DEP/DUA/1/30/16 (Normalised version)

Arabella Wallis

1782

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November 11^th. 1782.

Arabella Wallis at 10. of a pale & yellowish countenance, dark coloured hair & eyes, is affected with very frequent & sonorous respiration attended with a short interrupted cough

This symptom suffers frequent exacerbations & remissions at uncertain periods, but she is never wholly free from it. She expectorates but little & her sputum is not very viscid. She complains of pains in her forehead chin, ears, breast & the region of the umbilicus. She has frequently the sensation of a ball, rising from her stomach to her throat & inducing an asthmatic paroxysm.

But she has never discharged any wind. She has frequent contractions of the fingers & pains in the calves of her legs. she has sometimes cold shiverings succeeded by febrile heats

Her sleep is interrupted during the night.

Pulse 120 rather full but not sharp or hard. Tongue natural, Belly regular appetite indifferent. She is sometimes thirsty. She had the measles about a year ago since which she has been much afflicted with Catarrhal symptoms for which she was admitted a patient at the Dispensary, on the 12^th of September

Her pulse was at that time above 100, she was also troubled with dyspnoea but in a less degree than at present & her respiration was not then remarkably sonorous.

She had two vomits & a blister & was dismissed relieved.

Very soon after her dismission, which is about seven weeks ago, she was suddenly affected with the symptoms described in the case, but with much greater violence than at present.

She had a blister immediately applied to her back without the least relief. The mother ascribes good effects to the Mistura Oleosa which she has been taking now above a month

She has had three vomits without deriving the least advantage from them.

The present affection began without any obvious cause & she finds no alteration in it from change of weather or exposure to different temperatures in respect to heat or cold. She is remarkably acute & sensible for her age, as appears from the answers she gives to the questions put to her.

November 16. Rx. Spt. Aether Vitriol

℥ii. Mucil. G. Arab. ℥ii. Ag.

Font. ℥IV M. cap. ℥P. bis indies.

nec non Rx Calc Zinci. gr iii

Pulv. Valer. Sylv. Ji. M. cap. dos om. m.

23. Has taken the mixture with the Spiritus Aethereus without any inconvenience, but the powders have in general produced sickness at stomach & sometimes vomiting

Her respiration is on the whole rather easier but still much affected.

January 11^th At one o’Clock after complaining of a stitch in her side & the sense of a ball rising to her throat, she fell into a Syncope which terminated fatally. She had taken the last spoonful of the medicine prescribed for her the night before her death & had no stool for twenty four hours previous to that event. The last thing which she took was a draught of cold water.

January 12 one p.m. the body was opened. The Trachea was perfectly sound excepting a small ulcer at the head of the Larynx.

Some water was found in the cavity of the Thorax & about five ounces in the Pericardium. The heart was in a sound state but contained a large polypous concretion in the right auricle & ventricle.

The lungs adhered in several places to the pleura [wall] full of small hard knots & on incision discharged a considerable quantity of purulent matter, but no large ulcer was found in them.

The cavity of the abdomen contained six or seven ounces of water.

All the abdominal viscera were in a sound state, only the kidneys were larger than usual & the Lymphatic glands of the mesentery appeared somewhat enlarged. There were some constrictions in the course of the intestines. The omentum as well as they tata adiposa contained more fat than might be expected considering the long duration of her complaints.

We are informed that for some time before her death she had evening exacerbations of fever, with increased cough & dyspnoea. She could not lie on bed easily on either side & slept generally in an half erect posture, supported by pillows. She had no sonorous respiration for some weeks before her death.

Opinion formerly delivered of this [patients] disease that was female of peculiarly irritable habit.

And although only in very early period of life yet subjected to distinctly marked Hysteria

From this cause inordinate action [taken] place even without any obvious circumstance [exciting] it in many different parts of body.

But more especially apt to affect muscles of Larynx.

Probably effect of some local marked affection there.

Now therefore necessary that from account of death & dissection just read, should consider how far reason to believe that this conjecture well founded or contrary.

How far evidence of any other affection, of which did not entertain suspicions.

And to what cause death of patient with greatest probability to be attributed.

Here must acknowledge that event of disease has been different from what expected.

And that has taken place also in different manner.

Did not imagine that would have terminated fatally.

And little expected, that if such event had been to take place, would have occurred in manner that did.

