DEP/DUA/1/21/25 (Normalised version)

Joseph Harley

(1779-1780)

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Joseph Harley.

With regard to particular name to be affixed to the disease some room for doubt.

Yet whatever most proper appellation can be no doubt that exhibits example of one of most deplorable affections to which human body can be subjected.

Most distressing part of his affection consists in fits returning at very short intervals.

These on some occasions appear principally under form of rigidity.

And while convulsive motions the attendant of Epilepsia, uncommon rigidity the characteristic mark of Catalepsis.

To definition of that disease however the case of our patient in some respects does not agree.

For in Catalepsis patient fixed immovable in situation in which attacked

With our patient however always observed to fall to the ground.

And even then by no means in every case marked by rigidity alone.

For in particular fits convulsive motion both of legs & arms very strong.

And these also attended with what commonly reckoned indication of strongest marks of Epilepsy foaming at mouth.

But besides this there here also occurs what reckon still stronger symptom that is the total abolition of sense.

For that this case evidently appears from his remembering nothing done during the paroxysm.

Nay abolition of sense so complete throughout whole that is not even sensible that any fit has taken place

From all these circumstances then notwithstanding some peculiar considerations it as better entitled to name of Epilepsy than any other

Necessary however to remark that [besides] sometimes appearing merely in form of rigidity is not without several other [singularities] also.

And among others may mention cause to which attributed.

According to account given us was [immediate] consequence of having eaten part of [illegible] liver.

How far in this particular case any peculiarity from diseased state of liver hard to say.

For that from liver more than any other part no particular bad effect is confirmed by daily observations.

Well known however that liver a viscus of all animals much subjected to disease

And would not pretend to say what may be effect of certain morbid states of it.

While at same [time] as fits immediate consequence of this & an affection to which never before subjected strong presumption at least of connection.

Here however perhaps not less probable supposition that operated by quantity than by quality.

For that in many cases affect of excessive eating not to be doubted.

And accordingly among other species nosologists¹ have enumerated as one Epilepsy a Carpula.

With our patient besides alleged cause several other circumstances also indicate connection with state of stomach.

For to be remarked that fits most apt to occur when stomach empty

Morning paroxysms in particular observed to be postponed when supper taken later

But besides effect of empty stomach other appearances also indicating connection with state of alimentary canal.

While affected with almost constant sense of bitter taste in mouth complains also of Borborygmi & Flatus.

Was also perhaps to be considered as farther indication of affection of alimentary canal, that affected with constant thirst.

But what of all circumstances the strong proof of this was state of discharge by stool.

Belly more loose than natural state

But still greater change from natural standing both in appearance & smell.

While very much varied from natural appearance particularly as having green colour with large mixture of slimy matter was observed to have peculiarly foetid smell.

From all circumstances then led to conclude that state of alimentary canal very much connected with disease.

And that probably to be considered as origin from whence proceeded.

This at least it must be allowed a cause adequate to [affect].

For well known that from irritation of different kinds most violent convulsive affections induced.

This particularly exemplified in case of worms

From presence of these in stomach or intestines well known that cases both of Epilepsy & of catalepsy very frequently arise

Great reason to believe however that produce effect only from acting as cause of peculiar irritation

And that many other irritations in intestines whether from secreted matters or [ingestion] may be product of same effect

Perhaps however principally, if not only, while peculiarly irritated state subsists

These then was disposed to consider as causes on which depended in present instance.

And from this view grounds at least for hoping that might not prove [an] incurable affection.

From history of case however many circumstances rendering prospect of recovery very doubtful.

Epilepsy, unless when occurs as prelude to a febrile contagion particularly smallpox, sometimes also of measles, almost always a very obstinate affection.

And indeed in most cases, after continuation for any considerable length of time, unless from peculiar revolutions of system deemed incurable.

Here indeed when patient came under care could not be considered as of long standing.

For first commenced little more than year before.

