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The Medical History of the American Civil War III

Friday, September 4th, 2015

This continues the series from a lecture I have given a few times.

William W Keen was a student when he first served as an Army surgeon at Bull Run. That experience changed the Army medical services and gave a great deal of power to the volunteer organizations.

William Hammond quickly replaced the incompetent surgeons who had been in place when the war began. He was competent but argumentative and clashed with Stanton who became Secretary of War.

Hammond met Jonathan Letterman. Hammond worked with Letterman and Rosecrans on the design of a new ambulance wagon.

The atmosphere in the upper levels of medical services was then one of internal strife and personal conflicts. Hammond—a tall and imposing young man[12]—was no man of intrigue, nor even, according to all accounts, a very flexible person. However, the situation offered him the possibility for advancement. When Finley, the 10th Surgeon General, was fired after an argument with Secretary of War Edwin M. Stanton, Abraham Lincoln, against Stanton’s advice and the normal rules of promotion, named the 34-year-old Hammond to succeed him with the rank of brigadier general. Hammond became Surgeon General of the Army on 25 April 1862, less than a year after rejoining the army.

Lincoln liked “Men who fight” and defended his choices but Hammond was just too hard headed.

On his initiative, Letterman’s ambulance system was thoroughly tested before being extended to the whole Union. Mortality decreased significantly. Efficiency increased, as Hammond promoted people on the basis of competence, not rank or connections, and his initiatives were positive and timely.

On 4 May 1863 Hammond banned the mercury compound calomel from army supplies, as he believed it to be neither safe nor effective (he was later proved correct). He thought it dangerous to make an already debilitated patient vomit. A “Calomel Rebellion” ensued, as many of his colleagues had no alternative treatments and resented the move as an infringement on their liberty of practice. Hammond’s arrogant nature did not help him solve the problem, and his relations with Secretary of War Stanton became strained. On 3 September 1863 he was sent on a protracted “inspection tour” to the South, which effectively removed him from office. Joseph Barnes, a friend of Stanton’s and his personal physician, became acting Surgeon General

Stanton later died of an asthma attack so his “personal physician” was important to him. Calomel was “The Blue Pill” that had been advocated by Benjamin Rush. It was an ancient remedy based on the success of mercury in the treatment of syphilis dating back to Paracelsus in the 14th century. Medicine until the 20th century was quite primitive and many remedies were tried for wildly inappropriate indications.

For example, a Van Gogh painting of his doctor shows evidence of digitalis intoxication which might have caused his death. Yellow vision is one indication of overdose of digitalis (sudden death is another) and a Van Gogh painting, Portrait of Dr. Gachet shows the characteristic yellow tint plus an example of the plant held by the doctor.

Anyway, Hammond was replaced after some of his innovations including evacuating the wounded from the Peninsula Campaign of McClellan. They were taken by ship back to large hospitals near DC.

Treatment of the wounded early in the war was primitive and would soon improve under Hammond’s reforms.

The volunteer organizations began to make their influence felt and the Army was unable to resist the reforms.

Tripler, for whom the great Army hospital in Hawaii is named, was chosen by McClellan to be the chief surgeon for the Army of the Potomac. His great innovation was the “Ambulance Corps.”

The “Ambulance Corps” restored the invention of Baron Larrey and began the reforms of the Union

To be continued

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The Medical History of the American Civil War II

Friday, September 4th, 2015

This continues the story of medicine in the Civil War. Samuel Gross, a Professor of Surgery at Pennsylvania Hospital in 1860, realized that no textbook of military medicine and surgery existed so he wrote his own in 60 days. It is shown in this exhibit at the Warren Collection at Harvard’s medical library.

The Confederate Army also had no manual so the Gross manual was used by both sides in the war. It was quickly copied for Confederate Military surgeons. A copy of the manual, which was identical to the Union Army manual is preserved at Jefferson Medical College in digital form.

The first battle, famously, was at Fort Sumpter where the commanding office during the battle was actually the medical officer, Samuel Crawford.

