Excursions in Medical History: Cataract Surgery

Warning: this post may contain some graphic images and descriptions. Viewer discretion advised.

I'm going to try producing a new series here this summer: Excursions in Medical History - an occasional, brief stroll through the annals of our collective clinical past. A kind of "History of Medicine 101."

Photo: Dr. Rizal Treating His Own Mother, Romeo Enriquez, 1960. Courtesy of the National Historical Institute, Manila, the Philippines. Adapted from JAMA.

Because I've had the luxury of being "in eyes" - that is, providing sedation for cataract surgery - not once but twice this week, I started thinking a lot about cataract surgery. What's a cataract? It's a clouding of the crystalline lens in the eye, so named because in antiquity physicians conceived of the clouding material as something that cascaded into the eye.

Some people who haven't undergone the procedure get a little alarmed when I inform them that they'll be awake for the entire surgery, and I don't blame them - who wants to sit there under a giant drape while a masked figure in blue scrubs pokes into your eyeball with a sharp object?

(Taken, with permission from the patient, off a video monitor of cataract surgery at one of the hospitals I serve.)

But the truth is, I have never seen any patient experience pain or distress during cataract surgery. The ophthalmologist numbs the eye completely, with drops of local anesthetic and perhaps a regional block (retrobulbar or subtenons). The anesthetist may give a little sedation through the I.V. And that's really all you need! The incision is tiny - two or three millimeters, tops. The surgeon might occasionally ask the patient to look in a certain direction, or tilt the chin a certain way, the patient says, "Ok," and the surgery progresses - the clouded lens is removed and replaced with a new lens.

Not so back in the day, oh, maybe 2500 years ago. As the American Academy of Ophthalmology recounts, the earliest form of cataract surgery was couching, a procedure described in 5th century B.C. Sanskrit manuscripts. This involved displacing the lens away from the pupil and into the vitreous cavity. Centuries later discission, or needling to break up the cataract into pieces, was practiced. In the mid-1700's Jacques Daviel of France and Samuel Sharp of London began surgically removing the lenses from their patients with "the services of a strong assistant...to hold the patient's head still." Local anesthetic drops would not ease the pain and terror of the procedure until 1884.

Which brings me to José Rizal, my country's national hero, whom I've mentioned briefly before and whose birth anniversary was just yesterday. Rizal was a real Renaissance man - poet, novelist, polyglot, political activist, physician (click here for a wonderful article from the Archives of Ophthalmology by Tracy B. Ravin, M.D. on Rizal's medical training). He studied ophthalmic surgery in Madrid, Paris, and Heidelberg, then brought his skills and other talents back to the Philippines, where he practiced from 1888-1896. People would sometimes travel for miles, through heat and dust and mosquitoes, to receive treatment from him.

After his execution by firing squad for "rebellion" against Spain, Rudolf Virchow (of "Virchow's triad," the first triad I ever learned in medical school) gave a speech in his memory at the annual general meeting of the Berlin Society for Anthropology, Ethnology and Pre-history. Another statement by Virchow seems a fitting reminder of what Rizal's life represented: "Medicine is a social science, and politics is nothing more than medicine on a larger scale." Rizal embodied the old adage about the pen being mightier than the sword and used his gifts as a physician-writer - a good eye and an intelligent use of language - to try to bring about social change, political action, respect for human rights, and freedom for all in his homeland. I am reminded of one last quote, from The Word as Scalpel by Samuel William Bloom: “If words, the main substance of human relations, are so potent for harm, how equally powerful can they be to help if used with disciplined knowledge and understanding? And where more certainly does this simple truth apply than in the making of a physician?”