Cataract surgery without anaesthesia: two descriptions by Arthur Jacob.
Abstract: Dr Arthur Jacob (1790-1874), of Dublin, Ireland, was one of the leading ophthalmologists of his time. He was the first to describe the membrane that contains the rods and cones in the eye (membrana Jacobi) and basal cell carcinoma (Jacob's ulcer). He made a curved needle for cataract surgery from a sewing needle (Jacob's needle). Two descriptions of cataract surgery without anaesthesia are presented.

Key Words: Arthur Jacob, cataract surgery
Article Type: Report
Subject: Anesthesia (Usage)
Ophthalmologists (Evaluation)
Cataract (Surgery)
Cataract (Methods)
Author: Haridas, R.P.
Pub Date: 07/01/2009
Publication: Name: Anaesthesia and Intensive Care Publisher: Australian Society of Anaesthetists Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2009 Australian Society of Anaesthetists ISSN: 0310-057X
Issue: Date: July, 2009 Source Volume: 37 Source Issue: 4
Persons: Named Person: Jacob, Arthur
Geographic: Geographic Scope: Ireland Geographic Code: 4EUIR Ireland
Accession Number: 204614248
Full Text: Cataract surgery is now usually performed with the aid of one of several techniques of local anaesthesia. The cornea and conjunctiva are well innervated and in modern societies there is usually an expectation that there will be minimal or no pain during procedures on the eye.

Cataracts were treated in the early 19th century by extraction through an incision in the cornea, inferior displacement of the lens with a needle (depression or couching) or by fragmentation of the lens using a needle. For the latter procedure, the needle was introduced either through the cornea, anterior to the iris (keratonyxis) or through the "sclerotic" (sclera), posterior to the iris (scleroticonyxis).

This article provides a brief biography of Dr Arthur Jacob, one of the leading ophthalmologists of his time, a description by him of the making of his needle for cataract surgery and extracts from two descriptions of cataract surgery without anaesthesia. The two descriptions are unusual as they also include the patient's responses to the procedures and provide a vivid and chilling account of surgery in the first half of the 19th century. The descriptions, from the late 1830s and 1850, are within a few years of the introduction of ether anaesthesia and several decades before the development of measures for infection control. No indication of the success rates and rates of complications of ocular surgical procedures were found. Surgical procedures were then not commonly performed and the mortality from major procedures was high.

ARTHUR JACOB

Arthur Jacob (1790-1874) (Figure 1) was born in Knockfin, a townland near Maryborough (now Portlaoise), in Queens County (now County Laois), ireland (1,2). Both his father and grandfather were surgeons. He was apprenticed to his father in 1808 and studied medicine under Abraham Colles at Steevens's Hospital, Dublin. He received his M.D. from Edinburgh in 1814. He also attended lectures and studied in Paris and London. in London, he studied under Sir Benjamin Brodie, Sir Astley Cooper and Sir William Lawrence.

[FIGURE 1 OMITTED]

On his return to Dublin in 1819, he was appointed as Demonstrator of Anatomy in the School of Trinity College. He was one of the founders of the Park Street School of Medicine in 1824. In 1827, he became Professor of Anatomy and Physiology at the Royal College of Surgeons in ireland, and held the post until 1867 (3). in 1832, he was one of the College Professors who founded the City of Dublin Hospital. He was twice elected President of the Royal College of Surgeons in ireland (in 1837 and 1864).

Arthur Jacob and Henry Maunsell founded The Dublin Medical Press in 1839, with Arthur Jacob as its first editor from 1839 to 1859. He was known for his "robust" language and personal attacks on medical colleagues1. The following quotation, from p. 604 of an article on Arthur Jacob by Somerville-Large (1), contains examples of the language used at that time in medical journals: "He assails a professorial rival with 'the chronic medico-literary diarrhoea under which the learned Professor has so long laboured', 'the heterogeneous discharges with which he inundates the journals', 'the foetid ichor which distills from such a quill'. The editor of The Lancet (1841) is no less outspoken. 'Messrs. Jacob, Maunsell, Porter, all the rag, tag and bobtail of the College School, hatched in corruption, though they still linger about the dunghill that gave them birth' " (1).

