No. 3010.

MAY 7, 1881.

ABSTRACT OF A

Clinical LectureON THE

TREATMENT OF SOME FORMS OFEPILEPSY.

Delivered at the Hospital for Epilepsy and Paralysis.BY J. S. RAMSKILL, M.D. LOND.,

SENIOR PHYSICIAN TO THE HOSPITAL, CONSULTING PHYSICIAN TO THELONDON HOSPITAL.

CEXTLEMEN,—You will recollect we gave L- thirteengrains of bromide of potassium with eight and then twelvegrains of carbonate of ammonia, besides the zinc pill andthe chloral hydrate and camphor inunction. With respectto ammonia, it has long been known that it increased theaction of iodide, and I think it does the same for bromideof potassium. It has also the advantage of being anantacid and stimulant. It is of great use in cases whereyou administer the iodide and bromide together, and,indeed, in every case where there is much depression. Now,as to bromide of potassium. It is a salt of high diffusivepower, readily entering and quickly leaving the blood. Itshould be given freely diluted, otherwise part escapes fromthe system without getting absorbed. Besides its well-known power of diminishing central irritability, it has asimilar effect on mucous membranes, on the motor andsensory nerves, and even on voluntary muscles. Witnessthe effect of the salt on the fauces and pharynx, on irritablebladder, in which, however, the ammonium is superior tothe potassium salt. The same effect is seen in the mucousmembrane and muscular coat of the stomach and intestine,as evidenced by the gastric catarrh, anorexia, torpor of

intestine, flatulence, &c., and not less indirectly evidentin the manner these evils are removed by capsicum anddouble acids. We would say, then, that the bromides actwherever the blood carries them, sometimes more energeti-cally. Remembering this, I had a tincture of bromidemade after the formula for tincture of iodine, and used it forsimilar indications ; but whether the free bromine was toocaustic, or whether bromine has any action at all in epilepsy,I can only say the combination fails to act after the mannerof the iodide and its tincture. I am still more disappointedwith hydrobromic acid. An acid combination of bromidehas seemed to me a most desirable one, but the potassic saltis decomposed by even vegetable acids. We do, indeed,meet with formulse where dilute hydrochloric and otheracids are mixed with bromide; the resulting mixture canonly be a solution of hydrobromic acid and a potash salt.And solution of hydrobromic acid itself is of little if anyuse, at any rate in moderate doses, in epilepsy.Bromide of lithium is supposed by some to be a more

powerful salt than potassium ; it contains a larger per-centage of bromine than either the sodic or potassic salt, andmay therefore be given in smaller doses. I do not think itbad practice to give the potassic salt for a period, and, whenits action ceases to be protective, to add small doses of thelithium salt. Of the other salts of bromide of magnesium,calcium, starch, they are of no use in epilepsy. You are allaware that in some cases of specific disease large doses ofiodide of potassium are curative ; also that in some few casesvery large doses, having succeeded to a certain point, thensuddenly fail. At this juncture more iodide of potassiumwill not succeed, but the addition of a few drops of tincturemakes a combination which acts magically on specific disease.Remembering this, I have used inunction of the bromides,with oleic acid, with fats, and with vaseline, but after manymonths of steady trial found all useless. Some bromidedid find its way into the system, for traces of it could bediscovered in the urine, but not on any occasion did I suc-ceed in getting absorbed sufficient to protect the patientfrom attacks. Of the various salts, potassium, sodium, andammonium, their therapeutic value in epilepsy may beexpressed as three, two, and one respectively. I think itis manifest that the best epileptic remedies act on

the fauces and throat; witness the bromides, belladonna.atropine, hyoscyamus, stramonium, and clover hay. Perhapsthis observation may some day lead us to discover otheraids to our present therapeutics.Now as to the dose of the potassium salt. For an adult I

have commonly found from forty-nve to sixty grains a dayto be sufficient. That sufficiency is precisely the object tobe aimed at, and beyond the quantity necessary not agrain more should be used, and for reasons to be presentlymentioned. Voisin says that the reflex condition of theepiglottis gives him the key to the difficulty. He says a

