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ON THE OPERATION FOR ARTIFICIAL PUPIL.
10 Should it be desirable, on the other hand, to obtain an effect solely optical-that is, to give passage to rays of light when the natural aperture of the pupil is obstructed, by a partial and stationary cataract for instance-it would be generally preferable to make a narrow artificial pupil, forthe same reasons that, in optical instruments, have governed. the adoption of diaphragms with narrow apertures. In some other cases-for instance, in central opacities of the cornea, with adhesion of the iris,-it is frequently desirable to excise a large portion of the pupillary margin of the membrane, and only a narrow extent of its periphery. If on penetrating more deeply into this question, the individual cases in these categories be analysed, it is impossible not to recognise the fact, that it is very necessary to be able to vary the iridectomy at will in order to render it as useful as possible in each individual case. But hitherto we have not been in possession of the very desirable means necessary to accomplish this end. We are ordinarily incommoded. by certain difficulties in the mechanism of the operation. We have not the freedom of action necessary in order to vary the shape and size of the iridectomy according to the urgency of the case. In the usual operation, after having made an incision in the cornea, a small pair of forceps is introduced into the, anterior chamber, with which the iris is seized and drawn out of the wound, and a portion of it excised. But it is the size and position of the incision in the cornea which almost solely determine the shape and size of the excision. For the forceps, which should always be introduced in a direction corresponding to the radius of the cornea-that is, towards the pupillary centre,-are limited in their expansion by the extent of the aperture in the cornea. If the grasp of the forceps has not been sufficiently extensive, and the portion of iris excised consequently is too limited, this fault can rarely be corrected after the first attempt.,. because a repeated introduction of the forceps is fraught with danger to the crystalline lens, which is no longer protected at this point by the iris. In order to avoid these difficulties, and render the shapeof the artificial pupil more independent of the dimensions. of the corneal incision, which it is not always possible to make of the size deemed necessary, it has seemed to me desirable to substitute for the ordinary iridectomy forceps an instrument which it shall be possible to introduce through ON THE a narrow opening in the cornea, and which nevertheless’ OPERATION FOR ARTIFICIAL PUPIL. shall expand widely in the anterior chamber. It was necessary that this instrument should be capable BY PROFESSOR LIEBREICH. of being introduced in any desirable direction other than radial. To the Editor of THE LANCET. Starting from these practical considerations, I have inSIR,-I beg to forward you for insertion a translation of vented a new form of forceps, answering completely all a note on the Operation for Artificial Pupil, which was lately read by Professor Liebreich before the Academy of Sciences at Paris, and by him communicated to me. Trusting that the great interest of the subject, and the just celebrity of the author, are sufficient reasons for troubling you,-I am, dear Sir, yours truly, LLOYD OWEN. Birmingham, May, 1870. _____
THE advances made by modern ophthalmology have so greatly increased the number of indications for the performance of iridectomy, that this operation has become one of the most important in surgery. In fact, it is well known that it sometimes produces a therapeutical effect, at others an effect purely optical, whilst occasionally the two effects are
combined.
Other operative methods for artificial pupil, such as iridodialysis and incarceration of the iris in the wound, have been completely abandoned for several years. At the present day the operation consists invariably in the excision of a piece of the iris.
I It is hardly necessary to say that the form and extent of the excised portion must vary greatly in each particular case, according to the effect sought by the operation. Thus, for example, when iridectomy is employed as the sole and powerful remedy against the various forms of glaucoma, and certain forms of irido-choroiditis, the excision of a large portion of the iris must be practised, including both the ciliary insertion and the pupillary margin; in these cases, the aperture resulting from the union of the natural and artificial pupils assumes the form of a keyhole.
