DEP/DUA/1/27/12 (Normalised version)

Margaret Gray

(1781-1782)

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Margaret Gray.

Not altogether without doubt as to name

Yet little hesitation in considering as simple.

Though symptoms numerous yet connected.

Chief difficulty whether Hysteria or Epilepsy.

These affections in some states easily distinguished

But in others in appearance nearly [approximate]

At same time inclined to think nature very distinct

In some particulars indeed cure in common

Yet in others not a little varied.

Hence distinction not immaterial.

Appearance gives presumption of hysteria most numerous.

Sex of patient in favour of supposition.

With females, though not exempt from Epilepsy yet hysteria one of most common diseases.

Began at period of life when hysteria very frequent viz early period

Traced to cause from which sometimes arises.

viz Excessive fatigue & consequential cold.

Besides general circumstances corroborated also by appearance in affection itself.

Begins with sensation of ball rolling about in belly.

And even in many cases extended to oesophagus giving difficulty of breathing.

Hence [exactly] corresponding to description of Globus Hysteria.

Ascent of ball to throat succeeded by fainting.

But this fainting without convulsive [agitation]

No account that ever foaming at mouth.

Hence much more what occurs in Hysteria than in Epilepsy.

Affection frequently attended also with eructation & flatus

Symptoms well known almost inseparable from Hysteria fits

To these farther to be added effect of Urine.

Sometimes difficult passage.

Sometimes again profuse discharge.

These well known to be appearances very common in Hysteria

In so much that with many enters even definition

Thus then not only from predisposition & exciting causes but also from symptoms of disease itself strong presumption of Hysteria.

Most however observe that in my opinion no less strong evidence of Epilepsy.

And of the two inclined rather to consider present case as an affection of that nature

Between these diseases when most near resemblance great distinction in my opinion not from convulsive agitation but from mental affection.

In hysteria indeed mind often affected.

But different from what in Epilepsy.

In one often delirious.

In other almost always for some time at least total abolition of senses.

One accompanied with particular change & often even volatile temperament.

Other with constant depression & dullness.

And indeed nothing more common than termination in idiotism.

In as far however as this state of mind distinguishes Epilepsy from Hysteria occurs in present case.

From [expression] of countenance alone some marks of approaching if not to idiotism at least to dullness & stupidity.

But besides this in fits themselves several other particulars indicating Epilepsy.

In particular [may] mention total abolition of senses during fit.

This I take to be great difference between hysterical & epileptic fits.

And in present instance so considerable that patient even injured herself materially without being sensible of it at time.

Thus in some instances tongue bitten without being able to tell when happened.

And besides time of fit insensibility even continues long afterwards

May also observe that although some fits preceded by globus hysteria others without it.

And in such cases patient suddenly falls down insensible

Would appear then that in this disease total abolition of senses forms no inconsiderable part.

And from this consider it as example of Epilepsia.

Under this genus however several different species by practical as well as nosological¹ writers.

And these differ not merely in appearance but in treatment.

Would not indeed contend that necessary for all minute divisions of Mr Sauvages.

But of various species which he has described corresponds most exactly with epileptic hysteria.

A species to which has also given name of Epilepsy uterina.

Must however admit that in case before us affection seems to have no connection with menstrual discharge.

And during whole course for space of twelve years this regular.

This however no objection against supposition.

For now certain that hysteria by no means so much connected with state of womb as once imagined.

And although in some instances of most distinctly marked Epilepsy connection with state of menstrual discharge yet in others not observed.

Hence then no argument either for or against its particularly belonging to one or other disease

Still less for its [partaking] as here suppose in some measure of nature of both.

With this idea of the disease must own not disposed to give favourable opinion of prognosis

Even supposing that merely Hysteria still an obstinate affection.

But much more so if Epilepsy.

An affection in majority of instances incurable.

And after continuation for twelve years hopes necessarily diminished.

But besides this patient already on border of 40^th year.

Cannot therefore look for recovery from those changes to which at earlier period system subjected.

To these must add also another unfavourable circumstance.

Some medicines & these probably not least powerful already employed without effect.

Hence then hopes of recovery not great.

At same time not such as to discourage from trial.

Not improbable that some medicines which will succeed in certain cases never employed.

And farther medicines failing at one time will succeed at another.

On these grounds then selected as subject of practice.

With regard to grounds of practice in this affection must own much at loss.

For theory of the disease by no mean certainly determined.

And on this subject no [positive] opinion

Am inclined however to suppose that every fit of Epilepsy immediately induced by some exciting cause whether obvious or not.

