\if ON THE TREATMENT OF IRITIS WITHOUT MERCURY. BY HENRY W. WILLIAMS, M.D., ONE OF THE SURGEONS OP THE BOSTON DISPENSARY. Read bbfore the Boston Society for Medical Observation, August 4th, 1856. Re-printed from " The Boston Medical and Surgical Journal." BOSTON: PRINTED BY DAVID CLAPP, Over 184 Washington Street. 1856. TREATMENT OF IRITIS WITHOUT MERCURY. Whoever proposes an important, deviation from the canonical precepts of our profession, is bound to justify his innovation by more than a mere array of statistics, given on his own authority, stating that a certain course has been pursued in a given number of cases, with such and such results. He should produce ample evidence of the nature of the disease he professes to have encountered, by de- tailed descriptions of the symptoms ; otherwise, it may be doubted, by those to whom he is personally unknown, whether ihe cases to which he refers were really instances of the disease in question, or whether the severity of the attacks was such as to constitute Ihem fair specimens of ihe disease. These points being established, it remains for him to exhibit the efFects of treatment, and to justify ihe value he ascribes to it. As a general rule, the universal approval of any plan of treatment is prima facie evidence of its excellence ; but there are not wanting instances where the profession has condemned and abandoned the practice it had deemed correct. As respects iritis, there are peculiar reasons why ihe course inculcated by ihe highest authorities has been deferentially followed by those who have succeeded them. It was not till ihe beginning of the present century that iritis was re- cognized and described as a distinct disease. Its symptoms and grave results having been ihen forcibly brought to the notice of the profession, they were enjoined to lose no time in resort in «■ to ihe use of appropriate means for checking those symptoms, lest the golden opportunity should be lost and never regained. Thev were taught, that to ensure the safety of the organ of vision, and the pre- servation of its powers, it was necessary to employ, at once, vigor- ous antiphlogistic and alterative measures; and, especially, that unless ihe system could be speedily brought under ihe influence of 4 mercury, it might be too late to secure its salutary influence, which, above all, it was essential to obtain. Knowing, as we do, the serious consequences of the unchecked disease, we can understand how it has happened that physicians have felt unwilling to incur the consequences of delay, and have hastened to follow the course marked out as the only path of safety. The number of cases falling under the care of most physicians haa been loo small to allow them to form confident opinions of their own, and they have concurred in the treatment which seemed to be adopted by general consent. The successful cases have been passed to the credit of the remedies ; the unfortunate results have been ascribed to the formidable character of the malady, the constitution of the patient, his delay in invoking medical aid, or his insuscepti- bility to the influence of the specific treatment. But it is obvious that if we can, safely, spare our patients the in- fliction of heroic remedies, from the effects of which they may be months in recovering, we confer a great benefit on them, and obtain another triumph for our profession. The conclusions arrived at in this paper are based upon sixly- four cases of iritis, of every degree of severity, including its idio- pathic, traumalic, rheumatic, and syphilitic varieties. To these might be added others, where the patients have not remained under my observation, but where I have heard of a successful result of the Ireatment advised. The sum of the above embraces all the cases I have met with since I fully adopted the treatment described, and is not a report of the favorable cases only. In no instance within my knowledge have the results obtained been less fortunate than in the cases which will be related. Not to weary the attention of the members of the Society by a repetition of almost precisely similar symptoms, details will be given of a small number of cases only ; but sufficient to afford the evi- dence, which, as I have already shown, should be demanded, to sustain the positions assumed. It is proper, however, to state, that in forty-three of the cases alluded to, my diagnosis has been con- firmed by other physicians with whom I have seen the patients; and among these a considerable number are colleagues in this Society. The number of cases may seem too small to warrant their being brought forward ; but it appears considerable, when we reflect that iritis is, comparatively, a rare disease. I was first induced to vary from the plan of treatment we have 5 usually pursued, by having under my care, within a short period, several cases, where, on account of the age or constitutional condi- tion of the patients, it seemed desirable, if possible, to dispense with depletion and mercurials. The improvement was in some of these cases so rapid, and their termination so unexpectedly favorable, that the same method was cautiously adopted in the treatment of oiher patients. Case I.—Mr.----, a gentleman of middle age, was seen in consultation in ihe midst of a severe attack of iritis, on the 25th of April, 1854. He was subject to rheumatism, but free from other constitutional affection. The pain in and above the eye had be- come so severe that he was unable to obtain sleep, even under the influence of large opiates. The photophobia was so intense that he remained in a room from which light was wholly excluded, and it was with difficulty that he could support an instant's examination of his eye. The pupil was extremely contracted, irregular and hazy, and the sclerolical injection very vivid. Vision was almost abolished. The previous treatment had consisted in an application of leeches to the temple, and a cathartic of blue pill, together with opiates to relieve pain. We at once applied a solution of atropia (ten grains to an ounce of water) to the conjunctiva, and directed that the application should be repealed in the afternoon. To bathe the eyelids frequently with an infusion of rose leaves and poppy capsules. Quin. sulph. gr. i. ter die. Ten grains of Dover's powder to be taken at once, and, if the pain becomes aggravated towards evening, to take the same every hour till the pain is relieved. He had little appetite, on ac- count of the suffering he had experienced, but wras encouraged to eat as much as he felt inclined to do. 25th.