Chapter Vi. Poland Also Commenced a Series of Articles, Which Were

continued in subsequent parts, on “Protrusion of the Eyeball.” They contain a number of well recorded cases with interesting remarks, giving a vivid description of the treatment of inflammatory affection in pre-antiseptic days, by what was termed “antiphlogistic measures.” In the third volume of the Reports Poland contributed an article on “Medico-legal Observations in Connection with Lesions of the Eye.” Much has been written on this subject since, but little has been added, as regards matters in this country, which is not dealt with by Poland. He quotes Mr. Harry Bodkin Poland, barrister-at-law, no doubt a relative of his, as stating the legal position in the assessment of damages for accidents to be as follows:

“There is no fixed mode of assessing damages from accident. When it can be shown that a particular person is liable for causing an accident, etc., the jury decide as to the amount of damages to which the injured person is entitled, and neither the medical man nor the lawyer interferes, except to put before the jury the real nature of the injuries inflicted.”

The following precautionary remarks, which he wrote some seventy years ago, evidently as the outcome of his experiences at Moorfields, are so applicable to-day that they may well be quoted:

“The causes which may lead to the loss of an eye through carelessness and negligence ought well to be borne in mind by the thoughtless, so that should any person be employed in any of the following acts, he should pay due regard to the passers-by, or those standing near, and thus obviate any necessity for rendering himself liable for the damages committed.

“The carrying or whirling about of sticks, umbrellas, guns, etc., in the public thoroughfares, the slashing about of whips, the careless use of the line and rod in fishing, the letting off of fireworks, the shooting of arrows, the throwing of missiles such as stones, lime, etc.; the chipping of wood, stone, and metals in the public highways, without adequate protection; the playing at tip-cat; the uncorking of effervescing draughts; the explosion of chemicals and gunpowder; and numerous other acts each and all of which have caused the loss of an eye or of both, and have been the means of litigation.”

In 1861 Alfred Poland was elected surgeon to Guy’s Hospital with charge of the large ophthalmic department, and, in accepting the appointment, was required by the Governors of Guy’s to resign his post of surgeon at Moorfields, which he did most reluctantly. Many competent observers described him as the best operator on the eye they had ever seen. He was a spare, thin man, and made remarkable recoveries from several severe illnesses, but died ultimately of consumption at the age of fifty-two. The following account of some of his other characteristics have been recorded by one of his colleagues at Guy’s:

“Poland had a remarkable power of gathering together detailed knowledge, including dry facts and figures, so that his essays are complete treaties on the subjects in hand, and are of permanent value.

“It was said with great truth that if Poland had been shut in a room containing not a single book, but with only pens and paper, he could have written a complete work on surgery, not in a vague way, giving merely general descriptions and treatment, but in a systematic manner, detailing the distinct forms and varieties of the disease then in his mind.

“He was utterly careless as to his personal appearance. He would leave the dissecting room without changing his coat, and it was often the subject of surmise whether he washed his hands.

“On his appointment to the surgeoncy at Guy’s, the Treasurer had no hesitation in telling him he would have to dress himself more decently and cleanly. It is not, therefore, surprising that Poland never had any practice to speak of. There was nothing in his manner to give confidence, but he was a great favourite with students.

“His marriage a few years before his death was a misalliance, and added much to his misfortunes.”

One of the most conspicuous features of the Reports since their commencement has been the contributions made to them by the several occupants in succession of the post of curator of the Museum, beginning with Charles Bader. This post has afforded the holders of it a most valuable field for pathological research, as all the eyes removed by the members of the staff are entrusted to the curator for his investigation, and often also a large number of specimens from elsewhere. The articles written by the several curators contain most of the valuable original work which has been done in this country on the subject.

In the fourth part of the journal, published in July, 1858, Jonathan Hutchinson, who was then working as a clinical assistant at the Hospital, commenced his ever memorable series of articles “On the Different Forms of Inflammation of the Eye consequent on Inherited Syphilis.” In these articles he first definitely established the connection of interstitial keratitis with inherited syphilis, and showed its frequent connection with certain characteristics of the complexion and physiognomy, and with peculiarities in the formation of the permanent teeth. Which latter are now universally known as “Hutchinson’s teeth.”

PLATE XVI.

