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Charlotte Medical Journal.

Vol. I. CHARLOTTE, N. C, JAN., 1893. No. 7.

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A Few Plain Words on Glaucoma.

By Richard H. Lewis, M. D., Surgeon for Diseases of the Eye, Ear, Throat and Nose
to St. John's Hospital, Raleigh, N. C.

The relatively large number of cases of absolute and hopeless
blindness from neglected glaucoma coming under my observation
has suggested to me the propriety of making an effort to do some-
thing in the way of prevention of such sad occurrences. Blindness
from this cause is peculiarly deplorable for the reason that the
afflicted one is not only cut off from all perception of light even —
a deprivation that only the blind who retain the power of discrim-
inating between day and night can fully appreciate — but is a suf-
ferer in many instances from repeated and long-continued attacks
of severest pain. So that, if, by what I shall have to say, I prove
to be the indirect means of saving not more than one person from
such a fate, I shall feel that this imposition on your patience was
not without justification.

Before going further, I wish it to be distinctly understood that
in using the expression "neglected glaucoma" I did not mean to
indicate an intention to lecture my brethren of the general profes-
sion, because, as a matter of fact, I believe that, in most instances,
the patient is to blame. But I cannot in candor say that it is
always the patient's neglect. It must be admitted that, sometimes,
the failure of the physician first consulted to make a correct diag-
nosis, which, it should be said, is not always an easy matter, con-
signs a curable case to hopeless and life-long darkness. Conse-
quently, since the best informed amongst us is liable to become
more or less rusty in his knowledge of a disease that is so rarely
brought to his attention as the one we have under consideration, it
would not be amiss to emphasize a few salient points bearing on

f -t Read before the North Carolina Medical Association at Wilmington, May 17th, 1892.

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CHARLOTTE MEDICAL JOURNAL.



its diagnosis and early management. I shall not attempt to draw
a complete and finished picture of the malady, filled in with minute
details and nice touches, but a simple sketch, made with a few
broad strokes, representing only the essential features manifest to
the ordinary medical observer. And so, a citation of the ophthal-
moscopic signs, and all discussion of its etiology and pathology, as
well as the consideration of whatever is exceptional, will be pur-
posely omitted as not coming within the limited scope of this paper.
For our purpose it would be best to consider only the three ordi-
nary forms of the simple or chronic, the subacute and acute inflam-
matory. The symptoms common to all forms are, failure of sight,
increased tension or hardness of the eye-ball, dilated pupil, and
contraction of the visual field, especially towards the nose. The
most characteristic of these is increased tension, which is to be
ascertained by gently palpating the globe through the upper lid as
the patient looks at his feet, very much in the same way as for pus
in a suspected abscess. If not familiar with the feeling of the
normal eye, a comparison should be made with the other eye, if
unaffected, or with the examiner's own. The next most important
symptom is dilatation of the pupil, particularly if it does not re-
spond to light. A fact of great assistance, in a negative way, in
helping to a correct diagnosis, is that the subject of glaucoma is
almost sure to be past middle age, or old enough to wear spectacles
for reading. And the first thing one suffering with chronic glau-
coma, as a rule, notices is that his spectacles do not suit him as
well as they once did, and that he cannot find any that will bring
his sight up to the original standard. The need for frequent
changes in his glasses is often a premonitory sign. He will then
complain that at times there is a fog or haze over his sight, lasting
for a greater or less period, and then passing off entirely for a
while, only, however, to return again at shorter intervals, denser
in character and hanging over him longer. While this fog is present
he will tell you, usually, that when he looks at a lamp or other
light it seems to be surrounded by colored rings, haloes or rainbows
— a phenomenon only found in glaucoma, except when produced
by mucus on the cornea, which can be easily removed by winking.
Pain, if present at all, will be slight and occasional. A superficial
inspection of the eye will show the sclerotic white, the cornea clear
and bright, and, in a word, the eye perfectly normal in appearance,



CHARLOTTE MEDICAL JOURNAL. 19



save a slight dilatation and some sluggishness of the pupil. The
tension will probably be a little increased, and the field of the
vision somewhat narrowed.

