DEP/DUA/1/22/07 (Normalised version)

Jean Duncan

(1779-1780)

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Jean Duncan.

Affection to which subjected singular.

Consists of but few symptoms, & of these principal part obvious

Yet not characteristic of any disease with which acquainted in Nosological systems¹.

Has indeed some pectoral complaint as [slight] Cough

And some inconsiderable affection of alimentary canal

Borborygmi, flatus, & costiveness.

But all these symptoms far from distressing

And if not at same time subjected to other complaints should not have selected her as subject of practice here.

Much more alarming complaint in affection of skin.

On different parts of body large purple blotches.

Very much of same appearance as [accidental] contusion.

But here without either swelling or pain.

And certain that take place without any such cause.

As may naturally be expected in few days disappear

Probably as [effused] matter absorbed.

But while disappear at one part become observable at another.

An indication that cause producing still operates.

A circumstance demonstrating an affection which cannot be considered as slight.

But this appearance conjoined also with [another] no less alarming.

That is great number of small [livid] spots on different parts.

But particularly on breast.

Whoever have examined these must be satisfied of resemblance to petechial eruption.

To appearance in every respect same with what occurs in fevers of most [putrid] tendency

While again in large blotches have those vibices also occurring in such affections

Here however total absence of every febrile symptom.

And indeed patient so far free from debility or [anxietas] febrile that able regularly to attend since applied for assistance.

For this circumstance then evidently not referred to head of Typhus.

Nor even to that of Petechia as adopted by some nosologists, for a febrile disease.

Although consider affection however as not having place in nosological systems not only instance of it which have [met] with

First case occurred in 1776.

And will find it related in Volume of medical cases² published two years afterwards.

Before met with that case had been favoured with an inaugural dissertation, in which the affection very minutely & distinctly described.

That dissertation published at Gottingen, written by Dr Graaf & entitled, De Petechiae sine Febre³.

With him was disposed to consider Petechiae as characteristic mark of disease

From this circumstance then was disposed to give it appellation of Petechanous

In that case some other symptoms occurred which inclined to think merely accidental.

But one appearance which as well as Petechiae & Vibices considered as depending on [cause] of affection.

That is slight haemorrhage observed from gums.

And a discharge by stool of bloody coloured matter which considered indeed as depending merely on similar haemorrhage into alimentary canal.

Since that time have met with several similar instances.

And in all haemorrhage to greater or lesser degree.

In some even very considerable.

With present patient however no such appearance.

Would not however from this have any hesitation in considering as example of same affection.

Want of this symptom probably indicative of inferior degree only.

Or perhaps independent of degree may proceed from state of extreme vessels at parts from which Haemorrhage most common.

Or from condition of circulation with respect to impetus.

While disposed however to give this name to affection question of much greater importance in what nature consists.

Here from general extent of affection over system from disappearance at one part & appearance at another little doubt that not a local affection.

Can hardly I think refer it to any other cause than general affection of fluids.

And but few diseased states of these from which phenomena to be explained.

From appearance evidence of red globus [affect] in cellular membrane at many different parts.

Or in other words have here what may be considered as subcutaneous haemorrhage.

But this can hardly suppose to occur with red globus in natural state.

Necessarily then led to suppose that is affect of these being at least [partly] broken down.

This a morbid condition of system which may I imagine arise from [various] [causes].

But from none more frequently than from superabundance of saline matter or from [putrefied] state.

That from both this effects, demonstrably proved from experiments out of body.

And no reason to doubt that will not have same effect in living animal system.

Have I think manifest example of each in different diseases.

Thus destruction of red globus from putrid [manifestation] in typhus.

While again destruction from superabundant salivation exemplified in Scorbutus.

Or at least whatever may be case in latest stages this would appear to be cause of dissolved state of blood at commencement.

To one or other of these then would naturally refer it in present instance.

Must own that see here no certain grounds from which led to either conclusion.

Yet of the two most disposed to consider it as effect of putrid.

To this chiefly led from resemblance in appearance to those cases where [putrid] is certainly the cause

For here both petechiae & vibices most exact resemblance to what occurs in most malign state of putrid fever.

May indeed here occur as objection to supposition of putrid that with our patient no fever.

But in many cases besides present have I think evidence that [putrid] may exist without fever.

And because often combined with fever does not follow that to be considered as cause inducing it.

In some instances both may be effect of peculiar contagion.

In others putrid state of fluids may even be consequence of fever.

At same time may be true, that putrid to certain extent, or with certain constitutions, will infallibly induce fever.

Yet where these absent may exist separately.

