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).

Footnotes have been numbered sequentially and positioned below the
relevant paragraphs.




                         _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.


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.

  AMERICAN ENCYCLOPÆDIA and Dictionary of Ophthalmology, Casey Wood;
  Chicago, 1916.

  BASSO: La Clinica Oculistica, January, 1904.

  BLAND-SUTTON, SIR JOHN: On an Apocryphal Miracle, Middlesex Hospital
  Journal, vol. xx., No. 1.

  BRISSEAU: Traité de la Cataracte et du Glaucome; Tournay, 1706.

  CELSUS, A. CORNELIUS: Of Medicine, trans. by James Grieve; printed by
  D. Wilson and T. Durham, Strand, London, 1756.

  COLLINS, E. TREACHER: R.L.O.H. Rep., 1893, vol. xiii.,
  p. 308.

  CUSSON, M. P.: Remarques sur la Cataracte, à l’Académie des Sciences
  de Montpellier, 1779.

  DRAKE-BROCKMAN, Surg.-Capt. H. E.: The Indian Oculist and his
  Equipment, Trans. of the O.S. of the U.K., vol. xv., 1895.

  DRAKE-BROCKMAN, Lieut.-Col. E. F.: The Indian Oculist and his
  Equipment, Trans. of the O.S. of the U.K., vol. xv., 1895.

  EKAMBARAM, R.: Couchers and their Methods, Ind. Med. Gaz., 1910.

  ELLIOT, R. H.: Couching of the Lens, Ind. Med. Gaz., August, 1906.

  ELLIOT, R. H.: The Operation of Couching as practised in Southern
  India: a Review of 550 Cases, Proc. of S. Ind. Branch of B.M.A.,
  1912, and Ophthalmic Review, vol. xxxi., 1912.

  ENCYCLOPÆDIA BRITANNICA.

  GALEN: De partib. art. med.

  HAY-WILLIAMS: Practical Observations on Surgery; London, 1803.

  HIRSCHBERG: Centralblatt für Praktische Augenheilkunde, February 1,
  1894.

  HIRSCHBERG: Centralblatt für Praktische Augenheilkunde, 1908,
  vol. xxxii., p. 2.

  HISTOIRE DE LA MÉDECINE, par Kurt Sprengel, trad. par
  A. J. L. Jourdan; Paris, 1815.

  HISTOIRE DE L’OPHTHALMOLOGIE à l’École de Montpellier, par H. Truc et
  P. Pansier; Paris, A. Moloine, 1907.

  HUDSON, H. C.: R.L.O.H. Rep., vol. xviii., part ii.

  MACKENZIE, W.: On the Diseases of the Eye, 4th edit., London, 1854.

  MAYNARD, F. P.: Ophthalmic Review, April, 1903.

  MAYNARD, F. P.: Ind. Med. Gaz., May, 1905.

  PAULUS ÆGINETA, vol. ii., Sydenham Society, 1845–46.

  POTT, PERCIVAL: Remarks on Cataract.

  POWER, H.: Depression in Cases of Cataract, Brit. Med. Journ.,
  October, 1901.

  QUARTILLERA, CASTILLEY: Arch. de Oftal. Hispano-Americanos, October,
  1904.

  SMITH, H.: Cataract Couching, Ind. Med. Gaz., May, 1905; and Trans.
  of the O.S. of the U.K., 1904, p. 264.

  WARE, JAMES: The Cataract and Gutta Serena, 3rd edit., London, 1812.

  WILKINSON, MISS K. E.: The Manuscripts of Naples and the Vatican,
  etc., trans. from Albertotti, Ind. Med. Gaz., October, 1904.




CHAPTER II

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.




CHAPTER III

THE INDIAN COUCHER AND HIS HABITS


The coucher goes by different names in different parts of India. In
Bengal and in the United and Central Provinces he is known as the
“suttya” or “mal,” and in the Punjab as the “rawal.” Ekambaram, who
came into intimate contact with these men in the Madras Presidency,
always describes them as “vaidyans,” the term signifying surgeons. In
the north they are Hindus, of the Kayasth caste, a class well known for
its astuteness and educational qualifications. Drake-Brockman states
that in the north Mahomedan couchers are rare, whilst in the Southern
Presidency it appears to be the exception to find a Hindu doing such
work. Like every other occupation, couching in India is hereditary, the
principles of the craft being handed down from father to son by word of
mouth and by practical instruction. It has been stated that there is no
literature on the subject. This, however, would appear to be a mistake,
for Ekambaram learnt that there are “some old texts written on palmyra
leaves laying down the method.” A literal translation of one of these
runs: “Removing the lancet after making a puncture, insert the copper
probe; and holding it with three fingers, depress the lens with the
three-sided edge.”

By tradition and ancestral habit, the coucher is a wanderer on the face
of the earth, and like a gipsy he carries his wares, such as they are,
to the very doors of the people’s homes; but it is probable that in
each of the large provinces of India these men have a headquarters of
their own. This in the Madras Presidency is known as “Kannadiputhur,”
which signifies the “village of eye operations.” During part of the
year these men are agriculturists and fishermen; but when the dry
season robs them of their occupations, they wander forth to practise
the art, with which their ancestors have been identified from time
immemorial. They do not, however, confine themselves to eye operations,
but practise as well a crude form of general surgery. Like many other
disciples of Æsculapius, their fee is a very elastic one, and, in
common with other artists, they learn to know both the smiles and the
frowns of fortune. Luxury rarely comes their way, whilst hardship and
toil are their constant lot. Their spare evening hours are filled in
with such arduous and monotonous occupations as net-weaving; and full
many a night they go hungry to sleep, with the sun-baked earth for
their only bed.

All, who have seen them at work, agree that their methods are dirty
and septic to a degree, and the oft-expressed wonder has ever been,
not that their results are so bad, but that they are ever good. Their
surgical equipment is carried in a bag or in a box, which would be
considered dirty alongside of the tool-chest or work-basket of any
English artisan. The filth alike of their clothes, their hands, and
their person, stagger description from a surgical point of view.
The exact patterns of the instruments used vary in different parts
of India, and so also do some of the couchers’ customs. Allusion
has already been made to the slaughter of a fowl and the use of its
blood in Southern India. This is readily understood, as the Mahomedan
couchers are flesh-eaters. In the north, where these experts are
Hindus, the fowl plays no part, but a very subtle form of deception is
described by Drake-Brockman. Each suttiah carries in a little bag a
store of pieces of dried membrane. One of these is dropped into water
before the operation commences, and is produced at the psychologic
moment as evidence that the Indian surgeon can, and does, remove the
cataract from the eye, just as much as his Western brother. This
tribute to our science is as subtle as it is nefarious. The pieces
carried are of various tints, in order that the colour of the cataract,
as seen before operation, may be matched as closely as possible.

Right through the ages the shadow of charlatanism has lain over the
operation of couching. We are told that it did so in Alexandria and in
Rome at the dawn of the Christian era, and from that time up to the
present we find numerous traces of it in literature. Not the least
interesting of such comes from the Dark Ages, and, despite its pathos,
has a distinctly amusing side. The operator and his assistant took
the patient alone into a darkened room; a candle was lighted and kept
carefully behind the victim’s back by one of the knaves, while the
other in front asked if he could see the flame. A sham operation was
then performed, and the process was again repeated, but this time with
the light in front; naturally the blind man could now see it, and, on
being assured that “the change” was due to what had been done, his
gratitude was likely to rise to the production of the necessary fee. If
it did so, the impostors speedily made off. It seems hard to believe
that even the Dark Ages were dark enough for so transparent a trick to
be tried often in one town.

In a recent personal communication, Dr. Ekambaram has very kindly
furnished the writer with some additional information, as new as it
is interesting. He divides the Indian couchers, with whom he has come
into contact, into two classes, the Mahomedan couchers of the south,
whose work we mainly meet with in Madras, and the Punjabis (people of
the Punjab) from the north. The same method of operation is adopted
by both, but there would appear to be a great difference between the
status and the attainments of the two classes. The Mahomedans are much
the lower type; their practice is confined to the villages through
which they roam, and they very rarely visit big towns. Their length
of stay is limited to one or two days, and they make haste to escape
soon after having performed an operation, “for fear of being clubbed
for their stupid action.” They do not use any form of anæsthetic. On
the other hand, the Punjabi couchers are described as intelligent,
respectable, decently clad men, who confine their work to the towns,
and stay in each place four or five months, amassing considerable
wealth thereby. Before couching, they drop into the eye a fine yellow
powder, which Ekambaram believes to be stained cocaine. They were,
however, extremely secretive on this subject, and refused to part with
even a grain of the drug at any price he could offer. Its efficiency
is testified to by the fact that the patients remained absolutely
quiet and collected during the whole of the operation. The cases are
kept under observation for from a week to a month after operation,
putting in a daily attendance. Their results are much better than
those obtained by the Mahomedans. Some of the fees they obtain are
relatively very large. An idea of their social status may be gathered
from the fact that carriages are sent for them by their better-class
patients; but, in Ekambaram’s opinion, the aristocracy of Indian
intelligence is learning to keep aloof from these men, owing to the
influence of the Western surgeons, whose method of extraction is
steadily establishing itself in the esteem of the people at large.
He gives credit to the Punjabis for a more efficient technique of
operation than that practised by the Mahomedans.

In this connection it is interesting to record some of the opinions
of Western surgeons, who have come in contact with the work of these
northern men. Captain H. E. Drake-Brockman had nothing too bad to
say of them, and his uncle Lieut.-Colonel E. F. Drake-Brockman
(formerly of the Madras Eye Hospital), in presenting his nephew’s
paper before the Ophthalmological Society of the United Kingdom,
estimated the coucher’s successes at not more than 10 per cent.
Lieut.-Colonel Henry Smith went so far as to declare that even the
best cases, if followed long enough, ended in absolute blindness.
Lieut.-Colonel F. P. Maynard formed a much less unfavourable
estimate of the coucher’s results (46 per cent. of successes). The
writer’s own statistics will be given later. Not the least interesting
of Drake-Brockman’s contributions to the subject is his statement
that vaccinators and compounders in the pay of the Indian Government
are not infrequently couchers in disguise. The full significance of
this observation can only be appreciated by one who knows the East
intimately. Scientifically, Western medicine is educating the Indian
medical man out into the light from pagan depths of darkness. Even
to-day there are those of them who practise Eastern and Western
medicine side by side. It would seem strange to a British surgeon to
learn that it is possible for a medical man (whose qualifications, from
an educational point of view, compare favourably with those of our home
Universities) to lay stress before his patients on the right quarter of
the moon, and on the correct aspect of the ground, for the gathering
of a particular drug; yet the writer has known this happen, and that,
too, in the case of a medical man who held an important scientific
appointment under Government. The very fact of a man holding a post
under the British Rāj would add to his prestige and increase the
confidence of the people in him. That such an one should advocate and
practise couching would cause no surprise to his own people, whose
faith in methods based on tradition is firmly founded. Some idea of
the complexity and confusion of the Indian mind to-day may be gathered
from a knowledge of the strange blend of dissimilar lines of thought
in those who have adopted Christianity. There are many such who keep a
foot in both camps, in a way that would have been thought impossible by
anyone who had not been brought into intimate contact with such people.
Under these circumstances, it is hardly strange that the same kind of
thing should be found in evidence in other lines of life; and yet it is
no time to blame these men. Their need--I speak now from the scientific
stand-point--is for “more light.” We ourselves retain to-day the taint
of superstitions that come down from our witch-burning ancestors. Shall
we not, then, be lenient to those who have never had our advantages?
As we flood India with the daylight of true scientific knowledge, the
vermin of ignorance and superstition will scurry away to hide. That
the coucher believes in himself is indisputable; that he resents the
invasion of our Western operation is easily understood; and that he
must disappear, washed out by the advancing flood of better methods, is
as certain as the fate of the furrows left on the sand by last night’s
tide. Meanwhile he has stopped a gap and filled a place in the life of
a nation, and it behoves us, in our estimate of him, to remember that
the highest earthly honour ever awarded was given to a woman whom the
world despised and blamed, in the immortal words: “She hath done what
she could.”

