However lead poisoning so thoroughly important practically requires very frequent, small, finely divided amounts of lead and a long time for its development. Poisoning may long remain latent and then come into evidence when the external occasion has long since disappeared. Also the very slow excretion of metal which is moved with difficulty from the body, is even slower than the intake, scarcely furnishes an explanation for the situation. The accumulation purely to the amounts up to toxic doses according to all evidence does not correspond to the actual situation. According to animal experiments it involves less 688 a retention and accumulation of the toxic substance and much more a summation of slightly damaging after-effects. Also the frequent repetition of minimal insults by the smallest amounts of lead, but over a long period, leads finally to demonstrable organ injuries. The comparison with the constant dropping which wears away the stone, not through force but the frequent recurrence, seems especially likely. It symbolizes only one mechanism which we utilize so well in provings on the healthy and also advantageously many times in the therapeutic dosage. That the effect with such a procedure also is entirely different than with a single massive dose is emphasized with particular clarity in the example of lead poisoning. Because never in acute animal and human attempts with inorganic lead were similar acute pictures of lead intoxication obtained as those which are known from chronic intoxication. Particularly the late results in the nervous system appear exclusively in the chronic poisoning. With organic lead compounds (triethyl lead) however one can also experimentally produce nerve symptoms. This suggests that the nerve affinity of the chronic acting inorganic lead occur through a gradual transformation into an organic (lipoid soluble) compound. This behavior in lead is entirely similar to that in mercury.
Chronic lead poisoning seems at first to fulfill all the requirements which one can expect from a drug proving to and to make unnecessary intentionally arranged investigations in view of the large amount of observation material. But the descriptions of poisoning usually begin with symptoms which already represent the existence of definite organ injuries. These organ involvements are very good therapeutic signposts but the initial symptoms in sensitive people are (as expressions of the active defense) still more valuable for this. And this gap must be filled in as far as possible by intentional investigation in man. Lead obviously offers special difficulties, because its harmful effects remain latent for a long time and then suddenly manifest them-selves. Even if the available provings on the healthy 689 supplement and make a little precise, still a disproportion remains between the repeatedly demonstrated and extensive organ damages produced by lead and the present utility of these apparently so significant indications. But up to the present the significance lies more in the pathologic anatomic alterations than in the observation of subjective details and the very important modalities. Nevertheless that is what can be utilized homoeotherapeutically in the available observation material and usage indicates that this is considerable in comparison to the otherwise complete neglect of lead as an internal remedy.
Since the great trend of the lead picture can be designated distinctly as a chronic poisoning, we can use it as a guide and need only to discuss the therapeutic evaluation and to add the available details where they are known.
It is certain that lead is a chronic remedy of persistent, often only late action. Its suitability for chronic diseases is not excluded by the fact that it can produce sudden improvements.
The earliest objective signs involve the blood. The basophilic stippling of the red blood cells early shows an injury to the red cells which subsequently can lead to anemia and a wan, yellow grey, subicteric lead pallor; moreover an outspoken icterus can occur. The hemolytic action is obvious. Hematoporphyrinuria can be considered as a further sign of blood destruction by lead (with pathologic formation of this pigment in the liver). In this respect liver damage from the plumbum absorbed (in Kupfer’s star cells and the capillary endothelium) is probable. Lassitude, decrease of appetite, emaciation, wrinkled wan skin complete the cachectic picture. But the pale yellow appearance also depends partly on the vasoconstrictive action of lead.
Even in the early stage constipation with abdominal pains up to colic is present. The well known lead line, a precipitate of lead sulphide has merely diagnostic significance. Psychic disturbances likewise appear early: slowed comprehension and failure of memory, “cannot find the right word,” depression and anxiety (fear of being murdered). The state resembles that of cerebral sclerosis. Also in the later stages, after cerebral hemorrhage with hemiplegia has occurred, plumbum belongs to the remedies which deserve some confidence, for one finds many parallels with the symptoms of lead poisoning, especially in the sequela of central paralysis. The later symptoms of severe brain injury, the picture of so-called encephalopathia saturnina with mania, delirium, hallucinations, and illusions, eclamptic and epileptiform attacks, coma, give the parallel to general paresis, delirium tremens, epileptic insanity, etc., but are no longer useful therapeutically.
In manifest lead poisoning two chief trends of action can be differentiated: on the blood vessels and the nervous system. But the two systems are intermingled so that it is often difficult to determine the initial point of the toxic action. A majority of the symptoms can be traced back to vascular actions. They vary from angiospasm and ischemia to severe injuries of the vessel intima, endarteritis, and sclerosis. The increase of blood pressure is also conditioned by extensive vessel spasm.
