Epilepsy & Behavior 10 (2007) 304–310 www.elsevier.com/locate/yebeh A diary of epilepsy in the early 1800s Janna Devinsky 97 Westview Road, Short Hills, NJ 07078, USA Received 15 November 2006; revised 11 December 2006; accepted 17 December 2006 Available online 30 January 2007 Abstract This article describes the diary of a man from 19th-century England (1829–1834) that documents the onset and course of his wife’s epilepsy after a stroke. Her stroke produced aphasia and right hemiparesis, but her epilepsy was the diary’s focus and caused the greatest concern. The diary documents the history of her epilepsy in detail. In addition to tonic–clonic seizures, she experienced frequent bouts of status epilepticus and complex partial seizures. The diary contains some of the earliest recorded descriptions of status epilepticus and its aftermath of delirium, mood disorder, and hysteria. It also offers some of the earliest and most detailed accounts of complex partial seizures. Bleeding by cupping was the only symptomatic or prophylactic treatment recorded. These aspects of the diary are presented, as are the historical perspectives on epilepsy, including early beliefs and stigmas, therapeutic remedies, and early European views of epilepsy. Ó 2007 Published by Elsevier Inc. Keywords: History of epilepsy; Status epilepticus; Complex partial seizure; Cupping; Journal; Diary 1. Introduction Epilepsy has traditionally been studied from the medical perspective: physicians’ descriptions of symptoms, classification of the epilepsies and seizures, causation, and treatment. Scientifically focused documents constitute the main corpus of historical data on epilepsy from the ancient periods in Egypt [1], Greece [2], and Rome [3], as well as the medieval Byzantium and Europe [4]. The legal or religious implications of epilepsy are rarely mentioned in historical texts. Similarly, social implications, beyond an occasional mention that the disorder is associated with stigma, are almost never touched on in ancient sources. Medical texts on epilepsy around 1900 give extensive accounts of symptoms, classification, diagnosis, demographic factors, causes, cognitive and behavioral changes, pathology, treatment, and even medicolegal issues [5,6], but the experience of the person with epilepsy was rarely considered. Temkin’s landmark book, The Falling Sickness: A History of Epilepsy from the Greeks to the Beginning of Modern Neurology [7], provides a wealth of information E-mail address: Jbd5790@aol.com 1525-5050/$ - see front matter Ó 2007 Published by Elsevier Inc. doi:10.1016/j.yebeh.2006.12.006 on the scientific–medical view, but little on the life of people with epilepsy during historical times. The impact of epilepsy on the lives of famous people with epilepsy has received scant documentation in writings about their lives. The historical literature of Julius Caesar contains almost nothing about his epilepsy, although his life is among the best documented in antiquity. Plutarch offered anecdotes about Caesar’s epilepsy, but the diagnosis is still the subject of modern medical reexamination [8]. Details of his treatment and the psychological and social impact of his epilepsy remain unknown [9]. In his personal letters, Dostoevsky provided one of the best biographical and psychological records of epilepsy, and he often included a major character with epilepsy in his novels [10,11]. The vivid fictional accounts of auras and major ‘‘fits’’ were drawn from his personal experiences [10,11]. Even in Dostoevsky’s case, the treatment of his epilepsy is poorly documented, and debates persist as to whether he had temporal lobe [10,11] or generalized [12] epilepsy. Throughout history, negative beliefs about epilepsy led families to isolate the affected individual and conceal the disorder, inflicting social and psychological distress on the patient and undermining his or her familial support. Today, the stigma of epilepsy still is often more disabling J. Devinsky / Epilepsy & Behavior 10 (2007) 304–310 than its neurological effects [13–15]. Furthermore, with education about epilepsy, the adverse social consequences in modern times are much less severe than in the past. In 19th-century Europe, epilepsy was considered a highly hereditable disorder, associated with a familial tendency toward insanity, alcoholism, violence, criminal behavior, migraine, and gout [5, p. 5]. Gowers reviewed his 2400 cases of epilepsy and concluded that ‘‘Epilepsy and insanity are interchangeable in families’’ [5, p. 5]. He also recognized that some families hid their epilepsy, especially in the middle and upper classes, where knowledge of the disorder in