Arthur Jacob is especially known for his work in ophthalmology. in 1816, he discovered a membrane of the retina, the membrana Jacobi, now known to consist of rods and cones. His description of this new layer was published in 1819 (4). He is credited with reviving cataract surgery through the cornea with a curved needle which he had invented. This curved needle, called Jacob's needle, was first described in 1827 (5). He was the first to describe basal cell carcinoma, also known as rodent ulcer or Jacob's ulcer (6). His book, A treatise on the inflammations of the eyeball, is regarded as one of the classics in ophthalmology (7). Another aspect of Arthur Jacob's career was the animosity between him and William Wilde (father of Oscar Wilde), his "brilliant young contemporary" (1).

Arthur Jacob's second son, Samuel, became an oculist in Melbourne, Victoria. His fourth son, Archibald Hamilton, succeeded him as an oculist in Dublin and editor of The Dublin Medical Press (1).

Detailed accounts of his career (with some inconsistency in dates) can be found in two articles in the British Journal of Ophthalmology (1,2).

JACOB'S NEEDLE

in 1827, Arthur Jacob described how he made and used a curved needle for cataract surgery (5). The curved needle was made by bending an ordinary sewing needle at one end. The other end was inserted into a cedar handle. Cedar was used because it was light in weight.

"I determined to try a fine sewing needle curved at the point, and after about forty operations i do not feel in the least inclined to repent of my choice. i am on the contrary every day more and more satisfied that it affords peculiar and unquestionable advantages. it rarely, if ever, leaves even the slightest mark in the cornea ... There is one difficulty attending the use of the round needle; it requires very considerable force to pass it through the cornea; so much indeed as frequently to embarrass those who use it for the first time ... The greatest advantage in the use of the needle results from the very circumstance which causes the difficulty in its introduction, it is from its conical form firmly wedged in the cornea, prevents the aqueous humour from escaping, and in consequence of being thus fixed, gives the surgeon a power of holding the eye that defies every effort on the part of an unruly patient, unless he actually pluck out the instrument with his hand. if the head be suddenly drawn back the surgeon has only to let the instrument rest loosely on his hand, and follow the motions of the patient. i have seen the needle under such circumstances slip from the hand of the surgeon, and hang from the eye without serious mischief, the handle being very light" (5).

"The size of the needle is known in the shops as number seven, being the forty-fourth part of an inch in diameter, about one half the size of the finest Saunders's needle which is made ... The point can be turned to the requisite curve by means of a pair of cutting forceps, or the ward of a small key; of course without heat, which would destroy the temper. it must not however be expected that all needles are so soft as to be bent thus cold: there may not be ten in a hundred of this temper, but when once turned they retain the curve without any danger of bending or breaking, and certainly possess a degree of strength and temper never observed in needles separately forged and finished by the best cutlers. They should always be tried before use by passing them repeatedly through thick calves-skin leather. After they have received the requisite curve, the point should be cut flat on each side, on a fine hone, and carefully examined with a magnifying glass to ascertain that it is perfect. The extent to which the point should be curved may be left to the choice of the surgeon, reminding him that the greater the curve the more effectual the needle will be when introduced, but the difficulty of introducing it through the cornea will also be greater. I therefore recommend those who use it for the first time to choose one slightly curved. After the point has been turned, the needle, held in the jaws of a pair of pliers or a vice, is to be run down into a cedar handle, without cement, leaving only half an inch of blade, which i have found to answer every purpose" (5).

ARTHUR JACOB'S DESCRIPTION OF CATARACT SuRGERy

Arthur Jacob felt that using a needle through the cornea (keratonyxis) was the most easily performed operation for cataract and least traumatic to the eye. The disadvantages were that the procedure may need to be repeated and the improvement in the patient's vision was slower than that following the other operations for cataract.

The following extract from a description of cataract surgery is from pages 21 and 22 of Jacob's book, The Removal of Cataract as Performed with a Fine Sewing Needle through the Cornea8. The part of the surgical procedure that has the patient's response has been quoted. The pupil was usually dilated preoperatively using belladonna.

