PERSPECTIVE
The AJO A Century Ago:
Historical Review of Volume 1, 1918
ROBERT M. FEIBEL
A
S THE AMERICAN JOURNAL OF OPHTHALMOLOGY
celebrates the centennial of its publication in 2018,
I thought it would be interesting and informative
to review for today’s readers the inaugural volume. My goal
in this Perspective is twofold. First, I will describe how the
Journal was organized and what each section offered.
Secondly, I hope to present an impressionistic view of the ma-
jor medical and nonmedical issues as presented in the AJO.
This volume contains 1177 pages and I make no claim to
have comprehensively summarized the entire text (Figure 1).
EDITORIALS
THIS NEW AMERICAN JOURNAL OF OPHTHALMOLOGY WAS
the third publication to bear that name, and as such, was
referred to as the Third Series. The first AJO was published
from 1862 to 1864; this short-lived journal had no relation-
ship to the present AJO. The Second Series was founded by
Adolf Alt of St. Louis in1884, and continued for 34 years
until it merged with 6 other journals in 1918 to become
the present AJO. The major force in this consolidation
was Edward Jackson, who became the first editor
(Figure 2) The 6 other merged journals were the Annals
of Ophthalmology, the Ophthalmic Record, Ophthalmology
(no relationship to the present journal of that name), the
Anales de Oftalmologica, the Ophthalmic Year Book, and
Ophthalmic Literature, the last 2 of which were founded by
Jackson to organize and abstract the ophthalmologic liter-
ature, both domestic and foreign. The editors of these jour-
nals typically performed the role of owner, publisher, and
distributor, in addition to that of editor. Jackson sought
to reduce this duplication of effort by consolidating these
independent journals1,2 (Figure 3)
In 1917, 3 separate British ophthalmologic journals had
joined to form the new British Journal of Ophthalmology as a
Supplemental Material available at AJO.com.
Accepted for publication Jan 23, 2018.
From the Center for History of Medicine, and Department of
Ophthalmology and Visual Sciences, Washington University School of
Medicine, St. Louis, Missouri.
Inquiries to Robert M. Feibel, Center for History of Medicine, and
Department of Ophthalmology and Visual Sciences, Washington
University School of Medicine, Campus Box 8074, 660 South Euclid
Ave, St. Louis, MO 63110-1093; e-mail: feibel12@gmail.com
0002-9394/$36.00 © 2018 ELSEVIER INC. ALL
https://doi.org/10.1016/j.ajo.2018.01.026
way to deal with the economic constraints of World War I,
especially the scarcity and consequent high price of paper.
Jackson was impressed with this concept of a single
national monthly publication for ophthalmologists,
emphasizing that with 1 journal and the subsequent larger
subscriber base, the costs would be less. He extolled the
value of cooperation, not competition, among editors, pub-
lishers, contributors, and readers. Instead of a profit-driven
commercial publisher or a few medical editors, the
Ophthalmic Publishing Company, jointly formed by 44
ophthalmologists, launched, operated, and owned the
new American Journal of Ophthalmology. This assured that
the new Journal would be governed by medical decisions
from doctors, rather than publishers’ profit considerations.
The lone exception to Jackson’s efforts was the Archives of
Ophthalmology, the oldest American ophthalmic periodi-
cal, founded in 1869; it declined to affiliate with the new
AJO. This journal later affiliated with the American Med-
ical Association in 1929 and is now JAMA Ophthalmology.
Since he was already widely regarded for his extensive
study of refraction and optics (the Jackson cross cylinder),
his role as one of the principal founders and first chairman
of the American Board for Ophthalmic Examinations, and
his prior experience as journal editor and reviewer, Jackson
became the editor of the new journal, a position he would
occupy for 10 years.
Of the 39 editorials in Volume One, 16 discuss different as-
pects of the new journal. In the second editorial, Jackson
writes that ‘‘only strictly ethical advertisements will be
admitted,’’ applicable to both pharmaceutical products and
opticians. In the May issue, in an editorial ‘‘The Price of
This Journal,’’ he points out that the prior 6 journals would
have cost the subscriber a total of $34.50 ($560 today) per
year, while the new Journal, which contains all the depart-
ments from the older journals, cost only $10.00 ($162 today)
per year. ‘‘Probably few readers realize that, word for word,
this journal costs less to its readers than any other ophthalmic
journal published in the English language. The relative price
of a journal is not shown by the price per volume or the num-
ber of pages furnished per dollar. The number of words per
page has to be taken into account.’’ He calculates that in
1917 the British Journal of Ophthalmology published 784 pages
averaging 510 words per page, or 53,310 words per dollar of
the subscription price. For the Archives of Ophthalmology dur-
ing the same year, the comparable figure was 45,703 words per
RIGHTS RESERVED. xiii

FIGURE 1. Photograph of the entire American Journal of
Ophthalmology, Volume 1, 1918.
