DEP/DUA/1/17/02 (Normalised version)

Mary Gallet

(1778)

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First case in list that of Mary Gallat.

This patient selected not so much as giving rise to remarks useful in after practice as affording an example of an affection somewhat [singular]

And is indeed a case with regard to which must own have very great difficulty.

At same time this difficulty arises solely from nature of affection itself.

For in history introduced into register¹ drawn up by Gentleman who last [officiated] as Medical assistant at the Dispensary, have very full & accurate account of all her complaints.

And that disease not misrepresented but dependent really on even local cause can admit of no doubt, even from most superficial examination.

Most obvious part of complaint swelling of abdomen.

This even externally of such magnitude that cannot fail to strike every observer.

This enlargement extends through whole abdomen.

And in no degree attended with that fluctuation which if not universally at least very generally accompanies swelling depending on water

Besides this patient affected with at least few of the other symptoms which considered as common attendants of dropsy.

Is indeed remarked that after erect posture through the day her legs observed to be swelled towards evening.

And that while this subsides during night hands not unfrequently affected in similar manner in morning.

These transitory swellings so much connected with posture in all probability effect of deposits of water in cellular membrane.

This however by no means an uncommon occurrence where dropsy in other cavities entirely [wanting]

And in numerous instances takes rise as mere effect of debility.

That from this circumstance may arise in case before us can hardly be doubted, from what said, & indeed obvious, as to debilitated condition of patient.

Must own therefore that am much more disposed to adopt supposition of patient herself.

That swelling vizr to considerable degree at least is effect of wind.

Of this evidence in some measure from [feeling].

Still more from flatulence with which patient affected.

And lastly from change in point of size to which swelling subjected without any other discharge but that of wind.

From these different circumstances then more grounds for presuming, that swelling in part affection of wind rather than of water.

Yet must be admitted that far from [illegible] to certainty.

And that even swelling of legs not only dropsical symptom.

Complains also of some affection at least in discharge of urine.

Rather however difficulty in passing it than scarcity

Shall not however be surprised to find that from after circumstances [there] shall appear greater room for doubt.

But whether suppose general distension of abdomen from wind or from water, must necessarily entertain different suppositions as to greater part of it.

With this patient there is manifestly to be discovered also a local swelling in great measure fixed occupying greater part of abdomen but principally right side.

In this peculiarity of patients disease [consists]

And from this whatever it is are probably to account for all other symptoms.

From firm hard feel & from manifest inequality can be no doubt that [nature] to be ascribed to air nor water.

At least as lodged in cavity of abdomen.

Are necessarily led therefore to form some other supposition respecting it.

And here three different suppositions may be entertained.

May either depend on diseased state of some of those viscera natural to system.

On growth of some tumour totally preternatural.

Or may depend on the retention of a foetus.

And this last supposition which patient herself disposed to adopt.

Respecting circumstances of this case have [conversed] with many practitioners in this city.

And some of them have carried to examine her.

The conjectures which they entertain are different [may] I however own that I have however met with no one, who either has or has not examined her, who is disposed to give credit to supposition of patient.

And must observe that here my own opinion is very doubtful.

Yet of three mentioned cannot help thinking that greatest number of circumstances in favour of supposition that depends on [foetus].

Is indeed true that instances have often occurred of large preternatural tumour in the abdomen occupying if not exactly at least nearly same place as that in present case.

And in other instances viscera themselves have been morbidly increased.

This particularly observed with respect to ovaries.

Sometimes enlarged to very great size from scirrhous swelling.

Sometimes from dropsical affection.

And not unfrequently both conjoined.

That is while central part degenerates as it were into a [sac] coats of this [sac] at same time acquire peculiarly firm & hard consistency

And of all opinions with which have been favoured from others respecting present case this the most general

Is supposed that local tumour here either effect of mere scirrhous or of scirrhous containing water.

And is at least somewhat in favour of this supposition that is more common than either an instance of an [extracted] foetus, or [retention] of foetus in uterus

But still farther grounds for presumption from another circumstance which has occurred since last report.

That is an involuntary discharge of a clear watery fluid from vagina.

And according to her suspicion at least not from bladder but from uterus.

On supposition of Hydrom or Dropsy of uterus itself such an occurrence might be supposed to take place.

