DEP/DUA/1/30/03 (Normalised version)

Ann Stokes

(1782-1783)

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Ann Stokes

Of disease to which this patient subjected no room for doubt.

Can have no hesitation in pronouncing that subjected to Epilepsy.

This abundantly confirmed by symptoms of the disease.

From history [appears] that attacks patient in fits chiefly distinguished by convulsive agitation

These it is true besides Epilepsy occur also in some other diseases particularly in Chorea or Convulsivo strictly so called & in Hysteria.

But here evidently neither one nor other of these affections.

Besides absence of symptoms with which these attended here characterised by peculiar marks of Epilepsy.

Have evidence of Epilepsy in patients falling suddenly to ground in attack.

This so much the case that with some Epileptics has obtained name of falling sickness

And if ever at least very rarely case that either in fits of Hysteria or Chorea patient does fall.

Even in worst cases capable either of [reaching] bed or sitting down in convenient situation.

Still farther mark of Epilepsy in foaming or frothing at mouth during fit.

This by some considered as great characteristic of epileptic fits.

And indeed consider none as genuine Epilepsy where wanting.

For my own part must own that cannot by any means view it in that light.

Consider it as merely an accidental circumstance depending on mode of Respiration by which saliva about mouth filled with air bubbles.

But though not an essential of the disease yet a frequent attendant of it.

And at least a very rare occurrence in hysteria, perhaps never in Chorea.

Hence then no inconsiderable evidence of Epilepsy.

But if proof of Epilepsy in these particulars still more in third circumstance.

viz Total abolition of senses during the fit

This circumstance more than any other take to be distinguishing mark between Epilepsy & diseases most nearly resembling it.

In chorea senses for most part [remain] entire.

And after fit patient can tell everything that has passed during course.

Nay during fit can often from certain feelings tell what muscles will next be affected

In hysteria indeed sometimes happens that patient during fit degree of delirium.

But still this neither prevents recollection of what done around, nor removes sensibility to impression.

In Epilepsy again very rarely that formal fit during some part of which patient is not totally insensible.

Eyes either remain fixed as in case of our patient or are subjected to convulsive motions.

And in whatever state may be very generally patient neither sees, hears nor feels.

In so much that epileptics burnt to bone without showing, slightest mark of sensibility.

This mental affection in my opinion equally characteristic of the disease with convulsive agitations.

From this therefore joined to other particulars all doubts in present case removed.

But when pronounce disease to be Epilepsy another question arises.

To what species vizr of that genus is to be referred.

Among other species ranked under genus of Epilepsy will observe that practical authors in general have mentioned Epilepsy  [simulation]

And no doubt that this disease among lower class often feigned to answer patients purpose.

Is therefore in every case an objective of first consideration, to determine reality.

This determination best formed by attending to mark of Epilepsy just alluded to viz abolition of senses.

And in cases of Epilepsy simulation many effectively cured even by mere dread of [actual] cautery.

With our patient have had no opportunity of forming determination by any trial of this kind.

And indeed account of fits entirely taken from own relation & that of mother.

But in her case no circumstances giving any grounds of suspicion.

And in such situation in life that nothing to gain by feigning complaint.

On contrary must evidently be very much to her prejudice.

And indeed anxiety, both of herself & relations for cure, sufficient evidence of reality

Real Epilepsy however often originates from different causes.

And from these circumstances such variety in nature & treatment that by some [practitioners] divided into many different species.

In so much that Mr Sauvages has pointed out no less than 14.

But on same grounds might have multiplied them [even] to forty.

For different causes by which may be [indeed] unquestionably extended to that number.

And no doubt that in treatment of particular cases regard always to be [paid] to particular cause where can be known.

But differences thus arising proper to be considered only as varieties.

And Dr Cullen seems to me with much greater propriety to have reduced the whole to three species.

Nay inclined to think that with view to [illegible] least, do better in [following] [distinctions] long established among practical writers than in any other way.

Division viz of Epilepsy into Idiopathic & Symptomatic.

First of these corresponds with Epilepsy Cerebralis of Dr Cullen.

