DEP/DUA/1/28/09 (Normalised version)

Robert Cumming

(1781-1782)

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Robert Cumming.

Respecting case of this patient when came under care not without doubt.

Then however several circumstances which led me to consider principal affection as consisting of calculous complaint.

And on this supposition began treatment of case.

But from what have since seen as to progression of disease am now doubtful how far this opinion well founded.

And accordingly of late have treated the disease on a different footing.

This however will more fully appear on remarks on practice.

When came under our care most urgent part of complaint consisted in pains in different parts of body.

These sometimes in fore part occupy region of stomach.

Often in back affecting seat of kidneys.

And in this last situation to shoot downwards in course of ureters.

With this pain there occurred also very considerable affection of discharge of urine.

Patient indeed did not complain of greater desire to pass it than natural.

But colour observed to be considerably changed.

So much deepened in colour that according to description some suspicion even that might contain mixture of blood.

With this change in appearance more scanty than natural.

And discharge not affected without some pain – Particularly in passing last drops

From all these circumstances taken together thought that grounds to presume that disease principally an affection of urinary organs.

And that depended on action of calculus or sand.

Had not indeed in this case what could be considered as all symptoms of Nephritic calculus.

Though pain in course of ureters yet not attended with retraction of testes which often occurs.

And here no vomiting which a symptom still more frequent.

Besides this not affected with [constant] inclination to discharge urine.

But although these symptoms so often occur that have in general entered definition of disease yet can by no means be considered as essential.

And often what afterwards [turns] out distinctly marked instance of this affection, attended with all worst symptoms, for long time with fewer appearances of disease than here occur.

Imagine therefore that at least [safest] practice to use such gentle remedies as might be useful on that footing.

And hoped that by these affection might soon be mitigated if not entirely removed

For upon supposition of affection being nephritic had every reason to conclude that would not be severe case.

Of this strong grounds for presumption from symptoms themselves.

Still stronger from having already continued for space of ten days without any aggravation.

From these circumstances conclude that irritation to urinary passages did not arise from any powerful stimulating cause

And supposed it to be rather effect of sand than of calculus.

Hoped therefore that might be removed merely by increase of quantity of urine.

To this practice indeed in some cases of calculus strong objections.

Where by calculus total obstruction to passage of urine must aggravate all symptoms

Here however though some pain in discharge yet had regularly taken place at usual intervals.

And this pain, as well as high colour, was disposed to attribute more to scarcity of [separate] than to any other cause.

For when this the case very generally saline impregnation & consequential acrimony very much increased.

On this ground therefore some of most distressing symptoms to be explained whether scarcity of discharge from calculus or not.

Hence then was natural indication for use of those medicines which would augment secretion.

Was with this intention that directed for patient the Spirit Nitre dulcified.

This as have often had occasion to observe considered to be one of best diuretics with which am acquainted.

Do not indeed look upon it to be one of most powerful for giving very copious discharge.

Yet operates more expediently than any of these as giving immediate discharge.

While at same time, for my own part at least have never observed from it any inconvenience as affecting stomach.

Hence then to such instances as present peculiarly suited.

And wherever urine to be promoted in nephritic affections is I think preferable to any other.

Has in this way some effect even when given in small doses.

And in some habits obvious operation even from ten or 12 drops.

May however be given to much greater extent without any inconvenience.

And not unfrequently employed to quantity even of two drams or upwards in course of day.

But always inadvisable at least to begin with such doses.

And from half the quantity have often seen equally good effects.

Particularly if at same time operation promoted by any gentle diluent.

Here therefore began by directing it to extent of thirty drops twice a day.

And to aid influence directed as [dilutant] an infusion of Juniper.

Which even by itself has in this way no inconsiderable effect.

From use of these medicines were not disappointed.

For while product of no inconvenience or unease at stomach quantity of urine observed considerably increased.

With this as might naturally indeed have been expected colour also changed

Now became much less red than formerly

And what still more agreeable [discharge] attended with less pain.

Still however complains of pain in course of Ureters.

But in every other respect symptoms much easier.

Relief therefore already received not less than continuation of some symptoms both [induced] to continue

Directed therefore that should persist in use for another week.

And at end of this period no more remaining symptoms, of any affection of urinary organs.

Was not however entirely free from all complaints.

For now complained of considerable pain in back.

This however higher seated than region of kidney.

And as well as pain of hypochondriac had formerly been was aggravated by [external] touch.

Was inclined therefore to consider it as of Rheumatic kind

This the more probable from state of affection at time of attack.

For then all pains principally seated in larger joints.

These had formerly been removed by friction with Camphor oil

Now therefore had recourse to an application nearly similar.

viz Anodyne Balsam.

This as had lately occasion to observe consists in Camphor dissolved in Spirit of wine.

But with addition of considerable proportion of opium.

From this no doubt that immediate influence in allaying pain much more considerable.

Hoped therefore that might soon be product of considerable relief.

But besides pain of back at this time another particular also claims attention.

viz. Bound state of belly.

With view of obviating this symptom had recourse to aloes.

And as most effective means of obtaining merely effect wanted employed these in substance under form of pills.

And in place of simple aloetic pill had here recourse to what call pill foetid cum Aloe.

These from addition of proportion of Assafoetida more influence as discharging wind.

From which although no certainty [illegible] of it reason to presume that might in some degree depend.

For no doubt that wind in intestinal canal often cause of pain both in belly & back.

And at any rate this addition would in no degree counteract influence of aloes as obviating costiveness.

On contrary has manifest tendency to produce same effect.

Accordingly in operation expected from it were not disappointed.

For from these pills taken to extent of grain V at bed time, had regular discharge by belly.

Expectation however from anodyne Balsam not so fully answered.

For notwithstanding regular use pains still continued.

These however not so urgent as to indicate necessity of having recourse to any other practice.

Was therefore contented, with directing continuation of pills & Balsam as before.

In place however of mitigating, at next report found this part of affection rather aggravated.

While at same time from extension to shoulder had still strong evidence that was of Rheumatic kind.

In place therefore of anodyne balsam now substitute as stimulant & [illegible] the use of the Volatile Liniment.

And as belly no tolerable regularity without any evidence that pain aggravated by wind intermitted use of pills.

Principally that from long continual habit might not become always necessary

For to be observed that after intestines for some time accustomed to such stimulation due peristaltic motion will not take place without it.

Under use of Liniment Volatile pain somewhat abated.

In so much that at succeeding report was principally seated in left shoulder.

Since that however for two weeks past have seen nothing of this patient.

But informed that has been confined to house from aggravation of pains.

If therefore returns to attendance here shall probably have occasion to treat his case merely as Rheumatism.

And must own that from this termination of case as well as commencement, now begin to suspect, that even affection of discharge of urine, may have proceeded entirely from Rheumatism.

But even of this supposition still I think affords evidence of advantage of gentle diuretics in such cases.