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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.

S. LEWIS ZIEGLER, A.M., M.D., Sc.D.

Attending Surgeon, Wills Eye Hospital; Ophthalmic Surgeon, St. Joseph's Hospital.

PHILADELPHIA.

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:

In addition to these nine distinct methods certain combinations of these have been described and successfully practiced:

HISTORICAL REVIEW OF IRIDOTOMY.

In this brief review of iridotomy, 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.

Wagner, Karl Wilhelm Ulrich: Inaugural Thesis, G?ttingen, 1818. He invented the designation iridotomia, which he formed from the original Greek, ????, ?????? and ???? .

Cheselden, William: Philosophical Transactions, London, 1728, xxxv, p. 451.

Ibid, abridged, vii, pl. v, Figures 2, 3 and 5.

Sharpe, Samuel: A Treatise on the Operations of Surgery, London, 1739, p. 169.

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 and Adams, both describe the incision as being made from before backward. As Sharpe was his pupil, and presumably had seen him operate, Guthrie suggests the possibility of his having made his incision both ways, the technic being practically the same.

Adams, Sir William: Practical Observations on Ectropium, Artificial Pupil and Cataract, London, 1812, p. 37 et seq.

Guthrie, G. J.: Operative Surgery of the Eye, London, 1830, p. 428.

Morand, 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, 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.

Histoire et M?moires de l'Acad?mie Royale de Chirurgie, Paris, 1757, iii, p. 115.

Huguier, Pierre Charles: Des Op?rations de Pupille Artificielle, Paris, 1841.

Sharpe, 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 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 , but in his ninth edition he substitutes a broad lance-knife with two edges which closely resembled the one Wenzel had just introduced , 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, 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.

Heuermann, Georg: Abhandlung der Vornemsten Chirurgischen Operationen, Copenhagen and Leipzig, 1756, ii, p. 493.

Janin, 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.

England and India, bureaucracy, democracy, sedition, education, politics and Durbars:--the world with all its tumult and its roaring passes clean over their heads, unheeded, unobserved: for them the noise and bustle do not matter, do not trouble: they do not hear, they do not listen, they do not even care. It is curious, this peace, this indifference, this calm: it does not seem reality; it is like a thing looked at in a picture, like a dream. And, somehow, as I gazed at it, mechanically there came into my mind, as it were of its own accord, a story I had read in some old navigator's "yarn," of the albatross, sleeping on the great South Sea, in the fury of a storm, with its head beneath its wing.

CEYLON, 1912

A SPOILED CHILD

A SPOILED CHILD

BENEDICTION

There is, in the western quarter, a land of lonely desolation, that resembles a very sea, but of sand instead of brine, and rightly named Marusthali, being a very home of death, sending back to the midday sun rays hotter than his own, and challenging the midnight sky, with silent ashy laughter, as though to say: What am I but the rival and reflection of thyself, with bones instead of stars, and tracks of wasted skeletons instead of a Milky Way. And there, upon a day, it came about that Maheshwara was roaming with P?rwat? in his arms. And as they floated swiftly on, over the dusty waste, they watched their own huge shadows sweeping like the forms of clouds across the burning sand, exactly underneath, for it was noon: and the surface of the desert shook and quivered in the stillness, as if the wind, asleep, had, like a tired traveller, sought refuge from the fury of the sun above their heads. And all at once, the Daughter of the Snow exclaimed: See, there is the mirage! Let us descend, and sit for a little while upon the sand: for I love to watch this wonder, which resembles in its far faint blue the colour of a dream. And accordingly, to do her pleasure, Maheshwara sank softly to the earth, settling on it like a cloud gently resting on a hill.

So as they looked, after a while, that slender goddess said again: Surely it is a shame, and well may the poor antelopes be mistaken and deceived. For who could believe yonder water to be only an illusion? And when the eyes of even gods are bewildered by the cheat, how much more the eyes of thirsty and unreflecting little deer!