the family could ‘‘hinder marriage’’ and carry ‘‘social stigma’’ [5, p. 4]. Earlier in the century, medical authorities considered epilepsy to be an infectious disorder [7, p. 226], magnifying the stigma and isolation of the affected individual. Among the lower classes, many believed that epilepsy resulted from satanic possession or supernatural causes, reflecting the views of medieval medical authorities’ views [7, p. 138]. Living with epilepsy in past centuries was challenging; before the introduction of bromides in 1859 and phenobarbital in 1912, there were no effective prophylactic or symptomatic therapies for seizures in the Western medical tradition. Similarly, there were no effective psychotropic medications to treat the depression, anxiety, or psychoses often associated with epilepsy. Furthermore, harmful therapies were abundant, ranging from the abstraction of blood with a cupping glass to the administration of toxic substances such as turpentine and heavy metals. How did epilepsy touch the lives of individuals and their families in 19th-century Europe? The effects of the disorder probably varied dramatically according to the severity of the epilepsy, the time of its occurrence (i.e., nocturnal vs diurnal), the patient’s social status, and his or her financial and social supports. Although the experience of living with epilepsy is now the subject of many scholarly and lay writings [16–18], knowledge of this experience in earlier times is extremely limited. This article describes the diary of a man from 19th-century England [19] that documents the onset and course of his wife’s epilepsy after a stroke. 2. The diary W. Silke of Mistley, near Dedham, Essex, England, kept a diary of his wife’s illnesses and symptoms, including her epileptic attacks, between 1829 and 1834. He made daily entries from March 31 to May 10, 1830, and then made 271 entries over the following 49 months from June 5, 1830, to June 25, 1834, when she died. On the inside leaf, he listed the dates of 35 epileptic attacks (tonic–clonic seizures only) occurring between February 19, 1830, and May 12, 1834. She had six to nine epileptic attacks each year from 1830 to 1833 and four in the first 6 months of 1834, until her death in June. A nurse came to their house on the evening of June 22, 1829, and stayed until July 7, 1834, several weeks after Mrs. Silke’s death. 305 Mrs. Silke’s age is not reported, but she had a son and two grown daughters who frequently visited her, and often witnessed the attacks. No information is given about her past medical or family history. 3. History of illness 3.1. 1829 Her illness began on November 21, 1829. Soon ‘‘after Breakfast my dearest wife was most suddenly attacked with Apoplexy and Paralysis of the right side.’’ It took her just over 2 months ‘‘to first stick her tongue out of her mouth and articulate a few monosyllables.’’ This description strongly suggests that she suffered a large left middle cerebral or internal carotid artery stroke. 3.2. 1830 The first ‘‘Epileptic Fits’’ with severe convulsions of her whole frame occurred at 10 AM on February 19, 1830. Her next attack was a series of convulsions. March 31st . . . This Morning about half past ten my dearest Wife was again seized with dreadful convulsion fits which continued till after four—Mr. Thompson abstracted about six or eight ounces of Blood by cupping between the Shoulders. Over the next week, the diary entries state that she suffered from insomnia, confusion, and delirium. Nevertheless, she was able to ‘‘have her Head shaved’’ (for cupping). The attack on March 31 was almost certainly a bout of convulsive status followed by delirium and possible postictal psychosis lasting a week. She was taken downstairs to the breakfast parlor on July 16, 17, and 18. On July 19, she had another seizure. 19th . . . This Morning about ten o Clock . . . another fit . . . lasted at least half an hour—As soon as She partly recovered her senses, She submitted to be Cupped, and bore the operation with exemplary fortitude, considering how many times her dear Head and Back have been scarified. Over the next month, she recovered some strength but on August 15, ‘‘in hopes of preventing a recurrence of Epilepsy,’’ her husband used cupping, taking away ‘‘about half a pound of Blood.’’ However, 6 days later, she seized, ‘‘with appalling contortions of the whole Frame about twenty minutes.’’ By November, she was able to spend many afternoons outside in the garden. 3.3. 1831 On March 1, 1831, while her daughters were visiting, ‘‘She was suddenly attacked with a flushing of the countenance and great agitation of the whole Frame, which has 306 J. Devinsky / Epilepsy & Behavior 10 (2007) 304–310 frequently occurred of late, and sometimes to an alarming degree.’’ (Mr. Silke had previously made briefer and less complete references to these spells in April 1830 and February 1831.) He then mentions these episodes again, identifying them on April 25, 1831, as sudden in onset (‘‘suddenly very much flushed and agitated’’) and on April 26, 1831, as at times recurrent (‘‘several times similarly attacked with these distressing sensations’’). Mr. Silke interpreted the symptoms as an indication for cupping, and he removed about 8 ounces of blood on April 27. The next day (April 28), after a strong cathartic, she had two ‘‘convulsive fits.’’ On November 13, 1831, she suffered a seizure that lasted ‘‘nearly half an hour.’’ Fourteen hours later she was ‘‘very much recovered, but is restless and irritable.’’ On December 24, she had a severe and prolonged seizure. 24th . . . seized with Epilepsy . . . [and for some 30 minutes] continued insensible. From about half past two till near six, She suffered a quick succession of the most appalling convulsions. Following this episode of status epilepticus, she again suffered from delirium and severe confusion. Two days after this attack, her daughter visited for several hours, but ‘‘She was quite unconscious of her Daughter’s presence.’’ Five days after the status episode, he noted ‘‘increased delirium, attended by great expression of anxiety and tremor, fumbling the Bed-Clothes.’’ She remained intermittently confused and very depressed for at least 2 weeks after this episode of status. 3.4. 1832 Mrs. Silke’s health remained poor with approximately monthly seizures. She had a severe epileptic attack in October. 10th . . . eleven o Clock my dearest Wife was seized with Epilepsy, and continued dreadfully convulsed till a quarter past two, without scarcely any intermission—She then became comatose and perfectly insensible to any impressions whatever. For the next week, she was in a very lethargic state and intermittently ‘‘irritable and hysterical.’’ On December 26 and 29, 1832, her husband recorded frequent ‘‘flushings of the Face accompanied with a full pulse and great excitement’’ or ‘‘nervous irritation.’’ On the 26th, he removed 8 ounces of blood by cupping. On December 31, she had the ‘‘slightest fit’’ and hoped the cupping had mitigated its severity. 3.5. 1833 On February 26, he observed ‘‘that She has lately very much increased in size from obesity, and that her breathing is short and laborious.’’ On April 24, at 6 PM, she had ‘‘an Epileptic Fit’’ lasting about ‘‘a quarter of an hour . . . she appeared wonderfully recovered till about seven when She was again seized and continued to have the most appalling fits without any intermission till half past ten; uttering dreadful piercing moaning cries.’’ For the week afterward, she was at times lethargic, confused, hysterical, and depressed. On July 19, he reported a new type of attack. 19th . . . resembling apoplexy; Her Head suddenly drooped upon her Chest, the Countenance at the same time assuming a livid appearance, and She would certainly have fallen off her Chair, had not Miss Cook at the instant been near to support her . . . lasted not more than three or four minutes when She recovered her senses . . .. Within the last two or three Months She has several times been thus seized. 3.6. 1834 Mrs. Silke’s condition continued to decline after the severe seizure in October 1833. She had ‘‘slight’’ fits on February 11, April 2, and May 12. Beginning in June, her ability to eat diminished, and she became gradually weaker. She died on June 25. 4. Discussion Mr. Silke’s journal provides valuable insights into the life of a woman with epilepsy in 19th-century England. His personal record of her stroke and the epilepsy that subsequently complicated her life offer a detailed lay account of her seizures, postictal states, and treatments. His presumed lack of medical knowledge is advantageous because his descriptions are not significantly contaminated by medical theory or dogma. However, his writings reflect the practices of that particular time and his belief that bleeding by cupping was beneficial both prophylactically and symptomatically for her epilepsy. The diary contains detailed descriptions of tonic–clonic seizures and convulsive status epilepticus, complex partial seizures, postictal delirium, and postictal depression. Moreover, and perhaps most importantly, we are privy to a more intimate and humanistic view of the devastating effects of severe epilepsy on Mrs. Silke and her family from a time when little was known of it origins and no effective therapeutic remedies were available. 