Questions about the cause, the effect, the diagnosis, the infectivity, the clinical pattern, the prevention, and the treatment of trachoma are answered by an ophthalmologist from his experience and from the literature.

The Trachoma Story

By ARTHUR A. SINISCAL, M.D.

T lIE IMPORTAN-CE of trIachoma "as a well kniowni in the civilizations of the four great sourice of hlumtiani suii ngeiiiir, as a cause of river valleys-the Ilwaicr Ho anid the Yanig(tze blinidniess, anid as a niatioinal economnic loss over Kian(r, the IJiduts anid Ganges, the Euphlrates large tracts of the world's surface is seconid to aiid Tigris, anid the :Nile-many centuries be- nlonle amllonicg the diseases of the eye, or inideed, fore Chlrist. It was recogniized anid treated in monll (liseases of all kinids." aInIcienit Egyp)t, Greece, aind Romile, as well as Tlhus Sir Stewar-t Duke-Elder, a distin- in cotuntries of Bliblical famiie. The Moslem guislhed4 B3ritislh oplhthalnmologist, assessed tra- coniquests p)robably led to its spread to Europe elhomia in a textbook published in 1934 (1). As as early as tlle eightlh cenitury (4), anid, unii- late as 1950, it was estimllated that 15 to 20 per- dooubtedly, Napoleon's campaigni to Egypt in cenit of the world populationi suffered fromi this 1798-1802 was responisible in large measure for disease (2). its dispersion aiiiongt the Euiropeanis () Throughout the wvorld, traclhoiniatologists, B3elieved to lhavle been ilitlodiUCe(l inito the oplhtlhalmuologists, sociologists, ptublic hiealtl Uniited States duIIrinig coloniial tiimes by Euri-o- workers, aid otliers are strlivingr earnestly to im- pean inuniiigrianits (6), the disease was spread prove the liealtlh anid socioecoiomic coii(litionls thromughout a cenitral belt reaching fr-omii the Al- of those afflicted witlh trachlomlla. Buit tlhey e(,llelly AMounltaills to IK-anisas aiid Oklahoma, w'ave n1o imlaglic wand; wlhat they accomplish, amolg the Indianiis as well as others. Akccor-d- tlhey accomplish tlhrou(gli steady, organiized ef- inig to Cosgrove (7), the tr-achlomiia foundi(i in fort, whlicll depenids ini tUrnll uponi public under- Missouri anid.A,rkanisas o01iriginated fr oiii persoims standing anid sLupport. The followinge pagres wlho camIie inito these States fr'omii Tennliessee an11td tell of iinediciiie's planned attack atgaiiist this Kenitucky. The trachomna ini New AMexico anolil anicienit inifection. Arizoina anid probably Califforniia is believedi to According to MNouftinhlo, (3), tr-aclhoma was hIave coiie fr om i Mexico (8). Today, tr-achioinia is fouIInd( oni everyv contineleit (4). It is COmmlllOnl ill nost of sil,wlelre it Dr. Sin iscal since 1944 has been medical director of affects fromii 3) to 60 p)elrent of tIme poulaltion. the Alissouri Trachoma Hospital in Rolla, a service It is somi-iewhalt comniiioni in Emrope, whlsere it alf- of the division of health, Missouri Department of fects approxillately 5 PelrCenlit of the popllat ion. Public Health and Welfare. More prevalelit ill the 11a11kallk States alnd ill northiernii Emropean conititles thi i elsewvhere oni

Vol. 70, No. 5, May 1955 497 that continent, it is present also in France, the trachoma is indistinguishable morphologically Netherlands, Germany, Austria, Hungary, from that of the virus causing inclusion Italy, Ireland, Great Britain, Norway, Sweden, blennorrhea of infants and swimming pool con- and Denmark. junctivitis of adults (also called para- Once a serious public hiealth problem in the trachoma). Some workers have regarded the United States, particularly in the central por- agents of these infections as belonging to the tion where it is considered endemic, trachoma Rickett8sa group, but Bengtson's (9) research is now relatively rare. It is still present, how- has shown that the trachoma bodies are rather ever, in Missouri and Arkansas and, to a lesser distinct from the rickettsiae. Generally speak- extent, in southern Illinois. In Missouri, ac- ing, the view is taken that the trachoma body tive cases are found in the southern half of the is a virus, but the question has not yet been State, particularly in the cotton-growing low- finally settled. The dividing line between bac- lands and in remote regions of the Ozark hill teria and rickettsiae or between rickettsiae and country. Accounting for 1 out of 4 pensioners viruses is not sharp. on the State's blind pension roll 25 years ago, A great majority of scientists now believe trachoma now is the disease of only 1 out of that trachoma is due to the organism discovered every 10 blind pensioners. by Prowazek and Halberstaedter. In 1907, Questions asked most frequently about tra- they described cytoplasmic inclusions, the choma are given here with the answers availa- presence of which in the epithelial cells of the ble from the experience of many workers. Al- conjunctiva and the cornea manifests the first though much is known about the cause, the diag- detectable sign of the disease in the laboratory. nosis, the clinical manifestations, and the pre- Thygeson (10) has pointed out that these intra- vention and treatment of this disease, not every cellular parasites are relatively large particles question can yet be answered . finally or and that their life cycle is very similar to that completely. of the psittacosis and lymphogranuloma venereum viruses. What Is Trachoma? There is need for more research on the causa- Trachoma is an infectious disease of the ex- tive agent or agents of trachoma. The exact ternal lining membranes (or conjunctiva) of nature of the organism will remain obscure the eyeball and eyelids. It causes an inflam- until it is definitely isolated and successfully mation of chronic duration, characterized by cultivated. burning, itching, excessive lacrimation, and photophobia. Generally insidious in onset, it How Are the Eyes and Eyesight Affected? develops usually at a slow pace and is somewhat If the infection is allowed to progress without resistant to treatment. The disease is localized treatment for several months or longer, a strictly to the conjunctiva of the eyelids and- lymphoid infiltration in the conjunctiva and in eyeball and to the tarsus and the cornea. The the subepithelial tissue will result in hyper- pathological changes in the tarsus and the cor- trophy and thickening of the conjunctiva and nea are deep seated and usually irreversible eventually in connective tissue formation and when once established. Persistent duration of scarring. Even the tarsal plates are involved inflammatory symptoms may lead to blindness, and may become buckled or deformed as a re- which results from corneal opacification andl sult of cicatrization. Follicles may or may not disintegration and, further, from cicatrized de- develop, but the absence of these should not formities of the eyelids and eyeball. rule out the presence of the disease (11, 12). The most serious pathological complication What Is the Cause of Trachoma? of trachoma is considered to be the formation The etiological agent is believed to be a large of pannus, which is a vascular invasion under virus or inclusion body of the group which in- the epithelium of the cornea. When pannus is cludes the psittacosis and lymphogranuloma allowed to progress centrally, the pupil becomes venereum viruses. The inclusion body of obscured by this veil-like opacity. Trichiasis,

