DEP/DUA/1/19/22 (Normalised version)

Robert Morris

(1778-1779)

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Robert Morris.

Am much at loss to say whether case of this patient affords example of complication very singular or not.

In history of case as introduced into our register¹ some particulars which exhibit an assembly of symptoms by no means frequently occurring.

And if disease really proceeds from circumstances to which patient himself inclined to ascribe it may look upon it as a very uncommon complaint.

On other hand however reckon it [not] improbable that symptoms in disease of this patient not a little aided by his own [illegible] of mind

Is not indeed arrived at that period of life, when affection with tendency to Hypochondria most common.

Yet can be no doubt that many of his complaints effect of flatulence.

Of this sufficient evidence from propagation of pain from one part of alimentary canal to another

And from relief which discharge of flatus affords.

Besides these in disagreeable taste in mouth & bound state of belly farther evidence of affection of alimentary canal.

And if can suppose that with [this] there occurs that state of mind which takes place in hypochondria by which patient disposed to magnify every part of affection not improbable that affection may be solely of this nature.

To this conjecture the rather led from cause to which patient attributes it.

Had occasion it seems nearly 12 months ago to lift a dead body

And ascribes complaint to which now subjected to inspiration of air at that time discharged from mouth of dead person.

That such foetid air may have operated as cause of disease do not deny.

But at same time would chiefly suspect it as giving origin to affection of febrile nature & with [putrescent] tendency.

While on other hand is an accident of that nature on which a hypochondriac would readily dwell.

And which would strike [imagination] as giving rise to affection of most dangerous tendency.

Can however be no doubt that to such [accidental] numbers daily exposed without any inconvenience.

Yet must be allowed that besides symptoms indicating affection of alimentary canal patient enumerates others not common in Hypochondriasis.

Represents himself as being affected with constant & severe pain at [appar] part of sternum.

And this also as being attended with Dyspnoea & sense of heat.

Symptoms which would more readily suppose to be consequence of tumour or some similar local affection than from any other cause

And impossible to say that to such, even cause mentioned by our patient may not have given rise.

While again such an affection may have had beginning about that time from some other accident escaping observation of patient.

From all these circumstances then room for some suspicion.

Yet at same time to be observed that some appearance even of this pain being connected with affection of alimentary canal.

For are told that particularly aggravated when from flatus sense of ball in throat impeding respiration.

And that alleviated both by eructation & by smoking tobacco.

Circumstances both of which against supposition of local affection.

For in both cases must naturally ascribe relief to removal of distension & of [illegible] [structure].

At least is most probably on latter principle that to account for relief afforded by Tobacco.

While again no room for doubt as to principle on which relief afforded by eructation.

Upon whole then inclined to consider it as most probable supposition that disease consists principally if not totally in affection of alimentary canal.

And this conjoined with melancholy & timorous state of mind leading patient to represent ailments as more distressing than really are.

In this state of uncertainty however must be very diffident with respect to [Prognosis]

At any rate however in some respects rather unfavourable as otherwise.

If conjecture which disposed to adopt nearest the truth must at least consider as an affection which reason to apprehend [will] be tedious.

And if any grounds for supposition of local affection may even be dangerous.

While at same time neither in one case nor other is there any [remedy] from which can expect any remarkable [affect] in cure.

Measures therefore at first directed intended rather with view of palliating symptoms & that might have opportunity of being more thoroughly acquainted with affection than from hopes of proving beneficial as eradicating the complaint.

Prescribed for him at first a mixture of Tincture Amarum with Elixir ex Aloe & [illegible]

First long in high esteem against [effusions] of stomach.

In so much that has obtained name of Elixir Stomachicus.

In as far however as alleviates complaints of that viscus, can be little doubt that operation depends on influence as bitter & aromatic.

And as former may be considered as most active ingredient, while at same time in largest proportion now with propriety named Tincture Amarum.

In the Gentian, the article which [enters] this formula in greatest quantity, have one of purulent & strongest of the Vegetable bitters.

While same power also [to] considerable degree though conjunction with aromatic in [illegible]

In canella alba entering composition have an article intended for increasing aromatic flavour.

