Giacomo Lanteri.

Charlotte medical journal [serial] (Volume v.14(1899: Jan.-June)) online

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Vol. XfV JANUARY, 1899. No# u

The Charlotte

Medical Journal.


RY, %\

Edited by E. C. REGISTER, M. D., and J.C. MONTGOMERY, M. D.



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The Charlotte Medical Journal,

Vol. XV.


No. i

The Symptoms and Diagnosis of Simple

By Gaillard S. Tennent, M. D.. Asheville, N.C.

There are some diseases which ought to
be blotted out of existence, if for no other
reasons than the trouble they give the pro-
fession in making an absolute diagnosis,
and the danger arising from failure to make
this diagnosis early in the disease. Glau-'
coma, which, according to Fuchf , 'furnishes;
one per cent, of all eye diseases "is ®u6 of.'
these. - ' '

The fact that total .blindness is the Final
result in every untreated case of chronic
glaucoma, as well 1 as in the^ majority of
cases receiving the best Ml rtoeatmc-nt • ipja
sufficient reason and excuse for offering a
paper on the subject and occupying the
valuable time of the society with its dis-

It is true that there is something vague
about the term, and that the highest author-
ities still differ as to the causes which pro-
duce the condition known as glaucoma.
It is also true that there is a great deal of
uncertainty connected with the diagnosis
of many cases in their incipiency ; still
early diagnosis is possible and important.

The subject's interest to the general prac-
titioner centres around these points : First,
glaucoma in its different forms closely re-
sembles other ills of every-day occurrence;
Second, atropine, which is unfortunately
looked upon as a panacea in eye troubles by
some men, is decidedly contraindicated
where there is even a suspicion of its pres-
ence or a tendency in that direction.

The symptoms of simple glaucoma dur-
ing an exacerbation are very much like
those of supra-orbital neuralgia, or, if the
attack be more acute, may closely resemble
those of a bilious attack, sick headache, or
facial erysipelas. The appearance of the
eye may also lead to the diagnosis of some
less serious eye trouble, the treatment of
which, when applied to a glaucomatous eye
would be disastrous.

If everyone were to realize that the dis
ease is not such a very rare one and
that it is as fatal to the sight as it is stated
above, there would be far greater care exer

*Read before the Buncombe County Medica
Society, Nov. 21, 1898.

cised in the use of atropine, which often
brings into activity latent cases, often brings
on an acute attack in those predisposed to it
and may, by a single instillation produce
glaucoma in a perfectly normal eye after the
age of 40. In a case recently seen by the
author, atropine had been used continuously
for several months before the outbreak
which resulted in permanent blindness.
Not having the evidence of observation
during this time, it cannot be said that post
'k^ c \ ergo propter hoc, but it was decidedly
a/s&spi^fous case, the patient being over 50
years 6»P # £ge*;..and it is a sample of many
instances iTre^.wfth in treating eye troubles.
In order todeig&Up to the salient points in
the, di.agno§is, it necessary to enter
int&i^fm/oal deta*tfs of little interest to the
bnSy 'medical man, but it will be the au-
thor's aim to emphasize and dwell upon
only those things with which everyone
should be familiar.

Juler defines glaucoma as "the name
given to the group of symptoms caused by
an excess of intra-ocular tension." This
state of abnormal tension may be caused
and kept up by forces operating continu-
ously or intermittently through an indefi-
nite period of years, in which case it is
termed simple glaucoma, or it may be pro-
duced by certain conditions existing for
only a few hours and acting more rapidly,
in which case it is called acute glaucoma.
Between these two extremes there are vari-
ous shades of the disease, progressing with
more or less rapidity and acuity, and sepa-
rated by no distinct lines. A strict defini-
tion of the term simple glaucoma is "non-
inflammatory" glaucoma, which would ex-
clude all these cases presenting acute symp-
toms, but the generally accepted classifica-
tion includes all the chronic cases like those
described below, under the same head. No
attempt will be made to account for the
origin of the different symptoms, for by so
doing, one of the twelve digerent theories
as to the causation of the disease may be

Simple glaucoma is practically a disease
of the middle aged and of those advanced
in years, though it is sometimes seen in the
young. It presents, -usually, four well
marked stages: 1. The prodromal, which
is marked by occasional attacks of pain,
dimness of vision and halos, with increas-
ing presbyopia in the interim ; 2. The stage

ft! A I



of rapid advance in which the attacks are
more frequent and only remit instead of
intermitting; 3. Absolute glaucoma which
is synonymous with blindness; 4. The
stage of degeneration.

