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Extra-Uterine Pregnancy.-MATAS' reports a case in which there had been rupture of the sac and repeated hemorrhage. After laparotomy the convalescence was complicated by secondary abscess of the liver which was relieved by transplural hepatotomy, and followed by recovery. He draws the following conclusions from the case:

1. That ectopic pregnancy reaching nearly up to the third month of gestation existed in the left Fallopian tube. 2. That some time after the seeond month the tube ruptured into the corresponding broad ligament forming an intraligamentous hematocele. 3. That the hemotocele continued to increase until it also ruptured into the general peritoneal cavity, where the hemorrhage became partially encysted, forming a large intraperitoneal hematocele. 4. Coincidentally or prior to the ectopic pregnancy, an intraligamentous cyst formed in the opposite broad ligament. 5. The value of intravenous saline infusion was demonstrated in tiding over the dangerous crisis caused by shock and hemor rhage during the laparotomy required to extirpatethe sac, evacuate the blood collection and secure the vessels. 6. Septic bowel infection following the intestinal paresis of a moderate (limited) post-operative peritonitis. 7. Septic infarct of liver through portal vein as a consequence. 8. Aspiration of liver and removal of typic streptococcal pus.

9.

Free hepatotomy after resection of ribs, followed by final and complete recovery.

Suggestions as to the Treatment of Alcohol. ism.-D. R. BROWER' suggests for acute alcoholic intoxication, putting to bed and administering a hypodermic of apomorphia hydrochlorate, later capsicum, nux vomica, compound tincture of cinchona, koumiss, milk, beef juice, raw eggs. If the patient is too feeble for emetics, he orders liquor ammonii acetatis and a wet pack, and for insomnia, sodium bromide, chloral, tincture of hyoscyamus, For acute alcoholic delirium and acute alcoholi, mania, the patient should be put to bed in a quiet, dark room, and carefully watched. Sleep may be induced by the use of chloralamid and hyoscin hydrobromate. These should be supplemented by a wet pack. The strength should, of course, be sustained. Chronic alcoholism cannot be success fully treated without the power of forcing seclusion.

Lead Ileus Mistaken for Appendicitis.-J. P. LORD' relates the history of a case in which the symptoms pointed to appendicitis, and yet upon operation no inflammatory indications were found. Exploration towards the median line revealed a mass of iterm and ileum markedly contracted, their approximate size being about that of the little finger. A similar case occurred in the practice of Dr. Galbraith.

Journal of the Amer. Med. Association, April 15, 1899.

MISCELLANY

THE Commencement exercises of the St. Louis Medical College were held on Thursday evening, April 27th.

THE Commencement exercises of the College of Physicians and Surgeons were held Wednesday evening, April 26th.

THE thirty-first annual meeting of the Texas State Medical Association was held at San Antonio, on April 25, 26, 27 and 28.

DR. LOUIS J. WOLFORT, Coroner's physician, is recovering from a serious infection which he acquired while performing an autopsy.

IT is said at a recent meeting of the council of Rush Medical College, a proposition to establish a chair of homeopathy met with considerable favor.

A WELL-DEFINED rumor is going the rounds that the Marion-Sims College of Medicine and the Beaumont Hospital Medical College, of this city, are to consolidate.

PRESIDENT MCKINLEY will be invited to be present at the coming meeting of the American Medical Association. This will give an opportunity for presenting convincing arguments as to the necessity of a department of public health.

THE St. Louis Medical Library Association held its annual meeting on Wednesday, April 26th, and the following officers were elected: President, Dr. N. B. Carson; Vice-President, Dr. J. H. DunDr. A. R. Keiffer; Librarian, Dr. F. J. Lutz: can; Secretary, Dr. F. L. Henderson; Treasurer, Board of Trustees, Drs. A. Alt, B. Lewis, S. Pollak, A. Ravold, G. C. Crandall and J. Grindon.

Up to and including Saturday, April 22d, $4,244,670 had been subscribed and pledged by the citizens of St. Louis towards the fund of $5,000,000 which will be required for the purpose of properly inaugurating the World's Fair, by which St. Louis proposes to celebrate the centennial of the Louisiana purchase. It is now definitely determined that the fair will be held in 1903.

