DEP/DUA/1/15/16 (Normalised version)

Janet McKenlie

(1777-1778)

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On Saturday last entered on consideration of case of Janet McKenlie.

Observed that principle symptoms with which this patient affected Cough, Dyspnoea. pain of breast, etc, were such as might either arise from Phthisis or Catarrh.

And that in other respects present affection at that state when these two disease very difficultly distinguished from each other

Among other characteristics from which in such situations most certain judgement may be formed one is the ascertaining matter [expectorated]

If merely mucus presumption of disease being catarrhal.

But if contains pus certainty [that] is Phthisis.

After pointing out uncertainty of various tests already proposed mentioned another which had at least appearance of being more certain than any of those.

That whatever had not then been able to put in practice with matter [expectorated] by this patient.

[Tongue] indeed not uniformly clean a circumstance commonly occurring with purulent expectoration.

But was so at point.

And then usually first observed to occur.

Patient complained that matter expectorated has disagreeable taste

Circumstances from which some presumption without seeing matter

Nor indeed had we ever seen it so as to be able to examine it in any way.

On Saturday last however brought us some of what expectorated that morning.

And from every particular inclined to conclude that contained no inconsiderable proportion of pus.

Colour & consistency such as might [readily] be purulent

With white & yellowish cast of pus, had at same time its usual consistency in such conditions.

And viscidity not so great as that of mucus

At least not uniformly viscid.

While at same time greatest viscidity in parts most transparent.

From circumstances of appearance alone then present.

But still more from smell.

Emitted even in recent state in which we received it an odour somewhat foetid.

And this [foetur] more considerable on burning

Supposition of pus farther corroborated by specific gravity

When put into glass of common water sunk to bottom

And remained there even when specific gravity of water increased by addition of salt.

Thus then from common diagnosis strong presumption

And this presumption confirmed by tests which mentioned at last lecture.

Put portions of it in separate glasses to one of which added Caustic Alkali Lixivium to other vitriol acid.

In both cases by aid of agitation an apparently intimate union soon took place

And in that with vitriol acid a change from white colour of pus, with [colour] transparency of acid, to blackish hue.

On addition of water in case of Caustic alkali these soon took place evidently precipitated to bottom.

Fluid above, which consider to be lixivium now diluted, still [suspending] part of expectorated matter which consisted of mucus, remained transparent.

Addition of water to solution in vitriol acid led to same conclusion.

Here also there took place an evident deposit to bottom of glass.

And had at least appearance of pus in as far as respects colour & consistency.

But besides this a more viscid & [tenacious] matter also separated.

This again [swum] on surface of the glass.

And considered it to be part of mucus of the expectorated matter which the acid in diluted state no longer capable of keeping in solution.

This then would appear to be test by which pus & mucus as existing in expectorated matter may be separated from each other.

And as indicating in case now before us the presence of both.

Must own therefore than from this second trial am still more convinced than before of certainty of tests propriety.

And from every circumstance may with confidence conclude that matter expectorated by [patient] does contain pus.

From this expectoration notwithstanding doubt in other respects can have no hesitation in pronouncing case to be Phthisis Pulmonalis.

Here however next occurs as question whether this only disease with which our [patient] affected.

Or whether to consider her as subjected to other diseases to which this has only supervened.

And here circumstances giving principal difference is want of menstrual discharge.

This with females at period of life to which occurs has arrived will know to be chief constituent of an affection distinguished in nosological¹ systems by title of Amenorrhea.

Want of menstrual discharge as taking place in Phthisis may occur in one of three ways.

Either may occur as cause of Phthisis, as consequence of it. Or as unconnected.

In first and last of these ways to be considered as proper idiopathic disease

In the other would look upon it to be only symptom of phthisis.

And indeed in this latter way does not take place till circulation in extreme vessels has every where also failed.

A circumstance particularly manifested by [appearance] of eyes transparency viz of conjunction [from] total want of red vessels.

An occurrence which has not yet to remarkable degree taken place with our patient

From these circumstances alone then should conclude that want of menstrual discharge not here consequence of Phthisis.

