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in animals and plants before it could be utilized in nutrition.The cane-sugar stored up in beet-root and in the sugar-caneis changed by ferment-action into invert-sugar before it ispermitted to circulate in the sap, and take part in thenutritive operations of the plant. He found also that ananalogous transformation was requisite before cane-sugarcould be assimilated by animals. He states that whencane-sugar is injected into the blood it circuiates therein asan inert body, and is in no degree used as nutriment by thetissues, but is eventually entirely removed unchanged withthe urine. Cane-sugar is, however, an important article offood, and is consumed by us in large quantities every day ;and we know that when thus consumed it does not behavelike an inert matter, circulating a while in the blood, andthen being eliminated by the kidneys as a waste product. Itis evidently absorbed and assimilated, and must, therefore,somewhere or other be transformed or digested in animals asit is in plants. Reasoning this way, Bernard sought for aninversive ferment for cane-sugar in the alimentary tract ;and after searching in the saliva, in the stomach, and in thepancreas in vain, he at length discovered it in the smallintestine. In the small intestine he found that cane-sugarwas transformed into invert-sugar, and by a similar fermentwith that destined for analogous purposes in yeast, in beet-root, and in the sugar-cane.The transformation of cane-sugar into invert-sugar is

represented bv a verv simple equation :-

The inversive ferment was detected by Bernard in thesmall intestine of dogs, rabbits, birds, and frogs. Balbianifound it in the intestine of the silk-worm. It was recognisedby myself in an extract of the small intestine of the pig, thefowl, and the hare. It does not exist in the large intestine.But, although my observations on this subject coincided

in the main with those of Bernard, I noted two points whichI think merit further attention. The first was that while a

piece of small intestine infused in water yielded a mixturewhich was capable of inverting cane-sugar, the same infusionwhen filtered through paper until it was perfectly clear hadno such power. It seemed as if the inversive ferment didnot pass freely, if at all, into true solution, but remainedattached to some of the formed elements contained in theintestine. The second point I noted was the extreme slow-ness of the action. When cane-sugar was added to the un-filtered infusion of intestine, and the mixture maintained atblood heat, it generally took a couple of hours before a re-ducing effect with the copper test could be obtained. Boththese circumstances reminded one of the action of formedferments, and I could not help thinking that there was heresomething which required clearing up at some future time.

THE

Culstonian LecturesON

EPILEPSY.Delivered before the Royal College of Physicians,

BY W. R. GOWERS, M.D., F.R.C.P.,SENIOR ASSISTANT-PHYSICIAN TO UNIVERSITY COLLEGE HOSPITAL,

PHYSICIAN TO THE NATIONAL HOSPITAL FOR THEPARALYSED AND EPILEPTIC.

LECTURE III.-PART III.

THE treatment of epilepsy is a subject on which numericalanalysis gives little help. A large number of cases are

under observation too short a time to enable the effect ofremedies to be fairly estimated; and of the cases in whichbenefit is derived, we have no means of ascertaining howmany relapse when treatment is discontinued. My notes ofthe result of treatment in this series of cases extend to 562cases only. In the remainder, either the period of observa-tion was too short for a just conclusion to be drawn, or, inthe press of out-patient work, the influence of remedies wasnot noted with sufficient precision. The effect of treatmentis more likely to be recorded when it is distinct and con-

siderable than when it is slight. Hence the following figures

have no relative value. Of the 562 cases, the attacks ceasedwhile the treatment was maintained iu 241; doubtless manyof these relapsed when treatment was discontinued, but in afew I have been able to ascertain that the patients remainedfree from fits even for years after they ceased to take medi.cine. In 266 cases improvement short of arrest was ob.tained ; the fits being reduced in many to 2B’ -, 3, andeven 2h of their former frequency. In 55 cases little im.provement was obtained by any method of treatment.Time forbids me to enter at any length on the details of

treatment, and I can do little more than mention the reo

medies which in this series of cases were of most distinctservice. The subject of possible modes of action it is betterto leave almost untouched. It may be doubted whether arational therapeutics of epilepsy is yet possible. At anyrate, up to the present time remedies used empirically havebeen of most service.Although the results show that we must not only rely

