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.
A further light is thrown on the above figures by a study of the table
showing the duration of vision after couching. Of the 45 successful
cases, 23 of them, or more than 50 per cent., had been couched less
than two years before; 9 more had been couched between two and three
years, and 11 from three to ten years. In two this detail was unmarked.
The great preponderance of short histories in the cases of successful
operation is significant.
Against the vaidyans’ figures we may place the statistics of the
Madras Hospital, even so long ago as 1903, and before a rigid system
of antisepsis had been introduced. Recoveries numbered 96 per cent.,
poor results 2 per cent., and failures 2 per cent. These figures would
indicate that the coucher was losing 60 per cent. more eyes than
the hospital did even then. If the vast number of eyes submitted to
couching be taken into account, this 60 per cent. of avoidable loss
totals up to a staggering figure. Nor must we disregard the fact that,
even amongst the successes, the average vision obtained is greatly in
favour of the Western surgeon.
The table showing the causes of failure will repay a careful study.
The figure for iritis and iridocyclitis comes to 35·76 per cent.
of the _total_ number of cases; glaucoma accounts for 11·05 per
cent., imperfect dislocation of the lens for 8·94 per cent., retinal
detachment for 3·53 per cent., optic atrophy (including one case of
optic neuritis supervening as a septic complication of the operation)
for 2·59 per cent., retinitis pigmentosa and retinitis punctata
albescens for 0·49 per cent., retinochoroiditis for 1·41 per cent.,
vitreous opacities (admittedly a very vague term) for 1·18 per cent.,
and failure due to operation on a congenitally imperfect eye for 0·23
per cent.; 3·53 per cent. are, unfortunately, unaccounted for owing to
deficiencies in the notes.
In the great majority of cases ruined by iridocyclitis the inflammation
made its appearance within a few days after operation; but there were
instances in which this complication was delayed for a long period.
Our notes show three cases in which it came on from one and a half to
three years after operation, one case after seven years, and one after
ten years. There are also a few doubtful cases in which a history of
three or four months of useful vision preceded the inflammatory attack.
In one case at least, sympathetic ophthalmia would appear to have
destroyed the other eye two years after operation.
Similarly, it was found in most cases of glaucoma that the access
of high tension came on within a few days of operation. There were
six exceptions to this rule, three commencing from two to ten months
after the couching, one five years, one six years, and one fourteen
years after. From a clinical point of view, the cause of the onset
of glaucoma in these cases is obscure. Many of them appear to be
associated with iridocyclitis, but we must leave this matter for the
present. We shall have occasion to deal with it much more fully under
the heading of pathology.
Imperfect dislocation of the lens accounted for failure in 8·94 per
cent. of all cases operated on. In such cases the suspensory ligament
appeared to have been incompletely torn, with the result that the lens
swung, as it were, on a hinge. Sometimes this hinge lies above, and
the cataract falls quite out of the line of sight when the patient is
recumbent, but flaps back to block the pupil when the erect attitude is
assumed. In other cases, even when the hinge is laterally placed, the
same thing may happen, but much more rarely.
From a clinical point of view, detachment of the retina figures
in only 3·53 per cent. of the total cases; but it is unlikely
that this represents the true figure. In a number of instances an
ophthalmoscopic examination was quite impossible, either because the
pupil was blocked, or because no fundus reflex could be obtained. Our
pathological material has shown that in many such cases the retina
was totally detached, whereas, in arriving at the figure above given,
we were dealing only with those instances in which the diagnosis was
established by the aid of the ophthalmoscope.
Ten of the cases in which failure was ascribed to optic atrophy showed
no improvement in vision after operation. Their histories indicate
that the atrophic condition was present before operation, and there
seems to be a fair presumption that the coucher mistook the condition
for cataract, or at least failed to recognise its true nature. In one
case acute optic neuritis appears to have supervened as a septic
complication of the operation. This throws an interesting light on
those pathological specimens in which a cone of exudate is to be seen
passing from an inflamed optic nerve to the ciliary body.
In six cases there was evidence of choroido-retinitis with secondary
optic atrophy. Four of them showed no improvement after operation,
whilst two were improved thereby; subsequently even these two lost
their vision by the progress of the retinitis. In the four cases the
retinitic condition was evidently antecedent to the operation, and
was either mistaken for cataract or at least was not recognised. It
is impossible to say positively, from the history of the other two,
whether it existed prior to operation, but it possibly did.