4.1. The Silke family The diary includes very little information about Mr. Silke. Although his background, education, and occupation are unknown, the diary’s cursive script penmanship (Fig. 1), clear composition, and organization are evidence of a good education. In addition, Mr. Silke appears to have held strong religious convictions; he read services, psalms, and sermons to his wife on Sundays. On Mrs. Silke’s death, J. Devinsky / Epilepsy & Behavior 10 (2007) 304–310 307 Fig. 1. First two pages of the diary. The list of ‘‘epileptic attacks’’ is on the right. the diary entry reads, ‘‘I fervently pray to God in his infinite mercy, and through the intercession and merits of his Dear Son our Blessed Saviour to receive her Soul into Heavenly Bliss!’’ The Silkes appear to have had a comfortable life; along with a full-time nurse (Nurse Candler) who took care of Mrs. Silke, there is mention of another person (Miss Cook) helping with her care. A diary entry on July 30, 1830, states that Mr. Silke’s wife, as was her usual custom, ‘‘had all the Servants and the Nurse called into Prayers.’’ The diary mentions both of Mrs. Silke’s daughters coming to visit their mother, along with the visit of a granddaughter. Her children may have been from a prior marriage; her son and unmarried daughter had the last name of Harrison. Mr. Silke’s eldest sister supported the couple during Mrs. Silke’s illness. 4.2. Complex partial seizures The earliest medical description of complex partial seizures may date back to the Babylonian cuneiform text Sakikku [All Diseases] (1067–1046 BC): ‘‘If at the time of his possession, while he is sitting down, his (left) eye moves to the side, a lip puckers, saliva flows from mouth . . . at the time of possession his mind is consciously aware (the demon) can be driven out; if . . . not so aware, (the demon) cannot be driven out’’ [20]. Another early source was the Hippocratic writings (ca. 400 BC): ‘‘many persons in their sleep groan and cry out . . . others get up and flee outside and are deranged until they wake up afterwards healthy and sensible as before, only pale and weak, and this not once but often’’ (as quoted in Temkin [7, p. 316–7]). As is true for many historical sources, the nature of these episodes is difficult to determine with certainity. The Babylonian account may be of simple partial seizures progressing to complex partial or to secondarily generalized tonic– clonic seizures. The Hippocratic description could be frontal lobe complex partial seizures, given their occurrence from sleep, rapid recovery, and possible tendency to cluster. However, they could also be nocturnal convulsions followed by postictal delrium. Aretaeas, noting ‘‘sometimes it turns the mind distracted,’’ also recognized minor seizures that may have been complex partial [21, p. 52]. Yet these ancient accounts were brief and cryptic, as were subsequent ones, until Farlet (as cited in Temkin [7, p. 316–21]) and Jackson [22] gave clear and detailed descriptions of complex partial seizures. The diary strongly suggests that Mrs. Silke suffered from complex partial seizures. The initial entries describe sudden episodes of facial flushing, hypermotor truncal behavior (‘‘great agitation of the whole Frame’’), and a tendency to cluster, which suggest that the episodes were frontal lobe complex partial seizures. These attacks also occurred in close temporal association with convulsions, further supporting their epileptic nature. Other attacks, in which the the main symptoms were flushing, restlessness, and confusion, were probably also complex partial seizures. Mr. Silke also described periods of confusion and her picking at the bedclothes in the days after a bout of status. These periods may have represented prolonged postictal delirium with possible psychosis or complex partial seizures with hand automatisms. Eighteen months after Mrs. Silke’s first convulsion, she experienced new episodes ‘‘resembling apoplexy,’’ referring to a sudden attack that compromised the senses and power of motion (sudden drooping of the head on the chest and a 308 J. Devinsky / Epilepsy & Behavior 10 (2007) 304–310 ‘‘livid’’ or bluish color that lasted less than ‘‘three or four minutes’’). These were probably either syncopal episodes with cyanosis or partial seizures. Six months earlier, Mr. Silke reported respiratory problems and marked weight gain in a short period. This problem, possibly congestive heart failure together with the livid color, supports a diagnosis of syncope. However, partial seizures beginning from a temporal or extratemporal seizure focus can also mimic syncope [23]. 