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to Dr. Richardson's well-known observations on the organic bromides, as they have already been published in these pages.1
I have lately had an opportunity of trying the effect of the sodium salt in various forms of nervous disease, and with results which at all events, I think, justify a more full and complete investigation of its properties before finally assigning it to that limbo of useless drugs which has assumed of late years such unwieldy proportions.
The salt has a pungent saline flavour, is freely soluble in water, and forms a colourless solution. During the course of one evening I took five-and-twenty grains of the bromide upon an empty stomach, in two doses of ten and one of five grains, at intervals of about half an hour. The effect on the pulse and temperature was negative; upon retiring to rest as usual, I experienced a somewhat pleasant drowsy sensation and slept remarkably well, although I awoke several times during the night, as is customary with me. Towards morning, however, I felt a numbness and tingling in both fore-arms and in my right leg: these sensations did not entirely disappear for some hours subsequently. During the operation of the drug, I passed the usual quantity of urine, of normal colour. I ought to state that shortly after each dose of the medicine I experienced a burning sensation at the epigastrium, which quickly passed off. Beyond the above symptoms-pointing principally to a "decreased sensibility of the nerves which govern common sensibility," to use Dr. Richardson's words-of the bromides generally, no special peculiarity was observable in the action of the sodic bromide.
I shall here briefly give my experience of its effects as a remedy in various forms of nervous excitement.
Fred. B. came under my treatment on Nov. 13, 1872, for confirmed epilepsy. He was twenty-one years of age, of a dark sallow complexion; his face was spotted with acne punctata; his eyes somewhat deep-set, and placed closer together than usual. From his early childhood he had been subject to inveterate epileptic attacks, the fits averaging in frequency three or four weekly. For the first month he was treated with halfdrachm doses of the bromide of potassium three times daily, combined with a nightly dose of one-third of a grain of the 1 Practitioner, June 1871.
extract of belladonna. As he still continued to have severe fits occasionally (although their frequency was somewhat diminished), a seton was inserted in the back of his neck. For a short time. subsequently the fits appeared to diminish, both in severity and frequency, under this treatment: he, however, complained of lowness of spirits and general debility. I accordingly, on the 19th December, prescribed a grain of sulphate of iron, and the same quantity of sulphate of zinc, to be taken three times daily. This treatment was only continued a week, as the symptoms returned with all their former severity. I then gave him forty grains of the potassic bromide three times during the twentyfour hours: he, however, had three severe fits in the following week. On January 30, 1873, I added half a drachm of the succus conii to the mixture: the fits, although somewhat diminished in frequency (one occurring once a week upon the average), were severe when they took place. With the exception of a fresh seton inserted into the neck on March 13, no change of treatment was made until May 22. At this period, as the epilepsy continued, I tried the effect of a small dose (three grains) of sodic bromide in water three times daily during the next week he had two fits. On May 29 I increased each dose to fifteen grains: during the following week he had not had a fit, although he stated that he occasionally "fell about." I consider this was probably the result of attacks of the "petit mal;" in other words, the greater evil was transformed to the less. On June 5 I augmented the dose to twenty grains of the salt. The last time I saw him he stated that he had had one fit, and that his general health was much improved. I have detailed this case somewhat fully in order to show that in the sodic bromide I consider we have a powerful remedy in arresting (or at all events diminishing) attacks of epilepsy. The sodium salt appeared in the above case to exert a greater proportional influence in checking the epileptic seizures than did the potassium salt.
In another case, a boy of fourteen years of age, who had been subject to epilepsy since birth, after acquiring the habit of taking ten grains of the potassic bromide in decoction of bark three times daily, with the effect of checking the seizures, was placed upon three-grain doses of the sodium salt in place of other
84 VALUE OF SODIC BROMIDE AS A NERVOUS SEDATIVE.
medicine; and even this small quantity prevented the return of the fits, although he felt much depressed. This depression of spirits I find is a very frequent accompaniment of the exhibition of this salt, and I ascribe it partly to the fact that in all the cases I have or shall have occasion to detail in reference to the action of sodium salt, the watery solution of the drug was invariably used. I have no doubt that any such depression of spirits might be advantageously counteracted by the addition of some tonic, such as cinchona bark, to the daily dose of the bromide, or possibly by the admixture of small quantities of the tincture of Indian hemp, as has been found useful upon the accession of similar symptoms after the exhibition of the potassic bromide. In a third case of epilepsy, a cigar-maker, aged 25, who had occasionally as many as five fits in one day, had no return of the fits after taking daily fifteen grains of the sodium salt in three doses of five grains each; he also suffered from great depression of spirits and a "dull, heavy feeling."
