Ophthalmology in the British Isles









The ophthalmoscope

Ophthalmology in 
        the British Isles

Roman seals for the preparation of collyria constitute the earliest records of ophthalmology in England. A number of these have been unearthed and one, found in ireland, presents an interesting historical prblem, for the Roman invasion is not supposed to have included that country. These seals are not different from those found elsewhere, so that if any native ophthalmology existed, it does not appear to have influenced the imported practice. Some evidence of ocular treatment in Saxon times is furnished by the extant Saxon Leechdoms; the records speak of a number of herbs, amongst which, as James points out, eyebright is absent -- an interesting omission, for eyebright figured large in later herbals. Much more significant than this primitive ophthalmology are the learning and investigations that were to be found in the monasteries of Norman England. It is more than likely that Roger Bacon's contributions represent not an isolated brilliant achievement, but the acme of less far-reaching work that was going on steadily in these secluded seats of learning. James draws attention to Robert Grosseteste, Bacon's  teacher, whilst the work of John de Peckham has passed into history -- his is the first discussion on the refraction of concave lenses. 

The 14th century supplies the first native ocular treatise; Sir D'Arcy Power speaks of it as one of the lesser writings of John of Arderne. There are available the original Latin text and an early English translation; a full abstract of it has been published by James in his "History of Ophthalmology in England." It is largely a formulary and its most interesting passage is an autobiographical reference. It is only towards the end of the 16th century that an ophthalmic literature worthy of the name makes its appearance in England.

Short chapters on the eye occur in Philip Barrough's Method of Physick, the first edition of which appeared in 1583. They are are of no particular significance. Of not much greater significance is Walter Bayley's Briefe Treatise touching the Preservation of the Eyesight, consisting partly in Good Order of Diet and partly in Use of Medicine, first published in 1586. Bayley was physician to Queen Elizabeth, but his knowledge of ophthalmology extended to little beyond doubting the efficacy of urine for bathing the eye and recommending ale as strengthening the sight. Somewhere between 1586 and 1589 appeared a translation of Jacques Guillemeau's Maladies de l'Æei, a useful summary of the existing knowledge, mainly on Greek and Arabian sources, by a pupil of Ambroise Paré. The century closed with another translation, Andreas Laurentius' Discourse of the Preservation of the Eyesight. In the second decade of the 17th century appeared another tract, Two Treatises concerning the Preservation of Eiesight, the first one being a reprint of Bailey's essay, whilst the second - an anonymous "scissors and paste" production drawn from the writings of Benevenutus of Jerusalem, Riolanus and Fernelius -- contains nothing new. British ophthalmology had yet to be born. 

Its beginnings were created by Richard Banister in 1622. In that year he reissued the translation of Guillemeau's book, for this "worke ... being long since out of print, it is not now to be bought for money." He sent it "abroade again, that those which delight to labour in this Art, may runne the readier way to the better successe." He added a Breviary, "something of mine owne, that through my experience they may finde at first, what I was learning long." The something of his own is not always useful, but contains much bears the stamp fo the experienced oculist. Much the most significant passage is the one in which hardness of the eye is described as a diagnostic and prognostic feature in the treatment of gutta serena -- an observation that fell on stony soil and had to be rediscovered in the 19th century. Banister's Breviary is also of inestimable value as a document on the social standing of oculists in that age. He relates in a delighfully naïve way how he came to devote himself to the study of diseases of the eye; and in criticizing ignorant practitioners he has left a sidelight on the practice of ophthalmology in his days: --

