Wednesday, November 12, 2014

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.



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