Issues Health Illness in 1880. Early in the 1880s I had a long illness with a complete break-down of nervous rigor and energy. The cause was obscure. Leading doctors, physicians of high standing, were unable to help me, unable to understand it or get at its foundation. It looked as if I might not live. Then I chanced upon a book telling of some wonderful cures, well authenticated, that had been effected by suggestion, people being put into mesmeric tranees for the purpose of receiving the suggestion given them. Much I found had been written about it during a number of years past and remarkable experiments had been tried by a doctor whose name I now forget, on patients in a hospital in India maintained in charity for natives. The name Braid comes back to me in this connection but I cannot be sure of it now. This, the work done in this hospital, experimentally, was at the time of the discovery of ether. The physician in charge at the hospital who was trying the experiments found that not everyone was capable of being put into a memneric trance and that it was necessary, when he did suc- ceed, to train the patient for a time to make him, or her, subject to tre influence. But when he did succeed he was able to perform operations of the most serious nature without causing pain or loss of consciousness to the patient. Illness -2 The whole work was carried on on a high scientific plane; there was no charalatanism about it or lack of careful observation, nor lack of understanding by the physician conducting the experimentsof their profound importance. But on the publication of his experiments in England he had been attacked in the leading English medical and surgical journal, The Lancet, in the vilest manner. An account of these attacks being given publica- tion along with reports on the experiments themselves in the book I chanced upon. It made me indignant and showed me how little fair play or intelligence was to be counted on in the medical profession when brought in contact with new ideas. The result was a desire to make experiment of this new force myself and see if it might help me. At this time a remarkable new movement was taking place in Boston as a center but spreading widely out, making use of this same forde apparently but using no mesmeric or other trance to render people suggestable to its influence. A number of people had taken it up and were practicing it under different names. 'Mental healing was that taken by one group, and it was 8 good descriptive term for the mind was the instrument and one knew nothing nothing more, nothing 88 to how the suggestion became effective or the physical work was done, save that it operated plainly Illness -3 through the all-readhing and controlling nervous system. Another group, combining the new force with old religious doctrines, called themselves Christian Scientists and took up Mrs. Eddy as their leader. I had an open mind but was not superstitious or ready to take up on faith doctrines I could not understand or give rational credit to. But there was no question in my mind that a profoundly interesting and important force was there, and one which very probably might explain many phenomena of which there was record in the past, such as certain well-attested phenomena at Lourdes and else- where, miracles of the Catholic church, well-attested apparently but not to be explained along the lines of interpretation given them by the Catholic church. So my mother sought out for me a practitioner of the 'mental healing doctrine I first described and made an appointment for me to go and see her --for it was a woman -- and one, I found, of good intelligence and education whom I could talk with frankly. I told her I wanted to try if their new, to me, doctrine could help me, but frankly also that such books as I had come across upon the subject, other than Braid's, and one or two besides, carried no conviction to me as to the religious basis of the cures affected and that if I needed to be convinced of this I feared it would be useless for me to try. Illness -4 Mrs. D, to call her 80, said that there was no need for this; all that was necessary was to be quiescent in one's attitude and have an open mind. The power lay deeper than words. I might not be responsive to its influence but she would gladly try. And on that basis I went to her regularly at stated times for two weeks or so without perceiving any marked effects, but suddenly I realized a change and felt a new power, a new energy rising within me and th is cont inned for some weeks more, working a real transformation in my state, though no words had been exchanged carrying conviction to me. Whatever the change was did not enter through the gateeway of consciousness but through some influence of what I can describe only as the unconscious mind. It reached a certain point and there it stopped but it bad given me the lift I needed and the improvement continued on, gradually bringing me new strength and vigor. [G B. DORR] of good both New section, Cyl 2-- 1. (1891-92) syster On our return from our winter on the Nile with our spring in Palestine and Syria, we opened the house at Bar got Harbor again, at midsummer, as we had closed it at nearly that same time, though earlier the season before to go guests abroad, and entertained our friends as usual, at Oldfarm till fall. Then we went to Boston where soon after my mother developed what proved to be acute glaucoma in one eye in an agonizing form.xxxxxxxx More than ever before I realized the utter helplessness of man, much as he has learned and learned to overcome in the presence of such suffering. An operation became immediately necessary and was successfully pe rformed but it cost her the sight, absolute and entire, of one at eye. The other eye was unaffected and backnex retained its former vision. Somewhat later than she, I developed the same disease,glaucoma, but in non-acute form which caused no suffering but great- which, after attempts to arrest it with some drug, made operation necessary to save my sight at all, glaucoma being present both eyes. The operation was successful, 80 far as the glaucoma was concerned, but it led to that which if my oculist, two-- consulting and operating did not realize though it would have been necessary mjust the same had they done so, that it would immediately result in 5 Cylinder No 2 page 2 obscuring the vision of a prtion of the eye But, affected in glaucoma operation in cataracts which have made all vision obscure to me and stopped at once all reading and clear vision of any kind, near or distant. But before this happened Iw as able. to use my eyes with a freedom from muscular ad justment difficulties I had not had before since early college days on certain reading I had long wished to do, recalling the greek I had given up during my second year at college, because of the evelopment of thi 8 muscular trouble, my study of the old Italian, of Dante, whom untouched till then, I read through, with many notes and comments on it, but without other aid, with greatest interest and full appreciation. NARA,C CP, R679, CCF, Acadia. Nisc. Rpts. SOMERSET CLUB, BOSTON. March 18, 1918. Dear Mr. Mather: I have just received your kind letter of March 16. I have been quite ill with a sort of bronchial, germ attack accompanied with fever that has hung on persistently and quite knocked e out and I am not over it yet, though I manage against advice to keep about. I have tried my hand at writing the letter for Secretary lane but when one is done up, as you know, things come hard and I would like to work over it, if I may, a little longer. So won't you telegraph me here if you find at an:- reoment there is need of Caste, and I will either bring the Let- ter on myself or send it at once with special delivery stamp. in the meantime, former Cenator Murray Crane--a warm friend of `resident `liot's-- has put himself in touch with Representative Gillett about it, and I'-- ceived a very cordial letter on the subject from him. Our letters in regard to the suspended to. the sustended publi- cations, undertaken with the Boston & Maine R. R., were effective in set- ting things in motion, and I now inclose you a copy of the paper, written in the Department's and Park Service's names, on National Parks and Monu- ments. I hope you will like it. It has been brought out in an edition of 35,000, so you may, if you like, send it freely out. I have ordered you 50 copies sent by parcel post, and any number more will be sent you on your order to the printers, the Rand, Avery Supply Co, 117 Franklin St., Boston, with instructions for franking or other shipment. The three Railroads, by the way, the Boston E Kaine, the Taine Central, and New Haven, their heads meeting here the other day, drew u to and sent in GM their joint name, on President Hustis' initative, a letter to Mr. Sherley on the subject of the ?onument, in which t. et all are taking a warm interest. I was shown a COPY of their letter afterward by Mr. Newcomb. 3ishop Lawrence of as COMO on the wild Garden of Acadia board as representing Tarvers, OI MACSE corporation ne is, and will also write to Er. Sherley if it seems de- sirable. lie is one of the leading men in the East and one UI the earliest summer residents upon Mount Desert Island, joining also with President Eliot and myself in the movement tat led to the formation 01 the Monument. Yours sincerely, (Signed) Coorce 3. Dorr. -2- EHI IV TRANSCRIPTION OF G.B. DORR LETTER TO J.D.ROCKEFELLER JR. FEB. 14, 1927 Source: RAC III.2.I. B85. f. 839 What you said, incidentally, in your recent letter concerning the Arnold Arboretum, of having been laid up with a severe cold makes me think it worthwhile to write you of my own experience-starting some twenty odd years ago [during] one of the then prevalent influenza epidemics, I had a series of heavy and persistent 'cold' attacks, two of which- one in the winter in Boston; the other on a trip abroad-resulted in pneumonia. A third time, afterward, I narrowly escaped it. Bacterial infections apparently got into my system and I had a series of similar colds, staring from slight apparent cause and hanging on persistently, with tendency to temperature conditions, until a year ago at Mesa Verde, I caught a fresh infection which rapidly developed into an ear attack and absess, which later broke fortunately-for I was out of reach of surgical aid but was long in healing after I had returned to Boston and put myself under an aurist's care-owing to the constant recurrence of the cold infection which had brought it on. Finally, seeing this, my aorist advised me to try an anti-vaccine treatment, giving me the address in Boston of a man whom he thought highly of and who had made a speciality of this. I tried it. I was found infected on examination with a number of influenzas, or cold producing species of bacteria-probably of gradual and long accumulation in my system. An anti-vaccine was prepared to treat the condition and I underwent [for] some weeks vaccination treatment, since then I have had no serious attack or development into the old conditions. I found a number of my friends in Boston including doctors, had been taking similar treatment, and with good result SO far as I had chance to learn. This treatment is relatively new but I believe it has come to stay and that it points the way to overcoming what in these days of indoor, city life and widespread contagions is inescapable-infections carried on the air [which] has become a serious threat. You, of course, have at hand the best of medical advice, but the best, because it has attained to that position, is apt to be conservative and this is new-still in ?????-so take my experience into consideration to use if you find yourself-as I at times have done-'up against it.' The limit to our knowledge yet is narrow, but it is widening. No need to answer this, it is just a friendly word, telling of my own experience. The name of the doctor in Boston making a speciality of this to whom my aorist sent me-should you wish it-is George P. Sanborn (320 Commonwealth Ave. Boston). That is all! Yours Sincerely, George B. Dorr POLICE RECORD OF ACCIDENT to Mr. George B. Derr City of Boston Police Department LaGrange Street Station Saturday, Dec. 24, 1927. About 1.30 in the afternoon of Dec. 24, 1927, Mr. George B. Dorr, 94 years, single, of the Somerset Club, 42 Seacon Street, City, while crossing Charles Street from the Common side, at the center gate, stopped and then walked in front of a Willys-Enight sedan, Virginia registration 9 -778, Engine Number 332308 - W - 1, owner's name and address unknown but left in charge of Max Bornstein, No. 36 Claremont Street, Boston, and operated by Harry W. Pertney, 47 Walther Street, City, operator's license number Massachusetts 468200, which was pro- ceeding northerly on Charles Street at the time of the accident. Mr. Derr was taken to the Kassachusetts General Hospital in the same automobile and upon examination by Dr. Neptune was found to be suffering from a five-inch Inceration on the center of the scalp, shock and questionable fracture of the skull and his name was placed on the danger list. His cousin, William C. Indicott of 163 Marlborough Street, was notified by Division 16; also his club was notified by Patrolman Daniel I. Lynch of Division 3. Witnessess Elwym Bonney, 395 Cherry Street, West Newton, Mass: Alfred Goodman, 17 Allen Street, Bostony Patrolmen Sullivan and J. L. Marphy arrested it the time Harry W. Partney, 24 years of age, 47 Walthum Street, for violation of the automebile laws, to wit: operating an unregistered car on Charles Street this afternoon. This automobile was put up in the Eliot Street Garage this afternoon. Portney was bailed by Commissioner Fahey in the sum of $100, cash furnished by kinself this afternoon. Captain says car is not to be delivered until properly registered. Bornstein said this car was left (Daniel T. Lynch, Div. 3) in his garage on Jan. 4, 1927. (Driscell, to Sergt. Newell) RAC OMR. III. 2.I. B 85. F.840. c.3 Under the provisions of the copyright law of the United States private study sellolarship, orrescatch and in the Rocketeller this SH Rath Park Extract from Mr. Albright's letter of May 5,1935 Dour in Cammerer-enva SrHr copy not reproduced in atty form used Automobile road, 1935. individual. Also I quote from a letter just received from Mr. Dorr's secretary: Mr. Dorr walked to the spring and back, Sunday, while he was alone. That wound of last year which is in his leg ill not heal. His system fights it, of course, br he would have ganagrene. But he looks 'pell, eat$ well. The Park history is well on its way to completion. Mr.Dorr cannot see, Mr. Albright. That much is certain. He cannot distinguish people in the room, but with a strong light and glass he still can see to read. research from material in the Rockefeller Archive Center is granted, neither this SH HORACE MARDEN ALBRIGHT WYKAGYL GARDENS NEW ROCHELLE, N. Y. December 26, 1934. My dear Mr. Rockefeller: Our old friend, George B. Dorr, will be 81 years old on December 29th, and as he is not well and may not see another birthday, I am suggesting to a few of his friends here and in waven Washington that we send him some of words of greetings and good cheer, and I felt sure that you would like to be one to send him C a message. of course, Mr. Dorr's Christmas has been a sad one on account of Mr. Lynam's death. He will feel very keenly the loss of his old friend and associate. I hope that Mrs. Rockefeller and you are well and that you are enjoying a very happy holiday season with your fine family. Mrs. Albright joins me in New Years greetings and all good wishes to you both. Faithfully yours, Mr. John D. Rockefeller, Jr., 30 Rockefeller Plaza, New York, N.Y. sk OFFICE OF natl Park Don JOHN D. ROCKSFELLIA JM, August 2, 1933 Dear Mr. Dorr: I was glad to learn from Mr. Serems Modick yeater day that you were very mich better. Do take care of your self and de not do any more imprudent things like aliding down Green Nountain a the snow drifts, as the saw you de some years ago. You are greatly needed in this world and particularly on this island. I would not know what to de without you here and year and I must beth live at least to see the projected automobile road completed and then for a leng time thereafter to plan other worthwhile develop- ments of the island. If there is anything Mrs. Rocksfeller and I can do for your sellbeing or comfort, it will give us beth great pleasure to be given the opportunity. There are several things I have wanted to talk with yes about, in fact I had planned to try to see you last week but other things preventied. When you are feeling up to it and a little fisit from me would be & diversion rather than a strain, I should be delighted to case and see you. In the meantime please know always of # very deep regard and warm affection for you Very sincerely, JOHN D. ROCKEFELLER, JR. Mr. George B. Borr SEAL HARBOR, ME. Bar Herber Maine [Note: C.B.Dorrtiaucled in the Spring to Boston for a glaucoma operation and recouperation.] Continuation of the Mountain-to-Oceanfront Road through Bear Brook Valley [G.B.Dorr Hemoir] In the late summer of 1935 Mr. John D. Rockefeller, 1935 Jr. drove over from his home at Seal Harbor to talk with me concerning the continuation of the Park road then building over Great Pond Hill and round the Great Meadow, on its northern and eastern sides, for which an allotment byth of $350,000 had recently been made and for which surveys got were in process. The matter he wished to discuss with me was that of taking the continuation of the road past the northern base of Champlain Mountain instead of through the Gorge as originally planned. I told him he might count upon my cooperation but I did not take up with him, nor he with me, the question of upon what terms or conditions the Government might acquire the necessary lands. Mr. Rockefeller then asked, referring to my state- ment that I would cooperate: Health "How about your executors?" Upon this I laughed and said: "You think it then so immediate?" He replied that he closed up his affairs every night; and I asked, humourously, whether he did not really think that once a week would do. UNITED STATES DEPARTMENT OF THE INTERIOR NATIONAL PARK SERVICE ACADIA NATIONAL PARK BAR HARBOR, MAINE OFFICE OF THE SUPERINTENDENT September 3. 1935. Nessrs Pinkham and Smith, Boylston Street, Boston, Mass. Dear Sirs: will you kindly send me by earliest mail the prescription by Dr. Dunphy for the glasses - two pairs - which you recently made me, the prescription for which I neglected to bring away with me; and also the prescription for the last pair of reading glasses with prisms made for me under Dr. Cheney's ordering. Thanking you, I am Yours sincerely. GBD-0 George B. Dorr Parkman (1) 10farm Bar Marbor. Maine Dear Fanny, I received your card for the reception you are giving for Harry and his wife with real pleasure and thankfulness that it has all at last worked out so right. Some day, when this is over, won't you write me a word about the reception among quest- ing people that your book has had, and the in- terest it has aroused. My old interest in the subject, that opens SO importantly if at all, has never dropped. Ever yours sincerely, or I should do so, I cannot write now in my own hand, but must dictate and be read to. health January 9th, 1937. The Secret Diary of Harold L. Iches Vacation at Bar Harbor 202 203 trains, and then caught the Bar Harbor Express out of the Pennsyl- maintained with the office. Afternoons and evenings I spend reading vania Station at 5:15 P.M. or loafing, except when the spirit moves me and then I revise some When I went into the dining car last night I saw Mr. and Mrs. of the manuscript that Miss Conley has written for me. John D. Rockeleller, Jr. His back was turned to me and I just caught My coming here was far from being a state secret. The front page a glimpse of him as I passed. As 1 did not want anyone to know that of the local paper had a circumstantial story about me and my in- I was to be at Acadia Park, I managed to evade him. When I went in formation is that it was given out by George B. Dorr, the Superin- for breakfast this morning the coast scemed to be clear, but he and tendent of the park. This apparently was his idea of carrying out in- Mrs. Rockefeller came in later. He recognized me and caine over to junctions from Washington that I was to be kept quiet and secluded. speak to me. He said that if I didn't want to be disturbed while I was However, I haven't had it in my heart to take Mr. Dorr to task. He here, he wouldn't bother me, but that he and Mrs. Rockefeller were is eighty-four years old and when I called on him Wednesday after- alone and they would be glad if 1 would care to call or come for din- noon at his home, I found him to have little use of his eyes. During ner. He was most friendly. I do not want to be ungracious and since the last couple of years lie has been operated on for glaucoma- and he has asked me to go to Williamsburg two or three times and I have he also has the beginning of a cataract. I must say that he is gallant been unable to do so, I will see him while I am here. about it all. 1 had sent my car from Washington by Jones and Miss Conley Two years ago when I was here, he was rereading his Greek clas- drove up with him. Jones was waiting for me at Ellsworth. 