CLINICAL
There are, in connection with cases of couched cataract, some points of
clinical interest which will repay closer attention. These will now be
dealt with in turn.
=Pain.=--The pain which follows the operation of couching has attracted
the attention of surgeons from very early times, and there has been
much speculation as to its cause. When, after Daviel’s discovery,
extraction came into serious competition with the older operation,
surgeons discussed at much length the relative merit of the two
procedures, and it was strongly urged by the extractionists that their
operation gave rise to less pain than that of couching. The subject
is a very difficult one, for no surgeon, who has had a large cataract
practice, can fail to have been struck by the extraordinary difference
in the statements of patients as to the amount of suffering they have
endured during the first twenty-four hours after the removal of a lens.
The majority of them confess to a good deal of pain; this comes on as
the effect of the anæsthetic wears off, reaches a maximum, and then
slowly dies away, leaving them at the end of twelve hours, and often
even at the end of six hours, comparatively comfortable. Occasionally,
but rarely, the report is that the pain has been negligible throughout.
On the other hand, a bitter complaint of very severe pain is sometimes
encountered; fortunately such an occurrence is infrequent. In the case
sheets on which the writer’s 780 cases were taken, a special heading
was provided for notes on the pain inflicted at or after operation. A
striking feature of the replies given was the extraordinary difference
between them; this is the more astonishing because in a large number of
the operations it is probable that no anæsthetic of any kind was used,
and yet it was by no means uncommon to meet with patients, who made
little or nothing of the pain either at the operation or after it.
On the other hand, some complained of terrible suffering, commencing
as soon as the needle was inserted, and lasting for long periods
thereafter. The majority admitted to some pain, but neither belittled
nor exaggerated it. It will thus be seen that, so far as pain is
concerned, the experiences of the coucher and of the extractor are much
alike; it is unfair to judge either operation on exceptional cases.
Looking at the subject from the anatomical side, the writer is bound
to confess that an argument _a priori_ would have led him to expect
extraction to have been by far the more painful of the two procedures,
both at the time and during the early hours of convalescence, although
much has been made by early writers of injury to the retina and to the
sensitive ciliary body, and of the extensive damage done by the needle
during a couching. We know, however, that injury to the retina does not
produce pain; and we are also well aware of the extreme susceptibility
of the cornea to pain. Surely the extent of damage inflicted on
sensitive structures is, as a rule, much greater in an extraction than
it is in a couching. How then are we to explain the dread with which
surgeons, in the days of couching, looked forward to the suffering and
vomiting which sometimes followed the operation? In answer to this
question the following suggestions are put forward. The pain of the
first twelve hours is to be sharply differentiated from that which
begins on the second or third day, always remembering, however, that,
though the causes are different, the one may run into the other. The
early pain may be ascribed (1) to injury to the nerves of the ciliary
body and iris, especially when the laceration of those structures is
considerable, as our clinical experience and our specimens alike show
it sometimes is; (2) to hæmorrhage from the vessels of the ciliary
body, the iris, the choroid or the retina: such hæmorrhage may produce
pain in two ways--(_a_) by dissecting up sensitive structures, and
(_b_) by increasing the tension of the eye; and (3) to the rapid
production of early glaucoma. There are several ways in which we may
conceive that such a glaucoma might be produced. We have already
mentioned the possibility of hæmorrhage. Then we have to remember that,
in the course of this operation, the anterior portion of the vitreous
body is often extensively interfered with. It is conceivable that a
forward movement of this part may close the angle of the chamber, and
so interfere with excretion. Again, when the lens is forced back on
the vitreous body, and the anterior hyaloid layer remains unbroken,
we sometimes find it acting as a wedge, pushing the base of the iris
forward, and thrusting the hyaloid membrane backward. The latter action
must press on the vitreous body, and so make it bulge at other parts
of the circumference of the eye, thus tending to close the angle of
filtration over such areas. It is obvious that the pressure of the lens
on the iris base will directly close the sinus locally to a greater or
less degree. A point that we must never lose sight of is that the very
great majority of these patients are in the glaucoma period of life,
and with a certain number of them very little alteration of the _status
quo_ is required to precipitate an attack of pathological high tension.
If we take all these factors into account, and especially if we bear
in mind the great variability that different patients present in their
sensibility to pain, we shall have little difficulty in understanding
that couching may sometimes be followed within the first few hours by
great suffering attended with vomiting.
When we come to discuss the later pain, all difficulty vanishes. The
frequency with which iridocyclitis and glaucoma dog the footsteps of
couching in India, explains at once the bitter and oft-repeated history
of pain coming on within the first two or three days, and lasting for
months or even for years.
