LECTURE 0^ DISEASES OF THE IRIS?BY DR. C. MACNAMARA.
Mat 1, 1867.]
LECTUEE ON DISEASES OF THE IRIS By
Superintendent,
C.
(No. II.)
Macnamara, Ophthalmic Hospital.
Calcutta
Parenchymatous Iritis.?The characteristic feature of this form of inflammation is that the hyperaction going on in the part leads to the formation of nodules of a lowly organized fibrocellular structure at one or more points on the iris ; these excrescences vary in size, in some instances as small as a being
whereas in others they cover the greater portion of the iris ; in the early stages of the disease they are usually of a reddish brown colour, assume a yellowish
pin's head,
subsequently they
then look very like collections of pus on the iris. Ihese excrescences may either become absorbed or else they suppurate, and the pus gravitating down into the lower part
tinge,
and
of the anterior chamber, forms an hypopion ; on the other hand, should the fibro-ccllular formations of parenchymatous iritis become absorbed, the iris may return to its normal condition, its contractile tissue
We seldom, of spontaneous recovery ; more often cicatrices form in the iris, and extensive synechia are the result of this form of inflammation. Parenchymatous iritis may often be traced to the effects of
however,
meet with
either primary
being apparently uninjured.
a case
syphilis; in the latter form of disease itself before the little patient is more than a few months old, but in all instances in which the affection arises from syphilis we may expect to find the fibro-cellular excrescences particularly well defined, in fact almost isolated, the remainder of the fibrous structure of the iris being comit
usually
or
inherited
manifests
paratively healthy, although apparently altered in colour when The nodules observed on seen through the muddy aqueous. the iris under these circumstances, are nothing more nor less lhan gummy tumours, similar to those met with in other. Our diagnosis will parts of the body, as a result of syphilis. of course be confirmed, in instances of this kind, by the history of the case and the existence of constitutional symptoms, but still the condition of the iris alone will lead us at once to entertain suspicions as to the origin of the disease. It by no means follows, however, that parenchymatous iritis may not result from other causes than syphilis; in fact we often meet with cases of the kind arising from operations or injuries involving the iris and also from other causes; it is a matter of some importance, therefore, to discard the term syphilitic iritis from our nomenclature, as it is apt to give rise to errors to the treatment of the disease, and I shall subsein.
regard
quently explain a syphilitic taint may without doubt induce the plastic, or serous form of inflammation, as well as the parenchymatous.
and other races or individuals whose Among the natives of India contains black pigment, it is uifficult at times to recognize the fibro-cellular excrescences in the early stages of this affec-
uvea
tion,
on
account of the free
pigmentary
matter which is dissem-
of the new growth, its among the cellular elements colour differing but slightly from the rest of the iris, and unless the part he carefully examined by transmitted light, the nodules, especially when small, will probably be overlooked. Among fair skinned people we have no complication of this kind to inated
encounter, and
we shall have but little difficulty in forming the excrescences assuming, as before remarked, a reddish brown colour in the early stages of the disease ; they subsequently become yellow, and can hardly fail to attract the attention of the most superficial observer. our
diagnosis,
Although parenchymatous iritis occasionally disappears withinflicting any serious injury to the affected parts, still, as a general rule, it is the most destructive form of inflammation to which the iris is subject, often leading to multiple posterior synechia (and it may be to anterior synechia, that is, to adhesions between the iris and cornea) than any other disease. The symptoms, therefore, which I have enumerated as common to inflamout
of the iris
H7
intensified in the affection now To this rule there are exceptions especially among syphilitic patients. We occasionally see parenchymatous iritis run a chronic or sub-acute course, without inducing any very prominent symptoms, hut usually ending mation
usually
are
under ,our consideration.
