GLAUCOMA 
AND IT3 
CURE BY IRIDECTOMY. 
ftrattelalefc bg 
C. A. ROBERTSON, A.M., M.D., 
Member (if the American Ophthalmdoffical Society; Honorary Member of the Massachusetts 
Medical Society ; Member qf the Albany County Medical Society, <Cc. 
i'rcm 11)e irrstul) 
OF 
TESTELIN AND WARLOMONT. 
ALBANY: 
J. MUNSELL, 82 STATE STREET. 
1866. (GrL AU COMA 
AND ITS 
CURE BY IRIDECTOMY. 
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C. A. ROBERTSOK, A.M., M.D., 
Member <ifthe American OphthdlmcHogical Society; Honorary Member of the Massachusetts 
Medical Society ; Member qf the Albany County Medical Society, dk. 
iFrottt tlje -tfretul) 
OF 
TESTELIN AND WARLOMONT. 
ALBANY: 
J. MUNSELL, 82 STATE STREET. 
1866. PREFACE. 
The following pages contain a translation from a 
recent French work, a chapter of which appeared in a 
late number of the Annales d! Ophihalmoscopique. It 
furnishes an excellent synopsis of the whole matter of 
glaucoma, its nature, aetiology, objective and subject- 
ive manifestations, its pathology and proper treatment. 
The translator presents it in an English version with 
the motive of disseminating accurate knowledge of a 
disease as yet little understood in the general profes- 
sion. Among the recent remarkable achievements 
in the diagnosis and treatment of ophthalmic disease 
and disorders of vision, none is more important than 
what has been accomplished in the diagnosis and 
method of curing glaucoma. Vague conjectures have 
yielded to precise knowledge, and a hitherto incurable 
disease, whose inevitable result was blindness, without 
even that forlorn event being always mitigated by 
relief from severe pain, has been rendered amenable to 4 
curative measures. The urgent necessity of promptness 
in order to secure the happy results of timely surgical 
interposition, renders it highly important for the intelli- 
gent physician to be able to detect the characteristic 
features of glaucoma early, lest by a mistake in diag- 
nosis the sight of his patient be hopelessly lost. 
17 Washington Avenue, 
Albany, N. Y., November, 1866. GLAUCOMA 
AND ITS 
CURE BY IRIDECTOMY. 
1. The globe of the Eye is formed of two parts, one 
containing and the other contained. The containing part 
is composed of the membranes called external, viz.: con- 
junctiva, and sclerotica, and of the membranes called inter- 
nal, viz.: choroid and retina, to which may be added the 
iris, which constitutes the anterior portion of the contain- 
ing part, whenever the communication is interrupted be- 
tween the posterior chamber and the anterior chamber. 
The part contained comprises the vitreous humor, the 
system of the crystalline lens, the uvea and the aqueous 
humor. 
When there is a perfect equilibrium between the con- 
tained part of the eye and the membranous sphere, which 
encloses it, the tension of the globe is normal and its hard- 
ness physiological: the fluids there enclosed exert upon 
the enveloping membranes a pressure by virtue of which, 
each of them lives, is nourished and exercises regularly 
the different functions which are devolved upon it. When, 
on the contrary, this equilibrium comes to be interrupted, 
either through lack or through excess of internal pressure, 
the whole organ undergoes disturbances in its nutrition, 
in its outward aspect and in its form; likewise in the play 
of its functional manifestations. 
Whenever the fluids of the eye become diminished or aug- 
mented in quantity, one of the two following results is pro- 
duced ; in the first case (atrophy), the eye becomes softened; 
in the second case (hypersecretion), its becomes hardened 6 
and tense. This is because the ocular envelope is composed 
of extremely inelastic membranes, which collapse in the 
former, and are distended in the latter state. In each state 
special phenomena of the highest interest are developed. 
In modern times, there is designated under the name of 
glaucoma a disease of the eye, characterized by a combina- 
tion or totality of the symptoms responsive to a slow or 
rapid development of excessive intra ocular pressure, be 
the cause what it may. Among these symptoms are dis- 
tinguished : tension of the globe, pulsation of the central 
artery of the retina, either spontaneous or very easily pro- 
voked, peculiar excavation of the optic papilla, anaesthesia of the 
cornea, dilatation of the pupil, flattening and turhidness of the 
anterior chamber, green color of the bottom, of the eye, sub-con- 
junctival injection and pain. All these symptoms are the 
result of abnormal internal pressure, as will be demon- 
strated further on. No one of them pertains peculiarly to 
any determined disease or, in an isolated state, would 
suffice to characterize glaucoma ; combined, on the other 
hand, they have a most precise signification. 
To Professor Yon Graffe is due this ingenious manner 
of regarding glaucomatous affections. It has enabled him 
not only to fix some order in the statement of ideas ad- 
vanced before him, concerning a pathological process in 
respect of which authors had never till then succeeded in 
making themselves understood ; but, besides, to arrive at a 
rational therapeutic treatment, whose happy results, while 
they have narrowed the still too large field of incurable 
afflictions, have raised the author to rank with the greatest 
benefactors of humanity. This fact once admitted, that in- 
ternal pressure was the cause of glaucomatous affections, 
it became necessary to find the means of arresting or re- 
moving the cause of the disorder. This means Yon Grsefe 
has had the merit of seeking, and the fortune of finding. 
Let us cast a rapid glance at the principal symptoms above 
enumerated, so far as they relate to the origination of the 
affection called “glaucomatous.” 7 
1st, Tension.—This is one of the first effects of the glau- 
comatous state, and precedes at times a great while the ex- 
plosion of an attack of glaucoma. It is, then, a symptom 
of great value, above all, if it appears without any inflam- 
matory complication. Mr.' Bowman advises that, when- 
ever a patient complains of enfeeblement of vision, the state 
of ocular tension should he learned, as this might lead di- 
rectly to the diagnosis. For that purpose it is necessary to 
employ the two index fingers laid upon the upper lid lightly 
closed: one of the fingers fixes the eye by pressing upon 
it with a proper degree of force, while the other appreciates 
the tension, or rather both of them appreciate it, while acting 
thus in concert. Mr. Bowman has found it practicable 
and useful to distinguish nine degrees of tension, and in 
order to facilitate the notation he has designated them 
by special signs: T represents tension. Tn normal ten- 
sion. The mark of interrogation (?) indicates a doubt, 
with which, in such matters, one is often forced to be con- 
tent. The numerical figures placed after the letter T indi- 
cate the degree of augmentation of tension. If the T is 
preceded by the minus sign (—) it indicates a diminution 
of tension. Examples: 
T 3. Third degree of tension, or extreme tension. A strong 
pressure of the finger cannot make an impression on the 
eye. 
T 2. Second degree or considerable tension. 
T 1. First degree. Slight, but positive augmentation of tension. 
T 1 ?. Indicates a doubt as to tension. 
Tn. Tension normal. 
— T 1 ?. Indicates a doubt as to diminution of tension. 
— T 1. First negative degree. Slight, but positive diminution 
of tension, 
— T 2. Successive degrees of diminution of tension to 
— 3, the point where the finger makes a deep impression in the 
ocular tunics. It is easier indicating this by signs than 
by words. 
Yon Grsefe has had an instrument made for the pur- 
pose of measuring the intra ocular pressure. Messieurs 
Donders and Hamer have also designed one, but these 8 
different contrivances are not sufficiently accurate to serve 
advantageously instead of the application of intelligent 
fingers. The instrument recently devised by M. Dor has 
secured a remarkable accuracy in this respect. 
2d, Pulsation of the central artery of the retina.—In the 
state of normal pressure sustained by the arteries of the 
interior of the eye, the blood courses without resistance 
through the canals which enclose it. When, on the other 
hand, resistance occurs, either on account of pressure 
made on the exterior of the organ, or of repletion of the 
globe, this same blood requires the impulse which the 
ventricular systole imparts to it, in order to overcome the 
obstacle opposing it. Hence the arterial pulse, which ap- 
pears spontaneously in glaucomatous affections, and which 
is one of their most interesting symptoms, as a manifesta- 
tion of the internal pressure. When this is only slightly 
increased, the pulsation may not be spontaneous, but then 
a very slight pressure of the finger upon the globe suffices 
to cause it. 
3d, Excavation of the optic papilla.—At the beginning, 
the cupping extends specially from the external side, but 
soon all the surface of the papilla is sunken to its border. 