It has been said of these men that they have no diagnostic powers, and
it is quite certain that they sometimes couch the lens in cases of
optic atrophy, of glaucoma, and of certain other diseases, in which
such a step is useless and worse. It is fair to add that the number of
cases of this kind which the writer saw was not large. This observation
is the more significant, since he was keenly on the lookout for any
instances of the kind, and that, too, during many years of Indian
experience in an exceptionally large cataract practice. Ekambaram
speaks of a case of operable cataract in which he had dilated the
pupil, and on which he (purely experimentally, and with no intention of
allowing it to be done) asked couchers if they would operate. As soon
as they found the pupil was motionless and dilated, they declined to
undertake any operation. He comments favourably on the acumen they thus
displayed.

A word may not be out of place on the subject of the covering of the
head of the patient and surgeon with a cloth, as adopted by some few
couchers during the operation. Such a procedure is, from the point of
view of lost light, a handicap to the operator, but it has, from his
way of looking at it, certain advantages. It shuts the patient off
from the distractions of his surroundings, which are otherwise very
public; it hides the actual operative procedure from prying eyes;
and it conceals the facial and other evidence of pain. The greatest
factor of all, in an Eastern land, is the air of mystery with which it
shrouds the proceeding. The element of “jadu” (magic) so introduced is
paramount in its psychologic interest.




CHAPTER IV

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.




CHAPTER V

THE PATHOLOGICAL ANATOMY OF COUCHED EYES

Being the Hunterian Lectures delivered before the Royal College of
Surgeons of England on February 19 and 21, 1917


_The material at our disposal consists of 54 globes_, the great
majority of which were removed in the Madras Ophthalmic Hospital in
the period from 1911 to 1915, though some are of much older date. They
were placed in 5 per cent. formalin immediately on removal, and were
subsequently frozen and bisected. In a number of instances one half
of the eye was submitted to microscopic examination after suitable
sectioning. Each of the half-globes and a number of microscopic
specimens have been photographed for purposes of illustration. It will
be convenient to classify our observations under a number of separate
headings.


=The Various Directions in which Dislocation of the Lens is found to
have taken place.=

Before considering this subject in the light of the pathological
specimens before us, it is necessary to make certain preliminary
statements:

1. Inasmuch as all our material is derived from blinded eyes, it is
obvious that we are dealing with the coucher’s failures alone, and
are excluding his successes. In a very large percentage of the latter
the lens is seen, during life, to be floating freely in the vitreous,
apparently untrammelled by adhesions.

2. The position in which we find the lens on bisection of the eyeball
is not necessarily that into which it was thrust at the time of
operation, for the changes which occur in the eye as a result of
inflammatory action may profoundly alter the position into which the
lens was originally forced by the coucher. Nor must we forget that
in those globes, in which the cataract is not tightly tethered by
adhesions, gravity plays a part.

Having thus cleared the ground, we may start with the statement
that, though the lens may be displaced in any direction within the
sclero-corneal coat, backward dislocations are by far the most common,
whilst forward ones were only found 4 times in the whole series
of 54 globes. None the less, each of these latter cases possesses
considerable interest.

=Forward Dislocations.=--(1) In No. 8[1] the couching instrument passed
through the limbus, and the track of the wound can be plainly followed
in microscopic sections. The ciliary body was pushed bodily away from
the sclera, and the lens nucleus was forcibly thrust into the space
formed by this cyclodialysis (Pl. II., Fig. 10); it is to be
seen imbedded in a mass of inflammatory exudate, whilst its capsule,
with some of the cortex, lies in the normal situation.

[1] The whole series of specimens has been presented to the Royal
College of Surgeons of England. The present chapter forms a descriptive
catalogue of the most instructive of them. The original Madras numbers
within the bottles have been retained, and are here quoted for ready
reference.

(2) In No. 44 the capsule and the nucleus of a Morgagnian cataract
are seen floating in the vitreous chamber (Pl. II., Fig. 11). During
life the nucleus frequently passed backwards and forwards between the
aqueous and vitreous cavities. The same phenomenon, though rare, has
been observed in other couched eyes.

(3) No. 61 is probably an instance of the same kind of thing having
happened at an earlier period (Pl. II., Fig. 12). Now, however, the
small dark Morgagnian nucleus is seen fixed in the lower part of the
anterior chamber, into which it doubtless gravitated by its own weight,
and there set up inflammatory mischief, which led to its adhesion to
the surrounding parts, and to its becoming fixed _in situ_ by the
formation of organising exudate.

(4) In No. 108 the only evidence of lens material present was the
capsule of a Morgagnian cataract, which lay impacted in the lower part
of the anterior chamber (Pl. II., Fig. 13). On section, Morgagnian
fluid escaped, and no trace of a nucleus could be detected. It is of
interest to record that the writer has, on a number of occasions,
operated on Morgagnian cataracts in which the lens nucleus had been
reduced to the thickness of a lamellar disc, or in which no trace of a
nucleus could be detected. In this case no adhesions had formed, and
during the transit of the specimen to England the capsule fell from its
position to the bottom of the bottle.

PLATE II

Fig. 10: Specimen No. 8, Whole-Section.--The lens can be seen
dislocated between the ciliary body and the sclera; the pectinate
ligament had been ruptured at the operation.

Fig. 11: Specimen No. 44.--The small Morgagnian nucleus lies in the
anterior part of the vitreous chamber; it passed freely between this
and the aqueous chambers, sometimes appearing in the one, and sometimes
in the other. The scar of the operation wound can be seen in the lower
part of the illustration, close to the ciliary body. Notice the folds
into which the detached retina has been dragged by the shrinking
inflammatory exudate. A tongue, consisting of the posterior surface of
the iris, was stripped back at the time of operation, and can be seen
attached posteriorly to the front of the hyaloid body.

Fig. 12: Specimen No. 61.--A small dark Morgagnian nucleus lies
impacted in the lower angle of the anterior chamber, which is largely
filled by a flocculent coagulated exudate. Notice the coagulated
subretinal exudate, and the cyst in the outer wall of the lower part of
the retina.

Fig. 13: Specimen No. 108.--The capsule of a Morgagnian lens lies
impacted in the angle of the anterior chamber; it had contracted no
adhesions. The vitreous body is represented by a fine cone of exudate,
which stretched forward from its apex at the optic nerve to a broad
base at the ora serrata.

Fig. 14: Specimen No. 50.--A large Morgagnian cataract floated free in
the vitreous chamber. The retina is extensively detached.

Fig. 15: Specimen No. 136.--A large hard laminated lens lies lightly
imprisoned in the inflammatory exudate which formed in the vitreous
body. A long curved scar can be seen over the ora serrata at the
temporal side of the specimen.

[Illustration: PLATE II.

Fig. 10 (No. 8).--Lens dislocated between cil. body and sclera.

Fig. 11 (No. 44).--Left eye, lower half.

Fig. 12 (No. 61).--Left eye, temporal half.

Fig. 13 (No. 108).--Right eye, nasal half.

Fig. 14 (No. 50).--Right eye, lower half.

Fig. 15 (No. 136).--Left eye, upper half.]

=Backward Dislocations.=--Dislocations backward are the rule, and very
wide variations are found both in the completeness and in the direction
of the displacement.

Those in which the _lenses_, or their nuclei, have been _completely
dislocated into the vitreous, and there lie floating_ more or less
freely (Pl. II., Fig. 14), are 9 in number. In 7 of them
the cataracts were Morgagnian, and in the 2 others there was a bulky
nucleus with a thin covering of stiff cortex. In 7 the tension of the
globe was high; in 6 the retina was completely or nearly completely
detached, and in 2 of them it was so much folded as to limit the
movements of the lens.

From a consideration of the lenses found floating in the vitreous,
we turn to that of those which were _entangled in a more or less
consistent inflammatory exudate occupying the vitreous chamber_
(Pl. II., Fig. 15). During life such lenses were reported to
be fixed, or nearly so. In the specimens they are seen to be nested
in a mass of exudate, which holds them imprisoned against the ciliary
body and the back of the iris. Usually this exudate is limited in
quantity and is confined to the anterior portion of the eye, and
principally to the neighbourhood of the dislocated lens. More rarely
it is very abundant, and occupies a large part or even the whole of
the vitreous chamber (Pl. III., Fig. 16). We shall deal with
this exudate more fully at a later stage; for the present it suffices
to state that it is inflammatory in origin, and that it contains a
large number of cells. Of the 6 cases which form this group, 3 were
Morgagnian cataracts; 5 were certainly dislocated in their capsule, the
sixth is hidden in such dense exudate that it cannot be clearly seen.
It is desirable to make it clear that intermediate forms are found
between this group and the previous one. In other words, there is no
hard-and-fast line between the cases in which the lenses float freely
in the vitreous and those in which they are, to a greater or less
degree, tethered by the pathological thickening of the hyaloid body.

We have next to consider a group of 10 eyeballs, in each of which
the dislocated _cataract was firmly fixed to the ciliary body and
to the back of the iris by definitely organised fibrous tissue_
(Pl. III., Fig. 17). These globes present certain well-marked
features of some interest: (1) The percentage of Morgagnian cataract is
much lower than that in the preceding groups, and corresponds closely
with the normal frequency of this form of cataract in Indian practice.
(2) The cataract was dislocated _in its capsule_ in no less than 8
of the 10 cases. (3) The retina was totally detached in 2 and very
extensively so in one; in every one of the remaining 7 this membrane
showed the presence of white dots, apparently on its surface. (4) The
time which had elapsed since operation in the cases falling under this
group is remarkable. In one it is given as seven months; in 2 others
there is no history; in the remaining 7 the duration was from two to
twenty years, with an average of well over seven years. The association
of the presence of white dots with these long histories is remarkable,
and will be taken up in a later section.

No. 99 (Pl. III., Fig. 18) is a specimen of special interest
for two reasons--viz., (1) the cataract is fixed to the globe unusually
far back, being attached to the retina a little behind the equator of
the eye; (2) the dislocation has taken place in an upward direction,
and therefore against the action of gravity. From time to time we meet
clinically with a couched lens whose suspensory ligament, though torn
through over a wide circumference, has been spared at one part, which
acts as a hinge. The loosened lens flaps backwards and forwards with
the movements of the eye, at times obstructing the pupil, and at others
being lost to sight. If the hinge is above, the cataract usually blocks
the pupil when the head is erect; but one meets with cases in which the
lens floats up out of the way unless the face is thrown forward into
the horizontal plane; this is apparently due to a check-ligament action
of the remaining suspensory fibres of the lens, acting on a lens which
is very nearly of the same specific gravity as the vitreous in which it
lies. Should inflammation be set up in such an eye and the lens become
involved in the exudate, it may become fixed, as in this case, in the
upper segment of the globe.

PLATE III

Fig. 16: Specimen No. 197.--The exudate into the vitreous cavity is
abundant and opaque, concealing the dislocated cataract. (Time since
operation, one month.)

Fig. 17: Specimen No. 37.--The lens is tied to the back of the iris and
ciliary body by firm organised exudate, which is continuous with and
part of the cone of inflammatory material representing the shrunken
vitreous. Notice the advanced organisation evident in the apex of the
cone near the optic nerve, also the white line apparently representing
the hyaloid canal. Some large dots and many small ones are to be seen
on the retina.

Fig. 18: Specimen No. 99.--A large lens in its capsule is dislocated
upward and inward, and is adherent to the retina by inflammatory bands.
The retina shows very numerous white dots. There is a tendency to
equatorial scleral staphyloma.

Fig. 19: Specimen No. 171.--The retina is totally detached and rolled
up tight; cysts both false and true are to be seen in it. The lens is
imbedded in a mass of inflammatory exudate, matted to the iris and
ciliary body in front, and to the retina behind; the ciliary body
is detached. The coagulated subretinal exudate gives the specimen
the appearance of a half-marble. The sclera is folded owing to the
shrinking of the eyeball.

Fig. 20: Specimen No. 119.--From before backwards can be seen the iris,
the remains of the lens capsule, and the thickened anterior layer of
the hyaloid. The lens is dislocated backward between the second and
third of these, and is wedging them apart. The retina is detached over
nearly half the globe; this is in large part determined by the pull of
the shrinking thickened anterior hyaloid layer.