synechia ; nevertheless there are exceptional cases. The symptoms generally present in parenchymatous iritis are more acute than in any other form of inflammation of the iris; the vessels of the iris, more particularly those covering the excrescences and surrounding their base, are engorged with in extensive
blood, and the sclerotic gested; the conjunctiva
zone
of vessels is
proportionately
con-
ofoen deeply injected, and considerable chimosis may exist. The aqueous is remarkably turbid, and flakes of lymph may often be seen floating about in it. In many cases the posterior elastic lamina of the cornea becomes hazy; its epithelial cells undergoing fatty degeneration, become white and opaque, presenting a spotted appearance. The brilliant fibrous aspect of the iris is destroyed, and its colour as seen through the hazy cornea and muddy aqueous is remarkably altered ; one
or more
is
fibro-cellular
excrescences
will be
seen
on
the
iris, they vary in size and color as before described. The pupil is insensible to the stimulus of light, and if dilatable by the aid of mydriatics, it assumes an irregular shape, the functions of the nerves, vessels, and contractile fibres of the iris being impeded by the abnormal action going on in it, or from the formation of synechia which tie it clown to the lens or cornea. The patient usually complains of pain in the eye and forehead from the commencement of the disease, subsequently the pain extends to the head and side of the face, and is often most excruciating, generally lessening during the day, but increasing in intensity as the night advances. The intolerance of light and increased lachrymation are also symptoms from which the patient suffers very considerably, a gush of tears pouring out of the eye the instant the eyelids arc opened. The symptoms above enumerated necessarily differ in the several stages of the disease, but though cases of parenchymatous iritis may vary as to their intensity, they too often lead to irreparable damage to the eye ; the fibro-cellular excrescences to which it gives rise degenerating into pus, an abscess forms, a cicatrix of greater or les3 extent in the connective tissue of the iris is the result. In other instances synechia appears, which tends to keep up irritation and excite inflammation in the part, ultimately leading to occlusion of the pupil, and glaucomatous
and
in the eye. We may now proceed to consider the data upon which a prognosis is to be fcased in cases of the various forms of inflammation of the iris I have described; this will depend, as Mackenzie remarks, on " the cause, as iritis presents not only different stages, but the disease is met with of very different
changes
degrees of severity. In slight and recent cases, complete restoration may be promised ; in more severe cases, the recovery which can take place is only partial; in severe and neglected cases, it is but too often evident that no hope can be held out of even being able to restore vision or even to save the form of the
eye."
synechia
tion in
It
is, however,
to the presence and extent of the we should direct our attento arrive at .a conclusion, as to the proba-
which have formed that
endeavouring
ble result of any particular case which may be brought to If bands of adhesion exist between the iris and our notice. lens, we may be almost certain that repeated attacks of inflammain in all tion of the iris will supervene,
probability,
terminating,
occlusion of the pupil and glaucoma.
But
even
supposing
the
loss of slight, they keep up constant irritation in the part, which is very likely to lead to congestion of the choroid and degenerative changes in the vitreous lens or retina. I am aware that many surgeons do not believe in the deleterious influences which an eye undergoing changes, such as
synechia
do not thus
I have above
directly
cause
described, exercises
over
the other eye ; it appears,
THE INDIAN MEDICAL GAZETTE.
118
however, that the integrity of the healthy eye is thus endangered ; we are bound, therefore, in instances of this kind, not only to form an unfavourable prognosis as regards the diseased eye, but to warn the patient of the danger he runs of losing the sight of the other eye, unless the source of irritation be
resulting
removed.
or
Synechia being
less
frequently
early stages of necessarily follows
met with in the
than in the other forms of iritis, it that in serous iritis we may reasonably expect to restore our patient's eye-sight, if the case is brought sufficiently early under The patient's vision, however, is apt to remain our treatment.
serous
confused and hazy for
some
time,
on
account of the
semi-opa.que
condition of the posterior layers of the cornea, which, as I have before stated, is generally met with in this form of inflammation.
