Fig. 9.—Instruments used in Couching.

The Posterior Operation.—Much that has been written on the preceding method applies with equal force to this. It is, however, possible to describe the technique much more accurately, as it has been carefully studied at first-hand by Dr. Ekambaram, who for many years worked under the writer in the Government Ophthalmic Hospital, Madras. His original description of the method will well repay a careful perusal. He speaks of the operators as being ambidextrous and very skilful. Their surgical equipment (Fig. 9) for the operation consists of a small lancet-shaped knife, guarded to within a few millimetres of its tip by a roll of cotton-wool, wrapped round it for the purpose, and of a copper probe 4 inches long and about 1 1/2 mm. in diameter. A cotton thread twisted round this probe at a spot 12 mm. from its point serves the same purpose as the stop in the Bowman’s needle. From the point to this stop the instrument is triangular in section. The patient is directed to look well towards the nose, and the surgeon then gently marks out the selected spot by pressing with his thumbnail on the conjunctiva covering the sclera, about 8 mm. out from the cornea, and about 2 mm. below the horizontal meridian. In some cases the operator steadies the eye by firm digital pressure exerted through the partly everted lower lid. He next takes his lancet in his hand, and it will be observed from the illustration (Fig. [9]) that it might easily pass for a roll of cotton-wool; this, indeed, is what the patient is led to believe it really is. To heighten such an impression, the point is covered with a sandalwood paste, prepared beforehand coram publico, with a good deal of ostentation. The patient is informed that this “cataract-cleansing drug is about to be applied to the eye,” and under cover of the suggestion the operator plunges the lancet through the tunic of the globe at the spot already selected. The alarm thus occasioned is allayed by the assurance that the “medicinal application” is over. The copper probe is next produced, and is inserted through the wound up to its stop, being held between the thumb and two fingers; a circular movement is given to its point, the stop resting against the puncture, and serving as a pivot for the movement. According to Ekambaram, the object is to tear through the suspensory ligament from behind. Immediately following this step, a downward stroke of the point is made in order to depress the now loosened lens. Ekambaram graphically describes the care taken by these operators to impress, alike on the patient and on the friends, the magical effects of the procedure. The former is shown a number of objects, and is bidden to name them in turn, and to state their colour. The crowning point is reached when the surgeon removes a thread from his garment, and the patient not merely recognizes it as such, but triumphantly tells its hue. The Western ophthalmic surgeon, with his wide incision and his anxiety for the safety of the vitreous, can never savour such dramatic moments as these. They carry us back to the descriptions of the early Christian miracles, with all the mental and spiritual associations, which enwrap such stories as those of Bartimæus, and of the pools of Siloam and Bethesda. Alas that life’s “hereafters” should so often be fraught with disillusionment, disappointment, and suffering! Palestine and its storied past rise before us as we read how the vaidyan called for a white cloth and for water, how he dipped the cloth in the fluid and washed out the sufferer’s eye therewith, how he made a paste and smeared it over the skin around the brow, how he closed the eye with “clean white linen,” and then sent the erstwhile blind man rejoicing away. Over the abyss of nearly twenty centuries, the East stretches out her unfaltering hand to the past of the nearer East, whilst the West looks on in wonder, not unmixed with admiration, for a spirit which the corroding passage of time seems unable either to fret or to change.

There is a step of the procedure which has been purposely left to the last, as its interest is psychologic, and not surgical. It is common to both methods of operation. I refer to the anointing of the eye with the blood of a freshly killed fowl. It is a measure in which superstition, cunning, self-preservation, and greed, overwhelm and mask a faint and feeble therapeutic design. The sacrificial element is present, and a hazy idea that the death of the votive bird may turn evil from the patient looms in the background. Next comes the need to mask the shedding of the patient’s blood, since he is often told that no operation is to be performed, but that a mere “medicinal application” is to be made; the blood of the outraged bird covers the guilt of the vaidyan’s falsehood. Largest of all towers the fact that the curry-pot even of a worker of surgical marvels needs constant replenishing, and that fowl is an excellent substitute for mutton on such occasions. Lastly, these men seem to believe that the coagulation of the fowl’s blood helps to close the puncture. In view of the dirty condition of the instruments which they introduce into the interior of the eye, this last factor may practically be neglected.

CHAPTER III
THE INDIAN COUCHER AND HIS HABITS

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.”