Fig. 21: Specimen No. 46.--The hard dark nuclear cataract had been
depressed; it lies in front of the unruptured anterior hyaloid
membrane, and therefore outside the vitreous cavity.

[Illustration: PLATE III.

Fig. 16 (No. 197).--Left eye, lower half.

Fig. 17 (No. 37).--Left eye, lower half.

Fig. 18 (No. 99).--Left eye, upper half.

Fig. 19 (No. 171).--Left eye, upper half.

Fig. 20 (No. 119).--Right eye, upper half.

Fig. 21 (No. 46).--Left eye, lower half.]

When we come to speak of the changes found in the vitreous, we shall
have occasion to refer to the frequency with which the hyaloid body is
represented by a shrunken cone with its apex at the optic nerve and
its base in the neighbourhood of the ora serrata. This form, which is
well known to pathologists, is due to the anatomical attachments of
the vitreous body, and to the fact that the latter undergoes shrinkage
after being thickened and opacified by the presence of inflammatory
exudate. In studying the present collection, one cannot fail to be
struck with the fact that the exudate, which fixes, or helps to
fix, the lens in its pathologic position, is one with, and part of,
this cone-shaped new formation. Before leaving the consideration of
this group, we must once again point out that no hard-and-fast line
separates it from the preceding one, and that intermediate links
between the two can easily be pointed to.

In 11 globes, _dislocated cataracts were found matted between the
iris and ciliary body in front and the completely detached retina
behind_. It is very difficult to say what the nature of the original
cataracts was, since all that one can now find is a nucleus, usually
rather dark-coloured, imbedded in a mass of inflammatory tissue
(Pl. III., Fig. 19). These nuclei are undergoing steady
reduction in bulk as the result of phagocytic action. In 7 of the 11,
the lens remnants lie either within the complete capsule or in its near
neighbourhood. The interior of the capsule is usually found to have
been invaded by the mass of inflammatory and organising tissue which
mats together all the structures (_i.e._, the iris, the ciliary body,
the remains of the lens, and the detached retina), and which occludes
the angle of the anterior chamber. The completeness of the dislocation
varies greatly. In some cases the lens is hardly moved from its usual
position, and lies in front of the anterior hyaloid membrane, whilst
in others it is displaced into the vitreous cavity. In one instance
the detachment of the retina and the inflammatory changes are sharply
limited to the lateral half of the eye towards which the cataract was
dislocated, but this case belongs more to the next group than to the
one we are now discussing.

There are three outstanding and very important features common to these
cases: (1) In the great majority of them there is evidence that the
operation was followed by severe iridocyclitis; (2) 9 of the 11 were
shrinking eyes with low tension; and (3) the time which had intervened
between the couching and the enucleation was between one and two years
in every case save one, in which it is probable that the furnished
statement of three months was inaccurate. It will be noticed that the
histories are much shorter than those in the previous group. This,
together with the other two points mentioned, indicates that we have to
deal with a condition widely different from that in any of the previous
groups. Here the inflammatory process had been induced by a septic
infection of the eyes of a decidedly more virulent character, though it
fell short of that acme of infectivity, which leads in so many cases of
the Indian operation to panophthalmitis and destruction of the globe
within a few weeks.

We come next to a group of 5 cases, which have one feature in
common--viz., that the cataract, though _dislocated backwards, lies
distinctly in front of the anterior hyaloid membrane_, and therefore
outside the vitreous cavity (Pl. III., Figs. 20 and 21). In
3 of them the solid parts of the lenses have been pushed back from
their original position in such a way that they act like wedges,
forcibly keeping the anterior hyaloid membrane in a plane posterior to
that which it would normally occupy. Out of these 5 cataracts 4 were
cortico-nuclear; the fifth was too much altered for it to be possible
to state what its nature was. In certainly 4 out of the 5 moderately
severe iridocyclitis had followed the couching, but the exudative
process was a much less severe one than that which characterised the
specimens of the previous group. The consequence was that there was
no such matting of all the parts concerned as is there seen. In every
case the detachment of the retina was complete or nearly so, but in
not one was the lens enwrapped in its folds. This we may attribute to
two causes: (1) a merely contributory one, that the vitreous cavity
was not invaded; and (2) that the infection was less virulent, and
the inflammation consequently less severe, than in the members of the
previous group.

There is a small group of 3 cases in which the remains of the lens lie
_in situ_ in the periphery of the capsule, whilst the central portion
has disappeared. These resemble the peripheral after-cataracts not
infrequently seen following the extraction of a not fully mature lens.

In conclusion we have to mention 2 specimens in which the condition
found was so unusual that it would scarcely have been possible to have
anticipated its occurrence.

The first of these was one of the earliest globes sectioned. A
Morgagnian lens, entire in its capsule, was found _thrust behind the
retina_. It lay against the scleral coat close to the ciliary body; it
had detached the retina over a large area in the neighbourhood of the
ora serrata, and had led to a complete separation of it on that (the
nasal) half of the eye. The edge of the detached retina had contracted
adhesions to the front of the lens capsule, and was much puckered in
that neighbourhood, doubtless as the result of cicatrisation.

The second specimen (Pl. IV., Fig. 22) shows many features
in common with the last. The lens is entire in its capsule, and is
almost certainly Morgagnian; the tear in the retina through which it
was thrust has now cicatrised up, leaving a puckered scar. The retina
is totally detached, and on section the cataract lay as far forward as
the separation of that membrane would permit. The pupil was blocked
by exudate, and atrophic scars in the iris showed that there had been
extensive laceration of that membrane. The globe was removed a year
after operation.

The sequence of events in these two cases was possibly as follows:
The posterior operation may have been adopted and the incision placed
far back; a wide tear in the retina resulted; the lens, completely
separated from its attachments, was kept entire by the toughness of
the Morgagnian capsule, whilst the fluidity of its contents made its
insinuation through the retinal tear an easy matter. The fact that a
case has recently been recorded in which, in a boy of seventeen, the
lens spontaneously escaped through a 2 mm. trephine hole throws a
sidelight on such cases as these.


=Accidental Injuries to Other Structures than the Lens during Couching.=

Though the primary object of the Indian cataract coucher is to depress
the lens, he may accidentally injure any or all of the other structures
of the eye. Evidence of such damage is obtained both clinically and
pathologically.

=The Cornea.=--Opaque scars on the cornea are quite frequently seen in
the out-patient room in eyes which have been subjected to the anterior
operation, but are rendered invisible in formalin-mounted specimens
owing to the opacification of the membrane. Other evidence of corneal
injury is, however, available.

In No. 9 a corneal fistula is present, lying to the inner side of
the centre of the eye (Pl. IV., Fig. 23). The lamellæ immediately
surrounding it are largely replaced by connective tissue; the whole
thickness of the membrane is markedly reduced, and the lining
epithelium is irregular and vacuolated. The iris is very closely
adherent to the back of the cornea near the fistula, but more loosely
attached farther out. There has evidently been some ulceration of the
cornea and the formation of a limited staphyloma, which burst at a
later date, leaving the fistula now seen. It is probable that the point
of fistulisation was determined by the use of a septic instrument at
the time of operation, and that septic keratitis followed, leading to
early perforation with entanglement of the iris. On the other hand,
it is possible that the _enclavement_ of the iris occurred as the
instrument was withdrawn. In either case, the later sequence of events
included a dsecondary rise in tension, the formation of a staphyloma,
and a fresh perforation at the weakest point, resulting in the
production of a permanent fistula.

In No. 45 the lens capsule is adherent to the back of the cornea,
the iris being widely torn, and being probably also involved in the
synechia (Pl. IV., Fig. 24). All that remains of the lens is a brown
nucleus; the cataract was evidently Morgagnian. It is probable that,
after the escape of the fluid it contained, the lax capsule prolapsed
into the wound, either with the gush of fluid which accompanied the
withdrawal of the instrument or at a later date.

PLATE IV

Fig. 22: Specimen No. 138.--A large Morgagnian cataract in its capsule
lies dislocated behind the totally detached retina; the tear in the
front part of the lower half of the retina, through which the lens was
thrust, is now represented by a wide puckered scar.

Fig. 23: Specimen No. 9.--A whole-section showing a persistent fistula
of the cornea.

Fig. 24: Specimen No. 45.--A brown nucleus dislocated downward in its
capsule lies tightly adherent to the back of the iris and ciliary
body; it is fixed there by organised exudate, the bands from which
radiate out into the retina and are determining the detachment of that
membrane. The iris is torn on the nasal side, and through the tear
there passes a capsulo-corneal synechia.

Fig. 25: Specimen No. 116.--The retina is totally detached, and rolled
up like a closed umbrella. There is a retino-corneal synechia. The lens
has been reclined; it probably lay outside the vitreous cavity. The
subretinal exudate, coagulated by preparation, gives the eyeball the
appearance of a cut marble. During life the pressure of the lens, which
had been wedged backward, thrust the retina and the parts adherent
to it backward below, thus displacing the subretinal exudate there,
and causing it to bulge in the upper half of the eyeball; this bulge
effectually obliterated the upper part of the anterior chamber, whilst
the direct pressure of the lens obliterated the chamber below.

Fig. 26: Specimen No. 306.--There is a pigmented scar running through
the thickness of the sclera, just behind the level of the ciliary
processes. The optic disc is deeply cupped, and the anterior chamber is
very shallow.

Fig. 27: Specimen No. 306.--Low-power magnification of the previous
specimen shows a persistent fistula running through the substance of
the sclera; the ciliary body is impacted in its deeper part, and there
is a filtering scar on its surface.

[Illustration: PLATE IV.

Fig. 22 (No. 138).--Right eye, lower half.

Fig. 23 (No. 9).--Left eye, whole section.

Fig. 24 (No. 45).--Right eye, lower half.

Fig. 25 (No. 116).--Right eye, nasal half.

Fig. 26 (No. 306).--Left eye, upper half.

Fig. 27 (No. 306).--Microscopic section, low power.]

In No. 116 it is the retina which is impacted in the corneal wound
(Pl. IV., Fig. 25). It seems likely that in this instance
the sequence of events was as follows: A severe plastic inflammation
resulted from the couching, and involved among other structures a
capsular synechia, which had formed at the time of operation or soon
after. The vitreous became heavily infected, and the consequent exudate
became adherent on the one hand to the retina, which thereby underwent
total detachment, and on the other to the capsule and its synechia. The
progressive contraction of the scar-tissue then drew the retina into
the wound. This would appear to be the most likely explanation, but
it is not impossible, in dealing with such an operation as couching,
that the retinal detachment was very extensive, and that the injury
inflicted provided a path along which a direct prolapse of the retina
may have occurred.

=The Sclera.=--A very large number of Indian cataract couchers perform
the posterior operation, and therefore make their preliminary incision
in the sclera outside the limbus. Dr. Ekambaram, who has watched these
men at work, believes that they deliberately endeavour to avoid the
ciliary body, and it also looks as if some of them purposely place
their incision below the external rectus muscle. Like his Western
confrère, the Indian surgeon does not always succeed in placing his
incision just where he wishes to; this is not surprising, as many of
these men work without any local anæsthetic, and not a few of their
patients are nervous and unruly to the last degree. Moreover, it is
more than probable that there are different opinions amongst couchers
as to the best site for the preliminary cut. These considerations will
serve to explain the variety of location of the scars, as found in the
specimens before us; indeed, some such explanation is called for, since
the cicatrices may be found as far forward as the limbus, and as far
back as the equator of the globe; what is more, they may be seen in the
present collection, not only in their common situation, on or near the
horizontal meridian, but in any of the quadrants of the eye.

As a rule, the evidence of injury to the sclera is to be inferred from
the interference with the parts beneath that coat, and such instances
will be taken up when we come to consider the lesions of the ciliary
body and choroid; but occasionally we have been fortunate enough to
hit off the scleral scar either in the original division of the globe
or during the course of sectioning of part of it for the purpose of
microscopic examination.

