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+Project Gutenberg (https://www.gutenberg.org) public repository for
+eBook #67117 (https://www.gutenberg.org/ebooks/67117)
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-The Project Gutenberg eBook of History of Iridotomy, by S. Lewis
-Ziegler
-
-This eBook is for the use of anyone anywhere in the United States and
-most other parts of the world at no cost and with almost no restrictions
-whatsoever. You may copy it, give it away or re-use it under the terms
-of the Project Gutenberg License included with this eBook or online at
-www.gutenberg.org. If you are not located in the United States, you
-will have to check the laws of the country where you are located before
-using this eBook.
-
-Title: History of Iridotomy
-       Knife-Needle vs. Scissors—Description of Author’s V-Shaped
-       Method
-
-Author: S. Lewis Ziegler
-
-Release Date: January 7, 2022 [eBook #67117]
-
-Language: English
-
-Produced by: Thiers Halliwell, deaurider and the Online Distributed
-             Proofreading Team at https://www.pgdp.net (This file was
-             produced from images generously made available by The
-             Internet Archive)
-
-*** START OF THE PROJECT GUTENBERG EBOOK HISTORY OF IRIDOTOMY ***
-
-Transcriber’s notes:
-
-The text of this e-book has mostly been preserved in its original
-form, including some archaic spellings. Footnotes have been numbered
-and positioned below the relevant paragraphs, and some illustration
-captions moved closer to the relevant text. _Underscores_ have been
-used to denote italic text.
-
-
-
-
-  History of Iridotomy
-
-  Knife-Needle vs. Scissors--Description of Author’s
-  V-Shaped Method.
-
-
-  S. LEWIS ZIEGLER, A.M., M.D., Sc.D.
-  Attending Surgeon, Wills Eye Hospital; Ophthalmic Surgeon, St.
-  Joseph’s Hospital.
-  PHILADELPHIA.
-
-
-
-
-HISTORY OF IRIDOTOMY.
-
-KNIFE-NEEDLE VS. SCISSORS--DESCRIPTION OF AUTHOR’S V-SHAPED METHOD.[1]
-
-S. LEWIS ZIEGLER, A.M., M.D., Sc.D.
-
-Attending Surgeon, Wills Eye Hospital; Ophthalmic Surgeon, St. Joseph’s
-Hospital.
-
-PHILADELPHIA.
-
-[1] Read in the Section on Ophthalmology of the American Medical
-Association, at the Fifty-ninth Annual Session, held at Chicago, June,
-1908.
-
-
-To Cheselden has been conceded the honor of being the father and
-originator of iridotomy. Nearly two centuries have elapsed since he
-first published the report of his procedure in the Philosophical
-Transactions for 1728. Ever since that time, his signal success has
-been acknowledged by all except those who either failed to equal his
-dexterity, or who were prejudiced by their ambition to originate a new
-method.
-
-A careful review of the medical literature of the century and a half
-following Cheselden’s announcement can not fail to impress the reader
-with the great interest attached to operations for the formation of
-an artificial pupil, which subject was considered second only in
-importance to that of cataract itself. Not only were a large number of
-monographs devoted wholly to this subject, but every work on general
-surgical topics set aside one or more chapters for the discussion of
-artificial pupil. This is in great contrast to the limited space which
-modern works on ophthalmology grudgingly yield to this still important
-subject.
-
-It is difficult for us to appreciate the conditions which brought about
-so large a percentage of cases of pupillary occlusion. Crude surgical
-procedures, poor operative technic and the utter lack of asepsis often
-resulted in iridocyclitis or iridochorioiditis. The couching of the
-lens, the free discission of both hard and soft cataracts, the frequent
-introduction of the knife-needle through the dangerous ciliary zone,
-and the bungling efforts at extraction all increased the tendency
-to inflammatory reaction, while inadequate therapeutics and lack of
-antiphlogistic measures frequently permitted the deposit of plastic
-exudate in the pupillary area, thus resulting in membranous occlusion
-of the pupil.
-
-
-OPERATIONS FOR ARTIFICIAL PUPIL.
-
-For the sake of historical completeness, and in order to better
-emphasize the special domain of iridotomy, I will mention briefly the
-various methods that have been employed in making an artificial pupil.
-These are:
-
-(1) _Division_ of the thickened iris-membrane by an incision made
-either through the sclerotica or through the cornea. This is true
-_iridotomy_.
-
-(2) _Excision_ of a portion of the iris through a previously made
-corneal opening. This is now known as _iridectomy_.
-
-(3) _Separation_ of the iris from its ciliary attachment. This was
-generally known as _iridodialysis_, but sometimes called _iridorrhexis_.
-
-(4) Simple _incision_ of the pupillary margin, and of the free iris
-tissue. This has been designated _sphincterotomy_ by some, and
-_coretomy_ or _iritomy_ by others. Either one of the latter terms is to
-be preferred, because it is more clearly descriptive.
-
-(5) _Detachment_ of the synechiæ at the pupillary margin, either
-anterior or posterior, thus allowing the pupil to retract. This was
-known as _corelysis_.
-
-(6) _Strangulation_ of the prolapsed iris in the corneal incision was
-called _iridencleisis_. The prolapse was sometimes tied with a ligature.
-
-(7) _Trephining_ of the iris-membrane, by passing a small trephine or
-punch through a corneal incision.
-
-(8) _Section_ and removal of a portion of the sclerotica and chorioid
-by knife or trephine, with replacement of the conjunctiva over this
-opening, the conjunctiva thus acting as a substitute for the cornea in
-transmitting light. This was called _sclerectomy_.
-
-(9) _Transplantation_ of the cornea for total leucoma. This was usually
-preceded by partial or complete trephining of this membrane.
-
-In addition to these nine distinct methods certain combinations of
-these have been described and successfully practiced:
-
-(10) _Division_ and _excision_ have frequently been performed together.
-
-(11) _Separation_ and _excision_ have likewise had some vogue.
-
-(12) _Separation_ and _strangulation_ have occasionally been practiced.
-
-(13) _Detachment_ of the synechiæ and _excision_ have also been
-performed.
-
-
-HISTORICAL REVIEW OF IRIDOTOMY.
-
-In this brief review of iridotomy,[2] we shall confine our attention to
-the methods that have been advanced for the formation of an artificial
-pupil in cases of membranous occlusion of the pupil following removal
-of the lens, either by couching, extraction or discission, the
-iris-membrane in these cases being chiefly composed of inflamed iris
-tissue glued down by retro-iridian exudate to the thickened lens
-capsule.
-
-[2] Wagner, Karl Wilhelm Ulrich: Inaugural Thesis, Göttingen, 1818. He
-invented the designation iridotomia, which he formed from the original
-Greek, ἶρις, ἶριδος (the iris) and τομή (cut).
-
-The early history of iridotomy shows that the advocates of this
-operation were divided into two schools, (1) those recommending the use
-of the _knife-needle_ for incising the iris-membrane, and (2) those
-adopting the method of introducing _scissors_ through a previously made
-corneal section and freely incising the iris-membrane, or excising a
-portion of the same. We will first consider the school which advocated
-incision by the knife-needle.
-
-[Illustration: Portrait of William Cheselden, 1688–1752. Painted by
-Richardson.]
-
-
-I. KNIFE-NEEDLE METHOD.
-
-Cheselden,[3] a renowned surgeon, and oculist to Her Majesty, Queen
-Caroline of England, first announced, in 1728, his success in making
-an artificial pupil by means of his knife-needle. He made his puncture
-back of the corneoscleral junction on the temporal side, passing the
-knife across the posterior chamber, and making a counter-puncture
-in the iris-membrane near the nasal margin. He then cut through the
-iris from behind forward as he withdrew the knife, the incision being
-carried through two-thirds of its extent. The pupillary opening
-thus made was a long oval slit, horizontally placed. He has reported
-two successful cases[4] (Figs. 1 and 2), occurring in patients who
-had previously undergone couching of the lens. His instrument,
-strange to say, was practically of the same general shape as the Hays
-knife-needle, but was larger, and judging from the description more
-clumsily constructed, as there was danger of leakage of the aqueous
-and sometimes of the vitreous when it was used. Its form resembled a
-combination of a bistoury and a sickle-shaped knife, having a sharp
-edge on one side, a rounded back, and an acute point. We possess two
-good illustrations of this knife-needle, one by Cheselden himself (Fig.
-3), and the other by his pupil, Sharpe[5] (Fig. 4).
-
-[3] Cheselden, William: Philosophical Transactions, London, 1728, xxxv,
-p. 451.
-
-[4] Ibid, abridged, vii, pl. v, Figures 2, 3 and 5.
-
-[5] Sharpe, Samuel: A Treatise on the Operations of Surgery, London,
-1739, p. 169.
-
-[Illustration: Fig. 1.--Original case of iridotomy. Iris incised above
-(Cheselden).]
-
-[Illustration: Fig. 2.--Second case of iridotomy. Iris incised below
-(Cheselden).]
-
-[Illustration: Fig. 3.--Original knife-needle in situ, behind the iris
-(Cheselden).]
-
-For more than a century the method of Cheselden seems to have been the
-storm center of controversy. Some doubted his veracity, others essayed
-his operation but failed, while a few had a moderate degree of success.
-Many attributed to him statements which do not appear in his published
-report. He says clearly that in each of his cases couching had
-previously been performed, and yet some have insisted that the lens was
-present, and must have been wounded. He also states that his incision
-was made from behind forward, and yet his followers, Sharpe[4]
-and Adams,[6] both describe the incision as being made from before
-backward. As Sharpe was his pupil, and presumably had seen him operate,
-Guthrie[7] suggests the possibility of his having made his incision
-both ways, the technic being practically the same.
-
-[6] Adams, Sir William: Practical Observations on Ectropium, Artificial
-Pupil and Cataract, London, 1812, p. 37 et seq.
-
-[7] Guthrie, G. J.: Operative Surgery of the Eye, London, 1830, p. 428.
-
-Morand,[8] in his “Eulogy of Cheselden,” claims to have personally seen
-him operate “on an eye in which the iris was closed by an accident,”
-and gives a more detailed description which closely follows the
-original method. He states that Cheselden presented him with one of
-his knife-needles as a souvenir of the occasion. Although Morand does
-not record the exact date of his visit to London, he does state that
-it occurred during the year 1729. Huguier,[9] in his exhaustive thesis
-on artificial pupil, also places the date of this visit in the year
-1729. This fact is important, as some writers have declared that Morand
-neither made the visit to London nor saw Cheselden operate, but only
-quoted the original account given in the Philosophical Transactions.
-The publication of Morand’s high encomiums in 1757 attracted renewed
-interest to the subject of Cheselden’s operation among men of
-scientific and medical attainments.
-
-[8] Histoire et Mémoires de l’Académie Royale de Chirurgie, Paris,
-1757, iii, p. 115.
-
-[9] Huguier, Pierre Charles: Des Opérations de Pupille Artificielle,
-Paris, 1841.
-
-Sharpe,[4] in 1739, performed this operation in the same manner as
-Cheselden, except that after he had entered the knife-needle through
-the sclerotic he passed it through the iris and across the anterior
-chamber, and then incised the iris-membrane from before backward.
-Although he was Cheselden’s pupil, and dedicated his small volume on
-surgery to him, he probably did his master more harm than good, as
-all the objections to Cheselden’s method seemed to be based on the
-deprecatory remarks of Sharpe. He says, “I once performed it with
-tolerable success, and a few months after, the very orifice I had made
-contracted and brought on blindness again.” He mentions the danger
-of wounding the lens, the lack of success in paralytic iris with
-affection of the retina, the danger of iridodialysis from traction of
-the knife, and the possibility of failure because the incision would
-not enlarge sufficiently. Thirty years later (1769) he published the
-ninth edition of his book without recording a single additional case,
-but added the thought that, since extraction of the crystalline lens
-showed the cornea was not so vulnerable as had been believed, he would
-“imagine” that a larger knife might be introduced perpendicularly
-through the cornea and iris and a similar incision made. In his first
-eight editions he pictures Cheselden’s iris-knife (Fig. 4, vide p.
-25), but in his ninth edition he substitutes a broad lance-knife with
-two edges which closely resembled the one Wenzel (vide Fig. 17) had
-just introduced (1767), and which Sharpe suggests “can also be used for
-the extraction of the cataract.” He evidently did not have a very clear
-idea of the subject, and only succeeded in casting doubt and discredit
-on the method of Cheselden, which, judging by his own statement, he had
-tried but once.
-
-Heuermann,[10] in 1756, had already antedated these thoughts of Sharpe
-by practising a similar method. He passed a double edged lance-knife
-through the cornea instead of through the sclera, and then made a
-sweeping incision through the iris-membrane without enlarging the
-corneal wound. He was probably the first to puncture the cornea with
-the iris-knife.
-
-[10] Heuermann, Georg: Abhandlung der Vornemsten Chirurgischen
-Operationen, Copenhagen and Leipzig, 1756, ii, p. 493.
-
-Janin,[11] about 1766, performed Cheselden’s operation several times
-with but little success owing to reclosure of the wound by plastic
-exudate. He adopted Sharpe’s modification, but later on changed the
-incision from a horizontal to a vertical one with better results. He,
-however, afterward abandoned this procedure and became the originator
-of the other school, composed of those who preferred to use the
-scissors.
-
-[11] Janin, Jean: Mémoires et Observations sur L’Oeil, Lyon 1772, p.
-191.
-
-Guérin,[12] in 1769, made a free corneal incision with a large
-cataract knife, and then introduced a small iris-knife, with which
-he made a crucial incision from before backward in the center of the
-iris-membrane. Although Guthrie[6] distinctly states that Guérin
-afterwards removed the four angles of the cross with a pair of scissors
-in order to prevent reclosure of the incision, no direct confirmation
-of this statement can be found in his writings.
-
-[12] Guérin, M.: Maladies des Yeux, Lyon 1769, p. 235.
-
-Beer,[13] in 1792, first published his method, which he designated
-as “an improvement on Cheselden’s method.” Although the technic is
-somewhat different, the procedure is practically the same as that
-originated by Heuermann in 1756. Beer selected certain cases in which
-a prolapsed iris had followed the lower incision for cataract, causing
-adherent leucoma with a tensely drawn iris-membrane. He plunged his
-double-edged lance-knife (Fig. 5) through the cornea and stretched out
-iris, from above downward and a little obliquely (Fig. 6), so as to
-incise the center of the tense iris fibers crosswise, at right angles
-to the line of traction; cutting horizontally when the traction was
-vertical, and vertically when this was horizontal. In his monograph on
-artificial pupil,[14] 1805, he substitutes for the lance-knife his new
-broad iris-knife, which is practically the same as that later shown
-by Walton (vide Fig. 12), as, indeed, Walton’s procedure (vide Fig.
-13) was almost identical with that of Beer. For other conditions he
-usually employed Wenzel’s operation until by chance he encountered a
-puzzling case which led him to perform the operation we now know as
-iridectomy (1797) and which thereafter became his favorite procedure
-for artificial pupil.
-
-[13] Beer, Georg Joseph: Lehre der Augenkrankheiten, Wien, 1792, ii, p.
-12.
-
-[14] Beer, Georg Joseph: Ansicht der Künstlichen Pupillen-Bildung,
-Wien, 1805, p. 105.
-
-[Illustration: Fig. 6.--Beer’s iridotomy with broad iris-knife (after
-Mackenzie).]
-
-Adams,[15] in 1812, revived the operation of Cheselden with certain
-modifications. While his puncture was made in the same location,
-his technic was different. He entered the sclera with a small
-iris-scalpel[5] of his own special design (Fig. 7), which, like
-Sharpe, he passed through the iris-membrane into the anterior chamber,
-carrying it across to the nasal side (Fig. 8). From entrance to exit
-he always kept the edge of the knife turned back toward the iris, so
-as to cut from before backward. He was thus able by the most delicate
-pressure of his instrument, to make a long horizontal incision, without
-causing iridodialysis (Fig. 9). If the first incision appeared to be
-too short, he did not withdraw the knife entirely, but again carried it
-forward and partially withdrew it, always cutting in the same plane.
-To quote his own words, “by repeating the efforts to divide the iris
-(taking care in so doing to make as slight a degree of pressure as
-possible upon the instrument, instead of withdrawing it out of the eye
-at once, as recommended by Cheselden), a division of that membrane may,
-in almost all cases be effected, of a requisite size to establish a
-permanent artificial pupil” (Figs. 10 and 11).
-
-[15] Adams, Sir William: A Treatise on Artificial Pupil, London, 1819,
-p. 34, et seq.
-
-[Illustration: Fig. 8.--Adams’ iris scalpel in situ, showing location
-of scleral puncture (after Lawrence).]
-
-[Illustration: Fig. 9.--Iridotomy by Adams’ method (after Lawrence).]
-
-[Illustration: Fig. 10.--Occlusion of pupil (Adams).]
-
-[Illustration: Fig. 11.--The resulting pupil after iridotomy (Adams).]
-
-Here were three elements of success, a sharp knife, a gentle sawing
-movement, and the most delicate pressure of the instrument. His method
-was a decided advance, and he reported success in nearly one hundred
-cases. Others, less skilful, however, failed of success, and the
-severe criticisms of Scarpa,[16] though evidently unjust and tinged by
-personal animosity,[17] cast a shadow of doubt on the method.
-
-[16] Scarpa, Antonio: Trattato Delle Principali Malattie Degli Occhi,
-Ed. quinta, l’avia, 1816, translated by James Briggs, London, 1818, p.
-373.
-
-[17] Edin. Med. and Surg. Jour., No. 58.
-
-[Illustration: Fig. 13.--Iris-knife in position to make central pupil
-(Walton, after Beer).]
-
-From that time on for nearly half a century this form of iridotomy
-was practically abandoned, the pendulum swinging toward the use of
-scissors, which Maunoir had popularized and Scarpa had indorsed.
-Walton,[18] however, about 1852, proposed a method closely resembling
-that of Heuermann and almost identical with that of Beer (vide Fig.
-6). His iris-knife (Fig. 12) was practically the same as the broad
-iris-knife of Beer. He incised the cornea near the limbus, and
-passed the knife across the anterior chamber to the middle of the
-iris-membrane which he punctured with a sweeping vertical incision
-(Fig. 13). If the tissue still retained its elasticity there appeared
-a long pupillary aperture, elliptical and vertical (Figs. 14 and 15).
-This incision, however, like all those made through a single set of the
-iris fibers, was only successful when there was sufficient resiliency
-remaining in the iris tissue to draw the slit open, and thus keep the
-edges from uniting. While this method never became very popular, there
-were some who later practiced it by substituting a very narrow Graefe
-knife for the iris-knife of Heuermann, Beer and Walton. In fact, this
-latter procedure still has considerable vogue, both for iridotomy and
-capsulotomy.
-
-[18] Walton, H. Haynes: The Surgical Diseases of the Eye, London, 1861,
-p. 604.
-
-[Illustration: Fig. 14.--Occlusion of pupil (Walton).]
