In the greater number of cases, only one eye is affected, though sometimes both may be the seat of the complaint--at least in succession or alternately. This is a highly discriminating feature in the complaint, and should always excite suspicion as to the nature of the ophthalmia. Another remarkable peculiarity is the disposition to migration or metastasis. When this occurs, the original inflammation, however severe, sometimes disap. pears entirely-even within a few hours, so that its former existence could scarcely be suspected-the new one attaining to its almost violence in a time as short-often to disappear in its turn. Our author naturally expresses his surprise that so extraordinary a fact as this should not have, long ago, attracted suspicion, since nothing analogous to it occurs in other diseases, with the exception of gout. Like other neuralgia and intermittents, it may be limited to one attack--or, having occurred once, it may be liable to relapse repeatedly. Like all other diseases, it often disappears spontaneously, while the remedies gain a credit to which they are not entitled.

"As to the theory of neuralgic ophthalmia, if it is not very evident, it is at least as intelligible as that of any other form of neuralgic inflammation. Of the true, the ultimate theory, of any inflammation, we know absolutely nothing; since, after all that has been written on this subject, we have but so many words; one term substituted for another. If all that we can know as yet of the cause of neuralgic inflammation is no better, it is at least not worse; while we are in no want of analogies, or the difficulty, such as it is, is countenanced by parallel difficulties." 273.

The author next proceeds to the narrative of two or three cases—because such narratives often excite an attention that would not otherwise be commanded by the most laboured general description.

"In the first case that I shall notice, which was not under my own care, but under that of a medical friend particularly interested in the result, the original disorder or attack was a periodical and daily rheumatism in the neck, remarkably well defined. After this had lasted a week, there occurred suddenly a pain in the eye, with inflammation of a very violent character. I entertain no doubt that the intermittent form remained either in the febrile symptoms or in the pain about the eye: the violence and acuteness of this being a very discriminating mark, as it does not happen in any other ophthalmia But as this physician had never considered the rheumatism in question as a disorder belonging to intermittent or Neuralgia, he had paid no attention to the symptoms, and was therefore unable to describe the case more minutely. Far less had he ever considered any ophthalmia to be a disease of this nature; and the patient was therefore treated in the usual manner, with the unfortunate termination in blindness, from the formation of a pustule in the cornea. I have given this case as I received it from the physician himself, so that others may judge; while the suddenness and violence of the attack of inflammation, the accompanying severe pain, and the previous periodical rheumatism, leave no doubt in my own mind respecting the nature of the disease." 275.

In the following case our author attended with a most learned and talented physician--not a routine practitioner, and who was yet misled--shewing the necessity for a new investigation of this class of complaints.

Case 2. "In this instance, and where the personal interest was as great, the patient was suddenly attacked in the evening with an inflammation of one eye, which ceased by the following morning. On the next evening, there was no inflammation; but it returned on the alternate one, and in the other eye, terminating similarly on the following morning. As I chanced to reside in the house, I could perceive and point out the tertian cold stage; this being evidently a tertian intermittent, or rather, that disorder doubled, (not double tertian,) inasmuch as the succeeding fits were different. Nothing was done; as it was wished to watch the natural progress of the disorder, which, after lasting thus about ten days, or

displaying six different alterations of this nature, became a decided double tertian; the inflammation returning every evening in the alternate eyes, to terminate in the morning. And in this instance, the neuralgic intermittent pain occurred in each eyebrow alternately, accompanying the inflammation; so as to produce a case as strongly marked as is easily conceived. I shall only add that it was afterwards cured by bark; but that I did not even then succeed in producing a free assent to opinions which, probably, I might even now have kept to myself, for all the impression they are likely to make for these twenty years to come; when those who have been most active in opposition, will be among the first to recollect that all this was long ago their own opinions." 280.

Case 3. In the last case which our author notices, the patient had been for some time afflicted with a general or diffused periodical rheumatism, followed at length by inflammation of both eyes, the original disease continuing. The disease was of such long standing that a cure was hopeless. pupils were so contracted that a pin could with difficulty have passed through one, the other being absolutely closed.

