CHAPTER III. Benjamin Travers and Sir William Lawrence

BENJAMIN TRAVERS AND SIR WILLIAM LAWRENCE

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

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

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

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

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

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

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

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

PLATE III.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

PLATE IV.

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

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

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

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

His first and most important occupation is defined as follows:

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

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

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

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

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

After venesection the next best method of taking blood is:

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

With regard to the use of leeches he writes:

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

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

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

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

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

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

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

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

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

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

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

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

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

PLATE V.

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

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

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

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

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

In the first chapter of the book Lawrence says:

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

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

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

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

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

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

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