Medical Society of the State of North Carolina. An.

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their families. If the State would be more liberal in its appropriation
for the maintenance of the school, we are led to the conclusion that even
better results would arise. The operations are now seriously handi-
capped for lack of funds. I should like to enter a plea that the members
of your noble profession aid us in creating a public sentiment which
would result in better equipment for the solution of the serious problem
confronting us.

Our State has not been cursed with trachoma as some others have been.
In the mountains of Kentucky and West Virginia, as well as in parts of
Ohio, there have been epidemics of this dread disease amounting to
almost a scourge. Let us rejoice that our State is comparatively free
from this curse.

I wanted to speak of consanguineous marriages, but time forbids. I
know there is considerable divergence of opinion upon this subject, but
the rather significant fact stares me in the face that there are in our
school 48 white blind children, out of 274, who are the offspring of
parents who are related, one of whom married his niece ! Take it for
what it is worth.



296 NORTH CAROLINA MEDICAL SOCIETY.

SAVIN^G SIGHT— SAVING CITIZENS.



Gordon L. Berky, Field Secretary National Committee for the Prevention
OF Blindness, New York, N. Y.



Mr. Chairman, Members of the Medical Society of the State of North
Carolina:

I presume that many of those who make up this audience have asked
themselves, when perusing this morning's program, *'Why has a layman
been included on the program of the State Medical Society?" And yet,
on second thought, I am confident that you will agree with me when I
say that many of the public health problems of today call for both
medical and social treatment. Believe me when I add that we laymen
who are doing the social work under the inspiration which you, as phy-
sicians, are constantly providing us, are indeed appreciative of the op-
portunity of telling our story to you, and I thank you for extending this
courtesy to me, that I may tell you of the work, accomplished and pro-
posed, by the National Committee for the Prevention of Blindness.

Following the loss of a Titanic, in the wake of a disaster such as
more recently overtook the Lusitania, in the gloom such as pervades the
world today in the contemplation of the mammoth European conflagra-
tion, we find a fervid awakening of the public conscience, with the re-
sult that there is set in motion such machinery as may tend to prevent
such a recurrence of national or international disaster. As a part of
such awakening there is sounded from pulpit, from lecture platform,
from the highways, and by the press, the galling reminder that the
disaster might have been averted had the proper preventive measures
been originally adopted. Although we feel that the attitude of "I told
you so" of the wiseacres is frequently overemphasized, it is in large part
due to them that we find the idea of prevention — the Safety First move-
ment — now established so firmly in the consideration of our public health
and industrial problems. But the loss resulting from the sinking of a
Titanic or a Lusitania, or the burning of an Iroquois Theater, sinks into
insignificance when compared with the daily toll of tuberculosis and
cancer, or the ravages caused by ophthalmia neonatorum, trachoma, in-
dustrial accidents, hookworm, and pellagra. And by none of these is life
snuffed out in a moment or an hour or a day — but through years of
sufi^ering, of constant decrease in efficiency, the afflicted labor on until
they become sooner or later a charge upon the State, some charitable
institution, or their families — a derelict in all senses of the word.



CONSERVATION OF VISION.



297



It is my privilege to be with you today, as representing a N'ational
Committee which has for its objects the elimination of certain of those
menaces to human efficiency, health and happiness mentioned hereto-
fore — in short, those which have to do with eyesight, and as this topic
is one which is to be of increasing interest in the Commonwealth of
jSTorth Carolina, I am glad to have this opportunity of telling you of
the endeavors of the ISTational Committee for the Prevention of Blind-
ness, and the possibilities for cooperative service with organized State
preventive work.

It is now nearly eighty-five years since the first schools for the blind
were established in the United States; it is thirty-five years since the
discovery by Crede of the preventive for the disease responsible for a
full 25 per cent of the enrollment in these schools for the blind; it is
twenty-five years since the establishment of a committee on conservation
of vision by the American Medical Association, and from the date of the
formation of that committee we may say that the effective campaign for
the prevention of blindness was launched. With its branch committees
and its volunteer lecturers in many States, the message of prevention
during the past year has been carried to audiences totaling 160,000 lay-
men.