Both

"By the patient's account, he had been seized with occasional fits of blindness during the progress of the disease, arising doubtless from the contraction of the pupil, while I have as little doubt that the Iris was affected by the neuralgic inflammation. I could not obtain a more minute account of the case, as he was a man in low life, and had no medical attendant; but enough remained to prove that the judgment I had formed was correct. For, at this time, though one eye seemed hopelessly obstructed, the other was occasionally of use; while the patient observed, and without inquiry or leading question, that whenever the general fits of rheumatism in the limbs came on, the eye became blind, from the closing of the pupil, recovering again when those ceased. I need only add, that as the disease had at this time lasted many years, the fits were no longer as regular as they had originally been, as happens in all chronic intermittent disorders; and as the contraction of the pupil accompanied them then accurately, it is probable this had done so from the commencement, though the exact particulars had been forgotten." 281.

The

Dr. M. suggests, that amaurosis is sometimes dependent on a neuralgic affection, and informs us that, while his work was in the press, two wellmarked cases of amaurosis of one eye, produced very pointedly, and within a few weeks, by a neuralgia occupying the external part of the orbit. gradual paralysis of the nerve, and the total absence of all other affection of the head, or of the corresponding eye, offering evidence as clear as could be desired, of the real source of the disease, and of the truth of the above conjectures.

"I may here introduce a fact which appears to me to bear on this question, and on the original one, viz. the power in this respect, of the inflammatory diseases; but of the value of which I shall suffer others to judge. This fact is, that in the Mediterranean, and in the same districts where that ophthalmia which I suppose to be the disorder under review is common, nyctalopia, as it is there improperly called, or in reality, the loss of vision after sunset, is a very common affection: while I need not remark that this is, in fact, a modified amaurosis, or a partially, or moderately paralytic affection of the retina or nerve." 289.

After a philippic against the sub-divisions of the medical art into oculists, aurists, dentists, &c. and still more against the spine, liver, and stomach doctors, our author enters on a consideration of the treatment of rheumatic ophthalmia. There can be no doubt that, while this inflammation was or is confounded with common ophthalmia, and the usual depletory measures employed, the practice will be not only unsuccessful, but even injurious. The fundamental error consists in looking at the disease as a purely local inflammation,

and over-looking "the constitutional affection which belongs to every neuralgia." Mr. Wardrop is acknowledged to have perceived the difference between the rheumatic and the common ophthalmia, though not the true nature or cause of the former. Mr. W. varied the treatment, and with success. The chronic cases of ophthalmia too, which from the overwhelming majority, are still confounded with common inflammation, and consequently maltreated. The bark has been used either empirically, or at the end of treatment conducted on opposite principles.

Dr. M. has already said, that in all intermittent and neuralgic diseases, the evacuating and debilitating system is pernicious-more especially bloodletting, both general and local. He does not deny, however, that in some cases of intermittent and remittent fevers, moderate depletion, at the beginning, may be useful.

"Thus it is in this ophthalmia, when violent, and particularly on the first attack; since the effect may often be to reduce the local disease which threatens local injury; while, though that remedy be really pernicious as it regards the constitutional affection, inasmuch as it commonly renders that more obstinate, the evil from this cause would be as nothing compared to the possibly impending local evil. It is plain therefore that I do not absolutely exclude blood-letting, both general and local, in this ophthalmia, at least when recent and severe; yet I think it highly essential that the reasons for permitting its use should be duly understood, as I trust they will now be by reverting to what was formerly said on this subject." 298.

The disease, in short, is not to be considered as a purely local inflammation, but as a peculiar disorder connected with and dependent on a constitutional cause, which cause is inconsistent with the depleting system, except in rare cases. In the chronic cases of this ophthalmia, the evacuating system is positively injurious-and the consequences sometimes most serious. Low diet and abstinence from wine are considered by our author among the lædentia in this class of complaints. The following case will prove illustrative of this and of several other points under discussion.

