CHAPTER VI. The Introduction of Inhalation anæsthesia and Ophthalmic Surgery

THE INTRODUCTION OF INHALATION ANÆSTHESIA AND OPHTHALMIC SURGERY

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

PLATE XI.

In 1844 Lawrence wrote:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

PLATE XII.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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