DEP/DUA/1/26/17 (Normalised version)

Margaret Sinclair

(1780)

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Margaret Sinclair.

Although disease of this patient entirely constituted of obvious symptoms yet much at a loss as to name.

Here disease evidently of cutaneous kind.

And from situation being still at least merely local may infer that does not depend on state of fluids.

Of difficulty in distinguishing cutaneous affection from assuming in course very different appearances have already often had occasion to speak.

Am however disposed to consider greater part of those affecting body in general as being either of leprous or herpetic kind.

At least if excepting Psora a disease arising from peculiar infection & when can be distinctly seen having peculiar appearance.

But besides these an affection attacking head which both from appearance from peculiar nature & from difficulty in cure well entitled to be considered as distinct genus viz Tinea Capitis

This in all probability a disease depending on morbid condition of bulbs of hair.

And appearance given by morbid separation from thence.

When attend to appearance in present case no doubt that has much more near [resemblance] to Tinea than to any of two other affections mentioned.

For here same firm thick hard incrustation covers diseased parts.

Same red & raw appearance when that incrustation removed.

And in this state similar exudation again giving rise to fresh incrustation

Here however, objection, to considering it as being that disease, from situation.

For tinea almost universally considered as disease of hairy scalp.

And when observed in other parts, has yet very generally begun there.

From parts indeed where here situated hair abundantly arises.

But of no larger size than from every other part of surface.

And indeed so small that could hardly consider them capable of giving rise to so considerable disease as present.

At same time hard to say what may be change in state of separation, even by small organs in morbid condition

And present affection in every respect greater resemblance to Tinea, than to any other complaint.

Am disposed therefore to look upon it as being a peculiar instance of that disease.

Apt must observe, that have never before in practice met with any instance precisely similar.

In this case doubtful as to Progression.

Yet no circumstance in case which can be considered as favourable.

If conjecture well founded, even from nature of affection alone, should infer tedious & obstinate disease.

Still more obstinacy to be dreaded from being peculiar & uncommon modification.

But particularly from appearance which puts on

For to be observed that encrustation peculiarly hard & thick

And that at same time of very dark colour

These however in cases of Tinea, well known to be unfavourable circumstances.

But in present instance one still more discouraging & even alarming.

Affection viz of bones immediately below.

Here some question whether to be considered as consequence or cause.

And would not pretend to give [decisive] judgement

Yet inclined to former opinion.

And that principally from circumstances of affection of bones occurring only in [partial] manner.

As well as from being only observed in those of most spongy texture & least covered.

Even in this view however still to infer from it, that not merely cutaneous but propagated to some depth

And although in reality a consequence of superficial disease yet after now being induced must tend to support it.

And may even give rise to other affections as, ulcus mali moris, producing hectic fever.

In this manner may even prove dangerous.

To all these unfavourable circumstances, must also add long continuation of affection.

Although patient but in early life has already subsisted for 6 years

And during that period has resisted many very efficacious medicines.

Upon whole then must acknowledge that hopes of recovery here but very faint.

At same time although pronounce case not without danger yet no immediate apprehension.

Tinea itself rather an obstinate than a dangerous complaint.

And in many instances in which proves incurable will yet continue for long life without any dangerous appearance

While again affection of bones even proceeding to such length as to produce ulceration above, does not always give rise to hectic fever.

Hence then if patient continues regularly in attendance at least opportunity for trial of different medicines.

And to this the rather encouraged from favourable appearances which have already taken place.

Cannot indeed say that progression to recovery has been great.

Yet affection in point of extent at least, somewhat diminished.

And this may I think with some probability be attributed to measures to which have already had recourse.

If conjectures as to nature of affection well founded, objective must be to prevent vitiated secretion, by restoring parts to natural state

And in instance of proper tinea where this cannot be readily effected, cure performed by complete removal of diseased parts

In case before us however supposing that restoration cannot be effected, do not see how removal at all attainable.

