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

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

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and tracheal membranes, also of the lungs, and in these organs often
oedema was found, with congestion, ecchymoses, effusions, cheesy masses,
and sometimes a condition resembling phthisis (Archiv Iflebs, August,
1878).

Nutrition. Krahmer concluded from observations on himself, that
the presence of silver in the system lessened oxygenation and the excre-
tion of urea, of uric acid, and of the watery constituents of urine; the
non-nitrogenous elements were, however, increased, and the sp. gr. ren-
dered higher. If the administration of silver salts be continued beyond



8 MATERIA MEDICA AND THERAPEUTICS.

a certain point, cachexia sets in, appetite and digestion are impaired, ca-
tarrh and effusions take place, the temperature is lowered, and the action
of the heart and lungs weakened. The general debility and emaciation
are mainly dependent upon gastric irritation, but the drug seems to exert
a special " alterative effect " on tissue-change. Dr. H. Wood classes it
with "mineral astringents," Dr. Bartholow with "agents increasing
waste," but I think it better placed among those that " moderate or re-
tard nutritive processes " (Rabuteau). The recent observations of Roz-
sahezzi show a very marked diminution of tissue-change and of weight,
under the continued influence of small doses of nitrate. This occurred
even while the animal was taking a good amount of food, and when no
increased excretion could account for the loss; he thinks it indirect from
impaired blood and muscle-condition.

He finds (as opposed to Bogolowsky) that small doses cause a rise in
temperature, but agrees with Falck that large ones lower it.

When death has followed the long-continued use of the drug, the epi-
thelial structures, and the solid tissues generally the liver, heart, mus-
cles, kidneys, etc. have been found in a state of "cloudy swelling" and
fatty, degeneration, and the metal has been detected in most parts of the
body.

Fatal Dose (Acute Poisoning). This varies with the gastric ^pndi-
tion, period of vomiting, and of treatment, etc.: 30 gr. of nitrate have
caused death in one case, while 1 oz. has failed to do so in another (that
of Poumarede). Large doses have been neutralized by excess of natural
mucus, or of albuminous food.

SYNERGISTS. As regards local effects, the nitrate is allied with irri-
tants and caustics, such as iodine and arsenic. In its general action, es-
pecially in therapeutical doses, a resemblance may also be found with
these medicines as well as with compounds of chlorine, bromine, and salts
of bismuth, and in a less degree, of zinc. Some analogy with strychnia
has been traced (Charcot).

ANTAGONISTS AND INCOMPATIBLES. Sulphuric, hydrochloric, and tar-
taric acids and their compounds are chemically incompatible: also alkalies
and their carbonates, astringent infusions, and lime-water; also creosote
(v. p. 24). All soluble chlorides and cyanides are incompatible, since
they precipitate an insoluble chloride of silver; most natural waters do
so because they contain common salt: this salt is the best antidote to
poisonous doses of the drug, and should be given freely so as. to cause
emesis as well as to neutralize the poison.

THERAPEUTICAL ACTION (EXTERNAL). Nitrate of silver may be ap-
plied either (1) as a caustic, (2) astringent and alterative, (3) counter-
irritant, or (4) as a direct irritant.

1. Caustic. Lupus. In cases of tubercular and ulcerating lupus the
" lunar caustic " is sometimes suitable, and in the hands of Hebra, Neu-



SILVER. 9

mann, and others, has given good results. No ordinary application or
simple pencilling will be of any service, for it will not extend deeply
enough, but a well-pointed " stick " should be firmly pressed into the soft
tissue, in various directions and until hard tissue is met with : this is an
extremely painful process, and in my experience can seldom be thoroughly
done except under chloroform. As a rule, I prefer the nitrates of mercury
or of zinc, but silver has the advantage sometimes where the face is affect-
ed, because its action can be so precisely limited to the diseased part,
and does not cause so marked a cicatrix. Dr. Piffard recommends fine
needles to be coated with the caustic and passed into the growth, finding
this to be less painful than Hebra's method. Soothing applications, such
as poultices and lead lotions, should be made after the cauterization, which
may require repetition once or even twice weekly for some time. M.
Claude specially recommends the double iodide of silver and potash (in-
ternally) in lupus and skin-disorders.

Warty Growths Corns, etc. The use of the stick-nitrate for destruc-
tion of these growths is familiar in practice, and is safe and painless,
though not very quick in its results, for only a thin layer can be acted
upon at each application: the part should be thoroughly softened and
pared before the remedy is applied.

