DEP/DUA/1/33/10 (Normalised version)

John Chisholm

1783

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John Chisholm December. 7. 1783.

With regard to case of this patient little room for doubt.

Is a distinctly marked instance of Scrofula.

A disease in this country & particularly about city of Edinburgh now no less common than destructive.

Here disease characterised both by number, situation, & nature of tumours.

And not less so by their duration

Has not indeed all the marks of scrofula entering definition of best nosologists¹.

Thus for example wants swelling of abdomen & upper lip, mentioned in definition of Dr Cullen.

But though these common by no means constant symptoms of this affection.

Often entirely wanting even when disease to such height that patient falls victim to it.

Here however, evident characteristics of the disease, in glandular suppuration taking place in so many parts at once

And particularly in affection of neck & under part of cheek.

To this also to be added that here occurs, with that habit in which well known to be most common.

For our patient of fine skin, & florid complexion

And although by no means peculiar to such, yet with [these] habits so frequent that if external appearance even much more equivalent, would have no doubt respecting the disease.

[Here] scrofula appears in what may be called its most simple form.

For while occupies those places in which most commonly situated seems entirely to consist in affection of lymph glands

And although in advanced stages of the disease every part of system even bones themselves materially affected yet no doubt that in Lymph glands disease first & most obviously appears.

Is indeed by some contended that though there first manifested disease has a deeper root.

And that in every instance Lymph Glands only affected in secondary way, by some matters viz [absorbed] & [retained] in these.

From these operates as a stimulant swelling inflammation, & suppuration of the glands supposed to be induced.

That Lymph glands may thus be diseased unquestionably true.

And that in some cases scrofula tumours may thus have had commencement would not deny.

Accordingly enlargement of toe or finger showing manifest disease of bones then not unfrequently observed to precede scrofula tumours of glands of limb.

But even in these cases reason to think that such scrofula swellings happen only from Lymph system being previously in diseased state.

For on other occasions well known that much larger absorption without any such effect.

Nay cases where whole [earth] of bones absorbed, & discharged without any influence on Lymph glands through which must have passed.

Besides many cases where no evident source from whence reason to conclude that absorption takes place

And there too as happens with our patient affection will appear in glands at very distant parts.

Hence then if not certain at least probable grounds for concluding that in simple state is a principal affect of Lymph System

Such am inclined to consider it in case before us.

And view it as still at least example of the Scrofula simple external or vulgar.

That is without affection of bones, of viscera or of any important functions.

But consisting merely in Lymph glands in different parts of body being subjected to inflammation & suppuration.

From this view of the disease prognosis at least as favourable as can be, in almost any instance of distinctly marked Scrofula.

Age of patient also somewhat in favour.

For has already arrived at 12 year.

Is indeed true that [illegible] to that period very bad cases often occur.

But in greater number of such unless where affects lungs has commenced at earlier period.

And even in general remarked that natural tendency to cure as life advances.

Particularly from seventh year or termination of childhood.

To all this to be added that disease still but in recent state.

Hence then upon whole grounds to hope for recovery.

On other hand however to be remarked that disease, in general in nature obstinate.

And that even when slightest appearance will yet continue to increase notwithstanding utmost efforts of art.

Would not therefore be surprising or uncommon if in hopes expressed should be disappointed.

But in present circumstance of disease have even grounds to look for natural cure.

And this may at least somewhat aided by use of proper remedies.

With this view you will observe have had recourse to a practice already spoken of in another case.

A combination viz of Cicuta with the Peruvian Bark.

Of benefits to be derived from this in scrofula cases have already had occasion to state sentiments.

Here indeed cannot expect benefit from it entirely on same footing as in case of Betty Murray.

For with this patient no cough

In case before us objectives chiefly to be aimed at are in 1^st place the obtaining where it can be done resolution of swellings without suppuration.

And in 2^d place where suppuration has already taken place, the [procuring] a discharge of [proper] matter, & the inducing of adhesive inflammation.

For answering these views, am inclined to think that much may be expected from medicines here employed.

And am therefore desirous of giving it fair trial.

Full effects however, not to be expected till used for some length of time.

And that might be better able to determine how far had such, wished as far as could easily be done to [illegible] at same time any other practices.

But where tumours terminated in ulcer some dressing became necessary.

As such have had recourse to the Unguent Saturn.

Which while answers general purpose of gently emolliating ointment has also some influence from metallic [impregnation].

As now directed to be prepared is formed you will observe by adding due proportion of Saccharum Saturn to simple ointment of wax & oil.

May expect therefore in some degree to obtain from it sedative effect of the lead as removing that inflammation giving vitiated matter.

From these practices must indeed admit that hitherto no considerable advantage has been derived.

But this as already observed to be expected only from continuation for some length of time.

Is my intention therefore to persist in use of Unguent Saturn externally & of Cicuta & Bark, internally till able to form some probable conjecture at least with regard to effects.

If under employment patient has complete recovery may I think with justice attribute somewhat to practices employed.

Indeed true, that scrofula sores particularly in such circumstances as that of present patient often heal by spontaneous operation of system.

Cannot therefore positively say, if recovery should happen that this may not be case with present patient.

At same time, when consider obstinacy of greater part of them, will be more probable that practices directed have had considerable share.

Should recovery however not readily ensue, before other practices, mean to push topical application of lead still farther.

And in place of Unguent Saturn to try regular continual application of a Solution of the Sal. Saturn.

Or at least to wash & bathe the part with it for space of some hours every day.

From this mode of treatment in a case which has lately occurred to me in private practice have I think seen best effects.

And here, if shall be found necessary, may I hope be product of equal benefit.

But if from none of measures mentioned desired effect should be obtained others may be tried.

And though none with any certain prospect of success several which may here employed.

When season of year will permit sea bathing & drinking sea water of great service.

And benefit also from mineral springs, particularly of purgative qualities.

To these therefore may here try substitution by employing solution of Glauber or Epsom salts or Salt Polychrest.

And may direct washing of ulcerous parts by same solution or by solution of common salt in water.

May try some of more [acrid] applications externally as ointment with [illegible]

Or may have recourse to sulphuric alkali under form of Salt Soda.

But in these or other practices to which may have recourse must be entirely directed by condition of patient at the time.

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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.