DEP/DUA/1/17/11 (Normalised version)

Peggy McGlashan

(1778)

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Peggy McGlashan.

With regard to case of this patient in some particulars little room for doubt.

Yet in explanation of several [particulars] very great difficulty.

And can have no hesitation in pronouncing it if not a complicated affection, at least a [disease] with appearances considerably different from those which genus to which belongs usually puts on.

Principle affections to which is subjected are discharge of white matter from Vagina.

Flow of milk from breasts.

And general debility particularly appearing under form of great pain in back.

These constitute if not constant at least more permanent parts of this affection.

And in two former have great distinguishing marks of particular genera of disease.

Latter debility and pain of back a frequent occurrence in great variety of affections.

Debility sometimes [taken] as chief symptom of a proper idiopathic affection but more frequently as consequence of other diseases

And when consider situation & circumstances with which here occurred can be little doubt that to be viewed in latter light.

Same also probably the case with some other symptoms which occasionally occur.

Particularly uneasiness at stomach, flatulence & vomiting.

Name therefore to be given to affection to be sought for in one or other of two first particulars pointed out.

From first of these discharge from vagina would naturally think of referring this affection either to Leucorrhoea or Gonorrhoea.

Into the various particulars distinguishing these two complaints not here our business to enter.

And now the rather avoid it, as in former lecture had occasion to say something on this subject.

Here in as far as can rely on veracity of patient discharge is from Leucorrhoea.

And this account the rather to be trusted to as patient not single but married woman

For in latter situation if had smallest suspicion of Venereal affection would probably be anxious to disclose it as means of cure

To this may farther add as corroborating circumstance of Leucorrhoea both duration & quantity of [discharge]

These according to representation given us by no means in such state as will correspond with gonorrhoea

And lastly supposition of Leucorrhoea favoured by concomitant circumstances of the case.

Particularly by great debility & pain of back.

Even admitting Leucorrhoea however, must still be observed that by no means without peculiarity.

Is indeed far from being uncommon to find this affection connected with menstrual discharge.

In even greatest number of cases flow [observed] most abundant immediately after menstrual.

Sometimes most copious immediately preceding menstrual flow.

And in both cases not difficult to conceive why this should occur.

As taking place in augmented quantity previous to menstrual would explain it from [congealing] of blood which then suppose to have occurred in uterine & neighbouring vessels.

And as following in great quantity [would] refer it to open state in which vessels left from previous bleeding.

But with our patient circumstances in a great measure opposite to either of these.

Discharge most troublesome [at] middle period between menstrual.

And least in quantity for few days before & after menstrual flux.

While this circumstance to be considered a great peculiarity so I apprehend [difficultly] explained.

And must own at loss to conject on what footing to be accounted for.

May perhaps however be suggested as mode of explanation that takes place most copiously with certain degree of distension.

That with present patient from peculiar condition of [separate] vessels are then most readily acted upon

But whatever be explanation must from account given by patient take it as fact.

And as occurring in Leucorrhoea unquestionably to be looked upon as great singularity.

This however not only circumstance in present case which may be viewed as peculiar.

Have an appearance still more uncommon in discharge of milk from breast.

And here at loss to think whether should be considered as merely symptom of Leucorrhoea or as separate genus of disease.

That milk as well as other discharge may be subjected to morbid states, [should] naturally be led to infer.

And particularly might suspect that discharge of this fluid would occur at times when [according] to laws of system not natural.

Accordingly find that Galactia & Galacturrhoea constitute affections in greater part of Nosological¹ systems.

Such a genus indeed has not place in system of Dr Cullen.

And must at least be allowed that is not a common affection.

But if ever occurs as idiopathic disease at least served mention among genera.

And that this in some instances the case inferred on sufficient authority when supported by Sauvages [ Senatus] & others.

But besides that occurs as separate & distinct affection by itself may take place also as symptom of other complaints.

And am inclined to think that this the case in instance before us.