THE sum of $200,000 is now available for the construction of the St. Louis City Hospital. According to Mayor Ziegenhein, work upon the new building will begin at once. The hospital will be built in sections and additions are to be made as rapidly as the money for construction is available. When completed, the hospital will be as commodious and perfect in every detail as any hospital in the world.

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ORIGINAL ARTICLES

THE THERAPEUTIC VALUE OF SOLUBLE SILVER.

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BY JOHN ZAHORSKY, M.D., St. Louis.*

N 1889 Carey Lea, by the action of such reducing agents as sodium tartrate and citrate, dextrin and tannin, on solutions of silver compounds, obtained a number of precipitates which he regarded as allotropic forms of silver. These, according to color and solubility, were regarded as a variety of forms. Thus he distinguished-(1) a dull blue-black precipitate which has a bluish-green metallic luster when dry and dissolves in water, forming a deep red solution; (2) a dark reddish-brown precipitate; (3) a bronzecolored precipitate which has the color of gold on drying. Subsequently other forms were obtained. Solutions of these precipitates contain the silver in a colloidal state, and hence arose the term colloidal silver. These forms readily pass into ordinary silver when treated with acids or salts, or subjected to the action of heat. The gold-like modification on being moderately heated becomes a brighter yellow which is less active and unchanged by salts. The conductivity of these substances is much less than ordinary silver. He regarded the first mentioned form as silver in its atomic condition. The gold-like substance was regarded as polymerized

silver.

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YEARLY SUBSCRIPTION, $1.00 SINGLE COPIES, FIVE CENTS

which is an ointment containing 15 per cent of colloidal silver.

The first is used for hypodermic medication and can be given per os; the second is administered by inunction. From one-half to two grains are thus administered.

From Crede's practice scores of cases have been reported in which this treatment attained marvelous results in various forms of septc infection. Werler, of Berlin, regards it as almost a specific in acute and chronic sepsis.

Wolfran, of Magdeburg-Buckan, finds it a valuable agent in acute and chronic infections. In chronic furunculosis particularly have the results been most gratifying.

Dr. Schirmer, of New York, reported several cases of cerebro-spinal meningitis cured by daily inunctions.

Seabury Jones has reported a remarkable case of puerperal sepsis which rapidly subsided under this treatment. Crede states that he has had no deaths from sepsis in his surgical hospital since the introduction of silver salts and colloidal silver.

ber of clinical cases reported to induce the clinician There seems, therefore, to be quite a large numto give this medicament a trial.

It is stated that eight to twelve hours after the of sepsis become ameliorated. inunction the temperature falls and all symptóms

How does it act? Crede laid stress on its anti

septic value; but in nearly all diseases reported a true septicemia did not exist, consequently it did not kill the bacteria in the blood. At most, only duced even when totally absorbed, hence its one to three grains of this silver could be introstrength in the blood would be 1 to 30,000 or 60,000. It is difficult to understand an antiseptic action in this dilution. Moreover, the fact that the

silver solution is chemically almost inert would

tend to throw doubt on its destruction of microorganisms.

It is impossible, therefore, to accede to the theory that it acts directly on micro-organisms when dissolved in blood. Crede has also asserted that it neutralizes toxins or renders then inert.

It is still more difficult to accept this statement since this silver does not unite with any albuminous substances, and, as far as we know, does not readily

combine with salts or alkaloids. Its activity, therefore, would have to be specific; and in the light of our present knowledge of biologic processes this is absurd. Its inactivity is further proven by the fact that it does not produce argyria, as silver salts. Moreover, it has been shown that the local use of colloidal silver is inferior to silver salts as an antiseptic; and, in fact, Crede asserts that its local antiseptic effect is due to the fact that lactate of silver is produced in the putrefactive process. This change can hardly take place in the organism, since such great difficulties present themselves on the theoretical consideration of the antiseptic value of argentum colloidale, that we must necessarily infer that the explanation is not correct. If it really possesses some antiseptic value as an internal antiseptic-and I believe this is still not proven-it must be explained by the fact that this silver in the blood acts as a cellular stimulant, as any other foreign body, or it does combine with some substance, and this becomes the cellular stimulant. We see, therefore, that while its therapeutic activity may be valuable in selected cases, it is far from being a specific in septic processes.

