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 Copybight 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 Hon- 
orary 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. 
Nelson1 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 Em- 
ployes; 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. State 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; affin- 
ity 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 recognized, 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 liga- 
mentum 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. 
5 III. Concerning Non-surgical Measures for the Re- 
duction of Increased Intraocular Tension. 
Abstract:- 
(a) The use of myotics; their preparation, method 
of administration, and explanation of their 
action. 
(b) Reduction of increased intraocular tension by 
means of various mechanical measures, not- 
ably massage, vibration massage, suction 
massage, electricity and diathermy. 
(c) Indirect reduction of increased intraocular 
tension, brought about by lowering the gen- 
eral 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 
intraocular 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 un- 
touched. 
(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. 
6 V. Operations Other than Scleral Trephining for the 
Relief of Glaucoma. 
Abstract:- 
Most of the ordinary surgical procedures employed 
for lowering intraocular tension furnish a perma- 
nent cure of certain fairly well defined varieties of 
glaucoma. They also relieve the symptoms and re- 
tard 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 ar- 
resting 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 at- 
tended by serious complications and is available for 
the largest number of cases? Reasons for believing 
that of the better known procedures simple iridec- 
tomy 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. 
7 Etiology and Classification 
of Glaucoma 
BY 
Edward Jackson, M. D., 
Denver. 
It is convenient to start with the concep- 
tion that glaucoma is increased tension of 
the eye-ball, 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 eye-ball 
is essential to ocular refraction, and closely 
related to ocular nutrition. Fully to under- 
stand the mechanism for its regulation 
would carry us far toward an understand- 
ing of the causes of glaucoma. Normal 
9 tension is maintained with a continuous 
flow of fluid into the eye and a correspond- 
ing 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 pres- 
sure 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 func- 
tion 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 
10 has shown, that when the enucleated eye- 
ball is placed in a weak solution of hydro- 
chloric acid, the swelling of the tissue col- 
loids 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 oxida- 
tion, are the chief causes of increased affin- 
ity 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 de- 
parture from a normal pressure balance. 
We must assume that intra-ocular pres- 
sure 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 in- 
11 crease 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 ten- 
sion. 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 ten- 
sion and may be a factor in the etiology of 
acute attacks. It affords a possible mech- 
anism 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 be- 
tween the arterial blood pressure and the 
12 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 in- 
creased blood pressure with glaucoma seems 
to be generally an indirect one through 
vascular lesions and disturbances of nutri- 
tion. 
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 nutri- 
tion, that it is hard to think they will be- 
come 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 enuclea- 
tion, in spite of the fact that a greater force 
is operating to drive fluid out of the eye. In 
his recent tonometric studies Schoenberg 
13 noted that under manipulation the glau- 
comatous eye softened more slowly than the 
normal eye; and suggests this diminished 
drainage as an important evidence of glau- 
coma. 
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 inflamma- 
tion, to be presently referred to, may be 
due to some such tendency. But it is ra- 
tional to ascribe to obstruction of the filtra- 
tion angle of the anterior chamber, the im- 
portant 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 dur- 
ing 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 in- 
flammatory adhesion of the iris to the filtra- 
tion area; ballooning of the iris, or its dis- 
14 placement by traumatic cataract; or ad- 
hesion 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 pig- 
ment granules into Fontana's space; or a 
process of sclerosis closing the spaces by 
contraction of new-formed connective tis- 
sue, 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 block- 
ing 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 impor- 
tance. 
The escape of the outflow of fluid from 
the eye is ultimately through the veins. 
The general venous blood pressure is so 
15 low (often negative in the great veins of 
the neck during inspiration) that no ob- 
stacle can come from it to the ocular out- 
flow. 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. In- 
creased intra-ocular pressure requires that 
there must be some obstacle that keeps the 
intra-ocular fluid from reaching the gen- 
eral 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 gen- 
eral 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. Obstruc- 
tion to outflow of blood through the vorti- 
16 cose veins, by the increased intra-ocular 
pressure, has long been a recognized ex- 
planation of the malignant tendency of 
glaucoma-a part of the vicious circle es- 
tablished in this disease. There is reason 
that we should give careful attention to the 
views of Heerfordt and Zirm, that obstruc- 
tion to the venous outflow may be the ef- 
fective cause of the disease. Zirm believes 
the venous plexus of the choroid is an essen- 
tial part of the mechanism for the regula- 
tion 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 con- 
ceivable without some highly specialized, 
extremely sensitive nerve mechanism to pre- 
side over it. This is suggested by analogy 
with the regulation of secretion in the 
lacrimal, salivary, or peptic glands, or the 
17 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 gen- 
erally 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 ex- 
posed to extreme cold, had her first attack 
of glaucoma, so severe as to destroy the 
sight of one eye. The other eye, also af- 
fected 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 operat- 
ing room, with luncheon delayed two hours. 
The connection of his later attacks with 
anger, worry, embarrassment, even the ex- 
18 citement 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 cam- 
paign. 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 fre- 
quency of glaucoma among Jews may be 
due to a small cornea, as suggested by 
Priestley Smith; but it is quite as reason- 
able to connect it with a racial excitability 
or nervous instability. More definite 
knowledge of the nervous mechanism con- 
cerned 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 
19 fluid from the eyeball might be due to a 
change of character in the fluid, is a con- 
ception that has been entertained as a work- 
ing 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 pos- 
sible etiologic factor. Glaucoma secondary 
to intra-ocular hemorrhage, operations on 
the lens or its capsule, or severe nutritional 
disturbance may be capable of such ex- 
planation. 
