CHAPTER II. The Work of John Cunningham Saunders

THE WORK OF JOHN CUNNINGHAM SAUNDERS

That the Institution which Saunders had founded provided a much felt want is evident from the following statement of the number of patients with eye diseases dealt with, and the numbers stated to be “cured,” during the first four years of its existence.

1st year, 1805, admitted 600, cured 500. 2nd year, 1806, admitted 1,526, cured 1,036. 3rd year, 1807, admitted 2,126, cured 1,796. 4th year, 1808, admitted 2,357, cured 1,970.

It must be admitted that it is somewhat doubtful what the term cured actually implied, for in a list of the diseases which those “cured” suffered from are included some, such as total opacity of the cornea, for which even to-day no absolute cure is known.

Successful as the Institution proved to be in dealing with eye disease, it was far less so in connection with ear disease.

Saunders’ first publication was a book entitled The Anatomy of the Ear: A Treatise on the Diseases of that Organ. The Causes of Deafness and their Treatment. It must evidently have met with much demand, for a third edition was published after his death, in 1829. Although he had devoted so much study to the treatment of diseases of this organ, he seems soon to have realised that the interests of his Institution would be best served by restricting its aims to the treatment of diseases of the eye only. His reasons for doing so are set out in the following letter which he sent to the Committee in December, 1807:

“Gentlemen,

“Antecedent to the establishment of this Dispensary the diseases of the Eye and Ear had never been made the object of a specific institution, although their great variety and complexity seem to require the most minute and attentive investigation. Those who have practised on the eye have always partially cultivated the ear, and when I chose the former for professed pursuit, the latter also became the subject of my serious enquiry. I had ascertained by observation that certain cases of disease are alleviable. Still I was aware how little would be the success, as the most complicated structure of the organ, which occupies an inaccessible part of our frame, is most frequently the seat of disease. Regardless of this conviction and solely influenced by a knowledge of the positive good which the deaf occasionally receive, I did combine in my proposal for the institution of this charity, the ear with the eye, solicitous of gaining public esteem by doing for the public all the good in my power. But the experience which this institution affords demonstrated the proportion of curable and incurable cases, a proportion much smaller than was expected, at most exceeding (obstruction from inspissated wax excepted) one in a hundred. It grieves me now to state, this branch of our institution exhausts the funds without an adequate advantage, and consumes a portion of my time on an impracticable point, that must ultimately tend to diminish my reputation. The performance of this part of my duty is, therefore, irksome to me, not because it is laborious, but because it neither leads to distinction nor obtains even the common reward of benevolent institutions. To be thankful for intended benefits demands a refinement of reason which none but liberal minds possess. Of those who are dismissed incurable more are made vindictive by disappointment than are grateful for the care bestowed upon them, and the former almost universally represent him who has ineffectually attempted their relief as the author of their misfortunes.

“My attention to the vast number of irremediably deaf which are accumulated at the Charity is not merely disagreeable to my feelings, but absolutely injurious to my interest by causing me to be considered as an Aurist when I am in fact an Oculist. The branch of the profession has always been in my private practice a secondary object. In this light I should wish it to be placed in the Dispensary. The Ear may consistently with the preservation of those privileges which the Governors have acquired be withdrawn from public notice. Then, whilst I render the same service to those for whom they may individually be interested, it will cease to operate to my prejudice. The mode to be adopted for the accomplishment of this object is implicitly submitted to your judgment.

“I am, gentlemen,

“Your obedient servant,

“J. C. SAUNDERS.”

After consideration of this letter by the Governors it was resolved, at a General Meeting in the following January:

“That diseases of the Eye shall in future be the sole object of the Charity, and that its name be changed to that of The London Infirmary for Curing Diseases of the Eye.”

In June, 1806, Saunders published an Essay “On Inflammation of the Iris, and the Influence of the Extract of Belladonna to prevent the Consequent Obliteration of the Pupil.” In it he gives an accurate description of the clinical characteristics of the affection, and records several cases treated at the Dispensary in which he had prevented loss of sight from closure of the pupils by keeping them dilated with the extract of belladonna, applied to the conjunctiva whilst the inflammation lasted.

