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Tous les autres exemplaires originaux sont film^s en commenpant par la premidre page qu< comporte une empreinte d'impression ou d'illustration et en terminant par la dernidre page qui comporte une telle empreintf). Un des symbolea suivants apparaitra sur la dernidre image de chaque microfiche, selon le cas: le symbole — ^signifie "A SUIVRE", le symbole V signifie "FIN ". Les cartes, planches, tableaux, etc., peuvent dtre filmds d des taux de reduction diffdrents. Lorsque le document est trop grand pour dtre reproduit en un seul cliche, il est filmd 6 partir de Tangle sup6rieur gauche, de gauche d droite, et de haut en bas, en prenant le nombre d'images ndcessaire. Les diagrammes suivants illustrent la mdthode. 1 2 3 1 2 3 4 5 6 *a-' y-Wk, ON SOME PRACTICAL POINTS IN TBX TREATMENT OF THOSE FORMS OF EYE DIS- EASE OF MOST FREQUENT OCCURRENCE IN GENERAL PRACTICE. Wi//i the Cutnptinients of the Author BY A. M. ROSEBRUGH, M.D., SVROBON TO THE TORONTO EYE AKD EAR INFIRHART. /?«arf «^/f>« the Canailian Medieal Aaaociation, Halifax, N. S.,-^g. 4, 1875. ^m , ../r^ONTOs J DUDLEY k BtJRire, 3,-11 )RN> STREET. i876. r ii- 4 » , / ON SOME PRACTICAL POINTS IN THE TREAT- MENT OF THOSE FORMS OF EYE DISEASE OF MOST FREQUENT OCCURRENCE IN GENERAL PRACTICE. BY A. M. ROSEBRUGH, M.D. SURGEON TO THE TORONTO EVE AND EAR INFIRMARY. Read before the Canadian Medical Association, at Halifax, N. S., on the 4th «f August, 1876. I. Catarrhal Conjunctivitis. — In preparing a paper to be read before tins As.sociation, it has been my endeavour to write a practical paper that would be interesting both to tliose of extensive and to those of limited experience in ophthalmic medicine and surgery. I have purposely omitted all unneccssaiy technicality, and avoided all pathological points not absolutely necessary for the purposes of this communication. I wish to direct your attention to "some practical points in the treat- ment of those forms of eye disease of most frequent occurrence in general practice," namely, certain diseases of the Conjunctiva and C(jrnea. Of simple Conjunctivitis, 1 wouhl merely say, in passing, that it is nothing more than a passive congestion of the ocular conjunctiva, with no oedema, and with very little discharge. It does not usually run a course of more than one or two weeks and readily yields to a simple astringent, such as that of the solution of the sulphate of zinc, of tht; strength of from one to two grains to the ounce of distilled water, applied three or four times a-day. In purulent conjunctivitis we have the other extreme, the inflammation being most intense, and frequently resulting in total sloughing of the cornea in a few daj'-s. The 2 Treatvient of Eye Biaense characteristic symptoms are (i^dema and elongation of the u])per eyelid, with copious purulent discharge from the conjunctival surface. The suh-conjunctival tissue is intensely iniiltrated, and the conjunctiva raised into a hard ring around the cornea, giving rise to the condition called cheilosis. This form of ophthalmia is very contagious ; but fortunately, in Canada it is as rare as it is destructive. Catarrhal conjunctivitis occupies a position between these extremes, and is the form of ophthalmia to which I wish now to sjiecially direct your attention. At the Toronto Eye and Ear Infii'mary, about four per cent, of the eye cases are registered as cases of catarrlial conjunctivitis; but this jiercentage does not accurately represent the relative freciuency with which these cases occur in Western Canada, as patients with acute inflammation of the conjunctiva are seldom sent to be treated as hospital patients. (Jatarrhal conjunctivitis is characterized by congestion and an edematous condition of the ocular con- junctiva, with muco-purulent discharge. There is little infil- tration of the sub-conjunct ival tissue, and the conjunctiva, though raised and deeply colored, remains, soft and movable. The upper eyelid does not become elongated nor the integument (edematou.'-', and the inflammation of the cornea is very rarely su])purative. It is contagious in the acute stage only, and then by direct con- tact of the discharge with the conjunctival surface. Usually in six or eight days after the affection begins in one eye, the other becomes aflfected, unless special precautions are taken to prevent the discharge passing from one eye to the other. I find the disease more prevalent among farm labourers and shanty men, where very frequently one wash-basin, with one towel, is made to do duty for a number of persons. So far as these cases have come under my observation from the Province of OnU.io, and the neighbouring States of New York and Michigan, I find that, not unlike the exanthematous diseases, they run a regular course, which is usually from two to four weeks of acute inflam- mation ; then the oedema and vascularity of the ocular conjunc- tiva subside, and the patients affirm and believe that their eyes are perfectly cured ; but upon everting the eyelids, the palpebral conjunctiva will be found to be velvety and the papillae already In Oeveral Practice. 