SURVEY OF OPHTHALMOLOGY VOLUME 55 � NUMBER 4 � JULY–AUGUST 2010

HISTORY OF OPHTHALMOLOGYMICHAEL F. MARMOR, EDITOR

Couching for Cataract in ChinaChi-Chao Chan, MD

Section of Immunopathology, Laboratory of Immunology, National Eye Institute, National Institutes of Health, Bethesda,Maryland, USA

Published

Abstract. Couching for cataract is one of the most ancient surgical procedures. Maharshi Sushruta, anancient Indian surgeon, first described the procedure around 600 BCE in Sushruta Samhita. Theprocedure, also known as jin pi shu in Mandarin, was introduced to China via the Silk Road during thelate West Han Dynasty (206 BCE--9 CE), and it spread throughout China during the Tang Dynasty(618--907 CE). As the procedure was combined with the Chinese concept of acupuncture, jin pi shu wasintegrated into Chinese medical practice until the founding of the Republic of China in 1911. Thegovernment of the Republic of China considered jin pi shu to be unscientific. In 1949, the Communistsestablished the People’s Republic of China. Jin pi shu was revitalized by Chairman Mao Zedong (1893--1976), who thought that traditional Chinese medicine, including jin pi shu, was a great treasure. Afterhis death and the opening of China to the external world, many Chinese ophthalmologists pointed outthat jin pi shu had relatively high complications and a low success rate, compared to various moderntechniques for cataract surgery. This procedure is gradually fading away in China. The use of jin pi shureflects the history, culture, and political transformation of China. (Surv Ophthalmol 55:393--398,2010. Published by Elsevier Inc.)

Key words. cataract � China � couching � history � Sushruta � Maharshi

The operation known as couching or reclination forcataract is one of the most ancient known surgicalprocedures. The Greek philosopher Aulus Corne-lius Celsus (25 BCE--50 CE), who lived during thereign of Emperor Tiberius (14--37 CE), describedthe detailed method of couching for cataract in hisDe medicina, a classical medical treatise in Greek andLatin that has survived to the present day.7,12 Celsusexplained:21

The needle used is to be sharp enough topenetrate, yet not too fine; and this to beinserted straight through . . . at a spot betweenthe pupil of the eye and the angle adjacent tothe temple, away from the middle of the

393

by Elsevier Inc.

cataract, in such a way that no vein is wounded.When the spot is reached, the needle is to besloped against the suffusion itself and rotatedgently, guiding it little by little below the pupil.When the cataract has passed below the pupil,it is pressed upon more firmly in order that itmay settle below.

Galen (131--201 CE), a physician to five Romanemperors, indicated during the time of EmperorMarcus Aurelius that cataract surgery was practiced inthe Alexandrian School and probably originatedfrom Hindustani medicine. The first documentedevidence of cataract couching can be found in thewritings of Chrysippos, the Stoic philosopher of Soli

0039-6257/$--see front matterdoi:10.1016/j.survophthal.2010.02.001

394 Surv Ophthalmol 55 (4) July--August 2010 CHAN

from the third century BCE, when cataract couchingwas still unheard of in ancient Egypt and classicalGreece. Indeed, the procedure was recorded around600 BCE in Sushruta Samhita, a treatise written byMaharshi Sushruta, an ancient surgeon fromIndia.7,20 The surgeon used a sharp lancet to piercethe sclera, then a blunt instrument (needle) to probeinto the eye. Seeing a drop of fluid indicateda successful puncture. The inserted needle was aimedat the suffusion (cataractous lens), and, with a down-ward movement, the lens was dislodged away from thepupil into the vitreous cavity. When the patient wasable to see objects, the needle was removed.8,20

Interestingly, the risk of injury with the Indiancouching method might be lower than with the useof just a sharp needle as described by Celsus. Thissimple procedure spread to Europe and attractedmany quack doctors throughout the Middle Ages.