1 am now sics in the original. Now he can scarcely read at all. However, he has in the Homans House in Acadia National Park. I have been here someone read to him and his keen interest in life and events is not twice before for a day or two on each occasion. This time 1 plan to abated. He is a man of real culture and I note no impairment of his stay for two or three weeks, if all goes well at Washington. This house intellectual vigor. belongs to the park and is beautifully situated on the lower edge of I commit the sin of envy whenever I am in Mr. Dorr's house. He a mountain overlooking the water. I can look across at Schoodic and has such beautiful things in the way of furniture and dishes and in the bay between are several rugged islands. The house is a ceramics, especially dishes, that my mouth literally waters. Most modern one, but sparsely furnished. However, it serves my purpose of these have come down to him from former generations. Some of admirably, since Mr. Dorr has sent up some of his furnishings to his ancestors were sca captains and his immediate background was that of the Back Bay of Boston. He himself is of Harvard and he was make me comfortable. a close friend of the late President Eliot, Dr. Oliver Wendell Holmes, Tuesday, August 3I, 1937 and others with a distinct intellectual and social background. Mr. I have been at Bar Harbor a full six days and I like it very much. The Dorr has never married and he tells me he has no close relatives. I Homans House is beautifully located, well above the water and at asked him what he was going to do with these real treasures of his the foot of a high, rugged and partially wooded ridge. It has a won- and he frankly said that he did not know. Modesty and good breed- derful outlook. Directly across the bay is Schoodic Mountain and the ing restrained me from making a suggestion which, if it had ap- bay itself is dotted with rockbound islands. The days generally are pealed to him, would have redounded to my personal advantage. fairly warm, but not oppressively so, and the evenings are invari- On the whole I find that I am sleeping better here than I had been ably cool, making blankets comfortable during at least the early in Washington, but I am still far from being in the clear. I continue to take nembutal to put me to sleep. This isn't so bad but I waken in hours of the morning. 1 spend my mornings dictating. I am making a serious effort to the morning earlier even than I did in Washington, where I was complete the political autobiography that I have been working at greeting the first peep of dawn with open eyes. The trouble is that in a desultory fashion for a number of years. I really hope to be when I get awake I can not go to sleep again, except on very rare OC- able to bring it up to the year 1933, when I began to keep current a casions. Up here, for some reason, I have awakened even before dawn. diary. This work I am able 10 do without strain. There is also a cer- tain amount of correspondence to keep up with and contacts to be Miss Conley and 1 went to see Paul Muni in Zola last night. Ernst, J. W. (Ld.) WORTHWHILE PLACES : Correspondence of John D. Copy 1934 - 1943 Horace Albright. Bronx: Fordham u.P., 1991. with finality as to his readiness to condemn and was going is covered by a $46,000 mortgage. I gathered from my discussions to look up just what powers the Federal Government had. with Mr. Dorr Saturday night, which ran well toward 2 a.m. Sunday, that his income, except his salary of $3,000., had been Very sincerely, cut off through the total loss of securities in New England JOHN D. ROCKEFELLER, JR. industries such as the Amoskeag mills, and others, the securities of which years ago were gilt edge. In other words, he must have lost that part of his inheritance which was represented Mr. Ernest B. Dane. A summer resident on Mt. Desert. Owned by stocks and bonds. Wildwood Farm. In building up the park and carrying on his various Mr. Leo Grossman. National Park Service road engineer. activities perhaps including the nurseries, he got heavily in debt. Your purchase of 123.2 acres of the Great Meadow and adjacent territory for $100,000 must have enabled Mr. Dorr to greatly reduce his indebtedness but it is probably true that he used some of that money to buy other lands for the park. When the Park Service undertook the recreational June 27, 1938 demonstration project in the western part of the Island it Dear Mr. Rockefeller: bought some 5,000 acres of land, and included a number of tracts that Mr. Dorr had. From the sale of these tracts Mr. Land problems Dorr realized a little over $20,000., over $17,000. of which was applied on mortgages held by the local bank. The I have just returned from a trip to Acadia National Park. remainder went into clearing titles of other lands, which the I spent Saturday and Sunday there. This report is being hastily Government was acquiring, the money being spent on the dictated, and perhaps will not be as orderly and as coherent Government's behalf since its funds could not be used for as it should be. However, it will include in it all of the important title clearing. In other words, Mr. Dorr made further sacrifices matters that I discussed while down there. out of his own funds to facilitate land acquisition in the western In the first place, let me say that I found Superintendent part of the Island. George B. Dorr in poor health. He is almost totally blind. It He now has about 206 acres of land including Oldfarm, is a mystery how he manages to get around his house, and the nurseries, the quarry tract, the Bear Brook Pond tract, etc., up and down stairs as well as he does. He is growing thinner. and they are all pledged to the bank to secure outstanding He has angina pectoris, and the presence of this coronary trouble mortgages totalling about $46,000. It is perfectly clear, therefore, was confirmed recently by a Boston heart specialist. It is causing that Mr. Dorr cannot under any circumstances donate the lands him some discomfort and at night rather serious sweating, which that are necessary for the continuation of the motor road around breaks up his sleep. His associates believe him to be in rather Champlain Mountain. It is probable that in these times of serious state, and I think he himself regards his own condition depression the whole of his property if sold would not realize as quite hopeless. Two or three times he told me that he would $50,000. There is no possibility of selling the big old summer not be here long, and might go at any moment. Another time mansion Oldfarm. The little house he lives in is not valuable. he humorously referred to having his valise packed. Of course, he has a good many antiques, book, etc. but even He has his affairs in good shape; that is they are in as to suggest selling these would be a death blow to the old good shape as it is possible to put them when all his property gentleman. 166 167 after health Cylinder No 3, page 1 Wednesday evening, Fabruary 1st, In Greek, which I could not read at all at first, but soon brought back to the point which I had reached before when I gave it up at college so long ago, I began at once, with a good dictionary at hand, with Homer's lik on Odyssey, which I particularly wished to read and had not early been willing to read in translation or with the aid of callege others which hampers always one's full appreciation of the (187) original, which, save in matters of artistry, one d 063 get, I think, in its full spirit, when one works things out for oneself, gaining gradually, I read the whole Odyssey through and read it thoroughly. Then I turned to the Iliad, which I by no means liked so well as literature but found interesting along another angle, tt which Gilbert Murray, the Greek scholar of Oxford, who had made the subject of the Iliad his own and written adelightful book upon which I had earlier read, had pointed out in the evidence it gives of actual construction with different elements of time involved in its 'patched-up' parts and the development of civilization which they show - our perhaps the development from II should m rither - and which, quite evidently, Cyl 3, page 2 I felt, represent in large part a much earlier period than that exhibited in the Odyssey's which forms! also quite evidently a connected whole, a story as we know it. At the period the Odyssey was written, e verything beyond the Ionian Isles in the Adriatic was a region of one mystery to the composer, the bard, of mystery and dread. So t hat one at least can date it at not later, at latest, more, than the 8th century probably,before Christ -- when Greek trade from the Aegean sea began its rapid development to (look up with me the name of the city west of Naples) where the earliest Christian colony was, along the western coast of Italy or on the island pt through the straits of Messina, or along the sout heastern coast of Italy. The Iliad is in large part quite evidently much earlier than the Odyssey, representing with later alteration not d afficult to recognize at least in part, a far more barbarous and savage and less idealistic stage of human development. It be ft, on the hole, a rather painful impression ie, but it tee I read thoroughly to tha and, Cyl 3 page 3 I then turned to Aeschylus, whom I much wished to read in certain plays and read them too without encountering though much difficulty, : no doubt losing many of the finer points, not all of which can be grasped now by any means of modern shholarship, of grecian dramatic art in this great period. The Witk one play remaining to us, which I wish to read beyond all others was Prometheus Bound, one of the greatest in imagination and creative art the world at any time has known. C. I Death plans Augg.2 File 1853 1944 Bar Harbor, Maine, January 5, 1939. Dear Serenus: I have recently passed another milestone in the shape of a birthday, my 85th -- being born during the night of December 29th, 1853, in my father's and mother's home on the shore of Jamaica Pond, Jamaica Plain, Massa- chusetts, in a house which they built themselves upon their marriage and occupied till the death of my Grandfather Ward, when they moved to his home in Boston, on Park Street, fronting out across the Common to the sunset. The house 1853 I was born in and the land it was built upon were long since taken over by the Boston Metropolitan Park system, one of whose principal roads passes directly across the house's site and through the garden ground, where I re- member my father pruning his pear trees of a summer after- noon and where my brother and I played together as young children. This is but a preamble to what I write to say, which is that in case anything should happen to me now unexpectedly, by night or day, I have made plans, carefully thought out, 2. for my last resting place at the long journey's end, which Dana Young and Richard Sherman, our National Park engineer, are working out upon the ground and setting down on paper for me. Of these they will be able to tell you, as Hadley, now in Washington, will be able to do also in part, though soon I trust to have all in shape to lay before you both, and others with you, as my last wish and what, upon much thought, appeals to me as the most in accordance with my plans and wi shes and the best from every point of view. With thanks once more for all you have done and are doing for me, Believe me Yours sincerely GBD-O The Mr. Serenus B. Rodick Dear Bar Harbor, Maine. Note: Nearly three years later (10/16/41) he writes to J.D.L. works that "The exact their penalties: My memory though, now less years instantly and promply than of old, all their give it time things come back to me with old detail or Joseph N.Emst [Ed.]] WORTHWHILE PLACES 1934 - 1943 Bronx Fordham U.P., 1991. with finality as to his readiness to condemn and was going is covered by a $46,000 mortgage. I gathered from my discussions to look up just what powers the Federal Government had. with Mr. Dorr Saturday night, which ran well toward 2 a.m. Sunday, that his income, except his salary of $3,000., had been Very sincerely, cut off through the total loss of securities in New England JOHN D. ROCKEFELLER, JR. industries such as the Amoskeag mills, and others, the securities of which years ago were gilt edge. In other words, he must have lost that part of his inheritance which was represented Mr. Ernest B. Dane. A summer resident on Mt. Desert. Owned by stocks and bonds. Wildwood Farm. In building up the park and carrying on his various activities perhaps including the nurseries, he got heavily in debt. Mr. Leo Grossman. National Park Service road engineer. Your purchase of 123.2 acres of the Great Meadow and adjacent territory for $100,000 must have enabled Mr. Dorr to greatly reduce his indebtedness but it is probably true that he used some of that money to buy other lands for the park. When the Park Service undertook the recreational June 27, 1938 demonstration project in the western part of the Island it Dear Mr. Rockefeller: bought some 5,000 acres of land, and included a number of tracts that Mr. Dorr had. From the sale of these tracts Mr. Land problems Dorr realized a little over $20,000., over $17,000. of which was applied on mortgages held by the local bank. The I have just returned from a trip to Acadia National Park. remainder went into clearing titles of other lands, which the I spent Saturday and Sunday there. This report is being hastily Government was acquiring, the money being spent on the Government's behalf since its funds could not be used for dictated, and perhaps will not be as orderly and as coherent as it should be. However, it will include in it all of the important title clearing. In other words, Mr. Dorr made further sacrifices Statement matters that I discussed while down there. out of his own funds to facilitate land acquisition in the western In the first place, let me say that I found Superintendent part of the Island. George B. Dorr in poor health. He is almost totally blind. It He now has about 206 acres of land including Oldfarm, is a mystery how he manages to get around his house, and the nurseries, the quarry tract, the Bear Brook Pond tract, etc., up and down stairs as well as he does. He is growing thinner. and they are all pledged to the bank to secure outstanding He has angina pectoris, and the presence of this coronary trouble mortgages totalling about $46,000. It is perfectly clear, therefore, was confirmed recently by a Boston heart specialist. It is causing that Mr. Dorr cannot under any circumstances donate the lands him some discomfort and at night rather serious sweating, which that are necessary for the continuation of the motor road around breaks up his sleep. His associates believe him to be in rather Champlain Mountain. It is probable that in these times of serious state, and I think he himself regards his own condition depression the whole of his property if sold would not realize as quite hopeless. Two or three times he told me that he would $50,000. There is no possibility of selling the big old summer not be here long, and might go at any moment. Another time mansion Oldfarm. The little house he lives in is not valuable. he humorously referred to having his valise packed. Of course, he has a good many antiques, book, etc. but even He has his affairs in good shape; that is they are in as to suggest selling these would be a death blow to the old good shape as it is possible to put them when all his property gentleman. 166 167 WORTHWHILE PLACES 1934 - 1943 His land holdings are roughly divided as follows: two of whom are to be Serenus Rodick and Ben Hadley. I did not ask the names of the other trustees. 76 acres in the Oldfarm and adjacent land excluding the It seems clear that Mr. Dorr has made arrangements for nurseries, 22 acres - nurseries, the disposition of everything he has upon his death, and that 9 acres - the Bear Brook Pond tract, everything goes to the public, assuming of course, that some 7 acres - the quarry tract. way can be found to liquidate the mortgages. Should that not be possible everything will have to be sold to satisfy the bank. Then he has 25 acres in the gorge beyond the tarn. On The George B. Dorr Foundation will administer Oldfarm, the the western part of the Island he has about 89 acres lying between homes, antiques, books, fine glassware, and other heirlooms, Echo Lake and Great Pond. The tracts on Great Pond are which Mr. Dorr has. The income, if any, will be used to print right at the southern and most valuable end of that body of a history of the park, and other essays and papers that he has water. He has control of the situation there. He also has a prepared. Apparently he has been working on them during the few lots on Strawberry Hill. It is probable that there are some winter for several years. These statements have been well other small miscellaneous lots but I have listed most of his prepared and are very interesting. I put in a number of hours holdings. reviewing them, of course, reading only here and there in It has been Mr. Dorr's ambition all these years to donate voluminous manuscripts: It is doubtful, of course, whether there the Bear Brook Pond tract and the quarry tract, and I feel will be enough income from the Foundation to carry out Mr. that whatever is done about clearing up the mortgages some Dorr's wishes but I am quite sure that the Foundation has way should be found to make it possible for the old gentleman authority to sell property necessary in order to do certain things. to donate these tracts. Roughly his holdings should be divided Next Mr. Dorr wishes the nurseries to be operated, if in, four parts. shings. possible, for the benefit of the Foundation but open to public The first should include all of the lands south of Oldfarm, inspection, and he hopes that attention will be given to carrying part of the nursery lands, the gorge tract, and the tracts on out the Wild Gardens idea. The nursery lands, of course, would the western side of the Island, which should be purchased for be greatly limited because of the necessity for selling as much say $50,000 or at least enough to liquidate the mortgage. land as possible in order to liquidate the indebtedness hanging The second group would include the Bear Brook Pond over all the property. 2 and the quarry tracts, which would be freed from the mortgage Next Mr. Dorr would give the Quarry and Bear Brook so that Mr. Dorr could donate them to the Government for Pond tracts, thus completing his gifts to the park. Finally but the right-of-way of the road. really the first thing to be done is the sale to the Government, 3 The third group should be enough land to continue the if possible, of the other lands about Oldfarm, in the gorge, nursery, which would be operated if possible at a profit to the and between Echo Lake and Great Pond. I am taking up the Dorr Foundation but which would always be handled as question of the sale of these lands in Washington, and hope exhibition gardens. Mr. Dorr hopes that here may be carried that there is still money available which might be matched with on his plans for the Acadia Wild Gardens. outside funds under the old authority granted to the Park Service 4 The fourth tract would simply include the water front of in 1929 and 1930. If that authority is still available the fund Oldfarm, the gardens of the old houses, the houses themselves of $23,000 or $25,000 to be matched dollar per dollar by the with their furnishings. These would continue in the ownership Government would clear up this situation and at once free the of the George B. Dorr Foundation, which has already been lands for the right-of-way. established, and which will be operated by a Board of Trustees, The only further question that arises is whether Govern- 168 169 WORTHWHILE PLACES 1934 1943 ment appraisers would agree on a value for the lands back month. This is an exquisitely beautiful section of the highway. of Oldfarm, in the gorge and between Echo Lake and Great The town's people and summer people have been using each Pond that would justify a total expenditure of $50,000. I am end the road to the bridge, and apparently for the first time afraid that the per acre cost would be regarded as too high. they have come to fully realize what the motor road means There might be added to the land to be sold the quarry itself, in giving access to the beauties of the park and the beautiful leaving only the lands above the quarry to be donated by Mr. views from it without encountering village streets, telephone Dorr. It seems that the quarry is an exceptionally fine one, lines, etc. I went over the improved surveyed lines of the has superior granite, and of course, it is easily accessible. As extension of this road to the quarry. I believe that the engineers a quarry it may have considerable value. To regard those rocks have at last solved all the problems. as quarry rocks is like thinking of board feet in a noble sugar I wonder how you still feel about the horse road in the pine. When I once remarked that a sugar pine contained 25,000 Kebo Valley. If you are still certain that it ought to be built board feet Secretary Wilbur said it sounded as bad as if I spoke would you want to consider letting the Park Service undertake in war times of the amount of lard in a German soldier. all or part of its construction, possibly in connection with the Nevertheless, it may be necessary to have the quarry tract sold clearing up of this land problem, continuing the application although I had hoped that this might be avoided so that Mr. of the theory that it would be best for you to round out the Dorr's donation ambition might be carried out. park lands while the Park Service rounds out the road I am afraid I have taken too much space to explain the improvements. I have not refreshed my memory with the land situation but I hope I have made it clear. I have asked correspondence with Secretary Ickes about the taking over of Messrs. Hadley and Rodick to prepare a map, showing these road building by the Government, and I cannot recall what various tracts in different colors, and told them if they did commitment you made in reference to the continuation of the not hear from me in the next week to see that you got a copy horse road system. There would seem to be several good grounds of this map when you arrived in Seal Harbor. on which the Government might build this one section of the Mr. Dorr's health and the necessity for getting the road horse road. In the first place, it would tie the system into project on its way require quick and positive action. I do not headquarters, and in the second place the Hemlock Road is know whether you would want to consider taking control of already available for inclusion in the horse road line. In the the situation by buying the mortgages, leaving it to us to work third place, it would be a public demonstration of the out next fall some kind of a basis for Government participation Department's strong interest in recreation of horseback riding in this acquisition with you or with you and others working and horse driving. I realize this suggestion may not be of any together; or whether you would prefer to let the whole matter value, and is simply placed in this report for any consideration stand until I can get back from Europe the latter part of August. that you think it deserves. Of course, it is possible that the The great danger in delay is, of course, that Mr. Dorr may Department would not consider building any horse roads at not