Journal of Refractive Surgery

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History of Corneal Surgery 

The Founder of the First Eye Bank: R. Townley Paton, MD

David Paton, MD

Figure 1: R. Townley Paton, MD in 1975.

Figure 1: R. Townley Paton, MD in 1975.

He was an inordinately genteel and private person, my father. I cannot recall ever hearing him boast, except in fun. He rarely was angry and was never rude. He had a pleasant sense of humor with no rough edges. His twinkle was almost always there, and sometimes a chuckle - but that was a far cry from a belly roar. He was an inside man; he enjoyed life from the inside. He wrote scientific papers and several text books, but was not driven by academia, nor in awe of it. His was the world of private practice, voluminous patient care, and hands-on and sometimes homespun creativity. He was not an orator nor gifted with repartee. He seemed to be a wonderfully average man for also being a special kind of genius.

Richard Townley Paton, born in 1901, was a descendent of one of the first ophthalmologists in the United States, Cornelius Ray Agnew. Predominantly of Scottish blood - he sewed his own buttons - Paton was the second son and third child of Stewart and Margaret Paton of Baltimore. By the time he married, he was called by his middle name, Townley, rather than Dick, as he had been known in college. His father was an early American psychiatrist and a professor at Johns Hopkins. In those days, American psychiatrists spent much time with their peers in Europe, working on the development of their new specialty and integrating sex with science according to the theories of Vienna's Sigmund Freud. Thus, the Paton children grew up with an annual commute between continents; and for a time, they spoke Italian, German, and even French better than English. My father was not much on Freud; we did not talk about sex at home, and he disliked being seen with his shoes off

His older brother suffered from tuberculosis and went to Wyoming to seek a healthier climate and became a cowboy, later, managing his own small dude ranch in Wyoming. His sister married a naval officer and was in distant parts of the world for most of her life; she was an excellent linguist. My father had sufficiently advanced chest x-ray signs of tuberculosis to prevent his enlistment in World War II and probably as much foreign language exposure as the interpreters at the League of Nations, but by the time I was old enough to need help with French and later German homework, he had forgotten his foreign languages. And if his scarred lungs were unacceptable to the military, they seemed to have no adverse effect on his game of tennis.

My father found ophthalmology in medical school, and after that, he lost interest in other aspirations - except family life. That would have to have been his first passion and ophthalmology his second. He married my mother, a New Yorker, while still in his house staff years. He was a Wilmer Institute resident, and in 1932, became the chief resident under the commanding influences of its Director, William Holland Wilmer. As a resident, Paton was apprentice to the era's great master in the care of difficult eye cases and the feeding of VIP's, but - despite the preceptorial system of medical education - he never learned to be imperious.

The Professor's rounds were held at bedsides by candlelight, the best illumination for sore eyes if you don't depend upon microscopic detail. Back in the 1930s, leaches were still being used on the temple in certain cases. Hospitalization after surgery often required weeks of immobility, with the patient's head secured between sandbags. Bedpans were the hardware and bandages the software ofthat period. The most frequently used eye drops were tincture of silver (Argyrol) and - note the touch of romanticism - "belladonna." Compare that with apraclonidine which tells me nothing.

Ethics shadowed every act a doctor performed; ethics were self-mediated, except under most unusual circumstances. Dr Wilmer, for example, adamantly refused to permit fund raisers to contact his millionaire patients for funding the construction of the Wilmer Institute. But others surreptitiously sought out his wealthy patients, and the building was built by their donations.

Figure 2: Dr Paton (left) and his son, David, as they departed for 4 months in Iran on a trachoma survey in 1948.

Figure 2: Dr Paton (left) and his son, David, as they departed for 4 months in Iran on a trachoma survey in 1948.

Dr Wilmer's practice included many remarkable individuals - the King of Siam being one of them, and - you may know the story - after the King's cataract surgery was successfully completed, Wilmer was asked by an aide what the bill would be. Wilmer, with his baronial presence is alleged to have replied, "The King can do no wrong!" (We don't know for sure, but I suspect he said it slowly and with the emphasis on "King" and "no," and in basso profundo.) In any case, the grateful monarch showered Wilmer with gifts of unique appeal and immense value.

