path: root/36474.txt

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. Demy 8vo, 2s.

============

FANCOURT BARNES, M.D., M.R.C.P.

_Physician to the Chelsea Hospital for Women; Obstetric Physician to the
Great Northern Hospital, &c._

A GERMAN-ENGLISH DICTIONARY OF WORDS AND TERMS USED IN MEDICINE AND ITS
COGNATE SCIENCES. Square 12mo, Roxburgh binding, 9s.

============

ROBERTS BARTHOLOW, M.A., M.D., LL.D.

_Professor of Materia Medica and Therapeutics, in the Jefferson Medical
College of Philadelphia, etc., etc._

I.

A TREATISE ON THE PRACTICE OF MEDICINE, FOR THE USE OF STUDENTS AND
PRACTITIONERS. With Illustrations, Fifth Edition, large 8vo, 21s. [_Just
published._

II.

A PRACTICAL TREATISE ON MATERIA MEDICA AND THERAPEUTICS. Fifth Edition,
Revised and Enlarged, 8vo, 18s. [_Just published._

============

GEO. M. BEARD, A.M., M.D. _Fellow of the New York Academy of Medicine;
Member of the American Academy of Medicine, &c._

AND

A. D. ROCKWELL, A.M., M.D.

_Fellow of the New York Academy of Medicine; Member of the American
Academy of Medicine, &c._

A PRACTICAL TREATISE ON THE MEDICAL AND SURGICAL USES OF ELECTRICITY.
Including Localized and General Faradization; Localized and Central
Galvanization; Franklinization; Electrolysis and Galvano-Cautery. Fourth
Edition. With nearly 200 Illustrations, roy. 8vo, 28s. [_Just
published._

============

A. HUGHES BENNETT, M.D.

_Member of the Royal College of Physicians of London; Physician to the
Hospital for Epilepsy and Paralysis, Regent's Park, and Assistant
Physician to the Westminster Hospital_.

I.

A PRACTICAL TREATISE ON ELECTRO-DIAGNOSIS IN DISEASES OF THE
NERVOUS-SYSTEM. With Illustrations, 8vo, 8s. 6d.

II.

ILLUSTRATIONS OF THE SUPERFICIAL NERVES AND MUSCLES, WITH THEIR MOTOR
POINTS, A knowledge of which is essential in the Art of
Electro-Diagnosis. (Extracted from the above). 8vo, paper cover 1s. 6d.,
cloth 2s.

III.

ON EPILEPSY AND ITS TREATMENT. [_In the press._

============

DR. THEODOR BILLROTH.

_Professor of Surgery in Vienna._

GENERAL SURGICAL PATHOLOGY AND THERAPEUTICS. In Fifty-one Lectures. A
Text-book for Students and Physicians. With additions by Dr. ALEXANDER
VON WINIWARTER, Professor of Surgery in Luttich. Translated from the
Fourth German edition with the special permission of the Author, and
revised from the Tenth edition, by C. E. HACKLEY, A.M., M.D. Copiously
illustrated, 8vo, 18s.

============

G. H. BRANDT, M.D.

I.

ROYAT (LES BAINS) IN AUVERGNE, ITS MINERAL WATERS AND CLIMATE. With
Frontispiece and Map. Second edition, crown 8vo, 2s. 6d.

II.

HAMMAM R'IRHA, ALGIERS. A Winter Health Resort and Mineral Water Cure
Combined. 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. Third Edition, 8vo, 25s.

II.

CONTRIBUTIONS TO MEDICINE AND SURGERY:--

    PART 1.--Intestinal Obstruction; with an Appendix on the Action
    of Remedies. 10s.

    PART 2.--The Principles of the Treatment of Joint Disease,
    Inflammation, Anchylosis, Reduction of Joint Deformity, Bone
    Setting. 5s.

    PART 5.--On Fractures of the Lower Jaw. 1s.

    PART 8.--The Inhibition of Nerves by Drugs. Proof that
    Inhibitory Nerve-Fibres do not exist. 1s.

(Parts 3, 4, 6, 7, 9, 10, are expected shortly).

