting species reckon unnecessary.

For although many by Sauvages Sagar etc yet merely of same [essential] nature, proceeding from different causes.

As to prognosis in this case may be thought, from beginning haemorrhage very slight.

And that now [appearances] have almost entirely vanished.

Yet even on these grounds cannot venture to give favourable prognosis.

For to be observed that haemoptysis, not so much indeed from itself, as from consequences, a very dangerous disease

Well known that often terminates in Phthisis pulmonalis.

And this more frequently the case when haemorrhage very slight than when very severe.

Though sometimes yet seldom death from mere discharge of blood in this disease.

Hold therefore that even trifling discharge when long continued the most dangerous.

And although with our patient has been but of short continuation yet not free from alarm while any pain of breast.

Would not therefore be surprised at recurrence.

And although does not at present happen, may afterwards take place.

At same time if no threatening appears soon, may consider farther attendance as now at least unnecessary.

And may dismiss patient as cured at least for the time.

This however cannot I think with any great degree of confidence attribute to measures here employed.

For some reason to think that would not have proceeded to any greater extent although no measures had recourse to

At least farther than avoiding accidents by which might have been aggravated

Here however proceeded on same plan that should have done had haemorrhage been much more considerable.

First objective to be aimed at in all [such] cases the prevention of farther discharge by the lungs.

Active haemorrhage often it is true occurs with state of system in which discharge of blood [requisite] & [healing]

Thus in some cases epistaxis rather to be encouraged as otherwise.

But though may be proper to diminish quantity of blood, yet never I apprehend proper that diminishment should take place by lungs.

For from such always danger of suppuration & consequentially Phthisis.

Hence therefore always objective to stop & prevent as soon as possible.

This however not to be attempted by increased resistance to passage of blood by lungs

For from this merely worst consequences might arise.

Must be objective therefore to prevent it by removal of cause.

And particularly by diminishment of impetus of blood, by which rupture produced & discharge continued.

From situation of lungs however have it not in power to diminish impetus at vessels there in particular.

Must endeavour to effect it therefore by diminishment of impetus in general.

On this footing will readily understand meaning in different practices to which had here recourse.

Although no manifest signs of plethoric state, yet began by directing blood letting.

For plethora may excite although not strongly indicated by any mark.

And in this affect reduction to natural standard essentially necessary

As means of diminishing impetus [nothing] more effective than reducing below natural quantity, the inducement of state of inanity

For well known that quantity of blood principal if not only stimulant to action of vessels.

Here however no necessity for large bleeding, as in symptoms nothing urgent.

And if large evacuation necessary more benefit to be had from repetition of blood letting at short intervals.

From this then limited quantity to eight ounces.

And was intention if circumstances required to have again recourse to repetition

Meanwhile however had recourse also to another medicine.

The use viz of Nitre.

Well known that nitre excites sense of cold both in mouth & in stomach

But besides this influence in same way extended over whole system.

And sense of cold accompanied with considerable diminishment of impetus of circulation.

Here therefore useful as answers same end with blood letting.

But as with former remedy also here no necessity for being precipitative.

Employed therefore only in small doses.

And combined with Gum Arabic rather to give proper form than with any other intention.

On this course although no return of bloody spitting, at least for some time past, patient still continued.

Rather indeed that attendance might be continued, & that might thus be able to judge how far in reality [remedied] than with any other intention.

And had in view the dismissing him at last weekly visit.

But at that time informed of [circumstance] from which led to alter resolution.

That affected viz with local pain in breast.

This may indeed proceed from [various] causes & may be totally unconnected with Haemoptysis.

Yet where such symptoms had taken place some grounds for alarm.

For although not urgent might be prelude to another haemorrhage.

Reckoned it therefore proper that attendance should be continued till saw [conclusion]

And on whatever cause might depend, whether connected with Haemorrhage or not, thought some benefit might be obtained from blister

To this measure therefore had recourse

And am in hopes that by next report may be informed has had affect of complete removal.

If this the case without return of bloody spitting shall reckon farther attendance unnecessary.

But if pain continues may according to circumstances in which find it have recourse to measures for obviating it.

If Haemoptysis returns shall prosecute plan already begun.

And unless attended with new occurrences shall put more dependence on blood letting than any other measures

At same time however enjoin the carefully avoiding all causes which can tend to augment [quantity] of impetus of blood.

Particularly recommend low diet & the shunning stimuli whether external or internal.

Am in hopes that except such regimens no farther measures will be necessary