During the prodromal stage, which lasts
from several months to many years, the
patient complains of an increase in the
asthenopic symptoms (a great majority of
cases occur in the subjects of hyperopia or
astigmatism) which cannot be relieved by
glasses ; he will be subject to attacks of
dimness of vision attended with more or
less neuralgic pain in the frontal region,
and will state that during the attack, arti-
ficial lights are surrounded by halos of color
and that objects appear as though seen
through a fog. If the attack be a severe
one, the conjunctiva becomes congested,
the lids and surrounding tissues ## becfeiVi£
swollen and ocdematous, the paiaAa'd 'intol-
erance of light are acute, tfnd'^paere will,
be a feeling of tendernV§s.*-6r soreness
through the frontal regie*fi.Yor several days
after its subsidence. . .* ." ; # . # •;;.•: :

After some time the attacks betQflie" rrtorS
frequent and the patient enters u'pbn the
second stage, in which the tension is con-
stantly raised and a certain degree of pain
and discomfort persists between seizures.
The visual acuity may now be permanently
lowered and the patient may be unable to
use his eyes for near work, despite the fre-
quent changes of glasses. The visual field
becomes canstantly narrowed till, finally,
the little vision which has been coming
and going for some time past is perma-
nently blotted out and the third stage or
absolute glaucoma is reached.

From this time on there is no perception
of light , except occasional subjective flashes
which delude the unfortunate victim into
the belief that sight is not permanently
destroyed. The painful attacks continue
until the undue pressure has had its effect ;
degeneration sets in, with reduction of ten-
sion and the eye becomes quiet.

The physical signs or objective symptoms,
which are of more importance than the sub-
jective from a diagnostic point of view,
naturally fall into two classes : those dis-
cernible by ordinary means, and those re-
quiring the use of special examinations for
their detection.

Unless seen during an exacerbation, there
is nothing distinctive in the external ap-
pearance of or feeling of the eye during
the prodromal stage, and it is then that the
ophthalmoscope and perimeter are most
valuable. If, however, the patient be seen
in one of his attacks, or if increased ten-
sion becomes permanent, it will readily be
observed that the pupil is dilated, or very

sluggish, the anterior chamber is shallow,
and the eyeball distinctly harder than nor-

This hardness may be detected very read-
ily, as Schweiger remarks, if one have "only
enough faith;" more readily still at this
time, because one eye is usually implicated
long before its fellow, and its hardness con-
trasts with the feeling of the normal eye.
Measuring the different degrees of tension is
no harder than, and very similar to, testing
the degrees of ripeness of large plums by their
feeling. In practicing palpation, the pa-
tient should be told to close his eyes and
look downward, pressure should then be
made and increased alternately with the
tips of the forefingers on the opposite sides
of the ball.

If the onset be a severe one, resembling
acute* '.glaucoma, in addition to the signs
•.notfeVl.'ab'gyfV. tb.ere will be intense conges-
tion of " thQ/Zcojijunctiva, the cornea
.v^H*; be steamy*,/ o»* .hazy looking and
antithetic, and th*e*.i*id's..and surrounding
tissues^ wUl pra^sent a'^wdllen, oedematous
flfrrdj te*Qse*jjsM6ct: so that the brow cannot
Toe wrinU'ed.

Late in the disease, the pupils are widely
and irregularly dilated, showing in the ab-
solute stage the peculiar green reflex from
which the malady has derived its name.
The sclerotic, at this time, is of a bluish
tint, and several enlarged, tortuous vessels
may be seen near the corneal margin.

A direct ophthalmoscopic examination
reveals two very important changes in the
fundus: 1st. Cupping of the disc, or push-
ing back of the yielding nerve tissue at the
point of least resistance; 2d. Pulsation, or
permanent change in the calibre of the
retinal vessels.

The cupping of the disc is progressive
and goes hand in hand with the other symp-
toms, from a depression similar to that of
early atrophy, to a condition in which the
whole disc is deeply concave, with vessels
disappearing over the edge of the cup like
snakes crawling into a hole. The bottom
of the cup is formed of the macula crib-
rosa, and at first is glistening white but
finally assumes the gray color of atrophy.
Cupping commences about the time of the
first noticable subjective symptoms, and at
first, may only occupy the temporal half of
the nerve head, in which case it is hard to
differentiate it from physiological cupping.

Arterial pulsation is sometimes sponta-
neous and can always be produced by slight
pressure when abnormal tension exists ;
the diagnosis often depends upon the facil-
ity with which it can be brought about.
Venous pulsation, though generally present,
is a negative sign, it being often seen in



normal eyes. In addition to this, as the
disease progresses, the calibre of the arte-
ries becomes smaller and the veins become
enlarged and tortuous.

