(a) John Cunningham Saunders’ restraint for surgery  in 1811. “The child must now be placed on a table parallel with a window, from which the eye, that is to be submitted to the operation, is farthest. Four assistants and in stouter children five, are required to confine the patient…. The surgeon seated on a high chair behind the patient proceeds in the following manner……” (Figure courtesy of Gillian Lee FMAA). (b) Restraint was still practised in the mid-1970s. This figure shows how an infant was restrained after cataract surgery by having each limb tied to the four corners of the cot. Such restraint became less frequent for normal cases once it was realised how well infants responded to comfort, were allowed early breast or bottle feeding, cuddling and being held by their parent (Figure courtesy of Gillian Lee FMAA)
1.2 The Post-anaesthetic and Antisepsis Era
Joseph Priestley and Thomas Beddoes, members of the philosophical-scientific eighteenth century Lunar Society, and Humphrey Davy, discovered the anaesthetic properties of Nitrous Oxide but were not involved in its later use in surgery. Chloroform and Ether were used for years but the former was cardio- and hepato-toxic and the latter a volatile explosive. Modern anaesthetics for children have totally revolutionised the management of surgical ophthalmology in children of all ages.
Alexander Gordon (Scotland), Louis Pasteur (France), Oliver Wendell Holmes (USA), Ignaz Semmelweiss (Hungary) and Charles White (England) all pointed towards the germ theory of infection: Joseph Lister proved it with the effects of Carbolic Acid and layered dressings for surgery, opening the door to a previously unbelievably low infection rate for all surgery.
The discovery of sulphonamides by Gerhardt Domagk and of Penicillin by Alexander Fleming, Ernst Chain and Howard Florey, revolutionised management of eye diseases in children: care is needed to ensure we do not return to before that era!
1.3 Surgical Techniques
Early couching would likely have been helped by the skills of the Arab metalworkers but the instruments were necessarily simple. In Europe, the nineteenth century saw the manufacture of instruments to previously unreachable fineness and quality (Figs. 1.2, 1.3, 1.4, and 1.5), driven by the industrial skills of the instrument makers, metallurgical advances and the obsessive-compulsive drive of the surgeons.
Innumerable fine instruments were made by skilled instrument makers . Instruments such as this needle for “dissolution” of soft cataract was one half the size of a displacement (couching) needle and introduced through the sclera into the anterior chamber, the lens capsule is lacerated, the cortex cut into pieces (discission). Mackenzie practised this on infants
By the mid eighteenth century, under the influence of watch-and clock-makers many of whom were highly skilled Huguenots fleeing France in the late seventeenth century, very fine quality instruments were made. Mackenzie  attributed the intra-ocular scissors on the right to Wilde of Dublin: they were interchangeable with a forceps. On the left there are various hooks for forming an artificial pupil by iridectomy
A speculum and needles used for cataract surgery by discission , the lower being larger and the upper two being the smaller; The Fig. 1.3 in this illustration shows the lateral view. The needles tapered, the tips sharp on both edges and were used to “cut up the texture of the lens and its capsule”- discission
Instruments from Guthrie’s 1819 book . 1–4 on the left, Langenbeck’s “Coreonceon” in ‘exploded’ view. 5. The Iriankistron of Dr Schlagintweit. 6. Dr Reisinger’s double-hooked forceps. 7. Dr Embden’s Raphiankistron. 8. Gräefe’s Coreoncion. 9. Iris scalpel, sharp on one side only
Antyllus, a contemporary of the Greek, Galen, in the Aesculapium in Pergamum removed cataracts by couching . This was attributed to him by Rhazes (854 CE–925 CE), the Persian polymath and physician. Couching probably started long before then in South Asia and, possibly, earlier in Egypt and it was many centuries before Jaques Daviel developed the art of surgical removal of cataracts in the eighteenth century.
Couching was performed by inserting a sharp and often fairly broad needle through the limbus anterior to the iris or through the sclera posterior to the iris, across the anterior surface of the lens and it is then directed backwards, rupturing the superior zonules and thrusting it down below the inferior pupil margin where, hopefully, it remained. If the lens floated up on partial withdrawal, the procedure was repeated before the needle was withdrawn. Alternatively, later, a knife incision was made and a blunt, flattish needle used to dislocate the lens downward. It is likely that couching was performed on children with cataracts but the likely high complication rate from the strength of the juvenile zonule was not recorded.
Percival Pott  (1714–1788) the surgeon to St Bartholomew’s hospital in London in 1775 (a year before the United States was founded), however, had strong opinions on couching.
(the practice of the day was to use an f instead of a non-pluralizing s.)
P712: “The objections, which are made againft the operation of couching, at leaft thofe which have any femblance of truth, or force, are reducible to four:
The firft is, that if the cataract be perfectly soft, the operation will not be fuccefsful, from the impoffibility of accomplifhing the propofed end of it.
The fecond is, that if it be the mixed kind, partly soft, and partly hard, it will alfo most probably fail of fuccefs, not only from the impossibility of depreffing the fofter parts, but alfo becaufe the more firm ones will either elude the point of the needle, and remaining in the posterior chamber, still form a cataract; or getting through the pupil into the anterior chamber, will there bring on pain and inflammation, and induce a neceffity of dividing the cornea for their difcharge.
