I have previously expressed my views before this society in regard to the inaccuracy of some of the observations made by Dr. Moore while here. My remarks concerning his work, however, are made with the utmost friendly feeling, as I have the greatest admiration for him. He is a gentleman in every respect, although we may totally disagree in the diagnosis of trachoma. Some of the cases which he diagnosed as trachoma were under my care, and the patients recovered within a few months under conservative treatment. Had he been able to observe these patients for a longer period, I am quite sure no diagnostic errors would have occurred; so after all it largely depends upon the men who watch the patients, and I believe this is the only way we can determine whether or not the disease is really trachoma. Of course we are at a disadvantage in that the diagnosis must be based solely upon the clinical manifestations, as we are able to obtain no assistance from the microscope.

One phase of the subject which I had hoped Dr. McMullen would discuss more at length is the trachoma situation in reference to the public schools. The majority of those present have heard numerous discussions upon this subject, and I am glad the school inspectors are here tonight. The committee appointed by the chairman of this society has met with the school inspectors, and has taken the position that it is unwise for them to create the impression among the school children that there is a widespread epidemic of trachoma. We have recommended that they refrain from making a positive diagnosis even in cases where they are morally certain the disease is trachoma. The objection from their standpoint (and I hope we shall hear from them to-night), is that treatment cannot be enforced unless they make this diagnosis. It seems to me there ought to be some way of enforcing treatment by the civil authorities. I believe our advice to them has been proper and conservative, that in doubtful cases where according to their judgment the children should be kept out of school and be referred to the specialist for attention and treatment, that these cases should be labeled conjunctivitis; and where they are certain the children have trachoma, they should say it is probably trachoma, or suspicious of trachoma. We have all had the experience of children being sent to us by the school inspectors with the diagnosis of trachoma, and are familiar with the panic this diagnosis has created among the parents who feel that trachoma is a disease of which they should be ashamed. The majority of these patients are found to be suffering from a mild form of follicular conjunctivitis without inflammation, simply presenting a few isolated follicles. Many of them are children with adenoids and enlarged tonsils, and few require operation, the majority of them getting well under simple treatment.

This is a phase of the subject upon which I would like to have heard more from Dr. McMul

len. In the mountain cases he sees there is probably no question as to accuracy in diagnosis, and they all undoubtedly represent well marked trachoma. We see, such cases oftentimes in Louisville.

With reference to Dr. Dabney's remarks about our having so many border line cases: While I will admit that we should isolate and treat these cases as trachoma, yet this disease is not always as contagious as has been commonly supposed. In substantiation of this statement I will mention a family recently observed. A girl living in Highland Park, whose parents migrated from some interior town in Kentucky, applied to one of our city opticians for glasses. He recognized that it was a case requiring treatment, and refused to examine her. The patient then came under my observation. This girl had one-sided trachoma in the transitional stage between hypertrophy and cicatrization, with marked pannus. She had received no treatment and had not complained of any eye trouble excepting impairment of vision in that eye. The other eye was unaffected, both the cornea and conjunctiva being normal. The father of this girl, who accompanied her, had bilateral trachoma in the cicatricial stage, there were no follicles to be seen on examination, but there was slight ptosis of both lids with the characteristic cicatricial line on the conjunctiva, showing that he had passed through true trachoma. At my request the mother and the three other members of the family were brought for examination. Every one had absolutely normal cornea and conjunctiva. They are people in the lower walks of like who know nothing of sanitary and hygienic precautions.

In connection with the foregoing, we know that follicular conjunctivitis often occurs in more than one member of the family; but the fact that there are two or three children with follicular conjunctival affections in the same family is no proof that the disease is trachoma. Such instances are not unusual from the simple fact that the children are of the same general type and temperament, living in the same hygienic surroundings and environment, eating the same character of food, etc.

In the diagnosis and treatment of trachoma, we are certainly "up against" a difficult proposition, and while we would all like to be conservative, at the same time I admit that all doubtful cases should be isolated and treated as trachoma until we are certain of the diagnosis.

J. R. Wright: I have enjoyed Dr. Ray's paper very much, and there seems little to be added. I have never understood why the disease under discussion happened to be called trachoma, unless it is because the name has simply been handed down to us from previous generations. As is well known, the term trachoma merely means something which is rough. i.e., a roughened surface, and has no more reference to the conjunctiva than any other portion of the human organism.

