T H E D U B L I N J O U R N A L OF

M E D I C A L S C I E N C E .

A P R I L 2, 1888.

PART I.

O R I G I N A L COMMUNICATIONS.

ART. X I I I . - - , V o t e on Silver-stainlng (Argyr la ) . a By A a T g c a WYNN~ FOOT, M.D., Univ. Dubl. ; Senior Physician to the Meath Hospital; Vice-President of the King and Queen's College of Physicians in Ireland; Professor of the Practice of Medicine, Royal College of Surgeons in Ireland; Fellow of tile Royal Academy of Medicine in Ireland; Diplomate in State Medicine, Trinity College, Dublin.

IT will be within the knowledge of the members of the Profession that some correspondence has taken place in the medical journals of late b on the subject of " discoloration of the skin by nitrate of silver." The gist of this discussion is merely as to the place of entrance of the silver into the body, for that discoloration of the skin was likely to follow the internal use of nitrate of silver has been known to all since the subject was brought before the Medico-Chirurgical Society of London by Dr. L A. Albers, of Bremen, in a paper read before that body, November 14, 1815,~ in which Albers reported a case of his own along with three others communicated to him by Dr. Schleiden, of Hamburg.

The point under discussion at present is the occurrence of stain- ing" after the local application of nitrate of silver to the throat. On the 22nd of October last Dr. Barclay Baron reported a case of

a Read before the Section of Medicine in the Royal Academy of Medicine in Ireland, Friday, December 16, 1887. [For the discussion on this paper see page 172].

b Brit. Med. Jour., Oct. 22nd and Nov. Sth, 1887, pages 881 and 992. c l~Ied.-Chirurg. Trans. Vol. VII . , p. 284.

VOL, L X X X V . - - N O . 196, T H I R D SERIES. X

29~: Note on Silver-staining.

discoloration of the skin by nitrate of silver used for swabbing t h e throat. On November 5th Dr. Wi]ks wrote that he had met with a similar case in a mlddle-aged woman who had never taken any nitrate of silver internally, but had been in the habit of applying it to her throat every day for two years. In the same number of the journal Dr. Duffey drew attention to a report of two similar cases given in the P~.actitioner in 1875 (Vol. XIV., p. 462).

I t is in reference to this subject that I now offer a note on the occurrence of argyria or silver staining from the long-continued employment of nitrate of silver to the throat. The drawing which I exhibit gives an admirable representation of the violet-gray metallic colour of the patient. The skin of the entire body was discoloured, but that of the uncovered parts, such as the face and hands, was most so. The nails and the mucous membranes of the mouth and eyes were stained. This drawing was made twelve years ago. The man is at present alive and well, and his condition is unchanged, except that he is not quite as dark as he was twelve years ago. A t the time the drawing was made (1875) this man had excellent general health, and was about his business as a working jeweller every day. I examined his urine at that time for what is called "argentine albuminuria," and found no evidence of it. On the back of the drawing the notes written at the time were that thirteen or fourteen years previously he was under treatment in the Meath Hospital (under the care of the late Mr. Josiah Smyly) for "lumps in the throat." He had derived so much benefit from the use of solid nitrate of silver, locally applied, that after his discharge he provided himself with sticks of lunar caustic, and continued to apply them diligently for about eight years, when he desisted owing to the alteration in the colour of his skin becoming apparent. His appearance was peculiar and so remarkable that one day in the town of Waterford some children took fright at him and ran away, crying out that he was the devil.

There can be little doubt that in this case much of the nitrate of silver applied to the throat was swallowed, and so the case will come under the category of those who have taken silver nitrate internally for long periods because of chronic affections of the nervous system, such as tabes or epilepsy. Neumann has reported the case of a physician affected with ulcer of the stomach who, for several months injected two or three times daily into his stomach by means of the cesophageal sound a solution containing about 1"5 gin. of silver nitrate. After about twelve doses the first indi-

By DR. A. W. FooT. 295

cations of the discoloration are said to have appeared. This appears to have been an extremely large dose, equivalent to over 20 grains. I t is remarkable that the attempts which have been repeatedly made to produce argyria artificially in animals by long-continued feeding with silver nitrate have hitherto been always attended with negative results as regards the skin.

