Bromine (Br.) and salts-sodium bromide (NaBr) and potassium bromide (KBr.) Dilutions.
THE records of bromine poisonings and some of the provings are not of great value clinically on account of their consisting very largely of the irritant and corrosive effects of the vapour and solution.
A considerable dose caused, in one case, “a very acute burning from tongue to stomach, nausea, retching, salivation, soft unformed stool, abdominal pains, oppressed and painful breathing, violent stitches in lungs on deep breathing, frequent cough and full hard pulse.” Another prover felt the effects chiefly in the respiratory sphere-suffocative cough and gasping for air came on at once (after a dose of five drops in half an ounce of water), constriction of fauces with burning and soreness, nasal catarrh and eructations. Some digestive symptoms similar to those of the above-mentioned prover were also elicited. Weariness and sleepiness, with sensitiveness to cold air and chilliness in the evening when moving were experienced in another case.
Head.-Unilateral headache, either side, with heaviness of eyelids was experienced by some, and pains in the forehead were felt by others, one of whom had a feeling that someone was standing behind him, compelling him to turn and look round.
Experiments on animals bring out the fact that besides the spasmodic respiratory phenomena actual inflammation of bronchi and lungs developed and false membranes were produced. Superficial, difficult, irregular breathing, sneezing, croupy cough and mucous rales were observed. Frothy blood was in the bronchi. Convulsive movements, great prostration and widely dilated pupils were observed before death took place (C.D.P. sub voce).
Nervous System.-The effects on the central nervous system are best observed from the bromine, salts, especially the sodium bromide. The irritability of the cerebral motor areas is notably reduced, so that a stimulus extends its influence much less widely than in the unpoisoned state, ex.gr., localized contractions only occur in place of an epileptiform seizure, and simulation of the back of the throat, usually producing retching induces no such reflex. After very large doses sensory impressions are lessened, amounting ultimately to complete anaesthesia.
The respiration is somewhat slowed, temperature and pulse are reduced, and dull headache and “a feeling of lassitude, fatigue, disinclination for exertion, mental and physical and often muscular weakness” are induced (Cushny op. cit. p.270)
The bromides produce drowsiness,confusion, slowness in grasping ideas and impaired memory. When sleep is induced it is less heavy and less refreshing then from some other sedatives,k excretion is slow, so that headache, languor and apathy are apt to follow their use. Genitourinary reflexes are notably less active; the conjunctival reflex may be abolished.
Bromism is produced by persistence in medicinal doses for a long period. This consists in: (a) skin affections of different kinds especially acne spots in the glands of the skin which may ulcerate; or simple erythema; or a bronzing of the skin may gradually develop; (b) digestive disturbances come on; (c) increased nasal and bronchial secretion occur: (d) definite mental and nervous impairment takes place; memory fails, speech is hesitating, wrong words are used power to study calculate and reason is lessened; a heavy expressionless air comes on, and muscular inco-ordination and tremors occur. From very large doses definite hebetude and drowsiness come on, the pupils are dilated and sluggish, the conjunctival and corneal reflex is diminished and hearing becomes culled. Diminished throat reflexes may result in choking, from passing of fluid or solid particles into the larynx, exciting cough and spasm, though not of very severe degree.
Weakness of limbs comes on with staggering, tremor of arms and hands when muscles are brought into use-like delirium tremens or disseminated spinal sclerosis.
A quotation by Hughes in his Manual is as follows; “As the bromism becomes more profound the patient lies quietly in bed, unable to move, or feel or swallow or speak, with dilated and uncontractile pupils, and scarcely any colour of the skin or face; the extremities grow gradually colder and colder, the action of the heart becomes feebler and slower until it ceases altogether.”
In chronic cases of less advanced degree general body resistance is lowered, laying the patient open to various incidental inflammatory ailments.
Of moderate and small doses bring out other points :-
Vertigo is worse from rapid motion and looking at running water, and may be relieved by bleeding of the nose.
Nose.-Obstinate coryza is caused, the margins of the nostrils become sore, and the nares sore and stuffed up. Violent sneezing paroxysms occur with acrid discharge.
Mouth and Throat.-Stomatitis, tonsillitis, elongated uvula and general swelling of buccal mucosa are present, and are likely to induce spasmodic cough.
Abdomen.-Pain in the abdomen and back, tympanites and painful piles are produced.
