path: root/78625-0.txt

*** START OF THE PROJECT GUTENBERG EBOOK 78625 ***

Transcriber’s notes

As the title indicates, this book recounts the history of Moorfields
Eye Hospital over the first one hundred years following its founding
in 1805, the significance of which is that it was the world’s first
hospital created to service a single specialty, viz. ophthalmology. In
recent times, two more volumes have been published to bring the history
up to date but copyright constraints prevent them being available in
digitised format.

The text of this e-transcription has been preserved as in the original,
including inconsistent spelling (storey/story) and hyphenation
(inpatient/in-patient, and ‘retching’ being misspelt as ’reaching’
on p.165. Italic text is denoted by _underscores_ and bold text by
*asterisks*




                   THE HISTORY AND TRADITIONS OF THE
                        MOORFIELDS EYE HOSPITAL

PLATE I.

[Illustration: JOHN CUNNINGHAM SAUNDERS.

From an engraving by Anthony Cardon, after a picture by A. W. Devis.]



                        THE HISTORY & TRADITIONS
                                 OF THE
                        MOORFIELDS EYE HOSPITAL

                          ONE HUNDRED YEARS OF
                   OPHTHALMIC DISCOVERY & DEVELOPMENT

                                   BY

                          E. TREACHER COLLINS

       CONSULTING SURGEON; MEMBER OF THE COMMITTEE OF MANAGEMENT;
         FORMERLY, CLINICAL ASSISTANT; JUNIOR AND SENIOR HOUSE
             SURGEON; CURATOR OF THE MUSEUM AND LIBRARIAN;
                     ASSISTANT SURGEON AND SURGEON

                        WITH TWENTY-SEVEN PLATES


[Illustration: Publisher's logo]

                                 LONDON

                          H. K.  LEWIS CO. LTD.

                                  1929



                        DEDICATED TO THE MEMORY
                                 OF THE
                     MEMBERS OF THE SURGICAL STAFF
                                 OF THE
                        MOORFIELDS EYE HOSPITAL
                       IN THE YEARS 1883 TO 1887

                   TO WHOSE INFLUENCE AND INSTRUCTION
                    THE AUTHOR IS SO DEEPLY INDEBTED




PREFACE


Great traditions are the most valuable assets which a hospital or a
teaching establishment can possess. They give it a personality which
makes it beloved and respected. Traditions are made up of the energies
and enterprise of those who have gone before, and will live on from
generation to generation long after the bones of those who have created
them have crumbled into dust. The primary aim of this book is to put on
record the traditions of the Moorfields Eye Hospital for the benefit of
past, present, and future workers within its walls.

So intimately associated has this Hospital been with all the
discoveries and developments which have taken place in connection with
ophthalmology during the nineteenth century, that it was not possible
to write a history of the first hundred years of its existence without
giving an account of them also. By having done this, it is hoped that
the book may find a wider circle of readers than those for whom it was
in the first instance intended.

An endeavour has been made to give an account of events as they have
happened in chronological order, and by so doing to produce the effect
of a cinematograph film, rather than that of an album of photographs.

For the facts recorded, numerous different sources have been tapped.
Much information as to the commencement of the Institution has been
derived from Barnsby Cooper’s biography of his uncle, Sir Astley
Cooper. Great use has been made of the minute books of the Committee of
Management of the Hospital, and of its annual reports.

For biographical details, the _Dictionary of National Biography_ has
been consulted, and also the articles on the “British Masters of
Ophthalmology” which have been published in the _British Journal of
Ophthalmology_.

It has been said that “when a medical man begins to write on the
history of his subject it is a sure sign of senility.” The writer of
these traditions does not claim that his case is any exception to this
rule. In early life a man has to learn history. In middle life he is
engaged in making history; and it is in his later years that he becomes
best qualified to write history. It is then that, on looking back, he
obtains the most comprehensive view, and is able to regard objects in
their truest perspective.

In conclusion I have to thank the Committee of Management of the
Hospital for its permission to reproduce the portraits of several
former members of the surgical staff, which hang in its Board Room;
also the _British Journal of Ophthalmology_ for permission to use the
blocks of some of the illustrations which have been published in its
pages; and lastly my friend Mr. Frank Juler for kindly reading through
and correcting the proof-sheets.




CONTENTS


  CHAPTER                                                PAGE

     I. THE FOUNDERS AND FOUNDATION                         1

    II. THE WORK OF JOHN CUNNINGHAM SAUNDERS               17

   III. BENJAMIN TRAVERS AND SIR WILLIAM LAWRENCE          33

    IV. REMOVAL TO MOORFIELDS                              48

     V. THE ROYAL LONDON OPHTHALMIC HOSPITAL               67

    VI. THE INTRODUCTION OF INHALATION ANÆSTHESIA
          AND OPHTHALMIC SURGERY                           82

   VII. THE DISCOVERY OF THE OPHTHALMOSCOPE                99

  VIII. THE COMMENCEMENT OF “THE OPHTHALMIC
          HOSPITAL REPORTS”                               119

    IX. GROWTH AND EXTENSION                              132

     X. ANTISEPTICS, BACTERIOLOGY, AND LOCAL ANÆSTHESIA   152

    XI. THE SELECTION OF A NEW SITE, AND THE ERECTION
          OF THE NEW HOSPITAL                             168

   XII. THE HOSPITAL IN THE CITY ROAD                     190




LIST OF PLATES


PLATE FACING PAGE

      I. JOHN CUNNINGHAM SAUNDERS              _Frontispiece_

     II. SHOWING THE SOUTH SIDE OF CHARTERHOUSE
           SQUARE AND NO. 40 WHERE THE LONDON DISPENSARY
           FOR CURING DISEASES OF THE EYE AND EAR
           WAS FIRST OPENED IN 1805                        14

    III. SIR ASTLEY PASTON COOPER, BART., F.R.S.           34

     IV. BENJAMIN TRAVERS, F.R.S.                          38

      V. SIR WILLIAM LAWRENCE, BART., F.R.S.               44

     VI. THE LONDON OPHTHALMIC INFIRMARY AS FIRST
           ERECTED AT MOORFIELDS IN 1822                   52

    VII. FREDERICK TYRRELL                                 62

   VIII. JOHN SCOTT                                        65

     IX. DR. JOHN RICHARD FARRE                            73

      X. JOHN DALRYMPLE, F.R.S.                            78

     XI. GEORGE CRITCHETT                                  86

    XII. SIR WILLIAM BOWMAN, BART., F.R.S.                 94

   XIII. WILLIAM CUMMING                                  102

    XIV. JAMES DIXON                                      105
         JOHN CAWOOD WORDSWORTH                           105

     XV. JOHN WHITAKER HULKE                              111
         GEORGE LAWSON                                    111

    XVI. SIR JONATHAN HUTCHINSON, F.R.S.                  123

   XVII. EDWARD NETTLESHIP, F.R.S.                        140

  XVIII. THE HOSPITAL AT MOORFIELDS AFTER THE ADDITION
           OF A NEW WING IN 1868, AND A NEW STOREY
           IN 1875                                        143

    XIX. WAREN TAY                                        151

     XX. JOHN COUPER                                      157

    XXI. R. MARCUS GUNN                                   160

   XXII. JAMES E. ADAMS                                   163

  XXIII. A. QUARRY SILCOCK                                167

   XXIV. THE PLEASURE BATH, PEERLESS POOL, CITY ROAD      175

    XXV. THE ROYAL LONDON OPHTHALMIC HOSPITAL IN
           THE CITY ROAD, OPENED IN 1899                  190

   XXVI. SIR JOHN TWEEDY, LL.D.                           202

  XXVII. WILLIAM LANG                                     204




THE HISTORY AND TRADITIONS OF THE MOORFIELDS EYE HOSPITAL




CHAPTER I

THE FOUNDERS AND FOUNDATION


In the board room of the Royal London Ophthalmic Hospital hangs a
framed document in which the names of Saunders, Farre, and Battley are
associated as being the first promoters of the institution.

Who were these three men? What brought them together? And how came they
to establish an institution unlike any which had previously existed?

John Cunningham Saunders was born and bred in Devonshire; he first saw
the light of day at Levistone on October 10th, 1773. He went to school
at Tavistock and South Molton, and at the age of seventeen commenced a
five years’ apprenticeship to Mr. John Hill, surgeon, of Barnstaple.
It was during his apprenticeship that he had his first introduction to
ophthalmic surgery, for Mr. Hill, though only a country practitioner,
was bold enough in those pre-anæsthetic days to operate for cataract.
It was from him also that Saunders first learnt the value of the use of
belladonna for dilatation of the pupil. William Adams, who also became
an ophthalmic surgeon, was likewise a pupil of Mr. John Hill, but of
him more anon.

Saunders, at the expiration of his apprenticeship, came to London to
complete his medical education at the then combined borough schools
of St. Thomas’s and Guy’s Hospitals. The skill and diligence which
he displayed in the dissecting room, together with his deftness as a
draftsman, soon attracted the attention of Astley Cooper, who was then
rapidly rising into fame. On Cooper’s election to the chair of anatomy
in 1797, he offered to take Saunders into his house and make him a
demonstrator of anatomy on the terms shown in the following letter:

  “Dear Sir,

  “I ought long since to have informed you of my plan for the winter,
  so far as it concerns you, and as I have been able to decide.

  “It is my wish that you should lodge and board in my house. I have
  informed you that I live in a plain and economical style, and that
  you are only to expect a joint of meat and a pudding; if this will
  satisfy you, a bed will be ready whenever you return to London.

  “I can say nothing about the salary you are to receive, for I have
  not been able to form any idea of what will be proper, or how much
  you may expect; all I can say is that the sum shall be annually
  increased, which at the same time as it may act as a stimulus to
  you, and make it an object to proceed in your career, will be more
  convenient to myself, because, if no stroke of adverse fortune
  prevents it, my income must be yearly improving.

  “It is my wish that you should dissect for lecture-work in
  Comparative Anatomy, and assist in my preparations. With respect to
  the first of these, the labour is certain, and all other occupations
  and objects must yield to it; with regard to the latter, the quantum
  of employment shall be guided by your feelings. It is a duty I have
  performed, without injury to my health, with much amusement, and
  great advantage.

  “I am in hopes that you will have no objection to giving me three
  months’ information if any other pursuit should lead you to quit the
  situation, as otherwise, I may be unable to procure a substitute, and
  suffer great inconvenience from the want of one.”

Saunders accepted the offer, and was shortly afterwards appointed the
demonstrator of anatomy at St. Thomas’s Hospital. His association with
Astley Cooper proved an exceedingly happy one, he on several occasions
being entrusted with the charge of Cooper’s patients during his absence
in the country. Saunders was evidently a good teacher, and possessed
of a most attractive personality, so that he became exceedingly popular
with the students, who on several occasions presented him with pieces
of plate as a token of their regard.

John Richard Farre was two years younger than Saunders, being born in
Barbados in 1775, where he was educated, and commenced the study of
medicine under his father. He came to England in 1792 to complete his
studies at St. Thomas’s and Guy’s Hospitals. The commencement of his
acquaintance with Saunders and Battley may best be given in his own
words:

  “In 1792 I entered as a dresser at Guy’s Hospital. At that time Sir
  Astley Cooper had, by his open manner, become well known among the
  pupils, but I was not intimate with him, until after my return, in
  1794, from the expedition in which I served under Lord Moria. I then
  became more particularly acquainted with him in the following manner.

  “About the year 1798, Sir Astley excited great zeal in the
  prosecution of minute anatomy, and the order of the day became the
  injection of the absorbents, and the dissection of parts concerned in
  operations, especially those of hernia. It was at this time that my
  acquaintance commenced with Mr. Saunders and Mr. Battley, who were
  both engaged in the dissecting room. So earnest were we all in the
  pursuit of the subjects above described, that Mr. Saunders and myself
  became jaundiced, in consequence of the continually constrained
  position to which we were subjected, while leaning over bodies under
  dissection.

  “Mr. Saunders also suffered from a punctured wound of the finger
  received while dissecting, which was followed by extensive
  inflammation of the arm; nor did this subside until nearly two
  hundred leeches had been applied.”

Richard Battley was older than his two friends, having been born at
Wakefield in 1770; he was educated at the Grammar School there, and
subsequently became the pupil of a physician in that town. For a while
he studied at the Infirmary in Newcastle-on-Tyne, and came to London in
1795. Entering as a pupil at St. Thomas’s Hospital at the same time as
Saunders, a close and lasting intimacy sprang up between the two men.

Having thus brought these three men together from Devonshire, Bermuda,
and Wakefield to the dissecting room at St. Thomas’s Hospital, it next
becomes necessary to trace the circumstances which led them to start
the “London Dispensary for Curing Diseases of the Eye and Ear,” the
name by which the present “Royal London Ophthalmic Hospital” was first
known.

In 1800, when twenty-seven years of age, Saunders became anxious
about his future prospects. His ambition prompted him with the desire
to practise as a surgeon in London; probably also about this time
influences began to work which made him desire to settle down with an
assured income, so that he might enter into the state of matrimony.
There was little prospect of his obtaining any higher appointment
than that of demonstrator of anatomy in the hospital at which he was
working, the custom in the old-established hospitals at that time being
to select for the staff appointments a pupil of one of their surgeons,
and one who had been articled at the Royal College of Surgeons for
at least six years. Saunders had not been so articled, having served
his apprenticeship in the country. He was not, therefore, eligible to
compete against those who had proceeded in the recognised manner, no
matter how great his merits. This was pointed out to him by Astley
Cooper, who advised him in his own interests to seek some other means
of support. Saunders then resigned his post as demonstrator of anatomy
and took over the practice of a surgeon in Gravesend.

Astley Cooper, however, soon began to miss his able assistant, and
found that the other arrangements he had made, which had to some extent
caused Saunders to take offence, did not work smoothly. He therefore
wrote him the following letter, and induced Saunders’ friend Battley to
go to Gravesend to use his influence in persuading him to resume his
old post:

  “LONDON,

  “_July_ 28_th_, 1801.

  “Dear Sir,

  “I have so often explained my reasons for the change which I made
  last winter at the Hospital, that I consider it as almost unnecessary
  to say anything further upon the subject. The trial has been made;
  Mr. D——has been weighed against you in the balance, and been found
  wanting.

  “His excessive vanity has disgusted, his want of perseverance has
  disappointed me, and I feel most thoroughly convinced that his
  abilities are inadequate to the task which has been assigned to him.

  “I felt it my duty to act as I have done, and my conduct, I fear, has
  been the cause of uneasiness to you; but as our separation was not
  the effect of misconduct upon your part, or of any disapprobation
  on mine, I hope we shall be again united in the pursuit of medical
  science, and that we shall entertain for each other that respect and
  esteem which I must ever feel for you.

  “As I told you in our last conversation, I have ever felt a degree
  of veneration for your acquirements and abilities, which has made me
  diffident in expressing my wishes. But as you have now courted it, I
  will say, that I have wished to see you join in the debates of Guy’s
  Medical Society. The capability of expressing our ideas in public is
  a source of more power than anything with which I am acquainted. It
  is the road to bring a public teacher to character and to fortune.

  “_Secondly_, I should much wish for your assistance in making
  experiments upon animals. I am certain that everything valuable
  in physiology is only to be so obtained. What is every day under
  observation of the senses is well known, but few men have sufficient
  knowledge of anatomy to be capable of making the interior parts of
  the body the subject of inquiry.

  “_Thirdly_, you will do me a favour by making my collection in
  comparative anatomy more complete. This, I am aware, is the greatest
  favour I can ask, as you are neither captivated by its splendour nor
  convinced of its utility; but as I have embarked on it, you will
  confer an obligation upon me by assisting me in making it complete.

  “I shall endeavour to make your situation comfortable in a pecuniary
  point of view, but I had rather make that the subject of conversation
  when I see you.

  “I am, dear Sir,

  “Yours, with the utmost esteem,

  “A. C. ”

Battley had a high appreciation of his friend’s talents, and felt
strongly that they would not have sufficient scope in such a confined
sphere as Gravesend. The combined effect of his persuasive influence,
and of Cooper’s letter, ultimately induced Saunders to resume the
duties of demonstrator of anatomy at St. Thomas’s.

Shortly afterwards he took a house in Ely Place, with the intention
of practising as a surgeon, and on April 7th, 1803, married Miss Jane
Louisa Colkett.

During the last years of the eighteenth and the first years of the
nineteenth centuries England was at war with France. Farre, in 1793,
went with Lord Moira’s expedition to France, returning, however, to
London on its failure. Battley for a time served in the Navy as an
assistant surgeon, and was present at several engagements under Sir
Sidney Smith.

In 1799 Napoleon invaded Egypt, and after the destruction of his fleet
by Nelson at the Battle of the Nile, English troops under Sir Ralph
Abercrombie were landed at Aboukir, in 1800. Almost all were attacked
by what was called “Egyptian ophthalmia,” but which we now know must
have been a mixed infection of purulent ophthalmia and trachoma.
After the evacuation of Egypt by the English in 1803, the troops were
disbanded, and spread this very infectious form of eye disease in all
the stations at which they stopped and throughout Great Britain.

Mr. Patrick Macgregor, surgeon to the Royal Military Asylum, writes of
the effects of the disease in the Army as follows:

  “The progress of the ophthalmia since its first introduction into
  this country in the year 1800 has, in the Army, been very rapid and
  extensive, and has at different periods materially interfered with
  its discipline and efficiency. It has crippled many of our best
  regular regiments to such a degree as for a time to render them unfit
  for service; and though the regiments which were in Egypt have,
  in general, suffered most from the disease, yet it has prevailed
  extensively in others which have never served in that country.”

The terribly destructive character of the disease may be shown by its
effects on the second battalion of the 52nd Light Infantry, which are
recorded by Dr. Vetch: out of 636 cases 50 were dismissed with the loss
of both eyes, and 40 with that of one.

The spread of the disease was not confined to the Army, but extended
widely throughout the country in the towns and villages, when the
disbanded troops returned to their homes carrying infection with them.

That the medical men and the hospitals in this country were badly
prepared to deal with such an immense increase in eye diseases may be
shown by quoting a description of the condition of things which then
existed, written by Sir William Lawrence some thirty years later:

  “The diseases of the eye, in general hospitals, are inadequate, from
  the smallness of their number, to the purposes of practical study,
  particularly that of exemplifying the various operations. Thus these
  institutions have been inefficient in reference to this important
  department. As the general body of surgeons did not understand
  diseases of the eye, the public naturally resorted to ‘oculists’” [in
  speaking of “oculists” he refers to those that have bestowed that
  title on themselves without having had any regular medical training]
  “who, seeing such cases in greater numbers, became better acquainted
  with the symptoms, diagnosis, and treatment; and especially
  more skilful in the operative department. At the same time, the
  subject, being imperfectly understood, was neglected in the general
  surgical courses, in which many important affections were entirely
  unnoticed, and the whole very inadequately explained. Thus students,
  who resorted to London for the completion of their professional
  studies, had no means of learning this important department of
  the profession, which was tacitly abandoned, even by the hospital
  surgeons, and turned over to the ‘oculists.’ The latter, not being
  conversant with the principles derived from anatomy, physiology, and
  general pathology, attended merely to the organ, and relied almost
  exclusively on what is comparatively of little importance, local
  treatment. Hence ophthalmic surgery, being in a manner dismembered
  from the general science, was reduced to a very low ebb. Until within
  a few years, it was, in this country at least, in a state of almost
  total darkness.”

It will thus be seen that at the time Saunders established himself as
a surgeon in London there was an immense increase in the amount of
eye disease, but that very few medical men were in any way trained or
competent to deal with it, and scanty, if any, provision was made for
its treatment in the hospitals.

Saunders’ attention had early in his career been attracted to diseases
of the eye during his apprenticeship under Mr. John Hill, and his
studies in the dissecting room had afforded him a sound basis for their
treatment, in an intimate knowledge of the anatomy of the organ and its
surrounding structures. His association with Astley Cooper had also
led him to devote special attention to the anatomy of the ear and to
disorders of hearing. Astley Cooper in 1800 made a communication to the
Royal Society, on the effects of destruction of the tympanic membrane
of the ear. He had found that considerable openings might be made in it
without impairment of the hearing power, and was thereby led to perform
the operation of puncturing the membrane in cases of deafness resulting
from obstruction in the Eustachian tube, with a remarkably good result
in the restoration of hearing, in the first cases in which he employed
it. Subsequent experience, however, showed it not to be so generally
useful as he had originally anticipated. He made a second communication
on the same subject in the following year, and in 1802 was elected a
Fellow of the Royal Society, and awarded the Copley Medal.

Whilst these papers were being written the subject of them must have
been much discussed by Cooper and his assistant Saunders, the latter’s
interest in ear disease being thereby awakened.

On starting in practice at Ely Place, Saunders decided to devote
himself to the treatment of diseases of the eye and ear, a decision
which must have required considerable courage at that time by one who
wished to remain of good repute with other members of his profession.
Up to that time the treatment of eye diseases had been mainly in the
hands of itinerant quacks, who dubbed themselves oculists.

George Coats, who has written an account of the lives and practices
of many of these worthies, has well described the condition of things
which then existed. He says:

  “In the eighteenth century ophthalmology had not yet vindicated,
  in England, its position as a separate branch of practice. It was
  the province of a set of ambulant practitioners who toured the
  country accompanied by all the apparatus of shameless advertisement
  (including ‘monkies,’ we are told), couching cataracts, and selling
  infallible salves and eyewashes. This taint of quackery appears
  to have deterred respectable surgeons from meddling much with the
  subject; their operative experience was probably small, and the
  procedure of couching, attended frequently with brilliant immediate,
  but disastrous after, results, was likely to be performed with fewer
  scruples by itinerant oculists, here to-day and gone to-morrow, than
  by settled practitioners who had to abide the consequences of their
  handiwork.”

Such men were naturally looked upon as charlatans by the medical
profession, but that did not prevent them becoming the recipients of
royal favours.

One William Read, who commenced life as a tailor, and became a
mountebank and itinerant quack oculist, settled in London in 1694,
advertising in the _Tatler_ “that he had been thirty-five years in the
practice of couching cataracts, taking off all sorts of wens, curing
wry necks and hair-lips [_sic_] without blemish.” In 1705 he was
knighted, “as a mark of royal favour for his great services, done in
curing great numbers of seamen and soldiers of blindness gratis”; and
about the same time was appointed oculist-in-ordinary to Queen Anne. It
is stated that the wealth he acquired enabled him to mix with the best
literary society of the day. Swift, in writing to Stella, commented on
the quality of his punch which he served in golden vessels. One sample
of his methods of treatment need only be quoted—“the putting of a louse
into the eye when it is dull and obscure, and wanteth humours and
spirits. This,” he says, “tickleth and pricketh, so that it maketh the
eye moist and rheumatick and quickeneth the spirits.”

On Sir William Read’s death in 1715, his rival, Roger Grant, succeeded
to the post of oculist to Queen Anne, and afterwards to George I.
Grant, originally a cobbler and later a Baptist minister, lost one eye
as a soldier in the service of the German Emperor, and then set up as
an oculist in Mouse Alley, Wapping. He advertised profusely in the
journals of the day, giving accounts of his cures, with certificates
attached from the patients themselves and others.

George II. appointed as his oculist-in-ordinary John Taylor, better
known as “Chevalier Taylor,” of whom Coats says:

  “Amongst travelling quacks the name of the ‘Chevalier’ Taylor stands
  pre-eminent for unblushing effrontery, blatant self-laudation, and
  all the methods of the charlatan, but also for mental endowments far
  above the average of his tribe, and for real acquaintance with the
  contemporary state of ophthalmic knowledge. His fame extended to
  every country in Europe; his boast of having conversed with kings
  and princes is no idle one; he had an acquaintance, not always
  felicitous, with some of the best known men, medical and lay, of
  his time; counting translations and minor works he was the author
  of nearly fifty books; and in later life he wrote an autobiography,
  which, if it gives few and unreliable particulars as to his actions,
  does much to reveal the character of the man.”

The Chevalier’s talents seem to have been hereditary, for his son and
two grandsons followed the same line of practice, and were each in turn
the recipients of royal favours.

It was with such prating mountebanks that Saunders ran the risk
of being confused in devoting himself specially to the treatment
of eye diseases. He was not, however, the first reputable medical
practitioner in London to specialise in this line of work, having
been preceded by both Wathen and James Ware. Dr. Wathen published, in
1785, _A Dissertation on the Theory and Cure of Cataract_, and held
the appointment of oculist to George III. He took Ware when a young
man into partnership with him, a partnership which lasted for fourteen
years, during which time Ware acquired such a liking for eye work that
he decided to devote himself exclusively to it.

Ware, like Saunders, had studied at St. Thomas’s Hospital, and held
there the post of demonstrator of anatomy, so it would seem highly
probable that his example may have had some influence in determining
Saunders to take up surgery of the eye as a special branch of practice.

In 1801 Ware contributed to the Royal Society a paper dealing with
the case of a boy of seven years of age upon whom he had operated for
cataract, and as the result of this communication he was elected a
Fellow of the Royal Society. It was one of Saunders’ most noteworthy
achievements, as we shall see later, to introduce an operation for
cataract in infants who are born blind.

The suggestion that Saunders should start a special institution for the
treatment of diseases of the eye and ear is stated by Battley to have
originated with Astley Cooper, whose own experience, in the treatment
of diseases of the ear, had shown him what insufficient accommodation
the General Hospitals offered for the treatment of diseases of the
special organs. As his letters show, he held a very high opinion of
Saunders’ professional abilities, and he saw only too clearly that the
nature of Saunders’ apprenticeship would prevent him being promoted
to any surgical post at either of the Borough Hospitals. Consequently
the idea suggested itself to him that a special hospital might be
established for diseases of the eye and ear, at which Saunders might
find a suitable field for the exercise of his skill and ingenuity.

Before taking any action in the matter, Saunders first sought the
advice of the physicians and surgeons of St. Thomas’s and Guy’s
Hospitals, and having obtained from them a testimonial of their
approbation, on October 1st, 1804, he published the following proposal
for instituting “A Dispensary for the Poor afflicted with Diseases of
the Eye and Ear,” with their testimonial attached:

  “Among the many charitable institutions which mark the wisdom and
  benevolence of the inhabitants of this Metropolis there is none
  particularly appropriated to the relief of the poor afflicted with
  diseases of the Eye and Ear. No diseases which do not affect the
  life of the patient are more distressing than such as are incident
  to these organs or demand greater dexterity and skill in their
  treatment. The structure of the Eye and Ear is so delicate and
  complex and their irritability under injury so extreme, that they
  cannot easily be treated but by those who make them the objects of
  peculiar study and attention. The acknowledged difficulty in the
  treatment of the diseases to which they are liable has induced a few
  to separate themselves from the general practice of professional
  duties and to devote themselves to the exercise of this branch alone,
  a fact which sufficiently establishes the necessity of making them
  the objects of a specific institution. Every surgeon must allow
  that most unremitting care and attention is necessary after some
  of the capital operations on the eye, and that through the want of
  it some of the most dexterous operations are frequently defeated.
  In large hospitals and dispensaries which embrace a variety of
  objects, where the medical attendants are deeply interested in the
  most formidable and excruciating diseases, it can rarely happen that
  sufficient leisure is afforded for the exercise of that strict care
  and attention which operations on the eye demand, much less will
  it happen, when patients are the subjects of fortuitous operations
  and retire afterwards to their own homes where they experience a
  miserable want of every comfort and convenience, that such operation
  can be successful. Impressed with these considerations the author of
  this address, who devotes himself to the treatments of diseases of
  the Eye and the Ear, solicits the public to patronise an institution
  which will enable him to extend relief to the poor afflicted with
  these diseases. An institution of this kind will be the means of
  restoring to society the exertions of many industrious individuals
  and will be established and carried on at a very moderate expense.
  The author of this address offers his services to the Charity without
  any emolument to himself and he pledges himself to the promoters
  of the institution, that the public shall reap the fruits of their
  beneficence.

  “J. C. SAUNDERS,

  “_Surgeon and Demonstrator of Practical Anatomy at St. Thomas’s
  Hospital_.

  “24, Ely Place, Holborn,

  “_October_ 1_st_, 1804.”

  “We are of the opinion that the establishment of the dispensary will
  prove beneficial, and is therefore worthy of public support, and that
  the author of the proposal is qualified to procure the accomplishment
  of its object.

  Signed:

  _Physicians of St. Thomas’s_.    _Physicians of Guy’s_.
    Wm. Lister, M.D.                 Wm. Babington, M.D.
    W. C. Wills, M.D.                James Curry, M.D.
    Thos. Turner, M.D.               M. Alexander, M.D.
    G. Gilbert Currey, M.D.

  _Surgeons of St. Thomas’s._      _Surgeons of Guy’s_.
    G. Chander.                      T. Foster.
    I. Birch.                        Wm. Lucas.
    H. Cline.                        Astley Cooper.”

As the outcome of the issue of this circular a committee was formed
which held its first meeting at the City Coffee House on January 4th,
1805, Mr. Benjamin Travers, a wealthy City merchant and the father of
the surgeon of the same name, being in the chair.

This Mr. Benjamin Travers, Sen., in the keen pursuit of knowledge,
had attended Astley Cooper’s lectures on anatomy, and had become so
interested in them and the lecturer, that he apprenticed his son to him
as a pupil, and later extended his patronage to the project of founding
an eye dispensary put forward by Cooper’s demonstrator and protégé.

At the meeting the following resolutions were moved and unanimously
agreed to:

  “That a dispensary be instituted under the name of the London
  Dispensary for the Relief of the Poor afflicted with Diseases of the
  Eye and the Ear, where they may apply and obtain advice and medicines
  gratis.

  “That the dispensary be situated in a central part of this city and
  contain beds for the reception of patients who undergo the operation
  for the cataract or any other operation of the eye requiring minute
  care.

  “That the Charity consist of a Treasurer, Governors, Secretary, and
  Medical Officers.

  “That Henry Kensington, Esq., be appointed Treasurer.

  “That a person contributing an annual subscription of one guinea
  be a governor and have the right of recommending and keeping under
  the care of the charity one out-patient, and if two guineas, two
  out-patients, and so in proportion to his subscription.

  “That patients admitted into the house be admitted according to
  priority of recommendation, except in cases of emergency, when the
  medical officers must determine.

  “That Mr. J. C. Saunders be appointed Surgeon of the Dispensary, and
  that Dr. Farre be appointed Consulting Physician in cases requiring
  medical aid.”

Richard Battley, who was then practising as an apothecary in St. Paul’s
Churchyard, undertook the duties of Secretary, which he continued to
discharge in an honorary capacity, with the utmost assiduity, for
fourteen years.

Many City merchants, with whom Saunders had no previous acquaintance,
became subscribers, and sufficient funds were soon forthcoming to
provide for the purchase of the lease of No. 40, Charterhouse Square,
for eighteen years, for the sum of £300 and an annual rental of £65.

PLATE II.

[Illustration: SHOWING THE SOUTH SIDE OF CHARTERHOUSE SQUARE AND NO. 40

Where the London Dispensary for Curing Diseases of the Eye and Ear was
first opened in 1805.]

On March 25th, 1805, _The London Dispensary for Curing Diseases of the
Eye and Ear_ was opened for the reception of patients.

Sir Charles Price, Bart., a former Lord Mayor, and Member of
Parliament for the City of London, accepted the post of President of
the Institution, and several of the Aldermen of the City became its
Vice-Presidents.

One Sarah Clark was appointed nurse and housekeeper, she being required
to act under the control of the Surgeon, who had power to dismiss her
for misconduct. She was allowed coals and candles and a gratuity at the
end of the year “such as the Committee may deem proportionate to her
services.” Her husband was subsequently engaged to dispense drugs, and
the two of them received £50 a year for their services, together with
the aforesaid coals and candles.

In 1804, after Saunders had brought forward his proposal for the
establishment of an Eye Dispensary, Mr. Wathen (afterwards Sir Wathen
Waller), an oculist of eminence, described to King George III. the sad
state of the soldiers and sailors who had returned from the campaign
in Egypt suffering from ophthalmia, and suggested the desirability
of establishing an Infirmary exclusively for eye diseases: “Their
Majesties and the Royal Family graciously and humanely approved of the
plan, and honoured it with their patronage and benefactions.” Such was
the origin of the Royal Infirmary for Diseases of the Eye, in Cork
Street, which commenced under Mr. Wathen, and was subsequently carried
on as a comparatively private institution, under the charge of Mr.
Charles Alexander, up to the time of his death in 1872.

This institution must not be confused with that started in the Western
district of London, by the Army surgeon Guthrie, in 1816, which exists
to-day as the Royal Westminster Ophthalmic Hospital.

That Wathen’s Infirmary was opened for the reception of patients three
months before the London Dispensary, though the proposal for its
establishment was not made until after the publication of Saunders’
circular, evidently caused the latter considerable annoyance, for in a
letter addressed to the Committee of the Dispensary in 1808 Saunders
writes:

  “Subsequently to the date of my Proposal, a similar Institution,
  honoured with the Royal Patronage, was formed and established in
  Westminster. Although the Prospectus of the Royal Infirmary was not
  heard of until many months after the Publication of my Proposal,
  yet it must be admitted that that Institution first appeared before
  the Public in a regular and organised form, and this, which is the
  original, is consequently considered by all who are unacquainted with
  the facts as the copy. Apprehensive of this impression, I immediately
  claimed by public advertisements, which were never answered, the
  priority of my Proposal.

  “I should be excused for thus obtruding on your notice if I sought
  merely the indulgence of honest pride, by maintaining this just
  claim to respect, but I shall yet more readily be excused, when
  you reflect, that if I had abandoned this claim, the Public would
  continue to regard me as an humble copyist.”

This Royal Infirmary, whose rivalry at its commencement caused Saunders
so much annoyance, continued in existence until Alexander’s death in
1872. It was then resolved at a meeting of its Life Governors and
Subscribers to close the Institution and to hand over the balance of
its funds, after the settlement of all its liabilities, to the Royal
London Ophthalmic Hospital. Two hundred pounds was ultimately received
by the Hospital, and three of the Committee of the old Infirmary were
elected as Life Governors, one of them being a relative of the late Mr.
Alexander.




CHAPTER II

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.[A]

  [A] 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.




CHAPTER III

BENJAMIN TRAVERS AND SIR WILLIAM LAWRENCE


The death of the founder of the Charity only five years after it was
first opened placed its Committee of Management in a most difficult and
unexpected position. Astley Cooper came to its immediate assistance,
conducting the operating department and frequently attending in
the receiving room until a new surgeon was appointed. Being keenly
interested in all branches of surgery, he was probably pleased to have
this opportunity of gaining experience in the surgery of the eye.

The vacancy was advertised in three leading London newspapers, several
applications being received in response. Amongst the candidates were
Saunders’ former pupil at the Infirmary, John Stevenson, and William
Lawrence (afterwards Sir William), who was then demonstrator of anatomy
at St. Bartholomew’s Hospital; both of these, however, withdrew their
applications in favour of Benjamin Travers’ who was unanimously elected
at a ballot of the General Committee.

Benjamin Travers was then twenty-seven years of age, and had been
a house pupil of Astley Cooper’s, of whom evidently he was a great
admirer, for in later years he wrote this description of him:

  “Astley Cooper, when I first knew him, had the decidedly handsomest,
  that is the most intelligent and finely formed countenance and person
  of any man I remember to have seen. He wore his hair powdered,
  with a queue, then the custom, and having dark hair and always a
  fine, healthy glow in his cheeks, this fashion became him well. His
  frequent costume during the summer when taking horse exercise (for
  at this season he rode daily on horseback) was a blue coat, yellow
  buckskin breeches and top-boots, then much in vogue.”

Travers had been articled at the Royal College of Surgeons for six
years; he was, therefore, unlike Saunders, eligible for appointment
as surgeon to a general hospital when a vacancy arose, and was so
appointed to St. Thomas’s Hospital in 1815. At the time of Saunders’
death he was demonstrator of anatomy at Guy’s Hospital and surgeon to
the East India Company.

In accepting the post of surgeon to the Eye Infirmary he did not, like
Saunders, devote himself exclusively to treating diseases of the eye
and ear, but combined the practice of ophthalmic surgery with that
of general surgery. In the preface of a book he subsequently wrote,
entitled _A Synopsis of Disease of the Eye_, he claims to have been the
first general hospital surgeon in this country to have given more than
a cursory attention to diseases of the eye. In doing so he incurred
no small risk to his reputation as a general surgeon, for, as already
stated, those who practised as oculists at that time were of but low
repute. His courageous and disinterested action in this matter served,
however, to raise the surgery of the eye out of the condition of
quackery into which it had fallen.

Shortly after Travers was appointed surgeon to the Infirmary it was
decided to increase its accommodation by providing eight additional
beds, so that other than cataract cases might be admitted.

In 1811, in accordance with the recommendation of Dr. Farre and Mr.
Travers, the practice of the Infirmary was opened to medical students,
and permission was granted to the medical officers to deliver lectures
on the subject of their profession. Thus was started the school of
ophthalmology which has since developed into a teaching centre of
worldwide renown.

PLATE III.

[Illustration: SIR ASTLEY PASTON COOPER, BART., F.R.S.

From an engraving by W. H. Mote, after a picture by Sir T. Lawrence,
P.R.A.]

Amongst the earliest students to avail themselves of the instruction
given were two young Americans, who had recently graduated in medicine
at the College of Physicians and Surgeons in New York, and who had come
to London to complete their training: Dr. Edward Delafield and Dr. J.
Kearney Rodgers. So impressed were they with the Institution and its
teaching that, on their return to New York in 1818, they determined
to establish one on similar lines in that city. In August, 1820, “The
New York Eye and Ear Infirmary” was opened, and continues as one of
the leading special hospitals of the sort in America at the present
time. It is interesting to note that whilst the parent Institution has
changed its title from that of “Infirmary” to that of “Hospital,” the
daughter Institutions both in Exeter and New York retain the older name.

Dr. Delafield later showed his appreciation of Travers’ teaching by
editing an edition of his _Synopsis of Diseases of the Eye_, which
was published in New York. As one of the first surgeons in the United
States to devote himself to the study of diseases of the eye, he was,
when the American Ophthalmological Society was founded in 1864, most
appropriately elected its first President.

A few years later Dr. Edward Reynolds came from Boston, Mass., to
London to pursue his medical studies. He attended the practice and
lectures at the Eye Infirmary under Benjamin Travers and William
Lawrence, and, in a letter written home to Dr. J. C. Warren, gave the
following description of the former:

  “He is not a very pleasant lecturer—his voice is low and his manner
  is very inanimate and uninteresting, but his matter, however, is very
  valuable.”

On Dr. Reynolds’ return from Europe he found his father blind from
cataract in both eyes. There were no specialists in that part of the
country at that time, so, fortified by his recent experiences in
London, he decided to operate, happily with complete success. The
following is an interesting description of this event, written by Dr.
Edward Reynolds’ grandson in 1910:

  “I well remember my grandfather’s telling me of his operation on
  his father’s eye. He told me that his father, finding his eyesight
  failing, made great efforts to accustom himself to its gradual
  disappearance and to the performance of his ordinary duties without
  the aid of sight, and that upon one occasion, after finishing the
  process of shaving between two windows in his room, he put away his
  razor and, turning to his wife, said to her: ‘My dear, I am at last
  totally blind, I can see nothing.’ My grandfather said that his
  father had written him nothing of this infirmity, which came on while
  he was a student in London; that it was, in consequence, a great
  shock to him to find his father blind. He said that on looking at the
  eyes, and satisfying himself that the blindness was due to cataracts,
  he thought the situation over; that his father was too old to take
  the sailing voyage to London and, so far as he knew, no operation
  for cataracts had been performed in America, and certainly none in
  this locality; that he was therefore probably better qualified than
  any one available for the performance of the operation; and that he
  decided to attempt it. He said: ‘I went into my closet and offered a
  prayer to Deity for success, took a glass of sherry and went ahead to
  do my best.’ The three phrases of this sentence have always seemed to
  me exceedingly characteristic of the man as I knew him.”

The success of the operation becoming widely known led to the
foundation of Dr. Reynolds’ reputation as the leading surgeon in
Boston in diseases of the eye, and to the foundation in 1824 of “The
Massachusetts Charitable Eye and Ear Infirmary.”

As already mentioned, Travers held the appointment of surgeon in
London to the East India Company. In 1819 its Honourable Directors
became impressed by the great prevalence of eye disease in the large
and populous districts over which they ruled, and applied to Travers
in the matter. He pointed out to them the excellent results which
had followed the establishment of the Eye Infirmary in London, and
that similar Institutions might be started in India. This advice was
accepted, and Mr. R. Richardson, one of the Company’s surgeons, who
had studied ophthalmology under Travers, was sent to Madras, where he
founded “The Madras Eye Infirmary,” which was each year resorted to by
increasing numbers of patients. The Infirmary has been several times
enlarged, and in 1888 its name was altered to that by which it is now
known, “The Government Ophthalmic Hospital.”

Stimulated by the success which attended the establishment of the
Eye Infirmary in Madras, the East India Company determined to start
similar Institutions in other provinces. In 1824 two other surgeons
who had studied at the London Eye Infirmary were sent out to India for
this purpose: Mr. Jeafferson went to Bombay and Mr. C. J. Egerton to
Calcutta, where each of them founded an Eye Hospital.

During the first seven years that the London Eye Infirmary was open for
medical students 412 pupils received instruction there, of whom fifty
were physicians and the rest surgeons. They came not only from the
three divisions of the United Kingdom, but also from India, America,
Germany, Portugal, and other countries; many of them held important
posts in the Army and Navy. Ten years later still it is recorded that
the number who had received instruction at the Institution considerably
exceeded one thousand, and that they were spread over every part of the
world.

In 1814 Travers found the increasing number of patients coming to
the Infirmary made the work so arduous that it was impossible for
one individual to cope with it satisfactorily, and he wrote to the
Committee requesting them to appoint a second surgeon to co-operate
with him. This they readily agreed to, and, at a meeting of the General
Committee, with whom the election of members of the medical staff
then rested, William Lawrence, demonstrator of anatomy and assistant
surgeon to St. Bartholomew’s Hospital, was appointed.

One of Travers’ earliest surgical achievements was the cure of a
pulsating tumour of the orbit, described as an aneurism by anastomosis,
by ligature of the common carotid artery. It was the first case
in which such treatment had been employed, and the second case on
record of successful ligature of that artery. He communicated the
case to the newly formed Medico-Chirurgical Society in 1809. He was
possessed of considerable literary ability, and rendered Sir Astley
Cooper considerable assistance in collaborating with him in the
production of a volume of surgical essays. In 1815 Travers was elected
a Fellow of the Royal Society, and in 1820, after he had resigned
his appointment at the London Eye Infirmary, published the treatise
already referred to, entitled _A Synopsis of Diseases of the Eye_,
which he dedicated to Dr. J. R. Farre, in esteem for his character,
admiration of his talents, and gratitude for his friendship. This book
had the merit of being entirely the outcome of his own observations at
the Eye Infirmary, and was not a compilation of the work of others.
It is stated to have been the application of Hunterian principles
of inflammation to the diseases of the eye. That it met with a wide
appreciation is shown by its having passed through three editions, by
its having been translated into Italian, and by its being reedited and
reproduced in New York by Travers’ former pupil, Dr. Delafield.

From a writer of an obituary notice we get the following description of
Travers as a man:

  “He was tall, large formed, and well proportioned, with a highly
  intelligent and pleasing countenance. His manners were prepossessing,
  and in consultation with his professional brethren he showed a
  high-bred courtesy which marked the refinement of his mind.”

Pressure of work, and some fears as to his health, necessitated his
retirement from the staff of the Eye Infirmary in 1817. He lived,
however, until 1858, and was twice elected President of the Royal
College of Surgeons. The year before his death he was appointed
serjeant surgeon to Queen Victoria.

PLATE IV.

[Illustration: BENJAMIN TRAVERS, F.R.S.]

