DEP/DUA/1/32/03 (Normalised version)

John More

(1783)

---

John More. May 22

History of this patients case in my opinion affords example of an affection both singular & important

Cannot however represent it as an affection which have never before seen.

For about two years ago this patient under care for same complaint

And at that time as may indeed infer from history now read, symptoms much more alarming

But besides present patient, on former occasions, since began practice in Edinburgh have treated five or six patients labouring under what I think same affection

First of these [cases] which fell under my care with some [observations] concerning I published some years.

But after all must acknowledge that both with regard to name & nature of affection not without [doubt].

Disease whatever may be proper name or real nature in my opinion has been by no means considered by practical writers with that attention which it deserves.

Am inclined to think that this has in some measure arisen from being confused with an affection to which in some respects resembles viz Scorbutus Or Sea Scurvy

At same time, from full consideration of circumstances, can have little doubt in determining it to be very different disease.

And that not merely with respect to symptoms & causes, but also with regard to method of cure.

In symptoms indeed to which patient now & formerly subjected several in which must be allowed, strong resemblance to scorbutus.

Thus one of principal parts of complaint haemorrhages.

And these have not merely taken place from nose but also from other parts, especially when subjected to slightest injury.

And while copious haemorrhage took place from very slight cut in lips said also to have taken place spontaneously from other parts of Gums.

Nay told that gums have at times been observed to have spongy appearance

This however for my own part I have not seen.

And at present at least, when under care are apparently sound.

Whether such an affection however, has or has not taken place, in other circumstances mentioned & with regard to which no doubt, have evident resemblance to Scorbutus.

For Scorbutus when occurs not more remarkably characterised, by any circumstance, than by bleeding of Gums.

In so much that stomaccace by many considered as an essential & characteristic symptom of the affection.

Besides this, another symptom resembling scorbutus in large livid [blotches] in different parts of body.

These at present constitute principal symptoms to which our patient subjected.

And are also an [appearance] resembling what takes place in Scorbutus.

For maculae lividae flavae & purpura. enter definition & description of this disease by best practical writers.

In these respects then in present case symptoms of Scorbutus.

But when pay due attention to history of Scorbutus can by no means consider our patient as subjected to that disease

And from consideration of history of that affection, unsurmountable objections to the supposition.

In first place may observe that circumstances here taking place [ Hom] & Maculae by no means peculiar to Scurvy

Occur at least to equal, if not to greater degree, in typhoid fever.

And as shall afterwards have occasion to suggest, may probably arise from very different causes.

Hence then as here occurring grounds only for presumption.

And this presumption in my opinion much more than outweighed by other circumstances.

Strong objection to that supposition from age of patient.

Our patient, yet only at very early period of life.

Scorbutus however a disease when remarked to occur principally, if not entirely with adults.

And indeed to these must be in great measure confined, from causes by which observed to be induced.

Has particularly arisen, from long continued use of salted animal food.

But even this will have no effect, if at same time recent vegetable [aliment] to be had.

And for my own part know no well authenticated instance scorbutus prevailing where any considerable proportion of recent vegetable food to be obtained.

Accordingly as having from this cause chiefly occurred in long voyages has got name of Sea Scurvy.

Although at same time certain that will equally occur on shore where same cause operates, as in garrisons besieged.

And that too in places, where except recent vegetables, great abundance of provisions of every other kind.

And where even in times of much greater scarcity, while recent vegetables were not wanting, disease unknown.

If therefore in age & situation of patient strong objections to supposition of Scorbutus, still more from circumstances of diet

Food on which our patient has hitherto been supported has consisted chiefly of milk & [farm] vegetables.

With this for some time past, has been conjoined once a day, fresh meat & fresh animal broth.

With such diet has been [supplied] in sufficient abundance.

And perhaps has hardly during whole course of life, ever even tasted salted meat.

Hence then from absence of what may justly be reckoned great cause of Scorbutus & from presence of what may be esteemed certain [prevailing] strong objections to that supposition.

But besides these particulars no less strong objection, from due attention to symptoms of Scorbutus.