The woeful state of the army medical department was recognized immediately and a volunteer organization quickly organized. The first was the US Sanitary Commission. It was rebuffed by the Army but quickly became very powerful. This was a people’s war and the Army was incompetent, as everyone knew.

Here is the cover of Gross’s book. It was used throughout the war, which had enormous influence on American and world Medicine. The book from which this lecture is taken was used by Theodore von Billroth to design the Prussian Army medical corps for the Franco-Prussian War in 1870. The French had forgotten Baron Larrey’s lessons and suffered terribly.

The cover of the Confederate version of Gross’s textbook.

Joseph Woodward was an academic surgeon, such as it was known at the time.

“Woodward was the first scientist to establish photomicrography as a tool for both scientific and medical investigations.” According to an article in the Archives of Pathology and Laboratory Medicine:[2] “In addition to collecting specimens for the museum’s archive, he co-authored the definitive medical history of the Civil War in the 6-volume 1870 publication of the MSHWR.4 Woodward’s technique using aniline dyes for staining thin sections of tissue, along with his pioneering work in photomicroscopy, helped prepare the groundwork for modern surgical pathology.”

The “History” is “The Medical and Surgery History of the War of the Rebellion” of which there are six existing full copies. I found one copy in the USC Medical Library and asked the library staff, who had no idea of its value, to place it in a locked collection room. It would be like finding a copy of “De Revolutionibus” on the shelves of an open university library.

The design of Union Army Hospitals was entrusted to Frederick Olmsted, who had designed New York City’s Central Park. He was, after the war, very involved in establishing The National Park Service.

The first battle of the war illustrated the appalling condition of the medical services of both sides. There were no ambulances and the wounded and to walk back to Washington City, as DC was known then.

A famous American surgeon, who would write one of the world’s great medical textbooks, William W Keen acted as a young army surgeon at the battle.

He studied at Brown University, where he graduated in 1859. He graduated in medicine from Jefferson Medical College in 1862. During the American Civil War, he worked for the U.S. Army as a surgeon. After the war, he spent two years studying in Paris and Berlin.

His “An American Textbook of Surgery” was a hugely influential text and the 1905 edition had a chapter on brain surgery by Harvey Cushing and a chapter on “Appendicitis,” the first use of the term in medical literature, written by John B Murphy, who was the first advocate of early appendectomy for appendicitis.

To be continued.

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The Medical History of the American Civil War.

Wednesday, September 2nd, 2015

This is a lecture I have given a few times and am converting to a long blog post. The American Civil War was the first major war since a number of major advances of medicine had occurred. Sanitation had been studied by John Snow and Florence Nightingale. Anesthesia had been discovered by two Americans, Morton and

Unfortunately, antisepsis would not be described until, 1867, after the war. Infection than was the great scourge of the wounded.

The state of medical art before the war was limited.

Baron Larrey was the greatest army surgeon of the Napoleonic Wars. He invented the ambulance and pioneered some sanitary advances but the cause of infection was still obscure.

Benjamin Rush was a famous American physician but little of what he knew or advocated was of use.

The discovery of Ether anesthesia was momentous but it did add the factor that more operations would be attempted before infection was understood.

Semmelweiss was tragic figure who realized that infection was transmissible from physicians’ hands to patients but he was unable to convince his colleagues. His discovery of the uses of hand washing were ignored.

Florence Nightingale discovered the use of hand washing in caring for the wounded but she did not know why it worked. She is a great hero of the British Army and her apartment in Scutari Barracks in Istanbul is preserved in a shrine.

The Scutari Barracks from across the Bosphorus.

I visited the museum about ten years ago and visited her quarters which the Turkish Army preserves.

The history of Military Medicine really begins with Ambrose Pare’ who served several French Kings and who invented the hemostat.

His methods were a huge improvement on the Greeks but not much else can be said for their efficacy.

The American Army in 1860 was tiny and the medical establishment was a joke.

The war resulted in many of the army surgeons resigning to join the Confederacy. The lack of military medical texts resulted in Samuel D Gross, professor of surgery at Jefferson Medical College, writing his own textbook.

