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+The Project Gutenberg EBook of Glaucoma, by Various
+
+This eBook is for the use of anyone anywhere at no cost and with
+almost no restrictions whatsoever.  You may copy it, give it away or
+re-use it under the terms of the Project Gutenberg License included
+with this eBook or online at www.gutenberg.org
+
+
+Title: Glaucoma
+       A Symposium Presented at a Meeting of the Chicago
+       Ophthalmological Society, November 17, 1913
+
+Author: Various
+
+Editor: Willis O. Nance
+        Wesley Hamilton Peck
+
+Release Date: November 19, 2007 [EBook #23544]
+
+Language: English
+
+Character set encoding: ISO-8859-1
+
+*** START OF THIS PROJECT GUTENBERG EBOOK GLAUCOMA ***
+
+
+
+
+Produced by Bryan Ness, Martin Pettit and the Online
+Distributed Proofreading Team at http://www.pgdp.net (This
+book was produced from scanned images of public domain
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+
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+
+
+
+
+GLAUCOMA
+
+A SYMPOSIUM PRESENTED AT A MEETING OF THE
+CHICAGO OPHTHALMOLOGICAL SOCIETY,
+NOVEMBER 17, 1913.
+
+EDITED BY
+
+WILLIS O. NANCE, M.D.,
+
+PRESIDENT CHICAGO OPHTHALMOLOGICAL SOCIETY (1913); OPHTHALMIC
+SURGEON, ILLINOIS CHARITABLE EYE AND EAR INFIRMARY; FORMER
+OCULIST AND AURIST, COOK COUNTY HOSPITAL; EDITOR
+JOURNAL OF OPHTHALMOLOGY AND OTO-LARYNGOLOGY,
+
+AND
+
+WESLEY HAMILTON PECK, M.D.,
+
+PRESIDENT CHICAGO OPHTHALMOLOGICAL SOCIETY (1914); FORMER
+PROFESSOR OPHTHALMOLOGY, CHICAGO EYE, EAR, NOSE AND
+THROAT COLLEGE; ASSISTANT SURGEON, ILLINOIS
+CHARITABLE EYE AND EAR INFIRMARY;
+OPHTHALMIC SURGEON, OAK
+PARK HOSPITAL.
+
+1914
+CHICAGO MEDICAL BOOK COMPANY
+CHICAGO
+
+
+COPYRIGHT 1914
+BY
+CHICAGO MEDICAL BOOK COMPANY
+
+
+
+
+CONTRIBUTORS
+
+EDWARD JACKSON, A.M., M.D.
+Prof. Ophth. Univ. Colo.; Emer. Prof. Ophth. Phila. Polyclinic; Ex-Ch.
+Sec. Ophth. A.M.A.; Ex-Pres. Am. Acad. Med. and Am. Acad. Ophth. and
+Oto-Laryng.; Mem. Am. Ophth. Soc. and Honorary Mem. Chicago Ophth.
+Society.
+
+JOHN ELMER WEEKS, M.D., D.Sc.
+Prof. Ophth. Univ. and Bellevue Hosp. Med. Coll., N.Y.; Ophth. Surg.
+N.Y. Eye and Ear Inf.; Mem. Am. Ophth. Soc.; Hon. Mem. Chicago Ophth.
+Soc. and Royal Hungarian Med. Soc. Budapest.
+
+GEORGE EDMUND DE SCHWEINITZ, A.M., LL.D., M.D.
+Prof. Ophth. Univ. Penn.; Ophth. Surg. Univ. Hosp., Phila. Hosp.,
+Orthop. Hosp. and Inf. for Nerv. Dis.; Consult. Ophth. Surg, Phila.
+Polyclinic; Honorary Member Chicago Ophth. Soc.
+
+ROBERT HENRY ELLIOT, M.D., B.S. LOND., Sc.D. EDIN., F.R.C.S. ENG., ETC.,
+LIEUT.-COLONEL, I.M.S.
+Supt. Gov. Ophth. Hosp., Madras. India; Prof. Ophth. Med. Coll., Madras;
+Fellow Univ. of Madras; Honorary Member Chicago Ophthalmological
+Society, U.S.A.
+
+CASEY A. WOOD, M.D., C.M., D.C.L.
+Prof. Ophth. Univ. Ill.; Late Prof. Ophth. N. W. Univ.; Ex-Pres. Am.
+Acad. of Med.; Am. Acad. Ophth. and of the Chicago Ophth. Soc.;
+Ophthalmic Surg. St. Luke's Hosp.; Consulting Ophth. Surg. St. Luke's
+and Cook County Hosp.; Ex-Ch. Ophth. Sec. A.M.A.; Editor System Ophth.
+Therapeutics. Sys. Ophth. Operations and American Encylopedia
+Ophthalmology.
+
+FRANCIS LANE, A.B., M.D.
+Pathologist and Asst. Ophthalmic Surgeon Ill. Char. Eye and Ear Inf.;
+Instructor in Ophth. Rush Med. Coll.; Asst, Ophth. Surg. Presbyterian
+Hospital.
+
+E. V. L. BROWN, M.D.
+Asst. Prof. Pathology of the Eye, Univ. Chicago; Asst. Prof. Ophth. Rush
+Med. College; Ophth. Surg. Ill. Eye and Ear Inf. and Cook County Hosp.;
+Mem. Am. Ophth. Soc.
+
+NELSON M. BLACK, PH.G., M.D.
+Author of The Development of the Fusion Center in the Treatment of
+Strabismus; Examination of the Eyes of Transportation Employes;
+Artificial illumination a Factor in Ocular Discomfort, etc.
+
+FRANK C. TODD, M.D.
+Prof. Ophth. and Oto-Laryng., Univ. Minn.; Chairman Sec. Ophth. A.M.A.
+and second Vice-Pres. A.M.A.; Ophth. Surg. Univ. and Hill Crest
+Hospital.
+
+ALBERT EUGENE BULSON, JR., B.S., M.D.
+Prof. Ophth. Ind. School Med.; Ex-Ch. Sec. Ophth. A.M.A.; Ophth. Surg.
+St. Joseph's Hospital; Editor Jour. Ind, Slate Med. Assn.
+
+
+
+
+DEDICATED TO
+DR. EDWARD JACKSON
+DR. JOHN E. WEEKS
+DR. GEORGE EDMUND DE SCHWEINITZ
+LIEUTENANT COLONEL ROBERT HENRY ELLIOT
+HONORARY MEMBERS
+BY THE CHICAGO OPHTHALMOLOGICAL SOCIETY
+IN RECOGNITION OF THEIR SPLENDID ACHIEVEMENTS
+IN THE DOMAIN OF OPHTHALMOLOGY
+
+
+
+
+ABSTRACTS.
+
+
+I. Etiology and Classification of Glaucoma.
+
+Abstract:--
+
+Etiologic factors include: obstruction of lymph spaces, especially the
+angle of the anterior chamber; blood pressure, arterial, capillary and
+venous; affinity of tissues for fluids; alterations of the intra-ocular
+fluids; inflammations in the eye ball; and failure of a nerve apparatus
+to control fluid in the globe. Classification: various types of glaucoma
+constituting clinical entities must be recognised, as: simple glaucoma,
+recurring exacerbations, congestive, mechanical, and increased tension
+arising during uveal inflammations.
+
+DR. EDWARD JACKSON, Denver.
+
+Discussion by DR. FRANCIS LANE, Chicago.
+
+
+II. Pathology of Glaucoma.
+
+Abstract:--
+
+(a) Changes taking place in corneal tissue.
+
+(b) Iris angle with particular reference to the ligamentum pectinatum.
+
+(c) Variations in the condition of the ciliary body.
+
+(d) Consideration of the anatomical changes that take place in glaucoma
+secondary to retinal and chorioidal hemorrhage.
+
+DR. JOHN E. WEEKS, New York City.
+
+Discussion by DR. E. V. L. BROWN, Chicago.
+
+
+III. Concerning Non-surgical Measures for the Reduction of Increased
+Intra-ocular Tension.
+
+Abstract:--
+
+(a) The use of myotics; their preparation, method of administration, and
+explanation of their action.
+
+(b) Reduction of increased intra-ocular tension by means of various
+mechanical measures, notably massage, vibration massage, suction
+massage, electricity and diathermy.
+
+(c) Indirect reduction of increased intra-ocular tension, brought about
+by lowering the general vascular pressure.
+
+(d) The relation of osmosis, lymphagogue activity, the absorption of
+edema, the stimulation of capillary contractility, and the lowering of
+the affinity of ocular colloids for water in their relation to the
+reduction of increased intra-ocular tension.
+
+DR. GEORGE EDMUND DE SCHWEINITZ, Philadelphia.
+
+Discussion by DR. NELSON M. BLACK, Milwaukee.
+
+
+IV. Trephining for Glaucoma.
+
+Abstract:--
+
+(a) The aim of the operation is the formation of a foreign-body-free
+fistula.
+
+(b) It is most important to leave uveal tissue untouched.
+
+(c) Method of doing this explained.
+
+(d) The area available for trephining.
+
+(e) Method of increasing that area.
+
+(f) Cornea splitting.
+
+(g) Placing of trephine.
+
+(h) Technique of using trephine.
+
+(i) The operation is not difficult.
+
+(j) The operation valuable as a prophylactic measure.
+
+DR. ROBERT H. ELLIOT, F.R.C.S., Lieut.-Col. I.M.S., Madras, India.
+
+Discussion by DR. FRANK C. TODD, Minneapolis.
+
+
+V. Operations Other than Scleral Trephining for the Relief of Glaucoma.
+
+Abstract:--
+
+Most of the ordinary surgical procedures employed for lowering
+intra-ocular tension furnish a permanent cure of certain fairly well
+defined varieties of glaucoma. They also relieve the symptoms and retard
+the progress of other varieties of the disease, even if they do not
+perform a cure. In a third class of cases, they either have no effect
+whatever in arresting the disease or they hasten its march towards
+blindness.
+
+What operative procedure gives, on the whole, the best results? In other
+words, what operation is the easiest of performance, is the least likely
+to be attended by serious complications and is available for the largest
+number of cases? Reasons for believing that of the better known
+procedures simple iridectomy is the least effective, while those
+interventions producing a large, thin, scleral filtration-cicatrix are
+the most valuable.
+
+DR. CASEY A. WOOD, Chicago.
+
+Discussion by DR. A. E. BULSON, JR., Fort Wayne
+
+
+
+
+Etiology and Classification of Glaucoma
+
+BY
+
+EDWARD JACKSON, M.D.,
+
+Denver.
+
+
+It is convenient to start with the conception that glaucoma is increased
+tension of the eyeball, plus the causes and effects of such increase;
+although a broad survey of the facts may reveal a clinical entity to be
+called glaucoma, without increased tension constantly or necessarily
+present, and cases of increased intra-ocular tension not to be classed
+as glaucoma.
+
+The physiologic tension of the eyeball is essential to ocular
+refraction, and closely related to ocular nutrition. Fully to understand
+the mechanism for its regulation would carry us far toward an
+understanding of the causes of glaucoma. Normal tension is maintained
+with a continuous flow of fluid into the eye and a corresponding
+outflow. Complete interruption of the nutritional stream would be speedy
+death; partial interruption may be held responsible for most of the
+visual impairment and pain of glaucoma.
+
+The balance of intra-ocular pressure is not maintained by the slight
+distensibility of the sclero-corneal coat. Increased pressure does not
+open new channels for the escape of intra-ocular fluid; if, indeed, it
+does not tend to close the normal channels.
+
+The affinity of the tissues for water, or, as Fischer explains it, the
+affinity of the tissue colloids for water, seems too little related to
+the requirements of ocular function to furnish the needed regulation of
+tension. The lymph spaces and blood-channels of the eye are large, as
+compared with the mass of its tissue colloids. In these spaces and
+channels must be sought a means for rapid response to the need for
+regulation of intra-ocular tension. Fischer has shown, that when the
+enucleated eyeball is placed in a weak solution of hydrochloric acid,
+the swelling of the tissue colloids is sufficient in a few hours, to
+burst the sclero-corneal coat. But this is an eye in which all
+nutritional changes have ceased. He brings together many facts to
+support the view that in the living tissues impaired circulation, and
+especially diminished oxidation, are the chief causes of increased
+affinity of the colloids for water. Such affinity increased by the
+impairment of the intra-ocular circulation, may well constitute a factor
+making for malignancy in glaucoma. But it can hardly explain the
+original departure from a normal pressure balance.
+
+We must assume that intra-ocular pressure is kept down to the normal
+limit, by the prompt response of a regulative mechanism, which
+diminishes the flow of fluid into the eye, or permits its more rapid
+escape, whenever fluid tends to accumulate in the eye and increase its
+tension.
+
+Little has been done to show that increase of fluid entering into the
+eye is the cause of glaucoma. A normal, or even a low arterial blood
+pressure is sufficiently above the normal intra-ocular pressure to
+furnish a source of increased fluid in the eye. Increased arterial
+pressure has been found in a large proportion of cases of glaucoma; and
+may be necessary to the production of the highest intra-ocular tension.
+A sudden relaxation of the arterial walls, that would permit the
+arterial blood pressure to make itself felt in the eye, might cause an
+important rise of intra-ocular tension and may be a factor in the
+etiology of acute attacks. It affords a possible mechanism through which
+may be produced the recognized glaucomatous effects of certain nerve
+disturbances. But such attacks are not commonly associated with
+noticeable flushing of the head and face generally; and paralysis of the
+cervical sympathetic is known to lower the intra-ocular tension.
+
+Capillary blood pressure must lie between the arterial blood pressure
+and the venous blood pressure. It must be closely associated with the
+nutritional processes like secretion or inflammation; beyond this we
+know little about it. The association of increased blood pressure with
+glaucoma seems to be generally an indirect one through vascular lesions
+and disturbances of nutrition.
+
+
+_Obstructed Outflow_
+
+A reservoir with a free outlet can only fill during a flood; and then
+quickly empties itself again. The outflow channels in the normal eye
+provide for carrying away of the waste products of such an active
+nutrition, that it is hard to think they will become inadequate in
+glaucoma until there has been a marked decrease from their normal
+capacity. Priestley Smith has pointed out that the glaucomatous eye
+softens more slowly than the normal eye after enucleation, in spite of
+the fact that a greater force is operating to drive fluid out of the
+eye. In his recent tonometric studies Schoenberg noted that under
+manipulation the glaucomatous eye softened more slowly than the normal
+eye; and suggests this diminished drainage as an important evidence of
+glaucoma.
+
+Obstructed outflow might begin in an abnormal tendency of the tissues to
+retain fluid, a tendency that Fischer might locate in the colloids. The
+increase of intra-ocular pressure noted in cases of uveal inflammation,
+to be presently referred to, may be due to some such tendency. But it is
+rational to ascribe to obstruction of the filtration angle of the
+anterior chamber, the important part it has been supposed to play in the
+pathology of glaucoma. However this obstruction may be brought about,
+whether by thickening of the iris root during dilatation of the pupil,
+pushing forward of the iris root by the larger ciliary processes of age,
+or the enlarged crystalline lens pressing on the ciliary processes; or
+by inflammatory adhesion of the iris to the filtration area; ballooning
+of the iris, or its displacement by traumatic cataract; or adhesion to
+the cornea after perforating ulcer in the secondary glaucomas; or
+whether the obstruction is due to the accumulation of experimental
+precipitates, as shown by Schreiber and Wengler, or possibly of pigment
+granules into Fontana's space; or a process of sclerosis closing the
+spaces by contraction of new-formed connective tissue, or the covering
+over with proliferating implanted epithelium following injury opening
+the anterior chamber; glaucoma follows impairment of this drainage
+space, and lessened outflow through it. This blocking of the angle of
+the anterior chamber must be regarded as an established fact in the
+etiology of glaucoma. But because it is so definitely established, and
+because so much work has been done with reference to it, we may attach
+to it an undue importance.
+
+The escape of the outflow of fluid from the eye is ultimately through
+the veins. The general venous blood pressure is so low (often negative
+in the great veins of the neck during inspiration) that no obstacle can
+come from it to the ocular outflow. The venous blood pressure permits
+the eyeball to become perfectly soft. We have all seen tension of 5 mm.,
+or even less; and general venous pressure does not rise to the normal
+intra-ocular tension. Increased intra-ocular pressure requires that
+there must be some obstacle that keeps the intra-ocular fluid from
+reaching the general venous system. This may be in the lymph drainage
+system of the eye; but it may also be in the ocular veins themselves.
+
+Experimentally the eyeball can be made to burst by tying all the venous
+outlets from it. I have seen very high intra-ocular tension develop in a
+few hours after general thrombosis of the orbital veins. The absence of
+the canal of Schlemm is noted in congenital buphthalmos. The enlargement
+of the anterior perforating veins is an old symptom of chronic glaucoma.
+Obstruction to outflow of blood through the vorticose veins, by the
+increased intra-ocular pressure, has long been a recognized explanation
+of the malignant tendency of glaucoma--a part of the vicious circle
+established in this disease. There is reason that we should give careful
+attention to the views of Heerfordt and Zirm, that obstruction to the
+venous outflow may be the effective cause of the disease. Zirm believes
+the venous plexus of the choroid is an essential part of the mechanism
+for the regulation of intra-ocular tension, the necessary vaso-motor
+control depending on nerve centers situated in the iris.
+
+
+_Nerve Control_
+
+The accurate control of normal intra-ocular pressure, by mutual
+adjustment of inflow and outflow of fluid, is scarcely conceivable
+without some highly specialized, extremely sensitive nerve mechanism to
+preside over it. This is suggested by analogy with the regulation of
+secretion in the lacrimal, salivary, or peptic glands, or the
+maintenance of blood pressure in the heart and arteries. Clinical
+observations point the same way. Many patients connect their attacks
+(especially their earlier ones of ocular discomfort, impaired vision,
+haloes around the light, and dilated pupil) with social excitement,
+anxiety, worry, anger or fatigue. A patient of mine gave up her card
+parties, because an exciting game generally ended in blurred vision, a
+rainbow around the light, and a dilated pupil, and sometimes an aching
+eye. Another woman watching beside her dying husband and exposed to
+extreme cold, had her first attack of glaucoma, so severe as to destroy
+the sight of one eye. The other eye, also affected at the time,
+recovered good vision, and has remained several years without a second
+attack and without treatment.
+
+Laqueur's first attack occurred at the end of a long exhausting morning
+in the operating room, with luncheon delayed two hours. The connection
+of his later attacks with anger, worry, embarrassment, even the
+excitement of watching a play at the theatre, was noted again and
+again. In Javal's case, the attack fatal to one eye came at the
+culmination of an exciting electoral campaign. The other eye was
+stricken at the termination of the Dreyfus case, in which Javal was
+intensely interested. There seems to be a special liability to glaucoma
+among those residing at high altitudes, best explained by nerve
+influence. The frequency of glaucoma among Jews may be due to a small
+cornea, as suggested by Priestley Smith; but it is quite as reasonable
+to connect it with a racial excitability or nervous instability. More
+definite knowledge of the nervous mechanism concerned in the regulation
+of intra-ocular pressure and the production of glaucoma is much needed.
+
+
+_Alterations of Fluids and Tissues_
+
+The influence of increased affinity of the tissues for fluid has already
+been referred to. That a similar obstacle to the escape of fluid from
+the eyeball might be due to a change of character in the fluid, is a
+conception that has been entertained as a working hypothesis, and much
+experimental and analytical work has been done to test its correctness.
+This work has been so slightly related to practical ophthalmology, and
+so contradictory in its results that alterations in the fluids can only
+be regarded as a possible etiologic factor. Glaucoma secondary to
+intra-ocular hemorrhage, operations on the lens or its capsule, or
+severe nutritional disturbance may be capable of such explanation.
+
+
+_Different Kinds of Glaucoma_
+
+A better grasp of the etiology of glaucoma may be attained by
+considering separately various types of cases; although perfectly
+typical cases may be rare; and cases of mixed type and etiology much
+more frequent.
+
+Simple glaucoma has been recognized as closely related to atrophy of the
+optic nerve with deep excavation. No line of demarcation can be drawn
+between them, except by reserving the term of glaucoma for cases that
+depart from the pure type, terminating in glaucoma of some other kind,
+which is no more significant than the passage of a conjunctivitis into a
+keratitis, or an iritis into a glaucoma. Cases of simple glaucoma do run
+their course of many years to complete blindness, or to death, without
+exacerbations, inflammation, or characteristic pain. In such cases the
+intra-ocular tension does not rise suddenly; and it may be little or not
+at all elevated above the usual normal limit.
+
+For nine years I have watched the progress of such a glaucoma in a man
+now aged 87, with slow development of glaucomatous cupping of the optic
+disc, now more than 3 D. deep. The tension has never been noted at more
+than Plus T (?), and when taken with the tonometer varied from 9 to 32
+mm. for the worse eye, and 13 to 24 mm. for the other. Similar cases in
+which the tension lay within the commonly accepted normal limits have
+been reported recently by Bietti and Stock.
+
+In the eye there is probably a normal equilibrium between blood
+pressure, tissue activity, and intra-ocular tension. This may be
+destroyed either by increasing the intra-ocular tension, or lowering the
+tissue activity, or the blood pressure. Lowered blood pressure has been
+suggested by Paton as an explanation of symptoms usually ascribed to
+vascular obstruction. Rising blood pressure may be required in old age
+to compensate for diminished tissue activity; and it is conceivable,
+under normal intra-ocular tension, that diminished nutritional activity
+may result in the same symptoms as are produced in other eyes by
+increased tension. Glaucoma is probably not so much an increase of
+tension as a loss of balance between intra-ocular tension and
+nutritional activity.
+
+In contrast with the above are the cases marked by sudden elevations of
+ocular tension recurring repeatedly over long periods without permanent
+visual impairment. Laqueur's case continued of this character for six
+years, under the use of miotics, and then was cured by iridectomy, the
+cure remaining permanent with normal vision until his death after 30
+years. Millikin has reported the case of a patient who in five years had
+"many hundreds" of attacks, in which vision was impaired, haloes
+appeared about the light, the pupil dilated, the cornea became steamy,
+and tension rose to plus T. 1 or plus T. 2. After iridectomy the attacks
+ceased, leaving no pathological cupping of the disc, full vision, and a
+good field. I have seen cases of this type in women under middle age,
+and of marked nervous instability.
+
+A third type which will come to be more generally recognized, as the
+tonometer comes to be more widely used, includes cases in which there is
+little beside the increase of intra-ocular tension to justify their
+mention in a discussion on glaucoma. A patient, then aged 21, suffered
+three years ago from a scotoma almost central; and was first seen six
+months after that with a macular choroidal atrophy and abnormal
+pigmentation. She suffered, we afterwards concluded, from choroidal
+tuberculosis. A recurrence involving adjoining choroid occurred fourteen
+months ago. There was at the start pain, slight dilatation of the pupil,
+and slight general hyperemia of the globe. The tension of the eyeball
+rose to 60 mm., that of the fellow eye being 20 mm. Under miotics the
+tension fell at first but slightly. It was 55 mm. at the end of a week;
+but after two weeks came down to normal, 20 mm. A month later the
+tension rose to 28 mm., but for a year has continued normal; the eye did
+well under tuberculin treatment, and without any local treatment. In
+September of this year I had two cases of iritis in which the
+intra-ocular tension rose to 45 and 52 mm., respectively, and gradually
+returned to normal, with the cure of the iritis under atropine. In one
+of these cases, a lady of 70, I used atropine also in the other eye,
+but the tension of that eye remained normal, 22 to 24 mm., throughout.
+After needling the lens in young people I have seen a rise of
+intra-ocular tension to 50 and 60 mm., maintained for many days, with
+considerable general deep hyperemia, and soreness of the globe, followed
+by gradual return to normal tension, and no permanent impairment of
+vision or the visual field.
+
+One other type may be mentioned. That of an elderly patient with marked
+vascular disease, often renal involvement, and distinctly impaired
+nutrition. There may be renal retinitis or retinal hemorrhages. The case
+may easily become one of hemorrhagic glaucoma. It may run a very chronic
+course. But it may become suddenly worse, or go on to complete blindness
+with pain, demanding enucleation, after some temporary perturbation, as
+the performance of a glaucoma operation. It is pre-eminently the kind of
+a case you would prefer would go to some one else.
+
+Each of these types illustrate a distinct cause or group of causes. The
+first type brings us near to what may be the essential nature of
+glaucoma, impairment of ocular nutrition by the intra-ocular tension,
+which is generally elevated, but may not be above the usual normal. A
+special weakness in the nutrition of nerve tissue may be assumed. It
+would help to explain the cavernous atrophy of the optic nerve
+associated with simple glaucoma. The second type shows impairment of the
+regulative mechanism permitting rapid rise of the intra-ocular pressure.
+In persons of good nerve nutrition and strong recuperative power, it may
+exist for years without doing permanent damage. But joined to causes of
+the first type, lowered nutritive activity, it causes rapid and
+permanent loss of sight. The third group are cases associated with
+glaucoma only as causes. In eyes with low nutritive power, or subject to
+exacerbations of increased intra-ocular pressure, uveal inflammations
+may prove disastrous. The fourth type shows the results of the
+combination of the causes of the other types; with the elements of acute
+or slow malignancy added--the impaired circulation and lowered oxidation
+producing some degree of edema of the tissues that insures a fatal
+result.
+
+This is no complete presentation of my subject, but a selection of facts
+bearing on the etiology, to serve as a foundation for the discussion of
+those practical aspects of glaucoma which are to claim your attention
+through the papers and remarks of subsequent speakers.
+
+
+
+
+Dr. Edward Jackson's Paper on Etiology and Classification of Glaucoma
+
+Discussion,
+
+FRANCIS LANE, M.D.
+
+Chicago.
+
+
+Not one of the theories thus far propounded to explain the essential
+cause of increased intra-ocular tension is satisfactory. Our present day
+knowledge apparently ceases with a more or less incomplete understanding
+of the mere circumstance under which increase of tension in general
+depends.
+
+The question of the source of the normal intra-ocular pressure must
+first be solved before any discussion of a pathological increase can be
+engaged in. This question primarily hinges on whether the corneo-sclera
+is to be regarded as an unelastic capsule with a fixed volume, or as a
+yielding envelope with an ever changing capacity.
+
+This brings us at once to the consideration of that theory which
+probably has held our attention for the longest period of time, _i. e._,
+the volumetric theory. According to it, the normal intra-ocular tension
+depends on the volume of fluids within the eyeball. Any variation in the
+quantity of the contents gives rise to a change in the pressure,
+therefore, the globe has been regarded as "an elastic capsule, whose
+capacity, form, and internal pressure depend on the balance struck
+between a constant inflow, or formation of aqueous, and a proportionate
+outflow or resorption." (Henderson.)
+
+Hill has satisfactorily demonstrated that, under physiological
+conditions, the hydrostatic pressure within the eye and the skull is
+identical; it rises and falls simultaneously; it is the same as the
+cerebral venous pressure; it is constantly varying, depending directly
+on the general circulation. Upon these findings Henderson based his
+opinion that the physiological properties of the tunica fibrosa and the
+skull are identical, realizing at the same time, that the rigidity of
+the corneo-sclera, because of its fibrous nature, is not as firm as the
+cranium. In accepting this belief the inference was that the cubic
+capacity of both coverings is fixed. Applying these conclusions to the
+eye, it can be said that the pressure of the fixed intra-ocular volume
+varies with the venous tension within the bulb, which in turn is
+influenced by the general circulation. Such a conception, while not
+strictly in accord with recognized physiological teachings, proves that
+the normal intra-ocular pressure is not a question of volume content,
+but that it is purely a question of pressure of a fixed volume within an
+unyielding capsule. Dr. Jackson virtually puts aside the volumetric
+theory with his statement, that "the balance of intra-ocular pressure is
+not maintained by the slight distensibility of the sclero-corneal coat."
+Further discussion on the inadequacy of the volumetric theory need not
+detain us.
+
+It is well to recall a few anatomical features because of their bearing
+on the theories herein considered.
+
+1. The angle of the anterior chamber is a true angle and not an annular
+sinus.
+
+2. The meshwork of the iris angle (ligamentum pectinatum), a cellular
+structure at birth, undergoes a progressive and physiological fibrosis
+with early subsequent sclerosis, until finally it becomes a fibrous
+structure. The individual strands of this meshwork are more than two
+times as large at advanced age as at birth, consequently the alveoli of
+the meshwork becomes markedly reduced in size.
+
+3. The spongy nature of this meshwork affords free access of aqueous to
+the venous sinus of Schlemm, thence by tributaries into the
+supra-choroidal space and anterior uveal venous system.
+
+4. Fuchs's iris cripts afford direct access of aqueous to the veins of
+the iris.
+
+Furthermore, two simple principles are taught by physics: Fluids are
+incompressible and they seek the lowest hydrostatic level. The
+application of these perfectly obvious principles to the eyeball makes
+the intra-ocular pressure the same as that within the elastic venous
+walls, which is the lowest circulating pressure within the bulb.
+
+To summarize: The aqueous has direct access to the anterior uveal venous
+system; the physiological thickening of the strands of the meshwork of
+the iris angle supplies a mechanical obstruction between the anterior
+chamber and the venous sinus of Schlemm; intra-ocular pressure stands at
+the same level as the intra-venous, consequently, the hydrostatic
+pressure is the same on both sides of the iris angle meshwork, because
+the canal of Schlemm is a secondary venous system; lastly, the outflow
+of aqueous into the venous sinus is by diffusion, not by filtration,
+because the pressure is the same on both sides of the meshwork.
+
+These facts and deductions have given rise to the present day
+circulatory theory of intra-ocular pressure, so we now can approach the
+predisposing and exciting factors which determine glaucoma.
+
+The central fact to be borne in mind is, if the physiological pressure
+is vascular in origin and nature, the pathological pressure must
+likewise be derived from the same source.
+
+Sclerosis of the meshwork of the iris angle is the predisposing factor
+because it hinders free access of aqueous into the venous sinus of
+Schlemm. Sclerosis alone, however, will not cause glaucoma so long as
+access to the iris veins can keep the intra-ocular pressure at the
+intra-venous level, and, too, as long as the exciting cause is absent.
+
+The exciting cause is vascular, maintained and influenced by the general
+circulatory pressure. A rise of the general vascular tension alone will
+not cause glaucoma, because any alteration in intra-ocular pressure
+resulting would be purely a temporary change, easily taken care of by
+the extensive access of aqueous to the intra-ocular venous system. When
+these two factors coexist in their varying combinations, pathological
+increase of pressure results--in short, glaucoma.
+
+Syphilis, rheumatism, gout, auto-intoxication and many other
+constitutional disorders are well recognized agencies which induce
+sclerosis in body tissues, so there can be little doubt that these
+conditions produce pathological sclerosis of the meshwork of the iris
+angle. Psychic disturbances, congested portal or renal system, hard
+mental or muscular work, etc., etc., induce increased pressure of the
+general circulation, and so simultaneously the intra-ocular pressure.
+
+According to the edema theory advanced by Fischer, glaucoma is
+"essentially an edema of the eyeball, and for its production we must
+hold responsible the same circumstances which are responsible for a
+state of edema in any other part of the body." The magnificent
+experimental work of this investigator has shown that edema is nothing
+more or less than an increased capacity of the protein colloid tissues
+for water; that the most important factor leading to this increased
+hydration capacity is an abnormal production or accumulation of acid
+content, effected by those agencies which are instrumental in causing
+sclerosis and an increase of blood pressure.
+
+It seems that both of these theories afford an explanation for many of
+the secondary pathological manifestations which characterize the
+intra-ocular tissues during a glaucomatous onset.
+
+Fischer criticizes the Henderson theory on the ground that increased
+blood pressure alone does not lead to edema--edema is thwarted by high
+blood pressure. On the other hand, if Fischer believes that sclerosis of
+the meshwork of the iris angle is a result and not a cause of glaucoma,
+then it would seem that Henderson has the better of the argument. The
+physiological changes in this structure, which take place with advancing
+age, can rightfully be looked upon as a predisposing factor in glaucoma.
+
+Dr. Jackson has presented all other phases of this part of the
+symposium in such a comprehensive manner that nothing further remains to
+be said.
+
+
+
+
+Pathology of Glaucoma
+
+BY
+
+JOHN E. WEEKS, M.D.,
+
+New York City.
+
+
+In reviewing the pathology of glaucoma it seems proper to consider the
+various structures and tissues of the eye in logical order.
+
+_Lids and Conjunctiva._ "The only change observed in these tissues is a
+reflex edema, excited apparently by pressure on the ciliary nerves and,
+probably, irritation of the vaso-motor fibers of the sympathetic."
+
+_Lachrymal Gland._ Hyper secretion due to reflex irritation.
+
+_Cornea._ As has been shown by Priestley Smith, the cornea in
+glaucomatous eyes is, as a rule, smaller than in non-glaucomatous eyes,
+the mean of a series of measurements being 11.1 mm. horizontally and
+10.3 mm. vertically in glaucomatous and 11.6 mm. horizontally and 11
+mm. vertically in non-glaucomatous eyes. In cases of considerable
+increase of tension, particularly if the onset is sudden, the
+circulation of lymph in the cornea is interfered with, the anterior
+layers of the cornea become edematous, the spaces between the lamellae
+filled with albuminous fluid. Some of this fluid finds its way through
+Bowman's membrane, apparently by way of the minute channels which permit
+the passage of small nerve twigs, and enters the epithelial cell layer.
+The fluid finds its way between the epithelial cells in the deeper
+layers, apparently being taken into some of the superficial cells by
+imbibition. Some of the swollen surface cells open spontaneously and
+discharge their contents, others drop off. The process causes a
+roughening of the surface of the cornea and produces a faint haziness.
+There is another form of haziness that develops on sudden rise in
+tension and completely disappears on subsidence of the tension. This is
+due, as has been shown by V. Fleischl (Sitzungsberichle d. Weiner Akad.
+d. Wissensch, 1880) and others, to increased tension on the fibrillae of
+the cornea, a double refraction being induced. In cases of long
+continued increase of tension minute permanent vesicles form in the
+epithelial layers, particularly in the superficial portion. Anaesthesia
+of the cornea develops, due to pressure on the nerve fibers that are
+distributed to the epithelium, the compression probably occurring along
+the course of the long ciliary nerves, from which the corneal nerves are
+derived, as they pass between the choroid and the unyielding sclera
+(Collins & Mayou).
+
+In advanced cases of glaucoma after the congestive period has subsided
+the cornea becomes somewhat condensed, the lymph spaces contracted; a
+condition of sclerosis obtains. Alteration in the shape of the cornea
+occurs only rarely in adult life. When it does occur it takes place in
+corneæ that have suffered from keratitis. The alteration is usually in
+the form of ectasiæ. In infancy and early youth (buphthalmia) the cornea
+may become uniformly enlarged and globular. Often, however, the
+enlargement of the cornea is irregular. Increase in tension may produce
+fissures in Descemet's membrane. These occur more frequently in the
+cornea that have suffered a change in shape, as in buphthalmos. Gaps
+occur in the elastic membrane which become covered by endothelium. Some
+cloudiness may be seen in the corneal lamellae adjacent to these
+fissures, in some cases due evidently to the filtration of aqueous humor
+through defective endothelium. Prolonged high intra-ocular tension may
+be accompanied, particularly in cases of secondary glaucoma, by
+vesicular and bullous keratitis.
+
+In acute glaucoma the sclera appears to be edematous and slightly
+thickened. As the disease progresses the sclera becomes denser than
+normal. The oblique openings--passages for the venae vorticosae--are
+said to be narrowed. The openings for the passage of the anterior
+ciliary vessels are enlarged in many, particularly in advanced cases.
+Minute herniae at these openings are sometimes present. Dilatation and
+tortuosity of the anterior ciliary veins are due apparently to excessive
+flow of blood through them on account of the abnormally small amount
+carried off by the venae vorticosae. In the stage of degeneration,
+ectasae of the sclera occur most frequently near the equator of the
+globe. Spontaneous rupture may take place.
+
+_Anterior Chamber._ The anterior chamber is shallow, as a rule. This is
+almost without exception in primary glaucoma in adults. In secondary
+glaucoma in which occlusion of Fontana's spaces occurs as a result of
+the deposition of fibrin or other inflammatory products the anterior
+chamber may be of normal depth, or deeper than normal. Very deep
+anterior chamber may occur in glaucoma, due to retraction of lens and
+iris following fibrinous or plastic exudation into the vitreous, or
+when it occurs in congenital glaucoma, due to enlargement of the globe.
+
+_Aqueous Humor._ The aqueous humor, as has been pointed out by
+Uribe-Troncoso (Pathoginie du Glaucome 1903) contains a greatly
+increased quantity of albuminoids and inorganic salts in glaucoma. In
+acute glaucoma the increase of albuminoids (blood proteids) is greater
+than in chronic glaucoma. The aqueous humor becomes slightly turbid in
+acute attacks, coagulating more readily than the normal. The plastic
+principle contained in the aqueous is rarely sufficient to cause
+adhesion between the margin of the iris and the lens capsule, but the
+colloid nature of the aqueous, according to Troncoso, lessens its
+diffusibility and prevents its free passage into the lymph channels. The
+increase in albuminoids is a consequence of congestion and venous stasis
+and does not precede the attack.
+
+_Filtration Angle._ The changes that occur in the filtration angle
+before it is encroached upon by iris tissue are sclerosis of the
+ligamentum pectinatum in adults to which Henderson (Trans. Ophth. Soc.
+U.K. Vol. xxviii) has called our attention; the accompanying sclerosis
+of the other tissues to the inner side of Schlemm's canal; and, in some
+cases, the deposition of pigmented cells derived from the iris and
+ciliary processes (Levinsohn) which serve to obstruct the lymph spaces.
+In many of the cases of acute glaucoma and almost all of the cases of
+chronic glaucoma of long standing the filtration angle becomes blocked
+by the advance of the root of the iris.
+
+_Iris._ In acute glaucoma the iris is congested and thickened. It is
+pushed forward and may lie against the cornea at its periphery. When the
+attack subsides, the iris falls away from the cornea. Aside from the
+congestion, the primary changes that take place in the iris are
+indicative of paresis of the fibers of the motor oculi that supply the
+sphincter pupillae, and stimulation of the fibers from the sympathetic
+producing vasomotor spasm. The long diameter of the pupil apparently
+lies in the direction of the terminal vessels of the two principal
+branches of each long ciliary artery which form the circulus iridis
+major, where the vasomotor spasm would have the greatest effect in
+lessening the blood supply. The haziness of the cornea and slight
+turbidity of the aqueous contribute greatly to the apparent change in
+the color of the iris. In cases of simple chronic glaucoma there is but
+little evidence of edema of the iris. If the iris lies in contact with
+the sclera and cornea for some time, it becomes adherent (peripheral
+anterior synechia). As the disease progresses, the stroma of the iris
+atrophies and contracts. There is very little evidence of small-cell
+infiltration or the formation of cicatrical tissue. Numerous slits may
+develop in the iris through which the fundus of the eye may be seen
+(polycoria). The pigment layer does not atrophy in proportion to the
+stroma of the iris; by the contraction of the stroma of the pigment
+layer is doubled upon itself at the pupillary margin, forming a black
+ring of greater or less width (ectropian uveae). The iris becomes
+attached to the pectinate ligament and to the endothelium of Descemet's
+membrane. In a very few cases the closure of the angle is not complete
+at the apex, a small space remaining comparatively free for a long time.
+The adhesion of the iris to the pectinaform ligament and cornea is not
+uniform at all parts of the periphery; it varies in width. Portions of
+the iris angle may remain open while other parts are closed. Where the
+iris tissue lies in contact with the cornea, the stroma of the iris
+almost totally disappears. In some cases the iris becomes totally
+adherent to the cornea.
+
+_Ciliary Body and Chorioid._ In acute glaucoma there is congestion of
+the entire uveal tract, the congestion partaking more of a venous stasis
+than of an active or arterial congestion. The vessels of the ciliary
+process, which are larger and more tortuous in adults of advanced years
+than in the young, become enormously distended, causing almost complete
+obliteration of the perilental space. They press against the root of the
+iris and the equator of the lens, forcing them forward. There is edema
+of the ureal tract, apparently from transudation of serum. Many small,
+and sometimes rather large hemorrhages may occur. There is but little
+small cell infiltration, indicating almost total absence of what is
+ordinarily recognized as true inflammation. It is probable that the
+secretion from the glandular zone of the ciliary body is increased.
+
+On subsidence of the congestion, as after miotics or iridectomy, the
+tissues may return to very nearly a normal condition. The iris recedes
+from contact with the ligamentum pectinatum and cornea and the
+filtration angle is again open. In some cases the iris becomes adherent
+to the head of the ciliary processes and, when atrophy of the ciliary
+body occurs, is drawn backward at the base of the iris by the receding
+tissues. If the hypertension persists or is repeated at varying periods,
+a slow atrophy of the uveal tract sets in. Eventually the ciliary body
+becomes very much reduced in thickness, is flattened out, the ciliary
+processes reduced in size and the blood vessels disappear or are reduced
+much in caliber. Those that persist possess walls that are much
+thickened. This is particularly true of hemorrhagic glaucoma.
+
+In advanced absolute glaucoma the chorioid may become reduced to a very
+thin membrane consisting of connective tissue and pigmented cells,
+scarcely distinguishable even by moderate powers of the microscope.
+Atrophy is marked in the vicinity of the venae vorticosae. Czermak and
+Birnbacher describe proliferation of the endothelium of the large veins
+with contraction and obliteration of their lumen.
+
+_Optic Nerve and Retina._ In the acute form the retina and optic nerve
+present the same condition that is present in the vascular tunic;
+namely, that of venous stasis with the consequent edema. Frequently
+minute hemorrhages occur in the retina, particularly in violent acute
+attacks. Cupping of the discs slowly develops, causing more or less
+stretching of the nerve fibers over the edge of the cup. The gradual
+diminution of the field of vision is due in greater part to death of
+peripheral nervous elements of the retina, those parts of the field
+farthest removed from the large arterial trunks suffering first. The
+arrangement of the arteries at the disc, passing out as they do from the
+nasal side, of necessity make the vessels that pass to the temporal part
+of the retina longest and of less caliber. These vessels and their
+terminals are first to suffer marked diminution in size; death of the
+perceptive elements supplied with nutrition by these vessels follows.
+For this reason the nasal part of the field of vision is more often the
+first to disappear. In congestive (inflammatory) glaucoma, the typical
+field of vision shows most marked contraction on the nasal side. The
+disturbance of the nutrition of the retina accounts in greater part for
+the various forms of visual field met with.
+
+Death of all of the perceptive elements of the retina eventually occurs.
+The loss of nutrition is apparently not the whole cause of blindness.
+Atrophy of the nerve fibers follows death of retinal neurons, but
+atrophy of some of the nerve fibers may be, and probably is, due to the
+pressure and traction exerted upon them at the margin of the disc. It is
+probable that too much importance has been given to this mode of
+interference with the nerve fibers. However, the change in the position
+of the lamina cribrosa must exert a deleterious effect, particularly on
+those fibers which pass through the peripheral meshes, the shape of
+which must necessarily be much distorted. In glaucoma simplex, which is
+largely devoid of marked congestive periods (acute attacks), a
+surprisingly high degree of acuity of vision may exist with a deep
+excavation and pale nerve. Careful studies of the retinal vessels in
+glaucoma (Verhoeff Arch. of Ophth. XLII. p. 145; Opin. Soc. Française
+d'Ophth. 1908) disclose the fact that an increase in the elastic tissue
+and connective tissue elements occurs in _some cases_, also
+proliferation of the endothelial cells, which serve to irregularly
+narrow and, in some instances, obliterate the lumen of the vessel.
+Arteries and veins are both affected. Hyaline degeneration of the media
+also occurs. The process is not uniform.
+
+_Glaucomatous Cup._ The excavation of the disc progresses slowly and is
+due in part to stretching the fibers of the lamina cribrosa pressing
+this structure outward, and partly to atrophy and disappearance of the
+nerve tissue and much of the vascular tissues in the nerve head. The
+displacement backward of the lamina cribrosa may cause that structure
+to lie behind the outer surface of the sclera. Atrophy and cystic
+degeneration of the nerve trunk follows destruction of retinal neurons
+and cupping of the disc. Neuroglia remains in part. Connective tissue
+elements increase in the optic nerve as the nerve fibers disappear.
+
+_Glaucomatous Ring._ The development of the pale circle which surrounds
+the disc, particularly in glaucomatous eyes, is due to a very slight
+recession of the pigment layer of the retina and of the margin of the
+chorioid at this point with some atrophy, apparently consequent on the
+beginning retraction of the lamina cribrosa and slightly increased
+pressure of the nerve fiber layer on the underlying tissues at the
+margin of the disc. This permits the sclera to show through a very
+little at this part. In some eyes in which there is a beginning
+sclero-chorioiditis posterior, the condition is very similar to that
+presented by the glaucomatous ring.
+
+_Field of Vision._ The two pathological processes that operate to
+destroy the function of the retina suffice to produce scotomata in the
+field of vision of varying shapes. The typical glaucomatous field in the
+acute cases shows a defect most pronounced to the nasal side. As has
+been shown by Bjeraum, the blind spot corresponding with the optic disc
+is enlarged in glaucoma, a relative scotoma often connecting it with the
+blind nasal portion of the field either above or below the horizontal
+meridian (Straub). The field in a simple glaucoma is apt to approach
+concentric limitation; namely, more like the field in simple atrophy.
+This is consistent with the fact that simple glaucoma in many cases
+possesses the characteristics of glaucoma plus atrophy of the optic
+nerve.
+
+_Vitreous._ During the acute attack, the vitreous may become slightly
+turbid by transudation of serum from the vessel of the ciliary body and
+the chorioid and may become filled with fibrin. In some chronic cases
+in which absolute glaucoma is reached the development of small blood
+vessels in convoluted loops springing from the vessels of the discs has
+been observed. Any process that increases the volume of the contents of
+the vitreous chamber, as hemorrhage, neoplasm, profuse serous or plastic
+exudation, may by pushing iris and lens forward produce an attack of
+acute glaucoma.
+
+_Buphthalmos._ Reis (Graefe's Arch. f. Ophth. V. LX. 1905) states that
+there is always obliteration of the anterior scleral venous channels
+(Schlemm's canal) in buphthalmos. Seefelder (Graefe's Arch. V. LXIII.
+1906) mentions the abnormal position and abnormal narrowing of Schlemm's
+canal and the imperfect and insufficient differentiation of the
+cornea-scleral junction. In all of the cases in which the eye has been
+examined microscopically obliteration of Schlemm's canal has been
+reported. This is thought to be a defect in development. Magitot (Ann.
+d'Oculis CXLVII) suggests that injury to mesoderm which pushes itself
+between the ectoderm and anterior surface of the lens would account for
+the failure in development of Schlemm's canal. The changes that occur in
+the tissues of the eye appear to be largely due to the stretching
+consequent on the more or less uniform distentions of the globe as a
+result of hypertension.
+
+_Cornea._ This portion of the fibrous membrane is enlarged, globous or
+flattened, irregularly thinned, particularly at the periphery, where it
+may be as thin as tissue paper, nebulous because of the stretching of
+its fibers principally, but in some degree (differing in different
+cases) to edema of the epithelial layer. Fissures occur in Descemet's
+membrane.
+
+_Anterior Chamber._ This is very deep in the greater number of cases.
+However, this rule has many exceptions.
+
+The vascular tunic may be congested in young infants, but atrophy soon
+develops and may reach an extreme degree. The sclera ordinarily becomes
+quite thin throughout, but may retain almost a normal thickness at the
+equator of the globe and posteriorly. Posterior sclera ectasae may
+develop. The iris, as a rule, hangs free from the cornea, often
+tremulous because of retraction of the lens beyond the iris plane. In
+some cases the iris is partly or totally adherent to the posterior
+surface of the cornea.
+
+The vascular membrane (iris, ciliary body and chorioid) and the retina
+become atrophic, the atrophy varying in degree in various parts.
+Detachment of the retina may occur, often preceded by or accompanied by
+subretinal hemorrhage. The optic disc becomes deeply cupped and the
+tissues of the optic disc and optic nerve extremely atrophied. The
+crystalline lens may become cataractous and shrunken. Spontaneous
+rupture of the suspensory ligament with consequent subluxation of the
+lens may follow.
+
+_Secondary Glaucoma._ The pathological conditions that precede
+secondary glaucoma are many and differ widely. They may be briefly
+classified as:
+
+1. Those that cause a partial or complete closure of the lymph spaces
+and Schlemm's canal by cicatrical contraction, as in sclero-keratitis.
+
+2. Those that cause obstruction to the lymph spaces at the filtration
+angle by the deposition of fibrin or cellular elements, as in iritis,
+hemorrhage into the anterior chamber, etc.