—Slept very little on account of pain, which is still very se- vere. Has rather less intolerance of light; but there is no diminu- tion of the sclerotical injection, and the pupil has not yielded to the atropia. The iris is considerably discolored. Continue quinia. Potass, iod. gr. v. lev die. Substitute liq. morph. sulph. for the Do- ver's powder. Apply four leeches to temple. Employ the solution of atropia as yesterday. May take game. 27th.—Had a more comfortable night. There is a little less in- jection and photophobia, but the pupil remains as before. 23th.—Had more appetite and less pain yesterday. The pupil is enlarged in some directions, but slightly adherent at other points. 6 Less intolerance of light. Same treatment as yesterday, with ihe addition of an enema to procure an evacuation. He was advised to allow more light and air in his room, but to wear a shade over his eyes. Good diet. 29th.—Less injection. Pupil has become more dilated. Had a more comfortable night. I did not see him on the 30th ; but on the 1st of May his physi- cian again requested my attendance, as he had imprudently gone out of doors in unfavorable weather, and the symptoms had become aggravated. The eye, however, recovered at once from ihis re- lapse, and my attendance ceased after three more visits. During this time the pupil became well dilated, the injection of ihe eye rapidly diminished. The treatment was gradually discontinued, and when I saw him, some weeks after, the eye was entirely well, and the ad- hesions of the edge of the pupil had given way. He has had no recurrence of the disease. This case must certainly be considered as a severe attack of rheu- matic iritis, yet the urgent symptoms began to yield on the fifth day from the commencement of treatment, and the entire duration of the disease was but a brief period. The recovery, notwithstanding the temporary synechia, was perfect. Case II.—Mr.-----, clerk, aet. about 35. Is of lymphatic and debilitated constitution, and has a sedentary occupation. Not sub- ject to rheumatism. Never had syphilis, but only a discharge from urethra. June 25th, 1854.—He ascribes his attack to an exposure to reflection of the sun's rays from ihe water. The sclerotica was considerably injected, the anterior chamber so hazy that it was impossible to see the precise condition of the pupil, and vision very indistinct. The circum-orbital pain was not very severe. Conside- rable photophobia. Applied atropia. Ordered pil. cathar. co. gr. x. Liq. morph. sulph. to be taken during the night pro re nala. Quin. sulph. gr. ii. ter die. 26lh.—No improvement. Passed a restless night, but has less pain this morning. No enlargement of pupil. Re-applied atropia. Continue quinia. Three leeches to temple. Soothing fomen- tations. 27th.—Much the same as yesterday. Tn the afternoon he sent for me on account of an access of more severe pain. Three leeches to temple. Potass, iod. gr. v. ter die. 1 28th.__Has been more comfortable, and the pupil is perhaps slightly enlarged by the atropia. Anterior chamber less hazy, but there is slight hypopyon. He bears the light better. Continue medicines. 29th.—Hypopyon rather less. Pupil larger, but not perfectly round. Vision less hazy. Little pain. 30th.—Still improved. Less hypopyon. Less injection. No pain. Discontinue quinia. Appetite permitting, may take more food. July 3d.—Has steadily improved. Hypopyon absorbed. Walk- ed out a short distance. 5th.—Discontinued visiis. Eye is still slightly sensitive to light, and vision has not yet become perfect for small objects. In three or four weeks he had fully regained the use of this eye. Several months after this he had another, still more severe, attack, causing much apprehension in the minds of two gentlemen who saw him for me during my absence for a day from the city. But from this he recovered in three weeks, so far as to require no further treatment, although vision did not become absolutely perfect until some little time after the disappearance of all external traces of in- flammation. Case III.—Mr.----, set. 30, painter, was seen in consultation on the 3d of October, 1854. Has suffered very much from rheu- matism, from the effects of which he has not yet recovered. Gene- ral aspect feeble. Had chancres about nine months since. He says he had no uneasiness in his eye till a week since, and was then advised lo use a collyrium of nit. argenli, with calomel as an inter- nal remedy. For three or four days past his left eye has become much worse, vision being abolished. He has had much circum- orbital pain, and last night was unable to sleep. The eye exhibits considerable conjunctival and sclerotica! injection. The anterior chamber is very hazy, so that the exact condition of the pupil can- not be seen. The iris seems little altered in color, but has a dull aspect on account of the haziness just referred to. It has none of the greenish or reddish discoloration often seen in syphilitic iritis, and no tubercles of lymph are to be seen on its surface. The pupil is contracted, and its edge appears to be united to the crystalline capsule by a deposit of lymph. The solution of atropia was put into his eye. Quin. sulph. grs. ii. ter die. Ten grains of Dover's powder at night, and repeat the dose if required to ensure sleep. Good diet. 8 4lh.—Had a comfortable night after one dose of Dover's powder. Has no pain to-day. Pupil is not dilated by the atropia, but the anterior chamber seems clearer and the injection of the eye a little less. Repeat remedies. 6th.—Has been free from pain, and the eye is losing its injection. The pupil remains fixed, and he has no vision, but only a perception of light. The anterior chamber offers a curious appearance—as if a false membrane which had lined the cornea and rendered the ante- rior chamber dim to the eye of the observer, had become separaled and had shrunken to one half its dimensions, its edges being shri- velled. This membrane appears to be connected at its centre with another false membrane deposited on the anterior surface of the lens, and to which the edge of the pupil seems adherent. 8th.—The false membrane mentioned on the 6th, seems to have become absorbed from the anterior chamber. The central portion of the capsule of the lens is still covered with a cloudy deposit, but the pupil is dilated so as to leave a narrow clear space around this deposit, and he has some vision. 