Some Aspects of
Ancient and More recent
Tonight we might, in fact, begin this discussion some one or two thousand million years ago in the warm waters of the Archeozoic era and we might end it with speculations of tomorrow. However, some time and some where, like all things finite the art and science of Ophthalmology began and it surely existed for many a slow-unfolding age before it peeped from within the covers of a book. Therefore, we shall consider some of the ancient bases and developments in this particular area of medicine and shall mention the importance of cataracts, still the leading cause of blindness in the world today.
The earliest mention of Ophthalmology that can be found, oddly enough, is in an ancient collection of laws, promulgated and enforced by a king of Babylonia-Assyria, called HAMMURABI, who ruled about 2250 B.C. Sadly enough it relates mainly to ophthalmic negligence, or malpractice to wit:
-If a man destroy the eye of another man, they shall destroy his eye.
-If a physician opens an abscess in the eye of a man with a
bronze lancet and saves that man's eye, he shall receive ten shekels of silver.
-If he destroys the man's eye, they shall cut off his fingers.
Of these brief passages from the code of HAMMURABI, it can be noted that, in those days, the “lex talionis” (an eye for an eye) was literally enforced, that the surgical instruments in those days were made of bronze indicating that the Babylonians of that time were not yet out of the bronze age, and that the science of Ophthalmology was not very far advanced. It was also mixed to the vanishing point with the grossest of superstition and magic.
When primitive man found the forces of nature difficult and uncooperative, he created gods whose function was to preside over the uncertainties of his life and to whom he could appeal. By a necessary consequence, the medical practice of this earliest dawn of civilization was carried out through various incantations.
Here is a portion of a typical incantation:
The wicked god, the wicked demon,
the demon of the desert, the demon of the mountain, the demon of the sea, the demon of the marsh,
the evil genius,. the enormous uruku,
the bad wind by itself,
the wicked demon which seizes the body,
which distrubs the body.
Spirit of the heavens, conjure it!
Spirit of the earth, conjure it!
He who forges images, he who bewitches
the malevolent aspect, the evil eye,
the malevolent mouth, the malevolent tongue,
the malevolent lip, the finest sorcery.
Spirit of the heavens, conjure it!
Spirit of the earth, conjure it!
From these earliest beginnings, we pass in time, and space to ancient Egypt Circa 1650 B.C. Here none of the gods were particularly distinguished for curing the sick. Casting out the demons of disease was a minor function for them all. In fairness to the ancient Egyptian physicians it must be admitted that they seemed to place more emphasis on medications and less on prayers and incantations than their colleagues elsewhere. It was an advance not shared by the general public, who preferred to place each part of the body under the protection of a special deity. The goddess HATHOR was the protectoress of the eyes.
HATHOR is of interest in that she was originally a personification of the sky, as the meaning of her name, “Castle of (the sky-god) Horus,” shows. In the sun temples built by six kings of the 5th dynasty (ca. 2560-2450 B. C.) near Memphis, her worship was therefore, associated with that of another sun-god, Ra of Heliopolis. In the old center of her cult, at Dendera, in upper Egypt, however she was considered as the wife of Horus and as the goddess of festivity, dance and love. After the spread of her cult, owing to the proximity of the necropolis of Thebes, she became "Lady of the West" and patroness of the region of the dead, quite contrary to her earlier nature. The Greeks identified Hathor with their Aphrodite.