The chief financial support of the Infirmary for many years after its
foundation was derived from subscriptions and donations received at its
anniversary dinners. The exhibition of patients at these dinners was
apparently continued until 1812, for a minute of that year states that
their attendance was in future to be dispensed with.

Another method of raising funds in support of the Charity was to obtain
the services of some eminent divine to preach a sermon on its behalf
on the Sunday before the dinner, with permission for him to do so at
one of the City churches. Alderman Ansley, who had been one of the
Infirmary’s most jealous supporters since its conception, in the year
of his Mayoralty, not only presided at its annual meeting of Governors
and at the anniversary dinner, but also attended in state at Bow Church
when the Rev. Henry White preached a sermon in support of the Charity.

It is interesting further to note that, in spite of the Peninsular War,
which is said to have cost England £100,000,000, and of the European
campaign which followed Napoleon’s escape from Elba and ended with the
Battle of Waterloo, the funds of the Charity showed a steady increase,
both that for general purposes and one started in 1813 for purchase
of a freehold and the erection of a suitable building. In 1815, the
Waterloo year, the anniversary dinner was held in May, presided over by
the President, Sir Charles Price, Bart., and the anniversary sermon was
preached at St. Botolph’s, Aldersgate Street, before the Lord Mayor.
The invested fund for general purposes in April that year amounted to
£2,415, and the building fund to £852; in October the general purposes
fund had increased to £2,800 and the building fund to £1,160.

The rapid increase in the work of the Infirmary, both in the in-
and out-patients’ departments, necessitated in 1816 a reorganization
of its resident staff, and it was arranged that this should consist
of a housekeeper and sister with a salary of 25 guineas per annum, a
housemaid at 10 guineas, a cook at 12 guineas and a resident apothecary
and sub-secretary at £50 per annum. A year previously a dispenser had
been appointed to make up and distribute drugs for the patients in
place of Mr. Clarke, the porter; it was now decided that these duties
should be performed by a resident officer. From the rules drawn up
detailing the apothecary’s duties, they would seem to have included
all those now performed by the house surgeons, dispensers, and the
assistant secretary.

His first and most important occupation is defined as follows:

  “To compound and dispense the medicines, to cup, bleed, apply
  leeches, dress setons, etc., and to obey orders of the Medical
  Directors relative to the business of the Infirmary.”

The withdrawal of blood was regarded at that time as of the utmost
importance for the reduction of inflammatory conditions of the eye,
and the apothecary must have had his time fully occupied in this way.
Respecting the general principles for its employment, Lawrence wrote:

  “Of the means of reducing inflammation, abstraction of blood is the
  most powerful. Blood is the material by which the increasing action
  of the part is maintained. In the figurative language, which the
  obviously increased heat has suggested, we may say that it is the
  fuel by which the fire is kept up. If we could completely command the
  supply of blood, the increased action might be effectively controlled
  or arrested. In comparison with the loss of blood, all other means
  are of minor importance in lessening the local disorder and quieting
  the general disturbance.”

Regarding the quantity of blood to be drawn from the arm, he says:

  “We cannot determine the amount beforehand; we cannot decide that
  ten, twelve, or sixteen ounces will be sufficient; it may be
  necessary to take twenty, thirty, or forty ounces, or to produce
  syncope, if you cannot otherwise make the requisite impression on the
  vascular system.”

After venesection the next best method of taking blood is:

  “By cupping from the back of the neck or the temple, especially
  the latter, from which blood can be obtained quickly and in large
  quantity. Branches of the temporal artery are commonly wounded in
  this operation, facilitating the abstraction of the blood, and
  causing neither danger nor inconvenience.”

With regard to the use of leeches he writes:

  “It is a common error here, as in other inflammations, to apply them
  in too small a number; if the disease be active and the patient
  adult, it will seldom be proper to put on fewer than twelve, while
  eighteen or twenty-four will more frequently be necessary, in order
  to produce decided benefit.”

In a book published “on the traffic with leeches” in 1826, it is stated
that not less than seven million two hundred thousand of these animals
were annually sent to England.

This so-called “antiphlogistic treatment,” which was so implicitly
relied upon in those times for the relief of inflammation in the eye,
consisted, not only in the withdrawal of blood, but also in purging,
dieting and the administration of tartar emetic to excite perspiration,
nausea, or vomiting Lawrence writes:

  “It is not sufficient in the treatment of inflammation to diminish
  the quantity of the circulating fluid by the abstraction of blood, we
  must prevent the introduction of further supplies into the vascular
  system by the use of purgatives and the regulation of diet.”

The diet of the patients in the Infirmary, from the table then in use,
seems, according to our present standards, to have been both meagre
and monotonous. It was arranged under three headings, “Low diet”;
“Reduced diet”; and “Full diet.” Low diet consisted of milk pottage
or gruel, with 12 oz. of bread for women, and 1 lb. for men. Reduced
diet consisted of the same allowance of bread, but included broth
in addition to milk pottage. Full diet had, in addition to the milk
pottage and bread, 8 oz. of meat, broth and vegetables for dinner, and
one pint of small beer.

In 1817 new regulations were drawn up for the election of medical
officers. The qualifications required of candidates for the offices
of physician, surgeon, and apothecary were as follows: _Physician_:
that he be a Fellow or Licentiate of the London College of Physicians,
or a Bachelor of Medicine of one of the English Universities.
_Surgeon_: that he be a Member of the College of Surgeons, and have
served an apprenticeship at one of the hospitals of this Metropolis.
_Apothecary_: that he be a Member of the College of Surgeons, and a
Licentiate of the Society of Apothecaries. It was further arranged that
the election of medical officers should be vested in the Governors, and
not left to the General Committee, as was previously the case.

After these regulations had been passed Travers resigned the post
of surgeon, which he had held for seven years, and was elected a
Vice-President. It had been a source of great satisfaction to him to
have had a man of William Lawrence’s professional attainments appointed
as his colleague on the staff. In the year previous to his joining the
Infirmary Lawrence had been elected a Fellow of the Royal Society, and
appointed assistant-surgeon to St. Bartholomew’s Hospital. Travers
felt that, with Lawrence’s co-operation, his unprecedented step of
associating the practice of an oculist with that of a general surgeon
was being justified. The Infirmary also gained a better reputation in
the profession, by showing that it was not merely the offshoot of one
hospital, but was prepared to appoint as members of its staff those
educated at, and connected with, other institutions.

William Lawrence not only became the leading ophthalmic surgeon of
his time, but also a leading general surgeon, a philosophic writer,
an eloquent teacher and lecturer, and a strongly combative medical
politician. It is unnecessary here to go into the inconsistencies in
his career, such as the withdrawal from publication of his book on the
_Comparative Anatomy, Physiology, Zoology, and Natural History of Man_,
when it aroused an angry outcry from the orthodox religious folk of the
day; and his change from being a leading reformer of the constitution
of the College of Surgeons to one of its most vigorous supporters. In
his recognition of the importance of a knowledge of diseases of the eye
by medical men he always remained firm, being the first to advocate
that a course of instruction in it should be included in the medical
curriculum. In an introductory chapter to his _Treatise on Diseases
of the Eye_, he urged that the course of procedure in the study of
ophthalmology should be the same as that for diseases in general,
and be founded on the science of anatomy, physiology, pathology, and
therapeutics. He pointed out that the instruction given at the Eye
Infirmary was intended to impart to physicians and surgeons a knowledge
of ophthalmic disease, and not merely to make oculists.

In this same introductory chapter he gives a short history of
ophthalmology, from which some points may here be quoted. Amongst the
ancient Egyptians there were specialists for affections of the eye, as
there were for every other class of disease. Herodotus tells us that
Cyrus, King of Persia, sent to Amasis, King of Egypt, for an oculist.
The extent of the Greeks’ knowledge of eye disease is evidenced by the
imperishable records of language, for many of them still bear the names
given to them by the ancient Greek writers. That the Roman Emperors
Augustus and Tiberius had oculists is evident from inscriptions on
seals. In the fifteenth, sixteenth, seventeenth, and first half of
the eighteenth centuries, the management of diseases of the eye was
left to quacks, mountebanks, and itinerant practitioners, the French
writers on the subject, Maitre-Jan, St. Yves, and Janin, being more
respectable than their contemporary brethren in other countries.
The anatomy of the organ began to be more carefully cultivated by
the Germans about the middle of the eighteenth century, when Zinn,
Professor of Anatomy at Gottingen, published his excellent _Descriptio
Anatomic Oculi Humani_, and later Soemerring his _Icones Oculi Humani_,
with its beautiful and accurate engravings. Boerhaave of Leyden made
some study of the pathology of the eye in his _De Morbus Oculorum_.
But the most important era in the history of ophthalmic surgery was
the establishment of the Vienna school of ophthalmology in 1773, by
Joseph Barth, who was appointed lecturer on ophthalmic surgery in
the University of Vienna in that year. He was succeeded by Schmidt,
and afterwards by Beer, who held the post of Professor of Ophthalmic
Medicine in the University for many years, wrote several theses on the
subject, and attracted students to his clinic from all parts of Europe.

If a man’s worth is to be judged by the estimates of those who were
his pupils and assistants, then indeed Sir William Lawrence must be
described as great. Sir James Paget, who in his day was the most fluent
and mellifluous orator in the medical profession, said in describing
Lawrence’s teaching:

  “It was the best method of scientific speaking that I ever heard,
  and there was no one, at that time in England, if I may not say in
  Europe, who had more completely studied the whole principle and
  practice of surgery.”

Sir William Savory, Lawrence’s most devoted disciple, who described him
as “a model of intellectual beauty,” speaks of

  “his natural grace and dignity of bearing,” of “his vast and
  capacious intellect,” of “his unfailing fluency of pure and
  perspicuous language,” and says “he touched nothing that he did not
  adorn.”

PLATE V.

[Illustration: SIR WILLIAM LAWRENCE BART., F.R.S.

From an engraving by E. R. Whitfield, after a picture by Pickersgill,
R.A.]

On the vacancy on the staff being advertised after Travers’
retirement, applications were received from Edward Stanley, a former
pupil at the Infirmary, who was then demonstrator of anatomy at
St. Bartholomew’s Hospital; Frederick Tyrrell, who had served his
apprenticeship under Sir Astley Cooper at Guy’s and St. Thomas’s
Hospitals, who had also studied at Edinburgh University, and worked in
the Military Hospital at Brussels after Waterloo; Samuel Cooper, whose
name is famous in connection with his _Dictionary of Surgery_, Henry
Earle, surgeon of the Foundling Hospital and assistant-surgeon to St.
Bartholomew’s Hospital.

It soon became evident that the Governors were in favour of a
candidate coming from St. Thomas’s Hospital, with which Travers, who
was retiring, was connected, and the other candidates withdrew their
applications, expressing their wish to come forward again on some
future occasion, so that Tyrrell was elected.

Lawrence continued as senior surgeon to the Infirmary until 1826,
retiring at the age of forty-three. Both he and Dr. Farre were regular
attendants at the meetings of the Committee of Management, and lent
valuable aid and advice in the arrangements connected with the building
of the new Infirmary at Moorfields.

After his retirement he published a book on _The Venereal Diseases
of the Eye_. Previous to its appearance, affections of the eye had
received but scant attention from writers on venereal diseases in this
country, though they had been dealt with more extensively by Schmidt
and Beer in Vienna. The former seems to have been the first to describe
inflammation of the iris, and to have used the term “iritis.”

In the first chapter of the book Lawrence says:

  “The venereal diseases of the eye have been mentioned by many
  writers, but, for the most part, in such general terms as to convey
  no clear information respecting the circumstances under which they
  arise, their characteristic appearances, their progress, effects, or
  treatment. Hence, although one of these affections, namely acute
  gonorrhœal inflammation of the conjunctiva, is of the most violent
  and rapidly destructive kind, and another, syphilitic iritis,
  produces, more or less speedily, changes of structure which injure or
  destroy sight, they have entirely escaped the notice of some modern
  writers in this country, who have been regarded as the principal
  authorities on the venereal diseases.”

The book gives a full account of the nature, symptoms, and treatment of
these diseases, based entirely on Lawrence’s own experience. The notes
of the cases from which his descriptions were drawn are appended, most
of them having been under his care at the Eye Infirmary, thus bearing
evidence to the advantage of a special hospital in supplying material
for the study of the natural history of disease.

In 1833 he published his _Treatise on Diseases of the Eye_, a most
scholarly work, based, as he says in the advertisement, on the lectures
on Anatomy, Physiology, and Diseases of the Eye, which he delivered
at the London Ophthalmic Infirmary, and which were reported at the
time in the _Lancet_. It contained not only the outcome of his matured
experience, but also references to the views and practice of all the
best known European writers. It is probably one of the best, if not the
best, book dealing with eye disease in pre-ophthalmoscopic times; two
further editions were published in England and one in America. It was
also translated into several foreign languages, part even into Arabic.

Lawrence continued to hold his post of surgeon to St. Bartholomew’s
Hospital until 1865, when he retired at the age of eighty-two, no age
limit having been fixed previous to his appointment. In 1867 he was
appointed serjeant surgeon to Queen Victoria, and in 1867 was made a
Baronet, but died the following year.

In 1818 Richard Battley, who had gratuitously performed the duties
of secretary to the Institution since its establishment, found it
necessary to resign. He did not, however, cease to interest himself in
the work of the Charity he had helped to found; he continued to attend
its Committees, and, as we shall see later, he taught and lectured to
students on matters connected with pharmaceutical subjects.

In the same year the Infirmary lost, through death, two of its earliest
and most enthusiastic supporters, its first President, Sir Charles
Price, Bart., and the Chairman of its Committee, Mr. Harry Sedgwick. To
the post of President thus left vacant Mr. William Mellish, M.P., was
elected. The name of Sedgwick is still held in grateful remembrance at
the Hospital, and will be as long as it continues, for in his will he
provided for its endowment, as is shown by the following extract:

  “I leave the interest of the remainder of my Property to my wife and
  children or the survivors of them for their lives, and to my sister
  if she survives them for her life. After her decease, I leave in
  trust the principal, to be invested in the 3 Per Cent. Consols, in
  the names of the President, Treasurer, Physician, and Surgeon of
  the London Infirmary for Curing Diseases of the Eyes, now situated
  in Charterhouse Square, the principal on no account whatever to be
  touched, but the interest as it arises to be applied to the benefit
  of that truly benevolent and valuable Institution for ever.”




CHAPTER IV

REMOVAL TO MOORFIELDS


The lease of the house in Charterhouse Square was purchased for a
period of eighteen years; at the end of nine years it became obvious
that, to cope with the continuously increasing work of the Charity, it
would be necessary when the lease expired to provide larger and more
commodious premises. It was, therefore, decided in 1813 to open a fund
for the provision of a suitable freehold and building. To this fund the
Lord Mayor, Aldermen, and Common Council of the City of London, as a
mark of their approval, contributed £100.

In March, 1819, a Building Committee was appointed to find a suitable
site and to draw up plans. The possibility of acquiring from the City a
piece of ground in Moorfields soon came under consideration. Frederick
Tyrrell was the son of Timothy Tyrrell, who was the City Remembrancer
and resided at the Guildhall, and it was with his aid that negotiations
for this site were entered into. Timothy Tyrrell became a member of the
General Committee of the Infirmary, and his eldest son, John Tyrrell, a
barrister, became an active member of the Building Committee.

Though the option for refusal of a plot of land to the north of the
Roman Catholic Chapel in Moorfields was then obtained from the City,
it was not until more than a year later that an agreement to acquire
the freehold was decided upon. In the meantime, several other possible
sites had been inspected and rejected.

It was in October, 1820, that, at a meeting at the Guildhall with the
Committee of the City Lands, the following terms were finally entered
into:

  “That the Infirmary should acquire the freehold of a plot of land
  on the North-East side of Moorfields, to the extent of 88 ft. in
  width and 85 ft. in depth, for the sum of £800, to be paid at the
  time of the roof of the intended building being complete, and that
  a pepper-corn rent only be paid from Christmas next until Lady Day
  1822. The Institution to be at the expense of preparing the Title.”

Robert Smirke, F.R.S., F.A.S., R.A. (afterwards Sir Robert), was
commissioned to prepare plans for the building, the expenses of which
were to be limited to £5,000. Subsequently Smirke found that, in
consequence of the unexpected loose nature of the land of the site
chosen, extra expense would be incurred in forming the foundations of
the proposed building, and the limit of the amount was increased to
£5,500.

On May 2nd, 1821, the General Committee of the Infirmary, after
having assembled at the City of London Tavern, proceeded with the
President to the ground in Moorfields to lay the foundation stone of
the new building, in which stone was deposited the following coins: 1
sovereign, 1 half-sovereign, 1 crown, 1 half-crown, of the reign of
George IV.; 1 shilling, 1 sixpence, and in silver, one piece value each
4d., 3d., 2d., 1d., of the reign of George III.; upon these was placed
a brass plate having the following inscription engraved thereon:

  “London Infirmary for Curing Diseases of the Eye, founded by the late
  John Cunningham Saunders Esq., A.D. MDCCCIV. The foundation-stone of
  the new building for the same Institution, henceforth to be entitled
  The London Ophthalmic Infirmary, was laid in Moorfields, on the
  second day of May, 1821, by the President.

               _Patron_: Field-Marshal His Royal Highness
                      the Duke of York, K.G., etc.

                   _President_: William Mellish, Esq.

                           _Vice-Presidents_:

  St. Asaph, The Right Rev.        Sir Charles Flower, Bart., Ald.
    Lord Bishop of.                Thos. F.  Foster, Esq.
  John Ansley, Esq., Ald.          Sir William Leighton, Ald.
  John Julius Angerstein, Esq.     Sir Charles Price, Bart.
  William Babington, M.D., F.R.S.  Jeremiah Olive, Esq.
  George Bainbridge, Esq.          Thomas Rowcroft, Esq.
  Thomas Boddington, Esq.          Sir James Shaw, Bart., Ald.
  George Byng, Esq., M.P.          John Thompson, Esq.
  Henry Cline, Esq, F.R.S.         Benjamin Travers, Esq., F.R.S.
  Astley Cooper, Esq., F.R.S.      Sir Robert Wingram, Bart.


                _Treasurer_: Michael Bland, Esq., F.R.S.

                          _Medical Directors_.

                 _Physician_: John Richard Farre, M.D.
               _Surgeons_: William Lawrence, Esq., F.R.S.
                        Frederick Tyrrell, Esq.

                              _Committee_:

  Aaron, Lewis, Esq.               Kerr, Niven, Esq.
  Bainbridge, John, Esq.           Mackie, John, Esq.
  Bonsor, Joseph, Esq.             Mellish, Thos., Esq.
  Blades, John, Esq.               Ommanney, Sir F. M., M.P.
  Brandain, Samuel, Esq.           Pearce, J. M. , Esq.
  Brown, Thomas, Esq.              Price, Ralph, Esq.
  Browning, William, Esq.          Price, Richard, Esq.
  Brydon, William, Esq.            Price, Charles, Esq.
  Battley, Richard, Esq.           Russell, Rev. John, D.D.
  Cazenove, John, Esq.             Read, Samuel, Esq.
  Clarke, John, Esq.               Row, William, Esq.
  Cohen, Joseph, Esq.              Rudge, Rev. Jas., D.D., F.R.S.
  Crawley, William, Esq.           Smirke, Robert, Esq.
  Croskey, J. D., Esq.             Solly, Thomas, Esq.
  Curtis, Timothy, Esq.            Sparks, R. W. , Esq.
  Dean, John, Esq.                 Towle, Thomas, Esq.
  Elgie, William, Esq.             Thomas, John, Esq.
  Gamble, Robert, Esq.             Tyrrell, John, Esq.
  Hartshorne, John, Esq.           Tyrrell, Timothy, Esq.
  Heathfield, Richard, Esq.        Warburton, Thos., Esq.
  Hodgkinson, John, Esq.           Ward, Samuel, Esq.
  Horner, John, Esq.               Yates, William, Jun., Esq.


  _Hon. Chaplain_: The Rev. Thos. Gill, M.A.
  _Solicitor_: Robert Pitches, Esq.
  _Secretary_: Matthew Heathfield, Esq.
  _Apothecary_: Mr. Charles Craddock.
  _Architect_: Robert Smirke, Esq., F.R.S., F.A.S., R.A.”

A prayer suitable to the occasion was offered up to Almighty God by the
Chaplain.

At six o’clock the Governors and friends of the Charity dined at the
City of London Tavern, when contributions since January 1st of that
year were announced to the amount of about £1,200 for the building fund.

Moorfields was originally a piece of moorland lying to the north of
the old City wall, access to which was obtained through the Moorgate.
Early in the seventeenth century it was drained, laid out in walks, and
planted with trees. For a long time it remained a place of recreation
and jollification for the City folk—a place of swings and roundabouts,
as is described in the following verses in the vade mecum for malt
worms:

  “In Moor’s most pleasant Field, where Northern Lads
  With Western Youths contend for broken Heads,
  And where our Weal thy Citizens repair
  To lengthen out their Lives with wholesome Air;
  Jointing to Trotter’s famous Castle, stands
  A noted Mansion built by artful Hands;
  Where Young and Old, at small Expense can find
  Delightful Pastimes to refresh the Mind.
  Hither the sprightly Genius has recourse
  To practise Riding on the Flying-Horse;
  Where danger-free, he through the Air may scow’r,
  And, void the Wings, fly fifty miles an Hour;
  Nor that has this Courser, tho’ he runs so fast,
  One living Leg to expediate him hast,
  Yet carries double, treble, if requir’d,
  But never stumbles or is ever tir’d.
  As for the pregnant Wife, or tim’rous Maid,
  Here’s a true South-Sea Coach, that sporting flies
  Between the humble Earth and lofty skyes,
  Manag’d to rise and fall with little Pains,
  Like the uncertain Stock that turns our Brains.
  Liquors, the best, are also vended here,
  From Heav’nly Punch to Halsey’s Noble Beer,
  By gen’rous Whitehead, who deserves the Bays
  From all the Sons of Malt that Merit praise;
  Therefore, if any will prove the Poet just,
  Thither repair and you will surely find
  Your entertainment good and Landlord kind.”

In a map of London of the middle of the eighteenth century Moorfields
is shown divided up into three sectors, Upper, Middle, and Lower. The
site of the Upper Moorfields is now marked by Finsbury Square, and that
of Lower Moorfields by Finsbury Circus; Middle Moorfields lay between
the two.

It was at the north-east corner of Lower Moorfields that the Infirmary
was erected. No paved roads led up to it, only tracks: one of these to
the north, then called Broker Row, became Eldon Street, another leading
out of London Wall to Broker Row became Blomfield Street. It was in
the angle between these two streets that the Infirmary was situated.
The site now occupied by Broad Street Station, directly opposite the
Infirmary, was then an open space.

On the laying of the foundation-stone of the new building its name
was changed, for the third time, to that of “The London Ophthalmic
Infirmary and this was yet again altered in 1837, under circumstances
that will be mentioned later, to that which it now bears, “The Royal
London Ophthalmic Hospital.” The name, however, by which it is most
generally known is “The Moorfields Eye Hospital,” though it has never
been officially so designated.

PLATE VI.

[Illustration: THE LONDON OPHTHALMIC INFIRMARY AS FIRST ERECTED AT
MOORFIELDS IN 1822.

From an engraving by R. Acon, after a drawing by Tho. H. Shepherd.]

It was not the first “Moorfields Hospital”; if a patient had said that
he had been an inmate of “The Moorfields Hospital” in the eighteenth
century he would have been regarded as an escaped lunatic. “The
Bethlehem Royal Hospital” for lunatics was built on the south side of
Lower Moorfields in 1675; it was a substantial building accommodating
150 patients, and remained in existence until 1815, when it was
removed to Lambeth. To go and see the lunatics at Moorfields was for
over 200 years one of the sights of London, the public being admitted
to view the poor wretches on the payment of a small charge. It is
stated that as much as £400 a year was received towards the upkeep of
the Institution in this way; the chains with which the patients were
secured and the other sufferings to which they were subjected is,
however, not part of this history.

The architect of the Ophthalmic Infirmary, Robert Smirke, R.A., who
was knighted in 1832, has left his mark deeply impressed on London;
to him we owe, amongst other important London buildings, the British
Museum, Covent Garden Theatre, the East Wing of Somerset House, the
College of Physicians, and the Carlton and other Clubs. The Infirmary
in its original state was a plain, unpretentious, but not unpleasing
structure; in later years, whatever merits its external appearances
originally possessed were destroyed by the addition of a new wing
on one side and an upper storey. It originally consisted of three
floors, a flight of stone steps leading up to the entrance hall in
the centre of the ground floor. The out-patient consulting room was
on the right of the entrance hall, and a room was specially set apart
for Dr. Farre’s use on the left. In the basement, besides the kitchen,
etc., there were the porters’and maids’ rooms, and the one bathroom
and wash-house. On the first floor, in the centre, was the operating
theatre, on the right a committee room, and on the left a room
designated as the library, but not used as such for some years. The
apothecary and the nurse-housekeeper also had their apartments on this
floor, the second floor being devoted to wards for the patients.

The in-patients in the house in Charterhouse Square were restricted
to operation cases, and cases of purulent ophthalmia; with increased
accommodation in the new building no such restrictions were made, and
a nurse was engaged to assist the nurse-housekeeper. To relieve the
apothecary of some of his duties, a professional cupper was appointed
to attend three days a week, and a room was set apart for him in the
basement in which to carry on his sanguinary proceedings.

Smirke, the architect, advised the Committee of the Infirmary, and
as afterwards turned out most wisely, to secure the vacant land in
its immediate vicinity with a view to possible future extensions. The
ground immediately behind the Infirmary, having a frontage of 36 feet
to the north and a depth of 69 feet, had already been disposed of by
the City to a Mr. Turner, who consented to part with his purchase for
£15 per annum, or at twenty years’ purchase, £300, for which latter it
was ultimately secured.

When the building of the new Infirmary was completed, work commenced
there without any ceremonial opening procedure. The first committee
meeting held in it was on October 2nd, 1822, and it must have been
opened for the reception of patients the same month.

On November 12th, 1822, Dr. Farre delivered to the pupils an
introductory lecture in which he announced the arrangement of the
following courses of instruction:

  Lectures on Morbid Anatomy illustrative of the Practice of Physic in
  general, as well as Ophthalmic Medicine in particular. To be given
  occasionally and separately announced.

  By Dr. J. R. Farre, Physician to the Infirmary.

  Lectures of the Anatomy, Physiology, and Diseases of the Eye. First
  Course on Tuesdays, Thursdays, and Saturdays at half-past 5 o’clock.
  Second and subsequent courses on Tuesdays and Saturdays at the same
  hour.

  By Mr. William Lawrence, F.R.S., Senior Surgeon to the Infirmary.

  Clinical Lectures, on select cases of Ophthalmic Diseases occurring
  in the In- or Out-Patients of the Infirmary. To be given on days and
  at hours adapted to the convenience of the pupils.

  By Mr. F. Tyrrell, Junior Surgeon of the Infirmary.

  Lectures in Optics. To be given on Thursdays at 7 o’clock in the
  evening.

  By the Rev. T. Gill, M.A., Hon. Chaplain to the Infirmary.

Dr. Farre concluded his announcement of these lectures with the
following remarks:

  “There remains one subject of great interest—The Chemistry of
  Light—to which I have invited the attention of Mr. Battley, not
  because he was the oldest and most faithful friend of Mr. Saunders,
  but because he has actually worked for a long time at that part of
  the subject which respects the vegetable kingdom, and his labour has
  deservedly attracted the attention of the College of Physicians. I
  think that the profession is much obliged to him, and I shall do
  everything in my power to promote his very interesting enquiries
  respecting the composition and decomposition of those more important
  vegetable substances which form a part of the Materia Medica. His
  success in the decomposition of opium, and in the discovering the
  _Liquor Opii Sedativus_, one of the most valuable preparations of
  opium, whether externally applied for the mitigation of extreme
  suffering, as in the cancerous fungi of the eye and other parts
  of the body, or internally administered for the cure of various
  irritative diseases, and his beautiful preservation of the natural
  green pigment and medical virtues of other preparations of the
  narcotic tribe, as _Digitalis Conium_, and the like, induced me,
  in July last, to invite him to communicate his thoughts on those
  subjects to the class of the Infirmary, and, in a letter received
  only this day, he has led me to hope that he will indulge my wishes
  in the spring of the ensuing year.”

To what extent this ambitious programme of instructions was carried
out is uncertain. Of Dr. Farre’s teaching but few records remain; with
regard to it, Lawrence said in the introductory chapter of his treatise:

  “Dr. Farre set the example at the Infirmary, of applying the general
  principles of pathology and therapeutics to the elucidation and
  treatment of ophthalmic diseases. In the clinical illustration of
  cases, the exposition of curative indications and simplicity of
  treatment, he could not be surpassed. All who have had the advantage
  of his instructions will remember them with gratitude and respect,
  and will regret that he has not communicated to the public, through
  the Press, the interesting results of his long practice, his close
  observation and mature reflection.”

The report of one of his lectures at the Infirmary in the _Lancet_
gives anything but a good impression of him as a teacher; it is a long
rambling discourse, professedly on the cardiac system, with but scant
reference to eye disease, and set out with scriptural quotations and
protests against materialism. We learn, however, from it that he had
previously delivered a course of lectures on the gastric system as
applicable to ophthalmic medicine.

Lawrence’s lectures were reported as they were delivered in the
_Lancet_ in 1825–26, and subsequently formed the basis of his treatise.
The Rev. T. Gill resigned his appointment as Chaplain to the Infirmary
in February, 1823, owing to some disrespectful behaviour to him on the
part of the housekeeper, for which she was duly reprimanded. So he
could only have given one course of instruction on optics; there is no
record of any of his successors taking on a similar duty.

A room in the basement, which it had been suggested to Battley might be
used by him as a laboratory and museum, was not found suitable for that
purpose, and the courses of instruction which it was suggested that he
might give in Materia Medica seem to have been left in abeyance until
the establishment of what was termed “The Saunderian Institution.”

Besides the unoccupied land behind the Infirmary, already referred
to, there was another piece to the south of it, lying between it and
the Roman Catholic Chapel. The leasehold of this was offered to,
and secured by, Dr. Farre, who subsequently transferred it to the
Infirmary. Part of the agreement permitted the previous owner of the
lease to erect a stable for his own use on about two-thirds of the
site, for which he was to pay only a peppercorn rent. On the remaining
one-third, Dr. Farre obtained permission to erect, at the expense of
the Saunderian Fund, which had been established by him, a building to
be called “The Saunderian Institution.” The purpose of this Institution
was the cultivation of minute anatomy, especially of the eye, and a
general analysis of the Materia Medica to increase the remedial agents
of the Hospital, as well as benefit the profession. The management of
the Institution was to remain entirely in the hands of Dr. Farre during
his life.

“The Saunderian Fund” was one specially established for the erection
of a monument to John Cunningham Saunders; to it Dr. Farre himself
contributed £120, and to it also were added the proceeds of the sale
of the second edition of Saunders’ book edited by Dr. Farre. Out of
the fund a bust of the late J. C. Saunders was constructed, which now
stands in the entrance hall of the present Hospital; the remainder of
it seems to have been devoted to this Institution.

In the year 1827, the Laboratory of the Institution was opened by Mr.
Battley for the analysis of the vegetable substances of the Materia
Medica, with a view to the improvement of Pharmacy, by showing wherein
the efficient powers of these substances reside and by what means the
most useful preparations of them may be obtained. It appears that he
held large classes of students there, more than 2,000 from various
Medical Schools, British and foreign, having attended for instruction.

Dr. Farre, in an Introductory Lecture entitled “Apology for British
Anatomy,” at the opening of the pathological department of the
Institute, or Academy, as he sometimes described it, pointed out that
the objects which it had in view were: the study of the anatomy of
structure; the performance of post-mortem examinations; the study of
minute morbid anatomy; the publication of a journal; the publication
of separate essays; the cultivation of the Fine Arts of drawing and
modelling as connected with minute practical and morbid anatomy.

John Dalrymple, who afterwards became a surgeon to the Ophthalmic
Infirmary, was appointed demonstrator and secretary to the Academy.

In connection with the announcement of Lawrence’s resignation of his
post of surgeon to the Ophthalmic Infirmary in 1826, there commenced
a series of editorial articles in the _Lancet_, attacking members of
the Committee of Management and imputing to them the most base and
degrading motives.

The _Lancet_ had been founded in 1823 by Thomas Wakley, and at first,
as his biographer says, “Some men read it, some men laughed at it, and
some men wondered at it, but nobody much marked it, for its views were
not sufficiently condensed and its objects not definitely defined.”

In 1825 Tyrrell summoned Wakley for libel, claiming £2,000 damages, in
that the _Lancet_ had accused Tyrrell of plagiarism in connection with
his publication of Astley Cooper’s Surgical Lectures. Though the jury
gave their verdict in Tyrrell’s favour, they only assessed his damages
at £50.

Gradually after this trial the policy of the _Lancet_ became directed
to three main objects:

  (1) The maintenance of a right to publish, for the benefit of the
  profession at large, the sayings and doings of members of the
  Hospital Staff’s, with or without their permission.

  (2) A fight against nepotism in the matter of staff appointments at
  the Hospitals.

  (3) An exposure of, what Wakley delighted in calling, a “Hole in the
  Corner Policy” by members of Hospital Staffs—_i.e_., the employment
  of secretive methods in their practice.

In the affairs of the Ophthalmic Infirmary Wakley found a suitable
field for attack in these three directions, and, though his objects
may have been excellent, his mode of conducting his campaign was
inconsiderately bitter and personal.

For the unauthorised publication in his Journal of the notes of
cases at St. Thomas’s Hospital, Wakley had been expelled from that
Institution, where he had studied as a student, the letter of expulsion
being signed by the three surgeons, Travers, Tyrrell, and Green.

Lawrence, who was at that time a prominent medical reformer, and for
whom Wakley evidently had a great admiration, welcomed the publication
of his lectures, delivered at the Ophthalmic Infirmary, in the _Lancet_.

Tyrrell, who had been prominent in the fight against Wakley at St.
Thomas’s and who had also taken legal proceedings against him, resented
having his demonstrations at the Ophthalmic Infirmary reported in
the Journal. On this matter there may very likely have been some
disagreement between the two surgeons of the Infirmary. There is no
note in the minute book of the Committee of any discussion on the
matter having taken place, or of any bye-law being passed to the
effect that “no pupil should be allowed in future to take notes of
cases.” Wakley, therefore, seems to have been wrong in attributing
Lawrence’s resignation of his post on the staff of the Infirmary to
his disgust with the Committee for having passed such a bye-law. When
the _Lancet_’s first attacks on Dr. Farre and Mr. Battley were brought
to the notice of the Committee, Lawrence protested emphatically that
neither directly nor indirectly had he been in any way concerned in
them. The real reason of his resignation probably was that he had
become connected with the newly constituted Aldersgate Street School of
Medicine, where he delivered a course of lectures on Surgery.

As has been mentioned, the idea of establishing a special institution
for treating diseases of the eye was originally suggested to Saunders
by Sir Astley Cooper, who always took a fatherly interest in it.
It was, therefore, inevitable that, to commence with, it should be
mainly staffed by his disciples and followers. Saunders had been
his house pupil and demonstrator; Travers and Tyrrell were both his
articled pupils, the latter having also married his niece. Farre and
Battley had both studied under him. In making his charge of nepotism,
Wakley complained chiefly of the rule which made it obligatory that a
candidate for the post of surgeon should have served an apprenticeship
at one of the Hospitals of the Metropolis. He pointed out that for
these apprenticeships to the London Hospital surgeons a premium of as
much as £1,000 was sometimes demanded and received, and that those for
whom these large sums were paid thereby obtained an unfair advantage
when competing for staff appointments likely to lead to renown and
emoluments.

He also commented on a rumour that a post of assistant-physician to
the Infirmary was about to be created, to which Dr. Frederick Farre,
Dr. J. R. Farre’s son, was to be appointed. This, as we shall see, did
ultimately take place, but not until ten years later and after the post
had been duly advertised, Dr. Frederick Farre being the only applicant.

The Infirmary’s announcement of Saunders’ operation for cataract in
infancy, before he had made known to the profession his method of
procedure, afforded Wakley an excellent illustration of secret surgery,
or “Hole in the Corner methods” as he termed them. He eagerly made the
most of it, raking up what he considered the misdeeds of Saunders, who
had been dead seventeen years, and whom he had never known personally.
He reprinted much of Gibson’s article on operations for congenital
cataract from the _Edinburgh Medical and Surgical Journal_, to show
that the publication of his procedure actually preceded Farre’s
publication of Saunders’ posthumous work by two months. He even accused
Dr. Farre of wilful delay in the matter, a delay which was entirely due
to the difficulties which arose in connection with the copyright.

The Committee of the Infirmary took legal advice in connection with
these defamatory articles, but contented itself with the insertion of
the following letter in The Times and other leading papers:

  “LONDON OPHTHALMIC INFIRMARY, MOORFIELDS.

  “At a meeting of the Committee, 6th November, 1826, Ralph Price,
  Esq., in the Chair, five numbers of a weekly publication, called
  the _Lancet_, dated the 7th, 14th, 21st and 28th October last, and
  4th instant, and _The Times_ newspaper of the 28th October, were
  laid before the Meeting; the former containing false statements and
  offensive reflections upon the Members of this Committee in their
  official capacities, but in a particular manner calculated to insult
  the memory of the late Mr. Saunders, and wound the feelings of Dr.
  Farre and Mr. Battley; and the latter echoing similar calumnies in
  the form of a letter, directed ‘to the Editor of _The Times_’ and
  signed ‘A Governor’; when it was resolved: That the freedom of the
  Press has been violated, by becoming, in the instances referred
  to, an instrument of gross malignity and abuse, and of the foulest
  injustice towards two of the earliest and most tried supporters of
  the Charity; that this Meeting experiences the greatest satisfaction
  in again bearing testimony to the high value of Dr. Farre’s and Mr.
  Battley’s undeviating and disinterested exertions during a period of
  twenty-two years, which, in conjunction with their liberal pecuniary
  subscriptions, have largely contributed to the rise and establishment
  of this Institution.

  That, this Resolution, signed by the Chairman, be inserted in four of
  the Morning and two of the Evening Papers.

  “RALPH PRICE, _Chairman_.”

On the retirement of Lawrence from the post of surgeon to the
Infirmary, John Scott, who had served his apprenticeship at the London
Hospital with Sir William Blizard, was appointed as Tyrrell’s colleague.

Lawrence, as has been shown in the previous chapter, was what may
be described as “a whole hogger,” so far as withdrawal of blood was
concerned for the relief of inflammation in the eye. Tyrrell, though
he employed it in many cases, was evidently doubtful as to its general
utility; thus he writes in his textbook:

  “It is a great mistake to suppose that it is necessary to take away
  large quantities of blood; or to bleed to such an extent as to
  occasion faintness, in order to check severe local disease: I am
  confident that more harm than good results from such practice.”

He advocated the importance of promoting and maintaining power in
the circulation, the principal means on which he relied being “diet,
stimuli, and tonics, which are materially aided by quietude, proper
clothing, and pure air.”

In the preparation for extraction of cataract, to prevent subsequent
inflammation, especially in the robust and plethoric, Lawrence
practised depletion, taking blood freely and repeatedly by venesection
before operation. Gradually this preliminary measure seems to have been
less and less resorted to, and, in a small monograph on _Cataract and
its Treatment_, published by Scott in 1843, he writes:

  “Of the last fifty cases of extraction, taken in succession, which I
  have performed at the Ophthalmic Hospital, where an accurate record
  of the treatment is kept, I have not had occasion to draw blood from
  the arm in a single instance, either before or after the operation.”

An anonymous writer has recorded his personal recollections of Tyrrell
thus:

  “His appearance was prepossessing, his manner to his patients kind
  and reassuring, and his calmness was conspicuous in circumstances
  of difficulty. It is a singular fact that, when first attached to
  Moorfields, his ill success as an operator was so great that he was
  suspended from performing the major operations for a year; yet by
  steady perseverance he acquired a dexterity with either hand that
  could not be surpassed. In extraction of cataract his neatness was
  remarkable, and we well remember an instance of his coolness. The
  point of the section knife broke off, and dropped into the anterior
  chamber. Mr. Tyrrell withdrew the knife, and without the least
  expression of impatience, asked for the blunt-pointed knife, with
  which he enlarged the section. He then removed the bit of steel and
  proceeded to extract the lens with such perfect _sang froid_ that no
  one who had not seen the breaking of the knife would have known
  that anything untoward had occurred.

  “Mr. Tyrrell’s great success depended fully as much on his judicious
  after-treatment as on his manual dexterity; and his secret lay in not
  exhausting the systems of his patients unnecessarily, but keeping the
  balance of power precisely at healing point.

  “On a hot day in May, 1843, whilst an active competition for a
  house was going on at the Auction Mart, an alarm was raised that a
  gentleman had fainted. He was carried out. Alas! it was Frederick
  Tyrrell, who had attended the sale for the purpose of purchasing the
  very lot then under competition, which, indeed, was the house he
  occupied. His heart was diseased and thus he died!”

PLATE VII.

[Illustration: FREDERICK TYRRELL.]

In 1840 he published a book in two volumes entitled _A Practical Work
on the Diseases of the Eye and their Treatment, Medically, Topically,
and by Operation_. It was dedicated to his ophthalmic pupils, and
contained the outcome of the extensive experience which he had gained
at the Infirmary. His memory has, however, become enshrined in the
annals of ophthalmology, not so much by his writings, as by a blunt
hook which he introduced for the operation of making an artificial
pupil, which is still known as “Tyrrell’s hook,” and without which no
ophthalmic armamentarium is complete.

It is interesting here to note how far more frequent operations to
produce an artificial pupil were one hundred years ago than they
are now. In all the early treatises on eye disease much space was
devoted to the discussion of the various methods of producing such
artificial openings for the restoration of sight. The only inference
is that occlusion of the natural pupil by inflammatory membranes was
then of more frequent occurrence, and that the improved methods of
treating inflammatory eye affections, and the more successful operative
procedures for cataract, have reduced the number of such occlusions.

In 1828 a body of ladies interested in the Charity carried out a
most successful sale of useful and ornamental work on its behalf. The
President of the Infirmary, Mr. William Mellish, obtained for the sale
the patronage of the Lord and Lady Mayoress, and permission to hold it
in the Egyptian Hall at the Mansion House. The sale commenced on April
30th, and lasted three days; stalls were presided over by thirteen
ladies, and the sum of £2,309 9s. 6d. was realised.

On the announcement of this result at a General Meeting of Governors a
long and flowery resolution of thanks was passed to all concerned, of
which the opening sentence will suffice as an example of the rest:

  “That this unprecedented success of the plan conceived with so much
  benevolence and executed with so much zeal and ability by the ladies
  who have honoured the Institution with their patronage on this
  occasion, whilst it reflects the highest honour on the ingenuity,
  industry and charity, which combined to produce so beneficial a
  result, is eminently conducive to the best interests of the Infirmary
  and highly gratifying to its Governors and friends.”

In 1830 Tyrrell, who had been carrying on the duties of surgeon
to the Institution for twelve years, became desirous of receiving
some aid, and applied to the Committee for the appointment of an
assistant-surgeon; this was agreed to, and after the post had been
advertised two applicants came forward, Gilbert Mackmurdo and John
Dalrymple. In the ballot which ensued 591 Governors voted, Mackmurdo,
who had served his apprenticeship under Travers at St. Thomas’s
Hospital, obtaining a majority of 143.

Two years later it was found desirable to open the Infirmary for
out-patients on four days a week instead of three, as had up to
then been the custom, and also to make the hours of attendance from
8 a.m. until 10 a.m. instead of from 12 noon to 2 p.m. A second
assistant-surgeon was then appointed to act with John Scott, and John
Dalrymple, who was the only applicant, was elected.

PLATE VIII.

[Illustration: JOHN SCOTT.