Provided the pupil dilates regularly under the effects of
a
weak
solution of atropine, we may assure the patient that the haziness of vision will soon pass off; more particularly if there be no contraction of the field of vision, a very fair test of the healthy condition of the retina. Serous iritis, if allowed to
run
its course, may induce increased intra-ocular pressure,
particularly when the diseased action extends to the choroid, and it then becomes a very serious affection, its danger being in proportion to the augmentation of the tension of the eyeball, as described under the head of glaucoma, into which affection it gradually merges. In plastic iritis, if the synechia are slight, or have only been recently formed, so that they can be broken through by dilating the pupil with atropine, we may form a favourable prognosis, although the patient's sight for a time may be impaired by spots of uvea which remain adherent to the capsule of the lens, and from opacities of the posterior lamina of the cornea. It is often necessary to search very carefully for the deposits of uvea before they can be recognized; the pupil must be dilated as much as possible, and the lateral method of examination employed, or they may still better be seen by the aid of the ophthalmoscope. If the synechia cannot be torn down by the action of mydriatics, much may still be done to improve the condition of the patient by breaking through the bands of adhesion between the iris and lens, by means of an instrument introduced into the eye through the cornea, or by iridectomy, but our prognosis must be very guarded; the patient's sight is never likely to be perfectly restored, and in too many instances will have been absolutely destroyed for all practical purposes. In parenchymatous iritis, our prognosis, as a general rule, will be still more unfavourable, unless the disease be brought under treatment before it has made any very great progress; it is true some cases run a sub-acute course, giving the patient but little inconvenience, and leaving apparently no bad results behind them, but this is unusual; unless judiciously treated, the disease more commonly leads to multiple synechia and closed pupil. If, however, at any stage of the affection we can dilate the Pupil with atropine, we may with confidence expect a favourable issue, as we can then prevent the formation of synechia, and in all probability the further progress of the disease. In forming our prognosis, we should never lose sight of the fact that in all the cases of iritis we may have to deal with, there is always a tendency for the disease to recur, and that each successive attack is usually more severe than its nredecessor, and more likely, therefore, to spread to the choroid, or leave behind its mark in the form of fresh synechia. There is one deceptive condition of the eye I must warn you of as a result of iritis, the patient's sight remains remarkably good, although the iris is closely bound down to the lens by synechia. This state of things arises from the fact that a small but clear opening remains through the pupil, and the consequence is rays of light reach the retina without hindrance; nevertheless, the patient's sight is endangered from the occlusion more
of the communication between the chambers of the eye. Cases of this kind are but rarely met with in practice; we far more fre-
quently
see
instances of closed pupil and extensive synechia
[Mat I,
1867.
from severe or repeated attacks of iritis ; the patient may have sufficient sight left to find his way about, but is utterly unable to read or write ?with the diseased eye. If, under the circumstances, we fail to dilate the pupil with atropine, and if the tension of the eyeball is either increased
diminisned, the prognosis cannot but be very unfavourable, iridectomy may improve matters, but the chances are that the choroid, and very probably the retina also, will have become implicated in the disease. I have already expressed an opinion as to the ill effect that an eye undergoing atrophy, the results of iritis, is likely to exert on the sound eye. We are not unfrequently consulted in cases of this kind, and there can be no doubt of the advisability under these circumstances of removing the diseased eye ; it is better to take the entire globe away rather than cut through its anterior section, leaving the main
source
of the iritation to continue its baneful effects on
the other eye. The causes
of iritis are often veiled in considerable obscurity. Plastic iritis was formerly supposed to occur in the majority of instances among rheumatic persons, but the truth is we frequently meet with this form of disease in cases where no suspicion of rheumatism exists, and we hardly ever see an instance of advanced leprosy in which plastic iritis is not present. Syphilitic patients again are often subject to this form of iritis ; we see it also following blows or injuries to the eye; in fact it is absolutely impossible to assign a constant cause as the origin of this disease. The same remark applies to parenchymatous iritis: we are no doubt justified in attributing it to a special cause, if the patient has had primary syphilis, and if the excrescences on the iris are particularly well defined, but we shall in practice meet with instances of parenchymatous iritis occurring under circumstances which cannot be thus accounted for. In serous inflammation of the iris we must be on our guard as to choroidal complications; for, as I shall subsequently explain, the diseased action not unfrequently commences in the choroid and spreads to the iris. Independently of any such complications, this description of iritis is most apt to occur among persons in a debilitated state of health. The main point, however, to bear in mind is, that no form of iritis is characteristic of any particular constitutional dyscrasia ; it appears of iritis as
consequently to be an error to describe one form rheumatic, another as syphilitic, and so on; these and numerous other influences, such as malaria, gout, and the like, are equally frequent causes of iritis. It is necessary therefore in every instance to enquire carefully into all the circumstances of the case ; then, and not till then, shall we be able to determine the correct principle upon which our treatment is to be based.