In connection with the goddess Hathor, the god Horus was closely entwined. He represented the sky-god and took the form of a falcon whose eyes were the sun and the moon. With the god Setekh of Ombas in upper Egypt, Horus lived in peace during the first dynasties as a partner in joint incarnation of the king; Setekh remained the representative of upper Egypt, while Horus represented lower Egypt. Not later than the end of the 5th dynasty, however (ca. 2425), the cult of Osiris spread over Egypt, and Horus was introduced into the Osiris cycle. The deceased king, having been then identified with the god Osiris and the living and reigning king being an incarnation of Horus, Horus became the son of Osiris and of the goddess Isis, Isiris' sister-wife. As such he now became an opponent of Setekh, the murderer of Osiris and the contestant of Horus’ heritage - the royal throne of Egypt. According to myth Horus defeats Setekh, thus avenging his father and assuming the rule. In the fight, his left eye (i.e. - the moon) was damaged - this being the mythological explanation of the moon's phases - and was healed by the god Troth. The figure of the restored eye became a powerful amulet. The Greeks identified Horus with Appollo. Horus harpooning his enemy Setekh in the form of a crocodile was a potent magical figure and seems to have served as a model for St. George killing the dragon.
The eye of Horus is found extensively in Egyptology and was used by the priest pharmacists as amnemonic device for apothecary work as the following figure illustrates.
The earliest records of Ophthalmology in Egypt are in the Brugsch and Ebers papyrus, of which Ebers is much the more important. It was found by the Egyptologist Georg Ebers during the winter of 1872 - 1873 in the possession of a certain Arab, who, in turn, had discovered it between the legs of a common mummy in the necropolis of Thebes. It was 30 centimeters wide and 20 meters long, and described all the diseases that were known to the Egyptians; one hundred and ten pages of which eight pages were devoted exclusively to diseases of the eye and the various remedies available for therapy (less than 8%).
To comprehend the Ophthalmology of Egypt one must look, at least briefly, on medicine in general. In those far distant days in Egypt, medicine was taught, together with all the other learning of the age, in the temple schools. At first the priests were doctors and the doctors priests, there was no distinction. At an early date, however, a separation occurred, and physicians, surgeons, and exocisers formed entirely distinct classes in the community. Later still specialists appeared. Though anatomy was extremely unappreciated, the preservation of the body was a “Sine qua non”, to the resurrection of the individual from the dead. Good, bad, and indifferent, rich and poor, learned and unlearned, everybody in Egypt had to be embalmed.
Although the practice of mummification seems rather macabre and grotesque to modern man, it was carried out for this specific purpose. The intention was to preserve the body from the ravages of putrefaction, to maintain the identity of the dead man, and in later periods, to create a form which could resemble the embalmed God OSIRIS. The Egyptians, however, made no attempt to preserve the ocular globe. The usual treatment was to pack the orbits with pads of linen on which the iris might be roughly painted.
In pursuing some investigations on mummy palaeo-histology, A.T. Sandison, treated an Egyptian mummy head with rehydrating fluid in order to obtain material for very large histological sections, and was surprised to notice that gradually the apparently empty orbits became occupied by an unfolding of tissue which eventually approached the space between the partly open lids. After the contents were removed en masse, it became obvious that only the anterior portions had survived, but amazingly the circular cornea regained some of its former translucency. In the remaining portions the characteristic melanin pigmentation of the inner coats was still apparent and traces of the irido-corneal angle were present.
Though there is abundant evidence of many diseases from the examination of Egyptian mummies (fractures, spondylitis, Tbc, caries) the organ of sight is too delicate to resist a thousand years. Lacking autopsy evidence, we must return again to the testimonials of the Papyrus Ebers. Some of the more important ocular diseases and the remedies given in this ancient manuscript were:
- For “Dimness of Sight” (cataract, corneal opacities) the Egyptians recommended in the early stages, swamp water; later compresses of antimony and honey. A favorite prescription was honey mixed with excrement from a child.
- For “pain in the eye” an ointment was employed consisting of antimony and charcoal.
- For “turning of the eyes” (strabismus) equal parts of tortoise brain rubbed up with oriental spices
- For “pus in the eye” the clay honey and richins leaves each onr re (ro= 0.0141 1.)
- For “tear eyes” equal parts of verdigris and onions were mixed together and laid on.