Last [comprehends] his two other species of Sympathica & Occasional.

And between these cannot help thinking that distinction more in words than reality.

Of these two species, here no doubt in referring case of our patient to first.

Not smallest grounds for suspecting that here induced or supported by any other disease.

Is attributed to a cause immediately acting on brain itself, through [intervention] of mind influence viz of fear.

A cause which may by way observe has often induced obstinate nay incurable Epilepsy.

Upon whole then no doubt in pronouncing disease of this patient real instance of idiopathic Epilepsy

From this view of the disease prognosis cannot be very favourable.

For can be no doubt that true idiopathic Epilepsy one of most obstinate affections to which human body is subjected.

In so much that by some considered as being always an incurable disease.

Or at least look upon every instance where cure has been affected as of symptomatic kind.

To this opinion for my own part cannot subscribe.

For very much mistaken if have not met with recovery in some instances evidently idiopathic.

Must still however admit that such instances but rare.

And that in majority of cases disease resists all the modes of cure we can employ.

This therefore reason to fear at least may be the case in present instance.

And the rather to be apprehended as has already resisted several of most powerful remedies.

For with this patient have already employed to very considerable extent, Peruvian Bark Calx of Zinc & Cuprum Ammoniala.

And although many others may be tried yet none from which for my own part have equal or greater expectations.

These articles however have sometimes been found to succeed at one time although failed at another.

Sometimes to succeed when taken in conjunction although failed separately.

Even from these therefore still not altogether without hopes.

And although every remedy should fail yet no appearance of immediate danger from the disease.

Epilepsy indeed one of those affections which with adults at least but seldom proves fatal.

When it does so is sometimes from accident, but chiefly as inducing other diseases.

Particularly affections of mind & destruction of intellect.

In this way however with our patient seems yet to have had no influence.

Hope therefore that may be able to dismiss her, at least not worse than when she came under our care.

And is at present in such a situation that many practices may be tried.

With this view have here selected case as subject of practice for Collegium Casuale¹.

With regard to general indications of cure in epileptic cases, must own that am very much at loss.

A necessary consequence indeed of our being so much in dark with respect to [pathology] of disease

My own opinion however is, that in Epilepsy, both mental affection & convulsive agitation taking place during fit, proceed from peculiar action of Brain.

First & principle objective therefore where can be accomplished is to prevent this action.

And where that cannot be done to remove peculiar disposition to motion in moving fibres, without which inordinate action of brain would cease to have same influence.

With both these intentions different remedies may be employed.

Where Epilepsy idiopathic all those answering first intention, in my opinion have effect as inducing different state of action in brain.

Whether idiopathic or symptomatic second intention may be answered by remedy diminishing mobility of nervous energy or strengthening tone of moving fibres.

On this principle am inclined at least to explain benefits which have seen derived from remedies already employed with this patient.

Particularly Cuprum Ammoniala Calx of Zinc & Peruvian Bark.

Latter I am inclined to think principally operates as a tonic.

But two former while have this effect in my opinion have also influence as acting on extremities of nerves on stomach & thereby communicating peculiar impression to the brain.

But whether this reasoning as to action any foundation or not have for my own part at least very little doubt that have seen benefits from them.

And must confess, that when have recourse to them is more upon an empirical footing than any other.

Is also very much on same grounds that have recourse to the remedy at present employed with this patient.

Although with regard to this also as far as has any effect am inclined to refer it to peculiar impression on Nerves of stomach communicated to brain.

Remedy at present employed with this patient the Pill Picea.

These an article which have no place in Pharmacopoeias² either of London or Edinburgh Colleges³.

But long a good deal in use at this place with different intentions.

Formed of finest Tar or Rx liquid brought to proper consistency for mass of pills, by addition of Elecampane.

Will find a receipt for preparation then in Pharmacopoeia pauperum of Edinburgh Hospital.

And in my opinion is one of best modes of exhibiting pix liquida where can answer any useful purpose in medicine.

With this view have not unfrequently employed them in catarrhal & in stomach ailments.

