DEP/DUA/1/41/02 (Normalised version)

Agnes Mitchell

(1786-1787)

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Agnes Mitchell

In case of this patient many symptoms.

And these occurring in different [diseases]

Among others obstruction to usual menstrual discharge.

This well known may give rise to almost infinite diversity of symptoms.

And on other hand frequently merely symptom of other disease.

In these cases however mode of treatment essentially different.

Hence wherever occurs of essential service to determine whether to be viewed as cause or consequence of disease

In case before us as formerly [imagined] was inclined to adopt former opinion.

And to consider patient as subjected to idiopathic amenorrhoea.

To this chiefly led, 1^st from symptoms here taking place.

For all of these while not characteristic of any particular disease such as every day consequence of obstructed menstrual.

But still more from progression of affection

For to be observed that obstruction occurred as first [appearance].

Or at least from time that any symptoms took place menstrual discharge [illegible]

And from any inquiry made no reason to believe that previous to this any disease had taken place.

Where however amenorrhoea symptoms this not the case.

For principal disease, not only distinguished by peculiar marks during course of obstruction but observed to precede it.

Hence disposed to adopt opinion of patient in considering symptoms as [arising] from [want] of menstrual discharge.

But when this case still [illegible] circumstance to be attend to in Diagnosis.

Whether viz menses should flow or not.

Need hardly remark that should be obstructed during pregnancy.

And that obstruction, there attended with same marks as in idiopathic Amenorrhea.

Often however pregnancy denied & other causes pretended.

Hence in every instance this circumstance particularly to be attended to.

And will often for some time at least prevent cautious practitioners [from] use of powerful remedies.

This I own somewhat my case when this patient first came under care.

Saw indeed no circumstance giving particular suspicion of pregnancy.

And had assertion both of patient herself & her mother that did not proceed from that cause.

While if did not only deceive us in this, but also in many other particulars

For few of symptoms of which she complains though frequent in amenorrhea occur in pregnancy.

Such for example as pain of back & breast, twisting & [constriction] of bowels etc.

And symptoms of pregnancy as sickness at stomach vomiting etc wanting.

Were told that menses already obstructed for six months.

If however pregnant for that period, other marks, as enlargement etc, must have already appeared.

Besides this according to account given obstruction said to have taken place [without] any obvious cause.

By these however wishing to conceal pregnancy & to deceive some obvious cause for obstruction also pretended.

Such for example as imprudent exposure to cold, irregularity with respect to diet or like.

From these considerations then even from beginning disposition to look upon case as idiopathic amenorrhoea.

At same time no urgent symptoms requiring active medicine.

Thought it therefore prudent to attend to patient for some time

And at least to observe whether [during] that time, any circumstance should occur, giving suspicion.

From attention however to case no reason to alter opinion.

On contrary still more [confirmed] in sentiment that to be considered as example of idiopathic amenorrhoea.

From this view of nature of case could not speak with certainty as to termination.

For a disease which with regard to time at least, always precarious.

Often baffling utmost efforts.

And even then unexpected return by mere efforts of system itself.

Cases thus obstinate, where disease appears even most slight.

And where with patient in other respects in best health, obstruction has occurred as consequence of some accident

Here the rather uncertain in prognosis as cause unknown.

And might therefore either depend on some very trifling circumstance or on some change in system of uterus, not to be removed.

But though uncertain as to conclusion yet no grounds for apprehending danger.

At least no symptom of alarming nature had taken place.

And after absence for six months already duration of affection, not to be [expected].

Is indeed true that affections of most dangerous tendency & almost [illegible] sometimes consequence of obstruction.

Particularly convulsions & whole [train] of nervous symptoms.

But these, commonly make appearance in no long time.

And particularly severe when menstrual blood accumulates in uterus for 2 or 3 periods.

Often however, no such cause of unease takes place.

Though discharge obstructed; yet no accumulation in cavity of uterus.

And in most instances not an alarming disease.

Even where incurable yet not dangerous.

And this I own was more disposed to think would here happen than that would prove fatal to patient.

But at same time was more inclined to hope that should be able to accomplish cure.

And when consider age, state of health & other circumstances of patient hoped that soon favourable termination.

In removal of Amenorrhea is on all hands allowed, that same principle not adapted to every case.

But what proper principles of cure are, much subject of dispute.

Evident that for proper foundation of these, must have true theory of menstrual.

Respecting this however practitioners much divided.

Here however to enter into theory of menstrual altogether out of place

May only in general observe that [illegible] endeavour to show that depends on gradual accumulation of blood in uterine vessels, on which occurs at end of determined period, a peculiar action of uterus itself.

On this view, obstruction may arise from one of three general causes.

