The First Cataract Surgeons in the British Isles.

John of Gaddesden (1314).

John of Gaddesden (c. 1280-1349) was an English physician who wrote the medical treatise Rosa anglica.⁶ The generally accepted date for its composition is between 1314 and 1317, though Talbot has raised the possibility that it was written later.^59,60 Gaddesden frequently cited Henri de Mondeville’s work of 1316.⁵⁹ Gaddesden was a fellow of Merton College, Oxford from 1305 to 1307, and was appointed rector of St. Nicholas, Abingdon in 1316. As Gaddesden is unaccounted for between 1307 and 1316, Talbot has suggested that this would be a time when Gaddesden could have studied abroad.⁵⁹ Indeed, there is some evidence that Gaddesden trained at Montpellier.^61,62 It is interesting that the Rosa anglica is thought to have been written towards the end of the time that Gaddesden might have been studying in Montpellier, raising the possibility that it reflects the teachings and experience acquired in that region.

Some have written that Gaddesden studied at Montpellier at the same time as Guy de Chauliac,⁶³ though it is not clear that the timing works out. Writing in 1363, Chauliac disparaged the lack of originality in Gaddesden’s Rosa.^59,63 Gaddesden was listed as a Doctor of Medicine at Oxford in 1332.⁵⁹ He was a physician to both Edward II and Edward III, and was familiar with the works of Lanfranc of Milan.⁶

Gaddesden indicated that he had seen cataract couching, but did not specify whether his exposure was in England or on the Continent:

“But if the physician or surgeon knows how to cure it [cataract], he will obtain high fees, for it is a common ailment. And I have seen men doing wonders with a needle, so that they were held in high esteem and received more money for one cure of cataract than for ten other diseases.”⁵⁹

Gaddesden also described the procedure:

“the patient should sit in front of the physician in a well-lighted place whilst the sun is shining and there is no shadow. His knees should be drawn up to his chest, and bound together, so that he is almost lying down. Then he should look at the end of his nose, opening the eye that is affected: meanwhile the assistant should hold his head, bent back slightly and lift up the eye-lid. Then take the instrument or a steel needle with a round, sharp head, and begin to pierce from the side of lachrymal gland in the conjunctiva pressing it towards the pupil, beginning from the corner of the eye, and let him pierce until he comes to the covering and the pupil between the two tunicles, penetrating to the empty space of the eye which is in front of the pupil. And let the surgeon hold the eye until the perforation is complete, and press the needle down until it is hidden beneath the cornea.”⁵⁹

Gaddesden mentioned comforting the patient verbally, and having the patient look at his own nose. These ideas are not found in the surviving ancient Graeco-Roman works of Celsus and Paulus of Aegineta, but do appear in Arabic works such as that of Ibn Isa (Jesu Hali, c. 1000).² The fact that Gaddesden suggested the patient be outside in the sun (as Albucasis) and is almost laying down (suggesting being close to the ground, rather than on a stool), also show the emphasis on medieval Arabic works (or their translations into Latin).

Although Gaddesden appears not to have performed cataract surgery, he did perform other procedures. He removed a stone from under his father’s tongue.⁶⁴ Gaddesden also performed bleeding (phlebotomy), setting bones, drawing teeth, cutting corns and killing lice.⁶⁵ He died in 1349, probably of the plague.⁶

John of Arderne (1377).

John of Arderne (1307-1392) may have trained overseas, and had practiced with the military in Antwerp and in Spain.³⁴ He had returned to England by the time of the Black Death epidemic of 1348.³⁴ He was best known for performing and reporting surgery for fistula in ano.³⁴ He wrote a treatise on eye diseases, De Cura Oculorum, which did not mention cataract surgery.^8,34 Arderne’s ophthalmic work cited Lanfranc of Milan, and therefore, Arderne had the opportunity to review what was known about cataract and its surgical treatment. Instead, the only eye conditions specified by Arderne were pannus (panum), which he viewed as synonymous with macula (maculam), nonspecific terms for white spots on the eye, ulcer (ulcera), and eye inflammation (lippitudo) (Schwartz 2014).⁸ All the eye treatments were essentially medical, though he did recommend phlebotomy from the forehead vein.⁸ The detailing of Anglo-Saxon ophthalmic ingredients, which were locally available, and sometimes described in the local vernacular,⁸ suggests that the treatise was a practical guide which had been adapted for local use. The only personal experiences were mention of a man whose eye protruded onto his cheek after he was struck with a sword, but was successfully treated with a poultice.⁸ Also, Arderne mentioned that a lotion maintained his own eyes at the age of seventy, despite extensive studying and writing.⁸

Others were known for treating eye diseases in medieval England. John of Scarborough, active at the end of the 14^th century, was known for curing eye diseases, but he is described as a physician, rather than a surgeon.³⁴ Peter Blank, a surgeon, had legal action taken against him for by a stationer named Simon Lynde in about 1495 for failing to adequately treat the diseased eye of a child.³⁴

Treatise of Lanfranc of Milan (1380).

It is believed that Lanfranc studied under William of Saliceto, and brought many of his methods to France. Lanfranc’s surgical treatise of 1296 was translated into Middle English in the Ashmole MS (c. 1380) and the British Museum Additional MS 12,056 (c. 1420). The text from these manuscripts was published for scholars in 1894.⁶⁶ Lanfranc described cataracts as water falling into the eye:

“Cateracta. is water pat falliþ doun bitwixe þe .ij. skynnes of þe iʒe & abidiþ tofore pe place þat is clepid pupilla, þat is pe poynt of þe iʒ6. & þan it defendiþ þat a man mai not se; & it is clepid cataracta”.⁶⁶

This 1380 use of the term “cataracta” is the earliest known use of the word in English. Lanfranc described the technique in a reasonably detailed fashion.⁶⁶

Lanfranc’s treatise was published in English by surgeon John Hall (b. 1529 or 1530) in 1565. Hall claimed that his version was “reduced from dyuers translations to our vulgar or vsuall frase”.⁶⁷ However, Lanfranc’s original treatise had all sorts of practical details regarding cataract surgery that were not included in the 1565 publication. Lanfranc originally stated that the patient fasts preoperatively and sits on a stool during the procedure while the surgeon sits a little higher. The whole (nonoperative) eye is bound shut, the surgeon chews fennel and blows on the eye, and the couching instrument is made of silver. If the cataract returns, one repeats the depression with the needle.⁶⁶ The 1565 edition did not include any of these details.⁶⁷ Either Hall, or someone else involved in the translation and copying of Lanfranc’s treatise, did not think these practical details worth mentioning. Hall did see fit to begin by noting that one would have to learn the details of cataract surgery from personal observation:

“A Cataracte confirmed, is not holpen, but only by ha[n]dy worke, and to doe that, it is nedeful a Chirurgien doe firste learne, and se[e] it done, of a cunnynge man, that can well remoue, and put it away, wyth an instrume[n]t made lyke a ne[e]dle”⁶⁷

Of note, by 1562, Hall knew of and respected the oculist John Luke of London, as discussed below. Perhaps, as Hall did not perform the procedure himself, and he viewed the procedure as best learned by personal observation, he saw no need to record all the details.

Treatise of Benvenutus Grassus (c. 1400).

Continental surgeons wrote treatises describing their experience with cataract couching, some of which were translated into Middle English, and incorporated English versions of the word cataract. One of the earliest was the treatise of Benvenutus Grassus, an eye surgeon plausibly argued to be from a Jewish family, and from either Salerno, Jerusalem, or Montpellier.⁶⁸ He is thought to date from the first half of the 13^th century.⁶⁸ Grassus’ detailed understanding of couching has led historians to believe that he actually performed the procedure. His Latin treatise was one of the first medical texts to be printed in 1474.⁶⁹ Several versions of Grassus’ work in Middle or early modern English are of interest:

—The first half of the 15^th century is the date for Oxford Ashmole MS 1468, which includes not only portions of Grassus’ treatise, but also Guy de Chauliac’s Cyrugia.⁶⁸ The surviving portions use the term “cataractes” when referencing Grassus’ discussion of the disorder: “…we did nedill it after þe maner of agulying as it is taught aboue in doctrine of cataractes and so he was clenelich y heled and clerely he toke and recouered his siʒt…”⁶⁸ Corresponding text in the other Middle English manuscripts indicates that this patient was a child of Messana (Messina, Sicily) who developed a cataract after a ruptured globe.⁶⁸ Unfortunately, the portion of this manuscript with Grassus’ extended “doctrine” of treating cataracts has been lost.

— The mid-15^th century is the date for Glasgow Hunter MS 513.⁶⁸ This manuscript is closely related to Ashmole MS 1468, and may be a copy of it.⁶⁸

—The last quarter of the 15^th century is the date for Glasgow Hunter MS 503.⁶⁸ Marginal notes were later added by the Elizabethan surgeon Joseph Fenton, who apparently owned it.⁶⁸

—In 1583, an English version of Grassus treatise was incorporated in Philip Barrough’s Method of Physick, and was frequently republished in various medical works for the next 70 years.⁷⁰

—In 1590, the British Library Sloane MS 661 was produced by surgeon Joseph Fenton. Fenton added marginal notes disparaging Barrough’s translation.⁶⁸ The fact that Fenton also added marginal notes to Hunter MS 503 is consistent with analysis showing that Sloane MS 661 was an edited copy of Hunter MS 503.⁶⁸

Several lines of evidence demonstrate progress in ophthalmology between the medieval period and the Elizabethan era. The Middle English manuscripts do not use the term “couching” to describe the procedure, but surgeon Joseph Fenton’s 1590 copy does use the term. In addition, the late 1400s copyist of the Hunter MS 503 introduced an error, because he did not realize that cataract surgeons were supposed to be ambidextrous. This error was corrected by surgeon Joseph Fenton when he copied the manuscript in 1590, as discussed below.

Overall, these English manuscripts of Grassus’ treatise are consistent with the actual practice of cataract surgery being unfamiliar in England before the 15^th century, but established by the Elizabethan period.

Treatise of Guy de Chauliac (1425).

Guy de Chauliac (c. 1300-1368) was one of the pre-eminent surgical authors of the 14^th century. He was awarded the Master in medicine degree in 1325 at Montpellier.⁷¹ In 1363, while at Avignon, he wrote a surgical treatise in Latin, his Chirugia Magna, also called the Inventarium. One Middle English translation, known as the Inventorye, is found in a manuscript which dates from about 1425.⁷² An independent Middle English translation is known as the Cyrugie, and is found in the Bibliothèque Nationale, Paris, MS. anglais 25, and was recently published.⁷² No complete translation of the Inventarium was printed in early modern England.⁷² Chauliac had studied at Mountpylerz (Montpellier),⁷² and also at Bologna and Paris.⁷¹ Chauliac’s 1363 use of the term “oculistas” in Latin was translated into Middle English in about 1425 as “oculisterz”.⁷³ Chauliac’s Cyrugie used the term “catharacta” or “catheractes” to describe the fully-developed form of cataract.⁷² With respect to cataracts, Chauliac cited Galien (Galen), Avicen (Ibn Sina), Beneuenutus (Grassus), Iesus (Ibn Isa), Alcoatym, Accanamosalus, Rasis, Avenzoar, and Maistre Arnalde.⁷² The surgeon blows on the eye, and the patient turns the eye towards the nose.⁷² It seems likely that Chauliac had actually performed couching, given that he noted that others preferred a gold or silver needle, but he preferred iron, as it was less likely to break.⁷²

Balthasar Guercy (1519).

Balthasar Guercy (d. 1557), of Italy, was trained in medicine on the continent, and arrived in England in about 1515.⁷⁴ Two separate lines of evidence might link Guercy with cataract surgery: 1) the use of the term “couching” by his opponent Thomas Roos, and 2) Guercy’s treatment of the eye of archbishop and royal advisor Cardinal Thomas Wolsey.

Guercy’s opponent, Thomas Roos, was the warden of the Fellowship of Surgeons in 1514.⁶ Roos might have translated an edition of Henri de Mondeville’s Chirurgie (manuscript C.U.L. Peterhouse MS, 118).⁶ Mondeville died prematurely, and therefore was not able to include a chapter covering cataract surgery.

Roos felt threatened by the understanding of anatomy and physiology that Guercy had acquired overseas. Guercy complained to Katherine and then to King Henry VIII that Roos was harassing him.⁶ On November 7, 1519, Guercy was granted an injunction against Roos,⁷⁴ who was fined 100 pounds and ordered “not to molest Balthazar…or pursue information late put into the King’s Exchequer, till he proves that surgery is a handicraft”.⁶ In his response, Roos cited Lanfranc of Milan, Avicenna (Ibn Sina), Guy de Chauliac, and Gilbertus Anglicus.⁶ Roos believed that Guercy’s techniques were the domain of physicians, not surgeons, and that these newer techniques might spread throughout England, threatening the domestic surgeons.⁶ Roos defined surgery as including “..cuttyng of the sculle in due proporcyon to the pellicules of the brayne with instruments of iron, cowchyng of catharacts, takying owt bonys, sowying of the flesshe, launching of bocchis, cutting of apostumes…letting of blo[o]d, drawying of te[e]the…which restyth onely in manuall operation…”⁴ The Middle English translation of Chauliac had spelled “catharacts” similarly. Roos’ use of the term “cowchying” to describe cataract surgery is the earliest surviving instance (to our knowledge).

Guercy was closely connected with royalty at times, initially as the surgeon for Queen Katherine of Aragon, for which he obtained denization on March 16, 1522, and then as the surgeon for Anne Boleyn in 1532.⁷⁴

Cardinal Thomas Wolsey (1473-1530) received treatment for an eye disorder, at least a portion of which was provided by Guercy. When Wolsey was on the continent at Calais and Bruges in 1521 attending a peace conference, he suffered from ill health. Therefore, if cataract surgery was performed on Wolsey, it might have been performed outside the British Isles. A Spanish message from 1522 confirmed some sort of systemic problem affecting the eye of Wolsey, who was: “so very ill that he is in danger of losing an eye, and the rest of his body seems almost equally affected.”⁷⁵

John Skelton’s 1522 poem Why Come ye nat to Courte suggested that Guercy’s treatment of Cardinal Wolsey’s eye would render him blind:⁷⁴

“With a flap afore his eye

Men wene that he is pocky

Or els[e] his surgions they lye

For as far as the[y] can spy

By the craft of surgery

It is manus domini…

That all his trust hangis

In Balthasor [Guercy] / whiche he[a]led

Domi[n]gos nose / that was wheled…

Balthasor [Guercy] y he[a]lyd domi[n]gos nose

From the puskyde pocky pose

Now with his gumys of araby

Hath [pro]mised to he[a]le our cardinals [Wolsey’s] eye

Yet sum surgio[n]s put a dou[b]t

Lest he wyll put it cle[a]ne out.”⁷⁶

The “flap” has been thought by some to indicate disfigurement from the disease,⁷⁵ such as ptosis, but this line by Skelton is actually listed in the Oxford English Dictionary to define flap as “Anything that hangs broad and loose, fastened only by one side”.⁷³ This definition would be consistent with an eye patch. Skelton’s suggestion that Wolsey’s eye was “pocky” would typically suggest syphilis,⁷⁵ but might occasionally refer to smallpox.⁷³ The suggestion that a surgeon would put an eye out was exactly the criticism rendered towards later cataract surgeons not accepted by the mainstream, such as Valentine Russwurin.⁷⁷

Skelton’s summary of Wolsey’s condition in Latin translates as:

“Oppressed with the Neapolitan disease [syphilis], laid low under plaster poultices, pierced by the surgeon’s iron instrument [Pharmacapoli ferro foratum], relieved by nothing, nor made better by any medicine…”^75,76

Piercing would be more consistent with cataract surgery than with a procedure to scrape a corneal spot off the eye.

In January 1530, when Wolsey was terminally ill, Guercy was requested to provide therapeutic leeches.⁷⁸ Some have thought Wolsey’s final symptoms to be consistent with diabetes.⁷⁹ Wolsey must have retained some vision after Guercy’s treatment, because it is only in Wolsey’s final moments that “his sight failed him”.⁸⁰

Guercy married an English woman, and had a son in 1517.⁷⁴ At Cambridge, Guercy was granted an MB degree in 1530, and an MD degree in 1546.⁷⁴ In 1534, he received a license to travel to Italy. Elis son graduated from Oxford in 1538.⁷⁴ Guercy was back in England in December 1543 when he was sent to the Tower of London for 2 months for his papal sympathies.⁷⁴ Guercy fled England in 1551 but had returned by 1554, when he was pardoned by Queen Mary.⁷⁴ He became a fellow of the College of Physicians in 1556.⁷⁴

Treatise of Giovanni da Vigo (1543).

Giovanni da Vigo (c. 1450-1525) practiced in Genoa, Savona, and Rome. His major surgical work was published in 1514. Its English translation was published by Bartholomew Traheron (c. 1510-c. 1558) in 1543.⁸¹ Vigo wrote that the typical surgeon would not perform cataract surgery—it was left to “ye to[o]th drawers” (dentists).⁸¹

John Luke of London (1561).

Queen Elizabeth reigned from 1558 until her death in 1603. In the Elizabethan era, we find stronger evidence of cataract surgeons in the British Isles, beginning with England (Tables 2, 3; Figure 1). John Luke of London was licensed by the Royal College of Physicians to treat eye diseases in 1561.^9,82 The College stipulated that he was restricted to using external medicines. No internal medicines or enemas could be used. No mention of surgery was made. The license does not mention couching, but perhaps the physicians did not care to regulate procedures which did not encroach upon their clinical territory.

Luke seems to have made quite a splash in London at this time, and was respected by eminent surgeons and physicians. The 1562 lectures of physician William Bullein noted: “Of Foenigreke is an excellent Fomentum made for the iyen [eyes], that be sore or dim: which I have seen mayster Luke make, which is an excellent man, in the cure or Regiment for the eyes.” A footnote specifies “Maister Luke of London.”⁸³

Surgeon John Hall recounted another story from 1562 in which a shoemaker from Kent named William said that he could cure “sore eyes”, “And that whereas maister Luke of London, hath a great name of curing eyes: he could do that which maister Luke could not do, nor turn his hand to.” The shoemaker bragged that he could do some type of eye surgery which Luke could not. Hall called Luke “that reverent man of known learning and experience”, and demonstrated that the shoemaker knew no eye anatomy. Clearly, Luke was already well-established as an eye specialist.^67,68

Banister grants Luke priority among English “Oculistes”: “The first and cheifest was Luke of Erithe [in London] a man that lived in great fame and credit had the greatest practice and sums of money for he hath had from XX to LX L for Cataracke couchinge.”⁸ If this attribution of priority is correct, then Luke probably was couching in the early 1560s. Luke made money from a “diet drink”, required patients to lie on their backs for 9 days postoperatively, and occasionally practiced in an itinerant fashion.⁸ It is not clear that Luke took any apprentices, as Banister remembered “all his knowledge was buried with him.” Luke “died at London at Mr Best’s house in ye stocks.”⁸

It is thought that Luke might be the author of several anti-papist satirical tracts published about 1548 under the name Luke Shepherd.⁸² This suggestion seems reasonable. According to royal courtier Edward Underhill⁸⁴ Shepherd was “…Mr. Luke, my very friend, off Colemane street visissyone (physician)”.⁸⁵ Shepherd was born in Colchester, Essex, and was imprisoned at least briefly for his writings.⁸⁴ Shepherd refers to vision loss in the elderly in John Bon and Mast Person when the title character says: “…for plow men be but blynd/ I am an elder fellow of fifty winter and more”.⁸⁶ In “Pathose, or an inward passion of the pope for the losse of hys daughter the Masse,” Shepherd mentions several medical figures who discussed cataract surgery: Galen, Paul of Aegineta, Avicenna, Rhazes, and Mesue, as well as “doctors of Vienna”.⁸⁶ The author extolled Arabic physicians: “But send some arabies/ That worthy be and wise/ In phisike [medicine] and in phisonymes [physiognomy]”.⁸⁶

Thomas Surflet (1560s).