+
+3. Those that cause obstruction of the filtration angle by advancement
+of the iris and lens, as occurs when the volume of the contents of the
+vitreous chamber is increased, as from retinal or chorioidal hemorrhage
+or neoplasm.
+
+The various changes are so numerous that they need not be described
+further here. The ultimate changes due to high tension resemble those
+already described.
+
+
+
+
+Dr. John E. Weeks' Paper on Pathology of Glaucoma
+
+Discussion,
+
+E. V. L. BROWN, M.D.,
+
+Chicago.
+
+
+I would like to emphasize one of the newer features of the pathologic
+anatomy of glaucoma, one which has received too little attention in this
+country: the _lacunar_ or _cavernous atrophy_ of the _optic nerve_.
+
+The name accurately describes the condition. Tiny clear spaces form in
+the lamina cribrosa and in front and behind it in the nerve tissue.
+Their exact nature is unknown. Usually they are entirely empty, often
+they are traversed by fine glial fibers. They seem to be in no relation
+to the blood vessels. Adjoining lacunae are supposed to fuse to form
+larger cavernae and these finally merge and constitute the final
+glaucoma cup. The lamina may then bridge across the space like a cord,
+or lie back against the end of the nerve trunk.
+
+Schnabel considered all glaucoma cups to be formed in this way,
+independent of tension. His views were strongly supported by Elschnig,
+but as vigorously opposed by others. Axenfeld cites the fact that the
+glaucoma cup may disappear after operation. (I myself have seen a cup of
+7 D. reduced to 1 D. in the course of a year after the tension had been
+lowered from 62 to 12.) Stock found the same lacunae in eight cases of
+myopia. The last extended study of the subject was made by E. v. Hippel,
+who found lacunae in 20 of 33 cases (60 per cent); enough certainly to
+make one look for them carefully in every case. He publishes a large
+number of excellent photo-micrographs, but none more typical than one I
+have in my possession.
+
+I have been especially interested in this subject because I have met
+with a complete and total glaucoma cup, with the typical (ampulliform)
+undermining of the scleral ring, in a pair of eyes without increased
+tension. The (Schiotz) tonometer was used daily for 70 consecutive days
+and never registered more than 12-14 mm. Hg. The man had been blinded by
+wood alcohol. At the time I could find no other report in the
+literature, but overlooked a publication by Lewin and Guillery.
+Friedenberg has since reported cases of the same nature.
+
+If other conditions than increased tension can produce a typical
+(ampulliform) glaucomatous excavation of the disc, why may not the
+cavernous atrophy and cup in glaucoma be due in part at least to similar
+processes, possibly in the nature of a toxic oedema of the nerve, either
+in association with tension or independent of it, as contended for by
+Schnabel?
+
+
+
+
+Concerning Non-Surgical Measures for the Reduction of Increased
+Intra-ocular Tension
+
+BY
+
+GEORGE EDMUND DE SCHWEINITZ, M.D.,
+
+Philadelphia.
+
+
+Only a few years ago the literature of glaucoma was big with discussions
+of the comparative value of the surgical and non-surgical treatment of
+glaucoma, and especially of the chronic types of this disease. Now,
+thanks to the achievements of Lagrange, Fergus, Herbert and Elliot, the
+value of a filtering cicatrix, although known for a long time, has
+attained increased importance, due to the improvement and elaboration of
+operative technic, and the medical journals of the day are weighted with
+opinions and experiences from all over the world as to these surgical
+measures. But true as this is, we are not yet in a position to discard
+non-surgical procedures (1) because operation is not always possible,
+(2) because operation is not always permitted, and (3) because in
+certain circumstances operation is not advisable. Hence a glance at the
+non-surgical methods of reducing increased intra-ocular tension is not
+out of place, and for convenience they may be catalogued as follows:
+
+1. Myosis produced by means of solutions of various drugs, a myosis
+followed by reduction of intra-ocular tension.
+
+2. Reduction of tension by means of various mechanical measures, notably
+massage, vibration massage and suction massage, and by means of
+electricity and diathermy.
+
+3. Indirect reduction of intra-ocular tension, accomplished by lowering
+general vascular pressure.
+
+4. Reduction of ocular tension by stimulation of osmosis, of lymphagog
+activity, of absorption of edema, and of capillary contractility, and by
+decreasing affinity of ocular colloids for water.
+
+1. _The Myotics._ Of these, eserin (physostigmin) and pilocarpin, with
+their respective salts, the sulphate and the salicylate in the first
+instance, and the hydrochlorid and the nitrate in the second, are well
+established in favor and efficiency. Personally, it has always seemed to
+me that the salicylate of eserin is preferable to the sulphate, but I
+have not persuaded myself that the nitrate of pilocarpin possesses
+material advantages over the hydrochlorid, although some authors prefer
+it. With arecalin, the alkaloid of the Betel nut, I have no experience,
+nor have I used its mixture with eserin, recommended by Merck as more
+potent than either of the drugs in separate solution.
+
+The substance isophysostigmin, found with eserin in Calabar bean,
+according to Ogiu, exceeds in its myotic activity the sulphate of
+eserin, _i. e._, 1/80 of a grain of the drug is equal to 1/60 of a grain
+of the sulphate of eserin, but it is certainly not less irritating than
+physostigmin, and according to Stephenson's researches, is more so, and
+in this sense has no superiority over the usual alkaloid. In general
+terms, it may be said that the time has not arrived to make a preachment
+"on the passing of eserin and pilocarpin."
+
+_Physiologic Action._ Concerning the ocular, physiologic action of the
+two chief alkaloids respectively of Calabar Bean and of Jaborandi, there
+still exists difference of opinion. It has always been easy to attribute
+the myotic action of these drugs, or at least, of eserin, to their
+stimulant action on the peripheral ends of the oculo-motor, thus causing
+sphincter contraction, and to a depressing action on the sympathetic
+fibers, thus causing removal of the action of the dilatator of the iris.
+But complete experimental proof of such action is wanting, and it is
+probable that myosis follows a direct stimulation of the sphincter
+muscle fibers, aided, perhaps, by contraction of the iris vessels,
+although the last named effect is denied by so competent an authority as
+Hobart Hare.
+
+Exactly how the myotics reduce intra-ocular tension is not definitely
+proven. Usually it is taught that because of the myosis the base of the
+iris wedged in the angle of the anterior chamber is loosened and
+withdrawn, precisely as a fold in a coat is straightened by a tug on the
+fabric beneath it. Experiments, however, for example, by E. E.
+Henderson, have shown that the rate of filtration in an eye with
+artificially raised pressure is considerably larger when it is under the
+influence of eserin than it is when under the influence of atropin; that
+is by the contraction of the pupil the iris-surface filtration is
+increased and consequently the pressure is reduced. We all know that
+Thomas Henderson maintains that the results of iridectomy are beneficial
+because the raw edges of the coloboma, which do not cicatrize, permit
+access of the aqueous to the iris veins, and that myotics, inasmuch as
+they contract the pupil, open the iris crypts and therefore act, less
+efficiently, perhaps, but act none the less like an iridectomy. The
+normal intra-ocular pressure is uninfluenced by myotics because this
+pressure represents the lowest circulatory pressure in the eye, and
+further contact between aqueous and veins cannot reduce it below this
+level, another point which is made by Thomas Henderson in support of his
+contention.
+
+The clinical fact remains that either by mechanical means, as it were,
+in the liberation of a plugged filtering angle, or by the increasing of
+iris-surface filtration, the myotics markedly reduce the abnormal
+intra-ocular pressure.
+
+_Methods of Administration and Indications._ With the methods of
+administration of the myotics we are all so familiar that time need not
+be wasted in their reiteration, except to refer to a few practical
+points. In acute glaucoma, and every one knows that in this disease
+their action is often prompt and sometimes curative, eserin in a
+strength of one to four grains to the ounce may be instilled with
+sufficient frequency to establish myosis, and its action in this respect
+is enhanced if the congestion of the eye is lowered by measures to which
+I shall refer later. There is a good deal of clinical evidence to
+indicate that in this type of glaucoma, as well as in the so-called
+sub-acute varieties, myotic activity is increased by a mixture of
+pilocarpin and eserin in the same solution, exactly as a mixture of
+arecalin and eserin is more potent than either of the drugs in separate
+solution.
+
+Prior to the happy advent of technically correctly placed filtering
+cicatrices, a large number of surgeons depended almost exclusively on
+the use of myotics in so-called simple, chronic or non-inflammatory
+glaucoma. This is not the place to introduce a discussion of the
+comparative value of iridectomy and myotic treatment in simple glaucoma
+as based upon statistical records. We must wait now for a sufficient
+period of time and then compare the value of myotic treatment with that
+of operations by means of which satisfactory filtration is produced. We
+are somewhat in the position that general surgeons occupied when aseptic
+methods first became prevalent. We do not usually compare the statistics
+of early aseptic days with those of the pre-antiseptic period, and I do
+not think we ought to compare the statistics of myotic treatment with
+ordinary iridectomy any longer, but that we should wait until we can
+make a comparison between the results of prolonged myosis and those of
+an improved modern technic which establishes a permanent filtration. In
+the meantime the patients who will not or cannot submit to operation
+must be reckoned with. Doubtless many patients with chronic glaucoma can
+be satisfactorily managed with myotic treatment, although personally I
+have always advocated operation when this could be performed, but it
+cannot always be performed. This rule should guide us, namely, to begin
+with a comparatively weak solution of the selected drug, for example, as
+Posey has advocated a tenth of a grain of salicylate of eserin to the
+ounce, and the strength gradually increased so that at the end of some
+months the patient is using a solution 1 grain to the ounce; or if the
+pilocarpin is preferred, solutions in double these strengths. It is my
+own belief, and that of many who have studied this subject, that if,
+without eserin irritation, a myosis can be maintained, and if the
+treatment can be begun early enough, the chances of preserving vision
+and the field of vision are good. I believe that the two most important
+instillations during the twenty-four hours of the number necessary to
+maintain this myosis are on retiring and if possible in the very early
+morning, some time between two and four o'clock. Most patients can be
+taught to wake themselves at the proper period of time, and are little
+inconvenienced by this disturbance of their sleep. I believe that eserin
+irritation is most successfully avoided, not by preparations of the
+myotics in combination with the antiseptics, for example, tricresol,
+which has been so much advocated, but by ordering very small quantities
+of the solution, insisting that it shall be frequently renewed and
+sterilized at each preparation, and that a half an hour after its
+instillation, during the day time at least, the eye shall be thoroughly
+flushed with some mild antiseptic solution, for example, boric acid and
+sodium chlorid. Whether the action of the eserin on the choroidal
+circulation, which is maintained by Wahlfours, aids in this favorable
+action of the myotics remains to be proved. It has been maintained by
+this author and by others who have followed him.
+
+The great trouble with myotic treatment is not its lack of efficiency,
+but the difficulty of carrying it out successfully on ambulant
+patients, even in the better walks of life. It is hard successfully to
+maintain in a patient with chronic glaucoma what I may call an eserin
+life, just as it is hard to maintain in a person with an enlarged
+prostate a catheter life and escape infection, resulting, if it occurs,
+in the one instance in a difficult and stubborn conjunctivitis, and in
+the other in a cystitis. Still, we are obliged to use myotics, and the
+way to employ them to the patients' best advantage, I have ventured to
+repeat in spite of the universal familiarity with the methods. Perhaps
+we may reach that happy day when, especially with improved tonometric
+methods, increased skill in measuring the rate of filtration and better
+instruments for determining the light sense, we can anticipate the
+advent of glaucoma and get ahead of the ocular and visual deterioration
+which increased tension produces, by performing preventive operations
+which shall aid nature's filtration channels in the establishment of an
+artificial one. But increased tension is not the whole story of
+glaucoma, and a filtering cicatrix is not the last word in surgical
+therapeutics, and there is much to learn.
+
+2. _Reduction of tension by means of various mechanical measures,
+notably massage, and by means of electricity and diathermy._ Massage is
+of ancient lineage. In general terms, in so far as ocular massage is
+concerned, it may be applied to the eye with the finger tips (ordinary
+massage), by means of various instruments (vibration massage), and with
+the help of certain suction cups (suction massage, which is indeed a
+form of vibratory massage). Many authors are satisfied with their
+results without the employment of any instrument, and prefer simple
+massage with the tip of the finger to any form of the instrumental
+variety, to quote the words of Casey Wood. At one time in my career I
+experimented very extensively with massage, not alone for the purpose
+of reducing intra-ocular tension, but in various diseases of the lid and
+cornea, and taught a trained nurse, who herself had a nebulous cornea,
+to make what I may call a specialty of this particular therapeutic
+procedure. She became exceedingly skillful and was quite faithful. We
+believed that the best results were obtained in a seance of two or three
+minutes, the finger tip being used over the lid, and the surface of the
+cornea lubricated with a drop of pure olive oil, although in glaucoma
+the addition of the oil is not necessary. Four movements were utilized,
+the first a stroking movement in lines radiating from the central
+pressure, very much as the spokes of a wheel radiate from the hub,
+second a circular movement, third a pressure movement, a little dipping
+motion, so that the cornea was slightly depressed, and finally, a gentle
+tapping movement, precisely the same, except that it was a diminutive
+one, as the tapping movement that the Swedish masseur makes. Usually
+each movement occupied from a half to one minute, according to the
+results desired. I agree with Casey Wood that such a technic furnishes
+just as good results as any one with the aid of an instrument.
+
+Referring particularly to the reduction of intra-ocular tension, many
+surgeons have been impressed with the value of various instruments.
+Thus, Ohm, who has worked particularly in the reduction of the increased
+tension of secondary glaucoma, for example, after discussion of lamellar
+cataract, advocates the Piesbergen instrument, which makes 3,000
+vibrations a minute, and is applied over the closed lids. I think the
+instrument best known is the one introduced by Malakow. For this purpose
+the point of an Edison electric pen is armed with a small ivory ball,
+and the vibration rate varies from 200 to several thousand a minute, the
+rapidly revolving ball being passed over the closed lids, in some
+instances directly upon the cornea itself. I am frankly afraid of these
+vibrating machines, and again make a plea for the finger tip, just as I
+am afraid of a Von Hippel trephine, and prefer one which is rotated with
+the fingers.
+
+A special investigation of pressure massage according to the method of
+Domec has been made by Paul Knapp of Basel. This, as you know, consists
+in applying the thumb to the cornea through the closed lids, and making
+repeated pressures upon it at the rate or 60 to 100 a minute. He checked
+his results with the tonometer after 200, 500 and 1,000 pressures, and
+found that even in normal eyeballs such massage was followed by a fall
+of intra-ocular tension, the average being nearly 9 mm. after a thousand
+pressures. Within three-quarters of an hour the tension returns to the
+normal. In acute glaucoma such massage is not available, but it is of
+assistance in encouraging a reduction of the intra-ocular tension and
+keeping it at a normal grade after operative work, particularly after a
+filtering cicatrix has been made, as was well shown by Weeks in his
+study of glaucomatous eyes operated upon by the Lagrange method. It is
+interesting to remember that Paul Knapp, in the course of this
+investigation, observed reduction of the tension after the use of
+holocain.
+
+Another method of reducing the intra-ocular tension is by the suction
+method, which consists in the use of certain cups from which the air is
+exhausted by means of a suction apparatus. Domec uses an elliptical eye
+cup, the concave margins of which fit closely about the globe. The air
+is exhausted with each respiration of the patient and from 50 to 200
+tractions are made at each sitting. Domec is of the opinion that this
+method succeeds in two ways, namely, in producing analgesia by traction
+on the ciliary nerves, and in reducing intra-ocular tension.
+
+Unfortunately, it is difficult for regular physicians to make reference
+to massage of the eyeball lest their words should be misquoted by
+irregular practitioners who employ this method, selling various
+instruments to trusting patients, and attributing to this simple and
+often beneficial procedure all sorts of marvelous influences. Doubtless
+all of us have seen eyes utterly ruined because the patient has trusted
+to the advertisements of these people, and has continued to use some
+foolish little suction pump, when what his eye needed was operative
+procedure or skilled therapeutics.
+
+If I should sum up my opinion of massage in the reduction of
+intra-ocular tension, I would say that it is useful in enhancing the
+action of myotics, and particularly useful, as Domec, Knapp, Ohm, Weeks
+and many others have shown, after the filtering angle has been opened by
+a proper operative procedure. It seems to me that it is distinctly our
+duty to inform patients that it is no panacea, and that they must never
+trust themselves in the hands of irregular practitioners who pretend to
+cure all ocular ills with massage.
+
+_Electricity._ The credit of first using high frequency currents in the
+treatment of glaucoma belongs to Truc, Imbert and Marques, and Roure's
+experiments indicate that this current suitably applied appears to have
+an influence not only in reducing the arterial tension, but also the
+ocular tension. Thus, in an interesting series of experiments he has
+been able to reduce an arterial pressure of 200 mm. to 140 mm., and an
+ocular tension of plus 2 to the normal after eighteen applications of
+the high frequency current. The current is applied for ten to fifteen
+minutes at a time twice a week. Some surgeons, for example, Würdemann,
+have suggested the use of electricity combined with massage, and have
+apparently achieved satisfactory results.
+
+The constant current has also been much employed for the purpose of
+reducing intra-ocular tension. Coleman quotes Le Prince's observations,
+who applies the negative pole to the eye and the positive pole to the
+neck, gradually passing a current of 30 to 40 ma. during a quarter of an
+hour, and who reports notable diminution of tension. Coleman points out
+that in his own experience he has not found any patient who would
+willingly tolerate more than 19 ma. of current with an ordinary sized
+electrode, although he grants that it is possible that Le Prince used a
+very large electrode. Unfortunately he does not mention its size.
+Ziegler of my own city, who has studied most scientifically and
+intelligently the use of electricity in diseases of the eye, announces
+this rule: The positive pole should be used in all inflammatory
+processes of the eye, glaucoma excepted, and with this rule Coleman
+agrees. Now, although the negative pole is a stimulant and therefore not
+generally indicated in inflammation, as Coleman points out, the object
+in view is to diminish the density of the ocular capsule and its
+tension, hence the negative rather than the positive pole should be
+used, inasmuch as the former, according to him, while it is a sedative,
+hardens tissue and would tend to increase intra-ocular tension by
+diminishing excretion. Moreover, in chronic glaucoma the ordinary
+inflammatory processes are not present, indeed, primary acute glaucoma
+itself is not an inflammation.
+
+I have no personal experience in the use of the constant current with
+negative pole application to the eye in the reduction of increased
+intra-ocular tension, but quote for our general benefit the opinions of
+those who have employed it. I have always been very frankly pessimistic
+in regard to the therapeutic value of electricity in ocular disorders.
+Perhaps I am wrong; I am willing to be enlightened. There seems little
+doubt that Truc and Imbert's observations that high frequency currents
+can temporarily reduce intra-ocular tension is correct, that they are
+able to relieve the pain of primary and of secondary glaucoma would
+seem to be proved by many observations, some of which I have myself
+made, and other very accurate and excellent ones have been made by
+Risley in Philadelphia.
+
+A word might be said in regard to _diathermy_. According to Zahn, the
+method of applying diathermy to the human eye is to take a layer of
+cotton wool 1 cm. thick soaked in a 2 per cent solution of sodium
+chlorid, which is applied close to the outside of the lids. On this is
+put an electrode 15 cm. in size with a large indifferent electrode
+applied to the back of the neck. It is not germane to the subject to
+name the various ocular diseases which were treated in this manner, but
+Clausnizer has made an investigation of the influence of diathermy on
+intra-ocular tension. In a number of diseases, for example,
+iridocyclitis, the method produced distinct rise of pressure. In one, a
+patient with secondary glaucoma, prior to the diathermic application
+the tension was 37½ mm., after the passage of the current it had
+fallen to 28 mm., but the next morning the tension rose to 45 mm. In a
+patient with chronic glaucoma no definite alteration of tension could be
+found. This observation is mentioned, not because it puts us in
+possession of a valuable therapeutic measure, but largely because it is
+a good example of how in this disease it is wise to investigate any
+method which furnishes a hope of relief.
+
+In a few instances endeavor has been made to reduce the intra-ocular
+tension, or at least to relieve glaucomatous symptoms, by galvanism of
+the cervical sympathetic, for example, by placing one electrode along
+the whole length of this nerve in the neck and one on the back of the
+neck on the opposite side, 15 to 20 ma. of current being used. Good
+results have been reported by an observer named Allard. I confess that I
+am entirely faithless in regard to any results that may be reached in
+this manner. It is possible that as the positive pole is a sedative, if
+there were any influence, the influence of sedation would be present,
+but certainly it has over and over again been experimentally proved that
+irritation of the cervical sympathetic quite rapidly produces elevation
+of intra-ocular tension of 2 to 4 mm. In some experimental work the
+primary elevation of intra-ocular tension was followed by a secondary
+drop.
+
+3. _Indirect reduction of increased intra-ocular tension brought about
+by lowering general vascular pressure._ Much has been written in regard
+to the association between increased vascular pressure and increased
+intra-ocular pressure. It is not my province to analyze observations
+often contradictory and not infrequently inaccurate. This much seems to
+be established: First, that at corresponding ages there is usually a
+higher average blood pressure in glaucomatous subjects than there is in
+non-glaucomatous subjects; second, that arteriosclerosis and therefore
+usually increased blood pressure, with all its concomitant conditions,
+is correctly classified as an exciting cause of glaucoma; and third,
+that the regulation of this increased blood pressure is part of the
+advantageous management of increased intra-ocular pressure, although it
+may be too much to say, as Gilbert has, that blood pressure and
+intra-ocular pressure rise and fall together. It may be true, as Thomas
+Henderson says, that the intra-ocular pressure is influenced by changes
+in the general arterial or general venous pressures, whereby a rise in
+general arterial pressure induces a proportionate rise in the
+intra-ocular pressure, but it would seem that future investigations must
+confirm this statement before it can be entirely accepted, as well as
+his further statement that the effect of an increased general venous
+pressure is a direct one, producing millimeter for millimeter a
+corresponding increase in the intra-ocular pressure.
+
+Now, it goes without saying, if these data are correct, or even only
+partly correct, that part of the treatment of the increased intra-ocular
+pressure state must be constitutional in that the vascular pressures
+should be lowered in order that the beneficial effect of their
+relationship to the intra-ocular pressure shall be established. It is
+further a great mistake to drive down a high arterial pressure simply
+because that exists. In other words, it is often necessary from the
+general standpoint that a certain amount of plus pressure shall remain
+if the patient's general well-being is to be maintained. There must
+always be a differential diagnosis between plus pressure and what may be
+called over plus pressure. That is to say, a man may be perfectly
+comfortable and properly need, for example, a pressure of 160 or 165
+mm., which is above the physiologic limit, but which is a plus pressure,
+while some disturbance in his general life may add to that 10, 15 or 20
+mm. more of pressure, which is then the over plus amount. This over
+plus amount may be in association with a rise of intra-ocular pressure,
+and must be eliminated if the latter is to be controlled by a
+non-operative procedure, or, indeed, by an operative one.
+
+It is no easy matter to determine the presence of increased venous
+pressure, although there are tolerably accurate instrumental technics,
+and yet, as Henderson points out, it is just this increased general
+venous pressure which is often detrimental. Therefore the perfunctory
+use of such drugs as nitrite of amyl and the other nitrites may not be
+in the least indicated when, for example, the venous pressure depends
+upon inability of the right heart to perform its functions, and the drug
+needed may, for example, be digitalis. Far better than pressure-reducing
+drugs like nitrite of amyl, urgently indicated in some instances and for
+some purposes, is the regulation of life and the restoration to their
+normality of the metabolic processes, the elimination of the worry
+which is usually the exciting agent that brings about the over plus
+pressure, which may have as one of its expressions an acute rise of
+intra-ocular tension. I believe that in the management of a case of
+glaucoma, whether it be chronic or chronic with sub-acute exacerbations,
+the greatest care with the aid of an expert clinician must be exercised
+to find out exactly what mean pressure of the arterial and venous system
+best conforms with the patient's general welfare, and I am bitterly
+opposed, and I think with right, to the sudden reduction of tensions,
+except in emergencies, without a perfect understanding of the facts I
+have ventured to indicate. This does not for a moment mean that prior,
+for example, to operative work it is not necessary to get rid by means
+of drugs of an over plus tension, for surely the elimination of such an
+over plus tension may be the means of preventing, for example, an
+intra-ocular hemorrhage, and in this emergency we must not lose sight
+of Gilbert's recent investigation, who has found that blood withdrawn to
+the extent of 8 grams to each kilogram of the body weight always
+produces lowering of the intra-ocular tension, appearing in six to eight
+hours and lasting to the next day in simple glaucoma, and in
+inflammatory glaucoma commencing the day after the venesection and
+lasting two to three days. It is not necessary for me to point out the
+value of free purgation and diaphoresis in this respect.
+
+In most instances the successful maintenance of a glaucomatous life,
+exclusive of operative interference, in addition to sustained myosis,
+demands the investigation of the patient's metabolism, which must be
+kept at the normal standard, the removal of the evil effects of
+auto-infection, as we are wont to call it, and especially the
+elimination of the cause which is responsible for the over plus tension
+of the arteries and of the veins. This is best secured by just such
+regulation of life as has been referred to, aided when necessary by the
+ordinary drugs which the patient's condition indicate, and the success
+of all treatments, be they operative or non-operative, is enhanced if
+such a happy state of affairs can be brought about.
+
+I am firmly convinced that every glaucomatous patient, and I now refer
+to those who are the subjects of chronic progressive glaucoma, should be
+carefully studied from the general standpoint by the oculist with the
+aid of an expert internist, just as I am convinced that the modern
+expert internist should not study his cases of cardio-vascular disease
+without the help of the oculist. Perhaps I am going a little far afield,
+but in justification of my statement I want to quote the opinion of Dr.
+Hobart Hare, one of America's most expert clinicians, on blood pressure,
+because it seems to me much harm has been done by the more or less
+brutal knocking down of blood pressure simply because blood pressure
+above the normal existed. "Concerning the matter of high blood
+pressure," writes Hare, "independent of cerebral lesions, the longer I
+study the matter the more convinced I am that this blood pressure is
+devised by nature to compensate for fibroid changes in peripheral
+vessels, in order that tissues which would otherwise be cut off from
+adequate blood supply may receive plenty of blood, and I consider it one
+of the most vital points to ascertain whether a pressure is what may be
+called the patient's pathological norm, that is, the pressure which is
+required in the face of vascular changes, or whether this pressure is in
+excess of his pathological norm. If it is in excess, measures directed
+to bring it to the pathological norm should be instituted, but if the
+pressure found proves to be the pathological norm it is a bitter mistake
+to lower it, be the pressure what it may. If it is lowered below the
+pathological norm, all manner of disturbed cardiac action, etc., may
+result. There is no more reason for reducing a blood pressure below his
+pathological norm than there is for reducing it below his physiological
+norm. The adjustment of a man's blood pressure to his pathological norm
+often has to be as correctly done as the adjustment of a watch which is
+losing or gaining time."
+
+I shall not quote Hare's elaborate methods for determining these various
+points because they do not belong to a paper of this character, but I
+quote his admirable advice because it emphasizes what I believe to be an
+essential in the treatment of chronic glaucoma, exclusive of operative
+work, that is, the intelligent co-operation of the oculist and the
+internist.
+
+Some such thought was in the mind of Ibershoff, who quotes Sterling and
+Henderson's views that the rate of secretion depends upon and varies
+with the difference in the blood pressure and the tension of the
+eyeball, and that the specific gravity of the secretion increases
+directly with the blood pressure and inversely with the ocular tension.
+Should the blood pressure be very high, paracentesis, for example, would
+apparently not be the proper procedure, and the resulting difference
+produced between the blood pressure and the eye tension would cause a
+rapid reformation of fluid with higher specific gravity and higher
+osmotic coefficient. The proper procedure in these circumstances is
+first properly to reduce the blood pressure, or what I have, quoting
+Hare, ventured to call the over plus pressure.
+
+4. _The relation of osmosis, lymphagogue activity, absorption of edema,
+capillary contractility and decreased affinity of ocular colloids for
+water to the reduction of increased intra-ocular tension._ We are all
+familiar with the attention which was directed some years ago to the
+statements coming from French clinics that the treatment of glaucoma
+should include the administration of osmotic substances as adjuvants in
+the reduction of increased intra-ocular tension. Particularly was this
+treatment advocated by Cantonnet in the administration of daily doses of
+3 grams of chlorid of sodium, preceded, of course, by a careful urinary
+examination and the estimation of the amount of urine and its contained
+chlorids. Carefully this dose was increased in proper circumstances to
+15 grams per diem, and in Cantonnet's original paper good results were
+achieved in 12 of the 17 patients so treated. I have myself experimented
+somewhat, not with the administration of sodium chlorid by the mouth,
+but with the introduction by the bowel of fairly large quantities of
+physiologic salt solution in patients with glaucoma whose quantity of
+urinary secretion was markedly below the normal, and in one or two
+startling instances, which have been reported, achieved success in the
+rapid reduction of the intra-ocular tension when by this technic the
+urine secretion rose to the normal amount. To be sure, myotics were
+also used, but these myotics were insufficient, totally so in the two
+instances noted prior to the enteroclysis.
+
+Very interesting are the observations on the subconjunctival injections
+of various substances, notably the citrate of sodium, because of its
+power of decreasing the affinity of ocular colloids for water. This
+method of treating increased intra-ocular tension, introduced, as you
+know, by Thomas and Fischer, has met with confirmation from a number of
+sources in spite of the fact that Happe's experimental study failed to
+confirm Fischer's observations; indeed, he even reports in several
+instances a rise of tension.
+
+As you will remember, the strength of ordinary crystallized sodium
+citrate in water should be from 4.05 to 5.41 per cent. Of this five to
+fifteen minims are injected, the eye having been previously cocainized
+and adrenalinized. With frequent injections the weaker of the two
+solutions is mixed with 2 to 4 parts of physiologic salt solution. These
+authors in no sense claim to cure glaucoma, but to ameloriate it and
+reduce the tension. Weekers has used the salts of calcium, 3 grams a
+day, with success in so far as lowering of tension is concerned,
+although it must be stated, as a reviewer of his work has said, that his
+recommendation of this drug in these respects is poorly supported. On
+the other hand, Tristiano seems to have proved that calcium chlorid is
+capable of lowering ocular tension and clinically may be used as an
+adjuvant in the treatment of glaucoma for this purpose, largely because
+he believes that he has proven that it facilitates the absorption of
+edema. Darier has reported that a single subconjunctival injection of a
+milligram of iodate of sodium has cleared the cornea and lessened the
+intra-ocular pain in glaucoma.
+
+What shall be said in regard to certain medicinal agents which stimulate
+the lymphagogue activity of the eyeball in their relation to the
+reduction of intra-ocular tension, notably of dionin? Toczyski's
+experiments with this drug on the normal eye indicate that it produces
+first a rise of tension, which shortly falls to the normal and sometimes
+below it, the tension being high as long as the primary narrowing of the
+pupil is maintained, but more than one author, particularly A. Senn,
+holds an opposite view and reports acute glaucoma following its
+instillation into a chronic glaucomatous eye. He believes that dionin
+not only does not reduce the tension but hinders the filtration through
+the anterior lymph channels by the pressure of the edema which is
+produced on the veins and by the increased secretion of the ciliary
+processes. In spite of this statement, most of us must agree with Karl
+Grossman's observations that certainly in acute and particularly in
+chronic secondary glaucoma, this is a most valuable agent, especially if
+it is combined with holocain, which Paul Knapp in his well-known
+research has proved can reduce the tension even of the normal eye. I
+cannot think that anybody who has systematically used dionin with
+holocain, the former in gradually increasing strength, beginning with 2
+per cent and going up to 8 per cent, in various types of acute glaucoma,
+particularly of the secondary variety, can fail to have noted a
+favorable influence.
+
+Many authors, for example, Darier, Grandclement and others, are strong
+in their recommendation of adrenalin, particularly if this drug is added
+to the various myotic mixtures, and yet adrenalin is certainly not
+without danger in the treatment of glaucoma. McCallan has seen a number
+of instances of striking increase of intra-ocular tension following this
+instillation in the conjunctival sac. Harmon has had a similar
+experience, as also has Senn. It is possible that in these circumstances
+the solution was too strong. Should the rise of tension occur, and I
+have seen it myself, it is doubtless due to the fact that this drug
+dilates the pupil, which would be especially dangerous if the dilatation
+should occur before contraction of the ciliary vessels; also the
+narrowing of the ciliary veins by the adrenalin might by virtue of this
+narrowing obstruct the gate of outflow. I have never been able to
+persuade myself that, except as an adjuvant to operative work, there was
+any real therapeutic value in the instillation of adrenalin.
+
+A word in regard to the effect of general narcosis on intra-ocular
+tension. Thus, Neuschuler has observed that narcosis causes an elevation
+of the intra-ocular tension of from 2 to 6 degrees as measured with
+Fick's tonometer. These observations were made while he was
+experimenting on irritation of the sympathetic as a method of producing
+increased intra-ocular tension. This is not in accord with Axenfeld's
+recent observations. It is well known, this observer points out, that
+after the period of excitation and muscular rigidity disappears, there
+is a lowering of blood pressure in chloroform narcosis and coincidently
+a sinking of the intra-ocular pressure. Not only this, the intra-ocular
+tension of normal eyes during this narcosis drops several millimeters.
+Only such eyes as have high hypertony, for example, in absolute
+glaucoma, are unaffected during chloroform narcosis. In the light of
+this observation it will be interesting to measure the tension both of
+normal and glaucomatous eyes during narcosis in a large series of cases,
+and if it is confirmed there will be an additional reason why in many
+circumstances general narcosis is advantageous in glaucomatous patients.
+Formerly I thought it was essential, if iridectomy was to be performed,
+lest some sudden movement on the part of the patient might bring the
+point of the knife in contact with the lens. I have rarely employed it
+in corneo-scleral trephining, and yet if there is this temporary
+reduction of intra-ocular pressure, it is not without a certain
+therapeutic value, and the matter is mentioned as a suggestion that
+additional observations along this line shall be made.
+
+
+
+
+Dr. George Edmund de Schweinitz' Paper on Concerning Non-Surgical
+Measures for the Reduction of Increased Intra-ocular Tension
+
+Discussion,
+
+NELSON MILES BLACK, M.D.,
+
+Milwaukee.
+
+
+It seems almost useless to attempt any discussion of Dr. de Schweinitz'
+most terse and comprehensive paper. However, Dr. de Schweinitz mentioned
+the close relationship which should exist in the non-surgical treatment
+of increased intra-ocular tension between the internist and the
+ophthalmologist, but neglected to mention a corresponding relation which
+should exist between the rhinologist and the ophthalmologist, and
+possibly between the dental surgeon and the ophthalmologist.
+
+I would like to refer to the _now_ recognized close relationship which
+exists between disease of the nasal accessory sinuses and diseases of
+the eye. The definition of glaucoma found in Dr. Wood's system of
+therapeutics gives rise to an hypothesis as to why disease of the nasal
+accessory sinuses may be a factor in producing increased intra-ocular
+tension and why treatment directed toward obtaining free drainage from
+the sinuses gives good results in so many cases, especially if the
+relationship is recognized sufficiently early. "Glaucoma proper is
+essentially a damming or blocking of the drainage from the interior of
+the eye. The chief lymph stream flows from the posterior chamber past
+the margin of the lens, through the zonula of Zinn, beneath the iris,
+through the pupil into the anterior chamber, thence through the tissue
+at the junction of the iris and sclera into the circular canal of
+Schlemm and from this space into _the external lymph channels_.
+_Obstruction to the steady escape of the intra-ocular fluids at any
+point in this drainage system or any undue increase of the fluids
+themselves may produce glaucoma._ Probably the most important
+obstruction to the exosmosis is at the angle close to Schlemm's canal."
+
+The following hypothesis is based upon Fischer's edema theory of
+glaucoma and the relation of the circulation of the eye and orbit and
+that of the nose and the accessory sinuses, the minute anatomy of which
+is not as yet thoroughly understood. However, sufficient work has been
+done to make it appear that the lymph channels which drain the eyes and
+orbits empty into the same main channel as do those which drain the
+sinuses. Admitted for sake of argument that such is the case, then
+disease either acute or chronic of one or more of the sinuses with the
+accompanying inflammatory reaction, congestion and stasis, will cause an
+increased amount of fluid to be taken care of by the lymph channels
+draining these sinuses. This will in turn cause flooding of the common
+lymph channel, producing a stagnation in the flow of fluid from the
+orbits and eyes at the junction with the main channel, with backing up
+of the fluid within these channels and retention of the waste products
+within the orbits and eyes; thus will be brought about conditions most
+favorable (to quote from Fischer's theory of glaucoma) "to an abnormal
+production or accumulation of acid in the eye. In consequence of this
+abnormal acid content the hydration capacity of the ocular colloids is
+raised and glaucoma results, not because water is pushed into the ocular
+colloids, but because these suffer changes which make them suck in water
+from any available source."
+
+This hypothesis also might suggest why the subconjunctival injection of
+sodium citrate in addition to alkalinizing the ocular contents, may be
+effective in reducing tension, _i. e._, the amount of fluid injected
+beneath conjunctiva may overcome the stagnation in the lymph passages,
+flush out these channels and improve ocular elimination.
+
+Fischer in a personal letter says:
+
+"You have two possibilities for the production of glaucoma with sinus
+disease: A toxic factor due to poisons being carried into the eye; and
+second, interference with a proper blood supply to the eye through
+compression of the efferent or afferent blood vessels supplying the eye
+from edema of the tissues about the eye consequent upon the sinus
+infection. Either is associated with the production of substances which
+increase the hydration capacity of the ocular colloids."
+
+If such is the case why could not the existence of pyorrhea and blind
+abscesses about the roots of the teeth be the source of the toxic
+factors mentioned by Fischer? Hence the suggested association of the
+dental surgeon with the ophthalmologist in these cases of apparently
+idiopathic increased intra-ocular tension.
+
+It would be well to state here a cursory examination of the mouth will
+not discover root abscesses any more than such examination will
+discover non-suppurative sinus disease. A careful examination of each
+tooth together with radiograms of the entire maxilla are absolutely
+essential to determine their presence or absence.
+
+
+
+
+Trephining for Glaucoma
+
+BY
+
+ROBERT HENRY ELLIOT, M.D.,
+
+London, England.
+
+
+Mr. President and Members of The Chicago Ophthalmological Society:
+
+As the hour is late I propose to take up only the principal points in
+connection with my subject and to deal with each one shortly.
+
+First: The operation of trephining is suitable, not merely for chronic
+cases, but for sub-acute and acute cases of glaucoma as well. I would
+urge on your attention that, of all the operations dealing with
+glaucoma, this one involves the minimum of surgical violence, and
+should, therefore, in acute cases be the operation of choice. It is,
+moreover, much safer than any other operation I know of, and is no less
+certain in its results. I do not advise trephining in the secondary
+glaucoma following intumescent cataract, for in such cases the
+semi-fluid lens bulges into and blocks the trephine hole. Nor for
+obvious reasons do I recommend it in cases where there is reason to
+believe that a communication exists between the aqueous and vitreous
+chambers.
+
+Second: The object of trephining is to tap and permanently drain the
+aqueous fluid from the anterior chamber of the eye into the
+sub-conjunctival space; in doing so it is essential to avoid as far as
+possible all interference with the uveal tissue. The purpose of an
+iridectomy is to avoid the danger of the iris in the neighborhood of the
+wound being drawn and impacted in the trephined hole. We have found in a
+large number of cases in which an iridectomy has been omitted, that the
+results have been in no way inferior to those in which a piece of iris
+has been removed, provided always that no subsequent iris prolapse
+takes place. In pursuance of our purpose to avoid uveal tissue, we split
+the cornea, and place the trephine as far forward as such splitting will
+allow, and we bear on the trephine in such a way that it cuts through on
+the corneal edge of the wound first. This insures establishing our
+fistula in the most anterior position possible, and, therefore, as far
+away as possible from the ciliary body and the angle of the chamber.
+
+Third: The difficulties of the operation. Far too much stress has been
+laid on these. Trephining is an operation which can be performed by any
+surgeon who is used to ophthalmic manipulations, and who has good sight.
+It is essential that he should work in a good light. The necessary
+technique can be acquired from a written description. It is not for a
+moment necessary that the surgeon who wishes to learn trephining should
+see the originator of the operation at work. If, however, he feels
+diffident at undertaking the procedure until he has seen it done by
+another, there are many centers in this country where the operation is
+now being successfully performed. I would mention amongst those which I
+have visited New York, Minneapolis, St. Louis, Nashville, Louisville,
+Detroit and Chicago. I have seen results of trephining by American
+surgeons which could not be bettered anywhere.
+
+Fourth: I am sure that everybody will recognize the difficulties of
+operating during such a tour as I am now making. I have so far in the
+last month performed over seventy trephinings in ten cities, and in
+twice as many clinics. To adapt one's self to different clinical
+methods, different assistants and different nurses is so difficult that,
+as you are aware, many distinguished surgeons refuse to work out of
+their own clinics. One cannot expect the results of such a tour to be on
+a par with those one obtains in one's own quiet daily surroundings. I
+am, however, confident that you will make a generous allowance for
+these difficulties, and I gladly welcome the suggestion that all the
+cases which I have operated on in America be collected together and
+reviewed as a whole.
+
+Fifth: In conclusion I would like to express the pleasure with which I
+listened to Dr. de Schweinitz' paper. I believed from the title that
+there might be a wide divergence of opinion between us. I find to my
+great relief that we are in absolute accord. I know, however, that there
+are in America and elsewhere able men who consider that the medical
+treatment of glaucoma should be pushed as long as possible. I cannot but
+feel that this is a survival of the dread that most surgeons have felt
+in recommending one of the older operations for glaucoma. We have now in
+our hands a method so safe, so easy and so certain that I feel sure that
+this dread will ere long pass away, and that the diagnosis of glaucoma
+will then be followed by a very early operation. In India I have gone
+farther than this, and where one eye has shown high tension, I have
+frequently trephined both. The prophylactic use of the operation is more
+than justified in that land of long distances and scattered medical aid,
+and where the patient is not likely to return a second time for surgical
+help. This prophylactic trephining is a proposition that I put before
+you today for your consideration, reminding you at the same time that
+glaucoma is practically invariably a bi-lateral condition. I have seen
+even in America not a few people blind in both eyes who might have
+retained the sight of the second eye had the surgeon advised a double
+sclerectomy when he first saw the case, despite the fact that the second
+eye was then to all appearances non-glaucomatous.
+
+
+
+
+Dr. Robert Henry Elliot's Paper on Trephining for Glaucoma
+
+Discussion,
+
+FRANK C. TODD, M.D.,
+
+Minneapolis.
+
+
+It is very difficult for one of limited experience to discuss a subject
+presented so ably by Lieutenant Colonel Elliot to whom we are indebted
+for the sclero-corneal trephine operation. He has already over a period
+of a little over four years performed over 900 trephinings, and has made
+a most careful subsequent study of the results of those operations on as
+many cases as he had the opportunity to observe.
+
+Anyone who has read Colonel Elliot's book on the sclera-corneal
+trephining operation will be struck with the fact that he has not only
+had a tremendous experience in ophthalmic surgery, but that he has made
+the best of that unusual opportunity, and that to a foundation of a
+careful training he has added the experience of twenty-two years of hard
+painstaking work.
+
+I have recently had the privilege of entertaining Colonel Elliot in my
+own city, where I had the opportunity of assisting him and hence closely
+observing his technique in eighteen trephinings. It has since been my
+duty, and responsibility I may add, to care for those eighteen eyes. For
+two years I have been doing the Herbert tongue flap, or a similar
+operation. The results have been highly satisfactory thus far and
+similar to those following the trephining operation, which operation I
+have performed in a number of cases during the past ten months. My
+conclusions as to these two operations are favorable to the trephining
+operation because the Herbert tongue flap operation is much more
+difficult, and hence less certain than the Elliot trephining operation.
+
+The time for discussion does not permit a detailed statement of the
+results nor experiences in the handling of these trephining cases. Of
+the entire number five totally blind eyes were trephined. Tension was
+reduced in all but one. In that one hemorrhage occurred at the time of
+the operation. One of these blind eyes had not been totally blind longer
+than a few weeks. Hand movement vision developed in this eye. Another
+eye totally blind one year has thus far developed perception of light.
+Of the cases with varying degrees of vision from hand movements to
+six-ninths all but one have either remained the same or shown some
+improvement. The one exception was an eye having six-ninths vision. A
+small button hole iridectomy was made; prolapse of the iris into the
+wound occurred four days later requiring incision. Upon incision of the
+prolapse intra-ocular hemorrhage occurred, causing nearly total
+blindness for two weeks. Vision is clearing fast and it remains yet to
+be seen what the final results may be. One buphthalmic eye trephined by
+myself gave good results.
+
+I have as yet seen no cases of remote infection, but the report of
+Axenfeld and some others would indicate that this occurred following the
+Lagrange as well as the trephining operation, the then bulging
+conjunctiva having become eroded and infection having taken place
+through the eroded conjunctiva as shown when stained with flourescin.
+
+The opinion, not yet conclusive, that I have thus far formed as a
+consequence of my experience and the information obtained from others of
+greater experience is as follows:
+
+First: That in those cases of chronic glaucoma in which iridectomy has
+been of benefit in preventing or retarding the oncoming of blindness,
+the result has apparently been secured by reason of the fact that
+filtration has been produced, and not merely because a piece of iris has
+been removed.
+
+Second: That in chronic glaucoma (in acute glaucoma iridectomy has
+proven a satisfactory operation) when the progress of the disease
+cannot be arrested by non-surgical treatment (an even in some of these,
+where, for instance the patient cannot be kept under observation or will
+not carry out the treatment) some form of operation intended to produce
+filtration should be performed.
+
+Third: The Elliot sclero-corneal trephining operation carefully
+performed in accordance with the author's technique in the light of our
+present knowledge seems to be the best and safest operation to produce
+that result.
+
+Fourth: That to glaucoma may be added buphthalmos and staphyloma, as
+diseases often capable of relief by trephining and indeed toward the
+relief of which trephining is the best form of operation yet presented.
+
+Fifth: That the results secured when the operation is well done and the
+after care is properly followed out are satisfactory, in that the
+operation in a large proportion of cases apparently permanently lowers
+the tension to normal or below normal, relieves pain, prevents the
+oncoming blindness (otherwise inevitable) and in many cases causes an
+improvement in the acuity of vision, in the visual field. And in
+occasional cases of blindness of not too long duration, it restores some
+vision, occasionally to a marked degree.
+
+Sixth: That it is not a simple nor easy operation and should, therefore,
+be performed only by an operator well trained in ophthalmic surgery. The
+careful and skillful technique of the originator of the operation
+perhaps accounts for his greater success in its results and those who
+perform the operation should follow his technique and be capable of
+handling complications that may later arise.
+
+In conclusion, Mr. President, I wish to say that we ophthalmologists the
+world over are indebted to Lieutenant Colonel Elliot not alone for his
+contributions to our knowledge, but for his persistence against
+precedent and criticism in establishing the facts upon which rest the
+foundation for the success of his operation, and for so emphasizing the
+great importance of this epoch-making achievement.
+
+It is because we respect his wisdom gained by incessant study and
+experience in a country where climatic conditions are such that a man of
+ordinary energy would have failed to do even average work that we so
+readily welcome the teaching of this enthusiastic evangelist.
+
+His pilgrimage to our country will be the means of starting many in this
+new field, and we shall soon be able to draw more definite and final
+conclusions from our own experiences.
+
+
+
+
+Operations Other than Scleral Trephining for the Relief of Glaucoma
+
+BY
+
+CASEY A. WOOD, M.D.,
+
+Chicago.
+
+
+In this paper I shall say a few words about the large number of
+operative procedures that, apart from trephining, or, preferably,
+_trepanation_, have been urged in the treatment of the various forms of
+glaucoma. Their name is legion and among them we find peripheral
+iridectomy; anterior sclerotomy; irido-sclerotomy; scleriritomy; de
+Wecker's dialysis of the iris; Hancock's division of the ciliary muscle;
+the incision of the iridian angle of de Vincentiis; sclero-cyclo-iridic
+puncture; the Sterns-Semmereole _sclerotomia antero-posterior_; the
+_transfixio iridis_ of Fuchs; Antonelli's peripheral iritomy; Holth's
+formation of a cystoid cicatrix; Hern's operation; Terson's
+sclero-iridectomy; Abadie's ciliarotomy; Ballantyne's incarceration of
+iris method; Masselon's small equatorial sclerotomy; Simi's equatorial
+sclerotomy; Galezowski's sclero-choriotomy; excision of the cervical
+ganglion; removal of the ciliary ganglion; Querenghi's operation of
+sclero-choriotomy; Bettremieux's simple anterior sclerectomy; Heine's
+cyclodialysis; Herbert's wedge-isolation operation; Verhoeff's operation
+with a special sclerotome; Holth's sclerectomy with a punch-forceps;
+Walker's hyposcleral cyclotomy; posterior sclerotomy; T-shaped
+sclerotomy; and last but not least the Lagrange form of sclerectomy with
+its various modifications by Brooksbank James, myself and others.
