51°31′05″N 0°05′19″W / 51.518188°N 0.088611°W
Moorfields was an open space, partly in the City of London, lying adjacent to – and outside – its northern wall, near the eponymous Moorgate. It was known for its marshy conditions, the result of the defensive wall acting as a dam, impeding the flow of the River Walbrook and its tributaries.[1]
Moorfields gives its name to the Moorfields Eye Hospital which occupied a site on the former fields from 1822–1899, and is still based close by, in the St Luke's area of the London Borough of Islington.[2]
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Mr Gus Gazzard lecture "Case from Hell" at Moorfields International Glaucoma Symposiurm 2011
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Moorfields Train Station
Transcription
this is a case that hasn't had surgery and having heard from the previous speakers this may actually be a case from Purgatory rather then the case from Hell the other ones are definitely making me nervous let's talk it through it. It's quite a long history there's quite a lot has been going on and that's the reason that I chose this as an an instructive or as a teaching case is i think there are lots and lots of different issues particularly medical issues in the choice of medication and i know that within these forums that most people tend to choose from quite exciting surgical cases which don't necessarily apply to everyone here i don't know what the rates of tube surgery is in the audience but i know that not everyone does tube surgery but everyone here prescribes meds so... that's that's why i've chosen this one. And also because of that there's something in it for everyone, there's something in it for everyone to sit there and think "what would i have done differently" and don't worry about saying that because you won't offend me because a lot of the case occurred before i saw them uh... but also to just get our minds thinking and questioning about all the various complexities of complex medical cases. So this was a lady that when she first... came under the care of Moorfields uh... had already had a diagnosis of primary open angle glaucoma for a decade She'd been seen and managed elsewhere then moved By this stage she was already eighty And i know that some units really don't like surgical interventions in the extremes of life... And also people tend to start thinking "well, what is the life expectancy? how long are we going to keep them seeing for? maybe we can moderate or adjust our target pressures accordingly" and looking into the crystal ball and this is perhaps a salutary tale that we have to be careful She'd already had infective keratitis, she'd been described as having severe blepharitis, had her lenses out we had no idea what her maximal pressures are, and she had polymyalgia rheumatica. She was being managed on prostaglandine and and a not particularly effective beta blocker and she was taking a lot of steroids for her for her polymyalgia and she was bit depressed because she had to make some aches and pains of old age and she had pretty good fields. so we started off in pretty good base.... open angles normal HRC and vision's at 6:9. So she's 80, she's got full fields her vision's at 6:9 and her pressures are great so we're all very happy with that and think we can see her at a nice long follow-up interval and we're not worried. So what do you already thinking?? well you're probably thinking Did she have any systemic steroid effect? was there any contribution from her kind physicians who had been really quite heavily dosing her with oral steroids for her polymyalgia - she's a little frail thing - she's is about five foot five or she could be if she could stand up these days How robust is her original diagnosis, does she really need those steroids? Can she use the drops? Polymyalgia gives you a proximal limb weakness and ache, can she actually get the drops in, who's doing them for her? i think we have all heard about compliance this morning She's had a poor tear film, could we minimise her preservative load? Does an 80-year old really need any beta blockers? Her exercise tolerance is going to be limited, unfortunately, by her walking. What might we be doing with those beta blockers? And is this really glaucoma at all, if she's got full fields and healthy discs, what are we actually dealing with and has anyone actually thought about bone prophylaxis? because often these people get started on oral steroids by ophthalmologists - everyone diligently carries on prescribing them, and no one necessarily thinks about all the other prophylaxis so... We switched her onto a better beta blocker and her pressures were even lower. She still had a blepharitis and she still had a band keratopathy, and then she came back a few years later and her pressure was 37 She had a series of fields, she now has definitely got some visual field loss and we can now say yes she's getting worse, and in that period. whether this was non-compliance whether this was an escape from control she definitely had glaucoma. Then, under the hands of my predecessors, she had a Teracheolectomy because of the multiple treatment she was having she was poorly tolerating Partly she's got a poor optical surface, and she had surgery So, now she's had surgery and medicine in the other eye, and topical lubricants and good pressures. This was the year before last, and she's not doing too well. But now she's had a diagnosis of ATRAL fibrillation, Polyarteritis Nodosa, so part of the whole spectrum of collagen disorders She's developed an anxiety disorder This is her drug history. She's now on she has got some bone prophylaxis she's got some Cholecalciferol, some Calcium Carbonate, Warfarin, Alendronate weekly, Digoxin once a day, Diltiazem twice a day, Prednisolone once a day, Methotrexate Doxepin once a day, Folic Acid three days after the Methotrexate if she remembers, plus all her eye drops so i'm thinking about... What are you thinking about? well i would probably be thinking that's a hell of a drug regime We hope that she's got somebody to help her out with that even with a little dosset box to regularly dish her out the tablets at the