770 PEKCY FRIDEKBERG 



} 



How can we reconcile these observations with the known facts that the 

 pupil in and after middle age tends to be small and somewhat spastic, 

 especially in hyperopes, and that under these circumstances there is rather 

 a resistance than a susceptibility to atropin? 



The clue is given, I am convinced, by the factor of acute paralysis of 

 vagus activation under the influence of emotion, fatigue, cold, or other 

 vago-depressing agencies. When such factors act on a structurally pre- 

 disposed eye, as described above, the outcome is apt to be an acute attack 

 of glaucoma. Given the opposite type of eye, i. e., an eye with myopic 

 build, large pupil, deep anterior chamber, and roomy circumlental space 

 with a rather thin and non-rigid sclera already established by the axial 

 elongation, and the endocrin storm may well pass over without a sudden 

 rise in intra-ocular tension. Here, the ocular symptoms are those of sym- 

 pathetic irritation, and when the attacks are repeated often we may 

 have all the appearances of Graves' disease. 



Glaucoma and exophthalmic goiter would on this supposition be mu- 

 tually exclusive, to a degree, if not completely. Or, otherwise expressed, 

 the emotional and other stresses which deplete the vagotonic system, par- 

 ticularly excessive sympathetic irritation via thyroid irritation, produce 

 either an acute attack of glaucoma or a tendency to exophthalmic goiter, 

 according to whether the eye is hyperopic and vagotonic, -or, on the other 

 hand, myopic and sympathetico-tonic. v. Hippel found evidence of thy- 

 mus, as well as of thyroid, hyperplasia in his cases of glaucoma. 



Glaucoma. Theories of causation of pathologically increased intra- 

 ocular tension are as leaves in Valombrosa, or as cures for hay-fever. 

 Through all the hypotheses there has run, however, the red thread of 

 a possible neurotic factor. The purely mechanical theory of predisposing 

 topographic relations, of the combination of a large lens, flat anterior 

 chamber, hyperopic refraction, was superseded or rather completed by 

 the idea of an edema of the vitreous, a conception taken over almost 

 wholly from colloidal chemistry. 



Hamburger's theory assumes that the entire iris acts as a sponge in 

 contact with anterior chamber and that this tissue is of paramount im- 

 portance for fluid exchange, while the canal of Schlemm, despite Leber, 

 is of little value. Paralysis of the pupil and lowered sensibility of the 

 cornea are explained by the influence of the central ( ? vegetative) nervous 

 system. Racial predisposition of Jews shows nervous ( ?) factor. 



Etiology. Emotional stress, worry, fatigue, cold, thyroid depletion 

 by climacteric changes, and chronic infections. 



Glaucoma is almost without exception an affection of later middle 

 life coinciding with the menopause and the male climacteric. Emotional 

 disturbances, especially those like prolonged worry from business trou- 

 bles or ill health which deplete the endocrin (adrenal) reserve, are 

 important factors, as are repeated exposure to cold and fatigue. The 



