Our next consideration is that of the cases in which the cataract still lies behind the pupil. It then seldom, if ever, is in absolutely normal position, and it very frequently is found to have been moved bodily downwards or to one side, or obliquely. Again, but more rarely, it may be tilted backward at an angle with the plane of its normal position. In a great number of cases the history will help one, and, even when the patient denies couching, he will very often admit to having had “medicine applied to his eye by a native practitioner.” Should no such evidence be forthcoming, there may still remain that of the lesions to the cornea, the sclera, or the iris, to which attention has already been directed in the previous section.
From these cases we pass on to consider those in which the lens cannot be seen at all, owing to the occlusion of the pupil. Here our difficulties are greater still, and, if the history fails us, we must fall back on a careful search for signs of wound scars in the cornea or sclera, or of tears in the iris. A point which is always suggestive is the existence of a cataract in the opposite eye. In such cases as these, the contents of the chamber may be found to consist of pus or of blood.
Our next group is a still more difficult one, for in it no fundus reflex can be obtained. It embraces a number of conditions which may be shortly dealt with in turn: (1) Those in which the vitreous body has been converted into a more or less highly organised inflammatory exudate, which is impenetrable to the light of the ophthalmoscope. (2) Those in which this vitreous exudate has contracted inflammatory adhesions to the retina, and by its shrinkage has determined the total detachment of that membrane. (3) Those in which the vitreous chamber has become filled with blood. It is obvious that in all such cases our main dependence must be upon the history, though the other indications already outlined may help us in some of them.
Lastly there are the cases in which the eye is undergoing shrinkage, and those in which phthisis bulbi is following panophthalmitis. The history of the signs and symptoms of severe iridocyclitis or of suppuration will, in India at least, always excite a suspicion of couching having been performed, unless the patient has a definite story to tell of some other form of injury. Strangely enough, the inventive faculty of the Indian patient does not rise to the height of vamping a narrative of the kind. If he has had an injury, he tells of it readily. If he has been couched, he stolidly denies that anything occurred to cause his trouble, which he states “simply came of itself.”
It will be observed that in the preceding remarks we have dealt with two of the problems which confront us in diagnosis, for the simple reason that it is very difficult to separate them; to do so would mean needless repetition. The discovery of the new position of the lens, and of the degree of fixation, if any, it has undergone, can hardly be divorced from the question of whether a couching has or has not been performed. Our third problem was to decide whether it is advisable to operate in any cases, and if so, in which. The Baron de Wenzel, in his treatise on cataract,[4] records two cases in which his father successfully extracted couched lenses. A number of Anglo-Indian surgeons have had similar experiences, but most of them are reluctant to interfere with these cases oftener than they can help, because, should the operation fail, it is extremely likely that they will unjustly incur the odium for the loss of the patient’s vision. On this subject Maynard wrote (Ophthalmic Review, April, 1903): “It may be justifiable to attempt the removal of a recently couched lens. If not recent, and more especially if the lens is fixed, it is wiser to leave it alone, even if the sight is failing.” To the writer’s mind, the one crying indication for removal of a couched lens is that it flaps across and obstructs the pupil. He agrees strongly with Maynard, that if the lens is fixed it is better left alone; but he is doubtful whether the time element is of very great importance, in comparison with the mobility of the cataract; for a study of the fifty-four globes already dealt with has shown him that the fixation or otherwise of the lens is a question of the amount of septic action set up by the operation. If this is small, the lens may continue mobile, even for a very long period; if it is more severe, the latter will soon be tethered. Dealing with this subject five years ago (Proc. of S. Indian Branch of B.M.A., March 13, 1912), the author wrote as follows:
“We are extremely reluctant in Madras to undertake further operative procedures on an eye in which couching has been performed. Removal of a lens dislocated into the posterior chamber obviously means a wide opening up of the vitreous; and even if the immediate result appears good, there is little guarantee that the benefit will continue. Of eighteen cases in which the lens was removed, twelve obtained better vision at the time, four remained in statu quo, and two were rendered worse. I cannot but think that these statistics would suffer if the cases were followed for some years. On five occasions we undertook the laceration of an after-cataract which blocked the line of sight after couching. In two cases there was considerable benefit, whilst in three vision remained in statu quo ante. In four cases an iridectomy was performed for optical purposes. In two vision improved slightly, whilst in the two others it remained as before.
“Personally I have a strong and growing objection to undertake any operative procedure on a couched eye. Firstly, there is the risk of lighting up a septic explosion, for which the real responsibility lies with the coucher’s original operation; and, secondly, there is the danger of being saddled with the discredit which is justly due to another man’s failure.”
Reviewing these paragraphs in the light of the much better knowledge of the pathology of couching which we possess to-day, he would urge that only freely movable cataracts should be touched, since want of mobility is associated with profound changes in the vitreous due to septic action. The object that a surgeon sets before him, work where he may, is ever the same—“The greatest good of the greatest number.” Failure in such cases as these may play into the hands of the coucher, and enable him to extend his sphere of influence at the expense of the beneficent work of the Western hospitals. The problem in India is a difficult one, in which surgical considerations do not stand alone, but are interwoven with social, moral, and even political questions. Each surgeon must decide for himself what line he will take, and follow it fearlessly.
In this connection, Major Kirkpatrick’s experience[5] in Madras is of considerable value, for he has removed a number of couched lenses, and has been “struck by the rarity of vitreous escape, even after fairly extensive investigation with a spoon,” during this operation. He adds: “I have noticed that the vitreous body becomes shrunken and extraordinarily tough, so much so that, when an eye is excised (either for glaucoma or for iridocyclitis following Mahomedan operation), the whole globe can be held up by a strabismus hook transfixing the vitreous, though the latter appears perfectly clear. The vitreous undoubtedly does undergo shrinkage, and leaves a large space, which is occupied by aqueous.” It is plain that he is referring here to cases in which the vitreous body has undergone some measure of inflammatory organisation, which might be expected to limit the mobility of the lens, and it will be of great interest to learn whether the conclusions of so reliable and experienced an observer ultimately coincide with the author’s, that interference should be confined to those cases in which the movements of the cataract within the vitreous body are noted to be free. Once again, let it be emphasised that there are two distinct questions at issue—one the benefit of the individual patient, and the other the good name of Western surgery. Each man must be guided according to the dictates of his own personality and of his environment.