In one case of retinitis pigmentosa, in one of retinitis punctata
albescens, and in eleven of glaucoma, the vaidyan appears to have
mistaken the condition present for cataract. At least, the vision was
not bettered even temporarily by the operation in any of these patients.
Of the five cases shown under vitreous opacities, three were obviously
due to the inflammation of the uveal tract posterior to the iris; two
others were due to hæmorrhage into the vitreous. Many more cases would
undoubtedly have shown vitreous opacities had the pupils been patent.
Moreover, our pathological data show that not a few of the cases in
which the fundus reflex was absent presented dense exudates into the
vitreous cavity. This subject will be dealt with at length under
pathology. The genesis of hæmorrhage into the vitreous is obvious, and
it is more than probable that if all the cases were seen at an early
stage the figure for this complication would be much higher.
From the foregoing notes, it is clear that the native coucher
undertakes a certain number of what we should recognise as inoperable
cases. It is possible that in many of them a secondary cataract is
present; but it is clear that his diagnostic powers are low. He is a
standing menace to the safety of the public.
It has from time to time been suggested that the presence of the lens
in the vitreous chamber brings about retinal changes. The author is
not, however, aware of any reliable evidence either ophthalmoscopic
or pathological to support this view. As far as possible, all cases
seen in Madras were submitted to ophthalmoscopic examination, whether
the couching had resulted in success or failure. We were unable to
discover any characteristic change which could be attributed to the
couching. A large percentage of the fundi examined appeared to be
absolutely normal. The most frequent departure from normal was an undue
distinctness of the choroidal vessels, which was evidently due to
the absorption of the pigment of the pigmentary layer of the retina.
It is probably this phenomenon which has misled some into the belief
that couching is followed by changes in the retina allied to those
in retinitis pigmentosa _sine_ pigmento. This absorption of retinal
pigment is, however, well known to occur in other conditions, as, for
instance, in high myopia; moreover, in the case of couched eyes, it is
not accompanied by the changes in the disc and vessels characteristic
of retinitis pigmentosa, or by the equally characteristic night
blindness. In searching for the explanation of this phenomenon, four
solutions at once present themselves for consideration: (1) It might
be, as has been suggested, a result of couching; (2) it might be due to
the alterations in the refractive conditions under which the fundus is
seen; (3) it might be a physiological abnormality; and (4) it might be
an accompaniment of, and a direct result of pathological changes in the
eye accompanying the development of cataract. The third suggestion is
thrown out by our experience of normal native eyes. An important light
has been thrown on the whole question by the observation that a similar
change is found in quite a number of eyes which have been submitted
to cataract extraction. This disposes of the first idea, that the
presence of the lens in the vitreous would account for the phenomenon.
Neither experience nor theory support the view that an alteration in
refraction is responsible for the appearance. We are thus narrowed
down to the conclusion that the pigmentary change is an accompaniment
of the development of cataract in a certain percentage of eyes, and is
independent of the method of operation resorted to for the relief of
that condition.
In this connection, two interesting observations deserve record, as
they possibly throw an important sidelight on the question at issue:
(1) Lenses extracted in India differ from those met with in European
practice, in the amount of colouring matter they contain. A very large
percentage of them are stained with pigment, which is frequently of a
deep tint. Many of them are dark brown, and a few are almost black. (2)
Cyanopsia is of extraordinarily frequent occurrence as a sequela during
convalescence after cataract extraction in Madras. Over 50 per cent.
of the patients complain of it, whilst only 2·8 per cent. suffer from
erythropsia, and 1·2 per cent. from yellow or green vision.
We thus find two very striking differences between Western and Eastern
cataract experience, and there is, to say the least of it, a strong
suggestion that the phenomena are closely connected with each other--in
other words, that the cyanopsia is a result of the retina becoming
tired out for the perception of yellow by long exposure to a tropical
light filtering through a brown or yellow lens. There is also a strong
presumption that the coloration of the lenses is due to a migration
of pigment, which takes place during the development of cataract in
the East, a migration which is directed from the pigmentary layer of
the retina, and probably from other parts as well, towards and into
the developing cataracts. If the above hypothesis is correct, we might
assume that the retina is more likely to be functionally affected in
an adverse sense when deprived of the protection ordinarily afforded
by its pigmentary layer. In order to test this, the author some years
ago made a systematic examination of a large number of eyes from which
cataracts had recently been removed, with the object of ascertaining
whether cyanopsia was complained of, principally or only, in those
cases in which the choroidal vessels were seen to stand out with
unusual distinctness under ophthalmoscopic examination. The depth
of discoloration of the lenses was at the same time noted in each
case. The results obtained appear to favour the views we have above
enunciated, but they were not sufficiently conclusive to justify the
formation of a decisive opinion. It must be remembered that, whilst a
tinge of colour runs through most of the cataractous lenses removed in
the East, there are very wide variations, not only in the depth of the
pigmentation, but also in the actual coloration present. Some of them
are yellow, some reddish-brown, some almost coal black, with every
intermediate shade between. It is possible that our investigations
failed for want of competent assistance with the spectroscopic analysis
of the lenses. An interesting field for research is here presented.