"I seat the patient in a chair and make him sit straight up or inclining, according to his height. if very tall I raise myself by standing on a large book or two, or on anything which answers the purpose to be found at hand. in my own place of business I find old medical folios answer the purpose well: operating chairs, although very imposing and calculated to produce effect, I have not adopted; not finding myself at ease with such things. When he is seated I lay the patient's head against my chest, and placing the middle finger of my left hand on his lower and the forefinger on his upper eyelid, and gently holding the eye between them, I strike the point of the needle suddenly into the cornea, about a line from its margin, and there hold it until any struggles of the patient, which may be made, cease. There must be no hesitation here, for if the cornea be touched without fixing the point of the needle in it, the eye will turn rapidly and the surface will be scratched. I advise the operator to pause here for a moment, holding the eye firmly and steadily on the point of his needle, and if necessary to say a word of encouragement or remonstrance to the patient. After quietness becomes restored, the needle is to be pushed on with a firm hand through the cornea into the anterior chamber, directing its point downward and backward to the centre of the surface of the lens. This is the most difficult step in the operation, and that part of it which requires most confidence in the instrument. If the surgeon now hesitates from the feel of resistance experienced he will not succeed. He must push on, fearless of consequences, until the needle passes through: in doing so, however, the eye will often turn from him or yield before the pressure, even until the pupil, iris, and the cornea itself are hidden under the eyelid; still he must push on until he is satisfied that the needle has fairly entered the anterior chamber, when he relaxes the pressure and allows the eye to recover its natural position. Here, again, he had better pause a moment to allow the patient to recover his composure, which is often disturbed in this the roughest step of the operation, and also to ascertain the distance to which the needle has passed, and how the point lies as to the margin of the pupil" (8).

WILLIAM GUYBON ATHERSTONE'S LECTURE NOTES

in 1996, while researching early ether anaesthesia in South Africa, the author came across a notebook of William Guybon Atherstone (1814 to 1898) of lectures he had attended in Dublin in the late 1830s. The notebook (accession number KCM 97/22/4) was archived at the Killie Campbell Africana Library (now called Campbell Collections), University of KwaZulu-Natal, Durban, South Africa. One of the lectures, "Dr Arthur Jacob on Diseases of the Eye", contained a description of cataract surgery and several sketches of ocular incisions and instruments. One of the sketches was of Dr Jacob's curved needle for keratonyxis (Figure 2).

William Guybon Atherstone was initially apprenticed to his father, John Atherstone, a doctor in Grahamstown, South Africa. He then studied Medicine in Dublin and returned to Grahamstown in 1839. He was also a keen naturalist, geologist, founder of the Albany Museum in Grahamstown and, later in his life, a Member of the Cape Parliament. His two main claims to fame are his role in the identification of the first diamond found in the Kimberley district of South Africa and the first administration of ether for a major surgical procedure (an above knee amputation performed on 16 June, 1847) in South Africa (9).

[FIGURE 1 OMITTED]

Extracts from the notes made by William Guybon Atherstone of a lecture by Arthur Jacob

The extracts below are from pages 14 to 17 of Atherstone's notes of the lecture by Arthur Jacob. The original spelling has been retained. The discussion of Jacob's needle is followed by a note on the use of a needle to break up a cataract. An operation to extract a cataract and instructions for postoperative care are then described.

"Jacob's needle for keratonyxis (cedar handle)" (Figure 2).

"The great difficulty in using it is the force it requires to send it thro' the cornea. but it repays you when you get it in for no aqueous humour can escape and let them roll their eyes how they like it will not slip out. he has even let it alone hanging from the eye, but generally in this dilemma it is best just to support the handle. He therefore makes the handle of cedar for lightness. Opthalmostats are instruments for fixing the eye in operation, Dr J. does not like them. if you once begin to use them you can never do without them. The hand is the best instrument, your finger the best opthalmostat."

"Tuesday Apr. 11. Dr J. performed the operation of breaking up the lens on a soft cataract. The pupil previously irregular became regular directly that adhesions were broken thro'. He waited some time after the first thrust before beginning to break it up. never stop an operation from any contingency or effort of the patient. finish when once you have begun sooner than risk a 2nd operation pending inflamm. even if the iris was transfixed by the needle draw it back and push it into the pupil."

"Operation of Extraction. only desirable in hard cataract but even in this it is often very difficult in small sunken eyes. The great objection to it is its much greater complexity, difficulty, risk of after ill effects ... learn how much the patient will wince by first applying a blunt instrument."

