DEP/DUA/1/23/13 (Normalised version)

Mary Goodall

(1780)

---

Mary Goodall.

Has not attended here for some time past.

But when left us so far in favourable [train] of recovery that can have little doubt complete cure now effected.

And that probably in good measure by remedies here employed.

Disease of patient so distinctly marked that could have no room for doubt as to name.

External appearance of affection marked by obvious yellowness of whole surface but particularly of eyes.

This indeed taken merely by itself may proceed from different causes.

And particularly great reason to believe that sometimes is effect of change in colour of serum of blood.

Probably in some measure consequence of red globus being dissolved & broke down in it.

At least of this strong presumptive argument from what happens in case of ecchymosis.

There red globus effused in cellular membrane.

Before taken up, well known gives yellow colour to all neighbouring parts.

But such yellowness as here occurs, though possible that from blood, yet much more frequently matter introduced.

And of all matters from none so often as from bile.

When occurs from this cause attended with lassitude & debility.

While at same time takes place in sudden manner.

And although most obvious in some particular places yet more generally extended than perhaps from any other cause.

Here then from these circumstances alone great reason to conclude that depends on bile.

Well known that introduction of bile into blood constitutes at least greatest part of jaundice.

And whether wherever occurs are to consider disease as jaundice or not will in good measure depend on definition

For my own part am disposed to consider absence of bile in intestinal canal as being an essential constituent.

And indeed hold that this disease with greater propriety referred to obstructed discharge than any other.

From state of discharge though less obvious yet no less certain characteristic.

For excretion of bile into alimentary canal in many respects essential to system.

And has particularly very great influence both on discharge of faeces & urine.

In condition of these therefore as well as in yellowness, to seek for [constituents] of jaundice

Here however, at time history of case taken, patient not able to give all satisfaction that could have been wished.

Had indeed observed that urine of particularly high colour.

But had never made any trials whether capable of giving tinge to [linen]

That is whether contains any of [coloured] material of bile

And to appearance of stools had paid no attention.

While represented discharge by belly as in point of time nearly regular.

With regard to these circumstances therefore farther enquiries became necessary.

And notwithstanding appearance of countenance, report might have been such as to lead us to pronounce disease not jaundice.

But on this subject, after observations of patient, gave fullest satisfaction.

For will observe that between 17^th of May, & 26^th, day of second report, was not only subjected to bound state of belly, but had found faeces of white colour & urine giving yellow tinge to [linen]

From these circumstances then no room to doubt that bile wanting in alimentary canal & present in blood.

Or in other words that patient subjected to jaundice.

That all these appearances the consequence of obstruction to passage between liver & intestines universally allowed.

And therefore in strict propriety I think to be held as [illegible] cause of disease.

That is cause from which principal symptoms to be explained.

Yet how this cause operates has been very much subject of debate.

Into this controversy here foreign to our business to enter.

In practical lecture, delivered sentiments on this subject at considerable length.

And particularly in examining argument employed by an ingenious Professor at this place, for [overt] supposition of regurgitation & demonstration that entirely effect of absorption.

Here therefore shall wave all inquiry with respect to it.

May only observe that in a late practical treatise on jaundice published in German language by Dr Marcard physician at Hanover a [hypothesis] somewhat different from any before entertained is proposed.

Of this treatise, which contains many ingenious observations will soon see [analysed] in a number of Medical Commentaries now in preparation

May only observe that author laboured to establish distinction between bile of liver & that which has undergone preparation & change in gall bladder.

Endeavoured to show that former incapable of giving jaundice.

And hence infers that can arise only from latter.

This however he supposes not to be effect of immediate absorption from gall bladder.

But imagines that [transudes] through coats, into cavity of abdomen & thus abdomen

Although to this theory am not a [convert], yet far from denying every part of it.

In first place may observe that several objections to supposition of immediate absorption to which is not liable.

Secondly is a certain fact that the colouring matter of bile capable of transuding through coats.

And in third place, can be no doubt, of at least possibility of absorption from abdomen.

But allowing that bile thus taken up, does not follow that is only chance for admission.