And, as far as can learn, till that time, when patient about 14^th year of age had shown no disposition to it.

From commencement however till came under our care many medicines tried under direction of different practitioners.

And although from some of these seemed for short time to be alleviated yet upon whole no material benefit.

In so much that when came under our care fits rather more severe than ever before.

While at same time so frequent that often even more than thirty in week.

From these circumstances then could not entertain sanguine hopes either of certain or speedy cure.

From change however which has now taken place grounds I think to entertain more favourable expectations.

For of late patient has enjoyed longer remission than at any time since commencement of affection.

Would not however from this by any means venture to pronounce that already completely cured or that cause of the disease removed.

Consider it even as more probable supposition that after medicine intermitted, will again be subjected to some return of affection.

And perhaps even notwithstanding use of medicine may not remain entirely free from it.

Yet must own that consider relief which patient has obtained from practices employed as in some measure corroborating conjecture.

And am now, by no means without hopes of radical cure.

If this however should not be effected still expect, that continuation & repetition of measures may be means of alleviating complaint.

Practices in this case ever since patient came under care very simple & very uniform.

Considering affection as consequence of peculiar irritation in intestines was objective to obtain complete expulsion of irritated matter.

And for this purpose determined in having recourse to repeated doses of brisk purgative.

As such here employed the [composite] powder of Jalap.

And to such extent that might be supposed to operate briskly by Jalap alone

But while something might be expected from Cream of Tartar still farther to aid operation added to each dose grain ii of Calomel

An article even by itself often operating as cathartic.

Not indeed commonly with adults unless given to much greater extent than here employed.

But even to this quantity powerful effect as brisk operation of others.

This purgative directed to be repeated thrice in course of week.

For here after complete evacuation [still] reason to conclude that farther irritated [matter] soon supplied

Probably both from [system] itself in consequence of vitiated secretion deposited in alimentary canal & from [ingestion] in consequence of vitiated action.

In obvious effects of purgative were not here disappointed.

For while brisk operation produced also copious discharge of peculiarly feculent matter.

And what was a circumstance still more agreeable with this state of discharge severity of disease diminished.

From this then naturally encouraged to farther use.

As continual equally good effect has led to persistence in employment.

And now for space even of several weeks patient has not had even single fit.

Still however from appearance & quality of matter discharged by stool am unwilling either to discontinue cathartic or to alter plan

Have however diminished frequency of dose

And in place of three doses now only one in space of week.

For same reason that consider less frequent repetition as requisite consider it also as inadvisable that should be of former strength

And accordingly have directed Calomel to be omitted.

Am hopeful that powder of Jalap alone once a week, sufficient to prevent any fresh accumulation in intestinal canal.

Still however have evidence of remaining tendency to such a state.

For when purgative employed discharge produced, not restored to natural appearance.

Notwithstanding advantage from evacuation therefore reason to presume that will not be of itself sufficient for radical cure.

Naturally occurred as principle objective in this case not only to discharge matter from intestines giving peculiar irritation but to prevent return.

With this intention have from the beginning had in view the employment of some article of astringent & tonic kind.

And had it not been for success which has attended use of Cathartic should probably ere now have had recourse to these.

But while these so remarkable effects was unwilling to do anything which might counteract influence.

And from article I have mentioned some tendency at least to bind belly.

If now however find patient in same situation as at last report shall think of having recourse to employment

And have here thoughts of trying Peruvian Bark.

Am not without hopes, that by this cure may be completed.

And if patient indeed continues free from fits with restoration of excrement discharged to natural state shall reckon it [unnecessary] for him to attend much longer.

If this either disagrees with patient or not product of desired effect shall probably make trial of other bitters & astringents.

And if these useful may have recourse to some of those articles which have found most powerful in other epileptic cases

Particularly Cuprum Ammoniala & Calx of Zinc.

At same time with respect to these as well as other practices must be entirely regulated by future occurrences.

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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.