exclusively upon bromides in our treatment of epilepsy,they show also, as might be expected, that on these ourchief trust must still be placed. Of the arrests of fits, 66 percent., and of the improvements short of arrest, 62 per cent,,were due to bromides given alone. Of the three alkalinesalts of bromide, that of potassium deserves, I think, as ithas popularly received, the first place. I have made a care.ful comparison between the salt of sodium and potassium ina series of about fifty cases, substituting the one for theother. In a few cases the sodic salt appeared to do better;in the great majority it was distinctly less useful. Bromideof ammonium possesses slightly more power than bromideof potasium, but this is not greater than the larger quantityof bromine which it contains will account for.The period after its administration at which maximum

effect of a dose of bromide is obtained varies, I believe,with the dose. The larger the dose the longer is maximumeffect deferred; the smaller the dose the sooner does itoccur, and the sooner is its action over. When small dosesare employed in cases in which attacks occur at regulartimes, they should not therefore be given more than two or

three hours before the attack is expected. This is contraryto some opinions which have been expressed, but I haveseveral times known attacks arrested when a dose was givensome two or three hours before the fit was expected, whichwere not arrested when the same dose was given twelvehours earlier.The effect of bromide upon fits appears to be for a time

cumulative, just as is, indeed, its action in causing bromism.Attacks may continue under its administration tor a time,a.nd yet ultimately cease without any increase in the dose,

, On the other hand, still later, tolerance, or rather indiffer.ence, may be established, and attacks which have been fora time arrested may ultimately recur.Drugs which increase reflex action, such as strychnia, are

now believed to do so by lessening the resistance in thenerve-centres involved. Bromide diminishes reflex action,antagonises strychnia, and it is probable that it does so byincreasing the resistance in the centres. If the view above

expressed be correct, that the morbid state in epilepsy is

essentially an instability of the resistance in the cells, it isalso probable that bromide acts by increasing the stabihtyof ofthis resistance.Bromide is commonly administered in a continuous course,

in such moderate doses as will just suffice to keep the fits illcheck. Given thus it needs to be given frequently. I havemore than once observed that a daily quantity which givenin two doses did not quite arrest the fits, arrested them completely when given in three doses. If, therefore, the greaterconvenience of infrequent doses, one or two daily, is pre.ferred, a somewhat larger quantity needs to be given.When bromide is thus given continuously, it has not

seemed to me desirable to increase the daily dose beyond adrachm or a drachm and a half. If this does not arrest thefits, I have very rarely found that larger doses succeed so

. well as the combination of bromide with other drugs. But

. it is, I think, open to question whether this method of ad.ministration, using doses only just sufficient to arrest thefits, is the wisest in all cases. If bromide cures epilepsy,

- as without doubt it does sometimes, it must be by effectinga nutritive change in the nerve-cells corresponding to its

- action, whereby they are rendered permanently more stable.t

That it, or any other drug, does good in epilepsy by in-fluencing the vascular state of the brain, appears to me with-

- out even probable proof. Even if such were its action, wes are only driven back to a similar influence in increasing the

553

stability of the cells of the vaso-motor centre. There are, Of the cases of this series in which it was employed it wasI think, many grounds for the belief that the change in the distinctly useful in ten, but in only three did the attacksnutrition of the cells may be produced more effectually by cease. In three other cases attacks which continued under

subjecting the patientfor a time to the full influence of bromide ceased under bromide and zinc, and in a fourthbromide, giving doses much larger than are needed to arrest they ceased under zinc, digitalis, and bromide. The oxidethe fits, in the hope of producing more readily a permanent of zinc was the form commonly employed. Its nauseatingnutritive change. In giving bromide thus I have preferred influence constitutes a serious drawback to its use, as tolera-

large doses at intervals of two or three days, gradually tion is difficult to establish, and I have rarely succeeded inincreasing the dose until it is as large as can be well borne, giving more than twenty grains a day. Bromide of zinc hasand then diminishing it. The largest single doses which I seemed of small value, and is borne badly. The addition ofhave given in this way have been doses of one ounce. This arsenic to bromide in no case produced any marked effect onin some patients produces slight stupor, sometimes reaching the attacks. It was used in a large number of cases onits maximum on the second day after the dose. In other account of the readiness with which, it was found, thecases it produces very little disturbance beyond headache. bromide rash could be prevented by its use.From the marked differences which patients present in their Bromide of camphor, highly praised by Bourneville, wastolerance, it is not well to begin this method of treatment tried in a considerable number of cases, but without anywith a larger dose than four drachms. good results. Turpentine has been recommended by Dr.The value of the various combinations of bromide with Radcliffe, and I have seen it produce very striking benefit,