Then the Moony-crested deity said slowly: O Daughter of the Snow, thy own reflection on this beautiful illusion is the truth. And yet, well were it for the world, were its illusion limited only to its eyes, not extending, as it actually does, to its understanding also. For this deceptive picture on the sand is far inferior in power and importance to the bewildering delusion of this world below, fluttering about whose shifting dancing light, like moths about a wind-blown torch, men singe their silly souls, and burning off their wings, drop helpless, maimed and mutilated, into the black gulf of birth and death, and lose emancipation; till, after countless ages, their wings begin to sprout and grow again, under the influence of works. Yet they who after all emerge, and soar away, unburdened even by an atom of the guilt that weighs them down, and brings them back into the vortex of rebirth, are very few. And yonder bones, now lying in the sand, could they but rise and speak, would be a proof of what I say.

And the goddess looked, and saw, close by, a little heap of bones, that lay half-buried in the sand. And she said with curiosity: Whose are the bones, and how are they a proof of thy consideration?

And Maheshwara replied: These are bones, not of a man, but of a camel, that perished in the desert long ago. For into this body of a camel fell the soul of which I spoke, in punishment of crimes committed in the birth before, in the body of a man; who, blinded by passion, slew three of his fellow mortals; as, if thou wilt, I will tell thee while we sit, watching the illusion of the senses, that so closely represents the illusion of the souls of the lovers in the tale.

Know, then, that once upon a time, long ago, all the gods had assembled in the hall of Indra's palace, to listen to a singing competition that took place among the Gandharwas. And all sat listening attentively, till at length, all at once, came a pause in the performance. And in the silence, while all the heavenly singers rested, it so fell out, by the decree of destiny, that the flowery-arrowed god, striving to recollect a cadence that had pleased him, hummed it, as well as he could, over again, aloud; and like the unskilful imitator that he was, played havoc with his model, stumbling at the quarter tones, and singing fiat. And out of delicacy and politeness, the gods all turned away their faces, hiding their smiles, except Brahma, whose face never moved. But K?madewa, looking up suddenly, caught the vestige of a smile, hovering, just before it disappeared, on the corner of the lips of Saraswati, as if it were unwilling to leave a resting-place so unutterably sweet as that lovely lady's mouth. And instantly, he turned red and pale alternately, with rage that followed shame: so little does he who delights in making others blush like doing it himself. And suddenly taking fire, he cried aloud: Ha! dost thou turn me into ridicule, O thou malapert blue-stocking? Then will I curse thee for thy pains. Fall instantly into a lower birth, and suffer anguish in the form of a mortal woman, for thy presumption and ill-mannered mirth.

And then, as he listened to my doom, K?madewa turned paler than the ashes to which I had reduced him long ago, finding himself punished for his insolence by me, for the second time. But the gods all exclaimed, with approbation and delight: Victory to Maheshwara! who has once more bitten the biter, and condemned him, by a sentence even more merciful than he deserved. For what could be more intolerable than even Heaven without Saraswati, unless it be the curse that is about to produce such a melancholy condition of affairs?

And then, those two deities disappeared suddenly from Heaven, and descended to be born as man and woman on the earth.

Now just at that very moment, it happened, that there were living in the desert two Rajpoots of the race of the Moon; and the name of the one was Bimba, and that of the other, Jaya. And Saraswati was born as the daughter of the wife of Bimba, while K?madewa was born as the son of the wife of Jaya. Now Bimba was a king: and Jaya was his cousin on the mother's side. And very soon afterwards, Jaya set upon his cousin, laying claim to the throne, and driving him away, took his kingdom, and kept it for himself. And he caught the wife of Bimba, and put her to death, as he would have done also with her daughter and her husband. But Bimba succeeded in escaping with his daughter, and ran away and hid himself. So Jaya remained in triumph, reigning over the kingdom, whose capital stood on the very spot on which we are sitting now. For the kingdoms of the earth come and go upon it, like the shadows of the clouds: and they grow up suddenly like grass, and perish a little later, and vanish clean away, leaving behind them absolutely nothing but mounds, such as those now lying all about thee, and fragments of recollections, and half-forgotten names, like the dreams of the night which morning obliterates and drives away, vaguely hanging in its memory like wreaths of mist curling and twisting on the black still surface of a pool in some dark valley screened from the early sun by one of thy father's peaks.

