of Dresden. We have been for decades looking in vain for an effective antiseptic which is devoid of marked toxic or irritating properties. Allotropic silver (collargolum) seems to offer us the nearest approach thereto. Between this silver preparation which is so bland and the silver salts like nitrate of silver, there are the lactate and citrate of silver, also introduced by Credé, of which reasonably strong solutions can be used upon quite sensitive surfaces without producing much if any disturbance.

Let us first take the aqueous solution of soluble metallic silver (collargolum), which in its strength of 1 to 500 in distilled water makes a somewhat cloudy solution. In this strength it may be used by intravenous injection in cases of severe general or puerperal sepsis, rapidly spreading gangrene, acute articular rheumatism, or other serious infections. In fact, solutions as strong as 1 to 100 may be employed; it being desirable to introduce cg. (.9 grains) to 10 cg. (1 grains) at least. If there be difficulty in injecting it into a vein it may even be given beneath the skin. Unpleasant effects will not be noticed, neither will any immediate relief follow, but the solution thus introduced coming into contact with the blood, which in these cases is swarming with germs, will promptly begin its bactericidal work, whose effects should be manifested after two or three hours by a fall of temperature and amelic ration of septic symptoms. Silver used in this way has been of great service in cases of carbuncle and even of acute anthrax. Moreover, its administration may be repeated as often as may seem necessary.

When metallic silver is made iuto a suitable ointment (Unguentum Credé) which, by the way, much resembles mercurial ointment, and is then applied to the skin, there is a rapid absorption of the silver itself with its dissemination into the blood stream and results like those just mentioned. It is simply a somewhat slower method of introducing it into the system. For many years I held and taught that the combination of resorcin, ichthyol and mercurial ointment, which I believe I introduced into surgical practice, was the most effective remedy for the treatment of erysipelas and all other septic infections. To-day I have found but one combination which I think superior for this purpose, and that is the silver ointment-Unguentum Credé. I believe that its properties are more marked than those of the

ointment which I so long used. No matter what part of the body be anointed absorption takes place readily and promptly, consequently any convenient surface may be medicated in this way. Cleanse the skin thoroughly, smear the ointment freely over the surface, cover the area with oiled silk, and put over this, if comfortable to the patient, a warm application to promote absorption. If the surface be not tender, the ointment may be rubbed in. In cases of puerperal sepsis it may be applied over the abdomen or to the inside of the thighs. In erysipelas it should be applied to the affected part. It makes very little difference what the exact nature of the infection is, one may rely upon it that the silver will be absorbed and will do good work. This is true for instance in such acute infections as endocarditis and meningitis.

Advantage may also be taken of the properties of metallic silver by giving it internally as an intestinal or urinary antiseptic, for which purpose it should be given in pills or capsules. These are unirritating and extremely efficient, and may be given where remedies like salol, benzozol, etc., are ordinarily exhibited.

Lastly, I would speak of the use of lactate and citrate of silver, not only for such purposes as the preparation of catgut, silk, gauze, etc., but in solutions of from 1 to 300 or 1 to 500 for the irrigation of septic cavities, and for such purposes as washing out the peritoneal cavity in cases of tuberculous peritonitis, for which I have repeatedly used it, and always with benefit. I differ from my friend, Dr. Fenger, of Chicago, now dead, who did not favorably regard washing out the abdominal cavity in these cases. In my own experience, in several instances, a flushing of that cavity with a 1 to 500 solution had been of the greatest apparent benefit, and has never occasioned any regret. Infected bladders, uterine cavities and vaginas may be advantageously, freely and frequently washed out with similar solutions. When using them one may have the feeling that he is using solutions of greater efficiency and of far less toxicity than any of the mercurial preparations would afford. Therein lies the beauty of these preparations, that in anything like equal strength they are more effective and much less toxic than the mercurial salts.

This is a very brief epitome of my views regarding the value

of the silver preparation in surgery. I often state in my clinic that the good old-fashioned nitrate of silver is not used nearly so much as it should be, and prove the strength of my conviction by its general use in one to ten per cent. solution in pus cavities. Not only is a full germicidal effect obtained, but also that stimulation to healthy granulation which the nitrate is well known to afford. All in all, if I could have but one source for antiseptic solutions and applications I would rather look toward the preparations of silver than in any other direction.

Clinical Reports.

CLINICAL SOCIETY OF THE NEW YORK POLYCLINIC MEDICAL SCHOOL AND HOSPITAL.

MEETING HELD JANUARY 4, 1903.

The President, Dr. Alexander Lyle, in the chair.

TRACHOMA.

