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

Materia medica and therapeutics, inorganic substances; (Volume 2) online

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I have seen instances in which a large vessel must have been wounded by
an incision in the tonsil, effectively treated by the local use of tincture of
the perchloride; it should always be tried before more serious measures
are commenced. As styptic applications to the bleeding surfaces of
wounds, iron compounds are not so suitable as some others, because they
necessarily prevent union by " the first intention," and they leave a coag-
ulum, on the separation of which hemorrhage is apt to recur. Maison-
neuve, however, performed some of his boldest and most brillant oper-
ations with their help; thus, he removed a growth occupying half the
face and head, and involving numerous vessels, applying perchloride on
pledgets of charpie at almost every stroke of the knife, and so that the
weakened boy lost but little blood; a brown eschar formed, and separated
about the twentieth day (Medico- Chimrgical Review, ii., 1856). Bour-
gade applied perchloride to the bleeding surface immediately after all
operations calculating to render them by this means "as painless and as
safe as if caustic had been used instead of the knife " and to prevent
septicaemia; the application was painful for a few hours, but not much
pus formed, and granulation occurred in a healthy manner. He reports
ninety-five cases ( Union Medicale, 1867, No. 104). The perchloride is
still thus used sometimes in operating upon soft tissues in ansernic sub-
jects when hemorrhage is likely to be serious. I have seen it applied
in the removal of a cancerous tongue and of a cancerous breast, and also

1 The original Monsel's solution was made with persulphate, as described by him
(Recueil des Memoires, t. xvii., 1856, quoted by Buisson).



150 MATERIA MEDICA AND THERAPEUTICS.

in a thigh-amputation, and in each case secondary hemorrhage occurred,
and I was not at all satisfied with the action of the styptic; further, it is
not free from risk of causing embolism.

Haemoptysis. In various forms of haemoptysis, phthisical and other-
wise, preparations of iron are useful if active febrile reaction is not present.
For internal use I prefer the acetate, or sometimes the sulphate, to other
preparations, and they are especially indicated in the passive hemorrhage
of anaemic weakly subjects (of the acetate, I give the tincture in 5 to 20-
min. doses every half-hour to two hours). Caution is needed as to their
internal use in phthisis (v. p. 173), but their local use in spray or powder
is advisable whenever the loss is severe or alarming. A striking case, in
which death seemed imminent, and in which the insufflation of powdered
sulphate at once and permanently controlled the bleeding, is given by
Wetherby (Ranking, ii., 1866). Brondgeest (Brussels) treated successfully
three phthisical cases by an atomized spray containing the chloride (Bul-
letin de Therapeutique, 1866, t. Ixxii.), and Cornil has related similar
results.

I have treated several severe cases with satisfactory results by an
" iron spray " containing either ^ part of liquor ferri perchloridi, or 1 to
2 gr. of sulphate in the ounce of glycerin and water. It might be thought
that blood thus coagulated in situ would increase a tendency to lung-con-
gestion or chronic pneumonic phthisis, but practically I have not found it
do so.

Epistaxis. When this occurs frequently in patients already anaemic,
or when the amount of blood lost threatens to bring on anaemia, iron will
be found of great value, and especially in the form of acetate or per-
chloride: it should be commenced as soon as possible, while the hemor-
rhage is going on, and continued for some time after it ceases. I have
seen this treatment useful in the severe epistaxis of habitual drunkards;
it is not, however, always safe for epistaxis occurring in the old, or those
disposed to apoplexy.

Hcematemesis. I have frequently treated this form of hemorrhage
successfully by means of the perchloride of iron given internally; it has a
direct local styptic effect, and in some aggravated cases, when the hem-
orrhage has occurred frequently, it has arrested it at the time, apparently
prevented relapse, and certainly lessened after ill-effects, such as anaemia.
In recent acute cases, ipecacuanha powder in doses of 1 or 2 gr. is more
efficacious, but in semi-acute cases it is well to alternate this remedy
(every half-hour to every two or three hours) with 15 to 30 min. of the
iron tincture in water. I have known this method check severe hemor-
rhage in a case of gastric ulceration. after other remedies had failed, and
Mr. Bowles records similar instances: he used 1 dr. of the tincture in 1
oz. of water, giving it after the stomach had been emptied by emesis, so
that it could directly reach the bleeding part (British Medical Journal,



IRON. 151

i., 1872). Deleau, Pleischl, and others have also recorded excellent re-
sults from this treatment (Medical Times, i., 1857, Medico- Chirurgical
Review, 1859), and it might with advantage be more generally adopted.
Iron alum (a double sulphate of iron and ammonia) is also very valuable
in this and other forms of internal hemorrhage (Lancet, i., 1871, p. 806).

