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.