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Contribution of Anatomy to Clinical Ophthalmology*
LAGRANGE-FORONI OPERATION
55
sequential to dense cicatricial tissue formed about the cysts. I have observed such adhe sions when bleeding from the episclera was controlled
by cautery.
Very
elevated
and
thin-walled cysts may thus be formed, pre senting the danger o f perforation, even when neither
side
of
the
conjunctival
incision
strikes the limbus. In these cases I p e r f o r m a debridement of the cicatrix
(fig. 5 ) . A
small incision is
made through the temporal side o f the con junctiva, five mm. from the adherent border. A curved scissors with dulled points is plied Fig. 5 (Busacca). Diagram illustrating debridement of blocked cystoid cicatrix.
against the sclera to f o r m a tunnel to the cicatricial band which is c u t ; then the cysts are cut through down to the limbus till the scissor
points
reach
the adhesions at
the
cicatrix. This results from firm adhesions o f
nasal border which are likewise cut. A f t e r a
the conjunctiva to the sclera over the entire
lapse o f some weeks the cystic mass
extent of the conjunctival incision or may be
CONTRIBUTION
O F A N A T O M Y
GEORGE K . SMELSER,
CP.
flattens.
2813.
T O CLINICAL
OPHTHALMOLOGY*
P H . D . , A N D VICTORIA O Z A N I C S , M . S . New
York
I am very grateful to y o u for allowing me
Standing o f the structures with which he
to join in sharing y o u r pleasure in the o p
deals. Currently, the increase in scientific re
portunity which these new laboratories offer.
search in this and other fields is so rapid and
I am glad f o r you, and I am glad f o r the
vast that the contributions cannot be satis
laboratories,
factorily sorted out or evaluated as they are
next
years
f o r they will house in many
these
exciting moments,
and,
with a little luck, very important ones.
reported. This rapid increase is occurring be cause the value o f basic scientific research to
It is scarcely necessary to emphasize the
clinical medicine is widely recognized and,
value of anatomic knowledge to clinical oph
therefore, more workers are recruited to this
thalmology. It is axiomatic that a physician
effort.
and surgeon must have a thorough under-
nology
* From the Department of Ophthalmology, Col lege of Physicians and Surgeons, Columbia Uni versity. This investigation was supported by grant 00492-10 from the Department of Health, Educa tion and Welfare, Public Health Service, National Institutes of Health and by Research Career Award NB-K6-19, 609-01. This paper was pre sented at the dedication of the Eye Research Laboratories of The University of Chicago, De cember 16, 1964.
In addition, the advances in tech greatly
enhance
the
investigator's
productivity. N o one can determine the value o f a spe cific
finding
to clinical ophthalmology or,
what is more important, what fields an in dividual discovery may lead to. Perhaps it is m o r e appropriate if w e regard the contribu tions o f anatomy to ophthalmology as a con tinuum, and consider the role it has been.
GEORGE Κ. S M E L S E R A N D V I C T O R I A O Z A N I C S
56
and is, playing in tlie development o f oph
been lost, hence the oldest existing eye dia
thalmology.
grams are Arabic. During the middle ages,
T h e problems in the past were really much the same then, as today, as are the methods, inasmuch as anatomists have always studied
medical teaching relied on retranslation of the Arabic manuscripts into Latin. In the middle of the 16th century anatomy
tool
as a science was revived b y Vesalius, w h o
which was currently available. It is most im
broke with the tradit ions of the preceding
portant not to forget the men w h o made
16 centuries, and stimulated actual study o f
these contributions, to see h o w they evalu
the body, rather than the re\-iewing and par
unknown
structures and
used
every
ated their o w n work, and how discoveries
roting o f ancient manuscripts. Although he
we recognize as clinically important
today
included the eye in his writings, there is no
were made without realization o f their value.
evidence that he and his school made any
.Such considerations give us a perspective
contributions to our knowledge of its struc
from which to view today's progress, and
ture.
pride in the work which is being done, and
This really brings us to the beginning of
in our association with colleagues w h o have
the most amazing period, the last 375 years,
worked on these problems a little before us.
which is only one sixth of the 23 centuries
In early times there was no regularly or
which span the development of our knowl
ganized profession of anatijmy as we know
edge of eye structure (fig. 1 ) . There were
it today; anatomists were often natural his
many men during this period whose work
torians,
catholic tastes, or
was important and exceedingly interesting,
practitioners whose interest in anatomy grew
though seemingly remote to us now. Recall
scientists
with
out of their concern with treatment of dis
ing their names and w o r k creates a vivid link
ease. W e must make our own definition o f
with the past and gives us a greater ap])reci-
anatomists
ation o f the work in which w e are engaged.
were scientists w h o learned by dissection,
Today's problems gain in stature when con
anatomists.
Since,
classically,
separating
sidered in this relationship. O n e can only
those w h o used scalpel and unaided observ
touch upon the contributions o f a f e w o f the
ing eyes, or those utilizing on ultratome for
outstanding men.
there is really great difficulty in
slicing 10O.\ sections, from those ordinarily
The older texts refer to Felix
Fontana
dissect molecules
(fig. 2 ) as a scientist and physiologist. H e
with enzymes. T h e y are all anatomists inter
was certainly also an anatomist. H e had a
ested in the structure of the living body, and
long life extending from 1720 to 1805. A s
today's anatomists use all of the contempo
a young man he studied in Padua, Bologna,
rary tools which they and allied
and Rome, and finally was awarded the chair
called
biochemists
who
scientists
can find.
of philosophy in Pisa. In those days the uni
The eye has always intrigued such men, beginning with the earliest anatomists. Those who gave us our early concepts of eye structure were Greeks. Greek knowledge of the eye was perfected by the Alexandrian school, especially by Herophilos, about 300 B.C. This information, particularly as pre sented by R u f o s and later Galen (ca. 200 A . D . ) had been transmitted to the A r a b world which preserved the knowledge, but without modification o f the anatomic con cepts. T h e original Greek manuscripts have
versities in the provinces of Italy operated under patrons. It was the Duke o f Tuscany w h o directed him to establish a department of natural history at Pisa. W h i l e there, he worked in, at the time, an advanced manner, which would n o w be considered the classical anatomic tradition. H e made w a x models to be used in teaching. His studies were really of comparative anatomy directed mostly at neural structures. H e was one of the first to use chemical fixatives, which allowed him to preserve and examine the retina. H e found
57
CONTRIBUTION OF A N A T O M Y V A N I K U W f NHOEK 1 «UVSCM 1 MAÍTtE J A N \ POUWOUt DU PETIT \ V O N MALLEI ZINN I FONTANA SOEMMBllNG SCHLEMM [THEVIIIANUS 1; Í O W M A N 'I ! H E N L E
Ih. muller 1! K O E L L I K E R
SCHWALBE IsCHULTZE BAMON Y CAJAL
KRAUSE
EUSTACHIUS VESALIUS
DOGIEL H. V I R C H O W ROCHON DUVICNEAUO
¡SALZMAN TRONCOSO POLYAK
ISOO
IMO
1700
ΙΘ0Ο
1900
Fig. 1 (Smelser and Ozanics). Chart of outstanding anatomists who contributed to the growth of ophthalmic knowledge.
retinal "globules," which he likened to those of the brain but found them to be more regu lar and uniform. H e clearly distinguished between cellular and supporting structure in the retina by chemical and physical separa tion o f these two elements. H e described the retinal vessels, which you see daily, the ret inal nerve
fibers,
and dissected the optic
nerve of many animals. W e have forgotten most of these studies, but
remember Fontana because of his de
scription o f a canal in the anterior chamber angle. H e found this structure while dissect ing
the eye o f an o x . ' Although
it was
clearly shown that this canal of Fontana did not exist in man, the spaces in the trabecular meshwork are still often referred to as the spaces o f Fontana. T h e gracious manner in which the old anatomists reported their find ings, and the importance and function which they assigned to them gives us an insight into their scientific attitude and the dignity of their lives. Fontana's discovery was re ported in a letter addressed to Prof. Murray in Upsala (fig. 3 ) . T h e following is a quota tion from the closing paragraphs of this let-
Fig. 2 (Smelser and Ozanics). Portrait of Felice Fontana, from Mary A. B. Brazier: The evolution of concepts relating to the electrical activity of the nervous system 1600 to 1800. Figure 10 in The Brain and its Functions. An Anglo-American Symposium, London, 1957. Oxford, Blackwell Scientific Publica tions Ltd., 1958. Permission to reproduce this figure given by the author. Dr. Mary A. B. Brazier and by the publisher. Blackwell Scientific Publications Ltd., Oxford, England, is gratefully acknowledged.
GEORGE Κ. S M E L S E R A N D VICTOREA. O Z A N I C S
58
let tri ccr'ite a Ms Adolphe Murray Celebre Profeßcur ιΓAnatomie a Upfal Pmné ιηη%. j - E vous envoye conjointement ä
cctte Lettre trois deíTcinj
,1 marqués i , i , 3 , que (a) j'ai crö fu/üfc pour vous rappeller i'idcc de ce nouveau canal que j'ai crouvé dans Γοβϊ1> et que j'ai eu le plaißr de vous faire voir lorfque vous pafsåtes par Florence. G'cíl dans cette occalion que j'eus la fatisfaftion
de
vous connoítre ct que vous m'accordates, vótre agreablc amitie · Ά
un Anatomiile auffi eclaírc que vous, c'ell aílcz que d '
indíquer feulcraent les parties principales; le refteferoit tout-á-faic faperflu. Les rrois figures VIH. IX. X . ( P I . VII.) font voir ces trois fcftions principales que je fis dans l'ocil du bocuf, et qoc )c vous montrai quand vousécicz ä Florence. Jene vous parlcrai pas des autres fcftions,
Fig. 3 (Smelser and Ozanics). Reproduction of the beginning of the letter by Felice Fontana in which his canal is described. Page 267 from: Traite sur le vénin de la vipére sur les jioisons americains sur le laurier-cerise et sur qualques antres poisons végetau.x. On y a joint des observations sur la structure primitive de corps animal. Différentes experiences sur la reproduction des nerfs et la description d'un nouveau canal de I'oeil. Avec plusieurs planches. Tome second, Florence, 1781.
