DEP/DUA/1/17/07 (Normalised version)

William Bell

(1778)

---

William Bell.

Case of this patient [neither] of complicated nor intricate nature.

Affords manifest example of a disease very frequently occurring [in] practice & at same time well meriting attention of practitioner.

Here disease evidently consists in obvious swelling

And can be no hesitation in pronouncing that these swellings although at different parts evidently dependent on water.

Or in other words that patient subjected to dropsical affection.

Under this general appellation however several distinct diseases comprehended.

And can be no question that water as lodged in different cavities produces lesion of different functions.

Hence then sufficient grounds for different names.

Of all others perhaps most common that where effusion takes place into cellular membrane

And that such exists in present case is uncontestably [proved] from swelling of [illegible] [dep]. parts particularly legs & [illegible].

But besides this evidence also of effusion into cavity of abdomen.

Of this some presumption from manifest swelling of belly.

But where anasarca exists such a circumstance may arise from [more] watery effusion in [integumentary] of abdomen.

In present instance however any ambiguity of this kind totally removed

For from evident fluctuation can be no doubt that water here also effused into cavity of abdomen

Must here therefore conclude that patient subjected to some degree of ascites as well as of anasarca.

And by no means an infrequent occurrence.

May farther be [stated] as query [whether] has not operated in manner still more general.

And besides effusion into cavity of abdomen produced also same [effusion] into cavity of Thorax.

This also by no means an rare affection

And in case before us some circumstances which would even lead to such suspicion.

Particularly state of respiration.

Remarked that breathing difficult not only on going up hill or such other [exercise] but even when patient laid in recumbent [position]

These however necessary consequences of effusion of water into cavity of thorax.

Yet from these symptoms can by no means infer that such effusion has in reality taken place.

For when that the case combined also with many other symptoms here wanting.

Particularly peculiarly sudden unease at breast during sleep.

From this uneasiness patient starts up from even most profound sleep with [inexpressible] anxiety & commonly great palpitation.

This circumstance so frequently an occurrence that by some even considered as pathognomonic of Hydrothorax

But although would not go so far yet consider absence as strong presumption against that disease.

And symptoms here mentioned often present where does not exist.

Difficulty of breathing almost uniformly consequence of large collection of water in abdomen.

For by this means particularly when patient in horizontal posture free motion of diaphragm prevented.

From this cause alone then may here arise.

But besides this may farther be observed that is also a very frequent symptom in anasarca.

For where this disease to any considerable degree there must necessarily occur anasarca of lungs as well as of other parts.

Would then upon whole conclude that present patient, whatever may hereafter be case not yet at least subjected to Hydrothorax.

Have indeed unquestionable evidence that to certain degree ascites has taken place.

Yet look upon present affection to be principally anasarca.

On this ground then next to give opinion as to probable termination.

And here must own cannot speak with very great confidence.

Disease to which patient subjected by no means of trifling nature.

Nor does it now subsist to inconsiderable degree

Will not therefore be greatly surprised if should soon even increase to such degree as to threaten very great danger.

With present state of patient however reckon it more probable that under our hands may have different termination.

Hope at least, that may be able to evacuate water already [effused].

And for affecting this possess many [powerful] remedies.

Although however by aid of these [may] at present be able to remove disease yet can by no means be considered a radical cure.

For perhaps may add that few affections more apt to return.

And indeed evacuation of water, properly speaking but an inconsiderable part of cure.

Although this therefore once affect obtained should not yet be surprised if from recurrence patient at length cut off.

In practice here however evacuation of water must at least be first part of cure.

And after this obtained next objective to prevent [farther] effusion.

Evacuation here can be brought about only in one of two ways

Either by artificial or by natural outlets

When however can be obtained by latter is both most safe & most efficacious practice.

First attempts therefore perhaps in every instance to be made in this way.

Previous however to evacuation by natural outlets must be taken up by Lymph [absorbed] from cells or cavity in which deposited.

