III.AN INQUIRYINTO THEEFFECTS OF THE PROLONGEDADMINISTRATION OF THE BROMIDESIN EPILEPSY.[D]

III.AN INQUIRYINTO THEEFFECTS OF THE PROLONGEDADMINISTRATION OF THE BROMIDESIN 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 ofthis 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 thishas 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 incoördinated. 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, diarrhœa, &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 symptomspeculiar 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 fallacyalready 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 unaffected39, or 76.4 per cent.Physical and mental powers impaired6, or 11.7 per cent.Physical powers alone impaired3, or 5.9 per cent.Mental powers alone impaired2, or 3.9 per cent.General symptoms of neurasthenia13, or 25.4 per cent.Bromide eruption8, or 15.6 per cent.II.For two years (34 cases).Physical and mental powers unaffected28, or 82.3 per cent.Physical and mental powers impaired2, or 5.8 per cent.Physical powers alone impaired1, or 2.9 per cent.Mental powers alone impaired2, or 5.8 per cent.General symptoms of neurasthenia5, or 14.7 per cent.Bromide eruption6, or 17.6 per cent.III.For three years (30 cases).Physical and mental powers unaffected28, or 93.3 per cent.Physical and mental powers impaired1, or 3.3 per cent.Physical powers alone impaired1, or 3.3 per cent.Mental powers alone impaired0, or 0.0 per cent.General symptoms of neurasthenia3, or 10.0 per cent.Bromide eruption3, or 10.0 per cent.IV.For four years (16 cases).Physical and mental powers unaffected12, or 75.0 per cent.Physical and mental powers impaired0, or 0.0 per cent.Physical powers alone impaired2, or 12.5 per cent.Mental powers alone impaired2, or 12.5 per cent.General symptoms of neurasthenia0, or 0.0 per cent.Bromide eruption2, or 12.5 per cent.V.For five years (6 cases).Physical and mental powers unaffected6, or 100.0 per cent.Physical and mental powers impaired0, or 0.0 per cent.Physical powers alone impaired0, or 0.0 per cent.Mental powers alone impaired0, or 0.0 per cent.General symptoms of neurasthenia3, or 50.0 per cent.Bromide eruption0, or 0.0 per cent.VI.For six years (4 cases).Physical and mental powers unaffected4, or 100.0 per cent.Physical and mental powers impaired0, or 0.0 per cent.Physical powers alone impaired0, or 0.0 per cent.Mental powers alone impaired0, or 0.0 per cent.General symptoms of neurasthenia2, or 50.0 per cent.Bromide eruption0, 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 extremelycommon 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 goodspirits. 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 anæmic, 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 fromepilepsy 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 fromepilepsy from infancy, and who for the last five years has takenfour and a half drachmsof the bromides daily—i.e., during that time he has consumed upwards ofeighty poundsof 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 andtreatmenton 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 directlyattributableto the toxic effects of the bromides; and if abnormal conditions do exist, these are the sequelæ of the malady, andnot 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 epilepticthat 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 thelong-continuedabsence 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.