"The person in question, an artisan under the patronage and care of an opulent family delighting in physic, was seized with the common neuralgia of the face, occasionally in its more ordinary form, and at other times under that of toothach. I was permitted to cure this by means of arsenic; but after a short time it returned in the temple, and was then followed by a tolerably severe ophthalmia, affecting the conjunctiva of the neighbouring eye, and also attacking the iris. Nothing could be better marked than the disorder; as it was attended with a distinct intermittent and quotidian cold stage, and as the neuralgia of the temple was equally regular; while the contraction of the iris was also as periodical, occurring once a day, and lasting a determinate number of hours.

"I attempted of course to explain my views of the character of the disease, while I proposed the method of cure; and with exactly the same success which I have generally had, as well with patients as with my brethren of the profession, for these twenty years and much more; at the manner of which I can now but smile, while I regret the price at which the unfortunate patients have so often purchased this imaginary triumph.

"The patient was therefore sent to an oculist, at that time of high reputation; it having been concluded, as it is still, that neither physician nor surgeon could possibly understand a disease of the eye like the man of experience; such are the ideas attached by the vulgar to a word, which, if their meaning was the true definition of that term, would make the oldest nurse, or the empiric who sees a hundred patients in a day, the best physician; just as he who has manufactured the most tons of Glauber salt and calomel in his life-time, is the most philosophical chemist.

"If out of humanity to the unfortunate patient, I attempted to explain the case to the oculist, the suggestion was received just as I expected; and, from that time, I could but

watch, for instruction, the progress of the case. The first effect of local blood-letting, blistering, and topical applications, was a great increase of the inflammation; and as the same means were continued and repeated, the disorder became daily more severe; while, the Neuralgia also increasing in severity and extent, and the intermittent becoming much more strongly marked, it was declared that there was a flow of blood to the head, and so forth. General blood-letting from a vein, together with that from the temporal artery, was therefore adopted and repeated; while after a certain progress in this practice, aided by more topical remedies, more purging, and more low diet, the patient became so ill that he could no longer attend the oculist, and was therefore sent to an hospital. These operations occupied about two months; and if I was, after this, cut off from as frequent a sight of the patient as formerly, I was easily able to ascertain, before this imprisonment, that he was labouring under an inveterate quotidian intermittent, with a Neuralgia that scarcely left any repose, extreme debility with various nervous affections, and a partial fatuity; all of them the effects which I had gradually foretold to his patrons, as any one may foretel them under such practice; while the inflammation was such as apparently to extend to the bottom of the eye, from the excessive and constant pain, and while total blindness on that side had also resulted from the complete closing of the iris.

"In the hospital, all this, in the usual way, justified more bleeding and more of every thing which had already proved so injurious; while the disease persevered without a single feature of alteration, except for the worse, during nearly three months, when the gradually increasing fatuity became a mania, and the patient attempted to destroy himself by cutting his throat. The attempt was however unsuccessful; and after the wound was healed, he was sent home, to be transferred to a lunatic asylum, during which interval, I was enabled for a week or more, to see him daily. He was then in a state of melancholy fatuity, rather than of proper mania; while the inflammation continued, but in a comparatively mild state, with occasional headach, apparently of great severity and still periodical, though the state of the intellect prevented any very accurate examination. What was done in the lunatic hospital, I could never discover; but in about two months he died, and, as I understood through his wife, with the eye still in the same condition." 308.

The above case is extremely interesting; and our author avers, that every symptom, as well as the general progress, is that which occurs, in a greater or less degree, not only in this ophthalmia, but in every anomalous intermittent and neuralgia, "wherever the evacuant practice has been pursued."

