DEP/DUA/1/35/20 (Normalised version)

May Ross

1784

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May Ross. June 25. 1784

With regard to disease of this patient must own am very much at loss.

And particularly do not know what name with greatest propriety to be affixed to it.

But little doubt in asserting that disease of a complicated nature.

Symptom in case of the most remarkable is considerable swelling of legs

And with this many circumstances connected which would lead to opinion of its being a hydropsical affection.

Particularly increase towards evening & diminishment from horizontal posture during the night.

The thirst with which connected.

The scanty discharge & high colour of the [urine]

All these unquestionably to be considered as indications of a dropsical affection.

Here however one circumstance giving difficulty.

The want viz of pitting on pressure.

This if not a constant at least a very general attendant of anasarca swellings.

And would at least argue some singularity.

In anasarca pitting a consequence not only of nature of fluid effused, but also of situation.

A thin watery fluid viz in cellular membrane

Here then reason to suspect either difference of fluid or difference in situation.

And when consider condition of superficial [vessels] of leg, some reason to suspect that this may be case.

These you will observe described as in remarkably varicose state.

Reason therefore to believe that though swelling may in part be affect of effusion, yet in great measure effect of accumulation of blood in vessels.

Thus then would appear that even this most obvious part of complaint in its nature singular.

But not more so with regard to nature than cause.

By patient indeed herself attributed to obstructed menstrual.

A cause which although not frequent yet as well as other obstructed discharge has sometimes given rise to dropsy.

And particularly under form of Anasarca.

Here however will observe that affection of legs of much longer standing than want of menstrual discharge.

At least although no considerable swelling, yet numerous varicose veins in legs of much earlier date.

And great reason to believe that to these, swelling at least in part to be ascribed.

To what accident however varicose state of veins to be referred cannot readily discover.

But while different morbid conditions to which may be referred, none more probable than loss of due tone in vessels.

To some accident therefore inducing this, would refer that state.

And to condition of vessels thus induced, think that swelling in part at least to be attributed.

But whether Amenorrhea any share in giving rise to it or not, from account given us appears that patient subjected also to that affection.

And here likewise in all probability want of menstrual arises not merely as symptom of other affection.

For while now absent for space of three months interruption of course followed as consequence of a particular accident.

Exposure viz to cold during period of natural flow.

This an accident by which well known that obstruction often induced.

And which probably operates in checking this as well as other haemorrhages, by sudden constriction which gives to ruptured vessels.

By this means not only stopped in first instance, but gives rise also to [change] of determination & additional resistance.

And in this manner, obstruction continued till natural course of blood & condition of vessels be restored.

But whether in this manner that cold operates or not, can be no doubt that from imprudent exposure to action, during flow of menses, is frequent cause of Amenorrhea.

And to this little hesitation in attributing it in present case.

To amenorrhea many of the symptoms may be referred.

And whether any share in inducing swelling of legs or not at least presumption that gives rise to [illegible] debility, aversion to action & like, to which this patient subjected.

For while these very common consequences of this affection, to be observed that here took rise only after menstrual flux was obstructed.

And therefore probably with propriety referred to that cause.

This then neither least considerable nor least distressing part of affection.

Thus appears that patient labours under complication of affections.

And some of these probably but little connected with each other.

Hence termination may be [various]

But at same time from complication conjecture with respect to any of them much more uncertain.

Of all affections what consider as most important & what at same time probably best chance of removing is Amenorrhea.

This at least has not hitherto subsisted for such length of time as to give suspicion of obstinate or dangerous disease.

And often even by operation of system itself spontaneously removed in cases apparently less favourable.

To be however observed that even where seemingly slightest will sometimes foil every attempt.

Hence then even with respect to this cannot speak with great confidence.

If however menstrual flux restored gives at least better chance of removal of other affections.

For though varicose state of [vessels] of legs long prior to this, yet little doubt that from want of regular circulation through system of womb much augmented.

Hence then restoration of menses may at least tend to diminish.

While by proper means for [bracing] & increasing tone of vessels may be still farther diminished.

But after of so long standing [cannot] reasonably expect complete removal.

And while this the case may also conclude that now at least will not be entirely free from swelling.

At same time this part of disease perhaps to certain extent at least more readily removed than any other.

In as far as depends on effused watery fluids & is really of dropsical kind may be combated by increased action of absorbency, & augmenting serous discharge.

As far as depends on accumulation in proper vessels may be removed by renewing & supporting proper circulation.

And after once removed from whatever cause arises, return best prevented, by strengthening tone of parts particularly of the vessels.

Is chiefly with these intentions that practices hitherto employed have been directed.

Began you will observe by directing for patient use of brisk cathartic.

Composite powder viz of Jalap.

From this could expect little effect indeed as restoring menstrual discharge

But yet in some instances cathartic stimulation to rectum some influence in this way

Would not therefore have been surprised had appearance of menstrual been consequence of repeated use.

But here principally given with view of evacuating water & thus promoting absorption from legs.

And well known that as hydragogue cathartics few more safe or more powerful.

While however wished to promote absorption & discharge of water by catharsis had in view also same intention by diuresis.

And was on this account that had recourse to mixture with Spirit of Nitre.

An article which in many cases have found to operate both with safety & care as a diuretic.

In operation however in this respect in present instance expectation not answered.

For was not sensible of its having any affect as increasing quantity of urine.

When however in present instance without obvious operation, could not expect that would have any influence in combating disease

As little benefit apparently derived from the purgative.

With regard to these indeed were not disappointed of obvious operation.

For from both doses brisk & free catharsis.

But this little affect in [counteracting] any symptoms.

Thought indeed that swelling of legs somewhat diminished.

But still, as might indeed have been reasonably [expected], varicose veins in these continued as before.

And pains in different parts of body nothing abated.

Continuation of this course then, from which state of debility could not fail to be induced, hardly to be advised at least without some interruption.

In place therefore of immediately repeating cathartic resolved to continue in use of diuretic.

But as what formerly employed had not succeeded thought it advisable to have recourse to another.

And for dulcified spirit of Nitre had recourse to Nitre in substance.

This employed under form of watery solution.

With view of covering taste added a proportion of mucilage.

And as a means of correcting immediate action on stomach directed a small quantity of Vinegar.

From this medicine, expected some influence as augmenting quantity of urine.

And this probably good effect on state of legs.

But at same time even from complete removal of swelling of these, will have by no means cure of disease.

And this removal, after has now subsisted for so great length of time hardly to be expected.

Especially while amenorrhea continues.

To forward therefore removal of affection of legs, as well as of other symptoms measures to be taken with regard to restoration of menstrual discharge.

And for accomplishing this end see no remedy that promises more success than Electricity.

That indeed not fitted to every case of Amenorrhea will readily allow.

But power of combating many causes of obstruction now confirmed by numerous trials & observations.

And here the rather led to use as imagining that might be serviceable in other respects.

Particularly some advantage I think to be looked for from electric sparks [drawn] from legs.

For by this means both absorption may be promoted, & tone of vessels augmented.

Thus in different respects [suited] to present complaint.

Is therefore intention with continuation of Nitrous mixture, to put patient on Electricity course.

And if during this, menses restored may I think look for advantage from it as mitigating, if not removing, severity of most urgent symptoms.

But if electricity fails future practices must be directed by situation in which shall then find patient.