-
-[Illustration: Fig. 15. New pupil after incision with iris-knife
-(Walton).]
-
-During the following seventeen years no notable advance was made, the
-scissors method still retaining its hold on the profession, until
-in 1869, von Graefe, after long reflection, became convinced of the
-dangers of that method, and communicated to one of his pupils, M.
-Meyer, his method of simple iridotomy performed with the knife-needle.
-Meyer[19] quotes his views as follows:
-
-[19] Meyer, Edouard: Traité Pratique des Maladies des Yeux, Paris,
-1880, translated by Freeland Fergus, Philadelphia, 1887, p. 396.
-
-  “For such cases von Graefe has suggested another method of operation,
-  the principle and execution of which are contained in the following
-  note written for us by that illustrious savant in 1869:
-
-  “When, in consequence of a cataract operation, the lens is absent,
-  and when there is highly developed retro-iritic exudation, with
-  disorganization of the iris tissue, flattening of the cornea and
-  the other sequelæ of a destructive iridocyclitis, I substitute
-  simple iridotomy for iridectomy, which is the operation hitherto
-  performed, generally without success. The operation consists in
-  inserting a double-edged knife, resembling in shape a very sharp
-  pointed lance-knife, through the cornea and newly formed tissues till
-  it pierces the vitreous body, and immediately withdrawing it; and,
-  while withdrawing it, enlarging the wound in the membranes without
-  increasing the size of the corneal wound. Experience shows that such
-  plastic membranes attached to the atrophied iris and to the capsule
-  of the lens have a tendency to contract sufficient to maintain, to a
-  certain extent, the opening which has been made.
-
-  “If, in the ordinary method of iridectomy, combined with laceration
-  or extraction of the false membranes, we find that the artificial
-  pupil usually becomes closed, we must attribute this to an
-  excessive vulnerability, which immediately sets up proliferation
-  in those tissues which have been touched, and which are endowed,
-  in consequence on their structure, with an irritability altogether
-  peculiar. We know that even the transitory reduction of the
-  intraocular pressure, which follows the evacuation of the aqueous
-  humor, is sufficient to give rise to hemorrhage in the anterior
-  chamber, which interferes with the perfect success of the intended
-  operation; but most of our failures in the ordinary methods are
-  due to the irritation caused by the forceps and the traction on
-  the surrounding structures. Simple iridotomy is free from such
-  inconveniences; it is, so to speak, a sub-corneal act, and enjoys the
-  immunity which belongs to subcutaneous operations.
-
-  “I have also reduced the corneal wound to a minimum, by using small
-  falciform knives. These are passed through the false membranes, which
-  are then cut from behind forward.”
-
-Von Graefe thus proposed two methods, (1) by cutting from before
-backward with a double-edged lance-knife, according to the method of
-Heuermann, and (2) by cutting from behind forward with a sickle-shaped
-knife, after the original suggestion of Cheselden. Later in the same
-year, as he lay on his last bed of illness, he became so absorbed in
-the study of this subject that he sent a telegram to the Heidelberg
-Congress[20] (September, 1869), in which he advocated the method by
-the sickle-shaped knife-needle as the best procedure. His last message
-to his colleagues showed, therefore, that through mature conviction
-he strongly favored the use of the knife-needle, and the making of
-a sub-corneal incision in the iris-membrane without evacuating the
-aqueous humor. His untimely death, however, prevented him from further
-perfecting this procedure and presenting it to the profession.
-
-[20] Klinische Monatsblätter für Augenheilkunde, 1869, p. 431.
-
-Galezowski,[21] in 1875, published a somewhat similar method in which
-he used his falciform knife, _aiguille-a-serpette_ (Fig. 16), which
-he introduced through the cornea and iris-membrane, making either
-a horizontal or a vertical incision, with a “go-and-come” (sawing)
-movement, after the suggestion of Adams. If this single cut was not
-sufficient, he made a linear incision of the cornea with a Graefe
-knife, drew out the iris and cut it off with scissors. By a process of
-evolution, however, he perfected the former procedure and eliminated
-the scissors. This latter method was published in the third edition of
-his book in 1888. He punctured the cornea and iris-membrane with the
-sickle-shaped knife, making first a horizontal incision by the sawing
-movement of Adams, and finishing with a second cut in the vertical
-direction, thus forming a T-shaped incision. In actual practice,
-however, he almost always prolonged this second cut, thus making a
-crucial incision after the manner of Guérin.[11]
-
-[21] Galezowski, Xavier: Maladies des Yeux, 2d. ed., Paris, 1875, p.
-401, and 3rd. ed., Paris, 1888, p. 384.
-
-The writer,[22] in 1888, was led to devise an operation with a modified
-Hays knife-needle, in which through a corneal puncture he made a
-converging incision in the iris-membrane which resembled an inverted
-V. The resulting pupil opened up and formed either a triangular or an
-oval-shaped pupil depending on the degree of stiffness or resiliency of
-the iris-membrane. This method will be described in detail later on.
-
-[22] A brief description of the author’s method, written by him, was
-first published in de Schweinitz on Diseases of the Eye, Philadelphia,
-2nd. ed., 1896, p. 607.
-
-
-II. SCISSORS METHOD.
-
-We will now return to the consideration of the second school in which
-scissors were introduced through a previously made corneal section and
-a free incision was made in the iris-membrane, or a portion of the
-membrane excised.
-
-[Illustration: Fig. 17.--Wenzel’s cataract knife, and method of
-incision (after Mackenzie).]
-
-Janin,[10] in 1768, having abandoned the procedure of Cheselden,
-proposed a new method. He incised the cornea below as for cataract
-extraction, and raised the corneal lip with a spatula while he
-introduced a pair of curved scissors, the lower blade of which was
-pointed. He plunged this sharp blade through the iris-membrane,
-and with a single vertical cut made a crescentic pupil which gaped
-sufficiently for visual purposes. As this is the first known
-description of iridotomy by the scissors method it is probable that
-Janin was the originator of this procedure.
-
-Wenzel,[23] in 1786, employed a different method. With a lance-shaped
-cataract knife he entered the cornea, dipped through the
-iris-membrane, returned to the anterior chamber, and continuing to cut
-made a counter-puncture on the opposite side of the cornea, following
-which he completed his cataract incision. This gave a semilunar flap of
-iris tissue which could easily be excised by scissors passed through
-the large corneal opening (Fig. 17).
-
-[23] Wenzel, Baron de: Traité de la Cataracte, Paris, 1786, translated
-by James Ware, London, 1805, ii, p. 256.
-
-[Illustration: Fig. 18.--Maunoir’s scissors.]
-
-[Illustration: Fig. 19.--V-shaped iridotomy with scissors (Maunoir).]
-
-[Illustration: Fig. 20.--Parallelogram pupil (Maunoir).]
-
-Maunoir,[24] in 1802, took up the method of Janin, with the object of
-improving it. He made an incision near the corneal margin, through
-which he introduced a pair of long, thin, angular scissors of his own
-design (Fig. 18), one blade of which was sharp-pointed like a lancet,
-and the other button-pointed like a probe. The iris-membrane was
-then punctured by the sharp blade at about the natural location of
-the pupil, and an incision executed toward the ciliary margin of the
-iris. Finding that this single incision did not always succeed,[25] he
-subsequently improved this method by making a second incision from the
-pupillary area toward the iris margin, in the line of the radiating
-iris fibers, thus making a divergent V (Fig. 19). This triangular flap
-was then allowed to shrink back, or if too stiff, was drawn out and
-excised. The resultant pupil assumed the shape either of a triangle, a
-parallelogram (Fig. 20), or a crescent (Fig. 21). He always made his
-incision parallel with the radiating fibers of the iris and across the
-circular fibers.
-
-[24] Maunoir, Jean Pierre: Mémoires sur l’Organisation de l’Iris, et
-l’Opération de la Pupille Artificielle, Paris, 1812.
-
-[25] Medico-Chir. Trans., London, 1816, vii, p. 301, and ix, p. 382.
-
-Scarpa,[15] in 1818, having abandoned his own method of
-iridodialysis as wholly unsatisfactory, adopted Maunoir’s
-procedure with enthusiasm, chiefly because he had by a friendly
-correspondence[24] personally encouraged Maunoir with advice and
-suggestion during its development. He indorsed Maunoir’s plan of a
-double incision when he stated his conviction that “experience has
-proved that in order to obtain, with the most absolute certainty, a
-_permanent_ artificial pupil, it is necessary to make _two_ incisions
-in the iris so as to form a triangular flap in the membrane, in the
-form of a letter V, the apex being precisely in the center of the iris
-and the base near the great margin.” Some have claimed that Scarpa
-himself originated the V-shaped incision, but he gives Maunoir full
-credit for its successful accomplishment, although he does suggest some
-additional indications for its practical application.
-
-[Illustration: Fig. 21.--Crescent pupil (Maunoir).]
-
-His opposition to the knife-needle incision of Cheselden arose from
-the fact that the pupil either did not open, or if it did open would
-not remain permanent, chiefly because of the single iris incision. His
-antagonism to the more successful procedure of Adams was the result
-of a caustic personal controversy[16] with that skilful surgeon,
-who ably parried his charges.[14] His great influence with the
-profession of that day, however, served to check the sentiment in favor
-of Adams’ procedure, and when the weight of his indorsement was cast in
-favor of Maunoir’s operation the scales were decisively turned toward
-the side of the scissors method.
-
-Mackenzie,[26] in 1840, practiced Maunoir’s operation with considerable
-success, but in certain cases found it necessary to employ a slight
-modification of this procedure. He reversed Maunoir’s incision by
-making the same divergent V across the radiating fibers of the iris
-instead of parallel with them (Fig. 22), thus securing a triangular
-pupil (Fig. 23), which Lawrence[27] thought might succeed in some cases
-where Maunoir’s method would not be available.
-
-[26] Mackenzie, William: Diseases of the Eye, 3rd. ed., London, 1840,
-p. 746, American edition, edited by Hewson, Philadelphia, 1855, p. 815.
-
-[27] Lawrence, Sir William: Diseases of the Eye, American edition,
-edited by Hays, Philadelphia, 1854, p. 478.
-
-[Illustration: Fig. 22.--Mackenzie’s incision in cornea and
-iris-membrane (Mackenzie).]
-
-[Illustration: Fig. 23.--Resulting triangular pupil from Mackenzie’s
-incision (Mackenzie).]
-
-Bowman,[28] in 1872, proposed a method which, though surgically
-difficult to execute, was quite ingenious, and may have been the
-initial suggestion that stimulated DeWecker to write his monograph
-in the following year. I will quote his description as follows: “We
-make a double opening simultaneously on opposite sides of the cornea.
-It is more convenient, of course, to make these two openings in a
-horizontal than in a vertical direction. I then run a pair of scissors
-in two diverging lines (V) from each incision, thus enclosing between
-the incisions a large square or rhomboidal portion of the iridial
-region including the pupil, and all the structures there. You then
-withdraw the portion thus cut out. There is no drag on the ciliary
-region; whatever is withdrawn has been cut away from its connections
-beforehand” (Figs. 24, 25 and 26).
-
-[28] Transactions, Fourth Int. Ophth. Cong., London, 1872, p. 179.
-
-[Illustration: Fig 24.--Plan of Bowman’s first iris incision.
-Divergent V.]
-
-[Illustration: Fig. 25.--First incision completed. Plan of second,
-showing double V.]
-
-[Illustration: Fig. 26.--Rhomboidal pupil, resulting from Bowman’s
-iridotomy.]
-
-This method is simply an elaboration of the one proposed by Maunoir, in
-which, instead of forming one divergent V, Bowman has made a duplicate
-incision on the opposite side, and by joining the bases of these two
-resultant triangles has caused them to take the shape of a rhomboid,
-thus <>.
-
-[Illustration: Fig. 27.--Stop keratomes, straight and angular
-(De Wecker).]
-
-[Illustration: Fig. 28.--Forceps-scissors (pinces-ciseaux) (DeWecker).]
-
-DeWecker,[29] in 1873, published his admirable monograph on iridotomy,
-in which he proposed the operation which bears his name, and which
-has long stood as the best recognized method of this procedure. He
-advocated two different ways of performing this: 1, simple iridotomy,
-and 2, double iridotomy.
-
-[29] De Wecker, Louis: Annales d’Oculistique, Sept., 1873, p. 123, et
-seq.
-
-1. _Simple Iridotomy._--This is practically the same operation as
-Critchett’s sphincterotomy and Bowman’s visual iridotomy, although
-differently executed. It has been supplanted in our day by iridectomy,
-and does not, therefore, come within the purview of this discussion.
-
-2. _Double Iridotomy._--He rightly claimed that this was both
-antiphlogistic and optical in its purpose. He employed two distinct
-methods, which he designated as (_a_) iritoectomie, and (_b_)
-iridodialysis. The instruments he used were a small stop-keratome (Fig.
-27) and a pair of specially devised fine iris scissors (pinces-ciseaux)
-(Fig. 28), one blade being sharp pointed and the other blunt. These
-scissors were a great mechanical advance over all previous instruments
-of this kind, and undoubtedly proved to be a most important element in
-the success of his procedure.
-
-[Illustration: Fig. 29.--Iritoectomie. Convergent V (DeWecker).]
-
-[Illustration: Fig. 30.--Iridodialysis. Divergent V (DeWecker).]
-
-(_a_) _Iritoectomie._--He entered the stop-keratome through the cornea,
-made an exact 4 millimeter incision, and then partly withdrew it
-while letting the aqueous slowly escape. As soon as the iris-membrane
-floated up against the knife, he pressed forward, making a 2 millimeter
-incision in the iris. Slowly withdrawing the knife, he introduced
-the sharp point of the scissors through the iris buttonhole and cut
-obliquely from either extremity of the incision toward the apex of a
-triangle, thus making a convergent V (Fig. 29). He then grasped the
-resulting triangular flap with the forceps and removed it, leaving an
-open central pupil.
-
-(_b_) _Iridodialysis._--His second method was a counterpart of
-Maunoir’s earlier operation, with the addition of iridodialysis. He
-made the corneal and iris incision with the stop-knife, as in the
-previous method. Slipping in his scissors he cut from the center of the
-iris-membrane toward the periphery, and duplicated this incision at an
-oblique angle to the first, thus making a divergent V (Fig. 30). This
-formed a triangular flap which he grasped with forceps and tore from
-its ciliary attachment by iridodialysis.
-
-DeWecker’s procedure was planned by a skilled operator, and required
-great dexterity in its execution. When successful, however, the result
-was most brilliant. Nevertheless, it was impossible to eliminate the
-danger of hemorrhage and loss of fluid vitreous in iritoectomie, while
-in iridodialysis there was the added danger of a torn ciliary surface
-and traction on the ciliary body. His strict injunction to have a
-trained assistant hold up the speculum blades in order to avoid the
-loss of fluid vitreous, showed how much he feared this disastrous
-contretemps. The success of his method of incision is well shown in the
-illustration of his two cases (Figs. 31 and 32).
-
-[Illustration: Fig. 31.--Pupil by iritoectomie. Two incisions.
-Convergent V (DeWecker).]
-
-[Illustration: Fig. 32.--Stenopaic pupil. Single iris incision
-(DeWecker).]
-
-I have already suggested the possibility of Bowman’s paper before the
-London Congress of 1872 having given origin to DeWecker’s monograph
-in 1873. This seems quite reasonable when we consider that Bowman
-proposed two methods of iridotomy, one his double V operation with a
-rhomboidal pupil (previously quoted), and the other a visual iridotomy
-or sphincterotomy, by cutting through the pupillary margin with a blunt
-corneal knife. These two methods are exact prototypes of DeWecker’s
-proposals. Furthermore, DeWecker was present at the London Congress
-where he heard Bowman’s paper, and took part in its discussion. In
-fact, thirteen years later DeWecker acknowledged[30] that after
-considering the objections to Bowman’s method of iridotomy “I addressed
-myself at that time to the search for an instrument which allows
-the avoidance of all traction on the iris, and which can be handled
-through a narrow opening, while exerting its cutting action in a plane
-parallel to the surface of the cornea, against which the diaphragm of
-the iris applies itself, after the escape of the aqueous humor. The
-forceps-scissors having been discovered, it was easy for me to cause to
-be revived the procedure of Janin, and to make it decisively take rank
-in modern ocular surgery.”
-
-[30] DeWecker et Landolt: Traité Complet d’Ophtalmologie, Paris, 1886,
-ii, p. 393.
-
-DeWecker makes only a casual reference to Maunoir’s method, but credits
-Janin with the original suggestion of the method which he has thus
-elaborated. Nevertheless, it is quite evident that DeWecker’s method
-was simply a modification of the one outlined by Maunoir seventy
-years before. Furthermore, he lays down the same rule that Maunoir
-first offered: “Always cut parallel to the radiating fibers and
-perpendicularly to the circular fibers of the iris.”
-
-
-RELATIVE ADVANTAGES OF KNIFE-NEEDLE VS. SCISSORS.
-
-In reviewing the questions at issue between these two schools of
-iridotomy, one can not help noticing the constant oscillation from one
-method to the other as certain advances were made. The method by the
-knife-needle seemed to possess the advantage of easy accomplishment
-and less postoperative disturbance, but with the disadvantage that
-often the pupillary opening was inadequate and promptly reclosed
-by plastic exudate. On the other hand, the method by the scissors
-was more difficult of accomplishment, caused more traumatism to the
-eye, was often complicated by great loss of fluid vitreous, and was
-frequently followed by severe inflammatory reaction. If, however, it
-proved successful, the resulting pupil was permanent and sufficiently
-large for visual purposes. The inclination of all operators seemed
-to be toward the use of the knife-needle, and it was only necessity
-that forced them to adopt the more complicated procedure of the open
-operation with scissors. Von Graefe seemed to recognize this when he
-referred to the knife-needle incision as “a sub-corneal act which
-enjoys the immunity of subcutaneous operations.”
-
-The chief advantages of iridotomy by the knife-needle are the ease
-of incision, the lack of traction on the ciliary body, the freedom
-from postoperative inflammatory reaction, the avoidance of opening
-an eyeball which may contain fluid vitreous, the lessening of the
-tendency to iris hemorrhage from lowered tension, and the avoidance
-of the nebulous scar which often follows a large corneal incision in
-old inflammatory eyes. The disadvantages revealed in the method of
-the knife-needle lay partly in the method and partly in the faulty
-instruments constructed in that day. Cheselden, Morand, Sharpe
-and Adams all made the mistake of entering the eye back of the
-corneoscleral junction, which is so near to the danger zone of the eye.
-Adams, however, made a two-fold improvement in adding to his operation
-a sawing movement and in advocating the “most delicate pressure of the
-instrument” in order to make a free incision. Heuermann was apparently
-the first to make the puncture through the cornea instead of through
-the sclera.
