DEP/DUA/1/16/02 (Normalised version)

Ann Mason

(1777-1778)

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Ann Mason.

When this patient came under our care disease in some respects more doubtful than at present.

From state of symptoms with which is now affected can have no hesitation in pronouncing that is subjected to Phthisis Pulmonalis.

And this indeed opinion which would probably have given had we been to trial of case immediately after admission

For even in history at first given had greater part at least of symptoms indicating Phthisis

Patient then affected with cough & fixed pain of breast.

And this cough attended with expectoration containing mixture of blood.

To all these may add that had then to remarkable degree emaciated & [red] appearance which constantly occurs during that affection.

Look viz distinguished by title of Facies Hippocratica.

From these circumstances at least strong presumption.

Yet very far from amounting to certainty.

And patient then subjected to some other complaint particularly what respected menstrual flux by which case rendered more doubtful.

Now however farther progression of disease has put this matter beyond all doubt.

Have already had occasion to remark that from different trials made on matter expectorated by this patient strongest evidence of its containing purulent matter.

And accordingly progress of hectic fever, with colliquative diarrhoea has reduced her, if still alive, to last [extremes].

Whatever therefore may have been affection at earlier periods, no doubt concerning it at latter part.

With respect to origin & progression of this affection here room for many [remarks]

But as in many particulars similar to case of Janet McKenlie of which have already spoken several observations which might be offered are in great measure superseded.

Here also as in that case complication of Amenorrhea with Phthisis

This consider to be one of most powerful causes of obstruction.

[illegible] operation is affect of stricture [induced] on bleeding vessels.

But stricture occurs on extremities of [vessel] at time when farther up [distended] with blood.

Chance therefore at least that [illegible] may thus be induced.

And vessels thus filled with [thrombi] of coagulated lymph by which ever afterwards rendered impervious.

Do not pretend to say that this always happens.

But when from this circumstance permanent obstruction occurs am disposed to think that is thus to be explained.

And such concluded to have occurred in present case.

Is evident however that will seldom take place in every vessel. Hence even with strongest evidence of occurrence no grounds for pronouncing disease incurable

Here also Amenorrhea considered as prior cause of affection.

And said to derive origin from imprudent exposure to cold checking natural flow.

In present case see no circumstances which can lead us to entertain any suspicion respecting this account.

And in all these particulars then exhibits example of affection formerly spoken of

Here however connection with menstrual discharge seems to be still more immediate than in case of McKenlie

And to have constituted at least at earlier periods greater part of morbid affection to which was subjected.

Here from date of obstructed menstrual no room to suspect that was consequence of Phthisis.

And for long time after first obstruction evident that did not proceed from either state of inanity or want of due [impetus] in circulation.

Partial accumulation in uterus seems for several months to have gone on in usual [manner].

At least cannot help thinking that of this sufficient evidence in periodic return of pain of [loins], with sense of weight & [tension] about region of uterus.

And indeed this may readily be concluded if in reality arose from cause before suggested.

This [different] Physiology according to theories held of cause of menstrual would explain on different principles.

On opinion elsewhere delivered would refer it accumulation of blood in uterine vessels.

While at same time would ascribe periodic relief after few days continuation to blood being again expelled from thence.

This expulsion am disposed to refer to action excited from uterus itself.

When supervenes after blood accumulated in uterus one of two things must follow as consequence.

Either discharge of blood into cavity of uterus or return into system.

In present instance resistance in former way seems to have been greatest.

And here from return into system would explain severity of symptoms.

To this I apprehend are to refer periodic looseness to which was subjected.

And disposed to look upon it as being in some measure a vicarious evacuation.

At same time have not before met with any similar cause.

Although daily experience must afford numerous instances of other haemorrhages occurring during obstructed menses.

And these I apprehend to be explained on basis mentioned.

Occur sometimes under form of Epistaxis sometimes of Haemoptysis.

But of all others most frequently of Haemoptoe

Is in few cases only that haemorrhage ensues from other part of alimentary canal.

Yet on same ground as occurs from vessels of stomach may also from those of Intestines.

And cause thus in some cases producing bloody discharge in others may give rise to mere [serous] evacuation.

Such indeed not in reality an occurrence so frequent as might thus infer from [prin].

Yet when does take place may I apprehend be better explained on theory of menstrual alluded to than on any other hitherto proposed.

This then idea of nature of affection to which patient subjected for several months before came under our care.

And apprehend that circumstances now mentioned no inconsiderable influence as inducing affection of breast.

