With the Compliments of the Author. 
ACUTE 
GLAUCOMA 
BY \ / 
A. B. NORTON, M. D. 
Surgeon to the New York Ophthalmic Hospital; Professor of Ophthalmology and Secretary of the 
Faculty of the College of the New York Ophthalmic Hospital; Ophthalmic Surgeon to 
Protestant Half Orphan Asylum ; Chairman of the Bureau of Ophthalmology 
and Otology American Institute of Homoeopathy, etc. 
Read before the Homoeopathic Medical Society of the State of 
New York, October, 1890. 
[REPRINT FROM THE NEW ENGLAND MEDICAL 
BOSTON: 
OTIS CLAPP & SON, 
1890. ACUTE 
GLAUCOMA 
BY 
A. B. NORTON, M. D. 
Surgeon to the New York Ophthalmic Hospital; Professor of Ophthalmology and Secretary of the 
Faculty of the College of the New York Ophthalmic Hospital; Ophthalmic Surgeon to 
Protestant Half Orphan Asylum ; Chairman of the Bureau of Ophthalmology 
and Otology American Institute of Homoeopathy, etc. 
Read before the iIomceopathic Medical Society oe the State of 
New York, October, 1890. 
[REPRINT FROM THE NEW ENGLAND MEDICAL GAZETTE.] 
BOSTON: 
OTIS CLAPP & SON, 
1890. ACUTE GLAUCOMA. 
A. B. NORTON, M.D., NEW YORK CITY. 
[A'*wZ at the Semi-Annual Meeting of the Homoeopathic Medical Society of the State 
of New York, Brooklyn, October u/] 
Glaucoma is "the expression of a disturbance of equilibrium 
between secretion and excretion, with increase in the contents 
of the eye, and increased tension."-DcWccker. 
PATHOLOGY. 
Different authorities attribute glaucoma to either one of the 
three following conditions or to them all .combined, viz., ist. 
A hypersecretion of the inflamed ciliary body. 2d. Impeded 
outflow caused by pressure of the enlarged ciliary body upon 
the periphery of the iris, or 3d. From impeded outflow from 
the vitreous chamber by enlargement of the lens. Owing to 
this diversity as to the initial cause, the pathological changes 
are imperfectly understood, but the following conditions have 
been sufficiently often noticed to be placed under this heading. 
An inflammation and enlargement of the ciliary body in the 
early stages which later becomes atrophied. The iris which at 
first is slightly inflamed, becomes as the disease advances adher- 
ent to the cornea, thus partially blocking up the flow of the 
aqueous to the canal of Schlemn, and finally the iris may be- 
come atrophied. The entire surroundings of Schlemn's canal 
are infiltrated with cells. The optic nerve is at first somewhat 
inflamed, while in the advanced stages the nerve fibres are 
shrunken with hypertrophy of the intervening connective tissue, 
together with hypertrophy of the pial sheath of the optic nerve 
and the lamina cribrosa. The choroid and retina become atro- 
phied in the later stages from pressure. The retinal vessels 
become degenerated and the walls of the arteries thickened. 
The vitreous shows externally an increase of consistence, and 
internally liquefaction. 
SYMPTOMATOLOGY. 
In about one-half of all cases of glaucoma, careful inquiry will 
elicit the history of prodromal symptoms, recurring at longer or 
shorter intervals for a period sometimes extending over months ACUTE GLAUCOMA. 
4 
or years, and seeming to result from mental or physical fatigue. 
These premonitory symptoms consist of increased tension, pre- 
mature recession of the near point (a higher degree of presbyo- 
pia than the age of the patient would indicate), the appearance 
of haloes around a light and periodic dimness of vision, while in 
some cases the pupil may be dilated and sluggish, the field of 
vision contracted and the retina hyperaemic. 
These prodromal symptoms may occur from time to time, the 
intervals between the attacks becoming'shorter and shorter, un- 
til suddenly an attack of severe pain will usher in the onset of 
acute glaucoma. This is apt to occur at night and is often the 
result of some sudden excitement or great grief. An examina- 
tion will reveal a part or all of the following symptoms. The 
lids somewhat swollen may be oedematous. The conjunctiva 
reddened, possibly chemosed ; scleral vessels injected and en- 
larged, eyeball protruded, lachrymation, photophobia. Cornea 
hazy, an'd may have lost its sensitiveness to touch. Iris discol- 
ored, pupils dilated and inactive, greenish reflex from the pupil. 
