DEP/DUA/1/38/39 (Normalised version)

David Bickerton

(1785-1786)

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David Bickerton

Disease of this patient cannot be said to be altogether without doubts.

But at same time many circumstances giving strong presumption of Phthisis Pulmonalis.

His most distressing symptoms, cough dyspnoea & pain of breast, though not certain marks are yet constant attendants of Phthisis.

These indeed even with such appearance of expectoration as here described occur also in chronic catarrh.

But age of patient much more in favour of Phthisis.

Is you will observe in 19^th year a period when Phthisis frequent, chronic catarrh but rare.

From this circumstance however much less decisive evidence than some others

Particularly state of pulse & strength.

Latter has failed so much that though a young man, now with difficulty able to go abroad.

Has not indeed, as far as we can learn, any distinctly marked accession of hectic fever.

But pulse when we have had occasion to observe it, uniformly small & quick.

At 120 in minute.

To this might add also, other circumstances.

Such for example as appearance of countenance of Tongue & of Eyes.

Is not indeed, of that colour of hair & complexion, marking the sanguine temperament, & with which probable disease most common.

But this well known to be no security against affection

And notwithstanding black hair & swarthy complexion yet somewhat of that appearance often the attendant of Phthisis.

A [circumstantial] redness viz in cheek.

Tongue more appearance of health, than of disease.

But marked you will observe to be particularly red, towards point.

This condition of tongue, more a mark of Phthisis, than of very much furred or dry.

For never fails to be attendant of any purulence in the expectoration.

Often even gives reason to presume it, where from appearance of expectorated matter should not infer so.

And when, as in case before us, no suspicion of pus, either from disagreeable taste or smell.

When expectoration highly purulent mouth not merely affected in this way.

Not only abraded Tongue which may always suppose to be case, where peculiar redness, but even ulcerated.

Such a condition indeed, has not here taken place.

But at same time, appearance of tongue such, that may evidently pronounce it, to favourable, opinion of Phthisis.

Same also may be said respecting eyes.

The adnata, marked to be of pale blue colour, & with few red vessels.

An appearance which although neither constant in Phthisis, nor never occurring in other diseases, yet marked to be frequent concomitant of that affection.

But all these circumstances, though giving presumption of this disease, weigh much less, than another yet to be mentioned.

Manner viz in which affection commenced.

Began you will observe, by very profuse haemoptysis.

This, I need hardly observe, very frequently lays foundation for Phthisis.

Not indeed by any means in every case that one a consequence of other.

Many instances where after very profuse haemoptoe, a complete & perfect recovery.

And can readily conceive, why haemorrhage from lungs, as well as from nose, or any other part, may terminate without suppuration.

Indeed, as far as my observation goes, this more frequently case, where haemorrhage very copious at once, than where slight but very long continuation.

And accordingly if had seen patient, during time of haemorrhage, should have considered him as having better chance of not terminating in Phthisis, [here] if much slighter.

But at same time, cannot be [alleged] that copious discharge of blood, from lungs, never terminates in Phthisis.

And to be remarked, that since this accident, our patient never free from symptoms indicating that affection.

Upon whole then, though cannot be said, that in this case, a distinctly marked hectic fever yet will at least be allowed that presumption of Phthisis very strong.

And especially when consider insidious nature of affection.

For can be no doubt, that in many instances, where Phthisis in end fatal, disease has subsisted for long time with much less appearance of it.

From cause assigned are led even to conjecture as to species of Phthisis.

For every instance, where death from purulency of lungs not of [illegible] [illegible]

In practical lectures shall endeavour to point out these species falling under genus of Phthisis which I think require considerable variety in [treatment]

These distinguished by appellation of the catarrhal where purulence entirely from surface of lungs.

The ulcerous where proceeds from some large vomica or ulcer.

And the tuberculous where, sometimes even without suppuration, an ichor sanies yielded by hard indurated substances probably scrofula glands in lungs.