circes font ces trois que je confidere córameles plus cíltnticllcs , ct les plus ncceíliiire å fatisfaircs á vos demandes, ct par coufc(¡acnt je paflcrai le relie fous lilence.
ter, which recreates the atmosphere of that period. I send you the illustrations of this new canal of the eye (fig. 4 ) , not because I wish that you should publish tliem, as you have indicated that you want to do in the Acta of the Academy of Upsala, but solely because you have asked me for them: It is sufficient for me that you should be persuaded of
my esteem for you, and of my pleasure in corresponding with a man of your merit. Do with them whatever it pleases you for I am altogether indifferent on tliis matter. You may certainly have noticed, during the time you were here, the little importance I gave to this old discovery; I say "discovery" because it pleases you to call it thus. I shall not say anything, however, on the subject of the function of this new canal and of the transparent humor with which it is bathed. For the present I have no certain observations or definite experiment which could shed light on this subject: I do not want to advance imaginary hypotheses, or simple probabilities. I am abandoning and submitting this difficult subject to your genius, and it is to you I leave the glory of its explanation. Fontana's use
of
chemical
fixatives
was
mentioned. T h i s was an enormous advance f o r anatomic science and was used by a number of investigators of that period. Antoine Maitre-Jan, a century earlier, was one of the first
to
use
this extremely
important
new
anatomic tool. H e was primarily an ophthalFig. 4. (Smelser and Ozanics). Illustrations of Fontana's canal, Plate \ T I , figures V I I I , I X , X , from his book Traite sur le vénin de la vipere sur les poisons americans sur le laurier-cerise et sur quelques antres poisons végetaux. On y a joint des observations sur la structure primitive du corps animal. Différentes experiences sur la reproduction des nerfs ct la description d'un nouveau canal de I'oeil. Avec plusieurs planches. Tome second, Florence, 1781. Note figure I X , m at the right indicates Fontana's canal within the ciliary body. The letters r and o indicate the ojien ends where the cut has been made into the canal.
mologist rather than an anatomist. Later, another w h o contributed greatly to our understanding of the anatomy of the eye, did not use
chemical
fixation,
but
freezing,
as
a
method of preservation and an aid in study. H e was F r a n ς o i s - P o u r f o u r du Petit, whose name w e associate with another canal.
He
was the first really to demonstrate that the cornea was avascular and, in 1728, the exist ence of the
posterior chamber, although it
CONTRIBUTION OF A N A T O M Y
59
required 100 years f o r this to be generally accepted. Du Petit studied both human and animal material. In one experiment, the eye was suspended by a thread passed through the optic nerve and allowed to freeze, where upon it was bisected along its anteroposte rior axis. D u Petit determined the existence and the volume o f the anterior and posterior chambers by measuring the ice he removed from them. Using fresh cadavers, he meas ured corneal curvature, length o f the eyeball, radius of curvature of the lens surfaces and located accurately the position o f the lens —all of them clinically important discov eries. His examinations showed that the lens capsule remained transparent in cataracts. H e was an extremely enthusiastic and ac curate observer. Apparently he was much in advance of his time for, in 1727, Philip H e c quet, dean o f the Paris Faculty of Medicine, stated in an article "Remarques sur Γ abus des purgatifs" that the lens lies in the mid dle of the eyeball and that cataract is a mem brane." W h e n du Petit offered to demon strate the actual facts to him, M . Hecquet replied that he had neither the time nor the inclination for it! After a long period o f dis tinguished, if little known, anatomic re search, du Petit gradually put his remark able knowledge to practical use and became a successful ophthalmic surgeon. Discovery o f another ocular structure pro vided us with another household word in ophthalmology, the canal o f Schlemm. In Friedrich Schlemm's (fig. 5 ) day anatomy was already well organized. H e was born in 1795 near Hanover, and studied in Braun schweig. His doctoral thesis in 1821 was en titled, " D e arteriarum faciei anastomosibus." Interested in the nervous system o f fish, which was the subject o f a prize-winning dissertation, he later received a medal for his description of the arteries of the head, and wrote on the anatomy of the auditory ganglia o f snakes. H e was, therefore, a true anatomist and became "ausser-ordentlicher Professor" of anatomy in 1829 and P r o f e s -
Fig. 5 (Smelser and Ozanics). Portrait of Friedrich Schlemm, from System of Ophthalmology: Volume 2: The Anatomy of the Visual System (fig. 207, p. 189) by Sir Stewart Duke-Elder and Kenneth C. Wybar. St. Louis, Missouri, C. V. Mosby Company, 1961. Permission to reproduce this figure given by the author. Sir Stewart DukeElder, is gratefully acknowledged.
sor Ordinarius in 1833. H e wrote widely, and described f o r the first time the nerves o f the cornea, which he studied in beef and deer eyes, and only assumed that similar struc tures were to be found in man.^ It is somewhat difficult to find the original description o f the canal o f Schlemm because of some errors in references in the litera ture. It may be found quoted in an editorial in the first volume o f the Zeitschrift für die Ophthalmologie.^ T h e quotation is taken from a chapter contributed by Schlemm to a book edited by Rust.* H i s name appears only in tiny letters ( S c h l e m m ) at the end o f his chapter. T h e following is a translation from the original. The posterior concave side (of the cornea) ends in a circular border, behind which the sclerotic has a groove-shaped concavity, where the orbiculus ciliaris is inserted. In this groove there is a circu lar, thin-walled canal, which I discovered in 1827 in the eye of a hanged man, because it was filled with blood. A small bristle could be introduced into it after the cornea and sclera were cut through fore
60
GEORGE Κ. S M E L S E R A N D V I C T O R I A O Z A N I C S
there is not a word o f his canal which had been reported in an obscure surgical hand book several years earlier. It was this dis covery which finally secured immortality for him. In this connection it is interesting to note the comment o f Rochon-Duvigneaud, in the preface to his book,^ that anatomists, as a group, entirely neglected the formation and removal o f intraocular fluids and the mainte nance of intraocular pressure. The relation of structure to this important ocular func tion, it must be admitted, was the contribu tion o f clinical men. Modern anatomists are fortunate in being able to work with some knowledge o f the function o f the structures which they describe. The comment o f Rochon-Duvigneaud is not applicable today.
Fig. 6 (Smelser and Ozanics). Portrait of Johann Gottfried Zinn from System of Ophthalmology: Volume 2 : The Anatomy of the Visual System (fig. 385, p. 326) by Sir Stewart Duke-Elder and Kenneth C. Wybar. St. Louis, Missouri, C. V. Mosby Company, 1961, Permission to reproduce this figure given by the author. Sir Stewart Duke-Elder and by the pubhsher, Henry Kimpton, 134 Great Portland Street, London, W . l , England, is gratefully acknowledged.
Let us go to another older anatomist whom we feel we know because his name is used so often. Johann Gottfried Zinn (fig. 6 ) was one of those brilliant scholars whose in-
and aft. The canal should not be confused with that of Fontana which is to be found in the beef eye.
This was reported, as were the canals of Fontana and du Petit, with no comment on their possible significance or function. These were the days when descriptions o f structure had to be made without the excitement which is added when we try to relate functional significance to structure. Schlemm is quoted today more often than Fontana or du Petit because we now find the canal to have clini cal significance. Fame often rests on most fortuitous foun dations. In the 1833 edition of the Medizin isches Schriftsteller Lexikon der jetzt leben den Aerzte, Schlemm already had his place of honor because o f the surgical exercises on cadavers which he made for his students, but
Fig. 7 (Smelser and Ozanics). Reproduction of front page of Zinn's book, Descriptio Anatómica Oculi Humani Iconibus Illustra. Gottingae, Abrami Vandenhoeck, 1755.
CONTRIBUTION OF A N A T O M Y
terest was wide and ability great. H e was born December 4, 1727, in Ansbach, but his professional life began in Göttingen un der the great anatomist A . v . Haller. There, he early became interested in the eye, and described its vessels and those of the orbit. H i s greatest work was Descriptio anatómica oculi humani iconibus (fig. 7 ) , written in clear and precise Latin, and it is this book which established him in the annals o f anatomy. It is the first text wholly devoted to the structures of the eye and orbit. Fol lowing his early work with von Haller, he continued his anatomic studies in Berlin where, in 1753, he received an invitation to return to Göttingen as professor o f medicine and as the director o f the Botanical Gardens. H i s book was published while he was in W ü r z b u r g . Figures from it show h o w ac curately he observed and h o w beautifully he illustrated the gross anatomic features which show for example, (figs. 8, 9, 1 0 ) , the annulus which bears his name, orbital nerves and blood vessels, and the vessels o f the
Fig. 8 (Smelser and Ozanics). Illustration of orbital dissections. Table V from J. G. Zinn: Descriptio Anatómica Oculi Humani. Note Figure 3.
61
Fig. 9 (Smelser and Ozanics). Illustration of orbital nerves and blood vessels. Table V I , Figure 2, from J. G. Zinn: Descriptio Anatómica Oculi Humani.
Fig. 10 (Smelser and Ozanics). Drawings of partially dissected globe (fig. 1). Anterior half of the globe viewed from behind, likened by Zinn to an aster (fig. 2 ) . Figure 3 is an injection prepa ration of three ciliary processes. From J. G. Zinn: Descriptio Anatómica Oculi Humani.
62
G E O R G E Κ. S M E L S E R A N D V I C T O R I A O Z A N I C S
ciliary processes (he failed to find the mus
ture o f which is not stated; however, he died
cle in the ciliary b o d y ) .*
when he was not yet 32 years of age.
His
dissection
and
description
of
the
Another important and touching figure in
structure which supports the lens, although
the history
he was not the first to observe it, was master
worked about 100 years later. M y first inter
o f ocular anatomy
lived and
fully done. It appears that he thought o f the
est in Heinrich Müller (fig. 11) was aroused
zonula, later named after him, as a broad
because so many ocular structures bear his
belt or membrane around the lens (zonula
name. Three smooth muscles, one in
means "little b e l t " ) , rising out of the vitre
floor
the
of the orbit, one in the lid, and the
ous humor, separating that structure from
circular muscle in the ciliary body, as well
the ciliary body, and attaching to the an
as the reticulum
terior surface o f the lens capsule. Posterior
the ciliary epithelium, the intraocular
to this sheet he found other supporting struc
glion cells (in the uvea) and, finally, the sup
tures,
porting cells of Müller in the retina.
fibrous
in appearance.