In No. 306 the track of the original wound can be seen as a pigmented
scar in the sclera immediately behind the line of the ciliary processes
(Pl. IV., Fig. 26). Microscopic sections show--(1) that the
pigmentation of the deeper part of the scar is due to the impaction
of uveal tissue in its depth; (2) that there is a fistulous scar
running right through the thickness of the sclera; and (3) that
the subconjunctival tissue in the neighbourhood of the wound is
permeated by large open spaces lined with endothelium (Pl. IV.,
Fig. 27). It is clear that a limited measure of filtration had
been established, but this apparently proved insufficient to keep the
tension of the eye from rising, as is shown by the deep glaucomatous
cupping and by the obliteration of the anterior chamber.

No. 43 shows a scar a little farther back, in the neighbourhood of the
ora serrata; but in this case the wound appears to have healed solidly.
The pigment of the underlying uveal tissue shows a marked disturbance,
whilst before the specimen was cut it was observed that the sclera was
pigmented in the neighbourhood of the cicatrix.

In No. 8 the wound lay in the limbus, and the solidifying scar can be
traced right through the thickness of the ocular tunic and down to the
mass of inflammatory exudate which surrounds the dislocated lens, and
fills the angle of the anterior chamber. Here, again, the pigment can
be traced some distance up into the scar, in which the uveal tissue is
distinctly entangled.

=The Uveal Tract.=--In quite a large number of couched eyes one can
see, during life, evidence of past injury to the iris in the form of
more or less extensive scars, many of which probably also involve the
ciliary body. Moreover, in other cases, one can infer the presence
of injury to the ciliary body and the choroid from the existence of
pigmented cicatrices in the sclera. Anatomically, the present series
of eyeballs affords additional information on this head. Iris scars
are fairly common. In one case, already referred to, the coucher had
effected a cyclodialysis; in 3 more the wounds lie across the front
parts of the ciliary processes; in 6 they involved the region of the
orbiculus ciliaris, and in one of these the scar lies as much on the
choroid as it does on the ciliary body (Pl. II., Fig. 15);
lastly, in 4 the wounds lie well behind the ciliary body, being placed
in 2 of them just in front of the equator, and in 2 more well behind
it. Taking them as a whole, the wounds tend to be grouped in the
outer quadrant of the eye, above or below the horizontal meridian.
It has already been pointed out that this is in accordance with
Ekambaram’s evidence as to the site of selection for the incision in
the posterior operation. Far the best method of examining these scars
is by transillumination with a bright light from behind. Some points of
interest remain for consideration.

In No. 44 the wound lay behind the ciliary processes (Pl. II.,
Fig. 11), the instrument, most probably at its point, tore off
a tongue-shaped process from the posterior surface of the iris, thus
thinning that membrane over this area; the torn portion contracted
an adhesion to the subjacent hyaloid membrane, which was itself
infiltrated with inflammatory exudate; the appearance presented is
curious and interesting.

In several of the globes scar-tissue radiates from the wound area into
the surrounding tissues, and is then a strong contributory factor
in the production of retinal detachment. In one globe (No. 130) two
scars are to be seen, one of which was evidently placed too far
back by mistake (Pl. V., Fig. 28); the eye also furnishes
contributory evidence that things did not go well during the operation,
for the iris is very widely lacerated. It seems probable that the
patient was refractory or the surgeon unskilful. In any case, it is
clear that the instrument was introduced a second time.

In No. 148 a caseating mass in the eyeball (Pl. V., Fig. 29),
lying behind the equator, was found to contain a fragment of metal; the
latter was most unfortunately lost at the time the section was cut, but
it was presumably the tip of the couching instrument, and its presence,
taken with the facts that the wound was placed very far back and that
dislocation of the lens was not effected by the operation, would seem
to indicate that the patient moved violently and that the operator
failed in his purpose. The strong but strictly localised inflammation
excited suggests that the metallic fragment was of copper, and this is
in accordance with the known facts of the case, since the probes used
by these men to displace the lens are made of that metal.

No. 72 is also a specimen of special interest. Here, too, the puncture
lay behind the equator, and there seems to have been some difficulty
in penetrating the choroidal and retinal coats, which were carried in
front of the instrument, the result being a wide separation of these
two tunics from their scleral bed (Pl. V., Fig. 30).

No. 297, removed six weeks after the operation, is an eyeball which had
undergone panophthalmitis, and had burst through a point in the sclera
on the horizontal meridian somewhere in front of the equator. It is
probable that a septic wound of entrance determined the site of the
bursting. The lecturer has seen suppurating globes in which the sclera
at one point had completely sloughed, the intense inflammation present
bearing witness to the violence of the infective process excited.

=Uveitis.=--The type of inflammation of the uvea found in these
specimens was plastic, and was mostly confined to the iris and ciliary
body. The intensity of the inflammation varied very greatly. In a
number of specimens the evidence of inflammatory action was either
absent or only to be detected on very careful examination. On the other
hand, a large number of cases present themselves at Indian hospitals
in which suppurative panophthalmitis has followed the operation of
couching. In Madras such globes were eviscerated, as it was considered
dangerous to enucleate them, and much interesting material has thus
been lost. All the intermediate stages between the very slight and
the very severe inflammations can be traced in the specimens before
us. This is in accordance with what we should have expected in what
was practically a series of inoculations of healthy globes with
pathological materials, which varied enormously in their nature and
in the quantity introduced. Nor must we forget the great differences
in the ages and in the conditions of health of the patients. The
plastic mass poured out from the ciliary body and iris had in many
cases enveloped the remains of the lenses (Pl. V., Fig. 31; also Pl.
III., Fig. 19), which can be seen in process of disintegration under
the action of phagocytosis (Pl. V., Figs. 32 and 33) or of fluid
absorption. Evidence of calcification of the lens was obtained in
at least one specimen (Pl. VI., Fig. 35), and the same process was
also found at work in the uveal coat of several others. The rupture
of the lens capsule often provides a ready path of ingress for the
inflammatory exudate, which can then be seen filling the cavity of
the capsule as well as surrounding it. The curly remains, both of the
anterior and of the posterior portions of the capsule, can be clearly
traced in many of the specimens, imbedded in dense masses of organising
inflammatory exudate. In several such, the absence of the capsule
opposite or to one side of the pupillary area, and the curled-up ends
of the elastic membrane, mark the spot where rupture was effected at
the time of operation.

PLATE V

Fig. 28: Specimen No. 130.--The iris shows a deep jagged tear. There
are two scars made at the operation, one over the posterior part of the
ciliary body, the other near the equator of the eye. Numerous white
dots are seen on the choroid and iris.

Fig. 29: Specimen No. 148.--There is a localised patch of inflammation
within the globe behind the equator; in this was found a foreign body,
probably the tip of the copper probe used in the operation. It lay in
the vitreous cavity within the retina, which is totally detached.

Fig. 30: Specimen No. 72.--The operation scar can be seen on the
temporal side of the sclera behind the equator. The choroid and retina
are extensively detached on this side, having evidently been pushed
before the instrument before it succeeded in penetrating them. To the
nasal side in the anterior part of the vitreous chamber lies a cone of
exudate, the apex of which (posteriorly) is adherent to the retina, and
has raised it from its bed in the form of a shallow bleb. The cornea
fell in during preparation; it was ulcerated. The anterior chamber was
full of pus and blood. What is left of the lens lies buried at the base
of the cone of exudate already referred to, being bound thereby to the
ciliary body and to the back of the iris.

Fig. 31: Specimen No. 171.--A whole-section of the eye shown in
Fig. 19. For details of description refer to that figure.

Fig. 32: Specimen No. 171.--Low-power magnification of a portion of
the specimen shown in the previous figure. To the right is seen the
inflamed and matted iris; beneath this lies a mass of inflammatory
exudate in which the curled remains of the lens capsule can be traced.
In this mass of exudate the lens nucleus lies imbedded, its margins
being surrounded by large phagocytes.

Fig. 33: Specimen No. 171.--High-power magnification of portion of the
previous specimen, showing some of the phagocytes much enlarged. Notice
their processes invading the lens substance.

[Illustration: PLATE V.

Fig. 28 (No. 130).--Left eye, upper half.

Fig. 29 (No. 148).--Left eye, upper half.

Fig. 30 (No. 72).--Right eye, lower half.

Fig. 31 (No. 171).--Left eye, whole section.

Fig. 32 (No. 171).--Microscopic section, low power.

Fig. 33 (No. 171).--Microscopic section, high power.]

In only one instance has any evidence of proliferative uveitis come to
light, and in this one the nodule in the iris consists of mononuclear
lymphocytes; epithelioid and giant cells are conspicuous by their
absence. The interest of this observation centres in the fact that a
large number of these globes were removed with the object of guarding
against the occurrence of sympathetic ophthalmia, or of making safer
the performance of an extraction in the opposite eye. So far as the
first indication is concerned, it would appear that the danger of
sympathetic mischief in the second eye after couching is not great.
The deduction thus drawn from pathological data is confirmed by the
author’s clinical experience, for, as far as his observations go, it
is extremely rare to see the second eye lost by sympathetic ophthalmia
after this operation.


=The Chambers of the Eye.=

=The Anterior Chamber.=--This chamber showed departures from the normal
in different directions. These will be dealt with under separate
headings.

1. _Scantiness of Contents._--One chamber was quite empty, due to
the presence of a corneal fistula (Pl. IV., Fig. 23). In
a number of cases the chamber was greatly shallowed, owing to the
encroachment of the vitreous body upon it. In these the filtering angle
was sealed by adhesion over a wide area. In a few cases _l’iris bombé_
was responsible for the shallowing of the chamber (Pl. VI.,
Fig. 34). In yet others a severe plastic inflammation had involved
the structures, lying in and posterior to the aqueous chamber, and
had matted them to the posterior surface of the cornea, thus almost
obliterating the cavity. This union had been so strong that in the
process of hardening the membrane of Descemet remained adherent to the
organised exudate beneath it, and a spurious chamber was thus formed
lying in the substance of the cornea (Pl. VI., Figs. 35 and
36).

2. _Hypopyon_ was present in 6 specimens, and in one the pus was mixed
with blood. The length of histories in these cases varied from a matter
of months up to twenty years.

3. _Hyphæma._--Blood was present in the anterior chamber in 9
specimens. In some of them it was fresh, whilst in others it was
altered and decolorised. The long histories given by a number of
these cases suggest either that there had been some recent cause
for hæmorrhage, or else that a leakage of blood had been constantly
occurring. In 2 of the eyes the iris had been torn; in every one of the
others there was evidence that severe iritis had been present.

4. _Vitreous in the Anterior Chamber._--In 4 eyeballs the aqueous
and vitreous cavities appear to have been in free communication with
each other, and filaments of the vitreous body can be traced into the
anterior chamber. In 2 of these the angle was widely open, and in the
other 2 it was closed by irido-corneal adhesions.

5. _Lens Matter in the Chamber_ (Pl. II., _Figs. 10, 12,
and 13_).--In 4 eyes lens matter was found in the anterior chamber.
In one the history showed that a nucleus had passed freely backwards
and forwards between the two chambers (Pl. II., Fig. 11). In
another a Morgagnian cataract was wedged in the angle of the chamber,
but had contracted no adhesions; in the remaining 2 the nuclear masses
were firmly fixed in position by an abundant quantity of exudate.

6. _Albuminous Exudates in the Anterior Chamber._--These were found
in 3 cases; few or no structural elements were present. During life
the contents of the chamber were fluid, but they had coagulated under
the influence of the formalin preparation of the specimens; they were
probably derived from the iris and ciliary body.

PLATE VI

Fig. 34: Specimen No. 111.--The anterior chamber is much shallowed by
the bulging forward of the iris (l’iris bombé); the pupil is blocked,
and its edges are adherent to a layer composed of the lens capsule
and the anterior layer of the hyaloid, which are inflamed and matted
together. The retina is totally detached, and the choroid partly so. A
large cyst can be seen in what was the central region of the retina. It
is cut across in the section. (See also Fig. 44.)

Fig. 35: Specimen No. 74.--From before backward we see (1) the cornea;
(2) a space which might be mistaken for the anterior chamber, but
which is really an artificial tear in the substance of the cornea (see
Fig. 36); (3) the remains of the iris and ciliary body matted in
a mass of exudate in which is imbedded (4) what is left of the lens.
Large areas of this structure have undergone calcification; the wavy
capsule can be seen surrounding the lens remnants. Behind this and
continuous with it is a further mass of exudate, which tightly mats the
folds of the detached retina to the structures already mentioned.

