The glycogen of the liver under antimony very markedly diminishes and may vanish completely. As with phosphorus and arsenic the CO2 content of the blood, falls, obviously here the result of an acidosis from disturbance of the carbohydrate and protein metabolism.
In the blood at first appears a leucopenia and eosinophilia and then a leucocytosis follows. The reports regarding th red blood cells are indefinite, Kolle and his co-workers observing after chronic poisoning in mice a marked decrease of the erythrocytes and poikilocytosis, which recalls the action of atoxyl. Mayerhofer found the coagulability of the blood markedly reduced. The blood pressure sinks gradually and continually and in chronic poisoning one finds also a slight reduction. This fall is not simply the result of cardiac weakness, because by arotic compression and under helleborein there still occurs an increase of pressure. The fall in blood pressure is the result of vascular paralysis primarily in the abdominal capillaries. In acute poisonings there is cardiac standstill in diastole.
A stimulation of respiration in acute poisoning from tartar emetic has been traced by Grimm to an immediate action on the respiratory center.
The typical vomiting which appears not only with tartar emetic but also from other antimony preparations also occurs after intravenous introduction whereby the vomitus contains antimony. According to Hermann the vomiting is not the result of an immediate central action because greater doses are necessary for its production intravenously than by mouth. The vomiting is regarded as released reflexly from the gastric wall and indeed by the antimony that has been excreted also after intravenous administration. According to the investigation of Wesis and Hatcher on cats the vomiting movements appear after intravenous injection and even after removal of the entire gastro-intestinal tract. According to them the action probably proceeds over the vagus (whose sensory nucleus is essentially concerned with the act of vomiting), and to a lesser degree over the sympathetic. These authors hold it as probable that by intravenous injection the heart comes into consideration as the site of origin for the vomiting reflex and from there, as well as from the stomach and duodenum for the most part over the vagus and only to a slight extent over the sympathetic, the centripetal stimulus for vomiting passes.
An influence on the vegetative system is also suggested by the observation of the angioneurotic manifestations in the antimony therapy of multiple sclerosis.
Apart from these central and vegetative actions, antimony has no essential significance for the central nervous system. With fatal antimony poisoning the reflexes are lost and even if the vessels are ligated before the intoxication. Accordingly the disturbance does not arise from the spinal cord. On the other hand Michiels found no alteration of reflex excitability. According to Soloweitschyk the irritability of the nervous system persists after cardiac standstill. In the beginning of the intoxication an irritant state of the medulla is observed, then the reflex excitability is diminished. But the voluntary movements may persist. The irritability of the motor nerves and voluntary muscles is also maintained.
Occasionally the remark is found that antimony aggravates pulmonary tuberculosis, but that with small doses the therapy of lung tuberculosis can be assisted in that it acts as a “tonic” on the total organism.
Provings of Antimon. tartar. are found:
1. Stapf: Arch.f.d.hom. Heilk, Bd. 3, H.2, p. 146, 1824.
2. Mayerhofer: Heller’s Arch.f. physiol. u. path. Chem. u. Mikr., 3Jg,. p.111, 1846.
3. Nobling: Ztschr. f. Biol,. Bd. 4, p.40, 1868 (see above)
4. Ackermann: Ztschr. f.ration. Medorrhinum von Henle u. Pfeiffer, Bd. 2, p. 241.
5. Boeker: Beitr.z. Heilk, Bd. 2, p.324, 1849.
6. Molin: Des specifiques en medicine, Paris, 1847.
All antimony compounds unfold their chief action on the mucous membranes, particularly of the gastrointestinal canal, the respiratory passages and on the skin. But in use the preparations are differentiated by elective organ trends.
