judiciously treated-is sure to leave behind it more or less permanent injury to the eye.

In the 153 cases which have furnished the clinical material for this paper, a large number of them are classified as chronic, and sequelæ of iritis. These are cases which have been left with more or less extensive adhesions between the cornea and iris, or the iris and lens or both, and were going through the slowly destructive changes already described, and showing either increased or dimin ished tension of the ball.

The 153 cases include all possible gradations in point of severity, ranging from slight inflammation, forming delicate thread-like synechia readily torn by the mydriatic, to the severe destructive disease I have endeavored to portray in your hearing.

Iritis may, however, pursue a very different history from the one I have sketched. Instead of the violent acute disease racking the patient with pain and rapidly destroying his sight, it may come on almost unnoticed by the patient or his friends. There is very slight ciliary redness, no dread of light, no pain. When closely questioned he remembers to have had occasional attacks of redness and discomfort, which, lasting a few days, had subsided without treatment, thinking he had "taken a cold." He seeks advice after many months, it may be, because his eyes are weak and because he has failing sight. Instillation of atropia reveals the presence of synechiæ, and if the process has not already gone so far as to prevent inspection of the deeper structures by blocking the pupil, the vitreous will be found muddy, or at least with numerous opacities floating about in its partly disorganized and fluid mass.

It is of very great importance that iritis should be recognized at an early stage of the disease, since it is only then, before adhesions have formed between the iris and lens, that permanent injury is to be prevented.

During the stage of hyperæmia it is often possible to cut short or prevent entirely an attack of iritis. The first and most important object in the treatment should be to secure at the outset a complete dilatation of the pupil, and this must be maintained throughout. When widely dilated the zone of iris in contact with the lens during the usual state of contraction is drawn back and away from the capsule, and by this means their adhesion by bands of lymph is prevented and the chain of evils depending upon occlusion and exclusion of the pupil is avoided. It is not always easy to effect the dilatation of the pupil, however. During health a very dilute solution of atropia will dilate it ad maximum, but if deeply congested it dilates sluggishly even after instillation of strong solu

tions. If infiltration into the tissue of the iris has already taken place, or beads of lymph have been exuded along the pupillary margin and on its surface, dilatation will be gained with great difficulty. My practice has been to secure it, however, during the first visit of my patient if possible, by the instillation of a solution of sulphate of atropia (gr. iv-f3j) at intervals of a few moments until the pupil dilates or until it was obvious that the effort must fail.

The dilatation often follows on the abstraction of blood from the temple, or the action of a brisk saline purge. The artificial leech has seemed more efficacious than natural leeches, probably from the more rapid abstraction effected in this way. This local depletion has the advantage also of relieving the pain, always diminishing its severity, and frequently affording entire immunity for a few hours after. By the vigorous use of atropia solution and the artificial leech I have repeatedly had the satisfaction of seeing the symptoms subside and rapid recovery ensue in cases which had at the first presented most threatening symptoms. This has only been true, however, in cases traceable to cold taking from exposure, and where there was no attendant constitutional disease. Where the iritis has been associated with other symptoms of syphilis the treatment of the constitutional disease has, in every instance, been deemed necessary. Here, however, the necessity for a dilated pupil is just as great; but when adhesions have already formed I have but rarely been able to tear them apart by the action of the mydriatic until the system was well under the influence of a mercurial.

I have repeatedly, for many days, used strong solutions of atropia in the most persistent and vigorous manner, assisted by the local abstraction of blood, with no effect upon the synechia, other than slightly stretching them; but no sooner were the gums spongy and a slight mercurial fetor on the breath than the adhesions lost their tenacity, either melting down and disappearing as by magic, or becoming friable, lose their hold upon the capsule, and the pupil being free expands widely under the action of the atropia.

This beneficial action of mercury in iritis is by no means confined to cases of syphilitic iritis. In any case of acute iritis with marked tendency to plastic exudation, the surgeon does not do his whole duty who fails to use mercury to the first manifestation of its systemic effects, except, possibly, in the comparatively rare cases where such an acute attack is obviously due to a gouty or rheumatic diathesis.

There has been much said and written on the influence of mer. cury in plastic inflammations in general, and the iris being fairly open to inspection has been called upon to prove or deny its utility,

but whatever may be its effect over inflammation elsewhere, I am fully convinced of its beneficial influence in plastic iritis. It is not necessary that ptyalism should be produced, for the beneficial effects. of the drug are fully realized without producing so profound an impression.

The method of administration has many times seemed a matter of importance. Inunctions have certainly, in my experience, proved of greater value than the administration by the mouth in any form. In several instances I have seen violent attacks of iritis come on while the patient was taking full doses of protiodide of mercury by the mouth for secondary syphilis. No improvement took place until inunctions were substituted;-in three cases the favorable influence from the change in the method of administration over the course of the disease was well-marked.

