Mr. President and Members of The Chicago Ophthalmological Society:

As the hour is late I propose to take up only the principal points in connection with my subject and to deal with each one shortly.

First: The operation of trephining is suitable, not merely for chronic cases, but for sub-acute and acute cases of glaucoma as well. I would urge on your attention that, of all the operations dealing with glaucoma, this one involves the minimum of surgical violence, and should, therefore, in acute cases be the operation of choice. It is, moreover, much safer than any other operation I know of, and is no less certain in its results. I do not advise trephining in the secondary glaucoma following intumescent cataract, for in such cases the semi-fluid lens bulges into and blocks the trephine hole. Nor for obvious reasons do I recommend it in cases where there is reason to believe that a communication exists between the aqueous and vitreous chambers.

Second: The object of trephining is to tap and permanently drain the aqueous fluid from the anterior chamber of the eye into the sub-conjunctival space; in doing so it is essential to avoid as far as possible all interference with the uveal tissue. The purpose of an iridectomy is to avoid the danger of the iris in the neighborhood of the wound being drawn and impacted in the trephined hole. We have found in a large number of cases in which an iridectomy has been omitted, that the results have been in no way inferior to those in which a piece of iris has been removed, provided always that no subsequent iris prolapse takes place. In pursuance of our purpose to avoid uveal tissue, we split the cornea, and place the trephine as far forward as such splitting will allow, and we bear on the trephine in such a way that it cuts through on the corneal edge of the wound first. This insures establishing our fistula in the most anterior position possible, and, therefore, as far away as possible from the ciliary body and the angle of the chamber.

Third: The difficulties of the operation. Far too much stress has been laid on these. Trephining is an operation which can be performed by any surgeon who is used to ophthalmic manipulations, and who has good sight. It is essential that he should work in a good light. The necessary technique can be acquired from a written description. It is not for a moment necessary that the surgeon who wishes to learn trephining should see the originator of the operation at work. If, however, he feels diffident at undertaking the procedure until he has seen it done by another, there are many centers in this country where the operation is now being successfully performed. I would mention amongst those which I have visited New York, Minneapolis, St. Louis, Nashville, Louisville, Detroit and Chicago. I have seen results of trephining by American surgeons which could not be bettered anywhere.

Fourth: I am sure that everybody will recognize the difficulties of operating during such a tour as I am now making. I have so far in the last month performed over seventy trephinings in ten cities, and in twice as many clinics. To adapt one's self to different clinical methods, different assistants and different nurses is so difficult that, as you are aware, many distinguished surgeons refuse to work out of their own clinics. One cannot expect the results of such a tour to be on a par with those one obtains in one's own quiet daily surroundings. I am, however, confident that you will make a generous allowance for these difficulties, and I gladly welcome the suggestion that all the cases which I have operated on in America be collected together and reviewed as a whole.

Fifth: In conclusion I would like to express the pleasure with which I listened to Dr. de Schweinitz' paper. I believed from the title that there might be a wide divergence of opinion between us. I find to my great relief that we are in absolute accord. I know, however, that there are in America and elsewhere able men who consider that the medical treatment of glaucoma should be pushed as long as possible. I cannot but feel that this is a survival of the dread that most surgeons have felt in recommending one of the older operations for glaucoma. We have now in our hands a method so safe, so easy and so certain that I feel sure that this dread will ere long pass away, and that the diagnosis of glaucoma will then be followed by a very early operation. In India I have gone farther than this, and where one eye has shown high tension, I have frequently trephined both. The prophylactic use of the operation is more than justified in that land of long distances and scattered medical aid, and where the patient is not likely to return a second time for surgical help. This prophylactic trephining is a proposition that I put before you today for your consideration, reminding you at the same time that glaucoma is practically invariably a bi-lateral condition. I have seen even in America not a few people blind in both eyes who might have retained the sight of the second eye had the surgeon advised a double sclerectomy when he first saw the case, despite the fact that the second eye was then to all appearances non-glaucomatous.