The choroidal margin, deprived in great measure of its 
pigment, is more or less effaced, and appears only in an in- 
distinct manner on the sclerotic margin. The latter, on 
the other hand, represents now a broad ring, ordinarily 
yellowish, quite encompassing the optic nerve, the distinct 
periphery of which appears perfectly defined, and its 
color, changed to a greenish gray, grows darker and darker 
from the centre to the circumference. The vessels of the 
papilla, just where they reach its margin, dip into its con- 
cavity and disappear from sight in the whole extent of 
the perpendicular wall of the papillary cup which they tra- 
verse, to reappear, denovo, as soon as they have reached the 
posterior wall (or bottom) of the excavation, proving that the 
bottom of the depression is more extended than the ante- 
rior opening. This appearance is pathognomonic. The 9 
cupping of the optic papilla is admirably recognized by 
means of the binocular ophthalmoscope, and in its absence, 
by the parallax in making the lens of an ophthalmoscope act 
as a prism when placed obliquely across the axis of vision. 
The cupping does not pertain to the first phase of acute 
inflammatory glaucoma, but it is the principal sign by which 
non-inflammatory glaucoma is recognized. This effect may 
be readily conceived, if it is borne in mind that the optic 
nerve enclosed in its neurilemma is free in the envelope 
which the dura-mater furnishes it to a certain degree, as a 
viscus in a serous cavity. These relations allow the nerve 
to retreat posteriorly into its sheath before a long contin- 
ued pressure bearing on the lamina cribrosa. Ammon at- 
tributes the cupping of the optic nerve to atrophy of the 
vessels. 
4th, Ancesthesia of the cornea.— This may be slightly pro- 
nounced ; but in certain cases it is pushed to the extent of 
causing complete insensibility, so that the cornea may be 
touched without the patient shrinking. Now sensibility 
is almost always restored to this membrane from the 
moment when evacuation of the aqueous humor has caused 
even a momentary cessation of intra ocular tension, the 
evident cause of the anaesthesia, which is due to com- 
pression of the nervous branches distributed to the 
cornea. 
5th, Dilatation of the pupil.—-This is sometimes slight at 
the beginning ; but when the disease is of long standing, 
the mydriasis may attain the last limits. It is the result 
of an actual iridoplegia, caused by the compression which 
the ciliary nerves undergo. This is proved by the fact 
that the pupil does not contract under the influence of 
light, which strikes one of the eyes, as occurs in the case 
of paralysis of the retina. 
6th, Flattening and turbidness of the anterior chamber.— 
This results from the diminution of corneal convexity 
and the curved projection of the iris. The first effect is 
determined by comparison with a healthy eye by means 10 
of reflected images, or by the employment of the ophthal- 
mometer of Helmholtz. “ When the radius of curvature of 
the cornea approaches that of the sclerotic, the periphery 
of the cornea is borne forward. A change of form in the 
anterior chamber and a diminution of the coving of 
the iris are produced. How, the contrary takes place in 
glaucoma, where the iris bulges forward. It must be then 
that at the same time the cornea becomes flattened, a 
greater pressure takes place on the hyaloid than on the 
anterior chamber, a pressure which reestablishes the equili- 
brium, or, more exactly, surpasses it and projects the iris 
forward.” The cloudiness of the anterior chamber depends 
on the haziness of the aqueous humor and of the posterior 
wall of the cornea. 
7th, Greenish appearance of the fundus of the eye.—This 
only occurs in cases of very long standing, or in those 
where the symptoms are declared at the very outset with 
great intensity. In simple glaucoma it is only observed 
very late. It appears due to the turbidity of the aqueous 
humor, to the cloudiness of the posterior face of the cor- 
nea, to the normal yellowish coloration of the crystalline 
lens in patients of a certain age, exaggerated by the re- 
fraction of light passing obliquely through a largely dilated 
pupil, and lastly, but in a small proportion, to the diffused 
opacity of the hyaloid body. At a certain period the crys- 
talline becomes opake, and takes a much greater part in 
the general appearance of the fundus of the eye. A mis- 
take must not be made however, as the crystalline often 
appears cataractous, when it is only diplochromatic, a con- 
dition which Mackenzie attributes to a perversion of the 
action of nutritive vessels of the ciliary body. 
8th, Sub-conjunctival injection.—This is explained by a 
mechanical obstacle to the deep circulation produced by 
an augmentation of pressure in the region circumscribed 
by the choroid and the crystalline system ; hence the re- 
flux of blood into the superficial veins, the anterior ciliary 
veins, which empty into the veins of the muscles, and 11 
production of the vascularity — so characteristic, which 
authors have denominated “ arthritic, abdominal, glau- 
comatous.’ ’ 
9th, Pain.—In glaucomatous affections of slow progress, 
the pain is not fixed, rather extended in the brow and 
temple than in the eye, and often of intermittent character. 
When inflammation complicates them, the pain becomes 
acute, deep and agonizing, and has its principal seat in the 
eye, not without still spreading to the brow, the temples 
and the lateral regions of the nose. It is above all intense, 
when the disease is of sudden violence (glaucoma fulminans) 
and the membranes are surprised without having had 
time to allow of distension. If this ceases finally, it seems 
owing to the fact that the internal membranes become ac- 
customed to endure a pressure, whose first shock caused 
extreme suffering. Depletive agents and paracentesis comeee 
are measures which succeed best in calming it, until a 
fresh access supervenes to arouse all its first intensity. 
2. Glaucomatous affections may be complicated with 
inflammation of the deep parts of the eye, or be entirely 
free from it, at least in appearance. This inflammation 
may be the first thing, and cause at the start an acute 
glaucoma, or attack on eye already a prey to other symp- 
toms of simple glaucoma. Heuce the different forms we 
are about to examine. 
§ I. Non-inflammatory Glaucoma. 
This is the Glaucoma simplex of M. Donders, first 
described by M. Grade under the denomination of “ am- 
aurosis with cupping of the optic nerve.” Starting with 
this idea well fixed, that by glaucoma ought to he under- 
stood every affection of the eye, characterized by an 
exaggeration of intra-ocular tension, M. Donders con- 
siders as such every state in which this organ has acquired 
a certain hardness, without offering fhe least trace of 
inflammatory symptoms. With this tension coincide: the 12 
pulsation of the central artery of the retina, the excavation 
(or cupping) of the papilla, the different modifications of 
vision (flashes of light, obscurations of sight, progressive 
narrowing of the visual field), ciliary pain and anaesthesia 
of the cornea. The absence of all inflammatory symptoms 
has suggested to M. Bonders the idea that glaucoma, 
properly so called, has its origin in a neurosis of the 
secretory nerves of the eye, sustained and increased by 
the tension and traction of the iris as a result of the 
increase of the fluids secreted under the influence of this 
neurosis. Thus, from a reciprocal action, which the disease, 
once established, sets in operation, it cannot be spontane- 
ously cured. This theory rests upon the opinion that the 
secretion of the humors of the eye is subject to the influence 
of the nervous system, as has been demonstrated in respect 
of the secretion of several glands, especially the lacrymal 
gland ; an hypothesis based on the fact that paralysis of the 
trifacial nerve is often accompanied with an excessive soften- 
ing of the globe, and that section of the trifacial (in rabbits) 
is soon followed by diminution of ocular tension. 
Glaucoma simplex may appear as a result of primary 
irritation of the secretory nerves of the iris; but it may 
also be that this irritation is consecutive to the reflex 
action of the sensitive nerves of this membrane upon the 
secretory nerves, as happens whenever the iris is irritated 
by mechanical means, such as foreign bodies, disten- 
sion of the crystalline after lesions of the capsule, and 
especially the traction in cases of anterior synechia, with 
a more or less stapliylomatous condition of the cornea. 
The ocular tension is, in fact, invariably augmented under 
the influence of these different causes. 
The strain of the iris plays also an important part in 
spontaneous glaucoma, considered as resulting from pri- 
mary irritation of the secretory nerves. “Indeed,” says 
M. Bonders, “ in spontaneous glaucoma, the pressure under 
which the secretion of the vitreous body takes place, may 
be, at first, only slightly augmented, and push the crys- 13 
talline and iris forward scarcely appreciably, yet the ten- 
sion of the iris, which is the result of it, in reacting on 
the secretory nerves, is a cause of further augmentation of 
pressure, which makes the tension of the iris increase 
anew. This circle, in wThich cause produces effects, 
which, in their turn become causes, explains why glaucoma 
is not spontaneously curable.” 
Glaucoma simplex has an essentially chronic course; 
ocular tension is its first objective symptom, but often 
before that has been ascertained, or even sought for, 
patients have complained of diminution of peripheric 
vision, while central vision remains unimpaired, so that 
these persons may still read small characters, while it is 
not possible for them to find their way about. The 
dimness of vision and flashes of light which are observed 
at the beginning of the other forms of glaucoma are most 
commonly absent in this. As to tension, it may offer all 
degrees from the slightest to the greatest. The most 
essential symptom of this morbid condition is the excava- 
tion of the papilla, the appearances of which we have 
noted above (i. e.: excavation like a cup, surrounded by 
a somewhat broad, yellowish white njargin, displacement 
of the vessels, greenish grey tint of the papilla, etc.). It 
differs from the papillary retraction which is observed in 
cerebral amauroses in this, that in these the vessels are 
not displaced and diminished in volume, and in this, too, 
that the papilla, retracted and small, takes a pearly hue, 
with is not observed in the glaucomatous papilla. Finally, 
in cerebral amauroses accompanied with papillary retrac- 
tion, the spontaneous pulse is only very exceptionally 
observed, and never except in a very feeble degree. 
