more marked relief is obtained. Thus, a pressure on the carotid in the neck will produce a suspension of the throbbing and the pain, but the effect is only for a time, as the blood apparently soon finds its way to the head by other channels. Although the use of pressure may at the present time have a show of reason, it has no doubt always been adopted at the dictate of nature.Medical Times and Gazette, Jan. 2, 1869, p. 1.

20. ON THE TREATMENT OF EPILEPSY.

By Dr. SAMUEL WILKS, Physician to Guy's Hospital.

As regards the treatment of epilepsy, it must be considered entirely empirical. The term rational can scarcely be introduced even in the minor questions of diet, air, &c. I have certainly known patients reduce their amount of food and drink, especially in the article of meat, and with a corresponding diminution in the number and severity of fits; but on the other hand, I know other cases where a generous diet has been equally necessitated. It is just one of those cases where particular drugs may be of service, and beyond their administration we can do little. If any old woman had the possession of a herb or a salt which could antagonise the disease, her knowledge would be worth more than that of the whole College of Physicians. I am happy to say that this does not apply to many other diseases where the knowledge you have acquired of their nature will serve you far more than all the medicines in the Pharmacopoeia. The remedies, then, are empirical; those that have hitherto been most in vogue have been the metallic tonics. It is remarkable that such class of drugs seem to have more efficiency in morbid states of the nervous system than those which have a more direct physiological effect. In the whole range of nervous affections you will find this to be the case. In my own experience the only remedies of this kind which I have seen useful have been belladonna and nux vomica-drugs having different physiological actions. I have had cases where both remedies have been apparently beneficial. The metals have been used with a certain amount of success from time immemorial, such as arsenic, silver, iron, and zinc. Some years ago I used all these remedies largely amongst the out-patients, and should certainly give the preference to zinc; I know now more than one case of epilepsy where the patient is always better on the resumption of this remedy. If you suspect any local cause in the brain, you may adopt other measures; thus I have seen a case apparently cured by mercury. Those which were benefited by iodide of potassium had no doubt a syphilitic origin.

It was whilst I was examining the effects of the various remedies that I discovered the very superior value of the bromide of potassium. I was at that time trying this remedy against the iodide in bronchocele and some other disorders, and being in the habit of often using the iodide in epilepsy, I substituted the bromide for it. I was at first under the impression that it was acting as an absorbent, and was picking out for its operations those cases where the disease had a syphilitic or local origin; but when the cures came to be numerous, the explanation would not apply, and it was evident that a very valuable specific remedy had been obtained. Various writers had certainly mentioned the drug with a host of others, but only to again lay it on the shelf with them. I was not aware at that time that Sir C. Locock had recommended its use, for it does not appear that his observations had been specially brought before the profession, much less been confirmed by others. As far as I know it was when Sir C. Locock was President of the Royal Medical and Chirurgical Society, on the occasion of Dr. Sieveking reading a paper on epilepsy, that he made the following remarks, and which I quote from the Lancet of May, 1857:-"Some years since he had read in the British and Foreign Medical Review an account of some experiments performed by a German on himself with bromide of potassium. The experimenter had found that when he took ten grains of the preparation three times a day for fourteen days it produced temporary impotency, the virile powers returning after leav

ing off the medicine. He (Dr. Locock) determined to try this remedy in cases of hysteria in young women unaccompanied by epilepsy. He had found it, in doses of from five to ten grains three times a day, of the greatest service. In a case of hysterical epilepsy which had occurred every month for nine years, and had resisted every kind of treatment, he had administered the bromide of potassium. He commenced this treatment about fourteen months since. For three months he gave ten grains of the potassium three times a day. He then reduced the amount, and the patient had no epilepsy since the commencement of the potassium. Out of fourteen or fifteen cases treated by this medicine only one half had failed." It was in the early part of 1860 that I commenced to use it; in the following year about a dozen cases were published in the Medical Times and Gazette, being the first series of cases systematically described (that I can find) in which the remedy had been found eminently successful. It was thus evident that the bromide was not simply supplanting the iodide in the cure of some special form of the complaint, but that the drug had some remarkable influence over the pure and simple form of epilepsy. This has now been confirmed by others, and even by those who had previously merely administered the bromide, as they had done many other remedies, without sufficient trial, and had discarded it. Of course, like every other remedy, its success has been overrated, and thus the disappointment which naturally accompanied the reaction of opinion, more especially when it was employed for almost every disease in the nosology. As regards drugs, then, I should say that zinc and the bromide are the most important; but you will have no lack of opportunity of trying the effects of remedies, for epileptics often insist on being physicked year after year when absolutely nothing is being done for them.

