Historiographical context and source considerations

Before examining the specific transformations in cataract surgery, it is necessary to situate this research within the broader historiography of early modern medical practices and to critically assess the nature of our primary sources. Many aspects of these developments remain imperfectly understood, and the surviving sources provide only a partial view of how cataract surgery was actually practised. Traditionally, the history of surgery in France has been framed around a triumphant and somewhat linear narrative of ‘emancipation’ from medicine, culminating in the establishment of the Académie Royale de Chirurgie in 1731 and the royal decree of 1743 that definitively separated surgeons from the barbers.Footnote ¹⁴

However, recent historiography has fundamentally revised this view. Scholars such as Toby Gelfand, Laurence Brockliss, and Colin Jones have demonstrated that the relationship between surgery, medicine, and empiricism was far more complex, pluralistic, and fluid than older narratives suggest.Footnote ¹⁵ The ‘emancipation’ of surgery was not a sudden scientific awakening, but rather a protracted socio-political project orchestrated by an elite group of practitioners seeking to elevate their craft to the status of a liberal art. Furthermore, this process was highly uneven over time. While Paris became the epicentre of a state-sponsored campaign to consolidate surgical authority, provincial realities differed significantly. In Montpellier, for instance, the integration of medical and surgical instruction followed a distinct and often more collaborative trajectory, possessing a university tradition that integrated surgical theory long before the Parisian reforms.Footnote ¹⁶ Conversely, in the rural parts of France, the decrees of Parisian elites meant very little; itinerant healers, bone-setters, and traveling oculists remained the primary providers of surgical care well into the nineteenth century.Footnote ¹⁷ Recognizing this change over time – from a highly fragmented, localized medical marketplace in the sixteenth century to an increasingly standardized, state-regulated profession by the late eighteenth century – is crucial for understanding how and why specific cataract techniques were championed or discarded.

This complex professional landscape also necessitates a critical approach to our primary sources. The treatises, medical dictionary entries, and memoirs submitted to the Royal Academies utilized in this study cannot be taken entirely at face value. These texts are inherently normative and polemical. They were authored almost exclusively by elite, and increasingly urban surgeons who had a vested professional interest in monopolizing legitimate medical knowledge and marginalizing their competitors.Footnote ¹⁸ Consequently, these sources overwhelmingly privilege the perspective of the learned institutional practitioner. When these texts describe the traditional practice of couching as ‘crude’ or routinely characterize itinerant oculists as dangerous ‘quacks’ or ‘charlatans’, they are engaging in a rhetoric of professional boundary-work. Because the itinerant empirics who predominantly performed couching left behind very few written records, their actual empirical skills, practical successes, and voices are largely lost to history. Therefore, when eighteenth-century institutional surgeons enthusiastically heralded the ‘superiority’ of extraction over couching, we must read their claims not merely as objective clinical evidence, but as strategic assertions designed to align surgical practice with the broader ambitions of a centralizing, professionalizing discipline.

The cataract and its treatment in early modern France

During the early modern age in France, the aetiology and treatment of cataracts were often situated within the framework of Galenic medicine. Cataracts were considered the consequence of alterations to the healthy temperaments of the bodily organsFootnote ¹⁹ caused either by overly heavy foods or by exposure to a too cold and humid climate. Both conditions, it was believed, would cause the production of vapours that, from the stomach, would rise to the head. From there, these vapours would descend downwards and freeze upon coming into contact with the eyes, forming an opaque membrane clouding the vision.Footnote ²⁰ Medical treatises of the time indicated several remedies to cure cataracts or stop their progression, such as a special diet, vesication, bloodletting, and purgatives. A surgical operation was taken into consideration only if these procedures were ineffective. Caution and scepticism around this intervention dominated among physicians. In the context of Galenic medicine, removing a part of the body was seen as a radical and irreversible alteration of physical integrity and, therefore, only contemplated as a last resort.Footnote ²¹ When cataract surgery was deemed indispensable, it had to follow a rigorous protocol. First of all, a favourable season had to be chosen.Footnote ²² The patient had to follow a particular diet and take purgatives the day before the procedure. The actual operation had to be performed as follows: ‘The operator sits in front of the patient, makes the eye turn towards the nose, introduces the needle through the middle of the conjunctiva, pushes it to the middle of the pupil while slightly folding the cataract, then transposes it downwards and holds it with the needle while one could recite the Pater or the Miserere three times’.Footnote ²³ If the cataract raised again after being couched, it had to be taken down with the needle as many times as necessary. The prognosis of this intervention was uncertain: ‘Do not be too confident in matters of cataracts’, notes Guy de Chauliac, ‘for … the operation with the needle is quite disappointing, even when it is well demonstrated’.Footnote ²⁴