Different Kinds of Glaucoma 
A better grasp of the etiology of glau- 
coma may be attained by considering sepa- 
rately various types of cases; although per- 
fectly typical cases may be rare; and cases 
of mixed type and etiology much more fre- 
quent. 
Simple glaucoma has been recognized as 
closely related to atrophy of the optic nerve 
with deep excavation. No line of demarca- 
20 tion 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 com- 
plete blindness, or to death, without exacer- 
bations, inflammation, or characteristic 
pain. In such cases the intra-ocular ten- 
sion 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 prog- 
ress 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 
21 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 activ- 
ity; and it is conceivable, under normal 
intra-ocular tension, that diminished nutri- 
tional activity may result in the same symp- 
toms as are produced in other eyes by in- 
creased 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 ten- 
sion recurring repeatedly over long periods 
22 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 re- 
maining permanent with normal vision until 
his death after 30 years. Millikin has re- 
ported 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 be- 
came 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 in- 
stability. 
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 in- 
crease of intra-ocular tension to justify 
their mention in a discussion on glaucoma. 
A patient, then aged 21, suffered three 
23 years ago from a scotoma almost central; 
and was first seen six months after that 
with a macular choroidal atrophy and ab- 
normal pigmentation. She suffered, we 
afterwards concluded, from choroidal tu- 
berculosis. A recurrence involving adjoin- 
ing 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 ten- 
sion rose to 28 mm., but for a year has con- 
tinued normal; the eye did well under tuber- 
culin 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., re- 
spectively, and gradually returned to nor- 
mal, with the cure of the iritis under atro- 
pine. In one of these cases, a lady of 70, 
24 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 consider- 
able general deep hyperemia, and soreness 
of the globe, followed by gradual return to 
normal tension, and no permanent impair- 
ment 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 dis- 
tinctly 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, de- 
manding enucleation, after some temporary 
perturbation, as the performance of a glau- 
coma operation. It is pre-eminently the 
kind of a case you would prefer would go 
to some one else. 
25 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 as- 
sumed. It would help to explain the cav- 
ernous atrophy of the optic nerve associated 
with simple glaucoma. The second type 
shows impairment of the regulative mech- 
anism 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 perma- 
nent 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 in- 
flammations may prove disastrous. The 
26 fourth type shows the results of the com- 
bination of the causes of the other types; 
with the elements of acute or slow malig- 
nancy 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 subse- 
quent 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 pro- 
pounded to explain the essential cause of 
increased intra-ocular tension is satisfac- 
tory. Our present day knowledge appar- 
ently 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 in- 
crease can be engaged in. This question 
primarily hinges on whether the corneo- 
sclera is to be regarded as an unelastic cap- 
sule with a fixed volume, or as a yielding 
28 envelope with an ever changing capacity. 
This brings us at once to the considera- 
tion 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 con- 
tents 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 forma- 
tion of aqueous, and a proportionate out- 
flow or resorption." (Henderson.) 
Hill has satisfactorily demonstrated that, 
under physiological conditions, the hydro- 
static 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 
29 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. Apply- 
ing these conclusions to the eye, it can be 
said that the pressure of the fixed intra- 
ocular volume varies with the venous ten- 
sion within the bulb, which in turn is in- 
fluenced 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-cor- 
neal coat." Further discussion on the in- 
adequacy of the volumetric theory need not 
detain us. 
30 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 (liga- 
mentum 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, conse- 
quently the alveoli of the meshwork becomes 
markedly reduced in size. 
3. The spongy nature of this mesh work 
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 incompres- 
31 sible 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 with- 
in 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 an- 
terior chamber and the venous sinus of 
Schlemm; intra-ocular pressure stands at 
the same level as the intra-venous, conse- 
quently, the hydrostatic pressure is the same 
on both sides of the iris angle meshwork, be- 
cause the canal of Schlemm is a secondary 
venous system; lastly, the outflow of aque- 
ous 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 ap- 
32 proach the predisposing and exciting fac- 
tors 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 pres- 
sure at the intra-venous level, and, too, as 
long as the exciting cause is absent. 
The exciting cause is vascular, main- 
tained and influenced by the general cir- 
culatory pressure. A rise of the general 
vascular tension alone will not cause glau- 
coma, because any alteration in intra-ocular 
pressure resulting would be purely a tem- 
porary change, easily taken care of by the 
extensive access of aqueous to the intra- 
ocular venous system. When these two fac- 
33 tors coexist in their varying combinations, 
pathological increase of pressure results- 
in short, glaucoma. 
Syphilis, rheumatism, gout, auto-intoxi- 
cation and many other constitutional dis- 
orders 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, con- 
gested portal or renal system, hard mental 
or muscular work, etc., etc., induce in- 
creased pressure of the general circulation, 
and so simultaneously the intra-ocular pres- 
sure. 
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 circum- 
stances which are responsible for a state of 
edema in any other part of the body." The 
magnificent experimental work of this in- 
vestigator has shown that edema is nothing 
more or less than an increased capacity of 
34 the protein colloid tissues for water; that the 
most important factor leading to this in- 
creased hydration capacity is an abnormal 
production or accumulation of acid content, 
effected by those agencies which are instru- 
mental 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 charac- 
terize 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 ad- 
vancing age, can rightfully be looked upon 
as a predisposing factor in glaucoma. 
35 Dr. Jackson has presented all other 
phases of this part of the symposium in such 
a comprehensive manner that nothing fur- 
ther remains to be said. 
36 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. 