I ought to mention the occasional value of counter-irritants to the back of the neck, and of setons. I well remember two men who some years ago attended at the Hospital, and whilst the seton was open the fits were absent; when this dried up they returned. I have seen other cases of the kind since this time. I have already mentioned the case of a man whose life was saved by bleeding. I do not know that it is a remedy against the disease, but that it acts in the most beneficial manner if the paroxysm is long continued I have no doubt. In the case I referred to, the man had had a succession of fits for some hours, had swallowed nothing, and must shortly have died from congestion of the lungs, had not the lancet relieved his circulation and almost immediately restored him to consciousness. I think it very probable that in those cases in former times which were considered apoplectic, and in which recovery rapidly took place after bleeding, epilepsy was the real disease. I am convinced that I have seen several such, and therefore think they cannot be uncommon. A man, for example, is seized with a fit; you are called to him, and find him comatose, with stertor and apparent paralysis of one side; you consider it to be a case of apoplexy, and recommend bleeding; he soon afterwards recovers his consciousness, and after a few hours the weakness of the limb has passed, and the patient is comparatively well. Whatever the diagnosis, the remedy has succeeded, and thus, in a severe fit of epilepsy which becomes protracted, I have no hesitation at all in recommending you to open a vein. It might appear strange, after declaring that an epileptiform fit may be induced by loss of blood, immediately to recommend venesection as a remedy, but it does not follow that the theory and the treatment are antagonistic, for whatever may be the immediate cause of the seizure the result is a spasm of the chest, which, ending in congestion of the lungs, is best relieved by liberating the blood from the overcharged venous system.

I ought not to forget to mention the remarkable circumstance of our capability of arresting the attack by acting on the spot whence the aura proceeds. If the attacks were due directly to an irritation reflected from one spot, then the removal of this cause would stop the fit, as in the case of the child I mentioned, whose father assured me that the application of laudanum to a sore spot on the face would arrest or mitigate the paroxysm. But when the sensation on the surface is altogether subjective, a great difficulty in the explanation arises; unless we are content with supposing that as one portion

of the brain must be more especially involved in order for the sensation to be felt in one part of the body rather than another, so some external application to that part may cause a corresponding reflection backwards, and arrest the process that had already commenced.-Med. Times and Gazette, Jan. 23, 1869, P. 84.

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21. THE TREATMENT OF EPILEPTIFORM" NEURALGIA IN ITS EARLIER STAGES.

By Dr. FRANCIS E. ANSTIE, Senior Assistant-Physician to the Westminster Hospital. ["Epileptiform" neuralgia is that terrible form of facial neuralgia characterised less by the spasmodic onset of the pains than by the remarkable constitutional and family history which distinguishes the victims of the disease. Trousseau considered that nothing but a temporary alleviation of suffering could be expected.]

There is no doubt that Trousseau's description of spasmodic facial neuralgia, as a disease hopeless of cure, was, at the moment, nearly correct. He is evidently speaking of a malady quite different from the milder neuralgia which may occur at any time of life-a neuralgia which is rare, is confined to certain highly neurotic families, and which, among those families, only attacks a limited number of individuals who have passed the prime of life and entered upon the period of organic degeneration. The pain is of frightful severity, and is all the more difficult to bear because of the agonising suddenness with which it darts through the affected nerve, perhaps aroused by some trifling and necessary muscular movement, such as mastication. That very large doses of opium are required to produce any great impression on the disease, if the medicine be given by the stomach, is also perfectly true. These doses must be continued, and rapidly increased, with the unfailing effect of seriously disordering the functions of digestion and assimilation, And, after all, the best result attainable is, that for a few weeks or months there may be a notable diminution of the severity of the pain; but with the certainty that, sooner or later it will revive in all its intensity, and that then neither opium nor anything else will produce any perceptible impression upon it. The remainder of such a patient's life is rendered additionally miserable, in most cases, by a total derangement of digestion and consequent failure of nutrition.

