of the means of estimating his fitness. We may ask how it is possible that the physician, who is qualified to pass such an elaborate examination on laboratory methods, can possibly give any time whatever to his preparation for the practice of medicine? The fact appears to be, that in order to pass such examinations as this, the candidate must absolutely exclude from his consideration, during his entire college course, all questions in regard to the actual practice of his profession, all his time being required to post himself on the laboratory methods.

The practical application of this system may be seen in an examination recently held in one of the western states: Seven candidates presented themselves, four being old practicians, three of them just out of college; the latter three passed with flying colors, but all the four old practicians were excluded. It hardly seems necessary to ask which of these classes were actually qualified to attend to the sick successfully. A man may be proficient in the use of the microscope, be perfectly able to make widal tests, or a diagnosis by cryoscopy, be even well up on serum therapeutics, the X-ray, static electricity, hydropathy, or omotherapy, and be able to demonstrate his efficiency in chemical, physiologic, and all the other laboratories which now for ma part of the student's curriculum, and nevertheless be thoroughly incapable of diagnosing a case in the sick room or of applying the remedies suited to that case in time to be of service.

Socologically, this matter is of serious importance. It is contrary to sound political principles that anything should be done to hinder the free passage of individuals from one state to the other. Men leave one state in the union, pass to another one and settle there; and this favors the homogeneity of the population and prevents the development of sectional feeling and sentiment. It is therefore a matter to be encouraged whenever it is possible. Circumstances frequently arise, which we well know, in the life of a physician,

when it is desirable for him to change his location. Hs health may gve way, hs wfe may become consumptive, his children may exhibit such delicacy as makes it desirable for him to change his location. Under the operation of these laws, a practically insurmountable obstacle is placed in the way of his doing this. It is impossible for him. to leave one state and go to another, without first taking considerable time and going to a great expense for special preparation in order to enable him to pass these examinations. In our selfdenying profession this is not always possible for a physician to do. Too many of us pass through life in the active work of our professions, never being able to give to our financial problems more attention than is just sufficient to secure us our daily bread; and when called upon for a large outlay, such as would be necessitated by such a preparation, we are unable to lay our hands upon the means. men to whom this remark applies are by no means the least qualified in their profession.

The

Anything which interferes with the free movement of physicians from one state to another, is, therefore, a hardship to the individual and to the profession, and a detriment to the community at large. It has been suggested that a remedy for this might be found in the institution of a national examining board, whose license would be equally good in all parts of the United States, in fact, wherever the flag flies the license to practice could be carried with it. Such a measure, however, would be contrary to the Constitution of the United States, which distinctly reserves to the individual states the power of regulating their domestic affairs; and by no stretch of imagination could the right to practice medicine be considered anything but a domestic affair. We have departed very widely from the Jeffersonian idea of a correct balance between the central government and the states on which the whole theory of our government is founded. The pendulum has swung, since the

opening of the Civil War, very far to the side of the central government, too far, many of us believe, and it is high time that it should swing back. Such a regulation is therefore undesirable in many points.

The only way at present for securing relief from this abuse seems to be in the development of the principle of reciprocity between the state boards. This has been recognized by some of the state examining state boards. This has been recognized by some of the state examining boards to a large extent, so that many of the states publish lists of other states with which they reciprocate. The difficulty is in the varying requirements of the various states; each may be willing to reciprocate with other states whose requirements are similar to its own, but as long as men will differ upon such a subject it is certain that the various boards will make different requirements. However, a sentiment of mutual forbearance and concession will go far toward extending this matter. The state examining boards are, after all, members of our own profession, and it seems certain when the profession voices its desires in this matter they will be given due consideration. It is, therefore, a wise thing that we, instead of simply voicing our discontent for the present arrangement, should signify our wishes in the matter by resolution and otherwise to the various state boards, that they may have the sentiment of the profession, especially when assembled together in organization, upon this topic.

In this connection I would speak a word of commendation for the state examining board of the state of Illinois, which has in many ways evidenced its desire to interpret the laws by which it is governed in the true interests of the medical profession and of the people. To it is due the credit of having inaugurated a great reform, by making a generous allowance to each practician for the number of years he has been in actual practice, this to be credited to

him besides the number which he makes on this examination. The justice of this is so obvious that we trust we will see it adopted by other state boards.