37 vertically in glaucomatous and 11.6 mm. 
horizontally and 11 mm. vertically in non- 
glaucomatous eyes. In cases of consider- 
able 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 al- 
buminous fluid. Some of this fluid finds its 
way through Bowman's membrane, appar- 
ently 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 imbibi- 
tion. 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, 
38 as has been shown by V. Fleischl (Sitzungs- 
berichle d. Weiner Akad. d. Wissensch, 
1880) and others, to increased tension on 
the fibrillae of the cornea, a double refrac- 
tion being induced. In cases of long con- 
tinued increase of tension minute permanent 
vesicles form in the epithelial layers, partic- 
ularly in the superficial portion. Anaes- 
thesia of the cornea develops, due to pres- 
sure 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 (Col- 
lins & 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 corneas 
that have suffered from keratitis. The 
39 alteration is usually in the form of ectasia? 
In infancy and early youth (buphthalmia) 
the cornea may become uniformly enlarged 
and globular. Often, however, the en- 
largement of the cornea is irregular. In- 
crease in tension may produce fissures in 
Descemet's membrane. These occur more 
frequently in the cornae 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 endo- 
thelium. Prolonged high intra-ocular ten- 
sion 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 open- 
ings-passages for the venae vorticosae- 
40 are said to be narrowed. The openings for 
the passage of the anterior ciliary vessels 
are enlarged in many, particularly in ad- 
vanced cases. Minute herniae at these 
openings are sometimes present. Dilata- 
tion 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 de- 
generation, ectasae of the sclera occur most 
frequently near the equator of the globe. 
Spontaneous rupture may take place. 
Anterior Chamber. The anterior cham- 
ber 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 cham- 
ber 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 exu- 
41 dation 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, accord- 
ing 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 oc- 
cur in the filtration angle before it is en- 
42 croached 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 pig- 
mented 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 con- 
gested and thickened. It is pushed for- 
ward 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 stimula- 
43 tion of the fibers from the sympathetic pro- 
ducing vasomotor spasm. The long diam- 
eter 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 sup- 
ply. 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. Numer- 
ous 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 
44 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 Des- 
cemet's membrane. In a very few cases 
the closure of the angle is not complete at 
the apex, a small space remaining com- 
paratively free for a long time. The ad- 
hesion of the iris to the pectinaform liga- 
ment and cornea is not uniform at all parts 
of the periphery; it varies in width. Por- 
tions 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 disap- 
pears. In some cases the iris becomes to- 
tally 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 
45 ciliary process, which are larger and more 
tortuous in adults of advanced years than 
in the young, become enormously dis- 
tended, causing almost complete oblitera- 
tion 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 uveal 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 se- 
cretion from the glandular zone of the 
ciliary body is increased. 
On subsidence of the congestion, as after 
miotics or iridectomy, the tissues may re- 
turn 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 
46 atrophy of the ciliary body occurs, is drawn 
backward at the base of the iris by the 
receding tissues. If the hypertension per- 
sists 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 dis- 
tinguishable 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 
47 the same condition that is present in the 
vascular tunic; namely, that of venous 
stasis with the consequent edema. Fre- 
quently minute hemorrhages occur in the 
retina, particularly in violent acute at- 
tacks. Cupping of the discs slowly de- 
velops, 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 nutri- 
tion by these vessels follows. For this 
reason the nasal part of the field of vision 
is more often the first to disappear. In 
48 congestive (inflammatory) glaucoma, the 
typical field of vision shows most marked 
contraction on the nasal side. The dis- 
turbance of the nutrition of the retina ac- 
counts 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 posi- 
tion of the lamina cribrosa must exert a 
deleterious effect, particularly on those 
fibers which pass through the peripheral 
meshes, the shape of which must neces- 
sarily be much distorted. In glaucoma 
simplex, which is largely devoid of marked 
49 congestive periods (acute attacks), a sur- 
prisingly high degree of acuity of vision 
may exist with a deep excavation and pale 
nerve. Careful studies of the retinal ves- 
sels in glaucoma (Verhoeff Arch, of 
Ophth. XLII. p. 145; Opin. Soc. Fran- 
caise 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 vas- 
cular tissues in the nerve head. The dis- 
placement backward of the lamina cribrosa 
50 may cause that structure to lie behind the 
outer surface of the sclera. Atrophy and 
cystic degeneration of the nerve trunk fol- 
lows destruction of retinal neurons and 
cupping of the disc. Neuroglia remains 
in part. Connective tissue elements in- 
crease 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 pos- 
terior, the condition is very similar to that 
presented by the glaucomatous ring. 
51 Field of Vision. The two pathological 
processes that operate to destroy the func- 
tion of the retina suffice to produce scoto- 
mata in the field of vision of varying 
shapes. The typical glaucomatous field in 
the acute cases shows a defect most pro- 
nounced to the nasal side. As has been 
shown by Bjeraum, the blind spot cor- 
responding with the optic disc is enlarged 
in glaucoma, a relative scotoma often con- 
necting it with the blind nasal portion of 
the field either above or below the hori- 
zontal meridian (Straub). The field in a 
simple glaucoma is apt to approach concen- 
tric 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 glau- 
coma 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 
52 cases in which absolute glaucoma is reached 
the development of small blood vessels in 
convoluted loops springing from the ves- 
sels 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 (Greafe'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 corneo- 
scleral junction. In all of the cases in 
which the eye has been examined micro- 
scopically obliteration of Schlemm's canal 
has been reported. This is thought to 
be a defect in development. Magitot 
53 (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 hyper- 
tension. 