In 1583, George Bartisch wrote in his book on thecare of the eyes about the practitioners of the art:1

Nor is there any lack of old women, vagrant hags,therica sellers, tooth-pullers, ruined shop-keepers, rat and mouse catchers, knaves, tinkers,hog-butchers, hangmen, bum-bailiffs, and otherwanton good for nothing vagabonds . . . all ofwhom boldly try to perform this noble cure.

Couching is a relatively ineffective and dangerousmethod of cataract therapy and often results inpatients remaining blind or with their vision onlypartially restored. The procedure was graduallyreplaced by extracapsular cataract surgery in themiddle of the 18th century, when different surgicaltechniques for cataract extraction with better out-comes were developed.7 In modern times, a plannedcataract extraction of phacoemulsification and in-traocular lens implantation is recommended.

In 1917, Robert Henry Elliot (1864--1936), in-ventor of the sclero-corneal trephine and thesuperintendent (1904--1913) of the GovernmentOphthalmic Hospital, the oldest eye hospital in India(built in 1819 in Madras), reviewed the results ofcouching operations performed by the local oritinerant practitioners. Out of 550 patients, only20% demonstrated improved vision; in addition,retinal detachment occurred in 54 of the couchedeye specimens.9 Elliot concluded that the method wascrude and filthy. His conclusion only represents theconditions and techniques in India at that time, ofcourse, and results may have been different else-where. However, it is hard to imagine that couchingcould have been very reliable anywhere in ancienttimes, with non-sterile procedures and inappropriateanesthesia. We may presume that it survived in thoseeras only for the lack of any alternative.

Couching for Cataract in Imperial China

The procedure of couching for cataract wasintroduced to China via the Silk Road during theHan Dynasty, which followed the Qin Dynasty(221--206 BCE), when the Great Wall was first built.The reign of the Han Dynasty, including the WestHan (206 BCE--9 CE) and the East Han (25--220CE) periods and lasting over 401 years, is one of thegreatest eras in the history of China. Today, theethnic majority of China is referred to as the Hanpeople. During the Han Dynasty, China becamea Confucian state and prospered through growth inagriculture, commerce, and population.2 Confusius(551--479 BCE), a famous Chinese thinker andphilosopher, emphasized personal and governmen-tal morality, correctness of social relationships,justice, and sincerity. Confucian theories on moral-ity and ethics, with goodness as the core and rites asthe norm, served as the keynote of traditionalmedical practice in China. The empire of the HanDynasty extended its political, cultural, and territo-rial influences; the Han Dynasty expanded to NorthKorea, inner Mongolia, north Vietnam, and eastCentral Asia (from the current Caspian Sea in thewest to central China in the east, and fromsouthern Russia in the north to northern India inthe south). To export Chinese silk, a path ofcaravan traffic became the Silk Road to CentralAsia. Subsequently, international cultural exchangebegan through the Silk Road from China andcontinued westward beyond the Caspian Sea.Indian travelers, mainly Buddhist monks, intro-duced various Indian religions such as Buddhismand Brahmanism to China. To promote theirreligion, these monks provided medical care tothe poor. At the end of West Han Dynasty, theIndian method of couching was brought to theChinese oculists.4,10

The Chinese historians regard the Tang Dynasty(618--907 CE), preceded by the Sui Dynasty (580--618CE), as a high point in Chinese civilization—equal toor surpassing the Han Dynasty, as well as a golden ageof cosmopolitan culture. Its territory, acquiredthrough military campaigns of earlier rulers, wasgreater than that of the Han Dynasty. Chinese cultureflourished, and it was considered the greatest age forChinese poetry. The creative vigor of Tang let it bea more open society, welcoming foreigners fromJapan, Korea, and Vietnam, as well as visitors fromIndia and the Middle East. It was during the TangDynasty that the first organized school of medicine(Tai Yi Shu or Imperial Medical College) run by thegovernment was completed in Xian, and that manyforeign medical practices became available andwidespread in China.

