GLAUCOMA:
SYMPTOMS,  DIAGNOSIS,
TREATMENT.
PETER DIRCK KEYSER, M.D.
      P III L A O E L PII1 A :
L I X D S A Y & BLAKIST O X,
           IS 64. 
 
T 
 
GLAUCOMA.
i 
 
GLAUCOMA:
SYMPTOMS,  DIAGNOSIS,
TREATMENT.
PETER DIRCK KEYSER, M. D.

      PHILADELPHIA:
LINDSAY  &  BLAKISTON
           18 64. 
      Entered, according to Act of Congress, in the year 1864,
                     By P. Dirck Keyser,
In the Clerk's Office of the District Court of the United States for the
                 Eastern District of Pennsylvania.
TAXTON PRESS. OF  SHERMAN *  CO. 
            HENKY TIEDEMANK,  M.D.,







                     STIjis ^roc^fiirjc







IS, IN TESTIMONY OF THE HIGHEST ESTEEM- AND FRIENDSHIP,







                      INSCRIBED, BY 
 
PREFACE.
  Should any apology  be  deemed necessary for
obtruding on  the  medical public a new pamphlet
on ophthalmic science, it may, perhaps, be furnished
by the interest which that department of medicine
and  surgery has acquired in the last few  years,
and  the  attention  it now commands from  the pro-
fession.
  I  have endeavored in these pages to lay before
the  reader,  in  an easy and practical  form,  the
latest  theories relating to Glaucoma,  so as  to en-
able him at once* to grasp  the  most salient and
important points in the symptoms,  diagnosis, and
treatment of this disease.
  I  have chiefly  followed the vicavs  of Professor
A.  Von  Graefe, of Berlin, in the  diagnosis and
treatment of this  disease; indeed, Ave are mainly
indebted to  his admirable and important researches 
Vlll
PREFACE.
for the elucidation and treatment of this and many
other diseases of the eye.
   The substance of this  work  is from my notes
taken Avhile attending the clinical lectures of  Pro-
fessor Von Graefe, during  the Avinter of 1863  and
1864, in  Berlin, and I have  compiled and pub-
lished them, thinking that they would not only be
of interest, but  of  advantage to the medical  pro-
fession in this country.
  500 North Fourth Street.
      September, 18f>4. 
GLAUCOMA.
  The term glaucoma Avas  applied by Hippocrates to
all opacities situated behind the pupil.  After a time, it
was confined to those which presented a green appear-
ance, the nature of which Avas not, however, understood,
although the fact was recognized that such green opa-
cities were  not curable  by operations.  By some, the
seat of the affection Avas supposed to be in the vitreous
humor, by others, in the retina and optic nerve.  At a
later period, it Avas thouglit that glaucoma Avas due to
a peculiar inflammation of the choroid, Avhich occurred
most frequently in  gouty persons, Ifence it Avas termed
arthritic ophthalmia,  a name still retained by some Avri-
tcrs.  LaAvrence considered that the symptoms of glau-
coma ay ere  caused by an affection of the retina and
choroid.   \Y~eller  gave  a most excellent  and graphic
description of the symptoms of glaucoma, including in
it many of the principal and most important points, e. g.,
the intermitting course of the disease,  the  sluggishness
and  dilatation of the pupil, the circumorbital pain, the
rainboAvs  round a candle, «.\:c.   He also made mention
of the tenseness of the eyeball,  but Mackenzie first 
10
GLAUCOMA.
pointed out  (in  1830), the  importance of  the  latter
symptom.
  In 1851, Helmholtz  discovered the  ophthalmoscope,
which has proved of such incalculable value in diseases
of the eye, and has so completely revolutionized ophthal-
mic  surgery.  The first results of the ophthalmoscopic
examination of cases of glaucoma Avere negative ; soon,
hoAvever, it Avas ascertained that there always existed a
peculiar alteration in the optic disc in all cases of well-
marked glaucoma.  In 1854, Edward Jager gave an ex-
cellent illustration of the  ophthalmoscopic appearances
of the optic nerve-entrance in a case of glaucoma, show-
ing the peculiar displacement of the vessels at the edge
of the disc, the slight rim surrounding the latter, &c.  It
Avas, hoAvever, reserved for  the great genius of Yon
Graefe to unite these various and disjointed links of the
chain of symptoms presented by glaucoma, and welding
them into  one connected  whole, not only to found the
modern doctrine of glaucoma, but at  the same time, to
bless humanity with* a cure for this hitherto irremediable
disease.   Soon after Jager's  delineation of the ophthal-
moscopic appearances  of the  optic disc, Von  Graefe de-
scribed these peculiar  appearances still more accurately,
and  at the same time, pointed out a  most important
fact, ATiz., that an arterial pulsation exists in the optic
nerve in glaucoma, being either spontaneous, or produ-
cible by a A'cry slight pressure upon the eyeball, a pres-
sure far less than is necessary for its  production in the
normal eye.   AVithin  a short time afterAvards, he  also
discovered that the peculiar  appearance of the  optic 
G L A U C 0 M A.
11
disc, AAdiieh had been supposed by him and other observ-
ers to be due to an  arching forward of the optic nerve-
entrance, was in reality due  to its being excavated or
cupped.  He at once recognized the connection of these
two  symptoms (the  excavation  and the spontaneous or
easily producible arterial pulsation), Avith the increased
hardness of the globe, and his clinical observations soon
shoAved him  that  all the other symptoms Avere also
closely  connected Avith  this  augmented tension.  The
next problem was, to  solve hoAV this  tension might be
permanently diminished.  All the usual remedies, such
as  mercurials, antiphlogistics,  diuretics,  diaphoretics,
had proved as insufficient in his bands, as  in those of
other practitioners.   Mydriatics, which had been found
to diminish intraocular pressure, Avere next had recourse
to, but they also proved of no avail.   He then tried tap-
ping the anterior chamber, but this was only folloAved by
a temporary benefit, Avhich soon passed aAvay again.  The
disease gradually progressed, nor could the relapses be
stayed  by a methodical repetition of the paracentesis,
for  lie  found that its  therapeutical effect became each
time less, and finally null, as far as the sight Avas con-
cerned.  In only tAvo  cases out of a great number thus
treated, did it prove of lasting benefit.
   Paracentesis haAang been of no  avail in permanently
reducing the intraocular pressure, he  next had recourse
to iridectomy, haA^ing  found that it  proved of  great
benefit in  ulcerations  and infiltrations of the cornea, by
diminishing pressure; and that in cases of partial sta-
phyloma of the cornea,  and in staphyloma of the sclero- 
12
GLAUCOMA.
tic, the  protruding part often receded completely after
this operation.
  He first tried iridectomy in glaucoma, in 1856, and
soon found that it not only permanently diminished the
intraocular pressure, but that it  might  indeed be  re-
garded  is a true curative treatment of the glaucomatous
process;  aving, however, like every other therapeutic
agent, its natural  limits.  Since that time iridectomy
has been recognized by most of the eminent oculists in
Europe, as the only cure  knoAvn at  present  for  glau-
coma ;  but although it  has achieved  most brilliant re-
sults  in the lands of many of the most distinguished
ophthalmic surgeons, there are yet some English ocu-
lists of repute avIlo condemn the operation completely.
  My own experience  of the beneficial eft'ects  of iri-
dectomy in glaucoma, enables me. not only to recom-
mend the operation  most strongly, but even to trust to
no  other remedies, as they haA~e all proved  insufficient,
and most valuable time would thus be permitted to pass
irrevocably aAvay, AA'hen an iridectomy might still saATe
the eye.  We shall see hereafter  that an accurate prog-
nosis of the  benefits to be expected  from iridectomy
may be made in the majority of cases, and it AA'ill be
shown Avhy the operation may have proA'ed unsuccessful
in the hands of some practitioners.  But too frequently
impossibilities were expected of it; it was tried for the
first and only  time, perhaps, in chronic  cases  of glau-
coma, Avhich  avcre beyond help: it  proA'ed, as mi^ht
have been  foretold, unsuccessful,  and  AA'as then at once
discarded as useless. 
GLAUCOMA.
13
  The commencement of the disease, the development
of the different symptoms, and the course which glau-
coma may run, present  numerous variations, and for
this reason a precise classification is somewhat difficult.
But on closer observation, it Avill be found that the se-
veral A'arieties also show a great tendency to pass over
into   each  other.   The family  resemblance of these
different forms is  very  marked, for they are distin-
guished from the commencement, by certain character-
istic symptoms, and although they Avill vary someA\diat
in their course, they all, but too surely, lead, sooner or
later, to that last hopeless condition, in Avhich the eye-
ball is stony hard, the pupil widely dilated and fixed,
the refractive media clouded, the optic disc cupped, and
the sight either  entirely or nearly entirely lost; that
condition, in short, to Avhich our forefathers confined
the term glaucoma.   The modern school of ophthal-
mology, hoAvever, no longer limits the name  glaucoma
to this last hopeless condition, but embraces in it all
the varieties of the disease from their commencement,
Avhich lead to this last stage.  In  regarding the differ-
ent varieties of glaucoma from a clinical point of ATieAV,
Ave are particularly struck by the fact, that one  class  of
cases is distinguished from the commencement by more
or less marked inflammatory symptoms, whilst another
appears, in the commencement at least, to be free from
inflammation,  although  in its  course,  inflammatory
symptoms, even of an acute kind, generally make their
appearance.  We may, therefore, divide cases of glau-
coma into tAvo principal classes: 
14                  (il.AUCOMA.

  I. ('ases attended with inflammatory symptoms.
  II.  Cases in which there are apparently no inflamma-
tory symptoms present.
   Glaucoma may  exist as a primary disease, or may
complicate a previously existing affection.
   We find that the different varieties of glaucoma shoAv
certain common characteristics, and Ave may generally
 recognize the four folloAving stages:
   1.  A premonitory stage (glaucoma imminens, inci-
 piens of Yon Graefe);
   2.  A stage in which the glaucoma  is fully developed
 (glaucoma eArolutum, confirmatum, Yon Graefe);
    3.  A stage in which quantitative perception of light
 has been completely lost for some time (glaucoma abso-
 lutum, consummatuni, Yon Graefe);
   4.  A stage in which  the eye  undergoes glaucomatous
 degeneration (Yon Graefe).


              1.  Inflammatory Glaucoma.

   We distinguish tAvo  principal forms of inflammatory
 glaucoma,—the acute and the chronic.
   As  it is  of consequence, in the examination of cases
of glaucoma,  that the obsen-er should knoAV 1ioav to
estimate  the  degree  of intraocular  pressure, and the
extent  of the  field (d' vision,  I  shall, before entering
upon a description of  the  symptoms  of glaucoma, ex-
plain in Avhat manner  the  tension of the eyeball is to
be estimated, and the extent of the field of vision ascer-
tained. 
IX FLAM MA TORY  GLAUCOMA.
15
  A just appreciation of the degree of tension of the
eyeball is of great importance in glaucoma, for in the
majority  of cases  it  is  considerably  increased.  Al-
though there is some difference in the degree of tension
met Avith in perfectly normal eyes, according to the age
of the patient, the temperament, and indiATidual peculi-
arities, it is but  seldom very marked, and generally
Aaries but inconsiderably from  the normal  standard.
But the  amount  of tension  may  undergo occasional
variations, at times becoming more increased;  this aug-
mented  tension lasting  for a certain  time, and then
again  diminishing.   It is necessary, therefore, to exa-
mine the tension of the eye at different times, if other
symptoms of glaucoma  be present, Avithout a marked
increase in the tenseness of the eyeball.
  The degree of tension is to be  ascertained in the fol-
lowing manner:  The  patient being directed to  look
slightly doAviiAvards, and gently to close the eyelids, the
surgeon applies both his forefingers  to the upper part of
the eyeball behind the region of the cornea.   The one
forefinger is then pressed  slightly  against the  eye  so
as to  steady it, AAdiilst the other  presses gently against
the eye, and estimates the amount of tension, ascertain-
ing Avhether  the  globe  can  be readily  dimpled,  or
whether it is perhaps of a stony hardness, yielding not
in the slightest degree even to the firm  pressure of the
finder.   The beginner will  do Avell to make himself
thoroughly conversant with the normal degree of ten-
sion, by the examination of a number of healthy eyes,
and then, if he should be at all in doubt as to the de- 
16
GLAUCOMA.
gree of tension in any individual case, he should test
the tension of the patient's other eye  (if healthy),  or
that of some other healthy eye, so as to be able to draw
a comparison between them.   If  there is much oedema
of the lids, or  conjunctival chemosis, or if the eyes are
small and  deeply set, it may  be  difficult accurately to
estimate the degree of tension.  It  is also to be borne
in mind that the normal tension has a certain range  or
variety  in  persons of  different age, build, or tempera-
ment;  and according  to  varying temporary states of
system as regards emptiness or repletion.
   The extent of the  field of vision may be ascertained
in  the  following manner:  The  patient being placed
straight before us, at a distance of from  fifteen to eigh-
teen inches, is directed to look, with the eye under'exa-
mination (closing the other with his left hand) into one
of our eyes.  In this Avay any movement of his eye may
be at once detected and checked.   AYhilst he still keeps
his eye steadily fixed upon ours, Ave next move one of
our hands  in  different directions throughout the whole
extent of the  field of A'ision (upwards, downwards, and
laterally), and ascertain Iioav far from the optic axis it is
still visible; avc then approach the  hand nearer to the
optic axis,  and examine up to how far from it he is able
to count fingers  in  different  directions.   The number
of  the  extended fingers  is to be  constantly changed,
and the examination to be repeated several times, so
that Ave may ascertain whether  the patient can count
them with  certainty, or Avhether he hesitates in his an-
swers, or only guesses  at  their number.   We may thus 
               INFLAMMATORY GLAUCOMA.          17

   readily discover whether the field of ATision is of normal
   extent, or Avhether it is defectiA7e or obliterated in cer-
   tain directions.
     We may term that part of the field in which the pa-
   tient can still distinguish an object (a hand, a piece of
   chalk, &.('.)., the rpiant'dative field of vision, in contradistinc-
   tion to that smfcller portion in which he is able to count
   fingers, and which may be designated the qualitative field.
     The following method of examining the  field is still
   more accurate,  and I should advise its adoption  in  all
   cases AA'here it  is of importance to have an exact map
   of the  extent of the field, as in glaucoma, detachment
   of the retina, &c, so that a record  may be  kept of the
   condition of the field during the progress of the disease,
   or that avc  may be  able to compare its extent before
   and after an operation.  The patient being placed before
   a large  black  board,  at a  distance of from tAvelve to
   sixteen  inches, is directed to close one eye Avith  the
   hand, and to keep the other steadily fixed upon a chalk
   dot, marked on the centre of the board  and on a level
   Avith his  eye.  A piece of chalk, fixed in a dark handle,
   is then gradually advanced from the periphery of the
   board toAvards the centre, and the spot Avhere the chalk
..  first becomes visible is  then marked upon the board.
   This proceeding is to be repeated throughout the whole
   extent  of the field; the different points at AAThich  the
   object first becomes visible  are then to be  united by a
   line, Avhich indicates the outline of  the  quantitative field
   of vision.  The extent of the qualitative visual field is
   next to be examined, and it is to be ascertained how far 
18                  GLAUCOMA.

from the central spot  the  patient can count fingers  in
different directions.  The points  thus found are also  to
be  marked on  the  board, and  the  marks afterwards
united Avith each other by  a line, which should be  of a
different color or character to that indicating the extent
of the quantitative field, so  that the two may not be
confounded.  It need hardly be mentioned that care  is
to be taken  that during the examination the patient's
eye  remains steadily fixed  upon the central  spot, that
the other eye is kept closed, and  that his  distance from
the  board  is not altered.   The extent of the field in-
wards will, naturally, vary according to the prominence
of the patient's nose.
  But the sight of the patient may be  so much impaired
that he can  no longer count fingers even in the optic
axis, being only able to  distinguish between  light and
dark, as in cases of mature cataract,  seA-ere cases  of
glaucoma, &c, and yet it may be of great importance
to know Avhether or not the field of vision is  of normal
extent.  This may be readily ascertained  in the follow-
ing manner: The patient is directed to look with the one
eye (the other being closed) in the direction of his up-
lifted hand (held on  a  level with  his  eye, and at a dis-
tance of from twelve  to eighteen  inches').  A lighted
candle  is then  held  in different  portions of the visual
field, and the furthest point at which it  is still visible
in various  directions is  noted, the candle being alter-
nately shaded and uncovered by our hand, so  as to test
the readiness and accuracy  of the patient's  answers.
« 
        ACUTE INFLAMMATORY GLAUCOMA.      19

Care  should be taken to shade the candle Avhen it is
removed to another portion of the field.
  The contraction of the field in glaucoma is generally
very  characteristic.   In  the great  majority of cases it
commences at the inner (nasal) side (the outer part of
the retina  being  the first  to suffer), from thence it
passes upAvards and downwards; the outer side (tempo-
ral) becomes last affected.   The contraction is generally
diagonal, but may occasionally be concentric; sometimes
the field of vision is nearly  completely obliterated, only
a small  slit-shaped portion remaining.   Chronic glau-
coma furnishes the best instances of the mutilation of
the visual field.  It does not constitute one of the earliest
symptoms of glaucoma.  In cases of cerebral amaurosis
complicated Avith glaucoma, the field of vision appears
to become contracted first at the outer side, and  not at
the inner, as is usual in glaucoma.

