DEP/DUA/1/27/13 (Normalised version)

James Mitchell

(1781-1782)

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James Mitchell.

Symptoms of patient such as often met with in practice.

And indeed what already have oftener than once had occasion to mention in present course.

Principle complaints cough, dyspnoea & expectoration of whitish matter.

With these symptoms only doubt whether affection Phthisis or Catarrh.

Even at commencement from symptoms of case considered patient as subjected to former affection

But if then any doubt now none

For from what afterwards saw of progress of affection Phthisis sufficiently characterised.

Particularly by distinctly marked hectic fever, colliquative sweats, & colliquative diarrhoea.

And indeed under these, patient since came under our care has fallen victim to disease.

Unnecessary therefore to offer many observations on circumstances characterising it when first called for assistance.

While symptoms as cough & dyspnoea, in common to both affections, many more particulars indicating Phthisis.

Of this some presumption from age

Patient at 30^th year only.

This indeed in general considered as past Phthisis period.

And unquestionable that Phthisis, particularly that species which most common, occurs more frequently between 15 and 25 years of age.

But if somewhat passed Phthisis period is still more distinct from catarrh.

Or at least from that period when catarrh appears in chronic state, in which condition alone resembles Phthisis.

Admit indeed that may occur at any age

But much less frequent than Phthisis at 30^th.

Besides age presumption in favour of Phthisis from appearance of expectorated matter.

Expectoration indeed copious & of white colour

But without that degree of viscidity which very generally occurs in chronic catarrh.

Another circumstance giving presumption swelling of legs.

This indeed in common to both affections.

But seldom that occurs so early in Catarrhal affections, as in present instance.

If from these circumstances some presumption still stronger from state of pulse.

With present patient, uniformly much quickened above natural standing.

Even when most free from fever, symptoms, never under 100.

And probably if opportunity of examining when fever exacerbated came on much quicker.

This however while almost constant attendant in Phthisis, rare in Catarrh.

And perhaps no circumstance which seems more to distinguish Phthisis, where makes appearance under form of other affections.

For to be observed that Phthisis an insidious affection and often has made considerable progress before distinctly marked.

When quickness of pulse however with other marks always strong suspicion.

To all these circumstances, in present case [still] another to be added.

And that too not less characteristic of affection

I mean colliquative sweats during night.

In many instances indeed Phthisis even fatally terminates without occurrence of these.

And on other hand often do occur in cases where no Phthisis.

But when accompanies other symptoms of Phthisis not only certain characteristic, but also very dangerous appearance.

From all these particulars then, at first concluded case to be Phthisis.

And as already observed from farther progress had no doubt that opinion justified.

For in course of disease had opportunity of observing distinctly marked Hectic fever.

And besides colliquative sweats there occurred also, towards conclusion of affection colliquative diarrhoea.

Hence then no hesitation in pronouncing that this patient subjected to Phthisis.

Has been much dispute among nosologists¹ & other writers, whether Phthisis should properly be considered as genus of disease or not.

But in whatever light view it, no doubt that both one of most common & most dangerous affections in this country.

And besides pronouncing case to be Phthisis, for proper conduct of practice, must go one step farther.

For Phthisis one of those diseases in which room for many distinctions.

Without entering into consideration of these shall at present only observe that with view to practice, may be divided into 3 Species

These shall afterwards have occasion particularly describe in practical lecture.

And shall then assign reasons for distinguishing them by title of Catarrhal Tuberculous & Ulcerous.

Here then to inquire to which of these patient to be considered as subjected.

Look upon case now read as exhibiting example of first species catarrhal Phthisis.

To this conclusion led both from symptoms with which is attended, & from absence of those marks which commonly occur in others

Here no fixed local pain in side commonly symptomatic of ulcer.

Not that dyspnoea, from lying particularly on either side, with which attended.

Not great discharge of matter obviously purulent or peculiar cleanness of tongue, with which almost uniformly attended.

From these marks then would [infer] that not the ulcer.

On other hand passed period of life at which tuberculous most common.

Did not as is commonly case, thus arise without any obvious cause.

Is not attended with dry cough without any expectoration as generally happens there.

And no other marks from which smallest reason to infer Scrofula habit.