Treatment.?Having mentioned some of the numerous circumgive rise to inflammation of the iris, I need hardly add that before commencing the treatment of any particular case, we must, as before remarked, if possible, arrive at a definite conclusion as to its origin, otherwise our efforts to cure may fall wide of the mark. There is usually no difficulty in ascertaining the presence of a rheumatic, syphilitic, or malarious diathesis, but it is generally a far more troublesome matter to arrive at a correct diagnosis, if a patient be suffering from any of those numerous ailments induced by functional derangement of the secreting organs, which by altering the character of the blood interfere with the nutrition of the various tissues of the body. We must nevertheless attempt to fathom even these complications, and to right matters by some of the powerful agencies at our command; these means embrace a knowledge of the influence which drugs, hygiene, dietary, and the like exercise on the organism, including well nigh the whole system of medicine, and are subjects beyond the scope of these lectures ; it will consequently
stances which
be necessary for me to confine my remarks to the consideration of certain drugs, and other means which have the repute oi peculiar efficacy in the treatment of inflammation of the iris.
May 1,
POISONOUS SNAKES.?BY H. COOKSON.
1867.]
invaluable drag in cases of iritis it may be administered in the form of blue pill, or calomel combined with opium, or as a calomel vapour-bath ; the latter, I believe, is in the majority of instances the best plan of administering mercury in the class of cases now under our consideration, but if it appears advisable to
Mercury?Is
doubtless
an
having a syphilitic origin ;
affect the system rapidly on account of the severity of the symptoms, two grains of calomel with one of opium may be given every three hours, for two days ; we may then generally trust to the vapour-bath. If the patient be a young child, it will be ad-
visable to rub
a
drachm of the blue mercurial ointment into
thighs night and morning, but in the case of an adult, from ten to twenty grains of calomel may be employed as a vapourbath every night for a week or ten days, in fact until it makes a decided impression on the diseased action going on in the iris, and the same remark applies to the rubbing-in system, but it will be necessary, although lessening the quantity of mercury employed after the iritis has begun to subside, to continue its use for some time, our object being, if possible, to eradicate or destroy the active principle of the disease, and thus prevent the return of the iritis. In instances of inflammations of the iris, apparently originating in an injury to the part, if the patient be labouring under a syphilitic diathesis, the effects of the mercurial vapour-bath may be tried ; in complicated cases of this description its effects are often very marked, but, as a general rule, it may be affirmed that mercury is never to be employed in iritis, unless in cases arising directly from inherited or primary syphilis ; in other cases this drug is useless, and in very many instances positively injurious. The efficacy of mercury is generally confined to the early stages of iritis; when synechia have formed, it is useless to attempt their absorption by its aid; on the other hand, if the plastic or fibro-cellular his
formations I have described as characteristic of certain forms of have not become organized, their further development are of syphilitic origin) may doubtless be stayed (provided they by mercury judiciously administered. It is seldom necessary to
iritis,
give the drug by the mouth, unless in rapidy advancing cases, it being far more under control when used in the form of inunction or as a vapour-bath, and if the mercury does not appear to check the progress of the disease before salivation is induced, it is futile continuing its employment,?that is, the treatment should never be pushed to such an extent that the harmful influence of the drug on the system becomes developed. (To be continued.)
