DEP/DUA/1/25/07 (Normalised version)

John Lethem

(1780-1781)

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John Lethem.

In case of this patient no great variety or complication of symptoms.

And what most alarming at same time most distinctly marked.

viz very considerable bloody discharge by the mouth.

For of this, cough & dyspnoea to be considered as merely symptoms.

And same also evidently case with respect to sense of tumour which refers to region of stomach.

Here then no doubt in considering affection as referable to head of haemorrhage.

May however be some question whether blood discharged from lungs or stomach

That is whether affection to be considered as instance of Haemoptysis or Haematoma.

May be considered as in favour of latter supposition that discharge of blood to considerable extent.

That in quantity even of pounds comes up by vomiting.

And lastly that discharge preceded by sense of tumour which [referred] to region of stomach

But must at same time observe that none of these symptoms conclusive

For on some occasions discharge of blood from lungs very copious.

And when that case seldom fails to excite vomiting

While again as to feeling great room for deception.

And what referred to region of stomach may very readily be above the diaphragm

While these circumstances of little weight as determining it haematoma, others as [strongly] favouring supposition of Haemoptysis.

This particularly favoured by cough & dyspnoea with which attended.

By blood being often evidently coughed up from lungs in small quantity

And by state of expectoration when no bloody discharge

For then according to account given us has every mark of serous & sometimes even of purulent appearance.

Farther also to be added that no bloody discharge by stool.

A circumstance almost never failing to happen where haemorrhage in stomach or any part of alimentary canal.

Upon whole then although not altogether without difficulty yet would pronounce it a case of haemoptysis.

Still however a question of no less importance.

Whether viz haemorrhage of active or passive kind.

For while in both discharge of blood yet require very different treatment.

Here little doubt that at commencement haemorrhage of the active kind.

Took place with habit of body & at period of life when active haemorrhage most common.

And did not arise from any violence or accident.

Little doubt however that from [rupture] this induced way paved to future [disease]

And am inclined to think that now both renewed & [supported] by agitation from coughing.

Hence then inclined to think that what has taken place since came under our care principally of passive kind.

At same time from quickness & hardness of pulse little doubt that [favoured] by [disposition] to active haemorrhage.

This then idea of disease on which to found opinion of prognosis as well as plan of cure.

With respect to former sentiments not favourable.

Affection always considered as dangerous.

And from several circumstances more remarkably so than any other haemorrhage.

In case before us already of considerable continuation & has gone to great height.

And even fatal conclusion to be apprehended in two ways.

Either viz from immediate effect of excessive haemorrhage.

Or from supervening Phthisis in consequence of suppuration.

And of the two, this the termination of which must own am most apprehensive.

At same time would fain hope that neither one nor other will take place while remains under our care

And although cannot expect to remove disposition to renewal from slight causes yet for present at least may ward off danger of affection.

Measures to be prosecuted for this purpose directed with one of two views.

1 The restraining or stopping discharge of blood when urgent.

& Secondly The prevention of return.

These according to circumstances of case to be aimed at on different principles.

And on what principles have here endeavoured to accomplish them will appear from few remarks on practices employed.

First prescription powder of Succus Japonica & Cream of Tartar.

First of these articles, a vegetable extract from a species of Mimosoideae one of most powerful of vegetable astringents.

With which however at same time combines mild mucilage quality.

A circumstance here particularly favourable as [might] then be serviceable in allaying cough.

But principally used with view to astringency.

And from idea that haemorrhage now a good deal of passive kind & [supported] by state of vessels.

No doubt that astringent power of this medicine as acting upon stomach communicated to every part of system.

And accordingly in last edition of Edinburgh pharmacopoeia¹ is one of article of Pulveris Stypticus

Here expected that as gently increasing resistance to passage of blood through [ruptured] vessels, might have tendency both to check present discharge & prevent return

From idea however that still tendency to active haemorrhage could not trust to this mode alone.

While at same time after exhaustion [which] had already occurred unwilling to employ any powerful evacuant.

Imagined therefore that intention might be better answered by Cream of Tartar than any other.

And in this conjunction of refrigerant with gently purgative powers.

Could not however in latter way expect much from ʒiii in day.

But this quantity with most [people] will move belly.

And hoped at least that might counter tendency to Succus Japonica to bind

From conjunction therefore in several respects looked for good effects.

And from continuation for space of week symptoms if not alleviated at least continue moderate - Little bloody expectoration

Still however much affected with severe cough, hoarseness & dyspnoea.

In this situation recourse to blister with issue.

From which while expected that these symptoms might be relieved hoped also that as diminishing determination to [breast] might prevent haemoptysis.

Benefits reaped has led even to repetition.

And although symptoms very far from gone yet is I think in such situation as to encourage to continuation.

With this view mean not only to persist in repeated blisters & issues but to increase both Succus Japonica & Cream Tartar

And shall probably also conjoin with these some demulcents with view of lubricating fauces.

If these measures unsuccessful may next have recourse to more powerful evacuant or more powerful astringent accordingly as symptoms seem to indicate that tendency to active or passive haemorrhage is the greatest.

Or perhaps even may be necessary to turn attention to counteracting sequel.

But measures for this purpose hope will not be necessary.

And therefore nothing at present to be said with regard to them

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Explanatory notes:

1) 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.