DEP/DUA/1/45/10 (Normalised version)

Alexander Dingwall

(1788-1789)

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N^o29. Alexander Dingwall at 14.

In case of this patient have an example of a disease which has not in my opinion a place in any nosological system.

But which at same time cannot be considered as a very rare affection.

For in my own practice have met with upwards of dozen of instances of it.

But although not in writings of Nosologists¹ yet has not escaped observations of all practical writers.

Particularly described by Dr Graaf a German Physician in a treatise de [Petechiis] sine fibre².

And not long after in Volume of medical cases which published at this place³ described one of this disease, the first that fell under my own observation.

Then disposed to give this disease name of petechianosos or Morbid Petechal.

And need hardly remark that a petechial eruption consisting in general most obvious part of the disease.

This evidently case with present patient.

Hence to his case appellation given might with sufficient propriety be applied.

But have met with some other cases of same disease where this could not be said to be case.

And may observe that besides petechiae in most instances, vibices, or large livid blotches are also a very frequent appearance.

Still more generally however is the disease attended with haemorrhages.

These occur spontaneously as in case of our patient from almost every different part of body.

And take place even to excessive degree on slightest & most superficial scratch.

In some instances I have met with, chief symptoms Haemorrhage & vibices without Petechiae

In others haemorrhage & Petechiae without vibices.

But in every instance I have met with haemorrhages have been present.

And indeed probable that both petechiae & vibices to be considered as [species] of haemorrhage under the skin.

Hence then disease better distinguished from that circumstance than any other.

And perhaps better distinguished by title of [ Aimanrhoea]

As evidently consists in tendency to escape of blood from vessels.

But whether give it appellation of Morbus Petechialis, Petechanous or [ Aimanhoea], no doubt that in present case a distinctly marked instance of that affection

Of this unquestionable evidence from petechial & haemorrhage without fever.

Some indeed who contend, that should not be considered as a separate genus.

But that merely to be viewed as particular modification of Scorbutus.

A disease which although most frequently occurs at Sea certainly also does take place on shore.

As indeed abundant example in besieged garrisons, excluded from fresh provisions.

But supposing that present disease & scorbutus are the same, can be the effect only of ignorance of either or both affections.

For anyone who has had opportunity of seeing both must even from slightest observation be sensible of very remarkable difference.

Nay in most instances hardly any resemblance between the two.

Thus in case before us almost every symptom of scorbutus is absent.

Such for example as spontaneous lassitude anorexia, stomaccace, scorbutus ulcers, etc.

But here totally unnecessary to be more particular.

For anyone who has either seen scorbutus or is acquainted with history must at once see difference.

For my own part, never saw a case of scorbutus of any standing in which bad ulcers did not occur.

And have never yet met with any instance of this affection, in which ulcers of any kind took place.

Here though cut or scratch gives profuse haemorrhage, yet heals without ulceration.

In scorbutus on other hand not only uniform tendency to fresh ulceration, but even old ulcers break out again.

Nay even ulceration of bones, as apparent from solution of callus of form [fracture].

Would not however from this assert that no symptom can occur in common to two diseases.

And have particularly been informed that in some instances where petechiae vibices & haemorrhages constituting [ aemarrhoea] present [ stommacca] or spongy & bleeding gums have also occurred.

If however this does take place is very rare occurrence.

In all instances of [ aimarrh.] falling under my observation have not happened in any one of them. And in case of present patient [given] as sound as any patient can be.

+ A symptom which although very common in Scorbutus have never once heard of as occurring in present [affection]

Not indeed to be doubted, that from scratch or other injury haemorrhage should take place from them as well as [other] parts.

Nor even [wonderful] if subjected to spontaneous haemorrhage, as well as tender vessels of nose lungs or other parts.

But this essential difference from livid, swelled, soft spongy gums, bearing impression of finger, which constitute stomaccace of Scorbutus.

And which in all probability, connected with peculiar morbid secretion in mouth.

as probably from peculiar acrid taste of spittle in that [illegible]

But even allowing that stomaccace should here occur, would by no means argue same of disease.

Is indeed a constituent symptom of Scorbutus In so much that [where] absent notwithstanding all other symptoms may pronounce that disease does not occur.

But on other hand, often present where no scorbutus.

Of this daily examples to be met with. In so much that stomaccace as a genus of disease by itself has entered almost every nosological system.

And have myself had occasion to treat many examples of it where patient labours under no other affection.

Hence then not surprised that [complication] with [ aimorrh.] should have sometimes occurred.

And even where [complication] does take place, yet many other marks readily distinguishing present affection from scorbutus.

And as have already said, supposition of their being the same can have proceeded only from ignorance of both affections.

Nay in present disease much greater resemblance to some other affection.

Thus petechiae vibices & haemorrhage the leading symptoms of present affection occur also in worst kinds of [illegible] fever.

But from these sufficiently distinguished by progress of disease & absence of Fever.

Of all affections most near resemblance to those symptoms resulting from bite of certain species of Viper.

These indeed have never for my own part had any opportunity of observing.

Nor can it be said that symptoms resembling those of [ aimarh]. consequence of bite of every viper.

But according to description, affects of some of them, particularly of certain [Libyan] vipers. Haemorrhage in all probability of passive kind still more considerable than in any instance of this disease takes place.

+ describes consequence of bite of that very venomous species of Viper the Haemorrhois in the following words. [vide] quotation

For account of these may refer you to works of Dr Mead, & particularly to account which he quotes from Lucan.

But notwithstanding similarity of symptoms cannot here suppose that disease to which our patient subjected the same with that from bite of viper.

And even independent of circumstance of its not arising from same cause, is sufficiently distinguished by difference in progression.

For in case of venom of viper disease much more rapid.

In so much that very generally terminates fatally even in short time

With present patient however disease has already subsisted even for space of two years.

And have met with some instances [where] had still longer duration.

From all these circumstances then no doubt in concluding that justly to be considered as a genus of disease by itself & entitled to peculiar name.

And from marks pointed out readily distinguished from those most nearly resembling.

Although however hold that diagnosis not difficult, yet cannot make this observation either with respect to prognosis or practice.

If to judge a priori, either from appearance in disease, or from analogy of those affections most nearly resembling it, should be inclined to look upon it, as highly dangerous.

And in actual practice have met with one instance where proved suddenly fatal.

But judging from majority of cases I have seen entertain more favourable hopes.

And if patient does not obtain relief may yet hope that will leave us in no worse state than when came under care.

But by what remedy either alleviation of [cure] here to be expected must own am at loss to say.

For must own that any opinion I have formed respecting pathology of disease has by no means led to successful practice.

Nor have I been more fortunate, in trials of different remedies, to which recourse has been, had merely with view of witnessing effects.

In first case indeed, which had occasion to treat, thought removal affected by Elixir of Vitriol & Peruvian Bark.

But these remedies have since repeatedly tried with but little success.

And already oftener than once used with present patient to considerable extent without benefit.

Now therefore intention to make trial of other practices.

But of these as well as of Pathology of disease reserve observations till future opportunity.

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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) Eberhard Gottlieb Graff, De petechiis sine febre (1775).

3) Andrew Duncan, Medical cases, selected from the records of the Public Dispensary at Edinburgh : with remarks and observations : being the substance of case-lectures, delivered during the years 1776-7 (1778).