Edward Holmes: A Story of Humanitarianism

By Katelyn Meehan, 4-25-11 by Rush University Medical Center

Being a student in library and information science at Dominican University and coming to the Rush Archives for an internship, it was difficult for me to understand the complex history of Rush University Medical Center and how it has evolved into the institution it is today. In the archives, I was exposed firsthand to the people who were involved in the development of Rush, and the material they created during the process. Having all this exciting knowledge at my fingertips was an amazing experience. But when faced with a mountain of information, how could I uncover just one piece of Rush’s history?

By processing a collection of someone from Rush, I found my answer. I was assigned the task of processing the small collection of Rush Medical College president, instructor and ophthalmologist Edward L. Holmes, 1828-1900. I was presented with a box that contained seemingly random papers, instructions on what to do with the papers, and a note pad to write down my observations about the collection as I examined it.

Rush’s assistant archivist, Nathalie Wheaton, recently told me, “Everyone has a story; you just have to find it.” The story behind Edward Holmes was his humanitarianism.

While Holmes was a medical pioneer and an educator, I think his greatest impact was his humanitarian efforts. One example of his great work was his founding of the Central Free Dispensary, which was located at Rush. In his own notes from 1899, Holmes described the Central Free Dispensary as an institution that “was organized in 1867 for the gratuitous treatment of the sick poor and for no other purpose.” Holmes was concerned with providing medical care to those people who needed it regardless if they could pay for it or not. The Central Free Dispensary raised awareness about public health and evolved to become the outpatient service for Presbyterian Hospital in the 1940s and the Presbyterian-St. Luke’s Health Center in 1961.

Another of Holmes’s great humanitarian efforts was the founding of the Chicago Charitable Eye and Ear Infirmary in 1858. Again, Holmes gathered the help of other physicians, including the founder of Rush Medical College, Daniel Brainard, to help establish the infirmary and attempt to meet the needs of the citizens of Chicago. The infirmary provided treatment for patients, mainly poor children, with ear and eye problems. Without the service of the infirmary, many of the children would have been left blind for life. Over the years, the infirmary was taken over by the state of Illinois, becoming the Illinois Charitable Eye and Ear Clinic, and treated an increasing number of patients, including members of the military. After an affiliation with the College of Physicians and Surgeons, in 1943 the Illinois Eye and Ear Infirmary joined with the University of Illinois at Chicago.

Holmes showed a drive and determination in providing care to patients who needed it. He overcame a lack of staff, a lack of funds, obsolete facilities and equipment, administrative indifference and political obstruction to make a difference in the world. One of the most exciting things that I learned through this discovery of a piece of Rush’s history was that the humanitarian efforts Holmes made in the 1850s are still making a difference today in 2011.

Katelyn Meehan is pursuing a Master of Information and Library Science degree through Dominican University’s Graduate School of Information and Library Science. She recently ended her semester-long practicum at Rush University Medical Center Archives.

Image: Edward L. Holmes, portrait by Frederick W. Freer, 1894

From: rushinperson.rush.edu

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The Illinois Eye and Ear Infirmary

By Samantha L. Williamson, MD, University of Illinois, Chicago, Illinois

The direct ophthalmoscope debuted in Germany in 1851, ushering in the modern era of ophthalmology. Seven years later, the introduction of the laryngoscope allowed direct visualization of the airway. In 1858, on the heel of these discoveries, Edward Holmes, a Massachusetts native who had trained in Vienna and Berlin, opened the doors of the Chicago Charitable Eye and Ear Infirmary. Dedicated to serving the burgeoning, underserved population in the city, the institution represented one of the first in America focused on the disciplines of ophthalmology and otolaryngology. The Illinois Eye and Ear Infirmary (IEEI), as it is now known, has been a clinical and research leader for over 150 years.

Initially operated as a philanthropic organization out of a single room on Clark Street, the Infirmary expanded significantly during and after the Civil War by meeting the needs of veterans from Illinois and bordering states. Buoyed by state and federal subsidies, Holmes moved the institution to larger quarters, only to have them destroyed in the Great Fire of 1871.1 As the opening of Rush Medical College and Cook County Hospital established the Illinois Medical District, the Infirmary settled nearby at the corner of Peoria and Adams.2 The rebuilt facility boarded 100 patients, housed several operating rooms, and, notable for its time, provided equipment for one of the first eye pathology laboratories in the country. In the 1880s, the Infirmary assumed the critical role of medical education, training both students of the newly-opened College of Physicians and Surgeons, the precursor of today’s medical school at the University of Illinois, and its own residents.2 Twenty-two surgeons saw nearly 1200 patients in 1874. By 1900, the staff at the Infirmary treated over 15,000 patients per year.1

In the early twentieth century, trachoma, an infectious and potentially blinding conjunctivitis caused by Chlamydia trachomatis, was endemic throughout the state of Illinois. E.V.L Brown, a University of Illinois physician, mapped the incidence in each county near the turn of the century, and founded the first trachoma clinic in the state in Mt. Vernon in 1920.3 Owing to a large patient burden, the Departments of Public Welfare and Public Health and the Illinois Society for the Prevention of Blindness  provided resources to establish five more centers for the treating “indigent victims of trachoma in Southern Illinois.”1 Harry Gradle, the Director of the Infirmary, sent IEEI physicians to staff these clinics, held in libraries, Elks clubs, and courthouses.3 Over 3,500 cases of trachoma were diagnosed at the clinics, and thousands more evaluated.1 The clinics closed in 1965 after the epidemic was eradicated, and represent a historic and successful partnership between the Eye and Ear Infirmary and state government.

