not impaired. The congested vessels are in the conjunctiva and present a raw, red appearance.

CYCLITIS.

In cyclitis there is usually severe pain and tenderness on pressure over the ciliary body. The anterior chamber is generally deep. The intra-ocular tension may be raised or diminished. There is cedema of the upper eyelid, with greater impairment of vision than is usually seen in iritis. In addition we have all the symptoms of iritis, with the exception of the changes in the iritis itself. The ciliary body and iris being parts of the uveal tract, nourished by the same blood supply, it is practically impossible for cyclitis to exist without sooner or later involving the iris. Hence a differential diagnosis between iritis and cyclitis is not of much practical importance, as they are usually due to the same causes and are amenable to the same general principles of treatment.

PROGNOSIS.

The prognosis will depend upon the nature, cause, complications and treatment of the disease. In all diseases of the uveal tract or any part of it, the prognosis is exceedingly grave, as it is the vascular and nutritive coat of the eye. From it, all of the non-vascular and transparent tissues receive their nutrition. At the outset it is impossible to tell what complications may arise or what will be the ultimate result. In rheumatic and gouty iritis relapses are very common, while relapses are very rare in syphilitic iritis if the disease has been properly treated. The prognosis is generally good in simple plastic iritis if the pupil has been dilated before synechiæ have formed, or before they have become too firm to be broken down by a mydriatic. Posterior synechiæ are the most dangerous complications in iritis. Even when few, they inhibit or interfere with the free movements of the pupil and predispose to relapses by dragging on the iris, each recurrence being followed by fresh adhesions, until finally complete posterior synechiæ may be established. In such cases the aqueous humor being still secreted behind the iris, it cannot escape through the pupil into the anterior chamber to reach the canal of Schlemm. Consequently the pressure of the imprisoned aqueous forces the iris

The pu

forward in contact with the periphery of the cornea. pillary border of the iris being adherent to the anterior capsule of the lens, retains its normal depth, giving characteristic funnel-shaped appearance to the iris. The tension of the eye-ball is sooner or later raised, resulting in secondary glaucoma with loss of the eye.

TREATMENT.

As we have seen, iritis may be due to many causes. But fortunately it is not necessary to delay treatment in order to determine the cause, as all cases are treated on practically the same line. Especially is this true of local treatment. Atropine is indicated, and must be used in all cases to dilate the pupil and to keep it dilated until all inflammation has disappeared, for the purpose of preventing, as far as possible, the formation of adhesions and to break down those which may have formed before treatment had commenced. One drop of a one per cent. solution of atropine should be instilled into the eye from four to six times a day, or until the pupil is dilated ad maximum. Then the instillations may be less often, as indicated. Atropine not only dilates the pupil, but it lessens congestion by contracting the vessels of the iris and forcing the blood into the ciliary vessels. It relieves pain by paralyzing the ciliary muscle and putting the eye at rest, which is a most important thing in all inflammatory conditions.

The activity of atropine is increased by the addition of cocaine and adrenalin. Occasionally we meet with individuals who exhibit an idiosyncrasy for atropine. The toxic symptoms may be manifested locally or constitutionally. In such cases its use must be discontinued and some other mydriatic substituted. The sol. ext. of belladonna may be used, grains 8 to the ounce of water, or the hydrobromate of hyoscin or duboisin. Hyoscin and duboisin being much more powerful mydriatics than atropine, should be used with extreme caution. The strength of each solution should not exceed 2 grains to the ounce of water.

Pain and inflammation are greatly relieved by the application of hot fomentations; moist heat being much more convenient, should be applied by wringing napkins out of hot water and placing them over the closed eyelids from twenty to thirty minutes at a time and repeated every few hours. Cold applications are indicated in traumatic iritis, and should be applied

continuously for twenty-four or thirty-six hours; after which time it is best to substitute heat. The eye should be protected from bright light by smoked glasses, or if the photophobia is very great, the patient should be confined to a darkened room. The abstraction of blood by applying leeches, either natural or artificial, to the temple sometimes gives relief. About one ounce of blood should be withdrawn.

CONSTITUTIONAL TREATMENT.

