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diff --git a/36474.txt b/36474.txt new file mode 100644 index 0000000..d84cdd4 --- /dev/null +++ b/36474.txt @@ -0,0 +1,3769 @@ +The Project Gutenberg EBook of A Statistical Inquiry Into the Nature and +Treatment of Epilepsy, by Alexander Hughes Bennett + +This eBook is for the use of anyone anywhere at no cost and with +almost no restrictions whatsoever. You may copy it, give it away or +re-use it under the terms of the Project Gutenberg License included +with this eBook or online at www.gutenberg.org + + +Title: A Statistical Inquiry Into the Nature and Treatment of Epilepsy + +Author: Alexander Hughes Bennett + +Release Date: June 20, 2011 [EBook #36474] + +Language: English + +Character set encoding: ASCII + +*** START OF THIS PROJECT GUTENBERG EBOOK STATISTICAL INQUIRY--EPILEPSY *** + + + + +Produced by Bryan Ness, Leonard Johnson and the Online +Distributed Proofreading Team at https://www.pgdp.net (This +book was produced from scanned images of public domain +material from the Google Print project.) + + + + + + + + + A STATISTICAL INQUIRY + + INTO + + THE NATURE AND TREATMENT + + OF + + EPILEPSY + + + + BY + + A. HUGHES BENNETT, M.D., + + PHYSICIAN TO THE HOSPITAL FOR EPILEPSY AND PARALYSIS, AND + ASSISTANT PHYSICIAN TO THE WESTMINSTER HOSPITAL. + + + + LONDON + + H. K. LEWIS, 136, GOWER STREET, W.C. + 1884. + + +These three papers have already appeared in the Medical Journals, at +different dates, during the past few years. They are now republished +together, so as to form a connected inquiry. Since the production of the +first and second of them, increased experience has greatly augmented the +clinical material which might have been utilised in their investigation: +but, as the essential facts have only thus been confirmed, and the +general conclusions arrived at have remained the same, it has been +thought best, with the exception of certain verbal alterations, to +preserve the text of the articles as they originally appeared. + + A. H. B. + + 38, QUEEN ANNE STREET, W. + + _May, 1884_ + + + + +CONTENTS. + + I.--AN INQUIRY INTO THE ETIOLOGY AND SYMPTOMATOLOGY OF EPILEPSY. + + II.--AN INQUIRY INTO THE ACTION OF THE BROMIDES ON EPILEPTIC ATTACKS. + + III.--AN INQUIRY INTO THE EFFECTS OF THE PROLONGED ADMINISTRATION OF + THE BROMIDES IN EPILEPSY. + + + + +I. + +AN ENQUIRY + +INTO THE + +ETIOLOGY AND SYMPTOMATOLOGY + +OF EPILEPSY.[A] + + +The science of medicine is to be advanced by the careful collection of +well-recorded facts, rather than by general statements or unsupported +assertions. No inquiry thus conducted with scientific precision can fail +to be without value, and to add a mite to that store of positive +knowledge from which must emanate all hopes of progress for the healing +art. Our acquaintance with the nature of epilepsy is as yet in its +infancy, and although much valuable practical information has been put +on record regarding this disease, it is believed that the following +contribution may not be useless in either confirming or questioning +previous conclusions. + +The clinical aspects of epilepsy are especially difficult to investigate +with exactitude. The physician, as a rule, is not himself a witness to +the chief phenomena characteristic of the disease. He is therefore +compelled, in most cases, to trust to the statements of the patient and +his friends for their description, and even when the cross-examination +is conducted with the greatest care, there are many points impossible to +ascertain with certainty. In the following cases of epilepsy, which have +been under my own care, those only are included in which loss of +consciousness formed the chief feature of the attack; and in the +succeeding particulars, attention will be specially directed to etiology +and symptomatology. + + +ETIOLOGY. + +This may conveniently be discussed under (1) Predisposing causes, and +(2) Exciting causes. + +1.--PREDISPOSING CAUSES. + +_Sex and Sexual Conditions._--In one hundred unselected cases of +epilepsy there were-- + + Males, 47 per cent. + Females, 53 per cent. + +showing that practically the sexes were affected in equal proportions. +Of the females there were-- + + Unmarried, 58.5 per cent. + Married, 41.5 per cent. + +The greater number amongst the unmarried females is probably due to the +list including children, and also to the fact that epilepsy is not an +attraction to a man who purposes matrimony. Of the married females-- + + The attacks were uninfluenced by marriage in 68.1 per cent. + The attacks were diminished after marriage in 27.2 per cent. + The attacks were increased after marriage in 4.5 per cent. + +Thus, in the majority of cases, marriage seems to have no influence on +the epileptic attacks of women, although in 27.2 per cent. the fits +appear to have been diminished after that ceremony. + +Of the married females there were-- + + Children in 82.3 per cent. + No children in 17.6 per cent. + +_Age._--In one hundred cases the age at which the first attack of +epilepsy took place will be seen from the following tables:-- + + Males. Females. Total. + + From 1 to 10 years 9 14 23 + From 10 to 20 years 11 23 34 + From 20 to 30 years 14 9 23 + From 30 to 40 years 10 6 16 + From 40 to 50 years 1 0 1 + From 50 to 60 years 2 1 3 + +It will thus be seen that, in males, the most prevalent period for the +first invasion of epilepsy is from the tenth to the thirtieth year; in +females, from the first to the twentieth year. In both sexes the disease +rarely commences after forty. The following table shows the ages of the +patients under observation:-- + + Males. Females. Total. + + From 1 to 10 years 4 1 5 + From 0 to 20 years 10 20 30 + From 20 to 30 years 17 15 32 + From 30 to 40 years 11 9 20 + From 40 to 50 years 2 6 8 + From 50 to 60 years 3 2 5 + +This indicates that cases of epilepsy comparatively rarely come under +observation after the age of forty. A large series of cases would +however be required to determine any definite conclusions as to the +mortality and longevity of the patients. + +_Occupation and Profession._--These do not appear to have any special +relation to the production of epilepsy. + +_Hereditary Tendency._--In each of the cases under observation a very +careful inquiry was made into the family history. This was confined to +the parents, grand parents, uncles, aunts, brothers, sisters, and +children of the patient. The following are the results:-- + +No family history of epilepsy, insanity, nervous or other hereditary +disorders in 59 per cent. + +One or more members of family affected with one or more of the above +disorders in 41 per cent. + +Of these last, in which there was a tainted hereditary history, one or +more members of the family suffered from-- + + Epilepsy in 63.4 per cent. + Insanity in 12.1 per cent. + Phthisis in 12.1 per cent. + Asthma in 2.4 per cent. + Apoplexy in 2.4 per cent. + Hysteria in 2.4 per cent. + Hemiplegia in 2.4 per cent. + Spinal complaint in 2.4 per cent. + +Concerning the above table, it is to be remarked that frequently the +patient had several relatives suffering from different diseases; for +example, one with epilepsy, a second with insanity, and so on. In such a +case these have been classified under epilepsy, and, if this did not +exist, under insanity, or other afflictions in the above order. + +Of those cases in which epilepsy was present in the family of the +patient, it existed in the following members:-- + + Father in 11.5 per cent. + Mother in 7.6 per cent. + Father, mother, and brother in 3.8 per cent. + Mother and child in 3.8 per cent. + Grandmother, mother, and two sisters in 3.8 per cent. + Mother and sister in 3.8 per cent. + Grandfather in 7.6 per cent. + Grandmother in 3.8 per cent. + Brother in 11.5 per cent. + Sister in 11.5 per cent. + Two brothers in 3.8 per cent. + Sister and child in 7.6 per cent. + Brother and uncle in 3.8 per cent. + Two uncles in 3.8 per cent. + Uncle in 3.8 per cent. + Aunt in 3.8 per cent. + Child in 3.8 per cent. + +From these figures it will be seen that in no less than 41 per cent. of +the total number of cases there was a distinct family history of +hereditary disease. Of these no less than 87.5 per cent. were affections +of the nervous system, and 12.1 per cent. of phthisis. Of the former +63.4 per cent. had relatives afflicted with epilepsy, and 12.1 per cent. +with insanity. Epilepsy, according to these figures is eminently a +hereditary disease, and it is possible even to a greater extent than is +here represented; for the family history is often very difficult to +arrive at, in the class of persons on whom most of these observations +were made, who, either from ignorance or from prejudice, display a great +want of knowledge concerning the health of their ancestors. + +_General health prior to the first attack._--As far as could be +ascertained this was-- + + Unimpaired in 90 per cent. + Delicate in 10 per cent. + +By the term delicate is understood any chronic derangement of health. +The figures serve to indicate that, in the large majority of cases +epilepsy has no necessary connection with the impaired general health of +the patient. + +_Special illnesses prior to the first attack._--There were-- + + No antecedent diseases in 78 per cent. + Antecedent diseases in 32 per cent. + +Of these persons who, prior to the first attack of epilepsy, had +suffered from illnesses, the details are as follows:-- + + Convulsions at dentition in 43.7 per cent. + Rheumatic fever in 12.5 per cent. + Chorea in 6.2 per cent. + Mental derangement in 6.2 per cent. + Constant headache in 6.2 per cent. + Suppurating glands in 3.1 per cent. + Brain fever (?) in 3.1 per cent. + Small-pox in 3.1 per cent. + Typhus fever in 3.1 per cent. + Spinal curvature in 3.1 per cent. + Somnambulism in 3.1 per cent. + Scarlatina in 3.1 per cent. + +The only special feature of this table is the fact that, of the cases of +epilepsy under observation, convulsions at dentition were positively +ascertained in 15 per cent. of the total number of cases, and in 43.7 +per cent. of those having suffered from former illnesses. Here also the +percentage is probably in reality greater, as it is obvious that many of +the patients were ignorant as to whether or not these symptoms existed. +There is no evidence that any of the other illnesses had any relation to +the epilepsy. + +_Temperance and Intemperance._--On this head nothing definite could be +ascertained. The patients either do not tell the truth, or have very +elastic notions as to moderation in the use of alcoholic stimuli. + +2.--EXCITING CAUSES. + +To ascertain the exciting causes of epileptic seizures with exactitude +is usually a matter of very great difficulty. It is simple enough when +the results directly follow the cause; but this is not commonly the +case. If, for example, a man, after a blow on the head (having been +previously in good health) becomes suddenly seized with epileptic +attacks within a few hours or days of the accident, we may fairly assume +that the injury has originated or developed his illness. But should the +seizure not supervene for some months or years afterwards, the external +wound having in the meantime completely recovered, there remains on this +question a considerable element of doubt. In the same way a patient +often attributes the attacks to a fright which may have occurred weeks +or months before they began; yet great care should be taken in accepting +such a statement: on the other hand, it should not be utterly ignored. +Again, if a person develops epilepsy after severe and prolonged domestic +trouble or affliction, how are we accurately to determine the relation +between the two? These difficulties render an exact method of +ascertaining the exciting causes almost impossible, and this can only be +approximated by a careful consideration of the entire history and +circumstances of the case. Taking these into consideration, the +following statements have been drawn up, in which only those conditions +are recorded, where from a review of the whole case a reasonable +relation was found to exist between cause and effect. + +In a hundred unselected cases of epilepsy there were-- + + No apparent exciting cause in 43 per cent. + Possible exciting cause in 57 per cent. + +Of the cases where a possible exciting cause was present, the following +is an analysis:-- + + Blow or injury to head in 28.1 per cent. + Uterine disorder in 22.8 per cent. + Domestic trouble in 15.7 per cent. + Disease of the nervous system in 8.7 per cent. + Fright in 5.2 per cent. + Depression in 5.2 per cent. + Pregnancy in 5.2 per cent. + Mental strain in 3.5 per cent. + Sunstroke in 3.5 per cent. + Emotion in 1.7 per cent. + +Thus, in no fewer than 16 per cent. of the total number of cases, and +28.1 of those in which a possible exciting cause was present, did +epileptic seizures follow injuries to the head. Of the cases recorded +under uterine disorders, it must be stated that these conditions were as +much the accompaniments as the cause of epilepsy, the relations between +the two being as follows:-- + + Attacks occurring at menstrual periods in 61.5 per cent. + Attacks associated with irregular menstruation in 30.7 per cent. + Attacks associated with uterine disease in 7.6 per cent. + +An attempt was made in twenty-two cases to ascertain whether, in women, +the age at which the epileptic attacks began had any relation to the +period at which the catamenia commenced, with the following results:-- + + Average age at which attacks began 14.6 years + Average age at which catamenia began 14.6 years + +This shows singularly enough exactly the same figures, and serves to +point out, that in women, the earliest manifestation of puberty is a +decided exciting cause for epileptic attacks. It must however be stated +that, in the female epileptics, the attacks commenced before the age of +puberty in 16.9 per cent. of their numbers. Of the 8.7 per cent. of +cases included under the term "diseases of the nervous system," the +epilepsy was associated with hemiplegia in all. + + +SYMPTOMATOLOGY. + +In a hundred unselected cases of epilepsy there were-- + + Epilepsia gravior in 62 per cent. + Epilepsia mitior in 10 per cent. + Epilepsia gravior and mitior in 28 per cent. + +1.