Glaucoma simplex may lead gradually to blindness, with- 
out patients being aware of its existence. The diagnosis 
is not difficult, the characteristic state of the papilla being 
seen, but at the very beginning, when this symptom does 
not exist, and only a slightly appreciable abnormal tension, 
coincident with a diminution of excentric vision and a 14 
certain sluggishness of the pupil, is the only indication 
on which one may depend, large experience is needed to 
recognize it with certainty. A good ophthalmotonometer* 
would here be of great assistance. 
§ II. Inflammatory Glaucoma. 
I. Acute form..— Acute glaucoma may declare itself ab- 
ruptly, coming as it were like a thunderbolt before any 
warning whatever has intimated the attack. Most fre- 
quently, however, (about seven times in ten, according to 
Von Gnefe) a series of precursory signs precede it. Some 
patients state that they have felt pains in the brow and 
temples, occurring suddenly and accompanied by temporary 
blurring of sight; the family physician pronounced them 
as due to neuralgia, administered sulphate of quinia, and 
the pains subsided to reappear some months, weeks or days 
later. If, at this time, the physical state of the globe is 
carefully examined, an abnormal tension, intermittent or 
permanent, may be recognized, which, occurring suddenly 
in eyes, that afford no mark of inflammation or of abnor- 
mal injection, is of.great diagnostic value [glaucoma sim- 
plex). At the same time presbyopia increases (the disease 
generally attacks persons who have arrived at an age where 
this is observed), iridescent rings encircle the flame of a 
candle, flashes of light shoot across the eye, objects appear 
enveloped in fog and a certain diminution of the field of 
vision is complained of. When this last symptom comes 
to be well pronounced, the images of objects near each 
other tend to be confounded, finding the way about becomes 
difficult, the dimness of vision grows much greater, and 
mydriasis is produced; while the aqueous humor acquires 
a turbid, milky aspect, behind which the pupil can no 
longer be seen in its physiological exactness and clear- 
ness. 
*Name proposed by M. Donders for instruments designed to measure 
the tension of the globe. 15 
All these symptoms may last months and years without 
the patients applying to a physician, or without the latter 
knowing how to interpret them, when suddenly, all at 
once, comes an attack, that, most frequently, is only an 
exaggeration of the different phenomena which we have 
just mentioned,’ but which is to change the scene. Under 
the influence of some accidental cause, such as a sudden 
cold, a severe tasking of the eyes with too bright a light, 
or without the occurrence of any appreciable cause, the 
patient is taken suddenly, most frequently after one or 
more sleepless nights, with a violent, intolerable pain in the 
eye, which flashes to the brow, the temples and sides of 
the nose as far as the bones of it extend. This pain, some- 
times continuous, sometimes intermittent, is often so ago- 
nizingas to extort shrieks from the sufferers, and to plunge 
them into indescribable anxiety. Vision undergoes, at the 
same time, a serious alteration ; sometimes in a few hours 
it becomes completely extinct, so that it is impossible to 
distinguish day from night. The eye is congested and suf- 
fused, and the conjunctiva raised up by serosity (chemosis). 
The pupil is widely dilated, and the iris is forced forward, 
so as to diminish the anterior chamber, which is filled 
with a turbid, foggy fluid. Sometimes the posterior sur- 
face of the cornea is also hazy, and the iris more or less 
discolored, adherent in numerous points to the anterior 
capsule of the crystalline [synechia posterior). Finally, the 
cornea is, in a measure, insensible to the touch. 
It may be that all this combination of symptoms shall 
suddenly yield at the end of a few days to the active use 
of narcotics, of atropine, of depletion, or to paracentesis 
of the cornea; sometimes this remission is quite sponta- 
neous : a certain diminution of vision, and particularly a 
narrowing of the visual field, sluggishness of the pupil, 
flattening of the anterior chamber, and discoloration of 
the iris in some places, are the only signs regaining of 
the attack, until a fresh access disturbs anew this always 
temporary remission. 16 
It is rare, during this first attack, at least, when it has 
not lasted long, that the excavation of the papilla can be 
observed. Ordinarily, it is not produced until after a num- 
ber of attacks. Besides, the turbidity of the vitreous, 
which often appears at the very beginning of the disease, and 
is one of its most constant manifestations, may hinder the 
ophthalmoscopic exploration of the fundus oculi. 
These attacks succeed, generally, at tolerably short inter- 
vals, if the disease is not at once checked in its progress 
by the most energetic measures. They are in all respects 
like the first; but, each time, the disorders which follow 
them are more serious; the visual field is more contracted 
each time; and the sight becomes more and more obscure, 
if it was not entirely abolished at the first attack. While 
the vitreous body permits exploration of the fundus oculi, 
material alterations in the deep membranes may be ob- 
served, such as ecchymoses on the retina, and spots of 
exudation, or irregular collections of pigment on the choroid 
principally in the equatorial regions, which, together with 
the papillary excavation, constitute such lesions as the fu- 
ture will be unable to repair. 
The disease which we have just described is essentially 
inflammatory; it is accompanied by febrile reaction, 
insomnia and inappetence, and, if prolonged, may have 
an unfavorable reaction on the constitution. It is now 
almost universally agreed in accordance with Von Grsefe, 
to consider it as a genuine inflammation of the choroid 
and uveal region. In support of this opinion, one may 
consider: the diffuse opacity of the vitreous body, due 
probably to a pathological exudation from the choroid, 
which, as is known, presides over the nutrition of this 
medium ; the ectases which are produced in the equatorial 
region of the choroid; the rigidity and infiltration of the 
iris, easily recognized in the strips excised from it; the 
dimness of the posterior surface of the cornea, due to 
alteration of the membrane of the aqueous humor and to 
synechise, such as are produced in serous iritis. 17 
This inflammation may be consecutive to a state of 
glaucoma simplex (precursory period) which has produced 
the internal pressure, that the intercurrent choroiditis 
operates to increase. It may, also be primary, and, at 
first, only a serous choroiditis, producing at once a 
superabundance of fluids in the eye and all the phenomena 
thence resulting. 
2. Subacute and chronic form.— The symptoms of glau- 
coma derive their character not only from the sudden 
invasion of the disease, and its extreme gravity, but from 
this fact, viz. : that the internal tension occurring in 
such a violent manner takes by surprise a coat of the eye 
little disposed to yield. The fullness of the eye is not 
moderated by a modification of the membranes, so as to 
be accommodated to the distension. The resistance they 
oppose is absolute, and hence this internal pressure, 
which expresses itself in every form, and which often 
causes irremediable disorders in a very few days. 
When instead of invading thus suddenly, the choroidal 
exudation, from which results the excess in the contained 
portion of the eye, takes place slowly, the resistance on 
the part of the internal membranes is less absolute. 
Some distension occurs in them, which, in time, produces 
staphylomatous tumors. The optic papilla is forced back- 
ward ; the internal membranes, the ciliary nerves, the 
retina conform themselves to the pressure, which harasses 
them, and the reactions from it become less active and 
lest painful. This is the condition which exists in sub- 
acute glaucoma. All the signs pertaining to acute glaucoma 
may be remarked here, but in a slighter degree, and 
others occur besides. 
When an eye is to be invaded by subacute glaucoma, the 
precursory signs (obscurations of sight, narrowing of the 
visual field, intermittent ciliary pains) increase with time. 
There is, ordinarily, no more access, properly so called, 
but all the symptoms persist without ever entirely disap- 
pearing. Exacerbations only manifest themselves which, 18 
each time, leave after them more appreciable disorders: the 
pain is continual, hut the patient gives an imperfect state- 
ment respecting it; it is often to his mind only hemicrania, 
or neuralgia, which he does not dream has any relation to 
the eye, and his mistake is almost always supported by his 
physician, who sees nothing else in the case, and does not 
hesitate to regard the disturbance of vision as an epiphee- 
nomenon, which he makes very light of and neglects. How 
many a glaucoma has been thus announced long before 
hand, which it would have been easy to arrest in it leisurely 
disorganizing course ! The state of the pupil characterizes 
it. This is widely dilated, no longer reacts to the stimulus 
of light, and its depth, instead of being a bright black, ap- 
pears of a greenish grey, dull and muddy. The cornea is 
dim, as if covered with a granular coating, and almost in- 
sensible to the touch. The arched vascularity (abdominal 
vessels) is distinct; it is composed of seven principal trunks, 
which, starting from the conjunctival cul-de-sac, reunite 
to form arches, which spread out around the cornea at a cer- 
tain distance from its periphery, like a circle excentric to it. 
