CHRONIC INTERSTITIAL OPHTHALMITIS. 
(CHRONIC SIMPLE GLAUCOMA). 
BY 
S. O. RICHEY, M.D. 
OF WASHINGTON, D. C. 
REPRINTED FROM 
ANNALS OF OPHTHALMOLOGY AND OTOLOGY, Vol. IV, No. 8, 
July, 1895. [Reprinted from the Annals of1 Ophthalmology and Otology, July, 1895.] 
CHRONIC INTERSTITIAL OPHTHALMITIS. 
(CHRONIC SIMPLE GLAUCOMA.) 
By S. O. Richey, M. D., 
OF WASHINGTON, D. C. 
THE reader of the literature of glaucoma must be 
impressed with the regional consideration given to the 
subject by all writers, since the announcement of Von 
Graefe's high-tension theory. The whole process, and its 
explanation, have been confined to the ocidar structures 
alone. In 1892,1 the writer attempted to show why glaucoma 
should be regarded as a local expression of a diathesis. One 
of the ablest advocates of the retention theory (Knies), of 
increased intra-ocular tension, Priestley Smith, thinks " that 
the high tension depends more upon an excess of blood in the 
eye than upon an excess of intra-ocular fluid." In favor of 
this is the rapid advancement of the lens and iris in acute 
glaucoma; the engorgement of the venal system; and the 
pulsation of the retinal arteries, intensified by slight pressure 
upon the globe; thus showing increased general arterial 
tension, accentuated by the added insistence to the entrance 
of blood into the eye. 
High tension of the bulb is not glaucoma, but with the other 
symptoms of glaucoma, is a localized expression of a general 
affection, which is aggravated by violent emotion, by shock, 
by excess of food and indigestion, by hunger, by loss of 
sleep, by the climacteric, by constipation, and by palpitation 
of the heart; just such disturbances as aggravate this disease 
1 Trans. American Ophthal. Society, 1892. -2- 
expressed elsewhere in the system. Such passing conditions 
do not cause glaucoma, but they precipitate the attacks when 
a predisposition already exists, and the modifications of 
tension can be more readily understood, attributed to this 
factor, than when referred to either of the most prominent 
theories of high tension, that of hypersecretion, and that of 
retention, of the intra-ocular fluids, to each of which fatal 
objections exist. For, the mechanical resistance of the eye- 
ball excludes the possibility of hypersecretion beyond the 
point at which the two would balance each other; and this 
objection stands equally against the theory of retention, as 
the secretion of fluids can not be continued beyond a certain 
fullness of the globe, which is reached more quickly if the 
secretions are retained. Also, the channels of excretion are 
often found open after the highest degree of tension, which 
takes place in the acute form of glaucoma, when the heart's 
action is usually excitedly strong, in its effort to overcome 
spasmodic contraction of the remote arterioles; a condition 
shown by the pallor of the face, followed by dilatation of the 
vessels and congestion of the face and head, with slight 
protrusion of the eyeball, and some edema of the lids, the 
condition in which we usually first see the cases. 
The bilateral character of glaucoma must be remembered, 
for in nearly all cases, sooner or later, both eyes are affected 
in this way. Attention has already been called to its close 
resemblance to another local expression of the same constitu- 
tional malady in another extremity of the body, of which 
high tension is as constant a peculiarity, and which is accepted 
as due to turgesccnce of the blood vessels. Von Graefe 
believed all forms of glaucoma to have one cause, which he 
judged to be local, increased intra-ocular tension; by which 
the attempt has been made to account for all the other phases 
of the disease, local and general, symptomatic and anatomic; 
hence, much of the confusion. 
Corneal opacity, which has by no means been ignored, as 
the reports of the vast majority of cases mention it, has not 
had due prominence, nor the importance attached to it, which 
its constant presence deserves. It is, perhaps, more constant 
than increased intra-ocular tension, which it often precedes; -3- 
and, in such instances can no more be due to increased tension 
than can disc excavation in a case in which tension has never 
been above normal. 
To take a lesson from the affection, and begin at the 
beginning, is a course which is simple and logical. Donders 
indicated the beginning when he declared chronic simple 
glaucoma to be the type of the disease. The other forms of 
glaucoma have the same origin, the cause acting with a vary- 
ing degree of force or virulence. Chronic simple glaucoma, 
the primary and uncomplicated form, is the initial localization 
of the process, from which arise all other forms and compli- 
cations. It may be so slight that its known symptoms are 
not recognizable, for the disease has often developed beyond 
the first stage, lacking most of the diagnostic symptoms, until 
an added impulse has declared them; and yet, in nearly 
every case, there is an antecedent history of headaches, called 
neuralgic, which seem to start from the occiput, like the 
headache due to breathing coal gas. To quote Foster:2 
" The dominating center of the vaso-motor nerves lies in the 
upper floor of the medulla oblongata. Stimulation of this central 
area causes contraction of all the arteries and great increase of arterial 
blood-pressure, with swelling of the veins and heart. Paralysis 
causes dilatation of the arteries and fall of blood pressure. This 
center may be excited directly and reflexly. * * * Psychical 
excitement influences this center, causing constriction of the small 
arteries. * * * A pale, cold, collapsed side of the face, 
contraction of the temporal artery like a whip-cord, dilatation of the 
pupil, and secretion of thick saliva, are sure signs of intense stimu- 
lation of the cervical sympathetic nerve, which may be brought 
about by some poisons, and by emotion. Lactic acid (1-10,000 
saline solution) passed through the blood vessels of a frog always 
enlarges their caliber (Gaskell)." 
