TRACHOMA IN WEST VIRGINIA
By H. Frank Stiltner, M. D., Pineville,
W. Va., County Health Officer, Wyoming County.
(Read before School of Health Officers at Charleston, April 27, 1915)
Published in The West Virginia Medical Journal, Volume 10, July 1915
By West Virginia State Medical Association
Transcribed by K. Torp
Trachoma. Egyptian ophthalmia, granular ophthalmia, or granulated lids is one of the oldest of diseases known that
affect the human eye. The Good Book which we read on Sundays tells us of a character named Jacob who worked seven
years for a girl named Rachel, and after his seven years of labor an old sore-eyed girl named Leah was palmed off
on him. Perhaps some Egyptians had come down into their country trading and infected Jacob's Uncle Laban's family
with trachoma.
Diagnosis: The diagnosis of trachoma is very simple. It is characterized by a warty growth which involves the conjunctiva
much resembling the spawn of frogs, accompanied by pain, redness, heat, swelling and epiphora.
Trachoma is to be differentiated from follicular conjunctivitis. Arguments concerning the unity or duality of the
two, on the part of the several supporters of these theories, remind one of the Knight in Butler's Hudibras :
"On either side he would dispute, Confute, change hands, and still confute."
In follicular conjunctivitis the conjunctiva does not lose its mirror-like reflex, and the follicles are never
infiltrated, but seem rather as if set on the conjunctiva. The conjunctiva is not infiltrated or thickened: there
is no scar tissue, formations or pannus. It is amenable to treatment and leaves the conjunctiva unchanged.
Pathology: The pathology is very simple. The granular bodies are imbedded in the stroma and the inflammation is
accompanied by all grades of infection. The course of trachoma always being chronic, the types and histological
structure are one and the same thing, whether rich in lymphoid cells or not, and whether lax or firm, varying with
the vascularity of the different individual.
Prognosis: The prognosis for vision is not good. About 90 per cent of all cases of trachoma result in damage to
vision, ranging from slight refractive errors due to changes in corneal curvature to complete blindness. Distortion
of the lids producing entropion, ectropion, trichiasis, and distichiasis is the result of the contraction of scar
tissue formed in the layers of the conjunctiva. Epiphora is the cause of obliteration of the caruncle and closure
of the canaliculi by cicatricial contraction. Narrowing of the palpebral slit is occasioned by thickening and distortion
of lids, as well as by formation of symblepharon. Pannus failing to clear up, staphyloma and scars of healed ulcers
occasion blindness. Blindness is also induced, late in life, when the circulation of lymph is normally sluggish,
by pressure on the thickened lids of a recovered trachoma impeding still farther the flow of lymph in the meshes
of the corneal structure which interferes with the proper nutrition of the infected eye.
Treatment: The treatment of trachoma lies run the therapeutic gamut, from antitoxin to the instilling of urine
in the eye. Indeed this is not to be wondered at, because no one method can be employed with any decree of certainty
or as a matter of routine, and each must be treated on its individual merits.
The earlier treatment is instituted the greater will be the success in arresting the disease. Some cases do very
nicely under the mildest kind of treatment, and in others it often becomes necessary to discontinue treatment for
a time, especially when too violent reaction ensues. Grattage, of Philadelphia, uses a toothbrush and 1 in 5000
bichloride of mercury solution. The method of Coover is nearly the same. He uses No. 0 to No. 00 sand paper and
general anesthesia. We presume that many of his patients recover from both the disease and treatment. Expression
with Knapp's roller forceps, carbon dioxide snow, the burning with X rays, and jequirity have been employed. Excision
and scarification have been tried. Stretching of the lids with the tips of the fingers introduced into the conjunctival
sac, making firm traction in the direction of the outer canthus, has also been tried.
The following prescriptions have been successfully tried :
- No. 1. Suprarenal liquid with chloretone. Put two drops in each eye after breakfast.
- No. 2. Hydrastine alkaloid, grains two ; acid acetic, drops four ; zinc acetate and copper acetate, each grains
two; distilled water, one ounce. Put two drops in each eye after dinner.
- No. 3. Bichloride mercury, one- tenth grain ; zinc chloride, one grain ; distilled water, quantity sufficient
to make one ounce. Put two drops in each eye after supper.
- No. 4. Pagenstecher's ointment. Put some in each eye at bed-time.
Another treatment is as follows:
- No. 1. Copper sulphate, two grains ; glycerine, 1 drachm ; distilled water, quantity sufficient for one ounce.
Put two drops in each eye morning and night.
- No. 2. Copper sulphate, two grains ; glycerin, 2 drachms; distilled water, quantity sufficient for half an ounce.