other drugs was tested, as far as possible, on a uniform plan. but only in cases of hystero-epilepsy.First, bromide was given alone for several months, and then The use of iron in epilepsy has been discountenanced byadditional drug was added to the same dose of bromide, and high authorities, on grounds which are not altogether beyondthe result watched for several months longer. Of the various question. In rare cases it increased the frequency of attacks;combinations which are in common use, those with digitalis in the majority of cases in which it was used it was borneand belladonna unquestionably deserve, as they have com- without any ill result ; in many the addition of iron to bro-monly received, the first place. Digitalis is one of the oldest mide was attended with a marked and permanent improve-remedies for epilepsy. It was recommended by Parkinson two ment, and in some cases iron alone arrested the fits. Thehundred years ago, and has been perhaps for a still longer series includes 4 cases which ceased under iron only, andtime a popular remedy for this disease in certain rural dis- 8 others in which iron alone was distinctly better than bro-tricts in the west of England. I have met with no case in mide, and 19 cases in which the addition of iron to bromidewhich, given alone, digitalis arrested the fits for more than exercised a marked influence. In no less than 11 cases

a few months, but in several cases it effected very distinct attacks which persisted on bromide, ceased on the additionimprovement. The combination of digitalis and bromide, of iron, and remained absent as long as the treatment washowever, was distinctly more useful than bromide only, in continued.no less than sixty-three cases. In more than half of these, In several inveterate cases of epilepsy in which bromidethirty-seven cases, the attacks ceased under its use, although had no effect, I. have tried borax. In some cases it did nothey had continued under bromide alone. In the cases in good, but in 12 its value was most distinct. I may mentionwhich cardiac disturbance was associated the combination one or two. In one, fits which had continued on bromide andwas almost always superior to bromide alone ; but its use on zinc ceased entirely on borax for three months, and thenis not confined to these cases. Many cases of nocturnal only recurred when the medicine was discontinued. Inand other forms of epilepsy yielded to the combination, another case the fits continued, about one weekly, during threealthough the attacks had continued under bromide, and months’ treatment on bromide and on belladonna. Boraxthis when there was no evidence of cardiac disease. I was then substituted, the fits at once ceased, and for fiveknow of one patient with nocturnal epilepsy who, for two months the patient had not a single fit ; then he had one inyears, under this combination, has not had a single fit, each of the two following months ; the dose of borax wasalthough the attacks occurred every few weeks on bromide increased, and up to the present time, eight months later,only. no other attack has occurred. In a third case, one or twoIn rare cases belladonna alone will arrest attacks. I have attacks occurred once a fortnight on bromide. Borax was sub-

met with only one case in which attacks, which continued stituted, and for five months the patient had not a single fit.on bromide, ceased entirely when belladonna was substi- The doses given have been ten or fifteen grains twice or threetuted, and this was a case with hystero-epileptic symptoms. times a day. It produces in some patients gastro-intestinalThe combination of bromide and belladonna, however, was disturbance, and rarely, a form of dysenteric diarrhoea. Bydistinctly better than bromide alone in 35 cases, and in 15 others it is well borne, and one of my patients has takenof these arrest of the fits was thus obtained. forty-five grains a day for twelve months without theIndian hemp was first employed in epilepsy by Dr. slightest inconvenience, and says that no medicine has ever

Reynolds, and is sometimes of clear valu e. In one case the done him so much good. In cases in which bromide fails,attacks were invariably arrested for many months by its borax certainly deserves a trial.use, recurring only when the patient ceased attendance, but The use of cocculus indicus in epilepsy, recommendedtwice on his resuming attendance the drug instantly arrested by Dujardin-Beaumetz, has lately attracted attention inthe attacks. When bromide was substituted for the Indian consequence of the recommendation of Planat. I havehemp the attacks at once recurred. Combined with bromide tried the alkaloid picrotoxine in a few instances, butit is also sometimes useful, and seems to exercise most in- in only one case has it appeared to do good. Myfluence over attacks in cases in which there is persistent own experience of its use has, however, been small, andheadache. The same fact has seemed true of the combiua- I am very much indebted to my colleague, Dr. Ramskill, fortion with gelseminum, which is occasionally of marked permitting me to mention some interesting results which heservice, has obtained by the hypodermic injection of picrotoxine.The use of opium in epilepsy has long been advocated by His experience of its effect on the fits when given through

