The element phosphorus. (P) Atomic weight 30’96. Saturated solution in absolute alcohol. Trituration of red, amorphous phosphorus.
PATHOGENESIS AND PHARMACODYNAMICS.
PHOSPHORUS is very insoluble in water and the body fluids and is therefore absorbed with difficulty when taken in mass, but if dissolved in oil or fats, or when finely divided, it causes symptoms even though administered in very small quantities, and has induced fatal poisoning in man in doses as small as two grains. The vapour of phosphorus is absorbed by the lungs, and it is thought that in chronic poisoning in lucifer match factories the poison gains admittance to the system by this route. Phosphorus does not penetrate the skin and phosphorus burns do not cause phosphorus poisoning. The red, amorphous phosphorus, which is less volatile and also less soluble, does not cause poisoning in the factories in which it is used. Phosphorus when absorbed into the blood produces its effect by its own presence and not through any compounds it may form; when oxidized it loses its specifics properties. It does not act on albumins in solution and has no local irritant effect on the tissues, such as occurs, for instance, with arsenic.
When a poisonous dose is taken nothing happens for several hours, then pain is felt in the stomach with nausea and eructations, which are phosphorescent in the dark, and taste of garlic; later, there is vomiting of bile and perhaps diarrhoea. These symptoms may continue but frequently disappear and for a few days nothing noticeable occurs. Then a second stage comes, vomiting and diarrhoea recur but the vomiting is now of bloody mucus and does not taste or smell of phosphorus as at first, the pain is greater and extends to the liver region and there may be some jaundice. The patient is weak and faint with a small, thready pulse, the liver is enlarged and tender and extends below the ribs, the urine contains fatty casts, blood and hemoglobin, possibly albumin, and there is increased excretion of nitrogen in the form of lactate of ammonia, leucin, tyrosin and also of phosphates, and, if there is jaundice, of bile pigment. Haemorrhages occur from the mucous membranes and under the skin. Finally, collapse and fatal coma come on. In many cases convulsions and delirium occur towards the termination of the poisoning.
“Phossy jaw” is due exposure to the fumes of phosphorus, which gain admission through carious teeth or some lesion of the gums and set up periostitis, which advances rapidly to necrosis of the bone, most markedly in the lower jaw. The prolonged suppuration and hectic fever which result often lead to death from exhaustion. The fumes of phosphorus may also give rise to chronic poisoning, apart from any affection of the jaws, the symptoms of which are cachexia, anaemia, albuminuria, chronic enteritis, bronchitis, and an affection of the bones that causes them to be unusually liable to fracture. That phosphorus fumes cause lesions in other bones that the jaws, lesions that do not proceed to necrosis, makes it probable that necrosis of the jaw when occurring is due to the combined action of phosphorus and of micro-organism which gain access through the carious teeth and injured gums; the subacute periostitis caused by phosphorus is a favorable site for the action of the micro-organisms.
Phosphorus produces fatty infiltration of the cells of many organs, notably of the liver, kidney, gastric and intestinal glands and the muscle fibres of the heart, stomach, intestines, arterioles and often of the skeletal muscles. This does not occur till the second stage of poisoning and is the cause of the symptoms then displayed. The fat in the cells is not formed, as formerly believed, by degeneration of the proteins of the cells in which it is found, but is ordinary fat transported from the positions it normally occupies. The cells in which the fat is deposited eventually degenerate and break up into detritus, so that, though it is primarily an infiltration of fat into the cells that takes place, the term “fatty degeneration,” as applied to the tissues, is not inappropriate.