Thomas Surflet (1531-1611) was probably one of the earliest couchers after Luke. In his published treatise, Banister listed “Master Surflet of Lynne” as among his “most skilfull” advisors who were “all excelling in the operations.”⁷ But in his unpublished manuscript, Banister told a different story about “…Mr. Surphlete, a man of excellent Diet and crusty fashion of body. He lived till he was four score years of age, lived most in Norfolke, & died at Linn, and in good estate…I cannot commend this Mr. Surphlete for any extraordinary skill, though of long experience.”⁸ Skilfull or not, it seems Surflet was an important early ophthalmic teacher.

In 1559, one Thomas Surflet was granted a license to practice surgery by Cambridge University on the basis of many years of the study and practice of surgery.⁸⁷ Between 1564 and 1577, a Thomas Surflet owned property in Peterborough.⁸⁷ One historian implied that Surflet might have taught Banister’s advisor “Master Barnabie of Peter-Borough”.⁸⁷ If so, then Surflet might have been performing couching by the early 1560s. Barnaby was probably a young man upon Surflet’s arrival. The marriage of William Barnaby at St. John’s Church in Peterborough in 1568 was followed by the birth of a number of Barnaby children over the next decade.⁸⁸ When Barnaby was buried there in 1600, he was remembered as “a good Townsman”. ^89,90

Surflet became a freeman in Lynn in 1579, and was required to treat the poor for free at the request of the mayor.⁸⁷ Banister recorded that at Lynn, Surflet “lay 2 or 3 years at a barber’s house at Linn to whom he taught some skill, who now professeth it with weak Understanding and given to drink.”⁸ We argue below that this barber was probably author Richard Seabrooke. Robert Greve (or Greene) was listed as an apprentice to Surflet in Lynn in 1589, and was excommunicated in 1597 for practicing surgery without a license.⁸⁷

A younger surgeon named Richard Surflet (c. 1560-1604) knew how to couch cataracts, and, because of the shared surname, is assumed to have learned from the elder Surflet.⁸⁷ In 1599, Richard Surflet translated into English A discourse of the preservation of the sight: of melancholike diseases: of rheumes, and of old age, originally written by André Du Laurens. In the preface, Surflet wrote: “Which Surphlet famous for his art-taught cunning hand, In clearing the Eyes of spots, and noisome Catarrhacts…” and also “Surphlet…famous for thy art, In curing of blind catarrhacted eyes.”⁸⁷ In 1604, Richard Surflet sailed for the East Indies as a ship’s physician and preacher, but he died on the return voyage.⁸⁷

Valentine Russwurin (1573).

Although cataract surgery by Englishmen in the 1560s is suggested by reports from several decades later, by the 1570s we begin to see contemporaneously documented records of immigrants performing the surgery.

We know that Queen Elizabeth was aware of the German surgeon Valentine Russwurin, of Schmalkalden.⁹¹ Russwurin had previously practiced at “Koningsburg in Prussia”, at “Hamburgh”, and at “Groninghen in west friseland”.⁹² The earliest reference to Russwurin in London is thought to be the report of an “Allmaigne [German] surgeon” in the letter from August 29, 1573 of William Herle to William Cecil.⁹¹ Herle’s job was to gather intelligence for Cecil, the chief advisor to the queen. Herle did not use the language which became typical of the Elizabethan era because that language had not yet evolved. Herle did not describe Russwurin as an oculist. Rather, Herle called Russwurin “the new surgion opthalmist”.⁹² Likewise, Herle never used the term “cataract” to describe the visual disorder of the patients, or the term “couching” to describe the procedure.⁹² Russwurin’s techniques were new enough that they merited report to the Queen’s deputy.

Russwurin performed at least some treatments at patient’s houses, but he advertised his services from a market stall he set up outside London’s Royal Exchange.⁹¹ Russwurin “had restored one Jone Wynter a widow to her sight, who hath been blind these 8 years, & is of the age of 66 years…”⁹² The “Towne surgions” could only suggest that she “applye contrary plasters to her eyes”.⁹² In contrast, Herle reported that in Russwurin’s hands, “…after some handling of her eye, what with instrument & otherwise, & then applying some juices & powder to the same, had made her to see in an instant well nye & to discern his face & chain of gold perfectly, with another color that was presented. But when the sight is thus restored, he accustoms to diet his patients & to keep them with plasters out of the air to confirm the tenderness of their sight for a month or 6 weeks after this cure: having now in cure at his own house within Bisshops gate street, on Ales Burton the wife of George Burton of Fullam who was blind, of the one eye 2 yeres, & of the other eye 3 weekes, & hath made her to see with that speed & facility which he did the other, but he entertains her in a dark parlor with plasters till the sight be confirmed against the air.…”⁹²

With Russwurrin during Burton’s surgery was Peter Turner (1542-1614), a young physician who had just returned from medical training at the University of Heidelberg:⁹¹ “…Doctor Turner & others were present at this act, to whom he expounded sundry things out of Galen, making the said Doctor Turner to perceive in this woman sundry defects of the eyes, which Galen treated of, & not able to be discerned by Turner, till the books of Galen & the eyes were confronted together.”⁹² Turner ascribed “unto this surgeon a Singular knowledge for the eyes, & an experience therein above other men.”⁹² Turner was a physician at St. Bartholomew’s Hospital from 1581-5.

Russwurin described himself as an “Opthalmiste”, and noted that “there were some causes & effect of blindness…that were utterly incurable.”⁹² He declared that upon examining a patient he could tell “whether she were to be helpen or no.”⁹² Russwurin determined if there were “obstructions of those sinews, called Nervi optici, or otherwise of too great a flux that passed by those Nervi optici, which were to be deciphered by proper colors belonging to the [cause] & disease; either white, green, yellow, or blue…”⁹²

Russwurin set up a stall at the Royal Exchange in London where he advertised his services.⁹³ He displayed bladder stones which he had removed, and provided testimonials from patients whom he had surgically treated for cataracts.⁹¹ He advocated the medical ideas of Paracelsus. In a letter to William Cecil, Russwurin cited Galen, Avicenna, and Paracelsus.⁹⁴ He also discussed Cecil’s mother’s cataracts, and Russwurrin discussed the hard “tartar” in the cataracts,⁹³ and indicated that he could treat Cecil’s mother.

Russwurin discussed the eyes of Cecil’s mother’s Jean⁹¹ in a letter to him:

“Now as y. L. [Lordship] is desirous also to under[s]tand whether y. L. mother may recover her sight agayne I have thought good with two or three lynes to signifye Unto y. L my iudgement in this case…she may be restored to her sight agayne as well as any that ever I take in hande. And whereas some have testified y. H. that I have taken some in hande which as yet I have done no good unto. In dede, I confesse there are two women whose eyes I have wrought which ae not yet cured. But the reason therof is not any want of arte in me but a great strayning with vomitinge with the one and to sudden a receiving of the aye and light in the other. By the which m[eans] the cataracts that I put downe with my instrument came forthe agayne and blynded the sight as at the first. And yet for all this I do not dispayre but that by the grace of god, I shall restore them to theyr sight wherein I r. myself to all those that have cuninge and iudgement in eye. For it is a small matter when theyr eye be a litle stronger it that oft tymes done once agayn to worke them yea if ne[e]de be the thirde tyme to[o], and that with as lit[t]le danger as at the first. Yea it happened oft that without any manifeste or externall cause even.. of it.. frome betwixt the .. downe by reason that the humour christalloides where under it should lye and tar[r]ye is .. stronge and toughe as to consume or ke[e]pe downe the cataracte.. this muche as concerning it that hath bene .. against me to the end that y. h. mother be not discontayed. And as concerning the doctores opinion which say that the older a cataracte is the better it is to be wrought, I am not simply of theyr minde. For sometyme it is trewe and othe[r] tymes starck false. For it happeneth divese tymes that a cataracte is so longe let alone until it growe to such a harde tartar that it is both harde to be broken of with the instrument and when it is put downe into the chrystalline muche harder there to be kept or consumed as by mannifolde experience I have diverse tymes tried. But that y. L. may understand these thinges the better, as shorte as I can I will describe the eye and the a[rt] therof. But before I come to that your Lordshippe .. first note that there is a greate difference betwixte the eye itselfe and the sight of the same. For it happeneth diverse tymes though both of them be ioyned in one yet the one may be hurte and the other not. As for an example there be diverse eyes which to see to are as fayre and sound as any ne[e]de to be and yet because the sight which cometh from the brayne which spirites by some impediment is stopped of his natural course and passage into the eye, see never a whit, whereby I may conclude that the eye is not the sight it selfe but onely the instrument therof. As for the partes that the eye consisteth of, they be in number tenne, wherof there are seven kinn[d]es of filmes and three humoures the first and uttermost kinn[d]e is called coniunctiva, and cometh from the filme which is next about the cranium.”⁹⁴

The letter is undated, but must have been written before 1587, when Cecil’s mother died.⁹¹ In fact, the letter was probably written before May 1574, when Russwurin was run out of town (see below). Russwurin’s letter of 1573 or 1574 about Cecil’s mother is the earliest known use of the term cataract with reference to a specific English patient, even if locals like Herle had not adopted the term. It is not known if Russwurin ultimately treated Cecil’s mother, but she was blind by December 1574.⁹¹ Russwurin’s time in London peaked when he was made a “denizen” by Elizabeth in early 1574.⁹³

However, Russwurin’s status rapidly spiraled downward. From the beginning, according to Herle, “…the Physicians & Surgeons do envy this [Russwurin’s practice], & have used many ways & speeches to deface him”.⁹² William Clowes, a member of the St. Bartholomew’s hospital staff⁹¹ derided “Valentine Rarsworme, of Smalcalde, a stranger born” for claiming the titles “of Medicus Spagiricus, chirurgus, Lithotomus, and Opthalmiste.”⁷⁷ In more than one patient, Russwurin tried to surgically extract bladder stones, but when no stone was to be found, he surreptitiously retrieved a stone already in his possession, and pretended it had come from the patient. The first such case was in April 1574.⁷⁷ According to Clowes, many of his lithotomy patients died.⁷⁷

Russwurin also unsuccessfully treated an ophthalmic ailment in Andrew Castleton (d. 1617), a deacon at Cambridge, who ultimately was remembered as being blind.⁹⁵

“…he promised to cure one Maister Castelton, then being a scholar of Cambridge, of an impediment in his eyes, he had some sight thereof, that he was able to discern many things, when this Valentine Rasworme, took him in cure. But within a very short time after Valentine, by his rustical dealings, put out his eyes clean, and so deprived him of all his sight. And then when Maister Castelton perceived that Valentine could not perform his cure, but that he was by him thus spoiled, then he did arrest him, first for his money, the which he recovered again…”⁷⁷

The treatments of Wynter, Burton, and Castleton appear consistent with cataract couching. If so, they would be the earliest identified patients to undergo couching in England.

After all of these clinical misadventures, a trial at Guild Hall.⁷⁷ was conducted in May of 1574.⁹³ Seeing that a pillory was being erected for him, Russwurin “doubting the worst, and to prevent the same, upon a sudden he hid his head…”⁷⁷ Presumably, Russwurin absconded.

Richard Seabrooke (1579).

Richard Seabrooke (1548-1624) of King’s Lynn wrote the earliest ophthalmic treatise by an English oculist.⁹⁶ As noted above, Seabrooke is likely the Lynn barber mentioned by Banister, and was taught by Thomas Surflet about 1579. Seabrooke’s age of about 30 years old upon Surflet’s arrival in the town would be consistent with his writing (at the age of 72): “being from my youth by profession an Occulist…”⁹⁶ Seabrooke shared patients with “M. Surfleet, a very skillful Occulist”.⁹⁶

The first chapter was devoted to blindness in infants. He explained the mechanism: “For the mould of the head not being then closed, the least offence of cold striking the brain, bringeth sudden and present blindnesse.”⁹⁶

In a 14-month-old infant who had lost vision, Surflet thought treatment was futile, but Seabrooke saw no harm in having the nursing mother regularly drink ale infused with eyebright (euphrasia), betony, and fennel. Seabrooke gathered herbs himself in May or June, and dried them for use throughout the year.⁹⁶

Just as Seabrooke was willing to disagree with Surflet about this case, he was also willing to disagree with the medical profession more generally about the effect of therapeutic bleeding. The student of history often wonders why clinicians could not discern that bleeding made patients worse. In fact, Seabrooke did figure that out. He saw no benefit, and in fact, described patients who went blind after bleeding. Seabrooke practiced not far from Richard Banister, and the patients’ hometowns were close to those of both oculists. For instance, there was “Goodman Fletcher, dwelling in a little Town near Bourne in Lincolne Shiere, having some small impediment in his eyes, and coming to an ignorant Practitioner, had a vein opened in his temples, and another by his nose, but the blood was no sooner received, when as the sight was utterly lost forever.”⁹⁶ It is likely that some of these patients were treated by Banister. As noted above, Banister returned the favor by describing Seabrooke as an alcoholic with weak understanding.

As with Russwurme, Seabrooke determined the curability of a “Catharack” by its color. The curable cataracts were hazel, “the color of the sky”, and “grayish”.⁹⁶ The incurable cataracts were black, white, and “yellowish green”.⁹⁵ The significance of these colors is discussed below in the section on Banister. Also, if the patient could not see sunlight or candlelight, there was no hope. Seabrooke did not divulge the specifics of how these were “cured by the Catharack needle” because he believed only trained experts should attempt the surgery. Seabrooke noted that “After the Catharack is couched, or taken away with the needle (by a skilfull Practicioner) the Patient must be exceeding carefull of himself…”⁹⁶ The patient must lay down for 8 or 9 days to prevent the cataract from rising.

Seabrooke described the red, inflamed eye as being afflicted with “sharp & scalding rhewmes”.⁹⁶ In this period, a rheum could represent a secretion dripping from the eyes, possibly originating in the brain or head, and contributing to a disease.⁷³ For this and other conditions, he advocated a plaister (adhesive therapeutic dressing) on the neck, with blistering cantharides or with gentler substances. He believed a plaister should never be placed on the temples, despite what other practitioners recommended.⁹⁶

To Seabrooke, “the Pin and the Web” represented small white corneal opacities, which were treated with eye drops made from honey, daisies, and woman’s milk. Scarring from “small Pocks” (smallpox) was treated by blowing a powder made from “white Sugar-candy”. For a “filme” upon the eye, one applied eyedrops made from “the marrow of a Goose wing” mixed with powdered ginger. If an injury thrust the eye onto the cheek, he pushed the eye back for several hours, and then applied a dressing of breadcrumbs mixed with milk. The doctor could also blow into the eye, provided he did not eat garlic or use tobacco ahead of time.⁹⁶

For difficulty reading at near in the elderly, he recommended the powder taken in ale. Young students with difficulty reading fine print could use the powder taken orally in ale, or a hat to protect them from the light. He did not mention spectacles or magnifying glasses.⁹⁶

Overall, Seabrooke’s treatments were above average for the period. He had many years experience as an oculist and performed couching. His greatest accomplishment was figuring out that therapeutic bleeding is harmful. He did not totally get away from harsh treatments such as blistering, purging, and enemas, but he did not emphasize them. His practice included both the gentle ale-based medicines of royal physician Walter Bailey, and, when indicated, the recently-arrived technique of couching.⁷⁰

Early Cataract Patients (1581).

For some early cataract patients, the surgeon who performed or considered cataract surgery is unknown. Edmund Grindal (c. 1519 – 1583), the archbishop of Canterbury, had declining vision by 1581⁹⁷ due to cataracts, according to later historians, and Queen Elizabeth suggested that he resign.⁹⁸ Grindal was close with the queen’s advisor, William Cecil,⁹⁷ to whom the exiled Russwurin’s ophthalmic treatments were reported. Indeed, until the end of 1582, Grindal had some hope of recovering his vision: “…he had before entertained some hope of recovering his sight, as some others in like case had done…”⁹⁹ By the end of 1582, however, he accepted the permanence of his blindness. Perhaps no surgeon could be found who deemed his cataracts treatable, or perhaps a surgery failed. On his stone effigy at Croydon Minster, “his eyes have a kind of white in the pupil to denote his blindness”.⁹⁹ Unfortunately, the effigy was destroyed when the church burned in 1867.