Mrs Pillsbury of the flour company of that name was one of Wilmer's patients who refused to let my white-suited, senior resident father examine her eyes. Thereafter, my mother never ever, not even once, bought Pillsbury flour - not for all her life, even though she conceded it was probably better than Gold Medal and the other brands.

Many years later, the then successor to the King of Siam, the Shah of Iran of the legendary Peacock Throne, became a frequent patient of my father's in his New York office. Once, after he had spent most of Thanksgiving Day at the office with the Shah, an aide asked my father what the Shah owed for his professional services. "There is no bill at all," my father replied. "It has been my privilege to be of service to His Majesty." He received from the Shah a rolled up, black-and-white glossy print of the Shah in uniform covered with medals which cost $50 to frame - it was not what Wilmer would have been given, but my father was enormously pleased with the picture.

Richard Townley Paton was one of the last residents under Dr Wilmer. When the Baltimore residency was completed, it was Wilmer who decided that he should leave Baltimore and practice in my mother's native city, New York, where Wilmer wanted to place an ophthalmologist for patients of his who could not always get to Baltimore. It was that simple - and another mark of the times - Wilmer decreed, and my family complied. That is quite how it was in those days. So, the Paton family moved to New York, where my father began his solo practice, performed his surgery at Manhattan Eye, Ear and Throat Hospital, and developed his interest in keratoplasty. He had only performed one or two corneal transplants in Baltimore. They were rare operations, being all too rarely successful in restoring a clear cornea and good vision. Tens of thousands of people with cloudy corneas awaited visual redemption, not knowing that it soon would become possible.

In New York City, Dr Ramon Castroviejo and my father became increasingly active as New York corneal surgeons, each chasing down corneas as best they could, usually from enucleations or "private deaths." My father was tall and relatively placid, Cassie (as Castroviejo was called by most everyone who knew him well) was short and usually in motion. Dr Castroviejo had come to New York from Spain; he had immense Hispanic charm and remarkable dedication to his very large practice. He had considerably more surgical volume than my father, attracting patients from far and near in this country and throughout Latin America. He was not evidently interested in the mechanisms and financing of eye banks, although he came to use them extensively. He was an ardent marketer of his skills and services, one of the first surgeons to size up and seize upon the attention of the press. This was not done to a degree that would seem brazen today but, unfortunately, to a degree that was considered outlandish by the medical societies at that time. It is ironic that articles mentioning my father were eye-bank induced, part of the process of gaining recognition for the bank that required financial support.

After Castroviejo died in his native Spain, I called his son on behalf of the EBAA to ask if he would contribute to the establishment of an American professorship or fellowship in his father's name. According to the son, Dr Castroviejo had felt abused by the medical profession in New York (being critical of his willingness to be publicized), and he was sure his father would not have cared for sponsoring such recognition.

Both Castroviejo and Paton had remarkable surgical hands, considerable pioneering spirit, and a gift for patient care - each gift quite unlike the other's. Paton, as you now know, was not the urbane professor that Wilmer had been but neither was he the kinetic, fiery iconoclast as was his colleagial rival across town. Castroviejo was a dynamo who ran his own private "lying-in" eye hospital, a converted private home in upper east side Manhattan. Cassie used to tell my father* it was time for him to learn appositional sutures rather than using overlying sutures: how right he was! And from the 1950s, both used direct suturing, aided by loupes and finally microscopes.

My father and Castroviejo were somewhat distant in their relationship - fish of separate species sharing the same pond. As a son, it is difficult for me to judge which fish was bigger. From the number of instruments named for the surgeon, Paton was no competition. Both used techniques that were to be replaced as more knowledge was gained through research. For example, Castroviejo required many of his pregraft patients to submit to extensive sinus surgery as a preventive measure against corneal transplant rejection. That exacting peculiarity aside, Castroviejo made immensely important contributions to the techniques of corneal surgery. Some of the leading corneal surgeons today were his students and associates, but similar words might be said about the doctors inspired (in a more low-key fashion) to work in keratoplasty through the example and training offered by my father at the Manhattan Eye and Ear Hospital.

