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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 | |
II. | THE TECHNIQUE OF THE OPERATION | |
III. | THE INDIAN COUCHER AND HIS HABITS | |
IV. | STATISTICAL | |
V. | THE PATHOLOGICAL ANATOMY OF COUCHED EYES | |
VI. | DIAGNOSIS | |
VII. | CLINICAL | |
| INDEX | ||
LIST OF ILLUSTRATIONS
| FIGS. 1 AND 2. BARTISCH’S OPERATION (PLATE 1.) | Frontispiece | ||
| FIG. | PAGE | ||
| 3. | THE STAGES OF DEPRESSION | ||
| 4. | THE STAGES OF RECLINATION | ||
| 5. | SCARPA’S NEEDLE AS USED BY MACKENZIE | ||
| 6. | THE ANTERIOR METHOD OF COUCHING | ||
| 7. | THE POSTERIOR METHOD OF COUCHING | ||
| 8. | GROUP SHOWING THE INDIAN OPERATION OF COUCHING | ||
| 9. | THE INSTRUMENTS USED IN COUCHING IN THE SOUTH OF INDIA | ||
PLATE II. | FACING | ||
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 | ||
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 | ||
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 | ||
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 | ||
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) | ||
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 | ||
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.)
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]).
Fig. 5.
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; (4a) 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; (4b) 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.
In this connection it is interesting to record some of the opinions of Western surgeons, who have come in contact with the work of these northern men. Captain H. E. Drake-Brockman had nothing too bad to say of them, and his uncle Lieut.-Colonel E. F. Drake-Brockman (formerly of the Madras Eye Hospital), in presenting his nephew’s paper before the Ophthalmological Society of the United Kingdom, estimated the coucher’s successes at not more than 10 per cent. Lieut.-Colonel Henry Smith went so far as to declare that even the best cases, if followed long enough, ended in absolute blindness. 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. Even to-day there are those of them who practise Eastern and Western medicine side by side. It would seem strange to a British surgeon to learn that it is possible for a medical man (whose qualifications, from an educational point of view, compare favourably with those of our home Universities) to lay stress before his patients on the right quarter of the moon, and on the correct aspect of the ground, for the gathering of a particular drug; yet the writer has known this happen, and that, too, in the case of a medical man who held an important scientific appointment under Government. The very fact of a man holding a post under the British Rāj would add to his prestige and increase the confidence of the people in him. 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. Under these circumstances, it is hardly strange that the same kind of thing should be found in evidence in other lines of life; and yet it is no time to blame these men. Their need—I speak now from the scientific stand-point—is for “more light.” We ourselves retain to-day the taint of superstitions that come down from our witch-burning ancestors. Shall we not, then, be lenient to those who have never had our advantages? As we flood India with the daylight of true scientific knowledge, the vermin of ignorance and superstition will scurry away to hide. That the coucher believes in himself is indisputable; that he resents the invasion of our Western operation is easily understood; and that he must disappear, washed out by the advancing flood of better methods, is as certain as the fate of the furrows left on the sand by last night’s tide. Meanwhile he has stopped a gap and filled a place in the life of a nation, and it behoves us, in our estimate of him, to remember that the highest earthly honour ever awarded was given to a woman whom the world despised and blamed, in the immortal words: “She hath done what she could.”
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. Ekambaram speaks of a case of operable cataract in which he had dilated the pupil, and on which he (purely experimentally, and with no intention of allowing it to be done) asked couchers if they would operate. As soon as they found the pupil was motionless and dilated, they declined to undertake any operation. He comments favourably on the acumen they thus displayed.
A word may not be out of place on the subject of the covering of the head of the patient and surgeon with a cloth, as adopted by some few couchers during the operation. Such a procedure is, from the point of view of lost light, a handicap to the operator, but it has, from his way of looking at it, certain advantages. It shuts the patient off from the distractions of his surroundings, which are otherwise very public; it hides the actual operative procedure from prying eyes; and it conceals the facial and other evidence of pain. The greatest factor of all, in an Eastern land, is the air of mystery with which it shrouds the proceeding. The element of “jadu” (magic) so introduced is paramount in its psychologic interest.
CHAPTER IV
STATISTICAL
In the Indian Medical Gazette of August, 1906, the writer published a review of 125 cases of couching of the lens by Indian vaidyans. On March 13, 1912, the total had swollen to 550, and an analysis of all the cases was conducted on the same lines as those followed in the earlier communication. Subsequent to this, Major H. Kirkpatrick, the succeeding Superintendent of the Madras Eye Hospital, analysed 350 cases of the Mahomedan operation (the first 120 of which overlapped the series already dealt with by the writer), and in forwarding them made the comment that “these statistics are remarkably similar to those of your series.” In view of the consistency of the results obtained and of the large figures dealt with it seems safe to assume that reliable deductions can now be drawn.
