DEP/DUA/1/14/18 (Normalised version)

Turnbull Carmichael

(1777)

---

Turnbull Carmichael.

Regarding name or nature of disease to which this patient subjected must acknowledge myself much at loss.

Yet affection under which he labours may be considered as entirely obvious.

For would consider bound belly, want of appetite & quickness of pulse as entirely consequences of other parts of his disease.

Particularly of pain to which is subjected.

And for this pain an obvious cause in swelling of joint of right arm with evident inflammation.

That this has now terminated in some kind of suppuration evident from discharge.

But when came under our care appearance of matter such that evidently not of most desirable kind.

Was indeed in some measure of colour of proper pus.

That is reckon it less deviant in having assumed yellow colour which here had than if had been more transparent.

But even with respect to colour deviation here from natural standard.

For in [mild] well digested pus [should] have found more pure white.

But this by no means worst part of appearance.

Had still greater deviation from proper standard in consistency.

For in place of thickness of proper pus discharge here nearly as fluid as water.

This circumstance then would naturally lead us to consider suppuration here [occurring] as of nature somewhat peculiar.

And when to these add the farther circumstance of slow progress may lead I think to suspicion of scrofula.

Had been affected with swelling, inflammation & pain for space even of two months before any suppuration occurred.

At least before any obvious discharge.

Well known however that slow tendency to suppuration an almost constant symptom of tumours of scrofula kind.

And that when do suppurate discharge of a watery nature.

To this may add as another circumstances favourable to scrofula situation of this tumour & suppuration.

Here affects one of large joints.

Though this not always case in scrofula yet frequently occurs.

And examples in almost every instance of what called white swellings of knee.

Farther to be added that affection here not the consequence of any accident

Suspected indeed to have proceeded from cold.

And this I must own consider to be not an impossible supposition.

Well known that Rheumatism frequently if not always effect of cold.

And sometimes though rarely happens that these terminate in suppuration

In this manner then cold may be [imagined] to have given rise to it.

But besides that an objection from rare occurrence, patient did not remember any particular cold to which was exposed.

Nor were complaints ushered in by common evidence of a rheumatic affection.

Reckon it much more probable therefore that took rise from no particular cause.

And that in this respect agrees with scrofula.

To all these particulars may add as last circumstance renewal of affection after once healed.

Then indeed can be no little doubt that this renewal the consequence of stroke.

And may have had affect whatever the origin of the disease of arm.

But particularly the case for scrofula sores to be renewed from slight causes.

Thus then several circumstances favouring supposition of scrofula

But if some particulars giving countenance to such a conjecture others against it.

Patient in former part of life never subjected to any such complaint.

Was long passed that period when usually makes first appearance.

Especially when does not occur as a hereditary affection but is acquired by other causes.

And in instance before us as far as we could learn scrofula neither disease of parents nor of near relatives.

Farther from seat of affection many of symptoms giving countenance to supposition of scrofula might perhaps be explained.

Particularly both continuation of affection & [nature] of discharge.

From motion to which joint necessarily subjected sore readily supported.

Even this circumstance sufficient to give vitiated appearance to matter.

And from large joints [have] farther another source of fluid in some respects resembling present.

That is when opening into capsule giving [exit] for synovia of joint

Had once occasion to see an instance of wound of knee where this remarkably [the] case.

There discharge of thin yellow fluid took place to very great extent.

And particularly on motion of joint after had been for some time at rest

Do not indeed suspect that in instance before us any part of the discharge is of synovia

For does not occur either to such extent or in so sudden manner on motion as takes place in synovia.

Mention it merely as an event at least possible.

To all circumstances already mentioned to be added that no other evidence of scrofula in habit.

And although, sometimes yet rarely happens that scrofula entirely confined to one place.

While then several circumstances favouring supposition of scrofula others against it.

And must own that consider the case to be a very doubtful one.

Yet upon whole disposed rather to view it as being of scrofula nature than otherwise.

If however doubt respecting nature must also be so with regard to [termination]

On any view cannot I think here look for expeditious cure.

For suppose it even not scrofula same causes by which hitherto [supposed] will still continue to operate.

If however of scrofula nature may be considered as an additional circumstance retarding cure.

And in that case probable that shall not only continue obstinately but that will be extended.

For although sometimes happens that a scrofula affection entirely confined to part at first attacked yet more frequent that makes appearance also in other parts.

And by this means gives evident indication of being an affection not merely local but of general system.

To such progress however may be observed that less chance with present patient, than if were at earlier period of life.

But even notwithstanding this should arm now heal will afterwards be exposed to [recurrence] from very slight causes.

And this indeed from what already happened may conclude to be case even although not scrofula.

If any foundation in conjecture that has penetrated into joint which at least not an impossible supposition may I apprehend have yet a different termination.

And with healing, bones may come to be united forming an [ chylos] afterwards depriving him of motion of arm.

This more readily the case if [affection] really scrofula.

For [this] seldom happens that sores of long continuation without in some degree affecting bones.

And giving at same time a diseased state in consequence of which more ready union.

What now mentioned consider as chief dangers to be apprehended in present instance.

Reckon it however more probable that disease shall have a less unfavourable termination

And if be not able to bring about total recovery may yet affect temporary cure

Of this I think some hopes from progress to recovery already made.

