Charles D. F. (Charles Douglas Fergusson) Phillips.

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be lined by the bismuth powder (American Medical Journal, July, 1858).
It is probable that more absorption occurs with small doses (such as the
grain or less used originally by Odier, of Geneva), than with the very
large ones (several hundred grains daily) prescribed by Monneret.

PHYSIOLOGICAL ACTION (EXTERNAL). The pulverulent bismuth com-
pounds have an absorbent and protective effect: they are also somewhat
astringent and sedative. The crystallized nitrate, especially when dis-
solved in .glycerin, is also astringent, but is more irritating, even some-
what caustic.

PHYSIOLOGICAL ACTION (INTERNAL). Digestive /System. Bismuth,
taken in a pulverulent form, exerts upon the gastric mucous membrane a
sedative, slightly astringent effect, similar to that already described as its
external action. Taken in a liquid (more soluble) form, the effects are
still of the same kind, but produced by smaller doses and with more ten-
dency to irritation. Whether pure bismuth salts, when taken internally,
can exert an irritant poisonous action, or are in the largest doses practi-
cally innocuous, has been much disputed. Orfila and Meyer, in experi-
ments on animals, found that both the nitrate and the subnitrate, in doses
of 1 to 2 dr., caused vomiting, tremor, depression, and death, with post-
mortem evidence of gastro-enteritis (" Toxicologie," ii., p. 10 ; and Wib-
mer : " Wirkungen," etc., i., p. 423). Kerner also records a case of a man
who took 40 gr. of the subnitrate, and suffered from gastric oppression,
and burning pain, bitter taste, thirst, loss of appetite, eructation, gripinir,
bilious vomiting and relaxation, with vertigo, dimness of sight, and head-
ache the pulse was small and tense; and another case a man who swal-
lowed 2 dr. (mixed with cream of tartar), and died after violent symptoms
of irritant poisoning, such as burning pain in the throat, purging, vomit-
ing, cramps, suppression of urine, tremor, and paralysis: after death, in-
flammation and even gangrene were found in the course of the alimentary
tract (Wibmer, loc. cit.). Sobernheim subjoins to these cases, one that
after a 2-dr. dose proved fatal in nine days, with similar symptoms, in-
cluding also delirium and general swelling of the face, limbs, and abdo-
men: in this instance also, inflammation and gangrene of the stomach and
intestines were found (" Arzneimittellehre," 6th Ed., p. 265). Trousseau
alludes to a similar case recorded by Pott in 1739, and Dr. Traill reports
one where vomiting and pain followed the taking of 6 dr. (in divided
doses). Christison describes " bismuth, in its saline combinations, as an
active poison," and Taylor quotes some of the above cases as " proving
that a substance very slightly soluble in water may exert a powerfully
poisonous action on the human system."

On the other hand we must place the strong evidence of Trousseau
and Monneret, and the daily experience of a majority of practitioners.



BISMUTH. 83

Trousseau states that during a very extensive use of the well-prepared
subriitrate in doses of from 15 to GO gr., he has never seen the slightest
accident, or the least cause for apprehension (" Materia Medica," i.), while
Monneret prescribed the enormous doses of 150 up to 900 gr. per diem,
without any inconvenience resulting. He noted only slight constipation
with lessened odor and blackened color of the faeces; there was no thirst,
nausea, or pain, nor any evidence of inflammation, and the appetite was
rather increased than diminished. Such doses as the above are not likely
to be now prescribed, but many physicians order 10, 20, or 30 gr. several
times daily without any evil result.

Trousseau and others explain the toxic symptoms above noted by the
presence of arsenic as an impurity, and in some cases correctly, as shown
by Taylor. II. C. Wood also records a case of bloody purging from the
use of an adulterated drug, and the effects are certainly those of an irri-
tant poison. Still, as a rule, there is no evidence of the requisite amount
of arsenic for serious results, even in the most adulterated specimens of
bismuth. Stille speaks of one-sixth of 1 per cent, as the maximum pro-
portion found, while Parral and Gamier ascertained that preparations
containing 0.129 per cent, did not poison dogs, even in doses of 200 to
500 gr. (see also Adulteration).