live until the end of the summer. all. There are two underpasses for the horse roads that should be built when the extension of the Kebo Mountain road to Road Problems and around Champlain Mountain is undertaken. I inspected all the roads in the Park except the horse roads. The Day Mountain Connection to Jordan Pond Road I never saw the roadside more beautiful. The wild flowers were blooming in abundance everywhere. The Kebo Valley road is Sunday morning I met Mr. Simpson and with him and completed except for the bridge, which will be finished next Mr. Hadley I walked over the line for the temporary connection 170 171 WORTHWHILE PLACES 1934 - 1943 along the north end of the Candage property. I found the line be given sufficient help to drive this project through. I should extraordinarily good. The brook is in a deeper gorge than I tell you that last winter Mr. Grossman took topography on expected to find but it turns eastward along the Candage line the Camplain Mountain road and ran a line across the Potter inside the Candage property so that there is practically no Palmer and Livingston properties. That whole road project now likelihood of Candage disturbing what must be the northeastern clear around to a connection with the ocean drive is in such corner of his property. It is only a short distance from the brook shape that it can be made ready for contract very quickly once to the Jordan Pond road, and the timber and brush is very thick the right-of-way problems are solved. along the line, so keeping back 25 ft. will give ample protection to the new road. As a matter of fact, the engineers plan to build Mary Roberts Rinehart. about a 24 ft. road, which is ample, on the northern part of the 65 ft. strip, that is 40 ft. road right-of-way plus the 25 ft. The famous writer, Mrs. Rinehart, who lives in the late protective strip. Assuming a 24 ft. road is to be built, therefore, Dr. Abbe's house now owned by Atwater Kent, invited me there would be a protective strip of 41 ft. The connection into to luncheon with her yesterday. She has been ill and is just the Jordan Pond road is going to be quite satisfactory. now beginning to see people. She has bought the Phillip I discussed standards with Mr. Grossman, and he said he Livingston place and will move into it this fall. She is thought it would be best to use a wooden trestle over the little tremendously enthusiastic over everything that has been done gorge, first in order to avoid excavation, second in order to avoid in the way of road and trail building. a fill which might later have to be removed, and third, in order She knows the National Park System through many visits to keep the new line more frankly temporary. Finally to keep in the West. She has ridden horseback in Glacier and the cost as low as possible. I agreed with all these points. Yellowstone Parks. She and her boys are enthusiastic riders. Mr. Simpson showed me where the new Dane approach She says her sons and their families have used your horse roads project underpass would be built. It occured to me there on and think they are the finest they have ever seen. She wants the ground that you ought to push this new approach road to be helpful in carrying out your projects, and those of Mr. to the Wildwood Farm as fast as possible, making it available Dorr. I told her about the Atwater Kent Meadow, and its for Mr. Dane before he leaves in the autumn. By that time importance to the Park. She believes that she can be very helpful the new park road would not yet have reached the underpass, in working out this problem. She says Atwater Kent is having and it might be that he would see how utterly foolish it will trouble with his wife and is pretty "low" now. She seemed to be to have two entrances to the Wildwood Farm road, and think that if something could happen that would give him a would not object to the connection with the Jordan Pond road little favorable publicity it would be a good thing for him. I along the permanent line. This is simply a suggestion for you told her a gift of this property or assistance on his part in to give such consideration as it merits. I predict that Mr. Dane arranging for its transfer to the Park would get him some is going to be tremendously pleased with the approach road magnificent publicity. I told her, however, not to do anything that you are going to build for him. about this until she heard from you. Unfortunately the Bureau of Public Roads has been short would strongly suggest that when you return, Mrs. of engineers, and has not made satisfactory progress in getting Rockefeller and you meet Mrs. Rinehart. I feel that you can ready for the extension of the motor road to the Day Mountain talk freely with her about all your hopes and plans for Acadia. pass including the underpasses. It looks now as if it will be She has the greatest admiration for you and your works. August or September before contract for this section can be She says that Potter Palmer is an uncertain person but that let. I am again writing to Washington urging that Mr. Grossman his wife is a lovely woman and thinks that if we want to get 172 173 UNITED STATES DEPARTMENT OF THE INTERIOR NATIONAL PARK SERVICE Acadia National Park Bar Harbor, Maine March 27, 1941. Mr. A. E. Demaray, Associate Director, National Park Service, Washington, D. C. Dear Mr. Demaray: Your telegram reached me this morning. I was at work already on my letter to Chairman Taylor, Mrs. Sylvia aiding, and together we have completed it in time to send it, as you advise, by air mail tonight, Dana Young taking it for me to Bangor this afternoon for the purpose. It should reach Washington, I am told, by noon tomorrow and will be taken by special delivery direct to Chairman Taylor's office at the Capitol, if all goes right. This letter, with the two copies of mine to him you asked Mrs. Sylvia to send you, goes by the same mail, directed to you at the National Park Service office. Handicapped as I am by loss of sight, I have done the best I could to make things clear within the limits of the time your telegram sets, but I trust, because of the vital importance this matter has for the whole Park's future, in fulfilment of my dream, that you will take the time to 50 over it, with the more intimate know- ledge the years and your visits here have given you, and see what more than I have said will present a fuller and truer picture to Mr. Taylor, whom I recall most pleasantly and would like, above all things, to have associated with me through his cooperation in the gift I hope to have accepted by the Government. It was a real pleasure to have you here again, even so briefly. Sincerely yours, [G.B.DORR] Personal C O UNITED STATES P DEPARTMENT OF THE INTERIOR A Y NATIONAL PARK SERVICE Acadia National Park Bar Harbor, Maine March 28, 1941. Hon. Edward E. Tavlor, Chairman, House Appropriations Committee, U. S. Capitol Building, Washington, D. C. Dear Mr. Taylor: One of the regrets I have from a partial blind- health ness that has come upon me these last few years is that it prevents me from keeping up the winter visits I used to make for so long to Washington and the loss of contact it has brought with friends my work had brought me and whose friendship I greatly value. Among these friends you stand out in my memory most pleasantly. You wrote a most kind letter to me, on 1934 June 25th, 1934, expressing your regret that you and Mrs. Taylor could not come down and stay with me in my old home here as I had hoped you might, and add- ing, in a spirit of kindness that I found myself much moved by, what I quote: "But I shall retain the memory of your invitation, and if I am reelected next fall and continue, as I undoubtedly will, to retain the chairmanship 01 the Interior Department Appropria- tion Sub-Committee, I am certainly going to try some day to come up and visit your wonderful Park. In the meantime, you certainly have my very best wishes, and if at any time anything occurs to that Park or any of its interests about which you think I should know, do not hesitate to write or wire me. ff Such a situation has arisen, and Mr. Demaray, Associate Director of the Park Service, who has been visiting me the last few days to talk Park matters over and has left on his return to Washington this afternoon, suggested, without knowing the old friendly relation that we have had together, that I should write and tell you of the need and opportunity that now confronts the Park. RAC. III. 2.I. 73.757 C.1- CBD health SH Hancock cty Trustees GEORGE L. STEBBINS SEAL HARBOR, MAINE Champlain that fd June 20. 9:44 was m Rockefeller your letter of June 2 in and my and 10 the news Ch am heain menument bank site was receive a long time ago Youth 8 have charged and wearing because under present conditions with The restrictions on Teams rentation and so many of The trues men away on was were is is difficult to determine me the sentiment of The problem in any question. I did have an connections To lack will m Them as the Town manager amex be naise that the subject came us in The meeting 2 the heed Warrants committee before the march Torm meeting and is was thought Best To picas home action untie the return of normal times That shous that I he Rubyin has nor been dropked Your 9 home when you are here you can 90 min me to The spath and in me show you where ms have done and what some of the chachem 15 the are a as pro runner mene. is to show the heave what an attraction heace a little house there mmed I In oten 2 take lunch trust before or after climing was meuntain we have heaux a later' Tenches There when some have already dune so you of course under the gas reston tions very frie can go There one advition The neov as Rurrey ad mas that is was nor square with the road - 9 home you can look is an wish That in minor 3 see if you would farm some change Inheal evice to lath it an usia ym when you 9ct There 7called are E Gear Don the other many and the now old man mas partatis - He is health CBD a very hishlers vanie man and a aid's cannat read so 9 run set here 2 There's We are having a good rain Your very sincing Georg. In Statemi REPRODUCED AT THE NATIONAL ARCHIVES CCF, 1933-491 Acadia Box 795 Name Date 8 1944 Jotost UNITED STATES Psyjum 8-10 81:2 DEPARTMENT OF THE INTERIOR NATIONAL PARK SERVICE 8-12 NATIONAL PARK SERVICE iec 9-14 AUG 8- - 1944 Acadia National Park ours LES Bar Harbor, Maine 9-11 al August 7, 1944 MEMORANDUM for the Director. I notified you by wire yesterday of the death of Superintendent Dorr and on receipt of Mr. Tolson's telegram this morning I wired the hour of the funeral and the names of the three distant cousins who are the only surviving relatives. This memorandum is to give you the remaining details in connection iltness with Mr. Dorr's passing. He has been in slowly failing health for some months, but there was no sudden decline. His daily habit was to arise about 8 in the morning and to come down stairs between 9:30 and 10 o'clock where he remained until his retiring hour, about 10 in the evening. He maintained his usual tranquil spirits and never did he utter a word of complaint about his loss of sight and gradually dimin- ishing physical strength. On the contrary, he seemed to derive a great deal of comfort through mental review of the past, his early associations, his work in creating the park, and his many allied inter-- ests. Whenever he spoke of the approaching end it was with the knowledge and satisfacti on of having lived a full and useful life. On Saturday morning he arose at his usual time and while on his Death way from the bedroom to the bath his heart failed and he crumpled to the floor. Death was immediate. From my intimate knowledge of Mr. Dorr and his personal viewpoint I know that the end came as he would have had it could he have ordered it. Tureeol The funeral services will be held at St. Saviour's Episcopal sewrees Church, Tar Harbor, at 3 o'clock on Monday afternoon, August 7. In accordance with his specific instruction the remains will be taken to Chimacon Boston for cremation. The ashes will be returned to Bar Harbor for disposition. B. House B. L. Hadley, Assistant Superintendent. CC: Regional Director, Region One. UNITED STATES DEPARTMENT OF THE INTERIOR NATIONAL PARK SERVICE Acadia National Park Bar Harbor, Mine August 14. 1944 Mr. H. M. Albright, Rockefeller Plana 30, New York 20, N. Y. Dear Mr. Albright: You have no doubt heard by now of Mr. Dorr's passing. In the stress of activity which the event occasioned you, as one who should be notified, completely escaped my consciousness. I deplore exceed- ingly my lapse of memory and hasten to repair the omission insofar as I can. Mr. Dorr had been in gradually failing health for some months, but no sudden or rapid decline had occurred. His physical strength waned slowly and in the last few months it became increasingly diffi- cult to get up and down stairs. Saturday morning, August 5, he got out of bed at his usual time and, on the way to the bathroom, his heart failed and he slumped to the floor. Death followed immediately. He lived a full and useful life and, from my intimate association with him for so long, I know that the end was welcome. There can be no regret at his passing, rather we should feel a relief that he was spared a lingering illness or physical incapacity which would have made him utterly helpless. Funeral services were held in St. Saviour's Episcopal Church here in town on Monday, August 7. The remains were taken to Boston for cremation. The ashes were returned to Bar Harbor and scattered on the Oldfarm land which he loved so dearly at a spot which he personally selected years ago. so ended a magnificent career. I hope that in time to come a suitable memorial may be established in Acadia, otherwise his name will become a legend, as no burial took place and no customary burial marker can be erected. Sincerely yours, B. L. Hadley, Acting Superintendent. BULLETIN OF THE INSTITUTE OF THE HISTORY OF MEDICINE T THE HISTORY OF THE JOHNS HOPKINS UNIVERSITY Club, an organization of (SUPPLEMENT TO THE BULLETIN OF THE JOHNS HOPKINS HOSPITAL) f Annapolis, and the Bi- Editor-HENRY E. SIGERIST isited the Institute. Dr. ent of the Johns Hopkins VOLUME II MAY, 1934 NUMBER 3 the History of Medicine. Pp.141-163. of ancient medical books ged in the Seminar Room, GLAUCOMA Johns Hopkins Medical A HISTORICAL ESSAY rial Amphitheatre. Dr. ROBERT CLARK LAUGHLIN ered an address on "The "And the eyes of them that see shall not be dim. -ISAIAH 32:3 e history of the printing 1479), a copy of which This visual affiction has probably been a source of unhappiness to y of the Library of Con- man from the time he first existed on the earth as the species Homo a later issue of this Bulle- sapiens. There is no prehistoric evidence of its existence and no actual f anaesthesia, made and record until late in historic times, but given our present knowledge of i, was shown. the eye, it is difficult to believe that such a condition could have been cal and Surgical Associa- non-existent. Sigerist discussed the re- Like so many other things in the field of medicine, glaucoma was ent, Dr. Garrison spoke first recorded by Hippocrates, when in the course of his Aphorisms phies, and Dr. Temkin he named "glaucosis" (1) as one of the diseases of old age. This was an entirely descriptive term meaning a greenish, or bluish-gray color. abscription, $5.00) may be Hippocrates states: "If the pupils assume a pathological appearance, and to be sure, if they are dark blue without occasion, and if this H.E.S. happens quickly and completely, then there is no hope for recovery. If the color is that of sea water, then the injury will develop steadily and very slowly and commonly will seize the second eye a long time after the first (2)." This is, in general, quite accurate, but Hippoc- rates made no attempt to distinguish it from cataract, a condition 141 The Development of Ophthalmology in America 1800 to 1870 A CONTRIBUTION TO OPHTHALMOLOGIC HISTORY AND BIOGRAPHY AN ADDRESS DELIVERED IN ABSTRACT BEFORE THESEC- TION OF OPHTHALMOLOGY OF THE AMERICAN MEDICAL ASSOCIATION, JUNE 4, 1907. REVISED AND ENLARGED. ILLUSTRATED BY SELECTED PORTRAITS AND CUTS. BY ALVIN A. HUBBELL, M.D., PR.D., PROFESSOR OF CLINICAL OPHTHALMOLOGY IN THE UNIVERSITY OF BUFFALO, ETC., BUFFALO, NEW YORK W. T. KEENER & COMPANY 90 WABASH AVE., CHICAGO DR. GEORGE FRICK (1793-1870), THE FATHER OF AMERICAN 1908 OPIITHALMOLOGY. University WWII AAI H8d 1908 CONTENTS. PAGE PREFACE 7 INTRODUCTION 9 FACTORS OF DEVELOPMENT-INSTITUTION AND SURGEONS 16 BIOGRAPHICAL SKETCHES-FRICK, HAYS, LITTELL AND OTHERS 40 Copyright, 1907, BY AMERICAN OPHTHALMOLOGIC LITERATURE TO ALVIN A. HUBBELL, M.D. 1850 96 SPECIAL AMERICAN CONTRIBUTIONS 110 TRANSITION PERIOD FROM THE OPHTHALMOLOGY OF THE PHYSICIAN AND SURGEON TO THE OPHTHALMOLOGY OF THE SPECIALIST 138 THE PIONEER SPECIALISTS - 140 AN ERA OF RAPID CHANGE AFTER 1850 150 OTHER FACTORS OF ADVANCEMENT 174 THE NEW AMERICAN OPHTHALMOLOGY 193 CONCLUSION 196 CHICAGO: AMERICAN MEDICAL ASSOCIATION PRESS 1907 7318 VII. THE PIONEER SPECIALISTS. HENRY W. WILLIAMS. The first American, I believe, to set himself to ex- Desth clusively special study in Europe was Dr. Henry W. Williams (1821-1895), of Boston. He had begun his medical studies at Harvard in 1844, but it appears that before graduating he went to Europe, where he spent three years, returning in 1849. In the same year he received his M.D. degree from Harvard. While in Europe he took a systematic course in ophthalmology at the them famous clinics of Sichel and Desmarres, of Paris, also following the services at Vienna of Frederich Jacger and Rosas, and at London of Dalrymple, Law- rence, Dixon, Critchett and Bowman. It was too carly to study with von Gracle, von Helmholtz and Donders. for they were just entering on their life work. On his return to Boston, be was appointed one of the district physicians of the Boston Dispensary, and in 1850 was made its first ophthalmic surgeon. In the saine year he organized a class of Harvard medical students for instruction in discases of the eye, in which he was great- D ly aided by his lifelong friend, Dr. Charles E. Bucking- ham, who for several years placed at his disposal a very abundant and excellent clinical material at the "Old DR. HENRY W. WILLIAMS (1821-1895). City Institution" in South Boston. In 1864 Dr. Wil- liams was made ophthalmic surgeon to the City Hos- pital, a position which he held for many years. In OPHTHALMOLOGY IN AMERICA. 143 1869 he was made lecturer on ophthalmology, and in 1871 professor of ophthalmology in Harvard Medical College. It is said that his teaching was lucid and practical, and was always, admirably suited to the just requirements of the particular class of hearers, whether physicians or students, to whom it was addressed. Through the long succession of ophthalmic internes.7 and externes under him at the City Hospital, and the many classes of students taught by him at the medical college, also through the numerous editions of his books, which were bought and studied by physicians, he ex- erted a continuing and far-reaching influence. As an ophthalmologist, Dr. Williams won favorable recognition from the first years of his practice as a physi- cian in 1850. He was identified with this specialty from the beginning of a professional career which ex- tended through forty-six years, and, although a special- ist of high rank, he never gave up his interest in general medicine or in subjects of public interest. Throughout the whole of his professional life Dr. Wil- liams showed himself at once conservative and inde- pendent. A careful observer of the work of others, he possessed in a high degree the faculty of discrimination in respect to the relative merits of teachers and the value of their particular methods. Learning from all, lie owed no partisan allegiance to any single master or school. The method of Daviel, as perfected by Beer, was, with unimportant variations, practiced by all the great masters of the art with a deftness and finish which have never been rivaled. Influenced by such examples, it was only natural that he should adopt extraction in 144 OPHTHALMOLOGY IN AMERICA. preference to the brilliant but uncertain operation of reclination then in vogue in this country. In the per- formance of extraction he was unexcelled, and it is char- acteristic of the man that he never departed very widely from the method which he had learned to practice SO well and which he believed to be, on the whole, the most satisfactory in its results. He adhered to the classical flap incision long after the peripheral linear section of von Gracfe had been generally adopted, and steadfastly withstood the tidal wave of opinion in favor of iridec- tomy as an integral part of the operation. He was one of the first, if not the first, among ophthalmic surgeons to advocate and employ etherization as a general prac- tice in cataract extraction. He was a man of large stature and strong character, and was a conspicuous figure on all medical occasions. He was a frequent and forcible, but persuasive, speaker and an excellent presiding officer. He was sturdy and honest in suppressing quackery, and in a thousand ways left his mark on his times and on his community. 40 ELKANAII WILLIAMS. Elkanah Williams (1822-1888) began his profes- sional life a little later. He graduated from the Uni- versity of Louisville in 1850. After engaging in general practice for a short time, lie went abroad in 1852, with the avowed purpose of studying ophthalmology. 11c followed the same teachers as had Henry W. Williams at Vienna, Berlin, Paris and London. He was a young DR. ELKANAH WILLIAMS (1822-1888). man of intelligence and ambition, and he fitted himself for ophthalmologic practice as completely as possible. 40. From biographical sketch by Dr. John Green, Trans. Am. Oph. Soc., 1896, vil, 479. 100 Years of Progress in Glaucoma. edited by E. Michael Van Buskirk and M. Bruce Shields. GLAUCOMA FILTRATION OPERATION 279 Lippincott-Raven Publishers, Philadelphia © 1997. filtration with a filtering cicatrix, improvements in glaucoma surgery were slow to develop; even the decision of when to operate was in dispute. 