The fields of ophthalmology and otolaryngology grew along with the Infirmary. The disciplines established individual research and educational programs in the 1930s, and started some of the first sub-specialty clinics in the country, including those dedicated to glaucoma, uveitis, beta irradiation, and ocular motility.  By 1940, the Infirmary was treating up to 100,000 patients a year, including five thousand inpatients.1 Indeed, Ophthalmology dominated the College of Medicine after formally becoming part of the University of Illinois in 1943. The department recorded 70,000 yearly outpatient visits that year, and all other branches of medicine and surgery combined to total 133,000.1

In addition to providing clinical care and medical education, the physicians at the Eye and Ear Infirmary have a long history as leaders in research. Frank Waxham introduced the concept of intubation in the 1880s as an alternative to tracheotomy.4  In the first half of the twentieth century, Peter Kronfeld carried out early work on aqueous fluid, and H. Saul Sugar published a seminal study on various types of glaucoma.1 Henry Mundt Jr. and William Hughes published the first study describing the use of ultrasound to visualize posterior structures of the eye, and Joseph Brubaker and Paul Holinger created a revolutionary endoscopic camera.4  Francis Lederer, a chair in otolaryngology, served in the U.S. Navy during World War II, and the hearing loss suffered by many veterans inspired him to establish the Speech and Hearing center at the University of Illinois.4 He won a Navy Commendation for his audiologic rehabilitation efforts for these patients. Gholam Peyman, a visionary ophthalmologist with nearly 150 U.S. patents, made early contributions to LASIK, the vitrophage, and intraocular drug delivery.

Over 150 years after opening its doors, the Infirmary remains committed to superlative care and to training a future generation of eye and ear specialists.  During its history, it has made the transition from a small charitable project supported by local philanthropists to an international center of clinical and academic excellence that receives millions of dollars in research funding from the National Institutes of Health. And it continues to fulfill Edward Holmes’ mission to treat all in need, in their own community, and beyond.

References
Patricia Spain Ward, Ophthalmology at Illinois (Chicago: The University of Illinois at Chicago, 1985).
Stanley Burns, Ophthalmology: A Photographic History 1845-1945, Pioneers & Educators (Burns Archive Press, 2009).
Illinois Department of Welfare, Welfare Bulletin, 1920. 11-12: p. 43-5.
Illinois Eye and Ear Infirmary 1858-2008: A History of Dedication to the Future. (Chicago: The University of Illinois at Chicago, 2008).

SAMANTHA WILLIAMSON, MD is a practicing ophthalmologist. She was raised in Baltimore, Maryland and attended Johns Hopkins for medical school. She completed residency at Vanderbilt University, followed by a fellowship in Cornea and External Disease at Illinois Eye and Ear Infirmary, where she was introduced to its rich history.

From: hektoeninternational.org

Image: Antique Medical 1800s Doctors Liebreich Ophthalmoscope Instrument Set

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Civil War Era Photographs: Retinal Tissue

From: museumofvision.org

One of the least generally known uses of early medical photography was the work of New York surgeon Reed Brockway Bontecou, who photographed wounded Civil War soldiers between 1864 and 1865. He provides the earliest records of wounded and healed-state conditions of ocular injuries. Bontecou’s images are significant documents of pre-antiseptic era infection states and many of his cases were reproduced as engravings by the Surgeon General’s Office.

Photographs of retinal tissue, both gross and microscopic views, were important research tools used to identify retinal cell components and disease states. Budding ophthalmologists William Thompson and William Norris worked during the Civil War to create some of the highest magnification views of the retina.  However, photomicroscopic views of the retina did not begin to appear in medical journals until the mid 1880s. Here we see an illustration of the photomicrography apparatus as published in the “Catalogue of the Medical Section of the U.S. Army Medical Museum” in 1867.

In the mid 1860s gross pathological views of the retina played a surprising role in medico-legal medicine. Some criminologists believed the retina functioned exactly like film and that at death, a permanent image was formed on the retina that was the last scene observed by the deceased. Thus a murderer could be identified by his image on the retina of a murder victim. In 1868, photographs of the retina called ‘optograms’ were taken and published to disprove the idea.  Despite its implausibility the idea lives on in folk tales and some murderers destroy the eyes of their victims so as not to be identified.

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The Overlooked Prosthesis: The Use of the Artificial Eye and Orbital Reconstruction during the Civil War

By Salvatore Parascandola

When presented with the notion of Civil War medicine, the minds of most individuals will conjure images of the tireless battlefield surgeon, hurriedly moving between dozens of wounded young men, with neither enough time nor scientific understanding to clean himself or instruments of the blood from his previous patient. While it is argued that the surgeons of the Civil War do not necessarily deserve the reputation of “butchers” that society has seemed to bestow upon them, their lack surgical experience combined with utterly traumatic wounds and the sheer magnitude of patients did cause these physicians to turn to amputation as the primary means of treating wartime injuries. During the course of the war, 70% of the gunshot wounds would be on the extremities, leading to over 60,000 amputations between 1861 and 1865. This never before seen proliferation of amputees would drive the production of prosthetic limbs and eventually lead to the manifestation of the prosthesis industry in America. While much historical literature focuses on the sectors of this industry concerning prosthetic limbs, one aspect of Civil War prosthetics often overlooked is the use of the artificial eye. This however, is unsurprising, as only 49 prosthetic eyes were furnished to soldiers between July 16, 1862 and May 4, 1867, compared to 2,391 arms and 4,095 legs. However, despite the small proportion of prosthetic eyes that were issued to wounded soldiers relative to limbs, the methods of reconstructive and prosthetic work done with regard to orbital injuries during the Civil War were nonetheless monumental and are still reflected in modern ophthalmology.