Cornea. This portion of the fibrous 
membrane is enlarged, globous or flat- 
tened, 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 de- 
54 velops and may reach an extreme degree. 
The sclera ordinarily becomes quite thin 
throughout, but may retain almost a nor- 
mal thickness at the equator of the globe 
and posteriorly. Posterior scleral ectasae 
may develop. The iris, as a rule, hangs 
free from the cornea, often tremulous be- 
cause of retraction of the lens beyond the 
iris plane. In some cases the iris is partly 
or totally adherent to the posterior sur- 
face 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 accom- 
panied 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. 
55 Secondary Glaucoma. The pathological 
conditions that precede secondary glau- 
coma are many and differ widely. They 
may be briefly classified as: 
1. Those that cause a partial or com- 
plete 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 in- 
creased, 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. 
56 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 glau- 
coma, one which has received too little 
attention in this country: the lacunar or 
cavernous atrophy of the optic nerve. 
The name accurately describes the con- 
dition. 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 rela- 
tion to the blood vessels. Adjoining 
lacunae are supposed to fuse to form 
larger cavernae and these finally merge 
and constitute the final glaucoma cup. 
57 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 sup- 
ported by Elschnig, but as vigorously op- 
posed 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 pub- 
lishes 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 writh a com- 
58 plete and total glaucoma cup, with the 
typical (ampulliform) undermining of the 
scleral ring, in a pair of eyes without 
increased tension. The (Schiotz) to- 
nometer 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 over- 
looked a publication by Lewin and Guil- 
lery. Friedenberg has since reported cases 
of the same nature. 
If other conditions than increased ten- 
sion 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? 
59 Concerning Non-Surgical 
Measures for the Reduction 
of Increased Intraocular 
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 dis- 
ease. 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 im- 
portance, due to the improvement and elab- 
oration of operative technic, and the medical 
journals of the day are weighted with opin- 
61 ions 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 opera- 
tion is not always possible, (2) because 
operation is not always permitted, and 
(3) because in certain circumstances opera- 
tion is not advisable. Hence a glance at 
the non-surgical methods of reducing in- 
creased intra-ocular tension is not out of 
place, and for convenience they may be 
catalogued as follows: 
1. Myosis produced by means of solu- 
tions of various drugs, a myosis followed 
by reduction of intra-ocular tension. 
2. Reduction of tension by means of 
various mechanical measures, notably mas- 
sage, vibration massage and suction mas- 
sage, 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 
62 stimulation of osmosis, of lymphagog activ- 
ity, 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 effi- 
ciency. Personally, it has always seemed 
to me that the salicylate of eserin is pref- 
erable to the sulphate, but I have not per- 
suaded myself that the nitrate of pilo- 
carpin 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, recom- 
mended 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 
63 sulphate of eserin, i. e.t 1/80 of a grain 
of the drug is equal to 1/60 of a grain 
of the sulphate of eserin, but it is cer- 
tainly not less irritating than physostig- 
min, and according to Stephenson's re- 
searches, 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 sym- 
pathetic 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 
64 follows a direct stimulation of the sphinc- 
ter muscle fibers, aided, perhaps, by con- 
traction 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 
65 edges of the coloboma, which do not 
cicatrize, permit access of the aqueous 
to the iris veins, and that myotics, inas- 
much as they contract the pupil, open the 
iris crypts and therefore act, less effi- 
ciently, perhaps, but act none the less like 
an iridectomy. The normal intra-ocular 
pressure is uninfluenced by myotics because 
this pressure represents the lowest cir- 
culatory 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 libera- 
tion 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 Indica- 
tions. With the methods of administra- 
tion of the myotics we are all so familiar 
that time need not be wasted in their 
66 reiteration, except to refer to a few prac- 
tical 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 fre- 
quency to establish myosis, and its action 
in this respect is enhanced if the conges- 
tion 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 subacute varieties, myotic 
activity is increased by a mixture of pilo- 
carpin 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 ex- 
clusively on the use of myotics in so-called 
simple, chronic or non-inflammatory glau- 
coma. This is not the place to introduce a 
67 dicussion 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 preva- 
lent. 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 iridec- 
tomy 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 es- 
tablishes a permanent filtration. In the 
meantime the patients who will not or can- 
not submit to operation must be reckoned 
with. Doubtless many patients with 
chronic glaucoma can be satisfactorily 
68 managed with myotic treatment, although 
personally I have always advocated opera- 
tion 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 in- 
creased 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 num- 
ber necessary to maintain this myosis are 
on retiring and if possible in the very early 
morning, some time between two and four 
69 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 treat- 
ment is not its lack of efficiency, but the 
70 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 glau- 
coma what I may call an eserin life, just 
as it is hard to maintain in a person with 
an enlarged prostate a catherter 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 pre- 
ventive operations which shall aid nature's 
71 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 mas- 
sage, and by means of electricity and 
diathermy. Massage is of ancient lineage. 
