History of Medicine

 THE EYES HAVE IT: THE EARLY DAYS 

OF OPHTHALMOLOGY

 

         For many years, mankind endured diseases of the eyes with little remedy. Infections, especially from gonorrhea and syphilis, cataracts, injuries, and the ravages of untreated glaucoma were prevalent. Physicians had few remedies. Their inexperience was evident when a wave of “Egyptian ophthalmia” swept through Europe and England in the opening days of the 19^th century, introduced by Napoleon’s troops from a campaign in Egypt. The disease, now known as trachoma, and characterized by swollen, purulent eyes, eyelashes that scraped the cornea, corneal scarring, and blindness, resisted effective treatment. No department of ophthalmology existed at the time in Europe.

The first university chair of ophthalmology in the world was held by Georg Josef Beer, in Vienna. Beer had studied under the

Joseph Beer (Wikipedia)

Maltese anatomist and surgeon, Joseph Barth, who lectured on diseases of the eye. After graduating in 1786, Beer opened a private practice in his small apartment in Vienna focused on eye disease, treating the poor, mainly at his own expense. Twenty-six years later (1812), with no help from Barth, having earned a reputation on his own, he was appointed professor of ophthalmology at the University of Vienna.

Beer produced a two-volume practical text on eye disease. The text, though modern for its time, still cited contaminated air as the cause of purulence and recommended bleeding and leeches as treatments. But the new specialty was established. One of Beer’s pupils, Johan Nepomuk Fischer, founded a

Ferdinand Arlt (Wikipedia)

department of ophthalmology in Prague. His assistant, Ferdinand Arlt, the son a blacksmith, had trained in pathology with Carl von Rokitansky, the brilliant pathologist at Vienna’s Allgemeine Krankenhaus. He brought modern pathology and histology to the specialty and after succeeding Fischer in Prague assumed the prestigious ophthalmology chair in Vienna in 1856.

Two discoveries in midcentury dramatically enhanced the profession: the introduction of anesthesia in 1848 and the invention of the ophthalmoscope by Herman Helmholtz in 1851, both huge advances. For the first time doctors could operate without exquisite pain and could peer inside the eye. 

 The breakthroughs are reflected in Arlt’s three-volume text that grounded ophthalmology on a more scientific basis. First appearing in 1850, the work went through five editions in seven years and included ophthalmoscopic discoveries. Arlt also was the first to elucidate the cause of myopia: elongation of the longitudinal axis of the eye. He improved on methods of removing pterygia and developed new surgical procedures for complications of trachoma. 

One of Arlt’s students, Albrecht von Graefe, was awarded the

Albrecht von Graefe (Wellcome Library)

first chair of ophthalmology in Berlin. He founded the first journal devoted to ophthalmology, Archiv für Ophthalmologie. Graefe was a kindly man and after his death, three of his colleagues, including Arlt, renamed the journal Albrecht von Graefe’s Archiv für Ophthalmologie in his honor. 

Early Helmholtz ophthalmoscope owned by 
Albrecht von Graefe (National Museum of Health
and Medicine)

As an early user of the ophthalmoscope, Graefe was the first to describe changes in glaucoma from increased intraocular pressure, to describe swelling of the optic disc due to increased intracranial pressure, and record changes in the vessels, such as embolism of the central retinal artery. Tragically, Graefe developed tuberculosis and died in 1870 at the age of 42.

Von Graefe was well-known in Berlin. This image of him treating a young woman is from
a popular illustrated magazine, Die Gartenlaube, 1857 (Internet Archive)

Franz Cornelius Donders, his friend and professor in Utrecht, invented a tonometer to measure intraocular pressure and elucidated the mechanism of accommodation. His investigations of visual acuity

Snellen eye chart (Wikipedia)

and astigmatism led to the proper prescription of corrective lenses. His close associate was Herman Snellen, creator of the Snellen eye charts in use today.

