Finally, I will add a few words about the bromide treatment of epilepsy.
Ulrich was the first to control the bromide saturation or relative bromide content of his epileptic patients; that is to say, the percentage of total halogens in the urine represented by bromides. He found large individual differences as to the optimal individual saturation. Of forty-eight epileptic patients who had been kept free of convulsions for several years by bromide therapy, ten showed a relative bromide content of from 1 to 5 per cent; nineteen, from 5 to 10 per cent; five, from 10 to 15 per cent; eight, from 15 to 20 per cent, and six, from 20 to 25 per cent. Ulricas results probably are the best ever obtained by bromide treatment; a status epilepticus has not occurred with 'his house patients, numbering from 300 to 400, since 1911. These results can be obtained only by a chemical study and control of the patient's urinary or blood bromides. That this method has not been taken up as readily as one would have expected, and as would have been justified, is due to the complexity and methodological difficulties of the Berglunds method, even in Bernoulli's modification, which is used by Ulrich. I hope I have eliminated this difficulty to a great extent by having given a relatively simple technic.
Although my work, to date, with this simplified tcchnic has not been extensive (fifty cases), I feel justified in setting rough standards as to the safety limits of bromide content in the blood serum. I feel that it is not wise to exceed a limit of 125 mg. of sodium bromide per hundred cubic centimeters of serum for the average patient. It seems likely that the bromide tolerance of patients suffering from anemia, malnutrition, cardiorenal disease, and possibly also alcoholism and drug addiction, is lower, and therefore this arbitrary standard may be a little high in these particular cases. On the other hand, in some epileptic patients it is well known that certain factors tend to increase the frequency of convulsions (such as menstruation, unavoidable periods of overwork and excitements, or dietary alterations of salt balance), and under these circumstances it will probably be wise to allow this level of blood bromides to be exceeded. When the blood bromides increase beyond 150 mg. per hundred cubic centimeters of serum, I believe that the patient is liable to intoxication symptoms and therefore speak of bromide content above this figure as the "toxic zone."
As a matter of practical handling of epileptic patients, I recommend the following: It is wise to keep the patient slightly above the lowest level at which his convulsions have disappeared. This slightly increased level will guard against the effect of any sudden increase in salt intake. This will eliminate the possibility of the development of status epilepticus—an ever present serious danger for the epileptic patient. I feel that if convulsions, in the more severe cases, cannot be controlled by bromides up to from 170 to 200 mg. per hundred cubic centimeters of serum, there is no use to attempt to push bromide therapy—in fact, I should advise against maintaining this level for any length of time.
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