DEP/DUA/1/39/20 (Normalised version)

William Walker

(1785-1786)

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William Walker.

Of case of this patient can now say very little more than when formerly spoke of him.

Then gave it as my opinion, that although no certain yet strong presumption of Phthisis.

This had then reason to infer from long continual cough & pain of breast without expectoration.

But still more from continuation of these symptoms having induced emaciation & unhealthy appearance great loss of strength with feebleness & quickness of pulse.

And above all from the hectic symptoms as indicated by cold fits proceeding & copious morning sweats.

This Phthisis was disposed to consider as being of the tuberculous kind.

To this conclusion in some degree led by want of marks inducing other species.

For here had not that state of expectoration which attends both the catarrhal & ulcerous.

With these, though sometimes difficult to distinguish whether matter expectorated is principally purulent, or mucilaginous yet very generally copious expectoration.

At least after hectic fever comes on.

Here however on contrary cough of dry kind.

While at same time, hectic fever very considerable.

And this circumstance, the exquisite hectic, I consider as another strong mark of the species of consumption.

For in tuberculous no doubt that this much more the case than in other species of Phthisis.

And accordingly very generally at least, course of disease, much more rapid.

With our patient however, in [space] of three months, emaciation & great prostration of strength had ensued.

From species of Phthisis therefore confess most dangerous, though every species highly so, & from affects which had already produced, had reason to look for fatal termination.

And this accordingly prognosis which was disposed to give.

During course of attendance here, no reason for altering sentiment either with [regard], to nature of disease, or to termination.

For although at one time, some symptoms a little mitigated, yet this by no means case with all.

And particularly no mitigation of the indications of hectic fever, the cold fits, & profuse colliquative sweats, with constant quickness of pulse.

These during time of attendance continued even to be uniformly increased.

While relief from cough at utmost but temporary.

In so much that when last visited us here, even worse than ever.

Have not indeed seen or heard anything of him for some time past.

But even this also consider as a circumstance corroborating conjecture.

For probable that this the consequence of disease having made such progress that no longer able to attend.

After these remarks will readily suppose that here little to be said as to good affects remedy employed.

Am not indeed of the opinion of those who hold that in no case of Phthisis are remedies of any service.

Think have even seen manifest benefit & recovery in consequence of use, where strong evidence of Tuberculous Phthisis.

But much more frequently even in less dangerous kinds disease proves fatal.

And must on all hands be allowed that in tuberculous Phthisis recovery very rare.

And utmost benefit derived either from regimen or medicine is mere alleviation.

But by this means remainder of life, may often be rendered somewhat more tolerable & easy.

For obtaining these ends certain particulars with regard to which all practitioners are agreed.

As for example restoring colliquative diarrhoea by opiates, obviating costiveness by gentle laxatives etc.

But others still matter of controversy.

And this even very much the case with regard to Regimen.

Some recommend full diet of animal food.

By others again patient entirely confined, to most cooling & least [nutritious] vegetables.

In favour of one, contend that tuberculous Phthisis, may really be considered as a modification of scrofula.

That well known, scrofula often consequence of very poor & meagre diet.

And that ulcers often get disposition to heal, by liberal & nutritious aliment.

This it must be allowed so far in favour of that plan.

And farther argued that facts have occurred in practice confirming [advice].

Particularly that individuals long treated on starvation plan, manifest advantage from liberal Diet.

On other hand contend that much more numerous facts on opposite side.

That patients viz [indulged] in liberal diet, great benefit from being confined entirely to vegetables.

That every stimulating article, produces greater quickness pulse & augments hectic heats & [flushes]

That admit tuberculous to be of scrofula nature yet that produce hectic fever only by degenerating into state of [illegible].

And that this always consequence of preceding inflammation.

That there occurs a successful inflammation of different tubercles

And that therefore everything giving inflammatory disposition or quick circulation to be cautiously. [shunned].

Here am inclined to think that errors on both sides.

And that chiefly arises from not making proper distinction between affects of aliment as acting on stomach & as entering circulatory system.

In former way articles of aliment differ from each other as more or less stimulating.

In latter again as being more or less nutritious.

Is indeed true that many of [those] which operate as most powerful stimulants from action on nerves of stomach, are also most highly nutritious.

