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

James Keir

(1790)

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James Keir at 63.

In case of this patient, as formerly observed had as well as in that of Jean McKenzie, a distinct marked instance of Icterus.

For here unquestionable evidence both of presence of bile in blood & absence in alimentary canal.

Conditions, both of which, unquestionably essential to the disease.

And which when occur together, clearly demonstrate obstruction to natural passage.

This obstruction however as may readily conclude may proceed from different causes.

Some much more readily removed than others.

Of all causes perhaps most frequent is biliary calculus making way into ducts

A cause very generally at least admits of recovery in no long time.

For although in some rare instances so compacted as to be irremovable, yet very generally can be either driven backwards, or pushed forwards.

Particularly from aiding effects of concussion by that relaxation which is given by Antiphlogistic

This cause, calculus, from reasons formerly pointed out, suppose to induce affection in present instance.

And on this ground was inclined to give favourable prognosis.

In this particular have not at least been disappointed.

For in no long time, patient dismissed from attendance entirely free from affection.

And this with some probability at least might I think be attributed to remedy here employed.

Began practice you will observe by ordering an emetic for patient.

As being easiest & readiest means of giving mechanical concussion, tending to expel stone.

As an emetic had here recourse to Ipecacuanha.

An article from which can more certainly command full vomiting than from any other which yet acquainted.

While at same time, neither danger of operating by stool, nor of doing too much in way of Emetic.

When ordered vomit, directed also aloetic pills to extent of five grains om. n.

These in cases of jaundice useful on different footings

Where obstruction merely from mucus may entirely remove it as producing evacuation.

And from increase of persistent motion of intestinal canal tends at least to aid even expulsion of calculus.

But still more generally useful as obviating costiveness.

For this an almost necessary consequence of want of bile in intestine.

And from costiveness want of appetite indigestion, sickness & various other symptoms probably arise.

Operation of both of these medicines, fully answered expectation.

For while from Emetic, had the concussion of full vomiting, from after use of pills had an easy stool, daily.

Had some reason even to believe that by this first emetic obstruction removed

For afterwards both stools appeared of darker colour, & countenance less yellow.

In this situation however thought it still advisable to repeat the emetic.

For by no means that first [action] of vomiting always sufficient for removal of calculus.

Accordingly by some practitioners directed even to be repeated every second day.

And even after removal to be still continued, at longer intervals.

Here then lest first had not been effective, second naturally suggested.

And if had removed obstruction yet second emetic would at least be product of no inconvenience.

While equally little to be apprehended from pills.

In point of obviating operation same effect derived from medicine as before.

And now still more certain evidence of removal obstructing cause.

For with great diminishment of yellowness stools had regained natural colour.

An evident proof of free passage of bile into intestine, even although deep yellow colour should still remain.

For this often depends on effused bile into cellular membrane & not to be removed till taken up by absorption.

And accordingly chiefly to be expected as gradual operation of nature.

In this situation might perhaps have omitted medicine altogether.

But directed continuation of pills for another week, principally to secure attendance.

And as then found that no remains either of yellowness or any other symptom of jaundice was dismissed.

Had not it must be allowed in this case certain evidence of calculus from stomach being discharged.

But might either have been evacuated unobserved or thrown back into gall bladder

And additional evidence of its dependence on Calculus from cure.

To accomplishment of which think it probable that the emetic contributed.

While at same aloetic pills good effect as obviating symptoms.