From several circumstances view Galacturrhoea here as symptom of Fluor albus.

But particularly from evident connection which has with state of Leucorrhoea.

For to be observed that discharge of milk as well as that of white fluid from vagina has connection with menstrual evacuation.

And that for some time both before & after menstrual is entirely wanting.

While again at time when Leucorrhoea most abundant discharge of milk also most copious.

This connection may unquestionably be viewed as another great singularity in case before us.

And not more easily explained than that already pointed out.

Here however with some appearance of reason, may also have recourse to former conjecture.

Have little doubt that during nursing, secretion of milk occurs in consequence of peculiar circulation.

And that this particularly brought about by change occurring in state of circulation in system of uterus.

In this respect however for explanation of phenomena of Leucorrhoea, have supposed morbid affection to occur.

And this morbid affection may consist in condition somewhat analogous to that which succeeds the [puerperal] state

Thus then from uncommon case of Fluor albus can at least see some foundation why Galacturrhoea should occur as symptom.

And in consequence of vascular connection where anatomy [demonstrates] more grounds for supposing it symptom of affection of uterus than of any other viscus.

On this explanation would refer all complaints to which patient now subjected to a circumstance mentioned in the case

That is accident to which subjected during pregnancy & at time of delivery.

System of uterus in pregnant state liable to a series of changes which can arise from no other condition whatever.

And that these on some occasions [illegible] leave morbid condition cannot seem strange.

But besides what results from accidents to which necessarily subjected others also may occur from ignorance of assistants in time of delivery.

And such our patient suspects to have been case on extraction of Placenta.

How far this supposition in reality well founded cannot pretend to say.

Pain felt by patient immediately on extraction is at least something in favour of it.

And probably is that, more hurried than ought to have been.

Yet even when this the case, women often disposed to refer to this circumstance, what in reality consequence of other accidents.

And am disposed to view in this light even affection of urine which are told immediately succeeded.

More probably consequence of compression to which bladder subjected during pregnancy than to any accident in extraction of placenta.

But whether this opinion just or not that symptom at least has now entirely ceased.

And was not till near a year after that present affection is to be considered as having had commencement.

That is some time after weaning her child

How far then subjected to any accident which might have induced it hard to say.

But at least not informed of any circumstance of this nature.

And even at so late period may yet consider foundation of this affection as [tendered] during pregnancy or delivery.

For to be observed that with those who suckle infants during whole of that period uterus does not return to natural state.

Of this unquestionable evidence from want of menses

At least with greater part of nurses & particularly with those who are good nurses that is who have plenty of milk is always wanting.

Explanation of this circumstance must own consider as very difficult.

Nor can I by any means refer it as some disposed to do, to inanity [where] evacuation of milk produced.

For by no means uncommon to see even during nursing a plethoric state induced.

Nor this surprising when consider that with increased demands from system appetite for [foundation] also augmented.

And with many hireling nurses means of indulging that appetite more abundantly supplied.

Yet when from these evident fullness produced, menses do not return.

And when do return as far at least as my observation goes as frequently with those whose habits during nursing apparently exhausted.

Particularly if prevention of that laxity of habit giving disposition to Menorrhagia.

From want of menstrual then during nursing may infer some peculiar connection between uterus & mammae.

But on what that connection depends cannot pretend to say.

Must however think that more dependent on demonstrated connection between blood vessels than some disposed to allow.

Cannot indeed be [refused] that vessels betwixt two, which do [illegible] but small.

Yet equally undeniable that connection which does subsist a very singular one.

And must unquestionably be intended at least for some purpose.

But whatever cause, connection as have already remarked particularly with respect to function of uterus & mammae indubitable.

And thus then suppose, that operation of [cause], taking place during pregnancy or delivery, should not manifest affection on uterus till period of nursing finished.

This then conjecture which disposed to entertain respecting disease of present patient.

Would affix to it the name of Leucorrhoea.