HQ
Mat 1, 1867.]
LECTUEE ON DISEASES OF THE IRIS By
Superintendent,
C.
(No. II.)
Macnamara, Ophthalmic Hospital.
Calcutta
Parenchymatous Iritis.?The characteristic feature of this form of inflammation is that the hyperaction going on in the part leads to the formation of nodules of a lowly organized fibrocellular structure at one or more points on the iris ; these excrescences vary in size, in some instances as small as a being
whereas in others they cover the greater portion of the iris ; in the early stages of the disease they are usually of a reddish brown colour, assume a yellowish
pin's head,
subsequently they
then look very like collections of pus on the iris. Ihese excrescences may either become absorbed or else they suppurate, and the pus gravitating down into the lower part
tinge,
and
of the anterior chamber, forms an hypopion ; on the other hand, should the fibro-ccllular formations of parenchymatous iritis become absorbed, the iris may return to its normal condition, its contractile tissue
We seldom, of spontaneous recovery ; more often cicatrices form in the iris, and extensive synechia are the result of this form of inflammation. Parenchymatous iritis may often be traced to the effects of
however,
meet with
either primary
being apparently uninjured.
a case
syphilis; in the latter form of disease itself before the little patient is more than a few months old, but in all instances in which the affection arises from syphilis we may expect to find the fibro-cellular excrescences particularly well defined, in fact almost isolated, the remainder of the fibrous structure of the iris being comit
usually
or
inherited
manifests
paratively healthy, although apparently altered in colour when The nodules observed on seen through the muddy aqueous. the iris under these circumstances, are nothing more nor less lhan gummy tumours, similar to those met with in other. Our diagnosis will parts of the body, as a result of syphilis. of course be confirmed, in instances of this kind, by the history of the case and the existence of constitutional symptoms, but still the condition of the iris alone will lead us at once to entertain suspicions as to the origin of the disease. It by no means follows, however, that parenchymatous iritis may not result from other causes than syphilis; in fact we often meet with cases of the kind arising from operations or injuries involving the iris and also from other causes; it is a matter of some importance, therefore, to discard the term syphilitic iritis from our nomenclature, as it is apt to give rise to errors to the treatment of the disease, and I shall subsein.
regard
quently explain a syphilitic taint may without doubt induce the plastic, or serous form of inflammation, as well as the parenchymatous.
and other races or individuals whose Among the natives of India contains black pigment, it is uifficult at times to recognize the fibro-cellular excrescences in the early stages of this affec-
uvea
tion,
on
account of the free
pigmentary
matter which is dissem-
of the new growth, its among the cellular elements colour differing but slightly from the rest of the iris, and unless the part he carefully examined by transmitted light, the nodules, especially when small, will probably be overlooked. Among fair skinned people we have no complication of this kind to inated
encounter, and
we shall have but little difficulty in forming the excrescences assuming, as before remarked, a reddish brown colour in the early stages of the disease ; they subsequently become yellow, and can hardly fail to attract the attention of the most superficial observer. our
diagnosis,
Although parenchymatous iritis occasionally disappears withinflicting any serious injury to the affected parts, still, as a general rule, it is the most destructive form of inflammation to which the iris is subject, often leading to multiple posterior synechia (and it may be to anterior synechia, that is, to adhesions between the iris and cornea) than any other disease. The symptoms, therefore, which I have enumerated as common to inflamout
of the iris
H7
intensified in the affection now To this rule there are exceptions especially among syphilitic patients. We occasionally see parenchymatous iritis run a chronic or sub-acute course, without inducing any very prominent symptoms, hut usually ending mation
usually
are
under ,our consideration.