            1. Acute Inflammatory Glaucoma.
               Synon. Ophthalmia arthritica.
  Premonitory Stage.—In the great majority of cases (75
per cent.) there is a premonitory stage, Avhich is charac-
terized by the presence of several or all the  following
symptoms, which  are, hoAvever, of periodic  occurrence,
there  being in the interval a. perfect intermission.   AVhen
this ceases to  be  the case, when there  are no  longer
perfect intermissions, but only remissions of the symp-
toms,  avc  can no  longer designate  it the premonitory
stage, but must regard it as a confirmed glaucoma. 
20
GLAUCOMA.
  The following symptoms are met with in the premo-
nitory stage:
  1. Increased tension of the eyeball.
  2. Marked increase of any existing presbyopia.
  3. Venous hyperseniia.
  4. Haziness of the aqueous and Autreous humors.
  5. Dilatation and sluggishness of the pupil.
  6.  1 Vriodic dimness of sight.
  7.  The appearance of a halo or rainbow round a candle.
  8.  Intermitting pains in and around the eye; these
 are not ahvays present.
  9.  Slight contraction of the field of vision.
  The intensity of these symptoms varies wTith the  se-
 verity of the attack.  They may be so slight as to escape
 all observation, or they may be A*ery marked if the attack
 is severe, and then there are  often added to the symp-
 toms  aboAre enumerated, diminution in the size of the
 anterior chamber, arterial pulsation, and indistinctness
 of  eccentric vision, particularly if the illumination  be
 but slight.  Let  us uoav consider these premonitory
 symptoms more in detail.
  1.  The Increased Tension of the Eyeball.—This is gene-
 rally not very considerable; it varies  in  degree, howT-
 ever, but it never reaches that stony hardness in Avhich
 it is  impossible to dimple the  eyeball.  In families in
 which glaucoma is hereditary, a marked increase in the
 tension is met Avith even in early life, although the  dis-
 ease  does not break out,  perhaps,  till  a much  later
 period, or even not at all.  In such cases there can be
 no  objection to look upon this abnormal tension as a 
        ACUTE INFLAMMATORY GLAUCOMA.     21

 predisposing element of glaucoma, more  particularly if
 it be accompanied by hypermetropia, and a dispropor-
 tional diminution of the range of accommodation.   It
 has been  supposed by some  that  the increased degree
 of tension always precedes, for a  longer  or shorter  pe-
 riod, the other symptoms of glaucoma; Von Graefe has,
 however, met  with seATeral marked  exceptions to this
 rule.  In some cases in Avhich he operated for glaucoma
 in the one eye, the other was found to be of a perfectly
 normal tension at the time of operation, but was soon
 after attacked by glaucoma, in  one case,  even  by glau-
 coma  fulminans.   But an increase in the  tension of
 the  eyeball  should ahvays  excite  our suspicion, and
 should at once lead us to examine as to the presence of
 other  symptoms  of glaucoma; if avc  find none,  we
 should still Avatch the eye Avith care, and Avarn the pa-
 tient carefully  to observe AA'hether any other symptoms
 begin  to show themselves, e. g., rainbows round a can-
 dle,  rapidly increasing presbyopia, periodic dimness of
 vision, Ac.  We  must be upon our guard  against the
 too  frequent error, that  a sense  of fulness  or tension
 Avithin the eye experienced by  the patient, is any proof
 of the  increased hardness of the eyeball.  For this feel-
 ing of fulness  may exist without  the slightest  increase
 of tension.  Another frequent  error is to suppose that
 all acute inflammations of the eye are accompanied  by
 an increase in the intraocular pressure.   A careful ex-
 amination  of qrdinary cases 'of acute inflammation of
the conjunctiva, cornea, iris, Ac, Avill at once prove the
fallacy of this  opinion, for the tension Avill be found
                          3 
22
GLAUCOMA.
normal.   If the degree of tension is increased, we must
regard it as a  dangerous complication, which is to  be
carefully watched, lest it be the precursor of other glau-
comatous symptoms.
   2. Rapid Increase of any Pre-existing Presbyopia.—As
the persons attacked  by glaucoma are mostly beyond
forty-five or fifty years of age, some degree of presby-
opia is generally already present, but it is found that
this often increases in a very rapid and marked man-
ner during the  premonitory stage of glaucoma;  so that
the patient may  be obliged, in  the course of  a few
months,  frequently to change his  reading-glasses  for
stronger and stronger ones.   This rapid increase in the
presbyopia appears  to be not so much due to a flatten-
ing of the cornea through an increase in the intraocular
pressure,  as  to the action of this  pressure  upon  the
nerves supplying the ciliary muscle, thus  causing  the
paralysis  of the latter.  Haffhian has called particular
attention to the fact that hypermetropia very frequently
occurs together with glaucoma. It does not appear that
hypermetropic eyes are more prone  to glaucoma than
others, but rather  that hypermetropia is developed  in
the course of the  disease.   The cause of this is, how-
ever, still quite  uncertain; it is probably to be  sought
for in some changes in the crystalline lens (rapidly pro-
gressive senile involution), by which the refractive poAver
of the latter is considerably diminished.
  3.  Venous Ilypcrcemia.—.The congestion of the ciliary
veins is generally slight during the premonitory stage,
and they  never  present  that peculiar tortuous, dilated 
        ACUTE INFLAMMATORY GLAUCOMA.      23

appearance,  so  characteristic  of  chronic  glaucoma.
Generally, only a few scattered, dilated veins are seen
running over the sclerotic.   On  examination with the
ophthalmoscope, the retinal veins are also found to be
dilated and tortuous; there maybe likeAvise spontaneous
venous pulsation, or this may be  produced  by slight
pressure upon the eyeball.
  4. Cloudiness  of the Aqueous and  Vitreous Humors.—
The aqueous humor is often found slightly but uniformly
hazy, rendering the structure of  the iris somewhat  in-
distinct, and causing a slight  change in its color.  The
vitreous humor also  becomes a little clouded, but uni-
formly so, for  on ophthalmoscopic  examination, we  do
not  find  dark  masses floating about  in the vitreous
humor, but  only a diffused  cloudiness, Avhich renders
the details of the fundus more or less  indistinct.   This
haziness of the humors is vciy variable  in its degree and
duration;  sometimes it is so  slight as to be  hardly per-
ceptible, at others it is so considerable as to pre\ent any
ophthalmoscopic examination. In the majority of cases,
hoAvever,  it is  but moderate  in the premonitory stage.
It may come on  several  times a  day, lasting but for a
few minutes  at  a time, or it may be less frequent, or of
longer duration.
  5. Dilatation  and Slaggishncss of the Pupil.—On compar-
ing the pupil of the eye affected Avith premonitory symp-
toms of glaucoma Avith that of the other (supposing this
to be healthy),  the former Avill be found somewhat  di-
lated and  sluggish, reacting but slightly on the stimulus
of light.   The  dilatation is never so considerable as in 
24                  GLAUCOMA.

the advanced  stages of glaucoma, when we often  find
the pupil Avidely dilated and quite immovable.  Its slug-
gishness is, however, generally well  marked.  It is al-
Avays necessary to examine the state of the pupil of each
eye separately, for occasionally Ave  find that the pupil of
the affected eye may be of the same size as the other,
when both eyes are open and exposed to the light, but
that it dilates at once wdien the healthy eye is  covered,
and then  reacts but slightly on the stimulus of light,
and even under a strong light does not diminish to the
same  size as when the other eye  is open.  Sometimes
the dilatation is  irregular, AA'hich  is owing  to some of
the nerves being more compressed than others.
  6. Periodic Dimness of Sight.—The patient is  troubled
by occasional  intermittent dimness of sight.  At such
times, surrounding objects appear veiled and indistinct,
as if they Avere shrouded in a gray fog or smoke.   The
degree of dimness A^aries  considerably, as does also the
duration of these attacks ; sometimes they may last for
several  hours, at others only for  a few  minutes.   At
such a time, there mav also exist a slio-ht contraction of
the field of \lsion;  generally, hoAvever, there  is only
indistinctness  of eccentric impressions in certain direc-
tions.   These obscurations may be due to transitorv
cloudiness of the aqueous and vitreous humors, but they
are caused, for the most part, by disturbances in the cir-
culation of the eye.   The character of these obscurations
may be  imitated by pressure upon the healthy  eye, and
Donders has found that the  dimness  of vision  sIioavs
itself  as soon as arterial pulsation is produced by this 
         ACUTE INFLAMMATORY GLAUCOMA.     25

pressure upon the eyeball.  I have experimented a good
deal upon  this point, and  have arrived at the  same re-
sults.  I have also found, that by regulating the amount
of pressure, I have  been able to produce any kind of
obscuration,  from the slightest, in which only the ob-
jects lying quite at the periphery of the field of vision
appeared somewhat clouded, to  that excessive dimness
in A\rhich the light of a bright lamp was rendered quite
unapparent.   The increased intraocular pressure, acting
directly upon the retina, does  not, therefore, appear to
be so much the cause of these obscurations; but we must
seek for it rather in the impairment of the circulation,
the stagnation and fulness  of the veins, and perhaps, the
emptying of the arteries.   The increased pressure pro-
duces the changes  in the circulation, and the. latter
causes the obscurations.   The truth of this assertion is
also proved by the fact that these attacks  of dimness are
generally brought  on by anything that  causes conges-
tion of the bloodvessels  of the eye ; for instance, a full
meal,  great  excitement, long-continued  stooping, Ario-
lent exercise, <ve.
  7.  The Appearance of a Halo or Rainbow round a Can-
dle.—This is  also a very constant symptom of the pre-
monitory stage.  On  looking at  a candle, the patient
sees a colored halo, or rainbow round the light.  The
outer side of the  ring is  red, the inner bluish-green.
This has been supposed  by some to be a  mere physical
phenomenon, due  to a diffraction (interference) of the
rays of light, OAving to  some  change in  the refractive
media, especially the peripheral portion of the  lens.
                          3* 
26
GLAUCOMA.
   It is seen when the pupil is dilated, but disappears
 AA'hen  the  patient is  directed to look through a small
 opening.   It may,  hoAvever, be also due to congestion
 of the vessels, for I have seen it sometimes brought on
 by stooping for some time.
   8. Ciliary Neurosis,  i. e., pains, more or less acute, in
 the forehead and temples, and passing down the side of
 the nose, occur occasionally at an  early period, some-
 times  only at a  later part of the premonitory  stage,
 at the same time with the intermittent obscurations.
 Sometimes, hoAvewer, they are quite absent.
   9. The field of vision  is  occasionally somewdiat con-
 tracted ;  generally, hoAveA'er, there  is only  some indis-
 tinctness of eccentric impressions in certain directions,
 more particularly if the illumination is but slight.
   At the commencement, these symptoms only show
 themselves at long intervals, of perhaps several months.
 At first the patient only notices that the  surrounding
 objects appear somewhat hazy and indistinct, that there
is  a rainbow round a candle, accompanied perhaps by a
 slight  pain round the eve, and doAvn the side of the
nose.  On examining the eye during one of these attacks,
Ave find the tension increased, the A'eins on the  sclerotic
someAvhat  dilated,  Avith perhaps a  delicate rosy zone
round  the cornea, the aqueous humor slight!a' clouded
the pupil somcAAdiat dilated, and sluggish on the stimu-
lus of  light.  AVith the  ophthalmoscope,  the  Autreous
humor is perhaps found somewhat hazy, the retinal A'eins
dilated and tortuous, shoAving either a spontaneous ve-
nous pulsation, or this may be readily produced bv slio-ht 
         ACUTE  INFLAMMATORY GLAUCOMA.      27

 pressure upon the globe.  If the attack be severe, these
 different symptoms may be strongly marked, and there
 may, in such a case, be superadded spontaneous arterial
 pulsation, dimness in certain  portions  of the field of
 vision, and diminutions in the size of the anterior cham-
 ber.   In other cases  all the premonitory symptoms are
 so slight that they are unnoticed by  the patient.   He
 may have only remarked that he  is getting rapidly far-
 sighted, and that he  has had frequently to change his
 reading-glasses.  If, therefore, a person complains to us
 of this rapid increase of presbyopia, avc should at once
 ascertain whether any other premonitory symptoms  of.
 glaucoma are present.
   Gradually the intervals between these  periodic at-
 tacks become less and less.   At  first, perhaps months
 elapse between each attack, then weeks, then days, and
 Avhen  they occur at intervals  of a  few days only, the
 second stage, the glaucoma evolutum, may be expected,
 although this may even occur when the intervals are still
 distant.  If the periodic  attacks no longer leave behind
 them a normal pupil  and a normal acuteness of vision,
 still more, if the optic nerve  is already cupped, avc must
 no longer designate  it as the premonitory stage, but as
 a case  of glaucoma evolutum, Avitli periodic increase of
 the symptoms (Yon Graefe).
  The premonitory stage may last for  an indefinite pe-
riod; years may even elapse before it leads to confirmed
glaucoma ;  but in the majority of cases, it  does not ex-
tend beyond a feAV months, or  it may pass over into
glaucoma even after the  second or third attack, there 
28
GLAUCOMA.
~U
aiL
          being only remissions, and not clear and well-defined
          intervals, between the attacks.   Sometimes, as has been
          mentioned above, the  premonitory  symptoms are so
          slight as quite to escape the notice of the patient, par-
          ticularly if the other eye is still perfectly healthy.   It is
          different, however, Avhere one eye has already been lost
          by glaucoma, for then the patient's  attention and  anx-
          iety are at once  aroused by any of the  premonitory
          symptoms, and he early consults his medical attendant,
          fearful lest he should also lose the sight of the second
          eye.
            In the great majority (about 75 per cent.) of cases,
-^, %Q,   acute  inflammatory glaucoma is preceded by a more or
          less marked premonitory  stage, of varying  duration.
          The intervals between the  premonitory attacks become
          less and less frequent, until the attacks recur perhaps
          every two or three days, or eAren eATerv day.  The patient
          is then suddenly seized, frequently at night-time, and
          after rawing passed perhaps seA'eral sleepless nights, by
          a severe, often excruciating pain in and around the eye,
          which extends to the forehead, temple, and doAvn the cor-
          responding side of the nose, as far as the extremity of the
          bone.   Sometimes this pain extends also to the corre-
          sponding half of the head, and even to the occiput, Avhich
          causes it often to be mistaken for an attack of rheuma-
          tism.  At the same time there may be considerable con-
          stitutional disturbance, febrile excitement, and severe
          nausea and vomiting, and these symptoms  may be of
        •  such prominence that the patient is supposed to be suf-
          fering from a severe bilious attack, and the affection of 
        ACUTE INFLAMMATORY GLAUCOMA.      29