11 for iridectomy. The following is a main trunks, whether by disease or ligature, has never of the instrument :been sufficient to effect the cure of the aneurism-except, The limbs of these forceps do not open in the ordinary indeed, in Mr. Evans’s case, where, however, the cure demianner, but turn round a longitudinal axis in such a way pended probably upon inflammation extending to the sac. that their rotation alone suffices to open and close their Supposing each of the main trunks to receive one-third of curved extremities. The movement of opening and shutting the whole volume of blood passing through the innominate, takes place without the part of the instrument which is the obliteration of one of them will still leave two-thirds of engaged in the wound participating in the least degree: the amount passing through the aneurism. But in addithis part of the instrument, on the contrary, remains closed tion to this, there should, I think, be taken into considera’when the extremities are expanded. The size of the wound tion the fact that the stream must be sent with more force plays no part in the mode of action of the instrument on through the carotid and subclavian trunks, which are the the iris. As a result of this circumstance, the introduction continuations of the main vessel, than into the branches of of the instrument is not limited to a radial direction; it the subclavian which come off at right angles, or nearly so, may take place in a series of other directions, all comprised to the main current. Thus, I am not surprised to find that in the extent of a segment of a circle of which the circum- even when the subclavian and its branches have become ference is described by the curved extremities of the forceps obliterated, the carotid being pervious, the aneurism contaken as a radius, whilst the centre of the circle is the part tinued to make progress, as in a case of Dr. Herbert Davies, of the wound in which the instrument is situated. reported in the London Hospital Reports, vol. i., where the The application of these new forceps does not present the aneurism eventually burst into the trachea. By cutting off slightest difficulty. Holding them like a pen between the the two main streams, and limiting the flow of blood to the three fingers, they are opened by placing the index finger branches of the subclavian artery, it appeared probable that on the instrument, and closed by applying the middle finger. a cure might be effected, not by the entire obstruction of The manufacture of the instrument is also sufficiently the innominate artery, but by the deposit of fibrin within it and the aneurismal sac, so as to arrest the disease. Mr. simple. The principle on which the construction of these forceps Wardrop believed that the carotid was already obliterated depends has never been applied to any surgical instrument. in the case on which he first tied the subclavian for innoI believe that this principle may easily be utilised for many minate aneurism ; and had it been so, the result might have other instruments; but I hope, above all, that it may been different; but, as the tumour diminished, the carotid, render important services by perfecting the operation of being relieved from pressure, began to beat again, and the aneurism to make progress. In an unpublished case which iridectomy. M. Paul Broca has kindly communicated to me, and in which he tied the subclavian for an innominate aneurism in ON THE TREATMENT OF INTRA-THORACIC August, 1862, the carotid was thought to be obliterated, but proved not to be so at the patient’s death in the followANEURISM BY THE DISTAL LIGATURE. ing February, the vessel being much displaced by the pressure of the tumour, and being reduced to about half its size. BY CHRISTOPHER HEATH, F.R.C.S., In this case, however, pulsation never returned in the vessel, ASSISTANT-SURGEON TO UNIVERSITY COLLEGE HOSPITAL, AND TEACHER OF OPERATIVE SURGERY IN UNIVERSITY COLLEGE, LONDON. which was obstructed, though not obliterated; and the case therefore resembles one of simultaneous ligature of the two THE patient, Julia W-upon whom I tied the right main trunks. The death of the patient was caused by gan.subclavian and common carotid arteries simultaneously in grene of the lung, and was in no way attributable to the aneurism, which was filled with fibrinous clot, leaving a the Westminster Hospital on Nov. 21st, 1865 (vide LANCET, cavity in the centre of the size of a small fowl’s egg, comDec. 2nd, 1865, and Jan. 5th, 1867), died on Dec. 8th, 1869, municating above with the carotid and subclavian, and from the external bursting of an aortic aneurism. By the below with the aorta. This last case may fairly be cona cure as far as the aneurism is concerned (though patient’s own wish, I was able to have her body’removed to sidered the Royal College of Surgeons, where it was carefully in- M. Broca himself speaks of it as a "half-cure" (demiand it may be classed with Mr. Fearn’s welljected from the abdominal aorta, and afterwards dissected guérison), known case in which he tied the common carotid in 1836, by Mr. Moseley; and the preparation will be added to the and the subclavian artery in 1838. Here the patient died - College museum. nearly four months after the second operation, from an The condition of the patient at the time of the operation attack of pleurisy unconnected with the aneurism, and due to an accident; and, as may be seen in the preparation in was as follows :-There was a pulsating tumour at the inner museum of the College of Surgeons, the aneurismthe end of the right clavicle, which was thrust forward. The which is a sacculated one, involving the aorta in some deinterclavicular notch, which was obscured by the tumour, gree, as well as the root of the innominate artery-is - could be felt on making deep pressure with the finger. The thoroughly filled with laminated fibrine, a canal being left pulsation extended above the clavicle and slightly towards for the passage of the blood into the unobliterated branches the sterno-mastoid muscle. When first seen there was no of the subclavian artery. bruit, but subsequently a faint bruit could be heard. The My patient made a