Civil War Hospital Ship

The U.S.S. Red Rover, a captured Confederate vessel, was refitted as a hospital ship.

Evolution of Civil War Nursing

The evolution of the nursing profession in America was accelerated by the Civil War.

The Practice of Surgery

Amputations were the most common surgery performed during the Civil War.

Army Medical Museum and Library

Surgeon-General William Hammond established The Army Medical Museum in 1862. It was the first federal medical research facility.

Civil War Amputation Kit

Many Civil War surgical instruments had handles of bone, wood or ivory. They were never sterilized.

Showing posts with label eye disease. Show all posts
Showing posts with label eye disease. Show all posts

Wednesday, January 18, 2017

Vitamin A-Deficiency Eye Disease Among Soldiers in the U.S. Civil War: Spectrum of Clinical Disease.

By Lanska DJ1., July 2015

Abstract
During the U.S. Civil War, nutritional night blindness was a common problem among soldiers forced to subsist of nutritionally inadequate diets, but medical officers typically attributed this complaint to malingering and did not suspect or appreciate a dietary basis. More than 8,000 cases of night blindness were recorded among Union troops, but many cases were not tabulated because of incomplete data for black soldiers and prisoners of war. From 1864 to 1865, during which comparable data were available for both whites and blacks, the average annual cumulative incidence of night blindness was 4.3 per 1,000 troops for whites, compared with 11.0 per 1,000 troops for blacks. Affected patients had dilated pupils that were poorly responsive to candle light. Approximately 30 cases of keratomalacia were also reported among severely malnourished and emaciated soldiers with chronic diarrhea, generally within 2 weeks before death. The reported clinical manifestations are characteristic of the full range of vitamin A deficiency eye disease from night blindness to corneal ulceration and perforation. Although medical officers typically accused affected soldiers of malingering, malingering cannot account for either the observed abnormalities of pupillary reflexes, or the corneal epithelial pathology and mortality recorded in severe cases.

From: ncbi.nlm.nih.gov

Learn more about eye disease and blindness in the Civil War era at www.CivilWarRx.com

Tuesday, January 3, 2017

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

By Frank A. Sloan, PhD, Daniel W. Belsky, BA, and Idrissa A. Boly, MA

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.

From: ncbi.nlm.nih.gov

Tuesday, December 9, 2014

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.

Sunday, November 16, 2014

Definite Iindeterminacy: Blindness in the Civil War

By Vanessa Meikle Schulman

"[The wound around his eye] has been constantly open, suppurating and discharging ever since … with loss of strength and increasing blindness in the left eye which is very weak & he is less & less able each year to do any manual labor or care for himself. "

Applying in 1882 for an increase to his Civil War pension, Private James M. Greenleaf, who received his facial wound at the Battle of Fredericksburg in 1862, attempted to convince the government that his eye—unhealed and rapidly losing its sight—was so debilitating as to prevent him from earning a living through gainful employment. To the above statement in his pension application, Greenleaf added an “affidavit signed by 24 acquaintances stating that his wound was worse than the loss of an arm or a leg.” Though Greenleaf also complained of pain in his hip, it was the wound to his face, with its leaking pus, that made him “totally & permanently helpless,” as the government surgeon wrote on examining him in 1907. The claim that Greenleaf’s partial blindness incapacitated him more than the amputation of a limb stands out in a narrative—one of pathos, to be sure, given how frequently his applications were rejected by the government—that was all too common throughout the post-Civil War era. I take Greenleaf’s story not as a representative case of the logistical problems faced by veterans of the Civil War but rather as a signpost to a larger cultural narrative that emerged as a response to war trauma in the years following the conflict: that of blindness.

Two eyewitnesses to the war, author Ambrose Bierce and artist Winslow Homer, used different artistic media to come to terms with the trauma of the war. I argue that instead of being mere “realists,” as they are often described, they used metaphors of blindness or compromised vision in their literary and artistic works. Bierce and Homer deploy these strategies of incomplete representation as a commentary on the futility of using traditional forms of representation to depict the unprecedented horrors of mechanized warfare. Though working in different media, both men questioned how one might begin to represent such a conflict. After examining the ways that both Bierce and Homer developed theories of truth and vision, this essay will examine different modes of “blindness” that they presented in their representations of the war. These modes range from the paradoxical narrowing of vision created by technologies specifically designed to enhance natural sight, the moral and literal blindness of participating in a military engagement, and, finally, the ways that their war experiences caused both Homer and Bierce to question their own self-knowledge and clarity of vision.

The project of representing the Civil War took place in an atmosphere of widespread popular visual culture, manifested primarily in forms that were easy to mass-produce and disseminate. These forms of visuality—most notably popular illustration and photography—emerged in the 1850s in a reproducible form more or less similar to those they took during and just after the war. Displayed in prominent photographic galleries or seen every day in the pages of the illustrated magazines that dominated American news in the 1860s, these images familiarized ordinary viewers with horrific scenes of modern, industrialized warfare. Homer and many of his fellow artists such as Theodore R. Davis, Edwin Forbes, and William and Alfred Waud worked as “special correspondents” during the war, sketching scenes of battle and everyday events of camp life for the most popular illustrated weekly magazines of the nineteenth century, Harper’s Weekly and Frank Leslie’s Illustrated Newspaper. Both publications began circulating in the mid-1850s and both experienced massive increases in their readership during the war years, partly due to their exhaustive and timely visual coverage of the conflict. At the end of the war both magazines maintained competitive circulations, reaching audiences of hundreds of thousands each week.  Advancements in the printing press and technologies of reproduction generally, in addition to increased speeds of communication between reporters on the front lines and their editors in New York, created a visual milieu saturated with war reportage, maps, humorous scenes of military life, and portraits of heroic generals. The “faces and events which the war has made illustrious,” appeared often “tacked and pinned and pasted upon the humblest walls.”

Photography, too, contributed to the ways that nineteenth-century Americans visualized the war. While common soldiers still had their daguerreotypes made before leaving home, the newly-invented wet collodion plate process, with its drastically reduced exposure times and ability for replication using glass negatives, changed both the appearance and functions of photography. The collodion process allowed commercial photographers to take easily reproducible images of the war, though not, crucially, of the action. The photographs that have become famous—shots of bloated corpses on the battlefield at Gettysburg taken by the studio of Alexander Gardner and stark photographic documents of survivors’ ghastly wounds compiled by army surgeon-photographers such as Dr. Reed B. Bontecou—would seem to attest to photography’s supposed objectivity. Of course, despite the indexical nature of the medium, even early photographs were doctored or manipulated. Despite this, the first viewers of Civil War photographs, notable among them the prominent Boston physician Oliver Wendell Holmes, Sr., viewed the images as “terrible mementos” capable of truthfully illustrating “what war is.”