Intestinal Hemorrhage. Perchloride is often useful in hemorrhage
from the bowel, and I have known it answer well. Several cases, some-
what obscure in character, but recovering under perchloride, are given in
Bulletin de Therapeutique, 1877. The ordinary cause of such hemor-
rhage would be either cirrhosis of the liver or ulceration, and I do riot
think iron suitable for the former condition, but in the latter it is more
indicated, since we know that it relieves hemorrhage from gastric ulcer.
In the diarrhoea and hemorrhage of enteric fever, benefit has commonly
been derived from its use. Dr. Russell Reynolds has used the perchloride
(Medical Times, i., 1867, p. 32), and Dr. Broadbent the sulphate in en-
teric fever (British Medical Journal, ii., 1869), but I have not met with
any published conclusions as to the value of these remedies. "Iron
alum " I should myself prefer as a styptic in such cases.

Hcematuria. The internal administration of perchloride of iron is
not desirable in acute renal congestion, but I have occasionally met with
chronic recurrent hemorrhage, apparently from the kidney, the subjects
of which were anaemic and suffering from chilliness, nausea, faintness,
etc., and who received much benefit from the perchloride. The dose
should be from 15 to 30 min. every six hours, and its efficacy may often
be increased by 2-gr. doses of ipecacuanha powder, given midway be-
tween. A very successful case illustrative of treatment by perchloride is
reported by Vigla ( Gazette des Hopitaux, 1858). In urethral and vesi-
cal bleeding the same treatment is very serviceable, and in the latter
malady iron injections into the bladder have been employed with advan-
tage, but the solution must be weak, for if rapid and solid coagulation of
blood within the viscus were produced, the effects might be worse than
those of the hemorrhage itself.

Purpura Scorbutus. Iron has sometimes succeeded well in purpura
of passive character, but is not of much advantage in the bleeding of true
scorbutus. Both the sulphate and the perchloride have cured cases when
other remedies, such as sulphuric acid and change of diet, have had no
effect. Homolle was the first physician to recommend the sulphate
( Union Medicale, No. 135, 1856), and Dauvergne, recording a striking
instance of benefit from the perchloride, remarks that it acts better in
cases with large effusion (in plagues) than in the merely petechial forms,
and this I believe from my own experience to be correct (Bulletin de
Therapeutique, 1867). Other cases may be found in Bulletin, 1868, Brit-
ish and Foreign Review, i., 1861, and Medical Times, ii., 1861, p. 501;
they include one patient at seventy, arid one a child; in one the malady



152 MATEEIA MEDIC A AND THERAPEUTICS.

was connected with deficient supply of animal food; the arseniate an-
swered well in another case (Lancet, ii., 1872).

Uterine Hemorrhage. All cases of uterine hemorrhage must be care-
fully considered from every point of view, before resorting to medicinal
or local styptic treatment. In a large number of such cases iron is highly
useful, but it must not prevent the proper manual and surgical manage-
ment of, for instance, retained placenta or fibroid growth, nor the deple-
tive treatment of a congested uterus. In menorrhagia occurring in the
young or the delicate, and accompanied with a general lax anaemic condi-
tion, and often with intercurrent leucorrhoaa, the sulphate or perchloride
are suitable as internal medicines; the former, with sulphate of magnesia,
is especially good. The excessive loss, as well as other and general
symptoms which often occur at the climacteric period, may be also re-
lieved by these remedies.

Uterine Cancer, etc. Simpson knew the value of perchloride in re-
lieving the hemorrhage and discharge of cancer, and French surgeons
equally proved it. The liq. ferri fort, is exceedingly serviceable, as shown
in a good paper by Dr. Gibb, of Newcastle; he either filled the vagina
with a dilute solution for a few minutes, or plugged with tampons, or
painted the strong liquor on the affected part, and so far relieved bleed-
ing and pain, and improved the local condition, as to give, at least, a
period of comfort (Lancet, ii., 1874, p. 830). I have myself used the
same application with excellent results, and my colleague Dr. Potter con-
stantly uses in cancerous cases a plug of lint or cotton wool soaked in a
solution of liquor ferri perchlor. fortior and glycerin (equal parts), and
firmly pressed against the uterine surface, the vagina being filled with
wool soaked in glycerin. Another method is to apply the saturated solu-
tion of perchloride to the affected surface on a Playfair's uterine probe
wrapped with cotton wool; this is best in cases when the vagina will not
tolerate the presence of tampons.

