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

John More

(1783)

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John More. May 22

Hist of this pat case in my opin affords examp of an affect both singul. & import

Cannot however repres it as an affect which have never before seen.

For about two years ago this patient under care for same affect compl

And at that time as may indeed inferr from hist now read, symp much more alarm

But besides pres. pat, on former occas, since began pract in Edr have treated five or six patient lab. under what I think sam affec

First of these [cases] which fell under my care with some obs. concer. I pub. some years.

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

Disease whatever may be prop. name or real nature in my opin has been by no means consid by pract writers with that attent which it deserves.

Am inclind to think that this has in some meas arisen from being conf. with an affect to which in some respects resemb. viz Scorb. Or Sea Scurv

At same time, from full consid of circum, can have little doubt in determ it to be very diff. dis.

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

In sympt indeed to which patien now & formerly subj. several in which must be allowed, strong resemb. to scorbut.

Thus one of prin parts of compl. haemmorr.

And these have not merely taken place from nose but also from lips other parts, especially when subj to slightest injur.

And while copious haemmor. took place from very slight cut in lips said also to have taken place spon. from other parts of Gumms.

Nay told that gums have at times been obs. to have spungy app

This however for my own part I have not seen.

And at pres. at least, when undr care are app. sound.

Whether such an affect however, has or has not taken place, in other circum ment. & with regard to which no doubt, have evid resemb. to Scorbut.

For Scorbut when occurr. not more remark charact, by any circum, than by bleeding of Gums.

In so much that stomaccace by many consid as an essent & charact sympt of the affect.

Besides this, another sympt resemb. scorbut in large livid [blotch] in diff parts of body.

These at pres constit prin sympt to which our patient subj.

And are also an app. resemb. what takes place in Scorbut.

For maculae lividae flavae & purpur. enter defin & descript of this disease by best pract. writers.

In these respects then in pres case sympt of Scorbut.

But when pay due attent to hist of Scorbut. can by no means consid our pat. as subj to that disease

And from attent to consid of hist of that affect, unsurmount. obj. to the suppos.

In first place may obs. that circum here taking place Hom & Maculae by no means pecul to Scurvy

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

And as shall afterwards have occas to suggest, may prob. arise from very diff causes.

Hence then as here occurring ground only for presumpt.

And this presumpt in my opin much more than outweighd by other circum.

Strong obj. to that suppos from age of pat.

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

Scorbut. howevr a disease when remarkd to occurr prin, if not entirely with adults.

And indeed to these must be in great meas. conf, from causes by which obs. to be induced.

Has partic arisen, from long contin use of salted anim food.

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

And for my own part know no well authentic inst whereof scorb. said to prevailing where any consid prop of recent veget food to be obt.

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

Although at same time cert. that will equally occurr on shore where same cause oper, as in garris besieged.

And that too in places, where except recent vegetab, great abund of prov. of every other kind.

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

If therefore in age & situat of pat. strong obj to suppos of Scrobut, still more from circum of diet

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

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

With such diet has been supp in suff. abund.

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

Hence then from absence of what may justly be reckond sole great cause of Scrob. & from pres of what may be esteemed certain [prev] strong obj. to that suppos.

But besides these partic no less strong obj, from due attent to symp of Scorbut.

Strong obj from state of Gum

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

As very first sympt of affect Scorbus these assume morbid app.

Prior to any haemorh. obs. swelld & separ from teeth

Have soft spungy feel & livid colour

And disch of blood rather in form of gentle ouzing, from slight injur, than of prop. haemorrh.

Such a state cont. throughout almost whole course of affect.

With our patient howevr no such app.

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

Anoth of most charact & leading sympt of scurvy, foul ulcer in diff part. yeilding ichor sanies

And indeed in most inst. the livid [illegible] [illegible] in vesic [forming] such.

With pres patient however no such app. have occured.

A third leading sympt in Scorb. here wanting oedem swelling of legs.

Such a state rarely absent in that affect.

Nay often even extended over great part of body.

Of such an affect however no app. in pres case.

Nor indeed during whole course of it although has now subsist. for sever years.

During that period should have expected sympt of even most advan stages of Scorbut.

Greatest prost. of strength, deliq anim solut of contin &e.

But in place of these on accid fract. with our pat callus very read. formd.

Hence then notwith resemb in some partic to Scorb no hesit in assert that pat. not subj to that disease

But besides Scorbut anoth disease also to which pres case some resemb.

Haemorrh & vibices such as descr. in pres case hist of this pat. compl often attend of worst kinds of putrid fever

And now some other sympt have taken place which may also be consid as indic febrile state

Partic quickened pulse, & encreased heat.