Monneret suggested that in the above cases, either a previous illness
became suddenly exaggerated, or an excess of soluble nitrate acted as an
irritant: the last alternative seems possible after recent evidence that
soluble compounds of bismuth have an activity hitherto not supposed in
pure preparations. The acetate (according to Bricka), the double tar-
trate (Rabuteau), and the ammonio-citrate (Stephanowitsch) given in
large doses, produce poisonous symptoms very like those of the allied
metals, gold and quicksilver. Rabuteau " at first held the classical opin-
ion as to the remarkable harmlessness of bismuth," but his observations
with the double tartrate, or " emetic" of bismuth and potash (C 4 H 4 K
(BiO)O g ) have convinced him that slight solubility explains the general
absence of dynamic effects after large doses of the ordinary preparations.
The tartrate is soluble in water without decomposition, and gives a me-
tallic taste like that of ordinary " tartar emetic," it causes vomiting, and
30 to 60 gr. prove fatal to small dogs. In connection with this observa-
tion, it is noteworthy that in Kerner's fatal case, the patient took cream
of tartar with his dose of bismuth, and the salt referred to by Rabuteau
would probably be formed. Stephanowitsch records of the ammonio-
citrate that its hypodermic injection, in the proportion of 1 gramme to
each 1,000 grammes of body-weight, will kill animals, and that salivation
and buccal abscess follow its use, as well as steatosis of liver, kidneys,
and heart. The liver glycogen disappears under its prolonged adminis-
tration (Lebedeff).

Although, therefore, some of the older cases were connected with the



84 MATERIA MEDICA AND THERAPEUTICS.

presence of arsenic, yet bismuth cannot be held entirely innocuous, and
its activity clearly depends upon its solubility. The oxide, the subcar-
bonate, and subnitrate, though but slightly soluble, may be taken up to
some extent, especially when small doses are used. Thus, Odier, of Ge-
neva, gave only a few grains, or less than a grain, and noticed occasion-
ally vomiting, diarrhoea, a sense of heat, vertigo, and drowsiness. M.
Guersant has noted colic and " sense of anxiety," and Rabuteau some
general sedation, like the effect of antimony, and I have observed some
clinical evidence in the same direction; but the existence of a chronic
form of bismuth poisoning, marked by anaemia, swelling of gums, hemor-
rhage, etc., as described by Lussanna in man, 1 and by Stephanowitsch in
animals, has not been further verified. The only observation bearing
upon it that I have found is one by Dr. Brinton, who states that if the
subnitrate be taken continuously it will cause a bluish-red line on the
gums, " similar to, but wider and more red than that known to be caused
by lead " (" Diseases of Stomach," first edition, p. 197). I have not
found this noted by any other observer, but lead has been suggested as
an adulterant in the preparations used by Lussanna.

The action of Liquor Bismuthi differs somewhat from that of the solid
compounds, and probably represents rather the real activity of the drug,
independently of the mechanical effect of a powder; it is more irritant (H.
Wood), and it has failed to relieve gastric pain when the subnitrate has
succeeded (Macnamara). The carbonate is said to be less liable to irri-
tate than the subnitrate, and yet to be more soluble in the gastric juice
(Hannon); it does not perhaps absorb intestinal gases so readily as the
subnitrate or oxide, but has better antacid powers, and is not so likely to
constipate. The observer named, traced to it also some primary sedative
effects, like those described by Rabuteau of the nitrate, viz., weakening
and slowing of pulse, lessened appetite, and increased excretion of urine,
but found that its continued use improved strength and vigor like iron
preparations.

SYNERGISTS. Mechanical absorbents and antacids and sedatives.
Magnesia is specially suited for combination with bismuth salts.