498 Public Health Reports cicatrizatioii of corineal follicles; (e) finding ,Of the inclusioni bodies. A study by Rice and Siiti (17) of the rec- * ~~ords for 1,154 cases of trachioina found that 88 l)eprelr t shiowed the presence of pannus involve- niienit of the corniea. .According.to Cosgrove (7), a definiite diagniosis of trachoia cannot be miiade without pannuts unless a provedl case lias , beeni seenIin the sae family. Recently, iow- ever, Julianielle anid Smiithi (18) observed that alppr-oximnately 37 percent of ear-ly trachoma cases do niot shiow aniy pannus, anid Mitsuii (19) States that eveni a microscopic pannuiis cani be absent in the earliest stage in some cases of trachionia. AMitsuii observes that in J apan, miciroscopic l)palnus can be seen in about 50 L)er- cenit of trachioinia cases during the acute stage, anid that marginial punctate infiltration of the cornea can I)e seeni in a smtaller percentage of catses. (Cuenod and Naataf (20), who stress the value of slit-lampj) b)iomicroscopy in their monograplh Florid pannus covering complete upper half of oi corineal studies (21), state that pannus is one cornea, as seen in advanced stage of tra- of the most constant patlogical signs of tra- choma. Pannus is pathognomonic of the bf disease. clioma, but tlat tley believe it possible for true tiraclhoina to occuir without paiinits, especially at conditioni of inigrowinig eyelaslhes, resuilts fromii cicattrization of the lid structtues; it cauises the eyelashes to rub against the cornea, tlhereby de- stroying the epitlhelitunm anid predisposling to tiiicerationi, p)erforation, anml denise corneal scarri-iing. Blindiiess iimay -be due to diffuse corneal scars in genieral, or to pannus formiationi over the pupillary airea, or occasionally to sec- _ _ ondairy uveitis followinig perfoIrationi of the chamber and prolapse of its conitents, resulting__ eventually in phtlhisis bulbi.

Is Pannus Essential to the Diagnosis? Altiouigh the presenice of typical trachionia- tons palilIiius is a solid basis for making( a diag nosis of trachona, its absence does niot abso- Ilutely rule ouit the diagnosis. Somne observer-s (13-16) believe that any one or imiore of the followinig signis slhould be sufficient to establish a diagnosis of traclhoma: (a) presence of typi- cal follicles; (b) presence of painnuis; (c) pres- ence of cicatrization; (d) puinctate depressions Trachoma granules in the conjunctiva, as seen at the periphery of the cornea resuilting from in the florid stage of the disease.

