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owing to absence of subjective complaints, to lack of portance to that of cataract itself. Not only were a large cooperation on the part of patients in physical examina- number of monographs devoted wholly to this subject, tions, and to the difficulty of obtaining from such pa- but every work on general surgical topics set aside one or tients specimens of sputum for examination. more chapters for the discussion of artificial pupil. It seems to me, however, that the number of path- This is in great contrast to the limited space which mod- ologic records on which the above statistics are based is ern works on ophthalmology grudgingly yield to this still sufficiently large, and that in view of the remarkable important subject. showing of the figures the existence of a distinctly ft is difficult for us to appreciate the conditions which heightened immunity against tuberculosis in cases of brought about so large a percentage of cases of pupil- general paresis is hardly to be questioned. lary occlusion. Crude surgical procedures, poor opera- To what is this immunity due? tive technic and the utter lack of asepsis often resulted It has been shown by experimental inoculations that in iridocyclitis or iridochorioiditis. The couching of the paretics are immune against syphilitic infection.2 This lens, the free discission of both hard and soft cataracts, immunity is attributed to previous syphilitic infection, the frequent introduction of the knife-needle through which is now generally regarded as the one essent'al the dangerous ciliary zone, and the bungling efforts at factor in the etiology of general paresis. The question extraction all increased the tendency to inflammatory that naturally suggests itself is: May not the immunity reaction, while inadequate therapeutics and lack of against tuberculosis be due to the same cause? Syphi- antiphlogistic measures frequently permitted the de- litic infection, as is well known, gives rise in the human posit of plastic exúdate in the pupillary area, thus re- organism to an inflammatory reaction which is almost sulting in membranous occlusion of the pupil. identical in its nature with that which results from OPERATIONS FOR ARTIFICIAL PUPIL tuberculous infection. This fact, it seems to me, adds probability to the above assumption. For the sake of historical completeness, and in order In this connection also other questions of practical to better emphasize the special domain of iridotomy, 1 interest suggest themselves: If syphilis does confer will mention briefly the various methods that have been immunity against tuberculosis, at what clinical stale employed in making an artificial pupil. These are : of syphilis does this immunity develop? How would (1) Division of the thickened iris-membrane by an the course of a case of tuberculosis be affected by a su- incision made either through the sclerotica or through peradded syphilitic infection. the cornea. This is true iridotomy. I found among all the pathologic records which (2) Excision of a portion of the iris through a pre- I examined five cases of insanity due to syphilitic brain viously made corneal opening. This is now known as disease. All of the patients were entirely free from iridectomy. tuberculous lesions. I found also records of eight cases (3) Separation of the iris from its ciliary attachment. of cerebral hemorrhage with histories of syphilis; in This was generally known as iridodialysis, but sometimes two of these a few small scars were found at the apices called iridorrhexis. of both lungs probably healed tuberculous lesions', (4) Simple incision of the pupillary and of — margin, the rest showed no evidences of tuberculosis. The num- the free iris tissue. This has been designated sphincter- ber of these cases is too small, of course, to justify any otomy by some, and coretomy or iritomy by others. conclusion, and further investigation, both clinical and Either one of the latter terms is to be preferred, because anatomic, would be required to answer the above ques- it is more clearly descriptive. tions. (5) Detachment of the synechiae at the pupillary margin, either anterior or posterior, thus allowing the to retract. This was known as HISTORY OF IRIDOTOMY pupil corelysis. (6) Strangulation of the prolapsed iris in the corneal KNIFE-NEEDLE VS. SCISSORS\p=m-\DESCRIPTION OF AUTHOR'S incision was called iridencleisis. The prolapse was some- V-SHAPED METHOD times tied with a ligature. S. LEWIS ZIEGLER, A.M., M.D., Sc.D. (7) Trephining of the iris-membrane, by passing a Attending Surgeon, Wills Eye Hospital; Ophthalmic Surgeon. St. small trephine or punch through a corneal incision. Joseph's Hospital (8) Section and removal of a portion of the sclerotica PHILADELPHIA and chorioid by knife or trephine, with replacement of To Cheselden has been conceded the honor of being the conjunctiva over this opening, the conjunctiva thus the father and originator of iridotomy. Nearly two acting as a substitute for the cornea in transmitting centuries have elapsed since he first published the report light. This was called sclerectomy. of his procedure in the Philosophical Transactions for (9) Transplantation of the cornea for total leucoma. 