The look is lifeless. The glaucomatous aspect is charac- 
teristic, and distinguished by a totality (ensemble) which 
it is easier to catch at a single glance than to describe, 
whatever pains one may take in the description. 
A more careful examination of the organ detects other 
equally important alterations : the anterior chamber has 
diminished in capacity, as much by the flattening of the 
cornea, as by the propulsion of the iris forward; the iris 
has assumed a smoky and discolored look; the aqueous 
humor is cloudy, as it were milky, a state which may 
change several times in the course of a day ; the pulsation 
of the central artery of the retina, whether spontaneous 
or excited by the slightest pressure, manifests itself, so that 
the excavation of the optic papilla, with the disposition, 
so characteristic, of the vessels, and the tension of the 
globe in all its degrees, furnish the disease with a most 
reliable and distinct criterion. 19 
It has been seen, that in acute glaucoma, there is ordin- 
arily increase of existing presbyopia, or production of 
hypermetropia. In chronic glaucoma, the contrary frequently 
takes place, and • presbyopic patients are found, obliged 
previously to use convex glasses for reading, who, either 
very suddenly, or at least in the lapse of a very short time, 
lose a great deal of their power of vision for distant objects, 
and become able to read without spectacles much nearer 
than they could before with convex glasses. Query: does 
this phenomenon depend on density, which the glaucoma- 
tous state impresses on the nucleus of the crystalline lens, 
and the increase of its refractive power ? Such is the 
opinion of Mr. Mackenzie. 
§ III. Consecutive Glaucoma. 
Every cause of disorders that may induce after them 
either a neuropathic state of the iris, or an acute or chronic 
choroiditis, and as a result, a disproportion between the 
contents of the eye and the containing membranes, may 
give existence to a glaucomatous state which, in those 
cases, is called, “consecutive.” These causes are espe- 
cially : anterior synechise with a traction of the iris 
engaged in staphylomatous cicatrices, the accidents inci- 
dental to certain operations for cataract (too free division, 
couching, etc.), serous iritis, irido-choroiditis, occlusion of 
the pupil, sclero-choroiditis posterior, etc. 
In treating of glaucoma simplex, we have shown, according 
toM.Donders, the mechanism by means of which irritations 
experienced by the iris, no matter what influence caused 
them, may establish a consecutive glaucomatous state. Ante- 
rior synechise figure at the head of these aetiological influ- 
ences. The distention of the crystalline in consequence of too 
free an incision of the capsule, its disintegration in the opera- 
tion of breaking up the cataract, and the rapid turgescene of 
the fragments, may occasion the same complication, in excit- 
ing either glaucoma simplex by the slow irritation of the iris 20 
of which the contact of theforeign bodies is the cause, or in- 
flammatory glaucoma resulting from acute irido-choroiditis. 
In each one of these cases the signsof the intra ocular pres- 
sure manifest themselves, and with them all the disorders 
which follow in consequence. Also serous iritis and irido- 
choroiditis may lead to the same result through excess of 
the secretions, which takes place in these morbid states. 
On the condition of the ocular membranes, at the mo- 
ment when the hydrophthalmic hypersecretion occurs, the 
more or less rapid development of glaucomatous accidents 
depends. If these membranes are rigid, void of all extensi- 
bility, this development will be only subordinate to the ex- 
citing cause ; if, on the contrary, they enjoy a degree of 
suppleness and the hydrophthalmia proceeds with extreme 
slowness, the progressive distention of these membranes 
will be able to recoil from many threatening accidents, or 
even preserve the eye from them. 
The slowly progressive development of tumors of malign 
nature may excite, at some moment, all the symptoms of acute 
glaucoma, and require the practice of iridectomy. A mis- 
take is excessively easy, and even inevitable, if patients 
present themselves for the first time, at the moment of at- 
tack, to physicians, who have never before seen them. The 
impossibility of examining the fundus oculi, masked by 
the opacity of the media, and the perfect identity of symp- 
toms with those of acute glaucoma, do not allow error to be 
absolutely escaped. At the most, one will sometimes 
elect, if it is learned that vision has been lost a long while, 
to excise the entire globe in cases which seem doubtful. 
This excision will then permit the removal of all the contents 
of the orbit, if the examination of the anatomical struc- 
ture, made at the moment, indicates the necessity of it. 
Mr. Hutchinson cites four cases of this kind. In three of 
them a melanotic mass, and in the fourth a cancerous 
tumor occupied the fundus oculi and compressed the optic 
nerve. The disease only revealed itself as a detachment 
of the retina, which was perfectly diagnosticated. Twice, 21 
it was necessary to proceed in search of the cerebral end of 
the optic nerve, whose section afforded suspicions traces, 
in order to excise it as high up as possible, a search of 
which the success is not quite easy on account of the blood, 
which masks everything. Mr. Hutchinson advises, in these 
circumstances that one be guided by sight rather than by 
touch, to introduce the finger deep into the orbit, and to 
use it as a director for a pair of strong toothed forceps, with 
which to draw the trunk forwards, so that it may be excised 
sufficiently high up by means of curved scissors. 
3. The different forms of glaucoma, which we have just 
passed in review, are not ordinarily as distinct as one might 
believe. Thus the passage from simple to subacute is often 
made without actual change, just in the same manner as 
the acute succeeds the latter. Hence a confusion arises, 
augmented still more by the sequences in the train of 
glaucomatous attacks. For practical purposes, Prof. Yon 
Graafe has established the following classification: 
I. Precursory period: this comprehends all the cases in 
which the periodical glaucomatous attacks do not as yet 
leave after them any trace. 
H. Glaucoma must be considered as developed, as soon 
as the periods of access are no longer separated by inter- 
vals of complete remission ; in respect to the gravity of the 
evil, it is necessary to distinguish the following varieties : 
a. No appreciable symptoms of irritation: this is the 
amaurosis with excavation of the optic nerve of Grrefe, the 
glaucoma simplex of Donders. 
b. Transient symptoms of inflammation, slight opacity of 
the fluids of the eye, diminution of the clearness of vision, 
excavation of the optic nerve; glaucoma with 
intermittent inflammation. 
c. Chronic inflammation with exacerbations; chronic 
inflammatory glaucoma. 
d. Glaucoma under the form of an acute inflammation ; 
acute inflammatory glaucoma (ophthalmia arthritica). 
This group comprises the cases of glaucoma fubninans. 22 
III. When the glaucomatous affection succeeds another 
disease of the eye, for example, a staphyloma or a sclero- 
choroiditis, it constitutes secondary or consecutive 
glaucoma. 
IY. When perception of light no longer exists, glau- 
coma may he considsred as absolute. 
Y. The various changes in the eye often observed in 
cases of glaucoma: atrophy of the iris, opacity of the 
crystalline, etc., constitute glaucomatous degeneration. 
4. Pathological Anatomy. — In glaucoma simplex, such 
as has been described by M. Donders, the optic papilla 
presents the only appreciable alterations. It is more or 
less deeply cupped ; the lamina cribrosa is shrunken back- 
wards, so as to be on the same plane, or even on a plane 
posterior to the internal sclerotic limit; this forms the 
fundus of excavation, of which, the sclerotica constitutes 
the lateral walls. The excavation, itself, is occupied partly 
by the vitreous body, partly by the debris of the intra- 
ocular extremity of the optic nerve in front of the lamina 
cribrosa. It has the form of a cup, enlarged midway, 
more narrowed at its entrance than at its fundus, which 
explains the disappearance of the vessels, that disappear 
from sight in passing along the lateral walls, in order to 
reappear when they have reached the fundus. 
At the level of the choroid the papillary cup presents a 
distinct border, slightly widened ; it is often shallower on 
the side towards the macula lutea than on the opposite side. 
When the glaucomatous pressure has persisted a long time, 
the central canal of the optic nerve itself may be dilated. 
When the disease is old and well marked, the nervous 
fascicles of the optic nerve are destroyed, and the walls of 
the central artery of the retina where it is depressed more 
or less hypertrophied, without, on that account, the trunk 
of the vessel being dilated ; on the other hand, the vessels 
which are spread on the partitions, that separate these 
bundles of nerve fibres, are a good deal dilated. 