Fig. 1. Wang Tao (702--772 CE).

Fig. 2. A painting in the Dun Huang Cave. The Buddharestores the eyesight of a five robbers to see the truth of theDharma—a Jataka story. Cave 285, Western Wei, 535 CE.

COUCHING FOR CATARACT IN CHINA 395

Couching for cataract became more widespreadand popular during the Tang Dynasty; famouspoems and stories about couching and cataractswere recorded during this time. In 752 CE, medicalspecialist Wang Tao (702--772 CE, Fig. 1) authoredthe book Waitai Miyao [The Medical Secrets of AnOfficial], in which the causes and symptoms ofcataracts as well as the method of couching cataractswith a metal needle were described.3 The figures inthis book can still be found in the moxibustionscrolls in the Dun Huang Cave, Gansu Province(Fig. 2). The poem Zeng yan yi bo luo men seng [Apoem presented to an Indian monk and eyedoctor], written by the famed mid-Tang poet LiuYuxi (772--842 CE), acknowledged the Indian monkwho used the couching technique:15

These three years have I suffered a disease ofthe eye, and I cannot see clearly. Though butmiddle-aged, I appear to be an old man.Presented with a red object, I see it as green.

An Indian monk knew jin pi shu, an artcapable of curing my diseased eye and helpedme to see clearly.

In Eye Disease of Long Shu, the first famous Chinesebook on ophthalmology, the method of couchingcataracts with a (gold) metal needle was men-tioned.3,4,10 Couching for cataract is called jin pi

shu or jinzhen bozhang fa [to cure cataracts witha golden needle] in Chinese. The famous poet BaiJuyi (772--846 CE), who wrote 2,700 poems, sufferedfrom eye disease himself. He wrote a poem express-ing his appreciation to Long Shu.3

After the Tang Dynasty, jin pi shu was adopted andintegrated into the Chinese medical mainstream, asthe procedure was combined with the Chineseconcept of acupuncture.10 Acupuncture, moxibus-tion, herbal medicine, and dietary therapy are themain practices in traditional Chinese medicine.Traditional Chinese medicine is largely based onthe philosophical concept that the human body isa small universe with a set of complete andsophisticated interconnected systems, and that thesesystems usually work in balance to maintain healthyfunction of the human body. For example, thebalance of yin and yang is considered with respectto qi (breath or spiritual energy), blood, jing (kidneyessence or semen), other bodily fluids, the Wu Xing(the five movements or elements: wood, fire, earth,metal, water), emotions, and the soul or spirit.Traditional Chinese medicine has a unique modelof the body, notably aligned with the meridian system,which guides the placement of acupuncture needles.

The assumption that jin pi shu could be tracedback in Hung Di Nei Jing [Yellow Emperor’s Canon ofInternal Medicine], the oldest medical textbook inthe world (800--200 BCE), made the procedurepopular. The Yellow Emperor, the ‘‘Father of theChinese Nations,’’ who was credited with teachingthe Chinese how to make wooden houses, silk cloth,boats, carts, the bow and arrow, ceramics, and theart of writing, was the inventor of acupuncture.Chinese people were familiar with the story of HuaTao (110--207 CE, Fig. 3), the first of the Taoistphysicians and the most famous doctor in ancientChina, who discovered the anesthesia Mafei San(a narcotic drug) and used it in jin pi shu to treatEmperor Cao Cao’s (155--220 CE) cataracts.10

Fig. 3. Hua Tuo (110--207 CE).