FIGURE 2. Edward Jackson (1856-1942).
dollar. Jackson notes that the AJO in its first 4 months printed
81,291 words per dollar, and concludes that ‘‘the American
Journal of Ophthalmology will publish this year 26 per cent
more matter than both of the other journals put together,
and for 20 per cent less money,’’ with ‘‘less than ten per
cent given over to advertising.’’ I do not know if this editorial
was in reaction to complaints about the cost, but Jackson be-
trays not a hint of defensive tone, concluding that such econ-
xiv AMERICAN JOURNAL OF OPHTHALMOLOGY
omy is the result of the larger list of subscribers supporting this
cooperative effort. I wonder how, in the days before word
processing and computerized word counts, such information
was obtained. I suspect that Jackson, ever the meticulous ed-
itor, had the words actually hand-counted!
In another editorial, ‘‘Our Journal Form,’’ Jackson
thoughtfully explains the Journal’s ‘‘mechanical presenta-
tion of reading matter.’’ He insists the paper be of good
stock and highest durability, suitable as a permanent addi-
tion to any medical library, even though ‘‘the price on the
amount needed for the printing of the journal each month,
has increased about forty dollars [$650 today] since the
beginning of the year.’’ This was the reason the British
Journal of Ophthalmology reduced the average number of
pages per issue from 64 to 48, a constraint avoided by the
AJO. He has a rationale for the paper’s ‘‘highly-finished’’
surface (best for half-tone reproduction of photographs)
and color (‘‘white with a faint tint of color from near the
center of the spectrum,’’ which best contrasts with black
letters). And if you wonder why the Journal cover is yellow,
a tradition that still continues, ‘‘the black lettering appears
more distinct against the yellow, than against a back-
ground of any other decided color.’’ The double-column
page prevails over single-column, for ‘‘at the ordinary
reading distance a length of line of four inches or over
requires too wide a lateral excursion of the eyes in reading
it, for the greatest ease and comfort.’’ Even the form of
stitching used in binding is particular, so the high-gloss
pages may lie flat when opened, avoiding ‘‘a band of regular
reflection’’ off the roll along the spine. Knowing the reasons
behind these decisions, he argues, is especially important
for the ophthalmologist because ‘‘the ocular hygiene of
many patients requires attention to such details.’’
In the final issue of the year, Jackson writes 2 editorials
reflecting on the first year of publication. The one titled
‘‘Our Beginning’’ relates the progress of the Journal amid
the problems and constraints on the editorial office result-
ing from World War I: shortages of coal and skilled labor for
paper manufacturing and printing, 2 printers’ strikes, delays
in second-class mail, and significant portions of the edito-
rial staff (43%) and the contributors (40%) serving in the
military. Despite these impediments, all the issues were
printed and mailed to subscribers close to the monthly
deadline. With the war won and over, he hoped the
services of the new Journal would improve and expand.
The editorial continues that ‘‘2,000 ophthalmologists in
America were willing to spend ten dollars per year each, to
improve the current literature of their special branch of med-
icine, and to get a better command of that literature.’’ This is
an impressive figure in view of the small number of ophthal-
mologists who were then actually affiliated with organized
ophthalmologic and medical societies. In 1918, the (then)
American Academy of Ophthalmology and Otolaryngology
had 139 members identified as ophthalmologists and 487
members identified as EENTs (ear-eye-nose-throat)
(Benjamin J, personal communication, November 2,
MAY 2018
FIGURE 3. Title page of Volume 1.
2017). In its first 4 years of existence (1916-1919), the (then)
American Board for Ophthalmic Examinations examined
only a total of 51 candidates (Comber BA, personal commu-
nication, November 2, 2017). According to a news item in
the Journal, at the 1918 meeting of the American Medical
Association, the Section on Ophthalmology was one of the
best attended, with 407 registrants. Thus, I conclude that
the new AJO was supported by hundreds of ophthalmologists
who otherwise were not associated with national ophthalmo-
logic societies.
Some of Jackson’s editorials discuss issues we still
encounter today. This prescient warning resonates in our
VOL. 189 THE AJO A CENTURY AGO
present society: ‘‘Another form of injury against which warn-
ing is particularly appropriate at the present time, is that
which results from the various forms of guns in the hands
of children.’’ He saw guns as a public health issue because
‘‘when the eye is struck, serious injury very often results,
and sympathetic ophthalmia with complete blindness is a
possible outcome. The only effective method of preventing
such injuries is to keep the weapons in question out of the
hands of children.’’ In another editorial, published in May,
he warns that in the next month, there will be a total eclipse
of the sun and the path of totality will extend from the north
Pacific coast across the entire country, to the south Atlantic
xv
FIGURE 4. Visual fields of a patient with pellagra.
coast, the same geographic area as the recent eclipse in the
summer of 2017. He refers to the reports of several thousand
cases of visual loss from an eclipse in Europe in 1912 and
urges the ophthalmic community to educate the public.
