Transcriber’s notes:
The text of this e-book has been preserved as in the original,
except for the occasional silent insertion of missing punctuation and
correction of a few typographic flaws (recen → recent, antea → ante).
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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.
[Illustration: 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
[Illustration]
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 1
II. THE TECHNIQUE OF THE OPERATION 14
III. THE INDIAN COUCHER AND HIS HABITS 19
IV. STATISTICAL 25
V. THE PATHOLOGICAL ANATOMY OF COUCHED EYES 35
VI. DIAGNOSIS 77
VII. CLINICAL 85
INDEX 92
LIST OF ILLUSTRATIONS
FIGS. 1 AND 2. BARTISCH’S OPERATION (PLATE 1.) _Frontispiece_
FIG. PAGE
3. THE STAGES OF DEPRESSION 8
4. THE STAGES OF RECLINATION 8
5. SCARPA’S NEEDLE AS USED BY MACKENZIE 8
6. THE ANTERIOR METHOD OF COUCHING 14
7. THE POSTERIOR METHOD OF COUCHING 14
8. GROUP SHOWING THE INDIAN OPERATION OF COUCHING 15
9. THE INSTRUMENTS USED IN COUCHING IN THE SOUTH OF INDIA 17
PLATE II. FACING PAGE
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 }
} 38
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 } 42
}
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 } 48
}
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 } 54
}
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) } 58
}
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 } 72
}
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.
[Illustration: Fig. 3.--Depression.]
[Illustration: Fig. 4.--Reclination.]
The above two figures illustrate the path taken by the
cataract during the operation. (Mackenzie.)
[Illustration: Fig. 5.]
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).
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; (4_a_)
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; (4_b_) 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.
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