97 Ophthalmia (Conjunctivitis and Trachoma)

In its broadest sense, ophthalmia is an inflammation of the eye, especially of the conjunctiva of the eye. The term derives from the Greek word ophthalmos (the eye). Hence, almost any disease that attacked the eye was called ophthalmia in many Greco- Roman and later European sources until the begin­ning of the twentieth century.

Trachoma (also called granular conjunctivitis and Egyptian ophthalmia) has been defined as a conta­gious keratonconjunctivitis caused by Chlamydia trachomatis (serotypes A, B, Ba, and C). It is charac­terized by the formation of inflammatory granula­tions on the inner eyelid, severe scarring of the eye in the fourth stage, and blindness (but not in all cases). It was one of the leading causes of blindness in the past, and still blinds millions in Asia, the Middle East, and Africa (Bietti and Wemer 1967; Rodger 1981; Insler 1987).

Conjunctivitis {purulent ophthalmia) may appear with trachoma and may complicate the progression of the disease so that blindness rather than healing occurs. Although conjunctivitis may denote any in­flammation of the conjunctiva (“the mucous mem­brane lining the inner surface of the eyelids and cover­ing the frontpart of the eyeball”), bacteria often infect the conjunctiva at the same time as does trachoma, thus causing an acute bacterial conjunctivitis. In the Middle East, for example, “spring and fall epidemics of gonococcal and Koch-Weeks conjunctivitis ac­count for much of the comeal scarring seen in these populations” (Thygeson 1964).

Ophthalmia neonatorum is a term used for eye disease in newborns since the Greeks, but vague historical references make it difficult to identify the actual disease. Blindness in newborns may be due to various infections acquired in the birth canal. Before the twentieth century, ocular gonorrhea may have been the major cause of blindness in newborns, but in the twentieth century (at least in the industrial­ized nations) chlamydial infection is the most com­mon type of ophthalmia neonatorum (Thygeson 1971; Rodger 1981; Insler 1987).

Distribution and Incidence

Trachoma remains widespread in the twentieth cen­tury. Two estimates place the number of victims worldwide at 400 million to 500 million, with mil­lions suffering from sight defects and perhaps 2 mil­lion totally blinded (Bietti and Wemer 1967; Rodger 1981).

In 1935 Adalbert Fuchs found that the greatest frequency of the disease was in Egypt, “where 98 percent of schoolchildren in the fourth grade are afflicted by trachoma” (Fuchs 1962). In the 1960s, Egypt still led the list of areas where a majority of the population was affected. Because a dry climate seems to affect incidence, among the highest rates of infection are the countries of North Africa and the Muslim Middle East-that is, from Morocco to Egypt and the Sudan in North Africa, and from the Red Sea to Turkey and Iran in the Middle East.

Etiology and Epidemiology

Trachoma generally requires prolonged contact among individuals in filthy and overcrowded living conditions for transmission. In endemic areas, infec­tion first occurs in childhood as a result of close family contact. Transmission may be from mother to baby, from eye to eye, by fingers, and by eye-seeking flies. In urban slums or poor villages where people live crowded together under unsanitary conditions, garb­age and raw sewage attract flies that breed copiously. As the insects swarm on the faces of infants and children, they feed on the infected eye discharges of those with trachoma and carry it to the eyes of other victims. Most children in endemic areas have tra­choma at an early age, but hosting the disease in childhood does not provide a lifelong immunity.

Trachoma transmission may also occur by direct touch, by the contamination of clothing or bedding, possibly by bathing in pools in which people swim and wash, and by sexual means. According to B. R. Jones:

[I]n the vast majority of cases infection (with the TRIC agent) is transmitted from person to person by intimate sexual contact involving at various times genital, rectal, oral or other mucosal surfaces. No doubt it can be directly transferred to the eye during such activities. However, in the vast majority of cases it appears to be transferred to a genital mucosal area, and then by means of transferring a genital discharge by hand, or other vectors, it reaches the eye. (Cited by Rodger 1981)

Factors that contribute to the severity of trachoma are ocular irritants and bacterial conjunctivitis. It is most prevalent where the climate is hot and dry, and low humidity leads to excessive drying of the con­junctiva. Winds and dust, along with smoke in un­ventilated huts, further irritate the eyes. Bacterial infections, particularly the seasonal outbreak of bac­terial purulent conjunctivitis, often cause the worst cases. Frederick Rodger (1981) suspects that such infections are “related to the peak period of reproduc­tion of the fly population.”