18 THE MIDDLE FIFTY YEARS The Glaucoma Filtration Operation It was not until the early 20th century that Herbert (7) developed the sub- B. Thomas Hutchinson conjunctival paracentesis with sclerectomy in 1903 and Felix LaGrange (8) de- scribed the sclerecto-iridectomy, the first of the classic, time-tested filtration operations, in 1906. Soren Holth's iridencleisis in 1907 (9), the anterior sclerec- Ophthalmic Consultants of Boston, Boston, Massachusetts 02114 tomy in 1909 by Holth (10), and the cornea-scleral trephination with iridec- tomy by Robert Henry Elliott in 1909 (11) were the first filtering operations for chronic glaucoma that were performed with predictable success. The operations Ophthalmologists of the past century have produced a vastly improved knowl- by Holth and Elliott were to serve the ophthalmic profession as the principal operations for chronic glaucoma for the next 60 years. edge base on the understanding of the pathophysiology of the glaucomas, espe- cially on the etiology and treatment of both acute and chronic glaucoma as known to ophthalmologists of the 19th century. Even though the success rate SO CLOSE AND YET SO FAR of filtration surgery has been enhanced by a better understanding of the glauco- mas with new examining techniques, surgical technology, and a better aware- Just as today's advances are sometimes accompanied by controversy as to ness of complications and their management, the anatomy and the goals of who was first with a concept or operation or what works best, so it was in the successful primary glaucoma filtering surgery have changed little since the ear- early days. Whose operations become a standard is exemplified by trephination liest filtering operations. The operations of the beginning 20th century remain for glaucoma. As noted, Douglas Argyle Robertson trephined four blind eyes the prototype of today's filtering surgery, changed minimally by anatomy but over the pars plana in 1876 but, for reasons obvious to us now, the operation vastly improved by adjunctive measures. and the concept failed. In January of 1909, Freeland Fergus (12) of Scotland first trephined over the ciliary body, beneath the conjunctiva, combining the trephination with a cyclodialysis into the anterior chamber; he published his THE FIRST FIFTY YEARS cases in October of 1909. Robert Elliott, of Madras, India, at the Government Ophthalmic Hospital, was approximately one large millimeter forward in his The sclerostomy and iris inclusion by William MacKenzie in 1830 (1), the operation, trephining beneath the conjunctiva into the anterior chamber, com- paracentesis with iris inclusion by George Critchett in 1857 (2), and the iridec- bining the trephination with an iridectomy. He first performed the surgery in tomy by Albrecht von Graefe in 1857 (3) serve as initial milestones for con- August of 1909 and published 129 cases in December of 1909, 2 months after temporary glaucoma operations. Although von Graefe's iridectomy produced Fergus with a similar but very different operation. Had the Fergus trephine been successful filtration by accident rather than design, it was not until 10 years later placed one millimeter further forward and an iridectomy performed, we would that Louis DeWecker (4), a student of von Graefe, established the value of a have had the Fergus trephination as a commonly recognized and successful glaucoma filtering cicatrix by an anterior sclerotomy and an iridectomy, the procedure. combined procedures proving more effective than the sclerostomy or iridec- Had the Elliott trephine been one millimeter more posterior, his operation, tomy alone. Douglas Argyle Robertson (5), better known for the pupil (aper- too, would have failed, I would not have had the opportunity of presenting ture, not student), found success with filtration in four blind eyes by pars plana 129 trephination cases to the ophthalmologists at the Government Ophthalmic trephination in 1876, an early precursor to the filtration over the pars plana by Hospital in Madras, India more than 70 years later. Interestingly, I was told Sinclair et al. (6) more than a century later, their glaucoma operation being after the lecture that the trephination operation was no longer used in southern combined with complex vitreoretinal surgery. India because of thin anterior blebs and the risk of infection at a time when the Nevertheless, the understanding of glaucoma was quite limited in the last half procedure was still a favorite of Dr. Paul Chandler, Dr. Saul Sugar, and many of the 19th century. Although iridectomy in simple glaucoma and congestive other glaucoma subspecialists in the United States. glaucoma (angle closure) was known to be of irregular benefit for long-term Because space prevents a detailed description of similar scientific and per- 278 ,280 GLAUCOMA FILTRATION OPERATION GLAUCOMA FILTRATION OPERATION 281 sonal successes and failures in these earlier days of filtering surgery, the reader puncture at the completion of a goniotomy incision in 1961 (17). This latter is referred to historical accounts by Hirschberg (13), Albert and Edwards (14), operation, the knife passing across the anterior chamber with counterpunc- and many others, whose writings are not only informative but entertainingly ture through the sclera under the conjunctiva, has been the forerunner of the provocative in many instances! trabeculo-trephine of Brown et al. (18) and the internal laser sclerostomy by Latina and Rankin (19), and others. In these latter operations, filtration is cre- ated beneath the intact conjunctiva by an ab interno incision or by gonioscopi- THE EARLY TWENTIETH CENTURY cally focused laser energy. Iliff and Haas (20) popularized the posterior lip scle- rectomy with iridectomy in 1962, an easier and safer variation on the anterior Soon the 20th century surgeons were operating for glaucoma more fre- quently. Elliott in 1918 (15) noted, "If operations work, why do some surgeons sclerectomy by Holth. Their forward dissection of conjunctiva and posterior hesitate?" It was recognized that miotics could save some eyes but, if medicines punch of the sclera created fewer conjunctival "buttonholes" and cataracts in failed, that surgery should be performed. However, Elliott was cautious, also inexperienced hands, being technically less demanding than trephination. The complications of over-filtration with a soft eye, choroidal detachment, noting that one should evaluate the ocular status of the patient vs. the general status and should operate only if the eyes were failing faster than the individual! flat chamber, corneal edema, advancing cataract, and retinopathy of hypotony led to a search for operations limiting the flow of aqueous through the sclerect- As the comfort with trephination, iridencleisis, and anterior sclerectomy oper- omy. Cairns (21) described the trabeculectomy and iridectomy in 1968. This ations increased, the surgeons' fears of a bad result lessened and undertaking of operation and its modifications remain the standard today against which all new procedures became more common in the general ophthalmic community new operations for glaucoma are measured. Krasnov (22) initiated the sinusot- as compared to the 19th century, when only the professors and senior mentors omy, also in 1968, a filtering operation more difficult to perform and not as reigned in the major academic centers and clinics. The increasing success of predictable as the trabeculectomy. filtration surgery also led to complications and concerns as infection, hemor- Setons to maintain filtration in glaucoma were first reported in 1907 (23) rhage, and the development of cataract subsequent to the glaucoma operation with horsehair. Today, for eyes with complex glaucoma that have had previous became more frequent. surgery or injury with conjunctival or intraocular scarring at the surgical lim- Robert Henry Elliott, a major leader in the management of glaucoma in the bus, the modern drainage implant, first introduced in 1969 by Molteno (24), first quarter of the 20th century, developed in his text of 1918 several concepts produces filtration remote from the surgical limbus by passing aqueous through for glaucoma that are as true today as they were 75 years ago. He noted: "1) If a silicone tube from the anterior chamber to a disc overlying the equator of the an operation for glaucoma is to be undertaken, earlier is better; 2) Every case eye. This posterior filtration site, after a normal postoperative course, has less watched with utmost care, operate without delay the moment medical therapy chance for wound leak, bleb rupture, and endophthalmitis, but there is greater fails; 3) Special watch on: a. Visual field; b. Ocular tension; and C. Visual acuity; surgical risk with this extensive surgery, which has its own set of complications. 4) Iridectomy only with the intention of freeing the natural channels of excre- tion; 5) Each surgeon must be guided not only by the environment of his pa- tients but also by his own idiosyncrasies; 6) Each case must be considered on its ADJUNCTIVE THERAPY own merits; and 7) Statistics are wanted of both success and failure. Those who follow us will know what we guessed and walk boldly where we groped." There- Although the past 50 years have seen little change in the anatomy of the fore, by 1918 the anatomy and pathophysiology of glaucoma were better un- filtering operation, new adjunctive therapies and treatments now available have derstood: successful filtration surgery was the result of aqueous humor passing greatly improved the safety and efficacy of filtering surgeries, albeit with some from the anterior chamber to the subconjunctival space where filtration and additional risks. Little disadvantage is found in the use of preoperative, opera- absorption occur. tive, and postoperative antibiotics for prevention and treatment of endophthal- mitis. Nevertheless, with antibiotics we have only lessened but not eliminated OUR PAST FIFTY YEARS the risk for intraocular infection, perhaps the most serious vision-threatening complication of glaucoma filtration surgery. Similarly, the use of cycloplegia to Advances in the surgical technique for filtration surgery over the past 50 years reduce ciliary body spasm, decrease inflammation, maintain the anterior cham- have been limited to variations on the construction of the space communicating ber, and prevent adhesions, and the use of steroids and other medications to between the anterior chamber and the subconjunctival space. Harold Sheie (16) decrease inflammation, have been enhancements that increase the success of popularized sclerotomy by scleral cautery and iridectomy in 1958 and gonio- surgery. 282 GLAUCOMA FILTRATION OPERATION GLAUCOMA FILTRATION OPERATION 283 The use of intraoperative antimetabolites such as mitomycin-C (25) and the todisruption of intra-bleb membranes, disruption of iris adhesions, and sealing intraoperative or postoperative use of 5-fluorouracil (26) have provided advan- of filtration bleb leaks and postoperative bleeding vessels can be done with min- tages to the postoperative eye by reducing the fibroproliferative scarring that imal risk for infection or bleeding and may often constitute the difference be- often results in filtration bleb failure. (My personal experience over the past 30 tween success and failure in modern glaucoma surgery. Although the laser can years has spanned a dramatically exciting era in glaucoma management with be used as a primary instrument for producing a sclerotomy and iridectomy the development of new medications, ophthalmic lasers, and the use of antime- (31,32), these technologies, although available, have not yet been sufficiently tabolites. The latter has changed a practice pattern of over 25 years.) Lamping developed to supplant the conventional filtration operation. et al. (27), with Robert Bellows and my cases being the "et als," documented for over 20 years the clear advantage of a full-thickness sclerectomy over the COMBINED GLAUCOMA FILTRATION AND trabeculectomy. Before the use of antimetabolites, no carefully controlled stud- CATARACT SURGERY ies had found the trabeculectomy to be superior to the full-thickness sclerec- tomy for prevention of blindness, especially in re-operations or in eyes with Few changes have been made over the past 90 years in the subconjunctival additional risk factors for failure. Today, with the use of antimetabolites in com- sclerectomy with iridectomy, even though modifications of the operation, bet- plex cases, one can rely on trabeculectomy and will only rarely feel the need ter instrumentation, and adjunctive therapies have improved the filtering oper- for full-thickness procedures. However, in primary filtering procedures without ation. Early attempts to combine cataract and glaucoma operations were fail- unusual risk factors for failure, most glaucoma subspecialists do not use mito- ures. However, over the past decade, surgical technology and adjunctive mycin or 5-fluorouracil because of the complications often associated with treatment have produced dramatic advances in the surgical management of these agents. It is a challenging decision, because one must balance the need for combined cataract and glaucoma. The mitomycin-enhanced trabeculectomy, a significantly lowered IOP against the risks of obtaining it. These antimetabo- phacoemulsification, and placement of a posterior chamber intraocular lens are lites have the potential for serious complications in the immediate postopera- far more effective with the antimetabolite than without it, and this procedure is tive period, such as over-filtration, hypotony (often without choroidal detach- now generally preferred to the practice of first performing filtration surgery with ment and shallowing of the anterior chamber, as seen with filters without cataract extraction, followed by placement of an intraocular lens a few months mitomycin), with retinopathy of the macula, and thin avascular blebs produc- later. The antimetabolite trabeculectomy and the intraocular lens stand to- ing an indefinite added risk for infection. gether as the two most important advances in the management of combined Special adjunctive measures with specific types of poorly controlled glau- glaucoma and cataract. coma have often proved to make the difference between success and failure in complex glaucomas. The use of laser photocoagulation and/or panretinal cryotherapy is an example of disease-specific adjunctive measures used preop- TODAY'S TYPICAL GLAUCOMA FILTERING OPERATION eratively for neovascular glaucoma. These techniques, which greatly increase the success of neovascular glaucoma filtration surgery, were introduced by An ideal composite glaucoma filtering procedure today begins with a timely Wand and co-workers (28-30). preoperative humanistic, compassionate interface with the patient that is of variable duration, depending on circumstances. This communication between the physician and the patient not only educates the patient to the nature of the INSTRUMENTATION AND TECHNIQUE glaucoma, the rationale and plan for the surgery, the risk/benefit factors related to the operation, and significant adjunctive measures but also informs the phys- The ophthalmic surgeon who reduces preoperative inflammation and mini- ician of the particular needs of the individual patient. The dialogue should cre- mizes operative tissue manipulation and hemorrhage will enter the postopera- ate physician-patient bonding with trust and understanding. Ideally, even the tive period with an advantage for success. The miniaturization of instruments obtaining of an informed consent may become an educational commitment to and improvements in sutures for wound closure have similarly allowed more mutual understanding rather than an adversarial event. The preoperative phase discrete and effective surgery. The utilization of laser energy by complex optical of the surgery also includes evaluation of the patient's general medical status delivery systems is undoubtedly the most sophisticated and exciting adjunctive and the necessary personal support system for the patient postoperatively. In- methodology in glaucoma surgery today. The argon, YAG, holmium, and vari- flammation and vascular congestion of the eye should be treated by eliminating able dye lasers are invaluable both as adjunctive and primary surgical proce- offending irritative glaucoma medications and by adding prophylactic antibiot- dures for glaucoma filtration. Lascr suture lysis of the trabeculectomy flap, pho- ics and topical steroids when warranted. 284 GLAUCOMA FILTRATION OPERATION GLAUCOMA FILTRATION OPERATION 285 Superior orbital injections of anesthesia are avoided if possible, because acci- wound can be tested with 2% fluorescein to ensure that there is no leak at the dental subconjunctival bleeding in the operative field only adds to inflamma- sutured wound or defect in the previously dissected conjunctiva. tion and makes the surgical dissection more difficult. Antibiotic and steroid are injected under Tenon's fascia in the inferior fornix. The amount of the superior limbus covered by the lid will show where the Topical atropine, antibiotic, and steroid are applied and a dry sterile dressing filtering cicatrix should be placed so as to locate the iridectomy under the lid and protective shield are secured over the eye. Postoperatively, topical and not in the interpalpebral fissure. This is important to know because the cycloplegic, antibiotic, and steroid are titrated from several times daily to a globe may be inadvertently rotated after injection anesthesia of the orbit. If gradual taper over several weeks, as inflammation and comfort allow. One must rectus muscle "bridle" sutures are used, tapered needles are appropriate to min- guard against premature cessation of therapy because it may take a few months imize bleeding. A superior limbal corneal suture usually offers better exposure for some eyes to stabilize without potential for additional scarring. In deeply of the operative field and allows better mobilization of the conjunctiva. pigmented eyes and those with additional risk factors for failure, the steroid and Minimizing tissue trauma, protecting the conjunctiva by microsurgical tech- antibiotic may need to be continued indefinitely. niques; and maintaining strict hemostasis are mandatory. for the best result. The only differences between the operations of 90 years ago and the contem- Elliott learned from experience, as we have, to keep the limbal-based conjunc- porary glaucoma filtering procedures of today are found in the sutures, the tival flap broad so that the conjunctival incision later, on closure, can be sutured scleral flap dissection, the wet-field cautery, antimetabolites, antibiotics, ste- and anchored to the episclera as far from the sclerectomy as the operating field roids and the use of the paracentesis! The postoperative risks of glaucoma fil- will allow without invading the superior fornix. A dissection between conjunc- tering surgery are the same as the early 20th century. Although antibiotics are tiva and the underlying Tenon's fascia minimizes bleeding, and careful tenting now available in a broad spectrum, endophthalmitis remains a continual threat and excision of the fascia off the episclera exposes the sclerectomy site to wet- to the eye as long as bleb filtration is maintained. field cautery. Beneath the conjunctiva, a partial-thickness scleral flap is con- structed, the base anchored at the optical limbus beneath the conjunctival flap. THE FUTURE If sufficient risk factors for surgery dictate the use of mitomycin-C, the oper- ative antimetabolite currently in widest use, a fragment of antimetabolite- impregnated microsurgical sponge is applied to the under surfaces of the scleral The ophthalmic surgeon should expect, in the future, additional adjunctive flap and the conjunctiva and to the surface of the scleral bed for a variable measures that promote filtration and minimize risk for complications. Al- interval (0.4 mg/ml for 1-4 min). Copious irrigation washes away the active though the success rate for primary glaucoma filtering operations is in excess of mitomycin. Only after the tissues are irrigated free of the antimetabolite are the 90%, the final, successful product of the surgery still leaves the eye at risk for paracentesis at the optic limbus and the incision into the anterior chamber via over-filtration, bleb leak and hypotony with its multiple consequences, a seri- the anterior scleral bed performed. The sclerectomy is accomplished with a mi- ous, increased risk for late complications such as bleb infection and endoph- crosurgical scleral punch. A peripheral iridectomy will prevent closure of the I thalmitis, or filtration bleb failure with a return of uncontrolled glaucoma. A sclerectomy by iris adhesion should the chamber become sufficiently shallow to microsurgical or biochemical alteration of the trabecular meshwork, allowing allow iris-sclerectomy contact. Wet-field cautery or topical epinephrine can be increased aqueous flow through the original trabecular drainage system, would used to obtain hemostasis before closure of the scleral flap. advance our glaucoma management beyond the traditional operations of the The overlying scleral flap is repositioned in the scleral bed and anchored with past 150 years. Until the genetic and nonsurgical management of chronic glau- one or more sutures, with the knots being buried. A variety of suture material is coma yields a better result, the legacy of our past success in surgical glaucoma available; I prefer to use material that is minimally reactive with the tissues. If management should prod us forward with new modifications for glaucoma fil- desired, the initial IOP can be titrated by deepening the anterior chamber tration operations. Finally, as Robert Henry Elliott observed, "Statistics are through the paracentesis with saline to test the pressure required for the saline wanted for both success and failure. Those who follow us will know what we to leak from the sutured scleral flap. The conjunctiva is reflected into its normal guessed and walk boldly where we groped!" anatomic position before the original incision. The open posterior and anterior edges of the tissue are apposed and anchored to the episclera near the superior REFERENCES fornix, again as remote from the sclerectomy site as the tissue allows. The con- junctiva is closed by fine, nonreactive suture material, after which the anterior 1. Mackenzle W. 1 practical treatise on the diseases of the eye. London. 