Carcinoma. For the removal of cancerous growths, Thiersch has em-
ployed injections into their substance of solutions of 1 part of nitrate in
2,000 or 3,000 parts of water; this is followed by a similar injection of
dilute chloride of sodium (1 in 1,000), and is said to cause quick disinte-
gration and wasting of the morbid tissue. There is some independent
confirmation of his results, but usually suppuration and sloughing have
occurred an effect which Thiersch did not intend (Archives Generate,
January, 1867). I am not aware that the method has been extensively
tried.

Poisoned and Dissection Wounds. In such wounds a liquid and
penetrating caustic, like nitric acid or potash, is more thorough in its
effects, but nitrate of silver, being portable and at hand, has often been
employed with good result; its antiseptic power is a recommendation.
Mr. Youatt reports that he was bitten several times by rabid animals, and
after a free use of this remedy had no ill results; but the degree of
security given must vary with the thoroughness and time of the applica-
tion.

Variolous and other Pustules. Lunar caustic has proved useful some-
times in aborting purulent formations. The absence of pitting after
small-pox being dependent upon the small size and limited inflammation
of the pustules, Velpeau and others have endeavored to secure such a
result by puncturing the vesicle on the third or fourth day, and touching
the interior with a fine point of the nitrate; and if well carried out this
plan has often succeeded. It is painful, tedious, and not free from



10 MATERIA MEDICA AND THERAPEUTICS.

danger, but the plan devised by Dr. F. Bowen is an improvement upon
it, and is much more feasible: the vesicle is to be punctured with a fine
needle dipped in a solution of the salt (20 gr. to 1 oz.); a nurse can do
this quite well. In one case all the parts thus treated recovered per-
fectly, while the vesicles that were untouched left deep scars (quoted by
Ringer). Mr. Higginbottom recommends painting of the face with the
same strong solution that he used for erysipelas (80 gr. to \ oz.), but this
is too painful for ordinary use.

Molluscum Contagiosum. The rounded, white, firm tumors of this
malady are efficiently treated by evacuating their contents and applying
nitrate of silver to the interior, as above described for variola.

Chancre. Opinions have differed as to the possibility of preventing
venereal infection by applications of nitrate to the sore soon after its ap-
pearance; authorities in favor of such practice are to be found among
earlier writers, but modern opinion is decidedly against it. Hunter,
Ricord, and Acton (writing in 1846) agree in stating that if the com-
mencing chancre, the vesicle or pustule be thoroughly cauterized within
three to five days of its origin the cure is rapid, and systemic infection
very rare; but they agree also that if the sore be indurated no effect is
produced, so that some of the cases they relied upon were probably " soft
and non-infecting chancre: " on the other hand, Diday, Langston Parker,
and others, have thus destroyed chancres within a few hours of their ap-
pearance, and yet an indurated sore and secondary symptoms have fol-
lowed. We must conclude that cauterization of a true Hunterian chancre
at any stage will not prevent its development or the occurrence of sec-
ondary symptoms.

Early cauterization of soft chancres will, however, sometimes cause
rapid healing, and is a good treatment for sloughing or rapid spreading;
but it is very painful, and the sore will usually heal under simple treat-
ment. In syphilitic ulcers of the leg I have seen solid gelatinous f ungat-
ing growths, which are well treated locally by pushing in a point of caustic
and breaking them down freely with it, as already described under lupus.
For syphilitic cracks, fissures, and ulcers on tongue and cheeks, the solid
nitrate applied daily is very useful.

Granulations. A minor degree of the caustic action of nitrate of
silver will repress exuberant granulations in wounds; they should be
pencilled every day or every second day.

2. Astringent and Alterative. By the latter term we mean to ex-
press the modifying effect exerted on tissues, and especially on mucous
membranes, whereby an unhealthy condition, usually inflammatory in its
nature, is subdued, and healthy action is set up in its place. Trousseau
taught that this effect is due to the new agent (nitrate of silver) causing
a more powerful inflammation than the original one which it displaces,
afterward itself subsiding; and this idea he developed at length under



SILVER. 1 1

the term, "medication irritaute substitutive" (" Materia Medica," i., 537),
but we cannot prove the occurrence of any substitutive inflammation of
this kind. We refer the effects of the remedy partly to its known phys-
ical properties of constricting vessels, of coagulating and disinfecting se-
cretion, and of forming an adherent protective membrane; also, in cer-
tain conditions, e.g., in ulceration, the vessels immediately acted on being
constringed, those in the neighborhood receive a better supply of blood,
and the processes of repair are quickened. The remedial power which is
special to the drug, which distinguishes it from other astringents, and by
which it modifies nutritive processes, we cau only express by the term
alterative.

