It is probable that in bromization the chief actions is to be ascribed to the bromine anion itself; that this action is further increased through a chlorine defect, though, on the other side, the sodium salts of chlorine and bromine can interchange functionally to a certain degree.
We have here a very instructive example of a so-called ion antagonism before us: the close chemical relationship of chlorine and bromine makes possible to a certain degree an opposing interchange and displacement. On the other side the displacement of the physiologic chlorine by the less suitable, heavy bromine soon provokes functional disturbances in which the antagonism of the ions appears distinctly. Thereby the foreign bromine action can be removed much more easily through chlorine than an improvement of deficient chlorine symptoms is possible through bromine. A certain synergism of the two ions rests also upon the close chemical relationship, but an increasingly distinct antagonism is obvious from the completely different physiologic breadth of these ions. Lipschutz draws the practical conclusion from the above-mentioned facts that in the bromide treatment of epilepsy it depends less upon a definite salt deprivation than upon keeping the salt introduced constant, because only through this uniformity of dosage is the effectiveness of bromide made possible.
For the theory of bromine salts, according to the finding of Januschke, it is worthy of note that bromine does not seem to be especially rich in the brain. For its action in contrast to chlorine, a marked swelling of the brain tissue is perhaps of significance, and again the fact that bromine is more lipoid soluble than chlorine.
STIMULATING BROMINE ACTIONS
Of the various bromine salts, according to the findings of Januschke, it is worthy of note that ammonium bromide in large doses provokes severe paresis, reflex increase, tonic and clonic cramps, and respiratory paralysis. In this salt we have also toxic effects which might permit the remedy to be considered in epilepsy according to the simile rule. But in general chronic bromide medication in epilepsy is conceived as a palliative suppressing therapy.
But that the depression of the brain centers is not the sole phase of bromide action is perhaps most clearly shown by the self-investigation of Schabelitz using sodium bromide in large doses. The trial continued over a two months period. Very soon, after five grams, appeared an irritable frame of mind, a type of intoxication, with some confusion and uncertain gait. With continuous introduction of bromine great desire for undertaking work and a cheerful frame of mind alternated with lassitude and ill-humor. On the seventh day of taking bromides the variation in disposition ceased and a euphoric frame of mind remained. To inattentiveness and forgetfulness there were added joking, the urge to speak, pugnacity, unrestrained and noncritical attitude, a submanic state with many light and color manifestations, auditory delusions, disturbances of speech and language, cramp from writing, disturbance of convergence, ear noises, disturbance of equilibrium, mislaying of objects, inattention to clothing. Recollections from youth are very animated, while, recent impressions are unrecalled.
As epileptics tend to do, I could not simply name a picture but had to form a judgment about it.
The disposition was rosy, I made the most beautiful plans for the future and was irritated if any one contradicted me.
On the twentieth day of bromides there appeared a striking motor unrest. With the cessation of bromides and the addition of salt the disposition changed like a flash. Two days after the discontinuance of the bromides, there suddenly appeared marked delusions in the sense of relativity on the basis of a marked feeling of inferiority.
Under the use of bromides the sleep was deeper; during the day there were attacks of great malaise. With progressive bromization the pulse increased from 66 per minute to 110 and sudden increases up to 130 even in the state of complete rest. These suddenly appearing increases could be maintained for hours. Arhythmia and attacks of cardiac anxiety were observed. The appearance was bad, sallow, with temporary congestions of the head. The tongue was coated white and pasty. In the latter periods of bromides there were several days of acid risings, later bitter taste in the mouth. The urinary output varied with the introduction of salt. No manifestations in the skin were observed in the entire bromide period.
In the trial, the impairment of mind is well shown in respect to recently noted things and a slowing of psychic accomplishment of work, but most striking was the submaniacal state. Further, one cannot say that bromides in large doses act as a sedative in the healthy. Much more the therapeutic sedative action corresponds in a homoeopathic sense. The same also holds for the vasomotor irritability, the increased pulse rate and the motor unrest.