He
demon
(basement membrane) o f gan
strated this by inflating the canal of du Petit
Müller was born in Castell, southern Ger
with air. Many o f the descriptions o f ocular
many, in 1820. H e studied in Munich, Frei
structures
burg, W ü r z b u r g , Heidelberg and Vienna. His
were precisely and
beautifully
phrased, as is shown by the following para
wandering reminds one o f the
graph on the iris which is a translation from
N . I . H . fellows o f today. W e find he was scho-
the German o f Hirschberg:
lastically related to many important scientists
There is a wonderful spectacle when the anterior surface of the iris of a fresh eye is viewed under low magnification. In the greater circle numerous fibers appear, which are closely packed, almost parallel, converging towards the lesser circle, gently curving, the more so, the wider the pupil. In an eye preserved in spirits the lesser circle is distin guishable from the greater by a lightly undulating fold or wrinkle.'
It has already been noted that, in 1753, Zinn went to Göttingen, not only as profes sor of medicine but also as director o f the Botanical Gardens, indicating the breadth o f his interest and ability. It is possible that, after a day in surgery dealing with the zon ula o f Zinn in cataract extractions, you have returned home and admired a bowl o f zinnias on your table without thinking of a connection between them and the zonula. It was Zinn's description of Central and South American flowers o f the thisde family that caused Linnaeus to name that genus "zinnia." There are other threads connecting men in time and space. Anatomists could be botan ists, and botanists were pharmacologists. T h e direct academic decendant o f Linnaeus in the University of Upsala is Prof. Ernst Bárány. I have read that much of the work of Zinn was conducted under great hardship, the na
peripatetic
of his day. H e was introduced to histology by Henle and to ophthalmology by von Graefe. Eventually, in 1847, he returned to W ü r z burg to teach histology and pathology, and
Fig. 11 (Smelser and Ozanics). Heinrich Müller, from J. Hirschberg: Die Augenheilkunde in der Neuzeit, Figure 8. In: Graefe-Saemisch Handbuch der Augenheilkunde. 1918, ed. 2, v. 15,' p. 244. Per mission to reproduce this figure given by the pub lisher Springer-Verlag, Berlin, is gratefully ac knowledged.
CONTRIBUTION OF A N A T O M Y
Fig. 12 (Smelser and Ozanics). Rudolph Albert von KöUiker. Frontispiece to his Erinnerungen aus meinem Leben. Leipzig, Verlag Wilhelm Engel mann, 1899.
was in charge o f pathologic anatomy during the illness o f its chief. W h e n the chair fell vacant, however, not he, but V i r c h o w , was chosen as the professor. Miiller's interest in the eye was confirmed and intensified in 1854 by a mere three-week visit with v o n Graefe, from w h o m he learned the application of clinical methods to anatomy and, thereafter, much o f his ana tomic studies turned to ophthalmology. H e published little but investigated widely, and was greatly honored as a teacher. H i s labora tory was one o f the three great goals o f all students interested in the eye: von Graefe in Berlin, Helmholtz in Heidelberg, and Müller in W ü r z b u r g . O n e o f his students was H e r mann Knapp, w h o later came to this coun try and founded the Archives of Ophthal mology. After his death at the age of 44 years, Müller was eulogized by both v o n Graefe and v o n KölHker (fig. 1 2 ) , w h o added that Müller "had when he died a salary that the speaker ( K ö l l i k e r ) cannot take upon him self to make public, here one must put the
63
blame on the faculty because it had not done more for this investigator." ( J . Hirschberg) A major factor in the position the work of Müller attained was due to his friendship with von Kölliker, the giant o f early mi croscopy. V o n Kölliker,' a Swiss b o m in Zürich in 1817, lived into the first years o f this century. H e also studied under Henle but, in 1847, went to W ü r z b u r g and there became a good friend, colleague and collabo rator o f M u l l e n It was they together w h o first determined the correct order o f retinal structures from visual cells to the internal limiting membrane. A s the "dean" o f micro scopic anatomy his influence was enormous and his sponsorship added greatly to the ac ceptance of Müller's work. V o n Kölliker was later to exercise a similar role in the ad vancement and acceptance o f the ideas o f Cajal. There are so many aspects o f eye anatomy that it is obvious one cannot deal with more than a minute part of them. H o w e v e r , a few words should be given to the development o f our understanding o f the retina. It would seem that our knowledge o f the histology o f this structure starts with Leeuwenhoek. H i s lenses were not as crude as one might think for they were able to resolve lines two mi crons apart. Later the Italian anatomist, Paccini, described the layers of the pigeon retina very beautifully. H e distinguished nerve fibers, ganglion cells, so called gray fibers, the nuclei o f the rods and cones and, finally, a layer o f "little cylinders," the rods and cones. H e also saw the internal limiting membrane and the pigment epithelium cells. A c c o r d i n g to Heinrich Müller, the w o r k o f Paccini at Pisa never received its just recog nition. W i t h the use o f chromium salts, about 1840, and osmic acid in 1865, studies on the retina became much more rewarding. Camilio Golgi, the professor o f histology, and later of general pathology in Pavia, developed the use o f silver as a tool in delineating nerve cells and fibers. H e thought that the nerve fibers consisted of a continuous network
GEORGE Κ. S M E L S E R A N D V I C T O R L \ O Z A N I C S
64
rather than a system of distinct (each neuron and its
fiber).
elements
It was Cajal
(fig. 1 3 ) , later using the methods developed by Golgi and applying them with great skill, who was able to show that neural tissue, in cluding the retina, was made up of separate cells rather than of a continuum of
fibers.
Although there was a difference in their in terpretations, the contributions of both men were enormous. This was recognized when they were jointly awarded the Nobel Prize in 1906. In his later years, Cajal took all o f the nervous system as his province and devoted considerable effort to the study of the struc ture and
development of the
retina.
work may be found in all of our
His
current
textbooks. I am afraid that most of the stu dents regard him and his work in a very im personal way, scarcely realizing that Cajal was a man of passionate feelings and a vivid personality. A s a boy in northern Spain he was regarded as a rebel, a leader o f what w e might call today juvenile delinquents.
His
was the guiding spirit of local gangs w h o raided orchards, blew up gates with explo sives and attacked
the local police. A s a
youth he disappointed his father, w h o had
Fig. 13 (Smelser and Ozanics), Portrait of Cajal (aged 32 years) from Dorothy F. Cannon: E.xplorer of tlie Human Brain: The Life of Santiago Ramón y Cajal (1852-1934). Henry Schuman Inc., New York, 1949, illustration facing page 81. Per mission to reproduce this figure given by AbelardSchuman Publishers, New York, is gratefully ac knowledged.
started his career as a barber and bloodletter, but became a successful surgeon and physician in later years. H e hoped to guide his son into anatomy and medicine. Cajal only wished to be an artist, a profession held in low esteem by his father. Finally Cajal was apprenticed to a barber who at least taught him h o w to sharpen a razor, a tech nique he found very useful later when he prepared tissue sections. H e had his troubles with examinations in the university, particu larly as a result of his rebellious
spirit.
Eventually he completed his medical training in Spain but, instead of joining the faculty of one o f the medical schools, which was his father's dream, he joined the Spanish army and was sent to Cuba to help suppress the revolution there. Again, in Cuba, Cajal's re bellious spirit created difficulties f o r him, and he was transferred to the most undesir-
able posts in the jungles of that island, where he became seriously ill and was finally sent home. T h e military experience, illness, o r both, seem to have tamed Cajal and he channeled his energies into the new science o f his tology. Finally, the work of Golgi came to his attention and he applied this new method to the study of many tissues. H e became e x tremely enthusiastic about the silver tech niques, particularly because o f his early and continuing love for photography. H e became very skillful in the applications o f silver methods and utilized his native ability as an artist to depict the structures which he saw. Although he used the same basic method de vised by Golgi, his interpretation o f the structures was completely different. In 1889, Cajal attended a meeting o f anatomists in
CONTRIBUTION OF A N A T O M Y
65
Germany where his paper and demonstra tions were well received, particularly by the great
von Kölliker.
F r o m this
time,
the
reputation o f Cajal was established and he became a world-wide authority on the his tology of neural tissues. However, for many years he continued to work under a handicap which he felt was imposed by the selfish and provincial
attitudes
of
his
Spanish
col
leagues."' W e cannot close a discussion of the story of
retinal
studies
without
mentioning
Stephen Polyak (fig. 14) o f this University, who added a maximum refinement to those works which had preceded him. This man, whom many of us knew, serves as a vivid link with the past anatomists.
Fig. 15 (Smelser ami Ozanics). Schematic draw ing illustrating the inter-receptor contacts in the guinea pig retina. Four receptors of the Β type enter into moving contact relation with one receptor. On the right side is a slightly simplified drawing of the synaptic body of a cell. From Electron Microscopy of the Retina by Fritiof S. Sjöstrand. In The Structure of the Eye. (G. K. Smelser, ed.) New York and London, Academic Press, 1961. Permission to reproduce this figure given by the author, Dr. F. Sjöstrand, and Academic Press Inc., New York, publishers, is gratefully acknowledged.
Fig. 14 (Smelser and Ozanics). Portrait of Stephen Polyak, from Tlie Vertebrate Visual Sys tem, Figure 131-A by Stephen Polyak (edited by Heinrich Klüver) Chicago 37, The University of Chicago Press, 1957. Permission to reproduce this figure given by the publisher. The University of Chicago Press, Chicago 37, Illinois, is gratefully acknowledged.
