shrinking of the stroma of the iris from connective tissue changes and shortening by adhesions, also from synechia. in its perispherical area. By this very shortening the blood vessels appear numerous as they are brought nearer together.

vances.

Primary glaucoma may be induced. by a physiological change as age adAfter forty years the lens becomes thicker, firmer, and the anterior chamber shallow; hence more and more danger from glaucoma. The narrow shallow anterior chamber may be physiological and hence where hypermetropia exists there is more danger of glaucoma.

Secondary glaucoma is due to pathological changes in the eye. These two glaucomas, primary and secondary, are clinically different, but not different from a pathological standpoint. In long standing cases of secondary glaucoma you will see little or nothing of

the stroma of the iris as atrophy and absorption has taken place.

Among the many causes of secondary glaucoma we note the following:

Luxation of the lens, either spontaneous or from traumatism, either laterally or into the vitreous or into the anterior chamber.

Injury of the lens and swelling of the lens substance also produce like results. Operations upon the eye may be followed by glaucoma.

Perforating wounds and ulcers of the cornea followed by incarceration of the iris produce a very dangerous condition liable at any time to set up intraocular pressure.

The essential factor in these cases is a more or less obstruction to the filtration angle from adhesions.

In some fundus changes which have no relation to the anterior part of the eye, glaucoma follows, as in case of retinal hemorrhage and tomors. This

iris. On the right the pigment layer is pulled over the anterior surface of the pupillary margin, as is often the case when contraction and atrophy of the iris occurs. On the left the filtration angle is completely obliterated. The stroma of the iris and that of the cornea are united.

knife or a keratome and should be one
and one-half mm back from the cornea
in the scleral tissue and at least
eight mm in length, following the
curve of the cornea. Now one
of
two methods can be employed: One,
used often in the Royal Ophthalmic
Hospital, London, in which the iris is
seized firmly with a forcep and a sec-
tion "torn out by its roots. The other
method, which I prefer, is to seize the
iris, pull it strongly to one side of the
incision, cut one-half close to the globe,
then pull likewise to the other angle of
the incision and cut in like manner.

In the shallow anterior chamber the
knife is preferable to the keratome, as
the keratome is more liable to injure
the lens. In Fuch's Clinic, Vienna,
Heine's operation of cyclodialysis is re-
sorted to where the anterior chamber
is so shallow as not to permit the usual
iridectomy operation or where the
iridectomy has failed to give relief.
Meller, chief assistant in Fuch's Clinic,
stated to me that the operation was
without serious danger. That in most
cases the eye became soft to normal
tension in two or three days after the
operation. In older cases a longer time.
elapsed; that sometimes the tension
did not return. In this clinic the op-
eration was considered one of much
value. Heine prefers cyclodialysis to
iridectomy in many cases. Cases of
double operation in which one eye was
operated upon by iridectomy and the
other by cyclodialysis, the latter
showed the most favorable results. He
considers it less dangerous than iridec-
tomy. These conclusions are based
upon fifty-six operations.

The operation is as follows: An in-
cision through the conjunctiva and the
sclera two mm long is made five mm
from the sclero-corneal margin parallel
with the same. Scissors are used to cut
the conjunctiva, and the point of a
keratome the sclera. Now, a very thin
metal iris replacer is carried under the
sclera, hugging its inner surface, into
the anterior chamber, the point enter-
ing between the pectate ligament and
the sclera, the point is swung about

to make a free opening into the an-
terior chamber and then withdrawn.
Care is exercised to make the incision
between the ciliary vessels.

In cases of hopeless, painful glau-
comatous eyes, optico-ciliary neuroto-
my proves of value to the patient, re-
lieving them of their suffering and does
not disfigure as does enucleation.

I desire to report one case to illus-
trate under what erratic and variable
forms glaucoma may appear, violating
all rules: In 1905 I was called by Dr.
Earnheart of Oklahoma City to see a
patient in his practice. Found an un-
usually plethoric, robust girl of twelve
years of age, who always had enjoyed
perfect health. Prior to her present
trouble she had not had change in sur-
roundings or diet and no excessive use
of the eyes. Three days before my
visit she had suddenly been seized with
a pain in the left eye followed by red-
ness and heat. From the first this con-
dition had grown more and more se-
vere until when I saw her she had been
unable to sleep for twenty-four hours
and had been confined to the bed moan-
ing with pain in her eye.

