Journal of Pediatric Ophthalmology and Strabismus

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Strabismus: The First 3500 Years

Norman Medow, MD, FACS

Abstract

The earliest recorded description of strabismus is shrouded in controversy and conjecture. Strabismus is mentioned in the early papyri of ancient Egypt, specifically the Edwin Smith papyrus and the Ebers papyrus1 dating from approximately 1500 BC. The bible mentions strabismus, and in his writings, Claudius Galen2 (131-210 AD) described both acute acquired- presumably paralyticand congenital strabismus. There is no mention of strabismus in the writings of Susruta, the 7th-century BC Hindu physician who, among other things, is credited with being the father of the couching operation.

TAKE ONE PART TURTLE BRAIN. . .

In ancient times, strabismus carried with it a stigma; people believed that the person afflicted was inferior. Theories explaining strabismus included a beUef that a cramp of the muscles occurred after staring at an oil lamp or another object with one eye, leading to a deviation.3 Others believed the deviations were caused by the invocation of evil humors and spirits.

The earliest treatments for strabismus included a variety of purges and potions coupled with incantations that were hoped would remove the evil spirit from the body so that the eyes would straighten. For instance, equal parts of turtle brains and spices were popular remedies described in the Ebers papyrus.1 It is not clear, however, whether the concoction was ingested or applied topically.

Convergent and divergent masks were first used to treat strabismus by a Greek physician, Paul of Aegina (625-691 AD).4 This may be considered the origin of orthoptics. In addition, he suggested that when the eye turned toward the nose, purple flocks of wool should be fastened to the lateral canthus: the eye would be corrected if the afflicted person looked steadily at the wool. In 1540, Ambroise Pare5 attempted to cure strabismus with glasses made from horn with two pinholes placed at various pupillary distances. In his book written in 1583, 6 German physician George Bartisch (1535-1606) reported further refinement of these early attempts. Bartisch developed ski hoods that covered the head with perforated holes at various pupillary distances. Other people created more elaborate masks in an attempt to encourage the squinting eye to straighten and, although history records that none of these methods was helpful, this form of treatment still persists with nasal spectacle occlusion or temporal spectacle occlusion used by many visual training advocates.

A Surgeon With a Green Thumb

When Carl Ferdinand von Graefe (father of Albrecht), the professor of surgery at the University of Berlin died, Dieffenbach was asked to assume this position. In 1847, shortly before his death, Dieffenbach wrote an important paper on the value of ether in the management of pain. Dieffenbach is thus credited with introducing ether to Europe. In addition, Dieffenbach instituted the first nursing program in Germany at the University of Berlin soon after his appointment as chief of surgery.

Dieffenbach's interests were not restricted to ophthalmic surgery. He also was an accompUshed linguist, speaking fluent EngUsh, Russian, and French, in addition to German. He translated a book on the eyes of insects from the original French into German.13 An avid horticulturist, he first described a group of plants in the Arache family for which the Austrian Botanical Society honored him in 1840 by naming this group of plants Dieffenbachia.14 16 This highly ornamental plant is often seen in homes throughout the world.

Corneal Transplantation

Throughout his career, he was interested in corneal transplantation and performed many experiments on transplanting the cornea of rabbits and chickens by suturing the donor cornea to the conjunctiva.17 In 1992, at the 200th anniversary of the birth of Dieffenbach, Humboldt University honored his memory by authorizing that the chair…

The earliest recorded description of strabismus is shrouded in controversy and conjecture. Strabismus is mentioned in the early papyri of ancient Egypt, specifically the Edwin Smith papyrus and the Ebers papyrus1 dating from approximately 1500 BC. The bible mentions strabismus, and in his writings, Claudius Galen2 (131-210 AD) described both acute acquired- presumably paralyticand congenital strabismus. There is no mention of strabismus in the writings of Susruta, the 7th-century BC Hindu physician who, among other things, is credited with being the father of the couching operation.

TAKE ONE PART TURTLE BRAIN. . .

In ancient times, strabismus carried with it a stigma; people believed that the person afflicted was inferior. Theories explaining strabismus included a beUef that a cramp of the muscles occurred after staring at an oil lamp or another object with one eye, leading to a deviation.3 Others believed the deviations were caused by the invocation of evil humors and spirits.

The earliest treatments for strabismus included a variety of purges and potions coupled with incantations that were hoped would remove the evil spirit from the body so that the eyes would straighten. For instance, equal parts of turtle brains and spices were popular remedies described in the Ebers papyrus.1 It is not clear, however, whether the concoction was ingested or applied topically.

