Showcase 19 - 29

Looking at the eye
Wax Moulages from the Eye Clinic in Zurich

The Production of Moulages for the Eye Clinic in Zurich

Ophthalmology was developed in the 19th century out of the speciality of surgery. Ophthalmology established itself as an independent discipline through in-depth physiological and anatomical knowledge, the diagnostic possibilities of ophthalmoscopy and specific surgical instruments.

In 1859, the newly elected director of the surgical clinic in Zurich, Theodor Billroth (1829-1894), recommended the separation of the eye clinic under the direction of his senior physician Johann Friedrich Horner (1831-1886). Three years later, Horner was appointed the first associate professor of ophthalmology at the University of Zurich and ten years later was promoted to the first ordinary professor. Friedrich Horner was able to take over a surgical ‘men's room’ and a ‘women's room’ with a total of 20 beds for the newly founded eye clinic on 14 April 1862.

In 1886, he was succeeded by his senior physician Otto Haab (1850-1931) as Professor of Ophthalmology and Director of the Eye Clinic. In 1895, Haab moved into the newly built Eye Clinic at Rämistrasse 73 with 25 patients. He ran the eye clinic for 23 years.

In 1919, his long-time deputy Ernst Sidler-Hugenin became the new clinic director but fell seriously ill and died in December 1922.

In April 1923, Alfred Vogt from Basel was called to Zurich and remained head of the Eye Clinic until 1943. Under his leadership, the clinic strengthened its already excellent scientific reputation, specialising in retinal and lens surgery and genetic diseases, among other things. Diagnostically, he promoted the examination of the anterior eye with the slit lamp. His three-volume atlas of slit lamp microscopy was regarded as a standard work for many decades.

The collection of moulages from the Eye Clinic comprises 42 objects and was produced by Lotte Volger, who worked as a freelance moulageur at the Zurich Cantonal Hospital from 1917 and was employed at the Dermatological Clinic from 1918. The first moulages of external eye diseases were created in 1917 under the direction of Otto Haab. However, most of the moulages date from the 1920s under the direction of the eye clinic by Alfred Vogt.

The name of the patient is listed on the back of some moulage boards, very rarely supplemented with a keyword such as ‘before X-ray irradiation’. A comparison with the moulages from the dermatological clinic suggests that these moulages were also produced primarily for the documentation of special cases and for presentation and discussion at specialist conferences. It is still unclear whether and how they were later used for the training of students or in some cases produced specifically for teaching purposes.

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The Eye Clinic at Rämistrasse 73.
After 30 years in the two original surgical rooms, the Eye Clinic, designed by Haab, moved into the new neoclassical building at Rämistrasse 73 in December 1895. Today, the building houses the Archaeological Institute and Museum as well as the UZH Institute of Art History.

Image from Pettannice N.: 125 years of the House of Vision, 2022.

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“Haab’s magnet” by Otto Haab
Otto Haab became particularly well known for the giant magnet he built to remove metallic particles from the eye. During the heyday of heavy industry in an era without safety goggles, this was one of the most common injuries in the workplace.

Fig. from “Otto Haab (1850-1931) A Swiss ophthalmologist.”Diss med. Urs Hürlimann, 1979

 

Ectropion senile, moulage no. 25: 
The slackening of the eyelid muscles in old age or due to pathological muscle weakness (myasthenia) leads to an outward tilt (ectropion) of the lower eyelid. The drying out of the surface of the eye, when the eye can no longer be completely closed, irritates the eye, which can be recognized by the irritated conjunctiva. At the same time, the eyes water because the entrance to the tear duct at the edge of the eyelid is no longer in contact with the eye and can no longer collect the tear fluid.
In moulage no. 25, lifting the upper eyelid with a finger demonstrates that the patient also suffers from drooping of the upper eyelid (ptosis), with corresponding impairment of the visual field.

Epicanthus, moulage no. 35: 
The moulage shows two findings: a prominent port-wine stain on the left forehead and eyelid (naevus flammeus, a congenital malformation of the fine blood vessels of the epidermis) and a very pronounced vertical skin fold covering the centre corner of the eye (epicanthus) on both eyes. A slight epicanthus is very common in newborns and disappears to a greater or lesser extent in infancy, depending on ethnic origin. Both findings are harmless. However, the combination of a large naevus flammeus on the face together with a pronounced epicanthus, as shown in this moulage, can be an important indication of a genetic syndrome with malformations.

Third moulage: 
Unfortunately, there is no additional information on this moulage. The reddening of the skin, the clumped eyelashes and the heavily reddened and slightly swollen conjunctiva suggest that it was a bacterial infection.

Carrot nose (Karottennase): 
Eating large quantities of vegetables with a high beta-carotene content (carrots, tomatoes) can cause the skin on the hands and face to turn yellow (carotenaemia, carrot jaundice). In infants, a generous diet of carrot puree and juice typically leads to an orange nose and cheeks. Carotenaemia is harmless and has no effect on the rest of the body.

 

Legends

• “External eye diseases”, Otto Haab, 1899
  Atlas of the externally visible diseases of the eye together with an outline of their pathology and therapy.
  In 1899, Otto Haab published an atlas of external eye diseases with illustrations painted "from nature" by the painter F. Fink from Munich at the clinic in Zurich.
  In the preface, Haab emphasizes that most eye diseases can be easily identified at the first examination by using the correct examination technique. As this is primarily a visual diagnosis, it is essential to have “excellent visual acuity”. He recommends that young doctors only specialize in the field of ophthalmology “if a precise examination of their eyes has established that the visual acuity of each eye is at least 1.5 times the average norm, that they also have good binocular vision and that color blindness is excluded”.
   