That in consequence of this there takes place certain state of action in brain which immediate cause, both of [mental] [&] corporeal affection.

With regard to former can only say that somehow by [interval] of brain mind & body connected.

But in what manner entirely ignorant.

With regard to latter that action of Brain induced by mechanical irritation capable of producing strong convulsions undeniable.

These however more or less readily induced in proportion to disposition to motion in moving fibres.

Hence then by removal of this even although exciting causes continue to operate & inordinate action induced in brain yet may not be capable of inducing convulsive agitation.

Is in this manner in my opinion that means strengthening tone of muscular fibres chiefly useful in Epilepsy.

And on principles now mentioned can I think understand how in different cases different modes of treatment successful.

Some of them operate as removing cause by which brain acted upon.

Often as altering state of brain by which less disposed to be affected by these causes

And third set as diminishing disposition in moving fibres to inordinate action.

Hence see why sometimes cure performed by reducing system & removing plethora.

Sometimes by inducing if not plethora at least full & florid state in place of inanity

And in third case by increasing tone & vigour of moving fibres.

Is on these principles then that am inclined to think, the medicine hitherto most successful in any cases of Epilepsy [illegible] operates.

Would however be understood to suggest these opinions with diffidence.

But whether explanation just or not that remedies sometimes successful cannot be doubted.

And may here remark that even with most strictly dogmatic practitioners, success of remedies by no means depend on [justice] of [illegible]

In proof of this need only refer you to almost every page of former practitioners.

Thus Dr Sydenham who had merit of introducing free use of Peruvian Bark in cure of intermittents in Britain perhaps no less successful in employment than any practitioner of present day

Yet now universally allowed that theory a mistaken one.

Hence then though a medicine supposed to operate, or even introduced into practice on principles evidently erroneous, this should neither lead us to overlook effects nor to neglect use in practice.

These observations I thrown out that those who now hear me whether adopt opinion delivered or not may yet judge of remedies employed by effects.

At same time must observe that want of success in particular cases of Epilepsy by no means proof of inefficacy of medicine.

If any justice in opinion delivered would appear that different remedies fitted for different cases.

And while some admit of cure others of alleviation, third set not to be affected by any treatment.

In case before us have hitherto kept patient on use of one remedy.

viz Cuprum Ammoniala an article often before employed in similar cases.

In some of these must acknowledge have employed it to considerable extent without success.

In others however I think with manifest advantage & even with effect of producing complete cure.

This medicine formed from a metal activity of which in human body very great.

In so much that in saline state operates even in small quantity as poison.

Nay even among most active

For if except arsenic few perhaps of metal poisons more dangerous than Verdigris

Accordingly except present know no formula in common use in which copper in saline state taken internally.

And indeed externally, whether under form of blue vitriol or Verdigris commonly employed as much with view to corrosive as stimulant or astringent power.

But as rendered active by ammonia salt unquestionably milder than in any other state.

In so much that in several instances by gradual increase of dose at last both without inconvenience to considerable extent.

This form of exhibiting Copper for medical purposes first introduced into practice by that eminent philosopher Mr Boyle.

But for best account of use in Epilepsy may refer you to an inaugural dissertation published at this place about 20 years ago by Dr Russell.

Of late so much employed by different practitioners that has now had place in Pharmacopoeia².

And besides Cuprum ammoniala itself place also given to formula under which here employed viz Pill Caeruleae.

In these is formed into mass merely by soft bread.

But if any liquid necessary directed that spirit of Sal Ammoniac should still be employed.

As by this means, all danger of [precipitation], or of nervous combination is prevented.

Each pill contains Cuprum Ammoniala to quantity of grains s.

And this in general sufficient dose at commencement even for adult.

In early life will often excite such sickness at stomach, & even vomiting that necessary to divide pill.

Hence cannot help thinking that would be improvement of formula that each pill should contain only quarter of grain.

With our patient however advanced in life & probably with stomach not very irritable this hardly to be apprehended.

At same time have found that two pills & those too even taken at evening occasion considerable sickness at stomach.

And here may observe that with this medicine in particular evening dose much more easily borne than in morning.

Hence then when dose to be augmented trial should always be first made in latter part of day.

And here may observe that from precipitating use cure often impeded, or frustrated.

In general supposed to produce good effects in consequence of tonic power.

And objective is to obtain these to utmost extent, without inconvenience of stimulating power on stomach or intestines.

For when pushed so far as to excite vomiting or purging intentions frustrated.

Have often had experience of this in my own practice.

And hence now make it general rule never to increase dose, till stomach so habitual to it that can bear it without any sickness.