the eye is either overlooked, or is thought to be  depen-
dent upon this.  But the eye sIioavs marked symptoms
of acute internal inflammation.  The  eyelids may  be
much sAvollen, red, and puffy.  The conjunctival and sub-
conjunctival vessels are injected, the veins, in particular,
being dilated and gorged.  There may also be very con-
siderable  serous  chemosis, which completely hides the
deeper  subconjunctival vascularity, and  the rosy zone
round the cornea.  There is also much photophobia and
lachrymation, but accompanied  by very little  mucous
discharge, and this chiefly  of  a thin, frothy character.
The cornea is clouded on its posterior surface, being per-
haps studded Avith minute opacities, deposited  from the
aqueous humor.   The sensibility of the cornea may  be
also somewhat diminished, but this amesthesia never at-
tains the same degree as in chronic glaucoma, Avhere it is
often so great that the cornea  may be touched, or even
rubbed with a roll of paper or the brush  of a quill-pen,
Avithout its being felt.   Occasionally the  anaesthesia  is
only partial, being confined to a certain portion of the cor-
nea.  This loss, or diminution, in the sensibility, is due to
the compression  of the nerves supplying the cornea by
the increased intraocular pressure, as is proved in cases
of acute glaucoma, Avhere the sensibility at once  returns
after diminution  of the tension by iridectomy or para-
centesis.  The sensibility of the cornea is best tested by
touching  it  delicately  Avith a  finely-rolled spill  of  silk
paper, care  being taken to  keep the eyelids Avell apart,
so that the conjunctiva is not touched.  In healthy eyes, 
30                  GLAUCOMA.
the cornea is so exquisitely sensitive, that  the  slightest
touch of a foreign body will be felt and resented.
  The anterior chamber is found to be somewhat more
shallow, the iris  being pressed forward, and even, per-
haps, in contact  with the  cornea, the  aqueous humor
clouded, the iris someAvhat  discolored and of a dirty
hue ; in some cases, there may even be acute iritis, with
deposits of lymph at the edge of the pupil, the pupil is
dilated  and sluggish, and in elderly people a peculiar
green reflex is often seen, coming, apparently,  from the
back of the eye.
  It has already been stated, that this green reflex was
formerly considered as the principal and pathognomonic
symptom of glaucoma.   It is due to the following cause:
The lens undergoes certain physiological changes after
the age of  forty,  amongst others assuming a yellowish
tint; hoav if the eye of an elderly person (and  they  are
most prone to the disease) is attacked by glaucoma,  the
aqueous humor becomes turbid, and of a dirty bluish-gray
color, and this  bluish-gray tint, mixing AATith the yelloAV
of the lens, gives  rise to this peculiar green reflex.  The
latter is the more marked on account of the dilatation of
the pupil Avhich exists in glaucoma, as more light is thus
reflected from the lens,  more particularly its periphery,
than Avhen the pupil is of the normal size.   The grayish
haziness of the vitreous humor, moreover,  also tends to
increase the intensitv of the reflected lisdit.  Tavo facts
prove that this is the true explanation of this green re-
flex.  1st.  If the anterior chamber  is tapped,  and  the
aqueous humor flows off, the green reflex at once disap- 
       ACUTE INFLAMMATORY GLAUCOMA.     31

pears.  2d. If a youthful eye is attacked by glaucoma,
this green reflex is not visible, for at this period of life
the lens has not yet acquired a yellow tint, and in such
a case the pupil looks, therefore, only of a dirty, bluish-
gray color.
  The eyeball Avill be found abnormally  hard.   The re-
fractive media are generally so clouded as to render an
ophthalmoscopic examination impossible.  If they are,
however, sufficiently  clear to permit our seeing the de-
tails of the fundus, we find the retinal veins dilated and
tortuous, and perhaps pulsating, the optic  disc may be
slightly reddened or of a dirty  yellow appearance, and
there is either spontaneous arterial pulsation, or this may
be readily produced by  slight pressure  on the eyeball.
In the first attack of acute glaucoma, no cupping of the
optic nerve is found, for this only occurs  when the in-
creased tension has lasted for some time.   AYe also oc-
casionally find choroidal ecchymoses,  which are mostly
situated at the equator of the eye, and generally numer-
ous patches of retinal ecchymoses, chiefly at the point
of division of the retinal veins.  These  are particularly
seen after iridectomy, where the sudden  relief of tension
causes a rush of blood through the vessels, and the finer
cajplaries then give way.
   Vision may be either greatly impaired, so that the
patient is only able to distinguish letters of the largest
type, or to count fingers, or it may be lost completely and
suddenly, as at one stroke, being diminished to a mere
quantitative perception of light, i. e., to a mere distinc-
tion betAveen light  and dark,  not an  appreciation of 
32
GLAUCOMA.
colors and objects.  In some very severe cases even this
is lost.  The field of  vision is generally somewhat con-
tracted, often concentrically.  The patient is in the most
cases, also, troubled Avith subjective appearances of light,
balls of fire, showers of bright stars, &c.
  The inflammatory symptoms may gradually subside,
but the blindness continue; this is, hoAvever, very ex-
ceptional.   In most   cases, the inflammatory  attack
passes off after a  *few days or Aveeks,  having under-
gone, during this time, perhaps, several remissions, and
vision may be entirely restored.   Such a temporary  re-
covery  may  occur spontaneously,  or  after treatment
by  antiphlogistics, mercury, opium, leeches, &c.  But
the eye does  not  return  to its normal condition: the
anterior  chamber mostly remains  someAvhat  shallow,
the iris discolored, the pupil dilated and sluggish, and
the field of vision somewhat contracted, the tension of
the eyeball more or less augmented.  But the disease
is not arrested.  The acute inflammatory attacks may
recur again and  again, leaA'ing the sight each time in a
worse condition, and  the A-isual field more contracted,
until the sight is finally completely destroyed.   In other
cases, no further acute inflammatory attacks occur, but
chronic inflammatory exacerbations take place.  Or*he
disease may progress insidiously: A\Tithout any apparent
recurrence of  the  inflammatory symptoms, the eyeball
becomes more and more tense, the  field of A^ision more
contracted, often to a slit  shape, the  sight gradually
lost, the fixation becoming perhaps eccentric, the cornea
roughened and amesthetic, the  anterior chamber very 
       ACUTE  INFLAMMATORY  GLAUCOMA.     33

small, the pupil greatly dilated and fixed, the iris dis-
colored and atrophied, and shrivelled up to a narrow
rim, the subconjunctival veins turgid and tortuous, form-
ing loops round the cornea.  If the refractive media are
sufficiently clear to permit an ophthalmoscopic exami-
nation, we find that there is a progressive excavation of
the optic nerve, that the retinal veins are dilated and tor-
tuous, and that there is either a spontaneous or easily
producible arterial pulsation.   We*  not unfrequently
find, even after the disease has thus insidiously run its
course without  any inflammatory exacerbation since the
first acute attack, that at a later stage these inflamma-
tory attacks, even of a very acute kind, may recur again.
AVhen the disease  has run its course, and all, even quan-
titative perception of light, is lost, Von Graefe calls it
glaucoma consummatum, absolutum.
   Sometimes we  meet with a subacute form  of glau-
coma,  in which  all  the inflammatory  symptoms  are
much diminished  in intensity, the pain is also less, nor
is the siglit so much impaired as in the acute cases.
   There is  also a hemorrhagic  form, which  is pecu-
liarly dangerous, as it is far less favorably influenced by
iridectomy.   The glaucomatous  inflammation some-
times supervenes  upon certain hemorrhagic  affections
of the retina, particularly those met with in kidney dis-
ease.  In these, there is very considerable congestion
and stagnation of the intraocular circulation.  Now, al-
though  iridectomy may yield some temporary benefit,
yet relapses but too frequently recur, and the operation
is occasionally  followed in this form by  great intraocu-
                          4 
34
GLAUCOMA.
lar  haemorrhage, which often destroys the eye.  The
power of absorption is also very much impaired in these
cases, for we find that  haemorrhage,  into the  anterior
chamber for instance, Avhich is frequently produced by
a very slight cause, such as a fit of coughing, &c, is very
slowly and imperfectly absorbed.
  Von Graefe has lately called attention  to a class of
cases  in which the march of acute glaucoma is most
rapid, so that the sight, even all quantitative perception
of light, of a previously perfectly good eye, may be per-
fectly lost within a few hours,  or  even within half an
hour, of the outbreak of the disease.  He has termed
this glaucoma fulminans.  It is  a Arery rare  form in
comparison with the common acute glaucoma,  for up to
the publication of his last paper on glaucoma (1862), he
had only met with four cases, and these all occurred in
patients above the age of fifty-five.
  He has  found that cases of glaucoma fulminans are
also occasionally distinguished by a very rapid develop-
ment of the other symptoms of increased intraocular
pressure, viz., intense ciliary neurosis, rapid dilatation
of the pupil, soon reaching  its maximum extent, rapid
diminution in the size  of the anterior chamber, anaes-
thesia of  the cornea,  stony hardness of  the  eyeball.
Sometimes, however, these symptoms are not more pro-
nounced than in the common form of acute glaucoma,
and yet the sight may  be completely destroyed within
an hour or two.  The  phenomena of vascular excite-
ment may appear simultaneously A\-ith the  loss  of sight,
but they occasionally lag behind in a peculiar  manner. 
       ACUTE INFLAMMATORY  GLAUCOMA.      35

On ophthalmoscopic examination, the aqueous and vitre-
ous humors will be found to be diffusely clouded, but if
they are  sufficiently clear to permit the details of the
fundus to be seen, a considerable overfulness of the re-
tinal veins will be observed.   Decrease of the arteries
and excavation of the optic disc appear, comparatively
very rapidly.  Von Graefe has in  one case noticed the
latter, in a very deep form, even within a few weeks after
the outbreak of the disease.   He  thinks that we must
assume that,  in this form, the  increase in the tension is
either more  considerable or  more sudden than in the
ordinary  cases.   On  account  of a peculiar unyielding
rigidity of the sclerotic on the one hand, or  a peculiar
disposition of the optic disc  to yield (or a  functional
inability of the retina to bear  compression) on the other,
an otherwise still bearable hypersecretion may already
exert a deleterious effect upon the vision.  An explana-
tion may also perhaps be found in a too slight propul-
sive poAver of the heart, and in material changes in  the
coats of the vessels; causing a more ready development
of the arterial pulsation (impeding the retinal function),
and a complete cessation of entrance  of blood  into  the
retina.   The four cases AAdiich Von Graefe narrates are
of such interest and importance, that I shall give a short
summary of them.
   The left eye, in the first case, had been lost from abso-
lute glaucoma.   Without the occurrence of any premo-
nitory symptoms, the patient, on awakening one morn-
ing, noticed a cloud before the right eye, which increased
very rapidly, and within one hour and a half led to com- 
36
GLAUCOMA.
pletc blindness; it was accompanied by rather severe cili-
ary neurosis.  There was no vascularity or lachrymation
till a few days afterwards.   Von Graefe saw the patient
for the first time five weeks after the outbreak, and then
found the iris discolored and  reduced to  a narrow rim,
the cornea partially anaesthetic, the aqueous and proba-
bly the vitreous humor slightly, though diffusely clouded,
the eyeball stony hard,  the optic disc deeply excaA-ated,
the retinal veins considerably dilated.  As all quantita-
tive perception of light had been lost for five Aveeks, and
as the pain had subsided, no operation was performed.
  In two other cases the result was more satisfactory:
the one wras operated upon the ATery day of the attack,
the other on the third day  after it.  Both  patients had
been blind upon the other eye for  some  time  previous.
The external ATisible symptoms were similar to those in
the last case, but the diffuse opacity of the  refractive
media  more  considerable,  so that in  the first case it
could only be ascertained AA^ith difficulty that there Avas
an overfulness of the retinal \Teins and a  normal level
of the optic disc, but in the second case the fundus Avas
completely obscured.   In the first  there might still have
been some remnant of quantitative perception of light,
but the patient's ansAvers  on this  point Avere  so uncer-
tain that it remained doubtful.  Von Graefe operated
eight hours after the blindness began.   The day after
the operation the  patient  could distinguish the  move-
ments of a hand, and on the third day she could count
fingers.  The field of  vision was very  irregular, with
many great interruptions duo to extensive retinal haemor- 
        ACUTE INFLAMMATORY  GLAUCOMA.      37

rhages, which disappeared very gradually.   With their
absorption, vision  became very satisfactory (type No. 3
at ten inches, field of vision normal), and has remained
thus until now.
  In the other case, which was operated upon the third
day, there was absolutely no quantitative perception of
light remaining, it being said to have become extin-
guished  within  the first feAv hours after  the  attack.
Nor till the second day after the operation was there
any quantitative perception of light,  and  then it  was
only very feeble, and  confined to certain  portions up-
Avards and  outwards.   From thence  it gradually  ex-
tended.   On  the eighth day he could count fingers in
a small portion of the visual field.   In this case there
also appeared unusually  numerous  and extensive  reti-
nal haemorrhages.  The improvement of sight reached
its maximum degr.ee in about two  months, when  the
patient was  able to read No. 6 at ten inches, Avith  the
proper convex glasses.   There still remained, hoAvever,
an  indistinctness of eccentric vision  inwards (beyond
 20°), and a peripheral  defect (beyond 40°) in the same
 direction.  The optic nerve was very Avhite, and slightly
 cupped.  Vision afterAvards deteriorated slightly (from
 No. 6 to No. 8 of the test types), but has now remained
 in this state for nearly a year. This case shows us that
 iridectomy,  performed on  the third day  of glaucoma
 fulminans,  no longer yields a perfect result.
   In the following (the fourth) case the operation, per-
 formed  a fortnight after the outbreak of the  disease, 
38
GLAUCOMA.
hardly  exercised  any influence  upon  the sight,  and
proved in the end of no benefit whatever.
  The right eye of this lady, who was fifty-five years of
age, and of a very delicate constitution, had  been lost
from glaucoma  absolutum, which  had  existed several
years.  On the morning of the 16th of December, 1860,
the patient, without ever having experienced any pre-
monitory symptoms, suddenly, during  breakfast-time,
noticed a fog before the hitherto perfectly healthy left
eye, Avhich so rapidly increased in density, that  in the
course of an hour she could only distinguish the outlines
of very large objects, and  at  noon she was completely
blind, being no  longer  able  to perceive the  strongest
sunlight.  On the night of  the  16th the eye became
painful, the  next  day vascularity and lachrymation ap-
peared ; and on the folloAving days the ciliary neurosis
was so  severe  as to  deprive the patient of all sleep.
These symptoms had all continued in spite of the  em-
ployment of derivatives at the back of the neck,  and
local bleeding, which had been prescribed by her medi-
cal  attendant.  Aon Graefe first saAv the patient on the
1st  of January, isbl, worn out with the fatigue of the
journey  and the sufferings'  she had undergone.  lie
found the pupil very widely dilated, the  iris reduced to
a narrow Mrip, and grayishly discolored, the anterior
chamber very shallow; the  upper  portion of the  cornea
aiuesthetic, the aqueous humor and the cornea (as well
in its deeper as superficial layers) diffusely clouded, ren-
dering the  fundus of the  eye undistinguishable;  the
» \cball >lon\ hard, moderate injection  of the anterior 
        ACUTE INFLAMMATORY  GLAUCOMA.      39