Strong objection from state of Gums

These whatever may have been formerly case with our patient now perfectly sound.

As very first symptom of Scorbutus these assume morbid appearance.

Prior to any haemorrhage observed swelled & separated from teeth

Have soft spongy feel & livid colour

And discharge of blood rather in form of gentle oozing, from slight injury, than of proper haemorrhage.

Such a state continued throughout whole course of affection.

With our patient however no such appearance.

And as far as I have been able to observe never did take place

Another of most characteristic & leading symptoms of scurvy, foul ulcer in different parts yielding ichor sanies

And indeed in most instances the livid [illegible] [illegible] in vesicles [forming] such.

With present patient however no such appearances have occurred.

A third leading symptom in Scorbutus here wanting oedema swelling of legs.

Such a state rarely absent in that affection.

Nay often even extended over greater part of body.

Of such an affection however no appearance in present case.

Nor indeed during whole course of it although has now subsisted for several years.

During that period should have expected symptoms of even most advanced stages of Scorbutus.

Greatest prostration of strength, deliquium animi [solution] of [continuation] etc.

But in place of these on accidental fracture with our patient callus very readily formed.

Hence then notwithstanding resemblance in some particulars to Scorbutus no hesitation in asserting that patient not subjected to that disease

But besides Scorbutus another disease also to which present case some resemblance.

Haemorrhage & vibices such as described in history of this patients complaint often attendants of worst kinds of putrid fever

And now some other symptoms have taken place which may also be considered as indicating febrile state

Particularly quickened pulse, & increased heat.

But in as far, as fever even now takes place, hold it to be merely symptomatic.

And of this I think strong evidence in absence of a symptom, which am inclined to consider as great characteristic of all idiopathic fevers.

viz a peculiar uneasy feeling which as being a simple idea, does not admit of description or definition, but which everyone, who has had misfortune to be subjected to fever, cannot fail to remember.

To this symptom of fever, the title of anxietas febrilis, may I think with greater propriety be applied than any other

Consider its presence as stronger indication of fever than either debility, increased heat, quickness of pulse or any other symptom

Look upon its absence as strong evidence that other febrile appearances when occur merely symptoms.

And that proper idiopathic fever has not taken place.

Here however into characteristic symptoms of fever is not our business to enter.

May only observe that from circumstances of anxietas febrilis being still absent may conclude that patient not affected with idiopathic fever.

But whatever case at present could never consider disease as having been a fever of typhoid type.

For to this supposition, continuation alone, unsurmountable objection.

Patient subjected to affection even for upwards of year.

And during greater part of that time, has been unattended with any symptoms which could be considered as febrile. Still less reason therefore, for referring it to this genus than to Scorbutus.

Next to [these] may mention haemorrhage to which during course of affection patient so often subjected.

And of which still frequently threatening

These two excepted however know no genus entering practical or nosological¹ systems to which any resemblance.

Have thus therefore endeavoured to say what disease is not. Will occur however as more difficult matter to determine what it is.

But here may observe that is a matter of much less importance to [affix] proper name than to determine nature of disease, or morbid affection from which symptoms to be explained.

And with regard to latter may I think from [appearance] form if not certain yet probable conjecture.

Of these symptoms what may be considered as principle if not sole [constants] of affection at present are large livid blotches, or vibices, obvious on different parts of body.

Both according to account given us began at very early period of life, & have now continued for considerable length of time.

May therefore conclude that are the effect of same cause.

With regard to bloody discharge under form of haemorrhage, well known that may be either of active, or passive kind.

Former depends on quantity of blood & state of motion.

Latter on condition of blood, & state of vessels

With regard to livid blotches less variety of causes.

These universally the effect of red globus of blood, being effused into cellular membrane & there broken down.

This however occurring at so many different parts, must necessarily conclude to depend on condition of blood.

From being in what may be called dissolved state, with many of red globus broke down, in circulatory mass, will naturally make way where otherwise could not find access.

In this manner then would explain occurrence of livid blotches.

And after being thus produced again disappear without sloughing in consequence of matter effused being absorbed.