"...My special breeding has beene in the general skill of Chirurgeries. ... I left the greatest masse of that unmeasurable mysterie, as a heape too heavy for my undergoing; to take up onely some particular pieces, wherein I might the better proceed to some perfection: choosing rather to walk in a right line, whose very beginning points to a certaine end; then to run in a ring, whose mazefull compasse foretells much paine with little progresse, or a long journey without an Inne. ....I thought the Art would be no loser by me, if I did let goe many parts of her, to hold the rest more sure and certaine. And finding some defects in mine owne eyes, I chose their cure for my care, that so I might benefit my selfe first, and otheres after by mine owne experience: unto this also I adioyned the helpe of Hearing by the instrument, the cure of the Hare-lip, and the wry Necke. When in the threshold of my practice, I could couch the Cataract, and so began to gaine some name of an Oculist, I laboured to advance my skill by the advice of the most skillfull in those times: ...Byt in observing them, I noted much practice, but little Theories; therefore not contenting my selfe to have but one string to my bow, lest a time of night might overtake me wanting oyle in my lampe; and labouring to bee as cunning in knowledge of the reason, as perfect in practice upon the occasion; I addressed my selfe to the study of divers best approved Authors, ... And hereby wee see the boundlesse boldnesse of many women, who for lacke of learning, cannot be acquainted with the Teoricke part, and yet dare venture on the Practicke. I beleeve, scarce three of thirteen hundred, can define or describe the names and natures of the hundred and thirteene diseases of the eye; to shew whether they be in the Humors, Membranes, Muscles, Optick Spirits, etc., yet having snatched up some one or two medicines onely, they thinke themselves armed against all diseases ... Let these women therefore either applie themselves to learne the grounds of their practice, or leave their practice to them that are better grounded; that so they may cease by their ignorance to make them blinde, that by our Arte might be made to see. Many have come from these to me, lighted more by sorrow than by sight, with their eyes full of teares, but empty of opticke humors. And yet these firebrands that choke and smoke folks eyes out, can take hennes, chickens, and such reasonable rewards for their unreasonable wrongs."

Further on he relates: "Of proud quacksalving Mountebankes, that would undertake all Cure, and performe few."

"Such are they, that promise to make blind people see, deafe people heare, and to cure the Stone and Rupture by cutting. In the methodicall practice and cure of blind people, by couching of Cataracts, our English Oculists have alwayes have an expeciall care, according to Arts, to couch them within doores, out of the open aire, to prevent further danger. Yet some of these Mountebanks take their patients into open markets, and therefore vaineglories sake, make them see, hurting the Patient, only to make the people wonder at their rare skill. Some other make Scaffolds, on purpose to execute their skill upon, as the Frenchmen, and Irish man did in the Strand, making a trumpet to be blowne, before they went about their work. But these were not long suffered to use these lewd courses, before they were called before the company of the Chirurgions: being sharply reprooved, soone left the City, and their abusive practice.  ...Beside this lewd practice, some of the afore mentioned, will cut for the Stone and Rupture, when by other meanes they might performe the Cure and wicked practice.... The skins of which, these Empericks take away, they stuffe with wooll, or flax, to make them shew the greater, and these they hang upon a wall, or post, in the open markets, to make their gelding skill more knowne."

Banister was an itinerant oculist. He relates of his cures in Norwich, London, Lincoln and elsewhere, cures testified by the magistrates. His apologia for his itinerant activities and advertisements is delightful: --

"...It maybe, some will object, as they have done, I need not have travelled so farre form home to do these Cures: for they would have come to me. I answere, Three causes made me to do this: first, when I was abroad and made my selfe knowne in a strange place, I did see more defected Eyes in one moneth, then I should have seen in halfe a yeare at my owne house, whereby my knowledge and skill was increased so much the more, for the true judgement in defective Eyes. Secondly, if I had not made my Practice publikely knowne abroad, I should have had no resort to me at home, so that my small talent might have been hid in oblivion. Thirdly, Many poore people that wanted help, as well as rich, were not able to travell so far to me for helpe; both in respect of the weakness of their bodies, and disability of their estates, which I willingly helped as wel as others."

An important document on that period is published by James. It consists of an anonymous manuscript in the British Museum, and james is inclined to regard it as possibly the work of a son of Richard Banister, though some claim could be made for richard Banister himself. In a "Briefe discourse of ye Chefeste Oculistes" there is much light thrown on the ophthalmic practice of the day. 

There was Luke of Erithe, 

" a man that lived in greate fame and credite had the greatest practise and sumes of money for he hathe had from XX to LX L for Cataracke couchinge ... He neuer set upe bils that I heard of but those that desyred his helpe and dwelled far from him he would apponynte a tyme to come to them and would wyshe ym to gyve notis of his comminge to alle they knewe stoode in need of his helpe."

No less interesting was Mr. Surphelete, a man,

"of axeolente Dyet and crusty fasion of bodye. He lived till he was fouere score yeares of age lived moste in Norfolke & dyed at Linn and in good estate. He lay 2 or 3 years at a barber's house at Linn to whom he taught som skille, who nowe professethe it with weak Understandinge and gyven to drinke I cannot com'end this Mr. Surphlete for any extraordinarye skille though of longe experience."

