THE DOCTOR'S BAG
the blog about 19th century medicine and surgery
Keith Souter aka Clay More
Having good eyesight is something that everyone would like. Some deterioration takes place with age, of course, but nowadays there may be much that can be done to maintain eyesight. There are operations to remove cataracts and replace the lens of the eye, laser surgery to improve vision, retinal surgery to rear detached retinae. We have a greater understanding of conditions that can affect the eye, so we can reduce the complications of diabetes by controlling the blood glucose and we can treat conditions like temporal arteritis, a cause of sudden loss of vision with steroids. (Arteritis is an inflammation of the arteries, as opposed to arthritis, which is inflammation of joints.)
It was not like that in the days of the Old West. There were few options and the discipline of ophthalmology was only just beginning. This month I'm going to have a look at the history of the subject.
Ancient Babylon - a dangerous time to practice medicine
In 2250 BC, King Hammurabi, the ruler of Babylon-Assyria had a code of laws set out. These were written in cuneiform on huge stelae and clay tablets, many of which have survived to this day.
Cuneiform writing - a slab embedded in the wall of Agatha Christie's house in Devon. Her husband, Sir Max Mallowan was a professor of Assyriology and excavated extensively in Syria and Iraq
The code of Hammurabi contained 282 laws with rewards and punishments. Several of these related to doctors and their treatments of the eye.
Law 196: If a man destroy the eye of another man, they shall destroy his eye.
Law 215: If a physician open an abscess in a man's eye with a bronze lancet and save that man's eye, he shall receive ten shekels of silver - if the eye is destroyed they shall cut off his fingers - if a slave's eye is destroyed he shall pay one half of the price of the slave.
Ancient Egypt - the eye of Horus
The ancient Egyptians had a whole system of medical specialisation. They had priest-doctors who looked after different parts of the body. Eye doctors were designated swnw irty, meaning 'the doctor of the eyes'.
The Ebers papyrus, which was reputedly written by a physician called Hesy-Ra in about 1500 BC, contains 110 pages about diseases and treatments known to the Egyptians. Of these, 8 pages are about diseases and treatment of the eye. He talks about tears in the eye, pus in the eye, blood in the eye, turning of the eye and its movements (squints, paralysis or weakness of eye muscles), pain in the eye and visual disturbance and blindness. Treatments given included onions, leeks and beans, pomegranate, castor oil, copper salts, hemlock and opium.
The eye as a symbol was of course very important to the Egyptians, as shown by the eye of Horus talismans that were so ubiquitous in Egyptian society. They represent the legend that the god Seth tore out the eye of the hawk-headed god Horus, only to have it magically restored. The eye of Horus, known as the wedjat, became a symbol of protection and of cure.
The eye of Horus
Interestingly, the symbol used by doctors around the world for a prescription is Rx. It has always been thought that this was an abbreviation for the Latin word recipe, meaning exactly that, a recipe. An alternate theory was put forward in the British Medical Journal in 1999 by Jeff Aronson, a clinical pharmacologist, that the symbol was actually a corruption of the wedjat, the eye of Horus. If this is the case, then doctors have been using a symbol that links them directly with their ancient Egyptian counterparts.
The eye of Horus and the symbol used by doctors for a prescription
This idea is not as odd as it may seem, since Egyptian doctors did in fact use components of the eye of Horus as symbols representing fractions. Dr John Nunn, an eminent doctor who has extensively studied Egyptian medical practices discusses this in his excellent book Ancient Egyptian Medicine. Apparently, Egyptian doctors used these in their drug prescriptions to show what proportions of drug ingredients to use when making them medicines.
Parts of the eye of Horus were used to show quantities of medicines in ancient Egypt
Pliny the Elder, who died attempting a rescue operation at Pompeii in 79 AD was intrigued by the eye. He wondered why some animals had shining, brilliantly coloured eyes in the night, yet had black pupils, like humans during the day. The reason that the pupil was black merely because it was like a window of a darkened room was not discovered for many centuries. Yet once again, the Romans gave us the name for the pupil, which comes from the Latin word pupilla, meaning 'small doll'. The reason for this is that a small person like a doll (a reflection) is seen in the pupil of the person.
Pliny also recorded that henbane could be used to dilate the pupil for the removal of cataracts by couching.
Eye injuries were common in gladiatorial combats and several doctors studied and treated them, among them the great Galen of Pergamun (131-201 AD). He wrote about OVDO - Olympic Victor's Dark Ointment - and gave a prescription for making an ointment for treating bruises and black eyes. You will find it covered in my post Bleed, Blister, Vomit and Purge.
Slavery was an integral part of Roman life and short-sightedness reduced the value of a slave. In those days before spectacles a patrician's only way of dealing with presbyopia, (age-related visual loss) was to have an educated slave read to him.
Roger Bacon (1214-1292) was a Franciscan friar and scientist. In his book Opus Magnus, he discusses optics and the use that lenses could be put to. He was the first person to advocate that older people should use convex lenses to enhance their vision. Alexander de Spina, a Dominican monk is credited with taking Bacon's idea and inventing spectacles for reading in the 13th century.