=Some Rare Accidents following Couching.=--In a large series of cases
such as we now have under review, it was to be expected that some
unusual incidents would be met with. A few of these will be dealt with.
_1. The Dislocation of the Lens into the Anterior Chamber._--This
accident was known to the early writers. It may occur either at the
time of operation or subsequently. In the former case the nucleus alone
may be dislocated, or the whole lens may be driven forward in its
capsule. It may lie loose and freely movable in the chamber, or may
become mechanically impacted there, or, lastly, may be firmly fixed
_in situ_ as a result of inflammatory action. In the cases of late
dislocation it is usually the nucleus alone that passes forward, the
cortex having either become absorbed or the cataract having originally
been of the Morgagnian variety. Such are the cases which give rise to
the interesting clinical phenomenon of a nucleus which passes backwards
and forwards between the two chambers. In some cases alterations in the
position of the patient’s head suffice to make the lens travel in one
direction or the other.
_2. The Dislocation of the Lens between the Ciliary Body and the
Sclera_ through the ruptured pectinate ligament occurred in one case.
Such an accident must be very rare under any possible conditions of
eye injury. J. B. Lawford, in the Reports of the Royal London
Ophthalmic Hospital (1886–87, p. 334), recorded a similar happening
which followed a blow on the eye by a clasp-knife thrown at a woman.
Nettleship (Ophth. Soc. Trans., vol. i.) also published a case
in which an opaque lens disappeared into a pouch between the choroid
and sclera when the patient lay down, and reappeared in the anterior
chamber when he stood up. The condition followed a blow on the eye
inflicted some years previously.
_3. Dislocation of the Lens behind the Retina._--This accident was
known to the early writers, and Mackenzie expressly gives the warning
that, if in effecting depression “the handle of the needle is raised
much higher than the horizontal position, the cataract is apt to be
pressed through the retina, and vision extinguished.” Daviel had met
with the same condition in eyes which he dissected after death, and
which had been couched by other surgeons. We, too, encountered it twice
in our pathological material. In one eye the retina had been torn away
from the ora serrata, and the lens pushed behind it; in the other,
an extensive hole had been torn in the retina, and through this the
cataract had been thrust. In both, the cataracts were Morgagnian and
had been dislocated in their capsules, and in both, the retinæ had
undergone total detachment, in this latter respect testifying to the
value of Mackenzie’s warning.
=A Comparison of Depression and Reclination.=--There can be no question
that the operation of reclination breaks up the vitreous body to a
considerably greater extent than mere depression of the cataract does.
On the other hand, the claim is made that after its performance the
lens is much less likely to undergo reascension; indeed, it was for
this reason that Willburg introduced the method; and, if we may judge
from the evidence of later writers, he was justified by results. So
far as the Indian coucher is concerned, it seems a little doubtful
whether he has any clear conception of the difference between the two
procedures; indeed, so long as he gets the lens out of the way of the
pupil, it is probable that he neither knows nor cares which method he
has succeeded in adopting, though he probably much more often reclines
than depresses. This may be explained by the experience of a number
of European surgeons, that it is more easy to effect reclination than
depression. An interesting point is that in quite a number of our
pathological specimens the lens lay in front of the anterior hyaloid
membrane, and therefore outside the vitreous body; most of these were
cases of depression, but in a few of them the lens is turned backwards
at an angle with its ordinary plane, clearly showing that a partial
reclination had been effected.
=Reascension of Couched Cataract.=--This subject has been partly
dealt with in the preceding paragraphs. Naturally, it was a topic
which attracted a good deal of attention from the early writers, who
commented on its relative frequency immediately after the operation,
and gave elaborate instructions to prevent its occurrence. Some of them
went so far as to suggest the frequent repetition of the operation, if
necessary. In their experience it would appear that, if reascension
failed to occur within the first fortnight, the prospect of the lens
remaining down was good. Nevertheless, they were familiar with the fact
that, even after years of a happy result, the cataract might suddenly
be found to have returned to its old position opposite the pupil. In
some cases this misfortune followed a blow or fall on the head, or a
severe jar of the whole body. Similar stories may be heard in an Indian
out-patient room to-day. This is a point which must be taken well into
consideration by any who think fit to resort to couching in selected
cases.