Dr. Radcliffe, and in some cases it is certainly effective. The the skin is nearly the same as my own of itd employmentcombination of bromide and morphia I have rarely found by the mouth. In seven cases in which it was injected, into present special advantages. In the status epiiepticus in daily doses of from one to four milligrammes, no beneficialwhich attacks occur with great frequency and severity, and result was obtained ; in most cases, indeed, the attackswhere bromide, even in large doses, was useless, 1 have were rather more frequent and severe. Of course, we arefound small hypodermic injections of morphia of great not justified in assuming that the effect of picrotoxine andservice. of the cocculus indicus itself are identical. A very inter-The combination of bromide with aconite and hydro- esting fact has, however, been ascertained by Dr. Ramskill—

cyanie acid I have also tried, and found in some cases viz., that picrotoxine in larger doses of from fifteen toslightly better than bromide only. The addition of iodide eighteen milligrammes will almost invariably produce a fitto bromide has been lately said to increase its effect. Occa- in twenty or thirty minutes. In one patient, for instancesionally this is true, and in four cases of the series the com- (according to the notes of Mr. Broster, who carried out thebination was distinctly better than bromide ouly, but in experiments), the dose was daily increased, and when moremany other cases it was ineffective. Even in the cases on than five milligrammes were injected a sensation of giddi-the subjects of inherited syphilis it has not appeared of ness followed, similar to that with which the attacks com-special value. menced. The same effect followed larger injections, andZinc unquestionably deserves some of the repute it has when the dose reached eighteen milligrammes a severe

enjoyed for more than a hundred years as an anti-epileptic. I attack occurred thirty minutes later, and an attack always

554

followed the injection of this dose. In another patient asimilar progressive increase of the dose was followed bygiddiness and headache, when eight milligrammes were in-jected. When the dose of fifteen milligrammes was reacheda severe epileptic fit followed. Next day a second dose offifteen milligrammes did not cause a fit, but eighteen milli-grammes, two days later, caused a fit in half an hour. Aftera week’s intermission, twenty-four milligrammes were in-jected, and a severe fit occurred in twenty-five minutes. Ina third patient a fit occurred after one injection of eightmilligrammes, but ten milligrammes next day caused no fit.Fifteen milligrammes, however, were followed by a fit inthirty minutes, and a second injection of the same dose thefollowing day caused a fit in fifteen minutes. Seventeenmilligrammes next day caused a fit in thirty minutes. In afourth patient a single dose of eighteen milligrammes caused,in ten minutes, giddiness and slight dazzling before theeyes, and in thirty minutes there occurred the usual aura oian attack-a sensation of something creeping up the righ1arm to the top of the head, and numbness and twitching inthe right thigh, but no fit followed, although the patieniwas stupid and dull for a time just as after a fit.Among other drugs which I have tried and found useless

I may mention benzoate of soda and nitro-glycerine.In hystero-epilepsy bromides, sometimes useful, fail en

tirely much more frequently than in simple epilepsy, an(the combinations with digitalis and belladonna are also les:frequently useful. Iron, especially guarded by aloes, ioften of the highest value, quite apart from the existence oanæmia, and next to it valerianate of zinc, morphia, amturpentine.High authorities have urged on different grounds that the

diet of epileptics should contain little or no animal food.In a few observations which I have made by keeping apatient under unaltered medicinal treatment for alternateperiods on a diet with and without animal food, I couldobserve no difference in the attacks, except that in onepatient they were slightly more frequent in the periods whenanimal food was excluded, and in one patient hystero-epileptic attacks on ordinary diet became, when meat wasexcluded, severe epileptic fits, and again became hystero-epileptic when animal food was restored.In pure epilepsy the only treatment needed during the

attacks is such care as shall secure the patient, as far aspossible, from injury. It is very different with the attacksof hystero-epilepsy, which, from their character, severity,and long duration, often furnish the attendants with a taskof no small difficulty, and which can, almost always, be cutshort by appropriate treatment. The patients often hurtthemselves during the attacks, and some control is abso-lutely necessary. But, as already stated, restraint tends toincrease the violence and makes the paroxysm last longer.Hence considerable judgment is often required, so to adjustcontrol as to be efficient and not too much. I have seenthese patients put within padded partitions and left alone,but I have never mvself found this necessarv.