When phosphorus attacks the liver with extreme violence the condition of “acute yellow atrophy” is produced, a disease of the liver exactly resembling that sometimes caused by chloroform poisoning, and is rapidly fatal. In less severe attacks the liver is first enlarged from swelling of its cells but afterwards contracts owing to destruction of many of the cells, and to proliferation and subsequent contraction of the interstitial connective tissue which occurs as a secondary result of such destruction. Cirrhosis results. This happens not alone in the liver, but also in the stomach and kidneys and is the cause of many of the symptoms occurring in chronic poisoning by phosphorus. This drug alters the functional activity of the liver and prevents the complete oxidation of glycogen, fat and the non- nitrogenous results of protein breakdown, increased quantities of lactic and other acids accumulate and for their neutralization combine with ammonia which, with leucin and tyrosin, is produced in unusually large amount. These are derived from excessive protein metabolism due to phosphorus increasing the activity of the autolytic ferment of the liver.
Phosphorus weakens and slows the heart by the gradual production of fatty degeneration in its muscle fibres, and the fatty degeneration of the muscular coat of the smaller arteries throughout the body is the main cause of the haemorrhages that occur, though a lessened ability of the blood to clot, through deficiency of fibrinogen, may be a contributing cause.
The cells of the central nervous system and those of the peripheral nerves do not seem to be influenced directly by phosphorus, at least no gross changes occur in them and consciousness is preserved almost to the last, but the disordered metabolism, the haemorrhages and the altered function of stomach, liver and kidneys lead to many symptoms of a disordered nervous system. It is probable that phosphorus may in some cases act as a food to nervous tissue, of which it normally forms 1 per cent., when there is a deficiency of that substance in the nerves, in the same way as iron does to the blood when there is a deficiency of hemoglobin in the red cells.
At post-mortem examinations in cases of phosphorus poisoning the blood-vessels of the pia mater were congested with blood, and yellow, opalescent lymph was found collected between the pia and arachnoid; the grey matter was softened.
When phosphorus is given in minute doses it acts as a stimulant to the osteoclasts. Whenever cancellous bone is being formed in cartilage it causes at the growing point the deposit of a layer of dense bone, while at the same time the soft cancellous bone deposited before the phosphorus was taken is gradually absorbed. Consequently the medullary cavity of the bone is enlarged and may extend into the epiphyses. A similar process of absorption occurs in turn in the dense bone formed at first under phosphorus while fresh dense bone is formed in front of it. The Haversian canals are narrowed and the blood-supply to the bone is diminished. Bone deposited from the periosteum shows the same phenomenon. The red corpuscles, in chronic poisoning, are at first increased in later this degenerates and both red and white corpuscles are numbers from stimulation of the activity of the bone-marrow, diminished. In pregnant animals poisoned with phosphorus the drug passes through the placenta, as shown by the foetus undergoing fatty degeneration. The hear is not seriously affected till very late, when fatty infiltration and degeneration occur.
The above is a short summary of the pathology of phosphorus poisoning, which underlies the vast array of symptoms to which the drug gives rise, which symptoms will be most conveniently considered in relation to the diseases for which fatty degeneration of the cells of so many organs and tissues gives it a very wide range of action, and makes it a suitable medicine for many diseases, but, as in the case with all the polychrests, it has certain characteristics of its own that should d be evident in any particular case to ensure confidence in prescribing it. Though phosphorous has no specific pathology of nerve cells, it nevertheless has some noteworthy nervous and mental symptoms.
Mind- The patient suitable for treatment with this remedy is hypersensitive, easily excited by emotional impressions, such as arise from lively company, grief loss of friends or enthusiasm for a cause , but he does not bear the excitement well, suffers from it afterwards and is alternately depressed and apathetic, and these tend to become the dominant moods. He is fearful of many things, afraid of the dark, of being left alone, of things creeping out of corners, respecting the issue of his disease, of thunderstorms. He seems to be physically affected by thunderstorms, and to be very sensitive to electric states of the atmosphere. Many a person accustomed to be in a state of terror during thunderstorms has been enabled to pass through them calmly after treatment with phosphorous. There are anxiety and apprehension, which are often associated with a sensation as of fear at the pit of the stomach, the patient is prostrated buy the least unpleasant impression, or comes over in a heat “as if immersed in hot water,” with perspiring head and hot, perspiring hands, from anything that excites him. He has lascivious thoughts that excite a great desire for sexual intercourse, with corresponding orgasm of the sexual organs, which afterwards gives place to importance, though the mental excitement remains. He may be aroused to anger and violence by anything that vexes him. Anxiety and restlessness are worse at twilight and may be accompanied by palpitation. He is restless over and cannot keep still, and is especially fidgety in the hands. Excitement gives place to lethargy, to a feeling of indifference, to forgetfulness and an inability to fix the mind, and finally to stupor, from which he can be momentarily roused. With stupor there may be low muttering delirium and picking art the bedclothes.