In the subacute form, after, in all likelihood, a few premonitory
attacks embodying the syptoms just enumerated as belonging to
the chronic, there will be a more rapid failure of sight — pain in,
but chiefly around, the eye, over the brow, in the temple, down
the side of the nose, and, sometimes, all over the side of the head,
will be complained of— the globe will be very distinctly hard-
there will be some redness of the ball, or rather duskey character,
most marked just behind the sclero-corneal junction — the cornea
will look rather steamy — the anterior chamber will generally ap-
pear shallow, the pupil will be dilated and probable oval in shape,
and, instead of of being black, it will be of a yellowish green color.
The acute form is simply an exaggeration of the subacute.
The onset is more rapid — the tension greater — the pain more se-
vere — the redness more intense, in some instances extending to
the whole conjunction with a swelling of the lids — occasionally
there is a photophobia — the pupil is more widely dilated, though
not necessarily ad maximum, and fixed — the cornea looks more
hazy and insensible to the touch of a light, soft object, as a feather
or wisp of tisue paper — and sometimes there is fever with nausea
and vomiting. Inasmuch as the mistake has been made, I will
take the liberty of saying that, should you have a case of supposed
remittent fever, who, at the same time, has had a bad eye, do not
be satisfied with your diagnosis until all doubt as to the nature
of the ocular trouble is removed, and do not wait for him to recover
from the fever, or "bilious attack?' before attending to his eye.

The disease with which inflammatory glaucoma might be con-
founded are, iritis, conjunctivis, cataract, inflammation of the cor-
nea and neuralgia. There are many resemblances between acute
iritis and acute glaucoma, and there are many differences, but
the similar features, unfortunately, are of a coarser and more
easily recognised character than the dissimilar. In order to avoid
confusion, I will rest the differential on two symptoms, or signs,
on ] y — the state of tension and of the pupil. While in iritis the
tension is sometimes increased, it amounts to practically nothing,
but in glaucoma it is the pathogmouic symptom, and in the inflam-
matory form— with which alone iritis could be confounded— it is



CHARLOTTE MEDICAL JOURNAL.



almost certain to be very distinct, and pronounced. The pupil in
iritis, if changed at all in size, is smaller than the normal, but in
glaucoma it is almost invariably larger than natural, and, in an
immense majority of cases, very much larger. If in doubt, com-
pare with sound eye, should there be one, or with a healthy eye in
another individual of about the same age and in the same light.
Never fail, therefore, to examine more carefully the pupil in every
red eye belonging to an elderly person, and particular if that eye
be free from a muco-purulent or purulent discharge — the presence
of this discharge being the characteristic symptom of conjuctivitis.
Iu conjuctivitis the redness of the globe increases from before
backward, while in glaucoma, as well as in iritis just the reverse
is true. In conjunctivitis, too, the sight is scarcely, if at all, im-
paired — in glaucoma it is apt to be very bad.

The change in color of the pupil, together with the dimness of
sight, is suggestive of cataract ; but the fact that the loss of sight
has been more or less rapid, the signs of inflammation, congestive
and pain nearly always present, certainly in the severe forms, and
especially the dilated and fixed pupil; signify plainly that the
case is not one of simple cataract ; while, if the tension be increas-
ed, in addition to the above, it settles the question, proving that it
is not only not cataract, but glaucoma.

The only symptom of glaucoma calling to mind keratitis is the
haziness of cornea, but it is slight and generally and evenly dif-
fused, not patchy, as it always is in inflammation, of the cornea.
The opacity in interstitial keratitis, which by the way, it should
be remembered, is a disease of childhood, although diffused, is den-
ser in some parts than others — the cloud has thin places in it.
Again in affections of the cornea, a photophobia and lachrymation
are prominent symptoms — in glaucoma they are secondary, if not
altogether wanting

Although in neuralgia of the ophthalmic branch of the trifacial
lachrymation with redness of the conjuctiva and occasionally pho-
tophobia as well as sensations of dazzling light and colors are not
indifferently diagnosis is not difficult, even when they are. In the
neuralgic affection vision is practically unimpaired, the pupil is
normal in size or smaller than usual, the tension is not increased
and the sensations of light are subjective and different from the



CHARLOTTE MEDICAL JOURNAL.



rings or haloes of glaucoma that appear to surround the lamp or
other point of light looked at.

