Robert H. Elliot

“ We know, however, that injury to the retina does not produce pain; and we are also well aware of the extreme susceptibility of the cornea to pain. Surely the extent of damage inflicted on sensitive structures is, as a rule, much greater in an extraction than it is in a couching. How then are we to explain the dread with which surgeons, in the days of couching, looked forward to the suffering and vomiting which sometimes followed the operation? ”

“ 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. ”

“ 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. ”

“ One cannot conclude better than by a quotation from the writings of Lieut.-Colonel Henry Smith, who has had very large opportunities of observing the results of cataract couching. He is known to be a very skilful operator, and one, therefore, who is little likely to exaggerate the difficulties of any ophthalmic procedure, yet he writes: “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.” ”

“ 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. ”

“ In the rare event of a lens being dislocated into the anterior chamber and fixed there, its presence can be easily recognised. Again, in a large number of the cases which present themselves in the out-patient room, the cataract can be seen floating freely in the vitreous, and bobbing up and down with the movements of the eye. In the case of the milky Morgagnian cataracts, or of those cortico-nuclear cataracts which present a glistening and pearly-sectored appearance, it would be difficult even for a beginner to fail to see the lens, which usually lies at the lowest part of the eye. ”

“ Our next consideration is that of the cases in which the cataract still lies behind the pupil. It then seldom, if ever, is in absolutely normal position, and it very frequently is found to have been moved bodily downwards or to one side, or obliquely. Again, but more rarely, it may be tilted backward at an angle with the plane of its normal position. In a great number of cases the history will help one, and, even when the patient denies couching, he will very often admit to having had “medicine applied to his eye by a native practitioner.” ”

“ When, after Daviel’s discovery, extraction came into serious competition with the older operation, surgeons discussed at much length the relative merit of the two procedures, and it was strongly urged by the extractionists that their operation gave rise to less pain than that of couching. The subject is a very difficult one, for no surgeon, who has had a large cataract practice, can fail to have been struck by the extraordinary difference in the statements of patients as to the amount of suffering they have endured during the first twenty-four hours after the removal of a lens. ”

“ This subject has been dealt with much more fully in the chapter on pathology. The dilatation of the pupil by a mydriatic will often make it quite easy to discover the whereabouts of the cataract, especially if a strong light, whether natural or artificial, is focussed on the eye by means of a lens. Natural light is preferable to artificial if possible, especially in a country like India, where powerful daylight can be counted on during a large part of the year. The advantage of the white light is especially marked when dealing with brown or dark-coloured cataracts. ”

“ It has been said of these men that they have no diagnostic powers, and it is quite certain that they sometimes couch the lens in cases of optic atrophy, of glaucoma, and of certain other diseases, in which such a step is useless and worse. It is fair to add that the number of cases of this kind which the writer saw was not large. This observation is the more significant, since he was keenly on the lookout for any instances of the kind, and that, too, during many years of Indian experience in an exceptionally large cataract practice. ”

“ From these cases we pass on to consider those in which the lens cannot be seen at all, owing to the occlusion of the pupil. Here our difficulties are greater still, and, if the history fails us, we must fall back on a careful search for signs of wound scars in the cornea or sclera, or of tears in the iris. A point which is always suggestive is the existence of a cataract in the opposite eye. In such cases as these, the contents of the chamber may be found to consist of pus or of blood. ”

“ There is a retino-corneal synechia. The lens has been reclined; it probably lay outside the vitreous cavity. The subretinal exudate, coagulated by preparation, gives the eyeball the appearance of a cut marble. During life the pressure of the lens, which had been wedged backward, thrust the retina and the parts adherent to it backward below, thus displacing the subretinal exudate there, and causing it to bulge in the upper half of the eyeball; this bulge effectually obliterated the upper part of the anterior chamber, whilst the direct pressure of the lens obliterated the chamber below. ”

“ At a later stage, or perhaps in cases where the inflammation has been of a more plastic character, a distinct fibrillation of the exudate can be seen, and there may even be evidence of a definite fibrous tissue formation. If we confine our attention for the moment to those eyeballs in which the exuded mass is devoid of structure in the anterior portion of the cone, we shall find that, on tracing it back toward the apex by which it is attached to the optic nerve, it becomes more highly organised and more richly cellular, whilst fibrillation and fibrous tissue formation make their appearance. ”

“ Lastly there are the cases in which the eye is undergoing shrinkage, and those in which phthisis bulbi is following panophthalmitis. The history of the signs and symptoms of severe iridocyclitis or of suppuration will, in India at least, always excite a suspicion of couching having been performed, unless the patient has a definite story to tell of some other form of injury. Strangely enough, the inventive faculty of the Indian patient does not rise to the height of vamping a narrative of the kind. If he has had an injury, he tells of it readily. ”