In the 16th century, French surgeon Ambrose Paré was the first to describe the use of artificial eyes. His descriptions included pieces made to fit in the eye socket, made of silver and gold. Two types of ocular prosthesis he described were ekblphara, worn in front of the eye lids, and hypoblephara, worn under the eyelids. Because enucleation would not become a common ophthalmic procedure until the 19th century, the hypoblephara was typically used over the dysfunctional eye. During this time enamel prostheses were also used. However, despite being aesthetically pleasing, they were not very durable and very expensive. Consequently, German craftsmen in the 1830s developed a prosthetic eye made of cryolite glass that was of a greyish-white color, similar in color to a healthy eye. In Germany and France, the class art technique would soon bloom and these German craftsmen would eventually be coined “ocularists”. These artisans soon toured, among other parts of the world, American cities to fit and fabricate eyes upon request to patients in need of ocular prosthesis. In the United States, it was not uncommon for the newly termed “eye-doctor” to keep drawers full of hundreds of premade eyes, ready to be fit to their patients.

Upon the dawning of the American Civil War, eye hospitals and formal ophthalmic societies in the United States were only beginning to form. Consequently, very few physicians who served during the war had any formal training in ophthalmology. Before 1860, the enucleation procedure was paired with a very high mortality rate and was not yet perfected. Those who did have formal training were typically practicing in major cities or were operating away from the field hospitals, far from where their expertise was desperately needed. During battle, the eyes of soldiers were exceptionally vulnerable to shrapnel, debris, and injury from small arms fire. Also, because of the explosiveness of the Minié ball, those soldiers struck in eyeball by small arms fire nearly always experienced eyelid, orbit, and other secondary facial injuries.

Though specialized ophthalmic treatments existed, such as cataract removal, irodotomy, compression, and mercury ointments, poor equipment and a lack of ophthalmologic knowledge made it extremely rare for a soldier to be given such treatment. Instead, enucleation would become the most common ophthalmic surgical procedure for injuries to the globe or orbit. Physicians believed that even if the eye did heal correctly, it would eventually deteriorate and the other eye would be exposed the damaged eye’s pathology, thus inclining many physicians to enucleate. Of the 1,190 soldiers reported with isolated eye injuries, the loss of one eye characterized two-thirds of these cases. However, despite the large proportion of enucleation, only 5% of the soldiers with eye injuries lost sight in both eyes or died from their wounds, a statistic that brings great credit to the wartime physicians, especially considering the conditions under which they served and the lack of formal training.

Because of the disparity between limb injuries and eye injuries, the refinement of ocular prosthetics and surgery progressed at a much slower rate than that for amputees. The frequency of eye injuries was so much less than injury to the extremities that need to restore mobility in these veterans vastly overshadowed the need to repair a damaged eye or orbit. Many soldiers would simply wear patches overtheir damaged eye for several reasons. Patches were much more inexpensive than ocular prosthesis, there was a scarcity of glass eyes, and for some, their patch served as a badge of honor, a symbol of their service and sacrifice. Additionally, the destruction of the orbit was often so extensive that it was either inadvisable or impossible to find an artificial eye that would fit properly.

While evolution of ocularistry was slow, some reconstructions did occur which would mark the beginnings of eye and orbital plastic and reconstructive surgeries. For those who underwent orbit reconstruction, materials such as glass, gold, wool, silver, rubber, bone, or aluminum were used. In addition to the French and German-made lead or glass prosthesis, charred human bone was a particularly favorite implant material. Because the bone was charred, the fire had sterilized the material. Additionally, the canals within the bone allowed for the growth of living tissue into the implant, eliminated air pockets and the reducing the possibility of bacterial infiltration. Such materials were used until the 1930s when they were replaced by such materials as sterilized coral and such synthetic materials as plastic and aluminum.

An often overlooked topic within Civil War medicine, the use of ocular prosthesis and orbital reconstruction is nonetheless an area of considerable importance with its regard to its connection to modern day patient care. The topic also brings necessary undue credit to the battlefield physicians who labored under unimaginable conditions and possessed little knowledge of the field of ophthalmology yet were still able to prevent significant mortality among their patients with eye injuries. Current methods of reconstruction and prostheses use can trace its beginnings to the heroics and innovation of these physicians. The Civil War would prove to be a pivotal time in American medicine, and the field of ophthalmology would be no exception.

From: gucivilwarmed.blogspot.com

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Simon Pollak and Ophthalmology in St. Louis During the Civil War

By Stephen Logson
March 8, 2012

On Thursday, April 12th at 4:30 pm ]2012], the Bernard Becker Medical Library in collaboration with the Center for the History of Medicine presented the 24th Historia Medica Lecture.

