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.