4.3. Status epilepticus In the fifth century, Caelius Aurelianus provided what may be the first description of status epilepticus when he noted that seizures are often lethal if they extend into the second day (as cited in Temkin [7, p. 44]). In reviewing the history of status, Hunter [24] found fewer than 10 cases reported by physicians between 1500 and 1800. These descriptions were almost always brief, mentioning either ‘‘a series of convulsions,’’ a number of fits, or the lethality of fits if they complicate febrile or other illnesses. Lysons [25] reported a girl with violent fits who was ‘‘deprived of her senses for three days.’’ Prichard [26, p. 60] recognized a ‘‘rapid succession of fits . . . falling into one almost as soon as he escaped from the former . . . great danger . . . proving instantaneously fatal.’’ This is one of the earliest descriptions of a postictal state after status, but the account is much less detailed than those of Mr. Silke. Status epilepticus (état de mal) was named by Calmeil in his doctoral thesis in 1824 [24]. His observations of patients in hospitals and asylums led him to recognize that the grave prognosis of status was related to the succession of fits without recovery inbetween, not to the number or duration of singles in a cluster. Prichard [26, p. 98] also reported on patients who died after a severe cluster of seizures, but did not recognize the prognostic significance of lack of recovery between seizures. Hunter [24] noted that further reports about status were very rare before hospitals for neurological patients allowed for more prolonged and systematic observation, which approximately coincided with the introduction of potassium bromide in the early 1860s. Mrs. Silke’s illness suggests that status in the period before effective antiepileptic drugs was not rare. Mr. Silke described the status epilepticus with convulsive fits and their aftereffects in detail. His entries provide a much richer picture of a single patient’s course, postictal states, and recovery from bouts of status than any other case identified in medical writings up to this point in time. Mrs. Silke had nine probable bouts of status epilepticus. Two were individual seizures lasting approximately half an hour each, one lasted approximately an hour, and the others were series of seizures lasting an average of 6 hours (range, 3–11 hours). The first status attack (March 31, 1830) was a series of convulsions extending over more than 5 1/2 hours. In the following week, she was delirious and possibly psychotic. Another severe episode (December 24, 1831) consisted of a ‘‘quick succession of the most appalling convulsions,’’ and lasted approximately 3 1/2 hours. Following this bout, Mrs. Silke was also very delirious; for example, she did not recognize her daughter 2 days later. There is some suggestion that the postictal symptoms changed over time. After the status episode on October 10, 1832, she was irritable and hysterical. Later, after the bout on April 24, 1833, she was intermittently lethargic, confused, hysterical, and depressed over the subsequent week. Mr. Silke cataloged the epileptic attacks (tonic–clonic seizures) by date at the beginning of the diary. He differentiated those attacks from the episodes of ‘‘flushing of the countenance and great agitation of the whole Frame.’’ The latter episodes most probably were frontal lobe complex partial seizures. 4.4. Therapy Mrs. Silke’s epilepsy was treated mainly by the extraction of blood by cupping. Her first treatment was given after her second seizure, in which a Mr. Thompson removed 6 to 8 ounces of blood. Mr. Silke, after consultation with Mr. Thompson, performed the next several cuppings himself. Subsequently, he alone decided when to cup. A total of 12 cuppings were recorded in the journal. Three were done after convulsions, three were done for ‘‘precursory symptoms of Epilepsy,’’ two were done for symptoms that may have been complex partial seizures or medical problems (e.g., frequent flushings, excitement, fever), and four were for done for non-epilepsy-related issues such as disturbed sleep and fever, headache, and nosebleed. The efficacy and toxicity of the bleeding are difficult to assess. For the three cuppings done to prevent seizures, the average time to the next seizure was 17 days (6, 27, and 17 days). Overall, the average interseizure interval over the course of her illness was 36 days (34 intervals over 3 years, 4 1/2 months). Thus, seizures occurred more rapidly after preventive cupping than would be predicted. However, Mr. Silke may have correctly recognized premonitory symptoms that predicted an imminent seizure, and the cupping may have delayed its occurrence. On at least one occasion, following the cupping, she ‘‘became very faint to an alarming degree, but happily by giving her some Wine, She soon recovered.’’ No other adverse effects were reported. Mr. Silke described the successful use of cathartics on three occasions (March 13, April 28, and August 30, 1831), noting in each case that she was feverish. On one occasion, the ‘‘strong catharctic dose, which operated very satisfactorily,’’ apparently given for fever, was followed by two convulsive seizures. The seizure occurrence may have been due to fever and illness or coincidence, rather than the cathartic. Later authorities strongly recommended ‘‘that regular actions of the bowels should be secured. Nothing conduces to the attacks more than constipation and gastric disturbance’’ [5, p. 301]. Notably, no other treatments were recorded for the prevention of Mrs. Silke’s epilepsy. Although many medicinal J. Devinsky / Epilepsy & Behavior 10 (2007) 304–310 and nonmedicinal therapies were employed at this time (see below), none were apparently used by Mr. Silke to treat his wife. 4.5. Early European views of epilepsy The Enlightenment led medicine away from the occult, but the lack of scientific methodology allowed for the substitution of a different set of superstitions. Tissot’s influential text of 1770 deemed masturbation and sexual excess as leading causes of epilepsy (as cited in Temkin [7, p. 230]). Tissot promoted the popular view that epilepsy could result from moral (psychic) or physical causes. Common moral causes were strong emotions, especially sudden fright and mental overwork. By the late 18th century, Clarke associated a variety of structural (physical) insults with epilepsy, including supra- and infratentorial tumors, skull lesions, head trauma, infections, and hemorrhage (as cited in Temkin [7, p. 247]). Hall [27] considered the medulla oblongata a critical site for seizure genesis, as only the spinal cord and lower brainstem were considered capable of generating motor responses. However, Esquirol recognized from numerous autopsies that most patients with epilepsy had a normal brain (as cited in Temkin [7, p. 273]). Tissot referred to these cases as ‘‘essential epilepsy’’ (as cited in Temkin [7, p. 248]). William Cullen, in First Lines of the Practice of Physic, coined the term neuroses, which included epilepsy, chorea, and hysteria [28]. This text became England’s leading treatise on the classification and treatment of disease around the turn of the 19th century. Cullen recognized that he did not know the cause of epilepsy, but postulated that seizures result from disturbances of nervous energy. Maisonneuve, in another major classification of epilepsy, distinguished between cases resulting from a predisposition toward epilepsy or disorders directly affecting the brain and cases in which the primary pathological process was outside the brain and seizures were a secondary phenomenon. Maisonneuve’s theory (as cited in Temkin [7, p. 271]) distinguished five idiopathic causes—congenital, spontaneous, plethoric, humeral, and strong emotions—and five sympathetic causes—‘‘irradiation’’ from external parts, the stomach, the intestines, the uterus, and ‘‘vaporous or hypochondric epilepsy.’’ By the early 19th century, epilepsy was considered a disorder of the nervous system, although the classification, etiology, and therapy for epilepsy remained uncertain, with divergent views and ambiguity. Systematic attempts to identify the various causes of epilepsy were undertaken on asylum populations in early 19th-century France. As enumerated by Bouchet, Cazauvieilh, and Leuret, the leading causes of epilepsy, in order of frequency, were fear or fright, masturbation, sorrow, drunkenness, difficult menstruation, wrath, head injury, pregnancy, and heredity (as cited in Temkin [7, p. 261–2]). The role of the moon was also supported by some authorities (as cited in Temkin [7, p. 264–5]). 