DEP/DUA/1/16/01 (Normalised version)

Janet McKay

(1777-1778)

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Janet McKay.

A patient who after being but few weeks under our care dismissed from farther attendance.

And according to account given us free from complaint.

Respecting disease to which this patient subjected when came under our care, as far at least as her own account could be depended upon no room for doubt.

And all symptoms to which she was subjected to be considered as constituting only one affection viz Fluor albus or Leucorrhoea.

Of this affection chief symptom is discharge of peculiar matter from vagina.

And such described to be principle morbid appearance in present case.

Account of this however entirely taken on relation of patient.

And although could hardly be deceived with respect to it herself yet might perhaps wish to deceive us.

Of which I own led to entertain some suspicion from sudden removal

At same time some grounds for suspicion that from aversion to have necessary questions put to her in this place had represented herself as free from complaint when in reality still remains of it.

Yet must observe that to supposition of deceit in either way some objections.

With us could gain nothing by pretending complaint to which in reality not subjected.

And allegation of cure before recovered would have been frustrating intention of application.

While at same time had a sense of shame been her objective would probably have discontinued attendance without any intimation.

Hence then though not altogether without doubt am disposed to take account as represented to us.

And to consider her when came under care as having been affected with discharge of considerable quantity of whitish coloured matter from vagina.

While this however principle [characteristic] symptom of Leucorrhoea or Fluor albus occurs also in similar manner in another affection of very different nature viz Gonorrhoea.

And particularly as arising from [Weaning] [infant]

Is then often a matter of very great difficulty to distinguish in case of females Leucorrhoea from Gonorrhoea.

And perhaps no one mark from which certain judgment to be formed.

Where however have concurring evidence of many, gives if not certain evidence at least high probability.

And such I apprehend afforded in present case.

Of all means of distinguishing what would occur as most natural is account given by patient.

For the two affections must arise from [causes] in nature very opposite.

While Leucorrhoea consequence of peculiar habit but particularly of peculiar state of system of uterus Gonorrhoea uniformly from one cause viz infection.

But although thus materially different even when patient has no intention to deceive others, may yet be sometimes mistaken.

May either suspect infection where has not really taken place or the contrary.

Much more frequently however cannot put absolute reliance on account given.

Hence then, with regard to this mark, although when [ascertained] is an infallible one yet from two sources liable to deception.

Other [marks] therefore also employed.

Judgement in some measure [formed] from circumstances of discharge itself.

In both quantity of discharge very considerable

Yet seldom in Gonorrhoea to same extent as in Leucorrhoea.

In Gonorrhoea also in general a less [viscid] fluid

Particularly at commencement.

In common also some difference in colour.

In Leucorrhoea in general very pure white.

Particularly when extensive for most part is more of yellowish cast.

These however circumstances by no means universally holding.

And even when do hold seldom that can obtain proper information with regard to [this]

Patients themselves little [judges]

And from their report alone that information to be derived.

Has been proposed to distinguish the [disease] by ascertaining seat of the discharge.

In Gonorrhoea universally from vagina

In Leucorrhoea most frequently at least from uterus.

And this alleged may be determined by introduction of roll of linen into vagina

Upon withdrawing it after remaining for some time alleged that origin of discharge may be determined by situation of matter on [roller].

If on sides, discharge concluded to be from vagina & affection to be Gonorrhoea.

If at top concluded to come from uterus & disease to be Leucorrhoea.

This however am far from considering as certain diagnosis.

Whatever be [source] presumption that in every case matter to be found both on side & at top [of] roller.

And besides some instances of Leucorrhoea, as well as of Gonorrhoea, where discharge from vagina alone.

Perhaps in greater part some discharge from this source.

Have perhaps more certain diagnostic in [concomitant] symptoms with which disease attended.

Several generally [concomitant] of Leucorrhoea not usually occurring in Gonorrhoea

And others commonly present in Gonorrhoea but rarely to be met with in Leucorrhoea.

Thus Leucorrhoea usually attended with severe pains of back, loins, & intestines.

Accompanied also with peculiar paleness of complexion & with great debility.

Gonorrhoea on other hand even from commencement pain & inflammation about labia pudenda

And from very first periods attended with great ardor urinae.

From these circumstances when to considerable degree probable conjecture at least may be formed.

But not in every instance that occurs to remarkable extent.

And many of them rather concomitants of particular periods than of whole course of affection.

Besides information received must be entirely rested on veracity of patient.