If as formerly supposed, patients principal disease of hysteria kind, not to be considered, as in its nature very dangerous

And little reason I think to suppose that from this cause death has ensued.

This however gives no ground for concluding that patient was not really subjected to hysteria.

For certain that hysteria may be complicated or occur at same time with most dangerous diseases

Thus as in case before us not unfrequently the concomitant of Phthisis.

Within these few years have lost two patients sisters of same family both of whom died of Phthisis distinctly [marked]

And in both, for years before Phthisis began as well as during course of that affection Hysteria fits & other symptoms to very great degree.

That from dissection, [no] proof of hysteria afforded, cannot seem surprising.

For well known to be a disease where in very rare instances only that any local affection to be detected.

And when such are found, much more frequently consequences than causes of the disease.

Hence then dissection affords at least no objection to former supposition of hysteria.

While many of symptoms particularly globus hysteria which attended disease through whole course gave strong evidence of it.

Next to Hysteria symptoms what at one time at least the most alarming was affection of Respiration.

This I formerly endeavoured to show probably principally proceeded from spasmodic affection of muscles of Larynx.

And that thus connected also with hysteria.

But from constancy of affection, as well as length of time for which had subsisted, conjected that must be supported by some local affection.

And after dissection must own am now at loss to say whether [appearance] [illegible] corroborates this supposition or not.

Not long after last lecture on subject must own was inclined to desert supposition of local affection.

For suddenly & indeed unexpectedly entirely ceased.

And that too without any obvious change such for example, as discharge of purulent matter, uncommon expectoration or like, which could give reason to believe the removal of any local affection.

For this therefore was I own led to conclude that former idea a mistaken one.

Yet upon examination of Larynx on [dissection] an evident local affection was discovered.

An ulceration viz in Larynx at head of Trachea.

From this [appearance] however no pointed conclusion can I think be drawn.

Supposing to have taken place while peculiar affection of respiration existed, are yet uncertain how far a cause adequate to effect.

But besides this to be remarked that this symptom had been totally absent several weeks before death.

And that whole appearance here found may have occurred after had entirely ceased.

On the other hand however may be conjected, that what now found, merely remains of larger affection of same kind

And that when symptoms subsisted if not dependent on more extensive affection of same kind, at least connected with it.

Thus then would infer that from [appearance] found, no certain conclusion can be drawn.

At same time, think it more probable that this local affection had some share in inducing peculiar noise in respiration; than that had none.

But must also acknowledge that was not of that kind which formerly [suspected]

For apprehended some uncommon tumour scirrhous or the like

And of these no vestiges or indication

Polypous concretion in ventricles & aurum hardly to be ranked among morbid appearances.

For almost no case in which wanting.

And merely effect of [congealment] of blood after death.

But whether this local affection any concern in disordered respiration or not, disease [illegible] other morbid appearance with which no doubt that death of this patient more immediately connected.

That is affection in cavity of Thorax. Examiners of this cavity discovered two causes well known to produce powerful dangerous & even in general fatal effects.

These were a dropsical affection & a purulent state.

In cavity of Thorax, particularly in right side a very considerable quantity of water was found.

And in pericardia collected to extent of five or six ounces.

From this cause am now inclined to think that several circumstances occurring in case were to be explained.

Had probably very considerable share in inducing & supporting both cough & dyspnoea.

But still more now suspect it to have operated as cause of deliquium animi

For undoubted that whether from [compression] of blood vessels or any other cause, with water in pericardia fainting fits often connected.

Must however own that during life of patient suspected these to be entirely hysteria faints.

And this supposition I thought, if not proved, rendered at least very probable from their being preceded by Globus Hysteria.

When however consider that one of these faintings had fatal termination probable that arose from more serious cause.

And presumption even that water in the pericardia immediately connected with death of patient.

But although this the case, deserves to be remarked, that affection during life not attended with those symptoms commonly considered as indicating Hydrothorax & Hydrothorax Pericardia.

But besides this dissection showed us another important morbid affection.

Purulent matter to considerable extent in almost every cell of the lungs.

Upon cutting lobes both on right & left side could be squeezed out by gentle pressure from almost every [vessel]

And that really purulent might be inferred not only from appearance but also from sinking completely & entirely to bottom of water.

From this then appears that to affection formerly mentioned in lecture must not only superadd hydrothorax but also Phthisis Pulmonalis.