To be continued.

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The Coming Shortage of Doctors.

Monday, August 3rd, 2015

This Brietbart article discusses the looming doctor shortage.

Lieb notes, that the U.S. is only seeing 350 new general surgeons a year. That is not even a replacement rate, she observed.

A few years ago, I was talking to a woman general surgeon in San Francisco who told me that she did not know a general surgeon under 50 years old. The “reformers” who designed Obamacare and the other new developments in medicine are, if they are MDs, not in practice and they are almost all in primary care specialties in academic settings. They know nothing about surgical specialties.

They assume that primary care will be delivered by nurse practitioners and physician assistants. They are probably correct as we see with the new Wal Mart primary care clinics.

The company has opened five primary care locations in South Carolina and Texas, and plans to open a sixth clinic in Palestine, Tex., on Friday and another six by the end of the year. The clinics, it says, can offer a broader range of services, like chronic disease management, than the 100 or so acute care clinics leased by hospital operators at Walmarts across the country. Unlike CVS or Walgreens, which also offer some similar services, or Costco, which offers eye care, Walmart is marketing itself as a primary medical provider.

This is all well and good. What happens when a patient comes in with a serious condition ?

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Expensive babies.

Sunday, July 5th, 2015

There is a post on Instapundit today about expensive babies.

It references a new book about a premature baby and is named “Girl in Glass.”

That baby was referred to by the CEO of AOL in a speech to employees explaining why he was cutting benefits for all employees. Her care cost 1 million dollars. The Guardian article goes on to complain about US healthcare (of course) and the cost of premature baby care.

I have a somewhat similar story in my own new book, War Stories. My story is not about a premature baby, although I have one of those too, but a little boy who was born with a heart defect that caused an 18 month hospital stay at Childrens’ Hospital in Los Angeles.

Here it is:

Following my general surgical residency training, I spent an additional year training in pediatric heart surgery at Children’s Hospital. During this time I learned more about the amazing resiliency of children and their recovery from terrible illness. I was also reminded of the constant possibility of catastrophic error in medicine. One young patient named Chris was the best example of the tremendous recuperative powers of children. He was coming in for open-heart surgery to repair a large ventricular septal defect. The ventricles are separated by a muscular wall called the septum, which forms during early fetal development of the heart. The heart has four chambers, two atria and two ventricles, which are separated by walls called “septa,” plural of septum. There are a number of major cardiac anomalies associated with the development of the atrial and ventricular septa and also with the rotation of the heart and the connection of the great arteries to the ventricles from which they arise. Chris was born with a very large defect in the septum between the right and left ventricle. In this situation, the newborn goes into congestive heart failure very shortly after birth. The defect causes no trouble before birth because the lungs are not inflated and the blood flow through the lungs is very small. The cardiac circulation in utero consists of oxygenated blood returning from the placenta through the umbilical veins, passing in a shunt through the liver and then entering the right atrium, which also receives the non-oxygenated venous blood from the body. The oxygenated blood returning from the placenta enters the right atrium and passes through a normal atrial septal opening called “the foramen ovale,” which shunts it directly to the left atrium and left ventricle for circulation out to the body. This bypasses the lungs. The venous blood, and the umbilical vein oxygenated blood that does not go through the foramen ovale, enters the right ventricle where it is pumped into the pulmonary artery. There, because of the high pulmonary resistance it goes through another shunt, the ductus arteriosus, a connection between the pulmonary artery and the aorta, to bypass the lungs and circulate to the body. Minimal flow goes beyond the ductus into the pulmonary arteries until birth. During fetal life, the presence of a ventricular septal defect merely eases the task of shunting the oxygenated blood from the right side of the heart to the left and then out to the general circulation.

