DEP/DUA/1/36/19 (Normalised version)

William Smith

1784

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William Smith December 8^th 1784.

This patient subjected to a disease no less common than alarming

That species viz of haemoptysis which most liable to terminate in Phthisis.

Does not indeed correspond with definition of the disease as given by the best nosologists¹.

Not at least, particularly marked, as of the florid complexion.

Nor from any accounts which we have had, does he discharge blood, in a frothy or florid state.

But at same time has on different occasions been abundantly distinctly marked in matter expectorated.

Sometimes of bluish colour at other times mixed with mucus & of blackish appearance.

Circumstances from which may infer that effusion from vessels yielding it takes place in slow & gradual [manner]

And that before discharged by [expectoration] subjected to considerable stagnation.

Here then may occur as question whether Haemorrhage of active or passive kind.

Especially as attended also with severe cough.

But where even passive haemorrhage from this cause, blood usually florid.

And am I own here disposed to think, that both cough & haemorrhage from same cause.

That proceed from some local disease, probably a tubercle in lungs.

This I suppose has not yet degenerated into state of suppuration.

But is in such condition as to give irritation hence the severe cough

While at same time, the surrounding vessels, yield gradual effusion of blood.

And from this again, are I apprehend to account for dyspnoea.

While pain of side consequence of slight temporary inflammation excited in tubercle or neighbouring parts.

In short consider this case as a distinctly marked instance of the Haemoptysis a tubercule of Sauvages or Haemoptoe Phthisis of Dr Cullen.

With this view of nature of disease cannot give very favourable prognosis

In most instances has at length fatal termination.

And this I am inclined to suspect will be conclusion in present patient

Hold such haemoptysis to be much more dangerous than where large & free discharge of blood.

For then condition of vessels such that may unite & heal by first intent, in same manner as when haemorrhage happens from other parts

But here haemorrhage chiefly consequence as it were of diseased condition in lungs.

And of that condition too giving rise to worst Phthisis the Tuberculous.

An affection by many considered as being almost certainly fatal.

That therefore will terminate in this, at least highly probable.

But at same time, if even tuberculous Phthisis should occur, are not thence to relinquish all hopes of recovery.

For have no doubt in asserting, that have met with some distinctly marked instances of this affection from which recovery takes place

This however gives I own but faint chance of recovery.

And consider us as having better ground for expectation on a different footing.

That tubercle viz does not pass into state of suppuration.

For this though a common by no means a necessary consequence.

In all probability has already subsisted even for space of some years, without such an event taking place.

And although in end may occur yet may continue for equal or even greater length of time before happens.

Nay may either continue for life or even be removed by absorption.

But at same time these prospects must be represented as but very faint.

And much more probable, that in no very long period patient will fall a victim to affection.

In removal of cause of disease here, the tubercle viz which suppose to exist in lungs, can do little.

And practices principally to be directed to prevention of those changes from which greatest danger to be dreaded.

Particularly to prevent inflammation & suppuration

Is with these views that practices hitherto directed have been employed.

Began by ordering application of blister to pained part of side.

And directed, that after blister, drain should be supported under form of issue, by epispastic ointment.

Of explanation of action of this mode of cure in such cases different opinions have been entertained

Can however, I think, be little doubt, that partly if not entirely to be attributed to change in mode of circulation.

Has unquestionably the affect of producing increased circulation in part from which discharge takes place.

And from this reason to think that may have influence in diminishing flow in neighbourhood [of] diseased part.

Probably also in some degree operates as gentle & permanent evacuant.

And not improbable that has some influence as particular outlet.

And that thus has affect, [quasi] nova glandula, as some have [expressed] it.

But whatever difference of opinion as to mode of action hardly any with respect to affect.

By every one whose judgement guided by observation in actual practice, universally [allowed], that in such cases, a remedy of very considerable service.

Particularly, where haemoptysis occurring but to slight degree, attendant of severe cough

Though does not prevent termination in Phthisis, yet often gives temporary suspension of haemorrhage & mitigation of cough.

These then chief ends, which expected would be answered by it in present case.

And at present, is my principal view, with this patient, to see how far by means of it, these ends can be obtained.

Besides blister indeed, directed also, at same time, another medicine.

A mixture viz of powder of Gum Arabic & Nitre.

From former, might derive some benefit, in allaying cough from power as demulcent.

While latter, will to certain degree operate, as refrigerant.

And thus some influence in restraining both tendency to inflammation, & to haemorrhage.

For can be no doubt that sense of cold which excites in mouth & stomach also attended with diminishment of impetus of circulation.

From these articles given in conjunction expected more advantage than as taken separately.

At least Gum Arabic operates as a corrigent of nitre.

And thus less apt to occasion [sickness] or general affect of system from immediate action on stomach.

From use of these medicines cannot say that patient has yet reaped any considerable advantage.

Powders indeed taken without any inconvenience.

And blister & issue, product of copious discharge.

During use, pain of side became somewhat easier.

But cough still continued very severe.

And was not free, from return of bloody expectoration.

Imagine however, that by longer continuation, better affect may be obtained.

Hence without any farther addition directed that should persist in use at least for another week.

If during that time, should not receive material benefit, will still I own, be averse to relinquish present plan.

But will naturally think of aiding it, by something else.

And particularly, with view of mitigating severity of cough.

With this intention, nothing seems to promise more immediate benefit than use of opium.

For remarkable power which has as allaying inordinate action, universally known & admitted.

Here however some objection to use from dyspnoea to which patient subjected.

For little doubt that will retard expectoration of that matter, contained & effused in vesicles, on which Dyspnoea depends.

But this more than compensated by relief of cough.

And at least deserves [continuing] trial.

If therefore cough continues severe shall probably give up formula of Nitre powder.

And in place of it, may direct a mucilaginous mixture with Nitre dissolved in it, adding such proportion of Thebaic Tincture, as may reckon sufficient for obtaining sedative affects of Opium.

Or if no haemorrhage, may employ mucilaginous mixture with Thebaic Tincture without nitre.

If from these medicines, shall obtain freedom from cough, pain of breast & haemoptysis, is perhaps the utmost that can here expect.

And may dismiss patient, with alarming affection warded off at least for present.

This however could by no means consider as cure.

And on every slight accident, reason to dread return of complaint.

If however, which no less probable even thus favourable, should not take place other practices which may at least be tried.

And according to circumstances of case at time, may try course of Cicuta, Mercury or Gum Myrrh.

But if employ any of these, must reserve explanation to some future opportunity.

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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.