-
-The advocates of the knife-needle method long labored under the
-disadvantage of making a single iris incision, while those who
-employed the scissors early discovered that a double incision was
-necessary to success. Although Janin was the originator of the scissors
-method, Maunoir was the first to deliberately try a triangular flap,
-which DeWecker later elaborated and made a permanent success. The
-many disastrous results of the open operation, however, compelled
-conservative surgeons, like von Graefe, to revert to a study of
-Cheselden’s method, and to seriously consider the great advantages
-which a successful iridotomy by the knife-needle method would confer on
-surgeon and patient alike.
-
-
-THE CHOICE OF A KNIFE-NEEDLE.
-
-1. Cheselden’s knife-needle (Figs. 3 and 4) was a splendidly designed
-instrument, but a poorly executed one. The blade was too large (11 mm.)
-and the shank improperly rounded, so that both aqueous and vitreous
-were liable to escape through the scleral puncture. This leakage
-may explain many failures, although the single iris incision was
-undoubtedly the most serious fault of the method.
-
-2. The iris-scalpel of Adams (Fig. 7) was poorly designed but
-splendidly executed, the long blade completely filling the wound and
-thus preventing the escape of any fluid. The cutting edge, however, was
-too long (15 to 20 mm.), and especially so for the execution of the
-sawing movement advised by Adams.
-
-3. The double-edged lance-knife (Figs. 5, 12 and 33) employed by
-Heuermann, Beer and von Graefe, was useful for the long sweeping
-incision in the iris-membrane which they advocated, but is not adapted
-for the method which will be described later. The same shaped knife
-(Fig. 33) with a smaller blade and a longer shank is also used for
-this purpose, but is likewise too broad, too oval pointed and too
-much bellied to cut well, while the upper edge is liable to scarify
-Descemet’s membrane at the same time that the lower edge is executing
-the incision in the iris tissue.
-
-4. The sickle-shaped knife (Fig. 16) which von Graefe recommends and
-Galezowski employs, is excellent for making the puncture, but for
-the go-and-come movement, which Galezowski advises, is not nearly so
-good as the straight blade with a slight falciform point. It closely
-resembles the older falciform knife of Scarpa.
-
-5. The knife-needle of Knapp (Fig. 34), which is so generally used for
-capsulotomy, is unfortunately not well adapted for iridotomy. The point
-is too oval, the cutting edge is too much bellied, and the blade is too
-short (5 mm.). It will not easily puncture a dense iris-membrane, and
-the long sawing incision can not be well executed, because the short
-blade either persists in slipping out of the iris incision or else
-allows the membrane to ride up on the shank, in either case interfering
-with the completion of the operation.
-
-6. Sichel’s iridotome (Fig. 35) closely resembles Knapp’s knife-needle,
-and although specially designed for this purpose, has the same faults,
-an oval point and a bellied edge. On the other hand, the blade is too
-long (11 mm.) to be easily manipulated in the anterior chamber.
-
-7. The Hays knife-needle (Fig. 36), as suggested in the early part
-of this paper, has the same general shape as Cheselden’s instrument,
-although much smaller. It was devised by Dr. Isaac Hays, an early
-surgeon of the Wills Hospital, and, although not well known to the
-profession at large, has been in constant use by the staff of that
-hospital for more than half a century. I may be pardoned for briefly
-quoting the original description of the instrument as published by
-Hays[31] in 1855:
-
-[31] Amer. Jour. of the Med. Sciences, July, 1855, p. 82.
-
-  “This instrument from the point to the head, near the handle (a
-  to b, Fig. 36), is six-tenths of an inch, its cutting edge (a to
-  c) is nearly four-tenths of an inch. The back is straight to near
-  the point, where it is truncated so as to make the point stronger,
-  but at the same time leaving it very acute, and the edge of this
-  truncated portion of the back is made to cut. The remainder of the
-  back is simply rounded off. The cutting edge is perfectly straight
-  and is made to cut up to the part where the instrument becomes round,
-  c. This portion requires to be carefully constructed, so that as the
-  instrument enters the eye it shall fill up the incision, and thus
-  prevent the escape of the aqueous humor.”
-
-[Illustration: Fig. 4.--Cheselden’s knife-needle (after Sharpe).]
-
-[Illustration: Fig. 37.--Ziegler’s model of knife-needle.]
-
-[Illustration: Fig. 36.--Hays’ knife-needle, exact size and enlarged
-(Hays).]
-
-[Illustration: Fig. 16.--Sickle-shaped knife, Aiguille-à-serpette
-(Galezowski).]
-
-[Illustration: Fig. 35.--Sichel’s iridotome (after Meyer).]
-
-[Illustration: Fig. 34.--Knapp’s knife-needle.]
-
-[Illustration: Fig. 7.--Adams’ iris-scalpel; large and small size.]
-
-[Illustration: Fig. 33.--Double edged lance-knife (modern model).]
-
-[Illustration: Fig. 5.--Double edged lance-knife (Beer).]
-
-[Illustration: Fig. 12.--Iris-knife (Walton, after Beer).]
-
-[Illustration: The Various Knife-Needles and Iris-Knives Mentioned in
-the Text. (Grouped together for study and comparison.)]
-
-[Illustration: Fig. 37.--Ziegler’s model of knife-needle.]
-
-8. The knife-needle, which I invariably use, is a modified pattern of
-that devised by Hays. The form of this instrument lies midway between
-the falciform knife and the bistoury, and possesses the advantages
-of both. It has a very delicate point which punctures easily, and an
-excellent cutting edge of sufficient length (7 mm.). If the shank is
-properly rounded it can be used with a sawing motion, sliding backward
-and forward through the corneal puncture without injuring the cornea,
-and without allowing the aqueous to escape. To accomplish this the
-more easily, the shank has been made 4 mm. longer than the original
-model. This instrument, therefore, seems to meet all the requirements
-of a perfect iris-knife, viz., a falciform point which makes the
-best puncture, a straight edged blade which makes the best incision,
-and a cutting edge 7 mm. long, which is the best length for properly
-executing the sawing movement. My model[32] of knife-needle (Fig. 37)
-resembles Cheselden’s knife, as shown by Sharpe (Fig. 4), even more
-closely than the original pattern of Hays does.
-
-[32] This knife-needle has been carefully made for me by Luer, Paris,
-and by Ferguson, Philadelphia.
-
-
-ESSENTIALS OF SUCCESS IN IRIDOTOMY BY THE KNIFE-NEEDLE METHOD.
-
-1. A good knife-needle must be carefully selected. We have already
-concluded that the modified Hays knife-needle is the best model for
-this purpose. The knife-needle must, of course, have a well sharpened
-point and edge.
-
-2. The character of the incision in the iris-membrane is of vital
-importance. It should be a double incision. Guérin, Maunoir, DeWecker
-and Galezowski recognized this. Guérin made a crucial incision,
-Maunoir and DeWecker adopted the triangular flap, while Galezowski
-advocated the T-shaped cut. Our choice is the V-shaped incision, which
-is undoubtedly the only one that will cut through all the iritic fibers
-in such a way as to give us the greatest retraction of the membrane.
-
-3. Absolutely no pressure should be made in cutting with the
-knife-needle. This must be recognized as the main secret of success,
-whether you are incising a dense, felt-like iris-membrane, or a thin
-filmy capsule. If this rule is observed all traction on the ciliary
-body will be avoided.
-
-4. The knife-needle should slide backward and forward through the
-corneal puncture with a gentle sawing movement.
-
-5. The corneal puncture and membrane counter-puncture should be far
-enough apart to make the corneal puncture a good fulcrum for the
-delicate leverage necessary in executing the iris incision.
-
-6. The knife-needle should be so manipulated that no aqueous shall be
-lost, as this accident may prevent the completion of the operation, and
-may increase the tendency to iris hemorrhage by lowering the ocular
-tension.
-
-7. Every incision should be made a thoroughly clean cut, and all
-tearing of the tissues should be avoided.
-
-8. The most perfect artificial illumination should be secured, either
-by an electric photophore or a condensing lens, as both iridotomy and
-capsulotomy require constant and close inspection of the operative
-field.
-
-
-AUTHOR’S V-SHAPED IRIDOTOMY.
-
-The method of V-shaped iridotomy, performed by me with my modified Hays
-knife-needle, may be described as follows:
-
-_First Stage._--With the blade turned on the flat, the knife-needle is
-entered at the corneo-scleral junction, or through the upper part of
-the cornea (Fig. 38), and passed completely across the anterior chamber
-to within 3 millimeters[33] of the apparent iris periphery. The knife
-is then turned edge downward, and carried 3 millimeters to the left of
-the vertical plane (Fig. 39).
-
-[33] Compare with millimeter scale beneath each diagram.
-
-_Second Stage._--The point is now allowed to rest on the iris-membrane,
-and with a dart-like thrust the membrane is pierced. Then without
-making pressure on the tissue to be cut, the knife is drawn gently up
-and down with a saw-like motion, until the incision has been carried
-through the iris tissue from the point of the membrane puncture to
-just beneath the point of the corneal puncture. This movement is made
-wholly in a line with the axis of the knife, the shank passing to and
-fro through the corneal puncture, and the loss of any aqueous being
-carefully avoided in the manipulation.
-
-[Illustration: Fig. 38.--Author’s V-shaped iridotomy. Knife-needle
-entered through cornea.]
-
-[Illustration: Fig. 39.--Author’s method. Plan of first incision.]
-
-[Illustration: Fig. 40.--First incision completed. Plan of second
-incision.]
-
-[Illustration: Fig. 41.--Pupil resulting from V-shaped iridotomy.]
-
-_Third Stage._--The pressure of the vitreous will now cause the edges
-of the incision to immediately bulge open into a long oval (Fig.
-40) through which the knife-blade is raised upward, until above
-the iris-membrane, and then swung across the anterior chamber to a
-corresponding point on the right of the vertical plane, which, owing to
-the disturbance in the relation of the parts made by the first cut, is
-now somewhat displaced and the second puncture must be made at least
-1 millimeter farther over, i. e., 4 millimeters to the right of the
-vertical plane (Fig. 40).
-
-_Fourth Stage._--With the knife point again resting on the membrane,
-a second puncture is made by the same quick thrust, and the incision
-rapidly carried forward by the sawing movement to meet the extremity
-of the first incision, at the apex of the triangle, thus making a
-_converging_ V-shaped cut (Fig. 41). Care must be taken at this point
-that the pressure of the knife-edge on the tissue shall be most gentle,
-and that the second incision shall terminate a trifle inside the
-extremity of the first, in order that the last fiber may be severed and
-thus allow the apex of the flap to fall down behind the lower part of
-the iris-membrane. If the flap does not roll back of its own accord it
-may be pushed downward with the point of the knife. When the operation
-is completed the knife is again turned on the flat and quickly
-withdrawn.
-
-
-CAUSES OF FAILURE.
-
-The most fruitful sources of failure are, first, a poorly sharpened
-knife-needle; second, a badly planned incision; third, inability to
-sever the apex of the triangle; fourth, the early loss of aqueous;
-fifth, too heavy pressure with the knife-edge, and sixth, rocking or
-rotating the knife backward instead of making the sawing movement. All
-of these can easily be avoided, if the surgeon will only exercise care
-and good judgment.
-
-In an occasional case, the iris-membrane may be so stiff that the apex
-of the flap will not retract. If the apex can not be pushed down by the
-tip of the knife turn the blade on the flat, puncture the base of the
-flap by a quick thrust, and with a sawing motion cut across its fibers
-so that it will fall back as though hinged; or, if positive that the
-vitreous is not fluid, introduce a keratome in the cornea below, draw
-out the triangular tongue, cut it off with the iris scissors, and dress
-back the base with a silver spatula.
-
-It is possible that the capsule, or iris tissue, may lose its
-anchorage. In that event we must either reverse the procedure by
-entering the knife-needle below, and cut from above downward, or else
-pass a second knife-needle through the loosened edge of the membrane to
-fix it, and then proceed with the usual method.
-
-Occasionally, the apex of the triangular flap will hold fast, because
-the last fiber of tissue has not been severed. If the leverage is
-too short to incise it from above, withdraw the knife-needle and
-reintroduce it far enough from the apex to secure the proper leverage,
-and again incise it gently, until it falls back.
-
-Traction on the ciliary processes, accidental puncture of the ciliary
-body, or the tearing of the membrane from its ciliary attachment may
-all set up iridocyclitis or glaucoma, and should therefore be avoided.
-As tense capsular bands are liable to engender a similar condition they
-should be incised. If any of these traction bands should remain in the
-edge of the coloboma, we may enter the knife behind them and gently saw
-through into the already cleared pupil, before withdrawing the knife.
-
-[Illustration: Fig. 42, (Case 1).--Iridotomy in a stiff iris-membrane
-(author’s original case).]
-
-
-ILLUSTRATIVE CASES.
-
-I will briefly cite a few examples of the V-shaped operation, two that
-were my first efforts, and two that were recent cases. They were all of
-the class that are often abandoned as hopeless; hence the visual result
-is far below the operative success.
-
-  Case 1.--_History._--F. M., aged 65 years. O. D. complete membranous
-  occlusion of pupil from iridocyclitis, following cataract extraction.
-  The iris and capsule are tensely drawn up toward the ciliary border.
-  Light perception and projection good. Several efforts have been
-  made to incise the membrane, but without success. Admitted to Wills
-  Hospital by the late Dr. Goodman, through whose courtesy I operated.
-
-  _Operation._--On Jan. 15, 1889, I made two long incisions, almost
-  crucial, and extending beyond the apex of the V, resulting in a
-  W-shaped pupil, on account of the stiff iris membrane (Fig. 42). With
-  S. + 10 D. he saw 20/50.
-
-  Case 2.--_History._--J. S., aged 30 years. O. S. injured and
-  enucleated. O. D. sympathetic inflammation, chorioidal cataract;
-  three discissions and one iridectomy, down and in. Membranous
-  occlusion of pupil. I first saw him in 1888 while house surgeon at
-  the Wills Hospital, where iridotomy was skilfully performed nine
-  times by one of the surgeons, the methods being varied and ingenious,
-  but without success, as the incision was invariably closed by plastic
-  exudate. My interest in this series of operations first drew my
-  attention to the subject of iridotomy, and stimulated me to develop
-  the method I have here submitted and which I first tried in Case 1.
-
-  One year later this patient came to my clinic at St. Joseph’s
-  Hospital. Iris was discolored, capsule thickened and visible through
-  the coloboma, down and in; areas of scleral thinning, with pigmented
-  chorioid showing through. T--3. Light perception good, projection
-  only fair.
-
-  _Operation._--On June 17, 1889, I made a V-shaped iridotomy along the
-  outlines of the former iridectomy. The membrane freely opened up into
-  a triangular or pear-shaped pupil (Fig. 43), which proved permanent,
-  but was only useful for quantitative vision, about 5/200. No further
-  test could be made because the disorganized vitreous was filled
-  with floating masses. I have seen him within a year, going about
-  and earning his living. From an operative standpoint I have always
-  considered this early effort one of my most successful cases, chiefly
-  because of the great density of the iris-membrane and the lowered
-  tension of the eyeball.
-
-[Illustration: Fig. 43, (Case 2).--Iridotomy in a soft eyeball, with
-dense iris-membrane.]
-
-  Case 3.--_History._--Mrs. A. D., aged 45 years. O. D. iridectomy
-  for glaucoma seven years ago. O. S. iridectomy two years ago by
-  another surgeon, at which time there occurred slight incarceration
-  of iris, followed by sympathetic ophthalmitis in O. D. The severe
-  iridochorioiditis resulted in cataract and some shrinkage of globe.
-  The cataracts were extracted from both eyes in 1907, followed by
-  dense opacity of cornea above, iris bombé, shallow anterior chamber,
-  T--2. Here was a soft, distensible, iris tissue with shallow anterior
-  chamber and greatly lowered tension of the eyeball, constituting one
-  of the most difficult conditions to operate on.
-
-  _Operation._--On May 13, 1907, the eyes being quiet, and light
-  perception and projection fair, V-shaped iridotomy was performed
-  on both eyes. The leucomatous areas in the upper part of cornea
-  necessitated making the pupil below. In O. D. the pupil opened
-  up beautifully (Fig. 44), but in O. S. a tag of iris hung fast
-  (Fig. 45) and was again incised two months later. The artist has
-  illustrated the remaining portion of this tag very well. As soon as
-  the iris tissue was incised it retracted, making the pupils larger
-  than the area of incision. The test for glasses, nearly a year later,
-  March 15, 1908, yielded the following result:
-
-  O. D. S + 13 D ⁐ C + 4.75 D ax. 105° = 20/40.
-  O. D. S + 13 D ⁐ C + 3 D ax. 65° = 20/40.
-
-  Add
-
-  O. D. S + 4 D = J. 10.
-  O. S. S + 4 D = J. 10.
-
-  These were ordered in biconvex torics. She had worn glasses for
-  a year, but claims vision is much better with the new ones. This
-  seems like an excellent result when we consider that these eyes had
-  passed through glaucoma, iridochorioiditis and cataract, followed by
-  membranous occlusion of pupil, lowered tension and fluid vitreous.
-  The high hyperopia and astigmatism show the phthisical condition
-  of each globe. There is marked cupping of both nerve heads and the
-  fields are contracted.
-
-[Illustration: Fig. 44, (Case 3).--Iridotomy in a soft eyeball, with
-thin membrane and iris bombé.]
-
-[Illustration: Fig. 45, (Case 3).--Iridotomy showing apex of iris flap
-after incision through adherent fibers.]
-
-  Case 4.--_History._--Mrs. B. M., aged 64 years. O. S. struck by
-  a stone in childhood, destroying vision. Dense leucoma above,
-  chorioidal cataract, calcareous deposit; exclusion of pupil. T--1.
-  Lpc. good. Lpj. fair. O. D. recurrent attacks of inflammation for
-  seven years, posterior synechiæ and cataract. Counts fingers at 6
-  inches. Extraction with iridectomy, both eyes, in 1907. Site of
-  incision has become densely leucomatous. O. D. shows capsular area
-  above, iris drawn up. O. S. complete membranous occlusion of pupil.
-
-  _Operation._--Oct. 7, 1907, V-shaped incision was executed entirely
-  in the iris tissue of O. D., the pupil spreading out into an ovoid
-  shape (Fig. 46), leaving area of capsule and small band of iris
-  above. O. S. was operated on Jan, 13, 1908, by the same method, the
-  resulting pupil being almost round (Fig. 47) owing to the resilient
-  iris tissue.
-
-  The test for glasses, March 10, 1908, gave the following result:
-
-  O. D. S + 12 D ⁐ C + 1.25 D ax. 135° = 20/50.
-  O. S. S + 12 D ⁐ C + 1.25 D ax. 135° = 20/70.
-
-  Add
-
-  O. D. S + 5 D = J. 6.
-  O. S. S + 5 D = J. 12.
-
-  These were ordered in biconvex torics, which she now wears with great
-  comfort. It is worth noting that O. S. still retained good visual
-  acuity, although blinded by an injury nearly fifty years before.
-
-[Illustration: Fig. 46, (Case 4).--Irido-capsulotomy, with band of iris,
-and capsule in coloboma above.]
