DEP/DUA/1/33/30 (Normalised version)

Robert Mitchell

(1783-1784)

---

Robert Mitchell January

In case of this patient nothing very remarkable or peculiar.

Labours under a disease however which in this country & at this season of year no less frequent than troublesome

And as such here selected as subject of practice & lecture.

Affection consists in troublesome cough, particularly severe & frequent in night

And at same time attended with copious viscid expectoration.

When consider age to which this patient has arrived 64^th year might without hesitation term it Catarrhus senilis.

As however, though most frequent in advanced age yet by no means peculiar to it, with greater propriety termed Chronic Catarrh

A disease entirely dependent on uncommon secretion of mucus by lungs.

Where from [filling] & irritating air vesicles gives both dyspnoea & cough.

And accordingly, on free discharge, by excreting in large quantity, temporary relief at least is obtained.

This augmented secretion, very generally at least, consequence of change in determination

And particularly of want of free circulation on surface.

Accordingly disease much more frequent during winter than at any other season

And indeed many with whom a periodic affection, returning regularly with cold weather.

While by change of season almost completely & spontaneously removed.

This disease in general at least not esteemed dangerous.

And indeed numbers subjected to it for course of many years.

But though on this account often disregarded, yet in end not unfrequently fatal.

And particularly so with those far advanced in life.

For after accumulation considerable, & strength becomes insufficient for expectoration, suffocation must be necessary consequence.

In such a case therefore as present prognosis should always be given with great caution.

For although apparent relief obtained yet apt to be renewed on slightest accident.

And especially with those during such an inclement season as present, necessarily exposed to severity of weather

Hence then with present patient, already subjected to frequent recurrence, cannot [now] at least promise any permanent recovery.

In case however nothing at least immediate alarming

And by different practices may hope, although cannot in present circumstances remove, yet in some degree to alleviate his affection.

In this disease most immediate relief obtained by unloading breast from mucus already accumulated.

But still more permanent advantage from diminishing future secretion.

Not so much however by restraining secretion at part, as by giving determination to other parts.

Particularly to surface, to urinary passage or to intestinal canal.

With these different intentions, recourse had, in this affection, to various remedies.

And from what now said, will readily understand meaning, in different practices here employed.

Began you will observe by directing for this patient the use of an Emetic.

In this need hardly observe that intention in view was much more to unload the breast than the stomach.

Most immediate & obvious effect indeed is evacuation of stomach.

And where no matter accumulated in air vesicles of breast has probably little effect on these.

But can be no doubt that in cases where such accumulation takes place greatly promotes expectoration.

In so much, that some even disposed to consider emetic as only expectorant

To this opinion indeed, must own, that for my own part, I cannot subscribe.

Yet at same time, have no doubt in considering vomiting as most ready means of promoting Expectoration.

Perhaps may add most powerful

This then principle affect here expected from it.

But besides this, also expected somewhat, from influence of vomiting as giving determination to surface.

For in this way effect, though indeed but temporary, unquestionably powerful.

And from proper circulation on surface, in this disease, greatest benefit obtained.

This abundantly [evinced], from relief in warm, & aggravation in cold weather

From benefit derived from warm clothing, keeping the house etc in cold weather

And from great relief which those long periodically subjected to it, obtain from passing winter in warmer climate.

No disease in which change of climate so as to avoid severity of winter, more beneficial than present.

And this, entirely I apprehend to be explained, from different state of circulation on surface

From Emetic indeed effect in this way at utmost but temporary.

Has still however influence both as increasing discharge & renewing circulation on surface.

And when once restored often supported by means before insufficient such for example as warm clothing or like

How far on these principles was here beneficial to patient cannot positively pretend to say.

But at least were not disappointed in obvious operation.

And to this, am I own, inclined principally to attribute that considerable alleviation of symptoms which succeeded.

This were warranted to infer, not merely from relief in medicine succeeding operation, but from having been formerly observed attended with same effect.

Thus then, from former experience, as well as from principles here stated, may conclude that benefit derived from it.

But besides vomit must be [admitted] that here also had at same time recourse to another medicine.

