DEP/DUA/1/16/10 (Normalised version)

Frances Clerk

(1777-1778)

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Frances Clerk

With regard to disease of this patient was at beginning & still am very much at loss.

Complaints with which according to account she has given us is affected are of such nature that can not easily suppose her to be herself deceived.

While at same time not easy to see that can have any objective in deceiving us.

Yet if take disease as represented must consider it as being a difficult case.

And at same time necessity here for making some allowance for whimsical disposition of patient.

Entertaining theories of her own respecting consequences that must result from affection.

In particular that from want of discharge already distended to so great degree as to be able to hold no more

And that from this very great swelling induced.

Such swelling however neither obvious to external appearance now, nor at time when patient came under care.

And such her real or pretended modesty that will not submit to accurate examination.

From same cause also precluded from another source of information concerning disease.

That is what could be derived from examination by catheter or by sounding.

If from these no positive information might yet derive such evidence in negative way as would throw light on nature of disease.

If no discovery that certain particulars did exist, might at least be able to say that did not.

From all such information however by [positive] refusal of patient were here precluded.

For was not able to prevail upon her to submit to being sounded.

Nor even to allow of attempt being made to draw water by catheter.

In this situation then must necessarily speak with greatest uncertainty respecting nature of disease

And taking account as represented to us many different & even opposite conjectures may be entertained.

Of this account what would occur as most striking symptom is small discharge of urine.

Are told that seldom passes more than four ounces in twenty four hours.

And that even this consequence only of frequent attempts to discharge.

According to her representation would even appear that inclination to discharge rather increased than diminished

Or in other words that with scarcity of urine there occurs also a strangury affection.

Here then may occur as first question whether urine retained in Bladder after secretion or whether scarcity from want of [illegible]

These different states by nosologists¹ distinguished by titles of Ischuria renalis & vesical.

By use of Catheter or even by examination of region of pubis this question at least might have been certainly [decided]

When however to judge by symptoms are left very much in doubt

In some measure in favour of retention in Bladder that has frequent inclination to discharge.

Still more however that with pain in region of pubis there occur circumstances swelling these.

But while from these some presumption still stronger arguments against it.

If really retention in Bladder could not have spoken of swelling in uncertain state in which find her expressing it.

Pain of necessity must have been of much more excruciating nature.

And indeed few sensations more intolerable that what arises from distension of Bladder.

To all this may add that could not possibly have continued for length of time mentioned in case.

And in place of six months would probably even have proved mortal within space of six days.

Here then disposed to consider scarcity of urine as proceeding from want of due secretion.

But taking this to be case still another question occurs.

Whether viz want of secretion from morbid condition of kidney itself or of mass of fluid.

For well known that from this last cause scarcity of urine occurs in dropsical affections.

And that such here exists description which patient now gives of swelling of belly would lead us to conclude.

But here much disposed to think that account exaggerated.

If does take place is not such as to give obvious external appearance when dressed in ordinary manner.

Besides of dropsical swelling of abdomen is entirely confined to that part.

From patients own account no dropsical symptoms in other places.

Nor even besides swelling has she here other symptoms of ascites.

Neither complains of affection of breathing nor subjected to intense thirst.

Both however must necessarily have occurred, had disease gone to such length as to give great scarcity of urine here mentioned

This supposition also therefore inclined to reject.

And upon whole look upon it as most probable that want of secretion arises from affection of kidney.

Still however question of importance in cure in what that affection consists.

For want may be consequence of many different circumstances.

Particularly may proceed from want of action in consequence of paralytic state

From inflammation. From spasms. [illegible] etc.

But when consider circumstances of patient having often discharged small gravelly stones here, most probable that is affection of calculus at kidneys.

And this well known often to [induce] ischuria.

Must however be admitted that many of more common symptoms of Nephritis calculus here wanting.

And that while these absent very seldom that gives rise to this symptom for so great length of time.

Adopt it however not as supposition without difficulty but as what consider to be most probable.

And here in pain of loins, indigestion & affection of stomach, have at least some of symptoms of calculus in kidney.

While at same time know no circumstance which occurs as unsurmountable objection to the hypothesis.

This then conjecture which would reckon in case where so much uncertainty.

And if thus doubtful of nature of affection cannot speak with more confidence of Prognosis.

Must however observe that if had been to give opinion of this case several weeks ago should have been more afraid than at present.

To judge from symptoms alone several such as to be of very threatening nature

Yet after so long continuation without any dangerous consequences now less grounds for alarm.

Especially as according to account, scarcity of urine excepted other symptoms less considerable than formerly.

And even some reason to presume that patient represents discharge as being less than really is.

Should affection therefore continue do not consider it as highly threatening.

Yet see no grounds for expecting expedient cure.

And measures hitherto at least taken with this view of no affect.

Am farther at loss to think what measures can next be prosecuted with greater [prospect] of success.

While here therefore do not look for speedy recovery am even very doubtful how far can be of any service in alleviating complaint.

And is more with this view than with any expectation of radical cure that measures here proposed have been taken.

The intention however at which have aimed in each will more particularly appear when consider these in order.

From what already said consider it as most probable that patients affection depends on calculus.

Of numerous symptoms arising from this cause most may be counteracted by medicines particularly adapted to them.

Yet in this way relief obtained is at utmost but of transitory nature.

And more affect had by counteracting cause of symptoms

That is calculus itself.

Operation of calculus as giving disease from presence in bladder or urinary passages is in some measure or at least on some occasions the affection of obstruction.

But much more frequently of stimulation which occasions as irritating sensible parts.

Obstruction affect of size & position of stone.

Irritation in some measure of size but still more of state of surface.

On these grounds then are to look for counteracting influence of calculus on different [illegible].