In cancer other than uterine its application is also valued by myself
and many observers independently of 'its power as a haemostatic: it con-
stringes and modifies the affected surfaces, inducing a less rapid growth.
Iron cannot cure cancer, but the debility and the anaemia dependent upon
it may be much relieved by a course of it.

Villous Growth. A severe and obstinate menorrhagia, dependent on
this cause, was successfully treated by Breslau with an intra-uterine in-
jection of equal parts of liquor ferri (Bavarian) and water; it was made
through a catheter, left only one minute and then withdrawn (1858).
This was one of the earliest cases of the kind, and illustrates a method
which I have several times employed with advantage; but a more modern
and often curative practice is to scrape the surface of the lining mem-
brane with a curette.

Fibroid Tumor. If the patient is suffering from marked anaemia and



IRON. 153

from continued loss when she first applies for advice, considerable relief
to the symptom may be given for a time by the internal administration
of the perchloride, especially when combined with ergot; it may possibly
be required as a styptic to the cut surface after incision of the cervix; in
cases of emergency, plugging of the vagina with saturated tampons is a
valuable temporary resource.

Puerperal Hemorrhage. The local application of so excellent a remedy
has not been neglected in this perhaps the most anxious form of hemor-
rhage with which we have to deal. Sometimes the use of plugs or
tampons steeped in the solution, and packed in the vagina, has seemed
the best mode of treatment, but it is not free from risk, for it may only
conceal serious internal hemorrhage, and moreover, the prolonged contact
of strong preparations, even though at the time painless, has been fol-
lowed by serious loss of substance, and permanent contraction and cicatrix
(Gazette des Hopitaux, 1869, No. 113). In post-partum hemorrhage, the
rapid application of a saturated sponge to the interior of a non-contract-
ing uterus has proved efficient (Barnes), but the contact of a strong
solution so quickly corrugates the membrane of the vagina and the os
uteri, as to cause difficulty in carrying the instrument far enough, or in
withdrawing it (Braxton Hicks, Norris).

Intra-uterine Injections. Few surgical procedures have more widely
and earnestly engaged professional attention of late years than the intra-
uterine injection of strong ferric solutions. Schreier, of Hamburg, was
accustomed to use weak injections (5- to 1 dr. in 4 oz. water) for hemor-
rhage, either before or after delivery (Medical Times, ii., 1855), and still
weaker injections (1 dr. to the pint) have long been practised in the
Vienna school, if cold and ergot failed. Ford recorded the successful
arrest of severe hemorrhage after abortion by intra-uterine injection of
ferric sulphate (1 dr. in 4 oz. water), also three other cases (American
Journal, April, 1868). Probably other instances might be found, but
general interest in the subject was first thoroughly aroused by Dr. Barnes.
The mode adopted by him was to mix ^ pint of the liq. ferri perchlor.
fort., B. P., with water up to 1 quart, and to inject this slowly through a
Higginson's syringe, of which the delivery pipe was passed well to the
fundus uteri; by this plan he was satisfied that life had been saved several
times, and he held it specially applicable to cases when contractile power
could not be roused, and the uterus remained dilated and inert after a
prolonged labor. The styptic mechanically stayed the hemorrhage by
sealing the vessels, and usually induced also uterine contraction (Medical
Times, i., 1865; also Lancet, i., 1869, and British Medical Journal, ii.,
1873). Dr. Hugh Norris (Somerset) recorded a similar experience about
the same time (British Medical Journal, 1869-70). Cases for and against
were soon reported from different parts of the country, and it was not
long before a vehement controversy arose, tinged, unfortunately, with



154 IIATERIA MEDICA AND THERAPEUTICS.

some personal animus. A case of secondary hemorrhage really dependent
upon retained placenta, but in which several injections of perchloride so-
lution (the last one being of the strong and undiluted tincture) had been
practised, died ultimately of septicaemia, and furnished the text for a
full discussion at the Obstetrical Society. Such a case was not really
illustrative of Dr. Barnes' mode of treatment, and, although it proved
fatal, the opinion of practical and experienced accoucheurs such as Brax-
ton Hicks, Play fair, Potter, Edis, Murray, etc., was expressed decidedly in
favor of such injections in suitable cases (Lancet, i., 1873, pp. 306, 407).
On the other hand, Graily Hewitt, Routh, Bantock, and Snow Beck, re-
ferred to other instances in which such injections did apparently cause
septicaemia and embolism. In Dublin, the favorable experience of Dr.
Barnes was amply corroborated by Dr. Lombe Athill, while Dr. E. Ken-
nedy took a much more cautious view, and urged the reservation of the
method for a dernier ressort (Dublin Journal of Medical Science, May,
1874).

