MeSH in the Letters to Dr. James Carmichael & Son

By Alison White

One of the goals of the Carmichael Web site is to effectively link early nineteenth-century terminology, as expressed by the letter writers of the period, with the 2002 version of the National Library of Medicine’s Medical Subject Headings (MeSH). We want to make the Carmichael Collection as searchable as possible on as many levels as possible. Our user population probably includes historians, physicians, genealogists, the general public, and students from the elementary to the post-graduate level, and the inclusion of terms is based on who these users might be and how they might choose to look for items of interest. We questioned how well MeSH would coordinate with documents written in the early nineteenth century, but as we have amassed lists of terms and perused MeSH, we have been pleased with how well the language serves our needs.

The medical metadata tags are broken into categories of “complaint,” “disease,” “treatment,” and “instrument” and contain the actual language and terms used by the letter writers. The MeSH metadata tag applies medical subject headings to this original language and, to some degree, unifies the diverse wording while maintaining precision. When one term is used frequently, we include more specific terms, when possible, to augment the analyses of the letters. Some documents do not support this level of scrutiny. For example the letter from Lewis Ellis consists entirely of “will be so good as to send me by the barrier [bearer], the medicin that I left there on Friday last.” [see letter] The treatment tag for this letter is “medicine,” and the MeSH tag is “pharmaceutical preparations.” Most letters provide more detail and information. Generally the depth and richness of this collection encouraged us to index it exhaustively as can be seen from the following example: [see letter]

The letters written to Dr. Carmichael and his sons come from numerous patients whose language on a particular subject is distinctive and varied. For example, many letters contain some description of pain. Hubbard T. Minor describes a “lancinating pain,” [see letter] Ann Hill speaks of a “griping” [see letter], which is “a severe, pinching and usually spasmodic pain especially in the abdomen” (Appleton’s, 1904); while William Beverly tells of a “soarness of her brest.” [see letter] MeSH becomes a way of integrating complaint terms and imposing a searchable order on the collection. In MeSH, pain is a general term that can be coordinated with a body part, but there are also specific MeSH headings for certain types of bodily pain such as abdominal pain and chest pain. We accordingly index the letter writer’s complaints regarding pain by using the site of the pain as the entry term, for example, belly pain or side pain or ear pain. In addition, to make these letters accessible to someone looking for all references to pain, we include the MeSH term pain along with the more specific MeSH term of abdominal pain or flank pain or earache. The user can then search for all letters with references to pain, or only search for references to specific types of pain. Applying MeSH on specific and general levels allows us to bring all of these letters together under the MeSH term pain, while using the complaint terms to uphold the letter writer’s distinct voice.

Our application of MeSH is often interpretative but not diagnostic as we are careful not to impose twenty-first-century diagnoses on the descriptions of symptoms presented by the nineteenth-century letter writers. Bertha Almagro addresses the inconsistencies and difficulties of such analysis in her Preface to EarlyAmerican Medical Imprints, 1668-1820 (1981). Almagro becomes an historical detective and determines that certain outbreaks of disease in various geographical areas are yellow fever or malaria. Terms that she links to these specific diseases include intermittent fever and dumb ague as malaria, and bilious fever and black vomit as yellow fever. Many of our letters make reference to intermittent fevers, bilious fevers, or agues, but for a number of reasons, we did not connect these terms to specific diseases despite this existing precedent. The approximately 700 letters comprising our collection are from one geographic area of Virginia and cover a time span of just over a decade, and we do not have corresponding historical evidence to indicate that there were any major outbreaks of communicable diseases at this time and place. We are not drawing our information from various formats such as broadsides, sheets, and pamphlets that often include descriptive material to support such conclusions. Instead, we rely on the unique voice of either the ill person or the caretaker whose use of medical terminology is not always authoritative. Letter writer G. J. uses the term bilious fever to describe an ongoing liver ailment that in no way corresponds with the intense symptoms of yellow fever, which are unrelenting and often result in death within a week. [see letter] However, James S. Cole refers to others telling him that the disease is “the black vomit” and mentions imminent death. [see letter] For this one letter we do include the MeSH term yellow fever. We are not diagnosing, but interpreting a term already provided by the letter writer, though we have no way of knowing if the writer is correct. It is likely that some of the letters in our collection are describing the intense symptoms of malaria, but we choose to cautiously interpret the letters rather than diagnose them. Hopefully our selection of terms will allow medical experts to draw their own conclusions by helping them find those letters of interest.