With tartar emetic, antimon. tartaricum, the emetic action of large doses is not guiding but the milder action which stamped the agent as an expectorant even in antiquity. This old empirical use became discredited only because of unsuitable doses. While the aim with larger doses proceeded on the basis of increasing and relieving the scanty and tenacious sputum of bronchitis, the homoeopathic use is much more extensive in massive collection of mucus which is difficult to evacuate. In bronchitis, bronchiolitis, bronchopneumonia and threatening pulmonary oedema, the cardinal symptoms of tartar emetic loud, rough rales in the air passages has been proven ever again. The chest seems to refill constantly with foamy mucus. At the beginning the patient can evacuate some tenacious light, white mucus by retching, but finally he is unable to do so, an asphyxial state impends and signs of collapse with cold clammy sweat, white ala nasae and hippocratic facies (entirely as with arsenic) is noted. Antimon. tartar. is especially suitable for small children and old people with recurrent bronchitis, in whom tracheal rales and dyspnoea, finally sleepiness through the excess of carbon dioxide, dullness, lassitude and sweats appear. The increasing weakness expresses itself in the type of cough: attacks of coughing decrease slowly in duration and severity with increasing weakness; the cough alternates with yawning. In emphysema attended by bronchial asthma tartar emetic competes with arsenic. “Cannot lie down because of dyspnoea” is a symptom common to both. The old patient must sit up; there is a great desire for fresh air even though the skin is cool as a result of the impaired circulation. The child wants to be carried upright; they are anxious and peevish because everything bothers them; they will not be touched, etc. Owing to the defective power of reaction then fever in antimon. tartar. patients generally is not high; chilliness prevails.
Cardiovascular symptoms appear early in antimon. tartar. in exactly the same way as in arsenic. But in this field antimon. tartar. holds practical preference over arsenic when the cardiac stasis is combined with stasis in the pulmonic circulation and also when the failure of the heart is associated with the previously described severe disturbances of the respiratory organs. From antimon. tartar. D 3 at times one sees
an astonishing change appear in these extremely severe pictures of disease. It is assumed that the action occurs reflexly through the vagus; and if it is precisely antimon. tartar., which so favorably influences this syndrome of the respiratory passages and heart, then the potassium fraction is not without importance.
Likewise the arsenic like gastro-intestinal symptoms offer scarcely independent symptoms for antimon. tartar. However nausea, also retching and more rarely vomiting, often accompanies the antimon. tartar. picture. The broncho-pneumonia of drunkards is considered a special indication on this account. The vomiting which occurs in antimon. tartar. is accomplished only with great effort and relieves in so far as it assists the evacuation of tenacious mucus but it leaves profound exhaustion behind. An uncertain modality attributed to antimon. crudum is: desire for acids and fruits but still aggravation from acids. In this respect the gastro-intestinal symptoms without pulmonary or bronchial symptoms give preference to either arsenic or antimon. crudum and the selection is made easier through definite symptoms and yields better results.
Likewise the pustular, variola-like skin affections scarcely have an independent therapeutic significance. Old homeopathists, the Swedish Liedbeck for example, however, have extolled antimon. tartar. in smallpox, in varioloid and varicella. In chronic skin maladies antimon. crudum more often comes into question.
The lassitude in the extremities which has also been observed in the provings with antimon. tartar. and the muscle pains and stiffness throughout the entire musculature, but particularly in the back which are noted as untoward action in the intravenous injection of antimonial preparations give some support to the indications for antimon. tartar. in rheumatic affections, particularly in the back and arms, in lumbago with marked aggravation from each movement. For this special localization perhaps the potassium fraction is also not without significance. A general connection with rheumatic gouty maladies will also be encountered in antimon. crudum.
The mental symptoms and the headache of antimon. tartar. have in and of themselves nothing characteristic, except the previously mentioned peevishness of children. Anxiety, restlessness, melancholia, fear of being alone, are similar to arsenic and can be utilized just as the final stupefaction, only as accompanying manifestations of the severe diseases for which antimon. tartar. is suitable. Besides the general dullness the headaches are said to be predominantly localized in the frontal region and of a contractive type.
Chief Trends: 1. Respiratory passages:
Bronchitis, bronchiolitis, bronchopneumonia (especially of small children and old people), stasis in the lungs.
Mucous rales in the trachea with difficulty in expectoration.
Dullness, malaise, cold sweat. Alteration of coughing with yawning.
Precordial pressure, cardiac palpitation, dyspnoea, cyanosis, failure of the right heart.
Bronchial asthma, emphysema.
2. Stomach-intestine: Action similar to arsenic.
Nausea, retching, frequent accompanying manifestations.