I believe an examination of the cases already reported will confirm this. The single case of Jones proves nothing. Only recently a case of puerperal septicæmia under the care of Dr. Chapman was equally severe, yet it recovered promptly under ordinary treatment. Moreover, it also had peculiar remissions and exacerbations which really seemed to be part of the diseased process.

Schirmer's cases are not conclusive, since they were in older children; and these frequently recover without much treatment.

About ten days ago I was called suddenly to a case of cerebro-spinai meningitis. The girl, six years old, was taken with violent symptoms, high fever, opisthotonos; strabismus followed in a few hours. When I arrived child was in a semi-comatose condition, rapid pulse, temperature 104°, sighing respiration and persistent vomiting. I did not think she would live six hours. I prescribed the iodides and bromides more as a placebo, also cold to the head and mustard to the spine. The next morning the child was so much better that I thought it marvelous, and even questioned my diagnosis. But the course proved my diagnosis to be correct, and the child is now convalescent. If I had used Crede's ointment, as I should have if some had been at hand, I should now be rather inclined to believe its action to be marvelous in cerebro-spinal fever.

A similar case occurred in the practice of Dr. Saunders. I saw a third case in consultation with Dr. Schuchat, and the patient had had practically no medicine, as he vomited everything for three days,

and yet he was doing very well. Another case was an infant eleven months old, with the same disease. Ung. Crede was used assiduously in large doses from the start, but absolutely ineffectively. Dr. W. B. Moore related the details of a similar case, without result. In the practice of Dr. Saunders there were two more instances of this disease in infants in which this treatment was used without benefit. Consequently I am not inclined to support Schirmer's deductions, that unguentum Crede is a very effective treatment for cerebro-spinal fever.

An analysis of the various cases of septic infection reported by Crunston, Werler, Wolfran, and others reveals the fact that in chronic and subacute infections the results were most definite. In acute arthritis, endometritis, etc., results were almost negative. Then again, local antiseptic measures were instituted in many cases; consequently it was impossible to ascertain the exact effect of the inunction.

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In a case of erysipelas under the care of Dr. Saunders and myself, ung. Crede was thoroughly rubbed in the healthy skin surrounding the inflamed area, but the inflammation spread without the least cessation, neither was the temperature modified. In several cases of acute cervical adenitis, rubbing in the ointment in the skin over them seemed to have no effect. Locally in two cases of superficial ulceration due to the secretion of a streptococcic rhinitis, little benefit was obtained. In one case of apparent threatened peritonsillar abscess it seemed to prevent pus formation.

Two cases in the practice of Dr. Saunders were encouraging. The first was a case of peritonitis following appendicitis in a boy five years of age. As it was impossible to ascertain the micro-organism causing the disease, we administered ung. Crede inunctions and hypodermic injections of Fisch's antistreptococcic serum. Under this treatment the patient rapidly improved and recovered in twelve days. The second case was a phlegmon of the thigh originating from a burn and due to the staphylococcus. Locally a corrosive sublimate poultice and ung. Crede inunctions in the opposite limb rapidly controlled the inflammation and fever. In view of these theoretical and experimental considerations, the conclusion is rational that the antiseptic value of soluble colloidal silver on the organism in general is still not proven, and we must as yet regard its efficiency as doubtful. In chronic infections it certainly deserves a more extended trial; but in acute infections, it should not be relied upon exclusively. The evidence so far accumulated shows that it has some value in staphylococcic infections; but in those due to other pathogenic bacteria, beneficial effects are

very doubtful. It has been suggested that administration per os might be valuable; but the

chances are that the gastric and pancreatic juice would change it into ordinary silver or its salts. The recommendation, therefore, to give it in this way seems rather absurd, and its effect in gastrointestinal infections can be no more than any of the silver salts. As clinicians we must wait for more experimental and clinical evidence before placing this medicament among our valuable therapeutic agents.