Simple glaucoma has fairly constant features. Acute 
glaucoma is of many varieties, whose features in common are 
increased intra-ocular tension, advancement of the lens and 
iris, dilatation of the pupil, and opacity of the cornea; the 
variation depending upon the quantity of impulse, the special 
tissues involved, or upon the stage which has been reached 
by the chronic process, on which the acute form is engrafted. 
2 Foster's Text-book on Physiology, second edition, pp. 695-701. 4- 
That the acute form is propagated upon a local process 
already existing,* and more or less entangling the tissues of 
the whole organ, would seem to be supported by the irregu- 
larity and uncertainty of its development and response to 
measures adopted for its relief. The anatomic and micro- 
scopic changes noted, in the different series of glaucomatous 
eyes examined, may disagree; at times they directly contra- 
dict each other. This is not due to incapable or imperfect 
observation, though it causes great confusion in the mind of 
the student; but. to the fact that the underlying process has 
attacked a different set of tissues, or the same tissues in 
varying order; has not pursued an identical course in its 
encroachments, or has done so with diversity of power or 
rapidity. Observations have included all the tissues of the 
eyeball. In one case, at a given period of development, the 
disc will be deeply cupped, while in another the excavation 
may be shallow, if it exists; the anterior chamber may be 
shallow in one case, and deep in another; tension may be the 
same in all; or with any, or all, of these changes it may not be 
increased. The sinus of the anterior chamber may be closed 
with normal or subnormal tension3; in another, aniridia4, with 
the filtration angle closed by the rudimentary iris, and with 
increased tension. Any combination of symptoms and con- 
ditions existing together point to two processes at work: one, 
chronic and constantly progressive, the other spending itself 
in recurring attacks of more or less violence; both due to the 
same influence, which manifests itself in the two ways, in 
different degrees, in individual cases. A remote nervous 
influence manifests itself when mental perturbation excites 
an exacerbation, or when rest and quiet are followed by an 
improvement in the physical symptoms. 
Whatever other changes are observed, those of the cornea 
are nearly always present. That glaucoma may begin in the 
cornea there is hardly room for doubt, for repeated slight 
injuries to the cornea are frequently followed by acute 
glaucoma, as is shown by the interesting cases given below in 
* May not always be apparent. 
3 Schnabel, Archiv. Opkthal., Vol. VII., pp. 37, 38, 302. 
4 Collins reports several cases, Ophthal. Review, Vol. X., p. 101. -5- 
abstract; even two of Mr. Collins' three cases of aniridia 
with glaucoma were marked with initial corneal changes; one 
with central leucoma, consecutive to a perforating ulcer of 
the cornea, and a staphyloma in the ciliary region; another, 
with a corneal cicatrix and a staphyloma; the third had a 
glaucomatous cataract at 34 years of age. 
Von Graefe5 reports a woman 50 years of age, with an old eczema 
for many years, with an opaque and swollen spot with a yellow 
center, in the cornea opposite the pupil. Tension, which was not 
tested at the time of his first interview, was normal in the fourth 
and sixth week. While the corneal disease remained stationary, a 
subacute glaucoma developed. Iridectomy relieved the glaucoma 
and cured the corneal affection. 
Saemisch'1 relates a case, in which a striped opacity of the cornea 
existed previous to the development of a vesicle. When the corneal 
trouble was at its worst, acute glaucoma supervened. Iridectomy ; 
cure. 
Pooley7 observed a case of keratitis vesiculosa, ending in abso- 
lute glaucoma. A Jewess, 40 years of age, left eye. The anterior 
chamber, fundus and field normal, V. = j-g, in August. In October, 
pupil wide and immovable, anterior chamber shallow, T (r) no 
perception of light, great pain. Iridectomy reduced tension and 
relieved the pain, but did not restore vision. 
Saemisch* gives another case, blind from glaucoma, in which 
corneal vesicles developed. The eye had to be enucleated. 
Bowman reports a case of keratitis bullosa in an ill-fed woman ; 
the eye was destroyed by glaucoma. 
Landesberg9 details seven cases of keratitis bullosa, illus- 
trative in this connection: 
Case I. A child 8 years of age, in whom severe ciliary neural- 
gia, and increased intra-ocular tension, accompanied the development 
of each vesicle, which occurred at intervals of from eight to fifteen 
days. Reparation began in the deeper layers of the cornea. 
Case II. A man 38 years of age; the corneal affection pursued 
the same course for four months, ending in acute glaucoma, cured 
Archiv. f. Ophth., Vol. XV., p. 108. 
6 Berliner Klinische Wochenschrift, No. 37, p. 449. 
1 Archiv. Ophthal., Vol. IV., p. 46. 
% Handbuch der gesammten Augenheilk. 
* Archiv. Ophtkal., Vol. VI. p. 135. 6 
by iridectomy. His family physician judged this man's trouble to 
be of rheumatic* origin. 
Landesberg thinks there is such an interdependence between 
keratitis bullosa and glaucoma that every eye suffering from 
this form of corneal trouble is liable to be seized with glau- 
coma. 
Case III. In a man 22 years of age, ulceration of the cornea, 
consecutive to a foreign body (bit of metal) in the cornea, in 
October. Vesicles formed six times before the end of December, 
always announced by the presence of several small ulcerations in 
the deeper layers of the cornea, from which vertical parallel stripes 
proceeded. In four of the six attacks increase of tension was 
evident. 