And if intention to deceive in place of affording distinction may in reality [mistaken]

Another particular on which some put great reliance is connection with menstrual flux

In perhaps greater number of [cases] matter of Leucorrhoea from some vessels discharged menstrual blood.

While Gonorrhoea entirely from mucous glands in vagina.

Hence during menstrual discharge former [ceases] but latter remains unaltered.

This [mark] however although may often afford diagnostic yet in two particulars liable to objections.

Often impossible to say whether discharge does or does not continue.

For although present may be so involved with menstrual blood that not to be discovered

But besides that may be present [where] not seen, even certain evidence of presence does not prove Leucorrhoea.

For in some instances Leucorrhoea from vessels of Vagina.

Hence observed in certain cases to continue even during pregnancy when menses obstructed & no discharge whatever from os uteri.

This indeed, comparatively speaking, but a rare case

Yet often where discharge principally from uterus is to some degree from these vessels.

And even to such extent as to prevent [accuracy] of present diagnosis.

Lastly grounds for distinction between two affections now mentioned from capability of communicating infection.

Where with such discharge from vagina of female disease communicated to male can be not doubt that is Gonorrhoea.

And if no infection given as certain [that] is Leucorrhoea.

This also a mark with regard to which patient herself incapable of [deceiving]

Hence in case of married woman some disposed to trust diagnosis to account of husband.

Is however in such [instances] alone that can have benefit of this [mark]

And even in these but rarely.

Even admitting it then to be certain diagnosis in some cases can never be considered as general one

Thus then have pointed out difficulties with regard to certain diagnosis here.

And appears that no one on which absolute reliance can in every case be just.

Yet some giving at least strong probability

And presumption arising from one often strengthened by concurrent testimony from others.

Now come then to consider how far on this ground evidence of nature of affection in present case.

And in first place may observe that as far as account of patient to be relied upon not venereal.

While at same time no particular reason for suspecting veracity.

From after circumstances this account very much corroborated.

Some indeed from which here no opportunity of judging.

But other evidently tend to confirm account of patient.

As far as can judge from quantity of discharge or appearance of matter evidently in favour of Leucorrhoea.

From express indeed of considerable quantity cannot positively infer much.

For this entirely taken on report of patient herself.

And cannot suppose her a judge how far comparatively speaking discharge considerable or not.

Still less whether greater or not than what usually occurs in Gonorrhoea.

But when to what here said add the circumstance of continuation considerably in favour of supposition of Leucorrhoea.

With regard to appearance of matter less ambiguity

And according to account has not yellowness that might expect in Gonorrhoea.

But has hitherto had & still retains white colour most common in Leucorrhoea.

As to determining seat of discharge from linen roller introduced into vagina no trial made

And indeed from what said of this diagnostic reckon it so uncertain as to be unnecessary.

But from concomitant symptoms strong proof of supposition already adopted.

Here patients great complaint those pains & that debility which attendants of Leucorrhoea.

While not affected with ardor urinae almost inseparable from Gonorrhoea.

And although presence of ardor urinae no certainty against Leucorrhoea.

Yet absence strong evidence against Gonorrhoea.

Opinion also confirmed by connection of discharge of white matter in this case with menstrual evacuation.

For on appearance of this discharge manifestly diminished.

And lastly in this case have what of all circumstances perhaps most certain test.

That is what derived from circumstance of being of infectious nature or not.

For from disease of present patient who happens to be a married woman husband has suffered no injury.

Thus then every circumstance in favour of supposition of Leucorrhoea.

And although from no one by itself positive evidence yet from all taken together strong presumption.

Upon whole therefore little hesitation in pronouncing disease to be Leucorrhoea or Fluor Albus

Having gone thus far however another question of some importance occurs.

What viz particular nature of cause giving discharge.

For term Leucorrhoea a general appellation including affections in nature even dissimilar.

Thus for example discharge in some measure such as here described not [unfrequently] consequence of ulcer. fungous swelling, scirrhous cancer of uterus, & the like.

And accordingly in system of Mr Sauvages find Leucorrhoea fungosa, ulcer. cancer etc pointed out as particular species.

Into circumstances distinguishing present case from each of these unnecessary to enter.

Sufficient to observe that nature of pain here occurring removes suspicion of local affection

And that present case corresponds very exactly to that species described by Mr Sauvages under title of Leu. [Am.]

And which indeed except Leucorrhoea [illegible] only one in which there does not occur some local affection.

When however takes place without local disease discharge as already observed may either be from vessels of uterus or vagina.