Aqueous, cloudy. Anterior chamber shallow. Vision impaired. 
Eyeball hard. Field of vision contracted. An ophthalmoscopic 
examination will be difficult to make on account of the haziness 
and generally inflamed condition of the eye, but should show a 
pulsation of the retinal arteries, which are diminished in caliber, 
while the veins are large and full; excavation of the optic disc, 
and there may be extravasation of blood. 
An analysis of the chief symptoms of glaucdma proves in- 
structive as well as interesting, and hence is detailed. One of 
the first symptoms is the diminution of the range of accommo- 
dation, and although glaucoma is a disease especially found in 
elderly people in whom we would naturally have presbyopia, still 
it is much greater than should exist at that time of life, and is 
due to the increased pressure causing greater tension upon the 
choroid and suspensory ligment of the lens, thereby keeping the 
lens flatter. 
The halo around light appears like a rainbow with the colors 
of the solar spectrum, the usual arrangement being with the vio- 
let end inwards and separated from the light by a non-luminous 
space, with the red end of the spectrum outwards. This arrange- 
ment is probably due to the refraction,. because this is the 
arrangement in hyperopic eyes and is reversed in myopia, (the 
majority of cases of glaucoma occur in hyperopic eyes.) Priestly 
Smith considers the iridescent vision to be due to an exaggera- 
tion of the latent physiological chromatic aberration of the eye, 
while Bonders considers it due to a diffraction of the rays enter- 
ing the eye, owing to the opacity of the cornea. The halo seen 
is always circular in shape, and its size, and breadth of each col- 
ored ring increases the further the light is from the eye. ACUTE GLAUCOMA. 
5 
The increased tension is best determined by palpation with 
the index fingers of both hands applied to the upper lid of the 
closed eye, when the eye is turned downwards. It is customary 
to determine three grades in the variation of the tension, either 
above or below normal, and are designated by the signs T+ or - 
i, 2, 3. A marked increase in the hardness of the eye is noted 
as T+i, a greater increase but still admitting of some dimpling 
of the eyeball is noted as T+2, but an eye that admits of little 
or no impression is noted as T+3. This system of notation, 
while but relative and varying with different examiners is suf- 
ficiently accurate for all practical purposes, as the difference in 
the degree of hardness is of less importance than the demon- 
stration of the fact that hardness exists. Instruments called 
tonometers have been devised for measuring the tension, but 
experience shows that no more delicate information can be 
obtained from their use than by the tactus eruditus of the 
skilled surgeon. To determine the tension when but one eye is 
affected, it should always be compared with its fellow. The 
normal tension of the eye is noted as Tn ; this is apt to vary 
under certain conditions ; a large eye is apt to yield more than 
a small one ; the elasticity of the sclera may be increased or 
diminished by disease, and is more elastic in youth than in old 
age, and hence the tension would be greater than in an old 
person. The palpation should always be made when the eye 
is turned downwards, as it varies when made over the cornea 
from that made over the sclerotic. 
The haziness of the cornea is peculiar in that it is quite uni- 
form and most intense towards the centre of the cornea. The 
seat of the opacity is the parenchyma of the cornea, with some 
dotted appearances of the surfaces ; the opacity soon disappears 
upon the return of the tension to the normal. The cause of the 
opacity seems to be, according to the investigation of Fuchs, 
an oedema of the cornea which takes place through the nerve 
channels. Others have attributed the haziness to a disturbance 
of the nutrition of the cornea brought about by the pressure, 
and still others claim it is due to a compression of the cell ele- 
ments of the cornea, and thereby changing their relations. 
Anaesthesia of the cornea is usually present in chronic cases 
and may be found to a greater or less degree in acute cases ; 
this is due to a paralysis of the corneal nerve fibres resulting 
from the distention and pressure upon them by the increased 
amount of fluid in the nerve channels and the infiltration around 
the same. 