Put two drops in each eye twice a week.
Glycerite of tannin, argyrol, nitrate of silver, sulphate of copper stick, iodoform ointment, alum, and all the
astringents have been used with success.
The prescriptions which have been the most satisfactory in the writer's hands are:
- No. 1. Boric acid, five grains; zinc sulpho-carbolate, one grain ; cocaine hydrochlorate, one-half grain. Put
two drops in each eye four times daily.
- No. 2. Oil of thuja. Two drops in each eye at bed-time.
- No. 3. Jequirity, one grain ; distilled water, four ounces. Mix. Instill four drops in each eye two times a week.
If this fails to improve conditions make the solution stronger.
Can trachoma be cured ? I would say, "Yes," but only with the most persistent treatment. From many sources
it has been asserted that it can not be cured. But forty years ago, when Bell said we could talk over the telephone
from one town to another, many people said, ''It can't be done."
Why are not more cases of trachoma cured? Because there is an idea prevalent with the laity that every case of
trachoma should go to the specialist, on the presumption that his medicine is far superior to that of the general
practitioner, and in consequence the general practitioner takes but little interest in this class of work.
Prophylaxis: The best treatment of trachoma is prophylaxis. The study of prophylactic measures is of importance
to every community in which trachoma is prevalent.
The writer in 1913 assisted Dr. Taliaferro Clark, Surgeon United States Public Health Service, in making a survey
throughout the west end of Wyoming County and the east end of Mingo, Logan and Boone Counties. and found a total
of 440 cases, mostly children in the public schools, including also four school teachers. On Cedar Creek, Wyoming
County, we found 97 per cent of a total population of 109 people infected. Dr. Clark felt sure there were a large
number of other infected people that we could not see on account of the bad weather and high water.
Why has not this disease affected the west end of Mingo, Logan, and Boone Counties? The writer believes that this
has been because the people of those sections are mainly residents of mining, milling, and other industrial regions
and have access to good physicians, and they have gone to them for treatment, and prophylaxis has been employed
until it has been kept in check. The people of the west end of Wyoming County are in an isolated section, away
from a railroad, and as stated before, they believe their hope lies in the specialist. But through poverty and
ignorance their hope is a vain one and neither specialist nor any one else does them a great amount of good.
How came this disease in southern West Virginia? A number of years ago, some people named Goodman came to West
Virginia from Lawrence County, Kentucky, and they brought the disease. They located in isolated sections of Wyoming,
Mingo, and Logan Counties, where there were logging camps, and the natives soon contracted the disease from these
people. And the number of cases has increased except where there has been industrial development.
What should be the prophylaxis of trachoma? On the part of the state, trachoma should be declared a reportable
disease, to the end that every case may receive due and proper treatment. It should also be made conditionally
quarantinable, in order that any case, through inability or disinclination, failing to abide by the rules and regulations
controlling such, as provided by the State Board of Health, may be apprehended and treated at the expense of the
state, until in condition to be released without danger to others. Every case of trachoma should be excluded from
the public schools for such a time as may be determined by medical inspection, when it may be re-admitted. An examination
of school children will furnish a true index to the trachoma situation of any community. For that reason the writer
can not recommend too strongly the establishment of such inspection, especially in contagious territories.
The exclusion of trachoma from the public schools will not protect the community nor should responsibility end
here. The child should be followed to its home, the nature and danger of the disease carefully explained to its
family, and methods of individual prophylaxis carefully taught.
It therefore becomes necessary, in order to rid communities of this disease, that the state establish from the
sanitation fund a free dispensary in the infected zone and call upon the United States government which will furnish
trained specialists and nurses free of charge, as is being done in southeastern Kentucky and in parts of Minnesota
and Michigan.
I have had a fight of about six years against this disease in Wyoming County, often under discouraging circumstances,
because of the hold it had and still has upon the community. I have attended calls at places where I was afraid
to wash my face for fear of infecting my own eyes.
But I have also had some encouragement, and I am indebted to the president and secretary of the State Board of
Health ; to Dr. Taliaferro Clark, of the United States Public Health Service ; to his Excellency, the Governor
of West Virginia; and to Col. A. R. Wittenberg, a member of the Governor's staff, for their assistance and encouragement.
However, I come asking for more and greater favors. It will require prompt and drastic treatment to prevent the
further spread of trachoma among our people and to preserve vision to many of those who otherwise are doomed to
blindness. The state is threatened with a heritage of disease and blindness, which will be a dead economic loss
and which will heavily tax the resources of communities wherein these people may reside. Therefore I ask for state
aid to stamp out this disease from our entire state, and especially from my own county of Wyoming.
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