The city of Florence in Italy became famous for producing lenses and spectacles in the 15th century. They produced convex lenses for hypermetropia or long sight, and for presbyopia the age-related deterioration in vision. They also produced concave or diverging lenses for people with myopia or short sight. Not only that, but they appreciated that vision deteriorated with age, so they produced lenses graded in progressive five year increment strengths. The Florentine lead was taken up and English spectacle-makers were producing large quantities of spectacles for myopia and presbyopia before the end of the fifteenth century.
The types of lenses needed to correct visual problems, by focusing the image on the retina
Professional guilds started to spring up. In 1535 the Nuremburg Spectacle Maker's Guild was established, effectively setting standards for the manufacture of spectacles. In 1621 King Charles I of England gave a royal charter to the Worshipful Company of Spectacle Makers.
Benjamin Franklin (1706-1790), by David Martin
In the 1760s Benjamin Franklin invented bifocal spectacles. These had split lenses that corrected both myopia and presbyopia.
In 1775 John McAllister emigrated from Scotland to Philadelphia and there opened a cane and whip-making business. It was not long before he added spectacles to his range and in 1799 opened the first optical store in the United States. The bifocals that Benjamin Franklin had invented were especially popular. Although McAllister had imported spectacles to begin with, by 1815 he was manufacturing his own. By 1825 he had added lenses to deal with astigmatism.
The next two decades saw a surge in optical stores around the whole of the United States.
This is a condition in which the lens of the eye becomes opacified, so that light does not get through. Ultimately it leads to blindness in the affected eye. The name comes from the Greek kata, meaning 'down' and rrhoia, meaning 'rushes'.
The ancient Indian physician Sushruta described what happens in the fifth century BC. He said that it was a problem caused by disturbance in the flow of fluids inside the eye. By contrast, according to the humoural theory it was thought to be the result of a build up of a diseased humour in the eye. Sushruta was correct.
Sushruta described how to treat a cataract by couching it. This was therefore one of the earliest surgical operations. It involved making an incision in the top of the eye at the edge of the cornea and the sclera and using a blunt spatula to push the cloudy cataract to the bottom of the eye. The result would be spectacular, although the person would be left without a lens and would require a hand-held lens in order to focus. However, it would be markedly better than going blind.
Couching could only be done on a lens that had turned ripe. This meant that it had to have gone through the whole pathological process and was fully hardened, so it could be displaced without fragmenting, which would be disastrous. A cataract that was ripe like that would mean that the sight had almost gone before the couching was possible.
In 1748 Jacques Daviel (1696-1762) published his method for the operation of removing the lens of the eye entirely. It was the greatest advance since couching, although it took a century for it to become established practice.
Statue to Jacques Daviel in Bernay, France
The operation involved making an incision that went halfway round the circumference of the cornea. The whole lens had to be removed intact, which like couching meant that the operation could only be performed once a cataract was ripe. There were no sutures available at that time so the patient had to be kept perfectly still, for at least a week, with their head immobilised by sandbags while healing took place. They were permitted only soft food for 10 days.
In 1753 another French surgeon called De la Faye invented another type of operation called intra-capsular cataract surgery. This involved making a smaller incision and then opening up the capsule or sac that contains the lens. This had the advantage that a barrier was being left to prevent fragments of a ruptured lens from falling into the vitreous humour, the jelly inside the eye. The operation only became accepted and practiced at the end of the 19th century, when three British surgeons working in India used it and published their results.
The lack of adequate pain relief was a problem thoughout history. People depended on alcohol intoxication, or opium. General anaesthesia with first ether and then chloroform meant that more people could be offered life-changing surgery to have their cataracts removed. Then in 1884 Carl Koeller of Vienna used cocaine with great effect.
The dreaded complication
Ancient Greek doctors described a strange phenomenon in which a penetrating injury to one eye could be followed by signs of inflammation developing in the other eye, possibly leading to blindness in both eyes. In 1818 the Scottish surgeon James Wardop (1782-1860) observed that veterinary surgeons would destroy the injured eye of a horse with lime or a nail to save the good eye. In his book Essays on the Morbid Anatomy of the Human Eye he described this condition (and many others, including the important retinoblastoma, a rare malignant tumour of the retina which can occur in children) and its preventive treatment to save the good eye. He called it sympathetic ophthalmia.
Sympathetic ophthalmia is a rare but awful complication of eye surgery or of injury to the eye. Effectively, an inflammatory reaction can occur in the uninjured eye, resulting in loss of vision. At the time the only other treatment was to use leeches and highly toxic mercury drugs to prevent it occurring.
In Tombstone, Arizona Dr George Goodfellow and two colleagues, Drs Fender and Whitmore operated on June 3, 1892 to remove the eye of a Captain Burgess, in order to save the other eye.
This sounds like a case of sympathetic ophthalmia.