Subjects specially susceptible to phosphorous are tall, slender and delicate looking young people who grow too fast, who are anaemic, with narrow chest and inclined to stoop. They are hypersensitive to light, noise, odours, music and touch. They feel the cold much, like to be magnetized, and to be rubbed, are clairvoyant and may go into a state of ecstasy (see Lachesis).
Nerves.- Provers tremble all over the body from slight causes and are quickly exhausted mentally and physically. The weakness may become paretic, with which there are jerking and twitching of the muscles, especially fibrillary twitchings. Affection of the sensory nervous system is shown by numbness, formication and pain. The pains of phosphorus are cramping tearing, shooting or stitching and burning. Burning sensations may be observed anywhere : in brain, stomach, chest, skin, &c ; burning is felt between the scapulae and a hot wave seems to ascend the spine and travel up to the vertex. Co-ordination is often impaired. A complex of some of the above symptoms often results form over-work, exhaustion from haemorrhages, sexual excesses, prolonged suppuration or chronic diarrhoea, and phosphorus will then be a valuable remedy. It is sometimes indicated for severe nervous diseases, such as cerebral softening, whether primary or following apoplexy, for myelitis and for poliomyelitis. It is especially homoeopathic to pseudo- hypertrophic paralysis, an affection where, without discoverable organic spinal cord disease, there is loss of muscular power, associated with enlargement of the paralysed muscles, due to deposition of fat in them from fatty degeneration of the intermuscular connective tissue and probably of some of the striped muscular fibres also. Phosphorous has proved markedly successful in several cases of this disease.
Some of the mental symptoms suggest “anxiety neurosis” and maniacal attacks such as mania a potu. A kind of stupor from continued fear may develop.
Phosphorus is one of the most useful remedies for giddiness; it is worse in the morning, after meals, and on rising from bed or a seat, and is accompanied by faintness. The giddiness is usually an up-and -down movements, things seem to be moving up and down, or the patient seems to himself to be sinking through the floor; when seated the chair appears to rise.
The headaches for which phosphorous is indicated are congestive headaches. The head feels too full of blood, which seems to mount into it, and is often brought on by mental exertion or excitement, or by working under the heat of a gas jet or too bright a light. Sometimes the heat seems to enter the head from the spine. The pain is dull, pressive or throbbing, and usually is accompanied with a sensation of heat. It may be in the vertex or in the forehead, pressing down over the eyes and to the root of the nose, or a throbbing pain in the temples. The pain is violent and often attended with or preceded by hunger; it is sometimes accompanied by vomiting. It is worse in warm room, from noise, music, jars, masticating, light, warm food, and putting the hands into warm water, and is better from cold air, washing the face with cold water and sitting upright with cold applications pressed on the head. It is to be noted that though the symptoms of phosphorous are generally worse from cold and better from warmth, the reverse holds good for those of the head and stomach. The modality, that the headache is aggravated by putting the hands into hot water, and that it is made worse by physical exertion make it a remedy for “washerwoman’s headache.” The head feels weak, is easily tired, and excitement or grief will bring on a headache of the above description. Headaches such as this may occur in hydrocephalus or meningitis, in fevers and in nervous prostration, and phosphorus will be the suitable remedy. Sometimes prolonged study will bring on a violent headache, which comes as a sudden shock, as if an explosion had occurred in the head, or a splitting headache may be caused by a cough. Periodical headaches may occur every other day from mental exertion, accompanied by heat in the scalp and face, and tension in the face and forehead. A sensation of coldness and stiffness in the back of the head sometimes occurs. Scaly, bald spots appear on the scalp and have suggested the use of this drug for alopecia areata, for which it is a most effectual remedy.
