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For Mr M↑o↑unier at Plymouth

I had the favour of yours some days ago but have taken
some days to answer it both because the many occuppations at this
season allow me little time and because I am very desirous to make
the best return I can to the honour which you and Dr Musgrave do me
by this consultation. The Case is truly difficult and I must think so
especially from this, that it has resisted so many probable remedies
and so much judicious practice as you have already employed
I shall give you my opinion freely but submitting it always to be
corrected by Gentlemen of so much judgement who must be more
exactly acquainted with every circumstance of the Case.

I must observe in the first place that I am fully persuaded
there never was any veneral affection in this case, both for the
reasons you give and because I think the symptoms may be
accounted for upon another supposition. It appears to me very pro¬
bable that there was some morbid affection in the Vagina or in the
neck of the bladder and Urethra connected the Vagina before the
marriage in May 1771. What was the nature of the affection
which discovered itself by no symptom may be difficult to say, but
it is only the supposition of such affection that in a woman for¬
merly married can account for the pain and other consequen¬
ces of the first and after coitions. I think the affections which I sup¬
pose, must have been a congestion tending to schirrosity which often
exists for a long time in an indolent state but it seems here to
have produced some considerable constrictions of the Vagina.

This I think will account for the pain and other symptoms of ir¬
ritation communicated to these parts tho they had shewn no di¬
sease before. Possibly what is hinted of an original malformation
if further explained would throw some light on this matter.
However this might be the irritation of coition applied to parts
not in a sound condition will account for every thing that has
since happened. It is not unusual for an affection of the Vagina,
to be communicated to the Urinary passage. It happened so here and
at length the neck of the bladder affected, gave occasion to what is

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called by Lieutaud [lo?] Cattarrhus Vesicӕ, which is the consequence
of many nay most affections of the neck of the bladder. This has
been the Lady's chief distress ever since, and all her feelings and particul¬
larly the matter deposited by the urine are symptoms from the source,
which I am very well acquainted with. You call the matter purulent and it may
be so, as at length ulcerations affording pus do really happen, but I have
known the Mucus put on that purulent appearance for a long time, when
from the sequel of the case and even from dissection, we th knew there
was no ulcer, and in the present case I am hopeful there is none
I would not positively determine whether the original unsound con¬
dition of the parts, was first in the urinary passage or in the Vagina
but I think the latter most probable, for tho' the neck of the Bladder
has given the most trouble, yet as I have known the Catarrhus Vesicӕ
subsist long without being communicated to the Vagina and even to {illeg}
bear Coition without being much hurt by it & on the other hand as the
1st hurt in the present case was given to the Vagina, and morbid
symptoms have always appeared there, these with the present suspi¬
cions ↑of the diseas↑ being communicated to the Uterus, render it to me probable
that the disease was originally in the Uterine System. I am so full
in this discussion as I think it may have much influence on our
prognostic. From the whole I have said you will readily pick up my
notion of the case, and the grounds of it and I proceed to speak of the
Cure. In this what advice I can offer is founded on the supposition
that there is a tumefaction and probably some schirrosity of the Vagina
which is in danger of being communicated to the Uterus and that from the
one or t'other, perhaps from both there is a discharge of acrid matter
which inflames an excoriates the pudendum an perineum. Besides this
affection of the Genital system there is evidently a turn of action per¬
haps schirrosity of the neck of the bladder, attended as usual with a co¬
pious discharge of mucus and some Phlogosis of the internal membrane
of the bladder & Urethra. Upon these suppositions our prognositic