The presentation, "Simon Pollak and Ophthalmology in St. Louis During the Civil War," will be given by Dr. Robert Feibel, Professor of Clinical Opthalmology and Visual Sciences.

Simon Pollak (1814-1903) was a prominent physician in St. Louis who was the first in the city to specialize in ophthalmology. He played a key role in advancing education for the blind and visually impaired as one of the founders of the Missouri School for the Blind and was the first to introduce the Braille system of reading for the blind in the United States. He served energetically on the side of the Union in the Civil War, and established and conducted the first ophthalmology clinic in the city hospital of St. Louis. He championed the role of women physicians in organized medicine, and was able with considerable difficulty to obtain membership for one, Dr. Mary McLean, to the St. Louis Medical Society. Dr. McLean was the Society’s first female member.

The presentation took place in the King Center on the seventh floor of the Becker Library at the Washington University School of Medicine at 660 S. Euclid Ave., St. Louis.

From: becker.wustl.edu

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Prevalence of Major Eye Diseases Among US Civil War Veterans, 1890–1910

From: National Institutes of Health
By: Frank A. Sloan, PhD, Daniel W. Belsky, BA, and Idrissa A. Boly, MA

ABSTRACT
Objectives:
To estimate the prevalence of major eye diseases and low vision or blindness in a national sample of male US Union Army veterans from 1890 to 1910 and to compare these prevalence rates with contemporary rates for the same diseases and visual status.

Design:
Longitudinal histories of 16 022 white Union Army veterans receiving disability pensions from 1890 to 1910 were developed from pension board examination records. Prevalence rates of trachoma, corneal opacities, cataract, diseases of the retina and optic nerve, and low vision or blindness were calculated in 1895 and 1910. Changes in prevalence by age were examined.

Results:
By 1910, 11.9% of veterans had low vision or were blind in both eyes. Prevalence of cataract increased with age, resulting in 13.1% of veterans having had cataract in one or both eyes. Rates of trachoma were 3.2% in 1895 and 4.8% in 1910. Rates of corneal opacity were 3.0% and 5.1%, respectively. Glaucoma was rarely diagnosed from 1890 to 1910, but diseases of the optic nerve were reported in 2.0% of veterans in 1895 and 3.6% in 1910.

Conclusions:
This study documents substantial reductions in the prevalence of low vision or blindness and changes in the composition of eye diseases from an era in which there were few effective therapies for eye diseases to the present.

The 20th century experienced great changes in the treatment of major eye diseases. However, longevity also increased substantially. The US population aged older than 65 years increased from 4.1% in 1900 to 12.4% in 2000,1 and eye disease prevalence often increases with age. Thus, though innovations in treatment should have decreased prevalence, increases in population age may have, at least in part, offset these decreases. Nationally representative historical data documenting trends in prevalence of major eye diseases and low vision and blindness across several decades have been lacking.

Recently, data from a federal program that began in 1862 and paid pensions to Union Army veterans of the US Civil War (1861–1865) became available in machine-readable form. To obtain a pension, veterans had to be examined by a 3-physician panel, which determined whether their illnesses or injuries qualified for compensation. Prior to 1890, only service-connected disabilities were compensated. In 1890, the program was amended to include compensation for non–service-related conditions, which led to a major increase in veterans having examinations to obtain pensions. In 1907, the program was further amended to include old age as an eligibility criterion. Although old age was not recognized by statute as a basis for receiving a pension until 1907, a minimum pension was granted to all those aged 65 years or older from 1890 to 1907, unless the veteran was unusually vigorous.2

This was the first major national pension program in the United States to which a large portion of federal expenditures was allocated in the late 19th century.3 The program covered 85% of Union Army veterans who were alive in 1900 and more than 90% of veterans who were alive in 1910.4,5 Only Union Army veterans were eligible.

METHODS.
The data were produced by the Center for Population Economics at the University of Chicago. A 1-stage cluster sample of 331 Union Army companies was randomly selected by the Center for Population Economics from more than 20 000 company records stored at the National Archives in Washington, DC. These companies yielded a sample of 39 616 veterans. The following 3 public data files were used: surgeons’ certificates,6 military pension and medical records,7 and census records.8

The surgeons’ certificates data consist of medical records used by the US Bureau of Pensions to evaluate pension applications. Each record contains physical examination findings. Veterans could apply for a pension more than once (they could claim >1 disability at each application); therefore there were multiple medical records for some veterans. Surgeons’ certificates data were classified by the Center for Population Economics into 21 (primarily) organ system–based health screenings.

The total surgeons’ certificates sample includes 87 224 examinations of 17 721 veterans. The veterans sample was reduced to 16 022 because of missing information on birth or death dates. Once a veteran’s condition was diagnosed, we assumed that the veteran had that condition until death. In any year, the number of veterans in the sample was well below 16 022, because either the veteran had not yet been examined or had died by then. Our analysis focused on 1895 and 1910. The year 1895 was long enough after the statutory change of 1890 that allowed many veterans with non–service-related disabilities to be examined and added to the pension roles. By 1910, 3 years had passed since the statutory change of 1907, an eligibility expansion that classified old age (≥62 years) as a disability. Also, by 1910, most surviving veterans were aged 65 years or older. The death rate was high enough that sample sizes were too small to calculate reliable estimates of prevalence a decade or a decade and a half later.