Another important symptom is the grad-
ual limitation of the visual field, which,
though subjective, may be classed among
the physical signs, owing to the process
that has to be used in measuring it. The
limitation commences in the upper nasal
field, very early in the disease, and pro-
gresses gradually until there is only a nar-
row strip of relatively good vision extend-
ing outward from the centre. The disap-
pearance of this strip in a specially severe
attack, ushers in complete blindness. In
contrast with the narrowing of optic atro-
phy the field for white usually contracts
pari passu with that for colors.

Except in those cases which simulate op-
tic atrophy, the diagnosis is easily made, if
the following points be remembered : Early
signs — rapid, or premature presbyopia, at-
tacks of pain, dimness of vision and halos.
In the more severe attacks — swelling and
congestion with shallow anterior chamber,
dilated pupils, steamy and insensible cor-
nea; and recognizable hardness of the globe.

Seen during an attack, there is danger
of confounding the symptoms with those
of neuralgia, erysipelas or a bilious attack,
and, in every case, attended with frontal
or orbital pain, close attention should be
paid to the condition of the pupils, cornea,
and depth of the anterior chamber.

tis. In conjunctivitis the pupils are nor-
mal and there is no deep-seated or severe
pain. In keratitis the opacities are more
dense and well marked. The iris is dis-
colored and the pupils contracted in pain-
ful iritis. If, in any of these conditions,
a mydriatic has been used before the patient
is seen, the diagnosis becomes more difficult
and a very careful examination has to be

In absolute glaucoma the greenish opac-
ity of the pupils, arising from changes in
the vitrous, may be mistaken for cataract,
unless attention be paid to the dilated pu-
pils and tortuous vessels near the sclero-
corneal junction.

There are some cases ef glaucoma, espe-
cially among myopes, in which the tension
is never appreciably increased, these and
some other "quiet" cases are hard to differ-
entiate from optic atrophy with cupping
of the disc ; it is here that the retinal pul-
sation and the peculiarities of the visual
field assume special importance. It is some-
times necessary to examine the field in
different degrees of light and under differ-
ent circumstances to develop these peculiar-

The four cases which follow are pict-
ures of the conditions described above, and
three of them are types of the first three
stages, except in point of age. The other
is not glaucoma at all, but a semi-patho-
logical condition strongly resembling it,
sometimes termed false glaucoma. Cases



fc*M,i., *-4* **

t .

Locally, the appearances may lead to
diagnosis of conjunctivitis, keratitis or ir

III. and III., at the respective ages of 29
and 30 years, are remarkable as examples


of early development of the disease, while
cases III. and IV. show its well known
tendency to attack members of the same

Case i. — False Glaucoma. Miss ,

aet. 30. Seen October 4th, 1898. Has
three myopic brothers. Has been suffering
for several years from aortic insufficiency
which has affected her health moderately.

Has been wearing glasses for near sight
of moderate degree for about sixteen years.
Symptoms of asthenopia have been persis-
tent for past two or three years, in spite of
scrupulous correction of the myopia and
astigmatism ; correction giving vision of
} I plus, each eye. This asthenopia is ac-
counted for by the fact that there is marked
exophoria at the near point. Has never
had any attacks of orbital pain, dimness of
vision or halos.

Examination of the field shows that it is
practically normal as far as white is con-
cerned and slightly contracted for colors.
This suggests optic nerve trouble.

With the ophthalmoscope both optic
nerve heads are found to be decidedly cup-
ped on the temporal sides, one side of each
cup being precipitous enough to completely
hide the vessels as they dip down into the
nerve. Arterial pulsation on the disc is
only evoked by marked pressure or after
bodily exertion

Tension normal. Pulsa-

tion and tension tested negatively several
different days.

Diagnosis : Change in head of optic nerve
from the undue arterial tension of aortic in-
sufficiency, which accounts for the cupping
and the limitation of the color field.

Case II. — Simple glaucoma. Mr. ,

aet. 33, unmarried. Family history nega-
tive. General health has always been good.
Has been a moderate smoker since he was
a boy, and drinks a little beer occasionally.
Has always suffered from asthenopia, for
which he has worn improperly adjusted



:ral years. Vision is |~| plus,

each eye, with minus cylinders of low de-
gree, axes horizontal.

Has had several acute, painful attacks,
attended with congestion, photophobia and
oedematous swelling of lids and brow over
one eye. During these onsets the visual
acuity was decidedly lowered and halos
were noticed around artificial lights. The
last one occurred about four years ago, but
there have been times after fatigue or slight
dissipation when the halos appeared again,
and the vision became slightly foggy.

The field in each eye is found to be con-
tracted moderately for white and decidedly
for colors. The right field is more limited
than the left, and especially in the upper
nasal quadrant. Ophthalmoscopic examin-
ation reveals decided cupping of both discs,


• •


<Loac1£., T*i$YA %j* -

very similar to that observed in case 1.
The vessels are normal in calibre, but arte-
rial pulsation was elicited by very slight

pressure. Tension is normal. Pulsation
detected by repeated examinations at differ-
ent intervals.