In many forms of disorder accompanied by discharge, whether hemor-
rhagic, mucous, serous, or purulent, the nitrate, either solid or in injec-
tion or spray, is very valuable. (Delioux recommends the hyposulphite
of soda and silver as equally astringent and less irritant.)

Hemorrhage. In cases of continued oozing from small points in the
skin or mucous membranes, such as occurs after leech-bites, a finely-
pointed stick of nitrate firmly pressed on the part is a good astringent.
In bleeding from the mucous membrane of the bladder, such as accom-
panies vesical tumor, injections should be made, beginning with weak
solutions, and increasing the strength by degrees if necessary. Mr.
Christopher Heath speaks highly of this plan, and I have seen several
instances of its successful use in his hands.

Chronic Cystitis. After washing out the bladder, a solution contain-
ing 1 to 2 gr. in 1 oz. of distilled water should be injected and allowed
to remain for some minutes, or until micturition occurs; this lessens the
muco-purulent ropy secretion from the vesical membrane: Mr. Reeves
has used with success 20 gr. in 1 oz. (Lancet, i., 1853).

Gonorrhoea. At the commencement an injection containing 30 or
even 60 gr. to the ounce has sometimes succeeded in aborting the mal-
ady, but it causes severe pain, and may lead to serious inflammation. In
the female, a similar solution applied thoroughly, per speculum, to the
vagina, has given better results, and offers less risk on account of the
anatomical conditions; but, as a rule, the frequent use of a weaker solu-
tion is more advisable. I recommend, so soon as the acute inflammatory
stage begins to subside, an injection containing to 1 gr. in the ounce
every three or four hours; or sometimes a strength of only 1 gr. in 8 oz.,
to be injected every half-hour for the first eight hours, and afterward
every four hours until cure is effected, which should be in twenty-four to
forty-eight hours. I have had most excellent results in many obstinate
cases from this method; it should not be wholly omitted at the end of
forty-eight hours, but used once, or twice, or, if the discharge continues,
a little oftener for the following two or three days.

JBalatiitis. Gonorrhceal inflammation of the glans penis is effectually



12 MATERIA MEDICA AND THERAPEUTICS.

treated by the frequent use of a weak lotion (1 gr. in 1 oz.) in addition
to light pencilling with the solid stick.

Spermatorrhoea. The treatment by local application of a strong so-
lution to the prostatic urethra in the neighborhood of the openings of
the seminal ducts was strongly commended by Lallemand, but his state-
ments are exaggerated; it is useful sometimes, but should not be em-
ployed without due consideration: I have seen serious consequences fol-
low it.

Leucorrhoea. Injections of silver nitrate have been found effectual
in the vaginal form of this disorder, the strength of application being
proportioned to the duration of the malady: a drawback to its use is the
staining of linen. (There are several varieties of leucorrhoea, and each
must be treated on its own merits, as some will require internal remedies
as well as injections the checking of discharge by this or other astrin-
gents is only one part of successful treatment.)

In iiterine leucorrhcea the discharge is glairy and stiffens the linen,
and is accompanied with distinct suffering. It is usually connected with
cervicitis or endometritis, and in chronic stages, especially when the os
uteri is patulous, solutions, and even the solid nitrate, have been passed
into the uterine cavity with good result (Dr. Henry Bennet): this, how-
ever, has led to some abuse of the remedy, and I have seen very painful
symptoms connected with induration of the cervix and narrowing of the
canal as a consequence of too prolonged a course of cauterization.

Granular Erosion of Cervix (formerly known as uleeration). 'The
nitrate has been much used in this condition, but the solid salt can exer-
cise only a limited influence. In chronic cases, where the part is en-
larged, and the epithelium so long absent that the bared villi resemble
granulations, I have found benefit from recently prepared iodide of silver,
as recommended by Dr. Henry Wright. 1 All mechanical causes of erosion
of cervix, such as impacted faeces, must be considered, and if present,
treated at the same time.

Real uleeration of the cervix, as distinguished from erosion, is usually
connected with syphilis, struma, or malignant disease, and although the
nitrate has been often used for it, more potent remedies, such as the
acid nitrate of mercury, are really required.

