DEP/DUA/1/11/10 (Normalised version)

John Fergusson

(1776-1777)

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John Fergusson.

Case of this patient one with regard to which am not altogether without difficulty.

And expect to have still more in conduction of cure than in ascertaining nature of the disease.

Symptoms with which at present affected few.

And of these greater part obvious to senses.

Here naturally first & most important question respecting swelling in abdomen.

From equable nature may conclude that is some of abdominal viscera.

And can suspect none more probable than liver.

A viscus affection of which known to be very common.

And although on some occasions continues for life without inconvenience yet on other occasions attended with most serious consequences.

This then would consider as most essential part of patient’s present complaint.

And may even be question how far is not to be considered as cause of all.

Only other complaints at present distressing to him are difficult respiration & cough.

May I think be question whether these proper catarrhal affections or whether depend on disease of the liver.

In other instances have had occasion to speak of what called chronic catarrh.

And may occur that have here presently those symptoms which consider as necessary to characterise it.

May observe however that cough in some respects different from that of chronic Catarrh

As expressed in case is a constant tickling cough.

Would lead therefore to presumption that does not depend on stimulation from great quantity of viscid mucus.

For then fits of coughing not so frequent as they are severe.

And very rarely that a fit terminates without expectoration of very considerable quantity of mucus.

Hence to present cough being of this nature still farther objection from scanty discharge

Must own therefore that consider it to be most probable that both cough & difficult respiration of diseased state of liver.

On what principle swelling & tumour of liver should produce latter of these sufficiently obvious.

Must necessarily, particularly while body in recumbent position, prevent free action of diaphragm

The organ by means of which highly probable that ordinary respiration chiefly performed.

Nor difficult to conceive how should produce cough.

From this very circumstance will necessarily act as giving irritation to lungs.

And thus frequent cough with little or no expectoration.

In some parts of country liver considered as cause of almost every disease.

Most eminent physician at present in Bath that great receptor of invalids disposed to ascribe much to it.

Hence nothing more common among those who have been his patients, than to hear not only of complaints of stomach & bowels proceeding from the liver but of liver coughs, liver consumption & the like.

Am I own far from being disposed to imagine that liver so frequently a cause of disease.

Would however be equally groundless to refuse that may often act as such.

And whereas in present case high probability of its being diseased would even occur as most probable cause.

Thus far then respecting present symptoms

But besides these patient also since complaint first began has been affected with others

These although not constant return at certain intervals.

And may reasonably apprehend that will again be subjected to them.

What I allude to is discharge of blood by vomiting & stool.

With regard to this symptom also grounds for doubt.

May or may not be connected with fixed affection of liver.

Certain that tumour & scirrhous of liver very frequently without any such appearance.

And equally certain that blood may be discharged from alimentary canal derived from other sources.

Most commonly indeed happens from its own vessels.

Besides these circumstances another particular here also giving doubt.

Swelling of liver said to be only of two years duration.

While are told that at intervals has been affected with bloody stools for nearly three years.

In these circumstances cannot positively assume that are connected.

Yet must own that still disposed to think it not improbable.

Liver may very readily have been diseased for considerable time without any obvious swelling

And even now gives little or rather no pain.

At present however can be little doubt that in diseased state

Hence would rather suspect it to be cause of symptom than ascribe them to a cause of existence of which are not certain.

Besides blood discharged from vessels of liver ready access into alimentary canal.

And from this source greater chance of discharge both upwards & downwards than from any other.

Well known to happen with regard to fluid secreted by liver

And if bilious vomiting & purging a common occurrence bloody discharge may also happen from same origin.

Upon whole then disposed to look on present as what may be called liver case

Respecting cause first inducing it are here entirely in dark.

Patient himself does not ascribe complaint to any particular occurrence.

From this source therefore no light thrown on nature of disease.

And any conjecture from circumstances of patient’s employment must be very uncertain.

Yet when reflect on business that viz of Chairman¹ must conclude that exposed to very strong occasioning causes of disease.

Perhaps no employment subjected to greater vicissitudes of heat & cold.

And accordingly life of Chairmen very bad.

In London none undertake this business but those of stoutest & most robust habit.

And yet computed that at medium do not live above five years after entering [illegible] it

This therefore may conceive to have had some share as inducing present affection.

Not impossible that aided also by too free use of spirit liquors.

For while profession naturally leads to this, is at same time known to be very powerful cause inducing affections of liver.