synechia ; nevertheless there are exceptional cases. The symptoms generally present in parenchymatous iritis are more acute than in any other form of inflammation of the iris; the vessels of the iris, more particularly those covering the excrescences and surrounding their base, are engorged with in extensive
blood, and the sclerotic gested; the conjunctiva
zone
of vessels is
proportionately
con-
ofoen deeply injected, and considerable chimosis may exist. The aqueous is remarkably turbid, and flakes of lymph may often be seen floating about in it. In many cases the posterior elastic lamina of the cornea becomes hazy; its epithelial cells undergoing fatty degeneration, become white and opaque, presenting a spotted appearance. The brilliant fibrous aspect of the iris is destroyed, and its colour as seen through the hazy cornea and muddy aqueous is remarkably altered ; one
or more
is
fibro-cellular
excrescences
will be
seen
on
the
iris, they vary in size and color as before described. The pupil is insensible to the stimulus of light, and if dilatable by the aid of mydriatics, it assumes an irregular shape, the functions of the nerves, vessels, and contractile fibres of the iris being impeded by the abnormal action going on in it, or from the formation of synechia which tie it clown to the lens or cornea. The patient usually complains of pain in the eye and forehead from the commencement of the disease, subsequently the pain extends to the head and side of the face, and is often most excruciating, generally lessening during the day, but increasing in intensity as the night advances. The intolerance of light and increased lachrymation are also symptoms from which the patient suffers very considerably, a gush of tears pouring out of the eye the instant the eyelids arc opened. The symptoms above enumerated necessarily differ in the several stages of the disease, but though cases of parenchymatous iritis may vary as to their intensity, they too often lead to irreparable damage to the eye ; the fibro-cellular excrescences to which it gives rise degenerating into pus, an abscess forms, a cicatrix of greater or les3 extent in the connective tissue of the iris is the result. In other instances synechia appears, which tends to keep up irritation and excite inflammation in the part, ultimately leading to occlusion of the pupil, and glaucomatous
and
in the eye. We may now proceed to consider the data upon which a prognosis is to be fcased in cases of the various forms of inflammation of the iris I have described; this will depend, as Mackenzie remarks, on " the cause, as iritis presents not only different stages, but the disease is met with of very different
changes
degrees of severity. In slight and recent cases, complete restoration may be promised ; in more severe cases, the recovery which can take place is only partial; in severe and neglected cases, it is but too often evident that no hope can be held out of even being able to restore vision or even to save the form of the
eye."
synechia
tion in
It
is, however,
to the presence and extent of the we should direct our attento arrive at .a conclusion, as to the proba-
which have formed that
endeavouring
ble result of any particular case which may be brought to If bands of adhesion exist between the iris and our notice. lens, we may be almost certain that repeated attacks of inflammain in all tion of the iris will supervene,
probability,
terminating,
occlusion of the pupil and glaucoma.
But
even
supposing
the
loss of slight, they keep up constant irritation in the part, which is very likely to lead to congestion of the choroid and degenerative changes in the vitreous lens or retina. I am aware that many surgeons do not believe in the deleterious influences which an eye undergoing changes, such as
synechia
do not thus
I have above
directly
cause
described, exercises
over
the other eye ; it appears,
THE INDIAN MEDICAL GAZETTE.
118
however, that the integrity of the healthy eye is thus endangered ; we are bound, therefore, in instances of this kind, not only to form an unfavourable prognosis as regards the diseased eye, but to warn the patient of the danger he runs of losing the sight of the other eye, unless the source of irritation be
resulting
removed.
or
Synechia being
less
frequently
early stages of necessarily follows
met with in the
than in the other forms of iritis, it that in serous iritis we may reasonably expect to restore our patient's eye-sight, if the case is brought sufficiently early under The patient's vision, however, is apt to remain our treatment.
serous
confused and hazy for
some
time,
on
account of the
semi-opa.que
condition of the posterior layers of the cornea, which, as I have before stated, is generally met with in this form of inflammation.