In January, 1809, he advertised in the medical journals his intention of publishing a treatise on some practical points relating to the diseases of the eye, and particularly on the nature and cure of cataract in persons born blind.

Up to the beginning of the nineteenth century only two forms of operation for cataract were in vogue: that of displacing the opaque lens downwards with a needle out of the axis of vision, the operation of “couching,” which may be regarded as one of the most ancient of surgical procedures; and that of removal of the opaque lens out of the eye, the operation of “extraction,” first performed by the French surgeon Daviel in 1745.

It was observed by several operators who couched cataracts that if they failed in displacing the lens down it was sometimes possible to break it up with the needle, and that the fragments so formed tended in time to disappear. Percival Pott, a surgeon at St. Bartholomew’s Hospital, in 1775, first pointed out that this disappearance of the fragments of lens substance was due to them becoming dissolved in the fluids of the eye, and he advocated a procedure to facilitate their solution.

To Conradi, a surgeon at Nordheim in Hanover, seems to be due the merit of first proposing a distinct method of operating for cataract by its division with a needle through the cornea, and he published an account of his method in 1797.

Neither the operation of couching nor that of extraction were found suitable for small children afflicted with cataract, and it was customary in cases of congenital cataract to advise postponement of operation until the patient had arrived at the more manageable age of twelve to fourteen. As has been already mentioned, James Ware, in 1801, contributed a paper to the Royal Society, describing how he had removed a cataract from a boy, aged seven, by breaking it up with a couching needle.

In the medical report of the Dispensary at the end of its second year it is recorded that three children born blind with cataract had been cured at the respective ages of seven, five, and four years. On its receipt by the Governors the following resolution was passed:

“That the thanks of this General Meeting be given to Mr. Saunders for the ability and care by which he has cured so great a number of patients, many of them labouring under the most complicated diseases of the eye, and more especially for having been the first to establish by repeated success the propriety of performing the operation for the cataract at the earliest ages in children born blind of that disease.”

So pleased were the Governors with this proof of the value of their charitable institution that they directed that these three small children whose sight had been restored should be introduced at the anniversary dinner. These anniversary dinners were held each year for the purpose of increasing the number of subscribers to the Charity. The dinner at which these children were exhibited was held at the London Tavern, Bishopsgate Street, in May, 1807, at 5 p.m. It is recorded that the price of the dinner was 7s. per head, including beer, bread, cheese, and radishes. The dessert was 1s. 6d. extra, and the wines, port and sherry. The President, Sir Charles Price, Bart., M.P., was in the chair, and about one hundred gentlemen were present; sixty new subscribers were obtained.

At a similar dinner held in the following year the number of Governors and their friends who attended was 277, and new subscriptions to the amount of £708 15s. were received.

In a letter to the Committee, dated March, 1808, Saunders wrote as follows with reference to his work in connection with congenital cataract:

“By the adaptation of an operation on the cataract to the condition of childhood I have successively cured without a failure fourteen persons born blind, some of them even in infancy, and it has just been performed on an infant only two months old who is in a state of convalescence. As I reserve for another occasion the communication of the method which I pursue for the cure of very young children, I shall no further compare it with extraction, than by observing that extraction is wholly inapplicable to children, or only fortuitously successful. Those who on all occasions adhere to this operation, and have never turned their thoughts towards the application of means more suitable to this tender age, have been obliged to wait until the patient has acquired sufficient reason to be tractable; otherwise when they have deviated from this conduct, the event has afforded little cause of self-congratulation.

“How great the advantage of an early cure is a question of no difficult solution. Eyes originally affected with cataracts contract an unsteady and rolling motion, which remains after their removal, and retards, even when it does not ultimately prevent, the full benefit of the operation. A person cured at a late period cannot overcome this awkward habit by the utmost exertion of reason or efforts of the will. But the actions of infants are instinctive. Surrounding objects attract attention, and the eye naturally follows them. The management of the eye is therefore readily acquired, his vision rapidly improves, and he will most probably be susceptible of education about the usual period.”