therapeutic dose of bromide is not attained until reflexnausea is suppressed on introducing a spoon as far as theepiglottis; it is not till then that the bulb is certainly acted on,and its excitability diminished. This statement is generally,but not always true. I think you may sometimes successfullycombat the attacks without suppressing the condition of reflexnausea, and certainly much more frequently you may producethis condition and not in the least degree affect the numberor violence of the fits. Still, it is a frequent coincidence.In your treatment begin with a fairly sufficient dose-say,for a child of eight to twelve eight grains, for an adult fifteengrains; and observe both the progress of the attacks andthe excito-motory condition of the throat. Recollect, bro-mide has much less power over the petit than the grand mal.The more frequent and violent the fits, the more markedwill be your success. The most difficult kind of case is onein which several minor attacks occur during a month, withan occasional abortive attack in the intervals. Some autho-rities, oeuevmg tne emcacy or tne remedy aepends on itspresence in the blood, give the dose indicated three or fourtimes in the twenty-four hours ; others, depending more onthe vigour of a larger dose, give the whole quantity in oneor in two doses during the day; others recommend the coiii-mencement of the treatment by a small dose, which everyweek is to be increased by a few grains. The objection tothis method lies in the fact that in a few weeks you may begiving far more bromide than is necessary to act successfullyon the bulb, and may produce bromism-a condition inwhich all specific treatment ceases, and a host of miserablesymptoms of your own creation appear usually par’i passuwith a return of the fits. Surely the end of that case isworse than the beginning. I do not say the plan does notsometimes succeed. But it must be stopped or modified onthe first appearance of bromism, otherwise the occurrence ofthis complication is only a matter of time. Sometimes asmall dose of bromide given with care acts badly-that is tosay, with reference to the stomach disorder, which usuallyleads off on the road to bromism. As we used to say in theold mercurial days, "the mercury acts badly-it is setastray"; in other words, the condition of the stomachchiefly, but of the whole system really, was such that themercury acted as a poison. In such a case you must wait,and give general tonics, double acids, and a fair amount ofstimulants. These cases only occur in the aneemic andcachectic. They are rare, for epileptics are not often in badgeneral health. As far, then, as bromide is concerned, youare to solve this problem : to give just as much bromide asmay be necessary to keep off the attacks. Meanwhile youare to improve nutrition and restore mental and bodilyvigour by all and every means at your disposal. Withoutan impaired cerebro-spinal centre, irritable and in a senseweak bulb and neighbourhood, I take it the functional dis-order called epilepsy could not exist; and what is true ofthe cerebro-spinal centre is more or less true of the sympa-thetic and the entire nervous system. The complaint is, inits chronic form at least, a vast neurosis, having one or twofoci or centres of intense irritability, and occasiunal explosiveover-action.The advent of bromide has certainly done infinite mischief

to the advance of therapeutics on epilepsy. I fear that theusual role is just this. To hear the history of the case, toexamine with a view to the discovery of a syphilitic origin,or a coarse cerebral lesion, and, failing to find either, the caseis treated by bromide, and left to bromide, and to the vismedicatrix nat1ll’ae. And the vis medicatrix succeeds, some-times, pillS the bromide, but that is only either in com-paratively recent cases, or where there are no secondaryeccentric causes set up, to keep the primary mischief inthe cerebro-spinal centres alive. I do not see why, if thiswere not so, the natural history of a recent case of epilepsyshould not be towards cure.Returning to L-, our diagnosis was mainly irritable

and explosive action of bulb, exploding in different direc-T

730

tions, at different times, eccentric causes keeping up thiscondition, and coming chiefly vicc the splanchnic from theintestines.We gave bromide to act on the bulb and neighbourhood

especially, to the whole system in a less degree, but theintestine seemed to require additional help. There wasprobably a condition of constriction and dilatation, theresult of local or bowel convulsions, which occurred in theearlier fits. In such a condition we can hardly imagine thefunctions of the abdominal viscera could be carried on with-out continually teasing and vexing the sympathetic. Andof all the regions of the body there is none which reflects sostrongly on the brain. Remember the depression whichoften attends torpid colon, the melancholy attending consti-pation, and a similar condition of colon we are speaking of,common in the experience of alienists.What I wish particularly to say, then, is this that, al-

though this condition of intestine is originally produced bycentric disorder in most cases, it in turn becomes a freshsource of irritation, and keeps up the centric mischief.Whether this be so or not, the treatment founded on thissupposition gives admirable results. The boy takes daily apill with valerianate of zinc, aloes, and conium, in additionto the bromide. The bromide was tried fairly and diminishedthe number of attacks, but when the pill was added theydisappeared. It seems the valerianate of zinc allayed thefrequent spasm of the intestines, and gave tone; the coniumassisted it, and the aloes emptied the bowel in a natural andeffective way. Aided by the bromide the irritable bowelwas calmed and soothed, the weary sympathetic rested, andthe perpetuallv irritated splanchnics carried fewer disorderingmessages to the brain. We have forgotten the inunction ofchloral hydrate and camphor. Read by the light whichexperience gives in other cases, I say that sometimes it

proves of great value ; it is an anodyne, and as an outwardapplication is in the first rank. In neuralgia and localrheumatism it has been of great service in my hands. Itwould be too tedious for you to hear if I recounted all thelocal applications I have made, and the regions where I havemade them, in hundreds of cases of epilepsy, but I cansay that I have not met with such help from any other ex-ternal application as from this. But, like all remedies forepilepsy, it is uncertain. It seems to have most power overthe minor attacks. I have a case where the minor attacksall ceased, and for the first time in the history the full fitwas developed. In another mixed case of major and minorattacks it has abolished the latter without having had theleast effect on the former. In some cases it seems to possessno action whatever; still, I say, it is a valuable help.Whether it acts by continuity of tissue-improbable enough-or by causing some molecular alterations in the periphery ofthe nerves, and occasioning the same alteration in the nerve-trunks or in their nuclei, or by reflex action alone, I cannotdetermine. But I think for many years past we havehad too much metaphysics in epilepsy ; we have forgottenour function as medical men, and the time has come fortherapeutics to claim attention. This boy L-, then,we may look upon as in a fair way of cure. I say so becausewe have had no occasion to increase the dose of bromide orvary its mode of administration. Let me give you anothercase who, like L——, is in the hospital.Mabel M-, aged eleven, was admitted into the hospital

