diff options
Diffstat (limited to 'old/67117-0.txt')
| -rw-r--r-- | old/67117-0.txt | 1619 |
1 files changed, 0 insertions, 1619 deletions
diff --git a/old/67117-0.txt b/old/67117-0.txt deleted file mode 100644 index 76e1ec6..0000000 --- a/old/67117-0.txt +++ /dev/null @@ -1,1619 +0,0 @@ -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 *** - -Updated editions will replace the previous one--the old editions will -be renamed. - -Creating the works from print editions not protected by U.S. copyright -law means that no one owns a United States copyright in these works, -so the Foundation (and you!) can copy and distribute it in the -United States without permission and without paying copyright -royalties. Special rules, set forth in the General Terms of Use part -of this license, apply to copying and distributing Project -Gutenberg-tm electronic works to protect the PROJECT GUTENBERG-tm -concept and trademark. Project Gutenberg is a registered trademark, -and may not be used if you charge for an eBook, except by following -the terms of the trademark license, including paying royalties for use -of the Project Gutenberg trademark. If you do not charge anything for -copies of this eBook, complying with the trademark license is very -easy. You may use this eBook for nearly any purpose such as creation -of derivative works, reports, performances and research. Project -Gutenberg eBooks may be modified and printed and given away--you may -do practically ANYTHING in the United States with eBooks not protected -by U.S. copyright law. Redistribution is subject to the trademark -license, especially commercial redistribution. - -START: FULL LICENSE - -THE FULL PROJECT GUTENBERG LICENSE -PLEASE READ THIS BEFORE YOU DISTRIBUTE OR USE THIS WORK - -To protect the Project Gutenberg-tm mission of promoting the free -distribution of electronic works, by using or distributing this work -(or any other work associated in any way with the phrase "Project -Gutenberg"), you agree to comply with all the terms of the Full -Project Gutenberg-tm License available with this file or online at -www.gutenberg.org/license. - -Section 1. General Terms of Use and Redistributing Project -Gutenberg-tm electronic works - -1.A. By reading or using any part of this Project Gutenberg-tm -electronic work, you indicate that you have read, understand, agree to -and accept all the terms of this license and intellectual property -(trademark/copyright) agreement. If you do not agree to abide by all -the terms of this agreement, you must cease using and return or -destroy all copies of Project Gutenberg-tm electronic works in your -possession. If you paid a fee for obtaining a copy of or access to a -Project Gutenberg-tm electronic work and you do not agree to be bound -by the terms of this agreement, you may obtain a refund from the -person or entity to whom you paid the fee as set forth in paragraph -1.E.8. - -1.B. "Project Gutenberg" is a registered trademark. It may only be -used on or associated in any way with an electronic work by people who -agree to be bound by the terms of this agreement. There are a few -things that you can do with most Project Gutenberg-tm electronic works -even without complying with the full terms of this agreement. See -paragraph 1.C below. There are a lot of things you can do with Project -Gutenberg-tm electronic works if you follow the terms of this -agreement and help preserve free future access to Project Gutenberg-tm -electronic works. See paragraph 1.E below. - -1.C. The Project Gutenberg Literary Archive Foundation ("the -Foundation" or PGLAF), owns a compilation copyright in the collection -of Project Gutenberg-tm electronic works. Nearly all the individual -works in the collection are in the public domain in the United -States. If an individual work is unprotected by copyright law in the -United States and you are located in the United States, we do not -claim a right to prevent you from copying, distributing, performing, -displaying or creating derivative works based on the work as long as -all references to Project Gutenberg are removed. Of course, we hope -that you will support the Project Gutenberg-tm mission of promoting -free access to electronic works by freely sharing Project Gutenberg-tm -works in compliance with the terms of this agreement for keeping the -Project Gutenberg-tm name associated with the work. You can easily -comply with the terms of this agreement by keeping this work in the -same format with its attached full Project Gutenberg-tm License when -you share it without charge with others. - -1.D. The copyright laws of the place where you are located also