============

J. ASHBURTON THOMPSON, _M.R.C.S._

_Late Surgeon at King's Cross to the Great Northern Railway Company_.

FREE PHOSPHORUS IN MEDICINE WITH SPECIAL REFERENCE TO ITS USE IN
NEURALGIA. A contribution to Materia Medica and Therapeutics. An account
of the History, Pharmaceutical Preparations, Dose, Internal
Administration, and Therapeutic uses of Phosphorus; with a Complete
Bibliography of this subject, referring to nearly 200 works upon it.
Demy 8vo, 7s. 6d.

============

J. C. THOROWGOOD, M.D.

_Assistant Physician to the City of London Hospital for Diseases of the
Chest._

THE CLIMATIC TREATMENT OF CONSUMPTION AND CHRONIC LUNG DISEASES. Third
Edition, post 8vo, 3s. 6d.

============

EDWARD T. TIBBITS, M.D. LOND.

_Physician to the Bradford Infirmary; and to the Bradford Fever
Hospital._

MEDICAL FASHIONS IN THE NINETEENTH CENTURY, including a Sketch of
Bacterio-Mania and the Battle of the Bacilli. Crown 8vo, 2s. 6d.

============

LAURENCE TURNBULL, M.D., PH.G.

_Aural Surgeon to Jefferson Medical College Hospital, &c., &c._

ARTIFICIAL ANAESTHESIA: A Manual of Anaesthetic Agents, and their
Employment in the Treatment of Disease. Second Edition, with
Illustrations, crown 8vo, 6s.

============

W. H. VAN BUREN, M.D., LL.D.

_Professor of Surgery in the Bellevue Hospital Medical College._

DISEASES OF THE RECTUM: And the Surgery of the Lower Bowel. Second
Edition, with Illustrations, 8vo, 14s.

============

RUDOLPH VIRCHOW, M.D.

_Professor in the University, and Member of the Academy of Sciences of
Berlin, &c., &c._

INFECTION--DISEASES IN THE ARMY, Chiefly Wound Fever, Typhoid,
Dysentery, and Diphtheria. Translated from the German by JOHN JAMES,
M.B., F.R.C.S. Fcap. 8vo, 1s. 6d.

============

ALFRED VOGEL, M.D.

_Professor of Clinical Medicine in the University of Dorpat, Russia._

A PRACTICAL TREATISE ON THE DISEASES OF CHILDREN. Translated and Edited
by H. RAPHAEL, M.D. From the Fourth German Edition, illustrated by six
lithographic plates, part coloured, large 8vo, 18s.

============

A. DUNBAR WALKER, M.D., C.M.

THE PARENT'S MEDICAL NOTE BOOK. Oblong post 8vo, cloth, 1s.

============

W. SPENCER WATSON, F.R.C.S. ENG., B.M. LOND.

_Surgeon to the Great Northern Hospital; Surgeon to the Royal South
London Ophthalmic Hospital._

I.

DISEASES OF THE NOSE AND ITS ACCESSORY CAVITIES. Profusely Illustrated.
Demy 8vo, 18s.

II.

EYEBALL-TENSION: Its Effects on the Sight and its Treatment. With
woodcuts, p. 8vo, 2s. 6d.

III.

ON ABSCESS AND TUMOURS OF THE ORBIT. Post 8vo, 2s. 6d.

============

A. DE WATTEVILLE, M.A., M.D., B.SC., M.R.C.S.

_Physician in Charge of the Electro-therapeutical Department at St.
Mary's Hospital._

A PRACTICAL INTRODUCTION TO MEDICAL ELECTRICITY. Second Edition,
re-written and enlarged, copiously Illustrated, 8vo, 9s. [_Just
published._

============

FRANCIS H. WELCH, F.R.C.S.

_Surgeon Major, A.M.D._

ENTERIC FEVER: as Illustrated by Army Data at Home and Abroad, its
Prevalence and Modifications, AEtiology, Pathology and Treatment. 8vo,
5s. 6d.

[_Just published._

============

DR. F. WINCKEL.

_Formerly Professor and Director of the Gynecological Clinic at the
University of Rostock._

THE PATHOLOGY AND TREATMENT OF CHILD-BED: A Treatise for Physicians and
Students. Translated from the Second German edition, with many
additional notes by the Author, by J. R. CHADWICK, M.D. 8vo, 14s.