3 somewliat hypertrophied. In many of the slight cases, I doubt not that this hypertrophied condition recedes spontaneously; but in other cases, and I think the larger number, the disease, if inefficiently treated, extends to the sub-conjunctival tissue, and the papilljB become veiy much elongated, giving rise to the con- dition erroneously called "granular lids." This swollen and i-oughened condition of the palpebral conjunctiva is a constant source of irritation, and in many cases is the direct cause of N'ascular and ulcerative diseases of the cornea. Catarrhal inflammation of the conjunctiva is an innocent ilisease that seldom, in the acute stage, results in any serious trouble to either cornea or ocular conjunctiva; but the so-called " granular lids," in its effect on the cornea, undoubtedly loads to more cases of impaired vision and l)lindness than any other disease of the eye. The subjective symptoms in this affection are so misleading, that the patient is clamorous for treatment when comparatively little local treatment is required, and on the contrarj', can with difficulty be induced to continue treat- ment afterwards, when it is absolutely necessary to prevent hypertrophies of the palpebral conjunctiva and the diseases that result therefrom. In the treatment of catarrhal conjunctivitis, I do little more the first week than order the eye to be bathed frequently with warm water, and direct simple cerate of fresh lard to be applied to the edge of the eyelids at bed-time. A solution of ati'opia- sulph. (grs. ij — 3i) applied occasionally to the conjunctiva will show, by its effect on the shape of the pupil, whether the iris is involved or not. This is a point of great practical importance, and especiall}' so to young practitioners, who have little expe- rience in diagnosing inflammation of the iris. In the second week, the use of local applications should be begun, and I do not know which of two remedies to recommend most highly, namely, weak solutions of nitrate of silver, or the red oxide of mercury plasma. I have used the two remedies side by side, that is, one in the right eye, the other in the left, and have had about equally satisfactory results. The plasma of the red oxide of mercury is used of the uniform strength of eight gi-ains to the ounce of 4 Treatment of Eye DiHense the plasma; but in using the nitrate of silver, a solution of three grains to the ounce of distilled water is advised, and the strength gradually increased to fifteen grains to tlie ounce, during three weeks of treatment. The three-grain solution may be dropped into the eye by a nurse or friend three or four times a-day, and the eyes bathed afterwards in warm water. After the first week of treatment, when a stronger solution is being used, the eyelids should be everted, and the remedy applied to the palpebral con- junctiva with a camel's hair brush, and in a few seconds any excess of tne solution washed off with warm water, before the lid is replaced. The stronger solutions are applied in this manner once a-day, and in addition, the three-grain solution may be still used two or three times a-day, while the ocular conjunctiva remains congested and (I'dematous. The treatment is continued until both the ocular and palpebral conjunctiva have resumed _ the healthy condition. When the plasma of the red oxide of mercury is used, it is applied to the everted palpebral conjunc- tiva twice a-day (and not washed off), and no other local appli- cation used, with the exception of the occasional use of atropia solution as before mentioned, and fresh lard to the edge of the eyelids at bed-time. 11. " Granular Lids." — With the exception of phlyctenular diseases of the cornea, there is no affection of the eye more preva- lent in Ontario than that of so-called "granular lids." Out of a total of 1957 eye cases tabulated at the Toronto Eye and Ear Infirmaiy, 193, or about ten per cent., were recorded as cases of trachoma or " granular lid.s." In my private practice, the per- centage is a little less than ten per cent. The disease is a hypertrophied condition of the papilla? and sub-conjunctival tissue of the palpebral conjunctiva, and is the sequel of, and probably caused only by catarrhal con- junctivitis. Cases of " sago-grain," or follicular granulations, said to be the most common cause of granular ophthalmia among the military and in the crowded poor-houses of the Old World, have not come under my observation. To avoid circumlocution, I will continue the use of the term "granular lids," — it is at least In (rcneral Practice. 