right time of day, on the right day that's a hell of a thing to be coping with. And she's got to cope with her drops. i'm still thinking does she really need those beta blockers? because she's still got them and can't we do something about the ocular surface, because we're still poisoning her? Can she actually still take these drops? And yes, it was really glaucoma, or at least by the time we've now got this far it had become glaucoma. So she's now eighty-seven pretty unhappy she complained of ocular pain as well as pain everywhere else and she's got a blurred right eye. Visions dropped a bit I've managed to measure the corneal thicknesses, and she's now got pressures that are up in the right eye. her SHO gave her Diamox, which an 87-year old who's got multiple systemic pathologies -- I've scratched the surface of some of them -- was a brave thing to do. But he thought of that, so he gave her a low dose. She's got a pretty poor right cornea, and her discs are cupping out. so she may well be having poorer compliance in between visits anyway and she's obviously doing badly at the moment. We switched the Diamox to Iopidine, and I switched everything to preservative free. What else are you now thinking?? Drug interactions, Diamox; do we really want to be giving Diamox to her? Why we might not want to use Cosopt? we know that she's got pretty awful corneas. Why didn't we do a trab? Well, she's got polyarteritis nodosa, rheumatoid arthritis and an appalling ocular surface Just wondering about her antidepressants, just having a little think about the possibility of trachyphylaxis crossing the blood-brain barrier in our choices of alphaangulants I'm also thinking about lid hygiene, she's still got terrible blepharitis, and can't reach her lids to do any kind of lid hygiene although everyone's diligently written in the notes that's what we're doing Yes, she's still on beta blockers and an elderly woman. Her right eye is holding up pretty well, and then it crashes to counting fingers. She's now got, aged 87, a severe florid bilateral anterior uveitis, with cmo worse in the right eye and i'm told that these are not normal by my retinal colleagues appalling corneal surface disease she is very, very unhappy not least of which she's wheelchair-bound takes a long time to get into hospital and funnily enough she's coming back to see us and the uvitis service and the corneal guys quite frequently so she's got three different services managing what is the remainder of her, what? three years? five years? of life She's spending most of that time just in ophthalmology let alone the rest of it and she's now got a series of preservative-free drops, which GPs hate because it costs a fortune, but at least we can write to them and tell them they don't have a choice. The corneal team give her Hyloforte, which is for ocular surface, and Doxycycline, which hopefully is ringing some alarm bells somewhere in the audience. and she still unhappy So what else we thinking? Prizes for those people who wer worried about the Doxycycline because Doxycycline with the Warfarin anticoagulant is certainly one drug interaction that may well kill her. Most of what we've done so far isn't likely to kill her rapidly but the Doxycycline potentiates the action of Warfarin, and therefore may well push her RNR through the roof Then she may have a haemorrhagic stroke. There's a significant instance of with that sort of drug interaction. I've certainly seen a number of individuals come in with spontaneous supercorneal hemorrhages... two intelligible one intelligible injection required for people who have been given antibiotics that have potentiated Warfarin. and then develop an intractable secondary posterior segment mechanism angle closure glaucoma (because you wanted me to get angle closure in). So... that's the first thing. Then we stopped the Doxycycline so we didn't embarrass the corneal colleagues. Can we use systemic steroids? Why the uveitis? Well she's got an intermediate uveitis when you look a little more closely. Now she's got some controlled pressures on her medications. A new infection's coming along, so we reduce the corneal sensation, we give her Levofloxacin, preservative free this was not a case from the ivory towers because things still go wrong. She gets preserved medications the GP hadn't changed her records. She got preserved Levofloxacin because the pharmacist had that in stock, but not the unpreserved So what are we now thinking? Anyone want to do surgery? What about her compliance? I mentioned the fact that she's seeing three eye teams alone She's got multiple different scripts, repeat medications communication failures between the three eye teams the rheumatologist, the GP, and the psychologist. She's definitely getting anxious about all of this, and she's spending most of her remaining days in hospital. She comes back in She's now got a pressure in the originally unoperated eye of 36. Anyone want to operate? And she's fed up. so now she's on a series of preservative free drops her pressures back in control, we had a long sit down chat with with a little bit of help, some hand-holding, and a little bit of hand-holding with her long suffering carers. we've got her pressures under control So the preservative-free worked well, the preservative-free Prostogandene seemed to be a good thing in this case the laser trabeculoplasty - well, who knows. so it's a non-surgical case We managed to juggle and juggle and talk her and her carers into taking her drops. we finally for the time being get her under control we've managed to stop our corneal colleagues from killing her and the various messages are the old messages. that we always always always get and i think apply to all of us which is, compliance and I know Dave talked a lot about compliance but that's that such a big deal that we can't ignore it: protect the surface minimize the load if we can and then also just consider those drug interactions in the whole patient where we can they're all things we know and i think that at various different times in our practice they are things that we forget That was the reason for choosing her, and I hope that was some help.