+
+In addition to the foregoing list--which is by no means complete--there
+are several combinations of operations, as, for example, the Fergus
+trephining operation, which is really a combination of a sclero-corneal
+trepanation and a cyclodialysis.
+
+So far as it is practicable there is a certain amount of wisdom in
+comparing the results of an operative procedure with others with which
+it is brought in competition, and I believe we are even now in a
+position to form at least some idea of the comparative value of the
+three methods that comprise the great majority of interventions made use
+of by ophthalmic surgeons at the present time. I refer to _iridectomy_,
+the _Lagrange operation_, and the _Elliot operation_. So far as regards
+the last named procedure, I congratulate this Society that it has had an
+opportunity of seeing a demonstration and hearing a discussion by the
+famous ophthalmic surgeon who perfected it.
+
+As regards the others let me recommend to you the complete description
+of them given by Posey in _A System of Ophthalmic Operations_.
+
+Let us consider the first of the three procedures just
+mentioned--_iridectomy_--introduced by von Graefe. The mechanism of its
+mode of cure is best studied in cases of acute primary glaucoma, when
+there is apposition of the periphery of the iris to the cornea. In these
+acute cases there is probably only a mere _apposition_, and the blocking
+up of the sclero-iridian angle is largely mechanical. Here the root of
+the iris is readily removed in its entirety and a really peripheral
+iridectomy is easily done. When, however, a true _adhesion_ between
+corneal and iridic tissue takes place the filtration angle is not so
+easily opened. True peripheral adhesions are not readily broken up or
+separated, and the iridectomy is, for that reason at least, not
+effective. Moreover, this form of anterior synechia (resulting from a
+true union of iris and cornea) is so intimate that the iris root is, by
+the iridectomy, torn away only at the sclero-iridian angle at the
+anterior border of the adhesion--and does not open up a channel into
+Schlemm's canal. It is not, therefore, difficult to understand why
+iridectomy alone in any of the forms of chronic glaucoma fails to open
+up the true filtration spaces and does not provide a drain that permits
+of an escape of fluid from the posterior chamber through the loose
+tissue that surrounds it into the canal of Schlemm. Treacher Collins
+found, after a careful examination of eyes upon which iridectomy had
+been performed for glaucoma, that it is extremely rare for the initial
+section to pass through the pectinate ligament, while Schlemm's canal
+invariably escapes. Moreover, since the sclero-corneal incision is
+uniformly oblique, the position and extent of the external wound does
+not always furnish evidence of the character of the internal wound. In
+all likelihood many cases of relief or cure following iridectomy are
+those due to the formation of cystoid scars or minute fistulae, rather
+than as a result of the removal of a portion of the iris periphery.
+
+The best brief tabulation of the results obtained by iridectomy, in
+glaucoma, is to be found in Weeks' textbook on _Diseases of the Eye_,
+page 417: "Sulzer reports as follows: Acute glaucoma, 149 cases;
+improved, 72.5 per cent; serviceable vision preserved, 11.3 per cent;
+vision impaired at once, 4.08 per cent; very little vision, 12.12 per
+cent.
+
+"Zentmeyer and Posey: In simple glaucoma central vision increased in 60
+per cent; remained the same in 20 per cent; diminished in 20 per cent.
+
+"Wygodski: Inflammatory glaucoma, 37 cases; improvement, 76 per cent;
+unimproved, 5 per cent; deterioration, 19 per cent. Sub-acute (chronic
+inflammatory), 147 cases; improvement 10 per cent; unimproved (condition
+the same as before iridectomy), 40 per cent; deterioration, 30 per cent;
+blindness, 20 per cent. Cases operated on at an early stage gave 85 per
+cent of good results. Simple glaucoma, 104 cases; improvement, O.96 per
+cent; condition as before, 10.5 per cent; deterioration, 52 per cent;
+amaurosis, 36.5 per cent.
+
+"Hahnloser and Sidler: One hundred seventy-two eyes observed not less
+than ten years after operation; acute inflammatory, 31 eyes; good
+results, 64 per cent; relatively good, 13 per cent; blind 23 per cent;
+chronic inflammatory, 37 eyes; good result, 29.9 per cent; relatively
+good, 27 per cent; blind, 43 per cent; simple glaucoma, 76 eyes; good
+results, 42 per cent; relatively good, 28.9 per cent; blind, 28.9 per
+cent."
+
+As far as the _Lagrange procedure_ is concerned, you will remember that
+after eserinization an oblique incision is made through the sclera by
+means of a narrow Graefe knife and a large conjunctival flap secured.
+This is obtained by making a peripheral section of the sclero-corneal
+margin with the knife and, as soon as the edge of the knife reaches the
+upper limit of the anterior chamber, it is turned backward and brought
+out through the sclera obliquely. The conjunctival flap thus formed is
+turned back over the cornea, and the fragment of sclera that is left
+attached to the cornea is removed by means of a fine pair of delicate
+curved scissors. Following this an iridectomy is performed. The
+conjunctival flap is now replaced and a bandage applied.
+
+This operation opens a large filtration passage for the intra-ocular
+fluids and the prompt healing of the wound with its mucous covering
+prevents prolapse of the iris.
+
+Under no circumstances must iris be left between the lips of the wound.
+
+Although Lagrange advocated iridectomy in all cases in his first
+communication, he no longer judges the procedure to be necessary in all
+instances, reserving it for cases in which for any reason, such as
+hypertension, prolapse is to be feared.
+
+While Lagrange holds that it is necessary to open the anterior chamber,
+Bettremieux thinks that a removal of but a portion of the thickness of
+the sclera suffices. His procedure is as follows: After raising a flap
+of conjunctiva from the neighborhood of the limbus a medium sized
+needle, curved and flattened towards its point and firmly grasped in a
+needle holder, is thrust superficially into the sclera tangentially to
+the upper edge of the cornea, so as to become fixed in the capsule of
+the eyeball. A small shaving of the sclera, about ½ mm. thick, 1½ to 2
+mm. broad and from 2 to 3 mm. long, is then excised by means of a narrow
+Graefe knife. The scleral slip is then freed from the conjunctiva at
+each end and the mucous membrane brought together over the wound by fine
+catgut sutures.
+
+As you are well aware, numerous operators regard the Lagrange operation
+as superior to the iridectomy of von Graefe because they believe there
+is filtration through the newly formed tissue between the lips of the
+operative wound. Among those of many observers the conclusions of
+Ballantyne may be quoted: "The results of sclerectomy vary according to
+the degree of hypertension of the eye operated on. Three varieties of
+cicatrix are distinguishable according to the amount of sclera excised:
+(1) that in which there is mere thinning of the sclera owing to the
+excised portion not reaching the posterior surface of the cornea
+(conjunctiva smoothly covers the cicatrix); (2) that represented by a
+subconjunctival fistulette, due to excision of the whole thickness of
+the sclera, in an eye with moderate tension (the conjunctiva lies
+smoothly over the cicatrix); (3) the fistulous cicatrix with an
+ampulliform elevation of the overlying conjunctiva, resulting from
+excision of the whole thickness of the sclera in an eye the seat of high
+tension. In cases of high tension, even a simple sclerectomy will allow
+ample filtration, owing to the gaping of the wound, while in cases
+without elevation of the tension, sclerectomy will be quite ineffectual.
+Lagrange therefore proposes the following rules of procedure: (a) If
+tensions is normal to +1, do sclerectomy without iridectomy, the amount
+of sclera excised being inversely proportionate to the degree of
+hypertension. (b) If tension is +1 to +3, do sclerotomy-iridectomy, the
+iridectomy being added to avoid entanglement of the iris. Lagrange does
+not recommend his operation for acute glaucoma. It is especially adapted
+for cases of chronic simple glaucoma."
+
+During the past ten years or more I have been doing a modification of
+the Lagrange operation, the details of which (The Operative Treatment of
+Glaucoma with Special Reference to the Lagrange Method, _The Canadian
+Medical Association Journal_, November, 1911) I have elsewhere
+published.
+
+As stated in this paper I have modified the procedure to the extent of
+removing _all_ the conjunctiva attached to the borders of the operative
+wound. I admit that this intervention exposes the root of the iris and
+the ciliary body, but I have never yet had the slightest infection of
+the wound. I attribute this freedom from sepsis to careful cleansing of
+the conjunctival sac and to other pre-operative precautions, but
+especially to the use, before and after the operation, of White's
+ointment--a preparation of 1-3000 mercuric chloride in sterile vaseline.
+One cannot use sublimate in such a strong _watery_ solution, but the
+vaseline seems to modify it and to allow of such slow absorption that it
+is not only a non-irritant but a most excellent antiseptic application
+in operations on the eye.
+
+In any event the result of the Lagrange operation proper, as well as my
+modification of it, is to produce a drainage-oedema about the incisional
+wound which persists almost indefinitely. In many cases this swelling
+amounts to a bleb which may be increased by massage of or pressure upon
+the eyeball. The efficacy of the operation in lowering intra-ocular
+tension is to some extent measured by the degree and the constancy of
+this epibulbar oedema; indeed, I suspect that the most successful
+examples are those in which sclera fistulae, minute or otherwise, form
+as a sequel of the operation.
+
+My object in excising the conjunctiva about the sclero-corneal flap, is
+to delay union of the wound edges, to widen the bridge of loose
+cicatricial tissue between them, to prevent such a complete growth of
+the endothelium as would cover the wound and block the exit of fluids,
+and to insure intra-ocular rest.
+
+In cases of _chronic_ increase of intra-ocular tension associated with a
+quiet uveitis or an iridokeratitis, when the patient exhibits traces of
+old synechiae, or where there is danger of their re-formation, I do not
+hesitate to use atropia as long as the wound of operation has not
+healed.
+
+To the present time I have done 72 operations of the sort and have seen
+no reason to alter the opinion of it expressed in the article mentioned.
+Whatever objection may in the future arise--and I freely confess that
+it _seems_ to be fraught with the dangers that many of my colleagues
+have pointed out as probable--I have so far not seen a single case of
+infection of the wound of operation. While I believe the
+anti-glaucomatous results to be excellent, I may also claim that the
+operation is of the simplest character; and it is easy of performance
+and the resulting filtration-scar is large and (perhaps) more permeable
+to the changed intra-ocular fluids than the quicker healing wounds of
+the usual Lagrange and Elliot procedures.
+
+It is regarded by most operators as desirable that there should not be
+long delayed healing of the operative wound, and the fact that the
+conjunctiva covers the incision is often spoken of as an advantage,
+partly because it shields the large open area produced by the Lagrange
+incision from infection.
+
+My experience of this modified operation continues to be that it is
+necessary to clear the neighborhood of the operation wound entirely of
+conjunctiva. If the down-growth of epithelium into the operative wound
+is permitted the effects are by no means as pronounced, and the eventual
+lowering of tension is not as permanent as they otherwise would be.
+
+Another matter: I am satisfied that the delayed filling of the wound by
+connective tissue is desirable in most cases of _chronic_ glaucoma. A
+complete drainage of the intra-ocular fluids that results from long
+delayed union of the wound edges, allows the interior of the eye to
+regain, as far as possible, the _status quo ante_. On the other hand the
+comparatively early closure of the wound (or the termination of _free_
+drainage and minus tension) tends to re-establish the _status
+glaucamatosus_. Whether these desirable results are to be realized or
+not will, of course, depend upon a future experience larger than I have
+yet had. This modification of the Lagrange operation seems to be a
+radical one and I do not expect its adoption until the results of an
+extended trial are carefully recorded and reported.
+
+Quite recently several operators, who have been in a position to do so,
+have contrasted the results obtained by the Elliot method and those
+following the Lagrange procedure. Probably the most important of these
+observations is the experience of Meller (Die Sklerektomie nach Lagrange
+und die Trepanation nach Elliot) set forth in a paper read by him at the
+last meeting of the _Deutsche Naturforscher und Aertze_. In this report
+Meller gives an account of 389 sclerectomies following the usual
+Lagrange procedure. Twelve per cent of the cases were of acute glaucoma;
+61.5 per cent of chronic inflammatory glaucoma, and 9 per cent of simple
+glaucoma. The rest of the operations were done in other forms of the
+disease. In more than half the cases the usual iridectomy was performed;
+in 30 per cent the procedure was peripheral; in 4 per cent there was no
+iridectomy. The patients were studied during a period of five years. In
+more than half the instances there was a pale, cystic, oedematous
+cicatrix; in 11 per cent the scar was ectatic, and in the remainder the
+field of operation was quite flat. The form of the scar was described in
+most instances, but it was not noticed that there was a definite
+relation between the cicatrical formation and the intra-ocular tension.
+In 70 per cent of the cases a good result followed the operation, but in
+10 per cent the result was decidedly unsatisfactory. Cloudiness of the
+lens set in in 4 per cent of the cases, while posterior synechiae
+developed in the great majority of them. In 2.3 per cent the eye was
+attacked by iridocyclitis and in 3.4 per cent enucleation was found to
+be necessary. Six eyes became atrophic but were not, for various
+reasons, removed. One and three-tenths per cent of the eyes operated on
+were lost from late infection. Vitreous was lost in 6.2 per cent. Two
+eyes became blind from expulsive hemorrhage. The large majority of
+these complications arose in the eyes operated on for chronic glaucoma.
+There were fewer eyes lost following the operation for glaucoma simplex
+than in the other forms of the disease. Recurrences were noticed in 11.3
+per cent of all the cases; in simple glaucoma 14.3 per cent as against
+the acute and chronic forms with 6 per cent. A return of the glaucoma
+was noticed in 7 per cent of the pale, oedematous, post-operative scars,
+in 16 per cent of the flat cicatrices, and in 24 per cent of the ectatic
+variety. Considerable stress is laid upon the fact of the marked
+softness of the eyes after each operation. There were histological
+examinations made of the eyeballs in 11 cases, in which the position of
+the incision and excision, the development of the scar tissue, and the
+appearance of the complications were duly set forth. The operator then
+gave a history of over 178 trepanations after the Elliot method and
+compares them with the procedure of Lagrange. He concludes that the
+Elliot trephining operation is less dangerous, is more likely to be
+followed by the development of a cystic scar, and leads to loss of the
+eye in only 2.4 per cent of the eyes operated on. In Elliot's cases the
+percentage of relapse was more noticeable than in the Lagrange cases
+where no iridectomy was done. This observer concludes that the method of
+Elliot is to be preferred to that of Lagrange, and that in the former
+case iridectomy is an important factor in obtaining a favorable result.
+This being the case one cannot truthfully say that trephining alone can
+take the place of the old Graefe iridectomy. On the other hand,
+trephining may with advantage be employed instead of iridectomy for
+cases difficult or dangerous under the latter method.
+
+Whatever difference of opinion was noticeable at the Vienna meeting, all
+of those present, especially Meller, the reader of the paper just
+quoted, were decidedly of the opinion that the Elliot operation is in
+every respect the one best adapted to buphthalmia, or congenital
+glaucoma.
+
+In conclusion let me say that the acceptance or rejection of Colonel
+Elliot's procedure or any other operation is not to be decided by the
+percentage of iritis, secondary cataract, relapses, lost eyes, etc., but
+by deciding whether or not his procedure in the various forms of
+glaucoma gives the best results, including the preservation of
+comfortable eyes. In other words, we are seeking not the operation that
+will cure _every_ case of glaucoma but the one which is capable, _in the
+hands of the average ophthalmic surgeon_, of relieving or curing _most_
+cases of that affection.
+
+
+
+
+Dr. Casey A. Wood's Paper on Operations Other than Scleral Trephining
+for the Relief of Glaucoma
+
+Discussion,
+
+ALBERT E. BULSON, JR., M.D.,
+
+Fort Wayne.
+
+
+Increasing belief in Colonel Elliot's view that trephining should be the
+operation of choice in any form of glaucoma, makes it difficult to
+consider operations other than trephining in anything but a spirit of
+disfavor.
+
+Until recently the decision as to the kind of operative procedure to be
+employed for the relief of glaucoma has depended on the form and stage
+of the disease, and the amount and character of the vision of the
+affected eye. Many operators still hold that an iridectomy is the most
+valuable of all operations for acute inflammatory glaucoma, and not a
+few hold that the operation has a decided place in the treatment of
+simple glaucoma. The operation is not without difficulties, and one is
+inclined to agree with Elliot who says that "The man who can make a
+'finished iridectomy' quietly and cleanly has graduated as an ophthalmic
+operator." The difficulties of an iridectomy are especially pronounced
+in those cases in which the anterior chamber is extremely shallow and
+the iris is pressed against the cornea. It is in such cases that the
+success of the operation is increased by the addition of posterior
+sclerotomy and the intelligent use of miotics prior to the performance
+of the iridectomy. Even then the permanent results of the iridectomy
+will be modified in proportion to the success secured in freeing the
+filtration angle and opening Schlemm's canal by thorough removal of the
+root of the iris.
+
+The failure of many apparently well executed iridectomies may be
+attributed to the fact that the iris is not removed to the extreme
+root, and the remaining stump is sufficient to block the drainage. This
+is especially apt to be the case in chronic glaucoma where the iris is
+adherent to the cornea, and in efforts to free the filtration angle by
+an iridectomy the iris is torn off in front of the adhesion and the
+filtration angle is not opened.
+
+As Elliot has pointed out, iridectomy is most open to attack on the
+ground of safety. We have to take into account the large scleral wound
+made, and the fact that this lies close to the ciliary body. The sudden
+release of all tension and the simultaneous weakening of the supports of
+the lens and vitreous body create very unfavorable conditions under
+which to make the crucial step of the operation.
+
+The poor results following an iridectomy in chronic glaucoma have led to
+the devising of many substitute operations, of which those tending to
+the production of a filtering scar are now preferred, and, experience
+shows, hold out the most hope of bringing about long continued relief.
+It even is considered probable that the effects of an iridectomy which
+brings about more or less permanent reduction in the intra-ocular
+pressure is due to the formation of a filtering scar which augments
+whatever results may have been secured in the attempt to open up the
+drainage into the canal of Schlemm.
+
+Dr. Wood has referred to several of the many substitutes for iridectomy
+that have been proposed, and it is unnecessary to enumerate them again
+or to attempt to point out their good or bad features. It is sufficient
+to say that for the average operator and the larger per cent of cases,
+the operation which is easiest to perform, is attended with the least
+risk and offers the best hope of permanent results should be the one of
+choice. Sympathectomy has failed to secure a place in ophthalmic
+surgery, sclerotomy has not been found adequate, and cyclodialysis is
+not sufficiently simple of execution or permanently beneficial in its
+results to give it prominence.
+
+Of the operations proposed for the formation of a filtering cicatrix,
+those of Elliot and Lagrange are justifiably the most popular. Those of
+us who have had the pleasure of seeing the trephining operation done by
+Col. Elliot are impressed with the fact that the operation, even in the
+hands of its originator, is not, when properly done, uniformly easy of
+performance. It does, however, offer the advantage of carrying with it
+the minimum amount of risk, and the apparently permanent results secured
+justify the ophthalmologist in acquainting himself with the technique of
+the operation, for, as pointed out by Sydney Stephenson and others, "the
+technique is responsible for success or failure." Furthermore, there is
+no sufficient reason why the field of usefulness of the operation should
+be confined to the chronic forms of glaucoma, and Col. Elliot
+unhesitatingly recommends trephining as safer and more efficient than
+any other operative procedures at present employed for the relief of
+acute glaucoma.
+
+The success of the Lagrange operation, which, like the Elliot operation,
+aims to produce a fistulous communication between the anterior chamber
+and the sub-conjunctival area, depends upon securing the removal of a
+relatively large section of all of the layers of the scleral and corneal
+lip of the wound, so that a permanent opening, covered by the replaced
+conjunctival flap, is made. Unlike the trephine operation which was
+evolved from it, the Lagrange operation requires the same kind of an
+opening of the eyeball as required for a well executed iridectomy, and a
+properly placed section entirely in scleral tissue, with a good sized
+conjunctival flap, are elements which enter into the ultimate success or
+failure of the procedure.
+
+Aside from the dangers incident to a wide incision in the neighborhood
+of the ciliary body and the possibility of accident to the lens or
+vitreous body, or of intra-ocular hemorrhage, there is for the average
+operator the added difficulty and danger in removing a piece of sclera
+of the exact size required. The technique of the operation is even more
+difficult and exacting than in the performance of the trephine
+operation, and it also compares unfavorably in safety.
+
+The advisability of removing the conjunctival flap, as advocated by Dr.
+Wood, as a modification of the Lagrange operation, may be seriously
+questioned, for aside from the fact that apparently no advantages in
+aiding permanent filtration are added, there is, added to the objections
+to the Lagrange operation already mentioned, the very serious
+disadvantage of subjecting the area at the root of the iris to infection
+for a prolonged period of time. The advantages of the protection
+afforded by a conjunctival flap far outweigh the disadvantages of a
+remotely possible interference of drainage by the blocking of the open
+wound with conjunctival tissue. The fortunate experience of Dr. Wood in
+not having infection in a wound which remains open and unprotected for
+variable lengths of time is not likely to be the experience of any
+considerable number of operators, and probably will not always be the
+experience of Dr. Wood. Furthermore, the possibilities of damage by
+hemorrhage from the choroidal or retinal vessels, delayed formation of
+the anterior chamber and adhesion of the capsule of the lens to the
+wound, and the injurious effects of even slight trauma subsequent to the
+operation, including loss of vitreous, are increased by omitting the
+conjunctival flap.
+
+The modern operation for the relief of glaucoma, by which a filtering
+scar is produced which permits escape of liquid from the anterior
+chamber, is the one which apparently holds out the most hope of
+permanently relieving the condition. While success will depend always to
+a certain extent upon the personal equation, yet it seems now that for
+a large majority if not all of the cases we are justified in abandoning
+all other operations than trephining, notwithstanding the verdict of
+Elschnig and others that fistula forming operations eventually will be
+discarded in favor of iridectomy and cyclodialysis.
+
+Late or secondary infection, not unknown following iridectomy, may
+follow the trephine operation, and already some fifteen or sixteen cases
+have been reported. But while this possibility is a real danger, which
+improved technique may greatly minimize (Col. Elliot has not seen a case
+of secondary infection in an experience of over 1200 trephining cases of
+his own and a large number of others performed by his assistants and
+pupils) the ultimate verdict must rest with results as compared with
+other measures. At present, as pointed out by Meller, whose statistics
+Dr. Wood has cited, trephining heads the list of remedial measures for
+the relief of glaucoma, and it has the advantage of being applicable to
+any form of the disease, to be relatively free from danger, either
+immediate or remote, and to produce the highest percentage of favorable
+results. The addition of an iridectomy in every case of trephining does
+not unduly complicate the operation and has much to commend it in
+offering the patient every possibility of relief.
+
+
+
+
+INDEX
+
+                                                PAGE
+ETIOLOGY AND CLASSIFICATION OF GLAUCOMA,
+  _Edward Jackson, M.D._                           9
+
+ETIOLOGY AND CLASSIFICATION OF GLAUCOMA,
+  Discussion, _Francis Lane, M.D._                28
+
+PATHOLOGY OF GLAUCOMA,
+  _John Elmer Weeks, M.D._                        37
+
+PATHOLOGY OF GLAUCOMA,
+  Discussion, _E. V. L. Brown, M.D._              57
+
+CONCERNING NON-SURGICAL MEASURES FOR THE
+REDUCTION OF INCREASED INTRA-OCULAR TENSION,
+  _George Edmund de Schweinitz, M.D._             61
+
+CONCERNING NON-SURGICAL MEASURES FOR THE
+REDUCTION OF INCREASED INTRA-OCULAR TENSION,
+  Discussion, _Nelson Miles Black, M.D._         101
+
+TREPHINING FOR GLAUCOMA,
+  _Robert Henry Elliot, M.D._                    107
+
+TREPHINING FOR GLAUCOMA,
+  Discussion, _Frank C. Todd, M.D._              113
+
+OPERATIONS OTHER THAN SCLERAL TREPHINING
+FOR THE RELIEF OF GLAUCOMA,
+  _Casey A. Wood, M.D._                          121
+
+OPERATIONS OTHER THAN SCLERAL TREPHINING
+FOR THE RELIEF OF GLAUCOMA,
+  Discussion, _Albert E. Bulson, Jr., M.D._      141
+
+
+
+
+
+End of the Project Gutenberg EBook of Glaucoma, by Various
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+      The Project Gutenberg eBook of Glaucoma; a symposium, by Ed. Nance and Peck.
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+<pre>
+
+The Project Gutenberg EBook of Glaucoma, by Various
+
+This eBook is for the use of anyone anywhere at no cost and with
+almost no restrictions whatsoever.  You may copy it, give it away or
+re-use it under the terms of the Project Gutenberg License included
+with this eBook or online at www.gutenberg.org
+
+
+Title: Glaucoma
+       A Symposium Presented at a Meeting of the Chicago
+              Ophthalmological Society, November 17, 1913
+
+Author: Various
+
+Editor: Willis O. Nance
+        Wesley Hamilton Peck
+
+Release Date: November 19, 2007 [EBook #23544]
+
+Language: English
+
+Character set encoding: ISO-8859-1
+
+*** START OF THIS PROJECT GUTENBERG EBOOK GLAUCOMA ***
+
+
+
+
+Produced by Bryan Ness, Martin Pettit and the Online
+Distributed Proofreading Team at http://www.pgdp.net (This
+book was produced from scanned images of public domain
+material from the Google Print project.)
+
+
+
+
+
+
+</pre>
+
+
+<p><span class='pagenum'><a name="Page_1" id="Page_1">[Pg 1]</a></span></p>
+
+<p class="tbrk">&nbsp;</p>
+
+<h1>GLAUCOMA</h1>
+
+<h3>A SYMPOSIUM PRESENTED AT A MEETING OF THE<br />
+CHICAGO OPHTHALMOLOGICAL SOCIETY,<br />NOVEMBER 17, 1913.</h3>
+
+<h4>EDITED BY</h4>
+
+<h2>WILLIS O. NANCE, M.D.,</h2>
+
+<h4>PRESIDENT CHICAGO OPHTHALMOLOGICAL SOCIETY (1913); OPHTHALMIC<br />
+SURGEON, ILLINOIS CHARITABLE EYE AND EAR INFIRMARY; FORMER<br />
+OCULIST AND AURIST, COOK COUNTY HOSPITAL; EDITOR<br />JOURNAL OF OPHTHALMOLOGY AND OTO-LARYNGOLOGY,</h4>
+
+<h4>AND</h4>
+
+<h2>WESLEY HAMILTON PECK, M.D.,</h2>
+
+<h4>PRESIDENT CHICAGO OPHTHALMOLOGICAL SOCIETY (1914); FORMER<br />
+PROFESSOR OPHTHALMOLOGY, CHICAGO EYE, EAR, NOSE AND<br />
+THROAT COLLEGE; ASSISTANT SURGEON, ILLINOIS<br />CHARITABLE EYE AND EAR INFIRMARY;<br />
+OPHTHALMIC SURGEON, OAK<br />PARK HOSPITAL.</h4>
+
+<p class="tbrk">&nbsp;</p>
+
+<h4>1914<br />CHICAGO MEDICAL BOOK COMPANY<br />CHICAGO</h4>
+
+<hr />
+
+<p><span class='pagenum'><a name="Page_2" id="Page_2">[Pg 2]</a></span></p>
+
+<p class="tbrk">&nbsp;</p>
+
+<h4><span class="smcap">Copyright</span> 1914<br />
+<span class="smcap">BY</span><br /><span class="smcap">Chicago Medical Book Company</span></h4>
+
+<p class="tbrk">&nbsp;</p>
+
+<hr />
+
+<p><span class='pagenum'><a name="Page_3" id="Page_3">[Pg 3]</a></span></p>
+
+<h2>CONTRIBUTORS</h2>
+
+<p><span class="smcap">Edward Jackson</span>, A.M., M.D.<br />Prof. Ophth. Univ. Colo.; Emer. Prof. Ophth.
+Phila. Polyclinic; Ex-Ch. Sec. Ophth. A.M.A.; Ex-Pres. Am. Acad. Med.
+and Am. Acad. Ophth. and Oto-Laryng.; Mem. Am. Ophth. Soc. and Honorary
+Mem. Chicago Ophth. Society.</p>
+
+<p><span class="smcap">John Elmer Weeks</span>, M.D., D.Sc.<br />Prof. Ophth. Univ. and Bellevue Hosp. Med.
+Coll., N.Y.; Ophth. Surg. N.Y. Eye and Ear Inf.; Mem. Am. Ophth. Soc.;
+Hon. Mem. Chicago Ophth. Soc. and Royal Hungarian Med. Soc. Budapest.</p>
+
+<p><span class="smcap">George Edmund de Schweinitz</span>, A.M., LL.D., M.D.<br />Prof. Ophth. Univ. Penn.;
+Ophth. Surg. Univ. Hosp., Phila. Hosp., Orthop. Hosp. and Inf. for Nerv.
+Dis.; Consult. Ophth. Surg, Phila. Polyclinic; Honorary Member Chicago
+Ophth. Soc.</p>
+
+<p><span class="smcap">Robert Henry Elliot</span>, M.D., B.S. <span class="smcap">Lond</span>., Sc.D. <span class="smcap">Edin</span>., F.R.C.S. <span class="smcap">Eng.</span>, <span class="smcap">Etc.</span>,
+<span class="smcap">Lieut.-Colonel</span>, I.M.S.<br />Supt. Gov. Ophth. Hosp., Madras. India; Prof.
+Ophth. Med. Coll., Madras; Fellow Univ. of Madras; Honorary Member
+Chicago Ophthalmological Society, U.S.A.</p>
+
+<p><span class="smcap">Casey A. Wood</span>, M.D., C.M., D.C.L.<br />Prof. Ophth. Univ. Ill.; Late Prof.
+Ophth. N. W. Univ.; Ex-Pres. Am. Acad. of Med.; Am. Acad. Ophth. and of
+the Chicago Ophth. Soc.; Ophthalmic Surg. St. Luke's Hosp.; Consulting
+Ophth. Surg. St. Luke's and Cook County Hosp.; Ex-Ch. Ophth. Sec.
+A.M.A.; Editor System Ophth. Therapeutics. Sys. Ophth. Operations and
+American Encylopedia Ophthalmology.</p>
+
+<p><span class="smcap">Francis Lane</span>, A.B., M.D.<br />Pathologist and Asst. Ophthalmic Surgeon Ill.
+Char. Eye and Ear Inf.; Instructor in Ophth. Rush Med. Coll.; Asst,
+Ophth. Surg. Presbyterian Hospital.</p>
+
+<p>E. V. L. <span class="smcap">Brown</span>, M.D.<br />Asst. Prof. Pathology of the Eye, Univ. Chicago;
+Asst. Prof. Ophth. Rush Med. College; Ophth. Surg. Ill. Eye and Ear Inf.
+and Cook County Hosp.; Mem. Am. Ophth. Soc.</p>
+
+<p><span class="smcap">Nelson M. Black</span>, <span class="smcap">Ph</span>.G., M.D.<br />Author of The Development of the Fusion
+Center in the Treatment of Strabismus; Examination of the Eyes of
+Transportation Employes; Artificial illumination a Factor in Ocular
+Discomfort, etc.</p>
+
+<p><span class="smcap">Frank C. Todd</span>, M.D.<br />Prof. Ophth. and Oto-Laryng., Univ. Minn.; Chairman
+Sec. Ophth. A.M.A. and second Vice-Pres. A.M.A.; Ophth. Surg. Univ. and
+Hill Crest Hospital.</p>
+
+<p><span class="smcap">Albert Eugene Bulson, Jr.</span>, B.S., M.D.<br />Prof. Ophth. Ind. School Med.;
+Ex-Ch. Sec. Ophth. A.M.A.; Ophth. Surg. St. Joseph's Hospital; Editor
+Jour. Ind, Slate Med. Assn.</p>
+
+<hr />
+
+<p><span class='pagenum'><a name="Page_4" id="Page_4">[Pg 4]</a></span></p>
+
+<p class="center"><span class="smcap">Dedicated To<br />
+Dr. Edward Jackson<br />Dr. John E. Weeks<br />Dr. George Edmund de Schweinitz<br />
+Lieutenant Colonel Robert Henry Elliot<br />Honorary Members</span><br />
+<span class="smaller">BY THE</span><br /><span class="smcap">Chicago Ophthalmological Society<br />
+In Recognition Of<br />Their Splendid Achievements<br />In the Domain of Ophthalmology</span></p>
+
+<hr />
+
+<h2>INDEX</h2>
+
+<div class="index">
+<ul>
+<li><a href="#ABSTRACTS">ABSTRACTS.</a></li>
+<li><a href="#Etiology_and_Classification_of_Glaucoma"><span class="smcap">Etiology and Classification of Glaucoma</span>,</a>
+<ul>
+	<li class="subitem"><i>Edward Jackson, M.D.</i></li>
+</ul></li>
+<li><a href="#Dr_Edward_Jacksons_Paper_on_Etiology_and_Classification_of_Glaucoma"><span class="smcap">Etiology and Classification of Glaucoma</span>,</a>
+<ul>
+	<li class="subitem">Discussion, <i>Francis Lane, M.D.</i></li>
+</ul></li>
+<li><a href="#Pathology_of_Glaucoma"><span class="smcap">Pathology of Glaucoma</span>,</a>
+<ul>
+	<li class="subitem"><i>John Elmer Weeks, M.D.</i></li>
+</ul></li>
+<li><a href="#Dr_John_E_Weeks_Paper_on_Pathology_of_Glaucoma"><span class="smcap">Pathology of Glaucoma</span>,</a>
+<ul>
+	<li class="subitem">Discussion, <i>E. V. L. Brown, M.D.</i></li>
+</ul></li>
+<li><a href="#Concerning_Non-Surgical_Measures_for_the_Reduction_of_Increased"><span class="smcap">Concerning Non-surgical Measures for the Reduction of Increased Intra-Ocular Tension</span>,</a>
+<ul>
+	<li class="subitem"><i>George Edmund de Schweinitz, M.D.</i></li>
+</ul></li>
+<li><a href="#Dr_George_Edmund_de_Schweinitz_Paper_on_Concerning_Non-Surgical"><span class="smcap">Concerning Non-surgical Measures for the Reduction of Increased Intra-Ocular Tension</span>,</a>
+<ul>
+	<li class="subitem">Discussion, <i>Nelson Miles Black, M.D.</i></li>
+</ul></li>
+<li><a href="#Trephining_for_Glaucoma"><span class="smcap">Trephining for Glaucoma</span>,</a>
+<ul>
+	<li class="subitem"><i>Robert Henry Elliot, M.D.</i></li>
+</ul></li>
+<li><a href="#Dr_Robert_Henry_Elliots_Paper_on_Trephining_for_Glaucoma"><span class="smcap">Trephining for Glaucoma</span>,</a>
+<ul>
+	<li class="subitem">Discussion, <i>Frank C. Todd, M.D.</i></li>
+</ul></li>
+<li><a href="#Operations_Other_than_Scleral_Trephining_for_the_Relief_of_Glaucoma"><span class="smcap">Operations Other Than Scleral Trephining for the Relief of Glaucoma</span>,</a>
+<ul>
+	<li class="subitem"><i>Casey A. Wood, M.D.</i></li>
+</ul></li>
+<li><a href="#Dr_Casey_A_Woods_Paper_on_Operations_Other_than_Scleral_Trephining"><span class="smcap">Operations Other Than Scleral Trephining for the Relief of Glaucoma</span>,</a>
+<ul>
+	<li class="subitem">Discussion, <i>Albert E. Bulson, Jr., M.D.</i></li>
+</ul></li>
+</ul>
+</div>
+
+<hr />
+
+<p><span class='pagenum'><a name="Page_5" id="Page_5">[Pg 5]</a></span></p>
+
+<h2><a name="ABSTRACTS" id="ABSTRACTS"></a>ABSTRACTS.</h2>
+
+<p>I. Etiology and Classification of Glaucoma.</p>
+
+<blockquote><p>Abstract:&mdash;</p>
+
+<blockquote><p>Etiologic factors include: obstruction of lymph spaces, especially the
+angle of the anterior chamber; blood pressure, arterial, capillary and
+venous; affinity of tissues for fluids; alterations of the intra-ocular
+fluids; inflammations in the eye ball; and failure of a nerve apparatus
+to control fluid in the globe. Classification: various types of glaucoma
+constituting clinical entities must be recognised, as: simple glaucoma,
+recurring exacerbations, congestive, mechanical, and increased tension
+arising during uveal inflammations.</p>
+
+<p>DR. EDWARD JACKSON, Denver.</p></blockquote></blockquote>
+
+<p>Discussion by <span class="smcap">Dr. Francis Lane</span>, Chicago.</p>
+
+<p class="tbrk">&nbsp;</p>
+
+<p>II. Pathology of Glaucoma.</p>
+
+<blockquote><p>Abstract:&mdash;</p>
+
+<blockquote><p>(a) Changes taking place in corneal tissue.</p>
+
+<p>(b) Iris angle with particular reference to the ligamentum pectinatum.</p>
+
+<p>(c) Variations in the condition of the ciliary body.</p>
+
+<p>(d) Consideration of the anatomical changes that take place in glaucoma
+secondary to retinal and chorioidal hemorrhage.</p>
+
+<p>DR. JOHN E. WEEKS, New York City.</p></blockquote></blockquote>
+
+<p>Discussion by <span class="smcap">Dr. E. V. L. Brown</span>, Chicago.</p>
+
+<p class="tbrk">&nbsp;</p>
+
+<p><span class='pagenum'><a name="Page_6" id="Page_6">[Pg 6]</a></span></p>
+
+<p>III. Concerning Non-surgical Measures for the Reduction of Increased
+Intra-ocular Tension.</p>
+
+<blockquote><p>Abstract:&mdash;</p>
+
+<blockquote><p>(a) The use of myotics; their preparation, method of administration, and
+explanation of their action.</p>
+
+<p>(b) Reduction of increased intra-ocular tension by means of various
+mechanical measures, notably massage, vibration massage, suction
+massage, electricity and diathermy.</p>
+
+<p>(c) Indirect reduction of increased intra-ocular tension, brought about
+by lowering the general vascular pressure.</p>
+
+<p>(d) The relation of osmosis, lymphagogue activity, the absorption of
+edema, the stimulation of capillary contractility, and the lowering of
+the affinity of ocular colloids for water in their relation to the
+reduction of increased intra-ocular tension.</p>
+
+<p>DR. GEORGE EDMUND DE SCHWEINITZ, Philadelphia.</p></blockquote></blockquote>
+
+<p>Discussion by <span class="smcap">Dr. Nelson M. Black</span>, Milwaukee.</p>
+
+<p class="tbrk">&nbsp;</p>
+
+<p>IV. Trephining for Glaucoma.</p>
+
+<blockquote><p>Abstract:&mdash;</p>
+
+<blockquote><p>(a) The aim of the operation is the formation of a foreign-body-free
+fistula.</p>
+
+<p>(b) It is most important to leave uveal tissue untouched.</p>
+
+<p>(c) Method of doing this explained.</p>
+
+<p>(d) The area available for trephining.</p>
+
+<p>(e) Method of increasing that area.</p>
+
+<p>(f) Cornea splitting.</p>
+
+<p>(g) Placing of trephine.</p>
+
+<p>(h) Technique of using trephine.</p>
+
+<p>(i) The operation is not difficult.</p>
+
+<p>(j) The operation valuable as a prophylactic measure.</p>
+
+<p>DR. ROBERT H. ELLIOT, F.R.C.S., Lieut.-Col. I.M.S., Madras, India.</p></blockquote></blockquote>
+
+<p>Discussion by <span class="smcap">Dr. Frank C. Todd</span>, Minneapolis.</p>
+
+<p class="tbrk">&nbsp;</p>
+
+<p><span class='pagenum'><a name="Page_7" id="Page_7">[Pg 7]</a></span></p><p>V. Operations Other than Scleral Trephining for the Relief of Glaucoma.</p>
+
+<blockquote><p>Abstract:&mdash;</p>
+
+<blockquote><p>Most of the ordinary surgical procedures employed for lowering
+intra-ocular tension furnish a permanent cure of certain fairly well
+defined varieties of glaucoma. They also relieve the symptoms and retard
+the progress of other varieties of the disease, even if they do not
+perform a cure. In a third class of cases, they either have no effect
+whatever in arresting the disease or they hasten its march towards
+blindness.</p>
+
+<p>What operative procedure gives, on the whole, the best results? In other
+words, what operation is the easiest of performance, is the least likely
+to be attended by serious complications and is available for the largest
+number of cases? Reasons for believing that of the better known
+procedures simple iridectomy is the least effective, while those
+interventions producing a large, thin, scleral filtration-cicatrix are
+the most valuable.</p>
+
+<p>DR. CASEY A. WOOD, Chicago.</p></blockquote></blockquote>
+
+<p>Discussion by <span class="smcap">Dr. A. E. Bulson, Jr.</span>, Fort Wayne<span class='pagenum'><a name="Page_8" id="Page_8">[Pg 8]</a></span></p>
+
+<hr />
+
+<p><span class='pagenum'><a name="Page_9" id="Page_9">[Pg 9]</a></span></p>
+
+<h2><a name="Etiology_and_Classification_of_Glaucoma" id="Etiology_and_Classification_of_Glaucoma"></a>Etiology and Classification of Glaucoma</h2>
+
+<h4>BY</h4>
+
+<h3><span class="smcap">Edward Jackson</span>, M.D.,<br />Denver.</h3>
+
+<p>It is convenient to start with the conception that glaucoma is increased
+tension of the eyeball, plus the causes and effects of such increase;
+although a broad survey of the facts may reveal a clinical entity to be
+called glaucoma, without increased tension constantly or necessarily
+present, and cases of increased intra-ocular tension not to be classed
+as glaucoma.</p>
+
+<p>The physiologic tension of the eyeball is essential to ocular
+refraction, and closely related to ocular nutrition. Fully to understand
+the mechanism for its regulation would carry us far toward an
+understanding of the causes of glaucoma. Normal<span class='pagenum'><a name="Page_10" id="Page_10">[Pg 10]</a></span> tension is maintained
+with a continuous flow of fluid into the eye and a corresponding
+outflow. Complete interruption of the nutritional stream would be speedy
+death; partial interruption may be held responsible for most of the
+visual impairment and pain of glaucoma.</p>
+
+<p>The balance of intra-ocular pressure is not maintained by the slight
+distensibility of the sclero-corneal coat. Increased pressure does not
+open new channels for the escape of intra-ocular fluid; if, indeed, it
+does not tend to close the normal channels.</p>
+
+<p>The affinity of the tissues for water, or, as Fischer explains it, the
+affinity of the tissue colloids for water, seems too little related to
+the requirements of ocular function to furnish the needed regulation of
+tension. The lymph spaces and blood-channels of the eye are large, as
+compared with the mass of its tissue colloids. In these spaces and
+channels must be sought a means for rapid response to the need for
+regulation of intra-ocular tension. Fischer<span class='pagenum'><a name="Page_11" id="Page_11">[Pg 11]</a></span> has shown, that when the
+enucleated eyeball is placed in a weak solution of hydrochloric acid,
+the swelling of the tissue colloids is sufficient in a few hours, to
+burst the sclero-corneal coat. But this is an eye in which all
+nutritional changes have ceased. He brings together many facts to
+support the view that in the living tissues impaired circulation, and
+especially diminished oxidation, are the chief causes of increased
+affinity of the colloids for water. Such affinity increased by the
+impairment of the intra-ocular circulation, may well constitute a factor
+making for malignancy in glaucoma. But it can hardly explain the
+original departure from a normal pressure balance.</p>
+
+<p>We must assume that intra-ocular pressure is kept down to the normal
+limit, by the prompt response of a regulative mechanism, which
+diminishes the flow of fluid into the eye, or permits its more rapid
+escape, whenever fluid tends to accumulate in the eye and increase its
+tension.</p>
+
+<p>Little has been done to show that <span class='pagenum'><a name="Page_12" id="Page_12">[Pg 12]</a></span>increase of fluid entering into the
+eye is the cause of glaucoma. A normal, or even a low arterial blood
+pressure is sufficiently above the normal intra-ocular pressure to
+furnish a source of increased fluid in the eye. Increased arterial
+pressure has been found in a large proportion of cases of glaucoma; and
+may be necessary to the production of the highest intra-ocular tension.
+A sudden relaxation of the arterial walls, that would permit the
+arterial blood pressure to make itself felt in the eye, might cause an
+important rise of intra-ocular tension and may be a factor in the
+etiology of acute attacks. It affords a possible mechanism through which
+may be produced the recognized glaucomatous effects of certain nerve
+disturbances. But such attacks are not commonly associated with
+noticeable flushing of the head and face generally; and paralysis of the
+cervical sympathetic is known to lower the intra-ocular tension.</p>
+
+<p>Capillary blood pressure must lie between the arterial blood pressure
+and the<span class='pagenum'><a name="Page_13" id="Page_13">[Pg 13]</a></span> venous blood pressure. It must be closely associated with the
+nutritional processes like secretion or inflammation; beyond this we
+know little about it. The association of increased blood pressure with
+glaucoma seems to be generally an indirect one through vascular lesions
+and disturbances of nutrition.</p>
+
+<p class="center"><br /><i>Obstructed Outflow</i></p>
+
+<p>A reservoir with a free outlet can only fill during a flood; and then
+quickly empties itself again. The outflow channels in the normal eye
+provide for carrying away of the waste products of such an active
+nutrition, that it is hard to think they will become inadequate in
+glaucoma until there has been a marked decrease from their normal
+capacity. Priestley Smith has pointed out that the glaucomatous eye
+softens more slowly than the normal eye after enucleation, in spite of
+the fact that a greater force is operating to drive fluid out of the
+eye. In his recent tonometric studies Schoenberg<span class='pagenum'><a name="Page_14" id="Page_14">[Pg 14]</a></span> noted that under
+manipulation the glaucomatous eye softened more slowly than the normal
+eye; and suggests this diminished drainage as an important evidence of
+glaucoma.</p>
+
+<p>Obstructed outflow might begin in an abnormal tendency of the tissues to
+retain fluid, a tendency that Fischer might locate in the colloids. The
+increase of intra-ocular pressure noted in cases of uveal inflammation,
+to be presently referred to, may be due to some such tendency. But it is
+rational to ascribe to obstruction of the filtration angle of the
+anterior chamber, the important part it has been supposed to play in the
+pathology of glaucoma. However this obstruction may be brought about,
+whether by thickening of the iris root during dilatation of the pupil,
+pushing forward of the iris root by the larger ciliary processes of age,
+or the enlarged crystalline lens pressing on the ciliary processes; or
+by inflammatory adhesion of the iris to the filtration area; ballooning
+of the iris, or its <span class='pagenum'><a name="Page_15" id="Page_15">[Pg 15]</a></span>displacement by traumatic cataract; or adhesion to
+the cornea after perforating ulcer in the secondary glaucomas; or
+whether the obstruction is due to the accumulation of experimental
+precipitates, as shown by Schreiber and Wengler, or possibly of pigment
+granules into Fontana's space; or a process of sclerosis closing the
+spaces by contraction of new-formed connective tissue, or the covering
+over with proliferating implanted epithelium following injury opening
+the anterior chamber; glaucoma follows impairment of this drainage
+space, and lessened outflow through it. This blocking of the angle of
+the anterior chamber must be regarded as an established fact in the
+etiology of glaucoma. But because it is so definitely established, and
+because so much work has been done with reference to it, we may attach
+to it an undue importance.</p>
+
+<p>The escape of the outflow of fluid from the eye is ultimately through
+the veins. The general venous blood pressure is so<span class='pagenum'><a name="Page_16" id="Page_16">[Pg 16]</a></span> low (often negative
+in the great veins of the neck during inspiration) that no obstacle can
+come from it to the ocular outflow. The venous blood pressure permits
+the eyeball to become perfectly soft. We have all seen tension of 5 mm.,
+or even less; and general venous pressure does not rise to the normal
+intra-ocular tension. Increased intra-ocular pressure requires that
+there must be some obstacle that keeps the intra-ocular fluid from
+reaching the general venous system. This may be in the lymph drainage
+system of the eye; but it may also be in the ocular veins themselves.</p>
+
+<p>Experimentally the eyeball can be made to burst by tying all the venous
+outlets from it. I have seen very high intra-ocular tension develop in a
+few hours after general thrombosis of the orbital veins. The absence of
+the canal of Schlemm is noted in congenital buphthalmos. The enlargement
+of the anterior perforating veins is an old symptom of chronic glaucoma.