Without here entering into History or even diagnosis of each, may only observe that consider our patient as subjected to second species.

To this opinion as have already remarked am in some degree led by condition at commencement

For very generally where vessels ruptured in profuse haemorrhage from lungs do not heal by first intent, terminating in large vomica or considerable suppuration.

Bloody expectoration indeed sometimes arises from tubercules.

But then in general only very slight appearance of blood.

And that frequently occurring on severe coughing as if merely of passive kind.

What I style ulcerous Phthisis chiefly distinguished by fixed pain at some particular part of breast & by unease of patient when lying on side not pained.

Whereas in other species no particular pain of breast, & patient lies with equal ease on either side.

Here indeed cannot be said that either of these diagnoses in such state as to give strong evidence of the disease

Of pain of breast he complains only in a general way.

And can lie without augmentation of dyspnoea on either side.

An evident proof that not at least so considerable a vomica, as to prevent respiration even by diseased side of chest.

For when that the case patient can breathe only on pained side that other may be free for expansion, which not the case when compressed from weight of body.

But although these [diagnostics] not here to such extent, yet some affect from difference in posture.

For observed that cough most troublesome when lying on right side.

An evident proof that then some uncommon cause of irritation.

And that disease of lungs a local one.

Hence then, taken in conjunction, with other circumstances, particularly mode of attack, gives at least considerable probability of this species.

From this view of disease both with respect to genus & species, naturally led to Prognosis.

And here, need hardly observe, that when pronounced disease to be Phthisis, must at same time consider it as dangerous.

For no modification of Phthisis, in which danger is not very great.

But all not equally dangerous.

And though recovery from [any] [illegible] yet much more rare, from tuberculous than any other.

Recovery most frequently to be met with from the catarrhal.

And that species to which present patient subjected hold in point of danger to be intermediate

From this therefore all I can venture to say, is, that consider recovery as neither beyond power of art nor even of nature.

For where abscess formed in lungs & free discharge of matter, may heal there as well as in other parts.

And by assistance of art, both with respect to regimen & medicine, may do something to forward it.

But at same time from reduced situation should not be surprised if very soon sinks under affection.

Of this however no immediate appearance.

And am at least hopeful that may afford us opportunity for trial of medicine on which have here put him

In this disease as have already had occasion to remark first step towards cure is discharge of purulent matter already formed.

This may sometimes be aided by artificial means as action of vomiting.

But in general purulent matter itself, from acting as irritant in lungs, example cough sufficient for this purpose.

And much more an objective as far as can be accomplished, to promote adhesive inflammation by which ulcer to be healed.

This indeed also very much an operation of nature.

And perhaps more dependant, on condition of habit, than on any other particular.

But from this very circumstance, may infer, that will be affected by altering state of action in vessels.

Whether on this or on some other principle, that to explain operation of medicine here directed for this patient I know not.

But at same time in former instances of similar nature am much deceived if have not seen it attended with good effect.

The remedy here employed you will observe is Gum Myrrh.

This, till of late years at least, has not been extensively used in Phthisis cases

And indeed all healing vegetable balsams as have been called, have been [prominently] condemned in Phthisis, on authority of that accurate observer Dr Foster.

That some of these, notwithstanding boasting name of Balsam in many cases prejudicial will not deny.

Nor would I contend that this [never] effect of the Myrrh.

Must only observe that in my own practice have not found this to be the case.

And for some years past have employed it pretty extensively in such affections

This remedy of late particularly recommended to attention of practitioners in a publication by Dr Moses Griffith¹.

And afterwards still more fully by Dr Simmons in his treatise on Consumption².

But prior to either of these publications had been much in use with Physicians of Guys & St Thomas hospitals in London.

And in former in particular as will observe from Dr Simmons publication very extensively used by Dr Saunders.

An Gentleman who attended that hospital during course of last summer informed me that Dr Saunders no less fond of it than ever.

A proof that farther experience has not altered his opinion on this subject.