• Ophthalmoscope by Otto Haab
  The ophthalmoscope - the “eye mirror” - was invented by Hermann von Helmholtz in 1851 and significantly expanded the existing possibilities for examining the human eye. The Zurich ophthalmologist and professor Otto Haab became world famous above all for his invention of the “Haab eye magnet”. However, he also developed smaller instruments for ophthalmology, including this ophthalmoscope.
  MHSZ 5752, loan from the Medical Collection, Institute of Evolutionary Medicine (IEM), University of Zurich.

Cancer of the external eye

Different forms of cancer can also develop on the eye. The most common are the forms of light-coloured, non-melanocytic (non-black) skin cancer on the eyelids: Basal cell carcinomas and spinocellular carcinomas.

However, carcinomas can also form from the surface cells of the conjunctiva and cornea. They occur most frequently at the transition from the conjunctiva to the cornea. As with the skin, exposure to UV light is the main risk factor for the development of carcinoma in the outer eye.

Today, there are a variety of therapies for treating superficial tumours and precancerous skin lesions with excellent cosmetic and function-preserving results, such as microsurgery, cryotherapy (freezing), local chemotherapy, photo-dynamic therapy, radiotherapy and combinations thereof. Cancer of the eye was already being treated surgically around 1920. However, the risk of not completely removing the cancer cells was very high with eye-preserving operations and sufficiently radical surgery led to visual impairment or loss of the eye. After enucleation (removal of the entire eyeball), an artificial eye made of glass could be used to preserve the aesthetics.

As early as 1904, a few years after the discovery of X-rays, the first successes in treating eye cancer with X-rays were reported. By 1920, the technology had improved to such an extent that X-ray therapy alone or in combination with a previous surgical procedure could show excellent results.

Cancer of the cornea

Moulages no. 6 to 12, only partially labelled with numbers, show three cases of carcinoma of the cornea. The carcinomas can be recognised by a superficial opacity of the cornea and increased blood flow with enlarged blood vessels in the conjunctiva.

Moulage no. 7 and the unnumbered moulage on the right show the same patient before and after successful treatment of the carcinoma with X-rays.

The series of three moulages of a patient treated in 1921 documents the course of X-ray therapy of a carcinoma of the cornea. The first two moulages show the pronounced inflammation caused by X-rays a few days and three weeks after X-ray therapy, while the moulage on the right shows the disappearance of the corneal opacity after healing.

Skin cancer of the eyelids

It is not known whether the patients shown here were treated surgically or with X-rays. The moulages document various localisations and forms of white skin cancer of the eyelids.

Carcinoma of the skin on the chin and corner of the eyelid: This moulage shows half the face of a patient with several carcinomas: on the temple, on the lower part of the chin and in the medial corner of the eye. The clinical findings are consistent with spinocellular carcinomas, which slowly destroy the healthy tissue and can also form metastases over a longer period of time. There is also a long scar across the entire cheek towards the right nostril. This incision would fit very well with the fact that a carcinoma on the cheek had to be surgically removed in the past. To close the resulting defect next to the nose, the incision was continued across the cheek and the skin of the cheek was moved towards the defect. The cosmetic result was very good. 
Of the new carcinomas shown here, the skin cancer at the medial corner of the eye is particularly unfavorably located. Surgical treatment with a good functional and cosmetic result was no longer possible.

Carcinoma type. mixte, moulage no. 565: The moulage produced in 1922 shows a patient with a basal cell carcinoma which, however, also showed changes of a spinocellular carcinoma under the microscope. Basal cell carcinoma is the most common malignant tumor of the skin. It usually does not produce any metastases, and the patient is cured after complete surgical removal or successful X-ray irradiation.

Moulages no. 4, no. 5 and no. 1027: All three moulages show carcinomas of the lower eyelids. The clinical picture is most consistent with basal cell carcinoma in all moulages. They are located on the lower eyelid margin or at the outer corner of the eye, i.e. in areas that are strongly exposed to light. This suggests that they have developed as a result of chronic exposure to UV light. These connections were only slowly recognized in the 1930s. However, it took more than half a century before the dangers and harmfulness of UV exposure from sunlight became generally known and sun protection with textiles, appropriate behavior and sun creams became a matter of course.

Sarcomas and lymphomas of the eye

Sarcomas are malignant tumors that originate from connective tissue. Sarcomas of the eye are extremely rare. The fact that there are two moulages of patients with an orbital sarcoma in the collection of the Eye Clinic is remarkable and indicates that these moulages were made as documents for a scientific presentation or discussion.

This rare, very aggressive tumor usually affects younger people, as is the case with the historical patients documented here: moulage no. 30 shows a 16-year-old female patient and moulage no. 29 a child who was seen as a private patient of Otto Haab in 1917. The prognosis was very grave. Despite extensive removal of the affected eye and a combination of chemotherapy or radiotherapy, the risk of recidivism is still high today.

Lymphochloraemia: In 1849, Alexander King in Glasgow described a greenish tumor found on a six-year-old girl with changes in the white blood cells, which he called a “chloroma” because of its color. Since then, this name has been used for a group of malignant tumors that arise from precursors of white blood cells, even if these are usually white or grey. The rare chloroma affects children more often than adults and is often associated with a form of blood cancer (leukemia). The eye socket is the most common localization in children. At the time the moulage was produced, there was no effective therapy and the disease still has a very poor prognosis today.

The name “lymphochloraemia” summarizes that it is a disease of the white blood cells (lymphocytes) with a tumor (chloroma) and blood changes (aemia). This moulage shows an extremely rare disease and it can be assumed that it was produced for the scientific documentation of the case and not as a teaching aid for medical students.