‘‘Wherever a match and a piece of window glass are avail-
able, the old-fashioned smoked glass can be prepared. But
a more cleanly, safe, convenient means is a piece of devel-
oped photographic film. The part of a rather dense negative
that represents the sky may be all that is necessary; but film
specially exposed and prepared for the purpose is better.’’
(Such a technique would not be considered adequate today.)
Jackson was also knowledgeable in many areas, for
example in describing the ocular complications of systemic
disease. He wrote long and thorough editorials on ‘‘Eye
Lesions of Infective Jaundice,’’ ‘‘Ocular Lesions From
Filaria And Allied Parasites,’’ and ‘‘Ocular Lesions Of Influ-
enza.’’ His choice of subjects show some of his priorities for
the education of his subscribers.
Jackson’s life and contributions to ophthalmology have
been praised several times in past issues of the AJO.3,4
But I would also comment on Jackson’s role as the first
editor of the Journal. Of the 39 editorials, Jackson
personally wrote 22. Through his editorials Jackson shows
himself an effective and conscientious administrator. As I
read them, I sensed a quantitative and analytic approach
to the business of the new Journal, appropriate to a man
with an undergraduate education in civil engineering.
Reading the editorials by Jackson and other members of
the editorial board (there were 6 in addition to Jackson,
and they are listed in Figure 3) was the most interesting
part of reviewing the first year of the Journal. I recommend
them as a starting point to learn the history of the AJO and
the issues that concerned ophthalmologists a century ago.
xvi AMERICAN JOURNAL OF OPHTHALMOLOGY
ORIGINAL RESEARCH ARTICLES
‘‘ORIGINAL RESEARCH ARTICLES,’’ THE FIRST SECTION OF
each issue, consisting of between 5 and 11 articles, accounts
for only about 400, or a third, of the Journal’s total pages. By
contrast, in today’s AJO and other major medical journals,
original research articles occupy the vast majority of each
issue. In 1918, however, the Journal had many other
sections serving different purposes. Here are a few examples
of major studies.
One study evaluates the visual field findings in patients
with pellagra, a vitamin (niacin, or vitamin B-3) deficiency
disease common in persons with poor diet. Acknowledging
that performing quantitative perimetry is very difficult in
these patients because of mental confusion, the author con-
cludes that visual loss with both peripheral constriction
and central scotoma is common (Figure 4). (Visual loss is
not a common finding in pellagra, and it is possible that
this was owing to a deficiency of thiamine, vitamin B-1,
which can be associated with optic neuropathy.)
Another study deals with ocular conditions simulating
intraocular malignancy. The author reports 2 cases of
enucleation on suspicion of the eyes harboring sarcoma of
the choroid (choroidal melanoma). However, the patho-
logic diagnoses were granuloma of the choroid and tumor
formation associated with retinitis and massive exudation.
At that time there were no tests to confirm such a diagnosis
other than ophthalmoscopy. After reviewing the literature,
the author concludes that the 2 cases ‘‘indicate the
difficulty, or even the impossibility, of making a definite
diagnosis in some cases of neoplasm of the fundus, solely
on the ophthalmoscopic appearances.’’ (This problem
persisted for many years; in 1964, a pathologic review
MAY 2018

FIGURE 5. Fundus drawing of retinal arteriolar disease.
reported a 19% diagnostic error for eyes enucleated with a
diagnosis of melanoma.)
In addition to clinical research, there are several articles
from investigators studying experimental visual function in
the laboratory. ‘‘The Inertia of Adjustment of The Eye for
Clear Seeing at Different Distances’’ is a study of the time
required for the eye to adjust for clear vision at different
distances. It describes several techniques developed to quan-
tify the time to make such adjustments. One example from
these data showed that the time required for normal young
observers to change from near to far vision was between
0.50 and 1.16 seconds. Subjects could then be grouped based
on their response times; such data were thought to be helpful
in screening pilots for military service in World War I.
Today, many of the articles in this section would be clas-
sified as reviews of the literature, rather than original
research. One such article thoroughly reviews vernal
conjunctivitis based on 44 cases, carefully considering the
clinical findings and pathology, as well as the importance
of differentiating this condition from trachoma, which was
common in 1918. We would be surprised by what was
then considered the definitive therapy for cases of palpebral
vernal catarrh that have not responded to other treatments.
VOL. 189 THE AJO A CENTURY AGO
‘‘Probably for a radical cure, where such treatment is avail-
able, repeated exposures to the Roentgen-ray, or to radium,
are our most valuable therapeutic measures.’’ Two issues
later, another article advocates radium therapy: ‘‘The
method of application is to evert the upper lid by a pair of
forceps, which are held to the forehead by an adhesive strip.