396 Surv Ophthalmol 55 (4) July--August 2010 CHAN

Jin pi shu became more and more popular in China.During the Qing Dynasty (1644--1911), Ma Szeyay, theprivate secretary to the chief of the district, hada successful couching of his cataracts; this made thesurgery famous and no doubt influenced many toseek the same relief.18 The procedure was performedin the first Chinese-Western hospital, known as ‘‘theOphthalmic Hospital,’’ in Canton (Guangzhou),which was established by a Yale-educated Americanophthalmologist, Peter Parker (1804--1888), in1835.19 Interestingly, Parker’s good friend andmentor, Thomas Coledge (1796--1879), an Englishmissionary physician, was the first Western-trainedmedical doctor to come to China. He practiced inMacau, a small island under Portuguese colonialcontrol in Southern China, in 1827.19 Coledge alsoperformed couching for Chinese patients withcataracts.

Couching for Cataract in Modern China

With the violent overthrow of the Qing Dynastyand with its replacement by the Republic of Chinain 1911, leaders of the country desired to modern-ize, and Chinese physicians were highly encouragedto study and practice Western medicine.17 Thegovernment of that time proposed abolishingtraditional Chinese medicine and took measures tostop its development and practice. A critical sloganwas that traditional Chinese medicine was manifestlyunscientific. Therefore, jin pi shu was discouraged

and replaced by modern surgical techniques forcataract extraction.8

In 1949, the Chinese Communist party came topower under the leadership of Chairman MaoTsetung (1893--1976), and the People’s Republic ofChina was born. After its founding, China’s foreignpolicy initially focused on its solidarity with theSoviet Union, the Eastern Bloc nations, and othercommunist countries, and opposed the West, partic-ularly the U.S. In addition, China had gone throughthe Sino-Japanese war and the civil war between Mao’sCommunists and Chiang Kai-shek’s Nationalists(1887--1975) for over 15 years; the country’s resourceswere extremely limited. Consequently, medical ser-vice was quite inadequate in the early 1950s in China.Therefore, the new communist government encour-aged the application of traditional Chinese remediesbecause they were cheap, acceptable to the Chinese,and used skills already available in the countryside.Chairman Mao’s declaration in 1958 that ‘‘Chinesemedicine is a great treasure house!’’ inspired effortsto revitalize traditional Chinese medicine in China.As a result, traditional Chinese medicine regainedpopularity, and the use of acupuncture and herbalmedicine became standard medicine in many hospi-tals in the late 1950s and 1960s. Currently, thetraditional Chinese medicine practices of acupunc-ture and herbal medicine exist as a parallel medicalsystem to modernized (Western) medicine in China.In this system, both inpatient and outpatient medicalcare is delivered from large, well-equipped hospitals,as well as private clinics and pharmacies.17 Today,traditional Chinese medicine, with its manybranches, has spread far and wide, gaining popularityin all parts of the world.

With the restoration of traditional Chinesemedicine, jin pi shu was also revived in the 1960s.It was a required subject for physicians (medicalstudents and residents) who studied ophthalmologyin medical schools and hospitals. All ophthalmolo-gists, including my late parents (Fig. 4A), wererequired to learn and practice the procedure inChina. My father, Eugene Yao-zhen Chan (1899--1986),9,13 graduated from the Boston UniversitySchool of Medicine in 1927, and was Dr. WilliamHolland Wilmer’s post-doctoral fellow at the JohnsHopkins Medical School during 1929--1934. Mymother, Winifred Wen-shu Mao (1910--1988),14

who graduated from the Western China UnionUniversity Medical School in Chengdu in 1937, andcompleted two post-doctoral fellowships at theUniversity of Toronto and the University of Chicagoin 1947--1949, studied jin pi shu. During the 1960s,my mother also performed couching on somepatients with mature cataracts in the countryside(Fig. 4B). Although the traditional jin pi shu method

Fig. 4. The author’s parents. A: Drs. Eugene Chan andWinifred Mao in 1954. B: Dr. Winifred Mao (center)examined cataract patients in the countryside.

Fig. 5. Dr. Tang Youzhi.

COUCHING FOR CATARACT IN CHINA 397

of pushing the cataractous lens into the bottom ofthe vitreous cavity was not changed, the couchingneedle was appropriately sanitized. The eyelids ofthe cataract patients were sterilized topically withalcohol, and local anesthesia was applied prior tocouching, sometimes by acupuncture.

