DEP/DUA/1/17/13 (Normalised version)

Janet Brown

(1778)

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Janet Brown.

With case of this patient have very great difficulty.

And must here acknowledge that equally at loss both with respect to name & nature of the affection.

In doubt also whether should consider affection as being of simple or complicated nature.

All symptoms in affection to which is subjected may have originated from one cause.

Or may depend on particulars totally unconnected with each other.

And is at least somewhat in favour of this latter supposition that such a combination as here occurs not common.

Of symptoms to which is subjected those of longest continuation are affections of head.

Here chief particular of which she complains is pain at different parts of head.

This pain in some degree constant both in fore & back part of head.

But still more remarkably severe on left side particularly about condyle of jaw.

Pains affecting different places now mentioned can by no means be considered as a rare occurrence.

And in different nosological¹ systems pains of head considered as constituting even several different genera.

Particularly Hemicrania Cephalgia Cephalalgia etc

In all these cases however without any external appearance.

And probably without what can be considered as a topical cause.

Here however circumstances somewhat different.

For with pain at different [times] since patient came under our care manifestly affection of eye.

Tunica conjunctiva in affected side considerably more red than natural & more so than other side.

This affection however without either hectic or acute pungent pain.

May therefore be some doubt how far to be viewed as proper active inflammation

But if question respecting nature not less with respect to extent of this affection.

For as already remarked symptoms of disease not merely confined to eye

Pain much more considerable at other parts of head

And these also symptoms if not of same at least of very considerable local affection.

For between cranium & integumentary manifest marks of effusion of fluid matter

And least consider us as having sufficient evidence of this from fluctuation there discovered

When case indeed taken was rather [obscure] as otherwise.

But at different times since patient came under our care has been very obvious.

Yet what nature of it must own cannot positively say.

For although can conceive it only to proceed from fluid, yet may be affection of fluids of different kinds.

And particularly may proceed either from watery, bloody, or purulent matter.

Yet when consider that after being for some time very manifest will soon again disappear may conclude that of ready absorption.

And from this circumstance perhaps greater probability that of former kind than of [either] of two [latter].

But must at same time acknowledge that have never seen watery effusion in form here occurring.

But if any difficulty from this source is equally if not more an objection to supposition of effusion either of bloody or purulent matter.

When however on this subject can at utmost but conject shall not be much surprised if in end find myself mistaken.

Present opinion however is that obvious affection both of head and eye from cause in some measure [same]

That latter principally affection of blood making way into vessels not naturally filled to receive it.

And this not so much from increased action, as from relaxation in vessels [themselves]

Same relaxation also supposed to operate as cause of augmented effusion of watery fluid.

And from distension thus given to integumentary together with state of parts would account for pain

On this view of affection of head what name to be given to this part of the disease must own am at loss to say.

If as here conjected really a watery fluid [source] title to be ranked under genus of hydrocephalus.

And corresponds at least more [exactly] with definition of that genus as given by nosologists than species much more important.

Common division of hydrocephalus has been into externus & internus, or exterior & interior.

Apprehend however that if to found species here, on differences either in symptoms or nature may with greater propriety be referred to [three]

Hydrocephalus viz of Ventricle of brain, of Cranium or of integumentary.

First takes place when water [solely] confined within ventricle

And in this way effusion even to small extent almost certainly fatal.

In second case not lodged in ventricle but between skull & the brain.

This also as well as former very generally at least fatal

And by no means to be considered as a rare occurrence.

Here however while progression more slow death occurs only as consequence of more considerable effusion.

Third and least case hydrocephalus of integumentary perhaps more rare occurrence than [either].

And here water [entirely] external to cranium

Hence then cannot seem strange that should not be attended with dismal & dangerous consequences resulting from other kinds

Nor can it be wondered at that takes place but as rare occurrence.

For when effusion takes place here as no other cavity to receive it must happen principally if not only in cellular membrane.

And there from free communication of cells will soon make way into other in more dependable situation.

Hence then hydrocephalus of integumentary as may be called chiefly connected with general anasarca affection.

This however not appearing in present case.

For while no evidence of anasarca in other parts does not here appear under that form even in integumentary of head.

That is not a swelling retaining mark of pressure but giving sensation of fluctuation.

Must here therefore conclude that matter [effused] forms as it were larger cavity.

And somehow confined between integumentary & skull.

Still however if consists of water may be considered as a variety of this species of hydrocephalus.

And such an opinion have already observed am disposed to adopt as to this part of affection

Even allowing however that conjecture right both as to name & nature of this part of affection yet can by no means be viewed as whole of patients disease.

And perhaps even to be doubted whether are to look upon it as most material part of it.

For besides these affected also with [another] & apparently very different set of symptoms.

