DEP/DUA/1/15/04 (Normalised version)

Ann Dick

(1777-1778)

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Ann Dick.

Under care about three years ago for nearly same affection as at present.

And then also subject of remarks in Lecture

What then saw of this case throws some light on present situation.

Yet after all an affection not without difficulty

At present subjected to two sets of symptoms somewhat distinctive.

Her pectoral complaint viz. Cough Dyspnoea.

And a cutaneous affection of that kind in general known by title of Scurvy or Heat of Blood.

Here then several questions naturally occurring

First whether to consider her as subjected to one or to two diseases

On supposition of two diseases whether they are connected or not.

And lastly what name would give to affection in general or to each of separate parts

When this patient formerly under care in great measure same as at present.

Yet when then began treatment appearance somewhat different.

And attention to these will give some foundation for illustrating question already [stated]

Then principal appearances were the cutaneous affection.

And at that time much more considerable than is now.

Then as at present complained of remarkable heat of skin & itchy feeling where no obvious eruption.

But besides this eruption took place to very considerable degree over every part of body except face.

Was described as appearing under form of small distinct pustules.

These in short time formed into crustation.

Crusts soon after fell off leaving skin below sometimes whole, sometimes deprived of cuticle.

At that time although month of February & very cold weather, no affection of breathing.

When however by different measures eruption almost totally removed had sudden & very severe attack of Dyspnoea.

This at same time attended with considerable cough.

Patient herself ascribed both to accidental exposure to cold.

Must own however that had myself a different opinion.

And did not scruple to acknowledge in lecture that considered these symptoms as consequence of cure of cutaneous disease.

This immediately before attack of Dyspnoea had been removed by external application of Unguent Antipsoric.

And although consider external application as most expedient means of cure in cutaneous affections in general yet well known that often product of still worse consequences.

These in most systems you will find ascribed to repulsion as has been called of morbid matter.

This account naturally founded on the humoural pathology.

And am yet far from being satisfied that has not on some occasion a foundation in reality.

Yet at same time think that these consequences in general rather to be ascribed to alteration which takes place in [illegible] of circulation.

And this explanation was formerly disposed to give with patient now under care

But whatever proper mode of explanation had then little doubt that eruption then original disease & that cough & dyspnoea consequence of cure of it.

At that time therefore to affection of this patient gave name of Herpes.

As believing that the cutaneous disease in appearance most exactly corresponds to what described under that title.

Must here however observe that with regard to proper name to be given to cutaneous affection often much at loss.

And must give it as opinion that [in] nosological¹ systems cutaneous affections not yet distinguished with sufficient accuracy.

If excepting Psora Tinea & few others readily known must acknowledge that for my own part disposed to refer all others to two genera Lepra or Herpes.

And referred present affection to latter chiefly from moist state of parts below on being deprived of crust.

In general refer to Herpes eruption these when discharged of fluid matter to Lepra these where dry crusts.

But very sensible that distinction in this manner vague.

And cannot help thinking that subject of cutaneous affection with regard to diagnosis still to be much improved.

Am informed by an ingenious & learned Gentleman who honours me with correspondence & who practiced principally at [Spain] that a very elaborate work lately written on this subject by a French Physician.

But have neither yet seen the work itself nor do I know title of it.

Would fain hope however that may have thrown light on some of principle difficulties of this subject.

From considerations already mentioned however disposed to give this disease the title of Herpes.

And to consider cutaneous affection as cause of other appearance

Must however own that with respect to this opinion now somewhat more doubtful.

And that chiefly from a circumstance of which when patient before under care entirely ignorant.

viz that has been affected with cough & Dyspnoea of eight years standing.

While at same time both from present & former history eruption of later date.

But perhaps in this respect accuracy of patient not entirely to be depended on.

Seems throughout not very [exact] respecting dates

Certain that when formerly under care had at first nothing of Dyspnoea.