It is of vital importance that glaucoma and iritis should not be
confounded with one another, for the remedy appropriate to each
is generally positively injurious to the other, in some instances
actually exciting an attack in a healthy eye predisposed to that
particular affection. If the pupil be carefully examined and its
size noted the mistake in the application of remedies could not
well be made, for it is the most elementary common-sense, it seems
to me, for every one using remedies directed to the pupil to attempt
to contract a pupil that is too large and to dilate one that is too
small. Attention to this simple rule would insure practically the
use of a myotic, eserine sulphate or pilocarpine muriate, in glau-
coma, and a mydriatic, atropia sulphate, in iritis.

Having made the diagnosis of glaucoma its early management
is very simple. It consists in the im?nediate use locally of a
myotic, sulphate of eserine, a drop or two of a solution of a
strength varying from one to four grains to the ounce, or pilocar-
pine of double that strength, in the eye every hour until the pupil
contracts, pain is relieved and sight improved, and continued after-
wards three or four times a day until the trouble has passed off.
Hot applications, purgatives, hypodermic injections of pilocarpine,
etc., are sometimes helpful, but such uncertain palliatives should
never be depended on, except only when nothing better can be
done. Should the pupil not respond to the myotic and a marked
alleviation of the symptoms occur in- twenty-four hours, or if its
use increase the pain and inflammation, as it sometimes does, an
iridectomy or sclerotomy, preferably the former, in my opinion,
should be done at the earliest possible moment. Acute glaucoma
is a disease that allows no dallying in its treatment — the price of
sight is promptness — and, eserine or pilocarpine failing, the knife
is the only hope.

My experience with eserine, while very much mixed, has been,
on the whole, encouraging. One case is sufficiently striking to
deserve reporting, and the following is a brief account of it :

Mrs. N. J. M., age 33, was sent to me by my friend Dr. Thomas
F. Wood six years ago. At the time of her visit the left eye was
entirely blind, presenting the symptoms of absolute glaucoma with
scleral staphyloma. She stated that the trouble began in that eye



CHARLOTTE MEDICAL JOURNAL.



eighteen months before. The right eye was normal in every re-
spect, including acuteness of sight and amplitude of the field of
vision, except that the anterior chamber was too shallow, the pupil
plainly larger than it ought to have been, and the tension slightly
increased. But she had had some premonitions similar to those
leading up to the disastrous consequences shown in the left eye,
and she was wise enough to seek advice in time. She was given
a solution of eserine, re-enforced with boracic acid to preserve it,
instructed as to its use, and thoroughly impressed with the vital
importance of returning immediately for operation should the
eserine fail. It worked like a charm, and for three years sight
continued fully up to the standard, but a time came when it did
fail, and, true to instructions, she promptly returned for further
advice. Her good eye then presented all the symptoms of subacute
inflammatory glaucoma, and vision was reduced to an ability to
count fingers at a few feet. Thinking that her drops might have
lost their efficacy from age, a fresh two-grain solution was tried
before resorting to operation, and the attack was quickly relieved
and sight completely restored. Since then her attacks, returning
as they have from the beginning in a mild form, usually two or
three times a week, have been effectually aborted by the eserine,
and when last seen, eight months ago, her eye was in excellent
condition with one serious exception, namely, a severe attack of
follicular conjunctivitis. Whether the fungoid formations in old
solutions that had undergone decomposition excited the inflamma-
tion, or it was the result of the long-continued use of the alkaloid
I do not know ; not improbably the latter, however, as other ob-
servers have noticed the same condition after prolonged use of
eserine. The effect of atropia on this line is familiar to all, and
the persistent instillation of cocaine has been known to cause con-
junctivitis granulosa (follicular?) In a letter written just one
week ago to-day she says : "My eye improved rapidly after seeing
you last, the attacks not averaging more than one once in three
weeks up to the present. Within a day or two it looks a little in-
flamed, but am not suffering very much. Have not had an attack
in nearly a month. Can read No. XX at the distance of twenty
feet. I continue to use one drop once every day ; also use it when
I have an attack (more freely she means). P. S. — I forgot to tell
you I have had a few times of frequent attacks since I saw you."