Vol. 70, No. 5, May 1955 499 the early stage. Nataf (22) states further that, occur in other conjunctival diseases, but in an in hiis opinion, it is possible for certain forms of endemic area of trachoma, one would be remiss the infection to occur without pannus but that in his duties if he neglected to take cognizance diagnosis in such cases should be made with of them. reservations. Nataf believes that trachoma Lindner (5) states that in areas where tra- may possibly occur in certain regions without choma is prevalent, every case of slight, ordi- pannus, but that in order to prove diagnosis in nary conjunctivitis may be beginning trachoma. such cases, it would be necessary to detect, after He considers the most important sign of the first regression, the typical scarring pathognomonic stage to be the peculiar haziness of the con- of trachoma. junctiva of the lower cul-de-sac. Kuo (23) also stresses the importance of general haziness of Why Is Early Diagnosis Important? the lower cul-de-sac, together with incipient As in other infectious diseases, early diag- pannus, in making an early diagnosis. Tabone nosis and treatment of trachoma prevent its (24) discovered that in a series of cases of eye spread. Early discovery also makes it possible infection in which diagnosis was difficult, ap- to prevent the advanced stages with their ir- proximately one-half of those tentatively la- reversible complications. beled conjunctivitis later proved to be real A clinical diagnosis of trachoma in its early trachoma. stage is always difficult, since the classical land- marks of pannus, corneal infiltration, mature Is Trachoma Highly Contagious? follicles, or cicatrization may not be present. Trachoma is not highly contagious; other- The lack of agreement as to a definite differen- wise, it would be more widespread than it is. tial. diagnosis of early trachoma makes neces- Because trachoma is more likely to be trans- sary a laboratory confirmation of the diagnosis ferred from one member of a family to another whlenever possible. However, because the virus member than to contacts outside the lhome, it is difficult to isolate or cultivate, a negative is sometimes referred to as a family disease, but laboratory finding is unreliable. it is not hereditary. Although the presence of inclusion bodies Important factors in the epidemiology of may clinch a positive diagnosis, their absence trachoma are general levels of living, particu- does not necessarily verify a negative diagnosis. larly as they relate to sanitation and housing The reason for this is that microbiotic or cellu- conditions and geography and climate. Migra- lar findings typical of trachoma infection are tion of infected persons into areas with hiigh not present throughout the length of the dis- standards of domestic hygiene is not attended ease; it may be possible to find positive material with danger, but such migration into areas from conjunctival scrapings early in the disease, with low standards of hygiene, where geo- but not always. In this connection a serologic graphic and climatic conditions favor the dis- test would be helpful. There is a clear-cut need ease, would tend to facilitate its dissemination. for research on the serology and immunology of Like other infectious diseases, traclhoma is this disease. more likely to spread where unsanitary and The presence of several or all of the following overcrowded living conditions prevail. Al- signis plus a history of contact should make one tlhouglh it is sometimes seen in persons of ex- strongly suspect that the diagnosis is early tra- emplary habits of personal hygiene, it is more choma: excessive lacrimation with photophobia; likely to take root in persons who are careless papillary hypertrophy of the palpebral conjunc- about such matters. The use of a common towel tiva; a peculiar haziness of the lower cul-de-sac to wipe the face, for example, is an almost indicating diffuse infiltration therein; swelling certain invitation to the disease. Improvement and decreased rigidity of the upper tarsus; tiny in economic status, witl its concomitant im- filamentous symblephara in the uppeir fornices; provement in sanitation and housing, will ma- large, discrete follicles; incipient pannus; and terially aid in the elimination of the disease. uipper corneal infiltration. These signs may In general, a high incidence of trachoma is

500 Public Health Reports observed in areas with a high mean tempera- veys indicate that the disease affects about 29 ture and little rainfall and in flood districts near percent of the natives in that area. the estuaries of large rivers. In all of these, In Missouri, the disease predominates among sun, wind, and dust act as conjunctival irritants persons of northern European ancestry, nota- and are factors predisposing to the infection. bly Irish, Scottish, English, German, and Scan- In Missouri, trachoma is prevalent not only in dinavian. Their forefathers formed the for- the mountainous areas, where the climate is hiot ward ranks of the pioneers who moved west- and the-air dusty, but also in the cotton-grow- ward from the coastal States, bringing the in- ing lowlands of the southeastern delta, where fection with them. The disease became es- the climate is humid and windy and the winds tablished in these families and still flourishes are dust laden. in some of their settlement areas, notably in the southern half of the State. Negroes in the Does Diet Have Any Effect on Trachoma? State do not acquire the disease. According to Rice and his co-workers (25), It is thought by some observers that the dark- there is no evidence that a balanced diet sup- pigmented races, especially Negroes, are more plemented with cod liver oil affected the course immune to trachoma than the liglht-pigmented of trachoma in 18 untreated patients kept unider ones. Seemingly in support of this contention observation for varying periods of time. How- is the fact that when trachoma in an Egyptian ever, it is the opinion of this writer, as well passes over to a European, the disease mani- as that of other observers, notably Stucky (26) fests itself much more rapidly and has a much who made a great contribution to the prevention more devastating effect. Wilson (30) states of trachoma in Kentucky, that inadequate diet that trachoma tends toward spontaneous cure and avitaminosis are contributory factors. At more frequently among Egyptians than among present, however, this concept must be regarded Europeans. He observes further that some of as unproved. the Egyptians suffer little from this disease and Glikson (27) states that his observations of that the lesions are mild in comparison with the over 25 years in Israel indicate that general lesions among Europeans. nutrition is a decisive factor in an individual's Studies by Thygeson (31) indicate that the immunity to this disease, and he adds that trachoma bodies show a predilection for the proper diet, including fresh milk and fresh, superficial cells of the conjunctiva without in- green vegetables, will shorten the duration of volvement of the basal cells and that they tend the disease or actually heal it. Murray (28) to spare the pigmented cells. This possibly states that in South Africa adequate feeding could explain the resistance in certain dark- supplemented by vitamin concentrates gener- pigmented races to trachoma and the more fav- ally brings about a remarkable improvement orable development of the disease among them. within a few weeks even if no specific medica- Bietti (32) states that there are racial dif- tion other than ablutions with saline is used. ferences in the sensitivity to the disease and According to Bietti (29), if there is any im- that the Negro particularly is more resistant. portance in nutritional factors, lack of animal lie does not maintain that degree of pigmenta- proteins and of calories is more likely to play tion is important, but rather that some innate, a role than avitaminosis. racial characteristic itself is responsible. In support of this theory, he mentions that among Are All Races Equally Susceptible? various African native tribes of equal pigmen- the disease more Generally speaking, all races are susceptible tation, some tribes develop to trachoma in only slightly varying degrees. severely and in greater numbers than others. American Negroes seem not to acquire the dis- Rice (33) believes that the severity of tra- ease, but miscegenates are not necessarily im- choma varies considerably in different parts mune. Murray (28) reports that in South of the world and even within the borders of our Africa, Negro tribes become afflicted with tra- own country. He states that traclhoma prob- choma to a rather large extent. Extensive sur- ably does less damage among the Chinese, for