--EPILEPSIA GRAVIOR. + +_Premonitory Symptoms._--In the cases in which epilepsia gravior was +present there were-- + + No premonitory symptoms in 34.4 per cent. + Premonitory symptoms in 65.5 per cent. + +Of those cases in which there were symptoms premonitory to the attack, +there were-- + + General premonitory symptoms in 47.4 per cent. + Special Aurae in 72.8 per cent. + +By _general premonitory_ symptoms are understood those morbid conditions +lasting for some hours or days before each attack, and of the cases +under consideration in which these were present, the following is an +analysis:-- + + Prolonged vertigo in 46.4 per cent. + Headache in 21.4 per cent. + Nervousness in 14.2 per cent. + Drowsiness in 3.5 per cent. + Faintness in 3.5 per cent. + Depression of spirits in 3.5 per cent. + Cramps in 3.5 per cent. + Numbness of extremities in 3.5 per cent. + +Of the cases in which a _special aura_ preceded the attack, the details +are as follows (the special symptom in each case being sudden):-- + + Loss of sight in 2.3 per cent. + Loss of speech in 13.9 per cent. + Loss of hearing in 2.3 per cent. + General tremor in 16.2 per cent. + Tremor of one foot in 2.3 per cent. + Sensation in epigastrium in 6.9 per cent. + Sensation in abdomen in 4.6 per cent. + Sensation in throat in 6.9 per cent. + Sensation in left side in 2.3 per cent. + Sensation in both hands in 2.3 per cent. + Sensation in one hand in 2.3 per cent. + Violent pain in head in 2.3 per cent. + Pain in one foot in 2.3 per cent. + Sparkling sensation in eyes in 6.9 per cent. + Pumping sensation in head in 4.6 per cent. + Noises in ears in 4.6 per cent. + Diplopia in 2.3 per cent. + Contraction of one leg in 2.3 per cent. + Rotation of head in 2.3 per cent. + Distortion of face in 2.3 per cent. + Twitching of thumb in 2.3 per cent. + Spasm of eye-balls in 2.3 per cent. + Disagreeable smell in 2.3 per cent. + +From these figures we find that in 34.4 per cent. of the cases of +epilepsia gravior there are no special symptoms announcing the seizure, +which takes place without warning of any kind; and it is especially in +such cases that patients in falling, seriously injure themselves. In +65.5 per cent. there are premonitory symptoms of some kind, which +indicate often many hours before the approach of an attack. Of these +last 47.4 per cent. are of a general character, and in no less than 72.8 +per cent. is there a distinct special aura, which in 25.4 per cent. +alone precede the attack, the remainder being associated with the +general premonitory symptoms. + +_Symptoms of the Attack._--In the cases of epilepsia gravior there were +complete loss of consciousness with convulsions, lasting from five to +ten minutes, and occurring at intervals, leaving no question as to the +true nature of the disease, and all doubtful examples have been excluded +from this collection. Attempts were made to form an analysis of the +different symptoms constituting the paroxysm, but with indifferent +success, and these are not here reproduced, because they are not +sufficiently accurate for scientific purposes. The patient himself can +give no account of what takes place. The friends around do not look upon +the phenomena of the attack with the critical and philosophic eye of the +physician; hence any information from them as to the part convulsed, the +colour of the skin, the duration of the seizure, and so on, is extremely +vague and untrustworthy. The number of cases personally observed +actually during attacks is too limited to warrant any generalizations. +There is, however, one important point which can be accurately +demonstrated--namely, whether or not the tongue is bitten, and in the +cases under observation + + The tongue was bitten in 68.8 per cent. + The tongue was not bitten in 31.2 per cent. + +_Frequency of Attacks._--Only a general average of the number of attacks +can be made; and in the present series the following gives an idea of +the frequency of seizures in different individuals. + + Average of one or more attacks per day in 8.8 per cent. + Average of one or more attacks per week in 31.1 per cent. + Average of one or more attacks per month in 32.2 per cent. + Average of one or more attacks per year in 15.5 per cent. + At longer or more irregular intervals in 12.2 per cent. + +This roughly indicates that, in the majority of cases, attacks of +epilepsia gravior occur one or more times weekly or monthly. Under the +last series, of attacks taking place at longer and more irregular +intervals than a year, are included those cases where a few only have +occurred during the lifetime of the patients. + +_Regularity of Attacks._--Many epileptics are attacked at regular +intervals, sometimes on the same day or even hour; while others are +afflicted at any time, day or night. The following indicate the +proportion:-- + + Attacks occur at regular intervals in 21.1 per cent. + Attacks occur at irregular intervals in 78.8 per cent. + +_Time of Attack._--The following particulars alone could be definitely +ascertained:-- + + Attacks only during sleep in 8.8 per cent. + Attacks only during day while awake in 8.8 per cent. + Attacks only during early morning in 15.5 per cent. + Attacks at no particular time in 55.4 per cent. + +The chief feature of this observation is that in 15.5 per cent. of cases +of E. Gravior the attacks always took place immediately after the +patients had wakened in the morning, and this is probably due to the +sudden alteration of the cerebral circulation from the sleeping to the +wakeful state. + +_Symptoms immediately after the Attack._--The moment the attack is over +sometimes the patient is in his usual condition, and feels no ill +effects from the paroxysm. More commonly, however, he suffers from +various symptoms, the chief of which, and their relative frequency, is +as follows:-- + + Return to usual condition in 12.2 per cent. + Drowsy in 66.6 per cent. + Confused in 14.4 per cent. + Stupid in 13.3 per cent. + Irritable in 14.4 per cent. + Excitable in 3.3 per cent. + Vertigo in 13.3 per cent. + Headache in 41.1 per cent. + +The above conditions may last from an hour to several days. + +_Present condition, or state between the Attacks._--It is impossible to +enter minutely into the actual physical and mental health of all the +epileptic cases under notice, but the following statement gives a +sketch of some of the more important conditions associated with the +disease, and the frequency with which they occur. In the +inter-paroxysmal state the condition of the patients were-- + + Healthy in every respect in 17.7 per cent. + With some abnormal peculiarity in 82.2 per cent. + + General health good in 75.5 per cent. + General health impaired in 24.4 per cent. + + Robust in 66.6 per cent. + Not robust in 33.3 per cent. + + Intelligence intact in 74.4 per cent. + Intelligence impaired in 25.5 per cent. + + Loss of memory in 58.8 per cent. + No loss of memory in 41.1 per cent. + + Stupid in 16.6 per cent. + Dull in 31.1 per cent. + Irritable in 25.4 per cent. + Frequent headaches in 41.1 per cent. + Frequent vertigo in 22.2 per cent. + Nervous in 21.1 per cent. + Special diseases in 21.1 per cent. + +Of the 21.1 per cent. under the heading of special diseases, there +were-- + + Hemiplegia in 6.6 per cent. + Paralysis of seventh nerve in 1.1 per cent. + Impediment of speech in 1.1 per cent. + Cicatrix over sciatic nerve in 1.1 per cent. + Idiot in 1.1 per cent. + Anaemia in 5.5 per cent. + Phthisis in 2.2 per cent. + Confirmed dyspepsia in 1.1 per cent. + +From these details it is evident that epilepsy is not of necessity +associated with impairment of the physical or mental health. On the +contrary, we find that in 17.7 per cent. of the patients there was +apparently no flaw of any kind in their constitutions, which were +absolutely normal, with the exception of the periodic seizures. In no +less than 75.5 per cent. was the general health good, and in 66.6 per +cent. the patients were robust and vigorous. At the same time the +health was markedly impaired in 24.4 per cent., and the sufferers were +of delicate or weak habit in 33.3 per cent. The main fact, however, to +be observed is that, in the majority of cases of epilepsy, the general +health and vigour of the patient is not deteriorated. In the same way, +the intellectual capacities are not of necessity affected. In 74.4 per +cent. the intelligence is recorded as not seriously impaired; and in +41.1 per cent. the memory as good. On the other hand, the mental +faculties were markedly deficient in 25.5 per cent.; the patients were +dull and slow in 31.1 per cent.; and in more than half, or 58.8 per +cent., was there evidence of loss of memory. Another frequent symptom is +repeated and constant headache, which, in the present series of cases, +existed in 41.1 per cent. + +2.--EPILEPSIA MITIOR. + +This occurred altogether in 38 per cent. of the total number of cases. +In these it occurred-- + + By itself in 26.3 per cent. + Associated with E. Gravior in 73.6 per cent. + +In all, the usual characteristics of the _petit mal_ presented +themselves; there being temporary loss of consciousness, sometimes with +slight spasms, but without true convulsion, biting of the tongue, &c. + +_Frequency of Attacks._--The rough average frequency of attacks, as +estimated in the cases under consideration, was as follows:-- + + 20 to 30 attacks per day in 3.7 per cent. + 10 to 20 attacks per day in 7.4 per cent. + 5 to 10 attacks per day in 14.8 per cent. + 1 to 5 attacks per day in 40.7 per cent. + 1 or more attacks per week in 22.2 per cent. + 1 or more attacks per month in 7.4 per cent. + At rarer intervals in 3.7 per cent. + +Thus when epilepsia mitior exists, in the majority of cases the attacks +are of daily occurrence. + +_Loss of consciousness_, as ascertained in a series of cases, was + + Complete in 48.3 per cent. + Partial in 51.6 per cent. + +_Premonitory Symptoms._--These are not, as a rule, so well marked in +epilepsia mitior as in E. Gravior; but frequently the aura is quite as +distinctly appreciated. In the 28 per cent. of cases in which E. Mitior +is associated with E. Gravior, the aura was apparently the same in both. +Of the 10 per cent. cases of E. Mitior occurring by itself, the +following is the record:-- + + No aura in 20 per cent. + Sensation in epigastrium in 20 per cent. + Loss of speech in 10 per cent. + Violent pain in head in 10 per cent. + Tingling of extremities in 10 per cent. + Choking sensation in 10 per cent. + Hallucination in 10 per cent. + Vertigo in 10 per cent. + +The number of cases in E. Mitior is too limited to warrant further +generalization. + +FOOTNOTES: + +[A] Reprinted from the "British Medical Journal" of March 15 & 22, 1879. + + + + +II. + +AN INQUIRY + +INTO THE + +ACTION OF THE BROMIDES ON + +EPILEPTIC ATTACKS.[B] + + +Bromide of potassium is generally recognised as the most effective +anti-epileptic remedy we at present possess. There exists, however, +great difference of opinion as to its method of administration and to +the amount of benefit which we may expect from its use. Some physicians +who employ the drug after one method come to totally different +conclusions as to its efficacy from those who use another. Many believe +the remedy to be only useful in certain forms of the disease, and to be +very uncertain and imperfect in its action. Others, again, maintain that +it is positively injurious to the general health of the patient. These +and other unsettled points the following inquiry attempts to make clear. + +Epilepsy, like all other chronic diseases, presents great difficulties +in scientifically estimating the exact value of any particular remedy; +and unless the investigation of the subject is approached with the +strictest impartiality, and observations made with rigid accuracy, we +are liable to fall into the most misleading fallacies. I believe that +these are to be avoided, and facts arrived at, however laborious it may +be to the experimenter and wearisome to the student, only by the careful +observation and elaborate record of an extensive series of cases. If, in +epilepsy, the disease, from its prolonged duration, its doubtful +causation and pathology, its serious complications and the many other +mysterious circumstances connected with it, offers almost unsurmountable +difficulties to any definite and uniform method of treatment and the +systematic estimation of the same, its symptoms furnish us with +tolerably accurate data upon which to base our observations. The +attacks, although only symptoms, may be practically considered as +representing the disease, as in the large majority of cases, in +proportion as these are frequent and severe, so much the more serious is +the affection. The influence of the bromides on these paroxysms is taken +in the following inquiry to represent the action of these drugs on the +epileptic state. + +Before proceeding to detail the facts arrived at, it is necessary +briefly to state the method of procedure adopted in treatment. Each case +in succession, and without selection, which was pronounced to be +epilepsy (all doubtful cases being eliminated), was considered as a +subject suitable for experiment. The general circumstances of the +individual were studied; his diet, hygienic surroundings, habits, and so +on, if faulty, were, when practicable, improved. The bromides were then +ordered, and taken without intermission for periods which will +subsequently be detailed. The minimum quantity for an adult, to begin +with, was thirty grains three times a day, the first dose half an hour +before rising in the morning, the second in the middle of the day on an +empty stomach, and the third at bedtime. This was continued for a +fortnight, and if with success, was persevered with, according to +circumstances, for a period varying from two to six months. If, on the +other hand, the attacks were not materially diminished in frequency, the +dose was immediately increased by ten grains at a time till the +paroxysms were arrested. In this way as much as from sixty to eighty +grains have been administered three times daily, and, with one or two +isolated exceptions to be afterwards pointed out, I have met with no +case of epilepsy which altogether resisted the influence of these large +doses; and, moreover, I have never seen any really serious symptoms of +poisoning or injury to the general health ensue in consequence. +Sometimes these quantities of the drugs have been taken for many months +with advantage; but as a rule it is preferable, when possible, after a +few weeks gradually to diminish the dose and endeavour to secure that +amount which, while it does not injuriously affect the general condition +of the patient, serves to keep the epileptic attacks in subjection. The +form of prescription to begin with in an adult has been as follows:-- + + R. Pot. bromid., gr. xv. + Ammon. bromid., gr. xv. + Sp. ammon. aromat., m. xx. + Infus. quassia, ad [Symbol: Apothecaries' ounce]j + + M. Ft. haust. ter die, sumendus. + +According to the age of the patient so must the dose be regulated; at +the same time, children bear the drug very well. The average quantity to +begin with for a child of ten or twelve years has been twenty grains +thrice daily. + +In this manner I have personally treated about two hundred cases, and in +all of these most careful records have been kept, not only of their past +history, present condition, etc., but of their progress during +observation. All these, however, are not available for the present +inquiry. It is necessary in order to judge of the true effect of a drug +in epilepsy that the patient should be under its influence continuously +for a certain period of time. Now, a large number of patients, +especially amongst the working classes, cannot or will not be induced to +persevere in the prolonged treatment necessary in so chronic a disease. +They either weary of the monotony of drinking physic, especially if, as +is often the case, they are relieved for the time, or other +circumstances prevent their carrying out the regimen to its full extent. +The minimum time I have fixed as a test for judging the influence of the +bromides on epileptic seizures is six months, and the maximum in my own +experience extends to four years.[C] All other cases have been +eliminated. I have arranged this experience in the form of tables for +reference, in which will be seen at a glance--_1st_, the average number +of attacks per month in each case prior to treatment; _2nd_, the average +number of attacks per month after treatment; and _3rd_, in the event of +these being fewer than one seizure per month, the total number during +the last six months of treatment. + +TABLE I.--_Sixty Cases of Epilepsy, showing Results of Treatment by the +Bromides during a Period of from 6 Months to 1 Year._ + + Average Average Number + No. number number attacks + of attacks attacks during + Case. per month per month last 6 + _before_ _after_ months of + treatment. treatment. treatment. + + 1 900 60 -- + 2 600 5 -- + 3 600 90 -- + 4 450 12 -- + 5 300 2 -- + 6 240 90 -- + 7 180 60 -- + 8 150 5 -- + 9 150 8 -- + 10 150 7 -- + 11 120 3 -- + 12 120 120 -- + 13 90 3 -- + 14 90 9 -- + 15 70 20 -- + 16 60 4 -- + 17 60 6 -- + 18 60 90 -- + 19 30 7 -- + 20 30 1 -- + 21 30 2 -- + 22 30 10 -- + 23 16 8 -- + 24 16 2 -- + 25 12 4 -- + 26 12 12 -- + 27 12 3 -- + 28 8 0 0 + 29 8 2 -- + 30 8 1 -- + 31 8 1 -- + 32 8 -- 4 + 33 8 1 -- + 34 8 4 -- + 35 6 0 0 + 36 5 -- 5 + 37 5 0 0 + 38 4 2 -- + 39 4 1 -- + 40 4 1 -- + 41 4 1 -- + 42 4 -- 2 + 43 4 -- 3 + 44 2 -- 3 + 45 2 -- 2 + 46 2 -- 1 + 47 2 -- 1 + 48 2 -- 4 + 49 2 -- 1 + 50 2 -- 2 + 51 1 0 0 + 52 1 -- 2 + 53 1 0 0 + 54 1 1 -- + 55 1 0 0 + 56 1 0 0 + 57 1 -- 1 + 58 1 -- 1 + 59 1 -- 1 + 60 1 150 -- + +TABLE II.--_Thirty-two Cases of Epilepsy, showing Results of Treatment +by the Bromides during a period of from 1 to 2 Years._ + + Average Average Number + No. number number attacks + of attacks attacks during + Case. per month per month last 6 + _before_ _after_ months of + treatment. treatment. treatment. + + 1 900 60 -- + 2 600 120 -- + 3 300 30 -- + 4 180 60 -- + 5 150 -- 2 + 6 150 1 -- + 7 90 9 -- + 8 90 15 -- + 9 60 2 -- + 10 6 -- 4 + 11 30 -- 1 + 12 30 4 -- + 13 30 2 -- + 14 30 3 -- + 15 16 -- 8 + 16 12 3 -- + 17 8 0 0 + 18 8 -- 3 + 19 8 -- 4 + 20 8 -- 1 + 21 8 -- 10 + 22 6 -- 1 + 23 4 -- 4 + 24 4 -- 4 + 25 4 2 -- + 26 2 -- 1 + 27 2 -- 2 + 28 2 -- 2 + 29 1 0 0 + 30 1 0 0 + 31 1 -- 3 + 32 1 -- 3 + +TABLE III.--_Seventeen Cases of Epilepsy, showing Results of Treatment +by the Bromides during a Period of from Two to Three Years._ + + Average Average Number + No. number number attacks + of attacks attacks during + Case. per month per month last 6 + _before_ _after_ months of + treatment. treatment. treatment. + + 1 600 60 -- + 2 300 15 -- + 3 60 -- 8 + 4 30 -- 4 + 5 30 -- 8 + 6 30 -- 2 + 7 16 2 -- + 8 12 -- 8 + 9 8 -- 2 + 10 8 -- 1 + 11 8 -- 3 + 12 4 -- 1 + 13 4 1 -- + 14 4 6 -- + 15 1 0 0 + 16 1 0 0 + 17 1 -- 3 + +TABLE IV.--_Eight Cases of Epilepsy, showing the Results of Treatment by +the Bromides during a period of from Three to Four Years._ + + Average Average Number + No. number number attacks + of attacks attacks during + Case. per month per month last 6 + _before_ _after_ months of + treatment. treatment. treatment. + + 1 300 3 -- + 2 60 1 -- + 3 60 4 -- + 4 30 1 -- + 5 16 -- 10 + 6 12 -- 3 + 7 8 0 0 + 8 1 0 0 + +These four tables consist of all the characteristic cases of epilepsy +which came under notice, without selection of any kind, all being +included, no matter what their form or severity, their age, complication +with organic disease, etc. In analyzing this miscellaneous series, the +chief fact to be noticed, whether the period of treatment has been +limited to six months or extended to four years, is the remarkable +effect of treatment upon the number of the epileptic seizures. Of the +total 117 cases, in 14, or about 12.1 per cent., the attacks were +entirely arrested during the whole period of treatment. In 97, or about +83.3 per cent., the monthly number of seizures was diminished. In 3, or +about 2.3 per cent., there was no change either for better or worse; and +in 3, or about 2.3 per cent., the attacks were more frequent after +treatment. + +With regard to the fourteen cases which were free from attacks during +treatment, it cannot, of course, be maintained that all of these were +cured in the strict sense of the term. It is probable that if any of +them discontinued the medicine the seizures would return. Still, the +results are such as to encourage a hope that if the bromides are +persevered with, and the attacks arrested for a sufficiently long +period, a permanent result might be anticipated. Even should no such +ultimate object be realized, it is obvious that an agent which can, +during its administration, completely cut short the distressing +epileptic paroxysms, without injuriously affecting the mental or bodily +health, is of immense importance. Take, for example, cases 7 and 8 of +Table IV., where, prior to treatment, in the one case eight fits a +month, and in the other one, were completely arrested during a period of +nearly four years. The experience of physicians agrees in considering +that the danger of epilepsy, both to mind and body, is in great part +directly proportionate to the severity of its symptoms. If these latter +can be completely arrested, even should we be compelled to continue the +treatment, if this is without injury to the patient, it is as close an +approach to cure as we can ever expect to arrive at by therapeutic +means. The permanent nature of the improvement, and the possibility of +subsequent discontinuance of the bromides without return of the disease, +is a question I shall not enter into, as my own personal experience is +not yet sufficiently extended to be able to form a practical opinion. A +satisfactory solution of this problem could only be made after a +life-long private practice, or by the accumulated experience of many +observers. With hospital patients such is almost impossible, as they are +lost sight of, especially if they recover. + +Of the total 117 cases which compose the tables, we find that in no less +than 97 were the attacks beneficially influenced by the bromides. In the +different cases this improvement varies in degree, but in most of them +it is very considerable--for example, Nos. 2, 5, 8, 11, 20, in Table I; +Nos. 5, 6, 11, 15, in Table II; Nos. 3, 4, 5, 6, in Table III; and all +the cases in Table IV. In these and others the attacks, if not actually +arrested, were so enormously curtailed, both in number and severity, in +comparison to what existed before treatment, as to constitute a most +important change in the condition of the patient. In those cases in +which improvement was not so well marked, in many it was most decided, +and in frequent instances caused life, which had become a burden to the +patient and his friends, to be bearable. + +Of the total number of cases, in 3 the administration of the bromides +had no effect whatever in diminishing the attacks, and in 3 others the +number of seizures was greater after treatment than before. Whether in +these last this circumstance was the result of the drug, or due to some +co-incident augmentation of the disease itself, I cannot decide, but am +inclined to believe in the latter as the explanation. + +After a consideration of these facts it is difficult to understand why +most physicians look upon epilepsy as an _opprobrium medicinae_, and of +all diseases as one of the least amenable to treatment, and the despair +of the therapeutist. For example, Nothnagel, one of the most recent and +representative authorities on the subject, in speaking of the treatment +of epilepsy, says, "Many remedies and methods of treatment have isolated +successes to show, but nothing is to be depended on; nothing can, on a +careful discrimination of cases, afford a sure prospect of recovery, or +even improvement." Such a statement indicates either an imperfect method +of treatment, or that in Germany epilepsy is more intractable than in +this country, as a "careful discrimination" of the above cases affords a +"sure prospect of improvement" and a reasonable one of recovery. That a +critical spirit and healthy scepticism should exist regarding the vague +and imperfect accounts of the efficacy of various drugs in disease is, I +believe, necessary to arrive at the truth; at the same time, we must not +refuse to credit evidence sufficiently based on observation and +experiment. The above collection of cases are facts, carefully and +laboriously recorded, and not originally intended for the purpose which +they at present fulfil. Having been brought up in the belief that +epilepsy was one of the most intractable of diseases, no one is more +surprised than myself at the readiness with which it responds to +treatment. So far, then, from this affection being the despair of the +profession, I believe that of all chronic nervous diseases it is the one +most amenable to treatment by drugs, resulting, if not in complete cure, +in great amelioration of the symptoms which practically constitute the +disease. + +An important consideration next arises. Assuming that practically the +treatment in all cases is alike, are there any special circumstances +which explain why some patients should have no attacks while under the +influence of the drugs, while others are only relieved; why some--though +the number is very small--should receive no benefit, and others have a +larger number of attacks after treatment? On a careful examination of +all the clinical facts of each case, no explanation can be found, the +same form of attack, the same complications and circumstances, occupying +each group. For example, one of those who had no attacks during +treatment was a woman who had been afflicted with epilepsy for eighteen +years, of a severe form, with general convulsions, biting tongue, etc. +Another was a very delicate, nervous woman, who suffered, in addition to +the seizures, from pulmonary and laryngeal phthisis, who came of a +family impregnated with epilepsy, and whose intellect was greatly +impaired. By far the largest class are those benefited by treatment, and +these comprehend every species of case, chronic and recent, complicated, +inherited, in the old and young, and so on; yet the most careful +analysis fails to discover why some should be more amenable to treatment +than others, or give any indication which might be useful in prognosis. +Neither does a study of the few cases which the bromides did not affect, +or those which increased in severity under their influence, throw any +light upon the subject, as some of these latter gave no indications +beforehand of their unfortunate termination, and in none of them was +there any serious complication or special departure from good mental or +bodily health. + +Another point must be noted, although there is no statistical method of +demonstrating the fact, namely, that in those cases in which the attacks +were not completely arrested, but only diminished in number, those +seizures which remained were frequently greatly modified in character +while the patient was under the influence of the bromides. These were +less severe, and characterized by the patients as "slight," while +formerly they were "strong." This by itself often proves of great +service, as, instead of a severe convulsive fit, in which the patient +severely injures himself, bites his tongue, etc., he has what he calls a +"sensation," in other words, an abortive attack. + +Having considered the general effects of the bromides on a series of +unselected cases, we now proceed to investigate whether any particular +form of the disease, or any special circumstances connected with the +patient or his surroundings, have any influence in modifying the results +of treatment. The following table shows epilepsy divided into its two +chief forms, namely, E. Gravior and E. Mitior. By the former is +understood the ordinary severe attack, with loss of consciousness and +convulsions; the latter is the slighter and very temporary seizure, of +loss of consciousness, but without convulsions. + +TABLE V.