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of patients on July 1, 1915, but the other was not opened until about October 1. This makes a total of five trachoma hospitals in operation at the close of the fiscal year. All arrangements have been completed for extending the work into Tennessee, and a trachoma hospital will be established at Tazewell, Claiborne County, Tenn., about August 17, 1916. The central office will remain at Lexington, Ky.

The original survey in 1913 showed Knott County to be heavily infected with trachoma and the first of these hospitals was therefore established in Hindman, the county seat, situated 20 miles from a railroad. In this manner treatment was given to hundreds of trachoma victims who would otherwise never have found relief. According to Surgeon McMullen, this county is now practically free of the disease and probably has less infection than any other county in Kentucky. The hospital will therefore be moved to another infected district in a short time.

Cooperation of State and local authorities. The State and local authorities are cooperating in the work. The local authorities at London, Ky, Coeburn, Va., and Welch, W. Va., furnish suitable two-story buildings, rent free, for the use of the hospitals, while Breathitt County, Ky., contributes toward the rental of a building for the Jackson Hospital. The local authorities at Tazewell, Claiborne County, Tenn., are making extensive improvements on the house they have agreed to furnish for the use of the hospital to be placed there.

During the year just ended the State of Virginia contributed $1,200 toward the maintenance of the Coeburn Hospital and West Virginia $600 for the Welch Hospital. The State board of health of Kentucky proposes to contribute $500 to the work in the State during the next fiscal year.

The service endeavors to educate one or more of the local physicians to do the work at all of the trachoma hospitals, in this manner preparing the way for the establishment of similar hospitals by the local authorities after the discontinuance of service operations in these localities.

Eradication. These hospitals, with a capacity of only 15 or 20 beds, are often crowded, and unable to care for the numbers of patients seeking relief.

Persons treated. During the past year the total daily attendance at the five trachoma hospitals was 19,530. Twenty thousand five hundred and forty-five treatments were given to dispensary patients. This, added to the 91,510 treatments given to the hospital cases, makes a total of 112,055 individual treatments given during the year by the doctors and nurses at these five hospitals. Nearly one-half of the number applying for relief for trachoma were found to have impaired vision. This ranged all the way from slight defects to total blindness as a result of trachoma. Many of these cases were among school children who were relieved of their trachoma while it was in the incipient stage and before the visual damage had been done.

A total of 1,880 persons were treated in the hospitals during the year. These were furnished subsistence and, as previously stated, given 91,510 individual treatments, an average of about 50 treatments per patient. There were 1,832 cases discharged from the hospitals, fiscal year.

leaving 48 remaining under treatment at the beginning of the new

The total days relief furnished was 18,302, and the number of rations furnished was 20,776. The total cost of rations furnished at the five hospitals was $7,849.55. The average cost of a ration was therefore 37.7 cents. The cost of the ration was materially increased on account of the fact that subsistence for the patients is necessarily contracted for at one of the hospitals at a much higher price than the cost of the other four hospitals where patients are subsisted in the hospitals. There were 1,687 operations performed at the five hospitals during the year, 534 of which were under general and 1,153 under local anaesthesia.

The following table gives the dispensary and hospital relief, and also the relative frequency of sequela.

Dispensary and hospital treatment, cost, operations, etc.

Welch
Jackson London Hindman Coeburn
Hospital. Hospital. Hospital. Hospital.

Hospital.
(9 months).

Grand
Total.

DISPENSARY RELIEF.

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Old cases applying for treatment, all

causes...
Old cases applying for treatment, tra-

choma.
New cases applying for treatment.
Total daily attendance..
Total number treatments given..
Average daily attendance.
New trachoma cases..
Cases of impaired vision from trachoma.
Cases corneal opacity from trachoma...
Cases blindness both eyes from trachoma.
Cases blindness one eye from trachoma.
Cases ulcer from trachoma.
Cases pannus from trachoma.
Cases entropion from trachoma..
Cases trichiasis from trachoma.
Cases photophobia from trachoma.
Cases conjunctivitis..
Cases glaucoma...
Cases trachoma cured during the year...

