Glaucoma | Page 7

these two factors coexist in their varying combinations, pathological increase of pressure results--in short, glaucoma.
Syphilis, rheumatism, gout, auto-intoxication and many other constitutional disorders are well recognized agencies which induce sclerosis in body tissues, so there can be little doubt that these conditions produce pathological sclerosis of the meshwork of the iris angle. Psychic disturbances, congested portal or renal system, hard mental or muscular work, etc., etc., induce increased pressure of the general circulation, and so simultaneously the intra-ocular pressure.
According to the edema theory advanced by Fischer, glaucoma is "essentially an edema of the eyeball, and for its production we must hold responsible the same circumstances which are responsible for a state of edema in any other part of the body." The magnificent experimental work of this investigator has shown that edema is nothing more or less than an increased capacity of the protein colloid tissues for water; that the most important factor leading to this increased hydration capacity is an abnormal production or accumulation of acid content, effected by those agencies which are instrumental in causing sclerosis and an increase of blood pressure.
It seems that both of these theories afford an explanation for many of the secondary pathological manifestations which characterize the intra-ocular tissues during a glaucomatous onset.
Fischer criticizes the Henderson theory on the ground that increased blood pressure alone does not lead to edema--edema is thwarted by high blood pressure. On the other hand, if Fischer believes that sclerosis of the meshwork of the iris angle is a result and not a cause of glaucoma, then it would seem that Henderson has the better of the argument. The physiological changes in this structure, which take place with advancing age, can rightfully be looked upon as a predisposing factor in glaucoma.
Dr. Jackson has presented all other phases of this part of the symposium in such a comprehensive manner that nothing further remains to be said.

Pathology of Glaucoma
BY
JOHN E. WEEKS, M.D.,
New York City.
In reviewing the pathology of glaucoma it seems proper to consider the various structures and tissues of the eye in logical order.
Lids and Conjunctiva. "The only change observed in these tissues is a reflex edema, excited apparently by pressure on the ciliary nerves and, probably, irritation of the vaso-motor fibers of the sympathetic."
Lachrymal Gland. Hyper secretion due to reflex irritation.
Cornea. As has been shown by Priestley Smith, the cornea in glaucomatous eyes is, as a rule, smaller than in non-glaucomatous eyes, the mean of a series of measurements being 11.1 mm. horizontally and 10.3 mm. vertically in glaucomatous and 11.6 mm. horizontally and 11 mm. vertically in non-glaucomatous eyes. In cases of considerable increase of tension, particularly if the onset is sudden, the circulation of lymph in the cornea is interfered with, the anterior layers of the cornea become edematous, the spaces between the lamellae filled with albuminous fluid. Some of this fluid finds its way through Bowman's membrane, apparently by way of the minute channels which permit the passage of small nerve twigs, and enters the epithelial cell layer. The fluid finds its way between the epithelial cells in the deeper layers, apparently being taken into some of the superficial cells by imbibition. Some of the swollen surface cells open spontaneously and discharge their contents, others drop off. The process causes a roughening of the surface of the cornea and produces a faint haziness. There is another form of haziness that develops on sudden rise in tension and completely disappears on subsidence of the tension. This is due, as has been shown by V. Fleischl (Sitzungsberichle d. Weiner Akad. d. Wissensch, 1880) and others, to increased tension on the fibrillae of the cornea, a double refraction being induced. In cases of long continued increase of tension minute permanent vesicles form in the epithelial layers, particularly in the superficial portion. Anaesthesia of the cornea develops, due to pressure on the nerve fibers that are distributed to the epithelium, the compression probably occurring along the course of the long ciliary nerves, from which the corneal nerves are derived, as they pass between the choroid and the unyielding sclera (Collins & Mayou).
In advanced cases of glaucoma after the congestive period has subsided the cornea becomes somewhat condensed, the lymph spaces contracted; a condition of sclerosis obtains. Alteration in the shape of the cornea occurs only rarely in adult life. When it does occur it takes place in corne? that have suffered from keratitis. The alteration is usually in the form of ectasi?. In infancy and early youth (buphthalmia) the cornea may become uniformly enlarged and globular. Often, however, the enlargement of the cornea is irregular. Increase in tension may produce fissures in Descemet's membrane. These occur more frequently in the cornea that have suffered a change in shape, as in buphthalmos. Gaps occur in the elastic membrane which become covered by