VoL 70, No. 5, May 1955 501 337521-55--6 instance, than it does among the white popula- Table 1. Operations pefformed at the Missouri tion of Missouri and Arkansas. Factors of im- Trachoma Hospital, 1932-53 munity and adaptability may even be more im- portant than factors of race. Num- Number of operations ber of To sum up, although tra-choma is very wide- Year patients _ | 1 spread throughout the Near East and the ad- Total Grat- Entro- Other I Orient, the disease appears to be less distress- mitted tage pion ing in natives of these regions than in Euro- 1932-33 - - - 635 598 257 64 277 peans and their descendants, among whom the 1934-35-- 609 452 228 77 147 prevalence is relatively low. 1936-37--- 562 297 139 56 102 1938-392_-- 468 137 65 53 19 1940-41L. 750 143 25 69 49 Does Trachoma 1942-43- 934 181 60 36 85 Why Still Exist? 1944-45--- 868 111 25 21 65 1946-47--- 893 114 25 33 56 Trachoma still exists because it was so wide- 1948-40 1,076 40 8 5 27 spread in the ancient civilized world and be- 1950-51-. 1, 179 61 8 11 42 cause, too, it did not receive the advantages of 1952-53.- 1,072 30 18 2 10 a modern medical campaign until the past 3 or I Includes canthoplasties, electrolytic epilation, 4 decades. Before the advent of sulfonamides pterygia, dacryocystectomies, tarsectomies, enuclea- and antibiotics, treatment was largely empirical tions, and miscellaneous procedures. 2 No surgery done for 6 months in 1939 during changeover to new rather than specific. hospital. Until recently, there was little organized at- tack against this disease abroad and practically hospital and clinic center was established at none in this country. The idea of internrational Rolla, Mo., by the Public Health Service in co- collaboration in trachoma control has been in operationi with the State. In more recent years, existence for almost 100 years, but only with the States of the trachoma belt have carried on the founding of the Anti-Trachoma League the battle against the disease. and the International Organization Against Trachoma in 1923 did the idea progress to ac- Can We Rid This Country of Trachoma? tion. Their quarterly publication, Revue in- ternationale du, trachome, provides an authori- During the past four decades, the prevalence tative and dynamic organ for the consolidation of trachoma has decreased markedly (36). The and disseminatioii of knowledge and facts about program agaifist the disease has been changing the disease. gradually from treatment of active, florid cases At present, mass treatment of trachoma has to the practice of preventive medicine and treat- been started by the governments of many for- ment of early and late and terminal cases. As eign countries, notably Formosa, French Mo- shown by the data in tables 1 and 2, the number rocco, and Tunisia, with the assistance of the of operations performed at the Missouri Tra- VWrorld Health Organization, and initial favor- clhoma Hospital for trichiasis, entropion, grat- able results are reported. Projects are being tage, and lid deformities and the number of planned in Yugoslavia and Egypt, and surveys cases of trachoma found among field clinic pa- in Western Australia (341) and in South Africa tients are declining steadily. (28) have emphasized the need for action in In the other States of the trachoma belt, the these areas. disease is no longer considered a significant In the United States, a program of attack problem. Arkansas has discontinued its ex- against the disease was begun in the Appalach- tensive case-finding program, but within the ian area*in 1913 by the Public Health Service next few years it will survey former high- (35). During the next 11 years, one or more incidence areas to see whether the disease has temporary diagnostic and treatment centers actually been eradicated. In southern Illinois, were set up in Kentucky, Virginia, West Vir- once an area of high incidence, a marked decline ginia, Tennessee, North Dakota, Arkansas, in the number of cases was observed between Georgia, and Missouri, and in 1923 a permanent. 1949 and 1953. No active cases have been re-

