Lacrimal History – Part IV: Doyens of Dacryology Series – The Contributions of Graeco-Roman Physicians

The Greeks and Medicine have been intertwined since time immemorial, much like the serpent coiled around the staff of Asclepius, the true symbol of medicine. The Graeco-Roman School of Medicine boasts of several scholars, philosophers, and physicians including Socrates, Hippocrates, Galen, Dioscordes, Celsus, and Paul of Aegina. Most of the original sources are lost or difficult to trace. The first written reference to battle surgeons can be found in the Iliad, by Homer with Machaon, son of Asclepius, a warrior-surgeon, who became a God worshipped for his skills as a healer.¹ Galen’s work remains an important resource to learn about medical discoveries even though he may not have mentioned the original source of the information.² The Graeco-Roman physicians were, essentially, observers, who documented or taught what they observed and used, which tried to introduce science as an entity and practice different from superstitions, philosophy, and religion.³ In this issue of the Doyens of Dacryology, we present a brief overview of their contributions to the understanding of lacrimal disorders.

Much of the information about Hippocrates comes from the dialogues of Plato. Hippocrates were an Asclepiad, i.e. belonging to the hereditary order of Priest-Physicians whose origins are traced to the mythological Greek God of Medicine, Asclepius.³ Hippocrates was born in approximately 460 B.C. on the Aegean Island of Cos and became an acclaimed physician and teacher at Cos and all over Greece. Hippocrates is also regarded as ‘The Father of Medicine’.³ The School of Hippocrates developed the knowledge of ophthalmology that has been both a foundation and a source of inspiration for the development of treatment of ophthalmic diseases.⁴ The Hippocratic literature mentions theories of lacrimation, eyelids, and their diseases but does not have a description of the lacrimal apparatus.³ They did, however, understand that clear watering from eyes due to irritation requires management that differs from the treatment of discharge of mucus.^2,5 The book ‘Gynaecological Diseases’, recommends the use of the juice of pomegranate apple cooked black and thick in a copper vessel “when the eye tears and there is pain” and dried juice of white grapes mixed with copper sulfate for “when eye tears and is thick.”² In addition, they also understood that epiphora can develop in old age as well- “Old men suffer from difficulty of breathing, catarrh accompanied by coughing, strangury, difficulty in micturition, pains at the joints, kidney diseases, apoplexy, pruritis of the whole body, sleeplessness, watery discharges from the bowels, eyes, and nostrils, dullness of sight, cataract, hardness of hearing,” and “In cases of nausea in which an upset of the bowels is followed by constipation, an eruption resembling a mosquito bite quickly appears and a lachrymose discharge occurs from the eyes.”^2,3 Hippocrates did not give any specific description of a lacrimal abscess or purulent dacryocystitis.² Both ‘Common Diseases’ and ‘Prognosis of Cos’, carry reports of cases of abscess near the eye, but these may or may not be related to the lacrimal drainage system.²

Aulus Cornelius Celsus (25 B.C.-50 A.D.) was a Graeco-Roman compiler and physicist who contributed to the knowledge of ophthalmic disorders and specifically to ophthalmic plastic surgery.⁶ His book, ‘De Medicina’ offers a systematic approach to oculoplasty surgery.⁶ According to Celsus, there was no eye disease that a simple home remedy could not cure. His descriptions of surgeries were better and more realistic. Among the diseases described by Celsus are epiphora, tumours of caruncle, and purulent dacryocystitis.

For Rome, Galen was an Episode; for the Middle Ages, an Epoch.⁷

Galenus, born in 129 AD in Pergamon (Asia Minor) was the son of Nikon, a famous architect and also, Galen’s first instructor.^2,5 He studied philosophy and then medicine in Smyrna, Corinth, and Alexandria.^2,5 It was a period when the very existence of science was endangered. Galen emerged as a formidable Graeco-Roman physician under whom the knowledge of ophthalmology continued to flourish.⁷ For the Romans, the dead were sacred and not to be defiled, leading Galen to gain much of his knowledge from the dissection of apes, pigs, dogs, and other animals.⁷ Galen’s description of the anatomy of the eye remained unchallenged till the 18^th Century. Although a lot was not accurate, the Scholar Aless Massaria wisely put it, “It is worse to err with Galen than to say the truth with modern authors.”² Several terms of the Anatomical Nomenclature, a list of words accepted by the Anatomical Society in the 9^th Congress, Basel, are derived from Galen’s anatomy of the eye.² Table 1 gives a list of ophthalmological words with Greek origins. Lacrimal terminology also has Greek origin: dacryocystitis is derived from dacryon (tear), and kystis (vesicle), and dacryoadenitis is derived from adenes (gland). Dacryops was coined by Schmidt in analogy to Aegiplops to describe a retention cyst of the lacrimal gland.²

Table 1. The anatomical nomenclature.

