DEP/DUA/1/47/33 (Normalised version)

Marion Mossman

(1789)

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N^o21 Marion Mossman.

In case of this patient that could have no difficulty in ascribing all other symptoms to affection of menstrual discharge.

This might naturally infer from influence which menstrual well known to have on system in general.

For well known that both from excess flow & obstruction an almost infinite variety of symptoms arise.

But [exclusive] of this connection here more particularly indicated by symptoms themselves.

For not merely affected with sense of fullness & suffocation or dyspnoea common symptoms in such cases, but complains also of considerable swelling at under part of abdomen region of uterus.

And this swelling evidently connected with menstrual evacuation.

For always particularly increased on appearance of discharge, & diminished after it.

Under affection of menstrual, by practical & nosological¹ writers different genera of diseases have been comprehended.

Thus by some a distinction made between Amenorrhea & Dysmenorrhea.

By others again between obstruction & suppression.

While by a third whole & perhaps with greatest propriety referred to one Genera.

If however to give to disease of present patient a general name strictly [applicable] is an example of Dysmenorrhoea of Linnaeus & others.

Apprehend however that Dr Cullen has done better in referring whole affection of menstrual to two Genera Menorrhagia & Amenorrhea

And has again subdivided last into different species according to its different modifications.

Amenorrhea emanis. where have never flowed but symptoms from want.

Amenorrhea suppressed where symptoms from want after have formerly been regulated.

Amenorrhea diff. where discharge scanty & with much pain.

Of this last can be no doubt that here an example.

Difficult or scanty menstrual however may arise from various causes.

And here conjecture entertained by our patient by no means improbable.

That viz the consequence of severe fever to which had been subjected.

This it will hardly be denied a cause adequate to effect.

While at same time [rendered] farther probable by occurrence of affection immediately after it.

In what manner however fever might here be supposed to operate a matter of greater difficulty.

And indeed Physicians disposed to give very various explanations of action of causes according to idea adopted of cause of menstrual itself.

My ideas on that subject have elsewhere had opportunity of stating at some length.

And here foreign to our business to enter into any inquiry of that nature.

May only observe that suppose menstrual affected by a gradual accumulation of blood on uterine vessels on which there supervenes at determined time, an action of uterine itself.

Amenorrhea therefore may [arise] either from want of due accumulation, want of due action, or uncommon resistance in outlets through which should pass.

And as one or other of these takes place cure must be [accommodated] accordingly.

Here no reason to suspect first of these causes.

Nay would even seem that in consequence of want of due discharge morbid accumulation takes place.

For to this would naturally attribute both swelling & hardness of abdomen.

Perhaps also no great reason to suspect want of due action.

For to action even beyond natural standing are probably to refer pain at menstrual periods.

At same time this even may be consequence also of circumstance last mentioned.

Distention viz arising from accumulated blood.

And at same time fever a cause from which diminished action may probably arise.

For well known that has not infrequent effect of diminishing muscular vigour.

And in some instances even gives rise to paralytic state of different organs.

Of these causes must however reckon it most probable that is here consequence of last.

Difficult transmission of blood viz, through vessels by which should make its way into cavity of uterus.

On this footing then are here to expect cure by removal of obstructing cause.

And in different cases this various.

Sometimes merely effect of spasm & at once removed by inducing relaxation.

But more frequent especially when of any long continuation is effect of some more fixed cause.

Particularly of fixed constriction of extreme vessels.

And in this case only means of removing is by increasing power & force of action.

Hence then remedy accommodated for such a state at same time suited for removal of obstruction from second cause mentioned.

Was then on this ground that here hoped to accomplish cure.

And of this the rather disposed to entertain hopes, as had employed hitherto no remedies.

While at same time though complaint of considerable standing yet never to great degree.

And cause had not hitherto operated to such extent as to produce total obstruction.

For discharge through scanty was yet regular to its periods.

Begun here by directing for our patient the common aloetic pill to extent of grain V om. n.