In general terms, in so far as ocular mas- 
sage is concerned, it may be applied to the 
eye with the finger tips (ordinary mas- 
sage), by means of various instruments 
(vibration massage), and with the help of 
certain suction cups (suction massage, 
which is indeed a form of vibratory mas- 
sage). Many authors are satisfied with 
their results without the employment of 
any instrument, and prefer simple mas- 
sage 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 extensive- 
72 ly 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 thera- 
peutic procedure. She became exceedingly 
skillful and was quite faithful. We be- 
lieved 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 glau- 
coma the addition of the oil is not neces- 
sary. Four movements were utilized, the 
first a stroking movement in lines radiat- 
ing 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 mo- 
tion, so that the cornea was slightly de- 
pressed, and finally, a gentle tapping 
movement, precisely the same, except that 
it was a diminutive one, as the tapping 
73 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 residts 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 instru- 
ment, which makes 3,000 vibrations a min- 
ute, 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 re- 
volving ball being passed over the closed 
74 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 mas- 
sage 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. With- 
in three-quarters of an hour the tension 
returns to the normal. In acute glau- 
coma such massage is not available, but it 
is of assistance in encouraging a reduction 
of the intra-ocular tension and keeping it 
75 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 in- 
teresting 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 pa- 
tient 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 
76 physicians to make reference to massage 
of the eyeball lest their words should be 
misquoted by irregular practitioners who 
employ this method, selling various instru- 
ments to trusting patients, and attributing 
to this simple and often beneficial pro- 
cedure 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 thera- 
peutics. 
If I should sum up my opinion of mas- 
sage in the reduction of intra-ocular ten- 
sion, I would say that it is useful in enhanc- 
ing 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 
77 never trust themselves in the hands of ir- 
regular 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 True, 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, Wiirdemann, 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 
78 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 cur- 
rent of 30 to 40 ma. during a quarter of 
an hour, and who reports notable diminu- 
tion 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 men- 
tion its size. Ziegler of my own city, who 
has studied most scientifically and intelli- 
gently 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 
79 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 excre- 
tion. 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 al- 
ways been very frankly pessimistic in re- 
gard to the therapeutic value of electricity 
in ocular disorders. Perhaps I am wrong; 
I am willing to be enlightened. There 
seems little doubt that True and Imbert's 
observations that high frequency currents 
can temporarily reduce intra-ocular ten- 
sion is correct, that they are able to relieve 
80 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 meth- 
od 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 in- 
different electrode applied to the back of 
the neck. It is not germane to the sub- 
ject 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 ten- 
sion. In a number of diseases, for ex- 
ample, iridocyclitis, the method produced 
distinct rise of pressure. In one, a patient 
with secondary glaucoma, prior to the 
81 diathermic application the tension was 
37^/2 mm., after the passage of the cur- 
rent 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 dis- 
ease 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 symp- 
toms, by galvanism of the cervical sympa- 
thetic, for example, by placing one elec- 
trode 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 re- 
sults have been reported by an observer 
named Allard. I confess that I am en- 
tirely faithless in regard to any results 
82 that may be reached in this maimer. 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 pro- 
duces elevation of intra-ocular tension of 
2 to 4 mm. In some experimental work 
the primary elevation of intra-ocular ten- 
sion 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 be- 
tween increased vascular pressure and in- 
creased intra-ocular pressure. It is not 
my province to analyze observations often 
contradictory and not infrequently inac- 
curate. 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 
83 arteriosclerosis and therefore usually in- 
creased blood pressure, with all its con- 
comitant 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 pres- 
sure, although it may be too much to say, 
as Gilbert has, that blood pressure and 
intra-ocular pressure rise and fall to- 
gether. It may be true, as Thomas Hen- 
derson 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 ac- 
cepted, 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. 
84 Now, it goes without saying, if these 
data are correct, or even only partly cor- 
rect, that part of the treatment of the 
increased intra-ocular pressure state must 
be constitutional in that the vascular pres- 
sures should be lowered in order that the 
beneficial effect of their relationship to 
the intra-ocular pressure shall be estab- 
lished. 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 stand- 
point that a certain amount of plus pres- 
sure 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 pres- 
sure, while some disturbance in his general 
life may add to that 10, 15 or 20 mm. 
85 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, al- 
though there are tolerably accurate in- 
strumental 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 proc- 
86 esses, 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 sys- 
tem best conforms with the patient's 
general welfare, and I am bitterly opposed, 
and I think with right, to the sudden re- 
duction 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 elimi- 
nation of such an over plus tension may 
be the means of preventing, for example, 
an intra-ocular hemorrhage, and in this 
87 emergency we must not lose sight of Gil- 
bert's recent investigation, who has found 
that blood withdrawn to the extent of 3 
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 main- 
tenance of a glaucomatous life, exclusive 
of operative interference, in addition to 
sustained myosis, demands the investiga- 
tion of the patient's metabolism, which 
must be kept at the normal standard, the 
removal of the evil effects of auto-infec- 
tion, as we are wont to call it, and espe- 
cially the elimination of the cause which 
is responsible for the over plus tension of 
the arteries and of the veins. This is best 
88 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 glau- 
comatous patient, and I now refer to those 
who are the subjects of chronic progres- 
sive 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 state- 
ment I want to quote the opinion of Dr. 
Hobart Hare, one of America's most ex- 
pert 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 
89 pressure above the normal existed. "Con- 
cerning 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 pres- 
sure 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 pres- 
sure 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 pres- 
sure what it may. If it is lowered below 
the pathological norm, all manner of dis- 
turbed cardiac action, etc., may result. 
90 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 in- 
ternist. 
Some such thought was in the mind of 
Ibershoff, who quotes Sterling and Hen- 
derson's views that the rate of secretion 
depends upon and varies with the differ- 
ence in the blood pressure and the ten- 
sion of the eyeball, and that the specific 
91 gravity of the secretion increases directly 
with the blood pressure and inversely with 
the ocular tension. Shoidd the blood pres- 
sure be very high, paracentesis, for ex- 
ample, 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 pres- 
sure, or what I have, quoting Hare, ven- 
tured to call the over plus pressure. 