Yet even supposing that certainly from uterus different conjectures might be given as to [cause]

And with retention of foetus & placenta room also for suspicion that separation of waters might in some degree [continue].

But perhaps still a more probable supposition than either that this fluid not from uterus but from bladder.

And to this, the affection in the discharge of urine, to which has long been subjected gives some countenance.

Hence then we have neither in [super] frequency of this affection to other possible causes, nor in late appearance what can by any means be considered as giving strong evidence.

While at same time such suppositions [liable] at least to some objections.

In most instances of such affections, increase of size of tumour by no means so rapid as in present instance

For to be observed that here arrived at present extent in less than space of nine months.

And since that has never suffered any farther augmentation.

May at least then be considered as remarkably singular that should have stopped at this period

In by much greater number of instances continued to increase even till death of patient.

Especially where at commencement progress observed to be so rapid.

With rapid increase also, either of tumour entirely preternatural, or of morbid affection occurring in other viscera health usually much more affected than has hitherto been case with our patient.

And indeed rarely considerable degree of hectic fever has not sooner occurred.

To these circumstances may farther be added that scirrhous of ovaries or preternatural tumour of other parts seldom with any affection of menstrual discharge.

Flow for most part continued nearly in usual [manner]

In present instance however very remarkable affect.

And that too even in opposite ways.

At commencement menstrual discharge obstructed.

In after course has become much more frequent than natural.

And when occurring of much longer continuation.

In all these particulars then if are to suppose tumour the affection of Dropsy or scirrhous of ovarium. [ Hydromat] or like will yet not be refused that at least peculiar occurrence.

And from this naturally led to inquire how far arguments occur either for or against supposition [entertained] by patient herself.

That to supposition, of irregular tumour depending on foetus retained, either in uterus or in cavity of abdomen, there are difficulties cannot be refused.

Yet must own that do not look upon any of them as unsurmountable.

Chief objective to this supposition occurs from three sources.

1 From cases of retention of a foetus being very uncommon

3. From lightness of uterus as felt at os tincae when examined by the Vagina.

2^dly from length of time for which has subsisted without purulent state or [discharge] of any part of foetus.

To these objections circumstances may be [urged] in [answer] by which are at least invalided.

Although must indeed be allowed that retention of dead foetuses uncommon, yet can by no means be represented as what has never occurred.

Besides many other cases on [record], two instances lately published in Medical Commentaries & third [communication] for publication.

And these too on most unquestionable [authority]

One by Dr Bell of Dublin other by Dr Percival of Manchester.

In first case foetus extracted by artificial operation & patient afterwards recovered.

In second patient died after having discharged by stool greatest part of foetus retained in abdomen for space of twenty two years.

In these then not only answer to objections from case being unusual but also to what drawn from length of time without putrescent state.

What has happened to others may also have occurred with our patient.

And would even be no unsurmountable objection if for much greater length of time no [putrescent] symptoms should appear.

But perhaps of all three objections mentioned that which yet remains to be spoken of the strongest.

That viz which drawn from lightness of uterus

This patient, among other Gentlemen in profession of midwifery & surgery has been examined by my very ingenious & intelligent friend Mr Hamilton.

And from touching the Os uteris he is convinced that at present it does not contain a foetus.

Should be very far from presuming on any [absence] reasonings of my own to contradict the authority of a Gentleman so much conversed in practices of this branch of healing art.

And cannot but admit that gives great difficulty to the supposition

Yet must own do not consider it as giving certain refutation.

And on several different grounds an answer may I apprehend be afforded to this objection.

In first place is possible that foetus may never have been in uterus.

Agreed among all authors that conception takes place not merely in uterus itself.

And in preternatural cases besides occurring in ovaries & fallopian tubes agreed also on all hands that there take place what have been called abdominal conceptions.

To such a supposition in present instance indeed is some objection that there seldom arrives at any great size.

Yet where or how limits fixed we can not pretend to say.

But besides this may have arisen to natural bulk in uterus & afterwards made its way from thence

Of two cases of retention of foetus to which have already alluded in one that viz by Dr Bell foetus during whole period for which retained supposed to [contain] in uterus.

And at length extracted from thence by operation

But in that of Dr Percival where circumstances in many respects similar to what occurred with our patient foetus not only forced [through] uterus but at length through rectum also.

