Trachoma in Kentucky

Sonnet inspired by the sight of a Kentucky child who was restored from blindness

A little girl am I, that once was blind
And shut in darkness from the shining day,
And God through you, your loving heart and kind,
From prison led me to the sun-lit way
Where other children walk and dance and see
The waving trees, the grass, a rose, the sky,
And little babies dear that run to me.
You are so sweet it makes me cry–
Just cry with happy tears to look at you,
Instead of trying hard with touch to trace you out.
And then to see that picture true
You gave to me of Jesus’ loving face,
I cannot understand that it could ever be
That anyone is sad who can only see.

-Unknown

What is Trachoma?

Trachoma granules on the lower eyelid before treatment. Image from the Bulletin of the State Board of Health, 1915.

Trachoma, historically known as granulated lids, was a highly contagious form of chlamydia that could cause irreversible damage or blindness to the eyes. The inside of the eyelids would scratch the eyes like sandpaper. As a result of this, the cornea of the eye would become red, inflamed, or even develop ulcerations. In 1900, statistics showed that half a million people in the United States had blindness, about sixty percent of those became blind as a result of trachoma. The eyelids become thickened and the eyelashes become distorted. Additionally, the tear ducts become clogged so that the eyes are continually full of tears. Some developed photophobia or an extreme sensitivity to the light; this can also lead to the complete loss of the use of the eyes. Trachoma was, and is, a highly contagious disease that was most often communicable by drying the face on a towel shared by someone with the disease, and, in schools, it could be spread by pencils, the exchange of books, and other close-contact methods.

In 1912, the United States Congress passed a bill that appropriated money which enabled the U.S. Public Health Service to study the prevalence of trachoma and other communicable diseases in the United States. In the Summer of 1912, an investigation into the prevalence of trachoma in the Eastern portion of the state of Kentucky was conducted by the U.S. Public Health Service at the request of Kentucky’s State Board of Public Health. The U.S. Public Health Service conducted surveys throughout the Appalachian region of the United States. The heaviest amounts of infection appeared to be in the junction of Kentucky, Tennessee, and the Virginias. The study conducted in 1912 in seven Kentucky counties found that, out of 4,000 people examined, 500 cases of trachoma were found. As time progressed, the study expanded to other Kentucky counties, and out of 18,016 people, 1,280 were found to have trachoma; that is about 7 percent suffering from trachoma. The type of disease was severe, and its mutilating effects were often seen in this population.

Left untreated, the disease more or less remained throughout the lifetime of the individual leaving him or her in constant bodily discomfort, damage to the eye, and “constituted him a menace to his neighbor.” Essentially, untreated trachoma was a chronic disease that lefts its victims totally blind. In addition to the dangers of it spreading it was also a veritable scourge in the regions it affected. As such, in addition to the importance of the ophthalmologist, it was also critical to involve public health officers. It quickly became evident that in the thousands of cases of trachoma in Kentucky, prompt relief from a public health standpoint, as well as a personal standpoint to the patient, become a top priority. The U.S. Public Health Service determined that trachoma hospitals could be operated at a comparatively low cost and it became the duty of the State and local authorities to establish a sufficient number of these hospitals in infected regions to be within easy reach of trachoma patients.

Prevalence of Trachoma in Kentucky



In Eastern Kentucky’s mountain region there are 35 counties. Outside of the mountain region, a number of cases, surprisingly, were found to be in the Blue Grass region. To a much lesser extent, trachoma cases were also found in the Western part of the state. A 1913-1914 study during the winter in Jefferson County showed that 805 school children had trachoma. The U.S. Public Health Service fell short of providing a concrete estimate of trachoma cases but felt confident in saying that it was likely that thousands of people were suffering from trachoma during that time period with the majority of cases being found amongst school children. The U.S. Public Health Service examined data from the 1910 Federal Census showing a population in Kentucky’s mountain counties at around 300,000. The general average of trachoma found among the people in those counties was 8.2 percent. If the same rate of prevalence existed among the rest of the population, there would be 24,000 cases of the disease in 20 of the 35 mountain counties. Deducting 25 percent for possible error that would leave 18,000 trachoma cases in those 20 counties with that being a conservative estimate. Estimating that the remaining 15 mountain counties had a population of 250,000, with the same amount of infection, this would add an additional 15,000 more cases totaling a staggering 33,000 cases in the mountain region of Eastern Kentucky.