govern -what you can do with this work. Copyright laws in most countries are -in a constant state of change. If you are outside the United States, -check the laws of your country in addition to the terms of this -agreement before downloading, copying, displaying, performing, -distributing or creating derivative works based on this work or any -other Project Gutenberg-tm work. The Foundation makes no -representations concerning the copyright status of any work in any -country other than the United States. - -1.E. Unless you have removed all references to Project Gutenberg: - -1.E.1. The following sentence, with active links to, or other -immediate access to, the full Project Gutenberg-tm License must appear -prominently whenever any copy of a Project Gutenberg-tm work (any work -on which the phrase "Project Gutenberg" appears, or with which the -phrase "Project Gutenberg" is associated) is accessed, displayed, -performed, viewed, copied or distributed: - - 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. - -1.E.2. If an individual Project Gutenberg-tm electronic work is -derived from texts not protected by U.S. copyright law (does not -contain a notice indicating that it is posted with permission of the -copyright holder), the work can be copied and distributed to anyone in -the United States without paying any fees or charges. If you are -redistributing or providing access to a work with the phrase "Project -Gutenberg" associated with or appearing on the work, you must comply -either with the requirements of paragraphs 1.E.1 through 1.E.7 or -obtain permission for the use of the work and the Project Gutenberg-tm -trademark as set forth in paragraphs 1.E.8 or 1.E.9. - -1.E.3. If an individual Project Gutenberg-tm electronic work is posted -with the permission of the copyright holder, your use and distribution -must comply with both paragraphs 1.E.1 through 1.E.7 and any -additional terms imposed by the copyright holder. Additional terms -will be linked to the Project Gutenberg-tm License for all works -posted with the permission of the copyright holder found at the -beginning of this work. - -1.E.4. Do not unlink or detach or remove the full Project Gutenberg-tm -License terms from this work, or any files containing a part of this -work or any other work associated with Project Gutenberg-tm. - -1.E.5. Do not copy, display, perform, distribute or redistribute this -electronic work, or any part of this electronic work, without -prominently displaying the sentence set forth in paragraph 1.E.1 with -active links or immediate access to the full terms of the Project -Gutenberg-tm License. - -1.E.6. You may convert to and distribute this work in any binary, -compressed, marked up, nonproprietary or proprietary form, including -any word processing or hypertext form. However, if you provide access -to or distribute copies of a Project Gutenberg-tm work in a format -other than "Plain Vanilla ASCII" or other format used in the official -version posted on the official Project Gutenberg-tm website -(www.gutenberg.org), you must, at no additional cost, fee or expense -to the user, provide a copy, a means of exporting a copy, or a means -of obtaining a copy upon request, of the work in its original "Plain -Vanilla ASCII" or other form. Any alternate format must include the -full Project Gutenberg-tm License as specified in paragraph 1.E.1. - -1.E.7. Do not charge a fee for access to, viewing, displaying, -performing, copying or distributing any Project Gutenberg-tm works -unless you comply with paragraph 1.E.8 or 1.E.9. - -1.E.8. You may charge a reasonable fee for copies of or providing -access to or distributing Project Gutenberg-tm electronic works -provided that: - -* You pay a royalty fee of 20% of the gross profits you derive from - the use of Project Gutenberg-tm works calculated using the method - you already use to calculate your applicable taxes. The fee is owed - to the owner of the Project Gutenberg-tm trademark, but he has - agreed to donate royalties under this paragraph to the Project - Gutenberg Literary Archive Foundation. Royalty payments must be paid - within 60 days following each date on which you prepare (or are - legally required to prepare) your periodic tax returns. Royalty - payments should be clearly marked as such and sent to the Project - Gutenberg Literary Archive Foundation at the address specified in - Section 4, "Information about donations to the Project Gutenberg - Literary Archive Foundation." - -* You provide a full refund of any money paid by a user who notifies - you in writing (or by e-mail) within 30 days of receipt that s/he - does