May naturally then suppose that after foetus had made its way from uterus [feeling] at os uteris came as if never [contained] it.

And lastly from feeling in natural cases cannot infer what may happen in particular morbid states.

If foetus here retained unquestionable that position much altered from natural.

Hence then while distension at other parts cervix uteri may in great measure have [retained] natural position.

From these different reasons then can by no means consider as unsurmountable objection to this supposition or as affording certain evidence that is groundless.

Next then to inquire what circumstances may be urged in support of the opinion.

Of these first which naturally occurs is origin & progression of the affection.

According to account of patient present complaint [began] during pregnancy.

When in state of perfect health she [became] affected with usual symptoms of pregnant condition.

That is, some degree of nausea & sickness of stomach, but particularly obstruction of menstrual discharge.

These symptoms at proper time followed by still farther evidence of pregnancy, motion of child

And matters we are told in every respect went on in natural condition till seventh month.

Then however an appearance which to a Woman in this situation could not fail to be highly alarming took place.

A profuse Haemorrhage viz from uterus.

And this not for short space only but for period even of eight days together.

This haemorrhage was at same time ascribed to an obvious cause.

According to her own account followed as immediate consequence of a draught of milk ale & sulphur.

In none of these articles however, such active powers, that taken to moderate extent any thing to be apprehended from them

And must own that in this particular [should] be inclined to think that patient mistaken

Especially as then exposed to a cause still more powerful.

Had for space of several weeks before been subjected to very great fatigue in consequence of sickness of her husband.

And immediately before commencement of morbidity had been under influence of great grief in consequence of his death

Was during this distress that draught she mentioned exhibited to her.

And in preceding circumstances have I think a much more powerful cause of disease.

But whether to be referred to one or other of these obvious causes is from this period that consider affection as having begun.

And ever since has been subjected to frequent returns of bloody discharge from vagina & if not to great extent at least of very considerable duration

To these all other present symptoms have supervened.

From time of Haemorrhage however marks indicating life & vigour of child diminished.

By ninth month from extraordinary [waste] & want of motion had reason to conclude that was dead.

And in place of natural delivery has ever since remained with no very remarkable changes in present situation.

If, on this account of patient entire reliance could be put, nature of affection could not admit of doubt.

Yet must be allowed that although patient no intention to deceive us may [have] been deceived herself.

Obvious enlargement of abdomen want of menses & even sense of motion are occurrences which may take place without pregnancy.

And from concurrence of all these circumstances women sometimes suppose themselves pregnant when in reality subjected to dropsy.

Mistaking for motion of child effect of flatulence in intestines or like.

Must however be observed that such mistakes principally during earliest period of pregnancy.

And hold chiefly with respect to motion at commencement.

For by seventh month motion of child so peculiar that nothing in any danger of being [confounded] with it.

Such mistakes also chiefly happen with those who never any child before.

And who on that account less acquainted with nature of motion.

Present patient however by no means in this situation.

For before commencement of present affection had been mother of many children.

To period then to which pregnancy said to be advanced this may be added as [farther] argument.

May subject as third that here no intention to deceive us.

That patient in reality subjected to disease could admit of no doubt.

And indeed rather surprising as otherwise that not affected with symptoms more distressing.

But may observe that of same complaint had happened to many other females would probably have heard much more of it.

For, as far at least, as can judge, seems to be natural disposition to avoid [complaint] as much as possible.

Yet while evident disease exists situation at [least] such as affords no objection to supposition & even in some measures favouring it.

Have a circumstance still farther in favour of supposition in manifest [inequality] of tumour.

Such indeed may occur in other cases.

Yet in scirrhous of ovaries in [ meteor]. or [preternatural] tumours such inequality as here discovered less frequently to be met with.

While in case of foetus must necessarily & unavoidably happen.

This then at least a circumstance more in favour of supposition of foetus than any other.

To [arguments] drawn from existing situation & inequality of tumour may add another from moveable nature.

Can not indeed allege that have here evidence of tumour being loose in abdomen without any attachment.

But this affection prevented by size.

While at same time is manifestly so far loose that can be pushed form one side to other by external force.

And that with much greater case than should imagine on any other supposition.

