Chapter VII: The Discovery of the Ophthalmoscope

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

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

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

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

The ophthalmoscope was, he said,

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

In speaking of his discovery in later years he said:

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

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

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

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

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

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

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

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

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

“2, Vittoria Place, Limehouse,

“_November_ 11_th_, 1862.

“Sir,

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

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

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

“I am, etc.,

“JOHN STEWART CUMMING.”

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

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

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

PLATE XIII.

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

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

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

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

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

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

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

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

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

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

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

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

PLATE XIV.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

PLATE XV.

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

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

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

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

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

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

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

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

Hulke, in some reminiscences of his youth, remarked:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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