--_Showing Results of Treatment by the Bromides in_--1. +_Epilepsia Gravior_; _and_ 2. _Epilepsia Mitior._ + + Average Average Number + No. number number attacks + of attacks attacks during + Case. per month per month last 6 + _before_ _after_ months of + treatment. treatment. treatment. + +1. _Epilepsia Gravior_. + + 1 600 5 -- + 2 450 12 -- + 3 249 90 -- + 4 180 60 -- + 5 120 3 -- + 6 60 1 -- + 7 60 6 -- + 8 30 -- 8 + 9 30 4 -- + 10 30 12 -- + 11 23 1 -- + 12 16 2 -- + 13 12 -- 4 + 14 12 3 -- + 15 12 10 -- + 16 8 0 0 + 17 8 -- 4 + 18 8 1 -- + 19 8 4 -- + 20 8 2 -- + 21 6 -- 1 + 22 5 -- 5 + 23 5 0 0 + 24 4 -- 2 + 25 4 1 -- + 26 4 2 -- + 27 2 -- 1 + 28 2 -- 1 + 29 2 -- 1 + 30 2 -- 1 + 31 2 -- 2 + 32 2 -- 2 + 33 1 0 0 + 34 1 0 0 + 35 1 0 0 + 36 1 0 0 + 37 1 0 0 + 38 1 0 0 + 39 1 -- 1 + 40 1 -- 1 + 41 1 -- 1 + 42 1 -- 1 + 43 1 -- 2 + 44 1 -- 4 + 45 1 -- 2 + 46 1 1 -- + 47 1 150 -- + +2. _Epilepsia Mitior_. + + 1 900 60 -- + 2 600 60 -- + 3 300 3 -- + 4 150 1 -- + 5 150 7 -- + 6 120 120 -- + 7 90 9 -- + 8 90 3 -- + 9 60 15 -- + 10 60 90 -- + 11 13 -- 2 + 12 16 -- 4 + 13 16 -- 8 + 14 8 -- 3 + 15 8 -- 3 + 16 4 -- 1 + 17 4 6 -- + 18 1 -- 4 + +Of 47 cases of E. Major, we find that in 8 there were no attacks during +the whole period of treatment, in 1 there was no improvement, in 1 the +attacks were augmented after treatment, and in 37 there was marked and +varying diminution of the seizures. Of 18 cases of E. Mitior there was +no case where the attacks were wholly suspended, in 1 there was no +improvement, in 2 the attacks were increased, and in 15 they were +diminished in number by treatment. This is scarcely a fair comparison +between the two forms, as the numbers are so unequal; but cases of +uncomplicated E. Mitior are not common, being generally associated with +the graver form, which combined cases are not inserted in this table. It +is generally asserted in books that the non-convulsive form is much more +intractable than the other, but the above table proves the contrary, as, +for example, in Nos. 3, 4, 11, 12. It is true that the results do not +appear so complete or striking in E. Mitior as in E. Gravior, but then +it must be remembered that the number of cases is more limited, and the +number of attacks originally much greater. In short, the table shows +that if treatment does not completely avert the attacks of E. Mitior, it +greatly diminishes their frequency. + +TABLE VI.--_Showing Effects of Treatment by the Bromides in Epilepsy. 1. +Diurnal Form; 2. Nocturnal Form_. + + Average Average Number + No. number number attacks + of attacks attacks during + Case. per month per month last 6 + _before_ _after_ months of + treatment. treatment. treatment. + +1. _Diurnal Form_. + + 1 300 3 -- + 2 90 9 -- + 3 60 6 -- + 4 30 -- 8 + 5 24 1 -- + 6 16 -- 8 + 7 12 -- 4 + 8 8 -- 3 + 9 8 -- 4 + 10 4 1 -- + 11 2 -- 1 + 12 1 0 0 + 13 1 0 0 + 14 1 0 0 + 15 1 -- 1 + +2. _Nocturnal Form_. + + 1 60 1 -- + 2 16 -- 4 + 3 8 2 -- + 4 2 -- 1 + 5 4 -- 2 + 6 1 -- -- + 7 1 150 -- + +Another variety of epilepsy is that which is characterized by the time +at which the attacks occur. In the large majority of cases these take +place both while the patient is awake and when he is asleep. I have, +unfortunately, no observations to offer as to the effects of treatment +on the diurnal or nocturnal attacks in patients suffering from both. The +preceding table shows the result of treatment in 15 cases in which the +attacks occurred only while the patient was awake, and in 7 cases where +they took place only while he was asleep. + +Of 15 cases of the purely diurnal form, we find that in 3 there was a +total cessation of attacks during treatment, and in all the others there +was diminution in their number. Of the 7 nocturnal cases, in none were +the seizures entirely arrested, in 1 the attacks increased in number +after treatment, and the remainder were relieved to a greater or less +extent. Here, again, our numbers are small, and therefore difficult to +found any definite principle upon; still there is enough to show that, +contrary to the opinion expressed by most authorities, the nocturnal +form of epilepsy appears to be as amenable to relief as the diurnal +variety. + +The next point for consideration is the question whether the fact of the +epilepsy being hereditary or not makes any difference in the results of +treatment by the bromides. In the following table all the cases with a +perfectly sound family history are placed in the first part, and the +second includes those in which either epilepsy or insanity could be +proved to exist in any near relation. + +Thus in 39 cases with a perfectly sound family history, in 3 the attacks +were totally arrested during treatment, in 2 there was no improvement, +in 2 there was increase of seizures after treatment, and in the +remainder there was diminution of the fits. In 18 cases, where at least +one near relation suffered from either epilepsy or insanity, in 3 the +attacks were arrested, in 1 they were increased, and in the remainder +diminished. In short, from a review of the details of the table, it does +not appear that the fact of the disease being inherited, or of its +existing in other members of the family, makes any difference to the +benefit we may expect to derive from treatment. + +TABLE VII.--_Showing Effects of Treatment by the Bromides in Epilepsy._ +1. _Non-Hereditary Cases_, 2. _Hereditary Cases_. + + Average Average Number + No. number number attacks + of attacks attacks during + Case. per month per month last 6 + _before_ _after_ months of + treatment. treatment. treatment. + +1. _Non-Hereditary Cases._ + + 1 600 5 -- + 2 600 60 -- + 3 450 12 -- + 4 240 90 -- + 5 300 3 -- + 6 150 7 -- + 7 120 3 -- + 8 120 120 -- + 9 150 1 -- + 10 70 20 -- + 11 60 6 -- + 12 60 90 -- + 13 60 1 -- + 14 30 12 -- + 15 90 3 -- + 16 30 -- 2 + 17 16 -- 4 + 18 16 2 -- + 19 8 0 0 + 20 8 2 -- + 21 8 -- 3 + 22 8 4 -- + 23 6 -- 1 + 24 5 0 0 + 25 5 -- 5 + 26 4 2 -- + 27 4 1 -- + 28 2 -- 2 + 29 2 -- 1 + 30 2 1 -- + 31 2 -- 2 + 32 1 0 0 + 33 1 -- 2 + 34 1 -- 4 + 35 1 1 -- + 36 1 -- 1 + 37 1 -- 1 + 38 1 -- 1 + 39 1 150 -- + +2. _Hereditary Cases._ + + 1 900 60 -- + 2 180 60 -- + 3 90 9 -- + 4 24 1 -- + 5 16 -- 8 + 6 12 -- 4 + 7 12 3 -- + 8 8 1 -- + 9 8 -- 3 + 10 8 -- 4 + 11 4 -- 2 + 12 4 6 -- + 13 2 -- 1 + 14 2 -- 1 + 15 1 0 0 + 16 1 0 0 + 17 1 0 0 + 18 4 -- 1 + +The next table attempts to show whether or not the age of the patient +when he came under observation has any effect in modifying the action of +the bromides, or whether it assists us prognosing the probable result. + +A survey of this table shows in general terms that the age of the +patient is neither an assistance nor impediment to the successful action +of the bromides in the treatment of epilepsy. Whatever the age may be, +whether in a young child or in an old person, the average of beneficial +effects appears to be the same. At first sight it would seem as if +treatment would be more successful in the young; but it is not so, as +the two cases in the table over fifty years of age received as much +average benefit as any of the others. + +TABLE VIII.--_Showing Effects of Treatment by the Bromides in Epilepsy +at Different Ages_. 1. _Under 15 Years_; 2. _Between 15 and 30 Years_; +3. _Between 30 and 50 Years_; 4. _Over 50 Years_. + + Average Average Number + No. number number attacks + of attacks attacks during + Case. per month per month last 6 + _before_ _after_ months of + treatment. treatment. treatment. + +1. _Under 15 Years._ + + 1 900 60 -- + 2 600 5 -- + 3 600 60 -- + 4 450 12 -- + 5 240 90 -- + 6 180 60 -- + 7 150 7 -- + 8 30 4 -- + 9 8 0 0 + 10 8 -- 3 + 11 4 6 -- + 12 4 2 -- + 13 2 -- 1 + 14 1 150 -- + +2. _Between 15 and 30 Years._ + + 1 300 3 -- + 2 150 7 -- + 3 120 3 -- + 4 120 120 -- + 5 90 3 -- + 6 60 1 -- + 7 60 6 -- + 8 60 90 -- + 9 16 -- 4 + 10 16 -- 8 + 11 16 2 -- + 12 12 -- 4 + 13 8 1 4 + 14 8 2 -- + 15 8 4 -- + 16 70 20 -- + 17 5 0 0 + 18 4 -- 2 + 19 4 1 -- + 20 4 1 -- + 21 2 -- 2 + 22 2 -- 1 + 23 2 -- 1 + 24 2 -- 2 + 25 1 0 0 + 26 1 0 0 + 27 1 0 0 + 28 1 -- 1 + 29 1 -- 2 + 30 1 -- 4 + 31 1 1 -- + +3. _Between 30 and 50 Years._ + + 1 30 -- 2 + 2 30 -- 12 + 3 12 3 -- + 4 8 1 -- + 5 8 -- 3 + 6 5 -- 5 + 7 2 -- 2 + 8 1 0 0 + 9 1 -- 1 + 10 1 -- 1 + +4. _Over 50 Years._ + + 1 30 -- 8 + 2 24 1 -- + +Does the fact of the disease being recent or chronic affect the +prognosis of treatment? This will be seen by the following table, in +which the length of time that the disease has existed is divided into +four periods, namely--1, those cases in which the attacks first began +less than a year before treatment was commenced; 2, those in which they +had begun from one to five years before; 3, those in which they began +from five to ten years before; and, 4, those in which the disease had +existed for over ten years. + +TABLE IX.--_Showing Effects of Treatment by the Bromides in Epilepsy in +Recent and Chronic Cases. 1. Under 1 Year; 2. From 1 to 5 Years; 3. From +5 to 10 Years; 4. Over 10 Years._ + + Average Average Number + No. number number attacks + of attacks attacks during + Case. per month per month last 6 + _before_ _after_ months of + treatment. treatment. treatment. + +1. _Under 1 Year._ + + 1 600 60 -- + 2 60 6 -- + 3 8 -- 3 + 4 5 0 0 + 5 4 -- 2 + 6 4 2 -- + 7 2 -- 1 + 8 2 -- 1 + 9 2 -- 2 + +2. _From 1 to 5 Years._ + + 1 600 5 -- + 2 240 90 -- + 3 180 60 -- + 4 90 3 -- + 5 30 -- 2 + 6 30 -- 8 + 7 30 12 -- + 8 16 -- 8 + 9 12 3 -- + 10 8 0 0 + 11 150 7 -- + 12 8 2 -- + 13 6 1 -- + 14 4 -- 1 + 15 2 -- 1 + 16 2 -- 2 + 17 1 0 0 + 18 1 0 0 + 19 1 -- 1 + 20 1 1 -- + 21 1 150 -- + +3. _From 5 to 10 Years._ + + 1 450 12 -- + 2 300 3 -- + 3 900 60 -- + 4 90 9 -- + 5 60 1 -- + 6 30 4 -- + 7 16 2 -- + 8 8 -- 4 + 9 8 -- 3 + 10 8 1 -- + 11 4 1 -- + 12 3 1 -- + 13 1 -- 1 + 14 1 -- 1 + 15 1 -- 2 + +4. _Over 10 Years._ + + 1 150 1 -- + 2 120 3 -- + 3 120 120 -- + 4 70 20 -- + 5 60 90 -- + 6 16 -- 4 + 7 12 -- 4 + 8 8 4 -- + 9 5 -- 5 + 10 1 0 0 + 11 1 0 0 + 12 1 -- 4 + +In this table we observe very singular results in the treatment of this +remarkable disease. In most ailments, the longer they have existed and +the more chronic they are, the more difficult and imperfect is the +prospect of recovery. This does not appear to hold good in the case of +epilepsy. For when we analyze the above table we find that the results, +on an average, are as satisfactory in those cases in which the disease +has existed over ten years as in those which began less than one year +before the patient came under observation. For example, we find in +section 4 of Table IX. 12 cases in which epilepsy had existed for over +ten years prior to treatment; of these, in 2 the attacks were completely +arrested, in 1 there was no improvement, in 1 the attacks were +increased, and in the remainder the seizures were as beneficially +modified as in the other sections. Thus it would seem that we are not to +be deterred from treating cases of epilepsy, however chronic they may +be, as the results appear to be as good in modifying the attacks in old, +as in recent cases. + +TABLE X.--_Showing Effects of Treatment by the Bromides in Epilepsy--1. +In Healthy Persons; 2. In Diseased Persons._ + + Average Average Number + No. number number attacks + of attacks attacks during + Case. per month per month last 6 + _before_ _after_ months of + treatment. treatment. treatment. + +1. _Healthy Persons._ + + 1 900 60 -- + 2 600 60 -- + 3 150 7 -- + 4 150 1 -- + 5 120 3 -- + 6 90 9 -- + 7 70 20 -- + 8 60 1 -- + 9 60 5 -- + 10 60 90 -- + 11 30 -- 2 + 12 30 -- 8 + 13 30 12 -- + 14 16 0 0 + 15 16 2 -- + 16 16 -- 4 + 17 12 3 -- + 18 8 2 -- + 19 8 0 0 + 20 8 -- 3 + 21 8 -- 4 + 22 8 4 -- + 23 4 2 -- + 24 4 1 -- + 25 4 2 -- + 26 2 -- 1 + 27 2 -- 2 + 28 2 -- 1 + 29 2 -- 1 + 30 2 -- 2 + 31 2 -- 1 + 32 1 0 0 + 33 1 -- 2 + 34 1 1 -- + 35 1 0 0 + 36 1 0 0 + 37 1 -- 1 + 38 1 -- 1 + 39 1 -- 1 + 40 1 1 4 + 41 1 150 -- + +2. _Diseased Persons._ + + 1 450 12 -- + 2 300 3 -- + 3 240 90 -- + 4 180 60 -- + 5 90 3 -- + 6 60 6 -- + 7 24 1 -- + 8 12 -- 4 + 9 8 -- 3 + 10 8 1 -- + 11 6 -- 1 + 12 5 -- 5 + 13 4 -- 1 + 14 4 6 -- + 15 1 0 0 + +Another important question arises: Does the general health of the +patient in any way influence the effects of treatment? In the preceding +table those cases are collected in section 1 whose general health was to +all appearances robust and free from disease. In section 2. are those in +which organic disease could be demonstrated, or in which the condition +of the patient was evidently unfavourable. + +Here, again, a consideration of the table demonstrates that the +condition of the general health has no influence on the successful +progress of treatment, as those cases under the head of diseased persons +made apparently as satisfactory progress as those in a perfectly robust +condition regarding their epileptic symptoms. + +As a specimen, the following table shows the result in those cases +complicated with a permanent lesion of a motor part of the brain, +namely, hemiplegia, and of an intellectual portion, in the shape of +idiocy:-- + +TABLE XI.