DEP/DUA/1/15/17 (Normalised version)

Peter Morison

(1777-1778)

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Peter Morison.

With disease very much difficulty.

Various symptoms to which is subjected cannot be considered as constituting only one disease

And at same time give indication of affection not so distinctly marked or fully characterised that can speak with confidence.

Selected this case as affording example of complication of affections even in a young subject.

From such will afterwards find that have greatest difficulty in practice.

And though most frequent with old people yet as in present case occurs also at early periods of life.

In present case with regard to complaint which occurs in some respects very uncertain.

Shall however briefly state opinion which here led to entertain.

From some symptoms reason to presume that water [effused] & collected in chest.

And if hydrothorax did or still does exist, may be looked upon as most material part of affection.

Other symptoms little connected with this indicate that affection of alimentary canal known by Pyrosis.

In third set evident proof of affection of the gland in neck

And in fourth such appearances as give presumption that [patient] may have distress from worms in alimentary canal.

To all this further to be added that patient formerly subjected to Hernia.

And although little reason to suspect that immediately concerned in present disease yet perhaps in some measure origin of it. And at least connected with some of present symptoms.

For some of these suppositions will perhaps be inclined to think that but little grounds.

And first not the least doubtful.

Hydrothorax one of those affections which sometimes suspected when not present.

More frequently however exists when but little suspected.

And even most alarming symptom of which is ever produced will arise from other causes.

Thus then patients often even cut off before the disease known to be present.

Hence is perhaps upon whole [safest] side to attend even to slightest diagnosis of this affection.

And perhaps even less danger of going on presumption of presence where does not really exist than of referring common diagnosis of it to other cause.

Was from this principle that chiefly led to [suspicion] of it in present case

Must here be admitted that many of those symptoms commonly occurring in the disease here wanting.

Patient has indeed somewhat of the leucophlegmatic leg appearing so often the attendant of hydrocephalus diathesis.

Is affected also with dyspnoea from which chiefly can be only on one side.

Circumstances which while occur in many affections in general also constituent part of definition of this.

But here no [evidence] of dropsical symptoms in other parts.

No swelling for example either of hands or feet

Nor was any peculiar scarcity of urine [observed]

But above all no sudden affection of respiration.

Particularly the starting up from soundest sleep with unexpressed feeling at breast & palpitation.

This however by some considered as [illegible] of the disease.

But although when occurring may give strong diagnostic of it, yet certain that disease often present when this circumstance does not take place.

And that other dropsical affection whether in way of swelling or of scarcity of [urine] merely [accidental]

Although frequent yet in no way connected with essential constituent of the disease.

Of all other circumstances then what gives greatest certainty of existence of water within thorax is [fluctuation] there.

Where this evident & distinctly marked [whether] other symptoms present or not can be little doubt as to existence of the affection.

And was I own, upon this ground that presumption in present case chiefly arose

To our feeling indeed no fluctuation in breast could be discovered.

But patient himself was very clear respecting such a sensation.

Was particularly sensible of it upon walking

Then more especially felt where water would necessarily be deposited viz most [dep]. part.

And may be remarked that patient better able to discover such than even most accurate practitioners.

Unless therefore feeling a mistaken one consider it even without other diagnostics as giving strong presumption of this affection.

And here although some of common symptoms wanting, yet others & these the most frequent, served to give countenance to the supposition.

Yet must be acknowledged that feeling of patients often deceitful.

That they too as well as [Physicians] have their theories.

And although present patient not at that period of life when might expect this yet by no means impossible that might be mistaken

Consider evidence then of Hydrothorax as far from being certain.

Yet such circumstances at least as gave reason to dread this affection.

Thus far then respecting principles [has] of complaint Dyspnoea & pain of breast.

For here although pains may arise from various causes as rheumatic affection or like yet reckon it not improbable that may be symptoms of disease mentioned.

And this the rather probable as pain chiefly arises from part at which sense of fluctuation chiefly felt.

Still more from long continuation of pain.

For has in some measure subsisted for space of two years.

From which may I apprehend conclude that has arisen from some cause in its nature of considerable permanence.

Although at same time augmented severely for short space before patient came under our care may have been more affect of accidental cold than of augmentation of this cause.

