Ernst Fuchs

Ernst Fuchs (1851- 1930)“If I have seen further than others, it is by standing upon the shoulders of giants.” Sir Isaac Newton Rome was not built in a day, and neither was ophthalmology. In our search for the greatest ophthalmic surgeons, whose work laid the foundations for the specialty to grow, we have travelled through several timelines and countries over the last six months and it is very hard to have a column on the history of ophthalmology without delving into the life and contributions of Professor Ernst Fuchs. Born of Bohemian ancestry, Ernst Fuchs lived in Vienna when medicine was flourishing in leaps and bounds. Despite a humble background, Fuchs‘ early education made him different from the others practising medicine. He was fond of art, nature, music, cycling, mountaineering, travelling and was a voracious reader. Fuchs had travelled to nearly all European countries, Asia minor, Ceylon, Thailand, Java, China, Japan, Central Africa and greater part of the Americas, which at that time, was a feat by itself. He was part of the Geographical Society of Vienna and regularly spoke about his travels around the world. Interestingly, he brought back a pair of “snow-shoes” from his trip to Scandinavia in 1875 and introduced skiing to Vienna.[1] His autobiography contains paintings that he made himself of redwood trees in California, Old Faithful in Yellowstone, Mesa Verde in Florida, Cathedral of Montreal and Diamond Head in Honolulu.[2] As a visiting professor to foreign land, in the words of Peter Kronfeld, “He may have contributed more towards mutual understanding between people after World War 1 than some of the peace treaties.”[3] In 1868, he entered the world of medicine at the Vienna University. They say, an apple does not fall far from the tree. This is exemplified by Fuchs, having been a student of Hyrtl, Brücke, Rokitansky, Skoda, Hebra, Billroth and Arlt. After completing his education in 1874, he took Arlt‘s advice and worked as a general surgeon under Billroth for two years before immersing himself completely into ophthalmology.[4] From 1876 to 1881, he worked as an assistant to Arlt and wrote his treatise on sarcom des uveal tractus (uveal sarcoma), known today as uveal melanoma. In his manuscript, he described 14 pathological types, hepatic metastasis and enucleation as the treatment of choice.[5] This piece of work catapulted him to fame and for the next four years he was invited to chair the newly created department of ophthalmology at the University of Liège. It was during this period that he wrote another masterpiece on the prevention of blindness, hereditary eye diseases, influence of general illness and occupation on eye diseases, their prophylaxis and management. He returned to Vienna in 1885 and became a professor of ophthalmology, a role he held for nearly 30 years before he retired in 1914.[4] Under Fuchs, the Vienna Ophthalmological School, or Klinik Fuchs‘ is said to have reached its zenith of fame and recognition. He was an honorary member of several scientific societies, the President of Honor of Ophthalmological Society of Madrid and Austrian Ophthalmological Society. In 1929, when International Association for the Prevention of Blindness was established, Fuchs was elected as the first honorary member.[1] It would not be an exaggeration to say that he is regarded as one of the greatest ophthalmologists of all time. Not only was he a doctor par excellence, with patients coming to him from all over the world, but an ideal teacher. He would teach in the simplest language with logical approach, a quick crayon drawing and demonstration of projected microscopic slides illustrating the lesion.[6] Almost everybody who became a faculty of ophthalmology had indeed studied under him.[4] At the 100th birth anniversary celebration of Ernst Fuchs, in 1951, the then director, Dr A. Pillat, simply put it, “The older ones among us, his disciples, and all of us, disciples of his disciples, are under the spell of his towering personality.”[7] Salzmann, his oldest pupil, observed that it was against Fuchs‘ very nature to teach anything ex kathedra, without him being absolutely sure about its correctness.[1] At that time, to become a faculty at the University of Vienna, one had to be a pioneer in his field of medicine with the ability to do original research. [Fig. 1] Fuchs published more than 250 papers and described many new conditions, including blepharochalasis, ptosis myotrophica, herpes iris of conjunctiva, episcleritis periodica fugax, the ‘Fuchs coloboma‘ (conus inferior), Foster-Fuchs spot in myopia, Dalen-Fuchs nodule, retinitis circinate, gyrate atrophy of choroid, choroidal detachment after cataract surgery and diffuse choroidal sarcoma. He was the first to distinguish between endophthalmitis and sympathetic ophthalmia.