Jonathan Hutchinson was born in Yorkshire in 1828, of Quaker ancestors. For four years he studied at the York School of Medicine, and then came to London, when he attended at St. Bartholomew’s Hospital. He there came under the influence of Sir William Lawrence, to whom he dedicated his book entitled Diseases of the Eye and Ear consequent on Inherited Syphilis, published in 1863, consisting mainly of his reprinted articles in the Ophthalmic Hospital Reports.

It has already been mentioned in Chapter III. how much Lawrence did to increase the knowledge of venereal diseases of the eye by the careful collection and collation of notes of cases at the Ophthalmic Hospital. It was by the same careful collection and collation that Hutchinson was able to establish the connection of certain inflammatory eye affections with inherited syphilis, and he likewise found the most fruitful field for his investigations in the out-patient department at Moorfields. He was a most patient and elaborate note-taker and, in apologising for the lengthy notes of some or his published cases, remarked:

“I must plead that they are the stones out of which the edifice is to be built, and that unless care be devoted to their preparation in the first instance, it will be useless to expend it on the subsequent elaboration.”

Jonathan Hutchinson was a man intensely interested in the study of the natural history of disease in all its manifestations, and it may be added not only in the natural history of the disease, but of natural history generally. He was a great collector of facts, and had a remarkable flair for grouping them so as to draw new and unsuspected inferences.

He was not inaptly described as “the greatest general practitioner in Europe,” and also as “the universal specialist.” He was appointed assistant-surgeon to the London Hospital in 1859 and full surgeon in 1862; he was also surgeon at the Blackfriars Skin Hospital.

He attracted around him a large number of able assistants of whose devoted services he was able to make very material use. His biographer writes:

“His teaching was made impressive by ingenious arguments, apt illustrations, vivid metaphors, and quaint expressions, and was driven home by the simplicity and solemnity with which they were delivered.”

On the retirement of Alfred Poland from the staff in 1861, it was decided that the surgical staff should be increased to eight in number by the appointment of two new assistant-surgeons. George Lawson and Jonathan Hutchinson were the only two candidates who came forward, and were both elected. Lawson, receiving a few more votes than Hutchinson, was appointed the senior of the two.

George Lawson, like Hulke, received his medical education at King’s College Hospital. There was a remarkable parallelism between the careers of these two men. Both served as house surgeons under Sir William Ferguson. Both served as surgeons at the Crimea. Both became assistants to Bowman, and inspired by him combined ophthalmic surgery with general surgery. Both became general surgeons at the Middlesex Hospital, and ophthalmic surgeons at Moorfields.

Though their careers were so similar, temperamentally they were very different. Hulke was an austere, conscientious disciplinarian, who seemed to have had no youth. Lawson, on the other hand, was full of kindly sympathy for the weaknesses of mankind, and never seemed to grow old. This difference was no doubt to some extent attributable, as Lawson himself suggested, to Hulke having had no children, whilst Lawson had a large family of boys.

Hulke earned for himself the greater scientific reputation, but Lawson had by far the larger private practice. Hulke’s articles in the early numbers of the Reports were numerous, some of them clinical records, but many of them dealing with histological and pathological investigations. Lawson’s contributions were also numerous, and dealt mostly with injuries of the eye and sympathetic ophthalmitis. In 1867 he published his collected experience on these matters in a book entitled Injuries of the Eye, Orbit, and Eyelids. His attention had doubtless been specially attracted to such injuries during his service with the Army in connection with the Crimean War. Early in 1854, when war was threatening, Lawson joined the Army as an assistant-surgeon, and went in March of that year with the first batch of troops to Malta. He landed with the first troops in the Crimea, and was present at the battles of Alma and Inkerman. He was invalided home in July, 1855, with typhus fever, which he contracted from some mule drivers whom he was attending, and which left his circulation permanently impaired.

In Part III. of the Reports, Streatfield gave a description of his operation of grooving the fibro-cartilage of the eyelid in cases where its margin or the eyelashes turned inwards: an operation which is still frequently performed as originally described, or in a modified form.

In the last part of the first volume, which appeared in January, 1859, Dixon recorded a case in which he successfully removed a chip of steel from the vitreous chamber by grasping it with a pair of forceps. The case is of particular interest because it seems to have been the first in which an attempt to remove a foreign body from the interior of the eyeball with a powerful magnet was made, a line of practice which has since reached a high degree of usefulness. In Dixon’s case, the effect of the magnet was only to drag the chip of steel into a less desirable position, so that a pair of forceps had to be used in order to effect its removal.

