DEP/DUA/1/11/16 (Normalised version)

Johan Scott

(1776-1777)

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Johan Scott

To disease little difficulty in affixing name

Is indeed affected with various complaints attendant of several genera.

Example debility, nausea, flatulence.

Can be no doubt however that all in present case from same origin.

Effects viz of debilitated system from excessive haemorrhage

For with this patient menses returns at shorter periods than usual.

When returns continue for uncommon length of time.

And during that discharge excessive

Little doubt then in pronouncing this case immoderate flow of menses.

Or in language of Nosologists¹ Menorrhagia.

Besides symptoms already mentioned patient affected with frequent transitory pains.

These from history evidently connected with disease

For occur chiefly preceding menstrual period.

And only remarkable when discharge does not occur at usual time.

Pains of this nature however frequently attendants of Menorrhagia.

In so much that by some introduced among diagnostic systems

But without considering them as essential are at least common.

And in place of giving doubt corroborate opinion.

As to name therefore little ambiguity.

In order to give either probable prognosis or lay down reasonable plan of cure must go farther.

These only to be derived from peculiar nature of case before us.

For under genus of Menorrhagia very different affection included.

And above all particularly necessary to determine whether haemorrhage of active or passive kind.

In latter case endeavours to restrain it in great measure necessary.

In former would often be attended with worst consequences.

For haemorrhaging to be considered as natural cure in such cases

In nature of uterine haemorrhage however remarkably peculiar.

And cannot disjoin consideration from that of menstrual.

Of theory of this function, very lately elsewhere occasion to treat.

While every other physiologist however would explain diseased states on his own doctrine must beg leave to go on supposition of truth of what lately delivered.

In this view then must consider all increased discharge as from one of three causes.

1 Uncommon determination to uterus

2 Increased action of that viscus or its vessels

3 Want of due resistance to impetus of blood at uterus.

To inquire then to which of these causes here to be referred.

Or how far different principles concerned.

First may be considered as giving haemorrhage now purely of active kind.

Last more particularly passive.

While remaining one may be considered as of intermediary nature.

Will evidently therefore lead to different practices.

Hence material to distinguish to which to be referred.

This to be done on one of two principles.

Either from causes inducing complaint or from concomitant circumstances.

In present instance first of these no light.

For not referred to any particular causes.

Are merely told that succeeded nursing.

During which period menses for most part wanting.

As then probably from anastomosis vessels real abstract of blood from uterus itself.

And never could be supposed to have tendency in inducing profluvia.

If therefore allowed to conject would be induced to go farther back.

And would look for it during state of pregnancy or delivery.

As well known that at these periods state of uterus & vessels very greatly affected

This however must consider as merely conjecture.

And must look for ascertaining question on last circumstance viz concomitant appearances.

On this ground then to take view of each in order.

Uncommon determination to uterus, first general cause of Menorrhagia sometimes from particular local affection.

Such for example as causes [retained] flow of blood into neighbouring vessels.

Hence [compress] of these useful remedies for restoring obstructed menses.

More frequently affect of general fatness.

Hence menstrual discharge accelerated & increased by high & plentiful living etc.

Of neither one nor other however any evidence in present case.

Circulation through inferior extremities same as usual

And every mark of general plethora absent

No tendency to drowsy or lethargic state.

No general sense of weight or fullness.

No turgescence or florid complexion.

No general haemorrhagic tendency

On contrary from paleness, delicacy & debility room rather for suspecting inanity.

Hence upon whole for supposition here of uncommon determination to uterus very little foundation.

2^nd General cause increased action of uterus.

Of peculiar action of this viscus reckon necessary to account for menstrual discharge.

Such an action unquestionably takes place at certain period of pregnancy.

And is then cause of delivery in some measure also of lochial discharge.

If however a natural action, that may be subjected to morbid condition not to be questioned.

And that these attended with preternatural state of discharge both as to time & quantity not to be doubted.

Such inordinate action may be considered as affection of Nervous kind.

May therefore be induced by all variety of causes giving rise to these.

And when present will be chiefly indicated by pain & irregularity in period of discharge.

Well known that temporary spasmodic contraction beginning in uterus propagated to neighbouring parts.

Such always the nature of labour pains unless in as far as the effect of distension.

Such frequently precede delivery with people of delicate habits for considerable time.

Such often described as attendant of Menorrhagia

And such for description given would seem to be the pains marked in present case.

Cannot help thinking therefore that strong presumption as to existence of this cause.

And when farther add short intervals between menstrual this presumption much corroborated.

Especially as when postponed to ordinary interval pains particularly severe.

Must conclude therefore that here an inordinate action of uterus takes place

And probably to degree sufficient to account for all symptoms.

But existence of this cause does not preclude others.

Remains therefore yet to inquire how far last cause can be supposed considerable.

viz. Want of due resistance to impetus of blood at the uterus.

Of all other causes of Menorrhagia perhaps most common.

And induced by various accidents either relaxing system in general or uterus in particular.

Product also of various morbid affections of uterus as cancer ulceration etc.

When such therefore multiplicity of causes not surprising that should be frequent occurrence.

And do not doubt that to some degree may take place in present case.

Of this even some presumption from continuation of discharge.

And from quantity to which occurs.

For while resists considerable inordinate action will never give very great discharge.

But on other hand no reason to presume that laxity sole cause.

Otherwise many of present symptoms would be wanting.

And patient not from thence affected with pains so distressing to her.

Some presumption even that laxity to no very considerable degree.

For patient as far as we can learn not affected with fluor albus.

Hence although bloody evacuation of considerable continuation, would appear that after most powerful causes removed, resistance to passage of fluids sufficient to prevent any other discharge.