Uleeration. When an ordinary ulcerated surface is discharging
freely, a lotion of moderate strength is usually more suitable than the
solid nitrate, because it does not involve confinement of discharge under
a limiting membrane (though, indeed, such membrane may be punctured
if necessary).



1 To a little of the strong sih'er solution ( 3 j. in j.) a few drops of tinct. iod. are
added, and the iodide of silver precipitates at once in white flakes, which should be
quickly applied through the speculum (Uterine Disorders, p. 260).



SILVER. 13

The best use of the solid stick is made in indolent ulcers with pale
small granulations, and but slight discharge. The remedy should be
lightly applied over the central parts, avoiding the new tissue at the
margins, and under this stimulus, and the protection of the film which is
formed, healing will be much quickened. The brittle stick nitrate is
superior to the prepared points of " lunar caustic," for it is more solu-
ble. Cuthill insists on the importance of stimulating an ulcer rather by
dots and lines of silver nitrate than by coating its whole surface, bet-
ter exit for discharge being thus given (Edinburgh Medical Journal,
1877).

Purulent Ophthalmia. In the ophthalmia of new-born children, and
also in the epidemic and the gonorrhceal forms of the disorder, solutions
of nitrate are extremely valuable, though they often cause severe pain
for a time. The lids should be separated and the eye cleansed by a
stream of tepid water, and in acute, not very severe cases, a few drops of
a solution (2 to 5 gr. in 1 oz.) should be instilled in very severe cases
with chemosis, a strength of 20 or 30 gr. in the ounce may be employed
once or twice daily, but should be followed by a syringeful of plain
water, or of weak salt-solution, in order to neutralize any excess of ni-
trate (v. p. 23). In chronic cases, especially when scrofulous in charac-
ter, with thickened conjunctiva, photophobia, lachrymation, etc., the
solid stick may be lightly used to the lids with advantage ; but in all
cases the liability to discoloration must be remembered, and the remedy
not be used too often nor too long ; when ulceration is present, or the
membrane not entire, other remedies should be preferred.

Otorrhcea, with perforation of tympanum and with tendency to forma-
tion of polypus, is best treated by touching the tympanic mucosa with a
concentrated solution of the nitrate: the discharge should be daily re-
moved by ordinary antiseptic lotion.

Ozcena Coryza. In chronic nasal discharges, if the bones be not
seriously affected, and in ordinary coryza, benefit may be derived from
injections of nitrate of silver (2 to 5 gr. in 1 oz.). In the former condi-
tion, a cleansing and disinfectant nasal douche should first be used, and
afterward the astringent should be injected from behind forward by
means of a curved tube passed to the back of the fauces, and connected
with a rubber ball.

Nitrate of silver in various forms is an important agent in the treat-
ment of diseases of the throat and air passages, but its strong and caus-
tic action is invoked much less frequently now than formerly; we require
rather the astringent or alterative action to relieve congested, or brace
relaxed parts. Dawosky concludes, after extensive experience, that,
whenever local applications are required for congested mucous mem-
branes, nitrate of silver gives the best results; besides its chemical influence,
it stimulates the congested vessels to contract and get rid of their excess



14 MATERIA MEDICA AND THERAPEUTICS.

of blood. For congested conditions of the fauces with adherent secre-
tion and patches of redness and swelling, he recommends a strength of 1
part in 8 (Medical Record, March, 1878), but I think it better to begin
at least with half this proportion.

Tonsillitis. In the early stage of this inflammation it must be at
least before suppuration has set in a strong solution (30 to 60 gr. to 1
oz.) applied once in twenty-four hours will sometimes abort further prog-
ress. Judgment is required to determine the suitability of cases for this
treatment, for if the inflammation be advanced and active, irritant appli-
cations tend to increase it. In sloughing ulceration about the fauces,
strong nitrate solutions are sometimes serviceable, and are better than
the solid caustic; but more active disinfectants, such as iodine or carbolic
acid, are still better.

