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Dr. Johnson mentioned another disease, ophthalmia neonatorum, which decreased around 97 percent in the last 15 years. Injuries are a cause of blindness and have decreased somewhat. Among children there has been about a 30-percent decrease during the last 10 or 15 years due to educational activities by many groups, and I would like to commend the House of Representatives in this connection for its wisdom in passing the bill sponsored by Congresswoman Marguerite Stitt Church of Illinois to prevent the interstate travel or traflic in fireworks—the importation of fireworks into thirty-odd States in which there was indiscriminate public sale and which is not permitted by State law, and yet there is now going on bootlegging of fireworks within those States. I know that this committee has a particular interest in that type of legislation and that bill is now before the Senate.

Again, going down the list of some of these diseases, I will mention 1 or 2 of which we know the causes. Poisoning from wood alcohol and lead cause about 1 percent of blindness, tumors about 1 percent, and general diseases 6 percent. This includes diabetes, which causes about 2 percent of all blindness. That leaves about 50 percent of all the total causes of blindness—-57 percent, rather, due to conditions in which we do not know the nature of the underlying cause. A name can be assigned to the condition such as retrolental fibroplasia and other long impressive diseases, but we do not know the nature of the underlying cause.

This does not mean always that nothing can be done about the condition. We do not know the causes of most of the cataracts, most of the glaucoma which occurs, and yet a good deal can be done in treatment in either preventing loss of vision in the case of glaucoma or in restoring sight in the case of cataracts.

We regretted very much about 2 years ago that a study which was undertaken in the city of Philadelphia with the help of the Division of Chronic Diseases and Tuberculosis of the Public Health Service a study of early diagnosis in glaucoma-that that had to be dropped after i or 2 years' help from the Public Health Service because of curtailment of funds. That is the type of thing which does not come perhaps under the jurisdiction of one particular division, but which might come under another as a demonstration project. It is one that perhaps some other branch of the Public Health Service might again take up.

The causes of blindness can also be classified by the portion of the eye involved, and I am not going to go into the several score of these that there are.

I mentioned glaucoma already, which causes about 12 percent of all blindness, in that the entire eyeball is affected. The front of the eye-the transparent window of the eye--the cornea-is involved in about 14 percent of all blindness. Cataract, as you know, affects the Jens inside the eyeball, accounting for about 19 percent. Some of the deeper tissues of the eye, the choroid and retina—and when I mention these, perhaps some of you know of choroiditis and the various other diseases which come under this heading-altogether they add up to about 14 percent of all blindness. These are not all caused by the same kinds of conditions. For example, some conditions of the cornea may be due to nutritional deficiencies; some of them are due to heredity; about 4 percent, perhaps, or more are due to aging or degenerative processes, in which we simply do not know the underlying factor. The optic nerve—the nerve leading from the eye back to the brain—the visual pathways and visual centers, account for 18 percent of all blindness.

Now, I have told you some of the things that we do not know, and yet we do know a good deal about the eye and there are many who feel we know a good deal better than we are doing.

We feel a good deal of the blindness that is now occurring, is occurring unnecessarily, and estimates on this vary from 25 percent to 75 percent. We would take an inbetween estimate of possibly 50 percent. But, in the light of present scientific knowledge, about onehalf of the blindness that has occurred among our present population could have been prevented were the right thing done at the right time. That means 50 percent could not have been prevented even with the best possible medical care given at the earliest possible time.

Dr. Owens of the staff of Johns Hopkins University's School of Medicine, department of ophthalmology, made a study of 104 cases of blindness in Baltimore—a study which was published in 1951, and I have a copy which I can give the committee clerk.

In this study, to confirm what I said, he found that there were 50 cases where, had the right thing been done at the right time, blindness could have been prevented.

There were 54 cases who received the best possible care in his opinion and, yet, were permanently blind and sight could not be restored. You might think it surprising that blindness could have been prevented in some instances, and yet, the right thing was not done. In 8 of these 50 cases in which he believed that occurred, the blindness was due to injuries which he believed were preventableinjuries to both eyes. In 32 cases he felt the entire responsibility, or at least the major responsibility, lay on the patient himself or herself. He found delays from the onset of signs or symptoms of serious eye trouble ranging from 10 months to 16 years. In the case of about a dozen of these cases, the patients lived within the city of Baltimore, a city in which there are 2 medical schools, a city with clinical facilities, and in which there is certainly no lack of medical care, and yet they delayed from 10 months to 16 years from the date they first noticed the symptoms or signs of trouble.