And at any rate only to be aimed at while other cannot be accomplished

With former view then, of restoring parts affected to sound state, measures already used solely directed.

Was with intention of immediate action on these, that had here recourse to saturnine lotion.

Medical powers of lead, in a saline state, have been now for some time the subject of much observation.

Were indeed in use long prior to Mr Goulards publication.

But since so highly extolled by him & since judicious remarks on this subject by Mr Aikin of Warrington & others has been much used.

And although by no means entitled to [encom] by Goulard, yet now on all hands allowed a very useful medicine & more extensively applicable than formerly.

Is particularly observed from application to [moving] fibres to have tendency to diminish inordinate action.

And at same time to take off sensibility to impression.

In strictest sense of word then may be considered as sedative although does not operate as narcotic.

That is does not to any considerable degree affect state of sentient principle.

Influence in way mentioned particularly evident from use in cases of topical [inflammation]

Especially in what arises by scalding from hot water etc.

Now established by undeniable observation that has most surprising influence in allaying pain as well as in diminishing other effects of such accidents.

And here when consider state of part below after incrustation removed not altogether without similarity.

For although not painful yet some red, & raw appearance.

And here evidence of morbid action, in morbid separation which takes place

Some grounds for hoping therefore that may be means of allaying it.

These then were considerations, here suggesting use.

At same time well known that the checking any accustomed discharge, without corresponding evacuation, often product of worst effects

Hence then in all such cases, is at least a prudent measure, to increase evacuation by some other outlet.

And this also farther advantageous as diminishing impetus at part affected.

A circumstance to no inconsiderable degree [conspiring] with cure.

Both as tending to diminish morbid separation at affected part, & to enable that part by operation of system itself to recover sound state.

These observations will explain what to be here expected from other measures employed

By blister converted into issue, a drain in some respects at least analogous, formed from neighbouring part.

By this means reason to hope not only that inconvenience obviated but that determination of fluids to the face also considerably diminished.

This end however reason to hope might be still farther obtained by [ref]. catharsis

By which regular continuation in such a manner as gently to open belly [impetus] to surface in general diminished.

With this intention nothing promised to be more effective than Cream of Tartar

And accordingly ordered to extent of ℥i every morning.

In this quantity however found at succeeding report that no influence.

With continuation of former measures therefore was directed to be doubled - ℥ii.

And as solution from thickness of incrustation no ready opportunity for action on diseased parts, directed application of emollient cataplasm with view to immediate removal

In obtaining this effect from it were not disappointed.

That condition of parts below however, still but little [attended] evidently appeared from speedy return of incrustation.

This then rendered it necessary that same [expedience] should again be had recourse to, as circumstances might require

And by continual removal, with continued application of Saturn solution, had at least opportunity of giving fair trial.

Notwithstanding increased dose however, of Cream of Tartar still disappointed in effects expected from it.

Yet still wished however to obtain aid as [illegible] in cure.

But with this intention in place of farther augmentation of dose, ordered small proportion of Jalap to [illegible] operation.

In consequence of this addition have now obtained from it desired effects

And under this course may at least venture to say that affection not augmented.

Still indeed even after repeated removal tendency to return of incrustation appeared to be very strong.

But is evidently to less extent over face than when at first came under care.

And several parts then covered which on removal appeared to be in raw state, have now regained natural appearance.

This then encouragement to give at least longer trial to measures already begun.

And if capable of producing same effect on all, that has already done on some parts, patient may be cured by means of it.

This however I must own is more than expect.

But if in end [ineffective], other measures of which may at least make trial.

Of these none from which should have greater expectation than Mercury.

Particularly as applied externally, under form of solution of corrosive sublimate.

While saturnine medicine employed with view of diminishing action, this again intended to induce different state of action from what already subsists.

To aid effects of immediate application in this way should at same time employ it internally.

If Mercurial course also fails [must] own that expectation of recovery will be much diminished.

And as probable that circumstances will not then be in same situation as present if any opportunity of employing others must be accommodated to circumstances at the time.