It seems to me we should adopt a more distinctive name, one which would at least indicate the pathology present and the anatomical situation. Dr. Rose, of New York, has suggested the name epipephycitis. but I must confess this is a hard term "to digest" and I do not know whether it really means all it sounds like or not! It appears to me, however, that a disease which can create so much trouble as trachoma ought to have a name which would in some measure indicate the condition that really exists. While of course in trachoma the eyelids are rough, that is all the term signifies.

I would like to hear something more about the treatment of trachoma. The discussion thus far has been confined almost entirely to the differential diagnosis. If anyone can enlighten us in regard to the treatment, I am sure we would all appreciate it.

G. C. Hall: I have thoroughly enjoyed the excellent paper read by Dr. Ray. All border line cases where no one can positively determine whether or not the disease is trachoma, and whether there will eventually result cicatricial changes of the conjunctiva, corneal involvement, etc., I believe should be isolated and treated as trachoma.

In another class, while there is but slight in flammation and little secretion, marked granulations occur in both the lower and upper cul de sacs. I have seen a number of such cases, and while they yielded to conservative treatment, I am convinced they were cases of true trachoma. I believe that in this, as in every other disease, there are various degrees of severity, and it would be just as fallacions to exclude all these cases in making the diagnosis of trachoma as it would to include all cases of follicular conjunctivitis in the diagnosis of trachoma..

In my opinion all cases where there are marked granulations especially in the upper cul de sac should be treated as trachoma. We know that patients with trachoma, as well as other diseases, sometimes recover with little or no treatment, but this observation is of no especial importance in connection with the diagnosis. We all see trachoma in its various stages, and some paticats will get well without operative treatment, yet they are true cases of trachoma. In other cases the disease is intractable, and response is slow to any method of treatment. Locality may have something to do with the severity of the disease. The cases Dr. McMullen sees in the Kentucky mountains are probably more severe than those observed in Louisville.

I believe we are all aware of the fact that the expression operation alone does not cure the disease, and that appropriate after treatment is required to restore the conjunctiva so far as may be possible to its normal condition. If the disease has persisted for a considerable period and extensive cicatricial changes have occurred, no operation will absolutely restore normal conditions,

but by expression and appropriate after treatment we can bring the disease to a close and restore to a cetrain extent the changes which have occurred in the conjunctiva.

Adolph O. Pfingst: There was a time when I thought the diagnosis of trachoma was easy. My first and largest experience with the disease was during my interneship at one of the New York eye clinics where the patients were mainly Russians, Poles, etc., and where eight out of every ten cases seemed to have advanced trachoma. We saw there very few cases of follicular disease. I then thought the diagnosis of trachoma was an easy matter.

Since being in practice here I have seen comparatively few cases of trachoma, but a great many of follicular diseases. Even during the present campaign against trachoma I have seen no more cases than before, that is, if my diagnosis of trachoma based upon clinical manifestations is correct.

Some good is always accomplished by discussions of this kind, but until differential diagnosis between follicular conjunctivitis and trachoma can be made from a bacteriological standpoint I do not believe that a satisfactory conclusion will result from our discussion. Even with a microscopic section before you a differential diagnosis is difficult or impossible in the early stages of trachoma, as the pathological picture is practically the same in the two diseases. About the only distinction pathologists make is that in follicular conjunctivitis the lymph nodes or follicles are separated from the epithelial surface by few lymphoid cells, whereas in trachoma there are a great many cells in the conjunctival stroma. It is this difference in the amount of cellular structure that makes the follicles more pronounced and isolated in follicular disease and less pronounced in trachoma.

In the advanced stages of trachoma, after cicatrization and corneal involvement have supervened, the differential diagnosis is comparatively easy; but in the early stages much confusion exists.

It has always been my belief that an important clinical point of differentiation has been the presence or absence of follicles in the upper calde-sac. Whenever there is considerable formation of follicles in the upper cul-de-sac suspicion rests strongly on trachoma. In the majority of the cases recently seen here the follicles were in the lower cul-de-sac. They were in many cases not numerous and were associated with little or no inflammatory reaction. I have yet to see a case in which the follicles appear in rows as they are described in the text books. When the lid is everted a fold of the mucous membrane is made more prominent and the follicies appear on a line. Such cases are not trachoma, but ordinary follicular conjunctivitis.