1st ed. 1830; 2nd ed. chamber is again deepened with saline and the conjunctival bleb elevated for 1835; 3rd ed. 1854. evidence of good anterior chamber-subconjunctival communication. The 2. Critchett G. R Lond Ophthal Hosp Rep 1857;1:57. 286 GLAUCOMA FILTRATION OPERATION 100 Years of Progress in Glaucoma. edited by E. Michael Van Buskirk and M. Bruce Shields. Lippincott-Raven Publishers, Philadelphia © 1997, 3. von Graefe A. Ueber die Iridectomie bei Glaucom und über den glaucomatosen Process. Graefes Arch Clin Exp Ophthalmol 1857;3:456. 4. de Wecker L. Ber Dtsch Ophthal Ges 1869; Klin Monatsbl Augenheilk 1871:9:305; Ann Ocul (Paris) 1894;111:321; Bull Soc Fr Ophtal 1901; 18:1. 5. Robertson D. R Lond Ophthal Hosp Rep 76;8:404. 19 6. Sinclair SH, Aaberg TM, Meredith TA. A pars plana filtering procedure combined with lensec- tomy and vitrectomy for neovascular glaucoma. Am / Ophthalmol 1982;93:185. 7. Herbert. Trans Ophthal Soc UK 1903;23:324. 8. LaGrange F. Iridectomie et sclerectomie combinées dans le traitement du glaucome chronique: Glaucoma Drainage Devices; procede nouveau pour l'establissement de la cicatrice filtrante (1). Arch Ophthalmolol Rev Gen 1906;26:481. Horsehair to Silicone 9. Holth S. Ann Ocult (Paris) 1907;37:345. 10. Holth S. Sclerectomie avec la pince emporte pièce dans le glaucome de préferénce apres incision a la pique. Ann Ocul 1909; 142:1. 11. Elliott RH. A preliminary note on a new operative procedure for the establishment of a filtering Don Minckler cicatrix in the treatment of glaucoma. Ophthalmoscope 7:804, 12. Fergus F. Treatment of glaucoma by trephining. BMJ 1909;2:983, 13. Hirschberg. The history of Sophthalmology. English ed. J.P. Wayenborgh-Verlag, 1992. 14. Albert, Edwards. The history of ophthalmology. London: Blackwell Science, 1996. 15. Ellot RH. Glaucoma: a textbook for the student of ophthalmology. Paul E. Hober, 1918. The Doheny Eye Institute, University of Southern California, Los Angeles, 16. Scheje HG. Retraction of scleral wound edges as a fistulizing procedure for glaucoma. Am J California, 90033 Ophihalmol 1958;45:220. 17. Scheie HG. Filtering operations for glaucoma: a comparative study. Am. Ophthalmol 1962:53: 571. 18. Brown RM et al. Internal sclerectomy for glaucoma filtering surgery with automated trephine. Arch Ophthalmol 1987; 105:133. 19. Latina MA, Rankin GA. Internal and transconjunctival neodymium: YAG laser revision of late falling filters. Ophthalmology 1991;98:215. Glaucoma drainage devices (GDDs) have gradually gained an enthusiastic fol- 20. Iliff CE, Haas JS. Posterior lip sclerectomy. Am J Ophthalmol 1962;54:688. lowing over the past two decades as preferred therapy for some complicated 21. Cairns JE. Trabeculectomy-preliminary report of a new method. Am / Ophthalmol 1968;66: glaucoma cases, especially those that have previously failed all standard thera- 673. 22. Krasnov. Br J Ophthalmol 1968;52:157. pies. On the basis of a recent informal survey of manufacturers, it is estimated 23. Rollet M, Moreau M. Traitement de hypopyon par le drainage capillaire de la chambre ante- that approximately 4,000 to 6,000 such devices are being used per year in the rieure. Rev Gen Ophthalmol 906;25:481. United States, and undoubtedly many more around the world. 24. Molteno ACE. New implant for drainage in glaucoma. Br ,/ Ophihalmol 1959;53:606. 25. Chen CW. Trans Asia-Pacific Acad Ophthalmol 1983;9:172-177. Horsehair was perhaps the first foreign material surgically inserted into a hu- 26. Heuer, Parrish, Gressel, et al. Ophthalmology 1986;93:1537. man eye in hopes that it would/function as an artificial drainage device to facil- 27. Lamping KA, Bellows AR, Hutchinson BT, Afran SI. Long-term evaluation of initial filtration itate drainage of aqueous from anterior chamber to subconjunctival spaces. surgery. Ophthalmology 1986;93:91. 28. Wand M, Dueker DK, Aiello LM, et al. Effects of panretinal photocoagulation on rubeosis Rollet and Moreau reported this procedure in 1906, almost 100 years ago (1). iridis, angle neovascularization and incovascular glaucoma. Am J Ophthalmol 1978;86:332. During the subsequent decades through 1960, a remarkable variety of materi- 29. Wand M, Ducker DK, Aiello LM. Am J Ophthalmol 1978;86:332. als, including silk thread, various metal rods and tubes, glass tubes, acrylic 30. Wand M, Hutchinson BT. The surgical management of neovascular glaucoma. Perspect Oph- thalmol 1980;4:147. plates, gelatin, polyethylene tubes, and silicone tubes, have been similarly used 31. Hoskins HD, Iwach AG, Drake MV, et al. Subconjunctival THC: YAG laser limbal scleros- to help control intraocular pressure (IOP) in complicated glaucomas. Early re- tomy ab externo in the rabbit. Ophthal Surg 1990;21:589. ports described individual cases or small case series and, more recently, large 32, Latina MA, Long F, Deutsch T, et al. Dye-enhanced ablation of sclera using a pulsed dye laser. Invest Ophthalmol Vis Sci 1986;27(Suppl):254. prospective clinical studies and experimental animal studies have also been re- ported with various different devices. The Molteno implant, first reported clinically in 1969 (2), was the first drain- age device widely acknowledged as reasonably successful and remains the "gold standard" to which all subsequent designs have been compared. To his great credit, Molteno remains actively engaged and will soon report an analysis of long-term clinical outcomes and clinicopathologic correlations among his own cases, He has managed to collect autopsy eyes from many patients in New Zealand, including some with 20 or more years of clinical follow-up after in- stallation of one or the other variations of his device. 287 Volunteer Opportunities by United - at America & / United Way of Massachusetts Bay Together, we make things happen Home Login Search I Spotlight | Calendar Agencies Opportunities I Opportunities About Us Massachusetts Eye and Ear Infirmary Last updated on July 7, 2003 Agency Listing The Massachusetts Eye and Ear Infirmary is a specialty View Info hospital dedicated to excellence of care for disorders that Add to Favorites affect the eye, ear, nose, throat, head and neck region. 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Record 2 of 8. 2 Mark: Prev Next Notz: See chapter 11 Detailed More Info. Record by Peter C.Kronfeld The history of ophthalmology or "Glasscoma." pp. 203-222 (include Daniel M Albert; Diane D Edwards biblography attached). 1996 English Book xvi, 394 p., [12] p. of plates : ill. (some col.) ; 26 cm. Cambridge, Mass., USA : Blackwell Science, ISBN: 0865423784 (alk. paper) GET THIS ITEM Availability: Check the catalogs in your library. Libraries worldwide that own item: 109 FIND RELATED More Like This: Search for versions with same title and author I Advanced options Find Items About: The history of ophthalmology / (1) Title: The history of ophthalmology / Author(s): Albert, Daniel M. ; Edwards, Diane D. Publication: Cambridge, Mass., USA : Blackwell Science, Year: 1996 Description: xvi, 394 p., [12] p. of plates : ill. (some col.) ; 26 cm. Language: English Standard No: ISBN: 0865423784 (alk. paper); National Library: 9610195; LCCN: 96-9847 SUBJECT(S) http://firstsearch.oclc.org/WebZ/FSFETCH?fetchtype=fullrecord:sessionid=sp06. numrecs= 3/26/2004 222 THE HISTORY OF OPHTHALMOLOGY Bader C. Scelrotomy in glaucoma. London: Trans. VII Inter- Hirschberg J. Geschichte der Augenheilkunde in Graefes- national Congress of Medicine (section on ophthalmol- Sämisch Handbuch der gesamten Augenheilkunde. ogy), 1881;98. Zweite Aufl. Vol. 14, Chap. XXIII. Leipzig: W. Engel- Barkan O. Glaucoma: classification, causes, and surgical con- mann, 1911;304-310. trol; results of microgonioscopic research. Am J Knies M. Über das Wesen des Glaukoms. von Graefe's Arch Ophthalmol 1938;21:1099-1114. Ophthalmol 1876;22:163-202. Baurmann M. Der Kammerwasser-Abfluss in Handbuch der Kronfeld PC. Theodor Leber, the foundation builder. Surv normalen und pathologischen Physiologie. Receptions- Ophthalmol 1971;16:98-107. organe II 1931;1339-1348. Kronfeld PC. The rise of the filtering operations. Surv Bowman W. Glaucomatous affections, and their treatment by Ophthalmol 1974;17:168-178. iridectomy. Br Med J, Oct. 11, 1852;377-382. Laqueur L Neue therapeutische Indikation für Physostig- Curran EJ. A new operation for glaucoma involving a new mine. Centralbl med Wissensch 1876; 14:421-422. principle in the etiology and treatment of chronic pri- Laqueur L. Über Atropin und Physostigmin and ihre mary glaucoma. Arch Ophthalmol 1920;49:131-155. Wirkung auf den intraocularen Druck. von Graefe's Czermak W. Einiges sur Lehre von der Entstehung and dem Arch Ophthalmol 1877;23:149-176. Verlaufe des prodromalen und acuten Glaukomanfalles. Lasker C. Ein experimenteller Beitrag zur Lehre von der Prager Med Wochenschr 1897;22:15-17. glaucomatösen Excavation. von Graefe's Arch Ophthal- de Wecker L. La cicatrice à filtration. Ann d'ocul 1882; mol 1886;24:187-201. 87:133-143. Lauber H. Das Gesichtsfeld, Untersuchungsgrundlagen, Draeger J. Geschichte der Tonometrie. Bibl Ophthalmol Physiologie und Pathologie. Munich: J.F. Bergmann; 1961;56:37. Berlin and Vienna: Springer Verlag, 1944;236-237. Elliot RH, Lagrange PF, Priestley Smith J. Report on glauocma Leber T. Studien über den Flüssigkeitswechsel im Auge. Arch operations with special reference to the comparative Ophth 1873;19:87-185m. results attained by iridectomy and its recent substitutes. Löhlein W. Überblick über den heutigen Stand der Glauk- London: Trans. XVIIth International Congress of Medi- omtherapie. Zentralbl ges Ophthalmol Grenzgeb cine ( section on ophthalmology), 57-146. 1930;22:1-96. Elschnig A. Glaucom in Henke-Lubarsch Handbuch der MacKenzie W. Practical treatise on the diseases of the eye. speziellen pathologischen Anatomie und Histologie. London: Longman, Reese, Orme, Brown, and Green, Berlin: J. Springer, 1928. 1830;710. Foroni C. Sclerectomia ab externo. von Graefe's Arch Müller H. Anatomische Beiträge zur Ophthalmologie. Ueber Ophthalmol 1915;89:393-399. Niveau-Veränderungen an der Eintrittsstelle des Sehner- Friedenwald JS. Calibration of tonometers in standardization ven. Arch Ophthalmol 1958;4:1-39. of tonometers. Decennial report, committee on stand- Phillips CI. Aetiology of angle-closure glaucoma. Br J ardization of tonometers. Am Acad Ophthalmol Otol, Ophthalmol 1972;56:248-253. 1954;95. Schiotz H. Tonometry. Br J Ophthalmol 1920;4:201-210 and Fuchs E. Ablösung der Aderhaut nach Staaroperation. von 249-266. Graefe's Arch Ophthalmol 1900;51:199-210. Schmidt-Rimpler H. Glaukom in Graefe-Sämisch Handbuch Fuchs E. Ablösung der Aderhaut nach Operation. von der gesamten Augenheilkunde, Zweite Aufl. Leipzig: W. Graefe's Arch Ophthalmol 1902;53: 375-401. Engelmann, 1908;188 Fuchs E. Über die Lamina cribrosa. von Graefe's Arch Schnabel I. Die glaukomatöse Sehnervenatrophie. Wiener Ophthalmol 1915;91:435-485. Klin Wochenschr 1900;18:469-470. Grant WM. A tonographic method for measuring the facility Schnabel I. Klinische Daten zur Entwicklung der glauk- and rate of aqueous flow in human eyes. Arch Ophthal- omatösen Exkavation. Klin Montasbl Augenh mol 1950;14:204-214. 1908;46:318. Haffmanns JHA. Zur Kenntnis des Glaukoms. Arch Ophth Schwalbe G. Untersuchungen über die Lymphobahnen des 1862;8:124-178. Auges und ihre Begrenzungen. Arch Mikroskop Anat Heine L. Die Cyklodialyse, eine neue Glaukomoperation. 1870;6:261-362. Deutsche med Wochenschr 1905;31:824-830. Seidel E. Weiters experimentelle Untersuchungen über die Herbert H. Subconjunctival fistula operation in the treatment Quelle und den Verlauf der intraokularen Saftströmung. of primary chronic glaucoma. Trans Ophthalmol Soc VI. Die Filtrationsfähigkeit, eine wesentliche Eigen- UK, 1903;23:32+-346. schaft der Scleralnarben nach erfolgreicher Elliotschner GLAUCOMA 223 Trepanation. von Graefe's Arch Ophthalmol von Graefe A. Weitere Zusätze über Glaukom und die Heil- 1921;107:158-161. wirkung der Iridectomie. Arch Ophthalmol Singer C, Ashworth Underwood E. A short history of medi- 1861;8:254-271. cine. 2nd ed. New York and Oxford: Oxford University Walker G. A new method of relieving tension in chronic Press, 1962;647. glaucoma. Trans VIIIth International Ophthalmology Smith JP. Glaucoma: its cause, symptoms, pathology, and Congress 1894;315-317. treatment. London: J and A. Churchill, 1879. Weber A.. Ein Fall von partieller Hyperämie der Choroideal bei Spengler E. Kritisches Sammel-Referat über die Verwendung einem Kaninchen. Arch Ophthalmol 1855;2:133-157. einiger neuerer Arzneimittel in der Augenheilkunde. Weber A. Über Calabar und seine therapeutische Verwen- Zeitschr Augenhielk 1905;13:33-46. dung. von Graefe's Arch Ophthalmol 1876;22:215. Terson A. Les premiers observateurs de la dureté de l'oeil Weber A. Die Ursache des Glaukoms. von Graefe's Arch dans le glaucome. Arch d'Ophthamol (Paris) Ophthalmol 1877;23:1-91. 1970;27:625-630. Wright Tomson AM. William MacKenzie--an appreciation. von Graefe A. Vorläufige Notize über das Wesen des Glau- In Stanley Cant J (ed). The ocular circulation in health coms. Arch Ophthalmol 1854;1:371-382. and disease. St. Louis: C.V. Mosby Co., 1969;1-4. von Graefe A. Über die Wirkung der Iridectomie bei Glau- Zentmayer W, Posey WC. A clinical study of 167 cases of glau- com. Arch Ophthalmol 1857;3:456-555. coma simplex. Arch Ophthalmol 1895;24:378-394. HISTORICAL INTRODUCTION Development of Our Concept of Glaucoma and Its Treatment The word glaucoma derives from the Greek word glaukós, meaning a watery or diluted blue. Hippocrates mentioned the condition of glaukosis among the infirmi- ties suffered by old people. Hippocrates meant by the term a bluish discoloration of the pupil. The condition was later called ypochyma and corresponded to a cataract. In antiquity glaukosis and hypochyma were considered identical. Later, during the Alexandrian time, glaucoma was thought to be a disease of the crystalline body (or fluid), which changed its normal color to light blue; hypochyma, in contrast, was regarded as the exudation of a fluid that later congealed and lay between the iris and the lens. All glaucomas were considered incurable, while it was believed that some hypochymata could be improved. The authors of antiquity and Arab physicians interpreted glaucoma as an incur- able cataract with desiccation of the lens. During the Middle Ages, the School of Salerno introduced the concept of "gutta serena," which was supposed to be one type of incurable cataract in which the pupil was dilated and clear; the condition was considered to be possibly congenital. According to this school, another type of incurable cataract existed in which the pupil would dilate suddenly and appear green. Pierre Brisseau, with his little book on cataract and glaucoma published in 1709, was the first to consider glaucoma as a vitreous opacification. He correctly interpreted cataract as an opaque crystalline lens. The first reasonably satisfactory description of glaucoma was written by Charles St. Yves (1722): "Glaucoma is one of the spurious cataracts. First the patients see smoke and fog; then they lose vision while the pupil becomes dilated; finally, only a remnant of vision remains tempo- rally. The disease may begin with severe pain. The prognosis is poor. There is danger that the other eye will also be affected." Quite likely he was describing angle- closure glaucoma. Johann Zacharias Platner (1745) was the first to state that the glaucomatous eye was hard, resisting the pressure exerted by the fingers. The pressure theory was then emphasized and clarified by William Mackenzie (1830). Jakob Wenzel (1808) thought that glaucoma was primarily a disease of the retina, while S. Canstatt (1831), Julius Sichel (1841), and followers declared glaucoma a form of choroiditis. All of them considered glaucoma incurable. Georg Josef Beer (1817) thought that glau- coma was an opacification of the vitreous and the sequel of an arthritic ophthalmia that would only develop in patients with gout who had had no preceding ocular inflammation. A few futile attempts were made to treat glaucoma in the early nineteenth cen- tury. Mackenzie suggested a sclerotomy or lensectomy. Georg Stromeyer recom- mended tenotomy of the superior oblique and myotomy of the inferior oblique. 3 St. Yves wanted to enucleate the affected eye to prevent involvement of the second eye. The first real breakthrough in treatment was the discovery in 1856 by Albrecht von Graefe that iridectomy could be a curative procedure for certain types of glau- coma. He had first tried without success the instillation of atropine and repeated paracenteses to lower intraocular pressure (IOP). Only with the invention of the ophthalmoscope by Hermann von Helmholtz in 1851 was it possible to observe the changes in the optic nerve head associated with glaucoma. The term pressure excavation had been coined by von Graefe. This oph- thalmoscopic concept was corroborated by careful pathologic examinations initiat- ed by Heinrich Müller. Edward Jaeger and Isidor Schnabel defended the hypothesis that glaucoma was characterized by specific optic nerve disease. It soon became obvious that an iridectomy could not cure all types of glauco- ma. Albrecht von Graefe had already noted that a "cystoid scar," meaning a filtering bleb in today's jargon, would offer certain advantages for normalizing IOP. Sclerot- omy was first proposed by Louis de Wecker in 1869. Surgeons then tried to keep the wound open on purpose, either by infolding of the conjunctiva (H. Herbert, 1903) or by incarceration of the iris (George Critchett of London in 1858 and Soren Holth of Oslo in 1904). Finally, the iridosclerectomy was devised by Pierre Lagrange in Paris (1905), and the trephining operation was introduced by Robert H. Elliot of Madras, India. Thermosclerotomy was first described by Luigi Preziosi of Malta in 1924, and it was later modified and popularized by Harold Scheie of Philadelphia in 1958. Trabeculectomy was subsequently described by Watson and Cairns in the 1950s in England. The medical treatment of glaucoma was initiated with eserine, which is derived from the Calabar bean of West Africa. This drug was first recognized as a miotic and used for treating iris prolapse. In 1876 Ludwig Laqueur of Strasbourg and Adolf Weber of Darmstadt were the first to use eserine to treat glaucoma. The alkaloid pilo- carpine was isolated in 1875, and it was first topically applied to the eye by John Tweedy of London (1875) and by Weber (1876) in an effort to lower IOP. Frederick C. Blodi, MD 4 WellcomeLibrary/Hist.Med. Page 1 of 1 WellcomeLibrary The Wellcome Trust The Wellcome Library for the History and Understanding of Medicine Cross Home News Sitemap Contact About Us FAQs Join the Library Using the Library Catalogues Electronic resources Collections Tour Exhibitions Projects The Wellcome Library > Catalogues > Library HP SALES REQUEST FROM EFFECTS (Search History) WORD glaucoma History of Medicine Collections Search Sorted by Date Title On the pathology and treatment of glaucoma : being a revised publication, with additions, of the Erasmus Wilson lectures delivered at the Royal College of Surgeons of England in March, 1889 / by Priestley Smith Imprint London : J. & A. Churchill, 1891 ACCESS SHELFMARK STATUS COMMENTS Modern Medicine Room WW100 1891S650 - OPEN SHELVES Phys. desc. xi, 198 p. : ill. ; 23 cm. Note Copy 1 Copy 2 Author, etc. Smith, Priestley, 1845- Topic-mesh Glaucoma. Classifications WW100 1891 System no. b10069860 Old rec. no. 69618 Publ. place England London Record no. 12000650 RR Present KEWES START (Search History) All rights reserved : The Wellcome Trust ./frameset&FF=Xglaucoma%261=%26m=%26z=%26Da=%26Db=%26b=%26p=%26n=%26c12/9/2003 WellcomeLibrary/Hist.Med. Page 1 of 1 WellcomeLibrary 2 $ The Wellcome Trust The Wellcome Library for the History and Understanding of Medicine Home News Sitemap Contact About Us FAQs Join the Library Using the Library Catalogues Electronic resources Collections Tour Exhibitions Projects The Wellcome Library > Catalogues > Library HILL 18.6 SPECIMEN REQUIRED FRESH (Search History) WORD glaucoma History of Medicine Collections Search Sorted by Date Title Glaucoma : a symposium / organized by the Council for International Organizations of Medical Sciences ; editor: Sir Stewart Duke-Elder Imprint Oxford : Blackwell Scientific Publications, 1955 ACCESS SHELFMARK STATUS COMMENTS REQUEST Med. XWW - ONLINE REQUEST Phys. desc. X, 350 p., [16] p. of plates : ill., ports. ; 23 cm. Note Also published Springfield, Ill. : Charles C. Thomas, 1955. Copy 1 Copy 2 Supplier/Donor: BMA Author, etc. Duke-Elder, Stewart (William Stewart), Sir, 1898-1978. Council for International Organizations of Medical Sciences. Topic-mesh Glaucoma. Ophthalmology. Genre/technique Conference proceedings. System no. b12216240 Old rec. no. 216880 Record no. 14660679 1358 00000000 INFORMATION would KENSE (3) RECURED STREE (Search History) All rights reserved : The Wellcome Trust ./frameset&FF=Xglaucoma%261=%26m=%26z=%26Da=%26Db=%26b=%26p=%26n=%26c12/9/2001 Wellcome Library /Hist.Med. Page 1 of 1 Wellcomel library The Wellcome Library for the History and Understanding of Medicine The Wellcome Trust Home I News I Sitemap Contact About Us FAQs Join the Library Using the Library Catalogues Electronic resources Collections Tour Exhibitions Projects The Wellcome Library > Catalogues > Library NIK No. 2014 BE@ E REPLACE FRON (Search History) WORD glaucoma History of Medicine Collections Search Sorted by Date Title Lectures on diseases of the eye / by Charles Bell Taylor imprint London : G. Redway, 1888 ACCESS SHELFMARK STATUS COMMENTS Modern Medicine Room WW7.T23 1888 - OPEN SHELVES Phys. desc. 97 p. : ill. ; 22 cm. Note Appeared originally in the Lancet Contents 1. Cataract.-- Squint. -- 3. Glaucoma. 