DEP/DUA/1/44/33 (Normalised version)

John Boyd

(1788)

---

John Boyd at 40^th N^o7.

In case of this patient formerly observed had a distinctly marked example of Anasarca.

A disease which even in incipient state very little danger of confusing with any other.

But if then room for any doubt now none.

For affection has not only continued but increased.

And as indeed in some degree natural consequence collection of water in abdomen when then only [suspected] has now taken place to very considerable degree.

Now therefore no doubt, that here anasarca & ascites combined.

And indeed a complication of dropsical affections [particularly] of these much more frequent than either separate.

Often even what begins under form of one particular dropsy terminates in general dropsical affection of every cavity.

And this particularly remarked to be case with Anasarca.

A modification of the disease in which a general affection of lymphatics more frequent than perhaps any other.

Hence then every occurrence which has since taken place tends rather to confirm than to alter former opinion.

In one particular however cannot retain same opinion of this disease as before.

Then represented it as a recent & a favourable case

And disposed to hope that by aid of proper medicine might be brought to favourable termination.

Now however must acknowledge that hopes of recovery much less sanguine than before.

Would by no means indeed represent it as incurable.

And indeed few dropsical cases unless when water repeatedly evacuated & rapidly accumulating to be viewed in this light.

But always attended with danger where water not easily evacuated.

And where at same time such loss of strength, that strong evacuant dare not be employed.

This however remarkably case with our patient.

And may also add that he is placed in situation very unfavourable to recovery.

Is placed in confined & ill aired habitation.

Has no attendance but from a very infirm old woman.

And in all probability very badly off with respect to diet.

From all these circumstances have [suggested] to himself that I think chance of recovery not a little increased from going [into] the hospital.

To this however hitherto at least has constantly expressed aversion.

And must be acknowledged that would by no means ensure recovery.

Indeed in present circumstance look upon chance as being in any situation much against him.

Still however not precluded from attempting same plan of cure as at first begun.

In this disease the objective which naturally first presents itself, is the evacuation of water already effused.

And in next place the giving such condition to system as to preclude farther effusion

At same time however not neglecting to employ means for obviating such urgent symptoms as many occur.

On these grounds will readily understand intention which had in view in different practices here employed.

Began you will observe by prescribing an Emetic

And as such directed Ipecacuanha to extent of scruple¹.

To this gave preference as of all emetics which I have tried, consider as most certain in producing full vomiting.

From action of vomiting cannot here look for discharge of water.

And not even perhaps same proof of immediate discharge by [expulsion] of stomach as in some cases of stagnant ascites.

If any discharge from action is more even by surface than stomach.

But principal operation of emetic is to increase action of absorption.

And water in anasarca after being taken up by lymph & landed in circulatory mass readily discharged by any [illegible].

But particularly by urinary organs which where large effusion takes place, are most natural outlet.

Hence then with use of emetic here also you will observe combined a diuretic.

And as such had recourse to Cream of Tartar.

Which as a gentle & easy emetic, in general not exciting sickness at stomach is perhaps one of best we can employ.

From first effect of these medicines, appearance rather favourable than otherwise.

For while vomit operated well, urine not indeed [previously] diminished was yet increased.

While at same time powder had some influence in opening belly.

An effect rather desirable than otherwise.

And above all was here favourable that with these operations swellings somewhat diminished.

Was not however from single emetic that complete evacuation here to be expected.

And with repetition of emetic at proper intervals was intention to have persisted in [duration] for same length of time.

Nay even to have conjoined it with tonics with view of answering 2^d intention mentioned.

Accordingly at succeeding report directed that emetic should be repeated.

And as found that Cream of Tartar agreed well with stomach, not only ordered continuation but increase of dose.

Was not [deterred] from this by effect in moving belly.

For had looseness even been increased nothing to be [apprehended] from it.

On contrary by brisk cathartic, although has great influence in weakening system one of most powerful means of evacuating water.

Had no reason however to expect much from quantity of Cream of Tartar here directed.

For very generally from repeated use influence in moving the belly much diminished.

Hence did not expect that would now do more than before.

This accordingly found to be case

Or at least while vomit operated freely found that from Cream of Tartar, had no more than two or at utmost three stools in day.

But notwithstanding use, urine in place of being increased rather diminished.

And with this diminishment there occurred also increase of swelling.

While at same time some other unfavourable circumstances.

Particularly loss of strength, & what generally the attendant of a debilitating state quickness of pulse.

In this situation considered immediate repetition of Emetic as unadvisable.

Still however unwilling to desert former plan.

Ordered therefore, continuation of Cream of Tartar alone.

And that might [more] determine action to kidney, ordered a diuretic of diluent kind.

Infusion viz of Juniper to be taken by way of common drink.

Need hardly remark that essential oil of these berries, & which they contain in very considerable proportion a very active diuretic

And as such given in different forms.

Not unfrequently as united with spirit by distillation & diluted with water, or what called Gin-punch.

But in greater number of instances when not disagreeable to taste of patient have found more benefit from simple watery infusion.

And in many dropsical cases, have found it to operate as a very powerful diuretic.

Was in hopes therefore of obtaining same effect in present case.

But after this saw nothing of patient, for space of several weeks.

Accordingly succeeding report in register² at end of upwards of months from this present.

Then found that during intervening period, affection in every respect much aggravated.

That while was himself unable to attend, could not [convince] send any body to give account of situation.

And perhaps may mention as additional reason for not sending, that having taken aversion to Cream of Tartar, had used none of it.

Not only had there taken place aggravation of swellings but also of Dyspepsia.

While at same time situation in point of strength such, that could not attempt discharge by any other [illegible] than urinary organs.

Now however from [reluctance] to Cream of Tartar, became necessary to try some other.

And at same time, one easily [introduced] in smaller form.

Had formerly indeed suggested intention of trying one of late strongly recommended.

The recent juice viz of the Mesen brianthemum crystallinum, the diamond [Ticoides], or ice plant as commonly called.

But besides objection from necessary size of formula, in consequence of frosts which had occurred, plants destroyed so that could not now obtain it.

These considerations then led me to think of employing powder of dry squills.

Which of all the diuretics with which I am acquainted one of most powerful.

And particularly when given in combination with Calomel.

An article probably operating in different ways.

But particularly as increasing action of absorbents.

What effects however have resulted from this medicine have not learnt.

For since prescription have had no farther intelligence of him.

And I own should not be surprised to learn that has already fallen victim to his disease.

If however contrary the case, & any prospect of benefit from medicine, as discharging water with continuation shall think of conjoining it with some tonic as peruvian bark.

If unsuccessful in discharging water still other practices may be tried.

But in choice of these must be entirely regulated by circumstance of case & situation of patient.

---

Explanatory notes:

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

2) References are made throughout the case notes to a dispensary patient register. However, no evidence has been found that this register survives.