DEP/DUA/1/27/17 (Normalised version)

Isabel Sim

(1781-1782)

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Isabel Sim.

With regard to this case must own equally at loss both as to nature & name of affection.

Consists of very numerous assembly of different symptoms.

And hard to say whether can be considered as connected or not.

But besides this still farther difficulty from peculiarity of some appearances.

And particularly of two principles cutaneous affection & disease of throat.

Must own that in former practice have not met with any case in circumstances similar to present.

Am not without doubt how far present affection, ought or ought not to be considered as depending on causes to which attributed.

Supposing them to be connected as cause & effect equally at loss to conceive how connection to be explained.

These doubts however did not deter me from taking case under care.

And that not merely as subject of practice but of lecture also.

To this led both from considering as example of singular & rare complication of affections.

And likewise from expectation that during course of affection circumstances might occur illustrating nature of affection.

Of this latter circumstance however now very little probability.

For patient has not attended us for some weeks past.

And highly probable that from not speedily receiving benefit wished for, has gone to seek assistance somewhere else & that shall see no more of her.

In present state of uncertainty therefore unnecessary to say much either with [regard] to nature of affection, or plan of cure.

May only remark that when patient applied for our assistance most obvious disease at least Cutaneous affection.

This appeared, under form of pustules which in as far as resemblance to any I had before seen, approached most nearly to Smallpox.

At same time neither when came under care, nor at any time during whole course, attended with febrile symptoms

And before we saw her, had continued for space of several months.

Hence then could in no point of view, consider it as belonging to any of Exanthem of Nosologists¹.

With regard to cutaneous affections, occurring as chronic diseases, have already had occasion to observe that except Psora & Tinea which peculiarly & distinctly marked, consider all others as referred to general [appellation] of Herpes or Lepra.

And that in nature of these no very essential difference.

In so much that very frequently [transitions] from appearance most exactly corresponding to definition of one, to what answers to that of other.

To be considered therefore rather as opposite extremes of same affection, than as different.

In appearance of these, it must be allowed, very considerable variety.

But in case before us, nothing which could be considered as approaching in appearance to either.

And for my own part can give it no other name than that of anomalous cutaneous affection.

With regard to cause, no circumstance to which could with any degree of confidence be traced.

Had indeed we are told, succeeded soon after drying up of abscess on shoulder

And can be no doubt, that from obstruction of accustomed discharge, particularly by [surface], cutaneous eruptions of different kinds, often produced.

But besides this, some circumstances in case, from which would infer peculiar affection of skin.

Particularly from what happened with regard to blisters.

From these even on repeated application, no effect whatever produced.

Would argue then, that here there existed some degree of paralysis if may so be called, of cutaneous or [external] vessels

And if such an affection existed, not improbable that may have derived origin from excessive loss of blood, which are told had suffered, by accidental removal of band on arm.

An accident to which all other former parts of complaint were attributed.

Of nearly same standing with cutaneous eruption, was affection of throat.

And this when she came under our care, if not equally obvious more distressing to her.

Here also however affection very singular appearance.

Cannot indeed consider as such common symptoms which here occurred of cough, hoarseness & difficulty of deglutition.

Nor could it be thought uncommon that with these on inspection of fauces one of Tonsils should have been discovered swelled & inflamed.

But was I think very greatly singular that should have continued in this state for space of three months.

At least for that period are informed that symptoms above mentioned had subsisted

And are also told that had not of late increased in severity.

Hence then in as far as dependence on local affection here obvious may conclude that had continued same.

Such an affection however not similar to any modification of cynanche which I have seen.

And does not correspond to any description I have met with in practical authors.

Here therefore likewise reduced to necessity of looking upon it as an affection of throat of anomalous nature

But while these principal symptoms when patient came under care, to be observed that preceded by set of affections commonly totally unconnected with [either] one or other.

These particularly consisted of variety of dyspeptic symptoms.

And attended with severe pains of head & back shooting particularly through region of uterus.

Though these of very different nature yet here some reason to infer [connection] from one having preceded other.

And from having much diminished at least on appearance of other.

In case of complaint last mentioned however, evidence of connection with still another circumstance.

With want viz of menstrual flow.

This evinced both by want of menstrual discharge & by periodic aggravation at time when should flow.

For obstruction of menstrual discharge [however] a very satisfactory cause assigned.

Profuse haemorrhage viz already [mentioned] to which patient accidentally subjected.

This however well known to be a circumstance in female oeconomy² producing most considerable morbid affection.

Upon whole then only conjecture which to me seemed in any degree probable was that to this cause all symptoms to be referred.