But most interesting of all was henry Blackbourne,

"who travelled contynuouslye from one market towne to another, who could couche ye Cataracke welle, cure yt, Laye oa scar Lipe, set a crockt necke strayght & helpe deafness. Though he could doe good in these cures yet he was soe wickedlye gyven that he would cousen & deceave men of great som of moneys by taken incurable diseases in hand. He was lust amorously gyven to seueral women so that his coseninge made him fearfully to flee from place to place and often changed his name and habits in divers places & was often imprisoned for women. His skille was excelente, but his vices ... longus, his practeste was this, yf he made a blinde man see; after he had couched ye Cataracke ...yf he herde they welle he woulde see ym agayne, yf not he would neuer come at ym. If cum payne or accedentyles fell out they receaved no comforte from him....Though before I com'ended him for a good oculist it was for his manuel operation & not his method or medicines. He hyed in Kent after he had thoroughly travelled alle partes of the lande, he left no memorie of his gaynes or gettinges his wicked lyfe was suche that I thinke he had not one friend that he trusted, but alwayes that he got he caryed about with him. He was often deceaued of great sums of money yet neuer robbed. He hyed but in meane estate had one sonne and left him nothing."

When the curtain is thus first lifted on English ophthalmology, there is not much to excite admiration. And the rest of the 17th century offers little relief. Robert Turner in 1654 and again in 1665 brought out " The Compleat Bone Setter, " in which a section is devoted to the Perfect Oculist, this itself being nothing more than an unacknowledged adaptation of the anonymous tract published in 1616. But the century did not close altogether in this bleak fashion. Apparently the orthodox practitioners were turning to the study of the eye. Daubigney Tuberville of Salisbury was a properly qualified practitioner and belonged to an old family. He had a great reputation and his services were widely sought; thought not on good terms with the Court physicians he was called in to treat the  future Queen Anne. The Philosophical Transactions contain two letters of his, in one of which an account is given of the use of a magnet to withdraw a piece of steel embedded in the "iris" [limbus]. William Briggs' Latin treatise on the anatomy of the eye, containing the first account of the optic disc, belongs to this period. Briggs was more than anatomist; his "Theory of Vision" is of interest as showing the searching that was going on for new explanations. Another qualified practitioner of that period, though hardly worthy of consideration together with Turberville and Briggs, is William Coward. His Latin Ophthlamiatria, published in 1706, is of little significance.

Coward's book was one of three that appeared in the first decade of the 18th century. The two others were even more insignificant than his. A brief Treatise of the Eyes by William Crosse is a rather long advertisement of the author's secret remedies, whilst Sir William Read's Treatise for the Eyes is an unacknowledged reprint of Banister's Breviary and the translation from Guillemeau, together with a rodomontade on Read's manual dexterity and styptic water. Read's Short but Exact ACcount of all the Diseases Incident to the Eyes is but the same production with a different title page; it is not even a reprint. A rather more significant publication was Peter Kennedy's ophthalmographia, published in 1713; if unoriginal, it is at any rate honest. 

Quack flourish in all ages, and the eye has always been a happy hunting ground for such practitioners. No one will question the the statement that the 18th century was the heyday of ophthalmic quackery. Sir William Read (the inserted picture shows his advertisement), who was knighted by Queen Anne, set the fashion in high places, and was followed by Roger Grant and the whole tribe of the Chevalier Taylor. 

Sir William Read flourished from about 1675 till his death in 1715; he was succeeded by Roger Grant; each of these men was illiterate. Read was the son of a Suffolk cobbler and apparently could not even sign his name, while Roger Grant rested his pretensions to practise ophthalmology on the fact that he had lost an eye in the Emperor's service in the continental wars; thus reversing the case of the gladiator alluded to by Martial:

Oplomachus nunc es, fueras ophthlamicus ante.
fescisti medicus quod facis oplomachus.
The conflict between orthodoxy and quackery was to last for the rest of the century, largely because of the indifference of the profession to ophthalmic matters. Benedict Duddell had to complain in 1729 that surgeons undertook treatment of eye conditions without the necessary knowledge: "to the question how a certain surgeon did to know the different natures of the distempers of the eye: His answer was that he undertook all. If his operation succeeded, so much the better; if not the patients could but be blind, or in danger of being so, as they were before." In such an atmosphere charlatanism could not but prosper, especially as the charlatan was often well grounded in the subject; Woolhouse and the Chevalier Taylor were certainly the equals in knowledge to most of the more orthodox oculists. Though Cheselden, who introduced the operation for artificial pupil, and Duddell, who wrote an excellent monograph on the cornea, flourished in the first half of the century, significant names of surgeons who were interested in eye diseases begin to appear only in the second half. Amongst the earliest was Sharp of Guy's Hospital, a pupil of Cheselden; he contributed the single incision by puncture and counterpuncture to the operation for extraction of cataract, whilst towards the end of the century Ware contributed very largely to the recognition of the venereal origin of neonatal ophthalmia. Yet even so, Benjamin Bell, writing in 1785, had to complain that the difficulty in deciding whether couching or extraction is the better operation, is due to the fact that operations are left to itinerant practitioners.