Bernardino de Mendoza (c. 1540 – 1604) arrived in England as the Spanish ambassador in 1578. In 1579, at age 39, he wrote that he had “precoz ceguera” (precocious blindness).¹⁰⁰ In 1583, his poor vision resulted in an accident.¹⁰⁰ In 1584, he was expelled from England, and his king stationed him in Paris. Therefore, he endured at least 5 years of visual difficulties in England, apparently without undergoing any eye surgeries. Either English surgeons did not want to operate, or he did not seek their advice. In 1585, he noted that he had fatigue of the eyes due to “el humor” which had settled in them, causing “dolor” (pain) and “caliente” (heat).¹⁰⁰ In 1586, he had surgery performed with “la aguja” (the needle) for “una catarata” of the left eye while under the care of “los médicos y oculistas” of Paris.¹⁰⁰ Nonetheless, by 1589 he was almost completely blind.¹⁰⁰

Richard Carew of Cornwall (1555-1620) was a translator and antiquary who began to go blind in his late 50s.¹⁰¹ By 1612, others had to read print to him, and he was “quite blind” by 1613.¹⁰² His son, of the same name, remembered: “When my father was blind, he made a little treatise to persuade others thus afflicted to suffer that great loss of one of our most precious senses at least with patience and equanimity, if they could not reach so far as to do it with true thankfulness.”¹⁰² The son recalled these events using the newer language (“cataract”), and at first tried veronica juice because “I have heard that it hath cured the cataract…”¹⁰² The son then persuaded his father to undergo surgery:

“…He [God] made that man’s hand to help him, who failed in his endeavour in the same kind for many others whom he could not cure, and gave my father his sight perfect, with the help of his block spectacles, in that eye first that he which undertook it, when he was doing of it even despaired to perform; and when he had done all, left him blind in that eye which he was very confident to cure. Yet after, without any further help of the oculist, God restored the sight thereof also, and continued it unto him about five years [from 1615 onward], even as long as he lived. And the first thing he spake of unto us after the removal of his cataracts was: ‘None of you knows how great a blessing God gives us by light and sight, but I who had now almost forgotten it by wanting of it continually two years together, when He removed my film the light appeared suddenly with such a glory…”¹⁰²

This bilateral cataract surgery, apparently in about 1615, contains a few firsts. The reference to the use of spectacles after cataract surgery is the first that we know of in England. Note that the father used the term “film”, while the son used the newer term “cataract”. The fact that the cataract surgery in the second eye at first seemed to fail, but then worked later, could be attributed either to the slow absorption of residual lens cortex, or from the lens initially blocking the visual axis, but later dislocating.^39,103

Physician and astrologer Richard Napier (1559-1634) recorded the cataract couchings of several patients whose surgeon is unknown. In 1600, Napier referred to William Burnet of Great Horwood having a “cataract of w[hi]ch he was twice cut”.¹⁰⁴ On July 7 1622, Napier asked whether in Goodman Robert Richardson of Newport, Wales, “the Dutchma[n] will recoav[e]r his…eye sight”.¹⁰⁵ In that era, “Dutchman” referred to someone from Germany or Holland. Bartholomew Vanderlashe of Germany was indeed couching cataracts in that era. By July 22, 1622, the surgery had been performed: “Richardson…had his eyes opened.”¹⁰⁶ Nonetheless, in 1629, Richardson was described as “blynd 7 y[ears] extremely tormented in his left ey[e] w[hi]ch was good for a long tyme & now is tormented”.¹⁰⁷ Napier recorded on June 3, 1625 that Nicholas Ridley of Weston, age 74 years, was “cut of on Cataract & doth see by a skilfull oculist”.¹⁰⁸

Other cataract patients are known, independent of advertisements from the surgeon. Bartholomew Vanderlashe was given permission to perform eye surgery on one Melser Gisberd in 1612.¹ Peter Heylyn (1599-1662), the royal chaplain, had cataracts from 1654 onward, severe enough to require other men to guide him but the cataracts were considered too immature to couch.¹⁰⁹ George Williamson performed an unsuccessful couching in 1663.¹¹⁰ Steward Walter Powell (1603-1654) of Wales was couched in 1653-4 successively by Mr. Middleton, Anthony Atwood, and Mr. Fayrfax.¹¹¹ William Green of Newcastle was the “Dr. Green” who unsuccessfully couched the cataract of benefactor Robert Thomlinson (1668–1748) on July 17, 1736.^112,113 Minister David Maitland of Aberdeen had been blind for several years beginning in about 1734 when he was “couched of a cataract by the celebrated Mr. George Lauder, Surgeon [of Edinburg], by which his sight was restored.”¹¹⁴

Marian Lerret (1588).

In 1588, physician and astrologer Simon Forman witnessed a cataract surgery performed by Marian Lerret (or Lerat) (Ashmole 403, f. 176V).¹¹⁵ The procedure was unsuccessful, Forman explained, because the timing was not propitious.¹¹⁵ Forman also recorded in Ashmole 1495 (folio 501v, Personal Communication, Lauren Kassell, 2019):

“…a French man on Marian Lerret a chirurgian that wold take one him to rec[o]ver. on that had a cataract on his lefte eye of long continuance and it was my chance to be present by him at the first dressing, and this is the figure of the instant 1588 the 25 of January 7:15 am. And he cured him not’

Lerret was still associated with Forman in 1600. Lerret’s daughter, born in about 1568, had an English last name as an adult (Dodge), suggesting integration of Lerret’s family into central England (Ashmole MS 236, f. 158v).

Cesare Scacchi (1590).

According to texts from Italy, Queen Elizabeth summoned the surgeon Cesare Scacchi (b. 1555) of Preci to her court for 10 months on a medical errand, just before 1590.^116,117 It has been suggested that Scacchi was in England to perform cataract surgery on the queen.^116,118 We therefore reviewed the medical history of the queen for evidence of eye problems.¹¹⁹ In about 1552, at age 19, she wrote “…a disease of the head and eyes has come upon me…”¹¹⁹ This has been attributed to refractive error.¹¹⁹ In 1562, she had smallpox.¹¹⁹ Her handwriting seems to have deteriorated over the years, though this could be as much a motor as a visual deficit.¹¹⁹ There is no record of the queen having eye surgery, or using aphakic spectacles or magnifiers.¹¹⁹

It is plausible that the queen might turn to a foreign surgeon for eye problems. In the late 1580s, a handful of empirics such as Thomas Surflet might have been couching locally, but this procedure was not performed by established university-affiliated surgical authors. In 1586, Walter Bailey, one of the queen’s physicians had written a treatise about preserving eyesight with euphrasia and fennel dissolved in wine or ale, but this treatise did not discuss surgery.⁷⁰

It has been suggested that Scacchi might actually have been summoned to England to treat the queen’s principal secretary, Francis Walsingham (c. 1532 – 1590), who was known to have urinary difficulties.¹¹⁷ This suggestion seems plausible.

Joseph Fenton (1590).

Joseph Fenton (c. 1565/1570-1634) was an Elizabethan surgeon who, in copying and correcting the treatise of Benvenutus Grassus in 1590, demonstrated a keen interest in cataract surgery.

Fenton’s study of Grassus’ treatise came relatively early in his career. Fenton was apprenticed to Fondon barber-surgeon Christopher Bewter, and became a freeman of the Barber-Surgeons’ Company in 1590.¹²⁰ In 1597, Fenton was appointed as a surgeon at St. Bartholomew’s.¹²⁰ In 1599, he traveled to Ireland with the army of the Earl of Essex.¹²⁰

Interest in Grassus’ ophthalmic treatise must have surged within England when Barrough incorporated the work within his popular 1583 “Methode of Phisicke”. The copy of Grassus’ treatise within British Fibrary Sloane MS 661 has been dated based on the handwriting style to “the late 16^th century”.⁶⁸ In fact, the manuscript is known to have been written by Fenton in 1590.^68,120

A comparison of the late 16^th century Sloane manuscript with the 15^th century Middle English versions suggests progress in British ophthalmology. Fenton’s copy shows that he was familiar with cataract surgery in Britain. The Sloane MS 661 uses the word couching to describe cataract surgery:

“The fourth kinde of curable Cataracte is of a citrine color, yt is harder than any of the Other and also yt is rownde, wherefore yt maye not be cowched ryghte downe in the eye, for yt will not abide there, by reason of the roundness and hardnes[s] there of, and therefore yt muste be cowched in the corner of the Eye toward the eare, and there be kepte with the Ne[e]dle a good while…”⁶⁸

This use is only the third known instance of the term couching to describe cataract surgery. As the term “couching” was not used to describe cataract couching in other countries, it must have become prevalent locally, and Fenton had become familiar with it. (The etymology of the term “couching” is reviewed below.)

An additional line of argument demonstrates progression in understanding of cataract surgery in the Elizabethan era. Since antiquity, many descriptions of cataract surgery, including that by Celsus, had noted the importance of ambidexterity. One held the couching needle with the right hand for the left eye, and the left hand for the right eye. This rule had been promulgated in the medieval Arabic period in works such as those of Ibn Isa (Latinized as Jesu Hali) and Albucasis.² It was extremely rare for an ophthalmic author, such as Ammar, to recommend always holding the needle in the right hand.²

Grassus’ Latin treatise was ambiguous about the hand used: “With one hand raise the upper lid, and with the other hold a silver needle and direct it toward the outer lacrimal region”⁵¹ If Grassus followed the prevailing tradition, then he was ambidextrous, even though he did not say so. The Hunter MS 513 (mid-1400s) omits mention of the raising of the upper lid.⁶⁸ But the Hunter MS 503 (late 1400s) introduces an error by stating (apparently for either eye): “…with thy lyfthand [left hand] lyft vp hys oon ey lyd and with þin[e] oþer hande put yn thy ne[e]dyl made per fore on the forpersyde from the nose.”⁶⁸ Here, the needle is held in the right hand, apparently without regard to the eye being treated. Thus, the late 1400s copyist was not very familiar with the prevailing ambidextrous approach to couching. Philip Barrough in 1583 propagated this error, which he must have found in Hunter MS 503 or a related copy: “Then with your left hand lifte vp the ouer eyelidde, and with your other hand putte in the needle made therfore, on the side furthest from the nose”.¹²¹

When Fenton copied Hunter MS 503 in 1590 to create Sloane MS 661, he corrected this error by introducing a parenthetical expression: “with thye lefte hand (if yt be for his lefte eye) lyfte vpp his eye lydd, and with the other hand, put in the Needle”⁶⁸ Of note, Fenton specifically criticized Barrough for propagating errors: “…Barrow in his Method, of Phisike, stealinge all out of this Author, with out once naming him, paßeth ma[n]ye of these faultes & doth seme not to vnderstand them”.⁶⁸ And later: “Barrowe is verye faultye. in lettinge pass all the errors as he founde them”.⁶⁸ Fenton might have known that cataract surgeons were expected to be ambidextrous from a written source, or from first-hand experience.

Hunton’s 1587 translation of Guillemeau (which also used the term couching) implied some degree of ambidexterity in the preparation: “Let the Chirurgian rubbe the right eye with the left hand, and the left eye with the right hande, before he begin his vvorke”, but the next page which describes penetration of the needle does not mention holding the eyelids, or which hand would hold the needle.¹²² Thus, Guillemeau would be an unlikely source for Fenton.

Fenton’s library included multiple ophthalmic authors who discussed couching: Celsus, Galen, Paulus Aegineta, Jean Riolan, Avicenna, Rhazes, Albucasis, Arnaldus de Villanova, and Pare.¹²⁰ Of note, several of the ophthalmic authors in Fenton’s library (e.g. Celsus, Guy de Chauliac,⁷² and John da Vigo⁸¹) were explicit about ambidexterity during cataract depression.¹²⁰ Of note, these works known to be in Fenton’s library were not in English (though he must have read Barrough’s translation of Grassus). Fenton’s use of the term “cowched” in Sloane MS 661 would indicate that his understanding of cataract surgery did not come strictly from these foreign works—he was familiar with modern English vernacular regarding the procedure.

In July 1607, Fenton was appointed one of the Examiners of Surgeons for the Barber Company of London.¹⁰ He therefore would have examined Mathias Jenkinson in July 1608, who was “lycenced to cut for the hernia or Rupture to couch the Cat[a]rac[t] to cut for the wry neck & the hare lip”, but was required to have a representative of the Company present at “every such Cure”.¹⁰ However, in June 1609, Jenkinson was “discharged from his practice in Surgery” for violating the licensure terms “and for his evil & unskillful[l] practice.”¹⁰ Jenkinson still described himself as “surgeon of London” in his will, probated in 1625.¹²³ Jenkinson gave to “his servant William Watson all his Bookes concerninge Chirurgery and all his instrumente[s] concerninge Chirurgery.”¹²³

Fenton later had as apprentices Joseph Binns and John Colston (d. 1625), who was Fenton’s son-in-law and also practiced at St. Bartholomew’s Hospital.¹²⁰ When Fenton died in 1634, he left his medical books and silver and iron surgical instruments to his grandson Joseph Colston.¹²⁰ We do not know whether Fenton performed cataract couching, but he was clearly well-versed in the procedure, and the fact that quite early in his career he copied an entire ophthalmic treatise which had already been published, and corrected what he perceived to be errors, demonstrates a keen ophthalmic interest.

Henry Blackborne (1594).

One dynamic ophthalmic teacher of the period was Henry Blackborne (d. 1611), probably born about 1573 in Halifax, Yorkshire.^124,125 [The birth of Blackborne in 1573-4 in Halifax is assigned tentatively, assuming that Henry and his sister Agnes (also written Anne) were of the same father and baptized in the same parish.] His family might have moved to Kent. Banister painted a mixed picture of “Henry Blackburne who travelled continuously from one market town to another, who could couche ye Cataracke well, cure it, Lay a scar [cleft] Lipe, set a cro[o]ckt necke straight & help deafnesse.”⁸ On the other hand, Blackborne deceived patients by charging handsomely to treat incurable conditions.⁸ Likewise, Blackborne himself was “often deceived of great sums of money but never robbed.”⁸ Because he was “lusty amorously given to several women”, he frequently had to flee and change his name, and “was often imprisoned for women”.⁸

After couching a cataract, Blackborne placed a linen cloth dipped in beaten egg white over the eye, with instructions to change the dressing twice daily for 9 days.⁸ He only returned for a postoperative visit if he heard that the patient had done well.⁸

Blackborne taught an apothecary named Page, who never acquired much skill.⁸ The first surgeon Blackborne instructed in cataract couching was named Hanle.⁸ Hanle also practiced in an itinerant fashion, and conflicted with his teacher over who had the bigger practice.⁸ Hanle also operated on cataracts before they were ready, and was once beaten by an unsatisfied patient.⁸ If patients could not see after 9 days, they would demand their money back, so Hanle moved along before the bandages came off the eye.⁸ Hanle had no academic understanding of disease, but “For couching of Cataracke he would do it exellent well.”⁸ He treated eye inflammation or “Reumes” with a water containing white wine, rose water, and camphor.⁸ Banister met Hanle when Hanle visited Sleaford and set up “his show” in the market, and only later did Banister meet Blackborne at York.⁸ Banister probably began practicing at Sleaford in the early 1600s, and given Banister’s depth of familiarity with both men, he probably met them early in his Sleaford period.

Banister informs us that “Blackburne instructed one Nelson that married his sister. He could couche the Cataracke well but was given to drunkeness & so died beggarly.”⁸ Blackborne’s sister married John Nelson of York, “Chirurgeon” in Bishopsbourne, Kent in 1596.¹²⁶ Blackborne had married into the Nelson family of York in 1594.¹²⁷ Nelson’s listing as a surgeon suggests that Blackborne had already begun teaching by 1596.

One “Blackborne” of Canterbury was granted a license to practice surgery on June 4, 1594.¹²⁸ On August 17, 1605, Henry Blackborne was licensed to also cure eye diseases in Canterbury.^128,129 On September 7, 1610, the mayor of Rye in Sussex provided a certificate for Henry Blackborne, “chirurgion and occulist” for curing the blind of Rye one year before: “by…his art and skill, did recover diverse persons…that were blinde, unto their sight again”.¹³⁰ Blackborne treated a 74-year-old widow “darke and blinde” for 2 years, and the 65- and 75-year-old wives of two fishermen, one of whom had been “blinde” for 10 years.¹³⁰ The lengthy duration speaks to the lack of availability of couching. All 3 patients “can see, and go about the town without any guide.”¹³⁰

Blackborne described himself as an “Oculist” of Edgeware, Middlesex in his will, probated in 1611.¹³¹ Banister remembered that he “died in Kent”.⁸

James Van Otten (c. 1601).

James Van Otten (1568-1622) of Ypres, Belgium went by the first name James in England, but was identified on formal documents as “Jacobus”.^10,132–134 He received a medical degree from Leiden University in 1593.¹³² He was present in England by 1601, and began training apprentices. Some time about 1601, he trained Richard Banister (as discussed below).

Nicholas Bowden (1576-1649), another Van Otten apprentice, was born in Loughborough in Leicestershire.¹³⁵ In 1601, Van Otten and Bowden were jointly permitted by the Company of Barber-Surgeons to practice in London “only for the couchinge of the catarack, cutting for the rupture [hernia], stone, and wenne [boil].”¹⁰ Moreover, “Bowlden shall be assistant unto the said James Vanotten”.¹⁰ In return, the surgeons were required to pay a fee to the Company which would be used for the poor.¹⁰ They could hang an advertising banner at their lodging, but nowhere else.¹⁰

In 1602, Bowden was licensed by the University of Cambridge to practice surgery.⁹⁵ By about 1605, Bowden advertised as a “Chirurgion, cutter of the stone, and also Occulest, curer of the Ruptures [hernias] without cutting…”¹³⁶ Bowden also treated “All hare or cleft lippes”.¹³⁶ With respect to vision, he promised: “All Rumes, pearles, blemishes, or Catteracts curable, although they have been long blind, they shall in short time receive sight.”¹³⁶ In 1614, “Nicholas Booden” was “certified fit by the professor” and licensed to practice surgery by Oxford University.¹³⁴ In July of 1648, Bowden gave a manuscript on alchemy to antiquarian Elias Ashmole, who later donated it to the University of Oxford.¹³⁷ Bowden, described as “Master Of Chirurgiens”, was buried in Reading on December 24, 1649.¹³⁸

In November 1607, van Otten recommended the otherwise unknown Mr. Charles to couch a cataract, according to the records of physician Richard Napier:

“Mr Van Otten commendeth Mr Charles for the couching of Goody Reeves cataract novemb. 17”¹³⁹

One Richard Charles was licensed as a doctor (but not a surgeon) in London in 1615.¹²⁹

By 1619, van Otten had a new favorite oculist, when Napier recorded: “Atwood of Worcester a gentlema[n] of 500 ll [libra] the ye[a]re & the best Co [sic] Oculist in England comended by Mr Van Otten”.¹⁴⁰ It is interesting that van Otten preferred Atwood over van Otten’s former students Banister and Bowden, the latter of whom was van Otten’s colleague at Oxford. Whether Atwood was trained by van Otten is not known. Atwood was ultimately the patriarch of a family with 5 generations of oculists between 1619 and 1751, including luminaries such as John Stepkins and John Thomas Woolhouse.

In May 1620, when the teacher Van Otten was licensed to practice surgery by the University of Oxford, he was hailed as “A very learned expert chirurgian well practiced in the faculty these thirty years in his own country, this, and other kingdoms.”¹³⁴ He was matriculated as a privileged person at Oxford on April 6, 1621.¹³⁴

In 1619, Van Otten took an apprentice named Percivall Willughby, in return for receiving £100 for seven years.¹³³ However, Van Otten died in 1622. Under the heading: “On the death of Mr. James Van Otten an expert Chirurgion, who dyed att Oxford: March: 1. 1622”¹⁴¹ poet William Strode remembered: “Death now growes politique:/ While Otton liv’d herselfe was weake and sicke/ For want of food, therefore at him she aimde…Behold Death’s triumph and our fatall losse.”¹⁴²

Richard Banister (c. 1602).

Richard Banister (c. 1570-1626) has been called the “father of British ophthalmology”,¹⁴³ primarily because his 1622 ophthalmic treatise contained some novel and important observations, and was influential enough to be republished almost a century later.