Of this I need hardly observe the common obvious operation is that of a cathartic.

And indeed is chiefly with view of obtaining discharge by belly that is employed in practice.

But well known that effects in this way chiefly exerted on rectum.

This the tendency of aloetics in general.

But particularly so when given in form of pills.

As then from slow solution little influence till reaches the rectum.

But while purgative effect chiefly from action on rectum is not only consequence of influence there.

By operating as stimulant to blood vessels often even product of inconvenience.

Thus well known to aggravate haemorrhagic affections from exciting inflammation.

Influence as stimulant communicated in similar manner to neighbouring parts.

And in this way can I think be little doubt that tends to increase circulation through extreme uterine vessels.

According not unfrequently employed in Amenorrhea.

And in some instances applied at least with good effects.

Is at least an article from which on rational grounds may expect more than from many reputed emmenagogues.

And although not calculated for every instance of Amenorrhea yet am much deceived if have not sometimes seen benefits from use.

While at same time in ambiguous cases as for example where suspicion of Pregnancy may, in small doses at least be employed without hazard.

Here however as an emmenagogue, nothing to be expected from purgative power.

On contrary, by [considerable] evacuation in this intention rather countered.

Directed it therefore in what consider as but small dose grain V om. n.

Operation of aloetic purgatives however often observed not strictly proportional to quantity.

For while small dose has effect of giving single stool, from much larger little more operation.

While however this the case with respect to quantity, must be allowed that considerable variety from constitution.

And with some even small dose will induce considerable catharsis.

This would appear to have been constitution of present patient.

For from each pill had two or three stools the succeeding day.

This however as already observed more than wished for.

Accordingly although under catharsis some symptoms relieved yet directed one only every second night.

With this however had recourse also to another remedy.

A mixture viz of Peruvian Bark & Rubia Tincture.

First of these need hardly observe well known to be powerful tonic.

And by increasing vigour of vessels tends to promote circulation even in extreme ones.

Latter the Rubia again, one of many articles supposed to operate as a peculiar & specific stimulant to uterus.

And accordingly with some highly esteemed as an emmenagogue.

For a very favourable account of its effects may refer you to Clinical cases of Dr Home & Inaugural Dissertation of Dr [Spens]².

In both several cases collected in which apparently attended with best effects.

And must be confessed that although with respect to removal of Amenorrhea great room for deception yet more accurate test in favour than in support of many other articles.

Must however own that for my own part very doubtful as to any specific stimulating power here

Yet will on all hands be admitted that Rubia an article of very penetrating nature.

This abundantly evinced from tinge which gives even to bones.

And at least some reason to believe that stimulating power, carried as far as colouring matter.

On these grounds then, as well as on account given of efficacy by others thought it not unworthy of trial in present instance.

At same time must confess that in any former trials which have myself made, have not met with any decided proof or even strong presumption of efficacy.

These medicines continued regularly for space of week without obvious inconvenience.

And now also pills taken without having more influence than that merely of moving belly.

At this time however pain & swelling in under part of belly became more considerable.

A consequence of near approach of menstrual period.

From this then rather increase to hope for good consequences than otherwise.

And naturally led to persist in employment.

But for space of more than a month saw nothing more of patient at this place.

From January 9^th did not return till February 13^th

Then learned that menstrual discharge had taken place regularly & in nearly natural state as to quantity.

And probably would have seen nothing more of her had she been freed also of other symptoms.

But was still affected with pain & swelling in belly.

Now found however that averse to continuation of powder.

And ascribed to them probably without any good reason induction of headache

In this situation therefore little grounds to hope that would continue use

Have now therefore directed her to go on with pills alone.

And as menses of late sufficiently large hope that nothing farther will be necessary for restoration of health.

Especially as period not far distant when menses may be expected altogether to cease.

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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.

2) It is not clear exactly what publication of Dr Home this refers to but it may be Francis Home, Clinical Experiments Histories and Dissections (1780); Thomas Spens, De amenorrhoea (1784).