perfect recovery from the operation. ’patient was pale, but well nourished; she suffered consider- Pulsation returned in the right temporal artery on the able pain in the tumour at intervals, was unable to assume night of the operation, and in the brachial two days after. the horizontal position without distress and dyspncea, and There were never any head symptoms. The tumour did had some difficulty in swallowing. The right radial pulse ’, not alter in size immediately, but two days after the operation the patient was able to lie down with perfect comfort; was smaller than the left. The patient was examined by numerous physicians and and by the third day the tumour had decidedly altered, the surgeons of eminence, and the almost unanimous opinion pulsation could not be so distinctly felt, and there was a was that the aneurism affected the innominate artery, distinct double beat, but no bruit. By the sixth day after though there was some difference as to whether or not the the operation the tumour had so much diminished that the aorta was slightly involved in addition. In the week during outline of the inner end of the clavicle and upper margin which the patient was in the hospital under observation the of the sternum could be clearly defined, the pulsation being tumour decidedly increased, the pressure symptoms became felt both above and below the bone. By the ninth day aggravated, and pain with numbness in the right arm came pulsation in the upper part of the tumour had nearly dison. Under these circumstances, and believing the aneurism appeared. On the eighteenth day both the ligatures came to be one of the innominate artery, I tied the right sub- away without any haemorrhage. Attempts were made to clavian artery outside the scalenus, and the right common favour the deposit of fibrine in the aneurism by the admi- carotid artery above the omo-hyoid muscle, on Nov. 21st, nistration of the acetate of lead, by the application of ice to the tumour, and by careful regulation of the diet, but 1865. The patient wa.s disIn determining upon tying the two main arteries simul- without any material advantage. taneously in this case, I was influenced very considerably charged from hospital on March 6th, 1866, three months a half after the employed by Mr. Erichsen in his work on operation, in good health, with no by the Surgery, wherein he shows that obliteration of one of the symptoms referable to the aneurism, which was now
’conditions
requisite
- description
arguments
and
THE advances made by modern ophthalmology have so greatly increased the number of indications for the performance of iridectomy, that this operation has become one of the most important in surgery. In fact, it is well known that it sometimes produces a therapeutical effect, at others an effect purely optical, whilst occasionally the two effects are
combined.
Other operative methods for artificial pupil, such as iridodialysis and incarceration of the iris in the wound, have been completely abandoned for several years. At the present day the operation consists invariably in the excision of a piece of the iris.
I It is hardly necessary to say that the form and extent of the excised portion must vary greatly in each particular case, according to the effect sought by the operation. Thus, for example, when iridectomy is employed as the sole and powerful remedy against the various forms of glaucoma, and certain forms of irido-choroiditis, the excision of a large portion of the iris must be practised, including both the ciliary insertion and the pupillary margin; in these cases, the aperture resulting from the union of the natural and artificial pupils assumes the form of a keyhole.
11 for iridectomy. The following is a main trunks, whether by disease or ligature, has never of the instrument :been sufficient to effect the cure of the aneurism-except, The limbs of these forceps do not open in the ordinary indeed, in Mr. Evans’s case, where, however, the cure demianner, but turn round a longitudinal axis in such a way pended probably upon inflammation extending to the sac. that their rotation alone suffices to open and close their Supposing each of the main trunks to receive one-third of curved extremities. The movement of opening and shutting the whole volume of blood passing through the innominate, takes place without the part of the instrument which is the obliteration of one of them will still leave two-thirds of engaged in the wound participating in the least degree: the amount passing through the aneurism. But in addithis part of the instrument, on the contrary, remains closed tion to this, there should, I think, be taken into considera’when the extremities are expanded. The size of the wound tion the fact that the stream must be sent with more force plays no part in the mode of action of the instrument on through the carotid and subclavian trunks, which are the the iris. As a result of this circumstance, the introduction continuations of the main vessel, than into the branches of of the instrument is not limited to a radial direction; it the subclavian which come off at right angles, or nearly so, may take place in a series of other directions, all comprised to the main current. Thus, I am not surprised to find that in the extent of a segment of a circle of which the circum- even when the subclavian and its branches have become ference is described by the curved extremities of the forceps obliterated, the carotid being pervious, the aneurism contaken as a radius, whilst the centre of the circle is the part tinued to make progress, as in a case of Dr. Herbert Davies, of the wound in which the instrument is situated. reported in the London Hospital Reports, vol. i., where the The application of these new forceps does not present the aneurism eventually burst into the trachea. By cutting off slightest difficulty. Holding them like a pen between the the two main streams, and limiting the flow of blood to the three fingers, they are opened by placing the index finger branches of the subclavian artery, it appeared probable that on the instrument, and closed by applying the middle finger. a cure might be effected, not by the entire obstruction