But you can realize how impossible it is for any individual or organiza-
tion to carry out such a vast program as is presented to the educator in
preventive work, unless the entire time is given to such work, and in the
realization of the need for "full-time" workers, after months of thought-
ful consideration and conference with those medical authorities who
had given the movement its inception, an organization of both physi-
cians and laymen was created, whose activities might be under the
inspiration and w^atchful care of some of America's well known oculists
and other physicians, and which should work in close cooperation with
such organizations as the American Medical Association. Supported
financialh^ by two of the great Foundations, as well as by public contribu-
tions, the committee finds it possible to be of frequent service to State
commissions for the blind, and to any organization of workers interested
in the prevention of blindness. Its objects are the investigation of the
chief causes of blindness, the advocacy of the measures which shall lead
to the elimination of such causes, and the dissemination of knowledge
concerning all matters pertaining to the use of the eyes. I want to tell
you briefly somewhat of the great need, and of what is being done in
the way of prevention in other parts of our country where conditions are
nearly identical with those in ISTorth Carolina.



298 NORTH CAROLINA MEDICAL SOCIETY.

The great need is evidenced by tlie fact that of the 100,000 persons
in the United States who are blind, there are nearly 50 per cent who
might have had their sight. Of this 100,000 there are 10,000 blind from
ophthalmia neonatorum, and you as physicians know that 99 per cent of
these might have been in full possession of their eyesight had the two
drops of nitrate of silver, the few moments of time, the 2 cents expendi-
ture been made at the time of birth. Again, of the 160,000 industrial
accidents to the eyes occurring annually in the United States, the pro-
portion which might be prevented is indicated by the 75 per cent reduc-
tion of accidents among its 200,000 employees by the United States
Steel Corporation since its introduction of the safety committee a few
years ago. That organization finds it advisable to spend $750,000 an-
nually in its j)reventive campaign. Let us look for a moment at the
economic side of this matter.

It costs any State approximately $300 a year to educate a blind
child, as against an average cost to the State of but $30 a year to
educate a sighted child. Your own State bears a heavy financial bur-
den in educating 300 blind children at an annual expense of $72,500 as
against approximately $9,000 had they their sight. It costs any State
approximately $10,000 to support each dependent blind person through
life. Multiplied by the number of blind in our country, we have the
sum of $1,000,000,000. This divided by thirty-five years, the average
duration of life of the blind, gives us $26,000,000 as the expenditure
which this country will make in maintaining its present blind through
their lives. Could we ■ ask a more potent indication of the need for
preventive work than that which is shown by the expense account of the
department of the blind of the United States of America ? On a ''brass-
tacks" business basis, is it not worth while to save one-half of that
amount — which is needlessly expended? The proportion of that enor-
mous sum spent to maintain those blind from ophthalmia neonatorum is
being absolutely needlessly expended ! It would in fact require but the
expenditure of $25,000 a year to purchase and distribute a sufficient
amount of nitrate of silver to protect the eyes of every one of the 2,000,-
000 children who are born in the United States each year.

I have said nothing about the humanitarian side of this question —
the prevention of the sorrow and the tragedy caused by complete or
even partial loss of eyesight. N"either physician nor layman will need
to have that greatest of all reasons for preventive work brought out
more completely than his own imagination will suggest. The Creator
did not make the sandy shores and inlets of your eastern coast nor the
green valleys, the pine-clad mountains, and the sapphire skies of your



CONSERVATION OF VISION. 299

Avestern counties, for sightless eyes. Surely, man must do all in his
power to prevent the possibility of any such disaster, any such wreckage
of life, as follows in the train of blindness.