"1st Step. cut the cornea thus (Figure 3). flap the bottom part near the junction with the sclerotic ... the difficulty in making this cut is from the wincing of the patient, and his rolling his eye inwards. The humour always escapes and there is an obvious danger from prolapse of the iris. it falls under the blade of the knife it is very difficult to obviate this. if you withdraw the knife it is a spoiled operation and a lost eye most certainly, and therefore Dr Jacob says 'never mind it, cut away, iris and all, it escapes with a slight nick and it is the least of the two bad things'."

[FIGURE 2 OMITTED]

"2nd Step. Having made the cut calm the patient and let him lie still & quiet a few minutes; then tear open the capsule of the lens with any needle (as Scarpas'). then let the patient lie still again for a while. the lens often comes out of itself but a little manipulation is generally necessary. if much vitreous humour escapes the lens often falls back and you can't get it out at all. a little bistoury or scimitar blade is often requisite to enlarge the opening of the cornea. The curette is a small curved scoop to get at the lens where it is difficult to remove."

"Treatment after the operation. Don't put a full hot bandage round the head, but a nice little linnen pad on it. keep it wet with cold water. you must have the constant attendance of a good nurse, it is requisite to the cure. many a good operation is spoiled for want of a good nurse. The patient should be kept in the dark, and quiet. check all cough and nausea. the efforts are very bad in their effects. be very cautious for the first 3 or 4 days of touching the eye for fear of interfering with the healing process or interrupting it. antiphlogistics to be used when necessary."

CONCLUSiON

Arthur Jacob was a highly respected figure in medicine in Dublin. He revived cataract surgery through the cornea with a curved needle which he had invented (Jacob's needle). He was the first to describe the membrane consisting of rods and cones (membrana Jacobi) and also the first to describe basal cell carcinoma (rodent ulcer, Jacob's ulcer). His vivid descriptions of cataract surgery performed less than two hundred years ago, without any anaesthesia, are a reminder of the rapid progress that has been achieved in medicine and the changes that have occurred in the expectations of patients and society.

ACKNOWLEDGEMENT

I would like to thank Emily-Ann Krige, Senior Archivist, Campbell Collections, University of KwaZulu-Natal, Durban, South Africa for assistance regarding William Guybon Atherstone's notebook. I would also like to thank Mary O'Doherty, Assistant Librarian (Special Collections and Archives), The Mercer Library, the Royal College of Surgeons in ireland, Dublin, ireland.

Accepted for publication on April 25, 2009.

REFERENCES

(1.) Somerville-Large LB. The First irish Ocular Pathologist: Arthur Jacob (1790-1874). Br J Ophthalmol 1948; 32:601-617.

(2.) James RR. British masters of ophthalmology series: 20. Arthur Jacob, 1790-1874. Br J Ophthalmol 1927; 11:257-263.

(3.) O'Brien E, Crookshank A, Wolstenholme G. A Portrait of Irish Medicine: An Illustrated History of Medicine in Ireland. Published for the Bicentenary of the Royal College of Surgeons in ireland. Ward River Press, Swords, Co. Dublin, ireland 1984; p. 79, 96.

(4.) Jacob A. An Account of a Membrane in the Eye, now first described. Philosophical Transactions of the Royal Society of London 1819, 109:300-307.

(5.) Jacob A. On the form, construction and use of a cataract needle, of a particular description, employed by Arthur Jacob, M.D. The Dublin Hospital Reports and Communications in Medicine and Surgery 1827; 4:214-231.

(6.) Jacob A. Observations respecting an ulcer of peculiar character, which attacks the eye-lids and other parts of the face. The Dublin Hospital Reports and Communications in Medicine and Surgery 1827; 4:232-239.

(7.) Jacob A. A treatise on the inflammations of the eyeball. Dublin Medical Press, Dublin, Ireland 1849.

(8.) Jacob A. On the operation for the removal of cataract, as performed with a fine sewing needle through the cornea. Medical Press, Dublin, ireland 1850, p. 21-22.

(9.) Haridas RP. Ether Day and the first ether anaesthetics in South Africa. S Afr J Surg 1997; 35:54-58.

R. P. HARIDAS *

Mildura, Victoria, Australia

* M.B., Ch.B., F.A.N.Z.C.A.

Address for correspondence: Dr R. P. Haridas, PO Box 1201-CP, Mildura, Vic. 3501. Email: rajesh.haridas@bigpond.com
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