Alfred Vogt also conducted research in the field of genetic diseases and syndromes (diseases with typical symptom constellations). This explains why there are some moulages in the collection of the Eye Clinic with rare findings that may indicate a syndrome, such as epicanthus, blue sclera or atrophodermia reticularis.

In 1925, Vogt had to remove the right eye of a two-year-old girl due to a nerve tumor located behind the eye. He referred the child to Bruno Bloch, Director of the Dermatology Clinic, for assessment of a conspicuous pigmentary disorder. In the same year, Bloch demonstrated this case with the help of a moulage at the annual meeting of the Dermatological Society in Zurich. Two years later, Marion Sulzberger, a trainee doctor working with him, published the case as “Incontinentia pigmenti” with an illustration of moulage no. 245, which is on display in the showcase on the wall to the left of the entrance door. The pigmentation is the result of an inflammation similar to the “Atrophodermia reticularis” moulage shown above.

Atrophodermia reticularis cum incontinentia pigmenti et alopecia 14: Moulage no. 14 is found twice in the collection of the Moulage Museum: the duplicate with the number 795/798 comes from the Dermatological Clinic Zurich. Both were produced in 1938 and show the findings of a child with a thinning of the skin, a blotchy, streaky inflammatory reaction of the entire skin and a simultaneous lack of hair (baldness, alopecia). As the moulage has its own number in the collection of the Eye Clinic, it can be assumed that the child also had an eye problem. Unfortunately, it has not yet been possible to find any further documentation or references to the medical history, so it is unclear what kind of presumably genetic syndrome was involved. However, it can be assumed that it was at least planned to present and discuss this case with the help of the moulages at both ophthalmologic and dermatologic scientific conferences. This would explain the existence of these two elaborately produced moulages.

Pterygium 13: Pterygium is a benign growth of the conjunctiva that increases from the side towards the cornea and can spread to it. It is not uncommon and occurs in about 2% of the population. It is assumed that chronic irritants such as dust, wind and UV radiation promote its development, which explains its prevalence among farmers and sailors. Depending on its severity, the pterygium causes a foreign body sensation, redness or visual disturbances if it grows into the cornea. It can be removed surgically, although radiotherapy is also possible.

Papilloma of the cornea 12: Papillomas on the conjunctiva or cornea are growths that are usually caused by human papilloma viruses (HPV), i.e. warts. They occur more frequently on the skin (fingers, feet) or after infection by special types in the genital area (condylomas, see also showcase 30), but also occur on the eye. They are harmless, usually asymptomatic but cosmetically unpleasant growths that can be easily removed surgically, nowadays mainly by laser. A skin sample (biopsy) for examination under the microscope can be useful to exclude the beginnings of cancer (see also showcase 20).

Randphlyctaene 15 (marginal phlyctaenes): Phlyctaenes are small, yellowish, slightly raised blisters and superficial lesions of the conjunctiva at the edge of the cornea (limbus corneae). They are a typical sign of keratoconjunctivitis phlyctaenulosa, an inflammation of the cornea and conjunctiva as an allergic hypersensitivity reaction to bacterial or viral pathogen antigens. It is not the infection itself, but an immune reaction triggered by an infection that causes the lesions. The disease progresses even after the actual infection has healed and, if severe, can lead to corneal complications with visual disorders. At the time this moulage was produced, there was no effective local therapy. Today, anti-inflammatory treatment is possible with cortisone or cyclosporine.

Blue sclera 37: There are various reasons why the normally white sclera (sclera) of the eye appears bluish. This is normal in infants because the underlying blood vessels show through the very thin sclera. The bluish discoloration can also be caused by medication or inflammation. It has been described in numerous hereditary diseases and syndromes and is very typical in most forms of osteogenesis imperfecta, a congenital disorder of collagen production with increased bone fragility. We do not know if the child presented here had any other symptoms of a syndrome or if any were recognized.

Spring catarrh and follicular catarrh, Moulage No. 19 and No. 16: In so-called follicular conjunctivitis, there is an enlargement and inflammation of the lymph follicles (accumulation of immune cells) on the inside of the eyelids, which gives a “cobblestone-like” appearance. It is the result of chronic irritation, e.g. due to an allergy or nowadays due to contact lenses or an intolerance to eye drops. It can also be caused by an infection with viruses or special bacteria (chlamydia) (see also showcase 22). The word “catarrh”, which is rarely used today, refers to an inflammation of the mucous membrane with increased secretion of a watery or mucous secretion.

Scleral staphyloma: The Greek word staphyle means grape. A staphyloma is a “berry-shaped” protrusion of the middle eye skin (uvea) at a thinned area of the sclera (sclera) or cornea (cornea). It can occur congenitally, with severe short-sightedness or as a result of an injury or infection. The dark color is explained by the pigmented choroid shining through from the inside of the eyeball.

Hordeolum 23: Hordeolum (stye) is an acute inflammation with pain, redness and swelling of the sebaceous glands inside the eyelid margin or in the eyelash area, caused by bacteria (often staphylococci). The infection usually heals on its own and can also be treated with heat (red light) and nowadays with disinfectant or antibiotic eye creams. Hordeolum is sometimes confused with chalazion (hailstone). In contrast to hordeolum, however, a chalazion is less red and not painful. It is a slowly developing swelling and inflammation caused by a blocked sebaceous gland and can also occur following a hordeolum.

Legend 

Sample box with over 200 artificial glass eyes
Manufacturer: Schoen Oculariste, Lausanne/Geneva ca. 1880-1900

The artificial eye manufactory was founded by the Schoen family in Lausanne and later continued in Geneva. Ophthalmologists in various Swiss cities used the sample cassettes as “depots” or “branches” of the Schoen company in their daily practice. The doctors fitted the patients with suitable artificial eyes and the boxes were refilled by Schoen Oculariste. If a patient had to have an artificial eye replaced, this or fragments of it were sent to Schoen so that a suitable replacement artificial eye could be produced.
The sample cassette shown here belonged to the Zurich ophthalmologist Prof. Otto Haab (see display case 19), through whom a total of six sample cassettes ended up in the Medical Collection of the University of Zurich.