309 The treatment of epilepsy during the late 18th and early 19th centuries is less well documented. To some physicians of the 18th century, such as Boerhaave, no specific therapy was likely to work for all cases of epilepsy because the disorder had many causes (as cited in Temkin [7], p. 237]). Cullen [28] favored the use of tonics such as quinine, camphor, or wine to activate or inhibit the nervous system. He condemned the use of laxatives and purgatives. Each spring and fall, Esquirol would treat 30 epileptic patients at the Salpêtrière with new remedies (as cited in Temkin [7, p. 292]). He tried bloodletting (cupping), cathartics, baths, cauterization (hot irons on the head or other body parts), and antispasmodics. Most treatments improved the condition for 2 to 12 weeks, but he concluded that it was not the actual remedy but the belief in the remedy that caused the temporary remission. Other therapies—condemmed by some and praised by others—included peony, valerian, elk’s foot, mistletoe, selinum palustre, zinc oxide, silver nitrate, turpentine, belladonna, chloroform inhalation, and trephining (as cited in Temkin [7, p. 237, 292–4]). Personal diaries have played a limited role in the history of epilepsy. In 1803, Thomas Beddoes wrote an ‘‘Essay on the Nature and Prevention of some of the disorders, commonly called Nervous’’ (as cited in Temkin [7, p. 240–1]). Epilepsy is one of the two disorders discussed, with a focus on the disposition toward epilepsy. The information comes primarily from an epilepsy patient’s account of his own illness. 5. Conclusion Mr. Silke’s diary provides a rare window into a family affected by epilepsy in early 19th-century England. It offers a finely detailed record of some of the earliest observations of status epilepticus, complex partial seizures, and postictal states. Its greatest value, however, lies in communicating the human toll of epilepsy on the patient and family. Acknowledgments The author thanks Victor Schrager for his photograph of the journal and Souhel Najjar MD for his invaluable input and discussions on the journal and its historical importance. References [1] Martin-Araguz A, Bustamante-Martinez C, Emam-Mansour MT, Moreno-Martinez JM. [Neuroscience in ancient Egypt and in the school of Alexandria]. Rev Neurol 2002;34:1183–94. In Spanish. [2] Riggs AJ, Riggs JE. Epilepsy’s role in the historical differentiation of religion, magic, and science. Epilepsia 2005;46:452–3. [3] Karenberg A. Reconstructing a doctrine: Galen on apoplexy. J Hist Neurosci 1994;3:85–101. [4] Economou NT, Lascaratos J. The Byzantine physicians on epilepsy. J Hist Neurosci 2005;14:346–52. [5] Gowers WR. Epilepsy and other chronic convulsive diseases. Philadelphia: Blakiston’s; 1901. 310 J. Devinsky / Epilepsy & Behavior 10 (2007) 304–310 [6] Spratling WP. Epilepsy and its treatment. Philadelphia: WB Saunders; 1904. [7] Temkin O. The falling sickness: a history of epilepsy from the Greeks to the beginnings of modern neurology. 2nd ed. Baltimore: Johns Hopkins Univ Press; 1971. [8] Benediktson TD. Plutarch on the epilepsy of Julius Caesar. Ancient World 1994;25:159–64. [9] Hughes JR. Dictator Perpetuus: Julius Caesar—did he have seizures? If so, what was the etiology? Epilepsy Behav 2004;5:756–64. [10] Geschwind N. Dostoievsky’s epilepsy: psychiatric aspects of epilepsy. Washington, DC: American Psychiatric Press; 1984. p. 325–34. [11] Alajouanine T. Dostoiewski’s epilepsy. Brain 1963;86:209–18. [12] Hughes JR. The idiosyncratic aspects of the epilepsy of Fyodor Dostoevsky. Epilepsy Behav 2005;7:531–8. [13] Coelho T. The key to ending stigma. Epilepsy Behav 2006;8:3–4. [14] Morrell MJ, Pedley TA. ‘‘The scarlet E’’: epilepsy is still a burden. Neurology 2000;54:1882–3. [15] Jacoby A. Stigma, epilepsy, and quality of life. Epilepsy Behav 2002;3:10–20. [16] Schachter SC. Brainstorms—epilepsy in our words: personal accounts of living with seizures. Philadelphia: Lippincott Wiiliams & Wilkins; 1993. [17] Sander JW. Ultimate success in epilepsy—the patient’s perspective. Eur J Neurol 2005;12(Suppl. 4):3–11. [18] Chillemi S. Epilepsy: you are not alone. Writer’s Showcase Press; 2001. [19] Silke W. Personal journal. 1829–34. [20] Wilson JVK, Reynolds EH. Translation and analysis of a cuneiform text forming part of a Babylonian treatise on epilepsy. Med Hist 1990;34:185–98. [21] Aretaeus, the Cappadocian. In: Adams F, editor and transl. Aretaeus. Boston: Milford House; 1972. [Republication of the 1856 edition.]. [22] Jackson JH. On a particular variety of epilepsy (‘‘intellectual aura’’): one case with symptoms of organic brain disease. Brain 1888;11:197–207. [23] Gambardella A, Reutens DC, Andermann F, et al. Late-onset drop attacks in temporal lobe epilepsy: a reevaluation of the concept of temporal lobe syncope. Neurology 1994;44:1074–8. [24] Hunter RA. Status epilepticus; history, incidence and problems. Epilepsia 1959;1:162–88. [25] Lysons D. Practical essays upon intermitting fevers, dropsies, diseases of the liver, the epilepsy, etc. Bath: Hazard; 1772. [26] Prichard JC. A treatise on diseases of the nervous system. London: Underwood; 1822. [27] Hall M. Lectures on the nervous system. Philadelphia: EL Carey & A Hart; 1836. p. 197–8. [28] Cullen W. First lines of the practice of physic. New and improved edition. Brookfield: E. Merriam; 1807.