Two hundred years and counting . . .

March 15, 2013

Paging through NEJM provides historical perspective of changes in ophthalmology, language

Our Ophthalmic Heritage By Norman B. Medow, MD, FACS

With the new year well under way, just what does the year 2013 mean? For some it is the year of the snake. For almost all of us, it is the 13th year of the 21st century. It also is the 237th anniversary of the founding of the United States and the beginning of the second 4-year term of President Barack Obama.

For this article, it is the beginning of the third century of the publication of the New England Journal of Medicine (NEJM). The journal is believed to be the longest-running, continuous journal in the history of the United States.

The idea for the journal was brought forward in late 1811 by a distinguished group of Boston’s medical community, led by John Collins Warren, MD. A professor of surgery, Dr. Warren will forever be linked with a seminal event in the history of medicine. That event was the first public use of ether for surgical anesthesia on Oct. 16, 1846. This moment has been memorialized by Robert Hinckley who, in 1882, painted a recollection of the event (Figure 1).

Inaugural issue

Vol. 1, No. 1 of the NEJM was published on Jan. 1, 1812 (Figure 2). The issue was divided into three sections: original and selected communications, book reviews, and intelligence. Selection of the items to be published was at the discretion of the editor. There was no peer review as we know it today.

Interesting items included a discussion about how difficult it was to obtain leeches and the suggestion that physicians obtain quantities of leeches to keep on hand as they became available, or that they should learn how to raise them themselves. Another interesting communication was about a wound incurred by a cannon ball.

The first article about eyes appeared in the April 1 issue of Vol. 2. Dr. Warren, who not only was a plastic surgeon, but also was skilled at cataract surgery, wrote the article. This report offers an interesting insight into the language used at the time, as well as the extent of knowledge of ophthalmic surgery. I felt it, therefore, important to report this as it was written:

Case of operation for secondary cataract, communicated by Dr. John C. Warren.

On the 24th day of January, I performed the operation for secondary cataract, agreeably to the mode proposed by Mr. Gibson in the presence of the students of the Medical School of Harvard University. The patient had been couched by different gentleman, four times in the right eye and twice in the left; yet he saw very little with the right and not at all with the left. On examining him we could not discover any distinct opacity in the right eye, but in the left appeared a large opaque mass behind the pupil, which seem to change its situation occasionally, but never so much as to admit of his seeing any object with that eye. The pupils were both movable. The left was slightly irregular. The patient was placed in the usual position for removing the cataract. The eyelids were separated by the thumb and finger of the left hand and then, a broad cornea knife was pushed through the cornea at the outer angle of the eye, till its point approached the opposite side of the cornea. The knife was then withdrawn, and the aqueous humour being discharged, was immediately followed by a protrusion of the iris. The forceps, made by Mr. Beath of Boston agreeably to the plate of Mr. Gibson, were then introduced and carry the iris gently into its place; from which it did not afterwards remove. The opaque body eluding the grasp of the forceps, a fine hook was passed through the pupil and fixed in the thickened capsule, which was immediately drawn out entire. This substance was quite firm, about half a line in thickness, a line in diameter, and had a pearly whiteness. A light bandage was placed on the eye and the patient directed to wash it occasionally with warm water. On the fourth day, we examined the eye closely and found the cornea healed, the aqueous humour secreted anew, and the eye plump and fair as before the operation, without opacity and nearly free from inflammation. No inconvenience followed, till about two months after the operation, when a slight inflammation was brought on by some accident. Two or three bleedings removed this disorder. The patient is now well and sees to distinguish every object with the left eye, while the right, which is equally clear, has a very imperfect vision.

The event of this operation shows the superiority of the new method, to the frequent repetition of couching.

Evolution of science, language

The next article about ophthalmology appeared in the July 1813 issue. In this article, Dr. Warren discussed conjunctivitis, pterygium, and iris prolapse. In the October 1813 issue, an article by William Adams of London discussed ectropion of the eyelid and how to form an artificial pupil.

What is extraordinarily interesting in these three publications from the first 2 years of the NEJM is the language used by the authors. Much of it is taken from the way the English people spoke. The “American” language had not yet evolved to what it is today. Examining the English used in medical writing at the time and watching future publications, not only shows the evolution of science but also of American English-one needs only to spend some time “over the pond” to note the difference. It still exists. It is jolly nice!

fyi

Norman B. Medow, MD, FACS, is editor of the Our Ophthalmic Heritage column. He is director, pediatric ophthalmology and strabismus, Montefiore Hospital Medical Center, and professor of ophthalmology and pediatrics, Albert Einstein College of Medicine, Bronx, NY. He did not indicate a financial interest in the subject matter.

(Figure 1) “Ether Day,” Oct. 16, 1846, by Robert Hinckley, 1882; John Collins Warren, MD, surgeon; William Thomas Green Morton, anesthetist.

(Figure 2) Mockup of the masthead of the New England Journal of Medicine (Vol. 1, No. 1, Jan. 1, 1812) (Images courtesy of Norman B. Medow, MD, FACS)