I believe my views in regard to the treatment of these two conditions are somewhat different

from those of others working in this line, and in discussing the therapy I wish at the outset to enter a protest against the indiscriminate use of the roller forceps or other surgical means in cases such as those observed here recently. I have seen a number of patients who have been operated upon by this method, where there had evidently been follicles in only the lower cul-de-sac, and after the operation considerable fibrous scar tissue was noted in the conjunctiva. I am sure this is an undesirable condition, and for that reason I wish to protest against this method of treatment. In mild cases of follicular conjunctivitis or in what is called trachoma but is in a stage too early to make a diagnosis. I do not believe we ought to treat these cases as trachoma while we are in doubt, but as follicular conjunctivitis. There are in Louisville between 200 and 300 children who have the disease which has been called trachoma, and we are frequently asked what is to be done with these children. What should be our attitude as to the attendance of such cases in school. I think we should treat these cases, not as trachoma but as follicular conjunctivitis, at least until the diagnosis can be definitely determined, by the clinical course. These children ought to be allowed to attend school as they have no active conjunctival inflammation nor purulent secretion, and I do not believe the disease is contagious. If they do not respond to treatment, it is time enough then to talk about more radical measures and exclusion from school. G. A. Robertson: In 1910 I began work in the eye clinic of the University of Louisville, and since that time have observed many what we called follicular conjunctivitis (we did not diagnose them as trachoma), and all apparently recovered after the use of some simple eye wash. If all these cases of conjunctival inflammation were trachoma, why is it that during these fourteen years since none of these patients have returned with corneal complications and other sequelae? We did not isolate these children nor keep them from school, and as the treatment was so simple, if the disease were trachoma why have not the patients returned with complications, for further treatment? Why do we see each year only one or two cases of real trachoma? Why do we hear so much talk about the dangers of granulated lids in children, and yet when the same children, years afterwards, as adults, are examined for glasses, the conjunctiva is found normal? In my opinion all these cases are simple conjunetivitis and not trachoma.

cases of

I have recently seen two or three cases of undoubted trachoma presenting smooth conjunctival scars. The cornea was uninvolved but there was some deformity of the lids. It seems to me if all the cases we have seen during the last fifteen or twenty years represented true trachoma, our dispensaries would now be filled with trachomatons patients. Probably one-half per cent. of our dispensary cases have trachoma

I believe in employing simple methods of treatment until our diagnosis can be verified. B. G. Gribble: I appreciate very much the privilege of being present to hear the excellent paper read by Dr. Ray. The number of children with trachoma in the public schools, according to Dr. Moore's diagnosis, was about two per cent., not quite so large an average as Dr. McMullen found in the blue-grass county he mentioned. I would like to ask whether Dr. McMullen considers the diagnosis of trachoma correct in the five patients exhibited here to-night. If they are trachoma, then all the cases so diagnosed in the schools are trachoma; if they are follicular conjunctivitis, then we have been mistaken in our diagnosis (Dr. McMullen replied that while he had always refused to make the diagnosis excepting in daylight, the five cases looked like trachoma to him.)

I believe Dr. Moore was very conservative in his diagnosis. When in the least doubt he specified suspicious of trachoma" and it was so written on the health card. The object of these cards is to keep an accurate record of the cases examined from time to time. Many of the cases marked suspicious" have since developed what I consider true trachoma. A few have apparently recovered, but in the majority (at least in 80 percent of them) the granulations have increased.

66

Until within the last year I did not make the diagnosis of trachoma until the disease was pronounced. Dr. Moore's object was to teach us to recognize trachoma during the earliest stages when diagnosis and treatment are of the utmost importance. Almost any one can make the diagnosis in the advanced cicatricial stage, but he contended that early diagnosis and prompt treatment were of the greatest value, and he thought it his duty to diagnose the disease as trachoma.

We exclude children having trachoma from school only when they have excessive conjunctival secretions or fail to take treatment. The greatest number of trachoma cases are found in chiltren from institutions. In two orphanages under my jurisdiction there are now about twenty cases of trachoma. I believe Dr. Ray accompanied Dr. Moore on his visit to at least one of the public schools, where ten or twelve cases of trachoma were found. I do not know exactly what their conclusions were, but think Dr. Ray agreed that the disease was trachoma at that time.