We identified veterans with a visual disability who had diagnosed amblyopia or blindness in both eyes. We examined 5 categories of eye disease: trachoma, corneal opacity, cataract, disease of the retina, and disease of the optic nerve. Trachoma, corneal opacity, and cataract were all easily identified then by basic visual inspection. All were well-known causes of blindness and were considered when determining cause of impairment. Diseases of the retina and of the optic nerve, rather than being specific diagnoses, refer to findings from an examination with an ophthalmoscope. Ophthalmoscopes were reasonably well distributed by the 1890s.

Trachoma was identified by searching responses for trachoma within a category dealing with the conjunctiva. We identified cases of corneal opacity by searching for items pertaining to the cornea. Cataract was identified from variables for cataract and cataract extraction and was indicated as specific to the left, right, or both eyes. Diseases of the retina and optic nerve were identified by codes for infection or inflammation of the eye.
Few cases were explicitly classified as glaucoma, but glaucoma was also plausibly included in a separate category, diseases of the optic nerve. We included both in the category disease of the optic nerve.

RESULTS.
The sample increased by 50% between 1890 and 1895 (Table 1), reflecting the increase in veterans obtaining examinations after the statutory change in pension law in 1890. In 1895, of the 12 144 veterans in the sample, 84.8% were aged younger than 65 years. By 1910, of the 7782 remaining veterans in the sample, only 17.8% were aged younger than 65 years. Most veterans were aged 65 through 74 years in 1910 (66.2%).

Table 1
Age Distribution of a Sample of US Civil War Veterans for 1895 and 1910a
Cataract was by far the most common of the study diseases, with prevalence ranging from 4.5% for those younger than 55 years to 15.6% for those aged 75 years and older in 1895 (Table 2). In 1910, prevalence of cataract among those aged 75 years and older had risen to 17.1%. For those aged 65 through 74 years, prevalence of cataract was 8.4% in 1895 and 13.0% in 1910. Corneal opacity affected 3.8% and 4.8% of this age group in 1895 and 1910, respectively. Prevalence of trachoma was similar; that for diseases of the retina and optic nerve was much lower, ranging from just under 1% to 2% in 1895.

Table 2
Prevalence of Major Eye Disease Among US Civil War Veterans in 1895 and 1910 by Age
Prevalence of diseases of the retina increased between 1895 and 1910, even on an age-adjusted basis, possibly reflecting better detection in the latter year. However, in data for either year, rates of documented retinal disease did not increase with age, as is now typical in elderly populations. Prevalence of disease of the optic nerve did not change appreciably between 1895 and 1910 on an age-adjusted basis, and the patterns of prevalence rates with respect to age are irregular in both years.

In 1895 and 1910, respectively, 7.1% and 11.9% of the white male veteran population had low vision or blindness. The prevalence of low vision/blindness increased substantially with age. In 1895, 6.0% of veterans younger than 55 years and 11.0% aged 75 years or older had this diagnosis. In 1910, 14.1% of veterans aged 75 years or older were recorded as having low vision or being blind in both eyes.

Of those veterans with low vision or blindness, most had diagnosed cataract (Table 3). Corneal opacity and trachoma were present in one-quarter or more of these individuals. Diseases of the retina and optic nerve were documented in 13% to 15% and 8% to 10% of these cases, respectively.

Table 3
Prevalence of Major Eye Diseases Among US Civil War Veterans With Low Vision/Blindness

COMMENT.
Several major eye diseases and low vision/blindness were highly prevalent at the turn of the 20th century. Prevalence of some major eye diseases, especially cataract, increased substantially with age.

Owing to increased longevity and improved medical knowledge and diagnostic techniques, reported prevalence increased for many eye diseases. Current rates of cataract surgery, a reasonable proxy for cataract prevalence in high-income countries, are well above those for cataract and cataract surgery combined in the Union Army data,8–12 especially for populations aged 70 years or older. Data from populations aged 65 years or older in the 1990s indicate a prevalence rate of about 5% for age-related macular degeneration,13,14 about 7% for diabetic retinopathy,14 and close to 8% for glaucoma.14 The combined rates of 5% and 7% for the retinal diseases are far above the corresponding rates in the Union Army data (considering joint prevalence of both diseases), even allowing for a somewhat higher mean age of the more recent population. Diabetes prevalence among white veterans in 1895 was about 2% and was about 4% in 1910.15 Judging from recent data, far fewer than half of veterans with diagnosed diabetes would have had retinal disease (<1% in 1895 and <2% in 1910).14 Urinalysis was used during this period to diagnose diabetes.15 Recent prevalence of glaucoma is also much higher than the rates diagnosed in the Union Army veteran population, even accounting for some differences in age between the comparison and Union Army data.