Sexual Organs.-These are depressed. Membranous dysmenorrhoea is said to be induced.
Respiratory System.-The larynx is a good deal affected-a sensation of scraping causes dry cough or hawking of mucus, hoarseness and aphonia, croupy breathing and cough, paroxysmal cough on swallowing; oppressed breathing, relieved by walking- these are fairly frequent evidences of its action.
The bronchi and lungs are inflamed even by intravenous injection of the drug; “membranous croup”: is said to have been set up.
When the malady is fully developed patients are sensitive to the cold, especially to draughts, have cold hands and feet, and shivering with yawning.
Very little use seems to have been made of the well defined chronic effects of bromides, the loss of memory, reduced mental alertness and power, apathy, barrel-organ repetition of wards and ideas, &c., and diminished reflex response. The sleep is not refreshing, though it may be better than none at all; bromides are used antipathically in doses from 10 to 30 gr. often with chloral.
The bromides produce prolonged but unrefreshing sleep, the patient waking stupid and sluggish; the head feels as if constricted by a tight band or cap, and is weak, but better for moving about.
Sleep is disturbed by dreams- of the dead, of travel, of quarrelling; and the dreams are vividly remembered. The sexual depression, progressing to impotency, possibly however preceded by transitory excitement if the dose be small, is part of the bromism picture. If this symptom complex is met with owing to other causes, bromine or bromides could with confidence be prescribed.
Respiratory System.-The chief therapeutic use of bromine in this sphere has been-simple laryngitis, membranous laryngitis (diphtheria), bronchitis and pneumonia. Of these the most important is diphtheria. Although the local signs and symptoms fairly well counterfeit “natural” diphtheria due to the Klebs- Loeffler bacillus, it has not been used very extensively and its routine use has led to disappointment, partly probably because the cyanide of mercury is a more exact simile and partly because routine prescription leads to ignoring the constitutional idiosyncrasies of the patient and his modalities. As just implied, inflammation, membranous exudation, constrictive spasm, with the resulting hoarseness, crowing, stridulous breathing, harsh sawing cough, are all reproduced by the drug. This is not enough; the “general” indications must be taken into consideration. If all these symptoms exist in a patient (not poisoned by bromine) the case is probably one of diphtheria, but not necessarily a case for bromine. The chief general indication is that the exciting cause of the attack appears to be getting overheated, and the symptoms are worse in the hot weather and from going from cold into heat. Hot weather, excessive clothing, overheating from exertion in warm weather, followed by slight exposure to draught or cold, bring on the attack. The plethoric and red-faced child who is easily flushed and overheated and is generally worse in all respects (ill or well) from heat and close rooms is a bromide subject. The left side of the pharynx and larynx is oftenest affected. At a late stage where the patient is becoming asphyxiated and intoxicated and has a grey, pale or livid face, bromine may not be called for; at any rate, this facial aspect does not indicate or contra-indicate it. The prostration common to drug and disease furnishes another important indication.
In the same kind of subject simple laryngitis may require bromine. Laryngeal spasm, crowing inspiration due to spasm of the vocal cords, rattling of mucus in larynx and trachea are the symptoms common to most cases of laryngitis, but it is only in those with hyper sensitiveness of the larynx, in which the air inspired feels very cold although the weather is hot, where over heating appears to be the cause of the attack in patients with a hot flushed face, who easily feel the heat in early summer, or on going from cold air into a warm room- it is only in such that bromine is likely to prove the appropriate remedy. In acute cases the larynx may be tender to the touch-this also is a bromine symptom.
Acute coryza with much sneezing, burning in the nostril, even bleeding of the nose, and sensation of the air breathed being very cold though the season is hot, will be amenable to this remedy. This coryza may be accompanied by pyrexia and prostration, and the remedy has been found useful in influenza. The muscular pains of the drug in the dorsal and lumbar regions and the “chills running down the back” to the legs would be additional features calling for its use in influenza, when the stress of the disease falls on the larynx, or occasionally when the lungs are affected. The pains and chills are both worse from walking or moving about.
Ulceration of the nostrils, with hard infiltrated base and with or without false membranes in a “bromine subject” requires this remedy. Ulceration elsewhere, with a hard infiltrated base, and a whitish yellow membrane or film, and a pale greyish colour of the face-in chronic cases-may also require it. The red plethoric aspect of bromine cases is absent in the chronic invalid.