Amongst the numerous interesting articles in the second volume of the Reports are some short contributions from the celebrated Glasgow ophthalmic surgeon, William Mackenzie, then in his fifty-ninth year, whose masterly Practical Treatise on the Diseases of the Eye had obtained world-wide reputation. After serving his apprenticeship and passing his qualifying examination in Glasgow, he visited the medical schools of Paris, Pavia, and Vienna; at the latter he studied ophthalmology under Professor Beer. In 1818 he settled for a time in practice in London, in Newman Street, Oxford Street, and delivered a systematic course of lectures on “Diseases and Operative Surgery of the Eye.” Though we have no definite record of his attendance at the Eye Infirmary, then in Charterhouse Square, there can be little doubt that his keen interest in ophthalmology must have taken him there. In 1820 he returned to Glasgow to fill the Anatomical Chair in the Andersonian University, and in 1824 he established the Glasgow Eye Infirmary. One of his articles in the Reports deals with glaucoma, and he was the first to point out its connection with the increased tension of the eye—an increase of tension which he endeavoured to relieve by paracentesis of the eye through the sclerotic or cornea.

To those familiar with the operation for removal of cataract, the fixing of the eyeball whilst making the incision, by grasping the conjunctiva with a pair of toothed forceps, seems such an obvious procedure that it is surprising that it should not have always been employed. We find, however, in the second volume of the Reports, an article by France advocating such fixation as a new departure. France was surgeon in charge of the ophthalmic department at Guy’s Hospital. When Saunders first established a special institution for the treatment of eye diseases, and for many years afterwards, there were no such special departments at any of the London general hospitals. Guy’s Hospital was the first of the general hospitals to establish an ophthalmic department, and by 1858 similar departments had been started at University College Hospital under Wharton Jones, and at St. Mary’s Hospital under White Cooper. These two latter surgeons also contributed articles to the Ophthalmic Hospital Reports, which in its early days was not restricted to work carried on at Moorfields.

With the second volume of the journal the use of paper of a slightly yellow tint, instead of white, was commenced. Streatfield, the editor, explained that Charles Babbage, the mathematician, in printing his logarithmic tables, had experimented with specimens set up on paper of various shades and colours, and found that almost all those whom he consulted agreed with him in giving preference to the coloured papers. The particular tint, however, was not so unanimously fixed upon, though yellow appeared to have the preference. Several editions of Babbage’s Tables of Logarithms were printed on the yellow and the white paper; the former were always in most demand. This slightly yellow tinted paper was apparently approved of by the contributors and readers of the journal, as it continued in use for several years.

In this same volume there commenced a series of articles on “Paralytic Affections of the Muscles of the Eye,” by John Soelberg Wells, who in 1860 became one of Bowman’s clinical assistants.

Soelberg Wells was a tall, handsome man, of splendid physique, and possessed of ample private means. He graduated in medicine at Edinburgh University in 1856, but much of his education and training, general and professional, was conducted by German teachers, for he was partly German by extraction. For two years previous to his commencing work at Moorfields he studied under Graefe in Berlin, and was for a time one of his assistants. In his lectures and in his clinique Graefe devoted much time and patience to teaching the diagnosis of paralytic affections of the eye muscles, and Wells’ articles on the subject dealt with the rules he had learnt from Graefe, to the great accuracy and value of which he was able to testify.

In the third volume of the Reports commenced the publication of a “Periscope” of foreign ophthalmological literature; in this production Soelberg Wells’ knowledge of German and of the Continental cliniques was of great service, and he translated for the use of English readers articles by Müller, Donders, and Graefe. By such means international scientific intimacy, which is so eminently desirable, was stimulated and promoted.

After the issue of the thirteenth number of the Reports, Streatfield resigned his editorship, and in April, 1861, what was termed a New Series was commenced, with the following prefatory remarks:

“The first number was issued October, 1857, and the publication, though not strictly quarterly, has subsequently appeared with regularity sufficient to complete two volumes.

“The later numbers, however, have assumed a very different appearance to those which were at first submitted to the profession, and it has therefore been deemed necessary to remodel the journal: at the same time, as it is the only periodical in England specially devoted to ophthalmic medicine and surgery, it is thought desirable to extend its limits, by admitting reviews and periscopes, and thus to make it more generally useful.

“It will be edited by members of the staff, and appear under the title Ophthalmic Hospital Reports, and Journal of Ophthalmic Medicine and Surgery.”

