DEP/DUA/1/47/37 (Normalised version)

Jean McKenzie

(1790)

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N^o23. Jean McKenzie.

In disease of this patient as formerly observed a distinctly marked instance of jaundice.

For in symptoms undoubted evidence both of admission of bile into blood & absence in alimentary canal.

Has been much subject of controversy whether former to be ascribed to regurgitation or absorption.

But whether one or other very immaterial as to practice.

As cure to be effected only by removal of obstruction to passage into alimentary canal.

This however may be produced from very different causes.

And according to nature of obstruction not only is practice varied, but disease more or less obstinate.

Perhaps most common cause of jaundice, of any obstinacy, admitting of cure, is where depends on calculus.

And most common instance of incurable jaundice, where depends on scirrhous.

For hitherto at least, no remedy discovered by which resolution of this when of certain standing to be effected.

And although may at first exist without giving total obstruction yet a cause which has tendency gradually to increase.

Thus at length gives not only total but irremovable obstruction.

To this cause scirrhous was formerly disposed to conject that obstruction in present case to be attributed.

And during time that patients attendance continued here no reason to alter opinion.

Disease indeed while heard anything of this patient had not fatal termination.

But continued only to receive reports of her, for about a month after case under our care.

And since last of these reports near two months have already elapsed.

What therefore may now be state or whether has already had termination cannot pretend to say.

Not improbable I think that fatal conclusion may have already taken place.

But may here observe that supposing conjecture as to scirrhous giving an incurable disease being well founded, this by no means necessarily follows.

For in this case patients will yet often continue subject to the affection for many months.

Particularly where as [represented] to be case with our patient copious discharge of bile by urinary organs.

In this manner then reason to hope that disease might not be speedily fatal.

And that might at least have opportunity of employing measures which if not capable of curing might yet alleviate affection.

Began practice here you will observe by prescribing emetic

This need hardly observe one of the most successful remedies for jaundice depending on calculus.

And success depends on calculus being removed by concussion which occasions.

Is however very evident that on this principle can be of no use in scirrhous.

On contrary where gall bladder very much distended concussion may be product of worst consequences.

Reason even to [apprehend] [illegible]

Hence where decided evidence of scirrhous some have entirely prohibited use.

Seldom however that can conclude with such confidence as to this cause, as to deter from attempts to cure on other grounds.

And but rarely that state of distension such that from even severe vomiting any dangerous effects to be dreaded.

In present instance, notwithstanding advanced age of patient, unfavourable to any great concussion yet consider trial as both advantageous & proper

And if did not afford expectation of cure, at least from want of success would have negative evidence of scirrhous.

On these grounds therefore notwithstanding suspicion of scirrhous here directed the emetic.

And as safest & most certain [employed] the Ipecacuanha to extent of Ji.

From this not at least disappointed in brisk & proper operation.

But at same time without any evidence of effectiveness in removing cause of the disease.

For at distance of eight days after, both skin & stools, continued of same colour as before.

And although change on former, not always immediate consequence of removal of obstruction yet this uniformly case with respect to later.

But although first unsuccessful, yet from reasons formerly mentioned judged it proper to make second trial.

And from this at least not deterred by any bad effects resulting from first.

While however directed second emetic thought it advisable also, to do something with view of opening belly.

For while constipation natural consequence of want of that stimulation which bile affords tends always to augment stomach ailments.

As rather here had recourse to Pill Aloetic.

Formed of combination of Aloes with extract of Gentian.

One of most certain & consistent laxatives which can employ where single stool only is required.

And daily used with great advantage in jaundice as well as various other affections.

Here neither disappointed in operation of vomit nor cathartic.

For while former brisk action, latter had at least some effect in opening belly.

And were told that after this yellowness of skin seemed rather to be somewhat diminished.

This however probably more effect of inaccurate observations than anything else.

For in this respect even attentive observers apt to be deceived from difference in light in which patient placed.

At any rate no more reason now to imagine obstruction removed than before.

For matter discharged by stool, still equally white as formerly.

And while in this situation was also much affected, both with pain of belly & want of appetite.

In this situation thought that had now sufficient evidence, that obstruction not to be removed by action of vomit.

And in place of pushing emetic farther, thought it proper to do something with view of strengthening stomach.

With this intention had recourse to a mixture of bitter & aromatic Tincture.

And to combine with this a diuretic power added to it, a proportion of Fixed vegetable alkaline.

By this hoped, that tone of stomach might be increased & thus appetite promoted.

And that by increased dius, bile being more copious discharge by kidneys less chance of a [illegible] in blood.

Thus then though not tending to cure might at least in some degree alleviate affection.

Cannot however say, that expectations in these particulars altogether answered.

At least though imagines stomach somewhat relieved yet urine not increased.

And pills now ceased to keep belly open.

With continuation of mixture therefore obliged to increase dose of these.

Without however giving fair opportunity for trial patient may be said to have [deserted].

For have now heard nothing of her for near two months.