He spent 5 or 6 years studying under his uncle, surgeon and anatomist John Banister (1533-1610).⁸ The elder Banister always had some interest in the eyes. John Banister became life-long friends with Clowes when the two served as surgeons on a military expedition to Le Havre in 1563. John Banister had confirmed the finding of Italian anatomist Realdo Colombo that the “watrish” (aqueous) humor would reform after its loss through a wound to the eye: “To which I faithfully subscribe, having proved the like in Anno. 1570.”¹⁴⁴ In 1578, John Banister also reported the correct teaching of Realdo Columbo that the lens is anteriorly positioned,¹⁴⁴ in contrast with the fallacy dating from the medieval Arabic period that the lens is positioned in the exact center of the eye.¹ In 1578, John Banister noted the changing ophthalmic terminology among younger practitioners: in the anterior chamber “…suffusions are made, which the younger sort have called Cataractes.”¹⁴⁴ In his 1585 translation of Wecker’s surgical treatise, John Banister mentioned in the preface:

“For the cataractes and manuall administrations about the eyes, I referre the Reader to a treatise of olde Penemicus [Benevenutus Grassus], inserted and lately published in Philip Barroughes booke.”¹⁴⁵

John Banister gave Guillemeau’s 1585 ophthalmic treatise to Anthony Hunton, whose English translation was published in 1587.⁷⁰ Clowes noted in 1588: “I could here set down other special cures of wounds in the eyes done some by myself, and some being joined with other Surgeons in this City, as Maister Banester…”¹⁴⁶

Given this ophthalmic interest, some have looked to John Banister as the source of Richard Banister’s ophthalmic knowledge. However, Banister was clear that what he learned from his uncle was in the “general skill of Chirurgerie” and that “I did leave that generall practice which he brought me up in”.⁷ Banister recounted his education in his unpublished manuscript. After the time with his uncle, Richard Banister spent a year or two in the chamber of “Lorde Willaby”. Banister recounted, “then I spent a little tyme (with) one James of Utricke in ye Lowe C[o]untryes.”⁸ Given that James van Otten of Utrecht was in England training apprentices who subsequently couched cataracts, van Otten would seem to be Banister’s mentor. Banister then spent 14 years practicing at Sleaforde.⁸ Given that he was licensed to practice surgery in Sleaford in 1602,^129,143 his training with van Otten would probably been around 1601. Richard Banister decided to specialize in order to perfect his practice.⁷ He was interested in eyesight after “finding some defects in mine owne eyes”.⁷ He also performed “helpe of Hearing by the instrument, the cure of the Hare-lip, and the wry Necke. When in the threshold of my practice, I could couch the Cataract, and so began to gaine some name of an Oculist”.⁷ Banister recalled that he had sought the advice of other oculists: “Henry Blackborne,…Robert Hall of Worcester, Master Velder of Fennie-Stanton, Master [Thomas] Surflet of Lynne, and Master [William] Barnabie of Peter-Borough”.⁷ Robert Hall of Worcester was married in 1588. One Robert Hall received a license to practice surgery in Worcester in 1612.¹²⁹ Perhaps, Banister had a falling out with van Otten, because Banister only spent “a little tyme” with van Otten, in contrast with the 7 years planned for Percival Willoughby. Also, Banister failed to mention van Otten in his book. As noted above, in 1619 van Otten described Atwood of Worcester, not Banister, as the best oculist in England.

In contrast with his uncle, Richard Banister continued to promulgate the incorrect idea that the lens is in “the middest of the eyes”, which is perhaps not surprising given that he cited Vesalius but not Colombo.⁷ We might be tempted to call van Otten the grandfather of British ophthalmology, except that he was only two years older than Banister.

Banister believed that “Old men see better with spectacles then young men”.⁷ He maintained the old language for media opacities, while incorporating the new term cataract: “Blood coming by the Nerves cause Pinnes, Webs, Spots, Cataracts, and Opilations.”⁷ He also mentioned a “Pearle” in the eye.⁷ Unlike Seabrooke, Banister defended bloodletting: “Letting of blood is the chiefest remedy for Op[h]thalmia.”⁷ Banister also used other harsh treatments, such as leeches: “Fiery humours must be evacuated by cupping and horsleaches, behind the eare is best. Use Blist[e]ring to the Necke.”⁷ Banister wrote that “A golden needle is better for the Eyes, then a silver needle.”⁷ However, his will left to his son “my box of silver instruments”.⁸ Banister also noted: “some put a lowse into the Eye” for treatment.⁷ He clarified that the “lowse” was good for dry, dull, and obscure eyes, but not for inflamed eyes.⁷ Putting a louse in the eye was also advocated as far away as Alaska, by the native Kodiak.³⁹ Banister cautioned against “Licking the Eye with the Tongue”,⁷ which is found in the traditional ophthalmology of both the Old and the New Worlds.³⁹ Banister recommended pterygium excision: “Webs upon Conjunctiva that spread over Cornea, are cut with good successe and helpe, if by a good Artist.”.⁷ Banister noted a number of problems which could occur with couching: release of a milky substance which appeared to have been contained in a “blather”, i.e. a bladder—the lens capsule.⁷ One could also experience hyphema, apparent subluxation of the cataract into the anterior chamber obscuring the uvea (iris), cataracts that were too soft to be displaced, movement of the cataract back into the visual axis due to hardness of the cataract, and adherence of the cataract to the uvea (iris).⁷ He used the term “couched” and seems to be relating his own personal experiences. He described couching the cataract of a woman “in Walsingham in Norfolke” which was adherent to the uvea, and required parting “many small threds, or rather haires” (synechiolysis). In the early postoperative period, she could not see well, but after some time, the vision improved, and his local reputation improved.⁷ Banister cited “the Method of Physicke, by Philip Barrow”.⁷ Unlike the “mountebankes”, Banister insisted that “by couching of Cataracts, our English Oculists have alwayes had an especiall care, according to Arts, to couch them within doores, out of the open aire, to prevent further danger.”⁷

Banister criticized the clinical outcomes of “strangers” (foreigners) who drew teeth while “on horsebacke”. The brother of one of these came to Lynn, and also claimed to cure the blind, and “cut for the Stone and Rupture”.⁷

No oculists could guarantee good outcomes. In 1614, physician Richard Napier recorded:

“Mr Banyster did take away a cataract fro[m] mres Mo[nt]Gu[m]bry & anoth[e]r of Sherington & neyther doe see but a glymmering may 11.”¹⁴⁷

In 1616, Napier recorded:

“Mr Banyster of Sta[m]pfordshere the Oculist ca[n] helpe boath the blynd & deafe mr Banysters brother of Bedford 30 myles fro[m] linford a ma[n] of great experienc[e], & hath helpen manye al over spring & fall he goeth to london at other tymes men may have him at home.”¹⁴⁸

Banister reported curing of blindness, presumably by couching, 24 people in Norwich in 1609, and more in 1611, as certified by the mayor. Given the book’s dedication in June 1621, it seems he visited London in the Spring and Fall, with successful treatments there in 1606, 1611, 1614, 1617, and 1619.⁷ Moreover, the mayor, William Cockaine, certified over 20 such cures in 1621. Banister received similar certificates for the cure of over 12 blind people in “Lincolne”, and 8 or 9 in “Saint Edmund’s berry”.⁷ Banister noted that in one month in a distant city he could see more blind patients than in six months in his own town.⁷

Banister described what happened with a few cataract patients based on their sex and hometown, but he named only two patients. One was “The Lady Parker at Doctor Wamslies house at Snowhill” who was 83-years-old and had been blind in one eye for 40 years. Fie successfully couched her in 1621.⁷ Also, there was an old man named “Old Bucke” at “old Debnum in Suffolke” who was successfully couched in both eyes. Banister believed that performing a unilateral couching would prevent a cataract from developing in the other eye.⁷

Banister noted that many were drinking substantial quantities of “Beere or Ale” in the morning to help their sight. He thought that excessive use of these drinks could actually impair vision, but accepted them in moderation.⁷

From Banister’s treatise and unpublished manuscript, we know of many oculists, as detailed above, also to include “one Earle in Staffordshire a good artiste”.⁸ John Earle of Staffordshire was buried in 1617.¹⁴⁹

Richard Banister’s Breviary is known for being the first in the Western medical tradition to note the poor prognosis of couching the palpably hard eye. Banister did not actually use the term glaucoma in his Breviary, however. James writes that “His remarks fell on stony ground and more than two hundred years were to pass before his teaching became part of the ophthalmic creed.”⁸ Perhaps, there was a delay of a century, but it seems that Banister’s work enjoyed prolonged circulation and was ultimately influential. Banister was cited by English author William Drage in 1664,¹⁵⁰ and also by Benedict Duddell in 1733.¹⁵¹ William Read republished an edited version of Banister’s Breviary, along with the translation of Guillemeau, in 1706.¹⁵² Just one year later, in 1707, John Thomas Woolhouse wrote a letter describing angle-closure glaucoma including the palpably hard eye with mydriasis, and called it glaucome.¹⁵² This was the first time the term glaucoma had been used to describe the palpably hard eye. From his lectures and letters, we know that Woolhouse was aware of Banister’s work.¹⁵² Woolhouse’s student Platner in 1745 also used the term glaucoma to describe the palpably hard eye with mydriasis. Demours, who wrote about the palpably hard eye with mydriasis in 1818, cited elsewhere both Woolhouse and Platner.¹⁵² The chain of citations from Banister in 1622 to Demours in 1818 demonstrates Banister’s ultimate and longlasting influence.

Additional biographies of cataract surgeons in the British Isles following the Elizabethan period are provided in Appendix 3.

New Words: Cataract, Oculist, and Couching (by 1588).

There is no compelling reason to insist that the descriptions of cataract surgery in medieval English manuscripts translated into actual practice of the procedure in the British Isles. Consider the linguistic evidence. It is only in the Elizabethan era that we have evidence of the terms “cataract”, “couching”, and “oculist” being applied to actual patients, procedures, or doctors in the British Isles.

Although the word cataract had been used in a Norman French manuscript, and in multiple Middle English manuscripts as early as 1380, the term cataract did not enter the English vernacular for another 2 centuries. Patients continued to be diagnosed as having a web, which was just a nonspecific term for an ocular media opacity or film, often on the cornea, but not necessarily. Both the early manuscript of Grassus’ treatise (Ashmole MS 1468) and the later middle English versions (Flunter MS 513 and MS 503) used the colloquial term “webbe” to describe a film on the eye.⁶⁸ When Henry VIII authorized the use of herbalist remedies by unlicensed practitioners in 1543 (the so-called Quacks’ Charter), he mentioned “a Pin and the Web in the Eye”, but not cataract.¹⁵³

The earliest use of the term “cataract” to describe an eye disease in an English patient was in a letter by the German doctor Valentine Russwurin in 1573 or 1574 when he briefly resided in London.⁹⁴ John Banister noted in 1578 that some of the younger doctors were calling the disorder cataract.¹⁴⁴ It is not until 1588 that we know of a native Englishman, physician Simon Forman, describing an English patient as having a “cataract”.¹¹⁵

Likewise, the Middle English formulation of the Latin “oculistas” as “oculisterz” in the Chauliac manuscript of 1425 did not catch on.⁷³ Ultimately, the Latin-derived word resurfaced in English as “oculist”. The earliest known use in English was in 1588 when surgeon William Clowes listed a medical recipe: “This receit was giuen me for a secrete, of one I suppose to be a good occulist…”¹⁴⁶ The next known instance of a doctor in the British Isles being described as a “chirurgion and occulist” was Henry Blackborne in his certificate from the mayor of Rye of 1610, and then in his will of 1611.^130,131 Physician and astrologer Richard Napier wrote in 1616 of Richard Banister: “Mr Banyster of Stampfordshere the Oculist can helpe boath the blynd & deafe”.¹⁴⁸ In 1619, Napier recorded: “Atwood of Worcester a gentlema[n] of 500 ll [libra] the yere & the best Co [sic] Oculist in England co$\overline{m}$ended by Mr Van Otten”.¹⁴⁰ Richard Seabrooke described himself as an “occulist” in his treatise of 1620.⁹⁶

Roos’ 1519 use of the term couching to describe cataract surgery is fascinating, because it comes so much earlier than any other instance.⁴ It is often noted that the English term couching is ultimately derived from the French verb coucher, meaning to lie down. Therefore, one might assume that the French used this verb to describe cataract surgery. But the French did not. For instance, Jacques Guillemeau discussed which types of cataract were proper “á abbatre”.¹⁵⁴ Similarly, the Spanish referred to needles used to “abatir la catarata”.¹⁵⁵ It is true that in non-ophthalmic contexts, the English word “couch” had been adapted from the French as early as the 14^th century.⁷³ But use of the term couch to describe cataract surgery appears to be original in English. After 1519, the next known use of the term to describe cataract surgery was in 1587 with Anthony Hunton’s translation of Guillemeau’s treatise.¹²² Fenton’s use in 1590 when translating Grassus’ manuscript suggests that the term was becoming popular.⁶⁸ Its use in 1519, in an obscure setting, and again in 1587 might suggest some continuity in English colloquial use throughout that period. Alternatively, Roos and Hunton might independently have thought it an apt term.

Cataract surgeons in Scotland (by 1595).

The introduction of couching into Scotland roughly paralleled its introduction into England, though perhaps with a delay of a few decades. Indeed, others have written that “the progress of medical knowledge in Scotland…appears to have proceeded proportionably with that of England, although with slower steps.”¹⁵⁶

As with England, seemingly miraculous healings were performed by saints quite early in the Scottish medieval period, and historians have assumed that some of these accounts might relate to “surgical couching of cataract”.³⁵

King James IV of Scotland (1501).

Some have written that a cataract couching was performed in Scotland in 1501,³⁵ and even that it was performed by King James IV. This idea stems from the April 10, 1501 entry in the royal account books that 14 schillings were “giffin to the blind wif[e] that had hir eyne schorne”.¹⁵⁷ One early analysis suggested that this could have been a cataract couching in which the king merely “took a kindly and intelligent interest.”¹⁵⁷ Others suggested that the king performed a cataract couching himself.¹⁵⁸ The king was definitely interested in medicine. He visited a man “new schorn of the stane” in November 1496.¹⁵⁹ The king even performed some healing himself. He paid for cloths used while he healed a leg: “…quhilk he laid doun for claith to be wipes to John Balfouris sair leg quhilk the King helit.”¹⁵⁷

With respect to bloodletting and drawing teeth, the account entries indicate that King James IV was the practitioner of common, straightforward medical procedures, to which he also submitted as a patient. Bloodletting was common in Scotland. On April 14, 1491, the king paid a man “to gif the king leve to lat him blud”¹⁵⁹ The very next day, payment was made to “a leyche that leyt the king blud”.¹⁵⁹ It seems the king wanted to try his hand at the procedure before having it done on himself. In December 1503, reimbursement was made “to the barbour that come to tak furth the Kingis tuth.”¹⁵⁷ Two months later, (February 1503/4), the king purchased “ane turcas [pincers] to tak[e] out teith”.¹⁵⁷ In February 1511/2, the king gave gifts “to ane fallow, because the King pullit furtht his twtht” and also “to Kynnard the barbour for tua teith drawin furtht of his he[a]d be the king”.¹⁶⁰

There are reasons to doubt that the entry refers to cataract couching. The verb “to shear” is typically used in the sense “To cut (something) with a sharp instrument” and only “occasionally to pierce, thrust through”.⁷³ The dictionary lists several instances of the verb being used in the case of lithotomy (as in the Scottish account ledger). The relevant definition could be: “to remove (a part) from a body by cutting with a sharp instrument”, as in the nonsurgical examples from the years 1330 to 1902: “his blade sheares off their wrists” (from 1614) and “its sharpen’d Edge Shear’d both his Ears” (from 1740).⁷³ We did not find any examples of the verb “to shear” being used to describe couching cataracts, or any eye surgery. The blind wife might have lost her eye from trauma.

Indeed, the king frequently provided alms to the blind or injured. For instance, in March 1503/4, 9 shillings were given “to ane blind man, be the Kingis command.”¹⁵⁷ This payment to the blind wife was just one of 14 instances of alms to the blind in a 5 year period.¹⁵⁷ In February 1503/4, he provided financial support to “the maister cukis boy that brak his leg”.¹⁵⁷ This pattern of charity makes it entirely possible that the blind wife was injured from an accident or an assault.¹⁶¹

Maister Awin in Scotland (1595).

Given that ophthalmology in Scotland lagged behind that in England by a few decades, it is natural that on Feb 5, 1588/9, Philip Hislop, one of the regents of the college at Edinburgh, was granted a license to travel to England because he was “visite[d] with ane mellady in his ane eye, to the apperant lose thairof, and is in howpe to be curet thairof in Londoun…”¹⁶²

The Continental use of the term cataract for an eye disorder might have gained some popularity in Scotland in 1591 when King James VI (1566-1625) published his translation of the poems of Guillaume de Salluste Du Bartas, and noted:

“The Pearle vpon the eie,

That dimmes the shine, and Cataract,

That darke and cloudie bee”¹⁶³

As he became the king of England and Ireland in 1603 as James I, we can be sure that the monarch of the United Kingdom was aware of this disorder.

The ability to perform cataract surgery may have arrived in Scotland in 1595 (Table 4). On August 1, 1595, in response to a complaint by local surgeons,^156,158 a French surgeon, “Maister Awin [a] Parisian”, was fined by the town council of Edinburgh for practicing despite not belonging to the guild. The council ordered that he restrict his practice to: “the cutting of the stayne [lithotomy], the curing of that sort of rymbursin [hernia] quha hes their entrellis fallin in their bawcod [scrotum], the cataract or sluch of the eye, the pest and the diseases of wemin resultand upon their birth”.¹⁶⁴ The word cataract as a visual disorder had arrived in Scotland. On the other hand, though ophthalmic use of the term couching was taking hold in England, we have no evidence of its use in Scotland by 1595.

Peter Lowe in Scotland (1598).

Surgeon Peter Lowe (c. 1550-1610) was probably born in the west of Scotland.¹⁶⁵ In about 1566, he traveled to France, where he received medical training, served the royal household, and practiced in Paris.¹⁶⁵ He left France about 1596, and was probably in London in 1597.¹⁶⁵ By early 1598, he was living in Glasgow.¹⁶⁵ He asked King James VI of Scotland to grant a charter so that, along with a few colleagues, Lowe could examine all candidates to perform surgery in the west of Scotland.¹⁶⁵ This system ultimately led to the Royal College of Physicians and Surgeons of Glasgow.¹⁶⁵

Lowe had some familiarity with cataract surgery from his time in France. He signed the first edition of his surgical treatise in London in 1597. The text was prefaced by praise by surgeons William Clowes and George Baker.¹⁶⁶ Lowe had responded to one of his French professors: “…in blindness[s], the sight is abolished, dimished as suffocation as happeneth in the beginning of Catarack…”¹⁶⁶ Lowe also noted that one used “…in the eye, an instrume[n]t called speculu[m] oculi, a needle proper to abate the Cataract”.¹⁶⁶ This anglicized version of the French verb abattre, rather than the English “to couch”, shows that he had not yet been highly influenced by English practices. Historians have been somewhat perplexed that this first edition did not have a chapter explicitly discussing cataract surgery. Perhaps, his exposure in France to this procedure was limited.

