DEP/DUA/1/13/15 (Normalised version)

John Mitchel

(1777)

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John Mitchel.

Case of this patient in some respects singular.

And affords I apprehend an example of a disease not every day occurring in practice.

Disease consists in paroxysms which give evident indication of being affection of Nervous kind.

These at first commenced in some respects periodically returning every evening at certain hour

This state of appearance however but of short duration.

And in no long time was subjected to attacks of them with same irregularity as if had been fits of hysteria or epileptic kind.

May farther be observed that to hysteria & epileptic fits had in several particulars some resemblance.

Affections which well known by no means an infrequent occurrence.

Would necessarily occur therefore as probable supposition at least that might be peculiarly modified if either.

When however examine case with attention strong objections occur to either supposition.

Cannot indeed be refused that both diseases put on very various appearances.

Yet amidst all these certain characteristic symptoms which with each uniformly present.

And which, whatever may be variety in appearance serve to point out true nature of the affection.

Hysteria in every instance attended with peculiar affection of alimentary canal.

And with peculiar state of mind, patient being subjected to remarkable fluctuation both in point of cheerfulness & despondency.

No indication however either of one or other in instance before us.

Patient indeed as might naturally be imagined somewhat alarmed by disease to which has now become subjected.

But by this the affection of mind induced approaches to the despondent condition attending melancholy or hypochondria

And no marks of that variable state of temperament the concomitant of hysteria.

Here also must be allowed that affection of alimentary canal not entirely wanting.

And these also constitute as it were commencement of paroxysms.

For are informed in history that first attack of fits with irresistible inclination to discharge both of faeces & urine.

Such discharge must suppose to be consequence of involuntary muscular action.

And might proceed either from action of [cont.] organs as bladder & rectum, or from action of other muscles as abdomen one give [compression] to these.

A last supposition which of the two not least improbable have in this case no proper affection of alimentary canal.

But even adopting first is an affection very different from that murmuring of belly or sense of ball rising to throat, occurring in hysteria.

Besides, this appearance although at first taking place, has for some time ceased.

And has had even of late several very severe fits where no such appearance.

Can be no question then that essential symptoms of hysteria here wanting

And that must look for affection under some other genus.

To supposition of Epilepsy an affection of nervous kind to which also some resemblance still greater difficulty.

Even in convulsive agitation of legs & arms here occurring an obvious dissimilarity.

There motions violent but without rapid success.

In case before us of that quick terminating nature which gives the [ridiculous] contortions in chorea St Vitus.

Besides this a still more essential symptom of Epilepsy here wanting.

For during whole continuation of fit patient retained every sense & could even speak distinctly.

But in Epilepsy this by no means the case.

Senses both external & internal manifestly [affected]

Recovery from fit in general with marks of delirium.

And am even disposed to consider total abolition of sense as an essential characteristic of the affection

In present case have atonic spasm of voluntary muscles without any affection of mental faculty.

And look upon it as affording us a striking example of Convulsions strictly so called.

An affection which in different nosological¹ systems will find distinguished by titles of Chorea Scelotyrbe, Hieranosos etc.

An affection, which although even by some divided into different genera by no means common.

Would not however be understood to represent it as never occurring.

Is particularly known to practitioners under form of what called the Chorea St Vitus.

A disease in which odd motions occur affording at one & same time an object of pity & of laughter.

Besides this however according to muscles affected & mode of affect puts on very various appearances.

For description of these may refer you to practical writers in general.

Will find however a remarkable case of this affection related by Dr White of York in last Number of Medical Commentaries.

And from which appears that affection in some instances much more distressing than with our patient.

From favourable conclusion of that case then should be disposed to entertain greater hopes with regard to present.

Must however observe that respecting prognosis here cannot speak with very great confidence.

Do not indeed see any symptoms think very imminently dangerous.

And have therefore endeavoured as much as could to quiet apprehensions of patient

Such affections however, in general the consequence only of change being as it were [illegible] on constitution.

Hence when have once taken place not easily removed

Should not therefore be surprised if found to resist efficacy of medicine for some time.

Or even at length to baffle utmost efforts

This the rather to be feared as presumption that patient will continue to be subjected to cause at first inducing his affection.

For have little doubt in adopting his own supposition that was effect of frequent hard drinking

This generally enumerated among causes of convulsions & is I believe one of most common.

At least only instance of proper characteristic St Vitus which ever saw was I apprehend with justice attributed to same cause.

And indeed unsteadiness & shaking of hands which very general occurs with hard drinkers perhaps not less an approach to this than to paralysis.

Supposing this cause however not to be doubted that will again be exposed to it.

For am informed by tradesman to whom this patient a journeyman that of late years has fallen very much into habit of drinking.

A habit which when contracted not easily relinquished.

From this circumstance therefore conclude that cure will as much depend upon himself as on anything we can do for him.

While however continues to attend us measures may I apprehend be taken with some prospect of success.

And am even disposed to think that disease had already in some measure yielded to practices employed.

Come next then to explain principles on which have proceeded in what already done.

And briefly to state future objectives in cure

Consider all motions to be effect of Nervous influence

Would then place proximate cause of this disease in what may call inordinate motion of Nervous fluid.

For exciting this a certain stimulation requisite

And that stimulation again may have affect, peculiar irritability of moving fibre is necessary.

May then consider two great objectives as chiefly claiming attention in cure.

1 The removal of exciting causes.

2 The removal of that condition of moving fibre without which these causes can have no effect.

If either one or other completely affected evident that accession can no longer occur

To first however, are constantly & even in some measure unavoidably exposed.

Is therefore chiefly on last footing that radical cure to be expected.

And by removal of such a condition of system not only convulsions but even the much more obstinate effects of Epilepsy sometimes overcome

In case before us some measures taken with both intentions.

Put chief dependence however on last.

As fits at first by regular accession imagined that benefit might be derived from anticipating them

And was with this view that directed opiate to be taken at time of usual attack

With intention also of securing regular discharge by belly & thus at least preventing cause of irritation have employed different purgative pills.

But principally trusted cure to use of Cuprum Ammoniacum under form of pilulae Caeruleae.

Than which know no medicine more powerful as removing disposition to convulsive affections.

And had lately occasion to treat a case of Epilepsy little doubt that has been means of obtaining radical cure.

Is intention therefore to give it fair trial in present case.

And with that view have already augmented dose from one to three pills in the day.

To this extent no other obvious effect than perhaps that has some share in supporting sickness at stomach of which complains.

Am disposed to think however that has already had some good effects on his disease.

Consider it as in great measure product of long intermissions which have of late taken place.

And am even in hopes that by means of it complete cure may be affected.

If however should either be disappointed or if disease even tedious have thoughts of conjoining with it use of cold bathing.

And if both abortive is intention to try patient with peruvian bark.

During this course however requisite to avoid as much as possible every cause exciting paroxysms or supporting predisposition.

And above all to enjoin sobriety on which perhaps more than any other circumstance cure in instance before us depends.

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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.