4,506 1,584 6,616 7,054

18 530 228 104

1 6 55 105 51 31 213 486

2 217

968 2, 238 3, 516 3,514

9.6 495 237 86

6 28 36 64 52 38 205 349

3 232

689 2, 431 2,816

6 324 190 87

3 23 39 119 38 15 96 77

1 268

శిలుజిల్లా - హరిణి :

492
166
72
2
4

1,320 1, 259 3,248 3, 413

12 259 100 132

2 4 30 53 28 15 190 352

2 103

9, 171 7,970 19, 530 20, 545

57 2, 100

921 481 14 65 185 389 194 123

759 1, 496

11 916

232

96

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The patients treated at these hospitals came from counties throughout the State of Kentucky and from many counties in West Virginia, Virginia, Tennessee, and Ohio, as follows:

Jackson Hospital.-Kentucky: Bath, Bell, Breathitt, Carter, Clark, Clay, Elliott, Estill, Fayette, Fleming, Greenup, Jessamine, Johnson, Knott, Lee, Leslie, Letcher, Lewis, Madison, Magoffin, Menifee,

Montgomery, Morgan, Ohio, Owsley, Perry, Pike, Powell, Rockcastle, Rowan, Washington, Wolfe. Virginia: Dickenson. West Virginia : Wayne.

Hindman Ti ospital.Kentucky: Boyle, Breathitt, Carter, Floyd, Harlan, Jessamine, Johnson, Knott, Lawrence, Lee, Letcher, Madison, Magoffin, Perry, Pike, Powell, Pulaski. Virginia: Dickenson, Wise.

London Hospital.-Kentucky: Adair, Bell, Carter, Clay, Garrard, Graves, Harlan, Hart, Jackson, Knox, Laurel, Leslie, Letcher, Madison, Marion, Morgan, Perry, Pulaski, Rockcastle, Trigg, Wayne, Whitley. Tennessee: Claiborne.

Welch Hospital.-West Virginia: Cabell, Kanawha, Lincoln, Logan, McDowell, Mingo, Raleigh, Roane, Wayne, Wyoming. Virginia : Buchanan, Tazewell. Ohio: Jefferson. Kentucky: Boyd, Lawrence.

Coeburn Hospital.- Virginia : Buchanan, Dickenson, Lee, Russell, Scott, Tazewell, Washington, Wise. Kentucky: Bell, Harlan, Leslie, Letcher, Pike.

The number of cases of trachoma recorded as cured during this year was 916 and represents only those who were actually seen by the medical officer in charge, and therefore known to be cured. A very great number of the cases live long distances from the hospital and when relieved of their disease, and therefore not compelled to return, are not seen after a cure is effected, and their record cards remain incomplete as to the result obtained. This is true in a large number of cases, and it is believed that 50 per cent more than the recorded number would be a conservative estimate of the actual number of cures.

A very large percentage of these trachoma cases are helpless adults unable to earn a livelihood and children denied an education. Apart from the public health and humanitarian aspects, the relief of this large number of eye sufferers has an economic importance impossible to estimate.

Prevention.—The work of sanitation, which is, of course, of equal importance to that of eradication, has been carried on much in the same manner as during the previous year. The gradual perfection of the organization, however, has made it possible to extend this phase of the work and to reach a much larger number of people. Besides the house to house visits made by the hospital doctors and nurses, one nurse was detailed exclusively for the district work. During 10 months, beginning September 1, she visited 2,820 homes in the vicinities of the London, Ky., and Coeburn, Va., hospitals and in neighboring counties. There were 15,510 persons in these homes, and 494 of them were reported by the nurse to have diseased eyes. She also visited 117 schools, with an aggregate attendance of 2,940 pupils, and reported 346 of them to be suffering with diseased eyes. The water supply of these homes consisted of 1,338 wells, 2 cisterns, and 1,453 springs. Twenty-one families depended upon polluted surface water. Of these 2,820 homes visited by this district nurse, only 414 or less than 15 per cent of them had any pretense of toilet arrangements, the remainder being reported as having no accommodations.” Of the 117 schools visited only 17 had closets that could be classed as sanitary, 38 had surface closets, while the remaining 62, or 53 per cent, had no accommodations whatever. The great majority of these homes and schools visited were remotely situated.

66

а.

During the year the district nurse rode 4,094 miles on horseback to reach the homes visited. In addition to the work done by her, house to house visits were carried on from the hospitals by the doctors and other nurses at such times as they could be spared from their hospital duties.

