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.
[Illustration: Fig. 6.--Anterior Operation.]
[Illustration: Fig. 7.--Posterior Operation.]
[Illustration: 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.
[Illustration: Fig. 9.--Instruments used in Couching.]
=The Posterior Operation.=--Much that has been written on the preceding
method applies with equal force to this. It is, however, possible to
describe the technique much more accurately, as it has been carefully
studied at first-hand by Dr. Ekambaram, who for many years worked
under the writer in the Government Ophthalmic Hospital, Madras. His
original description of the method will well repay a careful perusal.
He speaks of the operators as being ambidextrous and very skilful.
Their surgical equipment (Fig. 9) for the operation consists of a
small lancet-shaped knife, guarded to within a few millimetres of its
tip by a roll of cotton-wool, wrapped round it for the purpose, and of
a copper probe 4 inches long and about 1-1/2 mm. in diameter. A cotton
thread twisted round this probe at a spot 12 mm. from its point serves
the same purpose as the stop in the Bowman’s needle. From the point
to this stop the instrument is triangular in section. The patient is
directed to look well towards the nose, and the surgeon then gently
marks out the selected spot by pressing with his thumbnail on the
conjunctiva covering the sclera, about 8 mm. out from the cornea, and
about 2 mm. below the horizontal meridian. In some cases the operator
steadies the eye by firm digital pressure exerted through the partly
everted lower lid. He next takes his lancet in his hand, and it will
be observed from the illustration (Fig. 9) that it might easily
pass for a roll of cotton-wool; this, indeed, is what the patient
is led to believe it really is. To heighten such an impression, the
point is covered with a sandalwood paste, prepared beforehand _coram
publico_, with a good deal of ostentation. The patient is informed that
this “cataract-cleansing drug is about to be applied to the eye,” and
under cover of the suggestion the operator plunges the lancet through
the tunic of the globe at the spot already selected. The alarm thus
occasioned is allayed by the assurance that the “medicinal application”
is over. The copper probe is next produced, and is inserted through the
wound up to its stop, being held between the thumb and two fingers;
a circular movement is given to its point, the stop resting against
the puncture, and serving as a pivot for the movement. According to
Ekambaram, the object is to tear through the suspensory ligament from
behind. Immediately following this step, a downward stroke of the
point is made in order to depress the now loosened lens. Ekambaram
graphically describes the care taken by these operators to impress,
alike on the patient and on the friends, the magical effects of the
procedure. The former is shown a number of objects, and is bidden to
name them in turn, and to state their colour. The crowning point is
reached when the surgeon removes a thread from his garment, and the
patient not merely recognizes it as such, but triumphantly tells its
hue. The Western ophthalmic surgeon, with his wide incision and his
anxiety for the safety of the vitreous, can never savour such dramatic
moments as these. They carry us back to the descriptions of the early
Christian miracles, with all the mental and spiritual associations,
which enwrap such stories as those of Bartimæus, and of the pools of
Siloam and Bethesda. Alas that life’s “hereafters” should so often be
fraught with disillusionment, disappointment, and suffering! Palestine
and its storied past rise before us as we read how the vaidyan called
for a white cloth and for water, how he dipped the cloth in the fluid
and washed out the sufferer’s eye therewith, how he made a paste and
smeared it over the skin around the brow, how he closed the eye with
“clean white linen,” and then sent the erstwhile blind man rejoicing
away. Over the abyss of nearly twenty centuries, the East stretches out
her unfaltering hand to the past of the nearer East, whilst the West
looks on in wonder, not unmixed with admiration, for a spirit which the
corroding passage of time seems unable either to fret or to change.
There is a step of the procedure which has been purposely left to the
last, as its interest is psychologic, and not surgical. It is common to
both methods of operation. I refer to the anointing of the eye with the
blood of a freshly killed fowl. It is a measure in which superstition,
cunning, self-preservation, and greed, overwhelm and mask a faint
and feeble therapeutic design. The sacrificial element is present,
and a hazy idea that the death of the votive bird may turn evil from
the patient looms in the background. Next comes the need to mask
the shedding of the patient’s blood, since he is often told that no
operation is to be performed, but that a mere “medicinal application”
is to be made; the blood of the outraged bird covers the guilt of the
vaidyan’s falsehood. Largest of all towers the fact that the curry-pot
even of a worker of surgical marvels needs constant replenishing, and
that fowl is an excellent substitute for mutton on such occasions.
Lastly, these men seem to believe that the coagulation of the fowl’s
blood helps to close the puncture. In view of the dirty condition of
the instruments which they introduce into the interior of the eye, this
last factor may practically be neglected.