Our perception of photography’s access to the “real,” its status as an impression from a thing that has been, gives it an important role in the reliving of trauma, as Michael S. Roth argues. He notes the apparent ability of photography to bring a “distant real” to the viewer, “making the temporally distant present.” He continues, “Photographic images seem to offer the possibility of reexperiencing the past, or of experiencing a past for the first time without a subjective intermediary.” In this interpretation, the very distinctness of Civil War photographs would seem to be a mechanism for facing—literally—the trauma of the national schism, for seeing it in the most straightforward light possible. It is the direct gaze forced by photography that allows one to deal with trauma; as Roth writes, “traumas seem to urge us not to look away.” In her article on Civil War medical photography cultural historian Kathy Newman reacts to the images of mutilated young men confronting the camera directly, which she characterizes as stark medical documents that “assaulted [her] senses.” As a scholar and a humanist, she claims, one “can neither refuse nor transform their traces of violence.” Newman argues that only through an intimate visual encounter with these images can their pain and discomfort be discharged; a greater disservice is done to the wounded in turning away, in not seeing, than in gazing at their wounds. And yet I argue that Bierce’s and Homer’s suspicion of vision is not a cruel rejection of pain but a legitimate and common response to the trauma of the war. Artists who attempted to depict the war faced obstacles, one of which was the inability of traditional modes of representation to express the political complexities of the war and the deep pain and confusion it caused to those who witnessed it. As Steven Conn records in his study of history paintings of the Civil War, the traditional narratives belonging to that genre—in the American context, most frequently nationalistic and teleological fictions of inevitable progress—were not applicable to this war. It was difficult to accept an overtly nationalistic interpretation of the conflict without mortally offending half the population, and a war in which crucial industrial and transportation infrastructure was damaged on both sides could hardly be said to contribute to progress. There also seemed to be a crippling lack of consensus on the causes and goals of the war—a topic that still bedevils scholars today. The war was, in Conn’s estimation, an event of “narrative trauma,” one that saw the collapse of “traditional representational strategies, the familiar ways of creating order and coherence out of experience.” Uncertainty about the best ways to represent the war stifled the traditional outlets of patriotic battle painting and hagiographic portraits of charismatic generals, leading to a breakdown in visual representation, at least among “high” art circles.

To this uncertainty we may also apply what transcendentalist philosopher Ralph Waldo Emerson termed the “angle of vision,” a moment when “the poles of the eye should coincide with the axis of the world” and the subject reach enlightenment. Throughout his writings, Emerson attempted to make sense of the individual’s capacity for acquiring spiritual knowledge using metaphors of vision, referring to the eye as the “first circle” of the perceived world. According to Emerson, writes literary scholar Sherman Paul, men might reach a “higher” state when “seeing became a unitary act” that combined physical, mental, and spiritual forms of knowledge. Tragically, in the Civil War, such elevated vision revealed itself as an impossible achievement and the “angle of vision” turned out to be oblique. Into this traumatic void stepped artists like Homer and Bierce who, instead of becoming paralyzed by the inability to represent the war through traditional means, adopted stylistic and formal tropes of blindness as metaphors for the dislocating experience of the war itself.

Bierce, Vision, and the Devil’s Dictionary

Both Bierce and Homer served on the front lines of the war, though in vastly different capacities. Bierce enlisted in the Union Army’s 9th Indiana Infantry regiment in 1861 and for the following four years served in the army as an infantryman until becoming a military engineer and mapmaker around 1862. Bierce suffered physical and emotional trauma during the war years. He fought in the Battle of Shiloh in 1862 and sustained a major head wound at the Battle of Kennesaw Mountain in 1864, experiences that influenced his later Civil War works profoundly.  After the war, Bierce became known for the acerbic humor and spare realist prose he employed to document his experiences during the conflict. Traditional interpretations of his work, such as journalist and critic H. L. Mencken’s comment in 1927 that Bierce was “the first writer of fiction ever to treat war realistically,” often focus on his evocation of war’s horror through precise details, sparingly and simply told. Yet Bierce’s Civil War stories contain another, more disturbing, theme: that of the impossibility of using vision alone to comprehend the full enormity of the war. Cathy N. Davidson adopts this perspective, arguing that in his stories Bierce consistently structures the narrative “in such a way that the nature of the self, the nature of the world, and the nature of the relationship between the two are called into question.” To Davidson’s interpretation I would add the peculiarly visual nature of Bierce’s writing and its contribution to this exploration of the interplay between inner and outer truths. To his constant focus upon explicit visual details Bierce adds moments when the abilities of sight break down, when epistemological knowledge cannot be gained by mere vision. Bierce intersperses vivid descriptions of the war’s mise-en-scène with ruminations on the instability of sight. His characters withdraw from the visual world in tragic errors of misrecognition or stumble blindly without vital visual information.

Bierce’s contrarian self-presentation in print makes it difficult to assess his attitudes toward the traumatic events he had witnessed as a member of the army. His sarcasm and rejection of sentiment may have functioned as a mechanism for repressing scenes better forgotten, though the grotesque forthrightness of some of his descriptions, such as this one from the short story “Chickamauga,” suggest a willingness to engage in depth with the more horrific elements of the war: “The man … turned upon him a face that lacked a lower jaw—from the upper teeth to the throat was a great red gap fringed with hanging shreds of flesh and splinters of bone.” Bierce’s stories are peppered with such horrific evocations of wartime injuries. However, the larger thematic thrust of his work is taken up with the difficulty of searching for truth amid such chaos. A close examination of entries from Bierce’s Devil’s Dictionary, a collection of humorous definitions of common words that he published serially in American magazines starting in 1875, demonstrates that Bierce took his own role as an interpreter of truths quite seriously. Under the entry for “geographer,” Bierce’s own profession during the war, he quips that he is “a chap who can tell you offhand the difference between the outside of the world and the inside.” Underlying Bierce’s humorous cynicism is the implication of a separation between the external and internal worlds, the sphere of things and that of thoughts, matter and mind. Nineteenth-century American culture was deeply concerned with whether external appearances offered a reliable reflection of the inner life of things and people. An underlying anxiety about the authenticity of images and people pervaded the postwar years as Americans pondered the complexities and contradictions of life in the modern nation. Bierce proposes himself as a guide to the gaps between observed realities and lived experience.

