DEP/DUA/1/26/09 (Normalised version)

Mary Monro

(1780)

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Mary Monro.

Case sufficiently characterised by obvious symptoms.

Here evident distortion & [malformation] of bones.

And although patient yet at early period not only in long bones, limbs & forearms, but also in many others.

Particularly remarkable both in growth & position of ribs, sternum & clavicle.

And in consequence of this distortion of chest, are without doubt to explain affection of breast [illegible]

While other bones thus diseased head also not unaffected.

Manifestly of size uncommonly large.

In these circumstances evident characteristics of disease very common in this country viz Rachitis.

An affection by some indeed supposed peculiar to Britain & has even been contended that in some measures peculiar to modern times.

An assertion however which cannot suppose strictly true.

For although not described as particular disease yet well known that distortion frequently no rare occurrence in ancient times.

And if some lived to manhood many others may presume died in early life

Hence for my own part put little credit in accounts of Glisson & others who consider it as of late date, & mention particular parts of English counties viz of [Sommer] & Dorsetshire as places where first [commenced].

But whatever progress of affection sufficiently demonstrated from number of [different] [figures] [among] adults that now [communicate] affection with those recovered.

And well known to every medical practitioner that many fall victims to it during infancy.

Hence then an affection which in modern times must be allowed to merit attention.

And must farther observe that for my own part at least acquainted with no certain or expedient mode of cure.

Where recovery is effected in general much more in gradual manner & by operation of system itself than by medical aid.

Is also during progression of the disease a very difficult matter to foretell what will be event

And in case now before us with regard to Prognosis am very doubtful.

Some circumstances rather favourable others very much the contrary.

In judging of termination besides progression & duration of affection & symptoms with which attended, conjectures also in some degree to be formed from causes inducing it, from condition of habit attacked, & from period of life at which occurs.

Of all instances of the affection those the worst where disease hereditary.

Or where though affection does not exist in parents, yet those in diseased & debilitated state when have child.

A very unfavourable circumstance also where arises from any fault in [illegible]

In all these cases interwoven as it were with originating constitution.

And accordingly in general commences most early, progress most rapid, & symptoms soon at greatest height.

Upon whole very few instances where live to manhood.

In these different respects case before us not so unfavourable as some others.

As far as can learn no hereditary taint, no morbid disposition in parents to which can be attributed.

Same parents other child entirely free from every symptom or appearance of it.

And these also reared by same nurse, their own mother.

Hence then may conclude that here arises from some accidental cause.

And probably from some circumstance to action of which child no longer exposed.

May also remark that as far as can learn this cause no [preceding] disease giving material affect of constitution

For according to account given us before commencement of present affection, enjoyed good health.

But if these particulars favourable others very much contrary.

Is much against patient that affection has taken place at very early period of life.

And although yet but of short continuation for space viz of six months, yet progression has been very rapid.

Affection of bones already general & to considerable degree.

And in thirst with which patient affected, state of heat. pulse, etc have indication of hectic fever by which in general fatal termination induced.

Upon whole therefore opinion of case notwithstanding circumstances first mentioned unfavourable.

Will by no means be surprised to find that notwithstanding best endeavours patient cut off by affection.

And if should not fall victim to disease yet recovery of proper shape, after destruction already taken place more than expect

Of general plan of treatment in this disease practitioners by no means agreed.

A circumstance necessarily arising from diversity of sentiments as to nature of affection.

Although disease chiefly appeared under form of affection of bones yet by many this considered as depending on condition of [illegible].

And in many cases at least symptoms [previous] to any remarkable affection of bones indicating a dropsical state.

Conclude that from this watery condition morbid affection of bones originates.

And that therefore prospect of removal, by evacuation.

But this plan though applicable in certain cases by no means generally so.

And even in these to which best suited, when pushed to great extent never fails to be product of much evil.

Proposition of having recourse to evacuation in any degree much regulated by circumstances & cause of affection.

In case before us, in neither of these any particulars which can lead to use of evacuation.

Only symptom which can [truly] be suspicious of dropsical kind is swelling of abdomen.

This however with such [illegible] much more frequently from wind in alimentary canal, than from water in cavity of abdomen.

Indeed this cause of swelling [seldom] absent even where swelling from water obvious.

That in present case totally dependent on wind, in no degree on water may infer from want of fluctuation & [absence] of other dropsical symptoms.

If in symptoms nothing induces to [illegible] as little in cause.

Here indeed cannot say from what affection originates.