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

And of this I think strong evid in absence of a sympt, which am inclind to consid as great charact of all idiopath fever.

viz a pecul uneasy feeling which as being a simple idea, does not admit of descript or definit, but which every one, who has had misf to be subj to fever, cannot fail to remb.

To this sympt of fever, the title of anxietas febrilis, may I think with greater prop be app than any other

Consid its pres as stronger indicat of fever than either debilit, encr. heat, quickness of pulse or any other sympt

Look upon its absence as strong evid that other febr. sympt appear when ocur merely sympt.

And that prop idiopath fever has not taken place.

Here however into charact sympt of fever is not our busin to enter.

May only observe that cause from circum of anxiet febril being still absent may conclude that patient not affected with idiopath fever.

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

For to be observed that this suppos, contin alone, unsurm obj.

Patient subj to affect even for upwards of year.

And during greater part of that time, has been unattend with any sympt. which could be consid as febrile. Still less reason therefore, for referring it to this genus than to Scorbut.

Next to [these] may mention haemorh. to which during course of affect pat. so often subj.

And of which still freq threatning

These two except. however know no genus entering practic or nosol. system to which any resemb.

After Have thus therefore endeav to say what disease is not. Will occ however as more diffic matter to determ what it is.

But here may observe that is a matter of much less import to [affix]. prop name than to determ nature of disease, or morbid affect from which sympt to be explaind.

And with regard to latter may I think from app. form if not cert. yet probab. conject.

Of these sympt. what may be consid as princip if not sole [const] of affect are the haemorrh or at pres. are large livid blotches, or vibices, obv. on diff parts of body.

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Both accord to acct given us began at very early period of life, & have now contin for consid length of time.

May therefore concl. that are the effect of same cause.

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

Former depend on quantity of blood & state of motion.

Latter on condit of blood, & state of vessels

With regard to livid blotches less variety of cause.

These univer. the effect of red glob of blood, being effused into cellul membr. & there broken down.

This however occurring at so many diff parts, must necess concl. to depend on condit of blood.

From being in what may be calld dissolvd state, with many of red glob broke down, in circul mass, will naturally make way where otherwise could not find access.

In this manner then would exp. occurr of livid blotches.

And after being thus prod again disapp. without sloughing in conseq of matter effused being absorbd.

While from this state of blood would expl. vibices or blotches to same also would referr haemorrh.

No circum of the case which can be consid as giving any counten to suppos of being of active kind.

And age of patient, as well as contin, strong object to it.

While at same time, although entirely from partic part, yet connex with vibices, gave even from begin strong evid of depend on condit of fluids.

But this I think put beyond doubt by an occurr which took place the day before about time when this patien came formerly under our care.

From accid fall under upper lip was cut on its inside against teeth, & at same time probab. gum of uppr jaw somewhat bruizd.

From this cut although slight bloody disch contin for whole night

And since began treatm of case has lost both from this & from gum of upper jaw very consid quan of blood.

In so much that has induced strong sympt of inanit, remark paleness & transp of surface in gener, but partic of those parts, in neigh, which natur. derive red colour from blood ex. lips.

These have sometimes app to me as pale as commonly case in deliq anim. or even after on approaching death when circul. in extreme vessels has entirely faild. From these circum then unden. evid that not of active kind.

+ Same also evincd by state in which blood obs. to be disch since that time. But although both cond. here occur, Yet are by no means necess connected.

Text of Glob. may be broke down through gluten still power of coagul.

And dispos in gluten to coag. may be dimin while red glob. not affected.

Want of attent to this circum has in my opin led Dr [Milman] in late Enquir concern Scurvy into many mist.

For const. inferrs because marks of coagul. that blood cannot be said to be in dissolved state.

But Notwith this however cannot be doubt that many of red glob. may be broke down & diff in seros.

But though these state may occur separ yet often, as in pres inst, [evid] of [taking] place together

In long contin of disch from so slight a wound & even from part merely bruisd have strong evid both of [dissolvd] state of red glob. & also of want of dispos. to coagul. in gluten.

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To this condit of fluids then would attrib princip constit of affect vibices & haemorrh.

And from haemorrh. are to expl. most, if not all of app, which have since superveend, since comm of affect

This then idea as to nature of pres. affect.

Must however observe that morb. condit here supposed to take place may occurr from very diff causes.

From experim of Mr Hewson app. that red glob. may be broke down in diff ways.

By encrease of saline matter in menst. are shrivelled, contracted & broke inwards.

By encr of water assume spheric fig are distended & broke outwards

Power of putres process as destroying text of glob. evinced by numb. experim.

That in living anim system in [state] of health, const. tend to it, undeniab.

And that in disease this septic tend may be augm, can never I think be questiond.

O For in my opin Typhus to be consid merely as simple fever with which [putres] tend conj.

And this I think evinced by observ. fever connected with inflam dispos at comm. & putres towards conclus.