During the early decades of the seventeenth century, qualified surgeons rarely performed cataract surgery. Contemporary sources suggest that the operation was most commonly carried out by itinerant practitioners – often referred to as ‘oculists’ – who specialised in the treatment of eye diseases. Over the course of the century, however, the situation appears to have evolved. Learned surgeons increasingly took an interest in ocular operations, and by the later seventeenth century, cataract couching had begun to appear more frequently in surgical treatises and academic discussions. Although the precise chronology of this shift remains difficult to reconstruct, it suggests that a procedure once associated primarily with itinerant specialists gradually entered the repertoire of learned surgery.Footnote ²⁵ Oculists travelled from town to town, and frequently from country to country, offering their services, which included surgery but also selling various remedies for weak or sick eyes, such as drops and ointments with allegedly beneficial if not miraculous properties. To attract their clientele, oculists adopted various types of promotional practices. For example, they hired people who praised their skills in public places, distributed flyers indicating the number of patients treated and the successes achieved, and published celebratory articles in the local press. These itinerant specialists frequently built a true mythology around themselves, boasting fictitious titles and exaggerating their successes. Oculists had a poor reputation among ‘legitimate’ surgeons, who accused them of quackery. Another reason surgeons refrained from performing cataract surgery was related to the unpredictable nature of its prognosis. One frequently cited concern was the risk of damaging the crystalline lens, which many early modern authors regarded as the principal seat of vision. This argument became particularly prominent the seventeenth century, when anatomical investigations increasingly placed the crystalline lens further forward in the eye than had previously been assumed. Authors such as Fabrizi d’Acquapendente, Johannes Kepler, Christoph Scheiner, and Vopiscus Plempius contributed to this shift in anatomical understanding, which in turn heightened anxiety about surgical injury to the lens. It should be noted, however, that these views were far from universally shared, and tracing the extent to which they shaped practical attitudes towards cataract couching remains difficult given the limited surviving evidence.Footnote ²⁶

Despite these reservations, cataract operations attracted the attention of learned surgical authors and institutional practitioners. Treatises written by trained surgeons – such as Ambroise Paré, Fabrizi d’Acquapendente, and their successors – regularly included discussions of cataracts and their treatment. These texts did not necessarily imply that such operations were commonly performed by academically trained surgeons, but they demonstrate that the procedure formed part of the theoretical corpus of learned surgery. Surgical treatises published in the early modern era dedicated several pages and sometimes entire chapters to cataracts and their treatment.Footnote ²⁷ These works described the location, nature, and causes of this ailment almost identically. Its medical and surgical treatment showed few variations compared to Guy de Chauliac’s Great Surgery throughout the modern era. Opinions on the prognosis of the operation were most often negative. As Fabrizi d’Acquapendente noted: ‘Through this operation … vision is weakened, or entirely blinded, and often in the other healthy eye by sympathy because the lens is cut in two by the needle … so it should not be surprising that these surgeons often have poor success in this operation’.Footnote ²⁸ The interest in this operation on the part of surgeons was related to the presence of a particular group of ‘experts’ approved by the Guild of Surgeons – the Confraternity of Saint Cosmas and Saint Damian – who worked under the direct supervision of the Masters of the Art. It was indeed possible for a healer treating specific pathologies to receive an official title from the Confraternity. After being examined by its members and by the city’s provost, an ‘expert’ was authorised to perform specific treatments (such as cataract surgery, lithotomy, or tooth extraction) on the condition of respecting the rules of the Art and to act in compliance with the Statutes of the Confraternity. Experts were also required to dress ‘decently, without gaudiness’ and not to ‘announce their talents in the streets, public squares, markets, fairs, either verbally or through posters’, in short, to do ‘nothing that resembles a Charlatan’.Footnote ²⁹