11th.—He has taken cold, and there is some lachrymalion and more redness of the globe, but the state of the pupil is improved. 13th.—He had so much pain that he took an opiate on the even- ing of the 11th. The pupil has become perfectly clear, except a single shred of false, membrane, and vision is quite good, though not yet perfect. 18th.—Vision continues good, though he has had two attacks of pain, probably occasioned by very unfavorable weather. 24th.—Vision is good for large objects. Pupil clear. Eye not sensitive to light or air. Discharged cured. Some time afterwards vision had again become perfect for small objects. This case was one of great interest, from its probable syphilitic complication, and from the perfect re-absorption of very extensive effusion, rendering the result a far more fortunate one than I had anticipated. The prognosis, at the lime the patient was first seen, was quite unfavorable. Case IV.__Mr.-----, set. 24, returned from California at the end of September, 1854. A year since he had chancre, followed by a small bubo, which discharged a little pus. Has lately had rheuma- tism. Has been subject, as well as I can judge from his statement, to attacks of conjunctivitis, easily subdued by applications of cold water. 9 A week since, he began to have uneasiness in right eye, and no- ticed dimness of vi>ion. Cold water gave him no relief. Has had some pain in temples when facing the lamp in the evening, but has slept free from pain. Was first seen on the 25lh of October, 1854. The right pupil is contracted, and adherent at numerous points around its entire margin. It dilates but very slightly, and only at some points, under the influence of solution of atropia, ten grains to the ounce of water. There is no discoloration of iris. The anterior chamber and the field of the pupil are slightly cloudy. Vision is very dim. Sclero- tica slightly injected. Ordered an infusion of rose leaves and althea root, to be used, tepid, as a lotion. Quin. sulph. gr. iss. ter die. 27th.—He says ihe pupil remained small and irregular after the application of the atropia, but the next morning it had dilated and become regular. It is now moderately dilated, all its adhesions have become detached, and the pupil seems less cloudy in the cen- tre of its field. The sclerotical injection is less, and the eye is less sensitive lo light. 29ih.—The pupil is not at all cloudy, but its edge is turned slightly backward, showing that there is congestion of the iris. The effect of the atropia has passed off. Eye free from injection. 31st.—Yesterday and to-day have been rainy, and the eye is as much injected as on the 27th. The globe is more sensitive when pressed upon. Re-applied atropia. Continue quinia. Nov. 3d.—He has steadily improved. The eye is free from in- jection. Pupil is clear, and dilates readily under the influence of atropia. I allowed him to return home to the country, and when I next saw him he had continued well during the whole period of several months. In this instance the subjective symptoms were not very severe, but the apparent alterations in ihe field of the pupil were very con- siderable. Had the patient been placed under the influence of mer- cury, the case might have been cited as a proof of its efficacy in promoting the absorption of the effused lymph forming the adhe- sions of the edge of the pupil. Case V.—Master----, set. 15, schoolboy, was attacked with se- vere inflammation of both irides in consequence of riding in the wind. I saw him Jan. 24th, 1855, There was much sclerotical and conjunctival inflammation, copious lachrymation, severe pain, and considerable photophobia. Iris has in both eyes lost its natural 2 10 striated aspect; pupils are contracted, but regular ; vision very dim. Applied solution of atropia. Ordered quin. sulph. gr. i. ter die. Do- ver's powder at night pro re ?iata. Apply two leeches to each tem- ple, and repeat atropia at evening. Bathe eyes with tepid lotions of milk and water. 25th.—No improvement. Slept little, and through yesterday had pain almost continuously. No appetite. Tinct. opii at night p. r. n. 26th.—Had a comfortable day, but severe pain last night, though he look laudanum in addition to his Dover's powder. Apply three leeches to right temple. Potass, iod. gr. v. ter die. 27th.—Patient had a rather more comfortable night, but is much depressed by dimness of vision and long-continued pain. The in- jection of the eyes is rather less, but the irides still look puffy and congested, and their color remains abnormal. Pupils are still contracted. 30th.—The eyes have rapidly improved, so that for two days he has had little pain or intolerance of light. The pupils have dilated to a moderate extent, but are slightly adherent at some points to the capsule of the lens. He has some vision. Feb. 1.—The injection of the eyes slowly diminishes. Continue quin. and potass, iod. Good diet. Atropia to be used once in two days, to endeavor to detach the adhesions. 10th.—Is able to go out, with a shade to protect the eyes from bright light. Color and aspect of irides almost natural. Pupils nearly regular. Vision good for large objects. Continue potass. iod. only. I ceased my visits on this date, seventeen days from the begin- ning of the attack. His vision became perfectly good in a short time. Two or three slight adhesions of the margin of the pupil were the only remaining evidences of past inflammation. After an interval of six months, this boy had another attack ; but it was less severe, and under a similar treatment continued but ten days, though both eyes were affected. Case VI.—Mr. ■----, first officer of an India trading ship, ffit. about 35, was attacked on a homeward voyage with severe rheu- matism in one foot and in his right eye. He says the nocturnal pain in the eye was so intense that for forty days he scarcely allowed any- one to sleep in the cabin of the vessel, the agony he endured caus- ing constant groans and complaint. The eye was seen by me on 11 the. 9th of February, 1855. It was extremely intolerant of light, and much injected. As far as can be judged by examination in as much light as he can endure, the pupil seems entirely closed by a deposit of lymph. The iris is congested, and has none of its bril- liant fibrous aspect. There is slight hypopyon. No vision with this eye. The pain is still excessive. He had large quantities of calomel in the commencement of the attack, and has been on low diet. Belladonna has not been used. Applied solution of atropia. Quin. sulph. gr. iss. three times daily, before meals. Dover's pow- der gr. xii. at. bedtime, and repeat the dose as often as necessary at intervals of an hour. Good"diet. 10th.