In acute glaucoma, the changes resulting from inflamma- 23 
tion come to be superadded to this state of the papilla. The 
capillaries of the choroid are enlarged and engorged with 
blood ; sanguineous exudations of this membrane show 
themselves in the equatorial region, and irregular collec- 
tions of pigment in front of the equator, where the subjacent 
elastic lamina is thickened. In the vicinity of the ora 
serrata, the choroidal epithelium is often completely want- 
ing, which allows the naked, white sclerotic to be seen. 
The vessels of the ciliary body and of the iris are much 
dilated and distended, but their muscular elements are not 
altered. The retina is sometimes studded with hemorrha- 
gic points (most frequently after iridectomy) and atro- 
phied; generally the layer of rods and bulbs is conserved 
to a certain degree, but the internal granular layer, the 
ganglionic cells and the nervous fibres are more or less 
completely wanting, especially in front of the equator, and 
are very much changed in the posterior portion. The 
veins of the retina are dilated, while the arteries are pale 
and contracted ; their coats are affected by atheromatous 
or fatty degeneration. Staphylomatous depressions are 
observed principally in the equatorial region, behind the 
insertion of the recti muscles; the retina and the choroid 
are there somewhat atrophied. Autopsies have not yet 
permitted positive assurance respecting the state of the 
sclerotic, and authors are not agreed as to the alterations 
of which this membrane is the seat. 
According to M. Cusco, and he has based on this opinion 
a new theory respecting glaucoma, the sclerotic is affected 
in this disorder, with inflammation, accompanied with 
retraction and thickening of its tissue at the borders of the 
sclerotic limits causing deformation of the papilla. On 
the other hand it is known how often this membrane 
undergoes a manifest expansion, principally in the parts 
affected by staphyloma. 
Sometimes the vitreous body is clear and normal, the 
same as the aqueous humor: at other times these two me- 
dia are dull and milky. The vitreous body is often liqui- 24 
fied; in a case where the fluid escaping from the anterior 
chamber during an iridectomy was received in a vessel, 
the presence of pus globules was fully determined. In an- 
other, the vitreous body was found tolerably hard (the pa- 
tient, who had died of disease of the heart had been suc- 
cessfully operated on for iridectomy, six weeks before); it 
was transparent, although it presented a slightly amber tint, 
and was here and there traversed with irregular strice of a 
dirty grey hue, caused by a proliferation of large round 
cells in the nucleus. The choroid offered no other alter- 
ation than a diminution of pigment; the papilla and the 
retina were unaffected. In acute glaucoma, fluid is effused 
into the vitreous body, while in chronic glaucoma entire 
solution of this body takes place; in the latter case a 
large proportion escapes, if a puncture of the sclerotic is 
made, and in the former only a few drops ooze out. 
5. EEUology.— In vain, would one seek to-day to still 
attribute glaucoma, no matter under what form, to an 
arthritic or rheumatic cause. Every practitioner knows 
that it is found, in a multitude of cases, in persons who 
have never shown the least disposition to these morbid 
states. All that is positively known is that glaucomatous 
affections are more frequently remarked, especially in the 
acute state, among females than among males, and princi- 
pally between the ages of forty and seventy years, that is 
during the period of menstrual cessation. In some 
statistics prepared by M. Magawly, the disease is seen to 
have commenced: 
Between 10 and 20 
years in 
Men. 
1 
Women. 
0 
Total. 
1 
44 
20 
44 
30 
44 
1 
0 
1 
U 
30 
44 
40 
44 
1 
2 
3 
u 
40 
44 
50 
44 
7 
11 
18 
u 
50 
44 
60 
44 
12 
23 
35 
a 
60 
44 
70 
44 
13 
15 
28 
a 
70 
44 
80 
44 
3 
5 
8 
u 
80 
44 
90 
44 
1 
0 
1 
39 
56 
95 
The total number of patients received at the ophthalmic 25 
hospital was 1,943; 1,070 men, 873 women. It is a signifi- 
cant fact that 3.64 per cent of glaucoma was found among 
men, and 6.41 among women. Further, it is ascertained 
from this same statistical table that of 158 eyes attacked by 
glaucoma, 12 were of an acute character, and that 10 of these 
eyes belonged to women, 2 only to men. On the other 
hand, of 11 cases of glaucoma simplex 10 belonged to men, 
1 only to women. Such a difference would not have been 
by chance, as the author sensibly remarks. 
6. Prognosis.— The results afforded by iridectomy are 
so constant when the indications have been well appre- 
hended, that it may be said, almost absolutely, that the 
prognosis of glaucoma is completely subordinate to the 
way in which it is treated. Left to itself, glaucoma leads 
fatally to blindness, sooner or later. Properly treated 
from the beginning, it may almost be said that it is only a 
disease of medium gravity. We have seen patients, 
siezed with acute glaucoma, having lost, amidst poignant 
sufferings, almost all sensation of light, recover, by means 
of an iridectomy, in less than a fortnight, sufficient vision 
to read the smallest type, and the new pupil, concealed by 
the superior lid, no longer served to recall the remem- 
brance of this cruel pain. We have seen others, who 
were in the same circumstances, treated by antiphlogistics, 
chloroform, revulsives, autiperiodics, arrive at total blind- 
ness, spite of having received and followed the advice of 
distinguished practitioners. In a single word, one is 
authorized to blend the prognosis of glaucoma with that 
of the iridectomy applied to its treatment, 
7. Hypotheses as to the causes influencing the development of 
glaucoma.—It has been remarked above (p. 16) that Prof. 
Von Gfrsefe considers glaucoma as being always under the 
influence of inflammatory action, having its principle seat 
in the choroid and uveal tract. M. Donders, on the con- 
trary, refers it to a neurosis of the ciliary nerves, and to 
the action of this on the secretory nerves of the iris (p. 
12). It may be said that these two are the only opinions 26 
which are really at issue. M. Magni also thinks that the 
ciliary nerves play an important part in glaucoma, but he 
attributes this to a primary, or progressive atrophy of these 
nerves, and not to irritation as does M. Bonders. This 
hypothesis may have some value in respect of chronic or 
simple primary glaucoma; but so far as it relates to acute 
glaucoma, it does not appear tenable. The author of it, 
moreover, implies this, in citing, in order to support it, 
the slow progress of the disease. We shall say the same 
of the theory of M. Cusco, who places the cause of glau- 
coma in the progressive retraction of the inflamed sclerotic. 
In fact, as is known, acute glaucoma does not afford the 
least perceptible trace of inflammation. Perhaps it is not 
quite the same in chronic glaucoma, where the sclerotic 
undergoes manifest changes, but which generally appear 
to be consecutive. According to M. Cusco, these changes 
are owing to inflammation, acute or chronic, having its seat 
in the fibrous coat, the development of which is most fre- 
quently connected with the existence of a constitutional 
malady, and occasions retraction of its tissue, (a mechani- 
cal cause of all the signs of intra-ocular compression) and 
plastic infiltration of its blastema, the result of which is an 
increase of its thickness. It may be objected to this way 
of viewing things, that chronic sclerotitis, especially when 
complicated with choroiditis, much rather occasions expan- 
sion and softening, than retraction of tissue (sclero-choroi- 
ditis posterior) and that it is besides always partial. How- 
ever, the opinion of M. Cusco has its adherents ; thus M. 
Coccius considers likewise the retraction of the sclerotic 
as the cause of glaucoma. 
Mr. Hancock, like M. Cusco, thinks that glaucoma is 
due to gout or rheumatism, which affects the muscular 
fibres and the blood vessels of the ocular globe. He sup- 
poses that in the first or acute stage the ciliary muscle 
possesses excessive action, while later this muscle atrophies 
and thus looses its elasticity. He believes that, in conse- 
quence of special connections which exist between this 27 
muscle and the vessels of the choroid, the circulation in 
the vessels is hindered ; that their coats being already 
weakened by the antecedent malady yield, forming sacci- 
form dilatations, rupturing or becoming varicose, and 
that these morbid changes determine the increase of 
intra-ocular pressure. His operation was suggested by 
this idea, that the ciliary muscle girts the eye as a band, 
and that it hinders the circulation, as a cord around a 
muscle does. 
The opinion of Mr. Hancock is only supported by mere 
hypothesis, and seems to have no other object than to 
justify the pretended section of the ciliary muscle. Daily 
experience demonstrates that glaucoma is not more fre- 
quent in the gouty and rheumatic than in others. Ho 
one has observed the atrophy of the ciliary muscle, and it 
is impossible to understand how an atrophied muscle 
should compress the vessels more than in its healthy state. 
Moreover, if no one has observed this atrophy of the 
ciliary muscle in glaucomatous cases, it has, on the contrary, 
been observed by all who have examined for it in the eyes 
of the aged. It is now known that persons, who present 
the arcus senilis, have the ciliary muscles to a certain extent 
atrophied and affected by fatty degeneration. It is a result 
of the progress of age, and sooner or later it affects every 
one. Presbyopia, to mention it by the way, is the first 
symptom of the commencing ill, and yet the immense 
majority of the subjects of it never have glaucoma. 
