“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.