+Obstruction to outflow of blood through the <span class='pagenum'><a name="Page_17" id="Page_17">[Pg 17]</a></span>vorticose veins, by the
+increased intra-ocular pressure, has long been a recognized explanation
+of the malignant tendency of glaucoma&mdash;a part of the vicious circle
+established in this disease. There is reason that we should give careful
+attention to the views of Heerfordt and Zirm, that obstruction to the
+venous outflow may be the effective cause of the disease. Zirm believes
+the venous plexus of the choroid is an essential part of the mechanism
+for the regulation of intra-ocular tension, the necessary vaso-motor
+control depending on nerve centers situated in the iris.</p>
+
+<p class="center"><br /><i>Nerve Control</i></p>
+
+<p>The accurate control of normal intra-ocular pressure, by mutual
+adjustment of inflow and outflow of fluid, is scarcely conceivable
+without some highly specialized, extremely sensitive nerve mechanism to
+preside over it. This is suggested by analogy with the regulation of
+secretion in the lacrimal, salivary, or peptic glands, or the<span class='pagenum'><a name="Page_18" id="Page_18">[Pg 18]</a></span>
+maintenance of blood pressure in the heart and arteries. Clinical
+observations point the same way. Many patients connect their attacks
+(especially their earlier ones of ocular discomfort, impaired vision,
+haloes around the light, and dilated pupil) with social excitement,
+anxiety, worry, anger or fatigue. A patient of mine gave up her card
+parties, because an exciting game generally ended in blurred vision, a
+rainbow around the light, and a dilated pupil, and sometimes an aching
+eye. Another woman watching beside her dying husband and exposed to
+extreme cold, had her first attack of glaucoma, so severe as to destroy
+the sight of one eye. The other eye, also affected at the time,
+recovered good vision, and has remained several years without a second
+attack and without treatment.</p>
+
+<p>Laqueur's first attack occurred at the end of a long exhausting morning
+in the operating room, with luncheon delayed two hours. The connection
+of his later attacks with anger, worry, embarrassment, even the
+<span class='pagenum'><a name="Page_19" id="Page_19">[Pg 19]</a></span>excitement of watching a play at the theatre, was noted again and
+again. In Javal's case, the attack fatal to one eye came at the
+culmination of an exciting electoral campaign. The other eye was
+stricken at the termination of the Dreyfus case, in which Javal was
+intensely interested. There seems to be a special liability to glaucoma
+among those residing at high altitudes, best explained by nerve
+influence. The frequency of glaucoma among Jews may be due to a small
+cornea, as suggested by Priestley Smith; but it is quite as reasonable
+to connect it with a racial excitability or nervous instability. More
+definite knowledge of the nervous mechanism concerned in the regulation
+of intra-ocular pressure and the production of glaucoma is much needed.</p>
+
+<p class="center"><br /><i>Alterations of Fluids and Tissues</i></p>
+
+<p>The influence of increased affinity of the tissues for fluid has already
+been referred to. That a similar obstacle to the escape of<span class='pagenum'><a name="Page_20" id="Page_20">[Pg 20]</a></span> fluid from
+the eyeball might be due to a change of character in the fluid, is a
+conception that has been entertained as a working hypothesis, and much
+experimental and analytical work has been done to test its correctness.
+This work has been so slightly related to practical ophthalmology, and
+so contradictory in its results that alterations in the fluids can only
+be regarded as a possible etiologic factor. Glaucoma secondary to
+intra-ocular hemorrhage, operations on the lens or its capsule, or
+severe nutritional disturbance may be capable of such explanation.</p>
+
+<p class="center"><br /><i>Different Kinds of Glaucoma</i></p>
+
+<p>A better grasp of the etiology of glaucoma may be attained by
+considering separately various types of cases; although perfectly
+typical cases may be rare; and cases of mixed type and etiology much
+more frequent.</p>
+
+<p>Simple glaucoma has been recognized as closely related to atrophy of the
+optic nerve with deep excavation. No line of <span class='pagenum'><a name="Page_21" id="Page_21">[Pg 21]</a></span>demarcation can be drawn
+between them, except by reserving the term of glaucoma for cases that
+depart from the pure type, terminating in glaucoma of some other kind,
+which is no more significant than the passage of a conjunctivitis into a
+keratitis, or an iritis into a glaucoma. Cases of simple glaucoma do run
+their course of many years to complete blindness, or to death, without
+exacerbations, inflammation, or characteristic pain. In such cases the
+intra-ocular tension does not rise suddenly; and it may be little or not
+at all elevated above the usual normal limit.</p>
+
+<p>For nine years I have watched the progress of such a glaucoma in a man
+now aged 87, with slow development of glaucomatous cupping of the optic
+disc, now more than 3 D. deep. The tension has never been noted at more
+than Plus T (?), and when taken with the tonometer varied from 9 to 32
+mm. for the worse eye, and 13 to 24 mm. for the other. Similar cases in
+which the tension lay within the commonly accepted<span class='pagenum'><a name="Page_22" id="Page_22">[Pg 22]</a></span> normal limits have
+been reported recently by Bietti and Stock.</p>
+
+<p>In the eye there is probably a normal equilibrium between blood
+pressure, tissue activity, and intra-ocular tension. This may be
+destroyed either by increasing the intra-ocular tension, or lowering the
+tissue activity, or the blood pressure. Lowered blood pressure has been
+suggested by Paton as an explanation of symptoms usually ascribed to
+vascular obstruction. Rising blood pressure may be required in old age
+to compensate for diminished tissue activity; and it is conceivable,
+under normal intra-ocular tension, that diminished nutritional activity
+may result in the same symptoms as are produced in other eyes by
+increased tension. Glaucoma is probably not so much an increase of
+tension as a loss of balance between intra-ocular tension and
+nutritional activity.</p>
+
+<p>In contrast with the above are the cases marked by sudden elevations of
+ocular tension recurring repeatedly over long periods<span class='pagenum'><a name="Page_23" id="Page_23">[Pg 23]</a></span> without permanent
+visual impairment. Laqueur's case continued of this character for six
+years, under the use of miotics, and then was cured by iridectomy, the
+cure remaining permanent with normal vision until his death after 30
+years. Millikin has reported the case of a patient who in five years had
+"many hundreds" of attacks, in which vision was impaired, haloes
+appeared about the light, the pupil dilated, the cornea became steamy,
+and tension rose to plus T. 1 or plus T. 2. After iridectomy the attacks
+ceased, leaving no pathological cupping of the disc, full vision, and a
+good field. I have seen cases of this type in women under middle age,
+and of marked nervous instability.</p>
+
+<p>A third type which will come to be more generally recognized, as the
+tonometer comes to be more widely used, includes cases in which there is
+little beside the increase of intra-ocular tension to justify their
+mention in a discussion on glaucoma. A patient, then aged 21, suffered
+three<span class='pagenum'><a name="Page_24" id="Page_24">[Pg 24]</a></span> years ago from a scotoma almost central; and was first seen six
+months after that with a macular choroidal atrophy and abnormal
+pigmentation. She suffered, we afterwards concluded, from choroidal
+tuberculosis. A recurrence involving adjoining choroid occurred fourteen
+months ago. There was at the start pain, slight dilatation of the pupil,
+and slight general hyperemia of the globe. The tension of the eyeball
+rose to 60 mm., that of the fellow eye being 20 mm. Under miotics the
+tension fell at first but slightly. It was 55 mm. at the end of a week;
+but after two weeks came down to normal, 20 mm. A month later the
+tension rose to 28 mm., but for a year has continued normal; the eye did
+well under tuberculin treatment, and without any local treatment. In
+September of this year I had two cases of iritis in which the
+intra-ocular tension rose to 45 and 52 mm., respectively, and gradually
+returned to normal, with the cure of the iritis under atropine. In one
+of these cases, a lady of 70,<span class='pagenum'><a name="Page_25" id="Page_25">[Pg 25]</a></span> I used atropine also in the other eye,
+but the tension of that eye remained normal, 22 to 24 mm., throughout.
+After needling the lens in young people I have seen a rise of
+intra-ocular tension to 50 and 60 mm., maintained for many days, with
+considerable general deep hyperemia, and soreness of the globe, followed
+by gradual return to normal tension, and no permanent impairment of
+vision or the visual field.</p>
+
+<p>One other type may be mentioned. That of an elderly patient with marked
+vascular disease, often renal involvement, and distinctly impaired
+nutrition. There may be renal retinitis or retinal hemorrhages. The case
+may easily become one of hemorrhagic glaucoma. It may run a very chronic
+course. But it may become suddenly worse, or go on to complete blindness
+with pain, demanding enucleation, after some temporary perturbation, as
+the performance of a glaucoma operation. It is pre-eminently the kind of
+a case you would prefer would go to some one else.</p>
+
+<p><span class='pagenum'><a name="Page_26" id="Page_26">[Pg 26]</a></span></p><p>Each of these types illustrate a distinct cause or group of causes. The
+first type brings us near to what may be the essential nature of
+glaucoma, impairment of ocular nutrition by the intra-ocular tension,
+which is generally elevated, but may not be above the usual normal. A
+special weakness in the nutrition of nerve tissue may be assumed. It
+would help to explain the cavernous atrophy of the optic nerve
+associated with simple glaucoma. The second type shows impairment of the
+regulative mechanism permitting rapid rise of the intra-ocular pressure.
+In persons of good nerve nutrition and strong recuperative power, it may
+exist for years without doing permanent damage. But joined to causes of
+the first type, lowered nutritive activity, it causes rapid and
+permanent loss of sight. The third group are cases associated with
+glaucoma only as causes. In eyes with low nutritive power, or subject to
+exacerbations of increased intra-ocular pressure, uveal inflammations
+may prove disastrous. The<span class='pagenum'><a name="Page_27" id="Page_27">[Pg 27]</a></span> fourth type shows the results of the
+combination of the causes of the other types; with the elements of acute
+or slow malignancy added&mdash;the impaired circulation and lowered oxidation
+producing some degree of edema of the tissues that insures a fatal
+result.</p>
+
+<p>This is no complete presentation of my subject, but a selection of facts
+bearing on the etiology, to serve as a foundation for the discussion of
+those practical aspects of glaucoma which are to claim your attention
+through the papers and remarks of subsequent speakers.</p>
+
+<hr />
+
+<p><span class='pagenum'><a name="Page_28" id="Page_28">[Pg 28]</a></span></p>
+
+<h2><a name="Dr_Edward_Jacksons_Paper_on_Etiology_and_Classification_of_Glaucoma" id="Dr_Edward_Jacksons_Paper_on_Etiology_and_Classification_of_Glaucoma"></a>Dr. Edward Jackson's Paper on Etiology and Classification of Glaucoma</h2>
+
+<h3>Discussion,<br /><span class="smcap">Francis Lane</span>, M.D.<br />Chicago.</h3>
+
+<p>Not one of the theories thus far propounded to explain the essential
+cause of increased intra-ocular tension is satisfactory. Our present day
+knowledge apparently ceases with a more or less incomplete understanding
+of the mere circumstance under which increase of tension in general
+depends.</p>
+
+<p>The question of the source of the normal intra-ocular pressure must
+first be solved before any discussion of a pathological increase can be
+engaged in. This question primarily hinges on whether the corneo-sclera
+is to be regarded as an unelastic capsule with a fixed volume, or as a
+yielding<span class='pagenum'><a name="Page_29" id="Page_29">[Pg 29]</a></span> envelope with an ever changing capacity.</p>
+
+<p>This brings us at once to the consideration of that theory which
+probably has held our attention for the longest period of time, <i>i. e.</i>,
+the volumetric theory. According to it, the normal intra-ocular tension
+depends on the volume of fluids within the eyeball. Any variation in the
+quantity of the contents gives rise to a change in the pressure,
+therefore, the globe has been regarded as "an elastic capsule, whose
+capacity, form, and internal pressure depend on the balance struck
+between a constant inflow, or formation of aqueous, and a proportionate
+outflow or resorption." (Henderson.)</p>
+
+<p>Hill has satisfactorily demonstrated that, under physiological
+conditions, the hydrostatic pressure within the eye and the skull is
+identical; it rises and falls simultaneously; it is the same as the
+cerebral venous pressure; it is constantly varying, depending directly
+on the general circulation. Upon these findings Henderson based his
+opinion that the physiological properties of the tunica<span class='pagenum'><a name="Page_30" id="Page_30">[Pg 30]</a></span> fibrosa and the
+skull are identical, realizing at the same time, that the rigidity of
+the corneo-sclera, because of its fibrous nature, is not as firm as the
+cranium. In accepting this belief the inference was that the cubic
+capacity of both coverings is fixed. Applying these conclusions to the
+eye, it can be said that the pressure of the fixed intra-ocular volume
+varies with the venous tension within the bulb, which in turn is
+influenced by the general circulation. Such a conception, while not
+strictly in accord with recognized physiological teachings, proves that
+the normal intra-ocular pressure is not a question of volume content,
+but that it is purely a question of pressure of a fixed volume within an
+unyielding capsule. Dr. Jackson virtually puts aside the volumetric
+theory with his statement, that "the balance of intra-ocular pressure is
+not maintained by the slight distensibility of the sclero-corneal coat."
+Further discussion on the inadequacy of the volumetric theory need not
+detain us.</p>
+
+<p><span class='pagenum'><a name="Page_31" id="Page_31">[Pg 31]</a></span></p><p>It is well to recall a few anatomical features because of their bearing
+on the theories herein considered.</p>
+
+<p>1. The angle of the anterior chamber is a true angle and not an annular
+sinus.</p>
+
+<p>2. The meshwork of the iris angle (ligamentum pectinatum), a cellular
+structure at birth, undergoes a progressive and physiological fibrosis
+with early subsequent sclerosis, until finally it becomes a fibrous
+structure. The individual strands of this meshwork are more than two
+times as large at advanced age as at birth, consequently the alveoli of
+the meshwork becomes markedly reduced in size.</p>
+
+<p>3. The spongy nature of this meshwork affords free access of aqueous to
+the venous sinus of Schlemm, thence by tributaries into the
+supra-choroidal space and anterior uveal venous system.</p>
+
+<p>4. Fuchs's iris cripts afford direct access of aqueous to the veins of
+the iris.</p>
+
+<p>Furthermore, two simple principles are taught by physics: Fluids are
+<span class='pagenum'><a name="Page_32" id="Page_32">[Pg 32]</a></span>incompressible and they seek the lowest hydrostatic level. The
+application of these perfectly obvious principles to the eyeball makes
+the intra-ocular pressure the same as that within the elastic venous
+walls, which is the lowest circulating pressure within the bulb.</p>
+
+<p>To summarize: The aqueous has direct access to the anterior uveal venous
+system; the physiological thickening of the strands of the meshwork of
+the iris angle supplies a mechanical obstruction between the anterior
+chamber and the venous sinus of Schlemm; intra-ocular pressure stands at
+the same level as the intra-venous, consequently, the hydrostatic
+pressure is the same on both sides of the iris angle meshwork, because
+the canal of Schlemm is a secondary venous system; lastly, the outflow
+of aqueous into the venous sinus is by diffusion, not by filtration,
+because the pressure is the same on both sides of the meshwork.</p>
+
+<p>These facts and deductions have given rise to the present day
+circulatory theory of intra-ocular pressure, so we now can <span class='pagenum'><a name="Page_33" id="Page_33">[Pg 33]</a></span>approach the
+predisposing and exciting factors which determine glaucoma.</p>
+
+<p>The central fact to be borne in mind is, if the physiological pressure
+is vascular in origin and nature, the pathological pressure must
+likewise be derived from the same source.</p>
+
+<p>Sclerosis of the meshwork of the iris angle is the predisposing factor
+because it hinders free access of aqueous into the venous sinus of
+Schlemm. Sclerosis alone, however, will not cause glaucoma so long as
+access to the iris veins can keep the intra-ocular pressure at the
+intra-venous level, and, too, as long as the exciting cause is absent.</p>
+
+<p>The exciting cause is vascular, maintained and influenced by the general
+circulatory pressure. A rise of the general vascular tension alone will
+not cause glaucoma, because any alteration in intra-ocular pressure
+resulting would be purely a temporary change, easily taken care of by
+the extensive access of aqueous to the intra-ocular venous system. When
+these two <span class='pagenum'><a name="Page_34" id="Page_34">[Pg 34]</a></span>factors coexist in their varying combinations, pathological
+increase of pressure results&mdash;in short, glaucoma.</p>
+
+<p>Syphilis, rheumatism, gout, auto-intoxication and many other
+constitutional disorders are well recognized agencies which induce
+sclerosis in body tissues, so there can be little doubt that these
+conditions produce pathological sclerosis of the meshwork of the iris
+angle. Psychic disturbances, congested portal or renal system, hard
+mental or muscular work, etc., etc., induce increased pressure of the
+general circulation, and so simultaneously the intra-ocular pressure.</p>
+
+<p>According to the edema theory advanced by Fischer, glaucoma is
+"essentially an edema of the eyeball, and for its production we must
+hold responsible the same circumstances which are responsible for a
+state of edema in any other part of the body." The magnificent
+experimental work of this investigator has shown that edema is nothing
+more or less than an increased capacity of<span class='pagenum'><a name="Page_35" id="Page_35">[Pg 35]</a></span> the protein colloid tissues
+for water; that the most important factor leading to this increased
+hydration capacity is an abnormal production or accumulation of acid
+content, effected by those agencies which are instrumental in causing
+sclerosis and an increase of blood pressure.</p>
+
+<p>It seems that both of these theories afford an explanation for many of
+the secondary pathological manifestations which characterize the
+intra-ocular tissues during a glaucomatous onset.</p>
+
+<p>Fischer criticizes the Henderson theory on the ground that increased
+blood pressure alone does not lead to edema&mdash;edema is thwarted by high
+blood pressure. On the other hand, if Fischer believes that sclerosis of
+the meshwork of the iris angle is a result and not a cause of glaucoma,
+then it would seem that Henderson has the better of the argument. The
+physiological changes in this structure, which take place with advancing
+age, can rightfully be looked upon as a predisposing factor in glaucoma.</p>
+
+<p><span class='pagenum'><a name="Page_36" id="Page_36">[Pg 36]</a></span></p><p>Dr. Jackson has presented all other phases of this part of the
+symposium in such a comprehensive manner that nothing further remains to
+be said.</p>
+
+<hr />
+
+<p><span class='pagenum'><a name="Page_37" id="Page_37">[Pg 37]</a></span></p>
+
+<h2><a name="Pathology_of_Glaucoma" id="Pathology_of_Glaucoma"></a>Pathology of Glaucoma</h2>
+
+<h4>BY</h4>
+
+<h3><span class="smcap">John E. Weeks</span>, M.D.,<br />New York City.</h3>
+
+<p>In reviewing the pathology of glaucoma it seems proper to consider the
+various structures and tissues of the eye in logical order.</p>
+
+<p><i>Lids and Conjunctiva.</i> "The only change observed in these tissues is a
+reflex edema, excited apparently by pressure on the ciliary nerves and,
+probably, irritation of the vaso-motor fibers of the sympathetic."</p>
+
+<p><i>Lachrymal Gland.</i> Hyper secretion due to reflex irritation.</p>
+
+<p><i>Cornea.</i> As has been shown by Priestley Smith, the cornea in
+glaucomatous eyes is, as a rule, smaller than in non-glaucomatous eyes,
+the mean of a series of measurements being 11.1 mm. horizontally and
+10.3 mm.<span class='pagenum'><a name="Page_38" id="Page_38">[Pg 38]</a></span> vertically in glaucomatous and 11.6 mm. horizontally and 11
+mm. vertically in non-glaucomatous eyes. In cases of considerable
+increase of tension, particularly if the onset is sudden, the
+circulation of lymph in the cornea is interfered with, the anterior
+layers of the cornea become edematous, the spaces between the lamellae
+filled with albuminous fluid. Some of this fluid finds its way through
+Bowman's membrane, apparently by way of the minute channels which permit
+the passage of small nerve twigs, and enters the epithelial cell layer.
+The fluid finds its way between the epithelial cells in the deeper
+layers, apparently being taken into some of the superficial cells by
+imbibition. Some of the swollen surface cells open spontaneously and
+discharge their contents, others drop off. The process causes a
+roughening of the surface of the cornea and produces a faint haziness.
+There is another form of haziness that develops on sudden rise in
+tension and completely disappears on subsidence of the tension. This is
+due,<span class='pagenum'><a name="Page_39" id="Page_39">[Pg 39]</a></span> as has been shown by V. Fleischl (Sitzungsberichle d. Weiner Akad.
+d. Wissensch, 1880) and others, to increased tension on the fibrillae of
+the cornea, a double refraction being induced. In cases of long
+continued increase of tension minute permanent vesicles form in the
+epithelial layers, particularly in the superficial portion. Anaesthesia
+of the cornea develops, due to pressure on the nerve fibers that are
+distributed to the epithelium, the compression probably occurring along
+the course of the long ciliary nerves, from which the corneal nerves are
+derived, as they pass between the choroid and the unyielding sclera
+(Collins &amp; Mayou).</p>
+
+<p>In advanced cases of glaucoma after the congestive period has subsided
+the cornea becomes somewhat condensed, the lymph spaces contracted; a
+condition of sclerosis obtains. Alteration in the shape of the cornea
+occurs only rarely in adult life. When it does occur it takes place in
+corne&aelig; that have suffered from keratitis. The<span class='pagenum'><a name="Page_40" id="Page_40">[Pg 40]</a></span> alteration is usually in
+the form of ectasi&aelig;. In infancy and early youth (buphthalmia) the cornea
+may become uniformly enlarged and globular. Often, however, the
+enlargement of the cornea is irregular. Increase in tension may produce
+fissures in Descemet's membrane. These occur more frequently in the
+cornea that have suffered a change in shape, as in buphthalmos. Gaps
+occur in the elastic membrane which become covered by endothelium. Some
+cloudiness may be seen in the corneal lamellae adjacent to these
+fissures, in some cases due evidently to the filtration of aqueous humor
+through defective endothelium. Prolonged high intra-ocular tension may
+be accompanied, particularly in cases of secondary glaucoma, by
+vesicular and bullous keratitis.</p>
+
+<p>In acute glaucoma the sclera appears to be edematous and slightly
+thickened. As the disease progresses the sclera becomes denser than
+normal. The oblique openings&mdash;passages for the venae vorticosae<span class='pagenum'><a name="Page_41" id="Page_41">[Pg 41]</a></span>&mdash;are
+said to be narrowed. The openings for the passage of the anterior
+ciliary vessels are enlarged in many, particularly in advanced cases.
+Minute herniae at these openings are sometimes present. Dilatation and
+tortuosity of the anterior ciliary veins are due apparently to excessive
+flow of blood through them on account of the abnormally small amount
+carried off by the venae vorticosae. In the stage of degeneration,
+ectasae of the sclera occur most frequently near the equator of the
+globe. Spontaneous rupture may take place.</p>
+
+<p><i>Anterior Chamber.</i> The anterior chamber is shallow, as a rule. This is
+almost without exception in primary glaucoma in adults. In secondary
+glaucoma in which occlusion of Fontana's spaces occurs as a result of
+the deposition of fibrin or other inflammatory products the anterior
+chamber may be of normal depth, or deeper than normal. Very deep
+anterior chamber may occur in glaucoma, due to retraction of lens and
+iris following fibrinous or plastic <span class='pagenum'><a name="Page_42" id="Page_42">[Pg 42]</a></span>exudation into the vitreous, or
+when it occurs in congenital glaucoma, due to enlargement of the globe.</p>
+
+<p><i>Aqueous Humor.</i> The aqueous humor, as has been pointed out by
+Uribe-Troncoso (Pathoginie du Glaucome 1903) contains a greatly
+increased quantity of albuminoids and inorganic salts in glaucoma. In
+acute glaucoma the increase of albuminoids (blood proteids) is greater
+than in chronic glaucoma. The aqueous humor becomes slightly turbid in
+acute attacks, coagulating more readily than the normal. The plastic
+principle contained in the aqueous is rarely sufficient to cause
+adhesion between the margin of the iris and the lens capsule, but the
+colloid nature of the aqueous, according to Troncoso, lessens its
+diffusibility and prevents its free passage into the lymph channels. The
+increase in albuminoids is a consequence of congestion and venous stasis
+and does not precede the attack.</p>
+
+<p><i>Filtration Angle.</i> The changes that occur in the filtration angle
+before it is <span class='pagenum'><a name="Page_43" id="Page_43">[Pg 43]</a></span>encroached upon by iris tissue are sclerosis of the
+ligamentum pectinatum in adults to which Henderson (Trans. Ophth. Soc.
+U.K. Vol. xxviii) has called our attention; the accompanying sclerosis
+of the other tissues to the inner side of Schlemm's canal; and, in some
+cases, the deposition of pigmented cells derived from the iris and
+ciliary processes (Levinsohn) which serve to obstruct the lymph spaces.
+In many of the cases of acute glaucoma and almost all of the cases of
+chronic glaucoma of long standing the filtration angle becomes blocked
+by the advance of the root of the iris.</p>
+
+<p><i>Iris.</i> In acute glaucoma the iris is congested and thickened. It is
+pushed forward and may lie against the cornea at its periphery. When the
+attack subsides, the iris falls away from the cornea. Aside from the
+congestion, the primary changes that take place in the iris are
+indicative of paresis of the fibers of the motor oculi that supply the
+sphincter pupillae, and <span class='pagenum'><a name="Page_44" id="Page_44">[Pg 44]</a></span>stimulation of the fibers from the sympathetic
+producing vasomotor spasm. The long diameter of the pupil apparently
+lies in the direction of the terminal vessels of the two principal
+branches of each long ciliary artery which form the circulus iridis
+major, where the vasomotor spasm would have the greatest effect in
+lessening the blood supply. The haziness of the cornea and slight
+turbidity of the aqueous contribute greatly to the apparent change in
+the color of the iris. In cases of simple chronic glaucoma there is but
+little evidence of edema of the iris. If the iris lies in contact with
+the sclera and cornea for some time, it becomes adherent (peripheral
+anterior synechia). As the disease progresses, the stroma of the iris
+atrophies and contracts. There is very little evidence of small-cell
+infiltration or the formation of cicatrical tissue. Numerous slits may
+develop in the iris through which the fundus of the eye may be seen
+(polycoria). The pigment layer does not atrophy in proportion to the
+stroma of the<span class='pagenum'><a name="Page_45" id="Page_45">[Pg 45]</a></span> iris; by the contraction of the stroma of the pigment
+layer is doubled upon itself at the pupillary margin, forming a black
+ring of greater or less width (ectropian uveae). The iris becomes
+attached to the pectinate ligament and to the endothelium of Descemet's
+membrane. In a very few cases the closure of the angle is not complete
+at the apex, a small space remaining comparatively free for a long time.
+The adhesion of the iris to the pectinaform ligament and cornea is not
+uniform at all parts of the periphery; it varies in width. Portions of
+the iris angle may remain open while other parts are closed. Where the
+iris tissue lies in contact with the cornea, the stroma of the iris
+almost totally disappears. In some cases the iris becomes totally
+adherent to the cornea.</p>
+
+<p><i>Ciliary Body and Chorioid.</i> In acute glaucoma there is congestion of
+the entire uveal tract, the congestion partaking more of a venous stasis
+than of an active or arterial congestion. The vessels of the<span class='pagenum'><a name="Page_46" id="Page_46">[Pg 46]</a></span> ciliary
+process, which are larger and more tortuous in adults of advanced years
+than in the young, become enormously distended, causing almost complete
+obliteration of the perilental space. They press against the root of the
+iris and the equator of the lens, forcing them forward. There is edema
+of the ureal tract, apparently from transudation of serum. Many small,
+and sometimes rather large hemorrhages may occur. There is but little
+small cell infiltration, indicating almost total absence of what is
+ordinarily recognized as true inflammation. It is probable that the
+secretion from the glandular zone of the ciliary body is increased.</p>
+
+<p>On subsidence of the congestion, as after miotics or iridectomy, the
+tissues may return to very nearly a normal condition. The iris recedes
+from contact with the ligamentum pectinatum and cornea and the
+filtration angle is again open. In some cases the iris becomes adherent
+to the head of the ciliary processes and, when<span class='pagenum'><a name="Page_47" id="Page_47">[Pg 47]</a></span> atrophy of the ciliary
+body occurs, is drawn backward at the base of the iris by the receding
+tissues. If the hypertension persists or is repeated at varying periods,
+a slow atrophy of the uveal tract sets in. Eventually the ciliary body
+becomes very much reduced in thickness, is flattened out, the ciliary
+processes reduced in size and the blood vessels disappear or are reduced
+much in caliber. Those that persist possess walls that are much
+thickened. This is particularly true of hemorrhagic glaucoma.</p>
+
+<p>In advanced absolute glaucoma the chorioid may become reduced to a very
+thin membrane consisting of connective tissue and pigmented cells,
+scarcely distinguishable even by moderate powers of the microscope.
+Atrophy is marked in the vicinity of the venae vorticosae. Czermak and
+Birnbacher describe proliferation of the endothelium of the large veins
+with contraction and obliteration of their lumen.</p>
+
+<p><i>Optic Nerve and Retina.</i> In the acute form the retina and optic nerve
+present<span class='pagenum'><a name="Page_48" id="Page_48">[Pg 48]</a></span> the same condition that is present in the vascular tunic;
+namely, that of venous stasis with the consequent edema. Frequently
+minute hemorrhages occur in the retina, particularly in violent acute
+attacks. Cupping of the discs slowly develops, causing more or less
+stretching of the nerve fibers over the edge of the cup. The gradual
+diminution of the field of vision is due in greater part to death of
+peripheral nervous elements of the retina, those parts of the field
+farthest removed from the large arterial trunks suffering first. The
+arrangement of the arteries at the disc, passing out as they do from the
+nasal side, of necessity make the vessels that pass to the temporal part
+of the retina longest and of less caliber. These vessels and their
+terminals are first to suffer marked diminution in size; death of the
+perceptive elements supplied with nutrition by these vessels follows.
+For this reason the nasal part of the field of vision is more often the
+first to disappear. In<span class='pagenum'><a name="Page_49" id="Page_49">[Pg 49]</a></span> congestive (inflammatory) glaucoma, the typical
+field of vision shows most marked contraction on the nasal side. The
+disturbance of the nutrition of the retina accounts in greater part for
+the various forms of visual field met with.</p>
+
+<p>Death of all of the perceptive elements of the retina eventually occurs.
+The loss of nutrition is apparently not the whole cause of blindness.
+Atrophy of the nerve fibers follows death of retinal neurons, but
+atrophy of some of the nerve fibers may be, and probably is, due to the
+pressure and traction exerted upon them at the margin of the disc. It is
+probable that too much importance has been given to this mode of
+interference with the nerve fibers. However, the change in the position
+of the lamina cribrosa must exert a deleterious effect, particularly on
+those fibers which pass through the peripheral meshes, the shape of
+which must necessarily be much distorted. In glaucoma simplex, which is
+largely devoid of marked<span class='pagenum'><a name="Page_50" id="Page_50">[Pg 50]</a></span> congestive periods (acute attacks), a
+surprisingly high degree of acuity of vision may exist with a deep
+excavation and pale nerve. Careful studies of the retinal vessels in
+glaucoma (Verhoeff Arch. of Ophth. XLII. p. 145; Opin. Soc. Fran&ccedil;aise
+d'Ophth. 1908) disclose the fact that an increase in the elastic tissue
+and connective tissue elements occurs in <i>some cases</i>, also
+proliferation of the endothelial cells, which serve to irregularly
+narrow and, in some instances, obliterate the lumen of the vessel.
+Arteries and veins are both affected. Hyaline degeneration of the media
+also occurs. The process is not uniform.</p>
+
+<p><i>Glaucomatous Cup.</i> The excavation of the disc progresses slowly and is
+due in part to stretching the fibers of the lamina cribrosa pressing
+this structure outward, and partly to atrophy and disappearance of the
+nerve tissue and much of the vascular tissues in the nerve head. The
+displacement backward of the lamina cribrosa<span class='pagenum'><a name="Page_51" id="Page_51">[Pg 51]</a></span> may cause that structure
+to lie behind the outer surface of the sclera. Atrophy and cystic
+degeneration of the nerve trunk follows destruction of retinal neurons
+and cupping of the disc. Neuroglia remains in part. Connective tissue
+elements increase in the optic nerve as the nerve fibers disappear.</p>
+
+<p><i>Glaucomatous Ring.</i> The development of the pale circle which surrounds
+the disc, particularly in glaucomatous eyes, is due to a very slight
+recession of the pigment layer of the retina and of the margin of the
+chorioid at this point with some atrophy, apparently consequent on the
+beginning retraction of the lamina cribrosa and slightly increased
+pressure of the nerve fiber layer on the underlying tissues at the
+margin of the disc. This permits the sclera to show through a very
+little at this part. In some eyes in which there is a beginning
+sclero-chorioiditis posterior, the condition is very similar to that
+presented by the glaucomatous ring.</p>
+
+<p><span class='pagenum'><a name="Page_52" id="Page_52">[Pg 52]</a></span></p><p><i>Field of Vision.</i> The two pathological processes that operate to
+destroy the function of the retina suffice to produce scotomata in the
+field of vision of varying shapes. The typical glaucomatous field in the
+acute cases shows a defect most pronounced to the nasal side. As has
+been shown by Bjeraum, the blind spot corresponding with the optic disc
+is enlarged in glaucoma, a relative scotoma often connecting it with the
+blind nasal portion of the field either above or below the horizontal
+meridian (Straub). The field in a simple glaucoma is apt to approach
+concentric limitation; namely, more like the field in simple atrophy.
+This is consistent with the fact that simple glaucoma in many cases
+possesses the characteristics of glaucoma plus atrophy of the optic
+nerve.</p>
+
+<p><i>Vitreous.</i> During the acute attack, the vitreous may become slightly
+turbid by transudation of serum from the vessel of the ciliary body and
+the chorioid and may become filled with fibrin. In some chronic<span class='pagenum'><a name="Page_53" id="Page_53">[Pg 53]</a></span> cases
+in which absolute glaucoma is reached the development of small blood
+vessels in convoluted loops springing from the vessels of the discs has
+been observed. Any process that increases the volume of the contents of
+the vitreous chamber, as hemorrhage, neoplasm, profuse serous or plastic
+exudation, may by pushing iris and lens forward produce an attack of
+acute glaucoma.</p>
+
+<p><i>Buphthalmos.</i> Reis (Graefe's Arch. f. Ophth. V. LX. 1905) states that
+there is always obliteration of the anterior scleral venous channels
+(Schlemm's canal) in buphthalmos. Seefelder (Graefe's Arch. V. LXIII.
+1906) mentions the abnormal position and abnormal narrowing of Schlemm's
+canal and the imperfect and insufficient differentiation of the
+cornea-scleral junction. In all of the cases in which the eye has been
+examined microscopically obliteration of Schlemm's canal has been
+reported. This is thought to be a defect in development. Magitot<span class='pagenum'><a name="Page_54" id="Page_54">[Pg 54]</a></span> (Ann.
+d'Oculis CXLVII) suggests that injury to mesoderm which pushes itself
+between the ectoderm and anterior surface of the lens would account for
+the failure in development of Schlemm's canal. The changes that occur in
+the tissues of the eye appear to be largely due to the stretching
+consequent on the more or less uniform distentions of the globe as a
+result of hypertension.</p>
+
+<p><i>Cornea.</i> This portion of the fibrous membrane is enlarged, globous or
+flattened, irregularly thinned, particularly at the periphery, where it
+may be as thin as tissue paper, nebulous because of the stretching of
+its fibers principally, but in some degree (differing in different
+cases) to edema of the epithelial layer. Fissures occur in Descemet's
+membrane.</p>
+
+<p><i>Anterior Chamber.</i> This is very deep in the greater number of cases.
+However, this rule has many exceptions.</p>
+
+<p>The vascular tunic may be congested in young infants, but atrophy soon
+<span class='pagenum'><a name="Page_55" id="Page_55">[Pg 55]</a></span>develops and may reach an extreme degree. The sclera ordinarily becomes
+quite thin throughout, but may retain almost a normal thickness at the
+equator of the globe and posteriorly. Posterior sclera ectasae may
+develop. The iris, as a rule, hangs free from the cornea, often
+tremulous because of retraction of the lens beyond the iris plane. In
+some cases the iris is partly or totally adherent to the posterior
+surface of the cornea.</p>
+
+<p>The vascular membrane (iris, ciliary body and chorioid) and the retina
+become atrophic, the atrophy varying in degree in various parts.
+Detachment of the retina may occur, often preceded by or accompanied by
+subretinal hemorrhage. The optic disc becomes deeply cupped and the
+tissues of the optic disc and optic nerve extremely atrophied. The
+crystalline lens may become cataractous and shrunken. Spontaneous
+rupture of the suspensory ligament with consequent subluxation of the
+lens may follow.</p>
+
+<p><span class='pagenum'><a name="Page_56" id="Page_56">[Pg 56]</a></span></p><p><i>Secondary Glaucoma.</i> The pathological conditions that precede
+secondary glaucoma are many and differ widely. They may be briefly
+classified as:</p>
+
+<p>1. Those that cause a partial or complete closure of the lymph spaces
+and Schlemm's canal by cicatrical contraction, as in sclero-keratitis.</p>
+
+<p>2. Those that cause obstruction to the lymph spaces at the filtration
+angle by the deposition of fibrin or cellular elements, as in iritis,
+hemorrhage into the anterior chamber, etc.</p>
+
+<p>3. Those that cause obstruction of the filtration angle by advancement
+of the iris and lens, as occurs when the volume of the contents of the
+vitreous chamber is increased, as from retinal or chorioidal hemorrhage
+or neoplasm.</p>
+
+<p>The various changes are so numerous that they need not be described
+further here. The ultimate changes due to high tension resemble those
+already described.</p>
+
+<hr />
+
+<p><span class='pagenum'><a name="Page_57" id="Page_57">[Pg 57]</a></span></p>
+
+<h2><a name="Dr_John_E_Weeks_Paper_on_Pathology_of_Glaucoma" id="Dr_John_E_Weeks_Paper_on_Pathology_of_Glaucoma"></a>Dr. John E. Weeks' Paper on Pathology of Glaucoma</h2>
+
+<h3>Discussion,<br /><span class="smcap">E. V. L. Brown</span>, M.D.,<br />Chicago.</h3>
+
+<p>I would like to emphasize one of the newer features of the pathologic
+anatomy of glaucoma, one which has received too little attention in this
+country: the <i>lacunar</i> or <i>cavernous atrophy</i> of the <i>optic nerve</i>.</p>
+
+<p>The name accurately describes the condition. Tiny clear spaces form in
+the lamina cribrosa and in front and behind it in the nerve tissue.
+Their exact nature is unknown. Usually they are entirely empty, often
+they are traversed by fine glial fibers. They seem to be in no relation
+to the blood vessels. Adjoining lacunae are supposed to fuse to form
+larger cavernae and these finally merge and constitute the final
+glaucoma cup.<span class='pagenum'><a name="Page_58" id="Page_58">[Pg 58]</a></span> The lamina may then bridge across the space like a cord,
+or lie back against the end of the nerve trunk.</p>
+
+<p>Schnabel considered all glaucoma cups to be formed in this way,
+independent of tension. His views were strongly supported by Elschnig,
+but as vigorously opposed by others. Axenfeld cites the fact that the
+glaucoma cup may disappear after operation. (I myself have seen a cup of
+7 D. reduced to 1 D. in the course of a year after the tension had been
+lowered from 62 to 12.) Stock found the same lacunae in eight cases of
+myopia. The last extended study of the subject was made by E. v. Hippel,
+who found lacunae in 20 of 33 cases (60 per cent); enough certainly to
+make one look for them carefully in every case. He publishes a large
+number of excellent photo-micrographs, but none more typical than one I
+have in my possession.</p>
+
+<p>I have been especially interested in this subject because I have met
+with a <span class='pagenum'><a name="Page_59" id="Page_59">[Pg 59]</a></span>complete and total glaucoma cup, with the typical (ampulliform)
+undermining of the scleral ring, in a pair of eyes without increased
+tension. The (Schiotz) tonometer was used daily for 70 consecutive days
+and never registered more than 12-14 mm. Hg. The man had been blinded by
+wood alcohol. At the time I could find no other report in the
+literature, but overlooked a publication by Lewin and Guillery.
+Friedenberg has since reported cases of the same nature.</p>
+
+<p>If other conditions than increased tension can produce a typical
+(ampulliform) glaucomatous excavation of the disc, why may not the
+cavernous atrophy and cup in glaucoma be due in part at least to similar
+processes, possibly in the nature of a toxic oedema of the nerve, either
+in association with tension or independent of it, as contended for by Schnabel?</p>
+
+<hr />
+
+<p><span class='pagenum'><a name="Page_61" id="Page_61">[Pg 61]</a></span></p>
+
+<h2><a name="Concerning_Non-Surgical_Measures_for_the_Reduction_of_Increased" id="Concerning_Non-Surgical_Measures_for_the_Reduction_of_Increased"></a>Concerning Non-Surgical Measures for the Reduction of Increased Intra-ocular Tension</h2>
+
+<h4>BY</h4>
+
+<h3><span class="smcap">George Edmund de Schweinitz</span>, M.D.,<br />Philadelphia.</h3>
+
+<p>Only a few years ago the literature of glaucoma was big with discussions
+of the comparative value of the surgical and non-surgical treatment of
+glaucoma, and especially of the chronic types of this disease. Now,
+thanks to the achievements of Lagrange, Fergus, Herbert and Elliot, the
+value of a filtering cicatrix, although known for a long time, has
+attained increased importance, due to the improvement and elaboration of
+operative technic, and the medical journals of the day are weighted with
+<span class='pagenum'><a name="Page_62" id="Page_62">[Pg 62]</a></span>opinions and experiences from all over the world as to these surgical
+measures. But true as this is, we are not yet in a position to discard
+non-surgical procedures (1) because operation is not always possible,
+(2) because operation is not always permitted, and (3) because in
+certain circumstances operation is not advisable. Hence a glance at the
+non-surgical methods of reducing increased intra-ocular tension is not
+out of place, and for convenience they may be catalogued as follows:</p>
+
+<p>1. Myosis produced by means of solutions of various drugs, a myosis
+followed by reduction of intra-ocular tension.</p>
+
+<p>2. Reduction of tension by means of various mechanical measures, notably
+massage, vibration massage and suction massage, and by means of
+electricity and diathermy.</p>
+
+<p>3. Indirect reduction of intra-ocular tension, accomplished by lowering
+general vascular pressure.</p>
+
+<p>4. Reduction of ocular tension by<span class='pagenum'><a name="Page_63" id="Page_63">[Pg 63]</a></span> stimulation of osmosis, of lymphagog
+activity, of absorption of edema, and of capillary contractility, and by
+decreasing affinity of ocular colloids for water.</p>
+
+<p>1. <i>The Myotics.</i> Of these, eserin (physostigmin) and pilocarpin, with
+their respective salts, the sulphate and the salicylate in the first
+instance, and the hydrochlorid and the nitrate in the second, are well
+established in favor and efficiency. Personally, it has always seemed to
+me that the salicylate of eserin is preferable to the sulphate, but I
+have not persuaded myself that the nitrate of pilocarpin possesses
+material advantages over the hydrochlorid, although some authors prefer
+it. With arecalin, the alkaloid of the Betel nut, I have no experience,
+nor have I used its mixture with eserin, recommended by Merck as more
+potent than either of the drugs in separate solution.</p>
+
+<p>The substance isophysostigmin, found with eserin in Calabar bean,
+according to Ogiu, exceeds in its myotic activity the<span class='pagenum'><a name="Page_64" id="Page_64">[Pg 64]</a></span> sulphate of
+eserin, <i>i. e.</i>, 1/80 of a grain of the drug is equal to 1/60 of a grain
+of the sulphate of eserin, but it is certainly not less irritating than
+physostigmin, and according to Stephenson's researches, is more so, and
+in this sense has no superiority over the usual alkaloid. In general
+terms, it may be said that the time has not arrived to make a preachment
+"on the passing of eserin and pilocarpin."</p>
+
+<p><i>Physiologic Action.</i> Concerning the ocular, physiologic action of the
+two chief alkaloids respectively of Calabar Bean and of Jaborandi, there
+still exists difference of opinion. It has always been easy to attribute
+the myotic action of these drugs, or at least, of eserin, to their
+stimulant action on the peripheral ends of the oculo-motor, thus causing
+sphincter contraction, and to a depressing action on the sympathetic
+fibers, thus causing removal of the action of the dilatator of the iris.
+But complete experimental proof of such action is wanting, and it is
+probable that myosis<span class='pagenum'><a name="Page_65" id="Page_65">[Pg 65]</a></span> follows a direct stimulation of the sphincter
+muscle fibers, aided, perhaps, by contraction of the iris vessels,
+although the last named effect is denied by so competent an authority as
+Hobart Hare.</p>
+
+<p>Exactly how the myotics reduce intra-ocular tension is not definitely
+proven. Usually it is taught that because of the myosis the base of the
+iris wedged in the angle of the anterior chamber is loosened and
+withdrawn, precisely as a fold in a coat is straightened by a tug on the
+fabric beneath it. Experiments, however, for example, by E. E.