502 Public Health Reports ported in the State since 1949. Kentucky dis- ltnited States in- time. Cooperationl of inde- continued its trachoma control program more pendenit oplhthalmologists in trachoma areas than 4 years ago, and Oklahoma reports that and constant effort to teach the affected people the disease is now a negligible problem in areas good lhealth hlabits will aid in reaching this goal. wlhere the incidence was once high. In Arizona An improved standard of living(, aind a rise in and New Mexico, where an estimated 20 percent the general socioeconiomic status are factors of of the Indian population before 1938 was importance. afflicted with the disease, a 1952 survey of the Indian reservation residents in all areas except What Treatment Is Given for Trachoma? Albuquerque found only 2.6 cases per 1,000 At the Missouri TLrPhQma Hospital anid population. generally in this country, the infection is With continued organized attack against this treated with sulfonaniide medications. Sul- disease, it should be entirely wiped out in the fonamide solutions are used as drops in the eyes several times daily, and sulfonamide tablets ad- Table 2. Trachoma cases among patients of the ministered orally anid sulfonamide ointments Missouri Trachoma Hospital field clinics used nightly are adjunictive therapeutic nmeas- ures. If thle infection is in the early stage, New and old New trachoma treatment may be completed in Ttl trachoma approximately num- 3 weeks; if it is of long duration, treatment may Year ber Num- Per- Num- Per- last as long as 2 or 3 months, or even longer if patients ber cent of ber cent of the disease has become established. cases patients cases patients Sulfonamides have been used to treat trachoma since about 1938, and most authorities St. Louis County agree they are active against the trachoma virus. More recently, the antibiotics have been 1941 83 17 20.4 11 14.2 1942 0 0 0 0 0 used with favorable results in some instances. 1943 229 35 15.2 27 11.7 In the experience of this writer, the sul- 1944 368 95 25.8 42 11.4 1945 217 65 29.9 25 11.5 fonamides have proved more effective than any 1946 382 85 22.2 21 5.4 other agents, the antibiotics appear- 1947 411 41 10.0 11 2.6 therapeutic 1948 01 0 0 0 0 ing to be of secondary help (37). 1949 112 15 13.3 0 0 Of the antibiotics, terramycin and possibly aureomycin seem to be most active against the Potosi, Washington County trachoma virus (38-45). Chloramphenicol is considered much less effective, and penicillin, 1945 135 62 45.9 35 25. 9 seem to be of little 1946 154 70 45.4 36 23.3 bacitracin, and streptomycin 1947 90 64 71.1 30 33.3 or no value in uncomplicated trachoma. 1948 213 91- 42.7 47 22. 0 both 1949 244 140 57.3 58 23.7 Mitsui (43, 44) reports that in Japan 1950 456 191 41.8 98 21.4 acute and chronic trachoma respond well to ter- 1951 780 241 30.8 108 13.8 1952 428 89 20.7 48 11.2 ramycin treatment; but he observes further (45) 1953 --- 159 54 33.9 8 5. 0 that while in his opinion sulfonamides may not be the best agents against trachoma in these Eminence, Shannon County days of antibiotics, they certainly constitute a means of treatment in those cases that do not 1945 268 59 22. 0 25 9.3 respond to antibiotics alone. Loe, who first 1946 264 42 15. 9 14 5. 3 1947 130 11 8. 4 3 2. 3 used sulfonamides successfully against tra- 1948 289 107 37. 0 50 -17. 3 choma in 1937 among the American Indians in 1949 106 51 48. 1 16 15. 0 1950- 125 58 46.4 20 16. 0 the southwest (46), has stated that in hIis experi- 1951 - 442 74 16. 0 36 8. 1 ence tlhe antibiotics have not proved successful 1952 464 42 9.0 25 5. 3 1953 395 21 5. 3 6 1. 5 in the treatment of this disease in Arizona and New Mexico.

Vol. 70, No. 5, May 1955 503 Cosgrove (47), director of the Arkansas the presence of inclusion bodies) are univer- State lhealth program for trachoma control, be- sally accepted, the disease varies considerably lieves that sulfonamides are the most effective in different parts of tlhe world and would there- agents against trachoma, and that the anti- fore seem to be polymorphic. According to biotics, including the broad-spectrum group, Lyons (49), trachoma may show variations in lhave Ino effect against this disease. any of the following factors: (a) mode of trans- mission, (b) average age of onset, (c) clinical Does Trachoma Tend to Recur? course and the resultant disability, (d) condi- Trachoma is a disease of recurrences and re- tioning effect of secondary infection, (e) inci- lapses. The infection may have become dor- dence of inclusion bodies at various stages of mant or latent so that not infrequently an ar- the disease, and (f) response to treatment with rested case may later slhow signs of activity. sulfonamides and antibiotics. Reports from A recurrence may be due to the patient's having workers in different countries illustrate some returned to an environment of smoke, dust, or of these variations. win(l, or to a mode of living not conducive to Lyons (50) states that in Egypt trachoma in eye health. its active stages causes surprisingly little dis- Recurrences sometimes result from insuffi- ability; that gross thickening of lids is rare and cient or inadequate treatment and occasionally the pannus seldom encroaches on the pupillary from trauma, scarring, or possibly allergy. zone; and that photophobia and lacrimation are Some recurrences, of course, are due to reinfec- usually minimal and often absent. He adds tioIl from a member of the family who has not that it usually is only the corneal lesions caused lhad treatment. All familv members should be by neglected trichiasis in the late stage of the examinied whein trachoma is found to be present disease which lead to any serious reduction in in one of them. vision. Mitsui (45) of Japan declares trachoma to Is There a Definite Criterion Cure? be an acute disease in its initial stage without of exception. MacCallan (51) states that in As. yet there is no definite criterion of cure in Egypt and in eastern Europe, trachoma begins trachoma. However, a combination of all the always with an inflammatory stage that con- negative signs-quiescence of inflammation, tinues for some time, buit that in England the deturgescence of the pannus, resolution of the onset of trachoma in an acute or subacute form foilicles, a smooth, pink conjunctiva with or further that witlhout cicatrices, absence of inclusion bodies- rarely occurs. He states (13) un- indicates that the disease is arrested. Without mixed trachoma is always a chronic disease; any one of these sigiis, the patient cannot be that when it commences with acute manifesta- considered cured, even if no active lesion is tions or exhibits acute exacerbations, these are present. the result of superadded infections. Postic Tlhygeson (.48) poinlts out that, when con- (52) of Yugoslavia observes that Mitsui's state- fronted with the problem of distinguishing ment that all trachoma is acute in the initial healed trachoma from trachoma of low activity, stage must be taken to mean that such is the microscopic examination is helpful only in a case in Japan, but not necessarily everywhere. limited way. The finding of inclusion bodies Gradle (6) states that trachoma in the IUnited indicates trachomatous activity, but inability to States varies somewhat with the characteristics finid tlhem, even on repeated examination, does of the population and the degree of sanitationi not necessarily mean a lack of a trachomatous present, but that entirely lacking is the oi)set of activity. acute traclhoma associated witlh ophthalmia, as seen so universally in Egypt. Lavery (53) Is There a Worldwide Clinical Pattern? states that in Ireland the disease usually starts Althouglh the cardinal signls of trachoma insidiously, and that he has never seen an attack (follicle formation, pannus, cicatrization, and of acute trachoma. He reports, lhowever, that