But consider it as an example of Leucorrhoea with peculiar circumstances.

And among these while remarkable for period at which discharge most abundant is still [more] so for Galacturrhoea or [morbid] discharge of milk from the breasts.

This however considered rather as depending on former & symptom of it, than as a separate disease

And look upon all parts of the affection as here originating from same cause

That is accident to which uterus system & probably also in some measure mammae subjected during pregnant state.

Not however from extraction of Placenta or like, but from those great & unavoidable changes to which uterus [must] necessarily be subjected & that too in sudden manner.

And which although in by much greater number of cases product of no inconvenience yet in others will sometimes be followed by consequences still more distressing than what here occur.

After opinion now delivered as to nature of affection sentiments respecting prognosis must be very doubtful.

While present symptoms continue must unquestionably be very distressing to her.

And at last may even prove fatal.

But of dangerous tendencies at present at least see no appearance.

Notwithstanding complaints of debility yet both vital & natural functions seem to be very little if in any degree affected.

And while these unimpaired, much less at least to be dreaded from other symptoms.

But while here no great apprehension of danger equally little grounds to look for expedient cure.

Leucorrhoea in any form, a disease which in general cannot be speedily or effectively [removed]

In many instances indeed no difficult matter to produce temporary diminution or even entire stop of discharge.

Yet several accidents having tendency to renew it are to be considered as in nature almost unavoidable.

Besides other accidents, this a consequence even of regular menstrual discharge.

Hence often happens that when apparently cured yet in very short time again [returns]

And can have no hesitation in ranking it among affections which difficult to remove.

If this however the case with respect to it in ordinary state much more reason to apprehend obstinacy where occurs in anomalous form.

And besides that this its condition with present patient same conjecture supported also by continuation of affection

For with this patient has already [subsisted] for space of nearly four years.

During that time indeed all parts of affection not to equal extent.

And of late discharge from vagina in [part] very considerably increased.

This circumstance therefore as well as continuation removes probable chance at least of natural cure.

While at same time gives indication not only of obstinacy, but of additional inconvenience that may result from this affection if left to itself.

Would not however from these particulars conclude that even natural cure to be despaired of.

Is I apprehend in this way that may look for most speedy recovery.

And two occurrences from which inclined to think may yet be expected.

vizr Either total cessation of menstrual flux or temporary interruption in consequence of pregnancy.

First from age of patient may yet be supposed at a distant period.

With all females however cessation of this discharge does not take place at same time.

And in diseased cases often leaves them sooner than others.

May not therefore be here so distant as from being but 25 years of age should imagine

But have unquestionable chance of more expedient cure from becoming again pregnant.

Of this however must be allowed much less probable than if present disease had never taken place.

And after not having become pregnant for four preceding years chance of [now] happening not very great.

Should it even occur in place of curing may aggravate affection.

Yet still must consider it as giving at least one chance of recovery.

If however some ground for expectation from natural cure may also entertain hopes from artificial means.

And perhaps to be considered as [most] favourable circumstance in case that hitherto no medicines used.

This therefore at least affords greater latitude for trial.

Of such trials then as have already or may hereafter be made next proceed to speak.

And here must observe that case such as affords opportunity rather for random trials than any thing else.

For must own that even supposing [conjecture] well founded still at loss to say on what principle rational cure to be conducted.

For allowing morbid state to exist yet in dark with regard to nature of it.

Consider it however as by no means improbable that at least connected with certain state of laxity.

And that therefore most probable chance of removal by such means as would have tendency to restore due vigour

Advantages of these in ordinary cases of Leucorrhoea well known

And although present case with some peculiarities yet general nature of morbid affection may be ultimately the same.

By this means also whether diseases connected or not, expected also, some good affects in Galacturrhoea as well as Leucorrhoea

For here also morbid discharge from no cause more frequent than from laxity

True indeed that even most relaxed state in mamma without other circumstances by no means of itself sufficient to produce [separation] of milk.

