jams, the wound for the extraction of the needle was enlarged, and an incision carried down through the intercostal muscle one and a half inches to the left of the sternum in the fifth interspace, keeping as nearly as could be to the point of entrance of the needle. A careful dissection soon carried us through the pericardium which seemed to be attached to the anterior wall. About an ounce of thick pus and a considerable amount of puro-sanguinoform half clotted matter was evacuated. No effort was made to make extensive exploration, but the finger detected within the pericardium much soft, fibrous material which was easily broken down. The cavity was flushed with a saline solution and an iodoform wick inserted. No great shock was suffered. The temperature was normal on the evening of the day of the operation, with a pulse of 108, and never again went above 100°. The patient made an uneventful recovery, being discharged cured just twenty-four days after the operation.

The extreme gravity of a case of purulent pericarditis warrants almost any measure that holds out hope of relief. When that measure is so well grounded a principle of surgery as that of the free evacuation of septic material wherever found, it is gratifying to find its application in practice followed by so encouraging results as a review of the preceding cases show. Out of twelve cases here reported, some of which were complicated with diseases in themselves necessarily fatal, there were eight recoveries. It is my belief that under proper precautions pericardiotomy is attended by no greater danger than pleurotomy, and in cases uncomplicated by maladies tending toward a fatal termination, the results will be equally as good. It is the only procedure which justifies itself to the modern surgeon. The danger attending incision and drainage are not to be compared with the danger of expectant inactivity, and I am certain that many of them are overestimated. Pericardiotomy offers the only chance for safety in these cases, and must take its place among the operations sanctioned by good usage and by good

sense.

DISCUSSION.

DR. TIBBALS, Detroit: It is not right to let an interesting case like the one just reported go by absolutely without discussion, and I rise simply for the purpose of congratulating the doctor upon his courage in the management of the case and upon the happy outcome.

DR MACLEAN, Detroit: I think I ought to say that I also have listened to the paper with very great interest indeed; I don't know when I have listened to one more interesting, and in a certain way it is well calculated to endorse the force of the concluding sentence of my own paper. I would like to know how much satisfaction a surgeon would get exploring a case of this kind with an aspirator. In all probability he would have got no information. He might possibly strike the depot with the aspirator but more likely to miss it, whereas if examined intelligently with proper anatomical knowledge he could pass his finger in various directions and explore satisfactorily. The one method is efficient, scientific and accurate, the other is exceedingly indefinite, uncertain and unscientific. I think that is one of the most important lessons taught by this very interesting case, and there are so many more practical suggestions in it that I should like to hear the paper still further discussed.

SIMPLE GLAUCOMA.

EUGENE SMITH, M. D.,
Detroit.

One of the most important affections in the whole range of eye diseases is glaucoma, not only on account of its relative frequency and its disastrous course when left alone or improperly treated, but on account of its curability if properly treated at an early stage. Blindness too frequently occurs from glaucoma. The disease is too often overlooked by the attendant, who may be misled by not finding at the time of examination prominent symptoms of glaucoma, viz., increase of tension and cupping of the optic disc, either of which may exist for a time without marked evidence of the other, and one of which, increase of tension, may be absent at the time of examination but present at some other time of the day.

I think it very unfortunate that the text books portray the cupping of the optic nerve in its complete or final stage when the excavation is deep and flask-shaped, thus leading many to overlook the many cases of commencing cupping or shallow saucer shaped cup. It is quite generally admitted at the present day that a pressure excavation may include only a part of the surface of the disc. This, of course, renders greater care in the distinction between it and the physiological cup necessary and this is a point I wish to emphasize, i. e., that no cup, whatever its shape or depth may be, should be considered as physiological when other symptoms point to the possibility of its being a commencing pathological condition. The visual field and visual acuity must be carefully considered. In my experience the usual course of the excava

tion is this: In the beginning of the cupping process, the center of the optic disc is pushed back, excavated; then one or another portion of the edge sinks in, the vessels being crowded to one side of the disc, the diagnosis of cupping being assured by the bending of the vessels. If we take into consideration these facts, glaucoma will be recognized more frequently and the correct treatment, operation, be employed

I can readily appreciate that even if a shallow saucershaped cup be seen, but increase of tension, shallow anterior chamber and sluggish, dilated pupil be wanting, that the disease may be overlooked; and one object of this paper is to attract attention to the fact that increase of tension is many times intermittent in character in the earliest stages of the disease.

Another feature to which I wish to call attention is the field of vision. If taken in a too bright light, a contraction may be overlooked which would be found to be quite marked, if the perimenter were used in a subdued light. Since the discovery of Graefe and the efforts of his successors it can be safely said that the prognosis is good in a large majority of cases of glaucoma. As operative procedure is the recognized remedy, the earlier the disease is diagnosticated and the remedy applied, the better the chance of cure.

In the incipiency of glaucoma, where the symptoms are slight and seemingly increase slowly, one will undergo no great risk, if in doubt, if he directs the treatment towards keeping away all sources of injury which may tend to aggravate the condition, particularly the removal of all disorders of the circulation. But as soon as he is satisfied that the condition of glaucoma is present he should advise operative

treatment.

The surgical treatment of glaucoma necessitates great prudence. Iridectomy is a double edged sword, and while it proves successful even when poorly and incompletely done in the inflammatory type, it has been known to be ineffectual in the simple form, and in many cases it has been followed by

disaster. What, then, shall be the operative procedure in these cases?

In 1873, while attending Mr. Bader's clinic at Guy's Hospital, my attention was attracted to a simple section of the sclera (sclerotomy) in glaucoma. Later I found that De Wecker, Galezowski, Mauthner and others were also interested in finding a method which would seemingly re-establish the balance between secretion and excretion, without the danger in many cases incident to the operation of iridectomy per se.

Many methods of making sclerotomy have been proposed. For many years I was in the habit of making a double. sclerotomy with two knives, one in either hand, but of late years I have been better satisfied with the method of De Wecker, using his narrow knife. A puncture and counterpuncture are made in the sclera as far as possible in the periphery of the anterior chamber, similar to the Graefe extraction section. The section is enlarged upward until only a bridge of sclera about 3 m. m. in breadth is left, when the knife is withdrawn slowly and the handle depressed in such a manner as to sweep the uncut portion of the filtration zone, between the puncture and the counter-puncture, with the point of the knife. Before the operation a one-grain solution of eserine should be instilled several times and the pupil contracted ad maximum. The pupil should be kept contracted for some days after the operation with a solution of eserine or pilocarpine.

In my experience when the disease has been recognized and the operation made early, a very large percentage of cures has followed. I believe iridectomy should be entirely relegated to the acute inflammatory cases, and only sclerotomy made in the simple forms of glaucoma. The operation can be repeated several times if necessary.