While from this state of blood would explain vibices or blotches to same also would refer haemorrhage.

No circumstance of the case which can be considered as giving any countenance to supposition of being of active kind.

And age of patient, as well as continuation, strong objection to it.

While at same time, connection with vibices, gave even from beginning strong evidence of dependency on condition of fluids.

But this I think put beyond doubt by an occurrence which took place about time when this patient came formerly under our care.

From accidental fall upper lip was cut on its inside against teeth, & at same time probably gum of upper jaw somewhat bruised.

From this cut although slight bloody discharge continued for whole night

And lost both from this & from gum of upper jaw very considerable quantity of blood.

In so much that induced strong symptoms of inanity, remarkable paleness & transparency of surface in general, but particularly of those parts, in neighbourhood, which naturally derive red colour from blood example lips.

These sometimes appear to me as pale as commonly case in deliquium animi or even on approaching death when circulation in extreme vessels has entirely failed. From these circumstances then undeniable evidence that not of active kind.

+ Same also evinced by state in which blood observed to be discharged since that time. But although both conditions here occur, Yet are by no means necessarily connected.

Texture of Globus may be broken down through gluten still power of coagulating.

And disposition in gluten to coagulate may be diminished while red globus not affected.

Want of attention to this circumstance has in my opinion led Dr Milman in late Enquiry concerning Scurvy into many mistakes.

For constantly infers because marks of coagulation that blood cannot be said to be in dissolved state.

Notwithstanding this however cannot be doubt that many of red globus may be broke down & diffused in serous.

But though these states may occur separately yet often, as in present instance, [evidence] of [taking] place together

In long continuation of discharge from so slight a wound & even from part merely bruised have strong evidence both of [dissolved] state of red globus & also of want of disposition to coagulation in gluten.

To this condition of fluids then would attribute principal constituent of affect vibices & haemorrhage.

And from haemorrhage are to explain most, if not all of appearances, which have supervened, since commencement of affection

This then idea as to nature of present affection.

Must however observe that morbid condition here supposed to take place may occur from very different causes.

From experiments of Mr Hewson appears that red globus may be broken down in different ways.

By increase of saline matter in [menstruum] are shrivelled, contracted & broke inwards.

By increase of water assume spherical [figures] are distended & broken outwards

Power of putrescent process as destroying texture of globus evinced by [number] experiments.

That in living animal system in [state] of health, constant tendency to it, undeniable.

And that in disease this septic tendency may be augmented, can never I think be questioned.

O For in my opinion Typhus to be considered merely as simple fever with which [putrescence] tendency conjoined.

And this I think evinced by observing fever connected with inflammatory disposition at commencement & putrescence towards conclusion.

Septic process however to uncommon degree may also occur without fever

Either of these causes of destruction may unquestionably take place in vessels of human system.

But of all causes operating there, no one more frequently produces dissolved state, than putrescent tendency.

And while to increase of saline matter would attribute partial destruction of Globus texture in scorbutus, to putrescent process would attribute dissolution in Typhus fever.

Accordingly Petechiae vibices & haemorrhage are there frequently produced.

But although putrescent process in fluids, may arise to this height in typhus fever, may also occur without it.

O

To this then as most common cause of dissolved state of blood am here disposed to attribute it.

Thus then have stated opinion with regard to nature of morbid affection to which patient subjected.

And may again add as formerly [observed] although consider it to be rare disease yet is not only instance of the kind which have had occasion to treat.

In former practice have treated several instances where supposed disease to depend on similar morbid state of fluids.

First of these which occurred to me about five years ago will find published in Volume of Medical cases selected from records of Public Dispensary².

And in [observations] subject have quoted description of similar affection by Dr Graaf of Gottingen in a Dissertation of his entitled De Petechiis sine Fibre³.

In that case, the first instance of this affection which occurred in my practice, symptoms in many respects by no means so alarming as have been at different times with present patient

Yet not only vibices & haemorrhage, But also very copious petechial eruption.