+Henderson, have shown that the rate of filtration in an eye with
+artificially raised pressure is considerably larger when it is under the
+influence of eserin than it is when under the influence of atropin; that
+is by the contraction of the pupil the iris-surface filtration is
+increased and consequently the pressure is reduced. We all know that
+Thomas Henderson maintains that the results of iridectomy are beneficial
+because the raw<span class='pagenum'><a name="Page_66" id="Page_66">[Pg 66]</a></span> edges of the coloboma, which do not cicatrize, permit
+access of the aqueous to the iris veins, and that myotics, inasmuch as
+they contract the pupil, open the iris crypts and therefore act, less
+efficiently, perhaps, but act none the less like an iridectomy. The
+normal intra-ocular pressure is uninfluenced by myotics because this
+pressure represents the lowest circulatory pressure in the eye, and
+further contact between aqueous and veins cannot reduce it below this
+level, another point which is made by Thomas Henderson in support of his
+contention.</p>
+
+<p>The clinical fact remains that either by mechanical means, as it were,
+in the liberation of a plugged filtering angle, or by the increasing of
+iris-surface filtration, the myotics markedly reduce the abnormal
+intra-ocular pressure.</p>
+
+<p><i>Methods of Administration and Indications.</i> With the methods of
+administration of the myotics we are all so familiar that time need not
+be wasted in their<span class='pagenum'><a name="Page_67" id="Page_67">[Pg 67]</a></span> reiteration, except to refer to a few practical
+points. In acute glaucoma, and every one knows that in this disease
+their action is often prompt and sometimes curative, eserin in a
+strength of one to four grains to the ounce may be instilled with
+sufficient frequency to establish myosis, and its action in this respect
+is enhanced if the congestion of the eye is lowered by measures to which
+I shall refer later. There is a good deal of clinical evidence to
+indicate that in this type of glaucoma, as well as in the so-called
+sub-acute varieties, myotic activity is increased by a mixture of
+pilocarpin and eserin in the same solution, exactly as a mixture of
+arecalin and eserin is more potent than either of the drugs in separate
+solution.</p>
+
+<p>Prior to the happy advent of technically correctly placed filtering
+cicatrices, a large number of surgeons depended almost exclusively on
+the use of myotics in so-called simple, chronic or non-inflammatory
+glaucoma. This is not the place to introduce a<span class='pagenum'><a name="Page_68" id="Page_68">[Pg 68]</a></span> discussion of the
+comparative value of iridectomy and myotic treatment in simple glaucoma
+as based upon statistical records. We must wait now for a sufficient
+period of time and then compare the value of myotic treatment with that
+of operations by means of which satisfactory filtration is produced. We
+are somewhat in the position that general surgeons occupied when aseptic
+methods first became prevalent. We do not usually compare the statistics
+of early aseptic days with those of the pre-antiseptic period, and I do
+not think we ought to compare the statistics of myotic treatment with
+ordinary iridectomy any longer, but that we should wait until we can
+make a comparison between the results of prolonged myosis and those of
+an improved modern technic which establishes a permanent filtration. In
+the meantime the patients who will not or cannot submit to operation
+must be reckoned with. Doubtless many patients with chronic glaucoma can
+be satisfactorily<span class='pagenum'><a name="Page_69" id="Page_69">[Pg 69]</a></span> managed with myotic treatment, although personally I
+have always advocated operation when this could be performed, but it
+cannot always be performed. This rule should guide us, namely, to begin
+with a comparatively weak solution of the selected drug, for example, as
+Posey has advocated a tenth of a grain of salicylate of eserin to the
+ounce, and the strength gradually increased so that at the end of some
+months the patient is using a solution 1 grain to the ounce; or if the
+pilocarpin is preferred, solutions in double these strengths. It is my
+own belief, and that of many who have studied this subject, that if,
+without eserin irritation, a myosis can be maintained, and if the
+treatment can be begun early enough, the chances of preserving vision
+and the field of vision are good. I believe that the two most important
+instillations during the twenty-four hours of the number necessary to
+maintain this myosis are on retiring and if possible in the very early
+morning, some time between two and four<span class='pagenum'><a name="Page_70" id="Page_70">[Pg 70]</a></span> o'clock. Most patients can be
+taught to wake themselves at the proper period of time, and are little
+inconvenienced by this disturbance of their sleep. I believe that eserin
+irritation is most successfully avoided, not by preparations of the
+myotics in combination with the antiseptics, for example, tricresol,
+which has been so much advocated, but by ordering very small quantities
+of the solution, insisting that it shall be frequently renewed and
+sterilized at each preparation, and that a half an hour after its
+instillation, during the day time at least, the eye shall be thoroughly
+flushed with some mild antiseptic solution, for example, boric acid and
+sodium chlorid. Whether the action of the eserin on the choroidal
+circulation, which is maintained by Wahlfours, aids in this favorable
+action of the myotics remains to be proved. It has been maintained by
+this author and by others who have followed him.</p>
+
+<p>The great trouble with myotic treatment is not its lack of efficiency,
+but the<span class='pagenum'><a name="Page_71" id="Page_71">[Pg 71]</a></span> difficulty of carrying it out successfully on ambulant
+patients, even in the better walks of life. It is hard successfully to
+maintain in a patient with chronic glaucoma what I may call an eserin
+life, just as it is hard to maintain in a person with an enlarged
+prostate a catheter life and escape infection, resulting, if it occurs,
+in the one instance in a difficult and stubborn conjunctivitis, and in
+the other in a cystitis. Still, we are obliged to use myotics, and the
+way to employ them to the patients' best advantage, I have ventured to
+repeat in spite of the universal familiarity with the methods. Perhaps
+we may reach that happy day when, especially with improved tonometric
+methods, increased skill in measuring the rate of filtration and better
+instruments for determining the light sense, we can anticipate the
+advent of glaucoma and get ahead of the ocular and visual deterioration
+which increased tension produces, by performing preventive operations
+which shall aid nature's<span class='pagenum'><a name="Page_72" id="Page_72">[Pg 72]</a></span> filtration channels in the establishment of an
+artificial one. But increased tension is not the whole story of
+glaucoma, and a filtering cicatrix is not the last word in surgical
+therapeutics, and there is much to learn.</p>
+
+<p>2. <i>Reduction of tension by means of various mechanical measures,
+notably massage, and by means of electricity and diathermy.</i> Massage is
+of ancient lineage. In general terms, in so far as ocular massage is
+concerned, it may be applied to the eye with the finger tips (ordinary
+massage), by means of various instruments (vibration massage), and with
+the help of certain suction cups (suction massage, which is indeed a
+form of vibratory massage). Many authors are satisfied with their
+results without the employment of any instrument, and prefer simple
+massage with the tip of the finger to any form of the instrumental
+variety, to quote the words of Casey Wood. At one time in my career I
+experimented very <span class='pagenum'><a name="Page_73" id="Page_73">[Pg 73]</a></span>extensively with massage, not alone for the purpose
+of reducing intra-ocular tension, but in various diseases of the lid and
+cornea, and taught a trained nurse, who herself had a nebulous cornea,
+to make what I may call a specialty of this particular therapeutic
+procedure. She became exceedingly skillful and was quite faithful. We
+believed that the best results were obtained in a seance of two or three
+minutes, the finger tip being used over the lid, and the surface of the
+cornea lubricated with a drop of pure olive oil, although in glaucoma
+the addition of the oil is not necessary. Four movements were utilized,
+the first a stroking movement in lines radiating from the central
+pressure, very much as the spokes of a wheel radiate from the hub,
+second a circular movement, third a pressure movement, a little dipping
+motion, so that the cornea was slightly depressed, and finally, a gentle
+tapping movement, precisely the same, except that it was a diminutive
+one, as the tapping<span class='pagenum'><a name="Page_74" id="Page_74">[Pg 74]</a></span> movement that the Swedish masseur makes. Usually
+each movement occupied from a half to one minute, according to the
+results desired. I agree with Casey Wood that such a technic furnishes
+just as good results as any one with the aid of an instrument.</p>
+
+<p>Referring particularly to the reduction of intra-ocular tension, many
+surgeons have been impressed with the value of various instruments.
+Thus, Ohm, who has worked particularly in the reduction of the increased
+tension of secondary glaucoma, for example, after discussion of lamellar
+cataract, advocates the Piesbergen instrument, which makes 3,000
+vibrations a minute, and is applied over the closed lids. I think the
+instrument best known is the one introduced by Malakow. For this purpose
+the point of an Edison electric pen is armed with a small ivory ball,
+and the vibration rate varies from 200 to several thousand a minute, the
+rapidly revolving ball being passed over the closed<span class='pagenum'><a name="Page_75" id="Page_75">[Pg 75]</a></span> lids, in some
+instances directly upon the cornea itself. I am frankly afraid of these
+vibrating machines, and again make a plea for the finger tip, just as I
+am afraid of a Von Hippel trephine, and prefer one which is rotated with
+the fingers.</p>
+
+<p>A special investigation of pressure massage according to the method of
+Domec has been made by Paul Knapp of Basel. This, as you know, consists
+in applying the thumb to the cornea through the closed lids, and making
+repeated pressures upon it at the rate or 60 to 100 a minute. He checked
+his results with the tonometer after 200, 500 and 1,000 pressures, and
+found that even in normal eyeballs such massage was followed by a fall
+of intra-ocular tension, the average being nearly 9 mm. after a thousand
+pressures. Within three-quarters of an hour the tension returns to the
+normal. In acute glaucoma such massage is not available, but it is of
+assistance in encouraging a reduction of the intra-ocular tension and
+keeping it<span class='pagenum'><a name="Page_76" id="Page_76">[Pg 76]</a></span> at a normal grade after operative work, particularly after a
+filtering cicatrix has been made, as was well shown by Weeks in his
+study of glaucomatous eyes operated upon by the Lagrange method. It is
+interesting to remember that Paul Knapp, in the course of this
+investigation, observed reduction of the tension after the use of
+holocain.</p>
+
+<p>Another method of reducing the intra-ocular tension is by the suction
+method, which consists in the use of certain cups from which the air is
+exhausted by means of a suction apparatus. Domec uses an elliptical eye
+cup, the concave margins of which fit closely about the globe. The air
+is exhausted with each respiration of the patient and from 50 to 200
+tractions are made at each sitting. Domec is of the opinion that this
+method succeeds in two ways, namely, in producing analgesia by traction
+on the ciliary nerves, and in reducing intra-ocular tension.</p>
+
+<p>Unfortunately, it is difficult for regular<span class='pagenum'><a name="Page_77" id="Page_77">[Pg 77]</a></span> physicians to make reference
+to massage of the eyeball lest their words should be misquoted by
+irregular practitioners who employ this method, selling various
+instruments to trusting patients, and attributing to this simple and
+often beneficial procedure all sorts of marvelous influences. Doubtless
+all of us have seen eyes utterly ruined because the patient has trusted
+to the advertisements of these people, and has continued to use some
+foolish little suction pump, when what his eye needed was operative
+procedure or skilled therapeutics.</p>
+
+<p>If I should sum up my opinion of massage in the reduction of
+intra-ocular tension, I would say that it is useful in enhancing the
+action of myotics, and particularly useful, as Domec, Knapp, Ohm, Weeks
+and many others have shown, after the filtering angle has been opened by
+a proper operative procedure. It seems to me that it is distinctly our
+duty to inform patients that it is no panacea, and that they must<span class='pagenum'><a name="Page_78" id="Page_78">[Pg 78]</a></span> never
+trust themselves in the hands of irregular practitioners who pretend to
+cure all ocular ills with massage.</p>
+
+<p><i>Electricity.</i> The credit of first using high frequency currents in the
+treatment of glaucoma belongs to Truc, Imbert and Marques, and Roure's
+experiments indicate that this current suitably applied appears to have
+an influence not only in reducing the arterial tension, but also the
+ocular tension. Thus, in an interesting series of experiments he has
+been able to reduce an arterial pressure of 200 mm. to 140 mm., and an
+ocular tension of plus 2 to the normal after eighteen applications of
+the high frequency current. The current is applied for ten to fifteen
+minutes at a time twice a week. Some surgeons, for example, W&uuml;rdemann,
+have suggested the use of electricity combined with massage, and have
+apparently achieved satisfactory results.</p>
+
+<p>The constant current has also been much employed for the purpose of
+reducing<span class='pagenum'><a name="Page_79" id="Page_79">[Pg 79]</a></span> intra-ocular tension. Coleman quotes Le Prince's observations,
+who applies the negative pole to the eye and the positive pole to the
+neck, gradually passing a current of 30 to 40 ma. during a quarter of an
+hour, and who reports notable diminution of tension. Coleman points out
+that in his own experience he has not found any patient who would
+willingly tolerate more than 19 ma. of current with an ordinary sized
+electrode, although he grants that it is possible that Le Prince used a
+very large electrode. Unfortunately he does not mention its size.
+Ziegler of my own city, who has studied most scientifically and
+intelligently the use of electricity in diseases of the eye, announces
+this rule: The positive pole should be used in all inflammatory
+processes of the eye, glaucoma excepted, and with this rule Coleman
+agrees. Now, although the negative pole is a stimulant and therefore not
+generally indicated in inflammation, as Coleman points out, the object
+in view is to diminish the density<span class='pagenum'><a name="Page_80" id="Page_80">[Pg 80]</a></span> of the ocular capsule and its
+tension, hence the negative rather than the positive pole should be
+used, inasmuch as the former, according to him, while it is a sedative,
+hardens tissue and would tend to increase intra-ocular tension by
+diminishing excretion. Moreover, in chronic glaucoma the ordinary
+inflammatory processes are not present, indeed, primary acute glaucoma
+itself is not an inflammation.</p>
+
+<p>I have no personal experience in the use of the constant current with
+negative pole application to the eye in the reduction of increased
+intra-ocular tension, but quote for our general benefit the opinions of
+those who have employed it. I have always been very frankly pessimistic
+in regard to the therapeutic value of electricity in ocular disorders.
+Perhaps I am wrong; I am willing to be enlightened. There seems little
+doubt that Truc and Imbert's observations that high frequency currents
+can temporarily reduce intra-ocular tension is correct, that they are
+able to relieve<span class='pagenum'><a name="Page_81" id="Page_81">[Pg 81]</a></span> the pain of primary and of secondary glaucoma would
+seem to be proved by many observations, some of which I have myself
+made, and other very accurate and excellent ones have been made by
+Risley in Philadelphia.</p>
+
+<p>A word might be said in regard to <i>diathermy</i>. According to Zahn, the
+method of applying diathermy to the human eye is to take a layer of
+cotton wool 1 cm. thick soaked in a 2 per cent solution of sodium
+chlorid, which is applied close to the outside of the lids. On this is
+put an electrode 15 cm. in size with a large indifferent electrode
+applied to the back of the neck. It is not germane to the subject to
+name the various ocular diseases which were treated in this manner, but
+Clausnizer has made an investigation of the influence of diathermy on
+intra-ocular tension. In a number of diseases, for example,
+iridocyclitis, the method produced distinct rise of pressure. In one, a
+patient with secondary glaucoma, prior to the<span class='pagenum'><a name="Page_82" id="Page_82">[Pg 82]</a></span> diathermic application
+the tension was 37&frac12; mm., after the passage of the current it had
+fallen to 28 mm., but the next morning the tension rose to 45 mm. In a
+patient with chronic glaucoma no definite alteration of tension could be
+found. This observation is mentioned, not because it puts us in
+possession of a valuable therapeutic measure, but largely because it is
+a good example of how in this disease it is wise to investigate any
+method which furnishes a hope of relief.</p>
+
+<p>In a few instances endeavor has been made to reduce the intra-ocular
+tension, or at least to relieve glaucomatous symptoms, by galvanism of
+the cervical sympathetic, for example, by placing one electrode along
+the whole length of this nerve in the neck and one on the back of the
+neck on the opposite side, 15 to 20 ma. of current being used. Good
+results have been reported by an observer named Allard. I confess that I
+am entirely faithless in regard to any results<span class='pagenum'><a name="Page_83" id="Page_83">[Pg 83]</a></span> that may be reached in
+this manner. It is possible that as the positive pole is a sedative, if
+there were any influence, the influence of sedation would be present,
+but certainly it has over and over again been experimentally proved that
+irritation of the cervical sympathetic quite rapidly produces elevation
+of intra-ocular tension of 2 to 4 mm. In some experimental work the
+primary elevation of intra-ocular tension was followed by a secondary
+drop.</p>
+
+<p>3. <i>Indirect reduction of increased intra-ocular tension brought about
+by lowering general vascular pressure.</i> Much has been written in regard
+to the association between increased vascular pressure and increased
+intra-ocular pressure. It is not my province to analyze observations
+often contradictory and not infrequently inaccurate. This much seems to
+be established: First, that at corresponding ages there is usually a
+higher average blood pressure in glaucomatous subjects than there is in
+non-glaucomatous subjects; second, that<span class='pagenum'><a name="Page_84" id="Page_84">[Pg 84]</a></span> arteriosclerosis and therefore
+usually increased blood pressure, with all its concomitant conditions,
+is correctly classified as an exciting cause of glaucoma; and third,
+that the regulation of this increased blood pressure is part of the
+advantageous management of increased intra-ocular pressure, although it
+may be too much to say, as Gilbert has, that blood pressure and
+intra-ocular pressure rise and fall together. It may be true, as Thomas
+Henderson says, that the intra-ocular pressure is influenced by changes
+in the general arterial or general venous pressures, whereby a rise in
+general arterial pressure induces a proportionate rise in the
+intra-ocular pressure, but it would seem that future investigations must
+confirm this statement before it can be entirely accepted, as well as
+his further statement that the effect of an increased general venous
+pressure is a direct one, producing millimeter for millimeter a
+corresponding increase in the intra-ocular pressure.</p>
+
+<p><span class='pagenum'><a name="Page_85" id="Page_85">[Pg 85]</a></span></p><p>Now, it goes without saying, if these data are correct, or even only
+partly correct, that part of the treatment of the increased intra-ocular
+pressure state must be constitutional in that the vascular pressures
+should be lowered in order that the beneficial effect of their
+relationship to the intra-ocular pressure shall be established. It is
+further a great mistake to drive down a high arterial pressure simply
+because that exists. In other words, it is often necessary from the
+general standpoint that a certain amount of plus pressure shall remain
+if the patient's general well-being is to be maintained. There must
+always be a differential diagnosis between plus pressure and what may be
+called over plus pressure. That is to say, a man may be perfectly
+comfortable and properly need, for example, a pressure of 160 or 165
+mm., which is above the physiologic limit, but which is a plus pressure,
+while some disturbance in his general life may add to that 10, 15 or 20
+mm.<span class='pagenum'><a name="Page_86" id="Page_86">[Pg 86]</a></span> more of pressure, which is then the over plus amount. This over
+plus amount may be in association with a rise of intra-ocular pressure,
+and must be eliminated if the latter is to be controlled by a
+non-operative procedure, or, indeed, by an operative one.</p>
+
+<p>It is no easy matter to determine the presence of increased venous
+pressure, although there are tolerably accurate instrumental technics,
+and yet, as Henderson points out, it is just this increased general
+venous pressure which is often detrimental. Therefore the perfunctory
+use of such drugs as nitrite of amyl and the other nitrites may not be
+in the least indicated when, for example, the venous pressure depends
+upon inability of the right heart to perform its functions, and the drug
+needed may, for example, be digitalis. Far better than pressure-reducing
+drugs like nitrite of amyl, urgently indicated in some instances and for
+some purposes, is the regulation of life and the restoration to their
+normality of the metabolic <span class='pagenum'><a name="Page_87" id="Page_87">[Pg 87]</a></span>processes, the elimination of the worry
+which is usually the exciting agent that brings about the over plus
+pressure, which may have as one of its expressions an acute rise of
+intra-ocular tension. I believe that in the management of a case of
+glaucoma, whether it be chronic or chronic with sub-acute exacerbations,
+the greatest care with the aid of an expert clinician must be exercised
+to find out exactly what mean pressure of the arterial and venous system
+best conforms with the patient's general welfare, and I am bitterly
+opposed, and I think with right, to the sudden reduction of tensions,
+except in emergencies, without a perfect understanding of the facts I
+have ventured to indicate. This does not for a moment mean that prior,
+for example, to operative work it is not necessary to get rid by means
+of drugs of an over plus tension, for surely the elimination of such an
+over plus tension may be the means of preventing, for example, an
+intra-ocular hemorrhage, and in this<span class='pagenum'><a name="Page_88" id="Page_88">[Pg 88]</a></span> emergency we must not lose sight
+of Gilbert's recent investigation, who has found that blood withdrawn to
+the extent of 8 grams to each kilogram of the body weight always
+produces lowering of the intra-ocular tension, appearing in six to eight
+hours and lasting to the next day in simple glaucoma, and in
+inflammatory glaucoma commencing the day after the venesection and
+lasting two to three days. It is not necessary for me to point out the
+value of free purgation and diaphoresis in this respect.</p>
+
+<p>In most instances the successful maintenance of a glaucomatous life,
+exclusive of operative interference, in addition to sustained myosis,
+demands the investigation of the patient's metabolism, which must be
+kept at the normal standard, the removal of the evil effects of
+auto-infection, as we are wont to call it, and especially the
+elimination of the cause which is responsible for the over plus tension
+of the arteries and of the veins. This is best<span class='pagenum'><a name="Page_89" id="Page_89">[Pg 89]</a></span> secured by just such
+regulation of life as has been referred to, aided when necessary by the
+ordinary drugs which the patient's condition indicate, and the success
+of all treatments, be they operative or non-operative, is enhanced if
+such a happy state of affairs can be brought about.</p>
+
+<p>I am firmly convinced that every glaucomatous patient, and I now refer
+to those who are the subjects of chronic progressive glaucoma, should be
+carefully studied from the general standpoint by the oculist with the
+aid of an expert internist, just as I am convinced that the modern
+expert internist should not study his cases of cardio-vascular disease
+without the help of the oculist. Perhaps I am going a little far afield,
+but in justification of my statement I want to quote the opinion of Dr.
+Hobart Hare, one of America's most expert clinicians, on blood pressure,
+because it seems to me much harm has been done by the more or less
+brutal knocking down of blood pressure simply because blood<span class='pagenum'><a name="Page_90" id="Page_90">[Pg 90]</a></span> pressure
+above the normal existed. "Concerning the matter of high blood
+pressure," writes Hare, "independent of cerebral lesions, the longer I
+study the matter the more convinced I am that this blood pressure is
+devised by nature to compensate for fibroid changes in peripheral
+vessels, in order that tissues which would otherwise be cut off from
+adequate blood supply may receive plenty of blood, and I consider it one
+of the most vital points to ascertain whether a pressure is what may be
+called the patient's pathological norm, that is, the pressure which is
+required in the face of vascular changes, or whether this pressure is in
+excess of his pathological norm. If it is in excess, measures directed
+to bring it to the pathological norm should be instituted, but if the
+pressure found proves to be the pathological norm it is a bitter mistake
+to lower it, be the pressure what it may. If it is lowered below the
+pathological norm, all manner of disturbed cardiac action, etc., may
+result.<span class='pagenum'><a name="Page_91" id="Page_91">[Pg 91]</a></span> There is no more reason for reducing a blood pressure below his
+pathological norm than there is for reducing it below his physiological
+norm. The adjustment of a man's blood pressure to his pathological norm
+often has to be as correctly done as the adjustment of a watch which is
+losing or gaining time."</p>
+
+<p>I shall not quote Hare's elaborate methods for determining these various
+points because they do not belong to a paper of this character, but I
+quote his admirable advice because it emphasizes what I believe to be an
+essential in the treatment of chronic glaucoma, exclusive of operative
+work, that is, the intelligent co-operation of the oculist and the
+internist.</p>
+
+<p>Some such thought was in the mind of Ibershoff, who quotes Sterling and
+Henderson's views that the rate of secretion depends upon and varies
+with the difference in the blood pressure and the tension of the
+eyeball, and that the specific<span class='pagenum'><a name="Page_92" id="Page_92">[Pg 92]</a></span> gravity of the secretion increases
+directly with the blood pressure and inversely with the ocular tension.
+Should the blood pressure be very high, paracentesis, for example, would
+apparently not be the proper procedure, and the resulting difference
+produced between the blood pressure and the eye tension would cause a
+rapid reformation of fluid with higher specific gravity and higher
+osmotic coefficient. The proper procedure in these circumstances is
+first properly to reduce the blood pressure, or what I have, quoting
+Hare, ventured to call the over plus pressure.</p>
+
+<p>4. <i>The relation of osmosis, lymphagogue activity, absorption of edema,
+capillary contractility and decreased affinity of ocular colloids for
+water to the reduction of increased intra-ocular tension.</i> We are all
+familiar with the attention which was directed some years ago to the
+statements coming from French clinics that the treatment of glaucoma
+should include the administration of osmotic substances as<span class='pagenum'><a name="Page_93" id="Page_93">[Pg 93]</a></span> adjuvants in
+the reduction of increased intra-ocular tension. Particularly was this
+treatment advocated by Cantonnet in the administration of daily doses of
+3 grams of chlorid of sodium, preceded, of course, by a careful urinary
+examination and the estimation of the amount of urine and its contained
+chlorids. Carefully this dose was increased in proper circumstances to
+15 grams per diem, and in Cantonnet's original paper good results were
+achieved in 12 of the 17 patients so treated. I have myself experimented
+somewhat, not with the administration of sodium chlorid by the mouth,
+but with the introduction by the bowel of fairly large quantities of
+physiologic salt solution in patients with glaucoma whose quantity of
+urinary secretion was markedly below the normal, and in one or two
+startling instances, which have been reported, achieved success in the
+rapid reduction of the intra-ocular tension when by this technic the
+urine secretion rose to the normal amount. To<span class='pagenum'><a name="Page_94" id="Page_94">[Pg 94]</a></span> be sure, myotics were
+also used, but these myotics were insufficient, totally so in the two
+instances noted prior to the enteroclysis.</p>
+
+<p>Very interesting are the observations on the subconjunctival injections
+of various substances, notably the citrate of sodium, because of its
+power of decreasing the affinity of ocular colloids for water. This
+method of treating increased intra-ocular tension, introduced, as you
+know, by Thomas and Fischer, has met with confirmation from a number of
+sources in spite of the fact that Happe's experimental study failed to
+confirm Fischer's observations; indeed, he even reports in several
+instances a rise of tension.</p>
+
+<p>As you will remember, the strength of ordinary crystallized sodium
+citrate in water should be from 4.05 to 5.41 per cent. Of this five to
+fifteen minims are injected, the eye having been previously cocainized
+and adrenalinized. With frequent injections the weaker of the two<span class='pagenum'><a name="Page_95" id="Page_95">[Pg 95]</a></span>
+solutions is mixed with 2 to 4 parts of physiologic salt solution. These
+authors in no sense claim to cure glaucoma, but to ameloriate it and
+reduce the tension. Weekers has used the salts of calcium, 3 grams a
+day, with success in so far as lowering of tension is concerned,
+although it must be stated, as a reviewer of his work has said, that his
+recommendation of this drug in these respects is poorly supported. On
+the other hand, Tristiano seems to have proved that calcium chlorid is
+capable of lowering ocular tension and clinically may be used as an
+adjuvant in the treatment of glaucoma for this purpose, largely because
+he believes that he has proven that it facilitates the absorption of
+edema. Darier has reported that a single subconjunctival injection of a
+milligram of iodate of sodium has cleared the cornea and lessened the
+intra-ocular pain in glaucoma.</p>
+
+<p>What shall be said in regard to certain medicinal agents which stimulate
+the<span class='pagenum'><a name="Page_96" id="Page_96">[Pg 96]</a></span> lymphagogue activity of the eyeball in their relation to the
+reduction of intra-ocular tension, notably of dionin? Toczyski's
+experiments with this drug on the normal eye indicate that it produces
+first a rise of tension, which shortly falls to the normal and sometimes
+below it, the tension being high as long as the primary narrowing of the
+pupil is maintained, but more than one author, particularly A. Senn,
+holds an opposite view and reports acute glaucoma following its
+instillation into a chronic glaucomatous eye. He believes that dionin
+not only does not reduce the tension but hinders the filtration through
+the anterior lymph channels by the pressure of the edema which is
+produced on the veins and by the increased secretion of the ciliary
+processes. In spite of this statement, most of us must agree with Karl
+Grossman's observations that certainly in acute and particularly in
+chronic secondary glaucoma, this is a most valuable agent, especially if
+it is combined with<span class='pagenum'><a name="Page_97" id="Page_97">[Pg 97]</a></span> holocain, which Paul Knapp in his well-known
+research has proved can reduce the tension even of the normal eye. I
+cannot think that anybody who has systematically used dionin with
+holocain, the former in gradually increasing strength, beginning with 2
+per cent and going up to 8 per cent, in various types of acute glaucoma,
+particularly of the secondary variety, can fail to have noted a
+favorable influence.</p>
+
+<p>Many authors, for example, Darier, Grandclement and others, are strong
+in their recommendation of adrenalin, particularly if this drug is added
+to the various myotic mixtures, and yet adrenalin is certainly not
+without danger in the treatment of glaucoma. McCallan has seen a number
+of instances of striking increase of intra-ocular tension following this
+instillation in the conjunctival sac. Harmon has had a similar
+experience, as also has Senn. It is possible that in these circumstances
+the solution was too strong. Should the rise of tension occur, and I<span class='pagenum'><a name="Page_98" id="Page_98">[Pg 98]</a></span>
+have seen it myself, it is doubtless due to the fact that this drug
+dilates the pupil, which would be especially dangerous if the dilatation
+should occur before contraction of the ciliary vessels; also the
+narrowing of the ciliary veins by the adrenalin might by virtue of this
+narrowing obstruct the gate of outflow. I have never been able to
+persuade myself that, except as an adjuvant to operative work, there was
+any real therapeutic value in the instillation of adrenalin.</p>
+
+<p>A word in regard to the effect of general narcosis on intra-ocular
+tension. Thus, Neuschuler has observed that narcosis causes an elevation
+of the intra-ocular tension of from 2 to 6 degrees as measured with
+Fick's tonometer. These observations were made while he was
+experimenting on irritation of the sympathetic as a method of producing
+increased intra-ocular tension. This is not in accord with Axenfeld's
+recent observations. It is well known, this observer points out, that
+after the period<span class='pagenum'><a name="Page_99" id="Page_99">[Pg 99]</a></span> of excitation and muscular rigidity disappears, there
+is a lowering of blood pressure in chloroform narcosis and coincidently
+a sinking of the intra-ocular pressure. Not only this, the intra-ocular
+tension of normal eyes during this narcosis drops several millimeters.
+Only such eyes as have high hypertony, for example, in absolute
+glaucoma, are unaffected during chloroform narcosis. In the light of
+this observation it will be interesting to measure the tension both of
+normal and glaucomatous eyes during narcosis in a large series of cases,
+and if it is confirmed there will be an additional reason why in many
+circumstances general narcosis is advantageous in glaucomatous patients.
+Formerly I thought it was essential, if iridectomy was to be performed,
+lest some sudden movement on the part of the patient might bring the
+point of the knife in contact with the lens. I have rarely employed it
+in corneo-scleral trephining, and yet if there is this temporary
+<span class='pagenum'><a name="Page_100" id="Page_100">[Pg 100]</a></span>reduction of intra-ocular pressure, it is not without a certain
+therapeutic value, and the matter is mentioned as a suggestion that
+additional observations along this line shall be made.</p>
+
+<hr />
+
+<p><span class='pagenum'><a name="Page_101" id="Page_101">[Pg 101]</a></span></p>
+
+<h2><a name="Dr_George_Edmund_de_Schweinitz_Paper_on_Concerning_Non-Surgical" id="Dr_George_Edmund_de_Schweinitz_Paper_on_Concerning_Non-Surgical"></a>Dr. George Edmund de Schweinitz' Paper on Concerning Non-Surgical
+Measures for the Reduction of Increased Intra-ocular Tension</h2>
+
+<h3>Discussion,<br /><span class="smcap">Nelson Miles Black</span>, M.D.,<br />Milwaukee.</h3>
+
+<p>It seems almost useless to attempt any discussion of Dr. de Schweinitz'
+most terse and comprehensive paper. However, Dr. de Schweinitz mentioned
+the close relationship which should exist in the non-surgical treatment
+of increased intra-ocular tension between the internist and the
+ophthalmologist, but neglected to mention a corresponding relation which
+should exist between the rhinologist and the ophthalmologist, and
+possibly between the dental surgeon and the ophthalmologist.</p>
+
+<p>I would like to refer to the <i>now</i> recognized close relationship which
+exists between disease of the nasal accessory<span class='pagenum'><a name="Page_102" id="Page_102">[Pg 102]</a></span> sinuses and diseases of
+the eye. The definition of glaucoma found in Dr. Wood's system of
+therapeutics gives rise to an hypothesis as to why disease of the nasal
+accessory sinuses may be a factor in producing increased intra-ocular
+tension and why treatment directed toward obtaining free drainage from
+the sinuses gives good results in so many cases, especially if the
+relationship is recognized sufficiently early. "Glaucoma proper is
+essentially a damming or blocking of the drainage from the interior of
+the eye. The chief lymph stream flows from the posterior chamber past
+the margin of the lens, through the zonula of Zinn, beneath the iris,
+through the pupil into the anterior chamber, thence through the tissue
+at the junction of the iris and sclera into the circular canal of
+Schlemm and from this space into <i>the external lymph channels</i>.
+<i>Obstruction to the steady escape of the intra-ocular fluids at any
+point in this drainage system or any undue increase of the fluids
+themselves may</i><span class='pagenum'><a name="Page_103" id="Page_103">[Pg 103]</a></span> <i>produce glaucoma.</i> Probably the most important
+obstruction to the exosmosis is at the angle close to Schlemm's canal."</p>
+
+<p>The following hypothesis is based upon Fischer's edema theory of
+glaucoma and the relation of the circulation of the eye and orbit and
+that of the nose and the accessory sinuses, the minute anatomy of which
+is not as yet thoroughly understood. However, sufficient work has been
+done to make it appear that the lymph channels which drain the eyes and
+orbits empty into the same main channel as do those which drain the
+sinuses. Admitted for sake of argument that such is the case, then
+disease either acute or chronic of one or more of the sinuses with the
+accompanying inflammatory reaction, congestion and stasis, will cause an
+increased amount of fluid to be taken care of by the lymph channels
+draining these sinuses. This will in turn cause flooding of the common
+lymph channel, producing a stagnation in the flow of fluid from the
+orbits and eyes at the<span class='pagenum'><a name="Page_104" id="Page_104">[Pg 104]</a></span> junction with the main channel, with backing up
+of the fluid within these channels and retention of the waste products
+within the orbits and eyes; thus will be brought about conditions most
+favorable (to quote from Fischer's theory of glaucoma) "to an abnormal
+production or accumulation of acid in the eye. In consequence of this
+abnormal acid content the hydration capacity of the ocular colloids is
+raised and glaucoma results, not because water is pushed into the ocular
+colloids, but because these suffer changes which make them suck in water
+from any available source."</p>
+
+<p>This hypothesis also might suggest why the subconjunctival injection of
+sodium citrate in addition to alkalinizing the ocular contents, may be
+effective in reducing tension, <i>i. e.</i>, the amount of fluid injected
+beneath conjunctiva may overcome the stagnation in the lymph passages,
+flush out these channels and improve ocular elimination.</p>
+
+<p><span class='pagenum'><a name="Page_105" id="Page_105">[Pg 105]</a></span></p><p>Fischer in a personal letter says:</p>
+
+<p>"You have two possibilities for the production of glaucoma with sinus
+disease: A toxic factor due to poisons being carried into the eye; and
+second, interference with a proper blood supply to the eye through
+compression of the efferent or afferent blood vessels supplying the eye
+from edema of the tissues about the eye consequent upon the sinus
+infection. Either is associated with the production of substances which
+increase the hydration capacity of the ocular colloids."</p>
+
+<p>If such is the case why could not the existence of pyorrhea and blind
+abscesses about the roots of the teeth be the source of the toxic
+factors mentioned by Fischer? Hence the suggested association of the
+dental surgeon with the ophthalmologist in these cases of apparently
+idiopathic increased intra-ocular tension.</p>
+
+<p>It would be well to state here a cursory examination of the mouth will
+not discover root abscesses any more than such <span class='pagenum'><a name="Page_106" id="Page_106">[Pg 106]</a></span>examination will
+discover non-suppurative sinus disease. A careful examination of each
+tooth together with radiograms of the entire maxilla are absolutely
+essential to determine their presence or absence.</p>
+
+<hr />
+
+<p><span class='pagenum'><a name="Page_107" id="Page_107">[Pg 107]</a></span></p>
+
+<h2><a name="Trephining_for_Glaucoma" id="Trephining_for_Glaucoma"></a>Trephining for Glaucoma</h2>
+
+<h4>BY</h4>
+
+<h3><span class="smcap">Robert Henry Elliot</span>, M.D.,<br />London, England.</h3>
+
+<p>Mr. President and Members of The Chicago Ophthalmological Society:</p>
+
+<p>As the hour is late I propose to take up only the principal points in
+connection with my subject and to deal with each one shortly.</p>
+
+<p>First: The operation of trephining is suitable, not merely for chronic
+cases, but for sub-acute and acute cases of glaucoma as well. I would
+urge on your attention that, of all the operations dealing with
+glaucoma, this one involves the minimum of surgical violence, and
+should, therefore, in acute cases be the operation of choice. It is,
+moreover, much safer than any other operation I know of, and is no less
+certain<span class='pagenum'><a name="Page_108" id="Page_108">[Pg 108]</a></span> in its results. I do not advise trephining in the secondary
+glaucoma following intumescent cataract, for in such cases the
+semi-fluid lens bulges into and blocks the trephine hole. Nor for
+obvious reasons do I recommend it in cases where there is reason to
+believe that a communication exists between the aqueous and vitreous
+chambers.</p>
+
+<p>Second: The object of trephining is to tap and permanently drain the
+aqueous fluid from the anterior chamber of the eye into the
+sub-conjunctival space; in doing so it is essential to avoid as far as
+possible all interference with the uveal tissue. The purpose of an
+iridectomy is to avoid the danger of the iris in the neighborhood of the
+wound being drawn and impacted in the trephined hole. We have found in a
+large number of cases in which an iridectomy has been omitted, that the
+results have been in no way inferior to those in which a piece of iris
+has been removed, provided always that<span class='pagenum'><a name="Page_109" id="Page_109">[Pg 109]</a></span> no subsequent iris prolapse
+takes place. In pursuance of our purpose to avoid uveal tissue, we split
+the cornea, and place the trephine as far forward as such splitting will
+allow, and we bear on the trephine in such a way that it cuts through on
+the corneal edge of the wound first. This insures establishing our
+fistula in the most anterior position possible, and, therefore, as far
+away as possible from the ciliary body and the angle of the chamber.</p>
+
+<p>Third: The difficulties of the operation. Far too much stress has been
+laid on these. Trephining is an operation which can be performed by any
+surgeon who is used to ophthalmic manipulations, and who has good sight.
+It is essential that he should work in a good light. The necessary
+technique can be acquired from a written description. It is not for a
+moment necessary that the surgeon who wishes to learn trephining should
+see the originator of the operation at work. If, however, he feels
+diffident at undertaking the procedure until<span class='pagenum'><a name="Page_110" id="Page_110">[Pg 110]</a></span> he has seen it done by
+another, there are many centers in this country where the operation is
+now being successfully performed. I would mention amongst those which I
+have visited New York, Minneapolis, St. Louis, Nashville, Louisville,
+Detroit and Chicago. I have seen results of trephining by American
+surgeons which could not be bettered anywhere.</p>
+
+<p>Fourth: I am sure that everybody will recognize the difficulties of
+operating during such a tour as I am now making. I have so far in the
+last month performed over seventy trephinings in ten cities, and in
+twice as many clinics. To adapt one's self to different clinical
+methods, different assistants and different nurses is so difficult that,
+as you are aware, many distinguished surgeons refuse to work out of
+their own clinics. One cannot expect the results of such a tour to be on
+a par with those one obtains in one's own quiet daily surroundings. I
+am, however, confident that you will make a generous allowance<span class='pagenum'><a name="Page_111" id="Page_111">[Pg 111]</a></span> for
+these difficulties, and I gladly welcome the suggestion that all the
+cases which I have operated on in America be collected together and
+reviewed as a whole.</p>
+
+<p>Fifth: In conclusion I would like to express the pleasure with which I
+listened to Dr. de Schweinitz' paper. I believed from the title that
+there might be a wide divergence of opinion between us. I find to my
+great relief that we are in absolute accord. I know, however, that there
+are in America and elsewhere able men who consider that the medical
+treatment of glaucoma should be pushed as long as possible. I cannot but
+feel that this is a survival of the dread that most surgeons have felt
+in recommending one of the older operations for glaucoma. We have now in
+our hands a method so safe, so easy and so certain that I feel sure that
+this dread will ere long pass away, and that the diagnosis of glaucoma
+will then be followed by a very early operation. In India I have gone
+farther than this, and where<span class='pagenum'><a name="Page_112" id="Page_112">[Pg 112]</a></span> one eye has shown high tension, I have
+frequently trephined both. The prophylactic use of the operation is more
+than justified in that land of long distances and scattered medical aid,
+and where the patient is not likely to return a second time for surgical
+help. This prophylactic trephining is a proposition that I put before
+you today for your consideration, reminding you at the same time that
+glaucoma is practically invariably a bi-lateral condition. I have seen
+even in America not a few people blind in both eyes who might have
+retained the sight of the second eye had the surgeon advised a double
+sclerectomy when he first saw the case, despite the fact that the second
+eye was then to all appearances non-glaucomatous.</p>
+
+<hr />
+
+<p><span class='pagenum'><a name="Page_113" id="Page_113">[Pg 113]</a></span></p>
+
+<h2><a name="Dr_Robert_Henry_Elliots_Paper_on_Trephining_for_Glaucoma" id="Dr_Robert_Henry_Elliots_Paper_on_Trephining_for_Glaucoma"></a>Dr. Robert Henry Elliot's Paper on Trephining for Glaucoma</h2>
+
+<h3>Discussion,<br /><span class="smcap">Frank C. Todd</span>, M.D.,<br />Minneapolis.</h3>
+
+<p>It is very difficult for one of limited experience to discuss a subject
+presented so ably by Lieutenant Colonel Elliot to whom we are indebted
+for the sclero-corneal trephine operation. He has already over a period
+of a little over four years performed over 900 trephinings, and has made
+a most careful subsequent study of the results of those operations on as
+many cases as he had the opportunity to observe.</p>
+
+<p>Anyone who has read Colonel Elliot's book on the sclera-corneal
+trephining operation will be struck with the fact that he has not only
+had a tremendous experience in ophthalmic surgery, but that he has made
+the best of that unusual opportunity,<span class='pagenum'><a name="Page_114" id="Page_114">[Pg 114]</a></span> and that to a foundation of a
+careful training he has added the experience of twenty-two years of hard
+painstaking work.</p>
+
+<p>I have recently had the privilege of entertaining Colonel Elliot in my
+own city, where I had the opportunity of assisting him and hence closely
+observing his technique in eighteen trephinings. It has since been my
+duty, and responsibility I may add, to care for those eighteen eyes. For
+two years I have been doing the Herbert tongue flap, or a similar
+operation. The results have been highly satisfactory thus far and
+similar to those following the trephining operation, which operation I
+have performed in a number of cases during the past ten months. My
+conclusions as to these two operations are favorable to the trephining
+operation because the Herbert tongue flap operation is much more
+difficult, and hence less certain than the Elliot trephining operation.</p>
+
+<p>The time for discussion does not permit a detailed statement of the
+results nor <span class='pagenum'><a name="Page_115" id="Page_115">[Pg 115]</a></span>experiences in the handling of these trephining cases. Of
+the entire number five totally blind eyes were trephined. Tension was
+reduced in all but one. In that one hemorrhage occurred at the time of
+the operation. One of these blind eyes had not been totally blind longer
+than a few weeks. Hand movement vision developed in this eye. Another
+eye totally blind one year has thus far developed perception of light.
+Of the cases with varying degrees of vision from hand movements to
+six-ninths all but one have either remained the same or shown some
+improvement. The one exception was an eye having six-ninths vision. A
+small button hole iridectomy was made; prolapse of the iris into the
+wound occurred four days later requiring incision. Upon incision of the
+prolapse intra-ocular hemorrhage occurred, causing nearly total
+blindness for two weeks. Vision is clearing fast and it remains yet to
+be seen what the final results may be. One buphthalmic eye trephined by
+myself gave good results.</p>
+
+<p><span class='pagenum'><a name="Page_116" id="Page_116">[Pg 116]</a></span></p><p>I have as yet seen no cases of remote infection, but the report of
+Axenfeld and some others would indicate that this occurred following the
+Lagrange as well as the trephining operation, the then bulging
+conjunctiva having become eroded and infection having taken place
+through the eroded conjunctiva as shown when stained with flourescin.</p>
+
+<p>The opinion, not yet conclusive, that I have thus far formed as a
+consequence of my experience and the information obtained from others of
+greater experience is as follows:</p>
+
+<p>First: That in those cases of chronic glaucoma in which iridectomy has
+been of benefit in preventing or retarding the oncoming of blindness,
+the result has apparently been secured by reason of the fact that
+filtration has been produced, and not merely because a piece of iris has
+been removed.</p>
+
+<p>Second: That in chronic glaucoma (in acute glaucoma iridectomy has
+proven a<span class='pagenum'><a name="Page_117" id="Page_117">[Pg 117]</a></span> satisfactory operation) when the progress of the disease
+cannot be arrested by non-surgical treatment (an even in some of these,
+where, for instance the patient cannot be kept under observation or will
+not carry out the treatment) some form of operation intended to produce
+filtration should be performed.</p>
+
+<p>Third: The Elliot sclero-corneal trephining operation carefully
+performed in accordance with the author's technique in the light of our
+present knowledge seems to be the best and safest operation to produce
+that result.</p>
+
+<p>Fourth: That to glaucoma may be added buphthalmos and staphyloma, as
+diseases often capable of relief by trephining and indeed toward the
+relief of which trephining is the best form of operation yet presented.</p>
+
+<p>Fifth: That the results secured when the operation is well done and the
+after care is properly followed out are satisfactory, in that the
+operation in a large <span class='pagenum'><a name="Page_118" id="Page_118">[Pg 118]</a></span>proportion of cases apparently permanently lowers
+the tension to normal or below normal, relieves pain, prevents the
+oncoming blindness (otherwise inevitable) and in many cases causes an
+improvement in the acuity of vision, in the visual field. And in
+occasional cases of blindness of not too long duration, it restores some
+vision, occasionally to a marked degree.</p>
+
+<p>Sixth: That it is not a simple nor easy operation and should, therefore,
+be performed only by an operator well trained in ophthalmic surgery. The
+careful and skillful technique of the originator of the operation
+perhaps accounts for his greater success in its results and those who
+perform the operation should follow his technique and be capable of
+handling complications that may later arise.</p>
+
+<p>In conclusion, Mr. President, I wish to say that we ophthalmologists the
+world over are indebted to Lieutenant Colonel Elliot not alone for his
+contributions to our knowledge, but for his persistence<span class='pagenum'><a name="Page_119" id="Page_119">[Pg 119]</a></span> against
+precedent and criticism in establishing the facts upon which rest the
+foundation for the success of his operation, and for so emphasizing the
+great importance of this epoch-making achievement.</p>
+
+<p>It is because we respect his wisdom gained by incessant study and
+experience in a country where climatic conditions are such that a man of
+ordinary energy would have failed to do even average work that we so
+readily welcome the teaching of this enthusiastic evangelist.</p>
+
+<p>His pilgrimage to our country will be the means of starting many in this
+new field, and we shall soon be able to draw more definite and final
+conclusions from our own experiences.</p>
+
+<hr />
+
+<p><span class='pagenum'><a name="Page_121" id="Page_121">[Pg 121]</a></span></p>
+
+<h2><a name="Operations_Other_than_Scleral_Trephining_for_the_Relief_of_Glaucoma" id="Operations_Other_than_Scleral_Trephining_for_the_Relief_of_Glaucoma"></a>Operations Other than Scleral Trephining for the Relief of Glaucoma</h2>
+
+<h4>BY</h4>
+
+<h3><span class="smcap">Casey A. Wood</span>, M.D.,<br />Chicago.</h3>
+
+<p>In this paper I shall say a few words about the large number of
+operative procedures that, apart from trephining, or, preferably,
+<i>trepanation</i>, have been urged in the treatment of the various forms of
+glaucoma. Their name is legion and among them we find peripheral
+iridectomy; anterior sclerotomy; irido-sclerotomy; scleriritomy; de
+Wecker's dialysis of the iris; Hancock's division of the ciliary muscle;
+the incision of the iridian angle of de Vincentiis; sclero-cyclo-iridic
+puncture; the Sterns-Semmereole <span class='pagenum'><a name="Page_122" id="Page_122">[Pg 122]</a></span><i>sclerotomia antero-posterior</i>; the
+<i>transfixio iridis</i> of Fuchs; Antonelli's peripheral iritomy; Holth's
+formation of a cystoid cicatrix; Hern's operation; Terson's
+sclero-iridectomy; Abadie's ciliarotomy; Ballantyne's incarceration of
+iris method; Masselon's small equatorial sclerotomy; Simi's equatorial
+sclerotomy; Galezowski's sclero-choriotomy; excision of the cervical
+ganglion; removal of the ciliary ganglion; Querenghi's operation of
+sclero-choriotomy; Bettremieux's simple anterior sclerectomy; Heine's
+cyclodialysis; Herbert's wedge-isolation operation; Verhoeff's operation
+with a special sclerotome; Holth's sclerectomy with a punch-forceps;
+Walker's hyposcleral cyclotomy; posterior sclerotomy; T-shaped
+sclerotomy; and last but not least the Lagrange form of sclerectomy with
+its various modifications by Brooksbank James, myself and others.</p>
+
+<p>In addition to the foregoing list&mdash;which is by no means complete&mdash;there
+are several combinations of operations, as, for example, the Fergus
+trephining operation, which is<span class='pagenum'><a name="Page_123" id="Page_123">[Pg 123]</a></span> really a combination of a sclero-corneal
+trepanation and a cyclodialysis.</p>
+
+<p>So far as it is practicable there is a certain amount of wisdom in
+comparing the results of an operative procedure with others with which
+it is brought in competition, and I believe we are even now in a
+position to form at least some idea of the comparative value of the
+three methods that comprise the great majority of interventions made use
+of by ophthalmic surgeons at the present time. I refer to <i>iridectomy</i>,
+the <i>Lagrange operation</i>, and the <i>Elliot operation</i>. So far as regards
+the last named procedure, I congratulate this Society that it has had an
+opportunity of seeing a demonstration and hearing a discussion by the
+famous ophthalmic surgeon who perfected it.</p>
+
+<p>As regards the others let me recommend to you the complete description
+of them given by Posey in <i>A System of Ophthalmic Operations</i>.</p>
+
+<p>Let us consider the first of the three<span class='pagenum'><a name="Page_124" id="Page_124">[Pg 124]</a></span> procedures just
+mentioned&mdash;<i>iridectomy</i>&mdash;introduced by von Graefe. The mechanism of its
+mode of cure is best studied in cases of acute primary glaucoma, when
+there is apposition of the periphery of the iris to the cornea. In these
+acute cases there is probably only a mere <i>apposition</i>, and the blocking
+up of the sclero-iridian angle is largely mechanical. Here the root of
+the iris is readily removed in its entirety and a really peripheral
+iridectomy is easily done. When, however, a true <i>adhesion</i> between
+corneal and iridic tissue takes place the filtration angle is not so
+easily opened. True peripheral adhesions are not readily broken up or
+separated, and the iridectomy is, for that reason at least, not
+effective. Moreover, this form of anterior synechia (resulting from a
+true union of iris and cornea) is so intimate that the iris root is, by
+the iridectomy, torn away only at the sclero-iridian angle at the
+anterior border of the adhesion&mdash;and does not open up a channel into
+Schlemm's canal. It<span class='pagenum'><a name="Page_125" id="Page_125">[Pg 125]</a></span> is not, therefore, difficult to understand why
+iridectomy alone in any of the forms of chronic glaucoma fails to open
+up the true filtration spaces and does not provide a drain that permits
+of an escape of fluid from the posterior chamber through the loose
+tissue that surrounds it into the canal of Schlemm. Treacher Collins
+found, after a careful examination of eyes upon which iridectomy had
+been performed for glaucoma, that it is extremely rare for the initial
+section to pass through the pectinate ligament, while Schlemm's canal
+invariably escapes. Moreover, since the sclero-corneal incision is
+uniformly oblique, the position and extent of the external wound does
+not always furnish evidence of the character of the internal wound. In
+all likelihood many cases of relief or cure following iridectomy are
+those due to the formation of cystoid scars or minute fistulae, rather
+than as a result of the removal of a portion of the iris periphery.</p>
+
+<p>The best brief tabulation of the results<span class='pagenum'><a name="Page_126" id="Page_126">[Pg 126]</a></span> obtained by iridectomy, in
+glaucoma, is to be found in Weeks' textbook on <i>Diseases of the Eye</i>,
+page 417: "Sulzer reports as follows: Acute glaucoma, 149 cases;
+improved, 72.5 per cent; serviceable vision preserved, 11.3 per cent;
+vision impaired at once, 4.08 per cent; very little vision, 12.12 per
+cent.</p>
+
+<p>"Zentmeyer and Posey: In simple glaucoma central vision increased in 60
+per cent; remained the same in 20 per cent; diminished in 20 per cent.</p>
+
+<p>"Wygodski: Inflammatory glaucoma, 37 cases; improvement, 76 per cent;
+unimproved, 5 per cent; deterioration, 19 per cent. Sub-acute (chronic
+inflammatory), 147 cases; improvement 10 per cent; unimproved (condition
+the same as before iridectomy), 40 per cent; deterioration, 30 per cent;
+blindness, 20 per cent. Cases operated on at an early stage gave 85 per
+cent of good results. Simple glaucoma, 104 cases; improvement, O.96 per
+cent; condition as before, 10.5 per cent; <span class='pagenum'><a name="Page_127" id="Page_127">[Pg 127]</a></span>deterioration, 52 per cent;
+amaurosis, 36.5 per cent.</p>
+
+<p>"Hahnloser and Sidler: One hundred seventy-two eyes observed not less
+than ten years after operation; acute inflammatory, 31 eyes; good
+results, 64 per cent; relatively good, 13 per cent; blind 23 per cent;
+chronic inflammatory, 37 eyes; good result, 29.9 per cent; relatively
+good, 27 per cent; blind, 43 per cent; simple glaucoma, 76 eyes; good
+results, 42 per cent; relatively good, 28.9 per cent; blind, 28.9 per
+cent."</p>
+
+<p>As far as the <i>Lagrange procedure</i> is concerned, you will remember that
+after eserinization an oblique incision is made through the sclera by
+means of a narrow Graefe knife and a large conjunctival flap secured.
