THE UNSUITABILITY OF SILVER TUBES FOR TRACHEOTOMY.1

819 Riemer also published a case4 in which the patient became affected after thirteen months’ treatment. During this period he had taken 2900 pills containing 17’40 grammes of the nitrate, or 21-61 grammes of the metallic silver; death BY DOCENT DR. ST. SZCZ. ZALESKI, following after the consumption of 5672 pills, which conOF DORPAT. tained 34 032 grammes of nitrate, or 21’61 grammes of metallic silver. Finally Dittrich published a case5 in which FouR or five years ago, while I was working in the toxic symptoms came on after six months’ treatment of a Chemical Institute of the University of Dorpat, the assistant tabetic patient, after he had taken 1 83 grammes of the in the surgical clinic came to the director of the institute nitrate (10 milligrammes daily), or 1’16 grammes of metallic with the remains of a silver tracheotomy tube, which, if I silver, the patient succumbing at the end of two years of this treatment after having taken 7’32 grammes of remember rightly, had been left in for about two years the nitrate equivalent to 4 69 grammes of metallic without having been withdrawn or cleansed. Of the tube silver. there only remained, owing to the solvent action of the It will thus be seen that the manifestation of the deposicontents of the air passages, the merest shell, in appearance tion of silver in the tissues by the occurrence of a grey dislike a kind of coarse cobweb. Thin, rough, uneven, sharp- colouration of the skin takes some time, but the actual deposition of the metal in the liver, bone, medulla, kidneys, and edged portions were connected by silver threads, and it was spleen commences very much sooner, producing what has surprising that the whole had hung together as well as it been called latent argyria, during which there is no dishad done, and that a tube so nearly destroyed had not colouration, though the health is affected, as experiments on given way and caused the patient to die from asphyxia animals show. When it is considered that a silver tracheotomy tube or from injury of the air passages. The silver had been from 10 to 16 grammes, and that, if only half of it weighs dissolved by the secretions of the bronchi and trachea is dissolved, from 5 to 8 grammes are absorbed into the and had the tube beenallowed to remain much longer tissues, we must admit that all the conditions are present there can be but little doubt that no part of it would for the production of argyria. Of course, a certain part is have been left. expectorated, but by far the larger part is absorbed, at all I can only explain the chemical process by which the events, as soon as the mucous membrane of the air passages metal was dissolved by the continual action, non vi, has become inflamed. If we do not look upon argyria in sed stpe cadendo, of the chloride which exists in almost the light in which it is considered by Charcot, but as a all the secretions of the body, and which is at times grave and dangerous affection, as it is considered by the abundantly present in the mucous glands, upon the metallic majority of physicians, and as a series of experiments on it silver, which thus becomes converted into chloride of animals in the Pharmacological Institute hereushas shown that to the which is forced is the conclusion be, upon in this its a stable silver, turn, although very substance, of such a comparatively easily soluble metal as silver being acted upon and dissolved by the alkaline secre- use tions, which contain ammonia and cyanides, in the same for the construction of tracheotomy tubes is fraught with of an irritant action of way as the sulphocyanide of potassium of the saliva has danger to life. Again, the danger the power of dissolving chloride of silver. This dissolved the dissolved silver on so delicate a tissue as the mucous silver is of course partly expectorated, but part probably membrane of the air passages setting up a catarrhal condition is absorbed. It may be that it goes directly to form should not be lost sight of. There is also another circumstance which must be taken organic compounds, or these may be reached by indirect into account in estimating the sources of danger. If the means. I do not know whether this case, so interesting and im- patient or his attendants are so negligent that the tube is cleaned and examined as to its perfect condition, the portant both from a chemico-physiological and from a not destructive action will go on until a time comes when, as in If of was ever it not, may published. practical point view, case related above, it will have become thin, and only perhaps be desirable to obtain as detailed an account of it as the is now possible, together with a drawing of the cobweb- threads and films of metal remain-a condition which renderslike remains of the tube. I am not aware whether the the patient’s life most precarious, as there is always grave of his being choked or injured by fragments broken patient suffered from argyria, but as soon as possible after- danger wards I performed tracheotomy on a cat, and inserted a off. That there is a possibility of this happening cannot be silver biliary fistula tube, which I allowed to remain until doubted after the case I have mentioned. the animal died a month later. By carefully weighing the Regarding the second question-of what material the tube tube before and after the operation, I found that it had should be constructed in order that it may remain for a long sustained a very appreciable loss, the original weight, which timein the trachea without danger,—I think that for patients was 1’9892 gramme, having been reduced by 0’0056 gramme, in good circumstances the most suitable materials are gold, so that it had lost 0’282 per cent. of its total weight. It platinum, or rock crystal. For those in the humbler classes, is thus quite evident that not only silver pessaries in porcelain, glass, or even ivory might be used. These subthe vagina or silver tubes in biliary or gastric fistu]ob, stances are, it is true, to some extent acted upon by the but silver tracheotomy tubes in the trachea, can be fluids of the body, the silica of glass being even soluble in dissolved, the metallic silver being taken up by the fluids traces in distilled water, but not in any appreciable quantity, besides which silica is one of the substances which is conof the body. Two questions present themselves: (1) To what extent is tained in the body, especially in the case of vegetable such a gradual wearing away of silver detrimental to theIeaters, and is not hurtful to it. Gold and platinum may I after a long time, be to some extent dissolved, organism ; and (2) What substance can best be substituteddoubtless, for silver in the construction of tracheotomy tubes ?P Asespecially by the sulphuretted hydrogen which, if the disregards the first question, we know that the long-con-infection is not perfect, is sure to exist. tinued and constant internal, and even sometimes ex4 Ein Fall von Argyria. Arch. f. Heilk., Leipzig, 1875, ternal, use of silver preparations in very small doses xvi.,B.pp.Riemer: to 326, and xvii., pp. 330 to 363. 296 5 ultimately produces argyria, which, as both clinical experiPrager Med. Woch., Bd. ix., Nos. 46-47, p. 450. ence and experiments on animals teaches us, is a very serious and incurable disease. In the well-known case THE DEHRA DUN ASYLUM FOR LEPERS. The published by Orfila2 (who first described argyria), the use of nitrate of silver for eighteen months was followed, not byreport of this institution, which has just been issued by Dr. G. G. Maclaren, is very satisfactory. The number of argyria merely, but by death. In the case described byinmates is 81, and the annual average cost per inmate during Fromman3 the grey discolouration of the skin occurred 44 rupees, which is slightly in excess of the usual was 1887 after ten months’ treatment, during which period the iaverage, which since the opening of the asylum has been patient had taken altogether 104’51 grammes of the36 nitrate, equivalent to 6639 grammes of metallic silver.i rupees. The success of this institution is beyond doubt due to the personal exertions of Dr. Maclaren, and it would 1 translation. be well if what he has accomplished could be effected Abridged 2 Traité de Toxicologie, pp. 21, 22. Paris, 1843. 3 C. Fromman : Ein Fall von Argyria mit Silberabscheidungen im throughout the length and breadth of India. Such district Darm, Leber, Nieren, und Milz. Virch. Arch., Bd. xvii., pp. 135, 147. asylums would be very powerful factors in the final suppres1859. sion of this most deplorable scourge.

THE UNSUITABILITY OF SILVER TUBES FOR TRACHEOTOMY.1

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