Frequently we include general MeSH terms as well as specific terms. This proves especially appropriate in the application of MeSH terms to treatments. One example involves castor oil, a frequently dispensed medicine. We use the corresponding MeSH term of castor oil. The MeSH scope note indicates castor oil’s use as a cathartic and a plasticizer. Our letters point to castor oil’s use as a cathartic so we include the MeSH term cathartics. The scope note also leads to the addition of the term plants, medicinal as this MeSH term is particularly useful to those with an interest in herbal or traditional remedies. The MeSH tree structure then leads to the more general term, plant oils. Finally, we include the even more general term of oils because oils is an entry term for other letters that reference oils without specifying type or use. These broader terms facilitate the grouping of all letters that mention oil, from castor oil to Bordeaux oil to oil, alone, on the most general level, while still allowing specific searching at the plant oils or castor oil level.

A creative aspect of MeSH reveals itself as we match MeSH terms to the medicines mentioned in the letters. Additional historical references prove indispensable. Both Appleton’s Medical Dictionary (1904) and John Redman Coxe’s The American Dispensatory (1827) facilitate research on specific medicines described in the letters, and many references to various medical treatments coordinate with MeSH. For example, nine letters refer to blue pills. The American Dispensatory (1827) describes on p. 474, pilulae hydrargyri, mercurial or blue pill. This information allows us to index this group of letters under the MeSH term for mercury as well as the more general MeSH terms of tablets and pharmaceutical preparations. As contemporary medical historians know, mercury was used for numerous medical purposes at this time despite its toxicity. It is a good example of a popular treatment that could be detrimental to the health of the user. A researcher, looking for examples of mercury use in the early nineteenth century, will pull up all letters that mention blue pills. That researcher will probably know that a symptom of mercury poisoning is increased salivation and may delight in finding that three letters using the complaint term of salivation also have mercury or mercury compounds in the MeSH tags due to the mention of either calomel or blue pills, medications containing mercury. [see letter 1, see letter 2, and see letter 3]

MeSH is a far more flexible vocabulary than we originally expected it to be. Initially we focused on the extraction of complaint, disease, treatment, and instrument terms and matching these, when possible, to corresponding MeSH terms. However, as we reviewed our work, we discovered certain concepts that asked to be heard. MeSH offers terms for some of these concepts, such as physician-patient relations, house calls or office visits, interprofessional relations, self administration, and self medication. Arguably every letter from a patient in the collection could be considered an example of physician-patient relations. We use this term to highlight those that stood out in this area, such as Lewis L. Holladay’s remark concerning Dr. James Minor: “as he has more confidence in your skill and judgment than in that of any other Physicians in this part of the country, he is induced to apply to you for advice.” [see letter] We apply the term, house calls, to all letters that ask the doctor to visit. When the sick person is sent to the doctor we use the term, office visit. Interprofessional relations is a MeSH tag we apply to letters from another doctor to Dr. Carmichael or to letters where the writer indicates another doctor referred him to Carmichael. We learn from these letters that Dr. Carmichael’s judgment is greatly respected by other physicians. The scope note for self medication describes the administration of medication not prescribed by a physician as opposed to self administration which is the administration of a drug under the direction of a physician. We apply these terms broadly, so that letters indicating use of a medication prescribed by Dr. Carmichael are tagged with the term self administration. This would include letters where the writer himself took the medicine: “Sir the medisen that you gave me seen to answer the desired affect,” [see letter]; as well as letters that describe a third party taking the medicine: “Virginia has continued to take the medecine agreeable to your direction,” [see letter]; or the administration of medicine to a child by a parent: “Our little Anne remained tolerably easy after you left us & rested pretty well through the night – At twelve we applied the blister and took it off at six this morning.” [see letter] Our goal is to distinguish between treatment initiated without consultation with a doctor and treatment based on medicines prescribed by the doctor.