During 1809 Saunders, in preparation for the publication of his advertised treatise, wrote essays “On the Inflammation of the Conjunctiva in Infants” and “On the Cure of the Inversion of the Eyelids by Excision of the Tarsus.” He also commenced to put together his notes on congenital cataracts and of his methods of operating on them. His work, however, in these matters became much impeded by recurrent, violent, acute attacks of headache due to brain disease, which in February of the following year proved fatal.

Saunders had realised that congenital cataracts varied considerably in character and consistency, and also that they might be dealt with either by passing the needle, as in couching, through the sclerotic and behind the iris in its approach to the pupillary area, or through the cornea, the so-called anterior operation. He was wisely waiting to gain experience as to which form of procedure was better suited for the different forms of cataract before rushing into print on the matter. He had two pupils working with him at the Dispensary, both of whom subsequently became ophthalmic surgeons, and both of whom in later years wrote in glowing appreciation of all they learnt from him. The one was William (afterwards Sir William) Adams, and the other John Stevenson. Two letters addressed to the latter in April and August, 1808, are the only authentic documents in Saunders’ writing descriptive of his operation for cataract; with the first he enclosed two of his improved needles for Stevenson’s own use. Needles of a similar pattern are still employed, and known by Saunders’ name, at the present time.

“My dear Friend,

“I confide the method of operating which I pursue for cataract to your honour, and I am very certain that it is safely deposited. I shall not have time to point out all the advantages which result from this deviation from the old method of couching; but simple as they appear, they are very important, as you will perceive when I detail all the circumstances, which I shall sometime do, in a treatise on the cataract.

“I always use the solution of Belladonna, and never begin the operation until the pupil is as much dilated as it will admit of, keeping the eye, by means of Pellier’s elevator, or else my own fingers, as steady as possible. The object of my introducing the instrument into the eye is, to cut the capsule in the anterior part of the crystalline; and therefore, as the lens is generally more dense towards the centre, I take care that it shall pass through the crystalline as near to the capsule as possible. That the instrument may traverse the lens freely, you will observe that it is made of the greatest tenuity, and flat, and that it cuts towards the point on each side. I find by experience that it can be conducted, with care, through the hardest lens; whereas the needles, such as Scarpa’s and Hey’s, only push the whole lens before them, and without being able to carry the instrument to the capsule, the lens is made to press on and protrude the iris; whence results the consequent inflammation. As for the crystalline itself, you may or may not meddle with that; it may be well to loosen its texture in some instances, but you ought never to depress it....

“The instrument should enter the sclerotica about a line behind the ciliary ligament, and should be conducted through the anterior part of the crystalline which is softest. You may loosen the texture of the cataract before you divide the capsule, or after, as in the operation seems most convenient, but the capsule must be divided at all events. I do not much care what becomes of the substance of the crystalline. I sometimes let it go in considerable quantity into the anterior chamber, if it seems tending that way, but I never push it, because that must press the iris. N. B.—Follow Hey’s rule, to be careful not to do too much. After the operation the plan with me is purely antiphlogistic, and I believe you well know what that is. If your operation should not succeed at the first attempt, describe to me the appearances, and I will gladly give you my sentiments as to repeating it.

“With respect to congenital cataracts, from the repeated conversations we have had on the subject, it seems scarcely necessary for me to remind you, that they are generally capsular, the whole or greater part of the lens having probably been, at some antecedent period during the foetal state, spontaneously absorbed. I shall only add to what I have already stated, that the steps to be pursued in the operation are nearly similar to those adopted for lenticular cataract; the great object being either to make a sufficiently large central aperture for the rays of light to pass freely through it to the retina, or also to endeavour to tear the condensed capsule into as small fragments as possible, and be gradually absorbed; for which purpose, you may use the needle with much more freedom than in the former case.

“With our united regards,

“I am yours faithfully,

“J. C. SAUNDERS.”

It is interesting to note how in these pre-anæsthetic days the small children were kept sufficiently still to allow of operations for cataract to be performed on their eyes. The following is the description of the method employed given by Dr. Farre:

“Four assistants, and in stouter children five, are required to confine the patient. The first fixes the head with reversed hands, the second not only depresses the lower lid with his forefinger, but also receives the chin of the child between his thumb and forefinger, as in a crutch. By this means the play of the head on the breast is prevented, a motion which the child incessantly attempts, and which will very much embarrass the surgeon. The third assistant confines the upper extremities and body; the fourth the lower extremities. The surgeon, seated on a high chair behind the patient, takes Pellier’s elevator in his left hand, and the needle in his right, if he is about to operate on the right eye, or the speculum in his right hand and the needle in his left, if the operation is to be performed on the left eye.”

