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.