← The Indian operation of couching for cataract

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By the Same Author

=SCLERO-CORNEAL TREPHINING IN
THE OPERATIVE TREATMENT OF
GLAUCOMA=, 1913. Second Edition,
1914. George Pulman and Sons, London.

=GLAUCOMA: DIGEST OF THE YEAR’S
LITERATURE.= The Ophthalmic Yearbook,
1913–1916. Herrick Book and Stationery
Company, Denver, Colorado, U.S.A.

=GLAUCOMA: A HANDBOOK FOR THE
GENERAL PRACTITIONER=, 1917.
H. K. Lewis and Co. Ltd., London.

=GLAUCOMA: A TEXTBOOK FOR THE
STUDENT OF OPHTHALMOLOGY.=
(Now in the press.)
H. K. Lewis and Co. Ltd., London.

PLATE I. Copied by C. A. R. H. FIG. 1.--The positions of the patient, operator, and assistant, as depicted by Bartisch (Albertotti). Copied by C. A. R. H. FIG. 2.--To illustrate the method of introducing the needle in Bartisch’s operation (Albertotti). The cataract is in situ in the right eye, and couched in the left eye.

THE INDIAN OPERATION OF

COUCHING

FOR CATARACT

INCORPORATING

THE HUNTERIAN LECTURES
DELIVERED BEFORE THE ROYAL COLLEGE OF SURGEONS OF ENGLAND ON
FEBRUARY 19 AND 21, 1917

BY

ROBERT HENRY ELLIOT
M.D., B.S. Lond., Sc.D. Edin., F.R.C.S. Eng., etc.
Lieut.-Colonel I.M.S. (retired)

LATE SUPERINTENDENT OF THE GOVERNMENT OPHTHALMIC HOSPITAL, MADRAS;

LATE PROFESSOR OF OPHTHALMOLOGY, MEDICAL COLLEGE, MADRAS; AND LATE FELLOW OF THE UNIVERSITY OF MADRAS;

HONORARY FELLOW OF THE AMERICAN ACADEMY OF OPHTHALMOLOGY AND OTOLARYNGOLOGY.

WITH 45 ILLUSTRATIONS

PAUL B. HOEBER
67 & 69 EAST 59TH STREET
NEW YORK
1918

Printed in England

To
E. C. I. E.

To

E. TREACHER COLLINS, ESQ., F.R.C.S. ENG.,

IN GRATEFUL ACKNOWLEDGMENT OF THE ASSISTANCE
WHICH HIS WORK ON THE PATHOLOGY OF THE EYE
HAS BEEN TO ALL WHO DESIRE TO ADVANCE THE
SCIENCE OF OPHTHALMOLOGY

PREFACE

It is a quarter of a century since I first landed in India. In common with very many other surgeons, my attention was early attracted to the operation of couching as performed by its Indian exponents, and I was horrified to see how bad the majority of the results were. It appeared to me that the outstanding need was for carefully compiled statistics, in order that a fair judgment might be formed on the subject. I divested my mind of partisanship and bias, and sought every opportunity to discuss the method and its results with anyone and everyone whose knowledge was likely to be of use to me in my quest, whether they were laymen or surgeons, Europeans or Indians, officials or non-officials. The office of Superintendent of the Government Ophthalmic Hospital, Madras, afforded an unrivalled field for work, and the staff of the hospital co-operated with me in a manner which I find it impossible to acknowledge suitably. My thanks are especially due to Lieutenant H. C. Craggs, Assistant-Surgeon C. Taylor, and Dr. Ekambaram, for the valuable help they gave me. After I left India, Captain W. C. Gray acted for me as Superintendent, and later Major H. Kirkpatrick succeeded me permanently. Both of these officers most generously placed the material of the hospital still at my disposal, and rendered me very valuable service in the study of my subject. The great majority of the microscopic slides were very beautifully prepared for me by Mr. W. Chesterman. I am also indebted to Mr. S. Stephenson and Mr. A. C. Hudson for very kindly sectioning some of the globes for me. The photographs, both macroscopic and microscopic, were taken by Mrs. Elliot, without whose help I could not have written the book. Mr. E. Treacher Collins has generously given me advice and assistance of the greatest value in the study of a number of the preparations, and I have acted freely on the suggestions he has been good enough to make. I desire to express to the Council of the Royal College of Surgeons of England my acknowledgment of the honour they conferred on me by electing me to a Hunterian Professorship of the College. By the kindness of the authorities concerned, I have been enabled to include in this book articles which have appeared in the Lancet, in the Ophthalmic Record, and in the Proceedings of the Ophthalmological Society of the United Kingdom.