At some loss to determine whether should consider stomach complaint as connected with this part of affection.

To be observed however that complication of stomach complaint with dropsical affection in general not a frequent occurrence.

And that those taking place with our patient constitute a particular disease.

Are not constant affections but occur only at particular times.

Then consist of fits of nausea & sickness at stomach.

These succeeded by discharge of quantity of watery fluid by mouth

In these circumstances have the indications of an affection very frequently occurring.

And which in this country well known by title of Water Brash.

In nosological¹ systems has obtained name of pyrosis, as is generally attended with some degree of heat at stomach.

But although this symptom gives scientific name to the disease yet am far from considering it as essential.

Is unquestionably different from what in this country gets [appellation] of Heart-burn & which generally considered as the cardialgia of system writers.

Although at same time according to definition of Mr Sauvages should rather consider him as under title of Pyrosis defined Heart burn & under that of Cardialgia Water Brash.

In nosology of Dr Cullen term Cardialgia not employed as a general appellation.

And with him at least Pyrosis & Water Brash synonymous appellations.

And as being of this nature am disposed to consider attacks of sickness, nausea & discharge of watery fluid to which patient subjected.

In this light view it to be an affection unconnected with other parts of his complaint

And a disease which although not very much regarded yet far from being infrequent.

But whether present connected with former or not can be little doubt that next to be mentioned vizr glandular tumour on left side of neck no dependency on others

Here affection evident & according to account which we have received is cause of much pain.

Has now we are told continued for space of eight years.

And was at first consequence of stroke

Although but lately only that has had much pain from it.

Respecting this account have no particular reason for entertaining suspicions.

And most probable that disease arising from cause here mentioned is an affection of parotid gland.

Yet by no means uncommon for Lymph glands every where dispersed over surface to be [hovd] up to such size.

And affection here may in reality be a scrofula tumour.

To all these different complaints must farther observe that still some grounds for suspecting another.

Not long ago patient had discharged by stool a worm of lumbricus kind.

From existence of more of these in alimentary canal not at present at least any [inconvenience].

Yet seldom that worms of this kind are solitary there.

In so much that term of solitary worm has been appropriated to another species.

And lumbricus often will remain in intestines when product of no inconvenience.

Farther to be observed that one symptom here with which their presence in intestines often connected.

That is itchy sensation at point of nose.

From this circumstance alone many would be disposed to conclude presence with great certainty

Must own however that far from looking upon it as by any means so conclusive

And merely mention it as a supposition not improbable that are present.

Yet if should be present do not consider them as in any degree [concerned] in product of other complaints.

After these conjectures respecting disease must be sensible that can say very little with confidence respecting prognosis

And where with such complications are so much at loss matters may turn out very different from what expect.

But on opinion already delivered may form some conjecture as to Prognosis.

And here danger to be apprehended from different parts of his complaint very various

Pyrosis although an uneasy affection yet not to be considered as of much consequence.

And never yet met with any instance where could be considered as threatening danger.

Besides since patient came under our care has been but very little affected with it.

Hence neither has been nor perhaps will be object of practice.

And do not consider it as here of much importance

Although at same time shall not be surprised to find that patient subjected to returns of it as long as remains under our care.

From what said of worms also may be concluded that from these no great reason to be alarmed.

From presence of lumbricus indeed in alimentary canal most dangerous symptoms will sometimes arise.

Yet comparatively speaking this but rarely the case.

And now very doubtful whether with this patient any present in alimentary canal.

In this situation then must conclude that little grounds for apprehension.

Especially as although present probable that might soon be removed.

Consider these therefore as a source of disease from which have not here reason to apprehend either tedious or dangerous affection.

As to termination of swelling on neck am I must own much more doubtful.

From standing which has already had every reason to dread that will be tedious.

And from progress which has of late made some grounds for apprehension that may be dangerous

Glandular swellings in general very difficultly brought to suppuration.

And when do suppurate for most part not in favourable manner.

Hence even where not scrofula give [illegible] with equally little disposition to heal.

Should this then be case in present occurrence may have tedious & troublesome affection.

If does not end in suppuration may be no less painful still more dangerous.

