Let me pose a question: how much do you value the sight of your loved ones?
How much stock do you place by seeing your children, your parents, perhaps a lover? How much would you miss the sight of a sumptuous red-lined morning sky, or a panorama of stars in full splendor on a warm summer night?
Rather a lot, I would presume.
Now consider this; how much value would you place in these ocular treats if, to save your eyesight, it was necessary to endure the excruciating pain of a single needle being plunged directly into your eyeball, then wiggled around for good measure, all without any form of pain relief and without certainty of a positive outcome?
This describes the most commonplace of all medical procedures, and is the price one might pay to mitigate that nemesis of human sight; the cataract, and is also the focus of this week’s article…
For the layman, cataracts are the milky-white misting in the lens of the human eye. Half of all forms of blindness are caused by this pernicious malady, so it is logical that the battle to cure it is without doubt the oldest of all medical struggles, with documented efforts dating as far back as ancient Egyptian times.
Until recently, cataracts were seen as a build-up of humors behind the eye, and, as with bleeding and purging, attempts to cure this ailment with herbal remedies and salves proved of little value except to those scoundrels filling their purses from the proceeds of such quackery. No, as usual, one must take to surgery to truly effect a potential solution; the lancet, the scalpel and a physician sufficiently immune to loud screaming.
Cataract removal methods via surgery fall into roughly three categories; extraction, and a procedure called couching. The third method, less invasive and popular in Roman times, involved repeated sharp blows to the head, which although brutally comical, would have actually seen some successes; an occluded lens can indeed become dislodged in this fashion. This is not however an excuse to go and bludgeon grandma, you understand. Put down the cudgel and sit down, there’s a good chap.
Both extraction and couching were believed to have been performed as far back as 560 B.C.. Kassandane, a member of the 26th royal Egyptian dynasty was sent to an eye doctor. The Greek scholar Herodotus records that by ‘cutting the skin that covered the pupil of the eye’ her sight was restored. Although depictions of needles and similar surgical implements have been found on the facades of Egyptian temples, it was early Indian texts from 250 B.C. that first fully describe the horrifying procedure…
According to the Sushruta Samhita text, the patient would be sat before the surgeon and tied up to restrict the inevitable squirming. The surgeon would then rub the closed eye (likely to momentarily distract the patient) and then whilst firmly securing the victims head, would hold a sharp lancet between finger and thumb, and:
“… introduce it into the patient’s eye, towards the pupil, half a finger’s breadth from the black of the eye and a quarter of finger’s breadth from the outer corner of the eye… moving the lancet gracefully back and forth and upwards… there was a small sound and a drop of water came out…”
The surgeon would then ‘speak a few words of comfort to the patient’ – more likely something along the lines of “oh for goodness sake stop screaming” – and then would shove the needle in further, driving ‘the slime’ (the cataract) towards the nose, before removing the lancet. The patient was then required to unceremoniously hawk out the slime through the nose. The erroneous belief was that the bad ‘phlegmatic humors’ had been ejected from the body, when in fact the now detached lens of the eye had been forced to the bottom and rear of the eye, the ejected ‘slime’ being only that of an extremely distressed physiological response on the part of the patient.
Before I express sympathy for your recently consumed meal now dislodged from the seat of your stomach, know that this was hardly the worst of it. The ancient Sanskrit texts explain further methods, one of which was by having the eyeball cut via a crossed incision, and the phlegm would be ejected by increasing pressure within the eyeball caused by a sharp exhalation of breath via the nose. I wouldn’t be seated before the patient at that point in the procedure, that’s for sure.
These methods of couching spread across the ancient world like a painful rash, whilst only providing an estimated 20% success rate. Roman physicians, Arab doctors and Byzantine oculist specialists performed the procedure with gusto. However, similar to the early days of the surgeon’s profession in Europe where practitioners were regarded as little more than clinical menials and barbers (and frequently were), oculists in ancient times were treated with an equivalent disdain.
Little evidence exists of attempts by Medieval doctors (which is a loose term indeed) to perform the couching surgery and the procedure took a step back. Roger Frugardi, a base oculist from the time mentions his discreet method:
“[It] arises from a viscous humour that clings to a part of the eye and turns into a film that can be separated with a fine hook and cut off with a lancet… it is sometimes curable sometimes not.”
How exactly the hook and lancet worked in concert is a detail mercifully missing from the historical record.
In the next installment, we’ll look at the surgical developments arising in the 16th century and the decline of couching as the prevalent method. However, don’t wipe your brow too soon – the successor, that is, cataract extraction, performed without anesthetic for another three hundred years, is hardly a more reassuring option…