Exactly the influence of bromine on the psychic functions, as came into expression here in the production, of a hypomanic state, is of high interest in respect to the newer investigations of H. Zondek and Bier. Bromine stands in the relation of 100:1 to iodine in the blood. The amount of bromine is extraordinarily constant. Only in the manic depressive insanities it lies 40-60 per cent under the normal, and indeed only in the endogenous and not in the reactive forms. In the anterior lobe the hypophysis contains unusually large amounts of bromine. A substance which resembles thyroxin, in which the iodine is replaced by bromine, released very marked fatigue. These organic bromine compounds should, moreover, be markedly more effective than the inorganic bromine compounds. The hypophysis is perceived as the absorption and regulation organ for bromine, similarly as the thyroid for iodine.
Undoubtedly, bromine has for its most important field the psychic functions, which until now have not received due attention in homoeopathy. One was obviously of the opinion that the well-known sedative action was to be viewed as a purely palliative antipathy. According to the self-investigation of Schabelitz, however, this cannot be maintained in general. So it comes to the point that the suitable bromine preparation in correct dose for the psychic and motor excitation and disturbances of coordination must be determined in order to obtain more than a transient result.
THE BROMINE DRUG PICTURE
The rare use of bromine and bromine compounds in homoeopathy up to the present is based upon older observations of intoxication, animal, investigations and provings on the healthy:
(1) Horing: Ueber die Wirkung des Broms und mehrerer seiner Praparate auf den tierischen Organismus Gekronte Preisschrift, Tubingen, 1838.
(2) Heimerdinger: In. Diss., Tubingen, 1837.
(3) Fournet: Schmidts Jahrb, vol. 22, p.144.
(4) Hering: Neues Archiv.f. Homoop. Heik., vol. 2, p.109, 1846.
(5) Lembke; Allg. homoop. Ztg. vol. 37, p. 115;
vol. 44., p. 369; vol. 49., p. 186.
In addition on potassium bromide:
(1) Graf: In Diss., Leipzig, refer. in Allg. hom. Ztg., vol. 19, p.126 (eight provers and few organ symptoms).
(2) Korsz: In. Diss., Kiel, 1875.
In many observation on bromism the chief actions appear in the skin and mucous membranes and central nervous system. In the provings arranged with bromine water, chiefly irritative symptoms of the mucous membranes of the respiratory passages and of the gastro-intestinal canal are noted. Of the psychic symptoms, illusions as though someone stood behind him and looked over his shoulder, many dreams, anxiety, restless moving around in sleep, trembling and weakness on awakening, are reported; in potassium bromide there is the urgency of occupation, so well known from iodine, and the motor unrest, the hypomanic excited state besides the well-known depressive actions of the psychic functions (thought, conceptions, judgment, speech); the detailed observations with sodium bromide by Schabelitz read similarly. It is conceivable that for medical use it is not the depressive and paralytic symptoms which are suitable for comparison but the excitation symptoms. Also that many similarities of bromism exist with the psychic state of epileptics suggest that, with better adaptation to the single case, bromides may become more than mere palliatives in many forms of epilepsy. Here there is lacking as yet an exact working out of the symptomatology. A modality which agrees with the urgency for moving is also worthy of note for the central nerve action: the improvement through movement and walking about. Further, a connection with the sexual function, which may be reduced from large and persistent doses of bromides, may be significant for the selection of bromine. The special bromine symptom audible discharge of gas from the vagina, has been reported to me as a symptom from an epileptic with a distention of the os of the cervix and at times accompanies states of excitation of the sexual organs.
To what extent the indication of dysmenorrhea membranacea is useful or bromine, still requires testing. The toxic actions of bromine on the sexual organs are like those of iodine. At first the testes and ovaries swell and then atrophy and harden. The breasts also swell and pain.