Importantly, Bierce also proposes himself as a figure who sees properly, sees things others cannot. A self-described cynic (the first edition of the Devil’s Dictionary was titled The Cynic’s Word Book), Bierce defined his own vocation thus: “A blackguard whose faulty vision sees things as they are, not as they ought to be. Hence the custom among the Scythians of plucking out a cynic’s eyes to improve his vision.” The emphasis on vision again makes an explicit reference to Bierce’s role as a revelatory figure uncovering truths that others would rather not face. But ironically, this vision is only “faulty” when seen from the point of view of an optimist, the cynic’s foil and bête noire. Bierce excoriates the philosophy of optimism using another visual metaphor: “Being a blind faith, it is inaccessible to the light of disproof—an intellectual disorder, yielding to no treatment but death. It is hereditary, but fortunately not contagious.” The optimist’s blindness causes him to mis-see, to believe “that everything is beautiful, including what is ugly.” The cynic’s “faulty” worldview is, in Bierce’s estimation, far the more truthful. But it is also threatening to the hegemonic establishment of optimists, who visit violent trauma upon the cynic, correcting his “faulty vision” by the extreme expedient of creating a state of total blindness.

Bierce would probably have greatly appreciated—if in an ironical fashion—the disapproving review his 1892 collection of war stories received in the Atlantic Monthly, an apotheosis of the optimist’s rejection of the cynic: “It has never been our fortune to read a collection of tales so uniformly horrible and revolting. Told with some power, and now and then with strokes of wonderfully vivid description, with plots ingenious in their terror and photographic in their sickening details, we must pronounce the book too brutal to be either good art or good literature.”

“I Paint it Exactly as it Appears”

Though he was also a direct witness to major battles as well as to the day-to-day experience of life in camp, Winslow Homer, a visual artist, had a quite different experience of the war. Almost ten years older than Bierce, Homer was already a somewhat well-established professional at the outbreak of the war, having served for the previous four years as a freelance illustrator for various New York-based magazines. Along with a large group of other artists, Homer traveled with the Army of the Potomac on assignment with Harper’s Weekly during 1861-62 and later as a freelancer. After returning from the Peninsular Campaign, he began to experiment with oil painting; his first canvases were of Civil War scenes, some based on the same sketches he translated into wood engravings for Harper’s. Though he was untrained as a “fine” artist, his oils of the war earned acclaim and he was elected a full Academician of the National Academy of Design (NAD) in 1865 at the age of 29, quite young for an artist with very little formal training. From 1863 through the early 1870s, Homer painted at least twenty canvases related to both the home and camp life during the war. His works were considered truthful, straightforward, and honest representations of life on the front and in the wartime domestic sphere; one critic wrote in New Path that Homer was the only American artist “to tell us any truth about the war.”  The London Art Journal concurred: “These works are real: the artist paints what he has seen and known.”  The strong reception of Homer’s war paintings as documents of lived experience seems to contradict my claim that Homer’s war works thematize blindness and trouble the reliability of vision, but I believe that an examination of the spiritual elements within Homer’s art may demonstrate how his indeterminate visions of war suggest a special, privileged kind of vision. The primacy Homer himself placed on the role of the eye, or of vision, as part of a revelatory experience may be seen in his angry response to John W. Beatty, who inquired whether the he “modified” nature in his compositions: “‘Never! Never!’ the artist cried, ‘When I have selected the thing carefully, I paint it exactly as it appears.’”

Homer had a long and successful career in the decades following the war, during which he pursued formal and stylistic experimentation, and it is usually these later paintings that are credited with possessing a sense of indeterminacy, for all their lifelike bodies and violent, crashing waves. Art historians Jules Prown and Charles Colbert interpret Homer’s representations of survival and rescue at sea from the 1880s as manifestations of a battle that is spiritual rather than physical, separating the materiality of his artwork from the ineffable that lies within or beneath.  In these works Homer uses metaphors of rescue and resuscitation to posit a relationship between external, tangible, and observable reality and inner faith. Contemporary reviews focused with startling regularity on Homer’s eye as an organ of both sight and deeper revelations. “This is the picture of a man who has the seeing eye,” wrote Eugene Benson in a review of Homer’s The Bridle Path at the NAD show in 1870, continuing: “We have no figure-painter who … sees the actuality of his subject better; not one who is closer to the objective fact of nature.” Homer’s supposedly direct access to nature was one way for professional art critics to praise him despite his untrained technique. A reluctant admirer of Homer, art critic Mariana van Rensselaer, wrote: “But always, whether it be austerely beautiful or frankly ugly, his work is vital art—not mere painting, not the record of mere artistic seeing, but the record of strong artistic feeling” (emphasis original).  This confluence of sight and emotion, of the outer skin of things somehow invested with an inner life or spirit, this seems in some ways similar to Bierce’s formulation of himself as a privileged figure possessed of uncommon understanding. Learning that Homer possessed a copy of George Chaplin Child’s religious tract The Great Architect, which posits a connection between the technical workings of the eye as an optical apparatus and the inner illumination required for salvation, Colbert reads the painter’s late oeuvre as concerned with the “‘correspondence’ of the material and the spiritual.”34 As previously mentioned, concern with the eye’s ability to perceive a higher “truth” through external observations permeated American culture during this period. But these truths, when it came to making sense of the Civil War, turned out to be fragmentary.

Thus far, both artists have been considered in light of their contemporary reception and self-professed role as figures with access to unique forms of truth. What was this privileged form of sight that both Bierce and Homer shared? Both realized that the real truth of the war was blindness. The contested nature of the war—its multiplied causes and meanings, the still-fractured nation it left behind—was the ultimate truth that Bierce’s and Homer’s direct vision grasped. Both understood that true vision was not purely optical. Concerns and anxiety about the trustworthiness of vision were rampant in these years, and there was a certain horror in the sheer amount of information that threatened to overwhelm the viewer or reader in a torrent of factuality. An odd review of Homer’s art, given by Eugene Benson in a cynical and almost Biercean phraseology, noted that his work usually “falls below the standard of finish and detail which is within the reach of our most childish and mediocre painters, and which misleads many, and deceives painters with the thought that by going from particular to particular, of itself insures a fine result in art.”  While seeming to call Homer worse than mediocre, Benson in fact praises his ability to see only that which is important, removing extraneous detail. The act of a painter moving painstakingly “from particular to particular” sends a creeping horror down the reader’s neck as he imagines a painting—not unlike the Victorian parlor—completely crammed with objects, all rendered in delicate and excruciating detail. Bierce, too, seemed to find the modern obsession with detail a horror vacui; his definition of “telescope” describes an apparatus “enabling distant objects to plague us with a multitude of needless details.”  Homer escapes this fate, van Rensselaer agreed: “He had boldly omitted everything that could not serve his purpose.” Bierce, too, was praised for the stripped-down, often spare forms of his prose. Both Bierce’s and Homer’s narratives, whether textual or visual, deal with the confluence of vision, memory, and trauma by conceptualizing blindness as a narrative strategy for dealing with traumatic events by appealing to non-visual, “inner” truths.