It is to be hoped that these boards will also pay more attention to essentials and less to technicalities in their examination. One board, for instance, refused a properly qualified physician the right to present himself for examination, because it happened that a very small part of his education in chemistry had been taken in a college not medical. There was no question, whatever, as to his proficiency in chemistry or in any other branch. Such pedantary is calculated to make state board examinations ridiculous and excite a prejudice against them in the minds of all healthily constituted people characterized by the possession of common sense. As such instances of incapacity are multiplied the hands of these men will be strengthened who opopse state boards altogether, and urge a return to the old system of free practice for anybody who wishes to practice. Under present conditions this could be little less than a disaster to the community, and anything that tends in any manner to lead to it should be discouraged. In brief our objections to the present system seems to be that some medical examining boards have totally forgotten both the interests of the people at large and those of the medical profession, and to operate wholly for the benefit of certain not very practical branches of education in the medical colleges.

A law has been enacted in Denmark regarding syphilis. Under this law the police may punish as vagabonds females who cannot show their ability to earn a living in a decent manner. Anyone suffering from syphilis is entitled to a free attendance at the hands of certain medical men appointed for this purpose and paid from public funds. The act has very materially reduced the incidence of the disease.

*SOME OBSERVATIONS ON GLAUCOMA.

L. HAYNES BUXTON, M. D., LL. D. Member of the American Academy of Ophthalmology and Oto-Laryngology-Oculist to Oklahoma State Baptist Orphanage and St. Anthony HospitalProfessor of Ophthalmology, Medical Department of Epworth University, Oklahoma City. This paper does not presume to review the literature of glaucoma or to give a treatise of the disease, which would require a large volume, but rather to present some personal observations and conclusions upon the etiology and pathology of the disease and its treatment.

A general knowledge of glaucoma is of vital importance to the general practitioner, for in no disease is an early diagnosis more important. After destructive changes have occurred in the optic nerve, treatment directed to restore sight is of no avail, hence a tardy or mistaken diagnosis is fatal.

A familiar acquaintance with the anatomy of the iris angle and the physiology of intra-ocular pressure are necessary to an intelligent consideration of glaucoma. Therefore I desire to note a few of the many points of interest in the anatomical structures and their physiological actions that have to do with maintaining a normal intra-ocular pressure, as well as to call your attention to the pathological changes that produce an increase of that pressure.

Although the disease was recognized from Hippocrates down through the following centuries, nevertheless no observer mentions the hardness of the globe and increase of its watery contents until Mackenzie in 1830. The discovery of the ophthalmoscope brought a new era to ophthalmic knowledge, and Jules Jacobson in 1855. and Jaeger and von Graefe in 1854, made investigations which materially increased the circle of the knowledge of glaucoma. Yet these observers

*Read before the Medical Association of the Southwest at Hot Springs, Ark., 1907.

failed to connect the discoveries of Mackenzie (1830) with the etiology of the disease. It remained for v. Graefe, in 1869, to present the idea that intraocular pressure produces the symptoms of simple glaucoma. From observations upon animals, v. Graefe advocated iridectomy as a cure for glaucoma. In the sixties many ophthalmic workers made observations associating glaucoma with increased activity of the secretory nerves, attributing glaucoma to irritation of these nerves or nerve centers. From 1856 to 1876 nearly all the students of ophthalmology were little by little adding to the general knowledge of the disease. In the centennial year of our national independence, Max Knies and Adolph Weber, working independently, gave to the ophthalmic world the key that has unlocked many of the mysteries of this disease, viz., pathological changes in, or obstruction of, the filtration angle of the eye. Hence the dates and the men to remember in the history of glaucoma are: Mackenzie, 1830; Jules Jacobson, 1853; v. Graefe, 1856; Max Knies and Adolph Weber, 1876.