Even more frequently than the already mentioned cerebral vascular action is the injury to the kidney by lead; as the result of the ischemia there is a chronic nephritis with degeneration of the parenchyma or a nephrosclerosis in consequence to an endarteritis. If other etiological causes have induced these two morbid states, which merge into each other, then the prolonged
use of lead which acts very similarly is recommended in the middle or high potencies, in order to save what may be saved.
Even in the spastic contracture of the intestine which is designated as lead colic, one can be in doubt whether it is to be traced more to the spasm of the mesenteric vessels or to direct excitation of the smooth muscle through the vagus. This syndrome also gives frequent therapeutic indications for lead in the event of colic and constipation. The attacks are spasmodic, radiating, mostly below the umbilicus, with rigid retraction of the abdominal muscles; they are relieved by pressure so that the patient bends double at one time but at another he has the desire to stretch. The “thready pulse” during the attack shows the marked participation of the vessels. Persistent spasic constipation can also appear with or before the colic and may be an indication for lead by itself. The anus is spastically contracted and retracted, if stools are passed they consist of hard, black balls. There is a spasmodic urgency to stools, but even flatus is retained. The intestinal paresis can produce severe signs of intestinal obstruction, of intussusception, still one would not pursue medical therapy in such parallel states but seek to relieve the mechanical cause. But if it involves a dyspraxia intestinalis arteriosclerotica, this true image of lead action, then plumbum is to be esteemed as a remedy with better prospects of success.
Oesophageal and gastric spasms are more rare than the intestinal. The picture resembles the tabetic crisis and the similarity with tabes extends in many other directions as we shall see (arthralgias, nerve actions).
The crampy pains with retraction of the abdomen can also direct attention to plumbum in dysmenorrhoea. Thereby the bleeding may be immoderately severe or amenorrhoea may exist. The tendency to abortion in lead poisoning is very great, even in wives whose husbands have lead poisoning. How far the degenerative alterations in the reproductive glands and the parotitis, the trophic actions, originates in the vessels or immediately through vegetative nerves, must be left undecided. Impotence, testicular swelling and atrophy can scarcely be therapeutic indications for lead. Irritative phenomena in the external genitals as cremasteric spasm, sensation of constriction in the testes or hyperesthesia and spasm of the vagina (vaginismus) are more inviting for therapy, even though there is rarely opportunity for it.
The disturbances in the central and peripheral nervous system are so diverse according to site and degree that all types of irritative and paralytic states appear when there is opportunity. Whether the endarteritic processes, at times ischemic, or the small hemorrhages lie at the basis of a direct injury of the nerve tissue by lead-after preliminary transformation into an organic lipoid soluble compound-cannot be decided at present. Lead action has special sites of appearance. Among the cranial nerves the optic nerve is one. It may occur as a transient blindness after previous disturbances of consciousness or as the gradual development of an optic neuritis ending in atrophy of the optic nerve. Here also the similarity with tabes is observed. A neuroretinitis in conjunction with the other suitable symptoms of the basic malady can lead to a useful employment of lead.
From the spinal cord nerves the extensor paralysis of the hands are known best. Their origin of departure probably depends on an injury to the grey substance of the anterior horn of the spinal cord. But the perfected paralysis is not the comparative picture for the therapeutic indications of lead with the prospect of success, but rather the transient sensory, trophic and motor irritative manifestations; thus severe neuralgias with local hyperesthesias and anesthesias. The skin in spots is very sensitive to contact and cold air. Numbness, twitching, lightning-like pains indicate the neuritis. Cramps in groups of muscles, for example, in the calves appear; they are worse at night and on movement, but are temporarily relieved by pressure. The tearing and boring pains of so-called lead arthralgia come paroxysmally like lead colic, and may alternate with it. The pains may be so severe that they force the patient into cramped positions. Trembling and muscle weakness introduce the motor paralysis which soon leads to atrophy. Lead is to be considered as a remedy in the occupational cramps, moreover in the chronic neuritis of mixed nerves, for example in chronic sciatica.
The numerous spinal cord injuries of lead poisoning have a great similarity at one time with tabes, at another with amyotrophic lateral sclerosis, again with bulbar paralysis. But one cannot expect the stimulative reaction from lead to have much room for play and prospect of results in these diseases. According to personal experience it seems that at most the course of progressive muscle atrophy can be favorably influenced by lead.
Lead gout whose origin is still very dark, has great similarity with arthritis urica, but therapeutic deductions can hardly be drawn from this at present.
Only the most common of the lead injuries are mentioned above. Lead poisoning can imitate many severe pictures of disease so remarkably that at first it seems peculiar why the therapeutic domain of lead is proportionately small from the standpoint of the simile rule. But this is understandable when one recalls how many degenerative, severe or irreparable disease processes appear in the picture of lead poisoning.
Slowly acting remedy.
Malaise, emaciation, wan, yellow, dry, withered skin-cachexia.