The slighter attacks can be arrested by closing the mouthand nose with a towel for some thirty seconds, after Dr. Hare’smethod. The profound effect on the respiratory centre,and the related higher centres, caused by the anoxæmia,seems to arrest the convulsive action. Cold water over thehead is often successful if applied freely; in severe attacksa moderate quantity only excites redoubled violence, whilea second gallon is often more effectual than the first. Thishas the disadvantage of drenching the patient’s head, andoften giving cold. When the mouth is open during theattacks a small quantity of water poured into it is ofteneffectual. A much more convenient and more effectualremedy than water, however, is strong faradisation to theskin; applied almost anywhere it will commonly quicklystop the attack. Of ovarian compression I spoke in thelast lecture. In this country it is rare that ovarianpressure will arrest an attack. In some cases all thesemeans fail, even when thoroughly used, and I have knownsuch attacks go on, in spite of skilled treatment, for severalhours. Chloroform is of little use ; its administration is amatter of extreme difficulty, often impossibility, and theattack is commonly renewed when the influence of theanaesthetic passes off. The remarkable effect of nausea inrelaxing spasm, led me some years ago to try the effect ofinjections of apomorphia, and I have found in it an un-failing means of arresting the attacks. After the injectionof a twelfth of a grain in four minutes with certainty allspasm ceases, and normal consciousness is restored ; in six

minutes the patient will get up and go to the sink; ineight minutes will vomit, and afterwards, except for slightnausea, is well. A twentieth of a grain has the sameaction, but is rather longer in its operation. Moreover, Ihave found that the treatment is, so far as the hysteroidsymptoms are concerned, curative as well as palliative, forthe attacks in many cases ceased after a few paroxysms hadbeen thus cut short.

I regret that in this survey of some points in the clinicalhistory of these diseases it has been necessary to omit allreference’ to many facts regarding symptoms, diagnosis, and

prognosis, which are presented by the series of cases ana.

lysed. I am conscious that as it is, in the details I have in.troduced, I have made a large demand upon your patience.But it is only by ascertaining the facts of these diseases thatwe can hope to learn their nature, or to find the guidancein our PtFnrtq at prevention or at cure.Whatever may have been the nature of the demoniacal

possessions of old, few who have watched an epileptic fit candoubt that they have their representatives among us still.The old power of casting them out has gone from the earth;and it is only by the study of their origin and history, andcareful experiment in their treatment that we can hope toregain over them such power as may still be possible toman. And the present generation has witnessed an advancein the treatment of these diseases, equalled in perhaps noother branch of therapeutics. Thanks to the influence ofone drug, the use of which in epilepsy is due wholly toFellows of this College, hundreds of epileptics have beencured, and thousands are leading useful lives who wouldotherwise have been incapacitated by the disease. Althoughthe condition of many sufferers is still gloomy enough, it isnot without hope, and to them also, we may surely trust,the progress of the recent past is the dawn of a brighterday.

_____________

LecturesON THE

PHYSICAL EXAMINATION OF THEMOUTH AND THROAT.

Delivered to the Junior Class of Clinical Medicine,University College,

BY G. V. POORE, M.D., F.R.C.P.,PROFESSOR OF MEDICAL JURISPRUDENCE, UNIVERSITY COLLEGE; LATE

ASSISTANT PROFESSOR OF CLINICAL MEDICINE; ASSISTANT

PHYSICIAN, AND PHYSICIAN IN CHARGE OF THETHROAT DEPARTMENT OF THE HOSPITAL, ETC.

LECTURE I.THE PHYSICAL SIGNS DERIVABLE FROM THE BREATH,

LIPS, TEETH, AND MOUTH.

GENTLEMEN,-It is my duty to bring to your notice thevarious physical signs of disease which are to be obtainedfrom an examination of the throat and windpipe ; but in-

asmuch as it is impossible to properly examine the throatwithout at the same time examining the mouth and nose,I think I shall be best fulfilling my duty by dealing methodically not only with the throat, but also with the oral andnasal cavities which lie above it.The physical signs met with in these regions of the body

appeal not only to the sight, touch, and hearing, but occa-sionally to the sense of smell as well ; and the first thingwhich forces itself on our attention is often the odour of thebreath.The smell of the brcath is a valuable physical sign, and in

many diseases is so characteristic as to enable the mallof experience to form a diagnosis from it alone withalmost absolute certainty. It is impossible to describethe various odours of the breath; experience alone willenable you to distinguish one from the other, and I shallmerely content myself with cataloguing some of themost distinctive of them. The smell of drink is the mostcommon of all, and in cases of insensibility is often a valuable indication of the cause. It may give a valuable hint as