MHSZ 8533.1, loan from the Medical Collection, Institute of Evolutionary Medicine (IEM), University of Zurich.

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https://www.delcampe.net/de/

Infections of the external eye

In addition to the surrounding skin, the other structures of the external eye can also be infected by bacteria, viruses and, rarely, fungi. Infection of the sebaceous glands on the eyelids is not uncommon (Hordeolum, Moulage No. 23, showcase 21). Sometimes the inside of the eyelids, the conjunctiva and the lacrimal sac are also affected. Infections of the cornea can lead to visual problems due to scarring or, if the infection breaks through into the anterior chamber of the eye, to loss of the eye. Bacterial infections could only be successfully treated with the use of antibiotics (sulfanomides in the 1930s, penicillin in 1945, antibiotics against tuberculosis after 1947). Today, damage to the cornea can be cured with a corneal transplant. Attempts to transplant the cornea led to severe inflammation and death of the transplant at the time the moulages were produced.

Conjunctivitis tuberculosa Parinaud, moulage no. 38: Moulage no. 38 shows an inflammation of the conjunctiva in the case of tuberculosis. At first glance, one is amazed at the elaborately produced moulage of half the young patient's face with the “hovering” finger, which pulls down the lower eyelid and makes the conjunctivitis visible. Swelling on the cheek in front of the ear and a blurred jawline with a swelling under the jaw are then noticeable.

Parinaud's disease is an infection of the eye with unilateral conjunctivitis in combination with swelling of the lymph nodes in front of the ear and under the jaw. This is typically seen in tularemia (rabbit plague) transmitted from animals to humans and was previously also a symptom of syphilis or tuberculosis, as in this case.

Ulcus serpens hypopyonkeratitis, moulage no. 14: Ulcus serpens is a painful ulcer that spreads rapidly to the intact cornea. It is caused by a bacterial infection and leads to redness and a hypopyon. The hypopyon is an accumulation of pus in the anterior chamber of the eye, i.e. in the space between the cornea and the iris or lens. A hypopyon is recognizable as a discrete whitish fluid formation at the lower edge behind the cornea in front of the iris.

The rapidly spreading ulcer can lead to a hole (perforation) in the cornea and loss of the eye. Today's effective therapies, antibiotics as drops and for oral use, and rapid corneal transplantation in the event of perforation, were not yet possible at the time this moulage was made.

Trachoma, moulage no. 17: This is a follicular conjunctivitis (see also moulages 16 and 19 in showcase 20). In the moulage, the inflammatory enlarged lymph follicles on the inside of the eye are shown by lifting the eyelid. In chronic cases, trachoma can lead to scarring of the conjunctiva with inward growth of the eyelashes (trichiasis) and corneal opacity and blindness caused by scratching of the eyelashes. This inflammation is caused by an infection with the bacterium Chlamydia trachomatis and is still the most common cause of blindness worldwide.

Trichophytia with trichophytid and conjunctivitis, Moulage No. 198: In the Dermatological Clinic of Zurich, Bruno Bloch and his colleagues researched immunological hypersensitivity reactions to fungal infections, so-called mycides or trichophytides (see also showcase 3). Numerous cases of allergic skin reactions triggered by fungal infections were documented and published using moulages. Moulage 198 shows an allergic reaction of the conjunctiva of the eye on a boy with a fungal infection of the scalp (Kerion celsi, see also showcase 10). There are also moulages of the knee and flank from the same patient, showing an allergic rash on the whole body.

Measles, moulage no. 55: Infection with the measles virus leads to a second rise of fever about two weeks after a phase of fever, abdominal pain, photophobia and inflammation of the oral mucosa, combined with the typical rash also shown in showcase 24. The disease can also cause irritation of the conjunctiva with redness, which in rare cases can lead to long-term scarring and even blindness.

Measles is feared especially because of its complications. In around 50 out of 1000 cases, a sometimes very severe middle ear or lung infection develops and in one out of 1000 cases there is an inflammation of the brain with the risk of permanent brain damage. Occasionally, measles complications lead to death. Like the diphtheria bacterium (see below), the measles virus only occurs in humans and could be eradicated if the population were consistently vaccinated.

Tuberculous lacrimal sac, moulage no. 39: The pathogen causing tuberculosis, Mycobacterium tuberulosis, can affect any organ, see also showcase 12. Moulage no. 39 shows a child with a scrofuloderm, an infestation of the cervical lymph nodes with breaking through purulent fistulas and a purulent infestation of the lacrimal sac (dacryocystitis).

Other bacteria, most commonly staphylococci, can also lead to dacryocystitis. The cause is often a drainage disorder in the tear duct, which leads to colonization of the lacrimal sac by bacteria.

In everyday language, a “lacrimal sac” refers to a cosmetically disturbing swelling in the area of the lower eyelid. The anatomical lacrimal sac referred to here is located between the inner corner of the eye and the nose. It collects the tear fluid via two small tear ducts, which have their entrance at the lacrimal puncta on the upper and lower eyelid in the medial corner of the eye and directs it through the nasolacrimal duct into the nasal cavity.

Conjunctivitis diphtherica: Infection with the corynebacterium dipththeriae can also lead to this severe form of conjunctivitis, with heavy suppuration of the eye and deep ulcers on the affected inner side of the eyelids.