Must vary somewhat according to the cause of the disease. In syphilitic iritis mercury in some form must be pushed until its full physiologic effect is reached. Personally, I prefer the bichloride given in combination with the iodide of potassium, one-twelfth of a grain of bichloride with ten or fifteen grains of iodide of potassium should be taken three times a day in a full glass of water, until the gums are somewhat tender and swollen; then the dose of mercury is reduced to one-sixteenth of a grain. This treatment should be kept up for several months after the inflammation of the iris has disappeared. In anemic and poorly nourished patients tonics should be given, containing iron, quinine, strychnine, etc., with an abundance of good, substantial food. Small doses of mercury and iodide of potassium may be given with decided benefit in all forms of iritis, irrespective of cause. When rheumatism, gout or gonorrhoea is the cause, the salicylates should be given freely. Twenty grains of the salicylate of soda from three to six times a day. The alkalies and alkaline waters are also indicated in the gouty, rheumatic, gonorrhoeal and diabetic types. Kutnow's effervescent powder being a very convenient, efficient and pleasant method of administration. The diet should be carefully regulated, especially in gout and diabetes, and all alcoholic drinks excluded. In tubercular iritis, which is fortunately exceedingly rare, if of the solitary type, an iridectomy may be performed, if all of the tubercular tissue can be removed; if not, the entire eyeball should be enucleated. In the miliary form, iridectomy is of no value, as the tubercular nodules are too widely distributed over the surface of the iris to be removed by operation. The usual local and constitutional measures should be employed; but if the disease continues to progress, removal of the eye is the only means of relief. In some instances the pain in iritis is very severe, and many oculists advocate the use of opiates. In my experience they are

never indicated, as they check secretions, impair digestion and lower the vitality of the patient and prolong the disease. The remedies already given are more efficient in relieving pain than opiates. Surgical measures are frequently employed for the relief of complications. In serous iritis if the tension is high and remains so for several days, paracentesis of the anterior chamber should be performed. It gives great relief by lowering tension and allowing inflammatory products to escape with the aqueous. The operation should be repeated as often as necessary to maintain the normal intraocular tension. Iridectomy is indicated in those cases of complete posterior synechiæ (exclusion of the pupil), for the purpose of preventing secondary glaucoma by furnishing an outlet for the aqueous, which is imprisoned in the posterior chamber. Or an iridectomy may be performed in those cases of less extensive adhesion where there are frequent recurrences of iritis. An iridectomy should never be undertaken until the inflammation of the iris has completely subsided. It is still a mooted question whether or not an iridectomy tends to prevent relapses.

DISCUSSION.

Dr. A. A. Greene: While this subject is a very important one, there has been very little written about it in any of the journals devoted to ophthalmology during the last two or three years. I did not realize how little attention had been paid to this subject until I began, on last Sunday, to review the files of Opthalmic Journals, and found very little written about the iris except that relating to malignant tumors.

As Dr. Woodson has said, the subject is an important one to the general practitioner, because he is the first to see these cases and much depends on the diagnosis. It is easy to differentiate between iritis and catarrhal conjunctivitis if one is careful and persistent. Simple catarrhal inflammation of the conjunctiva should be recognized at a glance by the excessive secretion. In iritis, there may be present a slight secretion, but the character of the pain should prevent confounding this trouble with catarrhal conjunctivitis. In the latter the patient complains of a "gritty" sensation in the eye, while in iritis the pain is intense, deep-seated and persistent, and when this pain is present, it would be wise to suspect iritis. Also in catarrhal conjunctivitis, the pupil responds to light. In differentiating between iritis and glaucoma, there is a symptom

KIDNEY SURGERY IN ITS RELATION TO THE CURE OF DISEASES.

HARRY TUTWILER INGE, OF Mobile, Ala.

Grand Senior Counsellor of the Medical Association of the State of Alabama.

No department in all the broad field of modern surgica! science has made greater strides within the past few years than that to which it is my pleasure to invite your attention upon this occasion-surgery of the kidney. The unquestioned good results obtained by the proper operative treatment of certain states of diseases are still new to many, and not fully accepted by some of the profession. Those, however, who are in position to see and know, are convinced that the hopes and expectations of its advoctaes have already been more than justified, and feel that the pioneer work already done points for us the way to greater things.

Without entering upon a historical review of the development of renal surgery, I will simply say that my attention was first directed to its possibilities by the work and writings of Edebohls and of Reginald Harrison. In the autumn of 1895. it was my good fortune to see Edebohls perform several of his earlier operations upon the kidneys; operations which, while differing in technique from the more recent work of this distinguished surgeon, were quite sufficiently brilliant in results to arouse my intense interest and enthusiasm.

Since that time, it has been my experience to operate upon the kidneys in fifty-six cases without a single death; the results being either cure or great benefit in every instance.

These fifty-six cases fall naturally into two classes: First, those in which the kidney itself was diseased, and, second, those in which the operation was done for the relief of reflex and other symptoms due to excessive movability of the kidney. Of the twelve cases, included under the first head, one was an instance of pyonephrosis, and eleven of the cases were characterized by the presence of renal tube casts and other evidence of disintegrating disease of the renal parenchyma, together