1728. Ever since that time, his signal success has been This was usually preceded by partial or complete tre- acknowledged by all except those who either failed to phining of this membrane. equal his dexterity, or who were prejudiced by their In addition to these nine distinct methods certain ambition to originate a new method. combinations of these have been described and success- A careful review of the medical literature of the cen- fully practiced : and a tury half following Cheselden's announcement (10) Division and excision have frequently been per- can not fail to impress the reader with the great interest formed together. attached the an to operations for formation of artificial (11) Separation and excision have likewise had some pupil, which subject was considered second only in im- vogue. and have 2. Krafft-Ebing: Die Aetiologie der progressiven Paralyse, (12) Separation strangulation occasionally Arbeiten, 1897, ii, 12. been practiced. Read in the Section on Ophthalmology of the American Medical Detachment of the and excision have Association, at the Fifty-ninth Annual Session, held at Chicago, (13) synechia3 June, 1908. also been performed. Downloaded From: http://jama.jamanetwork.com/ by a Carleton University User on 06/19/2015 HISTORICAL REVIEW OF IRIDOTOMY For more than a century the method of Cheselden seems to have been the storm of In this brief review of iridotomy1 we shall confine center controversy. Some our attention to the methods that have been advanced doubted his veracity, others essayed his operation but while a few a success. for the formation of an artificial pupil in cases of mem- failed, had moderate degree of branous occlusion of the removal of the Many attributed to him statements which do not appear pupil following in in lens, either by couching, extraction Or discission, the iris- his published report. He says clearly that each of his cases membrane in these cases being chiefly composed of in- couching had previously been performed, flamed iris tissue glued clown by retro-iridian exúdate and yet some have insisted that the lens was present, and to the thickened lens capsule. must have been wounded. He also states that his inci- The early history of iridotomy shows that the advo- sion was made from behind forward, and yet his fol- cates of this operation were divided into two schools, lowers, Sharpe4 and Adams,5 both describe the incision (1) those recommending the use of the knife-needle as being made from before backward. As Sharpe was for incising the iris-membrane, and (2) those adopt- his pupil, and presumably had seen him operate, Guth- ing the method of introducing scissors through a rie6 suggests the possibility of his having made his in- previously made corneal section and freely excising cision both ways, the teehnic being practically the same. the iris-membrane, or excising a portion of the same. Morand,7 in his "Eulogy of Cheselden," claims to have We will first consider the school which advocated personally seen him operate "on an eye in which the iris incision by the knife-needle. was closed by an accident," and gives a more detailed I. KNIFE-NEEDLE METHOD description which closely Cheselden,2 a renowned follows the original method. surgeon, and oculist to Her He states that Cheselden Majesty, Queen Caroline of presented him with one of England, first announced, his knife-needles as a sou- in 1728, his success in mak- venir of the occasion. Al- ing an artificial pupil by though Morand does not means of his knife-needle. record the exact date of his He made his puncture back visit to London, he does of the corneoscleral junc- state that it occurred dur- tion on the temporal side, ing the year 1729. Hu- passing the knife across the guier,8 in his exhaustive posterior chamber, and thesis on artificial pupil, making a counter-puncture also places the date of this in the iris-membrane near visit in the year 1729. This the nasal margin. He then fact is important, as some cut through the iris from writers have declared that behind forward as he with- Morand neither made the drew the knife, the incision visit to London nor saw being carried through two- Cheselden operate, but only thirds of its extent. The quoted the original account pupillary opening thus given in the Philosophical made was a long oval slit, Transactions. The publica- horizontally placed. He has tion of Morand's high en- reported two successful comiums in 1757 attracted cases3 (Pigs. 1 and 2), oc- renewed interest to the sub- curring in patients who ject of Cheselden's opera- had previously undergone tion among men of scien- couching of the lens.

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