But this still more confirmed by date of complaint.

For of equal standing with other parts of her affection.

And indeed by her assigned as cause to which complaint to be attributed.

Must then here conclude amenorrhea to be idiopathic.

But does not from this follow that has had so great share in inducing affection as patient herself imagined.

No doubt that irregularity in menstrual discharge cause of many disorders in female oeconomy².

And particularly so when during flow causes operate giving sudden obstruction.

But if powerful cause of disease women not less apt to attribute much to it.

And sometimes blamed when in reality has no share.

This may even have been case with present patient.

For causes giving rise to obstruction of menstrual such also as might be supposed to produce affection of breast.

Well known that Phthisis often originates from simple catarrh

And that this frequent effect of exposure to cold.

But especially of partial exposure.

May therefore have here arisen from cause to which obstruction of menses attributed

That this really affect of accident to which ascribed by patient can I apprehend be matter of little doubt.

Perhaps indeed few circumstances, on which can put less reliance on account given by patients than in what say respecting causes obstructing menses.

When actually arises from pregnancy with unmarried Women often pretended that from other causes.

As thus hopes that by means used for restoration abortion may be procured.

From this then should perhaps be laid down as general rule never to put [implicit] reliance on account of unmarried patients respecting this particular.

But to judge also from other circumstances.

And particularly to determine from presence or absence either of marks of pregnancy or of other affections.

In instance before us while no appearance of pregnancy have certain indications of [diseased] state in other respects.

And cause to which obstruction ascribed well known to be very powerful means inducing it.

With many women a common practice [constructed] to promote this discharge by [illegible] at every period.

And this may suppose operates only in consequence of heat.

From fact alone then influence of [this] circumstance here mentioned as affecting menstrual discharge put beyond doubt.

Nor is it difficult to conceive on what principle operation of cold as producing this affection to be accounted for.

This explanation indeed must be in some measure connected with cause on which suppose menstrual to depend.

But on every theory admitted that discharge from vessels whose mouths either expand or whose sides rupture.

Hence may be checked by [constriction] indeed.

And this will be necessary consequence of cold in cases of menstrual evacuation as well as of other haemorrhages.

On supposition that menstrual from general plethora, by this means blood which ought to be discharged retained in circulatory mass.

And on supposition which have [elsewhere] endeavoured to establish nearly same thing will also occur.

Cause of obstruction here would operate merely as impeding exit of blood by usual course.

But from action of uterus, blood accumulated in vessels not [finding] exit by natural passage again forced into system.

Thus then would operate as giving tendency to plethoric state.

And thus imagine amenorrhea [concerned] in [inducement] of Phthisis.

Have thus then delivered opinion respecting disease to which suppose this patient subjected.

Consider most material part of complaint to be Phthisis pulmonalis.

And this conjunction with Amenorrhea not as symptom of Phthisis but as idiopathic [disease].

And indeed as having had some [share] in inducing Phthisis.

Progress from opinion delivered respecting nature of this affection must unquestionably be by no means favourable.

Phthisis when distinctly marked in general [reputed] an incurable affection.

To this opinion however although convinced that is a most dangerous disease can by no means entirely agree.

And even where cannot be cured by art will yet in some cases have natural termination in recovery.

Of instances having fatal conclusion most certain are perhaps to consider those originating from scrofula.

And in such if expectoration of matter is rather bloody sanies than proper pus.

And is chiefly to absorption of such that are I apprehend to ascribe Hectic fever.

Where mild & bland pus formed no reason to dread any peculiar bad [affect] because from lungs more than other parts.

And where opportunity for free discharge ulceration formed in lungs may no doubt heal as well as in other parts.

Must indeed be allowed that here some unfavourable circumstances.

Such for example as constant exposure to air & constant motion

Yet at any rate better chance of recovery where free discharge than in contrary circumstances

And where matter expectorated apparently mild pus than where bloody sanies.

From these circumstances then inclined to look upon case of present patient as an instance of Phthisis not altogether irrecoverable

But when go this length is utmost that dare venture to say.