The chief use of bromine preparations in homoeopathy up to the present has been in affections of the upper air passages. All halogens seem to have a special affinity for the throat. Animal investigations have shown a membranous inflammation of the diphtheritic type. However, the bromides are more rarely used in laryngeal croup and diphtheria than the iodides and cyanides, although the bromine symptoms are pictured as extremely similar to severe laryngeal diphtheria. An indication for bromine is also said to be its general modality: worse from heat, from hot water; and the etiology is said to be cooling after overheating, excessive coverings, close spaces. For bromine there is a specially type of blond, blue-eyed children with reddened face. In such children bromine is preferred in croupy coughs, also in simple laryngitis, in scrofulous catarrhs, and in hard, nonsuppurative swelling of the cervical lymph nodes, the brunette types corresponding more to iodine.
The hoarseness is, as are all symptoms, worse from becoming warm and from overheating. Dry cough with hoarseness and burning under the sternum is spasmodic. Here the well-known use of bromoform in whooping cough is to be recalled. Inhalations provoke coughing in which the inhaled air seems cold, although the weather is warm (indeed, in the state of overheating). Inspiration is labored; attacks of suffocation appear in a warm room and there may be mucous rales in the larynx and air passages. In bromine the inflammation can extend into the bronchi and lungs (pneumonia is frequent in experimental bromine poisoning and also in bromidized epileptics) but still bromine is much more rarely employed than iodine. The laryngeal symptoms are decisive, and thereby the larynx should be very sensitive, especially to dust. So bromine is considered a remedy in sailors who have asthma ashore and again lose it at sea.
As with iodine there is also an irritant state of the nasal mucous membrane with much sneezing, which was also observed by Schabelitz on the twenty-second day with sodium bromide. Thereby pressure in the frontal sinus seems to be frequent. The feeling of coldness of the inhaled air, aggravation from heat and overheating, can perhaps give an occasion to select bromine in place of the usual iodine.
The well known skin manifestations of bromine are rarely utilized medically. However, Clarke recommends kali. brom. highly in the 30th in simple acne. Ammann has observed an eruption like psoriasis in bromine intoxications and has employed kali. brom with results in psoriasis.
(1) Psychic: Hypomanic state (sedative and antiepileptic action many times curative?)
(2) Upper air passages: laryngeal croup.
Spasmodic cough (blond, blue-eyed children).
(3) Modalities: better by moving around; worse from heat and overheating.
Usually bromine (fresh preparations!) are recommended in the lower potencies, usually as kali. brom.
Chlorine in molecular form, that is, as the yellow-green gas, comes into consideration for medicinal use just as little as molecular fluorine. The severe toxic action of chlorine is associated with its great chemical activity toward almost all elements, in particular its avidity for oxygen. This so great that a hydrolysis of the chlorine molecule occurs even in water whereby ClOH, hypochlorous acid, and HCl, hydrochloric acid, are formed. The destruction of water by chlorine is catalyzed by higher temperature and light. By the development of HCl, oxygen is liberated, this constantly oxidizing Cl to ClOH and this again in HCl and O. By this process oxygen constantly becomes free, and so chlorine acts as strong oxidizing agent on substances containing water and destroys all living substances.
ACTIONS OF MOLECULAR CHLORINE
When chlorine is in a sufficiently strong concentration, the organism is first involved in regard to the respiratory passages: spasm of the glottis, cough and dyspnea; the dyspnea is expiratory. If the amount of chlorine entering is sufficiently large, then there soon follow dyspnea, cyanosis, cold sweat, eventually pulmonary edema, accelerated small pulse and death through cardiac and respiratory paralysis. If there is prolonged stay in a chlorine atmosphere of moderate concentration, the reflex defenses are penetrated so that there develops bronchitis, pneumonia, pulmonary bleeding or edema. Bronchial maladies, pulmonary hemorrhages, the development of tuberculous foci on such a damaged soil, have been observed in subacute toxic concentrations, and, moreover, in chlorine workers, gastric pain, acid, eructations, pale, greenish appearance, emaciation, premature old age. The first acute irritative manifestations of small concentrations of chlorine are burning in the eyes and nose. Lewin also reports turbidity and inflammation of the cornea.