The main headings of these statistics will next be taken up. Before commencing to do so, it is of special interest to note that the methods observed by Colonel Drake-Brockman in other parts of India tally closely with those described by Ekambaram in Southern India. This is the more readily understood when we remember that many of the operators in the South of India come from the north. This observation puts our cases on all fours with those published from other parts of India.
It is perhaps difficult to form an accurate opinion as to how far the figures before us represent the best results attained by the coucher. His apologists might urge that only his failures would come to English hospitals. On the other hand, there can be little doubt that quite a considerable number of eyes are lost, after couching, from panophthalmitis and from shrinkage of the eye following iridocyclitis. Patients in such conditions will often stay away from hospital owing to their very hopelessness; and even if they do resort to English treatment, they will stoutly deny that their eyes have been interfered with. Thus in both ways the records of such failures are lost, making the net result appear better than it really is. In collecting our statistics, we were constantly on the lookout for all cases of couched lens, and have notes of a large number of patients who did not come to hospital for the eye in which reclination had been performed.
Considerable interest attaches to the study of the column showing the periods that elapsed between the Mahomedan operation and the date at which the patient came under observation. Only 6·82 per cent. were seen within the first month, and but 17·88 per cent. within the first six months. The following six months added only 5·65 per cent. The great mass of the eyes had been operated on from one to ten years previous to being seen. This in itself would indicate that the cases, from which our observations were made, were drawn from the mass of the people rather than from the coucher’s failures alone.
An argument in support of the reliability of our figures may be drawn from the extraordinarily widespread opinion, amongst both European and Indian practitioners, that the vaidyans’ results are appalling. The writer had the opportunity of talking on the subject with a large number of men who practised in the parts where couching was rifest, and their testimony was unanimous. Ekambaram, who has already been freely quoted, has made these men’s methods a special study, and, impressed by the wholesale destruction of eyes he had witnessed, made the request that the matter should be brought to the notice of Government through the Surgeon-General, which was accordingly done. Apropos of the figures now under discussion, Colonel Drake-Brockman wrote: “I have seen quite enough to convince me of the truth of Major Elliot’s statement, and that his percentage of actual loss of eyes from this cause alone is by no means exaggerated.” Major Smith has given his experience of the disastrous results of couching, and has gone so far as to say that even the best cases, if followed long enough, end in absolute blindness. With this last observation we cannot wholly agree, nor do our statistics in the south bear out his opinion that “partial dislocation is more frequent than the complete dislocation in the hands of adepts in the art.” He is satisfied that a great majority of cases go bad immediately, either from suppuration or from iridocyclitis, and that a large proportion of the remainder are but imperfectly couched. Other surgeons, too, have testified to the disastrous nature of the vaidyans’ results.
Only 4·94 per cent. of the total number of cases lie below the age of 36, and nearly 69 per cent. lie between the ages of 40 and 60. This is in accordance with what we know of senile cataract in India. Of the fourteen cases which show an age of 30 or below, eight may be excluded as having probably given their ages too low; one was lost by suppuration after couching, and no deduction can be made as to the condition before operation; in two it seems probable that the cataract was secondary to syphilitic iritis: they were two eyes of different persons; in one patient the operation failed on both sides: the eyes were congenitally imperfect, and in addition iritis was present as a complication in one of them. In the sixth the operator evidently burst the capsule and let out its semi-fluid contents; but the nucleus remained in situ and blocked the pupil. It is obvious that couching is an extremely unsuitable operation for this class of case; it requires for its easy performance a firm lenticular mass, but as will be seen when we come to discuss the morbid anatomy of the subject, it is quite possible to dislocate one of these fluid lenses intact. There is at least a presumption that in such cases the posterior operation has been performed, though, in view of the toughness of the capsules of not a few Morgagnian cataracts, one cannot say with certainty in all such cases that the anterior operation has not been done.
No table is more interesting than that which gives the state of vision when the patients came under observation. In only 10·59 per cent. was the vision 1/3 and upward. In another 11·05 per cent. the vision was 1/4 to 1/10, in 9·64 per cent. it was 1/10 to 1/50, and in 7·05 per cent. it was a finger-count at 2 feet or less. The figures given refer in each case to the vision corrected with lenses. If every case that got a vision of 1/10 and upward be considered a success, the coucher can claim 21·64 per cent. Again, if anything from 1/10 vision to the ability to count fingers close to the face be counted as partial success, the figure for this class is 16·69 cent. This is very much more liberal treatment than would be accorded to the cataract statistics of any modern surgeon.