When the infant is delivered into the world from its mother’s uterus, it inflates its lungs and very rapidly major circulatory changes occur in the heart and lungs. The pulmonary arteries to the lungs, which during intrauterine life carry almost no blood because of a very high resistance to flow in the collapsed lungs, suddenly become a low resistance circuit with the inflation. The foramen ovale, which has a flap valve as a part of its normal structure, begins to close very quickly and the ductus arteriosus, connecting the pulmonary artery and the aorta, also closes within a matter of several hours. These two shunt closures are accomplished by hormonal changes associated with the changing physiology of the newborn. In very low birth weight preemies, that have low blood oxygen concentration due to immature lungs, the ductus often does not close. In the child with a ventricular septal defect, the sudden drop in resistance to flow in the pulmonary circulation together with the closing of the ductus arteriosus causes the shunt, which was directed from the right to the left heart in utero, to switch to a left to right shunt after birth. The pulmonary circulation is now the low resistance circuit and the systemic circulation; that is, the aorta going out to the arms, legs, and organs is now a relatively high resistance circuit. The flow in the pulmonary circuit goes up tremendously, a short circuit in effect, taxing the ability of the right ventricle to handle the load. At the same time circulation to the organs, the brain and the extremities, drops because of the shunt. This combination of circumstances produces acute congestive heart failure in a newborn. Cardiac output is huge but the flow is going around in a circle through the lungs and then back to the lungs.

Chris had a huge ventricular septal defect and as soon as his lungs inflated and the pulmonary circulation began to assume the normal low resistance of the newborn, he developed an enormous left to right shunt and went into heart failure. The venous return from the body entered his right atrium, passed into the right ventricle and on into the pulmonary artery to circulate through the lungs. Once the oxygenated blood returned to the left atrium on its way to the body, it was shunted back to the lungs because the pressure in the aorta and left ventricle was much higher than that in the right ventricle and pulmonary artery. The short circuit in the heart diverted almost all blood flow to the lungs and little went to the body. The right ventricle, which is thin walled and flat like a wallet, cannot handle the load and quickly fails. The treatment of an infant with a large ventricular septal defect and heart failure is to perform a temporary correction by placing a band around the pulmonary artery above the heart. This accomplishes two purposes. One, it artificially creates a high resistance and equalizes the pressure in the right and left ventricles so that the flow across the ventricular septal defect is minimized. The right ventricular pressure is as high as the left ventricular pressure and little or no shunt occurs. This stops the huge shunt and, with the smaller flow, the ventricle can handle the pressure. It also protects the lungs from high blood flow that damages the pulmonary circulation.

In a related anomaly called “Tetralogy of Fallot” a partial shunt occurs but it is the other way, right to left, since the pulmonary artery is severely narrowed at its origin as part of the anomaly. These children do not go into heart failure, but they are blue because of the mixture of venous blood from the right side and arterial blood from the left. Some patients with ventricular septal defect (VSD) do not go into heart failure because the shunt is not that large but if treatment is delayed and a continued high flow through the lungs persists, in later life they develop irreversible changes in the lungs from the damage to the pulmonary circulation by high flow rates. They become blue later as the increasing pulmonary resistance in the lungs reverses the shunt from left to right to right to left as in Tetrology of Fallot. This condition is called “Eisenmenger’s Complex” and, once it occurs, cannot be corrected. Once this reversal occurs they do not benefit from correction and require heart and lung transplantation. Some VSDs are small and do not produce enough flow to cause trouble, at least in childhood.

Chris had a pulmonary artery banding procedure at about two or three days of life and an extremely stormy course for a very long time postop. He was in the Intensive Care Unit at Children’s Hospital for over a year. He had a tracheostomy for much of that time as he was unable to breathe without a respirator for a year. He had intravenous feeding for well over a year. During this time he had several cardiac arrests and the staff became convinced that he would be brain damaged if he survived. Finally, after 18 months in Children’s Hospital, he went home. This had all occurred before my time. Now, 3 years later, he was being admitted for the definitive repair of his heart defect. The pulmonary band is Teflon tape and does not grow so the pulmonary stenosis, which had saved his life, was now a threat, as it did not permit adequate flow to his growing lungs. He was five years old and was joyously normal. His intellectual development, in spite of everything, was normal and he was a very calm and self-confident little kid. He was not afraid of the hospital or of us, the white coat brigade. Most nurses and staff in children’s hospitals and pediatric clinics avoid white coats preferring colorful smocks to reassure kids that we are all regular folks. The kids are not fooled but it does seem to defuse the tension, especially at first. When we would make rounds on the ward for the few days Chris was in the hospital for pre-op checks, he would go around with us. He wore his little bathrobe and sometimes carried charts for us. He was completely unafraid. I don’t know if it was because he remembered his previous experience; I didn’t think that memory would be very reassuring.