But for my own part have no experience of their effects in Epilepsy.

Present the first instance in which I have directed them in that disease

Do it on authority of a very ingenious & [attentive] gentleman who informs me that in several instances of Epilepsy has of late seen Pix Liquida at first used accidentally attended with surprising benefits.

In cases indeed in which he saw it employed was given under form of Tar Water

But in patient in situation of ours are I think more certain of its being regularly & properly taken in present form.

And if one successful may expect equal benefit from the other.

Shall not however so far trust to this theoretical opinion as not to give trial to Tar water.

For may be something in exhibiting under that form, of which am not aware, which may have influence.

And in all such cases trial is to be preferable to opinion.

Especially where attended with no hazard.

If does succeed in this case, after failure of remedies already mentioned will I own give me high opinion of efficacy.

Reckon it however more probable that from this also shall derive no very great benefit.

And if after due trial disappointed [expectations] from other measures still less.

Still however several practices which in case of want of success have thoughts of trying.

Among first of these intend having recourse to drain from neighbourhood of head.

For apprehend that by state of circulation at brain fits in this case often induced.

Such a drain may be instituted either in form of issue in back part of head or of seton in neck.

Another practice which have also in view with this case is trial of Electricity

This in some cases of Epilepsy even as made to act immediately on brain itself has been of service.

But here shall principally have recourse to it with a view to Emmenagogic powers.

And with view of obtaining more copious menstrual discharge.

For will remark in history of case that although menses regular yet scanty.

And now also observed that fits most frequent about period of menstrual discharge.

This indeed disposed to attribute merely to system being at that time peculiarly irritated.

And certain that impressions of every kind have then more powerful influence than at almost any other time.

But this conjecture may be without foundation.

And hard to say what favourable change might be induced by more copious menstrual if could be brought about.

With this view therefore consider Electricity as meriting trial

Besides Electricity another practice which have also in view here is the use of Valerian.

This by some much extolled in epileptic cases.

And although for my own part must own never saw it successful in any of these yet have good opinion of it as Antispasmodic.

Reckon it therefore by no means improbable that in certain circumstances may have succeeded.

If shall here have recourse to it with view of augmenting chance of success is my intention to combine it with another powerful antispasmodic

Use viz of Vitriol Aether.

This mean chiefly to employ with view of anticipating fits.

That is by giving it in tolerably large dose when threatening of fits occurs.

By such prevention of fits alleged that in some instances even complete cure has been obtained.

And certain that where can be accomplished always in some degree contributes to cure.

For by frequent fits, constitution impaired, disease rivetted, & disposition to fits augmented.

If anything however can have influence in anticipating fits may be expected from Aether.

And in case of our patient, although no long warning yet sufficient for having recourse to dose of this remedy.

While this given immediately before fits valerian may be employed during [interval]

And from conjunction of two would not be surprised even after failure of other remedies if considerable benefit obtained.

At same time more probable that would also prove ineffective at least for perfect cure.

After making this observation of several remedies unnecessary to suggest any

Shall content myself therefore with mentioning only one other practice.

That is the employment of cold Bathing

This indeed in different modes of administration not altogether a safe practice with epileptic patients.

And when have ventured to bathe in deep water drowning sometimes [consequence] of accidental fit.

Yet under prudent administration has in some cases been attended with best effects.

In one instance in which I directed it was in my opinion means of complete cure.

And that too after other remedies tried in vain.

Of all modes of exhibiting cold bathing in this affection consider that of shower bath as one of best.

Not only as free from danger but as impression which gives both considerable & long continued.

But although can furnish our patient with an apparatus for purpose yet some doubt whether she can have, at her own habitation, convenience in other respects for employment of it.

Upon whole though in this patients case can have for my own part but little hopes of recovery yet may afford us opportunity for trial of different practices.

And if any of those successful this example may be attended with some advantages in future practices.

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Explanatory notes:

1) A term used in the 1700s in Leiden, Padua and elsewhere to describe clinical teaching, using demonstrations of outpatients.

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.

3) Royal College of Physicians of London and Royal College of Physicians of Edinburgh.