Mr. Wharton Jones thinks that the fundamental morbid 
condition of glaucoma consists of a strong venous con- 
gestion, affecting particularly the retina and choroid. 
The arteries of the retina are contracted and pale, while 
the veins are turgid and dark. The vessels of the white of 
the eye are in the same state, the veins corresponding to 
the recti muscles are engorged and tortuous, while the 
arteries are scarcely visible. In examining with a micro- 
scope the retina of a glaucomatous eye, he found the 
venous radicles to present varicose dilatations and am- 28 
pullee. It has been said that the capillaries are varicose, 
but he did not find them so ; and in the whole of his 
researches upon the state of the blood vessels, he did not 
remember to have ever seen any thing which deserved the 
name of varicose condition of the capillaries. In glau- 
coma, the congestion of the choroid and of the retina 
occasions a certain degree of intra-ocular distention ; then, 
in consequence of the persistence of the congestion, an 
increase of the fluid of the cells of the vitreous body takes 
place, which determines a corresponding increase of the 
intra-ocular distention, a distention which has its principal 
seat in the posterior segment of the ocular globe. One of 
the effects of this distention is that the iris and crystalline 
are pushed forwards, and that the chambers of the aqueous 
humor are diminished in depth. Another of these effects 
appears to be the excavation of the optic papilla. Iridec- 
tomy in glaucoma causes the venous intra-ocular conges- 
tion to cease, the circulation of blood becoming more free 
in the eye, absorption of the excess of fluid in the cells of 
the vitreous body is favored, so that the intra-ocular dis- 
tention diminishes. The pain is removed and the retina, 
at least, if the combined action of congestion and pressure 
has not produced any material structural alteration, may 
assume again its functions and vision reappear. The 
excision of a bit of iris and the evacuation of a small 
quantity of blood, make the congestion of the choroid 
and retina cease, and promote the circulation as a conse- 
quence. Scarifications of the palpebral conjunctiva ope- 
rate in the same way, in exercising a favorable action, 
when this membrane is the seat of strong inflammatory 
congestion. It is not only the loss of blood which does 
good, for this is insignificant, but it suffices also to empty 
certain vessels in order to allow the reestablishment of 
the general circulation and restore its usual activity. 
M. A. Desmarres divides all cases of glaucoma into 
anterior and 'posterior, based on the different systems of cir- 
culation in the eye, the anterior and posterior circulation. 29 
Anterior, or acute glaucoma manifests itself in the anterior 
part of the vascular membrane of the eye; the iris and 
ciliary body are the only parts at first seized. All the 
symptoms are much complained of, the pains are sharp, 
inasmuch as the sensibility of the ciliary body and of the 
iris are infinitely greater than that of the posterior por- 
tion of the choroid. Acute glaucoma, through its duration 
alonej passes on to the chronic state. Posterior, or chronic 
glaucoma manifests itself in the posterior portion of the 
choroid. It invades at once the entire vascular system of 
the posterior hemisphere, compresses from the first the 
optic nerve and produces its excavation. It only communi- 
cates with the anterior portions of the vascular membranes, 
when the primary disorders have induced atrophy of the 
papilla. It begins slowly, without pain, without changes 
in the iris or in the pupil, and without diminution of the 
anterior chamber. The absence of a great part of the 
essential symptoms of glaucoma can only be explained, 
according to M. Desmarres, by the seat of the disease 
being in the posterior portion of the choroid. This mem- 
brane being less sensitive suffers less from neuralgia ; the 
anterior ciliary nerves are not compressed in posterior 
glaucoma, and therefore the pupil conserves its normal 
size, and the iris does not cease to perform its functions. 
Chronic glaucoma does not stop any more than acute 
glaucoma where it took its origin ; and as the first proceeds 
from the anterior towards the posterior portion of the 
choroid, and becomes transformed into a posterior glauco- 
ma, in the same manner, the chronic glaucoma advances 
forward, little by little, invades the ciliary processes and 
iris, and may induce all the signs of acute, or anterior 
glaucoma. 
M. A. Desmarres believes that iridectomy can have, and 
should properly be expected to have, an influence only 
upon that portion of the choroidal vessels, which has 
direct communication with the vessels of the iris. Daily 
experience demonstrates, in fact, that the operation sue- 30 
ceeds in acute glaucoma especially during the first fort- 
night, when the disease is localized in the anterior 
hemisphere; but as soon as the glaucoma has passed 
beyond this limit, and the acute and anterior transforms 
itself into a chronic glaucoma, iridectomy is then of little 
use. 
8. Treatment of glaucoma.— The fact, so well established 
by M. Yon Grade, of the existence of an exaggerated in- 
tra-ocular pressure as the cause of the glaucomatous 
state, being once admitted, the only therapeutic indication 
should be; to seek the proper means of reducing this ex- 
cessive tension to its normal condition. If, this physiolo- 
gical tension being restored, the symptoms which before 
existed disappear, the strongest confirmation results of the 
prevision which attributed the symptoms, a priori, to an 
understood cause. The result has shown the correctness 
of the views of the illustrious Berlin professor. Not only 
did the means extolled by him result in abolishing the 
internal pressure, but it restored the organ, which was the 
seat of it, to its functional conditions, nearly as in the 
healthy state, whenever it was seasonably applied. M. 
Yon Grsefe has then the merit of having discovered, at 
the same time, both the nature of glaucoma and the 
means of curing it. 
This means is iridectomy. W e are not to demand of the 
discoverer, in what manner nature proceeds in order to 
accommodate herself to such an operation, and to find in 
it the elements of cure, which experience has recognized ; 
we must accept the fact without exacting the explanation, 
too happy that the fact is henceforth incontestable. M. 
Yon Grsefe hazards, however, the following hypothesis, 
viz.: 1st, By diminishing the secreting surface of the iris, 
the quantity of fluid secreted is diminished; 2d, The 
excision of a portion of the iris, by relaxing the tension 
of the choroid, induces a diminution of the pressure 
through a modification of the muscles; 3d, Iridectomy 
acts strongly upon the circulation of the eye, and may 31 
thus diminish the power of the secretions acting there. M. 
Bonders explains the modus opera.ndi of iridectomy by the 
cessation of the tension, of which the iris was the seat, 
tension, through influence of which the secretory nerves of 
the iris were excited to exaggerate the products of their 
secretion, whence resulted a fresh augmentation of this 
same tension; this chain of causes and effects is thus 
broken by the operation. Finally, according to Mr. Hart, 
the benefits of iridectomy result from the arrest of the 
hypersecretion, in consequence of the excision of nervous 
plexuses and glanglions of the ciliary body. 
Whatever may be the different explanations, Gracfe did 
not draw the germ of his operation from the ingenious 
promptings of his own mind, but derived it from obser- 
vation. He had often observed in cases of partial staphy- 
loma of the cornea and sclerotica, when iridectomy was 
practiced for the purpose of replacing the defective pupil, 
that the staphyloma disappeared spontaneously without 
having to be removed. Repeated experiments upon the 
healthy eyes of animals, from which large pieces of the 
iris were removed, gave the same result: the eyes became 
softer. 
Besides these, also, a certain diminution of consistence 
of the eye followed the operation for artificial pupil in 
patients affected with leucoma complicated with anterior 
synechia. There was no need of more to put him on the 
track. 
Iridectomy has become henceforth the means, par excel- 
lence, for the treatment of glaucoma. To argue in support 
of this statement would now be superfluous. It remains 
to examine carefully the indications and contraindications 
of the-operation. It is, doubtless, from not having done 
this with sufficient care, that authors, in other respects to 
be recommended, have denied the importance of this new 
therapeutic measure. 
A. Aon-inflammatory glaucoma.— When one eye only is 
attacked, it is rare that the physician is consulted ; the 32 
functional disturbances are scarcely perceived by tbe 
patient, and if he should happen to perceive them and to 
complain of them, it is not with the thought of recourse to 
a severe treatment, and it would not be well to advise an 
operation under such circumstances. But, if the ocular 
tension is manifest, the papillary excavation deep, and the 
contracting of the visual field progressive, the indication 
for the operation exists, and it is the duty of the surgeon 
to propose it, as the only means of arresting the invading 
march of the disease. 
If both eyes are attacked, the indication is much more 
urgent, and the benefits to result from the operation more 
appreciable. Besides, it must not be forgotten that, when 
well performed, iridectomy is a harmless enough operation, 
and that, if care is taken to form the new pupil under the 
upper lid, it can never cause either discomfort or de- 
formity. 