504 Public Health Reports lhe hlas observed attacks of acute conjunctivitis Do Associated Infections Affect Treatment? superimposed upon trachoma. Most authorities agree that the associated In Missouri, trachoma is usually a chronic infections of traclhonia hlave a conditioninig ef- disease, progressing slowly over a long period fect on treatment. Lyons (50) states that anti- of time; acute trachoma may occur, but only biotics usually produce rapid and striking im- occasionally. In my experience, the disease provement in secondarily infected cases and takes from one to several months to show early have little or no imnmediate effect in uncoinpli- clinical signs after contact with a known infec- cated trachoma. Bietti (39) points out that tion has taken place. sulfonamide and antibiotic treatments may give Birch-Hirschfeld (11) believes that the first different results according to the country in stage of trachoma with its inflammatory infil- which they are administered. In Egypt, for tration passes early and imperceptibly into the instance, where associated infections are the stage of scarring and that the follicles are not rule, the response to treatment by various sul- of essential importance for the progress of the fonamides and antibiotics may well depend on disease; that they are found botlh in early and the conditioning effect of these infections, as late trachoma and are usually invaded and well as perhaps on otlher factors. Pages' (55) broken up by strands of fibroblasts. survey of experiments has shown that the tra- The first appearance of the follicles on the choma-bacteria complex is characterized by a conijunctiva may vary as to location. MacCal- kind of mutual stimulation on the part of the lan (13) notes that in Egyptians the granula- associated micro-organisms, or, in other words, tions appear first on the tarsus, but in Euro- a synergic attack. In the United States, whlere peans, in the cul-de-sac (retrotarsal fold of the the complicated trachoma common in Egypt is conjunctiva). Fuchs (12) states that papil- seldom seen, sulfonamides have generally pro- lary hypertrophy is a predominant feature of duced more favorable results tlhan the antibi- the tarsal conjunctiva, and that the retrotarsal otics (37). fold is the seat of formation for trachoma gran- ules. Among the white population of Missouri, Summary and Conclusions it is in the retrotarsal fold that follicle forma- Trachoma is a disease that may vary consid- tion is most pronounced and where the follicles erably in different parts of the world. Its clin- first manifest themselves. When trachoma is ical phase may be condition-ed by climate, en- seen in the florid form, however, a generalized vironment, associated infections, race, and gen- follicular distribution throughout the conjunc- eral health and living conditions. From a tiva of botlh tarsus and fornix in botlh the upper worldwide point of view, therefore, botlh sul- aind lower lids is found. fonamides and antibiotics are useful in tlherapy, In many, but not all, parts of the world, tra- although sulfonamides lhave been found more choma is frequently complicated with secondary effective in the United States. infections, commonly the Koch-Weeks bacillus There is definite need for researchl on the and the gonococcus (in epidemic and endemic serology and immunology of this disease and form), and less frequently the Morax-Axenfeld on its causative agent or agents. In this con- diplobacillus and the pneumococcus. The asso- nection, a more simple and more direct diag- ciated infections greatly affect the clinical pic- nostic laboratory test would be of infinite value tuire as well as the prognosis and the infectivity in making an early diagnosis. A more clearly of the disease. Nataf (54) of Tunisia includes defined clinical picture of trachoma as it oc- trachoma witlh secondary infections always; he curs in various regions of the world would make believes that pure trachoma exists very rarely it possible to correlate better the results of and that numerous infections are very often as- chemo-antibiotic treatmenit. A universally ac- sociated with it, the traclhoma itself constitut- cepted classification of traclhoma would lhelp ing the basic disease, the endemic and epidemic clarify many questions of medical, administra- clharacteristics of whiclh are conditioned by re- tive, investigational, and international clhar- lated disorders. acter.