============

EDWARD WOAKES, M.D. LOND.

_Senior Aural Surgeon and Lecturer on Aural Surgery at the London
Hospital; Senior Surgeon to the Hospital for Diseases of the Throat._

ON DEAFNESS, GIDDINESS AND NOISES IN THE HEAD.

VOL. I.--CATARRH, AND DISEASES OF THE NOSE CAUSING DEAFNESS. With
Illustrations, cr. 8vo, 6s. 6d. [_Just published._

VOL. II.--ON DEAFNESS, GIDDINESS AND NOISES IN THE HEAD. Third Edition,
with Illustrations, cr. 8vo. [_In preparation._

============

E. T. WILSON, B.M. OXON., F.R.C.P. LOND.

_Physician to the Cheltenham General Hospital and Dispensary._

DISINFECTANTS AND HOW TO USE THEM. In Packets of one doz. price 1s.

============

Clinical Charts For Temperature Observations, etc.

    Arranged by W. RINDEN, M.R.C.S. Price 7s. per 100, or 1s. per
    dozen.

    Each Chart is arranged for four weeks, and is ruled at the back
    for making notes of cases; they are convenient in size, and are
    suitable both for hospital and private practice.

============

PERIODICAL WORKS PUBLISHED BY H. K. LEWIS.

THE NEW SYDENHAM SOCIETY'S PUBLICATIONS. Annual Subscription, One
Guinea.

(Report of the Society, with Complete List of Works and other
information, gratis on application.)

ARCHIVES OF PEDIATRICS. A Monthly Journal, devoted to the Diseases of
Infants and Children. Annual Subscription, 12s. 6d., post free.

THE NEW YORK MEDICAL JOURNAL. A Weekly Review of Medicine. Annual
Subscription, One Guinea, post free.

THE THERAPEUTIC GAZETTE.--A Monthly Journal, devoted to the Science of
Pharmacology, and to the introduction of New Therapeutic Agents. Annual
Subscription, 5s., post free.

THE GLASGOW MEDICAL JOURNAL. Published Monthly. Annual Subscription,
20s., post free. Single numbers, 2s. each.

LIVERPOOL MEDICO-CHIRURGICAL JOURNAL, including the Proceedings of the
Liverpool Medical Institution. Published twice yearly, 3s. 6d. each.

THE MIDLAND MEDICAL MISCELLANY AND PROVINCIAL MEDICAL JOURNAL. Annual
Subscription, 7s. 6d., post free.

TRANSACTIONS OF THE COLLEGE OF PHYSICIANS OF PHILADELPHIA. Volumes I to
VI., now ready, 8vo, 10s. 6d. each.

============

*** MR. LEWIS has transactions with the leading publishing firms in
America for the sale of his publications in that country. Arrangements
are made in the interests of Authors either for sending a number of
copies of their works to the United States, or having them reprinted
there, as may be most advantageous.

Mr. Lewis's publications can be procured of any bookseller in any part
of the world.

============

London: Printed by H. K. Lewis, 196 Gower Street, W.C.



Transcriber's Notes


  [***] is used to replace an asterism.

  ============ 12 equal signs replace horizontal rules in text.

  The words 'rewritten' and 're-written' are used interchangeably.

  Page 15

  (In the inter-paroxysmal state). Changed 'interparoxysmal' to
  'inter-paroxysmal'.

  Page 22

  (  11          8           --            3). Changed duplicate case
  '12' to case '11'.

  Page 27

  (were diminished in number). Changed 'dimished' to 'diminished'.

  Page 34

  (4. In 2.3 per cent. the number). Changed duplicate label from '3.' to
  '4.'.

  Page 45

  (and treatment on the other,). Changed 'treatmeat' to 'treatment'.

  (symptoms directly attributable). Changed 'attribuable' to
  'attributable'.

  Page 47

  (long-continued absence). Changed 'continned' to 'continued'.

  Advertisements

  Page 10

  (GERMS: A contribution). Changed 'Contribu-bution' to 'Contribution'.