Convergent and divergent masks were first used to treat strabismus by a Greek physician, Paul of Aegina (625-691 AD).4 This may be considered the origin of orthoptics. In addition, he suggested that when the eye turned toward the nose, purple flocks of wool should be fastened to the lateral canthus: the eye would be corrected if the afflicted person looked steadily at the wool. In 1540, Ambroise Pare5 attempted to cure strabismus with glasses made from horn with two pinholes placed at various pupillary distances. In his book written in 1583, 6 German physician George Bartisch (1535-1606) reported further refinement of these early attempts. Bartisch developed ski hoods that covered the head with perforated holes at various pupillary distances. Other people created more elaborate masks in an attempt to encourage the squinting eye to straighten and, although history records that none of these methods was helpful, this form of treatment still persists with nasal spectacle occlusion or temporal spectacle occlusion used by many visual training advocates.

Edwin Smith Papyrus c 1500 BC. Photo courtesy of the New York Academy of Medicine.

Edwin Smith Papyrus c 1500 BC. Photo courtesy of the New York Academy of Medicine.

THE SEARCH FOR A CAUSE

Between the 15th and 17th centuries, a variety of causes, including irregularities of the cornea, lens, and retina were thought to be responsible for strabismus. Amblyopia as a term was first described around 1700. In 1743, Buffon4 suggested that only one eye deviates at any given moment, never both eyes at the same time. Although this is accepted without question today, little was known about the concept in 1743. Buffon felt that squint was caused by an inequality in power of the eyes and recommended that the good eye, which had more power, be occluded in an effort to strengthen and straighten the squinting eye.

Buffon's work was tried in France with little success and was repeated in England by Erasmus Darwin,7 Charles' grandfather. Darwin beUeved that the better eye should be covered for many hours a day. Like Buffon, his success was limited, probably because refractive errors, which may have been present, were not corrected and occlusion methods used at that time were inadequate.

CHEVALIER JOHN TAYLOR

So, for about the first 3000 years of recorded strabismus history, no surgery was performed on the eye musclesbut not for lack of trying! Credit for trying goes to Chevalier John Taylor (1703-1772),8 one of medicine's "great* figures, whose imprint on the history of strabismus surgery is well documented. Taylor was one of the most extravagant of all the traveling quacks, a charlatan supreme and a figure chosen by history to play a major role in our strabismic heritage and, for that matter, our entire ophthalmic legacy.

The Chevalier John Taylor. Photo courtesy of Norman Medow, MD.

The Chevalier John Taylor. Photo courtesy of Norman Medow, MD.

Taylor trained in London in traditional medicine, receiving the best education available during the early 18th century. Rather than choose the route of traditional medicine in a hospital or office, however, Taylor became an itinerant surgeon traveling throughout Europe with a large retinue, including satisfied patients, musicians, and an ample stock of press releases and pubUc relations managers. Taylor gave himself the title "Chevalier," proof of his self-laudatory skills.

'Performing' Surgery

Although his main interest was cataract couching, he became convinced that strabismus could be cured. He recognized that in many strabismus cases, the deviated eye had substantial vision and could pick up fixation if the dominant eye was covered. He knew human nature very weU and reaUzed that people could be easily fooled. So, when he arrived in town sind examined potential surgical patients, he chose patients with esotropia. He performed surgery in the town square, surrounded by a select circle of people.

His method, which was recorded by contemporaneous observers, consisted of his passing a fine needle with a silk thread through a portion of the conjunctiva of the squinting eye a few millimeters from the lirnbus - usually inferior on the globe, probably between the medial rectus and the inferior rectus of the eye. Having made a loop with the silk thread, he then pulled on the conjunctiva with the silk thread passed through it, and excised a portion of the conjunctiva with a pair of scissors. The surgery was nowhere near the medial rectus or the inferior rectus.

"A miracle!'

Once the conjunctiva had been cut, he appUed a patch to the good eye, the deviating eye immediately picking up fixation. A miracle had occurred! Taylor explained that the eye squinted because nerve filaments between the muscles of the eye was in some way imbalanced. To restore this balance, it was necessary to weaken the muscle that dominated the strabismus by cutting the nerve filaments to it. He theorized that by doing this, the patient's strabismus was cured. Cutting a nerve filament to the muscle is interesting but, of course, false in its premise; however, the thought processes that Taylor exhibited in 1738- well over 200 years ago- come very close to our present day weakening of the medial rectus in cases of esotropia.

Following this superb show, Taylor would leave town in his carriage, which had his motto, Qui dat videre, dat vivere, or He who gives sight gives Ufe, prominently displayed on its side. When the patch came off and the deviation returned, Taylor was long gone from the site of his most recent surgical failure, never to return.

Right: Title page of Ueber da Schielen in die Heilung desselben durch die operation.

Right: Title page of Ueber da Schielen in die Heilung desselben durch die operation.

Bottom: Grapic from Dieffenbach's 1842 book illustrating the isolation of each of the six eye muscles.Photos courtesy of Norman Medow, MD.

Bottom: Grapic from Dieffenbach's 1842 book illustrating the isolation of each of the six eye muscles.