In addition to the routine measures for the prevention of infantile
blindness from ophthalmia neonatorum through the use of a prophy-
lactic, certain legal provisions are necessary. It may interest you to
know that the reporting of babies' sore eyes to a physician or local health
officer is compulsory in 30 States; that the reporting law is printed on
the birth certificate in 5 States; that local health officers are authorized
and required to secure medical attention for uncared-for cases in 11 ;
that births are reported early enough to be of assistance in prevention
of blindness Avork in 4; the question as to whether or not precautions
were taken against ophthalmia neonatorum is included on the birth
certificate in 9 ; the use of a prophylactic as a routine is compulsory in
10, and free prophylactic outfits are distributed to physicians and mid-
wives in 12.

Quite evidently there is yet much for the States to do toward safe-
guarding the eyesight of their infant citizens, for in no State do we
find that all of the desired provisions exist, while in some no preventive
legislation has been enacted. But legislation does not end the matter,
as you will find in your own State, and unless the provisions made
statutory by your last session of the State Legislature are enforced, where
is to be the advantage? There is no physician here tonight who will not,
if he is not already doing so, accede to the present law's provisions ; but
you will have the unscrupulous physician to deal with, the untrained,
ignorant midwife also, and unless the health authorities of every city
and town see to the carrying out of this law, no benefit can be reaped.
AVhat enforcement of the law will do is shown by the increase in cases
of ophthalmia neonatorum reported in the State of Massachusetts, where
but two years ago, in spite of the reporting law, less than 100 cases were
reported. Following insistence in some localities, through actual prose-
cution, the number of cases appearing on the health records for the year
1914 leaped to over 2,700.

I mentioned, a moment ago, the midwives; and in every State where
the prevention of blindness is sought it will be found necessary to deal
with this question. Forty per cent of the births in this country are
attended by midwives. The majority of these women are, as you know,
dirty, ignorant, and generally unfit to assume the care of mothers and
babies. With our great foreign population accustomed to attendance
at such times by women, with the existing poverty which cannot secure
competent medical attention, we must not expect to eliminate the mid-



300 NORTH CAROLINA MEDICAL SOCIETY.

wife; but we may look forward to and work towards the time when
her services shall not be followed by the harvest of disease, malformity,
or death now so frequently the case. If midwives are practicing in any
community, would it not be advisable to have them registered by an
official body, adequately trained, examined, and licensed ? In connection
with every hospital could not there be a short course of training such as
has already proven feasible at Bellevue, so that the midwife graduate
can give clean, careful nursing care to mother and child, and instruction
to the mother concerning hygiene of pregnancy and care of her child?
Already in many communities the State or city departments of health
have adopted rules regulating midwives' practice in detail and requiring
them to summon a physician in all but normal cases. Inspectors enforce
these rules, and give helpful advice to the midwives.

And now, crossing the threshold from infancy to childhood, let us look
at a few of the hazards to eyesight, inattention to which is responsible
in no small part for the necessity of sending many of the little folks Avho
annually enroll in the schools for the blind. Accidents at play, or
through carelessness as a result of the use of toy pistols, air rifles, sharp-
pointed scissors, tools, etc., are reported each day, and until recent years
Fourth of July accidents added largely to the number of needlessly blind
children. Fortunately, we have devised saner forms of patriotism, and
accidents to the eyes from that source are rapidly decreasing. To pre-
vent loss of eyesight from this source, education is the chief means. We
must educate not only the child, but the parent as well, and that is being
accomplished by public lectures to parent-teachers associations, clubs,
churches, and in the schools themselves.

I shall not do more than mention the possibilities of loss of sight fol-
lowing measles, scarlet fever, and other diseases of childhood, although
the consideration of these is necessary by every association interested in
this kind of preventive work; but there are causes responsible for so
much more of the blindness in our country that I feel it more essential
to stress these others rather than attempt to include all.

