DEP/DUA/1/14/19 (Normalised version)

William Morison

(1777)

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William Morison.

Of case of this patient had occasion to speak during winter lectures.

Is now our patient a second time for same disease.

An event which then considered as very probable.

For some of you may remember that when last spoke of this case did not entertain very [sanguine] hopes of successful cure.

For change for better indeed which had then taken place expected that patient might obtain a temporary cure.

And in this expectation was not disappointed.

But at same time apprehension which entertained of return of affection has been also verified.

Might certainly from every appearance consider present as renewal of former affection.

And with respect to name properly to be given to it still subjected to same difficulty as before

At time when came under our care sore so considerable that might without impropriety have obtained name of ulcus as defined by nosological¹ writers.

Evident however that affection of such a nature that ulceration not to be considered as essential to it.

And when skin heals which not unfrequently the case disease still to great degree remains.

Are probably to consider peculiar state of vessels of part manifesting itself sometimes in one way sometimes another as constituting essential nature of affection.

Of this nature several genera of diseases

And particularly exemplified in that [dismal] affection the cancer.

Well known to make appearance in different states of open & occult cancer.

And from latter to former of these very frequently transitions.

Sometimes also from former to latter.

Although however such a succession here can by no means bestow upon it the title of Carcinoma.

For although consider it as by no means of favourable tendency yet do not look upon it to be of natura [no] malignant.

And in place of bestowing upon it title of carcinoma would still as formerly give it appellation of Noma or [ Phagid.] of Nosologists.

Affections between which must own do not know any proper distinction.

And consider both as merely affections of a local nature depending on a depraved condition of state of vessels at part.

True indeed in many instances as in present accompanied also with affections of system of different kinds.

For here must own consider headache to be connected with the obvious complaint

And indeed to be rather consequence resulting from it than a concomitant [symptom]

Must however acknowledge that of [this] opinion am now rather more doubtful than formerly.

Particularly from increased severity of headache in a horizontal posture.

And from very considerable vertigo with which attended.

Do not doubt that headache not entirely to be considered as symptom

But that in some measure consequence of idiopathic affection of [head] itself.

Yet when consider intimate connection which has all along had with sore of leg must look upon this at least as exciting [cause].

And at same time a cause so far essential to headache, that without it [that] affection would not occur.

Still therefore consider both cure & prognosis as solely to be rested on local affection of legs.

And here must own that now entertain greater apprehension even of fatal termination than formerly did.

For to be observed that patient now [subjected] to frequent feverish attacks.

And although perhaps could hardly strictly speaking be [termed] hectic yet had little doubt that was effect of absorption from [sore].

And this also probably cause of constant quick state of circulation.

Though at same time, presumption that [altering] of bloods motion supported by sore acting as cause of irritation to system in general.

But whether these conjectures respecting cause of such affection well founded or not, can be little doubt that while they exist room for apprehension.

And should an unfavourable event occur will not be unexpected.

Although however not without such fears yet disposed rather to think that patient will again obtain relief under our care.

And that shall be able to least to affect temporary cure.

Although at same time shall ever consider him as subjected to return from causes so slight that may not even be obvious.

From what said of nature of this case will readily suppose that in treatment endeavour principally directed to affection of leg.

And supposing this to depend on [vitiated] condition of vessels at part cure must [turn] on two principles.

Either to be attempted by removal of causes supporting vitiated condition.

Or by such means as will induce different condition.

Was chiefly on latter of these that formerly attempted cure with this patient.

And for that purpose had recourse to use of Mezereon.

Of manner of operation had occasion to make some observations in last lecture when spoke of case of [Carmichael].

And when formerly used with Morison was I apprehend means of producing temporary cure.

Not improbable that may again have recourse to it with this patient.

But wish first to try whether could obtain more affective & permanent relief on other principles

Or at least to see what affect could be derived from it.

Removal of causes however supporting diseased state at part an extensive scope in practice.

As such causes of different sometimes even of opposing kind.

But of all others perhaps what chiefly claims attention is impetus of blood at part.

