Optometry and Ocular Surgery in the Middle Ages

Apr 30, 2020
7 min read
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Sure, some forms of ophthalmic surgery today might seem intimidating, but we took a dive into the history of eyecare to illustrate just how far we've come!

ocular surgery in the middle ages

While even some modern ophthalmic surgeries may seem less than pleasing, what if we lived during the middle ages and needed to have a procedure done? This light dose of ophthalmic history is sure to lighten your quarantine experience and bring a few laughs with it. In this article we’ll explore how people experienced various eye procedures back then, primarily in the way of ocular surgery, refractive correction, and other abstract remedies for ocular ailments.

To set the scene, the Middle Ages refers to the time period between the 400s and mid/late 1400s. This article mostly refers to the time period from 1100 through the 1400s. Fashion? Think tights and tunics for men and long, flowing dresses for women. You may have had roommates during optometry school—however, in the Middle Ages, you would have lived in a cottage or hut with your family, cows and other livestock. While we’re currently living with coronavirus, those in the Middle Ages had regular cases of dysentery, smallpox and malaria (not to mention the Bubonic Plague). Bloodletting was also regular practice for many medical conditions.

In the 1200s, there were two main beliefs as to how vision functioned. Aristotle had previously proposed that light originates from objects and enters the eye to stimulate vision. The second belief was proposed by Peter of Spain, a doctor, medical professor and renowned thinker of the time. His theory postulated that the human spirit arose in the brain, passed through hollow optic nerves and touched an object in the world. It then returned to the eye with the sense of vision.

In 1276, Peter of Spain collaborated with Pope John XXI to write a book, De Oculus. This book was intended for physicians of the time to treat eye diseases. It gives us insight into the knowledge of ocular anatomy, physiology and treatments of the 13th century. Here are some recommendations from his text.

This author, however, does NOT recommend putting any homemade solutions directly into your eye

Artificial tears? Why spend $13 a bottle when you could make your own with these 13th century techniques? Simply mix “pomegranate, juice of wood sorrel (sourgrass), sugar, white wine in equal parts to be used three times a day.” Can’t find wood sorrel at your local grocery store? Try this eye wash instead: “bile of swallows and partridges mixed with fennel root juice.” However, one caution when using this eye wash: “the patient should be warned from motion of the eyes and too much sex.”

Do your patients ever ask you what they can do to keep their eyes healthy? “A useful salve for the eyes; sugar, unpierced pearls, white lead, opium, all made into a fine powder with egg white and a slice of pepper and dissolved with urine.” With regard to bloodletting for ocular conditions, “frequent small phlebotomies of blood from a vein which is at the elbows strengthens the eyes . . . phlebotomy is not useful after the fiftieth year.”

Allergy season is also upon us. What was the cure for itchy eyes, before Pataday was available? In the 1200s you would make your patient a solution of “rosemary and thyme . . . placed in white wine and set aside three days and three nights and then placed in the eye.” Despite the discomfort and toxic keratitis this would likely cause, there may be some validity behind this therapy: thyme has antihistamine properties and is used today in herbal allergy-fighting remedies. If this treatment isn’t sufficient, “The best remedy is as follows: Take the urine of a fasting virgin boy and white wine in equal parts and boil in a pot with rue, sage and fennel. Place this in the eye.” This too has at least some merit, as fennel is also now known to have antihistamine properties because it contains the antioxidant quercetin.

While some of these writings may seem strange to us today, these ideas had been based on practices for the previous thousand years. Additionally, Peter of Spain wrote extensively about medical and philosophical issues of the time, so this was considered sound medical advice from an eminent figure in the field.

Cataracts

In medieval times, it was believed that the lens was in the center of the eye anatomically. A cataract was thought to be an abnormal humor flowing in this previously clear space in front of the lens (cataract means waterfall, hence the flowing). A procedure called “couching” was commonly used for treatment. This technique was used at least since the 5th century BC and is still used today in some developing countries.

medieval eye diagram.png

Image 1: Diagram showing lens in the center of the eye and “empty space” believed to reside in front of the lens where “bad humor” or cataracts flowed.

To perform couching in the Middle Ages, a traveling surgeon would visit from town to town, performing the technique only on patients with very dense cataracts. The patient would be aligned so that sunlight was streaming over the surgeon’s shoulder and toward the patient’s face. (Remember, there was no operating room, electricity or sterilization procedures being used.) An assistant would restrain the patient physically while the surgeon inserted a knife or needle posterior to the corneoscleral junction to break the zonules and dislocate the lens inferiorly. The eye would then be patched with wool soaked in either egg white, breast milk or clarified butter.

The improvement in vision could actually have made a significant impact on a patient’s daily life. Despite the fact that they are now aphakic and without a glasses correction, they can make out forms in their environment to navigate familiar areas. This was an improvement from the near blindness caused by their previously dense cataract. Initially it had great success. By the time inflammation from the retained lens and disrupted capsule set in, the surgeon had already moved on to the next town.

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Image 2: Three steps of couching procedure

medieval couching emphasis on ouch

Image 3:Couching being performed(does not show patient being restrained)

Eyeglass Evolution

It is unknown exactly who the first person to invent eyeglasses was, but it is thought that they were invented in Italy in the 1280s. Glassblowing was a large industry in Italy, so it is fitting that Italians were the first to form glass into convex lenses to aid in reading. The earliest style of glasses consisted of two convex lenses held in place with bone, wood, metal, wire and leather, and were connected by a central joint. They could either be held in front of both eyes, pinched onto the nose to stay in place without temples (pince-nez style) or folded on top of each other for monocular use and more magnification.

Reading stones were also likely used since at least 1000 AD. These could magnify a near image but were likely more useful once spectacles were invented to bring the images further into focus.

pince nez oldest pair with known owner.png

Image 4: According to the Online Museum and Encyclopedia of Vision Aids, this is the oldest pair of glasses whose owner was known although older spectacles have been found with unknown owners

medieval reading stone

Image 5:medieval reading stone

In the 1440s, Johannes Gutenberg invented the printing press. As books became more widely available (compared to previously handwritten documents) people, especially presbyopes, had more need for glasses . Likely because of the greater numbers of people reading, they were even able to make estimates of the most useful powers of reading glasses based on a person’s age.

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Image 5: Earliest fresco showing a cardinal wearing glasses in pince nez style

To conclude our exploration of medieval eye history and procedures, we now have a better understanding of where some aspects of our profession may have originated long ago. Hindsight being 20/20, some of these techniques not only seem antiquated but also downright bizarre! Who knows what modern treatmentswe use today will seem far fetched 600 years from now. Only time will tell.

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About Kevin Cornwell, OD

Dr. Kevin Cornwell graduated from The New England College of Optometry in 2015. He went on to complete a residency in ocular and systemic disease with Indian Health Services in Zuni, New Mexico. He now works with MACT Health Board, Inc in Northern California, a nonprofit organization that provides healthcare for Native Americans. He is enthusiastic about bringing eye care to populations in need, both domestically and abroad. He has been involved with several humanitarian outreach projects, in various parts of California, New Mexico, Nicaragua and Mexico. He is passionate about managing the ocular manifestations of systemic disease, and monitoring ocular pathology through retinal imaging with spectral domain optical coherence tomography. He’s also an avid health crusader and enjoys educating and encouraging patients to better manage metabolic disease. Dr. Cornwell enjoys hiking in the Sierras and recording music as a guitarist for Cornwell Studios' youtube channel.


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