The symptoms of diphtheria are caused by a toxin produced by the bacterium. Depending on the location of the infection, there is inflammation of the affected skin or mucous membrane, most commonly the throat with a whitish coating, severe swelling of the lymph nodes and the risk of asphyxiation due to massive swelling of the airways. If the toxin spreads throughout the body, there is a risk of dangerous complications with inflammation of the heart muscle, pneumonia and nerve paralysis.

Diphtheria has become very rare in industrialized countries thanks to vaccination prophylaxis, which is given in combination with tetanus and whooping cough (DiTePer). The bacterium is only found in humans and is only transmitted directly from person to person. It could therefore be completely eradicated with consistent immunization of the population. Unfortunately, the immunization rate is decreasing - it is 85% among adults in Switzerland and only 50% in Germany - and smaller epidemics occur from time to time.

Carcinoma of the lower eyelid, moulage no. 3: For skin cancer of the eye, see showcase 20.

Protrusio bulbi, moulage 28: Protrusio bulbi, the protrusion of the eyeball out of the eye socket, is also known as exophthalmos, goggle eye or, in common language, ‘glub eye’. It is a symptom of various diseases that push the eyeball forwards due to tissue proliferation in the eye socket. This results in a widened palpebral fissure and the eye appears ‘torn open’. 

Exophthalmos must always be clarified. In metabolic diseases, e.g. of the thyroid gland, this occurs symmetrically in both eyes. A unilateral protrusio bulbi without visible signs of inflammation, as in this patient, indicates a growing tumour behind the eye. Infections, thromboses and haemorrhages after injuries can be other reasons for swelling in the depth of the eye socket.

The shell eye and the ‘reform eye’

In the middle of the 19th century, enucleation (surgical removal of the eyeball) became more common. The thin-walled artificial shell eye was mainly used to cover a blind eye but could not replace the missing volume in the eye socket after enucleation. The Utrecht doctor Herman Snellen Sr (1834-1908) contacted the company F. Ad. Müller Söhne in Wiesbaden with the idea of a more voluminous artificial eye, which could be adapted to the back of the eye socket and the remaining muscles. At the end of the 19th century, the company developed the so-called ‘reform eyes’ or Snellen eyes. These were double-walled, hollow and therefore light and comfortable to wear artificial eyes made of glass with rounded edges. They were adopted by many ocularists and temporarily replaced the shell eyes.

Today, thanks to improved surgical possibilities with preservation of the eye muscles and the use of orbital implants, both reform and shell eyes are being used again and the prostheses show a natural movement.

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Illustration of a shell eye, above, and a ‘reform eye’, below.
Illustrations in: Coulomb, R. (1905).
l'ŒIL ARTIFICIEL. Paris: J.-B. Baillière et fils. P. 37f.

 

 

Computer tomographic examinations of moulages no. 3 and 28

X-ray examinations using computer tomography (CT) allow a view into the interior of the moulages. Due to the different radiation-attenuating properties of wax and glass, the artificial eyes are clearly visible. Moulages no. 3 and 28 contain artificial eyes that have the shape of prostheses and can be identified in cross-section as double-walled hollow bodies. These are presumably so-called ‘reform eyes’. The artificial eyes were fixed in the moulage mainly with liquid wax.

In addition to the artificial eyes, the CT images also show how the moulages were fixed to the wooden boards with nails and screws.

CT: Institute of Forensic Medicine of the University of Zurich

The history of the manufacture of glass eye prostheses

The history of the artificial eye dates back to the 3rd millennium BC. Artificial eyes were made in ancient Egypt, Greece, Rome and China from various materials such as ivory, metals and precious stones as grave jewelry, for masks, mummies, puppets and statues of gods and heroes.

The use of artificial eyes as prostheses in a medical context has been documented particularly since the Renaissance. The renowned French military surgeon Ambroise Paré (1510-1590) described two different types of artificial eyes:
- The prosthetic eye, l'ecbléphara, an eye painted on leather to cover the diseased or missing eye, similar to an eye patch.
- The inlay eye, l'hypobléphara, a cup-shaped eye that is inserted behind the eyelids. It is still used today in a similar version made of glass.
In Paré's time, the inlay or cup eye was made of enameled metal and was therefore heavy and uncomfortable to wear. From the end of the 16th century, the artificial eye made of glass was developed. One key to this was the production of colored glass on Murano near Venice.

In France and Germany, the production of artificial eyes made of glass for prosthetics, the manufacture of dolls and taxidermy was promoted. At the beginning of the 19th century, Paris was regarded as the centre of glass or enamel eye prosthetics. The French ocular prosthetist Auguste Boissonneau (1802-1883) introduced the professional title ‘ocularist’, which is still used today.
From the 1830s onwards, the glassblower Ludwig Müller-Uri (1811-1888) in Lauscha, Germany, revolutionized the manufacture of glass prostheses. Among other things, he developed a new technique to create the colored iris and found a substitute for the lead-containing glass previously used. This caused skin irritation in patients and meant that the prostheses were less durable. With the development of cryolite glass in 1868, a material became available that had good processing properties, high resistance to tear fluid and fracture resistance and is still used today together with crystal glass.

In addition to an aesthetically pleasing and realistic result, the aim of fabricating eye prostheses from glass was to achieve a high level of wearing comfort. This was achieved by customizing the shape and size, the formation of a homogeneous tear film on the glass surface, good material compatibility and rounded prosthesis edges. In addition to the shell eye, the so-called ‘reform eye’ was developed in Lauscha in the second half of the 19th century (see showcase 22).

A glass eye prosthesis must be replaced with a new one approximately every 1-2 years. In the course of the development of ocular prostheses, various materials have been experimented with, e.g. semi-synthetic plastics such as celluloid. Whilst these have not become established, acrylic glass eye prostheses are now available.