Whatever may have been original cause however will now but little affect prognosis.

And must own that in present case can form no very favourable opinion.

As yet indeed complaint not very urgent.

And what appears most so is perhaps in reality the least considerable viz Cough.

May indeed distress him but do not consider it as dangerous.

And even while cause of complaint continues although not perhaps entirely to be removed may yet admit of considerable alleviation

Swelling in abdomen however will probably be more obstinate.

May not merely resist all attempts but even increase

And as suggested with respect to case of Janet Brown may yet terminate in suppuration.

And patient be at last cut off with tabes hepatica.

See no reason to imagine however that progress in present case will be rapid

And hope that may at least allow opportunity for trial of different medicines.

Am even not altogether without expectation that from these may be overcome.

Upon whole however reckon it most probable that this principal part of complaint even after long attendance here will rather if anything increase.

While however continues attendance here is our business to try whatever measures we can with view to cure.

And with this view many different medicines may at least be tried.

Here great objective is to remove obstruction in liver & restore due circulation through it.

Not to be imagined that even by obtaining these ends swelling would be entirely removed.

For probable that solids even in some degree increased.

Yet little doubt that greater part of swelling depends on impacted fluids.

And that by free circulation these would be removed.

While at same by restoration of this any farther bad consequences avoided.

Of all medicines known by name of discutients or deobstruent none longer fashionable than Mercury.

And indeed incontestable evidence of its action as a peculiar yet powerful stimulant to particular parts after introduction into system.

Hence as proposed in case of Janet Brown to make trial of Cicuta wished in present case to try affects of Mercury.

And with this view put patient on use of it both externally & internally.

First meant in some measure as topical application.

And with this intention conjoined Mercurial ointment with small preparation of Camphor.

Hoped that influence even when rubbed upon [integumentary] might in some degree extend to viscera.

And cannot help thinking that have seen instances of benefit from it where equally little connection.

But even suppose that in this way no effect still equally powerful means of introducing into system as by friction on any other part.

With this however wished also to compare internal use.

As by this means greater certainty.

And could sooner, with safety, charge system with Mercury than if trusted to one mode only.

Or if employed that to great degree.

Here directed Mercury merely rendered active by triture

As being state in which greatest chance of being retained for some time in system.

And on such retention hopes of success chiefly founded.

Here directed triture with Confection Cynosbati.

A substance which some imagine has very powerful effect as killing Men

And hence a fashionable formula with some of London practitioners particularly Sir John Pringle

By these and others Mercury is intended to keep patient for some time on verge of salivation.

Not that imagine any benefit to be reaped from that discharge.

But that consider it as only certain evidence of Mercury having fully entered system.

In prosecution of this plan however will be somewhat restrained from present state of weather.

But if has any influence in diminishing tumour will be induced to continue it for longer time.

Should it in end fail may be induced to try here some of medicines so highly recommend as deobstruent by Dr Stork.

Such for example as Stramonium Dulcamara or Cicuta.

Am far from thinking that these will succeed in every case.

Yet have no doubt that are medicines possessing active powers.

And on some occasions have had very wonderful affects.

Should not however be much disappointed even at failure of all of them.

In that event may perhaps try electricity.

Particularly if find that has any good effects in case to which lately ordered.

But should even entirely fail there will be no sufficient reason why may not give trial in others.

And present may perhaps be one.

But before even trials already proposed not improbable that disease may so far change appearance as to lead to very different practices from what at present suspect.

And while prosecuting radical cure alleviation of symptoms not to be neglected.

With that view indeed have hitherto done little

As excepting cough nothing in this way urgent

Is however as means of alleviating this that have ordered the pill Thebaicae.

While these afford relief may be occasionally continued.

Or may have recourse to other remedies as demulcents or blisters.

While however is merely tickling cough in present state should I own expect more from opiate.

And take present to be one of these coughs in which Trochisci Bechici Nigri a new formula of Edinburgh Pharmacopoeia² may be used with advantage.

May probably therefore in present case give these a trial.

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Explanatory notes:

1) Occupation involving transporting people around the city in a sedan chair. A common occupation in cities such as Edinburgh with narrow winding streets which could not accommodate a horse and carriage.

2) An official publication containing a list of medicinal drugs with their effects and directions for their use. The Royal College of Physicians of Edinburgh's Pharmacopoeia was first published in 1699.