Fig. 36: Specimen No. 74.--A higher magnification of a portion of the
preceding section. From above downward in the figure we see (1) the
cornea; (2) the artificial space; (3) the papillary margins of the iris
imbedded in dense exudate. Lining the lower boundary of the space is
seen the greatly convoluted membrane of Descemet, which has been torn
away from its corneal attachments, having clung more tightly to the
exudate, in which the iris is imbedded, than to its normal attachments.

Fig. 37: Specimen No. 250.--A large Morgagnian cataract lies imbedded
in a fine inflammatory exudate into the vitreous cavity; in this
exudate are many white inflammatory foci. The retina also shows many
white dots, the sclera is staphylomatous, and the anterior chamber is
extremely shallow.

Fig. 38: Specimen No. 72.--The inflamed optic nerve head shows a
mass of exudate occupying the physiological cup and bulging into the
vitreous cavity. This mass is undergoing organisation, and new-formed
vessels are to be seen in it at numerous points; it was the apical
end of a conical mass which represented the infiltrated and shrunken
vitreous body. Notice the pull of the roots of the mass on the edges of
the physiological cup.

Fig. 39: Specimen No. 199.--The conical mass occupying the vitreous
cavity has here undergone a high degree of organisation, especially
towards its apex at the optic nerve and in the neighbourhood of the
ora serrata. The canal of Stilling is probably indicated by the white
irregular lines seen in the centre of the cone. The pupil is blocked
with dense exudate which fuses with that of the cone; the contraction
of the latter has completely detached the retina from its bed.


[Illustration: PLATE VI.

Fig. 34 (No. 111).--Left eye, upper half.

Fig. 35 (No. 74).--Microscopic section, low power.

Fig. 36 (No. 74).--Microscopic section, higher power.

Fig. 37 (No. 250).--Right eye, lower half.

Fig. 38 (No. 72).--Microscopic section, low power.

Fig. 39 (No. 199).--Right eye, lower half.]

=The Vitreous Chamber.=--In the great majority of the eyeballs under
examination, it was observed that the vitreous body had become
detached and shrunken, and that its remnants showed distinct signs
of infiltration, and often of organisation. The appearances observed
in the various cases fall naturally under a number of headings: (1)
Very slight evidence of vitreous structure is discernible (Pl. II.,
Fig. 14). (2) Filmy masses are present in the chamber (Pl. II., Fig.
15). These either (_a_) are confined to the anterior portion of the
chamber, or (_b_) take the form of a cone with its apex at the nerve
head, and its base in the neighbourhood of the ora serrata and ciliary
body. (3) Masses are present which give the impression of being freely
infiltrated with inflammatory material, either throughout their
substance (Pl. III., Fig. 16) or in isolated foci (Pl. VI., Fig. 37);
these may be divided into the same subgroups, (_a_) and (_b_), as
those under the previous heading. (4) A distinct fibrous organisation
is noticeable in the conical masses, which represent the detached and
shrunken vitreous (Pl. III., Fig. 17). (5) No detail is discernible
(Pl. III., Fig. 19), owing to the fact that the retina has become
detached and inextricably matted with the one-time vitreous contents,
and with the iris and ciliary body.

There are certain preliminary points which we must first settle:

1. There is no essential difference between the cases in which there
is a definite cone of filmy or infiltrated membrane reaching from the
optic nerve head to the ciliary body, and those in which deposits of
a similar nature are found confined to the anterior portion of the
vitreous chamber. The grounds for this statement are as follows: (_a_)
An examination of the more complete specimens of conical exudate shows
that the membrane becomes very slender as the nerve head is approached,
and it is obvious that very little violence would be required to break
this delicate thread across, and so to allow the whole membrane to
be gathered up by its own elasticity towards its large and strong
anterior attachments. (_b_) There is strong evidence in a number of the
specimens of this series to show that the contraction of the shrinking
inflammatory material within the globes takes place with such force as
might easily suffice to break across the slender nerve attachment of
some of these cones. (_c_) It is obvious that in not a few cases the
tapering apex of a conical exudate is likely to be cut across during
section of the globe, or broken across during subsequent manipulations.
(_d_) Specimens in which the exudates presented a definite conical
shape, when they were first cut in India, have arrived in this country
transformed during the voyage into the similitude of those in which
the exudate is loosely gathered into the fore part of the vitreous
chamber; the apex of the cone had been broken off at the nerve head,
and the exudate had moved forward by virtue of its own elasticity
toward the anterior attachments of the mass. Taking all these
points into consideration, we may conclude that in all the eyeballs
which present the appearance of shrunken vitreous the structure was
originally conical in form, and that departures from that shape are
merely artefacts. Stress is laid on this point, because in a number of
the globes the appearances present suggest that the exudate is poured
out from the ciliary body, and is confined to the neighbourhood of that
structure. We believe such an interpretation to be quite erroneous, and
to be founded on the observation of artefacts.

2. Is this appearance of a shrunken vitreous body definitely
pathological? The answer is in the affirmative, for the following
reasons: (_a_) All these globes were treated alike, being dropped
into 5 per cent. formalin solution on removal, and kept there till
frozen and cut. (_b_) Normal eyeballs treated in this way present no
such evidence of definite vitreous structure. (_c_) Every grade can
be traced in the series before us, between the appearance of delicate
filmy membranes in the vitreous and the presence of firmly organised
structures. (_d_) Though it is very difficult to examine these exudates
satisfactorily under the microscope, there are a large number of
specimens which definitely show evidence of an inflammatory exudation,
strengthening and thickening the vitreous body. In not a few of these
the anterior hyaloid membrane (the term is used in a non-committal
sense) is definitely thickened and infiltrated with inflammatory
material (Pl. III., Fig. 20). The conclusion arrived at
is that these widely varying evidences of structural alteration in
the vitreous body are to be interpreted as due to the penetration of
the hyaloid by inflammatory material of chemotaxic origin, and to
the subsequent organisation of that infiltration. (_e_) There still
remains the clinical evidence. The author was increasingly reluctant,
as his Indian experience accumulated, to remove lenses which had been
couched. It was not that vitreous escaped, but that the results of
operation were usually poor, and that the blame of the lost sight was
then apt to be most unfairly ascribed to the extraction operation. In
view of the frequent occurrence of vitreous changes, this failure to
help the patients is easily explained. Major Kirkpatrick has taken a
different, and possibly a more generous, view of the position, and has
removed a number of these couched lenses. His evidence is of extreme
interest in the light of our recent pathological findings; he has been
“struck by the rarity of vitreous escape even after a fairly extensive
investigation with a spoon” in extracting couched lenses. He adds:

“I have noticed that the vitreous body becomes shrunken and
extraordinarily tough, so much so that when an eye is excised (either
for glaucoma or for iridocyclitis following Mahomedan operation),
the whole globe can be held up by a strabismus hook transfixing the
vitreous, though the latter appears perfectly clear. The vitreous
undoubtedly does undergo shrinkage, and leaves a large space, which is
occupied by aqueous.”

Straub[2] has described some experiments which he made on animals,
in the course of which he injected pathogenic organisms either into
the vitreous or into the ciliary body. The result varied according
to the part infected, and the poisoned area attracted leucocytes by
chemotaxis to itself. Particular interest attaches to the following
of his findings: (1) The optic nerve head was swollen and filled up
with leucocytes; (2) there was evidence “that the lymph current of the
vitreous goes by the optic nerve, and that chemotaxic substances are
brought by this current from the granuloma (the artificial infection)
to the nerve”; (3) the leucocytes found in the vitreous showed the way
from the granuloma to the cup of the optic nerve--they were seated on
thin membranes, and most of them were heaped together in small dots;
(4) aggregations were found on the walls of the cavities of the eye
(on the cornea, on the retina, on the lens capsule, etc.), attracted
there, in Straub’s opinion, by a chemotaxic action.

[2] “The Pathology of Dust-like Bodies in the Vitreous,” etc., Trans.
of the O.S. of the U.K., 1912, xxxii. 60.

In the experiments above considered, which were very limited in number,
an effort was made to localise the infection to one or other part
of the eye, and to work with a virus (tubercle bacilli) which was
comparatively constant in its toxicity.

What Straub did with a few eyes has been done in the series now
before us, by the Indian coucher, in fifty-four. The interest of the
experiments is heightened by the fact that, whereas in the Dutch
experiments the toxicity of the virus was kept as constant as possible,
in the Indian ones it varied from that of organisms which took many
years to destroy the sight to that of one which at once produced a
fulminating panophthalmitis. One point more: The Indian operator made
no effort to confine his procedure (and with that procedure went
infection) to any one structure; sometimes he attacked the lens from
in front, and in doing so he often primarily injured the iris, but may
have spared the vitreous chamber; sometimes he entered through the
ciliary body or through the choroid, opening up the hyaloid cavity
in doing so. His want of skill and the slenderness of his anatomical
knowledge made him catholic in the damage he inflicted, but running
through his work is the trail of septic infection of the eyeball by
penetrating wounds. The result is that he has provided us with a large
material of extraordinary interest in the study of the problem which
Straub started on.

_The Filmy Masses in the Vitreous Chamber._--As has already been
stated, the contents of the vitreous chamber in these specimens vary
from thin gauzy films, which can only be detected by careful search, up
to thick masses which strike the eye as soon as the specimen is looked
at.

It is not easy to obtain a view of these exudates in section, but
nevertheless they appear in a considerable number of the microscopic
specimens, and their character is always the same; they consist of
more or less structureless masses with blood-cells and leucocytes
imbedded in their substance. In fact, they would seem to be identical
with the membrane spoken of by Straub as harbouring the leucocytes
which gave rise to dust-like and other opacities of the vitreous in
his experimental cases. At a later stage, or perhaps in cases where
the inflammation has been of a more plastic character, a distinct
fibrillation of the exudate can be seen, and there may even be evidence
of a definite fibrous tissue formation. If we confine our attention
for the moment to those eyeballs in which the exuded mass is devoid of
structure in the anterior portion of the cone, we shall find that, on
tracing it back toward the apex by which it is attached to the optic
nerve, it becomes more highly organised and more richly cellular,
whilst fibrillation and fibrous tissue formation make their appearance.
The same thing, though in a lesser degree, may be observed in the
neighbourhood of the ciliary body, doubtless due to the presence of a
plastic exudate derived from that structure.

An examination (Pl. VI., Fig. 38) of the optic nerve and
of the exudate attached to it reveals the following features: (1)
The nerve head is congested, and its vessels stand out in prominent
relief. (2) There is a considerable effusion of leucocytes in the
neighbourhood of these vessels. (3) A mass of exudate fills up and
projects from the optic nerve cup, whether this latter is physiological
or glaucomatous. This mass is clearly contracting, and thereby pulling
on the tissue which lines the edges of the cup. (4) Along the centre of
the projecting exudate are to be seen (_a_) an abundance of mononuclear
cells; (_b_) the commencement of a fibrous tissue formation; and (_c_)
a new formation of bloodvessels.

The appearances above enumerated would indicate that we have to do
with an inflammation of the optic nerve, which had been induced by
chemotaxic substances brought thither along Stilling’s canal. Such
an idea is not a new one. It was suggested by Straub in order to
explain the optic neuritis he found in his two cases of experimental
inoculations of the ciliary body, and it also enjoys provisionally the
support of Fuchs’s[3] authority. The idea that part of the lymph of
the eye passes backward along a passage corresponding to the central
hyaloid canal is not generally accepted, and rests largely on inference
from the observation of pathological specimens. It would be difficult,
however, for anyone who has carefully studied this series to doubt
that such a flow exists; it is, of course, not suggested that any large
percentage of the lymph travels in this direction.

[3] Fuchs: “Textbook of Ophthalmology,” Duane, fourth edition. 1911, p.
16.