+This is obtained by making a peripheral section of the sclero-corneal
+margin with the knife and, as soon as the edge of the knife reaches the
+upper limit of the anterior chamber, it is turned backward and brought
+out through the sclera obliquely. The conjunctival flap thus formed is<span class='pagenum'><a name="Page_128" id="Page_128">[Pg 128]</a></span>
+turned back over the cornea, and the fragment of sclera that is left
+attached to the cornea is removed by means of a fine pair of delicate
+curved scissors. Following this an iridectomy is performed. The
+conjunctival flap is now replaced and a bandage applied.</p>
+
+<p>This operation opens a large filtration passage for the intra-ocular
+fluids and the prompt healing of the wound with its mucous covering
+prevents prolapse of the iris.</p>
+
+<p>Under no circumstances must iris be left between the lips of the wound.</p>
+
+<p>Although Lagrange advocated iridectomy in all cases in his first
+communication, he no longer judges the procedure to be necessary in all
+instances, reserving it for cases in which for any reason, such as
+hypertension, prolapse is to be feared.</p>
+
+<p>While Lagrange holds that it is necessary to open the anterior chamber,
+Bettremieux thinks that a removal of but a portion of the thickness of
+the sclera <span class='pagenum'><a name="Page_129" id="Page_129">[Pg 129]</a></span>suffices. His procedure is as follows: After raising a flap
+of conjunctiva from the neighborhood of the limbus a medium sized
+needle, curved and flattened towards its point and firmly grasped in a
+needle holder, is thrust superficially into the sclera tangentially to
+the upper edge of the cornea, so as to become fixed in the capsule of
+the eyeball. A small shaving of the sclera, about &frac12; mm. thick, 1&frac12;
+to 2 mm. broad and from 2 to 3 mm. long, is then excised by means of a
+narrow Graefe knife. The scleral slip is then freed from the conjunctiva
+at each end and the mucous membrane brought together over the wound by
+fine catgut sutures.</p>
+
+<p>As you are well aware, numerous operators regard the Lagrange operation
+as superior to the iridectomy of von Graefe because they believe there
+is filtration through the newly formed tissue between the lips of the
+operative wound. Among those of many observers the conclusions of
+Ballantyne may be quoted: "The <span class='pagenum'><a name="Page_130" id="Page_130">[Pg 130]</a></span>results of sclerectomy vary according to
+the degree of hypertension of the eye operated on. Three varieties of
+cicatrix are distinguishable according to the amount of sclera excised:
+(1) that in which there is mere thinning of the sclera owing to the
+excised portion not reaching the posterior surface of the cornea
+(conjunctiva smoothly covers the cicatrix); (2) that represented by a
+subconjunctival fistulette, due to excision of the whole thickness of
+the sclera, in an eye with moderate tension (the conjunctiva lies
+smoothly over the cicatrix); (3) the fistulous cicatrix with an
+ampulliform elevation of the overlying conjunctiva, resulting from
+excision of the whole thickness of the sclera in an eye the seat of high
+tension. In cases of high tension, even a simple sclerectomy will allow
+ample filtration, owing to the gaping of the wound, while in cases
+without elevation of the tension, sclerectomy will be quite ineffectual.
+Lagrange therefore proposes the following rules of procedure: (a) If<span class='pagenum'><a name="Page_131" id="Page_131">[Pg 131]</a></span>
+tensions is normal to +1, do sclerectomy without iridectomy, the amount
+of sclera excised being inversely proportionate to the degree of
+hypertension. (b) If tension is +1 to +3, do sclerotomy-iridectomy, the
+iridectomy being added to avoid entanglement of the iris. Lagrange does
+not recommend his operation for acute glaucoma. It is especially adapted
+for cases of chronic simple glaucoma."</p>
+
+<p>During the past ten years or more I have been doing a modification of
+the Lagrange operation, the details of which (The Operative Treatment of
+Glaucoma with Special Reference to the Lagrange Method, <i>The Canadian
+Medical Association Journal</i>, November, 1911) I have elsewhere
+published.</p>
+
+<p>As stated in this paper I have modified the procedure to the extent of
+removing <i>all</i> the conjunctiva attached to the borders of the operative
+wound. I admit that this intervention exposes the root of the iris and
+the ciliary body, but I have never yet<span class='pagenum'><a name="Page_132" id="Page_132">[Pg 132]</a></span> had the slightest infection of
+the wound. I attribute this freedom from sepsis to careful cleansing of
+the conjunctival sac and to other pre-operative precautions, but
+especially to the use, before and after the operation, of White's
+ointment&mdash;a preparation of 1-3000 mercuric chloride in sterile vaseline.
+One cannot use sublimate in such a strong <i>watery</i> solution, but the
+vaseline seems to modify it and to allow of such slow absorption that it
+is not only a non-irritant but a most excellent antiseptic application
+in operations on the eye.</p>
+
+<p>In any event the result of the Lagrange operation proper, as well as my
+modification of it, is to produce a drainage-oedema about the incisional
+wound which persists almost indefinitely. In many cases this swelling
+amounts to a bleb which may be increased by massage of or pressure upon
+the eyeball. The efficacy of the operation in lowering intra-ocular
+tension is to some extent measured by the degree and the constancy of
+this epibulbar oedema; indeed,<span class='pagenum'><a name="Page_133" id="Page_133">[Pg 133]</a></span> I suspect that the most successful
+examples are those in which sclera fistulae, minute or otherwise, form
+as a sequel of the operation.</p>
+
+<p>My object in excising the conjunctiva about the sclero-corneal flap, is
+to delay union of the wound edges, to widen the bridge of loose
+cicatricial tissue between them, to prevent such a complete growth of
+the endothelium as would cover the wound and block the exit of fluids,
+and to insure intra-ocular rest.</p>
+
+<p>In cases of <i>chronic</i> increase of intra-ocular tension associated with a
+quiet uveitis or an iridokeratitis, when the patient exhibits traces of
+old synechiae, or where there is danger of their re-formation, I do not
+hesitate to use atropia as long as the wound of operation has not
+healed.</p>
+
+<p>To the present time I have done 72 operations of the sort and have seen
+no reason to alter the opinion of it expressed in the article mentioned.
+Whatever objection may in the future arise&mdash;and I freely <span class='pagenum'><a name="Page_134" id="Page_134">[Pg 134]</a></span>confess that
+it <i>seems</i> to be fraught with the dangers that many of my colleagues
+have pointed out as probable&mdash;I have so far not seen a single case of
+infection of the wound of operation. While I believe the
+anti-glaucomatous results to be excellent, I may also claim that the
+operation is of the simplest character; and it is easy of performance
+and the resulting filtration-scar is large and (perhaps) more permeable
+to the changed intra-ocular fluids than the quicker healing wounds of
+the usual Lagrange and Elliot procedures.</p>
+
+<p>It is regarded by most operators as desirable that there should not be
+long delayed healing of the operative wound, and the fact that the
+conjunctiva covers the incision is often spoken of as an advantage,
+partly because it shields the large open area produced by the Lagrange
+incision from infection.</p>
+
+<p>My experience of this modified operation continues to be that it is
+necessary to clear the neighborhood of the operation wound<span class='pagenum'><a name="Page_135" id="Page_135">[Pg 135]</a></span> entirely of
+conjunctiva. If the down-growth of epithelium into the operative wound
+is permitted the effects are by no means as pronounced, and the eventual
+lowering of tension is not as permanent as they otherwise would be.</p>
+
+<p>Another matter: I am satisfied that the delayed filling of the wound by
+connective tissue is desirable in most cases of <i>chronic</i> glaucoma. A
+complete drainage of the intra-ocular fluids that results from long
+delayed union of the wound edges, allows the interior of the eye to
+regain, as far as possible, the <i>status quo ante</i>. On the other hand the
+comparatively early closure of the wound (or the termination of <i>free</i>
+drainage and minus tension) tends to re-establish the <i>status
+glaucamatosus</i>. Whether these desirable results are to be realized or
+not will, of course, depend upon a future experience larger than I have
+yet had. This modification of the Lagrange operation seems to be a
+radical one and I do not expect its adoption until the results<span class='pagenum'><a name="Page_136" id="Page_136">[Pg 136]</a></span> of an
+extended trial are carefully recorded and reported.</p>
+
+<p>Quite recently several operators, who have been in a position to do so,
+have contrasted the results obtained by the Elliot method and those
+following the Lagrange procedure. Probably the most important of these
+observations is the experience of Meller (Die Sklerektomie nach Lagrange
+und die Trepanation nach Elliot) set forth in a paper read by him at the
+last meeting of the <i>Deutsche Naturforscher und Aertze</i>. In this report
+Meller gives an account of 389 sclerectomies following the usual
+Lagrange procedure. Twelve per cent of the cases were of acute glaucoma;
+61.5 per cent of chronic inflammatory glaucoma, and 9 per cent of simple
+glaucoma. The rest of the operations were done in other forms of the
+disease. In more than half the cases the usual iridectomy was performed;
+in 30 per cent the procedure was peripheral; in 4 per cent there was no
+iridectomy. The patients were studied<span class='pagenum'><a name="Page_137" id="Page_137">[Pg 137]</a></span> during a period of five years. In
+more than half the instances there was a pale, cystic, oedematous
+cicatrix; in 11 per cent the scar was ectatic, and in the remainder the
+field of operation was quite flat. The form of the scar was described in
+most instances, but it was not noticed that there was a definite
+relation between the cicatrical formation and the intra-ocular tension.
+In 70 per cent of the cases a good result followed the operation, but in
+10 per cent the result was decidedly unsatisfactory. Cloudiness of the
+lens set in in 4 per cent of the cases, while posterior synechiae
+developed in the great majority of them. In 2.3 per cent the eye was
+attacked by iridocyclitis and in 3.4 per cent enucleation was found to
+be necessary. Six eyes became atrophic but were not, for various
+reasons, removed. One and three-tenths per cent of the eyes operated on
+were lost from late infection. Vitreous was lost in 6.2 per cent. Two
+eyes became blind from expulsive hemorrhage. The<span class='pagenum'><a name="Page_138" id="Page_138">[Pg 138]</a></span> large majority of
+these complications arose in the eyes operated on for chronic glaucoma.
+There were fewer eyes lost following the operation for glaucoma simplex
+than in the other forms of the disease. Recurrences were noticed in 11.3
+per cent of all the cases; in simple glaucoma 14.3 per cent as against
+the acute and chronic forms with 6 per cent. A return of the glaucoma
+was noticed in 7 per cent of the pale, oedematous, post-operative scars,
+in 16 per cent of the flat cicatrices, and in 24 per cent of the ectatic
+variety. Considerable stress is laid upon the fact of the marked
+softness of the eyes after each operation. There were histological
+examinations made of the eyeballs in 11 cases, in which the position of
+the incision and excision, the development of the scar tissue, and the
+appearance of the complications were duly set forth. The operator then
+gave a history of over 178 trepanations after the Elliot method and
+compares them with the procedure of Lagrange. He concludes that<span class='pagenum'><a name="Page_139" id="Page_139">[Pg 139]</a></span> the
+Elliot trephining operation is less dangerous, is more likely to be
+followed by the development of a cystic scar, and leads to loss of the
+eye in only 2.4 per cent of the eyes operated on. In Elliot's cases the
+percentage of relapse was more noticeable than in the Lagrange cases
+where no iridectomy was done. This observer concludes that the method of
+Elliot is to be preferred to that of Lagrange, and that in the former
+case iridectomy is an important factor in obtaining a favorable result.
+This being the case one cannot truthfully say that trephining alone can
+take the place of the old Graefe iridectomy. On the other hand,
+trephining may with advantage be employed instead of iridectomy for
+cases difficult or dangerous under the latter method.</p>
+
+<p>Whatever difference of opinion was noticeable at the Vienna meeting, all
+of those present, especially Meller, the reader of the paper just
+quoted, were decidedly of the opinion that the Elliot operation is in<span class='pagenum'><a name="Page_140" id="Page_140">[Pg 140]</a></span>
+every respect the one best adapted to buphthalmia, or congenital
+glaucoma.</p>
+
+<p>In conclusion let me say that the acceptance or rejection of Colonel
+Elliot's procedure or any other operation is not to be decided by the
+percentage of iritis, secondary cataract, relapses, lost eyes, etc., but
+by deciding whether or not his procedure in the various forms of
+glaucoma gives the best results, including the preservation of
+comfortable eyes. In other words, we are seeking not the operation that
+will cure <i>every</i> case of glaucoma but the one which is capable, <i>in the
+hands of the average ophthalmic surgeon</i>, of relieving or curing <i>most</i>
+cases of that affection.</p>
+
+<hr />
+
+<p><span class='pagenum'><a name="Page_141" id="Page_141">[Pg 141]</a></span></p>
+
+<h2><a name="Dr_Casey_A_Woods_Paper_on_Operations_Other_than_Scleral_Trephining" id="Dr_Casey_A_Woods_Paper_on_Operations_Other_than_Scleral_Trephining"></a>Dr. Casey A. Wood's Paper on Operations Other than Scleral Trephining
+for the Relief of Glaucoma</h2>
+
+<h3>Discussion,<br /><span class="smcap">Albert E. Bulson, Jr.</span>, M.D.,<br />Fort Wayne.</h3>
+
+<p>Increasing belief in Colonel Elliot's view that trephining should be the
+operation of choice in any form of glaucoma, makes it difficult to
+consider operations other than trephining in anything but a spirit of
+disfavor.</p>
+
+<p>Until recently the decision as to the kind of operative procedure to be
+employed for the relief of glaucoma has depended on the form and stage
+of the disease, and the amount and character of the vision of the
+affected eye. Many operators still hold that an iridectomy is the most
+valuable of all operations for acute inflammatory <span class='pagenum'><a name="Page_142" id="Page_142">[Pg 142]</a></span>glaucoma, and not a
+few hold that the operation has a decided place in the treatment of
+simple glaucoma. The operation is not without difficulties, and one is
+inclined to agree with Elliot who says that "The man who can make a
+'finished iridectomy' quietly and cleanly has graduated as an ophthalmic
+operator." The difficulties of an iridectomy are especially pronounced
+in those cases in which the anterior chamber is extremely shallow and
+the iris is pressed against the cornea. It is in such cases that the
+success of the operation is increased by the addition of posterior
+sclerotomy and the intelligent use of miotics prior to the performance
+of the iridectomy. Even then the permanent results of the iridectomy
+will be modified in proportion to the success secured in freeing the
+filtration angle and opening Schlemm's canal by thorough removal of the
+root of the iris.</p>
+
+<p>The failure of many apparently well executed iridectomies may be
+attributed to the fact that the iris is not removed to<span class='pagenum'><a name="Page_143" id="Page_143">[Pg 143]</a></span> the extreme
+root, and the remaining stump is sufficient to block the drainage. This
+is especially apt to be the case in chronic glaucoma where the iris is
+adherent to the cornea, and in efforts to free the filtration angle by
+an iridectomy the iris is torn off in front of the adhesion and the
+filtration angle is not opened.</p>
+
+<p>As Elliot has pointed out, iridectomy is most open to attack on the
+ground of safety. We have to take into account the large scleral wound
+made, and the fact that this lies close to the ciliary body. The sudden
+release of all tension and the simultaneous weakening of the supports of
+the lens and vitreous body create very unfavorable conditions under
+which to make the crucial step of the operation.</p>
+
+<p>The poor results following an iridectomy in chronic glaucoma have led to
+the devising of many substitute operations, of which those tending to
+the production of a filtering scar are now preferred, and, experience
+shows, hold out the most hope of bringing<span class='pagenum'><a name="Page_144" id="Page_144">[Pg 144]</a></span> about long continued relief.
+It even is considered probable that the effects of an iridectomy which
+brings about more or less permanent reduction in the intra-ocular
+pressure is due to the formation of a filtering scar which augments
+whatever results may have been secured in the attempt to open up the
+drainage into the canal of Schlemm.</p>
+
+<p>Dr. Wood has referred to several of the many substitutes for iridectomy
+that have been proposed, and it is unnecessary to enumerate them again
+or to attempt to point out their good or bad features. It is sufficient
+to say that for the average operator and the larger per cent of cases,
+the operation which is easiest to perform, is attended with the least
+risk and offers the best hope of permanent results should be the one of
+choice. Sympathectomy has failed to secure a place in ophthalmic
+surgery, sclerotomy has not been found adequate, and cyclodialysis is
+not sufficiently simple of execution or permanently <span class='pagenum'><a name="Page_145" id="Page_145">[Pg 145]</a></span>beneficial in its
+results to give it prominence.</p>
+
+<p>Of the operations proposed for the formation of a filtering cicatrix,
+those of Elliot and Lagrange are justifiably the most popular. Those of
+us who have had the pleasure of seeing the trephining operation done by
+Col. Elliot are impressed with the fact that the operation, even in the
+hands of its originator, is not, when properly done, uniformly easy of
+performance. It does, however, offer the advantage of carrying with it
+the minimum amount of risk, and the apparently permanent results secured
+justify the ophthalmologist in acquainting himself with the technique of
+the operation, for, as pointed out by Sydney Stephenson and others, "the
+technique is responsible for success or failure." Furthermore, there is
+no sufficient reason why the field of usefulness of the operation should
+be confined to the chronic forms of glaucoma, and Col. Elliot
+unhesitatingly recommends trephining as safer and more efficient than
+any<span class='pagenum'><a name="Page_146" id="Page_146">[Pg 146]</a></span> other operative procedures at present employed for the relief of
+acute glaucoma.</p>
+
+<p>The success of the Lagrange operation, which, like the Elliot operation,
+aims to produce a fistulous communication between the anterior chamber
+and the sub-conjunctival area, depends upon securing the removal of a
+relatively large section of all of the layers of the scleral and corneal
+lip of the wound, so that a permanent opening, covered by the replaced
+conjunctival flap, is made. Unlike the trephine operation which was
+evolved from it, the Lagrange operation requires the same kind of an
+opening of the eyeball as required for a well executed iridectomy, and a
+properly placed section entirely in scleral tissue, with a good sized
+conjunctival flap, are elements which enter into the ultimate success or
+failure of the procedure.</p>
+
+<p>Aside from the dangers incident to a wide incision in the neighborhood
+of the ciliary body and the possibility of accident to the lens or
+vitreous body, or of <span class='pagenum'><a name="Page_147" id="Page_147">[Pg 147]</a></span>intra-ocular hemorrhage, there is for the average
+operator the added difficulty and danger in removing a piece of sclera
+of the exact size required. The technique of the operation is even more
+difficult and exacting than in the performance of the trephine
+operation, and it also compares unfavorably in safety.</p>
+
+<p>The advisability of removing the conjunctival flap, as advocated by Dr.
+Wood, as a modification of the Lagrange operation, may be seriously
+questioned, for aside from the fact that apparently no advantages in
+aiding permanent filtration are added, there is, added to the objections
+to the Lagrange operation already mentioned, the very serious
+disadvantage of subjecting the area at the root of the iris to infection
+for a prolonged period of time. The advantages of the protection
+afforded by a conjunctival flap far outweigh the disadvantages of a
+remotely possible interference of drainage by the blocking of the open
+wound with conjunctival tissue. The<span class='pagenum'><a name="Page_148" id="Page_148">[Pg 148]</a></span> fortunate experience of Dr. Wood in
+not having infection in a wound which remains open and unprotected for
+variable lengths of time is not likely to be the experience of any
+considerable number of operators, and probably will not always be the
+experience of Dr. Wood. Furthermore, the possibilities of damage by
+hemorrhage from the choroidal or retinal vessels, delayed formation of
+the anterior chamber and adhesion of the capsule of the lens to the
+wound, and the injurious effects of even slight trauma subsequent to the
+operation, including loss of vitreous, are increased by omitting the
+conjunctival flap.</p>
+
+<p>The modern operation for the relief of glaucoma, by which a filtering
+scar is produced which permits escape of liquid from the anterior
+chamber, is the one which apparently holds out the most hope of
+permanently relieving the condition. While success will depend always to
+a certain extent upon the personal equation,<span class='pagenum'><a name="Page_149" id="Page_149">[Pg 149]</a></span> yet it seems now that for
+a large majority if not all of the cases we are justified in abandoning
+all other operations than trephining, notwithstanding the verdict of
+Elschnig and others that fistula forming operations eventually will be
+discarded in favor of iridectomy and cyclodialysis.</p>
+
+<p>Late or secondary infection, not unknown following iridectomy, may
+follow the trephine operation, and already some fifteen or sixteen cases
+have been reported. But while this possibility is a real danger, which
+improved technique may greatly minimize (Col. Elliot has not seen a case
+of secondary infection in an experience of over 1200 trephining cases of
+his own and a large number of others performed by his assistants and
+pupils) the ultimate verdict must rest with results as compared with
+other measures. At present, as pointed out by Meller, whose statistics
+Dr. Wood has cited, trephining heads the list of remedial measures for
+the relief of glaucoma, and it has the advantage of<span class='pagenum'><a name="Page_150" id="Page_150">[Pg 150]</a></span> being applicable to
+any form of the disease, to be relatively free from danger, either
+immediate or remote, and to produce the highest percentage of favorable
+results. The addition of an iridectomy in every case of trephining does
+not unduly complicate the operation and has much to commend it in
+offering the patient every possibility of relief.</p>
+
+<div class = "mynote"><p class="center">Transcriber's Note:<br /><br />
+The index has been moved to the beginning of the text and has been used as a table of contents.</p></div>
+
+
+
+
+
+
+
+
+
+<pre>
+
+
+
+
+
+End of the Project Gutenberg EBook of Glaucoma, by Various
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+</body>
+</html>
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@@ -0,0 +1,2894 @@
+The Project Gutenberg EBook of Glaucoma, by Various
+
+This eBook is for the use of anyone anywhere at no cost and with
+almost no restrictions whatsoever.  You may copy it, give it away or
+re-use it under the terms of the Project Gutenberg License included
+with this eBook or online at www.gutenberg.org
+
+
+Title: Glaucoma
+       A Symposium Presented at a Meeting of the Chicago
+       Ophthalmological Society, November 17, 1913
+
+Author: Various
+
+Editor: Willis O. Nance
+        Wesley Hamilton Peck
+
+Release Date: November 19, 2007 [EBook #23544]
+
+Language: English
+
+Character set encoding: ASCII
+
+*** START OF THIS PROJECT GUTENBERG EBOOK GLAUCOMA ***
+
+
+
+
+Produced by Bryan Ness, Martin Pettit and the Online
+Distributed Proofreading Team at http://www.pgdp.net (This
+book was produced from scanned images of public domain
+material from the Google Print project.)
+
+
+
+
+
+
+GLAUCOMA
+
+A SYMPOSIUM PRESENTED AT A MEETING OF THE
+CHICAGO OPHTHALMOLOGICAL SOCIETY,
+NOVEMBER 17, 1913.
+
+EDITED BY
+
+WILLIS O. NANCE, M.D.,
+
+PRESIDENT CHICAGO OPHTHALMOLOGICAL SOCIETY (1913); OPHTHALMIC
+SURGEON, ILLINOIS CHARITABLE EYE AND EAR INFIRMARY; FORMER
+OCULIST AND AURIST, COOK COUNTY HOSPITAL; EDITOR
+JOURNAL OF OPHTHALMOLOGY AND OTO-LARYNGOLOGY,
+
+AND
+
+WESLEY HAMILTON PECK, M.D.,
+
+PRESIDENT CHICAGO OPHTHALMOLOGICAL SOCIETY (1914); FORMER
+PROFESSOR OPHTHALMOLOGY, CHICAGO EYE, EAR, NOSE AND
+THROAT COLLEGE; ASSISTANT SURGEON, ILLINOIS
+CHARITABLE EYE AND EAR INFIRMARY;
+OPHTHALMIC SURGEON, OAK
+PARK HOSPITAL.
+
+1914
+CHICAGO MEDICAL BOOK COMPANY
+CHICAGO
+
+
+COPYRIGHT 1914
+BY
+CHICAGO MEDICAL BOOK COMPANY
+
+
+
+
+CONTRIBUTORS
+
+EDWARD JACKSON, A.M., M.D.
+Prof. Ophth. Univ. Colo.; Emer. Prof. Ophth. Phila. Polyclinic; Ex-Ch.
+Sec. Ophth. A.M.A.; Ex-Pres. Am. Acad. Med. and Am. Acad. Ophth. and
+Oto-Laryng.; Mem. Am. Ophth. Soc. and Honorary Mem. Chicago Ophth.
+Society.
+
+JOHN ELMER WEEKS, M.D., D.Sc.
+Prof. Ophth. Univ. and Bellevue Hosp. Med. Coll., N.Y.; Ophth. Surg.
+N.Y. Eye and Ear Inf.; Mem. Am. Ophth. Soc.; Hon. Mem. Chicago Ophth.
+Soc. and Royal Hungarian Med. Soc. Budapest.
+
+GEORGE EDMUND DE SCHWEINITZ, A.M., LL.D., M.D.
+Prof. Ophth. Univ. Penn.; Ophth. Surg. Univ. Hosp., Phila. Hosp.,
+Orthop. Hosp. and Inf. for Nerv. Dis.; Consult. Ophth. Surg, Phila.
+Polyclinic; Honorary Member Chicago Ophth. Soc.
+
+ROBERT HENRY ELLIOT, M.D., B.S. LOND., Sc.D. EDIN., F.R.C.S. ENG., ETC.,
+LIEUT.-COLONEL, I.M.S.
+Supt. Gov. Ophth. Hosp., Madras. India; Prof. Ophth. Med. Coll., Madras;
+Fellow Univ. of Madras; Honorary Member Chicago Ophthalmological
+Society, U.S.A.
+
+CASEY A. WOOD, M.D., C.M., D.C.L.
+Prof. Ophth. Univ. Ill.; Late Prof. Ophth. N. W. Univ.; Ex-Pres. Am.
+Acad. of Med.; Am. Acad. Ophth. and of the Chicago Ophth. Soc.;
+Ophthalmic Surg. St. Luke's Hosp.; Consulting Ophth. Surg. St. Luke's
+and Cook County Hosp.; Ex-Ch. Ophth. Sec. A.M.A.; Editor System Ophth.
+Therapeutics. Sys. Ophth. Operations and American Encylopedia
+Ophthalmology.
+
+FRANCIS LANE, A.B., M.D.
+Pathologist and Asst. Ophthalmic Surgeon Ill. Char. Eye and Ear Inf.;
+Instructor in Ophth. Rush Med. Coll.; Asst, Ophth. Surg. Presbyterian
+Hospital.
+
+E. V. L. BROWN, M.D.
+Asst. Prof. Pathology of the Eye, Univ. Chicago; Asst. Prof. Ophth. Rush
+Med. College; Ophth. Surg. Ill. Eye and Ear Inf. and Cook County Hosp.;
+Mem. Am. Ophth. Soc.
+
+NELSON M. BLACK, PH.G., M.D.
+Author of The Development of the Fusion Center in the Treatment of
+Strabismus; Examination of the Eyes of Transportation Employes;
+Artificial illumination a Factor in Ocular Discomfort, etc.
+
+FRANK C. TODD, M.D.
+Prof. Ophth. and Oto-Laryng., Univ. Minn.; Chairman Sec. Ophth. A.M.A.
+and second Vice-Pres. A.M.A.; Ophth. Surg. Univ. and Hill Crest
+Hospital.
+
+ALBERT EUGENE BULSON, JR., B.S., M.D.
+Prof. Ophth. Ind. School Med.; Ex-Ch. Sec. Ophth. A.M.A.; Ophth. Surg.
+St. Joseph's Hospital; Editor Jour. Ind, Slate Med. Assn.
+
+
+
+
+DEDICATED TO
+DR. EDWARD JACKSON
+DR. JOHN E. WEEKS
+DR. GEORGE EDMUND DE SCHWEINITZ
+LIEUTENANT COLONEL ROBERT HENRY ELLIOT
+HONORARY MEMBERS
+BY THE CHICAGO OPHTHALMOLOGICAL SOCIETY
+IN RECOGNITION OF THEIR SPLENDID ACHIEVEMENTS
+IN THE DOMAIN OF OPHTHALMOLOGY
+
+
+
+
+ABSTRACTS.
+
+
+I. Etiology and Classification of Glaucoma.
+
+Abstract:--
+
+Etiologic factors include: obstruction of lymph spaces, especially the
+angle of the anterior chamber; blood pressure, arterial, capillary and
+venous; affinity of tissues for fluids; alterations of the intra-ocular
+fluids; inflammations in the eye ball; and failure of a nerve apparatus
+to control fluid in the globe. Classification: various types of glaucoma
+constituting clinical entities must be recognised, as: simple glaucoma,
+recurring exacerbations, congestive, mechanical, and increased tension
+arising during uveal inflammations.
+
+DR. EDWARD JACKSON, Denver.
+
+Discussion by DR. FRANCIS LANE, Chicago.
+
+
+II. Pathology of Glaucoma.
+
+Abstract:--
+
+(a) Changes taking place in corneal tissue.
+
+(b) Iris angle with particular reference to the ligamentum pectinatum.
+
+(c) Variations in the condition of the ciliary body.
+
+(d) Consideration of the anatomical changes that take place in glaucoma
+secondary to retinal and chorioidal hemorrhage.
+
+DR. JOHN E. WEEKS, New York City.
+
+Discussion by DR. E. V. L. BROWN, Chicago.
+
+
+III. Concerning Non-surgical Measures for the Reduction of Increased
+Intra-ocular Tension.
+
+Abstract:--
+
+(a) The use of myotics; their preparation, method of administration, and
+explanation of their action.
+
+(b) Reduction of increased intra-ocular tension by means of various
+mechanical measures, notably massage, vibration massage, suction
+massage, electricity and diathermy.
+
+(c) Indirect reduction of increased intra-ocular tension, brought about
+by lowering the general vascular pressure.
+
+(d) The relation of osmosis, lymphagogue activity, the absorption of
+edema, the stimulation of capillary contractility, and the lowering of
+the affinity of ocular colloids for water in their relation to the
+reduction of increased intra-ocular tension.
+
+DR. GEORGE EDMUND DE SCHWEINITZ, Philadelphia.
+
+Discussion by DR. NELSON M. BLACK, Milwaukee.
+
+
+IV. Trephining for Glaucoma.
+
+Abstract:--
+
+(a) The aim of the operation is the formation of a foreign-body-free
+fistula.
+
+(b) It is most important to leave uveal tissue untouched.
+
+(c) Method of doing this explained.
+
+(d) The area available for trephining.
+
+(e) Method of increasing that area.
+
+(f) Cornea splitting.
+
+(g) Placing of trephine.
+
+(h) Technique of using trephine.
+
+(i) The operation is not difficult.
+
+(j) The operation valuable as a prophylactic measure.
+
+DR. ROBERT H. ELLIOT, F.R.C.S., Lieut.-Col. I.M.S., Madras, India.
+
+Discussion by DR. FRANK C. TODD, Minneapolis.
+
+
+V. Operations Other than Scleral Trephining for the Relief of Glaucoma.
+
+Abstract:--
+
+Most of the ordinary surgical procedures employed for lowering
+intra-ocular tension furnish a permanent cure of certain fairly well
+defined varieties of glaucoma. They also relieve the symptoms and retard
+the progress of other varieties of the disease, even if they do not
+perform a cure. In a third class of cases, they either have no effect
+whatever in arresting the disease or they hasten its march towards
+blindness.
+
+What operative procedure gives, on the whole, the best results? In other
+words, what operation is the easiest of performance, is the least likely
+to be attended by serious complications and is available for the largest
+number of cases? Reasons for believing that of the better known
+procedures simple iridectomy is the least effective, while those
+interventions producing a large, thin, scleral filtration-cicatrix are
+the most valuable.
+
+DR. CASEY A. WOOD, Chicago.
+
+Discussion by DR. A. E. BULSON, JR., Fort Wayne
+
+
+
+
+Etiology and Classification of Glaucoma
+
+BY
+
+EDWARD JACKSON, M.D.,
+
+Denver.
+
+
+It is convenient to start with the conception that glaucoma is increased
+tension of the eyeball, plus the causes and effects of such increase;
+although a broad survey of the facts may reveal a clinical entity to be
+called glaucoma, without increased tension constantly or necessarily
+present, and cases of increased intra-ocular tension not to be classed
+as glaucoma.
+
+The physiologic tension of the eyeball is essential to ocular
+refraction, and closely related to ocular nutrition. Fully to understand
+the mechanism for its regulation would carry us far toward an
+understanding of the causes of glaucoma. Normal tension is maintained
+with a continuous flow of fluid into the eye and a corresponding
+outflow. Complete interruption of the nutritional stream would be speedy
+death; partial interruption may be held responsible for most of the
+visual impairment and pain of glaucoma.
+
+The balance of intra-ocular pressure is not maintained by the slight
+distensibility of the sclero-corneal coat. Increased pressure does not
+open new channels for the escape of intra-ocular fluid; if, indeed, it
+does not tend to close the normal channels.
+
+The affinity of the tissues for water, or, as Fischer explains it, the
+affinity of the tissue colloids for water, seems too little related to
+the requirements of ocular function to furnish the needed regulation of
+tension. The lymph spaces and blood-channels of the eye are large, as
+compared with the mass of its tissue colloids. In these spaces and
+channels must be sought a means for rapid response to the need for
+regulation of intra-ocular tension. Fischer has shown, that when the
+enucleated eyeball is placed in a weak solution of hydrochloric acid,
+the swelling of the tissue colloids is sufficient in a few hours, to
+burst the sclero-corneal coat. But this is an eye in which all
+nutritional changes have ceased. He brings together many facts to
+support the view that in the living tissues impaired circulation, and
+especially diminished oxidation, are the chief causes of increased
+affinity of the colloids for water. Such affinity increased by the
+impairment of the intra-ocular circulation, may well constitute a factor
+making for malignancy in glaucoma. But it can hardly explain the
+original departure from a normal pressure balance.
+
+We must assume that intra-ocular pressure is kept down to the normal
+limit, by the prompt response of a regulative mechanism, which
+diminishes the flow of fluid into the eye, or permits its more rapid
+escape, whenever fluid tends to accumulate in the eye and increase its
+tension.
+
+Little has been done to show that increase of fluid entering into the
+eye is the cause of glaucoma. A normal, or even a low arterial blood
+pressure is sufficiently above the normal intra-ocular pressure to
+furnish a source of increased fluid in the eye. Increased arterial
+pressure has been found in a large proportion of cases of glaucoma; and
+may be necessary to the production of the highest intra-ocular tension.
+A sudden relaxation of the arterial walls, that would permit the
+arterial blood pressure to make itself felt in the eye, might cause an
+important rise of intra-ocular tension and may be a factor in the
+etiology of acute attacks. It affords a possible mechanism through which
+may be produced the recognized glaucomatous effects of certain nerve
+disturbances. But such attacks are not commonly associated with
+noticeable flushing of the head and face generally; and paralysis of the
+cervical sympathetic is known to lower the intra-ocular tension.
+
+Capillary blood pressure must lie between the arterial blood pressure
+and the venous blood pressure. It must be closely associated with the
+nutritional processes like secretion or inflammation; beyond this we
+know little about it. The association of increased blood pressure with
+glaucoma seems to be generally an indirect one through vascular lesions
+and disturbances of nutrition.
+
+
+_Obstructed Outflow_
+
+A reservoir with a free outlet can only fill during a flood; and then
+quickly empties itself again. The outflow channels in the normal eye
+provide for carrying away of the waste products of such an active
+nutrition, that it is hard to think they will become inadequate in
+glaucoma until there has been a marked decrease from their normal
+capacity. Priestley Smith has pointed out that the glaucomatous eye
+softens more slowly than the normal eye after enucleation, in spite of
+the fact that a greater force is operating to drive fluid out of the
+eye. In his recent tonometric studies Schoenberg noted that under
+manipulation the glaucomatous eye softened more slowly than the normal
+eye; and suggests this diminished drainage as an important evidence of
+glaucoma.
+
+Obstructed outflow might begin in an abnormal tendency of the tissues to
+retain fluid, a tendency that Fischer might locate in the colloids. The
+increase of intra-ocular pressure noted in cases of uveal inflammation,
+to be presently referred to, may be due to some such tendency. But it is
+rational to ascribe to obstruction of the filtration angle of the
+anterior chamber, the important part it has been supposed to play in the
+pathology of glaucoma. However this obstruction may be brought about,
+whether by thickening of the iris root during dilatation of the pupil,
+pushing forward of the iris root by the larger ciliary processes of age,
+or the enlarged crystalline lens pressing on the ciliary processes; or
+by inflammatory adhesion of the iris to the filtration area; ballooning
+of the iris, or its displacement by traumatic cataract; or adhesion to
+the cornea after perforating ulcer in the secondary glaucomas; or
+whether the obstruction is due to the accumulation of experimental
+precipitates, as shown by Schreiber and Wengler, or possibly of pigment
+granules into Fontana's space; or a process of sclerosis closing the
+spaces by contraction of new-formed connective tissue, or the covering
+over with proliferating implanted epithelium following injury opening
+the anterior chamber; glaucoma follows impairment of this drainage
+space, and lessened outflow through it. This blocking of the angle of
+the anterior chamber must be regarded as an established fact in the
+etiology of glaucoma. But because it is so definitely established, and
+because so much work has been done with reference to it, we may attach
+to it an undue importance.
+
+The escape of the outflow of fluid from the eye is ultimately through
+the veins. The general venous blood pressure is so low (often negative
+in the great veins of the neck during inspiration) that no obstacle can
+come from it to the ocular outflow. The venous blood pressure permits
+the eyeball to become perfectly soft. We have all seen tension of 5 mm.,
+or even less; and general venous pressure does not rise to the normal
+intra-ocular tension. Increased intra-ocular pressure requires that
+there must be some obstacle that keeps the intra-ocular fluid from
+reaching the general venous system. This may be in the lymph drainage
+system of the eye; but it may also be in the ocular veins themselves.
+
+Experimentally the eyeball can be made to burst by tying all the venous
+outlets from it. I have seen very high intra-ocular tension develop in a
+few hours after general thrombosis of the orbital veins. The absence of
+the canal of Schlemm is noted in congenital buphthalmos. The enlargement
+of the anterior perforating veins is an old symptom of chronic glaucoma.
+Obstruction to outflow of blood through the vorticose veins, by the
+increased intra-ocular pressure, has long been a recognized explanation
+of the malignant tendency of glaucoma--a part of the vicious circle
+established in this disease. There is reason that we should give careful
+attention to the views of Heerfordt and Zirm, that obstruction to the
+venous outflow may be the effective cause of the disease. Zirm believes
+the venous plexus of the choroid is an essential part of the mechanism
+for the regulation of intra-ocular tension, the necessary vaso-motor
+control depending on nerve centers situated in the iris.
+
+
+_Nerve Control_
+
+The accurate control of normal intra-ocular pressure, by mutual
+adjustment of inflow and outflow of fluid, is scarcely conceivable
+without some highly specialized, extremely sensitive nerve mechanism to
+preside over it. This is suggested by analogy with the regulation of
+secretion in the lacrimal, salivary, or peptic glands, or the
+maintenance of blood pressure in the heart and arteries. Clinical
+observations point the same way. Many patients connect their attacks
+(especially their earlier ones of ocular discomfort, impaired vision,
+haloes around the light, and dilated pupil) with social excitement,
+anxiety, worry, anger or fatigue. A patient of mine gave up her card
+parties, because an exciting game generally ended in blurred vision, a
+rainbow around the light, and a dilated pupil, and sometimes an aching
+eye. Another woman watching beside her dying husband and exposed to
+extreme cold, had her first attack of glaucoma, so severe as to destroy
+the sight of one eye. The other eye, also affected at the time,
+recovered good vision, and has remained several years without a second
+attack and without treatment.
+
+Laqueur's first attack occurred at the end of a long exhausting morning
+in the operating room, with luncheon delayed two hours. The connection
+of his later attacks with anger, worry, embarrassment, even the
+excitement of watching a play at the theatre, was noted again and
+again. In Javal's case, the attack fatal to one eye came at the
+culmination of an exciting electoral campaign. The other eye was
+stricken at the termination of the Dreyfus case, in which Javal was
+intensely interested. There seems to be a special liability to glaucoma
+among those residing at high altitudes, best explained by nerve
+influence. The frequency of glaucoma among Jews may be due to a small
+cornea, as suggested by Priestley Smith; but it is quite as reasonable
+to connect it with a racial excitability or nervous instability. More
+definite knowledge of the nervous mechanism concerned in the regulation
+of intra-ocular pressure and the production of glaucoma is much needed.
+
+
+_Alterations of Fluids and Tissues_
+
+The influence of increased affinity of the tissues for fluid has already
+been referred to. That a similar obstacle to the escape of fluid from
+the eyeball might be due to a change of character in the fluid, is a
+conception that has been entertained as a working hypothesis, and much
+experimental and analytical work has been done to test its correctness.
+This work has been so slightly related to practical ophthalmology, and
+so contradictory in its results that alterations in the fluids can only
+be regarded as a possible etiologic factor. Glaucoma secondary to
+intra-ocular hemorrhage, operations on the lens or its capsule, or
+severe nutritional disturbance may be capable of such explanation.
+
+
+_Different Kinds of Glaucoma_
+
+A better grasp of the etiology of glaucoma may be attained by
+considering separately various types of cases; although perfectly
+typical cases may be rare; and cases of mixed type and etiology much
+more frequent.
+
+Simple glaucoma has been recognized as closely related to atrophy of the
+optic nerve with deep excavation. No line of demarcation can be drawn
+between them, except by reserving the term of glaucoma for cases that
+depart from the pure type, terminating in glaucoma of some other kind,
+which is no more significant than the passage of a conjunctivitis into a
+keratitis, or an iritis into a glaucoma. Cases of simple glaucoma do run
+their course of many years to complete blindness, or to death, without
+exacerbations, inflammation, or characteristic pain. In such cases the
+intra-ocular tension does not rise suddenly; and it may be little or not
+at all elevated above the usual normal limit.
+
+For nine years I have watched the progress of such a glaucoma in a man
+now aged 87, with slow development of glaucomatous cupping of the optic
+disc, now more than 3 D. deep. The tension has never been noted at more
+than Plus T (?), and when taken with the tonometer varied from 9 to 32
+mm. for the worse eye, and 13 to 24 mm. for the other. Similar cases in
+which the tension lay within the commonly accepted normal limits have
+been reported recently by Bietti and Stock.
+
+In the eye there is probably a normal equilibrium between blood
+pressure, tissue activity, and intra-ocular tension. This may be
+destroyed either by increasing the intra-ocular tension, or lowering the
+tissue activity, or the blood pressure. Lowered blood pressure has been
+suggested by Paton as an explanation of symptoms usually ascribed to
+vascular obstruction. Rising blood pressure may be required in old age
+to compensate for diminished tissue activity; and it is conceivable,
+under normal intra-ocular tension, that diminished nutritional activity
+may result in the same symptoms as are produced in other eyes by
+increased tension. Glaucoma is probably not so much an increase of
+tension as a loss of balance between intra-ocular tension and
+nutritional activity.
+
+In contrast with the above are the cases marked by sudden elevations of
+ocular tension recurring repeatedly over long periods without permanent
+visual impairment. Laqueur's case continued of this character for six
+years, under the use of miotics, and then was cured by iridectomy, the
+cure remaining permanent with normal vision until his death after 30
+years. Millikin has reported the case of a patient who in five years had
+"many hundreds" of attacks, in which vision was impaired, haloes
+appeared about the light, the pupil dilated, the cornea became steamy,
+and tension rose to plus T. 1 or plus T. 2. After iridectomy the attacks
+ceased, leaving no pathological cupping of the disc, full vision, and a
+good field. I have seen cases of this type in women under middle age,
+and of marked nervous instability.
+
+A third type which will come to be more generally recognized, as the
+tonometer comes to be more widely used, includes cases in which there is
+little beside the increase of intra-ocular tension to justify their
+mention in a discussion on glaucoma. A patient, then aged 21, suffered
+three years ago from a scotoma almost central; and was first seen six
+months after that with a macular choroidal atrophy and abnormal
+pigmentation. She suffered, we afterwards concluded, from choroidal
+tuberculosis. A recurrence involving adjoining choroid occurred fourteen
+months ago. There was at the start pain, slight dilatation of the pupil,
+and slight general hyperemia of the globe. The tension of the eyeball
+rose to 60 mm., that of the fellow eye being 20 mm. Under miotics the
+tension fell at first but slightly. It was 55 mm. at the end of a week;
+but after two weeks came down to normal, 20 mm. A month later the
+tension rose to 28 mm., but for a year has continued normal; the eye did
+well under tuberculin treatment, and without any local treatment. In
+September of this year I had two cases of iritis in which the
+intra-ocular tension rose to 45 and 52 mm., respectively, and gradually
+returned to normal, with the cure of the iritis under atropine. In one
+of these cases, a lady of 70, I used atropine also in the other eye,
+but the tension of that eye remained normal, 22 to 24 mm., throughout.
+After needling the lens in young people I have seen a rise of
+intra-ocular tension to 50 and 60 mm., maintained for many days, with
+considerable general deep hyperemia, and soreness of the globe, followed
+by gradual return to normal tension, and no permanent impairment of
+vision or the visual field.
+
+One other type may be mentioned. That of an elderly patient with marked
+vascular disease, often renal involvement, and distinctly impaired
+nutrition. There may be renal retinitis or retinal hemorrhages. The case
+may easily become one of hemorrhagic glaucoma. It may run a very chronic
+course. But it may become suddenly worse, or go on to complete blindness
+with pain, demanding enucleation, after some temporary perturbation, as
+the performance of a glaucoma operation. It is pre-eminently the kind of
+a case you would prefer would go to some one else.
+
+Each of these types illustrate a distinct cause or group of causes. The
+first type brings us near to what may be the essential nature of
+glaucoma, impairment of ocular nutrition by the intra-ocular tension,
+which is generally elevated, but may not be above the usual normal. A
+special weakness in the nutrition of nerve tissue may be assumed. It
+would help to explain the cavernous atrophy of the optic nerve
+associated with simple glaucoma. The second type shows impairment of the
+regulative mechanism permitting rapid rise of the intra-ocular pressure.