The Blindness of Technologized Vision

Art historians have usually only analyzed one of Homer’s Civil War scenes with explicit attention to vision: the artist’s earliest known oil painting, Sharpshooter of 1863 [Fig. 1]. Since the 1988 publication of an important article by Christopher Kent Wilson, academic discussion of Sharpshooter has tended to hinge on its relation to the new technology of the sniper’s long-range rifle and the intensified looking that the sharpshooter, armed with a highly accurate scope, embodied.  Randall C. Griffin, for example, connects Sharpshooter with “the theme of intense looking” and Homer’s compositional “passion for clarity,” both of which would seem to be diametrically opposed to an interpretation of the work as a figuration of blindness. And yet, two key elements of the composition suggest blindness of different kinds. First, the very close-cropped, intense focus on the body and weapon of the sharpshooter actually serves to obscure the viewer’s larger frame of reference. In addition, the very weapon that enhanced the sharpshooter’s natural vision, the long-range rifle with its high-intensity scope, acts to create a new and fearful moral blindness in the body of the sniper himself.

By focusing his composition so intently on the isolated sharpshooter, high in his treetop vantage point, Homer excludes us from any engagement either with the man depicted or with the greater context of battle going on around him. Despite art historian Julian Grossman’s praise of “the sharpness of the soldier’s eye,” Homer paints that eagle eye as an obscured smudge under the shadow of the marksman’s cap. We are completely cut off from the consciousness of this soldier and from what he actually sees through the scope of his rifle. Bierce might give some hint. In “One of the Missing,” he composes the inner monologue of just such a reconnaissance man, Jerome Searing:

After a keen reconnaissance from the safe seclusion of a clump of young pines Searing ran lightly across a field and through an orchard to a small structure which stood apart from the other farm buildings, on a slight elevation. This he thought would enable him to overlook a large scope of the country … Searing looked across the open ground between his point of view and a spur of Kennesaw Mountain, a half-mile away. A road leading up and across this spur was crowded with troops—the rear-guard of the retiring enemy, their gun-barrels gleaming in the morning sunlight.

Bierce encapsulates the extremely long range of Searing’s view and the precision with which his “searing” vision appreciates his surroundings, elements intentionally excluded from the composition of Sharpshooter. Technological advancements in riflery, as Wilson notes, greatly increased the speed and accuracy of long-range marksmen; Civil War sharpshooters were feared because they could bring instant and unseen death, as one Confederate lieutenant later reported: “I’ve seen them pick a man off who was a mile away. They could hit you so far you couldn’t hear the report of the gun. You wouldn’t have any idea anybody was in sight of you.”  However, the viewer can only speculate as to what Homer’s sharpshooter sees. Homer’s deceptively simple composition cleverly blinds the viewer to the larger context of the sharpshooter’s situation.

The emphasis on his role as a highly-trained marksman, in combination with the importance to the war of sharpshooters’ technologized vision, leads to the second blindness represented by this painting: that of the moral blindness of the sharpshooters and of the war itself. As Wilson argues, the technological developments in marksmanship were crucial to Northern successes, but they were also connected in the contemporary mind with a troubling new phenomenon: that of the machine-like killer, uncaring of human life, who, rather than using his newly-accurate weapon as a tool, was himself becoming a dispassionate extension of that weapon. In a much-quoted letter, Homer later wrote that he regarded sharpshooting “as near murder as anything I ever could think of in connection with the army.”  Bierce was no fan of these marksmen, either, having been severely wounded by one at the Battle of Kennesaw Mountain. In his 1888 essay “Modern Warfare,” he complained that humankind was “taking a deal of pains to invent offensive weapons that will wield themselves … A modern battle is a quarrel of skulkers trying to have all the killing done a long way from their persons.”  His evocation of the interior life of the Union sharpshooter in “One of the Missing” is less snide but far more chilling: “Jerome Searing drew back the hammer of his rifle and with his eyes upon the distant Confederates considered where he could plant his shot with the best hope of making a widow or an orphan or a childless mother,—perhaps all three, for Private Searing, although he had repeatedly refused promotion, was not without a certain kind of ambition.”  Fears about these marksmen’s distance from the sites of the deaths they caused gave many civilians a complicated reaction to their skills. Though they look with exceptionally sharp eyes, they are blind to the suffering they cause. They were represented in the press, indeed, as terrifyingly calm and dispassionate.  A soldier should do his duty in wartime, true, but a kind of moral panic indicted sharpshooters for suspected ethical blindness and even, most fearfully, an enjoyment of killing like that of Bierce’s Searing.

Bierce addressed the impersonality of technologized vision in “The Coupe de Grâce,” a story in which Captain Downing Madwell performs a mercy killing on his childhood friend Sergeant Caffal Halcrow, whom he finds lying on the ground partially eaten by roving pigs but still, painfully, alive. Both Halcrow and Madwell exhibit a kind of temporary blindness; Halcrow, half-conscious “stared blankly into the face of his friend,” while above him Madwell’s “tears splashed upon the livid face beneath his own and blinded himself.” Recognizing that the kindest gesture would be to kill his old companion, Madwell finds himself unable to do so and departs. Seeing a wounded horse nearby, he shoots it quickly and then noting how its “sharp, clean-cut profile took on a look of profound peace and rest” after its agonized death throes, he changes his mind and returns to where Halcrow lies wounded. “Apparently lost to all sense of his surroundings,” Madwell takes the pistol he has just used to execute the horse, holds it to his friend’s head, “and turning away his eyes pulled the trigger.”  The sharp irony of the story comes from the fact that his gun is empty; he has used his last bullet to put the dying animal out of its misery. Determined, however, to complete the deed, Madwell next takes out his sword and plunges it into his friend’s chest. “This time he did not withdraw his eyes,” Bierce records, despite the gruesomeness of the death.  It seems telling in this atmosphere of technologized warfare and heightened vision that Madwell cannot bring himself to watch Halcrow’s death by pistol—surely the more humane, if not the more human, method—but looks directly at his friend as he skewers him with a saber. Guns, by which the killing of men had become no different than the killing of animals, had rendered slaughter impersonal and thus terrible to witness, while Madwell’s final execution of the wounded man becomes a deeply personal and thus moral act from which he need not look away.