=A Comparison of the Corneal and Scleral Routes for Operation.=--It has
been already shown that the Indian operators of the present day vary
in their technique, some attacking the lens from in front through the
cornea, and others from behind through the sclera. It is interesting
to note that there is a similar difference in practice amongst those of
the modern surgeons who have adopted couching in special cases. There
can, however, be no doubt that the weight of opinion among the old
writers was all in favour of the posterior operation; and Mackenzie,
whose practical experience was, we may hope, vastly greater than that
of any modern surgeon, summed up the position in these words: “In
this way (_i.e._, through the cornea) neither operation (depression
or reclination) can be satisfactorily performed.” We may close this
subject with another word of warning to any who are inclined to favour
the couching of lenses in selected cases. From the time of Celsus
onwards, surgeons who have had large experience in couching have warned
their disciples that it is an operation much more easy to undertake
than to carry to a successful technical issue, and have cautioned them
against venturing on it until they have seen it performed many times at
the hands of an expert. One cannot conclude better than by a quotation
from the writings of Lieut.-Colonel Henry Smith, who has had very large
opportunities of observing the results of cataract couching. He is
known to be a very skilful operator, and one, therefore, who is little
likely to exaggerate the difficulties of any ophthalmic procedure, yet
he writes: “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.”
=The Dislocation of Morgagnian Cataracts.=--A curious error is to be
found pervading many of the early writings on couching--viz., that a
Morgagnian cataract could not be couched in its capsule. Our hospital
experience in India proved that this idea was erroneous, and the
examination of our pathological specimens has shown the correctness of
our clinical deductions. The Morgagnian lens may be dislocated forward
into the anterior chamber, backward into the vitreous, and even through
the coats of the retina, without rupture of its capsule. This is far
from being a surprise to any surgeon who has operated on a number of
these cases, for the Morgagnian capsule is usually very much tougher
than that of any other form of cataract. It has already been mentioned
that, if the capsule bursts, the nucleus may escape, and may then
sometimes be found either floating freely in one of the chambers of the
eye, or fixed in one position by inflammatory adhesions, or, still more
rarely, passing from chamber to chamber at intervals. The writer has
observed that in some cases the escape of Morgagnian fluid into an eye
appears to cause great irritation. The same fact has been observed by
some of the early writers on couching.
INDEX
A
Abu el Kasim, 2, 4
Accidental injuries during couching, 46
Advocacy (modified) of couching, 10, 11, 12
Ægineta, Paulus, 3
Age of patient, usual in couching, 27
Albertotti, 10
Alexandria, ophthalmic surgeons in, 1
Anæsthesia during couching, 15, 21
Anatomical examination of couched eyes, by Collins, 11;
by Hudson, 11;
by Kirkpatrick, 11;
by Parsons, 10
Anterior chamber, 55
albuminous exudates in, 56
blood in, 56
lens matter in, 56
pus in, 56
scantiness of contents, 55
vitreous substance in, 56
Anterior operation, 14
Antiquity of couching, 1
Antillus, 7
Apology for the coucher, 23
Avicenna, 2, 3, 4
B
Bartisch, 5
Basso, 11
Bell, Benjamin, 7
Benvenuto, 4
Bland-Sutton, Sir John, 1
Brisseau, Pierre, 7
C
Capsulo-corneal synechia, 46
Cataracts, entangled in vitreous exudate, 39, 81
fixed in vitreous chamber, 40, 80
floating freely in vitreous, 39
matted in inflammatory tissue, 43
peculiarities of, in India, 32
Causes of failure after couching, 28
Celsus, 1, 2, 3, 7, 90
Charlatanism, 6, 7, 20
Chemotaxis, 61, 63
Choroid, 73
changes in, due to hypotony, 73
detachments of, 73
Choroidal vessels unusually distinct, 74
Collins, E. T., 11, 12, 73
Comparison of depression and reclination, 88
of pain after couching and after extraction, 86
of scleral and corneal routes for operation, 89
Condemnation of couching, 11, 22, 26, 77
Copper probe, 16, 17, 51
Cornea, fistula of, 46, 78
scars in, 16, 46, 78