Clinical Manifestations and Pathology

Trachoma

The clinical features of trachoma are usually divided into four stages, following the classification system of A. F. MacCallan published in 1931:

Stage 1 (incipient trachoma) is characterized by increasing redness of the conjunctiva lining the up­per lids and covering the tarsal plate. Magnification reveals many small red dots in the congested con­junctiva. As the organism proliferates, larger pale follicles appear. Both features then spread across the upper conjunctival surface. A minimal exudate oc­curs, which may be more profuse if there is a secon­dary bacterial infection. This stage is difficult to distinguish from the similar follicles of folliculosis and follicular conjunctivitis.

Stage 2 (established trachoma) marks the increase of all the symptoms established in Stage 1 and is often termed the “florid stage” because of the “florid inflammation mainly of the upper tarsal conjunctiva with the formation of follicles” and then of papillae with the “follicles appearing like sago grains.” The pannus increases toward the apex of the cornea. Because the red vessels in the cornea are dilated, they are visible to the naked eye. In severe cases, because a secondary bacterial infection may worsen the appearance of the eye, there will be purulent and copious secretions. In dark-skinned populations the conjunctiva may take on pigment, which remains after the healing stage. The duration is 6 months to several years.

Stage 3 (cicatrizing trachoma) is the scarring and healing stage. The follicles rupture, and scar tissue forms on the undersurface of the upper lids. Scar tissue also appears elsewhere on the conjunctiva. At first, the scars are pink but later turn white. It is not uncommon for a new infection of C. trachomatis to occur at this stage and to start the process all over again. Thus Stages 2 and 3 may coexist for many years and may be further complicated by repeated bacterial infections. With each new attack, more scar tissue appears, and an ever-increasing pannus covers the cornea. This phase may be several years in duration.

Stage 4 (healed trachoma) is the final stage of the disease in which healing has been completed without any signs of inflammation, and the disease is no longer infectious.

Conjunctivitis

Simple acute conjunctivitis is a common eye infec­tion, caused by a variety of microorganisms. Its most characteristic sign is the red or bloodshot eye. In mild cases, there may be a “feeling of roughness or sand in the eyes,” but in serious cases there is “great pain” and photophobia (dread of light). In its early stages discharges from the eyes are thin and serous, but after a few days they may become so purulent that the secretions gum the lids together, and it becomes difficult to open the eyes, especially upon waking. The infection often begins in one eye before spreading to the other one. An acute conjunctivitis may last for 1 to 2 weeks (Thomson 1984).

Severe forms of conjunctivitis include ophthalmia neonatorum, due to infectious discharges in the birth canal; follicular conjunctivitis, which is often con­fused with the early stages of trachoma; phlyctenu­lar conjunctivitis, which may lead to ulceration in the cornea; and a highly infectious hemorrhagic con­junctivitis, which affected 15 to 20 million in India in 1981 (Thomson 1984).

Gonococcal conjunctivitis, due to Neisseria gonor­rhea, infects newborns as well as children and adults. Whereas newborns acquire the eye disease in the birth canal from their mother’s vaginal secre­tions, others may contract the disease by direct or indirect contact. Although there may be nonvene- real transmission - especially in the tropics - the disease is now transmitted mainly by sexual inter­course. In infants the eyelids may be very swollen, and ulceration of the cornea often follows. Ocular gonorrhea infection used to be one of the principal causes Ofblindness in Europe until the 1880s, when a silver nitrate solution came into use in newborns. Since then, “the dramatic decrease in blindness that has resulted” is “one of great victories of scientific medicine” (Thygeson 1971; Insler 1987).