The third is, that if the cataract is of the firm, solid kind…….it will remain undiffolved, folid and opake……yet prove fome hindrance to perfect vision.
The fourth objection………the operation will neceffarily occasion fuch violation, and derangement of the internal parts of the eye, as muft cause confiderable mischief”.
Benjamin Gibson , the Manchester ophthalmologist, attributed Cheselden as, in about 1728, having used a couching needle (sharp on one side only) mostly on cases which were couched and then the pupil had closed. In infants he just used a couching needle, or an instrument resembling it…..“it is more certain to remove the disease in these young subjects.”
Pott  invented the operation, discission, which was to remain popular for decades. His description was clear: P 718: “……I have fometimes, when I have found the cataract to be of the mixed kind, not attempted depreffion: but have contented myfelf with a free laceration of the capfula; and having turned the needle round and round between my finger and thumb, within the body of the cryftalline, have left all the parts within their natural fituation: in which cafes I have hardly ever known them fail of diffolving fo entirely, as not to leave the fmalleft veftige of a cataract.”
Benjamin Travers (1783–1858), the ophthalmologist to St Thomas’ Hospital in London, in a hand written book of lectures felt that Pott’s invention was poorly recognised: “Mr Potts’ operation of breaking up the substance of the cataract of the cataract by introducing a needle and turning it about in the lens did not excite the attention, which is merited, perhaps it would not have been prosecuted further, had it not been for Mr Saunders who first watched the progress of the operation on a shoemaker who had accidentally wounded his lens by an awl. It was he who first devised and applied this operation to Congenital Cataract as also the flocculent. He performed on infants of all ages with the most complete success, the result was the restoration of very good vision……… I cannot help considering it, as one of the greatest discoveries in modern surgery. Mr Saunders intended to ascertain its result in adults but was prevented by death. I have followed up his intentions but must own it has proved inadequate to my expectations”.
Discission was still practised in the twentieth century. Zeigler , an ophthalmologist in Philadelphia, invented a sickle- shaped knife-needle (Fig. 1.6). “Discission is a cutting through of lens in toto rather than an incision of the anterior capsule or cutting up the lens into fragments.” “Boldness in incision is a virtue and conversely, timidity a vice!” “Do not stir up the cortex or vitreous but saw in a straight line. Incision of the vitreous is, in itself, not dangerous if you make a clean cut……”. The operation had few other advocates but the knife found many uses elsewhere, particularly in the cutting of fibrous membranes and anomalies in congenital cataracts, PHPV etc.
Nutt, in 1957  was still practising discission. “….first to make an adequate incision in the (anterior) lens capsule and second to disintegrate the lens substance as much as possible without damaging the posterior lens capsule or vitreous”.
Henry Smith, an Indian Army Medical Service Colonel in the early twentieth century, regarded it safe to operate on infants from 6 months to a year . He practised needling, a form of discission, for infant cataracts except he preferred a fine Graefe’s knife, sharp only for 3/16ths of an inch (4.8 mm) at the tip, blunted elsewhere. He found Daviel’s procedure  the most satisfactory in older children. He performed a capsulectomy with iris forceps at the same sitting. “If a bead of vitreous does escape, it should be snipped off with the scissors- it is of no consequence”.
In about 1980, I was one of an international panel of about six ophthalmologists asked to examine a young Royal Prince of a Middle Eastern country who was a combat aircraft pilot. He had been injured in one eye resulting in a cataract and at least 180° angle recession. All except one of the panel agreed that a simple lens aspiration accompanied or followed by an intra-ocular lens was the safest way forward. The panellist from the Soviet Union disagreed: discission and when the lens material had absorbed, an IOL: clearly the young man was going to end up with angle obstruction, glaucoma et sequitur. By chance, I was passing through 6 months later and was asked to see him. He was aphakic, waiting for his IOL, with 6/6 corrected acuity, normal intraocular pressure and a clear, intact, posterior capsule!
1.6 Daviel’s Operation
Jaques Daviel (1696–1762) , a physician trained in Rouen and Paris, invented an operation in 1747, it is said, after an unsuccessful first couching on a man blind in both eyes from cataract. Before operating the second eye, he developed the technique on human cadaver and animal eyes in which the eye was opened with a broad keratome and enlarged with knife and scissors . The cataract material was removed usually by a spoon-spatula: it was the first extracapsular extraction but it employed a large incision, unsutured and must have had a high complication rate, especially if applied to children.
1.7 Linear Extraction
Gibson  couched infant cataracts “……and I have been in the habit of operating, for ten years, upon subjects of all ages; although I prefer an infant, from half a year, to a year or two old”. But he found that with soft cataract, which was difficult to couch, he would convert to an anterior capsulotomy and discission “to break down the substance of the cataract by passing the couching needle cautiously through it, in different directions, that the aqueous humour may more readily act upon it, and reduce it to a pulpy state”. Two or three weeks later he went back, opened the eye through a corneal incision using a large cornea knife. Aqueous and some lens material would spontaneously evacuate: that left behind was removed with a curette.