The collection of fifty-four eyeballs, on which the work for my Hunterian Lectures was founded, I have had the honour to present to the Museum of the Royal College of Surgeons. I think I am justified in claiming that it is unrivalled, and likely to remain so. At the suggestion of Sir John Bland-Sutton, I have endeavoured so to write the chapter on pathology that it may furnish a guide to any who care to study the subject within the walls of that museum. At the same time, I have striven to make it readable and of interest to those who have no such opportunity. In this the photographs have greatly helped me.

As I have already said, I have given nearly a quarter of a century’s intermittent work to elucidate these problems, which I felt were of wide interest, not merely to India or to the East alone, but to the whole civilized world. During the last two years I have devoted a very large proportion of my spare time continuously to the subject, but it is so immense and so far-reaching that I feel I have left much unfinished. On every hand fresh problems open up, till there seems no limit to what might be done, given time and opportunity. This operation of couching, so old that its origin is lost in the dim mists of antiquity, has still much that is new to be learnt for the seeking. There are many of the younger surgeons in the East who could carry the work much farther if they would, and who would be a hundred-fold repaid if they did. Will they?

ROBERT HENRY ELLIOT.

54, Welbeck Street,
Cavendish Square, W.,
1917.

CONTENTS

CHAPTER PAGE

I. THE HISTORY OF COUCHING 1

II. THE TECHNIQUE OF THE OPERATION 14

III. THE INDIAN COUCHER AND HIS HABITS 19

IV. STATISTICAL 25

V. THE PATHOLOGICAL ANATOMY OF COUCHED EYES 35

VI. DIAGNOSIS 77

VII. CLINICAL 85

INDEX 92

LIST OF ILLUSTRATIONS

FIGS. 1 AND 2. BARTISCH’S OPERATION (PLATE 1.) Frontispiece

FIG. PAGE

3. THE STAGES OF DEPRESSION 8

4. THE STAGES OF RECLINATION 8

5. SCARPA’S NEEDLE AS USED BY MACKENZIE 8

6. THE ANTERIOR METHOD OF COUCHING 14

7. THE POSTERIOR METHOD OF COUCHING 14

8. GROUP SHOWING THE INDIAN OPERATION OF COUCHING 15

9. THE INSTRUMENTS USED IN COUCHING IN THE SOUTH OF INDIA 17

PLATE II. FACING PAGE

10. LENS DISLOCATED BETWEEN CILIARY BODY AND SCLERA } } 11. NUCLEUS OF CATARACT FREELY MOVABLE BETWEEN THE AQUEOUS } AND VITREOUS CHAMBERS } } 12. LENS IMPACTED IN ANGLE OF ANTERIOR CHAMBER } } 38 13. CAPSULE OF MORGAGNIAN CATARACT IMPACTED IN ANGLE OF } ANTERIOR CHAMBER } } 14. LENS FLOATING FREE IN VITREOUS CHAMBER } } 15. LENS LIGHTLY IMPRISONED IN EXUDATE INTO VITREOUS CAVITY }

PLATE III.

16. ABUNDANT EXUDATE INTO VITREOUS CAVITY } } 17. LENS FIRMLY FIXED BY ORGANIZED EXUDATE } } 18. LENS FIRMLY FIXED BY ORGANIZED EXUDATE, BUT IN UNUSUAL } POSITION } 42 } 19. TOTAL DETACHMENT OF RETINA, WITH CYST FORMATION } } 20. RECLINED LENS LYING IN FRONT OF THE HYALOID BODY } } 21. RECLINED LENS LYING IN FRONT OF THE HYALOID BODY }

PLATE IV.

22. LENS DISLOCATED BEHIND RETINA } } 23. FISTULA OF THE CORNEA } } 24. CAPSULO-CORNEAL SYNECHIA } 48 } 25. RETINO-CORNEAL SYNECHIA } } 26. SCLERAL FISTULA } } 27. " " (MAGNIFIED) }

PLATE V.

28. INJURIES TO UVEAL TRACT } } 29. FOREIGN BODY (TIP OF COPPER PROBE) IMBEDDED IN THE EYE } } 30. TRAUMATIC DETACHMENT OF RETINA AND CHOROID } } 31. WHOLE-SECTION OF FIG. 19 } 54 } 32. PART OF THE ABOVE MAGNIFIED TO SHOW LENS IMBEDDED IN } INFLAMMATORY EXUDATE } } 33. PHAGOCYTOSIS }

PLATE VI.

34. L’IRIS BOMBÉ AND RETINAL CYST } } 35. MATTING OF STRUCTURES OF THE EYE DUE TO INFLAMMATION } } 36. " " " " " } (HIGHER MAGNIFICATION) } 58 } 37. UNUSUAL APPEARANCE OF EXUDATE INTO THE VITREOUS CAVITY } } 38. INFLAMED OPTIC NERVE HEAD } } 39. ADVANCED ORGANIZATION OF VITREOUS EXUDATE }

PLATE VII.

