DEP/DUA/1/30/05 (Normalised version)

Ann Saunders

(1782-1783)

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Ann Saunders. November 16^th

Disease to which this patient subjected not uncommon.

And in appearance which exhibited nothing peculiar.

Yet must own at a loss what name strictly & properly to be given it.

Disease evidently a cutaneous affection.

Among these when of chronic kind no proper distinctions are I think established.

To establish such with propriety unquestionably a very difficult matter.

And much to be doubted whether ever accomplished in satisfactory manner.

This in some degree effect of variety in appearance.

But still more consequence of those changes in appearance to which such affections are subjected.

Hence even where cutaneous eruptions most accurately described, & although case before most exact resemblance to this description, yet can hardly positively refer it to that genus.

For in no very long period may have as exact resemblance to another.

Hence I own long inclined to think that the instituted numerous divisions among these, tends to perplex practitioners to very little purpose.

Accordingly am myself disposed to consider all of them, as referring to one of two Genus.

Either Lepra or Herpes.

Am inclined to use latter of these appellations when erupts with considerable fluidity.

And former when of more dry & scaly appearance.

Must however admit that often occasion to remark transition from one state to other.

Yet following this rule would bestow upon this affection the title of Lepra.

By this however would not be understood to mean that our patient subjected to that loathsome disease so dreadful among ancient nations particularly Jews.

And which from infectious nature required almost total exclusion of those subjected to it from rest of mankind.

From this disease, we are now fortunately free in this country.

At the same time cannot boast that has always been the case

For from examining History of Edinburgh will find that in neighbourhood of this city, formerly several hospitals for reception of unhappy victims to that disease.

And there patients were confined within certain limits & to certain restrictions with utmost rigour.

In so much that at end of each hospital there stood a gallows for immediate execution of transgressors.

While this in some degree effect of necessity probable that still more proceeded from credulous belief of times.

Now at least are certain that no such precautions requisite here.

And indeed, that disease under form in which then often to be met with, has entirely ceased.

By what means this change so remarkable has happened, not now our business to enquire.

May only observe that much probably to be attributed to greater cleanliness, to more common use, & more frequent changes of linen, together also with introduction of different aliments particularly more liberal use of different vegetables.

But although now in this country at least no instance of Lepra Graecorum as it has been styled, yet many other cases of cutaneous affections answering to generic description given of Lepra by Nosological¹ writers.

And in case before us have what I reckon an instance of Lepra. Herpetic.

Whether this should really be reckoned a different genus of disease from true Lepra will not pretend to say.

To this opinion must own am rather inclined

For if consult nature of affection, several particulars in which they essentially differ.

Especially in circumstances of highly infectious nature of Lepra Graecorum.

For this does not in any degree seem to hold, with such affections as that of present patient.

Neither in this case nor in any similar instances that I have seen at least any marks of infection.

Accordingly both husband & children remain perfectly free from it.

But although a very different disease from Lepra of ancient times, yet by no means to be considered as slight affection.

In many instances obstinately resists every mode of cure, which can employ.

And in others, although [apparently] successfully removed, yet in short time again returns.

Hence in such affections, can neither promise on expedient cure, nor when seems to be obtained can we with confidence pronounce it radically.

But although this often the case, yet by no means a rare circumstance to see favourable termination.

As little ground therefore, for despairing of recovery

And here must observe that know no circumstances in appearance of the disease from which can form any certain or even probable prognosis.

As far as probable conjecture can be formed, is I apprehend chiefly to be drawn from concomitant circumstances.

Particularly causes of disease, duration of complaint & habits with which occur

And most of these, in present case would lead to favourable opinion.

To eruptions of this kind we are told has not formerly been liable.

And present, which has occurred only, after has passed 40 years, but of short duration.

When she came under our care, but of few months standing.

During that time, very little done with view to removal.

Could not therefore be said to have resisted use of any powerful remedies.

And indeed this less to be wondered at when consider that had in no degree affected general health.

When applied more from apprehension of consequences than from any inconvenience which had really taken place.

For at time when disease began had at least one appearance of better health than usual viz uncommon degree of fat.

This although sometimes arises to such degree as to be morbid yet much more frequently connected with good health.

With our patient are told constitution formerly very different.

And became corpulent only on return from West Indies where had lived many years.

That this may have been affect of change of climate not impossible.

No doubt that sweating to which strong disposition occurs in warm climates, one cause preventing deposit of fat, even where natural tendency to it.

That this therefore may sometimes have effect will not deny

Yet upon whole, not remarked that from this cause fatness frequently occurs.

Should therefore be rather inclined to attribute it, to some other circumstance.

But whatever cause, as here occurring even with the cutaneous eruption an indication of good health.

As with regard to any judgement which can be formed of this eruption from causes are much in the dark.

Are indeed informed of certain circumstances at commencement of this affection, which may be supposed to have had some share in inducing it.

That commenced viz on death of child which was then suckling.

That this child died of smallpox

And that eruption first commenced on breast.

From all these circumstances taken together may be perhaps inferred that in some degree connected as cause & effect.

And would be very far from venturing to represent this as an idea, either absent or impossible.

At same time no uncommon thing for women, to lose by smallpox, child whom suckling without any such effect.

Reckon it therefore more probable that here the effect of some other [cause]

And indeed in many cases, takes place even to great degree where totally ignorant of any cause to which attributed.

But whatever cause, in present case, may conclude that has now either ceased or at least in part countered or removed.

For since came under our care is at least considerably diminished.

This circumstance as well as others [therefore] would also lead to favourable opinion as to termination

And upon whole hope that in this case by aid of proper remedies may be able to obtain if not radical at least temporary cure.