To return to the figure of the sharpshooter, a final example from Bierce’s “The Mocking-bird” depicts the cruel impersonality of shooting at distant enemies. Posted on picket duty, Union Private William Grayrock spends his night “staring at the darkness in his front and trying to recognize known objects.” Upon hearing the approach of someone he cannot see, Grayrock shoots blindly into the night and is certain he has hit a man in the darkness. For, as Bierce informs us, “he had a marksman’s intuitive sense of having hit; for he was one of those born experts who shoot without aim by an instinctive sense of direction, and are nearly as dangerous by night as by day.”  Grayrock is an even more terrifying version of Homer’s Sharpshooter, because not only is the reader blind to the enemy he shoots at, but Grayrock himself shoots blindly and still manages to execute his man. The danger of this blind shooting becomes apparent the next day when Grayrock searches for the enemy soldier he is certain he has wounded and finds the dead body of his own twin brother John, a Confederate soldier. Shooting blindly at invisible enemies was not particular to the marksman’s routine, however. It was woven into both the symbolic meaning and the lived experience of Civil War battles.

“A Battle Which No Man Saw”

The Battle of the Wilderness, a fight Homer probably witnessed firsthand, was described in 1888 by participant Robert Stoddard Robertson as “the strangest and most indescribable battle in history.” Robertson added that as it was fought in an impenetrable forest at close hand, “the lines of battle were invisible to their commanders … the enemy was also invisible.”  Homer famously rendered this obscurity in his only oil painting of a Civil War battle in progress, Skirmish in the Wilderness, which shows indeterminate clusters of men lost in a dark thicket of trees, puffs of smoke from rifles providing the only clues to the action. It was indeed, as another eyewitness, William Swinton, described it, “a region of gloom and the shadow of death.” But such opacity of battle was not specific to the Wilderness action; Bierce also utilized the theme of visual impenetrability in the autobiographical essay “What I Saw of Shiloh.” Throughout the piece, Bierce and his men experience the bewildering attacks of unseen enemies as they fight through dense, gloomy forests. “What I Saw of Shiloh” may, indeed, be titled ironically, as much of the piece chronicles the difficulty of viewing what is going on around the narrator. First, as Bierce and his men wait to be ferried across the Tennessee River to relieve embattled troops, he records the confused impressions of the battle going on nearby, “obscured … by blue sheets of low-lying smoke.” Bierce continues: “The farther edge of the water could not be seen; the boats came out of the obscurity, took on their passengers and vanished in the darkness.” The air is lit with “blinding flashes” and the soldiers on the opposite bank are seen only as “moving black figures.”

Bierce’s description of the scene at Shiloh matches Homer’s evocation of the Battle of the Wilderness, a small and obscure canvas showing a tangled cluster of soldiers taking cover from enemy fire behind a tree. The viewer sees the scene from a vantage point a little behind them, facing the ongoing action. Homer outlines their figures against a haze of white smoke from the discharge of their weapons. The color of the men’s uniforms—whether a grey darkened by the gloom of the forest, or a blue made grey by the sickly yellow light filtering through the leafy canopy of the woods—is indistinguishable. From the right, a column of Union soldiers marches into the scene; in the space between the central grouping and this more orderly formation, an undulating mass in the green-black murkiness of the background may herald approaching enemies or may merely be tangled vegetation. The “blinding” flashes of gunfire do not serve to elaborate the positions of either friendly or unfriendly troops.  Grossman writes of Wilderness that it “gives some idea of the difficult terrain, in which dense thickets broke up battle lines and the enemy, more often than not, remained unseen … in the tangled woods.”  Homer’s indistinct topography contrasts with Bierce’s own visual renderings of the war: the maps he produced as personal cartographer to General W. B. Hazen were “meticulous” with “never an erasure, never a smudge.”  Their sharp black lines differ starkly from the chaotic, indeterminate milieu of Homer’s Wilderness.

And yet Bierce’s exquisite maps are explicitly dissimilar from his descriptions of the confusing sights that greeted him and his men when they eventually reached the scene of battle at Shiloh. Sensory deprivation strikes both the eyes and the ears of his unit as he notes: “A few audible commands from an invisible leader had placed us in order of battle. But where was the enemy? Where, too, were the riddled regiments we had come to save? … What protected our right? Who lay upon our left? Was there really anything in our front?”  Bierce’s litany of questions speaks to the confusion of this contentious battle—considered a failure of strategy on the part of Ulysses S. Grant, despite the Union’s eventual victory on the second day of fighting—but also to an epistemological instability inherent in the condition of battle more generally. Throughout the piece, Bierce speaks of troops—enemy and ally alike—that are “screened from view,” woods “impervious to sight,” men directed “we knew not whither.”  Homer’s visual articulation of the confusion of battle suggests the contingency and confusion of modern warfare and, through its sketchy and episodic character, the failure of traditional narratives of heroism. Conn’s theory of “narrative trauma” comes again to mind. A fragmented, indistinct canvas reflects the unpleasant realities of this fragmented, indistinct war in a way that no traditionally composed history painting could. In Skirmish in the Wilderness, Homer uses visual confusion, limited sight range, and intentional obscurity of figures in relation to the landscape and to one another to represent the actual conditions of this 1864 clash, but he employs them in support of a larger argument that the Civil War proved to be “impossible to paint” because it “stood as the great, glaring, and unarguable challenge to any facile notion of American progress.”  Bierce’s writings, Sharon Talley asserts, “reflect not only his own psychic conflict but also the related national crisis in sensibilities, marking the transition between concepts of the heroic.”  Likewise, as both Conn and Nicolai Cikovsky, Jr., argue, Homer succeeded as a painter of the Civil War precisely because he turned away from the traditional narrative conventions of wartime representation.  But the turn from battle painting to the domestic side of war—what art historian Elizabeth Johns terms “American males in social relationship with each other as men”—had its areas of blindness as well.  The homosocial camaraderie and ersatz domesticity created by wartime conditions enabled observers to contrast soldiers’ lived realities with their idealized visions of prewar household life.

Home Sweet Home

For the first time during the Civil War, army doctors treated homesickness as a deleterious illness that affected the troops as they camped far from their loved ones.66 Homesickness can in many ways be defined as visual, and the thought of one day seeing far away people rings out in soldiers’ letters. Aides-memoires such as daguerreotypes or tintypes kept soldiers’ visual memories alive in their homes, while those on the front might have carries likenesses of wives, sweethearts, or mothers with them. But despite its underlying visual qualities, homesickness is, at base, about the absence of persons and scenes one most desires to see. Homesickness is based on a kind of interrupted vision, a blankness on the retina, filled in with snatched glances at a tintype in its protective case or re-imagined with the eyes closed. It is in light of this visually impenetrable homesickness that I reinterpret Homer’s 1863 painting Home, Sweet Home, which one reviewer described as possessing a “hearty, homely actuality.”