The manufacturing of wax moulages with artificial glass eyes

Artificial eyes made of glass were used in wax moulages for several reasons. If the aim is to show a disease of the external eye or the area around the eye, an artificial eye allows a true-to-life copy of the real findings. If only one eye is affected by the disease, the representation of the healthy eye serves as a comparison. Open eyes contribute significantly to a lively and individualized facial expression. This reinforces the impression of real patients and makes it easier to understand the medical case. In the Zurich moulage collection, children's faces are often provided with glass eyes, even if there are no ophthalmological findings (see the example of the ‘carrot nose’ in showcase 19).

Based on the examinations of the moulages, it can be assumed that the artificial eyes were made by ocularists from an ophthalmic prosthetics workshop who worked for the Eye Clinic.

The medical wax moulage is made using a plaster cast of the diseased person. It is not possible to make such an impression on an open eye. To produce the plaster negative, the model therefore closes the eyes and the eye opening is later modelled by hand in the wax positive. Pathological changes in the skin around the eye are precisely transferred to the wax moulage via the plaster. The components of the wax mass and the colors chosen for painting the wax surface correspond in principle to the moulage technique used in Zurich (see showcase 16).

Disease findings on the eye (e.g. on the cornea) can be made directly from glass during the production of the artificial eye. In the Zurich collection, however, the findings were mostly applied to the surface of the finished glass eyes using waxes, resins and colors. This could be done before and/or after inserting the artificial eyes into the wax moulage.

To complete the realistic appearance, eyelashes and eyebrows are recreated. For eyebrows, individual real hairs are either stitched in or strands of hair are attached to the wax surface over the entire length of the brow. To create the upper and lower lash line, eyelash bands are often used; thin paper or textile strips with glued-on eyelash hairs.

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Manufacture of eyelash bands.
Illustration in: L. Gatineau. (ca. 1922). La céroplastique. 
Manuel à l'usage des dermatologistes et chirurgiens- dentistes. 
Paris: C. Ash, Sons & Co. p. 70.

 

 Manufacturing process of a wax moulage with artificial eye

 

1.  Creating the negative mould
   • Taking an impression of the closed eye with plaster mixed in water.
   • Preparation: Protect the eyebrows and eyelashes with a release agent.
2. Casting the raw moulage

   • Casting wax into the negative plaster mould. The wax mass is colored in advance with oil paints in the lightest shade of the skin.

   • Cleaning and repairing the raw moulage.

3. Creating the eye opening and findings

   • Cutting and modelling of the eye-opening incl. upper and lower eyelid with heated tools.

   • Painting the glass surface with the findings (corneal inflammation). Shaping of fine blood vessels with wool threads.

   • Creating the eyelash bands.

4. Finishing the moulage
   • Fixing the glass eye to the back of the moulage. 
   • Processing the transitions from the lids to the glass eye.
   • Attaching the eyelash bands and stitching in the eyebrows.
   • Painting the wax surface with oil colors. 
   • Framing and labelling the moulage.
      

The manufacture of artificial eyes made of glass

The production of glass eye prostheses requires many years of training and a high level of expertise and craftsmanship. An artificial eye should anatomically accurately represent the various parts of the eye such as the sclera, iris, pupil, transparent anterior chamber and cornea and be customized as a prosthesis.

In the course of the development of the artificial eye made of glass, a wide variety of techniques and materials have been used. Certain manufacturing methods and material compositions are difficult to trace today, as ocularists liked to keep their techniques a professional secret.

Basically, the production of an artificial eye made of glass involved the following steps:

• Eyeball: A ball is blown out of a white glass tube. One end of the tube remains intact for the time being and serves as a handle.
• Iris and pupil: Various manufacturing techniques are possible: The separately manufactured iris and pupil are placed in a prefabricated hole in the base of the sphere (typical of the French glass eye) or melted directly onto the prefabricated sphere (technique from Lauscha). A glass stamp designed in the colors of the iris can be used for this or the iris can be ‘painted’ directly onto the sphere which has been coated with a base color. Glass rods, so-called drawing rods, previously made in the colors of the iris are used for this purpose. The pupil is made of black glass and placed in the center of the iris.
• Anterior eye chamber and cornea: Transparent glass is fused over the iris and pupil.
• Sclera: The color of the sclera (the white of the eye) is reproduced with greyish blue to yellowish glass. Threads of red glass are used to create the fine blood vessels.
• Adaptation of the shape: The bowl-shaped eye is separated from the glass sphere in the required shape. The surfaces and edges of the prosthesis are melted smooth in the flame so that the mucous membranes are not irritated when the prosthesis is worn.

The technique of artificial eye production developed in Lauscha, Thüringen, still exists today. Workshops in Switzerland also refer to it.

 

BILD

 

Illustration of a. sclera, b. cornea, c. anterior chamber, d. pupil and e. iris.

Illustration in: Wettlaufer, C. (1893). Artificial eyes. 
In: Köner, A. [ed.] The Garden Arbour. Issue 25, 1893, Leipzig: Ernst Keil (Gr.). S. 474.

 

Legends

• Working materials from the Schoen Oculariste workshop
  Manufacturer/user: Schoen Oculariste, Lausanne/Geneva ca. 1880-1900
  
  Raw materials and accessories for the production of glass eyes from the Arthur Schoen workshop. Contents: various glass rods in different colors; 1 round metal box with lid with Schoen's maker's mark; fragments of glass artificial eyes; hollow artificial eyes (blanks) on a stem.
  
  MHSZ 8533.2, loan from the Medical Collection, Institute for Evolutionary Medicine (IEM), University of Zurich.
• Sample cassette with artificial glass eyes
  Manufacturer: F. Ad. Müller Soehne, factory of artificial eyes, Wiesbaden, late 19th century.
  