40. HÆMORRHAGE INTO VITREOUS CAVITY } } 41. PROLIFERATIVE DOT IN RETINA } } 42. COLLECTION OF LEUCOCYTES ON SURFACE OF RETINA } } 43. SMALL CYSTS IN RETINA } 72 } 44. WHOLE-SECTION OF FIG. 34, SHOWING L’IRIS BOMBÉ AND } RETINAL CYST } } 45. ADHERENT LENS PRESSING ON IRIS BASE }

COUCHING FOR CATARACT

CHAPTER I

THE HISTORY OF COUCHING

The operation of couching for cataract is one of the most ancient procedures known to surgery, the earliest description of the method being that given by Celsus, a contemporary of Christ’s. The first historical mention of ophthalmic surgeons was in Alexandria, at the time when medicine and surgery underwent separation from each other in that great and flourishing city, nearly three centuries before the dawn of the Christian era, and Galen states that some of these surgeons devoted themselves exclusively to operating on cataracts. Celsus speaks of the writings of a famous Alexandrian surgeon, named Philoxenes, who lived 270 years before Christ, and from whom he apparently derived much of his lore. These writings have unfortunately been lost, thus yielding to Celsus the proud position of being the first author whose description of the operation has come down to modern times. Sprengel is of the opinion that couching was not only known long before the time of Celsus, but also that the technique of the operation, even at that distant era, varied widely in the hands of its different exponents. Of the correctness of this view there can be little doubt. Sir John Bland-Sutton has recently published a most interesting memoir on the recovery of the sight of Tobit at the hands of his son Tobias, as described in the Apocrypha, and has included in it a copy of Rembrandt’s picture of the famous operation. Whether the displacement of the lens was due to the rubbing employed or to more definite operative measures must be left to speculation, but, in considering this point, it is worth remembering that the Eastern coucher of to-day hides the fact that he is performing an operation under the cloak of the application of a medicinal paste. Nor must we forget that the anointing of the eyes of the blind with clay played a leading part in one at least of the New Testament miracles, and is suggested in a second. It is to be remembered that the Founder of Christianity took His examples from, and moulded His teachings by the aid of things familiar to the people in their everyday life. The influence of the Oriental on the introduction of couching to the Western surgeon is shown by the repeated references in the history of the subject to Eastern exponents of the procedure. Thus, Razes speaks of the work of an Indian named Tabri, and Avicenna, himself an Arabian, describes at length the instruments and technique of the Arab cataract operators. Abu El Kasim’s name proclaims his Arab parentage, despite the fact that he is spoken of as a Spanish surgeon, and the conviction is deepened by the fact that he spoke of the Arabs in Spain as confining themselves to couching in the treatment of cataract, showing he was in intimate touch with them. Nor must we forget to mention the work of Haly Abbas, and of his distinguished son Jesu Haly.

When we endeavour to ascertain the probable date of the first invention of the operation in the East, the fog of uncertainty closes down over us, obliterates all trace of our quest, and drives us to fall back on inference. Those who have spent their lives in an Eastern land know the unbending force of tradition, the hereditary character of occupations, and the intense conservatism of Oriental peoples. All these influences are against change of any kind, and greatly retard the spread of new ideas. When we consider an operation like couching, which is well known over the whole of the East, and which meets in the simplest manner an age-long need, felt in every village of a tropical or subtropical country, it is not difficult to believe that the procedure may have been one of the early fruits of advancing civilisation, far away back in Babylon the Great, or even earlier still in the home of the Pyramids, tens of centuries before the dawn of the Christian era. From these attractive speculations we must return to weigh the literature of our subject, of which the foundation was so well and truly laid by the great Celsus. His description of the technique he employed is as follows:

“Before the operation the patient must use a spare diet.... After this preparation he must sit in a light place, in a seat facing the light, and the physician must sit opposite the patient on a seat a little higher; an assistant behind taking hold of the patient’s head, and keeping it immovable, for the sight may be lost for ever by a slight motion. Moreover, the eye itself must be rendered more fixed by laying wool upon the other and tying it on. The operation must be performed on the left eye by the right hand, and on the right by the left hand. Then the needle, sharp-pointed, but by no means too slender, is to be applied and must be thrust in, but in a straight direction, through the two coats, in the middle part betwixt the black of the eye and the external angle opposite to the middle of the cataract.... The needle must be turned upon the cataract and gently moved up and down there, and by degrees work the cataract downward below the pupil; when it has passed the pupil, it must be pressed down with a considerable force that it may settle in the inferior part.”

Further details follow. To put the matter shortly in modern terminology, Celsus introduced a needle through the sclera and choroid into the vitreous chamber, and depressed the lens from behind, after first rupturing its posterior capsule by vertical strokes made with the point of the instrument. As already mentioned, Galen (born A.D. 131) states that there were both in Alexandria and in Rome surgeons who confined themselves to operating upon cataract. Apparently he also described his own procedure, for some five centuries later Paulus Ægineta (circa A.D. 630), in detailing his technique, gave Galen the credit for it. There is practically no difference between the method they both employed and that originally laid down by Celsus. A point of real interest in this connection is that the description of the operation given by Paulus is practically the only one extant from the pen of a Greek author, though not a few of them mention couching and advocate it.