The following is the commencement of an unfinished medical report which Saunders had in preparation to present to the Committee of the Infirmary at the time of his death.

“Gentlemen,

“Five years have now passed since my proposal for establishing this Infirmary was submitted to your notice, during which I have incessantly and anxiously laboured to redeem the pledge then given to make it a beneficial Institution to Society. My anxiety has been relieved, and my labour consoled in the progress of this Institution, by repeated instances of your respect; and the recollection of them at present only heightens the satisfaction I feel, on finding myself confirmed as the conductor of an establishment supported by liberal and zealous advocates, and possessed of the means of performing an important part in Society, and esteemed by Society for it.

“In prosecuting the object of attracting public attention towards this Institution, I trust I have kept free from the practice of any disingenuous art. Popularity has not been snatched; but studiously and unremittingly sought: it was expected only as a reward of service; and the share of it which has been gained, is ascribable to the estimation in which the Governors have been pleased to hold this service. I have confided the character of the Institution to the quantum of professional good—excepting you may be pleased to add, that mindful of being an agent for liberal and philanthropic men, I have always administered with humanity and attention to the feelings of the poor that relief which their bounty has supplied.”

Owing to the early death of Saunders, before the publication of his promised book on diseases of the eye, and of any description of his operation for cataract, there was much heated controversy for many years afterwards, in which the Committee of Management of the Infirmary became involved.

The chief matters around which dispute arose were: the publication of Saunders’ unfinished manuscripts; his claim to having introduced a new form of treatment for cataract; the advertisement of his successful results prior to making known to the profession his method of procedure; and the priority of his invention of an operation for the restoration of sight in those in whom it had become impaired from Egyptian ophthalmia.

Saunders died intestate, and there was nothing left for his widow but what might result from the publication of his unfinished manuscripts. The Governors of the Institution decided, in the first instance, that the book should be published at its expense, and that the proceeds of the work (without any deduction) should be appropriated to the sole use and benefit of Mrs. Saunders. It was afterwards found that Mr. Saunders’ brother and sister could claim legal rights to the proceeds. It was, therefore, decided in lieu to present £50 to Mrs. Saunders and an annuity of £40. Dr. Farre, at the request of the widow and of Mr. Saunders’ brother, consented to edit the book and make good its deficiencies, and it was published by Messrs. Longman and Company in 1811, delay being caused in connection with the question of copyright. Eighteen months after Saunders’ death his widow married again, under which circumstances the Committee considered they had reserved to themselves the right of reconsidering her annuity, and it was discontinued. It was agreed, however, that she should retain the copyright of her late husband’s book and receive any further proceeds that might arise from its sale; these rights she later parted with to Messrs. Longman and Company for the sum of £50. When a second edition of the book was called for, Longmans offered the copyright to Dr. Farre; he refused it for himself, but accepted it on behalf of the Infirmary. The discontinuance of the annuity to Saunders’ widow after her second marriage was the subject of an attack by those at enmity with Farre and Battley up to the time of her death in 1817.

The book, entitled A Treatise on some Practical Points relating to the Diseases of the Eye, opens with a short account of Saunders’ life, a rather detailed account of his last illness, and a statement of the morbid appearances found by Astley Cooper on the examination of his body. The account of his illness suggests that he suffered from a tumour of the brain, which had affected one of his optic nerves and caused impairment of the sight of his right eye. At the post-mortem examination, however, no tumour was found, the immediate cause of death being cerebral haemorrhage.

The first two chapters of the book consist of the three previously published essays already referred to; the other three of unfinished notes which were arranged and added to by Dr. Farre, and which deal with “Cases illustrating Changes of Structure in the Eye,” and with “Congenital Cataract.”