INCOMPATIBLES. Acids are said to be incompatible with the subni-
trate of bismuth (Gubler), and some have advised the omission of all
acids from the diet during its administration. Practically, however,

1 Dr. Lussanna remarks that Honneret's results with large doses " have destroyed
the Orfilian scarecrow," but his own conclusions are almost as alarming as those of
Orfila. From large doses, used apparently chiefly in tuberculous diarrhoea, he wit-
nessed no irritation, nor any arrest of .the malady, but supervention of a " colliquative
and scorbutic state," connected, he presumes, with a solvent action on globulin he
traces a profuse epistaxis in a case of mesenteric tuberculosis to the use of bismuth,
but gives no sufficient details of the cases on which his exceptional conclusions are
based .



BISMUTH. 85

their effect is only to favor the production of the more soluble nitrate,
which should, in suitable dose, act favorably without discomfort, and a
few minims of nitric acid are not infrequently prescribed with it; they
should be omitted, however, if a merely protective effect is desired from
an insoluble preparation. Bismuth prescribed with a strong solution of
iodide of potassium precipitates as a red iodide, which is insoluble and ap-
parently inactive (British Medical Journal, ii., 1870).

THERAPEUTICAL ACTION (EXTERNAL). Erythema, Eczema, etc. In
these and allied forms of congestive and inflammatory skin disease, bis-
muth compounds are often extremely useful, -by virtue of their absorbent,
astringent, and soothing properties. In erythema and erysipelas, inter-
trigo, and bedsore they may be applied in powder, alone, or diluted with
starch or magnesia, or made into a cream with water and glycerin, or
into an ointment in the proportion of 30 to 120 gr. in the ounce of pre-
pared lard, cold cream, or vaseline. (Dr. McCall Anderson, in praising
this ointment, notes that it should not be made with benzoated lard, or
else, for some unexplained reason, it becomes liable to irritate.) An
oleate of bismuth is also a good preparation: according to Dr. Louis
Lewis, oleic acid may be made to take up 20 per cent, of oxide (Pharma-
ceutical Journal, December, 1876).

In the acute stages of eczema, when there is much irritability and
much serous discharge, these preparations are also very serviceable; they
seem to be sufficiently astringent, yet not so much so as lead, zinc, or
tannin, and will often act better than those remedies. In later stages,
when there is infiltration with redness and scaliness, a stronger solution
of the soluble nitrate in glycerin becomes suitable.

In the erythema connected with acne of the face, bismuth forms a
good ingredient in soothing lotions: a small quantity of corrosive subli-
mate (2 gr. to 8 or 10 oz. of liquid) is often combined with great advan-
tage, when sulphur and other stimulants could not be borne.

As a cosmetic under the name of "blanc de perle," bismuth salts
have long been celebrated: they are liable to become darkened by con-
tact with sulphur in any form (e.g., the sulphuretted hydrogen of ordi-
nary gas, etc.), some proportion of the black sulphide being generated.

For chaps, and fissures about the hands, lips, nipples, etc., bismuth
ointment is very good, and especially with a little tincture of benzoin (20
to 30 min. to 1 oz.). Trousseau specially commends it for anal fissure
(Bulletin de TJierapeutique, v., p. G3), and others for ulceration of the
septum nasi, and excoriations of the cervix uteri. Follin used a glyce-
role, containing 1 or 2 parts in 3 of the liquid, for chronic granular con-
junctivitis.

Catarrh Chronic Discharges. Monneret recommended the insuffla-
tion of bismuth powders for coryza, and in chronic catarrhal conditions
Soubrier used a snuff containing 4 parts of the subnitrate with 8 of



86 MATERIA MEDIC A AND THERAPEUTICS.

liquorice and 30 of iodide of sulphur (Bulletin, 1859). For acute cases
Dr. Ferrier has lately reintroduced a formula containing ^ to 1 gr. of
morphia, well triturated with 60 gr. each of the subnitrate and of gum
acacia, and this often acts well in cutting short a troublesome " cold in
the head; " this I have frequently prescribed, but find patients discon-
tinue it on account of its causing frontal headache and clogging of the
nostrils. In leucorrhoea bismuth has been applied in powder or paste, on
charpie, or as injection in the proportion of 1 to 8 of water, and has been
used with advantage in gonorrhoea and gleet (Caby).