Even with this caution however will sometimes happen that vomiting will ensue

For stomach not at every time equally able to bear same quantity.

Hence then of opinion that in general more advantage from gradual than [precipitated] employment.

In this manner may in the end most certainly obtain full tonic power.

And with most practices am inclined to think that is upon this principle that efficacy to be accounted for.

In this manner though neither remedy exciting causes, nor preventing peculiar action of brain, supposed to occur in Epilepsy may yet prevent occurrence of fits by diminishment of disposition to inordinate action in moving fibres

But besides this am I own inclined to think that effects of impression which produces on stomach may influence brain itself.

And here would observe that influence of impression communicated from so sensible an organ as stomach to brain by interval of Nervous energy must be very much [divined].

Has been common indeed to consider all these affects as either stimulating or sedative

And to look upon them as varying from each other only in degree.

But can I think be no doubt that still infinitely greater variety in kind.

And perhaps even no two articles either of class of stimulant, or sedative, effect of which on nervous power or on [foundation] of power, the Brain, is precisely same

Such then may be effect of impression from this active metallic substance that brain thereby acquires condition less apt to have action excited by causes immediately inducing epileptic fit.

This conjecture as to mode of operation have for some time been disposed to entertain.

And several observations which have since had occasion to make tend to strengthen opinion.

Particularly its producing more effect than thought could easily be explained from increase of tonic power.

As while advantage obtained yet in other respects no evidence of increase of tonic power.

That however at same time powerful medicine with this latter intention do not deny.

And nothing inconsistent with what every day observed to happen that should operate in both ways.

But whatever mode of operation seem so far at least to have been attended with good effects in present case.

Since began use no other obvious operation than that of exciting slight sickness at stomach & gently opening belly.

Yet under continuation both frequency & violence of fits very much diminished.

Before began use seldom day passed without many paroxysms.

Now will be free from attacks for many days together.

And when do occur very generally less severe.

This case then affords some evidence of power of medicine in present affection.

At same time all benefits received not sufficient to make me alter opinion as to prognosis.

For have often before seen similar diminishment of symptoms where yet incapable of producing cure.

And indeed sometimes beneficial at first not afterwards

From habitual use loses affect.

And that too although medicine not only continued but increased.

Hence then after material benefit obtained has been questionable with some how far use should be persisted in.

Contended that more advantage from intermitting, & again returning to use.

And in as, far operation depends on influence of impression communicated to brain, can understand why this may be the case.

But although theory may suggest such mode of exhibition yet properly to be determined by practice alone.

Mean therefore to try it in present instance.

At same time should be sorry to intermit use as long as [case] continues progress.

While therefore benefits now obtained [increase] will go on with it.

But after comes to be stationary [illegible] to intermit use.

And during interval shall employ something rather by way of placebo to induce to regular attendance, than means of cure.

As thus best able to ascertain real effect.

In this manner then mean to give full & fair trial to the Cuprum alone.

And if thus able in end to effect a cure, must own will consider it as an additional instance of Epilepsy which have been fortunate enough to remove by it.

Even supposing mistaken as to nature of disease yet still will not be denied if shall be means of cure, that has removed very obstinate & distressing affection of Nervous kind.

And although in end fail have already seen example of benefits.

But if this should be case & if patient still disposed to continue attending may afterwards make trial of other measures

Particularly may have recourse to use of Calx of Zinc.

A medicine lately introduced into practice & of which have I own a favourable opinion.

Of use however, shall probably in some future, case have occasion to [speak]

May only observe, that at present employing it with an epileptic patient, formerly subject of lecture here with apparent good effects.

And that too after Cuprum had been used without success.

Must however admit that patient not cured.

But fits for some time past less frequent than before.

And this alone, I think, sufficient inducement to trial of Zinc after Cuprum in other cases.

If both ineffective must own little expectation from any other

Particularly after long continuation of affection & period of life to which patient has arrived.

At same time, even in that situation may still advise prudent administration of cold bathing.

For well authenticated instances, where after other methods this has been successful.

At same time always requires cautious [management].

For in consequence of [occurrence] of accession in sea, or in deep water fatal consequences in way of drowning have sometimes happened.

Hence perhaps most generally advise in bathing tub, in the house, or under form of shower bath.

Besides these, still another measure also, which would suggest in present case

That is issue from neighbourhood of head.

From this also in certain instances have I think often seen considerable advantage.

But highly probable, that have already suggested more than shall have any opportunity of accomplishing although patient shows disposition to regular attendance.

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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.

2) 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.