In the course of events it not infrequently happens that circumstances lead up to an epoch when some new development becomes ripe for discovery, and that then more than one mind independently “hits the moment” at about the same time. Later on, when history steps in to record the event, considerable discussion is liable to arise as to whom the palm of priority is to be awarded. This is what occurred in connection with the introduction of the operation of solution for the removal of congenital cataracts.

The solubility of the substance of the crystalline lens in the aqueous humour of the eye had been recognised long before Saunders began to operate for cataract. But in introducing the method of solution for the dispersion of cataracts in infancy he undoubtedly believed he had discovered a new method of treatment. He appears to have been unaware of Conradi’s method of needling cataracts in adults, published in Germany. The real value of his contribution to ophthalmology in this matter is well estimated in the following extract from a lecture published in the Lancet by Mr. Green, a surgeon at St. Thomas’s Hospital, in 1823:

“I do not mean to say that this operation is entirely new; if you read Mr. Pott’s works, you will find that, in some instances, he performed a very similar operation. He tells you, that in cases where the cataract was too soft for depression, he sometimes lacerated the anterior layers of the capsule, so as to admit the aqueous humour, and procure the solution of the cataract. Hey, Scarpa, and Ware have performed similar operations. We are not, however, to consider those as inventors of any practice who have merely employed it here and there, without stating any certain rules for its general applicability. It is to Dr. Saunders that we are indebted for having shown the principle on which he performed this particular operation, its applicability to cataract in children, and to some cases of cataract in adults. Dr. Saunders, therefore, may be justly considered as the inventor of this operation, and entitled to our respect and admiration of so material an improvement in this branch of surgery.”

It must, however, be admitted that it was an error of judgment on Saunders’ part to have allowed the Committee of Management to advertise in the public press, stating that operations were being performed at the Infirmary on children born blind of cataract, before the nature of the operation had been made known to the medical profession. Such a practice, together with the exhibition of the children who had been operated on at a public dinner, savoured rather of the methods of the quack oculists, though Saunders himself derived no pecuniary benefit and died a poor man.

Benjamin Gibson in Manchester, independently of Saunders, recognised the possibility of operating successfully on congenital cataracts in infancy, and in the October number, for 1811, of the Edinburgh Medical and Surgical Journal, published a description of his methods in an article entitled “On the Use of the Couching-needle in Infants of a Few Months Old.” The description of his operation was, therefore, published almost at the same time as Dr. Farre’s description of Saunders’ methods of procedure.

Saunders’ two pupils, William Adams (afterwards Sir William) and John Stevenson, followed the example of their teacher, both claiming to having introduced new methods of operating on the eye, and both founding institutions for the treatment of its diseases.

William Adams, as already mentioned, had, like Saunders, served his apprenticeship with John Hill, of Barnstaple, and had completed his medical education at St. Thomas’s and Guy’s Hospitals. He worked under Saunders in the dissecting room and also at the Eye Infirmary, assisting him for a year and a half in both his public and private operations. After obtaining the diploma M.R.C.S. in 1807, he went to reside in Exeter, where he founded the West of England Eye Infirmary for curing diseases of the eye, on the same lines as the one in London; this Institution continues its work to-day under the same name. To it Saunders allowed his name to be attached as Consulting Surgeon, and wrote advice on several occasions to Adams concerning his work there.

Saunders had pledged Adams not to reveal the nature of the operations he had learnt from him before he had had time to publish a description of them. Even before Saunders’ death Adams resented being bound to observe this pledge, and after his death considered himself exonerated from its further observance. Most operators in the course of their practice introduce modifications in their procedures. Adams considered that the modifications which he introduced in the operations he had learnt from Saunders justified him in claiming them as his own. It was on the strength of these claims, that on his return to London, after Saunders’ death in 1810, he was appointed to operate on pensioners dismissed from the Army as blind through Egyptian ophthalmia. The operation he performed was a modification of that introduced by Saunders of excision of the tarsus of the eyelid. He was also appointed to operate for cataract on seamen at Greenwich, and later an Ophthalmic Institution was founded for him in part of the York Hospital, Chelsea, which was afterwards transferred to Regent’s Park.

He became oculist extraordinary to the Prince Regent and to the Dukes of Kent and Sussex, and in 1814 was knighted. A Select Committee of Parliament reported on his work at the Ophthalmic Institution and on his claim to public money, and with Lord Palmerston’s support he was voted the sum of £4,000.

