DEP/DUA/1/18/08 (Normalised version)

John Thomson

(1778-1779)

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John Thomson

To disease of this patient at some loss what name to be affixed.

And still more difficulty respecting nature

According to account given us principle part of disease consists in discharge of peculiar matter by vomiting.

From colour of this matter as discharged should be inclined to consider it as consisting principally of blood.

While from nauseous taste & foetid smell presumption that contained also a mixture of purulent matter.

And that this may really be case by no means improbable.

For wherever bloody vomiting of long continuation at least great chance of some degree of ulceration.

Forming this judgement then from appearance & other qualities of matter vomited would still be inclined to affix to disease name of Haematemesis

For although by Haematemesis taken strictly are to understand bloody discharge by vomiting yet no [objection] that mixture also of other matters.

And among different species of Haematemesis as described by Mr Sauvages by no means in every case that vomiting of pure blood.

But before speaking of species to which present case to be referred may not be improper to observe that Haematemesis not [received] as genus into system of every nosologist¹.

This particularly the case with respect to system of Dr Cullen which consider as improving upon all preceding ones.

Refers Haematemesis entirely to head of symptom haemorrhages.

And can be no doubt, that more frequently takes place as symptom of obstructed menses or such other affections than as an idiopathic diseases

Yet in striking it out of lecture of [genera] cannot help thinking that has omitted a very important disease.

And at same time one which by no means unfrequently occurs in practice.

In this light then would consider it as being the affection to which our present patient is subjected.

Here however among all different species of the affection some difficulty to which should refer it.

In system of Mr Sauvages different species pointed out as arising from Plethoric Aneurism Accidental wounds, Leeches in Stomach etc.

Of any such cause however no suspicion in instance before us.

Of all species which he has [described] consider case before us as most nearly resembling Haematemesis atra.

And this according to account given of it, seems in nature to differ very little from another species which has described under title of Haematemesis ex [illegible]

For in case which he relates of Haematemesis Atra as well as of Haematemesis Splen affection [depended] in disease induced in the spleen.

From several circumstances am inclined to suspect this to be case with present patient.

Situation indeed to which he refers pain higher than would naturally be led to expect of spleen.

But may remark that with regard to pains of abdominal viscera in particular feelings gives by no means just representation of seat

Thus for example nothing more common than from affection of liver to have severe pain of shoulder.

And indeed extension of pain along [cont] membrane in every part of system very common.

Consider place then to which uneasy sensations referred as giving no objection.

While at same time very difficult to suppose that could arise, from affection of any viscus situated at part to which pain referred.

On other hand arises from affections of spleen perhaps more frequently than from any other cause

And where no immediate or preternatural rupture yet connection of blood vessels such that diseased state of spleen readily gives rise to it.

Cause also such as may readily have been supposed to induce disease of this viscus viz external pressure

When to all these circumstances add that [apparently] here taking place in vomiting such as spleen often produces, am inclined to think that opinion already delivered most probable.

And while give to this patients affection name of Haematemesis Atra consider it as depending on diseased state of Spleen.

From this view of complaint are necessarily led to prognosis rather unfavourable as otherwise.

In some cases haemorrhage to certain extent may be considered as natural tendency to cure or [prevention] of other diseases.

But in every instance beyond certain degree threatens danger.

And in many cases where not immediately fatal often so by consequence.

From this circumstance alone then [especially] when consider continuation which has already had must look upon it as threatening danger.

And besides continuation farther to be [remarked] that of late increased in violence.

Unless therefore prevented by removal, all the consequences of excessive haemorrhage to be dreaded.

But besides this from idea given of present case still farther danger.

For here both from taste & smell of matter discharged have indication of something more.

And reason to conclude that haemorrhage in some degree already complicated with ulcer.

Well known that from lungs, haemorrhage often terminates in fatal Phthisis.

And besides this similarly hectic fevers with general wasting of system frequently induced from like affection taking place in any viscus.

Accordingly find particular species under genus of Tabes arising from stomach, liver in like.

In present case cannot be said that hectic fever with all its characteristics yet present.

And particularly is in no degree affected with hectic diarrhoea one of worst & in general indeed last symptoms.

But with total loss of appetite is affected with considerable thirst.