And cochineal with no other view than to give colour.

In as far however as gives red colour & therefore when vomited apt to give [suspicion] to patients of blood reckon, it no advantage.

But from other articles bitters & aromatics have basis of remedy which may [readily] suppose will operate from increasing tone of stomach & stimulation to action.

And powers in this way sometimes at least increased by [menstruum] employed.

Here indeed may observe that same articles frequently in use against stomach complaints when acted upon by watery menstruum.

For infusion amarum of Pharmacopoeia² formed of same article although indeed in lesser proportion.

But in formula here employed the menstruum used is weak vinous [spirit]

From this indeed extent to which bitter & aromatic can be thrown in more limited than where watery menstruum.

But at same time Spirit itself unquestionably acts as stimulant exciting action of stomach

And perhaps as means of alleviating stomach complaint too frequently employed in [pure] state

From use first begun in this manner, many brought to state of habitual dram drinkers.

Of this however unquestionably less hazardous where used as basis of bitter Tincture than where taken by itself.

And hence do not consider it as a circumstance giving watery infusion [preference] over Spirit

While with latter have advantage of the menstruum.

Here however bitter or stomachic Tincture did not constitute greatest part of medicine at first ordered.

Was conjoined with another [composition] also very frequently in use

And which in my opinion deserves consideration as a medicine greatly used Elixir [illegible] Aloe & Rhoei or as commonly called the sacred Elixir.

Article on which action of this composite depends fully expressed in title now given to it.

For proportion of Cardamom seeds which [enter] it meant merely as corrigent.

In combination of Rhubarb with Aloes, have what with many an useful purgative.

And can be no doubt that operates as such when given in large doses.

But when exhibited in smaller quantity while gently opens belly at same time increases tone of intestinal canal.

Was such affects than here [expected] from it.

And while in latter way hoped that would increase power of other stomachicus imagined that on former footing might be means of affording great relief to patient

And would not only obviate costiveness to which subjected but as promoting discharge of flatus, gives to more considerable degree that relief which derives from such an [occurrence] when taking place without any medicine.

During course of first week did not reap from this medicine all the benefits which I own I expected.

And from this some grounds for suspicion that disease [sought] [illegible] merely consisting in affection of alimentary canal.

But at same time even to extent to which here given not without affects.

For had both some influence in moving belly & in alleviating complaint of stomach

In frequent eructations however & in sense of ball rising to throat had still evidence of inordinate action of alimentary canal.

And might therefore conclude that no inconsiderable part of remaining complaint from this source.

Still however complained particularly of fixed pain on sternum as before.

While former part of complaint then led to continuation of medicine before prescribed, consider this also as now meriting some attention.

If indeed as have conjected might be case depending on local cause & that situation internally could have but little expectation from [medicine] soon [producing] [efficacy]

And indeed if really any local affection, that such affection was seated internally, rendered probable from want of external appearance.

Still however consider it as not an impossible supposition that might be either a muscular pain or that might depend on integumentary & [membrane] external to thorax.

And if this the case expected at least some degree of temporary alleviation from external friction with camphor oil.

Than which perhaps possess few more penetrating topical applications.

Consider it therefore as advisable to recommend such a trial.

As from this without any hazard, might at least have some farther opportunity of judging of nature of affection.

But when directed this measure thought also of doing something farther with [view] to affection of alimentary canal than contents of stomach with purgative.

And imagined that might be in good measure freed from one of most distressing symptoms of which now complains sense of ball vizr rising to throat from counteracting inordinate action by antispasmodic.

As such had here recourse to Assafoetida under form of Pill Gummos.

But what has been affect of these last prescriptions have not yet learned.

And in this state of uncertainty can hardly venture to say what other measures would prosecute should present fail of affording relief.

Opinion however of disposition of patient gives reason to apprehend that may not see him here again.

But if should return could only prosecute present or similar palliative course till more satisfied of nature of complaint.

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Explanatory notes:

1) References are made throughout the case notes to a dispensary patient register. However, no evidence has been found that this register survives.

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.