In other cases, other things entered into it. In some instances the persons went down to the local 5 and 10 cent store, as they are permitted to do in Maryland and in the District of Columbia-over which the Congress of the United States has jurisdiction and they selected their own eyeglasses over the counter, and sometimes went back a half dozen times and selected eyeglasses which seemed for a short period of time to permit them to see a little bit better, and they did that, postponing calling a physician or even an ophthalmologist, for months and even years. I think this is a case where someone should do something in the way of legislation. There are 4 States which have legislation to eliminate that factor leading to neglect as the cause of blindness, but I would think it would be within the province of Congress to do something about a situation in our Nation's Capital.

Mr. HESELTON. Would vou be kind enough to name those States?

Dr. FOOTE. Minnesota, Massachusetts, Rhode Island and New York State; they are the four States with that legislation.

Passing on for a moment to a discussion of the question of controls, and I will do this very briefly because I know our time is passing, it seems to us as a result of studying these causes in great detail, which I cannot go into further now, that control can be broken down into three different categories. One is education--the need for public education and we believe also a need for professional education. There is a need for more ophthalmologists practicing ophthalmology, and there is a need of better education of other professional groups, particularly general medical practitioners, ophthalmologists and other groups.

There are certain services which need to be provided on a larger scale. For example, early case finding among children. In only onehalf of the schools of this country is vision tested. For example, vision testing is not done on school children annually as it should be done. Early case finding of eye disease among adults has only been done in 1 or 2 areas and on a very sketehy basis. These are matters that health departments could do through support given by grants-in-aid from the Public Health Service; boards of education also have a place, and voluntary agencies have a place in this case-finding problem.

Other services that need to be provided on a larger scale are the provision of treatment facilities and follow-up facilities for persons with eve disease. The Office of Vocational Rehabilitation at the Federal level and the State level has been doing a very good job among the groups which can be classified as being rehabilitated groups. Certain welfare departments, as in the State of North Carolina, Louisiana, Kansas, California, Florida and others are doing a splendid job among the recipients of aid to the blind which they receive under title X of the Social Security Act. Those programs are entirely sponsored and financed by the State. There is no Federal fund for medical care given to blind persons in those programs. We feel all the States should have as good a program, however, as the best ones anong those I have listed. There has been one obstacle placed in the vay of carrying this out by the Congress in the year 1950.

In amending the Social Security Act in that year, the Ways and Means Committee chairman had introduced a very brief phrase permitting examinations of blind individuals by optometrists, by inserting the word “or by optometrists,” which was added to the bill. We opposed it at that time and we still oppose that practice, because, as I described to you, blindness is caused either by injury or disease and optometrists are permitted by law in no State in this country to give a diagnosis of disease in the case of a person with eye trouble. They are only permitted to examine them for glasses and to prescribe glasses and fit them with suitable glasses and to provide visual testing. They are not permitted to diagnose or treat eye diseases, and yet under the Social Security Act at the present time they are permitted to examine the blind to see whether or not they deserve aid under title X, and such aid as provided under title X includes medical care. So, there is another point that I think deserves attention by the Congress.

The Lions Clubs and various other volunteer agencies over the United States have been interested in providing treatment facilities and have helped a great deal in financing treatment for some of these persons, particularly in certain regions of the country through organizations that they have formed, and they are beginning to help in the financing of research in the eye field.

That brings me to the third point of the program I have mentioned: education. I have mentioned services that need to be provided, and research I think is the third and perhaps the most important factor that needs to be emphasized. I said 50 percent of blindness cannot be prevented in the light of our present knowledge, even when you get the best possible care, and for 57 percent of the blindness we do not know the nature of the underlying cause.

This summer I delivered a paper at the American Association of Workers for the Blind describing some of the advances that have been made in research in the last 3 years in the provision of funds for research. The distinguished members of our research committee of the national society sponsored a study of research and progress throughout the United States in 1949, just before the Institute was set up. At that time we found a total of $906,000 available in both public and private funds for research in this field. The study was repeated for the year 1952, and for that year we find a total of $1,600,000 available, an increase of about 74 percent over 1949.