However, trachoma, which was highly prevalent in the United States around 1900, is now virtually nonexistent in the developed world, which is largely a result of better sanitation, improved personal hygiene, and antibiotics.16–19 The disease now exists almost exclusively in low-income countries, where prevalence is similar to that found in our study,19–21 though it was sometimes higher depending on the region.22,23

In contrast to increases in reported prevalence of major eye diseases, visual outcomes in the United States have improved dramatically since about 1900. Data from the World Health Organization from 200224 indicate that blindness prevalence (defined as visual acuity <20/400 OU) among those aged 50 years or older in the United States was 0.4%. The Eye Disease Prevalence Research Group (EDPRG)25 reported a combined prevalence of blindness (defined as best-corrected visual acuity<20/200 OU) and low vision (defined as best-corrected visual acuity<20/40 OU) for those aged 40 years or older of less than 3%. Rates for other high-income countries are similar.26–28

Eye disease prevalence in the Union Army veterans data are more similar to reported prevalence in low-income countries, where sanitation and hygiene may be more like that of the United States in the early 20th century. According to the World Health Organization,22 prevalence of blindness in Africa among individuals aged 50 years or older was 9% in 2002. In Southeast Asia, including Indonesia, Malaysia, the Philippines, and Thailand, prevalence in 2002 was 6.3%. Combined prevalence of blindness and low vision (best-corrected visual acuity<20/60 OU and > 20/200 OU) among adults in Pakistan and Bangladesh is around 10%.29,30 Rates for persons aged 60 to 69 years have been reported at 13% in Malaysia31 and 8% in Nepal.32

Access to affordable, safe, and effective cataract surgery is of primary importance in decreasing prevalence of blindness in the developed world. Cataract is the leading cause of blindness globally, accounting for 47.8% of adult-onset blindness.23 The EDPRG estimated that among white Americans, cataract caused less than 9% of blindness,16 even though the US population is proportionally much older than the world as a whole; 7.4% of the global population is aged 65 years or older33 compared with more than 12% of the US population.1
Causes of low vision or blindness cannot be ascertained from the Union Army data; however, prevalence of eye diseases among those with low vision or blindness provide an approximation. These data assign a major role to cataract as causing low vision or blindness. Even with better technology, contemporary estimates of the causes of the 2 conditions in the United States differ appreciably. According to EDPRG’s meta-analysis, cataract, for example, accounts for 59.9% of low vision and only 8.7% of blindness among white Americans. Rates are 3.3% and 6.4% for glaucoma and 22.9% and 54.4% for age-related macular degeneration among white individuals with low vision and blindness, respectively.23 Age-related macular degeneration’s prominence in the EDPRG meta-analysis relative to that in the Union Army data (even considering that some diabetic retinopathy would have also been included in diseases of the retina) primarily reflects current knowledge compared with that of a century ago as well as the higher fraction of younger elderly in the veterans’ analysis.
Unlike cataract, age-related macular degeneration, and glaucoma, corneal opacities were much more common among those with low vision or blindness in the Union Army sample compared with contemporary populations in both the United States or low-income countries. Corneal opacities accounted for 3% of blindness in the United States and 8% to 12% of blindness in Africa in 2002.22 Higher prevalence of trachoma, the most important infectious cause of corneal opacity,34 cannot fully explain this effect. While rates of trachoma in Africa (6%–8%24) are higher than those in our data, the reported effect of corneal opacity on vision is substantially lower. Corneal scarring from war-related trauma is the likeliest explanation for the high rates of corneal opacity among those with visual impairments in the veterans’ sample. This explanation is supported by the decline in the prevalence of corneal opacity among those with serious visual impairment as the sample aged and other eye diseases become more common.

A strength of the veterans data is that they are fairly representative of middle-aged and elderly white men who were alive around 1900. About half of adult white men in the North fought in the Civil War.35 Many men whose poor health precluded fighting in the Civil War, owing to, eg, congenital heart disease, probably did not survive to 1895. The pension program covered 85% of all Union Army veterans by 1900 and more than 90% by 1910.4,5 Because of the relaxation of regulations in 1890 that allowed pensions to be granted to almost all veterans older than 65 years and the formalization of this policy in 1907, there was a substantial incentive for even veterans without disabilities to apply for pensions. Fogel36 conducted analyses comparing the examined soldiers with other men of this period, concluding that the veterans sample was representative of the Northern white male population according to geographic distribution, wealth, and cause of death.

We acknowledge several study limitations. Our data only pertain to adult white men and exclude men in states not held by the Union Army until the end of the Civil War. Second, methods of diagnosing and classifying disease and depth of understanding of disease processes differed substantially between the beginning and the end of the 20th century. Diagnostic techniques around 1900 were very limited, the field of ophthalmology was comparatively young, and the physicians performing the examinations were not likely to be familiar with any ocular pathologies besides the very most common. Consequently, misdiagnosis and underdiagnosis were likely to have been more common relative to more recent data. For example, around 1900, the presence of cataracts was typically based on observing a “white pupil” rather than by methods used more recently. Vision loss at the time of cataract surgery today is comparatively mild. Thus, using contemporary criteria, prevalence of cataract in 1895 and 1910 reported in our study is likely to be understated.

However, visual and functional status was observable. Graeff,37 in his book Das Menschliche Auge published in 1933, urged those rating severe visual impairment and blindness to classify them based on the conditions’ effects on patients’ ability to function in their usual activities.

Classification, terminology, and knowledge of disease processes also differed. For example, the 1898 English edition of Fuchs’ Text-Book of Ophthalmology,38 a widely respected reference at the time, defines amblyopia as weak sight or low vision that cannot be corrected by eyeglasses. Similar definitions are found in Alt’s 1884 A Treatise on Ophthalmology for the General Practitioner39 and Higgens’ 1888 Ophthalmic Practice.40 Complete blindness is referred to in these 3 texts as amaurosis. Our analysis considered a diagnosis of amblyopia in both eyes as functional blindness.