In Edinburgh, the discussion of an unsuccessful case showed a-balance
of opinion against the procedure. Dr. Mathews Duncan especially ques-
tioned its propriety, though Dr. Alexander Simpson expressed a more
favorable view (Edinburgh Medical Journal, February, 1875). In
France, if we may judge by the observations of M. Budin, of the Mater-
nite, professional opinion is decidedly adverse (Bulletin de T/ierapeutigiie,
1876, p. 89). In Germany ferric injections seem to have been scarcely
tried, for no account of them is to be found in the Archiv, Zeitschrift,
Centralblatt fur Gyncecologie, nor any comments on German cases in
Schmidt or Virchow and Hersch Jahrsbericht.

An impartial estimate of English writings on the subject leads to the
conclusion that the greater part of the favorable testimony comes from
those who have really used the method of Dr. Barnes, while objections
are made chiefly by those who have not ventured to try it. The latter
urge (1) that the proper object in the treatment of post-partum hemor-
rhage is to secure uterine contraction (not simply a plugging of the ves-
sels with clot), and that cold, friction, etc., are better and safer agents
for the purpose; (2) that there is too great tendency to neglect these
measures for the more energetic iron treatment; and (3), which is most
important, that such treatment exposes the patient to grave risk from the
formation of emboli or the injection of air into veins, or the forcing of
fluid through the Fallopian tubes. The first objection as to uterine con-
traction is met by the statement that highly experienced men have, in
some instances, failed to secure uterine contraction by any ordinary
means, and have succeeded with the ferric injection, and have thus stayed
severe hemorrhage, and probably sa\ r ed life, without any ill-result; but
much weight must be allowed to the other objections. It is within my
own experience that iron injections have sometimes been employed far



IRON. 155

too soon, from over-anxiety to stay what I should consider not excessive
hemorrhage, and which would have yielded, I believe, to cold and the
judicious use of ergot. I am also cognizant of at least five cases in which
death has followed apparently from embolism, and yet I do not blame the
principle of the treatment so much as some defect in carrying it out. Thus,
sometimes the uterus has not been properly emptied of clot beforehand;
sometimes the solution has not been strong enough, and at other times
the exit has not been free. The greatest care is required as to all these
points. The patient should be on her back, the womb emptied of clot
and gently compressed, the uterine tube should be long enough (about
9 in.) to reach to the fundus, the solution should be of about 2 oz. dry
perchloride to 12 oz. water, or 2 oz. liquor ferri perchloridi fort, to 10
oz. water, free from air, and injected slowly and steadily, and the os must
be patulous, and the exit quite free, so that no undue pressure or disten-
tion should force fluid into vessels or through the Fallopian tubes. If these
precautions be all adopted, I believe the ferric injections may be used
with safety and with the best results, even in most serious cases; they are
an important addition to our means of saving life, but of late years the
injection of hot water into the uterus has been found to be as efficacious
as solution of iron and devoid of its dangers, and promises to entirely
replace it in practice.

Injections in Aneurism, etc. In 1852 Pravaz, of Lyons, excited the
utmost interest by his discovery of the coagulating powers of ferric per-
chloride, its effects when injected into the vessels of animals, and its suc-
cessful use in various forms of aneurism. His observations were con-
firmed and extended by Giraldes, Broca, and others, who formulated
rules for securing a good and firm clot, and obviating the dangers of in-
flammation and embolism which were soon found to be involved. The
greatest importance was attached to the purity and neutrality of the
preparation, its due density and proportioned amount to the size of the
aneurism, and to the securing of pressure on the vessel above and below
the seat of operation. Five drops of an aqueous solution at 30 density
(Beaume) = 1.261 sp. gr., or 10 drops at 20 (1.160), was the calcula-
tion for each cubic centimetre (15 gr. ) of blood to be acted upon (Giral-
des). Dieulafoy has calculated even less than this. If too strong a
solution, as of 45 to 50 (Beaume) =sp. gr. 1.449 to 1.526, be used, the
vascular coats may become inflamed or gangrenous, and, if compression
be omitted, embolism certainly may occur; and it will be found that
some fault in these respects would explain most of the serious and fatal
results which excited the vehement opposition of Malgaigne and others
to the new procedure.