At the beginning of the eighteenth century in France, cataract operation was hence fixed in an official protocol based on canonical texts and approved by members of the Guild of Surgeons. Its practice was controlled and monitored. This procedure can thus be classified as a ‘closed’ technique: it was not subject to variations or experiments. Its stability and normate nature corresponded to the characteristics of surgery of the time.Footnote ³⁰

The first ‘end’ of cataract couching

During the first decades of the eighteenth century, cataract couching became the subject of renewed interest by surgeons and physicians across France and Europe following a debate concerning the seat of the cataract. Between 1705 and 1709, the Royal Academy of Sciences of Paris examined the hypothesis that cataracts were located in the crystalline lens rather than in the aqueous humour, as was previously thought. The subject was brought to the academy’s attention by a memoir published in 1705 and signed by Michel Brisseau, a doctor and professor at the University of Douai,Footnote ³¹ and by a treatise published the following year by the surgeon Antoine Maître-Jan.Footnote ³² In these two texts, both authors declared – very similarly, although independently from each other – that the theory formulated by the Ancients, which posited that a cataract was a membrane located in the aqueous humour, was erroneous. They asserted, on the contrary, that the lens was actually the part of the eye affected by this disease. Based on dissections of corpses and experiments conducted on animals, Brisseau and Maître-Jan, affirmed that it was the crystalline lens that was displaced during the operation.Footnote ³³

The hypothesis that the cataract was a pathology of the crystalline lens was not original. It had been formulated during the sixteenth and seventeenth centuries by a number of surgeons and physicians, some of whom also relied on the results of dissections.Footnote ³⁴ However, these simple points of observation did not cross the boundaries of scholarly works and did not lead to any controversies.Footnote ³⁵ In contrast, Brisseau’s and Maître-Jan’s works directly challenged the authority of the Ancients: whose texts were declared erroneous and whose mistakes they claimed to correct on the basis of observation and experience. Presented within the confines of a conservative institution, their writings originated a series of arguments and counterarguments in favour of or against their theory. Brisseau’s and Maître-Jan’s hypothesis was in line with the retinal theory, according to which the retina rather than the crystalline lens was the part of the eye responsible for visual sensation. Proposed by Johannes Kepler in 1604, this theory had progressively gained popularity and support among physicians and surgeons throughout the seventeenth century, via authors such as Vopiscus Fortunatus Plempius and Thomas Bartholin.Footnote ³⁶ By the beginning of the eighteenth century, the retinal theory had become widely accepted among the scientific and medical communities. This explains why, at the centre of the debate sparked by Maître-Jan’s and Brisseau’s work were not the new theory’s implications for the physiology of vision more broadly, but almost exclusively for cataract surgery. In their work, the authors stressed the fact that, as the crystalline lens was not essential to visual perception, there was no reason to fear blinding a patient as a result of an accidental injury to the crystalline lens. This possibility generated renewed optimism around this procedure. In several treatises and papers published afterwards, surgeons declared now that cataract surgery would carry few risks and yield positive results, provided it was performed according to the rules of the Art.Footnote ³⁷ The authors also expressed the necessity to modify the instruments used to perform this operation, as the needles previously employed were not designed to lower the crystalline lens, but merely to clear a membrane. Several surgeons then suggested using stronger and sharper needles or employing new instruments of their own invention.Footnote ³⁸