not agree to the terms of the full Project Gutenberg-tm - License. You must require such a user to return or destroy all - copies of the works possessed in a physical medium and discontinue - all use of and all access to other copies of Project Gutenberg-tm - works. - -* You provide, in accordance with paragraph 1.F.3, a full refund of - any money paid for a work or a replacement copy, if a defect in the - electronic work is discovered and reported to you within 90 days of - receipt of the work. - -* You comply with all other terms of this agreement for free - distribution of Project Gutenberg-tm works. - -1.E.9. If you wish to charge a fee or distribute a Project -Gutenberg-tm electronic work or group of works on different terms than -are set forth in this agreement, you must obtain permission in writing -from the Project Gutenberg Literary Archive Foundation, the manager of -the Project Gutenberg-tm trademark. Contact the Foundation as set -forth in Section 3 below. - -1.F. - -1.F.1. Project Gutenberg volunteers and employees expend considerable -effort to identify, do copyright research on, transcribe and proofread -works not protected by U.S. copyright law in creating the Project -Gutenberg-tm collection. Despite these efforts, Project Gutenberg-tm -electronic works, and the medium on which they may be stored, may -contain "Defects," such as, but not limited to, incomplete, inaccurate -or corrupt data, transcription errors, a copyright or other -intellectual property infringement, a defective or damaged disk or -other medium, a computer virus, or computer codes that damage or -cannot be read by your equipment. - -1.F.2. LIMITED WARRANTY, DISCLAIMER OF DAMAGES - Except for the "Right -of Replacement or Refund" described in paragraph 1.F.3, the Project -Gutenberg Literary Archive Foundation, the owner of the Project -Gutenberg-tm trademark, and any other party distributing a Project -Gutenberg-tm electronic work under this agreement, disclaim all -liability to you for damages, costs and expenses, including legal -fees. YOU AGREE THAT YOU HAVE NO REMEDIES FOR NEGLIGENCE, STRICT -LIABILITY, BREACH OF WARRANTY OR BREACH OF CONTRACT EXCEPT THOSE -PROVIDED IN PARAGRAPH 1.F.3. YOU AGREE THAT THE FOUNDATION, THE -TRADEMARK OWNER, AND ANY DISTRIBUTOR UNDER THIS AGREEMENT WILL NOT BE -LIABLE TO YOU FOR ACTUAL, DIRECT, INDIRECT, CONSEQUENTIAL, PUNITIVE OR -INCIDENTAL DAMAGES EVEN IF YOU GIVE NOTICE OF THE POSSIBILITY OF SUCH -DAMAGE. - -1.F.3. LIMITED RIGHT OF REPLACEMENT OR REFUND - If you discover a -defect in this electronic work within 90 days of receiving it, you can -receive a refund of the money (if any) you paid for it by sending a -written explanation to the person you received the work from. If you -received the work on a physical medium, you must return the medium -with your written explanation. The person or entity that provided you -with the defective work may elect to provide a replacement copy in -lieu of a refund. If you received the work electronically, the person -or entity providing it to you may choose to give you a second -opportunity to receive the work electronically in lieu of a refund. If -the second copy is also defective, you may demand a refund in writing -without further opportunities to fix the problem. - -1.F.4. Except for the limited right of replacement or refund set forth -in paragraph 1.F.3, this work is provided to you 'AS-IS', WITH NO -OTHER WARRANTIES OF ANY KIND, EXPRESS OR IMPLIED, INCLUDING BUT NOT -LIMITED TO WARRANTIES OF MERCHANTABILITY OR FITNESS FOR ANY PURPOSE. - -1.F.5. Some states do not allow disclaimers of certain implied -warranties or the exclusion or limitation of certain types of -damages. If any disclaimer or limitation set forth in this agreement -violates the law of the state applicable to this agreement, the -agreement shall be interpreted to make the maximum disclaimer or -limitation permitted by the applicable state law. The invalidity or -unenforceability of any provision of this agreement shall not void the -remaining provisions. - -1.F.6. INDEMNITY - You agree to indemnify and hold the Foundation, the -trademark owner, any agent or employee of the Foundation, anyone -providing copies of Project Gutenberg-tm electronic works in -accordance with this agreement, and any volunteers associated with the -production, promotion and distribution of Project Gutenberg-tm -electronic works, harmless from all liability, costs and expenses, -including legal fees, that arise directly or indirectly from any of -the following which you do or cause to occur: (a) distribution of this -or any Project Gutenberg-tm work, (b) alteration, modification, or -additions or deletions to any Project Gutenberg-tm work, and (c) any -Defect you cause. - -Section 2. Information about the Mission of Project Gutenberg-tm - -Project Gutenberg-tm is synonymous with the free distribution of -electronic works in formats readable by the widest variety of -computers including obsolete, old, middle-aged and new computers. It -exists because of the efforts of hundreds of volunteers and donations -from people in all walks of life. - -Volunteers and financial support to provide volunteers with the -assistance they need are critical to reaching Project Gutenberg-tm's -goals and ensuring that the Project Gutenberg-tm collection will -remain freely available for generations to come. In 2001, the Project -Gutenberg Literary Archive Foundation was created to provide a secure -and permanent future for Project Gutenberg-tm and future -generations. To learn more about the Project Gutenberg Literary -Archive Foundation and how your efforts and donations can help, see -Sections 3 and 4 and the Foundation information page at -www.gutenberg.org - -Section 3. Information about the Project Gutenberg Literary -Archive Foundation - -The Project Gutenberg Literary Archive Foundation is a non-profit -501(c)(3) educational corporation organized under the laws of the -state of Mississippi and granted tax exempt status by the Internal -Revenue Service. The Foundation's EIN or federal tax identification -number is 64-6221541. Contributions to the Project Gutenberg Literary -Archive Foundation are tax deductible to the full extent permitted by -U.S. federal laws and your state's laws. - -The Foundation's business office is located at 809 North 1500 West, -Salt Lake City, UT 84116, (801) 596-1887. Email contact links and up -to date contact information can be found at the Foundation's website -and official page at www.gutenberg.org/contact - -Section 4. Information about Donations to the Project Gutenberg -Literary Archive Foundation - -Project Gutenberg-tm depends upon and cannot survive without -widespread public support and donations to carry out its mission of -increasing the number of public domain and licensed works that can be -freely distributed in machine-readable form accessible by the widest -array of equipment including outdated equipment. Many small donations -($1 to $5,000) are particularly important to maintaining tax exempt -status with the IRS. - -The Foundation is committed to complying with the laws regulating -charities and charitable donations in all 50 states of the United -States. Compliance requirements are not uniform and it takes a -considerable effort, much paperwork and many fees to meet and keep up -with these requirements. We do not solicit donations in locations -where we have not received written confirmation of compliance. To SEND -DONATIONS or determine the status of compliance for any particular -state visit www.gutenberg.org/donate - -While we cannot and do not solicit contributions from states where we -have not met the solicitation requirements, we know of no prohibition -against accepting unsolicited donations from donors in such states who -approach us with offers to donate. - -International donations are gratefully accepted, but we cannot make -any statements concerning tax treatment of donations received from -outside the United States. U.S. laws alone swamp our small staff. - -Please check the Project Gutenberg web pages for current donation -methods and addresses. Donations are accepted in a number of other -ways including checks, online payments and credit card donations. To -donate, please visit: www.gutenberg.org/donate - -Section 5. General Information About Project Gutenberg-tm electronic works - -Professor Michael S. Hart was the originator of the Project -Gutenberg-tm concept of a library of electronic works that could be -freely shared with anyone. For forty years, he produced and -distributed Project Gutenberg-tm eBooks with only a loose network of -volunteer support. - -Project Gutenberg-tm eBooks are often created from several printed -editions, all of which are confirmed as not protected by copyright in -the U.S. unless a copyright notice is included. Thus, we do not -necessarily keep eBooks in compliance with any particular paper -edition. - -Most people start at our website which has the main PG search -facility: www.gutenberg.org - -This website includes information about Project Gutenberg-tm, -including how to make donations to the Project Gutenberg Literary -Archive Foundation, how to help produce our new eBooks, and how to -subscribe to our email newsletter to hear about new eBooks. |