Increased intra-ocular tension, be it primary or from a secondary cause, stamps the case as one of glaucoma. The tension of the eye depends upon the amount of fluid in the eye, increased tension-increased fluid. This may be due to (a) over-secretion, or (b) impaired filtration-usually the latter. This process of filtration is mechanical in its nature, as is demonstrated by the fact that glaucomatous eyes often remain hard after enucleation, while other eyes become soft, filtration but not secretion continuing after removal.

Although glaucoma covers all those conditions in which there is a pathological increase of intra-ocular tension, nevertheless there is a wide pathogenic difference between a class of cases(a) with moderate increase of tension, deep anterior chamber and more or less ciliary inflammation, and another class-(b) with all grades of increased tension, shallow anterior chamber, and

wanting in definite signs of ciliary inflammation, although there may be marked signs of congestion and inflammation. The clinical history and treatment of these two divisions of glaucoma widely differ. As much of my paper has to do only with the second group, I will briefly mention at few differences between the first group, or spurious glaucoma, and the second group, or true glaucoma. Priestly Smith in 1891 showed that ascitic fluid, blood serum and other highly albuminous fluids, escape very slowly from the anterior chamber. We know that in

sub-acute forms of Irido-cyclitis the aqueous become albuminous and that leucocytes are deposited on the posterior surface of the cornea. In these very cases we have what we would expect an increased tension due to inability of the filtration angle to carry off the changed fluid. We have raised tension, wide filtration angle, deep anterior chamber, chamber, and a wide pupil from backward pressure on the periphery of the iris. In this condition the secretion of the ciliary vessels, due to inflammatory changes, is the prime cause in producing these results. Par

The lens is slightly luxated to one side. The condition of the iris is the most interesting in this case. It has become split-the posterior pigment layer is separated from the body of the iris and is adherent to the lens while the body of the iris is pushed forward except where the margin is attached to the lens producing seclusion of the pupil. The seclusion was complete and there was no communication between the posterior and the anterior aqueous chamber. Cicatricial tissue changes occurring around the lens have produced such results as would be expected, namely, the form has become more spherical. We know that a

sphere has the smallest surface relative to its contents of any body, hence as surrounding contraction takes place, the normal lens assumes more and more the shape of a sphere. In this case the luxation of the lens and changes in and around the lens must have occurred at an early age. The case well illustrates how an iridectomy may fail to help when part of the iris has united with the lens, the anterior portion being the only portion accessible for an operation.

The detached retina is also incidentally shown in this specimen. A small amount of connective tissue joins the margin of the retina to the lens.

sons of London does not think that this alone is a solution of the problem of the deep anterior chamber, for in true glaucoma of the second group of cases, the obstruction of the filtrate angle, although of another nature, is nevertheless in each case physical or mechanical. If we accept the conclusions of Leber the solution is more complicated. Leber considers the eye a hollow sphere, so far as pressure is concerned. Fluid easily passing from the aqueous to the vitreous chamber, also the diaphragm separateing the chambers being easily movable.

True glaucoma of the second group may be better considered under two classes: First, primary or idiopathic acute and chronic glaucoma; second, secondary glaucoma. The problem involved in determining the etiology of primary glaucoma are much more in

tricate than those of secondary glau

coma.

The loss of sensitiveness of the cornea during an attack of glaucoma is due to pressure on the nerve filaments from fluid which collects in the nerve canals in Bowman's membrane. These rupture where the epithelium is raised. Pressure of the nerves against the sclerotic may also cause diminished function of the nerves of all parts of the ciliary region and the iris.

The haziness of the cornea seen in glaucoma is due to displacement by pressure of the fibrillae of which the cornea is composed. This can be artificially produced in the eyes of animals. Upon the removal of pressure the cornea resumes its normal condition.

The dilatation of the pupil in advanced cases of glaucoma is due to

Also the changes in the iris, atrophy due to irido-cyclitis praecipitates, as is gree of infiltration, shows that the case is one of secondary trouble, a glaucoma following a prior inflammation. A new layer of cicatricial tissue has

formed on the anterior surface of the iris from changed endothelium. The pectate ligament has been replaced by cicatricial and connective tissue. The iris angle is completely obliterated. The place of incision for a useless iridectomy is shown on the cornea.