For the next landmark in the study of the subject we have to pass over three and a half centuries, till we come to the writings of Avicenna (circa A.D. 980), in which we find introduced a new feature in the technique; for he mentions that the Arab surgeons used two instruments for couching--viz., a two-edged lancet with which they made a corneal incision, and a needle with which they depressed the cataract, after introducing it through the incision thus made. In this needle there was an eye near the point, through which a thread was inserted. According to Avicenna, the object of this was to help depress the lens, but it seems at least possible that the thread passed through this eye was wound round the instrument, and so served as a stop, similar to that used by the Indian coucher to-day. In any case the description is of great interest, linking as it does the Mahomedan operator of the twentieth century with his predecessor of the tenth. The famous Spanish surgeon Abu El Kasim adopted exactly the same technique for couching as that we have just described. This, as has already been suggested, is not in the least remarkable, for his name bespeaks his Arab descent.

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.)

Fig. 5.

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). He divides the operation of couching into four stages, in only the last of which reclination differs from depression. These are: (1) the pushing of a special needle (Fig. 5) through the coats of the eye at a distance of 1/6 inch behind the temporal edge of the cornea, and to a depth of 1/5 inch; (2) the laceration of the posterior capsule of the lens by vertical movements of the point of the needle, to prepare an aperture for the passage of the lens; (3) the passing of the needle into the anterior chamber around the edge of the lens, and the laceration of the anterior capsule by vertical strokes; (4_a_) to depress the lens, the point of the needle is carried over its upper edge, and the handle is raised a little above the horizontal, thereby correspondingly lowering the point, which forces the cataract downward out of sight behind the pupil: the needle is then withdrawn by rotation; (4_b_) to effect reclination, the needle-point is raised not more than 1/10 inch above the transverse diameter of the lens: its concave surface is pressed against the cataract, which is reclined by moving the handle of the instrument upward and forward, thereby causing its point to pass downward and backward. The cataract is thus made to fall over into the vitreous humour, and is then pressed downward, backward, and a little outward. Mackenzie adds many interesting details as to the modifications of the operation, according to the variety of the cataract to be dealt with, and as to the after-treatment and complications met with.

We come now to a very interesting phase in the study of the operation of couching. We have shown reason to believe that, like many another valued heritage of the West, it was brought there originally by Wise Men of the East. For more than eighteen centuries it remained a treasured possession of surgery, only to yield its ground before the fierce competition of a method better able to survive the stern test of experience. Slowly but surely its decadence banished it from modern scientific European literature, and then, strangely enough, the advent of Listerism fanned the dying flame of interest in the method; but this time in the East, and not in the West. From the East it had sprung to find a home in the West, and in the East, at the hand of Western surgeons, its last, and by no means least, interesting chapter is in the course of being written. A review of the more recent literature on the subject will establish this contention, and will show how large a share the officers of the Indian Medical Service have taken in the settlement of a question which, apart from its scientific value, has important social and even political bearings.

After a brief visit to India, Hirschberg, in 1894, published an article on couching, in the course of which he spoke favourably of the results of the operation. He was, unfortunately, handicapped by his ignorance of the natives of India and of their ways and customs, with the result that his views on the subject are of comparatively little interest to us. In the following year Captain H. E. Drake-Brockman described the operation of couching as explained to him by one of its Indian exponents. The latter pierced the sclerotic with a small lancet in the lower outer quadrant close to the cornea, and then introduced a copper needle; “a series of motions of the hand are made from the position on first introduction of the needle to a point corresponding to it in the upper section of the outer diameter of the eyeball.” The depression of the lens appears to have taken place next, but the description is throughout somewhat vague. Presumably the operation was the same as that described by Ekambaram, but the coucher does not seem to have been able to make the steps of the procedure as clear as that surgeon has done.

Henry Power, in the British Medical Journal (October, 1901), entered a plea for the occasional performance of the operation of depression in cases of cataract. His experience went far enough back to enable him to remember the time, not only when he had seen surgeons of repute employ this method, but when he had himself imitated the example thus set. His own practice had been to attack the cataract, via the sclerotic, through the posterior capsule. He framed a number of indications which to his mind justified the occasional performance of couching. It is safe to say that very few of these would be seriously entertained by surgeons to-day. The most interesting point he made was in connection with Himly, in whose work, published in 1843, the statement occurred that “severe inflammation rarely followed reclination, and when it did it often cleared up without leaving any bad consequences.” A doubt as to the reliability of Himly’s statements is suggested by his claim that he had only two failures in fifty cases, one of these not being attributable to the operation. This is so much at variance with the experience of others as to make one sceptical about accepting any of his assertions without some reservation.