+In persons of good nerve nutrition and strong recuperative power, it may
+exist for years without doing permanent damage. But joined to causes of
+the first type, lowered nutritive activity, it causes rapid and
+permanent loss of sight. The third group are cases associated with
+glaucoma only as causes. In eyes with low nutritive power, or subject to
+exacerbations of increased intra-ocular pressure, uveal inflammations
+may prove disastrous. The fourth type shows the results of the
+combination of the causes of the other types; with the elements of acute
+or slow malignancy added--the impaired circulation and lowered oxidation
+producing some degree of edema of the tissues that insures a fatal
+result.
+
+This is no complete presentation of my subject, but a selection of facts
+bearing on the etiology, to serve as a foundation for the discussion of
+those practical aspects of glaucoma which are to claim your attention
+through the papers and remarks of subsequent speakers.
+
+
+
+
+Dr. Edward Jackson's Paper on Etiology and Classification of Glaucoma
+
+Discussion,
+
+FRANCIS LANE, M.D.
+
+Chicago.
+
+
+Not one of the theories thus far propounded to explain the essential
+cause of increased intra-ocular tension is satisfactory. Our present day
+knowledge apparently ceases with a more or less incomplete understanding
+of the mere circumstance under which increase of tension in general
+depends.
+
+The question of the source of the normal intra-ocular pressure must
+first be solved before any discussion of a pathological increase can be
+engaged in. This question primarily hinges on whether the corneo-sclera
+is to be regarded as an unelastic capsule with a fixed volume, or as a
+yielding envelope with an ever changing capacity.
+
+This brings us at once to the consideration of that theory which
+probably has held our attention for the longest period of time, _i. e._,
+the volumetric theory. According to it, the normal intra-ocular tension
+depends on the volume of fluids within the eyeball. Any variation in the
+quantity of the contents gives rise to a change in the pressure,
+therefore, the globe has been regarded as "an elastic capsule, whose
+capacity, form, and internal pressure depend on the balance struck
+between a constant inflow, or formation of aqueous, and a proportionate
+outflow or resorption." (Henderson.)
+
+Hill has satisfactorily demonstrated that, under physiological
+conditions, the hydrostatic pressure within the eye and the skull is
+identical; it rises and falls simultaneously; it is the same as the
+cerebral venous pressure; it is constantly varying, depending directly
+on the general circulation. Upon these findings Henderson based his
+opinion that the physiological properties of the tunica fibrosa and the
+skull are identical, realizing at the same time, that the rigidity of
+the corneo-sclera, because of its fibrous nature, is not as firm as the
+cranium. In accepting this belief the inference was that the cubic
+capacity of both coverings is fixed. Applying these conclusions to the
+eye, it can be said that the pressure of the fixed intra-ocular volume
+varies with the venous tension within the bulb, which in turn is
+influenced by the general circulation. Such a conception, while not
+strictly in accord with recognized physiological teachings, proves that
+the normal intra-ocular pressure is not a question of volume content,
+but that it is purely a question of pressure of a fixed volume within an
+unyielding capsule. Dr. Jackson virtually puts aside the volumetric
+theory with his statement, that "the balance of intra-ocular pressure is
+not maintained by the slight distensibility of the sclero-corneal coat."
+Further discussion on the inadequacy of the volumetric theory need not
+detain us.
+
+It is well to recall a few anatomical features because of their bearing
+on the theories herein considered.
+
+1. The angle of the anterior chamber is a true angle and not an annular
+sinus.
+
+2. The meshwork of the iris angle (ligamentum pectinatum), a cellular
+structure at birth, undergoes a progressive and physiological fibrosis
+with early subsequent sclerosis, until finally it becomes a fibrous
+structure. The individual strands of this meshwork are more than two
+times as large at advanced age as at birth, consequently the alveoli of
+the meshwork becomes markedly reduced in size.
+
+3. The spongy nature of this meshwork affords free access of aqueous to
+the venous sinus of Schlemm, thence by tributaries into the
+supra-choroidal space and anterior uveal venous system.
+
+4. Fuchs's iris cripts afford direct access of aqueous to the veins of
+the iris.
+
+Furthermore, two simple principles are taught by physics: Fluids are
+incompressible and they seek the lowest hydrostatic level. The
+application of these perfectly obvious principles to the eyeball makes
+the intra-ocular pressure the same as that within the elastic venous
+walls, which is the lowest circulating pressure within the bulb.
+
+To summarize: The aqueous has direct access to the anterior uveal venous
+system; the physiological thickening of the strands of the meshwork of
+the iris angle supplies a mechanical obstruction between the anterior
+chamber and the venous sinus of Schlemm; intra-ocular pressure stands at
+the same level as the intra-venous, consequently, the hydrostatic
+pressure is the same on both sides of the iris angle meshwork, because
+the canal of Schlemm is a secondary venous system; lastly, the outflow
+of aqueous into the venous sinus is by diffusion, not by filtration,
+because the pressure is the same on both sides of the meshwork.
+
+These facts and deductions have given rise to the present day
+circulatory theory of intra-ocular pressure, so we now can approach the
+predisposing and exciting factors which determine glaucoma.
+
+The central fact to be borne in mind is, if the physiological pressure
+is vascular in origin and nature, the pathological pressure must
+likewise be derived from the same source.
+
+Sclerosis of the meshwork of the iris angle is the predisposing factor
+because it hinders free access of aqueous into the venous sinus of
+Schlemm. Sclerosis alone, however, will not cause glaucoma so long as
+access to the iris veins can keep the intra-ocular pressure at the
+intra-venous level, and, too, as long as the exciting cause is absent.
+
+The exciting cause is vascular, maintained and influenced by the general
+circulatory pressure. A rise of the general vascular tension alone will
+not cause glaucoma, because any alteration in intra-ocular pressure
+resulting would be purely a temporary change, easily taken care of by
+the extensive access of aqueous to the intra-ocular venous system. When
+these two factors coexist in their varying combinations, pathological
+increase of pressure results--in short, glaucoma.
+
+Syphilis, rheumatism, gout, auto-intoxication and many other
+constitutional disorders are well recognized agencies which induce
+sclerosis in body tissues, so there can be little doubt that these
+conditions produce pathological sclerosis of the meshwork of the iris
+angle. Psychic disturbances, congested portal or renal system, hard
+mental or muscular work, etc., etc., induce increased pressure of the
+general circulation, and so simultaneously the intra-ocular pressure.
+
+According to the edema theory advanced by Fischer, glaucoma is
+"essentially an edema of the eyeball, and for its production we must
+hold responsible the same circumstances which are responsible for a
+state of edema in any other part of the body." The magnificent
+experimental work of this investigator has shown that edema is nothing
+more or less than an increased capacity of the protein colloid tissues
+for water; that the most important factor leading to this increased
+hydration capacity is an abnormal production or accumulation of acid
+content, effected by those agencies which are instrumental in causing
+sclerosis and an increase of blood pressure.
+
+It seems that both of these theories afford an explanation for many of
+the secondary pathological manifestations which characterize the
+intra-ocular tissues during a glaucomatous onset.
+
+Fischer criticizes the Henderson theory on the ground that increased
+blood pressure alone does not lead to edema--edema is thwarted by high
+blood pressure. On the other hand, if Fischer believes that sclerosis of
+the meshwork of the iris angle is a result and not a cause of glaucoma,
+then it would seem that Henderson has the better of the argument. The
+physiological changes in this structure, which take place with advancing
+age, can rightfully be looked upon as a predisposing factor in glaucoma.
+
+Dr. Jackson has presented all other phases of this part of the
+symposium in such a comprehensive manner that nothing further remains to
+be said.
+
+
+
+
+Pathology of Glaucoma
+
+BY
+
+JOHN E. WEEKS, M.D.,
+
+New York City.
+
+
+In reviewing the pathology of glaucoma it seems proper to consider the
+various structures and tissues of the eye in logical order.
+
+_Lids and Conjunctiva._ "The only change observed in these tissues is a
+reflex edema, excited apparently by pressure on the ciliary nerves and,
+probably, irritation of the vaso-motor fibers of the sympathetic."
+
+_Lachrymal Gland._ Hyper secretion due to reflex irritation.
+
+_Cornea._ As has been shown by Priestley Smith, the cornea in
+glaucomatous eyes is, as a rule, smaller than in non-glaucomatous eyes,
+the mean of a series of measurements being 11.1 mm. horizontally and
+10.3 mm. vertically in glaucomatous and 11.6 mm. horizontally and 11
+mm. vertically in non-glaucomatous eyes. In cases of considerable
+increase of tension, particularly if the onset is sudden, the
+circulation of lymph in the cornea is interfered with, the anterior
+layers of the cornea become edematous, the spaces between the lamellae
+filled with albuminous fluid. Some of this fluid finds its way through
+Bowman's membrane, apparently by way of the minute channels which permit
+the passage of small nerve twigs, and enters the epithelial cell layer.
+The fluid finds its way between the epithelial cells in the deeper
+layers, apparently being taken into some of the superficial cells by
+imbibition. Some of the swollen surface cells open spontaneously and
+discharge their contents, others drop off. The process causes a
+roughening of the surface of the cornea and produces a faint haziness.
+There is another form of haziness that develops on sudden rise in
+tension and completely disappears on subsidence of the tension. This is
+due, as has been shown by V. Fleischl (Sitzungsberichle d. Weiner Akad.
+d. Wissensch, 1880) and others, to increased tension on the fibrillae of
+the cornea, a double refraction being induced. In cases of long
+continued increase of tension minute permanent vesicles form in the
+epithelial layers, particularly in the superficial portion. Anaesthesia
+of the cornea develops, due to pressure on the nerve fibers that are
+distributed to the epithelium, the compression probably occurring along
+the course of the long ciliary nerves, from which the corneal nerves are
+derived, as they pass between the choroid and the unyielding sclera
+(Collins & Mayou).
+
+In advanced cases of glaucoma after the congestive period has subsided
+the cornea becomes somewhat condensed, the lymph spaces contracted; a
+condition of sclerosis obtains. Alteration in the shape of the cornea
+occurs only rarely in adult life. When it does occur it takes place in
+corneae that have suffered from keratitis. The alteration is usually in
+the form of ectasiae. In infancy and early youth (buphthalmia) the cornea
+may become uniformly enlarged and globular. Often, however, the
+enlargement of the cornea is irregular. Increase in tension may produce
+fissures in Descemet's membrane. These occur more frequently in the
+cornea that have suffered a change in shape, as in buphthalmos. Gaps
+occur in the elastic membrane which become covered by endothelium. Some
+cloudiness may be seen in the corneal lamellae adjacent to these
+fissures, in some cases due evidently to the filtration of aqueous humor
+through defective endothelium. Prolonged high intra-ocular tension may
+be accompanied, particularly in cases of secondary glaucoma, by
+vesicular and bullous keratitis.
+
+In acute glaucoma the sclera appears to be edematous and slightly
+thickened. As the disease progresses the sclera becomes denser than
+normal. The oblique openings--passages for the venae vorticosae--are
+said to be narrowed. The openings for the passage of the anterior
+ciliary vessels are enlarged in many, particularly in advanced cases.
+Minute herniae at these openings are sometimes present. Dilatation and
+tortuosity of the anterior ciliary veins are due apparently to excessive
+flow of blood through them on account of the abnormally small amount
+carried off by the venae vorticosae. In the stage of degeneration,
+ectasae of the sclera occur most frequently near the equator of the
+globe. Spontaneous rupture may take place.
+
+_Anterior Chamber._ The anterior chamber is shallow, as a rule. This is
+almost without exception in primary glaucoma in adults. In secondary
+glaucoma in which occlusion of Fontana's spaces occurs as a result of
+the deposition of fibrin or other inflammatory products the anterior
+chamber may be of normal depth, or deeper than normal. Very deep
+anterior chamber may occur in glaucoma, due to retraction of lens and
+iris following fibrinous or plastic exudation into the vitreous, or
+when it occurs in congenital glaucoma, due to enlargement of the globe.
+
+_Aqueous Humor._ The aqueous humor, as has been pointed out by
+Uribe-Troncoso (Pathoginie du Glaucome 1903) contains a greatly
+increased quantity of albuminoids and inorganic salts in glaucoma. In
+acute glaucoma the increase of albuminoids (blood proteids) is greater
+than in chronic glaucoma. The aqueous humor becomes slightly turbid in
+acute attacks, coagulating more readily than the normal. The plastic
+principle contained in the aqueous is rarely sufficient to cause
+adhesion between the margin of the iris and the lens capsule, but the
+colloid nature of the aqueous, according to Troncoso, lessens its
+diffusibility and prevents its free passage into the lymph channels. The
+increase in albuminoids is a consequence of congestion and venous stasis
+and does not precede the attack.
+
+_Filtration Angle._ The changes that occur in the filtration angle
+before it is encroached upon by iris tissue are sclerosis of the
+ligamentum pectinatum in adults to which Henderson (Trans. Ophth. Soc.
+U.K. Vol. xxviii) has called our attention; the accompanying sclerosis
+of the other tissues to the inner side of Schlemm's canal; and, in some
+cases, the deposition of pigmented cells derived from the iris and
+ciliary processes (Levinsohn) which serve to obstruct the lymph spaces.
+In many of the cases of acute glaucoma and almost all of the cases of
+chronic glaucoma of long standing the filtration angle becomes blocked
+by the advance of the root of the iris.
+
+_Iris._ In acute glaucoma the iris is congested and thickened. It is
+pushed forward and may lie against the cornea at its periphery. When the
+attack subsides, the iris falls away from the cornea. Aside from the
+congestion, the primary changes that take place in the iris are
+indicative of paresis of the fibers of the motor oculi that supply the
+sphincter pupillae, and stimulation of the fibers from the sympathetic
+producing vasomotor spasm. The long diameter of the pupil apparently
+lies in the direction of the terminal vessels of the two principal
+branches of each long ciliary artery which form the circulus iridis
+major, where the vasomotor spasm would have the greatest effect in
+lessening the blood supply. The haziness of the cornea and slight
+turbidity of the aqueous contribute greatly to the apparent change in
+the color of the iris. In cases of simple chronic glaucoma there is but
+little evidence of edema of the iris. If the iris lies in contact with
+the sclera and cornea for some time, it becomes adherent (peripheral
+anterior synechia). As the disease progresses, the stroma of the iris
+atrophies and contracts. There is very little evidence of small-cell
+infiltration or the formation of cicatrical tissue. Numerous slits may
+develop in the iris through which the fundus of the eye may be seen
+(polycoria). The pigment layer does not atrophy in proportion to the
+stroma of the iris; by the contraction of the stroma of the pigment
+layer is doubled upon itself at the pupillary margin, forming a black
+ring of greater or less width (ectropian uveae). The iris becomes
+attached to the pectinate ligament and to the endothelium of Descemet's
+membrane. In a very few cases the closure of the angle is not complete
+at the apex, a small space remaining comparatively free for a long time.
+The adhesion of the iris to the pectinaform ligament and cornea is not
+uniform at all parts of the periphery; it varies in width. Portions of
+the iris angle may remain open while other parts are closed. Where the
+iris tissue lies in contact with the cornea, the stroma of the iris
+almost totally disappears. In some cases the iris becomes totally
+adherent to the cornea.
+
+_Ciliary Body and Chorioid._ In acute glaucoma there is congestion of
+the entire uveal tract, the congestion partaking more of a venous stasis
+than of an active or arterial congestion. The vessels of the ciliary
+process, which are larger and more tortuous in adults of advanced years
+than in the young, become enormously distended, causing almost complete
+obliteration of the perilental space. They press against the root of the
+iris and the equator of the lens, forcing them forward. There is edema
+of the ureal tract, apparently from transudation of serum. Many small,
+and sometimes rather large hemorrhages may occur. There is but little
+small cell infiltration, indicating almost total absence of what is
+ordinarily recognized as true inflammation. It is probable that the
+secretion from the glandular zone of the ciliary body is increased.
+
+On subsidence of the congestion, as after miotics or iridectomy, the
+tissues may return to very nearly a normal condition. The iris recedes
+from contact with the ligamentum pectinatum and cornea and the
+filtration angle is again open. In some cases the iris becomes adherent
+to the head of the ciliary processes and, when atrophy of the ciliary
+body occurs, is drawn backward at the base of the iris by the receding
+tissues. If the hypertension persists or is repeated at varying periods,
+a slow atrophy of the uveal tract sets in. Eventually the ciliary body
+becomes very much reduced in thickness, is flattened out, the ciliary
+processes reduced in size and the blood vessels disappear or are reduced
+much in caliber. Those that persist possess walls that are much
+thickened. This is particularly true of hemorrhagic glaucoma.
+
+In advanced absolute glaucoma the chorioid may become reduced to a very
+thin membrane consisting of connective tissue and pigmented cells,
+scarcely distinguishable even by moderate powers of the microscope.
+Atrophy is marked in the vicinity of the venae vorticosae. Czermak and
+Birnbacher describe proliferation of the endothelium of the large veins
+with contraction and obliteration of their lumen.
+
+_Optic Nerve and Retina._ In the acute form the retina and optic nerve
+present the same condition that is present in the vascular tunic;
+namely, that of venous stasis with the consequent edema. Frequently
+minute hemorrhages occur in the retina, particularly in violent acute
+attacks. Cupping of the discs slowly develops, causing more or less
+stretching of the nerve fibers over the edge of the cup. The gradual
+diminution of the field of vision is due in greater part to death of
+peripheral nervous elements of the retina, those parts of the field
+farthest removed from the large arterial trunks suffering first. The
+arrangement of the arteries at the disc, passing out as they do from the
+nasal side, of necessity make the vessels that pass to the temporal part
+of the retina longest and of less caliber. These vessels and their
+terminals are first to suffer marked diminution in size; death of the
+perceptive elements supplied with nutrition by these vessels follows.
+For this reason the nasal part of the field of vision is more often the
+first to disappear. In congestive (inflammatory) glaucoma, the typical
+field of vision shows most marked contraction on the nasal side. The
+disturbance of the nutrition of the retina accounts in greater part for
+the various forms of visual field met with.
+
+Death of all of the perceptive elements of the retina eventually occurs.
+The loss of nutrition is apparently not the whole cause of blindness.
+Atrophy of the nerve fibers follows death of retinal neurons, but
+atrophy of some of the nerve fibers may be, and probably is, due to the
+pressure and traction exerted upon them at the margin of the disc. It is
+probable that too much importance has been given to this mode of
+interference with the nerve fibers. However, the change in the position
+of the lamina cribrosa must exert a deleterious effect, particularly on
+those fibers which pass through the peripheral meshes, the shape of
+which must necessarily be much distorted. In glaucoma simplex, which is
+largely devoid of marked congestive periods (acute attacks), a
+surprisingly high degree of acuity of vision may exist with a deep
+excavation and pale nerve. Careful studies of the retinal vessels in
+glaucoma (Verhoeff Arch. of Ophth. XLII. p. 145; Opin. Soc. Francaise
+d'Ophth. 1908) disclose the fact that an increase in the elastic tissue
+and connective tissue elements occurs in _some cases_, also
+proliferation of the endothelial cells, which serve to irregularly
+narrow and, in some instances, obliterate the lumen of the vessel.
+Arteries and veins are both affected. Hyaline degeneration of the media
+also occurs. The process is not uniform.
+
+_Glaucomatous Cup._ The excavation of the disc progresses slowly and is
+due in part to stretching the fibers of the lamina cribrosa pressing
+this structure outward, and partly to atrophy and disappearance of the
+nerve tissue and much of the vascular tissues in the nerve head. The
+displacement backward of the lamina cribrosa may cause that structure
+to lie behind the outer surface of the sclera. Atrophy and cystic
+degeneration of the nerve trunk follows destruction of retinal neurons
+and cupping of the disc. Neuroglia remains in part. Connective tissue
+elements increase in the optic nerve as the nerve fibers disappear.
+
+_Glaucomatous Ring._ The development of the pale circle which surrounds
+the disc, particularly in glaucomatous eyes, is due to a very slight
+recession of the pigment layer of the retina and of the margin of the
+chorioid at this point with some atrophy, apparently consequent on the
+beginning retraction of the lamina cribrosa and slightly increased
+pressure of the nerve fiber layer on the underlying tissues at the
+margin of the disc. This permits the sclera to show through a very
+little at this part. In some eyes in which there is a beginning
+sclero-chorioiditis posterior, the condition is very similar to that
+presented by the glaucomatous ring.
+
+_Field of Vision._ The two pathological processes that operate to
+destroy the function of the retina suffice to produce scotomata in the
+field of vision of varying shapes. The typical glaucomatous field in the
+acute cases shows a defect most pronounced to the nasal side. As has
+been shown by Bjeraum, the blind spot corresponding with the optic disc
+is enlarged in glaucoma, a relative scotoma often connecting it with the
+blind nasal portion of the field either above or below the horizontal
+meridian (Straub). The field in a simple glaucoma is apt to approach
+concentric limitation; namely, more like the field in simple atrophy.
+This is consistent with the fact that simple glaucoma in many cases
+possesses the characteristics of glaucoma plus atrophy of the optic
+nerve.
+
+_Vitreous._ During the acute attack, the vitreous may become slightly
+turbid by transudation of serum from the vessel of the ciliary body and
+the chorioid and may become filled with fibrin. In some chronic cases
+in which absolute glaucoma is reached the development of small blood
+vessels in convoluted loops springing from the vessels of the discs has
+been observed. Any process that increases the volume of the contents of
+the vitreous chamber, as hemorrhage, neoplasm, profuse serous or plastic
+exudation, may by pushing iris and lens forward produce an attack of
+acute glaucoma.
+
+_Buphthalmos._ Reis (Graefe's Arch. f. Ophth. V. LX. 1905) states that
+there is always obliteration of the anterior scleral venous channels
+(Schlemm's canal) in buphthalmos. Seefelder (Graefe's Arch. V. LXIII.
+1906) mentions the abnormal position and abnormal narrowing of Schlemm's
+canal and the imperfect and insufficient differentiation of the
+cornea-scleral junction. In all of the cases in which the eye has been
+examined microscopically obliteration of Schlemm's canal has been
+reported. This is thought to be a defect in development. Magitot (Ann.
+d'Oculis CXLVII) suggests that injury to mesoderm which pushes itself
+between the ectoderm and anterior surface of the lens would account for
+the failure in development of Schlemm's canal. The changes that occur in
+the tissues of the eye appear to be largely due to the stretching
+consequent on the more or less uniform distentions of the globe as a
+result of hypertension.
+
+_Cornea._ This portion of the fibrous membrane is enlarged, globous or
+flattened, irregularly thinned, particularly at the periphery, where it
+may be as thin as tissue paper, nebulous because of the stretching of
+its fibers principally, but in some degree (differing in different
+cases) to edema of the epithelial layer. Fissures occur in Descemet's
+membrane.
+
+_Anterior Chamber._ This is very deep in the greater number of cases.
+However, this rule has many exceptions.
+
+The vascular tunic may be congested in young infants, but atrophy soon
+develops and may reach an extreme degree. The sclera ordinarily becomes
+quite thin throughout, but may retain almost a normal thickness at the
+equator of the globe and posteriorly. Posterior sclera ectasae may
+develop. The iris, as a rule, hangs free from the cornea, often
+tremulous because of retraction of the lens beyond the iris plane. In
+some cases the iris is partly or totally adherent to the posterior
+surface of the cornea.
+
+The vascular membrane (iris, ciliary body and chorioid) and the retina
+become atrophic, the atrophy varying in degree in various parts.
+Detachment of the retina may occur, often preceded by or accompanied by
+subretinal hemorrhage. The optic disc becomes deeply cupped and the
+tissues of the optic disc and optic nerve extremely atrophied. The
+crystalline lens may become cataractous and shrunken. Spontaneous
+rupture of the suspensory ligament with consequent subluxation of the
+lens may follow.
+
+_Secondary Glaucoma._ The pathological conditions that precede
+secondary glaucoma are many and differ widely. They may be briefly
+classified as:
+
+1. Those that cause a partial or complete closure of the lymph spaces
+and Schlemm's canal by cicatrical contraction, as in sclero-keratitis.
+
+2. Those that cause obstruction to the lymph spaces at the filtration
+angle by the deposition of fibrin or cellular elements, as in iritis,
+hemorrhage into the anterior chamber, etc.
+
+3. Those that cause obstruction of the filtration angle by advancement
+of the iris and lens, as occurs when the volume of the contents of the
+vitreous chamber is increased, as from retinal or chorioidal hemorrhage
+or neoplasm.
+
+The various changes are so numerous that they need not be described
+further here. The ultimate changes due to high tension resemble those
+already described.
+
+
+
+
+Dr. John E. Weeks' Paper on Pathology of Glaucoma
+
+Discussion,
+
+E. V. L. BROWN, M.D.,
+
+Chicago.
+
+
+I would like to emphasize one of the newer features of the pathologic
+anatomy of glaucoma, one which has received too little attention in this
+country: the _lacunar_ or _cavernous atrophy_ of the _optic nerve_.
+
+The name accurately describes the condition. Tiny clear spaces form in
+the lamina cribrosa and in front and behind it in the nerve tissue.
+Their exact nature is unknown. Usually they are entirely empty, often
+they are traversed by fine glial fibers. They seem to be in no relation
+to the blood vessels. Adjoining lacunae are supposed to fuse to form
+larger cavernae and these finally merge and constitute the final
+glaucoma cup. The lamina may then bridge across the space like a cord,
+or lie back against the end of the nerve trunk.
+
+Schnabel considered all glaucoma cups to be formed in this way,
+independent of tension. His views were strongly supported by Elschnig,
+but as vigorously opposed by others. Axenfeld cites the fact that the
+glaucoma cup may disappear after operation. (I myself have seen a cup of
+7 D. reduced to 1 D. in the course of a year after the tension had been
+lowered from 62 to 12.) Stock found the same lacunae in eight cases of
+myopia. The last extended study of the subject was made by E. v. Hippel,
+who found lacunae in 20 of 33 cases (60 per cent); enough certainly to
+make one look for them carefully in every case. He publishes a large
+number of excellent photo-micrographs, but none more typical than one I
+have in my possession.
+
+I have been especially interested in this subject because I have met
+with a complete and total glaucoma cup, with the typical (ampulliform)
+undermining of the scleral ring, in a pair of eyes without increased
+tension. The (Schiotz) tonometer was used daily for 70 consecutive days
+and never registered more than 12-14 mm. Hg. The man had been blinded by
+wood alcohol. At the time I could find no other report in the
+literature, but overlooked a publication by Lewin and Guillery.
+Friedenberg has since reported cases of the same nature.
+
+If other conditions than increased tension can produce a typical
+(ampulliform) glaucomatous excavation of the disc, why may not the
+cavernous atrophy and cup in glaucoma be due in part at least to similar
+processes, possibly in the nature of a toxic oedema of the nerve, either
+in association with tension or independent of it, as contended for by
+Schnabel?
+
+
+
+
+Concerning Non-Surgical Measures for the Reduction of Increased
+Intra-ocular Tension
+
+BY
+
+GEORGE EDMUND DE SCHWEINITZ, M.D.,
+
+Philadelphia.
+
+
+Only a few years ago the literature of glaucoma was big with discussions
+of the comparative value of the surgical and non-surgical treatment of
+glaucoma, and especially of the chronic types of this disease. Now,
+thanks to the achievements of Lagrange, Fergus, Herbert and Elliot, the
+value of a filtering cicatrix, although known for a long time, has
+attained increased importance, due to the improvement and elaboration of
+operative technic, and the medical journals of the day are weighted with
+opinions and experiences from all over the world as to these surgical
+measures. But true as this is, we are not yet in a position to discard
+non-surgical procedures (1) because operation is not always possible,
+(2) because operation is not always permitted, and (3) because in
+certain circumstances operation is not advisable. Hence a glance at the
+non-surgical methods of reducing increased intra-ocular tension is not
+out of place, and for convenience they may be catalogued as follows:
+
+1. Myosis produced by means of solutions of various drugs, a myosis
+followed by reduction of intra-ocular tension.
+
+2. Reduction of tension by means of various mechanical measures, notably
+massage, vibration massage and suction massage, and by means of
+electricity and diathermy.
+
+3. Indirect reduction of intra-ocular tension, accomplished by lowering
+general vascular pressure.
+
+4. Reduction of ocular tension by stimulation of osmosis, of lymphagog
+activity, of absorption of edema, and of capillary contractility, and by
+decreasing affinity of ocular colloids for water.
+
+1. _The Myotics._ Of these, eserin (physostigmin) and pilocarpin, with
+their respective salts, the sulphate and the salicylate in the first
+instance, and the hydrochlorid and the nitrate in the second, are well
+established in favor and efficiency. Personally, it has always seemed to
+me that the salicylate of eserin is preferable to the sulphate, but I
+have not persuaded myself that the nitrate of pilocarpin possesses
+material advantages over the hydrochlorid, although some authors prefer
+it. With arecalin, the alkaloid of the Betel nut, I have no experience,
+nor have I used its mixture with eserin, recommended by Merck as more
+potent than either of the drugs in separate solution.
+
+The substance isophysostigmin, found with eserin in Calabar bean,
+according to Ogiu, exceeds in its myotic activity the sulphate of
+eserin, _i. e._, 1/80 of a grain of the drug is equal to 1/60 of a grain
+of the sulphate of eserin, but it is certainly not less irritating than
+physostigmin, and according to Stephenson's researches, is more so, and
+in this sense has no superiority over the usual alkaloid. In general
+terms, it may be said that the time has not arrived to make a preachment
+"on the passing of eserin and pilocarpin."
+
+_Physiologic Action._ Concerning the ocular, physiologic action of the
+two chief alkaloids respectively of Calabar Bean and of Jaborandi, there
+still exists difference of opinion. It has always been easy to attribute
+the myotic action of these drugs, or at least, of eserin, to their
+stimulant action on the peripheral ends of the oculo-motor, thus causing
+sphincter contraction, and to a depressing action on the sympathetic
+fibers, thus causing removal of the action of the dilatator of the iris.
+But complete experimental proof of such action is wanting, and it is
+probable that myosis follows a direct stimulation of the sphincter
+muscle fibers, aided, perhaps, by contraction of the iris vessels,
+although the last named effect is denied by so competent an authority as
+Hobart Hare.
+
+Exactly how the myotics reduce intra-ocular tension is not definitely
+proven. Usually it is taught that because of the myosis the base of the
+iris wedged in the angle of the anterior chamber is loosened and
+withdrawn, precisely as a fold in a coat is straightened by a tug on the
+fabric beneath it. Experiments, however, for example, by E. E.
+Henderson, have shown that the rate of filtration in an eye with
+artificially raised pressure is considerably larger when it is under the
+influence of eserin than it is when under the influence of atropin; that
+is by the contraction of the pupil the iris-surface filtration is
+increased and consequently the pressure is reduced. We all know that
+Thomas Henderson maintains that the results of iridectomy are beneficial
+because the raw edges of the coloboma, which do not cicatrize, permit
+access of the aqueous to the iris veins, and that myotics, inasmuch as
+they contract the pupil, open the iris crypts and therefore act, less
+efficiently, perhaps, but act none the less like an iridectomy. The
+normal intra-ocular pressure is uninfluenced by myotics because this
+pressure represents the lowest circulatory pressure in the eye, and
+further contact between aqueous and veins cannot reduce it below this
+level, another point which is made by Thomas Henderson in support of his
+contention.
+
+The clinical fact remains that either by mechanical means, as it were,
+in the liberation of a plugged filtering angle, or by the increasing of
+iris-surface filtration, the myotics markedly reduce the abnormal
+intra-ocular pressure.
+
+_Methods of Administration and Indications._ With the methods of
+administration of the myotics we are all so familiar that time need not
+be wasted in their reiteration, except to refer to a few practical
+points. In acute glaucoma, and every one knows that in this disease
+their action is often prompt and sometimes curative, eserin in a
+strength of one to four grains to the ounce may be instilled with
+sufficient frequency to establish myosis, and its action in this respect
+is enhanced if the congestion of the eye is lowered by measures to which
+I shall refer later. There is a good deal of clinical evidence to
+indicate that in this type of glaucoma, as well as in the so-called
+sub-acute varieties, myotic activity is increased by a mixture of
+pilocarpin and eserin in the same solution, exactly as a mixture of
+arecalin and eserin is more potent than either of the drugs in separate
+solution.
+
+Prior to the happy advent of technically correctly placed filtering
+cicatrices, a large number of surgeons depended almost exclusively on
+the use of myotics in so-called simple, chronic or non-inflammatory
+glaucoma. This is not the place to introduce a discussion of the
+comparative value of iridectomy and myotic treatment in simple glaucoma
+as based upon statistical records. We must wait now for a sufficient
+period of time and then compare the value of myotic treatment with that
+of operations by means of which satisfactory filtration is produced. We
+are somewhat in the position that general surgeons occupied when aseptic
+methods first became prevalent. We do not usually compare the statistics
+of early aseptic days with those of the pre-antiseptic period, and I do
+not think we ought to compare the statistics of myotic treatment with
+ordinary iridectomy any longer, but that we should wait until we can
+make a comparison between the results of prolonged myosis and those of
+an improved modern technic which establishes a permanent filtration. In
+the meantime the patients who will not or cannot submit to operation
+must be reckoned with. Doubtless many patients with chronic glaucoma can
+be satisfactorily managed with myotic treatment, although personally I
+have always advocated operation when this could be performed, but it
+cannot always be performed. This rule should guide us, namely, to begin
+with a comparatively weak solution of the selected drug, for example, as
+Posey has advocated a tenth of a grain of salicylate of eserin to the
+ounce, and the strength gradually increased so that at the end of some
+months the patient is using a solution 1 grain to the ounce; or if the
+pilocarpin is preferred, solutions in double these strengths. It is my
+own belief, and that of many who have studied this subject, that if,
+without eserin irritation, a myosis can be maintained, and if the
+treatment can be begun early enough, the chances of preserving vision
+and the field of vision are good. I believe that the two most important
+instillations during the twenty-four hours of the number necessary to
+maintain this myosis are on retiring and if possible in the very early
+morning, some time between two and four o'clock. Most patients can be
+taught to wake themselves at the proper period of time, and are little
+inconvenienced by this disturbance of their sleep. I believe that eserin
+irritation is most successfully avoided, not by preparations of the
+myotics in combination with the antiseptics, for example, tricresol,
+which has been so much advocated, but by ordering very small quantities
+of the solution, insisting that it shall be frequently renewed and
+sterilized at each preparation, and that a half an hour after its
+instillation, during the day time at least, the eye shall be thoroughly
+flushed with some mild antiseptic solution, for example, boric acid and
+sodium chlorid. Whether the action of the eserin on the choroidal
+circulation, which is maintained by Wahlfours, aids in this favorable
+action of the myotics remains to be proved. It has been maintained by
+this author and by others who have followed him.
+
+The great trouble with myotic treatment is not its lack of efficiency,
+but the difficulty of carrying it out successfully on ambulant
+patients, even in the better walks of life. It is hard successfully to
+maintain in a patient with chronic glaucoma what I may call an eserin
+life, just as it is hard to maintain in a person with an enlarged
+prostate a catheter life and escape infection, resulting, if it occurs,
+in the one instance in a difficult and stubborn conjunctivitis, and in
+the other in a cystitis. Still, we are obliged to use myotics, and the
+way to employ them to the patients' best advantage, I have ventured to
+repeat in spite of the universal familiarity with the methods. Perhaps
+we may reach that happy day when, especially with improved tonometric
+methods, increased skill in measuring the rate of filtration and better
+instruments for determining the light sense, we can anticipate the
+advent of glaucoma and get ahead of the ocular and visual deterioration
+which increased tension produces, by performing preventive operations
+which shall aid nature's filtration channels in the establishment of an
+artificial one. But increased tension is not the whole story of
+glaucoma, and a filtering cicatrix is not the last word in surgical
+therapeutics, and there is much to learn.
+
+2. _Reduction of tension by means of various mechanical measures,
+notably massage, and by means of electricity and diathermy._ Massage is
+of ancient lineage. In general terms, in so far as ocular massage is
+concerned, it may be applied to the eye with the finger tips (ordinary
+massage), by means of various instruments (vibration massage), and with
+the help of certain suction cups (suction massage, which is indeed a
+form of vibratory massage). Many authors are satisfied with their
+results without the employment of any instrument, and prefer simple
+massage with the tip of the finger to any form of the instrumental
+variety, to quote the words of Casey Wood. At one time in my career I
+experimented very extensively with massage, not alone for the purpose
+of reducing intra-ocular tension, but in various diseases of the lid and
+cornea, and taught a trained nurse, who herself had a nebulous cornea,
+to make what I may call a specialty of this particular therapeutic
+procedure. She became exceedingly skillful and was quite faithful. We
+believed that the best results were obtained in a seance of two or three
+minutes, the finger tip being used over the lid, and the surface of the
+cornea lubricated with a drop of pure olive oil, although in glaucoma
+the addition of the oil is not necessary. Four movements were utilized,
+the first a stroking movement in lines radiating from the central
+pressure, very much as the spokes of a wheel radiate from the hub,
+second a circular movement, third a pressure movement, a little dipping
+motion, so that the cornea was slightly depressed, and finally, a gentle
+tapping movement, precisely the same, except that it was a diminutive
+one, as the tapping movement that the Swedish masseur makes. Usually
+each movement occupied from a half to one minute, according to the
+results desired. I agree with Casey Wood that such a technic furnishes
+just as good results as any one with the aid of an instrument.
+
+Referring particularly to the reduction of intra-ocular tension, many
+surgeons have been impressed with the value of various instruments.
+Thus, Ohm, who has worked particularly in the reduction of the increased
+tension of secondary glaucoma, for example, after discussion of lamellar
+cataract, advocates the Piesbergen instrument, which makes 3,000
+vibrations a minute, and is applied over the closed lids. I think the
+instrument best known is the one introduced by Malakow. For this purpose
+the point of an Edison electric pen is armed with a small ivory ball,
+and the vibration rate varies from 200 to several thousand a minute, the
+rapidly revolving ball being passed over the closed lids, in some
+instances directly upon the cornea itself. I am frankly afraid of these
+vibrating machines, and again make a plea for the finger tip, just as I
+am afraid of a Von Hippel trephine, and prefer one which is rotated with
+the fingers.
+
+A special investigation of pressure massage according to the method of
+Domec has been made by Paul Knapp of Basel. This, as you know, consists
+in applying the thumb to the cornea through the closed lids, and making
+repeated pressures upon it at the rate or 60 to 100 a minute. He checked
+his results with the tonometer after 200, 500 and 1,000 pressures, and
+found that even in normal eyeballs such massage was followed by a fall
+of intra-ocular tension, the average being nearly 9 mm. after a thousand
+pressures. Within three-quarters of an hour the tension returns to the
+normal. In acute glaucoma such massage is not available, but it is of
+assistance in encouraging a reduction of the intra-ocular tension and
+keeping it at a normal grade after operative work, particularly after a
+filtering cicatrix has been made, as was well shown by Weeks in his
+study of glaucomatous eyes operated upon by the Lagrange method. It is
+interesting to remember that Paul Knapp, in the course of this
+investigation, observed reduction of the tension after the use of
+holocain.
+
+Another method of reducing the intra-ocular tension is by the suction
+method, which consists in the use of certain cups from which the air is
+exhausted by means of a suction apparatus. Domec uses an elliptical eye
+cup, the concave margins of which fit closely about the globe. The air
+is exhausted with each respiration of the patient and from 50 to 200
+tractions are made at each sitting. Domec is of the opinion that this
+method succeeds in two ways, namely, in producing analgesia by traction
+on the ciliary nerves, and in reducing intra-ocular tension.
+
+Unfortunately, it is difficult for regular physicians to make reference
+to massage of the eyeball lest their words should be misquoted by
+irregular practitioners who employ this method, selling various
+instruments to trusting patients, and attributing to this simple and
+often beneficial procedure all sorts of marvelous influences. Doubtless
+all of us have seen eyes utterly ruined because the patient has trusted
+to the advertisements of these people, and has continued to use some
+foolish little suction pump, when what his eye needed was operative
+procedure or skilled therapeutics.
+
+If I should sum up my opinion of massage in the reduction of
+intra-ocular tension, I would say that it is useful in enhancing the
+action of myotics, and particularly useful, as Domec, Knapp, Ohm, Weeks
+and many others have shown, after the filtering angle has been opened by
+a proper operative procedure. It seems to me that it is distinctly our
+duty to inform patients that it is no panacea, and that they must never
+trust themselves in the hands of irregular practitioners who pretend to
+cure all ocular ills with massage.
+
+_Electricity._ The credit of first using high frequency currents in the
+treatment of glaucoma belongs to Truc, Imbert and Marques, and Roure's
+experiments indicate that this current suitably applied appears to have
+an influence not only in reducing the arterial tension, but also the
+ocular tension. Thus, in an interesting series of experiments he has
+been able to reduce an arterial pressure of 200 mm. to 140 mm., and an
+ocular tension of plus 2 to the normal after eighteen applications of
+the high frequency current. The current is applied for ten to fifteen
+minutes at a time twice a week. Some surgeons, for example, Wuerdemann,
+have suggested the use of electricity combined with massage, and have
+apparently achieved satisfactory results.
+
+The constant current has also been much employed for the purpose of
+reducing intra-ocular tension. Coleman quotes Le Prince's observations,
+who applies the negative pole to the eye and the positive pole to the
+neck, gradually passing a current of 30 to 40 ma. during a quarter of an
+hour, and who reports notable diminution of tension. Coleman points out
+that in his own experience he has not found any patient who would
+willingly tolerate more than 19 ma. of current with an ordinary sized
+electrode, although he grants that it is possible that Le Prince used a
+very large electrode. Unfortunately he does not mention its size.
+Ziegler of my own city, who has studied most scientifically and
+intelligently the use of electricity in diseases of the eye, announces
+this rule: The positive pole should be used in all inflammatory
+processes of the eye, glaucoma excepted, and with this rule Coleman
+agrees. Now, although the negative pole is a stimulant and therefore not
+generally indicated in inflammation, as Coleman points out, the object
+in view is to diminish the density of the ocular capsule and its
+tension, hence the negative rather than the positive pole should be
+used, inasmuch as the former, according to him, while it is a sedative,
+hardens tissue and would tend to increase intra-ocular tension by
+diminishing excretion. Moreover, in chronic glaucoma the ordinary
+inflammatory processes are not present, indeed, primary acute glaucoma
+itself is not an inflammation.
+
+I have no personal experience in the use of the constant current with
+negative pole application to the eye in the reduction of increased
+intra-ocular tension, but quote for our general benefit the opinions of
+those who have employed it. I have always been very frankly pessimistic
+in regard to the therapeutic value of electricity in ocular disorders.
+Perhaps I am wrong; I am willing to be enlightened. There seems little
+doubt that Truc and Imbert's observations that high frequency currents
+can temporarily reduce intra-ocular tension is correct, that they are
+able to relieve the pain of primary and of secondary glaucoma would
+seem to be proved by many observations, some of which I have myself
+made, and other very accurate and excellent ones have been made by
+Risley in Philadelphia.
+
+A word might be said in regard to _diathermy_. According to Zahn, the
+method of applying diathermy to the human eye is to take a layer of
+cotton wool 1 cm. thick soaked in a 2 per cent solution of sodium
+chlorid, which is applied close to the outside of the lids. On this is
+put an electrode 15 cm. in size with a large indifferent electrode
+applied to the back of the neck. It is not germane to the subject to
+name the various ocular diseases which were treated in this manner, but
+Clausnizer has made an investigation of the influence of diathermy on
+intra-ocular tension. In a number of diseases, for example,
+iridocyclitis, the method produced distinct rise of pressure. In one, a
+patient with secondary glaucoma, prior to the diathermic application
+the tension was 371/2 mm., after the passage of the current it had
+fallen to 28 mm., but the next morning the tension rose to 45 mm. In a
+patient with chronic glaucoma no definite alteration of tension could be
+found. This observation is mentioned, not because it puts us in
+possession of a valuable therapeutic measure, but largely because it is
+a good example of how in this disease it is wise to investigate any
+method which furnishes a hope of relief.
+
+In a few instances endeavor has been made to reduce the intra-ocular
+tension, or at least to relieve glaucomatous symptoms, by galvanism of
+the cervical sympathetic, for example, by placing one electrode along
+the whole length of this nerve in the neck and one on the back of the
+neck on the opposite side, 15 to 20 ma. of current being used. Good
+results have been reported by an observer named Allard. I confess that I
+am entirely faithless in regard to any results that may be reached in
+this manner. It is possible that as the positive pole is a sedative, if
+there were any influence, the influence of sedation would be present,
+but certainly it has over and over again been experimentally proved that
+irritation of the cervical sympathetic quite rapidly produces elevation
+of intra-ocular tension of 2 to 4 mm. In some experimental work the
+primary elevation of intra-ocular tension was followed by a secondary
+drop.
+
+3. _Indirect reduction of increased intra-ocular tension brought about
+by lowering general vascular pressure._ Much has been written in regard
+to the association between increased vascular pressure and increased
+intra-ocular pressure. It is not my province to analyze observations
+often contradictory and not infrequently inaccurate. This much seems to
+be established: First, that at corresponding ages there is usually a
+higher average blood pressure in glaucomatous subjects than there is in
+non-glaucomatous subjects; second, that arteriosclerosis and therefore
+usually increased blood pressure, with all its concomitant conditions,
+is correctly classified as an exciting cause of glaucoma; and third,
+that the regulation of this increased blood pressure is part of the
+advantageous management of increased intra-ocular pressure, although it
+may be too much to say, as Gilbert has, that blood pressure and
+intra-ocular pressure rise and fall together. It may be true, as Thomas
+Henderson says, that the intra-ocular pressure is influenced by changes
+in the general arterial or general venous pressures, whereby a rise in
+general arterial pressure induces a proportionate rise in the
+intra-ocular pressure, but it would seem that future investigations must
+confirm this statement before it can be entirely accepted, as well as
+his further statement that the effect of an increased general venous
+pressure is a direct one, producing millimeter for millimeter a
+corresponding increase in the intra-ocular pressure.
+
+Now, it goes without saying, if these data are correct, or even only
+partly correct, that part of the treatment of the increased intra-ocular
+pressure state must be constitutional in that the vascular pressures
+should be lowered in order that the beneficial effect of their
+relationship to the intra-ocular pressure shall be established. It is
+further a great mistake to drive down a high arterial pressure simply
+because that exists. In other words, it is often necessary from the
+general standpoint that a certain amount of plus pressure shall remain
+if the patient's general well-being is to be maintained. There must
+always be a differential diagnosis between plus pressure and what may be
+called over plus pressure. That is to say, a man may be perfectly
+comfortable and properly need, for example, a pressure of 160 or 165
+mm., which is above the physiologic limit, but which is a plus pressure,
+while some disturbance in his general life may add to that 10, 15 or 20
+mm. more of pressure, which is then the over plus amount. This over
+plus amount may be in association with a rise of intra-ocular pressure,
+and must be eliminated if the latter is to be controlled by a
+non-operative procedure, or, indeed, by an operative one.
+
+It is no easy matter to determine the presence of increased venous
+pressure, although there are tolerably accurate instrumental technics,
+and yet, as Henderson points out, it is just this increased general
+venous pressure which is often detrimental. Therefore the perfunctory
+use of such drugs as nitrite of amyl and the other nitrites may not be
+in the least indicated when, for example, the venous pressure depends
+upon inability of the right heart to perform its functions, and the drug
+needed may, for example, be digitalis. Far better than pressure-reducing
+drugs like nitrite of amyl, urgently indicated in some instances and for
+some purposes, is the regulation of life and the restoration to their
+normality of the metabolic processes, the elimination of the worry
+which is usually the exciting agent that brings about the over plus
+pressure, which may have as one of its expressions an acute rise of
+intra-ocular tension. I believe that in the management of a case of
+glaucoma, whether it be chronic or chronic with sub-acute exacerbations,
+the greatest care with the aid of an expert clinician must be exercised
+to find out exactly what mean pressure of the arterial and venous system
+best conforms with the patient's general welfare, and I am bitterly
+opposed, and I think with right, to the sudden reduction of tensions,
+except in emergencies, without a perfect understanding of the facts I
+have ventured to indicate. This does not for a moment mean that prior,
+for example, to operative work it is not necessary to get rid by means
+of drugs of an over plus tension, for surely the elimination of such an
+over plus tension may be the means of preventing, for example, an
+intra-ocular hemorrhage, and in this emergency we must not lose sight
+of Gilbert's recent investigation, who has found that blood withdrawn to
+the extent of 8 grams to each kilogram of the body weight always
+produces lowering of the intra-ocular tension, appearing in six to eight
+hours and lasting to the next day in simple glaucoma, and in
+inflammatory glaucoma commencing the day after the venesection and
+lasting two to three days. It is not necessary for me to point out the
+value of free purgation and diaphoresis in this respect.