By the 1940s, the eye bank was an idea whose time had come. Many so-called breakthroughs seem to be mere extrapolations of existing facts and services, and that was the case with the first eye bank. To mention anlagen, Elschnig in Prague had worked extensively with human donor material in the early 1930s, and his work was soon complemented by Filatov in Odessa. Filatov believed that eye tissue could be "preserved" at 4° C for several days, making it superior in quality than when first excised from the dead. He advocated administration of various substances for "tissue therapy" to control the rejection of graft tissue: human placenta, aloe, rare earths. Filatov died in Odessa several years after the eye bank was established in New York. As more and more corneal transplants were being done in that city, the supply of donor corneas became the limiting factor. Blood banks were existent, but as yet, there were no actual tissue banks.

Paton saw the need to facilitate the process of permission to use donor material from the dead and to expedite the delivery of the donated tissue to the intended recipient. He worked on organizing the infrastructure of how that should be done, and he sought available donor sources that might be readily available. In the 1940s, electrocutions were a fairly common means of meting justice at New York's Sing Sing prison. He approached the warden and later other prison officials and then spoke with the doomed prisoners themselves. With the help of the clergy, written permission to use their eyes was obtained from most of the prisoners approached. He himself enucleated the eyes, brought them home overnight, storing them briefly in the refrigerator. Those forays almost led to the loss of the family cook who was dismayed, put mildly, to find eyeballs when reaching for the milk bottle. Eye banking was soon to acquire its own refrigerator.

Figure 3: Paton (wearing loupes) with observers and photographer as he performed one of the first corneal transplants in New York City, Manhattan Eye & Ear Hospital in 1937.

Figure 3: Paton (wearing loupes) with observers and photographer as he performed one of the first corneal transplants in New York City, Manhattan Eye & Ear Hospital in 1937.

By 1944, the eye bank was established at Manhattan Eye, Ear and Throat Hospital. It was a single room, occupied largely by a single person, Aida Breckenridge, a remarkable woman who had been instrumental in fund raising to create the Wilmer Institute and now was totally dedicated to this new entity. She was a power person - a formidable presence, a society-based crusader. Incidentally, for a single year, the bank was moved to Cornell University Medical Center where John McLean was the professor, but it was thereafter returned to the original site at Manhattan Eye, Ear and Throat Hospital where it has remained ever since: The Eye Bank for Sight Restoration. There have been only five Executive Directors after Mrs Breckenridge until the present one, Mary Jane O'Neill - most all of them also remarkably capable persons upon whose shoulders the actual work of eye banking has been rested.

And now there are hundreds of eye banks around the world, and many other kinds of tissue banks have more recently been developed. It was always my father's conviction that a medically-related organization with intrusion into the public domain must have its medical policies controlled by medical people. This has remained the management principle at the first eye bank and may account in part for its sustained success over decades of difficult evolution. Dr Wing Chu is currently that eye bank's remarkably capable medical director.

In the earliest efforts to raise money to meet the expenses of the eye bank, publicity was required. A system of pledge cards for willing future donors to sign was one of the most effective means the bank had of making its presence known. Moreover, Paton (more willing than Wilmer to involve his own patients) approached many wealthy persons with eye troubles and found in them staunch supporters of his bank. But more money was needed. Mrs Breckenridge and various other laypersons who had joined the bank's board had no hesitation in soliciting journalists to tell the eye bank story in newspapers, magazines, and radio reports. The material that resulted lauded the eye bank, mentioned the hospital where it was located, and gave the name of the founder. There were even interviews with resulting quotes and commentary. The medical profession was aroused. Many were outspokenly critical. In the 1940s, having one's name mentioned in news stories was for scoundrels - certainly not for professionals.