Coucher, descriptive titles of, 19
Coucher’s methods, 20, 33
Cusson, 7
Cyanopsia, 32
D
Dark Ages, couching in, 6, 20
Daviel’s extraction, 7
Delayed iridocyclitis, 28
Demonstration of couched cataract, method of, 79
Depression of cataract, 8, 88
Diagnosis of couching having been performed, 77
Difficulties in deciding surgical questions in India, 84
Difficulty of couching, 11, 90
Dislocation of cataract, backward, 39
behind retina, 45, 88
between ciliary body and sclera, 88
forward, 36, 87
in front of anterior hyaloid membrane, 44
partial, 81
Drake-Brockman, E. F., 22
Drake-Brockman, H. E., 9, 22
E
Ekambaram, 10, 11, 16, 17, 24, 26, 49
Extraction of cataract, 7
Extraction of couched cataract, 61, 77, 82, 83, 84
F
Fees of couchers, 22
Fixation of lens, degree of, 82
Fowl’s blood, use of, by couchers, 18, 20
Fundus reflex absent, 81
G
Galen, 3
Glaucoma, 28, 29, 74
after couching, 86
causes of, after couching, 75, 76
frequency of, after couching, 74, 75
Government servants as couchers, 22
H
Habits of couchers, 19
Hæmorrhage after couching, 67
Haly Abbas, 2
Hay, William, 7
Headquarters of couchers, 19
Hindu couchers, 19
Hirschberg, 9
Histories of Indian patients, unreliable, 77, 82
Hudson, A. C., 11
Hyphæma, 56
Hypopyon, 56
Hypotony, effect of, on uveal tract, 73
I
Imperfect dislocation of cataract, 28, 29
Incision, variation of site of, in couching, 49
Indian Medical Service Officers and couching, 9
Instruments for couching, 4, 16, 20
Invention of couching, first, 2
Iridocyclitis, 25, 28
Iris, atrophy of, 78
flat plane of, in couched eye, 77
scars in, 16, 78
tremulous, 78
Iris bombé, 55
J
Jesu Haly, 2
K
Kirkpatrick, H., 11, 61, 84
Knife, guarded, 16
L
Lens, calcification of, 55
Listerism, influence of, on couching, 9
M
Mackenzie, 7, 90
Magic, element of, in couching, 24
Mahomedan couchers, 19, 21
Maynard, F. P., 11
Membrane, dried pieces of, used by couchers, 20
Metabolic changes in development of cataract, 33
Miracles, early Christian, 18
Mistakes in diagnosis, couchers’, 23, 29, 30
Morgagnian cataracts, 27, 90
O
Ophthalmoscopy of couched eyes, 31, 80
Optic atrophy, 28, 29
Optic neuritis, 30, 63
P
Pain during couching, 15
following couching, 85, 87
causes of, 86
Panophthalmitis, 25, 52, 82
Parsons, J. H., 10
Pathological material available, 35
Philoxenes, 1
Phthisis bulbi, 82
Position of couched cataract, recognition of, 77, 79, 80, 82
Posterior operation, 16
Pott, Percival, 7
Power, Henry, 10
Punjabi couchers, 21
Pupil, blackness of, in couched cataract, 77
occlusion of, 81
Q
Quartillera, 11
R
Razes, 2
Reascension of couched cataract, 89
Reclination of cataract, 7, 8, 88
Reluctance to remove couched lenses, 77
Removal of couched lens, 61
Results of couching, 25, 26, 27
Retina, cysts of, 65, 70, 73
dots on, 68
dots on, frequency of, 68
dots on, pathology of, 69
Retinal changes ascribed to couching, 30
Retinal detachment, 28, 29, 64
causes of, 64, 65, 66
due to operative traumatism, 68
stick-like, 65
Retinal pigment, changes found in, after cataract-extraction, 32
Retinal pigment, changes in, found in couched eyes, 31, 32
Retino-corneal synechia, 46
S
Sandalwood paste, 17
Scarpa, 7
Scarpa’s needle, 8
Sclera, scars of, 49, 78
Scleral fistula, 50
Smith, H., 11, 22, 26
Social status of couchers, 22
Sprengel, 1
Statistics of couching, author’s, 11, 22, 25, 26
Kirkpatrick’s, 11, 25
Maynard’s, 10, 22
Straub on experimental hyalitis, 61
Subretinal exudate, 67
Suction of cataract, 7
Suppression of couching, 34
Sympathetic ophthalmia, 29, 55
T
Tabri, 2
Technique of couching, Abu el Kasim, 4
Avicenna, 4
Bartisch, 5
Benvenuto, 4
Brisseau, 7
Celsus, 2, 3
Indian operators, 10, 14, 16, 25
Mackenzie, 7
Thorn used in couching, 14
Tobit, recovery of sight of, 1
Transillumination of couched eyes, 80
U
Uveal coat, calcification of, 55
Uveal tract, injuries of, 50
Uveitis, plastic, 52
Uveitis, proliferative, 55
V
Visual results after couching, 27
Visual results of couching and extraction compared, 28
Visual tests employed by couchers, 16
Vitreous body, infiltration of, 59
Vitreous chamber, 56
cone of exudate in, 30, 43
cone of exudate in, altered artificially, 60
cone of exudate definitely pathological, 60
filmy exudate in, 62
Vitreous exudate, fibrous organisation of, 59, 64
Vitreous opacities, 28
W
Ware, James, 7
Willburg, 7
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