  MHSZ 3843, loan from the Medical Collection, Institute for Evolutionary Medicine (IEM), University of Zurich.

 

Viral Infectious Diseases

Measles (Morbilli)
Catalogue p. 13

The typical rash appears three days after the initial fever and cold symptoms. Lung- and middle ear inflammation (pneumonia and otitis media) are common complications. A feared, but fortunately rare complication is the accompanying encephalitis. The measles virus only exists in humans and could be eradicated by consistent vaccination. 

Moulage 403-3
Typical spotty measles rash about two weeks after infection.

Herpes simplex
Catalogue p. 16

The herpes simplex virus (HSV) infests the skin and the nerve tissue. When transmitted via the mouth cavity, the virus causes the so-called “Fieberbläschen” (engl. fever blister). When sexually transmitted, however, the infection presents itself with redness and blisters in the genital region. The virus remains in the nerval ganglion and the disease can break out repeatedly. 

Moulage 73
“Fever blister” on the upper lip. 

Wart (Verruca vulgaris)
Catalogue p. 17

The verruca viruses cause a benign, tumor-like thickening of the epidermis.

Moulage 1478
Verrucae occur most frequently on body parts that are mechanically stressed or poorly supplied with blood (fingers, soles of the feet).

Water Warts (Molluscum contagiosum)
Catalogue p. 16

Moulage 1308
Water warts are highly contagious. Particularly affected are children between the age of 3 and 10. 

Chickenpox (Varicella)
Catalogue p. 14

Chickenpox, induced by the Varicella-Zoster-Virus (VZV), is one of the most common infectious diseases. 95% of humans have gone through this disease by the age of 15.

Moulage 15/16
About two weeks after the droplet infection, small papulae appear on the skin and mucosae, evolving into blisters. In adults, an subsequent infection of the lungs and the meninges can be life-threatening.

Shingles (Herpes zoster)
Catalogue p. 15

After the healing of the chickenpox, the “sleeping” virus remains inactive in the nerve cells. When reactivated, it travels along the nerves and into the skin, producing shingles. The inflammation of the nerves can cause sharp or burning pain.

Moulages 15-16
Herpes zoster in the area of the abdominal wall with a belt-like pattern. Beside it, so-called aberrant blisters on the entire body. 

Additional moulages on viral skin diseases in showcase 47 on the left. 

Bacterial Infectious Diseases  

Borreliosis (Lyme disease)
Catalogue p. 18

Not only can ticks transmit the Early Summer Meningoencephalitis (ESME) by their bite, but also the bacterium Borrelia burgdorferi. This infection (Borreliosis, Lyme disease) can be treated with antibiotics, however, there exists no vaccination as in the case of ESME.

Moulage 1252
Days or weeks after the infection, a rash will spread annularly: the Erythema migrans. 

Moulage 396
In early stages, swelling or lumps (pseudolymphocytoma) may appear on the skin, typically located on the earlobe or on the nipple. 

Moulage BS 18 
On the skin the chronic infection leads to acrodermatitis chronica atrophicans, an inflammation with swelling, pain and eventual atrophy. 

Moulage 181
Sometimes fibrinoid nodes may occur in close proximity to joints. 

Erysipelas 
Catalogue p. 19 

Bacteria, usually streptococci or staphylococci, can enter the skin through injuries and will subsequently spread. The following extensive inflammation brings with it the danger of sepsis. 

In the past, only an amputation of the affected limb well in advance could save the patient from a fatal sepsis. Nowadays, in addition to immobilisation, the use of antibiotics at an early stage is of prime importance.

Moulage 1331
Erysipelas on the thigh. 

Moulage 1079
Erysipelas with participation of the eye with the danger of dissemination along the veins into the brain.

Folliculitis
Catalogue p. 20

Moulage 712
The bacterium Staphylococcus aureus can cause particularly purulent inflammations of the hair root (follicle).  

Moulage 722
Sycosis, also termed barber’s itch, resembles a sliced fig (gr. sykon = fig). Bacteria, fungi or, more infrequently, herpes viruses can be possible pathogens. 

Furuncle, Carbuncle
Catalogue p. 20

A folliculitis with heavy inflammation and necrosis may result in a painful abscess. 

Moulage 1244
Furuncle on the upper lip. 

Moulage 434
Erysipelas in the face with formation of a furuncle. 

Impetigo
Catalogue p. 21

If the skin gets injured by an eczema or by scratching, staphylococci or streptococci can enter and trigger a blistery and scabby inflammation – especially in children. 

Moulage 738
Impetigo

Moulage K8
Impetiginized atopic eczema (neurodermatitis), superinfected with bacteria.

Staphylococcal Scalded Skin Syndrome (SSSS)
Catalogue p. 22

Certain groups of the bacterium Staphylococcus aureus produce a toxin, which disrupts the linkage between the horny cells (corneocytes) of the skin. Such an infection can lead to an extended flush, and superficial blisters with the destruction of the protecting epidermis in a very short time, especially in infants. Without treatment, this disease is fatal in up to half of the cases. 

Moulage 606
Staphylococcal Scalded Skin Syndrome, lethal outcome.

Lepra
Catalogue p. 21

The chronic infection with the Mycobacterium Leprae can lead to heavy mutilation. The disease can be transmitted from human to human, but is only mildly contagious. 

Depending on the patient’s immune response, an infection can evolve very diversely: from mere skin changes to severe damages of the nerves, skin and other organs. By taking antibiotics for several months, lepra can be cured.

Moulage 1347 and 1370
Infectious type of lepra with a weak immune response and poor prognosis.