That continued free from it for considerable time

And that when did take place was a sudden occurrence on eruption [disappeared].

To these circumstances may now add that still [marks] of connection.

For patient at present informs that [when] skin worst breathing easiest & [contrary]

Upon whole therefore still disposed to adopt in great measure former opinion.

To consider all symptoms with which patient at present affected as constituting strictly speaking but one disease.

And to that affection do not know that any name can now be affixed with greater propriety than Herpes.

This supposition corroborated by what often observed with regard to connection between state of Respiration & disease of skin.

Many instances on record where complaints of these kinds observed to alternate.

Of this a very remarkable example in [illegible]

Records collection of cases treated in military hospital in France.

There history of an inveterate Asthmatic affection observed to alternate with a cutaneous disease.

In such instances then have [something] of opinion now given.

At same time supposing us right as to name of disease is now sufficient foundation for conducting cure.

For this must be accommodated not to name but to nature of complaint.

And if at loss in giving appellation to cutaneous affection not less so with regard to pathology.

Must own that considered by much greater part of them as depending on diseased affection merely local.

And principally on morbid condition of subcutaneous blood vessels.

Of bulbs of hair. Or of sebaceous glands of skin.

Yet do not consider these as only causes

And although very far from admitting doctrine of morbid matter in light in which once received, yet hold that cutaneous disease may be affect of [depraved] state of general mass of fluids.

Of this can be no doubt in severity of eruptive febrile affection.

That in Smallpox Measles & like there is what may be called morbid state of general mass of fluids can admit of no dispute.

That this also may occur with respect to eruptions not febrile is at least equally probable.

And many circumstances favouring such a supposition in present case

Here eruption not confined to any particular spot but as it was extended over whole [system]

Not permanent at any particular place but transitioning sometimes attacking one place sometimes another.

Uneasiness of surface excited even to very considerable degree when no eruption.

And particularly from those causes promoting circulation of blood on surface.

To all these circumstances may add affection of respiration here occurring.

Particularly when from want of eruption, we may conclude that least free circulation on surface.

Here then inclined to consider all complaints as depending on what may be called acrimony in general mass of fluids.

And this acrimony suppose to have affect of acting as stimulant at skin.

Hence successful processes of itchy [sensation] inflammation, separation of peculiar fluid, first formed into crusts, & then removed by desquamation.

Hence also when blood not as it were freed of matters by this outlet, & when circulate on surface less force exerts influence on lungs.

This then idea which at present hold respecting pathology of case of which now [trial]

Take it for granted some of you will be of opinion that such doctrines better calculated for schools of medicine twenty or thirty years ago than at present.

Yet in teaching doctrines now delivered have adhered to rule which hitherto invariably followed of giving what my real sentiments whether fashionable or not.

And perhaps even those most [adverse] to diseases of fluids may yet admit of it to all extent I have now done

After this account of opinion respecting both name & nature of patients disease should next offer conjectures respecting what may be event.

But before leaving present subject one other particular yet to be taken notice of.

That is state of menses.

These are told in present history irregular both with respect to time & quantity.

This also case when patient last under care.

And to this circumstance she ascribes present complaints.

That this opinion may be true is not impossible.

For well known that from obstruction of menses various affections take origin.

Yet have no sufficient grounds for adopting the supposition merely because is opinion of patient herself.

For if obstruction of menses a powerful cause of disease women not less apt to attribute much to it.

And frequently to attribute to it affections of which is in reality the consequence.

And this perhaps equally probable in present case with supposition that operate as cause.

For regularity of menstrual depends on some measure at least on health of system.

But may be mentioned as still third supposition that the irregularity of menses unconnected with other complaints.

And of the three this seems to me to be the most probable.

Especially as patient arrived at a period of life when irregularity not to be wondered at.

Is already passed her fortieth year

Well known however that towards termination of this affection is very generally irregular.

And with many Women even before forty has entirely ceased.