The second edition of his surgical treatise was printed as if from 1612, but this may be a publisher’s error, given that Lowe died in 1610.¹⁶⁵ This edition does have detailed chapters on cataract diagnosis and surgery, and even uses the term “couching” to describe procedures which he personally performed. Lowe had a figure of a cataract needle which could be hidden in a protective metal covering.¹⁶⁷ During the procedure, one would turn the needle “…until such time as you couch it to the lowest point of the eye…”¹⁶⁷ He noted that in English the terms “cataract” and “tey” were synonymous.¹⁶⁷ Lowe discussed the treatment of cataracts in several patients:

“The one of a seruant of my Lord of Laudum, who had a Cataract fiue years on both hir Eyes, which when I did see, I caused hir to stay one yeare there longer till it became more ripe, then I did coutch them both and restored hir to hir sight. Likewise a Seruitour of the Lord of Craiggie Wallase, who had a Tay on his Eyes the space of nine months or thereabouts, which was sufficientlie ripe, so I did couch it, and restored him in like manner to his sight.”¹⁶⁷

Perhaps, Lowe was not called upon to personally perform this procedure in France. In Scotland, the dearth of established oculists required him to perform cataract surgery. His use of the term “couching” reflects English influences, whether from his time in London, from treatises such as Hunton’s translation of Guillemeau, or from English itinerants to Scotland.

As in England, there is little evidence that this introduction of cataract surgery really took root among academic or traditional surgeons. In 1627, Robert Archibald of Glasgow was admitted a freeman “in the calling of chirurgerie & in particular in the Incision of the Stone, Cataract, hernia…”¹⁶⁸ Archibald continues to be mentioned in the Faculty Minute Books through 1641.¹⁶⁸

The competency examination by the Incorporation of Surgeons in Edinburgh of Andrew Johnston in 1712 did not mention cataracts, but that of James Robertson in 1719 included “couching of the cataract, fistula lachrimalis”.¹⁶⁹ Likewise, that of John Douglas in 1724 included “operation of couching the cataract, theory of vision.¹⁶⁹

Echoes of cataract surgery in Shakespeare (1606).

William Shakespeare (1564-1616) wrote when cataract surgery was becoming widespread in England. It would not be surprising if this new procedure influenced his art, such as in King Lear, first performed in 1606, and attributed to Shakespeare by 1608. The Earl of Gloucester is blinded when Cornwall orders his servants “To this chaire bind him [Gloucester]” and gouges out Gloucester’s eyes with his foot (Act 3, Scene 7).¹⁷⁰ As we show below, the image of a person tied to a chair and screaming as others damage their eyes would call to mind cataract surgery. Indeed, this procedure was sometimes performed in public on a stage, just as in a play.

In antiquity and much of the medieval period, the patient might be sitting on the ground. However, by the medieval period, the patient was gradually elevated onto a bench, and then a chair.² According to the early 1400s Middle English translation of Grassus (Hunter MS 513), during the procedure the surgeon should “…make the pacient to sitte on astole [a stool] and thou shalt sitte with the pacient face to face…” The late 1400s manuscript Hunter MS 503 was a little more clear that the patient and surgeon were actually straddling the same bench as if riding a horse, and were facing each other: “…do hym sitte ouerthwhart ryding wyse. and sytte þou also on the stoke yn lykwyse face to face.”⁶⁹ In the Latin treatises of Grassus published in 1474, the word used for seat was “sedere”,⁶⁹ as it was in other Latin manuscripts.⁶⁸

Lanfranc of Milan also had the patient on a stool:

“First þou schalt make pe pacient sitte vpon a stool tofore þee, & þou schalt sitte a litil hiʒer pan he…”⁶⁷

When Guy de Chauliac described the couching procedure in 1363, the patient was “sittynge vppon a stedfast sto[o]le. And be pere a good seruant byhynde hym pat schal[l] holde his he[a]de wel[l] stille.”⁷² The surgeon sits “vpon pe same sto[o]le”, but a little higher than the patient, and the patient’s hands are placed under the patient’s knees. Meanwhile, “þe wirchere schal byclippe þe pacientes knees wiþ his fe[e]te”.⁷²

Binding of the patient’s limbs during cataract surgery had occurred at least since the 11^th century treatise of oculist ‘Alī ibn Īsā al-Kahhal of Baghdad, known later in the west as Jesu Hali.² De Vigo in 1514 combined these ideas, as the patient was bound to a chair:

“comforte the patie[n]t, & set hym vpo[n] a streyght be[n]che of a meane height. Bynd the hole [nonoperative] eye, and also hys legges & hys ha[n]des, that he hynder not the operation of ye chirurgien”⁸¹

At the end of the attack in King Lear, Cornwall cries “out vild Ielly [vile jelly]”, apparently referencing the vitreous.¹⁷⁰ At a minimum, this line suggests that Shakespeare had some knowledge of the internal ocular structures. In 1594, a medical author described how a splinter of wood impacted the eye of a maiden with such force that “the gellie of her eye came forth”.¹⁷¹ But Shakespeare may even have intended to suggest an eye disease. Many have seen parallels between the paradoxical themes in King Lear and in Charles Estienne’s Defence of Contraries, translated in 1593, and have suggested that Shakespeare may have read this work.¹⁷² In the chapter “That it is better to be blinde, then to see cleerely” Estienne refers to “eye-gellie” as an ophthalmic disease.¹⁷³ A 1611 translation from French defined “catharact” as “a disease in the Eye distilling a tough humour like gelly”. ¹⁷⁴ In 1578, Thomas Cooper defined cataracta as “a disease of the eyes, when a tough humour like a gelly droppeth out.” ¹⁷⁵ This instance is particularly important because Shakespeare is thought to have used Cooper’s dictionary.¹⁷⁶ Thus, if Shakespeare were intrigued by the new ophthalmic surgery sweeping the land, he might turn to a dictionary which compared a cataract to ocular jelly.

The Mountebanks (by the 1630s).

In the 17^th century, the family continued to be an important vehicle for transmitting ophthalmic knowledge, but another institution also served this purpose: mountebank troupes. Sometimes these institutions overlapped, when the troupes were family affairs. Universities and hospitals were not prominent teachers of cataract surgery in this era.

Mountebanks had probably been present in the British Isles for many years. In 1622, Banister derided mountebanks who performed their cures outdoors:

“Of proud quacksalving Mountebankes…Such are they, that promise to make blind people see, deafe people heare, and to cure the Stone and Rupture by cutting. In the methodicall practice and cure of blind people, by couching of Cataracts, our English Oculists have alwayes had an especiall care…to couch them within doores, out of the open aire, to prevent further danger. Yet some of these Mountebankes take their Patients into open markets, and there for vainglories sake, make them see, hurting the Patients, only to make the people wonder at their rare skill. Some others make Scaffolds, on purpose to execute their skill upon, as the French-men, and Irish-man did in the Strand, making a trumpet to be blowne, before they went about their work…Great is the hurt that is done to the Eyes, being pearced with an instrument, in an open and airy place: for the aire getting into it, bringeth many evill accidents to the part, most commonly privation of sight.”⁷

One accusation against itinerants is that they might move on before the postoperative recovery was complete. Banister remembered that Blackborne’s former student Hanle “would neuer stay in a place where he had couched Cataracts, till their eyes were opened but traueled in haste…”⁸

Physician James Primerose (c. 1598-1659) in a diatribe against mountebanks, actually approved of itinerant cataract surgeons:

“…I exempt from their rank those manuall Operatists that cut for the Stone…as also such as couch the Cataract, and those that cut for the Rupture, for they are lawfull Artificers…”¹⁷⁷

Beginning in the 1630s, mountebanks operated on a grander scale in the British Isles. This trend began with John Ponteus, thought to be of Italy,¹⁷⁸ who had traveled to London with a 10-person troupe by 1630.^179,180 Ponteus was described by physician Walter Harris in 1683 as “Pontaeus, the first Mountebank that ever appeared on a Stage in England”.¹⁷⁸ The entertainment provided by Ponteus consisted of “stage playis” by 1643,¹⁸¹ and by 1663, both rope dancing, and sliding on a taut rope “his hands low and streatched out lyke the winges of a fowel.”¹⁸¹ Ponteus took his entourage to Oxford University,^183,184 and traveled throughout England and Scotland.^{178,181,182,185} Another prominent mountebank was Salvator Winter. The lay publications of both Ponteus and Winter emphasized medicines, and do not mention cataract surgery.^179,186,187 However, Ponteus was licensed to practice surgery, and published works on surgery.^183,184 Winter called himself “an expert operator” and offered “to Cut, and Cure” a number of ailments.^188,189 Moreover, subsequent cataract couchers such as John Church and William Read cited Ponteus and Winter as authorities.^190,191 Church claimed to have trained with them.¹⁹¹ Read called Ponteus his master, and lauded Winter’s medical formulas.¹⁹⁰ Therefore, we cannot exclude the possibility Ponteus or Winter may have performed eye surgery. At a minimum, Ponteus and Winter inspired subsequent generations of oculists.

In addition to medical care, the mountebanks provided entertainment. Edward Green, the younger (d. 1745), had rope dancers and tumblers perform on a stage in Edinburgh.¹⁸² The audience was asked to throw a handkerchief containing one or two shillings, and the handkerchief would generally be returned with medicine. Sometimes, a silver cup might be returned in the handkerchief, to encourage the patients to gamble.¹⁸²

Usually, the entertainment took a back seat to the performance of surgery and the sale of medicines. But in one family, dancing and acrobatics were the main attractions. Andreas Larini (also known as Signor Violante), the husband of a professional dancer, performed acrobatic feats of rope-sliding. He slid down a rope on May 31, 1727 from the steeple of St. Martin-in-the-Fields, Westminster, and in July 1728, slid across the River Severn, while firing a pistol held in each hand.¹⁹¹ Violante has been identified as one of the acrobats on the ropes in Hogarth’s painting Southwark Fair of 1733.¹⁹¹ Thereafter, the Signor adopted a less adventuresome career. He advertised as “Andreas Laurini”, a long-time “occulist” in Dublin in May 1731 when his wife performed there.^192,193 In 1735, “Mr. Larini” danced with his wife in the Newcastle theater.¹⁹⁴

Not only did the mountebanks conduct a large portion of the eye surgeries, but their troupes also functioned as educational institutions. Sometimes, as in the case of the Green family, these mountebanks were training their own kinsmen. But in many cases, the knowledge was transmitted to apprentices who were hired. There are stories of apprentices running away, with advertisements declaring them imposters or seeking their apprehension. In 1724, oculist Roger Grant advertised that William Grant was his footman, and, despite William’s claims, had never been instructed “in the Ophthalmic Art”.¹⁹⁵ William Grant retorted that he had indeed learned couching from his Uncle Roger.¹⁹⁶ William Grant (d. 1769) went on to have a long career in Reading.¹⁹⁷

In 1793, Liverpool oculist Mr. Johnson announced that his apprentice John Dunn had run away, and offered a one guinea reward for the apprehension and delivery of Dunn to a druggist.¹⁹⁸ Dunn escaped, and was advertising as “Dr. Dunn, Occulist” from 1799 to 1826.^199,200

Despite the possibility of learning a trade, working as an assistant could be exploitive and even dangerous. Walter Harris (1647-1732) heard that Ponteus “made a Challenge to the Physicians at Oxford, to prepare for one of his Servants, the Rankest Poyson that they could contrive”.¹⁷⁸ According to Harris, the servant survived the poison by eating several pounds of butter in advance to coat his stomach, and then after collapsing on stage and being removed from site, vomiting up the poison.¹⁷⁸ Thus, it seems the Oxford physicians were complicit in the whole affair.

In 1684, the mountebank Cornelius Tilborg erected a stage in Edinburgh, and attempted to prove the efficacy of his antidotes after one of his servants ingested poison. However, the experiment failed, and the servant died.²⁰¹

In 1695, Edward Green (d. 1729) complained to the Justices of the Peace in Middlesex that his apprenticeship to Roger Gateley did not involve surgical instruction.²⁰² Rather, Gately “compelled him to practice the art and employment of rope-dancing, tumbling, and acting as a jack-pudding, on a mountebank’s stage…and…Gately also had at several times immoderately beat and misused his said apprentice”. The Justices permitted Green to be relieved of his obligations as an apprentice.²⁰³ Green went on to have a successful career as the patriarch of 3 generations of itinerant oculists.

Harris heard that Ponteus would have an assistant howl in pain when what looked like molten lead was poured over his hands, only to be miraculously healed by an ointment. The secret was that the apparent lead was really “Quick-silver” (mercury).¹⁷⁸

In 1687, an oculist named “Doctor Reid” (possibly Richard Reidman) in Edinburgh filed litigation against a couple “for stealing away from him a little girl called the Tumbling Lassie, who danced upon his stage; she danced in all shapes, and, to make her supple, he daily oiled all her joints…he had bought her from her mother for £30 Scots.”²⁰⁴ However, physicians testified that “the employment of tumbling would bruise all her bowels and kill her; and her joints were now grown stiff.” The mountebank lost his case.²⁰⁴

Traditional ophthalmic histories downplay the importance of the mountebank in the latter half of the 17^th century by emphasizing the practice of Daubeney Turberville (c. 1612-1696) of Salisbury. He was well-connected to the country’s elite political and academic circles, and attended Oxford University from 1634 to 1640.²⁰⁵ Some university historians have implied that he learned ophthalmology at Oxford.²⁰⁶ In fact, we do not know where Turberville learned to practice as an oculist, but it could very well have been through family connections or from the mountebanks who visited Oxford. It is not clear that any of the doctors at Oxford during Turberville’s time there knew how to couch cataracts. Turberville “bore Arms for the King” during the English civil war.²⁰⁷ He is probably the “chirurgeon or oculist” who spied for the royal side in January 1645/6,²⁰⁸ acting as an agent of Lord George Digby (1612 – 1677), the second Earl of Bristol, who also attended Oxford.²⁰⁹

During the rule of Oliver Cromwell, Turberville was relegated to be a provincial oculist in the 1650s in Crookhorn.^210,211 He was almost certainly the oculist from “Crewkerne” who was paid 3 pounds by the town of Dorchester to perform cataract surgeries on an elderly couple.²¹⁰ With the restoration of the monarchy in 1660, Turberville was now rewarded for his previous royal support. He was awarded an essentially honorary MD degree at Oxford,²¹² and traveled to London to provide medical care to elites, such as Samuel Pepys²¹³ and Princess Anne.²⁰⁷

However, Turberville’s training appears to have been empiric, rather than academic. It was not until 1668 that, while at an alehouse with friends, he had the opportunity to observe the dissection of an eye.²¹³ Pepys was incredulous that such a famous oculist would not be more familiar with the interior of the eye. Turberville was said to have learned how to perform paracentesis to release aqueous from a ship captain who had spent 15 years in Peking.¹¹⁰ Turberville may have also had connections with the Stepkins-Woolhouse dynasty of oculists, given that he was said to have demonstrated paracentesis for Thomas Woolhouse.¹¹⁰ Paracentesis for a new condition called hydrophthalmia was just entering Europe at the end of the 17^th century, as oculists were inspired by the Asian practice of acupuncture.¹¹⁰

Some of the stories advertised by mountebanks were fantastic, even if unverifiable. Honoratus Le Begg received a medical license in 1668 from the diocese of Canterbury, and was still active in 1677.^214,215 He then disappeared until 1694, when he advertised in London that “Doctor Lebeg, Oculist…eminent for Couching of Cataracts” had been traveling to Spain to treat an eminent blind person with cataracts when Le Begg was captured by a “Turks Man of War”, sold as a slave in Algiers and then Egypt, where he remained for two years before returning to practice in the North of England.²¹⁶

The most prominent eye surgeon in the British Isles in the decades following Turberville was William Read, of England. Historians have differed radically in their assessment of Read. His Oxford biographer wrote that “Sir William was a more effective self-promoter and plagiarist than he was an oculist”.²¹⁷ However, we agree more with the historian who wrote that Read was the “best eye man in England”.¹⁹⁰ In order to understand Read, it is essential to study the progression in his career. Read probably began working in the medical field in some capacity by about 1673.²¹⁸ Both antiquarian Le Neve, and Read himself, probably in about 1691, indicated that Read got his start working under John Ponteus.^190,219 Ponteus had faded from the scene by about 1676, but perhaps the careers of Ponteus and Read overlapped by a few years. In any event, Read saw himself in his early days as carrying on the tradition of one of the most theatrical mountebanks in the British Isles, a man who was accused of using deception in his stage shows. It was probably in about 1691 when Read published “a catalogue of those medicaments he sold off his stages during the time of his eighteen years travelling in England, Scotland, Ireland, and many foreign kingdoms”.²²⁰

But Read evolved. His first gambit was to take his stage presentations to the major universities. In 1684, he couched cataracts in Dublin, and received a certificate from officials at Trinity College.²²¹ In 1689, he treated patients at Oxford University, reportedly to the satisfaction of the spectators.²²² In 1697, he treated patients at Cambridge University.²²³ Although Read performed surgeries and probably sold medicines from his stage, there is no evidence he performed plays, hired dancers, or had assistants poisoned or bitten by snakes, etc. Perhaps, in his early days as a junior servant to Ponteus or others, Read engaged in such theatrics (we have no way of knowing), but when on his own, he chose not to do so. When Jonathan Swift received an invitation to a party from Read, Swift wrote that Read “has been a mountebank”,⁸ not that he still was one.

Read’s success at the universities led to opportunities to treat the ruling class. Read was the dominant oculist in London during the period which saw the couching of physician Peter Barwick (1619-1705) in 1692,²²⁴ and of Lady Rachel Russell (1637-1723) in 1694 and 1695.²²⁵ As an oculist, Read became in 1698 the “Servant in Ordinary to His present Majesty” (King William III).²²⁶ In 1702, Read couched the cataract of Sir Cecil Bishopp, 4th Baronet (c. 1635 - 1705).²²⁷ In August 1705, Read was knighted by Queen Anne for the charity care he provided to soldiers and sailors.²²⁸ Read was recommended as the best surgeon for couching cataracts by William Coward in his Ophthalmiatria of 1706.²²⁹ Read’s couching of the cataract of parliamentarian Simon Harcourt (1661-1727) in August 1710 was successful, and was followed by Harcourt’s reappointment as attorney general the following month.²³⁰

From the mid-1690s onward, Read was no longer a mountebank performing on a stage. He advertised in newspapers that patients could come to his house to be treated. He still practiced as an itinerant throughout England. In his absence, he would leave first his brother-in-law the oculist J. Brinsden in London to treat his patients, beginning in 1703,²³¹ and then, beginning in 1709, his wife Augustina, the Lady Read.⁸ Account books document that Brinsden was paid £1 for couching Isabella Manning in 1707. ²³² Both of these family members couched cataracts. For most of the oculists of this period, we have very little outcomes data independent of the oculist’s own advertisements. Unfavorable outcomes might occasionally be publicized by a competitor, but we could not find such reports with respect to Read. Couching in this era undoubtedly could fail frequently, but given his high surgical volume and ability to readily find patients at all strata of society, we might imagine that his outcomes were as good as anyone else’s.