In regard to the narcotic action of aliphatic chlorine compounds (chloroform, chloral hydrate), the observation of Cameron is worthy of note, in which is reported a narcosis through chlorine gas (sleeping in the region of smashed boxes of calcium chloride) and free chlorine was demonstrated in the tissues by smell. Moreover, Binz reported narcosis and the appearance of free chlorine in the tissues in rabbits. A cerebral action expressed itself in the proving of chlorine water in the symptoms: loss of memory, especially for names, fear of losing the mind. The mental weakness is particularly worthy of note because of the similarity with more expressed action of the closely related bromine.
Likewise, not because of its therapeutic utility but for the understanding of the working relationships with the other halogens, bromine, and iodine, the so-called chlorine acne should be mentioned here. It is naturally assumed that it is not the free chlorine but organic compounds of chlorine (especially with tar derivatives) which are the cause of this affection of the sebaceous glands. Still, one, may assume that the organic combination merely conditions conduction of chlorine to the skin just as the aliphatic compounds favor conduction to the nervous system.
AQUA CHLORATA AS A REMEDY
The homoeopathic use of chlorine in the form of potentized chlorine water, aqua chlorata, is recommended in croup, spasm of the glottis, asthma with expiratory dyspnea, coryza with sudden flow of acrid corrosive mucus, and loss of voice in damp weather; but it is rarely used. Chlorine water is, moreover, too unstable a preparation since it contains constantly changing amounts of hypochlorous acid and hydrochloric acid, even with fresh preparation and preservation in brown bottles which excludes light. The use of aqua chlorata, which has survived from older medicine in the febrile diseases in which it should produce a slowing of the pulse and lowering of the temperature with an outbreak of sweat, in typhoid, in aphthous stomatitis, in dental spasms, is probably explained by the hydrochloric acid and hypochlorous acids being the active constituents. For the similarity of the indications with those of muriatic acid, as we shall soon see, is striking.
CHLORINE ION AND SODIUM CHLORIDE
Chlorine is of great significance in the organism in the ionic form, primarily in its neutral salt compound with sodium. In sodium chloride are bound two very aggressive elements, each of which attacks water; sodium turns water into a strong alkali, chlorine turns water into a strong acid. And the neutral compound, NaCl which is so extensive in the lithosphere and the hydrosphere as sodium chloride, is not only taken into the body daily in amounts of grams, but is granted so wide a physiologic range that the thought of any damaging or medicinal effect of this food and condiment at first seems to be very remote. The capacity for adaptation in the intermediary metabolism for quantities of sodium chloride is so great that in the adult twenty to thirty grams in a day scarcely provoke any alterations, at least not for brief periods of observation. It is otherwise in children in whom even three grams of a concentrated solution can provoke fever.
SODIUM CHLORIDE AS A DRUG?
It must seem as highly strange that such a material is conceded to have the medical effect ascribed to it in homoeopathy. For this reason natrium muriaticum is a favorite source of attack on homoeopathy. Still, the problem here is no different than it is with potassium and calcium salts. The homoeopathic assertions seem impossible only when the glance is cast at the quantity of the material. Just as little as we deal with quantitative factors in the salts of potassium, calcium and magnesium concerning a theory of deficiency, so is it true of sodium chloride. The different, unusual state of form is perhaps one of the conditions whereby we attain new type of working possibilities with such a substance. For the fulfilling of this condition, the type of preparation of such a remedy is significant and should be a trituration with sugar of milk, carefully performed up to 6th decimal potency; only beyond this is a dilution in diluted alcohol arranged.