__No sleep last night, but is inclined to sleep to-day. Con- tinue remedies. Give liq. morph. sulph. in addition to the Dover's powder, if he does not sleep after one dose of the latter. 12lh.—Took several doses of liq. morph. sulph. before sleep was induced on the 10th, but last night slept better. Eye less injected and less painful. Potass, iod. gr. vi. ter die. 14th.—Sleeps tolerably well by the aid of one Dover's powder. Eye less red, and anterior chamber nearly free from hypopyon. There is less intolerance of light, and he begins to have a slight perception of objects. Gave laxative of ol. ricin. and lemon juice, to relieve constipation. 18th.—His eye and foot have improved. He can bear more light, and move about the room. Has more appetite. He sees objects rather better. The pupil can now be examined in a good light, and is seen to be very much contracted, and its edge attached by firm deposits of lymph to the capsule of the crystalline. The more opaque portions of these deposits have the form of a Greek cross; but only one small point in the field of the contracted pupil appears to be entirely clear. 27th.—He bears considerable light, and is free from pain. The pupil seems to have enlarged to a slight extent under the action of the atropia, the use of which has been continued. March 13th.—A little more than a month from my first visit. He has gained a distinct perception of the features of individuals, and sees large objects quite well. The eye is not yet absolutely free from injection. Two spaces, between the opaque bands which confine the edge of the pupil, have become quite clear, and, though small, will allow of very tolerable vision. He was absent from town two months, on a visit to friends. On his return his eye was so much improved that he could read with it. 12 He afterwards embarked for anolher voyage, receiving directions and medicines to be made use of in case of a fresh aitack. Case VII.—Dr.---- had an attack of irilis in the middle of March, 1855, attended with considerable circum-orbital pain and slight discoloration of iris. From this he recovered without other treatment than shading the eye from light, confinement lothe house. and two leeches to left temple. Two days after, he had a slight relapse in consequence of a change of weather. I advised him to apply two more leeches, and to take three grains of quin. sulph. per diem. Though the symptoms wSre rather more severe than during the first attack, they yielded almost at once. On the 1st of April he rode out of town on business in very stormy weather, and next day had a return of the symptoms. On Ihe 3d he had con- siderable dull pain in the eye, and much injection of sclerotica, with some discoloration of iris. On the 4th he observed irregularity of the pupil, but had less pain than the previous day. I found the iris discolored, and the pupil adherent at several points. Under the action of atropia it dilated in an hour-glass form, enlarging laterally, but was prevented from expanding in a vertical direction by the adhesions. Recommenced the use of quinia, and advised leeches to be applied to temple if pain should supervene in the evening. 5th.—Less injection. Did not find it necessary to apply leeches. There is some soreness of upper part of eyeball. Iris is more clear. The adhesions of the pupil seem disposed to give way. 8th.__Continued for two days to improve, but to-day has slight intolerance of light and perhaps a slight increase of injection. In- crease quinine to gr. vi. per diem. Three leeches to temple. 9th.__The leeches seemed to give great relief. The eye is less injected and less sensitive. Hot pediluvium at bedtime. Hth.__He applied two more leeches last evening, and took an- other hot foot-bath. Feels better, and the sclerotical injection is much less. 28th.—The eye has recovered its normal condition, except that there is one slight adhesion of the lower edge of the pupil. Vision is good for the finest print. Seeing Dr.----some months after, he reported his own eye in excellent condition, and mentioned that he had had opportunity to employ the same plan of treatment, in the naval service, in a case where it had proved effectual after the disease had been unchecked by mercurial treatment. 13 Case VIII.—Mr.----, set. 40, has formerly had syphilis, as is evident from his account of the symptoms and from his being the possessor of a characierislic eruption at the present time. Some weeks ^ince, he had an attack of iritis in one of ihe West India Islands, and on applying to a skilful physician he received no fur- ther encouragement than to be told he could promise him a very excellent glass eye in case he should require one. During the voy- age to New York he suffered agonizing circum-orbital pain. He came to consult me on the 27th of July, 1855. At this time he had slight iritis, with evidence of ihe previous existence of a much greater amount of the disease. Several adhesions had form- ed between the margin of the pupil and the capsule of ihe lens, preventing dilatation of ihe pupil. Ordered solution of atropia to be daily dropped into the eye. Two leeches to temple. Quin. sulph. gr. iv. per diem. The slight symptoms gradually faded, but little change occurred in ihe state of the pupil. On the 15th of August he was sufficiently well to absent himself from the city. During the first day of this absence, however, he took cold and brought on a relapse with se- vere symptoms. On ihe 19th, the. whole iris had a muddy look, and a large globule of lymph projected from its surface into the anterior chamber, near the lower edge of the pupil. Ordered five leeches to temple. Quin. sulph. to be continued. Potass, iod. gr. xv. per diem. Apply atropia morning and evening. 20th.—He has had severe pain. Little alteration in local ap- pearances. Liq. morph. sulph. at accession of paroxysms of pain. 22d.—Has suffered less, and the iris seems rather less congested. Continue medicines. 24th.—The injection of the sclerotica and the pholophobia have considerably diminished. The pupil does not enlarge, except to a slight degree. 26th.—The iris is regaining its natural aspect, and the eye is less injected. Photophobia diminished. Has had no pain. 28th.