Home, Sweet Home, Homer’s first exhibition picture, appears to be a sentimental scene of camp life in which Union soldiers listen to a band play the popular sentimental melody “Home, Sweet Home.”  This supposed focal point is located in the far background of the scene, barely discernable as a cluster of blue-clad men listening to music. Homer instead focuses on the ersatz home of two weary soldiers: a meager fire of twigs, a boiling can of broth or coffee, discarded items of equipment placed on makeshift coat and boot racks. The two central figures seem intensely quiet, contemplative, their faces highlighted with broad strokes of the brush that make out sketchy lineaments rather than identifiable physiognomies. In her recent evaluation of the relationship between “inner” life and observed reality in Homer’s work, Elizabeth Johns interprets Home, Sweet Home as part of Homer’s maturation as an artist. She suggests that this canvas demonstrates the artist’s increased interest in psychological realism rather than the drama of battles, for it “probed other aspects of male psychology in war … [such as] homesickness.”  Julian Grossman agrees that Homer did experience a shift at some point during the war: “like other sensitive artists, he turned away from the face of death, away from the front, to scenes in camp, concentrating on the camaraderie formed during trials suffered together.”  In its rendering of a stand-in for the family hearth, Home, Sweet Home accessed both a generalized mid-century sentimentalization of family life and the fact of homesickness as a particular problem rampant among troops of both armies. In an 1862 letter to his wife, Union soldier John Henry Jenks specifically references the touchstone of the home’s hearth, here abandoned and cold “among all the desolations of war, the sundering of family ties, the deserted hearthstones, the vacant chairs, the intense solicitude for absent freinds [sic].”

The problem of homesickness is not merely the subject matter of the painting. Through numerous lacunae in the viewer’s apprehension of the scene, Homer constructs a quietly powerful narrative of homesickness that imagines “home” as an unknown territory: a blind spot. The first such blind spot is the immediate “home” of the camp as it is shown. The two-man tents that compositionally bookend the men and act as their temporary homes—mobile and ever-shifting sites where they merely rest themselves occasionally—are drawn as blanks: triangular, black gaping holes surrounding the central figures. In the crooks of their arms and the opening of the man on the right’s jacket to reveal a blood-red shirt beneath, the triangular forms of the tent flaps are mirrored in their bodies, physically tying them to these dim openings leading to unseen interior spaces. Barely emerging out of the left hand tent is the sole of a boot, catching a glint of light on its curvature, suggesting the body of a comrade within.

These darkened spots in the composition contrast directly with the beige canvas of the tents’ exteriors and, most dramatically, with the large and tattered piece of canvas hanging behind the standing man like a theatrical backdrop. Literary historian Martin Griffin uses the metaphor of the tableau vivant when discussing Bierce’s manipulation of time and memory in his Civil War stories. In the practice of tableaux vivants, a popular parlor game of the nineteenth century, human actors would recreate famous works of art or, dressed in elaborate costume and standing perfectly still, present a narrative in a series of posed scenes. Griffin argues that Bierce’s war stories may be read as tableaux, series of carefully framed narrative moments, complete with the gaps in memory, the temporal breaks, and the discontinuity this art form necessarily possesses. He writes: “Each tableau in the story is individually loaded with meaning, but exists only in its own context of realization.” It is an art form that is structured around the concept of a narrativity that is by necessity incomplete. Homer’s Civil War paintings, too, particularly the scenes of daily incidents in camp life including Home, Sweet Home, Playing Old Soldier, Pitching Quoits, The Last Goose at Yorktown, Sutler’s Tent, The Brierwood Pipe, and A Rainy Day in Camp, may be interpreted as a series of tableaux played out against sceneries as artificial as painted backdrops. This becomes even more striking when we note that five of these seven canvases feature similar backdrops of hanging or blank fabric.

But, particularly in Home, Sweet Home, which contains the largest and most prominent usage of this feature, these canvas curtains evoke not merely tableaux but also veils that block access to what lies behind, creating sites of indeterminacy. The representation of painted fabric curtains in the Western artistic tradition goes back to Pliny the Elder, and it has become a shorthand for epistemological uncertainty.  In a contest between Zeuxis and Parrhasius to paint the most convincing illusion, the latter wins by producing a painted curtain so lifelike that his competitor attempted to lift it to see the painting underneath. American artists and audiences were familiar with this story, most famously articulated by Raphaelle Peale in his painting Venus Rising from the Sea: A Deception.  Oddly for Homer, who was known and often mocked by contemporaries for his somewhat clumsy modeling and large, flat planes of color, the effects of light bouncing off the folds in the large swath of canvas in Home, Sweet Home are rendered in precise and almost illusionistic detail. The care lavished on this expanse of fabric—the largest single section of the painting other than the sky—suggests its importance in Homer’s composition. It serves here less as Parrhasius’s actual curtain than as a test for the viewer’s eye. Instead it cuts off the “home” of the painting from that larger home beyond. As Grossman writes, “Perhaps because home was around the corner, just up the road but still agonizingly far away, the longing was greater.”  As soldiers’ letters suggest, the true home ceased to feel real after a certain length of time in the “home” given by the army. One unknown young man wrote back to his mother in 1862: “What a day it was,—and a Sunday too! … I think of you all at rest, with the sound of church-bells in your ears, with a strange, distant feeling.”  Many wrote of home as a place they could only dream of, as Josiah B. Corban told his wife in a letter of 1863: “I dreamed of being at home how I wish it might come to pass. I wish George and Julia [their children] would write often they cant think how much I want to see them they seem very dear to me all the time.”  In Bierce’s story “The Mocking-bird,” which, as we have seen, ends with the tragic murder of John Grayrock by his twin, the main character “dreamed … himself a boy, living in a far, fair land by the border of a great river.”   Bierce slowly reveals this vivid dream as an actual memory of his happy home life before the war. The heartrending juxtaposition of the two homes—family home and army home, with neither feeling entirely real—the knowledge that home may be just beyond the curtain (but, then again, it may not), is what creates the claustrophobic homesickness of Homer’s scene.