Anyway, the day of surgery came. His mother was a nervous wreck because she had come so close to losing him and here they were risking him again. I did not see much of the family on the day of surgery. His grandfather was a famous movie star, one of the biggest box office leaders of all time, and the hospital had thrown a big luncheon bash for the family as they waited. We heard about it and grumbled that they could have spent the money on a better blood bank (we were having trouble getting blood for elective cases), but no doubt they hoped for a big donation. The surgery, itself, was almost an anticlimax. The data from the original heart cath, when he was a newborn, suggested that he had almost no interventricular septum and we anticipated trouble reconstructing a new septum. As it turned out, his heart, in its growth during the past five years, had developed a good septum with a modest sized defect in the usual place. It was easy to patch and the surgery went well. The other worry with VSDs is the conduction system, the Bundle of His, which carries the electrical stimulation to the ventricles, and runs right along the edge of the defect but this was not a problem. There was no sign of heart block after the sutures were placed and tied. Postop we always took the kids straight to the Heart Room, a combination recovery room and ICU. The nurses there knew more about cardiology than I did and probably more than anyone else at Children’s below the rank of associate professor. His mother came in and stood at his bedside for a while just thankful to have him. I never saw the rest of the family although I did meet his father before he went home. He recovered quickly and completely. I had one more encounter with him about a year later.

After his recovery from the heart surgery he had another operation, this time on his leg. He had been in the hospital for so long as a baby with an IV line in his groin that his hip would not straighten out completely. A few months after the heart surgery he had another operation to release that contracture, the scar that had formed limiting his hip movement. It also went well but had been postponed until his heart was fixed. A couple of months after that procedure he was well enough to climb trees. I know that because he fell out of one of them and cut his forehead requiring several stitches. I removed the stitches in the office a couple of months after I started practice in Burbank. He recovered completely and is now an executive in the entertainment business. I have not seen him since 1972.

I don’t know what Chris’s care cost but I think it was worth it. AOL was foolish to self-insure and not buy reinsurance for catastrophic cases like Chris and Mila’s. There are ways to reform health care and to cut costs but they are not what AOL did or what Obamacare did.

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Obamacare Lives !

Thursday, June 25th, 2015

UPDATE: The decision is analyzed at Powerline today with quotes for the decision.

The Affordable Care Act contains more than a few examples of inartful drafting. (To cite just one, the Act creates three separate Section 1563s. See 124 Stat. 270, 911, 912.) Several features of the Act’s passage contributed to that unfortunate reality. Congress wrote key parts of the Act behind closed doors, rather than through “the traditional legislative process.” Cannan, A Legislative History of the Affordable Care Act: How Legislative Procedure Shapes Legislative History, 105 L. Lib. J. 131, 163 (2013). And Congress passed much of the Act using a complicated budgetary procedure known as “reconciliation,” which limited opportunities for debate and amendment, and bypassed the Senate’s normal 60-vote filibuster requirement. Id., at 159–167.

Therefore, Roberts rewrote it. Nice !

Today, the Supreme Court upheld the Obamacare state exchange subsidies.

The Supreme Court has justified the contempt held for the American people by Jonathan Gruber. He was widely quoted as saying that the “stupidity of the American people “ was a feature of the Obamacare debate. This does not bother the left one whit.

Like my counterparts, I have relied heavily on Gruber’s expertise over the years and have come to know him very well. He’s served as an explainer of basic economic concepts, he’s delivered data at my request, and he’s even published articles here at the New Republic. My feelings about Gruber, in other words, are not that of a distant observer. They are, for better or worse, the views of somebody who holds him and his work in high esteem.