-
-[Illustration: Fig. 47, (Case 4).--Iridotomy with round central pupil
-in a resilient iris-membrane.]
-
-
-CAPSULOTOMY BY THE V-SHAPED METHOD.
-
-The application of the V-shaped method to capsulotomy shows an even
-greater field of usefulness, as this method is par excellence the best
-way of incising a delicate secondary capsular cataract. This should
-be done under artificial illumination. The pupil should be dilated,
-as the area of incision is necessarily smaller than in iridotomy,
-and unnecessary wounding of the iris should be avoided. The proposed
-capsular opening must be so calculated as to fall within the area of
-the undilated pupil, or partly within the coloboma if an iridectomy has
-been previously performed.
-
-[Illustration: Fig. 48.--Author’s V-shaped capsulotomy. Plan of first
-incision.]
-
-[Illustration: Fig. 49.--First incision completed. Plan of second
-incision.]
-
-[Illustration: Fig 50.--Pupil resulting from V-shaped capsulotomy.]
-
-The knife-needle is entered at the upper corneal margin, passed across
-the anterior chamber to a point 2 mm. to the left of the vertical
-plane (Fig. 48), the capsule punctured by a quick thrust, and the
-saw-like incision carried from below upward, as in iridotomy. The knife
-is then raised up above the capsule and swung 3 mm. to the right of
-the vertical plane (Fig. 49), the capsule is again punctured, and a
-duplicate incision carried up to join the first, at the apex of the
-converging V (Fig. 50).
-
-Where the pupillary margin is adherent to the underlying capsule, or
-the pupillary space is too small, it may be necessary to start the
-incision in the iris tissue, a little below the pupil, and then cut
-upward until the knife emerges into the pupillary area, thus making
-an irido-capsulotomy. The soft iris tissue is easily incised if no
-pressure is made with the knife, and the sawing motion is maintained.
-
-
-AFTER-TREATMENT.
-
-Postoperative inflammatory reaction is infrequent, but if it should
-occur the usual antiphlogistic treatment of atropin, calomel, ice-pads
-and leeching should be actively instituted and continued until the
-eye is absolutely quiet. The operation itself is frequently an
-antiphlogistic measure, because it relieves iris-tension and traction
-on the ciliary body. The usual compress of gauze and cotton, covered
-with a Liebreich patch, may be applied to the eye for the first
-twenty-four hours and rest in bed enjoined for that period.
-
-
-IN CONCLUSION.
-
-We have carefully reviewed the history of iridotomy for nearly two
-centuries, and noted how the pendulum has swung from knife-needle to
-scissors, and back again. We have learned that Cheselden, the father
-of iridotomy, originated the method of incision by the knife-needle,
-which Heuermann modified, and Adams later revived and improved. We have
-seen how Janin abandoned this procedure and originated the scissors
-method, which Maunoir greatly improved and caused to hold sway for more
-than half a century. We have been deeply impressed by the fact that the
-mature, judicial mind of von Graefe led him to abandon the scissors and
-revert to the knife-needle method. We have seen how, soon after his
-death, the great influence of De Wecker had swerved the thought of
-the ophthalmic world back to the adoption of the scissors method in a
-greatly improved form.
-
-Whether I have succeeded in citing sufficient facts and arguments
-to establish my thesis in favor of the knife-needle, or not, I
-nevertheless submit to the profession my V-shaped method of iridotomy
-and capsulotomy with a confidence born of twenty years’ successful
-experience in its use, and with the hope that it may prove equally
-efficient in the hands of others who will take pains to study and
-understand the method, and who may have the patience to put it in
-practice.
-
-*** END OF THE PROJECT GUTENBERG EBOOK HISTORY OF IRIDOTOMY ***
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-<p style='text-align:center; font-size:1.2em; font-weight:bold'>The Project Gutenberg eBook of History of Iridotomy, by S. Lewis Ziegler</p>
-<div style='display:block; margin:1em 0'>
-This eBook is for the use of anyone anywhere in the United States and
-most other parts of the world at no cost and with almost no restrictions
-whatsoever. You may copy it, give it away or re-use it under the terms
-of the Project Gutenberg License included with this eBook or online
-at <a href="https://www.gutenberg.org">www.gutenberg.org</a>. If you
-are not located in the United States, you will have to check the laws of the
-country where you are located before using this eBook.
-</div>
-
-<p style='display:block; margin-top:1em; margin-bottom:0; margin-left:2em; text-indent:-2em'>Title: History of Iridotomy</p>
-<p style='display:block; margin-left:2em; text-indent:0; margin-top:0; margin-bottom:1em;'>Knife-Needle vs. Scissors—Description of Author’s V-Shaped Method</p>
-<p style='display:block; margin-top:1em; margin-bottom:0; margin-left:2em; text-indent:-2em'>Author: S. Lewis Ziegler</p>
-<p style='display:block; text-indent:0; margin:1em 0'>Release Date: January 7, 2022 [eBook #67117]</p>
-<p style='display:block; text-indent:0; margin:1em 0'>Language: English</p>
-  <p style='display:block; margin-top:1em; margin-bottom:0; margin-left:2em; text-indent:-2em; text-align:left'>Produced by: Thiers Halliwell, deaurider and the Online Distributed Proofreading Team at https://www.pgdp.net (This file was produced from images generously made available by The Internet Archive)</p>
-<div style='margin-top:2em; margin-bottom:4em'>*** START OF THE PROJECT GUTENBERG EBOOK HISTORY OF IRIDOTOMY ***</div>
-
-<div class="transnote"> <p><b><a
-id="Transcribers_notes"></a>Transcriber’s notes</b>:</p>
-
-<p>The text of this e-book has mostly been preserved in its original
-form, including some archaic spellings. A composite illustration on
-page 25 showing surgical knives lined up vertically side by side has
-been split into its individual components in order to display the
-instruments in horizontal orientation along with their respective
-captions. Hyperlinks have been added to textual cross-references
-and to footnotes. <span class="htmlonly">Page numbers are shown in
-the right margin and footnotes are located at the end.</span> <span
-class="epubonly">Footnotes are listed at the end.</span></p>
-
-<p class="epubonly">The cover image of the book was created by the
-transcriber and is placed in the public domain.</p>
-</div>
-
-
-<div class="titlepage">
-<h1><span class="t1">History of Iridotomy</span><br />
-
-<span class="t2">Knife-Needle vs. Scissors&mdash;Description of Author’s<br />
-V-Shaped Method.</span></h1>
-
-<hr class="r8" />
-
-
-<div class="tp1">S. LEWIS ZIEGLER, A.M., M.D., Sc.D.</div>
-<div class="tp2">Attending Surgeon, Wills Eye Hospital; Ophthalmic Surgeon,<br />
-St. Joseph’s Hospital.</div>
-<div class="tp3">PHILADELPHIA.</div>
-</div>
-
-<p><span class="pagenum" id="Page_3">3</span></p>
-
-
-<hr class="chap x-ebookmaker-drop" />
-
-<p class="tac fs120">HISTORY OF IRIDOTOMY.</p>
-
-<p class="tac fs90">KNIFE-NEEDLE VS. SCISSORS&mdash;DESCRIPTION OF AUTHOR’S<br />
-V-SHAPED METHOD<span class="nowrap">.<a id="FNanchor_1" href="#Footnote_1" class="fnanchor">1</a></span></p>
-
-<hr class="r6" />
-
-<p class="tac">S. LEWIS ZIEGLER, A.M., M.D., Sc.D.</p>
-
-<p class=" tac fs80">Attending Surgeon, Wills Eye Hospital; Ophthalmic Surgeon,<br />
-St. Joseph’s Hospital.</p>
-
-<p class="tac fs80">PHILADELPHIA.</p>
-
-<hr class="r6" />
-
-<p>To Cheselden has been conceded the honor of being
-the father and originator of iridotomy. Nearly two
-centuries have elapsed since he first published the report
-of his procedure in the Philosophical Transactions for
-1728. Ever since that time, his signal success has been
-acknowledged by all except those who either failed to
-equal his dexterity, or who were prejudiced by their
-ambition to originate a new method.</p>
-
-<p>A careful review of the medical literature of the century
-and a half following Cheselden’s announcement
-can not fail to impress the reader with the great interest
-attached to operations for the formation of an artificial
-pupil, which subject was considered second only in importance
-to that of cataract itself. Not only were a large
-number of monographs devoted wholly to this subject,
-but every work on general surgical topics set aside one or
-more chapters for the discussion of artificial pupil.
-This is in great contrast to the limited space which modern
-works on ophthalmology grudgingly yield to this still
-important subject.</p>
-
-<p>It is difficult for us to appreciate the conditions which
-brought about so large a percentage of cases of pupillary
-occlusion. Crude surgical procedures, poor operative
-technic and the utter lack of asepsis often resulted
-in iridocyclitis or iridochorioiditis. The couching of the<span class="pagenum" id="Page_4">4</span>
-lens, the free discission of both hard and soft cataracts,
-the frequent introduction of the knife-needle through
-the dangerous ciliary zone, and the bungling efforts at
-extraction all increased the tendency to inflammatory
-reaction, while inadequate therapeutics and lack of
-antiphlogistic measures frequently permitted the deposit
-of plastic exudate in the pupillary area, thus resulting
-in membranous occlusion of the pupil.</p>
-
-
-<h2>OPERATIONS FOR ARTIFICIAL PUPIL.</h2>
-
-<p>For the sake of historical completeness, and in order
-to better emphasize the special domain of iridotomy, I
-will mention briefly the various methods that have been
-employed in making an artificial pupil. These are:</p>
-
-<p>(1) <i>Division</i> of the thickened iris-membrane by an
-incision made either through the sclerotica or through
-the cornea. This is true <i>iridotomy</i>.</p>
-
-<p>(2) <i>Excision</i> of a portion of the iris through a previously
-made corneal opening. This is now known as
-<i>iridectomy</i>.</p>
-
-<p>(3) <i>Separation</i> of the iris from its ciliary attachment.
-This was generally known as <i>iridodialysis</i>, but sometimes
-called <i>iridorrhexis</i>.</p>
-
-<p>(4) Simple <i>incision</i> of the pupillary margin, and of
-the free iris tissue. This has been designated <i>sphincterotomy</i>
-by some, and <i>coretomy</i> or <i>iritomy</i> by others.
-Either one of the latter terms is to be preferred, because
-it is more clearly descriptive.</p>
-
-<p>(5) <i>Detachment</i> of the synechiæ at the pupillary
-margin, either anterior or posterior, thus allowing the
-pupil to retract. This was known as <i>corelysis</i>.</p>
-
-<p>(6) <i>Strangulation</i> of the prolapsed iris in the corneal
-incision was called <i>iridencleisis</i>. The prolapse was sometimes
-tied with a ligature.</p>
-
-<p>(7) <i>Trephining</i> of the iris-membrane, by passing a
-small trephine or punch through a corneal incision.</p>
-
-<p>(8) <i>Section</i> and removal of a portion of the sclerotica
-and chorioid by knife or trephine, with replacement of
-the conjunctiva over this opening, the conjunctiva thus
-acting as a substitute for the cornea in transmitting
-light. This was called <i>sclerectomy</i>.</p>
-
-<p>(9) <i>Transplantation</i> of the cornea for total leucoma.
-This was usually preceded by partial or complete trephining
-of this membrane.</p>
-
-<p><span class="pagenum" id="Page_5">5</span></p>
-
-<p>In addition to these nine distinct methods certain
-combinations of these have been described and successfully
-practiced:</p>
-
-<p>(10) <i>Division</i> and <i>excision</i> have frequently been performed
-together.</p>
-
-<p>(11) <i>Separation</i> and <i>excision</i> have likewise had some
-vogue.</p>
-
-<p>(12) <i>Separation</i> and <i>strangulation</i> have occasionally
-been practiced.</p>
-
-<p>(13) <i>Detachment</i> of the synechiæ and <i>excision</i> have
-also been performed.</p>
-
-
-<h2>HISTORICAL REVIEW OF IRIDOTOMY.</h2>
-
-<p>In this brief review of iridotomy<span class="nowrap">,<a id="FNanchor_2" href="#Footnote_2" class="fnanchor">2</a></span> we shall confine
-our attention to the methods that have been advanced
-for the formation of an artificial pupil in cases of membranous
-occlusion of the pupil following removal of the
-lens, either by couching, extraction or discission, the iris-membrane
-in these cases being chiefly composed of inflamed
-iris tissue glued down by retro-iridian exudate
-to the thickened lens capsule.</p>
-
-<p>The early history of iridotomy shows that the advocates
-of this operation were divided into two schools, (1)
-those recommending the use of the <i>knife-needle</i> for incising
-the iris-membrane, and (2) those adopting the
-method of introducing <i>scissors</i> through a previously
-made corneal section and freely incising the iris-membrane,
-or excising a portion of the same. We will first
-consider the school which advocated incision by the
-knife-needle.</p>
-
-
-<div class="figcenter illowp52" id="i_06" style="max-width: 23.125em;">
-  <img class="w100" src="images/i_06.jpg" alt="" />
-  <div class="caption"><p>Portrait of William Cheselden, 1688–1752. Painted by Richardson.</p></div>
-</div>
-
-
-<h2>I. KNIFE-NEEDLE METHOD.</h2>
-
-<p>Cheselden<span class="nowrap">,<a id="FNanchor_3" href="#Footnote_3" class="fnanchor">3</a></span> a renowned surgeon, and oculist to Her
-Majesty, Queen Caroline of England, first announced,
-in 1728, his success in making an artificial pupil by
-means of his knife-needle. He made his puncture
-back of the corneoscleral junction on the temporal
-side, passing the knife across the posterior chamber,
-and making a counter-puncture in the iris-membrane
-near the nasal margin. He then cut through the iris
-from behind forward as he withdrew the knife, the
-incision being carried through two-thirds of its extent.<span class="pagenum" id="Page_6">6</span>
-The pupillary opening thus made was a long
-oval slit, horizontally placed. He has reported two successful
-<span class="nowrap">cases<a id="FNanchor_4" href="#Footnote_4" class="fnanchor">4</a></span> (Figs.&nbsp;<a href="#i_07a">1</a> and 2), occurring in patients
-who had previously undergone couching of the lens. His
-instrument, strange to say, was practically of the same
-general shape as the Hays knife-needle, but was larger,
-and judging from the description more clumsily constructed,
-as there was danger of leakage of the aqueous
-and sometimes of the vitreous when it was used. Its
-form resembled a combination of a bistoury and a sickle-shaped<span class="pagenum" id="Page_7">7</span>
-knife, having a sharp edge on one side, a rounded
-back, and an acute point. We possess two good illustrations
-of this knife-needle, one by Cheselden himself
-(Fig.&nbsp;<a href="#i_07c">3</a>), and the other by his pupil, <span class="nowrap">Sharpe<a id="FNanchor_5" href="#Footnote_5" class="fnanchor">5</a></span> (Fig.&nbsp;<a href="#i_25-1">4</a>).</p>
-
-<div class="figcontainer">
-<div class="figsub illowp100" id="i_07a" style="max-width: 12.1875em; padding-top: 0.55em;">
-  <img class="w100" src="images/i_07a.jpg" alt="" />
-  <div class="caption"><p>Fig.&nbsp;1.&mdash;Original case of
-iridotomy. Iris incised above (Cheselden).</p></div>
-</div>
-
-<div class="figsub illowp97" id="i_07b" style="max-width: 10em;">
-  <img class="w100" src="images/i_07b.jpg" alt="" />
-  <div class="caption"><p>Fig.&nbsp;2.&mdash;Second case of iridotomy.
-Iris incised below (Cheselden).</p></div>
-</div>
-</div>
-
-<div class="figcenter illowp100" id="i_07c" style="max-width: 26.25em;">
-  <img class="w100" src="images/i_07c.jpg" alt="" />
-  <div class="caption"><p class="tac">Fig.&nbsp;3.&mdash;Original knife-needle in situ,
-behind the iris (Cheselden).</p></div>
-</div>
-
-<p>For more than a century the method of Cheselden
-seems to have been the storm center of controversy. Some
-doubted his veracity, others essayed his operation but
-failed, while a few had a moderate degree of success.
-Many attributed to him statements which do not appear
-in his published report. He says clearly that in each
-of his cases couching had previously been performed,
-and yet some have insisted that the lens was present, and
-must have been wounded. He also states that his incision
-was made from behind forward, and yet his followers,
-<span class="nowrap">Sharpe<a href="#Footnote_5" class="fnanchor">5</a></span> and Adams<span class="nowrap">,<a id="FNanchor_6" href="#Footnote_6" class="fnanchor">6</a></span> both describe the incision
-as being made from before backward. As Sharpe was
-his pupil, and presumably had seen him operate, <span class="nowrap">Guthrie<a id="FNanchor_7" href="#Footnote_7" class="fnanchor">7</a></span>
-suggests the possibility of his having made his incision
-both ways, the technic being practically the same.</p>
-
-<p><span class="pagenum" id="Page_8">8</span></p>
-
-<p>Morand<span class="nowrap">,<a id="FNanchor_8" href="#Footnote_8" class="fnanchor">8</a></span> in his “Eulogy of Cheselden,” claims to have
-personally seen him operate “on an eye in which the iris
-was closed by an accident,” and gives a more detailed
-description which closely follows the original method.
-He states that Cheselden presented him with one of his
-knife-needles as a souvenir of the occasion. Although
-Morand does not record the exact date of his visit to
-London, he does state that it occurred during the year
-1729. Huguier<span class="nowrap">,<a id="FNanchor_9" href="#Footnote_9" class="fnanchor">9</a></span> in his exhaustive thesis on artificial
-pupil, also places the date of this visit in the year 1729.
-This fact is important, as some writers have declared
-that Morand neither made the visit to London nor saw
-Cheselden operate, but only quoted the original account
-given in the Philosophical Transactions. The publication
-of Morand’s high encomiums in 1757 attracted renewed
-interest to the subject of Cheselden’s operation
-among men of scientific and medical attainments.</p>
-
-<p>Sharpe<span class="nowrap">,<a href="#Footnote_5" class="fnanchor">5</a></span> in 1739, performed this operation in the
-same manner as Cheselden, except that after he had
-entered the knife-needle through the sclerotic he passed
-it through the iris and across the anterior chamber,
-and then incised the iris-membrane from before backward.
-Although he was Cheselden’s pupil, and dedicated
-his small volume on surgery to him, he probably
-did his master more harm than good, as all the
-objections to Cheselden’s method seemed to be based
-on the deprecatory remarks of Sharpe. He says, “I
-once performed it with tolerable success, and a few
-months after, the very orifice I had made contracted and
-brought on blindness again.” He mentions the danger
-of wounding the lens, the lack of success in paralytic iris
-with affection of the retina, the danger of iridodialysis
-from traction of the knife, and the possibility of failure
-because the incision would not enlarge sufficiently.