Setting
Moorfields is first recorded in the late 12th century, though not by name, as a great fen. The fen was larger than the area subsequently known as Moorfields.
Moorfields was contiguous with Finsbury Fields, Bunhill Fields and other open spaces, and until its eventual loss in the 19th century, was the innermost part of a green wedge of land which stretched from the wall, to the open countryside which lay close by. Moorfields separated the western and eastern growth of London beyond the city wall – with the eastern extension being better known as the East End.
The fields were divided into four areas; the Little Moorfields, Moorfields proper, Middle Moorfields and Upper Moorfields.
Great Fen
The origins of Moorfields lie in a wider area, described by William Fitzstephen as the "great fen which washed against the northern wall of the City".[3] The marshy conditions appear to have been caused by London's Wall acting as a dam, restricting the flow of the river.[4]
The fen covered much of the Manor of Finsbury, but its exact extent is not clear. It has been suggested that it extended west from the Walbrook which fed it, extending to the vicinity of Old Street in the north, and the road from Cripplegate in the west. Other commentators have suggested that the topography of the area means the marsh probably didn’t extend as far west due to higher ground there, but did extend further north and possibly, in places, further east.[5]
Little Moorfields and Moorfields Proper
The Little Moorfields and Moorfields proper (also known as Lower Moorfields) were just north of London's wall, and from 1676 to 1815 included the Bethlem Hospital. Little Moorfields was the element that was left lying just west of Moorgate Street after a gap had been made in the wall to create the Moorgate, and the associated road from the north, in the 15th and 16th century. These parts were inside the City boundaries, lying in the Coleman Street Ward.
It is thought that this open space was not included within the City’s administrative boundaries until the 17th century, prior to that being part of the Manor of Finsbury.[6]
The Walbrook, known at this point as Deepditch and running on the line of modern Blomfield Street, seems to have formed the eastern boundary of Moorfields proper. It also formed an administrative boundary,[7] with Coleman Street Ward to the west (including the open spaces of Little Moorfields and Moorfields proper); while on the East End side lay the urbanised extra-mural ward of Bishopsgate Without, and also the parish of Shoreditch.
This section of the Walbrook, around Blomfield Street, was the focal point of the Walbrook Skulls; the result of the deposit of large numbers of decapitated Roman-era human skulls into the water.[8] These are still regularly uncovered during building work.
Middle and Upper Moorfields
Middle Moorfields and Upper Moorfields lay outside the City, to the north-west of Moorfields proper, in the Manor of Finsbury. The manor was coterminous with the parish of St Luke's (a late sub-division of the parish of St Giles-without-Cripplegate).[9]
Neighbouring areas
The Metropolitan Borough of Shoreditch (which replaced the parish of Shoreditch, being based on the same boundaries), had an electoral ward named Moorfields, this was adjacent to the former Moorfields (and also the famous Moorfields Eye Hospital) with only a small part of the area ever having been part of Moorfields, and only at an early date.
History
An early name for Moorfields proper appears to have been Moor Mead.[10] The Moor place-name element usually refers to fen environments,[11] and the wet nature of the area persisted, though this was improved by a drainage scheme in 1572.[12]
In the 15th century the monasteries of Charterhouse and St Bartholomews diverted the headwaters of the Walbrook to their sites in the River Fleet catchment. It has been suggested[13] that this caused a significant reduction in the flow of the river, causing Moorfields to become drier, and allowing the Mayor to construct the new Moorgate.
Moorgate was built by upgrading a postern built in 1415, and enlarged in 1472 and 1511. The gate remained poorly connected as there was no direct approach road from the south until 1846, long after the gate and wall were demolished.
After the Great Fire of London in 1666, refugees from the fire evacuated to Moorfields and set up temporary camps there. King Charles II of England encouraged the dispossessed to move on and leave London, but it is unknown how many newly impoverished and displaced persons instead settled in the Moorfields area.