The controversy surrounding the seat of the cataract was not yet overFootnote ³⁹ when another paper, this time presented before the Royal Academy of Surgery, brought a new question related to cataract surgery to the attention of the community of surgeons. In 1753, surgeon Jacques Daviel presented a memoir in which he proposed lens extraction as a method for cataract surgery instead of couching. In his manuscript, he suggested making an incision in the cornea and extracting the lens from the eye when operating on a cataract patient. He described this procedure as significantly superior to couching, particularly because it eliminated the risk of the lens rising after being lowered, the main disadvantage associated with the traditional technique.Footnote ⁴⁰ Extraction, Daviel admitted, also carried some risks, but not as serious as to compromise its chances of success. He declared that he had performed the new procedure dozens of times, almost always with excellent results. Immediately, the Academy assigned one of its members the task of verifying Daviel’s claims by examining some of the patients operated on by the new procedure.Footnote ⁴¹ Several prominent surgeons also hurried to comment on this memoir, expressing their approval or reservations. In general, the possibility of performing cataract extraction was seen as a positive and exciting new perspective. Shortly after the presentation of Daviel’s memoir, numerous surgeons proposed adjustments and modifications to the procedure, which they saw as susceptible to improvement.Footnote ⁴²

Multiple reasons can explain the sudden and keen interest in replacing the couching procedure with extraction. First was the prospect of achieving definitive results in cataract surgery. The danger of the rising lens was indeed one of the aspects of this intervention that originally caused scepticism among surgeons. Evaluated against the standards of modern ophthalmic surgery, Daviel’s procedure was not only extremely dangerous, but it would have been almost impossible to achieve a satisfactory result. This procedure involved operating on a patient’s eye with non-sterile tools and in a non-sterile environment; it encompassed making a massive – ten-millimetres-large – incision in the corneaFootnote ⁴³ that was subsequently enlarged to allow access to the lens. Several instruments were then used to extract the lens, increasing the risk of injuring other parts of the eye. Compared to couching, this procedure was longer, more invasive, and more painful. No sutures were performed, leaving the corneal flaps open to the risk of infection. It is, however, necessary to recall that the criteria defining the success of this surgical operation in the eighteenth century were very different from those of contemporary medicine. A cataract operation was considered successful if, first of all, the patient did not lose the operated eye; second, if after the operation the opaque lens was stably cleared from the front of the pupil, allowing the patient to regain some of their visual capacity. Extraction seemed to at least guarantee the second condition. The patients’ follow-up – when it occurred – was very brief, which did not allow for the intervention’s evolution to be observed adequately. An apparently successful surgery could result in the patient losing their operated eye a few weeks or months later, but the operator would not be privy to such developments. As for the visual outcome, once again, the criteria for satisfaction were very different from those of contemporary medicine. Eighteenth-century surgeons described, for example, the case of a man who, after having both eyes operated on, could read large letters with one eye and see well enough to walk without danger with the other as a complete success.Footnote ⁴⁴ It is, therefore, highly possible that the surgical successes proclaimed by Daviel corresponded to patients whose eyes were not immediately damaged by the operation and who had some visual perception for a while.

Another factor to consider is the resolute and almost triumphant way Daviel presented the technique of extraction. While it had already been practised in the past and discussed in surgical works,Footnote ⁴⁵ Daviel presented it as a completely new procedure, of which he claimed to be the inventor, and presented it as an innovative and almost miraculous solution. Though a certified surgeon, Daviel had, throughout his career, learned to use the typical promotional practices of itinerant oculists, particularly self-promotion through the press, and to master the art of communicating effectively to intellectual elites as well as to the uneducated public.Footnote ⁴⁶ By the time he presented his memoir, he had acquired a high reputation as a healer, first while serving in the King’s galleys and then in Marseille during the 1722 plague epidemic.Footnote ⁴⁷ Daviel showed a remarkable talent for exploiting his notoriety and building a reputation for himself as an infallible surgeon. In the months and years following the publication of his memoir, he undertook several journeys across Europe and performed cataract surgeries on numerous men and women of the high aristocracy, which allowed him to amplify and consolidate his reputation. These efforts proved effective, as evidenced by the numerous titles and awards he collected in the following years.Footnote ⁴⁸