And that to use words of eminent author whole affection to which patient subjected to be enumerated among multa, gravia, algue incredib [fue] sympt. quae ex suppression mentruorum [ovumtone].

With this idea of disease it may be imagined that notwithstanding number, & anomalous appearance of symptoms prognosis should not be unfavourable.

For if this the case, reason to hope that on restoration of menstrual flux all symptoms should cease.

This patient however at period of life when systems still subjected to many different revolutions.

In so much that no reason to despair of restoration, even by its own operation independent of artificial means.

At same time when consider that symptoms have already subsisted even with increased violence for space of some years no reason to expect that such natural recovery should occur during few weeks of attendance here.

And must own that from artificial means of cure had equally little prospect.

For here consider amenorrhea as being consequence of excessive loss of blood to which patient subjected.

And therefore as being symptom of general state of system, rather than of particular condition of uterus.

At same time from long want of distension vessels of uterus apt to become impervious.

Hence though due condition of system restored, does not follow that restoration of menstrual flux will be consequence.

At same time with this intention had in view the trial of different practices

And many means of cure also which might have been used with view to other complaints independent of menstrual discharge.

Even first trial which intended to make however interrupted if not disappointed by want of attendance on part of patient.

Began by directing use of Peruvian Bark.

In this had in view the restoring that condition to system of which had been deprived by excessive haemorrhage.

Particularly the restoration of due vigour to superficial & extreme vessels.

[This] however not to be expected from weak formula or short continuation.

Directed employment therefore in substance.

And to such an extent only that notwithstanding tendency to stomach complaints thought it might have been retained.

On this remedy then, if no circumstance should occur as objection to use, meant to continue her for some time.

But besides this at same time also directed another remedy.

Application viz of blister between the shoulders.

This chiefly intended with view to affection of throat.

And hoped that by derivation from [these] might have some influence both in diminishing inflammation & swelling.

But besides this thought it in some measure naturally indicated by another circumstance

Was observed that eruption first began on ulceration on shoulder drying up.

Wished therefore to see whether [diminishment] might not take place from similar discharge.

And on this account ordered that blistered part should be kept open by epispastic ointment.

Thus expected renewal of effect of former suppuration.

Expectation however in this particular totally disappointed.

For blister never rose.

Hence then not to be expected that should have any influence even on affections of throat or breast.

Still less on eruption

On this however would appear that no better effect from Peruvian Bark.

For although during first week taken without any inconvenience yet eruption increased & pustules became more numerous than before.

This however imagined in no degree to be attributed to medicine employed.

And as imagined that blister had failed in operation merely from some accidental circumstance ordered both continuation of Bark & repetition of Epispastic.

From this second trial of blister however no more effect than from first.

While at same time, blisters from same mass had full effect [illegible] [illegible]

Now therefore led to conclude that depended on state of extreme vessels.

And that from this practice nothing to be expected.

Still however thought of persisting in use of Bark.

But now an objection occurred to use which had not before taken place.

By last doses vomiting had been excited.

Was merely with view of restraining this, & that Bark might sit more easily on stomach, that ordered for patient mixture of Confection Japonica with Mint Water.

But whether this has had desired effect have not been able to learn.

For since prescribed have seen nothing of patient in this place.

And from time that has since elapsed, now more than probable, that will see no more of her.

Hence then in great measure unnecessary to say anything of other trials which had in view.

May only here remark that after trial of bark, if had proved unsuccessful had next in view the employment of Electricity.

Would indeed by no means represent as a certain remedy in every instance of Amenorrhea.

Although even this contended for by some.

Yet without supposing it so extensively useful, am convinced that many cases of Amenorrhea in which product of most considerable effects.

And upon whole know no means of restoring menstrual discharge equally powerful.

For this purpose most effective when slight shocks given through region of uterus.

But besides this was intention also in present case to have recourse to simple electuary or [illegible].

For no doubt that very powerful influence as increasing action of whole [ vacul.] system.

And on no part more considerable than on extreme vessels of surface.

This manifested by influence as augmenting perspiration.

Here then where reason for believing in some measure paralytic state of [these] might seem to be particularly indicated.

If therefore patient returns to attendance, without farther employment of Bark to which seems to have great objection mean to have recourse to this practice.

Rather however by way of trial than with much hopes of success.

For must acknowledge that belief in theoretical principles laid down is not so strong as to make me expect it with great confidence.

And as set out must conclude with observation that conjecture as to nature of disease not so far supported either by reason or former experience as to give even high degree of probability.

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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) Oeconomy is an archaic spelling of economy. In the context of medicine, the term animal oeconomy refers to the living system and its management. In these case notes all but one of the cases where this term is used are female.