Ophthalmological societies and hospital committees considered the wrongness of my father's name being mentioned in the lay press and gave him severe reprimands (unwritten) for his audacity and complicity in respect to the press - unwritten, unfortunately, for these would be fascinating historic documents today. By our present standards, those PR releases on behalf of the eye bank would hardly seem the once verboten verbiage they were considered by the most ethical and influential leaders of American ophthalmology in the 1940s and 1950s. Castroviejo and Paton were uniquely different from each other, but each was chastised for being mentioned in public publications. From what I said earlier, we can surmise that the turmoils of an evolving medical profession caused chronic wounds for Castroviejo. My father was hurt, too, but not obsessed by being considered negatively unconventional for a positive contribution. My mother was angered by it. I told you earlier of how she responded to affronts on her husband. But, the first eye bank was born - and human frailties were less important.

Townley Paton lived in New York City for 30 years and later "retired" to a soon busy practice in Southampton. There, the local university gave him an honorary degree as the founder of eye banking - and you would have thought it was the Nobel Prize to watch his excitement in receiving it. He died in 1984 at the age of 83.

Where, you may be wondering, was the genius I spoke of at the start? For one thing, he "began the book" on the increasingly important concept of tissue banking. Next, he was a masterful surgeon. But the best part is hidden from history. He was both a professional and a family man whose "way" was what really mattered. He was not puffed up. His life was free of anger and filled with love. He did not lose perspective. He never used leverage. He was not an imitator. (You must forgive a son these emphases, but those of you who remember him may agree): Eye banking is one thing, but it seems to me that there was some order of real genius in the unflappable equilibrium and equanimity ofthat special man.

Remembrances of R. Townley Paton, MD

The testimonial to R. Townley Paton, MD, the Founder of the first eye bank, by his son David, is an accurate portrayal of the man and his times. The unique events transpired over 40 years ago, but the challenges of the period, the moral and ethical dilemmas, and the colorful cast of talented personalities are still within easy recall.

It was my privilege to be under the tutelage of R. Townley Paton from 1949 through 1952 as a resident at the Manhattan Eye, Ear and Throat Hospital, thus affording me the opportunity to be a direct participant. It is quite true that Dr Paton was neither a great orator nor a full-time academician by modern standards. He did possess a creative mind, a kind, gentle personality, a love for people, a natural surgical ability, and a great deal of common sense. These traits made him a homespun genius and endeared him to his residents, all of whom he had great respect for.

In 1950, when his lovely wife Helen sustained an embedded corneal foreign body, he referred her to the resident on call at Manhattan Eye, Ear and Throat Hospital. As a result of this event, Helen (a truly gracious lady) and I became lifelong friends.

In April of 1951, an unusual event occurred that effectively launched and shaped my own career as a corneal transplant surgeon. The American College of Surgeons was holding a meeting in New York, and a number of the participants came to see Dr Paton perform a corneal transplant procedure. I was a junior resident at the time, and had not even performed any cataract surgery. I was drafted for duty when the senior resident unexpectedly became ill. With the room packed with some 15 to 20 visiting surgeons, Dr Paton turned to the audience and informed them that Dr Taylor would do the operation. This was totally unexpected, as Dr Paton had permitted few, if any, of the senior residents to perform a penetrating keratoplasty. With more nerve than judgment, but inspired by his confidence in me, I proceeded to place overlaying sutures (referred to in the article and scorned by Dr Castroviejo), trephined the donor and recipient, and uneventfully completed the procedure. It was undoubtedly one of the greatest moments of my life, and a milestone in my own career. Dr Paton's influence as mentor, father figure, and lifelong friend have shaped my entire professional life. Without his status and support, we could not have founded the Connecticut Eye Bank in 1961.

Unmentioned in David Paton's tribute is the fact that the early days of the Eye Bank Association of America (1961) were not without their political struggles. On many occasions, the EBAA seemed to be little more than a splinter group, rebelling against the authority of Dr Paton and his powerful New York Eye Bank with its chain of affiliated eye banks spread across the country. In this game of political intrigue, Dr Paton was unfortunately cast in the role of the leader of the enemy group whose power had to be broken. All problems were eventually resolved, and Dr Paton emerged with the love and respect of the entire group. Although I played only a minor role, it was one of the few times I could be supportive and helpful to Townley in an effort to repay him for all that he had done for me.