The radium in a suitable clamp, is then applied to the
exposed conjunctiva, and watched by a nurse, until the expi-
ration of the time of exposure directed by the physician in
charge.’’ The author does mention the prevention of compli-
cations by shielding the adjacent areas.
Forty-five, or roughly half, of the research articles are
single or small case reports, which today would not be consid-
ered major research articles, such as the single case report of a
young man with striking retinal arteriolar aneurysms.
Figure 5 shows the ophthalmoscopic findings, as well as the
quality of the retinal drawing. The findings are unilateral,
and systemic evaluation shows no diabetes or hypertension.
(In retrospect, this may be a case of Coats’ disease.)
SOCIETY PROCEEDINGS
THIS SECTION CONTAINS REPORTS OF ORAL PRESENTA-
tions and discussions submitted from local ophthalmologic
societies, whose educational value Jackson championed.
Reports from Colorado (Jackson lived in Denver),
Chicago, and the Wills Hospital and the Section on
Ophthalmology of the College of Physicians in Philadel-
phia appear most regularly, but some come from as far as
London and the Netherlands.
Much of this material consists of single case reports
with audience participation, but in a few proceedings,
societies did send in more comprehensive discussions
on a specific topic. Oculoplastic surgery garnered partic-
ular attention: for the treatment of nasolacrimal stenosis
and dacryocystitis, excision of the tear sac was generally
favored over performing a dacryocystorhinostomy; the
best surgical technique to remove large epitheliomas
(basal cell carcinomas) of the adnexa was ‘‘electrother-
mic dessication’’; and the reconstruction of a contracted
orbital socket. Another subject discussed at the annual
meeting of the American Ophthalmological Society
was the concept of focal infection as a cause of eye dis-
ease. Cases of uveitis, keratitis, retrobulbar optic
neuritis, and many other inflammatory ocular problems
were thought to be related to sinusitis, dental infection,
tonsillitis, and other sites of systemic infection. Removal
of the tonsils, repair of dental infection, or drainage of
the sinuses was almost always followed by a prompt
remission of the ocular process and marked improve-
ment in vision. Cases in which such surgery did not
help the eye were rarely described. (This theory, now
rejected, was generally accepted at that time.)
xvii
FIGURE 6. Ophthalmic Literature, sample page.

OPHTHALMIC LITERATURE AND DIGEST
OF THE LITERATURE
THESE 2 SECTIONS APPEAR TO HAVE BEEN OF GREAT UTILITY
and value to the reader. ‘‘Ophthalmic Literature’’ is the
continuation of a similar index published in Jackson’s prior
monthly journal Ophthalmic Literature. Here are listed the
title, subject, and citation of papers, both American and
international, relating to ophthalmology published in the
previous month. Where the original title is in a foreign
language, it is translated into English. The titles are catego-
rized as follows: Methods of Diagnosis, Therapeutics,

xviii AMERICAN JOURNAL OF OPHTHALMOLOGY MAY 2018

FIGURE 7. Digest of the Literature, sample page.

Operations, Refraction, Ocular Movements, Conjunctiva, Ball, Lacrimal Apparatus, Lids, Orbit, Parasites, Tumors,
Cornea and Sclera, Anterior Chamber and Pupil, Uveal Injuries, General Disease, Hygiene, and Ophthalmic Soci-
Tract, Sympathetic Disease, Glaucoma, Crystalline Lens, ology and History. Most of the references cited are from
Retina, Toxic Amblyopia, Visual Tracts and Centers, Eye ophthalmologic journals, but general medical journals

VOL. 189 THE AJO A CENTURY AGO xix

such as the Journal of the American Medical Association and
Lancet are also found. Those from several foreign countries
are represented: the United Kingdom, France, Italy, the
Netherlands, Japan, Australia, and India. In spite of the
war, journals from the enemy countries of Germany and
Austria-Hungary are still accessed and cited. To estimate
how many articles are referenced during the entire year, I
counted up the number of citations for 3 months and found
a total of 584, and by extrapolation, approximately 2300
citations in the 12 issues of Volume 1 (Figure 6).
‘‘Digest of the Literature’’ carries on Jackson’s Ophthalmic
Year Book, published as an annual volume since 1904. It
consists of abstracts (not just the titles, as found in
‘‘Ophthalmic Literature’’) from the world’s literature going
back roughly a year. They are sorted into categories similar
to those found in ‘‘Ophthalmic Literature.’’ To choose one
example, the section prepared by Jackson on the influence
of ‘‘general diseases’’ upon the eye has about 120 references
found in the world’s literature from January 1917 through
October 1918. The most common systemic diseases
discussed are syphilis and tuberculosis, to such extent
that one summary, on the newly introduced arsenical drugs
such as salvarsan for the treatment of syphilis, comments
that ‘‘where antisyphilitic treatment proved ineffective
tuberculosis should be suspected’’ and that mixed infection
is not uncommon. Ocular findings in various neurologic
problems, including multiple sclerosis, encephalitis, and
functional disease, are also enumerated (Figure 7).