End of the Project Gutenberg EBook of A Statistical Inquiry Into the Nature
and Treatment of Epilepsy, by Alexander Hughes Bennett

*** END OF THIS PROJECT GUTENBERG EBOOK STATISTICAL INQUIRY--EPILEPSY ***

***** This file should be named 36474.txt or 36474.zip *****
This and all associated files of various formats will be found in:
        https://www.gutenberg.org/3/6/4/7/36474/

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.)


Updated editions will replace the previous one--the old editions
will be renamed.

Creating the works from public domain print editions means that no
one owns a United States copyright in these works, so the Foundation
(and you!) can copy and distribute it in the United States without
permission and without paying copyright royalties.  Special rules,
set forth in the General Terms of Use part of this license, apply to
copying and distributing Project Gutenberg-tm electronic works to
protect the PROJECT GUTENBERG-tm concept and trademark.  Project
Gutenberg is a registered trademark, and may not be used if you
charge for the eBooks, unless you receive specific permission.  If you
do not charge anything for copies of this eBook, complying with the
rules is very easy.  You may use this eBook for nearly any purpose
such as creation of derivative works, reports, performances and
research.  They may be modified and printed and given away--you may do
practically ANYTHING with public domain eBooks.  Redistribution is
subject to the trademark license, especially commercial
redistribution.



*** START: FULL LICENSE ***

THE FULL PROJECT GUTENBERG LICENSE
PLEASE READ THIS BEFORE YOU DISTRIBUTE OR USE THIS WORK

To protect the Project Gutenberg-tm mission of promoting the free
distribution of electronic works, by using or distributing this work
(or any other work associated in any way with the phrase "Project
Gutenberg"), you agree to comply with all the terms of the Full Project
Gutenberg-tm License (available with this file or online at
https://gutenberg.org/license).


Section 1.  General Terms of Use and Redistributing Project Gutenberg-tm
electronic works

1.A.  By reading or using any part of this Project Gutenberg-tm
electronic work, you indicate that you have read, understand, agree to
and accept all the terms of this license and intellectual property
(trademark/copyright) agreement.  If you do not agree to abide by all
the terms of this agreement, you must cease using and return or destroy
all copies of Project Gutenberg-tm electronic works in your possession.
If you paid a fee for obtaining a copy of or access to a Project
Gutenberg-tm electronic work and you do not agree to be bound by the
terms of this agreement, you may obtain a refund from the person or
entity to whom you paid the fee as set forth in paragraph 1.E.8.

1.B.  "Project Gutenberg" is a registered trademark.  It may only be
used on or associated in any way with an electronic work by people who
agree to be bound by the terms of this agreement.  There are a few
things that you can do with most Project Gutenberg-tm electronic works
even without complying with the full terms of this agreement.  See
paragraph 1.C below.  There are a lot of things you can do with Project
Gutenberg-tm electronic works if you follow the terms of this agreement
and help preserve free future access to Project Gutenberg-tm electronic
works.  See paragraph 1.E below.

1.C.  The Project Gutenberg Literary Archive Foundation ("the Foundation"
or PGLAF), owns a compilation copyright in the collection of Project
Gutenberg-tm electronic works.  Nearly all the individual works in the
collection are in the public domain in the United States.  If an
individual work is in the public domain in the United States and you are
located in the United States, we do not claim a right to prevent you from
copying, distributing, performing, displaying or creating derivative
works based on the work as long as all references to Project Gutenberg
are removed.  Of course, we hope that you will support the Project
Gutenberg-tm mission of promoting free access to electronic works by
freely sharing Project Gutenberg-tm works in compliance with the terms of
this agreement for keeping the Project Gutenberg-tm name associated with
the work.  You can easily comply with the terms of this agreement by
keeping this work in the same format with its attached full Project
Gutenberg-tm License when you share it without charge with others.

1.D.  The copyright laws of the place where you are located also govern
what you can do with this work.  Copyright laws in most countries are in
a constant state of change.  If you are outside the United States, check
the laws of your country in addition to the terms of this agreement
before downloading, copying, displaying, performing, distributing or
creating derivative works based on this work or any other Project
Gutenberg-tm work.  The Foundation makes no representations concerning
the copyright status of any work in any country outside the United
States.

