DEP/DUA/1/30/24 (Normalised version)

Betty Smart

1783

---

Betty Smart. January 4^th. 1783

With regard to case of this patient have been & still am very much at loss.

Difficulty however not now [precisely] the same as at first.

For then many doubts respecting nature of affection.

Now chief difficulty as to mode of treatment.

But before saying anything of this first necessary to state former doubts as well as present sentiments respecting nature of disease.

When came under our care, as well indeed as at present, principal symptoms of the hysterical kind.

This affection evidently marked, in fits to which she is subjected.

Still more in pathognomonic symptoms of Globus hysteria

And may with confidence venture to say that hysteria often exists where much less distinctly marked.

To be observed however, that hysteria symptoms often feigned.

And that many females not only capable of very exact imitation of fits but even of inducing real fits when necessary.

Hence then incapable of judging with certainty even from seeing, still less from merely hearing account of fits.

But for doubt in present case, an additional reason occurred.

Affection here referred to a particular [cause]

Obstruction viz of menstrual discharge.

That this one of most powerful sources of disorder, in female oeconomy¹ no one can deny.

At same time often also pretended when does not really exist.

Or at least when obstructed at a period during which should not flow.

That is the state of pregnancy.

Frequently pretended by females that obstruction proceeds from other causes when wish either to conceal pregnancy or to procure abortion.

Before therefore can with confidence employ any powerful means of cure is of utmost consequence to determine this.

Which however only in general to be done by attending to progress of affection for some length of time.

When this patient however first came under care, from several circumstances, reckoned suspicion of pregnancy not improbable.

And this might be cause of Amenorrhea whether hysteria feigned or real.

For here, latter disease might proceed from other causes.

And by no means uncommon to find hysteria symptoms in pregnant state.

When first therefore begun treatment now so long ago as beginning of September entertained great doubts concerning nature of affection.

But if for these suspicions there had been any real foundation pregnancy would have been long since distinctly marked.

In four months which have since elapsed would have been indicated by obvious symptoms.

Now therefore, see little grounds for entertaining any doubt concerning account which she has given us.

And viewing hysteria affection as consequence of obstructed menstrual have little hesitation in considering as example of Hysteria Chlorosis of Sauvages.

At least as far as hysteria affection can give name to the disease, to which she is subjected.

But here will observe that do not consider hysteria as being primary [disease]

Has therefore at least equal title to be referred to Genus of Amenorrhea.

And here though patient only at 17^th year, yet from having already appeared at different times not strictly Emans. but Suppressed mensi.

A distinction the rather necessary in practice as menses may at first be obstructed from causes never afterwards operating.

Here therefore, following division of Dr Cullen, might give disease of our patient the name of Amenorrhea Suppressed.

But besides Amenorrhea & Hysteria will [observe] that in history of case, a circumstance mentioned still more alarming than either.

But a short time before selected as subject of lecture for Collegium Casuale² had been affected with Haemoptysis.

And although when case last taken no appearance of this kind yet could not venture to say that entirely free from it.

For well known, that from whatever cause it appears, very liable to remission & recurrence.

In so much that is only by frequent returns, that is in general found to terminate in Phthisis.

As having such a termination unquestionably to be viewed wherever it appears as an alarming affection.

If therefore to give name to disease from most important complaint to which [patient] subjected, should have no hesitation in pronouncing it Haemoptysis.

This disease however very much varied by differences in sex & circumstances.

And while, always much more dangerous in males than in females, in latter as arising from different causes [have] [very] great diversity in importance.

Of all cases, those the least dangerous which proceed from obstructed menses as cause.

In so much that nosological³ & practical writers consider this as distinctively the [case]

Here from circumstances already mentioned no doubt in considering present as an example of it.

May consider disease therefore as entitled to appellation of Haemoptysis catamenia of Sauvages – Haemoptysis vicaries of Dr Cullen.

Upon whole then three different genera the characteristic symptoms of which evident in present case.

And this circumstance for my own part have always considered as affording some objection to mode of [investigation] by nosologists [illegible] or [systematic] arrangement.

In different branches of natural history botany for example can never arrive at two conclusions.

Any flower which we examine from number of Stamina must belong to a determined & definite class.

But in diseases, affection may have just title as in present case to fall under several.

For my own part therefore although fully convinced of importance & advantage of nosological method, yet hold it to be matter of much greater importance to investigate nature than name of a disease.

And this in many cases may at least with some degree of confidence be able to accomplish by due attention to causes, [communication] & progression of affection.

On this subject however with regard to present case little need now be added.

Is indeed unacquainted with any particular cause to which obstruction of menses can be ascribed.

But this we are told was the first of her complaints.