THERAPEUTICAL ACTION (INTERNAL). Dyspepsia. According to
Monneret, " pain arising during digestion, from whatever cause," may be
relieved by mixing the subnitrate freely with the food, but more definite
indications may be given. Gastric pains dependent on indigestible food,
marked constipation or hepatic congestion, require emesis or purgation,
while in vomiting connected with fermentation of food, dilatation of
stomach, etc., antiseptic remedies and perhaps washing out of the viscus
may be necessary.

Bismuth is specially indicated in cases of difficult digestion with ten-
dency to diarrhoea, in subacute or chronic gastritis, and gastralgia with
marked irritability of mucous membrane: for such cases, Odier first in-
troduced it (in Geneva, 1786); he describes severe gastric pain as fre-
quent among the servants there who lift and carry on their heads large
vessels of water the pain was either spasmodic, sudden, intense, and re-
lieved by pressure, or more persistent and accompanied with sensations
of gnawing, sinking, and pulsation; eructation, nausea, and vomiting oc-
curred in greater or less degree, and the general health and mental state
became much depressed. Such cases were much relieved by bismuth in
moderate doses; and Marcet, Bardsley, and other English physicians
have published similar experiences.

Nothnagel finds it especially useful when pain occurs after food in
badly nourished overworked persons; but when there is marked anaemia
or a general neuralgic condition it. is not so serviceable alone, nor is it
very permanent in its good effects. Prussic acid, or opium, alkalies, and
later iron and bitters, may be conjoined with it. Caizergues especially
praises a combination of 4 gr. with -J gr. of extract of belladonna
in the gastralgia of chlorosis (London Journal of Medical Science,
1851).

When acid pyrosis is a marked symptom, bismuth is particularly in-
dicated either alone, or, if acidity be marked and constipation usual, then
combined with magnesia. According to Trousseau, if the rejected fluid
be insipid, glairy, or sour ropy phlegm, bismuth alone is contra-indicated,
but in most cases it deserves trial, requiring only that constipation be
remedied. The nausea and vomiting of gastric irritation is commonly
amenab^ to bismuth, reflex vomiting, such as that of pregnancy, not so



BISMUTH. 87

(Husemann); this is an argument in favor of the local protective effect
of the drug.

In infantile vomiting, which is frequently dependent on acidity or ill-
digested food, and accompanied by diarrhoea and pain, bismuth is exceed-
ingly useful, being, as it is, practically harmless and tasteless 1 to 2 gr.
may be placed on the infant's tongue with a moistened finger. A minute
dose of creosote, fa of a drop, may often be usefully combined (British
Medical Journal, ii., 1875).

In Ulceration of the /Stomach, when pain is very severe and exhaust-
ing, and when vomiting is frequent, much relief may be given by full
doses; and I have noticed that distressing thirst has been rather relieved
than increased by the remedy. Dr. Brinton attached great value to it;
it is often given with opium in such cases.

In Malignant Disease even, I have found bismuth palliate for a time
the most severe symptoms; and in both these conditions it acts mainly
by forming a smooth layer over exposed and hypersensitive nerves,
and so preventing the contact of food and unhealthy secretions : to
obtain such a result it is evident that more than ordinary doses are re-
quired.