1.E.  Unless you have removed all references to Project Gutenberg:

1.E.1.  The following sentence, with active links to, or other immediate
access to, the full Project Gutenberg-tm License must appear prominently
whenever any copy of a Project Gutenberg-tm work (any work on which the
phrase "Project Gutenberg" appears, or with which the phrase "Project
Gutenberg" is associated) is accessed, displayed, performed, viewed,
copied or distributed:

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

1.E.2.  If an individual Project Gutenberg-tm electronic work is derived
from the public domain (does not contain a notice indicating that it is
posted with permission of the copyright holder), the work can be copied
and distributed to anyone in the United States without paying any fees
or charges.  If you are redistributing or providing access to a work
with the phrase "Project Gutenberg" associated with or appearing on the
work, you must comply either with the requirements of paragraphs 1.E.1
through 1.E.7 or obtain permission for the use of the work and the
Project Gutenberg-tm trademark as set forth in paragraphs 1.E.8 or
1.E.9.

1.E.3.  If an individual Project Gutenberg-tm electronic work is posted
with the permission of the copyright holder, your use and distribution
must comply with both paragraphs 1.E.1 through 1.E.7 and any additional
terms imposed by the copyright holder.  Additional terms will be linked
to the Project Gutenberg-tm License for all works posted with the
permission of the copyright holder found at the beginning of this work.

1.E.4.  Do not unlink or detach or remove the full Project Gutenberg-tm
License terms from this work, or any files containing a part of this
work or any other work associated with Project Gutenberg-tm.

1.E.5.  Do not copy, display, perform, distribute or redistribute this
electronic work, or any part of this electronic work, without
prominently displaying the sentence set forth in paragraph 1.E.1 with
active links or immediate access to the full terms of the Project
Gutenberg-tm License.

1.E.6.  You may convert to and distribute this work in any binary,
compressed, marked up, nonproprietary or proprietary form, including any
word processing or hypertext form.  However, if you provide access to or
distribute copies of a Project Gutenberg-tm work in a format other than
"Plain Vanilla ASCII" or other format used in the official version
posted on the official Project Gutenberg-tm web site (www.gutenberg.org),
you must, at no additional cost, fee or expense to the user, provide a
copy, a means of exporting a copy, or a means of obtaining a copy upon
request, of the work in its original "Plain Vanilla ASCII" or other
form.  Any alternate format must include the full Project Gutenberg-tm
License as specified in paragraph 1.E.1.

1.E.7.  Do not charge a fee for access to, viewing, displaying,
performing, copying or distributing any Project Gutenberg-tm works
unless you comply with paragraph 1.E.8 or 1.E.9.

1.E.8.  You may charge a reasonable fee for copies of or providing
access to or distributing Project Gutenberg-tm electronic works provided
that

- You pay a royalty fee of 20% of the gross profits you derive from
     the use of Project Gutenberg-tm works calculated using the method
     you already use to calculate your applicable taxes.  The fee is
     owed to the owner of the Project Gutenberg-tm trademark, but he
     has agreed to donate royalties under this paragraph to the
     Project Gutenberg Literary Archive Foundation.  Royalty payments
     must be paid within 60 days following each date on which you
     prepare (or are legally required to prepare) your periodic tax
     returns.  Royalty payments should be clearly marked as such and
     sent to the Project Gutenberg Literary Archive Foundation at the
     address specified in Section 4, "Information about donations to
     the Project Gutenberg Literary Archive Foundation."

- You provide a full refund of any money paid by a user who notifies
     you in writing (or by e-mail) within 30 days of receipt that s/he
     does not agree to the terms of the full Project Gutenberg-tm
     License.  You must require such a user to return or
     destroy all copies of the works possessed in a physical medium
     and discontinue all use of and all access to other copies of
     Project Gutenberg-tm works.

- You provide, in accordance with paragraph 1.F.3, a full refund of any
     money paid for a work or a replacement copy, if a defect in the
     electronic work is discovered and reported to you within 90 days
     of receipt of the work.