The New Republic is fine with him and his concepts.

It’s possible that Gruber offered informal advice along the way, particularly when it came to positions he held strongly—like his well-known and sometimes controversial preference for a strong individual mandate. Paul Starr, the Princeton sociologist and highly regarded policy expert, once called the mandate Gruber’s “baby.” He didn’t mean it charitably.

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The book is now on Amazon.

Wednesday, June 17th, 2015

I have a new book out on Kindle that is now published. It is called “War Stories: 50 Years in Medicine.”

I’ve been working on this for 20 years and kept having to revise it as I would put it down and then go back to it after ten years. I finally decided to rework it and publish it two years ago. My students were reading the draft on my laptop while I was editing so maybe it will be interesting.

It is a memoir of patients. They are all patients’ stories that I have tried to describe accurately and to describe what we did then. Sometimes I screwed up and I tell those stories, too. Sometimes we did the best we could and we now know better. Some of these cases are still hard to explain.

Two of them, in the chapter on Melanoma, are about young women who developed major melanoma metastases years after the primary was excised but when they had become pregnant. The melanoma went wild in pregnancy, in one case ten years later. In the other, three years after I had removed the primary, she developed extensive metastases while pregnant. She refused abortion and I thought it would cost her her life. In both cases the melanoma vanished after pregnancy ended. In one case, the woman, last I heard, was free of melanoma 25 years later. The other was free ten years later. The medical literature says pregnancy has no effect on melanoma. Neither ever became pregnant again.

Another case is an example of the only supernatural near-death experience I have ever heard.

The book starts when I began medical school in 1961 and describes experiences with patients, including my summer working with schizophrenic men in 1962. I have a series of stories about patients I saw as a student and sometimes intersperse stories from later that are about similar cases and events. One that is amusing, I guess, is about my very first pelvic exam, on a 40 year old prostitute who had just gotten out of prison and enjoyed it thoroughly. I had a dozen student nurses as witnesses. I do have some biography in it but try to keep it to minimum.

After the first eight chapters, I go on to residency and then finally to private practice. I continued to teach and there are a few of those stories. There is a chapter on ethics including my thoughts on euthanasia and “benign neglect.” Toward the end of my career, I started and ran a trauma center in our community hospital. I also did a fair amount of testifying in court in both trauma cases and some civil cases where I testified for plaintiffs and for defense. I consider it a compliment that Kaiser Permanente had me testify for their defense even though I had also testified against them.

Anyway, the book is on Kindle and I hope somebody is interested. It has some similarity to my medical history book, which I plan to do a Kindle version of once this one is launched. In this one, I spend some time explaining the diseases in a way that I used to explain to patients and I still do to students. Without some basic understanding, most of these stories would not make sense and I hope the explanations are not too dull. If so, all comments are welcome. If anyone likes it, feel free to post a review on Amazon. Two reviewers from the first book in 2004 told me to let them know if I did another one and I have contacted them.

If anyone wants to discuss the book here, feel free to add comments. I guess I should add a link to my medical history book, A Brief History of Disease, Science and Medicine.

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Why Doctors Quit.

Friday, May 29th, 2015

Today, Charles Krauthammer has an excellent column on the electronic medical record. He has not been in practice for many years but he is obviously talking to other physicians. It is a subject much discussed in medical circles these days.

It’s one thing to say we need to improve quality. But what does that really mean? Defining healthcare quality can be a challenging task, but there are frameworks out there that help us better understand the concept of healthcare quality. One of these was put forth by the Institute of Medicine in their landmark report, Crossing the Quality Chasm. The report describes six domains that encompass quality. According to them, high-quality care is:

1) Safe: Avoids injuries to patients from care intended to help them
2) Equitable: Doesn’t vary because of personal characteristics
3) Patient-centered: Is respectful of and responsive to individual patient preferences, needs and values
4) Timely: Reduces waits and potentially harmful delays
5) Efficient: Avoids waste of equipment, supplies, ideas and energy
6) Effective: Services are based on scientific knowledge to all who could benefit, and it accomplishes what it sets out to accomplish

In 1994, I moved to New Hampshire and obtained a Master’s Degree in “Evaluative Clinical Sciences” to learn how to measure, and hopefully improve, medical quality. I had been working around this for years, serving on the Medicare Peer Review Organization for California and serving in several positions in organized medicine.