of The manufacture of the instrument is also sufficiently the innominate artery, but by the deposit of fibrin within it and the aneurismal sac, so as to arrest the disease. Mr. simple. The principle on which the construction of these forceps Wardrop believed that the carotid was already obliterated depends has never been applied to any surgical instrument. in the case on which he first tied the subclavian for innoI believe that this principle may easily be utilised for many minate aneurism ; and had it been so, the result might have other instruments; but I hope, above all, that it may been different; but, as the tumour diminished, the carotid, render important services by perfecting the operation of being relieved from pressure, began to beat again, and the aneurism to make progress. In an unpublished case which iridectomy. M. Paul Broca has kindly communicated to me, and in which he tied the subclavian for an innominate aneurism in ON THE TREATMENT OF INTRA-THORACIC August, 1862, the carotid was thought to be obliterated, but proved not to be so at the patient’s death in the followANEURISM BY THE DISTAL LIGATURE. ing February, the vessel being much displaced by the pressure of the tumour, and being reduced to about half its size. BY CHRISTOPHER HEATH, F.R.C.S., In this case, however, pulsation never returned in the vessel, ASSISTANT-SURGEON TO UNIVERSITY COLLEGE HOSPITAL, AND TEACHER OF OPERATIVE SURGERY IN UNIVERSITY COLLEGE, LONDON. which was obstructed, though not obliterated; and the case therefore resembles one of simultaneous ligature of the two THE patient, Julia W-upon whom I tied the right main trunks. The death of the patient was caused by gan.subclavian and common carotid arteries simultaneously in grene of the lung, and was in no way attributable to the aneurism, which was filled with fibrinous clot, leaving a the Westminster Hospital on Nov. 21st, 1865 (vide LANCET, cavity in the centre of the size of a small fowl’s egg, comDec. 2nd, 1865, and Jan. 5th, 1867), died on Dec. 8th, 1869, municating above with the carotid and subclavian, and from the external bursting of an aortic aneurism. By the below with the aorta. This last case may fairly be cona cure as far as the aneurism is concerned (though patient’s own wish, I was able to have her body’removed to sidered the Royal College of Surgeons, where it was carefully in- M. Broca himself speaks of it as a "half-cure" (demiand it may be classed with Mr. Fearn’s welljected from the abdominal aorta, and afterwards dissected guérison), known case in which he tied the common carotid in 1836, by Mr. Moseley; and the preparation will be added to the and the subclavian artery in 1838. Here the patient died - College museum. nearly four months after the second operation, from an The condition of the patient at the time of the operation attack of pleurisy unconnected with the aneurism, and due to an accident; and, as may be seen in the preparation in was as follows :-There was a pulsating tumour at the inner museum of the College of Surgeons, the aneurismthe end of the right clavicle, which was thrust forward. The which is a sacculated one, involving the aorta in some deinterclavicular notch, which was obscured by the tumour, gree, as well as the root of the innominate artery-is - could be felt on making deep pressure with the finger. The thoroughly filled with laminated fibrine, a canal being left pulsation extended above the clavicle and slightly towards for the passage of the blood into the unobliterated branches the sterno-mastoid muscle. When first seen there was no of the subclavian artery. bruit, but subsequently a faint bruit could be heard. The My patient made a perfect recovery from the operation. ’patient was pale, but well nourished; she suffered consider- Pulsation returned in the right temporal artery on the able pain in the tumour at intervals, was unable to assume night of the operation, and in the brachial two days after. the horizontal position without distress and dyspncea, and There were never any head symptoms. The tumour did had some difficulty in swallowing. The right radial pulse ’, not alter in size immediately, but two days after the operation the patient was able to lie down with perfect comfort; was smaller than the left. The patient was examined by numerous physicians and and by the third day the tumour had decidedly altered, the surgeons of eminence, and the almost unanimous opinion pulsation could not be so distinctly felt, and there was a was that the aneurism affected the innominate artery, distinct double beat, but no bruit. By the sixth day after though there was some difference as to whether or not the the operation the tumour had so much diminished that the aorta was slightly involved in addition. In the week during outline of the inner end of the clavicle and upper margin which the patient was in the hospital under observation the of the sternum could be clearly defined, the pulsation being tumour decidedly increased, the pressure symptoms became felt both above and below the bone. By the ninth day aggravated, and pain with numbness in the right arm came pulsation in the upper part of the tumour had nearly dison. Under these circumstances, and believing the aneurism appeared. On the eighteenth day both the ligatures came to be one of the innominate artery, I tied the right sub- away without any haemorrhage. Attempts were made to clavian artery outside the scalenus, and the right common favour the deposit of fibrine in the aneurism by the admi- carotid artery above the omo-hyoid muscle, on Nov. 21st, nistration of the acetate of lead, by the application of ice to the tumour, and by careful regulation of the diet, but 1865. The patient wa.s disIn determining upon tying the two main arteries simul- without any material advantage. taneously in this case, I was influenced very considerably charged from hospital on March 6th, 1866, three months a half after the employed by Mr. Erichsen in his work on operation, in good health, with no by the Surgery, wherein he shows that obliteration of one of the symptoms referable to the aneurism, which was now
’conditions
requisite
- description
arguments
and