And while subjected to frequent flushing has at same time general quickness of pulse, considerably above natural standard.

From all circumstances then taken together am apprehensive that patient will at last fall victim to disease.

And that probably rather by hectic fever, than by immediate loss of blood.

Must however at same time observe that cannot give this prognosis without expressing diffidence.

If indeed opinion of affection well founded little room for hope.

But in this must allow that may be in great measure if not entirely mistaken

And indeed hopes of recovery here chiefly founded on chance of such mistake.

For if conjecture true am acquainted with no measures from which can hope for much advantage

And must own took this patient under care rather with view of observing progress of affection & being able to discover what really nature of his disease, than with expectation of being of service to him.

While however patient continues under our care may at least give trial to different measures.

In treatment of this case first circumstance which naturally presented itself as grounds of indication, is discharge by vomiting, apparently at least of bloody matter.

But this again have supposed to proceed from diseased condition of vessels, which with blood, at same time yields discharge of purulent matter.

Hence then besides mere evacuation ulcer also to be considered as source of [indication].

In treatment of this case then hold that two great objectives to be particularly aimed at.

1 The restraining of the Haemorrhage.

2. The removal of diseased condition of spleen from which suppose it to arise.

For obtaining first of these ends measures in every case of haemorrhage greatly regulated by circumstances.

And in different conditions require even opposite treatment.

Particularly as evacuation of active, or passive kind.

Here both from circumstances by which suppose it to have been first induced & still supported, am inclined to consider it as entirely of latter kind.

Hence then recovery to be aimed at in some measure by diminishing impetus at part & thus allowing vessels to [contract]

But still more by those astringents which will have influence in producing such [contraction]

Even supposing however this fully accomplished still but part of cure.

And is an objective of still more importance to remove cause

That is to heal ulceration.

For if haemorrhage really from this [source] without being healed can hardly look for mitigation much less for radical removal of complaint.

Healing of ulceration however whether external or internal in great measure work of nature.

And in as far as depends on artificial means is brought about by induction of that state of inflammation which in [contradiction] to suppuration has been [termed] adhesive.

Have thus then stated general principles on which am inclined to think that cure in present case to be aimed at.

And shall next make few remarks on remedies already ordered or that have [after] thoughts of employing.

Began this patient with use of a medicine which till very lately, have not been in practice of employing in such complaints.

That was the Gum Myrrh.

This Gummi Resin substance long supposed possessed of what have been called balsamic powers.

And imagined to have very considerable efficacy in curing ulceration from external application.

Besides this also a common practice to give it internally where ulceration suspected particularly in consumptive cases.

But of late years that practice has fallen greatly into disrepute.

And this principally if not solely from a very elaborate paper written by one of most eminent practitioners in London Dr Fothergill

In that paper which will find in London Medical observations Dr Fothergill condemns in strong terms use of all balsams in consumptive complaints

And while asserts that from experience has found them product of worst effects contends also that this must appear from reason as well as experience.

Holds that use as externally applied solely to be referred to defence against air.

Endeavoured to show that even externally operate as exciting very considerable inflammation.

Alleges that from this in some instances the worst effects.

And concludes that in every case of ulceration of breast must be product of bad consequences.

Admitting [premise] here, must own could never be satisfied that conclusion followed.

Not indeed to be denied that certain degree of inflammation excited on internal as well as external ulceration, may be product of bad effects.

Yet no doubt that externally, certain state of inflammation, requisite for cure of ulcers.

And may conclude same to be case with respect to internal ulceration.

From admitting then premise which lays down, may I think draw opposite conclusion.

And supposing Myrrh & other balsams to excite inflammation, may yet be useful, when properly used in cure of Phthisis.

Or at least although many cases unquestionably incurable, may yet be suited for some others.

Must however own that on this subject was disposed to give much greater weight to facts of Dr Fothergill than to his reasoning.

And on assertion of so judicious & observant a practitioner had little doubt that universally pernicious

Must own therefore that when heard that Gum Myrrh strongly recommended by another London Practitioner was not without some [prejudice] against it, that thought of giving trial.

In disease however so very generally fatal every practitioner must be anxious to try different remedies.

Especially as slow progress of disease often affords best opportunity for this.