I spent a few years trying to work with the system, with a medical school for example, and finally gave up. A friend of mine had set up a medical group for managed care called CAPPCare, which was to be a Preferred Provider Organization when California set up “managed care.” It is now a meaningless hospital adjunct. In 1995, he told me, “Mike you are two years too early. Nobody cares about quality.” Two years later, we had lunch again and he laughed and said “You are still too years too early.”

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Obamacare = Medicaid

Friday, May 8th, 2015

I have been interested in health care reform for some time and have proposed a plan for reform. It is now too late for such a reform as Obamacare has engaged the political apparatus and sides have been taken. The Obamacare rollout was worse than anticipated and it was hoped that the Supreme Court would have mercy on the country, but that didn’t happen and it has been the law for two years.

What has it accomplished ? Well, the forecast drop in ER visits hasn’t happened. It also didn’t happen in Massachusetts when that plan took effect.

Wasn’t Obamacare supposed to solve the problem of people going to the ER for routine medical problems? We were told that if everyone had “healthcare” — either through the ACA exchanges or through Medicaid expansion — people would be able to go to their family doctors for routine care and emergency rooms would no longer be overrun by individuals who aren’t actually experiencing emergencies.

As it turns out, Medicaid patients can’t get appointments with physicians.

“America has severe primary care physician shortages, and many physicians will not accept Medicaid patients because Medicaid pays so inadequately,” said Michael Gerardi, MD, FAAP, FACEP, president of the ACEP.

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Myopia

Friday, April 24th, 2015

A couple of interesting articles about the increasing incidence of myopia in children.

Myopia isn’t an infectious disease, but it has reached nearly epidemic proportions in parts of Asia. In Taiwan, for example, the percentage of 7-year-old children suffering from nearsightedness increased from 5.8 percent in 1983 to 21 percent in 2000. An incredible 81 percent of Taiwanese 15-year-olds are myopic.

The first thought is that this is an Asian genetic thing. It isn’t.

In 2008 orthoptics professor Kathryn Rose found that only 3.3 percent of 6- and 7-year-olds of Chinese descent living in Sydney, Australia, suffered myopia, compared with 29.1 percent of those living in Singapore. The usual suspects, reading and time in front of an electronic screen, couldn’t account for the discrepancy. The Australian cohort read a few more books and spent slightly more time in front of the computer, but the Singaporean children watched a little more television. On the whole, the differences were small and probably canceled each other out. The most glaring difference between the groups was that the Australian kids spent 13.75 hours per week outdoors compared with a rather sad 3.05 hours for the children in Singapore.

This week the Wall Street Journal had more. There are some attempts to deal with the natural light effect.

Children in this small southern Chinese city sit and recite their vocabulary words in an experimental cube of a classroom built with translucent walls and ceilings. Sunlight lights up the room from all directions.

The goal of this unusual learning space: to test whether natural, bright light can help prevent nearsightedness, a problem for growing numbers of children, especially in Asia.

The schools have tried to get Chinese parents to send the kids outdoors more but it doesn’t seem to work.

And it isn’t limited to Asians.

In the U.S., the rate of nearsightedness in people 12 to 54 years old increased by nearly two-thirds between studies nearly three decades apart ending in 2004, to an estimated 41.6%, according to a National Eye Institute study.

But Asians with their focus on education are the most effected.

A full 80% of 4,798 Beijing teenagers tested as nearsighted in a study published in the journal PLOS One in March. Similar numbers plague teens in Singapore and Taiwan. In one 2012 survey in Seoul, nearly all of the 24,000 teenage males surveyed were nearsighted.