Case IV. A child, four years of age, with eczema of the head, 
nose and face, had frequent attacks of keratitis bullosa; irritation, 
pinhead infiltrations in the deeper layers of the cornea, from which 
proceeded vertical stripes : ciliary neuralgia and increased intra- 
ocular tension. The eye recovered with a circumscribed leucoma. 
Case I'. A man, 36 years of age, had frequent attacks of keratitis 
bullosa (seven to fifteen days interval), with the already described 
appearance of the cornea, and increased intra ocular tension. He 
recovered with a firm cicatrix at the site of the affection. 
Case VI. A man, 71 years of age, with a like appearance and 
condition of the cornea, anterior chamber shallow, pupil moderately 
dilated, increased (?) tension. Nine days later, a vesicle; acute 
glaucoma ; iridectomy. Two weeks later, another vesicle, tension 
increased. Cured, with a circumscribed central leucoma. 
Case VII. A girl, 20 years of age, without previous trouble. The 
appearance of the cornea as in the cases described ; tension normal. 
Three weeks later, vesicles formed with increased tension. A 
number of attacks followed in the next four months, when the 
patient discontinued her visits. At the last visit, the lower part of 
the cornea was dim, and tension was normal. 
Atropin was used in all these cases, but atropin will not 
cause increase of tension in a normal eye. A disposition to 
high tension must pre-exist, and its occurrence is only pre- 
cipitated by the mydriatic; possibly by the retraction of the 
iris,t and the consequent diminished resistance to the influx 
* The identity of the cause of gout and rheumatism can not be discussed 
here. 
f Eserin acts by resisting this influx; when the vis a tergo is too great or 
too persistent, it fails. -7- 
of blood into the eye in the presence of general high arterial 
pressure, as shown by the tendency to intra-ocular hemorrhage 
if too rapid esc ipe of aqueous is permitted during glaucoma 
operations. Landesberg found the best treatment of these 
cases to be by scarification and compression. He refers to the 
very rapid onset and course of the corneal phenomena, save 
the opacity; to the increased intra-ocular tension, which is 
constantly present and in proportion to the corneal irritation; 
to the immunity of the iris and choroid, and to the second- 
ary (?) glaucoma. 
Bullous keratitis, according to Graefe, is one of the symp- 
toms of a deep morbid process. In its nature it is a herpes, 
and not of true inflammatory character; it is an expression 
of irritation at the origin, or in the course, of a nerve, an 
evidence of which we have in the neuralgic pain inseparable 
from the development of the vesicles. The periodicity of its 
recurrence (seven to fifteen days) suggests an irritation of 
chronic character, and in this is supported by its apparent 
kinship to herpes preputialis, which has the same history, 
expresses itself in the same manner, runs the same course, and 
of whose origin there is no doubt; lithemia. The vesicles 
may precede the development of glaucoma, and be of some 
prognostic import; they may develop only in the stage of 
glaucoma degeneration. Appearing thus at widely different 
stages of this disease, the two must be due to the same cause, 
and form part of the same process. 
Landesberg10 further relates two cases of ribbon-shaped 
keratitis (?) followed by glaucoma, which are not without 
interest. 
Case I. "A man, 60 years of age. When first seen, the right 
cornea was the site of a wide ribbon-shaped and continuous opacity, 
corresponding to the palpebral fissure, and extending transversely 
over the whole cornea. The opacity was a reddish-brown, and had 
an equal degree of color intensity from the margins to the center of 
the cornea. The center itself appeared whitish-gray, as if a metallic 
salt had been precipitated there. The ribbon-shaped opacity had a 
sharply defined boundary above and below." Photophobia, tension 
normal, pupil reacted sluggishly to atropia ; ophthalmoscopic exam- 
w Archiv. Ofhtkal., Vol. III., p. 65. -8- 
ination impossible. The left eye showed the first stage of the 
affection ; near the inner and outer margins of the cornea, a narrow 
opaque stripe of slightly brown shade. The opacity had the appear- 
ance of a thin stripe of brown color, laid quite superficially on either 
side of the cornea with the most delicate touch of a brush ; the 
center of the cornea clear. He rejected an iridectomy on the right. 
Three months later he returned. The right eye was hard, with a 
shallow anterior chamber, posterior synechia, perception of light, 
subconjunctival injection ; corneal opacity unchanged. Iridectomy 
with good result. Three years later, there was no irritability, tension 
normal, and the corneal opacity had a tendinous appearance, having 
gained so much as to leave a very narrow rim of clear cornea. 
Case ][. A man, 55 years of age. When he presented himself, the 
right eye was the seat of subacute glaucoma. All the phenomena of 
glaucoma were present, with numerous hemorrhagic spots in the 
retina. The cornea was affected with ribbon-shaped opacities, brown 
in color ; the corneal epithelium was smooth and shining. Iridec- 
tomy reduced the tension and cleared up the hemorrhagic spots, and 
the eye remained in a satisfactory condition, with no gain in the 
ribbon-shaped opacity, a year later. 
Hirschberg11 records a case of acute glaucoma, following the use 
of atropin, in "an apparently healthy lady," 64 years of age. He 
found "fine maculae cornearum centrales of old date and punctate 
opacities of the front surface of the cornea." Atropin was used 
after iridectomy without mischief, and H raises the question if 
glaucoma malignum belongs to the eye or the individual. 