And of all the elements that made up Java's good fortune, there was not one which filled him with such pride and exultation as his son. And he looked upon him as the very fruit of his birth in visible form, little dreaming, that could he but have looked into the future, and seen what was coming, he would rather have deemed himself more fortunate to live and die without any son at all, than to have begotten such a son as he actually had. For sons resemble winds, which sometimes lift their families like clouds to heaven, and sometimes dash them to the earth, like hail.

And yet, all this beauty was nothing but a mask, and a lie: and so far from expressing the nature of that soul which it covered and disguised, it actually added evil to its original defect; and he resembled a bamboo, looking like a very incarnation of loveliness and symmetry outside, and singing in the wind, and yet absolutely hollow and without a heart, within. For from the very moment he was born, he did exactly as he pleased, and nothing else, being as capricious as the breeze that blows only as it chooses. For beginning with his parents, nobody ever crossed him, or placed any obstacle whatever in the path of his desires, which grew up accordingly like a very rank jungle impervious to the light, in which his will wandered like a wild young tiger-cub, wayward, and passionate, and absolutely uncontrolled. And he gave in to others, and was guided by them, in one point only, and that was in their extravagant admiration of himself. For finding others worship him, he fell in with their opinion, and followed their example: and became as it were the devotee at the shrine of his own beauty, making it a deity to which every other thing or body was only fitted to be sacrificed. And he filled his rooms with mirrors of many colours, made of crystal and lapiz-lazuli, and polished gold and silver, and the water of tanks whose slabs were of marble of every variety of hue; and he used to sit alone, when he had nothing else to do, for hours, watching his own image that seemed to offer him reciprocally worship as he watched it, as if it were doubtful which of the two, the reality or its reflection, was the deity, and which the devotee.

And gradually the world with all its objects came to appear in his eyes as nothing but a playground, and all its men and women merely his own animated toys. And from being utterly indifferent to everything but his own momentary pleasure and caprice, he became, little by little, first callous to the sufferings of others, and finally positively cruel, finding his amusement in making others victims to his own peremptory desires. And his appetite, like a fire, grew with the fuel that it fed upon, till it resembled voracity, and an intolerable thirst for more. But as long as he remained still a child, the fire, remaining as it were without its proper aliment, lay hidden: till he grew into a man. And then, all at once, it blazed out furiously like a very conflagration, striking terror into all the subjects of the kingdom, and threatening to consume them all, like forest trees and grass.

For whereas, till then, the fury of his self-will had been scattered, for want of concentration on one object only, manhood, like a flash of lightning, suddenly revealed to him that very object, in the form of woman: and he discovered, in the storm of his delight, that women were the very victims for whom he had been blindly groping in the darkness all his life. And he threw himself upon them, like a prey, finding with intoxication that the Creator had framed him as a weapon constructed wholly for their destruction. And he said to himself, in triumph: I am, as it seems, a magnetic gem, omnipotent and irresistible, to whose attraction the entire sex succumbs inevitably, like grass. And this opinion was justified by the conduct of the women themselves. For every woman that set eyes on him, no matter who she was, fell instantly, like a stone dropped into a well without a bottom, into the abyss of infatuation, and utterly forgot not only her relations and her home, but her honour and herself and everything in the three worlds, seized as it were by the very frenzy of devotion, and anxious only to immolate herself as a victim on the altar of his divinity. And strange! though he treated them all as more worthless than grass, throwing them away almost in the instant that he saw them, not one of them all ever took warning by the fate of her predecessors: and so far were they from shunning him as the common enemy of their entire sex, that on the contrary, they seemed to struggle with one another for the prize of his momentary affection, the more, the more openly he derided them; as if even his derision and the cheapness in which he openly held them, increased the power of his charm. Ha! very wonderful is the contradiction in the heart of a woman, and bitter the irony of the Creator that fashioned it out of so curious an antagonism! For she flies to the man who makes light of her, as if pulled by a cord; while she utterly despises the man who thinks himself nothing in comparison with her: saying as it were, by her own behaviour, that she is absolutely worthless in her own esteem.

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