Diphtheria. In diphtheritic inflammation with membranous deposit,
I cannot recommend the strong nitrate; if the part be irritated it is more
liable to inflame, and if the membrane be roughly detached the absorbents
more readily receive morbid material, so that, although this remedy was
at one time commended, I am satisfied that the use of a solvent or disin-
fectant spray is more serviceable, and is far more thoroughly and easily
effected. Strong nitrate of silver is not a suitable local remedy for mem-
branous croup (laryngeal diphtheria), or acute congestion of the larynx.
I have seen almost fatal suffocative spasm of the vocal cords induced by
the application of the solid nitrate in the latter condition. Guillon, how-
ever, states that the insufflation of finely powdered nitrate may be very
useful (Medical Record, 1877); sometimes a weak spray (1 gr. to 1 oz.)
has been of service.

(Edema Glottidis Chronic Congestion. This severe form of oedema
is sometimes quite controlled by strong silver-solutions, which may obvi-
ate the necessity for scarification or more serious procedures. In chronic
laryngeal and faucial congestion, a curved brush carrying a solution of
20 to 30 gr. to the ounce may be applied with the help of a mirror to the
exact part affected, and with very good result. Dr. Horace Green and
Dr. Hughes Bennett were early advocates of this method of treatment.
Many surgeons, however, now prefer solutions of copper, zinc, or iron, as
causing less irritation, and less risk of after-contraction, than the silver
salt. A weak spray is of very little service in these conditions, and the
use of the brush has largely superseded the method of insufflation which
was approved by Trousseau. He used 3 gr. of the nitrate mixed in fine
powder with 60 gr. of sugar of milk, and this was blown into the patient's
mouth during a deep inspiration, by which some of it was carried into
the larynx.

Laryngeal Phthisis. The solution is, according to my own experi-
ence, of much service in the early stage of this disease, and has been
recommended by the late Hughes Bennett, Marcet, and Sawyer, but ob-



SILVER. 15

jected to by L. Thomas (British Medical Journal, i., 1878). It has been
advised in malignant disease.

Relaxed Throat, etc, It is, however, in chronic relaxed conditions of
the fauces and pharynx, with dysphagia and constant discomfort, aching
in the throat, cough, and hawking of phlegm, that the remedy gives most
relief. There is no acute inflammation present, and the affected parts
are either pale with prominent follicles, or swollen and of purplish color,
with more or less viscid, yellowish secretion. In " clergyman's sore
throat," the follicles of the pharynx mainly are affected, and in all these
cases a solution of 20 gr. to the ounce, with glycerin, should be applied
once daily, or on alternate days, while tannin, borax, etc., are used in the
intervals.

In aphonia connected with local debility and relaxation, silver appli-
cations relieve by their astringent tonic action, and in hysterical aphonia
the irritation excited is often sufficient to restore the voice.

Relief may also be given to obstinate coughs arising from relaxed fau-
cial conditions, and not amenable to internal remedies, by a solution con-
taining about 5 to 10 gr. in the ounce, applied once or twice daily.

Chronic Bronchitis. In cases accompanied with profuse muco-puru-
lent discharge, I have often proved the efficacy of a spray containing ni-
trate of silver. I use only weak solutions from 1 to 4 gr. in the ounce
and find that they alter and restrain the secretion in a very satisfactory
manner.

Erysipelas. The power of the remedy in this disease depends much
on the mode of its application; the mere drawing of a line of caustic
round the inflamed margin (as sometimes practised) is illusory. The
best method is that of Mr. Higginbottom, who advises previous cleansing
of the part with soap and water, then with pure water, and afterward the
thorough application of a saturated solution (20 gr. in each fluid drachm)
two or three times over the whole affected surface, and beyond it on the
healthy skin for about two inches. This is effective in the superficial
forms of erysipelas, but not, according to my experience, when much
oedema or cellulitis are present, and I am reluctant to advise it over an
extensive surface, or in the idiopathic form. It causes severe burning
pain, and in the latter condition, at least, does not always stay the in-
flammation, so that I prefer milder applications and appropriate internal
medication.

Whitlow Furuncle Erythema. These conditions are sometimes
advantageously treated by the method of Higginbottom, but the solution
may be made weaker, and nitrous ether employed as the vehicle: it does
not dissolve so much as water, but 30 to 40 gr. in the ounce will be
strong enough; this should be painted over the affected finger, or the
commencing boil, or the inflamed and irritable patch. Chilblains are
relieved by it, and it is said to prevent a threatened eruption of herpes if



16 JIATERIA MEDICA AND THERAPEUTICS.

used early enough. To bedsore, in any stage, a solution of 5 to 10 gr. in
the ounce may be applied with advantage.

Eczema. The use of strong nitrate of silver in eczema should be re-



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