- You comply with all other terms of this agreement for free
     distribution of Project Gutenberg-tm works.

1.E.9.  If you wish to charge a fee or distribute a Project Gutenberg-tm
electronic work or group of works on different terms than are set
forth in this agreement, you must obtain permission in writing from
both the Project Gutenberg Literary Archive Foundation and Michael
Hart, the owner of the Project Gutenberg-tm trademark.  Contact the
Foundation as set forth in Section 3 below.

1.F.

1.F.1.  Project Gutenberg volunteers and employees expend considerable
effort to identify, do copyright research on, transcribe and proofread
public domain works in creating the Project Gutenberg-tm
collection.  Despite these efforts, Project Gutenberg-tm electronic
works, and the medium on which they may be stored, may contain
"Defects," such as, but not limited to, incomplete, inaccurate or
corrupt data, transcription errors, a copyright or other intellectual
property infringement, a defective or damaged disk or other medium, a
computer virus, or computer codes that damage or cannot be read by
your equipment.

1.F.2.  LIMITED WARRANTY, DISCLAIMER OF DAMAGES - Except for the "Right
of Replacement or Refund" described in paragraph 1.F.3, the Project
Gutenberg Literary Archive Foundation, the owner of the Project
Gutenberg-tm trademark, and any other party distributing a Project
Gutenberg-tm electronic work under this agreement, disclaim all
liability to you for damages, costs and expenses, including legal
fees.  YOU AGREE THAT YOU HAVE NO REMEDIES FOR NEGLIGENCE, STRICT
LIABILITY, BREACH OF WARRANTY OR BREACH OF CONTRACT EXCEPT THOSE
PROVIDED IN PARAGRAPH 1.F.3.  YOU AGREE THAT THE FOUNDATION, THE
TRADEMARK OWNER, AND ANY DISTRIBUTOR UNDER THIS AGREEMENT WILL NOT BE
LIABLE TO YOU FOR ACTUAL, DIRECT, INDIRECT, CONSEQUENTIAL, PUNITIVE OR
INCIDENTAL DAMAGES EVEN IF YOU GIVE NOTICE OF THE POSSIBILITY OF SUCH
DAMAGE.

1.F.3.  LIMITED RIGHT OF REPLACEMENT OR REFUND - If you discover a
defect in this electronic work within 90 days of receiving it, you can
receive a refund of the money (if any) you paid for it by sending a
written explanation to the person you received the work from.  If you
received the work on a physical medium, you must return the medium with
your written explanation.  The person or entity that provided you with
the defective work may elect to provide a replacement copy in lieu of a
refund.  If you received the work electronically, the person or entity
providing it to you may choose to give you a second opportunity to
receive the work electronically in lieu of a refund.  If the second copy
is also defective, you may demand a refund in writing without further
opportunities to fix the problem.

1.F.4.  Except for the limited right of replacement or refund set forth
in paragraph 1.F.3, this work is provided to you 'AS-IS' WITH NO OTHER
WARRANTIES OF ANY KIND, EXPRESS OR IMPLIED, INCLUDING BUT NOT LIMITED TO
WARRANTIES OF MERCHANTIBILITY OR FITNESS FOR ANY PURPOSE.

1.F.5.  Some states do not allow disclaimers of certain implied
warranties or the exclusion or limitation of certain types of damages.
If any disclaimer or limitation set forth in this agreement violates the
law of the state applicable to this agreement, the agreement shall be
interpreted to make the maximum disclaimer or limitation permitted by
the applicable state law.  The invalidity or unenforceability of any
provision of this agreement shall not void the remaining provisions.

1.F.6.  INDEMNITY - You agree to indemnify and hold the Foundation, the
trademark owner, any agent or employee of the Foundation, anyone
providing copies of Project Gutenberg-tm electronic works in accordance
with this agreement, and any volunteers associated with the production,
promotion and distribution of Project Gutenberg-tm electronic works,
harmless from all liability, costs and expenses, including legal fees,
that arise directly or indirectly from any of the following which you do
or cause to occur: (a) distribution of this or any Project Gutenberg-tm
work, (b) alteration, modification, or additions or deletions to any
Project Gutenberg-tm work, and (c) any Defect you cause.