B. Inflammatory glaucoma,— a.— Acute form.— What we 
have just said respecting simple glaucoma applies to the 
initial, or precursory stage of inflammatory glaucoma (with- 
out papillary excavation), on the condition always that the 
symptoms be sufficiently pronounced and repeat themselves 
at short intervals. In other cases it may be well to tempo- 
rize, especially if only one eye is bad. All procrastination, 
on the contrary, is forbidden when the second eye is 
involved. The operation should be done then as soon as 
the precursory symptoms appear, especially if they are 
accompanied with a marked dimness of vision, and it is 
all the more necessary, since in the prodromic period 
iridectomy has most chance of success. 
The/ diagnosis of an attack of acute glaucoma being 
once determined, there are rarely any serious difficulties 
in the way. The operation should be done as soon as 
possible, without the least hesitation, and without losing 
a single moment, under any pretext whatsoever. Procras- 
tination in cases of this nature is always a serious mistake, 
for its result may be to let-the disease produce disorders,  33 
in curing which, the operation would at a later period be 
powerless. “Every hour now is precarious,” says Mr. 
Bowman, “the urgency of the operation is indicated by the 
intensity of the inflammation. The loss of vision depends 
then, in part, upon the presence of the inflammatory pro- 
ducts in the substance of the retina and in front of this 
membrane, in part, upon the alteration of circulation in 
the nervous substance and the considerable pressure to 
which it is subjected. The operation causes all these 
unfavorable conditions to cease: the inflammation suc- 
cumbs, its products are generally absorbed, and often very 
rapidly; besides, the eye is relieved of extreme glaucoma- 
tous tension, which probably preceded the beginning of 
the acute inflammatory attack, and which constituted 
originally the essence of the disease.” Iridectomy is or- 
dinarily followed, from the first instant, with a healthy ex- 
pansion, the ocular tension ceases and the pain, excruci- 
ating until then, disappears as if by enchantment. Often, 
at the evening visit, patients say they are in paradise, so 
great is their relief. 
One is not always fortunate enough to be consulted at 
the beginning of such an attack; frequently the disease 
has existed days, weeks and months; the patients are 
greatly reduced by want of sleep and pain, and can 
scarcely distinguish light from darkness. In these 
cases the operation is less favorable than in the early 
periods of invasion, but it should be no longer neglected. 
Should its only effect be to banish pain, this is a result 
always to be hoped for, and to secure it, the operation 
should be done without hesitation. As a general rule, so 
long as a certain degree of vision exists, iridectomy is 
competent to restore it to a good condition : it is not 
proper to despair, even when the sensibility of the retina 
appears completely abolished, provided always that the 
disease is not of too long continuance, and that the ex- 
tinction of vision was produced with considerable rapidity. 
Mr. Bowman cites the example of a lady, aged 40 years, 34 
that all perception of light was abolished for thirty-five 
days, and that eight days after the operation she read No. 
8 of Jseger. Grsefe considers this fact as quite excep- 
tionable, for he has never observed a like case of reestab- 
lishment of sight, after a delay of more than ten days. 
Not only does iridectomy cause the signs of inflammation 
to disappear, but it also speedily restores to the media their 
transparence, so as to render an ophthalmoscopic examina- 
tion possible at. the end of five or six days. The roundish 
ecchymoses of the retina may be then almost constantly 
remarked, of which the greater part are produced after 
the operation, and persist quite a long time. It is other- 
wise with those which are observed in the equatorial 
region of the choroid; these existed almost always before 
the operation and disappear very rapidly after it. It may 
also be observed that, in the case of a first attack, unless 
it be grafted upon a chronic glaucoma, the optic papilla 
has not undergone either cupping or displacement of its 
vessels. 
The return of vision in consequence of iridectomy is 
only in a very small degree due to the escape of the turbid 
fluid which occupied the anterior chamber. It is chiefly 
owing to the reestablishment of retinal sensibility. Grjefe 
cites in this connection a case, where all qualitative pur- 
ception of light had disappeared, and where, however, the 
turbidity of the media did not prevent the recognition of 
the periphery of the optic nerve by aid of the ophthal- 
moscope. Five days after the operation, the anterior 
chamber contained a good deal of effused blood, which 
prevented the bottom of the eye being any longer seen, 
and yet the patient distinguished already the number of 
fingers, which one held up at the distance of three or four 
feet. Generally, the maximum of amelioration of vision 
is obtained after two or three weeks. The ciliary pains 
ordinarily disappear immediately after the operation, 
except slight frontal pains, which persist sometimes two 
pr three days. The corneal insensibility and the sub- 35 
choroidal injection resist only a little longer. Sometimes 
the vision delays several weeks in regaining all its power. 
This delay is owing to the retinal ecchymoses occasioned 
by the operation, and for absorption of which it is 
necessary to wait sometimes a month or two. 
b. Sub-acute and chronic form.— This is the form which 
most frequently presents itself to the knife of the operator. 
Patients, who are attacked with acute glaucoma, either 
because they are badly advised, or because fear restrains 
them, seek too often to escape it; but the sub-acute stage, 
which resists ordinary means indefinitely, ends inevitably 
in constraining them to it. Iridectomy is appropriate, 
speaking generally, in all cases where the object is to 
restore to the organ a certain degree of vision if the sight 
is not entirely gone, or has been gone only a short time; 
or to get rid of pain ; or finally, if one eye only is attacked, 
to have a favorable influence, as it may be hoped, on the 
other, by removing the tension of the diseased eye, which 
may react unfavorably on the sound one. The operation 
should be done in the interval of the paroxysms, if the 
frequent repetition of them permits waiting for the end 
of an attack without fear that it may cause too many 
evils. Not a moment is to be lost, ifthe attack is acute and 
threatens to leave serious traces. However long stand- 
ing cases may be, if ocular tension exists with neuralgic 
irradiations, it is proper to operate: the iridectomy causes 
the internal pressure to cease, removes the glaucomatous 
aspect, and lessens the alterations of structure in the iris. 
As to the excavation of the optic papilla, when once pro- 
duced, it never entirely disappears. 
The prognosis of iridectomy differs according to the case : 
It is, generally, the more favorable the less its duration, 
limited to the precursory period, the less excavated the 
optic papilla, and the less the visual field is contracted. 
In simple glaucoma the chances are so much the better, 
as excavation of the papilla is less pronounced. In in- 
flammatory glaucoma, other things being equal, there is 36 
the more to be expected from the operation, the earlier it is 
performed; nevertheless, it has been followed by perfect 
sight, although recourse to it was not had for several weeks 
or even several months after the invasion. Even when the 
first attacks were very violent and had been already some- 
what often repeated, iridectomy has succeeded in preventing 
its recurrence and giving to patients a good degree of vision, 
if the papilla has remained healthy and the field of vision of 
nearly its normal extent. When the papilla is excavated 
the operation may indeed diminish the cupping, hut not 
restore the papilla to its physiological state; also, it will 
afford ameliorations, more or less marked, but not perfect 
cures. An excessive contraction of the visual field only per- 
mits hope of amendment, more or less pronounced, as the 
diminution approaches the median line. The combination 
of these two unfavorable conditions ought to render the prog- 
nosis very guarded ; the operation, however, ought not to be 
deferred, for while it may not cure, it effects, at least, a check 
in the progress of the disease, often an amelioration and 
almost always an immediate cessation of the pain. When 
every trace of quantitative perception of light has disap- 
peared, the operation may still effect some amendment, 
but it is rarely more than the ability to perceive large ob- 
jects. When the intra-ocular pressure is very great, and 
the flattening of the anterior chamber, turbidity of the hu- 
mors, tension, iridoplegia and anaesthesia of the cornea 
are strongly pronounced, and the abolition of vision is the 
immediate result of this condition, as occurs in acute glau- 
coma, the prognosis of the operation is of the most favor- 
able character, for it always causes a distension, and by 
that means, cessation of the symptoms which the internal 
pressure occasioned. 
Indications of Iridectomy. —Prof. Von Gnefe has arranged 
these under the following propositions, viz.: 
1st. The best result is obtained in a case where an eye 
is menaced by glaucoma (the other being already lost). 
It is the duty of the physician to procure as soon as possi- 37 
ble for the afflicted the counsel of a specialist, who should 
point out to the attending physician the symptoms which 
call for the operation. 
2d. Glaucoma once in the process of development, the 
results of the operation are, in general, the more decided 
and durable, the earlier one operates. In very grave cases, 
which induce almost immediately loss of sight, it is neces- 
sary to perform an iridectomy as soon as possible. A 
prompt interference is then of capital importance, and as 
transportation of the patients in these cases is often difficult, 
it would be well if every physician, especially in the 
country and small towns, where ophthalmology is not 
specially cultivated, should understand the symptomatology 
of acute glaucoma and the operation of iridectomy. I 
believe the lat er will occasion fewer difficulties than 
the former. Iridectomy demands less imperatively good 
assistants than many other surgical operations, as trach- 
eotomy, for instance, which every physician must practice 
in urgent cases, sometimes in the most unfavorable condi- 
tions. Iridectomy occupies, in this respect, an exceptional 
position among ophthalmic operations, which being rarely 
of an urgent character remain as the domain of a small 
number of practitioners. 