A further light is thrown on the above figures by a study of the table showing the duration of vision after couching. Of the 45 successful cases, 23 of them, or more than 50 per cent., had been couched less than two years before; 9 more had been couched between two and three years, and 11 from three to ten years. In two this detail was unmarked. The great preponderance of short histories in the cases of successful operation is significant.
Against the vaidyans’ figures we may place the statistics of the Madras Hospital, even so long ago as 1903, and before a rigid system of antisepsis had been introduced. Recoveries numbered 96 per cent., poor results 2 per cent., and failures 2 per cent. These figures would indicate that the coucher was losing 60 per cent. more eyes than the hospital did even then. If the vast number of eyes submitted to couching be taken into account, this 60 per cent. of avoidable loss totals up to a staggering figure. Nor must we disregard the fact that, even amongst the successes, the average vision obtained is greatly in favour of the Western surgeon.
The table showing the causes of failure will repay a careful study. The figure for iritis and iridocyclitis comes to 35·76 per cent. of the total number of cases; glaucoma accounts for 11·05 per cent., imperfect dislocation of the lens for 8·94 per cent., retinal detachment for 3·53 per cent., optic atrophy (including one case of optic neuritis supervening as a septic complication of the operation) for 2·59 per cent., retinitis pigmentosa and retinitis punctata albescens for 0·49 per cent., retinochoroiditis for 1·41 per cent., vitreous opacities (admittedly a very vague term) for 1·18 per cent., and failure due to operation on a congenitally imperfect eye for 0·23 per cent.; 3·53 per cent. are, unfortunately, unaccounted for owing to deficiencies in the notes.
In the great majority of cases ruined by iridocyclitis the inflammation made its appearance within a few days after operation; but there were instances in which this complication was delayed for a long period. Our notes show three cases in which it came on from one and a half to three years after operation, one case after seven years, and one after ten years. There are also a few doubtful cases in which a history of three or four months of useful vision preceded the inflammatory attack. In one case at least, sympathetic ophthalmia would appear to have destroyed the other eye two years after operation.
Similarly, it was found in most cases of glaucoma that the access of high tension came on within a few days of operation. There were six exceptions to this rule, three commencing from two to ten months after the couching, one five years, one six years, and one fourteen years after. From a clinical point of view, the cause of the onset of glaucoma in these cases is obscure. Many of them appear to be associated with iridocyclitis, but we must leave this matter for the present. We shall have occasion to deal with it much more fully under the heading of pathology.
Imperfect dislocation of the lens accounted for failure in 8·94 per cent. of all cases operated on. In such cases the suspensory ligament appeared to have been incompletely torn, with the result that the lens swung, as it were, on a hinge. Sometimes this hinge lies above, and the cataract falls quite out of the line of sight when the patient is recumbent, but flaps back to block the pupil when the erect attitude is assumed. In other cases, even when the hinge is laterally placed, the same thing may happen, but much more rarely.
From a clinical point of view, detachment of the retina figures in only 3·53 per cent. of the total cases; but it is unlikely that this represents the true figure. In a number of instances an ophthalmoscopic examination was quite impossible, either because the pupil was blocked, or because no fundus reflex could be obtained. 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. In one case acute optic neuritis appears to have supervened as a septic complication of the operation. This throws an interesting light on those pathological specimens in which a cone of exudate is to be seen passing from an inflamed optic nerve to the ciliary body.
In six cases there was evidence of choroido-retinitis with secondary optic atrophy. Four of them showed no improvement after operation, whilst two were improved thereby; subsequently even these two lost their vision by the progress of the retinitis. In the four cases the retinitic condition was evidently antecedent to the operation, and was either mistaken for cataract or at least was not recognised. It is impossible to say positively, from the history of the other two, whether it existed prior to operation, but it possibly did.
In one case of retinitis pigmentosa, in one of retinitis punctata albescens, and in eleven of glaucoma, the vaidyan appears to have mistaken the condition present for cataract. At least, the vision was not bettered even temporarily by the operation in any of these patients.
Of the five cases shown under vitreous opacities, three were obviously due to the inflammation of the uveal tract posterior to the iris; two others were due to hæmorrhage into the vitreous. Many more cases would undoubtedly have shown vitreous opacities had the pupils been patent. Moreover, our pathological data show that not a few of the cases in which the fundus reflex was absent presented dense exudates into the vitreous cavity. This subject will be dealt with at length under pathology. The genesis of hæmorrhage into the vitreous is obvious, and it is more than probable that if all the cases were seen at an early stage the figure for this complication would be much higher.