From want of due accumulation of blood in uterine vessels.

From want of due action of uterus.

Or from uncommon resistance in passage through which should make way.

When latter cause assertion is for most part effect either of [illegible] [illegible] or of spasm [illegible].

In former case menstrual never appears at all.

In latter obstruction transitory only

Hence in such instances as present, obstruction to be referred, to one or other of two first circumstances mentioned.

Often however not an easy matter to determine to which.

Hence remedy directed with view to both.

And this I own very much case in present instance.

When patient first came under care, wished, as already said to be satisfied that no pregnancy.

And therefore did not think of having recourse to any active medicine.

But among other symptoms, patient with some cough, fullness at stomach.

Of this symptom formerly relieved by use of Emetic.

From which also in cases of Amenorrhea some benefit may be [expected]

For in consequence of concussion of system has at least effect of giving temporary [impetus] to circulation.

And thus renewing motion of fluids though extreme vessels.

From these circumstances then led to repetition of Emetic.

Expect good affect both as restoring appearance & giving tendency at least to restoration of menstrual discharge.

With Emetic directed also use of aloetic pills.

Not indeed to such extent as to produce purging.

Merely to such quantity as to keep belly gently open.

And at same time to operate as gentle stimulant to rectum.

An effect though not peculiar to aloes, arising more from these than almost any other medicine.

At least as far as can with safety be induced.

For from considerable stimulation, to rectum worst effects in way of Tenesmus Haemorrhage etc may be supposed to arise.

And even aloes themselves, often attended with this effect.

But even without this irritation of aloes very considerable influence, both in promoting circulation through vessels of rectum, & likewise through those of neighbouring viscera.

And is I apprehend in this manner, that to explain benefit from them, both in promoting & restoring menstrual discharge.

Particularly when gradually used during intervals.

Or even for some time previous to menstrual period.

As thus greater accumulation of blood in uterine vessels than would otherwise take place.

But whatever principle of operation have I think seen good effects from them.

In cases where menses before scanty giving full & natural discharge.

And in cases where entirely wanting, having in some instances effect of restoring it

Here however after use for space of week, did not find them attended with this consequence.

From vomit full operation.

And from pills effect of keeping belly gently open.

But at succeeding report found symptoms rather aggravated.

And no appearance of menstrual evacuation.

While at same time affected with much pain in legs.

And veins at pained part in varicose state with considerable [marks] of effusion.

Circumstances indicating obstruction to circulation.

From these circumstances case seemed more urgently to require use of more powerful medicines.

While now less restricted from [apprehension] of pregnancy.

For during this period no circumstance had occurred giving suspicion of it.

For these considerations then led to use of an article which am for my own part disposed to consider as one of most powerful emmenagogues viz Electricity.

Than this need hardly observe that do not possess more powerful or [penetrating] stimulant.

Influence as exciting muscular action manifested on many occasions.

Well known that has often affect of restoring power of motion as in paralytic limbs.

And of immediately exciting muscular action as in animal killed by hanging [illegible]

These after influence of chemical & mechanical stimulation has entirely ceased, by electric shock strong [activity] induced in all muscles.

Hence then as far as action of uterus necessary in Amenorrhea may operate in two ways.

May have effect of restoring power of action where that power deficient.

Or may have effect of [illegible] inducing action where naturally [illegible] as it were wanting.

Accordingly in some instances where electricity used flow restored before patients [given] the wheel.

In these cases, probable that accumulation of blood has already taken place in uterine vessels.

And stimulation only wanting by which action to be induced.

In others no restoration of discharge till electricity used for some time.

And then only occurs at stated time of periodic action.

Here again probable that electricity has had effect by restoring power of action.

Perhaps also, by promoting proper accumulation of blood in uterine vessels.

But whatever mode of operation or however to be explained no doubt that electricity a powerful emmenagogue.

And although some others, example Warm Bathing, Chalybeate, or Exercise, may succeed where this has failed, yet for my own part acquainted with none equally powerful.

And influence when properly used confirmed by concurrent testimonies of many practitioners.

Particularly late Dr Saunders of [Banff]. Mr Birch of London etc.

In hands of all these practitioners discharge sometimes immediate consequence even of first application.

Sometimes however only after use for considerable length of time.

Here did not operate in first of these ways.

Still however entertain hopes that in second way attended with desired affect.

And therefore directed continuation.

But patient herself did not probably entertain same sentiments.

Or at least did not like this mode of cure.

And must be allowed that to some electric shocks very disagreeable.

But whatever cause after found that repetition of same remedy [ordered] deserted attendance here.

Thus disappointed of intended [illegible] of electricity in this instance. And what has been case with patient since that time have not been able to learn.

Nelly Gordon, delayed