During the year a total of 328 public health talks were given to audiences of more than 21,000 people. Three thousand five hundred and seventy-one homes were visited, with a total population in the families of 24,982. A total of 624 schools were visited and 26,975 pupils examined. A grand total of 51,957 people were therefore reached by means of the district work. Of this number 3,666 were found to be suffering with trachoma. These district visits were used as a means of educating the people in the simple rules of hygiene, the prevention of disease, necessary procedures to be taken when ill, and practical points in caring for the sick. The old hospital cases were also followed up and advice given as to the further care of their eyes. All trachoma cases were told of the communicable nature of their disease and advised to seek relief at one of the service hospitals. A total of 11,286 pamphlets on “ Trachoma, its nature and prevention,” were distributed during the year.

Field clinics.—As in the past, field clinics were held as a means of carrying the prevention and eradication work into various infected localities. Preliminary to these clinics the service officer would go to the locality selected and interview the health officer and the educational authorities. He would then examine the children in the school and any others who might apply. After arranging for a temporary "hospital” in the locality, which was frequently improvised, the officer would perform operations for the relief of cases and for the instruction of physicians in attendance. When he departed a trained nurse would be placed in charge under the direction of the local physicians. The expenses of these clinics, including the care and after-treatment of the cases, were borne by the community, with the exception of the expenses of the service officer and the nurse accompanying him. As a further means of education illustrated lectures were given in the towns visited.

There were 12 such field clinics held during the year and 122 operations performed during these clinics. Of these, 77 were performed under general and 45 under local anæsthesia. A total of 145 local physicians were present at these clinics and were instructed in the diagnosis and treatment of trachoma. A number of them operated under the direction of the service officer in charge. An endeavor was always made to have the antitrachoma work continued, and permanent trachoma clinics have resulted in some of the places visited. The local physicians have adopted the methods followed by the service and conduct these clinics at stated periods.

The field clinics of the service are usually attended by representatives from the State board of health and other public health organizations, and the interest the clinics arouse is used to promote the general public health.

An effort will be made to increase the number of these clinics during the next fiscal year.

Financial side of hospital and clinical work.-The strict economy with which this work was commenced has been adhered to. However, as the people become educated to the importance of these hospitals and the prevention of disease generally, more apply for relief and adequate provision has to be made for the increased numbers. The total cost of maintaining these five hospitals, including the increased amount of district work, was $19.50 per day each. The States of Virginia and West Virginia, however, contributed $1,800, which makes the actual cost to the service only $18.50 per day.

Importance of trachoma work. There is no doubt that trachoma is increasing in the Appalachian Mountain region, and special effort should be made to prevent its further spread and to reach it among the school children, where it is usually incipient and readily curable.

Cases of cured trachoma, people saved to usefulness and society, are to be found in all sections of the country where this work is being done. In all of these little hospitals in the mountains and in the homes of former patients can be seen the far-reaching results of the public health work that is being accomplished in connection with the trachoma campaign. Expectoration on the floors of the hospitals, so common at the outset, is very noticeably less. The individual drinking cup, basin, towel, toilet articles, etc., now in use, are much more appreciated than formerly.

The field, however, is extensive, the difficulties many, and this work will therefore be continued and enlarged.

TRACHOMA AMONG SCHOOL CHILDREN IN ARKANSAS.

In the course of a survey to determine the prevalence of mental defects among school children in Arkansas, made on request of the governor, the Arkansas Commission for Feeble-minded, and the State board of health (see p. 62), Asst. Surg. W. L. Treadway made inquiries into the prevalence of endemic diseases in the communities studied, notably trachoma. These investigations show a widespread distribution of the disease throughout the State and indicate that it is more prevalent in rural than in urban communities. The disease was encountered in 1.1 per cent of the boys and 1 per cent of the girls in the rural schools, and in 0.2 per cent of the boys and 0.3 per cent of the girls in the city schools.

TRACHOMA AMONG SCHOOL CHILDREN AT NOGALES, ARIZ.

In an examination of 534 school children for trachoma at Nogales, Ariz., made unofficially, Asst. Surg. A. L. Gustetter found 27 pupils with the disease, a percentage of 5.05.

PRESENT STATUS OF TRACHOMA PROBLEM.

In view of the demonstrated prevalence of trachoma, its chronicity, and marked resistance to treatment, the control of this disease is a serious problem in the United States. The measures to be taken must have a twofold object, viz., the elimination of foci of the disease and

a the improvement of community sanitation. Trachoma is largely a disease of insanitary surroundings, and their abolishment will depend in great measure on improving the social and economic conditions in infected communities. The bringing about of these improvements will therefore be slow, and the education of children in individual prophylaxis is essential to success. Not only should children be

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