In formula recommended by Dr Griffith with Myrrh united to proportion of nitre a certain quantity of Sal Chalybeate is added.

But Dr Simmons seem to think that is from addition of refrigerant alone as corrigent that to look for any advantage.

Hence he seems to prefer combination with nitre alone.

In Guys hospital is chiefly present under form of what they call Mistura Antihectic.

In which have indeed a composition by no means inelegant but with more affect of art than to [me] seems necessary

And more complexity than is I think in any case advisable.

Contains proportion of [ Agrimona] [ Alexeteriol]. Simple & Of [ Agrimona] [ Alexeteriol] Spirit, with Syrup.

But while from these, are to look for no more, than any other excipient, as for example simple water, & be observed that Gum Myrrh, combined with two articles which may act as adjuvants.

Sal. Chalybeate viz recommended by Dr Griffith & a proportion of Sal. Absinthe.

How far these really advantageous will not positively venture to say.

Not improbable that Sal. Absinthe may not only facilitate its combination with water but also supply place of Nitre.

While Sal. Chalybeate From its tonic powers may give the system, that condition connected with tendency to adhesive inflammation.

But as far as my own experience goes have not been able to see benefit of any addition.

At least any farther than as giving minute division of resinous parts of Myrrh.

Hence, in choice of articles, with which combine it, am chiefly directed by circumstances of care.

Particularly by state of belly.

Where patient rather costive, or even where belly not loose, give it in combination with equal proportion of Cream of Tartar.

From this, have I think, every advantage, to be derived from addition of a refrigerant.

Obtaining affect of keeping belly, in easy state.

And have advantage of minute division of resinous parts of the Jalap.

But although in Phthisis, belly often bound, yet frequently happens, particularly towards conclusion, that diarrhoea occurs.

And indeed, colliquative diarrhoea one of most alarming symptoms.

In that case the Myrrh even by itself, but still more with Cream of Tartar, has tendency to increase symptoms.

Then have given it in combination sometimes with absorbents, as Pulveris Cretacea or Oc. Carm

Sometimes with astringents as, Succus Japonica or Gum Kino.

And sometimes even with opiates.

In all these ways, have I think seen it product of very considerable advantage.

Whether as Dr Simmons supposed from peculiar antiseptic power, as I am inclined to imagine from altering state of action in vessels of diseased part or on principal different from both not very material.

That is advantageous is fact of chief importance & of this am very much convinced from experience

And particularly in that species of Phthisis to which supposed this patient subjected, Ulcerous.

There I think, more useful than either in the tuberculous or even in the catarrhal a slighter disease

But in all, may I think be often employed with advantage.

Am far however from ascertaining that in any of them gives much chance of cure.

For must acknowledge that consider Phthisis to be a disease in which a great majority of cases will prove fatal in spite of every remedy we can employ.

But must hold it to be matter of very great consequence if by this remedy can overcome some instances.

And on grounds of my own experience in former instances as well as of that of other practitioners mentioned, have directed it to present patient.

And if here fails, must own that have no great expectation from any other article.

If however do not soon find some benefit from it in present form is my intention to add to it a proportion of Sal. Chalybeate.

Or perhaps to employ at same time a chalybeate in some other form.

If notwithstanding this affect goes on in progress see little here to be done but to obviate such symptoms as may occur.

As for example Dyspnoea & cough with which at present most harassed by blister & issue.

And any others that afterwards may take place by remedy best accommodated to these

At same time enjoin for patient as far as circumstances will admit the regimen commonly directed to Phthisis pain

Particularly warm clothing with view of supporting equable circulation on surface.

And a diet, which while nutritious at the same time not stimulating.

Such for example as milk, an intermediate substance between vegetable & animal kingdom.

And which while perhaps nearly as nutritious as even animal fats, is at same time as little stimulating as mild vegetables.

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Explanatory notes:

1) Moses Griffith, Practical observations on the cure of hectic and slow fevers and the pulmonary consumption (1799).

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