On the division of the ciliary muscle in the treatment of glaucoma, as compared with iridectomy / by Henry Hancock.
- Henry Hancock
- Date:
- 1860
Licence: Public Domain Mark
Credit: On the division of the ciliary muscle in the treatment of glaucoma, as compared with iridectomy / by Henry Hancock. Source: Wellcome Collection.
Provider: This material has been provided by The Royal College of Surgeons of England. The original may be consulted at The Royal College of Surgeons of England.
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![the Lancet,] ME. HANCOCK ON THE DIVISION OF THE CILIAKY MUSCLE IN GLAUCOMA. [Oct. 6, I860. ON THE DIVISION OF THE CILIARY MUSCLE IN THE TREATMENT OF GLAUCOMA, AS COMPARED WITH IRIDECTOMY. El- HENKY HANCOCK, Esq., F.R.C.S., SENIOR BURGEON TO THE ROYAL WESTMINSTER OPHTHALMIC HOSPITAL, ETC. ETC. A recent number of a medical journal contains a paper, by Mr. J. YV. Hulke, entitled “ Glaucoma and Iridectomy,” in which it is stated by that gentleman that Yon Graefe’s opera- tion of iridectomy “ is the only known successful treatment of this previously incurable disease” (glaucoma). Mr. Hulke, it is well known, is, and has been, a very strenu- ous and consistent supporter of Von Graefe’s operation, and he is also well known to have been an equally strenuous opponent to my operation of dividing the ciliary muscle, from the time it was first announced in October, 1S59, up to the present period, as is shown by his letter published in The Lancet of the 19th of November last, and more recently by his paper, read before the Medico-Chirurgical Society on June26th, I860. Of this no one can reasonably complain. Mr. Hulke has every right to entertain an opinion of his own, and to support the one operation m- opposition to the other if he thinks proper to do so; but it becomes quite another matter when he so un- hesitatingly makes an assertion (to use his own expression) “ so utterly at variance with fact,”* and one which he cannot pos- sibly substantiate. My first operation for the division of the ciliary muscle was performed on the 9th of September, 1S59; and on the 11th of February, 1S60, I published an account of the operation, with cases; at the same time stating that I was led to adopt this mode of treatment from the belief “ that the pathological and ophthalmoscopic appearances of the bloodvessels in glaucoma were due mainly to the constriction exercised by the ciliary muscle;” and that to remove this constriction I operated as follows—“ I introduce a Beer’s cataract knife at the outer and lower margin of the cornea, where it joins the sclerotica. The point of the knife is pushed obliquely backwards and down- wards until the fibres of the sclerotica are divided obliquely for rather more than oue-eighth of an inch; by this incision the ciliary muscle is divided.” This is the description of my operation which I published: it does not contain one word about “ striking a knife through the ciliary region towards the axis of the globe,” which is the incorrect version given by Mr. Hulke—a proceeding which would be carefully avoided by anyone conversant with the anatomy of the eyeball, from the risk of wounding the lens which would inevitably attend it. As my operation has now been before the profession above twelve months, and still continues to be attended with the best Tesults in the hands of my colleagues and myself, I cannot admit that iridectomy is the only known remedy for glaucoma. I propose, therefore, to consider, in the first place, the validity of Mr. Hulke’s objections to my operation, as set forth in the paper already alluded to, and read before the Royal Medical and Chirurgical Society. Next, to inquire into the results of the operation of iridectomy, as furnished by Dr. Bader’s papers in the “ Ophthalmic Hospital Reports” (Nos. 9 and 10); and lastly, to give the results of my own operation up to the pre- sent time, with my reasons for submitting it to the profession, not as the “ only known,” but as the best operation for the treatment of glaucoma. 1. The principal points upon which Mr. Hulke insists are, <l That the leading features of glaucoma are due to excessive tension of the eyeball, from a superabundance of fluid within it, which distends the vitreous humour; that this fluid (serum) is derived mainly from the choroid; that it might be considered a serous choroiditis.” 2. “ That the excessive tension of the globe is suggestive of tbe evacuation of some of the superabundant fluid by tapping.” 3. That he has “demonstrated, by microscopical examination, advanced atrophy of this muscle (ciliary) in many glaucomatous eyeballs; whence it follows tl;at the ciliary muscle is not actively concerned in maintaining the glaucomatous process.” 4. “ To avoid certain alleged disadvantages, paracentesis • The Lancbt, Nov. 19th, 1859. sclerotic® has been advocated by Middleraore, Desmarres, and Hancock.” 