3d. Iridectomy has not the same efficacy at all periods 
of the disease, and in the last stages its effects are uncer- 
tain or null. It is painful to see how many incurably 
blind undertake long journeys, in the hope that their 
infirmity may be cured, while the period when they could 
have been helped has long since passed away. We recom- 
mend, in order to spare ourselves moments painful alike 
to ourselves and to our fellows, that the unfortunates who 
have completely lost their sight in consequence of glaucoma 
remain at home, and that little hope should be given those, 
whose disease is already of long standing and accom- 
panied with marked enfeeblement of sight and diminu- 
tion of the visual field. 
It suffices to read these instructions in order to be con- 38 
vinced that M. Von Grsefe, so far from advising iridectomy 
in all cases, as he has been unjustly reproached with doing, 
reserves it, on the contrary, for certain well determined 
circumstances. Speaking generally, it is to be practiced 
whenever there is pain, even though no longer any chance 
exists of restoring the least degree of vision, not only when 
both eyes are lost, but also when one only is extinguished, 
in order to preserve the other from sympathetic influences 
which these pains may there arouse. 
When, on the contrary, the sight has been lost for a long 
time, and the eyes are completely painless, the operation is 
useless. To practice it in such circumstances would have 
no other result than to discredit the procedure. It must 
not be forgotten moreover, that quite harmless as iridec- 
tomy most commonly is, it may occasion accidents, such 
as lesion of the crystalline capsule and swelling of the lens 
as a consequence, hemorrhages and traumatic symptoms of 
which ophthalmitis may be the flnal result. 
Precautions demanded by iridectomy performed for glau- 
coma.— 1. When the operation is done for acute glaucoma 
where the eye is greatly inflamed and the conjunctiva che- 
motic, chloroform is indispensable, unless express contra- 
indications exist, in order to avoid having the patient, 
agitated by excessive pain, make such movements as may 
compromise everything.— 2. The place of election for the 
new pupil is by preference the upper part of the iris. The 
pupil there placed will be completely hidden by the upper 
lid, sparing the patient at once a disagreeable deformity 
and the dazzling which occurs at first from too great a 
quantity of light in the eye.— 3. In cases where great ten- 
sion ceases suddenly, as happens from the aqueous humor 
flowing out suddenly, the blood vessels of the interior of 
the eye being quickly relaxed may burst and cause internal 
hemorrhages: hence the express indication to withdraw 
the knife with extreme slowness, in order to allow the 
fluid, which escapes from the anterior chamber, to flow 
out, drop by drop, as gently as possible. During this flow, 
the point of the blade should be watched and moved in a 39 
direction rather towards the cornea than towards the crys- 
talline for fear of wounding the capsule. M. Yon Grsefe is in 
the habit of making a slight pressure of the finger upon 
the globe of the eye while the aqueous humor is flowing, 
and, a little while after the operation, of applying a light 
compressive bandage (a pledget of charpie retained by a 
bandage) which is carefully removed some hours after. 
It is very well to observe this precaution.— 4. If, as is 
usual, the pupil is largely dilated, it is of great advantage 
to cause it to contract before the operation, by means of 
extract of calabar bean, in the two-fold purpose of seizing 
more easily a large piece of iris and of avoiding more cer- 
tainly the crystalline capsule.— 5. It is a good practice- 
when the incision is made, to provoke a hernia of the iris 
by pressing lightly on the posterior lip of the wound by 
means of a forceps prepared to seize the hernial protrusion 
if it presents. The introduction of numerous instruments, 
always dangerous, into the anterior chamber and the 
liability of injuring the crystalline system are thus 
avoided. 
Other methods of treativg glaucoma. — We shall be brief 
in whatrelates to this subject: antiphlogistics, derivatives, 
inhalations of chloroform, narcotics, anti-periodics oranti- 
neuralgics are only palliatives, and it is almost dangerous 
to cite them, if they are to serve as a pretext for deferring 
a moment the practice of iridectomy. They have never 
cured a case of glaucoma. Paracentesis of the cornea has 
counted on some success, but it has always been temporary. 
It must not be too much underrated, however, but it should 
only serve to secure more certainly the moment when iri- 
dectomy shall be practicable. The absence of an operator 
capable of practicing the latter properly, and the ne- 
cessity of seeking one at a distance are circumstances which 
may render paracentesis useful. As a radical method, it 
must not be depended on, and besides iridectomy is not 
properly speaking more serious in its consequences than 
paracentesis. 40 
Authorities. 
Respecting glaucoma the following authorities maybe 
consulted: Von Grade. Archivfur Ophth. B. I, Abth. 1, S. 
371, 382, u. Abth. 2, S. 299; B. Ill, Abth. 2, S. 456; B. 
IV, Abth. 2, 8. 127; B. VI, Abth. 2, S. 254; B. VIII. 
Abth. 2, S. 242, et Annales d’Ocnlistique, tomes XXXIII p. 
137; XXXVI, 171; XXXVIII, 237; XXXIX, 228; 
XLV, 180; XLIX, 136; LI, 100.— Ed. Jaeger. Ueber 
Glaucomund seine Heilung durch Irideciomie, Wien, 1858, et 
Ann. d’Ocul. t. XL, p. 92.— Bonders. Klin. Monatsbl. B. 
II. S. 433, et Ann. d’Ocul. t. LIV, p. 120.— James Compte 
rendu de sa Thhesur /eglaucome, par Giraud-Teulon, (Gaz. 
Med. de Paris. 12 avril, 1862, p.235).— Wells. Glaucoma 
and its cure bg Iridectomy, London, 1864.—'Brown. Brit. 
Med. Journ. 1864, Jan. 30, p. 136.— Bader. Ophth. IIos. 
Heports, Vol. II, p. 226.— Wharton Jones. Three Clinical 
Lectures on Iridectomy and Glaucoma (Med. Times and 
Gazette, 1864, July 23 and 30, Aug. 6.— Hancock. Ophth. 
IIosp. Hep. Vol. Ill, p. 13.— Hunneley. Lancet, 1861, Jan. 
19 & 26, pp. 55, 82.— Pamard. Thise sur le Glaucome, Paris, 
1862, Annd’Oc. t. XLVIII, p. 290.— Critchett. Oph. IIosp. 
Hep. vol. I, p. 57.— Magni. Nouvelle Theorie du Glaucome 
{Ann. d'Oculist. t. XLIX, p. 160).— Hulke. Ophth. IIosp. 
Hep. vol. II, p. 69, etc., and A?m d'Ocul. t. XLVI, p. 54.— 
Quaglino. Giorno d’ Oftal. Hal. 1860, p. 169, and Ann. d' Ocul. 
t. XLVII, p. 274.— Huffman s Mein, sur le glaucome [Arch fiir 
Ophth. B. VIII, Abth. 2, S. 124.— A. Desmarres, sa Theorie 
sur le glaucome, par Galezowrski (Union Med. 1864, p. 201, and 
Ann. d'Ocul. t. LII, p. 248).— Magawly. Contributions a 
Vhistoire clinique du glaucome (St. Petersb. Medic. Zeitsch. 1864. 
vol. VI, p. 193, and Ann. d'Ocul, t. Ill, p. 250).— Coccius. 
Arch.f. Ophth. B. IX, Abth. 1,8. 1.— Fribelius. St. Petersb. 
Medic. Zeitsch. Ill, 155, and Ann. d’Ocul. t. LIV, p. 
221.— Little. Ophth. Heview Xo. 7, 1865.— Bowman. Con- 
troversy on Iridectomy, etc., (Brit. Med. Journ. 1863-1864). 
Ophthalmoscopic figures of Glaucoma.— Mackenzie, 
(French edition) T. II, p. XLIX. (Liebreich) — Ed. Jaeger, 
Ueber Staar and Staaroperationen, taf. VIII, fig. 34; Beitrage, 
etc., taf. XIX, XX.— Von Grsefe, Archiv fur Ophth. 1854 
B. I. Abth. I, Taf. Ill, fig. 1.— Quaglino, fig. 23.— Bader, 
Opldh. IIosp. Hep. 1857. 1859, vol. I, pi. I, fig. 1, 2.— 
Liebreich. Atlas d’ ophth. tab. XI, fig. 1, 2, 3, 4, 5.— Follin. 
Le9ons, etc., pi. I, fig. 4 (2).