--_Showing effects of Treatment by the Bromides in Epilepsy +complicated with--1. Hemiplegia; 2. Idiocy_. + + Average Average Number + No. number number attacks + of attacks attacks during + Case. per month per month last 6 + _before_ _after_ months of + treatment. treatment. treatment. + +1. _Hemiplegia._ + + 1 450 12 -- + 2 240 90 -- + 3 30 4 -- + 4 24 1 -- + 5 8 -- 3 + 6 8 1 -- + 7 4 6 -- + +2. _Idiocy._ + + 1 180 60 -- + 2 120 120 -- + 3 60 6 -- + 4 30 4 -- + 5 4 6 -- + +Here it may be observed that of 7 cases complicated with hemiplegia, in +1 the attacks were increased after treatment, but all the others were +relieved in average proportion. Of the 5 cases in idiots, in 1 there was +no improvement, in 1 the attacks were subsequently augmented, and in the +others there was improvement. The numbers are far too limited to found +any reliable dictum upon; at the same time, it must be admitted that +while epilepsy complicated with these grave lesions is perfectly +amenable to treatment, this table serves to show that the proportion of +non-success is comparatively large. + +It has been stated before that no attempt would be made in this paper to +prove that epilepsy was curable by therapeutic means. Its aim has been +to show the effects of the bromides on the attacks or symptoms of that +disease. It is common to hear it remarked, as if this were of no +importance, "You only arrest the fits, but you do not know, and cannot +cure, the original lesion. You do not go to the fountain-head of the +disease, but simply relieve its results." In reply, I would ask, Of what +disease do we know the ultimate nature any better than that of epilepsy? +and if we did, how would that assist us in treating it? What drug in our +pharmacopoeia cures any single disease, or do other than, by attacking +and relieving symptoms, leave nature to remove the morbid lesion? Even +quinine, to which therapeutists triumphantly point, only arrests certain +paroxysms until time removes the poison from the blood, as it does in +most malarious affections. So far from being a small matter, I believe +there are few, if any, drugs at our disposal which can be demonstrated +to have a more beneficial action in the treatment of disease than that +of the bromides, in epilepsy. Besides, I decline to admit the statement +that complete recovery does not follow their administration. Various +authors have reported cases, and that these are rare is due to reasons +stated before, and chiefly on account of the long period of treatment +necessary to ensure success. + +This inquiry may be summed up in the following general conclusions:-- + +1. In 12.1 per cent. of epileptics the attacks were completely arrested +during the whole period of treatment by the bromides. + +2. In 83.3 per cent. the attacks were greatly diminished both in number +and severity. + +3. In 2.3 per cent. the treatment had no apparent effect. + +4. In 2.3 per cent. the number of attacks was augmented during the +period of treatment. + +5. The form of the disease, whether it was inherited or not, whether +complicated or not, recent or chronic, in the young or in the old, in +healthy or diseased persons, appeared in no way to influence treatment, +the success being nearly in the _same ratio_ under all these +conditions. + +FOOTNOTES: + +[B] Reprinted from the "Edinburgh Medical Journal" for February and +March, 1881. + +[C] For an extended experience, see the next paper. + + + + +III. + +AN INQUIRY + +INTO THE + +EFFECTS OF THE PROLONGED + +ADMINISTRATION OF THE BROMIDES + +IN EPILEPSY.[D] + + +The present inquiry is the result of an experience of 300 cases of +epilepsy treated by myself with the bromides of potassium and ammonium. +In all of these the clinical facts, as well as the progress of the +malady, were carefully studied and recorded. The effects of the +administration of these remedies on epileptic seizures I have already +investigated and demonstrated in a somewhat elaborate series of +observations.[E] Further experience has confirmed the correctness of the +general propositions then arrived at, so that they need not again be +elaborated in detail. + +At present it is proposed to direct attention to the effects of the +prolonged administration of large doses of the bromides, and to attempt +to ascertain if, while arresting or diminishing the frequency and +severity of the paroxysmal symptoms, they beneficially influence the +disease itself, or in any way injuriously modify the constitution of the +patient. On this subject much difference of opinion and misconception +prevail. It is well known that the injudicious use of the drugs leads to +certain physiological phenomena which are comprised under the term +"bromism." It is also generally believed that the physical and mental +depression resulting from their prolonged toxic effects constitutes a +condition worse than the malady for which they are exhibited. One of the +objects of this article is to question the accuracy of this assertion, +a true apprehension of which is the more important when we reflect how +universal is this method of treatment, and the deterrent effect it +exercises upon epileptic attacks. The task, like other therapeutic +inquiries--especially those connected with chronic disease--is a +difficult one, there being innumerable pitfalls of error between us and +a sound scientific conclusion. These, however, may, I believe, in great +measure be surmounted by the accumulation of facts laboriously and +accurately recorded, by the intelligent study of their details, and the +impartial and logical deductions which may be drawn from the data +supplied. The value of a therapeutic inquiry depends, not upon the +opinions and undigested experience of individuals, or by the narration +of isolated cases, but upon the indisputable proofs resulting from the +unbiassed analysis of a large series of accurately observed and +unselected examples. The solution of the problem, if complex in all +clinical affections, is especially so in epilepsy. Although the symptoms +of this disease have been recognised from the earliest ages, our +knowledge of its essential nature is as yet shrouded in mystery. The +etiology and pathology are practically undetermined. The phenomena are +not only due to a varied series of morbid conditions, but may assume a +multitude of forms and degrees of severity, which may be, on the one +hand, of the briefest duration, or, on the other, of a life-long +permanence. The symptoms may comprise not only a diversity of physical +ailments, but intellectual disturbances of the most terrible import. The +malady may attack not only many whose systems are predisposed to +disease, but those of the most robust constitution and with a healthy, +family history. The consequences of the disorder may be comparatively +innocuous, but in other circumstances may be attended with the most +disastrous effects on mind and body and even on life itself. In a +disease presenting such an intricate and uncertain course, it is +obviously a task of the utmost difficulty to scientifically estimate the +exact value of any therapeutic measures which may be adopted for its +relief. The effects on one symptom, and that the most prominent, can, +however, be accurately determined--namely, the paroxysmal seizures, +which are definite and computable; and this has already been +accomplished with tolerable precision.[F] On the influence of the +bromides on the disease itself, or on the epileptic state, we have less +accurate information. In attempting to throw some light on this subject, +two preliminary considerations must be recognised--1st, the +physiological actions of the drug on the healthy subject; and 2nd, the +inter-paroxysmal symptoms of the epileptic constitution. + +1. Medicinal doses of the bromides produce in healthy persons a general +diminution of nervous energy. They act as a sedative, and thus dispose +to repose and sleep. If they are excessive in quantity and long +continued, especially in those susceptible to their action, a series of +toxic effects are produced. Various organs and functions of the body are +influenced, and the results of the poison may be briefly summed up as +follows:--The intellectual faculties are blunted, the memory is +impaired, the ideas confused, the patient is dull, stupid, and +apathetic, and has a constant tendency to somnolence. The speech is +impeded and slow, and the tongue is tremulous. The special senses are +weakened. The body, as a whole, is infirm, the limbs feeble, and the +gait staggering and incoordinated. The reflex excitability is lowered +and the sensibility diminished. The sexual powers are impaired or +abolished. These symptoms may be present in a variety of degrees, and in +advanced cases even imbecility or paralysis may ensue. The mucous +membranes become dry and insensitive, especially those of the fauces. +This is attended with various functional disorders, such as nausea, +flatulence, gastric catarrh, diarrhoea, &c. The skin is pale, and the +extremities are cold. The action of the heart is slow and weak. The +respiration is shallow, hurried, and imperfect. The integument is +frequently covered with an acne-like eruption. To these symptoms may be +added a general cachexia. All these abnormal conditions, as a rule, +disappear when the consumption of the poison is arrested. + +2. Although some persons, suffering from epileptic seizures, are, in the +intervals, of sound mind and body, in many the inter-paroxysmal state is +characterized by certain symptoms peculiar to this condition, and +independent of any form of treatment. These vary from the slightest +departures from health to the most serious mental and physical disease. +The general health is frequently unsatisfactory; the functions of the +body being impaired in vigour, the digestion is weak, and the +circulation feeble. The entire nervous system is in an unstable +condition, the patient being at one time irritable and excitable, and at +another depressed and despondent. There is a very common condition of +so-called "nervousness" which is accompanied by headache, pains, +tremors, and a variety of other subjective phenomena. The mental powers +are enfeebled, the memory defective, and these intellectual alterations +may exist in any degree, even to permanent and intractable forms of +insanity. The physical conditions may also be changed, the nutrition of +the tissues is often imperfect, the skin is pale, the muscles flabby, +and the motor powers generally enfeebled, all of which may also present +different degrees of severity, so as to culminate in actual paralysis. + +Admitting, then, that the prolonged and excessive administration of the +bromides causes a series of abnormal symptoms in the healthy individual, +affecting mainly the general nutrition, the mental faculties, and the +sensory and motor functions, and also that the epileptic state is itself +frequently accompanied by impairment of innervation of a somewhat +analogous nature, it follows that when the drug is given for the relief +of the disease, care must be taken not to confound the two series of +phenomena with one another. With this precaution in view, granting that +the therapeutic agent beneficially controls and suppresses the +convulsive seizures, we proceed to discuss whether in so doing it in any +way injuriously influences the constitution of the patient. To answer +this question has been found by no means easy. Comparatively few +physicians have opportunities of observing cases of epilepsy in +sufficient numbers to form substantial conclusions on the subject. Even +in favoured circumstances it is difficult, especially in hospital +practice, to ensure the regular attendance of the patient or to keep him +sufficiently long under observation. The study and the recording of the +facts, moreover, demand an expenditure of much time and labour. These, +added to the sources of fallacy already enumerated, render the inquiry +a complicated one; but it is believed that an approximation to the truth +may be arrived at by the following method of investigation. + +A large number of cases of epilepsy form the basis of the statistics, +the great majority of whom are adults. No selection of any kind is made, +and all are admitted irrespective of the cause, nature, or severity of +the disease. The particulars of each having been noted, treatment by the +bromides was instituted, the minimum dose being one drachm and a half +daily,[G] which, if necessary, was further increased in quantity. The +progress of the patient was observed at frequent and regular intervals, +and if the attendance was irregular the case was excluded from the +present inquiry. The result of this proceeding is an aggregate of 141 +cases, all of whom have been constantly under the influence of the drug +for periods varying from one to six years. These are arranged in groups +according to the length of time they were under treatment. The immense +mass of details thus collected, added to the varied circumstances +connected with individual cases, render it impossible, in constructing a +summary of the whole, to do more than select certain prominent features +of interest for examination and demonstration. These in tabular form are +as follows:-- + +TABLES SHOWING THE EFFECTS OF THE CONTINUOUS ADMINISTRATION OF THE +BROMIDES IN THE EPILEPTIC STATE, IN 141 CASES, THE CONDITION BEING +ASCERTAINED AT THE END OF EACH PERIOD. + +I. _For one year (51 cases)._ + + Physical and mental powers unaffected 39, or 76.4 per cent. + Physical and mental powers impaired 6, or 11.7 per cent. + Physical powers alone impaired 