And for my own part, now little hesitation in adopting her opinion, that is the origin to which all of them to be traced.

With this view then of nature of affection next to speak of prognosis.

And here must own by no means without apprehensions.

Some of complaints of patient indeed much more alarming than dangerous.

Amenorrhoea in every instance fatal only by its consequences.

And hitherto at least, few of those symptoms have taken place, tendency of which most certainly fatal.

Such for example as hydrops affection from evidently marked chlorosis.

Hysteria symptoms here the chief [which] take place although alarming yet very generally far from dangerous.

And even Haemoptysis as have already observed, much less alarming with females, & when proceeds from Amenorrhea than in any other situation.

Yet by continuation of all these can be little doubt that constitution must suffer very considerably.

And although at present no particular indication of either, yet would be by no means extraordinary if in short time should terminate either in Phthisis or Dropsy.

The rather to be apprehended, as little immediate prospect of cure of affection.

For have already, without effect, employed several remedies, from which I own more hopes of success than from any practices to which can now [have] recourse.

Restoration of menstrual discharge, also by operation of system itself, now much less to be expected, than if disease were in incipient state.

Has already continued for several months

And well known that tendency to return diminished in proportion to length of time for which wanting.

Besides this no reason to expect that soon any remarkable change on [system] of uterus with patient.

Such for example as that of pregnancy or the like.

And may here observe that should consider chance of recovery as better, if married than when single.

May also add that danger increased by age.

For is at present, at that period of life, when tendency to consumption, unquestionably strongest.

But although from these circumstances grounds for apprehension, yet disease can by no means be represented as in desperate situation.

Without restoration of menstrual discharge [indeed], cannot expect complete removal either of hysteria affection, or prevention of return of haemorrhage, by lungs.

Yet both may be moderate, & influence on system counteracted.

Hence then even with continuation of Amenorrhoea may not only prevent increase but even obtain mitigation of affects

But besides this, restoration of menstrual discharge one of those particulars in oeconomy concerning which great uncertainty.

Still much uncertainty both with regard to principle on which discharge proceeds & to causes of obstruction.

Hence then where practices appearing [best] accommodated fail, others seemingly much less so, will sometimes succeed.

Nay discharge will often spontaneously return, when entirely at loss from what cause it proceeds.

Thus not altogether without expectation, that in this manner, complete removal of all symptoms may suddenly take place.

These then sufficient to encourage to trial of different practices.

And with view to all different affections to which patient subjected, many which may be employed.

Yet must own very much at loss to determine which can be used with great [possibility] of [success]

Accordingly since commencement of case under our care have already tried different practices.

After reason to infer that suspicion of pregnancy groundless, endeavours chiefly directed to restoration of menstrual flux.

Want of this discharge may proceed from very various causes.

But apprehend that all of them ultimately operate on one of three principles.

Either depend on want of due accumulation of blood in uterus.

Want of due action of that viscus after blood is accumulated.

Or uncommon obstruction to passages through which should naturally make its way.

In case before us, saw no circumstance which could give presumption either of first or of last.

As patient had already regular menses for several periods, certain evidence that no [unsurmountable] obstruction depending on structure of parts.

As manifest tendency to vicarious haemorrhage occurring under form of haemoptysis had at least evidence that no want of blood in general symptoms.

While at same time symptoms [preceding] haemoptysis such as gave presumption even of due accumulation in uterine vessels.

From these circumstances then inclined to conclude that Amenorrhoea here proceeded from want of due action of uterus after accumulation there had taken place.

And this supposition seemed to be corroborated by constitution of patient.

Particularly by fair [countenance] delicacy of habit & hysterical complaints.

From these considerations then conclude that discharge would most readily be restored, by giving uterus due, [power] of action.

That is by increasing tone either from action on uterus itself, or on system in general.

On this ground will understand why had recourse to first remedy, mentioned in history of case use viz of Chalybeate.

These well known, to be among more powerful tonics, which possess.

Hence few remedies more frequently in use both in Amenorrhea & Hysteria.

And will particularly observe, that strongly recommended by Mr Sauvages in Hysteria Chlo. one of the names, which have observed applicable, to affection of present patient.

Here as one of best chalybeates with much acquainted employed Rubigo Ferri.

This exhibited as united with powder of Valerian.

Here added in some degree with intention of giving proper formula.

But still more from hopes that might be conducive in allaying inordinate [illegible]

For have no doubt that in certain circumstances, from impression which gives to stomach has in this way powerful influence.

That thus effect on Nervous energy very great, no one can deny who has ever witnessed its influence on Cats.

And indeed with them, a remedy to which directed by instinct for counteracts nervous diseases to which liable.

On these grounds then expected some advantage from proper trial of this remedy.