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 ofthis 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 thishas 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 incoördinated. 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, diarrhœa, &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 symptomspeculiar 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 fallacyalready 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 unaffected39, or 76.4 per cent.Physical and mental powers impaired6, or 11.7 per cent.Physical powers alone impaired3, or 5.9 per cent.Mental powers alone impaired2, or 3.9 per cent.General symptoms of neurasthenia13, or 25.4 per cent.Bromide eruption8, or 15.6 per cent.II.For two years (34 cases).Physical and mental powers unaffected28, or 82.3 per cent.Physical and mental powers impaired2, or 5.8 per cent.Physical powers alone impaired1, or 2.9 per cent.Mental powers alone impaired2, or 5.8 per cent.General symptoms of neurasthenia5, or 14.7 per cent.Bromide eruption6, or 17.6 per cent.III.For three years (30 cases).Physical and mental powers unaffected28, or 93.3 per cent.Physical and mental powers impaired1, or 3.3 per cent.Physical powers alone impaired1, or 3.3 per cent.Mental powers alone impaired0, or 0.0 per cent.General symptoms of neurasthenia3, or 10.0 per cent.Bromide eruption3, or 10.0 per cent.IV.For four years (16 cases).Physical and mental powers unaffected12, or 75.0 per cent.Physical and mental powers impaired0, or 0.0 per cent.Physical powers alone impaired2, or 12.5 per cent.Mental powers alone impaired2, or 12.5 per cent.General symptoms of neurasthenia0, or 0.0 per cent.Bromide eruption2, or 12.5 per cent.V.For five years (6 cases).Physical and mental powers unaffected6, or 100.0 per cent.Physical and mental powers impaired0, or 0.0 per cent.Physical powers alone impaired0, or 0.0 per cent.Mental powers alone impaired0, or 0.0 per cent.General symptoms of neurasthenia3, or 50.0 per cent.Bromide eruption0, or 0.0 per cent.VI.For six years (4 cases).Physical and mental powers unaffected4, or 100.0 per cent.Physical and mental powers impaired0, or 0.0 per cent.Physical powers alone impaired0, or 0.0 per cent.Mental powers alone impaired0, or 0.0 per cent.General symptoms of neurasthenia2, or 50.0 per cent.Bromide eruption0, 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 extremelycommon 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 goodspirits. 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 anæmic, 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 fromepilepsy 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 fromepilepsy from infancy, and who for the last five years has takenfour and a half drachmsof the bromides daily—i.e., during that time he has consumed upwards ofeighty poundsof 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 andtreatmenton 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 directlyattributableto the toxic effects of the bromides; and if abnormal conditions do exist, these are the sequelæ of the malady, andnot 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 epilepticthat 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 thelong-continuedabsence 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.

[D]Reprinted from the "Lancet" of May 17th and 24th, 1884.

[D]Reprinted from the "Lancet" of May 17th and 24th, 1884.

[E]See Article II.

[E]See Article II.

[F]Vide preceding paper.

[F]Vide preceding paper.

[G]The usual prescription contained the bromides of potassium and ammonium, fifteen grains of each for a dose.

[G]The usual prescription contained the bromides of potassium and ammonium, fifteen grains of each for a dose.

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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 HÆMOPHILIA, SOMETIMES CALLED THE HEREDITARY HÆMORRHAGIC 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 Charité Hospital, Berlin.THE TREATMENT OF SYPHILIS WITH SUBCUTANEOUS SUBLIMATE INJECTIONS. Translated byDr. Carl Prœgle, andDr. 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 aTHOROUGHLY PRACTICALnature, 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. 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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 Tübingen.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, byGeorge H. Humphrey, M.D., andCharles 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 Gynœcology 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 PLEURÆ. 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:—Part1.—Intestinal Obstruction; with an Appendix on the Action of Remedies. 10s.Part2.—The Principles of the Treatment of Joint Disease, Inflammation, Anchylosis, Reduction of Joint Deformity, Bone Setting. 5s.Part5.—On Fractures of the Lower Jaw. 1s.Part8.—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 ANÆSTHESIA: A Manual of Anæsthetic 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 byJohn 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 byH. 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, Ætiology, 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, byJ. 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. 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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.

June, 1884.

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, byC. 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, &.

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 byS. Tarnier. Translated from the Seventh French Edition byW. 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.

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 Pharmacopœia 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 PHARMACOPŒIA 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 HÆMOPHILIA, SOMETIMES CALLED THE HEREDITARY HÆMORRHAGIC 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 Charité Hospital, Berlin.

THE TREATMENT OF SYPHILIS WITH SUBCUTANEOUS SUBLIMATE INJECTIONS. Translated byDr. Carl Prœgle, andDr. 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 aTHOROUGHLY PRACTICALnature, 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 byW. 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 GYNÆCOLOGY. Edited byA. Martin, Docent in the University of Berlin. Translated and edited with additions byFancourt 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 PHARMACOPŒIA 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 byWilliam 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: AContributionto 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 Tübingen.

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, byGeorge H. Humphrey, M.D., andCharles 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 Gynœcology 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 PLEURÆ. 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:—Part1.—Intestinal Obstruction; with an Appendix on the Action of Remedies. 10s.Part2.—The Principles of the Treatment of Joint Disease, Inflammation, Anchylosis, Reduction of Joint Deformity, Bone Setting. 5s.Part5.—On Fractures of the Lower Jaw. 1s.Part8.—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).

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:—

(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 ANÆSTHESIA: A Manual of Anæsthetic 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 byJohn 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 byH. 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, Ætiology, 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, byJ. 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.

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.

[Just published.

[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. Lewishas 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.

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