In contrast to gonococcal conjunctivitis, which has declined in the developed world, chronic follicular conjunctivitis and acute conjunctivitis in newborns have been on the increase along with other sexually transmitted diseases. ^llChlamydia trachomatis [sero­types D through K] is now the most common sexu­ally transmitted infection in the developed world” (Insler 1987). It causes not only conjunctivitis in newborns and adults but also genital tract infec­tions. In adults symptoms of chronic follicular con­junctivitis include “foreign body sensation, tearing, redness, photophobia, and lid swelling.” In newborns inclusion conjunctivitis or blennorrhea of the new­born usually appears 5 to 14 days after birth, since the baby acquires the chlamydial infection during its passage through the birth canal. Descriptions of infants with purulent ophthalmia - abnormal dis­charges of mucus some days after birth - may sug­gest this disease. Because purulent ophthalmia usu­ally does not lead to severe visual loss, blindness in newborns is more likely due to gonococci and other bacteria that often complicate chlamydial infection.

The herpes simplex virus, other viral infections, or other bacterial infections (due to Staphylococcus or Pseudomonas) may also cause an ophthalmia neona­torum (Insler 1987).

History and Geography

Antiquity

Trachoma is an ancient disease. It was known in China in the twenty-seventh century B.C. (Bietti and Werner 1967) and ancient Egypt from the sixteenth century B.C. In 1872 George Ebers discovered a medi­cal papyrus at Thebes that clearly described a chronic conjunctivitis (ophthalmia, lippitudo, chronic granu­lar disease). The ancient Egyptians called the disease Hetae, and their symbol for it was the rain from heaven, which means a flowing downward of fluid. The papyrus also describes the white spot (sehet) or leukoma of the cornea, but still more clearly “the hairs in the eye” (shene m mert) or trichiasis (inward­growing eyelashes). All of this is very suggestive of trachoma (Worms and Marmoiton 1929; Hirschberg 1982; Meyerhof 1984).

Greek and Latin. By the time of the ancient Greeks, eye inflammations (ophthalmia) were fre­quently described and sometimes defined, and in about A.D. 60 the term trachoma (“roughness”) first was used by Dioscorides (Worms and Marmoiton 1929; Chance 1939). Although the Hippocratic books do not define ophthalmia precisely for us, Galen defines it as “an inflammation of the conjunctiva.” The Greeks also used the term Iippitudo (exudation from an eye) for the secreting eye, which is a possible reference to trachoma. Later Greek authors distin­guished among a severe irritation of the conjunctiva, the true conjunctivitis or secreting eye, and a simple conjunctivitis. The most important reference to tra­choma comes from the book On Vision, in which the Hippocratic corpus describes not the disease but rather its treatment. It stresses the scraping of the lids of the eye along with the cutting away from their inner side of the fleshy granulations followed by cauterization of the lid with a hot iron. Another book in the Hippocratic corpus describes an early operation for trichiasis (Meyerhof 1984). Possibly one reason for the amount of attention given to tra­choma in the Hippocratic corpus is that there ap­pears to have been a major outbreak of the disease among the Athenians during the Peloponnesian War (431 to 404 B.C.) (Chance 1939; Comand 1979).

For the treatment of trachoma, Greek physicians stressed scraping thickened lids with fig leaves or the rough skins of sea animals, such as sharks. Writ­ing in Latin in the first century A.D., Celsus de­scribes trachoma, which was then called aspiritudo. “This [roughness] often follows inflammations of the eyes, sometimes more sometimes less violently. Sometimes this roughness is followed by a running eye.” He also recommended treatment for trichiasis. About A.D. 45, a younger contemporary of Celsus wrote a book of remedies for many diseases, includ­ing several for trachoma. The Greek physician Dioscorides recommended fig leaves and the shell of octopus for scouring the “rough and fig-like granula­tions of the lids.” Galen also refers to the octopus­shell as well as to the skin of sharks for scraping the lid in severe cases of trachoma (Meyerhof 1984).

The Romans were also well acquainted with tra­choma. The movement of Roman troops throughout the empire must have dispersed trachoma from the Mediterranean region to wherever the Roman sol­diers sought to extend the empire. Some evidence for trachoma on the frontiers of the Roman Empire (France, England, and Germany) comes from the stone-seals of Roman oculists, which record the names of remedies used for trachoma (James 1933; Chance 1939). Roman medical books also include typical remedies for the ailment. In the fourth cen­tury A.D., Theodorus Priscianus reported his per­sonal experiences with patients who suffered from “the malady of roughness {asperitatis vitium)”; he used garlic juice to anoint the conjunctiva. In the sixth century A.D., Christian physicians from Asia Minor - Alexander of Tralles and Aetius of Amida - referred to trachoma and trichiasis. Aetius distin­guished four stages of trachoma (dasytes = “density” = slight thickening of the conjunctiva; trachytes — “roughness”; sykosis = “figlike granulation”; and tylosis = “callousness” = cicatricial trachoma) (Chance 1939; Meyerhof 1984). To some extent this understanding of the disease is reflected in the tra­choma descriptions in the seventh century A.D. of Paul of Aegina, an Alexandrian physician:

Trachoma is a roughness of the inner surface of the lids. When the disease is of greater intensity it is also called “fig disease.” If the disease is chronic and cicatricial then it is called “scar.” Topical medications are indicated. They consist of wine and two kinds of red iron ore. These are washed and then the inner surface of the lid is gently cauterized. (Hirschberg 1982)

Paul also provides descriptions of trachoma treat­ments. He refers to everting the lid and scraping it with pumice, octopus shell, fig leaves, or an instru­ment. Patients with trichiasis were operated on with a needle and thread, a procedure that was re­invented in 1844. To prevent inflammation of the eyes, he recommended the method of “cutting and of burning the forehead and temples” - a treatment that was used on St. Francis of Assisi in medieval Italy and that was still common among Egyptian peasants in the twentieth century (Meyerhof 1984; Green 1987). Paul and Aetius were also familiar with eye diseases in newborns. Paul, for example, referred to a “purulent exudation” in the eyes of newborns, while Aetius recommended the irrigation of the eyes of a newborn - “oil should be dropped into them” (Hirschberg 1982).

Arabic. After the important medical writings in Greek or Latin, the next significant surviving trea­tises on eye diseases are in Arabic, dating from the eighth and ninth centuries A.D. Unfortunately, ear­lier texts by Syriac-speaking Christians of Syria, Mesopotamia, and Persia have been lost except for one that follows Galen. The later Arabic authors, however, enable us to continue to track trachoma through accurate medical descriptions. In the ninth century, the first attempt, by Ibn Masawaih, does not provide a good description of trachoma but does refer to pannus and trichiasis. His successor and pupil, Hunain ibn Is-haq, distinguished the four forms of trachoma, using the Greek names but with Arabic explanations. He also called pannus “vari­cose ophthalmia” (Meyerhof 1984).

According to Max Meyerhof, the best Arabic sources on eye diseases including trachoma were composed after A.D. 1000. The first and best of these is The Memorandum-Book of a Tenth-Century Ocu­list (Tadhkirat al-Kahhalin), composed in the early eleventh century A.D. by a Christian oculist living in Baghdad, Ali ibn Isa. As well as distinguishing 13 diseases of the conjunctiva and 13 of the cornea (Hirschberg 1985), he clearly describes trachoma:

Trachoma is of four kinds: the first exhibits redness at the surface of the inner side of the lid. Its symptom is that you see, when you evert the lid, something like grains resem­bling those of dry mange (hasaf). It is less severe and painful than the three other kinds. It is accompanied by lachrymation: it mostly follows an acute ophthalmia (ramad = acute conjunctivitis). In general, the causes of all the kinds of trachoma are saline humours, long expo­sure to the sun, dust and smoke and improper treatment of ophthalmia....

The second kind of trachoma exhibits more roughness that [sic] the first; it is associated with pain and heaviness, and both kinds produce in the eye moisture and lachrymation....

The third kind of trachoma: It is stronger and more severe than the second kind and has more roughness. Its symptom is that you see the surface of the inner side of the lid like a split-up fig; therefore this kind [is] called the “figlike” (sycosis)....

The fourth kind of trachoma is more grave than the three other kinds and exhibits still more roughness; it is more dangerous and chronic. It is associated with severe pain and callosity, and it is impossible to root it out in a short space of time, on account of the thickening of the lid, especially when it is old. Sometimes it causes the growth of superfluous lashes. Its symptom is that you see on the everted lid a dark-red blackish colour and on it a kind of prominent crust (cicatricial tissue). (Meyerhof 1984; Hirschberg 1985)