His critics have focused not on his outcomes, but on the oxymoronic charge that he was an illiterate plagiarist. Given that Read published Banister’s work, incorporating his own edits, and that there is a manuscript in Read’s own hand,¹⁹⁰ it seems that he could read and write English. The charge of illiteracy is best interpreted to mean that he lacked formal university education, and could not read Latin or Greek well.¹⁹⁰ Another criticism of Read in the modern day,²¹⁷ and in one letter of the period,²³³ is that Read plagiarized Banister’s 1622 treatise. In fact, neither Banister nor Read acknowledged Guillemeau as the original source. What both authors did was quite similar. Both put their names on a volume which contained the material of others, and each added his own section (Banister’s Breviary and Read’s Practical Observations). Defenders of Banister and Read could argue that they put their own name on the section they wrote, but did not put their name at the start of the sections borrowed from predecessors. The standards of the period were still evolving, and this type of copying without attribution was quite common. We cannot lionize Banister as the heroic and unblemished father of British ophthalmology while condemning Read as a mountebank and plagiarist. Both were itinerants who read and republished ophthalmic works in English (without explicit acknowledgment of the source), while adding their own unique observations. Upon Read’s death in 1715, his wife carried on the practice.

One of the most prominent itinerant oculists of the 18^th century in the British Isles, and all of Europe, was John Taylor. He had experience with scholarly, hospital-based surgeons and with an itinerant oculist, and fused the academic lecture with the stage presentation of the mountebank. Rather than traditional entertainment, such as acrobats, he presented a scholarly lecture, oriented towards laypeople, community surgeons, and university doctors.

Hans-Reinhard Koch has noted that Taylor might have inspired Jacques Daviel to practice as an itinerant oculist during Taylor’s visit to Marseille in 1734.²³⁴ In fact, Taylor might have inspired William Cheselden to pursue ophthalmology in a public fashion. We have no evidence that Cheselden performed eye surgery prior to Taylor spending time training under him at St. Thomas’s Hospital. As Cheselden was an established surgeon, Taylor benefited by touting his time with Cheselden at the beginning of Taylor’s ophthalmic treatise of 1727. Still, Taylor seemed to damn Cheselden with faint praise by noting: “the little Damage you have ever done, where Unavoidable Accidents have conspir’d to render the Operation unsuccesful, is a great Evidence of the Accuracy of your Judgment.”²³⁵ Taylor’s grandson suggested that the training with Cheselden was of a general nature.²³⁶ Taylor touted his success performing cataract surgeries in his hometown of Norwich in July 1726 ²³⁷ before newspaper notices regarding Cheselden’s cataract surgeries began appearing in March 1727.²³⁸ Likewise, Taylor’s first ophthalmic treatise in 1727²³⁵ preceded the first scholarly ophthalmic publications by Cheselden in 1728. Taylor did not find his ophthalmic training at St. Thomas’s Hospital to be adequate. Thus, he spent 1729 touring Edinburgh and the rest of Scotland,²³⁹ apparently with an oculist who engaged in a “Method of public Practice”.²⁴⁰ We would note that the timing is consistent with the Scottish travels of Edward Green, the younger (d. 1745).¹⁸²

Taylor was actually well-versed in the scholarship of the day. He was the first to draw the semi-decussation of the optic nerves.²⁴¹ He gave an excellent description of angle-closure glaucoma.²⁴² Taylor was taken seriously by many of the established oculists and professors of the period. Thomas Hope had studied in Paris under Charles de St. Yves and John Thomas Woolhouse, and still felt it worth his while to spend 6 months with Taylor in Edinburgh in 1743.²⁴³ On the other hand, in 1744, the Royal College of Physicians and the Corporation of Surgeons in Edinburgh cautioned against accepting Taylor’s claims, and warned that some of his surgeries were unsuccessful.¹⁸² Taylor was accused by Le Cat of pretending to perform strabismus surgery by operating on the deviating eye, patching the sound eye, and declaring success when the strabismic eye was used to fixate.²⁴¹ We previously noted a newspaper report which confirmed that an oculist was conducting this charade in England in about 1742.²⁴¹ Our present efforts have provided the perspective that other English oculists were not trying to treat strabismus during this period. Thus, this oculist was most likely Taylor, and Le Cat’s story is confirmed.

Taylor went on to become one of the most prominent oculists in all of Europe. Elis many accomplishments must be balanced against his flamboyance (he called himself “Chevalier”) and his self-aggrandizement, which was deemed excessive even by the standards of his day. In addition, he had many unsatisfied patients, particularly on the Continent. He was forced to refund surgical fees in Mannheim, sued for malpractice in multiple locations, and forbidden to perform eye surgery in Habsburg territories.²⁴¹ One might be tempted to say that Taylor’s legacy lies in the work of his sons and grandsons, who practiced as oculists in London.²⁴¹ However, their style was that of the conventional oculist planting roots in one community. One who modeled himself on Taylor more completely was James Graham, who toured early America as an oculist, and adopted Taylor’s slogans and style as an itinerant oculist presenting academic lectures.³⁹

Female Oculists (by 1649).

Women have long played a role in providing medical care, learning within the family or from other women. But their role was often unofficial. Surviving records do not list any female physicians in the time of King Henry (c. 1100).⁵ Given their central role in family life, it is not surprising that there is a long history of women providing medical care, even as early as the medieval period.⁶ The wife of a medieval doctor or barber would sometimes help in his practice, and even take over his practice upon his death.⁶

Richard Banister derided female practitioners: “Let these women therefore either applie themselves to learne the grounds of their practice, or leave their practice to them that are better grounded; that so they may cease by their ignorance to make them blinde, that by our Arte might be made to see.”⁷ Banister had no objection to a few women practitioners who worked “for charity”,⁷ and presumably did not compete with him for the paying patients.

When cataract surgery moved into the British Isles, this new procedure became integrated into the life of medical families. There was a brief period when women not only provided medical care, but even performed intraocular surgeries (Table 5).

An interesting procedure was related by physician Theodore Mayerne (1573-1655), who had arrived in England by 1611 and retired by 1649.²⁴⁴ A female English oculist (“Mulier Angla oculista”) drained the aqueous humor (“humorem Aqueum”), which had grown muddy and opaque (“turbidus & obscurior”), by inserting a needle into the cornea. The eye collapsed, but was restored when the aqueous was replenished, and the vision returned.^245,246 As Mayerne related this story in the chapter on cataracts, some have thought this represented a cataract surgery, perhaps by discission (division).²⁴⁶ However, the passage clearly describes drainage of aqueous. If the aqueous had been clear, this case would upset our understanding of ophthalmic history, given that we do not know of paracentesis for hydrophthalmia being performed in Europe until the 1680s, when acupuncture was imported from Asia.¹¹⁰ However, drainage of hypopyon, as in this case, had long been practiced in Europe. The patient was described as My Lord Rich, son of the Earl of Warwick, i.e. Robert Rich (1611-1659).²⁴⁷ Our patient was known to have traveled to the Isle of Wight in July 1648 to be touched for “the king’s evil”.²⁴⁸ Parliamentarian intelligence suspected that this diagnosis was an excuse to visit the king, but all agreed he had some sort of illness: “The Lord Rich [eldest son of the earl of Warwick] is with the King. The pretence is to be touched for the King’s Evil, his disease being another.”²⁴⁹ Thus, the hypopyon drainage could have been performed in the setting of uveitis, possibly from tuberculosis.

The oculist draining the hypopyon could have been any number of women. Lady Katherine Partridge Springett (1599-1647) of Kent was known for “taking off cataracts and spots in eyes”, and was a colleague of John Stepkins (d. 1652).²⁵⁰ Stepkins’ daughter Lady Ivy was also known as an oculist.²⁵⁰ By 1655, Robert Boyle knew of an oculist named Mrs. Hunt.²⁵¹ Mary Rich (1625-1678), the sister of Robert Boyle and sister-in-law of our patient, was known for “Chirurgery and Physick”, as were several of her female colleagues.²⁵²

Some decades later, we learn of female oculists performing cataract surgery. Daubeney Turberville’s sister, Mary Turberville, practiced after his death in 1696.^207,253 Likewise, William Read’s wife, Augustina, was couching cataracts by 1709.²⁵⁴

The poet William Cowper (1731-1800) had “specks” on his eyes, and therefore was sent at age 8 to live with “Mrs. D, an eminent oculist”.²⁵⁵ Subsequent biographers have erroneously written that this was one “Mrs. Disney”, but there is no evidence of an oculist named Disney. We believe that this was the oculist Mrs. Frances Deane, who learned from Mrs. Jones (d. 1720) and had died by 1754.^256–260 A poem dedicated to Mrs. Deane and written by a grateful patient was advertised in 1744.²⁵⁹

One pattern observed is that women did not learn medicine from men outside their family. The only exception we encountered was a fourteen-year-old named Charles Hamilton, who apprenticed in 1740 with the oculist Edward Green (the younger, d. 1745), and then Finly Green, before practicing independently.²⁶¹ After marrying a woman in 1746, Hamilton was discovered to be a woman named Mary who had impersonated a man. Hamilton was convicted of fraud and sentenced to be whipped.²⁶¹

Surgical Illustrations (1674).

It is not until the age of the itinerants of the last quarter of the 16^th century that we have surviving illustrations of couching needles in the British Isles. Peter Lowe included figures of couching needles in his 1597 surgical treatise.¹⁶⁶ Eye instruments, including “the Needle to remove the Cataractes” were also drawn in the 1598 translation of Jacque Guillemeau’s The Frenche chirurgerye.²⁶² The 1634 translation of Ambroise Paré’s works also depicted a cataract couching needle which screwed into a handle.²⁶³

Well into the 17^th century, we begin to have surviving illustrations of cataract surgery from the British Isles. In the 1674 translation of the surgical treatise of Johannes Scultetus of Germany, we find drawings of “silver needles fit to couch a cataract”.²⁶⁴ Scultetus also depicted the head of a patient with “a suffusion in the right eye, that…must be put down with a needle…”²⁶⁴ It was actually the patient’s left eye being couched with the doctor’s right hand, and the nonsurgical eye was covered with a cloth, as in the texts of Celsus and Ibn Isa.

The first surviving illustration of a couching procedure drawn by an Englishman might be that of John Browne (1642-c. 1700) in his 1678 treatise.²⁶⁵ The patient and surgeon face each other, sitting on chairs. The right hand operates on the left eye with a temporal approach. No eyelid speculum is used. The patient’s head is stabilized by the surgeon’s left hand, and by an assistant from behind. The light from a window falls on the patient’s operative side.²⁶⁵ No cover can be seen over the nonoperative eye, even though the accompanying text recommended the surgeon “bind up the contrary Eye”.²⁶⁵ Browne seems to be clear that he is drawing on classic texts. Browne’s treatise was later criticized by John Yonge (1647-1721). Yonge specifically noted that the cataract surgery illustration did not have “the other eye bound fast”.²⁶⁶ Yonge’s general criticism of Browne was for plagiarism and incompleteness, but Yonge did not accuse him of plagiarizing the illustration. Browne’s illustration demonstrates interest of the hospital surgeons in the procedure.

John Russell’s handbills, which are thought to date from about 1680, illustrate the “Couching a catract of one that had been blind 30 years”.²⁶⁷ A man with his sound (right) eye covered with a cloth gazes straight forward as the couching needle enters the temporal aspect of his left eye.²⁶⁷

William Read’s handbill, which appears to date from 1694, shows him couching a man indoors. Both doctor and patient sit in chairs without armrests. The right hand operates on the left eye with a temporal approach. The nonoperative (right) eye is not covered. An attendant holds the patient’s head from behind. The patient gazes straight forward.⁸

A handbill of Cornelius Tilborg from the time of King William III (1694 to 1702) features an illustration of Tilborg apparently couching a cataract (BL 551a32[112]r). The procedure is performed indoors near a window. The surgeon stands in front of the patient, who is seated on a chair without arms. The surgeon’s left hand is used to operate on the right eye in a temporal approach, while the right hand holds the patient’s chin. A child watches..²⁶⁸

Cataract Surgeons and Oculists in Ireland (from 1684).

Early continental medical influences were felt in Ireland. Even though the Romans never captured the island, an oculist stamp from the Roman period found in 1842 at Golden in Tipperary has an inscription interpreted by Freeman to read “For Marcus Juventus Tutianus a copperas eye salve for old scars.” To our knowledge, ancient instruments for cataract couching have not been found in Ireland.

Medieval medical texts from Europe were carried to Ireland, just as they were carried elsewhere in the British Isles. The Book of the O’Lees, which dates to about 1434, was written in Gaelic. According to legend, the O’Lees family was given the book by an old man on an enchanted island, which has been suggested to he in Lough Corrib, Ireland.²⁶⁹ The description of cataract surgery in this book seems to derive ultimately from Arabic manuscripts. A postoperative plaster with egg yolk (rather than egg white) and oil of viola (or violet oil) is a rather idiosyncratic combination specific to both the Book of the O’Lees and Ibn Sina (Avicenna), from about 1020 CE.² Of note, in 2018, scholars identified a portion of a 14^th century Gaelic translation of Avicenna stitched to the inside binding of a 16^th century English book.²⁷⁰ Other couching practices in the Book of the O’Lees, such as having the patient sit on a pillow, comforting the patient with kind words during the procedure, and testing the vision during or immediately after the procedure²⁶⁹ are not specified in the surviving Graeco-Roman texts of Celsus and Paulus Aegineta, but are found in the works of Ibn Isa (Jesu Hali) and Albucasis.² Note that the O’Lees did not specify the patient on a stool or chair, as in many of the later medieval Latin works.² Thus, the legendary old man on the enchanted Irish island probably had at least indirect access to Arabic sources.

Well into the age of the itinerant mountebank, cataract surgery can be documented entering Ireland (Table 6). The aforementioned visit of English oculist William Read to Trinity College in Dublin in 1684 is the earliest known visit of a cataract surgeon to Ireland.²²¹ However, apparently by 1687, oculist Richard Reidman had also practiced in Ireland on two occasions.²⁷¹ Oculist John Thomas Woolhouse accompanied James II into exile, including a brief period in Ireland, from 1689 to 1690, in which Woolhouse performed paracentesis for hydrophthalmia.¹¹⁰

The earliest identified oculist to live for a prolonged period in Ireland was Mr. Cawood of Dublin, who trained in Paris, and had lived in Ireland beginning about 1700. He described himself as “Nephew to the deceas’d Sir Charles Scarborough”, and was called to Ireland “by a person of Quality, there being none of that profession in that Kingdom”.²⁷² Cawood practiced occasionally in London or Liverpool, and was still practicing, apparently in Dublin, in 1722.²⁷³

Sylvester O’Halloran of Limerick had tried his hand at couching by 1749,²⁷⁴ and extraction a few times by 1755.²⁷⁵ However, we have no evidence of him performing eye surgery after that date, even though he was a general surgeon, licensed at least through 1787.¹²⁹

A great deal of Irish ophthalmic care in the 18^th century was handled by itinerants, such as John Taylor, who toured the island several times between 1730 and 1760.²⁷⁶

The type of personality which would seek out opportunities at the Western edge of Europe might also be tempted to travel to America. Indeed, William Stork had visited Dublin and Belfast in 1753,^277,278 before becoming the first cataract coucher in the North American colonies in 1761.^39,103 Likewise, the 1772 visit to Belfast of Frederick William Jericho of Germany^279–281 was his last known European stop before traveling to the Caribbean, to become the earliest identified surgeon to perform cataract extraction in the New World by the time of his return in 1776^39,103,155

The next oculist to settle in Ireland for a prolonged period was Joseph Rouviere, of France (d. 1790). According to a June 1762 advertisement in Bristol, “S. Rouviere, Occulist” treated “Disorders in the Eyes, such as Webs, Abscess, Cataracts, &c.” while “at Knowle, where he is detained a Prisoner of War”.²⁸² The prison at Knowle held Acadians evacuated from Nova Scotia in 1755.²⁸³ His advertisements merely stated that he had come from Paris, and performed cataract extraction in the manner of his teacher, Daviel.²⁸⁴ By July 1765, Rouviere had moved to Dublin,²⁸⁵ where he had a family and settled down. Rouviere would occasionally tour the island, and was still doing cataract surgery in 1787, though he had recently been ill.²⁸⁶ Rouviere died the same year as the oculist Baron Wenzel,²⁸⁷ i.e. in 1790.²⁸⁸

Congenital Cataract Surgery: Cheselden’s case (1727).

Congenital cataract surgery played an important role in early British ophthalmology. The procedure was performed as early as 1000 CE by the oculist Ammār ibn ‘Alī Mawsilī of Cairo.²⁸⁹ However, in the Christian world, it was held that congenital blindness could only be healed with a miracle. This belief stemmed from the story of Jesus curing a man born blind: “Since the world began was it not heard that any man opened the eyes of one that was born blind” (John 9:32). This passage suggests at least a limited understanding of amblyopia in antiquity.

Nonetheless, such miracles were said to occur in early medieval England. After the miraculous restoration of sight of a peasant’s son by Ramelmus, a monk at Much Wenlock in Shropshire in about 1100, the other monks noted that the patient could at first only visually identify those objects which he had previously felt.⁵ There is no way to know if the story originated with a cataract surgery, but the description of the outcome raises the possibility.

After clerics were forbidden to study medicine by the Council of Tours in 1163, such apparent miracles might have been less common. The late 1400s Middle English manuscript of Grassus (Hunter MS 503) noted with regard to the incurable “Guttam serenam” with a clear pupil that those “…communly that haue thys Cateracte byth blynde borne”.⁶⁸ (The mid-1400s Hunter MS 513 of Grassus had not mentioned that guttam cerenam was congenital).⁶⁸

Patients or doctors might have an incentive to fraudulently claim a miracle had occurred. In 1529, Thomas More (1478-1535) published the story of a beggar from Berwycke who claimed to have been miraculously healed of congenital blindness during a visit of King Edward IV (1442-1483) to Saint Albonys. The beggar and his wife insisted that he “cou[l]d neuer se[e] nothi[n]g at all in all hys lyfe before” to Humphrey, the Duke of Gloucester (1390-1447).²⁹⁰ The beggar was able to name the colors of the Duke’s gown, and other objects. The Duke pronounced him a fraud, on the basis that the newly sighted might see colors, but would not be able to name them, and had the beggar set in the stocks as punishment. ²⁹⁰ It is hard to see how the tale could be completely accurate, given that the Duke died in 1447, when the king was just 5 years old.

Shakespeare retold the tale in Elenry VI (Part II, Act II, Scene I), with the Duke of Gloucester noting: “If thou hadst been born blind, thou mightest as well have known all our names as thus to name the several colours we do wear. Sight may distinguish of colours, but suddenly to nominate them all, it is impossible.”⁸ Shakespeare wrote this play between 1590 and 1592.²⁹¹ At that time, cataract surgery was blossoming in England, but congenital cataract surgery was not known there.

In 1622, Richard Banister compared cataract surgery to Christ’s miracles of the Scriptures, but believed that “Cataracts in children are uncurable”.⁷ Banister never claimed to heal congenital blindness.

Shortly after Banister’s treatise, secular claims to have healed congenital blindness by cataract surgery appear in England, and in Christendom, for the first time (to our knowledge). The earliest congenital cataract surgery that we can find in Western Europe was performed by English oculist John Stepkins, who died in 1652.^110,250 The surgery, performed in an 18-year-old “Maid” who “lived absolutely blind from the moment of her Birth”, was reported by Robert Boyle in 1663.²⁵⁰ Tier postoperative visual function is not specified, but her emotions suggested a positive outcome. She was “ravish at the surprising spectacle of so many and various Objects…that almost everything she saw transported her with admiration and delight.”²⁵⁰ Stepkins learned the oculist trade from his father-in-law, Atwood of Worcester, presumably after marrying his daughter in 1625.¹¹⁰ Thus, the earliest-identified congenital cataract surgery in England (and possibly Western Europe) occurred between 1625 and 1652.