And to its being sole mode of introduction there are I think many objections.

Cannot help still thinking, that neither this author nor any former [writer] have overturned argument brought to prove introduction by regurgitation.

Is however a matter of much less [consequence] in practice, by what means bile introduced, than by what cause [obstruction] is affected.

For on removal of obstructing cause removal of disease must depend.

And hence foundation both of prognosis & of practice.

In instance before us no circumstance which could lead to certainty or even high probability of cause

Of all causes the most obstinate, & what indeed often incurable are [comm] of ducts from scirrhous swelling of neighbouring viscera

Contraction, [induration] or even [coalescence] of ducts themselves from inflammatory or similar causes.

Here however none of those circumstances which universal forerunners of such affections

And indeed suddenness of attack with so little inconvenience in other respects strong objection to it.

Have a cause of jaundice still [more] common in biliary calculus.

These formed in gall bladder from various accidents, make way into ducts.

And perhaps from these greater number of instances of jaundice proceed than from any other cause.

That this may have operated with present patient by no means improbable.

And from nature must appear to be cause sudden in action.

But at same time stones [implanted] in duct seldom without some pain.

Of this our patient in no degree complained.

A circumstance chiefly occurring only where obstruction from viscid bile, or viscid mucus.

And this a cause from which jaundice still more slight than those depending on calculus often arises

From this circumstance then presumption that may have taken place in present instance.

And although at first suspected calculus am now inclined to think that proceeded only from viscid bile or mucus

With regard to prognosis, as consider case as having already terminated favourably all farther observations now superseded.

May only observe that when came under care was with no threatening appearance.

And from what already said, appeared that did not consider it as depending on a cause which threatened an obstinate or dangerous affection.

Yet had no reason to look for so expedient or complete recovery.

For by no means uncommon to find disease, even when appearance slight yet continuing with obstinacy for weeks together.

At same time even with firmly impacted calculus often very expedient recovery.

With respect to cure great objective to be [aimed] at is removal of obstructive cause

And for this purpose various measures taken according to nature of it.

When however affection of calculus, or of mucus, chiefly brought about in one of two ways.

1. By removal viz of causes tending to retain these example spasms or like.

2 By giving additional force to that furnished by system for expulsion.

These principles, will sufficiently explain intention in practices to which had here recourse.

As patient so free from pain had no reason to suspect any particular circumstance tending to retain [obstructing] cause.

Thought it therefore most proper to have immediate recourse to measures for [expulsion]

And was with this intention that directed emetic to patient.

In jaundice in general few modes of cure more frequently employed or more successful than emetics.

Cases indeed such for example as those depending on scirrhous in which not only unsuccessful but even hazardous.

But where arises from calculus of such a size that can pass through ducts no practice more successful.

And even when cannot pass yet often effective in pushing backwards.

In both ways affection equally admits of cure.

For large calculus may exist in gall bladder without any jaundice.

Principle on which effect here depends sufficiently obvious.

In no degree consequence of evacuation but solely of concussion.

Where succeeds therefore often an instant effect.

And where fails on different trials yet at least often brought about by repetition.

Hence then in jaundice from calculus no practice more common than course of emetics.

By some of best practitioners repetition advised for some time every day

Such a course then, when began first emetics if necessary meant here to have employed.

And accordingly as from first no obvious good effects directed repetition twice during course of succeeding week.

Besides this however had recourse also to another prescription viz Aloetic pills.

From bound state of patients belly thought that these might with advantage be combined with emetics.

And if obstruction merely from viscid mucus might even be means of removal.

Whether this was the case or not cannot positively pretend to say.

But vomits by some accident omitted.

Pills however had effect of gently opening belly.

And after continuation for space of week yellow colour very much diminished.

But had much stronger proof of removal of obstruction from both stools & urine assuming entirely natural colour.

Not improbable however that this [rather] effect of first emetic than of pills.

But to which ever owing gave certain evidence that cause of disease gone.

In this situation although directed continuation of pills yet considered farther measures as unnecessary.

And although have not since seen anything of patient yet look upon her as having obtained complete cure under our care.