4. The relation of osmosis, lympha- 
gogue activity, absorption of edema, capil- 
lary 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 treat- 
ment of glaucoma should include the ad- 
ministration of osmotic substances as 
92 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 secre- 
tion 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 
93 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 con- 
firmation from a number of sources in 
spite of the fact that Happe's experi- 
mental 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 fre- 
quent injections the weaker of the two 
94 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 sup- 
ported. 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-ocidar pain in glau- 
coma. 
What shall be said in regard to certain 
medicinal agents which stimulate the 
95 lymphagogue activity of the eyeball in 
their relation to the reduction of intra- 
ocular tension, notably of dionin? Toczy- 
ski'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 ten- 
sion 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 be- 
lieves 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 cer- 
tainly in acute and particularly in chronic 
secondary glaucoma, this is a most valuable 
agent, especially if it is combined with 
96 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, par- 
ticularly if this drug is added to the vari- 
ous myotic mixtures, and yet adrenalin 
is certainly not without danger in the 
treatment 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 
97 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 contrac- 
tion of the ciliary vessels; also the nar- 
rowing 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 ten- 
sion of from 2 to 6 degrees as measured with 
Fick's tonometer. These observations were 
made while he was experimenting on irri- 
tation of the sympathetic as a method of 
producing increased intra-ocular tension. 
This is not in accord with Axenfeld's re- 
cent observations. It is well known, this 
observer points out, that after the period 
98 of excitation and muscular rigidity dis- 
appears, there is a lowering of blood 
pressure in chloroform narcosis and co- 
incidently 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 glau- 
comatous 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 advan- 
tageous in glaucomatous patients. For- 
merly I thought it was essential, if iridec- 
tomy was to be performed, lest some 
sudden movement on the part of the pa- 
tient 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 reduc- 
99 tion of intra-ocular pressure, it is not with- 
out a certain therapeutic value, and the 
matter is mentioned as a suggestion that 
additional observations along this line shall 
be made. 
100 Dr. George Edmund de Schweinitz' 
Paper on Concerning Non-Surgical 
Measures for the Reduction of 
Increased Intraocular 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 relation- 
ship which should exist in the non-surgical 
treatment of increased intra-ocular ten- 
sion between the internist and the ophthal- 
mologist, but neglected to mention a cor- 
responding relation which should exist 
between the rhinologist and the ophthal- 
mologist, and possibly between the dental 
surgeon and the ophthalmologist. 
I would like to refer to the now recog- 
nized close relationship which exists be- 
tween disease of the nasal accessory 
101 sinuses and diseases of the eye. The defi- 
nition 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 pro- 
ducing 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 dam- 
ming 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 ex- 
ternal lymph channels. Obstruction to the 
steady escape of the intra-ocular fluids at 
any point in this drainage system or any un- 
due increase of the fluids themselves may 
102 produce glaucoma. Probably the most im- 
portant 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. How- 
ever, 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 dis- 
ease either acute or chronic of one or more 
of the sinuses with the accompanying in- 
flammatory 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 chan- 
nel, producing a stagnation in the flow 
of fluid from the orbits and eyes at the 
103 junction with the main channel, with 
backing up of the fluid within these chan- 
nels 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 glau- 
coma) "to an abnormal production or ac- 
cumulation of acid in the eye. In conse- 
quence 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 avail- 
able 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 ten- 
sion, i. e., the amount of fluid injected be- 
neath conjunctiva may overcome the stag- 
nation in the lymph passages, flush out 
these channels and improve ocular elimina- 
tion. 
104 Fischer in a personal letter says: 
"You have two possibilities for the pro- 
duction 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 asso- 
ciated 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 in- 
creased 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 ex- 
105 amination 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. 
106 Trephining for Glaucoma 
BY 
Robert Henry Elliot, M. D., 
London, England. 
Mr. President and Members of The Chi- 
cago 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 
107 in its results. I do not advise trephining 
in the secondary glaucoma following in- 
tumescent 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 ex- 
ists between the aqueous and vitreous cham- 
bers. 
Second: The object of trephining is 
to tap and permanently drain the aque- 
ous 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 iridec- 
tomy 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 
108 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 cor- 
neal 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 tech- 
nique can be acquired from a written de- 
scription. It is not for a moment necessary 
that the surgeon who wishes to learn tre- 
phining should see the originator of the 
operation at work. If, however, he feels 
diffident at undertaking the procedure until 
109 he has seen it done by another, there are 
many centers in this country where the 
operation is now being successfully per- 
formed. I would mention amongst those 
which 1 have visited New York, Minne- 
apolis, St. Louis, Nashville, Louisville, 
Detroit and Chicago. I have seen results 
of trephining by American surgeons which 
coidd not be bettered anywhere. 
Fourth: I am sure that everybody will 
recognize the difficulties of operating dur- 
ing 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 diffi- 
cult that, as you are aware, many dis- 
tinguished 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 
110 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 pos- 
sible. 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 diag- 
nosis of glaucoma will then be followed 
by a very early operation. In India I 
have gone farther than this, and where 
111 one eye has shown high tension, I have 
frequently trephined both. The prophy- 
lactic 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 trephin- 
ing 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. 
1 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 appear- 
ances non-glaucomatous. 
112 Dr. Robert Henry Elliot's Paper on 
Trephining for Glaucoma 
Dicussion, 
Frank C. Todd, M. D., 
Minneapolis. 
It is very difficult for one of limited ex- 
perience 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 per- 
formed 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 sclero-corneal trephining oper- 
ation 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, 
113 and that to a foundation of a careful train- 
ing he has added the experience of twenty- 
two years of hard painstaking work. 