The ‘‘Digest of the Literature’’ sections are quite extensive,
taking up 297 pages, in addition to the 880 pages of the rest of
the Journal. The quantity and quality of these abstracts indi-
cate a considerable effort on the part of the abstracters. The
reviewers generally appear to abstract these articles in an
impartial manner without regard to the reviewer’s opinions,
so the readers may formulate their own opinion.
At that time most ophthalmologists were male
(occasionally the Journal refers to the community of
ophthalmologists generically as ‘‘men’’), so I was pleased to
note that there was 1 female contributor, Florence Mayo
Schneideman from Philadelphia. In this volume, she pre-
pared the section of abstracts on Diseases of the Lids (10
pages long), as well as 2 listings of obituaries. She was mar-
ried to an ophthalmologist who was also a contributor.
NEWS ITEMS
THE EDITORIAL BOARD HAD ARRANGED FOR LOCAL VOLUN-
teers to send a monthly compendium of personals, death
notices, announcements from local societies, upcoming
meetings, and military notes. These make up ‘‘News Items,’’
a sort of society pages for ophthalmologists.
Some notices are tragic: ‘‘Dr. James Mills of Janesville,
Wisconsin, recently jumped from a bridge and was
xx AMERICAN JOURNAL OF OPHTHALMOLOGY
drowned.’’ Or: ‘‘Dr. Addison F. Sanders, Cincinnati, was
killed on May 5th by being struck by an automobile.’’
A disconcerting notice: ‘‘Dr. John G. Barnsdale, an
ophthalmologist of Superior, Wisconsin, was convicted of
violating the Harrison Narcotic Act and given a sentence
of three years in the Federal Penitentiary at Fort Leaven-
worth and fined $6,000 [$97,265 today]. He was released
on bond and will appeal his case on a writ of error, contest-
ing the constitutionality of the Harrison Act.’’ Others, in
comparison, seem rather trivial: ‘‘Dr. John F. Campbell,
of Chicago, has resumed his practice after an absence of
about ten weeks, touring most of the western part of the
continent.’’ Still others, almost humorous: in the May issue
we learn ‘‘Dr. Clark W. Hawley, of Chicago, has just under-
gone an operation for gall-bladder disease, and is making a
good recovery,’’ but whose luck runs short, for we read in
October that ‘‘Dr. Clark W. Hawley, of Chicago, was
thrown from his bicycle recently and sustained a painful
fracture of the nose.’’
The military notes list the names and duty stations of
ophthalmologists on active service in the Army. ‘‘Among
60,000 applicants for the Volunteer Medical Service
Corps, 305 have applied as ophthalmologists, and 1,845
as eye, ear, nose and throat specialists.’’ We read where
they were assigned for duty: ‘‘Capt. F. E. Woodruff, of
St. Louis, has been transferred from the Aviation
Camp at Mt. Clemens, Michigan, to Camp Wadsworth,
Spartansburg, S. C.’’ Another: ‘‘Lieut. M. H, Post, Jr., of
St. Louis, stationed at Fort Oglethorpe, Ga., suffered an
attack of lobar pneumonia recently. The crisis was suc-
cessfully passed, and we are pleased to note that Lieut.
Post is at present recuperating in Florida.’’ And: ‘‘Because
of the fact that more than half of the membership of the
Sioux Valley Eye and Ear Academy are in active army
service, there was no meeting of the Academy at Omaha
in July.’’ Such listings grow quite extensive as the year
progresses and more ophthalmologists enter service at
domestic duty stations or are deployed abroad. In the
May issue is an Honor List of 222 ophthalmologists
serving in the Medical Department of the United States
Army, and subsequent issues add to the list. It is sobering
to read injury and death notices as the war continues.
‘‘Dr. Sidney Walker, Jr., of Chicago, who was seriously
wounded during a recent engagement on the western
battle front, is at present in a hospital in the outskirts
of Paris.’’ The death of a well-known ophthalmologist,
‘‘Capt. Lorenzo Burrows, M.R.C., Buffalo, New York.
Aged fifty-one. Died in France, September 17th, from
pneumonia.’’ In December, at the peak of the influenza
pandemic of 1918, we find the notices of 16 ophthalmol-
ogists who had died from pneumonia secondary to influ-
enza, 3 of whom were serving in the military. Many
comments relate to the sweeping effects of the war on
organized ophthalmology. When 5 of the 11 members
of the American Board for Ophthalmic Examinations
MAY 2018
were absent on active duty, the Board stayed resolute:
‘‘In spite of this handicap and the delays entailed, the
work will still be carried on.’’
