SECT. XXI.—ON CATARACTS.
The cataract is a collection of inert fluids upon the cornea at the pupil, obstructing vision, or preventing distinct vision. It arises most commonly from a congelation and weakness of the visual spirit, and on that account the disease rather attacks old persons, and those who are debilitated by protracted illness. It is occasioned also by violent vomiting, a blow, and many other causes. Those kinds of cataract which are but commencing, as not being proper objects of surgery, have been treated of in the [Third Book]. We shall now give the characters of those which are fairly formed and have acquired consistence. All those, therefore, who have cataract see the light more or less, and by this we distinguish cataract from amaurosis and glaucoma; for persons affected with these complaints do not perceive the light at all. Wherefore, again, Galen well instructs us as to the consistence and difference of cataracts and which kinds ought to be operated upon. Having shut the eye affected with the cataract, and with the large finger pressing the eyelid to the eye, and moving it with pressure to this side and that, then opening the eyelids and observing the cataract in the eye; if it has not yet acquired consistence, a certain flow takes place from the pressure of the finger, and at first it appears broader, but straightway resumes its former figure and magnitude. But in those which have acquired consistence no change takes place as to breadth or figure from the pressure. But since this appearance is common to those which are of moderate consistence, and those which are over-compacted, we distinguish these cases from one another by their colour. For those which are of an iron, cœrulean, or leaden colour, are of moderate consistence, and fit for couching; but those which resemble gypsum and hailstones are over-compacted. After ascertaining these circumstances, as directed by Galen, having placed the patient opposite the light, but not in the sun, we bind up carefully the sound eye, and having separated the lids of the other, at the distance from the part called the iris towards the small canthus, of about the size of the knob of the specillum, we then with the point of the perforator mark the place about to be perforated; and if it is the left eye we operate with the right hand, or if the right eye with the left; and turning round the point of the perforator, which is bent at its extremity, we push it strongly through the part which was marked out, until we come to an empty place. The depth of the perforation should be as great as the distance of the pupil from the iris. Wherefore, raising the perforator to the apex of the cataract, (for the copper of it is seen through the transparency of the cornea,) we push down the cataract to the parts below, and if it is immediately carried downwards, we rest for a little, but if it reascends we press it back again. After the depression of the cataract we turn round the perforator and extract it gently. After this, bathing with water and injecting into the eye a little Cappadocian salts, we apply externally some wool soaked in the white of an egg with rose-oil, and bind it up, and at the same time bind up the sound eye, that it may not move. Then lodging the patient in an apartment below ground, we order him to remain in a state of perfect rest, and upon a spare diet; and the bandages are to be kept on, if nothing prevent, until the seventh day, after which we loose them, and make trial of the sight by presenting him with some object: but this we disapprove of during the operation and immediately after it, lest by the intense exertion the cataract reascend. If the inflammation become urgent we loose the dressing before the seventh day, and must direct our attention to it.
Commentary. See Celsus (vii, 7); Galen (Ars Medica, 35; Isagoge); Aëtius (vii, 53); Albucasis (Chirurg. ii, 23), Canamusali (vi); Avenzoar (i, 8, 19); Mesue (de Ægr. Oculi; 15); Haly Abbas (Pract. ix, 28); Jesu Hali (Tract. de Oculis, 68); Avicenna (iii, 3, 4, 20); Rhases (ad Mansor. ix, 27, and Cont. ii); Vegetius (Mulom. ii, 17.)
This disease is called suffusio by the Latins, and aqua by the Arabians.
We have stated in our commentary on affections of the eye, in the [Third Book], that the ancients were aware that the crystalline lens is the seat of one of the species of cataract. This opinion is clearly delivered by Galen, Aëtius, Oribasius, Haly Abbas, and some of the others. As a proof that this notion prevailed generally, we will give the words of Psellus literally translated: “Glaucoma is a grievous and incurable affection, being a certain change of the crystalline humour, and transmutation of its colour to a sea-green. The suffusion is a concretion of the fluid between the cornea and crystalline humour.” (Opus Medicum.) The other species then, as Psellus states, was held to be a concretion between the crystalline lens and the cornea. That such a disease, although of comparatively rare occurrence, is sometimes met with seems undeniable.
