Trachoma

“ The disease sometimes lasts for years without causing blindness, though it gives rise to great irritation. It is generally Trachoma.attended by a discharge, which is highly contagious, producing the same disease if it gets into other eyes. Want of cleanliness is one of the most important factors in the propagation of trachoma, hence its great prevalence in Oriental countries. Trachoma is very prevalent in Egypt, where those suffering from total or partial blindness are said to amount to 10% of the population. ”

“ The area in Europe where trachoma is most prevalent extends from the Gulf of Finland on the north to the Black Sea and the Mediterranean on the south, and from Moscow and the Volga on the east to the Carpathian Mountains on the west. ”

“ In 1912 of the 718 cases certified at New York, 64 were landed. If no inspection were made for trachoma, the victims of the disease would flock to the United States in hordes. We have a weighty and difficult problem in handling the trachoma already existent in this country. Every consideration demands its absolute exclusion in immigrants.
One other disease of national importance for the public health, and which has an intimate relation to immigration, is hookworm infection. The economic and social significance of this disease is well known. ”

“ The wide prevalence of trachoma in the United States and its importance in decreasing economic efficiency are only now beginning to be fully realized. It is stated that half of the 64,000 registered blind persons in the United States are needlessly blind and that the maintenance of one blind person for life by the community costs an average of $10,000. Sixty-seven per cent of the blindness in the Ohio State Institution for Italians the Blind was found to be due to trachoma. In the Kentucky Institute for the Blind, a year ago, 45 per cent, of the blindness followed trachoma. ”

“ In addition to the hospital work, surveys were made in sixteen counties in Kentucky, especially among school children. Eighteen thousand and sixteen people were examined, 7 per cent being found to have trachoma. Similar inspections in certain localities of Arizona, Alabama, and Florida resulted in finding the disease present in from three to six children out of every hundred. Periodic examination of school children for the disease and the exclusion of the afflicted from the public schools, are two of the recommendations the Public Health Service lays emphasis upon. ”

“ Educational facilities are inadequate to care for half the children of school age. In many of the schools, trachoma has afflicted numbers of the children. When tuberculosis develops among the school children they are sent home from the school to die without medical attendance. Mr. Allen suggests that more physicians, qualified to treat trachoma and tuberculosis, be appointed to service among the Navaho, and that each one be assigned a territory fifty miles square, with a field sanitarium located near the center of the territory. ”

“ Permanent injury to sight is most likely to occur in cases where early treatment is neglected. Among immigrants with trachoma, ignorance of personal hygiene and inability to secure proper treatment make the spread of this disease alarming and the consequences to sight disastrous. ”

“ Trachoma is an inflammatory communicable disease of the eyelids, of unknown causation, having most serious sequelæ of deformity of the eyelids, impairment of vision and blindness. In Europe and Asia it is a terrible scourge. ”

“ Certain diseases are found so frequently among immigrants, and others are so inherently dangerous, as to merit special mention because of their important relation to public health.
First among these might be placed trachoma, a disease of the eyelids characterized by extreme resistance to treatment, very chronic course and most serious results. Most of the immigrant cases occur in Russians, Austrians and Italians, although it is of common occurrence in oriental and Mediterranean countries. It causes a large percentage of the blindness in Syria and Egypt. ”

“ More than four fifths of the immigrants entering the United States come from southern and southeastern Europe. As a type these peoples are ignorant of hygiene and sanitation. They live on a low plane. Overcrowding, disregard of privacy, cleanliness and authority, their gregariousness and tendency to congestion along racial lines in cities, are all important factors in the spread of disease among them and by them.
Among the diseases whose prevalence, manner of spread and results constitute a national health problem, trachoma must be reckoned. ”

“ Under loathsome and dangerous contagious diseases there were 1,361 cases, of which 85 per cent, were trachoma. Over 11,000 aliens had a defect or diseases affecting ability to earn a living and half of these were due to age and the changes incident to senescence. ”

“ Mechanically and with quick movements we are examined for general physical defects and for the dreaded trachoma, an eye disease, the prevalence of which is greater in the imagination of some statisticians than it is on board immigrant vessels. ”

“ The veiling which it produces causes more or less defect of sight.
Various methods of treatment are in use for trachoma. Expression by means of roller-forceps or repeated grattage are amongst the more effective means of surgical treatment, while local applications of copper sulphate or of alum are certainly useful in suitable cases.
Diphtheritic conjunctivitis is characterized by an infiltration into the conjunctival tissues which, owing to great coagulability, rapidly interferes with the nutrition of the invaded area and thus leads to necrosis of the diphtheritic membrane. ”

“ The medical examiners must ever be on the alert for deception. The nonchalant individual with an overcoat on his arm is probably concealing an artificial arm; the child strapped to its mother's back, and who appears old enough to walk alone, may be unable to walk because of infantile paralysis; a case of favus may be so skilfully prepared for inspection that close scrutiny is required to detect the evidences of recent cleansing, and a bad case of trachoma may show no external evidence and be detected only upon everting the eyelid. ”

“ The most widely spread endemic diseases are malaria and trachoma. The former is naturally especially prevalent in all places where water stagnates, or where there are faulty or unclean cisterns. Trachoma is largely due to want of personal cleanliness, and is often accompanied by loss of sight. ”

“ Thus in China its prevalence is great, as is also true of India, Egypt and Japan.
Outside of imported cases it is very prevalent in many parts of the United States.
In this disease there is hypertrophy of the conjunctiva, granule formation and subsequent cicatricial changes. Pannus and corneal ulcerations are frequent complications.
The disease is contagious through transfer of the secretion by hands or flies. It is usually considered as caused by the so-called trachoma bodies or cell inclusions, which are best brought out by Giemsa staining. ”