And here from evident connection with menstrual flux would be disposed to consider it as principally of former kind.

Have thus then given opinion as to name & nature of affection when patient came under our care.

Observations on Prognosis now in great measure precluded.

For as informed us that entirely freed from complaint have already dismissed her from farther attendance.

Must own however that when came under care should not have been disposed to give this opinion.

And even now very apprehensive that cure rather temporary than will be permanent.

Shall not therefore be surprised to find that patient has again return of complaint.

Of this however not at present our business to speak

And remains only that should mention measures here employed while was under care & of intention with which used.

At least in as far as measures here used were advised on dogmatic plan.

Must however own that began practice here somewhat on different footing.

Or at least employed a medicine with regard to operation of which am much in the dark.

That is the [prepared] crabs eyes.

How long this remedy employed against such affections or by whom introduced do not know.

Medicine indeed somewhat analogous recommended by different practitioners.

Thus Lime water in very frequent [use]

And Mr Vogel recommends powder of egg shells a calcinated earth as well as crabs eyes

Of use however to be derived from this last for my own part first received information some years ago

Was informed by a Gentleman who after leaving this University visited Leyden that there Crabs eyes a favoured remedy against this affection with a learned professor Dr van Doeveren.

And particularly that had often employed it with great success in different cases treated at Collegium Casuale¹ at that place.

Of this letter will find an extract in first Volume of Medical Commentaries.

Since that information have not had opportunity of employing it in many cases.

But in some in which used have had reason to think that product of good consequences.

Respecting operation however must own am greatly at a loss.

Should be disposed to think that from insoluble nature would not readily act beyond alimentary canal.

A late writer however is a strong advocate for a different doctrine. I mean Dr Heysham of Carlisle

In inaugural dissertation on Rabies [Canina] in which many ingenious as well as judicious observations to be met with contends that absorbents may action [aid] in circulatory system.

And supposing that is as overcome peculiar [acids] that the remedy of Mr H of Ormskirk so much celebrated for [prevention] of [canine] madness producing its affects.

Contends that poison of Rabies is in its nature a peculiar [acid].

And demonstrated by very convenient [experiment] that basis of Mr H. remedy is an absorbent earth.

If this doctrine well founded hard to say to what extent in system operation of crabs eyes may go.

Must however own that with regard to several particulars in it entertain great doubts

And upon whole disposed rather to explain influence of absorbent here used from operating on primae viae.

When abundant acid, there present can be no doubt that will have affect of destroying it.

Well known however that affections of alimentary canal, as in present case a frequent occurrence in Leucorrhoea.

And that these affections particularly manifested by symptoms indicating presence of acid.

Is farther known that acid in alimentary canal a powerful cause inducing atonia of its muscular fibres.

And that affections of alimentary canal, [whether] of this or opposite nature induce similar conditions in other parts of system.

Thus then absorbent by removing cause of atonia in primae viae may counteract that laxity on which increased mucus discharge in Leucorrhoea depends.

In this manner then disposed in part at least to account for operation of absorbent in present disease.

But whether have also affects in any other way will not pretend to say.

Whatever might be method of operation seemed in present instance to have good affects

Before began [then] discharge we are told had continued, unless at menstrual period, without intermission for space of six months

And during that period had been uniformly increasing.

Had not however employed the remedy for eight days, before obtained at least temporary intermission.

This intermission so considerable that had not even return of discharge after flow of menses

A time at which even after violence of disease greatly mitigated will yet continue at least to some degree for few days.

During this intermission however affection of alimentary canal in other respects rather aggravated.

And particularly much distressed with unease from wind accompanied with bound state of belly.

Suspect that former in great measure consequence of latter.

And that constipation might in some measure be induced from use of absorbent.

By this consideration then led to omit it.

At same time with view to affection of wind & to moving belly directed use of Pill Guaiacum.

Of these the principle active article is the Assafoetida

Which while tends to expulsion of wind from antispasmodic affect also operates as stimulant to intestines.

From this however suspected that rather tendency to renewal of fluor albus than contrary.

Directed therefore as tonic the Peruvian bark to small extent.

By which hoped that advantages already obtained might be rendered permanent.

Under this course however had slight return of discharge.

But was only of short duration.

While at same time got rid of [all] other complaints.

And, if have not been deceived in accounts given us, present case affords strong evidence of efficacy of crabs eyes at least in some instances of Leucorrhoea

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Explanatory notes:

1) A term used in the 1700s in Leiden, Padua and elsewhere to describe clinical teaching, using demonstrations of outpatients.