Hence then from mere absence of symptoms characterising ulcerous & tuberculous Phthisis should be led to consider it as Catarrhal.

But besides this, draw same conclusions from symptoms here occurring, & from manner in which made attack.

Disease derived origin from an obvious cause.

Imprudent exposure of body to cold after being very much heated by [body] [illegible]

Prior to this, patient as far as could learn, strong & vigorous.

But although accident during warmest weather, yet succeeded by symptoms of common cold.

These in place of soon abating, which in summer months, might naturally have been expected, not only continued but aggravated.

In short, soon came to that state which in this country has name of sitten down cold.

A term generally employed in those instances, in which catarrh in place either of speedy recovery or degenerating into chronic state terminates in Phthisis.

From cause & progression then in this case strong reason for considering it to be a catarrhal Phthisis.

But still farther indicated by symptoms.

Particularly by want of fixed pain indicating any local affection at any particular part of breast.

By [illegible] being nothing affected by posture.

But above all by state of expectoration.

Matter of whitish colour we are told expectorated in large quantity.

From circumstances both of smell & taste may conclude that neither entirely nor even principally purulent.

Yet reason to believe that contained mixture of pus.

And if opportunity afforded of making proper trials by aid of caustic alkaline lixivium or like should probably have found decisive evidence of pus.

From this state of expectoration then may conclude that purulence giving hectic fever & other symptoms of Phthisis [furnished] by separation at surface of lungs.

This however idea which entertained [respecting] source of purulence in what would call catarrhal consumption.

And to this take to have been species or modification of Phthisis to which our patient subjected.

A species which although much less common than the tuberculous yet by no means a rare occurrence.

When occurs as well as every other Phthisis a dangerous complaint.

Of all the species of Phthisis indeed from this more recovery than from any other.

At same time, as in instance before us often fatal.

And after conclusion which has already had any farther observations on prognosis now altogether unnecessary.

For same reason also need say very little of practice.

For before patient came under care in such a state that little opportunity for trial of many medicines.

And even with these to which recourse might have been had without risk, from inability to give regular attendance, & other circumstances little trial made.

In this species of Phthisis great objective to be aimed at is the restoring [separation] by surface of lungs, to natural state.

And this sometimes to be affected even without any change in vessels by which separation affected.

But merely by change in circulation through these.

Particularly by diminishment of impetus at lungs, & determination to other parts.

With these intentions, in such cases often great benefit from blisters & issues.

And accordingly from use of blister patient had before derived very considerable benefit at least for time.

To such measures therefore, might naturally have thought of having recourse.

But from circumstance of constant drain, operating as exhausting strength, chose rather to give trial to emetics with same intention.

These from general concussion often useful as giving determination to extreme vessels in other parts of system.

And flow thus restored, often without any other measures becomes permanent.

Besides this, here as in chronic catarrh often of service also from unloading breast.

Is on these principles I imagine, that to explain benefits derived from them in this species of Phthisis.

Must however observe that used also in others.

And in tuberculous in particular probably operates in very different way.

In as far as have effect to be considered as consequence of producing resolution of tuberculous in same manner as said to do in some other cases of Scrofula tumour

But on whatever principle may operate, in instance before us seemed at first at least to have good effects.

For while operation such as could have wished was followed by considerable mitigation of cough.

This however consider as having been merely consequence of [unloading] air vesicles.

And accordingly of but short duration.

For at next report dyspnoea nearly as urgent as before

And patient still affected to equal degree with colliquative sweats.

With continuation of emetic therefore had recourse also to another measure.

Use viz of powder of Cicuta.

An article which consider indeed as chiefly accommodated for tuberculous Phthisis.

But which have seen serviceable not only in chin cough, but in every instance of obstinate cough.

And which probably has effect from diminishment of disposition to this inordinate action

But in instance before us, appears that very little influence.

For after this saw nothing of patient for some time.

Then learnt that affection so much aggravated & strength so much exhausted that unable to leave house & hardly even bed.

In this situation had recourse to [Mixture] Mucilage, merely as placebo & as means of slight temporary alleviation.

But from this also cannot say that derived any advantage.

For soon after patient fell victim to disease.

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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.