AMERICAN JOURNAL OF OPHTHALMOLOGY Published Monthly by the Ophthalmic Publishing Company

EDITORIAL STAFF LAWRENCE T. POST, Editor

640 S. Kingshighway, Saint Louis WILLIAM H. CRISP, Consulting Editor

530 Metropolitan Building, Denver EDWARD JACKSON, Consulting Editor

Republic Building, Denver HANS BARKAN

Stanford University Hospital, San Francisco WILLIAM L. BENEDICT

The Mayo Clinic, Rochester, Minnesota GRADY E. CLAY

Medical Arts Building, Atlanta FREDERICK C. CORDES

384 Post Street, San Francisco HARRY S. GRADLE

58 East Washington Street, Chicago

H. ROMMEL HILDRETH 824 Metropolitan Building, Saint Louis

F. PARK LEWIS 454 Franklin Street, Buffalo

C. S. O'BRIEN The State University of Iowa, College of

Medicine, Iowa City M. URIBE TRONCOSO

500 West End Avenue, New York DERRICK VAIL

441 Vine Street, Cincinnati F. E. WOODRUFF

824 Metropolitan Building, Saint Louis EMMA S. BUSS, Manuscript Editor

6820 Delmar Boulevard, Saint Louis Directors: LAWRENCE T. POST, President, WILLIAM L. BENEDICT, Vice-President, F. E.

WOODRUFF, Secretary and Treasurer, EDWARD JACKSON, WILLIAM H. CRISP, HARRY S. GRADLE. Address original papers, other scientific communications including correspondence, also books

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G L A U C O M A

The highly specialized nutrition of the eye provides for the transparency of the refractive media and the maintenance of its optical proportions. These conditions are totally different from what is achieved by the metabolism of any other part of the body. The history of glau­coma shows its complete confusion with cataract, atrophy of the optic nerve, and other conditions with which its connec­tion was entirely accidental. Priestley Smith opened the door to the under­standing of this disease when he defined glaucoma as increased intraocular ten­sion, plus the causes and effects of such increase. But the general investigations of metabolism and nutrition, turned in

other directions, threw very little light upon physiological intraocular tension, or the mechanism that maintained it.

Mackenzie had recognized the im­portance of ocular hypertension; but nothing was done for it until Graefe noticed that iridectomy sometimes low­ered the intraocular pressure. I t was soon accepted as a proper treatment for glaucoma. Not the kind of iridectomy used to make an artificial pupil, or as part of a cataract extract ion; but a wider iridectomy, removing the iris all the way to its attachment to the sclera. Fo r acute cases with little inflammation, it is still recognized as good treatment. But for many of the cases it proved ineffective. Hancock made a radial section through

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the ciliary body. This has also been done by a few operators, with good success. Posterior sclerotomy has been used to reduce the tension temporarily, before performing another operation for per­manent effect. Lagrange, with iridectomy, cut off a piece of the sclera. Heine, through an incision made back of the ciliary body, did cyclodialysis; separating the choroid and ciliary body from the sclera. Herbert's flap operation separated the sclera from the iris back of the limbus. Argyll Robertson suggested trephining the sclera to secure permanent drainage. Elliot trephined at the sclero-corneal junction with, or without, re­moval of a small piece of iris. This, extensively practiced in Egypt and India, was found to relieve the chronic cases there encountered; especially if it caused a bulging, or cystoid cicatrix. Iris-inclu­sion operations, in which portions of the iris were drawn into the corneoscleral incision, and in Holth's operation into a trephine opening, have also relieved cases of chronic glaucoma, and have been resorted to as being easier and less dangerous than other glaucoma opera­tions.

Each of these operations has been ad­vanced and supported with theoretical discussions of the pathology of glaucoma ; and the same is true of the latest pro­cedure of Otto Barkan, opening the angle of the anterior chamber and Schlemm's canal by an incision, under direct obser­vation with a modified corneal micro­scope. All the operations, by allowing di­rect escape of fluid from the interior of the eyeball, have produced an immediate decrease of intraocular pressure. In some cases the effect has been permanent; so that each operation is supported by a certain number of cures. But in other cases that seemed to be favorable, the relief has not been permanent; and in spite of all treatment the eyes have gone on to permanent blindness. It is evident

that our knowledge of glaucoma is in­complete. Some factor in the pathological hardening of the eyeball has been over­looked.

On this account, the study of glaucoma by Luedde (page 388), calling attention to the probable function of the capillary epithelium of the smaller blood vessels in the eye, and the probable escape of fluid through the permeability of the peripheral cornea, as observed by Ridley, seems to fill up a waiting gap in our understanding of glaucoma. With this we may well consider the relief of glau­coma reported by Miller, Luedde, and others, in a few cases. It points to the possibility of a tendency to glaucoma that may be removed possibly by administra­tion of splenic extract, or other means. The problem of glaucoma has often ended in what appeared to be an impasse; but these recent suggestions may open a new-field in ophthalmic therapeutics.

EDWARD JACKSON.

RETINAL CAPILLAROPATHY The invention of the ophthalmoscope

did more than expose to view during life the vital structure of the organ of vision. It placed before our eyes, in the living subject, a portion of the brain itself, with the ramifications of its blood supply in health and disease. For the retina is a highly specialized outgrowth of the brain, subject in large part to the same vascular disorders, the same degenerative changes, as occur in the brain itself. Many lessons as to cerebral pathology have been de­duced from the pictures disclosed by the ophthalmoscope; and the story is still be­ing unfolded.

For a long time the chief emphasis in regard to vascular disease in the retina was upon the larger vessels. But from retinal arteriosclerosis we have now progressed to thinking more seriously of