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Opinion

When I use a word . . . . Counterfactual medical history: Milton’s blindness

BMJ 2022; 377 doi: https://doi.org/10.1136/bmj.o1441 (Published 13 June 2022) Cite this as: BMJ 2022;377:o1441
  1. Jeffrey K Aronson
  1. Centre for Evidence Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford
  1. Twitter @JKAronson

The cause of John Milton’s blindness has been widely discussed, based on his own account of his symptoms and a wide range of suppositions. No clear consensus has emerged. Candidates include glaucoma, retinal detachment, possibly in association with myopia, and a craniopharyngioma. No single diagnosis fits all the available information. Perhaps therefore, abandoning Occam’s razor, the primary diagnosis was complicated by comorbidities, such as posterior vitreous detachment.

A literary festival

The email came out of the blue: “Your interest in how modern medicine might have changed history has attracted our interest. We have in our village the only building still standing in which John Milton lived (albeit for a few months). So with his blindness and Charles II’s character and fate, we’d be fascinated as to what you might say with reference to that time.”

The villages of Chalfont St Giles and Jordans are in the county of Buckinghamshire, 20 miles from central London. The Chalfont St Giles and Jordans Literary Festival (https://www.chalfontstgilesliteraryfestival.org.uk), held biennially, was inaugurated in 2008, to celebrate the 400th anniversary of the birth of John Milton on 9 December 1608. This year’s speakers included David Crystal on the topic of conversation, David Starkey on Henry VIII’s wives, and Zandra Rhodes on fashion.

In 1665 Milton’s young friend Thomas Ellwood rented a cottage in Chalfont St Giles on Milton’s behalf, allowing him to flee the plague in London.1 The cottage is a small dwelling towards the east end of the village. It is now a museum, housing books, such as an edition of Paradise Lost with illustrations by William Blake, and portraits, among other material. The tiered gardens behind the cottage are stunning, and populated by many of the plants that Milton described in his poems.

I set myself three questions to answer in my talk at the festival: What caused Milton’s blindness? Could it have been treated if modern techniques had been available? If it had been prevented or mitigated would Milton’s poetry have been different? Here I tackle the first of these.

Milton’s blindness—the patient’s tale

For the most part, Milton’s many biographers say little or nothing about the clinical aspects of his blindness. However, the Milton scholar Eleanor Gertrude Brown (1887–1964), herself blind, wrote an extensive discussion of it, published in 1934, Milton’s Blindness.2

On 28 September 1654 Milton wrote a letter to his Athenian friend, the scholar Leonardos Philaras, in the course of which he described the symptoms he had experienced when starting to lose his sight about 10 years before. Philaras had suggested to him that a Parisian physician, Dr Thévenot, might be able to offer a diagnosis and treatment. “Thévenot” has not been traced, but may have been François Thévenin.3 In the event, nothing came of it. The version of Milton’s letter to Philaras that Eleanor Brown reports differs in minor details from versions that later authors have reported, but the substance is the same.

“It is some ten years,” Milton begins, “since I perceived my sight to grow weak and dim, finding at the same time my intestines afflicted with flatulence and oppression.” Whether this is relevant, it has been suggested that Milton may have associated his loss of sight with his diet.4 “Even in the morning, if I began as usual to read, my eyes immediately suffered pain, and seemed to shrink from reading, but, after some moderate bodily exercise, were refreshed; whenever I looked at a candle I saw a sort of iris around it. Not long afterwards, on the left side of my left eye … a darkness arose. …In the last three years … before my sight was utterly gone, all things that I could discern, though I moved not myself, appeared to fluctuate, now to the right, now to the left. Obstinate vapours seemed to have settled over my forehead and my temples, overwhelming my eyes with a sort of sleepy heaviness, especially after food, till the evening; … while I had some little light remaining, as soon as I went to bed, and reclined on either side, a copious light used to dart from my closed eyes; then as my sight grew daily less, darker colours seemed to burst forth with vehemence, and a kind of internal noise; but now, as if everything lucid were extinguished, blackness, either absolute or checkered, and interwoven as it were with ash-colour, is accustomed to pour itself on my eyes; yet the darkness perpetually before them, as well during the night as in the day, seems always approaching rather to white than to black, admitting, as the eye rolls, a minute portion of light as through a crevice.”