Daviel’s memoir placed cataract surgery at the centre of the scholarly debate at a time when considerable transformations were taking place in the professional field of surgery. During the eighteenth century, the status of the surgeon gained dignity and prestige. A rapprochement between medicine and surgery was taking place, marked by the introduction of rigorous and institutionally supervised training for surgeons.Footnote ⁴⁹ These transformations were occurring throughout Europe with different characteristics and timelines. In Italy, for instance, medicine and surgery had lived in proximity since the sixteenth century, notably with the figure of the surgeon-anatomist of the Renaissance. In Germany, on the other hand, a strict distinction between university graduates and barber-surgeons – practitioners with little to no insight into their Art – remained until the third decade of the eighteenth century. In France, surgeons had been forced to merge with the guild of barbers around the mid-seventeenth century and were placed in a position of marked inferiority compared to physicians. But within a few decades, royal patronage had allowed them to embark on a rapid process of emancipation and elevation of their professional dignity. Apprenticeship training was gradually replaced by theoretical and practical surgery courses held in the new amphitheatre built at the Hôtel de Saint-Côme in 1674, which effectively became a surgical school; demonstrations of anatomy and surgery were also organised in the Jardin du Roi. A new appreciation was also given to manual skill, increasingly considered a marker of surgeons’ ability and talent. By the end of the eighteenth century, surgery was seen as a discipline combining a solid theoretical foundation with practical expertise based on experience.Footnote ⁵⁰

Cataract surgery, as Daviel presents it, was therefore perceived by surgeons of the time as representing a shift from a crude procedure with dubious results, performed by illiterate empiricists, to a rigorous procedure based on science. It thus became an ideal field in which to demonstrate this alliance between theoretical knowledge and technical precision. Paradoxically, the invasive and complex nature of extraction enhanced the value of this operation compared to couching. The numerous steps and instruments required to perform it demanded precise knowledge and a dexterity that itinerant surgeons did not possess.

In writing about extraction, many surgeons thus emphasised the operation’s scientific nature, a true manual virtuosity permitting the restoration of sight to the blind, and highlighted the benefits of such an innovation for surgery as a discipline. Already in 1753, Georges de Lafaye, professor and royal demonstrator in surgery, praised the advantages of extraction over couching (‘the old technique’) as ‘obvious’. In a letter dated 1755, royal surgeon Rémon de Vermale asserted extraction’s superiority over couching, a method he disparages for its ‘imperfection’ and ‘uncertainty of its successes’.Footnote ⁵¹ The cataract couching method, he continued, was followed by an infinite number of accidents, which only happened with extraction if performed by inexperienced hands.Footnote ⁵²

The choice of media for disseminating writings on cataracts reinforces this interpretation. While many British surgeons, for instance, preferred to publish in periodicals and proceedings of learned societies – notably the Philosophical Transactions of the Royal Society – or in the journals of local literary and philosophical societies, their French counterparts more often opted for different forms of publication: pamphlets, treatises, individual memoirs or, more institutionally, the Mémoires de l’Académie Royale de Chirurgie, published between 1743 and 1773 and intended for an informed professional audience. This more focused and disciplinary editorial approach accentuated the scientific legitimacy of the practice described.