[14]Figure 1: Famous Viennese doctors, with Ernst Fuchs among them[5]His eye for detail and extraordinary memory is evident by his description of the abnormality dystrophia epithelialis corneae based on 13 cases that he had seen over ten years, amongst thousand other cases. With a magnifying glass, a Schiotz tonometer and a direct ophthalmoscope as his only tools, he described the features of slowly progressive corneal clouding, greater involvement of inferior cornea, reduced corneal sensations and diurnal variation of symptoms. He considered the defect to lie in the corneal epithelium and wrote, “The first and primary place of alterations is the epithelium. For this reason, I name the disease Dystrophia epithelialis, a name which can be replaced later by better one when the true nature of the disease will be discerned…the cause of this disease is unknown, as well as an effective therapy.”[8] Today, we know it as Fuchs endothelial dystrophy. Similarly, his paper on iris heterochromic cyclitis (Fuchs heterochromic uveitis), based on his study on 38 patients and six enucleated eyes, was a landmark in ophthalmology and the features described are still used as diagnostic criteria.[9] He also described keratitis disciformis, keratitis pustuliformis profunda, keratitis punctata superficialis, dellen and nodular corneal dystrophy. His other works include the study of chalazion, pinguecula, pterygium, retinal degenerations, and “ulcers” of pars ciliaris retinae. Fuchs had an enviable collection of microscopic specimens and laid the foundation for the anatomical and pathological studies of tissues of the eye.[1] With these he could support any of his clinical work with a pathological and anatomical basis. Post his retirement, he went on to publish 99 articles, majority of them dealing with the study of his histological specimens. Duke-Elder dedicated the section on pathology in his textbook with a tribute to Fuchs, “It is difficult to think of the work done on the pathology of the eye without at the same time thinking of Prof. Ernst Fuchs.. one of the greatest of ophthalmologists and one of the most delightful of men. Although a clinician of exceptional ability and international fame, it was as a pathologist that he justly earned his unique reputation. His whole life, indeed, was devoted to the elucidation of the morphological basis of diseases of the eyes.”[2] Perhaps his greatest contribution is his book, Textbook of Ophthalmology, published first in 1889, followed by 12 editions by Fuchs himself. Fuchs did not like his students taking notes vigorously during his lecture instead of just listening to him attentively and he wrote this book to ensure that they could go back and refer to it whenever required.[4] This book was the bible of ophthalmology for nearly half a century and has been a source of “advise, advantage and stimulation” for ophthalmologists throughout the world.[7] It was translated in several languages, including an English translation by Duane. He never stopped learning and evolving. His thirst for knowledge is literally evident from a small incident reminisced by Prof. K. Lindner, during his obituary address, from the time that Fuchs was a college student. A whirlpool in the Danube River, between Kritzendorf and Klosterneuburg, was said to draw even the strongest swimmers under water and Fuchs jumped in to test this for himself. Fortunately, for him and for ophthalmology in general, he survived.[1] While he was fluent in English, French and Italian and had working knowledge of Latin and Greek, he learnt Spanish at the age of 70, to present his work in Spain and South America. In the 10th edition of his textbook, he truthfully wrote, “Nothing shows me the speed of scientific progress better than to leaf through the first editions of my book. I come across opinions that I shared with other experts and that now seem to have aged half a century. I would prefer not to admit to these opinions, would the proof not lie in front of me.”[1] He died on November 21, 1930 from coronary thrombosis at the ripe age of 80. A more loving tribute is rarely found, as the one by Bernard Samuels, “Often members of the younger generation of ophthalmologists, brought up by Fuchs through his textbook, sought interviews that they might say in after years that they had seen the Master. Long they will remember the tall, kindly old gentleman, whose head was bending low, as he showed them something of interest in the house or led them down the spiral stairs into the garden. It is sad to contemplate that those hills overlooking the Danube will know the sage of Kritzendorf no more. Loved, honored, mourned, he has fallen asleep. Immortal is his name.”[6] A curious heart, a steady hand, an analytical mind, a teacher at work and a student for life…we can all, most certainly take a leaf or two from Ernst Fuchs‘ book. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

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