In but few of the cases cited above was the cause suggested 
for the corneal changes observed. A notable exception was that 
in which a bit of metal excited the changes which followed: 
and yet a constitutional predisposition existed, or the forma- 
tion of vesicles would occur more frequently from foreign 
bodies in the cornea. This predisposition was probably 
"rheumatic," as suggested by the physician in another of 
the cases. 
The cornea may be measurably tolerant of injury, but just 
what persistent mechanical irritation will accomplish (if that 
alone did it) is shown by the cases reported by Dr. Hock,12 of 
Vienna, almost in the nature of an experiment. 
u Arckiv. Ophthal., Vol. IV., p. 203. 
12 Arckiv. Ofhtkal., Vol. V., p. 382. 9 
" A right eye had been lost six months previously from Egyptian 
ophthalmia, leaving a dense cicatrix in place of the cornea. Fingers 
could be counted at 2 feet, tension normal. The cornea was tatooed, 
and during the evening there was severe pain on the right side of 
the head, extending from the eye. Next day the bulb was of stony 
hardness. A former corneal fistula was reopened, and the globe 
immediately became quite soft. Tension was increased four times 
during the treatment; each time the lens was advanced, with bulging 
of the middle part of the scars. 
" The curative effect of artificial interference after each relapse 
(opening the fistula), and especially the recovery and persistence of 
normal tension after the last sitting (when the fistula was again 
reopened) proves to me that in this eye there were none of the con- 
ditions (!) predisposing to glaucoma, but that the effect was due 
entirely to the multitude of little wounds." 
" Irritation of the cornea is sufficient, without mediation, to give 
rise to glaucomatous increase of tension " (Von Graefe). Hock adds 
the case of a stout woman, 54 years of age, with palpitation of the 
heart, whose right eye had been lost a year before by glaucoma. 
"Just below the middle of the cornea was found a circular opacity 
as large as a hemp seed. Evidently there had been circumscribed 
corneal infiltration proceeding the glaucoma which had now passed 
by. Considering all the circumstances developed by the history of 
the right eye, we can hardly avoid the conclusion that here was a 
succession of corneal infiltrations, with consequent glaucoma." 
Mauthner13: A man, 71 years of age, injured by powder explosion 
a long time previously. In youth, he had some inflammation, which 
left several facets as large as a pin's head, stretching across the 
area of the pupil. Acute glaucoma of the right eye, with remarkable 
striped haziness of the corneal parenchyma; left eye hazy from an 
old parenchymatous grayish-white and striped cloudiness. Scle- 
rotomy, and the stripes became squares, so that forty-eight hours 
later the cornea looked like a chess board, the stripes giving way 
to squares, which disappeared in a week. Fourteen days after 
operation the cornea was perfectly transparent except for the old 
central facets; cured. 
Mauthner {Loe.cit.): A man, 64 years of age. Glaucoma simplex. 
Both eyes had been struck by the bowstring of a mouse trap a year 
before. Both corneae faceted ; pterygium covers the pupil of the 
right eye ; circular abrasion of the left cornea, upward and outward. 
ViLoc. Cit., Vol. VII., p. 224. -10- 
Tension moderately increased. Iridectomy of the right eye ; scle- 
rotomy of the left. Tension notably lessened. 
Mauthner (Loc. cit., p. 235) : Man, 74 years of age, with both 
corneae cloudy in distinct parenchymatous spots, which look like the 
remains of previous inflammation. Increased tension. R. V. = 
L. V. - ; F. F. free. Sclerotomy. Tension normal; spots in the 
cornea unaltered ; vision unchanged. 
Idem : Boy, 6 years of age ; blow on the head ; traumatic cataract 
of the left eye and glaucoma of the right eye. T. + 3, globe very 
large. Cornea cloudy in stripes, diameter of the cornea - - 18 mm., 
disc deeply cupped ; no pain ; no perception of light. Sclerotomy. 
T - ; fingers at 10 feet. Left cornea clear, diameter = 15 mm. 
(3 mm. less than that of the glaucomatous eye). 
Scholer14 produced glaucoma experimentally by burning the 
cornea. This was probably due to the irritation of the cornea, 
and the consequent disturbance of the normal supply of 
corneal nutritive elements or to reflex nerve influence upon 
the vaso-motor "dominating center" in the floor of the 
medulla. 
Dr. Elizabeth Sargent15 made an anatomical dissection of six eyes 
enucleated for absolute glaucoma. She found pannus of the cornea 
in all; superficial ulceration in one ; masses of round cells about 
the scleral and episcleral vessels, or in the cornea, in all; sinus of 
the anterior chamber patent in three ; closed in two ; partly open 
and partly obstructed in one ; iris atrophic, and adherent to the 
cornea, in all; Descemet's membrane pierced by inflammatory tissue 
(showing how this membrane may not always be intact), in one ; 
retina atrophic, and detached, in three ; with sclerosis of the arterial 
walls in three ; optic nerve excavated, with connective tissue hyper- 
trophy, or celular infiltration of the nerve, and atrophy of the nerve, 
in all. 
It is with difficulty that an abstract is made of such a 
detailed examination and reference is made to the paper. 
The examination was very pains-taking and offers evidence of 
the constancy with which corneal structure changes, cellular 
infiltration into the corneo-scleral region, and into the optic 
nerve and its sheath, and connective tissue hypertrophy, are 
met. These are the ultimate features of the structure changes, 
14 Berliner Phys. Gesellschaft, June 20, 1879. 
15 Ccntralb. fiir Augenheilk., December, 1884, p. 353. -11- 
for, in these cases, the malady had already run its course. To 
specify all the changes that had taken place at any particular 
period of its progress is manifestly impossible, as they can 
not be just the same in any two cases, and thus give rise to a 
diversity in the severity of the symptoms, and of the result of 
a given operation, in different cases. This examination seems 
to have been made with no purpose to support a preconceived 
theory, and is reliable. 