Before leaving the hazards to eyesight of children, let me mention the
great preventive possibilities that lie in the annual examination of school
children's eyes. Of the 20,000,000 children in attendance at our public
schools it is estimated that from 12 to 20 per cent are in need of medical
attention. Eyes that are near-sighted in the earl^^ years of childhood
become increasingly so as the upper grades are reached, unless attention
has been secured. Consequently at the time of graduation the child is,
because of his poor sight, barred from those occupations in which it is
not permissible to wear glasses, and his weakened eyes are predisposed



CONSERVATION OF VISION. 301

to various diseases injurious to vision. The teacher is usually the first
to notice any defect, and in many of our public schools it is now the cus-
tom to test the vision of all pupils periodically. Through the use of the
Snellen charts nearsightedness is discovered Avhile it is still of low
degree. It is essential that classrooms be adequately and properly
lighted, that the tops of desks and blackboards and pages of text-books
be lusterless, in order to secure the best conditions for the students of
today. The haziness and cloudy eifect of the slide I show is not the
result of improper focus of my stereopticon, but is a faithful representa-
tion of how a blackboard looks to the many children whose eyes are in
need of treatment. I have said that the initial examination of eyes
might be made by the teacher, and in a great many schools this has
worked out admirably. Where a full-time medical examiner cannot be
provided, it relie-ves the part-time physician of the necessity of examin-
ing the 80 per cent of those whose eyesight is normal. After examination
by the teacher, those who are in need of expert examination are sent to
the school inspector, and if treatment is needed a notice to that effect is
dispatched to the parents, w^ho are urged to secure immediate medical
attention for the child. Unfortunately, there is a large percentage of
the parents who will not appreciate the need, or who will be desultory
about securing prompt treatment, and it is to meet this need that many
communities have provided a school nurse, whose duties are in large part
the follow-up work in the homes, impressing upon the parents the need,
and instructing them in the a b c's of precautionary knowledge. The
final step is the establishment of a school clinic, where those who ai'e too
poor to pay for treatment may be helped gratis. I know of no better
example of successful accomplishment in this line than that provided by
the city of u^ashville, wher.e three medical examiners are constantly
Avatching over the health of the children, where a school nurse, paid by
the city, does the necessary follow-up work, and where Avithin the past
three months a well-equipped school clinic has been opened, with depart-
ments attended by Xashville's leading specialists, and in which, during
its first two months of operation, more than 250 children received treat-
ment that would otherwise have been omitted on account of inability to
pay even a small fee.

Another great and increasing menace to eyesight, one which has be-
come each year more prevalent in certain portions of our country, is
trachoma. As an indication of the hold it has already secured, I cite the
estimate of Dr. John McMullen, surgeon in charge of the Public Health
Service work in Kentucky and the Virginias, who recently put the num-
ber of those having trachoma in the State of Kentucky at 33,000. Dr.



302 NORTH CAROLINA MEDICAL SOCIETY.

Murpliy of the Indian Service advises me that fully 20 per cent of the
remaining 275,000 American Indians are afflicted with this disease. In
the knowledge that the trachomatous are in all cases in close proximity
to those with well eyes, and considering the great communicability of
trachoma in certain of its stages, we find a fertile field of preventive
effort opened at once. Although the recent report of Dr. Foster of the
Public Health Service, following his survey of the prevalence of
trachoma in the mountain sections of North Carolina, showed only 33
out of 10,000 persons examined as being afflicted Avith trachoma, this
does not in any way mean that a few years hence conditions might not
be growing rapidly towards those which now exist in your neighboring
States, unless barriers to the spread of this disease are put up at once.
It is safe to say that 75 per cent of those having trachoma Avould become
totally blind unless treatment were afforded, and even so, in advanced
stages of the disease, where symblepharon, pannus, or any of the well
known sequelae are in evidence, it is almost hopeless to attempt to restore
normal vision.

Let us look at a few of the causes, effects and opportunities for service
in this department of preventive work.