4. Optico-ciliary neurotomy. -5. The use and abuse of mydriatics. --6. Eye troubles in general practice. Note Copy 1 Copy 2 Prev. publ. Lancet London, England Author, etc. Taylor, Charles Bell, 1829-1909. Topic-mesh Eye Diseases. Classifications WW7.T23 1888 System no. b1278266x of Old rec. no. 94153 Publ. place England London Record no. 14787548 Sign EXPRESS $25.00 RECREES MACH GREEN (Search History) All rights reserved : The Wellcome Trust frameset&FF=Xglaucoma%261=%26m=%26z=%26Da=%26Db=%26b=%26p=%26n=%26c12/9/2003 CLASSIC PAPERS IN GLAUCOMA edited by Robert Ritch and Ronald M. Caronia Kugler Publications/The Hague/The Netherlands 2000, Health Science Library System Falk Library of the Health Sciences University of Pittsburgh Pittsburah. PA 15261 Kitch ₹ Caronia 2 Introduction At the dawn of the 21st century, we can truly say that the last century was one of profound scientific advancement. The rate of acquisition of knowledge changed from an arithmetic progression to a geometric one, in no small part because of the creation of computer technology. Rapid advances in molecular genetics promise many new frontiers ahead. Glaucoma, as a field, has taken a quantum leap forward. At the beginning of the 20th century, glaucoma was barely understood. Well into the century, it was divided into two broad categories based upon clinical presentation. Congestive glaucoma was characterized by a red eye and corneal edema, and was divided into acute and chronic forms, comprising such entities as acute angle-closure, neovascular, and uveitic glaucomas. Noncongestive glaucoma was characterized by a quiet eye, and included both chronic open-angle glaucoma and chronic angle-closure glaucoma. Angle-closure glaucoma as a distinct entity was unknown. Gonioscopy, developed by Trantas at the turn of the century, was largely ignored until Barkan popularized it in the 1930s. The concept of pupillary block, developed by Curran, was controversial for nearly two decades. It was not until the early 1950s that the fundamental differences between open-angle and angle-closure glaucomas became appreciated. Medical treatment for glaucoma at the turn of the century was limited to pilocarpine and some other cholinergic agents, such as physostigmine. Bleeding, purging, leeches, and inunction with mercury served to fill the gap. Laser, of course, was far in the future. Surgical iridectomy had been the standard treatment approach in the latter half of the 19th century, but because its success was limited, other surgical fistulizing procedures evolved, from full-thickness operations, to trabeculectomy, and finally to present day investigations into alternatives to trabeculectomy. Histeria Ophthalmolegia Internationalis 1 (1979-1980): Hist. ophthal. intern 1, 55 -65 (1979) Pp. 55 - 65, AN ESSAY ON THE HISTORY OF GLAUCOMA E. Grom Caracas Even though the word "Glaucoma" appears in the Hippocratic writings, the con- cept of the illness associated with the increase of intraocular pressure appears much later. In the Hippocratic Aphorisms, the term "Glaykoseis": greenish or bluish, has been used to describe the blindness which comes on in old age, associated with the greenish-blue hue of the pupil. When the pupil becomes "sea coloured", "sight is destroyed and blindness of the other eye frequently follows". This term has been used without being based on a specific pathology and did not represent a nosologi- cal entity, but probably comprised several syndromes, including absolute glaucoma. Chronic glaucoma as we know it today, was completely unknown and classified as amblyopia, amaurosis or gutta serena. Originally, this lesion could not be distin- guished from cataract. It was at a much later date, that Galen and other authors of the first centuries of the Christian era, situated this illness behind the pupil and con- sidered that it can be the cause of blindness. It was divided into two groups: "suf- fusions or hypochyma" or cataracts fit for surgical treatment, and "glaucomata" which were not. Charles Saint Yves (1722) already knew that in an advanced stage, the patient sees objects ("du coin de l'oeil") from "the corner of the eye". As late as the beginning of the XVIIth century, the famous French oculist Antoine Maître Wart H, Cambridge, Mazs., Capy. 22 March 1924 [Hubert Work] Dear Mr. Secretary: Your kind reply dated February 4th to my letter to you of February 1, 1924, encourages me to write to you again shout the Hearing you are to give next Wednesday to the persons interested in the development of the Lafayette National Park among whom you have horotofore supposed that divergent opinions concerning the management of the Park and of the construction sf roads therein are strongly held. At this Hearing I am sure you will find that the different parties are not "80 far apart in their conclusions as appears from ex parte statenents of each" a statement which I quote from your letter to ne of February 4th. There is one matter, however, closely connected with the subjects which will be discussed st that Hearing concerning which I want to tettify now before the Hearing, namely, the qual- ity and character of George B. Dorr, the present Superintendent of the Park, [os course I do not know whether you propose er do not propose to ask Mr. Dorr to testify at the Hearing; but I do know that he will avoid speaking at the Hearing if he can properly do so, partly because he dislikes very much to talk even in private about his own qualities and achievements, and partly because he has been from his boyhood afflicted with a stammer which was orig- inally very pronounced and conspicuous, and still is, although he has acquired remarkable control over it. This stammer provents him from uttering a word for an approciable time. [C.W.Eliot] What is Stuttering? Page 1 of 5 What is Stuttering? Stuttering is a condition which affects the fluency of speech. The symptoms generally display either through repetition of a part of word, i.e. would you like to d-d-d-dance, or through the speaker blocking on particular words, i.e. my name is {extended pause} Daisy. It is quite common for both these general symptoms to display simultaneously, i.e. my name is {extended paused} D-D-D-Daisy, especially if the stutterer tries to force the words out to break the block. These overt symptoms may also be accompanied by physical expression of embarrassment such as blushing, avoiding eye contact, etc., and sometimes also by physical tics such as spasmodic jerks as the stutterer tries to force the words out. As well as these overt symptoms, there are almost always covert symptoms such as avoidence and word substitution. The stutterer will often avoid speaking situations where they feel they may stutter, or even when they are speaking they may substitute one word for an easier word if they feel they are going to stutter on the former word. This can go as far as making up a new name if they feel they are going to stutter when giving their own name! For the purposes of this page, and in general throughout this site, the term disfluency will be used to cover all the symptoms of stuttering, whether overt or covert. The words stuttering and stammering may now be used interchangeably. In the past, stuttering has been identified with a disfluency in enunciated speech while stammering was identified with blocking where a person is unable to enunciated any spoken word at all. There were sometimes seen as different conditions, though of recent years they are now universally seen as symptoms of the same condition. Sheehan (1970) defines stuttering as a disorder of the social presentation of the self. He sees it as essentially a conflict revolving around self and role, and states that therapy should be role specific. He further claims that the stutterer typically experiences no difficulty when alone and that the stuttering behaviour requires both a listener and a speaker. I would disagree with this definition. I have sometimes experienced difficulties in fluency when reading aloud to myself when completely alone. However, I do recognise that there may be other people for whom disfluency is only experienced in a social context, and thereafter only in specific circumstances. Every stuttering problem is individual and while the symptoms may be similar, they are unlikely to be identical between different stutterers. This is why any therapy or cure may need to have a personalised bespoke element to be effective. Ipso facto, any current definition of stuttering should be defined by the symptoms and not the causes which are possibly multifarious and still largely nothing but conjecture at this point in time. I would define stuttering as a speech impairment where the speaker has difficulty in forming fluent speech to a greater or lesser extent depending of the severity of the condition and the specific situation in which he or she is trying to enunciate. Note that context is a much broader term than a role theory of speaker and listender. I then define two categories of disfluency in the context of stuttering: general disfluency and specific disfluency. General Disfluency http://www.geocities.com/batalosweb/what.htm?20085 3/5/2008 What is Stuttering? Page 2 of 5 General disfluency is disfluency associated with general non-optional dialogue. Non-optional dialogue is defined as a speaking situation which the speaker either chooses not to avoid or is not able to avoid. For example, a speaker may always choose never to avoid dialogue with close friends or family, regardless of the fact that they may experience disfluency of speech. Another example could be a work situation where the speaker is required to make a spoken presentation in circumstances where they are likely to experience disfluency. If the speaker resigns to the fact that they have no option than to comply the situation falls into the general category. Whether there is a choice or not is solely determined by the speaker, based on his or her assessment of the situation. Specific Disfluency Specific disfluency is associated with optional dialogue. Optional dialogue is defined as a speaking situation which the speaker feels he or she can choose to avoid if they so wish. This can include introducing yourself to a person you don't know, choosing to ask someone for directions, etc. To contextualise the difference between general and specific disfluency, in the example of the presentation outlined above, if the speaker feels that they have the option of refusing to give the presentation then the categorisation changes to specific disfluency. Therefore, the demarcation of a episode of disfluency into either general or specific is very much defined by the individual personal take on the situation. In the presentation example, the speaker may feel that they do have an option to refuse to make the presentation even though, to give an extreme example, they could be potentially dismissed for failing to meet the terms of their contract of employment. Therefore the situation falls into the specific category. Another person could recognise that the consequences of refusal are too potentially devistating to allow for such a choice and resigns themself to probable disfluency, this then falls into the category of general disfluency (the symptoms of stuttering have been assessed as being a lesser evil to other consequences). In contrast to general disfluency, the effects of specific disfluency are twofold: the speaker can still experience disfluency if they do in fact choose to speak; the additional effect is that the speaker may expend significant time and energy contemplating whether he or she should speak, weighing up the consequences based on their own perceptions (a sort of game theory). In general disfluency, only the former effect is experienced as the speaker has not given him or herself the option of avoidence. While the two effects can be mutually exclusive in some circumstances, in other situations they may seem to be experienced cotertainmously. For example, a speaking situation is not avoided but the speaker does not say exactly what he or she wants to say, or the speaker engages in dialogue but seeks to terminate the conversation as soon as possible to minimise the risk of disfluency. As explained above, specific disfluency does not seem to always involve a complete avoidence of speaking. Therefore, speakers can only really be stated to be experiencing general disfluency if as well as not avoiding a speaking situation, they in fact also say everything they want to say, and use all the words they want to use without substitution or other tricks. In contrast, general disfluency never involves the speaker making a choice about what to say or whether to speak. If they need to enunciate feared words to communicate what they want to say they will not avoid or try to substitute these words, but will continue to talk regardless of any disfluency experienced. If they experience a long http://www.geocities.com/batalosweb/what.htm?20085 3/5/2008 What is Stuttering? Page 3 of 5 block they will just wait until it finishes! In general, all situations should be defined into one or other of the disfluency categories: if there is any element of choice or potential avoidence, the situation should be defined under specific disfluency. However, it may not always be as clear-cut as that. For example, suppose a day-long meeting is scheduled, and it begins under the parameters of general disfluency where the speaker contributes exactly what they want to do regardless of any disfluency. Suppose that towards the end of the day, a senior manager which the speaker fears then joins the meeting and the speaker begins to avoid making contributions for fear of disfluency. In these circumstances, the meeting should be broken down into two separate sub-meetings for the purpose of defining fluency, demarcated by the point when the senior manager appeared on the scene. Note that specific disfluency is defined by what the speaker feels they should say; if the arrival of the senior manager meant that specific pertinent issues needed to be discussed within a limited timescale, the speaker may decide that something they were going to say is now relatively unimportant given the changed circumstances of the meeting. The same goes for contributions in general; the speaker only experiences disfluency if something they feel needs to be said is not being said. There is no need to say something just for the sake of doing so; no-one is impressed by people who speak at meetings just for the opportunity to hear their own voice! However, in this regard, the stutterer needs to be very honest about how he or she defines such circumstances and should not try to mislabel disfluency on the basis that they had nothing important to say By its nature, specific disfluency is relative. In the presentation example, the speaker may not completely avoid the whole situation but may try to avoid constituent parts. For example, say the presentation the speaker had been asked to make also, by virtue of being the first presentation at the briefing, involved making a sub-presentation introducing all the other speakers sitting at the front table. The speaker may make up an excuse such as work pressures mean that there is is a chance that they will be momentarily late to the briefing and that as such it would make more sense to have another person make the introductions and that he could make the second presentation instead. Symptoms of Disfluency Note that the disfluency experienced in either general or specific disfluency may be greater or lesser than that experienced in the other category. The stuttering experienced in general disfluency is by no means less extreme than examples of specific disfluency. There can still be a sense of foreboding when a situation of general disfluency is anticipated; the difference is that a fatalistic attitude is taken to anticipated disfluency which strangely enough can be no bad thing. In the context of the presentation example, the stutterer is unlikely to be particularly looking forward to having to give the presentation; however, in situations categorised under general disfluency, the stutterer has resigned themselves to the probable appearance of the symptoms of disfuency, but has just decided that they will have to deal with them if they occur. In contrast, scenarios involving a choice, may also exacerbate a cycle of fear; the stutterer is likely to think more about the situation in advance as there is the possibility of avoidence. They may also begin to make value judgements: are the potential symptoms of disfluency worth the kudos attained by giving the presentation in the first place? The anxiety this generates may exacerbate the disfluency. http://www.geocities.com/batalosweb/what.htm?20085 3/5/2008 What is Stuttering? Page 4 of 5 On the basis of a strict application of the definitions above, it unlikely that any stuttterer will experience general disfluency all the time, and they are likely to slip back in specific disfluency from time to time. If a stutterer is experiencing a significant amount of disfluency, there is a great temptation to limit the amount of speaking where at all possible; the stutterer may still communicate their point but using the mimimum amount of dialogue. In a conversation, they may make a number of contributions, but not at such a level that they would do so if totally fluent. On the other hand, being verbose is not always a quality that is appreciated by all. General (rather than specific) disfluency, if to be seen as a goal, should be assessed on the basis of an optimum value rather than a absolute basis. An approach which tries to categorise more and more speaking situations under the parameters of general disfluency is the Sheehan theory of Voluntary Stuttering. If a stutterer manages to move much of his or her speaking life under the auspices of the general disfluency, which is somewhat comparable to the aim of voluntary stuttering in making the stutterer comfortable with his or her disfluency, they may reach a stage where their stuttering, and their perception of it, no longer becomes such a big deal. In tandem, their fluency may also generally improve as the anxiety associated with their stuttering diminishes. By removing the symptoms specifically associated with specific disfluency, the stutterer may now be in a position to concentrate his or her personal resources on the causes of general disfluency. Similarily, given the relative nature of specific disfluency, it can be possible to work on incremental change SO more and more choices are removed from the equation. This can be a preliminary process to making the jump to general disfluency. To paraphrase Joseph Sheehan, this is akin to floating the submerged iceberg up towards the surface. Causes of Stuttering There has never been a definitive answer to the question of what causes stuttering. Heredity factors are often mentioned. Physiological causes have been suggested, as have neurological causes. While it may not be possible to define specific causative factors, it can be useful to keep all these factors in mind when experimenting with remedies. The most important thing is success with regards to therapy, the causitive factors, though it would be interesting to know them, can be relatively unimportant if relief from the symtoms of disfluency is achieved (as long as the relief is more than momentary). Issues relevant to stuttering may include the below (please note that inclusion in the list below in not indicative of any link with stuttering). Many of the items are included as some people may perceive a connection, however tenuous such a connection might be : Communication Developmental Disfluency Selective Mutism Social Anxiety Disorder Footnotes: 1: Joseph G.Sheehan, Stuttering Research and Therapy, p.277 (Harper & Row, 1970) http://www.geocities.com/batalosweb/what.htm?20085 3/5/2008 SPEECH HESITATION BY E. J. ELLERY THORPE 10 Robert wis VS 1 NEW YORK EDGAR S. WERNER PUBLISHING & SUPPLY CO. 1900 Univ Calif de Digitized by Microsoft @ PRESIDENT'S OFFICE, CLARK UNIVERSITY. WORCESTER, MASS. I have just read "Speech Hesitation" by Mrs. E. J. Thorpe, with much interest. Her method has the distinct advantage over nearly all others that I have known in that it is laid on a definite, and, as I think, a correct conception of what are probably the most common causes of the difficulty and seeks by a ration- al and systematic method to remove them. I am not sur- prised at the success she has met with, because, too, of the careful study of individual cases upon which she bases her treatment. The-whole subject is one of the most peculiar and scien- titically interesting in all the field of education. I am heartily in- accord with her conviction that one of the most urgent needs in view of the large per cent. afflicted, and of the kind of treatment needed, is for an institution where this very grave and painful, but most curable affliction of childhood and youth can be treated with conditions so con- trolled as to make the prospect of cure most favorable. Wealthy philanthropists, and, if need be, legislators should be appealed to. May 30, 1899. G. STANLEY HALL. Univ Calif - Digitized by Microsoft ® What is the relationship between stuttering and anxiety? - British Stammering Association Page 1 of 4 BSA The British HomePage Stammering www.stammerina.org Association The UK Website for Stammering Home About The BSA Information for Adults Speaking Out Teenagers What is the relationship between stuttering and School Children Under 5's anxiety? SLTs Teachers Partners, friends Professor Ashley Craig and Dr Yvonne Tran, Department of Health Employers Sciences, University of Technology, Sydney Media BSA Services Theories that have attempted to explain the causes of stuttering have often Helpline Library echoed the prevailing beliefs of the time. For example, in the mid 20th Shop century there was a trend to believe that many diseases were psychosomatic Speaking Out in origin, that is, they were caused by psychological factors such as anxiety. Where / What ? Research Coronary heart disease was a case in hand as many believed it to be caused by Type A personality. A person with a Type A personality by definition had Features high levels of anxiety and hostility. However, evidence for a primary causal Events Self-help role of anxiety in heart disease is lacking and therefore these theories have Scotland been largely discarded. It is interesting though, that latest research indicates Stammering Links that anxiety is a risk factor for heart disease. People with high levels of Site information anxiety have higher risks of experiencing heart attack. What's new Contents In a similar way, the prevailing view in the 20th century assumed that Search the Site Legal stuttering was caused by psychological factors such as anxiety in contrast to a physiological cause. Even though it was believed that anxiety caused The BSA stuttering, there is no evidence supporting this whatsoever (Craig, 2000). For About the BSA Join the BSA instance, stuttering is a childhood disorder, and therefore, one would assume Make a donation that if stuttering is caused by abnormal anxiety levels, then one should Contact us expect to see raised anxiety levels in children. We have not found that Speaking Out children who stutter are more chronically anxious about life than children who The BSA's do not stutter (Craig, 2000). Quarterly Magazine. The relationship between anxiety and stuttering This debate on the relationship between stuttering and anxiety has been continuing for many years. Because of this, it is important to clarify the relationship between anxiety and stuttering. First, it is important to say that people who stutter (PWS) are not any different to those who do not stutter in terms OT their personality or mood (Craig, 2000). We have looked long and hard, but we now believe that stuttering does not result from a special type of personality, nor is it caused by being depressed. Nonetheless, evidence does suggest that PWS have higher levels of social anxiety (Craig, 2000), in which the anxiety is more likely a consequence rather than a cause of stuttering. After all, speaking to others is an important social skill and experiencing an involuntary disruption to this skill will more than likely result in increased fears. Given the consequent social difficulties PWS can experience, we believe it is reasonable and rational to feel worried when, for instance, a PWS is faced with the prospect of feeling embarrassed and frustrated when attempting to get their opinion across in a group of fast speaking strangers (Craig, et al., 2003a). Research has found that many PWS are socially anxious people. http://www.stammering.org/anxiety.html 2/19/2008 8 and Stuttering, Introduction and Treatment Although the fascinating and frustrating subject of tast, Ph.D. (1833-14) stuttering lacks little in published articles and books, the historical treatment is still a rarity. Stammering and Stuttering, Their Nature and Treatment, by James ile of the 1861 edition. Hunt, Ph.D., is a rare scholarly presentation of more than 2,000 years of the history of stuttering. Hafner Publisher Co., 1967. The author was born in Dorsetshire, England in 1833, His father, Thomas Hunt, was known as a curer of stammering. James Hunt continued this specialty and in 1854 published the first edition of the book on stuttering which was to accrue seven editions by 1870. He studied medicine for some years, but be- same an ethnologist and founded the Anthropological Society in 1863. He was its first president and pub- lisher of the Anthropological Review. During his short lifetime he contributed to the status of anthropology and to the knowledge of stuttering, having treated over 1,700 stuttering cases. In 1869 ill health caused his death. It is my privilege to write this introduction to the facsimile reprint of Stammering and Stuttering, Their Nature and Treatment. A few years ago I studied the sixth and seventh editions, published in 1865 and 1870, respectively. 