In the 1960s, China began suffering from theeffects of the Great Leap Forward (1958--1961), a planfor the rapid development of agriculture and industryby using China’s massive supply of cheap laborersinstead of importing heavy machinery. ChairmanMao went into partial retirement, and the countrygradually recovered. Nevertheless, by the middle of

the decade, Mao decided to return to the spotlightand launched the Cultural Revolution (1966--1976),a mass movement to eradicate capitalism andbourgeoisie influence from the country. The resultwas widespread social and political upheaval, as wellas nationwide chaos and economic disarray. Manyphysicians were forced to abandon Western medi-cine. Traditional Chinese medicine, including jin pishu, was practiced everywhere.

Chairman Mao, who did not want to havea Western operation, demanded that his cataractsbe cured using jin pi shu. He, like some Chinese,considered jin pi shu to be an acupuncture pro-cedure, not a surgery. Dr. Tang Youzhi (Fig. 5), anophthalmologist who practiced traditional Chinesemedicine, successfully couched for his left eyecataract on July 23, 1975;5 my mother observed thesurgery in Beijing. The procedure was performedunder modern sterility and acupuncture anesthesia.Later, the cataract in Chairman Mao’s right eye wasalso couched. Soon, Dr. Tang became the firstdirector of the Eye Hospital at the China Academyof Traditional Chinese Medicine in Beijing.

Since the famous toast of reconciliation betweenthe US President Richard Nixon (1913--1994) andChinese Premier Zhou Enlai (1898--1976) on 25February 1972, and the historical meeting betweenPresident Nixon and Chairman Mao in Beijing inFebruary 1972, China has intensified her efforts toindustrialize and modernize, both economicallyand scientifically. Chinese modernization has influ-enced the practice of Chinese ophthalmology.Because jin pi shu has relatively high complicationsand a low success rate, and various moderntechniques for cataract surgery, including intraoc-ular lens implantation, have been introduced,couching for cataract is gradually fading away inChina. Jin pi shu was used in only 0.52% of the10,686 cataract operations performed in theGuangdong Province from 1988 to 1989, comparedto intracapsular extraction, extracapsular extrac-tion, and unknown modes, which accounted for

398 Surv Ophthalmol 55 (4) July--August 2010 CHAN

68.83%, 25.77%, and 4.88%, respectively.16 Eitherextracapsular cataract extraction (887 cases,87.30%) with intraocular lens implantation (855cases, 84.15%) or intracapsular cataract extraction(129 cases, 12.70%) was performed in 1,016cataract cases from a survey of 11,884 persons withthe stratified random sample rule in the Shang-dong Province in 1999, but there were no reportedcases of couching for cataract.6 In a study ofwillingness to pay for cataract surgery in ruralSouthern China in 2007, the cost of surgery wasdetermined to be 500 renminbi (US$ 63); in-terestingly, the survey did not even mentioncouching.11 Currently, jin pi shu is only taught asa traditional and historical procedure to treatcataracts in classes on traditional Chinese medi-cine, while acupuncture and herbal medicine stayalive and prosper in China. In fact, many youngChinese ophthalmologists who work in modernmedical schools and ophthalmology departmentshave not even heard the term jin pi shu during theirtraining.

Summary

In summary, Indian monks transferred the pro-cedure of couching for cataract to China via the SilkRoad at the end of the West Han Dynasty. Theprocedure jin pi shu was well accepted in the TangDynasty, when the country flourished and foreignexchanges were encouraged. Couching for cataractbecame popular after it was considered an elementof acupuncture and integrated into traditionalChinese medicine. This procedure was prohibitedin the Republic of China, when the governmentdeemed it ‘‘unscientific.’’ In the People’s Republicof China, led by the Communist Party, couching forcataract was revitalized, as Chairman Mao believedthat traditional Chinese medicine was a greattreasure house. After his death and the opening ofChina to the world, Chinese ophthalmologists wereable to compare and practice various modernsurgical cataract extractions, and the procedure isvanishing from China once again. In reality, thehistory and use of couching for cataract, jin pi shu, inChina, reflects the country’s history, culture, andpolitical transformation.