Provided the pupil dilates regularly under the effects of
a
weak
solution of atropine, we may assure the patient that the haziness of vision will soon pass off; more particularly if there be no contraction of the field of vision, a very fair test of the healthy condition of the retina. Serous iritis, if allowed to
run
its course, may induce increased intra-ocular pressure,
particularly when the diseased action extends to the choroid, and it then becomes a very serious affection, its danger being in proportion to the augmentation of the tension of the eyeball, as described under the head of glaucoma, into which affection it gradually merges. In plastic iritis, if the synechia are slight, or have only been recently formed, so that they can be broken through by dilating the pupil with atropine, we may form a favourable prognosis, although the patient's sight for a time may be impaired by spots of uvea which remain adherent to the capsule of the lens, and from opacities of the posterior lamina of the cornea. It is often necessary to search very carefully for the deposits of uvea before they can be recognized; the pupil must be dilated as much as possible, and the lateral method of examination employed, or they may still better be seen by the aid of the ophthalmoscope. If the synechia cannot be torn down by the action of mydriatics, much may still be done to improve the condition of the patient by breaking through the bands of adhesion between the iris and lens, by means of an instrument introduced into the eye through the cornea, or by iridectomy, but our prognosis must be very guarded; the patient's sight is never likely to be perfectly restored, and in too many instances will have been absolutely destroyed for all practical purposes. In parenchymatous iritis, our prognosis, as a general rule, will be still more unfavourable, unless the disease be brought under treatment before it has made any very great progress; it is true some cases run a sub-acute course, giving the patient but little inconvenience, and leaving apparently no bad results behind them, but this is unusual; unless judiciously treated, the disease more commonly leads to multiple synechia and closed pupil. If, however, at any stage of the affection we can dilate the Pupil with atropine, we may with confidence expect a favourable issue, as we can then prevent the formation of synechia, and in all probability the further progress of the disease. In forming our prognosis, we should never lose sight of the fact that in all the cases of iritis we may have to deal with, there is always a tendency for the disease to recur, and that each successive attack is usually more severe than its nredecessor, and more likely, therefore, to spread to the choroid, or leave behind its mark in the form of fresh synechia. There is one deceptive condition of the eye I must warn you of as a result of iritis, the patient's sight remains remarkably good, although the iris is closely bound down to the lens by synechia. This state of things arises from the fact that a small but clear opening remains through the pupil, and the consequence is rays of light reach the retina without hindrance; nevertheless, the patient's sight is endangered from the occlusion more
of the communication between the chambers of the eye. Cases of this kind are but rarely met with in practice; we far more fre-
quently
see
instances of closed pupil and extensive synechia
[Mat I,
1867.
from severe or repeated attacks of iritis ; the patient may have sufficient sight left to find his way about, but is utterly unable to read or write ?with the diseased eye. If, under the circumstances, we fail to dilate the pupil with atropine, and if the tension of the eyeball is either increased
diminisned, the prognosis cannot but be very unfavourable, iridectomy may improve matters, but the chances are that the choroid, and very probably the retina also, will have become implicated in the disease. I have already expressed an opinion as to the ill effect that an eye undergoing atrophy, the results of iritis, is likely to exert on the sound eye. We are not unfrequently consulted in cases of this kind, and there can be no doubt of the advisability under these circumstances of removing the diseased eye ; it is better to take the entire globe away rather than cut through its anterior section, leaving the main
source
of the iritation to continue its baneful effects on
the other eye. The causes
of iritis are often veiled in considerable obscurity. Plastic iritis was formerly supposed to occur in the majority of instances among rheumatic persons, but the truth is we frequently meet with this form of disease in cases where no suspicion of rheumatism exists, and we hardly ever see an instance of advanced leprosy in which plastic iritis is not present. Syphilitic patients again are often subject to this form of iritis ; we see it also following blows or injuries to the eye; in fact it is absolutely impossible to assign a constant cause as the origin of this disease. The same remark applies to parenchymatous iritis: we are no doubt justified in attributing it to a special cause, if the patient has had primary syphilis, and if the excrescences on the iris are particularly well defined, but we shall in practice meet with instances of parenchymatous iritis occurring under circumstances which cannot be thus accounted for. In serous inflammation of the iris we must be on our guard as to choroidal complications; for, as I shall subsequently explain, the diseased action not unfrequently commences in the choroid and spreads to the iris. Independently of any such complications, this description of iritis is most apt to occur among persons in a debilitated state of health. The main point, however, to bear in mind is, that no form of iritis is characteristic of any particular constitutional dyscrasia ; it appears of iritis as
consequently to be an error to describe one form rheumatic, another as syphilitic, and so on; these and numerous other influences, such as malaria, gout, and the like, are equally frequent causes of iritis. It is necessary therefore in every instance to enquire carefully into all the circumstances of the case ; then, and not till then, shall we be able to determine the correct principle upon which our treatment is to be based.