Nor perhaps is even quantity of discharge to be considered as much connected with laxity.

Yet other circumstances being equal from state of laxity will after secretion be at least more readily discharged.

And with due state of resistance in [extreme] vessels even when breasts filled during period of nursing no discharge without sucking.

On these grounds then against this part of affection also, benefits to be expected from astringents.

And as affecting system in general from action on stomach no less influence on Mamma than uterus.

And as astringent here have chiefly used the Vitriol acid in different forms.

Principally however employed it in state of Elixir acidum.

In this first diluted by mixture with Spirit of wine & then conjoined with some aromatics particularly Cinnamon. Ginger, & leaves of Peppermint

Gave this [preference] to acid merely diluted chiefly from state of patients stomach.

And hoped that without exciting any unease might from proper use be product of best affects.

In every case however the restraining accustomed discharge attended with inconvenience.

Wished therefore to affect cure here in gradual manner.

Was therefore on this account that began use to small extent only.

And when found, that while in this state had not desired affect & at same time product of no inconvenience had recourse to another medicine to be used together with Vitriol acid & on same principle.

That is powder of alum with Succus Japonica.

Former of these the alum considered [merely] as different state for exhibition of Vitriol acid.

And of utility of latter as a Vegetable astringent have already oftener than once had occasion to speak.

These powders however did not agree with patients stomach.

Or at least she herself disposed to think [so]

In place therefore of pushing use farther had recourse as substitute to Peruvian Bark

Which among tribe of vegetable tonics as far as experience yet goes is unquestionably most powerful with which acquainted.

On this course of Peruvian Bark & Elixir of vitriol patient at present continued.

And cannot pretend to say that hitherto has produced much change for better on state of her complaint.

From account at last report fluor albus even greater than ever.

Yet in some other particulars complaint [alleviated]

Especially case with regard to Galacturrhoea & affection of mammae.

But whether even in this respect benefit obtained will be permanent cannot pretend to say.

While however no very unfavourable occurrence shall wish to persist in this course.

And to employ both Elixir & Bark to greater extent than have hitherto done.

If however manifest benefits from course & if long continuation of Cortex shall seem necessary may probably think of trying some less expensive substitute.

Has often been regretted that many foreign articles used in medicine while substitutes of equal if not superior powers every day before eyes.

But for want of accurate trial these powers neglected & unknown

These considerations led the Academy of Lyon in France to propose as subject of prize medal inquiry respecting best substitute for most expensive foreign articles.

This has given rise to a very elaborate dissertation by Mr Coste of Calais.

Of that dissertation a short analysis will [appear] in Number of Medical Commentaries which will be published in few days.

And among other things reader will [there] be presented with a table extracted from the [work] giving distinct view of affects of trials.

Among other articles several substitutes proposed for Peruvian Bark. The [illegible] of [table].

Or as according to latest & most accurate botanists it ought perhaps to have been styled the Cinchona.

Of substitute for Cinchona or Peruvian Bark several articles mentioned which natives of this country & grow in great abundance.

Particularly Salix Alba or common white willow & Prunus Padus or Wild Cluster Cherry

In place of Bark then may here employ one or other of these.

At same time must be allowed that this by no means case for judging properly of affects.

And if disappointed from bark cannot expect much from this.

If disappointed from internal tonics may have recourse to external ones.

And particularly with view to Galacturrhoea may direct astringent application to breasts.

Or may direct cold bathing as a general tonic.

If this course entirely unsuccessful may next at least make attempt to cure on very different principle.

By use vizr of gentle evacuants.

Particularly Diaphoretics & Purgatives.

These also failing should not here consider it as irrational to try some medicines of Nervous tribe

Especially those having tendency to diminish morbid sensibility.

For by such not impossible that all phaenomena of the affection may be supported.

Yet to be doubted if shall even have opportunity of trying all the measures already suggested.

And would even fain hope that may not be necessary to have recourse to them.

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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.