From the foregoing notes, it is clear that the native coucher undertakes a certain number of what we should recognise as inoperable cases. It is possible that in many of them a secondary cataract is present; but it is clear that his diagnostic powers are low. He is a standing menace to the safety of the public.
It has from time to time been suggested that the presence of the lens in the vitreous chamber brings about retinal changes. The author is not, however, aware of any reliable evidence either ophthalmoscopic or pathological to support this view. As far as possible, all cases seen in Madras were submitted to ophthalmoscopic examination, whether the couching had resulted in success or failure. We were unable to discover any characteristic change which could be attributed to the couching. A large percentage of the fundi examined appeared to be absolutely normal. The most frequent departure from normal was an undue distinctness of the choroidal vessels, which was evidently due to the absorption of the pigment of the pigmentary layer of the retina. It is probably this phenomenon which has misled some into the belief that couching is followed by changes in the retina allied to those in retinitis pigmentosa sine pigmento. This absorption of retinal pigment is, however, well known to occur in other conditions, as, for instance, in high myopia; moreover, in the case of couched eyes, it is not accompanied by the changes in the disc and vessels characteristic of retinitis pigmentosa, or by the equally characteristic night blindness. In searching for the explanation of this phenomenon, four solutions at once present themselves for consideration: (1) It might be, as has been suggested, a result of couching; (2) it might be due to the alterations in the refractive conditions under which the fundus is seen; (3) it might be a physiological abnormality; and (4) it might be an accompaniment of, and a direct result of pathological changes in the eye accompanying the development of cataract. The third suggestion is thrown out by our experience of normal native eyes. An important light has been thrown on the whole question by the observation that a similar change is found in quite a number of eyes which have been submitted to cataract extraction. This disposes of the first idea, that the presence of the lens in the vitreous would account for the phenomenon. Neither experience nor theory support the view that an alteration in refraction is responsible for the appearance. We are thus narrowed down to the conclusion that the pigmentary change is an accompaniment of the development of cataract in a certain percentage of eyes, and is independent of the method of operation resorted to for the relief of that condition.
In this connection, two interesting observations deserve record, as they possibly throw an important sidelight on the question at issue: (1) Lenses extracted in India differ from those met with in European practice, in the amount of colouring matter they contain. A very large percentage of them are stained with pigment, which is frequently of a deep tint. Many of them are dark brown, and a few are almost black. (2) Cyanopsia is of extraordinarily frequent occurrence as a sequela during convalescence after cataract extraction in Madras. Over 50 per cent. of the patients complain of it, whilst only 2·8 per cent. suffer from erythropsia, and 1·2 per cent. from yellow or green vision.
We thus find two very striking differences between Western and Eastern cataract experience, and there is, to say the least of it, a strong suggestion that the phenomena are closely connected with each other—in other words, that the cyanopsia is a result of the retina becoming tired out for the perception of yellow by long exposure to a tropical light filtering through a brown or yellow lens. There is also a strong presumption that the coloration of the lenses is due to a migration of pigment, which takes place during the development of cataract in the East, a migration which is directed from the pigmentary layer of the retina, and probably from other parts as well, towards and into the developing cataracts. If the above hypothesis is correct, we might assume that the retina is more likely to be functionally affected in an adverse sense when deprived of the protection ordinarily afforded by its pigmentary layer. In order to test this, the author some years ago made a systematic examination of a large number of eyes from which cataracts had recently been removed, with the object of ascertaining whether cyanopsia was complained of, principally or only, in those cases in which the choroidal vessels were seen to stand out with unusual distinctness under ophthalmoscopic examination. The depth of discoloration of the lenses was at the same time noted in each case. The results obtained appear to favour the views we have above enunciated, but they were not sufficiently conclusive to justify the formation of a decisive opinion. It must be remembered that, whilst a tinge of colour runs through most of the cataractous lenses removed in the East, there are very wide variations, not only in the depth of the pigmentation, but also in the actual coloration present. Some of them are yellow, some reddish-brown, some almost coal black, with every intermediate shade between. It is possible that our investigations failed for want of competent assistance with the spectroscopic analysis of the lenses. An interesting field for research is here presented. That deep-seated metabolic changes accompany the development of a cataract has been shown by J. Burdon Cooper, and it seems not unlikely that the apparent prevalence of lenticular opacities in tropical countries may be closely bound up with the metabolic changes we have described. It is probable that the retinal pigment layer is not the only source of the deep discoloration of the lenses met with by surgeons in India. A point in favour of the argument we have been elaborating is that some years ago McHardy published the analysis by MacMunn of the spectrum of the pigment obtained from a black cataract. This was found to be quite distinct from blood-pigment, and to be allied to the cell-pigment, which gives coloration to ectodermal structures in animals (Trans. of the O.S. of the U.K., 1882).
