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.