DEP/DUA/1/27/15 (Normalised version)

James Gibson

(1781-1782)

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James Gibson.

Disease to which subjected in some respects obvious.

And no difficulty in affixing at least general name to principle part of complaint.

Complaint for which principally applied for our assistance affection of eyes.

And from obvious appearance of this affection could have no hesitation in giving name of Ophthalmia.

Affections of eyes however entitled to this appellation differ very much both in nature & appearance.

And accordingly in best nosological¹ systems different species

Perhaps more usefully divided in general from part affected than any other.

And accordingly idiopathic species with propriety divided by Dr Cullen into Ophthalmia membrane & Ophthalmia Tarsii.

At same time in many instances these conjoined.

And this in some degree case with present patient

For while palpebrae of both eyes diseased also, evident affection of membrane of right.

And from this or perhaps even from deeper seated affection are to account for incapability of bearing light.

While however ophthalmia appears in these forms either separately or conjoined as an idiopathic disease so likewise frequently symptom of other affection.

And here distinction the more necessary as often very materially affects cure.

In this manner instances often occur which to be treated as consequence of Febrile [illegible] Venereal Scrofula & even Cancerous affections.

Here then necessary & important subject of inquiry to consider how far depends on any of these.

Affection before came under our care of long standing.

And first commenced we are told after attack of measles.

In that disease well known that eyes as well as membrane mucosal [illegible] often very considerably affected.

Hence watering & tenderness of these no less common than even catarrhal affection

In so much that has been proposed to inoculate measles from discharge taking place from eyes.

And well known that after this affection, as well as smallpox, often left in diseased state.

But while measles sometimes immediately give rise to Ophthalmia, so also [induce] other diseases.

And among these from this affection scrofula complaints are often dated.

On other hand well known, that on scrofula in habit, symptomatic affections of eyes, such as occur in present case, are often dependant.

May perhaps even add that by much most frequent source of sympathetic ophthalmia, when occurs at age of present [patient]

Here then to inquire how far any other traces of such complaint in habit.

And [such] I apprehend not wanting

In description even of appearance of patient have those external marks with which Scrofula often connected.

viz Light coloured hair, fine skin, fair & florid complexion.

These not indeed inseparably connected with Scrofula.

But will at least be allowed that the disease much more frequent with such, than with those of black or dark coloured hair & more swarthy complexions.

Besides these still another mark in countenance not less characteristic of scrofula tendency, than any of these viz swelling of upper lip.

This indeed some have considered as infallible diagnostic of another affection.

Presence viz of worms in alimentary canal.

That these two may sometimes be conjoined will not pretend to deny.

And would not even contend that from worms such an external appearance may not arise

But certainly no necessary connection.

Often absent where worms present.

Often present [where] no worms.

And much more frequently connected with scrofula

Of such state of habit then, consider it as indicative in case before us.

Here no reason to believe that patient any hereditary disposition to scrofula.

At least such a disease not distinctly marked in parents or any of relatives.

But although scrofula frequently hereditary yet often also occurs when no such origin

Hence then affords no objection to supposition of scrofula.

In favour of this supposition, besides particulars already mentioned, others also to be taken notice of.

Here some symptoms of disease, as when most distinctly marked.

Glandular swellings viz in different parts of body.

Particularly under arm pits & on neck.

From all these particulars then taken together strong presumption of Scrofula.

And may at least say that many instances in which less distinctly marked, when yet no doubt of existence.

Upon whole then date this principal part of patients affection the Ophthalmia from Measles.

But consider these as having here operation as giving rise to Scrofula disposition in habit.

And look upon this part of affection as distinctly marked instance of Ophthalmia Scrofula.

This however though principle yet not only complaint when came under care

At that time affected also with slight cough, & some expectoration.

This so inconsiderable that in most cases would hardly have considered it as object of attention.

But wherever frequent tendency even to slight cough with Scrofula disposition never to be overlooked.

Particularly at that period of life to which present patient has arrived.

For well known that often incipient state of Phthisis.

In case before us, though cough very slight yet when came under our care had been of three weeks continuation.

And besides this frequently before subjected to it

Hence then in giving prognosis, part of affection at which perhaps ought to be principally alarmed.

At least if any part of disease proves dangerous will be this.

For from ophthalmia fatal consequences at least not to be apprehended.

But if cough in any degree from scrofula tuberculosis in lungs, if not absolutely certain, at least strong presumption that will end in death.

This suspicion however throw out merely from being acquainted with insidious nature of Phthisis.

For still at least, excepting cough, no symptoms which can give any alarm.

While appetite unimpaired, even pulse continues at natural standing.

Although therefore mention cough, & danger of Phthisis tendency, yet inclined to think that Ophthalmia only disease to be had in view either in prognosis or practice.

And with regard to this part of affection although as already observed no reason to apprehend danger yet grounds to suspect that should not soon be able to accomplish radical cure.

For scrofula well known to be in general so obstinate a disease, that has long been considered, as one of opprobrium medicorum

And if excepting affection of bones, under no form perhaps, more obstinate than under that of ophthalmia.

With present patient disease before came under our care had already continued for space even of several years

And although during that time different remedies employed yet only with temporary relief.

Must own therefore that expected little more than temporary relief in present instance.

And this I apprehend have been able to accomplish.

For consider desertion of patient as having arisen from benefit obtained

The rather as from reports it appears that unwilling to attend us any longer than necessary.

