DEP/DUA/1/25/14 (Normalised version)

Phillis Denham

(1780-1781)

---

Phillis Denham.

With regard to disease to which this patient subjected little room for doubt.

From history of affection before came under care as well as from present symptoms no doubt in considering it as instance of distinctly marked Phthisis Pulmonalis

This abundantly evinced both by state of pectoral complaint & other symptoms.

No room to doubt that with cough & dyspnoea matter expectorated of purulent kind.

This may presume both from smell & taste which told very disagreeable

But still more from bloody expectoration which here occurs.

This still at times very frequently takes place.

And from history of affection learn that at first occurred to very great degree.

Besides these particulars, if any farther proof wanted, afforded in cleanness of tongue

For with very considerable quickness of pulse, will observe that has not white furred appearance which might thus be expected.

But continues both moist & peculiarly clean

Such an appearance however never fails to take place where considerable purulent expectoration

And from continuation often even goes to greater length.

In place of natural colour gets peculiar redness rawness & soreness.

Often even to such degree as to be very painful nay ulcerous in different places.

Here though has not proceeded so far yet, at least, in such a state that from thence no objection to supposition of purulent expectoration.

On contrary affords even additional argument, as far as such here necessary.

But besides state of expectoration every other symptom also corroborates supposition of Phthisis.

This if not evident at least [rendered] highly probable from very appearance of patient.

For in external marks of exhausted habit & general expression of countenance, has as much of consumptive appearance as can well suppose

This indeed not as far at least as can learn effect of colliquative sweats or looseness.

For while not subjected to former, belly in general rather bound.

With frequent hectic accessions however is subjected to almost constant fever.

And indeed pulse in general between 100 & 120.

At same time never free from very considerable thirst.

Besides these symptoms, another also which may here be considered as deserving some notice

I mean state of menstrual discharge.

This before she came under care, had been absent for space of two months

And for near same length of time, during which has been here under care, no appearance of it.

Obstruction to this evacuation, frequently occurs in practice, both as consequence & cause of many different diseases.

And in some instances, gives rise to such symptoms as here occur particularly bloody spitting

But in case before us no grounds for such a supposition.

For while phthisis complaint of more than 12 months continuation this supervened only very lately.

Here then, in as far as any connection no doubt that to be considered as consequence.

And although menstrual will [sometimes] continue in very exhausted state of Phthisis yet failure a very frequent occurrence

And that had failed from this cause in instance before us, may be inferred if not with absolute certainty at least with high degree of probability.

Consider it therefore as one of the many symptoms of Phthisis in this case.

But while thus confidently pronounce case to be Phthisis, with view both to prognosis & practice, necessary that should go one step farther.

For every instance of Phthisis not of same nature, or requiring same treatment

This nosologists¹ have endeavoured to [correct] by division of affection into numerous species

But, as shall afterwards endeavour to show in practical course, for most useful divisions may be referred to there

These, which shall then have occasion particularly to describe, may be distinguished by titles of catarrhal, ulcerous, & tuberculous.

In first purulent matter afforded merely from internal surface of lungs.

In second from large ulcer or vomica

And in third from tubercle or indurated gland commonly of scrofulous nature.

Case before us consider as an instance of second kind mentioned or ulcerous Phthisis

To this in first place led from absence of characteristics of Catarrh or tuberculous.

And in second place from being attended with common characteristics of ulcer.

In particular manifested by quantity to which purulent matter expectorated

By pure state, in which according to accounts given us, is discharged.

But above all by bloody expectoration by which was at first ushered in & is still attended.

On this view of affection then as being viz an example of ulcerous Phthisis next proceed to few remarks on Prognosis & Practice

And here need hardly observe that Phthisis of every kind unquestionably a most dangerous affection.

Presumption therefore is, that patient will in end fall victim to this disease

And when consider present situation reason to apprehend that this termination not very far distant.

For although patient still strong enough for attendance here, yet state of expectoration & of pulse as well as general appearance of habit, give every reason to conclude that affection of very dangerous tendency.

Here may only observe that this species of consumption while more dangerous than catarrhal, is yet less so than the tuberculous.

And accordingly has not in general so rapid a course.

Matter commonly formed in [illegible] large abscesses more mild & bland than the sanies yielded by tubercles of scrofula kind

And accordingly hectic fever less rapid in progression.

From this however do not [illegible] us as having any great grounds to hope for cure.

But from slow progression at least better opportunity for trial of measures for that purpose.

And if by any measures which can here employ, recovery affected must own will consider it as strong evidence, of efficacy of these measures.

In ulcerous consumption great objective to be aimed at is the healing of the ulcer.

And for this purpose first necessary that purulent matter [collected] should be discharged.

And secondly that proper adhesive inflammation should be induced.

Here no doubt that vomica already burst

And by coughing, which matter [chiefly] excites, sufficient free discharge produced.

For first purpose then no measures [seem] here necessary.

And indeed when consider tendency to haemorrhage by lungs, becomes necessary to shun every cause of concussion.

Here therefore in as far as measures to be employed solely to be directed to second objective

The healing up ulceration from which pus already discharged.

This it must be allowed in great measure if not entirely a process of nature

And suppose that certain articles possessed healing, or [uniting] power in great measure if not entirely founded on credulity.

At same time no one can deny that process of healing connected with certain state of inflammation.

To this in contradiction to suppuration on one hand, & gangrene on other [most] physicians, particularly Mr John Hunter of London have I think with propriety appropriated name of adhesive

The inducement therefore of such a state of inflammation is of great consequence in cure.

And for this purpose sometimes necessary to increase sometimes to diminish action of vessels.

Is on former of these principles that are I think to account for operation of medicine here employed viz Gum Myrrh.

And with this intention had here recourse to use.

On this ground can readily understand why present as well as other healing balsams, as have been called, sometimes of service sometimes prejudicial in this complaint.

And accordingly while one set of practitioners entirely condemn use, by others very highly extolled.

But whatever may be principle of operation, none on which greater [illegible] of late bestowed than the Gum Myrrh.

Has in particular been for long time a favoured remedy with the Physicians at some of the hospitals.

+ Of principles indeed on which operates different opinions entertained.

But if efficacy ascertained this a matter of no great consequence.

And at present very much used both by Dr Fordyce & Saunders two of most eminent teachers of practice in London.

For most full accounts of observations respecting it, may refer you to Dr Simmons treatise on consumption².

And this authority also may be added to that of other gentlemen mentioned, in test of efficacy.

In confirmation of these, can I think also venture to add the results of my own experiments.

For although far from representing it as what has always succeeded with me, in cases even most favourable yet have sometimes I think seen it product of best effects.

And as far as my observation goes principally useful, in this species of consumption, the ulcerous.

On these grounds then here resolved, as far as circumstances would permit, to give it full & fair trial.

Combined with Cream of Tartar with view of obviating costiveness to which patient subjected.

Under this course patient has now continued for several weeks.

Cannot however say that as yet product of any considerable advantage.

And patient during course of attendance rather losing ground as otherwise.

This however no more than [should] have expected, in progression of affection.

And no reason to believe that has been product of any bad effects.

Is still therefore intention to persist in use.

Should it be necessary to [relinquish] employment have at present in view no other particular remedies to which thoughts of having recourse.

And practice must entirely be directed by circumstances of case at the time.

---

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) Samuel Foart Simmons, Practical observations on the treatment of consumptions (1780).