With respect to treatment of such affections must acknowledge that remedies to which have in general had recourse directed rather on footing of experience than on any proper knowledge of mode of operation.

For with respect to many of them at least have not been able to form any conjectures, which even to myself appear very probable.

Can however be no doubt that should have better chance of successful cure if properly acquainted with real nature of morbid affection.

And although remote causes of great diversity & often obscure, yet inclined to think that general morbid affections which induces not numerous.

Some of them in my opinion operate as inducing morbid affection of common [mass] of fluids

Others as bringing on diseased state of subcutaneous or extreme vessels.

Some as affecting state of secretion by sebaceous glands of surface.

Others as occasioning morbid affection of bulbs of hair.

Of all these affections great reason I think for presuming that disease of our patient depends on second.

Diseased state viz of subcutaneous vessels.

With general health which she enjoys can hardly I think suppose deprived condition of common mass of fluids.

While several objections both to supposition of affection of sebaceous glands & of bulbs of hair

For in these cases affection both more fixed & more limited in nature

Then, rarely happens, that as in present case extends over many different parts of system.

And not liable as with present patient, to appear at one place, & disappear at another.

On these grounds then presumption [found] that here principal morbid affection, a diseased state of extreme vessels of surface.

When this the case am of opinion that principle intentions of cure are

1 To promote free, regular, & natural discharge of perspired matter by surface.

2 To remove that local morbid action which takes place & which gives rise to the effusion & separation afterwards forming a scaly incrustation on the part.

This sometimes to be effected by diminished action.

Sometimes by inducing different state of action.

On these principles am inclined to explain operation of remedy, to which have here had recourse.

[Preparation] of lead, particularly saturninum solution well known to have very considerable influence in tending immediately to diminish action.

While antimony under most of different modes of preparation very generally at least, ranked among tribe of diaphoretics.

But whether operate on these principles or not, am much mistaken if in former practice have not seen benefits from them in similar cases.

And was entirely on footing of former experience, that had recourse to antimony, under form in which here used.

vizr in crude state reduced only to [ sublic] powder.

This, it is true, one of most uncertain modes of exhibiting antimony.

For here metalline part so involved with sulphur that hard to say to what extent will act.

And no doubt that degree of action must very much depends on state of stomach.

Effects of variety in this respect example in case before us.

For at one time dose to which [here] exhibited, that viz of half dram borne without any inconvenience.

At another, product not only of sickness but even of severe vomiting.

Notwithstanding this objection however, from any trials that I have been able to make, am inclined to look upon it as preferable to any other antimony in such cases.

At least for my own part, in cutaneous eruptions have seen more good effects from it, with less inconvenience than from any other.

And without [illegible] to explain how it happens think it not improbable that some peculiar advantage may result from combination of [illegible] part of Antimony with Sulphur.

Whatever be in it has long been a remedy in such affections.

And not only with human species but with other animals also.

For common practice with Farriers to give it to considerable extent to horses with view of obtaining smooth & soft skin.

These then reason for having recourse to antimony & for employing it in form in which here used.

Of mode here used, for exhibiting saturninum application need say nothing.

For now very generally allowed, that from Saccharum Saturni, can derive all benefits to be obtained from any of preparations of Goulard or others.

And one of most active as well as convenient modes of exhibiting it, is that of simple solution in pure water.

If mere lotion not sufficient in this state, may be applied in form of poultice

And by this means undoubtedly obtains longer continued application.

Here however parts affected not covered with such incrustation as to render this necessary.

And since this course began has apparently derived from it very considerable benefit.

Eruption now everywhere much [diminished]

Am hopeful therefore that by proper perseverance in same mode of treatment complete cure may at length be obtained.

Here however as you will observe from last report, have not been able, to persist in course as at first begun.

For from half a dram of the Antimony much sickness, & severe vomiting [excited]

And that too although same quantity before taken without any inconvenience.

An evident proof how much action of this preparation, affected by state of stomach.

From this effect have thought it advisable, at last report, to diminish dose to half the quantity.

And hope that may now be borne without any inconvenience.

Even when thus reduced in quantity however, am not certain, that will be the case

For even in much smaller dose, the metalline part, if wholly, & suddenly rendered active, sufficient to excite same effects.

Not impossible even, that from this circumstance, shall even be obliged to desert use in present form.

But before doing so, will first try, how far this effect may not be corrected by some slight addition.

Such for example as small proportion of Magnesium, Pulveris Cretacea or any other absorbent.

These from destroying acidity may have effect of rendering operation less considerable.

At same time on this very account, use, where it can be done, to be [illegible].

For may have effect not merely of diminishing power, but of rendering medicine totally inactive.

If find that even thus antimony not borne with ease, or not product of effects that could be wished in [cure], yet before desert use, will think of trying it in some other form.

And particularly, in that of Vinum Antimony

If Antimony, either cannot be taken, or although taken ineffective, not [improper] that may prosecute cure for some time with Saturninum solution alone.

Especially if disease continues in any degree to decline or even is not aggressive.

And I own am here hopeful that no other medicine will be necessary.

If in this however am disappointed a variety of practices may be had recourse to from which reason to hope for good effects.

These however at present reckon it unnecessary to detail.

May only observe that if present measures fail, have thoughts of next employing in this case, as an internal medicine, the Oenanthe Crocata or Hemlock dropwort.

And as an external medicine, strong camphor oil.

But of these medicines, delay making any observations till see whether actually employed in this case.

And as have already observed, must conclude with expressing hope if not expectation that will not 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.