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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—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—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. <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. <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. <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. 1.—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. 2.—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. 3.—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. <a href="#i_25-1">4</a>, 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. <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. <a href="#i_25-9">5</a>) through the cornea and stretched -out iris, from above downward and a little obliquely -(Fig. <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. <a href="#i_25-10">12</a>), as, -indeed, Walton’s procedure (vide Fig. <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. 6.—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. <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. <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. <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. <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. 8.—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. 9.—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. 10.—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. 11.—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. 13.—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. <a href="#i_10">6</a>). His iris-knife (Fig. <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. <a href="#i_12">13</a>). If the tissue still retained -its elasticity there appeared a long pupillary aperture, -elliptical and vertical (Figs. <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. 14.—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. 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. <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. 17.—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. <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. 18.—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. 19.—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. 20.—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. <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. <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. <a href="#i_16c">20</a>), -or a crescent (Fig. <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. 21.—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. <a href="#i_18a">22</a>), thus securing a -triangular pupil (Fig. <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. 22.—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. 23.—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.—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. 25.—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. 26.—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 <>.</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. 27.—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. 28.—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>—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>—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. <a href="#i_19a">27</a>) and a pair -of specially devised fine iris scissors (pinces-ciseaux) -(Fig. <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. 29.—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. 30.—Iridodialysis. Divergent -V (DeWecker).</p></div> -</div> -</div> - -<p>(<i>a</i>) <i>Iritoectomie.</i>—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. <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>—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. <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. <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. 31.—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. 32.—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. <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 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. <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 mm.), and especially so for the execution -of the sawing movement advised by Adams.</p> - -<p>3. The double-edged lance-knife (Figs. <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. <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. <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. <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 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. <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 mm.) to be easily manipulated in the anterior -chamber.</p> - -<p>7. The Hays knife-needle (Fig. <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. <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. 4.—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. 37.—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. 36.—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. 16.—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. 35.—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. 34.—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. 7.—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. 33.—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. 5.—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. 12.—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 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 -<span class="nowrap">model<a id="FNanchor_32" href="#Footnote_32" class="fnanchor">32</a></span> of knife-needle (Fig. <a href="#i_25-2">37</a>) resembles Cheselden’s -knife, as shown by Sharpe (Fig. <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. 37.—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>—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. <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. <a href="#i_28b">39</a>).</p> - -<p><i>Second Stage.</i>—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. 38.—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. 39.—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. 40.—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. 41.—Pupil -resulting from V-shaped iridotomy.</p></div> -</div> -</div> - -<p><i>Third Stage.</i>—The pressure of the vitreous will now -cause the edges of the incision to immediately bulge -open into a long oval (Fig. <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. <a href="#i_28c">40</a>).</p> - -<p><i>Fourth Stage.</i>—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. <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. 42, (<span class="smcap">Case 1</span>).—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>—<i>History.</i>—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.</p> - -<p><i>Operation.</i>—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. <a href="#i_30">42</a>). With S. + 10 D. he saw 20/50.</p> - -<p><span class="smcap">Case 2.</span>—<i>History.</i>—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<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—3. Light perception -good, projection only fair.</p> - -<p><i>Operation.</i>—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. 43, (<span class="smcap">Case 2</span>).—Iridotomy -in a soft eyeball, with dense iris-membrane.</p></div> -</div> - -<div class="blockquot"> - -<p><span class="smcap">Case 3.</span>—<i>History.</i>—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.</p> - -<p><i>Operation.</i>—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. <a href="#i_32a">44</a>), but in O. S. a tag<span class="pagenum" id="Page_32">32</span> -of iris hung fast (Fig. <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. 44, (<span class="smcap">Case 3</span>).—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. 45, (<span class="smcap">Case 3</span>).—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>—<i>History.</i>—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.</p> - -<p><i>Operation.</i>—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. <a href="#i_33a">46</a>), 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. <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. 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. 46, (<span class="smcap">Case 4</span>).—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. 47, (<span class="smcap">Case 4</span>).—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. 48.—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. 49.—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.—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 mm. -to the left of the vertical plane (Fig. <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 mm. -to the right of the vertical plane (Fig. <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. <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. 451.</p> - -</div> - -<div class="footnote"> - -<p><a id="Footnote_4" href="#FNanchor_4" class="label">4</a> -Ibid, abridged, vii, pl. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 301, and ix, p. 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. 746, American edition, edited by Hewson, Philadelphia, -1855, p. 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. 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. 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. 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. 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> - -<div style='display:block; margin-top:4em'>*** END OF THE PROJECT GUTENBERG EBOOK HISTORY OF IRIDOTOMY ***</div> -<div style='text-align:left'> - -<div style='display:block; margin:1em 0'> -Updated editions will replace the previous one—the old editions will -be renamed. -</div> - -<div style='display:block; margin:1em 0'> -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. 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