How this potentized preparation differs from a simple solution and by what means it can provoke new kinds of actions can be answered at present only by hypothesis. So might the increased distance between the NaCl particles or even into sodium and chloride ions be better obtained and maintained through the medium employed (milk sugar and later alcohol); in consequence the site of the first influence the tongue mucous membrane) can be of significance for its unusual working path. It would then be understandable that the preparation can provoke symptoms which are not observed from the usual introduction of larger amounts of sodium chloride even though the organism might be adapted for the usual form.
But the organism would so much sooner react to unusual preparation of sodium chloride with symptoms, the more labile the sodium chloride equilibrium was at the beginning. Disturbances in NaCl economy, or in sodium or chlorine equilibrium, alone will favor the effectiveness of the preparation. On this account it is necessary to learn the physiologic role of NaCl in the organism, the fact being that the normal and abnormal relation of NaCl in the organism designates the soil on which the preparation of NaCl can unfold special activity of medicinal effects.
PHYSIOLOGIC ROLE OF SODIUM CHLORIDE
On the step of mass action sodium chloride appears at first the most important factor and regulator for water balance. The behavior of water to dissolved particles, that is, the osmotic concentration or water concentration, will be especially strong and easily influenced by NaCl because NaCl has great span among the electrolytes of the body, as it also appears the strongest physiologically in the body fluids. Through sodium chloride the diffusion velocity of a solution is increased greatly, and so sodium chloride is the impulse factor also for the movement of body fluids. Sodium chloride is easily excreted and easily retained, will be absorbed dry or moist. From all these facts it is especially suitable for the maintenance of osmotic equilibrium. NaCl furnishes about 60 percent of the osmotic concentration of the blood. Because of its great breadth of adaptation it does not easily come to specific disturbance. For the understanding of this play of power between water and NaCl it must be grasped that sodium chloride (in contrast to KCl) is a constituent of the body fluids and the cell surfaces are quite impermeable to NaCl, at least for the sodium ion, while the chlorine ion can pass from outside in, and reverse.
Two materials, which physiologically work together as strongly as water and NaCl, appear as antagonists as soon as one attains predominance. The antagonism of a pair belonging together (also in itself synergistic) appears first when the effects are shifted one-sidedly. So water removes sodium chloride poisoning; and sodium chloride, water poisoning to a great extent. If, for example, one has effected a depression of diuresis with pure water, then it is overcome (to the point of isotonia) by a subsequent introduction of sodium chloride. The isotonia of the blood is protected against excessive amounts of water or sodium chloride to a remarkable extent; furthermore to assist in the regulation there are added such symptoms as thirst, dryness of the mucous membranes, hydremia and rapid excretion, chiefly through the kidneys with increased or diminished amounts of urine, according to the availability of water for excretion and the functional capacity of the kidneys. The chloride excretion by the sweat and faeces is slight in contrast to that of the kidneys. It is assumed that a transient deprivation of the cell of water from the introduction of excessive amounts of sodium chloride would not be without influence on the function of cells. Some alterations of intermediary metabolism could stand in connection therewith. So it has long been known that, after doses of concentrated salt solution, the urine becomes alkaline. Thereby the carbon dioxide capacity of the blood is lessened, there is a cumulation of fixed acids in the blood, and the acid excretion in the urine is reduced.
To the same field of action also belongs the increased nitrogen excretion from the introduction of hypertonic NaCl solution, which can be maintained for some days after the introduction of NaCl. Increased destruction of protein many also be responsible for the enrichment of the blood in fixed acids (reduction of CO2 capacity). Therein we think of the increased protein destruction and the emaciation in chronic misuse of salt. On the other hand, that NaCl with much water (that is markedly hypotonic amounts which are rapidly absorbed and therefore provoke a rapid transient hydremia) leads to a delay of protein transformation and also acts protein sparing, seems no contradiction; because it is concerned with a relative, transient NaCl deficiency.