And from this circumstance as well as from Dr Graafs description imagined that might bestow upon it title of petechianosos or morbus petechiales

That is a disease characterised by Petechiae.

To others which have since occurred to me, same appellation might have been applied with sufficient propriety.

But in present instance there is not now, nor as far as can learn, has there ever indeed been any appearance of Petechiae

Notwithstanding this however, from [corresponding] what said of present case, with observations added to case of Jean Allen, you will readily discover, on what grounds I consider them as instances of same affection

With regard to remote causes, by which morbid condition of fluids constituting this disease induced, are totally at loss

But may mention it as a very singular circumstance that same parents have before lost three male children of same affection.

While females of family have never had any symptoms of it.

For this peculiarity must own I can offer no explanation which appears to myself in any degree probable.

Yet is a fact with regard to which mother of child cannot I think be mistaken.

At same time, hardly possible to conceive, any reason which can have for wishing to deceive us in this particular.

Is but proper therefore to mention it as a circumstance deserving attention in future instance.

And after these observations on nature of this patients disease next prognosis.

Here must own that from several circumstances very apprehensive of fatal termination in the end

Should be disposed to apprehend danger from idea which have given of nature of affection.

If conjecture as to primary morbid affection which here occurs well founded may conclude that patient liable to be cut off in different ways.

But at same time must observe that in every instance more certain judgement of events to be formed from facts than from reasoning.

And whether opinion of nature if in all former instances affection had terminated favourably should have been disposed to hope for same conclusion in present case

Cannot however pretend that this has happened, even in few cases falling under own observation.

First indeed had successfully terminated.

And not long after was carried to see another, treated by Mr Anderson surgeon at this place in which similarly terminated.

But another case which occurred not long after in my own practice, had fatal termination & that too in very sudden manner

From this then inclined to consider no instance as free from danger.

And if in any case danger to be apprehended was so in present.

For not only have symptoms gone to great height but other children of same family have already fallen victims to the affection.

Of these according to account given by mother one died by haemorrhage from nose.

Another by haemorrhage from small accidental cut in brow by stone thrown at him by one of his companions.

Although cut very inconsiderable & although treated with great attention by a respected surgeon in Edinburgh yet haemorrhage could not be effectively stopped

When patient formerly under our care symptoms much worse than at present.

And may again be dismissed if not with complete cure at least with temporary relief

From time to time broke out till at last from excessive discharge patient who had arrived at eighth year of age, reduced to utmost state of exhaustion, attacked by fever from which soon cut off.

Such an event here rather to be dreaded from tender age of patient & state of great exhaustion which has already taken place.

Besides which febrile symptoms have also occurred to no inconsiderable degree

Upon whole then from every view of case reason for apprehending danger.

At the same time am far from looking upon it in light of desperate case.

In this case from what have said of nature of effect will readily understand principles on which disposed to conduct practice.

Upon supposition that principle morbid affection consists in dissolved state of blood, from strong tendency to replicate process what naturally presents itself as most important objective is the correcting this state by Antiseptic.

And as such have had here recourse to Vitriolic Acid one of more powerful with which am acquainted.

That this may have fair trial without any chance of hurting stomach from load of medicine has hitherto been employed alone.

During that period symptoms upon whole rather diminished.

For notwithstanding threatening appearance at last report no haemorrhage has ensued

And when I very lately saw this patient only remarkable [illegible] in scrotum.

Greatest part of which indeed same appearance as might be supposed to be consequence of [illegible] from violent blow or the like.

On this medicine then, unless new occurrence shall lead us to change plan, is [intention] to continue regularly for some time.

And expect more from persisting in use than from [throwing] in to great quantity at once.

Accordingly from this circumstance joined to tender age of patient am giving it in more diluted state than [illegible].

Only viz to extent of ℥i of strong acid in ℥IV of water.

And this taken to quantity of tea spoonful four times a day.

In this way however have had satisfaction of finding that agrees very well with stomach.

Is therefore intention to persist in it without alteration.

And may I hope in end be attended [with] good effects.

If however this shall not be the case must accommodate future measures to circumstances which may afterwards take place

---

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) 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).

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