There is good support for supposing that a diagnosis of amblyopia, as the term was used then, was associated with severe functional impairment. Wood,41 writing on the army pension program, stated that “No pension is given for a partial loss of sight or for the partial or complete loss of the field of vision or the muscular functions of the eyes.” Graeff,37 writing more than 3 decades after Fuchs,38 Alt,39 and Higgens,40 characterized amblyopia as a historical scientific term for severe visual impairment. He argued that if the criterion of amaurosis had been strictly applied as a basis for admission, 80% to 90% of all residents of institutions for the blind would have been there inappropriately.

Glaucoma provides an example of the lack of understanding of disease processes in the early 20th century. The term glaucoma appeared in ophthalmologic reference books of the period, and it was one of the listed diagnoses the board of surgeons could apply following their examinations of pension applicants; but the consequences of glaucoma were not understood then. There are 2 chief reasons for the rarity of reported glaucoma: (1) The disease was thought to be very uncommon and (2) the relationship between glaucoma and the optic nerve was not well understood. Fuchs38 wrote in 1898 that glaucoma accounted for less than 1% of all eye diseases. In 1900, Deyl and Sattler’s42 chapter “Diseases of the Optic Nerve” in Norris and Oliver’s System of Diseases of the Eye made no reference to glaucoma, though some connection with the optic disc was mentioned in Smith’s43 chapter on glaucoma in the same volume. Fuchs38 identified excavation of the optic nerve as the cause of blindness in advanced glaucoma but went no further. Both Alt39 and Higgens40 discussed glaucoma and the optic nerve separately. However, by the time Graeff’s37 text was published in 1933, examination of the optic nerve was used to diagnose glaucoma. Although tonometers existed in the late 1800s,44 in our data, there were more findings of disease of the optic nerve than there were of diagnoses labeled glaucoma. Thus, in our analysis, the latter was combined with the former group.

This study documents substantial reductions in the prevalence of low vision/blindness and changes in the composition of eye diseases from an era in which there were few effective therapies for eye diseases to the present. Comparisons of major eye diseases over the course of 100 years reveal substantial improvements in visual function. The appreciable reductions in the prevalence of low vision/blindness reflect such technological changes as innovations in the treatment of cataract and glaucoma and economic growth, which provided funds for developing capacity and financing provision of services. Other improvements, such as a reduction in the prevalence of trachoma, reflect improvements in environmental and public health, which is largely a byproduct of a country’s level of economic development.
The burden of chronic eye disease is substantial45,46 and is reflected by (1) the resources devoted to its diagnosis and treatment and (2) the losses in productivity and quality of life it can cause. Both are important components of the total burden. Around 1900, when therapeutic options were limited, the burden of such disease and disability was largely borne outside the health care system. But nevertheless, particularly as reflected in high rates of low vision/blindness, this burden was substantial and much greater than it is now.

Acknowledgments:
Funding/Support: This study was supported in part by grant 2R37-AG-17473-05A1 from the National Institute on Aging.
Role of the Sponsor: The sponsor had no role in the design or conduct of this study.

Footnotes.

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Jeff Davis Was Blind in His Left Eye

From: civilwartalk.com

Davis fought health problems for a good part of his life, including a nearly fatal bout with malaria in 1836. He was seriously ill again in the winter of 1857-1858, and by February he began suffering from a relapse of a chronic inflammation of his left eye. The disease was so bad that a visiting ophthalmologist commented “I do not see why this eye has not burst.” As a result, most photos of Davis are in right profile, thus hiding his left eye

The eye disease can be traced back to his first bout with malaria. About a dozen years later, during a relapse, Davis suffered a “severe eye attack” such that, in the words of his wife Varina, he could not “bear a ray of light on either eye.” Documents show that the disease recurred almost annually from that time and through the Civil War

In a severe relapse in 1858, Davis was seen by two famous eye physicians of the time – Drs. Robert Stone and Isaac Hayes. Stone described the condition of Davis’s left eye in detail, including “ulceration of the cornea,” “abscess of the eye,” and “hypopyon” (a collection of pus cells in the aqueous humor). It was Hayes who commented that he couldn't see why Davis’s eye had not already burst. Davis was given treatments of the day, including “quiet” and bandages soaked in herbal remedies; he also underwent eye surgeries in 1859 and 1860.

Davis was unquestionably suffering from another siege of metaherpetic keratoiritis (inflammation of the cornea due to structural damage to the cornea) in 1858. The cold and fever that had gripped him, as well as the intense stress over Kansas, could easily have contributed to the timing of the new assault on his left eye.

Dr. Stone's clinical notes specifically talk about ulceration of the cornea. His description indicates a ruptured healing descemetococle (hernia of the cornea) filled with iris tissue and a threatened abscess of the eyeball, as well as a possible hypopyon, an accumulation of pus in the anterior chamber of the eye.

Describing Davis upon his return to the Senate in 1857, a reporter underscored how raving his illness had been: "a pale ghastly-looking figure, his eye bandaged with strips of white linen passing over the head, his whole aspect presenting an appearance of feebleness and debility."

As a film covered the left eye, he could see only light and darkness but could no longer distinguish objects. Contemporaries used various terms when they mentioned the eye. A close friend mentioned "clouded"; another observer called it "discolored"; even the word "blind" was used. In photographs taken in 1859 and 1860, Davis did not look directly at the camera. Instead, he presented a profile which emphasized his right side and hid his left side and his damaged eye.