This is the first time that the connection between trichiasis and trachoma was made in the literature (Meyerhof 1984). It is also the best description of trachoma and its treatment written in antiquity and probably the best until the work of J. N. Fischer of Prague in 1832. Certainly subsequent works in Ara­bic do not improve on Ali ibn Isa’s, because most copied his chapters on trachoma. One exception is The Luminous Support on Eye-Diseases by the Cairo oculist Sadaqa ibn Ibrahim al-Sadhili, who used his personal experience in ophthalmic operations to write his textbook in the second half of the four­teenth century. For the first time, as Meyerhof (1984) notes, we have a reference to the “frequency of certain eye-diseases in Egypt.... The inhabitants of Egypt suffer mostly from ophthalmia, on account of the abundance of dust and sand in their land.” He goes on to describe the four kinds of trachoma, but what is new, he notes, is that “one of the forms developes [sic] from the preceding form by inappro­priate treatment. He insists on the frequency of trichiasis with the fourth and most severe form of trachoma” and states that “pannus is often a sequela of ingrown lashes.” Furthermore, he reported that “pannus is often observed after a neglected acute ophthalmia or a very chronic trachoma.”

The Greeks and the Arabs thus knew far more about trachoma than did their counterparts in Eu­rope until the nineteenth century. They recognized different forms of trachoma (MacCallan’s four stages in contemporary language); the follicles and papillae, which they compared to the appearance of a halved fig; the scars; the contagiousness (some­times referred to as “heredity,” meaning “in the family”); and the danger of old trachoma, or reinfec­tion. The Arabs were also able to recognize the con­nection of trichiasis and pannus with trachoma, and their operative and topical treatments of tra­choma were superior to those in the West (Meyer­hof 1984). From the accuracy of their descriptions, it is clear that they had had a long acquaintance with the disease.

Europe from Medieval Times Through the Eighteenth Century

In contrast, Medieval Europe was poorly prepared to confront trachoma when it appeared in epidemic forms, often accompanying returning Crusader ar­mies from North Africa or the Middle East (Comand 1979). Because Arab authors used the term jarab (scabies), medieval Latin translators from the Ara­bic called trachoma “scabies.” As late as 1561, Pierre Franco would term the disease scabie et prurit en oeil (Hirschberg 1985). That trachoma existed in Jerusa­lem is attested by the writings of Benvenutus of Jerusalem (thirteenth century), whose description of his surgical treatment of trachoma survives (Chance 1939; Hirschberg 1985). Because of the frequent movement of Italian merchants and crusading ar­mies between Italy and the Middle East, it is not surprising that Italy and especially Salemo became a center of knowledge about eye diseases (Chance 1939). Arabic and Greek writers were translated into Latin and influenced Italian concepts of tra­choma and its treatment. At the end of the thir­teenth century, Lanfranchi of Milan referred to a trachoma treatment (Worms and Marmoiton 1929). One possible description of trachoma from medieval Italy appears in a biography of St. Francis of Assisi, which traces the progression of his ophthalmia, ac­quired on a trip to Egypt and the Middle East. “Wip­ing the tears from his sore eyes,” he returned to Italy, in the early stages of the disease. As his sight deteriorated, he sought treatment at an ophthalmia center in Rieti and later underwent cauterization on both temples with a hot iron, an ancient treatment for trachoma. He was finally blinded shortly before his death (Green 1987).

In the fourteenth century, French surgeon Guy de Chauliac provided a “recognisable description” of trachoma (Boldt 1904; Chance 1939), whereas in England one medical tract on eye diseases survives from the same century. Written by John of Ardeme in 1377, it concentrates on treatments that seem characteristic of folk medicine, but some references suggest trachoma, although a form of conjunctivitis is more likely. Crocus, for example, “relieves the redness of the eyes and stays the flux of humours to the eye, it deletes pannus, which is macula of the eye, for it becomes dissolved and wasted away.” His cure for Iippitudo (the Greek term for “secreting

eye”) and watery eye included fresh butter and a man’s urine (James 1933).

Although trachoma was poorly identified, one sus­pects that it remained established in medieval and early modern Europe and did not die out between the period of the Crusades and the sixteenth century, when notable epidemics of “ophthalmia” occurred in connection with the movement of armies. A well- known epidemic occurred in 1556, and was described by Forestus. English doctors characterized the dis­ease by the term paupieres murales, because the conjunctiva seemed to them to be like a wall (Worms and Marmoiton 1929). A little later, Jean Costoeus referred to the treatment of trachoma by cautery. Other epidemics similar to the 1556 epidemic oc­curred at Breslau in 1699 and 1700, and again among the English troops at Westphalia in 1762. In the second half of the eighteenth century, trachoma epidemics swept through Sweden and Finland (Worms and Marmoiton 1929).