Septic process however to uncom. degree may also occurr without fever

Either of these causes of destruct may unquest take place in vessels of human syst.

But of all causes operat there, no one more freq. prod disolved state, than putres tenden.

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And while to encrease of saline matter would attrib dissol of blood partial destruct of Glob txt in scorbut, to putres process would attrib dissolut in Typhus fever.

And Accord Petechiae vibices & haemorrh. are there freq. prod.

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

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To this then as most common cause of dissolv. state of blood was am here disp to attrib it.

At same time no circum in case which could lead me to offer it on any other footing than as probab. conject.

Thus then have stated opin with regard to nature of morbid affect to which patient subj.

And may now again add as formerly [obs] althoug consid it to be rare disease yet is not only inst of the kind which have had occas to treat.

In former pract have treated three sever inst. where supposed diseas to depend on simil morbid state of fluids.

First of these which occurd to me about five years ago will find pub. in Vol of Medic cases selected from records of Pub. Disp.

And in observat subj. have quoted descript of simil affect by Dr Graaf of Gottingen in a Dissert. of his entit De Petechiis sine Fibre.

In that case, the first inst of this affect which occurd in my pract, sympt in many respects by no means so alarm as at pres. as have been at diff times with pres. patient

Yet not only vibices & haemorr, But also very cop. petech erupt.

And from this circum as well as from Dr Graaf descript imagind that might best upon it title of petechianosos or morbus petechiales

That is a disease charact by Petechiae.

To two others which have since occurrd to me, same appell might have been appl. with suff. prop.

But in pres inst there is not now, nor as far as can learn, has there ever indeed been any app. of Pet

Notwith this however, from [corrp] what said of pres. case, with obser. added to case of Jean Allen, you will readily discov, on what ground I consider them as inst of same affec

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

But may ment it as a very singul. circum that same parents have before lost three male child of same affect.

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

For this pecul. must own I can offer no explan which app to myself in any degree prob.

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

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

Is but prop. therefore to mention it as a circum deserv attent in future inst.

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

Here must own that from sever circum very appreh of fatal termin in the end

Should be disp to appreh danger from idea which have given of natr of affect.

If conject as to prim morbid affect which here occurs well founded may concl. that patient liab. to be cut off in diff. ways.

But at same time must observe that in every inst more cert judgem of event to be formd from facts than from reasoning.

And whether opin of nature if in all former inst affect had term. fav. should have been disp to hope for same conclus in pres. cas

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

First indeed had success. termin.

And not long after was carried to see another, treated by Mr Anders surgeon at this place in which simil termin.

But second anoth case which occurrd not long after in my own pract, had fatal termin & that too in very sudden mann

With event of third am not acqu. yet from what had seen in case ment above From this then inclind to consid no inst as free from danger.

And if in any case danger to be appreh. was so in pres.

For not only have sympt gone to great height but three other childr of same family have already fallen victims to the affect.

Of these accord to acct given by mother one died by haemorr from nose.

Another by haemorrh from small accid cut in brow by stone throw at him by one of his companions.

Although cut very inconsid & although treated with great atten by a respect surgeon in Ednr yet haemorr could not be effect stopt

When patient formerly under our care sympt much worse than at pres.

And may again be dismissd if not with compl. cure at least with tempor. relief

From time to time broke out till at last from excess. disch patn who had arrived at eight year of age, reduced to utmost state of exhaust, attackd by fever from which soon cut off.

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

Besides which febrile sympt have also occurrd to no inconsid degree

And would not be matter of surpr. even if patient already dead.

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

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

And in dimin of haemorr from lip allev of vomiting & retent of some sustin in stomach, appear. at least somewhat favourable.

In this case from what have said of nature of effect will readily understand prin on which disp to conduct pract.

Upon suppos. that prin morbid affect consists in dissolvd state of blood, from strong tenden to replic process what naturally pres itself as most import. obj is the correct this state by Antisep.

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

That this may have fair trial without any chance of hurting stom from load of med. has hither been empl alone.

During that period sympt upon whole rather dimin.

For notwith threatn app at last report no haemorh has ensued

And when I very lately saw this patient only remark [illegible] in scrot.

Greatest part of which indeed same app. as might be supp. to be conseq of [illegible] from violent blow or the like.

On this med then, unless new occr shall lead us to change plan, is [intent] to contin regul for some time.

And expect more from persist in use than from [through] in to great quant at once.

Accord from this circum joind to tender age of pat. 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 quant of tea spoonful four times a day.

In this way however have had satisf of finding that agrees very well with stom.

Is therefore intent to persist in it without alterat.

And may I hope in end be attend [with] good effect.

If howv this shall not be the case must accom future meas to circum which may afterwards take place