References

1. Blanchard DL. Bartisch on Theriac. Arch Ophthalmol. 2001;119:1360--3

2. Bulling A. A landscape representation of the Western Hanperiod. Artibus Asiae. 1962;25:293--317

3. Chan E. The general development of Chinese ophthalmol-ogy from its beginning to the 18th century. Doc Ophthal-mologica. 1988;68:177--84

4. Chen Y. Ramble in Chinese ophthalmology, past andpresent. Chin Med J. 1981;94:1--4

5. Chen K, Hao X. The integration of traditional Chinesemedicine and Western medicine. Eur Rev. 2003;11:225--35

6. Dang G, Zheng X, Yang Z, et al. An epidemiological surveyand treatment of blindness in Zhangqiu city Shandongprovince. Chin J Ophthalmol (Zhonghua Yan Ke Za Zhi).1999;35:352--4

7. Duke-Elder S. Vol. XI. Diseases of the Lens and Vitreous;Glaucoma and Hypotony, in Duke--Elder S (ed) Systemof Ophthalmology. St Louis, C.V. Mosby Co, 1969, pp248--51

8. Eichenbaum JW. Trends in cataract surgery. Bull NY AcadMed. 1992;68:367--89

9. Elliot RH. Indian operation of couching for cataract. Br JOphthalmol. 1917;1:64--5

10. Fan KW. Couching for cataract and Sino--Indian medicalexchange from the sixth to the twelfth century AD. Clin ExpOphthalmol. 2005;33:188--90

11. He M, Chan V, Baruwa E. Willingness to pay for cataractsurgery in rural Southern China. Ophthalmology. 2007;114:411--6

12. James P, Thorpe N. Ancient Inventions. New York, RandomHouse Inc., 1995. pp 19--20.

13. Kupfer C. Professor Chen Yao--Zhen (Eugene Chan), M.D.1899--1986. Am J Ophthalmol. 1986;102:286--7

14. Kupfer C. Wenshu (Winifred) Mao, MD, 1910--1988. ArchOphthalmol. 1989;107:498

15. Liu Y. Zeng yan yi bo luo men seng, in Qu T (ed) Liu Yuxi JiJian Zheng [Collected Works of Liu Yuxi]. Shanghai,Shanghai Guji Chubanshe, 1989, p 964

16. Liu SR, Su XL. Analysis of 10,686 cataract operations inGuangdong province. Chin J Ophthalmol (Zhonghua YanKe Za Zhi). 1992;28:267--9

17. Micozzi MS. Historical aspect of complementary medicine.Clinics Dermatol. 1998;16:651--8

18. Mogridge G. Points and Pickings of Information aboutChina and the Chinese, Chapter 1. 1844. Book from thecollections of Oxford University. Digitizing sponsor: Google.

19. Raven JG. Thomas Coledge. A pioneering British eyesurgeon in China. Arch Ophthalmol. 2001;119:1530--2

20. Roy PN, Mehra KS, Deshpande PJ. Cataract surgeryperformed before 800 BC. Br J Ophthalmol. 1975;51:171

21. Snyder C. Aurelius Cornelius Celsus on cataracts. ArchOphthalmol. 1964;71:144--6

The author reported no proprietary or commercial interest inany product mentioned or concept discussed in this article. TheNEI Intramural Research Program provided funding support.

Reprint address: Chi-Chao Chan, MD, 10 Center Drive, Bldg.10, Rm. 10N103, NIH/NEI, Bethesda, MD 20892-1857. e-mail:chanc@nei.nih.gov