The next paper of value that we come to is by Maynard (1903). In this he analysed sixty-three cases of couching, which he had met with in Indian practice, and recorded the anatomical examination by Parsons of a couched eye sent home for the purpose. The same year saw the appearance of a paper by Albertotti of Medina, in which that writer somewhat fanatically and unconvincingly advocated a return to couching, with the use of a corneal puncture and with the employment of special instruments for the purpose. A year later he was followed along the same lines by Basso of Genoa, whilst Quartillera published a paper whose recommendations were very similar to those made by Henry Power. In 1905, Major Henry Smith of Jullundur, in a very outspoken article in the Indian Medical Gazette, expressed the opinion “that lens couching at the present time is an operation which should not be practised outside the ranks of charlatans,” and added that “it is no easy matter to completely dislocate the lens, and in my observation the partial dislocation is more frequent than the complete in the hands of adepts of the art.” In reply to this paper, Maynard reaffirmed his belief that couching is “justifiable under certain conditions.” The editor of the Indian Medical Gazette invited further discussion of the subject, and in accordance with this request the writer published his statistics based on 125 cases of couching, carefully recorded on printed schedules. In the course of that paper he voiced his strong opposition to the adoption of the Indian operation, or of any modification of it, in the hands of surgeons who enjoy the unique opportunity of obtaining manipulative skill granted to those who work in India. A former pupil of his, Dr. Ekambaram, studied the ways of the Indian coucher at first-hand, and gave the results of his experience in one of the most valuable contributions to the subject yet made. This was in 1910. Two years later the writer was able to review the statistics of 550 consecutive cases of couching, all of which had been carefully noted. Still more cases accumulated before he left India, and by the kindness of Major Kirkpatrick, the total under review has now reached 780.

The examination by J. H. Parsons of a couched eye has already been mentioned. In 1913, A. C. Hudson sectioned and described a similar specimen sent him from India by the writer. The only previous published records of the same kind are from the pen of E. Treacher Collins, and refer to four specimens of couched eyes in the Museum of the Royal London Ophthalmic Hospital. Major H. Kirkpatrick has recently examined several more cases in Madras, and has kindly communicated some of the more interesting of his findings to the writer. Communications, that have been made from time to time before meetings of ophthalmologists, show that British surgeons of the first rank are still in favour of performing couching under certain special conditions. A marked instance of this is to be found in the discussion which took place before the Ophthalmological Society of the United Kingdom on February 8, 1906, following the presentation of a case by Holmes Spicer. On that occasion Rockliffe and Treacher Collins stated that, like Spicer, they had performed the operation in exceptional cases, and Devereux Marshall and G. W. Roll accorded it a modified support under such conditions. The writer has also learnt from personal communications that other leading surgeons have taken a similar line. There for the present we must leave the history of this operation, whose origin is lost in the dim mists of antiquity, and whose chequered career forms one of the most interesting pages in the literature of medicine.

BIBLIOGRAPHY

ALBERTOTTI, GIUSEPPE: Benevenuti Grassi, de oculis eorumque ægritudinibus (réédition de l’incunable de Ferrare, 1498); Paris, 1897.

ALBERTOTTI, GIUSEPPE: Depression of Cataract, La Clinica Oculistica, June, 1903.

AMERICAN ENCYCLOPÆDIA and Dictionary of Ophthalmology, Casey Wood; Chicago, 1916.

BASSO: La Clinica Oculistica, January, 1904.

BLAND-SUTTON, SIR JOHN: On an Apocryphal Miracle, Middlesex Hospital Journal, vol. xx., No. 1.

BRISSEAU: Traité de la Cataracte et du Glaucome; Tournay, 1706.

CELSUS, A. CORNELIUS: Of Medicine, trans. by James Grieve; printed by D. Wilson and T. Durham, Strand, London, 1756.

COLLINS, E. TREACHER: R.L.O.H. Rep., 1893, vol. xiii., p. 308.

CUSSON, M. P.: Remarques sur la Cataracte, à l’Académie des Sciences de Montpellier, 1779.

DRAKE-BROCKMAN, Surg.-Capt. H. E.: The Indian Oculist and his Equipment, Trans. of the O.S. of the U.K., vol. xv., 1895.

DRAKE-BROCKMAN, Lieut.-Col. E. F.: The Indian Oculist and his Equipment, Trans. of the O.S. of the U.K., vol. xv., 1895.

EKAMBARAM, R.: Couchers and their Methods, Ind. Med. Gaz., 1910.

ELLIOT, R. H.: Couching of the Lens, Ind. Med. Gaz., August, 1906.

ELLIOT, R. H.: The Operation of Couching as practised in Southern India: a Review of 550 Cases, Proc. of S. Ind. Branch of B.M.A., 1912, and Ophthalmic Review, vol. xxxi., 1912.