From an engraving, after a picture by H. Howard, R.A.]

John Scott, shortly after his appointment as surgeon to the
Infirmary, was appointed assistant-surgeon to the London Hospital,
becoming full surgeon there in 1831. He continued his work at the
Ophthalmic Infirmary until shortly before his death, which occurred
after a prolonged illness in 1846.

His name is best remembered in General Surgery in connection with his
treatment of joints and chronic ulcers of the leg. “Scott’s dressing”
and “Scott’s ointment” are still well known, the latter being a
camphorated mercurial ointment. He was the first surgeon in England to
remove the upper jaw, and was renowned for his skill in bandaging. His
only published contribution to ophthalmology was a small monograph on
_Cataract and its Treatment_, in which he described a new method of
making the section of the cornea in the operation of extraction. It
had previously been the custom to use a wedge-shaped knife for this
purpose, which was made to cut by thrusting it through the anterior
chamber of the eye; the force necessary to do so tended to rotate the
eyeball in an objectionable manner. Scott devised a knife, shaped like
a sickle, with which he was able to transfix the cornea and then cut
upwards. Though his knife has fallen completely out of use, the general
principle of first transfixing and then cutting out is now almost
universally employed. The writer of his obituary notice, his junior
colleague at the London Hospital, Walter Rivington, describes him as
“an honest but very irritable man,” and one who had no sympathy with
humanity.

Another writer who knew him says:

  “A colleague of Frederick Tyrrell’s at Moorfields was John Scott,
  who presented as great a contrast to the former as could well be
  imagined. Impatient and irritable in manner, he could not bear
  anything to go wrong; no man lost vitreous humour more frequently
  during extraction, at which he was invariably annoyed, ascribing it,
  however, to fluidity of that body.”

A great loss to the Infirmary in 1835 was occasioned by the death of
its secretary, Matthew Heathfield, who had served it in that capacity
with marked assiduity and enthusiasm for fifteen years. His successor
only held the office for a few months before he was obliged to give
it up on account of ill-health. In April, 1835, Francis William
Bircham was appointed secretary at a salary of £52 10s. annually.
It is noteworthy that the firm of solicitors to which he belonged,
Messrs. Bircham, Dalrymple and Drake, now Messrs. Bircham and Co., of
46, Parliament Street, S.W.1, still act as honorary solicitors to the
Hospital.




CHAPTER V

THE ROYAL LONDON OPHTHALMIC HOSPITAL


His Royal Highness the Duke of York, the Infirmary’s first Patron, died
in 1827.

At the three days’ sale at the Mansion House in 1828 the Duchess of
Kent was one of the Lady Patronesses. In 1836 the Rev. Dr. Blomberg,
a member of the General Committee of the Infirmary, stated that he
had reasons to hope that an application to their Royal Highnesses the
Duchess of Kent and the Princess Victoria to become Patronesses of
the Institution would be likely to meet with success. A letter was
then drawn up, addressed to the Rev. Dr. Blomberg, and signed by the
President, with a statement of the following claims by the Institution
to so high a distinction: That the grand total of patients admitted
since its establishment to the end of 1835 (a period of about thirty
years) was 116,890, during which time 1,070 cases of cataract or closed
pupil (including 136 born blind) had had their sight restored. That
the annual number of patients admitted of late years had varied from
5,000 to 5,500. That 74 capital operations were performed in 1834, 69
of which were successful, and of 78 performed in 1835 four only failed
to produce the desired effect. That no less than 1,320 physicians and
surgeons had been pupils at the Infirmary, and were now dispensing
its benefits in various parts of the globe. That it was the parent
institution of the numerous hospitals since established throughout the
kingdom for the same benevolent purpose.

It was requested that the Rev. Dr. Blomberg would bring these facts
before the notice of the Duchess of Kent and her illustrious daughter,
the Heiress-Presumptive to the Throne, requesting their gracious
permission to place the Institution under their august patronage.

In response to this petition the following letters were received:

  “KENSINGTON PALACE,

  “12_th March_, 1836.

  “My dear Sir,

  “By the accompanying letter which you will be so good as to forward
  you will see that the Duchess of Kent has lent her aid and that of
  the Princess Victoria to the excellent charity whose cause was so
  ably advocated in Mr. Mellish’s letter.

  “Her Royal Highness is very happy to find an occasion to meet a wish
  of yours.

  “Believe me always, my dear Sir,

  “Yours very faithfully,

  “JOHN CONROY.

  “THE REV. DR. BLOMBERG.”

  “KENSINGTON PALACE,

  “12_th March_, 1836.

  “Sir,

  “I have the honour to lay before the Duchess of Kent your letter of
  yesterday’s date, and Her Royal Highness begs you will assure the
  Committee of the London Ophthalmic Infirmary, Moorfields, that it
  will be very gratifying to her to allow her name and that of Her
  Royal Highness the Princess Victoria to be placed as Patronesses of
  so benevolent an Institution.

  “I have the honour to be, Sir,

  “Your most obedient servant,

  “JOHN CONROY.

  “WM. MELLISH, ESQ.,

  “112, Bishopsgate Street Without.”

As the outcome of the Royal Patronage, it was agreed at a General
Meeting of Governors, on April 20th, 1836, that the name of the
Institution should be changed to “The Royal London Ophthalmic Hospital,
Moorfields.”

In 1837, on Queen Victoria’s accession to the Throne, the Chairman
of the Committee of the Hospital applied to Lord John Russell, the
Secretary of State for the Home Department, to ascertain Her Majesty’s
pleasure as to continuing Patroness of the Hospital, and received from
him the following reply:

  “WHITEHALL,

  “_August_ 29_th_, 1837.

  Sir,

  “I have the honour to lay before the Queen the petition of the
  Committee of Management of the Royal Ophthalmic Hospital.

  “And I have the satisfaction to inform you that Her Majesty has been
  graciously pleased to be the Patroness of that Hospital.

  “I have the honour to be, Sir,

  “Your obedient servant,

  “J. RUSSELL.

  THE REV. J. RUSSELL, D.D., etc.,

  “Rectory House,

  “Devonshire Square.”

The Patronage of the Queen, thus commenced, continued throughout the
whole of her long reign.

In 1838 William Mellish, who had been President of the Hospital for
twenty years, died, and the Committee placed on record their gratitude
and respect for the uninterrupted paternal care and attention he had
shown to the interests of the Institution during his time of office. He
was what may be described as a real live President, having been always
ready to take the Chair at the annual meetings of Governors and at the
anniversary dinners. He was succeeded in the office of President by
Earl Fitzwilliam, who resided mainly in the country, and but seldom
visited the Hospital, so that the control of its affairs fell largely
into the hands of the Chairman of the General Committee, who was at
that time the Rev. J. Russell, D.D.

It was obvious at the foundation of a special institution devoted to
eye diseases that the treatment would be mainly surgical, but the
importance of the medical side of ophthalmology was recognised by the
appointment of a physician. With the expansion of the work of the
Institution during the first thirty years of its existence the number
of surgeons on the staff had to be increased from one to four. During
all that time Dr. J. R. Farre acted alone as consulting physician,
having referred to him for his advice and aid cases requiring medical
treatment. In 1836, when he had reached the age of sixty-one, a special
Committee, of which he was not a member, decided that it was desirable
to appoint an assistant-physician; the post was advertised in the
daily journals, and Dr. Frederick John Farre, assistant-physician at
St. Bartholomew’s Hospital, son of Dr. J. R. Farre, was appointed, he
being the only candidate. It was then arranged that the Hospital should
be opened for out-patients, to be seen by the assistant-physician, on
Wednesday mornings at eight o’clock, and that notices to that effect
should be advertised.

In turning over the leaves of the minute books recording the doings
of the various Committees, it is remarkable to find how much time and
attention Dr. J. R. Farre devoted to the management and administration
of the Infirmary during its first thirty years. Travers aptly described
him as “the foster-father of the London Ophthalmic Infirmary.” He has
also aptly been described as “the father of Ophthalmic Medicine.” He
was most regular in his attendance, and when a petition, a report, or
any letter of importance had to be composed, his assistance was always
sought for. Though his style now seems florid and verbose, it met the
requirements of the time, and generally effected the purpose for which
it was intended.

With remarkable foresight he endeavoured to establish, with varying
degrees of success, many of the developments which have in later
years become some of the most prominent features of the Hospital’s
work. Thus the Saunderian Institute, one of the purposes of which was
the investigation of the minute anatomy of the eye, foreshadowed the
Pathological Laboratory and Museum which were established later.

In 1828 Dr. Farre started the publication of a Journal, of which,
however, only one number appeared, but in a way it may be considered
the precursor of the Royal London Ophthalmic Hospital Reports, which
commenced in 1857. Farre’s Journal contained a most remarkable mixture
of subjects, and serves to show him as a man of wide and varied
interests.

It was entitled, _Journal of Morbid Anatomy, Ophthalmic Medicine
and Pharmaceutical Analysis, with Medico-Botanical Transactions
communicated by the Medico-Botanical Society_.

It contained reports from the Calcutta and Madras Eye Infirmaries;
notes on cases and pathological examinations of rupture of the heart,
angina pectoris, aneurysm, etc., by various observers; a paper by
Richard Battley on experiments on Chinchona; the Transactions of the
Medico-Botanical Society; observations on the climate of the Azores, of
Hastings, and Penzance; a paper by John Dalrymple, ‘On the Muscularity
of the Iris,” which, Dr. Farre said, in some introductory remarks, met
the principal object for which his Academy was instituted—

  “the inquiry having been physiologically conducted and pathologically
  directed, assumed the very spirit which he most desired to encourage
  amongst the many British candidates for anatomical character.”

It was announced that:

  “Parts of the Journal will be published at fixed periods of Midsummer
  and Christmas, and also intervening parts, as opportunity may admit,
  for the completion of each volume, if the Editor’s health should, by
  God’s permission, enable him to separate from the hours of his repose
  a portion of time adequate to the service announced in this notice to
  contributors.”

These good intentions were, however, not realised, no further number of
the Journal being issued.

The Library, for which a special room had been set apart in the new
building, was started by Dr. J. R. Farre’s presentation of eighteen
volumes of the Philosophical Transactions and various works on optics.
These formed a nucleus around which has been built up one of the most
extensive and valuable collections of books dealing with ophthalmology,
a collection which has proved of inestimable service for purposes of
reference and research to several successive generations of workers at
the Hospital.

In 1837 Dr. J. R. Farre advised the Committee that it was desirable
that a Pharmacopœia should be constructed for the use of the Hospital;
in its compilation Dr. Frederick Farre, who was lecturer on Botany at
St. Bartholomew’s Hospital, and later lecturer there on Materia Medica,
rendered valuable assistance.

Dr. Farre, senior, seems to have been a man who inspired the warmest
regard and affection in all who became associated with him; in 1838 a
full-length portrait of him was presented to the Hospital by some of
his friends with the accompanying letter:

  “LONDON, 18_th August_, 1838.

  “34, Montagu Square.

  “Gentlemen,

  “I have the honour on behalf of my brothers and myself to present to
  the Royal London Ophthalmic Hospital, of which he has so long been
  a liberal patron and zealous benefactor, a portrait of our esteemed
  friend Dr. John Richard Farre, painted by T. Phillips, R.A.

  “To those who appreciate the character and services of the worthy
  original we feel assured that we need only offer in order to obtain
  for it a welcome reception.

  “I am, Gentlemen,

  “Your most obedient servant,

  “J. ROACH BOVELL.

  “THE PRESIDENT, VICE-PRESIDENTS, TREASURER AND COMMITTEE OF THE
  R.L.O.H.”

On receiving it the Committee passed the following resolution:

  “That recognising in Dr. Farre not only one of the Founders of the
  Institution but a munificent contributor to its funds, and the able
  physician by whom the science communicated and dispensed within
  its walls has been effectively upheld and enlarged, the Committee
  accepts the testimonial of private esteem and affection with peculiar
  pleasure as the means of publicly manifesting, and of transmitting to
  posterity, the high claims of public respect and gratitude for that
  highly distinguished public benefactor.”

PLATE IX.

[Illustration: DR. JOHN RICHARD FARRE.

From an engraving by Frank Bromley, after a picture by Thomas Phillips,
R.A.]

Thomas Phillips, R.A., painted the portraits of most of the celebrated
literary and scientific men of his time; that of Dr. Farre must
certainly have been one of his largest works of this description. It
now occupies a dominating position in the Board Room of the Hospital,
and shows Dr. Farre clothed in stockings and knee-breeches, with a
buff-coloured waistcoat, stock, and blue coat with brass buttons. He is
represented seated at a table with the drawing of a malformed heart in
one hand, and a portfolio beside him, evidently containing his valuable
collection of drawings of pathological specimens, which was afterwards
presented to St. Bartholomew’s Hospital Museum.

Dr. Farre was a religiously devout man, and most appropriately there is
conspicuously shown amongst the books on his table a copy of the Holy
Bible. He continued to serve the Hospital in the capacity of consulting
physician until 1843, but lived on until 1862, when he died in his
eighty-eighth year, having outlived all those who had been associated
with him in the Hospital’s foundation.

His son, Dr. Frederick J. Farre, was educated at Charterhouse School,
and was the captain of it during Thackeray’s first year there.
Thackeray afterwards introduced him in _The Adventures of Philip_ as
Sampson Major, the cock of the whole school.

Mackmurdo and Dalrymple’s duties as assistant-surgeons consisted mainly
in the treatment of the out-patients. After having been so employed
for several years, they not unnaturally aspired to gaining skill and
experience in the performance of the major operations of ophthalmic
surgery on the in-patients. With such aspirations several members of
the Committee of Management were in sympathy, and much discussion took
place as to some alteration in the rules which would permit of them
acting as full surgeons. Tyrrell and Scott, however, were opposed
to any proposal which was likely to lead to a curtailment of their
privileges as senior officers.

The following return was drawn up and laid before the Committee to show
how the work of the Institution was distributed amongst the different
members of the medical staff in the year 1842.

  Out-patients:
    Dr. F. Farre          607 (one day a week)
    Mr. Tyrrell           1,090
    Mr. Scott             1,037 (two days a week)
    Mr. Mackmurdo         1,274
    Mr. Dalrymple         1,714


  Operations performed:
                    _Extraction of_  _Needling of_  _Artificial_
                      _Cataract._     _Cataract._     _Pupil._
    Mr. Tyrrell           42              20             7
    Mr. Scott             29               9             7
    Mr. Mackmurdo          0               4             0
    Mr. Dalrymple          0               5             0

The matter was brought to a head by the death of Tyrrell in June, 1843.
By that time Mackmurdo had served the Hospital as assistant-surgeon for
a period of thirteen years, and Dalrymple for eleven years.

After due notice had been given it was then agreed, at a special
General Meeting of the Governors, that the laws regarding the
appointment of the medical officers should be suspended, and that Mr.
Mackmurdo and Mr. Dalrymple should forthwith be appointed surgeons to
the Hospital; also that two new assistant-surgeons should be elected.
Mr. John Scott strongly protested against such an increase in the
surgical staff, pointing out, quite correctly, that such an increase
was out of proportion to the increase in the number of patients.

Shortly afterwards Dr. Frederick J. Farre was likewise promoted from
assistant-physician to physician to the Hospital, his father, Dr. J. R.
Farre, being described as consulting physician, the capacity in which
he claimed to have always served as a member of the staff.

The candidates for the two posts of assistant-surgeon were:

Mr. James Dixon, who had been articled as apprentice to Tyrrell, and
who was demonstrator of anatomy at St. Thomas’s Hospital.

Mr. George Critchett, who had been articled to Scott, and who was
demonstrator of anatomy at the London Hospital.

Mr. William Bowman, who had served his apprenticeship at the Birmingham
Hospital, and who was demonstrator of anatomy at King’s College
Hospital.

The latter withdrew his candidature in favour of the two former when
he found that they had been already working at the Hospital, but at
the same time intimated his intention of applying again when a further
vacancy arose. This occurred in 1846, due to Scott’s retirement from
ill-health, and Bowman was then elected assistant-surgeon unopposed.

Dr. J. R. Farre was, as already shown, a man of ideas as well as
of affairs; the time, however, occupied by the latter precluded
his putting many of the former into practice. He was, therefore,
exceedingly fortunate in finding in John Dalrymple a most energetic and
capable disciple.

John Dalrymple, who was related to the Stair family, was born in 1803.
His father, William Dalrymple, who had studied under Astley Cooper, was
surgeon to the Norfolk and Norwich Hospital. He was a liberal-minded
man as well as a skilful surgeon, and attracted considerable attention
in 1813 by repeating successfully Travers’ operation of tying the
common carotid artery in a case of “aneurism by anastomosis” of the
orbit. He had also devoted some attention to ocular pathology, and had
made a valuable collection of anatomical and pathological preparations,
which he presented to the Norfolk and Norwich Hospital.

John seems to have served his apprenticeship under his father, and to
have acquired from him a liking for both pathology and ophthalmology.
He studied for a time at Edinburgh University, and came to London,
where he qualified as M.R.C.S. in 1827.

His association with Dr. Farre and with the Moorfields Hospital then
commenced, with his appointment already mentioned, as demonstrator
and secretary to the newly opened Saunderian Institution, where he
carried out anatomical and pathological investigations. In 1834, as
the outcome of his work at the Institute, he published a treatise on
the _Anatomy of the Human Eye_, which he dedicated to Dr. J. R. Farre,
Frederick Tyrrell, and John Scott, his colleagues at the Infirmary,
to which he had been appointed assistant-surgeon the previous year.
This book, besides containing a description of his own dissections,
gives an excellent review of the work of previous investigators, and is
illustrated by five engraved plates from his own anatomical drawings.
Dalrymple’s investigations were not restricted to ophthalmology;
between the years 1840 and 1849 he contributed several papers to
the Medico-Chirurgical Society’s Transactions relating to general
pathology, and also wrote articles dealing with Natural History.

Tyrrell’s unexpected decease, and later Scott’s retirement, left
Dalrymple in a leading position in ophthalmology, and his reputation
and practice rapidly increased. In 1847 he found the state of his
health to be such as to render it impossible for him to keep up his
attendance at the Hospital during the winter months. As he was the only
surgeon in attendance on Wednesdays and Saturdays, whereas on the
other days of the week both a surgeon and an assistant-surgeon were
on duty, the Governors agreed to appoint a third assistant-surgeon,
and thereby relieve Dalrymple of his duties during the winter. Alfred
Poland, who had served his apprenticeship under Aston Key at Guy’s
Hospital, and who was a demonstrator of anatomy there, was elected to
the post.

Dalrymple’s health did not tend to improve, and in 1849 he felt
compelled to resign his appointment on the active staff, and was
appointed consulting surgeon. On his retirement no fresh appointment
was made to the staff, Critchett being promoted to the post of surgeon
in his place. In 1850 Dalrymple was elected a Fellow of the Royal
Society.

For a number of years John Scott and Dalrymple had been collecting
water-coloured drawings of diseases of the eye, made from patients
under their care at the Hospital by the best artists. Scott, at his
death, bequeathed to Dalrymple the drawings he had collected, and
these, added to Dalrymple’s own, amounted to several hundred. It was
from a selection of them that in 1852 Dalrymple was able to produce his
great Atlas of _Pathology of the Eye_. The publication of the volume
was entrusted to Mr. Churchill, and every advantage that fine paper
and artistic skill could afford was supplied. The Atlas consisted of
thirty-six plates, some containing six figures, and others full-page
illustrations, with explanatory letterpress. The original drawings
were made by W. H. Kearney and Leonard, and the drawings on stone
by W. Bragg. It can safely be asserted that no illustrations of eye
diseases ever surpassed or even equalled those in this Atlas, both
as regards artistic merits and faithfulness in the depiction of the
characteristics of the conditions they represent. The cost of the
production of the Atlas was nearly fifteen hundred pounds, and copies
of it now are exceedingly scarce. Dalrymple only lived a few weeks
after its completion, dying in the zenith of his fame and the full
tide of prosperity. The whole collection of drawings, from which those
reproduced in the Atlas were selected, was bequeathed by him in his
will to the library of the Royal London Ophthalmic Hospital, where they
are still preserved.

It is perhaps remarkable that, though Dalrymple did so much for
ophthalmology by his anatomical investigations and the production
of this Atlas, his name is best known by ophthalmic surgeons at the
present day in connection with the symptom of retraction of the upper
lids in “Graves’ disease” or “exophthalmic goitre,” which produces
the peculiar staring look that forms one of its most characteristic
features. This symptom is spoken of in textbooks as “Dalrymple’s sign,”
but to his description of it Dalrymple himself apparently attached but
little importance.

John Dalrymple was one of a family of nine; two of his brothers became
medical men and practised in Norwich; another, named Robert Francis,
was a solicitor in the firm of Bircham, Dalrymple, and Draise, and
on the retirement of Francis Bircham, his partner, from the post of
secretary to the Hospital in 1844, R. F. Dalrymple was appointed in his
place. He discharged the duties of the office most efficiently for two
years, and was then succeeded by Mr. F. A. Curling.

PLATE X.

[Illustration: JOHN DALRYMPLE, F.R.S.]

Richard Battley married one of Dalrymple’s sisters. John Dalrymple died
in May, 1852, and Battley in 1856. The latter’s widow, after the death
of her husband, presented to the Hospital a bust of her brother, which
now stands in the hall of the present building. In the same year, 1856,
Robert Dalrymple was elected a member of the Committee of Management of
the Hospital, and presented to it an engraving of his brother, which
still hangs in the Board Room of the Hospital, mounted in what was
described at the time as “an elegant gilt frame.” Another presentation
to the Hospital that year was a copy of Dalrymple’s Atlas from John
Churchill, the publisher, with the following inscription on the flyleaf:

  “Presented to the Royal London Ophthalmic Hospital, in honour of that
  sight-saving Institution, and as a memorial of the highest respect
  and esteem for the memory of the author, whose lamented death took
  place soon after the completion of his immortal work, the subscriber
  having enjoyed the friendship of the author, as well as being his
  publisher.

  “(Signed) JOHN CHURCHILL.

  “6_th October_, 1856.”

At the Annual General Meeting of the Governors of the Hospital, after
the death of Richard Battley, the following resolution was passed:

  “That this Meeting most gratefully acknowledge the eminent services
  to this Hospital of the late Mr. Richard Battley; that to his energy
  and perseverance are attributed more especially the establishment
  of the Hospital; that in its origin, when checked by impediments
  and surrounded by difficulties, it was fostered by his influence
  and exertions and, in the arduous circumstances which ensued and
  continued during many years, was succoured and sustained by his
  active zeal; and that it is especially to be recorded that he
  upheld the Institution by an undeviating regard to the professional
  appointments by which the Hospital has been distinguished from its
  foundation.

  “That this memorial be engraved and placed in the committee room of
  the Hospital with the portraits of his early friends, Saunders and
  Farre.”

Gilbert M. Mackmurdo was Dalrymple’s senior; he remained a member of
the active staff of the Hospital until 1856, and died at an advanced
age in 1869. In his obituary notice he is said to have had a fine
appearance, a fair patrimony, and to have enjoyed great City and
mercantile influence; it was largely due to the latter that he obtained
his early appointment to the staff at Moorfields, and that of surgeon
to St. Thomas’s Hospital and to Newgate Prison. The last appointment
gave him for many years a handsome salary, with a commensurate retiring
allowance.

Being well provided for with this world’s goods, he seems to have
contented himself with the practice of the art of his profession
without making contributions to its science. Early in life he was
elected a Fellow of the Royal Society, but for what particular reason
no record can be found. His only contribution to ophthalmic literature
seems to be a short description of a case of recurrent haemorrhage
from the inferior palpebral artery. He is said to have been thoroughly
popular with his pupils and with his patients of all degrees, and
never, never to have made an enemy in his life, either willingly or
wilfully.

In 1849 Mrs. Dodson, who had held the post of matron at the Hospital
for a number of years, died, and a Committee was appointed to report
on the general arrangements and accommodation of the Institution. The
following extract from it serves to show what these were, after the
Hospital had been in existence for half a century:

  “The establishment consists of a Resident Apothecary, a Matron, one
  Nurse, one Housemaid, and one Cook, all of whom reside upon the
  premises, and a Porter or Messenger who neither sleeps nor takes his
  meals in the building.

  “There are 23 beds for patients in five separate wards, and during
  the winter only from one to five are occupied, whilst during the
  summer, or from May to October, when the season is propitious for the
  various operations, the whole of the beds are occupied.

  “The Committee recommends that the new Matron to be appointed should
  be discreet and mild in her manner, whose standing and carriage
  is superior to a servant, of about 40 years of age and without
  encumbrances, and whose duties shall be to render assistance to and
  alleviate the sufferings of the patients by a regular oversight of
  them.

  “Her salary to be 30 guineas a year, with an allowance of £5 for tea
  and sugar.”

As the fame of the Hospital extended there was a rapid increase in
the patients who came to it seeking relief. The annual number of new
out-patients became doubled in the course of ten years; in 1841 there
were 5,643, and in 1851, 11,384.

This large increase made it necessary to provide for increased
accommodation in the out-patient department. In a letter to the
Committee, Dr. J. R. Farre drew attention to the early age at which the
death of several of the members of the surgical staff had taken place.
Saunders died at the age of thirty-six; Tyrrell at forty-nine; Scott
at forty-eight; and Dalrymple at forty-nine. Farre suggested that this
might to some extent be due to the tainted atmosphere of the receiving
rooms for patients, and to the strain involved in having to attend to
such large numbers.

A rearrangement of the rooms of the ground floor of the Hospital was
then made to provide more space for those waiting to be attended to;
an assistant was engaged to aid in the dispensing; and the staff was
increased by the appointment of another assistant-surgeon.

The candidates for this post were Mr. H. H. Mackmurdo and Mr. T. N.
Nunn; the former received 330 votes and the latter 160. The former
probably, like his brother Gilbert, was able to bring considerable City
and mercantile influence to assist him; he, however, only held the
post for a year, and then resigned. Mr. J. C. Wordsworth, who was a
descendant of a collateral branch of the poet’s family, and who was an
assistant-surgeon at the London Hospital, was appointed in his place.




CHAPTER VI

THE INTRODUCTION OF INHALATION ANÆSTHESIA AND OPHTHALMIC SURGERY


Ether was first employed as an anæsthetic for surgical operations
in England on December 19th, 1846, when Robert Liston performed an
amputation of the thigh, and the removal of a great toe-nail, on
patients under its influence, at University College Hospital, Gower
Street. In Edinburgh, Sir James Simpson first gave a description of his
use of chloroform, at the Medico-Chirurgical Society in that city, in
November, 1847.

The adoption of anæsthetics for general surgical procedures rapidly
followed, but, due to the sickness by which they were often followed,
their employment in ophthalmic surgery was for some time delayed. Thus,
Mackenzie of Glasgow, writing in 1854, says:

  “Needle operations may be performed on timid adults under the
  influence of chloroform. In extraction I have not ventured to use it,
  being afraid lest the vomiting which is apt to follow might cause
  rupture of the internal structures of the eye.”

In a review of Haynes Walton’s textbook on eye diseases in 1853, an
anonymous writer says:

  “We agree with Mr. Walton that it is not advisable to use chloroform
  in the extraction of cataract, and we would remark that a surgeon
  with a sharp eye, a cool head, and a steady hand will usually prefer
  to have the command of his patient’s voluntary motions, and to avoid
  the danger which may arise from his restlessness on awaking from his
  drunken sleep.”

Hulke, writing of his reminiscences of Sir William Bowman’s work, said:

  “In London, so far as my knowledge extends, Sir William Bowman was
  the first surgeon who employed chloroform in ‘extraction.’ In his
  first case the administration of chloroform was followed by vomiting
  after the completion of the operation—which could not have been more
  perfectly performed—and the violent straining induced choroidal
  hæmorrhage with extrusion of the vitreous humour and the retina
  through the corneal incision—the eye was lost. So serious a disaster
  would have deterred many men from the further trial of chloroform,
  but its advantages in respect of the performance of the operation
  were so manifest that Sir William Bowman persevered in its use, and
  in order to inspire confidence in his patients he experimentally
  inhaled it to complete anæsthesia himself. His conviction of its
  extreme usefulness in extraction was soon shared by others, and its
  employment quickly became general.”

The practice as regards the use of chloroform at Moorfields Hospital
during the first decade after its introduction is summed up in the
following extract on the subject from the second edition of James
Dixon’s _Guide to the Practical Study of the Diseases of the Eye_:

  “We may regard it under two aspects: as saving the patient from
  pain, and as facilitating the manipulations of the surgeon. Now, it
  is notorious that operations performed on the globe itself cause
  very little pain, and last but a very short time. Those on the
  lids, involving as they do the wounding of the skin, are of course
  more painful; but, in respect of the suffering they cause, none of
  these are comparable to the larger operations in General Surgery,
  and there are few adults who, if thoroughly informed as to the real
  nature of such operations as those for cataract, artificial pupil and
  strabismus or even entropion and ectropion in their slighter forms,
  will not readily undergo them without the aid of anæsthetics.

  “A perfect passive condition of the eye is so desirable in the
  delicate operations of cataract and artificial pupil, that one
  would naturally expect to find chloroform universally applicable
  in such cases; and specially indicated in the most delicate of
  all—extraction. But this forms a peculiar and exceptional case, and
  for the following reasons: We have seen that—provided the operation
  has been properly performed—the successful result of an extraction
  chiefly depends upon the rapidity with which the union of the corneal
  wound can be effected. Now, with every precaution it will sometimes
  happen that chloroform induces vomiting, and the violent efforts
  which attend this might disturb the lips of the wound, and cause the
  vitreous body to escape between them, thus inducing a prolapse of
  the iris, with all its accompanying irritation and retarded union.
  But, without taking such an extreme case as this, we shall find a
  very serious objection to the use of chloroform in the fact, that the
  squeamishness and disrelish for food which it induces may interfere
  with the reparative process, by impairing the nutrition of the cornea
  during the critical twenty-four hours immediately following the
  operation.

  “In adults who are extremely fearful and unsteady, chloroform may be
  required in the operations for artificial pupil and strabismus; it
  will always be indicated in cases of extirpation of the globe, and it
  may greatly facilitate the examination of eyes rendered irritable by
  disease or by the presence of foreign bodies.

  “In children all these manipulations will be greatly facilitated
  by the use of chloroform, and some can hardly be performed at all
  without its aid.”

White Cooper, who was a great friend and follower of Dalrymple, wrote
in 1853 as follows:

  “In common with many others, I for some time hesitated before using
  chloroform in extraction of cataract, from a fear that the object of
  the operation might be defeated by the eye receiving injury during
  the return of consciousness, or by vomiting afterwards. It appeared
  to me, however, so deserving of a trial that nearly two years ago I
  first employed it, and since that time have availed myself of it very
  frequently in operations on the eye, including 16 cases of extraction
  of cataract, 9 of artificial pupil, 4 of foreign body in the eyeball,
  and 2 of tumours of the globe, besides numerous needle cases.

  “The advantage obtained by the use of chloroform in operations on
  the eye are a perfectly quiescent condition of the globe or the
  lids, absence of congestion of the eye, and mental tranquillity for
  the patient. To the operator the perfect repose of the eye affords
  a manifest advantage, the various steps of the operation being
  performed with as much facility as in a demonstration on the dead
  subject; the risk of prolapse of the iris (which is usually caused by
  muscular action) is greatly diminished, and the corneal flap can be
  accurately adjusted.”

By improved methods of preparation of patients before the
administration of chloroform the risks of vomiting became reduced. By
a modification of the operation of extraction so that a piece of the
iris was removed, either at the time of the extraction of the cataract
or as a preliminary procedure, the risk of its protrusion into the
wound was avoided; and by the modification of the opening made in the
eye, so that it formed a straight linear incision instead of a flap,
the risk of its gaping open subsequently was diminished. Ultimately, up
to the time of the introduction of cocaine in 1884, the employment of
chloroform for extraction of cataract became the general custom, and
the performance of the operation without its aid the exception.

The following return of the number of cases to which chloroform was
administered during the first six months in 1868 shows how general
its use in operative procedures on the eye had then become: Cataract,
74; removal of eye, 67; iridectomy, 99; iriddesis, 11; syringe, 15;
entropion and ectropion, 36; abscission, 5; strabismus, 166; tumours of
lid and orbit, 8. Total, 481.

After the introduction of anæsthetics many new operative procedures
on the eye were invented, and those formerly in use, like that of
extraction of cataract, became modified and improved. In all these
changes and advances Critchett and Bowman, at Moorfields Hospital,
played a conspicuous part.

Excision of the eyeball was at one time a most formidable procedure,
and was only resorted to in cases of malignant growths. Hulke has
recorded the following graphic description of his recollections of it
at the time of his pupillage:

  “The first excision of the eyeball that I saw was to me, a novice,
  so horrible and distressing a scene that the impression it made
  still lingers in my recollection. No anæsthesia. The surgeon first
  passed through the eyeball a stout needle armed with stout silk,
  and knotting the ends, formed a loop. Next, with this he dragged
  forwards the eyeball, and then scooped it out of its socket with
  a double-edged scalpel curved on the flat of the blade. This done
  an assistant, who stood ready with a large brass clyster-syringe,
  checked the profuse bleeding by squirting into the orbit iced water.
  How different this from enucleation as now done—methodical circular
  division of the conjunctiva, severance of the muscles at their
  insertions into the globe, careful section of the optic nerve with
  scissors!”

The suggestion that the eyeball might thus neatly and safely be
dissected out of its encircling capsule originated with an anatomist,
O’Ferrall, in Dublin in 1841, and was first put into practice by
Bonnet in France in the following year. George Critchett independently
adopted it, and gave a description of the proceeding in 1851. After
that, excision of the eye became an increasingly frequent operation
for the relief of pain, when the sight was irretrievably destroyed, or
for the improvement of appearances where the eye had become unsightly
and disfiguring. The consequent increased demand for artificial eyes
resulted in their improvement in construction and appearance. Their
manufacture became a highly specialised art, and a Mr. Gray was
appointed purveyor of artificial eyes to the Hospital.

PLATE XI.

[Illustration: GEORGE CRITCHETT]

In 1844 Lawrence wrote:

  “The influence of one eye upon the other is not confined to cases
  of disease. When an eye has been lost by accident, the other
  often becomes diseased sooner or later, without any imprudence
  or any external influence that would be injurious under ordinary
  circumstances. This kind of occurrence is so common, that it is
  necessary to warn those who have lost an eye of this danger, and the
  necessary precautions for avoiding it.”

The prophylactic treatment of removal of eyes injured in such a way
as to provoke this sympathetic disease does not, however, seem to
have been put into practice until 1854, when it was first adopted by
Prichard of Bristol. So effectual did this prophylactic measure prove
that it soon became generally adopted, and excision of the eyeball at
Moorfields Hospital, from being a rarely performed operation, as it was
in the pre-anæsthetic days, became one of the commonest operations.

The operation for squint, before the introduction of anæsthetics, was
a very crude procedure, and was performed often in what seems to-day a
very indiscriminate manner.

The patient was seated in an armchair with a high back, against which
the head was fixed by an assistant who stood behind it. The same, or
another assistant, held the eyelids apart. The operator, standing in
front, exposed the muscle to be dealt with by making a long incision
in the membrane overlying it. He then passed a curved grooved director
beneath it, and divided the muscle by running a sharp-pointed bistoury,
or knife, along the groove in the director, no special attention being
paid as to whether the tendon or the muscle itself was cut across. Loss
of mobility with an unsightly prominence of the eye not infrequently
resulted; whilst the large, open wound which was left often developed a
mass of granulation tissue which considerably delayed healing.

Through the ingenuity of George Critchett, a much neater and simpler
procedure was devised, by which many of the disadvantages of the older
method were obviated. Only a small opening was made in the conjunctiva,
the whole proceeding for division of the tendon being carried on
beneath it, a hook was inserted under the muscle in place of the
director, and scissors were used to cut through the tendon close to its
insertion into the eyeball.

Disorders arising in connection with the drainage apparatus for the
passage of the tears from the eye to the nose have attracted the
attention of those engaged in the healing art since very ancient times.
In 1833 Sir William Lawrence wrote that to give a description of all
the proceedings which have been proposed for removing obstruction to
the tear duct would fill a moderate volume, but that the greater part
were obsolete. The collection of all those which have been proposed
since that date would fill a second volume. Amongst all these different
methods of treatment, that devised by Bowman in 1851 of slitting up
the openings into the tear sac at the inner angle of the eyelids, the
lacrymal puncta and canaliculi, represented a considerable advance on
those which had been previously employed. He first practised it in
cases of overflow of tears caused by closure or displacement of the
lacrymal puncta; afterwards, in the treatment of obstruction of the
nasal duct, he passed probes through the slit canaliculus to dilate the
stricture in the duct, and introduced through it styles to be worn for
a time in order to maintain the dilatation. The introduction of styles
worn in this way avoided the disfigurement entailed when, as formerly,
they were introduced through the skin of the nose overlying the tear
sac.

Gibson of Manchester (as mentioned in Chapter II.), independently of
Saunders, introduced in 1811 a method of operating on cataracts in
infants. He first broke up the lens, and reduced it to a pulp, with a
couching needle; then, two or three weeks later, evacuated it through a
small incision in the cornea by the introduction of a curette.

This operation, though practised for some time in Manchester, fell into
disuse. At Moorfields, the Saunderian tradition was still adhered to,
allowing the lens matter slowly to become dissolved in the fluids of
the eye. In 1851 Bowman revived and improved upon Gibson’s operation,
and in 1864, in the Ophthalmic Hospital Reports, T. Pridgin Teale,
junr., described how, in order to aid the removal of softened lens
matter, he had employed a suction curette. The curette was converted
into a tube by having its groove roofed over to within a line of
its extremity; it was connected with an indiarubber tube, and the
suction was made by the mouth of the operator. The idea of extraction
by suction can, he said, “boast of considerable antiquity, as the
following quotation, kindly sent me by Mr. Bowman, will show

  “According to Avicenna a similar proceeding (viz., excision of
  cataract, by opening in the cornea and drawing out the cataract by
  a needle) was practised by the Persians in the fourth century, and
  Albucasis reports that the procedure was gradually displaced by the
  ‘suctions-method,’ in which the cataract was sucked out through a
  hollow needle.”

Bowman himself, later on, had constructed a suction apparatus for soft
cataracts, which could be manipulated with one hand, the suction being
made by the movement upwards of a piston with the thumb.

After the introduction of anæsthetics, which allowed of patients being
kept perfectly quiet during the performance of operations on the eye,
procedures requiring great precision and skill were introduced by both
Bowman and Critchett for the formation of artificial pupils.

Bowman, in order to produce an enlargement of the pupil of a limited
extent, in a suitable direction, whilst still keeping it as central
as possible, made use of canula-scissors. These were scissors with
delicate blades expanding from a stem which moved up and down in a
canula, the size of a cataract needle, by means of a spring in the
handle. When the spring was pressed the scissors were closed by being
drawn partly into the canula, and when it was relaxed they opened,
being protruded by the spiral wire. One blade of the scissors, which
protruded beyond the other, was pointed with a sharp cutting edge
capable of penetrating the cornea and allowing the whole of the closed
scissors being introduced into the anterior chamber of the eye. The
other shorter blade of the scissors was blunt-pointed. When within
the eye, the blades of the scissors were opened and made to cut the
pupillary border of the iris, the blunt-pointed blade being passed
behind and the sharp-pointed one in front. The calibre of the canula
was so graduated as to plug the wound through which it was introduced,
and prevent the escape of the aqueous humour.

For use in other cases he had constructed a modified form of Tyrrell’s
hook. It was of the same size, but sharp and flattened at the point.
Its stem was cylindrical so as exactly to occupy the corneal wound and
prevent the escape of the aqueous humour. With this “needle hook,” as
he termed it, the necessity of making a preliminary incision with the
loss of the aqueous humour, before the introduction of the hook, was
avoided; the needle hook introduced itself into the eye, the retention
of the aqueous humour facilitating the precision with which the hook
could be passed round the pupillary border.

Critchett invented an operation which he called “iriddesis,” or the
formation of artificial pupil by tying the iris. The purpose of the
procedure he described as follows:

  “The formation of what is commonly called an artificial pupil is
  required under various morbid or abnormal conditions of the eye,
  and demands a corresponding variety in the modes by which it is
  accomplished. In some cases, a restoration of the original pupil as
  regards size and situation is all that is wanted; in others, a change
  in the size, shape, and situation of the natural pupil is required;
  or, again, it may be necessary to form a new pupil in an abnormal
  situation and in the very substance or tissue of the iris. In each
  of these different cases the object is the same—viz., to establish a
  clear pupil or aperture in the iris opposite to a transparent part of
  the cornea.

  “It is very desirable that, in the formation of an artificial pupil,
  the conditions upon which the perfection of the natural pupil
  depends should be as nearly as possible preserved and imitated, both
  as regards its position and defined border, its size, mobility,
  and sensitiveness to light. In the methods usually employed these
  conditions are frequently unattainable, and the circular fibres of
  the natural pupil are either cut or torn through, and an opening is
  formed which is very probably large and irregular in shape, fixed and
  insensible to light, ill-defined and extending to the margin of the
  cornea—thus admitting rays of light that are too much refracted by
  the margin of the lens, and having the effect altogether of confusion
  of vision.”

His operation, designed to overcome the disadvantages above mentioned,
consisted in drawing into a wound at the margin of the cornea, with
canula-forceps, a small piece of the periphery of the iris and fixing
it there by tying a loop of silk around it. In this way an alteration
of the position of the pupil was effected without its margin being cut
or the sphincter muscle interfered with.

The operation was for some time extensively practised at Moorfields,
not only by Critchett, but also by Bowman and Poland. In cases of
conical cornea, Bowman, by performing this operation at the outer and
inner margin of the cornea, produced a laterally elongated slit-like
opening; in order to create the same beneficial visual effect, in such
cases, as is sometimes derived by holding a slit-shaped opening in a
metal disc in close proximity to the eye.

Later on, it was found that this ingenious operation of iriddesis was
liable to be followed by inflammation in the eye of a type which might
spread to the fellow eye: it became, therefore, entirely abandoned.

Another discovery which largely extended the range of operative
ophthalmic surgery was that glaucoma could be relieved by the removal
of a piece of the iris.

A. von Graefe first performed an operation of this description for
glaucoma in Berlin in June, 1856. His study of the natural history
of the disease, and of its ophthalmoscopical appearances, had led
him to the conclusion that increased hardness, or tension, of the
eyeball was the leading factor in its causation, and that, if some
means could be devised of permanently lowering the tension, its cure
might be effected. Experience had shown him that after the removal
of a piece of the iris to form an artificial pupil, in eyes where the
tension was increased, normal tension became restored. After having
performed experimental iridectomies on animals’ eyes, he felt justified
in trying the effect of the operation on patients suffering from
glaucoma, and with the most gratifying results. Up to that time the
disease inevitably resulted in blindness, and in some of its forms was
accompanied by the most agonising pain and distress. The discovery of
a means whereby not only could the pain be relieved, but the loss of
sight also prevented, must always be regarded as one of the greatest
triumphs of ophthalmic surgery.

The successful performance of iridectomy for glaucoma requires a
steadier hand and more skill than any other operation on the eye. It is
also necessary to have the patient absolutely quiet. The acute pain to
which the affection gives rise renders the eye exceedingly sensitive,
and even to-day most surgeons prefer to perform it on patients under
the influence of a general anæsthetic. Indeed, the introduction of
inhalation anæsthesia may be said to have paved the way for the
operative treatment of glaucoma.

1851 was the year of the first Great Exhibition in London, held in
the Crystal Palace in Hyde Park. Visitors from all parts of the world
flocked to see it, and amongst them came Albrecht von Graefe, then
twenty-three years of age, full of enthusiastic ardour and fresh
from his studies in the clinics of Germany, Vienna, and Paris; also
Frans Cornelius Donders, thirty-three years of age, whom his friend
Moleschott described with fervid admiration as “a swelling rose-bud,
whose calix leaves signified nothing but pure science; the flower
leaves hidden glory. In one word, he was a man complete—perfect for
his time of life.” He was at that time Professor Extraordinary at the
University of Utrecht, and lectured on no less than four subjects—viz.,
Forensic Medicine, Anthropology, General Biology, and Ophthalmology.