I have recently had the privilege of en- 
tertaining Colonel Elliot in my own city, 
where I had the opportunity of assisting 
him and hence closely observing his tech- 
nique 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 tre- 
phining 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 diffi- 
cult, and hence less certain than the Elliot 
trephining operation. 
The time for discussion does not permit 
a detailed statement of the results nor ex- 
114 periences in the handling of these trephin- 
ing cases. Of the entire number five totally 
blind eyes were trephined. Tension was 
reduced in all but one. In that one hemor- 
rhage 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. An- 
other eye totally blind one year has thus 
far developed perception of fight. 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 hemor- 
rhage occurred, causing nearly total blind- 
ness for two weeks. Vision is clearing fast 
and it remains yet to be seen what the final 
results may be. One buphthalmic eye tre- 
phined by myself gave good results. 
115 I have as yet seen no cases of remote in- 
fection, but the report of Axenfeld and 
some others would indicate that this oc- 
curred following the Lagrange as well 
as the trephining operation, the then bulg- 
ing 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 ob- 
tained 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 on- 
coming of blindness, the result has appar- 
ently been secured by reason of the fact 
that filtration has been produced, and not 
merely because a piece of iris has been re- 
moved. 
Second: That in chronic glaucoma (in 
acute glaucoma iridectomy has proven a 
116 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 can- 
not 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 tre- 
phining 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 trephin- 
ing 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 satisfac- 
tory, in that the operation in a large pro- 
117 portion of cases apparently permanently 
lowers the tension to normal or below nor- 
mal, 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, oc- 
casionally to a marked degree. 
Sixth: That it is not a simple nor easy 
operation and should, therefore, be per- 
formed 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 
118 against precedent and criticism in estab- 
lishing the facts upon which rest the foun- 
dation 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. 
119 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 pro- 
cedures 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; scler- 
iritomy; de Wecker's dialysis of the iris; 
Hancock's division of the ciliary muscle; 
the incision of the iridian angle of de Vin- 
centiis; sclero-cyclo-iridic puncture; the 
Sterns-Semmereole sclerotomia antero-pos- 
121 terior; the trans fixio iridis of Fuchs; An- 
tonelli's peripheral iritomy; Holth's forma- 
tion of a cystoid cicatrix; Hern's operation; 
Terson's sclero-iridectomy; Abadie's ciliar- 
otomy; Ballantyne's incarceration of iris 
method; Masselon's small equatorial scler- 
otomy; Simi's equatorial sclerotomy; Gale- 
zowski'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; Her- 
bert's wedge-isolation operation; Verhoeff's 
operation with a special sclerotome; Holth's 
sclerectomy with a punch-forceps; Walk- 
er's hyposcleral cyclotomy; posterior scler- 
otomy; T-shaped sclerotomy; and last but 
not least the Lagrange form of sclerec- 
tomy 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 
122 really a combination of a sclero-corneal 
trepanation and a cyclodialysis. 
So far as it is practicable there is a cer- 
tain amount of wisdom in comparing the 
results of an operative procedure with 
others with which it is brought in competi- 
tion, 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 inter- 
ventions made use of by ophthalmic sur- 
geons at the present time. I refer to iri- 
dectomy, 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 dis- 
cussion 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 
123 procedures just mentioned-iridectomy- 
introduced by von Graefe. The mechan- 
ism 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 be- 
tween 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 bor- 
der of the adhesion-and does not open 
up a channel into Schlemm's canal. It 
124 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 glau- 
coma, 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 iri- 
dectomy are those due to the formation 
of cystoid scars or minute fistulae, rather 
than as a result of the removal of a por- 
tion of the iris periphery. 
The best brief tabulation of the results 
125 obtained by iridectomy, in glaucoma, is 
to be found in Weeks' textbook on Dis- 
eases of the Eye, page 417: "Sulzer re- 
ports as follows: Acute glaucoma, 149 
cases; improved, 72.5 per cent; serviceable 
vision preserved, 11.3 per cent; vision im- 
paired at once, 4.08 per cent; very little 
vision, 12.12 per cent. 
"Zentmeyer and Posey: In simple glau- 
coma 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; unim- 
proved, 5 per cent; deterioration, 19 per 
cent. Sub-acute (chronic inflammatory), 
147 cases; improvement 10 per cent; un- 
improved (condition the same as before 
iridectomy), 40 per cent; deterioration, 30 
per cent; blindness, 20 per cent. Cases op- 
erated on at an early stage gave 85 per 
cent of good results. Simple glaucoma, 
104 cases; improvement, 0.96 per cent; con- 
dition as before, 10.5 per cent; deteriora- 
126 tion, 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 inflamma- 
tory, 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 glau- 
coma, 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 peri- 
pheral section of the sclero-corneal margin 
with the knife and, as soon as the edge of 
the knife reaches the upper limit of the an- 
terior chamber, it is turned backward and 
brought out through the sclera obliquely. 
The conjunctival flap thus formed is 
127 turned back over the cornea, and the frag- 
ment 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 con- 
junctival flap is now replaced and a band- 
age 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 iridec- 
tomy 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 neces- 
sary to open the anterior chamber, Bet- 
tremieux thinks that a removal of but a 
portion of the thickness of the sclera suf- 
128 fices. 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 % mm. thick, 1% 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 oper- 
ators 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 re- 
129 suits of sclerectomy vary according to the 
degree of hypertension of the eye operated 
on. Three varieties of cicatrix are dis- 
tinguishable 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 smooth- 
ly covers the cicatrix); (2) that repre- 
sented 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 cica- 
trix) ; (3) the fistulous cicatrix with an am- 
pulliform elevation of the overlying con- 
junctiva, resulting from excision of the 
whole thickness of the sclera in an eye the 
seat of high tension. In cases of high ten- 
sion, 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 
130 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 en- 
tanglement of the iris. Lagrange does not 
recommend his operation for acute glau- 
coma. 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 Oper- 
ative Treatment of Glaucoma with Special 
Reference to the Lagrange Method, The 
Canadian Medical Association Journal, 
November, 1911) I have elsewhere pub- 
lished. 