In England, most of the early victims of the trachoma epidemic were military men. In one regiment, 636 out of 700 men were afflicted. John Cunningham Saunders, a young surgeon, on the advice of his superior, Astley Cooper, opened a practice for eye

John Cunningham Saunders 
(Wikipedia)

diseases. Saunders quickly recognized the extent of eye disease and especially the social consequences of blindness and, with state assistance, founded the London Dispensary for Eye Disease in 1805, which grew into the Royal London Ophthalmic Hospital of today. 

The European influence extended to America. In 1817 the Baltimore physician George Frick traveled to Vienna to study under Beer and returned to open a practice in eye disease. He published the first American text on ophthalmology, A Treatise on Diseases of the Eye, based largely on Beer’s tome and in use for

George Frick (From Hubble, A A,
The Development of Ophthalmology 
in America, Internet Archive)

some years. He taught at the University of Maryland and is considered by many to be the “father of American ophthalmology.”  In 1816 Edward Reynolds,  just ending a preceptorship under the Boston surgeon, John Collins Warren, and two recent graduates of the College of Physicians and Surgeons in New York, Edward Delafield and John Kearney Rodgers, journeyed to England. All three (and the poet, Keats) studied under John Cunningham Saunders. There they learned new surgical techniques, including the treatment of cataract by lens extraction (rather than by “couching,” an earlier process that dislodged the opaque lens, leaving it in the eye). 

On their return, the Americans founded two enduring institutions. Reynolds, with a second physician, established the Boston Eye Infirmary for the poor, later known as the Massachusetts Eye and Ear Infirmary, which exists to this day. Delafield and Rogers founded the New York Eye Infirmary, also providing free eye care to the city’s poor. It was the second permanent such institution in America, now affiliated with Mount Sinai Medical School. Both infirmaries were based on Saunders’ institute in London. The AMA recognized the specialty of ophthalmology with the founding of the American Ophthalmic Association in 1864.

 From Hubble, A A, The Development of Ophthalmology 
in America (Internet Archive)

         Knowledge of bacteriology in the late 19^th century allowed prevention and control of eye infections, the next major step toward modern eye care. Advancing technology continues to improve eye care and reduce blindness.

 

SOURCES:

Lesky, E, The Vienna Medical School of the 19^th Century. 1976, Johns Hopkins Univ Press.

 

Adler, F H, “Sketches from the Life of Albrecht von Graefe.” Ann Med Hist, 1928; 10(3): 284-90.

 

Rohrbach, J M, “Albrecht von Graefe in the Present, the Past, and the Future.” Graefe’s Archive for Clinical and Experimental Ophthalmology. 2020; 258: 1141-47.

 

Laios, K, et al, “Carl Ferdidand von Arlt, Ritter von Bergschmitt (1812-1887): A Pioneer in Ophthalmology.” Acta Medica Academica 2019; 48 (3): 331-36.

 

Ivanisevic´, M, “Prof. Dr. Carl Ferdinand Ritter von Arlt (1812-1887): His Life and Work During his Ophthalmological Career in Prague.” Čes. a slov. Oftal., 79, 2023, No. 1, p. 36–40. (available in English at: https://cs-ophthalmology.cz/en/journal/articles/268

Pearce, J M S, “The Ophthalmoscope: Helmholtz’s Augenspiegel.” European Neurology 2009; 61: 244-49.

Lyle, T K, “Some of the Great Historical Figures Associated with Moorfields.” Brit J Ophthalmology1961; 45: 251-58.

SchmidtiWyklicky, G and Gröger, H, “Georg Joseph Beer (1763–1821). Leben und Werk des Begründers der ältesten Universitäts-Augenklinik.” Spektrum Augenheilkunde 2012; 26: 266-72.

Duke-Elder, S, “Moorfields and British Ophthalmology.” Proc Royal Soc Med 1964; 58 (7): 541-45.

Tower, P, “George Frick: Factors Influencing Early Nineteenth Century Ophthalmology.” AMA Arch Ophthalmology 1958; 60: 989-94.

Kara, G B, “A Historical Review of the department of Ophthalmology at the New York Eye and Ear Infirmary.” N.Y. State J Medicine 1973; 73 (23): 1-10.

Snyder, C, Massachusetts Eye and Ear Infirmary: Studies in its History. 1984; Mass. Eye and Ear Infirmary.