This section is from the book "Materia Medica And Therapeutics Inorganic Substances", by Charles D. F. Phillips. Also available from Amazon: Materia medica and therapeutics.
For this malady the bromides are now, by common consent, held to be the most generally reliable remedies. They give the best results in sthenic cases of uncertain causation, when convulsive attacks are very violent, but have not become chronic. Attacks connected with tumor, or injury, or organic lesion, are also more or less relieved, probably in proportion to the amount of hyperoemia present. Dr. Wilks found better results from bromides in traumatic cases than in any other (Medical Times, ii., 1861, p. 635), and Dr. Broadbent noticed the same fact (Lancet, i., 1866, p. 92). Where there is excentric irritation, as in the generative system or the abdominal organs, benefit is almost always obtained, and Dr. Bill has compared the action of bromides in such cases to that of a ligature, interrupting communication between an impression or "aura," and the brain; they seem to diminish not only conductive, but reflex function. In a case in my own practice, where a large uterine fibroid produced alarming epileptiform symptoms, opium invariably increased the spasms, but bromides relieved quickly.
Minor forms of epilepsy, as "petit mal," evidenced by transient vertigo or loss of consciousness, with perhaps some spasm, but not true convulsion, are not so certainly relieved; and when the epileptic attacks occur only, or chiefly, at night, and at long intervals, bromides are not always the best remedies; also in very chronic cases of many years' duration, they can usually do little more than modify the character of the attacks. When the patient has become nerveless and stupid, belladonna has the advantage over bromides, and when there is marked anaemia or profound depression, they are not desirable. Nux vomica, or strychnia, in small doses, will act better, especially if consciousness be not completely lost during the fits. It must be noted, however, that according to statistics recently published by Dr. A. Hughes Bennett, all varieties of the disorder - petit mal, nocturnal or chronic epilepsy - have shown good results in large proportion under bromide treatment (Edinburgh Medical Journal, February 7, 1881).
Supposing the case be one suitable for this, it is important for success that it should be carried out thoroughly, in sufficient doses, and continued sufficiently long. It must not be interrupted as useless in any case, unless distinct evidence of its physiological effect has been obtained without relief to the symptoms. The production of drowsiness, or of a characteristic skin-eruption, may be taken as some guide, but a better one will be found in the degree of insensibility produced in the fauces; if no irritation or retching is caused by touching the uvula or pharynx, then probably the patient is under bromic influence. From 10 to 40 gr. thrice daily is an average limit, more being given at night-time, if necessary. At first, even larger quantities may be required, and many instances of success from very large doses are on record. Puche and other French physicians have given 100 and 200 gr., but not without some vomiting and prostration (Medical Times, i., 1874). Dr. Squibb found 60 gr. act well when less failed; and he notes that, if the medicine needs to be omitted for a time, it should be resumed at the full dose again. Dr. Farquhar-son gave 30 gr. four times daily with benefit, to a child aged five; and Dr. F. Beach, at the Clapton Asylum, commonly gives 15 gr. every two hours for a time, and 1 or 2 dr. during a paroxysm (British Medical Journal, ii., 1877). Thirty grains thrice daily have been taken for twelve years, and although before treatment the patient was incapable of work, he became equal to the conduct of an ordinary business (ibid, p. G55). There was no effect on the sexual power. I have often myself given similar large doses, and for a long period; but there is no one rule to follow, as I have found 10 gr. act as effectively in some cases as 60 gr. in others. Sometimes 5 gr. will cause troublesome acne.
When the attacks are once controlled, a single daily dose of from 2D to 60 gr. will usually suffice to keep up the effect, and may have to be continued for many months or years. Bromide, indeed, has been well called the "food of the epileptic," and sometimes needs to be taken as regularly as food; still, an occasional intermission - one or two days in a week or fortnight - is usually desirable, for thus the effect of the medicine is better preserved, with less injury to the patient. It is necessary to watch carefully its effect on the general health, and to omit it, or at least to lessen the dose, if the skin should be much affected, the extremities become cold, or anaemia, prostration, or diminished sexual power be traced to it. In exceptional cases there has been developed, under bromides, a peculiar general irritability of asthenic character, or even an excited condition resembling mania (Sequin, Voisin). Minor symptoms, such as headache, "stuffiness" of head, lachrymation, and gastric irritation, have been connected with the use of a preparation adulterated with iodide (Legrand du Saulle: Medical Times, i., 1872, p. 319). If during the omission of treatment convulsion threatens to return, bromide should be at once resumed, but perhaps in a different combination.
For weakness or anaemia, quinine or iron may be added with advantage. Strong coffee hinders development of bromism (Echeverria), and arsenic in small doses will prevent or cure bromic acne. The addition of a small quantity of strychnia to the bromide is recommended by Brown-Sequard and by Tyrrell (Medical Times, i., 187.1, p. 36); it certainly should be only in small doses, or it would antagonize the bromide. Nux vomica, in my opinion, holds but a doubtful place in the treatment of epilepsy; it will improve digestion, and give "tone" to a relaxed nerve-system, and relieve convulsive attacks when consciousness is not wholly lost, but in such cases it acts better alone than with bromides.