Microscopic examination of the human skin shows that, while the epithelial portions, the rete mucosum, and the glandular epithe- lium, are altogether free from depositions of silver, there are throughout the connective tissue portions of the skin accumulations of the finest granules of silver. These deposits of silver are most dense immediately beneath the epidermis in the uppermost layers of the papillary body and in the membran~e propri~ of the sweat- glands. I t has been long observed that in these cases of silver- staining blisters rise white as they do in negroes, the dark granules of reduced silver lying chiefly in the curls.

As to the chemistry of the process, Reimer's views are considered most probable. He assumes that the silver, having been reduced in the intestine, and being in a state of the finest subdivision, is taken up by the chyle-vessels, transported into the blood-current, and then deposited ia the various organs. There is a difficulty in reconciling this view with the indisputable fact of the influence of light on the staining of uncovered parts, for the colour of the reduced silver can no longer be altered in any way by the light. Were it found in the tissues as the insoluble chloride the pigmen- tation would be very intelligible, as the white chloride is very sen- sitive to light, especially in the presence of organic matter, and it is upon this fact the phenomena of photography depend. Post- ~nortem examinations show that the discoloration is not limited to the skin and superficial mucous membranes, but may extend to the liver, spleen, kidneys, and intestinal mucous membrane. In the internal organs the deposited silver is chiefly in the wails of the smaller al~eries. In the kidney the silver particles lie principally in the medullary zone, and give it a dark gray tint. The central nervous system appears to be exempt from depositions of silver granules2

In the present state of our knowledge argyria must be considered an incurable affection. :Neumann b alone reports that in a case under his observation, according to the statement of the patient,

�9 Von Ziemssen. Handbook of Skin Diseases. P. ~55. b Von Ziemssen. Handbook of Skin Diseases. P. 455.

296 Note on Silver-staining.

the intensity of the stain decreased in the course of several years. Duhring a refers to two cases, reported by Dr. L. P. Yandell in the American Practitioner for 1872, where iodide of potassium together with mercurial vapour baths were successfully employed. The patients were syphilitic, and took from ten to sixty-grain doses thrice daily for a period of months. In both cases the fading of the discoloured skin was gradual ; in one a faint trace remained, in the other the cure was complete. In the case of which I submit the facts in this paper the course I adopted was to give potassium iodide and sodium hyposulphite in alternate weeks--one week the iodide in ten-grain doses thrice daily, the next week the hyposul- phite in twenty-grain doses as often. The object of this process was an attempt to convert the deposited silver into an iodide which is readily soluble in an alkaline hyposulphite, but it is very doubtful whether these changes can be effected in relation to the living body with the safety and certainty they can in the laboratory.

The man considered that his colour improved under this treat- ment, but as he would attend only as an out-patient, and was often absent in the country for considerable periods, the method did not receive a fair and patient trial.

As the discoloration of the skin after its prolonged use is not the only disadvantage of the silver nitrate, I was glad of late to have come across Curci's b researches on the biological action of silver. In his communication thereon he recommends the double hyposul- phite of sodium and silver, this salt being soluble, non-irritant, not coagulating albuminoids, and readily absorbable by the subcuta- neous connective tissue. I t is also very diffusible, and promptly absorbed by the mucous membrane. He claims for it that its action on the nervous system is surely and quickly obtained, and the risk of argyria is avoided. I have had the double hyposulphite made and given it repeatedly in half and three-quarter grain doses subcutaneously, and in half-grain doses by the mouth three times a day. Its taste is sweet~ and it should be given fasting or h)To- dermically. My experience with the double hyposulphite of sodium and silver has been limited, and I am not yet prepared to endorse all that has been said in its favour. Curci recommends that the internal use of the nitrate should be abandoned, since in contact with the mucous membrane it is rapidly altered, and may cause argyria even without its action upon the nervous system having ever been obtained.

�9 P. 875. 3rd edition. 1883. b London ~Ied. Record. 1886. P. 210.