For since began treatment cannot help thinking that in several particulars [appeared] more favourable.

Not only diminishment of pain & swelling but change also in appearance of matter discharged which of all others reckon the most favourable circumstance.

Hope therefore that in no very long time may so far heal up that farther attendance here unnecessary.

Since this patient came under our care have continued uniform treatment at first [begun] with him.

Consider other circumstances to be consequences of affection of arm endeavours solely directed to this.

And here whatever may be supposition of nature, consider vitiated suppuration to be affect of morbid condition of vessels.

By which condition morbid state of [action] induced giving fluids [different] from [natural]

Becomes therefore chief intention in [cure] to counteract this peculiar action.

And with this measures of different kinds may be followed.

Must however chiefly turn on one of two principles.

Either by removal of causes tending to support present condition.

Or by such measures as may serve to induce a different state of action.

On first of these principles system as it were allowed to cure itself.

On last in place of that kind of [inflammation] yielding vitiated pus proper adhesive inflammation induced.

And by this means parts in ulcerated state united.

Among causes supporting vitiated [condition] perhaps principal is impetus of blood at the [illegible]

Hence in such affections benefits often derived from diminishment of general impetus

From diminishing flow to affected part

And from augmenting to other parts.

With these general intentions The [avoiding] motion of affected part – The avoiding dependent posture – issues in neighbourhood – compression – refrigerant purgative – mineral waters – [nature] etc in common use.

And in different circumstances productive of good affects.

Not unfrequently happens however that either causes supporting depraved action not to be removed.

Or although [removed] condition of vessels themselves such that by powers of system alone sound state not to be restored.

Hence on first general principle removal viz of causes supporting vitiated condition cure not always to be affected.

Becomes therefore necessary to attempt to bring about different state of action.

That state of action giving adhesive inflammation chiefly to be expected from astringent, tonic or peculiar stimulation, whether applied externally or taken internally.

Is on these general principles that would account for advantage from preparation of lead copper, mercury & camphor externally.

And from cicuta, peruvian Bark. Mercury Mezereon etc internally.

Where one of these found to fail shall often have success from use of another.

And on this account frequently tried in succession.

In present case as external sores consisted solely in small openings could [expect] little from mercurial [dressings].

On this account therefore ordered solely [sam] an emollient ointment as might prevent [illegible] of external orifice & thus lead to stagnation & accumulation of purulent matter about the joint.

And as an external application had recourse to use of camphor.

This hold to be one of most penetrating topical applications with which acquainted.

And from influence on [discussing] swellings have I think evidence of power as altering state of action of vessels.

Internally had here recourse to use of Mezereon.

From sensible qualities evidently appears to be one of most acrid vegetables employed in practice.

And from affects can be no doubt that this stimulating power penetrates even to most remote parts of system when introduced in course of circulation.

For is unquestionably basis both of Lisbon diet drink and of Decoction of Dr Kennedy of London. By both of which in cases of obstinate ulceration astonishing cures sometimes [performed]

With present patient resolved to employ it in most simple state.

That is as having active properties [extreme] merely by warm digestion rather than proper decoction.

In place however of simple water [used] here the Decoction Liquor.

Both to afford some covering for acrimony in primae viae & from diaphoretic [power] of decoction to promote more free circulation in extreme vessels.

How far this agree with decoction of Dr Kennedy do not know.

But reckon it preferable to farrago of medicine entering the Lisbon decoction as given in London Medical Transactions by Dr Monro.

Would perhaps indeed be here better in place of Guaiacum Liquor & Sassafras to employ Sarsaparilla alone

But to this article the high price an objection in practice conducted on footing of ours.

And whatever may be peculiar efficacy of sarsaparilla in venereal cases hold that in such a case as present could be of no other use than as covering taste of Mezereon & acting as a gentle diaphoretic.

And hold present formula to be a less expensive & equally efficacious medicine.

Effects of it somewhat varied according to constitution.

Where bowels irritable may readily be imagined that Mezereon will act upon these.

And with those easily sweated may conclude that notwithstanding addition of Mezereon usual diaphoretic power of Guaiacum will be exerted.

Operation however either in one or other way not the object in view.

And should be endeavour to use Mezereon to as great extent as can without any sensible [illegible] or at least without any great immediate inconvenience

With this intention most advisable to begin with small proportion of Mezereon gradually augmenting it

Is on this plan that have hitherto gone on with present patient & mean to continue.

From use at first same influence as moving belly.

From which concluded that without danger of gripes could not venture to augment it farther.

After however some continuation these affects went off.

And without much inconvenience has been able to bear it in higher proportions.

During use progress of affection in any one way has not been constant.

But upon whole has not only relief from pain but has regarding facility of motion.

And from change which has taken place in state of purulent discharge conclude that [action] of the vessels considerably altered.

While therefore [matter] continues to [wear] present appearance shall not probably think of altering course.

And have even hopes that shall find it sufficient for bringing about utmost that here expect.

The healing viz of sore & the [bringing] it to [that] state that without fresh [exciting] causes will have no return.

If however in end finally disappointed in this should reckon it next advisable to try a mercurial course.

And failing this also, the use of mineral or sea water both internally & in way of bathing.