The Indian operation of couching for cataract

by Robert Henry Elliot

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lowering the point, which forces the cataract downward out of sight behind the pupil: the needle is then withdrawn by rotation; (4b) to effect reclination, the needle-point is raised not more than  1/10 inch above the transverse diameter of the lens: its concave surface is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.