This however in great measure the affect even of more evacuation.

Particularly if combined with stimulating power.

Of evacuation of [serous] by natural outlets great variety which may be put in practice.

In different cases, from various circumstances, prefer sometimes to be given to one sometimes to another.

And circumstances which in present case led us to use of these here employed will more particularly appear when take short view of what already done or may hereafter be done in treatment of this case.

When patient came under care, considered vigour to be such as would bear even powerful evacuation.

[Ordered] therefore a remedy which hoped would operate both as cathartic & diuretic.

While at same time from general affects as stimulant [some] additional influence as promoting absorption.

This remedy was Pulveris Jalap Composite.

Need hardly observe that consists of two parts of Cream of Tartar & one of Jalap

And that is imagined particularly advantageously derived from two being pounded together in consequence of which more minute division.

As far however as my own experience goes have not been able to discover that any very great advantage from this circumstance

Yet no doubt that in conjunction of the two have a very useful composition.

And while operates as brisk cathartic has also tendency to evacuate by urinary passages.

Ordered this powder to extent of two [scruples]¹ by itself, but an inconsiderable dose.

That operation however might be farther [illegible] conjoined to it small proportion of Gamboge.

From this addition have often in other cases seen best effects

But whether was this or Jalap itself which disagreed with patients stomach, excited very severe vomiting.

In so much that reckoned it necessary first to diminish frequency of doses & then entirely to omit it.

Or at least to keep belly open by Cream of Tartar alone conjoined with an aromatic

With this however conjoined another remedy more especially intended to operate as a Diuretic.

While cathartics most immediate means of evacuation, diuretics are the least debilitating.

While former can be used only at certain intervals these may be employed in [uninterrupted] course.

From these circumstances then of opinion that ought in general to be conjoined.

As diuretics many different remedies in use.

Yet perhaps may observe that none of [this] class to be absolutely depended on.

Here made trial of one introduced with very high [character] by Dr Stork the Colchicum Autumn or meadow saffron.

By him recommended to be exhibited in form of Oxymel

To this however as well as other oxymel Edinburgh College² have now substituted syrup.

And while same advantage not liable to same inconvenience.

For in no constitution has sugar same tendency as honey to excite colic pains.

In this account then in constitutions with which were unacquainted could have no hesitation in ordering syrup.

This syrup began even from commencement in doses to extent of half an ounce.

With intention however of gradually increasing both quantity of dose once & frequency of repetition.

Although at same time half an ounce not long ago would have been considered even as large.

But of late given & with success to much greater extent than formerly employed

From increase which has already taken place patient has derived no inconvenience.

And has had some influence as increasing flow of urine.

Hitherto however very little affect in diminishment of swellings or relief of other symptoms

Yet is my intention while nothing urgent indicates contrary practice to [persist] in present trial.

And while contains Cream of Tartar at present dose to push [illegible] to still greater extent.

With this shall direct also use of different means of promoting absorption.

Particularly friction & exercise.

If however this diuretic proves abortive before having recourse to evacuants of different nature may perhaps try some others.

Particularly Squills combined either with vegetable bitters or with mercury.

If obliged to desert diuretics Mercury may be employed as cathartic.

Or may use others than those already directed particularly infusion Tamarind Syrup de [illegible] or like.

If in end disappointed of discharge, either by [urine] or stool may attempt evacuation by other [ emmenat]

Particularly by emetics as from absorption & by gentle sudorific as determined to surface.

If all natural outlets fail & symptoms very urgent may then have recourse to artificial.

Example [illegible], incision, blisters or issues.

To former however by no means without danger, while latter often ineffective.

Hence if can be done shall wish to avoid all.

And to aim at cure by remedy first mentioned

At same time conjoining such requisite as by restoring vigour may have tendency to prevent return.

---

Explanatory notes:

1) A unit of weight equal to 20 grains, used by apothecaries and physicians.

2) The Royal College of Physicians of Edinburgh, established in 1681.