That deep-seated metabolic changes accompany the development of a
cataract has been shown by J. Burdon Cooper, and it seems not unlikely
that the apparent prevalence of lenticular opacities in tropical
countries may be closely bound up with the metabolic changes we have
described. It is probable that the retinal pigment layer is not the
only source of the deep discoloration of the lenses met with by
surgeons in India. A point in favour of the argument we have been
elaborating is that some years ago McHardy published the analysis by
MacMunn of the spectrum of the pigment obtained from a black cataract.
This was found to be quite distinct from blood-pigment, and to be
allied to the cell-pigment, which gives coloration to ectodermal
structures in animals (Trans. of the O.S. of the U.K., 1882).
To collect the 780 cases now under review has taken over twelve years,
and the writer is deeply indebted to Major Kirkpatrick for his great
generosity in allowing his 230 cases, the later ones of the series, to
be made use of in this paper. Throughout all these years one definite
purpose has been kept in the forefront--viz., to ascertain the real
value of lens couching. After making every possible allowance for the
vaidyan, the fact remains that he is a standing menace to society,
and that he should be suppressed. His methods are crude, filthy, and
dangerous; his results are so appalling that anyone unacquainted
with the ignorance and credulity of the Indian ryot would think it
impossible for him to continue to exist. His impudent lying includes
not merely a grossly exaggerated statement of his own successes, but
extends to the most barefaced falsehoods as to the nature of the
results obtained in European hospitals. It may be permissible to
quote one instance--unfortunately, far from a solitary one in Madras
experience. Some years ago a peasant, who had had a cataract removed
in the Government Ophthalmic Hospital, and whose recollections of
his treatment there were most kindly, returned for operation on the
second eye. On the steps of a temple, within a hundred yards from
our operating theatre, this man, who had travelled several hundred
miles for aid, was induced, by a tissue of impudent lies, to sit
down and submit to couching. A few days later he presented himself
at the out-patient room with panophthalmitis. There is no branch of
ophthalmic disease and treatment in India which so profoundly impresses
the Western surgeon’s imagination as this one. Remember that cataract
strikes a man down in his maturity, at a period of his life when he has
begun to reap the benefits of his earlier years of toilsome industry.
His pay and his home expenses are both alike at their maximum. He is
treading the higher rungs of the official or business ladder, and is
endeavouring to afford his children the best education in his power.
Few pictures are more pitiful than that of such a man passing hopefully
down an avenue of credulity and ignorance to a fate to which death
itself is often preferred, the horror of a great and lifelong darkness.
On the other hand, Government, the protector of the poor, stands by
powerless to interfere, and supinely watches this catastrophic waste
of human energy. The cords that bind the individuals are woven a
million-fold together to tie the hands of the rulers more securely
still. Every civilized nation of to-day recognises it as a first
principle, that it is its duty to protect its people from avoidable
harm, and that to deal with preventable blindness is one of its primary
duties. That men and women, who ought to be burden-bearers, should
be thrown instead as a burden on their relatives or on the State, is
a social evil of no small magnitude. One does not presume to blame
either the State or the people. It would obviously be idle and wrong
to do so. The plain indication is to arouse the medical conscience of
the country, to start men thinking of the evils which are so rife in
the land; and so to introduce a ferment, as it were, into the medical
mind of India, and then to leave it to do its work. It is not suggested
that the country is ripe for legislation on the subject. The people are
not ready for it. There are, however, two distinct avenues along which
an advance may safely be made--viz., (1) the systematic dissemination
of knowledge through Government agencies amongst the people; (2) the
improvement of ophthalmic medical education. A movement in these two
directions is already on foot, and in time it will bear much fruit.