—Still further improvement. Has more vision. 29th.—The pupil yields to a considerable extent, in some por- tions of its margin, to the continued influence of ihe atropia. The iris has nearly resumed its healthy aspect. Vision improved. On the 31st he left the city to return home. The active symp- toms had vanished, and vision increased rapidly. He returned to Boston in May, 1856. During this interval his eye has steadily gained, and he is now capable of reading The 14 adhesions of the pupil have nearly, but not entirely disappeared. They interfere, however, very little with vision. Case IX.—Mr.----, counsellor, of past middle age, was seen in consultation December 16th, 1855. Twenty years before, he had an attack of iritis, for which he was treated with calomel, low diet, and a generally antiphlogistic treatment. It was six months after the removal of the active symptoms before his health and strength were fully restored ; but his eye entirely regained its power, and continued useful until the present attack. He now has great intolerance of light, copious lachrymalion, a high degree of sclero- tical injection, serous chemosis, contraction of the pupil, greenish discoloration of the iris of right eye, and very indistinct vision. He has considerable circum-orbital pain. Has recently been much reduced in strength, from disease of foot, and has had rheumatism in back. He has had a dose of calomel and jalap as a cathartic, and leeches have been applied to temple. Advised one grain of quinia and three grains of potass, iod. three limes a day. Sufficient Dover's powder to ensure sleep. Good diet. Atropia was applied to the eye, and the pupil yielded, though slowly, to its influence. The comfort experienced from the almost constant use of warm fo- mentations induced us to continue them. He remained in a dark- ened room. 17th.—Has been rather nauseated by Dover's powder. Substi- tute for it, liq. morph. sulph. The pain during the night has been severe. No improvement in aspect of iris. Pupil moderately di- lated. Much sensitiveness of the globe to touch. We advised a continuance of treatment, with a second application of atropia at evening. 18th.—Very little change in appearance of globe. Has had a very restless and painful night, but the pupil continues dilated and regular. 19lh.—Much the same. Four more leeches were applied at evening, without much relief. Takes large doses of morphia, with only partial relief of pain. 21st.—Rather less sensitiveness to touch, and less chemosis. Color of iris perhaps rather better. Till now the weather had been vari- able and stormy since the onset of the disease. After this date there was a steady improvement. The injection of the globe, lach- rymation and photophobia, subsided; the color of the iris became more normal, and vision slowly improved. As the amelioration 15 went on, the atropia was employed less frequently, and the quinia was discontinued. The iod. potass, was persevered in. Jan. 2d, 1856.—He is able to leave his room, and uses the other eye without inconvenience. He went to his office, I think, on the 3d or 4th of January, little more than a fortnight from the time I first saw him. 16th.—He has for some time been at his office as usual. Vision, in the affected eye, is nearly perfect, and improving. Case X.—Mrs. ----, est. 30, is a person apparently of robust health, but says she has always been an invalid. Has a weak sto- mach. Cannot walk far without bringing on pains in her back. Is very nervous. On the 6th January, 1856, she began to have slight soreness in one spot of the right eye, but thought it of no importance. I saw her on ihe 11th. The iris exhibited a lurgid appearance. Pupil much contracted. Sclerotica, around the margin of cornea, much injected. Slight photophobia. Had some pain yesterday in the infra-orbital nerve, and a very severe attack at daylight this morn- ing. Applied solution of atropia. Ordered good diet; shaded room; repose of eyes; pil. Blancard No. 1, twice a day. Liq. morph. sulph. if required. 12th.—Slept tolerably well; but had pain this morning. Pupil has dilated under the influence of atropia. 13th.—Less sclerotical injection, and less pain. The iris and pupil have a clearer aspect. Thinks the pills cause slight nausea. 14th.—Found the eye more injected, and pupil much contracted. Repeat atropia. Hot pediluvium at bedtime. 15th.—The pupil has only partially and irregularly dilated. Ap- ply atropia morning and evening. She has considerable pain in eye, more sensitiveness of the globe to touch, and less vision. Rather more circum-corneal injection. Hot pediluvium. Ol. ricin. with sue. limon. Three pills, containing each a grain of sulphate of quinia, were substituted for Blancard's pills, as she thought they caused nausea, even though taken after eating. 16th.—Eye has improved. Pupil well dilated. Slept well with- out morphia. 17th.—Yesterday afternoon, her hand slipping from its hold of a pillow she was pulling from under her head, she received a severe blow on this eye. Screamed from pain at the time, and the eye has been rather more painful since. There is contraction of the pupil 16 to about its normal size, and considerable serous chemosis. Con- tinue medicine. Atropia morning and evening. 18th.—Pupil not yet dilated beyond its natural size, the morphia she has taken probably counteracting in a degree the effect of ihe atropia. She had so much pain yesterday that two leeches were applied to temple. Chemosis continues, and the lids seem slightly infiltrated. Vision almost abolished. 19th.—Rather less pain. Has no appetite, and has taken only gruel. Repeat castor oil and lemon juice. Discontinue pills of quinine, as she thinks they nauseate. Substitute a mixture of linct. cinch, co. and spir. lavand. co. 20lh.—Had a better night. Sclerotica less injected. She sees only a lillle with this eye, though no actual adhesions or deposits seem to have formed in the field of the pupil. 21st.—Has had no pain of consequence. Belter appetite. Scle- rotica less red. Vision rather better. From this date until the 5th February there was constant but slow progress, and at this lime all symptoms had disappeared ex- cept the dimness of sight when tried upon small objects. In a short time longer, this lingering effect of the disease had also passed away, and ihe eyes were again perfect. Case XI.—Mr.