Depression and impairment of comprehension and memory.
Chief Trends of Action:
1. Blood vessels:
Angiospasms, endarteritis up to sclerosis. Chronic nephritis and nephrosclerosis.
Cerebral sclerosis and hemiplegia.
Dyspraxia intestinalis arteriosclerotica.
2. Participation of smooth muscles of organs.
Persistent spastic constipation with colic, better by pressure.
Dysmenorrhoea with colic-like picture.
3. Nervous system: States of irritation up to paralysis and atrophy.
Central nerves: particularly neuritis optica, neuroretinitis.
Spinal nerves: especially extensor paralysis of the hands.
Anaesthesias and hyperaesthesias.
Sensitivity of skin zones to contact and cold air.
Neuralgia, muscle spasm, worse at night and from movement; better from pressure.
Chronic neuritides. (Similarity with degenerative system diseases of the spinal cord often great but not useful.) Progressive muscle atrophy.
Worse from contact, from movement, at night.
Better from counterpressure.
Outside of plumbum metallicum, plumbum aceticum and plumbum iodatum are in use.
Plumbum aceticum will be preferred in painful cramps in paralyzed extremities.
Plumbum iodatum in arteriosclerosis, spinal cord diseases (lanci- nating pains) and inflammatory breast tumors.
DOSE —- Plumbum met. is used in D 6 and D 30, the salts in the lower and middle potencies.
In its chemical properties tin is in no way so uniform a metal as it might seem according to its usual physical state. There is also a non-metallic amorphous form of tin, a grey powder. By a prolonged stay in the cold, under 18 this non-metallic form develops out of the metallic crystalline. In the cold, tin objects gradually succumb to the so-called “zinnpest,” which depends upon this transformation and again changes regresses by heating.
In the periodic system tin immediately precedes antimony. It stands on a similar step in regard to its metallic character which is very preponderant but also gives space for a non- metallic modification.
Therefore it is to be considered that the horizontal kinship to antimony which is expressed structurally, that is, in nuclear relationship, also is not without significance for the similarity of properties. Because in the following outspoken metal step, to lead, we likewise have a distinct approximation to bismuth in physicochemical relation. This decrease of essential difference in horizontally related elements is again noted in the additional series of the 4,5,6th periods (and is demonstrated in a still higher degree in the compression of 15 rare earthy metals in the 6th period).
In stannum-antimony and plumbum-bismuth we can determine the approximation conditioned by a shifting of 10 elements in the horizontal series (or periods) but also demonstrate it between the elements of an additional series (IVa) and a chief group (V). At the same time the mutuality of the additional group IVa (the carbon and silicicum series) as also the relation of additional to chief groups, is very loose; amongst other things this refers merely to the occurrence of equal valences. The chemical group relationship also is only suggestive and for this the physical nuclear relationship comes more strongly into appearance.
For the comprehension of the pharmacologic actions of tin this approximation to antimony is worthy of note. I recall here that now here else in the heavy metals is there the outspoken affinity to the bronchi and lungs as with stannum which makes it comparable to antimony.
TOXICOLOGY ———- Toxicological interest up to the present has been largely limited to the question whether tin, as tin vessels, food containers with tin plate, that is iron with tin coating, or tin foil, passes into the food and is injurious to health. Even if decomposition of foods has often been cited as the cause of the injuries reported, still the possibility of a poisoning by tin salts is not excluded, particularly when strong acid foods form soluble tin salts. In animals such salts cause vomiting, diarrhoea, weakness of the movements muscle trembling, twitching and death through asphyxiation. 690 The intravenous injection of chloride of tin, SnCl2 and SnCl4, in animals causes the usual spasms, dyspnoea, paralysis, from which not much can be concluded. In the longer feeding of animals with tin preparations there are gastric disturbances, emaciation and disturbances of motility as well as ataxia. 691
After poisoning with tin chloride, stannous chloride, SnCl2, met- allic taste, constrictive sensation in the throat, vomiting, pains in the epigastrium, diarrhoea and prolonged colic occur in man. After the consumption of salt with bread from a moist tin container (compound of chlorine and tin) there develops: chillin- ess with heat, frontal headache, and pains in the distended, pressure sensitive gastric region, coating of the tongue, salivation associated with a foetid odor, grey discoloration of the gums and ulcers along the border of the tongue. 692
The gastro-enteric manifestations are to be conceived alsocal actions from a corrosive substance such as tin chloride is. Frontal headache and febrile disturbances are better considered as resorptive actions. According to Lewin 693 in its administration for epilepsy, as soon as the dose reaches more than 0.01 g. after each ingestion of tin chloride causes mild febrile attacks. In many epileptics the attacks at first increase somewhat, then subsequently diminish. Such untoward actions were considered necessary for a favorable effect.