But chiefly by attempting one or other of following.

1 The removal of stone where can be affected by mechanical means.

2. The solution of it as lodged in urinary passages.

3. The giving such a condition to surface that incapable of acting any longer as stimulant

4^th The changing situation by removal from narrow to more wide cavity.

On all these principles relief in this affection has been attempted.

And on some of them at least even radical cure successfully obtained.

Occurred then as question on which relief in present case in preference to be chiefly sought for.

That of all means of cure operation by knife the most to be depended upon cannot admit of doubt.

And where stone really exists in bladder perhaps but few instances where if patient will consent to it, ought on any account to be delayed.

Unquestionably should not from expectation of radical cure by any other means.

And where is to be performed no doubt that danger augmented from operation by previous use of many medicines employed as solvents.

Is however a mode of cure only applicable where calculus in bladder.

Has indeed been proposed by operation to extract calculus from kidney.

But independent of other circumstances to this uncertainty alone affords sufficient objections.

And although may have succeeded in some cases where stone has as it were formed abscess yet never to be attempted where integumentary in natural state.

If then, which here reckon most probable calculus seated in kidney, were patient even [willing] to submit to operation could be of no avail.

And although were in bladder & could removed by cutting yet refuses even to submit to sounding.

Of this mode of cure then unnecessary to say more.

Second solution of calculus in urinary passage must evidently seem at least a very desirable objective.

And that both as operation highly dangerous & as many cases in which cannot be performed.

Has long been opinion that many substances in nature capable of dissolving or wearing down stones.

Hence, as class of medicine, styled Lithontriptic

Now however certain that this not property of many substances once supposed to possess it.

Yet that such will never be discovered would by no means assert.

And while accurate experiments [undeceive] us with regard to some at same time lead us to entertain hopes from others.

Calculus of urinary passages indeed of very different consistency.

Some of them of most firm & hard nature

And even those, which softest & most friable in order to have cohesively dissolved require powerful menstruum.

Yet on other had well known that [informed] of many menstruums as tending to solution almost [irret].

And by aid of these much harder substances than any calculus brought into state of solution.

That by these means calculus out of bladder may be completely dissolved can admit of no doubt

But from situation in living system great difficulty to be overcome

Certain that many of [menstruums] capable of dissolving calculi capable also of dissolving visceras in which contained.

And those most powerful, that animal system can bear without injury to viscera cannot yet be applied.

For as taken into stomach before [reach] urinary organs nature totally changed.

Although however these objections against many menstruums yet may not hold against all.

And some solvent may yet be discovered which may with safety be applied to calculus contained in bladder as [thrown] in by [injury]

Or which may even be capable of exerting influence on calculus as contained in any part of urinary organs from reaching these in course of circulation.

A late very ingenious writer Dr Percival of Manchester contends that have such a property in fixed air.

Long since found by experiments of Mr Lavoisier & Mr Cavendish that water impregnated with fixed air becomes menstruum both for earth & metals

Building on these experiments Dr Percival thinks that has by his [ascertaining] that gives water property of dissolving urinary calculus

But goes even farther

Alleges that from water thus impregnated being taken [illegible] into stomach this property communicated to urine.

If his trials then confirmed by future observations may in such impregnation have a most useful medicine.

And should this entirely fail yet some other may yet be discovered.

Investigation by experimentation then not to be [neglected]

And that both with view of determining how far good foundations, for what already said to be discovered

Or if this insufficient with view of discovering one more powerful

Should however neither mechanical extraction nor solution promise any aid symptoms [may] yet be mitigated by action on stone.

And have pointed out as third grounds of relief the giving such condition to surface of stone that incapable of action.

Certain that several medicines, from intermittent use of which, painful symptoms resulting from calculus greatly mitigated.

And yet where calculus in bladder on examination by sounding found to remain as before.

With this relief of symptoms change also induced in state of urine.

And while before deposited large quantity of calcareous matter from use of such medicines acquires natural appearance.

Presume then that from this state of urine constituting calculus diathesis surface of calculus obtains condition by which more capable of stimulation.

And that with urine in natural condition acquires covering by which bladder or other urinary organ can less readily be affected.

On this principle are I imagine to account for action of Lime water & such other absorbents. And of Uva Ursi & similar astringents.

And where removal by other means not to be affected, alleviation on principles now mentioned of utmost importance to patient.

Lastly in calculus cases complaint sometimes not so much affect of stimulation as of situation of stone.

And means of relief afforded by removal from narrow to more wide cavity.

Thus then when in ureter must be endeavoured that should be got into bladder

When in urethra that should either be extracted or pushed back.

Latter to be effected merely by [illegible] means

Former by relaxing & antispasmodic medicines.

In present case however presumption, that, in this way nothing requisite.

And measures taken neither with view of removal, or of changing situation of calculus

But either as solvent or as removing that condition of urine by which calculi rendered capable of giving additional stimulation.

Need hardly observe that was with last of these intentions that had here recourse to Uva Ursi.

And with view to other that have since put her on mephitic water.

To this change induced from want of success with Uva Ursi.

And from uncertainty as to nature of affection.

Same reasons might again lead us to alter present medicine.

Yet if patient continues longer to attend us which with one of her temperament perhaps hardly to be expected shall wish to push it somewhat farther.

Have however already conjoined it with different diuretics.

And if scarcity & high colour of urine continues may change these for others.

But in case where so doubtful as present can speak with no probability.

And unnecessary to throw out farther suggestions respecting future practices when probably shall never have opportunity of trying.

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Explanatory notes:

1) Nosology is the branch of medical science dealing with the classification of diseases. Individuals referred to in the case notes as nosologists were commonly those who had published nosological, or classificatory, medical texts.