Diagnosis

The diagnosis of a well-marked case of trachoma presented no special difficulties to a trained professional familiar with the disease. The difficult cases were those noted as ‘borderland’ cases; those of long-standing and quiescent at the time of examination or those too acutely inflamed to classify. Observation and treatment were necessary in acute cases and relapses. Simple remedies cured acute conjunctivitis within a reasonable time frame but would not affect the trachoma. Follicular conjunctivitis resembled the granular form of trachoma. The follicles, however, were arranged in rows like small beads. The Vernal catarrh pavement-like epithelium, covered with a milky film and characterized by excessive itching, burning, and water of the eyes and coming on with the first warm days of spring, usually clear up the diagnosis. Among the first chief symptoms of trachoma was watering of the eyes; this was very similar to ordinary conjunctivitis, but the discharge was less purulent. As the disease progressed, there was hypertrophy of the palpebral conjunctiva which obliterated the small vesicles. The eyelids would stick together in the morning hours and there was usually irritation. Eventually, the cornea would become involved and small ulcers appeared and later pannus. This would eventually lead to relatively extreme photophobia. Early in the disease, ptosis of the affected eyelids would be noticed and progressed along with the advancement of the disease. Untreated trachoma would last for years followed by the finally cicatricial stage and the damage to the vision, often resulting in complete blindness. Latter staged were accompanied by the sequelae of entropion, trichiasis, etc.

Treatment

Treatment of trachoma in the early 20th-century was surgically followed by appropriate aftercare and treatment. In acute cases and relapses, medicinal treatment applied to the conjunctiva was advisable in order to clear up the diagnosis when there was doubt. Surgical treatment for the average case of trachoma was grattage. That is, the amount of trauma to be governed in each instance by the individual case. This would vary; the proper amount of grattage in one case might be entirely inadequate in another. As such, each case was unique in its own ways. The operation consisted of exposing the trachomatous eyelids, incising as many as possible of the individual granules, applying bichloride or mercury 1-2000 with a brush, and completing the operation by smoothing down the surface with plain sterile gauze. The amount of this was dependent upon each case and relied heavily on clinical experience. The 24 hours following grattage required special care to prevent synechiae from taking place and it was even better to extend precautions to 48 hours. Immediately following the operation, a 25% solution of Argyrol was to be instilled and repeated every three hours for several days. About a week following the surgery, a 2% solution of nitrate of silver applied every few days helped aid in smoothing down the conjunctiva and was continued for as long as necessary. The eyes were kept clean and the patient was to stay in a darkened room following the operation. Ulcerations of the cornea were to be given appropriate treatment.

Prognosis

While undoubtedly trachoma, like smallpox, diphtheria, scarlet fever, and other communicable diseases, varies in intensity in individual subjects, it is essentially a chronic disease and always demanded treatments. Without appropriate treatment, the disease persisted for years with ever-increasing damage to the vision.

Tips to Avoid Contracting Trachoma in 1915

  1. Keep in good physical condition
  2. Have large windows in your home, which will admit plenty of fresh air and sunshine
  3. Sleep with windows open even in winter, and keep the room well aired where you live and study
  4. Do not use the common family towel, especially in homes where there are cases of trachoma
  5. Have a towel and handkerchief of your own, and don’t let anybody else use them
  6. Always make sure that the washbasin is clean before you use it
  7. Do not sleep with persons who have “sore eyes” nor use bedclothes that have been used by them
  8. Do not wear the clothing of persons who have “sore eyes” nor use their eating utensils without previous cleansing
  9. Boil the handkerchief, etc., of persons having sore eyes, and do not touch their faces
  10. Advise persons with sore eyes to have them get treatment at one of the eye dispensaries


Kentucky Faces of Trachoma

Images from the Bulletin of the State Board of Health, 1915.


Contributed by Shawn Logan | contact@kyhi.org

⁘ Works Cited ⁘


  1. Bulletin of the State Board of Health of Kentucky. V. 1, No. 4-6 (1915-1916): 335-281.

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