-Thirty years later (1769) he published the ninth edition
-of his book without recording a single additional
-case, but added the thought that, since extraction of
-the crystalline lens showed the cornea was not so vulnerable
-as had been believed, he would “imagine” that
-a larger knife might be introduced perpendicularly
-through the cornea and iris and a similar incision
-made. In his first eight editions he pictures Cheselden’s<span class="pagenum" id="Page_9">9</span>
-iris-knife (Fig.&nbsp;<a href="#i_25-1">4</a>, vide p.&nbsp;25), but in his ninth
-edition he substitutes a broad lance-knife with two edges
-which closely resembled the one Wenzel (vide Fig.&nbsp;<a href="#i_15">17</a>)
-had just introduced (1767), and which Sharpe suggests
-“can also be used for the extraction of the cataract.”
-He evidently did not have a very clear idea of the subject,
-and only succeeded in casting doubt and discredit
-on the method of Cheselden, which, judging by his own
-statement, he had tried but once.</p>
-
-<p>Heuermann<span class="nowrap">,<a id="FNanchor_10" href="#Footnote_10" class="fnanchor">10</a></span> in 1756, had already antedated these
-thoughts of Sharpe by practising a similar method. He
-passed a double edged lance-knife through the cornea
-instead of through the sclera, and then made a sweeping
-incision through the iris-membrane without enlarging
-the corneal wound. He was probably the first to puncture
-the cornea with the iris-knife.</p>
-
-<p>Janin<span class="nowrap">,<a id="FNanchor_11" href="#Footnote_11" class="fnanchor">11</a></span> about 1766, performed Cheselden’s operation
-several times with but little success owing to reclosure
-of the wound by plastic exudate. He adopted Sharpe’s
-modification, but later on changed the incision from a
-horizontal to a vertical one with better results. He, however,
-afterward abandoned this procedure and became
-the originator of the other school, composed of those
-who preferred to use the scissors.</p>
-
-<p>Guérin<span class="nowrap">,<a id="FNanchor_12" href="#Footnote_12" class="fnanchor">12</a></span> in 1769, made a free corneal incision with a
-large cataract knife, and then introduced a small iris-knife,
-with which he made a crucial incision from before
-backward in the center of the iris-membrane. Although
-<span class="nowrap">Guthrie<a href="#Footnote_7" class="fnanchor">7</a></span> distinctly states that Guérin afterwards removed
-the four angles of the cross with a pair of scissors
-in order to prevent reclosure of the incision, no
-direct confirmation of this statement can be found in
-his writings.</p>
-
-<p>Beer<span class="nowrap">,<a id="FNanchor_13" href="#Footnote_13" class="fnanchor">13</a></span> in 1792, first published his method, which he
-designated as “an improvement on Cheselden’s method.”
-Although the technic is somewhat different, the
-procedure is practically the same as that originated by
-Heuermann in 1756. Beer selected certain cases in
-which a prolapsed iris had followed the lower incision
-for cataract, causing adherent leucoma with a tensely<span class="pagenum" id="Page_10">10</span>
-drawn iris-membrane. He plunged his double-edged
-lance-knife (Fig.&nbsp;<a href="#i_25-9">5</a>) through the cornea and stretched
-out iris, from above downward and a little obliquely
-(Fig.&nbsp;<a href="#i_10">6</a>), so as to incise the center of the tense iris
-fibers crosswise, at right angles to the line of traction;
-cutting horizontally when the traction was vertical, and
-vertically when this was horizontal. In his monograph
-on artificial pupil<span class="nowrap">,<a id="FNanchor_14" href="#Footnote_14" class="fnanchor">14</a></span> 1805, he substitutes for the lance-knife
-his new broad iris-knife, which is practically the
-same as that later shown by Walton (vide Fig.&nbsp;<a href="#i_25-10">12</a>), as,
-indeed, Walton’s procedure (vide Fig.&nbsp;<a href="#i_12">13</a>) was almost
-identical with that of Beer. For other conditions he
-usually employed Wenzel’s operation until by chance he
-encountered a puzzling case which led him to perform
-the operation we now know as iridectomy (1797) and
-which thereafter became his favorite procedure for artificial
-pupil.</p>
-
-<div class="figcenter illowp51" id="i_10" style="max-width: 15em;">
-  <img class="w100" src="images/i_10.jpg" alt="" />
-  <div class="caption"><p>Fig.&nbsp;6.&mdash;Beer’s iridotomy with broad iris-knife (after Mackenzie).</p></div>
-</div>
-
-<p>Adams<span class="nowrap">,<a id="FNanchor_15" href="#Footnote_15" class="fnanchor">15</a></span> in 1812, revived the operation of Cheselden
-with certain modifications. While his puncture was
-made in the same location, his technic was different. He
-entered the sclera with a small iris-<span class="nowrap">scalpel<a href="#Footnote_6" class="fnanchor"></a></span> of his own
-special design (Fig.&nbsp;<a href="#i_25-7">7</a>), which, like Sharpe, he passed
-through the iris-membrane into the anterior chamber,<span class="pagenum" id="Page_11">11</span>
-carrying it across to the nasal side (Fig.&nbsp;<a href="#i_11a">8</a>). From entrance
-to exit he always kept the edge of the knife
-turned back toward the iris, so as to cut from before
-backward. He was thus able by the most delicate pressure
-of his instrument, to make a long horizontal incision,
-without causing iridodialysis (Fig.&nbsp;<a href="#i_11b">9</a>). If the first
-incision appeared to be too short, he did not withdraw
-the knife entirely, but again carried it forward and
-partially withdrew it, always cutting in the same plane.
-To quote his own words, “by repeating the efforts to
-divide the iris (taking care in so doing to make as slight
-a degree of pressure as possible upon the instrument, instead
-of withdrawing it out of the eye at once, as recommended
-by Cheselden), a division of that membrane
-may, in almost all cases be effected, of a requisite size to
-establish a permanent artificial pupil” (Figs.&nbsp;<a href="#i_11c">10</a> and
-11).</p>
-
-<div class="figcontainer">
-<div class="figsub illowp100" id="i_11a" style="max-width: 15em; padding-top: 4.9em;">
-  <img class="w100" src="images/i_11a.jpg" alt="" />
-  <div class="caption"><p>Fig.&nbsp;8.&mdash;Adams’ iris scalpel in situ,
-showing location of scleral puncture (after Lawrence).</p></div>
-</div>
-
-<div class="figsub illowp97" id="i_11b" style="max-width: 9em;">
-  <img class="w100" src="images/i_11b.jpg" alt="" />
-  <div class="caption"><p>Fig.&nbsp;9.&mdash;Iridotomy
-by Adams’ method (after Lawrence).</p></div>
-</div>
-</div>
-
-<div class="figcontainer">
-<div class="figsub illowp100" id="i_11c" style="max-width: 12.1875em;">
-  <img class="w100" src="images/i_11c.jpg" alt="" />
-  <div class="caption"><p>Fig.&nbsp;10.&mdash;Occlusion of pupil
-(Adams).</p></div>
-</div>
-
-<div class="figsub illowp100" id="i_11d" style="max-width: 11.875em; padding-top: 0.12em;">
-  <img class="w100" src="images/i_11d.jpg" alt="" />
-  <div class="caption"><p>Fig.&nbsp;11.&mdash;The resulting pupil
-after iridotomy (Adams).</p></div>
-</div>
-</div>
-
-<p>Here were three elements of success, a sharp knife, a
-gentle sawing movement, and the most delicate pressure
-of the instrument. His method was a decided advance,
-and he reported success in nearly one hundred cases.
-Others, less skilful, however, failed of success, and the
-severe criticisms of Scarpa<span class="nowrap">,<a id="FNanchor_16" href="#Footnote_16" class="fnanchor">16</a></span> though evidently unjust
-and tinged by personal animosity<span class="nowrap">,<a id="FNanchor_17" href="#Footnote_17" class="fnanchor">17</a></span> cast a shadow of
-doubt on the method.</p>
-
-<p><span class="pagenum" id="Page_12">12</span></p>
-
-<div class="figcenter illowp64" id="i_12" style="max-width: 18.125em;">
-  <img class="w100" src="images/i_12.jpg" alt="" />
-  <div class="caption"><p>Fig.&nbsp;13.&mdash;Iris-knife in position to make central pupil (Walton,
-after Beer).</p></div>
-</div>
-
-<p>From that time on for nearly half a century this form
-of iridotomy was practically abandoned, the pendulum
-swinging toward the use of scissors, which Maunoir had
-popularized and Scarpa had indorsed. Walton<span class="nowrap">,<a id="FNanchor_18" href="#Footnote_18" class="fnanchor">18</a></span> however,
-about 1852, proposed a method closely resembling
-that of Heuermann and almost identical with that of
-Beer (vide Fig.&nbsp;<a href="#i_10">6</a>). His iris-knife (Fig.&nbsp;<a href="#i_25-10">12</a>) was
-practically the same as the broad iris-knife of Beer.
-He incised the cornea near the limbus, and passed
-the knife across the anterior chamber to the middle of
-the iris-membrane which he punctured with a sweeping
-vertical incision (Fig.&nbsp;<a href="#i_12">13</a>). If the tissue still retained
-its elasticity there appeared a long pupillary aperture,
-elliptical and vertical (Figs.&nbsp;<a href="#i_13a">14</a> and 15). This incision,
-however, like all those made through a single set of the
-iris fibers, was only successful when there was sufficient
-resiliency remaining in the iris tissue to draw the slit
-open, and thus keep the edges from uniting. While
-this method never became very popular, there were some
-who later practiced it by substituting a very narrow
-Graefe knife for the iris-knife of Heuermann, Beer and
-Walton. In fact, this latter procedure still has considerable
-vogue, both for iridotomy and capsulotomy.</p>
-<p><span class="pagenum" id="Page_13">13</span></p>
-
-<div class="figcontainer">
-<div class="figsub illowp100" id="i_13a" style="max-width: 13.75em;">
-  <img class="w100" src="images/i_13a.jpg" alt="" />
-  <div class="caption"><p>Fig.&nbsp;14.&mdash;Occlusion of pupil
-(Walton).</p></div>
-</div>
-
-<div class="figsub illowp100" id="i_13b" style="max-width: 13.75em; padding-top: 0.5em;">
-  <img class="w100" src="images/i_13b.jpg" alt="" />
-  <div class="caption"><p>Fig.&nbsp;15. New pupil after incision
-with iris-knife (Walton).</p></div>
-</div>
-</div>
-
-<p>During the following seventeen years no notable advance
-was made, the scissors method still retaining its
-hold on the profession, until in 1869, von Graefe, after
-long reflection, became convinced of the dangers of that
-method, and communicated to one of his pupils, M.
-Meyer, his method of simple iridotomy performed with
-the knife-needle. <span class="nowrap">Meyer<a id="FNanchor_19" href="#Footnote_19" class="fnanchor">19</a></span> quotes his views as follows:</p>
-
-<div class="blockquot">
-
-<p>“For such cases von Graefe has suggested another method of
-operation, the principle and execution of which are contained in
-the following note written for us by that illustrious savant in
-1869:</p>
-
-<p>“When, in consequence of a cataract operation, the lens is
-absent, and when there is highly developed retro-iritic exudation,
-with disorganization of the iris tissue, flattening of the
-cornea and the other sequelæ of a destructive iridocyclitis, I
-substitute simple iridotomy for iridectomy, which is the operation
-hitherto performed, generally without success. The operation
-consists in inserting a double-edged knife, resembling in
-shape a very sharp pointed lance-knife, through the cornea and
-newly formed tissues till it pierces the vitreous body, and immediately
-withdrawing it; and, while withdrawing it, enlarging
-the wound in the membranes without increasing the size
-of the corneal wound. Experience shows that such plastic
-membranes attached to the atrophied iris and to the capsule
-of the lens have a tendency to contract sufficient to maintain,
-to a certain extent, the opening which has been made.</p>
-
-<p>“If, in the ordinary method of iridectomy, combined with
-laceration or extraction of the false membranes, we find that
-the artificial pupil usually becomes closed, we must attribute
-this to an excessive vulnerability, which immediately sets up
-proliferation in those tissues which have been touched, and
-which are endowed, in consequence on their structure, with an
-irritability altogether peculiar. We know that even the transitory
-reduction of the intraocular pressure, which follows the
-evacuation of the aqueous humor, is sufficient to give rise to<span class="pagenum" id="Page_14">14</span>
-hemorrhage in the anterior chamber, which interferes with the
-perfect success of the intended operation; but most of our failures
-in the ordinary methods are due to the irritation caused
-by the forceps and the traction on the surrounding structures.
-Simple iridotomy is free from such inconveniences; it is, so to
-speak, a sub-corneal act, and enjoys the immunity which belongs
-to subcutaneous operations.</p>
-
-<p>“I have also reduced the corneal wound to a minimum, by
-using small falciform knives. These are passed through the
-false membranes, which are then cut from behind forward.”</p>
-</div>
-
-<p>Von Graefe thus proposed two methods, (1) by cutting
-from before backward with a double-edged lance-knife,
-according to the method of Heuermann, and (2) by
-cutting from behind forward with a sickle-shaped knife,
-after the original suggestion of Cheselden. Later in the
-same year, as he lay on his last bed of illness, he became
-so absorbed in the study of this subject that he sent a
-telegram to the Heidelberg <span class="nowrap">Congress<a id="FNanchor_20" href="#Footnote_20" class="fnanchor">20</a></span> (September,
-1869), in which he advocated the method by the sickle-shaped
-knife-needle as the best procedure. His last message
-to his colleagues showed, therefore, that through
-mature conviction he strongly favored the use of the
-knife-needle, and the making of a sub-corneal incision in
-the iris-membrane without evacuating the aqueous humor.
-His untimely death, however, prevented him from
-further perfecting this procedure and presenting it to
-the profession.</p>
-
-<p>Galezowski<span class="nowrap">,<a id="FNanchor_21" href="#Footnote_21" class="fnanchor">21</a></span> in 1875, published a somewhat similar
-method in which he used his falciform knife, <i>aiguille-a-serpette</i>
-(Fig.&nbsp;<a href="#i_25-4">16</a>), which he introduced through the
-cornea and iris-membrane, making either a horizontal
-or a vertical incision, with a “go-and-come” (sawing)
-movement, after the suggestion of Adams. If this
-single cut was not sufficient, he made a linear incision of
-the cornea with a Graefe knife, drew out the iris and cut
-it off with scissors. By a process of evolution, however,
-he perfected the former procedure and eliminated the
-scissors. This latter method was published in the third
-edition of his book in 1888. He punctured the cornea
-and iris-membrane with the sickle-shaped knife, making
-first a horizontal incision by the sawing movement of
-Adams, and finishing with a second cut in the vertical
-direction, thus forming a T-shaped incision. In actual<span class="pagenum" id="Page_15">15</span>
-practice, however, he almost always prolonged this second
-cut, thus making a crucial incision after the manner
-of Guérin<span class="nowrap">.<a href="#Footnote_12" class="fnanchor">12</a></span></p>
-
-<p>The writer<span class="nowrap">,<a id="FNanchor_22" href="#Footnote_22" class="fnanchor">22</a></span> in 1888, was led to devise an operation
-with a modified Hays knife-needle, in which through a
-corneal puncture he made a converging incision in the
-iris-membrane which resembled an inverted V. The resulting
-pupil opened up and formed either a triangular
-or an oval-shaped pupil depending on the degree of stiffness
-or resiliency of the iris-membrane. This method
-will be described in detail later on.</p>
-
-
-<h2>II. SCISSORS METHOD.</h2>
-
-<p>We will now return to the consideration of the second
-school in which scissors were introduced through a previously
-made corneal section and a free incision was made
-in the iris-membrane, or a portion of the membrane excised.</p>
-
-<div class="figcenter illowp100" id="i_15" style="max-width: 15em;">
-  <img class="w100" src="images/i_15.jpg" alt="" />
-  <div class="caption"><p>Fig.&nbsp;17.&mdash;Wenzel’s cataract knife, and method
-of incision (after Mackenzie).</p></div>
-</div>
-
-<p>Janin<span class="nowrap">,<a href="#Footnote_11" class="fnanchor">11</a></span> in 1768, having abandoned the procedure of
-Cheselden, proposed a new method. He incised the
-cornea below as for cataract extraction, and raised the
-corneal lip with a spatula while he introduced a pair of
-curved scissors, the lower blade of which was pointed.
-He plunged this sharp blade through the iris-membrane,
-and with a single vertical cut made a crescentic pupil
-which gaped sufficiently for visual purposes. As this is
-the first known description of iridotomy by the scissors
-method it is probable that Janin was the originator of
-this procedure.</p>
-
-<p>Wenzel<span class="nowrap">,<a id="FNanchor_23" href="#Footnote_23" class="fnanchor">23</a></span> in 1786, employed a different method. With
-a lance-shaped cataract knife he entered the cornea,<span class="pagenum" id="Page_16">16</span>
-dipped through the iris-membrane, returned to the anterior
-chamber, and continuing to cut made a counter-puncture
-on the opposite side of the cornea, following
-which he completed his cataract incision. This gave a
-semilunar flap of iris tissue which could easily be excised
-by scissors passed through the large corneal opening
-(Fig.&nbsp;<a href="#i_15">17</a>).</p>
-
-<div class="figcenter illowp100" id="i_16a" style="max-width: 29.375em;">
-  <img class="w100" src="images/i_16a.jpg" alt="" />
-  <div class="caption"><p class="tac">Fig.&nbsp;18.&mdash;Maunoir’s scissors.</p></div>
-</div>
-
-<div class="figcontainer">
-<div class="figsub illowp100" id="i_16b" style="max-width: 12.5em; padding-top: 2.7em;">
-  <img class="w100" src="images/i_16b.jpg" alt="" />
-  <div class="caption"><p>Fig.&nbsp;19.&mdash;V-shaped iridotomy
-with scissors (Maunoir).</p></div>
-</div>
-
-<div class="figsub illowp97" id="i_16c" style="max-width: 10em;">
-  <img class="w100" src="images/i_16c.jpg" alt="" />
-  <div class="caption"><p>Fig.&nbsp;20.&mdash;Parallelogram pupil
-(Maunoir).</p></div>
-</div>
-</div>
-
-<p>Maunoir<span class="nowrap">,<a id="FNanchor_24" href="#Footnote_24" class="fnanchor">24</a></span> in 1802, took up the method of Janin,
-with the object of improving it. He made an incision
-near the corneal margin, through which he introduced
-a pair of long, thin, angular scissors of his own design
-(Fig.&nbsp;<a href="#i_16a">18</a>), one blade of which was sharp-pointed like a
-lancet, and the other button-pointed like a probe. The
-iris-membrane was then punctured by the sharp blade
-at about the natural location of the pupil, and an incision
-executed toward the ciliary margin of the iris.