Dilatation of the pupil together with inactivity is usually pres- 
ent. The dilatation is not always circular, and when of an oval 
shape is believed to be due to a greater amount of adhesion of 6 
ACUTE GLAUCOMA. 
the iris to the sclera at that point. There are several theories 
as to the cause of the dilatation, none of which have been satis- 
factorily demonstrated as yet, it is most probable, however, a 
result of some vascular constriction of the vessels of the iris. 
The greenish reflex from the pupil is dependent upon the hazi- 
ness of the cornea and aqueous humor, combined with the phy- 
siological haziness of the lens. 
The shallowness of the anterior chamber is due to the in- 
creased pressure from the vitreous pushing forward the iris and 
lens. 
The haziness of the humors is a very slight, diffuse haziness, 
and is due to an increased amount of fluid in the eye. 
Dilatation of the anterior ciliary veins is the result of com- 
pression of the venae vorticosae causing a damming up of the 
blood, which then has to pass off through the anterior ciliary 
veins. 
Enlargement of the anterior ciliary arteries is due to an im- 
peded entrance of blood. 
Pulsation of retinal veins is a phenomenon occasionally found 
and is not a true pulsation, as the arterial wave cannot be trans- 
mitted through the capillaries, but is due to the external pres- 
sure upon the veins produced by the incoming arterial wave and 
transmitted to the vein through the vitreous humor. It also 
may be occasionally noticed in a normal eye when an artery 
crosses over a vein and the pulsation is then sent direct to the 
vein. 
Pulsation of the arteries of the optic disc. The physiological 
pulsation of the retinal arteries is so slight that it is not recog- 
nizable except in extremely rare instances, but it may often be 
produced in the normal eye by pressure on the globe with the 
fingers. In glaucoma, the increased tension causes a stoppage 
of the blood at the optic disc, and extra force is required to push 
it forward into the retina, which is done by the next systole of 
the heart. This pulsation disappears after an iridectomy is per- 
formed. The pain of glaucoma may be very slight or it may be 
the most intense ciliary neuralgia, and is due to pressure upon 
the ciliary nerves. 
Contraction of the field of vision, is one of the most charac- 
teristic signs of glaucoma. The contraction is first seen at the 
inner (or nasal) and later at the lower, then the upper, and lastly 
at the outer side of the field ; thus showing that the temporal 
side of the retina, then the upper and lower are first affected, 
and is probably due to the fact that there is less blood and 
nerve supply to the temporal than to the nasal side of the retina, 
and in consequence the result of increased pressure would be 
first noticed at the temporal side. It has also been shown by ACUTE GLAUCOMA. 
7 
Leber that the periphery of the retina receives its nerve supply 
from the centre of the optic disc, and as it is these central 
fibres that are first and mostly affected by the excavation of the 
disc, the contraction of the field may be the result of the exca- 
vation. 
Excavation of the optic disc. The cupping of the optic 
disc in glaucoma involves the whole of the nerve, is very abrupt 
at the edge, the vessels are lost sight of as they pass over it and 
the nerve has a greenish appearance. It is due to the increased 
pressure upon the lamina cribrosa, which gives way, is pushed 
backwards, and finally passes into an atrophic condition. 
.ETIOLOGY. 
Glaucoma averages about one per cent, of all eye cases. Its 
frequency varies somewhat in different countries, and the sex 
seems to cause little or no difference. It is especially a disease 
of advanced life and is very rarely found under the age of forty. 
Usually affects both eyes although rulably one eye is further 
advanced than the other. Chronic glaucoma is more frequently 
met with than acute, the proportion being about three to one. 
Heredity seems to have some influence. Hyperopia is found to 
exist in about 50 to 75 per cent, of the cases, and is considered 
by some to act as a cause of glaucoma owing to the excessive 
thickness and prominence of the ciliary muscle in hyperops, 
and also to the shallowness of the anterior chamber, owing 
to the more anterior position of the iris and lens in hyperops. 