Vol. 70, No. 5, May 1955 505 Althougih trachoma has beeni virtually eliim i- (12?) Fucehls, E.: 'T'ext-book of ophthalmology. Duwne niated fiomii many aleas of the worl(l, the jol) of Ed. (S. Ihilhldelplila, Lippincott. 1924, plp. 4.54- anid univiiersal eradication is niot 'vet 4356. compl)ete ( 1.) MahcCallan. A. F.: Trachoina and its- comijklica- accomll)lished. The combined efforts of re- tions in. Egypt. Cambridge, Canmbridge 1j.imi- search, mass therayl), alltl p)reA-enfivye measuires, versity Piress, 1913, p. 33. howev-er, are producing increasinugly favoorable (14) Romero, E.: M1i experiencia eni rnas de cllC(e muil results. New facts and niew i(leas in traclhomIa- casos de trluchoia. Arelh. Soc. oftal. hispano- tology are Ibeig brouight to ligrit and are beingw amtii. 9: 1107-1116 (1949). (15) Taborisky, J.: Trachomiia in northern.Itus-sia and( set forthi in the literattire. These reports lhell) in southern Palestine. Rev. internat. (lu tra- to definie the (liseXlse,to recogrnize its variatiois, ehomie 16: 201-208 (1939). to miaike p)ossible early diagnosis, and to deter- (16) Ching, R.: A new traclhomal concept. A. 'I. A. miinle the thieriapeuitic miletlhods msost suitabl)e for Archl. Ophth. 31: 750-761 (1934). withl it, regionally. (17) Rice, C. E.. and Siith, .1. E.: Trachonma in Mlis- eoping souri. J. Mlissoouri Mf. A. 29: 13-17 (1932). The outtlook today for a worlldwide attack oni (18) Julianielle. L. A., tind Siiiitlh, J. E.: A statistical trachoma is more encouraging thian ever before, analysis of clinical trachonia. Am1i. J. Oplith. partictilarly becatuse of better uinlerstanding, 26: 158-166 (1943). )etween ophlitlilmologists and trachiomiiatolo- (19) Mitsui, Y.: A( ute trachoma. Itev. internat. di lhere and and because, too, of trachoine 29: 323-323 (1952). gists atbroad:; 20 ) Cuenod, A., and 'Nataf. It.: Le trachoine. PLaris. g(reaiter reco,nitfion by governmIenital authiorities MaIasson et Cie., 1930. of tlhe, iml)ortance of this (lisease in relationi to (21) Cuenod, A., and Nataf, It.: Biomnicroseopie (Iu the health, e(cOnomy, anid welfaire of thie affected pannus trachoimiateux aun debut. Arch. d'opht. 48: 7.37-742 (1931). l)eol)le. (22) Nataf, R.: Le trachonme. Paris, 'Masson et Cie., 1952. REFERENCES (2'.3) Kuo, P. K.: Incipient panniu-s; in early diiagnosis of trachoima. Am. J. Ophth. 29: 645-653 (1) Duke-Elder, S.: Text book of ophthalmology. (1946). Ed. 1. St. Louis, C. V. 3Mosby Co., 1934, vol. 2, (92) Tabone, V.: Anti-trachomal campaign in Gozo 1). 15.93. (Malta). Rev. internat. (Iu trachome S29: (2) Sorsby, A.: The tusk of ophthaliniological re- 350-7 (1932). searclh. Ilrit. M. Bull. 1: 102-104 (1943). (.-25) Itice. C. E., Sory, Rt., Smiith. J. E., Faed, P. E.. 3-) AMoutinho, H.: Legislation internationale conntre and Drake, A. A.: Effect of diet and vitamins on le trachonie, pro.jet d'umtiifcationi mondiale. traclhomia. Aimi. .J. Ophtl. 17: 733-741 (1934). tev. internat. du trachoiiie 26: 3-65 (1949). (26) Stucky, J. A.: Observations and experiences with (4) Siebeek, It.: Trachoiima in Europe alnd the Near trachonia in eastern. Kentucky. Tr. AIIm. A(ad. East. In)i. World-atlas of epidemic disealses. Ophth. 33: 217-224 (1930); Eye, Ear. Nose & Hamburg, Falk-Verlag, 1952, pp. 79-80. Throat Monthly 9: 45-5-437 (19.3(). (5) Lindner. K.: Trachomiia. In The eye and its dis- ('7) Glickson, ..: Observationis on the trachoina prob- eases, edited by C. Berens. Philadelphia, W. B. lem. Amii. J. Ophth. 33: 616-617 (1930). Saunders and Company, 1936, p. 423. (28) 'Murray, N. L.: Tralchomiia in South Africa. South (6) Gradle, H.: Trachomna in the United States of African J. Clin. Sc. 4: 119-203 (1953). America. Rev. internat. du trachome 16: 143- (29) Bietti, G. B.: I1 traconma. Rome, Sanite Pub- 145 (1939). blica, 1947. I7) Cosgrove, K. XV.: Trachomia problems in Arkan- (30) Wilson, R. P.: Trachomila: A selection of pers-onal sais. Soutlh. M. J. 34: 1037-1040 (1941). observations and experiences. Giza Memorial (8) Forster, WV. G., anid McGibony, J. R.: Trachoma. Ophthalmic Laborgatory, Report No. 14. Cairo. Amii. J. Ophth. 27: 1107-1117 (1944). Egypt, The Laboratory, 1939-1944, pp. 24-25. (9) Bengtson, I. A.: Question of the rickettsial nature (31) Bietti, G. B.: Le trachome; vue d'ensemble des of trachoma. Amii. J. Ophth. 23: 770-779 travaux de la p6riod de guerre et d'apres (1946). guerre (Trachoma; suIiimary of the literature (10) Thygeson, P.: rhe nature of the elementary and of the perio(d of the war anld after the war). initial bodies of trachoma. Archi. Ophth. 12: Bibl. ophth. Basel No. 58, pp. 232-333. 307-318 (1934). (32) Bietti, G. B., and Cavara, V.: Le manifestazioni (11) Birch-Hirschfeld: Pathology of trachloma. Rev. oculari delle mallatie da virus e da rickettsie. internat. (du traclhomie 16: 110-112 (1939). Bologna, L. Cappelli, 1932, p. 184.