-Finding that this single incision did not always succeed<span class="nowrap">,<a id="FNanchor_25" href="#Footnote_25" class="fnanchor">25</a></span>
-he subsequently improved this method by making
-a second incision from the pupillary area toward the
-iris margin, in the line of the radiating iris fibers, thus
-making a divergent V (Fig.&nbsp;<a href="#i_16b">19</a>). This triangular flap
-was then allowed to shrink back, or if too stiff, was<span class="pagenum" id="Page_17">17</span>
-drawn out and excised. The resultant pupil assumed
-the shape either of a triangle, a parallelogram (Fig.&nbsp;<a href="#i_16c">20</a>),
-or a crescent (Fig.&nbsp;<a href="#i_17">21</a>). He always made his incision
-parallel with the radiating fibers of the iris and
-across the circular fibers.</p>
-
-<div class="figcenter illowp100" id="i_17" style="max-width: 15em;">
-  <img class="w100" src="images/i_17.jpg" alt="" />
-  <div class="caption"><p>Fig.&nbsp;21.&mdash;Crescent pupil (Maunoir).</p></div>
-</div>
-
-<p>Scarpa<span class="nowrap">,<a href="#Footnote_16" class="fnanchor">16</a></span> in 1818, having abandoned his own method
-of iridodialysis as wholly unsatisfactory, adopted Maunoir’s
-procedure with enthusiasm, chiefly because he had
-by a friendly <span class="nowrap">correspondence<a href="#Footnote_25" class="fnanchor">25</a></span> personally encouraged
-Maunoir with advice and suggestion during its development.
-He indorsed Maunoir’s plan of a double incision
-when he stated his conviction that “experience has
-proved that in order to obtain, with the most absolute
-certainty, a <i>permanent</i> artificial pupil, it is necessary to
-make <i>two</i> incisions in the iris so as to form a triangular
-flap in the membrane, in the form of a letter V, the
-apex being precisely in the center of the iris and the
-base near the great margin.” Some have claimed that
-Scarpa himself originated the V-shaped incision, but
-he gives Maunoir full credit for its successful accomplishment,
-although he does suggest some additional
-indications for its practical application.</p>
-
-<p>His opposition to the knife-needle incision of Cheselden
-arose from the fact that the pupil either did not
-open, or if it did open would not remain permanent,
-chiefly because of the single iris incision. His antagonism
-to the more successful procedure of Adams was the
-result of a caustic personal <span class="nowrap">controversy<a href="#Footnote_17" class="fnanchor">17</a></span> with that skilful
-surgeon, who ably parried his charges<span class="nowrap">.<a href="#Footnote_15" class="fnanchor">15</a></span> His great
-influence with the profession of that day, however,
-served to check the sentiment in favor of Adams’ procedure,
-and when the weight of his indorsement was cast
-in favor of Maunoir’s operation the scales were decisively
-turned toward the side of the scissors method.</p>
-
-<p><span class="pagenum" id="Page_18">18</span></p>
-
-<p>Mackenzie<span class="nowrap">,<a id="FNanchor_26" href="#Footnote_26" class="fnanchor">26</a></span> in 1840, practiced Maunoir’s operation
-with considerable success, but in certain cases found it
-necessary to employ a slight modification of this procedure.
-He reversed Maunoir’s incision by making the
-same divergent V across the radiating fibers of the iris
-instead of parallel with them (Fig.&nbsp;<a href="#i_18a">22</a>), thus securing a
-triangular pupil (Fig.&nbsp;<a href="#i_18b">23</a>), which <span class="nowrap">Lawrence<a id="FNanchor_27" href="#Footnote_27" class="fnanchor">27</a></span> thought
-might succeed in some cases where Maunoir’s method
-would not be available.</p>
-
-<div class="figcontainer">
-<div class="figsub illowp97" id="i_18a" style="max-width: 10em;">
-  <img class="w100" src="images/i_18a.jpg" alt="" />
-  <div class="caption"><p>Fig.&nbsp;22.&mdash;Mackenzie’s incision
-in cornea and iris-membrane (Mackenzie).</p></div>
-</div>
-
-<div class="figsub illowp97" id="i_18b" style="max-width: 9.5em; padding-top: 0.15em;">
-  <img class="w100" src="images/i_18b.jpg" alt="" />
-  <div class="caption"><p>Fig.&nbsp;23.&mdash;Resulting triangular
-pupil from Mackenzie’s incision (Mackenzie).</p></div>
-</div>
-</div>
-
-<p>Bowman<span class="nowrap">,<a id="FNanchor_28" href="#Footnote_28" class="fnanchor">28</a></span> in 1872, proposed a method which, though
-surgically difficult to execute, was quite ingenious, and
-may have been the initial suggestion that stimulated
-DeWecker to write his monograph in the following year.
-I will quote his description as follows: “We make a
-double opening simultaneously on opposite sides of the
-cornea. It is more convenient, of course, to make these
-two openings in a horizontal than in a vertical direction.
-I then run a pair of scissors in two diverging lines (V)
-from each incision, thus enclosing between the incisions
-a large square or rhomboidal portion of the iridial region
-including the pupil, and all the structures there. You
-then withdraw the portion thus cut out. There is no
-drag on the ciliary region; whatever is withdrawn has
-been cut away from its connections beforehand” (Figs.
-24, 25 and 26).</p>
-
-<div class="figcontainer">
-<div class="figsub illowp97" id="i_18c" style="max-width: 10em; padding-top: 0.25em;">
-  <img class="w100" src="images/i_18c.jpg" alt="" />
-  <div class="caption"><p>Fig 24.&mdash;Plan of
-Bowman’s first iris in­ci­sion. Divergent V.</p></div>
-</div>
-
-<div class="figsub illowp97" id="i_18d" style="max-width: 10em; padding-top: 0.15em;">
-  <img class="w100" src="images/i_18d.jpg" alt="" />
-  <div class="caption"><p>Fig.&nbsp;25.&mdash;First in­ci­sion completed.
-Plan of sec­ond, showing double V.</p></div>
-</div>
-
-<div class="figsub illowp97" id="i_18e" style="max-width: 10em;">
-  <img class="w100" src="images/i_18e.jpg" alt="" />
-  <div class="caption"><p>Fig.&nbsp;26.&mdash;Rhomboidal
-pupil, resulting from Bowman’s iridotomy.</p></div>
-</div>
-</div>
-
-<p><span class="pagenum" id="Page_19">19</span></p>
-
-<p>This method is simply an elaboration of the one proposed
-by Maunoir, in which, instead of forming one divergent
-V, Bowman has made a duplicate incision on the
-opposite side, and by joining the bases of these two resultant
-triangles has caused them to take the shape of a
-rhomboid, thus &lt;&gt;.</p>
-
-<div class="figcontainer">
-<div class="figsub illowp30" id="i_19a" style="max-width: 11em;">
-  <img class="w100" src="images/i_19a.jpg" alt="" />
-  <div class="caption"><p>Fig.&nbsp;27.&mdash;Stop keratomes,
-straight and angular (De Wecker).</p></div>
-</div>
-
-<div class="figsub illowp27" id="i_19b" style="max-width: 12.8125em;">
-  <img class="w100" src="images/i_19b.jpg" alt="" />
-  <div class="caption"><p>Fig.&nbsp;28.&mdash;Forceps-scissors
-(pinces-ciseaux) (DeWecker).</p></div>
-</div>
-</div>
-
-<p>DeWecker<span class="nowrap">,<a id="FNanchor_29" href="#Footnote_29" class="fnanchor">29</a></span> in 1873, published his admirable monograph
-on iridotomy, in which he proposed the operation
-which bears his name, and which has long stood as the
-best recognized method of this procedure. He advocated<span class="pagenum" id="Page_20">20</span>
-two different ways of performing this: 1, simple
-iridotomy, and 2, double iridotomy.</p>
-
-<p>1. <i>Simple Iridotomy.</i>&mdash;This is practically the same
-operation as Critchett’s sphincterotomy and Bowman’s
-visual iridotomy, although differently executed. It has
-been supplanted in our day by iridectomy, and does not,
-therefore, come within the purview of this discussion.</p>
-
-<p>2. <i>Double Iridotomy.</i>&mdash;He rightly claimed that this
-was both antiphlogistic and optical in its purpose. He
-employed two distinct methods, which he designated as
-(<i>a</i>) iritoectomie, and (<i>b</i>) iridodialysis. The instruments
-he used were a small stop-keratome (Fig.&nbsp;<a href="#i_19a">27</a>) and a pair
-of specially devised fine iris scissors (pinces-ciseaux)
-(Fig.&nbsp;<a href="#i_19b">28</a>), one blade being sharp pointed and the other
-blunt. These scissors were a great mechanical advance
-over all previous instruments of this kind, and undoubtedly
-proved to be a most important element in the success
-of his procedure.</p>
-
-<div class="figcontainer">
-<div class="figsub illowp76" id="i_20a" style="max-width: 10em; padding-top: 0.28em;">
-  <img class="w100" src="images/i_20a.jpg" alt="" />
-  <div class="caption"><p class="tal">Fig.&nbsp;29.&mdash;Iritoectomie. Convergent
-V (DeWecker).</p></div>
-</div>
-
-<div class="figsub illowp73" id="i_20b" style="max-width: 10em;">
-  <img class="w100" src="images/i_20b.jpg" alt="" />
-  <div class="caption"><p>Fig.&nbsp;30.&mdash;Iridodialysis. Divergent
-V (DeWecker).</p></div>
-</div>
-</div>
-
-<p>(<i>a</i>) <i>Iritoectomie.</i>&mdash;He entered the stop-keratome
-through the cornea, made an exact 4 millimeter incision,
-and then partly withdrew it while letting the
-aqueous slowly escape. As soon as the iris-membrane
-floated up against the knife, he pressed forward, making
-a 2 millimeter incision in the iris. Slowly withdrawing
-the knife, he introduced the sharp point of the scissors
-through the iris buttonhole and cut obliquely from
-either extremity of the incision toward the apex of a
-triangle, thus making a convergent V (Fig.&nbsp;<a href="#i_20a">29</a>). He
-then grasped the resulting triangular flap with the forceps
-and removed it, leaving an open central pupil.</p>
-
-<p>(<i>b</i>) <i>Iridodialysis.</i>&mdash;His second method was a counterpart
-of Maunoir’s earlier operation, with the addition
-of iridodialysis. He made the corneal and iris incision
-with the stop-knife, as in the previous method.
-Slipping in his scissors he cut from the center of the
-iris-membrane toward the periphery, and duplicated this
-incision at an oblique angle to the first, thus making a
-divergent V (Fig.&nbsp;<a href="#i_20b">30</a>). This formed a triangular flap<span class="pagenum" id="Page_21">21</span>
-which he grasped with forceps and tore from its ciliary
-attachment by iridodialysis.</p>
-
-<p>DeWecker’s procedure was planned by a skilled operator,
-and required great dexterity in its execution. When
-successful, however, the result was most brilliant. Nevertheless,
-it was impossible to eliminate the danger of
-hemorrhage and loss of fluid vitreous in iritoectomie,
-while in iridodialysis there was the added danger of a
-torn ciliary surface and traction on the ciliary body. His
-strict injunction to have a trained assistant hold up the
-speculum blades in order to avoid the loss of fluid
-vitreous, showed how much he feared this disastrous
-contretemps. The success of his method of incision is
-well shown in the illustration of his two cases (Figs.&nbsp;<a href="#i_21a">31</a>
-and 32).</p>
-
-<div class="figcontainer">
-<div class="figsub illowp100" id="i_21a" style="max-width: 12.75em;">
-  <img class="w100" src="images/i_21a.jpg" alt="" />
-  <div class="caption"><p>Fig.&nbsp;31.&mdash;Pupil by iritoectomie.
-Two incisions. Convergent V (DeWecker).</p></div>
-</div>
-
-<div class="figsub illowp100" id="i_21b" style="max-width: 11.5em; padding-top: 0.58em;">
-  <img class="w100" src="images/i_21b.jpg" alt="" />
-  <div class="caption"><p>Fig.&nbsp;32.&mdash;Stenopaic pupil.
-Single iris incision (DeWecker).</p></div>
-</div>
-</div>
-
-<p>I have already suggested the possibility of Bowman’s
-paper before the London Congress of 1872 having given
-origin to DeWecker’s monograph in 1873. This seems
-quite reasonable when we consider that Bowman proposed
-two methods of iridotomy, one his double V operation
-with a rhomboidal pupil (previously quoted), and
-the other a visual iridotomy or sphincterotomy, by cutting
-through the pupillary margin with a blunt corneal
-knife. These two methods are exact prototypes of
-DeWecker’s proposals. Furthermore, DeWecker was
-present at the London Congress where he heard Bowman’s
-paper, and took part in its discussion. In fact,
-thirteen years later DeWecker <span class="nowrap">acknowledged<a id="FNanchor_30" href="#Footnote_30" class="fnanchor">30</a></span> that after
-considering the objections to Bowman’s method of iridotomy
-“I addressed myself at that time to the search
-for an instrument which allows the avoidance of all traction
-on the iris, and which can be handled through a
-narrow opening, while exerting its cutting action in a<span class="pagenum" id="Page_22">22</span>
-plane parallel to the surface of the cornea, against which
-the diaphragm of the iris applies itself, after the escape
-of the aqueous humor. The forceps-scissors having been
-discovered, it was easy for me to cause to be revived the
-procedure of Janin, and to make it decisively take rank
-in modern ocular surgery.”</p>
-
-<p>DeWecker makes only a casual reference to Maunoir’s
-method, but credits Janin with the original suggestion
-of the method which he has thus elaborated. Nevertheless,
-it is quite evident that DeWecker’s method was
-simply a modification of the one outlined by Maunoir
-seventy years before. Furthermore, he lays down the
-same rule that Maunoir first offered: “Always cut parallel
-to the radiating fibers and perpendicularly to the
-circular fibers of the iris.”</p>
-
-
-<h2>RELATIVE ADVANTAGES OF KNIFE-NEEDLE VS. SCISSORS.</h2>
-
-<p>In reviewing the questions at issue between these two
-schools of iridotomy, one can not help noticing the constant
-oscillation from one method to the other as certain
-advances were made. The method by the knife-needle
-seemed to possess the advantage of easy accomplishment
-and less postoperative disturbance, but with the disadvantage
-that often the pupillary opening was inadequate
-and promptly reclosed by plastic exudate. On the other
-hand, the method by the scissors was more difficult of
-accomplishment, caused more traumatism to the eye,
-was often complicated by great loss of fluid vitreous, and
-was frequently followed by severe inflammatory reaction.
-If, however, it proved successful, the resulting
-pupil was permanent and sufficiently large for visual
-purposes. The inclination of all operators seemed to be
-toward the use of the knife-needle, and it was only necessity
-that forced them to adopt the more complicated
-procedure of the open operation with scissors.
-Von Graefe seemed to recognize this when he referred
-to the knife-needle incision as “a sub-corneal act which
-enjoys the immunity of subcutaneous operations.”</p>
-
-<p>The chief advantages of iridotomy by the knife-needle
-are the ease of incision, the lack of traction on
-the ciliary body, the freedom from postoperative inflammatory
-reaction, the avoidance of opening an eyeball
-which may contain fluid vitreous, the lessening of the
-tendency to iris hemorrhage from lowered tension, and
-the avoidance of the nebulous scar which often follows<span class="pagenum" id="Page_23">23</span>
-a large corneal incision in old inflammatory eyes. The
-disadvantages revealed in the method of the knife-needle
-lay partly in the method and partly in the faulty instruments
-constructed in that day. Cheselden, Morand,
-Sharpe and Adams all made the mistake of entering the
-eye back of the corneoscleral junction, which is so near
-to the danger zone of the eye. Adams, however, made
-a two-fold improvement in adding to his operation a
-sawing movement and in advocating the “most delicate
-pressure of the instrument” in order to make a free incision.
-Heuermann was apparently the first to make
-the puncture through the cornea instead of through the
-sclera.</p>
-
-<p>The advocates of the knife-needle method long labored
-under the disadvantage of making a single iris incision,
-while those who employed the scissors early discovered
-that a double incision was necessary to success. Although
-Janin was the originator of the scissors method, Maunoir
-was the first to deliberately try a triangular flap, which
-DeWecker later elaborated and made a permanent success.
-The many disastrous results of the open operation,
-however, compelled conservative surgeons, like von
-Graefe, to revert to a study of Cheselden’s method, and
-to seriously consider the great advantages which a successful
-iridotomy by the knife-needle method would confer
-on surgeon and patient alike.</p>
-
-
-<h2>THE CHOICE OF A KNIFE-NEEDLE.</h2>
-
-<p>1. Cheselden’s knife-needle (Figs.&nbsp;<a href="#i_07c">3</a> and <a href="#i_25-1">4</a>) was a
-splendidly designed instrument, but a poorly executed
-one. The blade was too large (11&nbsp;mm.) and the shank
-improperly rounded, so that both aqueous and vitreous
-were liable to escape through the scleral puncture. This
-leakage may explain many failures, although the single
-iris incision was undoubtedly the most serious fault of
-the method.</p>
-
-<p>2. The iris-scalpel of Adams (Fig.&nbsp;<a href="#i_25-7">7</a>) was poorly designed
-but splendidly executed, the long blade completely
-filling the wound and thus preventing the escape
-of any fluid. The cutting edge, however, was too
-long (15 to 20&nbsp;mm.), and especially so for the execution
-of the sawing movement advised by Adams.</p>
-
-<p>3. The double-edged lance-knife (Figs.&nbsp;<a href="#i_25-9">5</a>, <a href="#i_25-10">12</a> and <a href="#i_25-8">33</a>)
-employed by Heuermann, Beer and von Graefe, was useful
-for the long sweeping incision in the iris-membrane<span class="pagenum" id="Page_24">24</span>
-which they advocated, but is not adapted for the method
-which will be described later. The same shaped knife
-(Fig.&nbsp;<a href="#i_25-8">33</a>) with a smaller blade and a longer shank is
-also used for this purpose, but is likewise too broad, too
-oval pointed and too much bellied to cut well, while the
-upper edge is liable to scarify Descemet’s membrane at
-the same time that the lower edge is executing the incision
-in the iris tissue.</p>
-
-<p>4. The sickle-shaped knife (Fig.&nbsp;<a href="#i_25-4">16</a>) which von
-Graefe recommends and Galezowski employs, is excellent
-for making the puncture, but for the go-and-come
-movement, which Galezowski advises, is not nearly so
-good as the straight blade with a slight falciform point.