Not long before she became our patient an occurrence took place which may be supposed to deserve some attention.

That is bloody expectoration.

Haemoptysis have already remarked is not unfrequently consequence of obstructed menses.

Yet as attending Phthisis may arise also from other causes.

And particularly seldom fails to take place to some degree on rupture of vomicae.

To this indeed [only] cause of present haemorrhage some objection from quantity to which represented as having here occurred.

But in this respect great variety [from] different size of vessels which may be accidentally ruptured

And still stronger objection to supposition of its being Haemoptysis symptom of Amenorrhea from period at which occurred.

Did not take place at that time when should chiefly have expected such haemorrhage.

When consider then occurs at late period of disease & its being succeeded by purulent expectoration am disposed to consider it as being effect of rupture of vomicae.

And in such diseased state of [the] lungs suppose essential part of affection now to consist.

From this view of disease will naturally conclude that hopes of recovery must be very faint.

And indeed think it more than probable that a fatal termination has already taken place.

Is but in very rare instances where after Phthisis distinctly marked recovery ever takes place

Yet perhaps may add that no cause so desperate as to preclude all chance.

And hold chance to be even [better] when purulent matter has free discharge than when confined.

Or where in place of Vomica merely a tubercle yielding bloody sanies.

May also remark that in pronouncing fatal prognosis have sometimes found myself disappointed.

And have frequent occasion to see on streets of Edinburgh more than one patient who I was disposed to think would long before this time have fallen victim of Phthisis.

In one of these cases however am now inclined to believe that mistook obstinate catarrh for incipient Phthisis.

And in another some doubt whether purulent matter discharged to great extent really came from lungs.

If did was at least mild & bland [Residue]

For probable that hectic fever more consequence of peculiar separation from ulcerated parts than of proper pus.

But from these circumstances would only infer that do not look upon recovery in present instance as impossible.

Yet own is an event which if does take place will be much contrary to expectations.

And in affect which any measure which we can employ will have very little claim to mention.

Am even very doubtful how far can take measures that will have any considerable affect in alleviating.

And for some time prescription rather from intention of not seeming to desert patient than from any hopes of benefits.

When patient indeed came first under care did not view cause in same [despairing] light as at present.

And had recourse to some measures with view to radical cure.

Then considered affection as very much supported by want of menstrual discharge.

And hoped that if restoration took place disease might have favourable turn.

Patient however in such condition that durst¹ not venture to employ any medicine rough in operation.

Had I considered system as capable of bearing it should here have entertained [some] hopes from use of electricity.

But to this as well as many other [illegible] emmenagogue from affection of lungs & debilitated system objections occurred.

By this therefore induced as in case of McKenlie to make trial of the Rubia.

A medicine of efficacy of which can say nothing from own experience.

Yet from [penetrating] influence on system consider it as at least deserving trial.

And for forming proper opinion repeated trials in different circumstances requisite.

Here from tendency which evidently appeared of disposition to haemorrhage case in some respects favourable.

But on other hand was not a little against medicine that patient much affected with looseness.

By this led to conjoin Rubia with an astringent.

From which at least hoped that influence of the Rubia as tending to augment looseness might be counteracted.

In preference to others here used as an astringent the Terra Japonica.

A substance with great impropriety obtained name of earth.

For in as far as containing earth is merely an impurity.

From accurate investigation now discovered to be an extract from a species of Mimosoideae or [illegible] plant.

For best account of this substance may refer you to paper in London Medical observations by Mr Kerr a Surgeon in Bengal.

Has given accurate description & beautiful figure of vegetable from which obtained.

As well as particular account of method of preparing it.

From this learn that earthy appearance which has is totally derived from method of preparing it.

For after expression from vegetable is dried in earthen kilns dug for that purpose

Consider then authors of [Pharmacopoeia]² [illegible] as having made very proper alteration in name by substituting term Succus Japonica for Terra Japonica.

And in Succus Japonica [deparatus] a preparation intended merely to free it from earth have introduced a very useful improvement.

In purified state look upon it to be one of most useful vegetable astringents which we yet possess.

And particularly as employed in cases of Diarrhoea

But especially when such an affection the consequence of irritated or relaxed state of intestines.

In such cases reckon it even preferable to that now fashionable remedy the Gum Kino.

First introduced to notice of European practitioners by Dr Fothergill in London Medical observations under title of Gum Rubia Astringent [ Gambic].

Two remedies in some respects [suited] to similar affections of the alimentary canal.