Eyes.-Phosphorus causes numerous eye symptoms and affects all parts of the eye; it induces subacute conjunctivitis with lachrymation, swelling of the lids, suppuration of the meibomian glands, twitching of the eyelids and various disorders of vision. When reading the letters look red, after reading the eyes are painful; black spots or colours pass before them, especially when looking at bright objects. Momentary blindness is experienced, or paroxysms in which everything seems covered with a grey veil; a green halo is seen round the candle. The eyelids tremble and quiver. Phosphorus is therefore indicated in amblyopia and weakness of sight caused by loss of fluids or that come on in states of exhaustion from any cause, such as excess of venery, and in or after typhoid fever. It is useful in glaucoma and for haemorrhages into the retina or vitreous, and for albuminuric retinitis accompanying suppressed menses or Bright’s disease. It is the remedy for blindness caused by electric shock and lightning. It is useful for paralytic weakness of the muscles of the eye. It has been found serviceable in some cases of cataract, and arcus senilis has disappeared when phosphorus has been given for condition of general health indicating it. Meibomian cysts and episcleritis have been cured by it.
Ears.-Phosphorus causes at first hypersensitiveness of hearing and sounds reverberate through the ears, especially music; later, tinnitus and deafness supervene, the deafness being greater for the human voice than for other sounds. It is for this form of deafness that phosphorus is indicated, and such a deafness may occur after exhausting diseases, such as typhoid fever, or in brain diseases like cerebro-spinal meningitis.
Face.-The countenance of the phosphorus patient is sickly looking, earthy or pale, with blue rings round the eyes; or it may present a smooth, waxy appearance like “polished ivory.” With hectic fever circumscribed red spots are seen on the cheeks. The lips are dry, cracked at the corners and a fissure indents the middle of the lower lip. The skin of the face feels tense. Tearing pains and twitchings occur in the cheeks and lower jaw, and there is toothache, with receding gums which easily bleed. Phosphorous is useful for neuralgia of the jaws, threatened or commencing caries of the lower jaw and for toothache, when the gums bleed and the pain is worse from talking and eating and having the hands in hot or cold water. It is a good remedy, to arrest profuse haemorrhage after extraction of teeth. In neuralgia of the face the pain is better from having the head and face wrapped up and sheltered from exposure to wind. It is a useful remedy in inflammation of the parotid gland, especially when there are suppuration and fistulous openings.
Digestion.-With phosphorus the tongue is dry, coated white and swollen, so that it is moved with difficulty and speech is thereby impeded. In typhoid conditions it is yellow, brown or black. Sordes form on the teeth, and aphthous patches, which bleed easily, form on the roof of the mouth and tongue. Saliva is increased and tastes salt or sweet. The throat feels dry and glistens, the tonsils and uvula are swollen and there is a sensation as of cotton or velvet in the throat, with difficult hawking of lumps of white mucus, nearly transparent and feeling cold in the mouth. Pain and burning in the throat extend down the oesophagus, in which there may be spasmodic stricture. There is a bitter or sour taste in the mouth after a meal, especially after taking milk. Thirst is intense in both acute and chronic states and is for cold, juicy and refreshing drinks, for wine and sour things. Food when taken often comes up immediately, as if it had never been swallowed, it seems to get to the lower end of the oesophagus and then to be returned by a reversed peristalsis, coming up unchanged into the mouth as in rumination. The phosphorus patient is a hungry patient, cannot go long without food, if he does he feels utterly faint and exhausted and must have food to relieve this state, he does not want much at a time but must have it often. Hunger returns soon after a meal and he becomes very hungry at night and cannot rest until he has roused up and eaten something.