A superficial examination showed
the symptoms of an acute iritis, but
upon more careful scrutiny I found ten-
sion markedly increased, cornea cloudy
with sensation greatly reduced. All the
symptoms of an acute primary inflam-
matory glaucoma were present. Anti-
phlogistic treatment with eserine was
diligently employed for eight hours
with no favorable results, and as the
case was growing worse, I made a very
broad iridectomy. In two hours the
girl was asleep. The case made an
uneventful recovery. The other eve
was and has always remained normal.
Two weeks ago, after eighteen months,
I refracted this eye, gave +1.00 axis
180°, which gave a vision of 20-20.
Since the first attack no ocular trouble
has been experienced. Among other
interesting things in this case, the age
of the patient, the fact that the glau-
coma affected only one eye, the un-
known cause, and the perfect results
from the iridectomy are noticeable.

REPORT OF SOME ABDOMINAL

CASES.

WILLIAM BRITT BURNS, M. D.

Memphis, Tenn.

Surgeon to City Hospital, Division Surgeon
Frisco System.

Case One-E. A. P. Male aet, 25
was referred to me by Dr. B. F. Tay-
lor, of Marked Tree, Arkansas, October
17, 1905.

I found him at the City Hospital suf-
fering great pain, and crying out.

History-Had acute pains in region
of the gall bladder 15 years ago, last-
ing four days; thinks he had no fever.
Had some pains, not so acute in in-
tervals of one to four months. In ad-
dition to pains, had for eigheen
months prior to coming into my hands,
what he termed "flush-like" risings of
temperature, one-half to one degree,
about two hours after meals; with per-
spiration of legs and palms.

Operation-The usual incision was
made at ninth rib and abdominal
straight muscle. The gall bladder was.
found distended to twice its normal
size, phlegmonous and necrotic areas;
an abscess in the posterior wall of the
gall bladder, containing about a dram
of very white pus. A mulberry, choles-
terine stone .5 cm. by .9 cm. was found
blocking the cystic duct. The stone.
was removed and the operation of chol-
ecystectomy was done. The stump of
the cystic duct was tied off with silk
and a double layer of serous cuff su-
tured over the stump. Abdomen closed
in the usual three layers. There was
not an untoward symptom; he had
neither pain, fever nor accellerated
pulse; left the hospital in absolutely
first-class shape. He was not very
anxious to regain his muscular
strength; he had been a lieutenant in
the German army and was accustomed
to violent and outdoor exercise.
the twenty-ninth day he walked five
miles, in the morning and at about 2
o'clock P. M. of that day, stepped down
off a high coping on the street, and

On

Read before Frisco System Medical As-
sociation, sixth annual meeting at St
Louis, Mo., September 24th and 25th, 1907.

fell to the ground suffering great pain
in region of wound.

I at first attributed his pain to pull-
ing on adhesions in neighborhood of
stump. Waited until the next morning,
and opened up and found the belly full
of bile, and plastic material over vis-
cera. Peritonitis. Death. Autopsy
showed that the omentum which had
gone up and around the stump of the
cystic duct, in the first place had been
pulled away by the sudden and prob-
ably awkward step off of the coping.
Pretty good hard luck story?

Case Two-F. M. Male 35.

History Of syphilis and evidence of
same. I had seen him in several at-
tacks of pain in region of ball bladder.
Diagnosed; cholecystitis with probable
gall stones. Operation was done. The
usual incision was made-at junction
of ninth rib with abdominal straight
muscle. Chronic interstitial inflamma-
tion of the gall bladder was found; veri-
fied by the microscopic examination.
The walls were friable and cholecys-
tectomy was done. Rapid and unin-
terrupted progress up to the ninth
morning, when evidence of pulmonary
embolus set up. His lung was put in
splint. Morphine. Recovery.

Case Three-W. H. Male, age 23.
Gun shot of the abdomen; entering
right flank on level with umbilicus,
passing downward and to the left,
burying in the abdominal wall in up-
per left ilias region. Had been shot
eleven hours. The bullet passed
through one knuckle of small gut and
through mesentery.

Abdomen opened in median line;
perforations closed, wiped with wet
gauze (saline); belly filled with saline
solution and closed. Fowler position.
Recovery.

Case Four-Gun shot wound of ab-
domen. Bullet entered about junction
of ninth rib with outer border of rec-
tus muscle. Two perforations in car-
diac end of stomach and one in mes-
entery. Had been shot three hours.
Wiped out all blood clots and par-
ticles of food, etc., after having closed
Mickulicz drain and
perforations;