Diagnosis of simple glaucoma in the pro-
dromal stage is made from the fact that four
of the principal signs are, or have been,
present, viz. : cupping of the disc, arterial
pulsation on slight pressure, limitation of
the field and painful attacks, with dimness
of vision, congestion and halos.

Case III Simple glaucoma, second

stage. Mrs. , act. 29. First seen on

July 2d, 1898. Has an aunt blind from
glaucoma, and a sister said to be affected
in a manner similar to patient. General
health has been fairly good. Vision with
each eye is }| with minus .75D. Sph.

States that eyes have been weak for sev-
eral years, and that for the last two years
she has been subject to attacks about twice
monthly, during which vision becomes fog-
gy, neuralgic pain is felt in frontal region,
and the eyes become congested. She also
states that at these times artificial lights are
surrounded by large rings of colors, and, in
the worst seizures, upon looking at a lamp,

cent, solution, to be instilled once daily for
two months, as a test. Seen again four
months later, the ophthalmoscopic picture
was unchanged, pulse could not be elicited
and the tension was normal. The general
symptoms were better and no exacerbation
had occurred during the whole period, al-
though the eyes had been used freely and
without much discomfort.

The field was then measured, showing a
very extensive concentric limitation for the
left eye, and a similar but smaller reduction
for the right.

When first seen, the case had entered
upon the second stage because of the fre-
quent onsets, the serious symptoms in the
intervals and the extensive narrowing of
the field.

Case IV. — Absolute glaucoma. Mrs.

, aet. ^4. Married; mother of seven

or eight children. Seen Aug. 27th, 1898.
This patient is an aunt of the one designat-
ed, "Case III."

Co^^W.,.^^ 4 -

the flame is invisible, a halo of brightness
taking its place. During the intermissions,
there is a constant feeling of uneasiness,
generally amounting to pain, which pre-
cludes the use of the eyes for near work.

The discs are deeply cupped, and the
nasal edges, from which the vessels spring,
overhang the plainly visible macula cribrosa.
At this time the arteries pulsated on slight
pressure and the tension was perceptibly
above normal.

Eserine was prescribed in one-fourth per

States that she has had weak eyes for
thirty years. Is uncertain about first seri-
ous symptoms, but consulted an oculist fif-
teen years ago, who gave her large doses of
strych. Eyes have grown rapidly worse
during past four years, and typical glauco-
matous attacks have succeded each other
with increasing rapidity. For about eight
months there was only a small patch of
vision in each temporal field, which disap-
peared permanently four months ago.

Conditions present at time of examina-


tion : Vision abolished ; both pupils fixed
and dilated ; large, tortuous vessels in ante-
rior scleral region ; media clear ; discs
gray and deeply cupped in their whole ex-
tent ; enlarged veins and threadlike arteries
crawl out of sight over the edge of the cup,
to reappear on the bottom. The eyeballs
are decidedly hard and unyielding and the
painful attacks continue.

Hemorrhage in the New-Born.

By John N. Upshur, M. D., Richmond, Va.,

Professor of Practice, Medical College

of Virginia.

The successful termination of labor, the
mother and child both doing svell, the strain
of anxiety to the family relieved and the
joy experienced that beside the hearthstone
another heart throbs. When, in a few
hours after the shadow of dire calamity to
the infant, caused by hemorrhage from
some source, again excites the gravest ap-
prehensions of parents and friends — espe-
cially as in the presence of the malady the
physician feels more or less impotent to
bring the necessary relief because of the
difficulty of detecting the cause. Nor do I
find that much help is given us by authori-
ties, and we fall back upon the ability to
guess correctly, and administer remedies
most empirically and usually with poor suc-

I am led to the above preface by an expe-
rience in a case a year ago, which has set me
to thinking on this subject. Before relat-
ing the case, however, I would consider the
varieties and sources of hemorrhage in the
newly born. Early in my professional life,
I saw a case in which the blood oozed from
the skin around the umbilicus, and could
not be controlled by pressure styptics, or
even the actual cautery, the infant dying in
a few hours. The infant was about a week
old when the bleeding came on ; had seemed
well, was well nourished, and of parentage
free, so far as I could learn, from all taint.
Haemophilia is undoubtedly a cause, and
probably was in the case above related ; I
could not learn of any heredity in this fam-
ily. Comby (Twentieth Century Practice)
says, "among thousands of children seen by

Online LibraryGiacomo LanteriCharlotte medical journal [serial] (Volume v.14(1899: Jan.-June)) → online text (page 1 of 126)