ciliary vessels, slight lachrymation, and no trace of per-
ception of light remaining.   He performed iridectomy
on the same day.   Within the next few days the ciliary
neurosis had completely disappeared, the aqueous hu-
mor and cornea became more clear, the sensibility of
the latter returned, the tension diminished, and the iris
became somewhat broader and assumed a better appear-
ance.  But no perception of light had returned Avithin
the first few days; on the fifth day a trace seemed to
appear, but this only in a narrow portion upwards and
outAvards.  Some days later, she could, hoAvever, distin-
guish  between the  light and  darkness  of a brightly
burning lamp held at a foot distance, and in the orbital
axis, or a  little  to its outer side.   This perception of
light gradually increased up to the middle of the third
week,  when it reached its maximum extent; at the end
of this period she could see  a medium bright lamp at
about  three feet  distance in a slit-shaped visual  field *
lying to the outer side, the breadth of which equalled
an opening of about 20°.  The ophthalmoscopic exami-
nation was made at the  end of the  second Aveek; the
refractiAre media  avc re then found perfectly clear, the
optic nerve whitish and deeply cupped, the veins being
much  displaced  at the edge of the disc, the arteries
small,  and  showing no pulsation.   There were immense
retinal  ecchymoses,  situated at different depths, some
at the inner surface  of the retina, others in the layer
of the vessels, and behind the vessels, and, finally, some
at the outer surface  of the retina.  In the vitreous
humor there avc re like Aviso  htvmorrhagic opacities.  It 
40
GLAUCOMA.
 was hoped that perception of light would improve  as
 these ecchymoses became absorbed, but the  contrary
 was the case, for at the end  of the next week the slit-
 shaped visual field decreased  in size, and six weeks after
 the  operation all perception of light was again lost;
 the optic nerve  also became  more and more atrophied.
 In this  case iridectomy had Only afforded  relief to the
 inflammatory symptoms, but had caused  no improve-
 ment to the sight; and this  teaches us the imperative
 necessity of operating as early as possible  in these cases
 of glaucoma fulminans.   The  unusually extensive hae-
 morrhages, AAThich  supervene  upon the  operation in
 these cases, speak for the fact that great ATenous stag-
 nation occurs from the commencement of the disease.
 But it is still  doubtful, as in acute  glaucoma, whether
 the absolute blindness depends upon the  disturbances
 of the circulation, particularly the interruption  of the
 entrance and exit of  the  blood,-or upon a. direct com-
 pression of the conducting fibres.


           2. Chronic Inflammatory Glaucoma.
  This  disease may be insidiously developed from  the
premonitory  stage.   The  premonitory symptoms  be-
come more frequent and continue for a longer period;
the intermissions are  of less  duration, until there  are
no  longer  any  distinct intermissions, but only remis-
sions, and the disease  gradually and almost impercepti-
bly passes over into chronic glaucoma, the eye assuming
the same condition as  it did in the acute form, after the 
      CHRONIC  INFLAMMATORY GLAUCOMA.     41

conclusion of the inflammatory  process.  It becomes
more and  more  tense, until it may at last assume a
stony hardness, so that it cannot be dimpled by even a
firm pressure of our finger.  The subconjunctival veins
become dilated and tortuous, the sclerotic assuming in
the late stages of the  disease a peculiar waxen hue,
which is due  to  atrophy of the subconjunctival tissue,
and to a diminution in the calibre of the subconjunctival
arteries.  The cornea gradually loses its sensibility more
and more, frequently, however, only in certain portions.
It also becomes flatter.  The anterior chamber becomes
shallow, the aqueous humor clouded, and this turbidity
may change with great rapidity, occurring perhaps seve-
ral times a day.   It may be  produced by  any excite-
ment or  fatigue, often coming  on after a  full meal,
excessive exercise, &c.  The iris is pushed forward, so
as to be perhaps  almost in contact with the  cornea.  It
is dull and discolored, its fibrillae being more or less  ob-
literated, and not showing a clear and  distinct outline.
The  pupil is Avidely dilated, and either immovable or
extremely sluggish on the stimulus of light.  The field
of vision becomes greatly contracted, assuming, per-
haps, a slit shape.  As has been before pointed out,  the
contraction of the field in glaucoma begins, as a rule,
at the inner side, extending from thence upAvards and
doAviiAvards, so that the outer portion is the last to  be-
come  affected.   Alsion progressiA^ely deteriorates,  the
fixation  often becomes eccentric, and finally the sight
may be completely destroyed, so that not even a rem-
nant of quantitative perception of light is left,  even al- 
42
GLAUCOMA.
though the light be intensified by means of a powerful
biconvex  lens.  On ophthalmoscopic examination, we
find that the fundus always appears more or less clouded,
often to such an extent as to prevent our  distinguishing
the details of the background of the eye.   This haziness
is due  to  opacity of the  aqueous and vitreous humors,
and in some cases also of the cornea and lens.  But  if
the media remain sufficiently clear to permit an exami-
nation, Ave find the retinal veins  widely dilated and tor-
tuous,  the arteries diminished in calibre, and presenting
either  a spontaneous or easily producible pulsation; the
optic nerve more or less  deeply cupped, and the A-essels
displaced  at  its periphery.   The chief and character-
istic difference betAveen  the  acute and the  chronic in-
flammatory glaucoma  is, that the  latter may lead to
even complete destruction of sight, without any symp-
toms of severe inflammation or severe  pain.  There
may only be  insidious attacks of chronic, frequently re-
curring inflammation, leading gradually to loss of sight.
At  first, these inflammatory attacks may be  intermit-
tent, occurring at considerable intervals, but later they
may only show remissions.  In  other cases again, after
the eye has been suffering for some  time from these in-
sidious chronic inflammations, it may be suddenly at-
tacked by a  severe acute exacerbation,  causing A-ery
great pain and  suffering.  These acute  exacerbations
may recur again and again.   The pain may be so severe
that recourse must be  had to an iridectomy for its re-
lief, even*  although there is no chance of restoring any <
sight.  In such cases, the patient and his  friends must 
      CHRONIC INFLAMMATORY  GLAUCOMA.    43

be warned beforehand that the  operation is not per-
formed for the sake of giving any sight, but only in
order, if  possible, to relieve* the pain.  In many cases,
particularly if the iridectomy be made sufficiently large,
the relief may be permanent;  in others' it is  only tem-
porary.   AVhen speaking of  acute  glaucoma, it was
mentioned that after the first  acute attack the disease
might  gradually pass over  into chronic  inflammatory
glaucoma, no fresh acute attack occurring, but only
chronic, latent inflammatory exacerbations.  Sometimes
the course of chronic glaucoma is so insidious that the
sight of the eye may be completely lost without the pa-
tient being  aware that anything was the matter Avith
this  eye, the other being well.   Perchance he closes the
good eye, and then discovers the blindness of the other,
and  thus often supposes  the vision to have  been sud-
denly  lost.   On being questioned, he may  remember
that he  occasionally experienced slight  pain in and
around the  eye, which he  supposed  to be rheumatic;
that it  occasionally became  somewhat reddened, and
Avatered a little, Avhich was attributed to a cold; but
otherAvise he noticed nothing peculiar.  This may not
only occur amongst the humbler  classes, following pur-
suits Avhich  require but little employment of sight  in
reading, Ac, as among laborers;  but it may even hap-
pen  amongst men of literary habits and avocations, em-
ployed for many hours daily in reading and writing.
   AVhen the disease has run its course, and all sight  is
lost, Von Graefe terms it glaucoma absolutum.  Then
all chance of benefiting the sight by an operation is past. 
44
GLAUCOMA.
 The lens frequently becomes opaque, assuming the pe-
 culiar greenish hue so characteristic of glaucomatous
 cataract.  The glaucoma absolutum  may exist  for  a
 length of time without the eye undergoing any changes,
 except that atrophy of the iris, choroid, and optic nerve,
 become more and more  apparent.  In other cases, fre-
 quent, often very acute and violent, inflammatory symp-
 toms show themselves, accompanied by intense ciliary
 neurosis and headache.  In the last stages of the dis-
 ease other changes occur,—the iris becomes reduced to a
 narrow streak, the cornea opaque and softened, more
 particularly in its  central portions, and  haemorrhagic
 effusions take place into the anterior chamber, the vi-
 treous humor, and  the  inner tissues of the eyeball.
 Sclerotic staphylomata  are  formed,  and  suppurative
 inflammation  may  even  occur, leading to atrophy  of
 the globe.  Von Graefe calls this the stage of glaucoma-
 tous degeneration.   In it, iridectomy no longer proves
 a sure remedy for the inflammatory complication.  Ge-
 nerally sight is completely lost.  Sometimes the one eye
 may be lost from chronic inflammatory glaucoma, or
 from the apparently non-inflammatory form (glaucoma
 simplex), and the other be attacked by acute glaucoma.

 II.  TlIE APPARENTLY NON-INFLAMMATORY GLAUCOMA.
 Amaurosis with Glaucomatous Excavation of the Optic Nerve (Von
           Graofc).  Glaucoma Simplex (Donders).

  This disease Avas for a long time considered as distinc-
tive from glaucoma, with  Avhich it was supposed to have 
         NON-INFLAMMATORY  GLAUCOMA.       45

nothing  in  common  but the  excaATation  of  the  optic
nerve.   First  described by Von Graefe under the title
of "Amaurosis  Avith excaATation of the optic nerve."
But he has now  also admitted it into the glaucomatous
group of diseases.
  The course of the disease is often  exceedingly insidi-
ous, so that it  may be considerably advanced before the
patients pay any particular attention to it, supposing, but
too frequently, that the increasing weakness of sight is
simply OAving  to old age.  Though this impairment  of
vision may be noticed also for distance, it makes  itself
particularly felt in reading, writing, seAving, &c, and
convex glasses are found but of slight assistance.  There
is generally no  premonitory stage, for the intermittent
obscurations, rainbows found a candle, &c, are mostly
due to some slight inflammatory attack, accompanied by
cloudiness of the refractive media.
  The external  appearance of the eye may be perfectly
healthy.  The refractive media may be quite clear, the
cornea  sensitive, the anterior  chamber of the  normal
size, the  iris  healthy and not discolored, or but very
slightly so, this being only apparent on comparison Avith
the iris  of  the  other, healthy eye;  the pupil perhaps
slightly dilated and a little sluggish.   But the eyeball is
generally found to be abnormally tense, and Avith the
ophthalmoscope avc observe  that the optic nerve sIioavs
a glaucomatous excaA*ation.   Sometimes this increase in
tension  varies  greatly, being A^ery marked at one  time,
and hardly,  if  at all, apparent at another;  it is of  great
consequence, therefore, to examine such eyes frequently,
                         5 
46                  GLAUCOMA.
and at different periods of the day.  There is still a good
deal of discrepancy of opinion as to the invariable pre-
sence of increased tension of the eyeball in this form of
glaucoma.   Some assert that tension is always increased
in all cases of glaucoma  simplex;  others, again, think
that although this undoubtedly does occur  in the ma-
jority of cases,  yet that  in others it  is absent.  A'on
Graefe,  in  particular, maintains,  that the  intraocular
tension is not in all cases increased in a marked man-
ner.  He thinks that the occurrence of glaucomatous
excavation of the optic nerve, AAuthout any  marked in-
crease in the tension of the eyeball, may be explained
thus : That perhaps the resisting power of the optic pa-
pilla varies in different individuals, perhaps, also, at dif-
ferent ages.   Just as iritis and* irido-cyclitis  serosa may
occasionally be  observed, particularly in young indi-
viduals, to exist for some length of time Avith an unmis-
takable increase of tension, without any excavation; may
not, on  the  other hand, the power of resistance of the
optic papilla be  absolutely  or relatively so diminished,
that an  exceedingly  slight  increase of tension may al-
ready cause an excavation?  But every, even the most
considerable  increase of tension, requires to act some
time before it leads to cupping.   The truth of this is
shoAvn  in cases of acute glaucoma, Avhere  there is no
cup directly after the first  acute attack, although this
may haAe  lasted for some weeks, during Avhich the in-
traocular pressure Avas greatly increased.  In glaucoma
fulminans it is someAAdiat different: there it appears to
supervene  early.  But a  long-continued, though slight 
         NON-INFLAMMATORY  GLAUCOMA.       47

increase of tension will lead gradually to an excavation
of the optic nerve, which increases more and more in
depth; the  vessels then become interrupted at its edge,
and  there is  spontaneous or easily producible arterial
pulsation.  The veins appear dilated, and perhaps some-
what tortuous.  If the tension continues, the optic nerve
gradually atrophies, the arteries  become diminished in
calibre, and complete blindness  may supervene.  It is
found that if the increase in tension is very slow  and
gradual, the excavation of the optic nerve may become
very considerable in depth, without the sight or field of
vision being markedly impaired.  Increased intraocular
tension  is, therefore, generally the first symptom of
glaucoma simplex, accompanied perhaps by a relatively
rapid increase of presbyopia, and some hypermetropia;
gradually,  hoAvever, the optic nerve becomes cupped,
and  these  symptoms may last for a considerable time
Avithout others supervening.  In some cases, hoAvever,
the augmented tension may exist for a  long period with-
out the presence of other symptoms.
   Occasionally, glaucoma simplex may run its course,
even to complete blindness, AArithout the appearance of
any  inflammatory symptoms.   The  disease sloAvly, but
surely progresses, the eyeball becomes more and more
hard, the cornea anaesthetic, the  anterior chamber  nar-
roAvcr, the vessels more turgid  and congested, the pu-
pil dilated and sluggish, the retinal veins gorged, the
arteries diminished in calibre, and  perhaps pulsating,
the optic nerve deeply cupped and whitish in color, the
visual field more and more contracted, and the sight 
48                  GLAUCOMA.
finally destroyed.  But in the majority of cases, inflam-
matory symptoms show themselves during the progress
of the disease,  and  these  may assume  an  acute,  a
chronic,  or an  intermittent type.  They are accom-
panied by the same symptoms  as in acute or chronic
inflammatory glaucoma;  rapid diminution of vision, ob-
scurations, rainboAvs  round a candle, augmentation of
tension,  dulness of the aqueous and vitreous  humors,
&c.  Sometimes, hoAvever,  these  inflammatory symp-
toms may not appear until the  disease has long run its
course,  and  the sight has been  completely  lost.  In
other cases, they may be so transitory as to escape our
observation,  and their preATious existence may not be
ascertained, except by a A*cry close examination into the
history  of the case.   AVhere manifest symptoms of in-
flammation are apparently  Avanting in  a case  of  glau-
coma simplex, the condition of the other eye, if healthy,
should be ascertained, and then,  on a comparison of
the tAvo, Ave may often detect slight changes in the color
and structure of the iris, and slight haziness of the aque-
ous  humor of the affected eye, Avhich, but for this com-
parison,  Avould have escaped our attention.   A^on Graefe
also points out the  necessity  of examining  such pa-
tients at a period  of the day most favorable for the
observance of any inflammatory symptoms, and calls
attention to the important  fact that wliilst the inflam-
matory symptoms, particularly the deeper injection, be-
come commonly more apparent soon after  sleep, the re-
verse obtains  in glaucoma:  for here they become the
more prominent the  longer the patient keeps awake, 
NON-INFLAMMATORY GLAUCOMA.
49
more  particularly if he remains up beyond his custo-
mary time for retiring to bed.   He mentions an inte-
resting case, illustrative of the peculiar transitory cha-
racter which the inflammatory symptoms may occasion-
ally assume.  The right eye of the patient in question
ordinarily presented  a perfectly healthy  appearance,
but for several years past  it assumes a well-marked
glaucomatous condition when he has been playing cards
for some length of time, and only then.   On such oc-
casions, the anterior chamber becomes shallower,  the
aqueous humor diffusely clouded, the pupil somewhat
dilated and sluggish, the retinal veins dilated, particu-
larly  towards the edge  of the  optic disc, and arterial
pulsation may be produced by the faintest pressure upon
the eyeball; together with these symptoms, there is in-
distinctness of vision, surrounding objects appearing to
be covered by a  veil or  cloud.  Not till the  following
morning  have all these symptoms disappeared;  then
the sight is again  normal, and  the increase in the ten-
 sion of the eyeball, which was very manifest during the
 attack, is no longer appreciable.  We often find that in
 glaucoma simplex, the second eye becomes affected soon
 after the disease lias manifested itself in the other; it,
 moreover, often attacks  myopic eyes.  In both of these
 points it differs materially from the majority of cases of
 inflammatory glaucoma. 
50
GLAUCOMA.
        Secondary or Consecutive Glaucoma.