Consistency is important in the application of terms, but on occasion a dose of creativity is useful when applying MeSH headings. Occasionally we stray from literal applications of MeSH in order to make note of a particular subject. The MeSH term prescriptions, drug was problematic at first as the scope note indicates directions written for the preparation and administration of a drug. A number of letters refer to directions for preparation and administration of medicine, but sometimes it impossible to tell if the directions are verbal or written. Due to the historical nature of our collection, we focus on the concept of providing directions about the use of medication, rather than on the format of those directions. Consequently we apply prescriptions, drug whether we know if the directions are written or not. Another example of tailoring MeSH is the inclusion of the MeSH term, signs and symptoms, which is not supposed to be used for indexing. The scope note, clinical manifestations that can either be objective when observed by a physician, or subjective when perceived by the patient, makes this term useful as a way to tag letters that speak of general complaints without offering any specific details about the complaint, as in William Jones’ letter: “the bearer Reubin has a strong complaint you will be pleas’d to give him what is proper for it.” [see letter] For this reason we use signs and symptoms. Occasionally a letter writer mentions complaints that the patient does not have, such as chills, but no fever. Initially we ignored the fever aspect of such a letter, but then decided to include a reference to fever in case a researcher might consider the lack of a complaint as important as the letter writer did. One conceptual aspect of many letters that we do not capture with a MeSH term is the idea of getting worse or getting better. The closest terms we found are disease progression and convalescence, but neither of these work on the general level that we hope to convey.

Dr. Carmichael’s patients write frequently and in great detail about their bowel movements. This topic offers an interesting view of both the utility and clumsiness of MeSH when applied as an historical indexing tool. We use a variety of MeSH terms including constipation, defecation, diarrhea, feces, and intestines, often in combination, to convey the particular meaning of these letters. Sometimes we are satisfied that we communicate the sense of the letter fairly well. Francis C. Whiston states: “I am very costive not having had a passage for two days.” [see letter] When the complaint term is costive, the corresponding MeSH term is constipation. However the “bloody passages,” “disordered bowels,” and “straining” Charles R. Battaile reported are more challenging. [see letter] Gastrointestinal hemorrhage matches well with bloody passages with the additional term of feces. The general MeSH terms of intestinal diseases and intestines are our best attempt to express the concept of disordered bowels, but straining to defecate is more difficult to tag. The scope note for the MeSH term defecation is the normal process of elimination of fecal material from the rectum, and clearly this letter writer is not describing a process that is normal. Bilious is another commonly used complaint that lacks a perfect match. Appleton’s definition of bilious is “a popular term for a digestive derangement characterized by constipation, intellectual sluggishness, a feeling of general discomfort, offensiveness of the breath, and a furred state of the tongue, with or without headache, vomiting of bile and abdominal pain; attributed to a defective secretion or outflow of bile.” We do not assume that each writer complaining of “bilious affections” has all these symptoms, and we use the general term of digestive system diseases as our best choice.

The Carmichael collection provides an absorbing view of the lives of early nineteenth-century people in small, rural communities. Letters range from case histories written in great detail to notes of desperation written in haste. We transcribe and render these individual voices in a way that we hope will best allow them to be heard. We avoid diagnostic interpretation and utilize MeSH as a powerful means of translating a diversity of complaints and medical treatments into a contemporary language that improves the accessibility of the collection as a whole.