To collect the 780 cases now under review has taken over twelve years, and the writer is deeply indebted to Major Kirkpatrick for his great generosity in allowing his 230 cases, the later ones of the series, to be made use of in this paper. Throughout all these years one definite purpose has been kept in the forefront—viz., to ascertain the real value of lens couching. After making every possible allowance for the vaidyan, the fact remains that he is a standing menace to society, and that he should be suppressed. His methods are crude, filthy, and dangerous; his results are so appalling that anyone unacquainted with the ignorance and credulity of the Indian ryot would think it impossible for him to continue to exist. His impudent lying includes not merely a grossly exaggerated statement of his own successes, but extends to the most barefaced falsehoods as to the nature of the results obtained in European hospitals. It may be permissible to quote one instance—unfortunately, far from a solitary one in Madras experience. Some years ago a peasant, who had had a cataract removed in the Government Ophthalmic Hospital, and whose recollections of his treatment there were most kindly, returned for operation on the second eye. On the steps of a temple, within a hundred yards from our operating theatre, this man, who had travelled several hundred miles for aid, was induced, by a tissue of impudent lies, to sit down and submit to couching. 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. His pay and his home expenses are both alike at their maximum. He is treading the higher rungs of the official or business ladder, and is endeavouring to afford his children the best education in his power. 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. 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. Every civilized nation of to-day recognises it as a first principle, that it is its duty to protect its people from avoidable harm, and that to deal with preventable blindness is one of its primary duties. That men and women, who ought to be burden-bearers, should be thrown instead as a burden on their relatives or on the State, is a social evil of no small magnitude. One does not presume to blame either the State or the people. It would obviously be idle and wrong to do so. 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. There are, however, two distinct avenues along which an advance may safely be made—viz., (1) the systematic dissemination of knowledge through Government agencies amongst the people; (2) the improvement of ophthalmic medical education. A movement in these two directions is already on foot, and in time it will bear much fruit.
CHAPTER V
THE PATHOLOGICAL ANATOMY OF COUCHED EYES
Being the Hunterian Lectures delivered before the
Royal College of Surgeons of England on
February 19 and 21, 1917
The material at our disposal consists of 54 globes, the great majority of which were removed in the Madras Ophthalmic Hospital in the period from 1911 to 1915, though some are of much older date. They were placed in 5 per cent. formalin immediately on removal, and were subsequently frozen and bisected. In a number of instances one half of the eye was submitted to microscopic examination after suitable sectioning. Each of the half-globes and a number of microscopic specimens have been photographed for purposes of illustration. It will be convenient to classify our observations under a number of separate headings.
The Various Directions in which Dislocation of the Lens is
found to have taken place.
Before considering this subject in the light of the pathological specimens before us, it is necessary to make certain preliminary statements:
1. Inasmuch as all our material is derived from blinded eyes, it is obvious that we are dealing with the coucher’s failures alone, and are excluding his successes. In a very large percentage of the latter the lens is seen, during life, to be floating freely in the vitreous, apparently untrammelled by adhesions.
2. The position in which we find the lens on bisection of the eyeball is not necessarily that into which it was thrust at the time of operation, for the changes which occur in the eye as a result of inflammatory action may profoundly alter the position into which the lens was originally forced by the coucher. Nor must we forget that in those globes, in which the cataract is not tightly tethered by adhesions, gravity plays a part.
Having thus cleared the ground, we may start with the statement that, though the lens may be displaced in any direction within the sclero-corneal coat, backward dislocations are by far the most common, whilst forward ones were only found 4 times in the whole series of 54 globes. None the less, each of these latter cases possesses considerable interest.
Forward Dislocations.—(1) In No. 8[1] the couching instrument passed through the limbus, and the track of the wound can be plainly followed in microscopic sections. The ciliary body was pushed bodily away from the sclera, and the lens nucleus was forcibly thrust into the space formed by this cyclodialysis (Pl. II., Fig. [10]); it is to be seen imbedded in a mass of inflammatory exudate, whilst its capsule, with some of the cortex, lies in the normal situation.
(2) In No. 44 the capsule and the nucleus of a Morgagnian cataract are seen floating in the vitreous chamber (Pl. II., Fig. [11]). During life the nucleus frequently passed backwards and forwards between the aqueous and vitreous cavities. The same phenomenon, though rare, has been observed in other couched eyes.