In the early 18th century, Moorfields was the site of sporadic open-air markets, shows, and vendors/auctions. Additionally, the homes near and within Moorfields were places of the poor, and the area had a reputation for harbouring highwaymen, as well as brothels. James Dalton and Jack Sheppard both retreated to Moorfields when in hiding from the law. Parts of the area were known as public cruising areas for gay men.[14] A path in the Upper Moorfields, beside a wall that separated the Upper and Middle Moorfields, was known as Sodomites Walk: the wall was removed in 1752 but the path remains as the south side of Finsbury Square.[15]
In 1780 it was the site of some of the most violent rioting during the Gordon Riots.
The district was once the site of The Foundery, a former cannon foundry turned preaching house and an early centre of Wesleyan Methodism.[16]
A fashionable carpet manufactory was established here by Thomas Moore (c. 1700–1788) in the mid-eighteenth century. Moore's carpet manufactory at Moore Place made a number of fine carpets commissioned by the architect and interior designer, Robert Adam, for the grand rooms he designed for his wealthy clients. Thomas Moore lived at his home on Chiswell Street until his death. His Moore Park factory remained in operation until 1793, when his daughter, Jane, and her husband, Joseph Foskett, sold the lease to another carpet manufacturer.[17]
Demise and legacy
Much of Moorfields was developed in 1777, when Finsbury Square was developed; the remainder succumbed within the next few decades, notably when Moorfields proper was replaced by the modern Finsbury Circus in 1817.
Today the name survives in the names of Moorfields Eye Hospital (since moved to another site); St Mary Moorfields; Moorfields the short street (on which stands the headquarters of the British Red Cross) parallel with Moorgate (and containing some entrances to Moorgate station); and Moorfields Highwalk, one of the pedestrian "streets" at high level in the Barbican Estate. Moorfields Highwalk is featured in the music video to Robbie Williams' song "No Regrets".
References
- ^ On the wall eventually becoming an unintended? dam holding back the Walbrook https://www.british-history.ac.uk/rchme/london/vol3/pp10-18
- ^ History from the hospital's own web page https://www.moorfields.nhs.uk/content/our-history
- ^ Recorded by William Fitzstephen, writing in the 1170s, a discussion on the extent of the marsh is included in "Reclaiming the Marsh" by Pre-Construct Archaeology. This was authored by Johnathon Butler and others and sub-titled “Archaeological excavations at Moor House, City of London
- ^ On the wall eventually becoming an inadvertent? dam to hold back the walbrook https://www.british-history.ac.uk/rchme/london/vol3/pp10-18
- ^ Discussed in "Reclaiming the Marsh - Archaeological excavations at Moor House, City of London" by Pre-Construct Archaeology. The original suggestion had been made by Marjorie Honeybourne, with commentary and alternative views from the author of Chapter 5
- ^ The Ward did not extend beyond the wall at the time of John Stows survey of 1603 – but it did by the time of Ogilby and Morgans map of 1676
- ^ BHO source on the Moorfields area https://www.british-history.ac.uk/survey-london/vol8/pp88-90
- ^ London's Hadrianic War? Dominic Perring
- ^ Records of St Giles without Cripplegate, Chapter 6 see https://archive.org/stream/recordsstgilesc01dentgoog/recordsstgilesc01dentgoog_djvu.txt
- ^ Historical introduction: Moorfields. Vol. 8. London County Council, London. 2019 [1922]. pp. 88–90 – via British History Online.
{{cite book}}:|work=ignored (help) - ^ Concise Oxford Dictionary of Place Names, Eilert Ekwall, fourth edition. He doesn't refer to Moorfields, only the place name element.
- ^ The London Encyclopaedia, Weinreb and Hibbert
- ^ Stephen Myers, The River Walbrook and Roman London, 2016
- ^ Norton, Rictor (1992). Mother Clap's Molly House: The Gay Subculture in England 1700–1830. London: Gay Men's Press. pp. 71–90. ISBN 0854491880.
- ^ Norton, Rictor, ed. (22 April 2000). "The Trial of William Brown, 1726". Homosexuality in Eighteenth-Century England: A Sourcebook. Retrieved 25 July 2021.
- ^ "List of publications published or distributed at the Foundry". Copac. Retrieved 28 January 2010.
- ^ "The Moores. » 28 Apr 1866 » The Spectator Archive". The Spectator Archive. Retrieved 25 July 2021.
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