Furthermore, starting around the middle of the seventeenth century, a great increase in dissertations from medical schools on the topic of ophthalmology can be observed, indicating that ophthalmology was transitioning from a lower-status surgical specialty to a branch of learned surgery around this time.Footnote ⁵³ Institutional changes in the field of surgical education further reinforced this trend. The creation, in 1756, of a chair of ophthalmology at the Collège de Saint-Côme, followed by the opening in 1768 of the first ophthalmology course at the Collège de Chirurgie in Montpellier, provided an academic framework for ocular specialization. Within this context, several contemporary commentators presented Daviel’s extraction technique as a model of the new type of scientifically grounded surgical intervention that surgeons sought to promote. Likewise, the publication of Daviel’s memoir appears to have stimulated extensive discussion among European practitioners. The rise of the European debate surrounding cataracts contributed to amplifying this dynamic. Publications by British surgeons, the creation of a university chair of ophthalmology in Vienna, and the continuous exchange of knowledge and techniques within transnational scientific networks exerted additional pressure on French practitioners. These surgeons are encouraged not only to refine surgical techniques but also to contribute their research to a published body of work capable of supporting the international recognition of French surgery. In the years following the presentation of Daviel’s thesis, the extraction method underwent constant modifications. This paper sparked a debate across Europe, with physicians and surgeons dividing themselves into proponents of the ‘new’ or ‘old’ technique in a very Manichean fashion, while a handful maintained a more moderate position.Footnote ⁵⁴ Particular attention was paid to the instruments used in the operation. Those that Daviel proposed seemed unnecessarily numerous. Several surgeons published papers presenting modifications to the procedure and describing instruments of their own invention – such as scalpels, scissors, or devices designed to immobilise the eye during the operation – together with reports of the results obtained in their practice. Much of the retrospective description of this period comes from later observers such as Parisian surgeon A.-E. Tartra. Writing a few decades later, Tartra would say about this period that ‘the operation for the cataract is perhaps one of those that practitioners have modified the most; there are few famous oculists who did not have their own particular instruments’.Footnote ⁵⁵ New techniques for performing the couching procedure were also tested during this period. Supporters of couching proposed alternative ways to execute the operation to counter its opponents’ critiques.Footnote ⁵⁶ In both camps, the debate took place not only on a practical level but also on a theoretical one. Surgeons also conducted comparative trials to test the two methods side by side. Several treatises discussed the cases of patients operated on either by couching or extracting cataracts, and even instances of those with cataracts in both eyes having each eye operated on using a different technique.Footnote ⁵⁷

From a ‘closed’ surgical procedure fixed in a stable protocol and validated by the authority of classical texts, in the second half of the eighteenth century, cataract surgery had become an ‘open’ technique, a subject of debate and experimentation. While imperfect, the extraction was seen as susceptible to improvement. Numerous experiments were conducted to enhance it, the results of which were published and commented on by the medical community. Within surgical circles, the cataract operation increasingly came to be regarded as a relatively safe and effective procedure when performed by experienced practitioners. This perception reflected primarily the perspective of surgeons themselves; the judgment of patients towards these operations are much more difficult to reconstruct and were likely more ambivalent, given the persistent risks associated with the intervention. This evolution in the appreciation of cataract surgery resonated with the characteristics of surgery as a discipline and profession at the time. In France, extraction became the only practice officially recognised and taught until the beginning of the nineteenth century.Footnote ⁵⁸ It was only then that the risks and unfortunate consequences of this practice came to the medical profession’s attention.

From the return to couching to the adoption of extraction

In the decades following Daviel’s memoir, the increase in comparative surgical trials allowed surgeons to observe the advantages and disadvantages of both methods. If couching carried the risk of the lens rising after being lowered, it was still a simple and quick procedure in its execution. The subsequent inflammatory phenomena were considered as manageable, while complete failures – resulting in the total loss of the operated eye – were relatively rare. Extraction, on the other hand, demonstrated encompassing more numerous and serious risks: vitreous haemorrhage; iris injury; pupil deformation; and above all, suppuration of the corneal opening, whose ample flaps were not sutured, often resulting in sympathetic ophthalmia, a condition normally causing the loss of both eyes.Footnote ⁵⁹

At the beginning of the nineteenth century, the medical community revisited its opinions and almost unanimously declared the superiority of Couching over extraction as the procedure to be applied for cataract surgery. The return to couching, however, occurred in a different context compared to that preceding the two debates around the location of the cataract and around its extraction. Following the experiments and trials conducted in the previous century and the debates that accompanied them, the couching procedure was now framed within a strong scientific discourse. The reasons for applying this procedure were established on the basis of more precise anatomical knowledge resulting from autopsies and animal experiments, now routinely performed. In the medical treatises of that time, couching was discussed within the framework of the physiology of vision, a field that experienced a significant expansion during the nineteenth century, and of the nosology of the different types of cataracts, now framed within the developing discipline of pathological anatomy. Its execution was detailed, and all its phases and actions were explained and justified. Its risks were not overlooked, but the precautions to be taken to avoid them, as well as the measures to be adopted to remedy them, were systematically described and explicated.Footnote ⁶⁰ The enthusiasm with which the extraction had been welcomed and adopted in the previous century was now judged harshly and with a certain degree of embarrassment. Thus, Tartra wrote in his 1812 thesis about extraction:

In the medical press, cataract surgery was the subject of numerous articles, particularly in ophthalmology-specialised journals, that began appearing around the late 1830s. Several papers presented new techniques for performing couching, which continued to be the subject of studies and experiments. The method of reclination, for example, which involved tilting the lens to make its ascent more difficult, or the method of lifting, in which the lens was pushed into the upper outer part of the vitreous body,Footnote ⁶² or even the method of fragmentation, which involved breaking the lens before lowering it, were introduced into surgical practice and subject to comparative trials.Footnote ⁶³ Experimentations and discussions highlighted the rigorous and scientific nature of cataract surgery and the high professional competence of those who practised it. At the time, in France as elsewhere in Europe, specialisation in medicine was viewed with suspicion, as a doctor was expected to be able to treat the human body in its entirety. Specialisation was often associated with quackery, particularly in the case of specialists in eye diseases.Footnote ⁶⁴ In writing about cataract surgery, doctors who increasingly called themselves ophthalmologists thus highlighted their scientific training and the rigorous nature of their work.Footnote ⁶⁵ While not perfect, cataract couching was seen as a method that, compared to the alternatives, involved the least risk.

The experimental approach that characterised cataract surgery during the nineteenth century conformed with the context of ophthalmology’s progressive institutionalisation as a fully fledged medical speciality. If a movement in this direction is identifiable in France as early as the beginning of the nineteenth century, it had accelerated and expanded notably by the middle of the century.Footnote ⁶⁶ At that time, the discussion on cataracts had shifted towards a more comprehensive analysis of this pathology and the formulation of standardised knowledge: Its typologies, previously listed in long lists varying from one author to another, were now reduced to three.Footnote ⁶⁷ In the search for its causes, the humoral medicine explanatory framework was gradually abandoned, with examination using the ophthalmoscope and microscopic analysis of cataract-affected eyes having identified the alteration of the lens’s nourishing vessels as the main cause. Professions putting eyes under strain or diseases such as diabetes or syphilis were also highlighted as particularly dangerous.Footnote ⁶⁸ Cataracts and their treatment came to be framed within the new scientific parameters and characteristics of specialised medical knowledge. The mastery of such knowledge and specialised surgical skills laid the foundations of the professional identity of ophthalmologists, no longer mere surgeons but representatives of a new branch of medicine.Footnote ⁶⁹

Even though articles announcing successful outcomes continued to be published – especially authored by doctors wishing to draw attention to their own improved techniques or instrumentsFootnote ⁷⁰ – the prognosis of this intervention remained very uncertain.Footnote ⁷¹ If couching was the default method practised during the first half of the nineteenth century, extraction was not ruled out by principle. Considered applicable in some specific situations, it continued to be the subject of experimentation and discussion.Footnote ⁷² Among the variants tested for this procedure, one gained great popularity to the point of replacing the couching technique and establishing itself, for about fifteen years, as the most frequently practised surgical procedure for cataract operations in Europe. Around the mid-1860s, Prussian ophthalmologist Albrecht von Graefe (1828–1870) proposed a surgical technique that he called ‘extraction by modified linear incision’, or ‘small flap incision’. This method involved making a small linear opening in the cornea instead of the normally practised large semi-circular incision, reducing the risk of suppuration and facilitating wound healing. This procedure was coupled with an incision of the iris (iridectomy) to be performed the day before the operation to avoid any deformation of this part of the eye during the intervention. Graefe presented his method at the International Ophthalmological Congress in Paris in 1867.Footnote ⁷³ Operating with the small flap incision, he claimed, had allowed him to double the success rate, cutting in half the number of cases that resulted in the loss of the operated eye.