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must be doubtful and rather unfavourable, for in such cases, the
most we commonly can do is to palliate the pain & other uneasiness.
I am very glad to observe however that the pain tho' still constant is not
so severe as formerly, & that you have found a remedy for severe pains
when they occur, in the Vitriolum album. Tho I set out with doubtful
prognostic I am averse to give up any case in despair & shall still
propose a remedy. For resolving the schirrosity in the neck of the
bladder and for obviating that suspected to be ariving in the Uterus
I know nothing promises more than the Cicuta. Whatever doubts may
have been raised with respect to the efficacy of that medecine I am
certain that upon occasion it is very powerful and very lately I had
a remarkable cure effected by it in a schirrosity of the Uterus, &
I have had benefit from it in more than one instance of the Ca¬
tarrhus Vesicӕ. I must however to you tho' possibly you are ↑already↑ well
apprized of it, that nothing is to be expected from the Cicuta but when the
doses have some sensible effects in producing sickness, stricture
across the breast, tremor, giddiness or such like & when these effects
cease to appear after some repetition, it is always necessary to
increase the doses again. The effects of Cicuta are only to be expected
after some time, & in the mean while, the pains must be palliated by
the use of Opiates. I think it is all one whether these are given by
the mouth or by Glyster, providing the dose is as large as the pa¬
tient easily bears. You have now brought this Lady so far in the
use of Opiates that I think there can be little difficulty in keeping
her pains within bounds especially as there is so much tendency
to an open belly as not only admits but seems to require the
use of Opiates -

I have no objection to the continuance of the white Vitriol
injections, nor to the use of the Potato Poultice but I suspect that the
frequent use of poultices of any kind, may render the external parts
tender and liable to excoriations. In so far as there is any phlogosis

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of the external parts I think they may be relieved by a poultice of crum
of bread moistened by a Saccharum Saturni. This poultice
must not be allowed to be long at one time & never so long as to be¬
come hard. If for the reasons I have given even this poultice can¬
not be admitted I believe you may find benefit from Sacchar. Sat.
imployed in a lotion. I suspect much that the pains are increased
& the external parts fretted by an acrid matter issuing from the
Vagina & perhaps from the Uterus. I therefore propose to wash out
the Vagina frequently with some antiseptic liquor as a weak infusion
of the bark with a tenth or 12th part of brandy or more if the Lady bear
it easily. In cases of more considerable Acrimony I find it useful
to inject oil with a small proportion of Camphire dissolved in it,
and after the injection has remained for some time, at last before repe¬
tition, to wash out the Vagina with the infusion of Bark and brandy
as above I observe that of late you frequently employed some un¬
ctuous applications & undoubtedly the mildest one the best, but I
find that a small proportion of Camphire will give no irritation
is very useful in obviating the {illeg} of oils. When an injection
is proper, a liquid matter is necessary and then too the Camphire but
where an external unction is only to be applyed, a matter of some
tenacity is required, & I know nothing so good as the Linimentum
& Unguentum Album of the London Dispensatory. I do not think
that any mercurial preparation either internally or externally, is
suited to or indeed admissable in the Lady's case. Neither do I sup¬
pose that any benefit can be obtained by Bougie or pessary of any kind.
In some cases the Catarrhus Vesicӕ especially the Syphilitic has been
attended with strictures of the Urethra & in such case Bougies have
been of service, but I always think they operate mechanically by their
bulk, and consistence & never by the virtue of any ingredient or of what they
are anointed with

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I doubt very much if the Uva Ursi is of any service in this Case. I
have never found it of use but in nephritic or calculous affections & I am afraid
it may be hurtful to your patient as it has often a tendency to purge. I am dis¬
posed to say the same of the Bark & particularly as to its purging which
should be attended to. I percieve that the Lady feels a sinking when the
bark is ommitted, but I think this is ambiguous at the time of the
Catamenia & tho' it should be truly owing to the omission of the Bark
Bark I think it would be felt only for the first days of such omission
& not afterwards. I percieve a very great propriety in Dr Musgrave's
advice to avoid salt, spices, & Wine; & surely the Lady's sensibility
appears very strongly from the effects of the Cinnamon Water. I think
therefore you cannot be too careful in avoiding every thing the least
acrid either in Diet or Medecine. I consider all strong broths as
acrids. I am much disposed to you with the London Physician in
advising a milk diet. At least I would allow a little Animal food
only and that of the mildest lightest, gelatinous kind. Fruit and all
Vegetables from the Garden will be ready to increase the tendency to
Diarrœa &cc