The century closed as it began -- by plagiarism. William Rowley's Treatise of One Hundred and Eighteen Principal Disease of the Eyes is an unacknowledged and faulty translation of Plenck's Doctrina de Morbis Oculorum. Quackery, charlatanism and plagiarism is the unenviable record of the 18th century in England, a century during which modern clinical ophthalmology was being built up by orthodox practitioners in France. But the growing number of surgeons who studied eye disease and the advent of Porterfield in Edinburgh and Thomas Young in London, carried the promise which matured early in the succeeding century.

The founding of "Moorfields" was its first fruit. Started by John Cunningham Saunders in 1805 as an Eye and Ear Infirmary, it became transformed two years later into an exclusively ophthalmic hospital, the first of its kind in the world. From Moorfields emanated a new conception of the place of ophthalmology in medical practice; when the need for orthodox practitioners with knowledge of eye disease was satisfied, quackery as a force vanished without a struggle. After the foundation of Moorfields ophthalmology in England went from strength to strength. Other hospitals followed in rapid succession -- the West of England Eye Infirmary at Exeter in 1808, and institutions at Bristol and Manchester in 1810 and 1814. The second hospital to be established in London was the Royal Westminster Ophthalmic Hospital founded by George James Guthrie in 1816. At this hospital in 1817 the first course of lectures on disease of the eye was established. The Central London Ophthalmic Hospital came in 1843, the Western Ophthalmic Hospital in 1856, the Royal Eye Hospital was established a year later. The movement for eye hospitals stimulated the opening of ophthalmic departments in the general hospitals. Many more years were, however, to elapse before it came to be generally accepted that ophthalmology required an undivided allegiance; not a few of the great ophthalmologists of the 19th century were general surgeons as well as ophthalmologists. 

The activities of the new generation of ophthalmic surgeons led to the publication of a number of text-books, and in the third decade three books -- the first adequate books on ophthalmology in English -- made an almost simultaneous appearance: William Mackenzie's in 1830, Sir William Lawrence's in 1833 and Richard Middlemore's in 1835. These, like Wardrop's Essays on the Morbid Anatomy of the Human Eye, were no longer acknowledge or unacknowledged translations of continental books, but represented contributions to ophthalmic literature. Henceforth on the exchange of world ophthalmology had come to barter not to borrow.

The earliest effort for an ophthalmic journal came with the publication by John Richard Farre of a Journal of Morbid Anatomy, Ophthalmic Medicine and Pharmacological Analysis, with Medico-Botanical Transactions communicated by the Medico-Botanical Society. Only one issue appeared, and in a way the journal may be considered as the precursor of the Royal London Ophthalmic Hospital Reports, first published in 1857. In the meantime Richard Middlemore in 1837 had mooted the idea of a Journal of Ophthalmology, but nothing beyond a prospectus appeared. The first exclusively ophthalmic journal, planned on a wider scale than the Ophthalmic Hospital Reports, came in 1864 with the publication of the Ophthalmic Review, edited by John Zachariah Laurence and Thomas Windsor. The journal, a quarterly, lasted barely four year. The second Ophthalmic Review began to appear in 1881, and british ophthalmology had yet to see the rise of the Ophthalmoscope (1903) before it achieved its present central organ in The British Journal of Ophthalmology (1917).

The names of many of the makers of 19th century ophthalmology in the British Isles --- Bowman, Laurence, Hutchinson, Tay, Argyll robertson, Nettleship, Doyne, Marcus Gunn, Coats to mention only a few -- have become household words in ophthalmic practice. And there is reason to believe that they have left to their successors not only a record but an inspiration and a tradition.

Jonathan Hutchinson
George Coats
Robert Marcus Gunn
Edward Nettleship
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