Having reached the last milestone in a journey
which if it has had its ups and downs as all journeys
must, has been one of undisguised pleasure practically
all the way, we would fain survey our handiwork for
a second ere the curtain falls on its last chapter.
One of the many impressions which is perhaps
common to all those who would essay to write a thesis
is that this effort into which he has put so much
time and attention, somehow seems to lack a central
idea, and following on this, comes the thought that
several if not all of the subjects have been dealt
with very superficially. To these and many more less
complimentary emotions we would plead guilty.
Yet the answer to those denizens of Doubting
Castle is fairly obvious. An alternative heading for
the thesis might have been "An analysis of 982 cataract
case sheets". The central idea in such an undertaking
is the analysis itself and the individual results
achieved thereby. We were, I think, more than
usually fortunate in that our analysis yielded us not
only individual results, but in the shape of the
conclusion given here, a deduction of no small value.
To the charge that we have dealt with the
various sections in a somewhat superficial manner, we,
while agreeing, would enquire if it were possible to
do aught else with the material we had to review.
The macroscopic appearance of a tissue is always necessary
before we can have the microscopic finding,
and it was the macroscopic vi-ew of the cataract
question in one of India*a provinces we were trying
to give.
With this explanation, we will proceed to the
deductions derived from the findings in the various
sections.
Each of the parts of this thesis, though separate
and distinct in itself, also goes to form a whole.
In the formation of this whole, there are one or two
sections which stand out more clearly than the others;
we refer especially to the pages on 'etiology* and
'couching', for it is from them we wish to draw the
conclusions which form one of the uniting threads of
the preceding pages.
It will be remembered we gave the total number
of cataracts extracted annually in Bihar as somewhere
around 4,500 - Bamdah 1400, the other hospitals 5100 -
an arresting total, and one being increased annually,
but still capable of much improvement.
4,500 then is the number operated on each year;
what is the number not done? This question, like many
another asked in those pages, is impossible of solution,
but also like many another problem raised here, we
feel that a partial solution is better than none,
and perhaps will have sufficient in it of surprise to
stimulate further interest and research in the
matter.
Under etiology, it will be recalled, we estimated
that If cataract occurred among the six million Semi-
Hinduised aboriginees and cowherds in the same proportions
as among the other castes, then over 2000
cataract extractions which should have been done every
year, remained undone.
The women we estimated as compared with the men
had 900 cataracts not done which ought to have been
operated on.
The Couchers were calculated to do 1400 - 2400
cases per annum, and here I think we may well take the
latter figure considering the ultra conservative
estimate we have made in the two preceding cases.
Our total then of cataract cases not done - or
worse - comes to 5300 per annum as compared with the
4,500 done, i.e. the Province of Bihar has a cataract
bill, potential and real, of at least 9800 yearly;
in all probability the real figures are two or more
times this amount, but for our purpose the figure
given will suffice without further correction.
The facilities for the treatment of all those
patients seem excellent on paper. Hospitals there
are in comparative abundance, - government, mission,
railway, etc., but when we come to look at them in
more detail we find that practically without exception
they are general in nature; in fact in the whole of
this vast province of over 20,000,000 souls there is
not a single hospital devoted exclusively to eye
patients and yet surely nov/here else could we find so
much justification for the establishment of special
ophthalmic institutions.
If then we are dissatisfied with the existing
re/gime, our dissatisfaction if it is to be of any use
at all, must spur us on to a little constructive
effort, that- being so what type of hospital are we
going to build to answer India's needs in matters
ophthalmic.
The general hospital is, I think, out of the
question, the need for these is probably as great as
for eye hospitals, but with such abundant material to
hand, combining the two seems a great waste of men,
money and - most important of all - efficiency.
The next alternative, an eye hospital, run, as
far as possible, on altogether Western lines might be
ideal, but its cost would be prohibitive, more
especially as in all probability several such institutions
would be needed to satisfy the requirements
of an area so extensive as that with which we are
dealing.
We arrive then, by a process of exclusion at a
hospital modelled on the lines of that at Bamdah, wher
we find, not so much a hospital as a caravanserai, a
place where the blind of all castes foregather for
treatment, where we would have central modern operating
theatres with their attendant ante-rooms, surrounded b
long blocks of single roomed apartments, to each of
which a patient and his friends would be allocated, the
friends to do the cooking, the surgeon the treating -
and within reason, I think, it will be agreed that the
less a cataract is treated after operation the better
and the patient the waiting in hope. In addition ther
would be several general wards for those who required
less immobilisation than cataract patients after
operation.