Other evidence

According to John Aubrey, Milton’s father did not need glasses when in his 80s, suggesting that he had been myopic in his youth, corrected by presbyopia in old age. Aubrey also tells us that Milton’s mother needed glasses in her 30s, but we do not know whether she was myopic or hypermetropic. Nor indeed do we know whether Milton was himself myopic, although in the Defensio Secunda of 1654 he wrote that “from twelve years of age … my eyes were naturally weak.” Myopia can be associated with glaucoma,5 retinal detachment,6 and macular degeneration.7

Milton is known to have had gout. Aubrey reported that he “died in a fit of the goute …[and]… had been long troubled with that disease.” Ocular complications of gout are uncommon, but tophaceous deposits in different parts of the eye have been reported, as have dry eye syndrome, red eye, uveitis, intraocular hypertension, glaucoma, and cataracts,8 as well as retinal abnormalities.9

In the 17th century disorders of the eye were sometimes described as either “gutta obscura” or “gutta serena,” literally “a dark drop” and “a clear drop” respectively. The former implied cataracts, the latter other disorders, generally described as “amaurosis.” In the Defensio Secunda, Milton wrote that “so little do [my eyes] betray any external appearance of injury, that they are as unclouded and bright as the eyes of those who most distinctly see.” And in Paradise Lost (Book 3, lines 22–26), addressing God, he wrote:

but thou
Revisit’st not these eyes, that roll in vain
To find thy piercing ray, and find no dawn;
So thick a
Drop Serene hath quenched their Orbs,
Or dim suffusion veil’d
.”

Milton did not have cataracts.

The diagnosis

Leaving aside theories such as the wrath of God, a Royalist theory that Milton himself rejected, albinism,1011 and congenital syphilis,12 there are three likely diagnoses: glaucoma, retinal detachment, and a suprasellar tumour. These have recently been discussed.13

Eleanor Brown quotes personal communications from several ophthalmologists who asserted that Milton had glaucoma, and others have supported that diagnosis,1415 although not all have agreed. Some have dismissed the diagnosis on the grounds that the most usual visual defect starts on the nasal side,16 although that is not always the case. It has also been objected that most cases of glaucoma occur after the age of 4017 and Milton was only 36 at the time of onset; however, young cases can occur.18 It would also be unusual for glaucoma to be associated with haloes. However, acute closed-angle glaucoma is associated with pain, which Milton described early in the disease, brought on by reading in the morning and relieved by exercise; perhaps he had acute attacks when reading in poor light, relieved by taking a walk outside in the brighter light. Later, pain would not have been a problem as the condition became chronic.

Retinal detachment has also had its proponents1719 and was suggested as early as 1909 by the Swiss ophthalmologist Marc Dufour.20 He based his diagnosis on Milton’s dimming of vision, with “vapours” over the forehead and temples, unclear though that description is, and the light sensations that Milton experienced. However, the typical symptom is of a veil descending or ascending over the field of vision, which is not really what Milton described. When retinal detachment is associated with myopia, the myopia is typically severe.

In 1936 and again in 1949 Lambert Rogers suggested that Milton’s blindness may have been due to a suprachiasmatic cystic tumour, specifically a parapituitary craniopharyngioma.2122 He based this supposition on a patient who had presented with similar symptoms to those of Milton, the progression of whose blindness was halted by removal of such a tumour. If that was the diagnosis, one would have to postulate that the tumour had first affected the fibres in Milton’s left optic nerve supplying the left temporal field, then gradually growing to the left to encroach on the other fibres of the same nerve over a period of about seven years, after which it would have had to have grown more rapidly to the right over the next three years, to have taken out the right optic nerve as well. Rogers also suggested that Milton’s nickname when he was at Christ’s College in Cambridge in 1625, “The Lady of Christ’s Coll,” derived from changes in his facial appearance due to the craniopharyngioma, which is hard to see from his many portraits. Nor is there any evidence, documentary or visual, that Milton suffered any other possible endocrine disorders.

Conclusion

Milton’s symptoms were not pathognomonic of any specific condition. Phosphenes, for example, the flashes of light that he described, can occur in a wide range of conditions, including posterior vitreous detachment, macular degeneration, and retinal detachment. Haloes around lights, the iris that Milton described, can occur in glaucoma, cataracts, keratoconus, and opacities in the vitreous humour. This makes diagnosis difficult. Furthermore, no single diagnosis fits everything we know, and there is much to be conjectured.

My own non-expert preferred diagnosis is glaucoma. But perhaps we should abandon Occam’s razor, to accommodate possible comorbidities. For example, some of Milton’s symptoms could have been caused by posterior vitreous detachment, independently of the primary pathology, whatever it was.

Footnotes

  • Competing interests: None declared.

  • Provenance and peer review: Not commissioned; not peer reviewed.

References