DEP/DUA/1/11/20 (Normalised version)

Jean Allen

(1776-1777)

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A fortnight ago dismissed from attendance here Jean Allen.

A patient of whom as had not reached her in list of admission have hitherto said nothing.

Her case to me appeared in many respects singular

Had never I own before seen what could reckon an instance of same affection.

Till very lately had never read of it.

Or at least as mentioned only in such cursory & accidental manner as to merit little attention

A few months ago however had honour of receiving from Dr Baldinger of Gottingen several inaugural dissertations published at that University.

Among others one entitled De Petechiis sine fibre¹ by Dr Eberhard Graaf.

I own that from title alone was not disposed to give much credit to it.

Consider proper petechial eruption as solely confined to fevers of Typhus or putrid kind

And that too in worst states.

Was inclined therefore to believe some deception

And as cutaneous diseases easily confirmed at first occurred that some other cutaneous eruption might be mistaken for petechiae.

From perusal of treatise however necessarily led to different opinion.

Thesis to which I allude consists merely of case which had occurred to author & commentary on that case.

In history so many other concurring circumstances that no doubt of nature of eruption.

Not long after present case occurred.

And circumstances such as afforded evident example of what Dr Graaf has described.

His case and present in almost every particular similar.

In our case most evident symptom an eruption of small red spots on different parts of body particularly about breast & neck.

These spots correspond very exactly to every description of Petechiae.

In size & figure much resembling flea bites

In place of florid red however were of livid cast.

And had not evident mark of puncture in middle always attending flea bites.

But besides this matter put beyond all doubt from other appearance.

Together with these spots large livid blotches visible on many different parts.

Giving in great measure same appearance as effusion of blood in cellular membrane from strokes or similar causes.

Had also very great resemblance to the vibices attending putrid fever.

Have often seen cases where appearance not worse terminating even in sloughing of patient.

Same appearance particularly remarked also in case of Dr Graaf.

But neither so numerous nor to so great extent.

Two only mentioned in his case & these smaller than with our patient.

His words are In regione potissumum hypochondriaca sinistra conspexi duas maculas virides et sugillationibus simillima quae ovi columbini magnitudinem aequabant

That these of same nature with what occurred in greater number in our patient can be matter of no doubt.

And even little ground for hesitation in pronouncing that were affection of effused blood.

For here disposition to rupture of vessels manifested in various ways.

Before patient admitted under our care oftener than once spontaneous bleeding at gums.

And that too without any evidence of spungy texture or local affection.

On taking purgative also had been observed to discharge considerable quantity of blood by stool.

After came under our care in some measure same appearance.

That is still evidence of tendency to haemorrhage in discharge of blood by nose.

And without any grounds for suspecting that was the affect of haemorrhagic affection.

For neither quickness nor hardness of pulse nor any other symptom attending that state of body.

These the only morbid symptoms either evident in this case or of which patient complains of being affected after came under care

At one time indeed complained of some uneasiness & swelling at stomach.

Probable however that these rather consequence of remedy than connected with disease

May very naturally have arisen as affect of vitriol acid.

And at any rate a symptom of short duration & giving little uneasiness.

At another time discharged by stool a worm probably of lumbricus kind.

This however inclined to imagine no connection with primary affection.

Worms in alimentary canal indeed cause of great variety of symptoms.

Do not know however, that have ever been alleged to induce such as present.

And discharge of them from alimentary canal by no means infrequent consequence of other affections.

This am disposed to imagine in some measure case with our patient.

And would consider the petechial eruption, the blotches suggillations or vibices, & disposition to haemorrhaging as constituting affection for which came under our care.

Will naturally occur then what genus of disease these constitute.

And here must own that know no place to which can properly refer them in any nosological² system.

By some nosologists indeed petechial itself made a genus of disease.

But still confined to those cases where combined with febrile affections.

To such therefore cannot refer present instance.

Of symptoms here presented none which do not at times occur in Sea Scurvy.

But that affection characterised by many other marks not here present.

Nor in this instance was there by any means same progression as in scurvy.

No fetororosis of breath, softness of Gums, prostration of strength, ulceration, oedematic swellings or like.

Nor could patient be subjected to those causes very generally if not always inducing it

Evident impropriety thence in referring it to this head.

If however allowed to coin a name and in this way practitioners of our days have used greater freedom than all predecessors might call it Petechianosos.

That is a disease characterised by petechiae.

Whether appellation however proper or contrary will little affect idea of nature.

Not improbable however that in nature some analogy.

And if can form reasonable conjecture of nature, of more consequence in determining affection than giving name.