And consider continuation of discharge in form of Leucorrhoea to be even stronger mark of laxity, than large evacuation of blood.

Upon whole then idea of this complaint is that may in some measure be affect of diminishing resistance to blood at uterus.

But that principally the effect of inordinate action

Thus would consider it to be in great measure a nervous affection.

On this supposition must own that am greatly at loss with regard to prognosis.

After all attempts to illustrate nervous affection still much at loss with regard to them.

And particularly respecting termination much in dark.

Have no fixed or determined course.

Perhaps in general indeed continuing [proportion] to severity

Yet where seemingly slight will often be very obstinate, resisting all attempts to cure

And where most terrible will often suddenly disappear

Would not therefore be surprised if present patient even very suddenly recovers.

Will not be astonished if continues obstinately in spite of all that can do to remove it.

And this last event reckon of the two the most probable.

Disease has already remained for very considerable time

Even for space of several years.

During that period no tendency to mitigation

On contrary rather increase than diminishment of symptoms.

And debilitating nausea etc induced as sequel of former

Farther to be observed that has already used many remedies.

And may reasonably presume none of least powerful.

When therefore has resisted these less to be expected from others.

Nor on other hand any great prospect of natural cure

This might indeed be in some measure expected at time when system undergoes revolution.

Example period when menses usually leaves women

But with our patient this probably very far distant.

As hitherto but little past 20^th year.

Another circumstance indeed from which natural cure might sooner be expected.

As suppose morbid affection of uterus in great measure induced by one pregnancy might be removed by another.

Were patient in present situation to fall with child would probably give some temporary cure

But besides that husband now dead appears that very little chance for this even from second marriage.

Her complaint indeed such as in some respects not unfavourable to pregnancy.

But in others very much against it.

And while inordinate action giving pains resembling labour continues would be constantly exposed to danger of abortion.

Even pregnancy for natural time although giving some chance of cure might yet have very opposite effect.

And in place of removal might greatly aggravate disease.

Upon whole then probability I think is that present affection will be tedious.

At least if patient does not in short time fall victim to it.

Will naturally therefore occur as second question how far ought to be considered as dangerous.

And must own that am far from being without apprehension.

By no means rare to find this disease terminating fatally from immediate affect of quantity of discharge.

And in proportion to continuation always great danger of this

As thus resistance at uterus diminishing of course

Evacuation hitherto at least however not to such extent as to give any immediate danger of this.

And more to be apprehended from influence of long continuing evacuation on system.

In this way has already debilitated constitution

And by continuation may at last sink under it

Yet without some unexpected alteration of symptoms would fain hope that may not happen suddenly.

And that may at least have opportunity of trying different remedies.

Must however observe that here very much at loss both with respect to general plan of cure & particular remedies.

From view given of complaint inclined to consider it as chiefly of Nervous kind.

Hence neither to be properly combated by evacuation the cure for haemorrhages of active kind depending on stimulation of plethora.

Nor by astringent the cure for those of passive kind depending on rupture or relaxation.

Is not an affection connected with any state of Nervous system in general.

Hence neither suited to common means of cure in cases either of mobility or torpor.

But considered as an affection both local & at same time peculiar.

Hence without farther knowledge of laws & properties of Nervous system must be in great measure in dark respecting rational plan of cure.

Here our inquiries carry us no farther than to have recourse to those remedies observed most useful as restraining inordinate motions.

But with many of these very great difference.

For greater part of them to high degree either stimulating or sedative.

And from both one & other of these affects evils to be dreaded.

In such case therefore can hardly from reason venture to say, what will or will not agree with patient.

And must rather be regulated by trial.

Was on this ground that had recourse to Peruvian Bark.

Among other medicines taken by patient before came under care bark also employed.

And had been found product of good effects.

Thought therefore that by continuation & increased quantity some chance of cure.

And is one of those medicines which under prudent management may I apprehend be given to greater extent than is commonly the case

Thought also of conjoining it with more powerful astringents.

But neither one nor other have answer to wish

For from vitriol acid complains of swelling in belly, increase of pains etc

And from increased dose of bark complains of still worse consequences.

Do not question that both one and other medicine may have given some inconvenience.

Yet can hardly think affects so great as she disposed to represent.

And besides all other difficulties am afraid have another to combat in this case.

Have no doubt respecting reality of patient’s complaint.

Yet cannot help thinking that has natural disposition to aggravate description of every little alteration.

And that of timorous & suspicious temperament.

Hence will be led to ascribe to medicine, affects by no means following from them.

And will probably find great difficulty in getting her to make proper trial of any medicine.

If however can easily be affected shall yet wish to give farther trial to bark.

And if stomach will not bear large doses attempt to augment quantity by more frequent repetition.

May perhaps even alter form or conjoin present with some other

Example giving powder of bark in watery infusion of it combined with some aromatic or Orange skin

If bark fails have thoughts of trying at time of discharge the effects of anodyne medicine.

These indeed in greatest number of cases rather tend to augment discharge.

Hence those of female sex accustomed to frequent use of opiates, as well as those [illegible] in too free use of spirit.

But in present inclined to think that would have contrary affect.

And should it even produce more free discharge might yet be of consequence as giving relief of pain

From trial already made disposed to think that more to be expected from sedatives at this time than from astringents.

Yet during intervals of menstrual would chiefly look for radical cure from Tonics.

And failing bark have thoughts here of trying calx of Zinc.

Probably combined with some medicine of tribe distinguished by title of Nervous as Radix Valerian.

Should this also fail would I own be disposed to recommend to patient trial of cold bathing

And although would require continuous management yet I own should not be without expectations from use.

But from what have already said of patient’s temperament may easily propose more than will ever have opportunity of properly trying.

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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.