The next description of the operation, which claims our interest, is that by Benvenuto (Benevenutus Hyerosolimitamus), who flourished in the twelfth century. The quaint blending of religion and science, which it reveals, makes it very attractive reading: “Towards the third hour, the patient having fasted, thou shouldst make him sit astride of an ordinary chair, and thou shouldst sit before him in the same way. Keep the good eye of the patient shut, and begin to operate on the bad eye, in the name of Jesus Christ. With one hand raise the upper lid, and with the other hold the silver needle, and place it in the part where the small angle of the eye is. Perforate the same covering of the eye, turning the instrument round and round between the fingers, till thou hast touched with the point of the needle that putrid water which the Arabs and Saracens called Mesoret, and which we call cataract. Then beginning from the upper part, remove it from the place where it is before the pupil, and make it come down in front, and then hold it for as long as it takes to say four or five paternosters. After, remove the needle gently from the top part. If it happens that the cataract reascends, reduce it towards the lower angle, and when you have introduced the needle into the eye, do not draw it out unless the cataract be situated in the place described above; then gently extract the needle in the same way as you put it in, turning it about between the fingers. The needle being extracted, keep the eye closed and make the patient lie flat on a bed, keeping him in the dark with his eyes shut, so that he does not see the light or move for eight days, during which time put white of egg on twice a day and twice during the night.”
Passing over four centuries, we come to an even more interesting description of the operation from the pen of Bartisch of Dresden: “The day being decided upon, on which the operation is to be performed, the doctor who is obliged to, or who wishes to do it, must abstain from wine for two days beforehand. The patient must also fast the same day, and must neither eat much nor little till an hour after the operation. Given the aforesaid conditions, try and procure a well-lighted room, in which the patient may have everything necessary for going to bed and remaining there, as he ought not to be taken to any place far off; the nearer to bed the better. Set thyself on a bench in the light and turn thy back to the window. The patient may be seated on a chair, a stool, or on a box, before thee and near to thee; in any case he is to be seated lower than thyself. His legs between thine and his hands on thy thighs. A servant stands behind to hold the patient’s head. The servant should bend a little, so that the patient may rest his head against him (Fig. [1]). When the patient is blind of one eye only, the other eye should be bandaged with a cloth and a pad so that he cannot see. Then take the instrument or the needle in one hand, so that the right hand will be for the left eye, and vice versa. With the other hand separate with great care the upper lid from the lower, using the thumb and the first finger, so that thou canst see how to direct the needle into the eye. When thou wishest to introduce the needle, the eye must be turned towards the light and looking straight at thee; also, I should make the patient turn his eye a little towards his nose, so that thou canst use the instrument better and that thou wilt not injure the small veins of the eye, but respect them. Direct the needle straight and with attention over the membrane called the conjunctiva, straight towards the pupil and uvea, at the distance of two blades of a knife from the membrane called cornea or from the grey that is in the eye. Hold the needle quite straight, hold it steady so that it will not deviate or slip. Hold the needle and press it, and turn it with the fingers in the eye with great gentleness, according to the instructions you may gather from the figure, which shows an eye in which the cataract has been taken away, while the other eye has not been touched (Fig. [2]). Hold the needle firmly while turning it round, and be careful always to have the point towards the middle of the eye, that it almost touches the pupil and the uvea; and not to oscillate by any chance towards one side. When thou feelest that the needle has penetrated into the eye, that it almost touches the pupil and the uvea, and when thou hast proved to be really in the eye, hold the needle securely and move it, letting it slip backwards and forwards towards the pupil till thou art certain of being in the substance of the cataract, which thou canst easily be sure of by the movement of the cataract material. When thou hast remarked that, lower it carefully and gently and slowly, so as not to disturb the cataract; but try and free the matter entirely from the pupil and from the uvea with care, and keep it intact. Press the said matter with the needle under it, with the greatest care, and when thou perceivest that it is altogether free and loose, draw and direct the needle, with the matter behind it, upwards, and then pass it well downwards, behind the thin retina and the aranea of the eye; and take care that it remains there. . . . This is the recognised instruction, research, and indication of the means of operating, of pricking the cataract, or of the manner in which such an operation ought to be initiated and conducted. But no one ought to undertake such an operation unless he has learnt much and seen much, and unless he is fundamentally taught by intelligent doctors. Unless he is so, it is not well to operate. And it is not wise to trust to any of the brotherhood who happen to be dressed in velvet or silk, and who boast of being great oculists, and are capable of curing the blind from cataract. Certainly these can make holes in the eyes, but I do not know how they can succeed.”
The knowledge which the Greeks and the Arabs possessed, before and after the dawn of the Christian era, on the subject of the pathology and treatment of cataract, appears to have been largely forgotten during the Middle Ages. It would seem that both couching and extraction fell into disuse, and that the surgical treatment of cataract was left for centuries in the hands of wandering charlatans, whose ways brought much discredit upon it. Towards the close of the seventeenth century, Pierre Brisseau, a doctor of Tournay, revived the operation, inventing a needle of his own for the purpose. His advocacy of the method aroused bitter controversy, but it was undoubtedly the best operation in the field until the famous French surgeon Daviel performed his first extraction in 1745, and thus sounded the death-knell of a procedure which had held the pride of place in European surgery for over seventeen centuries. It was, however, many years before couching was definitely abandoned in favour of extraction. Indeed, the author has recently had the privilege of discussing this subject with a distinguished surgeon, who can remember the time when depression was still a recognised method of operating in London. It is a great mistake to suppose that Daviel was the first to endeavour to extract a cataract, for both extraction and suction of cataracts have their roots far back in history. Indeed, Antyllus described his method of extraction at the close of the first century of the Christian era, and there are numerous other references to it in early literature. What Daviel did was to adopt a technique which gave a reasonable prospect of success.
Fig. 3.—Depression.
Fig. 4.—Reclination.
The above two figures illustrate the path taken by the cataract during the operation. (Mackenzie.)
The introduction of reclination, as opposed to depression, by Willburg in a Nuremberg thesis, dated 1785, gave a fresh lease of life to couching in its dying struggle with the operation which was destined to supersede it. England, France, Sweden, Germany, and other countries, joined vigorously in the discussion, and amongst the powerful advocates of couching were ranked Percival Pott and William Hay of London, Cusson of Montpellier, and Scarpa of Pavia, whilst Benjamin Bell practised both couching and extraction. The admirable treatise by James Ware on cataract (1812) was all but a death-blow for Celsus’s operation. The newer procedure was then well in the ascendant, and only needed time to completely strangle its rival. Notwithstanding this, it was left to Mackenzie, so late as 1854 (fourth edition), to give the most complete and interesting description of couching to be found in literature. He distinguishes sharply between the operations of depression and reclination. In depression, the lens is pushed directly below the level of the pupil, being made to follow the curvature of the eye, to sweep over the corpus ciliare, until it comes to rest on the lower curve of the eyeball, with its anterior surface directed forward and downward (Fig. [3]). In reclination, the lens is made to turn over towards the bottom of the vitreous chamber in such a way that what was formerly its anterior surface now comes to look upward, and what was its upper edge is turned to the rear. The whole lens is swung backward as if on a hinge, composed of the lower fibres of its suspensory ligament, which still remain unbroken (Fig. [4]).