Photos courtesy of Norman Medow, MD.

Following the escapades of John Taylor, a number of legitimate advances were made; ultimately, strabismus surgery was performed for the first time on October 26, 1839. By that time, the Chevalier John Taylor had been dead for 67 years.

JOHANN FRIEDRICH DIEFFENBACH

In 1792, George Washington was in his third year as the first president of the United States of America. France was weU into its revolution, having just outlawed royalty. The guillotine was in full swing and Johann Friedrich Dieffenbach was born that February.9 His early years were spent in Königsberg, Prussia, the town of his birth, studying theology. After 2 years in the miUtary, he returned to Königsberg to study medicine. His primary interest during medical school was the transplantation of hair, still a rich area of research.

Johann Friederick Dieffenbach in 1831. Photo courtesy of Norman Medow, MD.

Johann Friederick Dieffenbach in 1831. Photo courtesy of Norman Medow, MD.

The story goes that as a result of an affair with a married woman, Johanna Moterby, Dieffenbach was asked to leave Königsberg. He followed his lady friend to Paris where he studied with Dupuytren, Magendie, and Larrey. When they went to MontpelUer, he studied with Delpech. After Johanna received her divorce, Dieffenbach married her. They then returned to Germany, where he received his medical degree at the University of Wurtzburg.

In 1823, they settled in Berlin and, after a stormy course (mostly from professional jealousy), he received a post at the Charité Hospital in Berlin, then the center of academic medicine

'Doctor of Doctors'

Dieffenbach was a gifted and innovative surgeon who was beloved by his students and patients. His popularity is exemplified by this song that was sung by children throughout Berlin at the time:

Werkennt nicht Doktor Dieffenbach Den Doktor der Doktoren? Er Schneidet arm und Beine Ab, Macht neue nas'und ohren

The translation for this is:

Who does not know Dr Dieffenbach, Doctor of doctors? He cuts off arms and bones and makes new noses and ears.

FATHER OF COSMETIC AND STRABISMIC SURGERY

Because of his innovation in the area of plastic and reconstructive surgery, he has been called the Father of Cosmetic Surgery. For instance, his surgery for nasal reconstruction, although modified, is widely used today. Up to the early 1800s, standard nasal reconstruction involved the inner arm flap, or the Tagliocozzi operation, first described by Gaspar Tagliocozzi of Bologna, Italy in 1597.

In essence, Dieffenback excised the nasal deformity, and prepared a clean surgical base. A pedical forehead flap was raised and rotated onto the surgical bed of the nose. After a number of months, the pedical can be severed and the flap re-shaped (see photos this page).

In the 1830s, Louis Stromeyer, professor of surgery at Hanover, proposed subcutaneous severing of the Achilles tendon for the correction of club foot. This operation was widely practiced. Dieffenbach learned of it from Stromeyer and successfully practiced it in Berlin. In addition, Dieffenbach and Stromeyer both performed tenotomies to improve torticollis.

In 1838, Professor Stromeyer proposed performing myotomy of the ocular muscle for correction of strabismus and experimented on cadaver eyes.10 In 1839, stimulated by Stromeyer's suggestion, Dieffenbach performed a myotomy of the medial rectus of a 7-year-old boy.11 In 1842, Dieffenbach reported his experience in 1200 cases of strabismus operation, and noted that if the tendon was severed, the results were better than if the muscle was cut. He also showed that adhesions were often formed, resulting in a variety of postoperative hyper- or hypodeviations.12 In his 1842 book, he explained that all six muscles of the eye could be operated on, describing specific instruments for performing strabismus surgery.

Dieffenbach's nasal reconstruction, modified. From left:Preoperative deformed nose; 6 weeks postoperative pedical flap from forehead; 5 months postoperative forehead flaps. Photos courtesy of Dan Baker, MD.

Dieffenbach's nasal reconstruction, modified. From left:Preoperative deformed nose; 6 weeks postoperative pedical flap from forehead; 5 months postoperative forehead flaps. Photos courtesy of Dan Baker, MD.

News of the success of this operation was heralded across Europe and by 1841, French and English surgeons had used Dieffenbach's methods. Edward Duffin, an EngUsh surgeon, wrote a book about strabismus surgery in 1840, 13 2 years before Dieffenbach. However, it contained only a composite of cases performed by English surgeons and reported in the Lancet, not descriptions of personal experience with this technique.

Much has changed since Dieffenbach's first strabismus operation, but his seminal surgical technique justifies our referring to him as the Father of Strabismus Surgery.

Dieffenbach repaired an ectropion by removing a triangular wedge of skin laterally and sliding the lower lid to effect a tightening and inward rotation of a lax lower Ud. Dieffenbach's blepharoplasty, his surgical correction for protruding ears, and his method of ectropion repair, are still in use today. Photo courtesy of Norman Medow, MD.