5 suggestive of the appeal ance, if not of the pathological condition of the palpebral conjunctiva. In order to treat thest; cases suc- cessfiilly, I find it of the utmost importance to secure, at the outset, perfect control over the patient, I never take charge of a case unless it is distinctly understood that the patient nnist not only be regular in his daily or semi-daily attendance, but that he must continue the attendance four, eight, or twelve wetiks, according to the length of time that the treatment will ])robably recpiire. In cases where the surgeon fails to secure this control over the patient, the treatment usually ends in disappointment to both. The local treatment is that of stlviulation. Absorption is most active when the palpebral conjunctiva is kept in a constant state of hyperemia. We stimulate without cauterizing, and take aire not to irritate the sensitive ocular conjunctiva. Moist heat, applied externally to the eyelids, is a very good method of imli- rcctly stimulating the palpebral conjunctiva. I have never been nble to carry out the experiment, but I doubt not that some of these cases might be cured by the stimulus of hot water alone. In one case there was also a penetrating ulcer of the cornea, the hot water treatment was used exclusively for two weeks, at the end of which time the ulcer was nearly healed, and the condition of the j)alpebral conjunctiva very much improved. We endeavour to keep up a pretty uniform condition of hypera;mia of the pal- pebral, without irritating or stimulating the ocular conjunctiva. The lid should be well everted, morning and evening, and a stimulating (not a cauterizing) application made to the palpebral conjunctiva. The exposed palpebral conjunctiva is immediately bathed with warm water, using either a soft brush or a small syringe. This bathing remove* any excess of the stimulating application, and thus saves the cornea and ocular conjunctiva from irritation. Between the applications, the eyelids are bathed once or twice with warm, almost hot, water. In cases imme- diately following the catarrhal inflammation, the treatment is commenced with a ten-grain solution of nitrate of silver, and the strength is gradually increased to twenty grains. In chronic cases, where the lid is thick, and the " granulations" prominent. 6 Tvedtmient of Eye Dlnease aiul where the patient is in rohust health, with no phlyctenular or ulcerative inflammation of the cornea, either a solution ot* nitrate of silver (thirty grains to the ounce) may he applied, tlic solid sulphate of copper, or the mitigated stick of nitrate of silv( r and nitrate of potash. In case«, however, either recent oi' chronic, where there is present, or where there is a tendency to phlyc- tenular or tilcerative inflammation of the cornea, the nitrate of silver or sulphate of copper is inadmissible. Again and again have I seen cases j)ut back for weeks by an attack of [)hlyc- tenular keratitis, evidently caused by the use of the "blue stone" or nitrate of silver. In these cases, the plasma of the red oxide of mercury, of the strength of gr. j — .^, may be applied morning and evening, without, however, brushing or syringing with watei-, the everted lid being returned with the oxide adhering to the palpebral conjunctiva. The eyelids are bathed occasi(mally, during the interval, with very warm water. The application of the red oxide is not so stimulating as the sulphate of cop]>er or nitr.ate of silver, and consequently the treatment extends over a longer period; but in my experience, there is no local application that is so well adapted to the corneal complications, and none that will more certainly prevent their recurrence. Of course the general condition of the patient must not be neglected. A gen- erous diet should be allowed, and when necessary, tonics pre- scribed The local treatment is continued until the palpebral conjunctiva is restored to its wonted healthy appearance, and the fibrous structure of the sub-conjunctival tissue distinctly seen beneath. I have endeavoured to give an outline of the general plan of treatment pursued with satisfactory results for the last fifteen years. The most chronic cases usually recover in from eight to twelve weeks; and in recent casts the treatment does not usually last more than three or four weeks. Any phlyctenular disease of the cornea present at the commencement, invariably disappears during the treatment, and relapses seldom or never occur. Whether the same satisfactory results with the same treat- ment could be obtained anywhere except in the salubrious climate of the Province of Ontario, I am not prepared to state. /(/ (htifval I'racfire. 7 ITT. T'HLYCTKNUi.Aii OpiiTHAF-MlA. — During the last tiftf.