(3) No. 61 is probably an instance of the same kind of thing having happened at an earlier period (Pl. II., Fig. [12]). Now, however, the small dark Morgagnian nucleus is seen fixed in the lower part of the anterior chamber, into which it doubtless gravitated by its own weight, and there set up inflammatory mischief, which led to its adhesion to the surrounding parts, and to its becoming fixed in situ by the formation of organising exudate.
(4) In No. 108 the only evidence of lens material present was the capsule of a Morgagnian cataract, which lay impacted in the lower part of the anterior chamber (Pl. II., Fig. [13]). On section, Morgagnian fluid escaped, and no trace of a nucleus could be detected. It is of interest to record that the writer has, on a number of occasions, operated on Morgagnian cataracts in which the lens nucleus had been reduced to the thickness of a lamellar disc, or in which no trace of a nucleus could be detected. In this case no adhesions had formed, and during the transit of the specimen to England the capsule fell from its position to the bottom of the bottle.
Fig. 10: Specimen No. 8, Whole-Section.—The lens can be seen dislocated between the ciliary body and the sclera; the pectinate ligament had been ruptured at the operation.
Fig. 11: Specimen No. 44.—The small Morgagnian nucleus lies in the anterior part of the vitreous chamber; it passed freely between this and the aqueous chambers, sometimes appearing in the one, and sometimes in the other. The scar of the operation wound can be seen in the lower part of the illustration, close to the ciliary body. Notice the folds into which the detached retina has been dragged by the shrinking inflammatory exudate. A tongue, consisting of the posterior surface of the iris, was stripped back at the time of operation, and can be seen attached posteriorly to the front of the hyaloid body.
Fig. 12: Specimen No. 61.—A small dark Morgagnian nucleus lies impacted in the lower angle of the anterior chamber, which is largely filled by a flocculent coagulated exudate. Notice the coagulated subretinal exudate, and the cyst in the outer wall of the lower part of the retina.
Fig. 13: Specimen No. 108.—The capsule of a Morgagnian lens lies impacted in the angle of the anterior chamber; it had contracted no adhesions. The vitreous body is represented by a fine cone of exudate, which stretched forward from its apex at the optic nerve to a broad base at the ora serrata.
Fig. 14: Specimen No. 50.—A large Morgagnian cataract floated free in the vitreous chamber. The retina is extensively detached.
Fig. 15: Specimen No. 136.—A large hard laminated lens lies lightly imprisoned in the inflammatory exudate which formed in the vitreous body. A long curved scar can be seen over the ora serrata at the temporal side of the specimen.
PLATE II.
Fig. 10 (No. 8).—Lens dislocated between cil. body and sclera.
Fig. 11 (No. 44).—Left eye, lower half.
Fig. 12 (No. 61).—Left eye, temporal half.
Fig. 13 (No. 108).—Right eye, nasal half.
Fig. 14 (No. 50).—Right eye, lower half.
Fig. 15 (No. 136).—Left eye, upper half.
Backward Dislocations.—Dislocations backward are the rule, and very wide variations are found both in the completeness and in the direction of the displacement.
Those in which the lenses, or their nuclei, have been completely dislocated into the vitreous, and there lie floating more or less freely (Pl. II., Fig. [14]), are 9 in number. In 7 of them the cataracts were Morgagnian, and in the 2 others there was a bulky nucleus with a thin covering of stiff cortex. In 7 the tension of the globe was high; in 6 the retina was completely or nearly completely detached, and in 2 of them it was so much folded as to limit the movements of the lens.
From a consideration of the lenses found floating in the vitreous, we turn to that of those which were entangled in a more or less consistent inflammatory exudate occupying the vitreous chamber (Pl. II., Fig. [15]). During life such lenses were reported to be fixed, or nearly so. In the specimens they are seen to be nested in a mass of exudate, which holds them imprisoned against the ciliary body and the back of the iris. Usually this exudate is limited in quantity and is confined to the anterior portion of the eye, and principally to the neighbourhood of the dislocated lens. More rarely it is very abundant, and occupies a large part or even the whole of the vitreous chamber (Pl. III., Fig. [16]). We shall deal with this exudate more fully at a later stage; for the present it suffices to state that it is inflammatory in origin, and that it contains a large number of cells. Of the 6 cases which form this group, 3 were Morgagnian cataracts; 5 were certainly dislocated in their capsule, the sixth is hidden in such dense exudate that it cannot be clearly seen. It is desirable to make it clear that intermediate forms are found between this group and the previous one. In other words, there is no hard-and-fast line between the cases in which the lenses float freely in the vitreous and those in which they are, to a greater or less degree, tethered by the pathological thickening of the hyaloid body.
