Skin And Mucous Membranes

Scattered acne pustules very frequently appear on the face, chest, and back; more rarely the eruption may be erythematous, urticarial, furuncular, or bullous. In some cases extensive superficial ulceration has caused serious symptoms. Bromide eruptions have been mistaken for tertiary syphilitic manifestations. The etiology of these rashes is a matter of some controversy. It has been suggested that the gland mouths are irritated by an accumulation of the excreted salt as 24 the sweat evaporates; also that the acid of the sebaceous secretion decomposes the bromide and sets free the irritating bromide. But irritation occurs in mucous membranes where the secretion is alkaline, and no excess of bromide and no free bromine have been found in washings from the skin, or in the sweat or sebaceous secretions, and though the drug is reported to have been found a few times in the sebaceous glands, most investigators have not found any there at all. But better evidence than any other that the rash is not due to gland irritation is the observation, by a number of careful dermatopathologists (Thin, Colcott Fox, Harris, etc.), that the changes begin in the papillary layer and not necessarily in or about the glands, though the glands may be involved secondarily.

It has been claimed that in chronic nephritis, on account of obstruction of the regular channel of elimination, the rashes are more severe. But rashes are too frequent in those with normal kidneys to allow us to consider diseased kidneys of any great importance as an etiologic factor, though they may have to do with the severity of the dermal reaction. L. Pierce Clark reports that even after enormous dosage he has been able to prevent the eruption by daily colon irrigations. That the nervous system is a factor is held by some, on the grounds that very small amounts are sufficient to produce a rash in those who show the idiosyncrasy, and that sometimes in these same persons the larger doses produce the least rash; in addition, most of these rashes are accompanied by vasomotor disturbances. On the theory that it is due to the elimination of toxic products, colon irrigations have been advised, also large doses of alkalies, intestinal antiseptics, arsenic, and potassium bitartrate, and, in addition, special cleanliness of the skin. The rash of the face, for example, is said to be lessened by vigorous washing. Stelwagon suggests diuretics and the free drinking of water, or, in other words, the promotion of rapid elimination. He states that sodium bromide is less likely to produce a rash than the potassium salt.

Kidneys

There is no special effect upon the kidneys, except that large doses with plenty of water act like other diffusible salts to increase the excretion of urine.

Toxicology

Acute poisoning from a single very large dose shows in profound depression and apathy, or an actual stupor lasting from one to several days, with slow respiration and rather low arterial pressure. Death has rarely, if ever, resulted from bromide alone.

Chronic Poisoning Or Bromism

Following repeated large doses of bromide the patient becomes dull, stupid, indifferent, the face expressionless, pale, usually bearing scattered pimples, the eyes heavy, all mental processes and voluntary movements sluggish (speaking is slow, replies to questions are delayed, walking is deliberate), the memory defective, general tone less, sexual desire and sexual power abolished, and there are loss of appetite, nausea, constipation, and a general lowering of vitality and vigor. This is the state into which some epileptics are brought by excessive bromide treatment; and it is nowadays thought better, except in refractory cases, to take some risk of convulsions rather than to bring a patient into such a hopeless condition of useless-ness. Many epileptics have led active lives, e. g., Napoleon I.

Treatment For Acute And Chronic Poisoning

Stop the drug, give sodium chloride and much water to favor elimination, keep up body activity and body nutrition, and counteract the central depression with strychnine and caffeine. Ulrich states that pushing the sodium chloride will positively abolish bromism.

Therapeutics

Bromides have their chief employment as sedatives in hyperesthetic states of the nervous system. They may also be employed to promote sleep, especially when wakefulness is due to worry or excitement or to moderate pain, as in toothache or neuralgia.

Some of their every-day uses are:

1. To lessen nervous irritability, as in general restlessness, in exophthalmic goiter, and in the gastric, intestinal, and cardiac neuroses.

2. To allay pain (as of neuralgia, neuritis, toothache, etc., which is felt keenly because of a hyperesthetic nervous state).

3. To check vomiting if reflex or central, as in seasickness, and not from stomach irritation. It is sometimes employed in the vomiting of pregnancy.

4. To lessen sexual hyperesthesia, as in nymphomania and chordee, and following operations upon the penis in the adult, as circumcision.

5. To prevent convulsions, as those of epilepsy, tetanus, and strychnine poisoning. For the last, doses of not less than half an ounce by mouth or rectum may be employed. It acts rather slowly.

6. To check spasmodic nervous affections of striated muscle, such as chorea, whooping-cough, persistent hiccup, laryngismus stridulus, and convulsive tic.

7. To quiet the reflexes (lessen the heightened tone) in spastic conditions due to lesions of the motor tract, as in multiple sclerosis.

8. To lessen cardiac excitability, as in extrasystoles and paroxysmal tachycardia - doses of 2 to 3 drams (8-12 gm.).

Of the various bromides, the potassium and sodium salts, in ordinary doses, have no measurable differences, and are preferred to the others. In the very large doses the potassium radicle may have a special depressing effect upon the muscle of the heart and arteries. The belief that ammonium bromide is less depressing to the heart than sodium bromide is not justified. (See Ammonium Chloride.)

Bromipin is a combination of bromine with oil of sesame, and may be given in the form of an emulsion. It is said to be free from irritating effects upon the stomach, and is sometimes substituted for the alkaline bromides when there is gastric irritability. It is of two strengths, 10 and 25 per cent., and the dose is 1 to 2 drams (4-8 c.c.) made into an emulsion. In epilepsy Kothe recommends 75 grains (5 gm.) three times a day, increasing up to 600 grains (40 gm.).

Bromoform (Chbr3) is a homologue of chloroform, Chcl3. It is a heavy liquid, readily soluble in alcohol, very slightly soluble in water, and sweet to the taste. It is very limpid, so that 1 minim contains about 5 or 6 drops. Its only therapeutic use is in the treatment of whooping-cough. The dose, 3 drops, or \ minim (0.03 c.c.) for a child one year old, or 5 minims (0.3 c.c.) for an adult, is usually given suspended in syrup, but is better dissolved in alcohol or oil. Poisoning has occurred a number of times from the undissolved bromoform at the bottom of a bottle, so it should be well shaken before the dose is poured out. Serious narcosis and collapse are reported in a child of eighteen months from a dose of 8 drops.