The examination of seven glaucomatous eyes by Birnbacher 
and Czermak 16 is of much the same character as the preced- 
ing, only it shows how persistently an accepted view possesses 
the mind. The four, first in order, had chronic inflammatory 
glaucoma; the next was one of hemorrhagic glaucoma; the 
last two, of glaucoma degeneration. 
Case I. Cornea rough and exfoliated ; T. -|- 2 ; slight edema of 
the corneal structure ; slight rupture of Bowman s membrane, and 
two or three-fold layers of spindle cells between it and the pavement 
cells ; spindle-form, and large groups of round cells, with single 
epitheloid cell forms about the episcleral veins. Cell infiltration 
into Schlemm's canal, membrane of Descemet, iris, ciliary body, 
choroid, in the sclerotico-choroid about the papilla; and masses of 
them rest in the perivascular spaces, and take on the form of young 
granulation tissue. The choroid is thinned about the papilla. An 
exuberant growth of endo-epithelium was found everywhere in the 
intervaginal space. 
Case IL Retina and choroid adherent in places. Pavement cells 
of the cornea destroyed. Bowman's membrane broken through, and 
epithelium thickened. Tn the upper layer of the corneal structure, 
and in Bowman's membrane, was found a thick, fibrous, richly 
nucleated tissue, having vessels, and penetrating the surface of the 
membrane, always at least to the extent of the area of the mem- 
brane. This tissue was found between Bowman's membrane and 
the epithelium, and in the epithelium, causing small elevations of its 
surface. Blood vessels extended to the center of the cornea, and 
along them thick rows of round and spindle cell nuclei. The canal 
of Schlemm was effaced. Fibrous connective tissue was found on 
the surface of the iris; the retina, posterior to the ora serrata was 
greatly thickened, and changed into an irregular meshwork of course 
and fine fibers; the posterior choroid thin and adherent to the 
i« Graefe's Archives, Vol. XXXII., 2, pp. 1 to 75. -12- 
sclera; nuclei of the optic nerve neuroglia increased in number; 
about the central vein a mass of granulation cells. 
Case III. Relation and position of the cells of the pavement 
epithelium of the cornea changed. No edema. Between the corneal 
epithelium and Bowman's membrane was found a tissue of coarse 
fiber bundles, and numerous long spindle-form nuclei, supplied 
sparsely with vessels, and extending over the whole cornea. Bow- 
man's membrane was broken through in many places by lines of 
spindle cells, which sink into the corneal structure. Scleral and 
epi-scleral vessels extended forward through all the layers. The 
corneo-scleral sinus was almost obliterated. In the anterior section 
of the corpiis vitrei were numerous wander-cells. 
Case IV. A hemp-seed sized sclerectasia; in the corneal epithe- 
lium were circumscribed small prominences; between Bowman's 
membrane and the epithelium the space was filled with a fine mass 
of striped network. Slight edema. 
Case F. In the corneal substance, especially near the periphery, 
and in the deeper layers was found a coarse network whose contents 
were invisible : membrane of Descemet intact. 
Case VI. Edema of the cornea, and colored nuclei. Bowman's 
membrane broken through by spindle-shaped cells. 
Case VII. A woman, 75 years of age, with high arterio-sclerosis 
and irregular heart action ; urine normal. Pericorneal injection, 
keratitis punctata, cornea uneven, anterior chamber abolished. In 
the cornea fine granulation masses were found in the epithelial 
spaces. Glaucoma pannus; spindle-celled formation in the corneal 
substance. 
It will be seen that the new-formed connective tissue was 
found in all these cases and in more than one structure, but 
especially marked and general in the cornea. 
I have herein referred to no cases of my own, for, in the 
language of Mooren, "I prefer to call attention to the state- 
ments of other observers rather than to mention cases of my 
own practice, in order to leave no room for the insinuation 
that my observations are biased in favor of a certain patho- 
logical view, thus bringing into connection with each other 
things which may be only the result of accident." 
I would say further, that, for obvious reasons, I have 
avoided reference to the " steaminess" of the cornea, which 
is always manifest in acute glaucoma, and which may, or may 
not, be due to edema of the cornea from increased intra- -13- 
ocular tension, as claimed by Fuchs17; nor to the arcus senilis 
(the early result of the affection of the corneal nutrient 
vessels, as the ulceration, or necrosis, of glaucoma degeneration 
is the late development) so often present in glaucoma; nor to 
the lenticular changes, though Rheindorf describes glaucoma 
with acute opacity of the lens, the cataract being incipient 
when the glaucoma developed. I would suggest that a closer 
relation exists than is realized, between the cause of glaucoma 
and the cause of senile cataract. 
Angelucci18 thinks that glaucoma is due to sclerosis of all 
the membranes of the eye, and especially of the walls of the 
blood vessels, as he found the arteries sclerosed, their caliber 
diminished, and the veins swollen and chronically inflamed. 
Steamy opacity of the cornea may precede increased intra- 
ocular tension, and two weeks may be required for its disap- 
pearance after tension is reduced. It is an open question, if 
fluid from the anterior chamber can penetrate to the corneal 
lamina while the membrane of Descemet remains uninjured. 