Dr. Earl Connor read a short paper on trachoma. He said in part: Under "trachoma" are grouped a variety of conditions apparently dissimilar, whose chief characteristic is hypertrophy of tissue. Clinically, we can safely accept the teaching of Prof. Born as to the differential diagnosis. First, there are cases which may be classed under the head, a lymphoid or follicular or granular conjuctivitis. The condition is one of slight consequence to the health of the eye, as it may exist for weeks or months until absorption takes place and the mucous membrane returns to its normal condition. Cases in which lymphoid hypertrophy and ulceration co-exist, the so-called "mixed lead to confusion. These are the ones that are subjected to operation and promptly cured; but they get well under the use of simple astringents and by the correction of the strumous condition which underlies it. The cervical glands are nearly always hypertrophied.

cases,

True trachoma is characterized by minute ulcers on the epithelial surfaces of the conjunctivæ and cornea, with more or less

profuse cell infiltration. In the lymphoid cases, there are no changes in the structure of the lids or cornea. In the ulcerous type the changes are more or less extensive and progressive, and it is not a self-limited process. The infiltration and cicatrization continues until a state of atrophy of the conjunctiva is reached, and a more or less dense opacity of the cornea results.

Sequela. It is only the patients who have the lightest attack, or those who come under treatment early, who escape more or less serious impairment of the eyes. Distortion of the eyelids, with faulty disposition of the cilia is common. In extreme cases the cilia are brought into constant contact with the cornea, causing pain and increased reduction of the poor vision by cell infiltration. The contraction of the cicatricial tissue causes atrophy of the mucous glands, and, in the final stages, reduces the conjunctiva to a dry, cuticular membrane.

Corneal opacities are the after-effects of both ulcers of the cornea and of pannus. A recent pannus, it is true, may disappear completely by a process of reabsorption, so that the cornea reacquires its normal transparency, but often further changes take place in the pannus which render its disappearance impossible. Transformation into connective tissue occurs if the pannus is of long duration. Such a cornea never becomes perfectly clear again. This is true of cases in which the pannus is complicated by ulcers; the regions which are occupied by the latter likewise become permanently opaque. Trachoma is a disease which is distinguished by its duration, in many cases rendering those who are attacked by it wholly or half blind. Add to this the fact because of its infectious nature it is exceedingly apt to spread, and one can understand why in those regions in which it is endemic, it is a veritable scourge.

Treatment. In the acute stages the application of silver nitrate until the secretion is lessened, and then of sulphate of copper (blue stone) as the condition demands more or less stimulation, will give the best results.

Dr. W. E. Lambert, opening the discussion, said that there is a great deal of uncertainty regarding the pathology of trachoma, as the bacillus has not yet been discovered. There is little doubt, however, that it is contagious. The so-called various forms of trachoma are simply different stages of the disease. He

differed with Dr. Connor as to treatment, stating that he was convinced by considerable experience that in all cases in which granulations are present, the operation of expression gives the quickest and best results.

RENAL CALCULUS.

Dr. J. A. Bodine showed a renal calculus which he had removed from the pelvis of the kidney of a patient 55 years old. For the past nine years the man had suffered from a dull, aching pain in the right loin. During the first two years this pain was characterized occasionally by acute exacerbations, which were so severe as to necessitate rest in bed and opiates for relief. During the past five or six years, however, these exacerbations lessened in severity and duration. He found that by lying down and raising his feet above the level of his head, the pain would disappear. His urine at no time showed kidney detritus or abnormality of any kind. A radiograph was taken, and showed accurately the presence of the stone. Its removal was very easy, and if, the speaker said, in all kidney work the placing of the patient in a prone position, over an air cushion, were taken advantage of, surgery of the kidney would be greatly facilitated. In this case, when the kidney was withdrawn through the wound, the stone was felt lying in the pelvis. An incision was made through the parenchyma of the kidney, along its convex surface, sufficiently large to permit the introduction of a finger into the pelvis over the stone. Incision into the pelvis of the kidney offers greater liability of persistent urinary fistula, and unless such incision can immediately be sewn up, it is better to make the incision through the renal substance. This case demonstrated the fact that the primary renal calculus may remain for years in the pelvis of the kidney without exciting inflammatory changes in the renal tissue or causing abnormalities in the urine. The change in the acuteness of the exacerbations of pain was another proof that in primary stone in the pelvis of the kidney the danger and pain are in inverse ratio to the size of the stone.

GLASS REMOVED FROM THE EYEBALL.

Dr. W. E. Lambert showed a piece of glass which he had removed from the lens of a patient, preserving the eyeball in a practically normal condition.