These few stories I have related concern ing some o f the older anatomists should not be construed as complete, or to indicate that there is any break in the continuum o f ana tomic research. O n e can readily imagine the enormous excitement and deep pleasure these men, Müller, v o n Kölliker, Golgi, Cajal and Polyak, would have if they were able to see h o w their subject continues to develop in the hands o f modern students o f anatomy, w h o give us such a detailed concept o f the struc ture of the visual element and synapse as that shown in Figure 15. They would surely regard with satisfac-
66
GEORGE Κ. S M E L S E R A N D V I C T O R I A O Z A N I C S
Fig. 16 (Smelser and Ozanics). An electron micrograph showing three types of presumptive synaptic arrangements involving receptors. Arrow, upper left, points to an external sjmapse, the center arrow, to an inter-receptor synapse; an enveloped synapse shows below the synaptic lamella (si) and a Müller cell (m) is shown. Chrome-osmic fixed, lead stained, χ27,000 from Adolph I. Cohen: Some observations on the fine structure of the retinal receptors of the American grey squirrel. Investigative Ophthalmology, 3:198-216, 1964. Permission to reproduce this figure given by the author, Dr. A. I. Cohen, and The C. V. Mosby Co., St. Louis, Missouri, publishers, is gratefully acknowledged.
tion the study of D r o z , " w h o showed that the proteins o f the outer segment o f the rod are continually being renewed at the base of the outer segment. T h e y would greatly admire the work of Wolken and W a l d , w h o are concerned with the molecular anatomy of the saccules of these rods, as well as that of Fernandez-Moran deinonstrating his su perb analysis of membrane structures. One could imagine Golgi and Cajal looking at
each other sheepishly should they see the evidence that, although the neurons were not continuous as one had thought, they were not so widely separated either (fig. 1 6 ) . They would only voice approval of the studies, made possible by the use o f isotopes, on the movement o f cells during the develop ment o f the retina, which S i d m a n " has shown to take place. Du Petit would be gleeful at the current
CONTRIBUTION OF A N A T O M Y
67
experiments in which tissue is plunged into
anatomic
liquid nitrogen to freeze it instantly, rather
closer
experimentation
than slowly as he had done, and to see that
than did the w o r k in the 18th and
sections o f these frozen eyes reveal the loca-
tury. W e should not be concerned if we do
to
brings
physiology
much
19th cen-
not
canee o f some anatomic observation. W e can
w a b a r a " and
do n o better than to f o l l o w the example o f
Müller would not think it odd to determine
Fontana w h o said in
the size o f spaces in the cornea and vitreous
his o w n anatomic
humor
by
dissecting
them
with
the
us
pathology
tion o f catalysts on which depend living and Fontana, Zinn and
immediately
and
visual processes, as has been shown b y K u Cogan.^*
know
basic
clinical
signifi-
1778, with respect to
discovery:
diffusing
the present I have no certain observations
molecules of hemoglobin, as David Maurice^'^
or definite experiment which could shed light on
has
been re-
*is subject: I do not want to advance imaginary
- j L - . , ^ ! !
hypotheses, or simple probabilities. I am abandoning
done. In their time, they had
^ . ^ j ^ ^ ,
,
.
stncted to the use o f various sized bristles! T h e immediate clinical application of anatomic research n o w , as then, is not always instantly obvious. Without question, modern
submitting this difficult subject to your genius. and it is to you I leave the glory of its explanation, 630 West
168th Street
(32).
BIBLIOGRAPHY
GENERAL REFERENCES Arrington, G. E., Jr.: A History of Ophthalmology. M D Monographs on Medical History, No. 3. New York, M D Publications Inc., 1959. Duke-Elder, S., and Wybar, K. C . : Svstem of Ophthalmology: The Anatomy of the Visual System, Vol. II. St. Louis, Mosby, 1961. Hirschberg, J.: Die Augenheilkunde in der Neuzeit. In Graefe-Saemisch Handbuch der Gesamten Augenheilkunde. Leipzig, ed. 2. v. 13, pp. 414-421, 1908; ν. IS,' pp. 1-25, 1918; v. 15," pp. 243-253, 1918. Horstmann, C . : Geschichte der Augenheilkunde. In Handbuch der Geschichte der Medizin (Th. Pusch mann) Wien, Jena, 1905, pp. 489-572. Magnus, H . : Die Anatomie des Auges bei den Griechen und Römern. Leipzig, 1878. : Die Anatomie des Auges in ihrer geschichtlichen Entwickelung. Breslau, 1906. Polyak, S.: The Vertebrate Visual System. (Edited by Heinrich Klüver.) Chicago, Univ. Chicago Press, 1957. Sorsby, Α . : A Short History of Ophthalmology. London, Staples Press Limited, ed. 2, 1948. Villard, H . : Histoire de I'anatomie, de la physiologic, de la pathologie et da thérapeutique de I'appareil oculaire. In Traite d'ophtalmologie (publié sous les auspices de la société Frangaise d'ophtalmologie). Paris, Masson et Cie, 1939, v. I, pp. 37-65. SPECIFIC REFERENCES 1. Fontana, F.: Traite sur le vénin de la vipere sur les poisons americains sur le laurier-cerise et sur quelques autres poisons végetaux. On y a joint des observations sur la structure primitive du corps animal. Différentes experiences sur la reproduction des nerfs et la description d'un nouveau canal de l'oeil. Tome second, Florence, 1781. 2. Callisen, Α. C. P.: Medicinisches Schriftsteller-Lexikon der jetzt lebenden Aerzte, Wundärzte, Geburtshelfer, Apotheker, und Naturforscher aller gebildeten Völker, Vol. 17, Copenhagen, 1833. 3. Schlemm, F.: Ueber einen kreisförmigen dünnhäutigen Kanal in der Verbindungstelle von Sclerotic und Cornea im menschlichen Auge. Ztschr. f. Ophth., 1 : X X X V : ( 3 0 ) 543-544, 1830-1831. 4. : In: Joh. Nep. Rust Ed: Theoretisch praktisches Handbuch der Chirurgie. Berlin, Th. Chr. Fr. Enslin, 1830, v. III, p. 333. 5. Rochon-Duvigneaud, A . : Les Yeux et la Vision des Vertebres. Paris, Masson et Cie, 1943. 6. Zinn, J. G.: Descripto Anatómica Ociili Humani Iconibus lUustrata. Göttingae, Abrami Vandenhoeck, 1755. 7. Hirschberg, T.: Geschichte der Augenheilkimde. In Handbuch der gesamten Augenheilkunde. 14 469-480 (ed. 2) 1911. 8. Koelliker, R. A. von: Erinnerungen aus meinem Leben. Leipzig, Wilhelm Engelmann, 1899. 9. Williams, H . : Don Quixote of the microscope: An interpretation of the Spanish savant Santiago Ramón y Cajal (1852-1934). London, Jonathan Cape, 1954. 10. Cannon, D. F.: Explorer of the Human Brain. The Life of Santiago Ramón y Cajal (1852-1934) New York, Henry Schuman Inc., 1949.
68
GEORGE Κ. S M E L S E R A N D V I C T O R I A O Z A N I C S
11. Droz, B.: Dynamic condition of proteins in the visual cells of rats and mice as shown by radioautography with labeled amino acids. Anat. Record, 145 :157-168, 1963. 12. Sidman, R. L.: Histogenesis of mouse retina studied witli thymidine-H. In The Structure of the Eye. (G. K. Smelser, ed.) New York and London, Academic Press, 1961. pp. 487-506. 13. Kuwabara, T. and Cogan, D. G.: Tctrazoliuni studies on the retina: III. Activity of metabolic inter mediates and miscellaneous sub.strates. J. of Histocliem. & Cytochem., 8:214-224, 1960. 14. Cogan, D. G., and Kuwabara, T . : Tetrazolium studies on the retina: IV. Distribution of reductase in ocular tissue. T. Histochem. & Cytochem., 8 :380-384, 1960. 15. Maurice, D. M . : The use of permeability studies in the investigation of submicroscopic structure. In The Structure of the Eye. (G. K. Smelser. ed.) New York and London, Academic Press, 1961, pp. 381-391.
CATARACT
SURGERY:
T H E HANDLING
R A M Ó N
CASTROVIF.JO,
New
In this brief discussion I shall refer to
OF
COMPLICATIONS*
M.D.
York
the vitreous strands that go around the pupil
only three complications of cataract surgery:
and
vitreous prolapse at the time o f operation;
making it necessary that a more central open
become
incarcerated
in
the
incision,
deflected pupil, a postoperative complication
ing be made in the iris for visual purposes at
caused by vitreous strands incarcerated in the
a later date.
incision; and anterior synechiae wh'ch result
Observation of such cases has convinced
from adhesion of the iris to some or all of
me that the iridectomy and iridotomy alone
the posterior aspect of the corneal wound.
will, in time, frequently cause alterations in the endothelium and these in turn will lead
VITREOUS
PROLAPSE
to corneal edema and bullous keratopathy if
Some surgeons advise the withdrawal o f
the
vitreous
remains
incarcerated
in
the
liquid? . . . vitreous when \'itreous prolapse
wound and in contact with the cornea. Fre
occurs during cataract extraction. T h e y ad
quently, secondary glaucoma caused by par
vocate the withdrawal from behind the iris
tial angle block is also observed in
with the aid o f an 18- or 20-gauge needle
cases and retinal detachment may occasion
to prevent postoperative complications but I
ally result from the pulling of the vitreous
feel withdrawal of the vitreous at this time
strands.
is never indicated. It does not prevent such complications as bullous keratopathy and de flected pupil as long as vitreous attachments to the incision persist and the vitreous re mains in contact with the cornea.
W h e n the corneal complications already mentioned present several weeks or months after
a cataract
extraction, the corrective
measure in general use is to enter the an terior chamber through a small slanting in
Other ophthalmologists consider that the pupil will be drawn upward after
these
cision at the limbus, se{)arate the vitreous
vitreous
from the cornea with a spatula and fill the
prolapse following cataract extraction unless
anterior chamber with air to prevent con
a large iridectomy is performed at the 12-
tact o f the vitreous and
o'clock position and a radial iridotomy is
However, these late postoperative complica
made at the 6-o'clock position. Unless this
tions can usually be avoided if the following
is done the pupil is eventually drawn up by
procedure to separate the vitreous from the
* From the Departments of Ophthalmology, St. Vincent's Hospital and New York University PostGraduate Medical School,
traction is performed:
the endothelium.
cornea is done at the time the cataract e x T h e incision is first closed with five cor-
55
sequential to dense cicatricial tissue formed about the cysts. I have observed such adhe sions when bleeding from the episclera was controlled
by cautery.