But after such a trial made, found expectation disappointed.

After this therefore had recourse to another practice which reckon still more powerful in Amenorrhea.

Use viz of Electricity.

Of all emmenagogues yet introduced into practice this in my opinion the most powerful.

Particularly where Amenorrhoea depends on want of due action of uterus.

Here I apprehend operation to be explained in two ways.

Sometimes has effect of inducing immediate action.

Sometimes of restoring power of action where lost or diminished.

Influence in latter of these ways exemplified in restoring power of motion to paralytic limbs.

On former again, have evidence of influence by convulsive motion which excites, in muscles of an animal apparently dead, & with whom all other stimulants ceased to have effect.

Thus then can I think readily understand why should be a powerful remedy in Amenorrhoea.

And accordingly utility in that affection now fully confirmed by publications on the subject by Dr Saunders Mr Birch & many others

And remedy itself daily use with most practitioners in this country.

Hence then even after chalybeate had failed entertained expectation of benefit from use.

But in present case, a circumstance occurred, by which prevented from, giving it fair trial.

Though electricity ordered to be employed in gentle manner had here a very [peculiar] effect.

Patient constantly found herself much [weakened] after coming from the wheel.

And this weakness to such extent even as to give tendency to deliquium animi.

These circumstances am disposed to attribute not so much to electricity as to fear [which] patient had been under.

For well known that even with the robust & vigorous Electricity [to] some individuals gives peculiar & very distressing sensation.

Hence then will hardly perhaps seem surprising that with irritated & hysterical female, should induce weakness & even tendency to deliquium.

Yet must view this effect as somewhat singular from having never before met with it.

And that too although have frequently employed hysteria with females of most timorous & irritated habits.

Hoped the rather therefore, that this unease from slight habit might go off.

But feelings of patient, for space of eight days, continued so distressing to her, that determined for present at least, to [illegible] use.

After trial therefore for eight days, during which time had no influence in restoring discharge, was omitted.

Besides these, before selected as subject of practice at Collegium Casuale, some other remedies also tried.

But these principally intended for obviating such urgent symptoms as have at times occurred.

After received as patient at Collegium Casuale first practice to which had recourse was Calc of Zinc.

Of this remedy in treatment of case of Arabella Wallace had very lately occasion to speak.

May here only repeat, that since introduced by Dr Gaubius have frequently employed it & [any] think with remarkable advantage.

Here intention with which chiefly used was with view of obtaining effects of Tonic.

In this manner as well as chalybeate expected that might be means of restoring menses

But had still greater expectation from influence as counteracting hysteria affection.

In this way have often I think seen good effects from it.

And if this could be counteracted hoped that restoration of menses might more readily follow from operation of system itself.

For no doubt that those inordinate actions which take place in hysteria frequently effect of checking discharge.

After due trial of Zinc however have been disappointed.

And have deserted use as inadequate to removal either of Hysteria or Amenorrhoea in present instance.

During employment of Zinc other practices sometimes introduced with view of [obviating] [symptoms]

Particularly with view of moving belly. And to be observed that tendency to costiveness often remarkably great.

Was with this view that had recourse to Pill Foetid cum Aloe.

These at first even in small dose had effect of inducing several loose stools.

But afterwards so far lost influence that substituted to them the Pulveris Jalap composite.

From this even to quantity of half a dram only obtained wished for effect.

But at last report found that had been affected with some return of bloody expectoration.

In this situation wished to avoid the stimulating effects of Jalap.

Have therefore directed, with view of moving belly Cream of Tartar without any Jalap.

And as means of counteracting hysteria symptoms particularly palpitation have advised use of Tincture Fuliginis.

At present however directed only in small dose

And if no inconvenience from use may probably try effects to greater extent.

But from this I own have bestowed little expectation.

And must also add that now very much at loss what practices to direct with much prospect of success.

When however present haemoptysis has ceased have thoughts of making trial here of the Rubia Tincture.

If succeeds will be by much strongest case that I have yet met with in favour of the medicine.

If fails, will be no more than has already happened to other Emmenagogues & therefore no grounds for concluding against it.

If disappointed from Rubia have some thoughts of trying a practice very opposite to course hitherto followed

Use viz of Warm Bathing or at least [illegible] conjoined with Opium.

Particularly employing these at period when reason to expect tendency to flow.

If this shall fail, will probably have recourse to trial of other tonics

Particularly Peruvian Bark & when the season will permit of it Cold Bathing

But in these must be very much directed by circumstances.

And if are employed shall probably afterwards state opinion with respect to them at more length.

---

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) A term used in the 1700s in Leiden, Padua and elsewhere to describe clinical teaching, using demonstrations of outpatients.

3) 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.