And one too from which benefit I think might have been expected.

Viz the Pill Scillitica.

In last edition of Edinburgh Pharmacopoeia¹, published under direction of Dr Cullen squill pills had no place.

Were not however thrown out on supposition of their being pernicious or inactive.

But merely because imagined that more efficacious as an extemporaneous prescription than as kept ready prepared in shops.

And that more convenient for practitioner to have it in his power, readily to vary preparation of Squills than to be tied down to any fixed formula.

But though these [arguments] of some weight, yet were not sufficient grounds for rejection.

From having fixed formula, practitioner by no means prevented from varying preparation in extemporaneous prescriptions as he pleases

And though pills made of recent squills, soon apt to suffer, yet those prepared from dry powder of root, kept good for considerable time.

And as thus prepared unquestionably most certain, & most efficacious medicine.

But besides this, still an additional reason for keeping them in shops.

Many patients, long habitual to use, in practice of prescribing them for themselves.

Hence, so often called for, that when no formula given by the College apothecaries obliged to keep them in shops, as prepared by former edition of Pharmacopoeia.

For these reasons then Edinburgh College² have thought it proper to restore Squill pills in present edition of Pharmacopoeia

And in doing so have considerably altered formula.

Besides Squills indeed, some other articles in both, such for example as Gum Ammoniacum as adjuvants, & Cardamom as corrigents still retained.

But in place of recent root, powder of dried root now employed.

And this unquestionably a much more active substance.

For in adhering water, which constitutes difference between the two, probably no activity whatever resides.

And by difference in proportion of this water, strength of root, in what called recent state, very much varied.

Hence present a much preferable formula to former one.

Into each pill, of grain V powder of dry squills, now enter to nearly [quantity] of grain.

And though this much lesser proportion than formerly, yet no less active & more certain.

Was from squills here, that benefit as employed in this case, entirely expected.

General properties of squills, need not here stop to enumerate.

Needless to observe, that in certain doses, from action on stomach operates as emetic.

And no less certain, that when not suddenly discharged from alimentary canal, active principle carried into circulating mass.

From reaching kidney in course of circulation, have very generally at least effect of operating as diuretic.

And indeed, though no diuretic always to be depended on, yet in general ranked among most certain of that tribe of medicine.

But if thus certain operates on urinary organs, may observe that has at least equal access to other parts

And from observation of facts has long been previously opinion, that has effect on [secretion] by breast

This opinion indeed some disposed to deny

But judging, not from any theory but from own observations, can entertain no doubt, of expectorant as well as diuretic power.

As far however as has tendency to increase secretion by breast, may seem adverse to this disease.

But while influence in this way has still more effect, as promoting tendency to speedy discharge.

Hence mucus excreted before [acquire] that viscidity, giving great dyspnoea & severe cough.

And thus it is, that has appearance of rendering mucus thinner, though in reality, no affect in that way.

Is then from influence on state of expectoration, as well as from diuretic power, that product of benefit in cases of Catarrh

And indeed whatever principle no doubt that here very considerable advantage derived from it.

And as formerly found benefit to patient again expected same effect from it.

Cannot however say that in this respect expectations yet accomplished.

For from [inquiring] at his habit find that still much distressed with cough.

This however may in part perhaps ascribe to himself.

For as will observe from register³ has not given regular attendance and of course has not been supplied with medicine for some time past.

But at same time if want of medicine somewhat against patient, state of weather still more so.

And with present severe frost while continues to go abroad in course of his employment can hardly expect benefit from any practice.

If however returns to attendance in former condition shall think of prosecuting same plan

Or in case of particular urgency of symptoms, may have recourse to a blister

In case of costiveness, may [direct] Cream of Tartar either by itself or combined with Sulphur.

In these particulars however must be directed, by condition in which shall then find patient.

---

Explanatory notes:

1) An official publication containing a list of medicinal drugs with their effects and directions for their use. The Royal College of Physicians of Edinburgh's Pharmacopoeia was first published in 1699.

2) The Royal College of Physicians of Edinburgh, established in 1681.

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