We have next to consider a group of 10 eyeballs, in each of which the dislocated cataract was firmly fixed to the ciliary body and to the back of the iris by definitely organised fibrous tissue (Pl. III., Fig. [17]). These globes present certain well-marked features of some interest: (1) The percentage of Morgagnian cataract is much lower than that in the preceding groups, and corresponds closely with the normal frequency of this form of cataract in Indian practice. (2) The cataract was dislocated in its capsule in no less than 8 of the 10 cases. (3) The retina was totally detached in 2 and very extensively so in one; in every one of the remaining 7 this membrane showed the presence of white dots, apparently on its surface. (4) The time which had elapsed since operation in the cases falling under this group is remarkable. In one it is given as seven months; in 2 others there is no history; in the remaining 7 the duration was from two to twenty years, with an average of well over seven years. The association of the presence of white dots with these long histories is remarkable, and will be taken up in a later section.
No. 99 (Pl. III., Fig. [18]) is a specimen of special interest for two reasons—viz., (1) the cataract is fixed to the globe unusually far back, being attached to the retina a little behind the equator of the eye; (2) the dislocation has taken place in an upward direction, and therefore against the action of gravity. From time to time we meet clinically with a couched lens whose suspensory ligament, though torn through over a wide circumference, has been spared at one part, which acts as a hinge. The loosened lens flaps backwards and forwards with the movements of the eye, at times obstructing the pupil, and at others being lost to sight. If the hinge is above, the cataract usually blocks the pupil when the head is erect; but one meets with cases in which the lens floats up out of the way unless the face is thrown forward into the horizontal plane; this is apparently due to a check-ligament action of the remaining suspensory fibres of the lens, acting on a lens which is very nearly of the same specific gravity as the vitreous in which it lies. Should inflammation be set up in such an eye and the lens become involved in the exudate, it may become fixed, as in this case, in the upper segment of the globe.
Fig. 16: Specimen No. 197.—The exudate into the vitreous cavity is abundant and opaque, concealing the dislocated cataract. (Time since operation, one month.)
Fig. 17: Specimen No. 37.—The lens is tied to the back of the iris and ciliary body by firm organised exudate, which is continuous with and part of the cone of inflammatory material representing the shrunken vitreous. Notice the advanced organisation evident in the apex of the cone near the optic nerve, also the white line apparently representing the hyaloid canal. Some large dots and many small ones are to be seen on the retina.
Fig. 18: Specimen No. 99.—A large lens in its capsule is dislocated upward and inward, and is adherent to the retina by inflammatory bands. The retina shows very numerous white dots. There is a tendency to equatorial scleral staphyloma.
Fig. 19: Specimen No. 171.—The retina is totally detached and rolled up tight; cysts both false and true are to be seen in it. The lens is imbedded in a mass of inflammatory exudate, matted to the iris and ciliary body in front, and to the retina behind; the ciliary body is detached. The coagulated subretinal exudate gives the specimen the appearance of a half-marble. The sclera is folded owing to the shrinking of the eyeball.
Fig. 20: Specimen No. 119.—From before backwards can be seen the iris, the remains of the lens capsule, and the thickened anterior layer of the hyaloid. The lens is dislocated backward between the second and third of these, and is wedging them apart. The retina is detached over nearly half the globe; this is in large part determined by the pull of the shrinking thickened anterior hyaloid layer.
Fig. 21: Specimen No. 46.—The hard dark nuclear cataract had been depressed; it lies in front of the unruptured anterior hyaloid membrane, and therefore outside the vitreous cavity.
PLATE III.
Fig. 16 (No. 197).—Left eye, lower half.
Fig. 17 (No. 37).—Left eye, lower half.
Fig. 18 (No. 99).—Left eye, upper half.
Fig. 19 (No. 171).—Left eye, upper half.
Fig. 20 (No. 119).—Right eye, upper half.
Fig. 21 (No. 46).—Left eye, lower half.
When we come to speak of the changes found in the vitreous, we shall have occasion to refer to the frequency with which the hyaloid body is represented by a shrunken cone with its apex at the optic nerve and its base in the neighbourhood of the ora serrata. This form, which is well known to pathologists, is due to the anatomical attachments of the vitreous body, and to the fact that the latter undergoes shrinkage after being thickened and opacified by the presence of inflammatory exudate. In studying the present collection, one cannot fail to be struck with the fact that the exudate, which fixes, or helps to fix, the lens in its pathologic position, is one with, and part of, this cone-shaped new formation. Before leaving the consideration of this group, we must once again point out that no hard-and-fast line separates it from the preceding one, and that intermediate links between the two can easily be pointed to.