And in this manner am disposed to imagine that Petechani or Morbus petechialis sine fibre occurs.

From this view of nature then disposed to consider it as a very different affection from Scorbutus.

With which however reason to presume that has in general been [conflated].

From what now said will understand opinion with regard to nature of present affection as well as with regard to name by which ought to be distinguished.

In giving prognosis if to form judgement from opinion of nature, should I own be apprehensive of great danger.

For although [putrescent] state may to certain extent, subsist consistent with health, yet from [chance] worst consequences to be apprehended.

Or although [constitution] able to [resist] influence at one time, may not be so at another

On these grounds then fatal consequences to be dreaded.

Yet in judging from greater part of facts which have had opportunity of observing should be led to contrary opinion.

For one case excepted, all which have had any occasion to treat, very soon favourably terminate.

From this then reason to presume same may happen in present instance.

Yet even one unsuccessful case enough to give alarm.

Especially when conjoined with idea of nature of affection.

Farther to be observed also that [the] progress to fatal state very quick.

Or rather fever producing death occurred very [unexpectedly] after disease had [subsisted] for considerable time without it.

And after occurring had in very short time fatal conclusion.

While from other facts then reason to presume that disease may run course without hazard, this serves to show that in no case should be without apprehension.

And therefore although soon expect favourable conclusion in present instance, yet should not be very greatly surprised at contrary termination.

If however idea of nature of disease well founded reason to presume that latter may be prevented & former promoted by measures here employed.

After however what already said of nature of disease, practices employed [hardly] to be considered as requiring illustration.

If conjecture well founded great objective to be [aimed] at, the counteracting putrid or putrescent state of fluids

Articles possessing this power assembled into one class under title of antiseptics.

From proper administration of these then cure here to be expected.

Before however having recourse to any antiseptics thought it first necessary to empty alimentary canal.

In this had principally in view that might more effectively obtain full action of antiseptics.

For while collection of viscid sordes already perhaps in putrid state, in stomach & intestines, little to be expected.

But besides this from [evacuation] of alimentary canal still another advantage.

By this means a putrid fomes supporting septic tendency often [removed] from system.

Thus although not of themselves antiseptic exert at least antiseptic effect.

For obtaining these purposes here employed Glauber salts.

Than which know no purgative more effectively evacuating alimentary canal through whole length.

While at same time influence as evacuant from system itself but very [inconsiderable].

And this an effect which here as much as possible to be avoided.

From these circumstances then seemed well calculated for our purpose.

In effects expected from it [were] not disappointed.

And in as far as could be product of advantage purpose answered.

Immediately after evacuation of intestines had recourse to Peruvian Bark.

Powers in this respect confirmed both by numerous experiences & daily observations.

And independent of other properties may [safely] venture to assert that is one of most powerful antiseptics yet known.

Whatever may be most efficacious method of exhibiting it in intermittents here no doubt from introduction into stomach by repeated small doses.

For thus constant and uniform effect as it were exerted upon system.

By this means full affect without any danger of rejection by vomiting or of [creating] inconvenience in other respects.

In this manner borne without any inconvenience

But after trial for space of week was not product of any obvious change for better

From this circumstance then thought it inadvisable to trust to bark alone

But in conjunction with it had recourse to another very powerful antiseptic the Vitriol Acid.

This employed in form of Elixir.

As from aromatic with which these combined sits more easily on stomach

While at same time antiseptic power in no degree diminished.

On this course has now continued for some length of time.

And may venture to say that progress of disease at least checked.

Since began use affection very manifestly has not increased.

And upon whole rather diminished as otherwise

Am in hopes therefore that under this course may soon have favourable conclusion.

And that other measures will be unnecessary.

If however present plan in end [unsuitable] will lead me to think that state of fluids supported by some other cause [than] [putrid]

And that perhaps rather to be considered as incipient state of Scorbutus.

Or that dissolution of fluids [supported] by prevalence of certain saline matter.

On this idea then will have [recourse] to measures known to be most effective in counteracting this state.

And particularly to introduction of Vegetable acids under form both of medicine & diet.

If these slow or ineffective may have recourse to infusion of [water].

Or to what have been [supposed] the basis of its operation fixed air.

And this will rather wish to employ by exhibition of Alkaline & acid mixture [producing] [form] in stomach than in any other way.

These however are measures which merely suggest.

Am in hopes that none of them will be here 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.

2) Andrew Duncan, Medical cases, selected from the records of the Public Dispensary at Edinburgh : with remarks and observations : being the substance of case-lectures, delivered during the years 1776-7 (1778).

3) Eberhard Gottlieb Graff, De petechiis sine febre (1775).