on Nov. 23rd, 1880. Her father is a painter. There is nohistory of fits, paralysis, insanity, or phthisis in the family.Patient has had scarlet, but not rheumatic fever. Her presentillness began when she was five years old. They were saidto be simple fainting fits. She has always a warning of acoming attack. She feels a curious sensation in the epi-gastrium. It does not fly to the head. She says simplyshe is going to have a fit and falls down, as seen in the hos-pital during the fit. She is convulsed on both sides, andit seems to begin bilaterally. Face is not much affected.There is no tongue-biting or micturition. In five minutesafter an attack she says she is all right, but sometimes shesays she has a headache and feels sleepy. In duration theattacks last only a few seconds. In frequency she hasabout three in the week, but sometimes as many in a day.There is no cardiac affection; pupils are large, equal, and reactnormally ; there are no ophthalmoscopic morbid appearances.Her memory is very good, and she is sharp and intelligent forher age. She has frontal headache and some giddiness onthe days when she has no fit, but she never feels sick. Shehas been under medical care, and I doubt not takenbromides. She is a fairly well-formed child, has a large

head for her size, looks cheerful ; none of the aspects oi sr.

epileptic, neither is there anything suggestive of hysteria.On the 24th ten grains of bromide of ammonium were

ordered three times daily, a pill of valerianate of zinc, aloe?,and conium every night, and the ice bag to be worn to thecervical and upper dorsal vertebrae three hours, night andmorning. On the 25th she had five fits of the characte.described above.On January 15th the ice bag was omitted ; the headache

and giddiness had disappeared, and there had been no Hgcof a fit. She was discharged on Feb. 15th, without havingexperienced a single attack since the 25th of November,Meanwhile she had gained weight, and looked and felt ieperfect health.This patient’s history and kind of attacks, her intellectualfreedom, her aspect, form a fair example of a class of casesnot at all uncommon, and in my experience they are

amenable to simple treatment, and make comparativelyquick recoveries. They are cases where a central irritationis kept up by an eccentric cause, and the latter being re-moved, the cerebral irritation is easily combated by theapplication of ice to the sympathetic nerve which issues fromthe last cervical and upper dorsal vertebrae, and by smalldoses of any of the bromides. Let me add a word on thevalue of ice. It it effective in proportion to the youth of thepatient and to the acuteness of the case. It is rarely bene.ficial in the chronic epilepsy of adults.In conclusion, I do not wish to say that all epilepsies have

these secondary exciting causes-that, in other words, everycase is to be treated by valerianate of zinc, aloes, and conium;any more than any case of petit mal is to be successfullymanaged by a treatment of which chloral and camphor in.unction forms a part. Further, I do not object to the lastnew theory of epilepsy, nor in my present frame of mind toany theory which can explain most of the facts. I onlymaintain in these lectures, that what are usually consideredeffects of epilepsy do in time assume the 1’{jle of causes of reopeated attacks, and that the treatment altered to meet thiscontingency is effectual beyond any other treatment adoptedto meet the centric mischief alone.

THE DIAGNOSIS AND TREATMENT OFWHOOPING-COUGH.

BY ROBERT LEE, M.A., M.D., F.R.C.P.,SENIOR ASSISTANT PHYSICIAN TO THE HOSPITAL FOR SICK CHILDREN,

GREAT ORMOND-STREET.

(Concluded from p. 694.)

THE fact of all others which has appeared to me mostsingular, and certainly the most important in diagnosis, isthe frequency with which whooping-cough in very youngchildren is mistaken for some other disorder, that this is

entirely due to the belief that the symptom of the whoopmust be present in order to satisfy the demands of diagnosis.Without the least hesitation, and without the least fear ofexaggeration, I venture to express the opinion that infantswhoop but rarely. Instead of expecting such a symptom, Iam surprised when it occurs in a very young child, and, onreflection, am still more surprised that we should expect itto do so.

Many medical practitioners must have remarked this factafter some experience of family practice, though I couldmention instances of personal friends who have beenastonished that they had not noticed it till their ownchildren were the subjects of their observation. That it waswell known, and carefully noted, years ago is quite evident,since it was stated and taught by Dr. Cullen. " I have hadinstances," he says, " of a disease which, though evidentlyarising from the chin-cough contagion, never put on anyother form than that of a common catarrh." And, again,"when the disease beginning in the form of a catarrh isattended with fever and difficult breathing, and with littleexpectoration, it often proves fatal, without taking on theform of the whooping-cough."

0

Now this is the form which the disease does assume invery young children, and which quite accounts for its beingso dangerous in early life. It is not quite correct to saythat it begins in the form of a catarrh. The disturbance ofthe system is more serious, and, if’the question is asked of