-It closely resembles the older falciform knife of Scarpa.</p>
-
-<p>5. The knife-needle of Knapp (Fig.&nbsp;<a href="#i_25-6">34</a>), which is so
-generally used for capsulotomy, is unfortunately not well
-adapted for iridotomy. The point is too oval, the cutting
-edge is too much bellied, and the blade is too short
-(5&nbsp;mm.). It will not easily puncture a dense iris-membrane,
-and the long sawing incision can not be
-well executed, because the short blade either persists in
-slipping out of the iris incision or else allows the membrane
-to ride up on the shank, in either case interfering
-with the completion of the operation.</p>
-
-<p>6. Sichel’s iridotome (Fig.&nbsp;<a href="#i_25-5">35</a>) closely resembles
-Knapp’s knife-needle, and although specially designed
-for this purpose, has the same faults, an oval point and
-a bellied edge. On the other hand, the blade is too long
-(11&nbsp;mm.) to be easily manipulated in the anterior
-chamber.</p>
-
-<p>7. The Hays knife-needle (Fig.&nbsp;<a href="#i_25-3">36</a>), as suggested in
-the early part of this paper, has the same general shape
-as Cheselden’s instrument, although much smaller. It
-was devised by Dr. Isaac Hays, an early surgeon of the
-Wills Hospital, and, although not well known to the
-profession at large, has been in constant use by the
-staff of that hospital for more than half a century. I
-may be pardoned for briefly quoting the original description
-of the instrument as published by <span class="nowrap">Hays<a id="FNanchor_31" href="#Footnote_31" class="fnanchor">31</a></span> in
-1855:</p>
-
-<p><span class="pagenum" id="Page_25">25</span></p><div class="blockquot">
-
-<p>“This instrument from the point to the head, near the handle
-(a to b, Fig.&nbsp;<a href="#i_25-3">36</a>), is six-tenths of an inch, its cutting edge
-(a to c) is nearly four-tenths of an inch. The back is straight
-to near the point, where it is truncated so as to make the<span class="pagenum" id="Page_26">26</span>
-point stronger, but at the same time leaving it very acute,
-and the edge of this truncated portion of the back is made to
-cut. The remainder of the back is simply rounded off. The
-cutting edge is perfectly straight and is made to cut up to the
-part where the instrument becomes round, c. This portion requires
-to be carefully constructed, so that as the instrument
-enters the eye it shall fill up the incision, and thus prevent the
-escape of the aqueous humor.”</p>
-</div>
-
-<div class="figcenter2 illowp100" id="i_25-1" style="max-width: 35.4375em;">
-  <img class="w100" src="images/i_25-1.jpg" alt="" />
-  <div class="caption"><p class="tac mt-04em">Fig.&nbsp;4.&mdash;Cheselden’s knife-needle (after Sharpe).</p></div>
-</div>
-
-<div class="figcenter2 illowp100" id="i_25-2" style="max-width: 35em;">
-  <img class="w100" src="images/i_25-2.jpg" alt="" />
-  <div class="caption"><p class="tac mt-04em">Fig.&nbsp;37.&mdash;Ziegler’s model of knife-needle.</p></div>
-</div>
-
-<div class="figcenter2 illowp100" id="i_25-3" style="max-width: 35em;">
-  <img class="w100" src="images/i_25-3.jpg" alt="" />
-  <div class="caption"><p class="tac mt-04em">Fig.&nbsp;36.&mdash;Hays’ knife-needle, exact size and enlarged (Hays).</p></div>
-</div>
-
-<div class="figcenter2 illowp100" id="i_25-4" style="max-width: 35em;">
-  <img class="w100" src="images/i_25-4.jpg" alt="" />
-  <div class="caption"><p class="tac mt-04em">Fig.&nbsp;16.&mdash;Sickle-shaped knife, Aiguille-à-serpette (Galezowski).</p></div>
-</div>
-
-<div class="figcenter2 illowp100" id="i_25-5" style="max-width: 35em;">
-  <img class="w100" src="images/i_25-5.jpg" alt="" />
-  <div class="caption"><p class="tac mt-04em">Fig.&nbsp;35.&mdash;Sichel’s iridotome (after Meyer).</p></div>
-</div>
-
-<div class="figcenter2 illowp100" id="i_25-6" style="max-width: 35em;">
-  <img class="w100" src="images/i_25-6.jpg" alt="" />
-  <div class="caption"><p class="tac mt-04em">Fig.&nbsp;34.&mdash;Knapp’s knife-needle.</p></div>
-</div>
-
-<div class="figcenter2 illowp100" id="i_25-7" style="max-width: 35em;">
-  <img class="w100" src="images/i_25-7.jpg" alt="" />
-  <div class="caption"><p class="tac mt-04em">Fig.&nbsp;7.&mdash;Adams’ iris-scalpel; large and small size.</p></div>
-</div>
-
-<div class="figcenter2 illowp100" id="i_25-8" style="max-width: 35em;">
-  <img class="w100" src="images/i_25-8.jpg" alt="" />
-  <div class="caption"><p class="tac mt-04em">Fig.&nbsp;33.&mdash;Double edged lance-knife (modern model).</p></div>
-</div>
-
-<div class="figcenter2 illowp100" id="i_25-9" style="max-width: 35em;">
-  <img class="w100" src="images/i_25-9.jpg" alt="" />
-  <div class="caption"><p class="tac mt-04em">Fig.&nbsp;5.&mdash;Double edged lance-knife (Beer).</p></div>
-</div>
-
-<div class="figcenter2 illowp100" id="i_25-10" style="max-width: 35em;">
-  <img class="w100" src="images/i_25-10.jpg" alt="" />
-  <div class="caption"><p class="tac mt-04em">Fig.&nbsp;12.&mdash;Iris-knife (Walton, after Beer).</p></div>
-</div>
-
-<p class="tac">The Various Knife-Needles and Iris-Knives Mentioned in the Text.<br />
-(Grouped together for study and comparison.)</p>
-
-<p>8. The knife-needle, which I invariably use, is a modified
-pattern of that devised by Hays. The form of this
-instrument lies midway between the falciform knife
-and the bistoury, and possesses the advantages of both.
-It has a very delicate point which punctures easily, and
-an excellent cutting edge of sufficient length (7&nbsp;mm.).
-If the shank is properly rounded it can be used with a
-sawing motion, sliding backward and forward through
-the corneal puncture without injuring the cornea, and
-without allowing the aqueous to escape. To accomplish
-this the more easily, the shank has been made 4&nbsp;mm.
-longer than the original model. This instrument, therefore,
-seems to meet all the requirements of a perfect
-iris-knife, viz., a falciform point which makes the best
-puncture, a straight edged blade which makes the best
-incision, and a cutting edge 7&nbsp;mm. long, which is the best
-length for properly executing the sawing movement. My
-<span class="nowrap">model<a id="FNanchor_32" href="#Footnote_32" class="fnanchor">32</a></span> of knife-needle (Fig.&nbsp;<a href="#i_25-2">37</a>) resembles Cheselden’s
-knife, as shown by Sharpe (Fig.&nbsp;<a href="#i_25-1">4</a>), even more closely
-than the original pattern of Hays does.</p>
-
-<div class="figcenter illowp100" id="i_26" style="max-width: 50em;">
-  <img class="w100" src="images/i_26.jpg" alt="" />
-  <div class="caption"><p class="tac">Fig.&nbsp;37.&mdash;Ziegler’s model of knife-needle.</p></div>
-</div>
-
-
-<h2>ESSENTIALS OF SUCCESS IN IRIDOTOMY BY THE KNIFE-NEEDLE
-METHOD.</h2>
-
-<p>1. A good knife-needle must be carefully selected.
-We have already concluded that the modified Hays
-knife-needle is the best model for this purpose. The
-knife-needle must, of course, have a well sharpened
-point and edge.</p>
-
-<p>2. The character of the incision in the iris-membrane
-is of vital importance. It should be a double incision.
-Guérin, Maunoir, DeWecker and Galezowski recognized<span class="pagenum" id="Page_27">27</span>
-this. Guérin made a crucial incision, Maunoir and DeWecker
-adopted the triangular flap, while Galezowski
-advocated the T-shaped cut. Our choice is the V-shaped
-incision, which is undoubtedly the only one that will cut
-through all the iritic fibers in such a way as to give us
-the greatest retraction of the membrane.</p>
-
-<p>3. Absolutely no pressure should be made in cutting
-with the knife-needle. This must be recognized as the
-main secret of success, whether you are incising a dense,
-felt-like iris-membrane, or a thin filmy capsule. If this
-rule is observed all traction on the ciliary body will be
-avoided.</p>
-
-<p>4. The knife-needle should slide backward and forward
-through the corneal puncture with a gentle sawing
-movement.</p>
-
-<p>5. The corneal puncture and membrane counter-puncture
-should be far enough apart to make the corneal
-puncture a good fulcrum for the delicate leverage necessary
-in executing the iris incision.</p>
-
-<p>6. The knife-needle should be so manipulated that no
-aqueous shall be lost, as this accident may prevent the
-completion of the operation, and may increase the tendency
-to iris hemorrhage by lowering the ocular tension.</p>
-
-<p>7. Every incision should be made a thoroughly clean
-cut, and all tearing of the tissues should be avoided.</p>
-
-<p>8. The most perfect artificial illumination should be
-secured, either by an electric photophore or a condensing
-lens, as both iridotomy and capsulotomy require constant
-and close inspection of the operative field.</p>
-
-
-<h2>AUTHOR’S V-SHAPED IRIDOTOMY.</h2>
-
-<p>The method of V-shaped iridotomy, performed by me
-with my modified Hays knife-needle, may be described
-as follows:</p>
-
-<p><i>First Stage.</i>&mdash;With the blade turned on the flat, the
-knife-needle is entered at the corneo-scleral junction, or
-through the upper part of the cornea (Fig.&nbsp;<a href="#i_28a">38</a>), and
-passed completely across the anterior chamber to within
-3 <span class="nowrap">millimeters<a id="FNanchor_33" href="#Footnote_33" class="fnanchor">33</a></span> of the apparent iris periphery. The knife
-is then turned edge downward, and carried 3 millimeters
-to the left of the vertical plane (Fig.&nbsp;<a href="#i_28b">39</a>).</p>
-
-<p><i>Second Stage.</i>&mdash;The point is now allowed to rest on
-the iris-membrane, and with a dart-like thrust the membrane<span class="pagenum" id="Page_28">28</span>
-is pierced. Then without making pressure on the
-tissue to be cut, the knife is drawn gently up and down
-with a saw-like motion, until the incision has been carried
-through the iris tissue from the point of the membrane
-puncture to just beneath the point of the corneal
-puncture. This movement is made wholly in a line with
-the axis of the knife, the shank passing to and fro
-through the corneal puncture, and the loss of any
-aqueous being carefully avoided in the manipulation.</p>
-
-<div class="figcenter illowp96" id="i_28a" style="max-width: 23.75em;">
-  <img class="w100" src="images/i_28a.jpg" alt="" />
-  <div class="caption"><p>Fig.&nbsp;38.&mdash;Author’s V-shaped iridotomy. Knife-needle entered
-through cornea.</p></div>
-</div>
-
-<div class="figcontainer">
-<div class="figsub illowp62" id="i_28b" style="max-width: 9em; padding-top: 0.55em;">
-  <img class="w100" src="images/i_28b.jpg" alt="" />
-  <div class="caption"><p>Fig.&nbsp;39.&mdash;Author’s
-method. Plan of first incision.</p></div>
-</div>
-
-<div class="figsub illowp60" id="i_28c" style="max-width: 9em; padding-top: 0.15em;">
-  <img class="w100" src="images/i_28c.jpg" alt="" />
-  <div class="caption"><p>Fig.&nbsp;40.&mdash;First
-in­ci­sion completed. Plan of second incision.</p></div>
-</div>
-
-<div class="figsub illowp58" id="i_28d" style="max-width: 9em;">
-  <img class="w100" src="images/i_28d.jpg" alt="" />
-  <div class="caption"><p>Fig.&nbsp;41.&mdash;Pupil
-re­sult­ing from V-shaped iridotomy.</p></div>
-</div>
-</div>
-
-<p><i>Third Stage.</i>&mdash;The pressure of the vitreous will now
-cause the edges of the incision to immediately bulge
-open into a long oval (Fig.&nbsp;<a href="#i_28c">40</a>) through which the knife-blade
-is raised upward, until above the iris-membrane,
-and then swung across the anterior chamber to a corresponding
-point on the right of the vertical plane,
-which, owing to the disturbance in the relation of the<span class="pagenum" id="Page_29">29</span>
-parts made by the first cut, is now somewhat displaced
-and the second puncture must be made at least 1 millimeter
-farther over, i. e., 4 millimeters to the right of
-the vertical plane (Fig.&nbsp;<a href="#i_28c">40</a>).</p>
-
-<p><i>Fourth Stage.</i>&mdash;With the knife point again resting on
-the membrane, a second puncture is made by the same
-quick thrust, and the incision rapidly carried forward
-by the sawing movement to meet the extremity of the
-first incision, at the apex of the triangle, thus making
-a <i>converging</i> V-shaped cut (Fig.&nbsp;<a href="#i_28d">41</a>). Care must be
-taken at this point that the pressure of the knife-edge on
-the tissue shall be most gentle, and that the second incision
-shall terminate a trifle inside the extremity of the
-first, in order that the last fiber may be severed and thus
-allow the apex of the flap to fall down behind the lower
-part of the iris-membrane. If the flap does not roll
-back of its own accord it may be pushed downward with
-the point of the knife. When the operation is completed
-the knife is again turned on the flat and quickly withdrawn.</p>
-
-
-<h2>CAUSES OF FAILURE.</h2>
-
-<p>The most fruitful sources of failure are, first, a poorly
-sharpened knife-needle; second, a badly planned incision;
-third, inability to sever the apex of the triangle;
-fourth, the early loss of aqueous; fifth, too heavy pressure
-with the knife-edge, and sixth, rocking or rotating
-the knife backward instead of making the sawing movement.
-All of these can easily be avoided, if the surgeon
-will only exercise care and good judgment.</p>
-
-<p>In an occasional case, the iris-membrane may be so
-stiff that the apex of the flap will not retract. If the
-apex can not be pushed down by the tip of the knife
-turn the blade on the flat, puncture the base of the flap
-by a quick thrust, and with a sawing motion cut across
-its fibers so that it will fall back as though hinged; or,
-if positive that the vitreous is not fluid, introduce a keratome
-in the cornea below, draw out the triangular tongue,
-cut it off with the iris scissors, and dress back the base
-with a silver spatula.</p>
-
-<p>It is possible that the capsule, or iris tissue, may lose
-its anchorage. In that event we must either reverse the
-procedure by entering the knife-needle below, and cut
-from above downward, or else pass a second knife-needle
-through the loosened edge of the membrane to fix it, and
-then proceed with the usual method.</p>
-
-<p><span class="pagenum" id="Page_30">30</span></p>
-
-<p>Occasionally, the apex of the triangular flap will hold
-fast, because the last fiber of tissue has not been severed.
-If the leverage is too short to incise it from above, withdraw
-the knife-needle and reintroduce it far enough
-from the apex to secure the proper leverage, and again
-incise it gently, until it falls back.</p>
-
-<p>Traction on the ciliary processes, accidental puncture
-of the ciliary body, or the tearing of the membrane from
-its ciliary attachment may all set up iridocyclitis or
-glaucoma, and should therefore be avoided. As tense
-capsular bands are liable to engender a similar condition
-they should be incised. If any of these traction bands
-should remain in the edge of the coloboma, we may enter
-the knife behind them and gently saw through into the
-already cleared pupil, before withdrawing the knife.</p>
-
-<div class="figcenter illowp100" id="i_30" style="max-width: 12.1875em;">
-  <img class="w100" src="images/i_30.jpg" alt="" />
-  <div class="caption"><p>Fig.&nbsp;42, (<span class="smcap">Case 1</span>).&mdash;Iridotomy in a stiff iris-membrane (author’s
-original case).</p></div>
-</div>
-
-
-<h2>ILLUSTRATIVE CASES.</h2>
-
-<p>I will briefly cite a few examples of the V-shaped operation,
-two that were my first efforts, and two that were
-recent cases. They were all of the class that are often
-abandoned as hopeless; hence the visual result is far below
-the operative success.</p>
-
-<div class="blockquot">
-
-<p><span class="smcap">Case 1.</span>&mdash;<i>History.</i>&mdash;F. M., aged 65 years. O.&nbsp;D. complete
-membranous occlusion of pupil from iridocyclitis, following
-cataract extraction. The iris and capsule are tensely drawn up
-toward the ciliary border. Light perception and projection
-good. Several efforts have been made to incise the membrane,
-but without success. Admitted to Wills Hospital by the late
-Dr. Goodman, through whose courtesy I operated.</p>
-
-<p><i>Operation.</i>&mdash;On Jan. 15, 1889, I made two long incisions,
-almost crucial, and extending beyond the apex of the V, resulting
-in a W-shaped pupil, on account of the stiff iris membrane
-(Fig.&nbsp;<a href="#i_30">42</a>). With S. + 10 D. he saw 20/50.</p>
-
-<p><span class="smcap">Case 2.</span>&mdash;<i>History.</i>&mdash;J.&nbsp;S., aged 30 years. O.&nbsp;S. injured and
-enucleated. O.&nbsp;D. sympathetic inflammation, chorioidal cataract;
-three discissions and one iridectomy, down and in.
-Membranous occlusion of pupil. I first saw him in 1888 while<span class="pagenum" id="Page_31">31</span>
-house surgeon at the Wills Hospital, where iridotomy was skilfully
-performed nine times by one of the surgeons, the methods
-being varied and ingenious, but without success, as the incision
-was invariably closed by plastic exudate. My interest
-in this series of operations first drew my attention to the
-subject of iridotomy, and stimulated me to develop the method
-I have here submitted and which I first tried in Case 1.</p>
-
-<p>One year later this patient came to my clinic at St. Joseph’s
-Hospital. Iris was discolored, capsule thickened and visible
-through the coloboma, down and in; areas of scleral thinning,
-with pigmented chorioid showing through. T&mdash;3. Light perception
-good, projection only fair.</p>
-
-<p><i>Operation.</i>&mdash;On June 17, 1889, I made a V-shaped iridotomy
-along the outlines of the former iridectomy. The membrane
-freely opened up into a triangular or pear-shaped pupil (Fig.
-43), which proved permanent, but was only useful for quantitative
-vision, about 5/200. No further test could be made
-because the disorganized vitreous was filled with floating
-masses. I have seen him within a year, going about and earning
-his living. From an operative standpoint I have always
-considered this early effort one of my most successful cases,
-chiefly because of the great density of the iris-membrane and
-the lowered tension of the eyeball.</p>
-</div>
-
-<div class="figcenter illowp100" id="i_31" style="max-width: 12.1875em;">
-  <img class="w100" src="images/i_31.jpg" alt="" />
-  <div class="caption"><p>Fig.&nbsp;43, (<span class="smcap">Case 2</span>).&mdash;Iridotomy
-in a soft eyeball, with dense iris-membrane.</p></div>
-</div>
-
-<div class="blockquot">
-
-<p><span class="smcap">Case 3.</span>&mdash;<i>History.</i>&mdash;Mrs. A.&nbsp;D., aged 45 years. O.&nbsp;D. iridectomy
-for glaucoma seven years ago. O.&nbsp;S. iridectomy two years
-ago by another surgeon, at which time there occurred slight
-incarceration of iris, followed by sympathetic ophthalmitis in
-O.&nbsp;D. The severe iridochorioiditis resulted in cataract and
-some shrinkage of globe. The cataracts were extracted from
-both eyes in 1907, followed by dense opacity of cornea above,
-iris bombé, shallow anterior chamber, T&mdash;2. Here was a
-soft, distensible, iris tissue with shallow anterior chamber and
-greatly lowered tension of the eyeball, constituting one of the
-most difficult conditions to operate on.</p>
-
-<p><i>Operation.</i>&mdash;On May 13, 1907, the eyes being quiet, and
-light perception and projection fair, V-shaped iridotomy was
-performed on both eyes. The leucomatous areas in the upper
-part of cornea necessitated making the pupil below. In O.&nbsp;D.