ENCYCLOPÆDIA BRITANNICA.

GALEN: De partib. art. med.

HAY-WILLIAMS: Practical Observations on Surgery; London, 1803.

HIRSCHBERG: Centralblatt für Praktische Augenheilkunde, February 1, 1894.

HIRSCHBERG: Centralblatt für Praktische Augenheilkunde, 1908, vol. xxxii., p. 2.

HISTOIRE DE LA MÉDECINE, par Kurt Sprengel, trad. par A. J. L. Jourdan; Paris, 1815.

HISTOIRE DE L’OPHTHALMOLOGIE à l’École de Montpellier, par H. Truc et P. Pansier; Paris, A. Moloine, 1907.

HUDSON, H. C.: R.L.O.H. Rep., vol. xviii., part ii.

MACKENZIE, W.: On the Diseases of the Eye, 4th edit., London, 1854.

MAYNARD, F. P.: Ophthalmic Review, April, 1903.

MAYNARD, F. P.: Ind. Med. Gaz., May, 1905.

PAULUS ÆGINETA, vol. ii., Sydenham Society, 1845–46.

POTT, PERCIVAL: Remarks on Cataract.

POWER, H.: Depression in Cases of Cataract, Brit. Med. Journ., October, 1901.

QUARTILLERA, CASTILLEY: Arch. de Oftal. Hispano-Americanos, October, 1904.

SMITH, H.: Cataract Couching, Ind. Med. Gaz., May, 1905; and Trans. of the O.S. of the U.K., 1904, p. 264.

WARE, JAMES: The Cataract and Gutta Serena, 3rd edit., London, 1812.

WILKINSON, MISS K. E.: The Manuscripts of Naples and the Vatican, etc., trans. from Albertotti, Ind. Med. Gaz., October, 1904.

CHAPTER II

THE TECHNIQUE OF THE OPERATION

The writer has never seen a native coucher at work, and consequently all his information on the subject has had to be gathered from those who have been more fortunate than himself in this respect. There would appear to be two distinct modes of operating, which for convenience’ sake may be spoken of as the anterior and the posterior, using the terms relatively to the plane of the ciliary body and iris (Figs. 6 and 7). We shall take them in turn.

Fig. 6.--Anterior Operation.

Fig. 7.--Posterior Operation.

Fig. 8.--The Operation of Couching.

=The Anterior Operation.=--The patient and operator sit facing each other in a good light; both squat on their hams in accordance with the immemorial custom of the East (Fig. 8). The patient is frequently, if not usually, told that no operation is to be performed, and that it is merely a question of putting medicine into the eye. He is directed to look downward, and the coucher raises the upper lid with one hand whilst in the other he conceals either a needle or a sharp thorn. It is said that the long needle-like thorn of the babul-tree is usually selected for the purpose. Many of the patients have mentioned that their heads were steadied by a friend from behind. In the majority of cases, at least, it would appear that no form of local anæsthesia is attempted. The operators appear to rely largely on manual dexterity, and to aim at completing the procedure in a minimum of time. The needle or thorn is thrust suddenly through the cornea, and on through the pupil or iris, into or on to the periphery of the lens. The next movement, which appears to follow the first so rapidly as practically to melt into it, is that of depression or reclination. In this, the spot where the cornea grasps the shaft of the needle serves as a fulcrum. The operator raises his end of the instrument, and the opposite one, which lies either on the surface of the lens or imbedded in it, is consequently depressed, thus carrying the cataract with it downwards, or downwards and backwards, and so clearing the pupil. In the course of speaking to a very large number of patients thus operated on, it has struck the writer as most remarkable that they made as little complaint as they usually did of the pain inflicted on them during the operation. They described the sensation of a sudden prick, but it was obvious that they had no acute recollection of agonising suffering. This point is emphasised by the fact that in nearly every case the operator tested his patient’s vision immediately after the operation by holding up fingers, coloured cloths, necklaces, or other common objects, for triumphant identification. Very great stress is laid on this part of the ritual, and the onlookers are not allowed to lose sight of the wonderful results achieved by the operation. There seems reason to believe that an effort is made to enter the point of the instrument through the pupil, and to pass it between the iris and the lens. This cannot fail to be a difficult thing to do, as is evidenced by the frequency with which we were able to discover scars in the iris, which had obviously resulted from tears at the time of the operation. The point of perforation of the cornea could frequently be discovered, especially if a loupe were used for the purpose. The relative positions of the scars in the cornea and iris were frequently of great value to us from the diagnostic point of view. The eye is bandaged for at least twenty-four hours. By the end of that time the operator has frequently placed a safe distance between himself and his patients of the day before, and is seeking fresh dupes in another village.

Fig. 9.--Instruments used in Couching.