Several alkaline bromides taken together sometimes act better than any single one (Brown-Sequard), and I have often found advantage from combining the potassium and ammonium salt. General experience has not yet corroborated the observations of Weir Mitchell as to the superior efficacy of the lithium salt, nor of Hammond as to the bromide of calcium, but they may be useful as alternatives. The bromide of sodium is less depressing to the heart than that of potassium, as has been illustrated by Dr. Hollis (Practitioner, 1878).
I cannot speak well of the addition of belladonna, often recommended. That medicine has its own field in cases rather acute in character, difficult to diagnose, but on the border-land between epilepsy and eclampsia. It is especially useful when they are traced to sudden fright, and are attended with congestive headache between the attacks, and again in the eclampsia of robust plethoric children with cerebral congestion; but, when given in combination with bromides, I have found its action unreliable and confusing. Dr. Beaman combined lactucarium and lupulin (Lancet, ii., 1867), and the addition of digitalis has been found valuable (Lancet, ii., 1871, p. 705). I have myself seen excellent results from the last-mentioned in conjunction with bromides, in epilepsy connected with masturbation or nocturnal emissions; it has marked control over such conditions.
I find it best to give the digitalis separately, morning and afternoon, and the bromide at night, and have found this treatment stop the onanism and emissions, and cure the epilepsy. The infusion of digitalis is the best preparation, and should be given in 1/2 to 1 dr. doses.
Charcot recommends the bromide of zinc (British Medical Journal, ii., 1877, p. 132), and Bourneville the bromide of camphor (i., 1877). I have frequently tried the latter compound, but have never seen from it results which could not be better obtained from other bromides, or from camphor separately. Beigel recorded good results from bromide with morphia hypodermically (Medical Times, i., 1869, p. 68), but morphia, when given internally for any length of time, acts injuriously, and when subcutaneously administered for a similar time is still more detrimental.
I am satisfied, from careful and long-continued observation, that opium does not, in any form or combination, cure epilepsy; but when convulsive attacks occur as complications of passing mental disease, it is sometimes helpful, either alone or combined with bromides, for allaying excitement and convulsion for a time, and procuring sleep, but its effects are transient.
The proportion of cures obtained by bromides or their combinations- meaning a cessation of convulsive attacks for from six months to four years or upwards, according to the period that cases remained under observation - has been stated at about one-half for adults, and one-quarter for children (Voisin, Legrand du Saulle); and even if absolute cure be not obtained quite in such proportion, it is so sufficiently often to prove its possibility. Probably, however, in the majority of cases, freedom from attack will be contingent upon more or less continued use of the remedy. In cases that are satisfactory, we see nothing of an effect sometimes mentioned as an objection to the use of bromides, viz., a greater violence of the attacks as they become less frequent. It is true that this occurs sometimes during the natural course of the malady, but it cannot be directly connected with the medicine; on the contrary, this, as a rule, diminishes the severity as well as the frequency of the convulsion.
Binz has suggested that not only the physiological, but also the therapeutical effect of the bromide of potassium is due to the latter agent (potassium), improving the blood-condition, etc. (Practitioner, 1874), and Sanders even states that the chloride of potassium has answered equally well in his hands (Centralblatt fur Medicin, 1868); but, while we agree that some of the depressant effects of bromide of potassium in the circulation might be explained by the known action of potash, its effects on the nervous system cannot be so, and the result of Sequin's observations showed that the use of chloride of potassium increased the attacks in cases which bromide relieved in the proportion of 80 per cent. (Medical Times, i., 1878). The nitrate and bicarbonate of potash have also been proved useless (Anstie: Practitioner, 1874).
In the "Gulstonian Lectures for 1880," Dr. Gowers, stating the results of his experience in the treatment of epilepsy, says that when small doses of the bromide are given to ward off regularly recurring attacks, they should be taken only a short time - two or three hours - before the fits are expected; that they will fail if taken at longer intervals before. Larger doses may, however, be taken then. He has met with many cases in which he has noticed a cumulative effect of the drug, but many others in which, after a time, a tolerance of it, or indifference to it, is attained, and an increase of the dose becomes necessary to obtain the customary result. To control the fits the bromide must be given frequently, but not in larger doses than a drachm or a drachm and a half in the day; but, for the cure of the disease, he considers it necessary to keep the patient for a time under the full influence of the drug, by giving a large dose every two or three days - as much as can be well borne. Gowers has given, in this way, as much as an ounce at a time, but adds the caution not to begin with a larger dose than half that quantity. He considers that only in this way can the "stability of the resistance of the nerve-cells" be reestablished. The drugs that he has found most useful in combination with bromide, where that by. itself has failed, are digitalis (where there is associated cardiac disturbance, or in nocturnal epilepsy), belladonna, cannabis indica (when between the attacks there is persistent headache), and iron.