These two men and Sir William Bowman, destined to revolutionise the
practice of ophthalmology, met for the first time in London in that
eventful year, and remained on terms of the most intimate friendship
for the rest of their lives. Donders and Bowman have left on record the
following interesting descriptions of their first meeting; the first
wrote:

  “In August, 1851, at the International Exhibition, chance threw von
  Graefe and myself together in London. I had already enjoyed the
  companionship of Friedrich von Jaeger, when one morning a young man
  in Alpine costume rushed into Guthrie’s eye hospital—he had reached
  London but two hours before—and threw himself into Jaeger’s arms.
  With the words, ‘You are made for each other,’ the latter literally
  threw him into mine. And he was not mistaken. From early morning,
  when, on our way to Moorfields Hospital, we took our modest breakfast
  in Oxford Street amongst the workmen going to their work, till late
  evening, when we gratefully quitted the hospitable home of our friend
  William Bowman, we remained inseparably united in common objects of
  pursuit. Von Graefe was my guide in practical work, of which I had as
  yet but little experience, and I again could impart to him much from
  the physiological side. This mutual instruction constituted for us a
  great attraction. These days in which von Graefe unfolded the whole
  charm of his nature belong to the happiest recollections of my life.”

Bowman, in describing Donders’ visit to London that year, says:

  “It was his first travel, and it brought him, at least, one thing for
  which he had great reason to be thankful—the personal friendship of
  Albrecht von Graefe, an association soon to be fraught with splendid
  results for the expanding science of ophthalmology; for these two
  men, both of the first capacity, laboured ever afterwards to advance
  it as brothers in council, and alike fruitfully; freely communicating
  their ideas to each other, always in perfect harmony of aim. While
  von Graefe, a stranger in London, was able to tell Donders of the
  European hospitals he had been visiting, and of the new clinical
  ideas he was maturing, as well as of the construction in that year,
  by Helmholtz at Konigsberg, of a dioptric apparatus for rendering
  visible the fundus of the eye, Donders, a stranger there too, could
  on his side explain many discoveries of his own in the physiological
  field, and, amongst other things, declare the true nature of the act
  of accommodation, quite recently disclosed with certainty by his
  countryman Cramer, under, it may be added, his own inspiration and in
  his own laboratory.”

Sir William Bowman at the time of this memorable meeting was older than
his two friends, being thirty-five years of age. His biographer wrote
of him:

  “At a period of life when most men are only beginning to apply
  their powers of observation and reflection, he, exercising both
  in a high degree, had already done work quite unexampled for its
  novelty, interest, variety, and above all for its accuracy. Before
  attaining the age of twenty-six, he had won for himself a leading
  position amongst the most eminent anatomists of his time as a
  microscopist of first-rate ability, and the discoveries he had made,
  with the conclusions he drew from them, have ever since exercised
  an important influence in practical medicine, and have served as
  models for all subsequent and similar investigations. Later in life
  he became distinguished as an original investigator in physiology,
  and as a teacher in that subject, and, at a still later period,
  devoting himself to a special branch of his profession, he stepped
  naturally and easily into the position of leader and representative
  of ophthalmic medicine and surgery, holding the same position in this
  country, though for a far longer period, that was occupied in Germany
  by his friend von Graefe, and in Holland by his still more intimate
  associate Donders.”

PLATE XII.

[Illustration: SIR WILLIAM BOWMAN, BART., F.R.S.]

As the immediate result of his histological work on muscle, Bowman was
in 1841, at the unusually early age of twenty-five, elected a Fellow
of the Royal Society. At the Oxford meeting of the British Medical
Association, in 1847, he read a paper entitled, “On some Points in the
Anatomy of the Eye, chiefly in Reference to the Power of Adjustment,”
in which he demonstrated, simultaneously with and independently of
Bruecke, the structure and function of the ciliary muscle.

In the same year, he delivered to the students at Moorfields Hospital a
series of six lectures dealing with the parts concerned in operations
on the eye and on the structure of the retina. They contained an
account of his investigations into the microscopical anatomy of the
eye, and were published in book form two years later, a book which ever
since has been regarded as one of the classics of ophthalmology; a
French translation of it by M. Testelin was published in the _Annales
d’Oculistiques_ in 1855.

Bowman’s discovery of the ciliary muscle, bearing as it did on Donders’
investigations on the accommodation of the eye, formed from the first a
bond of intellectual union between the two men, which, with the growth
of years, ripened into the warmest esteem and friendship. Donders wrote
on the front leaf of his great work, _On the Anomalies of Accommodation
and Refraction of the Eye_:

  “To William Bowman, F.R.S., whose merits in the advancement of
  Physiology and Ophthalmology are equally recognised and honoured
  in every country, this work on the anomalies of refraction and
  accommodation is, in testimony of the warmest friendship and of the
  highest esteem, inscribed by the Author.”

Though Graefe first performed the operation of iridectomy for glaucoma
in June, 1856, it was not until the following year that he published an
account of his great discovery. He wisely waited until he had tested it
in the different varieties and stages of the disease until he gave an
account of it to the world at large.

Dr. Bader, the curator and registrar at Moorfields, wrote in 1859:

  “The first instance of glaucoma treated by excision of a portion
  of iris by von Graefe’s method was in a case of chronic glaucoma,
  operated upon May 1st, 1857; a second case was treated in the same
  manner in October in the same year. Both were cases of chronic
  glaucoma in an advanced stage, and the immediate result for vision
  was not such as would recommend the operation. Then came several
  cases of acute and subacute glaucoma, in which a striking improvement
  followed shortly after the operation. Since then iridectomy has been
  tried extensively at Moorfields, and with good and lasting results in
  many cases.”

In the second number of the _Ophthalmic Hospital Reports_, published in
January, 1858, Critchett recorded some cases of acute glaucoma which he
had treated successfully by iridectomy, though not quite in accordance
with Graefe’s method.

Some years later Bowman wrote the following description of the
introduction of the operation into this country:

  “Since the winter of 1856–7, the splendid researches of von Graefe
  on the nature and treatment of glaucoma have prominently attracted
  attention. On the Continent, his proposal to arrest the disease by
  the excision of a portion of the circle of the iris has been adopted
  and practised by the ablest men, including especially Professors
  Donders of Utrecht, Arlt of Vienna, and Desmarres of Paris. In May,
  1857, I first performed it in England. At the Ophthalmological
  Congress at Brussels, in September following, von Graefe gave an
  account of his researches, and distributed amongst his friends an
  essay on the subject, then just presented to the French Institute.
  In the ensuing autumn, iridectomy as a remedy for glaucoma was, in
  my opinion, and in that of my friend and colleague, Mr. Critchett,
  established by the facts we had ourselves observed, as a proceeding
  competent to cope with the disease, by reducing that tension of the
  eyeball, and compression of the retina and its vessels, which is the
  cause of the loss of sight.

  “It was our earnest wish that the value of von Graefe’s discovery
  should be early and extensively acknowledged by medical men, so
  that those suffering from so serious a malady might no longer be
  drifting, as before, into hopeless blindness. Since then we have
  with no faltering voice continued to advocate the practice, and have
  performed the operation on all suitable occasions, both in private
  and in public. At Moorfields, iridectomy has been exhibited and
  tested on a very large scale, scarcely a week having passed since
  1858 without one or more instances of it; and a host of competent
  observers, both students and practitioners, have witnessed the method
  of performing it, and its results, in the hands of several of my
  colleagues and myself.”

Both Critchett and Bowman began as general surgeons as well as
ophthalmic surgeons. Critchett was appointed assistant-surgeon at the
London Hospital in 1846, and became full surgeon in 1861. Bowman was
appointed assistant-surgeon at King’s College Hospital in 1840, and
became full surgeon in 1856.

So extensive and absorbing became their work in ophthalmology that both
of them ultimately found it necessary to resign their general surgical
appointments and devote themselves exclusively to the treatment of eye
diseases.

Their reputation as masters in their speciality was not confined to
their own country, but became world-wide. George Critchett, who was
an admirable French scholar frequently attended the meetings of the
International Ophthalmological Congress, and his son, Sir Anderson, was
fond of relating how, at one of its meetings held in Paris in 1867, he
performed the operation of extraction of cataract before the assembled
Congress, on the two eyes of a patient, using his right hand for the
one eye and his left hand for the other. So great was his dexterity
that at the conclusion of the operation, Graefe, who was presiding
at the Congress threw his arms round his neck and kissed him on both
cheeks.

Both Critchett and Bowman were men with strong and attractive
personalities, and collected around them at Moorfields not only a large
body of students, but also practitioners who were devoting themselves
to ophthalmology from all parts of the world. In 1859 they commenced to
supplement their clinical teaching by giving a systematic three months
course of lectures on Ophthalmic Surgery, attendance at which course
enabled students to comply with the rules of the Royal College of
Surgeons for obtaining a certificate.

Most foreign missionaries from this country have endeavoured to
promote the spread of Christianity by practising gratuitously the
healing art. David Livingstone was a qualified medical man, and
administered medical relief to large numbers of the African natives
amongst whom he lived. From some remarks of Sir J. Risdon Bennett,
with reference to Livingstone’s medical studies in London in 1839, it
seems probable that he was then in attendance at Moorfields Hospital.
Many missionaries have not sufficient medical training to entitle them
to practise in this country, but, when abroad, feel themselves called
upon to administer such European drugs as they possess, having greater
knowledge of their uses than the inhabitants of the district in which
they are situated. It was to aid such persons to alleviate affections
of the eye that the Committee of Management of the Hospital obtained
the consent of the medical staff, in 1854—

  “To admit gratuitously to the practice of the Hospital gentlemen
  qualified to derive advantage from it, by the possession of some
  amount of preliminary medical knowledge; provided they be duly
  authenticated to them by a Missionary Society or otherwise, as being
  about to proceed on missionary labours abroad.”

A letter was then drawn up and printed, embodying this resolution, for
circulation amongst those whom it might interest. Large numbers of
missionaries, both men and women, have since availed themselves of the
opportunities thus afforded them before taking up their duties abroad,
and in this way the teaching and benefits of Moorfields have been
spread to remote regions and to many uncivilised people.




CHAPTER VII

THE DISCOVERY OF THE OPHTHALMOSCOPE


The two decades from 1850 to 1870 may well be described as the golden
age of ophthalmology, on account of the many new discoveries and
developments made in connection with it during that epoch.

In the last chapter the surgical improvements which were effected have
been spoken of, together with the crowning achievement of them all—the
introduction of the operation of iridectomy for the relief of glaucoma.

In this chapter will be described an event, destined not only to
change the whole outlook of ophthalmology, but also to add a valuable
means for the detection of disease in many of the organs and tissues
of the body—the discovery of the ophthalmoscope. Following on its
discovery, and to some extent incidental to it, came the recognition
of the different forms of errors of refraction, and the building up of
the methods for their correction with glasses, with which the name of
Donders will for all time be associated.

The merit of discovering the ophthalmoscope, and of having given it
to the world in 1851, belongs to Professor von Helmholtz, who, having
commenced his career as an army surgeon, was, by his mathematical
talents, led on from the study of physiology to that of physics, and
to the production of his greatest work, his _Manual of Physiological
Optics_.

The ophthalmoscope was, he said,

  “a discovery rather than an invention; that is to say, when a
  well-trained physicist came and grasped the importance of such an
  instrument, nothing more was wanted, since all the knowledge had been
  developed which was required for its construction.”

In speaking of his discovery in later years he said:

  “The ophthalmoscope has unfolded itself to me simply out of the
  necessity of discussing, in my lectures on physiology, the theory
  of emission of light by the eye. Why does the human eye not glisten
  under ordinary circumstances, since in its background there is
  situated a spot— small, indeed, but clear white; that is to say, the
  end of the optic nerve, which must reflect light in the same way as
  the most sparkling tapetum of animals’ eyes? Why do animals’ eyes
  sometimes shine with such remarkable lustre, though they may only
  be illuminated by a small distant flame? These questions, when once
  proposed, were not difficult to answer, and now the answer is known
  to everybody. Once answered, they furnished the means of lighting up
  the eye of another human being, and of seeing it plainly.”

It not infrequently happens, that when time is pregnant with some
new discovery, more than one person is found to have been hopefully
striving to become its accoucheur. So it was with the discovery of the
ophthalmoscope. Here in England, in 1846, William Cumming, a young
surgeon who was working at the Royal London Ophthalmic Hospital, had
noticed that a reflex could be obtained from the fundus of the human
eye under certain conditions of illumination. At the Medico-Chirurgical
Society that year he read a paper entitled “On a Luminous Appearance
of the Human Eye,” the conditions for obtaining which he described as
follows:

  “(a) That the eye must be at some distance from the source of light,
  the distance being greater in proportion to the intensity; (b) that
  the rays of light diffused around the patient (and sometimes around
  the eye itself) should be excluded; (c) that the observer should
  occupy a position as near as possible to the direct line between the
  source of light and the eye examined.”

With remarkable prospection he foreshadowed some of the results which
were ultimately obtained from the use of the ophthalmoscope; thus he
wrote:

  “The establishment of the fact of a similar reflection from the human
  eye to that from the eyes of animals appears to be chiefly important
  in its adoption as a mode of examining the posterior part of the
  eye. The retina and choroid hitherto concealed in the living eye,
  and little opportunity being afforded of examining their condition
  after life, in consequence of their diseases not terminating fatally,
  considerable uncertainty had hitherto attended the diseases ascribed
  to these structures; but the existence of this luminosity, its
  non-existence, or abnormal appearance may enable us to detect changes
  in these structures hitherto unknown, or satisfactorily to see those
  which we only suspected.

  “If we dilate the pupil with atropine, we have the means afforded
  of seeing the condition of the retina and choroid in every case.
  The cases I have examined in this way have confirmed the general
  impression that the retina is not frequently the seat of changes
  in amaurosis; for, out of several cases of amaurosis, in which the
  non-opacity of the cornea, lens, and humours allowed this mode of
  examination, I found but two in which the retina was so changed that
  the reflection was not seen.”

Cumming discussed these matters with Dixon and Bowman, the latter
suggesting to him that the choroid and its pigment was probably the
reflecting surface. Another quotation from his article will show how
near he actually came to the discovery of the ophthalmoscope; thus he
wrote:

  “On approaching within a few inches of the eye the reflection is
  not visible, for, before our eye can be brought within range of the
  reflected rays, the incident rays are excluded.”

Cumming died in 1855, at the early age of thirty-three, but just lived
sufficiently long to see that what he had fore-told was being realised.
In 1862 a portrait in oil-colours of him was presented to the Hospital
by one of his relatives with the following letter:

  “2, Vittoria Place, Limehouse,

  “_November_ 11_th_, 1862.

  “Sir,

  “I have the pleasure of presenting to the Hospital a portrait of
  the late William Cumming of Limehouse. It is from a painting in
  possession of the family.

  “William Cumming was honourably connected with the Institution, was
  discoverer that the fundus of the living eye could be explored, and a
  pioneer in the recent advances in Eye Surgery.

  “He died in 1855 at the early age of 33 years.

  “I am, etc.,

  “JOHN STEWART CUMMING.”

This portrait still hangs in the Board Room of the Hospital.

In 1847 Charles Babbage, a distinguished mathematician and scientific
mechanician, who held the Lucasian Chair of Mathematics at Cambridge,
and who spent a large part of his life in the construction of
a calculating machine, actually invented an ophthalmoscope. He
himself published no description of it, and we know nothing of the
circumstances which led up to this invention; the only record we have
concerning it is that published by Wharton Jones in 1854, in a “Report
on the Ophthalmoscope” in the _Medico-Chirurgical Review_. He wrote:

  “It is but justice that I should here state, however, that seven
  years ago Mr. Babbage showed me the model of an instrument that he
  had contrived for the purpose of looking into the interior of the
  eye. It consisted of a bit of plain mirror, with the silver scraped
  off at two or three spots in the middle, fixed within a tube at such
  an angle that the rays of light, falling on it through the side of
  the tube, were reflected to the eye to be observed, and to which one
  end of the tube was directed. The observer looked through the clear
  spot of the mirror from the other end.”

PLATE XIII.

[Illustration: WILLIAM CUMMING.

From a painting in the Board Room of the Hospital.]

Probably Wharton Jones, who was himself short-sighted, in using
Babbage’s reflecting mirror, without any lens, only obtained a red glow
from the fundus of the eye, and saw nothing of the optic nerve or of
the retinal bloodvessels, for, had he done so, it seems unlikely that a
man of his powers of observation and scientific attainments would not
have realised the possibilities of such an instrument.

Anyhow, he gave Babbage no encouragement, and the instrument was laid
aside as a mere toy.

Indeed, it seems doubtful if Helmholtz himself at first fully realised
the possibilities of his great discovery. On the occasion of the
presentation to him of the first Graefe medal in Heidelberg in 1886,
Donders spoke as follows:

  “How the ophthalmoscope could be serviceable to ophthalmologists,
  how the eye under examination, whilst its fundus becomes visible,
  constitutes for the emmetropic examiner a lens, too weak in myopia,
  in hypermetropia too strong; and how simultaneously with the
  examination of the fundus, the refraction can be determined; all this
  was clearly indicated by von Helmholtz. But he never thought, or at
  least he never said, that the new instrument implied the dawning of
  a new era for ophthalmology. Von Graefe felt it immediately. When
  he, for the first time, saw the background of the eye, with its
  nerve-entrance and its bloodvessels, his cheeks reddened, and he
  called out excitedly. ‘Helmholtz has unfolded to us a new world,’ and
  then, ‘What remains there to be discovered?’ added he thoughtfully.

  “It was, indeed, humiliating to hear it said, banteringly, that black
  cataract was that disease in which the patient saw nothing, nor the
  surgeon either. Treatment was then but a groping in the dark. Under
  the same name were thrown together the most diverse affections of
  the fundus oculi and of the nerve apparatus; and even disturbances
  of refraction and accommodation, such as astigmatism and muscular
  asthenopia, were reckoned with amblyopia. And, against these most
  diverse disturbances, the same empirical remedies were employed many
  of them a real torment to the patient not only with little beneficial
  result, but sometimes at the cost of health.”

The increasing number of operative procedures performed at the
Hospital, and the coming of the ophthalmoscope, created a demand for
more accommodation in both the in- and out-patient departments. The
alterations necessary to supply these wants extended over several
years, but ultimately resulted in the transference of the out-patient
department, together with the dispensary and a dark room for
ophthalmoscopic work, to newly erected buildings on the site of the
Saunderian Institute, and the yard at the back of the main building.
The ground floor of the latter was then utilised for rooms for the
resident staff and for a committee room, and the first floor was turned
into wards for in-patients.

Battley having ceased his pharmaceutical investigations and teaching,
and Dr. Farre his pathological researches, they consented to hand over
all their rights in the Saunderian Institute so that it might be made
use of by the Hospital.

Shortly before Tyrrell’s death, the Committee of Management had under
consideration the hardship of an assistant-surgeon remaining on
the staff for a number of years without the opportunity of gaining
experience in performing the major operations on the eye. When Tyrrell
died, both Mackmurdo and Dalrymple became full surgeons, and the matter
was left for a time in abeyance. In 1854, however, at a meeting of the
Governors, the rules were altered so that—

  “any assistant-surgeon who shall have served the Hospital five years
  shall, provided he be a Fellow of the College of Surgeons, become, if
  the Committee think fit, a surgeon.”

At the same time the title of the resident medical officer was changed
from apothecary to house surgeon.

In 1854 the Crimean War commenced; its immediate effect on the Hospital
was a reduction in its receipts from donations and subscriptions, which
together amounted to £614 in 1853, and only to £236 in 1854. A Jubilee
dinner to commemorate the fiftieth anniversary of the foundation of
the Hospital was abandoned, and the building operations of the new
out-patient department postponed.

PLATE XIV.

[Illustration: JAMES DIXON. JOHN CAWOOD WORDSWORTH.]

In 1855 Wordsworth, the junior assistant-surgeon, answered Mr. Sydney
Herbert’s call for volunteers in aid of the overtaxed military medical
officers in the East, and, having obtained leave of absence from the
Committee of Management, went as surgeon to the Civil Hospital at
Smyrna. Later he was transferred to the Crimea, which he reached just
in time to render good service “in the front” to those wounded in the
attack upon the Redan. For three months of the following winter he was
attached to the Castle Hospital on the heights above Balaclava.

On the conclusion of the war, at the annual general meeting of the
Governors, the following resolutions were passed:

  “That this meeting, holding in the highest respect and esteem the
  humane and benevolent consideration and sympathy manifested for the
  Army in the East, during the late War with Russia, by the Right
  Honourable Sydney Herbert, M.P., respectfully requests Mr. Herbert to
  accept the nomination of Honorary Life Governor and Vice-President of
  this Hospital.

  “That this meeting appreciates most highly the humane and benevolent
  ministrations of Miss Florence Nightingale to the sick and wounded
  in the service of the country in the East during the late War with
  Russia, and it is hereby resolved that Miss Nightingale be a Life
  Governor of this Hospital.”

Miss Nightingale and Mr. Sydney Herbert both replied accepting with
pleasure these nominations.

Though Miss Nightingale was made a Life Governor of the Hospital, it
was not until many years later that the reforms in the system of sick
nursing, which she was instrumental in bringing about, were introduced
at Moorfields.

In 1859, in consequence of the increased accommodation for in-patients,
it was arranged that there should be a nurse with an assistant on each
of the two floors. It was also ordered “that in future every patient
on admission to the wards be bathed, unless otherwise ordered by the
admitting officer.” But that much was left to be desired in the matter
of nursing will be gathered from a note directed to the Committee by
the Medical Council in 1861, in which it requested the Committee to
consider the advisability of providing proper receptacles for keeping
the in-patients’ clothes, “which are now generally put under the
bedding, the consequence of which is that the beds occasionally get
infested with vermin, to the serious discomfort of the patients who
subsequently occupy them.”

In 1856 Dr. Frederick Farre, who had become full physician at St.
Bartholomew’s Hospital, found that pressure of work necessitated his
resigning his post on the active staff at Moorfields. His father, Dr.
J. R. Farre, at the same time withdrew from his position of consulting
physician, and Dr. Frederick Farre was appointed in his place. The
family’s connection with the Hospital was still further maintained by
the appointment of Dr. J. R. Farre’s younger son, Dr. Arthur Farre, a
distinguished physician accoucheur, as a member of the Committee of
Management.

Dr. Robert Martin, an assistant-physician at St. Bartholomew’s
Hospital, being the only candidate, was elected physician.

In the same year Gilbert Mackmurdo, who had served on the staff of the
Hospital for a period of thirty-six years, resigned and was appointed
consulting surgeon. The appointment of a new assistant-surgeon to fill
the vacancy thus created gave rise to a most keenly contested election,
in which 458 Governors recorded their votes. One of the daily papers,
describing the event, stated “that the usually quiet neighbourhood of
Finsbury was the scene of great excitement.”

There were four candidates, and, at the close of the poll, the
scrutineers announced that the votes had been distributed as follows:

  Mr. J. S. Gamgee               3
  Mr. J. W. Hulke              148
  Mr. J. F. Streatfield        214
  Mr. Walter Tyrrell            93

This method of election by Governors of the members of the medical
staff was the general practice at most hospitals at that time; but
though it helped to increase the funds of those institutions, it
was not well calculated to secure the services of the most suitable
candidate, and, as we shall see later, was subsequently abandoned.

The Governors consisted of “Life Governors”—_i.e_. those who had
contributed ten guineas in the course of one year, and annual
subscribers of one guinea. A body of electors so formed was not well
qualified to judge of the relative merits of rival candidates; and a
candidate, with a number of friends willing to promote his interests
by becoming subscribers, might thereby bring about a preponderating
influence in his favour. Moreover, where more than two candidates
presented themselves, the successful candidate might, as in this 1856
election, be elected without having received a majority of the votes
recorded.

With an electorate of between 400 and 500 Governors, a candidate who
set out to canvass them had a formidable task before him, and one which
often proved an expensive proceeding. The last surgeon elected to the
staff in this way estimated his costs at nearly £100, which seems an
inordinate amount to expend for obtaining the privilege of giving
one’s time and service to the relief of the poor and needy. It can,
therefore, be easily understood why a candidate who found his chances
of election doubtful, frequently withdrew in favour of one of the
others, and contented himself with announcing his intention of applying
again on a future occasion.

John Fremlyn Streatfield was the son of a well-known antiquarian, the
Rev. Thomas Streatfield, of Charts Edge, Westerham, Kent. He inherited
his father’s antiquarian instincts and was also a staunch Churchman.
He studied medicine at the London Hospital, and, like several of the
other oncoming surgeons at Moorfields, served in the East at one of the
British hospitals during the Crimean War. In 1862 he was appointed
assistant ophthalmic surgeon at the University College Hospital, and
shortly afterwards, on the retirement from the staff there of Wharton
Jones, succeeded him as full surgeon.

Streatfield was gifted with remarkable manipulative dexterity, and
delighted in using his fingers in a way which most people would
have regarded as impracticable. There was, indeed, something almost
acrobatic in his method of operating, and George Critchett used
jokingly to remark that he expected one day, on going into the
operating theatre, to find Streatfield removing a cataract whilst at
the same time he balanced a feather on his nose.

On the death of Earl Fitzwilliam, in 1857, the post of President of
the Hospital became vacant, and Mr. William Cotton, D.C.L., F.R.S.,
an eminent merchant and philanthropist, having consented to be
nominated for the post, was elected by the Governors. He was at one
time Governor of the Bank of England, and invented a most ingenious
machine, which has ever since been in use, for weighing sovereigns at
the rate of twenty-three per minute; it is capable of discriminating
to a ten-thousandth part of a grain, discharging the full-weight and
the under-weight into different compartments. He was, perhaps, even
more noted for his philanthropy than his ingenuity: he founded several
churches and gave assistance to many charitable institutions.

At the same time H.R.H. the Duke of Cambridge was invited to become a
Patron of the Hospital, which invitation he most graciously accepted.

As the medical staff became enlarged, its members formed themselves
into a “Medical Council,” to give collective consideration to matters
referred to it by the Committee of Management, or to initiate measures
for promoting the prosperity of the Hospital and the progress of
ophthalmology. In 1857, when several regulations and practices which
had been introduced were being codified, the following rule became
included amongst those governing the Institution:

  “The physicians, if any, surgical officers, with the consulting
  physicians and consulting surgeons, if any, shall constitute a
  Medical Board empowered to consult on all matters connected with the
  medical department, with the admission and conduct of pupils, and
  shall report to the Committee from time to time.”

In 1856 this Medical Council made the following proposal to the
Committee which led to the establishment of the posts of clinical
assistants:

  “That with a view to aid in treating the less important cases, to
  assist the clinical work of the out-patient room and in case-taking,
  it might be worthy of the consideration of the Committee, whether
  advantage might not be taken of the zeal and knowledge of some of
  the younger surgeons attending the Hospital, by electing them for a
  period of six or twelve months, as assistants to the surgeons. The
  Committee might appoint such assistants to any of the surgeons who
  might require aid. They should be qualified to practise, and of such
  established character that perfect confidence could be placed in them
  for the steady performance of their duties. Many of these men, after
  completing their term of office, would carry skill to various parts
  of the country in which they settle, while from them the Governors
  would be gradually furnished with highly competent candidates for the
  vacancies which from time to time occur in the staff. Their title
  might be that of ‘clinical assistants,’ and they would be entitled on
  retirement to a superior certificate.”

These recommendations of the Medical Council were put into practice,
and have continued ever since to work out in the ways which it had
forecast. The first clinical assistants to be appointed were Mr. J. W.
Hulke, Mr. Jonathan Hutchinson, and Mr. Walter Tyrrell; and a year or
so later, Mr. G. Lawson, Mr. Harkness, Mr. Hughlings Jackson, Mr. J. S.
Wells, and Mr. J. Couper.

The following rule with regard to these appointments became embodied in
the laws of the Hospital in 1861:

  “That the appointment of clinical assistants be held for one year,
  and that these officers be annually re-eligible when approved by the
  Medical Council and sanctioned by the Committee of Management.”

The increasing number of eyes which were removed for the relief of
pain, on account of disfigurement, to prevent inflammation spreading to
the fellow eye, or on account of the presence of a new growth, supplied
a large amount of material for pathological investigation, and for the
formation of a museum of pathological specimens.

When the Saunderian Institute was converted into a waiting room for
out-patients, a room was set apart elsewhere for a museum and library;
and with some of the money left over from the Saunderian Fund a
microscope was purchased. In 1857 Dr. Charles Bader, a young German
skilled in the use of the ophthalmoscope, was appointed curator and
registrar, with an annual honorarium of 25 guineas.

The increasing interest excited in the various changes in the
fundus of the eye revealed by the ophthalmoscope made it desirable
to have a collection of water-coloured drawings depicting them for
preservation in the museum. An artist, Mr. Schweizer, was employed to
make such drawings under the superintendence of Bader. A long list
of those which he produced is recorded in the early numbers of the
_Ophthalmic Hospital Reports_, where also some of them are published in
lithographic plates. The changes represented are all drawn on a very
small scale, the pictures themselves only measuring inches in diameter.
They are, however, very faithful representations of the changes shown,
and contain a remarkable amount of fine detail. There can be little
doubt that Mr. Schweizer must himself have been short-sighted.

PLATE XV.

[Illustration: JOHN WHITAKER HULKE, F.R.S. GEORGE LAWSON]

The interpretation of the nature of the changes revealed by the
ophthalmoscope called for much careful dissection and microscopical
investigation. The two chief pioneers in this work at Moorfields were
Hulke and Bader. The former, in an article on the morbid anatomy and
pathology of the choroid and retina in 1857, wrote:

  “Since the discovery of the ophthalmoscope great advances have
  been made in our knowledge of the diseases of the deeper parts of
  the eyeball. We are daily becoming more familiar with the morbid
  appearances which characterise the various affections of the
  choroid, the retina the vitreous humour, and the lens. We read these
  appearances during life, as if portrayed upon the pages of a book;
  but our knowledge of them, of their exact situation and precise
  natures must remain very imperfect without the explanation afforded
  by dissections and the microscope. The extensive practice of the
  Moorfields Ophthalmic Hospital has, by the liberality of the medical
  staff, for a long time afforded me great opportunities for working
  with the ophthalmoscope, and for making microscopical examinations of
  diseased eyeballs immediately after their removal.”

In 1859 the Royal College of Surgeons chose as the subject for the
Jacksonian Prize Essay of that year:

  “The morbid changes in the retina as seen in the eye of the living
  person, and after removal from the body, together with the symptoms
  associated with several morbid conditions.”

John Whitaker Hulke’s essay was awarded the prize, and he subsequently
published it in a somewhat altered form as a handbook to the use of the
ophthalmoscope.

Hulke, who was born in 1830, was educated at the Moravian College at
Neuwied, and became a fluent German linguist; he studied medicine
at King’s College Hospital where he early became associated with
Bowman. During the Crimean War he was attached to the hospitals at
Smyrna and Sebastopol. In 1857 he was appointed assistant-surgeon
to King’s College Hospital, and in 1858, when an additional post of
assistant-surgeon was created at Moorfields, he was elected unopposed,
the only other candidate, Jonathan Hutchinson, retiring in his favour.
In 1862 he transferred his services as a general surgeon to the
Middlesex Hospital, where he became full surgeon in 1870. In 1867 he
was elected a Fellow of the Royal Society for his researches relating
to the anatomy and physiology of the retina in man and the lower
animals, particularly the reptiles.

Hulke not only distinguished himself as a general surgeon, an
ophthalmologist, a pathologist, but also as a geologist; he contributed
several papers to the Royal Society on Palæontology, more especially
in connection with the great extinct land reptiles (Dinosauria) of the
secondary period. In 1887 he was presented the Walleston Medal, the
greatest honour in the power of the Royal Society to bestow.

To those familiar with an Ophthalmic Hospital at the present time,
it is difficult to conceive of its work being carried on without the
devotion of much time and attention to the correction of errors of
refraction with glasses. Yet it was only during the latter part of the
nineteenth century that the scientific principles for the correction of
such errors became recognised.

Hulke, in some reminiscences of his youth, remarked:

  “In my earliest student days the ophthalmoscope was unknown,
  and errors of refraction were so little understood that a small
  tortoise-shell case, which could be easily carried in the trousers
  pocket, containing half a dozen convex and concave spherical lenses,
  was held to comprise a sufficient stock for every trial.”

The simultaneous but independent discovery by Bowman and Bruecke of the
muscular nature of what was formerly known as the ciliary ligament,
the change in the form of the lens in accommodation demonstrated by
Cramer, and the discovery of the ophthalmoscope by Helmholtz, prepared
the way for Donders’ great work, _On the Anomalies of Accommodation
and Refraction of the Eye_, which was published in English by the New
Sydenham Society in 1864.

James Ware, to whom reference has already been made, was one of
the first surgeons in England to devote himself specially to the
treatment of eye diseases (_vide_ Chapter I., p. 11). He is entitled,
Donders says, to be described as the discoverer of hypermetropia or
long-sightedness. In a paper on “Observations Relative to the Near and
Distant Sight of Different Persons,” which Ware read before the Royal
Society in 1812, he said:

  “There are also instances of young persons, who have so
  disproportionate a convexity of the cornea or crystalline, or of
  both, to the distance of these parts from the retina, that a glass of
  considerable convexity is required to enable them to see distinctly,
  not only near objects, but also those that are distant; and it is
  remarkable that the same glass will enable many such persons to see
  both near and distant objects, thus proving that the defect in their
  sight is occasioned solely by too small a convexity in one of the
  parts above-mentioned, and that it does not influence the power by
  which their eyes are adapted to see at distances variously remote. In
  this respect such persons differ from those who had the crystalline
  humour removed by an operation, since the latter always require a
  glass to enable them to discern distant objects, different from that
  which they use to see those that are near.”

These early and accurate observations of Ware’s were forgotten, and
it was not until 1859, at a meeting at Heidelberg, that Donders first
clearly differentiated long-sightedness or over-sightedness as some
then termed it, from presbyopia, and suggested the term “hypermetropia”
as an appropriate name for it. The importance of understanding
correctly the nature of this affection of the eye was summed up thus by
Donders:

  “He who knows by experience how commonly hypermetropia occurs, how
  necessary a knowledge of it is to the correct diagnosis of the
  various defects of the eye, and how deeply it affects the whole
  treatment of the oculist, will come to the sad conviction that an
  incredible number of patients have been tormented with all sorts of
  remedies and have been given over to painful anxiety, who have found
  immediate relief and deliverance in suitable spectacles.”

What is termed “asthenopia,” or tiredness of the eyes with confusion
of vision after close work, without any alteration in their external
appearance, had been attributed to a variety of causes by different
observers. Lawrence spoke of it as an affection of the retina from
excessive employment. Tyrrell endeavoured to prove that it was due to
congestion of the choroid. It became recognised that it was not caused
by contrasts of light and shade:

  “All day the vacant eye without fatigue
  Strays o’er the heaven and earth; but long intent
  On microscopic arts, its vigour fails.”

That it was produced by application of the eyes to near objects
suggested that the muscles that move the eyeballs might be concerned,
and some even practised tenotomy of them for its relief. It was not
until Donders demonstrated its association with hypermetropia that the
circumstances under which it may arise were made clear, and the way
shown in which it could be relieved by the use of spectacles. Though
we are indebted to Kepler for the earliest knowledge of short-sight,
or myopia, it was not until after the discovery of the ophthalmoscope
that the peculiar changes in the fundus of the eye associated with it,
and due to enlargement of the posterior part of the eyeball, became
recognised. At Moorfields they were described and pictured by Bader in
the _Ophthalmic Hospital Reports_ in 1858.

The elongation of the visual axis in myopic eyes, formed at the expense
of the posterior wall, was first demonstrated by dissection by Arlt in
Vienna in 1856.

The asymmetry of the dioptric system of the eye which we call
astigmatism was first observed by that versatile genius, Thomas Young,
in his own eyes in 1793; and later by Airy, the Astronomer Royal, in
1827, who introduced the use of cylindrical lenses for its correction.
Airy’s colleague, Whewell, suggested the term “astigmatism.” That it
was due to a difference in the curvature of the cornea in its two
meridians was asserted by Wharton Jones in 1855 and by Wilde of Dublin.
It was, however, Donders who by measurement first certainly proved that
such asymmetry of the cornea actually existed.

The introduction of systematic sight-testing for errors of refraction
at Moorfields was of gradual growth. In 1860 J. Soelberg Wells, who was
then working there as a clinical assistant, wrote as follows:

  “There are perhaps few subjects connected with ophthalmic practice
  which demand greater care and exactitude than the choice of a pair
  of spectacles. The very frequency with which we are called upon to
  improve vision by means of glasses is but too apt to make us somewhat
  careless and empirical in our mode of selection, and to prescribe
  those which the patient himself most fancies, even although they may
  not quite accord with the range of his accommodation, or with the
  scientific principles which should influence our choice. But how
  much more does not this inefficiency in selecting spectacles obtain
  among quasi-opticians, jewellers, etc. This is doubtlessly often
  attended with the most disastrous results, and eyes, which might with
  proper glasses have lasted a number of years, are soon recklessly
  and unwittingly destroyed through ignorance and carelessness of
  unscientific opticians. In order to obviate this, I would urgently
  advise the adoption of a method practised in many parts of the
  Continent. In Berlin, for instance, von Graefe has spectacle boxes,
  containing convex and concave glasses (whose number corresponds
  exactly with those kept by the opticians); from these he selects the
  proper glasses, and puts the number of their focal distance on a slip
  of paper, which the patient takes to an optician, who supplies him
  with the spectacles thereon prescribed.

  “I am fully aware that this proceeding would, at present, be carried
  out with some difficulty in England, owing to the fact that different
  opticians often number their glasses differently; but I have doubt,
  that if the leading opticians would adopt a certain standard, the
  others would soon follow their example.”

In order to overcome the difficulties caused by the inaccurate
dispensing of glasses, it was agreed in 1861, on the recommendation of
the Medical Council, to appoint Thomas Doublet, optician, of 7, City
Road, Finsbury Square, the official optician to the Hospital. This
appointment led to a letter of protest from William Hawes, optician, of
79, Leadenhall Street, in which he said that for the past twenty years
he had been supplying spectacles ordered by the surgeons to patients of
the Hospital at an agreed price. It is interesting to note this, as his
son, Alfred Hawes, was later on appointed optician to the Hospital, an
appointment which William’s grandson still holds.

The system then in vogue for numbering lenses was the “inch system,”
the unit on which it was based being a lens having a principal focal
distance of 1 inch. It was inconvenient, as it necessitated the
refractive power of any lens of a weaker strength being expressed
by a fraction, whose denominator represented its principal focal
distance. Complications also arose owing to the variations of the inch
in different countries. Thus in ordering glasses it was necessary to
state if the trial lenses employed were graduated in English, Paris,
or Prussian inches. It was Nagel in 1866 who proposed a metre system
of numbering lenses—_i.e_., taking a lens with the principal focal
distance of 1 metre as the unit, and speaking of it as having the
refractive power of 1 diopter. The advantages of this new system soon
became evident, and, after it had been considered and reported on
favourably at the International Congress of Ophthalmology in 1872, its
adoption became general.

Letters or figures have always been employed by ophthalmologists as
the most convenient method for testing the power of vision. Alfred
Smee, F.R.S., surgeon to the Bank of England and to the Central London
Ophthalmic Hospital, in a book entitled _Vision in Health and Disease;
the Value of Glasses for its Restoration and the Mischief caused by
their Abuse_, the first edition of which was published in 1847, gave
a series of graduated sized prints for the testing of vision, and
described an optometer he had constructed for “the adaption of glasses.”

Ed. von Jaeger of Vienna, in 1854, published a series of typographical
specimens, distinguishing the various sizes of the letters by numbers
instead of technical names, which allowed of their use by all nations.
These have ever since remained the most generally used test for near
vision. It was Snellen of Utrecht, however, who first constructed
test types on a definite scientific principle, so that the strokes
composing the letters are all drawn on a regularly proportional scale
of thickness, the letters exhibiting themselves under an angle of five
minutes at the distance at which they should normally be seen.

In 1860 the Committee of Management of Moorfields, at the request of
the Medical Council, had drawn up and printed test types for use in the
out-patient room.

By the death of Mr. Richard Heathfield in 1859 the Hospital lost one of
its oldest supporters, who had been a friend of Saunders and associated
with him in its foundation. When the Rev. J. Russell retired from the
Chairmanship of the Committee of Management, Heathfield had succeeded
him, and was a vigorous promoter of the extensions of the institution
rendered necessary by the advance of knowledge.

Mr. F. G. Sambrooke was appointed Chairman in his place.

On the death of Miss Marian Sedgwick, the last surviving daughter of
the late Harry Sedgwick, in January, 1860, the Hospital came into
possession of the reversion bequeathed by him (as mentioned in Chapter
III.) of the sum of £19,841 Three per Cent. Stock, subject to 10 per
cent. legacy duty. A portrait of this early supporter and munificent
benefactor of the Charity had been previously presented by his family,
and now hangs in the Board Room. In 1853 the Committee had commissioned
Mr. Henry Weekes to construct a marble bust of Mr. Harry Sedgwick at
the cost of £120, to be designed as a companion to that by the same
artist of J. Cunningham Saunders. These two busts, together with that
of Dalrymple, now adorn the entrance hall of the present building.




CHAPTER VIII

THE COMMENCEMENT OF “THE OPHTHALMIC HOSPITAL REPORTS”


The first English journal devoted specially to the subject of
ophthalmology originated with the medical staff of the Moorfields
Hospital. The first number of the _Ophthalmic Hospital Reports_, as the
journal was called, was published in October, 1857. Its origin and aims
were set forth as follows:

  “At a meeting of the Medical Council of the Hospital on the 25th
  of August last, it was determined to issue a periodical record of
  ophthalmic observation and experience; it was thought that, not only
  at Moorfields, much valuable information was gained and lost that
  should be preserved, and that such a journal might obtain favour
  throughout the country. Mr. Streatfield was appointed to collect and
  arrange, from time to time, the material and order its publication.

  “The Ophthalmic Journal will be, for the present, issued quarterly.
  It will give short monographs by members of the staff, and of the
  profession generally (if we are so fortunate as to engage their
  attention), on any physiological or pathological subjects connected
  with our especial study; with, it is hoped, occasional engravings,
  or photographs as illustrations. It will also contain a summary
  reprint of the monthly reports of the Registrar of the Hospital, and
  titles of books and preparations presented to the Ophthalmic Library
  and Museum of the Hospital. It will not contain reviews of books as
  such, or any correspondence, or anonymous publications. The opinions
  expressed in it must be understood to be those of individual authors.
  The editor will collect minor noteworthy observations, and record
  novelties and illustrative cases, with regard to consecutive detail.”

A list of the subscribers given in the fifth part, published a year
later, shows them to have then numbered 195. By its establishment the
Library at the Hospital became enriched, for exchanges were effected
between it and several other journals dealing directly or indirectly
with ophthalmology.

Though the highly specialised subject of the journal prevented it
from gaining a very extensive circulation, it became the medium for
publication of original articles which are now regarded as among the
classics of ophthalmic science.

