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

Frances Clerk

(1777-1778)

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Frances Clerk

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

Compl. with which accord to acct she has given us is affected are of such nature that can not easily hardly suppose her to be herself deceivd.

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

Yet if take disease as repres. must consider it as being a diffic case.

And at same time necessit here for making some allow. for whimsic. disp of patient.

Entert. theories of her own respecting conseq. that must result from affect.

In partic that from want of disch. already distend to so great degree as to be able to hold no more

And that from this very great swelling induced.

Such swelling however neither obv. to extern appear now, nor at time when patient came under care.

And such her real or pretended modesty that will not submit to accur. exam.

From same cause also preclud. from anoth source of inform concern. disease.

That is what could be derivd from exam by cathat or by sound.

If from these no posit informat. might yet derive such evid in negat way as would through light on nat. of dis.

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

From all such inform however by pos. refus of patient were here precluded.

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

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

In this situat then must necess speak with greatest uncert. respecting nature of disease

And taking acct as repres. to us many diff & even oppos. conject may be entert.

Of this acct. what would occurr as most stricking sympt. is small disch of urine.

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

And that even this conseq. only of freq. attempt to disch.

Accord. to her repres. would even app. that inclin to disch rather dim increased than incr dimn

Or in other words that with scarcity of urine there occurs also a strang. affect.

Here then may occurr as first quest. whether urine retaind in Bladder after secret. or whether scarcit from want of [illegible]

These diff states by nosol. disting by titles of Ischur renalis & vesical.

By use of Cathat. or even by exam of region of pubis this quest at least might have been certainly [dec]

When however to judge by sympt are left in some meas. very much in doubt

In some meas in fav of reten in Bladd that has freq. inclin to disch.

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

But while from these some presumpt still stronger argt against it.

If really retent in Bladder could not have spoken of swelling in uncert. state in which find her express. it.

Pain of necess. must have been of much more excruc. nature.

And indeed few sensat. more intol. that what arises from dist. of Bladder.

To all this may add that could not possib have cont. for length of time ment in case.

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

Here then disp to consider scarcity of urine as proceeding from want of due secret.

But taking this to be case still anoth quest occurrs.

Whether viz want of secret. from morbid condit of kidney itself or of mass of fluid.

For well known that from this last cause scarcit of urine occurrs in drop. affect.

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

But here much disp to think that acct. exagger.

If does take place is not such as to give obv. extern appear. when dressed in ordin. manner.

Besides of dropsic swelling of abdom is entirely conf. to that part.

From patients own acct. no dropsic sympt in other places.

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

Neither compl of affect of breathing nor subj. to intense thirst.

Both however must necess. have occurrd, had disease gone to such length as to give great scarcit of urine here mentiond

This suppos also therefore inclined to reject.

And upon whole look upon it as most probab. that want of secret arise from affect of kidney.

Still however quest of import in cure from in what that affect consists.

For want may be conseq. of many diff. circum.

Partic may proceed from want of action in conseq of paralyt. state

From inflam. From spas. [illegible] &e.

But when consider circum of patients having often disch. small gravelly stones here, most prob. that is affect of cal. at kidneys.

And this well known often to [induce] ischuria.

Must however be admitted that many of more common sympt of Neph. calcul. here wanting.

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

Adopt it however not as suppos. without diff. but as what consider to be most probab.

And here in pain of loins, indigest & affect of stom, have at least some of sympt of cal. in kidney.

While at same time know no circ which occurrs as unsurm. obj. to the hypoth.

This then conject which would reck in case where so much uncert.

And if thus doubtful of nature of affect cannot speak with more conf of Progn.

Must however observe that if had been to give opin of this case sever. weeks ago should have been more affraid than at pres.

To judge from sympt alone sever. such as to be of very threat nature

Yet after so long cont. without any danger conseq. now less ground for alarm.

Especialy as accord to acct, scarcity of urine excepted other sympt less consid than formerly.

And even some reason to presume that patient repres. disch. as being less than realy is.

Should affect therefore cont. do not consid it as highly threatening.

Yet see no ground for expect. exped cure.

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

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

While here therefore do not look for exped cure speedy recovery am even very doubtful how far can be be of any service in allev. compl.

And is more with this view than with any expect of radic cure that meas here prop. have been taken.

The intent however at which have aimd in each will more partic appear when consider these in order.

From what already said consid it as most probab. that patients affect dep. on calcul.

Of numer sympt arising from this cause most may be counteracted by med partic adapted to them.

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

And more affect had by counteracting cause of sympt

That is calcul. itself.

Operat of calcul as giving disease from pres. in bladder or urin passages is in some meas. or at least on some occas. the affect of obstruct.

But much more freq. of stim which occas. as irrit sensib parts.

Obstruct affect of size & posit of stone.

Irritat in some meas. of size but still more of state of surface.

On these grounds then are to look for counteracting influ of calcul on diff [illegible].