Of this in some cases an augmentation necessary.

More generally however diminished.

And such from state of circulation from sense of heat at part, & other particulars, conjecture to be necessary in case before us.

Diminishment of impetus in such cases to be brought about either by affecting general state of motion of blood.

Or by such measures as will affect it only in diseased part.

Either viz by means immediately restraining flow to part.

Or by means answering same end in more indirect manner from augmenting flow to other parts.

Without however aiming either at one or other of these was first intention to try [whether] could be done by action on general state of circulation

And with this view to put patient on use of nitre.

Nitre a medicine employed in [particular] of [plan] with various intentions.

And particularly often used as a diuretic

But hold it to be still more useful as diminishing impetus of circulation.

And indeed consider it to be one of best sedatives of refrigerant kind with which we are acquainted.

Of late particularly recommended to notice of practitioners against such affections as presented by Mr Rowley of London.

Wrote a treatise expressly to prove that by means of this medicine ulcerated legs might be cured without rest.

Not to be doubted however that indiscriminate application of it against all such affections would lead to many disappointments.

And accordingly soon fell into disrepute

Notwithstanding this however cannot help thinking that there are cases in which may be of service on principles now mentioned.

And supposing present to be one of [such] had here recourse to it.

Here employed it as combined with a proportion of Magnesia.

In this conjunction had no view of [improving] efficacy of medicine.

Was intended merely to give more friable form & minute division previous to exhibition.

And imagined also that might perhaps in some means protract action on nerves of stomach.

For hold that it is solely in consequence of this circumstance that exerts sedative & refrigerant powers on system.

While however entertain expectations from this medicine did not wish to trust to it alone.

But had recourse also to an external application to the sore from which expected some benefit.

That was use of Camphor.

This hold to be one of most penetrating topical applications which we possess.

Acts indeed most powerfully when introduction aided by friction.

But from ulcerated state of part had not opportunity of doing this.

And has even some affect from simple application.

Was with this view that here united it with a gently emollient ointment.

And from application expected that some change might be induced on state of action of vessels in part.

On this course our patient continued for about space of month.

And during that period cannot say that disease stationary.

In some respects has evidently [mended.]

But in others nothing changed for better.

Ulceration indeed healed up during continuation of medicines already mentioned.

And not improbable that these had some share in this for relieving affection.

But though no ulceration pain still continues.

And was not less affected with what consider to have been consequence of pain, or at least of affection of leg. Headache, vertigo shivering fits, succeeded by heat

In this situation not only expected less from Nitre but became more doubtful as to what might be tendency.

And considered it as a possible circumstance that refrigerant power might even add to [severity] of cold fits.

Thought it therefore advisable to discontinue cure

And as ulceration now skin heal ointment no longer necessary.

But while from these considerations induced to make some alterations did not think of entirely changing plan.

And particularly reckoned it still advisable to continue the Camphor.

But in place of employing it in form of ointment directed it in more powerful method of friction by conjunction with oil.

And in place of constant use of Nitre as a refrigerant directed at proper intervals use of Glauber Salt.

Although however imagined that did not prescribe large dose yet operated with very considerable severity.

Operation however attended with relief of many of most urgent symptoms.

And pain seemed considerably alleviated by use of camphorated oil.

Without therefore repeating salts thought it sufficient to continue this last prescription.

Either however causes producing pain augmented or from habitual influence of oil less powerful.

But with this increase of pain had return also of severity of other symptoms.

In this situation with continuation of external application determined to put patient on use of Peruvian Bark.

Thought that at least some chance of reaping benefits from this on different footing

Without affecting cause of disease was in hopes that might alleviate symptomatic headache

But besides this expected also that might mitigate pain.

And by giving different condition to living solids in general renders cure more permanent.

On these accounts is wish at least to give it trial for some length of time.

And if does not fully answer expectations am in hopes at least that will be product of some good affects.

Not improbable however that before fair opportunity of judging of influence course may be interrupted.

But if this the case shall entirely be directed in future measures by appearances which may then occur.

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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.