The first volume is composed of six parts, published at intervals
between October, 1857, and January, 1859. The first part opened with
an article by Bowman, giving an extended account of his investigations
into the treatment of lacrymal obstruction by slitting up the lacrymal
punctum and the use of probes, which has already been referred to in
Chapter VI. Poland also commenced a series of articles, which were
continued in subsequent parts, on “Protrusion of the Eyeball.” They
contain a number of well recorded cases with interesting remarks,
giving a vivid description of the treatment of inflammatory affection
in pre-antiseptic days, by what was termed “antiphlogistic measures.”
In the third volume of the _Reports_ Poland contributed an article on
“Medico-legal Observations in Connection with Lesions of the Eye.” Much
has been written on this subject since, but little has been added, as
regards matters in this country, which is not dealt with by Poland. He
quotes Mr. Harry Bodkin Poland, barrister-at-law, no doubt a relative
of his, as stating the legal position in the assessment of damages for
accidents to be as follows:

  “There is no fixed mode of assessing damages from accident. When
  it can be shown that a particular person is liable for causing an
  accident, etc., the jury decide as to the amount of damages to which
  the injured person is entitled, and neither the medical man nor the
  lawyer interferes, except to put before the jury the real nature of
  the injuries inflicted.”

The following precautionary remarks, which he wrote some seventy years
ago, evidently as the outcome of his experiences at Moorfields, are so
applicable to-day that they may well be quoted:

  “The causes which may lead to the loss of an eye through carelessness
  and negligence ought well to be borne in mind by the thoughtless,
  so that should any person be employed in any of the following acts,
  he should pay due regard to the passers-by, or those standing near,
  and thus obviate any necessity for rendering himself liable for the
  damages committed.

  “The carrying or whirling about of sticks, umbrellas, guns, etc., in
  the public thoroughfares, the slashing about of whips, the careless
  use of the line and rod in fishing, the letting off of fireworks, the
  shooting of arrows, the throwing of missiles such as stones, lime,
  etc.; the chipping of wood, stone, and metals in the public highways,
  without adequate protection; the playing at tip-cat; the uncorking of
  effervescing draughts; the explosion of chemicals and gunpowder; and
  numerous other acts each and all of which have caused the loss of an
  eye or of both, and have been the means of litigation.”

In 1861 Alfred Poland was elected surgeon to Guy’s Hospital with charge
of the large ophthalmic department, and, in accepting the appointment,
was required by the Governors of Guy’s to resign his post of surgeon
at Moorfields, which he did most reluctantly. Many competent observers
described him as the best operator on the eye they had ever seen. He
was a spare, thin man, and made remarkable recoveries from several
severe illnesses, but died ultimately of consumption at the age of
fifty-two. The following account of some of his other characteristics
have been recorded by one of his colleagues at Guy’s:

  “Poland had a remarkable power of gathering together detailed
  knowledge, including dry facts and figures, so that his essays are
  complete treaties on the subjects in hand, and are of permanent value.

  “It was said with great truth that if Poland had been shut in a
  room containing not a single book, but with only pens and paper, he
  could have written a complete work on surgery, not in a vague way,
  giving merely general descriptions and treatment, but in a systematic
  manner, detailing the distinct forms and varieties of the disease
  then in his mind.

  “He was utterly careless as to his personal appearance. He would
  leave the dissecting room without changing his coat, and it was often
  the subject of surmise whether he washed his hands.

  “On his appointment to the surgeoncy at Guy’s, the Treasurer had
  no hesitation in telling him he would have to dress himself more
  decently and cleanly. It is not, therefore, surprising that Poland
  never had any practice to speak of. There was nothing in his manner
  to give confidence, but he was a great favourite with students.

  “His marriage a few years before his death was a misalliance, and
  added much to his misfortunes.”

One of the most conspicuous features of the _Reports_ since their
commencement has been the contributions made to them by the several
occupants in succession of the post of curator of the Museum,
beginning with Charles Bader. This post has afforded the holders of
it a most valuable field for pathological research, as all the eyes
removed by the members of the staff are entrusted to the curator for
his investigation, and often also a large number of specimens from
elsewhere. The articles written by the several curators contain most of
the valuable original work which has been done in this country on the
subject.

In the fourth part of the journal, published in July, 1858, Jonathan
Hutchinson, who was then working as a clinical assistant at the
Hospital, commenced his ever memorable series of articles “On the
Different Forms of Inflammation of the Eye consequent on Inherited
Syphilis.” In these articles he first definitely established the
connection of interstitial keratitis with inherited syphilis, and
showed its frequent connection with certain characteristics of the
complexion and physiognomy, and with peculiarities in the formation
of the permanent teeth. Which latter are now universally known as
“Hutchinson’s teeth.”

PLATE XVI.

[Illustration: SIR JONATHAN HUTCHINSON, F.R.S.]

Jonathan Hutchinson was born in Yorkshire in 1828, of Quaker ancestors.
For four years he studied at the York School of Medicine, and then came
to London, when he attended at St. Bartholomew’s Hospital. He there
came under the influence of Sir William Lawrence, to whom he dedicated
his book entitled _Diseases of the Eye and Ear consequent on Inherited
Syphilis_, published in 1863, consisting mainly of his reprinted
articles in the _Ophthalmic Hospital Reports_.

It has already been mentioned in Chapter III. how much Lawrence did to
increase the knowledge of venereal diseases of the eye by the careful
collection and collation of notes of cases at the Ophthalmic Hospital.
It was by the same careful collection and collation that Hutchinson was
able to establish the connection of certain inflammatory eye affections
with inherited syphilis, and he likewise found the most fruitful field
for his investigations in the out-patient department at Moorfields. He
was a most patient and elaborate note-taker and, in apologising for the
lengthy notes of some or his published cases, remarked:

  “I must plead that they are the stones out of which the edifice is
  to be built, and that unless care be devoted to their preparation in
  the first instance, it will be useless to expend it on the subsequent
  elaboration.”

Jonathan Hutchinson was a man intensely interested in the study of
the natural history of disease in all its manifestations, and it
may be added not only in the natural history of the disease, but of
natural history generally. He was a great collector of facts, and had
a remarkable flair for grouping them so as to draw new and unsuspected
inferences.

He was not inaptly described as “the greatest general practitioner
in Europe,” and also as “the universal specialist.” He was appointed
assistant-surgeon to the London Hospital in 1859 and full surgeon in
1862; he was also surgeon at the Blackfriars Skin Hospital.

He attracted around him a large number of able assistants of whose
devoted services he was able to make very material use. His biographer
writes:

  “His teaching was made impressive by ingenious arguments, apt
  illustrations, vivid metaphors, and quaint expressions, and was
  driven home by the simplicity and solemnity with which they were
  delivered.”

On the retirement of Alfred Poland from the staff in 1861, it was
decided that the surgical staff should be increased to eight in number
by the appointment of two new assistant-surgeons. George Lawson and
Jonathan Hutchinson were the only two candidates who came forward, and
were both elected. Lawson, receiving a few more votes than Hutchinson,
was appointed the senior of the two.

George Lawson, like Hulke, received his medical education at King’s
College Hospital. There was a remarkable parallelism between the
careers of these two men. Both served as house surgeons under Sir
William Ferguson. Both served as surgeons at the Crimea. Both became
assistants to Bowman, and inspired by him combined ophthalmic surgery
with general surgery. Both became general surgeons at the Middlesex
Hospital, and ophthalmic surgeons at Moorfields.

Though their careers were so similar, temperamentally they were very
different. Hulke was an austere, conscientious disciplinarian, who
seemed to have had no youth. Lawson, on the other hand, was full of
kindly sympathy for the weaknesses of mankind, and never seemed to
grow old. This difference was no doubt to some extent attributable,
as Lawson himself suggested, to Hulke having had no children, whilst
Lawson had a large family of boys.

Hulke earned for himself the greater scientific reputation, but Lawson
had by far the larger private practice. Hulke’s articles in the
early numbers of the _Reports_ were numerous, some of them clinical
records, but many of them dealing with histological and pathological
investigations. Lawson’s contributions were also numerous, and dealt
mostly with injuries of the eye and sympathetic ophthalmitis. In 1867
he published his collected experience on these matters in a book
entitled _Injuries of the Eye, Orbit, and Eyelids_. His attention had
doubtless been specially attracted to such injuries during his service
with the Army in connection with the Crimean War. Early in 1854, when
war was threatening, Lawson joined the Army as an assistant-surgeon,
and went in March of that year with the first batch of troops to Malta.
He landed with the first troops in the Crimea, and was present at the
battles of Alma and Inkerman. He was invalided home in July, 1855, with
typhus fever, which he contracted from some mule drivers whom he was
attending, and which left his circulation permanently impaired.

In Part III. of the _Reports_, Streatfield gave a description of his
operation of grooving the fibro-cartilage of the eyelid in cases where
its margin or the eyelashes turned inwards: an operation which is still
frequently performed as originally described, or in a modified form.

In the last part of the first volume, which appeared in January, 1859,
Dixon recorded a case in which he successfully removed a chip of steel
from the vitreous chamber by grasping it with a pair of forceps. The
case is of particular interest because it seems to have been the first
in which an attempt to remove a foreign body from the interior of the
eyeball with a powerful magnet was made, a line of practice which has
since reached a high degree of usefulness. In Dixon’s case, the effect
of the magnet was only to drag the chip of steel into a less desirable
position, so that a pair of forceps had to be used in order to effect
its removal.

Amongst the numerous interesting articles in the second volume of the
_Reports_ are some short contributions from the celebrated Glasgow
ophthalmic surgeon, William Mackenzie, then in his fifty-ninth year,
whose masterly _Practical Treatise on the Diseases of the Eye_ had
obtained world-wide reputation. After serving his apprenticeship
and passing his qualifying examination in Glasgow, he visited the
medical schools of Paris, Pavia, and Vienna; at the latter he studied
ophthalmology under Professor Beer. In 1818 he settled for a time in
practice in London, in Newman Street, Oxford Street, and delivered a
systematic course of lectures on “Diseases and Operative Surgery of the
Eye.” Though we have no definite record of his attendance at the Eye
Infirmary, then in Charterhouse Square, there can be little doubt that
his keen interest in ophthalmology must have taken him there. In 1820
he returned to Glasgow to fill the Anatomical Chair in the Andersonian
University, and in 1824 he established the Glasgow Eye Infirmary.
One of his articles in the _Reports_ deals with glaucoma, and he was
the first to point out its connection with the increased tension of
the eye—an increase of tension which he endeavoured to relieve by
paracentesis of the eye through the sclerotic or cornea.

To those familiar with the operation for removal of cataract, the
fixing of the eyeball whilst making the incision, by grasping the
conjunctiva with a pair of toothed forceps, seems such an obvious
procedure that it is surprising that it should not have always been
employed. We find, however, in the second volume of the _Reports_,
an article by France advocating such fixation as a new departure.
France was surgeon in charge of the ophthalmic department at Guy’s
Hospital. When Saunders first established a special institution for the
treatment of eye diseases, and for many years afterwards, there were
no such special departments at any of the London general hospitals.
Guy’s Hospital was the first of the general hospitals to establish
an ophthalmic department, and by 1858 similar departments had been
started at University College Hospital under Wharton Jones, and at
St. Mary’s Hospital under White Cooper. These two latter surgeons also
contributed articles to the _Ophthalmic Hospital Reports_, which in its
early days was not restricted to work carried on at Moorfields.

With the second volume of the journal the use of paper of a slightly
yellow tint, instead of white, was commenced. Streatfield, the editor,
explained that Charles Babbage, the mathematician, in printing his
logarithmic tables, had experimented with specimens set up on paper of
various shades and colours, and found that almost all those whom he
consulted agreed with him in giving preference to the coloured papers.
The particular tint, however, was not so unanimously fixed upon, though
yellow appeared to have the preference. Several editions of Babbage’s
_Tables of Logarithms_ were printed on the yellow and the white paper;
the former were always in most demand. This slightly yellow tinted
paper was apparently approved of by the contributors and readers of the
journal, as it continued in use for several years.

In this same volume there commenced a series of articles on “Paralytic
Affections of the Muscles of the Eye,” by John Soelberg Wells, who in
1860 became one of Bowman’s clinical assistants.

Soelberg Wells was a tall, handsome man, of splendid physique, and
possessed of ample private means. He graduated in medicine at Edinburgh
University in 1856, but much of his education and training, general
and professional, was conducted by German teachers, for he was partly
German by extraction. For two years previous to his commencing work at
Moorfields he studied under Graefe in Berlin, and was for a time one of
his assistants. In his lectures and in his clinique Graefe devoted much
time and patience to teaching the diagnosis of paralytic affections
of the eye muscles, and Wells’ articles on the subject dealt with the
rules he had learnt from Graefe, to the great accuracy and value of
which he was able to testify.

In the third volume of the _Reports_ commenced the publication of a
“Periscope” of foreign ophthalmological literature; in this production
Soelberg Wells’ knowledge of German and of the Continental cliniques
was of great service, and he translated for the use of English readers
articles by Müller, Donders, and Graefe. By such means international
scientific intimacy, which is so eminently desirable, was stimulated
and promoted.

After the issue of the thirteenth number of the _Reports_, Streatfield
resigned his editorship, and in April, 1861, what was termed a New
Series was commenced, with the following prefatory remarks:

  “The first number was issued October, 1857, and the publication,
  though not strictly quarterly, has subsequently appeared with
  regularity sufficient to complete two volumes.

  “The later numbers, however, have assumed a very different appearance
  to those which were at first submitted to the profession, and it has
  therefore been deemed necessary to remodel the journal: at the same
  time, as it is the only periodical in England specially devoted to
  ophthalmic medicine and surgery, it is thought desirable to extend
  its limits, by admitting reviews and periscopes, and thus to make it
  more generally useful.

  “It will be edited by members of the staff, and appear under the
  title _Ophthalmic Hospital Reports, and Journal of Ophthalmic
  Medicine and Surgery_.”

Apparently very heavy expenses had been incurred in former numbers for
engravings and coloured lithographs, which made a change of management
desirable, for it was noted:

  “In future the amount of illustration will much depend on the support
  of the professional public, the medical officers of the Royal London
  Ophthalmic Hospital having led the way by devoting their fees,
  received from pupils, to the interests of the journal.”

The art of perimetry or of taking the field of vision, which has now
reached such a high degree of accuracy and importance, seems to have
originated with von Graefe in 1856, and to have been first employed
at Moorfields by Hulke in 1859. In the third volume of the _Reports_
he described some cases, as he says, “to illustrate some forms of
limitation of the field of vision.”

Hulke’s method of procedure was similar to Graefe’s. He placed the
patient before a large blackboard at a distance of 8 inches, covered
one of his eyes, and made him fix a chalked dot in the centre of the
board, on a level with his eyes, with the other. He then moved a white
object over the board in various directions from its margins towards
the centre and marked the places where it was first seen. A line
connecting these marks gave the outline of the field of vision.

The obvious defect of using a flat surface, like a blackboard, was
that the various parts of the retina were not situated at an equal
distance from it. To Forster belongs the credit of having introduced
an instrument in which the field was projected on a hollow sphere. His
perimeter consisted of a metallic semicircle capable of rotation in
various meridians, and on this general principle all other models since
produced have been constructed. Forster’s perimeter first came into use
at Moorfields in 1870.

The rapid development of surgical procedures in ophthalmology eclipsed
for a time at Moorfields the medical side. Dr. Robert Martin, who held
the post of physician from 1856 to 1884, made but little use of the
opportunities it afforded him. He did not have patients allotted to
him or any fixed time of attendance, like his predecessor. In 1867
he suffered from a severe illness which seemed to threaten his mind,
and necessitated his temporary retirement from work; he, however,
completely recovered, and no one was appointed in his place at
Moorfields during his absence.

The discovery of the ophthalmoscope opened up a new field for medical
investigation, which was fully taken advantage of by that distinguished
neurologist, Dr. Hughlings Jackson, who at the commencement of his
career worked at Moorfields, first with Poland and afterwards with
Jonathan Hutchinson. In a Presidential Address which he delivered at
the Ophthalmological Society in 1889, he remarked:

  “It was the luckiest thing in my early life that I began the
  scientific study of my profession at an Ophthalmic Hospital. Many
  years ago I had the good fortune to be Mr. Hutchinson’s clinical
  assistant at Moorfields. I suppose it is to his example and teaching
  that I owe the beginning of the little scientific development I may
  have. At an Ophthalmic Hospital one has the opportunity of being
  well disciplined in exact observation. When a physician sees how
  carefully and precisely ophthalmic surgeons investigate the simplest
  case of ocular paralysis, he is getting a lesson in exactness, and
  will be less likely in his own department of practice to deal in such
  generalities as that a patient’s fit ‘had all the characters of an
  ordinary epileptic fit,’ and more likely to take pains to describe
  the convulsion, the place of onset, the march and the range of the
  spasm.”

Dr. Hughlings Jackson contributed many most valuable papers to the
_Reports_ dealing with ophthalmoscopic findings in connection with
brain disease. He wrote, as he said in one of them, “as a physician and
not as an ophthalmologist,” having studied ophthalmic medicine merely
as a help to the study of diseases of the nervous system. And, again,
in another article he remarked:

  “The physician is quite as much indebted to Helmholtz as the
  ophthalmologist. Defects of sight of all kinds occur so often in
  affections of the nervous system that it is not too much to say that
  to the student of these diseases a knowledge of amaurosis, both in
  the widest and loosest, and in the narrowest and most precise use of
  the word, is of more importance than a knowledge of any other class
  of symptoms.”

He was never tired of impressing on physicians the value of the routine
use of the ophthalmoscope. Thus he wrote in 1889:

  “I urge young physicians to study eye diseases at an Ophthalmic
  Hospital or at an ophthalmic department of a General Hospital; this
  nowadays needs no urging on physicians especially interested in
  neurology.”

In 1863 Dr. Argyll Robertson contributed a paper from Edinburgh to the
_Reports_, “On the Effects of Calabar Bean on the Eye,” in which he
stated that the miotic action of this drug had been first discovered
by Dr. Thomas R. Fraser. Besides describing its effects on the normal
eye, he enumerates several affections in which he had found its use
beneficial, but makes no mention of glaucoma. It was apparently not
until 1876 that it became employed for the reduction of increased
intraocular tension, Adolph Weber and Laquer describing its use for
this purpose about the same time.




CHAPTER IX

GROWTH AND EXTENSION


When the Eye Infirmary was first built in lower Moorfields in 1821 the
district was an exceedingly quiet one; in front of it was a large open
space, which had been the old Bethlehem Hospital burial-ground, but had
not been used as such after the removal of that Hospital to the other
side of the river in 1814.

In 1899, when the Eye Hospital was transferred to the City Road, the
district had become one of the busiest and noisiest in the City of
London. The cause of this change was the erection of the Broad Street
and Liverpool Street Stations on the site of the old burial-ground,
and on that of a large number of courts and alleys in its vicinity,
which were cleared away for the purpose. Out of these terminal stations
there poured forth every morning the various City workers, and back to
them they streamed in the afternoons and evenings. The railway termini
became the starting-points of various omnibuses, the roll of the wheels
of which on stony streets and the clatter of the horses’ hoofs kept
up a continuous roar. The erection of the London and North-Western
Railway’s Goods Station, to the north of the Hospital on the opposite
side of Eldon Street, added noises at night, as well as day, in the
rattle and banging of milk-cans. To patients coming from country
districts this continuous noise proved very disturbing and detrimental.
In 1870 some mitigation of the trouble was obtained by the substitution
of asphalt paving in the streets around the Hospital in place of
cobble-stones.

The increased facilities which the railways and omnibuses afforded
for approach to the Hospital tended largely to increase the number
of patients coming to it for relief. In 1851 new out-patients
numbered 11,384, and in 1878 they had increased to 19,177. To provide
accommodation for this increase, and for the larger number of patients
requiring operative treatment, it became obvious that a new wing would
have to be added on the south side of the Hospital. A lease for the
land on which it was to be erected had, through the foresight of Dr.
Farre, been obtained in 1823 for a period of seventy-seven years from
the Corporation of London. On it a stables had been built and let off
until such time as the Hospital found it necessary to take possession.
When the new building was contemplated, an attempt was made to obtain
a freehold of the site from the Bridge House Estate, but owing to the
Hospital not being an incorporated body the negotiations fell through.

The original London terminus of the Great Eastern Railway, opened in
1839, was at Shoreditch. In 1863 a Bill was introduced into the House
of Lords to give the Great Eastern Railway power to extend their line
to Finsbury Circus, and to make a station there which would absorb all
the surrounding houses and the recently erected London Institution. It
was obvious that such an undertaking would seriously interfere with
the amenities of the Hospital, and the Committee of Management drew up
a petition against the Bill pointing out how the work of the Hospital
would be interfered with if it was passed. This petition they confided
to Mr. Alfred Smee, who at that time resided in Finsbury Circus, to be
forwarded to the Earl of Shaftesbury for presentation to the House of
Lords.

The Bill was rejected and the Committee of the Hospital passed a vote
of thanks to the Right Hon. the Earl of Shaftesbury for his important
services in the matter.

Pending the final selection of sites by the different railways for
their terminal stations, the Committee of the Hospital had to postpone
their plans for enlargement, but ultimately, early in 1868, the long
contemplated building was commenced; it did not, however, become ready
for occupation until July, 1870; the total cost was £7,226, towards
which Her Majesty the Queen graciously contributed £100.

The reform in hospital architecture which commenced after the Crimean
War with the publication of Miss Nightingale’s celebrated _Notes on
Hospitals_ was then still in its infancy. St. Thomas’s Hospital, which
was being erected on the Thames Embankment at the same time as the
new wing at Moorfields, was the embodiment of her ideas; adequate
cubic space, not only in the wards but also in the passages, being
considered the most essential factor. It has been jokingly said that,
at St. Thomas’s, so large and lofty is the children’s ward that it is
difficult to find the children. Listerism, with its passion for aseptic
cleanliness, rounded corners, and polished surfaces, had not then
dawned.

The new wing at Moorfields was designed by Mr. Robert Brass,
and consisted of three floors. The ground floor was devoted to
out-patients. The first and second floor each contained three small
six-bedded wards leading out of a long passage. Their arrangement
was neither good for administration or for ventilation. The curious
device was adopted of placing the fireplaces immediately beneath the
windows, which necessitated an elbow-shaped bend in the chimneys. The
consequence was that soot which collected in the bends caught fire,
causing from time to time considerable consternation and excitement
amongst the patients and resident staff.

In 1866 the staff of the Hospital consisted of four surgeons and
four assistant-surgeons, but Critchett was desirous of having an
assistant-surgeon to work with him on his days of attendance, and
it was mainly at his instigation that it was decided to appoint a
fifth assistant-surgeon. To this post John Couper, who for several
years had acted as Critchett’s clinical assistant, and who was an
assistant-surgeon at the London Hospital, was unanimously elected.

In 1867 the President of the Hospital, Mr. William Cotton, D.C.L.,
F.R.S., died, and the Governors obtained the consent of the
distinguished banker, scientist, and statesman, Sir John Lubbock,
F.R.S., M.P. (afterwards Lord Avebury), to take his place.

In that year yet another addition was made to the surgical staff by the
election as assistant-surgeon of John Soelberg Wells, to whose early
career and scientific attainments reference has already been made. By
that time several of the assistant-surgeons, by acting as such for
five years, had become eligible for promotion to surgeons; it was not,
however, until the new wing was opened, which provided an additional
thirty-six beds, that they were able to obtain the full advantages of
such promotion.

The establishment of special ophthalmic departments at the several
general hospitals in London caused the Governors of Moorfields some
alarm as to the ultimate welfare of their own institution, or as
Critchett picturesquely put it, “they feared that the heart of the
parent would be sucked out for the benefit of their children, without
any corresponding advantage to the public.” It was for this reason that
in 1864, at a meeting of the Governors, the following rule was passed:

  “No surgeon of the Hospital shall hold an ophthalmic appointment
  in any other institution, and if any surgeon, at the time when he
  becomes such, holds any ophthalmic appointment, he shall resign the
  same within three months.”

The first time this rule came into operation was when Streatfield
and Hulke became surgeons. The rule only applied to surgeons, not to
assistant-surgeons. Streatfield held the post of ophthalmic surgeon at
University College Hospital, and Hulke that of ophthalmic surgeon at
Middlesex Hospital. On their promotion at Moorfields, the Committee of
Management requested them to resign their appointments as ophthalmic
surgeons elsewhere. Hulke readily complied with the request, as he was
still able to maintain his connection as a general surgeon with the
Middlesex. Streatfield, however, who only practised as an ophthalmic
surgeon, was very reluctant to resign his connection with University
College. On the matter being discussed by the Medical Council, it
was found that its members were divided in their opinions: some,
like Critchett, feared rivalry from the newly developing ophthalmic
departments at general hospitals; others welcomed their up-growth, and
saw that they were essential parts of such institutions, both from the
patients’ and the students’ point of view. They considered it desirable
that those who enjoyed the exceptional experience afforded as surgeons
at Moorfields should be encouraged to join them, and that, as has
proved to be the case, their connection with them would induce students
requiring extended ophthalmic training to come to Moorfields. With such
division of opinion on the surgical staff the Committee did not at that
time consider themselves able to advise any alteration in the rule,
and Streatfield had to resign his appointment at University College
Hospital.

When Couper and Soelberg Wells became eligible for promotion as
surgeons in 1873, the matter again came under consideration; in the
interval several members of the staff had altered their opinions, and
the Medical Council unanimously recommended the abolition of the rule,
stating that “it felt assured that the cultivation of intimate relation
with General Hospitals through members of the staff is conducive to the
interests of Moorfields.” A special meeting of the Governors was then
summoned, at which the rule was rescinded. Streatfield was fortunate
enough to be reappointed to the post he had had to resign at University
College.

James Dixon retired from the active staff of the Hospital in 1868,
after having been connected with it for twenty-five years, and the
senior surgeon for a period of twelve years. As such he had a seat on
the Committee of Management, where he was a regular attendant and
rendered valuable assistance. In 1870, owing to domestic bereavements,
he gave up practice and lived in retirement, occupying himself with the
study of English history and English literature. He published a small
handbook, entitled _A Guide to the Practical Study of the Diseases of
the Eye_, in which he said he aimed at supplying a useful guide to
those commencing the study of eye diseases. That it fulfilled this
purpose is shown by its having passed through three editions. The last
which appeared in 1866, was brought well up to date with the numerous
developments which had taken place since it first made its appearance.

Dixon was particularly scathing on the dry and pedantic use of
unnecessarily complicated names in the description of affections of the
eye. Thus he writes:

  “It requires a more intimate knowledge of Greek than one has a
  right to expect from every student of medicine to recognise in
  ‘Iridoperiphakitis’ an inflamed iris and capsule, or at once to
  detect the operation for closing lacrymal fistula under such a
  disguise as that of ‘Dacryocystosyringokatlesis.’”

Though the world-wide reputation of Moorfields is mainly due to the
skill and scientific attainments of the medical staff, its progress
and prosperity have been to a large extent promoted by the services of
the able and devoted workers who have in succession held the post of
Chairman of the Committee of Management. Conspicuous among them for the
interest they took in everything connected with the Institution were
Mr. F. G. Sambrooke, who died in 1871, after having held the post for
eleven years, and Mr. Philip Cazenove, who succeeded him.

The medical staff of a hospital are the distributors of its benefits,
but in order that benefits may be distributed a collecting department
is essential, and the work of raising funds for its maintenance falls
upon the Committee of Management and the secretary.

Some individuals seem to have a special flair for begging successfully
for funds for charitable purposes. The united efforts of Mr. Sambrooke,
the Chairman at Moorfields, and of Mr. Mogford, its secretary, during
the sixties, met with a most excellent response. In the early days of
the Hospital funds were raised by means of festival dinners and special
sermons; but during the sixties, without such aid, subscriptions flowed
in both for the maintenance of the Institution and for its building
fund. Mr. Mogford attributed his success in this matter entirely to
his letters of appeal; but it must be remembered that it was a time of
peace and considerable commercial prosperity, under which conditions
philanthropic efforts stand the best chance of success. Excellent as
Mr. Mogford was as a collector of funds, he had certain weaknesses
which in 1872 necessitated his resignation, Mr. Robert J. Newstead
being appointed to fill his place.

In Mr. Sambrooke the medical staff had a most sympathetic supporter
in the promotion of the scientific side of ophthalmology. During
his chairmanship most liberal grants of money were made towards the
development and upkeep of the Museum and Library. Thus a grant of £72
was made in 1864 for the purchase of a collection of ophthalmoscopic
drawings of the fundus of the eye, and when the new museum was
completed in 1870 a grant of £235 was expended in book-cases and
suitable fittings for the display of specimens.

Charles Bader, who continued to hold the post of curator of the
Museum up to 1867, as the outcome of his experiences published a
book entitled _The Natural and Morbid Changes in the Human Eye_. He
was very dexterous in the mounting of museum specimens of the eye,
but unfortunately the only two methods then known of preserving such
specimens were by means of spirit or by the use of glycerine. The
former caused them to shrink and rendered the transparent parts opaque,
and the latter, though to some extent preserving their transparency,
caused them to swell. The introduction of the glycerine jelly method
of preserving museum specimens of eyes by Nettleship in 1871, and
elaborated by Priestley Smith in 1883, was a great improvement; but
even with this method considerable care and attention was necessary to
prevent deterioration. It was not until the introduction of formaline
as a hardening and preserving agent, by Professor Leber in 1894, that
a really satisfactory medium for museum specimens was found—one which
would retain indefinitely the relative degrees of transparency and
colour of the different parts which they presented during life.

On the resignation of Bader of the post of curator, Bowater Vernon, who
had been working as clinical assistant to Wordsworth, was appointed in
his place with a salary of £50 per annum. The duties of the post were
defined as follows:

  “That he shall attend daily from 10 to 1, and on the evenings of the
  ophthalmoscopic demonstrations, and at such other times as may be
  necessary to put up and display the morbid specimens presented.

  “That he be responsible for the due keeping, cataloguing and giving
  out under regulations of the books and plates under his charge.

  “That he shall prepare gradually a complete series of preparations
  illustrating the normal anatomy of the human eye and its appendages,
  and proceed as far as possible with a similar series illustrative of
  the comparative anatomy and pathology of the same.

  “That he shall be required to report upon the microscopic appearances
  of all specimens requiring such examination and to keep a register of
  such examinations, if possible, illustrated by drawings.”

The evening ophthalmoscopic demonstrations above referred to had been
started for the benefit of the students attending the Hospital in 1864,
and were conducted in turn by the different members of the staff.

In the records of pathological specimens, published by Vernon in the
_Reports_ in 1868, is the description of what must have been one
of the first cases of tubercle of the choroid which, having been
seen ophthalmoscopically, was later examined microscopically. In
1871 Vernon, being appointed ophthalmic surgeon to St. Bartholomew’s
Hospital, resigned the post of curator of the Museum; he was succeeded
by Edward Nettleship, who held it for two years in conjunction with
that of clinical assistant to Jonathan Hutchinson. The extensive
reports of the specimens committed to his care which Nettleship
published in the _Hospital Reports_ for those years show with what care
and diligence he discharged the duties of the office. This, together
with the stimulating influence of his chief, Jonathan Hutchinson,
formed an excellent training for the important work which Nettleship
did in connection with ophthalmology in later years.

In the middle of the nineteenth century a number of residential schools
were established in London for the children of parents in receipt of
Poor Law relief. Almost from their commencement outbreaks of ophthalmia
became very prevalent in these schools. In 1870 Critchett was asked to
visit and advise as to the ophthalmia in one of them at Anerley. He
stated in his report that he

  “found a large proportion of mild ophthalmia, which in most cases
  did not render the patients incapable of following the usual
  educational course, and he advised the establishment of a ward or
  separate school, where all such cases might be kept for an indefinite
  time until it was quite certain that they would not relapse, where
  they might be under such hygienic and medical treatment as seemed
  necessary, where their instruction and education should go on as
  if they were in the body of the school, and where, by prolonged
  isolation, they might be prevented from acting as sources of
  contagion to the healthy children in the school.”

PLATE XVII.

[Illustration: EDWARD NETTLESHIP, F.R.S.]

Action was taken in accordance with this advice in 1873, when 400
children who showed signs of ophthalmia at the Anerley School were
isolated in an unoccupied workhouse at Bow, which was kept going as
a combined infirmary and school with an efficient staff of teachers and
nurses for twelve months. Nettleship, having resigned his appointment
as curator at Moorfields, acted as its resident superintendent.
The experiment proved the soundness of Critchett’s advice, but it
became obvious that in some cases, more especially those of trachoma,
isolation and treatment would have to be continued for more than a
year. In 1889 a special isolation school was erected for children
affected with ophthalmia in the Central District School at Hanwell
and placed under the charge of Sydney Stephenson. Here, again, the
success of Critchett’s policy was so marked, that in 1897 the Local
Government Board instructed the Metropolitan Asylums Board to provide
accommodation for children suffering from ophthalmia in all the Poor
Law Schools of London. The result has been a steady and continuous
diminution in the number of cases to be dealt with and the practical
extinction altogether in these schools of that at most intractable of
all forms of ophthalmia—trachoma.

The salary for the curator of the Museum, whilst Vernon and Nettleship
held the office, seems to have been disproportionately small to the
liberal grants made for the upkeep of the Museum itself. During his
first year of office Nettleship’s salary was only £50 per annum; at the
end of that time, “in consideration of his very valuable and arduous
services in the work of the Museum,” it was raised to £75. When W. A.
Brailey was appointed to the post in 1874 it was found necessary to
increase the salary of it to £100, and in 1877 to £120. After increased
accommodation was made in connection with the laboratory in 1879,
courses of instruction in practical pathology of the eye were commenced
by the curator.

In 1870 ophthalmic science sustained a heavy loss by the death of
Albert von Graefe, its most zealous and successful cultivator, in
his forty-third year. His last extensive article dealing with “The
Pathology and Treatment of Glaucoma” was translated and published in
full in the _Ophthalmic Hospital Reports_ at the beginning of 1871.
Much as Graefe did to extend our knowledge of the conditions which lead
to an increased hardness of the eyeball, the disasters to which such
hardness gives rise, and the means by which they may be avoided, much
was still left unexplained. Even now, in spite of the reams which have
since been written, there is still much in connection with the subject
requiring further elucidation. In 1878 a stimulus was given to research
in this country in connection with glaucoma by the Royal College of
Surgeons setting as the subject for the Jacksonian Prize Essay for
that year, “Glaucoma: its Causes, Symptoms, Pathology, and Treatment.”
The prize was awarded to Priestley Smith, of Birmingham, and articles
dealing with its causation were published in the _Hospital Reports_
for 1881 by him, and by the curator of the Museum, W. A. Brailey. The
following year Brailey resigned the curatorship on his being appointed
assistant ophthalmic surgeon at Guy’s Hospital. His successor was W.
Jennings Milles, who had previously been house surgeon; he, however,
only held the post for eighteen months, resigning it to go to Shanghai.
He thus carried the practice and training of Moorfields to the Far
East, as others had done to all parts of the British Empire, and to
many of the leading cities in the United States of America.

In 1873 a Canadian, Frank Buller, was appointed house surgeon, and,
returning subsequently to Montreal, became the pioneer of ophthalmic
surgery in that colony. Incidentally, it is of interest to note that in
doing so he forestalled another young Canadian named Osler (afterwards
Sir William Osler, Bart.), who had come to Moorfields to study eye
diseases with the same end in view, but, learning there of Buller’s
intentions, he abandoned the practice of ophthalmology for that of
general medicine.

PLATE XVIII.

[Illustration: THE HOSPITAL AT MOORFIELDS AFTER THE ADDITION OF A NEW
WING IN 1868, AND A NEW STORY IN 1875.]

The length of time which those holding office at Moorfields retained
their posts, and the reluctance with which they resigned them, bears
eloquent testimony to their interest in the work of the Institution.
There was then no limit to the time that a house surgeon might retain
his post, and some continued to do so for more than three years. In
1870 Miss Boycott, who had held the post of matron for twenty-one
years, died at the Hospital. Miss Harnet succeeded her, but not being
herself a trained nurse did little to raise the standard of nursing,
which remained during her term of office in a very primitive condition.

As the number of new out-patients attending the Hospital continued
to increase—from 19,177 in 1868 to 20,687 in 1875—it soon became
evident that the newly erected wing did not supply all the in-patient
accommodation that was required. In 1875 a plan was drawn up and
adopted for the erection of another storey on the main building at
a cost of £2,430. This was completed the following year, when the
accommodation of the Hospital became increased to 45 beds for male
patients, 51 for women and children, and 4 for occasional use.

Bowman and Critchett were nearly of the same age, Bowman being a little
the senior. So much had they done to add to the fame and reputation
of Moorfields that as they approached the age of sixty, when in
accordance with the rules of the Hospital they would have to retire
from the active staff and become consulting surgeons, the Committee
of Management became anxious to find some way in which their services
could be retained. Both Bowman and Critchett, like many of those who
have come after them, felt very reluctant to sever their intimate
association with the Hospital’s work and welfare.

Bowman, in writing to the Chairman of the Committee in July, 1876, to
inform him that the time for his retirement was nearly due, requested
that the duties of a consulting surgeon might be defined, as so far
nothing had been laid down concerning them. Critchett also wrote at the
same time as follows:

  “I believe that Mr. Bowman is about to send in his resignation, and
  I wish to reiterate my conviction that it will be a serious loss to
  the Hospital. Every week I am a witness to the brilliant operations
  he performs, they are to me and to a crowded theatre a source of
  pleasure and profit; professors and students gather round him from
  far and near; the prestige of the Hospital and its value both in a
  scientific and benevolent aspect are enhanced by his presence, and by
  the admirable work that he does. I am sure that if he had voluntarily
  left us, or if he had been snatched from us, every one attached to
  the Institution, whether lay or professional, would have felt that
  they had sustained an irreparable loss. I would therefore suggest
  that some effort should be made to retain his services. In appointing
  him to be consulting surgeon, it seems desirable that he should have
  a few beds placed at his disposal for the admission of cases that may
  be sent up to him or that any of his professional colleagues may wish
  to place under his care; also that he should be invited to continue
  his clinical teaching and if possible give some clinical lectures at
  stated times. This would be a great service to us all.”

The Committee then, in accepting Bowman’s resignation, passed the
following resolution:

  “That in acknowledgment of his high reputation and long services to
  this Institution the Committee request him to continue his clinical
  instructions, which they are sure will be as acceptable to the staff
  as to themselves, and for that purpose are pleased for the present to
  place five beds at his disposal.”

In passing this resolution and forwarding it to Bowman the Committee
acted without first consulting the Medical Council. That body at once
notified the Committee that it was unanimously of opinion that it was
an infringement of the existing laws to assign beds thus to Bowman on
his becoming consulting surgeon. The Committee replied by requesting
the Medical Council to consider regulations as to the duties of a
consulting surgeon. The Medical Council then proceeded to collect
information as to the customs in force with reference to such officers
at the principal Metropolitan Hospitals. It found that in all of them
their duties were simply consultative, and that they attended only
when specially summoned at the request of the officer in charge of
the patient. The Medical Council then advised that a similar practice
should be adhered to at Moorfields, and that arrangements might be made
for the consulting surgeons to deliver clinical lectures. The Committee
were very loath to withdraw the offer of the use of beds which they
had made to Bowman, and had likewise extended to Critchett. The whole
matter was discussed at the Annual Meeting of the Governors, with
Sir John Lubbock, the President, in the Chair. In the end Bowman and
Critchett withdrew from all active participation in the work of the
Hospital with somewhat embittered feelings.

Bowman died in 1892 at the age of seventy-six. In one of his obituary
notices we read the following account of his doings after he left
Moorfields:

  “Fortunately, the opportunities for professional intercourse
  with Bowman did not cease with his retirement from Moorfields.
  Until some years later he held the leading place at all the chief
  meetings connected with our specialty. In 1880, when the British
  Medical Association held its Annual Meeting at Cambridge, Bowman
  was President of the ophthalmological section. Donders was present
  also. The Senate of the University conferred its honorary degree of
  LL.D. on both. In the following year Bowman presided over a still
  more important gathering in London—the ophthalmological section of
  the Seventh International Medical Congress. The fine nature of the
  man, his high ideals, simplicity, and modesty, are perhaps nowhere
  more clearly shown than in the inaugural address given by him on that
  occasion.

  “The Ophthalmological Society of the United Kingdom was founded in
  1880, and was fortunate in having Bowman as its president during
  its first three years—it was largely through his influence that the
  Society rose so rapidly into strength and importance. Its funds,
  moreover, were largely increased by his generosity. He was an ideal
  president: speaking little, but always with purpose and effect,
  showing interest in every communication and encouraging every effort
  at good work.

  “In the year 1883 the Council of the Ophthalmological Society
  resolved to establish an annual lecture—the Bowman lecture—‘in
  recognition of Mr. Bowman’s distinguished scientific position in
  ophthalmology and other branches of medicine, and in commemoration
  of his valuable services to the Ophthalmological Society, of which
  he was the first president.’ In the following year he was made a
  baronet in recognition of his scientific attainments and professional
  eminence. A little later, the suggestion that his portrait should be
  painted and presented to him was welcomed by a large number of his
  friends, in this and other countries, and the well-known portrait by
  Ouless, which was exhibited in the Royal Academy in 1889, was the
  result.

  “Not until he was seventy years of age did Sir William Bowman
  relinquish active practice, and even for some years longer he was
  still at times accessible to those who specially desired his opinion
  and advice.”

Critchett died in 1882 at the age of sixty-five. After retiring
from Moorfields he was appointed ophthalmic surgeon and lecturer on
ophthalmology at the Middlesex Hospital, an appointment which he
held for four years. It afforded him a few beds for needy patients,
and his son Anderson assisted him with the out-patients. He soon
endeared himself to the students there, who valued his teaching and
the opportunity of watching his operative dexterity. For some years he
suffered from enlarged prostate, cystitis, and granular kidney, but it
did not prevent his attending to his practice with unabated vigour,
and performing his numerous social engagements with his customary
hospitality up to the time of his death.

Several candidates who had acted as clinical assistants presented
themselves for the appointments on the staff rendered vacant by the
retirement of Bowman and Critchett, but all withdrew in favour of Waren
Tay and James Adams, both of whom were assistant general surgeons at
the London Hospital.

After the publication of Donders’ great work in English _On the
Anomalies of Accommodation and Refraction of the Eye_, by the New
Sydenham Society in 1864, and Soelberg Wells’ smaller book, which
embodied Donders’ teaching, _On Long, Short, and Weak Sight_,
sight-testing and the correction of errors of refraction with glasses
grew progressively in importance.

The prescription of lotions or ointments for the eyes took far less
time than the estimation of refractive errors and the prescription of
glasses, and with the increase of sight-testing the length of time
occupied in dealing with out-patients became considerably prolonged. At
first it was only the correction of the grosser errors of refraction
which received attention, but as the methods for their estimation
improved, and the importance of even small errors became recognised,
the amount of refractive work steadily increased.

The length of time many out-patients had to wait before they received
attention became a source of anxiety, extending over many years, not
only to the Committee of Management, but also to the surgical staff.
The surgeons’ time was fully occupied with the investigation of
diseased conditions and with operating; they had to depend mainly for
the carrying out of this refraction work on the devotion and goodwill
of their clinical assistants, who, being purely voluntary workers,
could not always be relied upon to stay for an indefinite time.

Many measures were tried to overcome the difficulty. Hulke, who had a
passion for punctuality, was never tired of urging the value of his
special virtue on all concerned. Though a painfully punctual individual
on a medical staff may at times be very trying to his colleagues
and assistants it is no doubt that he is a valuable asset to the
institution with which he is connected. Everybody knew at Moorfields
that on Hulke’s days of attendance they had to be early risers, with
the result that the work was finished more expeditiously.

Much trouble in connection with the refraction work of the Hospital
would probably have been avoided if the plan which has recently been
adopted, of paying an honorarium to one clinical assistant for each
surgeon, had been sooner resorted to. It was originally recommended by
the Medical Council in 1877, but the Committee could not for a long
time see its way to increase so considerably the Hospital’s annual
expenditure.

Jonathan Hutchinson, as has already been mentioned, was a man who took
the widest interest in all diseased conditions; the one subject which
did not specially attract him was refraction work. As the amount and
importance of it increased, and after he became deprived of the zealous
help of his two able assistants, Tay and Nettleship, he felt he could
no longer conscientiously carry out all the duties of his post, and in
1878 resigned his appointment on the staff.

