DEP/DUA/1/29/12 (Normalised version)

Ralph Johnstone

(1782)

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Ralph Johnstone

Respecting disease of this patient not altogether without doubts.

But whatever disease may be symptoms with which he is principally affected such that must consider it as a very alarming affection.

Here first at some loss to determine whether can consider patient as subjected to one disease only or to a complication of affections.

And secondly whether simple or complicated still more at loss with regard to cause of those symptoms which evidently constitute at least principal part of affection.

Can be no doubt that these are stomach complaints to which is subjected.

Most distressing symptom, pain at stomach sickness & vomiting.

These symptoms, as have already had occasion to observe, when treating of another case, are the great [constituents] of that affection which modern nosologists¹ have distinguished by title of Dyspepsia.

Where viz even most distressing stomach complaints take place from mere loss of tone & [depraved] action but without what can be called a local disease.

In case before us this may be sole disease to which patient subjected.

At least would not positively venture to affirm the contrary.

For unquestionably every symptom [which] here occurs even to much greater degree of severity has sometimes been observed to take place without any local affection.

Yet from all circumstances of the case cannot help being suspicious that an affection of this latter kind, does occur with present patient.

Of this, the mixture of blood in matter vomited, affords strong presumption.

Same also may be inferred from long & uniform continuation of affection.

And no less from constant soreness of left side increasing on pressure.

All the circumstances taken together are such as give at least some evidence of a local affection.

And if does not here take place, must yet be allowed that more of those symptoms which commonly indicate it, than to be found, in many instances where has really happened.

On dissection often apparent that scirrhous has really [existed] in stomach where much less strongly marked during life of patient than in present case

Upon whole then disposed to consider stomach complaint in present case as proceeding from scirrhous in that viscera.

Probably about pylorus.

Still however must be admitted that if exists has proceeded to no great extent.

And accordingly only certain mark by which can pronounce on presence of such a state, local hardness viz still wanting.

With this view of principle affection next to inquire whether any other disease.

Are informed that since present complaint began patient affected with some other symptoms which not commonly at least connected with other disease.

viz. Severe shooting pains in voiding excrement.

And these observed to be slightly streaked with blood.

This appearance may have proceeded from some slight haemorrhagic affection at time.

Or perhaps merely from that constipation to which patient subjected.

But whatever cause has now we are told ceased.

Hence then need not at present at least be farther subject of consideration.

But viewing patient as subjected to stomach complaint alone still at loss respecting prognosis.

A necessary consequence of doubt as to nature of these

But on any supposition cannot view affection as slight.

If mere dyspepsia from long continuation of symptoms from vomiting & from pain, may infer that affection will be very obstinate.

If on other hand, as I own am inclined to suspect, be really scirrhous will probably notwithstanding every endeavour we can employ prove fatal.

By no means however in such a state as to prevent attempts to cure.

Nor even supposing affection to be such as now suspect to preclude hopes of recovery.

In attempting this, have you will observe, proceeded from beginning on idea of scirrhous.

And accordingly had recourse to a remedy from which must own am for my own part disposed to entertain some expectation Cicuta

Am very far indeed from considering it in light represented by Dr Stork.

On other hand can as little adopt the opinion of those who hold it to be altogether ineffective & even insignificant.

To this influence which it demonstrates as affecting the head is I think a sufficient objection.

And in my own experience have met with many cases both of scirrhous & cancerous nature, in which I think evidently product of good effects.

At same time am inclined to think that many, nay most cases of this nature are incurable.

Hence then even frequent want of success no argument against future trials.

Here Cicuta employed under form of powder.

And have begun use to quantity of grain XV in day.

With intention if no objection shall occur of gradually increasing it.

Have ordered it as united with small proportion of Magnesia.

Principally with intention of giving proper form.

But also in some degree with view of obviating costiveness & correcting acidity.

And while well known to have former of these affects operates principally as laxative when [illegible] in stomach to be destroyed.

Here however such a state giving great uneasiness to patient.

Hence both requires to be obviated to increase prospect of obtaining the effect of gentle laxative from Magnesia.

At same time belly so bound that did not expect would be of itself sufficient.

Hence therefore ordered also the employment of Aloetic Pills.

Influence of both these & magnesia as obviating costiveness has been no more than sufficient.

On this course then for some time at least is intention to continue patient.

Increasing quantity of Cicuta & regular laxative according to circumstances.

If after proper trial no mitigation of affection takes place, or aggravation of symptoms, & no circumstance occurs to [alarm] opinion of disease hopes of recovery will be still less than before.

In that situation have next thoughts of trial of electricity.

Principally in way of drawing sparks from region of stomach.

And particularly from any part to which pain more especially referred.

If both tried in vain, may either look upon scirrhous as irremovable or idea of affection as a mistaken one

And unless some circumstances shall occur to give different view of it [endeavours] then probably employed merely to palliate.

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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.