Napoleonic Period

Although trachoma was a problem in Europe long before 1800, it could also be imported, as it was after Napoleon Bonaparte’s campaign in Egypt (1798­1801), when an ophthalmia epidemic swept Europe. Many of the returning French troops had lost their sight as a result of “ophthalmia.” Trachoma and forms of conjunctivitis were still endemic in Egypt. Indeed European travelers to Egypt, especially those of the eighteenth century, referred to Egypt as “the land of the blind.” A Bohemian visitor even de­scribed the “masses of flies on the eyes of the na­tives, especially children,” and he attributed the prevalence of eye disease to the “general filthiness” of the poor. Meyerhof (1932) suggests that the inci­dence of trachoma and blindness had increased in∣ Egypt under the rule of the Mamelukes and Turks, when 2 million peasants were living in misery. Per­haps it was that combination of poverty and the arrival of a foreign army that set the stage for the terrible epidemic or epidemics of “ophthalmia” that would torment Europe for half a century.

In any event, when Napoleon’s 40,000 troops in­vaded Egypt in the summer of 1798, they first suf­fered from a contagious ophthalmia, which was probably the conjunctivitis caused by the Koch- Weeks bacillus, prevalent in Egypt during the sum­mer months. By September, “few soldiers had es­caped ophthalmia,” and cases had become acute. Some were suffering from gonorrheal conjunctivitis and trachoma, and soldiers had “eyes completely blinded by the swelling of the lids.” Of one group of 3,000 soldiers, 1,400 were unable to fight because of “ophthalmia.” Thousands of others suffered from eye diseases, and the blinded were either hospitalized, sent home, or, in their helpless condition, massacred by local people or armies. Many veterans of the Egyp­tian campaigns continued to suffer from eye prob­lems for years after their return to Europe (Meyer­hof 1932).

The Turkish and British armies in Egypt also contracted ophthalmia. It was the British who first characterized it as contagious, a theory not always accepted in the nineteenth century. A British sur­geon, George Power, described the disease as a “puru­lent conjunctivitis,” which had been prevalent among the Irish peasantry about 1790. Actually, epi­demics of ophthalmia had been common among the peasants of Ireland in the eighteenth century, and Power regarded it as infectious and of “a species of the same disease” as Egyptian ophthalmia (Collins 1904; Meyerhof 1932). The French military surgeon Dominique Jean Larrey referred to the contagious disease of “granular conjunctivitis” in 1802 (Chance 1939).

“Egyptian ophthalmia” accompanied the British troops on their return to England and Ireland, where it became known to “almost every medical practitioner” by 1806 (Meyerhof 1932). As early as 1802, Patrick MacGregor described granulations that he observed on the conjunctivae of 56 veterans who had returned from Egypt. “In all of them the eye-lids were more or less affected; and when the inner surface of the eye-lids was examined with a magnifying glass, the small sebaceous glands situ­ated there were found increased in size, and of a redder colour than natural” (Meyerhof 1932). Most writers on that epidemic, according to E. Treacher Collins (1904), stress “the purulent character of the discharge, the acuteness of the symptoms, and the rapid and destructive ulceration of the cornea which was liable to ensue - characteristics which we associate today with gonorrhoeal ophthalmia rather than Trachoma.”

