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

Jean Frazer Younger

(1778-1779)

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Jean Frazer Younger

Respecting one part of this patients disease no room for doubt.

Can have no hesitation in asserting that in affection of head have an example of Tinea Capitis.

A disease in this country by no means a rare occurrence.

And when occurring putting on in different cases very variable appearances.

From this diversity among best nosological¹ writers has been divided into different species

And Mr Sauvages in his system has described no less than nine of these.

Cannot help thinking however that has here pushed diversity to greater extent than proper.

And although description must be allowed to be accurate yet may observe that affection seldom continues for any great length of time to correspond to any of the states described.

But what now, all characteristics of one species, will in few days have all characteristics of another.

Hence then rather to be considered as different stages or at utmost as varieties than of different species.

Of all that Mr Sauvages has described however case of our patient most nearly approaches to what he calls the Tinea Lactea,

An affection to which has given that name & which by others termed Crusta Lactea as occurs chiefly during nursing.

With our patient indeed although answers to description of that species does not seem to have begun so early.

But when consider that began during first year of age must at least infer that took place not long after weaned.

In this circumstance however cannot suppose that milk had any share as inducing it.

And may observe that as occurring with infant on breast is commonly referred probably not without good reason to improper food used by nurse.

How however would give it name of Tinea or Crusta Lactea not from cause, but merely from resemblance in appearance which has to affection as then occurring.

From what cause originated in present case do not know.

And parents of patient ignorant of any circumstance which could have induced it.

Am however inclined to think that no cause more frequently gives rise to it than want of due cleanliness.

And not improbable that this may have operated in present instance

But whatever cause can have little doubt in asserting that affection induced in its nature of considerable [obstinacy].

And in this respect at least differs from Crusta Lactea

For in that complaint affection for most part of transitory nature.

In so much that even without any remedies employed, for most part, even of [state] soon disappears.

But in present case affection has not only subsisted for great length of time, but during that time has resisted many of most effective remedies.

From these circumstances then restrained from giving favourable prognosis which otherwise should do.

And may here observe that although some cases slight particularly those in early life, yet in general rather obstinate as otherwise

In some will even baffle every effort which regular practitioners, at least, dare venture to employ.

From continuation of present case together with resistance to efficacious remedies some reason to presume that may prove of this kind.

Shall not therefore be surprised if in end disappointed in effecting a cure.

May indeed as has already been frequently done for some time entirely remove affection.

Yet if shall be able to bring about such removal that does not again return is more than at present inclined to expect

Thus far then as to opinion respecting name & probable event of principal part of complaint.

Here however to be observed that besides evident affection of head patient lately subjected to some other symptoms not usually concomitants of Tinea

These particularly are picking of nose & itchy sensation about anus.

Symptoms which although may proceed from different causes, are perhaps more frequently consequences of worms than of any other affection.

And when consider that when these most urgent ascarides actually discharged can have little doubt that proceeded from this cause.

At present however all appearances of this kind almost entirely gone

And of late indeed no worms discharged

May therefore upon whole consider her, as now at least subjected only to Tinea Capitis.

To this therefore future treatments at least to be wholly directed.

At first however when patient came under care considered ascarides as object of attention

And to treatment of these had first recourse as imagined that would be most easily removed.

Was with this intention that directed use of lime water by way of injection into rectum.

A remedy of which have already had occasion to speak when treated of case of Susan Paul.

And of efficacy of which that case affords us strong example.

In present instance from use of these injections no worms observed to be brought away.

This however probably proceeded from none being present in rectum.

For since that none observed discharged by stool or otherwise.

And what of still more consequence patient has been free from symptoms.

Reckoned any father repetition therefore at that time unnecessary.

And have not since had recourse to any other measures but with view to Tinea Capitis.

General principle on which Tinea to be combated not in every case the same

These must unquestionably be accommodated to pathology of affection.

And probable that in this as well as other genera, apparently same symptoms from different morbid conditions.

Not improbable that in some instances although disease apparently local may yet proceed from affection of general mass of fluids.

Yet very commonly at least without any affection of mass, to be considered as merely a local disease

In some instances from state of subcutaneous vessels, in others from condition of discharge but most frequently from morbid affection of bulbs of Hair.

And on this account particularly confined to hairy scalp.