In two cases of nervous excitement induced by mental anxiety the sodium bromide in small doses gave great relief. In a case of vertigo (probably epileptic) it did not seem to relieve the symptoms; whilst in the case of an old man afflicted with insomnia, the watery solution of the salt in ten-grain doses appeared to do positive harm. He was attacked with severe vertigo, fell down in the bed-room, and cut his head.
Notwithstanding these adverse cases, I think we have in sodic bromide a valuable nervous sedative, when it is judiciously used.
"WRITER'S CRAMP:" ITS PATHOLOGY AND
BY G. V. POORE, M.D.,
Assistant Physician to Charing Cross Hospital.
IN considering cases of "Writer's Cramp" we have hithert directed our attention to those instances (as being most common, in which certain muscles have been exhausted by excessive stimulation. It will be advisable, before considering the treatment of this disease, to point out that the irritability of a muscle may be lessened or annulled by causes other than that of over-stimulation, and that when the muscles thus affected are those of pen-prehension, we get a condition not to be distinguished from writer's cramp except by its history. I have lately had an opportunity of examining a gentleman who suddenly experiencec great difficulty in writing. He is a writer in the Civil Service, and while engaged at a competitive examination he found one morning, on beginning his paper, that his handwriting was bad and shaky (much resembling the third sample of writing in the lithograph which accompanied the second part of this paper), that he was able to write only slowly, that he was obliged to grasp his pen very tightly, and that he was unable to adjust his pen between the fingers of his right hand without the help of the left. He experienced very little difficulty in other acts: there was no very evident loss of power in the hand, and on a cursory examination the case might have been mistaken for one of true writer's cramp. A careful examination at once revealed the true cause of his difficulty,
which was paralysis of the ulnar nerve, brought on apparently by prolonged compression by resting the elbow on the table while poring over a book. In this case, some of the normal muscles of pen-prehension were paralysed, and the big flexors of the fingers and thumb were supplying their place. All voluntary power over the interossei and other muscles supplied by the ulnar nerve was quite lost, and it, was found that the reaction of these muscles to electricity was that which is usual in cases of peripheral paralysis; a too ready response to galvanism, but diminished irritability to faradism.
Another case, in some degree resembling the above, is that of a gentleman of independent means, who has been troubled with writer's cramp for thirteen years. He has never done much writing, certainly nothing which would be likely to overtire his muscles; he does not attribute his failure of writing-power to any cause, and cannot say precisely at what period it came on. On testing the power of the hand and arm, it was found that movements involving the use of any of the muscles supplied by the ulnar or musculo-spiral nerves were feebly executed and soon caused fatigue'; and on further testing the electric irritability of the muscles of the hand and fore-arm, it was found that the muscles deriving their nervous supply from the median manifested a normal amount of irritability to both currents, but that those supplied by the musculo-spiral or ulnar responded too much to galvanism, and too little to faradism. The cause of this failure of power was not evident, but the appearance of some coppery spots upon the skin induced me to prescribe iodide of potassium; with what result I have not learnt.
A third case- one of true writer's cramp, but possessing a peculiarity which would remove it from the ordinary category -is that of a gentleman whose failure of power came on two years ago, while engaged in working very hard at writing out a course of lectures. He states that he has always had occasional difficulties in writing, and that even from a boy the act of writing soon fatigued him. One of the muscles most at fault was the long flexor of the thumb, which was not only weak, but visibly wasted. While writing he held his pen very tightly, with the distal phalanx of the thumb kept at a complete right angle with the shaft of the pen. On examining the hands, it