No man at Moorfields ever made more thorough and effectual use of the
clinical work which it placed at his disposal than Jonathan Hutchinson.
For several years he, together with Wordsworth, edited the _Hospital
Reports_, and it was during that time that they were conducted with the
highest degree of efficiency and regularity. The “Periscope” in those
years, which was mainly the work of Waren Tay, formed an excellent and
very complete review of foreign ophthalmic literature. Hutchinson’s
own articles were numerous, containing groups of well-recorded cases,
designed to illustrate new and interesting observations.

In the November number of the _Reports_ for 1871 he published
“Statistical Details of Four Years’ Experience in Respect to the Form
of Amaurosis supposed to be due to Tobacco.” It was his third article
on the subject; the first, in which he suggested a connection between
excessive smoking and affections of the optic nerve, having appeared
in 1864. His attention became attracted by the almost exclusive
occurrence of what was then called “idiopathic symmetrical amaurosis”
in the male sex. He considered all the possible causes which might
account for such a prevalence in one sex only, and found the tobacco
hypothesis the most probable. His researches showed that there was
little evidence of any other affection of the nervous system in these
cases, and that all of them were excessive smokers, most of them having
used shag tobacco. Having watched them for some time, he discovered
that when the disuse of tobacco was real and complete vision generally
improved.

The less frequent issue of the _Reports_ after Hutchinson’s departure,
and the abandonment of the “Periscope,” was due to two things—the
establishment of the Ophthalmological Society in 1881, and the
commencement of the _Ophthalmic Review_ in 1882.

The unexpected vacancy on the staff caused by Hutchinson’s resignation
was filled by the election of John Tweedy who was a clinical assistant
to Streatfield, and held the post of assistant ophthalmic surgeon at
University College Hospital.

In 1879 Philip Cazenove resigned the post of Chairman of the Committee
of Management which he had held for eight years, and in doing so
presented the Hospital with a gift of £1,000. Charles Gordon, whose
name was, and is still, well known in connection with gin, was
appointed to succeed him.

The Hospital suffered a severe loss by the death of Soelberg Wells in
December, 1879; his health had been failing for some time, and he had
been granted repeated periods of leave from his work at the Hospital
on account of it. His _Treatise on the Diseases of the Eye_, first
published in 1869, ran through three editions, and was translated into
German and French. It was for a long time the standard textbook on
ophthalmology, having the supreme virtue of combining the best teaching
and practice of continental writers on the subject with those of our
own country, an undertaking for which Soelberg Wells was particularly
well fitted, owing to his familiarity with the continental clinics and
his linguistic abilities.

Robert Lyell, who had worked as Hulke’s clinical assistant and who was
an assistant general surgeon at the Middlesex Hospital, was elected
in Wells’ place. He was a man who, as a student, had had a brilliant
career and had obtained the highest qualifications and distinctions.
With his appointments at the Middlesex and Moorfields, the way seemed
open to him for a successful and prosperous future. Unfortunately, in
the summer holiday of 1882, he contracted pneumonia, and the opening
session at the Middlesex Hospital Medical School in October, at which
he was to have delivered the Introductory Address, was saddened by the
news of his death.

For the vacancy created by Lyell’s death several candidates presented
themselves, but ultimately withdrew their applications in favour
of Nettleship, who already held the post of ophthalmic surgeon at
St. Thomas’s Hospital. This was the last appointment on the staff
at Moorfields which was created by a vote of the Governors. In 1883
the Medical Council informed the Committee of Management that in its
opinion “the present mode of election of the honorary medical officers
did not secure the best interests of the Hospital.” A joint conference
was held at which it was decided to recommend that in future the
election of honorary officers should be invested in a committee, and
that this election committee should consist of the Board of Management,
together with six honorary medical officers, the quorum to consist of
seven; and that canvassing should be prohibited on the part of any
candidate under pain of disqualification. These recommendations were
agreed to at a meeting of the Governors, and in this way all subsequent
elections have been conducted. At the same time it was also agreed
that the Fellowship of the Royal College of Surgeons of England should
be the only requisite necessary for eligibility as a candidate for a
post on the surgical staff.

PLATE XIX.

[Illustration: WAREN TAY]

Manners and characteristics, besides being inherited by children
from parents, are also often acquired by pupils from teachers. The
latter most frequently occurs where the teacher possesses a strong
and impressive personality, and the taught are earnest and devout.
This transmission of traits is not uncommonly met with in the medical
profession, where some dominating member of a hospital staff impresses
his individuality on those who work under him. A conspicuous example
of this occurred at Moorfields, where Waren Tay and Edward Nettleship,
who worked as clinical assistants to Jonathan Hutchinson, acquired,
probably quite unconsciously, not only his mannerisms, but even his
method of speech. Tay, like Hutchinson, became skilled in the practice
of several different branches of his profession; like him, he became a
general surgeon at the London Hospital, a specialist in skin diseases
at the Blackfriars’ Hospital and in eye diseases at Moorfields. It
has already been mentioned how Hutchinson worked under Sir William
Lawrence, and acquired from him the habit of collecting and collating
the notes of clinical cases; in this most valuable method of advancing
our knowledge of the natural history of disease Hutchinson found a most
able disciple in Edward Nettleship, who, in the excellent field for
its employment which Moorfields Hospital afforded him, made the most
extensive use of it, more especially in tracing out the hereditary
transmission of diseases and deformities.




CHAPTER X

ANTISEPTICS, BACTERIOLOGY, AND LOCAL ANÆSTHESIA


Joseph Lister’s first paper on his method of preventing the access
to wounds of germs which cause putrefaction appeared in the _Lancet_
in 1867. It was not, however, until several years later that London
surgeons began to adopt his methods, and it was not until the teaching
and training of bacteriological laboratories exerted their influence
that the practice of Listerian principles became generally and
efficiently carried out.

Wounds of the eye, due to the protective influence afforded by the
eyelids, and to their continuous irrigation with tears, which normally
possess bactericidal powers, were less liable to septic infection than
those in other parts of the body. Hence, prior to the introduction of
antiseptic methods, the operations of ophthalmic surgery were less
frequently complicated by septic troubles than those of general surgery.

Where the tear duct became obstructed and discharge from the tear sac
regurgitated into the eye, and where contaminated instruments were
introduced into the interior of the eyeball, wounds became infected and
disastrous consequences ensued. The danger of operating for cataract
when there was obstruction to the tear duct was soon recognised, and
it became a routine practice to investigate the condition of the
tear passages before embarking on such operations. It was not until
some time after the introduction of antiseptic surgery that the
sterilisation of the instruments used in ophthalmic operations became
general.

In the third edition of Soelberg Wells’ _Treatise on Eye Diseases_,
published in 1873, which may certainly be taken as picturing the
high-water mark of ophthalmic practice at that date, no mention is made
of the use of any antiseptic precautions in connection with operations
on the eye.

The after-treatment of eyes operated on for extraction of cataract at
Moorfields in 1876 is described by A. S. Morton, who was then house
surgeon, as follows:

  “As soon as the operation was completed the lids of each eye were
  fastened by a very narrow vertical strip of plaster to prevent
  involuntary opening of the eye during recovery from the anæsthetic,
  then a piece of lint, on which was placed a layer of cotton-wool for
  each eye, and over all a bandage. The eyes were dressed each morning
  and evening after the operation, being gently bathed with tepid water
  and the lids oiled with a soft brush to prevent the dressing sticking
  to them. The patients were kept in bed till the third day, and the
  lids never opened till the fourth or fifth day after the operation,
  unless there were indications of mischief. About the end of a week
  they were handed over to the nurse to dress, and in about nine or ten
  days were allowed to have their eyes open, but very carefully shaded.”

Confinement in a dark room was for a long time regarded as an essential
part of the treatment of certain eye diseases. Some elderly people
still retain vivid recollections of having to submit to this unpleasant
form of treatment for some inflammatory eye affection in their youth.
The admission of light to the eye during the first few days after
an operation for cataract was believed to excite inflammation, and
elaborate precautions were taken to avoid it.

The cataract wards at Moorfields were darkened with double blinds, and
when the dressings on the eyes were being changed, a nurse stood at
the end of the bed holding a candle which she cautiously shaded with
her hand to prevent any of its rays falling on the patient’s eyes.
Some of the senior members of the staff received rather a shock when
a venturesome house surgeon, mindful of Florence Nightingale’s dictum
that “a dark room is always a dirty room,” had the blinds in the
cataract wards drawn up, letting the sun’s blessed rays stream in,
whilst the patient’s eyes were tied up or shaded with dark glasses.

The practice with regard to the instruments in the pre-antiseptic days
was for the nurse to wash them when used in ordinary tap-water, after
which they were stored in their velvet-lined cases. From these they
were transferred without further preparation, and handed to the surgeon
for the next operation on a tray lined with green baize.

Out-patients and in-patients were operated on in the same theatre, the
former coming to it just as they presented themselves at the Hospital,
without any change of clothing. The surgeons themselves made no change
in their costume when operating, and the nurses wore no regular uniform.

The former violent “antiphlogistic” treatment of extensive bleeding,
sweating, vomiting, and purging, for inflammatory affections of
the eyes, had in the seventies been given up, chief reliance being
then placed on the use of belladonna and poppy-head fomentations,
“astringents,” and the application of leeches, blisters, and setons to
the temples.

The year 1872 was an unusually disastrous one at Moorfields as regards
operations for the removal of cataract, as many as 20 per cent.
having resulted in failure. A joint meeting of the Committee and the
medical staff was held to consider the matter, and the disasters were
attributed to the presence in the Hospital at the time of a large
number of infectious cases, changes in the nursing staff, and the
absence of the house surgeon on a holiday. Measures to improve the
ventilation of the wards were taken, an assistant house surgeon was
appointed, and a long standing request of the Medical Council for the
appointment of a special night nurse was at last acceded to.

At the International Congress of Medicine held in London in 1881, a
discussion took place at the ophthalmological section on the employment
of antiseptics in ophthalmic surgery. Antiseptic surgery at that time
consisted in the use of carbolic acid in the form of a spray, as a
lotion, and in the dressings. Professor Horner of Zurich, who opened
the discussion, quoted his statistics of cataract operations from
1867 to 1881 to show that by the use of antiseptics there had been a
decrease in the number of cases of suppuration from 6·6 to 1·1 per
cent. Some speakers thought the good obtained from the use of carbolic
acid was counter-balanced by its irritating properties. Bowman, who
presided over the section, in his Inaugural Address, made the following
wise remarks which may be taken as foreshadowing the adoption of
aseptic as opposed to antiseptic measures:

  “I presume that no one nowadays will question the evils we are so
  familiar with in our practice, and which have so often marred the
  intention of well-devised operations skilfully performed, but where,
  as we hear it said, Nature has failed to do her part, to second the
  effort of the surgeon by a process of repair. The study of the causes
  of such failures and of the means of obviating them, constitutes far
  the most brilliant page of modern surgery; and in other sections of
  this Congress, while the name of Lister will be applauded, the wide
  questions he has raised, and in raising has so often cleared up, will
  receive the full consideration they call for.

  “In the case of the organ of sight, specially constituted, and in
  some respects screened from injury as it unquestionably is, there are
  reasons why the application of precautionary antiseptic measures,
  though the principle of them must still assert itself, should take a
  somewhat special form. Owing to the local structural conditions they
  may apparently be often more simple, though the possible need of the
  more elaborate of them should never be allowed to fall out of view.

  “The tears are a secretion as pure from extraneous particles as is
  the filtered air in the recesses of the lungs. They are poured out
  under cover, in the right place, in quantity suitable to the need;
  while the lids diffuse them over the conjunctival surface ere they
  escape to their proper channels. Their useful and multiple office is
  performed in a way so simple and so perfect, that no art, however
  skilful, could pretend to equal it. We should ponder well the deep
  marvels of adaptation of means to ends, and take heed that we do
  not hinder exquisite Nature by meddlesome or needless interference,
  by the _nimia diligentia Chirurgorum_, but only lend it tender and
  judicious help by our dressings and our methods. We should always
  still be able to apply the words of our great poet, ‘The Art itself
  is Nature.’”

In 1876 A. S. Morton, the house surgeon at Moorfields, recorded
that out of 146 cases of extraction of cataract 5·47 per cent, had
suppurated, and that 12·3 per cent, had suffered from severe iritis.
In an analysis of the results of cataract extraction at Moorfields
for five years, from 1889 to 1893, the house surgeon, C. D. Marshall,
records the number in which suppuration occurred as 1·69 per cent. The
preparation and after-treatment of patients undergoing this operation
during those years he describes as follows:

  “I shall here only mention the special points connected with the
  eye, the general examination and preparation of the patient being
  precisely the same as that adopted previous to the performance
  of any surgical operation. The lids and parts around the eye are
  carefully washed with soap and hot water over-night, and a pad
  which has been wrung out in a 1/4000 solution of the perchloride of
  mercury is applied. On removing this the next morning one is able
  to obtain a good idea as to the state of the conjunctiva; if the
  lids be gummed together, the operation is deferred until a more
  satisfactory state of things is obtained. If, however, there is
  nothing to contraindicate the performance of the operation the eye is
  anæsthetised with a 2 per cent. solution of freshly prepared cocaine
  and the conjunctival sac is washed out with a good stream of either
  warm boracic or perchloride lotion. The instruments are boiled before
  being used and kept in carbolic acid lotion 1 to 40.

  “After the operation both eyes are as a rule closed for a day or two,
  and tied up with pads of Gamgee tissue made of the double cyanide
  wool. The operated eye is kept bandaged for about a week, and after
  that dark goggles are worn.”

John Couper, who was a general surgeon at the London Hospital as
well as an ophthalmic surgeon at Moorfields, was one of the earliest
and most enthusiastic pioneers of antiseptic surgery, practising it
consistently before Lister came to London. At Moorfields he was one of
the first to welcome its application to ophthalmic surgery.

PLATE XX.

[Illustration: JOHN COUPER.]

In the following appreciation, written by Sir John Tweedy, we have
recorded a most faithful and striking word-picture of John Couper’s
characteristics:

  “When I first knew John Couper he was assistant-surgeon to the
  London Hospital and assistant-surgeon to the Royal London Ophthalmic
  Hospital, Moorfields. With his work as a general surgeon I was but
  slightly acquainted, but I do know that he was one of the first and
  most ardent of the disciples of the Listerian doctrine, and practised
  the Listerian method with patient confidence. It was my happy
  privilege to have as colleagues at Moorfields George Lawson and John
  Couper, and to work side by side with them for many years. Lawson was
  one of the best ophthalmic _surgeons_ I have ever known. Couper’s
  gifts were of a different order. Although a good surgeon and skilled
  operator, his qualities were those of an _ophthalmic physician_.
  _Facile princeps_ among the ophthalmoscopists of the day, he was one
  of the first in this country seriously and scientifically to study
  problems of the errors of refraction, and especially of astigmatism.
  His diagnostic skill and his careful method of investigation
  attracted a body of thoughtful pupils, not a few of whom afterwards
  attained a notable distinction. Couper’s was a charming personality;
  he was gentle, courteous, conciliatory, but strong in opinion and
  tenacious of principle. His mental temperament was essentially
  sceptical. Not unbelief, not mis-belief, but hardness of belief was
  his intellectual attitude to all surgical and scientific questions.
  He did not believe easily or lightly, but only when convinced by
  the force of reason and by the potency of well observed facts. His
  scepticism may not have been an unmixed benefit as a teacher to
  beginners, but it was a real advantage at a Hospital like Moorfields,
  where many of the pupils, assistants, and visitors were actual or
  potent experts. His hardness of belief often provoked keen but
  friendly controversy, sharp but generous differences of opinion,
  which rarely failed to elucidate truth, and open up fresh avenues
  of knowledge. No man was ever the worse for a difference of opinion
  with Couper, and most of us were often much the better. Thought was
  stimulated, reasons were clarified, opinions modified and amended,
  or maybe strengthened and confirmed; and, above all, a valuable
  lesson was learnt in mutual respect and tolerance. Couper was indeed
  a lovable man, a true friend, a staunch and loyal colleague. To
  have known him, and to have been so long associated with him, is an
  abiding satisfaction, and the recollection of a friendship unclouded
  throughout many years is a precious possession.”

John Couper was not only a pioneer in the use of antiseptics in
ophthalmic surgery, but also in the accurate correction of even
small errors of refraction with glasses. He was most emphatic and
uncompromising in advising his patients to wear their glasses
constantly. A young lady with a very pretty face, who felt very loath
to detract from its charms by wearing glasses, asked pitifully:
“Please, Mr. Couper, how long shall I have to wear these glasses?”
Couper replied by asking her her age, which was eighteen. “Well,”
said Couper, “the average age of woman is three score years and ten:
eighteen from that makes how long?”

Couper made use of his ophthalmoscope not only to explore the fundus
of the eye, but also as an optometer for the estimation of refractive
errors. He commenced to do so before the practice of “retinoscopy”
came into use, and having acquired considerable skill in the method,
continued to employ it in preference to the easier one. To render
the ophthalmoscope as serviceable as possible as an optometer, he
introduced several modifications in it. He found it most desirable
to have only one lens to look through behind the sight hole in the
mirror at a time, and to be able to bring the eye of the observer
as near as possible to that of the one being examined. For these
purposes he substituted a chain of lenses in place of the usual disc,
and, as he considered it necessary to have as many separate lenses
available as are contained in an ordinary trial case, the handle of his
ophthalmoscope in which the lenses circulated became of considerable
length. So long, indeed, was it that Couper had to arrange with his
tailor for the construction of a special coat pocket in which he could
carry it.

The method of estimating errors of refraction of the eye by what is
now known as “retinoscopy” was first introduced as a systematic method
by Cuignet in 1874, under the inappropriate name of “keratoscopy.”
Bowman had, however, ten years previously called attention to the
possibility of diagnosing regular astigmatism by using the mirror of
the ophthalmoscope to reflect light into the eye, much in the same way
as for detecting slight degrees of conical cornea.

An article advocating the use of Cuignet’s method, by Litton Forbes,
appeared in the _Ophthalmic Hospital Reports_ in 1880, and another,
descriptive of its optical basis, by W. Charnley, in 1882.

In 1883 John Cawood Wordsworth, having reached the age of sixty,
retired from the active staff after thirty-one years of service, and
died three years later from angina pectoris. He was described as
an admirable example of the genuine “dignity and reputation of the
profession,” and as “unobtrusive almost to a fault.” Though, together
with Hutchinson, he was for several years editor of the _Hospital
Reports_, he contributed but little himself to the literature of
ophthalmology.

He resided and commenced to practise in Finsbury Square; for some
time his private patients were but few and far between. He employed
a page boy who was instructed to fetch him from the Hospital if any
patient should happen to come whilst he was engaged there. One day the
boy came to the Hospital in hot haste to announce the arrival of a
patient. “Will he wait until I get round?” Wordsworth asked the boy. “I
am quite sure he will,” replied the boy, “for I have locked him in.”
Wordsworth then explained to the house surgeon and his assistants how
they must carry on the work for a time as he had been called away to
see a private patient; they helped him on with his coat, and away he
went with the boy. To their great surprise he returned after only a few
minutes. Noting the surprised look in their faces, he sadly explained
that it was only the tax collector.

Marcus Gunn, who had previously been the house surgeon, was appointed
to succeed Wordsworth; he was the first officer who had so served the
Hospital to become elected as a member of its honorary staff. He had
been a particularly able and energetic house surgeon, having instituted
a new system of note-taking for the in-patients, which has proved so
satisfactory that it is still in use at the present time. His intimate
acquaintance with the nursing and domestic arrangements of the Hospital
proved of considerable value in the reforms and general upheaval which
took place shortly after he was appointed. Previous to his becoming
house surgeon, he had studied ophthalmology in Vienna under Jaeger; so
impressed was he with the systematic courses of instruction carried
on at that school, that on his appointment as assistant-surgeon he at
once set to work to institute more regular and systematic teaching at
Moorfields. He himself conducted regular classes in ophthalmoscopic
examination at stated intervals, which became so popular that the list
of students which could be taken at any one class was always filled up
some time in advance.

PLATE XXI.

[Illustration: R. MARCUS GUNN.]

Early in 1884 Dr. Martin resigned the post of physician, and Dr.
Stephen Mackenzie (afterwards Sir Stephen Mackenzie), a physician at
the London Hospital, was appointed in his place. He resided at that
time in Finsbury Square, and it was easy, therefore, for him to attend
at the Hospital when requested to do so either by a member of the
surgical staff or the house surgeon. He took a keen interest in
medical ophthalmology, and contributed several communications on the
subject to the Ophthalmological Society, of which he was one of the
first secretaries.

During a large part of the nineteenth century the district of Finsbury
was a fashionable residential medical quarter of London; Finsbury
Square, Finsbury Pavement, Finsbury Circus, Broad Street, and St.
Helen’s Place, at one time swarmed with physicians and surgeons.
The City and its adjacent districts were then largely inhabited
by prosperous business folk and their families; as these migrated
westwards, the doctors naturally followed suit. Many of the younger
members of the staffs of St. Bartholomew’s, Guy’s and the London
Hospital lingered on so as to be within easy distance of those
Institutions. It gradually became the custom for those residing
around Moorfields Hospital, who were interested in ophthalmology, to
foregather there in the house surgeon’s room on certain evenings in
the week to discuss cases and other matters of mutual interest. So far
back as 1866 Jonathan Hutchinson records in the _Ophthalmic Hospital
Reports_ how he read a paper at the “Moorfields Club,” It was at one
of such informal meetings that early in 1880 a circular was drawn up
suggesting the formation of an Ophthalmological Society. This was sent
to the leading ophthalmic surgeons in the three divisions of the United
Kingdom, and met with a cordial response. In June of that year the
first meeting of “The Ophthalmological Society of the United Kingdom”
was held, at which William Bowman, who had been appointed President,
delivered an Inaugural Address.

Pasteur’s researches on fermentation and putrefaction, and Lister’s
application of them to the treatment of wounds, raised the study of
bacteriology to the dignity of a science.

Improvements in the microscope by the introduction of high power
oil-immersion lenses made it possible to study the morphology of
micro-organisms, and the introduction by Koch of improved methods for
obtaining pure cultivations of them paved the way to the investigation
of their life-history and bio-chemical reactions.

During the eighth decade of the nineteenth century the connection
of several different micro-organisms with diseases of the eye was
discovered, which aided in the study of their natural history and
treatment.

In 1884 incubators and other bacteriological apparatus were installed
in the pathological laboratory at Moorfields to allow of these new
methods of investigation being carried out.

In 1882 Koch demonstrated that a specific organism could be separated
from tuberculous tissue and cultivated outside the body, which would
reproduce tuberculosis when inoculated. A new test was thus supplied
for the recognition of tuberculous lesions, and some affections of
the eye, of which the real nature up to that time had been doubtful,
were by its means proved to be tubercular. J. B. Lawford, who, on the
resignation of Jennings Milles, had become curator of the Museum, was
among the first to detect Koch’s bacillus in the tissues of the eye.

In 1890 Koch introduced his original form of tuberculin treatment,
which, before its effects had been adequately investigated, raised the
greatest expectations, and caused a rush to Berlin of consumptives from
all parts of the world. This treatment was tested in January, 1891, on
a patient at Moorfields, under Waren Tay, with tubercular nodules in
the iris at the margin of the pupil. So situated it was possible to
watch the effects of the treatment on them with the greatest precision.
The nodules, which were at first separate, gradually increased in
size and became confluent, ultimately invading neighbouring parts and
necessitating the removal of the eye. Besides demonstrating the failure
of the treatment, this case was of interest, because the administration
of an injection of the tuberculin after the eye was removed produced a
general reaction, thus showing the presence of some other focus of
tuberculosis which had not been detected, and from which most probably
the eye had become secondarily affected.

PLATE XXII.

[Illustration: JAMES E. ADAMS.

From a painting by a patient upon whom he had performed the operation
of extraction of cataract.]

The employment of bacteriological investigation in connection with the
discharge from eyes affected with ophthalmia resulted in the discovery
of two new forms of bacilli—the Koch-Weeks bacillus in 1887, and the
Morax-Axenfeld diplo-bacillus in 1896—each receiving a dual name due to
their independent and almost simultaneous recognition by two different
workers.

The recognition of these and other micro-organisms which had been
discovered in connection with other affections (such as the gonococci,
Klebs-Löffler bacilli, pneumococci, streptococci, and staphylococci),
as the specific agents in the causation of the different forms of
ophthalmia, led to a new means of classifying them, the previous
classifications being based on the clinical appearances alone.

The rapid advance in bacteriology, and the introduction of vaccine
treatment arising out of it, tended to make its study and practice more
and more a special branch of medicine. In 1907, after the Hospital
had been removed to the City Road, it was found necessary to erect a
special laboratory for its development and to appoint a special officer
to take charge of it.

The premature decease of several members of the surgical staff just
as they had attained the acme of a successful career has already
been referred to; the cruellest fate of all was that which befell
James Adams, who, whilst engaged in restoring and saving the sight
of others, was doomed to watch the gradual failure of his own to
complete and irremediable blindness. This, too, whilst he was in the
hey-day of life, a successful general surgeon at the London Hospital
and ophthalmic surgeon at Moorfields. A man full of the joy of life,
deservedly popular with his colleagues and students, he combined
scientific with spotting interests, and was able to snatch a day here
and there from his arduous duties to follow the hounds.

A complete rest having failed to prove of any benefit to his gradually
increasing darkness, he, in the latter part of 1884, found it necessary
to resign all his appointments. William Lang, who had for some time
worked with him as clinical assistant, and who held the appointment
of ophthalmic surgeon at the Middlesex Hospital, was elected as his
successor at Moorfields.

Cocaine is derived from the leaves of a plant, _Erythroxylon coca_,
which grows in Peru and Bolivia. It was originally named “khoka,”
meaning “the tree of trees.” Joseph de Jussieu first sent a specimen
of the plant to Europe in 1750. The practice of chewing its leaves as
a means of appeasing hunger and thirst, and relieving fatigue, had
for long been a custom among the natives of South America. The famous
long-distance walker, Weston, employed them in this way when, in the
seventies, he trudged round and round the Agricultural Hall in his
efforts to cover the longest possible distance in the shortest possible
time. In 1872 Dr. Hughes Bennett of Edinburgh showed that cocaine, when
applied to a mucous membrane, produced anæsthesia, but no use was made
of it in practice.

It was Karl Roller of Vienna, in 1884, who first made applications of
it to the eye, which resulted in its employment in ophthalmic surgery.
Koller’s original article, describing the physiological effects of
the drug on the eye, was so complete that there was but little left
to be added. A description of it was given at the meeting of the
Heidelberg Ophthalmological Society in 1884, and a solution of the
drug was brought straight from there to Moorfields in the latter part
of September of that year. The first operation performed under its
influence in this country was a tattooing of the cornea by Marcus
Gunn. Its employment soon became general in all operations on the eye
in which there was not much congestion, and in which the tension of
the globe was not increased. The supply at first was so small and the
demand so great that its price rapidly rose to a guinea a grain.

The substitution of local for general anæsthesia in cataract
operations aided materially in their safety and success. The dreaded
effects on the eye of vomiting and reaching on the recovery from the
administration of ether or chloroform were avoided, and the aid of
the patient in turning the eye in any direction did away with the
necessity of dragging it into suitable positions, which was frequently
requisite when the patient was unconscious. The immediate result was
a considerable decrease in the number of cases in which the vitreous
humour escaped, and the possibility of greater precision in the
adjustment of parts after the removal of the cataract.

At first nothing was known of its toxic effects, and the small amount
absorbed when dropped into the eye did not give rise to them. It was
only when attempts were made to anæsthetise large areas of the skin by
subcutaneous injection that they became manifest.

In 1884 the surgical staff had become so dissatisfied with the system
of nursing at the Hospital, and with the standard of the nurses
employed, that they requested a conference with the Committee of
Management on the matter. At this conference it was agreed that no
satisfactory improvement could be effected without having at the head
of the establishment a lady who had herself been efficiently trained as
a nurse. Miss Harnet, who then held the post of matron, was advised to
tender her resignation. This she did, a pension being granted her. The
new matron, selected from a number of candidates for the post, was Mrs.
Peel, who had been trained at the London Hospital, where she had also
held the post of sister: later she had been matron at the Newcastle
Infirmary.

Shortly after her appointment, the head nurse was detected receiving
money from a patient; this being her second offence of the sort she
was at once dismissed. After her departure it was discovered to have
been a common form of corruption, notwithstanding the warning notices
concerning it posted about the Hospital. The forced resignation of
the former matron and the summary dismissal of the head nurse caused
consternation amongst the other members of the nursing staff, who
combined together to make things unpleasant for the new matron. She
received, however, the support of the medical staff and the Committee
of Management, and ultimately a complete change of the nursing staff
was effected, fully trained nurses being engaged to fill all the most
important posts.

In April, 1885, occurred the sudden and unexpected death of
Streatfield, who was at that time the senior surgeon. As has already
been mentioned, he was a most dexterous operator, and also possessed
of considerable ingenuity, which manifested itself sometimes in
peculiar ways. A few years before his death he had had constructed a
gigantic model of an eye, on which he could demonstrate to students
mechanically the various stages of operative procedures. As he truly
pointed out, in operations on the eye, the smallness of the organ and
of the parts dealt with renders it impossible for any, except those in
close proximity to the operator, to see clearly what is taking place.
He, therefore, devised this model, constructed with all its dimensions
ten times the size of the normal eye. The eyelids and sclerotic were
of white felt spread over wire, the cornea of glass, the iris of
indiarubber, the lens of xylonite, and the external muscles of the eye
of linen. Models of the instruments employed were of wood, also ten
times their actual size, except as regards their handles, which to
allow of the manipulation of such weapons had to be reduced. By various
artfully arranged mechanical contrivances, the lens could be made to
present and escape from the eye above the cornea when a certain spot on
the sclerotic was touched, and the cornea then roll back into position.
Ingenious as all these contrivances were, the effect of the model
when exhibited was to excite mirth more than anything else. It passed
into the possession of the Hospital after Streatfield’s death, but no
further use was made of it.

PLATE XXIII.

[Illustration: A. QUARRY SILCOCK.]

A. Quarry Silcock was elected to succeed Streatfield; besides being
an ophthalmic surgeon he was a general surgeon attached to St.
Mary’s Hospital. At one time, as has been shown, all members of the
surgical staff of the Hospital had to be either a general surgeon or a
demonstrator of anatomy connected with a general hospital. This rule
had, however, been altered, it being thought only necessary to insist
on candidates possessing the diploma of Fellowship of the College of
Surgeons of England, as a guarantee that they had attained a high
standard of general surgical efficiency. Silcock was the last member
of the staff appointed who combined the practice of ophthalmology
with that of general surgery; all those since appointed, though
Fellows of the College of Surgeons, have restricted their practice
to ophthalmology. With the growth of knowledge the speciality of
ophthalmology had come to consist of much besides mere dexterity in the
performance of certain surgical operations. Here may be aptly quoted
what the late Dr. James Anderson wrote with reference to it in 1889:

  “It seems to me the best and most hopeful feature of ophthalmology
  that it has relations, closer or more remote, with every branch of
  medicine and surgery—indeed, with almost every branch of science.”




CHAPTER XI

THE SELECTION OF A NEW SITE, AND THE ERECTION OF THE NEW HOSPITAL


The condition of the Moorfields Hospital in 1884 may be compared to
that of a man wearing a suit of clothes fitted to him in his youth,
which had since been added to, patched, and darned, to cover his
nakedness. The result was that he not only presented an incongruous
appearance, but lived in constant fear of fresh dilapidations.

To carry the analogy still further, those who would be called upon
to find funds for a fresh suit, and who had taken pains to make the
patches, desired to leave matters as they were. Whilst the man himself,
who had to wear and work in his old-fashioned clothes, was all agog for
a new rig-out.

The Hospital erected in 1821 was in keeping with the conceptions of
the time and adapted for the accommodation then required. With the
new ideas which arose out of Florence Nightingale’s teaching, and
later as the outcome of bacteriological investigations, the general
principles for hospital construction became completely changed. Though
the original Moorfields Hospital was added to and altered to meet new
requirements, it became obvious to the rising generation of medical
men working there that it could never be converted into an up-to-date
institution. It took time, however, before the Committee of Management
as a body could be induced to look at the matter in the same light,
especially its older members who had taken part in raising funds and
arranging for the additions.

In 1884 a piece of building land in Eldon Street to the west of the
Hospital became vacant, and the Controller of the City of London
offered to lay any proposal the Committee of Management might feel
inclined to make concerning it before the Bridge House Estates
Committee. Though urged by the Medical Council to acquire it, the
Committee of Management replied that it did not feel able to tender.

During the next three years circumstances arose which gradually
convinced the Committee that there were irremediable defects in the
Hospital as regards accommodation, ventilation and sanitation. The beds
were always full, and the waiting-list of patients requiring in-patient
treatment grew in dimensions. The cubic space per patient in the wards
was very deficient, and no cross-ventilation of them was possible.
There were no day rooms in which patients not confined to bed could
take their meals. There was no passenger lift to convey patients who
had been operated on to the upper floors, so that they had to walk up
a narrow staircase. There were no bath rooms, and very inefficient
accommodation, for the resident staff. The drainage, laid down without
any general plan, and in piecemeal fashion, was constantly being
attended to and tinkered with.

In 1887 the Medical Council complained of the defective sanitation
of the Hospital, and requested that a sanitary expert might be asked
to examine the drainage and advise in the matter. At the same time
it submitted to the Committee a report entitled, _Some Defects in
the Royal London Ophthalmic Hospital_, in which the above mentioned
deficiencies and others were set out in detail. From the consideration
of this report, and that received from the sanitary expert, it became
obvious that nothing but a new building would meet all the requirements.

The building land in the rear of the Hospital facing Eldon Street still
remained temptingly vacant, and, in 1887, a suggestion was received,
emanating from the City architect, that an exchange might possibly be
effected—i.e., the taking of the existing site of the Hospital for the
vacant site in Eldon Street together with a sum of £15,000.

Though this suggestion did not come to anything, it served to awaken
the Committee of Management to the valuable assets the Hospital
possessed in the greatly enhanced value of its freehold and leasehold
properties, due to the changes which had taken place in its environment
since it was first built—unearned increment, which was eventually put
to the best possible use by an extension of the means for the relief of
suffering in the community.

Mr. Lander, the Hospital’s surveyor, was then requested to obtain
valuations of the Hospital’s site and of that of the vacant land
adjoining it. No very precise figures were obtained, the site of the
Hospital being valued at anything between £50,000 and £100,000. The
Committee still, however, hesitated to make any tender for the vacant
land.

In July, 1888, after a consultation of representatives of the Medical
Council with Sir John Lubbock, the President of the Hospital, he
agreed to introduce a deputation to the Lord Mayor to request him to
use his influence in obtaining for the Hospital a gift of the vacant
land adjoining it from the Corporation. The Lord Mayor pointed out
that it was trust property held by the Bridge House Estates, which had
no power to comply with the appeal of the deputation “so earnestly
and reasonably made.” The deputation next waited on the Bridge House
Estates Committee, who replied that it was unable to pledge itself not
to accept any tender, but the matter would receive its most favourable
consideration.

Matters were still further advanced in that year: firstly, by the
receipt of an unsolicited donation of fifty guineas from the trustees
of St. Stephen’s, Coleman Street, towards a Building Fund, which led to
the opening of such a fund for subscriptions, to which the surgeons of
the Hospital in the following year promised a gift of £1,000; secondly,
by the desire of the City to effect a street improvement, so as to
widen the junction of Blomfield Street and Eldon Street, which would
necessitate a surrender of a slice of the Hospital’s ground.

A complication arose, due to the Hospital’s land not directly adjoining
that vacant in Eldon Street—a Welsh chapel, with a lease of four years
yet to run, intervening between them.

Ultimately, the Bridge House Estates Committee offered the Hospital
the vacant area, including that of the Welsh chapel, comprising in all
7,180 feet, on lease for ninety-nine years at a peppercorn rent of
£311 per annum until the chapel’s lease expired, and then at £388 per
annum, with, however, the provision that the Committee of the Hospital
or its trustees were made personally responsible for the payment of the
rent and the observance of the conditions of the lease. This provision
neither the members of the Committee nor the trustees of the Hospital
were prepared to accept, and the whole of the year 1889 was spent in
endeavouring to come to terms with the Law Guarantee and Trust Society
to take on these responsibilities. These negotiations not proving
satisfactory, it was decided, in 1890, that application should be made
to the Privy Council for a Charter of Incorporation. A Petition for
Incorporating the Hospital by Royal Charter was prepared and presented
to Her Majesty the Queen in Council, together with a draft form of the
Charter which would empower the Hospital to hold land in mortmain,
and thereby enable it to proceed with negotiations for the lease. The
Charter of Incorporation under the Great Seal was passed in December,
1890, to which a common seal, that had been designed for the Hospital,
was appended.

In the lease obtained for the ground in Eldon Street it was laid down
that building was to commence before January, 1893, and it became
necessary at once to appoint a suitable architect to draw up plans.
Messrs. Lander and Bedell were at that time acting as surveyors to
the Hospital, but hospital construction had developed into a very
specialised branch of architecture, and it was thought desirable to
employ for the new building one who had a large experience of that kind
of work. In August, 1891, Mr. Keith Young, who had already designed
several hospitals, was appointed, to be assisted by Mr. Lander, and
after his death in 1892 by Mr. Bedell.

After due and deliberate consideration, the architects arrived at the
opinion that the site, even including that of the Welsh chapel, would
not allow of sufficient space to meet all the requirements of the new
Hospital. They suggested that a larger one might be acquired in a less
valuable locality. Investigations were made, and a site which seemed to
offer many advantages was discovered in the City Road. Many of those
associated with the Hospital felt very loath to move the Institution
from the neighbourhood of Moorfields, with which it had become so
intimately associated. The matter was discussed at length at a joint
meeting of the Committee of Management and the medical staff, and in
July, 1892, the latter passed the following resolution:

  “That considering the alleged great value of the present site and the
  difficulty of constructing a suitable building upon it, the Medical
  Council is of opinion that the present site should be sold and that,
  so far as the information at present at its disposal goes, the City
  Road site is best adapted for a new Hospital provided that the whole
  of that site can be acquired.”

With the sanction of the Bridge House Estates Committee, the lease of
the Eldon Street site with all its obligation was transferred to a
substantial tenant, who was willing to pay the Hospital a premium of
£1,000.

The lease was then obtained for 999 years from March, 1894, of what was
termed the City Road and Peerless Street site of some 35,000 feet, in
the parish of St. Luke’s, Old Street, in the county of Middlesex, at a
rent of £1,210 per annum, from the Ecclesiastical Commissioners.

It is rather a remarkable coincidence that another hospital, which
was originally situated at Moorfields, should have previously removed
to the neighbourhood of the City Road, and not very far from the
Peerless Street site. St. Luke’s Hospital, which, though independent
of Bethlehem Hospital, dealt with the same class of ailments, was
originally established in 1750 on the north side of Moorfields. In 1782
a new building was erected near the junction of Old Street and the City
Road, it being recorded that at that time green fields could be seen in
every direction. The building continued as a hospital for the mentally
defective until the time of the Great War, when it was taken over by
the Bank of England, of which it continues to be a branch.

Peerless Street runs between the City Road and Bath Street. It is lined
by a row of small, mean houses, which, but for the Rent Restriction
Act, would have been swept away ere this by the ground landlord, St.
Bartholomew’s Hospital. Anyone unacquainted with the history of the
neighbourhood may well wonder how such a poverty-stricken street could
have acquired such a high-sounding name. It is the last remaining
sign of the delectable attractions which formerly existed in its
neighbourhood.

In ancient times some springs overflowed and formed a pond between
what is now Peerless Street and St. Luke’s Hospital; from it water was
conducted through pipes to Lothbury for the benefit of the inhabitants
of that district. Stowe describes it in 1603 as “cleare water called
the Perilous Pond because divers youths by swimming therein have been
drowned.” In consequence of such accidents (the inhabitants of Lothbury
having obtained water from elsewhere), the Perilous Pond was entirely
filled in. In 1743 Mr. William Kemp, an eminent jeweller and citizen
of London, having derived relief from violent pains in the head from
which he had suffered for several years by bathing in the water from
the spring, converted it into what William Maitland, in his _History
of London_, 1775, describes as “the completest swimming bath in the
whole world.” “He spared,” Maitland says, “no expense nor contrivances
to render it quite private and retired from public inspection,
decent in its regulations and as genteel in its furniture as such a
place could be made.” At the same time he changed its name from the
disagreeable one of the “Perilous Pond,” which it no longer was, to
the pleasing one of the “Peerless Pool,” which, owing to its size and
surroundings, it had undoubtedly become. The swimming bath measured
170 feet in length and 100 feet in width, and varied from 5 to 3 feet
in depth. The entrance to it was through a marble pavilion 30 feet
in length and across a bowling green; it was surrounded by dressing
compartments, outside which were lofty banks covered with shrubs and
a terraced walk planted with lime trees. Four pairs of marble steps
descended to the bath, which had a fine gravel bottom. Besides this
open swimming bath, there was a covered cold bath, supplied with water
from a specially cold spring, faced with marble and paved with stone.
The most remarkable feature, however, of the Peerless Pool was “a noble
fish pond constructed by Kemp due east and west. It was 320 feet long,
93 feet broad, and 11 feet deep, stocked with carp, tench, and a great
variety of the finney tribe, wherein subscribers and frequenters of
either the pleasure or the cold bath were privileged to angle.” William
Hone, in his _Every-day Book_, published in 1831, gives engravings of
the fish pond (showing the lime walk and Kemp’s house in the distance)
and of the swimming bath, made by Mr. John Cleghorn, an architectural
draftsman and engraver, who for many years resided near the Pool.

PLATE XXIV

[Illustration: *THE PLEASURE BATH, PEERLESS POOL, CITY ROAD.*]

  *TERMS OF SUBSCRIPTION*

  PLEASURE BATH
                 £. s. d.
  Month          0  9  0
  Two Months     0 10  0
  Year           1  1  0

  Single Bathe}
  with Towels }  0  1  0
  and Box     }
  Ditto without  0  0  6


  COLD BATH
                 £. s. d.
  Month          0 10  0
  Two Months     0 17  0
  Year           1 10  0

  Single Bathe   0  1  0

  [Illustration: Map of location]

  1 Bath Buildings; Entrance—2. Baldwyn
  Street Entrance—3. Cold Bath—4.
  Pleasure Bath—5. Dressing Boxes—6.
  Shrubberies

*THE PLEASURE BATH OF PEERLESS POOL,*

The largest in England, is situated in the immediate neighbourhood of
the heart of the City, within Ten minutes direct walk of the bank and
Exchange, (vide plan.) Surrounded by trees and shrubberies, open to the
air, although entirely screened from observation, and most ample in
its dimensions—*170* feet in length, by *108* in breadth—it offers to the
Bather the very advantages he would least expect to find at so short a
distance from the centre of the metropolis. Its depth, which increases
gradually from 3 feet 6 inches to 4 feet 8 inches, is such as to afford
free scope to the Swimmer, while it precludes all fear of accident
to any and the temperature of the water rises to a height sufficient
to ensure all the comfort and luxury of Bathing, without the risk of
injury to health, from a too violent contrast with the external air.

*THE COLD BATH,*

Thirty-Six feet by Eighteen, is the largest of its kind in London,
and both Baths are entirely supplied by Springs, which are constantly
overflowing.

_The City Road is the line from all parts of the West End to the City.
Omnibuses pass both ways nearly every minute throughout the day_.

BILL OF PEERLESS POOL. _Circ_. 1846.