The cases referred to show true corneal tissue changes, often 
of some duration when the glaucomatous attack developed: 
stripes, brown ribbon shapes with smooth and shining corneal 
epithelium, chess-board squares, vesicles, facets and leucoma; 
which differ greatly from the possible appearance of an 
intralaminar edema, with rough and desquamating corneal 
epithelium. Fuchs and others have seen intralaminar edema, 
and it, therefore, sometimes occurs, but only when the mem- 
brane is deficient at some point, as in Sargent's case, in which 
Descemet's membrane was perforated by inflammatory tissue. 
A few cases, however, do not show that the corneal opacity is 
due to edema from high tension. It may happen so, and 
another form of deficiency in the membrane of Descemet by 
which edema of the cornea from the interior of the eye may 
occur is shown by Tartuferi,19 who, in a microscopic examina- 
tion of the corneae of a collection of glaucomatous eyes, found 
in most of them tissue changes of important character: short- 
ening of the corneal diameter by connective tissue between 
17 Graefe's Archives, Vol. XXVII., 3, p. 66. 
18 Trans. Internal. Med. Cong., London, 1883. 
19 Giorii. di R. Acad, di Med. di Torino, Nos. 5 and 6, 1882. -14- 
the epithelium and the membrane in the periphery of the 
cornea; the presence of wander-cells which are easily changed 
into connective tissue; the epithelium often separated from 
Descemet's membrane by connective tissue, etc. 
Here again we find corneal changes which are of the same 
character as those noted in the other structures of the glau- 
comatous eye, for by anatomical and microscopical examina- 
tions connective tissue has been found in the ciliary nerves20, 
muscle,21 and processes,22 the cornea,23 the iris,21 the choroid24, 
the retina,25 and the optic nerve.26 Fuchs,27 himself, from the 
dissection of the eyes of a woman, dead at 64 years of age, 
which had been iridectomized for acute glaucoma eight years 
before, in which the lainina cribrosa was only slightly convex 
backward, with atrophy of one-fourth of the optic nerve 
fibers, concludes that simple hyperplasia accounts for the 
changes in the ciliary body, as they seem to have existed 
before the glaucoma, and to have excited the attack. Con- 
nective tissue hypertrophy was most marked in the region of 
the macula. 
Schnabel28 thinks opacities of the cornea do not depend 
upon increased tension, and that they are only a symptom; 
that they are not of inflammatory character in the. sense of 
a keratitis, differing so much in appearance, some being 
dotted, some ribbon-shaped, and others diffuse, occupying the 
whole corneal tissue. Yet, some of them have as much of 
the character of inflammation as the so-called inflammatory 
glaucoma; we do not see pus associated with either. It is 
true that ulcers and abscesses of the cornea in absolute slau- 
coma, are sometimes accompanied by hypopion, but only as 
20 Hocquard, Archiv. d' Ophth., Vol. III., No. 3. 
21Stolting, Graefe's Archiv. f. Ophth., Vol. XXXIV. 
22 Brailey, Royal Lond. Ophth. Hosp. Reports, Vol. X., p. 86. 
23 Birnbacher and Czermak, Graefe"'s Archiv., Vol. XXXII, 2. 
24 Knies, Ueber das Glaucom., Archiv. f. Ophth., Vol. XXII., p. 163. 
25 Schnabel, Archiv. Ophthal., Vol. VII., p. 307. 
26 Alt, Lectures on the Human Eye, p. 156. 
27 Graefe's Archiv., Vol. XXX., p. 123. 
28 Wien. Med. Presse, 22-26. -15- 
a result of necrosis, for the glaucomatous character of the 
affection has about ceased. It would, therefore, seem proper 
to attach to the corneal changes, observed in glaucoma, their 
true importance as part of the process instead of trying to 
account for them as a result of increased tension, a superficial 
view which the evidence does not justify. If, however, they 
must be regarded as a symptom, let it be as a symptom mani- 
fested in the cornea, exposed to view, of a tissue change 
progressing elsewhere in the structure of the eye, out of 
view; in the sclerotic. The epi-scleritis, which often fore- 
shadows a glaucoma, favors this view. 
Dr. J. Kostenitch29 reports the microscopic examination of 
a case of scleritis: 
"A woman, 24 years of age, left eye blind, larger than the right 
and sensitive to pressure ; Tn. Entire cornea a white scar. Optic 
disc excavated; anterior chamber shallow; iris atrophic, and adherent 
to the cornea at its periphery. Sclera, cornea, conjunctiva, iris, 
ciliary body and vitreous affected by cellular infiltration, and occu- 
pied by numbers of wander-cells (leucocytes); detachment of the 
membrane of Descemet; disappearance of Bowman's membrane ; 
new-formed tissue in the anterior chamber, and the corpus vitrei, 
the fibrillae being well marked; thickening of the walls of the 
arteries in the ciliary body and choroid ; atrophic degeneration of 
the retina." 
This is a typical picture of glaucoma, lacking the feature of 
high intra-ocular tension. It could not be examined ophthal- 
moscopically because of the corneal opacity, and was desig- 
nated scleritis from the most prominent clinical symptom of 
active localized disturbance. 