Treatment.?Having mentioned some of the numerous circumgive rise to inflammation of the iris, I need hardly add that before commencing the treatment of any particular case, we must, as before remarked, if possible, arrive at a definite conclusion as to its origin, otherwise our efforts to cure may fall wide of the mark. There is usually no difficulty in ascertaining the presence of a rheumatic, syphilitic, or malarious diathesis, but it is generally a far more troublesome matter to arrive at a correct diagnosis, if a patient be suffering from any of those numerous ailments induced by functional derangement of the secreting organs, which by altering the character of the blood interfere with the nutrition of the various tissues of the body. We must nevertheless attempt to fathom even these complications, and to right matters by some of the powerful agencies at our command; these means embrace a knowledge of the influence which drugs, hygiene, dietary, and the like exercise on the organism, including well nigh the whole system of medicine, and are subjects beyond the scope of these lectures ; it will consequently
stances which
be necessary for me to confine my remarks to the consideration of certain drugs, and other means which have the repute oi peculiar efficacy in the treatment of inflammation of the iris.
May 1,
POISONOUS SNAKES.?BY H. COOKSON.
1867.]
invaluable drag in cases of iritis it may be administered in the form of blue pill, or calomel combined with opium, or as a calomel vapour-bath ; the latter, I believe, is in the majority of instances the best plan of administering mercury in the class of cases now under our consideration, but if it appears advisable to
Mercury?Is
doubtless
an
having a syphilitic origin ;
affect the system rapidly on account of the severity of the symptoms, two grains of calomel with one of opium may be given every three hours, for two days ; we may then generally trust to the vapour-bath. If the patient be a young child, it will be ad-
visable to rub
a
drachm of the blue mercurial ointment into
thighs night and morning, but in the case of an adult, from ten to twenty grains of calomel may be employed as a vapourbath every night for a week or ten days, in fact until it makes a decided impression on the diseased action going on in the iris, and the same remark applies to the rubbing-in system, but it will be necessary, although lessening the quantity of mercury employed after the iritis has begun to subside, to continue its use for some time, our object being, if possible, to eradicate or destroy the active principle of the disease, and thus prevent the return of the iritis. In instances of inflammations of the iris, apparently originating in an injury to the part, if the patient be labouring under a syphilitic diathesis, the effects of the mercurial vapour-bath may be tried ; in complicated cases of this description its effects are often very marked, but, as a general rule, it may be affirmed that mercury is never to be employed in iritis, unless in cases arising directly from inherited or primary syphilis ; in other cases this drug is useless, and in very many instances positively injurious. The efficacy of mercury is generally confined to the early stages of iritis; when synechia have formed, it is useless to attempt their absorption by its aid; on the other hand, if the plastic or fibro-cellular his
formations I have described as characteristic of certain forms of have not become organized, their further development are of syphilitic origin) may doubtless be stayed (provided they by mercury judiciously administered. It is seldom necessary to
iritis,
give the drug by the mouth, unless in rapidy advancing cases, it being far more under control when used in the form of inunction or as a vapour-bath, and if the mercury does not appear to check the progress of the disease before salivation is induced, it is futile continuing its employment,?that is, the treatment should never be pushed to such an extent that the harmful influence of the drug on the system becomes developed. (To be continued.)
HQ