When the British tried to capture Egypt in 1807, the troops again came down with acute ophthalmia; and when they moved on to Sicily, they spread the disease there. Ophthalmia continued to ravage the British army for about 10 more years. By 1818, over 5,000 men had been invalided from the British army for blindness. The epidemics, of course, had spread to the other armies who fought during the Napoleonic period. The Italian troops were infected in 1801 at Elba and Leghorn by the French. This epidemic lasted until 1826. The Italians carried the disease to the Hungarian (1809) and Austrian (1814) armies. One of the most severe epidemics was in the Prus­sian army from 1813 to 1817, when 20,000 to 25,000 men were affected. From there it passed to the Swed­ish troops in 1814, and to the Dutch in 1815. More than 17,000 troops were attacked in the Russian army during the years 1816 to 1839, and by 1834, 4,000 Belgian soldiers had become completely blind. In fact, in 1840 one in five in the Belgian army still suffered from ophthalmia. When the epidemic hit Portugal in 1849, it affected 10,000 soldiers over an 8-year period. It even reached Cuba in the New World in 1813, where it devastated 7,000 soldiers, “most” of whom “became blind.” Because of its asso­ciation with soldiers in the nineteenth century, the disease had become known as “military ophthal­mia,” with some even believing that it was an “eye affection exclusively found among soldiers” (Boldt 1904; Worms and Marmoiton 1929; Meyerhof 1932; Hirschberg 1986).

The interesting question, of course, concerns the identity of the ophthalmia contracted in Egypt and disseminated in Europe. According to Meyerhof (1932), the diseases that afflicted the French, Turk­ish, and British forces were the same eye diseases that prevail in Egypt: two forms of conjunctivitis - (1) acute catarrhal conjunctivitis caused by the Koch-Weeks bacillus and (2) acute purulent conjunc­tivitis caused by the gonococcus, sometimes blended with streptococcus or pneumococcus, which is often Aallowedbypostgonorrhealconjunctivitis — and genu­ine trachoma in its various stages. When trachoma occurs along with an acute form of conjunctivitis, such as the Koch-Weeks, and when it attacks adults, it tends to be more severe and contagious. Lack of sanitation in the armies and among the local popula­tion facilitated the rapid spread of the ophthalmias. Meyerhof also contrasts the high incidence of ophthalmia among the British troops in the early nineteenth century with only scattered cases among them in the twentieth century. This he attributes to the vastly improved hygienic conditions among the troops.

Not all the eye ailments that afflicted nineteenth­century European armies, however, came from Egypt. As we saw, trachoma had existed in Europe before Napoleon’s time and, in fact, according to J. Boldt (1904), had long been endemic in Central Europe — from the Gulf of Finland to the Carpathian Mountains. Thus, when the Prussian army of the Napoleonic period became infected with trachoma, it was not due to the Egyptian epidemic, he believes, but rather to massive troop mobilizations that en­listed trachomatous recruits from endemic areas in Central Europe. It may have been the case, then, that the war of the Napoleonic period facilitated the dissemination of trachoma and other eye diseases throughout Europe, only some of which owed their origin to the Egyptian campaigns.

Nineteenth Century

With the disbanding of armies and the return of peace in the first half of the nineteenth century, trachoma virulence declined in Europe; but as Euro­pean nations turned their attention to imperial wars in Asia and Africa, the disease was on hand to attack the armies stationed abroad. Indeed, Collins (1904) notes that wherever British troops were quartered in the nineteenth century, ophthalmia “flourished.” Soldiers came down with the disease in Africa, In­dia, Ceylon, the West Indies, the Mediterranean, and Canada. In the German protectorate of the South Sea Islands, the Germans encountered a high inci­dence of ocular disease, including trachoma (1910­12). Military records thus permit historians to trace trachoma incidence throughout the world in the nineteenth century (Boldt 1904; Collins 1904; Cora- and 1979; Kluxen and Bernsmeier 1980).

But the civilians carried the disease as well. Both voluntary and forced immigrants brought ophthal­mia with them to the Americas. The British re­corded cases of trachoma among immigrants from Poland, Finland, Russia, and Armenia, who were in transit to the United States or Canada. The problem of contagious eye diseases was so serious that the United States and Canada declared trachoma to be a “dangerous” disease and prohibited the entry of those infected with it. Nonetheless, many immi­grants escaped detection. Among the immigrants with a high incidence of the disease were the Irish, for ophthalmia epidemics had been severe in the famine-plagued Ireland of the 1840s (Boldt 1904; Collins 1904).