A confirmation of these views is obtained if we refer to the three
eyeballs in which the organisation of the cone of exudate into the
vitreous has attained the highest development. We notice in these how
extremely far this process of organisation has been carried in the apex
of the cone, where it is represented as a well-defined opaque cord (Pl.
VI., Fig. 39; and Pl. III., Fig. 17). In one of the three a fibrous
band, presumably the remains of the canal of Stilling, is clearly
seen, whilst in the two others the existence of this structure is at
least indicated. It is possible that in the first-named a congenital
peculiarity exaggerated the distinctness of the appearance.


=The Retina.=

Detachment of the retina occurred in 38 of the 54 globes (70·38 per
cent.), and was absent in 16 (29·62 per cent.). It was partial and
ill-marked in 5 (9·25 per cent.), extensive in 9 (16·68 per cent.), and
complete in 24 (44·44 per cent.). The ocular tension was above normal
in 11 out of the 16, which presented no detachment, but in only 6 out
of the remaining 38; it was below the normal in 13 of the 24 globes
with complete detachment, and above it in 3 of them. In the very great
majority of the eyes the detachment of the retina was undoubtedly due
to traction from within. The sequence of events is plain from a study
of the whole series.

At the operation there was an infection of the coats of the eye, and
also of the vitreous chamber from without; this led to the formation
of inflammatory material within the vitreous chamber; adhesions took
place between these new-formed membranes and the retina; finally the
shrinkage of the organising inflammatory material tore the retina
from its bed. Every step of the process can be traced either in
microscopic sections or in the naked-eye specimens. The earliest
possible stage is seen under the microscope in sections of an eyeball
(No. 37), where in the neighbourhood of the ora serrata the shrinkage
of the exudate within the vitreous chamber has just begun to lift the
retina from its bed. The individual points of attachment between the
inflammatory membrane and the retina are beautifully illustrated. The
ultimate stage of the process is to be found in those cases in which
the retina is not merely totally detached, but has shrunk posteriorly
into a stick-like form (Pl. III., Fig. 19, and Pl. IV.,
Fig. 25), whilst it opens out anteriorly into a mass in which the
iris, the ciliary body, the lens, the remains of the vitreous, and
the retina are inextricably matted and tangled. When sections of such
specimens are examined under the microscope, their leading feature is
the evidence of severe plastic iridocyclitis, with the formation of
abundant cicatricial tissue, which mats all the parts together and
severely distorts the normal anatomical arrangement. The retina is
dragged forward from the neighbourhood of the ora serrata over the
ciliary body, whilst elsewhere it is thrown into abundant folds and
completely separated from its normal attachments. A pseudo-cystic
condition is thus produced, the apparent cysts being formed by the
elaborate folding of the membrane (Pl. III., Fig. 19, and
Pl. V., Fig. 31). These may be small and slit-like, or may be
large and round, so simulating the appearance of true cysts. In front
of the retinal mass, lens fragments and capsule are seen in a number of
the specimens entangled in the scar-tissue. As has already been said,
all grades can be traced, from the slightest detachments up to those
we have just been describing. The greater or less degree of separation
of the retina met with in the different globes is doubtless in part a
question of time, but it is also, and probably to a much larger extent,
one of the character and grade of the inflammatory process excited in
the eyeball. The more plastic the type of inflammation and the more
intense the process is, the greater will be the measure of ultimate
cicatrisation, always provided that the inflammation is not intense
enough to result in suppuration.

There are several different ways in which the exudate which forms
within the vitreous chamber may be placed in a favourable position for
the production of retinal detachment.

1. The first of these is illustrated by each of those globes (Nos. 44
and 72) in which the site of a wound of the retina forms the point of
connection between that membrane and the inflammatory exudate lying
in the vitreous cavity (Pl. V., Fig. 30). The traumatic
infection of the retina served to attach the vitreous exudate to its
walls, and thus paved the way for the separation of the membrane. In
one of these cases (No. 44) a longitudinal fold was detached, whilst in
the other (No. 72) the detachment was broad and shallow.

2. In the second method also, it is necessary to postulate an infection
of the retina before that membrane could have contracted adhesions,
either localised or widespread, to the neighbouring vitreous exudate.
Once, however, the virus was planted within the hyaloid chamber, it
probably diffused itself widely, and by means of chemotaxis set up an
inflammation of the retina; evidences of such a retinitis abound in
many of the specimens. Attachments between the vitreous exudate and the
retina having been thus formed, the contraction of the former would
naturally lead to the separation of the latter from its choroidal bed.

3. In a few of the globes the contracting membrane is merely an
infiltration and thickening of the anterior layer of the hyaloid. It
is well known that the vitreous body is, under normal conditions, more
firmly attached to the retina in the neighbourhood of the ora serrata
than it is elsewhere; it is therefore obvious that an inflammatory
contracting membrane in the anterior part of the vitreous will pull
throughout its whole circumference on the retina in its neighbourhood,
effecting a detachment over a very wide area (Pl. III.,
Fig. 20). This is just what we see happening in the globes we are
now discussing.

4. In a number of the specimens it can be clearly seen that the
bands, which drag upon the retina, radiate from the remains of lens
masses, which are themselves encased in inflammatory tissue, and are
bound thereby to the iris and ciliary body in their neighbourhood.
Such bands appear in some cases to lie in the substance of the retina
itself (Pl. IV., Fig. 24); in others they are situate in the
vitreous and present the form of membranous sheets, separated from the
subjacent retina only by narrow spaces, and finding attachment to it in
the neighbourhood of the equator (Nos. 117 and 170). The characteristic
of these cases would appear to be that the dislocated lens is in
them the principal focus of sepsis within the eye. The point is of
interest, since some of them, at least, represent ruptured Morgagnian
cataracts; for there is reason to believe, on clinical grounds, that
the liberation of Morgagnian fluid within the eye is, sometimes at
least, productive of considerable irritation to the surrounding parts.

There are two globes in the collection in which the exudate within the
hyaloid cavity, converted into organised fibrous tissue, is obviously
tearing the retina from its bed in the course of its contraction. A
very interesting feature of these eyeballs is that in each of them an
opaque band which strongly suggests Stilling’s canal can be traced
forward from the optic nerve head (Pl. VI., Fig. 39).

In many of the specimens an abundant subretinal exudate is present. In
the long-standing ones, with complete detachment of the retina, this
effusion fills up the whole of the space between the retina and the
choroid. When the latter membrane is also detached, a further exudate
of similar appearance is seen between it and the sclera. Owing to the
action of the formalin, the very firm coagulation of the long-standing
effusions gives the eyes a solid and very characteristic appearance
(Pl. III., Fig. 19); the half-globes look like sections
of marbles made of fissured and clouded glass. In earlier cases the
effused mass is much less firm, but is whiter and more opaque, with
a tendency to present a flocculent appearance. The question that
naturally presents itself is, whether these effusions were the cause or
the result of the retinal detachment. The presence of the inflammatory
exudate within the vitreous, with which we have already dealt, provides
such a satisfactory explanation of the detachments of the retina
throughout this series, that it seems unlikely that the effusions in
question, whether subretinal or subchoroidal, play any causative part
whatever.

We must place in quite a different category the cases, four in number,
in which the effused fluid consisted of blood. The source of the
hæmorrhage in these cases is different from that which is met with when
the pressure within an eye is suddenly reduced by the operative opening
of the globe. In the latter case it is the large choroidal vessels
which give way, and the hæmorrhage is subchoroidal, whereas in the four
cases under review the bleeding was subretinal in one (No. 157), into
the vitreous chamber alone in one (Pl. VII., Fig. 40), and
into both the vitreous chamber and the subretinal space in two. The
hæmorrhage into the vitreous chamber was probably due to injury to the
retinal vessels by the coucher’s instrument, though it is possible that
blood may have found its way through the retinal cut from choroidal
vessels divided at the time. The subretinal probably escaped from the
severed branches of the smaller choroidal vessels. The fact that in
no case was a large subchoroidal hæmorrhage present would indicate
that the large choroidal vessels were tough enough to escape injury,
being probably pushed aside by the comparatively blunt instrument the
coucher used. In one eyeball (No. 157) large cholesterine crystals were
seen shining on the cut surface of the sanguineous mass. A similar
phenomenon was observed in the case of one of the albuminous effusions
above spoken of.

It remains to deal with a rare cause of detachment of the retina or of
the retina and choroid--viz., the application of direct violence at the
time of operation. This is best exemplified in the two globes in which
the cataract was thrust through and behind the retina, by the coucher’s
instrument, at the time of operation (Pl. IV., Fig. 22). It
is also beautifully illustrated by specimen No. 72, in which the retina
and choroid were carried in front of the coucher’s instrument before
the latter succeeded in perforating them (Pl. V., Fig. 30).
The dislocation thus produced proved permanent.

=Dots on the Retina.=--A striking feature of the series of specimens
before us is the presence of numerous dots on the retina. These are to
be seen in 16 cases, and doubtfully in a seventeenth. In at least one
other, similar dots are present on the choroid and on the posterior
surface of the iris (Pl. V., Fig. 28). We therefore find this
peculiar appearance in one case in every three; but this is far from
representing what is probably its real relative frequency, for in 24
of the globes the retina was totally detached, and it was therefore
impossible to say whether there were dots present on it or not. If we
put these 24 to one side, we find that the dots were certainly present
in 16 out of 30--that is, in well over 50 per cent. If we include the
other 2 cases above alluded to, the figure rises to 60 per cent.

In some of the specimens the dots are so large that they could scarcely
be missed under a careful naked-eye examination (Pl. III.,
Fig. 18), whilst in others they were only discovered when
highly magnified photographs of the eyeballs were thrown on a screen
(Pl. III., Fig. 17). They could, however, be found easily
with a loupe once their presence was known. The variation in different
specimens was not confined to size; some of the dots were white, others
were a pale grey, and a few were bright and shiny. Again, some of them
appeared much more sharply defined than others.

It was at first thought that manifestations so distinct under slight
magnification would yield very definite appearances under the
microscope; but, on the contrary, much difficulty has been experienced
in deciding the nature of the changes which have given rise to this
phenomenon.

One of the first points noticed was that the dots were found almost
exclusively in long-standing cases. This of itself would appear to
indicate that their cause was to be sought in some degenerative
process; but a closer analysis of the histories revealed a probable
fallacy in such an argument, since a number of the eyes had had good
vision for a long period after operation, and had eventually succumbed
to a fresh inflammatory invasion, or possibly to a more severe
recrudescence of a septic condition implanted at the time of operation.

On examination of a number of specimens, three distinct appearances
have been found, any one of which might presumably account for the dots
seen with the naked eye.

1. In some of the globes a proliferative retinitis can be found along
certain of the vessels (Pl. VII., Fig. 41). These consist
in section of masses of mononuclear leucocytes surrounding the vessel
wall, and tending to make their way to the inner surface of the retina.
It might be thought that such a change would produce lines rather
than dots, and that those lines would run along the course of the
vessels; but there are two features which make this doubtful: (_a_)
Even under the same field some of the vessels appear quite healthy
on section, whilst others show distinct masses of proliferation; and
(_b_) along the course of a vessel cut obliquely one may find the
proliferative exudate confined to one part of its course, the rest
being comparatively free.

2. In the neighbourhood of some of the inflamed retinal vessels above
spoken of, one finds on the surface of the retina what appear to be
free collections of mononuclear cells (Pl. VII., Fig. 42).
These are apparently of the same nature as the dots described by Straub
on the posterior surface of the cornea and in the vitreous body. It
will be remembered that he attributed them to chemotaxic action. It
would appear not improbable that the same explanation holds for these
retinal dots. It is of interest that, though they occur in cases of
long standing, the history of a subsequent inflammation, destructive to
vision is of a much later, and indeed, of a comparatively recent date.
The presence of such exudative masses would then be easily explained.

3. The grouping of these dots varies considerably in different
specimens, but does not lend much colour to the idea that they are
vascular in origin, for in some at least of the eyes they certainly
do not follow the course of the vessels. On the other hand, in a few
of the eyeballs there is a massing of these dots in the neighbourhood
of the ora serrata, which is in itself suggestive of a degenerative
process, since this is the area of lowest circulatory activity,
inasmuch as this region is supplied by the ultimate twigs of the
retinal vessels. This observation gathers interest from the fact that
in quite a number of these specimens it is possible to demonstrate the
presence of small cysts in the walls of the retina (Pl. VII.,
Fig. 43). These cysts are produced by the coalescence of œdematous
spaces in degenerative areas. All stages of the process can be traced
in different specimens of the series before us. Such cysts are only
likely to be met with in long-standing cases in which the degenerative
processes have had time for full play.