Lastly in support of supposition of foetus may urge similarity in circumstance to other cases

Particularly to that mentioned by Dr Percival.

In some of these also for long time equal grounds for doubt & uncertainty as with present

At last however nature established beyond doubt either by dissection after death or by discharge during life of patient.

Upon whole then cannot help thinking that of all suppositions suggested this the most probable.

Must however conclude as began notes expressing difficulty.

And when find so many others of different opinion cannot be surprised if that which disposed to adopt should be found to be erroneous.

Yet whatever affection if not uncommon in nature is at least so in appearance.

With this uncertainty as to nature can say nothing with confidence respecting prognosis.

Yet on any of suppositions given have no foundation for giving favourable opinion of termination.

On supposition of tumour being of scirrhous [nature] are acquainted with no remedy from which any expectation of removal after present size.

While at same time very rarely if ever that such affections suffer natural [resolution]

On supposition of foetus equally little grounds for hope.

Without removal no possibility of recovery.

And if removal attempted by artificial means, or should happen naturally, not without utmost danger

While however thus faint hopes of recovery would not be understood to mean that patient will be suddenly cut off.

May even although symptoms at greater height than at present continue subjected to complaint for space even of many years.

And may farther remark that of late symptoms hardly in any degree aggravated

Yet must be observed that often affected with great [opposite] at precordia.

During night often awakened in sudden fright

Of late these have [prevailed] to such length as to threaten deliquium during day.

And should not I own be much [surprised] if during fainting fit scene unexpectedly closed

Yet reckon it more probable that may not soon fall a victim to affection.

And even before this happens circumstances may occur by which no longer left under any difficulty as to nature of disease.

Have thus then at some length given opinion or rather conjecture as to nature of the patients disease & probable termination.

Next follows that should speak of [treatment]

Here however will be necessary to say but very little.

From what already observed must be evident that can entertain no sanguine hopes either from artificial or natural cure.

In as far as natural cure may occur must be entirely affect of time.

And attention of practice solely bestowed in attempts to obviate symptoms.

Occurs then as question how far artificial cure in this case to be attempted.

And this the rather to be mentioned from what told in case as to propriety of removing cause of disease by incision.

This, as taken from account given by patient is said to have been joint opinion of two very eminent Professors & able practitioners Dr Monro & Young.

In this however patient unquestionably mistaken.

For have taken opportunity of speaking to both these Gentlemen on this subject.

Neither of them can now recollect the circumstances of this case.

But at same time are very clear that never recommended such an operation to any woman in that situation.

That complaints of present patient are not feigned any one may be fully satisfied who takes trouble of examination.

And that did make application to Dr Young & Dr Monro is at least highly probable.

But at same time is not less so that may have misunderstood what they had said as to treatment of affection.

Cannot then consider propriety of operating tumour as warranted by their opinion.

With regard to present instance may only observe that if absolute certainty as to cause supposed still doubtful as to advice

Certain that patient in very great danger of being cut off by operation itself.

Perhaps even more to be dreaded from operation than disease.

And although in case mentioned by Dr B complete recovery obtained by operation yet, this if not entirely a solitary case is at utmost very rare.

These however, as [integ] first burst of themselves, operation might be considered as [merely] aiding nature

And from discharge of bones from opening [prov] to use of knife nature of affection put beyond all dispute.

In present instance however besides danger of operation unsurmountable objection to it from doubtful nature of disease

And if affection in reality different from what supposed, would certainly terminate in death of patient, & hurt reputation of operator.

Of plans of radical cure on other suppositions as to nature of affection after opinion already give of disease reckon it unnecessary to say any thing.

And indeed on these also affection might be considered as equally desperate.

Utmost therefore here to be aimed at is the obviating symptoms.

And of these the chief to be combated are, the constipation, flatulence. haemorrhage & tendency to deliquium.

Has been merely with view of [counteracting] such symptoms that medicines hitherto directed have been employed.

Of the particulars however at present forbear to make any remarks.

And may conclude with observing that selected present case rather with view of exhibiting a singular affection & that might have opportunity of watching progress perhaps of investigating nature, than from expectation of being of any essential service.

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Explanatory notes:

1) References are made throughout the case notes to a dispensary patient register. However, no evidence has been found that this register survives.