Section  2.  Information about the Mission of Project Gutenberg-tm

Project Gutenberg-tm is synonymous with the free distribution of
electronic works in formats readable by the widest variety of computers
including obsolete, old, middle-aged and new computers.  It exists
because of the efforts of hundreds of volunteers and donations from
people in all walks of life.

Volunteers and financial support to provide volunteers with the
assistance they need are critical to reaching Project Gutenberg-tm's
goals and ensuring that the Project Gutenberg-tm collection will
remain freely available for generations to come.  In 2001, the Project
Gutenberg Literary Archive Foundation was created to provide a secure
and permanent future for Project Gutenberg-tm and future generations.
To learn more about the Project Gutenberg Literary Archive Foundation
and how your efforts and donations can help, see Sections 3 and 4
and the Foundation web page at https://www.pglaf.org.


Section 3.  Information about the Project Gutenberg Literary Archive
Foundation

The Project Gutenberg Literary Archive Foundation is a non profit
501(c)(3) educational corporation organized under the laws of the
state of Mississippi and granted tax exempt status by the Internal
Revenue Service.  The Foundation's EIN or federal tax identification
number is 64-6221541.  Its 501(c)(3) letter is posted at
https://pglaf.org/fundraising.  Contributions to the Project Gutenberg
Literary Archive Foundation are tax deductible to the full extent
permitted by U.S. federal laws and your state's laws.

The Foundation's principal office is located at 4557 Melan Dr. S.
Fairbanks, AK, 99712., but its volunteers and employees are scattered
throughout numerous locations.  Its business office is located at
809 North 1500 West, Salt Lake City, UT 84116, (801) 596-1887, email
business@pglaf.org.  Email contact links and up to date contact
information can be found at the Foundation's web site and official
page at https://pglaf.org

For additional contact information:
     Dr. Gregory B. Newby
     Chief Executive and Director
     gbnewby@pglaf.org


Section 4.  Information about Donations to the Project Gutenberg
Literary Archive Foundation

Project Gutenberg-tm depends upon and cannot survive without wide
spread public support and donations to carry out its mission of
increasing the number of public domain and licensed works that can be
freely distributed in machine readable form accessible by the widest
array of equipment including outdated equipment.  Many small donations
($1 to $5,000) are particularly important to maintaining tax exempt
status with the IRS.

The Foundation is committed to complying with the laws regulating
charities and charitable donations in all 50 states of the United
States.  Compliance requirements are not uniform and it takes a
considerable effort, much paperwork and many fees to meet and keep up
with these requirements.  We do not solicit donations in locations
where we have not received written confirmation of compliance.  To
SEND DONATIONS or determine the status of compliance for any
particular state visit https://pglaf.org

While we cannot and do not solicit contributions from states where we
have not met the solicitation requirements, we know of no prohibition
against accepting unsolicited donations from donors in such states who
approach us with offers to donate.

International donations are gratefully accepted, but we cannot make
any statements concerning tax treatment of donations received from
outside the United States.  U.S. laws alone swamp our small staff.

Please check the Project Gutenberg Web pages for current donation
methods and addresses.  Donations are accepted in a number of other
ways including including checks, online payments and credit card
donations.  To donate, please visit: https://pglaf.org/donate


Section 5.  General Information About Project Gutenberg-tm electronic
works.

Professor Michael S. Hart was the originator of the Project Gutenberg-tm
concept of a library of electronic works that could be freely shared
with anyone.  For thirty years, he produced and distributed Project
Gutenberg-tm eBooks with only a loose network of volunteer support.


Project Gutenberg-tm eBooks are often created from several printed
editions, all of which are confirmed as Public Domain in the U.S.
unless a copyright notice is included.  Thus, we do not necessarily
keep eBooks in compliance with any particular paper edition.


Most people start at our Web site which has the main PG search facility:

     https://www.gutenberg.org

This Web site includes information about Project Gutenberg-tm,
including how to make donations to the Project Gutenberg Literary
Archive Foundation, how to help produce our new eBooks, and how to
subscribe to our email newsletter to hear about new eBooks.