I was intrigued to read about political, economic, and
legal issues in 1918 that we still deal with 100 years
later. For example, the Journal requests its readers to
write their representatives in Washington: ‘‘Ophthalmol-
ogists throughout the country are urged to write their
senators and congressmen to support the bill to be intro-
duced in the coming session of Congress, which provides
that the Medical Officers of the Army shall have the
same rank as prevails in the Medical Corps of the
Navy.’’ Feeling threatened by insurance companies, the
physicians of California lobbied the state legislature
and ‘‘secured the defeat of the health insurance measure
by a large majority.’’ Some ophthalmologists served as
elected public officials: ‘‘Dr. Willis O. Nance, of
Chicago, has been re-elected for his fifth term as a mem-
ber of the city council. He is the only physician in the
council.’’ ‘‘The case of W. A. Beardsley versus Drs.
Fred E., and John Ewing of Kenmare, in which damages
were claimed on account of alleged mistreatment in a
case of disease of the eye, the decision of the District
Court is said to have been affirmed which awarded the
complainant $7,500 [$132,000 today] damages.’’ (At least
now this information would not be published in a med-
ical journal.)
Such notices are no longer published in today’s scholarly
medical journals, including the AJO. We seem to have lost
along with them some measure of pathos, humor, and
familial spirit in the daily goings-on among fellow ophthal-
mologists.
CATARACT SURGERY
I WAS SURPRISED HOW LITTLE DISCUSSION OF CATARACT
surgery was found in this volume. There are no original
articles, and only 2 lengthy discussions. At the time,
the main controversy in cataract surgery was whether
to continue the standard extracapsular removal of the
nucleus by expression and the cortex by irrigation (often
called the capsulotomy method) or to adopt the new
Smith-Indian technique to remove the lens in its
capsule, as introduced by Lieutenant-Colonel Henry
Smith of the British Medical Service in India, in which
the entire lens was expressed by pressure on the globe.
‘‘Society Proceedings’’ in the May issue report a spirited
debate among members of The Chicago Ophthalmolog-
ical Society about which procedure is superior. Several
discussants presented their experience with the Smith-
Indian technique and their general impression of a
greater rate of complications compared to the standard
capsulotomy method. Although the incidence of vitreous
VOL. 189 THE AJO A CENTURY AGO
loss varied widely, most surgeons reported between 2%
and 17% for intracapsular extraction (one report men-
tions 29%) and between 4% and 9% for capsulotomy
cases. Visual results, defined as seeing better than 20/
40, was measurably better for intracapsular extraction,
with 70%-86% of eyes gaining such vision but only
52%-69% in capsulotomy cases. The discussants did
not reach any agreement on which technique is prefer-
able. One proponent of the intracapsular technique
commented, ‘‘ophthalmic surgeons who are operating
by the intracapsular technique method cannot be
expected to abandon it and return to the capsulotomy
method just because some operators who are unfamiliar
with the technic choose to condemn it.’’
‘‘Digest of the Literature’’ in the June issue abstracts
publications about the lens and cataract in the following
subjects: embryology, dislocation of the lens, congenital
and zonular cataracts, pathogenesis of cataract, special
varieties of cataracts, concurrent conditions, complicated
cataracts, macular perception in advanced cataracts,
spontaneous absorption of cataract, and nonoperative
treatment to slow progression of age-related cataract
(mostly the use of topical drops containing iodide salts),
although the recommendation of subconjunctival injec-
tion of cyanid [sic] of mercury is curious. The abstracts
on surgical techniques include discission of infantile cat-
aracts, couching of the lens, whether to instill atropine
or eserine at the conclusion of surgery, the value or
disadvantage of using sutures to close the incision, the
comparison of the clear corneal or limbal incision with
a conjunctival flap, whether or not to perform an iridec-
tomy, and the suction method of extraction with an
erisophake. Complications reviewed include prevention
and management of infection, intraocular hemorrhage,
delayed reformation of the anterior chamber, iris pro-
lapse, vitreous loss, secondary cataract following extrac-
apsular extraction, postoperative delirium, and surgical
and visual results. The abstracter outlines the advantages
of intracapsular surgery, such as avoidance of secondary
capsular clouding requiring a needling procedure and
reduced postoperative iritis, but stresses the increased
risk of complications. His summary reveals the strongly
contrasting opinions held by the various surgeons in
favor of or against intracapsular extraction, with no
definitive agreement reached. This review cites and ab-
stracts about 110 articles from the literature and rein-
forces to me the great value of this department of the
AJO for the reader to quickly survey the literature and
find information on any subject desired.
(As surgical techniques improved with a reduction in the
incidence of vitreous loss and the regular use of sutures to
close the incision, the intracapsular technique gained
ground in the 1930s and became the technique of choice
in the 1940s. However, in the 1970s and 1980s, with the
rise of phacoemulsification and intraocular lens
xxi
implantation, extracapsular surgery again became the
preferred technique.)