Ophthalmia also attacked the “involuntary immi­grants” of the nineteenth century. What was called “Egyptian ophthalmia” or just “ophthalmia” was one of the most feared diseases of the slave trade, as it could sweep through slave ships, blinding the entire cargo and crew of a slaver. If fortunate, a few of the crew would regain their sight and bring the ship into port. Ships where this was not the case were on occa­sion discovered drifting helplessly on the open seas. In 1819, the French slave ShipLeRodeur experienced one of the best-documented cases of ophthalmia. The ship had traded at Bonny in West Africa. About 2 weeks into the voyage, the first symptoms of the disease appeared among the slaves in the intermedi­ate deck, and soon after this, the crew was infected:

In the morning when the patient wakes up he notices a slight irritation and itching at the lid margins which ap­pear red and swollen. On the next day the lids are more swollen and the patient experiences severe pain.... On the third day there is a secretion which appears yellow and thick, but later turns green and stringy; the secretion is so ample that every 15 minutes when the patients open their lids a few drops escape. There is from the beginning considerable photophobia and epiphora... the pain in­creases from day to day, similarly, the number of blinded patients;... Some of the sailors were three times affected by the disease. When the lid swelling decreased one could see a few vesicles on the bulbar conjunctiva. (Hirschberg 1986)

When the ship arrived in Guadeloupe, those af­flicted found their condition quickly improved by eating fresh fruit and by washing their eyes with fresh water and a lemon extract, which a black woman had recommended; but the epidemic had blinded 39 blacks and 12 crew members. The others lost vision only in one eye or had severe corneal scars (Hirschberg 1986).

Descriptions of ophthalmia also came from British reports on the conditions aboard slave ships that the Royal Navy detained in the nineteenth century. Thomas Nelson, a British surgeon, recorded two ship­board epidemics of blinding ophthalmia on slave ships off the coast of Brazil (1846). He reported on “swollen eyelids,” a “discharge which keeps con­stantly trickling down their cheeks,” and “ulcers on the cornea.” Of particular interest is his description of the treatment of infected slaves with silver ni­trate, which is now used in newborns to prevent blindness due to ocular gonorrhea.

When slave dealers unloaded the infected slaves in the markets of Brazil, epidemics of ophthalmia broke out in the port cities. In the 1830s and 1840s, slave ships from Angola and Benguela repeatedly introduced the disease into the slave market of Rio de Janeiro, and from there it spread into the city and to surrounding plantations. The exact cause of the ophthalmias in slaves is, however, difficult to determine.

On the other hand, ophthalmia was not the only cause of eye disease among slaves. Although descrip­tions of the blind (Luccock 1820) and the medical study of J. F. X. Sigaud (1844) suggest that trachoma was responsible for some blindness in Rio, Julius Hirschberg (1982-6) blames the epidemic aboard the Le Rodeur on an acute or contagious form of blennorrhea. Blinding ophthalmias also seemed to have appeared frequently in the same slaves suffer­ing from measles or smallpox; one of the slave ships Nelson examined, for example, that had been struck with ophthalmia had also experienced an epidemic of smallpox. Interestingly, during the North Ameri­can Civil War, many soldiers had ophthalmia after virulent smallpox and measles epidemics (Cunning­ham 1958). Fmthermore, blacks in the eastern United States seemed to escape trachoma. Swan Bur­nett of Washington observed only six “suspicious cases” of trachoma among 10,000 blacks (Boldt 1904). In Cuba, blacks had a lower incidence of the disease than whites-1.1 per 100, with a slightly higher rate of 2.3 for mulattoes. In sharp contrast, the incidence for whites was 42 per 100 (Santos Fernandez 1901). Although Africans and their de­scendants clearly contracted trachoma in Brazil, Cuba, and Africa (Rodger 1959, 1981; Fuchs 1962), such descriptions suggest that historians cannot at­tribute all ophthalmias in black slaves to trachoma. Along with acute conjunctivitis, other diseases that affect the eye, such as smallpox, measles, leprosy, tuberculosis, syphilis, and onchocerciasis (river blindness), doubtless also blinded slaves.

By the nineteenth century, the term ophthalmia had come to cover an extraordinary variety of identi­fiable and imaginary eye diseases in medical text­books. Hence, such terms as cachectic, senile, meno­pausal, abdominal, and scrofulous were attached to the word ophthalmia (Furnari 1845; Hirschberg 1986). Only in the twentieth century were the actual causes of eye diseases isolated, and more accurate scientific descriptions of trachoma and conjunctivitis made possible.

Mary C. Karasch

I am grateful for the assistance of Professors Leo Gerulaitis and Barry Winkler of Oakland University.

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