   We may meet with this complication in several groups
of eye diseases; and Ave are here again indebted to Von
Graefe, for  discovering the glaucomatous nature of the
changes AAdiich these diseases may  undergo  in  their
course; a remedy for Avhich is also to be  found in the
operation of iridectomy.   We find that glaucomatous
symptoms may supervene in the folloAving diseases:
       I. Iritis.
      II. Posterior staphyloma.
     III. Traumatic cataract.
     IV. Prominent corneal cicatrix (staphyloma).
   I. Iritis.—We find that there is a great tendency to a
recurrence  of the disease in  those  cases of  iritis in
which considerable posterior  synechias exist,  so great a
tendency, indeed,  that any slight exciting  cause Avill
often suffice to produce a  relapse.   After each of these,
further adhesions of the pupil will take place, further
changes occur in the iris,  and perhaps also in  the neigh-
boring structures, the  ciliary body, and  choroid.  Hoav
important is it, therefore,  thoroughly to dilate the pupil
by atropine during the  early stage of  acute iritis, so as
to prevent the formation of adhesions  between the edge
of the pupil and  the capsule  of the  lens,  and  thus to
obviate the most  frequent  cause of recurrent iritis.
On account  of its  diminished action in acute  inflamma-
tion  of the  iris, the atropine  solution must be strong.
and  must be  applied  to  the  eye  ten to twelve times 
SECONDARY OR CONSECUTIVE  GLAUCOMA.
51
daily, and the dilatation of the pupil must be continued
for  some weeks after the subsidence of the inflamma-
tion.  If it be found to irritate, it  should be changed
for  a collyrium of extract of belladonna and water, or  a
solution  of lead-water applied the first day before the
use of the atropine.
  If there is perfect exclusion of the pupil (that is,  if
the whole of the free margin of the pupil is  adherent
to  the capsule of the lens, the pupil being,  however,
perfectly free from exudation), avc find that other com-
plications, together with progressive loss of sight, gene-
rally ensue.  Amongst the most frequent of which are
chronic  irido-choroiditis, effusion into the vitreous hu-
mor, detachment of the retina, chalky opacity  of the
 lens, «x.c, the  eyeball gradually shrinking, and becom-
ing at last quite atrophied.   Though this is very often
the course  pursued by the disease, Von  Graefe has
 pointed out  that it  may be very different; that the eye
 may become glaucomatous.   The tension of the eyeball
 increases, the  sight rapidly deteriorates, and the field of
 vision  becomes  contracted.  On ophthalmoscopic exa-
 mination, avc find, if the pupil and refractive  media are
 clear,  progressive  excavation of the  optic  nerve.   In
 such cases,  the increasing  loss of sight  is due to the
 increased intraocular pressure, Avhich produces compres-
 sion of the  retina  and  cupping of the  optic  nerve.  If
 the disease  is permitted  to  run its course unchecked,
 the eveball, after remaining tense for some length of
 time, generally  becomes gradually softer,  and finally
 atrophies. 
52
GLAUCOMA.
  II.  Sclcrotieo-choroiditis posterior (posterior staphyloma).
—This disease is hardly ever absent in cases of conside-
rable  myopia.  Its ophthalmoscopic  symptoms are ge-
nerally  most marked  and unmistakable.   The charac-
teristic  symptom  is a  brilliant white crescent at the
edge of the optic nerve-entrance, generally at the outer
side (Avith the reverse image it Avould of course appear
towards  the  nasal side of the patient).  This  crescent
varies much in size, from a small Avhite arc  to a large
zone, extending perhaps all round the optic neiwe, and
embracing even  the  region  of the  macula lutea, its
greatest  extent being  always in the  direction of the
latter.  Its edges  may be cither sharply and distinctly
defined,  or may be irregular  and gradually lost in the
surrounding  healthy structures.  Irregular patches  of
pigment arc  streAvn about its  margin, and also  perhaps
on its surface, so that little dark  islets of varying size
and form appear in its expanse.  The crescent  itself is
of a brilliant Avhite color, so much so, indeed, that the
entrance, by contrast,  appears  abnormally pink.  The
small retinal vessels can, on account of the white  back-
ground,  be traced more distinctly,  and their  minute
branches tan be  more easily folloAA'ed over  this  patch
than  in  the  neighboring fundus.   This white crescent
is due to a  thinning or atrophy of the  stroma of the
choroid. The pigment-cells are not necessarily destroyed,
but there is  an absence of the pigment  molecules, for
those  irregular black  patches, mentioned  above, are
pathological  agglomerations of pigment.   On  account
of the loss of pigment, and the  atrophy or  thinning of 
   SECONDARY OR CONSECUTIVE  GLAUCOMA.    53

the stroma of the choroid, the glistening sclerotic shines
through the latter, and lends the brilliant white appear-
ance to the  figure/ Although  such patients may  be
extremely sliortsighted, avc  do not generally find that
tlic acutencss of vision is impaired, except the disease
has extended to the region of the yellow spot, or, as is
frequently  the  case, it has become  complicated Avith
opacities of the vitreous humor, detachment of the re-
tina, cataract,  &<;.   But apart from these causes, the
sight may become  very much  impaired,  the  field  of
vision  contracted, the  eyeball more  tense, and avc then
find that  glaucoma has supervened  upon the original
disease.  The  eye then  presents the folloAving symp-
toms :  It is abnormally  hard, the sclerotic A^essels per-
haps someAvhat injected, the anterior chamber of normal
size, the pupil  wide.   On ophthalmoscopic examination,
the  optic  nerve sIioavs symptoms  of excaATation.  The
edge of the optic disc contiguous to  the arc, Avhich Avas
before indistinct,  so  that it  Avas  perhaps  difficult  to
determine Avhere  the  margin  of the optic disc  really
began', uoav again becomes  sharply defined.   But there
is no considerable  change in the position of the vessels,
they are  only  someAvhat  displaced  and curved at the
edge of the excavation, but the  latter extends quite  up
to the margin of the nerve, Avhich distinguishes it from
the physiological cup, this being confined to the centre
of the  disc.   A "on Graefe at first met Avith this glauco-
matous condition, supervening upon  sclcrotieo-choroidi-
tis, only in  elderlv persons, who Avere suffering from
very considerable myopia, Avhich had increased rapidly 
54
GLAUCOMA.
 during their youth, but had afterwards remained nearly
 stationary.   In elderly persons, this complication may
 be due to  the fact that when  the  sclerotic  becomes
 thickened with advancing years, it loses  some  of  its
 elasticity,  and cannot, as heretofore,  yield to the  in-
 creased intraocular pressure and bulge  backwards  (at
 the posterior staphyloma), aud thus the optic nerve-en-
 trance, Avhich is the next least resisting part, Avill yield
 before  the  pressure  and become  excavated.   In  old
 persons the  excavation is generally not of a deep form.
 He has lately, however, seen some cases of glaucoma
 following sclerotico-choroiditis posterior  in young indi-
 viduals; in all these the eyes appeared very prominent,
 the myopia varying from £ to £j, the  symptoms of in-
 creased tension were slight, and less than  in the cases
 observed  in  older individuals;  in two there was,  in-
 deed, no perceptible  increase of tension.  The  excava-
 tion Avas deep  and abrupt.   Both  eyes were  generally
 simultaneously attacked.  Iridectomy proves also  most
 beneficial in these cases, saving the sight  of eyes Avhich
 would otherwise have become completely  blind.  But
 the operation must be performed very early, as no other
 remedy Avi 11 stay the  progress of the affection.   Great
 care must, however, be taken that the aqueous  humor
flows  off very slowly  indeed, as  there is in these cases
great  tendency to intraocular haemorrhage,  detachment
of the retina, <.ve.
   III. Cataract.—When the capsule of the lens has  been
divided, and the aqueous humor  conies in contact Avitli
the lens,  the  latter swells up through imbibition  of 
   SECONDARY OR  CONSECUTIVE GLAUCOMA.    55

the fluid, and often  sets up  a considerable amount of
inflammation.  This division of the capsule may either
be due to an operation for cataract (needle operation),
the object  of which is to cause the absorption of the
cataract by the  breaking up of the lens and admission
of the aqueous humor; or it may be  due  to an  acci-
dental wounding of the  capsule  by  a foreign body.
Now the amount of swelling  of the lens varies conside-
rably according to the age of the  patient and the con-
dition of the lens itself.  The more closely the  consis-
tence of the translucent or cataractous lens approaches
that of the normal lens, the  greater is the amount of
SAvelling it undergoes  upon the admission of the aque-
ous humor; and for this reason, those  forms of cataract
in which the opacity is confined to certain portions of
the lens, as, for instance, the lamellar cataract, swell up
very considerably after a needle  operation, as a  great
portion of the  lens still  retains its normal consistence.
In the hard cataracts of older individuals the absorption
of the  fluid is but  slight, and they swell up but very
little, even although  they may have  been very freely
divided by the needle.  Any accidental wounding of
the capsule of  the lens is frequently followed by a rapid
formation  of cataract, great  imbibition of the aqueous
humor, and very considerable swelling of the lenticular
substance.  The danger to  be apprehended from such
imbibition is far less in children than in the adult.  We
constantly  find that after the division of cataract in
children, or after some accidental  wounding of the lens,
great imbibition and swelling of the lens ensue, and yet 
56
GLAUCOMA.
that they give rise to hardly any inflammatory symp-
toms.  But in the adult  it is different;  here a division
of the capsule, even of moderate extent, will often lead
to most severe and  disastrous  inflammatory complica-
tions ;  for with advancing years the iris appears to get
more and more impatient of the pressure and irritation
produced by the swelling and contact of the lens sub-
stance.  We find in many cases  that after division of
the  capsule, be it operative or traumatic, the lens be-
comes swollen and presses  against the  iris  and ciliary
body,  producing a violent inflammation, accompanied
by exudation of plastic  lymph, the formation of thick
membranes  behind  the iris, effusion  into the vitreous
humor, detachment of the retina, &c, leading to destruc-
tion of  the  sight.  As  to  the diagnosis of the iritis
which occurs in such cases, I need say nothing.  But I
would call attention to the symptoms of inflammation
of the ciliary body (cyclitis) which often supervenes in
cases of traumatic cataract, needle operations, and re-
clination of the  lens.  The symptoms of  cyclitis  are
shortly as folloAvs:
  1. There is  a more  or less considerable  amount  of
subconjunctiA-al vascularity (sclerotic injection), the color
of the  iris is  someAvhat changed, and if there is conside-
rable iritis, it may even be greatly altered.
  2. The A'eins of the  iris are  considerably dilated.
This is a very pathognomonic symptom  of cyclitis, and
is due to the folloA\lng cause : On account of the inflam-
matory changes in the ciliary bod}-, the A*enous reflux is
someAvhat  impelled, and the blood  does not flow off 
   SECONDARY OR CONSECUTIVE GLAUCOMA.   Oi

readily from the veinlets of the iris, and hence they be-
come gorged and dilated.
  3. Tenderness of the region of the ciliary body to the
touch.   If avc  press with the point of a probe upon the
sclerotic just behind  its junction  with the cornea, we
find that at certain points it produces exquisite pain;
and whenever this is  the  case, we may be certain  that
there is inflammation  of the ciliary body.
  4. The formation of hypopium in the anterior cham-
ber. The exudation giving rise to  the hypopium may
be produced in three ways:  from  the cornea, the  iris,
or from the ciliary body; for at the rim  of the ante-
rior chamber the  ciliary body is only separated from the
latter by  the  division of the membrane of  Descemet,
through Avhich, matter  easily exudes into  the anterior
chamber, Avhere it becomes precipitated in the form of
hypopium.
  Gyclitis is a far more frequent complication in cases
of cataract than is  generally suspected, and the inflam-
mation  often extends  from the  ciliary body to the  cho-
roid; for avc must remember that in reality the iris, the
ciliary body, and the  choroid are almost one structure,
the uveal tract of some authors, and that an inflamma-
tion commencing in  the one is  very liable to extend to
the other portions of this tract.
  But the sight may also be lost in  another Avay in trau-
matic cataract,—the  eye may  become  glaucomatous.
During the sAvelling of the lens  it is found that the in-
traocular pressure increases,  the eyeball becomes more
tense, the field of vision contracted, the cornea ames-
                          16 
58
GLAUCOMA.
 thetic, the anterior chamber more shallow, the iris dis-
 colored, the pupil dilated  and sluggish.   If the disease
 is'allowed  to  run its course unchecked, the  lens may
 become  completely absorbed  and the pupil clear, but
 the patient  remains blind; with the ophthalmoscope Ave
 then find a deep  excaA-ation  of  the  optic nerve.  The
 process has been this: from the irritation caused by the
 sAvollen lens a state of internal congestion Avas caused,
 hypersecretion of fluid into the ATitreous  body, increase
 of intraocular  pressure,  Avhich has continued  for some
 time, and Avhich has caused excaA^ation by its action on
 the surface  of the papilla of the optic nerve.
  AVe must be constantly upon  the Avatch, in cases of
 division  of  cataract, traumatic cataract,  and after  the
 operation of couching (if this should ever be performed
 at the present  day), for the occurrence of inflammatory
 complications, more particularly cyclitis and choroiditis,
 and if these  make their appearance, or any symptoms of
 a glaucomatous complication begin to sIioav themselves,
 the lens should be at once removed.  If it be sufficiently
 softened, it  may be removed through a linear opening,
 and then these  symptoms will soon subside.  But if the"
 patient is an adult, the nucleus may still be hard, although
 the cortical  substance is softened  and sAAollen; it is then
 necessary to combine iridectomy  with the linear extrac-
 tion  (modified  linear  extraction), and  remove the nu-
 cleus  with a spoon.   It is essentially  necessary to re-
move the lens as soon as possible if a foreign body has
entered and  remained in  it; for Avhen the lens becomes •
swollen and partially  absorbed, to say nothing of the 
             (J L A I C 0 M A T O I' S PR O C E S S.           59