Now I believe that a very much better result than this may be obtained if the malady be treated, from an early stage, according to the following plan : -1. Counter-irritation of a peculiar kind. 2. Nutritive tonics. 3. Subcutaneous injection of morphia, or of atropia, according to circumstances.

1. Counter-irritation, to be useful in epileptiform facial tic, should not be applied to the branches of the fifth, but to those of the occipital nerve, at the nape of the neck. A blister in the former situation is as often hurtful as useful: in the latter, it is sometimes strikingly effective in gaining a short respite. And this is of very great consequence in this awful disease; for the mere fact of such pain being allowed to continue is itself of the worst possible omen. 2. The assiduous use of cod-liver oil, or of some fatty substitute for it, should be insisted on from the first, and is of the highest consequence. 3. Subcutaneous injection places us in a totally different position towards the use of opium in spasmodic tic. There is no longer any excuse for the use of enormous doses of opium from the first. It will be sufficient to commence with the use of one-sixth of a grain of morphia twice daily, increasing this, if necessary, to one-fourth and one-half a grain: and, in rare cases, to one grain. If this produces, along with the other measures, a notable remission of the pain, it should be cautiously and steadily decreased, as circumstances may admit. In cases where morphia fails, atropia may be tried, in cases commencing at one-sixtieth of a grain. The injection of a less quantity than this would probably be useless in severe tic.

Hopeless as was the cure of the form of neuralgia which I have now described, under Trousseau's plan, or any other which might be directed to the

object of deeply narcotising the patient, the prospect is by no means so cheerless when the subcutaneous injection is employed, with the precautions above mentioned. Although I cannot say that I have ever seen a positive and complete cure of a facial neuralgia setting in under the conditions which have been described as peculiar to this disease, it is certain that the experience of those who have used the subcutaneous method extensively has proved that the attacks may be kept at bay, and their severity greatly mitigated when they occur; with this general result-that the setting in of a facial tic in the latter period of life, even in a patient whose family and constitutional history is of the worst augury, is no longer a fatal warning of life-long and scarce endurable misery. The economy in the necessary use of opium effected by the use of hypodermic rather than gastric administration is enormous; and this not merely for the purpose of producing a given effect by a single dose, but also (which is most important in regard to the preservation of digestion and nutrition) with regard to the rate of increase in the doses.

In the above remarks I have only referred to methods of treatment which are within the reach of every practitioner. It is necessary to state, however, that for those who are so circumstanced as to be able to provide themselves with proper apparatus for the generation of a constant galvanic current, the prospects of effecting good in even the most seemingly hopeless cases of spasmodic facial tic are very greatly increased. Not to dwell, now, on my own more limited experience, I maintain that it is impossible for any candid person to study carefully the treatise of Benedikt without coming to the conclusion that we have in the constant current a remedy capable of effecting much more, in these severe cases, than any treatment by drugs, or any other means. A low-tension current from a Daniell's battery (using from five to fifteen cells, according to circumstances) applied daily in séances of a few minutes, appears sometimes to entirely arrest facial neuralgia of the worst type, and commencing under the most unfavorable omens. Especially may we indulge hope, as it seems to me, in regard to the results which may be obtained from the galvanisation of the sympathetic, in cases which would otherwise afford no rational hopes of more than the most trifling amendment. But on this point I have not space to dwell at length, and any very condensed account of this mode of treatment would be likely to mislead. To those who possess the requisite preliminary knowledge of electricity and electro-physiology, and also the opportunities of providing themselves with the somewhat expensive and troublesome luxury of a really effective constant battery, I would urge the necessity of a careful study of the English treatise of Althaus, and the German treatises of Remak, Benedikt, and Meyer, upon the medical uses of electricity. They will find facts therein which will at once arrest their attention, and engage them seriously in a most important branch of the therapeutics of nerve pain.-Lancet, Jan. 9, 1869, p. 42.

