SECTION ON OPHTHALMOLOGY, OTOLOGY,

RHINOLOGY, AND LARYNGOLOGY.

OPERATIVE TREATMENT OF GLAUCOMA.

W. A. HARPER, M. D.,

AUSTIN, TEXAS.

The name glaucoma is a misnomer, since it is suggested by one of the rarest symptoms of the disease, viz.: a greenish appearance of the pupil.

Many attempts have been made to change the name to something more appropriate, but so well established was the name glaucoma before a change was suggested, that all attempts have proved failures, and we are justified in the belief that the disease will continue indefinitely to be known as glaucoma.

The symptom most characteristic of glaucoma is increased intraocular tension. This is sooner or later followed by diminution in acuity of vision, and by the time this symptom is observed the ophthalmoscope will reveal another important symptom-excavation of the optic papilla.

These constitute three important symptoms common to nearly all cases of the disease. Other symptoms will usually be found to characterize the different varieties of the disease.

In no disease of the eye is an early diagnosis more important, as after sufficient progress has taken place to permanently impair the vision, neither medicinal nor operative interference can bring the eye back to its normal condition.

Simple glaucoma is preceded by a prodromal stage, consisting of one or more attacks during which vision is temporarily impaired. These prodromal attacks may extend over a period of from a few weeks to several years, each time the vision clearing up to normal, or almost so.

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In acute inflammatory glaucoma we are without the prodromal stage; a fully developed glaucoma is found with the first attack. During an attack of acute inflammatory glaucoma the cornea and the vitrious are more or less cloudy and thus interfere with the ophthalmoscopic examination. But usually other symptoms render the diagnosis possible.

But little difficulty will be found in differentiating the acute and the chronic cases, either in the simple or the inflammatory types. In the chronic inflammatory type we have a history of slow development of prominent symptoms, gradual lessening of visual acuity. Refractive media may or may not be clear.

In simple chronic glaucoma the prevailing subjective symptom is gradual lessening of visual acuity. The increased tension may be almost or quite imperceptible. The excavation of the papilla may be so slight on first examination as to leave doubt as to whether it is the result of glaucoma, or only simple nerve atrophy. Even a second examination a few weeks later may be necessary to clear up the diagnosis. However, the halo so often found around the papilla is not present in simple atrophy; and again, the narrowing of the visual field while central vision remains good, or comparatively so, is not found in the latter disease.

Difficulty may be encountered in differentiating primary acute glaucoma and hemorrhagic glaucoma, especially where the hemorrhage has been slight and where hemorrhages have not been observed previous to the glaucomatous attack. Also serous iritis might be mistaken for acute glaucoma.

An acute secondary glaucoma due to an intro-ocular tumor might be diagnosed as acute glaucoma. In fact, in dealing with glaucoma many obstacles are met with in the diagnosis. Once the diagnosis is made, treatment demands our whole attention.

Medicinal treatment is no more than palliative, and should not be expected to do more than to ward off a threatened attack, or cut short one already existing. All mydriatics mave a tendency to increase the tension and may serve to bring on an attack when there is the slightest tendency toward glaucoma.

Myotics, especially sulphate of eserine, on the other hand, lessen

the tension, and while its effect is temporary, it is often an important adjunct in combating the disease.

The only curative means yet known to the profession is an operation, the principal one being iridectomy, first performed by von Graefe in 1857. The operation should consist in the removal of not less than one-fifth of the whole iris, and great care should be taken to see that the portion removed extends well back to the ciliary muscle, and the success or failure of the operation will, in many cases, depend upon how well this detail of the operation is carried out. The manner in which the incision is made also plays an important rôle in iridectomy for glaucoma. The incision should be made in the sclera at least one millimeter from what seems to be the corneo-scleral junction in the upper quadrant, the utmost care being taken, of course, not to wound the ciliary body. The benefits derived from an operation of this kind may be two-fold. In the first place, it makes possible the removal of the iris close to the ciliary body, and also gives us a scar in tissue quite different from that of the cornea,-one that will more readily permit of filtration of the intra-ocular fluid. A healthy wound in the cornea will heal within less than one-half the time of a similar wound in the sclera, and when it has healed, the scar tissue will be less porous and permit of but little, if any, filtration from the interior. of the eye. If an iridectomy has been performed without the results hoped for, a careful examination may reveal a failure to get that portion of the iris next to the ciliary muscle removed, or the scar may show that the incision was made in the cornea, rather than well into the sclera. If this should be the case, extra care should be taken in a second operation opposite in position to the one just performed.

Simply puncturing the cornea will temporarily lessen the tension, but no permanent benefit has been reported from this operation.

The best results from iridectomy for glaucoma are obtained in the acute inflammatory variety. If properly performed, the prognosis is very favorable. If it be during the first attack, the eye is most likely to be restored permanently to its normal condition.

However, after several attacks have occurred and the vision has failed to regain its normal acuity, the prognosis is not so favorable, yet the operation is none the less indicated. If simple glaucoma is recognized during the prodromal stage, the operator may hope for as favorable results as in the acute inflammatory variety.

It is in simple chronic glaucoma that the operation fails most often to produce a cure. In fact, about all that may confidently be expected is to arrest the disease.

Since von Graefe first performed the iridectomy for glaucoma, many substitutes and many modifications have been offered. But De Wecker's sclerotomy, Hancock's cutting of the ciliary muscle, and more than a dozen other substitutes, all proposed by able men, have either proved failures, or are accompanied with more or less objectionable features.

Jonnesco recently came forward with his excision of the superior cervical sympathetic ganglion. As to the virtues of this operation, no one is yet prepared to say. At present it seems we are justified only in performing the operation when other operative measures have failed. The removal of this ganglion does, we have no doubt, result in reducing the intra-ocular tension in a certain per cent. of cases-and in some have produced what seems to be a permanent cure. And it is to be hoped that more will come of this operation than just at present seems probable.

RADICAL CURE OF TONSILITIS.

FRANK D. BOYD, M. D.,

FORT WORTH, TEXAS.

In presenting this paper to you, I do not intend to enter into the etiology, pathology nor give a train of symptoms following acute attacks of tonsilitis; neither shall I enter into the various remedies suggested as to the relief of this acute attack, for one paper could hardly cover all the ground.

The disease is no doubt the most common that we are called upon to treat, and our experiences in treatment are all about the same. I do desire to limit this paper to the radical cure. I mean by radical cure, to completely and permanently cure this trouble without having any further return of the symptoms. A patient is often brought to us giving the usual train of symptoms of having recurrent acute attacks of this trouble, and among the first questions asked, "Doctor, can you cure my child without using a knife, or rather without operation?" To all such questions I quote them what Dr. Lenox Browne, of London, says in his latest work on the nose and throat: "Chronic enlargement of the tonsils is only to be treated satisfactorily by the one method of excision, and there does not appear any valid reason why there should be two opinions on the question." Bosworth says, in his excellent work on diseases of the nose and throat, "I think there can be little question that the prominent indication for treatment in this condition is the removal of the growth." He goes on to give the best means for its complete removal. I could quote various authors, and each one is a unit in stating that nothing short of the complete removal by surgical means will radically cure this trouble. We are often confronted with various questions asking if the voice will suffer, or if the removal of the tonsil will prevent any conception. I remember a father of a little girl asked me very confidentially if the removal of the tonsils would prevent his child from becoming a mother.