Dr George Goodfellow surgeon extraordinnaire
It is thought that Louis Braille (1809-1852) may have gone blind in both eyes from sympathetic ophthamia after a childhood accident had damaged his left eye. He invented the system of reading and writing for the blind and visually impaired.
Nowadays powerful immune-suppressive drugs may be prescribed, because it is thought to be an auto-immune reaction, the body fighting against itself.
Examining the eye
In 1851 Herman von Helmholtz (1821-1894) a German physician and physicist invented one of the most useful instruments in the doctor's bag, the ophthalmoscope. With this doctors could look inside the eye to examine the lens, the vitreous humour and the retina. It opened up the subject of ophthalmology and allowed doctors to see how the eye was affected in different diseases.
Another German doctor, Professor Albert von Graefe (1828-1870) used the new ophthalmoscope to build the knowledge base upon which ophthalmology is based. He devised many surgical instruments to be used and he described and developed treatments for several conditions.
A commemorative West German stamp of 1970 celebrating the life of Albert von Graefe, ophthalmology pioneer. The stamp shows early ophthalmoscopes.
Opthalmoscopes were used by surgeons during the Civil War and enlightened frontier doctors like Dr George Goodfellow of Tombstone and later of Tucson would use them.
This is one such condition that Albert von Graefe described. It is actually the name for a group of conditions which can lead to blindness. They are due to raised pressure within the eyeball. He described the changes that occur on ophthalmoscopic examination and he was the first person to actually measure the pressure of the eyeball. This is a fundamental test that we do today.
To treat it he devised an operation called iridectomy, in which a wedge of the iris can be removed. This permits the flow of and circulation of fluids within the eye to prevent a rise in pressure.
Albert von Grafe also established the use of drugs, the plant alkaloids atropine, pilocarpine and eserine, which could be used as eye drops in the treatment of glaucoma. This saved the vision of thousands of people.
Grit, splinters of metal or wood, anything that flies into the eye and embeds itself is regarded as a foreign body. They can nowadays be removed fairly easily after simply using some local anaesthetic and then removing them with a fine forceps or probe.
In 1842 Nicholas Meyer was the first person to use a magnet to remove anion foreign body. Later, the invention of the electro-magnet allowed for controlled extraction of magnetic metal foreign bodies.
In 1867 the American surgeon Henry W Williams (1821-1895) introduced eye sutures to ophthalmology. This ended the need for sandbagging to immobilise the head while eye incisions healed. He would go on to become professor of ophthalmology at Harvard University and president of the American Ophthalmological Association.
A couple of eye conditions every town doc would come across
The result of blunt trauma to the area around the eye, producing bruising. As with any bruise it will usually subside in 7-10 days. As it does so it goes through the various shades of the rainbow, due to the absorption of the blood and the breakdown of the haemoglobin, the iron-containing pigment in blood. First it will be red from the blood in the tissues. Then by day five it goes blue or purple. The haemoglobin in the tissues then gets broken down into biliverdin and it takes on a greenish hue, then to bilirubin on about day ten when it appears yellow, before fading completely.
Cold flannel applications the sooner the better reduce the swelling. A beef steak directly applied is the traditional remedy, although it is doubtful that it would have any real value. Mayhap it was simply that it was cool and fairly malleable so would feel comfortable. It is not a treatment that would be recommended today.
Tincture of arnica applied with a camel-hair brush was a standard treatment for new bruises and black eyes.
Hamamelis (witch-hazel) lotion or ointment would be used after the bruise was established. One part of hamamelis tincture to six parts of water.
A poultice of bryony-root could also be used. This was a favoured remedy with prize-fighters.
And of course, a leech could be applied - see the post Bleed, Blister, Vomit and Purge.
Cold in the eye - conjunctivitis
Inflammation affecting both eyes at the same time is a common infection. It is highly contagious, so prevention with hand-washing is advised and would have ben advised by enlightened doctors familiar with the germ theory.
It would present with inflamed, red, gritty eyes and possibly with purulent discharge.
Unilateral red eye is unlikely to be this simple and nowadays is regarded as an eye emergency, since it could be a type of glaucoma or uveitis. It needs emergency treatment.
Now, this may surprise you, but in the 19th century the treatment was usually to give a mild aperient or purgative. The eyes were then bathed with an alum lotion. Six grains of alum were dissolved in an ounce of distilled water.
A little spermaceti ointment (a type of wax found in the head cavity of the sperm whale) would be applied to the eyelid margins at night, to prevent them sticking g together.
The condition would resolve in three or four days.
Some of Clay More's latest releases:
- a novelette- novella
Sam Gibson used to be a lawman, until the day he made a terrible mistake that could never be taken back. Since then, he has alternated between wishing there were a way he could redeem himself and believing he deserved punishment.
He’s about to get both…
And his collection of short stories about Doc Marcus Quigley is published by High Noon Press
Available at Amazon.com:
And his latest western novel Dry Gulch Revenge was published by Hale on 29th August.