-n yjiars, fully 1,000 eases of phlyctenular ophthahuia have heen either dircetly or iurlireetly under my treatment, and an tin* results, upon the whole, liave ))een most satisfactory, T trust that an outline of the treatment pursued will prove intei-e>tiug and suggestive, hoth to the general practitioner and specialist. The frequency with which thf!se cases occur in practice may lie inferred from tin; fact, that at the Toronto Kye and Ear Infirmary, out of a total of 1,957 eye cases, the large numhei- of 315, or over 16 per cent., were cases of phlyctenulai- inflamma- tion of the conjunctiva or cornea. Amon^T children, this j»er- eentage of phlyctenular disease is much h.^i,' t ; of all the children in attendance at the Infinnary for ey» disease, about 35 per cent, were suti'ering from some form of phlyctcTMilar ophthalmia. Out of a total of 330 cases '' eye (iisen<eu air. Aa soon as practicable, the eyes should be exposed to the light ; toleration of light increases the more they can be used. In phlyctenular, as well as in interstitial inflammation of the cornea, inflammation of the iris sometimes occurs, and fre- quently escapes notice; this should be anticipated by appropriate treatment. In the local treatment of phlyctenular ophthalmia, the solution of atropine, applied two or three times a-day, will allay the irritation of the conjunctival and corneal nerves, and, when the iris is not involved, keep the pupil dilated ; but in cases where we are unable to ascertain the condition of the iris, the midriatic should be applied more frequently. Where any irregularity in the shape of the ])upil is seen, the four grain solution of the neutral sulphate should be applied six or eight times a-day, until the pupil becomes widely dilated and free from adhesions. Of course, in very young children, the solution cannot be applied so frequently, on account of its toxic eflfect.* Since writing the above, a little girl has been brought to me, who had recovered from an attack of plilyctenular keratitis ; but an accompanying iritis had been overlooked, and plastic eft'usion had bound down the iris behind a leucomatous central opacity of the cornea. If atropine, instead of nitrate of silver, had been used, adhesions of the iris would liave been prevented, and perhaps the phlyctenular disease cured, before ulceration of the cornea had taken place. In adults, the photophobia is seldom excessive ; in mild cases it is entirely absent. It is this milder form of phlyc- tenular inflammation that is the great stumbling-block to many general practitioners. Phlyctenular conjunctivitis is some- times mistaken for that most rare disease, sclerotitis, and the patient put en iodide of potassium and colchicum. It is treated, by some, as catarrhal conjunctivitis, and by others, as "chronic ophthalmia." I have frequently seen cases of recognized phlyc- tenular keratitis under the influence of mercury ; the physician evidently believing such a course of treatment to be as appro- * The neutral sulphate of atropine is soluble without the addition of acid, and this 5olution doer, not irritate the eye. No alochol should be added. 10 Treatment of Eye Disease priate and necessary for opacity of the cornea, as for plastic effusion in the iris. This treatment is not indicated, and it depresses, and perhaps permanently injures, a constitution that requires to be invigorated. In the local treatment of phlyctenular inflammation, either of the conjunctiva or cornea, in adults, the plasma of the red oxide of mercury may truly be said to be a specific. I have used this remedy for nearly fifteen years, and I do not remember a single case that did not readily yield to this local treatment ; and I cannot now recall more than four cases where a relapse occurred during the treatment. In one case the relapse followed the operation of canthoplasty, and in another, — iridectomy ; the other cases were Infirmary patients. In ordinary cases, the treatment does not usually last more than three or four weeks ; in slight cases, not more than one or two weeks. Except in these cases of relapse, the worst cases are usually cured in six or eight weeks. Even in cases complicated with "granular lids," the treatment does not usually extend beyond two months. After the patient is discharged, he is directed to continue the use of the red oxide for two or three weeks longer.