Vomitimg very exhausting, but alleviates through evacuation of mucus.
Desire for acids but aggravation from them (better for ant.crud.).
3. Skin: Pustular eruptions (variola, varioloid)
4. Rheumatic muscle pains;
Lumbago worse from movement.
Guiding Symptoms and Modalities:
Mucous rales in the air passages.
Desire for fresh air.
Peevishness in children against being held, etc.
Better from erect position.
Worse from movement (muscle pains).
In threatening cases the D 3 is often helpful. I have not seen injuries from it. Otherwise the D 6 is most often employed, although the high potencies have also been recommended.
Provings of Antimonium crudum are found:
Hahnemann: Chr. Krkhtn, 2 Aufl. Bd. 2, p. 190, 1835.
Of the antimony preparations the sulphur compound, Sb2 S3, in which antimony usually appears in nature and for this reason bears the name antimon. crudum, practically considered, has the organ trends for the gastro-intestinal canal and the skin. Indeed symptoms in the respiratory tract are also observed but they are less expressive than in other antimony preparations.
In gastritis and gastro enteritis antimon. crudum has as a leading symptom a thickly coated white tongue which looks as if painted. Vesicles on the tongue and wrinkled angles of the mouth can be further indications. The taste is pappy (the metallic constructive taste on oral administration is locally conditioned.). There is nausea from all foods, constant qualmishness with a feeling of an overloaded stomach; violent retching leads finally to the vomiting of the gastric contents, then of fluids tasting of the food eaten and of tenacious mucus or bile. Severe thirst with dryness of the lips is present, but water, even in small amounts, will be vomited. The vomiting does not relieve but only exhausts the patient. Burning and crampy pains in the gastric region appears in attacks, pressure
on the epigastrium aggravates. Sour wine is particularly aggravating also vinegar and sour fruits, however, there is still a desire for acid foods. Cold bathing and washing are also said to aggravate.
The same modalities are decisive for the diarrhoea: many urgent, thin stools with tenesmus and finally exhaustion. Considerable admixture of mucus in the stool refers to the proctitis. Aethiops antimonialis, a mixture of antimon. crudum and mercuric sulphide, HgS, has been recommended by A. Stiegele in membranous colitis and ulcerative colitis. The outpouring of mucus from the anus can also make antimon. crudum suitable in the hemorrhoids of old people with morning diarrhoea. The heat of the sun aggravates the acute intestinal manifestations. This has given occasion for its use in the summer diarrhoeas of children. In nursing, milk is vomited in a curdled state. Antimon. crudum moreover, has a chronic intestinal symptom: diarrhoea alternating with constipation, particularly in old people. Likewise the variable stool which can consist of fluid with solid particles is given as characteristic.
The headache and mental symptoms in antimon. crudum are associated with the gastro-intestinal disturbances. The headaches are mostly in the frontal region, also unilateral, and the aggravation from the direct rays of the sun, from cold water and from washing may be mentioned here. Of the mental symptoms the irritable fretful peevish behavior of children, and here also in gastro-intestinal disturbances, are to be stressed; the child will not rest, not mind or even look. In the adult the absence of desire for work is worthy of mention as an indication. Sleepiness during the day and after eating characterizes the sluggish malaise. The modalities mentioned also hold for the general state.
The rheumatic muscle and joint complaints of antimony, soreness and stiffness will be found in this remedy in association with gastric disturbances and are said to alternate with the gastro- intestinal symptoms and to be aggravated by the same external states (over-eating, acids, cold baths, radiant heat). That a gouty disposition and manifestation of antimon. crudum actually prevails is doubtful. Even less well founded is the report that antimon. crudum is a remedy for obesity. This report “becoming obese” is taken over in the Hahnemann protocol from Kunkel v. Lowenstern. It may be that a similar increase of weight occurs from antimony as from long continued small doses of arsenic although in acute and chronic intoxications, only emaciation is otherwise reported, so that such a constitutional indication must still be established by practical observations in order to awaken trust.
Among the symptoms in the respiratory passages which are given especial mention, the cough on entrance into a warm room is not based on the provings.
