DEP/DUA/1/26/04 (Normalised version)

Thomas Gray

(1780)

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Thomas Gray.

In this case leading symptoms obvious.

Yet in some respects not altogether without difficulty.

At same time this rather with respect to what will be progression & termination of affection than present state.

Disease which here evidently takes place neither uncommon nor slight affection.

Symptom most characteristic, & indeed most alarming, discharge of blood by mouth & nose.

From extent to which this took place as well as from mode in which happened some doubt as to origin.

When discharging at once both from nose & mouth is more frequently that from former than from latter.

For much more easy passage of matter from nose into mouth than [contrary].

In so much that while discharge of blood from nose a very rare occurrence either in Haemoptysis & Haemoptoe nothing more common than discharge of blood from mouth in Epistaxis.

Here then as discharge from both if to judge from this circumstance alone should suspect to be from latter source.

In those cases where entirely from mouth & no [suspicion] of nose yet still different sources from whence may be derived

Besides discharge which may take place from gums or throat two great sources of haemorrhage by mouth viz Lungs & Stomach

Here one of most striking differences that in former brought up by cough in latter by vomiting.

But is also in most cases at least a farther ground of distinction that in latter more suddenly occurs to great extent.

In as far as this circumstance goes would here incline us to suppose that [here] [from] stomach

For are told that not unfrequently discharges even to near extent of pound at a time.

And when brought up so rapidly must always be difficult to distinguish whether in way of coughing or vomiting.

For even when not affect of vomiting seldom that such [illegible] of fauces will not produce effects in that way.

Hence then from these circumstances at least equal reason for inferring that from stomach as from lungs.

But these grounds for doubt as to source of bloody discharge are I think [entirely] removed when attend to history given of progression of affection

From this progression notwithstanding circumstances [giving] countenance to supposition that either from nose or stomach can have no doubt in considering discharge to be from lungs.

At time when came under our care affection of 12 months standing.

At first commencement preceded by pain of breast.

This pain evidently connected with cause of haemorrhage.

For from free discharge of blood was carried off, at least for time.

Since commencement pain of breast has been augmented.

And with this augmentation increase of haemorrhage has taken place.

These circumstances alone sufficient to indicate source of haemorrhage.

But in present case still farther established by others.

Among these may mention cough.

With this affected not only during haemorrhage but also when about to happen.

But free from it at other times.

Circumstances evidently showing that then, there takes place peculiar irritation of lungs.

This still farther demonstrated by peculiar sensation independent of cough.

For will observe that preceded also by sense of creeping motion in breast.

To these circumstances, if additional proof necessary, might add also state of discharge at commencement

For began with severe cough.

Then discharge of blood only to very slight degree

And adhering to matter evidently from lungs.

Lastly opinion as to seat of discharge corroborated by cause to which attributed.

Affection here represented as consequence of chin cough.

And although in that complaint [depends] as to seat of principle morbid affection, yet no doubt that lungs subjected to very violent motion.

And thus a cause much more probably inducing haemorrhage from thence than from other parts.

Upon whole then pronounce this affection when patient came under care to be case of haemoptysis

Here however a question of some importance both with respect to prognosis & practice, whether of active or passive kind.

Is somewhat in favour of latter supposition that immediately arose from circumstances just mentioned.

Violent concussion viz consequence of Chin cough.

This however may have begun [discharge] from mere mechanical rupture, although now supported by other causes.

And indeed may of itself have operated as cause giving determination to breast.

Thus producing morbid state of action

And that on such state of action, now at least principally depends, is proved by many circumstances.

Particularly by pain & sense of creeping motion [preceding] discharge.

But still more, by relief which the haemorrhage affords.

On these grounds then consider it as being principally at least of active kind.

Yet would not assert that by concussion by chin cough as well as frequent ruptures since happened vessels may not have been brought to state [ready] [rupture]

From this view of nature of affection next then to give opinion as to probable termination

And here must own that not without difficulty, although little doubt as to nature of disease

Haemoptysis in general an affection if not from itself, at least from consequences hugely dangerous.