And that this the source of many of symptoms cannot now be doubted.

Besides influence as inducing increasing & supporting cough & dyspnoea are to this probably to refer constant quickness of pulse, as well as diarrhoea with which [illegible] [close] of disease, very much affected.

When this latter symptom occurs in general supposition that in Phthisis death not far distant.

And not impossible that by compression of lungs from water without & purulence within that event not a little [hastened].

Perhaps had even more influence than water in pericardia affecting heart & large vessels.

Here however to be observed that though patient much reduced in point of strength was yet not in situation in which [those] dying of Phthisis commonly are.

Had not operated so far in [exhausting] the system.

For still considerable collection of fat both in Tela adiposa on surface of body & also in cells of Omentum.

If therefore do consider her as dying of Phthisis was not cut off in ordinary manner.

And while death, did not happen as affect of exhaustion so could not consider it, as proceeding either from hectic fever, or suffocation on fruitless attempts to expulse of purulent matter.

But whatever may have been here cause of death, dissection showed two diseases, of which I own during present illness had but little suspicion.

viz Phthisis Pulmonalis & Hydrothorax.

Of former indeed when now again examine case see several circumstances [which] might have given suspicion.

Particularly cough, dyspnoea & quickness of pulse.

Still more the origin to which her affection was attributed viz. Measles.

And indeed when first admitted a patient at the Dispensary in September last her affection chiefly appeared under form of Catarrhal symptoms threatening Phthisis

But was at that time very much against suspicion of Phthisis, that these soon yielded to remedies then employed.

Particularly an Emetic a blister & the use of Mistura Oleosa as demulcent.

On readmission, though some of catarrhal symptoms still remained, yet others appeared so much more distressing that these almost entirely overlooked.

And attention solely engaged with peculiar noise in respiration, globus hysteria flying pains, contraction of fingers & the like.

While at the same time but very natural to suppose that cough & quickness of pulse proceeded from same cause with other affections.

And well known that both of them very frequently hysterical symptoms.

This case therefore as well as many others which have before occurred to me in practice demonstrate insidious nature of Phthisis.

And shows to what advanced [period] will often arise where yet no certain evidence or even strong suspicion of existence.

If this however the case with regard to Phthisis not less so with respect to Hydrothorax.

Of this affection I own had never any suspicion.

Nor indeed did there here occur almost any of those marks by which in general thought to be characterised.

Confirms therefore the truth of an observation made in practical course that hydrothorax often exists when all symptoms by which has been defined by nosologists¹ entirely absent

Had we been able during life of patient to discover real nature & full extent of disease, would not I own have followed that mode of treatment here adopted.

Should have been less anxious then about counteracting some of most urgent symptoms particularly those of hysteria kind.

Would not probably have had recourse to Zinc or Valerian although from these no bad effects on either complaint to be apprehended.

Still less should I have employed the Aether & Tincture Fuliginis.

For action on stomach that viz of stimulation augmenting impetus of circulation unquestionably unfavourable to Phthisis.

These however which were [illegible] to counteract alarming symptoms at the time, continued only for short period & never given to any great extent.

Can hardly therefore suppose that were product of any bad effects.

And such at least we may venture to say did not obviously occur.

While had so far the effect of producing temporary mitigation of symptoms.

For obtaining which even where Phthisis or Hydrothorax known to be present often necessary to have recourse to practices adverse to the disease

Although therefore if had known real state of matters, would not [perhaps] have ventured to have employed them am yet inclined to think that did here more good than harm.

With regard to other practices employed particularly Emetics & Blisters are the remedies which would have chiefly depended on if had known nature of disease.

Know no remedy from which both in Phthisis & Hydrothorax more to be expected or more obtained.

And same also may be said both with regard to Electuary Japonica & Thebaic Tincture where colliquative diarrhoea occurs.

Hence therefore more from accident than intention, patient had here that chance of recovery, which most active medicines, that in my opinion, could have been with propriety tried, could have given her.

[Many] other active remedies indeed used both in Hydrothorax & Phthisis.

Thus strong cathartics & diuretics [often] successfully used in former, blood letting in latter

But while first [illegible] in Phthisis last still more so in Hydrothorax.

Hence then had we been even fully acquainted with different affections to which patient subjected do not think that remedies promoting greater success could have been employed.

And indeed thorough knowledge of disease would have precluded all hopes of recovery.

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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.