* In cases where the photophobia is excessive, the atropine solution is applied two or three times a-day ; and in cases where the ulcers of the cornea are not healing, and especially where they show a tendency to penetrate, the eyes are bathed two or three times a-day, for fifteen minutes at a time, with water as hot as can be home. This is a most valuable remedy ; and in the only case of phlyctenular keratitis in which I gave it an exclusive trial, a cure was effected in three weeks. The mercurial plasma is applied twice a-day, as follows Instead of applying it simply behind the lower eyelid, as is done by some practitioners, the eyelashes of the upper eyelid are held by the thumb and finger of the left hand, and the lid drawn forward ; a small quantity of the plasma is now pushed up * The red oxide is also used in the case of children, when there are leucoma- tous opacities remaining on the cornea, after the diminution or disappearance of the photophobia. These opacities, if not the result of deep ulcers, will, in most cases, completely disappear, if, after the subsidence of the phlyctenular inflammation, the case be followed up perseveringiy with the semi-daily use of this remedy. In General Practice. 11 under the lid with a camel's-hair brush. Before the brush is withdrawn, the lid is pressed down, so as to retain the plasma ; and on the removal of the brush, the oxide is well diflf'used over the eye by rubbing the eyelid over the eye. The treatment, in any case, should be commenced with the least quantity tliat will adhere to the end of the brush, and the quantity increased as it is tolerated. In cases of ulceration, where the patient can keep the eye steady, I apply the plasma directly to the affected part, and allow it to remain a few seconds, or so lonij as the eve can be kept open. Where the case is complicated with "granular lids," the oxide is applied to the everted palpebral conjum-tiva and allowed to remain about half a minute before tlic lid is closed. The strength generally used is one grain to the drachm ; but in some cases where the patient has been under treatment for several weeks, a preparation of double that strength (two grains to the drachm)* is frequently well borne, and the case improves more rapidly. The plasma of glycerine and starch is preferable to the ointment. It does not become rancid, and, being soluble in the lachrymal secretion, is more readily diffused over the conjunc- tival surface. I am aware that others, including some of my own profes- sional friends, who, apparently, have given the plasma of the red oxide a fair trial, are not able to report the same satisfactory results. This want of success can be explained partly by the fact of the want of care in its preparation, and partly from want of faith in its efficacy. There are cases, where, at the first, the eye is rendered more irritable by the treatment ; here it would seem to be contra-indicated, and a strong faith in its ultimate efiicacy is necessary in order to carry out the treatment perse- veringly ; moreover, it is possible that these cases of phlycten- ular disease, as well as those of " granular lids," respond to treat- ment more readily in Western Canada than elsewhere. * After applying the stronger preparation, however, the eye should be exam- ined in about ten minutes, and any particles of the oxide lodged on the palpebral conjunctiva removed, otherwise ulceration of the membrane may occur. 12 Treatment of Eye Disease In the city of New York, relapses occur in a large percent- age of these cases, to prevent which the operation of canthoplasty is fre({uently performed. In some Infirmary patients, this oper- ation has been done with benefit ; but I have never had occasion to perform the operation in a single case in private practice , and am of opinion that it will be less frequently needed, as the merits of the treatment with the oxide of mercury are better appreciated. o!«;o Dr. Pagenstecher, of Wiesbaden, recommends the yellow amorphous oxide of mercury, in these cases, in preference to the red precipitate, on the ground that it is less irritating, and adapted to a larger class of cases. It is true that, in the prepar- ation of the yellow oxide, it is precipitated in a state of the finest jwssible division ; whereas, the red oxide consists of crystals, which are found triturated to different degrees of fineness in different shops. An ointment or plasma made with the former should therefore be a more reliable preparation than that of the latter (as it is usually prepared), and we might expect the oint- ment of the yellow oxide to be more uniform in its effects ; but when the red oxide is properly triturated, and not used stronger than from eight to sixteen grains to the ounce, it does not usually cause much irritation, — the reaction usually passing away in ten or fifteen minutes. Pagenstecher uses an ointment as strong as from thirty to sixty grains to the ounce, but I have never used it stronger than eight to sixteen grains to the ounce. One of my colleagues at the Eye Infirmary has used the stronger preparations of the yellow oxide, but soon abandoned it, as he found its action alto- gether too energetic. In the trials made with the weaker pre- parations, the results were not satisfactory, and the yellow oxide was found to have the disadvantage of being more inclined tc collect in masses behind the upper eyelid. In General Practice. 