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 
131 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 prepa- 
ration of 1-3000 mercuric chloride in sterile 
vaseline. One cannot use sublimate m 
such a strong watery solution, but the vas- 
eline seems to modify it and to allow of such 
slow absorption that it is not only a non- 
irritant but a most excellent antiseptic ap- 
plication in operations on the eye. 
In any event the result of the Lagrange 
operation proper, as well as my modifica- 
tion 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, 
132 I suspect that the most successful examples 
are those in which scleral fistulae, minute 
or otherwise, form as a sequel of the oper- 
ation. 
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 pa- 
tient 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 op- 
erations 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 con- 
133 fess 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 per- 
formance 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 de- 
sirable that there should not be long de- 
layed 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 
134 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 glaucomatosus. 
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 
135 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 El- 
liot method and those following the La- 
grange procedure. Probably the most 
important of these observations is the ex- 
perience of Meller (Die Sklerektomie nach 
Lagrange und die Trepanation nach El- 
liot) set forth in a paper read by him at 
the last meeting of the Deutsche Natur- 
forscher und Aertze. In this report Mel- 
ler 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 inflam- 
matory 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 
136 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 cicatri- 
cal 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 enuclea- 
tion 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 
137 large majority of these complications arose 
in the eyes operated on for chronic glau- 
coma. There were fewer eyes lost follow- 
ing 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 ap- 
pearance of the complications were duly 
set forth. The operator then gave a his- 
tory of over 178 trepanations after the 
Elliot method and compares them with the 
procedure of Lagrange. He concludes that 
138 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 ob- 
server 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 iridec- 
tomy for cases difficult or dangerous under 
the latter method. 
Whatever difference of opinion was no- 
ticeable 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 
139 every respect the one best adapted to buph- 
thalmia, or congenital glaucoma. 
In conclusion let me say that the accept- 
ance or rejection of Colonel Elliot's pro- 
cedure or any other operation is not to be 
decided by the percentage of iritis, sec- 
ondary cataract, relapses, lost eyes, etc., 
but by deciding whether or not his pro- 
cedure in the various forms of glaucoma 
gives the best results, including the preser- 
vation 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 aver- 
age ophthalmic surgeon, of relieving or 
curing most cases of that affection. 
140 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 dis- 
favor. 
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 glau- 
141 coma, and not a few hold that the opera- 
tion 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 re- 
moval 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 
142 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 sud- 
den release of all tension and the simul- 
taneous weakening of the supports of the 
lens and vitreous body create very unfavor- 
able conditions under which to make the 
crucial step of the operation. 
The poor results following an iridectomy 
in chronic glaucoma have led to the devis- 
ing of many substitute operations, of which 
those tending to the production of a filter- 
ing scar are now preferred, and, experience 
shows, hold out the most hope of bringing 
143 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 filter- 
ing 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 sur- 
gery, sclerotomy has not been found ade- 
quate, and cyclodialysis is not sufficiently 
simple of execution or permanently bene- 
144 ficial in its results to give it prominence. 
Of the operations proposed for the for- 
mation 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 opera- 
tion 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 perform- 
ance. It does, however, offer the advan- 
tage of carrying with it the minimum 
amount of risk, and the apparently per- 
manent results secured justify the ophthal- 
mologist 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 suf- 
ficient reason why the field of usefulness 
of the operation should be confined to the 
chronic forms of glaucoma, and Col. 
Elliot unhesitatingly recommends trephin- 
ing as safer and more efficient than any 
145 other operative procedures at present em- 
ployed 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-conjunc- 
tival 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 open- 
ing, covered by the replaced conjunctival 
flap, is made. Unlike the trephine opera- 
tion which was evolved from it, the La- 
grange 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- 
146 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 opera- 
tion is even more difficult and exacting 
than in the performance of the trephine 
operation, and it also compares unfavor- 
ably in safety. 
The advisability of removing the con- 
junctival flap, as advocated by Dr. Wood, 
as a modification of the Lagrange opera- 
tion, may be seriously questioned, for aside 
from the fact that apparently no advan- 
tages in aiding permanent filtration are 
added, there is, added to the objections to 
the Lagrange operation already men- 
tioned, 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 inter- 
ference of drainage by the blocking of the 
open wound with conjunctival tissue. The 
147 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 expe- 
rience of Dr. Wood. Furthermore, the 
possibilities of damage by hemorrhage 
from the choroidal or retinal vessels, de- 
layed 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, 
148 yet it seems now that for a large majority 
if not all of the cases we are justified in 
abandoning all other operations than tre- 
phining, 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 un- 
known 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 
149 being applicable to any form of the dis- 
ease, 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 com- 
plicate the operation and has much to 
commend it in offering the patient every 
possibility of relief. 
150 INDEX 
PAGB 
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 Ten- 
sion, George Edmund de Schweinitz, M.D... 61 
Concerning Non-Surgical Measures for the 
Reduction of Increased Intra-Ocular Ten- 
sion, 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 
151