I lately spent a number of weeks in Kentucky and Tennessee with
Dr. McMullen,. visiting the Government hospitals for the treatment of
trachoma, and also seeing conditions responsible for its prevalence. In
the absence of roads, we took to the creek-beds and it scarcely seemed
believable that in this wonderful country, duplicated by your own west-
ern mountain counties, there could be found such conditions as we know
are in existence. Lack of proper means of sanitation is undoubtedly
chiefly responsible for the spread of the disease. In some of the homes
there are no windows, on the inside no plaster, and only one or two
rooms, in which the entire family, numbering perhaps from five to
twenty, must live. "With improper and insufficient food, paucity of
clothing, what could provide a better prospect for typhoid, hookworm,
pellagra, and trachoma ? Frequently an entire family makes use of one
towel, or a common wash basin ; children with sore eyes use the same bed
as those not yet afflicted ; the same tools are handled by all. Those are
the ways trachoma spreads. In the schools common handling of books
or playthings has made it necessary to segi-egate the trachomatous from
the other children until treatment has done away with the possibility of
spreading the infection. Trachoma is no respecter of persons — the little
chap shown here is recently home from the hospital, where they "put
him to sleep" and, after the gratage operation had removed the granula-
tions, he was sent back to the same conditions which originally were



CONSERVATIOIsr OF VISION". 303

responsible for liis having the disease. This old battle-scarred veteran
walked in 15 miles to the hospital at Jackson with his right eye so
infected, the adhesions so severe, that at best only partial help could be
afforded.

These illustrations give but the briefest indication of the great need
that has existed in many portions of our country, and I can point to no
better way for the control and eradication of trachoma than to refer to
the splendid work of the Government through its establishment of
trachoma hospitals in the heart of the neediest sections. The main diffi-
culties encountered are the chronic nature of the disease, the widespread
infection, and the disadvantages of the conditions under which the work
must necessarily be done. The problem has been considered under two
heads: (1) Prevention and (2) Eradication. The first is practically
synonymous with education, which has been carried on by means of lec-
tures and talks on health and sanitation, and by the follow-up work done
in the homes by the nurses and surgeons. Thousands of leaflets telling
the story of prevention in plain language have been mailed and dis-
tributed, and the cooperation of teachers and ministers secured in many
sections.

It must be borne in mind that this is largely demonstration work on
the part of the Federal Government, and there is no intention of taking
over a burden, financial and otherwise, that belongs to the State and
community. Furthermore, let me say that in Kentucky trachoma is not,
as is popularly supposed, confined to the eastern mountain sections. It
is prevalent to considerable degree in all sections of the State, and
examination of the eyes of the children in many of the public schools dis-
closes from 3 to 7 per cent of the children as infected.

In the West eight Government specialists and over two hundred gen-
eral practitioners are attempting to achieve its eradication among the
Indians, in their schools and on the reservations. We have outcroppings
of it among the foreign workmen in the mills and factories of Ohio and
Pennsylvania, as well as in the East, all of which places are contiguous
to places already infected. It must be dealt with now, and finnly, if we
are to check its spread.

It is becoming more generally known that wood alcohol is another of
the increasingly important causes of blindness — and frequently death, as
well. During recent years there have been a sufficient number of striking
examples of both to make it more than a matter of passing comment.
In Hungary some sixty men and women, who were celebrating, drank a
beverage in which wood alcohol had been used instead of grain alcohol,
and within twenty-four hours the entire number had died. A year ago,



304 NORTH CAROLINA MEDICAL SOCIETY.

in Vermont, fourteen were killed and a number of persons permanently
blinded through drinking whiskey containing wood alcohol, which when
received from the distillery had been labeled "Col. spirits" — meaning, of
course, to the distillery, ''Columbian spirits," but (through the abbrevia-
tion) being taken by the purchaser to indicate ''Cologne spirits," a trade
name for grain alcohol. During the past year there have been six
deaths and five cases of blindness in New York City from wood alcohol
poisoning, and three other deaths and two serious illnesses believed t*o
be due to the same cause. Three of the deaths and two cases of blindness
among those referred to occurred among Armenian rug weavers who had
purchased from a Greek grocer anisette consisting largely of rectified
wood alcohol. It was found that the grocer was ignorant of the poison-
ous nature of the beverage he was selling, but the manufacturer of the
anisette was indicted for manslaughter in the first degree and released



Online LibraryMedical Society of the State of North Carolina. AnTransactions of the Medical Society of the State of North Carolina [serial] (Volume 62 (1915)) → online text (page 34 of 58)