13 An ointment made of the yellow oxide is undoubtedly pre- ferable to one made with the ordinary red precipitate of the shops; but when the latter is properly triturated and thoroughly mixed with the glycerine plasma o^ proper consistence, it seems to leave nothing to be desired as an ophthalmic ointment. Unfortunately, it is very difficult to procure a reliable pre- paration of the plasma of the red oxide of mercury, and one carelessly prepared is worse than useless. The apothecary objects to the trouble and length of time involved in its preparation, unless it is ordered in large quantities. For many years, the only reliable preparation that I could obtain was that of the firm of Moore & Brierly, Hamilton; but of late, Mr. H. J. Kose, of Toronto, has been supplying the preparation used both at the Eye Infirmary and in my private practice. Mr. Rose's formula is as follows : " To make simple plasma or Glycerinum Amyli B.P., take 1 oz. starch and 8 fluid oz. pure glycerine (1 find corn starch to make the best product, though it seems to require a greater degree of heat), rub the starch with an ounce of distilled water till quite blended, then add the glycerine and apply heat, gradu- ally increased, till a thick jelly is produced. The preparation must be constantly and thoroughly stirred while making, and if an appearance of granular lumps is shown, squeeze the product before it is cold through cheese-cloth, or doubled muslin, pre- viously well washed to remove any loose fibres. " To make the mercurial plasma, it is necessary to have a perfectly smooth and even-surfaced mortar and pestle, in order to obtain the oxide in an impalpable powder. While triturating, keep it moist by the addition of rectified spirit from time to time. Care is also required to keep the powder, which may adhere to the pestle, scraped otf very frequently. When tho- roughly triturated, the simple plasma is added in the desired proportion, and mixed thoroughl3^ " The efficiency of the trituration may be best tested by rubbing a few grains of the plasma on a piece of fine white paper. On holding this up to the light, there should be no appearance whatever of any specks." 14 'fieatment of Eye Disease TREATMENT OF ACUTE IRITIS IN ADULTS. At the Eye and Ear Infirmary, Toronto, out of a total of 2122 cases of disease of the eye, 39 are recorded as iritis. Although occurring with far less fre([uency than catarrhal or phlyctenular diseases of the conjunctiva, or superficial phlyctenular disease of the cornea, acute infiamniatory disease of the iris runs a much more rapid course, and, vvheu neglected, is much more destruc- tive both to vision and to the integrity of the eye. A slight attack of inflammation of the iris, if overlooked, may result in adhesion of its posterior surface to the anterior capsule (jf the lens (anterior synechia), which, however slight, may be sufficient to cause recurrent attacks of iritis, — resulting in total closure of the pupil (annular synechia). When early recognized, tlicre is probably no pathological condition that responds so readily to treatment, and none that can be so efi'ectually kept under control. In this paper*, how- ever, I except from consideration those forms of iritis that result from injury, sympathetic irritation, or inflammation of the inte- rior of the eye, extending forwards. The plan of treatment that is found most .satisfactory, and almost uniformly successful, though not new, does not seem to be carefully carried out in many cases. Von Grsefe teaches that the sheet-anchor, in the treatment of acute iritis, is the local use of atropine. Atropine causes flilatation of the pupil, allays nervous irritation, and places the iris in a state of absolute rest. Though in some it may be advisable to ado]3t general treat- ment, for instance, when the patient sufl'ers from syphilis; in perhaps half the cases, if the treatment is commenced early, the disease can be brought to a successful termination by the local treatment alone. The following is a good illustrative case : — One Sabbath morning, a patient applied to me, stating that the eye had been painful that morning and the sight was " misty." On examination, I discovered nothing unusual in the appearance of the eye, with the exception of a very slight pink blush ai'ouud the cornea. Suspecting the possibility of iritis, and not having time for a more careful examination, I applied a four-grain solution of atropine. Two hours after, the pupil was slightly dilated, but irregular. Tiiere were three points of adhesion, one above and two below, giving the appearance represented in Fig. 1. The solution of atrop. sul. was again applied, and repeated la Geitcrnl Pvactlve. 