But if these not always sole seat seldom that do not acquire considerable degree of disease.

Hence to morbid condition of these principle part of cure to be chiefly directed.

Hold therefore that cure to be chiefly aimed at on one of two general principles.

Is unquestionably first & most important objective to restore bulbs of hair or other diseased parts to natural condition.

But when this cannot be effected radical cure may yet sometimes be obtained by total removal of parts.

Last however always a painful practice never entirely without danger & sometimes followed even by most disagreeable consequences.

And indeed measures employed with that view more frequently ventured upon by empirics who have no reputation to lose than by regular practitioners.

In treatment of present case then all measures which have hitherto employed or which probably shall employ, solely intended with view of restoring diseased parts to natural condition.

Of practices then already employed or which have hereafter thoughts of using shall next offer some observations.

For restoration of diseased parts to natural condition, in this as well as other complaints may have recourse to employment of remedies either externally or internally.

In first way however action both most immediate & most certain.

Hence will naturally think of making first attempts in this way.

At same time by internal remedies having topical action in course of circulation, cure may often be assisted.

And in some instances may even be successful alone where external remedies have failed.

To trial of such not improbable that shall yet be obliged to have recourse in case before us.

But first wished to try whether could not obtain more immediate cure by external means

And in this way great variety of applications which in different cases attended with most happy effects.

Here a very simple mode of cure apparently followed by very good consequences.

The application viz of simple poultice of bread & water over whole hairy scalp.

To this measure mother of patient had of herself recourse without any [directions] on own part.

Effect was complete removal of white hard scurf with which parts before covered.

And in this way removal as it were of obvious disease

For though parts below red & moist yet exhibited no other appearance than what occurs from mere excoriation.

But although thus considerable change in appearance, removal of crust in general but small progression in cure.

For is merely removal of consequences & not of cause of complaint.

Crust to be considered as exudation or rather as peculiar secretion poured forth by diseased vessels which of such nature as to obtain firm or solid state on exposure to air.

Is no farther than a step to cure than as exposing diseased vessels to action of topical remedy to which otherwise not accessible.

This simple remedy the poultice can suppose to have operated here only on one of two principles.

Either by moisture or by temperature whether hot or cold

In consequence of first effect has tendency to relax.

And this affection augmented where applied with temperature rather warm as otherwise

From relaxation diminished adhesion of solids to each other.

And is in this way that suppose it to have entirely operated in case before us.

When applied of cold temperature so as to operate in some measure as topical cold both may have effects still more considerable.

For can be no doubt that from influence of cold considerable action exerted on subcutaneous vessels.

And particularly where in state of relaxation will tend to increase tone.

But seldom however if ever that this sufficient for removal of that morbid affection occurring in Tinea.

For this purpose must have effects of medicine not so much increasing tone as altering state of action in vessels.

Hence chief advantage from those operating as peculiar stimuli to vessels of part.

Was in some measure with view of giving such stimulation that directed the washing of affected parts with strong solution of Soap.

In this state although action of alkaline salt in some measure restrained by mixture of oil yet has such affects as in every sensible part to occasion very considerable feeling.

And has farther advantage of being of a [penetrating] nature.

On these principles have I think seen very good effects from it in different cutaneous affections.

Here however chiefly exhibited with view to removal of sordes.

An effect which from rending various matter soluble in watery menstruum it very readily accomplishes.

And as here crust had obtained no great degree of thickness was in hopes that by this conjoined with friction might be removed

But as this effectively done by poultice applied by mother thought opportunity not to be lost of having recourse to more effective remedies.

And as such wished to try here a remedy which for my own part at least have not before used in this affection.

That was a saturnine preparation.

Need not observe that since publication of Mr Goulards treatise this active metallic substance has been very much employed for medical purposes.

By him recommended externally as an almost infallible remedy against tumours, [inflammation] & ulcerations of every kind.

But can be no doubt that by such a [fond] admirer powers as a medicine have been very much exaggerated.

The experience however of every candid observer has proved that affects very considerable.

For most just estimation of these may refer you to two essays on subject one by Mr Aikin of Warrington, other by Dr Lilie who lately published at this place a very ingenious & elaborate essay on subject of lead.

That lead when in saline state has very powerful influence both on nerves & blood vessels to which applied cannot be doubted.