506 Public Health Reports (33) Rice, C. E.: Trachomaa in the native white popu- 95 ) Mitsui, Y. : l'se of the new antihiotihs ill the lation of the Uinited States. Aitghit-Saving Re-. treatmient of traehoina. W lO/Trachonia,/1 6. 3: 105-114, (1933). Geneva, World lIeatltlh Or-anization. 1931. (34) Mann, I.: plhthalimic survey of the Kimiberley Pb JAoe, F.: Sulfalnilainide treatmiienit of trdachlonia. IDivision of Westein Australia. P'erth, W. 11. Preliminary repomrt. J. A. MI. A. 111 : 1371-1372 Wyatt, 1954. (1938). .35) Willianms, R. C.: The Uinited States P'ublic Health ) Cosgrove, K. W\.: Local uise o)f sulfanilanide in Service, 1798-1950. Washington, D. C., Coin- trachoII1a. Ama1. .J. ()phtlh. 23: 911-913 (1940). nmissionedl Officers Association of the Unitedl (.') Thygeson, P. : Criteria of (cire in trachonia. Rev. States Public Health Service, 1951, pp. 286-295. internat. (Iu trachoime 30: 45(-62 (1'9-53). (36) Siniscal, A. A.: Trachoma in MINlissouri. Arell. (A.9) Lyonis, F. 'I.: Observations on the inter-nationlit Ophiti. 42: 422-437 (1949). coordination of resealreh in trachoma. WHO/ (37) Siniscal, A. A.: The sulfonamiidixes and antibiotics Trachoma/4. Geneva, World Health Organiza- in trachoma. Am. J. Ophth. 35: 671-68:3 tion, 1951. (1952). (.;O) Lyonis, F. 'M.: Dual problem of acute o)phtliaunia (38) Antibiotics in trachoma-Bibliography. WHO/ aIId trachoma in Egypt. WHO/Trachomna/20. Trachoina/8. GenevarX, Worl(d Health rg9aniza- Geneva, World Health Organization. 1951. tion, 1951. (.d) 'MacCallan, A. F.: The initial signsl o)f traclhonia. (39) Bietti, G. B.: Treatiment of trachoma by various Rev. internat. diu traclhoine 297: 112-117 (1930). antibiotics and chemotherapy. WN'HO/Tra- choma/17. Genteva, World Health Olrganiza- (5.2) Postic, S.: Comminents oi (locumnent WH(O)/Tra- tion, 1951. choma/16; -Use of the new alntibiotics in the (4f0) Fernandez. P.: Aureomycin in the therapy of treatment of trachoma" by IDr. Y. IMitsui. trachonia. Arch. Soc. oftal. hispano-am. 13: WHO/Trachoina/27. Geneva. Worl(l Heaflth 79-99 (195i3). Organizationi, 1951. (41 ) Freyche, M. .J.: Chemotherapy of trachomna. Buill. ( ,,) Lavery, F. .l.: IIei(lenee anMd. (linical. type of World Health Org. 2: 523-544 (1950). trachoiua in Euirope. Rev. interinat. (Ii tra- (42) Naccache, R.: Terram,^ycin in trachoma. IBrit. .1. chome 16: 137-143 (19.39). Ophth. 37: 106-108 (1953). (54.) Nataf, R.: Organization of control of trachonma (43) Mitsui, Y.. anid Tanakal, C.: Terrainycin. au.reo- and associated infections in underdeveloped Imycin and (chloraINpheInicol in the treatmiienit of countries. WHO/Trachonita/1.9. (Geneva, World trachomia. WH( )/Trachoina/2. Geneva, World Health Organization, 1951. Health Organiization, 1951. (55) Pages, R.: Role of seasonal acute conjunctivitis (.4) Iitsui, Y., and others: Terriamycin in the treat- in the development of trachoma. WHO/Tra- menit of trachonma. WHO/Trachona/9. Ge- choma/7. Geneva, World Health Or,ganizationi, neva, World Health Organization, 1951. 1951.

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