In 11 globes, dislocated cataracts were found matted between the iris and ciliary body in front and the completely detached retina behind. It is very difficult to say what the nature of the original cataracts was, since all that one can now find is a nucleus, usually rather dark-coloured, imbedded in a mass of inflammatory tissue (Pl. III., Fig. [19]). These nuclei are undergoing steady reduction in bulk as the result of phagocytic action. In 7 of the 11, the lens remnants lie either within the complete capsule or in its near neighbourhood. The interior of the capsule is usually found to have been invaded by the mass of inflammatory and organising tissue which mats together all the structures (i.e., the iris, the ciliary body, the remains of the lens, and the detached retina), and which occludes the angle of the anterior chamber. The completeness of the dislocation varies greatly. In some cases the lens is hardly moved from its usual position, and lies in front of the anterior hyaloid membrane, whilst in others it is displaced into the vitreous cavity. In one instance the detachment of the retina and the inflammatory changes are sharply limited to the lateral half of the eye towards which the cataract was dislocated, but this case belongs more to the next group than to the one we are now discussing.
There are three outstanding and very important features common to these cases: (1) In the great majority of them there is evidence that the operation was followed by severe iridocyclitis; (2) 9 of the 11 were shrinking eyes with low tension; and (3) the time which had intervened between the couching and the enucleation was between one and two years in every case save one, in which it is probable that the furnished statement of three months was inaccurate. It will be noticed that the histories are much shorter than those in the previous group. This, together with the other two points mentioned, indicates that we have to deal with a condition widely different from that in any of the previous groups. Here the inflammatory process had been induced by a septic infection of the eyes of a decidedly more virulent character, though it fell short of that acme of infectivity, which leads in so many cases of the Indian operation to panophthalmitis and destruction of the globe within a few weeks.
We come next to a group of 5 cases, which have one feature in common—viz., that the cataract, though dislocated backwards, lies distinctly in front of the anterior hyaloid membrane, and therefore outside the vitreous cavity (Pl. III., Figs. [20] and 21). In 3 of them the solid parts of the lenses have been pushed back from their original position in such a way that they act like wedges, forcibly keeping the anterior hyaloid membrane in a plane posterior to that which it would normally occupy. Out of these 5 cataracts 4 were cortico-nuclear; the fifth was too much altered for it to be possible to state what its nature was. In certainly 4 out of the 5 moderately severe iridocyclitis had followed the couching, but the exudative process was a much less severe one than that which characterised the specimens of the previous group. The consequence was that there was no such matting of all the parts concerned as is there seen. In every case the detachment of the retina was complete or nearly so, but in not one was the lens enwrapped in its folds. This we may attribute to two causes: (1) a merely contributory one, that the vitreous cavity was not invaded; and (2) that the infection was less virulent, and the inflammation consequently less severe, than in the members of the previous group.
There is a small group of 3 cases in which the remains of the lens lie in situ in the periphery of the capsule, whilst the central portion has disappeared. These resemble the peripheral after-cataracts not infrequently seen following the extraction of a not fully mature lens.
In conclusion we have to mention 2 specimens in which the condition found was so unusual that it would scarcely have been possible to have anticipated its occurrence.
The first of these was one of the earliest globes sectioned. A Morgagnian lens, entire in its capsule, was found thrust behind the retina. It lay against the scleral coat close to the ciliary body; it had detached the retina over a large area in the neighbourhood of the ora serrata, and had led to a complete separation of it on that (the nasal) half of the eye. The edge of the detached retina had contracted adhesions to the front of the lens capsule, and was much puckered in that neighbourhood, doubtless as the result of cicatrisation.
The second specimen (Pl. IV., Fig. [22]) shows many features in common with the last. The lens is entire in its capsule, and is almost certainly Morgagnian; the tear in the retina through which it was thrust has now cicatrised up, leaving a puckered scar. The retina is totally detached, and on section the cataract lay as far forward as the separation of that membrane would permit. The pupil was blocked by exudate, and atrophic scars in the iris showed that there had been extensive laceration of that membrane. The globe was removed a year after operation.
The sequence of events in these two cases was possibly as follows: The posterior operation may have been adopted and the incision placed far back; a wide tear in the retina resulted; the lens, completely separated from its attachments, was kept entire by the toughness of the Morgagnian capsule, whilst the fluidity of its contents made its insinuation through the retinal tear an easy matter. The fact that a case has recently been recorded in which, in a boy of seventeen, the lens spontaneously escaped through a 2 mm. trephine hole throws a sidelight on such cases as these.