But cheifly by attempting one or other of following.

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

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

3. The giving such a condit to surface that incap. of acting any longer as stim

4^th The changing situat by removal from narrow to more wide cavit.

On all these princip relief in this affect has been attempted.

And on some of them at least success. obtaind even radic cure success obtaind.

Occurrd then as question on which relief in pres. case in pref to be attempted cheifly sought for.

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

And where stone really exist in bladd perhaps but few inst. where if patient will consent to it, ought on any acct to be delayd.

Unquest should not from expect of radic cure by any other means.

And where is to be performd no doubt that danger augm from operat by prev. use of many med employd as solv.

Is howevr a mode of cure only applc where calcul in bladder.

Has indeed been prop. by operat to extract calcul. from kidney.

But indep. of other circum to this uncertainty alone affords suff. obj.

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

If then, which here not improbab. reckon most probab calc seated in kidney, were patient even [willin] to subm to operat. could be of no avail.

And although were in bladder & could removd by cutting yet refuses even to subm to sounding.

Of this mode of cure then unnecess. to say more.

Second solut of calcul in urin passag. from danger of operat must evid seem at least a very desir obj.

And that equally fresh danger of oper both as operat highly danger & as many cases in which cannot be performd.

Has long been opin that many subst in nature capab of dissolv. or wearing down stones.

Hence, as class of med, stiled Lithontrip

Now however certain that this not prop of many subst. once supposed to possess it.

Yet that such will never be discov. dare not venture to would by no means assert.

And while accur. experim [undeceives] us with regard to some at same time lead us to entert. hopes from others.

Calcul. of urin passages indeed of very diff consist.

Some of them of most firm & hard nature

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

Yet on other had well known that inf. of many menst as tending to solut almost [irret].

And by aid of these much harder sub. than any calcul. brought into state of solut.

That by these means calcul out of bladder may be compl. dissolvd can admitt of no doubt

But from situat in living syst. great diffic to be overcome

Certain that many of solv menstrua capab. of dissolv calculi capab also of dissolv. visceras in which cont.

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

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

Although howevr these object against many menst. yet may not hold against all.

And some solv. may yet be discovered which may with safety be applied to calcul cont in bladder as [thrown] in by [injur]

Or which may even be capab of exert influ on calcul. as cont in any part of urin organs from reaching these in course of circul.

A late very ingen writer Dr Perciv of Manchest. contends that have such a prop. in fixed air.

Long since found by experim of Mr [Lavoisier] & Mr Cavend. that water impreg. with fixed air becomes menst both for earth & metalls

Building on these experim Dr Perciv thinks that has by his ascert. that gives water prop of dissolv urin [calcul]

But goes even farther

Alledges that from water thus impreg. being taken [illegible] into stom. this prop. commun. to urine.

If his trials then confirmd by future observat. may in such impregn have a most useful med.

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

Investing by experim then not to be [neglec]

And that both with view of determ. how far good found, for what already said to be discov

Or if this insuff with view of discov one more powerful

Should however neither mechan extract nor solut. promise any aid sympt [may] yet be mitig by action on stone.

And have pointd out as third grounded of relief the giving such condit to surf of stone that incap of action.

Certain that several med, from interm use of which, painful sympt result from calcul. greatly mitig.

And yet where calcul in bladder on examin by sounding found to remain as before.

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

And while before depos large quantity of calcar matter from use of such med acquires natur app.

Presum then that from this state of urine constit calcul. [diath] surface of calcul obtains condit by which more capab of stim.

And that with urine in natural cond acquires covering by which bladder or other urin. organ can less readily be affectd.

On this princip are I imagine to acct for action of Lime water & such other absorb. And of Uv Ursi & simil astring.

And where removal by other means not to be affectd, allev. on prin now mentiond of utmost import to patient.

Lastly in calcul cases compl. sometimes not so much affect of stim as of situat of stone.

And mean of relief afforded by removal from narrow to more wide cavit.

Thus then when in [ureter] must be endeav that should be got into bladder

When in urethra that should either be extractd or pushd back.

Latter to be effected merely by [illegible] means

Formr by relax & antispas. med.

Here In pres. case howevr presumpt, that, in this way nothing requis.

And meas taken neither with view of remov, our or of changing situat of calcul

But merely of either as solv. or as removing that condit of urine by which calculi rend capab of giving addit stim.

Need hardly observe that was with last of these intent that had here recourse to Uv Ursi.

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

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

And from uncertainty as to nature of affect.

Same reasons might again lead us to alter pres. med.

Yet if patient contin longer to attend us which with one of her tempr perhaps hardly to be expectd shall wish to push it somewhat farther.

Have howevr already conj it with diff diuret.

And if scarcit & high colour of urine cont. may change these for other.

But in case where so doubtful as pres. can speak with no probab.

And unnecss to throw out farther suggest. respect future pract when probab. shall never have opport of trying.