A final void appears in the foreground: a sheaf of white papers on the knee of the seated man. He rests his hand on the paper, not clutching it to him, but not careless enough that it could fly away. What can be seen of the paper is merely blank whiteness. But it is easy enough to guess that here is yet another reference to Homer’s title: a letter home, perhaps unfinished. Homer does not pay special attention to these papers, except that, folded in the shape of a rough triangle, they are the only place where he has used a large quantity of true white in the painting. Homer had received the English translation of the French chemist M. E. Chevreul’s The principles of harmony and contrast of colours from his older brother Charles in 1860. He referred to the book as “my bible” and carefully studied Chevreul’s analysis of the relationship between visual perception, artistic communication, and use of color.  On the relationship between dark and light, he later told John W. Beatty, “It is wonderful how much depends upon the relationship of black and white. … The construction, the balancing of parts is everything.”  In Home, Sweet Home’s small patch of paper, Homer utilizes such a contrast for great effect. He surrounds this flash of white with darker hues—the black of the tent openings, the deep blue of the uniforms—to highlight its importance but also its emptiness. Soldiers sometimes emphasized that they did not know what to say to their loved ones, or how to say it. In 1863 Harrison Clarke wrote a friend that “I have frequently made the attempt [to write you] and as often failed.”  The page in Home, Sweet Home trumpets its blankness. There was no good way to describe the sights of war in a letter. But more importantly, home was a blind spot in the soldier’s mind, no matter how faithfully he attempted to conjure it in his imagination.

The Perils of Self-Recognition

Though Homer and Bierce shared a sensibility in their representations of war, they seem almost diametrically opposed when it comes to depicting themselves in their art. Homer never painted a self-portrait; Bierce seems constantly to be re-articulating his own traumatic experiences of the war in his fiction by writing about the battles he fought. And yet, we may consider both of them in terms of a kind of faulty or flawed self-recognition that is expressed through their art and the record of their experiences in the war. Several scholars have commented on and evaluated how traumatic events in the war may have affected Bierce and Homer, based upon the form and content of their works surrounding the conflict. Bierce seemed to cling more tenaciously to the memory of the war than Homer, seeing in the war the experience of a sort of fracturing of the self, from which he retreated with a carefully-cultivated reputation for ironical misanthropy. The prominent twentieth-century leftist intellectual Carey McWilliams wrote of Bierce: “The war was a troubling memory. It never left him; he mused and puzzled about it all his life. … one is impressed with the frequency of his references to war, the constant presence in his mind of its images, and the color that it gave his thinking and even his vocabulary.”  Martin Griffin reminds us of “the persistence of traumatic memory of combat experience within the psyche of the individual veteran,” describing Bierce’s literary output as a post-traumatic symptom characterized by “a merciless, almost nihilistic representation of contingency, violence, and unresolved conflicts of character and environment.”  Similarly, art historian Peter Wood notes that Homer left little record of how the war affected him and that it is probable that “shadows of combat remained a lasting part of Homer’s life.”  If these assessments of trauma seem presumptive or based on a sketchy foundation, we should recall that it was not until Bierce and Homer were both deceased that trauma related to wartime experiences became recognized as a medical condition rather than a constitutional weakness. The nature of historical trauma is complex, as Michael S. Roth reminds us. There is, on one hand, “the part that is repressed, or at least insufficiently attended to,” which can perhaps be seen in Homer’s apparent rejection of or lack of interest in the war later in his career. However, Roth continues, “the problem is not that the past event has been forgotten … but that the event has not been left behind successfully. It continues to have effects in the present.”  It is impossible, of course, to gauge with any accuracy what the actual psychological effects of the war may have been, and whether they led to cases of lingering trauma in these two men. However, as multiple scholars have made clear, we must consider the possibility that the shattering effects of the war inflected their later artistic and literary outputs.

Bierce’s psychological state has been the focus of much scholarship, for the war evidently consumed him until the end of his life. Homer, on the other hand, had a long and prolific career—continuing unabated for almost fifty years after the end of the war—filled with works that seem to have little bearing on the conflict. And yet numerous art historians have focused on Homer’s seeming obsession with the fragility of man in the face of violent and uncontrollable forces, usually the forces of nature such as sea squalls or snowstorms. Jules Prown interprets this thematic fixation as an unresolved quest for spiritual salvation, while Sarah Burns has read it as a response to the late-nineteenth-century cult of rugged masculinity.  But both interpretations may also be applied to the lingering effects of the war, which historians link both to a newly modern atmosphere of spiritual uncertainty around the turn of the century and to a crisis in masculinity brought on by the losses of the war, which was offset by increased focus upon manliness during the same years.  Merely because Homer completed all of his important Civil War paintings within two years of the peace at Appomattox does not mean that he worked through his trauma and got over it. He constantly returned to the theme of conflict in his later paintings of fishermen struggling against violent natural forces; art historian Paul Staiti describes nature in Homer’s late work as “a cold and amoral environment of chance and brutality, devoid of justice.”  Such an inexorable and pitiless conception of fate could almost have come from the pen of Bierce in his descriptions of muddled and terrifying Civil War battles. So also did Homer’s later work reflect continued interest in themes indirectly associated with the war, and can be seen in his dealings with postwar African American life and his focus on farm labor, a theme he began exploring during the war with The Brush Harrow, Haymaking, and On Guard, which portray children taking on grown men’s roles. Regardless of how we interpret the seriousness of the war’s traumatic resonance with Homer, it is clear that it had a lasting impression on the way he looked at and represented the world. The war changed both men greatly, and not only their minds were affected.

These men’s experiences of the war caused physical changes as well, leading to situations in which the authors’ very bodies became unrecognizable. Homer’s mother wrote to his younger brother that after being starved while traveling with the army on the Peninsular Campaign, her son was “so changed that his best friends did not know him.”  We may interpret this as a mental change, perhaps, but as she comments on the hardships he faced on the front, it seems likely to have been a physical change as well. Homer’s lack of recognition by his friends is nothing to the lack of self-recognition faced by Bierce when, around forty years after the end of the war, he embarked on a tour of the battlefields. This trip seems to have underwhelmed but also disturbed him as he attempted to understand and recapture some of the feelings of his own youth. He described the tour in a letter to poet Herman Scheffauer as a meeting between his present and former selves:

"twelve miles from here, my age and my youth met—the latter a trifle wan, ghostly, and absent-minded, inhospitable to questioning. What I mean is that I was in Oakland (Md.) forty-odd years ago, as a young soldier … This country has been Dreamland to me ever since. I know I should not have sought it again, to dispel the illusions, but I just had to; and I mean to go over all my old campaigning routes and battle grounds…"