Thus, instead of being a consequence of increased tension, 
the process which it shows to be in action is the probable 
cause of high tension, and all the other symptoms for which 
high tension has been held responsible. By reflex action 
through the vaso-motor center in the medulla oblongata, either 
from the encroachment of new connective tissue upon the 
ciliary and other nerves of the bulb, or by the excitement of 
these same nerves by an irritant contained in the blood; or by 
the direct influence of this irritant itself upon the vaso-motor 
Archiv. Ophthal., Vol. XXIII., No. 4, p. 416. -16- 
center, causing contraction of the arterioles and increased 
heart's action (palpitation) to overcome the added resistance 
to the onward motion of the blood-stream, with consequent 
high arterial pressure and venous stasis, followed by dilata- 
tion of the arterioles in reaction, and the symptoms of inflam- 
mation, is the picture presented by irritative and inflammatory 
glaucoma, with increased intra-ocular tension, often relieving 
itself without interference, though not perhaps until visual 
power is abolished. A continued high tension is due to 
persisting venous stasis, as when tension slowly falls to the 
normal, after operation. If high tension depended upon the 
occlusion of the channels of filtration, nothing but mechanical 
interference would relieve it, when once " the vicious circle " 
had been formed; but we know that passing attacks of high 
tension are frequent. Eserin is effective in emptying the 
veins by the spasmodic pressure exerted by the iris muscle in 
its efforts to contract the pupil, and hence the greater efficiency 
of the weaker solutions, as a strong solution of eserin causes 
rigid contraction* of the iris. 
High intra-ocular tension, due to the increased amount of 
blood in the vessels of the bulb, explains those cases in which 
the sinus of the anterior chamber is open, the variations of 
tension so common in irritable glaucoma, the advancement of 
the lens and iris, and the shallow anterior chamber; it accounts 
for a hardness of the globe which may at least balance the 
vis a ter go, the general blood pressure. 
"When connective tissue is being supplied, the part becomes 
inflamed and swollen, owing to the exudation of plasma. The blood 
vessels become dilated and congested, and, notwithstanding the 
slower circulation, the amount of blood (in the part) is greater. The 
blood vessels are increased owing to the formation of new ones. 
Colorless blood corpuscles pass out of the vessels and reproduce 
themselves, and many of them undergo fatty degeneration, while 
others take up nutriment and become converted into large uni- 
nucleated protoplasma cells, from which giant cells are produced."30 
Vascular disturbance is essential, but however this may be, 
connective tissue germination is wont to be accompanied by 
* Perhaps well-devised manipulation of the eyeball would relieve tension. 
I have not tried it. 
30/''os/er's Text-book on Physiology, 2d Ed., p. 405. -17- 
edema, and would be a more natural explanation of the edema 
of the cornea described by Fuchs. 
Atrophy of the choroid, appearing earliest about the optic 
nerve in which an extra growth of connective tissue is so gen- 
erally found, gives some color to Mauthner's31 view: 
" That glaucoma is a serous choroiditis by which vision is 
destroyed, and not by high intra-ocular tension ; as the worst cases 
are those in which tension never rises above the normal." 
The observation of Straub,32 that when a meridional section of 
a glaucomatous eye is made, the choroid is found to have lost 
its elasticity, and does not withdraw from the sclera as in the 
healthy eye, is offered in evidence of its sclerosis, and its 
atrophy is due, at least in part, to this condition. Ulrich 33 
regards sclerosis of the iris and infiltration as the two great 
factors in the pathogenesis of glaucoma, and Heyne34 found 
in chronic glaucoma hyaline degeneration of the vessels. 
Valude35 reported observations in four cases of hemorrhagic 
glaucoma, all of which gave evidence of arterio-sclerosis. The 
retinal vessels showed hyaline degeneration and peri-vasculitis. 
Optic nerve cupping, and closure of the iris angle were not 
always found, but dilatation of the iris and ciliary bodies was 
constant. He thinks this form of glaucoma due to an altera- 
tion of the retinal blood vessels, secondary to a disease of 
the general vascular system. Garnier36 judges the compensa- 
tory endarteritis of glaucoma to begin in degenerated hyaline, 
or connective tissue masses between the elastic membranes. 
Schnabel37 did an iridectomy on two eyes. There was nothing 
remarkable in the left; but from the right eye, with and 
behind the iris, a grayish mass prolapsed, which proved to be 
"a thin whitish membrane, pervaded by delicate straight 
and somewhat tortuous connnective tissue fibrillae, and con- 
taining a few elastic fibers, numerous larger and smaller blood 
vessels filled with red blood discs; around these a larger quan- 
31 Wien. Med. Bl., 10, p. 300. 
32 Report of Seventh International Ophth. Congress, Heidelberg, 1888. 
33 Trans. Ofhthal. Society, Heidelberg, 1884. 
34 Inaugural Dissert., Konigsburg, 1884. 
35 Trans. Ophthal. Society, Heidelberg, 1802. 
Archiv. f. Atigenheilk., Vol. XXV. 
Archiv. Ophthal., Vol. VII., p. 277. -18- 
tity of fibrillar connective tissue, in which numerous cells 
were imbedded. * * * qqie exsected iris was thinner 
than normal." Prof. Jaeger had a similar experience in 
three iridectomies, and Dr. Kerzendorfer, in one. Schnabel38 
also reports sixteen, or more, cases of glaucoma, in all of 
which he found structure changes of the cornea (a cicatrix, 
an ulceration, or a staphyloma), or sclera, and closure or 
obstruction of Schlemm's canal, though some of them did not 
show increased tension. In some instances an increase 
of connective tissue was found in the ciliary muscle; and 
atrophy of the ciliary body first observed by Brailey,39 exists 
in the great majority of cases of simple glaucoma, sometimes 
even before the glaucoma is manifest. 