That is affection depending on flatulence.

Besides feelings of patient there manifested by almost constant eructation.

And must even observe that have never met with any patient where this so remarkable.

Patients frequently greater obvious distension from wind than takes place in present instance

And often also even greater pain.

But with our patient such frequent & constant discharge as gives evidence of superabundance in alimentary canal

And at same time, of that inordinate action as may be called by which is discharged upwards.

Of the two am disposed to view this latter circumstance as the most considerable.

For while obvious distension from wind not very great, disposition to inordinate action in alimentary canal, demonstrated not merely by eructation but also by vomiting & looseness.

Former, without any nausea often consequence merely of taking food.

While latter has arisen to considerable degree from medicines which in ordinary cases do not operate as inducing it.

Would then upon whole ascribe uneasiness from flatulence here rather to peculiar state of alimentary canal than to any very great extrication of air.

Have however little doubt that both circumstances in some measure conjoined.

But whatever may be share of each some other particulars in affection which should be disposed to refer to this source.

To this origin may probably refer difficulty of respiration.

For wherever distension of stomach the consequence of flatulence free action of diaphragm must necessarily be somewhat impeded.

But still more particularly may to this cause refer vertigo

Well known that not only this but also Tinnitus aurium & various other new affections are consequence of peculiar impression on alimentary canal.

But particularly of that stimuli which arises from sudden distention.

May here perhaps also be question whether impaired vision with which patient formerly affected may not also be referred to same source.

This however a symptom with which now affected to slight degree only.

And must own am disposed rather to refer it to affection of head.

For to be observed that formerly when not at all troubled with flatulence was more considerable than is now.

And that as a symptom of affection of head there occurs an obviously diseased state of eye.

True indeed that from all distension of vessels, cannot suppose that any diminution of vision here occurs from offuscation of Cornea

But when consider that besides obvious disease of eye, other parts of head still now affected led to different explanation.

And may reasonably conject that affection not less considerable in those parts of eye which not exposed to view than such as are obvious.

May conclude therefore that may give depravity of vision from affection of retina or of optic nerve

Thus then have afforded at least some conjecture respecting this complicated, difficult & [uncommon] case

Upon whole disposed to view patient as subjected to two distinct affections those viz of head & of alimentary canal.

Consider former as depending principally on a watery effusion from relaxation of vessels.

And latter as being in some measure consequence of such a state as gives latitude for uncommon extrication of air

But still more from peculiar condition of sensibility giving rise to inordinate action.

These opinions however must necessarily suggest with very great [diffidence].

For must conclude as have already observed that present affection not distinctly marked as belonging to any genus with which am acquainted.

Nor indeed in course of my practice or reading I have met with any cases in circumstances similar to it

From this acknowledgement then will not surprise you that express great doubt as to Prognosis.

Even on supposition that all conjectures thrown out are well founded, termination must yet be very uncertain.

In affection however of alimentary canal nothing at least threatening immediate danger.

Yet at same time as inducing general debility of system even this may at last prove fatal.

Still more however to be apprehended from affection of head.

Especially if as have here conjected affection of vision the consequence of watery deposit.

For if that the case reason to fear that may take place within as well as without cranium.

And if ever comes to give compression to brain, great reason to fear that will be attended with most [serious] consequences.

Still however if excepting circumstances of vision no reason to think that acts even on any considerable nerve.

And while affection whatever it be continues totally in integumentary exterior to skull, little to be apprehended from it.

On this view then am upon whole disposed to consider affection as one which threatens rather to be tedious & troublesome than dangerous.

And that will be tedious besides appearance may farther be inferred from length of time for which has already continued.

Is now about four years since first commencement of affection.

And during that period although has sometimes yielded to medicine yet relief at utmost has been but temporary.

Upon whole affection may be considered as having been increased in violence.

In these circumstances then if to judge either from opinion of nature of affection or from such particulars as admit of no doubt are led to look upon it as a complaint which will prove obstinate perhaps even in end fatal.

Even supposing conjecture ill founded little reason for entertaining opinion more favourable.

And allowing that symptoms to be explained on very different footing from that here proposed no reason to flatter ourselves with speedy or favourable termination.

And perhaps even greater grounds for apprehending danger than on conjectures stated.

Still however something to be hoped for from proper administration of remedies.

Especially as from practices formerly instituted, although radical cure not obtained yet considerably alleviated.

May therefore I apprehend again hope at least for some good affects from use of medicine.

But on same grounds that difficulty respecting name & nature of disease must also be at loss to say by what remedies such relief most readily to be obtained.

And here very much at loss to say on what rational plan, cure can properly be conducted.

According to opinions delivered am disposed to consider affections of head & of alimentary canal as unconnected.