On the skin the acute pustular eruptions of the antimonials are even less suited for antimon. crudum than chronic alterations: rhagades at the muco-cutaneous borders and itching eczema, but especially thickening on the epidermis, wart-like, callous, horny formations, particularly on the soles of the feet which makes walking painful. The similarity with the hyperkeratosis of chronic arsenic poisoning is obvious here. Likewise the growth of nails is disturbed, the nails grow long slowly, are split and discolored. Furthermore antimon. crudum will be seen as a suitable remedy for urticaria which is dependent upon gastro- intestinal disturbances.
Chief Trends: 1. Stomach-intestine.
Thickly coated white tongue.
Aggravation from acids but desire for them; from cold baths and washing; from radiant heat.
Mucous outpouring in proctitis and hemorrhoids.
Summer diarrhoea in children; vomiting of milk.
Chronic: diarrhoea alternating with constipation.
Stool: liquid with small solid particles.
Headaches and mental symptoms dependent upon gastro-intestinal phenomena.
Children: fretful, peevish; adults: lack of will power, sleepy, relaxed.
Soreness and stiffness of the muscles, likewise dependent upon gastro-intestinal phenomena or alternating with them.
(Obesity doubtful.) 2. Skin: Rhagades at muco-cutaneous borders.
Itching eczema. Urticaria from gastro intestinal disturbances.
Thickening of epidermis, especially soles of feet, painful gait. Disturbances of nail growth.
Modalities: Worse from overeating, from acids, wine, cold water, radiant heat.
DOSE: The usual potencies are 3-6 (trituration).
ANTIMONIUM SULFURATUM AURANTIACUM
Provings of antim. sulf. aur. are found: 1. Mayerhofer: Hellers’s Arch. f. physiol. u. path. Chem. u. Mikr., Bd. 3, p. 356, 1846.
2. Boecker: Beitr. z. Helik., Bd. 2 p.93.
3. Neidhard: Hahn. Monthly, Bd., 16, p.649.
Antimonium sulfur. aurant. has entirely similar symptoms from the stomach and skin as the other antimonials, but is used almost exclusively for diseases of the respiratory passages. The manifestations are similar to those of antimon. tartar., only of a more chronic and less severe type, they also involve the upper respiratory tract more. Obviously the antimony in the more stabile Sb2 S5 comes into action with greater difficulty. Outside of the collection of tenacious mucus in the bronchi with oppressed respiration (worse night) the larynx and the naso- pharyngeal space shows more involvement; much mucus collects there and the sense of smell is impaired.
OTHER ANTIMONY PREPARATIONS
Antimon. arsenicosum was briefly proven by Isnard but its use is largely empirical in outspoken emphysema with marked dyspnoea and cough and abundant production of mucus, in hypostatic pneumonia (as antimon. tartar.), moreover, in exudative pleurisy.
Aethiops antimonials, outside of the above mentioned indication of A. Stiegele, has an empiric reputation in scrofula, particularly the severe scrofulous ophthalmias, D 2-D 15 (aethiops mineralis does not contain antimony but is a trituration of mercury with sulphur with partial combination). It is also empirically employed in scrofula.
The lower potencies (triturations) of antimon. sulfur. aurant. and ant. arsen. are common, but of the latter, not below the third.
The name bismuth is derived from “Wisemut”, originating from the idiom of mountain folk, according to Paracelsus, “since it blooms as a beautiful meadow on which all types of colored flowers stand”. Probably it is the “marcasita” of the middle ages. Even in the 15th century Basilius Valentinus mentions it as a metallic substance. It appears sporadically in nature, usually being found in common with arsenic, also as bismuth oxide (Bi2O3) and bismuth sulphide (Bi2S3).
Chemically bismuth stands very near to antimony, corresponding to its position in the periodic system but still bismuth has definitely the properties of a heavy metal and thereby approximates the heavy metals in its actions. In the nitric acid salt, Bi(NO3)3, bismuth appears as a trivalent cation. This salt breaks down in water to the basic bismuth nitrate, bismuth subnitricum (formerly called magisterium Bismuthi). This white powder, insoluble in water, does not have a perfectly constant formula but in any case it contains bismuth in the bismuthyl form (BiO), perhaps also bismuthyl hydrate (BiO)OH.
