An Address on THE PATHOGENESIS OF ACUTE PRIMARY GLAUCOMA
Authors: A. M. Ramsay
Journal: BMJ (1928)

GLAUCOMA is niot a disease in itself, but rather a symptom- complex whlose characteristic feature is increase in thm tension of the eyeball.It was, however, the peculiar greeiiish reflex from the pupil that first attracted atten- tion and suggested the niame glaucoma.Centuries had to pass before William Mackenzie drew attention to the lhardniess of glaucomatous eyes.That was the first observa- tion of real value in the study of glaucoma, and may be regarded as the foundati,on of all present-day knowledge of thei subject.Whlen considered from the clinical standpoint glaucoma may be primary or secondary; primary when it is unasso- ciated with any other disease in the affected eye, and secondary when the glaucomatous seizure arises as a com- plication of a pre-existing pathological condition.The attack is acute or chronic, according to the presenoe or the absence of congestion of the ocular blood vessels, but iniflammation in the strict sense of the word never occurs during the course of acute primary glaucoma.Venous congestion is alone responsible for the severity of the sym- ptoms, which vary greatly in degree in different cases.In the miiajority they are subacute and recurrent, but in a small proportion they may be described as fulminating.In these circumiistances glaucoma is seen in its most tragic form-thle onset, course, anid termination being the inci- dents of a few hlours.A single attack occurring with dr-ramatic suddelnnless results in total and irrevocable loss of sight.Such a disaster is all the more overwhelming, because glaucoma usually affects botlh eyes, and although onie may be attacked considerably in advaance of the other, yet in a few desperate cases both suffer simultaneously. SYMPTOMATOLOGY.Acute glaucoma, cani be described as one of the emer- gencies of -general practice, and in many instances it- appears to come as a bolt from the blue.The patient goes to bed apparently in his usual health, but in the early hours of the morning is awakened by agonizing pain in the head, accompanied by feverishness, nausea, per- sistent retclhing, and -biliou.svomiting.The condition is so alarmingi that the family doctor is sent for in haste, and uinless he knows well what lie is about he may easily do the patient more harm tllan -good.It is quite probable that no: one will speak about the eye, because even although tlle failure iii -vision has been iioticed, it has been tacitly assume,d to be duie to biliousness.The attention of the patient and of those surrounding him is occupied wholly as a rule with the severity of the pain in the head, the nausea, anid the vomiting.The true nature of the condition, therefore, may be easily overlooked, anid if the doctor is also deceived the result will be deplorable.Acute glaucoma is not by any means a common disease.It may happen that a medical man has been many years in practice before lie is called to treat a case.He ought, however, always to bear the disease in mind, and never to 'forget to examinne the eye of a patient said to be suffering fromii a severe bilious attack.Every country doctor ought to be able to recognize acute glaucoma.TThere is not much difficiulty in the diagnosis.The eye is tender and the patient shrinks from -the'slightest touch; it is hard, and said to feel too big for its socket.The bulbar conjunctiva