And hold Gum Kino to be of the two the most powerful astringents.

But although has name of Gum is so much of resinous substance as to be very completely dissolved in Spirit.

And in any state in which can be exhibited is more irritated & acrid than succus Japonica.

Which on contrary is to considerable degree of mucilage nature & readily soluble in pure water

From this circumstance then while no inconsiderable astringent power acts as it were as demulcent & serves to lubricate [abraded] intestines.

Was from these considerations then that gave it preference in present instance.

How far here counteracted looseness which otherwise would have occurred cannot pretend to say.

Did not however render stools less frequent than had before been.

But on other hand no increase of looseness from use of Rubia.

And after had for some time continued this medicine appearance seemed rather favourable as otherwise

Had not indeed least show of bloody discharge by vagina.

But was again affected with sense of pain & weight about region of pubis [indi] accumulation of blood in uterine vessels.

This indeed no more than had often before experienced without use of any remedies.

Yet as followed so soon after use of medicine some reason for presuming that may in part at least have arisen from that cause

While at same time whatever may have been cause had reason to hope that while such accumulation existed menstrual discharge would be more easily restored.

By this then led to entertain some hopes, &, notwithstanding looseness, to push use of medicine.

With [confidence] therefore ordered that dose should be more frequently repeated.

While still farther to counteract looseness ordered additional use of succus japonica in different form.

From what already said of impurities depending on earth & of ready solution in water, must appear that simple infusion one of most elegant forms.

In sediment falling to bottom, [difference] quickly takes place.

While parts on which activity depends remain fully suspended in watery menstruum.

In this state where intestines highly irritable efficacy may be much augmented by conjoining it with a sedative.

A combination of succus japonica with opium long basis of very celebrated formula of [illegible] Pharmacopoeia vizr Diascordium .

A medicine deriving name from an article on which efficacy in no degree depends.

And accordingly while now denominated in Edinburgh Pharmacopoeia under title of Electuary Japonica the Scordium is entirely rejected.

Consists solely of astringent & aromatic conjoined with opiate.

In this state may either be given in substance or diffused through watery menstruum.

And no doubt that in many cases is a most useful & grateful medicine.

Not however in every case that conjoined with such aromatics as Cinnamon & Nutmeg [advanced]

Not always that wish for stronger astringent than Succus Japonica [sufficiently] capable of giving.

And frequently that would wish to give opiate in either larger or smaller proportions than these directed.

Is from these different considerations than that view Infusion Japonica as possessing advantage over mixture of Confection Japonica.

In simple infusion has moderate degree of astringency in proportion of ℥p to ℥IV of Water

And this strength at which suppose it to be made if contrary not [specified].

Here then while directed infusion without aromatic increased very considerable proportion of opium

Ordered simple infusion as conjoined with equal quantity of Syrup Diacodium.

This directed to take to extent of ℥i every night at bed time.

And with state of her expectoration hardly thought that could venture on use of opiate to greater extent at once.

Even in this way however with [use] of the succus japonica combined with Rubia looseness still continued severe.

While at same time powders set less easily on stomach than formerly.

Occasioning not only some degree of [sickness] but even vomiting.

To all this, to be added, that prospect of restoration of menses entirely vanished.

For by time of second report, feelings which seemed to indicate approach entirely gone.

In this situation then could have no hesitation in discontinuing Rubia.

For while now little hopes of future benefits from it reason to suspect that supported present uneasiness.

And patient reduced to so low a condition as to be very improper subject for precarious [medicine]

Confined her therefore to use of infusion Japonica alone but ordering more frequent repetition

Under this, looseness rather mitigated as [otherwise]

But without any material relief of affection.

For with increase of purulent expectoration had aggravation of hectic symptoms & much dyspnoea.

In this situation was doubtful as to the propriety of the anodyne.

For with debilitated state accumulation in breast may have produced suffocation

By this therefore led to omit it also.

And was merely with view of nature seeming to give up patient that [used] mucilage mixture.

With same intention also when thus disagreed with stomach substituted for Gum Arabic the Balsam Syrup.

And if finds any reluctance to this may vary it for some similar [innocent] prescription.

Yet without hopes of deriving least benefit from them.

And reckon it highly probable that if [scene] be not already closed, patient will very little longer stand in need of assistance.

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Explanatory notes:

1) Archaic or regional past of dare.

2) An official publication containing a list of medicinal drugs with their effects and directions for their use. The Royal College of Physicians of Edinburgh's Pharmacopoeia was first published in 1699.