In the Daily Advertiser of August, 1748, are some doggerel verses
extolling the attractions of the Peerless Pool, and also a statement
that—

  “any gentleman, who subscribes only one guinea per annum, is entitled
  to the pleasure and cold bath, and to the diversion of angling and
  skating at proper seasons; and that if any occasional visitor,
  who must pay 2s. each time he bathes, thinks proper to become a
  subscriber in the fourteen days from his first visit, he shall be
  allowed that he has paid it as part of his subscription.”

After Kemp’s death the Pool seems to have changed hands several times.
On the expiration of the lease in 1805, a new one was obtained from St.
Bartholomew’s Hospital by Mr. Joseph Watt, at an annual rental of £600.
To remunerate himself Mr. Watt drained the fish pond, felled the trees
around it, and built Baldwin Street, which lies just south of Peerless
Street, on its former site. He also erected Bath Buildings on the
ground occupied by Kemp’s orchard, but left the pleasure bath intact.
In 1831 William Hone wrote:

  “The pleasure bath is still a pleasant spot, and both that and the
  cold bath retain their ancient capabilities. Indeed, the attractions
  of the pleasure bath are undiminished. Its size is the same as in
  Kemp’s time, and trees enough remain to shade the visitor from the
  heat of the sun while on the brink, irresolute whether to plunge
  gloriously in, or ignobly walk down the steps.... Every fine Thursday
  and Saturday afternoon in the summer, columns of blue-coat boys, more
  than three score in each, headed by their respective beadles, arrive,
  and some half strip themselves ere they reach their destination; the
  rapid plunge they make into the pool, and their hilarity in the bath,
  testify their enjoyment of the tepid fluid.”

The Peerless Pool continued in existence as a public bath until 1850,
the site occupied by it being built over between that date and 1860.

Out of the City Road, on the opposite side to Peerless Street, leads
Shepherdess Walk, which marks the site of the Shepherd and Shepherdess
ale-house and tea-garden, built some time before 1745. The gardens were
frequented by visitors who regaled themselves with cream, cakes and
fromity. Invalids sometimes stayed at the inn to benefit by the pure
air of the neighbourhood.

  “To the Shepherd and Shepherdess then they go
  To tea with their wives, for a constant rule;
  And next cross the road to the Fountain also,
  And there they all sit, so pleasant and cool,
  And see, in and out,
  The folk walk about,
  And the gentlemen angling in Peerless Pool.”

In Baldwin Street there is still a public-house called “The Fountain,”
which is probably the survival of the one referred to in this old
rhyme, and of one which Franklin wrote of, “a very genteel public house
at the east end of Kemp’s garden.”

The City Road, which was opened in 1761, cut through the meadow grounds
which surrounded the Shepherd and Shepherdess, so that the place lost
its rural isolation. The inn was pulled down in 1825, and the Eagle
Tavern, which formed the nucleus of the famous Eagle establishment,
with its Grecian saloon and theatre, and its garden and dancing
pavilion, was erected near its site. It was this establishment which
was celebrated in the refrain of the popular song;

  “Up and down the City Road,
  In and out the Eagle,
  That’s the way the money goes,
  Pop goes the weasel.”

It has been suggested that this refrain might be paraphrased by those
employed at the Moorfields Hospital as follows:

  “Up and down the City Road,
  In and out Moorfields,
  That’s the way we spend our lives,
  Oh! the joy it yields.”

Whilst the above discussions and negotiations with regard to the
erection of a new Hospital were in progress several changes took place
in the personnel of the staff.

In 1890 John Whitaker Hulke, having reached the age of sixty, retired.
He died five years later whilst holding the highest position in his
profession, that of President of the Royal College of Surgeons in
England. John Browning Lawford, who had already held the posts of house
surgeon and of curator of the Museum, was elected in his place.

In 1891 George Lawson also had to retire under the age limit rule. In
1869 he had published a _Manual on Diseases and Injuries of the Eye_,
which, owing to its practical character, became exceedingly popular
amongst medical students, and rapidly ran through five editions. Lawson
endeared himself to his patients by the personal interest he manifested
in their welfare. His treatment went far beyond the mere prescription
of drugs or the performance of operations. He would instruct a mother
how to feed, clothe, and train her child. He would tell a patient,
for whom nothing could be done to restore the lost sight, what his
future might be and how to get to work to earn a livelihood. Many of
those engaged in seeing out-patients often wish they could prescribe
food for them instead of medicine. Lawson actually did this, having an
arrangement with a neighbouring butcher by which he could at his own
expense order patients so many pounds of meat. Nor did his generosity
to Hospital patients end with supplying sound advice and meat; many to
whom some unusually disastrous circumstance had occurred would be led
quietly aside and return with a smiling face and a closed palm.

In 1886 Lawson was appointed surgeon oculist to Her Majesty Queen
Victoria, which appointment he held until her death. He himself died
in 1903 at the age of seventy-two, having had the satisfaction of
seeing his son Arnold (now Sir Arnold Lawson) appointed on the staff at
Moorfields, where he himself had worked for so long.

The vacancy caused by Lawson’s retirement was filled by the election
of A. Stanford Morton, who was educated at Edinburgh University. He
had served the Hospital first as house surgeon and later as clinical
assistant for a period of sixteen years. He did not take the necessary
qualification of the Fellowship of the Royal College of Surgeons
of England, which would qualify him as a candidate for the staff,
until 1888, and was forty-eight years of age at the time of his
election. His name has become widely known throughout the ophthalmic
world in connection with the very serviceable and popular pattern of
ophthalmoscope which he had constructed for him by Messrs. Curry and
Paxton. It happily combined all the best features and adaptations which
had previously been suggested.

For dexterity and neatness as an operator on the eye Morton was
unsurpassed in his time. He enthusiastically instructed others in
the art, holding classes of operative ophthalmic surgery in which he
employed pigs’ eyes fixed in a frame to enable students to obtain the
necessary manipulative dexterity. Whilst he was working as a clinical
assistant, the practice of retinoscopy for the correction of errors of
refraction came into use, and he wrote a small book on _Refraction of
the Eye_, describing it in such an easily assimilated manner that the
book had a large sale, several editions being called for.

Being a good draftsman, and having an excellent eye for colour, Morton
made many beautiful coloured drawings of ophthalmoscopic changes, the
originals of which he presented to the Hospital on his retirement.
The extreme care which he took in their production often necessitated
several sittings on the part of the patient. In one interesting
and complicated case, the drawing of which took a very long time,
Morton found it necessary to remunerate the patient liberally after
each sitting to ensure his subsequent attendance. When the drawing
was finished the man found that Morton’s interest in his case had
evaporated, and, being hard up, appeared at the Hospital one morning
offering to sell him one of his eyes if he would like to take it out—an
offer which it is perhaps needless to say was not accepted. The man
afterwards went about to various ophthalmic clinics calling himself
the celebrated Moorfields case, and he informed those who examined him
“that gentlemen generally gave him something after looking at the backs
of his eyes,”

Though it had been the custom for a long time to print on the letters
given to patients, and to have posted up in the out-patient department,
a notice to the effect that the Hospital was only open for the
reception of really indigent patients, it was a rule which the medical
staff found very difficult to enforce, and which was obviously very
frequently infringed. In 1893 on the advice of the Medical Council, the
Committee of Management adopted the plan in use at several of the other
London hospitals of appointing an “inquiry officer” to attend daily and
make necessary inquiries, so that “no person should be admitted in the
first instance to Hospital relief who can afford to pay a fee of one
guinea for a consultation (except in cases of accident)” The officer
appointed for this Purpose was one selected by the Charity Organisation
Society, who had been trained under its superintendance. As the result
of his investigations, from about 500 applicants were refused yearly,
it being found that they were able to pay a surgeon’s fee, many of them
stating that they were unaware that the Hospital was open for the poor
only.

John Couper’s time for retirement from the staff came in 1895. He
continued in active practice for several years afterwards, and died in
1918, in his eighty-third year. He had always been a firm supporter of
the movement for the admission of women to the medical profession, and
welcomed Miss Elizabeth Garrett (afterwards Mrs. Garrett Anderson) as
an onlooker at his clinic at Moorfields. It was not, however, until
after he had left the staff, in 1898, that the eligibility of women to
become pupils and clinical assistants at the Hospital became officially
recognised.

E. Treacher Collins, who, like Lawford, had been both house surgeon
and curator of the Museum at the Hospital was appointed as Couper’s
successor.

The premature and unexpected resignation from the staff of Edward
Nettleship took place in 1898; his keen interest in the scientific
side of ophthalmology, however, did not slacken. He gave the Hospital
a donation of £250, to be expended on scientific apparatus and
appliances for the laboratory in the new building. With more time at
his disposal for research work, his valuable scientific contributions
increased in number. With indefatigable ardour and strenuous accuracy
he worked out pedigrees of hereditary diseases, the value of which
work was recognised in 1912 by his election as a Fellow of the Royal
Society. On his retirement from practice in 1901, his friends and
pupils inaugurated a fund to found the “Edward Nettleship Prize” for
the encouragement of scientific ophthalmic work. It took the form of a
Gold Medal to be awarded at intervals, at the discretion of the Council
of the Ophthalmological Society, British subjects alone being eligible.
He died in October, 1913, being actively employed up to the time of his
death, in conjunction with Karl Pearson and C. H. Usher, on a large
monograph upon “Albinism in Man.”

To fill the surprise vacancy caused by Nettleship’s retirement, W. T.
Holmes Spicer was appointed.

Three matrons at the Hospital resigned from ill-health in the course
of a few years, and, in 1895, Miss Ada Robertson, a former sister at
the London Hospital, was appointed to the post. She not only carried
through the difficult task of transferring the work of the Hospital
from the old to the new building, but also, with skill and tact, raised
the nursing to a higher standard of efficiency than it had reached
before.

In 1897 Mr. Charles Gordon, who had acted as Chairman of the Committee
of Management for eighteen years, and who had taken an active part in
all the negotiations for the removal of the Hospital to a new site, on
the eve of the laying of the foundation stone, found it incumbent upon
him to resign owing to his advanced years; he died two years later.
Thus, like Moses, having led his colleagues to within sight of the
promised land, he left it for them to enter into its occupation.

Mr. H. P. Sturgis, a director of the London and Westminster Bank, was
elected Chairman in his place.

About the same time, Mr. Robert J. Newstead, after twenty-five years’
service as secretary, had to resign from ill-health, and died at the
end of the year. Mr. Robert J. Bland was appointed as his successor.

On the 28th of May, 1897, the work of clearing and preparing the
foundations being sufficiently advanced His Royal Highness the Prince
of Wales (afterwards King Edward VII.), on behalf of Her Majesty
Queen Victoria, laid the foundation stone of the new Hospital. His
Royal Highness was accompanied by their Royal Highnesses the Princess
of Wales (afterwards Queen Alexandra) and Princess Victoria, the
former graciously consenting to receive purses containing donations
in aid of the Hospital. The silver trowel used on the occasion, which
was provided by Mr. E. Hogg, one of the members of the Committee of
Management, was presented to His Royal Highness, who stated “it is Her
Majesty’s great and earnest wish that this Hospital may be prosperous
and successful in every way.” Her Majesty further manifested her
continual interest in the Charity by giving a donation of £100 to
the Budding Fund. The Prince of Wales on his departure signified his
intention to become a Patron of the Hospital.

In the removal of the Hospital from a prominent situation which had
developed into a great business centre to a less known district easily
accessible to those to whose needs it ministered the Committee of
Management hoped to defray the cost of the building by the proceeds of
the sale of the old site, and in doing so it was not far out in its
reckoning. The old Hospital was sold for £78,500, and the new Hospital
cost about £80,000. To provide the funds for the new building, whilst
the work was being carried on in the old one, large loans had to be
negotiated on the security of its freehold and leasehold property.
In addition to the cost of the building the Committee had to provide
funds for furnishing the new building, and equipping it with appliances
and apparatus in keeping with its position as the leading ophthalmic
institution in the British Empire. For this purpose it made a special
appeal which was liberally responded to by the Corporation of the City
of London and the following City Companies: The Worshipful Company of
Carpenters, of Clothworkers, of Drapers, of Dyers, of Fishmongers, of
Goldsmiths, of Grocers, of Leather Sellers, of Mercers, of Merchant
Taylors, of Sadlers, of Salters, and of Skinners.

The fund was further augmented by a festival dinner held at the Grand
Hotel, Charing Cross, on the 6th of May, 1898, over which His Royal
Highness the Duke of Cambridge graciously presided, he himself making
a liberal contribution to the cause for which he pleaded. In the
following year a large and influential number of ladies promoted a ball
in the Empress Rooms at the Royal Palace Hotel, Kensington, on the
Hospital’s behalf, and Sir Squire Bancroft generously gave to it the
proceeds of one of his inimitable readings.

When the clearance of the site for the new Hospital in the City Road
was commenced, a Building Committee was appointed, consisting of
certain members of the Committee of Management, with Mr. H. Davidson
as chairman, and three representatives of the Medical Council, Tweedy,
Gunn, and its honorary secretary, at first Morton, and later Treacher
Collins.

One of the first questions this Committee had to consider was the dual
one of the ventilation and warming of the new building. Was the system
of ventilation to be “natural” or “artificial”? If artificial, was it
to take the form of propulsion or extraction, or a combination of
both? It has been well said “that theories in ventilation and warming
are as numerous as trees in a forest,” and so the Building Committee
discovered when they commenced to consider the problem. Several
hospitals in which artificial ventilation was in use were inspected;
ultimately it was decided that artificial ventilation on the planum
system should be adopted for the out-patient department, and that
natural ventilation should be relied upon for the wards.

The air forced into the out-patient department is first filtered, and
then warmed or cooled as required. A shaft is provided which allows the
foul air to escape. The force employed is a large rotating fan-wheel
which propels the air along underground passages, and through gratings
which open into the various compartments. It is filtered by passing
through a coke-screen, which is cleaned with a stream of water flowing
over it automatically at periodic intervals. It is warmed by passing
over hot-water radiators situated close to the gratings opening into
the compartments. It can be cooled by substituting blocks of ice placed
on the radiators for the hot water contained in them.

In the wards the position of the windows is arranged to allow of cross
ventilation, and the main sources of heat are open fires. Additional
sources for warmth and ventilation are provided by hot water radiators,
past which fresh air is allowed to enter through gratings near the
floor. A separate sanitary block running through the centre of the
building is cut off from it by cross-ventilation lobbies.

Only those who worked in the old Hospital in Blomfield Street can fully
appreciate the amenities afforded by the new one in the City Road.
Daily at noon the whole in-patient department in the old building
became permeated with the odour of cooked meat. In the new Hospital all
such disagreeable smells have been avoided by having the kitchen placed
on the top floor. Most of the cooking is carried on by steam, supplied
from boilers in the basement. A special service lift conveys goods to
the kitchen, and also permits of the distribution of food and fuel to
various parts of the building. Both this lift and the passenger lift
are worked by hydraulic power; the latter allows of the conveyance of
a patient on a wheeled trolley, in the recumbent position, to his bed
from the operating table.

The lighting arrangements in the out-patient department, for the
examination of the patients and the testing of their eyesight, and
in the operating theatre to meet its varied requirements, engaged
the architect’s and the Committee’s prolonged consideration. For the
examination of patients in the first instance, and for many operations,
uninterrupted direct skylight from a northern aspect was regarded as
essential, and the new building was so planned as to allow of this in
the large consulting room and in the operating theatre. As the work
of the Hospital has to be carried out on dark days as well as bright
ones, adequate means for the examination of patients by artificial
light, in the absence of daylight, had to be provided. In the old
Hospital, where gas was the main source of artificial illumination,
there were various contrivances rendering it more or less efficient
by the use of reflectors. In the operating theatre, a device used
by the Nottingham lace workers had been employed. It consisted of a
large hollow glass globe filled with water and suspended from the
ceiling, which concentrated light from a lamp placed behind it on to
the face of a patient lying on the operating table. The introduction
of electricity for illuminating purposes throughout the new building
simplified matters considerably. In the consulting room, movable
flexes and adjustments permit light being easily brought into the most
suitable position in which to conduct an examination. The employment
of electric light globes for ophthalmoscopic examinations in the dark
room, in place of argand gas burners, renders the atmosphere in it far
more healthy and pleasant to work in, but it is doubtful if any form of
electric bulb supplies quite such a uniform and satisfactory area of
illumination for these examinations as the old argand gas burner.

The electric current supplied to the Hospital for lighting purposes is
an alternating one; fortunately a constant current was also available
in the district, being used in neighbouring factories. One of the chief
purposes for which it is required is for working electro-magnets for
the extraction of chips of iron or steel implanted in the interior of
the eyeball.

It has been already mentioned how in 1858 Dixon tried unsuccessfully
to remove a chip off the edge of a chisel, seen floating in the
vitreous chamber, by a permanent magnet. In a similar case, McKeown of
Belfast, in 1874, succeeded in the removal of the foreign body by the
introduction of the tip of a permanent magnet into the interior of the
eye.

In 1878 Malcolm McHardy, who was later ophthalmic surgeon to King’s
College Hospital, employed for the first time an electro-magnet, and
with it successfully removed a chip of steel which had become embedded
in the crystalline lens. A few years later, Snell of Sheffield,
Hirschberg of Berlin, and Bradford of Boston, U.S.A., had constructed
electro-magnets which could be held in the hand, and have suitable
terminals attached to them for introduction into the interior of the
eye. Considerable success attended the use of such instruments when
fragments of iron were situated in the front parts of the eye, but only
on rare occasions when they had become deeply placed in the vitreous
humour. In these latter cases, the foreign body was often hid from
view, due to opacity of the lens caused by the injury, so that its
exact position was unknown, and there was some doubt as to whether it
had lodged in the eyeball or not. It was only when the nozzle of the
hand magnet came close to the foreign body that it possessed sufficient
traction power to draw it out, and in searching for it much damage was
liable to be inflicted on the structures in the interior of the eyeball.

On the discovery of the X-rays by Professor Röntgen in 1895 it occurred
to many ophthalmic surgeons that they might be utilised for the
detection of foreign bodies in the eye. Two practical difficulties at
first presented themselves, both of which were ultimately overcome.
One was the density of the bony structures around the eyeball, and the
other that of locating accurately the position of a foreign body when
detected. It was found that excellent skiagrams, showing exceedingly
minute pieces of metallic substances in the orbit, could be obtained
if the sensitive plate was placed against the temple on the side of
the injured eye, and the Crookes tube 10 to 15 mm. distant from the
opposite temple. The most accurate localisation of foreign bodies
implanted in the body was effected by an ingenious device of Mackenzie
Davidson’s in which, after superimposing two skiagrams taken at
slightly different positions, he followed the tract taken by the rays
from the Crookes tube to the foreign body by means of threads, noting
where they crossed in relation to the position of other known points.

Mackenzie Davidson (afterwards Sir James Mackenzie Davidson) worked
at Moorfields as clinical assistant, and subsequently practised as an
ophthalmic surgeon in Aberdeen. Soon after the discovery of X-rays, he
removed to London and devoted himself specially to their application
to surgery and medicine. His combined interest in ophthalmology and
X-rays made him desirous of testing his method of localising foreign
bodies in connection with eye injuries. Several members of the staff
at Moorfields sent cases to him to report on, and such accurate and
helpful information did he supply, not only as to the presence or
absence of a foreign body in the eye, but also as to the exact position
in which, when present, it could be found, that a desire arose to
establish a special X-ray department and to secure his services in
connection therewith. On the recommendation of the Medical Council,
this was agreed to by the Committee of Management in November, 1898,
£80 being voted for the cost of apparatus and an annual expenditure
of £20 for the working expenses of the department. Mackenzie Davidson
consented to accept the appointment of honorary medical officer in
charge of the X-ray department, and a special room was fitted up in the
new Hospital with the necessary conveniences for carrying on the work.

The introduction of the constant electric current into the operating
theatre allowed of the employment of far more powerful magnets for the
extraction of fragments of iron from the eyeball than had previously
been used in this country. These powerful magnets have appropriately
been described as “giant magnets”: they were originally introduced into
ophthalmic practice by Professor Haab of Zurich. Their traction force
is so great that a chip of iron hidden in the back part of the eyeball
can be drawn forward into view in the front part.

In the _Hospital Reports_, H. V. McKenzie, the house surgeon in 1895,
collected notes of all the cases in which a foreign body had been
removed from the eye by the small hand magnet—_i.e_., prior to the
introduction of X-ray localisation, and found that in 26 per cent, of
those in which it was lodged in the vitreous the eye was saved. In 1902
the house surgeon, A. F. MacCallan, tabulated the results obtained
by the use of Haab’s Giant Magnet, and found that in a similar class
of cases by its use 58 per cent. of the eyes were saved, and that in
half of these good vision was obtained. If accurate localisation of
the foreign body by X-rays was carried out previous to the use of the
magnet, a still larger percentage of success resulted.

The operating theatre in the new Hospital has been designed to make
possible the practice of aseptic surgery. Antiseptic surgery, as first
introduced, relied on the destruction of micro-organisms by chemical
agents, and it was thought essential, whilst an operation was in
progress, to have a spray of carbolic acid playing to prevent aerial
infection of the wound. Later, as the result of experience gained in
bacteriological laboratories, it became realised that such a precaution
was unnecessary; micro-organisms being like dust particles subject
to the law of gravitation, all that was required was to prevent any
accumulation of dust and to avoid currents of air.

To avoid any accumulation of dust in the new operating theatre, its
walls, ceilings, and floor are so constructed that at any time they
can be washed over with a hose. The wall and ceiling are lined with
glass tiles, technically known as “opalite,” the floor is paved with
terazzo, and all the corners are rounded. All the pipes are of copper,
and the radiators of the same metal. The latter are constructed so that
they can be swung out on a pivot, and no dirt be allowed to accumulate
behind them; they are in three divisions, which allow of variations in
the amount of warmth given out as may be required.

To permit as many onlookers as possible being able to watch the
operator’s procedures, without inconveniencing him or his assistants,
fixed stands are erected on each side of the operating table, each
stand being composed of three tiers, and each tier accommodating four
persons.

The colour of the tiles on the walls and ceiling is a creamy-white with
a dado of pale green. As some operations have to be conducted in a
darkened room by artificial light concentrated on the eye, a dark blind
is provided which can be drawn up from below, being enclosed when not
in use in a brass box.

The case in which the instruments are stored is constructed entirely of
brass and glass, and apparatus is provided to allow of the instruments
being sterilised by boiling them before use. A special steriliser for
dressings is also provided, with an outer jacket for steam, which
permits of them being delivered dry when required for use.

In the wards, passages, and other parts of the building, all possible
precautions are taken to avoid any lodgments for the accumulation of
dust, the floors of all the wards being constructed of polished teak,
and wherever possible the corners are rounded. All cupboards have
sloping tops, and are fixed to the walls at such a height that the
highest part of them is easily within reach. Arrangements are made for
the storage of the patients’ clothes, when in bed, in special cupboards
outside the wards, and the small marble-topped lockers placed beside
their beds were specially designed just to contain a few of their
possessions.

A special eye hospital differs from a general hospital in the large
proportion of its patients who are able to be up out of bed during the
daytime. It is, therefore, desirable to have special day rooms in which
they can congregate away from the wards, and have their meals. In the
new Hospital, on each floor, such day room accommodation is provided.

Notwithstanding the enormous amount of work involved in the removal to
the new building, it was effected with scarcely any interruption in
the routine work of the Institution. The new building was opened for
the reception of patients on September 4th, 1899, the work in the old
Hospital being carried on for in-patients up to August 19th, and for
out-patients up to August 26th.




CHAPTER XII

THE HOSPITAL IN THE CITY ROAD


On June 28th, 1899, the now dreary neighbourhood of the former
“Peerless Pool” once again awoke to life and notoriety with a visit
from their present Majesties King George V. and Queen Mary, then the
Duke and Duchess of York, to open the new “Peerless” Eye Hospital.
A lengthy description of the ceremony appeared in The Times on the
following day.

The Duke and Duchess of York, attended by Sir Charles Cust and Lady
Katherine Coke, arrived at the Hospital shortly after half-past 3
o’clock, and were received by Sir John Lubbock, the President, Mr.
H. P. Sturgis, Chairman of the Committee of Management, and the
architects, Messrs. Keith Young and H. Hall. The Duke, who received a
gold key from the architects, unlocked the door of the main entrance
hall, where the surgeons of the Hospital, the matron, Miss Robinson,
and the secretary, Mr. R. J. Bland, were presented to their Royal
Highnesses. The Royal party were then conducted over the building, and
after completing their inspection they entered the out-patients’ hall,
which had been prettily decorated for the opening ceremony, and where a
large company had assembled. Among the visitors, in addition to those
already named, were the Lord Mayor and Lady Mayoress, Mr. Alderman
and Sheriff Alliston, Lieutenant-Colonel and Sheriff Probyn and Mrs.
Probyn, the Bishop of Islington and Mrs. Turner, the Rev. Prebendary
Whittington (chaplain), Sir J. Whittaker Ellis and Lady Ellis, Lady
Faudel-Phillips, Sir Squire and Lady Bancroft, Mr. J. Lea Smith
(trustee), Mrs. Sturgis, Sir T. Lipton, and the Rev. Dr. Hermann Adler
and Mrs. Adler, Mr. H. Davison (chairman of the Building Committee)
and Mrs. Davison, Mr. A. G. Pollock (chairman of the Special Appeal
Committee) and Mrs. Pollock. The little daughter of Mr. John Tweedy,
the senior surgeon, presented a handsome bouquet of pink roses to the
Duchess, who was dressed in pale green eau de Nil silk with a toque of
pink roses. Prayers having been said by the Bishop of Islington, Sir
John Lubbock called upon Mr. Sturgis to make a statement.

PLATE XXV.

[Illustration: THE ROYAL LONDON OPHTHALMIC HOSPITAL IN THE CITY ROAD,
OPENED IN 1899.]

Mr. Sturgis said that they valued extremely the presence of the Duke
and Duchess of York, inasmuch as their Royal Highnesses represented
the fourth generation of the Royal Family who had shown interest in
the Hospital. He related the circumstances which had necessitated its
removal from its old site at Moorfields and the erection of the present
building, which the Committee had endeavoured to make as perfect as
possible, and which they would come into free from debt. This, however,
he went on to say, was only the beginning of their task. They had to
consider the maintenance of the establishment. The cost of maintenance
at the old building was about £8,000 a year, and their regular income,
including grants from the Hospital funds, did not reach the sum of
£3,000 a year, so that they had to make up the difference in other
ways. But the cost of maintenance in the new building would be as
much as £11,000 a year. He hoped their income would increase to a
corresponding extent. What they wanted more than anything else was an
increase in annual subscriptions, and they wished to raise a fund of
£50,000 which would be a guarantee for the large ground rent which they
now had to pay.

Sir John Lubbock, after expressing indebtedness to all those concerned
in the work of the Institution, asked the Duke of York to declare the
building open.

The Duke of York said:

  “Sir John Lubbock, Mr. Sturgis, Ladies and Gentlemen, I am grateful
  to Sir John Lubbock for the kind words he has used with regard to
  our coming here to-day, and I have been very much interested in all
  I have heard from Mr. Sturgis, the Chairman of the Committee. I
  thank you all in the Duchess’ name as well as my own for the very
  kind reception you have given us. It is an especial pleasure to
  the Duchess and myself to come here to-day, as my father laid the
  foundation stone of the new building in 1897, and therefore we are
  completing the work, so to speak, which he inaugurated.” (Cheers.)
  “As Mr. Sturgis told us just now, of late years the number of
  patients increased so enormously that the old buildings were found
  quite inadequate to their wants, and the Committee were compelled to
  seek a larger site for this new building. And, if I may be allowed to
  do so, I wish to congratulate the architects on the excellent result
  of their labours, and I also wish to congratulate the Committee and
  the medical staff on occupying a new Hospital designed and equipped
  according to the most modern requirements. The cost of maintenance of
  these new buildings, which cover three-quarters of an acre, will be,
  I fear, as Mr. Sturgis has just told us, very heavy, but I am sure
  the Committee deserve the generous support of the charitable public
  to enable them to continue the useful work that has been so ably
  carried out by this Hospital for nearly a century, and I can only say
  that I trust that the public will come forward and help this Hospital
  and prevent it from getting into debt by their annual subscriptions.
  I have now much pleasure in declaring this new building open, and the
  Duchess joins with me in wishing the Royal London Ophthalmic Hospital
  continued prosperity in this new building, and a long career in its
  great and important work.” (Cheers.)

Their Royal Highnesses then left the building, and were heartily
cheered by a large crowd in the street as they drove away.

As a lasting memorial of the visit of their Royal Highnesses the
Children’s Ward was named the “Princess May” Ward. After their visit,
they consented to become Patrons, and presented copies of their
portraits to the Hospital, with their autographs attached.

The hopes expressed by Mr. Sturgis, the Chairman of the Committee,
at this opening ceremony, that increased financial support would be
forthcoming to meet the additional annual expenditure, were completely
shattered for a time by the outbreak of the South African War. As at
the time of the Crimean War, the sympathies and contributions of the
public became diverted to funds for soldiers and sailors, and the
donations and new subscriptions to the Hospital almost ceased to come
in, the result being that the Hospital, in September, 1900, found
itself £5,000 in debt.

One of the largest and most unforeseen items in increased expenditure,
resulting from the removal of the Hospital, was the enormous addition
to the amount in rates which it was called upon to pay. The Hospital at
Moorfields was assessed by the City of London Union at a nominal amount
the rates for the year 1897 being only £88. The Holborn Union, in whose
area the new building was situated, adopted a different course, and
the rates for 1900 amounted to £870 nearly an eleventh part of the
Hospital’s annual total expenditure. In 1901 they increased to £948,
and in 1902 to £972. No other hospital in London was assessed so highly
in proportion to its income and size, St. Thomas’s and Guy’s being the
only London hospitals paying heavier rates.

In answer to an appeal against such excessive rating the authorities
replied that, as the Hospital relieves patients from every part of
London, as well as many parts of the country, they could not treat it
on the footing of a local charity.

In 1900 the Hospital, owing to its embarrassed financial condition,
was in arrears with the payment of two instalments of rates, amounting
to £324, and a summons was served on it. The Justice of the Peace who
had to deal with the matter stated “that he had no other course but
to order payment within fourteen days.” This summons became widely
reported and commented on in the public press; considerable sympathy
with the Hospital was thereby evoked, and in the course of three days
donations and subscriptions came in, amounting to £300, which enabled
it temporarily to meet its difficulties. Ever since, however, the
annual amount which it has had to pay in rates has fluctuated between
£800 and £1,000. Thus this Institution, which every year rescues
numbers of people from loss of sight and from becoming rate-supported,
has to raise this large sum in voluntary contributions from the
benevolent public to pay out in rates.

Until the year 1875 hospitals were not regarded as ratable, as there
was no obvious person connected with them to be assessed. In that year,
however, the House of Lords ruled that voluntary hospitals had no right
to such exemption and must pay rates as other premises, though no one’s
sense of justice had appeared to be offended. If, as they so frequently
profess, public bodies wish to aid and support the work of voluntary
hospitals, no more efficient method could be found than to exempt
them again from this inconsistent and burdensome form of taxation. In
connection with the Rating and Valuation Bill, which was before the
House of Commons in July, 1928, a discussion on the rating of hospitals
took place, being raised in connection with an amendment proposed by
Mr. Harris, Member for South-West Bethnal Green, and seconded by Mr.
Briant, Member for North Lambeth. The Minister of Health, Mr. Neville
Chamberlain, whilst expressing his sympathy with the matter, did not
consider the Bill to be one in which relief of that kind to hospitals
could be given effect, it being for the stimulation of industries,
and he refused to consider that the maintenance of the health of the
community was likely to give such stimulation.

What at first seemed likely to be a most severe blow to the Hospital’s
means of maintenance ultimately resulted in its salvation. This was
the establishment of the Prince of Wales’ Hospital Fund (afterwards
King Edward’s Hospital Fund), and the diversion to it of annual
subscriptions previously paid to the Hospital—_e.g_., the Drapers’
Company, which had for several years given a subscription of ten
guineas, notified in 1900 that it would in future be discontinued as
the Company was subscribing annually to the Prince of Wales’ Fund. The
receipt of the following letter was, therefore, a source of immense
relief and satisfaction to all connected with the Hospital:

  “THE PRINCE OF WALES’ HOSPITAL FUND FOR LONDON.

  “THE BANK OF ENGLAND,

  “27_th December_, 1901.

  “THE TREASURER,

  “ROYAL LONDON OPHTHALMIC HOSPITAL

  “City Road, E.C.

  “Sir,

  “By the desire of His Royal Highness, the President, I have the
  honour to enclose a cheque for £2,850.

  “Of this sum, £900 is an annual grant to open eighteen closed beds,
  on the condition that by the opening of these beds eighteen more are
  made available for the sick poor in your Hospital; and the balance of
  £1,250 is a special donation for this year.

  “I am also directed to inform you that your building is reported on
  as a very fine new building. The Visitors state that all the Wards,
  Operating Rooms, etc., are thoroughly practical and up-to-date, and
  that your very complete Hospital requires considerable additional
  funds to carry on its useful work.

  “Kindly acknowledge the receipt of the above.

  “Yours faithfully,

  “(Signed) S. CROSSLEY,

  “_Honorary Secretary_.”

In June, 1902, His Majesty the King himself became an annual subscriber
of ten guineas to the Hospital.

In December, 1902, a still more liberal grant was made by the King
Edward’s Hospital Fund for London, as shown by the following letter:

  “Sir,

  “I am directed by His Royal Highness the President to enclose a
  cheque for £4,500.

  “Of this sum, £900 is an annual grant to support 18 beds opened by
  the aid of this Fund. The balance, which consists of £1,100 as an
  annual grant and £2,500 as a special donation for this year, is given
  on the condition that 30 more beds are opened in your Hospital so
  that by opening those beds 30 more are made available for the sick
  poor in your Institution.

  “Kindly acknowledge the receipt of the above.

  “Yours faithfully,

  “(Signed) SAVILE CROSSLEY,

  “_Honorary Secretary_.”

The wards in the new Hospital were constructed to hold 138 beds, but at
first, owing to its serious financial deficiency, only 70 could be made
available for use. By the help of the King’s Hospital Fund in 1901, 18
more were opened up, and, in the following year, by the help of the
same fund, an additional 30, leaving only 20 vacant. The opening of the
wards containing the additional 30 beds in 1902 was made a ceremonial
occasion by the visit to the Hospital in state of the Lord Mayor and
some of the Sheriffs of the City of London.

In order to pay off its liabilities, the Committee of Management,
during 1902, had to obtain a loan of £5,000 on the security of the
Harry Sedgwick Trust Fund, £7,000 of which was retained by the Charity
Commissioners until such time as the compound interest on it had
sufficiently accumulated to repay the loan. The annual income of the
Hospital was thereby temporarily reduced by the interest on these
two amounts. In 1909, by the realisation of certain legacies, the
Hospital was enabled to repay this loan, the dividends on the fund then
reverting to it.

To find some fresh source of income it was agreed, at a joint meeting
of the Committee of Management and the Medical Council, to try
experimentally what could be obtained by asking each out-patient on
admission to make a voluntary contribution, no compulsion to do so
on any account being used. At the end of three months it was found
that an annual amount of £1,150 could be obtained in this way, without
giving any offence to those solicited for help.

The way in which the new building was constructed necessitated some
changes in the customs of the staff. The out-patient department was
entirely separated from the in-patients, and it was thought desirable
that the two classes of patients should be kept completely apart. This
necessitated a second operating room specially for out-patients, for
which provision had been made, and over which a special sister was
appointed to preside. In the immaculate in-patient operating theatre it
became the established custom for the surgeons working there to wear
sterilised white cotton coats, instead of their ordinary ones, as they
had done previously.

It may also be noted how customs have changed with regard to the
hirsute appendages of the face in the members of the medical staff at
different epochs. In the first half of the nineteenth century, all the
members of the staff wore side whiskers. During the Crimean War our
soldiers grew beards, and on their return beards became the fashion of
the time. The surgeons at Moorfields, from the middle of the century up
to the commencement of what may be described as the aseptic era, all
wore beards. No surgeon on the staff now wears a beard; they are all
either clean-shaven, or at most wear a closely-cut moustache.

The costume of the in-patients when taken into the operating theatre
also needed consideration, and in the provision for them of special
overalls the idea of a ladies’ working guild first originated. The
following description of its commencement and early progress was given
in its Fifth Annual Report, dated December 31st, 1904:

  “In the winter of the year 1900, Mrs. Quarry Silcock, Mrs. Treacher
  Collins, and the matron, Miss Richards, with a few other ladies who
  had special opportunities of knowing the difficulties with which the
  Hospital had to contend for lack of funds and public interest, banded
  themselves together and determined to help the Institution. They
  formed themselves into a Committee under the Presidency of Lady John
  Tweedy, and were fortunate in inducing many of their friends to join
  them. They determined to take upon themselves the essentially womanly
  task of supplying all the clothing, house and bed linen required in
  the Hospital for the use of the patients, and so successful were
  they that, not only were they able to do this, but by the end of
  the second year they were in a position to hand the sum of £50 to
  the general funds. The movement has since so far grown that many
  more necessaries have been added. The beds in the new wards, opened
  in 1903, were supplied with blankets, coverlets, and sheets from
  the fund, and the Guild has for the past two years maintained a
  Cot and a Woman’s bed in the wards. It also extends its operations
  in other directions that can be of help to the Hospital. Through
  the consideration of several members, the Nurses’ library has been
  replenished with interesting and useful books. Other members have
  rendered personal service by visiting at the Hospital, and have thus
  relieved the monotony of the hours spent by the suffering patients by
  reading pleasant books, entering into kindly conversation with them,
  and amusing them with singing and music. The cheering effect of such
  visits and the assistance they are in the work of recovery cannot be
  overestimated.”

Extensive as were the improvements in the new Hospital over the old,
in course of time fresh requirements cropped up, and it was discovered
that some of the arrangements might have been better still. Any
imperfections cannot, however, be attributed to oversight on the part
of the architect, but rather to want of foresight and imagination on
the part of those from whom he received instructions as to what to
provide for. When first the rebuilding of the Hospital was decided on,
the question was discussed as to whether the out-patient consulting
room should be constructed to allow for accommodation of an increase
in the number of the surgical staff, and the decision was deliberately
arrived at that no such increase was desirable or likely to be required.

By the appointment of Soelberg Wells as an additional assistant-surgeon
in 1867, the number of the surgical staff became increased to nine.
Three surgeons attended each day and each came twice a week. Such an
evenly balanced arrangement worked satisfactorily for a number of
years. In 1867 the number of new out-patients was 17,211; in 1900
the number had increased to 36,932—_i.e_., more than double. The
work entailed in dealing with this large increase of patients was,
however, far more than double in amount to what it was in 1867, because
sight-testing and the correction of errors of refraction had increased
both in extent and accuracy. It is not surprising, therefore, that
those surgeons who had but few clinical assistants found themselves
unable to cope with all the demands made on them. In 1890 the post of
paid refraction assistant had been created to aid the staff in that
class of work. T. Phillips held this post for a number of years: he
attended daily and became exceedingly expert in dealing with a large
number of cases in a very short time. When, however, he was absent
on a holiday or from illness, those who relied upon his assistance
experienced great difficulties in getting through their work, patients
even sometimes having to be sent away unseen.

In 1900 the Committee of Management determined that some fresh
arrangement was essential, and advocated the appointment of additional
assistant-surgeons: after considerable discussion this was agreed to,
and the surgical staff was increased to twelve. The three new members
to be appointed were to rank as assistant-surgeons, and their work
was to be confined to the out-patients, except in the absence of the
surgeon of the day. This was a reversion to a former plan, which after
a short trial broke down, each member of the staff again attending to
both out- and in-patients. Fortunately at that time there were a large
number of able clinical assistants, who became candidates for the new
posts, from amongst whom Percy Flemming, assistant ophthalmic surgeon
at University College Hospital, J. Herbert Fisher, assistant ophthalmic
surgeon at St. Thomas’s Hospital, and Arnold Lawson (afterwards Sir
Arnold, and ophthalmic surgeon at the Middlesex Hospital) were elected.

The result of this increase of the staff was that the out-patient
consulting room, originally designed to accommodate three surgeons and
their clinical assistants, had to accommodate four.

When the number of beds in use became increased to 118, the services
of a third house surgeon were found requisite, those of the two senior
being required for the in-patients, and those of the junior being
confined to the out-patients. No accommodation had been made in the new
building for an increase in the resident staff, and some reconstruction
of rooms became necessary.

The accommodation required for the nursing staff had been sadly
underestimated, and a part of the building which had been designed as
an isolation quarters for sick nurses had to be taken into general use.
At the present time, even with these additional rooms, it would be
impossible to make use of all the beds for in-patients with which the
Hospital is provided without first securing increased accommodation for
nurses.

A nurse may have completed three years’ training at a general hospital
and have acquired sufficient theoretical knowledge to pass the
examination which is considered essential before she is granted a
certificate, and yet be incompetent to nurse a case of eye disease.

Moorfields Hospital has become, not only a special training school for
ophthalmic surgeons, but also for ophthalmic nurses. Many who have
been trained there have subsequently been appointed to take charge of
ophthalmic institutions or departments in various parts of the United
Kingdom, in the Colonies, and in America.

In 1896 courses of lectures given by members of the surgical staff
were instituted for nurses, in addition to the instruction which they
received from the matron: such courses have been regularly carried on
ever since. In 1907 arrangements were made with the authorities of the
Queen Victoria’s Jubilee Institute for Nurses to allow of the district
nurses employed by them to attend at the Hospital and receive practical
instruction in ophthalmic nursing free of charge. Fifty-three such
nurses attended at the Hospital in 1907, and fresh ones have continued
to attend ever since.

A large room was set apart in the new Hospital as a lecture theatre,
and, as the teaching became more systematised and the number of
students steadily increased, it became desirable to have a Dean
appointed to advise the students as to their studies, and to
superintend the classes: to this post W. T. Holmes Spicer was elected
in 1899. The teaching at Moorfields up to 1920, when the Royal Colleges
of Physicians and Surgeons established a Diploma of Ophthalmology, had
been post-graduate and almost entirely clinical and pathological, the
laboratory and museum affording excellent facilities for the latter.
In order to obtain the Diploma of Ophthalmology it became necessary
for students to pass a first examination in optics, and in the anatomy
and physiology of the parts concerned in ophthalmic surgery. To meet
the requirements of candidates for this examination, Moorfields then
instituted special courses of instruction in these scientific subjects,
upon which the practice of ophthalmology must always be based. In so
doing it has become a complete school of ophthalmology.

Graefe, in his work on the ocular muscles, described what are termed
latent squints—_i.e_., squints which only become manifest when the
desire to see singly with the two eyes is removed. Increased attention
to them was awakened in 1886 when Stevens of New York suggested
a convenient form of nomenclature to describe their different
varieties, and in 1890 when Maddox of Bournemouth introduced a simple
and expeditious method for their detection and measurement. Some
enthusiasts at first tended to exaggerate the importance of these
defects in the balance of the ocular muscles, attributing to them
numerous ills to which the flesh is heir, and practising operative
procedures for their correction. On the other hand, some were slow
in devoting sufficient attention to them. Had more importance been
attached to them at Moorfields, at the time the new building was under
construction, better provision might have been made in it for their
investigation.

In the closing years of the nineteenth century the science of
bacteriology increased both in its importance and in its technique
by leaps and bounds. In 1901 the medical staff, finding that more
bacteriological investigations were required than the pathologist
had time to devote to them in association with his other duties,
recommended the establishment of a special bacteriological department
and the appointment of a special bacteriologist. This entailed the
provision of additional laboratory accommodation, and it was not until
six years later that the Committee could see their way to the erection
of a new laboratory above that part of the pathological department
occupied by the Museum and curator’s room, part of a legacy left to the
Hospital by the late Mr. Samuel Lewis being used to defray the cost.

PLATE XXVI.

[Illustration: SIR JOHN TWEEDY, LL.D.]