WORLD WAR I
WORLD WAR I BEGAN IN JULY 1914, BUT THE UNITED STATES
did not enter until April 6, 1917. The mobilization of
military and civilian life on a scale unprecedented in
American history was in full effect by 1918. The Journal
closely documents the war’s pervasive effects on both the
military and civilian practice of ophthalmology. As
discussed, the exigencies of the war prompted the founding
of the new AJO and motivated many ophthalmologists to
enter military service.
But from the war also came medical progress and discov-
ery. More soldiers suffered isolated wounds to the head than
in previous conflicts. The causes included the physical
nature of trench warfare, where the head was the part of
the body most exposed to injury, and the helmet used by
the British army, later adopted by the Americans, which
did not extend low over the back of the head, thus allowing
discrete injury to the occipital cortex. Further, the explo-
sive power and velocity of modern rifle bullets and artillery
shells produced wounds that tended to have localized
effects, either directly to the eyeball or to the optic nerve
and visual radiations. Patients suffering from discrete injury
to the occipital cortex and visual radiations were carefully
studied by the British neurologist Gordon Holmes and
ophthalmologist William Lister. Their seminal work gener-
ated a topographic mapping of the visual field in the occip-
ital cortex, which remains a basis of our current
interpretation of visual fields. Its importance was immedi-
ately recognized and the AJO presented these findings 3
times in 1918: a short abstract in the March issue, a long
abstract in the April issue, and a thorough review under
‘‘Digest of the Literature’’ in the August issue. In this
lengthy discussion, the abstracter carefully interprets these
findings; explains the Riddoch phenomenon, also discov-
ered during the war; and summarizes 12 other articles
from investigators in Europe, including Germany, on visual
disturbances from cerebral wounds.
The Journal contains many articles and abstracts relating
to direct ocular or orbital trauma from bullets, shrapnel, or
blunt trauma. Localization and removal of intraocular
foreign bodies are discussed at length, and different tech-
niques of magnetic removal of foreign bodies are compared.
Several authors observe that the failure rate of the magnet’s
removal of foreign bodies is much greater in the military
setting than in civilian practice, likely because the metals
alloyed with the steel used in munitions make the foreign
body much less attracted to the magnet. Several authors
in the French, Italian, and German literature comment
on the rarity of sympathetic ophthalmia in the present
war, in spite of many ocular injuries, compared to peace-
time. Two studies documented only 1 case of sympathetic
xxii AMERICAN JOURNAL OF OPHTHALMOLOGY
ophthalmia among 1500 wounded soldiers, an incidence
of 0.07%, compared to figures varying between 0.7% and
3.05% in civilian injuries. In the debate on prevention of
sympathetic ophthalmia by enucleation of the injured
globe, several authors make the plea to avoid immediate
enucleation of eyes with possible visual potential.
The British established a special hospital for such
procedures as oculoplastic and reconstructive surgery of
wounds of the adnexa and orbit, under the direction of
Harold Gillies, the first effort to offer specialized recon-
structive surgery for war injuries. Also of urgent interest
were contagious diseases among the large numbers of mobi-
lized soldiers, such as the spread of trachoma among Amer-
ican draftees and the outbreak of conjunctivitis at Army
camps. One research article reports the etiologic investiga-
tion of a severe and widespread epidemic of acute conjunc-
tivitis, which ran from October 1917 to January 1918 at
Camp Sherman in Ohio. Microbiologic studies revealed
that bacteria were found in 60% of cases, pneumococcus
being the most frequently isolated.
One study reviews the ocular examination of men
drafted into the army, a topic of urgent importance as the
United States was massively expanding its army to fight
in the war. At that time, army regulations stated ‘‘The min-
imum visual requirements to be as follows: 20/40 for the
better eye, and 20/100 for the poorer eye, provided that
no organic disease exists in either eye.’’ The most common
diseases that necessitated rejection from military duty were
trachoma, strabismus, pterygia, corneal scars, refractive
errors, and amblyopia. The author remarks on malingering:
‘‘It was not always easy to ascertain the acuteness of the
men’s sight, for many could neither read nor write, and
not a few did not understand the numeral characters. It
should be remembered that the men of greater degrees of
education had already enlisted in the National Guard.’’
We learn ocular problems were the major cause of draftees
being rejected for military duty: ‘‘From the records of the
first draft, when more than two and a half million men
from all parts of the United States were examined physi-
cally to determine their fitness for military service, it is
reported that defective eyes caused nearly three times as
many rejections as any other physical defect.’’
A major contribution in this volume is a comprehensive
review of the literature, citing 124 references, about the
present knowledge of toxic amblyopia from the use of
quinine for malaria. This information was of considerable
concern and importance, as during the war large armies
fought in countries where malaria was endemic and thus
quinine was extensively prescribed for both prophylaxis
and treatment.
A number of articles, abstracts, and editorials outline
plans for the welfare and rehabilitation of blinded soldiers.