3, or 5.9 per cent. + Mental powers alone impaired 2, or 3.9 per cent. + General symptoms of neurasthenia 13, or 25.4 per cent. + Bromide eruption 8, or 15.6 per cent. + +II. _For two years (34 cases)._ + + Physical and mental powers unaffected 28, or 82.3 per cent. + Physical and mental powers impaired 2, or 5.8 per cent. + Physical powers alone impaired 1, or 2.9 per cent. + Mental powers alone impaired 2, or 5.8 per cent. + General symptoms of neurasthenia 5, or 14.7 per cent. + Bromide eruption 6, or 17.6 per cent. + +III. _For three years (30 cases)._ + + Physical and mental powers unaffected 28, or 93.3 per cent. + Physical and mental powers impaired 1, or 3.3 per cent. + Physical powers alone impaired 1, or 3.3 per cent. + Mental powers alone impaired 0, or 0.0 per cent. + General symptoms of neurasthenia 3, or 10.0 per cent. + Bromide eruption 3, or 10.0 per cent. + +IV. _For four years (16 cases)._ + + Physical and mental powers unaffected 12, or 75.0 per cent. + Physical and mental powers impaired 0, or 0.0 per cent. + Physical powers alone impaired 2, or 12.5 per cent. + Mental powers alone impaired 2, or 12.5 per cent. + General symptoms of neurasthenia 0, or 0.0 per cent. + Bromide eruption 2, or 12.5 per cent. + +V. _For five years (6 cases)._ + + Physical and mental powers unaffected 6, or 100.0 per cent. + Physical and mental powers impaired 0, or 0.0 per cent. + Physical powers alone impaired 0, or 0.0 per cent. + Mental powers alone impaired 0, or 0.0 per cent. + General symptoms of neurasthenia 3, or 50.0 per cent. + Bromide eruption 0, or 0.0 per cent. + +VI. _For six years (4 cases)._ + + Physical and mental powers unaffected 4, or 100.0 per cent. + Physical and mental powers impaired 0, or 0.0 per cent. + Physical powers alone impaired 0, or 0.0 per cent. + Mental powers alone impaired 0, or 0.0 per cent. + General symptoms of neurasthenia 2, or 50.0 per cent. + Bromide eruption 0, or 0.0 per cent. + +In the construction of the details of the above tables, care has been +taken as far as possible to distinguish between the effects of the +remedy and the symptoms associated with the disease, although this has +not been always easy to accomplish. It has, however, been approximately +arrived at by a careful study of the patient's health before treatment, +as compared with his subsequent state, and those symptoms only were +considered toxic which were superadded to pre-existing abnormal +conditions. A general analysis of the facts thus collected shows that in +the majority of cases the physical and mental powers do not appear to be +injuriously affected by the prolonged use of the bromides. It is not +asserted that all the individuals placed under this section were +necessarily sound in mind and body. In many instances the functions of +these were impaired, but there was no evidence to indicate that this was +the result of the medicine taken; on the contrary, there was every +reason to believe that the symptoms thus displayed were a part of the +original disease, and had existed prior to treatment. + +In a very small percentage of cases were both physical and mental powers +unfavourably modified as a direct consequence of the use of the +bromides, and even in these there is no absolute certainty that the +drugs were entirely responsible for the symptoms, seeing that these +might be attributed to the epileptic condition as well as to the toxic +effects of the remedy. They are considered under this category, as the +abnormal phenomena appeared to be augmented after treatment and improved +on its temporary cessation. They mainly consisted, on the one hand, of +loss of memory, dulness of apprehension, apathy, somnolence, depression +of spirits, and mental debility; and on the other, of bodily languor, +muscular fatigue, and general physical weakness. In no case did any of +these symptoms attain an excessive or prominent position. The same +conditions apply when the physical or mental powers were impaired +independently of one another. + +Under the heading of general phenomena of neurasthenia is included a +series of indefinite subjective neurotic symptoms, without intellectual +or bodily deficiencies, in which the patient complained of headache, +neuralgic pains, tremors, of being easily startled and frightened, with +that general instability of the nervous system to which the term +neurasthenia has been given. This condition is extremely common in the +epileptic, and is frequently relieved by treatment. At other times it +remains persistent in spite of all medicaments, and the numbers in the +tables indicate those cases conspicuous by their continuance under the +use of the bromides. Those attacked by the follicular rash are seen at +first to be about 16 per cent., but gradually diminishing in number as +the treatment becomes chronic, and finally disappearing altogether. + +In addition to the points referred to in the tables, other questions +have been investigated, although on a smaller scale. For example, in +persons who have been under the influence of the bromides for many +years, the skin and tendon reflex action remain intact, and I have never +seen a case in which the knee-jerk or plantar phenomena were absent. In +only one case was the general sensibility of the skin perceptibly +diminished. With regard to the effects on the sexual powers, I have not +sufficient data upon which to found positive rules. This statement, +however, may be made, that the prolonged use of even large doses of this +drug does not of necessity abolish or even sensibly impair this +function, although, no doubt, it usually does so. On examining the +respiration and pulse, I have never been able to detect any +characteristic abnormality. + +I might record many cases in detail to prove the seemingly innocuous +nature of even large and long-continued doses of the bromides in +epilepsy. I shall, however, as an illustration, limit myself to a few +notes on the four cases which compose Table VI., all of whom were +continuously under the influence of the drugs for a period of not less +than six years. + +CASE 1.--Louisa C----, aged twenty-nine, has suffered from epileptic +attacks for fourteen years. Prior to treatment she had three or four +every week, of a severe character, consisting of loss of consciousness, +general convulsions, biting of the tongue, &c. She has always been a +delicate person, with a tendency to great nervousness, but otherwise +intelligent, and in fair general health. She has taken one and a half +drachms of bromide of potassium daily regularly for the last six years, +and states that if she attempts to discontinue the medicine all her +symptoms are aggravated. At present the patient is a robust, +healthy-looking woman, of fair intelligence and good spirits. Her +memory is deficient. Her physical powers are vigorous, and she earns her +living as a bookbinder. She has an attack about once a month, and with +the exception of this and occasional headaches and nervousness, she +professes and seems to be in excellent general health. Sensibility, the +knee-jerk, and plantar phenomena are normal. The fauces are insensitive, +and their reflex is abolished. Pulse 60, normal. The circulation, +respiration, and other functions are healthy. No traces of bromism. + +CASE 2.--Charles P----, aged thirty-five, has suffered from epileptic +attacks of a severe convulsive character for eighteen years, having had +one about once a month. Prior to treatment, although his memory was +defective, his intelligence and general health were good. For the last +six years he has regularly taken the bromides of potassium and ammonium +(one drachm and a half) daily. At present he still continues to have an +attack about once a month. His mental and physical conditions are the +same as before. He appears perfectly intelligent. His strength is +robust, so that he does his ordinary work as a pianoforte maker. Pulse +74, of good strength. All the reflexes are normal, except that of the +fauces, which is abolished. Sensibility of the skin to touch slightly +diminished. The sexual functions are normal. No symptoms of bromism. + +CASE 3.--Matilda W----, aged thirty-one, has suffered from epilepsia +gravior and mitior for twenty-two years, having of the former about one +seizure in three months, and of the latter ten or twelve a day. She has +always been a delicate woman, suffering from headaches, general +irritability, and nervousness. She is, however, perfectly intelligent. +For six years past she has taken regularly the bromides of potassium and +ammonium, one drachm of each daily. She has not had an attack of +epilepsy major for a year, and of epilepsy mitior has now only about one +a week. Although anaemic, her general health is good, and she is able to +do a full day's work as a washer-woman. Intellectually she is quite +sound, but has a treacherous memory, and is very nervous. Sensibility, +reflex acts, &c., are as in the other cases. + +CASE 4.--Lucy D----, aged twenty-two, has suffered from epilepsy major +for eight years. Formerly had about one attack a week. Has always been a +delicate girl, but her general health and mental condition have been +normal. For the last six years she has regularly taken one drachm and a +half of the bromides daily (potassium and ammonium in equal parts). She +has had only three attacks during the past year. Her general health is +excellent. She is robust and active, and takes her full share in +domestic work. She is well educated, intelligent, with good memory and +spirits, and has no tendency to depression or somnolence. The +sensibility, reflex acts, and other functions are as in the other cases. + +In these four cases it has been ascertained that the patients were +constantly under the influence of large doses of the bromides for a +period of not less than six years, and practically without intermission. +During this period not only were the frequency and severity of the +convulsive attacks beneficially modified, but there was no evidence to +show that the physical or mental condition had been in any way impaired. +It is further to be observed that these as well as many others of those +constituting the later tables, are examples of unusually long-standing +and severe forms of epilepsy, as evidenced by the fact of their chronic +and intractable nature even under treatment. Notwithstanding the +incompleteness of their recovery, these individuals have voluntarily, +and often at great inconvenience and expense, persevered in the use of +the remedy, which is a fair indication they derived some substantial +benefit from it. The examples before us, one and all, declared they have +found by experience that when they have attempted, even for brief +periods, to discontinue the medicine their symptoms have all become +aggravated. As a result the attacks increase in severity and number, the +headaches return, the nervousness augments, and they are unable to +perform either mental or bodily exertion. These sufferings, it is +maintained, are greatly modified by the bromides, as under their +influence epileptics may perform their daily work, when without them +they are comparatively useless. It would be easy to multiply individual +cases supporting the same general principles. One more instance only +need be particularized--namely, that of a man aged thirty, who has +suffered from epilepsy from infancy, and who for the last five years +has taken _four and a half drachms_ of the bromides daily--_i.e._, +during that time he has consumed upwards of _eighty pounds_ of the drug. +Although a delicate person and intellectually weak, his friends state +that during those years he has been more healthy and robust in mind and +body than at any other period of his life. And these statements were +confirmed by other testimony. + +While attempting to estimate the therapeutic value of the bromides from +a statistical aspect, one likely source of fallacy must not be +overlooked. Most patients, and especially those attending hospitals, are +difficult to keep under observation for long periods, more particularly +if the progress of the case is unsatisfactory. In this way we may lose +sight of those who do not benefit by treatment or who are injured by it. +Although it is difficult to estimate these with accuracy, a certain +rebatement must always be made on this count in computing results. At +the same time we have in the present inquiry positive evidence, in a +considerable number of cases, of the innocuous and beneficial nature of +the drug, against the negative possibility only of its disadvantages. Of +the 141 cases under notice, I only know of three who have died, and all +of then of phthisis pulmonalis. The relations existing between the +mortality and cause of death on the one hand, and the disease and +treatment on the other, the paucity of the data do not permit us to +determine. + +A further study of the tables would also seem to show that while the +beneficial action of the bromides remains permanent, the deleterious +effects diminish the longer the drug has been taken. This is doubtless +due, as in the case of most poisons, to the system becoming habituated +to its use. It has often been observed that the most marked effects of +bromism have appeared at the beginning of treatment, and that the +eruption, the physical and mental depression, &c., subsequently +disappeared, although the medicine was persevered in. Those who have +been under its influence for some years rarely present any symptoms +directly attributable to the toxic effects of the bromides; and if +abnormal conditions do exist, these are the sequelae of the malady, and +not the results of treatment, as shown by the fact that when the last is +suspended, the original sufferings are augmented. + +It may be suggested that a prolonged use of the bromides becomes, as in +the case of opium, a habit. There is, however, a marked distinction +between the two. Opium-smoking is a vice not only deleterious in itself, +but one indulged in merely to satisfy a morbid craving. The bromides, on +the other hand, are less hurtful in their effects, and are taken to +avert the symptoms of a distressing and terrible malady. Assuming, then, +that their consumption becomes a necessity, if it can be shown that the +results are not serious, while the evils they avert are important, the +habit acquired may be looked upon as a justifiable one. + +A general review of all these circumstances seems to render it probable +that the epileptic constitution is more tolerant of the toxic effects of +the bromides than the healthy system. The most severe effects of bromism +occur in those who are not the victims of this malady, in whom, as seen +by the foregoing facts, they are not common. Theoretically this may be +plausibly explained by the reasonable assumption that, as in epilepsy +the entire nervous apparatus is in a state of reflex hyper-excitability, +the sedative and poisonous effects of the bromides do not produce the +depressing or toxic actions they would do in a more stable organization. +Whatever the reason may be, the fact is that the symptoms of bromism are +not so severe in the epileptic as they are in otherwise healthy +subjects. + +Finally, the important question arises, Does a prolonged use of the +bromides tend towards the eradication of the disease itself and the +ultimate cure of the epileptic state? On this point I have no personal +statistical evidence to offer, nor am I aware of the existence of any +sufficiently scientific series of data to settle the question. Without +there being actual demonstration of the fact, there is every reason to +believe that such a supposition is possible. Clinical observation has +determined that the larger the number of convulsive seizures the greater +is the tendency to the production of others, and the more readily are +they caused. Such is the abnormal reflex hyper-excitability of the +nervous system of the epileptic that the irritative effects of one +attack seem directly to pre-dispose to the occurrence of a second; so +that the larger the number of explosions of nerve instability which +actually take place, the more there are likely to follow. Could such +seizures be kept in check, this cause of the production of convulsions +at least would be diminished, the liability for them to break out as a +result of trifling external stimuli would be lessened, and the +long-continued absence of this source of irritation might by the repose +and favourable circumstances thus obtained, encourage a healthy +transformation of tissue. Now, it has already been pointed out that in +12.1 per cent. of epileptics the attacks were completely arrested during +the entire time the drugs were being administered, and that in a much +larger percentage they were greatly modified in number and severity. It +has been further shown that the remedies themselves, even when in use +for long periods, are in themselves practically innocuous, while at the +same time they continue to maintain their beneficial effects on the +attacks. It therefore follows that a sufficiently prolonged treatment +might in a certain number of cases be succeeded by permanent curative +results. The chief impediment to arriving at trustworthy conclusions on +this subject has been the length of time necessary to judge of lasting +benefits, and the difficulty of keeping patients sufficiently long under +observation. Another has been the objection raised to the method of +treatment on the grounds of a visionary suspicion that the toxic effects +of the drug were of a dangerous nature, and their results more +distressing than the diseases for which they were given. So far as my +experience has extended, I believe this fear has not been warranted by +facts. + +FOOTNOTES: + +[D] Reprinted from the "Lancet" of May 17th and 24th, 1884. + +[E] See Article II. + +[F] Vide preceding paper. + +[G] The usual prescription contained the bromides of potassium and +ammonium, fifteen grains of each for a dose. + + + + +_June, 1884._ + + +CATALOGUE OF WORKS + +PUBLISHED BY + +H. K. LEWIS + +136 GOWER STREET, LONDON, W.C. + +============ + +G. GRANVILLE BANTOCK, M.D., F.R.C.S. EDIN. + +_Surgeon to the Samaritan Free Hospital for Women and Children._ + +I. + +ON THE USE AND ABUSE OF PESSARIES. With Illustrations, Second Edition, +8vo. [_In the press._ + +II. + +A PLEA FOR EARLY OVARIOTOMY. 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With Frontispiece and Map, crown 8vo, 2s. 6d. + +============ + +GURDON BUCK, M.D. + +CONTRIBUTIONS TO REPARATIVE SURGERY; SHOWING its Application to the +Treatment of Deformities, produced by Destructive Disease or Injury; +Congenital Defects from Arrest or Excess of Development; and Cicatricial +Contractions from Burns. Illustrated by numerous Engravings, large 8vo, +9s. + +============ + +ALFRED H. CARTER, M.D. LOND. + +_Member of the Royal College of Physicians; Physician to the Queen's +Hospital, Birmingham, &c_. + +ELEMENTS OF PRACTICAL MEDICINE. Third Edition, crown 8vo. [_In the +press._ + +============ + +P. CAZEAUX. + +_Adjunct Professor in the Faculty of Medicine of Paris, &c._ + +A THEORETICAL AND PRACTICAL TREATISE ON MIDWIFERY INCLUDING THE DISEASES +OF PREGNANCY AND PARTURITION. Revised and Annotated by S. TARNIER. +Translated from the Seventh French Edition by W. R. BULLOCK, M.D. Royal +8vo, Over 1100 pages, 175 Illustrations, 30s. + +============ + +JOHN COCKLE, M.A., M.D. + +_Physician to the Royal Free Hospital._ + +ON INTRA-THORACIC CANCER. 8vo, 4s. 6d. + +============ + +W. H. CORFIELD, M.A., M.D. OXON. + +_Professor of Hygiene and Public Health in University College, London._ + +DWELLING HOUSES: Their Sanitary Construction and Arrangements. Second +Edition, with Illustrations. [_In preparation._ + +============ + +J. THOMPSON DICKSON, M.A., M.B. CANTAB. + +_Late Lecturer on Mental Diseases at Guy's Hospital._ + +THE SCIENCE AND PRACTICE OF MEDICINE IN RELATION TO MIND, the Pathology +of the Nerve Centres, and the Jurisprudence of Insanity, being a course +of Lectures delivered at Guy's Hospital. Illustrated by +Chromo-lithographic Drawings and Physiological Portraits. 8vo, 14s. + +============ + +HORACE DOBELL, M.D. + +_Consulting Physician to the Royal Hospital for Diseases of the Chest, +&c._ + +I. + +ON DIET AND REGIMEN IN SICKNESS AND HEALTH, and on the Interdependence +and Prevention of Diseases and the Diminution of their Fatality. Seventh +edition, 8vo, 10s. 6d. + +II. + +AFFECTIONS OF THE HEART AND IN ITS NEIGHBOURHOOD. Cases, Aphorisms, and +Commentaries. Illustrated by the heliotype process, 8vo, 6s. 6d. + +============ + +JOHN EAGLE. + +_Member of the Pharmaceutical Society._ + +A NOTE-BOOK OF SOLUBILITIES. Arranged chiefly for the use of Prescribers +and Dispensers. 12mo, 2s. 6d. + +============ + +JOHN ERIC ERICHSEN. + +_Holme Professor of Clinical Surgery in University College; Senior +Surgeon to University College Hospital, &c._ + +MODERN SURGERY; Its Progress and Tendencies. Being the Introductory +Address delivered at University College at the opening of the Session +1893-74. Demy 8vo, 1s. + +============ + +DR. FERBER. + +MODEL DIAGRAM OF THE ORGANS IN THE THORAX AND UPPER PART OF THE ABDOMEN. +With Letter-press Description. In 4to, coloured, 5s. + +============ + +AUSTIN FLINT, JR., M.D. + +_Professor of Physiology and Physiological Anatomy in the Bellevue +Medical College, New York; attending Physician to the Bellevue Hospital, +&c._ + +I. + +A TEXT-BOOK OF HUMAN PHYSIOLOGY; DESIGNED for the Use of Practitioners +and Students of Medicine. New edition, Illustrated by plates, and 313 +wood engravings, large 8vo, 28s. + +II. + +THE PHYSIOLOGY OF THE SPECIAL SENSES AND GENERATION; Designed to +Represent the Existing State of Physiological Science, as applied to the +Functions of the Human Body. Being Vol. V of the Physiology of Man. Roy. +8vo, 18s. + +============ + +J. MILNER FOTHERGILL, M.D. + +_Member of the Royal College of Physicians of London; Physician to the +City of London Hospital for Diseases of the Chest, Victoria Park, &c._ + +I. + +THE HEART AND ITS DISEASES, WITH THEIR TREATMENT; INCLUDING THE GOUTY +HEART. Second Edition, entirely re-written, copiously illustrated with +woodcuts and lithographic plates. 8vo. 16s. + +II. + +INDIGESTION, BILIOUSNESS, AND GOUT IN ITS PROTEAN ASPECTS. + +PART I.--INDIGESTION AND BILIOUSNESS. Post 8vo, 7s. 6d. + +PART II.--GOUT IN ITS PROTEAN ASPECTS. Post 8vo, 7s. 6d. + +III. + +HEART STARVATION. (Reprinted from the Edinburgh Medical Journal), 8vo, +1s. + +============ + +ERNEST FRANCIS, F.C.S. + +_Demonstrator of Practical Chemistry, Charing Cross Hospital._ + +PRACTICAL EXAMPLES IN QUANTITATIVE ANALYSIS, forming a Concise Guide to +the Analysis of Water, &c. Illustrated, fcap. 8vo, 2s. 6d. + +============ + +HENEAGE GIBBES, M.D. + +_Lecturer on Physiology and Histology in the Medical School of +Westminster Hospital; late Curator of the Anatomical Museum at King's +College._ + +PRACTICAL HISTOLOGY AND PATHOLOGY. Second Edit. revised and enlarged. +Crown 8vo, 5s. + +============ + +C. A. GORDON, M.D., C.B. + +_Deputy Inspector General of Hospitals, Army Medical Department_. + +REMARKS ON ARMY SURGEONS AND THEIR WORKS. Demy 8vo, 5s. + +============ + +W. R. GOWERS, M.D., F.R.C.P. M.R.C.S. + +_Physician to University College Hospital, &c._ + +DIAGRAMS FOR THE RECORD OF PHYSICAL SIGNS. In books of 12 sets of +figures, 1s. Ditto, unbound, 1s. + +============ + +SAMUEL D. GROSS, M.D., LL.D., D.C.L., OXON. + +_Professor of Surgery in the Jefferson Medical College of Philadelphia._ + +A PRACTICAL TREATISE ON THE DISEASES, INJURIES, AND MALFORMATIONS OF THE +URINARY BLADDER, THE PROSTATE GLAND; AND THE URETHRA. Third Edition, +revised and edited by S. W. GROSS, A.M., M.D., Surgeon to the +Philadelphia Hospital. Illustrated by 170 engravings, 8vo, 18s. + +============ + +SAMUEL W. GROSS, A.M., M.D. + +_Surgeon to, and Lecturer on Clinical Surgery in, the Jefferson Medical +College Hospital, and the Philadelphia Hospital, &c._ + +A PRACTICAL TREATISE ON TUMOURS OF THE MAMMARY GLAND: embracing their +Histology, Pathology, Diagnosis, and Treatment. With Illustrations, 8vo, +10s. 6d. + +============ + +WILLIAM A. HAMMOND, M.D. + +_Professor Of Mental and Nervous Diseases in the Medical Department of +the University of the City of New York, &c._ + +I. + +A TREATISE ON THE DISEASES OF THE NERVOUS SYSTEM. Seventh edition, with +112 Illustrations, large 8vo, 25s. + +II. + +A TREATISE ON INSANITY. Large 8vo, 25s. + +[_Just published._ + +III. + +SPIRITUALISM AND ALLIED CAUSES AND CONDITIONS OF NERVOUS DERANGEMENT. +With Illustrations, post 8vo, 8s. 6d. + +============ + +ALEXANDER HARVEY, M.A., M.D. + +_Emeritus Professor of Materia Medica in the University of Aberdeen; +Consulting Physician to the Aberdeen Royal Infirmary, &c._ + +FIRST LINES OF THERAPEUTICS; as based on the Modes and the Processes of +Healing, as occurring Spontaneously in Disease; and on the Modes and the +Processes of Dying, as resulting Naturally from Disease. In a series of +Lectures. Post 8vo, 5s. + +============ + +ALEXANDER HARVEY, M.D. + +_Emeritus Professor of Materia Medica in the University of Aberdeen, +&c._ + +AND + +ALEXANDER DYCE DAVIDSON, M.D. + +_Professor of Materia Medica in the University of Aberdeen._ + +SYLLABUS OF MATERIA MEDICA FOR THE USE OF TEACHERS AND STUDENTS. Based +on a selection or definition of subjects in teaching and examining; and +also on an estimate of the relative values of articles and preparations +in the British Pharmacopoeia with doses affixed. Seventh Edition, +32mo. + +[_In preparation._ + +============ + +GRAILY HEWITT, M.D. + +_Professor of Midwifery and Diseases of Women in University College, +Obstetrical Physician to University College Hospital, &c._ + +OUTLINES OF PICTORIAL DIAGNOSIS OF DISEASES OF WOMEN. Fol. 6s. + +============ + +BERKELEY HILL, M.B. LOND., F.R.C.S. + +_Professor of Clinical Surgery in University College; Surgeon to +University College Hospital and to the Lock Hospital._ + +THE ESSENTIALS OF BANDAGING. For Managing Fractures and Dislocations; +for administering Ether and Chloroform; and for using other Surgical +Apparatus. Fifth Edition, revised and much enlarged, with Illustrations, +fcap. 8vo, 5s. + +============ + +BERKELEY HILL, M.B. LOND., F.R.C.S. + +_Professor of Clinical Surgery in University College; Surgeon to +University College Hospital and to the Lock Hospital._ + +AND + +ARTHUR COOPER, L.R.C.P., M.R.C.S. + +_Late House Surgeon to the Lock Hospital, &c._ + +I. + +SYPHILIS AND LOCAL CONTAGIOUS DISORDERS. Second Edition, entirely +re-written, royal 8vo, 18s. + +II. + +THE STUDENT'S MANUAL OF VENEREAL DISEASES. Being a Concise Description +of those Affections and of their Treatment. Third Edition, post 8vo, 2s. +6d. + +============ + +HINTS TO CANDIDATES FOR COMMISSIONS IN THE PUBLIC MEDICAL SERVICES, WITH +EXAMINATION QUESTIONS, VOCABULARY OF HINDUSTANI MEDICAL TERMS, ETC. 8vo, +2s. + +============ + +SIR W. JENNER, Bart., M.D. + +_Physician in Ordinary to H. M. the Queen, and to H. R. H. the Prince of +Wales._ + +THE PRACTICAL MEDICINE OF TO-DAY: Two Addresses delivered before the +British Medical Association, and the Epidemiological Society, (1869). +Small 8vo, 1s. 6d. + +============ + +C. M. JESSOP, M.R.C.P. + +_Associate of King's College, London: Brigade Surgeon H.M.'s British +Forces._ + +ASIATIC CHOLERA, being a Report on an Outbreak of Epidemic Cholera in +1876 at a Camp near Murree in India. With map, demy 8vo, 2s. 6d. + +============ + +GEORGE LINDSAY JOHNSON, M.A., M.B., B.C. CANTAB. _Clinical Assistant, +late House Surgeon and Chloroformist, Royal Westminster Ophthalmic +Hospital; Medical