1 2 Introduction to 1967 Reprint Introduction to 1967 Reprint 3 This book is as worthy of publication as Henry many theories still acceptable, the most valid, I be- Head's Aphasia and Kindred Disorders. What Head's Have, are those including an explanation of stuttering book is to aphasia, Hunt's book is to stuttering. It is As learned behavior. At the present time operant con- fitting that the same publisher should make available ditioning is prominent in speech therapy. both references. After reading dozens of books and Moses Mendelssohn, a stutterer himself, was another hundreds of articles on stuttering, I can say without who questioned the organic cause of stuttering. In reservation that no historical coverage is done so well. 1780, he wrote about conditions which aggravate and The book is rich in historical implications. It is in- conditions which reduce stuttering. His approach was eluctable that each age should have its authorities one of the first with psychological implications of with their concepts and prescribed treatments. One ituation fears, communicative stress, and feedback of the first mentioned by Hunt is Hippocrates, who attributed stuttering and stammering to dryness of the Another teacher of the deaf, Joseph Watson, in tongue, commenting that stutterers are freed from 1800, corroborated Amman's and Mendelssohn's con- their impediment by varices. I believe this to be the slusions that stuttering is not organic. Watson said first distraction device even though Hippocrates may that external objects and circumstances influence the not have intended it so. Since there is a reduction in Stutterer's mind resulting in disseveration. stuttering through distraction, the pain in causing Whose of us working with stutterers are well aware varices could get one's mind off his stuttering. We situational influences upon the stutterer. An im- are now aware of the speciosity of distraction devices. nt part of preventive therapy for young children In 1692, Johann Amman stated that stuttering is ergoing temporary stuttering is environmental not the result of organic defects, but originates in the Bipulation to reduce the stress of certain situations contraction of a vicious habit which in time becomes fraught with fluency disruptors. inveterate. This physician had helped the speech One of Hunt's admired contemporaries was Dr. handicapped and the deaf. His observation appears Klonoke whose remarks were so apropos that today's to be the first attempt to explain stuttering as learned Hintolan working with a difficult stutterer will nod behavior which is self-perpetuating. Regardless of the his-head in agreement. Stuttering is like a chamelon, 4 Introduction to 1967 Reprint Introduction to 1967 Reprint 5 he said. Theories effect nothing in the treatment of individual. He did not consider stuttering and stam- stuttering. A special didactic treatment is required. mering as the same problem. The pattern of stuttering Klencke has helped us understand the evasive nature or stammering had to be analyzed throughly and the of stuttering and the confusion of symptom with cause speaking mechanism restored to normal performance. which makes it possible to conceive stuttering as a When others engaged in correspondence courses problem of organic origin, disturbed personality (con- for stuttering, Hunt refused to treat anyone by this version or non-conversion), or learned behavior. These means. During an age when tongue surgery was still three, individually or in combination, cover the view- used for stuttering, he was opposed to it. Only a few points of the twentieth century. modern speech specialists are aware that Hunt, as an The kind of training and the extent of one's sophis- anthropologist reported that some American Indians tication and bias affect one's concept of stuttering. did not stutter and that people whose language is Thus, the psychiatrist feels that he should treat stut- monosyllabic are less prone to stuttering. He was also tering because of the need to remove the neurotic aware of the many tricks of stutter doctors and the cause. The speech therapist may question this pre- worthless contrivances such as the Itard fork, Colom- mise, noting that the stuttering remains even after bat's appliances, Malebouche's whale-bone, and Mrs. considerable psychotherapy. At the present time, it Leigh's American Method. appears that we must deal with perpetuating causes There were always times when the stutterer was an -some of which may well require psychotherapy; but easy victim for anyone with a cure. Stutterers could also needed is a thorough knowledge of stuttering invest large sums for personal treatment or invest two symptoms and how they can accrue because the stut- shillings and six pence at a toy shop for a pot of terer, trying a chance eye-blink or other effect, auto- directions "which assuredly cures stuttering." As stated suggests that it is only possible to say the troublesome by Hunt, in spite of the alleged desire to get over his word with this chance effect. These overlaid behavior stuttering, the stutterer resists really working on his patterns become fused with anxiety and further sug- problem. And yet, with a firm will, one can overcome gestion. stuttering! James Hunt insisted on treating each stutterer as an Because stuttering is readily comparable to so many 6 Introduction to 1967 Reprint Introduction to 1967 Reprint 7 diversified symptoms or behaviors, we are side-tracked mental nature, and the perpetuating factors. It will by inferences. Since Hippocrates and Aristotle said require extensive concerted research to find the causal that a defective tongue is involved in stuttering, we factors which include early communication frustra- should not be surprised to learn that over 2,000 years tion from lack of language facility, often temporary. later Dieffenbach's tongue surgery should evolve. In the meantime it would be wise to consider not the Nor should the band wagon effect surprise us. average stutterer, but rather individual A, individual When Velpeau heard that Dieffenbach was credited B, and individual C, all of whom may stutter. We do with tongue surgery in 1841, he (Velpeau) insisted not know what an average stutterer is because king that he had instituted tongue surgery in 1837. Untold and peasant, genius and retardate, aphasic and normal mutilations resulted no matter who deserved the individuals may all be involved. credit. Understanding this fascinating and frustrating phe- In the 1930's a rash of research proved that the nomenon requires a lifetime of study and experience. stutterer's breathing pattern, his heartbeat, and even Hunt's work is such an endeavor and should be rec- his deep reflexes were different and thus the organic ognized by everyone interested in stuttering. basis of stuttering was established. But soon after, this viewpoint was disavowed, to be replaced by a ELLIOTT J. SCHAFFER, PH.D. psychological concept. In many cases what is alleged State University of New York to be a causal theory of stuttering is actually an ex- College at Fredonia planation of what perpetuates stuttering. February, 1967 According to his knowledge and wisdom, each con- tributor presents some facet of stuttering which he feels is significant. In the meantime we wait for what we believe will be forthcoming-a parsimonious and sufficient theory. This theory should include the high probability of maleness, the probability that stuttering will start if certain conditions combine, the develop- ) 10 STAMMERING AND STUTTERING. SPANISH.-Tartamudear. GAELIC.-Gaggach gagganach (a stutterer); man- dach (lisping); briot (chitter-chatter). ANgLo-SAxon.-Stomettan ; stamer ; phlips ; melyst. GERMAN.-Stammeln; stottern ; anstossen. CHAPTER II. ENGLISH.-Stamme stut; stutter; lisp. STAMMERING AND STUTTERING DEFINED. THE MEANING OF WORDS.* " WHEN I began to examine the extent and cer- tainty of our understanding, I found that it had so near a connection with words that, unless their force and manner of signification were first well observed, there would be very little said clearly and pertinently con- cerning knowledge." " He that shall consider the errors and obscurity, the mistakes and confusion that are spread in the world by an ill-use of words, will find some reason to doubt whether language, as it has been employed, has contri- buted more to the improvement or hindrance of know- ledge among mankind." " I know there are not words enough in our language Extracts from Locke's Essay on the Human Understanding. 12 STAMMERING AND STUTTERING. STAMMERING AND STUTTERING DEFINED. 13 to answer all the variety of ideas that enter into man's elementary speech-sounds, accompanied or not, as the discourses and reasonings. But this hinders not that case may be, by a slow, hesitating, more or less indis- when he uses any term he may have in his mind a tinct delivery, but unattended with frequent repetitions determined idea, which he makes it the sign of, and to of the initial sounds, and consequent convulsive efforts which he should keep it steadily annexed during that to surmount the difficulty. discourse." Stuttering, on the other hand, is a vicious utterance, It will presently appear how forcibly these just manifested by frequent repetitions of initial or other remarks of our great philosopher apply to our subject. elementary sounds, and always more or less attended with muscular contortions. Having thus concisely stated the distinctive mark of Stammering as contra-distinguished from Stuttering. each disorder, I proceed to consider them in their The terms 'stammering" and "stuttering" are in individual characters. this country synonymously used to designate all kinds of defective utterance. In no English work written upon this subject has the exact discrimination between Stammering and its Causes. these disorders, which differ both in kind and in origin, Vowel Slammering.-The belief that stammering been laid down with scientific correctness. From this occurs only in the pronunciation of consonants is cer- confusion of terms have arisen many errors in theory tainly erroneous; the vowels are equally subject to this and in practice, for no treatment can be efficacious defect, though not to the same extent as the conso- unless our diagnosis be correct. nants. The proximate causes of defective vowel It is, therefore, requisite that the distinctive cha- sounds, may have their seat either in the vocal appa- racter of each affection should be clearly defined at the ratus, or in the oral canal. The original sounds may very outset. be deficient in quality, from an affection of the vocal Stammering Oper se) is characterised by an inability or ligaments, as in hoarseness; or the sounds may be difficulty of properly enunciating some or many of the altered in the buccal and nasal cavities, from defects, 14 STAMMERING AND STUTTERING. STAMMERING AND STUTTERING DEFINED 15 or an improper use of the velum ; in which cases the " In a person whom I had the pain of attending long vowels are frequently aspirated. Enlargement of the after the bones of the face were lost, and in whom I tonsils, defective lips and teeth, may also influence the I could look down behind the palate, I saw the oper- enunciation of the vowels. But the whole speech- ation of the vclum palati. During speech it was in apparatus may be in a healthy state, and yet the enun- constant motion and when the person pronounced the ciation of the vowels may be faulty, from misenploy- explosive letters, the velum rose convex, 80 as to inter- ment, or from defective association of the various organs rupt the ascent of breath in that directon and as the upon which the proper articulation of the vowels lips parted, or the tongue separated from the teeth or depends. In some cases the faulty pronunciation may palate, the velum recoiled forcibly." be traced to seme defect in the organ of hearing. On the other hand, closure of the nasal tube either from a common cold or other obstructions, affects the articulation of m,N,Ng, which then sound nearly as Defective enunciation of Consonants. b, d, g, hard. (See Rhinism). Consonantal Stammering may, like that of the vowels, be the result of an organic affection, either of the vocal The Chief Causes of Stammering. apparatus, or of the organs of articulation. When, for instance, the soft palate, either from existing apertures The variety of defects which constitute stammering or inactivity of its muscles, cannot close the posterior result either from actual defective organisation or nares, 80 that the oral canal may be separated from the from functional disturbance. Among organic defects nasal tube, speech acquires a nasal timbre, and the may be enumerated hare-lip, cleft-palate, abnormal articulation of many consonants is variously affected. length and thickness of the uvula, inflammation and B and p then assume the sound of an indistinct m ; enlargement of the tonsils, abnormal size and tumours and t sound somewhat like n; and g and 7c like ng. of the tongue, tumours in the buccal cavity, want or The action of the velum during speech is thus des. defective position of the teeth, &c. cribed by Sir Charles Bell. Dr. Ashburner, in his work on Dentition, mentions 16 STAMMERING AND STUTTERING. STAMMERING AND STUTTERING DEFINED. 17 a very curious case of a boy who, though not deaf, causes within the vocal and articulating apparatus; or could not speak. This he attributed to the smallness it is symptomatic, when, arising from cerebral irritation, of the jaws, which taking at length a sudden start in paralysis, general debility, intoxication, &c. Children growth by which the pressure being taken off from the stammer, partly from imperfect development of the dental nerves, the organs became free, and the boy organs of speech, want of control, deficiency of ideas, learned to speak. Considering that the teeth play but and imitation, or in consequence of cerebral and ab- a subordinate part in articulating-for all the speech dominal affections. The stammering, or rather falter- sounds, including even the dentals, may be pronounced ing of old people chiefly arises from local or general without their aid, as is the case in toothless age-it is debility. The cold stage of fever, intoxication, loss of certainly not a little singular that the mere pressure blood, narcotics, may all produce stammering. Stam- on the dental nerves should produce such an effect. It mering is idiopathic and permanent in imbecility, is very possible that in this case the motions of the when the slowness of thought keeps pace with the lower jaw and of the tongue were impeded, but even imperfection of speech. It may also be transitorily then, it is not easy to account for the fact that the produced by sudden emotions. Persons gifted with child never attempted to articulate, however imper- great volubility, when abruptly charged with some fectly. real or pretended delinquency may only be able to When the organs are in a normal condition, and the stammer out an excuse. person is unable to place them in a proper position to produce the desired effect, the affection is said to be Stuttering. functional. Debility, paralysis, spasms of the glottis, lips, &c., owing to a central or local affection of the THE main feature of stuttering consists in the nerves, habit, imitation, &c., may all more or less tend difficulty in conjoining and fluently enunciating syl- to produce stammering. lables, words, and sentences. The interruptions are From these observations it may be inferred that more or less frequent, the syllables or words being stammering is either idiopathic, when, arising from thrown out in jerks. Hence the speech of stutterers has 24 %TAMMERING AND STUTTERING. and not the cause of the disturbed relation. Both Sauvages and Joseph Frank* contend that the gutturals g and h offer the greatest impediment to the stutterer, and that the chief cause is the difficulty of moving the velum, the uvula, and the root of the tongue. This is not invariably the case. Some stutterers pronounce these consonants in various combinations easily enough, but stutter at the dentals and labials P, b, t, d. There are again some in whom the impediment varies; they hesitate one day at the gutturals, another day at the labials, or may be, at the dentals, depending, no doubt, in most cases on their combinations with the succeeding sounds. Principal Causes of Stuttering. AMONG the exciting causes of Stuttering may be enumerated, affections of the brain and spinal cord, the abdominal canal, abnormal irritability of the ner- vous system, solitary vices, spermatorrhooa, mental emotions, mimicry, and involuntary imitation. The proximate cause of stuttering is, in most cases, the abnormal action of the phonetic and respiratory appa- ratus, and not, like stainmering, the result either of organic defects, or the debility of the articulating organs. Nosol. method. 