Very
elevated
and
thin-walled cysts may thus be formed, pre senting the danger o f perforation, even when neither
side
of
the
conjunctival
incision
strikes the limbus. In these cases I p e r f o r m a debridement of the cicatrix
(fig. 5 ) . A
small incision is
made through the temporal side o f the con junctiva, five mm. from the adherent border. A curved scissors with dulled points is plied Fig. 5 (Busacca). Diagram illustrating debridement of blocked cystoid cicatrix.
against the sclera to f o r m a tunnel to the cicatricial band which is c u t ; then the cysts are cut through down to the limbus till the scissor
points
reach
the adhesions at
the
cicatrix. This results from firm adhesions o f
nasal border which are likewise cut. A f t e r a
the conjunctiva to the sclera over the entire
lapse o f some weeks the cystic mass
extent of the conjunctival incision or may be
CONTRIBUTION
O F A N A T O M Y
GEORGE K . SMELSER,
CP.
flattens.
2813.
T O CLINICAL
OPHTHALMOLOGY*
P H . D . , A N D VICTORIA O Z A N I C S , M . S . New
York
I am very grateful to y o u for allowing me
Standing o f the structures with which he
to join in sharing y o u r pleasure in the o p
deals. Currently, the increase in scientific re
portunity which these new laboratories offer.
search in this and other fields is so rapid and
I am glad f o r you, and I am glad f o r the
vast that the contributions cannot be satis
laboratories,
factorily sorted out or evaluated as they are
next
years
f o r they will house in many
these
exciting moments,
and,
with a little luck, very important ones.
reported. This rapid increase is occurring be cause the value o f basic scientific research to
It is scarcely necessary to emphasize the
clinical medicine is widely recognized and,
value of anatomic knowledge to clinical oph
therefore, more workers are recruited to this
thalmology. It is axiomatic that a physician
effort.
and surgeon must have a thorough under-
nology
* From the Department of Ophthalmology, Col lege of Physicians and Surgeons, Columbia Uni versity. This investigation was supported by grant 00492-10 from the Department of Health, Educa tion and Welfare, Public Health Service, National Institutes of Health and by Research Career Award NB-K6-19, 609-01. This paper was pre sented at the dedication of the Eye Research Laboratories of The University of Chicago, De cember 16, 1964.
In addition, the advances in tech greatly
enhance
the
investigator's
productivity. N o one can determine the value o f a spe cific
finding
to clinical ophthalmology or,
what is more important, what fields an in dividual discovery may lead to. Perhaps it is m o r e appropriate if w e regard the contribu tions o f anatomy to ophthalmology as a con tinuum, and consider the role it has been.
GEORGE Κ. S M E L S E R A N D V I C T O R I A O Z A N I C S
56
and is, playing in tlie development o f oph
been lost, hence the oldest existing eye dia
thalmology.
grams are Arabic. During the middle ages,
T h e problems in the past were really much the same then, as today, as are the methods, inasmuch as anatomists have always studied
medical teaching relied on retranslation of the Arabic manuscripts into Latin. In the middle of the 16th century anatomy
tool
as a science was revived b y Vesalius, w h o
which was currently available. It is most im
broke with the tradit ions of the preceding
portant not to forget the men w h o made
16 centuries, and stimulated actual study o f
these contributions, to see h o w they evalu
the body, rather than the re\-iewing and par
unknown
structures and
used
every
ated their o w n work, and how discoveries
roting o f ancient manuscripts. Although he
we recognize as clinically important
today
included the eye in his writings, there is no
were made without realization o f their value.
evidence that he and his school made any
.Such considerations give us a perspective
contributions to our knowledge of its struc
from which to view today's progress, and
ture.
pride in the work which is being done, and
This really brings us to the beginning of
in our association with colleagues w h o have
the most amazing period, the last 375 years,
worked on these problems a little before us.
which is only one sixth of the 23 centuries
In early times there was no regularly or
which span the development of our knowl
ganized profession of anatijmy as we know
edge of eye structure (fig. 1 ) . There were
it today; anatomists were often natural his
many men during this period whose work
torians,
catholic tastes, or
was important and exceedingly interesting,
practitioners whose interest in anatomy grew
though seemingly remote to us now. Recall
scientists
with
out of their concern with treatment of dis
ing their names and w o r k creates a vivid link
ease. W e must make our own definition o f
with the past and gives us a greater ap])reci-
anatomists
ation o f the work in which w e are engaged.
were scientists w h o learned by dissection,
Today's problems gain in stature when con
anatomists.
Since,
classically,
separating
sidered in this relationship. O n e can only
those w h o used scalpel and unaided observ
touch upon the contributions o f a f e w o f the
ing eyes, or those utilizing on ultratome for
outstanding men.
there is really great difficulty in
slicing 10O.\ sections, from those ordinarily
The older texts refer to Felix
Fontana
dissect molecules
(fig. 2 ) as a scientist and physiologist. H e
with enzymes. T h e y are all anatomists inter
was certainly also an anatomist. H e had a
ested in the structure of the living body, and
long life extending from 1720 to 1805. A s
today's anatomists use all of the contempo
a young man he studied in Padua, Bologna,
rary tools which they and allied
and Rome, and finally was awarded the chair
called
biochemists
who
scientists
can find.
of philosophy in Pisa. In those days the uni
The eye has always intrigued such men, beginning with the earliest anatomists. Those who gave us our early concepts of eye structure were Greeks. Greek knowledge of the eye was perfected by the Alexandrian school, especially by Herophilos, about 300 B.C. This information, particularly as pre sented by R u f o s and later Galen (ca. 200 A . D . ) had been transmitted to the A r a b world which preserved the knowledge, but without modification o f the anatomic con cepts. T h e original Greek manuscripts have
versities in the provinces of Italy operated under patrons. It was the Duke o f Tuscany w h o directed him to establish a department of natural history at Pisa. W h i l e there, he worked in, at the time, an advanced manner, which would n o w be considered the classical anatomic tradition. H e made w a x models to be used in teaching. His studies were really of comparative anatomy directed mostly at neural structures. H e was one of the first to use chemical fixatives, which allowed him to preserve and examine the retina. H e found
57
CONTRIBUTION OF A N A T O M Y V A N I K U W f NHOEK 1 «UVSCM 1 MAÍTtE J A N \ POUWOUt DU PETIT \ V O N MALLEI ZINN I FONTANA SOEMMBllNG SCHLEMM [THEVIIIANUS 1; Í O W M A N 'I ! H E N L E
Ih. muller 1! K O E L L I K E R
SCHWALBE IsCHULTZE BAMON Y CAJAL
KRAUSE
EUSTACHIUS VESALIUS
DOGIEL H. V I R C H O W ROCHON DUVICNEAUO
¡SALZMAN TRONCOSO POLYAK
ISOO
IMO
1700
ΙΘ0Ο
1900
Fig. 1 (Smelser and Ozanics). Chart of outstanding anatomists who contributed to the growth of ophthalmic knowledge.
retinal "globules," which he likened to those of the brain but found them to be more regu lar and uniform. H e clearly distinguished between cellular and supporting structure in the retina by chemical and physical separa tion o f these two elements. H e described the retinal vessels, which you see daily, the ret inal nerve
fibers,
and dissected the optic
nerve of many animals. W e have forgotten most of these studies, but
remember Fontana because of his de
scription o f a canal in the anterior chamber angle. H e found this structure while dissect ing
the eye o f an o x . ' Although
it was
clearly shown that this canal of Fontana did not exist in man, the spaces in the trabecular meshwork are still often referred to as the spaces o f Fontana. T h e gracious manner in which the old anatomists reported their find ings, and the importance and function which they assigned to them gives us an insight into their scientific attitude and the dignity of their lives. Fontana's discovery was re ported in a letter addressed to Prof. Murray in Upsala (fig. 3 ) . T h e following is a quota tion from the closing paragraphs of this let-
Fig. 2 (Smelser and Ozanics). Portrait of Felice Fontana, from Mary A. B. Brazier: The evolution of concepts relating to the electrical activity of the nervous system 1600 to 1800. Figure 10 in The Brain and its Functions. An Anglo-American Symposium, London, 1957. Oxford, Blackwell Scientific Publica tions Ltd., 1958. Permission to reproduce this figure given by the author. Dr. Mary A. B. Brazier and by the publisher. Blackwell Scientific Publications Ltd., Oxford, England, is gratefully acknowledged.
GEORGE Κ. S M E L S E R A N D VICTOREA. O Z A N I C S
58
let tri ccr'ite a Ms Adolphe Murray Celebre Profeßcur ιΓAnatomie a Upfal Pmné ιηη%. j - E vous envoye conjointement ä
cctte Lettre trois deíTcinj
,1 marqués i , i , 3 , que (a) j'ai crö fu/üfc pour vous rappeller i'idcc de ce nouveau canal que j'ai crouvé dans Γοβϊ1> et que j'ai eu le plaißr de vous faire voir lorfque vous pafsåtes par Florence. G'cíl dans cette occalion que j'eus la fatisfaftion
de
vous connoítre ct que vous m'accordates, vótre agreablc amitie · Ά
un Anatomiile auffi eclaírc que vous, c'ell aílcz que d '
indíquer feulcraent les parties principales; le refteferoit tout-á-faic faperflu. Les rrois figures VIH. IX. X . ( P I . VII.) font voir ces trois fcftions principales que je fis dans l'ocil du bocuf, et qoc )c vous montrai quand vousécicz ä Florence. Jene vous parlcrai pas des autres fcftions,
Fig. 3 (Smelser and Ozanics). Reproduction of the beginning of the letter by Felice Fontana in which his canal is described. Page 267 from: Traite sur le vénin de la vipére sur les jioisons americains sur le laurier-cerise et sur qualques antres poisons végetau.x. On y a joint des observations sur la structure primitive de corps animal. Différentes experiences sur la reproduction des nerfs et la description d'un nouveau canal de I'oeil. Avec plusieurs planches. Tome second, Florence, 1781.