Bismuth subnitrate is the most common preparation in pharmacology. The bismuthyl salt may be compared best to the antimonyl salt, antimonium tartaricum. But the bismuth salt like most heavy metals is much less susceptible to absorption. The poorly or insoluble bismuth salts may be considered as not absorbed by the unbroken skin or mucous membrane. Moreover it is probably taken up from granulating wounds and catarrhally inflamed mucous membranes. On the other hand fresh wounds transform these compounds into soluble forms and induce manifestations of poisoning.
ABSORPTION AND POISONING
One may well assume that a minimal absorption may occur from the intact mucous membrane, similarly as with other heavy metals, for example, iron. The absorption is assisted if, from the start, the size of the particles is diminished by trituration. Only one need not expect the severe toxic manifestations from a few milligrams. But it is worthy of note that recently bismuth subnitrate has been relinquished in the treatment of gastric ulcer because of the possible manifestations of intoxication and bismuth carbonate recommended in its place.
After the introduction of large amounts bismuth is found in the liver, spleen kidneys, intestinal wall, salivary glands and bones. Excretion occurs in the urine, faeces, saliva, intestinal glands and milk. Thereby the channels of excretion through the intestinal glands, saliva, and urine are noteworthy for explanation of the toxic actions observed.
In animal investigations (in the dog) the manifestations of acute poisoning from intravenous administration; Vomiting, barking, twitching and death. With more chronic intoxication, vomiting, loss of appetite, diarrhoea with tenesmus; the temperature falls to 34o, increasing weakness, there is reduced sensitivity, twitching of the facial muscles, fall of blood pressure and it cannot be raised by splanchnic stimulation or artificial asphyxiation; tetanic spasms, disturbances of coordination and increasing paralysis are frequently observed.
The milder states of intoxication in man consist of lassitude, loss of appetite, tendency to vomit. The bowels are somewhat constipated. Furthermore develop; burning in the throat, persistent vomiting, thirst and diarrhoea, then intermittence of the pulse, cyanosis, dyspnoea, etc. Moreover a state appears which closely recalls that of mercury: purulent oral inflammation, ulceration of the mucous membranes, loosening of the teeth, formation of a dark area on the margin of the gums; after healing, the scars of the ulcers show often a black base; the oral mucous membrane is loosened, marked salivation appears, the salivary glands swell and swallowing is impaired. Likewise intestinal catarrh and nephritis (or much more nephrosis since it is especially the tubular apparatus which is involved) are entirely the same as with mercury poisoning.
Anatomico-pathologically are found: the large intestine is colored black and contains necrotic foci: stomach and intestine, macroscopically, a relatively normal appearance but they may also show severe hemorrhagic ulcerated appearance. In the large intestinal mucosa are found many bismuth containing leucocytes. (According to Kobert bismuth penetrates the white and red blood corpuscles and leads to their destruction and haemosiderin deposit in the liver and spleen). Moreover, the liver shows hyperemia and parenchymatous inflammation, slight fatty degenerative infiltration. The liver glycogen diminishes from the use of bismuth. There is slight fatty infiltration in the heart; the kidneys show parenchymatous alterations and deposits of calcium carbonate and phosphate.
Animal experimentation up to the present has contributed very little to the clarification of the intermediate processes in bismuth poisoning. The most important findings are the following: action on the erythrocytes: in dogs following the subcutaneous injection of bismuth there is a transient slight decrease in the red cell count and the hemoglobin value. In the urine a few erythrocytes, which does not explain the decrease. In spite of larger doses of bismuth which cause a loss of weight, no further diminution of the red cell count occurs. Of small doses of 1:20,000 of a 12.3 Percent bismuth containing preparation there was a distinct increase of the resistance of the red blood cell, with larger doses a hemolysis. According to Mendola it should favor the output of new white blood cells while the red cells in rabbits remain unaltered.
On the heart a decrease in the rate has been observed and a peristaltic pulsation, in mammals also the heart beats are grouped. It often stops for 90 seconds and then beats again. The blood pressure falls, likewise the rate. The grouping of beats suggests an action upon the cardiac ganglia, and action not dependent upon the vagus since cutting the vagus has no influence.