Having been informed therefore that Dr Fordyce of London very high opinion of Myrrh in Phthisis affections, resolved after employing other practices in vain to give trial.

And within these last 12 months have used, it with several patients labouring under this most deplorable affection.

Can by no means ascertain that in all these have found it product of good effects.

In some, effects of action even on alimentary canal such as led to discontinue use.

In others although easily borne on stomach yet seemed to have no influence in cure.

And disease if not increased at least continued without mitigation.

But in third set of instances have employed it where to me affects seemed different.

And during use patients labouring under Phthisis with purulent expectoration, which conclude would have terminated fatally had at length happy recovery.

How far this to be ascribed Gum Myrrh dare not venture to say.

For have oftener than once seen other instances in which ulceration of lungs healed by free expectoration alone.

Yet must own that from considering all circumstances of cases eluded to, could not help thinking that Myrrh had affect.

And in this opinion, besides authority of London practitioners already mentioned I am not singular.

For Dr Webster my colleague at the Dispensary has also of late tried it with several Phthisis patients & in some instances he thinks with success.

Is then on these grounds that notwithstanding authority of Dr Fothergill still consider it as a medicine, deserving trial.

Do not however look upon it as equally calculated against all cases of Phthisis.

And particularly have never seen advantage from it where dry cough without expectoration.

That is either where vomica existed which not ruptured, or what indeed much more common, had indurated tubercules giving irritation & yielding sanies, but with no tendency to what could be called ulceration.

On contrary, cases where has apparently succeeded, those where evidence of considerable internal ulceration.

And where probable that peculiar inflammation on which adhesion depends, wanting for cure.

From these circumstances am inclined to look upon it, as a remedy applicable or at least meriting trial, not only in Phthisis but in other cases of internal ulceration.

And was on this account that directed it for present patient.

For as have already observed suspected that haemorrhage here supported by such a cause.

And in this case combined it with a proportion of Cream of Tartar.

From this addition, hoped that in [consequence] of refrigerant effect, might have some influence as restoring haemorrhage.

But expected still more from operating as a gentle cathartic.

By this means hoped, that costiveness, with which patient distressed, might in some measure be obviated.

And that thus from matters getting determination downwards, might in some measure be freed from sickness & want of appetite.

In these expectations however were altogether disappointed.

For Cream of Tartar in extent to which given quantity viz of ℥i, in day, no influence in moving belly.

And whether from this or from the Myrrh itself cannot say, but powders seemed rather to increase sickness at Stomach.

Hence then after trial for two weeks have been led at least for present to [intermit] this remedy.

Have however thus fully stated sentiments with regard to it as still some intention of returning to use.

And especially if matter discharged shall be changed from present bloody appearance to more purulent form.

Not improbable that may hereafter be found to disagree less with stomach.

Meanwhile however have substituted to use of Myrrh medicine more immediately directed, with view to bloody discharge.

With this view employed as astringent a mixture with the Gum Kino, a vegetable astringent which have in many cases employed with good success.

And of which may perhaps hereafter have opportunity of delivering sentiments more fully

For best account of it may refer you to a paper in London Medical Essays by Dr [F]

While used this astringent ordered also as a refrigerant continuation of Cream of Tartar with Nitre & Gum Arabic.

But still in expectations of gently moving belly [disappointed]

At same time discharge of blood by vomiting rather increased in violence as otherwise.

From this led to substitute to use of Gum Kino a more powerful astringent.

And at same time one which hoped might have less tendency to bind belly.

Was with these intentions that employed alum, combined with Succus Japonica.

At same time continued Cream of Tartar as before.

From this have not yet obtained effect of moving belly.

Yet as both frequency of attacks of [vomiting] & degree to which occurs diminished have resolved to continue.

And probably shall go on for another week either without alteration or merely increasing quantity.

If bloody vomiting restrained but still with symptoms of purulent discharge may as have already observed give farther trial to the Myrrh.

As probable when stomach less loaded with blood may sit more easily on it.

But in a case where so much danger & so ignorant of nature needless to speak of many different measures.

As by no means improbable that either from change in state of disease or from alteration of opinion shall soon be obliged to desist from all of them

And perhaps shall be reduced to necessity of merely confining practice to measures intended with view of alleviating symptoms.

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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.