Several decades later, surgeons claimed to successfully cure congenital blindness in order to distinguish themselves from their competitors. Oculist John Russell was licensed to practice in 1663, and several of his handbills thought to date from about 1680 advertise cataract couching in those “born blind”.^267,292

In April 1686, “Doctor Reid and Salvator Moscow, from Sicily” erected stages in Edinburgh, and advertised “64 blind persons restored to sight who had never seen from their birth, (which blasphemie out did our Savior’s recall miracles, for we read not that he cured so many borne blind)…”²⁹³ This Reid is generally assumed to be the oculist Richard Reidman.²⁹⁴

One of the first to regularly advertise congenital cataract surgery was William Read, who also became the earliest identified surgeon to couch cataracts in Ireland in 1684.²²¹ In 1687, William Read couched the cataract of “the daughter of Mr Johnson at Grundon in Northamptonshire, who was Born Blind and restored to her perfect sight”.⁸ Read publicized congenital cataract surgeries performed from 1687 onwards, including at “Eaton Colledge” in a handbill of 1694.⁸ In August 1697, “Dr. William Briggs, Physician in Ordinary to his Majesty” observed Read couch the cataracts of a 9-year-old boy named George Smith, who had been born blind.²⁹⁵ Read continued to perform the procedure through at least 1706.²⁹⁶

Others who performed congenital cataract surgery before 1700 included Thomas Clark by 1695,²⁹⁷ Daubeney Turberville (d. 1696),²⁰⁷ and Turberville’s student Richard Chubb by 1699.²⁹⁸ In about 1726, Benedict Duddell treated a 7-year-old girl who had been “born blind”: “Her Eyes had been needled twice by Dr. Clark…but without success.”²⁹⁹ Duddell was unsuccessful with an additional attempt at couching.²⁹⁹

In the late 1600s, congenital cataract surgery began to take on another role—an opportunity to explore the fundamental nature of visual perception. In 1688, William Molyneux (1656-1698) of Ireland proposed in a letter to John Locke that one born blind who suddenly acquired the ability to see would be unable to visually distinguish cubes from spheres, even if these had previously been known by a sense of touch.^300,301 It is interesting that, unbeknownst to Molyneux, his conjecture was already answered in the affirmative by the monks at Much Wenlock 600 years earlier. In 1690, Locke did not directly answer Molyneux’s question, but did explicitly relate the cure of congenital blindness to cataract surgery:

“But such an assent upon hearing, no more proves the Ideas to be innate, than it does, That one born blind (with Cataracts, which will be couched to morrow) had the innate Ideas of the Sun, or Light, or Saffron, or Yellow.”³⁰²

In 1694, Locke published Molyneux’s question, and wrote that he agreed with Molyneux.^300,301

Molyneux may already have been exposed to oculists who were familiar with congenital cataract surgery. Molyneux married in 1678, and several months later, his wife developed loss of vision.³⁰³ The reputation of oculist Daubeney Turberville of Salisbury extended to Molyneux in Dublin. Therefore, in May 1679, he and his wife traveled to London, where they were evaluated by the oculist Lady Ivy,³⁰⁴ the daughter of John Stepkins.²⁵⁰ When she indicated that she could not help them, Molyneux and his wife moved on to Salisbury, where Turberville treated her to no avail. Molyneux and his wife were treated by Turberville a second time in March 1680, this time in London, when Turberville presented the case to royal physician Charles Scarborough, Dr. Richard Lower, and others, who all pronounced the case hopeless.³⁰⁴ Finally, Molyneux may have crossed paths with Read, who practiced at Trinity College in Dublin in 1684.

In June 1709, oculist Roger Grant was said to have successfully cured a 20-year-old named William Jones, but this case was debunked that year, on the grounds that Jones had a speck on his eye, but was not blind before the treatment, and could not see much better afterward. Moreover, a certificate from the Minister verifying the oculist’s claims was forged.⁸

In 1709, Irish cleric and philosopher George Berkeley (1685-1753) agreed with Molyneux that one suddenly brought to sight would not be able to visually distinguish cubes from spheres, and added that the patient would also not be able to immediately judge distance and magnitude.³⁰⁰

Conventional accounts stipulate that the first credible, empirical evidence regarding Molyneux’s question came from the 1728 report of English surgeon William Cheselden, who was said to have restored to sight a boy who was born blind.^8,300,301 This case has been discussed by prominent philosophers such as Diderot and Buffon over the last 3 centuries.^300,301 In 1738, Voltaire (1694-1778) wrote that Cheselden’s patient was reluctant to consent, but that “The operation was however performed, and fully succeeded. The youth, then about fourteen years of age, saw the light for the first time. This experiment confirmed all that Locke and Barclay [Berkeley] had justly foreseen.”³⁰⁵ Cheselden’s remains one of the most highly cited case reports from centuries ago. However, we have obtained new information which might call this case into question.

None of these discussants has known the family story or the name of Cheselden’s patient, whom we have now identified. The patient’s father, Daniel Dolins, Esq, studied philosophy and mathematics with Johannes Luyts of Utrecht in 1697.³⁰⁶ The senior Dolins returned to London and in 1700 married Margaret, the daughter of Thomas Cooke of Hackney (d. 1694).^307,308 Dolins was knighted in 1722.³⁰⁹

Dolins and his wife Margaret had four children: Abraham (b. 1701), Mary (b. 1703/4), Daniel (b. 1713), and Margaret (b. 1715).³⁰⁸ Both sons had bilateral cataracts and died as young adults. Daniel, the son, was Cheselden’s patient.

Abraham, the older brother, was operated for one of his congenital cataracts at age 13. By 1721, surgery for congenital cataracts had been performed on children as early as age 18 months in Paris.^110,250 However, it was more common to defer surgery until affected children were older.^110,250 In a letter of October 11, 1714,³¹⁰ the father informed clergyman John Strype (1643-1737) that:

“It pleased God to afflict our Eldest Son with Cataracts in both Eyes from his Birth. We design God willing to have him Couched in one of them by Mrs. Jones on Thursday next.”³¹¹

As with many women of the period,²⁵⁰ Mrs. Jones was from a family which had been practicing as oculists since the mid-1600s. On October 15, 1714,³¹⁰ Dolins updated Strype:

“…the operation was yesterday very well perform’d by the Divine Assistance, & the Child is as well as we can expect in so short a time, but we must wait with some Patience for the ripening & dissolving of the matter before he can have his clean sight …”³¹²

Pediatric cataracts are typically soft, and would probably break up during an attempted couching before being gradually absorbed. In May 1715, Dolins informed Strype:

“Mrs. Jones designs God Willing on Wednesday next to renew the operation on one of my sons eyes in order to remove some remaining strings which obstruct his Perfect Sight…These are therefore to desire you to renew your Prayers…[to] make this second operation completely successful.”³¹³

The “strings” Mrs. Jones removed could be cortical remnants, synechiae or pupillary membranes. Several English oculists referred to “threads” connecting the iris to the lens, which could be disrupted surgically.¹¹⁰ John Thomas Woolhouse in 1721 introduced the term synechiae into ophthalmology and became well-known for lysis of synechiae and pupillary membranes.¹¹⁰

In 1720, “Last Week died one Mrs. Jones, a noted Occulist; she was a Gentlewoman of great Goodness and Charity…”²⁵⁶ Mrs. Jones’ legacy was carried on by a succession of women oculists who passed on her knowledge.^257,258

Congenital cataracts are sometimes associated with developmental disability, but there is no evidence of intellectual disability in the Dolins children. When Mary died at age 16 in February 1719/20, the family minister, Daniel Mayo, recalled that she “was desirous to instruct her younger Brother and Sister…And delighted to converse about religious Matters with her Brother [Abraham], that was older than herself.”³¹⁴ Mary had suffered for some time from “Consumption”, with pain and “frequent Coughing”.³¹⁴ Her eyes were apparently fine, as even to the end, she read the Bible and “Mr. Baxter’s Dying Thoughts”.³¹⁴ Abraham died at age 19 in 1720.³⁰⁸

Dolins, Berkeley, and Cheselden belonged to the same social networks. The fact that Berkeley was directly linked with the family of Cheselden’s patient (the Dolins family) has not been previously published. Moreover, the social ties between Berkeley and Cheselden have not been explored.

The senior Dolins was one of the Governours of St. Thomas’s Hospital from 1714 to 1725.^315,316 Surgeon William Cheselden joined the hospital staff in 1718. ³¹⁷

Berkeley spent most of the years 1724 through 1728 in London, and was elected to the Society for Promotion of Christian Knowledge (SPCK) in 1725.³¹⁸ The senior Dolins had been a member of this Society since 1710,^319,320 and appears to have made Berkeley’s acquaintance. Berkeley planned to found a university in Bermuda, which he would lead as president. Berkeley established a committee of prominent citizens who could receive contributions for this effort. Berkeley’s committee, announced on July 15, 1725, included “Sir Daniel Dolins, Kt.”³²¹ He also included the “Rev. Dr. [Richard] Mayo, Treasurer to the S.P.C.K., at St. Thomas’s Hospital”,³²² the brother of the Dolins family minister.

Berkeley’s committee also included “John Arbuthnot, M.D.”,³²² a friend of Cheselden³²³ with whom Berkeley had previously corresponded and also discussed philosophy while visiting Arbuthnot’s lodging for dinner.^322,324

The poet Alexander Pope was one of the closest friends of both Berkeley and Cheselden. In 1722, Pope requested that Cheselden write down lines from Shakespeare that Cheselden had mentioned to Arbuthnot.³²³ In fact, Cheselden played a role in editing Pope’s 1725 edition of Shakespeare.³²⁵ While preparing the book, Pope wrote to a colleague “Let friend Cheselden be of ye party”.³²⁶ Even though Cheselden was his doctor, Pope referred to him as “friend Cheselden” several times. Pope frequently ate dinner at Cheselden’s home, and when Pope needed medical treatment in 1736, he stayed there.³²³ Pope implied that Cheselden advised him about his own eyes, and notified Cheselden when there were cataracts to be operated on in Bath.³²³ Cheselden was with Pope during his final illness.³²³

Berkeley was also very close with Pope. The two met in 1713 when both contributed essays to Steele’s Guardian,³²⁷ One of Pope’s Guardian essays mirrors the themes in Berkeley’s New Theory of Vision, suggesting that Pope had read it, even though it had only been published in Dublin.³²⁷ Berkeley and Pope shared dinner with a friend in 1721, when Berkeley stayed with Pope for a week.³²⁷ Pope invited Berkeley, writing: “as I take You to be almost the only Friend I have, that is above the little vanities of the Town…”³²⁷ During 1726 and 1727 when Berkeley was putting together funding for his proposed Bermuda college, he asked Pope to translate a poem, some lines from which Berkeley inserted in his Bermuda literature.³²⁷

One joint acquaintance of Berkeley and Cheselden who ultimately publicized the surgery was Voltaire, who, while living in London from 1726 to 1728, also met with Pope and the Princess of Wales.³²⁸ Voltaire later wrote that he “had seen a great deal of Cheselden”,³²⁹ and handwrote a dedication to Cheselden in his 1738 Philosophies.³³⁰ Voltaire also wrote that “…the celebrated Cheselden, one of the greatest surgeons in London, told me that it was he who first caused them [surgical instruments] to be manufactured in that city, in 1715.”³³¹ Likewise, Voltaire indicated that he discussed philosophy several times with Berkeley while in England.³²⁸

Berkeley had originally met Caroline, the Princess of Wales (1683-1737), in 1712, after his earliest philosophical works were published.³²⁴ It is conceivable that the philosophical implications of Molyneux’s question would have come up early in their relationship, given that Berkeley had just published on the question, and that they were introduced by Molyneux’s son Samuel.³²⁴ During this London period, from 1724 to 1728, Berkeley debated philosophy and theology weekly in front of the intellectual Caroline.³³²

Perhaps, it was between 1722 and 1725 when Cheselden became interested in eye surgery. Cheselden’s 1722 edition of his anatomy text mentioned cataract couching in passing, whereas the earlier edition did not.^333,334 Students who finished their training with him before 1722 did not become known for eye surgery or teaching, while subsequent trainees did.^235,323 During this period, cataract surgery was still largely in the hands of dedicated oculists, and the volume of general surgeons such as Cheselden was typically quite low. The year-long logbook of a student named Charles Oxley who was training at St. Thomas’s Hospital records several cataract surgeries at the hospital, beginning in May 1725. In one case, performed successfully in a 30-year-old man in June 1725, Oxley recorded that Cheselden was the surgeon.³²³ The minute books of the charitable Westminster Hospital, where Cheselden was a surgeon, record no eye surgeries until 1735, when Cheselden successfully “couched” a cataract in one John Hayes.³³⁵

Daniel Dolins (the son) was born on April 2, 1713.³⁰⁸ On March 14, 1727, the Daily Journal contained the first public notice of any eye surgery by Cheselden:

“…Mr. Cheselden, a Surgeon of St. Thomas’s Hospital, presented to her Royal Highness the Princess of Wales, a Son of Sir Daniel Dolins of Hackney, that was bom blind, having had Cataracts, whom he had restored to Sight by Couching, and had the Honour to kiss her Royal Highness’s Hand.”²³⁸

Historians have not previously noticed this newspaper report which permits us to identify Daniel Dolins as Cheselden’s famous patient. In October 1727, Caroline was crowned queen following the death of King George I. In December 1727, Cheselden was named the surgeon to Queen Caroline.³²³

Cheselden’s only ophthalmic publications (outside the chapter on the eye in his anatomy treatise) were two curious reports published together in 1728 in the Philosophical Transactions of the Royal Society of London.^336,337 The first report concerned the perceptions and emotions of a 13-year-old boy, who had been blind from a young age and was then couched.³³⁶ The patient was referred to as a “gentleman”,³³⁶ as one would expect for the son of a knight.

In the 1730 edition of his anatomy text, Cheselden included this report, and wrote:

“I have couched several others who were born blind, whose observations were of the same kind; but they being younger, none of them gave so full an account as this gentleman.”³³⁸

This note helps to establish that the 1728 report was about Daniel, because the small number of other children operated on by Cheselden were younger.

An analysis of this 1728 report reveals: 1) Although the tone of the report implies that Daniel could see better, it is not actually specified that he could perform additional visual tasks, and 2) the report used language more characteristic of Berkeley than of Cheselden.³³⁶ To illustrate the latter, we have italicized words used in Berkeley’s writings, but never used by Cheselden (in a database of period texts).³³⁹

The report was ambiguous about whether Daniel’s visual disfunction was congenital. The report described “a young Gentleman, who was born blind, or lost his Sight so early, that he had no Remembrance of ever having seen”.³³⁶ Both the newspaper notice mentioning Cheselden and Cheselden’s anatomy text addendum implied that Daniel was “born blind”.^238,338 He was blind from his “infancy” according to Berkeley.³⁴⁰ Daniel was blind from the age of about two years, according to the most unbiased source—his longtime tutor.³⁴¹

The author suggested that Daniel could see better postoperatively by including vague statements, such as alluding to the postoperative period “when he first saw…”³³⁶ In addition, “A Year after first Seeing”, Daniel said he had “a new Kind of Seeing”.³³⁶

Daniel anticipated he would someday be able to perform numerous visual tasks: reading, writing, walking “abroad”.³³⁶ The reader might suppose that eventually Daniel could perform some of these tasks. In fact, no improvement in performance of any visual task is specified.³³⁶ The report was clear that even several months after the surgery, Daniel could not visually distinguish a cat from a dog.³³⁶ We know from Daniel’s tutor that Daniel was never able to read.³⁴¹

Peter Kennedy, a surgeon who had spoken with “the parent” of Daniel, wrote in 1739 that “…far from being able to read or write therewith…It seems even to be with considerable difficulty he can guide himself along without some Assistance; and…he still knows Puss…much better by his feeling than he does by his seeing.³⁴²

Daniel’s positive emotions after surgery were mentioned in the 1728 report, apparently in an attempt to suggest improved vision: he was alternately surprised, delighted, amazed, and felt pleasure.³³⁶ Various sights were a delight or pleasing.³³⁶ Referring to Cheselden in the third person, the author related Daniel’s emotions:

“…his Gratitude to his Operator he could not conceal, never seeing him for some Time without Tears of Joy in his Eyes, and other Marks of Affection: And if he did not happen to come at any Time when he was expected, he would be so griev’d, that he could not forbear crying at his Disappointment.”³³⁶

How could Cheselden know what occurred in his absence?

The 1728 report was signed “Chesselden”,³³⁶ which varied from how he spelled his name in his publications. The fact that the 1728 report was narrated in the plural form (“we”) suggests that it might have been a multi-author work.³³⁶

The report used Berkeley’s language regarding emotions (affection, ashamed, amazed, crying, delighted, disappointment, gay, gratitude, liked, loved, most agreeable, reconciled); mental or sensory processes (blindness, conceived, expecting, forgot, faint ideas, imagination, likeness, perceptions, remembrance, touched); geometry of images: (pencils, pictures, planes); and other idiosyncratic expressions (abroad, another time, any ways, ask, conceal, could not forbear, garden, express, I shall know, marks, most agreeable, new kind, quality, saying, scarlet, steadfastly, thousand things, undergoing, watch, i.e. timepiece, young gentleman).³³⁶

Berkeley, a cleric and philosopher, frequently discussed these words and concepts in his publications. Cheselden did not (see Appendix 4).

The observations of the 13-year-old Daniel were suspiciously similar to those of Berkeley. It was not until “about two Months” after surgery that Daniel discovered that pictures “represented solid Bodies”, instead of “Party-colour’d Planes, or Surfaces diversified with Variety of Paint”.³³⁶ In 1709, Berkeley had written that “What we strictly see are not Solids, nor yet Plains variously colour’d; they are only Diversity of Colours.”³⁴³

Daniel “ask’d which was the lying Sense, Feeling, or Seeing?” Berkeley frequently reviewed the teachings of the philosopher Heraclitus, who “used to call…eyesight a lying sense”.³⁴⁴

The 13-year-old Daniel thought objects looked “extremely large”.³³⁶ Daniel’s interlocutor found him:

“never being able to imagine any Lines beyond the Bounds he saw; the Room he was in he said, he knew to be but Part of the House, yet he could not conceive that the whole House could look bigger.”³³⁶

Who asked Daniel at his home whether he could imagine lines extending beyond the bounds he saw? Here is Berkeley writing about mathematics:

“…the Mind finds no difficulty in conceiving them [mathematical expressions] to be continued beyond any assignable Bounds.”³⁴⁵

Elsewhere, Berkeley wrote:

“Mathematicians…do not conceive or imagine Lines or Surfaces less than what are perceivable to the Sense.”³⁴⁶

Daniel’s preoperative perception of colors is described in the 1728 report as only producing “faint Ideas” in his mind. Berkeley, who viewed real objects as only existing in the mind, repeatedly described ideas as being faint.^343,346,347 In 1733, Berkeley claimed that his theories about perceptions after sudden acquisition of vision were “not a little confirmed” by the 1728 report.³⁴⁰

We actually learn more about the clinical course not from the 1728 report, but from Kennedy, who wrote that “six months after the operation on the last eye” the child “felt something in his Eye, which seemed to him to give a Crack.” The globe was inflamed and painful, with turbid aqueous humor, and “a great Flux of a watery Humour, probably from the Lachrymal Gland”. Kennedy supposed that the clinical picture might have been due to rupture of the crystalline lens,³⁴² though it seems doubtful that any diagnosis can be made definitively.