Tear eyes or watery eyes mean eye affections with considerable secretions, especially the sequalle of chronic granular conjunctivitis. Many historic investigators consider trachoma as the cause of “tear eyes”, and doubtlessly trachoma existed in ancient Egypt, yet we cannot conclude that it was spread over the whole population as it is today. “Anyone who has seen with his own eyes,” writes Hirschberg, “those wonderful monuments, the pyramids of the old empire, the rock tombs of the middle empire, the imperial sanctuary, the temples and the tombs of Thebes, covered with carving and inscription, of the new empire, cannot readily accept the view that even in the time of the Pharaohs the Egyptians were a “blind folk” as the humorous and more cultivated Nile dwellers are want to call themselves today.”
The disease was there, however; as this letter written in 1250 B.C. from father to son attests: “Do not abandon me, I am in distress! Do not cease to deplore me; for I am in darkness! My God Amon has abandoned me. Bring me some honey for my eyes and some fat and real eye-paint as soon as possible. Yes, I am weak. I want to have my eyes and they are missing!” All discussion on the origin of this disease might be summed up in the sentence: Trachoma is as old as the Nile, the simoon, and the desert.
The following incident referred to by Herodotus shows in what esteem the Egyptians oculists were held: Cambyses, son of Cyrus, King of Persia (Herodotus, Thal, III, i.p. 198), requested Amasis, King of Egypt, to send him his best oculist to treat his mother, Kassandane, who was blind. This request was complied with by sending Nebenchari, the most famous oculist in Egypt, who remained with the royal patient until her sight was restored. Her blindness was due to senile cataract, for the relief of which the operation known as “Cutting the skin that covered the pupil of the eye” was performed.
During the oculists' stay in Persia, his King, Amasis, became afflicted in the same manner and was operated on by Pentamon, a rival of Nebenchari, the latter being in reality the inventor of the operation. When Nebenchari heard of Pentamon's success in treating Amasis, he was convinced that he (Pentamon) had had access to his manuscript, and thereby learned the secret of the operation. He was informed later that Pentamon had destroyed this manuscript, and was deeply grieved at its loss; but it was afterwards discovered; and in it are described many remedies for disease of the eyes which were spoken of in the sacred books of Toth, and in the writings of the famous old physicians of Byblos, as incurable.
However, the reverence of the Egyptians for anything relating to the gods would have convicted Nebenchari of sacrilege had he published his work as a correction of the books of Toth, consequently, he named his work “Additional Writings on the Treatment of the Diseases of the Eyes, by the Great God, Toth, newly discovered by the oculist Nebenchari.” He had intended to bequeath his works to the library at Thebes, so that his successors and the afflicted might profit by his experience.
Nebenchari, who for some reason had deferred the operation on Kassandane, on hearing of the success of his rival, immediately performed the couching operation, in which he was very skillful.
This account of a surgical approach to the problem of cataract was in approximately 560 B.C. All the earlier descriptions point out the fact that cataract was well known to the Egyptians and many medicaments were prescribed. However, it is generally conceded that Susruta of India first introduced the couching operation for cataract in 600 B.C. After the conquest of northern India by Alexander the Great, his physician brought this knowledge to Alexandria where a thriving medical center existed. The first extant description of the couching operation is given by Celsus in 25 A.D. It is interesting also that Susruta also described Pterygium which is still today a tremendous problem in India and other tropical countries.
During the ensuing years, couching was widely practiced in Egypt, Arabis, India and Europe. Although there is not a great deal of information available as to specific ophthalmic practices during the early centuries A.D., Grassus, a Hebrew oculist published his work “Practica Oculorum” in 1050 A. D. In 1268 in the Opus Majur of Friar Roger Bacon, lenses are mentioned as being useful for patients who have weak sight. Spectacles, the crowning ophthalmologic achievement of the Middle Ages, led to the development of the telescope and the microscope.