=The Posterior Operation.=--Much that has been written on the preceding method applies with equal force to this. It is, however, possible to describe the technique much more accurately, as it has been carefully studied at first-hand by Dr. Ekambaram, who for many years worked under the writer in the Government Ophthalmic Hospital, Madras. His original description of the method will well repay a careful perusal. He speaks of the operators as being ambidextrous and very skilful. Their surgical equipment (Fig. 9) for the operation consists of a small lancet-shaped knife, guarded to within a few millimetres of its tip by a roll of cotton-wool, wrapped round it for the purpose, and of a copper probe 4 inches long and about 1-1/2 mm. in diameter. A cotton thread twisted round this probe at a spot 12 mm. from its point serves the same purpose as the stop in the Bowman’s needle. From the point to this stop the instrument is triangular in section. The patient is directed to look well towards the nose, and the surgeon then gently marks out the selected spot by pressing with his thumbnail on the conjunctiva covering the sclera, about 8 mm. out from the cornea, and about 2 mm. below the horizontal meridian. In some cases the operator steadies the eye by firm digital pressure exerted through the partly everted lower lid. He next takes his lancet in his hand, and it will be observed from the illustration (Fig. 9) that it might easily pass for a roll of cotton-wool; this, indeed, is what the patient is led to believe it really is. To heighten such an impression, the point is covered with a sandalwood paste, prepared beforehand coram publico, with a good deal of ostentation. The patient is informed that this “cataract-cleansing drug is about to be applied to the eye,” and under cover of the suggestion the operator plunges the lancet through the tunic of the globe at the spot already selected. The alarm thus occasioned is allayed by the assurance that the “medicinal application” is over. The copper probe is next produced, and is inserted through the wound up to its stop, being held between the thumb and two fingers; a circular movement is given to its point, the stop resting against the puncture, and serving as a pivot for the movement. According to Ekambaram, the object is to tear through the suspensory ligament from behind. Immediately following this step, a downward stroke of the point is made in order to depress the now loosened lens. Ekambaram graphically describes the care taken by these operators to impress, alike on the patient and on the friends, the magical effects of the procedure. The former is shown a number of objects, and is bidden to name them in turn, and to state their colour. The crowning point is reached when the surgeon removes a thread from his garment, and the patient not merely recognizes it as such, but triumphantly tells its hue. The Western ophthalmic surgeon, with his wide incision and his anxiety for the safety of the vitreous, can never savour such dramatic moments as these. They carry us back to the descriptions of the early Christian miracles, with all the mental and spiritual associations, which enwrap such stories as those of Bartimæus, and of the pools of Siloam and Bethesda. Alas that life’s “hereafters” should so often be fraught with disillusionment, disappointment, and suffering! Palestine and its storied past rise before us as we read how the vaidyan called for a white cloth and for water, how he dipped the cloth in the fluid and washed out the sufferer’s eye therewith, how he made a paste and smeared it over the skin around the brow, how he closed the eye with “clean white linen,” and then sent the erstwhile blind man rejoicing away. Over the abyss of nearly twenty centuries, the East stretches out her unfaltering hand to the past of the nearer East, whilst the West looks on in wonder, not unmixed with admiration, for a spirit which the corroding passage of time seems unable either to fret or to change.

There is a step of the procedure which has been purposely left to the last, as its interest is psychologic, and not surgical. It is common to both methods of operation. I refer to the anointing of the eye with the blood of a freshly killed fowl. It is a measure in which superstition, cunning, self-preservation, and greed, overwhelm and mask a faint and feeble therapeutic design. The sacrificial element is present, and a hazy idea that the death of the votive bird may turn evil from the patient looms in the background. Next comes the need to mask the shedding of the patient’s blood, since he is often told that no operation is to be performed, but that a mere “medicinal application” is to be made; the blood of the outraged bird covers the guilt of the vaidyan’s falsehood. Largest of all towers the fact that the curry-pot even of a worker of surgical marvels needs constant replenishing, and that fowl is an excellent substitute for mutton on such occasions. Lastly, these men seem to believe that the coagulation of the fowl’s blood helps to close the puncture. In view of the dirty condition of the instruments which they introduce into the interior of the eye, this last factor may practically be neglected.

CHAPTER III

THE INDIAN COUCHER AND HIS HABITS

The coucher goes by different names in different parts of India. In Bengal and in the United and Central Provinces he is known as the “suttya” or “mal,” and in the Punjab as the “rawal.” Ekambaram, who came into intimate contact with these men in the Madras Presidency, always describes them as “vaidyans,” the term signifying surgeons. In the north they are Hindus, of the Kayasth caste, a class well known for its astuteness and educational qualifications. Drake-Brockman states that in the north Mahomedan couchers are rare, whilst in the Southern Presidency it appears to be the exception to find a Hindu doing such work. Like every other occupation, couching in India is hereditary, the principles of the craft being handed down from father to son by word of mouth and by practical instruction. It has been stated that there is no literature on the subject. This, however, would appear to be a mistake, for Ekambaram learnt that there are “some old texts written on palmyra leaves laying down the method.” A literal translation of one of these runs: “Removing the lancet after making a puncture, insert the copper probe; and holding it with three fingers, depress the lens with the three-sided edge.”