CHARLOTTE MEDICAL JOURNAL. 23



This case is interesting and instructive for several reasons : the
comparative youth of the patient (33), the great frequency of the
attacks, two or three a week most of the time — as confirming the
opinion that the long-continued employment of eserine will excite
the follicular form of conjunctivitis — but chiefly as showing the
efficacy of that drug in the treatment of this most dangerous dis-
ease of the eye, and that, too, when used once every day, or oftener,
for so long a period as six years.* But it must be borne in mind
that this is a very exceptional case, and that in many instances
eserine is entirely without effect, and in some positively injurious.
Still it has been known to finally cure some cases, and is, unques-
tionably, of very great value as a palliative, often relieving the
urgent symptoms and saving the eye until more radical treatment
can be obtained. Indeed, eserine and pilocarpine, it may be said,
are the only medical remedies for glaucoma. And so, every prac-
titioner — certainly those not prepared to do an iridectomy — should
make it a point to see to it that either some druggist within reach
keeps them, or that he has a small quantity of one or the other of
them in his own medicine chest. As eserine deliquesces very
easily, it would probably be best to keep it in hermetically sealed
glass tubes or in the more elegant form of gelatine discs. Before
leaving this subject it is proper for me to add that I have never
had any personal experience with pilocarpine in glaucoma, because
I have always thought it safest to rely on eserine ; but, in the
opinion of some, it is, if used in double strength, just as effective,
and it certainly should be tried if the eserine cannot be obtained.
As a corollary to the above I would say : Every person old
enough to wear spectacles, complaining of an impairment of sight

*Just after reading this paper I had the gratification of seeing Mrs. M. and finding
her eye in excellent condition, notwithstanding a pretty sharp attack the day before—
the first in a month. Save a slight shallowness of the anterior chamber it was normal
in every respect— vision up to the standard and the optic disc not in the least cupped.
The follicular conjunctivitis present when seen eight months before had disappeared
under the use of a simple borax lotion prescribed at that time in spite of the continued
instillation— daily, if not more frequently— of the eserine collyrium. From this fact I
am confident that the conjunctivitis was excited not so much by the long-continued use
of the alkaloid as by the impurities resulting from degenerative changes in the solution.
I questioned her again as to the character of the frequent attacks, and she stated that
they were accompanied by dimness of sight, dilated pupil, hardness of the globe, as well
as she could ascertain, and the haloes around the lamp, and were therefore truly glauco-
matous. I shall try to wean the eye from the myotic by substituting pilocarpine, the
weaker of the two, for the eserine, and gradually diminishing the strength of that.
Later : Pilocarpine was tried, but did not act as well as eserine.



CHARLOTTE MEDICAL JOURNAL.



not remediable by a change of glasses, should seek medical advice.
And especially should this be done if he notices variations in
vision, sight being at one time hazy and at another clear, or if he
has observed the haloes or rainbows around the lamp. The fog in
glaucoma generally lifts entirely at times, or it rapidly becomes
dense, while in cataract it is always present and deepens very
slowly. But just here comes in the main difficulty alluded to in
the beginning, and that is, that the party with the cloud of blind-
ness hanging over his life will not seek advice until it is too late,
deluding himself with the theory that it is merely a little a cold in
the eye," and satisfying himself with "alum curds," rotten apple
and such other — "rot."