For where circumstances even most favourable recovery but very rare.

Considering Amenorrhea here occurring as a distinct affection do not think that circumstances such as to threaten great danger

Yet apprehend that very little prospect of return of discharge unless patient can recover vigour.

And if that shall be case may probably as readily occur from natural operation of system as from aid of medicine.

At same time if discharge could be restored would at least go some length as increasing patients chance of recovery.

For this change in balance of circulation would at least go greater length than any artificial alteration which are able to produce.

And to this opinion not only led on principle but from facts also.

Have not indeed seen any influence where restoration of menses had effect in curing ulceration of lungs

But think the doctrine supported by case of suppurating mamma which occurred to me some years ago.

A lady after delivered affected with swelling & inflammation of breast terminating in suppuration.

Suppuration which at first to great extent afterwards continued with great obstinacy.

And if for short time had appearance of healing was again renewed in same manner as before.

Although in this situation did not nurse her child yet menses did not return in usual manner.

This I own was inclined to consider as affection resulting from suppuration of breast

But from what afterwards happened appeared that the reverse was rather case

For after suppuration had subsisted for many months menstrual discharge happened to be restored.

Almost immediate consequence of this [attended] for better in appearance of sanies

And in no long time healed mildly.

From this then conclude that if menses restored chance of recovery increased

Yet after all prospect of cure very faint

While however able to attend us or willing to take medicines may at least give her whatever chance are able

And if cannot do more may at least use some measures with intention of alleviation

Shall now then explain practices already employed & point out future intentions.

In this affection consider us as having two distinct states to combat.

The ulceration in lungs which suppose to be cause of Phthisis symptoms.

And the obstruction of menstrual discharge.

Cure of ulceration in general to be affected by process totally depending on system itself.

And unless by removal of causes interrupting natural process art can do but very little.

Seems to be effect of peculiar inflammation.

And to distinguish from others, greatest Physician of our days Mr John Hunter has given it title of [adhesion].

This inflammation depends on peculiar state of action of vessels

And this again on sensible & tonic power which these vessels possess & on stimulation inducing to action.

Evident therefore that deviation in many respects will have affect of preventing [ready] healing.

And that this sometimes to be brought about by increased sometimes by diminished action

As however lungs so inaccessible these ends less readily obtained than when ulceration in other places.

And indeed what chiefly to be done is by regulating general state of circulation.

With this intention necessary to avoid all causes augmenting general impetus.

But more especially to avoid circumstances determining to lungs.

And even, as far as able, to diminish impetus there by determination to other parts.

Is on these principles that are I apprehend to explain benefits from mild aliments particularly diet of milk & vegetables

From warm climate, gentle exercise & emetics as determined to surface.

And from Blisters & issues as determined to particular parts in neighbourhood.

Yet probable that these last also operate from constituting as it were nervous secretion.

And that obviate hectic symptoms from allowing exit for [particular] matter absorbed into blood.

On general principles mentioned then consider greatest part of treatment of Phthisis to proceed.

And that cure in reality work of nature when does take place.

In greatest number of instances nothing perhaps to be attempted with view of altering state of action of vessels

Yet can be no doubt that in other cases of ulceration this affected both by external or topical application & by remedies taken internally.

Unless in way of [vass.] cannot be applied to ulceration in lungs.

But many remedies such as Peruvian Bark mercury. mezereon etc may undoubtedly act on lungs as well as other parts.

These not unfrequently employed even with very great advantage against other cases of [obt]. ulcers

And cannot help thinking that some cases at least even of Phthisis in which not only admissible but even useful.

Am even disposed to think that beside these several other remedies operate in same manner.

And among others may perhaps rank medicines on which have now put this patient viz the Gum Myrrh.

At same time as shall presently have occasion to observe have not yet had sufficient practice of this either to determine its affects or how produce these.

Besides medicine with views now mentioned many others also employed in Phthisis.