These may be carried to such length as to be product, not merely of salutary but of highly deleterious affects.

And how far can ever with safety be used internally still a question.

Tincture Antiphlogistic or Saturn indeed has long held & still holds place in most pharmacopoeias².

Yet no question that even from use in very small doses are exposed to specific effects of poison of lead upon system.

Or rather to deleterious consequences of topical action on alimentary canal.

For hold that in this way [induced] Colic [Pulon] of France. Devon Colic of England [illegible] of [illegible]

None of these however in any degree result of application to surface however extensive.

In this way operation derived from it seems to be almost totally of sedative kind

And thus diminishes sensibility of Nervous & action of vascular system in particular.

On these principles allays pain & inflammation & restrains excessive discharge.

Was with view then to action on affected vessels that had here recourse to employment

And was in hopes that by this means peculiar action giving morbid secretion might be removed.

In this expectation however disappointed.

For after continuation for some time saw again manifest inducement of renewal of symptoms.

After this trial therefore thought it advisable to have recourse to other measures.

And among different external applications next directed employment of Aerugine Aerugine

This also a metal substance in a saline state which very little if at all used internally.

In one saline state indeed, the copper employed internally in small doses. That is as rendered active by an Ammoniac Salt, & thus brought to what called Cuprum Ammoniala.

And as thus acting on alimentary canal exerts on whole system very peculiar stimulating & tonic powers.

Is from superior acrimony of other preparations, particularly the verdegrise that cannot be ventured upon internally.

And little doubt that these product of similar effects to still greater degree, at least on external parts to which are applied.

To many even of most delicate parts application can be made without any inconvenience.

Example case of eye.

And when used as eye ointment often found product of most beneficial consequences

In affections similar to present has also been long in use.

And in several instances in which have employed it, have I think seen it attended with best effects.

Although therefore inclined to consider present as obstinate case am not without hope

Yet if should even fail, will not prevent me from thinking favourably of it.

And if succeeds will I own have higher idea of efficacy than before.

In order to determine this shall wish yet to persist in trial for some time longer

But before go farther will endeavour to have head again cleaned by poultice or washing

And to continue with simple lotion for space of eight days.

That by this means may be able to determine how far tendency to renewal of crust is diminished.

If find any considerable diminution although not entirely removed shall persist with aerugine alone

But if equally great as formerly, before desist from this measure, have thoughts of uniting it with another

And with continuation of Aerugine mean to support drain from neighbourhood of head.

For this purpose shall direct application of blister to neck or betwixt shoulders.

To be afterwards converted into issue by epispastic ointment.

If these measures unsuccessful other external remedies which may still be tried.

And particularly may have recourse to Vitriol acid in form of ointment or Liniment.

Or to Hepar Sulphuris in way of Solution.

Of neither of these remedies have I for own part had any experience in this affection.

Former however have employed in various cutaneous complaints & with great advantage.

While am informed on good authority that latter often used with success in this complaint.

At same time from [prudent] trial of neither is anything to be apprehended.

[Previous] to any of these however should here have suggested external application of Mercury in active state

Particularly Corrosive Sublimate in Solution.

But am informed that this already used with attention & perseverance without effect.

If no benefit from these external applications, before dismiss patient, shall wish to give her also chance of internal.

And with this view may have recourse to antimony or mercury used as alterative.

When every remedy both externally & internally with view of restoring vessels to sound state proves abortive cure may sometimes be effected on another principle.

That is by total abstraction of diseased parts.

For this purpose common measure had recourse to is application of pitch plaster.

Allowed to remain for such time as to be firmly fixed in hair.

Hence when forcibly taken off hair torn up by roots & thus diseased bulbs removed.

This however a practice not only [powerful] but never without danger

And though an expedient method of cure yet seldom had recourse to by regular practitioners.

Trust rather to measures which though more slow less hazardous.

And cannot help thinking that should never be put in practice till every other remedy has failed & till patient at such an age as to be capable of giving own consent to it.

On this account then do not think of employing it in present case.

And if cannot remove affection by other measures must dismiss her, perhaps to be radically cured by some empiric who will without hesitation have recourse to the measure just mentioned.

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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.

2) An official publication containing a list of medicinal drugs with their effects and directions for their use. The Royal College of Physicians of Edinburgh's Pharmacopoeia was first published in 1699.