Inasmuch as these retinal dots are found in the cases in which the
retina is still in its normal position, it would seem probable that a
careful clinical search should reveal their presence in living eyes now
that their existence is established pathologically. It is a point which
should repay the study of surgeons who are practising where couching is
commonly resorted to, and especially in India.

PLATE VII

Fig. 40: Specimen No. 240.--The original cavity of the vitreous
is represented by a mass of blood-clot, surrounded by the walls of the
totally detached retina. The subretinal exudate is firm and abundant.
The iris and ciliary body, the lens remnants, and the anterior part of
the retina are matted together in a dense mass of cicatricial tissue.

Fig. 41: Specimen No. 175.--This shows a proliferative dot in the
retina. R, retina; SCL, sclera; CH, choroid; D, mass of leucocytes
surrounding vessel wall.

Fig. 42: Specimen No. 37.--A collection of leucocytes lying on the
inner surface of the retina, superficial to its limiting membrane, and
projecting freely into the vitreous. In the substance of the retina can
be seen the section of a vessel surrounded by a mass of leucocytes.

Fig. 43: Specimen No. 111.--Small cysts in the retina, which would
probably have coalesced before long to form a larger one.

Fig. 44: Specimen No. 111.--A whole-section of the eye already shown
in Fig. 34. The condition of l’iris bombé is well marked, the
pupillary edges being adherent to an inflammatory mass formed of the
capsule and the anterior layers of the hyaloid matted together. Notice
the large cysts occupying the central area of the detached retina, with
the macula lutea showing in its inner wall.

Fig. 45: Specimen No. 131.--A large Morgagnian lens in its capsule
was adherent to the iris base, the ciliary body, and the neighbouring
retina over a wide area. The capsule ruptured during the transit of
the specimen from India. Note the thickened white dots upon it; they
are characteristic of Morgagnian cataract. The large brown nucleus,
which escaped when the capsule burst, now lies free in the cavity of
the eye; notice the “bite” out of its edge. The optic disc was deeply
cupped, and the angle of the anterior chamber was widely obliterated,
the chamber itself being very shallow.

[Illustration: PLATE VII.

Fig. 40 (No. 240).--Left eye, lower half.

Fig. 41 (No. 175).--Microscopic section, low power.

Fig. 42 (No. 37).--Microscopic section, high power.

Fig. 43 (No. 111).--Cysts in retina. Microscopic section, high power.

Fig. 44 (No. 111).--Left eye, whole section.

Fig. 45 (No. 131).--Left eye, lower half.]

=Macroscopic Cysts of the Retina.=--It remains to speak of larger cysts
of the retina which can be recognised by the naked eye. It has already
been mentioned that, in those cases in which this membrane has been
found to be tightly folded on itself, a pseudo-cystic condition is
thereby produced; the cavities of these false cysts are merely shut-off
portions of the original vitreous chamber. Of a quite different nature
are the true cysts of the retina, three examples of which are to be
found in this collection. In one (Pl. II., Fig. 12) a narrow
slit-like cyst is seen in the outer layers of the detached retina at
its lower part. In the second, a whole-section of the globe shows a
large cyst occupying the central region, the macular area forming a
portion of its wall (Pl. VII., Fig. 44). Lastly, in the
third a large round cyst can be seen to the temporal side. A point of
interest in connection with this specimen is that it shows both true
and false retinal cysts (Pl. III., Fig. 19, and Pl. V.,
Fig. 31).


=The Choroid.=

It remains to add a few words to what has already been said about
this membrane. The great majority of the changes we have found in it
are, clearly, to be attributed to the effects either of hypertony or
of hypotony of the eye; they do not, therefore, differ from similar
appearances found under the same conditions generally.

Compared with detachments of the retina, those of the choroid are rare
in this series. In one instance, already mentioned, the two membranes
had been displaced together by the instrument used in couching
(Pl. V., Fig. 30). In another, in which severe inflammation
had occurred, the retina and choroid had adhered to each other, and
had been detached as one sheet by the contraction of an exudate, which
lay in the neighbourhood of the iris and ciliary body and in the front
part of the vitreous cavity. In a number of other globes, in which
the tension was low, the ciliary body and the anterior portion of
the choroid were found separated from the sclera as far back as the
line where the anterior segment of the latter coat was drawn over the
posterior in the manner pointed out by Treacher Collins in his work on
Hypotony (Trans. of the O.S. of the U.K., 1917).

In the previous chapter we have spoken of an appearance commonly
seen in successfully couched eyes--viz., an unusual distinctness of
the large vessels of the choroid in the ophthalmoscopic picture.
It is necessary to insist that in such cases the vessels are not
sclerosed; they are seen with unusual distinctness simply because
the pigment which usually hides them from view has disappeared. What
is more, a careful study of a number of these cases has created a
strong impression that the deficiency in pigmentation affects both the
pigmentary layer of the retina and also the pigment of the choroid. The
absence of the former lays bare what lies behind it; the absence of
the latter is inferred from the general appearance of pseudo-albinism.
These findings are the more noteworthy by reason of their contrast to
the usual deep pigmentation of the Indian eye. Some of our specimens
throw light on this phenomenon, for we observe in them two changes:
(1) The pigmentary layer of the retina is irregularly thinned and
altered, and at some points its pigment can be seen migrating into
the choroid; (2) the choroidal pigment itself is extensively altered
in an irregular manner, being heaped up in some areas and thinned in
others. It is necessary to remember that, inasmuch as our specimens are
wholly obtained from the coucher’s failures, whilst the interesting
appearance we are discussing is best seen in his successes, we cannot
expect very definite results from our pathological material, since the
changes we desire to study are there overlaid and obscured by those of
pathological processes, such as hypertony, hypotony, and inflammation.


=Glaucoma.=

It has long been known that couching is frequently followed by
secondary glaucoma. In the present series of 54 globes, 19 of them
showed evidence of high intra-ocular pressure. This figure must not,
however, be taken as a reliable index of the numerical frequency of
glaucoma as a complication of the operation. On the one hand, we
must remember that the present series deals with the failures only,
and that a large number of eyes are met with clinically in which the
lens is floating free in the vitreous chamber without any sign that
the intra-ocular tension is raised. Again, the cases which go on to
suppuration, and which are very numerous, are excluded from the present
series owing to the fact that all such were eviscerated in order to
avoid the risk of intracranial sepsis. This obviously diminishes the
total number of globes under consideration, and thereby raises the
apparent percentage of other conditions, such as glaucoma. On the other
hand, it would be a mistake to suppose that out of these 54 globes only
19 had suffered from secondary glaucoma, for in 24 of them a complete
detachment of the retina had covered up any evidence which may at some
time have existed of the presence of increased intra-ocular pressure,
though the conditions still found in some of them make it more than
probable that the globes were formerly glaucomatous. In any case, it
leaves us with the fact that, out of 30 eyeballs which were available
for accurate examination, no less than 19 were glaucomatous. In 17 of
the 19 the angle of the anterior chamber was extensively closed, and
in 3 of these the chamber was so shallow as almost to be reduced to
a potential slit. The remaining 2 are thus accounted for: In one the
angle was open save for a small marginal adhesion, and there was free
communication between the aqueous and vitreous chambers; unfortunately,
the specimen was almost spoilt in sectioning it for the microscope; in
the second, a Morgagnian lens was impacted in and had blocked the angle
of the anterior chamber.

Returning to the 17 cases in which the angle of the chamber was closed,
and to certain other eyeballs in which it seemed probable that glaucoma
had at some time been present, we found that in every one of them one
or other of the accepted causes of secondary glaucoma was revealed when
looked for; in some, more than one such cause was discoverable. We
shall content ourselves with enumerating these factors.

A corneal fistula, with evidence of past anterior staphyloma, was
present in one; here the cause of the glaucoma was evidently the
closure of the filtering angle, which resulted from the anterior
synechia; in one there was a capsulo-corneal synechia (Pl. IV.,
Fig. 24), and in another a retino-corneal synechia (Pl. IV.,
Fig. 25); in 5 the ciliary body was involved in the scar; in 6 the
dislocated lens pressed extensively on the iris base (Pl. VII.,
Fig. 45); in 3 the lenses, tilted at right angles to their normal
position, pressed the anterior hyaloid membrane severely back on the
side of the dislocation, whilst causing the vitreous to bulge the
iris forward into the anterior chamber on the opposite side; in 5 the
pupil was blocked, and in 3 of these l’iris bombé was present; in 2
the anterior layers of the hyaloid were so thickened by inflammatory
exudate as to suggest that there was an abnormal obstruction to the
passage of fluid across the membrane; in one a marked thickening of
the lens capsule in the form of an after-cataract may possibly have
provided an obstruction to the forward passage of fluid from the
vitreous; lastly, there is one globe in which glaucoma had probably
been present before the operation, if one may judge from the history of
the case and from the violent hæmorrhage which followed the couching.

It has been suggested that one of the causes of glaucoma after this
operation is an advance of the front part of the vitreous body owing to
a rupture of the anterior layers of the hyaloid during the operation.
Without in any way denying that the suggestion may be a valid one
in certain cases, the impression gained from a study of this series
is that we need look no farther than the well-recognised causes of
secondary glaucoma. We have only to remember that the trauma inflicted
is extensive and various, and that a greater or less degree of sepsis
accompanies every couching in the hands of its Indian exponents.




CHAPTER VI

DIAGNOSIS


The diagnosis of a case of couched cataract presents the surgeon with
three distinct problems: (1) To ascertain whether a couching has been
done or not; (2) to discover the new position of the lens and its
condition; and (3) to decide whether it is advisable to operate. Only
those who work in lands, where the couching of cataracts is an everyday
occurrence, will take a deep concern in such questions; but the subject
has a scientific interest which cannot fail to appeal to any one who
devotes his serious attention to the large questions of ophthalmology.

It might be thought that the simple and obvious way to ascertain
whether a couching had been done would be to ask the patient or his
relatives. In a large number of cases this is of course sufficient; but
in India, at all events, there are many who will deny the operation
they have undergone. This is due to the fact that it is widely known
among the people that the British surgeons view the coucher and all
his methods with extreme disfavour. Patients are therefore reluctant
to admit having consulted him, and they also are afraid lest treatment
should be refused them, once their true history is known; for it
is common knowledge amongst them that the Western practitioner is
extremely reluctant to interfere with an eye which a coucher has
spoilt. It is well, therefore, to consider carefully the grounds on
which the physical diagnosis of a couched lens should rest.

We will first consider the case of those eyes in which =the cataract
has been definitely removed from the neighbourhood of the pupil=.
These present certain well-marked signs: (1) _The pupil is brilliantly
black_, and (2) _the plane of the iris is flat_. It may seem strange to
insist upon these points, but to the trained eye they are so obvious
that a diagnosis can often be made, as soon as the patient takes his
seat in the out-patient room, in front of the surgeon. The quality
of the blackness of the pupil is difficult to put into words, but it
arrests the attention by its contrast to the ordinary appearance of the
pupil in people so advanced in life as the subjects of cataract usually
are. The phenomenon is due to the whole cataract, capsule and all,
being thrust away from the pupillary area, and it can be equally well
seen in cases which have undergone the intra-capsular operation. Then,
with regard to the flattening of the iris, the trained eye is used
to the appearance presented by the slight forward convexity of that
membrane as a result of the presence of the lens behind it; whereas the
complete removal, not merely of the lens, but also of the support of
the suspensory ligament, makes the iris flatten out in its own plane.