The setting up of the new Institute with a very small budget has so far greatly stimulated research in this field. It is a small start, however, compared with the need, and it is also very small with what it costs us for other things.

The American public last year spent between $4 and $5 million for the over-the-counter sale of eye lotions, eyedrops, to use in the eye, not on prescription of a physician, but on self-prescription, and between $6 and $7 million for cosmetics to be used in or around the eye to make the eyes more beautiful. The same year we spent $1,600,000 for research to keep those eyes seeing eyes. You have to compare the $1,600,000 figure with the $150 million that Miss Gruber recited as to what was spent. That figure includes funds from public and private sources, and the funds from the Institute of roughly $250,000. The remainder came from the medical schools themselves, foundations, and other organizations.

Mr. PRIEST. If I recall, the Institute figure was $400,000 on one occasion and I believe you mentioned $250,000.

Dr. Foote. It is $400,000 for the fiscal year 1954, but my figure was for the calendar year 1952.

Mr. Priest. I beg your pardon. I just wanted to be sure the record was correct on that.

The CHAIRMAN. Any questions?

Mr. HESELTON. I have no doubt of the effectiveness of the various groups that are interested in this problem. I just want to ask you a question based upon the fact that we have had submitted to us several organizations—the American Foundation for the Blind, the National Society for the Prevention of Blindness, and I understand there is the National Foundation for Research, and I believe that

you mentioned another group. My question is this: Are those various organizations duplicating in any degree, or cooperating, and do you think the overall effort is not subject to any criticism?

Dr. FOOTE. I think there could be better cooperation, but I know there is no duplication. The need is so great that even with the funds that all of us are able to bear there are a great many research centers set up to do more research than they now do because of a lack of funds, and we sometimes supplement each other's funds in these fields. We sometimes each give a grant to the same institution, but even with the total funds available that institution is not functioning to its full capacity.

Mr. HESELTON. Do you know whether or not there is a lack of expert personnel to attack this problem at the research level?

Dr. Foote. I think that there is a definite lack. I do not think the lack is as apparent as it might be. I think if you suddenly appropriated the $20 million that Dr. Johnson spoke of, and I would like to see that appropriated, we would have to scramble around pretty hard to spend that, but I think if you could look forward to such an appropriation in 3, 4, or 5 years and build up to it, and if you could make your grants, not to the narrowly restricted field in which they have been, and if there could be a broader field and if the funds could be provided for younger research men, I think the whole field would be helped enormously.

Mr. HESELTON. Do you know whether or not the National Science Foundation in its grants for fellowships and scholarships have provision for some of that type of work?

Dr. FOOTE. I understand, but I have not refreshed my memory on this recently, they have some funds for training fellowships, but not related to these eye diseases.

I think what the National Science Foundation is doing is splendid. I do not want to detract from it. It is fundamental. Just as cortisone had to be discovered by a biochemist and a pharmacologist, and penicillin discovered by a man in bacteriology, that is fundamental work, but there was a lag of 25 years of time between the time that penicillin was discovered and used clinically. I think there is a need for fundamental research in relation to clinical centers and research beyond anything the National Science Foundation can do.

Mr. HESELTON. I have before me a statement that 25 percent of the blinding eye diseases set forth are responding to the cortisone treatment and that 5,500 people can be saved each year due to the discovery in 1950 of the cortisone treatment of these diseases. That seems to be an extremely encouraging development, and being so recent I would think that would have some effect upon future research work.

Dr. FOOTE. I think that there are tremendous possibilities in this field. I do not believe that ACTH and cortisone are working quite as much a miracle now as was thought would be worked a year ago, but they are tremendously helpful because when an individual has an inflammation in the tissues in the back of the eye, and inflammation that may last only 2 or 3 weeks, and when that can be prevented from producing scar tissue and permanently blinding the patient by treatment with cortisone or ACTH, you prevent blindness in that person, but there are a great many other instances where it was felt it would be helpful in more chronic conditions, and the hopes that we once had for it have not been borne out, so I would not go as high as the 25-percent figure quoted there.

Mr. HESELTON. I believe that you did say, discussing one type of blindness, that diet was a factor.

Dr. FOOTE. Yes.
Mr. HESELTON. Is it a factor in all types of blindness?

Dr. FOOTE. We do not know. We need more fundamental research on that. We know that lack of vitamin A will affect some of the ex

39087-53—pt. 4--10

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