Fortunately glaucoma rarely ever attacks both eyes at the same
time, and consequently it is more than probable that some physicians
will be seen, if not for that, for some other trouble, before the sec-
ond eye is involved. If so, and the first eye should be found to
have been from that disease, he should feel it to be his imperative
duty to impress upon the patient, as forcible as possible, the fact
that the same trouble is practically sure to occur sooner or later
in the good eye, to insist upon his seeking medical advice upon
the very first signal of danger, and warn him of the fearful conse-
quences of delay. Having lost an eye he will be more ready to
listen to advice. But there is a rock that sometimes shows in this
latitude on which the medical mariner, inexperienced in sailing
ocular seas is liable to make shipwreck, and we must mark it
plainly on our chart. That rock is secondary cataract — cataract
coming after, and consequent upon, the glaucoma. The danger
consists in attributing the blindness to the cataract, instead of to
the glaucoma, its real cause, thereby permitting the patient to sink
into hopeless darkness under the false impression that his trouble
is one that can be almost surely relieved, and at any time, after he
has become completely blind, that may suit his convenience. It is
true that in most instances the second eye has been ruined before
the first becomes cataractious, but it is in danger nevertheless.
We will mark it by calling attention to the fact that in cataract
secondary to glaucoma the pupil is dilated and does not contract
on exposure to bright light, the perception of light indeed being
generally lost at that stage of the disease, while, in simple idiopa-
thic, or primary cataract, the pupil is normal, or, if slightly dila-



CHARLOTTE MEDICAL JOURNAL. 25



ted, quickly and promptly responds to variations in the amount
of light, the perception of which is good. This would be sufficient
to base an opinion upon, but hardness of the globe, en-
larged tortous vessels on its surface and the history of the case
would be confirmatory. Another reason for being careful to make
the distinction between ordinary seniel cataract and that conse-
quent upon glaucoma is that, by so doing, the patient may be saved,
perhaps, a long and expensive journey with bitter disappointment
at the end of it.

How to overcome the main difficulty, namely, the carelessness
and indifference of the person most interested, is, I confess, a ques-
tion hard of solution. The only thing I can suggest is for the
profession to attempt the education of the people — planting a seed
here and there — by calling attention whenever occasion may arise
to the fact that any elderly person with marked impairment of
sight beyond the aid of glasses and accompanied by any symptoms
whatsoever other than a very slowly increasing dimness, shows a
reckless disregard of one of God's choicest blessing if he does not
promptly obtain the opinion of his physician as to its nature.



Written Expressly for The Charlotte Medical Journal.

Clinical Reports.

Bellevue Hospital, New York City, Nov. 22, 1892.

SERVICE OF PROF. F. S. DENNIS.

Wiring Fractured Patella. — The patient was a boy, fourteen
years of age, who, a few days ago, in attempting to save himself
from a fall, sustained a simple fracture of the right patella, due to
the force of muscular action. The fracture was transverse and in
the center of the bone, as is usually the case in fracture of this
bone.

The symptoms of fractured patella were well marked, i. e., loss
of power to extend the leg, independent lateral mobility of the
fragments, and a well-marked gap between the fragments.

There are two methods of treatment for such fractures; the limb
could be placed in an apparatus to procure immobility and kept in
position for eight or ten weeks. This is applicable where the peri-
osteal covering of the bone is intact and the separation of the
fragments is slight. This method of treatment would be out of



26 CHARLOTTE M EDICAL JOURNAL.

place in a fracture of the nature that this boy has suffered. Liga-
mentous adhesions are all that would hold the pieces together and
the patient would be left in a semi-crippled condition during the
remainder of his life.

Cutting down into the joint and wiring the patella is a much
better course to pursue. In this way the patient is well in from
two to four weeks and sustains no subsequent difficulty in the
joint. The operator has wired the patella about fifty times and in
no case has he had unfavorable results or any reason to regret
having performed the operation. The objection to the operation
is that the limb, and often the life of the patient, is risked— a risk
which it is urged is too great, considering the nature of the wound
to be relieved. The same is true of any surgical operation ; but
select your patients and use proper antiseptics, and there is no
reason why the results of this operation should not present a low
mortality. It is not applicable to every case of fractured patella.
Your patient must have healthy heart, lungs and kindeys, and be
in general good health. After such an operation the patella which
was fractured is in better condition than it was before, for the line
of union is the strongest part of the bone and there is no well
authenticated report of a refracture of a patella when the fracture
has taken place at the old line of union.

Very rigid antiseptic precautions were made in regard to this