Apparently very heavy expenses had been incurred in former numbers for engravings and coloured lithographs, which made a change of management desirable, for it was noted:

“In future the amount of illustration will much depend on the support of the professional public, the medical officers of the Royal London Ophthalmic Hospital having led the way by devoting their fees, received from pupils, to the interests of the journal.”

The art of perimetry or of taking the field of vision, which has now reached such a high degree of accuracy and importance, seems to have originated with von Graefe in 1856, and to have been first employed at Moorfields by Hulke in 1859. In the third volume of the Reports he described some cases, as he says, “to illustrate some forms of limitation of the field of vision.”

Hulke’s method of procedure was similar to Graefe’s. He placed the patient before a large blackboard at a distance of 8 inches, covered one of his eyes, and made him fix a chalked dot in the centre of the board, on a level with his eyes, with the other. He then moved a white object over the board in various directions from its margins towards the centre and marked the places where it was first seen. A line connecting these marks gave the outline of the field of vision.

The obvious defect of using a flat surface, like a blackboard, was that the various parts of the retina were not situated at an equal distance from it. To Forster belongs the credit of having introduced an instrument in which the field was projected on a hollow sphere. His perimeter consisted of a metallic semicircle capable of rotation in various meridians, and on this general principle all other models since produced have been constructed. Forster’s perimeter first came into use at Moorfields in 1870.

The rapid development of surgical procedures in ophthalmology eclipsed for a time at Moorfields the medical side. Dr. Robert Martin, who held the post of physician from 1856 to 1884, made but little use of the opportunities it afforded him. He did not have patients allotted to him or any fixed time of attendance, like his predecessor. In 1867 he suffered from a severe illness which seemed to threaten his mind, and necessitated his temporary retirement from work; he, however, completely recovered, and no one was appointed in his place at Moorfields during his absence.

The discovery of the ophthalmoscope opened up a new field for medical investigation, which was fully taken advantage of by that distinguished neurologist, Dr. Hughlings Jackson, who at the commencement of his career worked at Moorfields, first with Poland and afterwards with Jonathan Hutchinson. In a Presidential Address which he delivered at the Ophthalmological Society in 1889, he remarked:

“It was the luckiest thing in my early life that I began the scientific study of my profession at an Ophthalmic Hospital. Many years ago I had the good fortune to be Mr. Hutchinson’s clinical assistant at Moorfields. I suppose it is to his example and teaching that I owe the beginning of the little scientific development I may have. At an Ophthalmic Hospital one has the opportunity of being well disciplined in exact observation. When a physician sees how carefully and precisely ophthalmic surgeons investigate the simplest case of ocular paralysis, he is getting a lesson in exactness, and will be less likely in his own department of practice to deal in such generalities as that a patient’s fit ‘had all the characters of an ordinary epileptic fit,’ and more likely to take pains to describe the convulsion, the place of onset, the march and the range of the spasm.”

Dr. Hughlings Jackson contributed many most valuable papers to the Reports dealing with ophthalmoscopic findings in connection with brain disease. He wrote, as he said in one of them, “as a physician and not as an ophthalmologist,” having studied ophthalmic medicine merely as a help to the study of diseases of the nervous system. And, again, in another article he remarked:

“The physician is quite as much indebted to Helmholtz as the ophthalmologist. Defects of sight of all kinds occur so often in affections of the nervous system that it is not too much to say that to the student of these diseases a knowledge of amaurosis, both in the widest and loosest, and in the narrowest and most precise use of the word, is of more importance than a knowledge of any other class of symptoms.”

He was never tired of impressing on physicians the value of the routine use of the ophthalmoscope. Thus he wrote in 1889:

“I urge young physicians to study eye diseases at an Ophthalmic Hospital or at an ophthalmic department of a General Hospital; this nowadays needs no urging on physicians especially interested in neurology.”

In 1863 Dr. Argyll Robertson contributed a paper from Edinburgh to the Reports, “On the Effects of Calabar Bean on the Eye,” in which he stated that the miotic action of this drug had been first discovered by Dr. Thomas R. Fraser. Besides describing its effects on the normal eye, he enumerates several affections in which he had found its use beneficial, but makes no mention of glaucoma. It was apparently not until 1876 that it became employed for the reduction of increased intraocular tension, Adolph Weber and Laquer describing its use for this purpose about the same time.