Celsus lays it down as a rule, that when the suffusion is small, immovable, and of the colour of sea-water, or of shining iron, and if a small degree of light can be perceived at the side, there is reason to hope well of the case. He forbids us to operate until the disease has attained a proper consistence. He directs us to place the patient opposite the operator, who is to sit on a higher seat, while the patient’s head is firmly held by an assistant. The sound eye is to be previously covered up with wool. If the left eye is affected the operator must use his right hand, and vice versa. A needle which is sharp and not too slender is to be passed direct through the two coats at a place intermediate between the temporal angle and the black of the eye, and towards the middle of the cataract. When the needle has perforated far enough, which is readily known by the absence of resistance, it is to be gently turned so as gradually to remove the cataract below the region of the pupil, and this object being attained it is to be strongly pressed to the lower part. If it remain there the operation is completed; but if it return it is to be cut and torn by the needle into many pieces, in which state they are easier depressed, and prove less troublesome. The needle is then to be drawn out direct, and soft wool smeared with the white of an egg, and other anti-inflammatory applications are to be used. Quiet, restricted diet, and soothing treatment will be proper.
Galen, in his ‘Ars Medica’ alludes to the operation, but does not describe it.
Paulus is the only Greek author who describes the operation. Sextus Platonicus, however, just mentions that the diseased part is sometimes to be depressed with a specillum. (De Medic. ex Animalibus.)
Mesue describes the operation of couching briefly, but nearly in the same terms as our author. He directs us to put the patient upon a spare diet, and to bleed him before the operation. He recommends us to be careful to depress the cataract (aqua) properly.
Albucasis describes the operation of Paulus very minutely, and gives drawings of the couching-needles, called by him almagda. The instrument is to be passed down into the eye to as great a space as the pupil of the eye is distant from the end of the black part called the corona. He says nothing of tearing the cataract into pieces when it proves difficult to depress. He mentions that he had heard of a certain oculist who, it was said, sucked out the cataract through a small tube. He adds, however, that he had never seen any person who performed this operation, nor had read anything about it in the works of the ancients.
Avenzoar briefly mentions that when a cataract cannot be got discussed it must be depressed. He gives directions to press it well down, but says nothing about tearing it into pieces. He recommends retirement, abstinence, and rest afterwards.
Avicenna’s description is evidently copied from our author. He also mentions that some surgeons open the lower part of the cornea, and extract by it. However, he does not approve much of this procedure.
Canamusali briefly mentions that cataract must sometimes be removed by a surgical operation. When convulsions come on after the operation he directs us to apply castor to the nose.
Rhases describes accurately the operations of couching, extracting, and sucking out the cataract. He is the only ancient author, except Celsus, who recommends the cataract to be torn in pieces when it cannot be got properly depressed. He mentions that the famous surgeon Antyllus practised extraction by opening the lower part of the cornea. He also speaks of a certain surgeon who sucked it out through a glass tube.
Haly Abbas describes distinctly the operation of couching, but evidently copies from Paulus. He makes no mention, however, of extraction, as far as we can discover, in any part of his works. The operation of couching the cataract is minutely described by Jesu Haly, but he makes no mention of extraction. He was the son of Haly Abbas.
Sprengel, in his ‘History of Medicine,’ refers to Haly Abbas as one of the ancient authorities who make mention of the operation of extracting the cataract; but if this be the case the edition from which they quote (Venetiis, 1492) must be considerably different from the one with which we are acquainted. (Lyon, 1523.) Haly forbids examinations of the eye after the operation, to ascertain whether or not the patient has recovered his sight.
We will give the description of Vegetius in his own language: “Jumentum igitur pridie temperabis a cibo vel potu maximè prohibebis, in loco molli elides caputque ejus et cervicem aptè collocabis: ita patentem oculum facies ut claudere non possit: deinde ab ipsâ fronte paracenterium inter tunicas oculares subjicito, ne pupillam tangas, aut aliquid lædas interius. sed ipsum album de superiori parte ubi hypochysis posita est, capitello paracenterii deorsum deprimis ad palpebram inferiorem subtiliter. Quod si depositum fuerit, non prius paracenterium eximas, nisi clausum oculum penicello calido diutissime vaporaveris. solet enim resilire. Quod si evenerit, reprimito, donec ita componatur ut resilire non possit. Cum itaque intellexeris claritatem pupillæ sine illo obstaculo hypochysis, tunc eximes ferrum, et invenies animal videre.”
Sprengel affirms, but not quite correctly, as will be perceived from the account of the ancient opinions given above, that it was towards the beginning of the 18th century that it was first discovered that the crystalline lens is the seat of the cataract. Otherwise he gives an admirable history of the operation, in which he does ample justice to the ingenuity and inventive genius of the ancients. (Hist. de la Méd. xviii. 2.)
Fabricius’s description is altogether borrowed from the ancient authors. (Œ. C. ii, 16.) Guy of Cauliac, and the other surgical writers of that age, describe the operation in the same terms as the ancients. Guy mentions the operation of sucking out the cataract through a cannula, but does not approve of it. (vi, 2.)