At this juncture, it is well to remember that historically many ways have been opened to us for removing cataract. We may either subject it to resorption by means of discission, we may tear a hole in it by dilaceration, or we may remove it altogether from the eye. But not even by this list are all the methods of restoring the sight of an eye blind with cataract exhausted. We may also, instead of removing the opaque lens, push it away from its place behind the pupil so that the latter becomes free again. This artificial luxation is not only practicable, but as a matter of fact, it has been practiced for a thousand years; it is the oldest method of operating for cataract as we have shown in the preceding pages. T his method, called depression of cataract (depressio cataractae), was made in the following way. A needle was passed into the sclera on the outer side of the margin of the cornea and about 4 mm. behind it, and it was pushed forward until at length it lay against the upper border of the lens. Then the point of the needle was lowered by a sweeping movement, and the lens was thus depressed into the vitreous. The moment this was done the pupil became black and the patient regained his sight. This was the only methods of operating upon cataract practiced in ancient times and throughout the Middle Ages. As time went on it was modified in various ways. The last and most important modification consisted in turning the lens over instead of depressing it. The needle in this case was passed by the margin of the pupil and into the anterior chamber, and with it pressure was made upon the upper part of the anterior surface of the lens. The latter was thus turned over in such a way that its anterior surface looked upward, its posterior surface downward. This procedure was called reclinatio cataractae.
The operation above mentioned, or “cataract pricking” was, as a rule, practiced by special physicians. In the middle ages these went from one annual fair to another, and there operated upon those who were blind with cataract. When the operation had been successfully performed and the honorarium had been paid, the “cataract pricker” traveled to another place. He did not see his patient again after the operation and it was a good thing for him that he did not, for the later consequences of the operation were as melancholy as the immediate result was brilliant. For the eyes very often were destroyed either by inflammation or by increase of tension. The inflammation probably was caused as a rule by infection with the cataract needle and not infrequently was transmitted to the other eye in the form of a sympathetic ophthalmia. At present inflammation might generally be avoided by operating aseptically and through the use of antibiotics and steroids, but we have no means of combating the other deleterious consequences of depression or reclination, and particularly the increase of tension that so frequently occurs when the lens is luxated except on a temporary basis. Hence the repeated attempts that have been made to take up reclination in the late 1800’s have always been abandoned again.
It sometimes happened after depression or reclination that the lens failed to remain in its place in the vitreous, particularly when the latter was liquefied. In such cases either immediately after operation or later, in some cases not till years afterward, it rises and places itself in its old position behind the pupil; it may even pass through the pupil into the anterior chamber. Such cases of luxation of the lens into the anterior chamber gave the first occasion for the performance of extraction of cataract. This method of operating, if we are to believe some authors, was perhaps practiced now and then even in ancient times, but at any rate it had in the Middle Ages fallen completely into oblivion. The first information that we have in regard to it we get from the seventeenth century, when there are several instances in which the lens was removed from the anterior chamber into which it had got after the operation of depression. The Frenchman Daviel had already done this in several cases, when in the year 1745 he first dared to undertake this operation upon a cataract which was situated in its normal position. In so doing Daviel inaugurated a new era in the history of cataract operations, since from that time the extraction of cataract began more and more to take the place of depression.
The original method of Daviel was naturally very much in need of improvement. Of the many modifications which it underwent in the course of time the last and best was that of Beer. The latter made the section with a knife invented by himself which broadens from point to handle so as to have a wedge shape. With Beer's cataract knife it is possible to complete the section by simply pushing the knife forward after it has been entered, and owing to this fact the section acquires a high degree of regularity. The section ran somewhat inside of the limbus, and separated exactly the lower half of the cornea from the sclera. Then, after opening the capsule, the lens was delivered, but no part of the iris was excised.
Beer's procedure was soon generally adopted, and was for a long time the prevailing method. In successful cases it gave ideal results. The pupil was black, round, and perfectly movable, and it was only upon close examination of the eye that it could be discovered that an operation for cataract had been performed at all. Unfortunately, it always happened that a considerable number of eyes were lost after this operation, especially by suppuration of the cornea. As at that time it was not known that this was caused by infection of the wound, the method of operating, and particularly the way in which the section was made, were regarded as accountable for it. Hence, other better procedures were sought after, and this time Von Graefe was the one to take the most important step forward and create a revolution in the methods of performing extraction, by the invention of this method.