1. Nervus opticus
2. Bulbus oculi
3. Tunical fibrosa oculi: sclera, cornea
4. Tunica vasculosa oculi: choroidea, Corp. ciliare, iris
5. Stratum pigmenti: retinae, corp. ciliar, irides
6. Retina
7. Camera oculi anterior. Humor aqueus
8. Camera oculi posterior. Humor vitreus
9. Lens crystallina
10. Organi oculi accessoria
11. Musculus orbitalis, rect. Sup., inf., med., lat.
12. Muscul. Obliq. Sup., Trochlea, m. obl. Inf.
13. Periorbita
14. Supercilium, Palpebra sup., inf.
15. Angulus oc. Lateral, med.
16. Tarsus sup., tars. inf.
17. Conjunctiva, plica semilunaris conj. Caruncula lacrimalis
18. Glandula lacrimalis sup., gl. I. inf.
19. Ductuli excretorii gland. Lacrim. Puncta lacrimalia. Ductus nasolacrimalis

The Greek physicians, including Aristotle, used kanthos to refer to the angle of the eye. The caruncle was described as a fleshy body that protects the two orifices, directs the tears into the orifices, and prevents tears from overflowing and therefore, damage to the caruncle would be a cause of secondary epiphora. Till the 19^th Century, tumefactions of the caruncle were called tumours of the canthus based on Galen’s descriptions.²

With relation to the lacrimal system, Galen recognized the orifices/openings in the upper and lower eyelid leading from the eye to the palate which produced or drained fluid from the eye as required. His anatomical description and causes of epiphora nearly 1900 years ago leave one in awe – “A canal goes from the eyes to the palate and empties there the secretion formed in the eye. Watering may have three causes; either this canal is blocked, or the secretion is excessive, or a scar at the nasal canthus. The latter most is incurable.”^8,9 Galen also understood the presence of the nasolacrimal duct - “Medications which are put into the eye will soon thereafter be spit out or exhaled.”² “In order to assure easy motility of the eyes there are in addition glands in the lower and upper one. They secrete through visible openings a fluid just like the glands of the root of the tongue which secrete saliva into the mouth,” Galen’s texts mention two tear-producing glands (upper and lower) which secrete fluid like the salivary glands, and adipose tissue around the eye to protect the globe. Wharton referred to the lacrimal gland as the glandula innominate of Galen.²

Paulus or Paul of Aegina (7^th Century A.D.) is also known as the “last of the Greek eclectics and compilers,” of the Alexandrian School.^1,5 An expert surgeon, it is believed that he would “operate on all that he could and all that he could not.”¹ The Byzantine called him ‘Iatrosophistis’ i.e. an authority in medicine.¹ He thought that irritation and ocular inflammation led to lacrimation, increased temperature, and discolouration. He also discussed caruncular hypertrophy and the resultant sac abscess and mechanical secondary acquired lacrimal duct obstruction. He referred to the abscess of the lacrimal sac as Agchiloph, which could break to form a fistula (aigiloph) down to the bone. This was derived from agchi, meaning close, and oph meaning eye, and eich, the goat.² This is because goats have an open groove from the nasal canthus, running downward and forward.²

It is important to note that the Greek physicians were also aware of cancer of the lacrimal sac and even described characteristic features including surrounding pale skin, hard mass, tenderness, presence of fine-dilated tortuous vessels, and inflammation of surrounding tissues.² The word cancer has its origins in karka in Sanskrit, derived from the root kar, meaning hard, and karkinos in Greek. Galenus thought that the terminology was because of the external similarity of the dilated veins around a tumour to the leg of a crab-like animal.²

Treatment of lacrimal disorders was both medical and surgical. Dioscordes recommended soot of fir cones and soot of resin for epiphora. Abscess of lacrimal sac was managed by a suffusion of myrrh with flour of beans, rancid nut, barley, mallow, ear of a mouse, baccaris, chamomile, nightshade, and weed of grain plants.² Celsus and School of Alexandria are credited with the surgeries for excision of the caruncular tumours, excision of fistule of the lacrimal sac with burning of the bone, and treatment of pathologic lashes with red-hot iron.² Surgery for lacrimal abscess involved excision of the ulcer to the bone and then burning the underlying bone with red-hot iron. This treatment remained standard till Anel in the 18^th century and Bowman in the 19^th century suggested new techniques.^2,10,11 Paul of Aegina condemned bone trephination and recommended celandine, saffron, extract of an herb, and frequent change of compresses for the treatment of lacrimal sac abscess.² For cancer of the lacrimal sac, surgery was considered dangerous, and nasal involvement was a sign of poor survival prognosis.² Hippocrates stated, “One should not operate on a patient who suffers from an occult cancer. If these patients are treated they die soon, if they are not treated they can live for a long time.”²

A lot has changed in our terminology, understanding of anatomy, physiology, pathology, diagnosis, and treatment of lacrimal diseases. These ancient descriptions have been lost in the tides of time, or translated from their original transcripts with unintentional errors, often becoming tarnished and warped. Why then do we go back to them? The answer is simple, history is interesting, fascinating, and a great teacher if it is read in the context of the time when it was written. What once was changes to what is that we see today and think about what is yet to be.

DISCLOSURE STATEMENT

No potential conflict of interest was reported by the author(s).

Additional information

Funding

Hyderabad Eye Research Foundation (MJA) and J.C. Bose Fellowship, SERB.