Trigeminal neuralgia is in some cases a precursor of glaucoma 
and is also considered as an exciting cause, as in animals, irri- 
tation of the fifth nerve will induce a temporary increase of the 
intraocular pressure. Irritation of the fifth nerve from decayed 
teeth will cause glaucoma in some cases. Convulsions, hyste- 
ria, anxiety, excitement, grief and mental depression have been 
recorded as causing glaucoma. Gout may predispose to it. 
Climatric changes and other disorders causing a vascular turges- 
ence may cause, as intoxication, indigestion, strain of the eyes, 
sleeplessness, fever, etc. Atropine has often been the cause. 
COURSE. 
Acute glaucoma is as a rule extremely sudden in its onset and 
will often run its course to complete blindness in a few days 
and sometimes in a few hours; occasionally a case will be met 
with in which the disease has been very slow in its attack, and 
in these there has been usually no pain or inflammatory symp- 
toms directing attention to the eye, so that careless people will 
often allow of an almost total destruction of sight before seek- 
ing a physician. 8 
ACUTE GLAUCOMA. 
PROGNOSIS, 
depends upon the time it has existed before coming under treat- 
ment ; if seen within a few hours after its onset the use of eser- 
ine and our homoeopathic remedies will often cut short an attack 
and vision be restored, but even in any stage treatment either 
medicinal or operative should be expected to save the existing 
vision with more or less improvement. 
DIAGNOSIS. 
Acute glaucoma should present no especial difficulty in its 
recognition, as its symptoms are so characteristic that they 
should be appreciated by any careful observer. When you find 
an inflamed eye with dilated pupil, intense ciliary neuralgia, 
haziness of the cornea, rapid loss of vision, etc., your attention 
should at once be directed to the tension and glaucoma be sus- 
pected. In glaucoma simplex, where there is no inflammation, 
pain, etc., it may be confused with atrophy of the optic nerve, 
but the duration, tension, excavation of the disc, etc., will at 
once clear up the diagnosis. 
TREATMENT. 
This should vary according to the stage of the disease; taken 
in the premonitory stage where the patient suffers from only oc- 
casional attacks of temporary blindness, pain, etc.,'while in the 
interval the vision is good, we may look for benefit from the use 
of remedies. The only local remedy to be considered is either 
the sulphate or salycylate of eserine, which is usually employed 
in the strength of a half per cent, solution and may be instilled 
into the eye as often as every hour or even oftener, and should 
in itself speedily cut short an attack. Even in some cases of 
acute glaucoma, if used early and often, the necessity of an oper- 
ation may be postponed, if not permanently avoided. In all 
cases the use of eserine should be early, very early, hence we 
believe it best in cases once having had a premonitory attack, 
that the patient should be supplied with the eserine with direc- 
tions as to its use that no time should be lost. The action of 
the eserine is by causing contraction of the iris, it is drawn 
away from the iritic angle and the filtration passages opened, it 
also by constriction of the vascular system of the eye diminishes 
secretion. 
IRIDECTOMY. 
The introduction of this operation for the relief of glaucoma 
was empirically made by von Graefe, in 1857, and is still the 
operation for this disease. Iridectomy has been the means of ACUTE GLAUCOMA. 
9 
saving useful vision in thousands of patients who would other- 
wise have been hopelessly blind. While iridectomy is the most 
valuable remedial agency extant for this disease, still it is not 
infallible, as in some cases or forms of glaucoma even this oper- 
ation will not check the disease. In operating, the previous use 
'of eserine is advisable, as it renders less liable accidents from 
sudden relief of the tension, and it has also been advised by 
Arlt and others, that it be used in the sound eye as well, for the 
mental anxiety caused from the dread of an operation has been 
considered not infrequently to have been the cause of an attack 
in the good eye. Ether should, as a rule, be used in this opera- 
tion, as thorough anaesthesia cannot be obtained from cocaine 
in a glaucomatous eye. The incision should be made entirely 
in the sclera, the iridectomy large, and care taken that the es- 
cape of the aqueous be very gradual, and that no remnants of the 
iris remain in the wound. 