Von Graefe considered that the cause of the suppuration of the cornea in Beer's method lay in the shape of the incision, in consequence of which the lips of the wounds are not properly applied to one another, and this fact was supposed to furnish the cause of the suppuration. Von Graefe accordingly believed that the linear incisions were preferable, as he had become convinced of the promptness with which they healed in the case of simple linear extraction, an operation which had already been practiced by him. Accordingly, he as well as others, attempted to apply the linear section which was made with the lance knife, and which originally was employed only for soft or shrunken cataracts, to large cataracts with a hard nucleus. With this object these experimenters tried to make the linear incision as large as possible by placing it in the upper part of the cornea and by combining it with iridectomy. Others tried to diminish the size of the lens first by crushing it so as to be able to extract it through the section. But these attempts were all unsuccessful. The section always remained too small for the cataract, which in its passage contused the lips of the wound, so that inflammation frequently ensued. Jacobson, who sought the remedy in another way, obtained better results. He placed the section in the sclera. He gave up the linear character of the section and made a flap incision, skirting the lower margin of the cornea, but situated still in the sclera. With this he combined iridectomy. This method gave better results, and particularly a less frequent suppuration of the wound. The cause of this was regarded as consisting in the fact that the sclera being a vascular tissue, is less disposed to suppuration than the non-vascular and hence more poorly nourished cornea.
Von Graefe now attempted to combine in a new method both advantages - namely, the linear character of the section, which ensures a good coaptation of the edges of the wound, and the position in the sclera, which affords protection against suppuration of the wound. It soon became apparent to him that a linear section, which should be of the necessary length and situated in the sclera, could not be performed with the lance-shaped knife. The lance knife must be pushed forward parallel with the plane of the iris, and therefore, as soon as it is desired to make a wound of any length at all, produces a section which is nearly concentric with the margin of the cornea, and hence has the character of a flap. Von Graefe accordingly devised the narrow or linear knife, which soon proved to be one of the most useful instruments in Ophthalmology.
In 1869, surgery was greatly stimulated by the contribution of Joseph, Lord Lister through his work in antisepsis. Anesthesia and asepsis were the two great contributions to surgery in the nineteenth century. It is also of interest that Lister introduced catgut and chromic catgut sutures. Sutures in Ophthalmology for cataract surgery became widely accepted in the latter 1920's.
In most recent years (1957) the introduction of Alpha-chymotrypsin by Barraquer of Barcelona, Spain has given us a chemical entity through which we are able to chemically dissolve the zonule, thus greatly facilitating extraction.
Dramatic victories in the restoration, improvement, and conservation of vision have been achieved in every field of Ophthalmogy. In Ophthalmic surgery the three most spectacular feats historically are the extraction of cataract by Daviel in 1747, iridectomy for acute glaucoma by Von Graefe in 1857 and the cure of retinal detachment by Gonin in 1929. Important medical advances were atropine for iritis, popularized by Von Graefe in 856; miotics for glaucoma, introduced by Laqueur in 1876; prophylaxis of ophthalmia neonatorum, evolved by Crede in 1884; local anesthesia, discovered by Koller in 1864; the tonometer, invented by Schiotz in 1905; antibiotics, first used in ocular infections by Florey and Chain in 1941 corticosteroids in Ophthalmology, studied by Alan Woods in 1950; and the prevention of the retinopathy of prematures unveiled by Patz and Ashton in 1953. The most salient optical accomplishments were the introduction of spectacles in the 13th c.; the invention of the ophthalmoscope by Helmholtz in 1851; the evaluation of visual acuity by Snellen in 1862; the scientific presentation of refraction by Donders in 1864; retinoscopy, revealed by Cuignet in 1873; the simplification of the ophthalmometer by Javal and Schiotz in 1884; and slitlamp illumination, conceived by Gullstrand in 1911.