DEP/DUA/1/13/04 (Normalised version)

Thomas Livingstone

(1777)

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Thomas Livingstone

Complaints of this patient but few in number

Only disease an affection at different parts of body obvious to senses

May be concluded therefore that while no complications, can with regard to name be little difficulty.

This however not altogether the case.

Can be no doubt indeed that disease under which this patient labours is totally a cutaneous affection.

And with vulgar in this part of island is what would pass by name of scurvy.

A term however when thus used employed in very vague sense.

And meant to express affection essentially different from Scorbutus of Nosological¹ writers or sea scurvy.

Have no doubt that among proper idiopathic cutaneous affections many distinctions may be made

And that these distinctions even useful in practice.

Must however acknowledge that know no proper grounds on which can proceed.

Mere description of appearance very difficult to examine in such manner as to give proper idea of differences.

And besides this in these nothing very steady.

With same affection even in same patient most accurate description of appearance at one time will by no means apply at another.

Cannot help thinking therefore that some nosologists have multiplied distinctions in manner both useless & perplexing.

And for my own part have never been able with any degree of certainty to push distinction farther than into two genera.

In denominating these would employ terms Lepra & Herpes as being most general ones.

And must own that even with respect to these frequent transitions from one to other.

Would however upon whole give denomination of Lepra when affection of dry scaly nature without any discharge.

And of herpes when more redness inflammation, moisture, & even tendency to ulceration.

On this ground then would pronounce present to be a case of Lepra.

Under this affection by nosological writers many different species comprehended.

And these merely derived from differences in appearance

Apprehend that of much more consequence to distinguish cause than to affix such even [within] utmost accuracy.

No doubt that may derive origin from very various causes.

Sometimes consequence of state of general mass of fluids.

More frequently however an affection in nature but local.

And depending on diseased condition of vessels of surface.

On diseased state of discharge from thence.

Or on affection of bulbs of hair.

In present history no circumstance which can lead us to form any very probable judgement in this respect.

Patient himself unacquainted with any particular cause to which affection can be ascribed.

And have not been able to learn any peculiar circumstance in situation in life to which can be disposed to refer it.

These consider as objection to supposition of affection of general mass of fluids.

And know no circumstance in health of patient in other respects giving countenance to that supposition.

Equally little reason to believe that is effect of disease of bulbs of hair.

For had this been case would not probably two years ago have got quit of it so easily.

Must own therefore am rather inclined to supposition of its arising from other causes mentioned.

And disposed to consider it as depending on local morbid condition of vessels affecting state of discharge.

And on this ground opinion both respecting prognosis to be given & practice to be followed here hitherto proceeded.

Symptoms of case such as could not be supposed to give any alarm.

Often however in cure cutaneous affections found to be very obstinate.

In no case therefore should a practitioner speak with great confidence of speedy termination

Apprehend however that of all cases such as have supposed present to be are the least obstinate.

In present instance has as yet been of no long duration.

When came under care had been but few weeks affected with it.

And such for a cutaneous affection might be considered as but a recent case

True indeed patient some years before had been subjected to similar complaint.

From this on one hand might be argued that apparent disposition to such an affection.

But on other might be supposed to afford grounds for favourable judgement.

For in that instance yielded without much difficulty.

May farther add that medicines employed in cure have already made very considerable progress.

From all circumstances taken together then here grounds for favourable prognosis.

And hope that case may soon terminate as we would wish.

Plan of treatment which consider best adapted to this case in some measure directed to general state of system.

Still more however to local affection.

Apprehend that where morbid action of vessel may be most effectively obviated by peculiar stimulation to those.

And was with this intention that in present case had recourse to Mercury.

This applied externally to affected part & that too in one of most acrid states.

Form viz of Corrosive sublimate.

First used merely in way of lotion.

But afterwards that might ensure longer application made in form of poultice by bread.

With same intention might have employed the Mercury internally

And that either in form here exhibited or any other.

For hold that after entering circulation is yet capable of exerting specific affects at even remotest parts of system

And in this manner internal use either assists externally or operates alone where not employed externally at same time.

In every case however am unwilling to push use of Mercury farther than is requisite

And did not reckon administration in this extremity necessary for present patient.

To be observed however that practitioners in general express great apprehension as to cure of cutaneous affections by externals means.

In almost every system writer, will find repulsion of cutaneous eruption as is called to be attended with worst consequences.

Go very generally on supposition that by this means a particular morbid matter generated in system is as it were thrown back into it.

This doctrine must own can by no means embrace

And am at same time persuaded, that in greater number of cases such particulars as present cure most successfully affected by extreme means.

At same time am fully aware that by employing these without external remedies are exposed to danger.

Consider that danger however as arising not from repulsion of foreign matter into system but from cure of the disease.

For by this means both state of discharge & state of circulation at part are attended.

May therefore be considered as having in some measure similar affect to repression of habitual evacuation.

To obviate bad consequences therefore requisite that change in balance of circulation should be prevented from exerting influence on organs of importance.

And that want of usual discharge should be compensated.

These ends in general most effectively obtained by means producing determination to surface & augmenting discharge there.

Was on this ground that had here recourse first to the Serpentine & afterwards to Antimony.

Both one & other of these hold to be with intention now mentioned very useful remedies.

And have seen them of greatest service in cutaneous affections.

This however chiefly the case when operate as producing gentle diaphoresis.

But in instance before us, were at least disappointed of this affect.

First contrary to what very generally happens from use was found to induce very considerable looseness.

Which although might have some good affect as compensating discharge & as determination to other parts yet apprehend should never be pushed to any very great extent.

And am satisfied that [illegible] of proper purgative which by many very much employed against cutaneous affections has often worst affects as debilitating system.

On this account not only interrupted use but had even recourse to an astringent with view of restraining looseness.

And afterwards with same intention as had before used Serpentine had recourse to antimony

Which in crude state without having much effect upon stomach has I think particular influence on state of circulation at [illegible]

With [illegible] patient however occasioned more sickness than wished for.

A circumstance very much depending on state of stomach with which employed.

This therefore was also obliged to omit.

And as belly continued open thought that might persist with safety in external cure of Mercury without any internal medicine.

Under this treatment patient now almost totally recovered.

And hopeful that for complete cure very little more remains to be done.

Mean merely therefore to persist in plan of external application of Corrosive.

And if shall be found necessary to augment discharge by surface, in place of again trying medicine already used may probably have recourse to decoction of wood.

But even this am hopeful shall not be found necessary.

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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.