Such a type of hospital is of course somewhat
obnoxious to the perhaps over-civilized taste of the
average European surgeon, but we have to remember that
India is not Europe, that if our first principles are
correct then the application of those principles must
surely change in the changing countries; that it
matters little whether the hospital or the patient
provide the bed clothes, so long as the patient is
content to remain in bed when he is told - and here
we have to bear it in mind that practically all Indians
when travelling carry their bedding with them, since
hotels as we know them here, are very few and far
between, so that to bury an eye patient between snow
white sheets is a kindness which he neither understand
nor appreciates, and it can hardly be said to be
necessary.
The thought which at once assails us is that
sepsis under the conditions above outlined would be
rampant; the strange thing is that it is not; in the
last 500 cases operated on at Bamdah during the cold
season there were only 2 cases of suppuration; the
bugbear of the operator was not sepsis but prolapse
of iris which was very frequent, being about 15%;
that this however is not an inherent defect of the
system is proved by the figures from Shikarpur
where doing some 1300 extractions per annum, they have
a prolapse rate averaging 3%, yet the hospital regime
at the hospital there is very similar to that in
operation at Bamdah.
So much then for the defects, possible and
real, of the system; what are its advantages?
Firstly, and pre-eminently, it is cheap; this is
essential for success in a land where 8d a day is
deemed a good wage for a labourer.
Secondly, it suits the patients, since coming
to hospital does not mean separation from their family
it also prevents them being filched of their money
by unscrupulous attendants and compounders, who are
all too frequent in a land where bribery is rife,
and where the traditions of both doctors and nurses
are hardly on the same level as in our own country.
Thirdly, this type of hospital closely resembles
the ancient Hindu houses of healing, and therefore at
a time like the present, is of value in that it excite
no racial prejudice against it.
Fourthly, it is extremely popular. This is
obviously a fact of considerable importance as no
matter how good a hospital may be, if it does not meet
the public favour then the good it does is a mere
shadow of what it otherwise would do; this is especially
applicable to India with its prejudices against
all things Western. As proving the popularity of this
type of hospital, we have only to look at the numbers
of operations performed in the few which are in
existence, to realise this.
Shikarpur does some 1300 extractions in about
7 weeks, in the cold season.
Bamdah does 1400 per annum as compared with 97
for the 6 government hospitals and dispensaries of
Monghyr in the same time.
Hazaribagh, a neighbouring district, contains
2 mission hospitals run on similar lines to Bamdah;
they between them do some 400 extractions per annum
as compared with 22 for the government hospitals and
dispensaries of the province.
The 195 extractions per annum of the SantalParganas are made up as follows
Government institutions . . . 79
Benagaria (a mission hospital run on
similar lines to Bamdah) . . . 116
These differences between the figures for the
government and the mission hospitals are rather striking;
the government hospitals have the advantage in many
ways, in numbers, in resources of men and money, yet
they obviously are not reaching the people as they
might; we have outlined some of the reasons why;
another is that the biggest and finest government
hospitals are built in large towns, whereas 90% of
IndiaTs inhabitants are country born and bred, and as
the statistics given -under etiology prove, less than
one-sixth of the inhabitants of the villages ever
visit their principal towns. In Europe we rightly
build our best hospitals in our biggest towns, in
India on the other hand if we would get patients we
ought to build our hospitals in the country, preferably
in a small country town.
Enough has been said in those few preceding
pages to give a somewhat sketchy idea as to what we
- think would constitute an ideal eye hospital from the
Indian point of view.
We do not propose to give a more detailed account,
for the present at any rate - as such a procedure
would not be In keeping with the general tenor of
this thesis, which has all along been to take a broad
rather than a deep view of the problems with which
the cataract operator in India has to grapple daily.
One word more, however, we would say on this
subject and that is in connection with the problem of
how best to popularise such hospitals once they were
built. The best solution here, we feel, would be
travelling dispensaries in charge of experienced subassistant
surgeons. Their duties would be (1) To
treat minor eye diseases, conjunctivitis, trachoma,
corneal ulcers, etc.
(2) To give ’refresher’ courses to the village
head man, school teacher, etc. in the a. b. c. of
the treatment of the commoner ailments of the eye.
(3) To diagnose cataracts, glaucomas, etc., and
send them to hospital for operation. In addition,to
supply all the patients whom he sent to hospital with
a free railway pass from the nearest station to the
hospital; a somewhat necessary piece of practical
philanthrophy if we would do the maximum amount of
good in a land where poverty holds such sway.
Such then are a few of the lessons learned from
our analysis; if the reader has derived as much
pleasure from the perusal of these observations as we
have in compiling them; the writer of this thesis
will be more than satisfied.