circes font ces trois que je confidere córameles plus cíltnticllcs , ct les plus ncceíliiire å fatisfaircs á vos demandes, ct par coufc(¡acnt je paflcrai le relie fous lilence.
ter, which recreates the atmosphere of that period. I send you the illustrations of this new canal of the eye (fig. 4 ) , not because I wish that you should publish tliem, as you have indicated that you want to do in the Acta of the Academy of Upsala, but solely because you have asked me for them: It is sufficient for me that you should be persuaded of
my esteem for you, and of my pleasure in corresponding with a man of your merit. Do with them whatever it pleases you for I am altogether indifferent on tliis matter. You may certainly have noticed, during the time you were here, the little importance I gave to this old discovery; I say "discovery" because it pleases you to call it thus. I shall not say anything, however, on the subject of the function of this new canal and of the transparent humor with which it is bathed. For the present I have no certain observations or definite experiment which could shed light on this subject: I do not want to advance imaginary hypotheses, or simple probabilities. I am abandoning and submitting this difficult subject to your genius, and it is to you I leave the glory of its explanation. Fontana's use
of
chemical
fixatives
was
mentioned. T h i s was an enormous advance f o r anatomic science and was used by a number of investigators of that period. Antoine Maitre-Jan, a century earlier, was one of the first
to
use
this extremely
important
new
anatomic tool. H e was primarily an ophthalFig. 4. (Smelser and Ozanics). Illustrations of Fontana's canal, Plate \ T I , figures V I I I , I X , X , from his book Traite sur le vénin de la vipere sur les poisons americans sur le laurier-cerise et sur quelques antres poisons végetaux. On y a joint des observations sur la structure primitive du corps animal. Différentes experiences sur la reproduction des nerfs ct la description d'un nouveau canal de I'oeil. Avec plusieurs planches. Tome second, Florence, 1781. Note figure I X , m at the right indicates Fontana's canal within the ciliary body. The letters r and o indicate the ojien ends where the cut has been made into the canal.
mologist rather than an anatomist. Later, another w h o contributed greatly to our understanding of the anatomy of the eye, did not use
chemical
fixation,
but
freezing,
as
a
method of preservation and an aid in study. H e was F r a n ς o i s - P o u r f o u r du Petit, whose name w e associate with another canal.
He
was the first really to demonstrate that the cornea was avascular and, in 1728, the exist ence of the
posterior chamber, although it
CONTRIBUTION OF A N A T O M Y
59
required 100 years f o r this to be generally accepted. Du Petit studied both human and animal material. In one experiment, the eye was suspended by a thread passed through the optic nerve and allowed to freeze, where upon it was bisected along its anteroposte rior axis. D u Petit determined the existence and the volume o f the anterior and posterior chambers by measuring the ice he removed from them. Using fresh cadavers, he meas ured corneal curvature, length o f the eyeball, radius of curvature of the lens surfaces and located accurately the position o f the lens —all of them clinically important discov eries. His examinations showed that the lens capsule remained transparent in cataracts. H e was an extremely enthusiastic and ac curate observer. Apparently he was much in advance of his time for, in 1727, Philip H e c quet, dean o f the Paris Faculty of Medicine, stated in an article "Remarques sur Γ abus des purgatifs" that the lens lies in the mid dle of the eyeball and that cataract is a mem brane." W h e n du Petit offered to demon strate the actual facts to him, M . Hecquet replied that he had neither the time nor the inclination for it! After a long period o f dis tinguished, if little known, anatomic re search, du Petit gradually put his remark able knowledge to practical use and became a successful ophthalmic surgeon. Discovery o f another ocular structure pro vided us with another household word in ophthalmology, the canal o f Schlemm. In Friedrich Schlemm's (fig. 5 ) day anatomy was already well organized. H e was born in 1795 near Hanover, and studied in Braun schweig. His doctoral thesis in 1821 was en titled, " D e arteriarum faciei anastomosibus." Interested in the nervous system o f fish, which was the subject o f a prize-winning dissertation, he later received a medal for his description of the arteries of the head, and wrote on the anatomy of the auditory ganglia o f snakes. H e was, therefore, a true anatomist and became "ausser-ordentlicher Professor" of anatomy in 1829 and P r o f e s -
Fig. 5 (Smelser and Ozanics). Portrait of Friedrich Schlemm, from System of Ophthalmology: Volume 2: The Anatomy of the Visual System (fig. 207, p. 189) by Sir Stewart Duke-Elder and Kenneth C. Wybar. St. Louis, Missouri, C. V. Mosby Company, 1961. Permission to reproduce this figure given by the author. Sir Stewart DukeElder, is gratefully acknowledged.
sor Ordinarius in 1833. H e wrote widely, and described f o r the first time the nerves o f the cornea, which he studied in beef and deer eyes, and only assumed that similar struc tures were to be found in man.^ It is somewhat difficult to find the original description o f the canal o f Schlemm because of some errors in references in the litera ture. It may be found quoted in an editorial in the first volume o f the Zeitschrift für die Ophthalmologie.^ T h e quotation is taken from a chapter contributed by Schlemm to a book edited by Rust.* H i s name appears only in tiny letters ( S c h l e m m ) at the end o f his chapter. T h e following is a translation from the original. The posterior concave side (of the cornea) ends in a circular border, behind which the sclerotic has a groove-shaped concavity, where the orbiculus ciliaris is inserted. In this groove there is a circu lar, thin-walled canal, which I discovered in 1827 in the eye of a hanged man, because it was filled with blood. A small bristle could be introduced into it after the cornea and sclera were cut through fore
60
GEORGE Κ. S M E L S E R A N D V I C T O R I A O Z A N I C S
there is not a word o f his canal which had been reported in an obscure surgical hand book several years earlier. It was this dis covery which finally secured immortality for him. In this connection it is interesting to note the comment o f Rochon-Duvigneaud, in the preface to his book,^ that anatomists, as a group, entirely neglected the formation and removal o f intraocular fluids and the mainte nance of intraocular pressure. The relation of structure to this important ocular func tion, it must be admitted, was the contribu tion o f clinical men. Modern anatomists are fortunate in being able to work with some knowledge o f the function o f the structures which they describe. The comment o f Rochon-Duvigneaud is not applicable today.
Fig. 6 (Smelser and Ozanics). Portrait of Johann Gottfried Zinn from System of Ophthalmology: Volume 2 : The Anatomy of the Visual System (fig. 385, p. 326) by Sir Stewart Duke-Elder and Kenneth C. Wybar. St. Louis, Missouri, C. V. Mosby Company, 1961, Permission to reproduce this figure given by the author. Sir Stewart Duke-Elder and by the pubhsher, Henry Kimpton, 134 Great Portland Street, London, W . l , England, is gratefully acknowledged.
Let us go to another older anatomist whom we feel we know because his name is used so often. Johann Gottfried Zinn (fig. 6 ) was one of those brilliant scholars whose in-
and aft. The canal should not be confused with that of Fontana which is to be found in the beef eye.
This was reported, as were the canals of Fontana and du Petit, with no comment on their possible significance or function. These were the days when descriptions o f structure had to be made without the excitement which is added when we try to relate functional significance to structure. Schlemm is quoted today more often than Fontana or du Petit because we now find the canal to have clini cal significance. Fame often rests on most fortuitous foun dations. In the 1833 edition of the Medizin isches Schriftsteller Lexikon der jetzt leben den Aerzte, Schlemm already had his place of honor because o f the surgical exercises on cadavers which he made for his students, but
Fig. 7 (Smelser and Ozanics). Reproduction of front page of Zinn's book, Descriptio Anatómica Oculi Humani Iconibus Illustra. Gottingae, Abrami Vandenhoeck, 1755.
CONTRIBUTION OF A N A T O M Y
terest was wide and ability great. H e was born December 4, 1727, in Ansbach, but his professional life began in Göttingen un der the great anatomist A . v . Haller. There, he early became interested in the eye, and described its vessels and those of the orbit. H i s greatest work was Descriptio anatómica oculi humani iconibus (fig. 7 ) , written in clear and precise Latin, and it is this book which established him in the annals o f anatomy. It is the first text wholly devoted to the structures of the eye and orbit. Fol lowing his early work with von Haller, he continued his anatomic studies in Berlin where, in 1753, he received an invitation to return to Göttingen as professor o f medicine and as the director o f the Botanical Gardens. H i s book was published while he was in W ü r z b u r g . Figures from it show h o w ac curately he observed and h o w beautifully he illustrated the gross anatomic features which show for example, (figs. 8, 9, 1 0 ) , the annulus which bears his name, orbital nerves and blood vessels, and the vessels o f the
Fig. 8 (Smelser and Ozanics). Illustration of orbital dissections. Table V from J. G. Zinn: Descriptio Anatómica Oculi Humani. Note Figure 3.
61
Fig. 9 (Smelser and Ozanics). Illustration of orbital nerves and blood vessels. Table V I , Figure 2, from J. G. Zinn: Descriptio Anatómica Oculi Humani.
Fig. 10 (Smelser and Ozanics). Drawings of partially dissected globe (fig. 1). Anterior half of the globe viewed from behind, likened by Zinn to an aster (fig. 2 ) . Figure 3 is an injection prepa ration of three ciliary processes. From J. G. Zinn: Descriptio Anatómica Oculi Humani.
62
G E O R G E Κ. S M E L S E R A N D V I C T O R I A O Z A N I C S
ciliary processes (he failed to find the mus
ture o f which is not stated; however, he died
cle in the ciliary b o d y ) .*
when he was not yet 32 years of age.
His
dissection
and
description
of
the
Another important and touching figure in
structure which supports the lens, although
the history
he was not the first to observe it, was master
worked about 100 years later. M y first inter
o f ocular anatomy
lived and
fully done. It appears that he thought o f the
est in Heinrich Müller (fig. 11) was aroused
zonula, later named after him, as a broad
because so many ocular structures bear his
belt or membrane around the lens (zonula
name. Three smooth muscles, one in
means "little b e l t " ) , rising out of the vitre
floor
the
of the orbit, one in the lid, and the
ous humor, separating that structure from
circular muscle in the ciliary body, as well
the ciliary body, and attaching to the an
as the reticulum
terior surface o f the lens capsule. Posterior
the ciliary epithelium, the intraocular
to this sheet he found other supporting struc
glion cells (in the uvea) and, finally, the sup
tures,
porting cells of Müller in the retina.
fibrous
in appearance.