Should the iritis bear an evident relation to rheumatic or gouty cachexia they should be treated by the constitutional measures directed to these diseases.

The arrest of pain is often a very important element in the treatment. Opiates are generally necessary in severe cases, and no form of administration is better than the Dover's powder in full doses, or morphia hypodermically.

In rheumatic cases, especially, complete rest in bed is often necessary. A case which has stubbornly refused to improve as long as the patient was allowed to go and come at will, will often date a rapid recovery from the hour he took to the bed.

The adhesions once formed are often so firm that they baffle the best efforts to detach them except by mechanical means. As a sequela of iritis these posterior synechia often present to the surgeon puzzling conditions for remedy. The best means by which these bands of lymph are to be detached without greater injury to the eye has long been an object for earnest discussion. Their presence is a source of danger to the eye, but their method of treatment would lead us beyond the limits of this paper into the realms of iridocyclitis and secondary glaucoma.

1630 WALNUT STREET, PHILADElphia.

ANESTHESIA IN PARTURITION.

By A. H. HALBERSTADT, A.M., M.D.,

OF POTTSVILLE.

FOR a number of years the teachings of this Society have been ominously silent in all allusions to the use of Anesthesia in Parturition, and so markedly was it at the meeting in 1874, that the mere mention of such use in puerperal eclampsia, in the Address in Obstetrics, elicited from the oldest and ablest members of the profession, who attended that meeting, a discussion on the relative importance of venesection, opium, and purgation that utterly ignored by silence the value of anæsthesia, or even the fact that it had the merit of respectable authority.

Whilst it is true that the merits of these agents were not discussed, nor in fact mentioned, beyond a bare introduction, yet, any one present and unfamiliar, from want of practical experience, with the subject, might have supposed from the known grave character of the disease under consideration, that this significant silence surely indicated a scarce toleration of such therapeutic means by the profession in any of the difficulties attending obstetric procedures.

The declarations of men, some of whom had large experience to justify their assertions, must have had great weight in forming the opinions of those who, from a perhaps commendable caution, had never solely depended upon anæsthesia in so grave and imperative a demand; and as this class of practitioners received their last public teaching from the Address in Obstetrics a year ago, in which its distinguished author cries aloud "for cerebral drainage," and yet proclaims that chloroform can only serve in the end to oppress those organs which are already below the normal standard, and hence we believe it to be injurious," we consider no apology necessary for the selection of this subject to be presented directly to the representatives of the profession of the State.

That there should be an aversion to deviate from the old customs is not to be wondered at, especially as in the practice of obstetrics,

where habits for generations have been fixed and under the popular notion that a different management might be attended with risk and no advantage to the patient, except escape from pain.

Yet, with this view, I years ago began the practice in all cases of parturition, when permitted, and considered it entirely justifiable to take some risk in order to save my patient the pain, but it was not long, however, until I discovered that the mere escape from pain was by no means the entire result of the administration, and, seeking subjects among ladies of highest culture and social position in my locality, careful observation in the first few cases showed beyond doubt its special therapeutic adaptability. Obtaining the consent of the patient, but a small quantity was inhaled at the beginning of the second stage of labor-sufficient to produce seminarcosis, and in almost all cases the effect, within a short time, was first to allay all emotional irritants or excitants, then to moderate central or peripheral nervous irritability, to excite secretion, to dilate the os uteri, to relax the perineum, to give force and direction to uterine contraction, and to establish in all the organs engaged in parturition their true physiological functional activity, all of which is so essential for the quick, safe, and happy completion of even the natural labor.

In all labors a firm perineum, a dry vagina, a rigid os, and false pains always yielded to the influence of the anaesthetic, but it sometimes happened that the force of the contractions was lessened, then ergot was administered, and, if the propulsive effort was not sufficient, the above conditions being established, the anesthetic was pushed to narcosis and the forceps or other means used with much greater safety for the delivery of the child.

With this exception no other possible or obstructive evil consequences attended, for the physiological therapeutic action was not that of any other condition of life in the same subject.

The small quantity necessary to produce semi-narcosis or full narcosis, the absence of nausea, exhaustion, or shock on the return of consciousness, the impossibility of any nervous perturbations, the freedom from hemorrhage, in comparison with cases in which anæsthetics were not administered, the invariably rapid "getting up," with a small percentage of stillborn children, and the questionable statement of but two cases of death to the mother, attributable to the anesthetic in the thousands and thousands of women to whom this aid has been granted, makes it an important consideration to all who have charge of child-bearing women as to what their line of duty should be, in good faith, toward conducting their labors to a safe and happy termination.