Sclerotomy has been strongly advocated by DeWecker, but it 
has not seemed to have met with the hearty support of the 
other authorities. In certain cases, especially the haemorrhagic 
form of glaucoma, sclerotomy may with advantage take the place 
of iridectomy. The writer has had the best of results from this 
operation in a few instances. Other operative procedures have 
been suggested for the relief of glaucoma, but thus far have not 
proved worthy of notice. 
REMEDIES. 
The results from the use of internal remedies in glaucoma 
seem to me somewhat problematical, chiefly because the reports 
of cases cured by remedies alone, seem sufficiently unreliable to 
warrant a question as to the diagnosis. In the majority of 
cases recorded, where no operation was made, the local use of 
eserine was employed as well as the remedy, and in consequence 
it is unscientific to give the credit to the remedy alone. 
Aconite may be of service at the commencement of an acute 
attack when we have much heat, redness and burning pain in 
the eye, together with fever and other symptoms of the drug 
generally. 
Belladonna may occasionally be indicated in severe throbbing 
pains aggravated by noise and light, together with the flushed 
face, etc. 
Bryonia is a remedy to which much credit is given. The 
eyes feel full. Sharp shooting pains through the eye and head' 
Eyes sore to touch and on moving them. Halo around the light. 
Cedron may relieve a severe shooting pain over the eye. 
Colocynth has a severe cutting pain in and around the eye 
which is relieved by pressure. ACUTE GLAUCOMA. 
10 
Gelsemium is one of our principle remedeis in this disease 
and is perhaps more frequently used than any other, and yet 
there seems to be no especial characteristic symptoms upon 
which it is given, hence we come to the conclusion that its use 
has depended upon the fact that clinically it has proven its 
value, as many favorable results are recorded from its use. 
Nux vom. has been used more in the later stages of the dis- 
ease when atrophy of the nerve is present, the morning aggra- 
vations, and the other symptoms of nux. 
Osmium is a remedy that has proven of value in the hands of 
some, and from its symptoms should be given a more thorough 
trial. It has sudden, sharp, severe pains in and around the eye. 
Dimness of vision, objects seem in a fog. Halo of various 
colors around a light. 
Phosphorous is useful after an iridectomy and in some cases 
is of value early. Halo around light. Objects appear red. 
Prunus spinosa has a very severe pain in the eye as though 
it were being pressed asunder, sharp, shooting pain in the eye 
and side of head. 
Rhododendrum has severe periodic pains in the eye aggra- 
vated before a storm. 
Spigeliawill also often relieve the sharp, shooting pains in the 
eyes and head of glaucoma. The pains are worse on motion 
and at night. Among other remedies we would note apis, eser- 
ine, mere, and thuya. 
Case. i. Mrs. B , aged fifty-six years, came to me Oct. 
io, 1885, to have her eyes examined for glasses, stating that for 
three or four months had noticed that she could not see as 
well with her glasses as formerly. Examination gave O. D. 
V= j- 1. D. O. S. dif.-j-i. D. slight 
difficulty. Has been wearing 4~3- 25D. for near vision, but now 
requires 4~4- 50D. States that she has suffered from more or 
less headaches of late, with occasionally neuralgic pains around 
the eyes. Says that at times vision seems to be very much 
poorer than usual for a day or two, and at these times cannot 
see to use the eyes at all. In answer to the question, says that 
she has noticed colors, especially red, around the light at times, 
but had supposed it was due to biliousness or something of that 
kind and had paid no attention to it. Has had sickness in the 
family for the last six months causing her a great deal of physi- 
cal fatigue as well as worry. Had been in the habit of reading 
aloud for hours at a time. Ophthalmoscopic examination re- 
veals a slight dilatation of the retinal veins, arteries normal. 
The slightest pressure on the eyeball produces a pulsation of 
the retinal arteries. The pupil slightly dilated and T-|-i ?. The 
diagnosis was made of prodromal glaucoma. The patient ACUTE GLAUCOMA. 
11 
forbidden all use of the eyes, was advised to get as much rest as 
possible, combined with moderate exercise in the fresh air, and 
placed upon a nutritious diet. Eserine sulphate one-half per 
cent, solution, was prescribed to be instilled into each eye every 
two hours and gelsemium given. 
Oct. 14th. Reported as feeling better in every way. Vision 
was found to be dif. with -f-iD. O. U. Pupil contracted. 
