The eye fungus

Fungus haematodes of the eyeballMy headline is somewhat misleading, for the ‘fungus’ referred to in today’s article, published in the Edinburgh Medical and Surgical Journal in 1823, has nothing to do with mushrooms. It’s a word which until the late nineteenth century was sometimes applied to certain forms of tumour. And in case you’re thinking that a story about eye cancer doesn’t sound much fun – please do read on, it’s probably not as bad as you think.

J.L., aged 9, son of Mr L., factor [land agent] to a nobleman in the neighbourhood of Edinburgh, was brought to me on the 12th May 1821, on account of an affection of the left eye. On examination, the eye was observed to have a general turbid [cloudy] appearance; it was devoid of lustre; and, on minute inspection, the cornea was found to be transparent, but numerous vessels passing over the sclerotica into it. The pupil had a slightly serrated appearance; was moderately dilated, but did not change its size on variations being made in the degree of light. In the posterior chamber an opacity was observed, resembling a yellow dusky membrane, lining the whole posterior part of the eyeball, more distinctly perceived when the eye was viewed laterally.

There are various bad signs here, but surely the worst is the ‘yellow dusky membrane’ seen inside the eyeball. The surgeon must at this point have begun to suspect it was a tumour; and known there was nothing he could do about it.

The vision was nearly gone; the eye watered profusely, especially when exposed to the light, which occasioned considerable pain and irritation; had at times a shooting pain in the frontal edge of the orbit, of short duration; pulse natural; general health good.

Mr Wishart asked the father about the history of the complaint.

About two months ago he received a blow on the eye while at school. The afternoon of that day it gave him no uneasiness, but next morning he felt great pain in the eye, and the vision was almost entirely lost. The effects of this injury were apparently removed by free local bleeding, and antiphlogistic [anti-inflammatory] treatment under the care of Mr Stewart of Queensferry; and in a few weeks he was able to return to school.

The injury may have had nothing to do with the ailment: a blow to the eye seems unlikely to provoke the growth of a tumour inside the globe of the eye.

About ten days ago, the eye again became inflamed and painful. Six leeches were ordered to be applied to the forehead, and a dose of infusion of senna to be given in the morning.

Leeches were often used to treat ophthalmic disease. Occasionally they were applied to the eyelids, but more often to the forehead or temples. It was a pointless intervention, since they would have had little effect on the blood supply to the eyeball itself.

This treatment was continued at intervals for two months, and the boy was also given purgatives and the eye itself was dressed with a poultice of poppy heads – a mild painkiller. But it had little effect.

July 3.—Within these last four days, considerable febrile symptoms have come on. The eye is very much inflamed, and intolerant of light, with considerable pain in the eye and frontal margin of the orbit, shooting occasionally to the posterior part of the head. For three days has had an attack of severe pain, which has usually continued for about an hour. Profuse watering of the eye. Pulse full and strong, but not quick.

The surgeon decided it was time for decisive action.

In consultation with Mr Gillespie, it was agreed that the removal of the eyeball was now expedient; but, with the view of lowering his system, two cupfuls of blood were directed to be taken from his arm on the 4th. On the 5th he had a dose of salts; on the 6th, six or eight leeches were applied to the forehead and temples; and on the 8th, the salts were to be repeated in a full dose.

‘Lowering the system’ meant reducing stimulation, and was frequently a prelude to surgery – it was achieved by emptying the alimentary canal and taking blood. The intention was to reduce the bleeding and inflammation that would inevitably follow surgery – but experienced surgeons cautioned against lowering the system too far, since this would inhibit the necessary healing processes.

On July 9th Mr Wishart finally operated.

The temporal angle of the eyelids was divided with a scalpel, which was then passed round, first at the frontal aspect of the eyeball, from the external to the internal angle, and the muscular and other attachments divided; the lower segment was divided in a similar manner.

The ‘temporal’ angle of the eye is the corner furthest from the nose. The surgeon began by making a nick in the eyelid at this point, and then sliding his scalpel (wince!) all round the eyeball, severing the six muscles that secure the eye and cause its movement.

The fore-finger of the left hand being passed from the nasal angle backwards, the optic nerve was found to form the only remaining connexion; it was readily divided with the same scalpel, and the whole removed from the orbit. The lacrymal gland was dissected out; the vessels were allowed to bleed for a few minutes. The divided eyelid was then brought together by a single small ligature; and the clotted blood being removed, two small strips of dry caddis were pushed gently into the orbit between the eyelids.

