DEP/DUA/1/19/05 (Normalised version)

Helen Essex

(1778-1779)

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Helen Essex.

In History given of complaint of this patient many different symptoms enumerated.

And these still continue with patient very nearly in same state as at time of admission on list.

Although however apparent diversity of symptoms are for most part indicative of two particulars.

Either of general debility or of debilitation of alimentary canal in particular.

Of first kind are weakness, pain of back, want of sleep & several other particulars.

Of last kind are flatulence. vomiting dyspnoea & headache.

These different symptoms as proceeding either from debility of alimentary canal in particular or of system in general may arise from different causes.

Here however can have little doubt in referring both of them to one particular viz State of menstrual discharge.

Every one in least conversive in practice must soon be satisfied how much influence state of this discharge has on condition of female oeconomy¹ in general.

And if obstruction product of numerous & dangerous symptoms those from increased flow no less alarming.

Accordingly in all nosological² systems & with almost every practical author the uterine Haemorrhage or Menorrhagia considered as genus.

But among different nosologists perhaps best definition is that given by Dr Cullen.

For not only takes in flow of menses to preternatural extent but also pains of back belly & [loins] in some measure resembling those of labour.

From finding therefore in case of our patient all these symptoms can have little doubt in affixing to it this name

And can have no difficulty in agreeing with patient in referring all symptoms to which she is subjected to frequent returns & large discharge of menstrual flux.

But besides mere bloody discharge little doubt that all circumstances aggravated by another particular.

Discharge viz of white matter from Vagina occurring immediately after menstrual flux has ceased

This discharge well known to be chief circumstance characterising a particular genus of disease very common with females viz Leucorrhoea

And although occurs also in some others as Gonorrhoea yet here there can be no suspicion of such an affection.

Only question therefore whether to be reckoned a separate disease or as part merely of other affection.

With some of best nosologists example Dr Cullen Leucorrhoea does not of itself constitute a genus.

But genus of Menorrhagia divided into Cruenta & Serosa.

While under last of these terms Leucorrhoea of other authors [illegible]

Must however own that inclined to follow those who consider them as separate generas.

And although often as in present case conjoined yet in number instances also totally unconnected.

To which may farther be added that often even in nature essentially different.

And here with respect even to Menorrhagia deserves to be remarked, that all circumstances by which it is characterised may occur from very different causes.

And in treatment of any particular case, of consequence to determine the nature of the cause.

Am inclined to think that every instance of increased discharge from the uterus under form of Menorrhagia may ultimately be referred to one of three circumstances

1 Uncommon determination of blood to uterus

2. Increased action of vessels of that viscus in same manner as in other cases of active haemorrhage, or increased action of uterus itself analogous to that giving menstrual [flow]

3. Want of due resistance to impetus of blood at uterus after vessels [illegible] become [illegible] in same manner as in other passive haemorrhages.

And here both with respect to prognosis & practice of material consequence to determine to which of these causes is to be referred.

Into circumstances however on which this investigation must proceed & into marks indicating each state do not now propose to enter.

For sentiments on this subject may refer to Volume of Medical cases³ published last Summer.

Here would only observe that from principles there laid down am inclined to consider present case as depending chiefly on latter cause.

Want viz of due resistance in uterine vessels

Of this very strong evidence from Menorrhagia terminating in Leucorrhoea.

A circumstance, even by itself, to be considered perhaps as stronger mark of laxity than even large evacuation of blood.

Here however both circumstances conjoined.

And although in some cases Menorrhagia & Leucorrhoea separate & distinct yet in present can have no doubt that both consequences of same morbid affection

From this laxity would account not only for extent of evacuation but also for frequency.

Am indeed inclined to believe that in order to [induce] of menstrual discharge in natural state, besides local accumulation of blood in uterus certain action of that viscus also requisite.

And from supposing inordinate state of this action can best account for [preternatural] frequency of return.

Yet from want of due resistance on occurrence of action Haemorrhage will be most easily induced.

And highly probable that will also take place more speedily.

Or at least that discharge of blood will ensue from action which otherwise would have no effect.

Upon whole then consider present case as depending if not entirely at least principally on state of laxity in uterine vessels from which incapable of giving due resistance to impetus of uterine blood.

At same time would by no means positively assert that is sole cause.

And must indeed be allowed that frequency of return gives some presumption of inordinate action of Uterus.

Have thus then delivered opinion as to name & nature of this patients affection.

And on these grounds come next to offer conjectures with respect to termination.

Here must own that from several circumstances expectations of recovery by no means sanguine.

According to account given us indeed before patient came under our care had employed no medicines.

And are certainly possessed of many medicines which have great activity as countering that morbid condition on which suppose affection principally to depend.

But any hopes which can be built on these circumstances more than [counterbalanced] by others.

Affection even in most slight form well known to be frequently obstinate.

And indeed Menorrhagia from this cause very generally more so than what proceeds either from increased impetus at uterus or augmented action of uterine vessels.

But to general obstinacy of affection several circumstances here to be added.

With our patient can by no means be said to occur to slight degree

The contrast may be justly inferred both from extent of discharge at once, frequency of return & symptoms which has induced.

With our patient does not occur in simple & uncomplicated state.

And perhaps conjunction with Leucorrhoea affords even grounds for more unfavourable opinion than any of circumstances mentioned above.

To these however must farther add a circumstance of still greater weight.

That is continuation of affection.

Has already remained with patient for about space of three years

During that time nothing abated in violence but as far as subjected to any [change] has increased.

