The Indian Operation of Couching for Cataract

CHAPTER I. The History of Couching

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.”

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