Chapter XII: The Hospital in the City Road

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

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

PLATE XXV.

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

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

The Duke of York said:

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

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

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

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

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

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

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

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

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

“THE PRINCE OF WALES’ HOSPITAL FUND FOR LONDON.

“THE BANK OF ENGLAND,

“27_th December_, 1901.

“THE TREASURER,

“ROYAL LONDON OPHTHALMIC HOSPITAL

“City Road, E.C.

“Sir,

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

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

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

“Kindly acknowledge the receipt of the above.

“Yours faithfully,

“(Signed) S. CROSSLEY,

“_Honorary Secretary_.”

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

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

“Sir,

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

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

“Kindly acknowledge the receipt of the above.

“Yours faithfully,

“(Signed) SAVILE CROSSLEY,

“_Honorary Secretary_.”

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

PLATE XXVI.

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

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

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

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

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

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

PLATE XXVII.

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

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

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

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

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

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

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

When the new Hospital was built, a portion of it on the ground floor had been left uncompleted, it being thought that it might ultimately be used as a chapel. The chaplain found it most convenient to conduct his services in the day wards. So, in 1909, through the generous help of some friends of the Hospital, donations were collected for the special purposes of carrying out certain alterations to this unoccupied part of the building to provide and equip a refraction department for school-children, separate from the other out-patients. This school-children’s department was completed and became ready for use in 1910. While the majority of the children which attend require spectacles for the correction of errors of refraction, some are found to be suffering from some other affections of the eye, and these are referred for treatment to the ordinary out-patient department.

On the death of Queen Victoria, who had been a Patron throughout the whole of her long reign, in 1901, King Edward VII, and Queen Alexandra consented to continue the patronage of the Institution which they had extended to it as Prince and Princess of Wales. In the same way, the Prince and Princess of Wales agreed to continue the patronage which they had bestowed on it when Duke and Duchess of York.

On the removal to the new Hospital, it had been foreseen that special steps would have to be taken to provide for the payment of the ground rent of £1,210 a year, and in 1899 John Tweedy started the “Rent Fund” with a generous donation of £150, to which he later added a further donation of £50. Owing, however, to the South African War and the pressing need to defray current expenses, but very slow progress was made in the collection of donations to this fund. In 1904, to celebrate the centenary of the foundation of the Hospital, the Committee decided to change the name of the fund to that of the “Centenary Fund,” and to make a special appeal for contributions to it, all donations to be invested and the interest on it devoted to the payment of the rent.

A Centenary Festival Dinner was held at the Hotel Cecil on May 10th, over which Sir Charles Wyndham presided, delivering a most eloquent appeal on behalf of the Charity. The following ladies kindly acted as hostesses on the occasion: Princess Alexis Dolgorouki, the Hon. Helen Henniker, Lady Critchett, Lady Burnand, Lady Wyndham, Lady Walker, Mrs. Marcus Gunn, Mrs. Widenham Fosbery, Mrs. Edward Nettleship, Mrs. F. C. Scotter, Mrs. Beerbohm Tree, Mrs. Brooman-White of Arddaroch, Mrs. J. S. Wood. Three hundred guests were present, and the proceeds of the dinner, amounting to £2,270, were added to the Centenary Fund.

In former times it was the custom to end a story by drawing a moral; all such moral conclusions are nowadays regarded as out of fashion, and even a plot is no longer considered as essential in a story. All that is required is just to describe a slice out of life, beginning anywhere and ending when the requisite number of pages have been filled. This story of the Moorfields Eye Hospital describes a slice out of the life of an institution, commencing with its foundation in 1804, and ending, whilst it is still full of progressive vigour, with the celebration of its centenary.

Most people will agree that the chief object of raking over the ashes of the past should be to acquire inspirations for the future; and so, though it may be hopelessly out of fashion, this story will conclude with some maxims which may be deduced from all that has gone before.

The general principle on which the Hospital was established was that the treatment of diseases of the eye and visual disorders should be recognised as a branch of medicine and surgery, and not left in the hands of unqualified and imperfectly trained practitioners. With this end in view, it has always been insisted on that the members of its medical staff should hold the highest possible qualifications as physicians and surgeons, and that every encouragement should be given to qualified medical men to come to it to study the treatment of eye diseases as a branch of medicine and surgery. The necessity for the recognition of this general principle, now in 1929, is just as necessary as in 1804, there being, as then, no short road to the efficient treatment of visual defects apart from a complete training as a medical practitioner.

The question is sometimes asked: Do special hospitals justify their existence? The perusal of this book, it is hoped, will at any rate show that the Moorfields Eye Hospital has justified its existence.

One of the incomparable advantages afforded by a special hospital is the field which it offers for mass observation, both clinical and pathological. It was by taking advantage of the extensive opportunities for clinical research which Moorfields Hospital affords that Sir William Lawrence, Sir Jonathan Hutchinson, Dr. Hughlings Jackson, Edward Nettleship, and others have been able to make their most valuable contributions to our knowledge of the natural history of eye diseases.