Additional moulages on bacterial skin diseases in showcase 47, left side.

Fungal Infections (Mycosis)

Fungal infections can cause different inflammatory reactions on the skin. Therefore, the presence of the fungus inside the lesion is essential for the diagnosis. Skin scales, nail material or hair can be checked directly under the microscope for fungi, and the pathogens are cultivated for further classification. 

Dermatophytosis
Catalogue p. 24

Diseases caused by hyphomycetes (dermatophytes, trichophytes) nowadays are also termed tinea. 

Moulage 1332
Tinea corporis: The fungus is often transmitted from the feet to the rest of the body. 

Moulage 1127
Folliculitis: Fungi can also affect the hair and the hair root. 

Moulage 1178 and 1170
Fungal infection of the nails. However, inflammatory diseases like psoriasis can lead to exactly the same nail alterations. For diagnosis, the presence of the fungus has to be proven under a microscope or in a culture.

Candidoses (Thrush, Candidiasis) 
Catalogue p. 24

The yeast fungus Candida albicans can not only be found on the mucosa of a sick person, but also in healthy people. Treatment is only necessary in case of an inflammation or immune deficiency.

Moulage 172
Candidoses can occur on humid, stressed skin parts, typically in skin folds and between the fingers. 

Tinea Versicolor
Catalogue p. 23

The yeast fungus Malassezia furfur can be found on greasy skin areas in many people, especially on the scalp. If the fungus proliferates, as a result of heavy sweating, it can cause a slight inflammation. 

Moulage 1204
On fair skin, brownish spots with a fine, branny poudery (pityriasiform) scaling may occur. 

Moulage 1393
As the fungus produces the bleaching azelaic acid, the spots appear brighter on tanned skin. 

Additional moulages on fungal infections in showcases 3, 10 and 11 and in showcase 47, left side. 

Tinea Pedis (athlete’s foot, foot fungus)
Catalogue p. 24

Roughly a third of the people in Europe have an athlete’s foot. Humid feet as a result of contemporary footwear as well as bad blood circulation increase the risk. 

Moulage 193 (showcase 27 above on the right)
The best-known form is the interdigital type with macerated skin and fissures between the fourth and fifth toe. 

Moulage 1055
Hyperkeratotic foot fungus at the sole. Without proof of the fungus, the symptoms cannot be told apart from an eczema or psoriasis. 

Moulage 233
In rare cases, a foot fungus infection can cause blisters. 

Parasites

Leishmaniasis
Catalogue p. 26

In tropical areas, the sand fly transmits Leishmania from rodents and dogs. Depending on the type of parasite and the immune state of the infected person, the infection remains limited to a spot on the skin or else spreads, sometimes affecting inner organs. 

Moulage 380
Local infection with a small, encrusted ulceration.

Moulage 1487
Other forms lead to various weeping skin changes, or to diffuse lumps. 

Lice (Pediculosis capitis et pubis)
Catalogue p. 26

Living on human beings are: the head louse, the clothes louse and the crab louse. Hereabouts, clothes lice are very rare. They can transmit pathogens of fever diseases. The head louse infests preferably children and people with long hair. At school, small epidemics occur at regular intervals. 

Moulage 747
After a few days, the stings evolve into red itchy papules and a scratched eczema as a reaction to the lice’s saliva.

Moulage 31
The small crab louse is transmitted by close body contact, usually sexual contact. The lice stings evolve into small, bluish bleedings (Tâches bleues). 

Scabies
Catalogue p. 27

The itch mite lives only in the human horny skin. It is transmitted by close body contact or through clothes and bedding. The strongly itchy rush is caused by a hypersensitivity reaction to the mite or its faeces. 

Typical locations are the folds between fingers and toes (Moulages 1450 and 728), the wrists, the penis shaft in men and the entire body (Moulage K42) as well as palms and soles in infants. 

Bedbugs (Cimicosis)

Moulage 155
The bedbug lives in old wood and visits and bites human beings during the night. 

Additional moulages on parasites on the skin in showcase 47, right side. 

Sexually Transmitted Infections (STI)  

When the medical speciality of skin diseases was established in the 19th century, sexually transmitted syphilis was very common. In advanced stages, its skin symptoms can imitate almost every skin disease. Therefore, profound dermatological knowledge was necessary for the clinical assessment of syphilis, and STIs still demand a dermatologist’s expertise today. 

The teaching of STIs is also termed venereology, derived from the name of Venus, the goddess of love. 

Syphilis (Lues)
Catalogue p. 39 

The pathogen of syphilis is the bacterium Treponema pallidum, which is sensitive to penicillin. After the introduction of penicillin in Switzerland in 1946, both incidence and severity of syphilis decreased rapidly. Nowadays, with the spread of HIV and a less consistent safe-sex prophylaxis, the infection rates are again increasing significantly. 

Primary stage, Lues I

Moulages “Dresden”, 460 and 495
Roughly three weeks after direct transmission, painless ulcerations (hard chancre) occur accompanied by swelling of the lymph nodes. 

Moulage 455
The ulceration can remain undetected, e.g. if located at the cervix. 

Moulage 602
In rare cases, the infection appears only as a hard, inflammatory swelling of the genital skin.

Secondary stage, Lues II

Moulages 700 and 463
After the healing of the primary stage, the infection slowly spreads throughout the entire body. Roughly three months later, a symptom-free, undulating rash occurs, which will eventually disappear, followed by a completely symptom-free phase. 

Moulage 487
A rash, which occurs symmetrically on both hands and feet, is typical for Lues II. 

Moulage 449
After the syphilitic inflammations have healed, pigment disorders may remain. The typical white, ring-like macules on the neck were formerly called “Necklace of Venus”.