----, a merchant, set. 35, subject io rheumatic attacks, exposed himself to a very cold wind, in walking out of town on the 8th March, 1856, and was attacked the next day with severe symptoms of iritis. When I saw him, on the 10th, the pupil was much contracted and its field cloudy, the iris was much con- gested, the sclerotica considerably vascular, and the eye extremely sensitive to light. Vision was imperfect. Made application of atropia as usual. Quin. sulph. gr. i. four times a day. Vin. col- chici gtt. xv. morning and evening. Dover's powder if necessary. 11th.—The pupil has partially yielded to atropia, but shows some adhesions already formed with the capsule of lens. He had some severe pain last evening, but slept well. Color and appearance of iris and sclerotica as yesterday. Continue remedies. 13th.—More pain last night. Aspect of eye unchanged. Apply four leeches to temple. 15th.—Has been more comfortable. The field of pupil seems less hazy, but the adhesions do not appear to have given way. The iris has regained somewhat of its natural color, and the sclerotical injection is less marked. The progress of the case offered so little n of interest that I will merely give its outlines. The symptoms were at no time very severe, never preventing him from visiting me at my house; and, but for the dimness of vision, he would not have given the disease any great attention. I have cited the case, as that which proved the most obstinate of any I have met with, its dura- lion having been till the end of April. Much of this time, how- ever, the disease exhibited merely slight traces of its presence, and would probably have disappeared had not the patient preferred to go regularly to his place of business, notwithstanding a changea- ble and inclement temperature and very frequent rains. The plan of treatment consisted in the administration of quinia and potass. iod., with good diet. Other anti-rheumatic remedies were occasion- ally given, as colchicum and Dover's powder, but with no evident effect on the disease. His recovery was perfect, the pupil becoming quite clear and free from adhesions. Case XII.—Mr.----, aet. 40, coachman, of full habit, but, as I believe, a perfectly temperate man, came to me on the 21st of June, H56, with the following statement. Three days before, ihe heat being oppressive, he took off his heavy boots while washing his car- riage, and stood for some time with his feet in cold water. The right eye became sensitive, but gave him no severe pain. Yester- day he drove a dozen miles, exposed along the whole road to a bright reflection of the sunlight, and returned in the evening. Last night and this morning has had severe pain in and about the eye. The iris is congested, and its color slightly altered and dull. Much conjunctival, and considerable sclerotical, injection. Applied atro- pia. Ordered a draught containing infusion of senna and sulphate of magnesia ; five leeches to temple ; quiet; darkness ; low diet, Tinct. opii at bedtime if pain should be urgent. 23d.—He thought his eye was better yesterday, but has had an- other attack of severe pain this morning. No effect from purga.- tive. Pupil well dilated. Rather less injection of eye. Repeat atropia. Three compound cathartic pills. One pill containing quin. sulph. gr. iss., with extract gentian, before each meal and at bedtime. 24th.—Has had no occasion to take laudanum, but has some pain this morning. He took three cathartic pills without effect, and last evening took three more, which operated "severely" this morn- ing. Feels less pain in eye since, than he had before the operation of the medicine. Little change in appearance of eye. Repeat 18 quinine and atropia. Is very anxious to go out; but this is not permitted. 26th.—Decidedly improved; the eye is much less sensitive to light, and considerably less injected. The pupil continues open. Allowed him to go out towards evening. 28th.—Found him at his place of business, in the next street lo that in which he resides. The eye was still further improved. lie desired to go to Vermont for a visit, and I assented, on condition that he should at once return if severe symptoms recurred. The pupil was at this time perfectly clear, and vision good, though the eye was still unable to support a strong light. He was directed to continue quinia, to avoid exposure to strong light or wind, and to re-apply the solution of atropia in case much injection of the eye or severe pain should come on. July 30th.—He returned to-day, with the eye considerably altered for the worse. It appears, from his own account, that a short time after his return to his friends in Vermont, he exposed himself lo taking cold, and the eye, which till then had gained, began to be more red and more sensitive. He used the atropia while his sup- ply lasted, but instead of sending or returning for further advice, he allowed the eye to grow worse, until at last he could scarcely see any objects. He says the sight has improved within two days; but the field of the pupil is now hazy and vision dim. The iris is rather greenish, but the margin of the pupil seems free from ad- hesions. Above the centre of the pupil, however, there is a small dot of opaque deposit which 1 fear will not be re-absorbed, and around this is a thinner deposit which I presume will be removed by absorption. Continue atropia. Aug. 1st.—Vision is better, and the pupil has become larger and is regular. Has had no pain. There is very little sclerotical injec- tion. 2d.__The eye seems to gain, day by day. Vision has become very good for large objects, and the deposit on the crystalline capsule is evidently thinner and less extensive than when seen on the 30th ultimo. Case XIII.—Mr. ----, a gentleman of not quite middle age, sent for me on the 25th of April, 1856, saying that he had previ- ously had five attacks of iritis, and now felt the symptoms which he had never known to be subdued till he had endured a severe at- tack. Has been treated in Boston, New York and Europe. The 19 pupil of right eye is partially closed by a deposit of lymph. He is of rheumatic constitution. The present symptoms are slight pink circum-corneal injection, con- siderable intolerance of light, lachrymation. Soreness on pressure upon the globe. Pain is felt when the eye is moved or pressed upon: not when at rest. The pupil is contracted, but there is no change of color of the iris. No appetite. Applied solution of atropia. Quin. sulph. gr. iss. ter die. Lotions with an infusion of ros. fol. and papav. capsul. 26th.