Supposition entertained by parents that affection arose from worms, have no doubt in considering as totally imaginary

Worms in this country in particular assigned as cause of numerous diseases which have no share in inducing.

To this indeed numerous & anomalous symptoms which unquestionably do produce gives some countenance.

And according seldom [appearance] [which] with vulgar are not assigned as cause of all other symptoms at same time present.

In rachitis cases however few appearances more common.

But with every one [bestowing] [reflection] on subject, this considered only as consequence of that state of alimentary canal attending disease, being most favourable to [generation]

While however consider appearance of worms as happening only on this principle & while no probable grounds of conjecture as to cause are yet certain that has not arisen from [obstructed] discharge to which body habitual.

The cause of all that take place the most indicating evacuant.

While against those tender age of patient & debilitated condition strong objections.

But whatever true pathology of affection if some cases in which evacuation useful still more numerous instances in which benefits from tonics.

Can hardly indeed be supposed that diminishment of tone of system is immediate [cure] of softness or any other affection of bones.

Yet can easily conceive that increase of tone may be means of removing morbid state in which affection of bones depends.

But whatever principle of operation certain that from tonics often very great benefits.

With this view many different articles in use.

And particularly to be recommended used in those cases where system very much weakened.

Of all the tonics used in Rachitis none perhaps from which greater benefit in general derived than cold bathing

And especially when conjoined with friction.

To this therefore not improbable that may yet have recourse with present patient

But while so great quickness of pulse & other febrile affections some objections to it.

On this account determined first to make trial of another tonic.

Well known that this quality possessed by many articles of mineral tribe.

And by few to greater degree than preparation of Iron.

This metal whether in active form by acquiring saline state, by being dissolved in water or any other [menstruum] or by being exhibited in form of calx universally allowed to exert tonic powers.

Is with view then of obtaining these that here resolved to try it with present patient.

And of various forms of chalybeate had here recourse to Sal Martis or as is termed by Edinburgh College¹ the Sal chalybeate.

In this preparation the Iron brought to saline state by Vitriol acid.

And with infants where objections to taste of medicine as well as to large form one of best modes of exhibiting.

From ready solution in stomach are more sure of effects than when exhibited under form of Limatura or Rubigo [form]

While at same time from exhibition in small doses can obtain tonic without stimulating powers

But for avoiding latter caution in administration necessary.

And doses small at first to be gradually augmented till see to what extent can be taken without inconvenience.

Here at first exhibited only to extent of two grains.

United with crabs eyes more with intention of giving form & covering taste than with any other view.

Since that dose of Sal Martis [illegible] without any inconvenience.

And is intention if circumstances permit still farther to increase dose, & order more frequent repetition

On this course mean to continue patient unless interrupted by some particular occurrence till has had full & fair trial.

Yet although should not be found attendant with success after what already said of nature of case shall not be disposed to consider it as proof of inefficacy of medicine.

On other hand recovery may take place during use, in which has in reality no merit.

Yet if circumstances admit of continuation will afford us opportunity of marking effects.

Not improbable however that from supervening effects may be obliged to desert from employment.

And if that the case practices [must] be directed to circumstances then occurring

But if without such occurrence disappointed in effects have thought of [trial] of another practice with this patient.

Use viz of oil prepared from liver of skate fish.

Of this practice for my own part have no experience.

And deterred from employing it at first in this instance from considering case as very precarious one.

For to be observed that although an external application effects by no means [slight]

At least this representation given of it by those with whom chiefly employed.

On subject of use will find short paper in late number of medical commentaries

Said that from topical application excites temporary fever.

Or at least increased heat of system with quickness of pulse.

And is opinion of most observers of those who have had opportunity of witnessing use that by this fever disease cured.

Evidence therefore that if have effect [alleged] cautious administration requisite.

And upon whole though wish to try it yet look on present as no very favourable instance.

Hence then the having recourse to this trial must in good measure depend on circumstances of case at time.

And not improbable that in preference to it may direct cold bathing in which I own have no less confidence.

If tendency to curvature, & other present symptoms could be overcome, might next be objective to restore to bones their proper figure.

And for this purpose many [mechanical] contrivances have been proposed.

But may with confidence represent whole if not as pernicious at least as dangerous.

For where not defective in contrivance yet often so in application.

Hence then unless by particular modes of exertion nothing in ways ever to be thought of.

And from dangerous tendency of present case very doubtful whether [direction] even in this way ever requisite.

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Explanatory notes:

1) The Royal College of Physicians of Edinburgh, established in 1681.