5. “ That in all probability the success of Mr. Hancock’s operation is solely due to the drawing away of some of the superabundant fluid. According to this view, it is simply a peculiar mode of paracentesis, and cannot rank as a substitute for ‘ iridectomy,’ until it has been thoroughly established that it permanently relieves excessive intra-ocular pressure,” which, in common with most surgeons, Mr. Hulke has found that tap- ping the vitreous humour fails to do. The assertion, “ that the leading features of glaucoma are due to excessive tension of the eyeball from a superabundance of fluid within it,” and that “ excessive tension of the globe is suggestive of the evacuation of some of the superabundant fluid by tappipg,” are contradicted and rendered untenable by other portions of Mr. Hulke’s paper; whilst the results he gives of the operation of iridectomy directly prove, that the operation is only of value when the fluid, for the evacuation of which it is performed, is actually not in existence to be evacuated. We are told that the reason why iridectomy has failed in the hands of some surgeons “ has proceeded, in many instances, from its having been performed at far too late a period that the propriety of operating in the premonitory period cannot be doubted that in acute glaucoma, where the operation is done during the first inflammatory attack, or soon afterwards, vision is very completely restored; whilst, in chronic glau- coma, the results are less uniform and less decided.” We may hence infer, that three stages of this disease are re- cognised: the premonitory, the acute, and the chronic, and that the success of the operation is greater the earlier it is performed. It is this great practical fact which seems to me to be fatal to Mr. Hulke’s theory of glaucoma being due to a superabundance of serum distending the “ vitreous humour,” more especially as that gentleman, in the same paper, describes the vitreous humour as being “unnaturally firm in this disease;” and that it is only at a late period, when all the component structures are undergoing atrophy, that the vitreous humour becomes fluid, at which time the results of the operation are admitted to be “ less uniform” and “less decided.” And I am still further supported in the opinion I have expressed here and elsewhere, that fluid is not the cause, but the result, of the disease termed glaucoma, by the following very corrobora- tive paragraph, extracted from Mr. Hulke’s paper on the “Pathology and Morbid Anatomy of Glaucoma,” read before the Medico-Chirurgical Society, Dec. 12th, 1857:—“With a view to relieve the tension of the globe, I have seen the scle- rotic freely punctured with an extraction knife, after which firm counter-pressure with the finger upon the opposite side of the globe only caused the protrusion of a very small bead of yellowish vitreous humour, such great firmness had it.” Whether the tension of the globe was relieved by the puncture is not stated. Nor is it by any means so conclusive as Mr. Hulke appears to imagine, that, because he has “ demonstrated advanced atrophy of the ciliary muscle in many glaucomatous eyeballs, this muscle is not concerned in maintaining the glaucomatous condition.” The word “many” is very indefinite and incon- clusive. Mr. Hulke does not state in how many instances he has found this muscle atrophied, or what proportion these in- stances bore to the number of glaucomatous eyeballs which he examined microscopically. He does not inform us whether these glapcomatous eyeballs were obtained after the death of the patient or before, or, if from the former, the time which had elapsed between the death and the examination; for the changes which take place, especially in diseased eyes, are so rapid, thfit very little reliance can be placed upon such exami- nations when they have been deferred for any length of time. Neither, where the glaucomatous eyes which he examined had been obtained from living patients, does he tell us the stage of the disease at which they were extirpated, or the circumstances which necessitated their extirpation. It had been but justice that these particulars should have been mentioned before a sweeping pathological statement was unhesitatingly advanced. I have already alluded to the three stages of glaucoma de- scribed in Mr. Hulke’s paper—the premonitory, the acute, and the chronic; to his admission that it is only late in the dis- ease that the component structures of the eyeball undergo atrophy; and that whilst iridectomy is most successful during the first two stages, its results are less uniform and decided in the last; whilst Dr. Bader states, in his report, “that the prognosis of chronic glaucoma depends upon the stage in which the eye affected is operated upon: when blind for some time, it is not expected to regain sight; a chronic glaucomatous eye, with mere perception of light, is rarely improved by operation.” 337](https://iiif.wellcomecollection.org/image/b22435980_0003.jp2/full/800%2C/0/default.jpg)