I think that scarcely sufficient importance has been attached to some
of the successful cases notably to one of aneurismal tumor of the orbit
recorded by an American surgeon (Brainard: Lancet, ii., 1853). The



156 MATERIA MEDICA AND THERAPEUTICS.

ligature of one carotid had given only temporary relief, and the actual
cautery still less, but a complete cure resulted from several injections of
the lactate of iron (8 gr. to 1 dr.). Brainard considered this salt more
suitable than the perchloride, as acting more slowly, and with less irrita-
tion or tendency to suppuration. Bribosia (Brussels), in a special trea-
tise on the use of coagulant injections, considers them best adapted for
such aneurisms as contain more liquid blood than fibrine, and are situated
on the smaller arteries (e.g., those of the cranium), and not too near the
trunk. It must be acknowledged, however, that the general opinion of
modern surgeons is adverse to the use of the perchloride as a coagulant
in aneurism: Mr. Hart points out that compression of the affected vessel
above and below the sac is a sine qud non, and when this can be obtained
usually safer methods of treatment may be employed (" Holmes' System,"
vol. iii., 2d Ed., 1870). Marsacci, in a recent work, came to the same
conclusion; Gross and Erichsen also discourage it, though the latter
speaks of curing with i a gluteal aneurism after some suppuration
(" Science and Art of Surgery ").

Ncevus Erectile Tumor. The application of ferric injections to
these cases, though often successful, was soon found to require as much
caution as in the more serious malady of aneurism. Thirty drops of the
tincture injected into a nsevus of the scalp caused erysipelas and slough-
ing before cure resulted (Medical Times, ii., 1853); in a few cases, situ-
ated about the face, immediate death resulted, this being sometimes
clearly due to a clot formed in a large vein (Archives de Medecine, No-
vember, 1868; Lancet, ii., 1867). In a few other cases cerebral embolism
and softening or pysemia followed (Lancet, i., 1874; Bulletin de Thera-
peutique, 1873). On the other hand, Mr. Cooper Forster had good suc-
cess after dividing the nsevus-tissue subcutaneously and then injecting a
" few drops " (Medical Times, 1853, p. 654). Mr. Morgan made an ex-
cellent cure of a large erectile tumor of scalp, using circular compression
by plaster and pasteboard; and other good results might be adduced,
and, with very great care, might, I believe, be still obtained, but by com-
mon consent the operation has been discontinued on account of its dan-
ger (G. Buchanan: "Lecture," Braithwaite, ii., 1875). A recent Paris
thesis, however, re-directs attention to the subject, and presents it in a
favorable light (Auguste Rigaud: These, Paris, 1876).

Another and a safer method of using the perchloride in nsevus is de-
scribed by Leclerc, who applied it on pledgets of lint to the part, and ob-
tained a cure at the expense of some erythema and suppuration. Guillot
used it after first destroying the epidermis with caustic potash, and Guer-
sant after vesication (Bulletin de Thtrapeutique, t. Ixvii.).

Varix. Varices, without pain or ulceration, should seldom be inter-
fered with by external treatment; but I have frequently known a very
marked improvement in them while patients were under a regular course



IRON. 157

of 15 to 30 min. of the perchloride of iron, three times a day, for other
affections. To judge by the recorded results of iron injections in varix,
a large amount of success has been obtained with much less risk than in
the last-named diseases; but yet the method is not generally approved
by most modern authorities. Minor reports five good cases in which
either the scrotum or the legs were affected, and three or four drops of a
solution of persulphate (1 part in 4 of water) were sufficient for cure; the
patient was in the upright position, and pressure was carefully applied
above and below the seat of puncture (Ranking, ii., 18GO). Sentoux, col-
lecting 126 cases, found 100 cured, 19 relieved, 6 unaffected, and only 1
death. Denuce reports many successful cases (Moniteur des Sciences
Medicales, November 15, 1862; British and Foreign Review, April,
1862); the perchloride was used with certain precautions. Desgranges
thought the method, with ordinary care, to be free from danger 2 drops
sufficed for the largest varicose lobule. He notes the improvement in
varicose ulcers after the operation (Abstract: British and Foreign Re-
view, ii., 1858). Morgan, of Dublin, succeeded in obliterating part of the
saphena vein by injecting 5 drops of Monsel's solution in two places,
carefully isolated: coagulum formed in fifteen minutes, and the case did



Online LibraryCharles D. F. (Charles Douglas Fergusson) PhillipsMateria medica and therapeutics, inorganic substances; (Volume 2) → online text (page 19 of 40)