Dieffenbach repaired an ectropion by removing a triangular wedge of skin laterally and sliding the lower lid to effect a tightening and inward rotation of a lax lower Ud. Dieffenbach's blepharoplasty, his surgical correction for protruding ears, and his method of ectropion repair, are still in use today. Photo courtesy of Norman Medow, MD.

A Surgeon With a Green Thumb

When Carl Ferdinand von Graefe (father of Albrecht), the professor of surgery at the University of Berlin died, Dieffenbach was asked to assume this position. In 1847, shortly before his death, Dieffenbach wrote an important paper on the value of ether in the management of pain. Dieffenbach is thus credited with introducing ether to Europe. In addition, Dieffenbach instituted the first nursing program in Germany at the University of Berlin soon after his appointment as chief of surgery.

Dieffenbach's interests were not restricted to ophthalmic surgery. He also was an accompUshed linguist, speaking fluent EngUsh, Russian, and French, in addition to German. He translated a book on the eyes of insects from the original French into German.13 An avid horticulturist, he first described a group of plants in the Arache family for which the Austrian Botanical Society honored him in 1840 by naming this group of plants Dieffenbachia.14 16 This highly ornamental plant is often seen in homes throughout the world.

Corneal Transplantation

Throughout his career, he was interested in corneal transplantation and performed many experiments on transplanting the cornea of rabbits and chickens by suturing the donor cornea to the conjunctiva.17 In 1992, at the 200th anniversary of the birth of Dieffenbach, Humboldt University honored his memory by authorizing that the chair of plastic surgery at the university be given the title of the Johann Friedrich Dieffenbach Professorship.18

Linguist, horticulturist, plastic surgeon, Father of Strabismus Surgery, overall accompUshed general surgeon, Dieffenbach was truly a man for all seasons. In his writings, he felt that the surgeon's best instrument was his pen. He used it to write down his observations at surgery and to evaluate them prior to future operations. This tenant of scientific research first voiced by Johann F. Dieffenbach, stiU holds today.

Upcoming issues of the Journal of Pediatric Ophthalmology & Strabismus will contain more recent history- the past 150 years of strabismus treatment. Please stay tuned!

REFERENCES

1. Joachim H. The Ebers Papyrus. Berlin, Germany: University Press; 1890:68.

2. Hirschberg J. History of Ophthalmology, vol 7. In: Biodi F, trans-ed. Bonn, Germany: Verlag JP Wayenborgh; 1985:53275335.

3. Keiner GB. New Viewpoints on the Origins of Squint. The Hague, Netherlands: Martinus Nijhoff; 1951:2-6.

4. Wood C. American Encyclopedia of Ophthalmology vol 2. Chicago, Dl: Cleveland Press; 1916:1323-1324.

5. Pare, A. The Works From the Latin and Compared With the French by Th. Johnson. London, England: Cotes & Young; 1634:583.

6. Bartisch G. Ophthalmodoueleia. Dresden, Germany: Mathies Stocker; 1583: 25-28.

7. Darwin E. Zoonomia. London, England: J. Johnson; 1801.

8. James RR. Studies in the History of Ophthalmology in England. London: Cambridge University Press; 1933:132-216.

9. Goldwyn, RM. Johann Friederich Dieffenbach (1794-1847). Plast Reconstr Surg. 1968;42:19-28.

10. Stromeyer GF. Bietrage Zur Operativen Orthopedik. Hanover, Germany: Helwig; 1838:79.

11. Dieffenbach JF. An Die Scheuen und dieHeilung. Berlin Med Zeitung. 1839;46:27.

12. Dieffenbach, JF. Ueber das Schielen in die Heilung desselben durch die operation. Berlin: Germany: Albert Forsner; 1842.

13. Duffin E. Practical remarks on the new operation for the cure of strabismus or squinting. London, England: John Churchill; 1840.

14. DeSerres M. Ueber den Augen der Insekten: Aus den Franzosischen. Dr. J.F. Dieffenbach; Berlin, Germany: Teho Christ. Fried Enslin; 1826.

15. Arditti J, Rodriquez F. Dieffenbachia: uses, abuses, and toxic constituents. Journal of Ethnopharmacology . 1982;5:293-302.

16. Birosey MR. Dieffenbachia Bausei: The Cultivated Arachids. Berkeley, Calif: GUliche Press; 1951:84.

17. Dieffenbach, JF. Beitrage Zur Verpflanzung der Hornhaut: Zeit. Fur die Opth (Von Ammon). 1831;1:172-176.

18. Gabka J, Vaubel E, Goldwyn R. International commemoration of the 20th birthday of JF. Dieffenbach, Feb 1-2 1992, in Berlin. Plast Reconstr Surg. 1993;91:185-188.

10.3928/0191-3913-19990101-07

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