His statements left a strong impression on his colleagues. The possibility of performing the extraction without fatally endangering a patient’s eye appeared to be captivating. At that time, it was increasingly possible to observe the results of cataract surgeries due to the establishment of hospitals and clinics specialised in treating eye diseases.Footnote ⁷⁴ The resolutive outcomes of the extraction had not been forgotten. The risk of the lens rising again after being lowered remained a source of concern and frustration for the operators. Autopsies, now regularly performed, had also shown that a dislocated lens remained in the eye without being absorbed, as previously believed, thus representing a permanent source of danger. Following the announcement of Graefe’s procedure, ophthalmological journals published numerous articles that were very positive, hailing the method as the future of cataract surgery. In the following years, articles reporting the successes of operators using the Graefe method multiplied.Footnote ⁷⁵ Quickly, the small flap incision became the most practised not only in France but internationally.Footnote ⁷⁶ Couching was once again abandoned as a technique belonging to the past and labelled as a ‘historical curiosity’.Footnote ⁷⁷ The name Albrecht von Graefe became synonymous with scientific progressFootnote ⁷⁸ and the benefits coming from medical specialisation.

To better understand the reaction engendered by the announcement of the new method, we must also consider that Graefe was, at the time, a very famous practitioner, regarded as one of the best specialists in eye diseases of his era. Several French ophthalmologists had studied with him before starting a career in their home country. Moreover, a significant number of eye specialists of German origin were working in France at the time and contributed to popularising the surgical techniques developed in their homeland.Footnote ⁷⁹

Dissenting voices, however, did not take long to appear. The follow-up of patients operated on using the Graefe method revealed the emergence of several complications that, in the medium term, compromised the apparent success of the intervention. If the smallest opening of the cornea limited the risk of suppuration, it offered more difficult access to the lens, whose removal often damaged other parts of the eye. The preliminary iridectomy was also the cause of complications.Footnote ⁸⁰ Several French ophthalmologists thus began to express reservations about the small flap incision.Footnote ⁸¹ During the 1870s, criticisms increased, shifting from caution to radical scepticism.Footnote ⁸² The very encouraging statistics published during the early years of the procedure’s popularity were now deemed misleading, as patient follow-up showed the severity of the sequelae.Footnote ⁸³ A sense of déjà vu started spreading among the profession, given the speed with which the new method for cataract operation had been welcomed. Once again, practitioners had been overly enthusiastic about a new procedure presented by a widely renowned doctor endorsed by the medical press. Among French specialists, another reason for criticising Graefe’s method was related to the nationality of its inventor. In a France wounded and humiliated by the military defeat suffered in 1870 at the hands of what was now the German Empire, hostility towards anything connected to its neighbouring country was widespread. Several French ophthalmologists began to denigrate the ‘Prussian method’Footnote ⁸⁴ and advocated for a return to the large flap extraction proposed by Daviel a century earlier. In an article published in 1883, the ophthalmologist Philippe Chavernac concluded that returning to ‘Daviel’s method’ was necessary, not only because of its better results but also because it was ‘a national property’ and it was ‘the duty of the French to demonstrate its outstanding superiority’.Footnote ⁸⁵

The Graefe procedure was gradually abandoned over the last two decades of the nineteenth century, and the large flap extraction was reintroduced as the method of choice. While this transition occurred quite rapidly in France, it also took place internationally, albeit with different timelines.Footnote ⁸⁶ The large flap extraction yielded, at the time, very appreciable results following the widespread adoption of asepsis and the use of local anaesthesia with cocaine.Footnote ⁸⁷ These two innovations drastically reduced infections and post-operative complications and allowed for healing within seven days. From the method originally devised by Daviel, the one practised by this time retained only the principle of the large corneal incision. The procedure’s other phases, the instruments used, how the patient was prepared, and the post-operative follow-up showed no resemblance to the past. This period also saw the gradual emergence of a historiographical narrative that celebrated Jacques Daviel as the ‘father’ of modern cataract surgery. Late nineteenth-century ophthalmological literature increasingly presented his extraction procedure as the decisive turning point in the history of the discipline. Such representations formed part of a broader tendency within medical writing of the period to construct heroic genealogies centred on great innovators.Footnote ⁸⁸