Pathological research in connection with eye disease depends almost entirely on the investigation of eyes which have had to be removed during life, and at Moorfields the custom of placing the mass of such material at the disposal of one man, the curator of the Museum, whilst he holds office, has proved to be of inestimable advantage in the promotion of that line of research.

To arrive at an accurate estimate of the benefits to be derived from any special line of treatment or from some operative procedure, it is necessary that it should be tried in the various varieties and phases of a disease; inferences drawn from isolated cases must always prove fallible. The mass of cases provided by a special hospital allows of reliable estimates being arrived at.

The facilities for mass observation which a special hospital affords are of as great advantage to the student as to the investigator. It enables him, not only to get a comprehensive picture of a disease in all its manifestations firmly impressed on his mind, but also to see in a comparatively short time several examples of what, in a more restricted sphere, would be regarded as rare affections. It has been the recognition of such advantages that has induced medical men from all parts of the world, for over a hundred years, to congregate at Moorfields to gain instruction and experience.

It has not, however, been only the size of the clinic which has attracted students of ophthalmology to Moorfields, but also to a large extent the personnel of its medical staff. To listen to discussions on debatable matters by able exponents, holding forth day after day from the same pulpits, and to watch varying forms of procedure on similar conditions carried out in the same theatre by different operators, stimulates students to observe and to think for themselves —a form of training which is far preferable to the absorption of dogmatic aphorisms from a single teacher, or the attendance at courses of didactic oratory.

Medicine and surgery are not exact sciences, and probably never will be; any increase in exactitude in connection with them may, however, be regarded as synonymous with progress. The immense increase in exactitude in connection with ophthalmology which has taken place since the discovery of the ophthalmoscope can be realised, if we consider the number of well understood conditions which are now differentiated, and which were formerly grouped under the vague heading of “Amaurosis.” Ophthalmology is closely associated with such exact sciences as mathematics, chemistry, and physics. It was, indeed, from the association of the latter with ophthalmology that the discovery of the ophthalmoscope resulted; for, as Helmholtz himself said, “When a well-trained physicist came and grasped the importance of such an instrument, nothing more was wanted, since all the knowledge had been developed which was required for its construction.”

William Cumming had grasped the possibilities of such a discovery, but, lacking himself the necessary training in physics and failing to consult anyone who had, missed the way to the end for which he was striving.

It was the fortunate circumstance of Sir James Mackenzie Davidson being interested in both physics and ophthalmology, at the time of Professor Röntgen’s discovery of the X-rays in 1895, that led to their early employment at Moorfields in connection with foreign bodies implanted in the eyeball, and the introduction of an accurate method for their localisation.

Of the intimate association of mathematics with ophthalmology we have evidence in Helmholtz’s great work on physiological dioptrics. Donders, in the preface to his book _On the Anomalies of Accommodation and Refraction of the Eye, with a Preliminary Essay on Physiological Dioptrics_, published by the New Sydenham Society in 1844, writes as follows:

“In the doctrine of the anomalies of refraction and accommodation,
the connection between science and practice is more closely drawn
together than in any part of medicine.

“Science here celebrates her triumph, for it is at her hand that
this branch has acquired the exact character which makes it also
worthy of the attention of natural philosophers and physiologists.
It is, indeed, satisfactory to see, how in the accurate distinction
between anomalies of refraction and accommodation with exclusion of
every condition foreign to those anomalies, the system assumed, as if
spontaneously, an elegant simplicity; and how the cause and mode of
origin of many an obscure type of disease emerged into the clearest
light.

“Practice, in connection with science, here enjoys the rare but
splendid satisfaction of not only being able to give infallible
precepts based upon fixed rules, but also of being guided by a clear
insight into the principles of her actions— advantages the more
highly to be estimated as the anomalies in question are of more
frequent occurrence, and as they more deeply affect the use and
functions of the eyes.

“Is it, then, strange that the study and treatment of my subject
have been to me a labour of love? the more so, as I felt proud in
having been called upon to elaborate it for a country in which Young,
Wells, Ware, Brewster, and Airy have pointed out to us the track
which we had only to follow, and happy in being able to offer my work
in this form to my highly esteemed friends and colleagues, whose
proofs of kindness and affection have left with me the most agreeable
recollections of my visits to England.”

In its indebtedness to chemistry, ophthalmology shares with all other branches of medicine and surgery. It was to the chemist Louis Pasteur that we owe the upgrowth of the new science of bacteriology. It is to Madame Curie’s chemical researches that we are indebted for radium, which promises to be the most effectual means for dealing with malignant neoplasms apart from operations.

It is to Wassermann that we owe the possibility of a chemical means of diagnosing syphilis, and to Ehrlich a chemical compound which will kill the invading organism without damaging the tissue of the infected host.