Here I own from all circumstances taken together should be inclined to suspect particular state of fluids.

And that too without any disease of other parts of system either as simple or living solids.

At least on this ground apprehensive that symptoms may most readily be explained.

That solids not affected evident from natural state of every function.

That fluids in such a state as to make way through passages not natural to them appears both from haemorrhage & extravasation.

For of this nature must consider both petechiae & blotches.

Former indeed in fevers of putrid nature sometimes reckoned rather critical than symptom.

But in all probability without any good reason.

Latter manifests same appearance as in extravasation from other causes.

Can be no hesitation therefore in referring it to this source.

Would therefore conclude that texture of blood, [probability] of red globules in some measure destroyed.

In this respect then may presume that no inconsiderable analogue to scurvy.

For there every evidence of similar destruction of texture

Still however cases may be materially different.

Experiments of Mr Hewson out of body throw new light on this subject.

Has shown that figure of Globus particularly connected with certain state of fluid in which they swim

That by increase of saline impregnation are shrivelled & broken inwards.

That by increase of watery part are distended & broken outwards.

And on all hands allowed that by putrefaction texture destroyed without any change of menstruum.

That these causes will all to some degree operate in living body not to be doubted.

And perhaps more frequently in combination than separately.

Presumption however from causes inducing the affection that first more particularly operates in scurvy.

That last chiefly cause of dissolving in [den] with putrescent tendency.

To which here to be referred [consideration] I own as somewhat doubtful.

And on this subject little grounds of conjecture afforded by alleged cause.

That viz of eating quantity of beans.

How far however these from quantity merely may have induced succeeding fever.

And fever having given rise to this state may reasonably at least be made questionable.

From this view disposed to refer it to that cause rather than any other.

And treatment conducted accordingly.

Of Prognosis here observations now precluded from disease having terminated favourably.

May naturally occur however as question how far ought to be considered as dangerous affection.

Probably judgement here to be formed only from two sources.

From former facts or where these wanting from knowledge of nature of disease.

Of facts have already observed that this first instance of kind have met with.

Here therefore no conclusion from any experience of my own.

Nor indeed much from that of others

Case described by Dr Graaf had similar favourable termination.

And that too in no long space of time.

Besides this towards end of treatise has collected several instances somewhat analogous from different sources.

Particularly from the Acta Academiae naturae curiosorum³ & that treatise of Dr Stahl entitled Collegium casuale minus⁴.

In these likewise disease had favourable termination

Upon whole therefore perhaps less grounds to be alarmed than would naturally be from idea given of disease

For must be acknowledged that from this view should conclude it of bad tendency.

And how far might not be severe when left to its own course at least matter of doubt.

Should any future instance occur then would reckon it improper to view it as of little account.

And till corrected by farther experiments would again be disposed to follow some plan of action

Which although not precisely same at least nearly similar to that which succeeded with Dr Graaf.

Conjecting symptoms to arise from destruction of globus in consequence of putrescent tendency imagined that to be combated by antiseptic.

And as such here employed Peruvian Bark & Elixir of Vitriol.

As symptoms not urgent wished rather to throw in Peruvian Bark gradually than in such quantity as to endanger any uneasiness at stomach.

In this way conjoined with Vitriol Acid was continued for near space of fortnight

And at end of that period cutaneous affection which had undergone different changes, but at same time with gradual tendency to diminish nearly gone

As complained of some disorder in alimentary canal which conjected might be affect of medicine directed their being discontinued.

And at same time ordered at intervals a purgative for evacuating contents of bowels.

By these means swelling of stomach removed.

But probably gave occasion to discharge of worm observed after second purgative.

Although concluded this accident, yet led at least to suspicion that might be otherwise

And accordingly thought at least of trial with this view.

From more active Anthelmintics however in some measure precluded by idea of former disease.

Was this circumstance that determined to trust of powder of Chamomile flower.

But as after continued for some days with respect of purgative no appearance of more worms, & patient in every other respect in health reckoned it unnecessary that should continue attending here.

At same time will not be surprised if soon again uneasiness from worms.

In that case if again comes under our care may with greater freedom have recourse to more powerful medicines.

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Explanatory notes:

1) Eberhard Gottlieb Graff, De petechiis sine febre (1775).

2) 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.

3) The Academia Naturae Curiosorum was established in Schweinfurt in 1652 as an academy of learned doctors. Their main publication, variously known as their laws, acts or miscellanea curiosa comprised of a collection of writings by the group's members on medical subjects.

4) Georg Ernst Stahl, Collegium Casuale: Sic Dictum Minus (1734).