Kent recommends it in ulcer of the stomach; there are pain, vomiting like coffee-grounds, eructations and diarrhoea. Aggravation occurs from eating, from acids, oysters, warm foods and from tobacco smoke.
In a chronic patient apathy, forgetfulness, loss of ideas, aversion to mental exertion, sadness and anxiety are conspicuous in acute cases these features are obscured by the local conditions.
Though the chief effect of bromine is on the larynx it is also clear that it causes bronchitis and pneumonia of the lobar type. It has been praised clinically for both these conditions and it may well be that it has not received the confidence it deserves in that serious condition influenzal pneumonia. The cough calling for it is paroxysmal and suffocative, the breathing tends to have a croupous or whistling sound and the voice to be hoarse as well as weak. It is also worse from dust, and the drug has been used for asthma of sailors on coming ashore, relieved at sea.
Whooping-cough is another disease for which bromine may come under consideration should the seasonal and weather modalities be conspicuous in the attack. In laryngeal and pulmonary tuberculosis, too, it must not be forgotten.
Induration of ulcers has been referred to; this feature is found in lymphatic, and salivary glands for which bromine is suitable, inflamed glands harden but do not suppurate and this may indicate the remedy in some cases of parotitis.
To these features of induration and infiltration are added emaciation, weakness, tremor of limbs, faintness and prostration, and the association of all these forms a group present not only in tuberculosis, but also in cancer, and for cancer in such parts it has accordingly been used. Whether more can be hoped for than relief to pain in suitable cases remains to be proved.
Skin.-Acne of face and back has been successfully treated by bromide of potassium in small ponderable doses.
Sexual Sphere.-In men depressed sexual instincts and power may be treated with good prospects if there are a sufficient number of other bromine symptoms in the patient’s case.
In women the curious symptoms “loud emission of flatus from vagina” has been interpreted to mean that the drug has caused some form of physometra. As this rare condition is due to some mechanical imprisonment of gas in the uterus from septic conditions, the symptom if genuine cannot be regarded as an indication for the use of bromide or bromides in physometra, except in the rare event of the totality of the patient’s symptoms coinciding with those of the drug.
There seems no good reason for doubting the power of bromine to irritate the uterine mucosa, though the supposed analogy of “membranous inflammation” in the respiratory tract cannot be regarded as supporting such a power. The false membrane of “croupous” type bears no resemblance to the thickened endometrium of “membranous dysmenorrhoea.” The drug., however, has a reputation in these cases.
Its usefulness for ovarian cysts, if more than a happy coincidence, must probably rest on its (antipathic) sedative effect on the reproductive organs.
The pronounced effects on the nervous system have not been adequately utilized on the homoeopathic principle. In similar mental states, in some functional paralyses, possibly the early stages of spinal organic conditions and of dementia, it should be borne in mind.
Finally, the headaches of bromine may be utilized in the treatment of migraine or headache associated with respiratory or digestive troubles. They are chiefly left-sided and worse from stooping and sometimes follow or are aggravated by drinking milk.
(1) Ailments in the bromine sphere brought on or aggravated by the patient becoming overheated, or by being in close, overheated rooms; or worse when entering a hot room from the open air, or from excessive clothing. Or alternatively the maladies may be induced by becoming chilled after being in overheated rooms or in hot weather, especially in spring or early summer when changes of temperature are sudden and considerable.
(2) Apathy, sadness and loss of ideas; or anxiety and fretfulness.
(3) Simple laryngitis from “colds” extending down towards the chest, or being part of febrile maladies.
(4) Inspired air feels icy-cold in larynx.
(5) Mobile alae nasi in respiratory affection (ant. t., lyc.)
(6) Diphtheria or diphtheria like complaints arising in the above-named conditions and involving larynx, trachea and pharynx.
(7) Bronchitis and pneumonia.
(8) Asthma of sailors when on shore.
(9) The left side is chiefly affected (lach).
(10) Hard, non-suppurating swelling of lymphatic and salivary glands and thyroid.
(11) Membranous dysmenorrhoea.
(12) The most susceptible subjects are stout blondes with blue eyes and red cheeks.
Close overheated rooms excessive clothing; mild (headache ); air of seashore (asthma of sailors); dust (cough)
Air over the sea (asthma of sailors).