—>No improvement. The iris seems more congested and has lost its lustre ; but still has its natural tint. The pupil has en- larged under the influence of atropia. As the lotions do not afford comfort, I substituted milk and water. I proposed an application of leeches; but on his representation that they affected him unfavora- bly, I refrained from ordering ihem, as the symptoms were by no means urgent. Good diet, if possible. 27th.— Is able to bear more light, and the iris has slightly im- proved in appearance. The globe is less sensitive on motion or pressure. He had more appetite yesterday. 23lh.—The symptoms are much mitigated. He may walk out. 29th.—Considered further attendance unnecessary. Advised use of quinia for some days to come ; but in half the quantity previ- ously taken. June 24th.—He has continued well. Case XIV.—Mr.----is a member of a family who are subject lo rheumatism, and who, among other manifestations of the disease in his own system, has had five or six attacks of iritis, sometimes in one, sometimes in the other, sometimes in both eyes. In one of these attacks, the right eye has been so much affected that the low- er half of the pupil adheres to the capsule of the lens by a deposit of lymph, and vision is somewhat diminished. May 14th, 1856.—He tells me he knows he is to have an attack in the right eye, as he feels soreness on pressure, and pain when the inlemal rectus is brought into action. There is slight sclerotical in- jection and some contraction of pupil. No change in color of iris. Applied solution atropia. Pills of quinine and gentian thrice a day. Good diet, with his usual amount of wine, his constitution being far from robust. During his previous attacks he has had low diet, mercurials, and antiphlogistic measures, in some instances re- quiring a long time for recovery. 20 15th.—Injection of sclerotica rather increased. The pupil has yielded to atropia. 16th.—Very little change. 17th.—Considerable improvement. Less sensitiveness and less injection. 19th.—The injection has nearly disappeared. Patient goes out each afternoon. 21st.—-He improved till yesterday, when, in consequence as I sup- pose of chill east winds, to which, however, he did not expose himself, he had a fresh attack, with the same symptoms described in the outset. To*day the eye is more injected than I have seen it. The color of the iris is altered, and vision dim. 23d.—There is a shade less of injection. 25th.—Vision is not improved ; but there is a decided change for ihe better as regards appearance of the eye and as regards its sensations. 27th.—The weather being cold and variable, he has continued in statu quo. Add to the remedies potass, iod. gr. vi. ter die. From this time till the 7th of June he gained steadily, and the symptoms had almost wholly disappeared. As he still feared a re- lapse, I saw him several times during the month of June. On the 22d he had a slight sensation on strongly contracting the inlernal rectus. On the 25th I thought it best, as a precaution, to resume quinine for two or three days. But on neither of these two dates were there any visible symptoms. On the 3d of July be considered himself well, and left the city in a steamboat. But this exposure induced a relapse, which lasted a week, when he was once more well. On the 18th he left the city for a distant watering place. Aug. 2d.—To-day I heard that he continues well. Case XV.—Mr.----, set. 35, was attacked, at the White Moun- tains, with severe iritis, on the 28th of June, 1856, in consequence of exposure lo a cold wind. He has had rheumatism and neural- gia, and been much reduced by the pain he has undergone, and was journeying for his health at the time of the invasion of the dis- ease of the eye. Has formerly had chancres; but says he has always had them burned out, and has never, to his knowledge, had any other symptom of infection. But it appears the chancres may have lasted a fortnight. He does not know if they were indurated. I did not see him till the 4th of July. He had had little sleep for 21 several nights, on account of the pain in and over the left eye. He has been freely purged, and two leeches have been applied to tem- ple ; but, as I learn, he has taken no mercury. Has had sore throat and used a gargle. The eye is very much injected, the pupil contracted and the iris dis- colored. On the side of the pupil towards the inner angle, there is a very large tubercle of lymph, projecting so much forwards as nearly to touch the cornea, and extending so far into the area of the pupil as to obscure the lower and inner portion of its field. Order- ed an instillation of a drop of solution of atropia, and a repetition of the same-at evening. Four grains of quinia with two grains ext. gentian, daily, in four doses. Good diet. Morphia at night if re- quired. 5th.—He slept well after 3-8 of a grain of morphia. Eye little changed, except in a slight dilatation of pupil. Continue remedies. 6th.—He slept less well, and has less appetite this morning. The eye is less sensitive to light, and the iris rather more clear. 7th.— Passed a belter night. Injection of sclerotica less. The pupil is moderately expanded, except on the side occupied by the tubercle, where adhesions had taken place before I saw him. The tubercle seems less dense, but diffused over a larger space. As he can bear more light, I examined his throat, and found several ulcers of the soft palate and one on ihe side of tongue. Touched these with crayon of argent, nit. 8th.—More of a reddish tinge upon the surface of tubercle, pro- bably from ihe presence of vessels. The mass, however, seems thinner. The iris has a clearer aspect, and the globe is less inject- ed. Less photophobia. Yesterday he had a great amount of pain, and did not sleep well. Potass, iod. gr. vi. ter die. 11th.—Has had severe pain every evening, only subdued by large doses of opium in some form. But the eye is rather less red, and the tubercle has diminished in size. 12th.—Slept all night; but has a little pain this morning. Eye much less injected. Pupil is larger, and iris looks better than I have seen it. The tubercle is smaller. 14th.—Has had no pain. Tubercle less. Injection less. Vision begins to improve. 16th.—Iris begins to have a natural look. Pupil more dilated. Tubercle constantly lessens. 18th.—Improvement goes on more and more rapidly. 19th.