Hence to be combatted by different remedies.

Treatment of first on supposition that principally depends on watery effusion should be inclined to conduct on same principles as other dropsical affections.

That is by attempting removal of water already deposited & by prevention of farther deposits.

In measures however which could employ with these intentions in several respects [restrained] from presence of other affections.

And although disease of head may be most threatening part of complaint yet not most urgent

Hence then no less attention requisite to symptoms depending on affection of alimentary canal.

And these according to idea which have ventured to suggest principle consequence of peculiar state of [sensibility] giving rise to inordinate action.

Radical cure therefore to be looked for from removal of such a state.

Yet more immediate relief to be had from counteracting inordinate action.

From inducing such a state of action as will tend to propagate wind that may be extricated in natural course of intestinal canal.

And lastly from avoiding whatever can have tendency to extraction of air either in stomach or intestines

Is on these general principles that practices already directed for this patient have proceeded.

Removal of water here deposited could [alone] be expected either by natural or artificial outlets.

From chief natural outlets however [those] viz by stool & urine in great measure precluded from [action] which such medicine [must] exert on alimentary canal.

By these circumstances then led rather to think of attempting discharge by artifice.

And for this purpose nothing better suited than gradual evacuation produced by Blisters.

Especially when running supported by application of issue ointment.

In these measures here greater grounds for confidence as formerly found to succeed.

But while might have expected good affects with view to evacuation of water no reason to look for any benefit as alleviating other parts of affection.

Is with this view that at different times have had recourse to different stimulants & antispasmodics.

With this intention had first recourse to powder of Valerian combined with ginger.

But finding that not product of any considerable affects.

That did not serve to keep patients belly open

And that patient always most easy with certain degree of looseness soon led to omit it.

At first substituted for it the pilulae Gum

And was in [hopes] that from Assafoetida would act both as gentle laxative & as obviating inordinate action.

But soon after begun pills became affected with considerable looseness.

Here indeed questionable how far this to be ascribed to pills.

But whether consequence of these or not could be little doubt that would tend to support it.

And as little, that although open belly of service, considerable looseness would be prejudicial to patient.

This then sufficient grounds at least for omitting use for some time

During this intermission however considered it as no improper opportunity to try another antispasmodic.

And with this view had recourse to Aether

To this chiefly led from [attending] to affects observed to result from it in some cases of Hysteria.

There very frequently happens that most distressing symptom from flatulence occurring as consequence of inordinate action.

And in such cases use of Aether frequently attended with most manifest & [most] sudden relief.

With our patient however, not so considerable as to [encourage] to continuation of use.

From this then led to repetition of Assafoetida as an antispasmodic.

But in place of solid now employed it in fluid state.

That viz of Tincture Fuliginis.

And with intention both of aiding operation & of assisting radical cure [conjoined] it with bitters & aromatics.

The Tincture Amarum viz or Elixir Stomachicus

While on [use] of this medicine however [discharge] from issue probably from inattention in [great] [measure] [ceased]

And swelling of head which before very considerably diminished again augmented.

From this led to repetition of Blister & direction of continuation under form of issue.

As now also tendency to, looseness [illegible] with assafoetida in fluid form conjoined in solid state.

And again directed pill foetid even to greater extent than formerly.

In some particulars however of course thus begun were soon interrupted

For patient became much distressed with a stranger affection which could have no hesitation in ascribing to action of cantharides.

From this therefore whatever might be advantage of issue necessary to discontinue it.

And as pills had no longer affect of inducing looseness omitted mixture employing these alone.

On these then patient at present continued

And notwithstanding various remedies to which have here had recourse cannot say that much benefit by any thing yet done.

Affection of [head] indeed at time of last report was but inconsiderable.

That however will again soon return is at least more than probable.

And after trial already made of Assafoetida if patient not soon better can hope for little from continuation of it.

With regard to both however much at loss to think what other measures can be adopted with greater probability of success.

And notwithstanding intermission of issue at present from strong affect yet if return of affection of head shall probably again have recourse to it.

But if continues still distressing may substitute seton in neck.

Or may try external friction of parts affected either in way of dry rubbing or with oily or stimulating application.

If these measures abortive shall be directed in future practices rather by appearance at the time than by any view which at present have of the affection.

For affection arising from wind after fruitless attempts already made by Antispasmodics have next thoughts of trying tonics

Such for example as Peruvian Bark Cold Bathing, or Electricity

But previously to this have thought [of] trying chalybeate.

These measures may be prosecuted in [illegible] & with some advantage.

But whatever affect will be necessary that at same time such means employed as will serve to keep patients belly gently open.

And is from [this] chiefly that have any expectation of giving much relief to patient.

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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.