December 2003

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Jules Gonin. Pioneer of Retinal Detachment Surgery

Thomas J Wolfensberger, MD, PD, MER

Before the turn of the 20th century, eyes with a retinal detachment were considered doomed. Contrary to other branches of ophthalmology, such as cataract extraction, the surgical treatment of retinal detachment was still in its infancy, and the surgical success rates were less than five percent. From 1902 to 1921 Jules Gonin almost single handedly changed the landscape of retinal detachment surgery forever. He recognised that the retinal break was the cause and not the consequence as it was largely believed at the time of the retinal detachment, and that the treatment had at all costs to comprise the closure of the break by cauterisation. He named the procedure ignipuncture, as he cauterised the retina through the sclera with a very hot pointed instrument. Despite rigorously detailed clinical observations and increasing success rates, his discovery was not readily accepted and sometimes openly opposed by a large part of the ophthalmic establishment. It was not until 1929 that he received worldwide acclaim at the International Ophthalmological Congress in Amsterdam for his surgical technique. His legacy lives on in the eye hospital in Lausanne that bears his name, in the Gonin Medal awarded by the International Council of Ophthalmology every four years for the highest achievement in ophthalmology, and in a street named after him, the very street that he used to walk from his home to the hospital every day. Key Words: Jules Gonin, retinal detachment, surgery, retinal break, ignipuncture, history, Lausanne Indian J Ophthalmol 2003;51:303-08

The importance of Jules Gonin in the development of modern retinal detachment surgery cannot be underestimated. Between 1902 and 1921 he developed his understanding of how retinal detachments formed and how they had to be effectively treated. The story of his life is an illustration of how an ophthalmologist persevered with his diligent studies for almost 20 years until his research bore its fruits.

Early years
Jules Gonin was born in Lausanne, the French part of Switzerland on 10 August 1870. In the 17th century, his ancestors had been forced to leave their native Piedmont in the north of Italy due to religious persecution. The young Jules grew up in a family where culture and religious faith were the pillars of communal, and his schooling at the local Lyce soon started to show his extraordinary talent for languages. He spoke French, Swiss German, and added Latin and Greek with little effort. He also studied English, Spanish and Italian and became proficient in all of them.1

In 1888 he enrolled in the College of Sciences and studied medicine at the University of Lausanne. He was very active in his fraternity called the Zofingia, and lobbied hard to abolish certain fencing rituals that were a part of the groups activities. After completing some research studies on butterflies, which earned him a distinction from the University, he entered the Institute of Pathology in Lausanne. After several travels around Europe during 1894-1895 to visit different hospitals in Paris, London, Berlin, Heidelberg, Vienna and Prague, he was drawn to ophthalmology. Dr. Marc Dufour, the director of the Eye Hospital in Lausanne at the time, offered him a post in 1896 to start his training. The Eye Hospital in Lausanne had started off as an asylum for the blind built in the first half of the 19th century (Figure 1). In 1873 a new hospital was erected next to it and it was only then that a proper eye department was opened with a permanent medical staff (Figure 2).

Hospital career at university of Lausanne

Gonin first worked in the outpatient clinics (Figure 3). Later he started several research projects covering such diverse topic as bacterial conjunctivitis, ocular tumours and hereditary retinopathies. He also developed a method to store enucleated globes in formol-hardened gelatine However, it was in 1902 that Dr. Dufour entrusted him with the writing of a chapter for the

Correspondence to Dr. Thomas J Wolfensberger, Jules Gonin Eye Hospital, 15, Av. de France 1004 Lausanne, Switzerland. E-mail: <thomas.wolfensberger@ophtal.vd.ch>

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1 2
Figure 1. Asylum for the blind in Lausanne built in the first half of the 19th century. This building was the first step to establish an eye clinic in Lausanne several years later. (From: Asile des Aveugles Lausanne, 1985); Figure 2. View of the new Eye Hospital which was built in 1873. This building was commissioned by the Foundation, which had put into place the asylum for the blind in the first place in 1843. (From: Asile des Aveugles, Lausanne, 1985); Figure 3. Examination of patients in the outpatient clinic of the Eye Hospital around 1900. Jules Gonin was then a junior doctor under Dr. Dufour, the chairman shown on the right in this photograph. (From: Asile des Aveugles Lausanne, 1985)

French Encyclopedia of Ophthalmology. This chapter dealt with the problem of retinal detachment. Gonins first publication covered the topic of the pathogenesis of spontaneous retinal detachment, which was studied in 3 enucleated eyes. At the International Congress in Lucerne in 1904 Gonin presented a paper on the role that the vitreous may have in traumatic retinal detachment. The fourth volume of the French Encyclopedia of Ophthalmology appeared in 1906,2 and Gonins contribution was particularly well received due to the many detailed drawings he submitted. Gonin even inserted the prophetic words in his chapter: In order to effectively fight a pathological process, we must know its nature and anatomic conditions. Only the study of pathogenesis of spontaneous detachment, based on facts and not on hypotheses, will make it possible to find the treatment of this disease.1 In 1903, at the age of 33, Gonin was promoted to Privat-Docent, which implied considerable teaching commitments. In 1908 he was one of co-founders of the Swiss Ophthalmological Society, and he also became its first

president. During the time between 1903 and 1918 Gonin continued his studies on the pathogenesis and the treatment of retinal detachment with perseverance, and he published several papers.2,3 In 1918 Jules Gonin was selected as the director of the Eye Hospital in Lausanne, and two years later, in 1920, he was appointed Professor of Ophthalmology at the University of Lausanne.