From what has gone before it would seem that measures, which tend to bring about a close association between the clinical work in the Hospital and the laboratory work of the trained observers in these exact sciences, are those most likely to prove fruitful in the promotion of the progress of ophthalmology in the future.

Hospitals in the first part of the nineteenth century were institutions founded and supported by the rich for the relief of suffering in the indigent poor, the inmates admitted to which were given everything for nothing.

Under altered conditions, they are now rapidly becoming institutions for the relief of suffering in the community at large, supported in part by donations from munificent persons, and in part by contributions from those who receive benefits in them.

In former times the word “hospital” raised in the mind a picture of a barrack-like building, associated with pain and suffering, with poverty and death.

John Couper, when senior surgeon at the London Hospital, was journeying to it down the Mile End Road in one of the old horse-drawn omnibuses, and asked the conductor to put him down at the London Hospital; the conductor shouted out to the driver, “Stop at the slaughter-house Bill.”

Since the introduction of anæsthetics and antiseptics hospitals are no longer regarded as slaughter-houses by the general public, but as places where pain and suffering are relieved, and health and vigour are restored. No longer are they forbidding barrack-like structures, but temples of hygienic cleanliness. No longer is it a luxury to be ill, or to have an operation performed in one’s own home, where all the necessary appliances have to be imported or improvised. Far preferable has it become to go to an institution specially constructed for such purposes, furnished with the most up-to-date contrivances, and with a staff efficiently trained to meet all emergencies.

In a Report of a Special Committee of the King Edward’s Hospital Fund for London on “Pay Beds,” dated July, 1928, the present relation of various sections of the general public to hospitals is set out as follows:

“During recent years there has been a considerable extension,
both of the classes included amongst Voluntary Hospital patients
and of the payments made by ordinary patients. There was a time
when the Hospitals were only called upon to provide comparatively
simple treatments for the necessitous poor, which meant those who
were unable to pay for medical attendance. With the development of
expensive methods of treatment and diagnoses, large numbers of the
middle and professional classes are now unable to pay the full cost
of these services, some of which, according to our evidence, are
often difficult to obtain outside the Hospital.

“At the same time, experience has shown that large numbers of the
ordinary Hospital patients are both able and willing to contribute
towards their cost. At present, therefore, there is a demand for
Hospital treatment from several different classes which may be
grouped into three: First, those who cannot afford to pay anything,
and who receive, when in the ordinary wards, free maintenance and
treatment; second, those who can and do contribute according to their
means towards their cost of maintenance in the ordinary wards, though
still receiving free medical attendance from the visiting staff of
physicians and surgeons; third, those whose standard of living causes
them to desire better accommodation, or at all events more privacy,
than is provided in the ordinary wards, and who are prepared to
pay for it according to their means, and also to pay something for
medical attendance. Beyond these, there is a fourth class, those who
can afford to obtain their treatment in private nursing homes and to
pay full medical fees.”

Institutions, like individuals, if they wish to survive in the struggle for existence, have to obey the universal law of adaptation to environment. Moorfields Hospital, during the first hundred years of its existence, has undergone reconstruction, had additions made to it, and has twice been removed to a new site, in response to the demands made upon it by the increasing number of patients attending for relief, and to the developments and discoveries in the methods of applying relief.

To be capable of such frequent fresh adaptations, an institution must be prepared to obey another biological law—that of retaining a high degree of plasticity, which, in the case of an institution, is equivalent to maintaining a big margin for expansion.

As has been shown, Moorfields is largely indebted to the foresight of its architects for having retained such a margin for expansion to meet new requirements. When first a new Hospital was erected on the Moorfields site, Sir Robert Smirke, the architect, advised the Committee to secure the freehold of a piece of vacant ground immediately behind the Hospital, upon which, after the discovery of the ophthalmoscope, a new out-patient department with a large dark-room was built. It was also, probably by his advice, that Dr. Farre secured the lease of the piece of ground on its south side, part of which he for a time let off for a stables and in part used for the Saunderian Institute, but upon which a new wing of the Hospital was subsequently built, when the demand for more in-patient accommodation became urgent, after the introduction of anæsthetics and the great increase in the number of operative procedures. When the removal to a new site again became necessary, it was the proceeds derived from the greatly enhanced value of these sites, which had been so fortunately obtained, that supplied the funds for the erection of the new building.

It was due to the advice of the architects, Keith Young and Bedell, that the large site in the City Road was chosen for the present Hospital, instead of the cramped one in Eldon Street adjoining the former building, to which at the time sentiment made a strong appeal.

In the twenty-five years which have elapsed since the celebration of the Hospital’s centenary, fresh discoveries and altered economic conditions have produced further changes in environment, calling for more expansion in one direction and another. Fortunately, the plasticity of the present large site is by no means exhausted, and with suitable adaptation it is capable of providing all the demands likely to be made upon it for several years to come.

The last maxim, however, to be drawn from the past history of the Hospital is the necessity of keeping ever alert for adaptations to meet fresh changes in its environment as they arise.