By tradition and ancestral habit, the coucher is a wanderer on the face of the earth, and like a gipsy he carries his wares, such as they are, to the very doors of the people’s homes; but it is probable that in each of the large provinces of India these men have a headquarters of their own. This in the Madras Presidency is known as “Kannadiputhur,” which signifies the “village of eye operations.” During part of the year these men are agriculturists and fishermen; but when the dry season robs them of their occupations, they wander forth to practise the art, with which their ancestors have been identified from time immemorial. They do not, however, confine themselves to eye operations, but practise as well a crude form of general surgery. Like many other disciples of Æsculapius, their fee is a very elastic one, and, in common with other artists, they learn to know both the smiles and the frowns of fortune. Luxury rarely comes their way, whilst hardship and toil are their constant lot. Their spare evening hours are filled in with such arduous and monotonous occupations as net-weaving; and full many a night they go hungry to sleep, with the sun-baked earth for their only bed.

All, who have seen them at work, agree that their methods are dirty and septic to a degree, and the oft-expressed wonder has ever been, not that their results are so bad, but that they are ever good. Their surgical equipment is carried in a bag or in a box, which would be considered dirty alongside of the tool-chest or work-basket of any English artisan. The filth alike of their clothes, their hands, and their person, stagger description from a surgical point of view. The exact patterns of the instruments used vary in different parts of India, and so also do some of the couchers’ customs. Allusion has already been made to the slaughter of a fowl and the use of its blood in Southern India. This is readily understood, as the Mahomedan couchers are flesh-eaters. In the north, where these experts are Hindus, the fowl plays no part, but a very subtle form of deception is described by Drake-Brockman. Each suttiah carries in a little bag a store of pieces of dried membrane. One of these is dropped into water before the operation commences, and is produced at the psychologic moment as evidence that the Indian surgeon can, and does, remove the cataract from the eye, just as much as his Western brother. This tribute to our science is as subtle as it is nefarious. The pieces carried are of various tints, in order that the colour of the cataract, as seen before operation, may be matched as closely as possible.

Right through the ages the shadow of charlatanism has lain over the operation of couching. We are told that it did so in Alexandria and in Rome at the dawn of the Christian era, and from that time up to the present we find numerous traces of it in literature. Not the least interesting of such comes from the Dark Ages, and, despite its pathos, has a distinctly amusing side. The operator and his assistant took the patient alone into a darkened room; a candle was lighted and kept carefully behind the victim’s back by one of the knaves, while the other in front asked if he could see the flame. A sham operation was then performed, and the process was again repeated, but this time with the light in front; naturally the blind man could now see it, and, on being assured that “the change” was due to what had been done, his gratitude was likely to rise to the production of the necessary fee. If it did so, the impostors speedily made off. It seems hard to believe that even the Dark Ages were dark enough for so transparent a trick to be tried often in one town.

In a recent personal communication, Dr. Ekambaram has very kindly furnished the writer with some additional information, as new as it is interesting. He divides the Indian couchers, with whom he has come into contact, into two classes, the Mahomedan couchers of the south, whose work we mainly meet with in Madras, and the Punjabis (people of the Punjab) from the north. The same method of operation is adopted by both, but there would appear to be a great difference between the status and the attainments of the two classes. The Mahomedans are much the lower type; their practice is confined to the villages through which they roam, and they very rarely visit big towns. Their length of stay is limited to one or two days, and they make haste to escape soon after having performed an operation, “for fear of being clubbed for their stupid action.” They do not use any form of anæsthetic. On the other hand, the Punjabi couchers are described as intelligent, respectable, decently clad men, who confine their work to the towns, and stay in each place four or five months, amassing considerable wealth thereby. Before couching, they drop into the eye a fine yellow powder, which Ekambaram believes to be stained cocaine. They were, however, extremely secretive on this subject, and refused to part with even a grain of the drug at any price he could offer. Its efficiency is testified to by the fact that the patients remained absolutely quiet and collected during the whole of the operation. The cases are kept under observation for from a week to a month after operation, putting in a daily attendance. Their results are much better than those obtained by the Mahomedans. Some of the fees they obtain are relatively very large. An idea of their social status may be gathered from the fact that carriages are sent for them by their better-class patients; but, in Ekambaram’s opinion, the aristocracy of Indian intelligence is learning to keep aloof from these men, owing to the influence of the Western surgeons, whose method of extraction is steadily establishing itself in the esteem of the people at large. He gives credit to the Punjabis for a more efficient technique of operation than that practised by the Mahomedans.