Risings are frequent and generally empty, or are sour and taste of food. There may be nausea coincident with hunger, which disappears after eating or drinking cold water, but as soon as the water or food becomes warm in the stomach it is thrown up. This is very characteristic of phosphorus vomiting; the desires are all for cold things-for cold food, for ice-cream or ice- water-which relieve temporarily, but as soon as they become warm are violently rejected. There is craving for salt (nat. mur.), and phosphorus relieves illness due to excessive indulgence in salt. The vomited matters are of food, of sour fluids, bile and mucus, or of blood, with black “coffee grounds” substances. There are distension and pain in the pit of the stomach, burning in the same locality, or pressure as of a hard substance there. There is sometimes a severe sinking or “gone” feeling in the stomach, and this may be worse at 11 a.m. (sulph.).
As phosphorus produces pathologically fatty degeneration of the Epithelial cells of the stomach and intestines and their glands, it is more likely to be useful in chronic than in acute affections of the stomach. It is useful in four different conditions: (1) Atonic dyspepsias occurring in broken-down constitutions, in debility following acute diseases, or in pregnancy, anaemia, and similar conditions where there is lowering of the general health. (2) In gastritis and ulceration of the stomach, where there occur “coffee grounds” and bloody vomit, great thirst and excruciating pains running through to the back. (3) In cancer of the stomach, where the vomited matters are of bloody mucus, “coffee grounds,” and are offensive, the stomach may be greatly distended from pyloric obstruction. It is not intended to suggest that phosphorus will do away with the necessity of surgical interference in such cases. It will certainly relieve some of the distress, improve the patient’s condition and facilitate recovery after operation. (4) In gastralgia when the general conditions are similar to those of atonic dyspepsia, but the pain will be greater, will be more periodic, and will often be relieved temporarily by food, especially cold food. In irritative conditions of the stomach, where it empties too quickly, phosphorus may be called for.
It causes enlargement and tenderness of the liver, and is a good remedy for hepatitis, acute or chronic; it is especially indicated in the stage of suppuration with hectic fever and night sweats. Enlargement if followed by cirrhosis, for which, again, phosphorus is useful, as it is for jaundice accompanying either or both these complaints, and for malignant jaundice; there are shooting pains over the liver region and painful pulsations in the right hypochondrium, aggravated by lying on the right side. It is useful in catarrhal jaundice, and in jaundice caused by emotions, such as anger and excitement. Phosphorus is the remedy to be given in acute yellow atrophy of the liver, and for the similar condition occurring from chloroform poisoning. It will also act as a prophylactic against post-operative vomiting when chloroform is to be the anesthetic used, and should be given in two or three doses of a high dilution during the twelve hours preceding the operation. It is a valuable remedy in the enlarged, fatty livers of beer drinkers, and in the waxy liver of prolonged suppuration.