So, what to do ?

Though glasses can correct vision in most myopic children, many aren’t getting them. Sometimes this is because parents don’t know their children need glasses or don’t understand how important they are for education. Other times, cultural beliefs lead parents to discourage their children from wearing them, according to Nathan Congdon, professor at Queen’s University Belfast and senior adviser to Orbis International, a nonprofit focused on preventing blindness. Many parents believe glasses weaken the eyes—they don’t.

Getting kids to spend even small amounts of time outdoors makes a difference.

Why myopia rates have soared isn’t entirely clear, but one factor that keeps cropping up in research is how much time children spend outdoors. The longer they’re outside, the less likely they are to become nearsighted, according to more than a dozen studies in various countries world-wide.

One preliminary study of 2,000 children under review for publication showed a 23% reduction in myopia in the group of Chinese children who spent an additional 40 minutes more outside each day, according to Ian Morgan, one of the researchers involved in the study and a retired professor at Australian National University in Canberra. (He still conducts research with Sun Yat-sen University in the Chinese city of Guangzhou.)

That is a very significant effect of small changes in behavior. Now the researchers are trying something new.

Dr. Morgan, Dr. Congdon and a team from Sun Yat-sen are now testing, as reported recently in the science magazine Nature, a so-called bright-light classroom made of translucent plastic walls in Yangjiang to see if the children can focus and sit comfortably in the classroom. So far it appears the answer is yes.

In 2007, Donald Mutti and his colleagues at the Ohio State University College of Optometry in Columbus reported the results of a study that tracked more than 500 eight- and nine-year-olds in California who started out with healthy vision6. The team examined how the children spent their days, and “sort of as an afterthought at the time, we asked about sports and outdoorsy stuff”, says Mutti.

It was a good thing they did. After five years, one in five of the children had developed myopia, and the only environmental factor that was strongly associated with risk was time spent outdoors6. “We thought it was an odd finding,” recalls Mutti, “but it just kept coming up as we did the analyses.” A year later, Rose and her colleagues arrived at much the same conclusion in Australia7. After studying more than 4,000 children at Sydney primary and secondary schools for three years, they found that children who spent less time outside were at greater risk of developing myopia.

What is the mechanism ? Maybe it is this.

The leading hypothesis is that light stimulates the release of dopamine in the retina, and this neurotransmitter in turn blocks the elongation of the eye during development. The best evidence for the ‘light–dopamine’ hypothesis comes — again — from chicks. In 2010, Ashby and Schaeffel showed that injecting a dopamine-inhibiting drug called spiperone into chicks’ eyes could abolish the protective effect of bright light11.

Retinal dopamine is normally produced on a diurnal cycle — ramping up during the day — and it tells the eye to switch from rod-based, nighttime vision to cone-based, daytime vision. Researchers now suspect that under dim (typically indoor) lighting, the cycle is disrupted, with consequences for eye growth. “If our system does not get a strong enough diurnal rhythm, things go out of control,” says Ashby, who is now at the University of Canberra. “The system starts to get a bit noisy and noisy means that it just grows in its own irregular fashion.”

Another possible treatment is the use of atropine drops in the eye.

Atropine, a drug used for decades to dilate the pupils, appears to slow the progression of myopia once it has started, according to several randomized, controlled trials. But used daily at the typical concentration of 1%, there are side effects, most notably sensitivity to light, as well as difficulty focusing on up-close images.

In recent years, studies in Singapore and Taiwan found that a lower dose of atropine reduces myopia progression by 50% to 60% in children without those side effects, says Donald Tan, professor of ophthalmology at the Singapore National Eye Centre. He has spearheaded many of the studies. Large-scale trials on low-dose atropine are expected to start soon in Japan and in Europe, he says.

More than a century ago, Henry Edward Juler, a renowned British eye surgeon, offered similar advice. In 1904, he wrote in A Handbook of Ophthalmic Science and Practice that when “the myopia had become stationary, change of air — a sea voyage if possible — should be prescribed”.

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