Tin filings were once recommended by Monro, Fother-gill and Richter. Tin oxide, SnO, was often recommended in ancient times for many types of spasms, hysterical states, nerve pains, and also cachexias with ulcerations. Antihecticum Poterii or bezoardicum joviale (Jupiter=stannum) is an old preparation from antimony, perhaps iron and tin which was extolled as diaphoretic, antispasmodic, depressant to profuse secretions and in tuberculo- sis for the removal of the profuse colliquative sweats. That tin was present in this remedy for tuberculosis in addition to antimony, is not without interest for us. In Hahnemann’s time tin was used only as a remedy for tapeworms. Hahnemann 694 turned against the conception that tin filings acted purely mechanically on the worms. On the whole he did not consider tin a good remedy for worms since the tapeworm was not killed but perhaps only stupefied. But older physicians also used a water which was boiled in tin vessels for a long time and an action against tape-worms and intestinal parasites was ascribed to it. At present one no longer finds any therapeutic use of tin in the school, or not even the chloride as an external corrosive.
Provings with pure tin are found in Hahnemann: Reine Arzneimitte- lehre. 2 Aufl. Bd. VI. Other isolated observations concern the chloride. Stannum iodatum, SnI4, is not proven.
Nervous and bodily weakness, relaxation of the muscles and tendons, give the accent to the entire stannum picture. The type is a weak patient with pale face, dark circles around the eyes, sunken eyes, of depressed irritable disposition, who tires when speaking or listening to others, has great aversion to undertaking any work; the legs and knees fail and tremble. Walking upstairs is particularly difficult; they must often sit or lie down; they fall into a chair in place of slowly sitting down. The extremities tremble and are heavy. In spite of the exhaustion a certain unrest occasions them to attempt movements. The voice and chest are particularly weak: weak, failing voice, weakness and hollow sensation in the chest.
There is also a weak and empty epigastric sensation which is not relieved by eating; the urge to stool is without result because of the weakness in the abdomen and rectum (expulsive weakness); weakness up to faintness when defecating and urinating. In relaxed and weakened women the uterus is fallen or displaced.
Palpitation or cardiac anxiety appears on the least effort, for example, in conferring on the order of house work. The vertigo, trembling, depression and anxiety, are worse before the period, better the appearance of the bleeding. It is concerned with an asthenic type with relaxed fibre, with emaciation and tendency to enteroptosis. On the general state of constant weakness and sensation of exhaustion is added the depicted depressive- hypochondriacal frame of mind described and the special symptoms in the nervous system and the vegetative organs.
The sensation of fatigue in the head as from over-work runs the gamut up to heaviness, pressing and drawing pains in the occiput and forehead, worse from bending, sharp cutting pains in the temples and about the eyes, supra-and infra-orbital neuralgias or even migraine. The pains are characterized chiefly by the modality: slow increase up to an acme then slow decrease, in the second line all pains are characterized by relief from pressure. Also for the neuralgias in other places, for example, in the trapezius over the shoulder and in colic, this modality holds and refers to stannum.
The old reports that tin is a remedy for spasms, particularly of an epileptic type, furthermore for the complaints of worms or de- ntition, have been taken over into the homoeopathic materia medica. The inclusion of tin under the antispasmodics besides cu- prum and zincum in the older literature can hardly exist with right. amongst the organs tin has a special trend on the respiratory passages. In the throat it excites a tenacious, thick, grey or grey-green mucus, which produces nausea on attempts to remove it. The sensation of weakness on speaking or singing, with the sensation of emptiness and loss of power in the chest, failing voice and hoarseness is expressed in the provings and has been mentioned. The hoarseness will be only temporarily improved by single coughs (perhaps with expulsion of sputum). Loss of power of expiration seems to speak particulary for tin in the complain- ts of singers.
Besides the loss of power and emptiness in the chest tensive sticking and a knife-like pain, sore sensation internally, oppression and constriction of the chest, a constant desire to cough and exhausting attacks of coughing are repeatedly observed. The irritation seems to proceed from the trachea, to lie beneath the upper part of the sternum and is aggravated by speaking, laughing, singing (and from warm drinks). The collection of much mucus, internal sensation of gasping, snoring, and rales, greenish sputum of offensive sweet taste (or yellow sputum with foul taste or bloody sputum) are the signs which have led to the use of stannum in chronic bronchitis with abundant decomposed sputum, but particularly in bronchiectasis and phthisis. In tuberculosis the downcast mental state is increased, naturally with the prevailing depressed disposition which is not common in tuberculosis. The tendency to hectic fever with chills about 10 in the morning, evening heat and thirst, profuse night sweats (of musty odor?), especially towards 4.5 in the morning, massive collection of mucopurulent sputum in the throat, especially in the second and third stages of tuberculosis.