—Has been out to attend to some business. Eve much less 22 injected, and not sensitive to light. The tubercle of lymph has nol yet wholly disappeared, nor has the adhesion at the lower edge of the pupil given way ; but in other directions the pupil is well dila- ted. Ulcers of the throat have been repealedly touched with nit. argent., and are nearly healed. 22d.—Eye very slightly injccled. Iris clear and nalural in colpr. Tubercle almost gone. Vision improves very rapidly. 23d.—Returned home. The eye is not entirely well, but suffi. ciently so to allow of his travelling with safety. Case XVI.—Mr.----, set. 36, residing in a manufacturing town, consulted me on the 18tli of July, 1806, for a severe attack of iritis* He has never had syphilis, nor been subject lo rheumatism, but now complains of pain and soreness about the knees and ankles, which seem of rheumatic character. He has been engaged in repairs of machinery in the mills, and has often been obliged to work at night in rooms brilliantly lighted with gas, going out afterwards into the cold air. For a week past his symptoms have been so severe 1 hat he has not slept at night, and scarcely any in the day. The pain has extended from the right eye over the whole of this side of the head< Much photophobia. Vision very dim. The iris is congested, but not discolored ; the sclerotica is highly vascular ; the field of the pupil is hazy, but there is no aclual deposit. Under an application of atropia, the pupil dilates regularly, and to a considerable size. His treatment has been, poultices of alum curd and sorrel, and lotions with a solution of acetate of lead. Two leeches have been applied near ihe eye. Low diet. Ordered two grains quin. sulph. four times a day. A drachm of liquor morph. sulph. at bedtime, to be repeated hourly if he is unable lo sleep. 19th.—Took two doses of morph., and had a perfectly comforta- ble night. Has less photophobia and lachrymation, and the eye is less injected. The left eye shows slight traces of the same af- fection. 22d.—-The right eye has much improved. Scarcely any photo- phobia or congestion of iris. Much less sclerotical injection. He has had no pain. The left eye is in the same state as on the 19th, showing very slight symptoms. 23d.—The left eye is nearly free from symptoms, and ihe right eye much improved. His vision being now sufficiently good, he was very anxious to return home and re-commence work. This was allowed, with directions to act with great caution, and merely 23 lo oversee ihe repairs which might be required, without doing any- thing to heat himself or to strain his eyes. To wear a shade in front of both when exposed to bright light or to wind. It may seem that in the treatment of these cases routine has been loo closely followed, and I should myself be disposed, now that I am satisfied it may be done with safety, lo make use of a grealer variety of remedies, adapted to different conditions and tempera- ments. But in making the trial of one plan of treatment instead of another of directly opposite character, it was desirable, in order to avoid uncertainty as to the results obtained, lo deviate as little as possible from a fixed course. It is by no means assumed that mer- curials or other antiphlogistic measures should be absolutely dis- carded from the treatment of this disease ; but the results of these cases, many of which were of unusual severity, prove that it is by- no means indispensable to resort, immediately, to their use in all instances. If not essential, it is evident that remedies having, at least temporarily, an unfavorable influence upon the general health, should be employed with great reserve. In some of ihe cases re- ported, I am satisfied that the patients would have been injured, and ihe chances of their recovery diminished, by active treatment adapted to reduce the vital powers or the vigor of ihe circulation. As a general rule, I should be disposed lo place most reliance on a mode of treatment which sustained ihe general system, whilst at the same time ihe local circulation should be relieved, if necessary, by moderate depletion, obtained, by preference, by ihe application of a few leeches to the temple. Narcotics have seemed to me of service, not merely in promoting the patient's comfort, but in relieving the local congestion, and pre- venting the effusions of lymph which seem so often to be poured out from the iris during the paroxysms of severe pain. I also ask special attention to the importance of a resort to the use of belladonna, atro- pia, or some other agent capable of causing enlargement of the pupil. If not used till the iris has become congested, it may be impossible for these remedies to exert their specific influence, and, effusion tak- ing place, the pupil may become blocked up by firmly organized lymph, before the disease can be subdued. In a dilated stale of the pupil its margin is so far removed from the convex surface of the lens, that considerable congestion may exist, or even effusion occur, without adhesion taking place ; and many mild cases would 24 recover, if no other treatment were pursued. But in the contract- ed state of the pupil the congested iris is in contact with the centre of the convexity of the capsule of the lens, and is very liable to adhere to it. These adhesions once formed, the prognosis becomes less favorable ; for, though in favorable cases they may be entirely removed by absorption, yet this fortunate result cannot invariably be obtained, even when the patient is judiciously treated from the moment the adhesions are discovered. When, as is often the case, the patient, deceived by the slight amount of apparent inflam- mation, does not apply for advice till warned, by paroxysms of severe pain, that the eye is the seat of serious disease, the physician often perceives that irreparable mischief has already been done, and that the bands of lymph obscuring ihe pupil have re- mained undisturbed till they have assumed a permanent organi- zation. The forty-eight other cases alluded to, but not reported at length, comprised every phase of the disease from the most mild to the most severe. Six of them were confessedly syphilitic, and some others had a suspicious character. With the exception of one case which had been neglected under the care of an " Indian physician," and three cases where the pa- tients had been injured by homoeopathic treatment, the results were invariably good ; the eyes being either perfectly restored, or if any adhesions were formed, they were so slight as not to impede vision.