22.-ON THE USE OF BRUCINE IN STOMACHAL EPILEPSY. By Dr. J. SPENCE RAMSKILL, Physician to the Hospital for Paralysis and Epilepsy; Physician to, and Lecturer on Medicine at, the London Hospital.

[Many cases of epilepsy have, as a warning of the coming fit, some disturbance referred to the stomach, such as nausea and flatulence. There may be no proper symptoms of dyspepsia in the intervals between the fits.] Suspension of epileptic attacks is, for many reasons, always desirable. Yet suspension is not cure; and, for the most part, when you cease to give bromide of potassium, the attacks return. Can we prevent these? I think we can often do so by building up the patient, by using means to improve the nutrition of the tissues, of the nervous masses, and of the ganglionic nerves especially; for I hold that a convulsion is an impossibility in a perfectly healthy brain and nervous system; and I think these views should form the basis of all treatment. Is there any tonic remedy of value for this purpose? I think so; and I have found the best in brucine-beyond many

of recognised value. Mr. Tyrrell (of Malvern) has published some cases treated successfully by strychnine. I have used this drug extensively, and when the patient can remain under close observation, or if he be attended by intelligent friends, I should not hesitate in proper cases to recommend its use But there are cases of idiosyncrasy, and small doses will sometimes evoke disagreeable toxic symptoms. I have not been annoyed in this respect with brucine, perhaps because it is a weaker alkaloid, and the patient gets more easily accustomed to its use. Its physiological effects, however, so closely resemble those of strychnia, that it may be taken for granted their therapeutical virtues are the same. I usually order it in a solution made of the same strength as the liquor strychniæ of the Pharmacopoeia, and commence with a dose of ten minims, to be taken twice daily; every third day an addition should be made of five minims to the dose, until from a third to half a grain is reached. If any stiffness of the jaws or other toxic symptoms appear, the dose is to be diminished by five minims, and continued until any new objectionable symptom is manifest; then it is again lessened. You will not find any benefit from either brucine or strychnine, till a full dose is reached; often the reverse effect. As a rule, patients will take twice as much brucine as strychnine, without any necessity for diminishing the dose. After the continuous administration of brucine for a month, I think it well to suspend its use for some days, and then again resume it. I may remind you that Dr. Marshall Hall used strychnine in epilepsy, but he gave it in very small doses, and without success. Given in large doses, and with the precautions already mentioned, I have not met with any case suggesting cumulative action, or suddenly poisonous effect, from the administration of either alkaloid. You will find great satisfaction in giving bromide in large doses at bed-time, at the same time ordering bruciue twice daily; thereby you ensure the sedative action of the bromide, and the tonic effect of brucine on the whole nervous system.-Lancet, Jan. 16, 1869, p. 76.

23.-ON THE TREATMENT OF CHOREA.

By Dr. SAMUEL WILKS, Physician to Guy's Hospital.

It might be thought by the inexperienced that those drugs which exert a physiological action over the nervous system would be those which would arrest the complaint known as chorea, but, as a matter of fact, this is not the case, so that I have almost given up looking for a remedy in the direction of this class of medicines. I do not despair, however, of finding some drug which might counteract that morbid condition of nervous system which is present in very bad cases, but in the absence of such, remedy our ordinary curative means are of little avail, seeing that they can act only slowly and tend to produce a change long after the time at which the acute form of the disease would prove fatal. In these very severe and bad cases we can only hope to preserve the life of the patient sufficiently long for the most approved tonic remedies to act. For example, in such cases as I mentioned just now of children suffering from acute chorea induced by fright, a fatal termination may occur in a few days, and in these the direct sedatives are suggested. Morphia, as far as I have seen, is useless. I can call to mind two cases where large doses were given, but the effect was only transitory. The same with chloroform; the vapour produces but a temporary tranquillising effect, and our experience of it is not encouraging either in chorea or in the allied disorders, tetanus and hydrophobia. I have never seen strychnia of any use in the acute affection; and the same of belladonna and conia. In the less severe cases it is possible that one or two of these medicines may be useful, but I feel convinced that the class of medicines of which I speak-those which have a physiological action on the nervous system-are far less efficacious than the metallic tonics. It would seem that in order to produce a cure, a bracing up or restoration of the original nerve-power is necessary, and that the mere subdual of symptoms in no way tends to cure