1635 S. Grand Avenue.

A CAPSULO-TENECTOMY.*

The Most Accurate and Dependable Operation for
Certain Cases of Squint or Insufficiency
of External Eye Muscles.

BY FRANK W. HILSCHER, M.D., St. Louis, Mo.

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HE unknown amount of correction obtained as an ultimate result in most operations on the recti muscles of the eve, induced me to make a special study of the subject with the object, first, of locating or defining the causes which make the result uncertain; and, secondly, if possible, to correct faulty methods of procedure, so as to be sure of definite and permanent results following surgical intervention.

That I have succeeded in solving all these difficult problems, I shall not for a moment contend, for a subject involving so many modifying factors as this will no doubt be one for discussion for many years to come, and will still continue to tax the ingenuity of the laborers in this field.

With your kind permission, I will give you here, however, the principle points resulting from my experience with the subject.

First, I wish to call your attention to something not new, but well known, but frequently sadly neglected or poorly done, and that is the optical treatment of squinting eyes. This is so common that I feel it my duty to reiterate it.

Every ophthalmologist knows that the great majority of squinting eyes are amblyopic. And why? Not only because the affected eye is not used (amblyopia exanopsia), but because such eyes generally have great errors of refraction and because their vision would be imperfect even though they were in line. He also knows that eyes which have become blind, or partially blind, from disease or injury will often deviate from parallelism to one side, in consequence of the loss of stimulus caused by indefinite images upon its retina. Therefore,

requires very careful examination under a powerful mydriatic. If refractive error is detected, this should be very carefully worked out objectively, and neutralized by correcting glasses. Subjective examination in these amblyopic eyes is usually of very little service, consequently it sometimes requires much patience and diligence in measuring the error. But, thanks to retinoscopy, this is now possible and practical to those exercising the necessary skill and patience.

By wearing the correcting glasses a very large percentage is cured without further procedure. By blindfolding the better eye for an hour or two every day the poor eye will gain immensely. After the vision of this eye is better and the squint still exists, there is no other recourse except operation. By way of operations, tenotomies, of course, will always be most commonly performed, largely, I suppose, because they are easily done, with little inconvenience to either the patient or surgeon; they certainly at present occupy first place. The immediate effect also can be varied considerably, all the way from the buttonhole of Stevens' or Snellen's to the extensive dissections in which the

check ligaments are loosened.

The ultimate effect, however, is an uncertain

quantity, and is one of its principle objections. Another is the sinking of the caruncle; exophthalmos sometimes follows very free tenotomies of the interni. The variation, I think, comes from the nature of the new attachment of the tendon to the

globe, which we know differs considerably. Sometimes the new attachment is strong, and, being spread over quite a considerable surface, gives

more chance for cicatricial contraction and consequent shortening; on the other hand, we may have a rather loose'attachment with, perhaps, no firm hold to the sclerotic, but in the episcleral tissue or capsule only. Thus the antagonist may draw it too far to that side, and we have, perhaps, a permanently weakened muscle; and so, after having nicely straightened a pair of crooked eyes, the case comes back again in a year or two with another deviation. Convergence is apt to be excessively weakened. There are strong objections to tenotomies, and though binocular vision for distance results at near should be displaced largely, perhaps entirely, by range, it may be absent; which argues that they other improved procedures.

Therefore, various operations have been devised for advancing the insertion or shortening the weak muscle. Some of these are very good, many worthless, and others difficult of execution and variable in results. Many are open to the same objections as tenotomies, viz., that the new attachsquint-ment of the tendon to the globe is insecure and alterations are frequent, sometimes from contraction, and at other times from relaxation of the

very careful attention must be given to the squint ing eye first to enable it to see.

*Read before the St. Louis Medical

This, of course,
This, of course,
Society, April 1, 1899.

cicatrical tissues, of which the new attachment must necessarily be formed.

In view of the general character of scar tissue and the smooth, spherical surface to which it must be attached, it is certainly not to be wondered at that results greatly vary sometimes in the same operation. I have seen these operations performed by others as well as myself, and I feel sure all who have had experience with the operations, will agree with me that, unless in advancement operations, one anchors the stitches in the sclerotic instead of episcleral tissues and conjunctiva, only he can not be sure that they will hold.