For not in every case that remains in state of an indolent scirrhous.

Not unfrequently degenerates even to a cancerous affection.

And in that event will not be [doubted] that very great danger.

To this indeed at present no immediate or apparent tendency.

Yet perhaps a termination not less likely to occur than that shall end by resolution.

And am I own disposed to imagining that if this part of complaint not product of much unease will at least be tedious.

But should former also occur will not be contrary to apprehensions.

While however something to be dreaded from this affection still more if supposition well grounded, to be apprehended from affection of breast.

Of different kinds of dropsy few more generally fatal than Hydrothorax.

And often even proves suddenly so where little suspected.

Besides even where seemingly relieved like dropsy in general is very apt to return

From all these circumstances then some grounds for alarm in present case.

Yet at least in favour of patient that symptoms giving [suspicion] of this affection have for present in great measure disappeared.

Thus then presumption that if water once [effused] is now absorbed.

And farther supposition that ever was [effused] may have been mistaken.

Grounds therefore for hoping that this part of affection shall claim little more of attention.

Hitherto however have looked upon it as most [inters.] part of disease.

And accordingly in treatment [hitherto] used means of cure chiefly directed to this.

Was with intention of relieving breast that have here employed different evacuants.

Particularly cathartic & diuretic evacuated by natural outlets

And epispastic to side by artificial one.

All these directed on supposition that water effused in breast.

And that absorption would be consequence of discharge.

Here to be remarked that at different times have had recourse to use of different cathartics.

At first with this intention employed Glauber salt.

To this chiefly led from Dyspnoea being at that time accompanied with very considerable pain.

From this some suspicion of inflamed affection by which directed to use of refrigerant [rather] than stimulating cathartic.

And of these few operating with greater certainty or expediently than the Sal. Glauber.

After however from repeated doses found that little relief changed it for Cream of Tartar.

Both as being a medicine which could [continue] more regularly and from which expected some degree of diuresis as well as catharsis.

But from extent to which given although augmented urine yet produced no discharge by stool.

By this led to addition of Jalap with view of rendering operation more brisk.

But in this state patient thought that disagreed with stomach.

To use of purgative therefore [substituted] as diuretic the dulcified spirit of Nitre.

Which has at least preference to many others from immediate action.

And from seldom affecting stomach.

With our patient had desired affect of increasing urine.

And with this breathing relieved.

To which however not improbable that free discharge from Blister contributed somewhat.

In this situation omitting use have again had recourse to a saline cathartic from which diuresis may be expected.

And with this intention in place of Cream of Tartar have now employed the Soluble Tartar

Principally that may be able to see whether will agree better with patients peculiar constitution.

For in other respects hold that influence in good measure similar.

If however continues free from Dyspnoea shall not probably think of persisting in it

And if that affection returns will again have recourse to Spirit Nitre & Blister.

If does not will probably next turn attention to tumour.

At least doing nothing farther on [presumption] of hydrothorax than supporting free excretion by serous discharge.

As to treatment of tumour from which of late has had much uneasiness must acknowledge myself much at loss.

Perhaps if could get it to remain without farther progress or without pain would be most desirable object.

And is chiefly on this ground that [hitherto] have done nothing towards it.

If continues however measures will be necessary

And here aim must be directed to one of two objectives.

Either the producing resolution or suppuration.

On means of producing both these ends many ingenious observations will be found in a work on surgery now at the press in this place & which will soon be published.

The author of that work Mr Bell surgeon at this place, a Gentleman of whose ability I have a very high opinion & which have happened to rank among number of [writer] friends, lays down with great judgement principles on which suppose resolution & [supposition] to depend.

And points out means by which to be affected.

Into these however cannot at present propose to enter.

And do not [choose] to anticipate pleasure which hope will derive from perusal of his work.

May only observe that if for this affection measures necessary shall first attempt resolution by Saccharum Saturni.

And if in this disappointed shall try to induce suppuration by fomentation.

For other affections, Pyrosis & symptoms giving suspicion of worms have done nothing

And unless from farther symptoms do not mean to do any thing.

Upon whole may conclude with remarking of this case that future treatment in great measure regulated by future occurrences.

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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.