DEP/DUA/1/39/08 (Normalised version)

William Ritchie

1785

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William Ritchie February 18^th 1785

In history of this patients case many symptoms enumerated.

And probably not all to be considered as connected.

But I think little room for doubt, that most numerous & most important symptoms are Phthisis.

As such may mention the cough dyspnoea & pain of breast.

While cold fits & quickness of pulse, to be considered as symptoms of Hectic fever.

Though indeed must here be allowed that not with all symptoms of that affection.

And particularly neither hot fits nor sweatings.

At least not subjected to these when came under our care

But even at that time very great degree of debility.

And this as well as other symptoms now not a little aggravated.

Hence then even from symptoms alone strong presumption of disease.

But this presumption much strengthened by two other particulars.

By symptoms viz which though absent when case taken had occurred during course of complaint & by disease of near relative

From last of these reason to presume that with our patient their exists hereditary disposition to Phthisis.

For told that a brother who fell victim to Phthisis.

While are [not] at present with such symptoms as gives strong presumption of that affection.

But on this I own put much less stress than on other parts mentioned

About two months ago had an attack of haemoptysis.

A circumstance from which I think may reasonably infer morbid condition of lungs.

Is by no means indeed every case of Haemoptysis that terminate in consumption.

And especially [where] copious bloody expectoration occurs with those of plethoric habit.

But at same time, even in these cases where symptoms of Phthisis follow, much ground for alarm.

And particularly alarming when bloody expectoration takes place, after symptoms of Phthisis have preceded.

This however the case with present patient.

And taken in conjunction with other circumstances am I confess disposed to consider this as affording if not certain evidence at least strong presumption of Phthisis.

While however view patient as subjected to this disease other symptoms in case probably unconnected with it

This I am inclined to think is the case with his sickness at stomach & vomiting after meals.

And still more with flatulence & acidity at stomach.

For these, never I [apprehend], to be considered as Phthisis symptoms.

Pure Phthisis universally without them

And when take place may always be considered as a [complex] or [surprising] affect.

These latter symptoms however not distressing to any high degree.

And even if were so still much less important than Phthisis affection.

For even in worst instances Dyspepsia more inconvenient than dangerous.

If however little to apprehend from this everything to dread from other.

Need hardly observe that every instance of Phthisis to be considered as highly dangerous.

And this even, when patient applied first for assistance, seemed not to be, of least dangerous kind.

Had not indeed, that exquisite hectic, which is in general attendant of tuberculous.

But from fixed pain at particular [part] of breast had reason to infer that not of catarrhal kind.

But that considerable vomica formed in lungs which indeed very generally case where either, preceded by Haemoptysis or attended with it.

If however thus unfavourable, when came under our care, is still more so since.

For of late very considerable return of Haemoptysis.

In this may consider him as subjected even to a third affection

And that too even by itself of dangerous nature.

For if frequently recurring, patient may even sink under loss of blood falling victim to Haemoptysis itself.

But much more to be dreaded from it, as influencing Phthisis Pulmonalis.

For must not only tend to exhaust a patient already highly debilitated, but to usher in fresh suppuration.

Hence then expectation of recovery in this case now very faint.

And I own opinion is, that in no long time, patient will fall victim to affection.

When came under our care imagined that might at least afford opportunity for trial of some medicines.

And as such resolved as in case of David Bickerton to have recourse to Gum Myrrh.

Of this article had already occasion to make some remarks when speak of that patient.

Then mentioned several authorities by which of late supported, particularly those of Dr Griffith Saunders & Simmons

And mentioned also, that from some instances which had occurred in course of my own practice, was inclined to think favourably of the remedy.

But am sorry to say that cannot add that case to number.

And will I apprehend have as [little] grounds to draw any favourable conclusion from present.

For when deserted use after trial for considerable time patient manifestly [worse]

Here from commencement of employment conjoined use not only with Cream of Tartar, but with Sal Chalybeate.

To this rather led from authority of others, than from any opinion which have of use.

But in trying medicine, wished to [experiment] in state, in which found successful by others.

As thus given, at least sat easily on stomach.

And for some time, thought affection rather relieved.

But this relief neither permanent nor considerable.

And indeed when some symptoms alleviated, others in general augmented.

Thus on mitigation of cough & pain of breast, became affected with considerable hoarseness.

Was with view to this symptom that on 7^th of January in addition to Myrrh had recourse also to Mistura Oleosa.

For as far as my own experience goes, have found nothing more affective in alleviating hoarseness than oil in any form

And when from state of stomach cannot be taken in pure state yet may in general be borne with ease when diffused in water by aid of small proportion of alkaline whether fixed or volatile.

When first begun this mixture, seemed to have but little affect, on hoarseness.

But after some continuation, whether in any degree as affect of medicine or not, went at least off.

In so much that on 21^st of January oily mixture intermitted, & continued with employment of Myrrh alone.

But soon after an occurrence much more alarming than the hoarseness took place.

A fresh attack viz of Haemoptysis.

With this also a considerable degree of pain in breast conjoined.

A circumstance from which might infer that was of active kind depending on increased action of vessels.

Even in this situation, do not imagine that patient would have suffered anything from continuation of Myrrh.

At least should not infer this, from any influence which have ever observed it to have, on circulation.

Especially as conjoined with Cream of Tartar.

But has at least been commonly ranked among what styled by Dr Fothergill & others the healing balsams.

And as in haemoptysis not only necessary to avoid what heats but to enjoin everything of [contrary] nature, thought it more prudent to omit use.

If in this situation had directed bleeding, would at least have followed common practice.

And have no doubt, that in such cases, has often affect of putting stop to haemoptysis.

But in every debilitated state, is in my opinion, a practice always to be avoided.

A much easier matter to withdraw blood, than to replace it.

And soon abstracted by blood letting, what would make very great figure if collected as discharge in haemoptysis.

Hence therefore, as discharge had ceased to be excessive, desirous to try whether could be stopped by other means

Accordingly directed application of blister, & use of powder composite of Cream of Tartar & Nitre.

To former of these practices in such cases, some objection the influence it has on state of circulation.

Has been supposed that will be product of bad affect as increases impetus

But influence in this way depends very much on previous condition of pulse.

And at any rate this affect much more than counterbalanced by operation in other particulars.

From experience which have had in many cases have no doubt that on whatever principle may operate have seen it attended with best affects.

And of this I think even high probability in present instance.

For with free discharge from blister pain of side alleviated.

And soon after spitting of blood entirely disappeared.

During this indeed, continued regularly with Cream of Tartar & Nitre.

From which no doubt that good affect derived both as gentle laxative & refrigerant.

Accordingly in such cases this or something of similar nature seldom omitted.

And although entirely free from haemoptysis yet as means of preventing [return] directed continuation.

But notwithstanding use continued to be subjected to severe cough, & at same time had considerable return of pain in breast.

On this account thought it advisable to have again recourse to blister.

And to secure advantage have directed issue after it.

Hope that by these means, with proper measures in other respects, pain may be alleviated & return of Haemoptysis prevented.

But even if this accomplished cannot I think entertain any great expectations.

For as already observed now great reason to fear, that nothing we can do, will prevent patient from falling victim to Phthisis.

And very doubtful whether shall now take any other measures than what [merely] calculated to obviate symptoms.

At same time if circumstances shall appear favourable may yet perhaps try practices before suggested viz weak infusion in Digitalis, which by Dr [ Willn] & some others of late extolled in such affections