While only a portion of the recorded evidence is here 
offered, it would seem sufficient to establish the claims of 
this and a preceding paper (The Disease Process, Glaucoma, 
American Jour. Med. Sci., June, 1893) that the local affection 
is a fibrosis, or connective tissue hyperplasia which, by the 
growth of the degraded tissue chokes to death the special 
functional tissues. The testimony of the eminent observers 
favors the further contention of this paper that the corneal 
appearance is not symptomatic of high tension, but is an 
organic change, shared in common with the other parts of the 
eye, especially with the sclerotic, whose density and opacity 
deny to us the observation of such slight manifestations as 
may be detected in the normally transparent cornea. 
Repeating that it is the type of the disease, primary simple 
glaucoma, the basis of the varieties, which is under considera- 
tion, and recognizing that the evidence may not be conclusive 
to some minds, perhaps, because it has been lamely presented; 
or, because, from a long acceptance of the idea that high intra- 
ocular tension and glaucoma are almost synonymous, mental 
adaptability to any other view is impossible, the paper pro- 
ceeds to the question: 
What are the factors which most probably promote con- 
nective tissue hypertrophy? 
Some of them have been named in the preceding pages. 
Archiv. Ophthal., Vol. VII., pp. 24 to 33 and 249 to 257. 
39 Royal Lond. Ophth. Hosp. Rep., Vol. IX, 2, p. 199. -19- 
The chief examples of overgrowth of connective tissue in 
organs of high functional character are interstitial hepatitis, 
interstitial nephritis and sclerosis of the spinal cord. 
Interstitial hepatitis may begin in a primary degeneration 
process, or in an irritative congestion. In either case cell 
degeneration seems to be the process, and is often preceded by 
pain and enlargement for three or four years before the estab- 
lishment of the sclerosis. It may be secondary to malarial ( ?) 
hyperemia; due to abuse of alcohol; to diffusion of degenera- 
tive processes (as others coexist) which cause hypertrophy 
first, and are not inflammatory (Handfield Jones). It has 
been seen as early as 10 years of age (Frerichs). The morbid 
process involves extravasations of blood, complete destruction 
of the secreting structures, and disintegration and partial 
absorption of the component tissues of the organ. 
Interstitial nephritis was shown in my paper, "The Disease 
Process, Glaucoma," to bear a close resemblance to glaucoma 
in its clinical history; in anatomical features it is of the same 
type. The capsule is less transparent than normal, with small 
vessels ramifying on its surface. In laying open the organ, 
the cut surfaces become convex, showing compression of its 
elements (tension). If the process is recent, the tissues are 
friable; if connective tissue overgrowth has taken place, the 
tissue is tough. There may be an accumulation of small 
round cells, and multitudes of new cells lying without their 
capsules. 
Semmola40 claims that true interstitial nephritis always 
consists in a general nutritive disorder, to which nephritis is 
secondary; beginning in diminished cutaneous respiration, 
followed by the imperfect digestion and transformation of 
albuminous foods. Palpitation of the heart, without organic 
change, conjoined with atonic or irritative dyspepsia is often 
found; observed in children as a heredity. A. Weber41 found 
heart disease in all young persons having glaucoma, and that 
iridectomy served little purpose in such cases. 
Sclerosis of the cord is a process of degeneration, though 
it may develop with some rapidity with symptoms of second- 
4(1 Gazette Medicale de Paris, 1875. 
41 Graefe's Archiv., Vol. XXIII., No. 1. -20- 
ary degeneration; it is a primary irritation, with consecutive 
connective tissue proliferation (increase of neuroglia), and 
absorption of nerve fiber. Causes: Inherited tendency, con- 
stitutional syphilis, possibly sexual excesses, chronic alcohol- 
ism, repeated over-exertion and exposure to cold, and lead 
poisoning. 
Thus, according to the most trustworthy views, connective 
tissue overgrowth is due to dirty blood; made so by imperfect 
digestion42 (to which the habitual use of alcohol contributes), 
so-called struma, syphilis,43 lithemia and lead poisoning; by 
the retention of effete matter and partially metamorphosed 
ingesta, through the inefficient action of the excretory organs. 
And glaucoma is found conjoined with albuminuria, eczema, 
palpitation of the heart, general high arterial tension, and 
constitutional syphilis; in fact with all the conditions which 
are supposed to foster the propagation of retrogressive tissue 
in organs of high functional value. Observation shows that 
excretion by the skin is very imperfect; that most of those 
who suffer from glaucoma have been accustomed to take cold 
still baths, thus increasing the contraction of the superficial 
arteries, and without the exercise which restores the circula- 
tion; and they eat too much for the waste they effect, and 
are habitually constipated. 
It is claimed that high arterial tension is never absent in 
glaucoma, is always found in vaso-renal changes; is due to a 
chronic irritant of low intensity, in action through a consider- 
able period of time; that it is the expression of Nature's 
effort to rid the circulation of the irritating element, and that 
it is always accompanied, or followed, by connective tissue 
hyperplasia. 
The term glaucoma has had no real significance since the 
invention of the ophthalmoscope, and conveys to our minds 
no idea of the disease; hence, the substitution of the term 
interstitial ophthalmitis, descriptive of the pathologic changes 
common to all the structures of the globe. 
42 "There is hardly any condition which is more certain to produce 
intense uric-acid-edemia than gastric catarrh." (Haig.) 
43 Within the past three years, I have seen two cases of simple glaucoma, 
clearly due to constitutional syphilis. ANNALS OF OPHTHALMOLOGY AND OTOLOGY 
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