And that others, which from action on stomach rather even refrigerant effect are much more slightly nutritious.

Of first example in many different kinds of solid animal food.

Of last again in [illegible] vegetable fruits & greens.

But from this by no means [follows] that quality of stimulating & highly nutritious or of refrigerant & slightly [nutritious] necessarily connected.

And in my opinion in Phthisis great objective is to employ nutritious & to avoid stimulating diet.

Former nutritious diet indicated by general wasting and emaciation.

Circumstance clearly demonstrating that supply necessary for support & recruitment of system.

But still more by state of appetite.

For in this affection, in place of [pron] often keen desire for food.

Patients, not here as in fever, affected with sickness & vomiting on taking food.

On contrary action of digestion as far as stomach concerned, goes on well.

And while this the case with keen appetite may at least venture to say, that seldom improper to indulge.

Indeed is perhaps very seldom if ever [improper] in cases of disease to indulge craving of any kind.

Some [indeed], trusting to their own theories have styled these, cases of unnatural instinct.

But for my own part at least, have never yet met with any hypothesis in medicine, which would for a moment put in competition with calls of nature.

On subject of indulgent appetites, have repeatedly heard, an observation from late Dr Monro, in which have uniformly followed his advice.

When any of his patients expressed strong desire for anything in way of food or aliment, first asked their reason for it

If in them this longing, the effect of any theory, for both patients & nurses as well as Physicians have theories, he indulged request or not according to his own judgement.

But if had longing for which could assign no reason never failed to comply with desire.

And never once met with any instance where had seen bad affects from it.

The longing for solid food then in cases of Phthisis, with me a stronger argument for employment than anything urged against it.

But here, as far as my own experience goes, longing not for stimulating but from nutritious diet.

Patient often strong desire for chicken, beef stake, [illegible] or like but never for highly seasoned or alkaline food.

And while waste of system may be considered as pointing out propriety of nutritious diet, state of circulation strongly [constrained] stimulation.

Not to be expected, by anyone who allows himself in smallest degree to reflect on subject, that, wasting of solids in system to be [supported] by ardent spirits, aether, volatile alkaline, or other article decidedly strong stimulant.

And no one I believe has ever thought of employment of such articles, those excepted, whose practice consists entirely in words, not in treatment of disease.

Nay certain that even very small quantity of wine, & with those too, formerly in habit of taking it, has affect of augmenting very considerably, heat, flushing quickness of pulse, & other hectic symptoms.

On contrary from milk, an article which while highly nutritious is at same time of mild & bland nature no such affect.

And accordingly hold milk, where agrees with patient, to be one of best kinds of aliment which can employ as being nutritious without being stimulating.

These then sentiments, on controversy respecting diet in Phthisis, which has lately taken place.

And accordingly diet directed for this patient, of mild & nutritious kind, particularly milk.

But though from this some advantage may be obtained yet satisfied, that in majority of cases cure neither to be accomplished by regimen, nor medicine.

And indeed latter as well as former chiefly serviceable in alleviating symptoms.

Here indeed wished to make trial also of the Gum Myrrh.

A remedy in Phthisis cases, of which as of late recommended by Dr Saunders Simmons have already had occasion to state sentiments.

After promoting emetic therefore with view of emptying stomach, had recourse to Myrrh under form of composite powder.

But cannot say that in this instance any example of benefit.

After began use indeed, cough for a little time somewhat mitigated & pain of breast rather relieved

But still frequent cold fits & sweating even more profuse than ever.

From this led to use of the Vitriolic acid as gentle restringent.

Well known that few articles more powerful as astringents restoring increased discharge of passive kind

And perhaps few affections, in which more evidently useful, than where increased discharge by surface.

But here no obvious influence.

For although, during first week of employment, cough still continued easier, yet sweatings nothing diminished.

And at succeeding report, with continuation of these, cough again considerably aggravated.

While at same time, pulse much quickened.

In this situation however, did not see what benefit could expect, from altering plan.

Accordingly directed continuation.

But since that now more than a month has elapsed since heard anything of him at this place.

And as already said reckon it most probable has proceeded from progress of disease giving aggravation of symptoms.

But whether this the case or not now no reason to believe that will be any longer subject of treatment here.

And hence farther observations on case unnecessary.