“ What was it?”
“It was a Rollertowl,” replied the doctor impressively and in a sonorous voice.
“I never heard of it,” said the Cherub, awestruck. “What is it like?”
“He means a roller-towel, goosie,” explained Julia. “A towel on a roller, that everybody wipes their hands and faces on.”
“Exactly. And because everybody uses it, any contagious disease that anybody has, everybody is liable to catch. I’d as soon put a rattlesnake in a school as a roller-towel. In this case, half the grade where it was had conjunctivitis. But that isn’t the worst. There was one case of trachoma in the grade ”

“ A dry character of the respiratory murmur some time after tracheotomy indicates the approach of death within from twelve to twenty-four hours from descent of the membrane; so does cyanosis, whatever be its degree of intensity. Diphtheria of the trachea, which ascends to the larynx, is positively fatal. It has a rapid course, and tracheotomy only postpones the end for a little while, if at all. The general health and strength of the little sufferer have no influence whatever. ”

“ Tracheotomy was at one time used in certain cases in order to give complete rest to the larynx, but this has been abandoned as unsatisfactory; it should not be performed unless there is urgent laryngeal obstruction, since ‘it has many and grave disadvantages. It materially diminishes the efficiency of the cough, the secretion from the lungs is apt to accumulate in the bronchi and alveoli, and set up miliary tuberculosis. Again, the patient can often ill withstand even this slight operation; his power of speaking is diminished or lost and his mental anxiety is increased. ”

“ When possible, a tampon canula is inserted into the lower part of the trachea. When the growth is low down, the patient is placed in the Trendelenburg position in order to prevent the inspiration of blood. Should the diagnosis be uncertain, a portion of the tumour can be excised and a frozen section made. If proved to be innocent, the growth can then be freely excised with scissors or galvano-cautery. The bleeding is arrested, and the tracheotomy tube is retained for several days. ”

“ But when the first alarm has quieted down, the attacks are likely to be only occasional, as when the article, drawn up with the expired air, comes in contact with the under aspect of the vocal cords. It may be that in a violent fmt of coughing it will be expelled, but, if not, the surgeon must be at hand ready to perform tracheotomy when the urgency of the symptoms demands it. Tracheotomy is the making of an opening into the trachea, the air-tube below the larynx. It is unsafe to leave a child with a foreign body loose in its windpipe, on account of the risk of sudden and fatal asphyxia. ”

“ The sooner the serum is injected the better the prognosis with tracheotomy. A large dose should be given, 8,000 to 18,000 units, irrespective of age, and the dose may be repeated on the second day if required. Improvement generally commences between twelve and twenty-four hours after injection; the swelling of the mucosa subsides, and secretion is diminished; false membrane is not so copious, and rarely extends to the trachea and bronchi; crusts become less adherent, and are expelled by the patient. ”

“ Excision of the larynx has found its chief indication in carcinoma, but has been employed in sarcoma, polyps, tuberculosis, enchondroma, stenosis, and necrosis. Whatever the procedure chosen for the operation, preliminary tracheotomy is a prerequisite. It should be made well below the isthmus of the thyroid gland, and from three to fifteen days before the laryngectomy. This affords time for the lungs to become accustomed to the new manner of breathing, and the trachea becomes fixed to the anterior wall of the neck. ”

“ The pathological nature of a tracheal tumor can sometimes be determined in situ with more or less probability. Without microscopical examination it is not always possible to say whether a growth is benign or malignant unless the mass has advanced to ulceration, and then specific disease must be excluded by the history and concomitant symptoms. Papillomata have a peculiarly uneven surface; fibromata are usually more smooth. With equally good illumination, tumors of the trachea resemble tumors of the larynx, and may be similarly differentiated. ”

“ If the body remains movable in the trachea, it is apt to be displaced when the patient moves or coughs, and it may be driven up and become impacted in the glottis, setting up violent attacks of coughing and spasmodic dyspnœa.
Tracheotomy should be performed at once, and the edges of the tracheal wound held widely open with retractors, the patient being inverted, or coughing induced by tickling the mucous membrane with a feather. The foreign body is usually expelled, but it may be inhaled into one of the bronchi. ”

“ But if no medication will have proved successful, the symptoms of stenosis, dyspnoea, cyanosis, and the supra- and intraclavicular and epigastric recension increase steadily to an alarming extent. When the pulse becomes frequent and intermitting, even without the presence of asphyxia and anæsthesia, air ought to be introduced into the lungs by tracheotomy. No positive rules can be laid down as to the length of time one ought to wait before performing it. No subdivision of the disease into several stages is of any benefit in selecting the exact period in which the trachea must or may be opened. ”

“ In considering the prognosis, not only must the symptoms peculiar to the case be taken into account (as for instance the pulse, temperature, respiration and general condition) , but also any complications that arise. It must be borne in mind that tracheotomy does not cure, although it can relieve, the patient; that nearly one-third of the cases die; that the disease, and not the operation, is responsible for most of the deaths. Moreover, the amount of toxæmia depends upon the virulence of the infection, which is variable in different epidemics; upon the area of mucous membrane infected ”

“ Every medical graduate has been taught that there are two kinds of tracheotomy, high and low, the low operation being very difficult, the high operation very easy. When he is suddenly called upon to do an emergency tracheotomy, this erroneous teaching is about all that remains in the dim recesses of his memory; consequently he makes sure of doing the operation high enough, and goes in through the larynx, usually dividing the cricoid cartilage, the only complete ring in the trachea. ”