As to the "scare'' created in the public schools by the diagnosis of trachoma among the children, I do not know which would be the greater crime, to fail to diagnose cases of trachoma, scarlet fever or diphtheria. They are certainly all serious diseases and early diagnosis is required. I believe it is always best to furnish the public with the actual facts, and it seems to me that instead of condemning us for making accurate diagnosis they should assist us all they possibly can.

In examining school children if I find a case that looks suspicious the first question I ask the child is, have you any brothers or sisters at

tending this school?" If I get an affirmative answer, the other children are immediately sent for and examined. If a similar condition is found in the other children, the diagnosis of trachoma is confirmed. I do not believe follicular conjunctivitis is a communicable disease like trachoma. I may be wrong in some of these ideas, but they have been gained by six years of school inspection experience and recent observations with Dr. Moore. Even if there is some question about the disease being trachoma, I do not believe it does any harm to make this diagnosis, because the people recognize trachoma as a more serious disease than follicular conjunctivitis, and will be more likely to seek treatment than if you merely say the children have "sore eyes."

Referring to the suggestion just made by Dr. Pfingst that the diagnosis of trachoma makes a bad impression upon the child, and that particularly is this true if the diagnosis is announced before the class. I wish to answer Dr.Pfingst by saying that after making the diagnosis we never announce that it is trachoma, we merely say T. R. or suspected T. R. It is a fact that we write the name trachoma on the slip, but this goes to the individual child. When a child is brought to the office for examination, we usually state to the mother at least, that the patient has trachoma. I do not see any good reason for changing our methods, as there is no disadvantage in the child knowing that the disease is trachoma, and in my opinion there are many advantages, as it may keep other members of the school or family from being infected and will particularly impress upon the child the necessity of immediate treatment.

J. M. Ray, (Closing): I wish to thank the gentleman for their liberal discussion of my paper. My first interest was aroused in regard to the local condition in Louisville when the Public Health Service men came here less than a year ago. Soon after their arrival there appeared several columns in a newspaper to the effect that they had discovered a new contagious eye disease prevalent in the public schools in Louisville. They were teaching the local doctors how to diagnose this new disease. Soon after my telephone bell began to ring and the mothers of school children would report that the government inspector had examined the eyes of her child and had told her she must not return to school as she had contagious eye disease. Other mothers would telephone and ask what I thought about their takthe child out of public school as they did not want them to become infected with this new disease. My duty was simply to pacify them and to assure them that the new disease was one perfectly understood by all the eye doctors in Louisville. They assured me thathe public health service men said they had examined a million eyes and this disease was very contagious. While I have not examined a million eyes I have examined a number of eyes many times and this is better

than a million eyes once. I visited one of the schools with the inspector and saw the diagnosis of trachoma made in cases that I had always considered follicular in character. After the inspectors left we became better acquainted with the local condition that had been called trachoma, and we began to scrap among ourselves about the matter. In one institution four or five cases of what had been called trachoma by the inspector were found to disappear under simple treatment. Recently I have had two cases before the clinic which were diagnosed trachoma by the inspectors and they cured up after one operation of simply rubbing the conjunctiva with a piece of gauze and a tooth brush with bichloride of mercury. I recognize the fact that it is often advisable to operate on these patients when the disease is not trachoma because as long as the folliculosis lasts they are more liable to the danger of acute infection either with little Kock Weeks or the Morax Axenfield variety of infection. As soon as the public schools started up in September a number of cases were seen of acute conjunctivitis engrafted on a folliculosis especially in boys who have been going swimming in the summer. This is especially true of one school in the West End as there is a bathing pond which they are very fond of swimming in. This type of infection was called to my attention a number of years ago when an interne in one of the New York Hospitals.

I certainly cannot think ali cases that have been diagnosed as trachoma can be the true disease since the majority of them recover perfectly in a few weeks after one operation leaving perfectly normal conjunctiva and from my standpoint no one operation can possibly cure a case of genuine trachoma as it is the experience of all men who treat this disease that they are subject to frequent relapses.

Apraxia. Long reviews the history of the conception and the literature of this subject and reports in detail a case in a spinister of 66. There is both lack of proper apprehension of the true nature of things and inability to perform certain acts even when the motion is done before her eyes and she has only to imitate it. She has therefore both the soul-blindness and the motor apraxia. By a series of deductions and eliminations the lesion responsible for the trouble can be localized Two years ago the patient developed symptoms suggesting foci of hemorrhage in the brain but there was no tendency to hemiplegia or hemianesthesia, hemianopsia or agnosia. Aphasia and apraxia were the only symptoms, and this testified to the comparatively trivial nature of the lesion and located it between the zone of Rolando and the occipital lobe.