Tn. Headache and pain is better yet has still seen the red color 
around the light at times. The eserine was ordered to be in- 
stilled but twice a day and the remedy continued. 
Oct. 24th. Still improving, none of the colored vision since 
the last date, and other symptoms disappeared. Tn. Fiserine 
to be used once a day and the remedy repeated. 
Nov. 20th. Seems to have been all right since the last date, 
and can now read as well as ever, she thinks, with her old 
glasses, but -J-3- 75D. are clearer and easier for near vision and 
were ordered for her. Distant vision the same as Oct. 14th. 
Patient was discharged at this date without further treatment, 
except that a solution of eserine was given her with directions 
to use it upon the return of any of her symptoms and to report 
at once. 
Jan. 8, 1886. Mrs. B. returned with the report that she 
seemed to have been all right until four days ago, at which time 
the death of her daughter was followed by a return of the halo, 
dimness of vision and very severe pain in the eye which was in- 
flamed. The eserine was at once used with a relief of her 
symptoms, and now beyond a slight irritable condition of the 
eye with an occasional ill-defined halo and some headache, 
seems to be all right. She was seen a few times after this until 
wholly recovered, and since which time has had no recurrence 
of the symptoms. In this case, I believe had it not been for 
the use of the eserine together with the remedy, that this lady 
would have continued to have these premonitory attacks, until 
the sudden grief from the loss of her daughter would have re- 
sulted in an onset of acute glaucoma with probably more or less 
destruction of sight. 
Case II. Mrs. W., aged seventy years, was first seen on 
July 31st, of the present year, when she gave the following his- 
tory. Four days ago she began to have very severe pain in the 
eyes and extending into the top of the head, with poor sight in 
the right eye. Could ascertain no prodromal history. Says the 
attack seemed to have come on suddenly one night. Has one 
daughter that had glaucoma in both eyes a few years ago and 
was relieved by an iridectomy, bias been under a severe physi- 
cal and mental strain, caused by serious sickness in her family, 
which a few days later resulted fatally. Examination gave O. D. 12 
ACUTE GLAUCOMA. 
V= fingers at eight feet with +14. glass V=1V<r O. S. V=Aht 
+ 14. V-dif. Pupil dilated, cornea hazy. T-|-2. Conjunc- 
tiva congested, lachrymation. Ophthalmoscopic examination 
could not be made on account of the haziness of the cornea. 
Diagnosis of acute glaucoma was made and an iridectomy to be 
made at once was advised. In the mean time eserine sulphate 
half per cent, solution was to be instilled into the eye every 
hour and gelsemium given internally. The eye the following 
day was about the same, but vision was reduced to the counting 
of fingers at seven feet. An iridectomy was then made under 
cocaine, with no pain from the operation. This patient made a 
very quick recovery, and on August 15th, two weeks after the 
iridectomy, all inflammatory symptoms had subsided and the 
eye was apparently as well as ever, with a vision of 4 z4, 
V=and two letters of 
These two cases are merely detailed as illustrating the most 
favorable results that may be expected from the treatment of 
cases of acute glaucoma when taken early, and not as displaying 
any especial skill in the treatment or brilliancy of operation. 
In all cases of glaucoma it may be considered as favorable re- 
sults to prevent further loss of vision, than that which exists 
when the patient first comes under treatment. My records, 
like those of all oculists, will show many other favorable cases 
where the disease has been checked and vision improved, but 
not to such an extent as in these, because not seen as early. In 
the first case the operation was avoided because the disease was 
simply in the prodromal stage when first seen, and the treatment 
undoubtedly prevented an attack of acute glaucoma. The re- 
sult in that case we believe may be considered as extremely 
favorable, and yet probably no more so than should be had in 
any similar case, i. e., seen at the same early period. 
In the second case the condition had progressed to such an 
extent, that we believe had the iridectomy been delayed while 
trying other treatment, no such favorable results could have 
occurred, as I think the improvement after the operation was 
unusually good, and was simply due to the fact that the opera- 
tion was made early. 
A. B. Norton, M.D. 
752 J Vest j 4th Street, New York.