+
+In most instances the successful maintenance of a glaucomatous life,
+exclusive of operative interference, in addition to sustained myosis,
+demands the investigation of the patient's metabolism, which must be
+kept at the normal standard, the removal of the evil effects of
+auto-infection, as we are wont to call it, and especially the
+elimination of the cause which is responsible for the over plus tension
+of the arteries and of the veins. This is best secured by just such
+regulation of life as has been referred to, aided when necessary by the
+ordinary drugs which the patient's condition indicate, and the success
+of all treatments, be they operative or non-operative, is enhanced if
+such a happy state of affairs can be brought about.
+
+I am firmly convinced that every glaucomatous patient, and I now refer
+to those who are the subjects of chronic progressive glaucoma, should be
+carefully studied from the general standpoint by the oculist with the
+aid of an expert internist, just as I am convinced that the modern
+expert internist should not study his cases of cardio-vascular disease
+without the help of the oculist. Perhaps I am going a little far afield,
+but in justification of my statement I want to quote the opinion of Dr.
+Hobart Hare, one of America's most expert clinicians, on blood pressure,
+because it seems to me much harm has been done by the more or less
+brutal knocking down of blood pressure simply because blood pressure
+above the normal existed. "Concerning the matter of high blood
+pressure," writes Hare, "independent of cerebral lesions, the longer I
+study the matter the more convinced I am that this blood pressure is
+devised by nature to compensate for fibroid changes in peripheral
+vessels, in order that tissues which would otherwise be cut off from
+adequate blood supply may receive plenty of blood, and I consider it one
+of the most vital points to ascertain whether a pressure is what may be
+called the patient's pathological norm, that is, the pressure which is
+required in the face of vascular changes, or whether this pressure is in
+excess of his pathological norm. If it is in excess, measures directed
+to bring it to the pathological norm should be instituted, but if the
+pressure found proves to be the pathological norm it is a bitter mistake
+to lower it, be the pressure what it may. If it is lowered below the
+pathological norm, all manner of disturbed cardiac action, etc., may
+result. There is no more reason for reducing a blood pressure below his
+pathological norm than there is for reducing it below his physiological
+norm. The adjustment of a man's blood pressure to his pathological norm
+often has to be as correctly done as the adjustment of a watch which is
+losing or gaining time."
+
+I shall not quote Hare's elaborate methods for determining these various
+points because they do not belong to a paper of this character, but I
+quote his admirable advice because it emphasizes what I believe to be an
+essential in the treatment of chronic glaucoma, exclusive of operative
+work, that is, the intelligent co-operation of the oculist and the
+internist.
+
+Some such thought was in the mind of Ibershoff, who quotes Sterling and
+Henderson's views that the rate of secretion depends upon and varies
+with the difference in the blood pressure and the tension of the
+eyeball, and that the specific gravity of the secretion increases
+directly with the blood pressure and inversely with the ocular tension.
+Should the blood pressure be very high, paracentesis, for example, would
+apparently not be the proper procedure, and the resulting difference
+produced between the blood pressure and the eye tension would cause a
+rapid reformation of fluid with higher specific gravity and higher
+osmotic coefficient. The proper procedure in these circumstances is
+first properly to reduce the blood pressure, or what I have, quoting
+Hare, ventured to call the over plus pressure.
+
+4. _The relation of osmosis, lymphagogue activity, absorption of edema,
+capillary contractility and decreased affinity of ocular colloids for
+water to the reduction of increased intra-ocular tension._ We are all
+familiar with the attention which was directed some years ago to the
+statements coming from French clinics that the treatment of glaucoma
+should include the administration of osmotic substances as adjuvants in
+the reduction of increased intra-ocular tension. Particularly was this
+treatment advocated by Cantonnet in the administration of daily doses of
+3 grams of chlorid of sodium, preceded, of course, by a careful urinary
+examination and the estimation of the amount of urine and its contained
+chlorids. Carefully this dose was increased in proper circumstances to
+15 grams per diem, and in Cantonnet's original paper good results were
+achieved in 12 of the 17 patients so treated. I have myself experimented
+somewhat, not with the administration of sodium chlorid by the mouth,
+but with the introduction by the bowel of fairly large quantities of
+physiologic salt solution in patients with glaucoma whose quantity of
+urinary secretion was markedly below the normal, and in one or two
+startling instances, which have been reported, achieved success in the
+rapid reduction of the intra-ocular tension when by this technic the
+urine secretion rose to the normal amount. To be sure, myotics were
+also used, but these myotics were insufficient, totally so in the two
+instances noted prior to the enteroclysis.
+
+Very interesting are the observations on the subconjunctival injections
+of various substances, notably the citrate of sodium, because of its
+power of decreasing the affinity of ocular colloids for water. This
+method of treating increased intra-ocular tension, introduced, as you
+know, by Thomas and Fischer, has met with confirmation from a number of
+sources in spite of the fact that Happe's experimental study failed to
+confirm Fischer's observations; indeed, he even reports in several
+instances a rise of tension.
+
+As you will remember, the strength of ordinary crystallized sodium
+citrate in water should be from 4.05 to 5.41 per cent. Of this five to
+fifteen minims are injected, the eye having been previously cocainized
+and adrenalinized. With frequent injections the weaker of the two
+solutions is mixed with 2 to 4 parts of physiologic salt solution. These
+authors in no sense claim to cure glaucoma, but to ameloriate it and
+reduce the tension. Weekers has used the salts of calcium, 3 grams a
+day, with success in so far as lowering of tension is concerned,
+although it must be stated, as a reviewer of his work has said, that his
+recommendation of this drug in these respects is poorly supported. On
+the other hand, Tristiano seems to have proved that calcium chlorid is
+capable of lowering ocular tension and clinically may be used as an
+adjuvant in the treatment of glaucoma for this purpose, largely because
+he believes that he has proven that it facilitates the absorption of
+edema. Darier has reported that a single subconjunctival injection of a
+milligram of iodate of sodium has cleared the cornea and lessened the
+intra-ocular pain in glaucoma.
+
+What shall be said in regard to certain medicinal agents which stimulate
+the lymphagogue activity of the eyeball in their relation to the
+reduction of intra-ocular tension, notably of dionin? Toczyski's
+experiments with this drug on the normal eye indicate that it produces
+first a rise of tension, which shortly falls to the normal and sometimes
+below it, the tension being high as long as the primary narrowing of the
+pupil is maintained, but more than one author, particularly A. Senn,
+holds an opposite view and reports acute glaucoma following its
+instillation into a chronic glaucomatous eye. He believes that dionin
+not only does not reduce the tension but hinders the filtration through
+the anterior lymph channels by the pressure of the edema which is
+produced on the veins and by the increased secretion of the ciliary
+processes. In spite of this statement, most of us must agree with Karl
+Grossman's observations that certainly in acute and particularly in
+chronic secondary glaucoma, this is a most valuable agent, especially if
+it is combined with holocain, which Paul Knapp in his well-known
+research has proved can reduce the tension even of the normal eye. I
+cannot think that anybody who has systematically used dionin with
+holocain, the former in gradually increasing strength, beginning with 2
+per cent and going up to 8 per cent, in various types of acute glaucoma,
+particularly of the secondary variety, can fail to have noted a
+favorable influence.
+
+Many authors, for example, Darier, Grandclement and others, are strong
+in their recommendation of adrenalin, particularly if this drug is added
+to the various myotic mixtures, and yet adrenalin is certainly not
+without danger in the treatment of glaucoma. McCallan has seen a number
+of instances of striking increase of intra-ocular tension following this
+instillation in the conjunctival sac. Harmon has had a similar
+experience, as also has Senn. It is possible that in these circumstances
+the solution was too strong. Should the rise of tension occur, and I
+have seen it myself, it is doubtless due to the fact that this drug
+dilates the pupil, which would be especially dangerous if the dilatation
+should occur before contraction of the ciliary vessels; also the
+narrowing of the ciliary veins by the adrenalin might by virtue of this
+narrowing obstruct the gate of outflow. I have never been able to
+persuade myself that, except as an adjuvant to operative work, there was
+any real therapeutic value in the instillation of adrenalin.
+
+A word in regard to the effect of general narcosis on intra-ocular
+tension. Thus, Neuschuler has observed that narcosis causes an elevation
+of the intra-ocular tension of from 2 to 6 degrees as measured with
+Fick's tonometer. These observations were made while he was
+experimenting on irritation of the sympathetic as a method of producing
+increased intra-ocular tension. This is not in accord with Axenfeld's
+recent observations. It is well known, this observer points out, that
+after the period of excitation and muscular rigidity disappears, there
+is a lowering of blood pressure in chloroform narcosis and coincidently
+a sinking of the intra-ocular pressure. Not only this, the intra-ocular
+tension of normal eyes during this narcosis drops several millimeters.
+Only such eyes as have high hypertony, for example, in absolute
+glaucoma, are unaffected during chloroform narcosis. In the light of
+this observation it will be interesting to measure the tension both of
+normal and glaucomatous eyes during narcosis in a large series of cases,
+and if it is confirmed there will be an additional reason why in many
+circumstances general narcosis is advantageous in glaucomatous patients.
+Formerly I thought it was essential, if iridectomy was to be performed,
+lest some sudden movement on the part of the patient might bring the
+point of the knife in contact with the lens. I have rarely employed it
+in corneo-scleral trephining, and yet if there is this temporary
+reduction of intra-ocular pressure, it is not without a certain
+therapeutic value, and the matter is mentioned as a suggestion that
+additional observations along this line shall be made.
+
+
+
+
+Dr. George Edmund de Schweinitz' Paper on Concerning Non-Surgical
+Measures for the Reduction of Increased Intra-ocular Tension
+
+Discussion,
+
+NELSON MILES BLACK, M.D.,
+
+Milwaukee.
+
+
+It seems almost useless to attempt any discussion of Dr. de Schweinitz'
+most terse and comprehensive paper. However, Dr. de Schweinitz mentioned
+the close relationship which should exist in the non-surgical treatment
+of increased intra-ocular tension between the internist and the
+ophthalmologist, but neglected to mention a corresponding relation which
+should exist between the rhinologist and the ophthalmologist, and
+possibly between the dental surgeon and the ophthalmologist.
+
+I would like to refer to the _now_ recognized close relationship which
+exists between disease of the nasal accessory sinuses and diseases of
+the eye. The definition of glaucoma found in Dr. Wood's system of
+therapeutics gives rise to an hypothesis as to why disease of the nasal
+accessory sinuses may be a factor in producing increased intra-ocular
+tension and why treatment directed toward obtaining free drainage from
+the sinuses gives good results in so many cases, especially if the
+relationship is recognized sufficiently early. "Glaucoma proper is
+essentially a damming or blocking of the drainage from the interior of
+the eye. The chief lymph stream flows from the posterior chamber past
+the margin of the lens, through the zonula of Zinn, beneath the iris,
+through the pupil into the anterior chamber, thence through the tissue
+at the junction of the iris and sclera into the circular canal of
+Schlemm and from this space into _the external lymph channels_.
+_Obstruction to the steady escape of the intra-ocular fluids at any
+point in this drainage system or any undue increase of the fluids
+themselves may produce glaucoma._ Probably the most important
+obstruction to the exosmosis is at the angle close to Schlemm's canal."
+
+The following hypothesis is based upon Fischer's edema theory of
+glaucoma and the relation of the circulation of the eye and orbit and
+that of the nose and the accessory sinuses, the minute anatomy of which
+is not as yet thoroughly understood. However, sufficient work has been
+done to make it appear that the lymph channels which drain the eyes and
+orbits empty into the same main channel as do those which drain the
+sinuses. Admitted for sake of argument that such is the case, then
+disease either acute or chronic of one or more of the sinuses with the
+accompanying inflammatory reaction, congestion and stasis, will cause an
+increased amount of fluid to be taken care of by the lymph channels
+draining these sinuses. This will in turn cause flooding of the common
+lymph channel, producing a stagnation in the flow of fluid from the
+orbits and eyes at the junction with the main channel, with backing up
+of the fluid within these channels and retention of the waste products
+within the orbits and eyes; thus will be brought about conditions most
+favorable (to quote from Fischer's theory of glaucoma) "to an abnormal
+production or accumulation of acid in the eye. In consequence of this
+abnormal acid content the hydration capacity of the ocular colloids is
+raised and glaucoma results, not because water is pushed into the ocular
+colloids, but because these suffer changes which make them suck in water
+from any available source."
+
+This hypothesis also might suggest why the subconjunctival injection of
+sodium citrate in addition to alkalinizing the ocular contents, may be
+effective in reducing tension, _i. e._, the amount of fluid injected
+beneath conjunctiva may overcome the stagnation in the lymph passages,
+flush out these channels and improve ocular elimination.
+
+Fischer in a personal letter says:
+
+"You have two possibilities for the production of glaucoma with sinus
+disease: A toxic factor due to poisons being carried into the eye; and
+second, interference with a proper blood supply to the eye through
+compression of the efferent or afferent blood vessels supplying the eye
+from edema of the tissues about the eye consequent upon the sinus
+infection. Either is associated with the production of substances which
+increase the hydration capacity of the ocular colloids."
+
+If such is the case why could not the existence of pyorrhea and blind
+abscesses about the roots of the teeth be the source of the toxic
+factors mentioned by Fischer? Hence the suggested association of the
+dental surgeon with the ophthalmologist in these cases of apparently
+idiopathic increased intra-ocular tension.
+
+It would be well to state here a cursory examination of the mouth will
+not discover root abscesses any more than such examination will
+discover non-suppurative sinus disease. A careful examination of each
+tooth together with radiograms of the entire maxilla are absolutely
+essential to determine their presence or absence.
+
+
+
+
+Trephining for Glaucoma
+
+BY
+
+ROBERT HENRY ELLIOT, M.D.,
+
+London, England.
+
+
+Mr. President and Members of The Chicago Ophthalmological Society:
+
+As the hour is late I propose to take up only the principal points in
+connection with my subject and to deal with each one shortly.
+
+First: The operation of trephining is suitable, not merely for chronic
+cases, but for sub-acute and acute cases of glaucoma as well. I would
+urge on your attention that, of all the operations dealing with
+glaucoma, this one involves the minimum of surgical violence, and
+should, therefore, in acute cases be the operation of choice. It is,
+moreover, much safer than any other operation I know of, and is no less
+certain in its results. I do not advise trephining in the secondary
+glaucoma following intumescent cataract, for in such cases the
+semi-fluid lens bulges into and blocks the trephine hole. Nor for
+obvious reasons do I recommend it in cases where there is reason to
+believe that a communication exists between the aqueous and vitreous
+chambers.
+
+Second: The object of trephining is to tap and permanently drain the
+aqueous fluid from the anterior chamber of the eye into the
+sub-conjunctival space; in doing so it is essential to avoid as far as
+possible all interference with the uveal tissue. The purpose of an
+iridectomy is to avoid the danger of the iris in the neighborhood of the
+wound being drawn and impacted in the trephined hole. We have found in a
+large number of cases in which an iridectomy has been omitted, that the
+results have been in no way inferior to those in which a piece of iris
+has been removed, provided always that no subsequent iris prolapse
+takes place. In pursuance of our purpose to avoid uveal tissue, we split
+the cornea, and place the trephine as far forward as such splitting will
+allow, and we bear on the trephine in such a way that it cuts through on
+the corneal edge of the wound first. This insures establishing our
+fistula in the most anterior position possible, and, therefore, as far
+away as possible from the ciliary body and the angle of the chamber.
+
+Third: The difficulties of the operation. Far too much stress has been
+laid on these. Trephining is an operation which can be performed by any
+surgeon who is used to ophthalmic manipulations, and who has good sight.
+It is essential that he should work in a good light. The necessary
+technique can be acquired from a written description. It is not for a
+moment necessary that the surgeon who wishes to learn trephining should
+see the originator of the operation at work. If, however, he feels
+diffident at undertaking the procedure until he has seen it done by
+another, there are many centers in this country where the operation is
+now being successfully performed. I would mention amongst those which I
+have visited New York, Minneapolis, St. Louis, Nashville, Louisville,
+Detroit and Chicago. I have seen results of trephining by American
+surgeons which could not be bettered anywhere.
+
+Fourth: I am sure that everybody will recognize the difficulties of
+operating during such a tour as I am now making. I have so far in the
+last month performed over seventy trephinings in ten cities, and in
+twice as many clinics. To adapt one's self to different clinical
+methods, different assistants and different nurses is so difficult that,
+as you are aware, many distinguished surgeons refuse to work out of
+their own clinics. One cannot expect the results of such a tour to be on
+a par with those one obtains in one's own quiet daily surroundings. I
+am, however, confident that you will make a generous allowance for
+these difficulties, and I gladly welcome the suggestion that all the
+cases which I have operated on in America be collected together and
+reviewed as a whole.
+
+Fifth: In conclusion I would like to express the pleasure with which I
+listened to Dr. de Schweinitz' paper. I believed from the title that
+there might be a wide divergence of opinion between us. I find to my
+great relief that we are in absolute accord. I know, however, that there
+are in America and elsewhere able men who consider that the medical
+treatment of glaucoma should be pushed as long as possible. I cannot but
+feel that this is a survival of the dread that most surgeons have felt
+in recommending one of the older operations for glaucoma. We have now in
+our hands a method so safe, so easy and so certain that I feel sure that
+this dread will ere long pass away, and that the diagnosis of glaucoma
+will then be followed by a very early operation. In India I have gone
+farther than this, and where one eye has shown high tension, I have
+frequently trephined both. The prophylactic use of the operation is more
+than justified in that land of long distances and scattered medical aid,
+and where the patient is not likely to return a second time for surgical
+help. This prophylactic trephining is a proposition that I put before
+you today for your consideration, reminding you at the same time that
+glaucoma is practically invariably a bi-lateral condition. I have seen
+even in America not a few people blind in both eyes who might have
+retained the sight of the second eye had the surgeon advised a double
+sclerectomy when he first saw the case, despite the fact that the second
+eye was then to all appearances non-glaucomatous.
+
+
+
+
+Dr. Robert Henry Elliot's Paper on Trephining for Glaucoma
+
+Discussion,
+
+FRANK C. TODD, M.D.,
+
+Minneapolis.
+
+
+It is very difficult for one of limited experience to discuss a subject
+presented so ably by Lieutenant Colonel Elliot to whom we are indebted
+for the sclero-corneal trephine operation. He has already over a period
+of a little over four years performed over 900 trephinings, and has made
+a most careful subsequent study of the results of those operations on as
+many cases as he had the opportunity to observe.
+
+Anyone who has read Colonel Elliot's book on the sclera-corneal
+trephining operation will be struck with the fact that he has not only
+had a tremendous experience in ophthalmic surgery, but that he has made
+the best of that unusual opportunity, and that to a foundation of a
+careful training he has added the experience of twenty-two years of hard
+painstaking work.
+
+I have recently had the privilege of entertaining Colonel Elliot in my
+own city, where I had the opportunity of assisting him and hence closely
+observing his technique in eighteen trephinings. It has since been my
+duty, and responsibility I may add, to care for those eighteen eyes. For
+two years I have been doing the Herbert tongue flap, or a similar
+operation. The results have been highly satisfactory thus far and
+similar to those following the trephining operation, which operation I
+have performed in a number of cases during the past ten months. My
+conclusions as to these two operations are favorable to the trephining
+operation because the Herbert tongue flap operation is much more
+difficult, and hence less certain than the Elliot trephining operation.
+
+The time for discussion does not permit a detailed statement of the
+results nor experiences in the handling of these trephining cases. Of
+the entire number five totally blind eyes were trephined. Tension was
+reduced in all but one. In that one hemorrhage occurred at the time of
+the operation. One of these blind eyes had not been totally blind longer
+than a few weeks. Hand movement vision developed in this eye. Another
+eye totally blind one year has thus far developed perception of light.
+Of the cases with varying degrees of vision from hand movements to
+six-ninths all but one have either remained the same or shown some
+improvement. The one exception was an eye having six-ninths vision. A
+small button hole iridectomy was made; prolapse of the iris into the
+wound occurred four days later requiring incision. Upon incision of the
+prolapse intra-ocular hemorrhage occurred, causing nearly total
+blindness for two weeks. Vision is clearing fast and it remains yet to
+be seen what the final results may be. One buphthalmic eye trephined by
+myself gave good results.
+
+I have as yet seen no cases of remote infection, but the report of
+Axenfeld and some others would indicate that this occurred following the
+Lagrange as well as the trephining operation, the then bulging
+conjunctiva having become eroded and infection having taken place
+through the eroded conjunctiva as shown when stained with flourescin.
+
+The opinion, not yet conclusive, that I have thus far formed as a
+consequence of my experience and the information obtained from others of
+greater experience is as follows:
+
+First: That in those cases of chronic glaucoma in which iridectomy has
+been of benefit in preventing or retarding the oncoming of blindness,
+the result has apparently been secured by reason of the fact that
+filtration has been produced, and not merely because a piece of iris has
+been removed.
+
+Second: That in chronic glaucoma (in acute glaucoma iridectomy has
+proven a satisfactory operation) when the progress of the disease
+cannot be arrested by non-surgical treatment (an even in some of these,
+where, for instance the patient cannot be kept under observation or will
+not carry out the treatment) some form of operation intended to produce
+filtration should be performed.
+
+Third: The Elliot sclero-corneal trephining operation carefully
+performed in accordance with the author's technique in the light of our
+present knowledge seems to be the best and safest operation to produce
+that result.
+
+Fourth: That to glaucoma may be added buphthalmos and staphyloma, as
+diseases often capable of relief by trephining and indeed toward the
+relief of which trephining is the best form of operation yet presented.
+
+Fifth: That the results secured when the operation is well done and the
+after care is properly followed out are satisfactory, in that the
+operation in a large proportion of cases apparently permanently lowers
+the tension to normal or below normal, relieves pain, prevents the
+oncoming blindness (otherwise inevitable) and in many cases causes an
+improvement in the acuity of vision, in the visual field. And in
+occasional cases of blindness of not too long duration, it restores some
+vision, occasionally to a marked degree.
+
+Sixth: That it is not a simple nor easy operation and should, therefore,
+be performed only by an operator well trained in ophthalmic surgery. The
+careful and skillful technique of the originator of the operation
+perhaps accounts for his greater success in its results and those who
+perform the operation should follow his technique and be capable of
+handling complications that may later arise.
+
+In conclusion, Mr. President, I wish to say that we ophthalmologists the
+world over are indebted to Lieutenant Colonel Elliot not alone for his
+contributions to our knowledge, but for his persistence against
+precedent and criticism in establishing the facts upon which rest the
+foundation for the success of his operation, and for so emphasizing the
+great importance of this epoch-making achievement.
+
+It is because we respect his wisdom gained by incessant study and
+experience in a country where climatic conditions are such that a man of
+ordinary energy would have failed to do even average work that we so
+readily welcome the teaching of this enthusiastic evangelist.
+
+His pilgrimage to our country will be the means of starting many in this
+new field, and we shall soon be able to draw more definite and final
+conclusions from our own experiences.
+
+
+
+
+Operations Other than Scleral Trephining for the Relief of Glaucoma
+
+BY
+
+CASEY A. WOOD, M.D.,
+
+Chicago.
+
+
+In this paper I shall say a few words about the large number of
+operative procedures that, apart from trephining, or, preferably,
+_trepanation_, have been urged in the treatment of the various forms of
+glaucoma. Their name is legion and among them we find peripheral
+iridectomy; anterior sclerotomy; irido-sclerotomy; scleriritomy; de
+Wecker's dialysis of the iris; Hancock's division of the ciliary muscle;
+the incision of the iridian angle of de Vincentiis; sclero-cyclo-iridic
+puncture; the Sterns-Semmereole _sclerotomia antero-posterior_; the
+_transfixio iridis_ of Fuchs; Antonelli's peripheral iritomy; Holth's
+formation of a cystoid cicatrix; Hern's operation; Terson's
+sclero-iridectomy; Abadie's ciliarotomy; Ballantyne's incarceration of
+iris method; Masselon's small equatorial sclerotomy; Simi's equatorial
+sclerotomy; Galezowski's sclero-choriotomy; excision of the cervical
+ganglion; removal of the ciliary ganglion; Querenghi's operation of
+sclero-choriotomy; Bettremieux's simple anterior sclerectomy; Heine's
+cyclodialysis; Herbert's wedge-isolation operation; Verhoeff's operation
+with a special sclerotome; Holth's sclerectomy with a punch-forceps;
+Walker's hyposcleral cyclotomy; posterior sclerotomy; T-shaped
+sclerotomy; and last but not least the Lagrange form of sclerectomy with
+its various modifications by Brooksbank James, myself and others.
+
+In addition to the foregoing list--which is by no means complete--there
+are several combinations of operations, as, for example, the Fergus
+trephining operation, which is really a combination of a sclero-corneal
+trepanation and a cyclodialysis.
+
+So far as it is practicable there is a certain amount of wisdom in
+comparing the results of an operative procedure with others with which
+it is brought in competition, and I believe we are even now in a
+position to form at least some idea of the comparative value of the
+three methods that comprise the great majority of interventions made use
+of by ophthalmic surgeons at the present time. I refer to _iridectomy_,
+the _Lagrange operation_, and the _Elliot operation_. So far as regards
+the last named procedure, I congratulate this Society that it has had an
+opportunity of seeing a demonstration and hearing a discussion by the
+famous ophthalmic surgeon who perfected it.
+
+As regards the others let me recommend to you the complete description
+of them given by Posey in _A System of Ophthalmic Operations_.
+
+Let us consider the first of the three procedures just
+mentioned--_iridectomy_--introduced by von Graefe. The mechanism of its
+mode of cure is best studied in cases of acute primary glaucoma, when
+there is apposition of the periphery of the iris to the cornea. In these
+acute cases there is probably only a mere _apposition_, and the blocking
+up of the sclero-iridian angle is largely mechanical. Here the root of
+the iris is readily removed in its entirety and a really peripheral
+iridectomy is easily done. When, however, a true _adhesion_ between
+corneal and iridic tissue takes place the filtration angle is not so
+easily opened. True peripheral adhesions are not readily broken up or
+separated, and the iridectomy is, for that reason at least, not
+effective. Moreover, this form of anterior synechia (resulting from a
+true union of iris and cornea) is so intimate that the iris root is, by
+the iridectomy, torn away only at the sclero-iridian angle at the
+anterior border of the adhesion--and does not open up a channel into
+Schlemm's canal. It is not, therefore, difficult to understand why
+iridectomy alone in any of the forms of chronic glaucoma fails to open
+up the true filtration spaces and does not provide a drain that permits
+of an escape of fluid from the posterior chamber through the loose
+tissue that surrounds it into the canal of Schlemm. Treacher Collins
+found, after a careful examination of eyes upon which iridectomy had
+been performed for glaucoma, that it is extremely rare for the initial
+section to pass through the pectinate ligament, while Schlemm's canal
+invariably escapes. Moreover, since the sclero-corneal incision is
+uniformly oblique, the position and extent of the external wound does
+not always furnish evidence of the character of the internal wound. In
+all likelihood many cases of relief or cure following iridectomy are
+those due to the formation of cystoid scars or minute fistulae, rather
+than as a result of the removal of a portion of the iris periphery.
+
+The best brief tabulation of the results obtained by iridectomy, in
+glaucoma, is to be found in Weeks' textbook on _Diseases of the Eye_,
+page 417: "Sulzer reports as follows: Acute glaucoma, 149 cases;
+improved, 72.5 per cent; serviceable vision preserved, 11.3 per cent;
+vision impaired at once, 4.08 per cent; very little vision, 12.12 per
+cent.
+
+"Zentmeyer and Posey: In simple glaucoma central vision increased in 60
+per cent; remained the same in 20 per cent; diminished in 20 per cent.
+
+"Wygodski: Inflammatory glaucoma, 37 cases; improvement, 76 per cent;
+unimproved, 5 per cent; deterioration, 19 per cent. Sub-acute (chronic
+inflammatory), 147 cases; improvement 10 per cent; unimproved (condition
+the same as before iridectomy), 40 per cent; deterioration, 30 per cent;
+blindness, 20 per cent. Cases operated on at an early stage gave 85 per
+cent of good results. Simple glaucoma, 104 cases; improvement, O.96 per
+cent; condition as before, 10.5 per cent; deterioration, 52 per cent;
+amaurosis, 36.5 per cent.
+
+"Hahnloser and Sidler: One hundred seventy-two eyes observed not less
+than ten years after operation; acute inflammatory, 31 eyes; good
+results, 64 per cent; relatively good, 13 per cent; blind 23 per cent;
+chronic inflammatory, 37 eyes; good result, 29.9 per cent; relatively
+good, 27 per cent; blind, 43 per cent; simple glaucoma, 76 eyes; good
+results, 42 per cent; relatively good, 28.9 per cent; blind, 28.9 per
+cent."
+
+As far as the _Lagrange procedure_ is concerned, you will remember that
+after eserinization an oblique incision is made through the sclera by
+means of a narrow Graefe knife and a large conjunctival flap secured.
+This is obtained by making a peripheral section of the sclero-corneal
+margin with the knife and, as soon as the edge of the knife reaches the
+upper limit of the anterior chamber, it is turned backward and brought
+out through the sclera obliquely. The conjunctival flap thus formed is
+turned back over the cornea, and the fragment of sclera that is left
+attached to the cornea is removed by means of a fine pair of delicate
+curved scissors. Following this an iridectomy is performed. The
+conjunctival flap is now replaced and a bandage applied.
+
+This operation opens a large filtration passage for the intra-ocular
+fluids and the prompt healing of the wound with its mucous covering
+prevents prolapse of the iris.
+
+Under no circumstances must iris be left between the lips of the wound.
+
+Although Lagrange advocated iridectomy in all cases in his first
+communication, he no longer judges the procedure to be necessary in all
+instances, reserving it for cases in which for any reason, such as
+hypertension, prolapse is to be feared.
+
+While Lagrange holds that it is necessary to open the anterior chamber,
+Bettremieux thinks that a removal of but a portion of the thickness of
+the sclera suffices. His procedure is as follows: After raising a flap
+of conjunctiva from the neighborhood of the limbus a medium sized
+needle, curved and flattened towards its point and firmly grasped in a
+needle holder, is thrust superficially into the sclera tangentially to
+the upper edge of the cornea, so as to become fixed in the capsule of
+the eyeball. A small shaving of the sclera, about 1/2 mm. thick, 11/2 to 2
+mm. broad and from 2 to 3 mm. long, is then excised by means of a narrow
+Graefe knife. The scleral slip is then freed from the conjunctiva at
+each end and the mucous membrane brought together over the wound by fine
+catgut sutures.
+
+As you are well aware, numerous operators regard the Lagrange operation
+as superior to the iridectomy of von Graefe because they believe there
+is filtration through the newly formed tissue between the lips of the
+operative wound. Among those of many observers the conclusions of
+Ballantyne may be quoted: "The results of sclerectomy vary according to
+the degree of hypertension of the eye operated on. Three varieties of
+cicatrix are distinguishable according to the amount of sclera excised:
+(1) that in which there is mere thinning of the sclera owing to the
+excised portion not reaching the posterior surface of the cornea
+(conjunctiva smoothly covers the cicatrix); (2) that represented by a
+subconjunctival fistulette, due to excision of the whole thickness of
+the sclera, in an eye with moderate tension (the conjunctiva lies
+smoothly over the cicatrix); (3) the fistulous cicatrix with an
+ampulliform elevation of the overlying conjunctiva, resulting from
+excision of the whole thickness of the sclera in an eye the seat of high
+tension. In cases of high tension, even a simple sclerectomy will allow
+ample filtration, owing to the gaping of the wound, while in cases
+without elevation of the tension, sclerectomy will be quite ineffectual.
+Lagrange therefore proposes the following rules of procedure: (a) If
+tensions is normal to +1, do sclerectomy without iridectomy, the amount
+of sclera excised being inversely proportionate to the degree of
+hypertension. (b) If tension is +1 to +3, do sclerotomy-iridectomy, the
+iridectomy being added to avoid entanglement of the iris. Lagrange does
+not recommend his operation for acute glaucoma. It is especially adapted
+for cases of chronic simple glaucoma."
+
+During the past ten years or more I have been doing a modification of
+the Lagrange operation, the details of which (The Operative Treatment of
+Glaucoma with Special Reference to the Lagrange Method, _The Canadian
+Medical Association Journal_, November, 1911) I have elsewhere
+published.
+
+As stated in this paper I have modified the procedure to the extent of
+removing _all_ the conjunctiva attached to the borders of the operative
+wound. I admit that this intervention exposes the root of the iris and
+the ciliary body, but I have never yet had the slightest infection of
+the wound. I attribute this freedom from sepsis to careful cleansing of
+the conjunctival sac and to other pre-operative precautions, but
+especially to the use, before and after the operation, of White's
+ointment--a preparation of 1-3000 mercuric chloride in sterile vaseline.
+One cannot use sublimate in such a strong _watery_ solution, but the
+vaseline seems to modify it and to allow of such slow absorption that it
+is not only a non-irritant but a most excellent antiseptic application
+in operations on the eye.
+
+In any event the result of the Lagrange operation proper, as well as my
+modification of it, is to produce a drainage-oedema about the incisional
+wound which persists almost indefinitely. In many cases this swelling
+amounts to a bleb which may be increased by massage of or pressure upon
+the eyeball. The efficacy of the operation in lowering intra-ocular
+tension is to some extent measured by the degree and the constancy of
+this epibulbar oedema; indeed, I suspect that the most successful
+examples are those in which sclera fistulae, minute or otherwise, form
+as a sequel of the operation.
+
+My object in excising the conjunctiva about the sclero-corneal flap, is
+to delay union of the wound edges, to widen the bridge of loose
+cicatricial tissue between them, to prevent such a complete growth of
+the endothelium as would cover the wound and block the exit of fluids,
+and to insure intra-ocular rest.
+
+In cases of _chronic_ increase of intra-ocular tension associated with a
+quiet uveitis or an iridokeratitis, when the patient exhibits traces of
+old synechiae, or where there is danger of their re-formation, I do not
+hesitate to use atropia as long as the wound of operation has not
+healed.
+
+To the present time I have done 72 operations of the sort and have seen
+no reason to alter the opinion of it expressed in the article mentioned.
+Whatever objection may in the future arise--and I freely confess that
+it _seems_ to be fraught with the dangers that many of my colleagues
+have pointed out as probable--I have so far not seen a single case of
+infection of the wound of operation. While I believe the
+anti-glaucomatous results to be excellent, I may also claim that the
+operation is of the simplest character; and it is easy of performance
+and the resulting filtration-scar is large and (perhaps) more permeable
+to the changed intra-ocular fluids than the quicker healing wounds of
+the usual Lagrange and Elliot procedures.
+
+It is regarded by most operators as desirable that there should not be
+long delayed healing of the operative wound, and the fact that the
+conjunctiva covers the incision is often spoken of as an advantage,
+partly because it shields the large open area produced by the Lagrange
+incision from infection.
+
+My experience of this modified operation continues to be that it is
+necessary to clear the neighborhood of the operation wound entirely of
+conjunctiva. If the down-growth of epithelium into the operative wound
+is permitted the effects are by no means as pronounced, and the eventual
+lowering of tension is not as permanent as they otherwise would be.
+
+Another matter: I am satisfied that the delayed filling of the wound by
+connective tissue is desirable in most cases of _chronic_ glaucoma. A
+complete drainage of the intra-ocular fluids that results from long
+delayed union of the wound edges, allows the interior of the eye to
+regain, as far as possible, the _status quo ante_. On the other hand the
+comparatively early closure of the wound (or the termination of _free_
+drainage and minus tension) tends to re-establish the _status
+glaucamatosus_. Whether these desirable results are to be realized or
+not will, of course, depend upon a future experience larger than I have
+yet had. This modification of the Lagrange operation seems to be a
+radical one and I do not expect its adoption until the results of an
+extended trial are carefully recorded and reported.
+
+Quite recently several operators, who have been in a position to do so,
+have contrasted the results obtained by the Elliot method and those
+following the Lagrange procedure. Probably the most important of these
+observations is the experience of Meller (Die Sklerektomie nach Lagrange
+und die Trepanation nach Elliot) set forth in a paper read by him at the
+last meeting of the _Deutsche Naturforscher und Aertze_. In this report
+Meller gives an account of 389 sclerectomies following the usual
+Lagrange procedure. Twelve per cent of the cases were of acute glaucoma;
+61.5 per cent of chronic inflammatory glaucoma, and 9 per cent of simple
+glaucoma. The rest of the operations were done in other forms of the
+disease. In more than half the cases the usual iridectomy was performed;
+in 30 per cent the procedure was peripheral; in 4 per cent there was no
+iridectomy. The patients were studied during a period of five years. In
+more than half the instances there was a pale, cystic, oedematous
+cicatrix; in 11 per cent the scar was ectatic, and in the remainder the
+field of operation was quite flat. The form of the scar was described in
+most instances, but it was not noticed that there was a definite
+relation between the cicatrical formation and the intra-ocular tension.
+In 70 per cent of the cases a good result followed the operation, but in
+10 per cent the result was decidedly unsatisfactory. Cloudiness of the
+lens set in in 4 per cent of the cases, while posterior synechiae
+developed in the great majority of them. In 2.3 per cent the eye was
+attacked by iridocyclitis and in 3.4 per cent enucleation was found to
+be necessary. Six eyes became atrophic but were not, for various
+reasons, removed. One and three-tenths per cent of the eyes operated on
+were lost from late infection. Vitreous was lost in 6.2 per cent. Two
+eyes became blind from expulsive hemorrhage. The large majority of
+these complications arose in the eyes operated on for chronic glaucoma.
+There were fewer eyes lost following the operation for glaucoma simplex
+than in the other forms of the disease. Recurrences were noticed in 11.3
+per cent of all the cases; in simple glaucoma 14.3 per cent as against
+the acute and chronic forms with 6 per cent. A return of the glaucoma
+was noticed in 7 per cent of the pale, oedematous, post-operative scars,
+in 16 per cent of the flat cicatrices, and in 24 per cent of the ectatic
+variety. Considerable stress is laid upon the fact of the marked
+softness of the eyes after each operation. There were histological
+examinations made of the eyeballs in 11 cases, in which the position of
+the incision and excision, the development of the scar tissue, and the
+appearance of the complications were duly set forth. The operator then
+gave a history of over 178 trepanations after the Elliot method and
+compares them with the procedure of Lagrange. He concludes that the
+Elliot trephining operation is less dangerous, is more likely to be
+followed by the development of a cystic scar, and leads to loss of the
+eye in only 2.4 per cent of the eyes operated on. In Elliot's cases the
+percentage of relapse was more noticeable than in the Lagrange cases
+where no iridectomy was done. This observer concludes that the method of
+Elliot is to be preferred to that of Lagrange, and that in the former
+case iridectomy is an important factor in obtaining a favorable result.
+This being the case one cannot truthfully say that trephining alone can
+take the place of the old Graefe iridectomy. On the other hand,
+trephining may with advantage be employed instead of iridectomy for
+cases difficult or dangerous under the latter method.
+
+Whatever difference of opinion was noticeable at the Vienna meeting, all
+of those present, especially Meller, the reader of the paper just
+quoted, were decidedly of the opinion that the Elliot operation is in
+every respect the one best adapted to buphthalmia, or congenital
+glaucoma.
+
+In conclusion let me say that the acceptance or rejection of Colonel
+Elliot's procedure or any other operation is not to be decided by the
+percentage of iritis, secondary cataract, relapses, lost eyes, etc., but
+by deciding whether or not his procedure in the various forms of
+glaucoma gives the best results, including the preservation of
+comfortable eyes. In other words, we are seeking not the operation that
+will cure _every_ case of glaucoma but the one which is capable, _in the
+hands of the average ophthalmic surgeon_, of relieving or curing _most_
+cases of that affection.
+
+
+
+
+Dr. Casey A. Wood's Paper on Operations Other than Scleral Trephining
+for the Relief of Glaucoma
+
+Discussion,
+
+ALBERT E. BULSON, JR., M.D.,
+
+Fort Wayne.
+
+
+Increasing belief in Colonel Elliot's view that trephining should be the
+operation of choice in any form of glaucoma, makes it difficult to
+consider operations other than trephining in anything but a spirit of
+disfavor.
+
+Until recently the decision as to the kind of operative procedure to be
+employed for the relief of glaucoma has depended on the form and stage
+of the disease, and the amount and character of the vision of the
+affected eye. Many operators still hold that an iridectomy is the most
+valuable of all operations for acute inflammatory glaucoma, and not a
+few hold that the operation has a decided place in the treatment of
+simple glaucoma. The operation is not without difficulties, and one is
+inclined to agree with Elliot who says that "The man who can make a
+'finished iridectomy' quietly and cleanly has graduated as an ophthalmic
+operator." The difficulties of an iridectomy are especially pronounced
+in those cases in which the anterior chamber is extremely shallow and
+the iris is pressed against the cornea. It is in such cases that the
+success of the operation is increased by the addition of posterior
+sclerotomy and the intelligent use of miotics prior to the performance
+of the iridectomy. Even then the permanent results of the iridectomy
+will be modified in proportion to the success secured in freeing the
+filtration angle and opening Schlemm's canal by thorough removal of the
+root of the iris.
+
+The failure of many apparently well executed iridectomies may be
+attributed to the fact that the iris is not removed to the extreme
+root, and the remaining stump is sufficient to block the drainage. This
+is especially apt to be the case in chronic glaucoma where the iris is
+adherent to the cornea, and in efforts to free the filtration angle by
+an iridectomy the iris is torn off in front of the adhesion and the
+filtration angle is not opened.
+
+As Elliot has pointed out, iridectomy is most open to attack on the
+ground of safety. We have to take into account the large scleral wound
+made, and the fact that this lies close to the ciliary body. The sudden
+release of all tension and the simultaneous weakening of the supports of
+the lens and vitreous body create very unfavorable conditions under
+which to make the crucial step of the operation.
+
+The poor results following an iridectomy in chronic glaucoma have led to
+the devising of many substitute operations, of which those tending to
+the production of a filtering scar are now preferred, and, experience
+shows, hold out the most hope of bringing about long continued relief.
+It even is considered probable that the effects of an iridectomy which
+brings about more or less permanent reduction in the intra-ocular
+pressure is due to the formation of a filtering scar which augments
+whatever results may have been secured in the attempt to open up the
+drainage into the canal of Schlemm.
+
+Dr. Wood has referred to several of the many substitutes for iridectomy
+that have been proposed, and it is unnecessary to enumerate them again
+or to attempt to point out their good or bad features. It is sufficient
+to say that for the average operator and the larger per cent of cases,
+the operation which is easiest to perform, is attended with the least
+risk and offers the best hope of permanent results should be the one of
+choice. Sympathectomy has failed to secure a place in ophthalmic
+surgery, sclerotomy has not been found adequate, and cyclodialysis is
+not sufficiently simple of execution or permanently beneficial in its
+results to give it prominence.
+
+Of the operations proposed for the formation of a filtering cicatrix,
+those of Elliot and Lagrange are justifiably the most popular. Those of
+us who have had the pleasure of seeing the trephining operation done by
+Col. Elliot are impressed with the fact that the operation, even in the
+hands of its originator, is not, when properly done, uniformly easy of
+performance. It does, however, offer the advantage of carrying with it
+the minimum amount of risk, and the apparently permanent results secured
+justify the ophthalmologist in acquainting himself with the technique of
+the operation, for, as pointed out by Sydney Stephenson and others, "the
+technique is responsible for success or failure." Furthermore, there is
+no sufficient reason why the field of usefulness of the operation should
+be confined to the chronic forms of glaucoma, and Col. Elliot
+unhesitatingly recommends trephining as safer and more efficient than
+any other operative procedures at present employed for the relief of
+acute glaucoma.
+
+The success of the Lagrange operation, which, like the Elliot operation,
+aims to produce a fistulous communication between the anterior chamber
+and the sub-conjunctival area, depends upon securing the removal of a
+relatively large section of all of the layers of the scleral and corneal
+lip of the wound, so that a permanent opening, covered by the replaced
+conjunctival flap, is made. Unlike the trephine operation which was
+evolved from it, the Lagrange operation requires the same kind of an
+opening of the eyeball as required for a well executed iridectomy, and a
+properly placed section entirely in scleral tissue, with a good sized
+conjunctival flap, are elements which enter into the ultimate success or
+failure of the procedure.
+
+Aside from the dangers incident to a wide incision in the neighborhood
+of the ciliary body and the possibility of accident to the lens or
+vitreous body, or of intra-ocular hemorrhage, there is for the average
+operator the added difficulty and danger in removing a piece of sclera
+of the exact size required. The technique of the operation is even more
+difficult and exacting than in the performance of the trephine
+operation, and it also compares unfavorably in safety.
+
+The advisability of removing the conjunctival flap, as advocated by Dr.
+Wood, as a modification of the Lagrange operation, may be seriously
+questioned, for aside from the fact that apparently no advantages in
+aiding permanent filtration are added, there is, added to the objections
+to the Lagrange operation already mentioned, the very serious
+disadvantage of subjecting the area at the root of the iris to infection
+for a prolonged period of time. The advantages of the protection
+afforded by a conjunctival flap far outweigh the disadvantages of a
+remotely possible interference of drainage by the blocking of the open
+wound with conjunctival tissue. The fortunate experience of Dr. Wood in
+not having infection in a wound which remains open and unprotected for
+variable lengths of time is not likely to be the experience of any
+considerable number of operators, and probably will not always be the
+experience of Dr. Wood. Furthermore, the possibilities of damage by
+hemorrhage from the choroidal or retinal vessels, delayed formation of
+the anterior chamber and adhesion of the capsule of the lens to the
+wound, and the injurious effects of even slight trauma subsequent to the
+operation, including loss of vitreous, are increased by omitting the
+conjunctival flap.
+
+The modern operation for the relief of glaucoma, by which a filtering
+scar is produced which permits escape of liquid from the anterior
+chamber, is the one which apparently holds out the most hope of
+permanently relieving the condition. While success will depend always to
+a certain extent upon the personal equation, yet it seems now that for
+a large majority if not all of the cases we are justified in abandoning
+all other operations than trephining, notwithstanding the verdict of
+Elschnig and others that fistula forming operations eventually will be
+discarded in favor of iridectomy and cyclodialysis.
+
+Late or secondary infection, not unknown following iridectomy, may
+follow the trephine operation, and already some fifteen or sixteen cases
+have been reported. But while this possibility is a real danger, which
+improved technique may greatly minimize (Col. Elliot has not seen a case
+of secondary infection in an experience of over 1200 trephining cases of
+his own and a large number of others performed by his assistants and
+pupils) the ultimate verdict must rest with results as compared with
+other measures. At present, as pointed out by Meller, whose statistics
+Dr. Wood has cited, trephining heads the list of remedial measures for
+the relief of glaucoma, and it has the advantage of being applicable to
+any form of the disease, to be relatively free from danger, either
+immediate or remote, and to produce the highest percentage of favorable
+results. The addition of an iridectomy in every case of trephining does
+not unduly complicate the operation and has much to commend it in
+offering the patient every possibility of relief.
+
+
+
+
+INDEX
+
+                                                PAGE
+ETIOLOGY AND CLASSIFICATION OF GLAUCOMA,
+  _Edward Jackson, M.D._                           9
+
+ETIOLOGY AND CLASSIFICATION OF GLAUCOMA,
+  Discussion, _Francis Lane, M.D._                28
+
+PATHOLOGY OF GLAUCOMA,
+  _John Elmer Weeks, M.D._                        37
+
+PATHOLOGY OF GLAUCOMA,
+  Discussion, _E. V. L. Brown, M.D._              57
+
+CONCERNING NON-SURGICAL MEASURES FOR THE
+REDUCTION OF INCREASED INTRA-OCULAR TENSION,
+  _George Edmund de Schweinitz, M.D._             61
+
+CONCERNING NON-SURGICAL MEASURES FOR THE
+REDUCTION OF INCREASED INTRA-OCULAR TENSION,
+  Discussion, _Nelson Miles Black, M.D._         101
+
+TREPHINING FOR GLAUCOMA,
+  _Robert Henry Elliot, M.D._                    107
+
+TREPHINING FOR GLAUCOMA,
+  Discussion, _Frank C. Todd, M.D._              113
+
+OPERATIONS OTHER THAN SCLERAL TREPHINING
+FOR THE RELIEF OF GLAUCOMA,
+  _Casey A. Wood, M.D._                          121
+
+OPERATIONS OTHER THAN SCLERAL TREPHINING
+FOR THE RELIEF OF GLAUCOMA,
+  Discussion, _Albert E. Bulson, Jr., M.D._      141
+
+
+
+
+
+End of the Project Gutenberg EBook of Glaucoma, by Various
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