While imprisoned, Mr. Davis referred very kindly, and in terms of admiration, to his former friend and medical attendant, Dr. Thomas miller , of Washington. Also to Dr. Stone of Washington, who had made a specialty of the eye and its diseases. From him he had received clearer ideas of the power of vision, and the adaptation of the eye to various distances and degrees of light, than from any other source. Referring to his own loss of sight in one eye from leucoma (a white, opaque scar of the cornea), or an ulceration of the cornea, he said he could discern light with it, but could not distinguish objects.

Although Davis never again experienced eye disease that remotely resemble the seriousness of the 1858 attack and the 1859 surgery, they left their marks. He turned to eyeglasses, with evidently some temporary help. As time passed, however, the degenerative ocular process connected with his affliction continued, and in all probability phthisisvalbi (shrunken, non-functioning eye) set in.

In 2006, Dr. R. W. Hertle, a prominent ophthalmologist at Children's Hospital in Pittsburgh concluded that Davis suffered from “herpes simplex keratouveitis,” (herpes simplex of the eye) a condition that remains a major cause of injury to the eye.

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Night Blindness

By Glenna R. Schroeder-Lein  

Night blindness, the inability to see at night while having normal vision during the day, is a result of vitamin A deficiency. Not surprisingly, the problem became worse as the war progressed because more soldiers had had poor nutrition for a longer period of time. At the time some doctors observed an increase in night blindness when scurvy increased. This is logical because both are related to vitamin deficiency, although not the same vitamins.

Other doctors considered complaints of night blindness to be a form of malingering. It seemed particularly to be an excuse to get a furlough because night blindness tended to disappear at home where the soldiers ate a more balanced diet. Few soldiers were hospitalized for night blindness because they could function perfectly well to fight during the day. There were significant problems with night blindness among William T. Sherman’s Union troops during the Atlanta Campaign and also in Robert E. Lee’s Confederate Army of Northern Virginia.

Excerpted from: The Encyclopedia of Civil War Medicine

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Eye Ailments

By Glenna R. Schroeder-Lein During the Civil War many Union and Confederate soldiers suffered from eye problems. These problems tended to fall into three categories: disease, injury, and nutritional deficiency. Though Civil War physicians treated eye problems according to current knowledge, one important innovation on both sides was to establish special wards or hospitals devoted to eye disease and staffed by a skilled doctor. The Union forces had eye infirmaries in St. Louis, Missouri, and Washington, D.C., while in 1864 the Confederate Army of Tennessee had the Opthalmic Hospital at Athens, Georgia. Eye diseases were often labeled ophthalmia, meaning a severe inflammation of the eye or eyes. Then, as now, these problems could be caused by germs or irritants. A number of soldiers developed ophthalmia as a consequence of having measles, a “childhood disease” that spread rapidly through new regiments when they joined the army. Eye injuries resulted from accidents or gunshot wounds. Excerpted from: “The Encyclopedia of Civil War Medicine” PHOTO: Civil War bullet wound of the eye, 1864. The Burns Archive Learn more about Civil War opthomologists at www.CivilWarRx.com.

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Civil War Optometrists

The practice of optometry began with the invention and subsequent refinement of eyeglasses in the early nineteenth century. Optometry guilds were formed at this time, and the practice eventually was regulated under statutory law. Jewelers were actually some of the first professionals to use eye charts and sell glasses to the public.

 

The industry in the United States expanded during the Civil War when the government purchased large quantities of binoculars and microscopes for the war effort. Eyeglasses became plentiful and, by the end of the nineteenth century, schools were teaching the science of optics, often in combination with instruction in watch repair.

 

Door-to-door peddlers, jewelers, and optometrists all sold eyeglasses in the late 1800s. At the beginning of the twentieth century, however, physicians conducted most of the eye examinations.

 

FROM: http://business.highbeam.com/industry-reports/business/offices-clinics-of-optometrists

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Research on Civil War Eye Glasses

By Johan Steele

My own research included talking to a local fella and present day optometrist who collects eye glasses and was rather enlightening. Surprisingly prices are about the same today, when compared to inflation.

The frame curving around the ear glasses are definitely a post war invention. Most typical had the lenses very small when compared to those of today, the pair I have were originally a set of sample/display glasses. The lenses aren't much larger than my eyes, you are forced to look straight at whoever you are talking to. There is NO peripheral vision with these. Some of the others I was shown that dated to the 1860's and prior were square or hex shaped. There was also a set that were designed to be folded up, those were surprisingly beefy.

Construction was from Brass, braided copper as well as steel. He also had a pair of 1860's glasses that had been coated with gutta percha.

An Optometrist was one of the most highly paid in the medical profession at the time and often traveled quite a bit. He would able to often put together a pair of glasses while you waited from the stock he carried. The collector owned an 1880's Optometrists tool chest which was rather large but still portable. When full he would have been able to both figure out & fill the needed prescription for well over a hundred people. The tools were very similar to a watchmakers or jewelers set and many an eye doctor hand made the frames as well as he could do so more cheaply than sending off for them and it was almost 100% pure profit for him. Needless to say the quality might vary rather dramatically.

Original eye glass frames didn't usually have screws but were fastened with a molten lead plug, which makes it almost impossible to put new lenses in an original set and is a way to date them. As I recall tt was actually during the ACW, in the US, that screws started to be commonly used.

FROM: http://civilwartalk.com/threads/civil-war-eye-glasses.69237/

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