For in many instances gives rise to fatal Phthisis.

And this more to be dreaded at early, [that] at advanced periods of life.

More to be apprehended when consequence of preceding disease in lungs, than when merely effect of haemorrhagic affection proceeding from plethora or other causes; that is when [there] active haemorrhage.

For in such cases but chance at least of ruptured vessels healing by first intention, & without suppuration.

In case before us however though consider it, as principally active yet in some measure of [mixed] nature.

Hence then perhaps upon whole most probable event that will terminate in Phthisis & from thence fatally.

This the rather to be dreaded from continuation which has already had.

Has subsisted for space of 12 months.

And during that time has not only become habitual to system but increased in violence

In so much that discharge at once to quantity of near pound.

From this circumstance reason even to dread still more sudden fatal conclusion.

Would not be singular if patient cut off even by haemorrhage itself.

Of this however must own, less apprehension.

And although in other way mentioned [consider] case of dangerous yet far from thinking it desperate.

Still at least consider it as in state of simple haemoptysis.

For no symptoms of hectic fever or other marks indicating tendency to Phthisis have yet taken place.

Although danger therefore yet from proper measures not without hopes of recovery.

In employment of these however from irregular attendance of patient little opportunity

Shall therefore think it less necessary to say much with respect to it.

Still however may state plan of cure & measures which should have [thought] of employing if attendance continued & circumstances of case permitted.

Here discharge at times to so great extent that might even be thought necessary to propose measures with view to stopping during course.

In administration of these however great [nicety]

And as patient not immediately under eye could not expect proper administration of measures to be regulated by state of pulse & other such circumstances.

Here sudden stoppage the rather doubtful as haemorrhage attended with relief.

And here became much more important objective to prevent recurrence when stopped.

This however if conjecture as to nature of case well founded most immediately affected by diminishment of augmented impetus at breast.

For this according to supposition [entirety] is the cause by which renewal produced

But besides this probable also that state of vessels such that rupture [renewed] from very slight causes.

Hence also consider it as objective here to increase resistance to passage at lungs.

For answering both intentions various measures may be employed.

And although sometimes may be aimed at together yet in general more easily attainable in succession.

Was with view to first that in instance before us had recourse to combination of Nitre with Gum Arabic.

Latter article intended principally for covering taste & giving form.

Imagined however that in some degree might act as demulcent.

But was from former solely that expected any effect as tending to diminish cause of haemorrhage.

Respecting action of Nitre indeed all practitioners by no means agreed.

Can be no doubt that to certain extent operates as stimulant to moving fibres.

This appears both from application to eye & other very sensible parts & likewise from injection into rectum by way of glyster.

Then as well as common or Glauber salt to certain extent at least produced Catharsis

Yet by greater part of practitioners held that from action on stomach produces refrigerant effect & diminishes impetus of circulation.

And this opinion, from what have seen of effects in practice, have for my own part no doubt in adopting.

Is undeniable that by solution in [mouth] very great sense of cold excited.

And that this effect as discovering on system in general still more remarkable for action on stomach.

With diminishment of heat there at same time occurs corresponding diminishment of [impetus] of blood.

And in own practice very much deceived if have not often found it product of best effects.

Hence then particularly calculated for cases of haemorrhage, where supported by increased impetus whether general or local, while at same time no general plethoric state

And still more where state of [illegible] constrained farther attempts to diminish by evacuation.

Accordingly in such cases very few [practitioners] who have not recourse to it.

On these grounds then here employed in preference to other measures

For trial during space of week taken to extent of ℥I a day product of no inconvenience.

And perhaps in some measure effect of medicine that during period mentioned no return of haemorrhage.

In this situation then could have no hesitation in ordering continuation.

And even in persisting in use till return of bleeding or other occurrence should indicate other measures.

In that situation had thoughts of blisters & gentle astringents.

Particularly Gum Kino or Succus Japonica.

But in these must entirely be regulated by circumstances of case.

And as not impossible that may see nothing more of patient farther remarks unnecessary.