‘Caddis = a Scotch term for surgical lint’ [Dictionary of Medical and Surgical Knowledge, 1864]

Over this a pledget [dressing] of simple ointment, secured by a compress of caddis, and a few turns of a double-headed roller passed round the head. The little patient was put to bed. He bore the operation uncommonly well. It occupied only four minutes.

Remarkably quick – but with a young patient who was given no anaesthesia. While the operation must have been extremely unpleasant, I suspect it was considerably less harrowing than undergoing an abdominal operation (such as a lithotomy to treat bladder stones) or a limb amputation. Indeed, he seems to have recovered without suffering too much pain.

After being in bed for about an hour, a slight dropping of blood was observed; but as he had fallen asleep, it was not thought necessary to remove the dressings, and it did not increase.

Over the next few weeks, the boy’s most serious complaint appears to have been hunger –he was put on a ‘low’ diet as a precautionary measure. On July 21st, less than a fortnight after the operation, the surgeon visited him again and found him so well that he was discharged as cured.

This was not quite the last he saw of him: nine months later the boy was taken into the hospital with a small ‘tumour’ which was projecting from the vacant eye socket. This turned out to be nothing sinister; just a piece of scar tissue which later fell off of its own accord.

Being anxious to ascertain whether this cure continued permanent, I wrote to Mr L. in July, and received the following very satisfactory answer:— “I am happy to say, that, since you last saw my son, the eye has appeared to be quite healthy and well. He has not, upon any occasion, complained of the slightest uneasiness in it, or of any affection of the head; and his general health has been perfectly good. It is consoling to think, that the consequences of the operation have hitherto been, and I now sincerely hope will continue to be, so favourable and satisfactory to all concerned.”

One important point remains unresolved: what had been wrong with him? Mr Wishart was also anxious to find out.

Dissection of the Eyeball—The eyeball was divided from the optic nerve to the apex of the cornea. The appearances presented were precisely the same as those so accurately delineated by Mr Wardrop in the engraving of the drawing sent him by Sir Astley Cooper, and subsequently copied by Professor Scarpa into the last edition of his work on the Diseases of the Eye.

The illustration (below) first appeared in a book published in 1809, James Wardrop’s Observations on Fungus Haematodes or Soft Cancer in Several of the Most Important Organs of the Human Body:

fungus haematode
Tumour of the eye, drawing supplied by Sir Astley Cooper for James Wardrop’s Observations on Fungus Haematodes (1809).

The origin of the disease in the retina was finely and satisfactorily illustrated. The optic nerve was quite healthy. The sclerotic and choroid coats were of natural texture. The cornea was a little softer than natural, and not perfectly transparent. The lens was pushed into contact with it, and seemed smaller than natural, and flattened. The diseased mass, into which the retina had been converted, connected only to the optic nerve, floated loosely in various folds, occupying both chambers of the eye. The eyeball did not appear to be at all enlarged.

So what was wrong? According to Mr Wishart, it was a ‘fungus haematode’- a term coined by Wardrop and only briefly used. Wardrop also used the alternative description ‘soft cancer’, in contrast to the firmer tumours (carcinomas) which were more commonly encountered. Today these are known as sarcomas.

Medics may wince at my amateur attempts at diagnosis, so please (as ever) feel free to point out my mistakes in the comments. But I suspect this wasn’t a sarcoma. The symptoms appear to indicate a retinoblastoma – a rare and rapidly proliferating cancer which develops from the retina. It usually develops in childhood, and is the likeliest diagnosis when a child develops an intraocular tumour. The usual symptoms include a fixed, non-contracting pupil, as noted by Wishart, and leukocoria, an abnormal milky-white reflection, which could explain the cloudy quality the surgeon observed. The boy’s eye was also irritated, a common sign of glaucoma, which is also a standard finding in retinoblastoma.

It’s impossible to be sure, of course – and the many types of cancer would not be more fully described and understood until later in the nineteenth century, when the microscope made it possible to differentiate them. But what is notable in this case is that the treatment was – unusually for the time – apparently effective. Removing the eyeball was (and would remain for well over a century) the only likely cure, and it was accomplished with assurance and relatively little distress to the patient.

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