Dr Paton was indeed a genius through his pioneering efforts in the field of eye banking, the forerunner of all modern organ and tissue banks. He has left a legacy to mankind that will go down in history for all time. He was truly a giant among men.

DANIEL M. TAYLOR, MD

New Britain, Conn

I am pleased to have the opportunity to put down on paper a most happy memory of a beloved and wonderful teacher who crossed my path in my early training years.

Dr R. Townley Paton was a remarkable man. Even when I was a junior ophthalmologist, he gave me a great deal of time, energy, and consideration when I was learning corneal transplantation. He was a very handsome patrician figure who, although extremely busy, seemed to find time to answer questions, and if buttonholed at the Academy meeting, for instance, would be glad to have a cup of coffee and talk about whatever problems were uppermost in our minds.

I think he knew he made a tremendous contribution to eye surgery with his work, and while there were others who may have been more vocal and flamboyant, Dr Paton's every utterance was taken to heart and found to be useful in solving our eye surgery problems. There was a group of us who would get together at the Academy for lunch and talk about eye surgery problems; when his name was brought up, all had the same reverence and affection for his kindness and thoughtfulness in helping us solve our problems.

MALCOLM A. McCANNEL, MD

Minneapolis, Minn

I first met Dr Paton while I was a resident at the New York Hospital Cornell Medical Center between 1945-1950. He and my mentor, John McLean, had both trained at the Wilmer Institute and had an interest in eye banking since they were among the pioneers in the new specialty of corneal surgery. We residents had the job of enucleating the donors as well as assisting in the surgery. I recall several trips to Sing Sing prison for donor material, which was always available following a dimming of the lights.

When I finished my training, Townley offered me the position of instructor to the residents at the Manhattan Eye, Ear and Throat Hospital where he was Surgeon Director and head of the Eye Department, and where he had established the Eye Bank for Sight Restoration, Inc. He was always very supportive of me in this position. AU of the residents were at least a few years older than I and the attending were also somewhat hostile to a university trained ophthalmologist. Townley wanted to introduce the Wilmer training system which he and John had enjoyed, and I was his chief instigator. We even tried to join the Manhattan Eye, Ear and Throat Hospital with Cornell, a project that failed after the residents we assigned there revolted. I had as a bonus during my 5-year tenure what amounted to a fellowship in cornea where I developed an abiding interest in this intriguing specialty.

After I became head of ophthalmology at the State University of New York, Dr Paton asked me in 1962 to return to the Manhattan Eye, Ear and Throat Hospital as a surgeon director where I had the privilege of working with him until his retirement. One of the highlights of those years was the annual corneal course he held at his summer home in Southampton. One could fit all the corneal surgeons of the day on the courts of the Southampton Tennis Club, where Townley also starred. He was not only a fine ophthalmologist but a great teacher and friend who remains one of the major influences on my professional life.

RICHARD C. TROUTMAN, MD

New York, NY

David Paton and I were classmates at Princeton and my first interaction with Townley Paton occurred when he addressed the Premedicai Society; first he stimulated my interest in ophthalmology, and then he showed a film on corneal transplantation which, in fact, made me ill.

Over the years, I helped teach Townley's course, which was one of the major sources for education of corneal surgeons. He was the kind of man who would invite not only the older, established physicians, but even someone in his 30s to come and work with him and take part in his course. He was incredibly knowledgeable, generous, and humble, and he provided extraordinary encouragement to us beginners in the field in which he was a master.

One of the great thrills of my life was when Townley Paton sent me a patient in Florida because he thought that some of our new developments might help. The idea of one of the best surgeons in the world referring a patient to a young upstart was unusual, but it was the kind of thing that Townley Paton would do and one of the things that I think illustrated his care for his patients, and his willingness to do anything he could to help them without any of the petty considerations that might influence others.

In addition to being a devoted and excellent physician, Townley was a genuinely warm person who truly gave no thought to pride and position but cared only for his profession and his patients.

HERBERT E. KAUFMAN, MD

New Orleans, La

10.3928/1081-597X-19910301-17

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