Unless therefore from speedy recurrence of affection little chance of seeing him again.

Hence then unnecessary to state sentiments as to what may be afterwards plan of cure.

Shall only briefly take notice of principles & views with which treatment directed while continued attending.

In all such instances of Ophthalmia, although the [eradicating] scrofula constituent to be considered as means of complete cure yet becomes always first objective to mitigate urgent symptoms depending on immediate affection of eye.

And is only after this to considerable degree accomplished, that can turn attention to scrofula affection.

Here as in other cases of inflammation then, first objective to diminish increased action of vessels.

On this general intention will readily [understand] meaning in these practices to which had here recourse.

At first report directed two different practices as means of accomplishing this end.

Bleeding viz with leeches & use of powder of Cream of Tartar as refrigerant cathartic.

In many instances of active inflammation, locally augmented action, connected with increase of general impetus of blood.

Hence then as means of reducing action, abstraction from common mass becomes necessary.

And without this, topical removal of blood very little influence.

But where no general increase of impetus, much more to be looked for, from that mode of evacuation than any other.

For can be no doubt that the nearer the abstraction is from affected vessels, the more the effect.

Unless indeed in those cases where from mode of abstraction, stimulation produced which [propelled] to affected vessels.

And this circumstance leads to caution in employment of leeches the mode of blood letting here directed.

In case before us pulse in natural state & no other mark of augmented impetus in circulation in general.

No indication of general plethora requiring abstraction from common mass.

Hence then imagine that more advantage to be derived from topical bleeding with less inconvenience.

From this in cases of Ophthalmia everyone who has had any experience, must have seen most remarkably good effects.

Sometimes performed even from affected vessels themselves by gentle scarification with lancet.

In this case however besides great nicety required in operation, abstraction of blood can be but very small

And hence commonly, topical bleeding directed from temples by cupping or leeches.

Of these two, if had opportunity for choice, should in general at least give preference to first.

For both more immediate & certain discharge & at same time with less inconvenience.

In our practice however, obliged to give preference to latter, as from being more familiar patients less afraid of it.

And as are capable of managing it themselves.

But besides that leeches cannot always be made to fix, effect of wound they make is that of very peculiar stimulation.

In so much that with some particulars constitute inflammation & swelling to considerable extent, unavoidable consequence.

On this account in no instance prudent that should be placed very near eye.

And accordingly proper that skin to certain extent round the eye, should be defended by enclosing eye, in top of wine glass or like.

Or perhaps even preferable, that leech enclosed object it, should be applied to temple & thus confined to particular space of skin on temple

And thus often affix of themselves more readily than in any other way.

These circumstances merely mention as particularly from attention to which, much inconvenience may often be avoided.

In case before us from topical bleeding employed no such inconvenience occurred.

And although two leeches only made to fix yet discharge of blood from these considerable.

To this may I think with confidence attribute diminution of inflammation of eye which followed.

For although Cream of Tartar at same time ordered yet in quantity to which directed had no sensible operation.

Would not indeed pretend to say, that even without this, benefit may not have been derived from it as giving some augmented determination to intestinal canal.

Yet principally expected good effects from acting as gentle purgative.

And here may observe that from such have seen more benefit in scrofula ophthalmia than from any other measure.

At least after many remedies tried in vain, have in more instances than one, seen remarkable benefits from course of [purging] mineral waters.

And that too not merely as giving temporary but even permanent relief.

On this account then while employed leeches as a means of giving immediate ease meant to continue use of Cream of Tartar as means of securing advantage.

And accordingly at next report although affection very much gone, yet ordered continuation to double extent that before employed.

To quantity viz of half an ounce every day.

From this hoped that daily two or three easy stools.

Which while product of effects wished for, not so considerable evacuation, as to [restrain] from continuation.

With this measure, also directed another.

Use viz of solution of Saccharum Saturni.

From this had in view the restoration to vessels which had been affected their due degree of vigour.

But still more the preventing return of increased action or counteracting it as soon as should occur.

Of late, with this intention, no application perhaps to which recourse more frequently had than to lead.

And with view to external application great variety of different forms of exhibiting, it of late proposed.

Particularly those introduced by Mr Goulard.

But of all forms none perhaps more immediately or considerably effective than that here employed.

Simple watery solution viz of Saccharum or as more properly to be called Sal. Saturn.

Without [put] to enter into explanation of operation certain that very powerful effects from external application to diseased parts, both in allaying inordinate action of vessels & in alleviating pain.

Of this indubitable proof in application to parts burnt or scalded.

And no less obvious in daily use in instances of ophthalmia.

Under this course then hoped that return of affection might be prevented & disease overcome.

After this however affection so much diminished that patient discontinued attendance & intermitted medicine.

But in no long time from accidental exposure to cold renewal of symptoms.

From this led to return to attendance.

As symptoms however more slight than formerly thought it unnecessary to have [again] [use] blood letting

Directed therefore repetition of Solution of Saccharum Saturni & of Cream of Tartar as formerly

When has now again deserted attendance presume at least that from same reason as formerly.

But notwithstanding temporary intervals, am far from considering disease as cured.

In many such instances, have known patients notwithstanding every attempt to cure subjected to returns of affection, on slight [accidents] during whole course of life.

And this may yet be case with present patient.

Probable however that shall see no more of him during present course.

Hence unnecessary to add anything respecting future plans.

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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.