These review the experience in the British and French
armies, and suggest various proposals. One news item
states: ‘‘A campaign to raise $100,000 [$1,621,000 today]
for the Maryland workshop for the blind was started
MAY 2018
January 14, in Baltimore, to take care of the increased num-
ber of blind soldiers returned from the front. It is to be
equipped with new machinery and other facilities for a
workshop for the blind.’’
Of the 39 editorials in this volume, 11 discuss the war’s
impact on the civilian practice of ophthalmology. Several
examine industrial and economic issues affecting the
ophthalmic community. One example concerns drugs
that could no longer be obtained, since they had previously
been imported from Europe and now were unavailable. The
supply of belladonna to manufacture atropine in the
United States became severely limited; the price accord-
ingly increased by as much as 6-fold. Jackson recommends
the substitution of daturin, a chemical derived from the
jimsonweed plant, Datura stramonium. Based on his clinical
experience and studies, he concludes that this drug has the
same pharmacologic value as atropine.
Prior to the war there was no need to manufacture artifi-
cial eyes in America; they could easily be imported from
Germany and were of good quality and fair price. Now
that such prostheses were unavailable, some ophthalmolo-
gists suggested petitioning the federal government to allow
special importation privileges to continue access to German
products. In a bellicose and nationalistic editorial titled
‘‘Artificial Eyes VS. Patriotism,’’ the writer (not Jackson) in-
sists that ‘‘loyal physicians of this country are in no mood to
have anything to do with the Central Germanic Powers,
except to defeat them unconditionally,’’ and that until
such time as domestic manufacturers could make them, we
should ‘‘cheerfully go without those articles we have previ-
ously imported from Germany, and patriotically abstain in
the future from depending upon new German made goods.’’
Even Jackson expressed his moral condemnation of the
German nation and praise for the British resolve and recti-
tude. In a book review of war injuries discussed by British
ophthalmologists, Jackson writes, ‘‘The cast of [British]
mind which can pursue its worthy object in spite of this
conflict precipitated by greed for world dominion will
certainly triumph over [German] barbarism, however ruth-
less and ‘efficient.’ The lesson of this volume is one of
courage and steadfastness.’’
In the December issue, after the war had ended, an edito-
rial sympathetically notes that those ophthalmologists who
FUNDING/SUPPORT: NO FUNDING OR GRANT SUPPORT. FINANCIAL DISCLOSURES: THE AUTHOR HAS NO FINANCIAL DISCLO-
sures. The author attests that he meets the current ICMJE criteria for authorship.
REFERENCES
1. Mann WA. History of the American Journal Of Opthalmol-
ogy. Am J Ophthalmol 1966;61(5 Pt 2):971–984.
2. Newell FW. The American Journal Of Ophthalmology-100
Years. Am J Ophthalmol 1984;97(4):519–524.
VOL. 189 THE AJO A CENTURY AGO
volunteered for military duty and closed their professional
offices had lost many of their patients to colleagues who
remained in civilian practice, and suggests that ‘‘Altho
[sic] the face of the profession is steadily set against adver-
tising, it would seem no more than just to allow these men
to insert in the daily papers a simple statement that they
have resumed the practice of medicine at such and such
an address, the same to run for a limited time, say one
month. Or as an alternative, the County Medical Society
might request the daily paper to run a column devoted to
returning physicians. Such a procedure could in no way
be construed as a letting down of the bars against unprofes-
sional advertising.’’
CONCLUSIONS
I HAVE NO DOUBT THAT THE INAUGURAL SUBSCRIBERS
received an excellent value for their 10 dollars. The infor-
mation presented is well organized and indexed, and the
quality of most of the articles seems excellent. The sections
‘‘Ophthalmic Literature’’ and ‘‘Digest of the Literature,’’
which organized, cited, and abstracted the literature, alone
seem well worth the price. We are now easily able, on our
computers, to search for and access the literature on any
subject we wish. A hundred years ago, the AJO reviews
served that function as effective means for any ophthalmol-
ogist to keep up with the literature.
The AJO today offers its readers the most up-to-date
knowledge of ophthalmology and allied sciences. But the
Journal in 1918 did more than just present the reader
with medical information. With ‘‘Society Proceedings’’
and ‘‘News Items,’’ it provided a social network that kept
the readers in touch with their colleagues. Reading these
sections, I sensed their sustained camaraderie.
In his December editorial, Jackson writes: ‘‘In our first
number the combination of ophthalmic journals was
spoken of, not as an achievement, but as a beginning—
an opportunity.’’ This modest and optimistic statement
rings true today. Every issue of the AJO is yet another
step forward, a new beginning. On this centennial, we
wish it many more!
3. Crisp WH. Edward Jackson, student and teacher. Am J
Ophthalmol 1943;26(1):1–12.
4. Albert DM. Edward Jackson in 1896: a man and his
specialty at a crossroads. LIII Edward Jackson
Memorial Lecture: Part I. Am J Ophthalmol 1996;
122(4):469–475.
xxiii