Gastro- Uterine Irritation. Trousseau undervalued the virtues of bis-
muth when he held it unsuited fqr gastric pain connected with leucorrhoea.
It has really a special sphere of action in various uterine disorders which
induce or follow on gastric derangement, as has been well shown by F.
W. Mackenzie (London Journal of Medicine, 1857). His cases seemed to
prove the stomach primarily at fault, since complaint was made of pain,
sinking, flatulence, etc., before the ordinary symptoms of uterine irritation
appeared; bismuth greatly relieved them, and my own experience is
somewhat to the same effect. In dysmenorrhoea, with severe pain in the
back, hips, legs, and hypogastric region, palpitation, etc., I have often
given it with good effect, and in uterine hemorrhage (profuse menstrua-
tion) it has proved strikingly efficacious when recognized styptics had
failed, being thus allied in action with oxide of silver and arsenic; ap-
parently a sedative influence is exerted both on the stomach and the
uterus through the mucous tract and connected nerve-ganglia.

Diarrhoea. In irritative diarrhoea, with red tongue, nausea, heart-
burn, griping pain, worse after meals, and frequent ill-formed stools, I have
found bismuth invaluable. In some persons, mostly women, such a con-
dition becomes habitual, and even ordinary articles of diet may cause
severe aggravation of symptoms; the constant use of this remedy, how-
ever, gives them the greatest relief, and enables them to take food with
comparative comfort; much flatulence is often present, and sometimes
the diarrhoea depends on irritation from the development of sulphuretted
hydrogen (Chambers). Bismuth is then also very suitable, for it com-
bines readily with that gas and absorbs it (Practitioner, 1869); sometimes



88 MATERIA MEDICA AND THERAPEUTICS.

charcoal, or aromatic chalk powder, or rhubarb, may be added with much
advantage.

Infantile Diarrhoea. When infants at the breast suffer from eructa-
tions, sour vomiting, diarrhoea, light-colored papescent stools of bad odor,
with crampy pains in the stomach, I have always found bismuth act well.
In that form of diarrhoea which so readily affects children while being
weaned, or during hot weather, or that "which continues even after irrita-
tion has been removed, it is also of great service; from 1 to 5 gr. may be
given several times daily to children of one year and under. Weller pre-
scribed for children as much as 30 to GO gr. of subnitrate every hour
(interdicting milk during the treatment), with no other than good results
(Deutsches Archiv, quoted American Journal, 1870).

The ulcerative diarrJioea a'nd aphthous -condition connected with
phthisis is alleviated by full doses. Traube (one of the first to recommend
the remedy in such cases) supports the view of its acting mainly as a
mechanical protective, lessening local irritation, and consequently reflex
peristalsis. We have already referred to a case in which the powder was
found to line the whole tract, and it is evident that for such protective
effect large doses are necessary. Dr. T. Thompson, who prescribed about
5 gr. of the subnitrate with magnesia and mucilage, and Monneret, who
gave many drachms for a dose, are strong advocates of its advantages.
The latter observer states that he had seen many persons who were ap-
parently dying with tuberculous diarrhoaa, restored for a time to com-
parative health (" Medico-Chirurgical Transactions," v., p. 31, and Bul-
letin, v., p. 47), but the results of others have not been so favorable.
The persistent diarrhoaa of enteric fever is sometimes well treated in the
same manner.

Dysentery. M. Brassac, of the French naval service, records the best
results from bismuth in epidemic dysentery. Finding little or no benefit
from small doses, he followed the teaching of Monneret, and beginning
with 230 to 300 gr. daily, increased to more than 1,000 gr.; he divided
this into about five doses, according to the case, giving it in broth or
milk, or sometimes by enema, and so long as more than one stool oc-
curred in the day. This plan was very successful, and had no ill result;
as a rule, his patients began at once to eat better and to gain strength
(quoted Edinburgh Medical Journal, 1867). Trousseau also used bis-
muth injections in dysentery (Lancet, i., 1855), and more recently Dr.
Houghton writes from Borneo, concerning their great value in subacute
and chronic cases in tropical climates; he prescribes 30 gr. with mucilage
to be injected two or three times daily, and retained if possible (Lancet,
ii., 1879). In acute and chronic colitis, Laseque also used, with the best
results, enemata of 30 to 150 gr. with egg or mucilage.