In this situation then may consider it as having now become in some measure habitual.

Hence then less surprising that has resisted different practices already employed.

Although at same time this also to be ranked among unfavourable circumstances.

And from all taken together little reason to expect speedy recovery.

Would not however from this be understood to pronounce affection highly dangerous

For even considering haemorrhage after then becoming habitual less distressing than at first.

Systems acquiring by habit power of [generally] [proportional] supply.

Although therefore should fail in cure yet hope that patient may not be cut off by affection.

And after all our attempts ineffective may yet have natural recovery.

This particularly to be looked for at time when menses may naturally be supposed to cease.

And when consider that patient already near 40^th year may look upon that [period] as not now far [distant]

Meanwhile however in expectation of this attempts to cure not to be neglected

Come next then to speak of plan on which these attempts to be conducted

Here great objective unquestionably is the restoring to vessels of the uterus that condition by which will be capable of giving due resistance.

But besides this in as far as tendency to inordinate action has taken place this also to be removed.

An end chiefly to be effected by removing peculiar irritation or disposition to action.

While again resistance to be augmented by increasing tone of system in general & of uterus in particular.

But while medicine employed with view to these ends not to be expected that urgent symptoms will not at times occur.

And hence without regard to general plan, sometimes even in opposition to it medicine must be directed to the obvious [illegible]

Is with view to general principles now mentioned that practices here directed have been employed.

Of these then next to speak.

Began this patient by putting her on use of an article which has not place in our Pharmacopoeia⁴.

viz Salix Alba.

An article which not only a native of this country but which grows almost in every part of it in great abundance.

Interior bark of this vegetable for a long time in some degree in use.

Has not however as far as I know entered [lectures] of many [colleges].

And has never had place in any edition of Pharmacopoeia of Edinburgh College⁵.

Only list in which have been able to find it is that of Dispensatory [Brunswick]⁶

Which while is one of latest considered also as one of best Pharmacopoeias [yet] [extracted].

There mentioned, only however in a general way as remedy for intermittent fever.

In confirmation of this assertion am informed by Dr Soemmering a gentleman at present residing in this place that has often seen it used in intermittent fever with advantage.

But in present instance principally led to trial of it on authority of an eminent French practitioner Dr Coste.

A gentleman to whom medical world much indebted for series of very useful experiments which has lately made with view of ascertaining how far foreign articles of high price may be supplied by articles indigenous in Europe.

And among others has recommended Salix Alba as substitute for Peruvian Bark

And from trial in different cases is inclined to consider it as possessing Febrifuge as well as astringent power of that medicine.

How far operation of Cortex Peruvian as febrifuge depends on any other quality than astringent or tonic power is with many matter of doubt.

But without entering into that [controversy] may observe that its having same sensible quality gives at least presumption of its possessing in some degree same medical virtues.

From this then hoped that such a state of vessels might be induced as might tend in future to prevent both excessive haemorrhage & fluor albus.

In these expectations however after had continued trial of medicine for some weeks were disappointed.

And either medicine inadequate to effect, or not exhibited here in such manner as to obtain full advantage from it.

As well indeed as Peruvian Bark & other analogous articles may expect most benefits from it when exhibited in substance.

And is in this state to extent of one or two drams for dose that advantage to be given by Dr Coste.

To me however appeared that could not be reduced to powder without very great difficulty.

Exhibited it therefore in form of watery infusion.

And by this menstruum active sensible quality at least very effectively extracted.

Was merely with view of preventing [mustiness] that here added a small proportion of spirit.

But even although this may be affective way of extracting virtues may still have been exhibited in under dose.

Yet from effect of exciting sickness at stomach & even vomiting could not push it farther.

Considering this therefore as case in which could hardly have fair trial have now substituted to Salix Alba the Peruvian Bark

And with view of answering same intention have given also a Mineral tonic the Elixir of Vitriol.

From this course however do not hitherto seem to have [reaped] more advantage than from former.

While at same time has had so far affect of binding belly that have been obliged to have recourse to different measures for obviating costiveness.

But excepting this no other symptom as occurred so urgent as to require farther attention.

If however patient does not soon derive benefit from course at present followed with view to radical cure shall not think of continuing it much longer.

Still however only expectations of being of service are from use of astringents & tonics.

And before dismissing her may [perhaps] make trial of some other of these

Particularly of Pulveris Stypticus of Edinburgh Pharmacopoeia which now consists of mixture of Alum & Gum Kino.

If this also abortive have thoughts of giving here trial to metal tonic the Copper.

And this will employ under form of Pill Caeruleae.

From which imagine that some reason to hope for advantage both as increasing resistance to blood & as [diminishing] disposition to inordinate action.

If this also ineffective shall probably dismiss patient with recommendation when season will permit to try effects of Cold Bathing

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Explanatory notes:

1) Oeconomy is an archaic spelling of economy. In the context of medicine, the term animal oeconomy refers to the living system and its management. In these case notes all but one of the cases where this term is used are female.

2) 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.

3) Andrew Duncan, Medical cases, selected from the records of the Public Dispensary at Edinburgh : with remarks and observations : being the substance of case-lectures, delivered during the years 1776-7 (1778).

4) 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.

5) The Royal College of Physicians of Edinburgh, established in 1681.

6) A book or medicinal formulary containing a systematic description of the drugs and preparations used in medicine. The Brunswick Dispensatory, published in 1777, was described by Bartholomew Parr in The London Medical Dictionary (1819) as 'a very inferior work, abounding in all the useless exuberance of some ancient collections'.