The event of finding old familiar places to be strange and of finding the self irrevocably and unaccountably changed is chillingly recounted in the short story “A Resumed Identity,” which Bierce composed after he had taken his trip around those now unfamiliar battlegrounds. When the tale opens, the unnamed character is walking on a moonlit road during summer. Bierce describes how “the man looked curiously about him on all sides, as one who among familiar surroundings is unable to determine his exact place and part in the scheme of things.”  During the night he sees a procession of soldiers moving, as he believes, to take Nashville. Meeting a doctor on the road the next morning, he informs the doctor that he is a lieutenant in the regiment of General Hazen (as was Bierce) and inquires about the troops. Learning that the doctor “met no troops” he stumbles further along the road in confusion.  Finally coming upon a monument “brown with age, weather-worn at the angles, spotted with moss and lichen,” he reads that it commemorates the troops of Hazen’s brigade lost at the Battle of Stone River in 1862. Still a sense of recognition does not seem to occur in the man, until he is finally granted direct access to his reflection in “a pool of clear water” just adjacent to the monument. “He uttered a terrible cry” upon recognizing his own elderly face; “he fell, face downward into the pool and yielded up the life that had spanned another life.”  In the beginning of the story the soldier fails to recognize what should be familiar places, accounting his difficulty to a head wound he believes he has recently sustained in action; even the explicit signs of age appearing upon the monument do not seem to allow him to recognize his predicament. It is only the sight of his own time-ravaged countenance—his inner and most inviolate “home,” which he has consistently failed to recognize or know for sure throughout the story—that removes the veil of forty years and, ironically, is the cause of his ultimate death.

Homer offered no such haunting coda to his own wartime experiences, other than in the moody oil sketch Trooper Meditating Beside a Grave of c. 1865.  This quiet work was never exhibited during Homer’s lifetime. Though Homer never painted a self portrait, what the viewer can see of the man’s downcast face bears some resemblance to his own, at least in superficial features such as the “great waving moustache” and “red, or nearly red, hair” noted by Harrison Morris in an amusing description of Homer’s appearance. Covering his downcast eyes, the brim of the trooper’s cap blocks our access to his thoughts. The opening paragraph of Bierce’s “The Mocking-bird” finds Private Grayrock similarly with “his cap downward over his eyes, almost concealing them.”  Homer repeated this strategic marker of blindness in many Civil War scenes, including Sharpshooter, A Rainy Day in Camp, Home, Sweet Home, Sutler’s Tent, and even his supposed masterpiece of psychological insight, Prisoners from the Front. As one critic wrote of Homer, “There is nothing personal, or rather, subjective in his work. … He must give the essential nature of what he sees. He gives the true import … and leaves you there, saying nothing of the effect of the scene upon himself.”  While Bierce might give us too much of himself without ever coming to a resolution about the true identity of his war-shattered self, Homer holds back in indeterminacy, refusing to meet our gaze. Both display a lack of self-recognition. Bruised by the war, seeming to work through the catastrophe in different ways, Homer and Bierce show us continually, through the piercing power of their own ability to observe, that we cannot trust what we see, that we are always blind to the true story of the Civil War.

Image: Winslow Homer (American, 1836-1910), Trooper Meditating Beside a Grave, c. 1865, oil on canvas, 16 x 8 inches. Joslyn Museum, Omaha, Nebraska. Gift of Dr. Harold Gifford and Ann Gifford Forbes, 1960.298

From: ivc.lib.rochester.edu


Wednesday, November 12, 2014

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

 By Frank A. Sloan, PhD; Daniel W. Belsky, BA; 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, 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.

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. The program covered 85% of Union Army veterans who were alive in 1900 and more than 90% of veterans who were alive in 1910. 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 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 trachomawithin 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%).

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.

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.

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, 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, about 7% for diabetic retinopathy, and close to 8% for glaucoma. 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. 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). Urinalysis was used during this period to diagnose diabetes. 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. The disease now exists almost exclusively in low-income countries, where prevalence is similar to that found in our study, though it was sometimes higher depending on the region.

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 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) 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.

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, 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%. Rates for persons aged 60 to 69 years have been reported at 13% in Malaysia and 8% in Nepal.

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. The EDPRG estimated that among white Americans, cataract caused less than 9% of blindness, 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 older compared with more than 12% of the US population.

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. 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. Higher prevalence of trachoma, the most important infectious cause of corneal opacity, 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. 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. 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. Fogel 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, in his book Das Menschliche Augepublished 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, 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 Practitioner and Higgens' 1888 Ophthalmic Practice. 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, 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, writing more than 3 decades after Fuchs, Alt, and Higgens, characterized amblyopiaas 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. Fuchs wrote in 1898 that glaucoma accounted for less than 1% of all eye diseases. In 1900, Deyl and Sattler’s chapter “Diseases of the Optic Nerve” in Norris and Oliver's System of Diseases of the Eyemade no reference to glaucoma, though some connection with the optic disc was mentioned in Smith’s chapter on glaucoma in the same volume. Fuchs identified excavation of the optic nerve as the cause of blindness in advanced glaucoma but went no further. Both Alt and Higgens discussed glaucoma and the optic nerve separately. However, by the time Graeff’s text was published in 1933, examination of the optic nerve was used to diagnose glaucoma. Although tonometers existed in the late 1800s, 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 substantial 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.

From: archopht.jamanetwork.com

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



Tuesday, October 29, 2013

The Maryland School for the Blind

FROM: mdschblind.org

In 1853, Franklin Pierce had just been elected as the 14th President of the United States, Abe Lincoln was still a young congressman in Illinois, and most people would scoff at the very suggestion that, in the very near future, Americans would turn against Americans in a bloody Civil War. It was also the year that our school, known as the Maryland Institution for the Instruction of the Blind, first opened its doors in downtown Baltimore.

Starting with a small group of students, the school had three superintendents in the first 11 years. The first superintendent was David E. Loughery who was a blind graduate of the Pennsylvania Institution for the Instruction of the Blind. It then settled into a period of tremendous growth under the direction of Fredrick Douglas Morrison, who was superintendent from 1864 to 1904. A national leader in his profession, instrumental in the founding of the American Association of Instructors of the Blind and an early proponent of a then controversial new system called "braille", Mr. Morrison lead the nation by example.

In 1868 he moved the campus to much larger quarters on North Avenue and changed the name to The Maryland School for the Blind. In 1872, when segregation was still the law of the land, he was a founder of The Maryland School for the Colored Blind and Deaf and served as the superintendent of both schools. John Frances Bledsoe became superintendent in 1906.

In 1908 Mr. Bledsoe moved the school to its present location in the Northeast corner of Baltimore City. The leadership at The Maryland School for the Blind reads like a Who’s Who in Education for the Blind in America. Francis M. Andrews, Herbert Joseph Wolfe, and Richard L. Welsh were all internationally recognized innovators who moved the school forward into the 20th century.

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