15 Pig. 1. Fig. % Fig. 3. during the afternoon and evening, and on Monday it was found that the adhesion above had yielded to the inidriatic (Fig. 2). The atropine solution was continued, and on the second day there was but one point of adhesion remaining (Fig. 3). The third day, the pupil was widely dilated, and the iris free from adhesions. The dilatation was continued for about a week longer, when all ii-ritation having disappeared, the treatment M^as discontinued. (Jonstitutional treatment is not resorted to until after the atropine solution has been vigorously applied foi' twenty-four or forty-eight houis, and then only in those cases where the pupil is not dilating. The adhesions of the iris will yield more promptly to the atropia after local depletion, and this should be resorted to in all cases of iritis accompanied with a considerable degree of pain. From one to three ounces taken from the temple, either by cup- ping or leeches, in the evening, is almost certain to relieve the patient from nocturnal pain. In 1866. Mr. Teale, of the Leeds Infirmary, published (Opli,- thalmic Hospital Reports, Vol. v.) a tabular report of 20 cases of acute iritis, in which ' the exactness of the results is so marked,' that he is justified in deducing certain principles of treatment, which accord with my own experience. The treatment is commenced with the vigorous use of the solution of atrop. sulph., and if, at the end of twenty-four or forty-eight hours, the pupil is not dilating, the patient, whether syphilitic or not, is put on mei'^urial treatment, and brought under its influence as rapidly as possible. The atropine solution is applied twelve times a day, as foUows : — six times in the morning and six times in the evening, it is dropped into the eye every five minutes, and care exercised to prevent any excess of the solution passing into the lachrymal duct. The head should be well thrown back, and the chin elevated as high or higher than the forehead. After the solution is applied, the head is rotated to the temporal side, and any excess allowed to escape at the external commissure. The strength of the solution of atrop. sulph. used by Mr. Teale is two grains to the ounce, but a solution of double that strength is more effectual. The neutral sulphate of atropine is or alcohol. In usin<4' mercury, Mr. Teale believes that it shoiild be intro- duced into the system through the skin only, as, in this way, its full remedial effects can be produced without in the least impair- ing the powers of nutrition. His method is as follows : — instead of rubbing in the ointment in the usual way, " the patient is ordered to lie in bed, and wrap round each arm a piece of flannel, well smeared with strong mercurial ointment, and to wear the mercurial bandage until the gums are slightly tender, a small quantity of fre.sh ointment being added every evening." " As soon as the symptoms of the disease begin to abate, or the gums begin to be tender (and these two conditions are generally coin- cident), the mercurial is discontinued." The instillation of the atropine should be continued for a week or ten days after all symptoms of iriitation have subsided, and longer if the pupil is not fully dilated. After the adhesions have completely yielded and the pupil is fully dilated, the atro- pine need be applied only two or three times a day. Effusions of lymph and adhesions of the iris are seen to much greater advantage by the method known as oblique or focal illumination. In a darkened room, a lamp is placed, two or three feet from the [>atient, on the same side as the affected eye, and with a double convex lens of two inch focus, the light is concentrated and directed acro.ss the anterior chamber. This examination is more satisfactorv when the iris is under the influence of atropine.* I would add that, in all cases of the least doubt, the ati'o- pine solution should be used experimentally ; it is far better to apply it occasionally where it is not needed, than to omit it in a single ca.se where it is needed. Considering the number of cases of closed pupil that are constantly occurring, — sometimes even in cases under clinical assistants at ophthalmic institutions, it would surely be far better to use the atropine empirically in every case of eye disease, than that a single case of iritis should be overlooked. Many cases of chronic occlusion of the pupil may be im- proved by the operation of iridectomy ; but a discussion of that does not come within the scope of a paper on the treatment of acute iritis. * Oblique illumination is also used in searching for incipient cataract or nehuLv of the cornea. The two inch lens accompanying the ophthalmoscope is used foi- this purpose. In its absence, one can be procured from Mr. Potter, the optician, for about 75 cents. *- - -^•''"'