Then again, we cannot feel so secure in making these stitches in the sclera, especially as it is always in the ciliary region. I do not know that any such cases have been reported as giving rise to iridocyclitis, but I have seen irritation from this source coming dangerously near this condition; and, as there is usually so much reaction from this operation in any event, operators of limited experience are apt, from timidity, to be deterred from giving their patients the advantage of such a procedure. How, then, can we obviate this unreliable attachment? Can we make one stronger, firmer, safer and easier of execution? I am sure we can, and at the same time we can graduate the amount of effect desired to a nicety. Of course, scar tissue can not be entirely obviated, as there will still be some at the union of the cut surfaces, but we can reduce it very much indeed.

Instead of a broad attachment on the surface of the eyeball itself, which is frequently insecure and liable to stretch-or, if secure, liable to contract-I make it in the tendon and capsule (Tenon's) a fractional distance from the eyeball; in other words, I cut the tendon with the overlying capsule, leaving a short stump of tendon, exsect a sufficient piece of tendon and capsule, and unite the edges by three or more interrupted sutures, thus bringing their cut surface into exact apposition. This makes a small linear wound, which heals rapidly and firmly with exceedingly little scar tissue or reaction, and leaves the natural attachment of the tendon to the sclerotic unaltered, hence firm and strong. such a wound there will be practically no contraction, hence little or no variation of result from this cause, and consequently the method admits of great exactness as to the result required. In addition to a strong, firm union there results a smooth surface, with no deformity or disfigurement so frequently consequent upon other methods.

The operation is performed as follows:

In

Under local anesthesia, or in children under general anesthesia, I begin with or without tenotomy of the antagonist, according to the decree of rotation required. If the effect desired is not very great, or if there is more or less exopthalmos,

it is best not to make a tenotomy, but proceed at once to shorten the muscle and capsule. The tendon is grasped at its lower edge, just back of its insertion, through conjunctiva and Tenon's capsule, by opening the fixation forceps vertically about five or six millimeters, and pressing firmly against the sclerotic, then closing with firm hold, so that not only the conjunctiva but the tendon and capsule are included in its grasp, raising thus a horizontal fold. This fold is incised with strabismus scissors by vertical cuts, the first dividing the conjunctiva, the second, Tenon's capsule containing the tendon; I now see that the lower blade of my scissors is beneath the tendon, when the cut is made upward until the tendon is completely severed, cutting straight through the tissues perpendicularly to its surface, thus leaving a small stump of tendon with the capsule and conjunctiva superimposed in their normal relation. With my curved but slighty blunt scissors I now undermine the tendon and capsule underneath the forceps, and free it from adhesion, as is done in tenotomy. When this is accomplished, I pass a curved needle on a doubly armed suture of strong black silk, through the tissues from the scleral side out through the middle of the tendon and as far back as necessary, so that the suture remains in the tendon and tissues after the portion to be exsected is removed. The forceps are now loosened, as the tendon and overlying tissues are secured by the thread, and the cut edge of tendon, capsule, and conjunctiva picked up, either by the forceps, or two sutures (one through the upper and one through the lower margin), and held on the stretch toward the corner; then, with a straight scissors, a piece is cut off according to the amount desired. The eye is rotated about the length of the exsected piece of tendon and capsule. The cut made in the portion containing the tendon is made parallel to the cut edge and in front of the first suture, after which it joins the first cut in the shape of a "V" below and an inverted "V" above.

The needle on the scleral end of the suture is now passed through the middle of the stump, another suture is similarly placed above and one below, but parallel to the first suture, and the three tied securely, the middle one first.

I might explain that the sutures include and unite the outer edges of conjunctiva at the same time, though in exsecting the piece of tendon and capsule it is not necessary to include any conjunctiva which usually retracts out of the way.

The sutures are left in situ five to eight days. It will be seen from this description that it somewhat resembles the Schweigger's operation, in which there is an exsection of a piece of the tendon only, and a union of the tendon with catgut, while the conjunctiva is stitched with silk. I

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