FOUR YEARS OF KENTUCKY VITAL

STATISTICS.*

By W. L. HEIZER, Bowling Green. Our exhibit in the basement of this hotel will illustrate better than I can say in words the work we are doing, and I hope you will study this exhibit very carefully. It shows, after all, the full problem consists in securing an alltime health officer. That is the keynote in the presentation of this exhibit. Several things stand out prominently after four years operation of the law. For the first two years twelve and a half per cent. of the certificates of death were returned for information as to the cause of death. I find physicians are careless in stating the proper cause of death. For instance, in deaths from cancer, there would be the simple statement "Cancer." The kind of cancer, the location of it or common contributory causes were left off entirely. In the last twelve months, since paying attention to the completion of certificates, on account of having to send them to the U. S. Government, not over one per cent. had to be returned. When a death occurs from accident or violence, the extent and kind of accident and all the facts relating to it are included in the death certificate. When a death occurs from carcinoma, the site of the disease is named and any operative procedures that may have

been undertaken. The statement as to the cause of death is usually very accurate.

Another thing that will interest you is that we have now approximately ninety-seven per cent. of the deaths of the State returned to the office. Fully ninety-five and a half per cent. of the births are returned. We learn this in various ways, from newspaper clippings, interviews with physicians, and personal inspections. We have an inspector who goes about in districts where we are not receiving complete returns and we verify our reports.

One of the reasons why I did not prepare a formal paper is that we publish in the monthly bulletin of the State Board of Health the tables and statistical data which the profession will need. You will find in the last bulletin the final and detailed compilations of statistics of Kentucky by the Federal Government for 1911-12; you will find in the Bulletin of the State Board of Health vital statistics for 1913 for preventable diseases. If any of you are interested in the age, sex, nativity, color and occupation, write the director of the census, the chief of vital statisties, and ask for bulletins number 109 and number 110, and they will contain the tables and vital statistics for the state.

*Read before the Kentucky State Medical Association, Newport, September 22-25, 1914.

I want to call your attention especially to the exhibit down stairs. It tells the story in about five minutes, so that you can grasp it. It tells three things. In the first place, a red light flashes once every complete turn of the wheel. It shows that one hundred and thirtysix people of Kentucky die every three and three-fourths days from diseases that can and ought to be prevented.

A white light flashes one hundred and thirty-six times every revolution of the wheel, representing that every forty minutes, every day of every year, some Kentuckian loses his life from the carelessness, ignorance or indifference of people in permitting disease seed to grow in their own families or their neighbors.

One hundred and thirty-six graves are planted around the rim of the large wheel, showing that of these tuberculosis kills fortynine of the number, typhoid fever kills ten, dysentery six, summer complaint of children twelve, diphtheria six, measles three, whooping cough five, scarlet fever, one ,etc. A total of 13,463 die each year of preventable diseases. This deadly rate has been in operation for three years, as shown by the official death records in the Bureau of Vital Statistics. It doubtless has been happening for years and will continue so long as you, as a citizen of Kentucky, remain as indifferent and neglectful as you have been in the past.

Tacks of fourteen colors in one hundred and twenty counties of Kentucky show that 13463 people died on an average for three years of diseases which can be prevented. More than ten times this number of people were sick, threatened with death, and the cost of those ill and their families amounted to more than four times what it cost to run the state government. The greater part of this cost, suffering and loss of life, can be stopped.

The purpose of this exhibit is to show the extent of the problem we are confronted with, but this information is useless unless we try to find some means to solve the problem, and I think this exhibit will show conclusively we are powerless to stop this dreadful destruction of life at a terrible cost to the people in money and sorrow unless we have an all-time competent health officer in every county. You are reminded that good health either in the individual or community is purchasable. How? Employ a whole-time health officer to enforce the laws that will give the people pure food, water and air, and to stop the spread of dangerous, communicable diseases when they start. This can be done by looking after the preparation and marketing of milk, meat, and other food stuffs liable to pollution; regulating the disposal of sewage, garbage and other filth, in cities, towns and homes;