Development of the Ignipuncture

The promotion to chairman of the Eye Hospital and to the professorship gave Gonin a new burst of energy to continue his research. Between 1919 and 1934 he published 40 papers which all dealt either with the pathogenesis of retinal detachment, or with the surgical treatment and its results.4,5 The key papers were read at the annual meetings of the Swiss, French or German Ophthalmological Societies. Gonin had realised, that the hole in the retina was not a consequence of the retinal detachment, but that it was in fact the origin of the detachment (Figure 4). He also rightly concluded that the retinal detachment could only be treated if the retinal break was closed. To this end he developed the therapy that would become his trademark: the ignipuncture (Figure 5).

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6a

6b

Figure 4. Drawing by Jules Gonin explaining the tractional forces on the retinal break induced by the posterior vitreous. (Drawing taken from J. Gonin: Le dcollement de rtine 1934, Payot, Lausanne); Figure 5. Illustration of the ignipuncture procedure. After having localised the break and incised the conjunctiva in that area, the surgeon pierces the sclera with the Graefe knife and then applies the curved thermocauter, which had been heated white, to the retinal break through the small sclerotomy. (Drawing taken from J. Gonin: Le dcollement de rtine 1934, Payot, Lausanne); Figure 6a. Drawing of retinal detachment in a left eye with a single break in the superonasal quadrant (Drawing taken from J. Gonin: Le dcollement de rtine 1934, Payot, Lausanne); Figure 6b. The same eye after ignipuncture. The retina is completely attached and a chorioretinal scar is present around the retinal break. (Drawing taken from J. Gonin: Le dcollement de rtine 1934, Payot, Lausanne)

This treatment consisted of localising the retinal break with direct ophthalmoscopy. Gonin then ordered bedrest with both eyes patched in a position favourable to the resorption of subretinal fluid. As soon as repeated examination showed that the subretinal fluid had resolved, Gonin estimated in disc diameters the distance from the tear to the ora serrata and converted it into milimeters of distance from the limbus. After having incised the conjunctiva in that area, he marked the site of the break on the sclera. He injected novocaine into the subconjuntival space, pierced the sclera with the Graefe knife and then applied the curved thermocauter,

which had been brought to white heat, to the retinal break through the small sclerotomy. At that time subretinal fluid drainage often occured. The cauterisation induced a chorioretinal scar where it was applied and help to closure of the retinal break (Figures a & b). The conjunctiva was then sutured. The patient was subsequently returned to bed with binocluar patching, and the head was put in such a position that the retinal break was at the lowest point allowing further subretinal fluid absorption. Patients were usually bed-bound in this strict position for at least a week.

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7b

7a

8b
Figure 7a. Photograph of Jules Gonin taken by de Jongh in the 1920s. (From: Asile des Aveugles: La prennit dune vocation Lausanne, 1993); b. Drawing of Jules Gonin by a colleague in Lausanne in later years. (From: Asile des Aveugles Lausanne, 1985); Figure 8a. Examination room at the Eye Hospital in the mid 1930ies, where patients were seen every day of the week including on saturday. (From: Asile des Aveugles: La prennit dune vocation Lausanne, 1993); 8b. Jules Gonin leaves the hospital after finishing his consultation in the evening. This picture was taken in the last few years of his life. (From: Asile des Aveugles: La prennit dune vocation Lausanne, 1993)

8a

In 1913 Gonin managed for the first time to treat a traumatic retinal detachment using the procedure with ignipuncture,6 and in 1916, he repeats the same feat in an idiopathic retinal detachment. In 1923 Gonin began to speak about his results at ophthalmic meetings.7 With his new cure he could increase the success rate from 1% to 30-40%. Despite his clear results his colleagues were scepctical. You have not convinced anyone was the reaction of Professor Gabriel Sourdille, another eminent retinal surgeon, whose technique to operate retinal detachments was to make deliberate holes in the sclera and the retina followed by the instillation of weak mercuric cyanide solution around the sclerotomy sites.1

It was not until 1929 that he received worldwide recognition at the International Ophthalmological Congress in Amsterdam for his surgical technique. Recognition from his home country came with the Benot Prize, the highest scientific honour in Switzerland. Jules Gonins ideas of clinic management were that his associates should enjoy complete freedom in how to run their day-to-day clinical and surgical duties. The only obligation of his associates was to lend him their patients for his lectures. Thus the management of cataract patients, as an example was very different. It depended purely under which associates the patient