and Surgical Registrar, etc._ + +A NEW METHOD OF TREATING CHRONIC GLAUCOMA, based on Recent Researches +into its Pathology. With Illustrations and coloured frontispiece, demy +8vo, 3s. 6d. + +============ + +NORMAN W. KINGSLEY, M.D.S., D.D.S. + +_President of the Board of Censors of the State of New York; Member of +the American Academy of Dental Science, &c._ + +A TREATISE ON ORAL DEFORMITIES AS A BRANCH OF MECHANICAL SURGERY. With +over 350 Illustrations, 8vo, 16s. + +============ + +E. A. KIRBY, M.D., M.R.C.S. ENG. + +_Late Physician to the City Dispensary._ + +I. + +A PHARMACOPOEIA OF SELECTED REMEDIES, WITH THERAPEUTIC ANNOTATIONS, +Notes on Alimentation in Disease, Air, Massage, Electricity and other +Supplementary Remedial Agents, and a Clinical Index; arranged as a +Handbook for Prescribers. Sixth Edition, enlarged and revised, demy 4to, +7s. + +II. + +ON THE VALUE OF PHOSPHORUS AS A REMEDY FOR LOSS OF NERVE POWER. Fifth +Edition, 8vo, 2s. 6d. + +============ + +J. WICKHAM LEGG, F.R.C.P. + +_Assistant Physician to Saint Bartholomew's Hospital and Lecturer on +Pathological Anatomy in the Medical School_. + +I. + +ON THE BILE, JAUNDICE, AND BILIOUS DISEASES. With Illustrations in +chroma-lithography, 719 pages, roy. 8vo, 25s. + +II. + +A GUIDE TO THE EXAMINATION OF THE URINE; intended chiefly for Clinical +Clerks and Students. Fifth Edition, revised and enlarged, with +additional Illustrations, fcap. 8vo, 2s. 6d. + +III. + +A TREATISE ON HAEMOPHILIA, SOMETIMES CALLED THE HEREDITARY HAEMORRHAGIC +DIATHESIS. Fcap. 4to, 7s. 6d. + +============ + +DR. GEORGE LEWIN. + +_Professor at the Fr. With. University, and Surgeon-in-Chief of the +Syphilitic Wards and Skin Disease Wards of the Charite Hospital, +Berlin._ + +THE TREATMENT OF SYPHILIS WITH SUBCUTANEOUS SUBLIMATE INJECTIONS. +Translated by DR. CARL PROEGLE, and DR. E. H. GALE, _late Surgeon +United States Army_. Small 8vo, 7s. + +============ + +LEWIS'S PRACTICAL SERIES. + +Under this title Mr. Lewis purposes publishing a complete Series of +Monographs, embracing the various branches of Medicine and Surgery. + +The volumes, written by well-known Hospital Physicians and Surgeons +recognized as authorities in the subjects of which they treat, are in +active preparation. The works are intended to be of a THOROUGHLY +PRACTICAL nature, calculated to meet the requirements of the general +practitioner, and to present the most recent information in a compact +and readable form; the volumes will be handsomely got up, and issued at +low prices, varying with the size of the works. + +Several volumes are nearly ready, and further particulars will be +shortly announced. + +============ + +LEWIS'S POCKET MEDICAL VOCABULARY. + +[_In the Press._ + +============ + +J. S. LOMBARD, M.D. + +_Formerly Assistant Professor of Physiology in Harvard College_. + +I. + +EXPERIMENTAL RESEARCHES ON THE REGIONAL TEMPERATURE OF THE HEAD, under +Conditions of Rest, Intellectual Activity and Emotion. With +Illustrations, 8vo, 8s. + +II. + +ON THE NORMAL TEMPERATURE OF THE HEAD. 8vo, 5s. + +============ + +WILLIAM THOMPSON LUSK, A.M., M.D. + +_Professor of Obstetrics and Diseases of Women in the Bellevue Hospital +Medical College, &c._ + +THE SCIENCE AND ART OF MIDWIFERY, Second Edition, with numerous +Illustrations, 8vo, 18s. + +============ + +JOHN MACPHERSON, M.D. + +_Inspector-General of Hospitals H.M. Bengal Army (Retired). Author of +"Cholera in its Home," &c._ + +ANNALS OF CHOLERA FROM THE EARLIEST PERIODS TO THE YEAR 1827. With a +map. Demy 8vo, 7s. 6d. + +============ + +DR. V. MAGNAN. + +_Physician to St. Anne Asylum, Paris; Laureate of the Institute._ + +ON ALCOHOLISM, the Various Forms of Alcoholic Delirium and their +Treatment. Translated by W. S. GREENFIELD, M.D., M.R.C.P. 8vo, 7s. 6d. + +============ + +A. COWLEY MALLEY, B.A., M.B., B.CE., T.C.D. + +MICRO-PHOTOGRAPHY; including a description of the Wet Collodion and +Gelatino-Bromide Processes, together with the best methods of Mounting +and Preparing Microscopic Objects for Micro-Photography. With +Illustrations and photograph, crown 8vo, 5s. + +============ + +PATRICK MANSON, M.D., C.M. + +_Amoy, China._ + +THE FILARIA SANGUINIS HOMINIS; AND CERTAIN NEW FORMS OF PARASITIC +DISEASE IN INDIA, CHINA, AND WARM COUNTRIES. Illustrated with Plates and +Charts. 8vo, 10s. 6d. + +============ + +PROFESSOR MARTIN. + +MARTIN'S ATLAS OF OBSTETRICS AND GYNAECOLOGY. Edited by A. MARTIN, Docent +in the University of Berlin. Translated and edited with additions by +FANCOURT BARNES, M.D., M.R.C.P., Physician to the Chelsea Hospital for +Women; Obstetric Physician to the Great Northern Hospital; and to the +Royal Maternity Charity of London, &c. Medium 4to, Morocco half bound, +31s. 6d. net. + +============ + +WILLIAM MARTINDALE, F.C.S. + +_Late Examiner of the Pharmaceutical Society, and late Teacher of +Pharmacy and Demonstrator of Materia Medica at University College._ + +AND + +W. WYNN WESTCOTT, M.B. LOND. + +_Deputy Coroner for Central Middlesex._ + +THE EXTRA PHARMACOPOEIA of Unofficial Drugs and Chemical and +Pharmaceutical Preparations, with References to their Use abstracted +from the Medical Journals and a Therapeutic Index of Diseases and +Symptoms. Third Edition, revised with numerous additions, limp roan, +med. 24mo, 7s., and an edition in fcap. 8vo, with room for marginal +notes, cloth, 7s. [_Now ready._ + +============ + +J. F. MEIGS, M.D. + +_Consulting Physician in the Children's Hospital, Philadelphia._ + +AND + +W. PEPPER, M.D. + +_Lecturer on Clinical Medicine in the University of Pennsylvania._ + +A PRACTICAL TREATISE ON THE DISEASES OF CHILDREN. Seventh Edition, +revised and enlarged, roy. 8vo, 28s. + +============ + +DR. MORITZ MEYER. + +_Royal Counsellor of Health, &c._ + +ELECTRICITY IN ITS RELATION TO PRACTICAL MEDICINE. Translated from the +Third German Edition, with notes and additions by WILLIAM A. HAMMOND, +M.D. With Illustrations, large 8vo, 18s. + +============ + +Wm. JULIUS MICKLE, M.D., M.R.C.P. LOND. + +_Member of the Medico-Psychological Association of Great Britain and +Ireland; member of the Clinical Society, London; Medical Superintendent, +Grove Hall Asylum, London._ + +GENERAL PARALYSIS OF THE INSANE. 8vo, 10s. + +============ + +KENNETH W. MILLICAN, B.A. CANTAB., M.R.C.S. + +THE EVOLUTION OF MORBID GERMS: A Contribution to Transcendental +Pathology. Cr. 8vo, 3s. 6d. + +============ + +E. A. MORSHEAD, M.R.C.S., L.R.C.P. + +_Assistant to the Professor of Medicine in University College, London._ + +TABLES OF THE PHYSIOLOGICAL ACTION OF DRUGS. Fcap, 8vo, 1s. + +============ + +A. STANFORD MORTON, M.B., F.R.C.E. ED. + +_Senior Assistant Surgeon, Royal South London Ophthalmic Hospital._ + +REFRACTION OF THE EYE: Its Diagnosis, and the Correction of its Errors, +with Chapter on Keratoscopy. Second edit., with Illustrations, small +8vo, 2s. 6d. + +============ + +WILLIAM MURRELL, M.D., M.R.C.P., M.R.C.S. + +_Lecturer on Materia Medica and Therapeutics at Westminster Hospital; +Senior Assistant Physician, Royal Hospital for Diseases of the Chest._ + +I. + +WHAT TO DO IN CASES OF POISONING. Fourth Edition, revised and enlarged, +royal 32mo. + +[_In the press._ + +II. + +NITRO-GLYCERINE AS A REMEDY FOR ANGINA PECTORIS. Crown 8vo, 3s. 6d. + +============ + +WILLIAM NEWMAN, M.D. LOND., F.R.C.S. + +_Surgeon to the Stamford Infirmary._ + +SURGICAL CASES: Mainly from the Wards of the Stamford, Rutland, and +General Infirmary, 8vo, paper boards, 4s. 6d. + +============ + +DR. FELIX von NIEMEYER. + +_Late Professor of Pathology and Therapeutics; Director of the Medical +Clinic of the University of Tuebingen._ + +A TEXT-BOOK OF PRACTICAL MEDICINE, WITH PARTICULAR REFERENCE TO +PHYSIOLOGY AND PATHOLOGICAL ANATOMY. Translated from the Eighth German +Edition, by special permission of the Author, by GEORGE H. HUMPHREY, +M.D., and CHARLES E. HACKLEY, M.D., Revised Edition, 2 vols., large 8vo, +36s. + +============ + +C. F. OLDHAM, M.R.C.S., L.R.C.P. + +_Surgeon H.M. Indian Forces; late in Medical charge of the Dalhousie +Sanitarium._ + +WHAT IS MALARIA? and why is it most intense in hot climates? An +explanation of the Nature and Cause of the so-called Marsh Poison, with +the Principles to be observed for the Preservation of Health in Tropical +Climates and Malarious Districts. Demy 8vo, 7s. 6d. + +============ + +G. OLIVER, M.D., M.R.C.P. + +I. + +THE HARROGATE WATERS: Data Chemical and Therapeutical, with notes an the +Climate of Harrogate. Addressed to the Medical Profession. Crown 8vo, +with Map of the Wells, 3s. 6d. + +II. + +ON BEDSIDE URINE TESTING: including Quantitative Albumen and Sugar. +Second edition, revised and enlarged, fcap, 8vo, 2s. 6d. + +============ + +JOHN S. PARRY, M.D. + +_Obstetrician to the Philadelphia Hospital, Vice-President of the +Obstetrical and Pathological Societies of Philadelphia, &c._ + +EXTRA-UTERINE PREGNANCY; Its Causes, Species, Pathological Anatomy. +Clinical History, Diagnosis, Prognosis and Treatment. 8vo, 8s. + +============ + +E. RANDOLPH PEASLEE, M.D., LL.D. + +_Late Professor of Gynoecology in the Medical Department of Dartmouth +College; President of the New York Academy of Medicine, &c., &c._ + +OVARIAN TUMOURS: Their Pathology, Diagnosis, and Treatment, especially +by Ovariotomy. Illustrations, roy. 8vo, 16s. + +============ + +G. V. POORE, M.D., F.R.C.P. + +_Professor of Medical Jurisprudence, University College; Assistant +Physician to, and Physician in charge of the Throat Department of +University College Hospital._ + +LECTURES ON THE PHYSICAL EXAMINATION OF THE MOUTH AND THROAT. With an +Appendix of Cases. 8vo, 3s. 6d. + +============ + +R. DOUGLAS POWELL, M.D., F.R.C.P. LOND. + +_Physician to the Middlesex Hospital, and Physician to the Hospital for +Consumption and Diseases of the Chest at Brompton._ + +DISEASES OF THE LUNGS AND PLEURAE. Third Edition, rewritten and enlarged. +With Illustrations, 8vo. + +[_In preparation._ + +============ + +AMBROSE L. RANNEY, A.M., M.D. + +_Adjunct Professor of Anatomy in the University of New York, etc._ + +THE APPLIED ANATOMY OF THE NERVOUS SYSTEM, being a study of this portion +of the Human Body from a standpoint of its general interest and +practical utility, designed for use as a Text-book and a Work of +Reference. With 179 Illustrations, 8vo, 20s. + +============ + +RALPH RICHARDSON, M.A., M.D. + +_Fellow of the College of Physicians, Edinburgh._ + +ON THE NATURE OF LIFE: An Introductory Chapter to Pathology. Second +Edition, revised and enlarged. Fcap. 4to, 10s. 6d. + +============ + +W. RICHARDSON, M.A., M.D., M.R.C.P. + +REMARKS ON DIABETES, ESPECIALLY IN REFERENCE TO TREATMENT. Demy 8vo, 4s. +6d. + +============ + +SYDNEY RINGER, M.D. + +_Professor of the Principles and Practice of Medicine in University +College; Physician to and Professor of Clinical Medicine in, University +College Hospital._ + +I. + +A HANDBOOK OF THERAPEUTICS. Tenth Edition, 8vo, 15s. + +II. + +ON THE TEMPERATURE OF THE BODY AS A MEANS OF DIAGNOSIS AND PROGNOSIS IN +PHTHISIS. Second Edition, small 8vo, 2s. 6d. + +============ + +FREDERICK T. ROBERTS, M.D., B.SC., F.R.C.P. + +_Examiner in Medicine at the Royal College of Surgeon; Professor of +Therapeutics in University College; Physician to University College +Hospital; Physician to Brompton Consumption Hospital, &c._ + +I. + +A HANDBOOK OF THE THEORY AND PRACTICE OF MEDICINE. Fifth Edition, with +Illustrations, in one volume, large 8vo, 21s. + +II. + +NOTES ON MATERIA MEDICA AND PHARMACY. Fcap. 8vo. [_Nearly ready._ + +============ + +D. B. St. JOHN ROOSA, M.A., M.D. + +_Professor of Diseases of the Eye and Ear in the University of the City +of New York; Surgeon to the Manhattan Eye and Ear Hospital; Consulting +Surgeon to the Brooklyn Eye and Ear Hospital, &c., &c._ + +A PRACTICAL TREATISE ON THE DISEASES OF THE EAR, including the Anatomy +of the Organ. Fourth Edition, Illustrated by wood engravings and +chromo-lithographs, large 8vo, 22s. + +============ + +J. BURDON SANDERSON, M.D., LL.D., F.R.S. + +_Jodrell Professor of Physiology in University College, London._ + +UNIVERSITY COLLEGE COURSE OF PRACTICAL EXERCISES IN PHYSIOLOGY. With the +co-operation of F. J. M. PAGE, B.Sc., F.C.S.; W. NORTH, B.A., F.C.S., +and AUG. WALLER, M.D. Demy 8vo, 3s. 6d. + +============ + +ALDER SMITH, M.B. LOND., F.R.C.S. + +_Resident Medical Officer, Christ's Hospital, London._ + +RINGWORM: Its Diagnosis and Treatment. Second Edition, rewritten and +enlarged. With Illustrations, fcap, 8vo, 4s. 6d. + +============ + +J. LEWIS SMITH, M.D. + +_Physician in the New York Infants' Hospital; Clinical Lecturer on +Diseases of Children in Bellevue Hospital Medical College._ + +A TREATISE ON THE DISEASES OF INFANCY AND CHILDHOOD. Fifth Edition, with +Illustrations, large 8vo, 21s. + +============ + +FRANCIS W. SMITH, M.B., B.S. + +THE LEAMINGTON WATERS; CHEMICALLY, THERAPEUTICALLY AND CLINICALLY +CONSIDERED; with observations on the climate of Leamington. With +Illustrations, crown 8vo, 2s. 6d. + +============ + +JAMES STARTIN, M.B., M.R.C.S. + +_Surgeon and Joint Lecturer to St. Johns Hospital for Diseases of the +Skin._ + +LECTURES ON THE PARASITIC DISEASES OF THE SKIN. VEGETOID AND ANIMAL. +With Illustrations, Crown 8vo, 3s. 6d. + +============ + +LEWIS A. STIMSON, B.A., M.D. + +_Surgeon to the Presbyterian Hospital; Professor of Pathological Anatomy +in the Medical Faculty of the University of the City of New York._ + +A MANUAL OF OPERATIVE SURGERY. With three hundred and thirty-two +Illustrations. Post 8vo, 10s. 6d. + +============ + +HUGH OWEN THOMAS, M.R.C.S. + +I. + +DISEASES OF THE HIP, KNEE, AND ANKLE JOINTS, with their Deformities, +treated by a new and efficient method. With an Introduction by RUSHTON +PARKER, F.R.C.S, Lecturer on Surgery at the School of Medicine, +Liverpool. 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