Cholera. In the epidemic at Warsaw, in 1831, it was highly ap-
proved by Leo, and in later epidemics at Paris it was commended by



BISMUTH. 89

Trousseau, and very largely used for the premonitory diarrhoea; at the
commencement of the attack only, a little opium may be added with
advantage; afterward, two full doses of bismuth daily will suffice.

The reputation which has been sometimes claimed for bismuth as a
valuable remedy in intermittent fever, and in nervous disorders, as epi-
lepsy, cephalalgia, asthma, and in whooping-cough, must be traced either
to its relieving gastric complications of such maladies, or to the presence
of contained arsenic: it has not been sustained in recent times.

PREPARATIONS AND DOSE. Bismuthi oxidum : dose, 5 to 15 gr. or
more. Bismuthi subnitras : dose, 5 to 20 gr. or more (see below).
Trochisci bismuthi: dose, 1 to 6 lozenges (each lozenge contains 2 gr.
with lime and magnesia). Liquor bisrnuthi et ammonice citratis : dose,
^ to 1 fl. dr. and upward (contains 3 gr. of oxide in each fluid drachm).
The preparation of Schacht is said to contain only 1 gr. of oxide in each
drachm: dose, 1 to 4 dr. Bismuthi carbonas : dose, 5 to 20 gr. or more.

Preparations of bismuth should be taken about a quarter of an hour
before, or with meals, and if a mechanical protective effect is most de-
sired, acids are better avoided during the medication.

Subnitrate. The dose should depend upon its molecular state. Thus, if
it be very dry and likely to become caked together in the stomach, very
large doses may not act at all, or may cause irritation, while if moistened
or formed into hydrate, or carefully mixed with some other fine powder,
moderate doses will give a much better result. Thus, Quesneville took
80 grammes without much advantage, but afterward using the drug
thoroughly soaked in water, soon obtained good effects with 5 to 10
grammes; his "bismuth-cream" is a valuable preparation, better known
abroad than in this country. Doses of ! to 2 dr. are now seldom used,
5 or 10 gr. representing an average prescription for adults. Much more
may, however, be given in organic disease when there is erosion or ulcer-
ation of the alimentary surface; milk or almond emulsion is a good vehi-
cle. The subriitrate forms a part of the " poudre de Wendt," also of the
powder of Robert Thomas; combined with magnesia it is "Patterson's,
or American powder," and with pepsin, the "poudre de Royer."

The liquor bismuthi et ammonias citratis is miscible with water and
spirit, but not with alkalies without precipitation. The so-called " lac
bismuthi" (Symes) contains the hydrate mechanically suspended.

A lactate, a tannate, and a valerianate of bismuth have been de-
scribed: the first is a soluble salt, and may be given in small doses; the
compound with tannin is designed to favor its astringent, and the valeri-
anate any nerve-tonic powers. A citrate of iron and bismuth is some-
times useful.

Besides these, there are many private preparations, as of bismuth and
pepsin, bismuth and strychnia, etc.

A glycerole of the neutral nitrate is best prepared by dissolving oz.



90 MATERIA MEDICA AND THERAPEUTICS.

of the crystallized salt in 2 dr. of pure glycerin and an equal quantity of
distilled water, afterward adding glycerin to 6 oz. Uhguentum bismuthi
may be prepared with $ to 1 dr. of any bismuth salt in 1 oz. of cold
cream (not benzoated). An oleate is made with oleic acid and the oxide
in strengths of from 10 to 20 per cent. A lotion or injection is made
with 1 part to 8 of liquid. Pessaries are made containing 15 gr. in each.



Online LibraryCharles D. F. (Charles Douglas Fergusson) PhillipsMateria medica and therapeutics, inorganic substances; (Volume 2) → online text (page 11 of 40)