Principally however with intention of alleviating particular urgent symptoms which may occur

Such for example as removing irritating cough checking colliquative sweats, or diarrhoea etc

And general principles already stated will at least explain foundation of particular practices in this case.

Thus for respecting Phthisis affection which consider as by much most [important] part of complaint.

Esteem it therefore less necessary to state to you general principles on which could hope to remove other parts of affection.

For in present situation of patient do not consider removal of Amenorrhea as a thing to be attempted.

May only in general way observe that from idea of cause of menstrual flux & of circumstances giving obstruction consider it as in different cases to be affected on different principles.

Chiefly however on one of these following

1 By promoting accumulation of Blood in [illegible] vessels where this wanting.

2. By restoring due & regular action where that deficient.

3. By removal of causes obstructing or retarding passage of blood by uterus where such exist.

Is then on these principles that imagine are to expect restoration of menstrual discharge & to explain action of different emmenagogues.

But how far in present case will think it advisable to take any farther measures with view to menses am I own very doubtful

But at same time should very high degree of debility occur [even] on most urgent state will be [inadmissible]

And shall conclude observations on this case with few remarks on the particular remedies which have already used.

Began treatment with an emetic with intention of unloading breast & determination to [illegible]

And were not disappointed either in obvious operation or in consequence which might have been expected from thence

With same intention therefore may have occasional recourse to this practice [especially] when dyspnoea urgent.

Was as means of restoring menses that had here recourse to madder root.

Represented by some as highly efficacious if not an infallible specific in [every] case of Amenorrhea.

In my own practice have not frequently employed it

And in cases where used have not found it product of affects alleged.

But from any trials have made dare not venture to pronounce it a remedy of little efficacy.

And wish to form opinion from results of full & candid experiments.

Must own that some circumstances which incline me to consider it as of active [power]

That of highly penetrating quality through system appears from being capable of communicating tinge even to hardest bones.

This circumstance alone I think affords full refutation of opinion of those who contend that can have no other affect but by action on stomach.

And there merely as gentle bitter & astringent.

In present instance however had no opportunity of determining affects.

For by looseness which occurred, either from affect of medicine or some other accidental cause [soon] obliged to omit it.

And to moderate this had recourse to infusion Japonica as an astringent.

While employed with view of removing irritation at fauces Mucilage mixture.

Symptoms being by these means somewhat mitigated have now put patient on another medicine

And if find that able to bear it shall endeavour to push it to some extent.

That medicine is the Gum Myrrh a bitter aromatic gummy resin.

Long esteemed to use language of materia medica³ writers both internally & externally for deobstruent [corroborating] antiseptic & traumatic [power]

Do not know however that has been much employed in such cases of Phthisis as that to which our patient subjected.

And for my own part have never employed it in any such case till within these few months.

Was first induced to try it on authority of that able teacher of medicine & great philosopher Dr George Fordyce of London.

Have been informed that in such cases is a remedy from which he thinks he has derived best effects

And in one instance in which have used it where undoubted evidence of very large internal suppuration, whether from the medicine or not patient recovered beyond all expectations.

From this then among other [reasons] wish to give it fair trial in present case.

If therefore no occurrence preventing it shall be desirous of continuing this course without at same time exhibiting other medicines.

And if patient recovers will I own be disposed to look upon it as strong proof of efficacy.

For as already observed look upon this case to be highly dangerous.

More than probable however that from recurrence of looseness or such similar accidents will not have opportunity of giving it fair trial.

And in that case shall hardly think it advisable to attempt any thing farther with this patient than merely [palliating] plan.

That is by directing mild [aliments] & gentle measures for determination either to [surface] or parts in neighbourhood of breast.

And by endeavouring mitigation such urgent symptoms as may occur.

If from these patient recovers cure must be ascribed to nature.

If ends fatally no more than I expect.

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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) Oeconomy is an archaic spelling of economy. In the context of medicine, the term animal oeconomy refers to the living system and its management. In these case notes all but one of the cases where this term is used are female.

3) Latin term referring to the body of collected knowledge about the therapeutic properties of any substance used for healing (i.e., medicines).