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Figure 9. The title page of Jules Gonins monograph on retinal detachment calledLe dcollement de rtine. The book was published in French by the local publishing house Payot in Lausanne one year before his death in 1934, (From J. Gonin: Le dcollement de rtine 1934, Payot, Lausanne); Figure 10. The original joint declaration by the University of Lausanne and the Swiss Ophthalmological Society in 1937 to establish the Gonin Medal to honour the individual who has contributed the most to ophthalmology. The International Council of Ophthalmology awards this medal every four years. (From: Asile des Aveugles Lausanne, 1985)

was admitted to hospital. Dr. Dufour preferred to do a sector iridectomy weeks before the cataract extraction, Jules Gonin preferred an extracapsular extraction with the iridectomy in the same sitting and Dr. Amsler preferred intracapsular extraction! Only the retinal detachment patients underwent the same surgical procedure by Gonin himself. He had no alphabetical file of his 38,000 patients but he would even get indignant if one of his patients forgot his code number from one visit to another1 (Figure 7). Although the clinical duties at the hospital commanded his wholehearted attention, Jules Gonin also found time to spend with his family. He was a very keen observer of the political scene in Switzerland. When proportional representation in the government was discussed, he and his father were strong supporters of it. He also advocated the vote for women as well as weighted votes; two votes for parents, and people with high school certificates, and non-commissioned officers, and three votes for parents of large families, officers or university graduates.1

Other personal pursuits included the study of the Arabic language and the collection of butterflies, an interest which never left him after his initial research on the metamorphosis of Lepidoptera during medical school. Gonin also loved to travel. Once he was taken for a spy in Greece and arrested. In Switzerland he travelled extensively on foot, and also loved mountain climbing, particularly if the path involved the crossing of glaciers.

Final years
Jules Gonins last few years of life were exceedingly exhausting. Apart from his normal daily work as chairman of the department, he was inundated with difficult cases from around Europe (Figure 8). Often these were patients with an only eye. In addition, he received innumerable visitors from all over the world who often made excessive demands on his time and energy. Once asked by a visitor where his laboratory was, Gonin replied, pointing at this forehead, Thats my lab. 1 Gonins wife died in 1932 when he was 62 years old, after a marriage that had lasted for 33

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years. This loss affected him greatly. Despite increasing weariness in his final years he decided to publish his book on retinal detachment surgery calledLe dcollement de la rtine(Figure 9) which he edited with the help of his daughter Gabrielle in 1934.8 Jules Gonin died unexpectedly in late May 1935. In his will he stipulated that a large part of his assets go the blind who had lost their sight late in life. The Nobel Prize Committee considered giving their award to Gonin. A questionnaire on Gonins work was sent to several ophthalmic authorities from around the world. All replied favourably, with one exception. This unfortunate decision persuaded the Nobel committee to postpone their decision on Gonins work for a year. It is

very likely that the prize would have been conferred to Gonin the year after, since the reasons for the opposition against him getting the prize were unsubstantiated. However, Gonins premature death prevented him from receiving the award.9 Today his name is carried into the future by the hospital that bears his name, and which functions as the University Eye Hospital in Lausanne. Furthermore, in 1937 the University of Lausanne established, with the help of the Swiss Ophthalmological Society, the Gonin Medal. This is awarded by the International Council of Ophthalmology every four years for the highest achievements in ophthalmology (Figure 10). Even a street is named after him in Lausanne, the very street that he used to walk from his home to the hospital every day.

References
1. 2. 3. 4. Rumpf J. Jules Gonin inventor of surgical treatment of retinal detachment. Surv Ophthalmol 1976;21:276-84. Gonin J. Dcollement rtinien. Encycl Fran Ophtalmol 1906;6:947-1025. Gonin J. La pathognie du dcollement spontan de la rtine. Ann Oculist, 1904;132:30-55. Gonin J. La thermoponction oblitrante des dchirures rtiniennes dans le dcollement de la rtine. Ann Oculist 1931;168:1-29. 5. Gonin J. Divergences of principles and differences of technics in the treatment of retinal detachment. Am J Ophthalmol 1934;17:74-79. Thilges V. Jules Gonin: Lhomme et son oeuvre. Ann Oculist 1970;203:631-37. Gonin J. Gurison opratoires de dcollements rtiniens. Rev Gn Ophtal 1923;37:337-40. Gonin J. Le dcollement de rtine. 1934, Lausanne: Payot. Arruga A. Little known aspects of Jules Gonins life. Doc Ophthalmol 1997;94:83-90.

6. 7. 8. 9.

Stories from stamps

Allvar Gullstrand (1862-1930) Vladimir Filatov (1875-1956) Jules Gonin (1870-1935)

Jules Gonin (1870-1935)

Courtesy: Samar K Basak, MD, DNB, Disha Eye Hospitals & Research Centre, Barrackpore, West Bengal-743 120, India. E-mail: <disha@cal2.vsnl.net.in>

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