Sir William Adams’ claims to the invention of new operative procedures was much resented by Farre and Battley, who regarded them as piracy of their deceased friend’s work at the Eye Infirmary. In 1814 the Committee of Management of that Institution requested its medical directors to furnish them with a report on the matter, showing how Sir William Adams’ claims had been anticipated. This report was sent to His Royal Highness the Duke of York, the Commander-in-Chief of the Army, and to His Majesty’s Ministers, with the request that deputations from those connected with the Infirmary might be received. As an outcome of the deputation to the Duke of York, His Royal Highness graciously condescended to become a Patron of the Infirmary.

In 1817, when the question of a monetary grant to Sir William Adams was raised in Parliament, further deputations waited on Lord Palmerston and on the Chancellor of the Exchequer with the object of refuting his claims, and of obtaining some pecuniary assistance for the Infirmary’s building fund, but no success in the latter direction was met with.

In later life Adams became interested in Anglo-Mexican mines, but his speculations do not appear to have been attended with success. Two years before his death he changed his name to Rawson in compliance with the will of his wife’s mother, the widow of Colonel Rawson.

It is due to this change of name that a writer of a life of Sir William Adams, in Vol. II. of the British Journal of Ophthalmology, failed to find a notice of him in the Dictionary of National Biography. It is from the description there given of Sir William Rawson that most of the above facts respecting him have been taken.

John Stevenson, like Adams, worked under Saunders in the dissecting room at St. Thomas’s Hospital and at the Eye Infirmary. Having obtained the diploma of M.R.C.S., he settled in or near Nottingham, but on Saunders’ death returned to London to practise there as an oculist and aurist. In 1813 he was appointed as such to the Prince of Wales and to Leopold, the Duke of Saxe-Coburg.

He wrote several treatises on the structure and functions of the eye and ear, and much on the subject of cataract and its treatment. Whilst always acknowledging his obligations to Saunders and his admiration for his genius and industry, he claimed credit for having introduced a method of successfully removing cataracts in adults at an earlier stage in their development than was then usual, and thereby obviating a prolonged period of semi-blindness.

In 1830 he founded at 13, Little Portland Street, Cavendish Square, the Royal Infirmary for Cataract and other Diseases of the Eye, under the Patronage of His Majesty King William IV., to whom he was soon after appointed oculist and aurist. This Infirmary, besides the patronage of the King, had a long list of Royal Patronesses and of noble supporters. The indigent poor suffering from all forms of diseases of the eye were treated gratis as out-patients, but only cataract cases were admitted as in-patients. In the Dictionary of National Biography it is stated that after 1844 all trace of Stevenson is lost.

It is noteworthy that both this Infirmary and Wathen’s Institution, which were established under Royal Patronage in the West End of London, existed for only a comparatively brief time, whilst that founded by Saunders, with the approval and support of the medical and surgical staffs of the Borough Hospitals, and under the patronage of the City fathers, has continued to flourish and grow in the manner which the following pages will relate.

Farre described Saunders as a man of middle size, well made and of an engaging mien, with an active mind, generous in his private practice, and perfectly unreserved in stating his opinion in cases submitted to his judgment. That he had the capacity of forming firm friendships is shown by the marked respect which Farre describes as having been paid to him at his funeral, and the steps which were taken to perpetuate his memory. At a General Meeting of the Governors of the Eye Infirmary it was unanimously agreed that a portrait and bust of Mr. Saunders should be obtained and placed in the Committee Room. In accordance with this resolution a portrait was painted by Devis, and a bust was executed by Henry Weekes. The former hangs to-day in the Board Room of the present Hospital, and an engraving of it by Anthony Cardon was inserted as a frontispiece to Saunders’ treatise, and is still used to adorn the certificates which are presented to students who have completed a course of instruction at the Hospital.

This portrait shows Saunders with a mass of brown curly hair coming low down over his forehead, with mutton-chop whiskers, pronounced features and a mouth shaped like a Cupid’s bow. He wears a high white stock round his neck, has a frill to his shirt, and a blue coat.