John Tweedy, who had been elected on the staff at the comparatively
early age of twenty-nine, resigned in 1900 at the age of fifty-one, and
was appointed consulting surgeon, the Committee of Management putting
on record at the time its appreciation of the “numerous occasions he
had pleaded the cause of the Hospital in powerful and most interesting
public addresses, endorsing his advocacy with liberal donations to
its funds.” Tweedy was a fluent and learned writer; he served for a
long time on the editorial staff of the _Lancet_, so that most of
his contributions appeared anonymously. He did not contribute much
to the literature of ophthalmology, though he had had a very large
experience and was frequently called into consultation by his
colleagues in difficult cases. An American student once asked him
which he considered the best textbook on ophthalmology. Tweedy took a
deep breath, with which, on account of some chest affection, he always
preceded any oratorical remark, and, with a dramatic wave of the arm
towards a crowd of patients that were waiting to see him, said: “There,
that is the best textbook.”

Three years after his retirement from the staff of the Hospital, he
became President of the Royal College of Surgeons; he held that post
for three years, and was knighted in 1906. He possessed remarkable
administrative capacity, and was skilful in putting through the
business of a meeting with efficiency and dispatch. He also presided
over the Ophthalmological and Medico-Legal Societies, the Medical
Defence Union, and the Royal Medical Benevolent Fund. He died in 1924
at the age of seventy-five.

With the discovery of the ophthalmoscope the interests of
ophthalmologists became largely medical as well as surgical; though
they still style themselves ophthalmic surgeons, some might more aptly
be termed ophthalmic physicians; Marcus Gunn was one of these. The
distinguished neurologist, Sir William Gowers, in 1879, wrote a book
on _Medical Ophthalmoscopy_, which was the leading manual of its kind
for many years; its third edition, which appeared in 1890, was edited
by Marcus Gunn. He was a most careful ophthalmoscopic observer, and for
several years devoted his attention to certain changes in the retinal
bloodvessels. Writing on the outcome of these observations in 1898, he
said:

  “The chief importance of this retinal arterial change lies in its
  association with a more general arterial disease of a similar nature,
  particularly in the kidneys and brain, and in its prognostic value in
  regard to the results which may follow in cerebral vessels. It has
  been well said that ‘a man is as old as his arteries.’ I would urge
  that ophthalmoscopic observation is one of the most ready clinical
  means for the early detection of important arterial changes.”

Rheumatism is a term which is applied to a multiple of ills, and
during the nineteenth century a number of cases of inflammation of
the iris were so classified. The most typical and well-defined form
of rheumatism is rheumatic fever or acute articular rheumatism, and
investigations of a number of such cases at general hospitals, and of
cases of iritis at Moorfields, showed that the two affections were but
rarely associated. Iritis not uncommonly occurs in connection with
inflammation of the joints due to gonorrhœa, which is sometimes termed
“gonorrhœal rheumatism,” but a very large number of cases of iritis
are met with unassociated with any joint affection or any venereal
disease. Of recent years, largely as the outcome of the observations
and teaching of William Lang, it has become recognised that such cases
are secondary to some focus of inflammation elsewhere in the body, very
often a septic condition in connection with the teeth. Seeing how many
people suffer from septic teeth who never develop iritis, considerable
scepticism at first prevailed as to its being the cause of the disease.
The satisfactory way in which iritis subsides and ceases to recur after
the septic focus in the mouth has been removed seems, however, to
have definitely established the relation of the one to the other, and
provided a means of eradicating a very potent cause of suffering and
destruction of sight.

The reawakening of the importance of the medical side of ophthalmology
made the surgical staff desirous in 1899 of securing for their patients
at the Hospital the aid and assistance of a physician who had had a
special training as a neurologist. For this purpose, it was decided
to appoint a second physician who should be required to attend the
Hospital once a week to examine and report on such cases as were
selected for him by the surgical staff. Dr. James Taylor, who had
studied under Dr. Hughlings Jackson, and who may be regarded as one of
his most ardent disciples, was elected to this post.

PLATE XXVII.

[Illustration: WILLIAM LANG]

The systematic and orderly keeping at Moorfields of the clinical
records of in-patients, and of the pathological examination of the
eyes removed, over a number of years by successive house surgeons
and curators of the Museum, has provided a large amount of valuable
material for the investigation of the natural history of certain
diseases from which useful inferences as to their incidence and
prognosis can be drawn. Such method of investigation has been applied
by a succession of workers, over a period of fifty-seven years, to the
different forms of malignant growths originating in the eyeball, and
has added considerably to our knowledge concerning them, the results
being published in the _Hospital Reports_.

A distinguished ophthalmic surgeon from New York who visited Moorfields
went away much impressed by Nettleship, because he showed and discussed
with him nothing but his failures. Most operating surgeons like to
exhibit their successes and keep their disasters in the background,
but by the study of our failures lies the road to future success.
The curator of the Museum at Moorfields, or pathologist as he is now
called, has the opportunity of examining critically all the eyes
removed after the failure of operative procedures by the various
members of the staff. From such examinations much valuable information
has been collected and published, both in connection with operations
for the removal of cataract and for the relief of glaucoma. To have had
the advantage of carrying out these examinations must necessarily be an
excellent training for one who is to become an operator himself. It is
not, therefore, surprising that all those who have in recent years held
the post of pathologist have subsequently been promoted to the surgical
staff.

C. Devereux Marshall, who held the post of curator of the Museum
from 1894 to 1899, was elected assistant- surgeon on the retirement
of Tweedy from the staff. William T. Lister (now Sir William Lister,
K.C.M.G.) was the curator from 1899 to 1901, and was elected
assistant-surgeon on the retirement of Waren Tay in 1904. John Herbert
Parsons (now Sir John Parsons, C.B., F.R.S.) was curator from 1901 to
1905, and was elected assistant-surgeon to fill the vacancy caused by
the death of A. Quarry Silcock in 1904.

When, in 1891, elementary education was made universal and compulsory,
those responsible for the measure little realised all that it would
involve. They little thought that in 1927 it would lead to the
provision of 16,000,000 meals for school-children, and the medical
examination of 2,000,000, involving the employment of about 2,000
doctors, 600 dentists, and 5,000 nurses, or that it would develop
into what Sir George Newman, the chief medical officer of the Board
of Education, describes as “the grand inquest of the nation directed
towards laying the foundation of the nation’s health.”

It soon became evident that it was futile to compel children to study
if their physical condition was such that they would not profit
thereby, or if it was likely to lead to their physical deterioration.
The question of their eyesight and its possible impairment from study
early attracted attention. At first the teachers of the London School
Board were given instructions to test the children’s eyesight, and to
give the parents of those in whom they found it defective a printed
paper, stating that their child was suffering from a defect of vision,
and, in the child’s interests, they were strongly advised to consult an
oculist without delay. To this notice was attached a list of hospitals
with eye clinics and the times at which they were open for patients.
The periodic rush of school-children with their parents to these
clinics created chaos in their ordinary working routine.

In 1908 the Board of Education issued a circular stating that
suitable provision can be made by a local education authority for the
prescription and purchase of spectacles; and that, in this connection,
the Board will be prepared to entertain proposals for contributions
to the funds of hospitals on terms of adequate advantage, and the
contributions are specially desirable in the case of eye hospitals.
Also that “it is permissible to include among the conditions of
contribution a provision allocating a reasonable remuneration to the
medical men working for such institutions.”

In the following year, in response to the invitation of the London
County Council Education Committee, the Committee of the Hospital
agreed to co-operate with it for the treatment of children whose eyes
required attention, on the basis that not less than 3,000 nor more than
6,000 children be sent during the year, and that the Council would pay
for the extra assistants which the Committee would have to appoint to
carry out the work.

When the new Hospital was built, a portion of it on the ground floor
had been left uncompleted, it being thought that it might ultimately
be used as a chapel. The chaplain found it most convenient to conduct
his services in the day wards. So, in 1909, through the generous
help of some friends of the Hospital, donations were collected for
the special purposes of carrying out certain alterations to this
unoccupied part of the building to provide and equip a refraction
department for school-children, separate from the other out-patients.
This school-children’s department was completed and became ready for
use in 1910. While the majority of the children which attend require
spectacles for the correction of errors of refraction, some are found
to be suffering from some other affections of the eye, and these are
referred for treatment to the ordinary out-patient department.

On the death of Queen Victoria, who had been a Patron throughout the
whole of her long reign, in 1901, King Edward VII, and Queen Alexandra
consented to continue the patronage of the Institution which they had
extended to it as Prince and Princess of Wales. In the same way, the
Prince and Princess of Wales agreed to continue the patronage which
they had bestowed on it when Duke and Duchess of York.

On the removal to the new Hospital, it had been foreseen that special
steps would have to be taken to provide for the payment of the ground
rent of £1,210 a year, and in 1899 John Tweedy started the “Rent Fund”
with a generous donation of £150, to which he later added a further
donation of £50. Owing, however, to the South African War and the
pressing need to defray current expenses, but very slow progress was
made in the collection of donations to this fund. In 1904, to celebrate
the centenary of the foundation of the Hospital, the Committee decided
to change the name of the fund to that of the “Centenary Fund,” and
to make a special appeal for contributions to it, all donations to be
invested and the interest on it devoted to the payment of the rent.

A Centenary Festival Dinner was held at the Hotel Cecil on May 10th,
over which Sir Charles Wyndham presided, delivering a most eloquent
appeal on behalf of the Charity. The following ladies kindly acted as
hostesses on the occasion: Princess Alexis Dolgorouki, the Hon. Helen
Henniker, Lady Critchett, Lady Burnand, Lady Wyndham, Lady Walker, Mrs.
Marcus Gunn, Mrs. Widenham Fosbery, Mrs. Edward Nettleship, Mrs. F. C.
Scotter, Mrs. Beerbohm Tree, Mrs. Brooman-White of Arddaroch, Mrs. J.
S. Wood. Three hundred guests were present, and the proceeds of the
dinner, amounting to £2,270, were added to the Centenary Fund.

In former times it was the custom to end a story by drawing a moral;
all such moral conclusions are nowadays regarded as out of fashion,
and even a plot is no longer considered as essential in a story. All
that is required is just to describe a slice out of life, beginning
anywhere and ending when the requisite number of pages have been
filled. This story of the Moorfields Eye Hospital describes a slice out
of the life of an institution, commencing with its foundation in 1804,
and ending, whilst it is still full of progressive vigour, with the
celebration of its centenary.

Most people will agree that the chief object of raking over the ashes
of the past should be to acquire inspirations for the future; and so,
though it may be hopelessly out of fashion, this story will conclude
with some maxims which may be deduced from all that has gone before.

The general principle on which the Hospital was established was that
the treatment of diseases of the eye and visual disorders should be
recognised as a branch of medicine and surgery, and not left in the
hands of unqualified and imperfectly trained practitioners. With
this end in view, it has always been insisted on that the members of
its medical staff should hold the highest possible qualifications
as physicians and surgeons, and that every encouragement should be
given to qualified medical men to come to it to study the treatment
of eye diseases as a branch of medicine and surgery. The necessity
for the recognition of this general principle, now in 1929, is just
as necessary as in 1804, there being, as then, no short road to the
efficient treatment of visual defects apart from a complete training as
a medical practitioner.

The question is sometimes asked: Do special hospitals justify their
existence? The perusal of this book, it is hoped, will at any rate show
that the Moorfields Eye Hospital has justified its existence.

One of the incomparable advantages afforded by a special hospital is
the field which it offers for mass observation, both clinical and
pathological. It was by taking advantage of the extensive opportunities
for clinical research which Moorfields Hospital affords that Sir
William Lawrence, Sir Jonathan Hutchinson, Dr. Hughlings Jackson,
Edward Nettleship, and others have been able to make their most
valuable contributions to our knowledge of the natural history of eye
diseases.

Pathological research in connection with eye disease depends almost
entirely on the investigation of eyes which have had to be removed
during life, and at Moorfields the custom of placing the mass of such
material at the disposal of one man, the curator of the Museum, whilst
he holds office, has proved to be of inestimable advantage in the
promotion of that line of research.

To arrive at an accurate estimate of the benefits to be derived from
any special line of treatment or from some operative procedure, it is
necessary that it should be tried in the various varieties and phases
of a disease; inferences drawn from isolated cases must always prove
fallible. The mass of cases provided by a special hospital allows of
reliable estimates being arrived at.

The facilities for mass observation which a special hospital affords
are of as great advantage to the student as to the investigator. It
enables him, not only to get a comprehensive picture of a disease in
all its manifestations firmly impressed on his mind, but also to see
in a comparatively short time several examples of what, in a more
restricted sphere, would be regarded as rare affections. It has been
the recognition of such advantages that has induced medical men from
all parts of the world, for over a hundred years, to congregate at
Moorfields to gain instruction and experience.

It has not, however, been only the size of the clinic which has
attracted students of ophthalmology to Moorfields, but also to a large
extent the personnel of its medical staff. To listen to discussions on
debatable matters by able exponents, holding forth day after day from
the same pulpits, and to watch varying forms of procedure on similar
conditions carried out in the same theatre by different operators,
stimulates students to observe and to think for themselves —a form
of training which is far preferable to the absorption of dogmatic
aphorisms from a single teacher, or the attendance at courses of
didactic oratory.

Medicine and surgery are not exact sciences, and probably never will
be; any increase in exactitude in connection with them may, however,
be regarded as synonymous with progress. The immense increase in
exactitude in connection with ophthalmology which has taken place
since the discovery of the ophthalmoscope can be realised, if we
consider the number of well understood conditions which are now
differentiated, and which were formerly grouped under the vague heading
of “Amaurosis.” Ophthalmology is closely associated with such exact
sciences as mathematics, chemistry, and physics. It was, indeed, from
the association of the latter with ophthalmology that the discovery
of the ophthalmoscope resulted; for, as Helmholtz himself said, “When
a well-trained physicist came and grasped the importance of such an
instrument, nothing more was wanted, since all the knowledge had been
developed which was required for its construction.”

William Cumming had grasped the possibilities of such a discovery,
but, lacking himself the necessary training in physics and failing to
consult anyone who had, missed the way to the end for which he was
striving.

It was the fortunate circumstance of Sir James Mackenzie Davidson being
interested in both physics and ophthalmology, at the time of Professor
Röntgen’s discovery of the X-rays in 1895, that led to their early
employment at Moorfields in connection with foreign bodies implanted
in the eyeball, and the introduction of an accurate method for their
localisation.

Of the intimate association of mathematics with ophthalmology we
have evidence in Helmholtz’s great work on physiological dioptrics.
Donders, in the preface to his book _On the Anomalies of Accommodation
and Refraction of the Eye, with a Preliminary Essay on Physiological
Dioptrics_, published by the New Sydenham Society in 1844, writes as
follows:

  “In the doctrine of the anomalies of refraction and accommodation,
  the connection between science and practice is more closely drawn
  together than in any part of medicine.

  “Science here celebrates her triumph, for it is at her hand that
  this branch has acquired the exact character which makes it also
  worthy of the attention of natural philosophers and physiologists.
  It is, indeed, satisfactory to see, how in the accurate distinction
  between anomalies of refraction and accommodation with exclusion of
  every condition foreign to those anomalies, the system assumed, as if
  spontaneously, an elegant simplicity; and how the cause and mode of
  origin of many an obscure type of disease emerged into the clearest
  light.

  “Practice, in connection with science, here enjoys the rare but
  splendid satisfaction of not only being able to give infallible
  precepts based upon fixed rules, but also of being guided by a clear
  insight into the principles of her actions— advantages the more
  highly to be estimated as the anomalies in question are of more
  frequent occurrence, and as they more deeply affect the use and
  functions of the eyes.

  “Is it, then, strange that the study and treatment of my subject
  have been to me a labour of love? the more so, as I felt proud in
  having been called upon to elaborate it for a country in which Young,
  Wells, Ware, Brewster, and Airy have pointed out to us the track
  which we had only to follow, and happy in being able to offer my work
  in this form to my highly esteemed friends and colleagues, whose
  proofs of kindness and affection have left with me the most agreeable
  recollections of my visits to England.”

In its indebtedness to chemistry, ophthalmology shares with all
other branches of medicine and surgery. It was to the chemist Louis
Pasteur that we owe the upgrowth of the new science of bacteriology.
It is to Madame Curie’s chemical researches that we are indebted for
radium, which promises to be the most effectual means for dealing with
malignant neoplasms apart from operations.

It is to Wassermann that we owe the possibility of a chemical means of
diagnosing syphilis, and to Ehrlich a chemical compound which will kill
the invading organism without damaging the tissue of the infected host.

From what has gone before it would seem that measures, which tend
to bring about a close association between the clinical work in the
Hospital and the laboratory work of the trained observers in these
exact sciences, are those most likely to prove fruitful in the
promotion of the progress of ophthalmology in the future.

Hospitals in the first part of the nineteenth century were institutions
founded and supported by the rich for the relief of suffering in the
indigent poor, the inmates admitted to which were given everything for
nothing.

Under altered conditions, they are now rapidly becoming institutions
for the relief of suffering in the community at large, supported in
part by donations from munificent persons, and in part by contributions
from those who receive benefits in them.

In former times the word “hospital” raised in the mind a picture of a
barrack-like building, associated with pain and suffering, with poverty
and death.

John Couper, when senior surgeon at the London Hospital, was journeying
to it down the Mile End Road in one of the old horse-drawn omnibuses,
and asked the conductor to put him down at the London Hospital; the
conductor shouted out to the driver, “Stop at the slaughter-house Bill.”

Since the introduction of anæsthetics and antiseptics hospitals are
no longer regarded as slaughter-houses by the general public, but as
places where pain and suffering are relieved, and health and vigour
are restored. No longer are they forbidding barrack-like structures,
but temples of hygienic cleanliness. No longer is it a luxury to be
ill, or to have an operation performed in one’s own home, where all the
necessary appliances have to be imported or improvised. Far preferable
has it become to go to an institution specially constructed for such
purposes, furnished with the most up-to-date contrivances, and with a
staff efficiently trained to meet all emergencies.

In a Report of a Special Committee of the King Edward’s Hospital Fund
for London on “Pay Beds,” dated July, 1928, the present relation of
various sections of the general public to hospitals is set out as
follows:

  “During recent years there has been a considerable extension,
  both of the classes included amongst Voluntary Hospital patients
  and of the payments made by ordinary patients. There was a time
  when the Hospitals were only called upon to provide comparatively
  simple treatments for the necessitous poor, which meant those who
  were unable to pay for medical attendance. With the development of
  expensive methods of treatment and diagnoses, large numbers of the
  middle and professional classes are now unable to pay the full cost
  of these services, some of which, according to our evidence, are
  often difficult to obtain outside the Hospital.

  “At the same time, experience has shown that large numbers of the
  ordinary Hospital patients are both able and willing to contribute
  towards their cost. At present, therefore, there is a demand for
  Hospital treatment from several different classes which may be
  grouped into three: First, those who cannot afford to pay anything,
  and who receive, when in the ordinary wards, free maintenance and
  treatment; second, those who can and do contribute according to their
  means towards their cost of maintenance in the ordinary wards, though
  still receiving free medical attendance from the visiting staff of
  physicians and surgeons; third, those whose standard of living causes
  them to desire better accommodation, or at all events more privacy,
  than is provided in the ordinary wards, and who are prepared to
  pay for it according to their means, and also to pay something for
  medical attendance. Beyond these, there is a fourth class, those who
  can afford to obtain their treatment in private nursing homes and to
  pay full medical fees.”

Institutions, like individuals, if they wish to survive in the struggle
for existence, have to obey the universal law of adaptation to
environment. Moorfields Hospital, during the first hundred years of
its existence, has undergone reconstruction, had additions made to it,
and has twice been removed to a new site, in response to the demands
made upon it by the increasing number of patients attending for relief,
and to the developments and discoveries in the methods of applying
relief.

To be capable of such frequent fresh adaptations, an institution
must be prepared to obey another biological law—that of retaining a
high degree of plasticity, which, in the case of an institution, is
equivalent to maintaining a big margin for expansion.

As has been shown, Moorfields is largely indebted to the foresight
of its architects for having retained such a margin for expansion
to meet new requirements. When first a new Hospital was erected
on the Moorfields site, Sir Robert Smirke, the architect, advised
the Committee to secure the freehold of a piece of vacant ground
immediately behind the Hospital, upon which, after the discovery of the
ophthalmoscope, a new out-patient department with a large dark-room
was built. It was also, probably by his advice, that Dr. Farre secured
the lease of the piece of ground on its south side, part of which he
for a time let off for a stables and in part used for the Saunderian
Institute, but upon which a new wing of the Hospital was subsequently
built, when the demand for more in-patient accommodation became urgent,
after the introduction of anæsthetics and the great increase in the
number of operative procedures. When the removal to a new site again
became necessary, it was the proceeds derived from the greatly enhanced
value of these sites, which had been so fortunately obtained, that
supplied the funds for the erection of the new building.

It was due to the advice of the architects, Keith Young and Bedell,
that the large site in the City Road was chosen for the present
Hospital, instead of the cramped one in Eldon Street adjoining the
former building, to which at the time sentiment made a strong appeal.

In the twenty-five years which have elapsed since the celebration
of the Hospital’s centenary, fresh discoveries and altered economic
conditions have produced further changes in environment, calling
for more expansion in one direction and another. Fortunately, the
plasticity of the present large site is by no means exhausted, and with
suitable adaptation it is capable of providing all the demands likely
to be made upon it for several years to come.

The last maxim, however, to be drawn from the past history of the
Hospital is the necessity of keeping ever alert for adaptations to meet
fresh changes in its environment as they arise.




  APPENDIX


  PRESIDENTS
                                           _Date of_        _Date of_
                                         _Appointment_.   _Resignation_.
  Sir Charles Price, Bart.                    1804            1818
  Mr. William Mellish                         1818            1838
  Rt. Hon. Earl Fitzwilliam                   1838            1856
  Mr. William Cotton, D.C.L., F.R.S.          1857            1867
  Sir John Lubbock, F.R.S., M.P.
    (afterwards Lord Avebury)                 1867            1913
  His Royal Highness Prince Arthur
    of Connaught, K.G.                        1914


  CHAIRMEN OF THE COMMITTEE OF MANAGEMENT

  Mr. Harry Sedgwick                          1804            1818
  Mr. Ralph Price                             1818            1830
  Mr. Stuart Donaldson                        1831            1837
  Rev. J. Russell, D.D.                       1837            1857
  Mr. Richard Heathfield                      1857            1859
  Mr. F. G. Sambrooke                         1860            1871
  Mr. Philip Cazenove                         1871            1879
  Mr. Charles Gordon                          1879            1897
  Mr. H. P. Sturgis                           1897            1921
  Mr. Theodore W. Luling                      1921


  HONORARY MEDICAL AND SURGICAL OFFICERS

  _Physicians_

  John Richard Farre, M.D.                    1805            1857
  Frederick J. Farre, M.D.                    1843            1880
  Robert Martin, M.D.                         1856            1884
  Sir Stephen Mackenzie, M.D.                 1884            1905
  James Taylor, C.B.E., M.D.                  1899            1919
  Gordon M. Holmes, C.M.G., C.B.E., M.D.      1914            1927
  William J. Adie, M.D.                       1927


  _Surgeons_

  J. Cunningham Saunders
  (Founder)                                   1804       Died 1810
  Benjamin Travers, F.R.S.                    1810            1817
  Sir William Lawrence, Bart., F.R.S.         1814            1826
  Frederick Tyrrell                           1817       Died 1843
  John Scott                                  1826            1846
  Gilbert Mackmurdo, F.R.S.                   1830            1856
  John Dalrymple, F.R.S.                      1832            1849
  James Dixon                                 1843            1868
  George Critchett                            1843            1877
  Sir William Bowman, Bart., F.R.S.           1846            1876
  Alfred Poland                               1848            1861
  H. H. Mackmurdo                             1851            1852
  John C. Wordsworth                          1852            1883
  J. F. Streatfield                           1856       Died 1886
  J. W. Hulke, F.R.S.                         1858            1890
  George Lawson                               1862            1891
  Sir Jonathan Hutchinson, F.R.S.             1862            1878
  John Couper                                 1866            1895
  J. Soelberg Wells                           1867       Died 1880
  Waren Tay                                   1877            1904
  James E. Adams                              1877            1884
  Sir John Tweedy, LL.D.                      1878            1900
  Robert Lyall                                1880       Died 1882
  Edward Nettleship, F.R.S.                   1882            1898
  R. Marcus Gunn                              1883            1909
  W. Lang                                     1884            1912
  A. Quarry Silcock                           1886       Died 1904
  J. B. Lawford, LL.D.                        1890            1918
  A. Stanford Morton                          1891            1909
  E. Treacher Collins                         1895            1922
  W. T. Holmes Spicer                         1898            1920
  Percy Fleming                               1900            1919
  J. Herbert Fisher                           1900            1927
  Sir Arnold Lawson, K.B.E.                   1900            1914
  C. Devereux Marshall                        1900       Died on active
                                                         service, 1918
  Sir William T. Lister, K.C.M.G.             1904            1905
                                              1919
  Sir John Herbert Parsons, C.B.E., F.R.S.    1905
  Claud Worth                                 1905            1921
  W. Ilbert Hancock                           1909       Died 1910
  George Coats                                1909       Died 1915
  Malcolm L. Hepburn                          1910            1926
  A. Cyril Hudson                             1913            1928
  R. Foster Moore, O.B.E.                     1914
  R. Affleck Greeves                          1915
  F. A. Juler                                 1918
  Charles Goulden, O.B.E.                     1919
  B. T. Lang                                  1920       Died 1928
  M. H. Whiting, O.B.E                        1921
  P. G. Doyne                                 1922
  Humphrey Neame                              1926
  Miss Ida C. Mann                            1927
  W. Stewart Duke-Elder                       1928
  Rupert S. Scott                             1928


  _Ear, Nose, and Throat Surgeon_

  G. Seccombe Hett                            1923            1929


  _Medical Officer to the X-Ray Department_

  Sir James Mackenzie Davidson                1899            1910
  Albert Bowie                                1910


  _Dental Surgeons_

  Arthur E. Relph                             1913            1915
  R. M. Fickling                              1915            1928
  Stanley A. Riddett                          1928


  _Medical Officer to the Ultra-Violet Ray Department_

  W. Stewart Duke-Elder                       1927
  Mr. Richard Battley                         1804            1818
  Mr. Matthew Heathfield                      1818            1834
  Mr. William Bircham                         1835            1844
  Mr. Robert Francis Dalrymple                1844            1846
  Mr. F. A. Curling                           1846            1856
  Mr. Charles Gordelier                       1856            1860
  Mr. J. Mogford                              1860            1872
  Mr. Robert J. Newstead                      1872            1897
  Mr. Robert J. Bland                         1897            1923
  Mr. Arthur J. M.  Tarrant



INDEX


  Abercrombie, Sir Ralph, 6

  Adams, James, 146
    his loss of sight, 163

  Adams, Sir William, 1, 22, 28
    at Exeter, 29
    monetary grant to, and change of name, 30

  Airy, the Astronomer Royal, 115, 212

  Alexander, Charles, 15, 16

  Amasis, King of Egypt, 43

  Anæsthesia, general, 82
    local, 165

  Anatomy of the human eye, 94

  Anderson, Mrs. Garrett, 179

  Anderson, Dr. James, 167

  Ansley, Alderman, 39

  Antiseptics in ophthalmology, 154

  Arlt, of Vienna, 96, 114

  Artificial eyes, 86

  Artificial pupil, operations for, 89–91

  Aseptic surgery, 187

  Asthenopia, 114

  Astigmatism, 114

  Avebury, Lord, 135, 217

  Avicenna, 89


  Babbage, Charles, his ophthalmoscope, 102, 127

  Bacteriology, 202

  Bader, Charles, 95
    appointed curator, 110, 122, 138

  Bancroft, Sir Squire, 182

  Barth, Joseph, of Vienna, 44

  Battley, Richard, early life, 3, 6, 11
    appointed secretary, 14, 30, 46
    and materia medica, 55–57, 59, 71
    death of, 79, 220

  Bedell, hospitals surveyor, 172, 215

  Beer, Professor, of Vienna, 44

  Belladonna, 1, 19, 23

  Bennett, Dr. Hughes, 164

  Bethlehem, Royal Hospital, 52
    its burial ground, 132

  Bircham, Francis William, 66, 78, 220

  Bircham and Co., solicitors to the Hospital, 66

  Blomberg, Rev. Dr., 67, 68

  Blood, withdrawal of, 40–41

  Boerhaave, of Leyden, 44

  Bonnet, of France, 86

  Bovell, J. Roach, 72

  Bowman, Sir William, candidature, 75
    employment of chloroform, 83
    operation on lacrymal passages, 88, 120
    operation for artificial pupil, 89–91
    meeting with Graefe and Donders, 93–95
    iridectomy for glaucoma, 96–97, 112
    retirement from Hospital, 143–144
    later life, 145–146
    and antiseptics, 155, 159, 161

  Boycott, Miss, 143

  Bradford, of Boston, U.S.A., 185

  Brailey, W. A. , curator, 141, 142

  Brass, Robert, architect, 134

  Bruecke, 95, 112

  Buller, Frank, 142


  Calabar bean, 131

  Cambridge, H.R.H. Duke of, 108, 182

  Cataract, congenital, 11, 19–24, 27, 60, 62, 88
    after-treatment, 153, 156

  Cazenove, Philip, 137, 149

  Charnley, W., 159

  Charter, granting of, 171

  Charterhouse Square, 14, 48

  Chloroform, 84–85

  Churchill, John, 77, 79

  City Companies, donations, from, 182

  City Road site, 172

  Clark, Sarah, 15

  Clinical assistants, institution of, 109

  Coats, George, 9, 10, 219

  Cocaine, 164

  Colkett, Miss Jane Louisa, 6

  Collins, E. Treacher, 179, 182, 218

  Conjunctiva, inflammation of,
    in infants, 22

  Conradi, 20, 27

  Consulting surgeons, duties of, 144–145

  Cooper, Sir Astley, connection with Saunders, 2–8
    suggestion for a special institution, 11, 13
    description of, by Travers, 33, 38
    his pupils and relatives, 59, 75

  Cooper, Samuel, 45

  Cooper, White, 84, 127

  Cork Street, Infirmary in, 15

  Cotton, William, 108, 135, 217

  Couper, John, 109
    appointed assistant-surgeon, 134, 136
    word picture of, 157–158
    his ophthalmoscope, 158–159, 179, 213, 218

  Cramer, 112

  Crimean War, 104, 125, 197

  Critchett, Sir Anderson, 97, 146

  Critchett, George, 75, 85
    and excision of the eyeball, 86
    and operation for squint, 87
    and operation for artificial pupil, 89–91
    for glaucoma, 96–97, 108, 134
    and duties of consulting surgeons, 143–145
    on Poor Law schools, 140–141, 146, 218

  Cuignet, 159

  Cumming, William, 100, 101, 102

  Curie, Madame, 212

  Curling, F. A. , 78, 220

  Cyrus, King of Persia, 43


  Dalrymple, John, secretary to academy, 58
    assistant surgeon, 64, 73, 74
    early training 75–76
    atlas of pathology of the eye, 77–78, 81, 118, 218

  Dalrymple, Robert Francis, 78, 220

  Dalrymple, William, 75–76

  Davidson, H., 182, 191

  Davidson, Sir James Mackenzie, 186, 187, 211, 219

  Daviel, 19

  Dean, appointment of, 201

  Delafield, Dr. Edward, 35, 38

  Desmarres, of Paris, 96

  Devis, portrait of Saunders by, 32

  Diet, 41

  Diploma of Ophthalmology, 201

  Dispensary for diseases of the eye and ear proposed, 12

  Dodson, Mrs., 80

  Donders, Franz Cornelius, first meeting with Graefe and Bowman,
        92–94, 95, 96, 99
    on Helmholtz, 103
    and anomalies of refraction and accommodation, 112–114, 145, 147,
        211

  Doublet, Thomas, 116


  Ear, anatomy of, 17

  Earle, Henry, 45

  East India Company, 34, 36

  Egerton, C. J. , 37

  Egyptian ophthalmia, 6, 29

  Ehrlich, 213

  Eldon Street, negotiations regarding site in, 169–171

  Electro-magnets, 185

  Ether, 82

  Excision of the eyeball, 85–86

  Exeter Eye Infirmary, 29


  Farre, Dr. Arthur, 106

  Farre, Dr. Frederick J., 60, 70, 72, 73, 75, 106, 215

  Farre, Dr. John Richard, early life, 3
    consulting physician, 14, 24
    edits Saunders’ writings, 26–28, 38, 45, 53
    courses of instruction, 54–56
    and Saunderian Institution, 56–57
    attacks on, in Lancet, 59–61
    his journal, 71
    his portrait, 72–73 74, 75, 81, 106, 215, 217

  Finsbury, neighbourhood of, 161

  Fisher, J. Herbert, 200, 218

  Fitzwilliam, Earl, 69, 108, 215

  Fixation forceps, 126

  Flemming, Percy, 199, 218

  Forbes, Litton, 159

  Forster, 129

  France, Mr., 126

  Fraser, Dr. Thomas R., 131


  Gamgee, J. S. , 106

  General hospitals, ophthalmic departments in, 126, 135

  Gibson, Benjamin, 28, 60, 88

  Gill, Rev. T. , 51, 55, 56

  Glaucoma, operations for and treatment of, 91–93, 126, 141–142

  Gordon, Charles, 149, 180, 215

  Governors, privileges of, 107

  Graefe, A. von, operation for glaucoma, 91
    meeting with Bowman and Donders, 93–94, 103, 127
    and perimetry, 129
    death of, 141
    and latent squints, 201

  Grant, Roger, 10

  Greek writers, 43

  Green, 27, 59

  Gunn, Marcus, 160, 203, 218

  Guthrie, 15


  Haab, of Zurich, 187

  Harkness, 109

  Harnet, Miss, 143, 165

  Hawes, Alfred, 116

  Hawes, William, 116

  Helmholtz, Professor von, 99, 103, 211

  Herbert, Sydney, 105

  Herodotus, 43

  Hey, 23

  Hill, John, 1, 8, 29

  Hirschberg, of Berlin, 185

  Hogg, E., 181

  Horner, Professor, of Zurich, 155

  Hulke, John Whitaker, 82, 85, 106, 109
    microscopical and scientific work, 111, 112
    career, 124–125
    and the perimeter, 129, 135, 147, 177, 218

  Hutchinson, Sir Jonathan, 109, 112
    work on inherited syphilis, 122–123, 130
    on tobacco amaurosis, 148–149 151, 159, 218

  Hypermetropia, 113


  Inquiry officer, 179

  Iriddesis, 90–91

  Iris, essay on inflammation of, 19

  Jackson, Dr. Hughlings, 109, 130, 205

  Jacksonian Prize Essay, for 1859, 111
    for 1878, 142

  Jaeger, Edward von, 117, 160

  Janin, 44

  Jeafferson, 37

  Jones, Wharton, 102, 115, 127

  _Journal of Morbid Anatomy, etc_., 71

  Jussieu, Joseph de, 164


  Kemp, William, 174

  Kensington, Henry, 14

  Kent, the Duchess of, 67, 68

  Kepler, 114

  King Edward VII., 208

  King Edward’s Hospital Fund, 195, 214

  King George I., oculist to, 10

  King George II., oculist to, 10

  King George III., oculist to, 11, 15

  King William IV., oculist to, 31

  Koller, Karl, 164


  Ladies’ Working Guild, 197–198

  Lancet, 46, 56, 58, 59, 202

  Lander, the hospitals surveyor, 170, 172

  Lang, William, 164, 204, 218

  Laquer, 131

  Lawford, J. B. , 162, 177, 218

  Lawrence, Sir William, treatment of eye diseases at general
        hospitals, 7, 33, 37
    the withdrawal of blood, 40–41
    history of ophthalmology, 43–44
    estimates of, 44
    and venereal diseases of the eye, 45–46, 54, 55
    and _Lancet_, 58–59, 61
    influence of one eye on the other, 86
    obstruction of tear duct, 88, 114, 123, 151, 209, 218

  Lawson, Sir Arnold, 200, 219

  Lawson, George, 109
    his career, 124, 125, 157
    treatment of out-patients, 177, 218

  Leber, Professor, 139

  Leeches, 41

  Lenses, system of numbering, 116

  Library, 72

  Lighting of new Hospital, 184

  Lister, Joseph, 152

  Lister, Sir William T., 206, 219

  Liston, Robert, 82

  Little Portland Street, Infirmary in, 31

  Livingstone, 98

  Lubbock, Sir John, 145, 170, 191, 217

  Lyell, Robert, 150, 218


  MacCallan, A. F. , 187

  Macgregor, Patrick, 6

  McHardy, Malcolm, 185

  McKenzie, H. V. , 187

  Mackenzie, of Glasgow, 82, 126

  Mackenzie, Sir Stephen, 160, 215

  McKeown, of Belfast, 185

  Mackmurdo, Gilbert, 64, 73, 74, 79, 106, 218

  Mackmurdo, H. H. , 81, 218

  Maddox, of Bournemouth, 201

  Madras Eye Infirmary, 37

  Magnet operations, 125, 187

  Maitre-Jan, 44

  Mansion House, sale at, 64

  Marshall, C. D. , 156, 205, 219

  Martin, Dr. Robert, 106, 129, 160, 215

  Massachusetts Charitable Eye and Ear Infirmary, 36

  Medical Council, formation of, 108–109

  Medical-legal observations, 120

  Mellish, William, 47, 49, 64, 68, 69, 215

  Milles, W. Jennings, 142

  Missionaries, admitted to study at Hospital, 98

  Mogford, J., 138, 220

  Moorfields, 48–53

  “Moorfields Club,” 161

  Morax-Axenfeld bacillus, 163

  Morton, A. Stanford, after-treatment of cataract operations, 153,
        156, 177
    his ophthalmoscopic drawings, 178, 218

  Muscles of eye, paralytic affections of, 127

  Myopia, 114


  Nagel, 116

  Nettleship, Edward, 139
    appointed curator, 140, 148, 150, 151
    his scientific work, 180, 205, 210, 218

  Newman, Sir George, 206

  Newstead, Robert J., 138, 181, 220

  New York Eye and Ear Infirmary, 35

  Nightingale, Miss Florence, 105, 134–153

  Nunn, T. N. , 81

  Nurses, Queen Victoria’s Jubilee Institute of, 201

  Nursing, changes in, 165, 166

  Nursing, School of, 200


  O’Ferrall, of Dublin, 86

  Ophthalmological Society, 145, 149, 161

  Ophthalmoscope, discovery of, 99

  Osler, Sir William, 142


  Paget, Sir James, 44

  Palmerston, Lord, 30

  Parsons, Sir John, 206, 219

  Pasteur, 161, 212

  Pay beds, report on, 214

  Pearson, Karl, 180

  Peel, Mrs., 165

  Peerless Pool, 174–175

  Peerless Street, 173

  Peninsular War, 39

  Perimetry, 129

  Periscope, 128, 148, 149

  Pharmacopœia, 72

  Phillips, T., 199

  Phillips, Thomas, R.A., 72, 73

  Price, Sir Charles, 15, 21, 39, 47, 215

  Price, Ralph, 61, 215

  Prichard, of Bristol, 87

  Prince and Princess of Wales, 181, 208

  Prince of Wales’ Hospital fund, 195

  Poor Law children and ophthalmia, 140, 141


  Queen Alexandra, 208

  Queen Anne, oculist to, 10

  Queen Victoria, 39, 46, 69, 177, 207

  Railway termini, 132, 133

  Rating and Valuation Bill, 194

  Rating of new Hospital, 193, 194

  Rawson, Sir William, 30

  Read, Sir William, 9, 10

  Reports, Ophthalmic Hospital, 119
    colour of paper in, 127

  Retinal arteries, changes in, 203

  Retinoscopy, 159

  Reynolds, Dr. Edward, 35

  Rheumatic affections of the eyes, 204

  Richardson, R., 37

  Robertson, Miss Ada, 180

  Robertson, Dr. Argyll, 131

  Rodgers, Dr. J. Kearney, 35

  Roman Emperors, 43

  Röntgen, Professor, 186

  Royal Westminster Ophthalmic Hospital, 15


  St. Ives, 44

  Sambrooke, F. G. , 117, 137, 138, 217

  Saunders, John Cunningham, early life, 1
    association with Astley Cooper, 2–6, 11
    proposal to start dispensary, 11–14, 16
    and diseases of the ear, 17–19
    operation for congenital cataract, 19–24
    death of, 25, 26, 28, 29, 32, 49, 57, 60, 81, 118, 218

  Saunderian Institution, 56, 57, 70

  Saunders, Mrs., 26

  Savory, Sir William, 44

  Scarpa, 23, 28

  Schmidt, 44

  School-children, sight-testing of, 206, 207

  School of Ophthalmology, opening of, 34

  Schweizer, 110

  Scott, John, 61; monograph on cataract, 62, 64
    obituary notice, 65; 74, 75, 77, 81, 218

  Sedgwick, Harry, 47
    trust fund, 117, 118, 196, 215

  Shepherdess Walk, 175, 176

  Silcock, A. Quarry, 167, 206, 218

  Simpson, Sir Janies, 82

  Smee, Alfred, 116, 133

  Smirke, Sir Robert, 49, 51, 53, 215

  Smith, Priestley, 139, 142

  Snell, of Sheffield, 185

  Snellen, of Utrecht, 117

  Soemerring, 44

  South African War, 193, 208

  Spicer, W. T. Holmes, 180, 201, 218

  Squint, operation for, 87

  Squints, latent, 201

  Stanley, Edward, 45

  Stephenson, Sydney, 141

  Stevens, of New York, 201

  Stevenson, John, 22, 28, 30, 31, 33

  Streatfield, J. F. , 106; his career, 107–108
    editor of the Reports, 119, 125, 127, 135, 136
    gigantic model of eye, 166, 218

  Tarsus, excision of, 22, 29

  Tay, Waren, 146, 148, 151, 162, 206, 218

  Taylor, “Chevalier,” 10

  Taylor, Dr. James, 205, 218

  Teale, Pridgin, jun., 88

  Tear duct, operations on, 88
    affections of, 152

  Tobacco, amaurosis due to, 148

  Travers, Benjamin, 33
    early career of, 34
    and East India Company, 36–37
    his treatise on eye diseases, 38, 42, 59, 64, 70, 218

  Travers, Benjamin, sen., 13

  Tubercle of the eye, 140, 162

  Tweedy, Sir John, 149, 157
    career of, 202–203, 206
    starts rent fund, 208, 218

  Tyrrell, Frederick, 45, 48, 54
    and Wakley, 58–59
    description of, 62–63, 64, 65, 74, 76, 104, 114, 218

  Tyrrell, John, 48, 50

  Tyrrell, Timothy, 48, 50

  Tyrrell, Walter, 106, 109


  Usher, C. H. , 180


  Venereal diseases of the eye, 45

  Ventilation of new Hospital, 182–183

  Vernon, Bowater, 139

  Vetch, Dr., 7

  Victoria, H.R.H. the Princess, 67–68


  Wakley, Thomas, 58, 59, 60

  Walton, Haynes, 82

  Ware, James, 11, 20, 28, 113, 212

  Wassermann, 212

  Wathen, Dr., 11, 15, 31

  Weber, Adolph, 131

  Weekes, Henry, bust of Saunders by, 32, 118

  Wells, J. Soelberg, 109
    and sight-testing, 115
    description of, 127–128 136, 147
    his treatise on diseases of the eye, 149–150, 152, 199, 212, 218

  Women become eligible as pupils and clinical assistants, 179

  Wyndham, Sir Charles, 208


  X-rays, 186

  York, H.R.H. the Duke of, 30, 49, 67

  York Hospital, Chelsea, 29

  Young, Keith, 172, 190, 215

  Young, Thomas, 114


  Zinn, Professor, 44



H. K. Lewis and Co., Ltd., 28, Gower Place, London, W.C.1.



*** END OF THE PROJECT GUTENBERG EBOOK 78625 ***