-the pupil opened up beautifully (Fig.&nbsp;<a href="#i_32a">44</a>), but in O.&nbsp;S. a tag<span class="pagenum" id="Page_32">32</span>
-of iris hung fast (Fig.&nbsp;<a href="#i_32b">45</a>) and was again incised two months
-later. The artist has illustrated the remaining portion of this
-tag very well. As soon as the iris tissue was incised it retracted,
-making the pupils larger than the area of incision.
-The test for glasses, nearly a year later, March 15, 1908,
-yielded the following result:</p>
-
-<p class="ml1em">
-O. D. S + 13 D ⁐ C + 4.75 D ax. 105° = 20/40.<br />
-O. D. S + 13 D ⁐ C + 3 D ax. 65° = 20/40.<br />
-</p>
-
-<p>Add</p>
-
-<p class="ml1em">
-O. D. S + 4 D = J. 10.<br />
-O. S. S + 4 D = J. 10.<br />
-</p>
-
-<p>These were ordered in biconvex torics. She had worn glasses
-for a year, but claims vision is much better with the new ones.
-This seems like an excellent result when we consider that these
-eyes had passed through glaucoma, iridochorioiditis and cataract,
-followed by membranous occlusion of pupil, lowered tension
-and fluid vitreous. The high hyperopia and astigmatism
-show the phthisical condition of each globe. There is marked
-cupping of both nerve heads and the fields are contracted.</p>
-</div>
-
-<div class="figcontainer">
-<div class="figsub illowp100" id="i_32a" style="max-width: 12.1875em; padding-top: 0.55em;">
-  <img class="w100" src="images/i_32a.jpg" alt="" />
-  <div class="caption"><p>Fig.&nbsp;44, (<span class="smcap">Case 3</span>).&mdash;Iridotomy
-in a soft eyeball, with thin mem­brane and iris bombé.</p></div>
-</div>
-
-<div class="figsub illowp100" id="i_32b" style="max-width: 12.1875em;">
-  <img class="w100" src="images/i_32b.jpg" alt="" />
-  <div class="caption"><p>Fig.&nbsp;45, (<span class="smcap">Case 3</span>).&mdash;Iridotomy
-showing apex of iris flap after in­ci­sion through adherent fi­bers.</p></div>
-</div>
-</div>
-
-<div class="blockquot">
-
-<p><span class="smcap">Case 4.</span>&mdash;<i>History.</i>&mdash;Mrs. B.&nbsp;M., aged 64 years. O.&nbsp;S. struck
-by a stone in childhood, destroying vision. Dense leucoma
-above, chorioidal cataract, calcareous deposit; exclusion of
-pupil. T&mdash;1. Lpc. good. Lpj. fair. O.&nbsp;D. recurrent attacks of
-inflammation for seven years, posterior synechiæ and cataract.
-Counts fingers at 6 inches. Extraction with iridectomy, both
-eyes, in 1907. Site of incision has become densely leucomatous.
-O.&nbsp;D. shows capsular area above, iris drawn up. O.&nbsp;S. complete
-membranous occlusion of pupil.</p>
-
-<p><i>Operation.</i>&mdash;Oct. 7, 1907, V-shaped incision was executed
-entirely in the iris tissue of O.&nbsp;D., the pupil spreading out
-into an ovoid shape (Fig.&nbsp;<a href="#i_33a">46</a>), leaving area of capsule and
-small band of iris above. O.&nbsp;S. was operated on Jan, 13,
-1908, by the same method, the resulting pupil being almost
-round (Fig.&nbsp;<a href="#i_33b">47</a>) owing to the resilient iris tissue.</p>
-
-<p>The test for glasses, March 10, 1908, gave the following result:</p>
-
-<p><span class="pagenum" id="Page_33">33</span></p>
-
-<p class="ml1em">
-O. D. S + 12 D ⁐ C + 1.25 D ax. 135° = 20/50.<br />
-O. S. S + 12 D ⁐ C + 1.25 D ax. 135° = 20/70.<br />
-</p>
-
-<p>Add</p>
-
-<p class="ml1em">
-O. D. S + 5 D = J. 6.<br />
-O. S. S + 5 D = J. 12.<br />
-</p>
-
-<p>These were ordered in biconvex torics, which she now wears
-with great comfort. It is worth noting that O.&nbsp;S. still retained
-good visual acuity, although blinded by an injury nearly fifty
-years before.</p>
-</div>
-
-<div class="figcontainer">
-<div class="figsub illowp100" id="i_33a" style="max-width: 12.1875em; padding-top: 0.3em;">
-  <img class="w100" src="images/i_33a.jpg" alt="" />
-  <div class="caption"><p>Fig.&nbsp;46, (<span class="smcap">Case 4</span>).&mdash;Irido-cap­sul­otomy,
-with band of iris, and capsule in coloboma above.</p></div>
-</div>
-
-<div class="figsub illowp100" id="i_33b" style="max-width: 12.1875em;">
-  <img class="w100" src="images/i_33b.jpg" alt="" />
-  <div class="caption"><p>Fig.&nbsp;47, (<span class="smcap">Case 4</span>).&mdash;Iridotomy
-with round central pupil in a resilient iris-membrane.</p></div>
-</div>
-</div>
-
-
-<h2>CAPSULOTOMY BY THE V-SHAPED METHOD.</h2>
-
-<p>The application of the V-shaped method to capsulotomy
-shows an even greater field of usefulness, as this
-method is par excellence the best way of incising a delicate
-secondary capsular cataract. This should be done
-under artificial illumination. The pupil should be dilated,
-as the area of incision is necessarily smaller than
-in iridotomy, and unnecessary wounding of the iris
-should be avoided. The proposed capsular opening must
-be so calculated as to fall within the area of the undilated
-pupil, or partly within the coloboma if an iridectomy
-has been previously performed.</p>
-
-<div class="figcontainer">
-<div class="figsub illowp60" id="i_33c" style="max-width: 9em; padding-top: 0.25em;">
-  <img class="w100" src="images/i_33c.jpg" alt="" />
-  <div class="caption"><p>Fig.&nbsp;48.&mdash;Author’s
-V­shaped cap­su­lo­to­my. Plan of first in­ci­sion.</p></div>
-</div>
-
-<div class="figsub illowp59" id="i_33d" style="max-width: 9em;">
-  <img class="w100" src="images/i_33d.jpg" alt="" />
-  <div class="caption"><p>Fig.&nbsp;49.&mdash;First
-in­ci­sion completed. Plan of second incision.</p></div>
-</div>
-
-<div class="figsub illowp59" id="i_33e" style="max-width: 9em; padding-top: 0.09em;">
-  <img class="w100" src="images/i_33e.jpg" alt="" />
-  <div class="caption"><p>Fig 50.&mdash;Pupil
-re­sult­ing from V-shaped capsulotomy.</p></div>
-</div>
-</div>
-
-<p>The knife-needle is entered at the upper corneal margin,
-passed across the anterior chamber to a point 2&nbsp;mm.
-to the left of the vertical plane (Fig.&nbsp;<a href="#i_33c">48</a>), the capsule<span class="pagenum" id="Page_34">34</span>
-punctured by a quick thrust, and the saw-like incision
-carried from below upward, as in iridotomy. The knife
-is then raised up above the capsule and swung 3&nbsp;mm.
-to the right of the vertical plane (Fig.&nbsp;<a href="#i_33d">49</a>), the capsule
-is again punctured, and a duplicate incision carried up
-to join the first, at the apex of the converging V (Fig.&nbsp;<a href="#i_33e">50</a>).</p>
-
-<p>Where the pupillary margin is adherent to the underlying
-capsule, or the pupillary space is too small, it may
-be necessary to start the incision in the iris tissue, a
-little below the pupil, and then cut upward until the
-knife emerges into the pupillary area, thus making an
-irido-capsulotomy. The soft iris tissue is easily incised
-if no pressure is made with the knife, and the sawing
-motion is maintained.</p>
-
-
-<h2>AFTER-TREATMENT.</h2>
-
-<p>Postoperative inflammatory reaction is infrequent,
-but if it should occur the usual antiphlogistic treatment
-of atropin, calomel, ice-pads and leeching should be
-actively instituted and continued until the eye is absolutely
-quiet. The operation itself is frequently an antiphlogistic
-measure, because it relieves iris-tension and
-traction on the ciliary body. The usual compress of
-gauze and cotton, covered with a Liebreich patch, may
-be applied to the eye for the first twenty-four hours and
-rest in bed enjoined for that period.</p>
-
-
-<h2>IN CONCLUSION.</h2>
-
-<p>We have carefully reviewed the history of iridotomy
-for nearly two centuries, and noted how the pendulum
-has swung from knife-needle to scissors, and back
-again. We have learned that Cheselden, the father of
-iridotomy, originated the method of incision by the
-knife-needle, which Heuermann modified, and Adams
-later revived and improved. We have seen how Janin
-abandoned this procedure and originated the scissors
-method, which Maunoir greatly improved and caused
-to hold sway for more than half a century. We have
-been deeply impressed by the fact that the mature, judicial
-mind of von Graefe led him to abandon the scissors
-and revert to the knife-needle method. We have
-seen how, soon after his death, the great influence of De<span class="pagenum" id="Page_35">35</span>
-Wecker had swerved the thought of the ophthalmic
-world back to the adoption of the scissors method in a
-greatly improved form.</p>
-
-<p>Whether I have succeeded in citing sufficient facts
-and arguments to establish my thesis in favor of the
-knife-needle, or not, I nevertheless submit to the profession
-my V-shaped method of iridotomy and capsulotomy
-with a confidence born of twenty years’ successful
-experience in its use, and with the hope that it
-may prove equally efficient in the hands of others who
-will take pains to study and understand the method, and
-who may have the patience to put it in practice.</p>
-
-
-<div class="footnotes"><h3>FOOTNOTES:</h3>
-
-<div class="footnote">
-
-<p><a id="Footnote_1" href="#FNanchor_1" class="label">1</a>
-Read in the Section on Ophthalmology of the American Medical
-Association, at the Fifty-ninth Annual Session, held at Chicago,
-June, 1908.</p>
-
-</div>
-
-<div class="footnote">
-
-<p><a id="Footnote_2" href="#FNanchor_2" class="label">2</a>
-Wagner, Karl Wilhelm Ulrich: Inaugural Thesis, Göttingen,
-1818. He invented the designation iridotomia, which he formed
-from the original Greek, ἶρις, ἶριδος (the iris) and τομή (cut).</p>
-
-</div>
-
-<div class="footnote">
-
-<p><a id="Footnote_3" href="#FNanchor_3" class="label">3</a>
-Cheselden, William: Philosophical Transactions, London,
-1728, xxxv, p.&nbsp;451.</p>
-
-</div>
-
-<div class="footnote">
-
-<p><a id="Footnote_4" href="#FNanchor_4" class="label">4</a>
-Ibid, abridged, vii, pl.&nbsp;v, Figures 2, 3 and 5.</p>
-
-</div>
-
-<div class="footnote">
-
-<p><a id="Footnote_5" href="#FNanchor_5" class="label">5</a>
-Sharpe, Samuel: A Treatise on the Operations of Surgery,
-London, 1739, p.&nbsp;169.</p>
-
-</div>
-
-<div class="footnote">
-
-<p><a id="Footnote_6" href="#FNanchor_6" class="label">6</a>
-Adams, Sir William: Practical Observations on Ectropium,
-Artificial Pupil and Cataract, London, 1812, p.&nbsp;37 et seq.</p>
-
-</div>
-
-<div class="footnote">
-
-<p><a id="Footnote_7" href="#FNanchor_7" class="label">7</a>
-Guthrie, G. J.: Operative Surgery of the Eye, London, 1830,
-p. 428.</p>
-
-</div>
-
-<div class="footnote">
-
-<p><a id="Footnote_8" href="#FNanchor_8" class="label">8</a>
-Histoire et Mémoires de l’Académie Royale de Chirurgie,
-Paris, 1757, iii, p.&nbsp;115.</p>
-
-</div>
-
-<div class="footnote">
-
-<p><a id="Footnote_9" href="#FNanchor_9" class="label">9</a>
-Huguier, Pierre Charles: Des Opérations de Pupille Artificielle,
-Paris, 1841.</p>
-
-</div>
-
-<div class="footnote">
-
-<p><a id="Footnote_10" href="#FNanchor_10" class="label">10</a>
-Heuermann, Georg: Abhandlung der Vornemsten Chirurgischen
-Operationen, Copenhagen and Leipzig, 1756, ii, p.&nbsp;493.</p>
-
-</div>
-
-<div class="footnote">
-
-<p><a id="Footnote_11" href="#FNanchor_11" class="label">11</a>
-Janin, Jean: Mémoires et Observations sur L’Oeil, Lyon 1772,
-p. 191.</p>
-
-</div>
-
-<div class="footnote">
-
-<p><a id="Footnote_12" href="#FNanchor_12" class="label">12</a>
-Guérin, M.: Maladies des Yeux, Lyon 1769, p.&nbsp;235.</p>
-
-</div>
-
-<div class="footnote">
-
-<p><a id="Footnote_13" href="#FNanchor_13" class="label">13</a>
-Beer, Georg Joseph: Lehre der Augenkrankheiten, Wien,
-1792, ii, p.&nbsp;12.</p>
-
-</div>
-
-<div class="footnote">
-
-<p><a id="Footnote_14" href="#FNanchor_14" class="label">14</a>
-Beer, Georg Joseph: Ansicht der Künstlichen Pupillen-Bildung,
-Wien, 1805, p.&nbsp;105.</p>
-
-</div>
-
-<div class="footnote">
-
-<p><a id="Footnote_15" href="#FNanchor_15" class="label">15</a>
-Adams, Sir William: A Treatise on Artificial Pupil, London,
-1819, p.&nbsp;34, et seq.</p>
-
-</div>
-
-<div class="footnote">
-
-<p><a id="Footnote_16" href="#FNanchor_16" class="label">16</a>
-Scarpa, Antonio: Trattato Delle Principali Malattie Degli
-Occhi, Ed. quinta, l’avia, 1816, translated by James Briggs, London,
-1818, p.&nbsp;373.</p>
-
-</div>
-
-<div class="footnote">
-
-<p><a id="Footnote_17" href="#FNanchor_17" class="label">17</a>
-Edin. Med. and Surg. Jour., No. 58.</p>
-
-</div>
-
-<div class="footnote">
-
-<p><a id="Footnote_18" href="#FNanchor_18" class="label">18</a>
-Walton, H. Haynes: The Surgical Diseases of the Eye, London,
-1861, p.&nbsp;604.</p>
-
-</div>
-
-<div class="footnote">
-
-<p><a id="Footnote_19" href="#FNanchor_19" class="label">19</a>
-Meyer, Edouard: Traité Pratique des Maladies des Yeux,
-Paris, 1880, translated by Freeland Fergus, Philadelphia, 1887, p.
-396.</p>
-
-</div>
-
-<div class="footnote">
-
-<p><a id="Footnote_20" href="#FNanchor_20" class="label">20</a>
-Klinische Monatsblätter für Augenheilkunde, 1869, p.&nbsp;431.</p>
-
-</div>
-
-<div class="footnote">
-
-<p><a id="Footnote_21" href="#FNanchor_21" class="label">21</a>
-Galezowski, Xavier: Maladies des Yeux, 2d. ed., Paris, 1875,
-p. 401, and 3rd. ed., Paris, 1888, p.&nbsp;384.</p>
-
-</div>
-
-<div class="footnote">
-
-<p><a id="Footnote_22" href="#FNanchor_22" class="label">22</a>
-A brief description of the author’s method, written by him,
-was first published in de Schweinitz on Diseases of the Eye, Philadelphia,
-2nd. ed., 1896, p.&nbsp;607.</p>
-
-</div>
-
-<div class="footnote">
-
-<p><a id="Footnote_23" href="#FNanchor_23" class="label">23</a>
-Wenzel, Baron de: Traité de la Cataracte, Paris, 1786, translated
-by James Ware, London, 1805, ii, p.&nbsp;256.</p>
-
-</div>
-
-<div class="footnote">
-
-<p><a id="Footnote_24" href="#FNanchor_24" class="label">24</a>
-Maunoir, Jean Pierre: Mémoires sur l’Organisation de l’Iris,
-et l’Opération de la Pupille Artificielle, Paris, 1812.</p>
-
-</div>
-
-<div class="footnote">
-
-<p><a id="Footnote_25" href="#FNanchor_25" class="label">25</a>
-Medico-Chir. Trans., London, 1816, vii, p.&nbsp;301, and ix, p.&nbsp;382.</p>
-
-</div>
-
-<div class="footnote">
-
-<p><a id="Footnote_26" href="#FNanchor_26" class="label">26</a>
-Mackenzie, William: Diseases of the Eye, 3rd. ed., London,
-1840, p.&nbsp;746, American edition, edited by Hewson, Philadelphia,
-1855, p.&nbsp;815.</p>
-
-</div>
-
-<div class="footnote">
-
-<p><a id="Footnote_27" href="#FNanchor_27" class="label">27</a>
-Lawrence, Sir William: Diseases of the Eye, American
-edition, edited by Hays, Philadelphia, 1854, p.&nbsp;478.</p>
-
-</div>
-
-<div class="footnote">
-
-<p><a id="Footnote_28" href="#FNanchor_28" class="label">28</a>
-Transactions, Fourth Int. Ophth. Cong., London, 1872, p.&nbsp;179.</p>
-
-</div>
-
-<div class="footnote">
-
-<p><a id="Footnote_29" href="#FNanchor_29" class="label">29</a>
-De Wecker, Louis: Annales d’Oculistique, Sept., 1873, p.
-123, et seq.</p>
-
-</div>
-
-<div class="footnote">
-
-<p><a id="Footnote_30" href="#FNanchor_30" class="label">30</a>
-DeWecker et Landolt: Traité Complet d’Ophtalmologie,
-Paris, 1886, ii, p.&nbsp;393.</p>
-
-</div>
-
-<div class="footnote">
-
-<p><a id="Footnote_31" href="#FNanchor_31" class="label">31</a>
-Amer. Jour. of the Med. Sciences, July, 1855, p.&nbsp;82.</p>
-
-</div>
-
-<div class="footnote">
-
-<p><a id="Footnote_32" href="#FNanchor_32" class="label">32</a>
-This knife-needle has been carefully made for me by Luer,
-Paris, and by Ferguson, Philadelphia.</p>
-
-</div>
-
-<div class="footnote">
-
-<p><a id="Footnote_33" href="#FNanchor_33" class="label">33</a>
-Compare with millimeter scale beneath each diagram.</p>
-
-</div>
-</div>
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