This therefore would be inclined to think may be case with present patient

And look upon irregularity of menstrual as no part of patients disease

From this therefore apprehend no danger

And affection in other respects does not put on very threatening appearance.

What chiefly to be apprehended is from dyspnoea & other pectoral complaints.

And were these to go to very great height might even suddenly cut off patient.

This still more to be dreaded if [which] not impossible should induce [inflammation] of lungs.

And of this must own that when patient formerly under care much afraid.

In so much that then obliged to have recourse to bleeding, blistering, & such like practices.

Cannot then be very confident that what happened before may not occur again.

Yet at present see no great threatening of it

And is in this way only that should presume disease to be speedily dangerous.

Cutaneous affection may indeed prove very [dir]

But were it ever to become fatal would only be in consequence of [gradually] exhausted constitution.

Yet while view present affection as not dangerous am far from thinking that will be speedily cured.

After having continued so long, whatever may be cause will not easily rid patient of her complaint.

Yet hope that may be able at least to give her some relief.

And even as formerly the case to affect at least a temporary cure.

On what principles however this to be aimed at must own am at a loss to say.

May indeed suppose that from conjecture respecting nature of disease [some] foundation afforded for rational indication.

And if right in supposition that depends on particular depravity of circulatory [mass] [must] be objective to correct that state.

But to do this with propriety should first know in what this particular depravity consists.

And with respect to this must own that almost totally in dark.

Of the two however, am here rather disposed to suspect depravity from state of Phlogistic.

And to this in some measure led from uncommon sense of heat.

Yet fully aware that sensation of heat in an affection often with corresponding heat & merely from feeling.

Hold that every depravation of fluids may be referred to two general heads.

Either to foreign matters or to natural contents in improper proportions.

And of the two should rather suspect that here of the latter kind

Especially as have no reason to [imagine] that complaint of an infectious nature

More active quality of fluids in general have elsewhere endeavoured to show are of two kinds.

Depend viz on Saline or Phlogistic impregnation.

And must own at loss to conject which should suspect in present case.

In place therefore of proceeding on reasoning which thus very doubtful have here made first attempt to cure on footing almost totally empirical.

Have resolved to try with this patient the effects of Vitriol acid taken internally

This remedy but lately introduced into practice against cutaneous diseases and as yet not extensively used.

Probably first employed in this manner against cutaneous affections & particularly [against] itch by Dr Cothenius one of Physicians to armies of Prussian Majesty during last war.

Since that success of this practice confirmed by many other accurate observers.

Several years ago published short account of it from Dr Gahn of Stockholm which inserted in first volume of Medical Commentaries.

Since that have frequently employed it.

And in different cutaneous affections have I think found it product of best effects.

Its action however in no way [observed] unless in as far as sometimes increases a little the quantity of urine.

Yet when consider affect of sulphur perhaps good consequences from it will not seem extraordinary.

For well known that by much greatest part of sulphur is vitriol acid.

But these in medicines [application] leaves room for supposition [which] cannot here adopt

And if effects which Dr Hope thinks has sometimes remarked [from] use of it, founded in fact may have affect of producing more regular menstrual.

If which not improbable Oenanthe crocata not to be procured may substitute to it Veratrum or White Hellebore.

A favourite remedy in cutaneous affections first with Gessner & lately with Sir John Pringle.

And must observe that have [never] yet heard any explanation offered of action.

My own conjecture on this subject too hypothetical for me to venture to offer them till supported by farther [facts].

Would have you then consider me as employing here the Vitriol acid on a footing purely empirical.

And should this fail it is nearly on same grounds that have thoughts of trying the Oenanthe crocata

A medicine first account of which against cutaneous affections lately published by Dr Poult in Philosophical Transactions.

If all abortive may have recourse to Mercury.

And chiefly with general intention of producing thorough change on mass of fluids.

These measures will probably occupy us as long as patient shall think it necessary to remain under our care

And hence reckon it unnecessary to suggest more

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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.