"Of the topical applications I must observe, that there are even acute cases of this disorder, sufficiently teasing to the patient, and even alarming to timid ones, where the mere local use of stimulants does alone remove the disorder; the constitutional affection in such instances being perhaps trifling, or even, it may be supposed, nothing; or else disappearing spontaneously, or, from slender changes of circumstances, as intermittents themselves, equally slight, so often do. In such cases, I know not that any thing is more efficacious than hot water, as hot as it can be endured: while in the chronic relapsing attacks it is often sufficient alone to the cure. In all these cases, acute as well as chronic, persistence is most necessary: but in saying this, I must also remark on a mistaken and injurious practice, not very rare, namely, that of applying ice; while I ought to say, generally, that cold washes of all kinds are either useless or mischievous. In the chronic cases also, especially, very strong metallic solutions, such for example as sulphate of zinc in the proportion of ten grains to the ounce of water, often remove the inflammation; while this particular class of remedies also dissipates the opacities of the cornea, unless caused by pustule or ulceration, or unless very dense, from repeated attacks. No incurable opacity from mere inflammation in the disease, ought in fact to exist: and when it is not prevented or cured, there has been neglect somewhere. Of other applications, opium, both within and without the eye, is often also useful: but let me remark here, that its chief, or almost sole value, is when applied on the subsiding of the paroxysm, or during that remission which

can always, with care, be discovered: diminishing thus, as in all the neuralgic affections of tender parts, that soreness, or pain, or uneasiness, which persists after the proper paroxysmatic attack has passed away. Thus is also the internal use of opium useful in the same circumstances. As far as this substance is of use as an application in the chronic cases, it must, I think, be classed with the stimulant remedies already mentioned.

"Lastly, in all the modes of this disease, that is, in the chronic ones at all times, and in the acute, whenever the febrile state permits, or when such evacuation as may be judged necessary has been premised, the remedies are those of intermittents and neuralgia; namely, Bark, and the tonics, under all those regulations which I need not again discuss; though I ought to remark, that in numerous cases of the long continued and relapsing disease, and in many indeed of the acuter or more severe ones, and even when of some standing, I have found both arsenic and bark eminently successful without any other aids, while rarely failing to cure a new case within even a few days. As usual in all other cases of Neulralgia under every variety, the inflammation has been more tantalizing, and the remedies less actively efficacious, as it has been of longer standing and more subjected to a previous course of maltreatment; though I can scarcely, with any effort, recall a case to mind, of whatever character, which was not cured, when the patient's confidence corresponded to my own. These, in reality, are the true remedies of this ophthalmia; a fact which if it had been always known, would have saved thousands from blindness as from suffering; and not only so, but from broken constitutions or even worse evils; since the long persistence of this disorder produces the same effects as the similar duration of any intermittent or any Neuralgia." 318.

To the above remedies must be added good diet and wine, by which alone the disease may sometimes be cured, when protracted by an opposite system. For more minute observations on the remedies, the reader is referred to the general discussion on the treatment of neuralgia.

CHAP. XI.-ON THE CONNEXION BETWEEN NEURALGIA AND INTERMITTENT.

If our author has shewn that all the diseases treated of in this Essay do occasionally or often arise from malaria-not, of course, excluding the occasional, action of other causes, as cold, &c. it forms a strong proof of a community in the nature of these diseases. The following passage offers an example of this family connexion.

"In this case, the situation was so decidedly subject to Malaria, that scarcely an individual, out of many different families which had resided in it, had escaped intermittent at some period of their stay. In one season, and in one family consisting of twelve or fourteen persons, the following were the effects in as many individuals One tertian; one double quotidian headach; another tertian; one diseased spleen; in one individual, aged only eighteen, a temporary hemiplegia with obscure quotidian; a second case of palsy in one leg in a person of twenty, with obscure quotidian and symptoms of diseased spleen; a regular Neuralgia of the face, of double tertian type. In a following, distant, season, and in some of the same persons, there occurred palsy of the face with imperfect speech, an attack lasting beyond a week, and replaced by quotidian neuralgia (Tic); a double tertian, common intermittent, terminating in a quotidian, or double tertian, neuralgia; a quotidian with neuralgia in the shin bone; the same patient having had, in a preceding season, a common tertian so obscurely marked, that he was ordered to Italy for a consumption, (a consumption which was cured by two ounces of bark and a change of place to ten miles distance,) and, in a following one, having been attacked again with a double tertian, of which one fit was attended by the neuralgia of the shin and the other by a headach.

"This particular instance, it will be seen, embraces a considerable number of varieties VOL. X. No. 20.

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