1772. Praxcos Medicae Universae precepta. Lipsia 1811-23. HISTORY Page 1 of 5 from Wm HISTORY The genus Salmonella was originally created by medical bacteriologists to include organisms that gave rise to a certain type of illness in man and animals and were related to one another antigenically. Later it became clear that salmonellae had many common biochemical characters. Thomas Willis can be regarded as the pioneer in typhoid fever. Until his classic description in 1659 and its translation into English in 1684, little had been done to separate this disease from the many which it might mimic. However, a disease very similar, was known long before this time. Hippocrates described a fever that probably was typhoid (Gay), and it is said that Antonius Musa, a Romanian physician, became famous by treating Emperor Augustus with cold baths when he fell ill with typhoid. Willis, in his description, described the typically variable onset and the classical type of pyrexia with its step-ladder rise during the first week, its maintenance during the second and third weeks, and its fall by lysis rather than crisis which subsequent authors have merely confirmed and enlarged upon. He described the variable symptoms, signs, duration and severity of the disease, with relapses when apparently cured. Willis's diagnosis was of necessity entirely on clinical grounds, and the fact that this was undoubtedly correct with few exceptions, is a gentle reminder that today, as 300 years ago, the diagnosis is essentially clinical and the laboratory, valuable as it is, must take second place to the senses. The pathologist and bacteriologist come into their own in the diagnosis of the atypical case and for differentiating certain similar diseases such as typhus, malaria, and the severe paratyphoids. They will always be essential in tracing the source of epidemics, and confirming a clinical diagnosis; but the present tendency to use the laboratory instead of one's clinical ability is to be deplored in typhoid more than in most diseases. Willis's treatment of "let blood, vomit and purge", may leave much to be desired, but it is doubtful whether his mortality was very much higher than ours was before the first introduction of an effective antibiotic in this disease. Another classical paper on certain aspects of typhoid was written by Trousseau in http://www.geocities.com/avinash_abhyankar/history.htm 7/2/2004 HISTORY Page 2 of 5 1826 on the work of Pierre Bretonneau of Paris. He attempted to clarify the picture of typhoid mainly from the pathological angle, and to separate true typhoid from all the other gastro-intestinal infections, which he stated were often confused with it. He described the classical inflammation of the glands of Peyer and Briinner and gave a detailed description of post-mortem appearances. Even at this time the cause of typhoid was unknown, the bacteriologist unheard of, yet the diagnosis was seldom in doubt. Trousseau summarised the knowledge of typhoid in the early nineteenth century with the words: - " This disease, just as common and no less murderous than smallpox, measles, and scarlet, fever, that few people go to the end of their lives without having experienced its attacks, affects an individual only once during life, and is perhaps of a contagious nature." The famous Pierre Louis in 1829 gave another classical picture of typhoid and described in detail post-mortem findings, especially the enlargement and ulceration of the Peyer's patches. He was also the first to use the word "Typhoid". He, however, did not clearly differentiate between typhoid and typhus, which were undoubtedly sométimes confused. in It remained for Gerhard in 1837 to he the first to differentiate clearly between the typhoid and typhus fevers. Again it was on the clinical picture alone that this was done. He described the `more acute onset of typhus with typical rash. Even after Gerhard's paper in 1837 most medical critics were unconvinced that the typhoid and typhus fevers were of different aetiology. Jenner in 1850, long before S. typhi was discovered, put the matter beyond all reasonable doubt in an admirable and detailed comparison of the two diseases, based on clinical and post-mortem appearances of 66 fatal cases. He showed how the general symptoms differed in the two diseases, that the rash was never identical and how the lesions of Peyer's patches and the mesenteric glands, so characteristic of typhoid, were never seen in typhus. With the publication of this paper the question was settled once and for all, Typhoid, also unlike typhus, is no respecter of classes, and both prince and common man are susceptible to its virulence. Prince Albert, the Prince Consort, died of it in 1861, and it has been calculated that about 50,000 cases a year occurred in England alone about this time. William Budd of Devon, from 1856 to 1860, 20 years before the bacterial origin of infectious diseases had been discovered, stated that typhoid fever was not spread by http://www.geocities.com/avinash_abhyankar/history.htm 7/2/2004 HISTORY Page 3 of 5 stench, but was an alimentary disease in which the infective material in faeces contaminated water, milk, and the hands of those who attended the sick. Marston in 1863 added another important string to the diagnostic bow with a differentiation between Malta Fever or Brucellosis and Typhoid Fever. This he did on clinical and pathological grounds, thus showing that brucellosis, which was at that time called "Gastric Remittent Fever", was a completely different disease from typhoid. In 1875 water supplies and sanitary conditions in England were improved by a Public Health Act. This more than halved the death rate in the next decade, and markedly diminished the incidence of typhoid fever. This was more than 20 years before prophylactic inoculation against typhoid had been thought of. It was not until 1880 that the crucial advance in the diagnosis of typhoid occurred with Eberth's discovery of "B typhosus". All proof of typhoid up to that time was of necessity purely clinical, and although undoubtedly correct in the vast majority of cases, was open to the occasional error that only the laboratory could prevent. Eberth's discovery opened new fields, both in diagnosis and prophylaxis. Gaffky in 1884 completed the diagnostic and prophylactic picture with the first successful culture of S. typhi and was one of the first (with Virehow) to stress that the infection was water borne, and not air borne. Achard and Bensaude in|1896 were the first to isolate S. paratyphi B, and to use the term 'Paratyphoid Fever'. Subsequently S. paratyphi A and C were discovered together with the numerous other members of the salmonella group. Widal in 1896, and Widal & Sicard in 1896 described the Widal reaction, and this test has proved of value in cases where positive cultures have been unobtainable. Advances in treatment during this era, however, were far less spectacular, and consisted of improvements in general treatment. It was becoming realised that bed rest and good nursing were the first essentials, and that Willis's recommended purge', which was quite the fashion, was liable to precipitate haemorrhage and perforation. Apart from this, nothing could be done except to allow the disease to follow its natural course. Osler in 1912 was still advocating cold baths every three hours for patients if their http://www.geocities.com/avinash _abhyankar/history.htm 7/2/2004 HISTORY Page 4 of 5 temperature rose above 102° C, and this appeared undoubtedly to reduce both mortality and toxaemia. Water was not restricted only to the 'outer man', and patients were treated by the 'washing out method'. These treatments, by present day standards might leave much to be desired, but their efficacy appeared undisputed at the beginning of this century. The first prophylactic inoculation against typhoid was introduced by Pfeiffer & Kolle in 1896 and Wright in 1896, and Wright & Semple in 1897. It consisted of a suspension of typhoid bacteria killed by heat and injected subcutaneously. This vaccine was not used to an appreciable extent in the Boer War, in which, as in previous wars there was a very high incidence of enteric infections with a correspondingly high mortality. It was first used with success in India before the Great War (Harvey) and had a great measure of success during the 1914-18 War. In 1915 it was fortified with S. paratyphi A and B, and this vaccine, modified by preservation with phenol, was used almost exclusively in Europe until alcoholised vaccine was introduced by Felix in 1941. In 1947 Marriott published his papers on salt and water depletion, and the greater appreciation of this important factor in disease has undoubtedly led to the saving of countless lives. This was especially true in the treatment of typhoid in the tropics where excessive sweating often accompanied by diarrhoea or vomiting, was enough to tip the fatal scales in a severely toxic patient. Even in 1947 there was no specific drug the the treatment of typhoid, and with, the best nursing and general treatment the mortality was often between 10 and 30 per cent, and sometimes higher, with a correspondingly high complication rate. It was, therefore, a very great advance when Woodward et al., in 1948 published the first report on the use of Chloromycetin in typhoid. This drug drastically cut the duration of pyrexia from about 35 days to an average of 3.5 days, with a corresponding diminution in toxaemia, morbidity, and mortality. It was not long before Chloromycetin was synthesised under the name of chloramphenicol, and was found to have an identical therapeutic action to its biological cousin, which was extracted, from a mould. Despite the dramatic effects of chloramphenicol, the perfect antibiotic was yet to be discovered. Relapses, complications and carriers still occurred, relapses even more frequently than previous to specific drug treatment. 3.5 days might be a great advance on 35 days, but it was still a period during which the disease might be, and occasionally was, fatal; especially as there was often an absolute lag period of 2 days http://www.geocities.com/avinash_abhyankar/history.htm 7/2/2004 HISTORY Page 5 of 5 in which there was no apparent effect at all of chloramphenicol. Since 1948 drugs such as Aureomycin, Terramycin and Achromycin have been tried, both in the acute disease and the carrier state, with only limited success. In 1951 both Woodward et al. and Smadel et al. published reports of trials with cortisone, and cortisone plus chloramphenicol in typhoid. They found that chloramphenicol with cortisone had a much speedier action than chloramphenicol alone, but that complications and relapses still occurred, and there were dangers associated with this combined therapy. Many other drugs had been tried recently, but nothing approached the efficacy of chloramphenicol. The terminology introduced by White (1929) and modified by Kauffmann accorded specific rank to each antigenically distinguishable salmonella type, and the convention was established that each new type should be named after the place in which it was first isolated. The first published table contained some 20 serotypes; the current number is 2200. http://www.geocities.com/avinash_abhyankar/history.htm 7/2/2004 From Quackery to Bacteriology, Document 7 Page 1 of 2 University of Toledo Libraries [Index] [Back] [Next] The Public Health Movement The public health movement began in Germany in the 1840s. The industrialization of Europe which started in the 18th century produced urban slums which were swept periodically by epidemics of typhoid and typhus. In the 1830s, a cholera epidemic hit London. As the epidemic spread to Germany, Rudolf Virchow (1821-1902) studied the obvious connection between poor sanitation and disease which became the genesis for the public health movement. While isolated geographically from the scourges of Europe, America was occasionally hit with epidemics of its own, especially in the growing east coast cities. Recognizing that disease may be coming from the ships that docked in their ports, cities instituted quarantines during outbreaks. Treatments for widespread disease did not improve. Benjamin Rush, America's leading physician, made detailed observations of the yellow fever epidemic that hit his native Philadelphia in 1793, but refused to accept contagion as the likely cause. Rush prescribed a treatment of intense bleeding and purging with Calomel. America largely escaped the typhus epidemics that devastated Europe in the early 19th century because the mostly rural country lacked overcrowding, poverty, and filth which promoted typhus transmission by lice. Typhus did strike ships ferrying passengers from Europe to the United States, however. An outbreak of the disease in Pennsylvania Hospital in 1836 provided the opportunity for physician William Wood Gerhard to study the disease carefully and differentiate it from typhoid. Typhoid was much deadlier in America: there were 75,000 reported cases during the Civil War alone. Dysentery too swept the United States, especially during the war, as did many of the common childhood diseases such as diphtheria, scarlet fever, and measles which hit young soldiers from isolated rural areas who had not developed immunities to them. In 1847, the newly-formed American Medical Association sponsored an investigation of large U.S. cities and found that living conditions for many residents had become as bad as the worst slums of Europe. The organization concluded that without improvements in hygiene and living standards, European-type epidemics would soon hit American cities. The organization also advocated collecting vital statistics to track the country's birth and death rates. Soon thereafter, many bureaus of vital statistics were organized, including in Ohio, where birth and death statistics were collected at the county level beginning in 1867. Local sanitary commissions formed in cities and towns, spurred on by reform movements which stressed healthier living and clean water. The Massachusetts Sanitary Commission, for example, http://www.cl.utoledo.edu/canaday/quackery/quack7.html 7/2/2004 From Quackery to Bacteriology, Document 7 Page 2 of 2 sought better venting of city homes to remove any noxious odors and fumes that might cause disease. To provide plentiful water, 32 waterworks were built in the country by 1825, and almost 600 were added by 1880. Unfortunately it was assumed that free-flowing water was pure, SO the first filtration plant was not built until 1871. If A map of the Cambridge (Massachusetts) health districts, from the Annual Report of the State Board of Health of Massachusetts, 1878. In 1856, Dr. Wilson Jewell of Philadelphia proposed a national convention to establish uniform quarantine laws. The first convention met in that city in May 1857, and four more such conventions to discuss public health issues were held before the Civil War disrupted the movement. The American Public Health Association was founded in 1872 by some of those who attended these earlier conventions. The following year the number of boards of health in the U.S. increased from 4 to 123. The most significant event in the public health movement, however, was the development of the germ theory and the realization that disease could be contagious. Buck, Albert H., ed. A Treatise on Hygiene and Public Health. New York: William Wood & Company, 1879. Massachusetts State Board of Health. Annual Reports of the State Board of Health of Massachusetts. Boston: Wright & Potter, 1872, 1876-1878. Shakespeare, Edward O., United States Commissioner. Report on Cholera in Europe and India. Washington: Government Printing Office, 1890. Barbara Floyd, University Archivist, University of Toledo [Index] [Back] [Next] Return to the University Libraries' Home Page http://www.cl.utoledo.edu/canaday/quackery/quack7.html 7/2/2004 Health Dan Papers. B1. F14. "Houide" Circa 1854-55 May Dair "attached y consumption "of which her "older sister x 2 brothers dud" Chailes tork may to Horde, leny um+ Group c kerson In Apey tg when though good part of lung was gone." 12 gras late (c. 1867 -67) toharles took Wm. to Ha of a delicate countrition" Health restored Took also future Dear it Howard Medisol School, Henry Bowlitch, Wrate her "long & delegetful letter to may lost. NIMH: Bipolar Disorder Page 1 of 13 Text Size: S M L Working to improve mental health through biomedical Search research on mind, brain, and behavior NIMH powered by Google Advanced Sear National Institute of Mental Health NIMH HOME HEALTH INFORMATION RESEARCH & FUNDING ABOUT NIMH Press Room I NIMH Outreach I Scientific Meetings Clinical Trials I Publications NATIONAL INSTITUTES OF HEALTH Bipolar Disorder What do you want to do? A detailed booklet that describes symptoms, causes, and treatments, with information on getting help and coping. Read now Download the PDF file 2001 E-mail to a friend Print this document Order through the mail See related items Browse all health information Bipolar Disorder Note: Frank Epstein U.D. Introduction suggested that G 3.DoeR What Are the Symptoms of Bipolar Disorder? might have had a bipolar Suicide What Is the Course of Bipolar Disorder? personality. Advanced during Can Children and Adolescents Have Bipolar Disorder? preparation for our public What Causes Bipolar Disorder? How Is Bipolar Disorder Treated? appearance at the MDIBL Do Other Illnesses Co-occur with Bipolar Disorder? How Can Individuals and Families Get Help for Bipolar Disorder? Aug. 15,2005. What About Clinical Studies for Bipolar Disorder? For More Information References Introduction Bipolar disorder, also known as manic-depressive illness, is a brain disorder that causes unusual shifts in a person's mood, energy, and ability to function. Different from the normal ups and downs that everyone goes through, the symptoms of bipolar disorder are severe. They can result in damaged relationships, poor job or school performance, and even suicide. But there is good news: bipolar disorder can be treated, and people with this illness can lead full and productive lives. More than 2 million American adults, 1 or about 1 percent of the population age 18 and older in any given year, 2 have bipolar disorder. Bipolar disorder typically develops in late adolescence or early adulthood. However, some people have their first symptoms Top http://www.nimh.nih.gov/publicat/bipolar.cfm 8/8/2005 NIMH: Bipolar Disorder Page 2 of 13 during childhood, and some develop them late in life. It is often not recognized as an Posted: 04/09/2004 illness, and people may suffer-for years before it is properly-diagnosed and treated. Like diabetes or heart disease, bipolar disorder is a long-term illness that must be SITE INDEX I US carefully managed throughout a person's life. SITE CON US ACCESSIBILITY CITATIONS P "Manic-depression distorts moods and thoughts, incites dreadful behaviors, destroys the basis of rational thought, and too often erodes the desire and will to live. It is an illness that is biological in its origins, yet one that feels psychological in the experience of it; an illness that is unique in conferring advantage and pleasure, yet one that brings in its wake almost unendurable suffering and, not infrequently, suicide." "I am fortunate that I have not died from my illness, fortunate in having received the best medical care available, and fortunate in having the friends, colleagues, and family that I do." Kay Redfield Jamison, Ph.D., An Unquiet Mind, 1995, p. 6. (Reprinted with permission from Alfred A. Knopf, a division of Random House, Inc.) What Are the Symptoms of Bipolar Disorder? Bipolar disorder causes dramatic mood swings-from overly "high" and/or irritable to sad and hopeless, and then back again, often with periods of normal mood in between. Severe changes in energy and behavior go along with these changes in mood. The periods of highs and lows are called episodes of mania and depression. Signs and symptoms of mania (or a manic episode) include: Increased energy, activity, and restlessness Excessively "high," overly good, euphoric mood Extreme irritability Racing thoughts and talking very fast, jumping from one idea to another Distractibility, can't concentrate well Little sleep needed Unrealistic beliefs in one's abilities and powers Poor judgment Spending sprees A lasting period of behavior that is different from usual Increased sexual drive Abuse of drugs, particularly cocaine, alcohol, and sleeping medications Provocative, intrusive, or aggressive behavior Denial that anything is wrong Back To Top A manic episode is diagnosed if elevated mood occurs with three or more of the other symptoms most of the day, nearly every day, for 1 week or longer. If the mood is irritable, four additional symptoms must be present. Signs and symptoms of depression (or a depressive episode) include: Lasting sad, anxious, or empty mood Feelings of hopelessness or pessimism Feelings of guilt, worthlessness, or helplessness Loss of interest or pleasure in activities once enjoyed, including sex Decreased energy, a feeling of fatigue or of being "slowed down" Difficulty concentrating, remembering, making decisions http://www.nimh.nih.gov/publicat/bipolar.cfm 8/8/2005 NIMH: Bipolar Disorder Page 3 of 13 Restlessness or irritability Sleeping too much, or can't sleep Change in appetite and/or unintended weight loss or gain Chronic pain or other persistent bodily symptoms that are not caused by physical illness or injury Thoughts of death or suicide, or suicide attempts A depressive episode is diagnosed if five or more of these symptoms last most of the day, nearly every day, for a period of 2 weeks or longer. A mild to moderate level of mania is called hypomania. Hypomania may feel good to the person who experiences it and may even be associated with good functioning and enhanced productivity. Thus even when family and friends learn to recognize the mood swings as possible bipolar disorder, the person may deny that anything is wrong. Without proper treatment, however, hypomania can become severe mania in some people or can switch into depression. Sometimes, severe episodes of mania or depression include symptoms of psychosis (or psychotic symptoms). Common psychotic symptoms are hallucinations (hearing, seeing, or otherwise sensing the presence of things not actually there) and delusions (false, strongly held beliefs not influenced by logical reasoning or explained by a person's usual cultural concepts). Psychotic symptoms in bipolar disorder tend to reflect the extreme mood state at the time. For example, delusions of grandiosity, such as believing one is the President or has special powers or wealth, may occur during mania; delusions of guilt or worthlessness, such as believing that one is ruined and penniless or has committed some terrible crime, may appear during depression. People with bipolar disorder who have these symptoms are sometimes incorrectly diagnosed as having schizophrenia, another severe mental illness. It may be helpful to think of the various mood states in bipolar disorder as a spectrum or continuous range. At one end is severe depression, above which is moderate depression and then mild low mood, which many people call "the blues" when it is short-lived but is termed "dysthymia" when it is chronic. Then there is normal or balanced mood, above which comes hypomania (mild to moderate mania), and then severe mania. severe mania hypomania (mild to moderate mania) normal/balanced mood mild to moderate depression severe depression In some people, however, symptoms of mania and depression may occur together in what is called a mixed bipolar state. Symptoms of a mixed state often include agitation, trouble sleeping, significant change in appetite, psychosis, and suicidal thinking. A person may have a very sad, hopeless mood while at the same time feeling extremely energized. Bipolar disorder may appear to be a problem other than mental illness-for instance, http://www.nimh.nih.gov/publicat/bipolar.cfm 8/8/2005 NIMH: Bipolar Disorder Page 13 of 13 26 Strakowski SM, Sax KW, McElroy SL, Keck PE Jr, Hawkins JM, West SA. Course of psychiatric and substance abuse syndromes co-occurring with bipolar disorder after a first psychiatric hospitalization. Journal of Clinical Psychiatry, 1998; 59(9): 465-71. This publication, written by Melissa Spearing of NIMH, is a revision and update of an earlier version by Mary Lynn Hendrix. Scientific information and review were provided by NIMH Director Steven E. Hyman, M.D., and NIMH staff members Matthew V. Rudorfer, M.D., and Jane L. Pearson, Ph.D. Editorial assistance was provided by Clarissa K. Wittenberg, Margaret Strock, and Lisa D. Alberts of NIMH. All material in this publication is in the public domain and may be copied or reproduced without permission of the Institute. Citation of the source is appreciated. NIH Publication No. 3679 Printed 2002 The National Institute of Mental Health (NIMH) is part of the National Institutes of Health (NIH), FIRSTGOV a component of the U.S. Department of Health and Human Services. http://www.nimh.nih.gov/publicat/bipolar.cfm 8/8/2005