dangerous  inflammatory  complications to  which  this
may give rise, the  foreign  body may disengage  itself
from the lens substance, and sink down to  the bottom
of the posterior chamber, giving rise, most probably, to
panophthalmitis, Avliich soon  leads to atrophy  of the
eyeball.  It  is, therefore, urgently necessary to remove
the  lens and foreign body as soon as possible.
  IY  Projecting Corneal Cicatrix.—Glaucomatous symp-
toms  may also supervene upon  this  form of corneal
cicatrix; indeed it has been long observed, that in  cases
of partial or complete staphyloma, of leucoma promi-
nens,  ivc, the  degree of blindness was quite dispropor-
tionate to the  optical condition.  In such cases there  is
very frequently contraction of the field of vision, eccen-
tric fixation, augmentation  of the intraocular pressure,
and excavation of the optic  nerve.   If glaucomatous
symptoms  should supervene  upon projecting  corneal
cicatrix, the latter becomes markedly prominent after it
has already  become thickened.  There appears to  be an
increase in the vitreous humor, giving rise to intraocu-
lar  pressure, and it is of consequence that this complica-
tion be  detected at an earlv  stage, as nothing can be   ,   ,  J
done  for the sight Avhcn the disease has run its course
                                                .   S ^!,P.H
  On  the Mature and-Causes of the Glaucomatous
                      Process.
  The nature of the glaucomatous process  is e\Tidently n
inflammatory, accompanied by an increase  in the  intra-  x W.tt-
ocular pressure.  The seat of the inflammation is chiefly  p Aft
in  the  uveal  tract, the choroid,  ciliarv bodv, and the 
60
GLAUCOMA.
 iris;  although other  structures may afterwards become
 involved, as the cornea, sclerotic, and the retina.  This
 irido-choroiditis is accompanied by diffuse imbibition of
 the aqueous and vitreous humors, causing an augmenta-
 tion .of  the  intraocular  pressure.   The characteristic
 symptoms of glaucoma, which  have been  already  de-
 scribed at length, are all  due to this increased tension,
 as for instance, the  hardness of the eyeball, the con-
 traction  of the visual field, the obscurations, the ciliary
 neurosis (caused  by pressure upon the  ciliary nerves),
 the anaesthesia of the  cornea, the dilatation and  slug-
 gishness of the pupil (due to paralysis of the nerves sup-
 plying the iris), the excavation  of the  optic nerve, and
 the pulsation of the retinal A-essels.  This augmentation
 of the intraocular pressure appears  to be due to an  in-
 crease in the volume of the vitreous humor, OAAdng to
 the inflammation of the uveal tract, Avhich  is the  chief
 secreting organ  of the  ocular  fluids.   Together  with
 this  increase  in  the  vitreous  humor, it appears also
 that the poAvers  of absorption are diminished in  glau-
 coma, and this  may  explain AA'hy such effusions are
 not,  as in other forms  of  choroiditis, removed by  in-
 creased activity of the absorbents.   This  diminution in
 the power of absorption may be, in part,  due to the
 changes  met Avith in the coats of the vessels, and to the
 great tendency to  overfulness  and stagnation in the
 bloodvessels Avhich occurs in glaucoma,  more  particu-
 larly during the  inflammatory exacerbations, as is evi-
 denced by the dilatation and tortuosity of the  conjunc-
tival and retinal veins, and by the frequency of hremor- 
             GLAUCOMATOUS  PROCESS.           61

rhagic effusions into the retina, optic nerve, and choroid.
Attention  has  latelv been  called to the fact, that the
sclerotic appears  peculiarly  rigid  and  unyielding in
glaucoma,  and it  has  been supposed that this  is not
unfrequently congenital or hereditary, and  may form a
predisposing element; to  glaucoma.  Xoav,' if such an
abnormal rigidity of the sclerotic exist, Ave  can  easily
understand how any rapid though slight augmentation
in the volume  of the contents of the eyeball, must not
only give rise to a  disproportionate increase  in the in-
traocular pressure, but must also augment the tendency
to stagnation in the bloodvessels.  Coccius has  lately
found  in  a  case  of glaucoma  that the sclerotic  had
undergone a fatty metamorphosis, that the cellular tis-
sue had become fattily ^generated; and he thinks  that
the affection of the sclerotic may perhaps have been the
cause of the increased intraocular pressure.
   When considering the different  forms of glaucoma
avc had frequent occasion to point out the great Aaria-
tions in the intensity of the inflammatory symptoms.
We  saAv that in acute glaucoma  tire inflammation  might
be very seven'  during the first attack, but that after its
subsidence, the inflammatory exacerbations  might as-
sume an insidious chronic character, and the disease
gradually pass  over into  glaucoma absolutum, without
the recurrence  of any acute attack.  Again, that  in the
chronic form the inflammatory symptoms might,  at the
outset, be  but  little marked, but that in the course of
the disease acute  exacerbations, even of a very severe
character,-might  slunv themselves.  In  the third form 
62                  GLAUCOMA.
(amaurosis with  glaucomatous excavation, glaucoma
simplex), it Avas stated  that the disease might occasion-
ally run its course without the apparent occurrence of
any  inflammatory  symptoms, the  eyeball  becoming
stony hard, the optic nerve deeply excavated, the sight
destroyed, but the refractive media remaining perfectly
clear.  But in the vast majority of cases of glaucoma
simplex,  inflammatory  symptoms, of ATarying severity,
do show themselves during the progress of the disease.
Xoav, on account  of the fact that glaucoma simplex may
occasionally run  its course Avithout the apparent pre-
sence of any inflammatory symptoms, and on account of
the increased tension being sometimes the first mani-
fest  symptom of  the disease,  it has been supposed by
Donders (of Utrecht) that the^nflammation is not the
integral part of the glaucomatous process, but only a
complication, Avhich, though occurring in the majority
of cases, need not  necessarily be ahvays present.  He
considers  the increase  in  the intraocular pressure as
the essence of the disease,  and,  therefore, the glau-
coma simplex, Avhrch runs its course without any inflam-
matory symptoms, as the primordial type  of the disease ;
and he thinks that the acute or chronic inflammation
Avliich shoAvs itself in the majority of cases of glaucoma
is but a complication, Avhich is of secondary importance,
and  not necessary to  the glaucomatous process.  He,
therefore,  speaks  of glaucoma simplex,  and glaucoma
cum ophthalmia.   The anomaly in the secretion of the
fluids of the eye lie thinks due to an abnormal irritation
of the nerves regulating the  intraocular secretion.  It 
GLAUCOMATOUS PROCESS.
63
 lias also been urged that inflammatory glaucoma (glau-
 comatous ophthalmia) cannot occur primarily in  a hith-
 erto healthy eye;  that an increase in the tension of the
 eyeball pre-existed; that, in fact, glaucoma simplex had
 existed, perhaps quite unknown to the patient," and that
 the inflammation supervened upon this.  But we some-
 times meet with cases of acute glaucoma in which there
 Avas no trace of increased tension, or any other glauco-
 matous symptom, prior to the outbreak of the  disease.
 Thus A'on Graefe mentions cases in Avhich he has  ope-
 rated for glaucoma upon the one eye, the other being,
 at the time  of  the  operation, of quite a normal  degree
 of tension;   and  yet the  latter Avas  soon after attacked
 by glaucoma, in one case even by glaucoma fulminans.
 lie thinks, moreover, that the mere increase of tension
 should not be allowed to constitute a premonitory stage,
 as even a considerable increase of tension  may exist for
 an  indefinite period Avithout the appearance of other
 glaucomatous  symptoms.  In  families in Avhich glau-
 coma is hereditary, an increased resistance, often  of a
 marked degree, exists even in infancy, and the disease
 may not sIioav  itself till middle age, or even not at all.
  The. question  is certainly a  most  important  one,
 Avhether the inflammation be but of secondary impor-
 tance or not.  The great difficulty  lies in those cases
 (although they are but rare),  in which Ave find the glau-
 comatous disease running its course Avithout any, even
the slightest, symptom of inflammation; for if this be
possible, then,  indeed, Ave cannot look upon the inflam-
matory  symptoms  as the sine qua nou  of  the disease. 
61
GLAUCOMA.
At present, however, this subject still remains in doubt.
Von Graefe maintains the inflammatory nature of glau-
coma,  accompanied  by an  increased  secretion of the
fluids of the eye, and by augmented tension.   He thinks
that in  the cases  of apparently  non-inflammatory glau-
coma, a lengthened obseiwation Avill generally sIioav us
that transitory inflammatory exacerbations do  mostly
occur.   Such  exacerbations  may be but  A'ery slightly
marked, and easily escape the attention of the patient
or his medical attendant, or they may only occur at
certain  periods, or be produced only by certain causes,
as, for example, in the case  mentioned, in Avhich  they
only came on AAmenever the patient played at cards.  The
absence of any externally visible  symptoms  of A'ascu-
larity, is no proof of the non-existence of internal in-
flammation, for the  ophthalmoscope  constantly reveals
the presence of even considerable inflammation of the
choroid and retina, Avithout the  existence  of any in-
creased vascularity of the external tunics of the eyeball.
The haziness of the aqueous andAdtreous humors AAmich
may arise during such an ephemeral  exacerbation, may
likewise be so slight and delicate as to escape detection
with the ophthalmoscope, for Ave knoAV that fine  diffuse
opacities of the aqueous humor are often quite invisible
by transmitted light.*
  Glaucoma is a  disease of old age.  It is  most  fre-
 .* For further information upon this interesting and important sub-
ject, I must refer the reader to Von (iraefe's Archiv fur Ophthal-
nioligie, viii, 2. 
GLAUCOMATOUS PROCESS.
65
quently met with between the ages of fifty  and sixty,
but may occur even at a much later  period.  It is sel-
dom met with in early  life, or before the age of thirty.
Females appear to be  more subject  to it than males,
and  it is most apt to occur soon after the cessation of
menstruation.  We find that the males who are attacked
by glaucoma, frequently suffer from gout and disorders
of the digestive organs, and are often subject to haemor-
rhoids.   There is no doubt that glaucoma may be he-
reditary, and  as has been  already mentioned, the eyes
of the individual members of families in Avhich this dis-
ease is  hereditary, often show, even in early life, a pe-
culiar  increase in the resistance of the eyeball, and a
rigidity and  unyieldingness of the sclerotic; and these
symptoms may exist for many years  without any glau-
comatous outbreak.   In fact, the latter does not gene-
rally occur until middle age.
   We  have stated that glaucoma may  appear as a pri-
mary or a secondary  disease.  In the former case,  it
may occur after several external injuries, or without any
apparent external or internal cause.  It ahvays  attacks
one  eye first, and may remain  confined to this; but
when once the  one eye has become affected by  glau-
coma, there is a great tendency in the disease to hiA-ade
the other also.   We  must, therefore,  ahvays  prepare
such a patient for the eA^entuality, the great likelihood,
even, of the other eye becoming also affected.  By care-
ful and judicious treatment, and by abstinence from ex-
cessive  fatigue and  exertion of the eye, much  may be
done to retard the attack, and to break its force.  The 
06
ULAUCOMA.
nature of the glaucomatous process in the first eye is no
criterion as  to the form Avhich may occur in the other.
We find, for instance, that the first eye may be  suffer-
ing from  glaucoma simplex,  or chronic inflammatory
glaucoma, and the other be attacked bv the acute form,
or even by glaucoma  fulminans.   The time which may
intervene before the second eye becomes affected, varies
greatly, sometimes a feAv days  only  elapse, in other
cases many  months, or  eA*en years.   In the secondary
glaucoma, Avhich may supervene upon another affection
(traumatic cataract, irido-choroiditis, &c),  this disposi-
tion to extension of the disease to the other eye, is far
less than in primary glaucoma, but still such a tendency
does exist, and may be called into activity by any injury
to, or operation upon, the sound eye.

      Ophthalmoscopic Symptoais of Glaucoma.

  The characteristic ophthalmoscopic symptoms of glau-
coma,  are pulsation of the central A*cssels of the  retina,
and excavation of the optic neiwe.
  The stagnation in the venous circulation of the retina
is often very  considerable, the veins are dilated  and
tortuous, the  smaller veinlets  assuming  a corkscreAV
appearance; if the stagnation be very great, the larger
venous branches  may  even  show  peculiar bead-like
swellings.   This is, hoAvever, very rare.  Dr. Liebreich
figures a case in his admirable lk Atlas d'Ophthalmosco-
pie,"  in which it existed  in the most marked  manner.
After diminution of the pathological increase in the in- 
 ophthalmoscopic symptoms of glaucoma.  67

traocular pressure, the stagnation in the A-enous circu-
lation ceases, the calibre of the Areins diminishes in size,
and they lose the tortuosity.   Thus, after  the  perfor-
mance of iridectomy, and the consequent diminution in
the tension of the eyeball, Ave frequently have an oppor-
tunity of observing  the change in the venous circula-
tion.   Extensive retinal  ecchymoses  are  perhaps met
with, and  the veins, which, before the operation,  were
very dilated and swollen, are noAV much  diminished in
size and paler.   The retinal arteries in glaucoma appear
very thin  and small, and much paler than in the  normal
eye.
   The pulsation of the central veins and arteries maybe
spontaneous in glaucoma, or producible by  slight pres-
sure upon the eyeball,—a pressure far slighter in degree
than  would produce it in the normal eye.   The venous
pulsation may, hoAvever, occur spontaneously in  normal
eyes ;  hence  it is not so pathognomonic of glaucoma as
the arterial pulsation, Avhich never occurs spontaneously,
except the intraocular pressure is considerably increased.
The venous pulsation is characterized by an alternating
increase and diminution in the  calibre of the A'ein ; the
emptying of the ATein  commences at the  centre of the
optic disc, and extends to its periphery ; the refilling, on
the other  hand, begins at the periphery and extends to
the centre.  The venous pulsation is mostly  only visible
in the expanse  of the optic disc, but in very rare cases,
it  may extend  beyond its  margin.  On increasing the
intraocular tension  by a slight pressure upon the eye-
ball, the venous pulsation  may be rendered still more 
68
GLAUCOMA.
 distinct, and we may thus alternately cause  a complete
 emptying and refilling of the vein.   On a  sudden re-
 laxation of a pressure aa hich has continued for some lit-
 tle time, the veins become rapidly overfilled and  swol-
 len, which  dilatation lasts for about a minute, Avhen
 they resume their normal calibre.  The respiration also
 affects the retinal circulation someAvhat; thus, durino- a
 strong  expiration, an increase in  the size of the vein
 may be noticed, whereas, a deep inspiration causes it to
 diminish.   The vein and artery are in an opposite state
 of fulness, the arterial systole being synchronous Avith
 the venous diastole.
   The arterial pulsation is synchronous with the radial
 pulse, but occurs slightly later than the pulsation of the
 carotid.   It is not spontaneously  present in a normal
 eye, and requires a  considerable  amount  of pressure
 upon the  globe to produce it, far  more so than is re-
 quired for the A^enous pulse.  I have before pointed out
 the important  fact, that, together with the appearance
 of the arterial pulsation, there  occurs an  obscuration of
 the field of Adsion, which disappears  together with  the
pulsation upon the cessation  of the pressure.   If the
augmentation in the  intraocular pressure be at all con-
siderable, the arterial pulsation is often spontaneous in
glaucoma, or, if not, it may be produced by slight pres-
sure upon the eyeball.  It is confined to  the optic disc,
and may occur in one or all the principal branches of
the central artery of the retina.  It is recognized bv a
rapid to-and-fro  movement, a rhvthmical filling and
emptying  of the arteries, the pulsation being synchro- 
 OPHTHALMOSCOPIC SYMPTOMS OF  GLAUCOMA.  69