The accompanying report by Cheselden in the 1728 Transactions concerned the production of “an Incision thro’ the Iris” (iridotomy) in two eyes.³³⁷ This report is written in a completely different style, and there is no reason to doubt Cheselden’s authorship. Cheselden matter-of-factly recounts how he cut the iris in the first person singular (“I”), without mentioning the patients’ emotions.³³⁷

In 1728, Sir Daniel Dolins passed away.³⁰⁸ Also, George Berkeley got married and headed for America, intending to start his Bermuda college.³¹⁸ The 1728 report ultimately became influential when Voltaire publicized it in France, and the report of “Chesselden” continues to be cited liberally in the modern era.

However, the funds for Berkeley’s Bermuda college were never disbursed by the government, and Berkeley returned to London in 1731.³¹⁸ In 1734, he wrote that he no longer attended (Caroline’s) court.³²⁴ It was surgeon John Ranby, rather than Cheselden, who was asked to attend to Queen Caroline when she was dying from a hernia.³²³

The 1728 report on recovery from congenital blindness must have interested John Eames (1686-1744), a fellow of the Royal Society. Eames was a clergyman who taught the writings of John Locke, as well as anatomy as early as 1617, and helped to lead the Fund Academy which trained dissenting clergymen.³⁴⁸ This academy subsequently placed tutors in Daniel’s home for the remainder of his life. We can assume that Daniel’s continued poor vision was familiar to Eames by 1734, when he edited an abridged version of the Transactions, which included the 1728 report about Daniel.³⁴⁹

Daniel’s first tutor was William Ford,³⁵⁰ who left to become ordained as a minister in December 1730.³⁵¹ Eames replaced Ford with Isaac Toms (1710-1801), who lived with the family for 11 years.³⁴¹ Toms’ memoirs recounted: “From the age of two years, this amiable youth [Daniel] had been almost blind; a circumstance which greatly increased the labour of Mr. Toms, who constantly read to, or conversed with him, eight hours in the day, on the subjects of religion or science.”³⁴¹ Toms did not mention DanieFs eye surgeries, perhaps because they had no significant impact on his vision. It is unlikely that this omission resulted from a lack of interest on the part of Toms, who when young had studied anatomy and considered becoming a surgeon.³⁵⁰

Toms was still living with the family in September 1742 when a friend wrote, sending his regards to Mr. Dolins, and recounting how the oculist John Taylor, a former Cheselden student, was healing the blind in Bath.³⁵²

The cataracts in the Dolins brothers were probably hereditary, but it is unlikely that the precise cause can be determined after 3 centuries. The absence of reports of vision impairment in prior generations is consistent with autosomal recessive inheritance. The premature deaths of the Dolins brothers might have been unrelated to the cataracts. More than 100 genes are known to be associated with nonsyndromic (isolated), inherited congenital cataracts. Pathogenic variants in the crystalline (α, β, and γ) genes are among the most frequently reported. As such, the CRYBA1, CRYBB1, CRYBB3, and CRYAA genes, variants of which can sometimes be manifest in an autosomal recessive fashion, would be leading candidates for being involved within the affected brothers.^353–355

Still, it is tempting to speculate on a single disorder to explain the brothers’ entire clinical picture. Sengers syndrome is an autosomal recessive disorder resulting in cataracts which are typically congenital (as in Abraham’s case), but can occur at a few years of age (as may have occurred in Daniel’s case).³⁵⁶ Sengers syndrome is associated with normal mental development, hypertrophic cardiomyopathy, skeletal myopathy, and lactic acidosis^357,358 The syndrome can result in chronic disability, followed, in its milder form, by death near the third decade of life, as occurred in the Dolins brothers.³⁵⁶ The initial series, and many subsequent cases, have been reported from the Netherlands,^356,359 whence Sir Daniel Dolins’ family hailed.³⁶⁰ In Iceland, which had a population of 244,000 in 1988, six cases were identified, for a prevalence of about 1 in 40,000 in that country³⁶¹

Publication standards regarding outcomes and authorship were very different during this period. As noted above, Cheselden wrote in 1730 that he had performed surgery in several other congenitally blind children, whose observations were similar to those of Daniel.³³⁸ However, English oculist Benedict Duddell recounted the story of a seven-year-old boy whose congenital cataract surgery by Cheselden was not successful.¹⁵¹

Kennedy, who knew Cheselden personally, thought the emphasis on visual physiology in the 1730 edition of Cheselden’s anatomy text, which reprinted the 1728 report about Daniel, was out of character for the surgically-minded Cheselden. Kennedy accused Cheselden of writing it “with the Advice and Assistance of his Friends”.³⁴²

Would Berkeley publish his own writing without putting his name on it? Previous scholarly efforts have used textual analysis to identify essays in the Guardian written by Berkeley either anonymously or under a pseudonym.^362,363 Elsewhere, he signed two works “A Lady”: 1) a work on etiquette which he compiled and edited,³⁶⁴ and, 2) a later pamphlet on patriotism.³⁶⁵ He thought pretending to be woman would lend credence to the works.

We may never know with certainty whether Berkeley wrote the report describing the eye surgery in his colleague’s son. But the report is certainly misleading. Whereas the report suggests that the cataracts might have been congenital, the most unbiased source (Daniel’s tutor) stated the vision loss began at about two years of age. Most importantly, there is no evidence that the surgery helped Daniel to read or perform any visual tasks. Therefore, the report cannot provide evidence regarding the perceptions of one suddenly acquiring vision, despite its centrality to the philosophical debates over the past 3 centuries. Congenital cataract surgery is a flawed model to answer the Molyneux question, because congenital cataract patients often have some (albeit reduced) visual function to begin with, and because dense amblyopia precludes the sudden acquisition of perfect vision with surgery. Berkeley was probably correct that one suddenly gaining vision would have difficulty visually distinguishing objects familiar from a sense of touch, though there is still some debate.^366,367 However, Berkeley’s claim that his theories were proved by the report is inconsistent with the clinical reality that Daniel truly lived.

Daniel Dolins had wanted to purchase a country estate to erect a chapel.³⁴¹ However, his plans did not come to fruition, and he died in July 1743:

“On Tuesday last died Daniel Dolins, Esq…A Gentleman as generally esteem’d as known; who, with all that was obliging had good Sense and Furniture of Mind…He was an ardent Lover of Truth, and under peculiar Disadvantages, arising from a Defect of Sight, search’d diligently for it…He died after a long illness…but not till he had said, a little before Death, My Sufferings are nothing, and I am happy.”³⁶⁸

Traditional Surgeons at Hospitals (1720s-1800).

As noted above, families and mountebanks were the major sources of ophthalmic instruction in the British Isles during the 17^th century. Despite the initial early efforts to couch cataracts by traditional surgeons in Oxford and Glasgow, there is little evidence that the practice became sustained among this group during the 17^th century. We do not find evidence of cataract surgery taught at hospitals staffed by traditional surgeons until the 18^th century.

It is true that when surgeon Alexander Read (1586-1641) lectured at “Chirurgeans Hall” in London from 1632-4, he reviewed “the couching of a cataract” and “the most exquisite manner of couching of such as are curable”.³⁶⁹ Read noted in 1638 of the aqueous humor that “…in man may be let out (as we see in the cowching of a cataract) without any great hurt to the sight. In a chicken if it be let out by pricking, it will bee repaired in fifteene dares.”³⁷⁰

Joseph Binns (d. 1664) performed his apprenticeship with Joseph Fenton, and was made free of the Company of Barber Surgeons in 1637.³⁷¹ Binns was a surgeon at St. Bartholomew’s Hospital from 1647 until his death.³⁷¹ His casebooks describe 671 patients, and do not mention cataract couching, though he did treat 3 corneal ulcers, one with blistering, purging, cupping, and medicines dropped in the eye.³⁷¹

Likewise, the observations of James Molins, a student at St. Thomas’s Hospital from 1674 to 1677, do not mention cataract couching.³⁷² Interestingly, the hospital was named after Saint Thomas Becket, source of the miraculous vision restoration in the Earl of Surrey.

William Briggs was sometimes called an oculist due to his interest in medical treatments of the eyes. Still, the mainstream physicians viewed the itinerants as the experts in eye surgery. As noted above, Briggs observed Read perform a congenital cataract surgery in 1697.

In the 1720s and 1730s, evidence emerges of cataract couching in hospitals: William Cheselden at St. Thomas’s Hospital, Samuel Palmer and John Freke at St. Bartholomew’s Hospital, John Ranby at St. George’s Hospital, Samuel Sharp at Guy’s Hospital, and Cheselden and Thomas Hope at the Westminster Infirmary (Table 7).^{323,349,373–379}

Even if many of the hospital-based or hospital-trained general surgeons did not have the surgical volume or skill of the specialist itinerant oculists, the entry of eye surgery into the hospitals did have important influences on the overall development of ophthalmology. Cataract couching became the domain of a significant fraction of general surgeons. The surgeries were performed indoors, rather than on an outdoor stage. The general surgeons typically were attached to a given hospital, and would be available to manage postoperative complications even months or years later. An apprentice bound to one surgeon was free to observe surgeries performed by other attendings at the hospital. In fact, apprentices at St. Thomas’s Hospital or Guy’s Hospital could attend surgeries at either hospital. Moreover, one attending might assist a fellow attending surgeon. While some of the larger itinerant productions also had served as educational institutions of a sort, they were unlikely to outlast the dominant personality. In contrast, the hospitals had institutional memory which would outlast any given surgeon, and thereby provided continuity.

Some prominent patients were couched by traditional surgeons in this era. In 1752, Samuel Sharp of Guy’s Hospital attempted to couch the cataract of the 46-year-old poet Anna Williams (1706-1783), but found that it was too soft.³⁸⁰ On November 3, 1752, composer “George-Frederick Handel, Esq; was couch’d by William Bromfield, Esq; Surgeon to her Royal Highness the Princess of Wales”.³⁸¹

Still, the traditional surgeons continued to look to itinerant oculists as teachers. Surgeon Richard Kay (1716-1751) observed John Taylor perform eye surgeries on a visit to Manchester in July 1742 prior to training at Guy’s Hospital.³⁸² William Hey of Leeds had trained with London surgeons, but he never performed cataract surgery himself until 1768, the same year Hilmer visited his city and demonstrated a small round couching needle to him.³⁸³ Similarly, surgeon James Lucas of Leeds observed Hilmer perform couching in 1769.³⁸⁴

Cataract Extraction (by 1753).

It was in the latter half of the 18^th century that planned cataract extraction was performed by some surgeons. Before cataract extraction could be routinely practiced, surgeons had to figure out that a cataract was an opacity of the crystalline lens. Since antiquity, it had been believed that the cataract was an opacity anterior to the lens. The correct understanding became widely known in the first half of the 18^th century in Paris. Some British students, such as Benedict Duddell, traveled to Paris to study with John Thomas Woolhouse, who did admit after 1715 that the structure being couched was an opaque crystalline lens, though he insisted on calling the diseased lens a “glaucoma”.¹¹⁰

In about 1713, Mr. Cawood couched a Dubliner with partial success, and when the patient died in 1722, Thomas Molyneux dissected the eye, and found neither a membrane, nor the crystalline lens, and surmised that the lens had been absorbed³⁸⁵

Surgical student Charles Oxley recorded in May 1725 that William Cheselden at St. Thomas’s Hospital had dissected a cadaver with a cataract to confirm that the entire crystalline lens was opaque.³⁷⁴ In his treatise of 1727, John Taylor claimed to have discovered that the cataract was an opacity of the lens, but credited Cheselden with laying the groundwork for this discovery:

“If I have in any Degree made it probable, that the Opacity of the Crystalline Humor is the True Cataract, I must here own that I had the First Hint of it from You.”²³⁵

In the early 1700s, when the lens happened to sublux into the anterior chamber during couching, it would be removed, by surgeons such as John Thomas Woolhouse in Paris and John Taylor of England.^110,243,386 Planned cataract extraction was presented in Paris by Jacques David in 1752.²⁴³ Daviel made a small inferior corneal limbal incision, which was then extended using right and left curved scissors. He also disrupted the lens capsule, to extract the lens without its capsule (extracapsular extraction).

After David’s presentation of planned cataract extraction, Samuel Sharp was an early adopter. However, Sharp made several modifications in one patient on April 7, 1753, and presented his experience to the Royal Society of London 5 days later.^387,388 First, he made the inferior corneal incision with a single knife.^387–389 Second, Sharp advocated removing the lens intact in its capsule (intracapsular extraction), with the lens expelled by pressure: “you press gently with your thumb against the inferior part of the globe of the eye, in order to expel the cataract”.³⁸⁷ If pressure did not suffice, Sharp impaled the lens with his knife to remove the lens still in its capsule.³⁸⁹

Although his surgical textbook became quite popular, it is not clear that any high-volume surgeons or oculists had success with the intracapsular technique. In fact, after 1758, Sharp preferred couching, and suspended judgment on cataract extraction until more was known.^390–393 The closest we see to an oculist adopting intracapsular extraction might be Frederick Bischoff, who noted that one could apply gentle pressure, but if this failed, a capsulorhexis was performed.³⁹⁴

In fact, few generalist surgeons trained in the British Isles had success with cataract extraction. Thomas Young (d. 1783) of the Royal Infirmary at Edinburgh published 6 cataract extractions using an extracapsular technique, apparently with success.³⁹⁵ However, within a few months, the sight was lost and Young soured on extraction in general.³⁹⁶

Joseph Warner (1717-1801) of London was familiar with both couching and extraction by 1754,³⁹⁷ but in 1760 wrote “…I am inclined to believe that the Operation of Couching will still prevail.”³⁹⁸

By the end of the century, only about half the cataract surgeons in the British Isles were known to perform cataract extraction (Figure 2). This is slightly higher than the one-third known to perform cataract extraction in the United States.³⁹

As in the heyday of couching, the English surgeons looked to foreign itinerant oculists as authorities regarding cataract surgery. In 1785, Benjamin Bell of Edinburgh favored couching, and though he was familiar with patients who had had cataract extraction, it was not totally clear that he had personally performed the procedure.³⁹⁶ However, in 1787, the ophthalmic sections of his treatise had been heavily edited to reflect what he had learned from assisting Jean Francois Pellier in cataract extractions³⁹⁹

In 1768, Sharp and Thomas Gataker observed Baron Wenzel perform bilateral cataract extractions on a woman in London.⁴⁰⁰ In 1775, surgeon George Chandler of London recounted that after cutting the cornea, the Baron Wenzel would wait for the eye to finish rolling about before performing the capsulorhexis.⁴⁰¹

Philip Anthony Miller of Germany settled in Edinburgh by 1771 and introduced numerous ophthalmic tools adopted locally: an eyelid speculum used by Benjamin Bell,³⁹⁶ a knife with a 90-degree turn which permitted either eye to be operated with the right hand, touted by Jonathan Wathen.⁴⁰² George Borthwick of Edinburgh used both these tools.⁴⁰³

In 1769, John Goldwyer of Sarum (and later Salisbury) advertised that in London he had learned “the improved Operation on the Eye, for the Cataract, after the Method of Wensel and Hilmer”.⁴⁰⁴

Although the traditional British surgeons dabbled with cataract extraction, oculists who traveled from the Continent continued to be the highest volume performers of the technique—Baron Wenzel, Pellier, Miller, Frederick William Jericho.

The first group of high-volume English oculists to master cataract extraction were the trio of Jonathan Wathen (c. 1728-1808), his student and subsequent partner James Ware (1756-1815), and Wathen’s step-grandson Jonathan Wathen (Phipps) Waller (1769-1853).¹²⁹ They performed extracapsular cataract extraction. As public evidence of interest in cataract surgery appears for both Wathen and Ware at about the same time, it is unclear whether the teacher or student was the first to become interested in ophthalmology. Perhaps, their relationship was forged through this mutual interest. Ware, the student, actually was the first to write an ophthalmic treatise—his Remarks on the Ophthalmy, Psorophthalmy and Purulent Eye of 1780, which indicated at least some practical familiarity with cataract extraction.⁴⁰⁵ The mentor Wathen followed suit in 1785 with A dissertation on the theory and cure of the cataract: in which the practice of extraction is supported.⁴⁰² Wathen had learned cataract extraction by experiments in animals, and recommended the technique not only by his own experience over many years, “but also by that of some others, who have practiced it in this country, in the course of the last twenty years.”⁴⁰² This time frame corresponds with the arrival of Baron Wenzel to England in 1764. The junior members of the trio were less shy about explicitly acknowledging Wenzel as an important authority. In 1791, as his partnership with Wathen ended, Ware translated the Traité de la cataracte of Wenzel’s son, which summarized the Baron’s techniques.⁴⁰⁰ In addition, Ware indicated that “…he [Ware] has derived the most useful and important information, from the opportunities with which he was favoured of seeing the Baron operate, and from the remarks occasionally made by the Baron, on the different parts of his process.”⁴⁰⁰ Likewise, in 1792, Phipps wrote that couching “has within these twenty years given place in this country to that of extraction, introduced by the late Baron de Wensel”.⁴⁰⁶

In 1804, Phipps founded and served as the Consulting and Operating Surgeon of the Royal Infirmary for the Diseases of the Eye in London, the first eye infirmary in the British Isles, and a surviving institution until 1872.⁴⁰⁷

The competing surgeons John Cunningham Saunders and John Richard Farre, who in 1805 opened the London Infirmary for Curing Diseases of the Eye, which subsequently became the Moorfields Eye Hospital, reserved extraction for rare cases with exceptionally hard lenses. They generally preferred discission (division) of the lens. Farre explained “…it is too well known how very limited the success of extraction in general practice has proved…”⁴⁰⁸

Some cataract innovations were proposed in the British Isles. In 1785, Benjamin Bell of Edinburgh proposed making the corneal incision for cataract extraction in the superior (rather than inferior) cornea. He was not aware of anyone doing this in humans, and so he experimented with this technique in animals.³⁹⁶ When performing bilateral surgery, Wathen made the corneal incisions for both left and right eyes before actually extracting either lens.⁴⁰²

Joseph Higgs, surgeon of Birmingham, proposed to John Theophilus Desaguliers (d. 1744) that couching of the lens might treat myopia.⁴⁰⁹ Higgs published the idea in 1755,⁴⁰⁹ but their conversation probably took place when Higgs was training in London in the mid-1720s.