“ Few pictures are more pitiful than that of such a man passing hopefully down an avenue of credulity and ignorance to a fate to which death itself is often preferred, the horror of a great and lifelong darkness. ”

“ A point that we must never lose sight of is that the very great majority of these patients are in the glaucoma period of life, and with a certain number of them very little alteration of the status quo is required to precipitate an attack of pathological high tension. If we take all these factors into account, and especially if we bear in mind the great variability that different patients present in their sensibility to pain, we shall have little difficulty in understanding that couching may sometimes be followed within the first few hours by great suffering attended with vomiting. ”

“ That such an one should advocate and practise couching would cause no surprise to his own people, whose faith in methods based on tradition is firmly founded. Some idea of the complexity and confusion of the Indian mind to-day may be gathered from a knowledge of the strange blend of dissimilar lines of thought in those who have adopted Christianity. There are many such who keep a foot in both camps, in a way that would have been thought impossible by anyone who had not been brought into intimate contact with such people. ”

“ The plain indication is to arouse the medical conscience of the country, to start men thinking of the evils which are so rife in the land; and so to introduce a ferment, as it were, into the medical mind of India, and then to leave it to do its work. It is not suggested that the country is ripe for legislation on the subject. The people are not ready for it. ”

“ When we come to discuss the later pain, all difficulty vanishes. The frequency with which iridocyclitis and glaucoma dog the footsteps of couching in India, explains at once the bitter and oft-repeated history of pain coming on within the first two or three days, and lasting for months or even for years. ”

“ A few days later he presented himself at the out-patient room with panophthalmitis. There is no branch of ophthalmic disease and treatment in India which so profoundly impresses the Western surgeon’s imagination as this one. Remember that cataract strikes a man down in his maturity, at a period of his life when he has begun to reap the benefits of his earlier years of toilsome industry. ”

“ 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. ”

“ 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.” ”

“ Our pathological material has shown that in many such cases the retina was totally detached, whereas, in arriving at the figure above given, we were dealing only with those instances in which the diagnosis was established by the aid of the ophthalmoscope.
Ten of the cases in which failure was ascribed to optic atrophy showed no improvement in vision after operation. Their histories indicate that the atrophic condition was present before operation, and there seems to be a fair presumption that the coucher mistook the condition for cataract, or at least failed to recognise its true nature. ”

“ Sometimes the lens falls away from the pupil so quickly that the surgeon must stoop down and look up at the eye in order to see it. If even after this test he fails to see the cataract, it is safe to80 assume that it is tied down in its new position by inflammatory adhesions excited by the septic matter introduced at the time of operation. Such adhesions may consist merely of delicate fibrils of exudate, which slightly increase the consistency of the vitreous body, and so to a small extent limit the excursions of the lens ”

“ On the other hand, Government, the protector of the poor, stands by powerless to interfere, and supinely watches this catastrophic waste of human energy. The cords that bind the individuals are woven a million-fold together to tie the hands of the rulers more securely still. ”

“ So far as the Indian coucher is concerned, it seems a little doubtful whether he has any clear conception of the difference between the two procedures; indeed, so long as he gets the lens out of the way of the pupil, it is probable that he neither knows nor cares which method he has succeeded in adopting, though he probably much more often reclines than depresses. This may be explained by the experience of a number of European surgeons, that it is more easy to effect reclination than depression. ”

“ 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. ”

“ Our next group is a still more difficult one, for in it no fundus reflex can be obtained. It embraces a number of conditions which may be shortly dealt with in turn: (1) Those in which the vitreous body has been converted into a more or less highly organised inflammatory exudate, which is impenetrable to82 the light of the ophthalmoscope. (2) Those in which this vitreous exudate has contracted inflammatory adhesions to the retina, and by its shrinkage has determined the total detachment of that membrane. (3) Those in which the vitreous chamber has become filled with blood. ”

“ Lieut.-Colonel F. P. Maynard formed a much less unfavourable estimate of the coucher’s results (46 per cent. of successes) . The writer’s own statistics will be given later. Not the least interesting of Drake-Brockman’s contributions to the subject is his statement that vaccinators and compounders in the pay of the Indian Government are not infrequently couchers in disguise. The full significance of this observation can only be appreciated by one who knows the East intimately. Scientifically, Western medicine is educating the Indian medical man out into the light from pagan depths of darkness. ”

“ The interest of the experiments is heightened by the fact that, whereas in the Dutch experiments the toxicity of the virus was kept as constant as possible, in the Indian ones it varied from that of organisms which took many years to destroy the sight to that of one which at once produced a fulminating panophthalmitis. One point more: The Indian operator made no effort to confine his procedure (and with that procedure went infection) to any one structure; sometimes he attacked the lens from in front, and in doing so he often primarily injured the iris, but may have spared the vitreous chamber ”