The principal symptoms occurring in the abdomen from phosphorus are a sensation of great emptiness, weakness and coldness, which is worse after a stool and from walking, and a gurgling, which begins in the stomach, rolls audibly through the intestines, and is attended with involuntary stool. The abdomen is very sensitive, and flaccid , or there is tympanites, mostly over the caecum and transverse colon. There are pinching and tearing pains, with urgent desire to evacuate, and diarrhoea. Diarrhoea is one of several varieties and is always very exhausting to the patient. It may be profuse, pouring from the rectum as from a hydrant, i.e., in a steady stream without any considerable admixture of flatus, with lumps of white mucus, like grains of tallow or undigested particles of food in it and occurring in the night or morning: or it may be an involuntary diarrhoea, with a lax, open sphincter,though which blood-stained mucus and soft faeces are constantly oozing; or a diarrhoea associated with inflammation and ulceration of the rectum, when there are frequent and painful urgings, with stools like “the scrapings” of intestine or of mucus mixed with blood, with painful tenesmus, which is prolonged for some time after stool and is associated with burning pain in the rectum and anus. Phosphorus is a remedy for painless diarrhoea that is worse in hot weather and which exhausts the patient, and also for cholera morbus and cholera infantum. It is useful in chronic diarrhoea with soft, thin stools that must be expelled as soon as they enter the rectum, any movement will cause a stool to pass. It is indicated in dysentery with scanty stools of bloody mucus, accompanied with violent tenesmus, and is to be prescribed for protruding haemorrhoids, which burn and bleed after every stool. Paralysis of the sphincter ani is a very characteristic symptom of phosphorus, and when present will indicate it in all kinds of diarrhoea. There is a constipation for which this remedy is useful, the stool is hard, long, and slender “like a dog’s” and is passed with difficulty.
Urine.-Phosphorus is a remedy for nephritis when the urine contains epithelial, waxy or fatty casts, and when there is haematuria.
Sexual.-It is valuable as a medicine for undue sexual excitement and for the impotence often associated with it, for satyriasis and for irritable weakness of the sexual organs caused by excesses in venery or masturbation. Similarly it is a remedy for nymphomania. The menses are too soon and too profuse, and phosphorus is indicated in menorrhagia and metrorrhagia, when its general symptoms are present. It is useful in amenorrhoea, accompanied by blood-spitting, epistaxis or loss of blood from the anus or urethra. It has been used in cancer of the uterus and is indicated by easy bleeding from the growth and burning pains. Chronic mastitis and abscesses in the breast, with sinuses, the orifices of which are surrounded by an erythematous blush, are successfully treated with phosphorus (phytol.)
Respiration.-Phosphorus is probably more often used in respiratory than in any other diseases. In the upper respiratory tract is causes and cures a fluent coryza or one that is alternately fluent and dry and accompanied by frequent sneezing which causes pain in the throat. When fluid the discharge is profuse and flows back into the fauces and, when dry, crusts are formed which adhere firmly. There may be chronic inflammation of the mucous membrane of the nose, which is swollen, causing a stuffed-up sensation, especially high up in the left nostril; profuse discharge of green or yellow mucus accompanies this condition. There may be polypi, which bleed freely and, in diphtheria, haemorrhage of a severe character from detachment of the membrane. In chronic catarrh there is frequent blowing of blood from the nose. The nasal bones may suffer necrosis as the result of phosphorus poisoning. When the nose is obstructed by polypi or from caries, a fan-like motion of the alae nasi is sometimes observed (lyc.). Phosphorus causes soreness of the larynx, worse in the morning, and loss of voice or hoarseness. Speaking loudly and coughing cause pain in the larynx (bell.). Aphonia may be due to catarrh or arise from nervous and emotional causes, or from over-strain of the voice, as from prolonged loud talking or reading aloud (arg. met., arg. nit., arum, t.), it is worse in the evening. Hoarseness an loss of voice of this kind have a sure remedy in this drug. It is useful in croup when collapse is threatening, with rattling breathing, rapid, thready pulse and cold sweat; it comes in usefully at the later stages after acon., hepar, and spong., and also in the intervals between the attacks to prevent their recurrence. It is very frequently needed for other forms of laryngitis and tracheitis, acute or chronic, with dry cough from tickling in the larynx or trachea. The cough is worse from change from warm to cold air (reverse, bry., rumex), from laughing, loud talking, change of weather, eating and drinking. It may be a nervous cough coming on when anyone enters the room, form strong odours or form the approach of a thunderstorm; it shakes the head, provoking a splitting headache, and shakes the abdomen, with the result of a sticking pain in the epigastrium and possibly the passing of an involuntary stool; it causes trembling of the whole body.