He
demon
(basement membrane) o f gan
strated this by inflating the canal of du Petit
Müller was born in Castell, southern Ger
with air. Many o f the descriptions o f ocular
many, in 1820. H e studied in Munich, Frei
structures
burg, W ü r z b u r g , Heidelberg and Vienna. His
were precisely and
beautifully
phrased, as is shown by the following para
wandering reminds one o f the
graph on the iris which is a translation from
N . I . H . fellows o f today. W e find he was scho-
the German o f Hirschberg:
lastically related to many important scientists
There is a wonderful spectacle when the anterior surface of the iris of a fresh eye is viewed under low magnification. In the greater circle numerous fibers appear, which are closely packed, almost parallel, converging towards the lesser circle, gently curving, the more so, the wider the pupil. In an eye preserved in spirits the lesser circle is distin guishable from the greater by a lightly undulating fold or wrinkle.'
It has already been noted that, in 1753, Zinn went to Göttingen, not only as profes sor of medicine but also as director o f the Botanical Gardens, indicating the breadth o f his interest and ability. It is possible that, after a day in surgery dealing with the zon ula o f Zinn in cataract extractions, you have returned home and admired a bowl o f zinnias on your table without thinking of a connection between them and the zonula. It was Zinn's description of Central and South American flowers o f the thisde family that caused Linnaeus to name that genus "zinnia." There are other threads connecting men in time and space. Anatomists could be botan ists, and botanists were pharmacologists. T h e direct academic decendant o f Linnaeus in the University of Upsala is Prof. Ernst Bárány. I have read that much of the work of Zinn was conducted under great hardship, the na
peripatetic
of his day. H e was introduced to histology by Henle and to ophthalmology by von Graefe. Eventually, in 1847, he returned to W ü r z burg to teach histology and pathology, and
Fig. 11 (Smelser and Ozanics). Heinrich Müller, from J. Hirschberg: Die Augenheilkunde in der Neuzeit, Figure 8. In: Graefe-Saemisch Handbuch der Augenheilkunde. 1918, ed. 2, v. 15,' p. 244. Per mission to reproduce this figure given by the pub lisher Springer-Verlag, Berlin, is gratefully ac knowledged.
CONTRIBUTION OF A N A T O M Y
Fig. 12 (Smelser and Ozanics). Rudolph Albert von KöUiker. Frontispiece to his Erinnerungen aus meinem Leben. Leipzig, Verlag Wilhelm Engel mann, 1899.
was in charge o f pathologic anatomy during the illness o f its chief. W h e n the chair fell vacant, however, not he, but V i r c h o w , was chosen as the professor. Miiller's interest in the eye was confirmed and intensified in 1854 by a mere three-week visit with v o n Graefe, from w h o m he learned the application of clinical methods to anatomy and, thereafter, much o f his ana tomic studies turned to ophthalmology. H e published little but investigated widely, and was greatly honored as a teacher. H i s labora tory was one o f the three great goals o f all students interested in the eye: von Graefe in Berlin, Helmholtz in Heidelberg, and Müller in W ü r z b u r g . O n e o f his students was H e r mann Knapp, w h o later came to this coun try and founded the Archives of Ophthal mology. After his death at the age of 44 years, Müller was eulogized by both v o n Graefe and v o n KölHker (fig. 1 2 ) , w h o added that Müller "had when he died a salary that the speaker ( K ö l l i k e r ) cannot take upon him self to make public, here one must put the
63
blame on the faculty because it had not done more for this investigator." ( J . Hirschberg) A major factor in the position the work of Müller attained was due to his friendship with von Kölliker, the giant o f early mi croscopy. V o n Kölliker,' a Swiss b o m in Zürich in 1817, lived into the first years o f this century. H e also studied under Henle but, in 1847, went to W ü r z b u r g and there became a good friend, colleague and collabo rator o f M u l l e n It was they together w h o first determined the correct order o f retinal structures from visual cells to the internal limiting membrane. A s the "dean" o f micro scopic anatomy his influence was enormous and his sponsorship added greatly to the ac ceptance of Müller's work. V o n Kölliker was later to exercise a similar role in the ad vancement and acceptance o f the ideas o f Cajal. There are so many aspects o f eye anatomy that it is obvious one cannot deal with more than a minute part of them. H o w e v e r , a few words should be given to the development o f our understanding o f the retina. It would seem that our knowledge o f the histology o f this structure starts with Leeuwenhoek. H i s lenses were not as crude as one might think for they were able to resolve lines two mi crons apart. Later the Italian anatomist, Paccini, described the layers of the pigeon retina very beautifully. H e distinguished nerve fibers, ganglion cells, so called gray fibers, the nuclei o f the rods and cones and, finally, a layer o f "little cylinders," the rods and cones. H e also saw the internal limiting membrane and the pigment epithelium cells. A c c o r d i n g to Heinrich Müller, the w o r k o f Paccini at Pisa never received its just recog nition. W i t h the use o f chromium salts, about 1840, and osmic acid in 1865, studies on the retina became much more rewarding. Camilio Golgi, the professor o f histology, and later of general pathology in Pavia, developed the use o f silver as a tool in delineating nerve cells and fibers. H e thought that the nerve fibers consisted of a continuous network
GEORGE Κ. S M E L S E R A N D V I C T O R L \ O Z A N I C S
64
rather than a system of distinct (each neuron and its
fiber).
elements
It was Cajal
(fig. 1 3 ) , later using the methods developed by Golgi and applying them with great skill, who was able to show that neural tissue, in cluding the retina, was made up of separate cells rather than of a continuum of
fibers.
Although there was a difference in their in terpretations, the contributions of both men were enormous. This was recognized when they were jointly awarded the Nobel Prize in 1906. In his later years, Cajal took all o f the nervous system as his province and devoted considerable effort to the study of the struc ture and
development of the
retina.
work may be found in all of our
His
current
textbooks. I am afraid that most of the stu dents regard him and his work in a very im personal way, scarcely realizing that Cajal was a man of passionate feelings and a vivid personality. A s a boy in northern Spain he was regarded as a rebel, a leader o f what w e might call today juvenile delinquents.
His
was the guiding spirit of local gangs w h o raided orchards, blew up gates with explo sives and attacked
the local police. A s a
youth he disappointed his father, w h o had
Fig. 13 (Smelser and Ozanics), Portrait of Cajal (aged 32 years) from Dorothy F. Cannon: E.xplorer of tlie Human Brain: The Life of Santiago Ramón y Cajal (1852-1934). Henry Schuman Inc., New York, 1949, illustration facing page 81. Per mission to reproduce this figure given by AbelardSchuman Publishers, New York, is gratefully ac knowledged.
started his career as a barber and bloodletter, but became a successful surgeon and physician in later years. H e hoped to guide his son into anatomy and medicine. Cajal only wished to be an artist, a profession held in low esteem by his father. Finally Cajal was apprenticed to a barber who at least taught him h o w to sharpen a razor, a tech nique he found very useful later when he prepared tissue sections. H e had his troubles with examinations in the university, particu larly as a result of his rebellious
spirit.
Eventually he completed his medical training in Spain but, instead of joining the faculty of one o f the medical schools, which was his father's dream, he joined the Spanish army and was sent to Cuba to help suppress the revolution there. Again, in Cuba, Cajal's re bellious spirit created difficulties f o r him, and he was transferred to the most undesir-
able posts in the jungles of that island, where he became seriously ill and was finally sent home. T h e military experience, illness, o r both, seem to have tamed Cajal and he channeled his energies into the new science o f his tology. Finally, the work of Golgi came to his attention and he applied this new method to the study of many tissues. H e became e x tremely enthusiastic about the silver tech niques, particularly because o f his early and continuing love for photography. H e became very skillful in the applications o f silver methods and utilized his native ability as an artist to depict the structures which he saw. Although he used the same basic method de vised by Golgi, his interpretation o f the structures was completely different. In 1889, Cajal attended a meeting o f anatomists in
CONTRIBUTION OF A N A T O M Y
65
Germany where his paper and demonstra tions were well received, particularly by the great
von Kölliker.
F r o m this
time,
the
reputation o f Cajal was established and he became a world-wide authority on the his tology of neural tissues. However, for many years he continued to work under a handicap which he felt was imposed by the selfish and provincial
attitudes
of
his
Spanish
col
leagues."' W e cannot close a discussion of the story of
retinal
studies
without
mentioning
Stephen Polyak (fig. 14) o f this University, who added a maximum refinement to those works which had preceded him. This man, whom many of us knew, serves as a vivid link with the past anatomists.
Fig. 15 (Smelser ami Ozanics). Schematic draw ing illustrating the inter-receptor contacts in the guinea pig retina. Four receptors of the Β type enter into moving contact relation with one receptor. On the right side is a slightly simplified drawing of the synaptic body of a cell. From Electron Microscopy of the Retina by Fritiof S. Sjöstrand. In The Structure of the Eye. (G. K. Smelser, ed.) New York and London, Academic Press, 1961. Permission to reproduce this figure given by the author, Dr. F. Sjöstrand, and Academic Press Inc., New York, publishers, is gratefully acknowledged.
Fig. 14 (Smelser and Ozanics). Portrait of Stephen Polyak, from Tlie Vertebrate Visual Sys tem, Figure 131-A by Stephen Polyak (edited by Heinrich Klüver) Chicago 37, The University of Chicago Press, 1957. Permission to reproduce this figure given by the publisher. The University of Chicago Press, Chicago 37, Illinois, is gratefully acknowledged.