nous  with the  radial pulse.  The arterial diastole  is
characterized by a rapid, jerky entrance of a column of
blood into a  previously empty artery, and takes far less
time than the systole, Avhich shows itself by a slow, cen-
trifugal emptying of the  vessel.   On  augmenting the
intraocular pressure, the  diastole  will  diminish  more
and more, whilst the systole increases in duration.   If
the pressure  be increased to a maximum degree Ave may
blanch the optic disc completely, the veins will become
emptied, the arterial pulsation will also disappear, and
a peculiar oscillation of the blood in the veins may shoAv
itself near the optic disc.
   Excavation of (he Optic Acrrc.—The excavation of the
optic  nerve Avhich is  met Avith in  glaucoma, and is due
to the increased intraocular pressure, is so peculiar in
character that in the majority of cases there is no dif-
ficulty in at once distinguishing it from the excavation
Avliich may be met Avith  in a  perfectly normal  eye, or
may occur in the atrophy of the optic nerve.  Before
considering the characteristic  symptoms of the glauco-
matous or "pressure" excavation, it AA'ill be  Avell to
notice the appearances met Avith in a physiological cup,
arid also in the excavation due to atrophy of the optic
nerve.
   In the congenital physiological excavation avc find that the
cupping is limited to the central  portion of the  optic
disc, that  it  is  generally very small and shalloAv, and.
that it  may  continue throughout life Avithout under-
going any changes.   Sometimes the excaA^ation  is Avell-
marked and  easily recognizable, the central portion of 
70
GLAUCOMA.
the optic disc  presenting a peculiar  white, glistening
appearance, of varying size  and form.   This central
glistening spot may be oval, circular, or longitudinal,
and its size is generally very inconsiderable in compari-
son Avith that of the  optic disc; it" is surrounded by a
reddish zone, which  may even be almost of the same
color as the background of the eye.  The Avidth of this
zone varies Avith the extent  of the excavation: if  the
latter be small, the  zone Avill be very considerable;  but
if it be large, the zone Avill be narrow, and limited to
the periphery of the  disc.   The edges of the cup  are
generally slightly sloping, and never  abrupt or steep;
but the excavation passes gradually over into the darker
zone, Avithout there being any sharply defined margin.
But  if the excavation  is conical or funnel-shaped,  the
edges are more abrupt, and the margin  more defined.
We find that the  retinal vessels also  undergo peculiar
changes in their course from the periphery towards  the
centre  of the disc, for,  aa hen  they arrive  at the margin
of the  excavation, instead of passing  straight on, they
describe a more or  less acute curve  as  they dip down
into  it.  This curve  may be very slight  and gradual if
the cup  is shalloAv, but if it  is deep and extensive  the
curve may be abrupt, giving rise to  a displacement of
the vessels.   In the  expanse of the excavation the ves-
sels generally  assume  a  slightly darker shade, but in
other cases they appear of a lighter, more rosy hue,  and
seem to be enveloped by a delicate veil.
  In the excara/iioi from atrophy <;/' the optic nerve, atten-
tion should also be paid to the characteristic symptoms 
 OPHTHALMOSCOPIC SYMPTOMS OF GLAUCOMA.  71

of such  atrophy.   The retinal  vessels will be found
greatly  diminished  in  calibre,  the arteries small and
threadlike, perhaps  hardly apparent; the veins may at
first retain their normal size, or be even slightly dilated,
but  in  the course of  the disease  they  also  diminish
greatly in diameter.   The color  of the disc is likeAvise
changed; instead  of the  rosy yelloav appearance which
it presents in the  normal eye, it  assumes a  more or less
gravish AAdiite or bluish white  color, A\diich may  be
limited  to a portion of the disc  or  extend  to  its Avhole
expanse, lending it  a peculiar glistening, tendinous, or
mother-of-pearl appearance.  The bluish gray color of
the optic nerve is  particularly met with in spinal amau-
rosis ; indeed it may be almost considered characteristic
of  this affection.   The excavations from  atrophy,  al-
though  perhaps extensive on the surface, are generally
very shalloAV, the  descent i?  gradual and  sloping, not
abrupt;  consequently, the retinal vessels, on arriving at
the edge of the cup from the  periphery  of the disc, do
not sIioav any marked displacement, but only describe a
more or less acute  curve.  Sometimes this curve is so
slight that it is hardly perceptible.   Even in those rare
cases in  Avhich the  excavation is  tolerably deep, the
descent is not abrupt, and for this reason there  is  no
marked displacement of the vessels at its edge; and on
moving the  convex lens of the ophthalmoscope to and
fro, so as to make it act  as a prism, the  bottom of the
excavation does not  moAre as a AA'hole, but only certain
portions of the excavation undergo a slight displace-
ment; and this parallax  is very different to, and easily 
72
GLAUCOMA.
distinguishable from, that met with in the glaucomatous
cup,  Moreover, the  sudden interruption of the over-
filled veins at the edge of the excavation, Avhich is so
very characteristic  in the glaucomatous form, is also
wanting.
   The glaucomatous or pressure excavation is distinguished
by the folloAving typical symptoms.  The cup is not par-
tial and confined to the central portion of the optic disc
as in the physiological form, but it extends quite to the
edge of the disc, its diameter equalling that of the latter,
and the lamina  cribrosa  is stretched and pushed back-
Avards.  Even although it may not yet have  attained a
considerable  depth, the edge is always abrupt and pre-
cipitous, thus differing greatly from the atrophic excaAji-
tion, in which the descent is gradual and sloping.  The
edges may also OA'erhang the cup, which has undermined
the  margin.   The optic  clip? is surrounded by a light
yellowish Avhite ring, AAdiich is probably caused  by the
reflection of light  from the  anterior  laminae  of the
scleral ring.  This zone varies in width according to the
depth of the  excavation;  the deeper and more advanced
the  latter, the broader  and more marked Avill  be the
ring.  The color of the disc is also much changed.  In-
stead of the yelloAvish pink appearance of the normal
disc, the central, highly shining portion, is surrounded
by a deep bluish gray  or bluish  green  shadoAV, which
gradually increases in darkness toAvards the periphery
of the disc,  AAdiere  it may assume the appearance of a
dark, avell-defined rim.   On slightly moving the minor
or the  object lens, this shadow Avill  vary in intensity, 
          OPHTHALMOSCOPIC SYMPTOM^ OF GLAUCOMA.  73

         more particularly in  the  central portion.  On account
         of this peculiar shading of the disc,  the  latter looks, at
         the first glance,  rather arched  forward than hollowed
>        and excavated.   The course of the retinal ATessels at  the
         cd^v  of the cup  is also  very peculiar.  They do  not
         pass, as  in the normal eye, straight  over the margin of
         the disc on  to  the retina Avithout showing  any curve or
         displacement;  but, if avc trace their course from  the
         retina, avc find that when they arrive at the margin of
         the excavation the dilated veins increase someAvhat in
         size,  and, making a more or less abrupt curve, descend
         into  the cup;  at the point of curvature the veins also
         appear someAvhat darker in color.   If the  excavation is
1        deep, the veins seem to curl  round over the  edge,  and
         are considerably displaced, so that the prolongations of
        ' the veins on the optic disc deviate so considerably from
         those at the  retinal  edge of the  cup that they do  not
          appear to belong to  the  same vessel.  Their continua-
          tion  seems interrupted,  and this displacement of the
          two portions may equal the Avhole, or ca'cu more, of the
          diameter of the  vessel.   The extent and suddenness of
          this displacement varies with the depth of the cup.  In
          the disc, the vessels appear  indistinct  and faded,  and
          diminished in calibre; sometimes they may almost com-
          pletelv disappear, so that they can  only be traced Avith
          difficulty.  If the object lens be moved, so as to give  it
          the action  of  a  prism, a very marked parallax Avill ap-
          pear; the wliole  bottom  of the excavation shifts its posi-
          tion, and the broad scleral ring may seem to move over
          it, as if a frame were unwed over a  picture, the different 
74
GLAUCOMA.
portions of the excaA^ation, hoAveATer, shifting their indi-
vidual positions but very slightly.  The degree of the
parallax also varies according to the depth of the exca-
vation.  It is particularly AA'ell seen, stereoscopically, with
the binocular ophthalmoscope.  The peculiarity of this
parallax distinguishes, in  a marked manner, the glauco-
matous excavation from that met AAuth in atrophy of the
optic nerve; for, in such a case, as has  been already
pointed out, certain portions of the excavation may shift
their position, but the  bottom of the cup does not moA^e
as a whole.  The displacement of the vessels  in the
glaucomatous excavation will also enable us to distin-
guish betAveen this and the phvsiological form.  In the
former  the  displacement is more or less  abrupt, and
occurs at the edge of the  disc, whereas in the partial or
physiological cup the displacement or cuiwature is not
abrupt, but  slight and gradual, and  does not occur at
the edge of the disc, hut Avithin its area, at a greater or
less  distance from the margin, according to  the extent
of the excavation.   Should a glaucomatous cup super-
vene upon a physiological one, AA~e may at  the outset of
the disease sometimes observe the hvo existing together,
the vessels shewing the double displacement,—the one
at the edge of the physiological excavation and Avithin
the area of the disc, the other more abrupt and marked,
and  situated at  the  edge of the optic  disc.  But, at a
later period, the appearances of the physiological, cup
are lost, the  latter becoming involved in the glaucoma-
tous excavation.
  In the majority of cases  it is not difficult to  distin- 
 OPHTHALMOSCOPIC  SYMPTOMS OF  GLAUCOAIA.  7-5

guish the glaucomatous excavation from the others, even
before it lias reached  any considerable depth; the ex-
tent of the cup, the abrupt and precipitous edges, the
peculiar displacement  of the vessels at its margin, and
the spontaneous or easily producible arterial pulsation,
will be found the surest guides.   Where symptoms of
atrophy of the optic nerve accompany the formation of
a glaucomatous excavation, there may be some difficulty
in  ascertaining which is  the  primary affection, more
particularly in  those cases in which atrophy of the optic
nerve, dependent  upon cerebral amaurosis, has become    ,
complicated  with  inflammatory glaucoma.  In such, a
comparison of  the two eyes, and a careful and searching
examination into the history of the case, Avill generally
clear up the difficulty.  But avc must remember that in
glaucomatous  excavation  the  optic nerve often under-
goes atrophic changes and becomes very Avhite.
   At the commencement of the glaucomatous excava-
tion the cupping may  be partial, being confined to one
portion of the optic disc; but it aa ill already show the
t vpical symptoms of the pressure excavation. The optic
disc is perhaps completely surrounded by a broad scleral
zone, the veins become someAvhat dilated and abruptly
displaced at the edge  of the cupped portion, and there
is a bluish shadow at the periphery of the latter, Avhich
is  gradually shaded off to a lighter color  tOAvards the
centre.
   Von Graefe  has  pointed out the very interesting and
important fact that a glaucomatous excavation may be-
come shallower after the  operation of iridectomy, thus 
76
GLAUCOMA.
           proving that the cup depends  upon an increase in the
           intraocular pressure.  If acute inflammatory exacerba-
           tions attack an eye AAdiich has been  suffering for some
           length of time from chronic glaucoma, Avith but slight
           deterioration of vision, moderate increase of intraocular
           pressure, and but an inconsiderable excavation, the lat-
           ter may rapidly increase in size.  If iridectomy be per-
           formed some days after the acute attack, or some Aveeks
           after the first subacute symptoms, A"ou Graefe states that
           Ave may generally perceive a diminution in the depth of
           the excavation.   The cup becomes  more shallow  and
           saucer-like,  the  ends  of the vessels less  abruptly  dis-
           placed,  and their interruptions disappear, so that the
           continuation of the vessel  from the retina on to the disc
           may be traced, although it may be somewhat  curved:
           we  may notice also  that A*essels AAdiich Avere  slightly
b-'Tt-nr+'f ^curved at the edge of  the  cup, become straight again.
&od^tZP*i Prognosis of Glaucoma.—If the  disease be left to
^A^it     itself, or be treated by  inefficient remedies, the prognosis
rp   __JA is most unfavorable, as it leads sooner or later to destrnc-
3Ju**,J*v   tion of sight.  The old treatment, AAdiich consisted in
-T'Cot     leeching, cupping, mercury, opium, eve, fails, and is sure
           to fail, in staying the progress of the disease.  The acute
           inflammatory attack may subside under their use, or
           even without any treatment Avhatever ;  the inflammatory
           symptoms  may  diminish, the  refractive  media again
           become transparent, the sight restored, and the patient
           and his medical attendant may deceive themselves Avith
           the fond hope  that the  dangerous  disease has passed
           away and is cured.  But this is not so.  Sooner or later 
PROGNOSIS OF  GLAUCOAIA.
77
the'eye again becomes attacked, perhaps  by acute ex-
acerbations, perhaps by insidious chronic inflammations,
Avhich gradually lead to total and irremediable blindness.
  The  chief and most important indication in the treat-
ment is the  diminution of the  abnormally increased
intraocular pressure, for as long as this exists we cannot
hope to arrest the progress of the disease.   Paracentesis
of the  cornea has long ago been tried in the treatment
of glaucoma; but Ave know that its effect is but  tran-
sient, that it relieves the intraocular pressure for a  short
time only, for increased intraocular tension and  other
glaucomatous symptoms soon manifest themselves again.
Division of the ciliary muscle  has also been much
praised as a cure for glaucoma.  That it may tempo-
rarily relieve tension by causing the escape of the  aque-
ous, and perhaps some of the vitreous humor, cannot
be  denied;  but tapping the anterior chamber  Avill  do
the same thing.  If a  considerable  amount of vitreous
humor Aoavs off, the  tension may eA^en be permanently
diminished.  But the escape of vitreous humor in  glau-
coma is a thing to be avoided if possible,  and not  to be
desired or courted; for avc find that the loss of Autreous
humor ahvays renders the eye more prone to chronic
inflammatory affections of  the choroid, accompanied by
opacities of  the vitreous  humor, &c.   At present  no
evidence has been  brought fonvard by the  supporters
of this operation that Avould permit our placing it, e\Ten
for a moment,.side by side  Avith iridectomy in the treat-
ment of glaucoma.
  Iridectomy, on the other hand, has  been proved to 
78
GLAUCOMA.
diminish (and in the vast majority of cases permanently),
the abnormally increased intraocular  pressure.  The
admirable results  of this operation in the treatment of
glaucoma  have long admitted of no  doubt, tested and
indorsed as they have been, by most of the distinguished
oculists of Europe.
  It is not claimed for it the power of restoring sight in
all  cases of glaucoma, whatever their stage or nature
might be, but only in those cases  in Avdiich  irreparable
changes in the structures of the eye had not taken place.
The extent of the benefit which may  be expected from
iridectomy, will depend upon the stage and  form of the
disease in which it is  had recourse to.  It may be laid
down as an axiom, that the sooner the operation is per-
formed when the premonitory symptoms  haA7e become
marked and frequent, or after the  outbreak  of the  dis-
ease, the better; so that the affection has not yet had
time to produce material changes in the structures of
the organ.   Let us hoav shortly consider Avhat prognosis
may generally be giA'en of the beneficial effects  of iri-
dectomy in the various stages and  forms of glaucoma*
   The Premonitory Stage.—As long as the premonitory
symptoms only occur at distant intervals,  and the inter-
missions are complete,  the eye returning  to its normal
condition during  the intervals, Ave may postpone the
operation Avith safety.  AYe  should, however, Avarn the
patient against everything .that may produce hyperaemia
and irritation of the organ, and aa liich nuiy thus hasten
the outbreak of the disease.  He must also abstain from
excesses of every kind.  But  the system  of loAvering 
PROGNOSIS OF GLAUCOMA.           79
and  starving patients suffering from  glaucoma  is not
advisable, indeed often most injurious, more particularly
if they are elderly, and have been very free livers.
  If the intermissions are no longer complete, but there
are  only  remissions  of the symptoms;  if the periodic
obscurations, the ciliary neurosis, the iridizations, occur
at short intervals of a day or two; if the  eccentric vision
becomes impaired, or the field even contracted, the ves-
sels congested, and the  eyeball tense, it would be dan-
gerous to delay the operation any  longer.  The acute
attack is then probably imminent, and avc  cannot fore-
tell what its severity may be, and  Avhether it may not
burst forth in a very acute form, even that of glaucoma
fulminans, and  rapidly lead to such  serious lesions of
 the structures as greatly to imperil, or even to spoil, the
 integrity of the  organ before operative aid can be ob-
 tained.   But there is another reason Avhy Ave should
 not wait for the acute outbreak of the disease, for  Ave
 cannot be certain that it Avill occur, as the affection may
 gradually, and  perhaps almost imperceptibly, pass over
 into chronic glaucoma with excavation  of  the  optic
 nerve, accompanied by such a deterioration of the retina
 and other tissues, that the operation may then prove of
 but little  avail.  If iridectomy is performed during  the
 premonitory stage, Avhen the symptoms become  marked
 and the  attacks  frequent, but  before any  structural
 changes have taken place, the prognosis is most favor-
 able, the  progress of the  disease  is arrested, and  the
 sight of the eve saved.
    In acute inflammatory glaucoma the prognosis is also 
80
GLAUCOMA.
favorable if only the operation is performed sufficiently
early.  If the impairment of vision  increases very ra-
pidly, if the sight is already diminished to a mere quan-
titative perception of light, or if the visual field is much
contracted,  the  delay of the operation would be most
dangerous, and  it should  be performed  at  once.  We
may generally expect a nearly perfect result  if iridec-
tomy be had recourse  to  AAdthin a fortnight  after the
outbreak of acute glaucoma; ahvays remembering, how-
ever, that at least good  quantitative perception of light
must still be present.   But we should never voluntarily
wait so long, as there is always a risk that  during the
delay the  tissues may  undergo serious changes.  ATon
Graefe lays particular stress upon the fact that the im-
mediate necessity for the  operation depends less upon
the intensity of  the inflammatory symptoms, the  acute-
ness of the pain,  or the amount of increased tension,
than upon the state of the  Ausion.   If this be not  greatly
impaired, if the patient is  still able to read  large type,
the  operation may be postponed, if it be necessary, for
a day or two.
  In glaucoma fulminans the operation must  be performed as
soon as possible.  The structures undergo such great and
rapid changes,  that the effect of the  operation is not
perfect  eATen Avhen  it  is performed  Avithin three days
after the outbreak of the disease.
  In those cases of acute glaucoma in AAdiich the pain is
very intense, and there is much inclination  to A*omit,
but the impairment of vision is  only moderate, A^on
Graefe thinks  it  mav  be  better  to Avait a  dav  or tAvo 
             PROGNOSIS OF  GLAUCOMA.           *1