On close inspection we notice other signs. (3) _The iris_, deprived
of the support of the lens, _is often tremulous_. This can best be
observed if the patient is bidden to move his eye sharply in different
directions. (4) _Scars_ may be seen _on the iris_. These are the result
of tears of the membrane during the operation. In some cases they are
associated with an irregularity of the pupil, which may be extreme, or
with a limitation or absence of pupillary movements. In other cases
the immobility of the pupil, which may be absolute, is associated
with (5) _an atrophic condition of the inner free margin of the
iris_. Such a condition is only met with in very long-standing cases.
Transillumination of the eye will sometimes show up the scars, or the
atrophic condition just referred to, as light spaces against the rest
of the dark background of the iris. (6) A careful study of the cornea,
or of the sclera in its neighbourhood, will often reveal _evidence of
the wound made by the instrument_ during couching. In the cornea these
take the form of small nebulæ or leucomata, lying just within the
limbus, and usually in the temporal quadrant. In one case a persistent
fistula was met with, as the result, presumably, of the bursting of a
staphyloma along the original track of a septic wound. Scars in the
sclera are much more difficult to distinguish, but they can sometimes
be detected by the pigmentation which overlies them; such pigmentation
may be due to the inclusion of uveal pigment in the track of the wound,
as has been shown by our pathological specimens: but this is not the
only possible explanation of the discoloration, for in dark-skinned
races a certain amount of pigmentation is not uncommon after injuries
of the conjunctiva. In one of the eyes we examined, there was a
filtering scar over a fistula which had formed along the track of a
scleral wound. (7) We come now to the leading feature in the diagnosis
of these cases--viz., _the recognition of the displaced cataract in
its new position_ within the eye. In the rare event of a lens being
dislocated into the anterior chamber and fixed there, its presence
can be easily recognised. Again, in a large number of the cases which
present themselves in the out-patient room, the cataract can be seen
floating freely in the vitreous, and bobbing up and down with the
movements of the eye. In the case of the milky Morgagnian cataracts,
or of those cortico-nuclear cataracts which present a glistening and
pearly-sectored appearance, it would be difficult even for a beginner
to fail to see the lens, which usually lies at the lowest part of the
eye. As the patient sits in front of the surgeon, the gleam of the
white cataract can be caught each time he looks downward, even though
a distance of two or three feet may separate him from the observer.
In the case of darker cataracts, such as the pigmented nuclear ones,
frequently met with in Indian practice, a closer examination is
required.

The patient must be brought nearer to the observer, and facing a good
source of illumination. The surgeon then focusses the light on the
pupil by the aid of a lens, bidding the patient at the same time to
look downward. If this fails, the patient is instructed to bend his
head forward, holding the face horizontal; the surgeon then places one
closed fist on the back of his head, and gives a number of sharp raps
on it with his other fist; when this is done, it is often found that
the lens has floated forward on to the pupil. If the patient’s head be
now quietly raised, the lens can be seen dropping gently away from the
pupil, which turns from white or brown (according to the nature of the
cataract) to black as it does so. The experiment can be repeated again
and again. Sometimes the lens falls away from the pupil so quickly that
the surgeon must stoop down and look up at the eye in order to see
it. If even after this test he fails to see the cataract, it is safe
to assume that it is tied down in its new position by inflammatory
adhesions excited by the septic matter introduced at the time of
operation. Such adhesions may consist merely of delicate fibrils of
exudate, which slightly increase the consistency of the vitreous body,
and so to a small extent limit the excursions of the lens; or they may
be represented by firm and highly organised fibrous tissue, which mats
the lens in its new position, and which may be so strong that even a
post-mortem dissection would fail to disengage the cataract from its
adventitious position. This subject has been dealt with much more
fully in the chapter on pathology. The dilatation of the pupil by a
mydriatic will often make it quite easy to discover the whereabouts
of the cataract, especially if a strong light, whether natural or
artificial, is focussed on the eye by means of a lens. Natural light
is preferable to artificial if possible, especially in a country like
India, where powerful daylight can be counted on during a large part of
the year. The advantage of the white light is especially marked when
dealing with brown or dark-coloured cataracts. An examination with the
ophthalmoscope or with a transilluminator may sometimes be of value,
but in the class of cases we are now discussing, these are seldom
of much use, if the examination just described fails to reveal the
whereabouts of the cataract.

There remain a few points of interest which deserve mention. Though in
the great majority of couched eyes the cataract lies in the lowest part
of the globe, it may be found either to the inner or to the outer side,
or even in the upper half of the eye. Sometimes it flaps backward and
forward with the movements of the globe, swinging on a hinge, which
evidently consists of the remaining fibres of the suspensory ligament,
and which may be situate in any possible direction, though most often
it lies below. It will be readily understood that if this hinge is
situate below, or to the inner or outer sides, the lens will flap away
from the pupil downward, or to the hinged side, as the case may be.
It is not inconceivable that, in repeatedly doing so, it may inflict
some measure of injury on the neighbouring part of the ciliary body and
retina, and may thus excite a local inflammation which will tend in
time to tie the cataract permanently in the new position towards which
it flaps, away from the pupil. In the event of the hinge being in one
of the three directions now under discussion, the cataract will tend
to fall forward on to the pupil only when the patient stoops forward,
so as to bring his face into the horizontal plane. When the hinge is
situate above, the latter is one of the few positions of the face in
which the pupil clears itself in ordinary cases; but one meets with
instances in which, despite the hinge being above, the pupil remains
clear except when the face is horizontal, the lens lying most of the
time in the upper segment of the eye. There is another factor, and
probably a more frequent one, than that of the local injury inflicted
by the lens during its movement, which tends to tether it _in situ_.
This is the increasing consistence of the vitreous, due to the deposit
within it of inflammatory matter, a point which has already been
alluded to.

Our next consideration is that of the =cases in which the cataract
still lies behind the pupil=. It then seldom, if ever, is in absolutely
normal position, and it very frequently is found to have been moved
bodily downwards or to one side, or obliquely. Again, but more rarely,
it may be tilted backward at an angle with the plane of its normal
position. In a great number of cases the history will help one, and,
even when the patient denies couching, he will very often admit to
having had “medicine applied to his eye by a native practitioner.”
Should no such evidence be forthcoming, there may still remain that of
the lesions to the cornea, the sclera, or the iris, to which attention
has already been directed in the previous section.

From these cases we pass on to consider =those in which the lens
cannot be seen at all, owing to the occlusion of the pupil=. Here our
difficulties are greater still, and, if the history fails us, we must
fall back on a careful search for signs of wound scars in the cornea
or sclera, or of tears in the iris. A point which is always suggestive
is the existence of a cataract in the opposite eye. In such cases as
these, the contents of the chamber may be found to consist of pus or of
blood.

Our next group is a still more difficult one, for in it =no fundus
reflex can be obtained=. It embraces a number of conditions which may
be shortly dealt with in turn: (1) Those in which the vitreous body
has been converted into a more or less highly organised inflammatory
exudate, which is impenetrable to the light of the ophthalmoscope.
(2) Those in which this vitreous exudate has contracted inflammatory
adhesions to the retina, and by its shrinkage has determined the total
detachment of that membrane. (3) Those in which the vitreous chamber
has become filled with blood. It is obvious that in all such cases our
main dependence must be upon the history, though the other indications
already outlined may help us in some of them.

Lastly there are the cases =in which the eye is undergoing shrinkage=,
and those in which =phthisis bulbi= is following panophthalmitis.
The history of the signs and symptoms of severe iridocyclitis or of
suppuration will, in India at least, always excite a suspicion of
couching having been performed, unless the patient has a definite story
to tell of some other form of injury. Strangely enough, the inventive
faculty of the Indian patient does not rise to the height of vamping a
narrative of the kind. If he has had an injury, he tells of it readily.
If he has been couched, he stolidly denies that anything occurred to
cause his trouble, which he states “simply came of itself.”

It will be observed that in the preceding remarks we have dealt with
two of the problems which confront us in diagnosis, for the simple
reason that it is very difficult to separate them; to do so would
mean needless repetition. The discovery of the new position of the
lens, and of the degree of fixation, if any, it has undergone, can
hardly be divorced from the question of whether a couching has or has
not been performed. Our third problem was to decide whether it is
advisable to operate in any cases, and if so, in which. The Baron de
Wenzel, in his treatise on cataract,[4] records two cases in which his
father successfully extracted couched lenses. A number of Anglo-Indian
surgeons have had similar experiences, but most of them are reluctant
to interfere with these cases oftener than they can help, because,
should the operation fail, it is extremely likely that they will
unjustly incur the odium for the loss of the patient’s vision. On this
subject Maynard wrote (_Ophthalmic Review_, April, 1903): “It may be
justifiable to attempt the removal of a recently couched lens. If not
recent, and more especially if the lens is fixed, it is wiser to leave
it alone, even if the sight is failing.” To the writer’s mind, the one
crying indication for removal of a couched lens is that it flaps across
and obstructs the pupil. He agrees strongly with Maynard, that if the
lens is fixed it is better left alone; but he is doubtful whether
the time element is of very great importance, in comparison with the
mobility of the cataract; for a study of the fifty-four globes already
dealt with has shown him that the fixation or otherwise of the lens
is a question of the amount of septic action set up by the operation.
If this is small, the lens may continue mobile, even for a very long
period; if it is more severe, the latter will soon be tethered. Dealing
with this subject five years ago (Proc. of S. Indian Branch of B.M.A.,
March 13, 1912), the author wrote as follows:

[4] Translation by James Ware, surgeon, F.R.S.; London, 1812.

“We are extremely reluctant in Madras to undertake further operative
procedures on an eye in which couching has been performed. Removal of
a lens dislocated into the posterior chamber obviously means a wide
opening up of the vitreous; and even if the immediate result appears
good, there is little guarantee that the benefit will continue. Of
eighteen cases in which the lens was removed, twelve obtained better
vision at the time, four remained _in statu quo_, and two were rendered
worse. I cannot but think that these statistics would suffer if the
cases were followed for some years. On five occasions we undertook the
laceration of an after-cataract which blocked the line of sight after
couching. In two cases there was considerable benefit, whilst in three
vision remained _in statu quo ante_. In four cases an iridectomy was
performed for optical purposes. In two vision improved slightly, whilst
in the two others it remained as before.

“Personally I have a strong and growing objection to undertake any
operative procedure on a couched eye. Firstly, there is the risk of
lighting up a septic explosion, for which the real responsibility
lies with the coucher’s original operation; and, secondly, there is
the danger of being saddled with the discredit which is justly due to
another man’s failure.”

Reviewing these paragraphs in the light of the much better knowledge
of the pathology of couching which we possess to-day, he would urge
that only freely movable cataracts should be touched, since want of
mobility is associated with profound changes in the vitreous due to
septic action. The object that a surgeon sets before him, work where
he may, is ever the same--“The greatest good of the greatest number.”
Failure in such cases as these may play into the hands of the coucher,
and enable him to extend his sphere of influence at the expense of the
beneficent work of the Western hospitals. The problem in India is a
difficult one, in which surgical considerations do not stand alone, but
are interwoven with social, moral, and even political questions. Each
surgeon must decide for himself what line he will take, and follow it
fearlessly.

In this connection, Major Kirkpatrick’s experience[5] in Madras is of
considerable value, for he has removed a number of couched lenses,
and has been “struck by the rarity of vitreous escape, even after
fairly extensive investigation with a spoon,” during this operation.
He adds: “I have noticed that the vitreous body becomes shrunken and
extraordinarily tough, so much so that, when an eye is excised (either
for glaucoma or for iridocyclitis following Mahomedan operation),
the whole globe can be held up by a strabismus hook transfixing the
vitreous, though the latter appears perfectly clear. The vitreous
undoubtedly does undergo shrinkage, and leaves a large space, which is
occupied by aqueous.” It is plain that he is referring here to cases
in which the vitreous body has undergone some measure of inflammatory
organisation, which might be expected to limit the mobility of the
lens, and it will be of great interest to learn whether the conclusions
of so reliable and experienced an observer ultimately coincide with the
author’s, that interference should be confined to those cases in which
the movements of the cataract within the vitreous body are noted to
be free. Once again, let it be emphasised that there are two distinct
questions at issue--one the benefit of the individual patient, and
the other the good name of Western surgery. Each man must be guided
according to the dictates of his own personality and of his environment.

[5] Personal communication.




CHAPTER VII

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




H. K. LEWIS & CO. LTD., GOWER STREET, LONDON, W.C.