These few stories I have related concern ing some o f the older anatomists should not be construed as complete, or to indicate that there is any break in the continuum o f ana tomic research. O n e can readily imagine the enormous excitement and deep pleasure these men, Müller, v o n Kölliker, Golgi, Cajal and Polyak, would have if they were able to see h o w their subject continues to develop in the hands o f modern students o f anatomy, w h o give us such a detailed concept o f the struc ture of the visual element and synapse as that shown in Figure 15. They would surely regard with satisfac-
66
GEORGE Κ. S M E L S E R A N D V I C T O R I A O Z A N I C S
Fig. 16 (Smelser and Ozanics). An electron micrograph showing three types of presumptive synaptic arrangements involving receptors. Arrow, upper left, points to an external sjmapse, the center arrow, to an inter-receptor synapse; an enveloped synapse shows below the synaptic lamella (si) and a Müller cell (m) is shown. Chrome-osmic fixed, lead stained, χ27,000 from Adolph I. Cohen: Some observations on the fine structure of the retinal receptors of the American grey squirrel. Investigative Ophthalmology, 3:198-216, 1964. Permission to reproduce this figure given by the author, Dr. A. I. Cohen, and The C. V. Mosby Co., St. Louis, Missouri, publishers, is gratefully acknowledged.
tion the study of D r o z , " w h o showed that the proteins o f the outer segment o f the rod are continually being renewed at the base of the outer segment. T h e y would greatly admire the work of Wolken and W a l d , w h o are concerned with the molecular anatomy of the saccules of these rods, as well as that of Fernandez-Moran deinonstrating his su perb analysis of membrane structures. One could imagine Golgi and Cajal looking at
each other sheepishly should they see the evidence that, although the neurons were not continuous as one had thought, they were not so widely separated either (fig. 1 6 ) . They would only voice approval of the studies, made possible by the use o f isotopes, on the movement o f cells during the develop ment o f the retina, which S i d m a n " has shown to take place. Du Petit would be gleeful at the current
CONTRIBUTION OF A N A T O M Y
67
experiments in which tissue is plunged into
anatomic
liquid nitrogen to freeze it instantly, rather
closer
experimentation
than slowly as he had done, and to see that
than did the w o r k in the 18th and
sections o f these frozen eyes reveal the loca-
tury. W e should not be concerned if we do
to
brings
physiology
much
19th cen-
not
canee o f some anatomic observation. W e can
w a b a r a " and
do n o better than to f o l l o w the example o f
Müller would not think it odd to determine
Fontana w h o said in
the size o f spaces in the cornea and vitreous
his o w n anatomic
humor
by
dissecting
them
with
the
us
pathology
tion o f catalysts on which depend living and Fontana, Zinn and
immediately
and
visual processes, as has been shown b y K u Cogan.^*
know
basic
clinical
signifi-
1778, with respect to
discovery:
diffusing
the present I have no certain observations
molecules of hemoglobin, as David Maurice^'^
or definite experiment which could shed light on
has
been re-
*is subject: I do not want to advance imaginary
- j L - . , ^ ! !
hypotheses, or simple probabilities. I am abandoning
done. In their time, they had
^ . ^ j ^ ^ ,
,
.
stncted to the use o f various sized bristles! T h e immediate clinical application of anatomic research n o w , as then, is not always instantly obvious. Without question, modern
submitting this difficult subject to your genius. and it is to you I leave the glory of its explanation, 630 West
168th Street
(32).
BIBLIOGRAPHY
GENERAL REFERENCES Arrington, G. E., Jr.: A History of Ophthalmology. M D Monographs on Medical History, No. 3. New York, M D Publications Inc., 1959. Duke-Elder, S., and Wybar, K. C . : Svstem of Ophthalmology: The Anatomy of the Visual System, Vol. II. St. Louis, Mosby, 1961. Hirschberg, J.: Die Augenheilkunde in der Neuzeit. In Graefe-Saemisch Handbuch der Gesamten Augenheilkunde. Leipzig, ed. 2. v. 13, pp. 414-421, 1908; ν. IS,' pp. 1-25, 1918; v. 15," pp. 243-253, 1918. Horstmann, C . : Geschichte der Augenheilkunde. In Handbuch der Geschichte der Medizin (Th. Pusch mann) Wien, Jena, 1905, pp. 489-572. Magnus, H . : Die Anatomie des Auges bei den Griechen und Römern. Leipzig, 1878. : Die Anatomie des Auges in ihrer geschichtlichen Entwickelung. Breslau, 1906. Polyak, S.: The Vertebrate Visual System. (Edited by Heinrich Klüver.) Chicago, Univ. Chicago Press, 1957. Sorsby, Α . : A Short History of Ophthalmology. London, Staples Press Limited, ed. 2, 1948. Villard, H . : Histoire de I'anatomie, de la physiologic, de la pathologie et da thérapeutique de I'appareil oculaire. In Traite d'ophtalmologie (publié sous les auspices de la société Frangaise d'ophtalmologie). Paris, Masson et Cie, 1939, v. I, pp. 37-65. SPECIFIC REFERENCES 1. Fontana, F.: Traite sur le vénin de la vipere sur les poisons americains sur le laurier-cerise et sur quelques autres poisons végetaux. On y a joint des observations sur la structure primitive du corps animal. Différentes experiences sur la reproduction des nerfs et la description d'un nouveau canal de l'oeil. Tome second, Florence, 1781. 2. Callisen, Α. C. P.: Medicinisches Schriftsteller-Lexikon der jetzt lebenden Aerzte, Wundärzte, Geburtshelfer, Apotheker, und Naturforscher aller gebildeten Völker, Vol. 17, Copenhagen, 1833. 3. Schlemm, F.: Ueber einen kreisförmigen dünnhäutigen Kanal in der Verbindungstelle von Sclerotic und Cornea im menschlichen Auge. Ztschr. f. Ophth., 1 : X X X V : ( 3 0 ) 543-544, 1830-1831. 4. : In: Joh. Nep. Rust Ed: Theoretisch praktisches Handbuch der Chirurgie. Berlin, Th. Chr. Fr. Enslin, 1830, v. III, p. 333. 5. Rochon-Duvigneaud, A . : Les Yeux et la Vision des Vertebres. Paris, Masson et Cie, 1943. 6. Zinn, J. G.: Descripto Anatómica Ociili Humani Iconibus lUustrata. Göttingae, Abrami Vandenhoeck, 1755. 7. Hirschberg, T.: Geschichte der Augenheilkimde. In Handbuch der gesamten Augenheilkunde. 14 469-480 (ed. 2) 1911. 8. Koelliker, R. A. von: Erinnerungen aus meinem Leben. Leipzig, Wilhelm Engelmann, 1899. 9. Williams, H . : Don Quixote of the microscope: An interpretation of the Spanish savant Santiago Ramón y Cajal (1852-1934). London, Jonathan Cape, 1954. 10. Cannon, D. F.: Explorer of the Human Brain. The Life of Santiago Ramón y Cajal (1852-1934) New York, Henry Schuman Inc., 1949.
68
GEORGE Κ. S M E L S E R A N D V I C T O R I A O Z A N I C S
11. Droz, B.: Dynamic condition of proteins in the visual cells of rats and mice as shown by radioautography with labeled amino acids. Anat. Record, 145 :157-168, 1963. 12. Sidman, R. L.: Histogenesis of mouse retina studied witli thymidine-H. In The Structure of the Eye. (G. K. Smelser, ed.) New York and London, Academic Press, 1961. pp. 487-506. 13. Kuwabara, T. and Cogan, D. G.: Tctrazoliuni studies on the retina: III. Activity of metabolic inter mediates and miscellaneous sub.strates. J. of Histocliem. & Cytochem., 8:214-224, 1960. 14. Cogan, D. G., and Kuwabara, T . : Tetrazolium studies on the retina: IV. Distribution of reductase in ocular tissue. T. Histochem. & Cytochem., 8 :380-384, 1960. 15. Maurice, D. M . : The use of permeability studies in the investigation of submicroscopic structure. In The Structure of the Eye. (G. K. Smelser. ed.) New York and London, Academic Press, 1961, pp. 381-391.
CATARACT
SURGERY:
T H E HANDLING
R A M Ó N
CASTROVIF.JO,
New
In this brief discussion I shall refer to
OF
COMPLICATIONS*
M.D.
York
the vitreous strands that go around the pupil
only three complications of cataract surgery:
and
vitreous prolapse at the time o f operation;
making it necessary that a more central open
become
incarcerated
in
the
incision,
deflected pupil, a postoperative complication
ing be made in the iris for visual purposes at
caused by vitreous strands incarcerated in the
a later date.
incision; and anterior synechiae wh'ch result
Observation of such cases has convinced
from adhesion of the iris to some or all of
me that the iridectomy and iridotomy alone
the posterior aspect of the corneal wound.
will, in time, frequently cause alterations in the endothelium and these in turn will lead
VITREOUS
PROLAPSE
to corneal edema and bullous keratopathy if
Some surgeons advise the withdrawal o f
the
vitreous
remains
incarcerated
in
the
liquid? . . . vitreous when \'itreous prolapse
wound and in contact with the cornea. Fre
occurs during cataract extraction. T h e y ad
quently, secondary glaucoma caused by par
vocate the withdrawal from behind the iris
tial angle block is also observed in
with the aid o f an 18- or 20-gauge needle
cases and retinal detachment may occasion
to prevent postoperative complications but I
ally result from the pulling of the vitreous
feel withdrawal of the vitreous at this time
strands.
is never indicated. It does not prevent such complications as bullous keratopathy and de flected pupil as long as vitreous attachments to the incision persist and the vitreous re mains in contact with the cornea.
W h e n the corneal complications already mentioned present several weeks or months after
a cataract
extraction, the corrective
measure in general use is to enter the an terior chamber through a small slanting in
Other ophthalmologists consider that the pupil will be drawn upward after
these
cision at the limbus, se{)arate the vitreous
vitreous
from the cornea with a spatula and fill the
prolapse following cataract extraction unless
anterior chamber with air to prevent con
a large iridectomy is performed at the 12-
tact o f the vitreous and
o'clock position and a radial iridotomy is
However, these late postoperative complica
made at the 6-o'clock position. Unless this
tions can usually be avoided if the following
is done the pupil is eventually drawn up by
procedure to separate the vitreous from the
* From the Departments of Ophthalmology, St. Vincent's Hospital and New York University PostGraduate Medical School,
traction is performed:
the endothelium.
cornea is done at the time the cataract e x T h e incision is first closed with five cor-