before performing iridectomy.   Here  he employs the
subcutaneous injection of morphia, gr.  | to J, in the
region of the temple, hi order to procure a good night's
rest, and to  (piiet the nervous system before operating.
But if we give chloroform  the operation need not, I
think, be postponed on  this account.  In  fact, iridec-
tomy proves the best antiphlogistic, and its beneficial
effects in acute glaucoma are  most marked and brilliant
if it be performed sufficiently early.   The relief of the
pain, often agonizing, is  generally immediate;  patients
soon fall into a tranquil and refreshing sleep, after luuv-
ing perhaps  passed  several sleepless, miserable nights;
the  inflammatory symptoms rapidly subside; the sight
is greatly improved, partly from the diminution in the
intraocular pressure, and partly from  the escape of the
turbid aqueous humor.   This improvement rapidly in-
creases during  the  first fortnight, Avhich is generally
due to the absorption of the  retinal ecchymoses Avhich
occurred  during the  operation.  The improvement of
sight reaches its maximum extent about t^o months
after the operation.   If  the  latter has been performed
sufficiently  early, vision  is  generally perfectly restored,
the  patient  being able to read the finest print (with, of
course, the  proper glasses, if  he is presbyopic), and this
improvement is, in  the  vast  majority of cases, perma-
nent.
   In the later stages of  acute  glaucoma the results of
the  operation vary.  In  such cases the prognosis Avill
depend upon the extent to A\diich degeneratiATe altera-
tions in  the tissues  have already  taken place.   The
                          8 
82
GLAUCOMA.
prognosis  may be  favorable  if the visual  field is only
moderately contracted, more particularly if it is not slit-
shaped, but the contraction concentric, the fixation cen-
tral, and vision  not very greatly impaired.  The opera-
tion will generally not only restore an  excellent and
useful amount of  vision,  but  this  improvement will
mostly be  permanent.   It is  different, howeA^er, if the
field  is greatly contracted, if the fixation  is eccentric,
vision much impaired, and the latter due to an already
considerable excavation of the optic neiwe and deterior-
ation of the retina.  Here  the prognosis must be guard-
ed, for, although the operation may do much good, the
results may sometimes not be permanent, but the sight
be gradually lost again, either through recurrence of in-
flammatory attacks, or through progressive excavation
and atrophy of the optic nerve.
  In  chronic inflammatory glaucoma the prognosis must
also be guarded.   The progress of the disease is but too
often so insidious  that  the patients do  not apply for
medical aid until very considerable changes have taken
place in the  tissues, more  particularly the optic  nerve
and retina,   Iridectomy aa ill,  hoAvever, generally  arrest
the disease, and preserve the existing amount of vision,
or even improve it.  This is particularly the case if the
fixation is still central, the sight not too much impaired,
the optic nerve not deeply excavated, and the field of
vision not slit-shaped, but  contracted laterally or con-
centrically.   In  such cases the progress of the disease
and of the structural changes is generally stayed, and
the existing  amount of vision permanently preserved. 
             PROGNOSIS  OF GLAUCOMA.           X'd

The beneficial effects of the operation are, hoAvever, far
more slowly developed than in acute glaucoma.  Months
elapse before the improArement has reached its  maxi-
mum degree, or before avc can be certain that the effect
will be permanent.  But even Avhen  the field is greatly
contracted and the fixation very eccentric, Ave  may yet
occasionally  be able to preserve a  certain amount of
sight, enough perhaps to enable the patient to  find his
Avay about.   And even this little must be looked upon
as  a great boon in comparison Avith total blindness.
But in such  cases the effect of the  operation is  some-
times only temporary,  the eye increases again in ten-
sion, the vision slowly but steadily deteriorates, leading
at last to complete loss of sight.
   In glaucoma  absolutum, in  AAdiich all sight, even the
quantitative  perception of light, is  lost, iridectomy is
never indicated except  to diminish  any inflammatory
symptoms or severe pain.  For these purposes it is to
be  performed, care being taken to impress upon the pa-
tient and his friends that the object  of the operation is
to ameliorate his sufferings, and not to restore the sight.
Should  it prove unable to  arrest the  inflammatory exa-
cerbation,  should it be folloAvcd by extensive  haemor-
rhages,  or should these occur spontaneously,  and all
sight is  lost, the  question may arise whether it would
not be better to remove the eye altogether, for fear of
the other eye sympathizing.
  I have endeavored to point out as plainly and simply
as possible the facts AAdiich should  guide  us in forming
a prognosis of the beneficial effects to be expected from 
84
GLAUCOMA.
iridectomy.   This part of the subject demands the most
earnest attention, as too slight a regard for the different
facts which should influence our prognosis of the effect
of iridectomy in glaucoma  has been one of the  chief
reasons why this  operation has proved  unsuccessful in
the hands of  some practitioners.
  How iridectomy diminishes the abnormally increased
intraocular pressure in glaucoma has not yet been de-
cided.  Various theories have  been advanced in order
to explain the  modus operandi.  Amongst other' hypo-
theses some have thought that the tension  was dimi-
nished by the excision of a considerable  portion of the
secreting (iris) surface; others, that the  removal of the
iris quite up to its ciliary insertion, and the consequent
exposure of the zonula Zinnii, facilitate  the interchange
of fluid betAveen the vitreous and aqueous humors, and
thus diminish the difference in the degree  of tension
between these humors.  We must admit, hoAvever, that
this problem has  not at  present been satisfactorily
solved.  Some  opponents of the operation apparently
reject it,  because the solution of the modus  operandi
has not yet  been found.   They  would, rather  deprive
their hapless  patient of the benefits of iridectomy, which
Avould, in all  probability,  either  restore or preserve
vision, than perform  an  operation, the effect of AA'hich
in diminishing tension, though fully pnwed, they can-
not at present satisfactorily explain.
  Some Avriters have stated that the operation of iridec-
tomy, as it is to be performed in glaucoma, is just the
same as the old operation for artificial pupil.  Nothing 
PROGNOSIS OF  GLAUCOMA.
85
could  be more erroneous.  The principle  of  the  tAvo
operations is perfectly different.   In the  old operation,
an opening Avas made in the cornea, and a small portion
of the iris excised.   In the modern operation for iridec-
tomy for glaucoma, the chief point  is to make the in-
cision in the sclerotic, or better, at the sclero-corneal
junction, and of sufficient extent to permit the  removal
of a large segment of the iris, quite  up to its ciliary at-
tachment.   The more intense the symptoms, the more
considerable the increase in the intraocular pressure,
the larger should the iridectomy be.  Many of the nega-
tive, or  only partially successful results Avhich haA-e fol-
lowed the employment of iridectomy in  glaucoma, are
undoubtedly often due to some fault in the performance
of the operation.  Either too small a portion of the iris
Avas excised, or it Avas not removed  quite up to its  cili-
ary attachment.  It is of great consequence that the iri-
dectomy should be made of sufficient size (about 5 or ^
of the Avhole circle of the iris), and that  the iris should
be removed quite up  to the ciliary attachment; for Ave
find that if both of these requirements are not  fulfilled,
the beneficial effects of the iridectomy are either greatly
diminished  or  not  permanent.   In such cases  it is,
therefore, necessary to repeat the operation, so  as to
make  the  iridectomy of the required size,  and at  the
same  time to excise the iris quite up to the margin.   If
the second  operation  be not delayed  too long it will
generally afford the best results.
  The after-treatment  of  iridectomy  is   mostly very
simple.  The intense pain of acute glaucoma generally 
86
GLAUCOMA.
disappears directly after the operation, and only a slight
feeling of uneasiness in and around the eye may remain
for a day or two.   If the  eye becomes painful  again
soon after the operation, a few leeches (better the artifi-
cial  leech of Heurteloup)  should be at  once applied
to the  temple,  and  free  after-bleeding  encouraged;
they will generally  speedily relieve  the  pain.   Some
belladonna ointment  should be rubbed o\Ter  the fore-
head.  A moist piece of lint  may be placed  over  the
eye, so  as to keep  it cool  and comfortable.   The  eye
may be examined two or  three days after the opera-
tion, care being taken that the light is not too  strong.
  If there was haemorrhage into the anterior chamber,
or loss of \dtreous humor,  it will be  better to apply a
compressive  bandage, AAdiich  greatly hastens  the  ab-
sorption of the blood.  It must, hoAvever,  be very care-
fully adjusted, otherwise it will do more harm than good.
Should  it prove too tight it must be at once someAvhat
relaxed.-  It should be removed once or  twice Avithin
the twenty-four hours, and the eye  bathed,  so  as to
remove any  discharge and permit the  escape of tears.
  Some  disadvantages AAdiich  may arise from the per-
formance of iridectomy must noAV be pointed  out;  but
they are slight indeed AAdien  compared to the inestimable
boon which  the operation affords.
  The operation upon the  one eye may accelerate  the
outbreak of  the  disease  in  the other.   The second  eye
may become affected by acute inflammatory glaucoma
Avithin a few weeks after _the  operation.   Such a rapid
succession is quite exceptional in the common  course of 
PROGNOSIS OF  GLAUCOMA.
87
inflammatory glaucoma, for the  second eye is generally
not attacked for several months, or even years, after the
first outbreak of the disease upon the other eye.  Gene-
rally in such cases the second  eye  has already shown
some  premonitory symptoms before the operation, but
the attack may even occur in a hitherto perfectly sound
eye.  This acceleration only occurs when the  operation
is employed in  the first stages of acute glaucoma.  The
patient should, therefore, always be Avarned beforehand
that the disease may perhaps affect the  second eye soon
after  the iridectomy.  But this contingency  must not
for a  moment be  allowed  to influence  our minds, and
thus induce us  to  postpone the  operation, for avc knoAV
Iioav very dangerous all  delay  is in  acute  glaucoma.
Besides, the disadvantage  of the disease breaking out
Avithin a few weeks upon  the second eye, is more than
compensated for by the fact that the patient Avill gene-
rally still be under the operator's care, and that the ope-
ration can be performed at once  Avith the greater chance
of an  admirable  result, as it Avill be employed at the
very outset.
  The incision  in the sclerotic may heal somewhat im-
perfectly.   Generally hardly any scar is left;  indeed in
some  cases no trace of the line of incision remains;  but
in others the lips  of the incision do not meet, but are
separated by a  kind of Aveb of  cicatricial fibres, AAdiich
shows a tendency to become bulged.  This structure is
composed of coarse cicatricial fibres running  across the
line of incision in  a diagonal direction, the intervening
spaces being filled up by a delicate,  transparent tissue.
The intraocular pressure causes this to vield  and bulge 
88
GLAUCOMA.
out between the fibres in the form of small vesicular or
bead-like elevations. It often gives Avay, and the aqueous
humor then escapes under the conjunctiATa, giving rise
to a bulging of the latter on the sclerotic.   This giving
Avay of the cicatricial tissue may occur seA^eral times,
even for some months after the operation; indeed Yon
Graefe  mentions cases in Avhich it took place for two
years afterAvards.  He has  termed this peculiar form of
healing " cystoid cicatrix."  If any tendency to this form
of cicatrization  shoAvs itself,  a  compressive bandage
must be at once applied and continued for some  time,
as it is the best prophylactic.   H the bulge is consider-
able it  should be removed, being first partially divided
with an extraction-knife, which will cause the escape of
the fluid and collapse of the membrane, Avhich should
then be cut off with the scissors, a compress being after-
Avards  applied.  Should suppuration have  supervened,
lukewarm fomentations should be applied, Avhich are to
be alternated afterv\rards Avith the compressive bandage.
A solution  of sulphate of atropia should be dropped in
the eye, and, in a case of purulent iritis,.rapid mercurial-
izatioft  of  the  patient.  To  escape the disadvantages
arising  from this  form of cicatrization, Arlt (Yienna)
advises that  the incision be made at the very edge of
the cornea, the sclero-corneal junction, instead of in the
sclerotic.  This, however, requires considerable skill on
the part of the operator, and  the  inexperienced  hand
aa ill find this proceeding somewhat  difficult, more par-
ticularly if the iridectomy is made upAvards or imvards;
nor is it free from danger if the anterior chamber is
extremely shallow, or the patient very restless.