armed with three parallel blades, and termed a "silloneur." Along the grooves made by this instrument are passed the terminals of an "electrolyser" in connection with four or six carbon and zinc cells. The operation thus combines scarification with electrolytic action. Johnson reports that he has carried out the method on ninety-eight eyes with good results. It may be remarked, however, that the technique of the operation is complicated; that special instruments are needed; and that the proper management of the electrical apparatus appears to be far from easy. Personally, I incline to the opinion, therefore, that however admirable the plan may be for the treatment of isolated cases, most surgeons will seek simpler methods of attacking the malady.

We have now glanced in succession at the various plans-medical and surgical, rational and fantastic-that have been employed in the fight against trachoma. We have seen the copious venesections of former days yield to the more rational treatment by escharotics, which, in their turn, have been more or less displaced by operative methods. At the present moment we witness the sight of two contending schools, of which one is opposed to almost all surgical interference, while the other urges that operative measures alone should be employed in the treatment of the disease. Fuchs,182 on the one hand, would operate only in those rare cases where the morbid process is limited to the particular portions of the conjunctiva. Jacobson,183 on the other hand, derides all methods of treatment by topical applications, and claims that a radical cure can be attained by surgical means alone.

Such differences of opinion among distinguished observers show that the relative value of surgical and escharotic treatment is still open to question. My own experience leads me to these conclusions. Beyond a doubt most cases of trachoma can be cured by local applications to the conjunctiva, and, on the other hand, comparatively few by surgical means alone. The escharotic treatment, however, which extends to many months, or even years, may be abridged, often with brilliance and certainty, by the timely use of surgical measures. A combined treatment, therefore, is, upon the

whole, not only the speediest, but the safest and the most rational that can be adopted, and it is such a plan that my experience leads me to recommend in a majority of instances.

In the following pages I purpose to discuss the various plans that have rendered me service in dealing with trachoma, and although I may be unable to bring forward much that is new, I can at least join my testimony to that of others in favour or in condemnation of the methods in common use. I would merely add that each plan may claim its successes, and that a multitude of agents, employed in the most diverse ways, are capable of effecting a cure. Time, perseverance, complete control of the patient, and avoidance of routine are the keynotes of success; and if there be no specific for trachoma, it may be nevertheless asserted that in the long run every case of that disease must yield to the resources of medical art.

For the sake of convenience operative and escharotic methods will be described separately. But it should be clearly understood that in actual practice, as hinted before, the two are often combined, and that they mutually complement and supplement one another.

EXCISION OF THE CUL-DE-SAC.

As already mentioned, the practice of cutting out pieces of diseased conjunctiva has been advocated at various times since the days of Hippocrates. Galezowski,108 however, was the first to recommend excision of the cul-de-sac as a formal surgical procedure. In a paper published in 1874 he stated that he had performed the operation with excellent results in a series of more than 200 cases. His plan was to evert the eyelid, and dissect away the fornix, previously seized with a pair of double fixation forceps, the so-called pince à granulation. As a rule, excision was confined to the upper cul-de-sac, but now and then the lower fold was also removed. It may be added, as a point of practical interest, that in almost all cases Galezowski resumed local treatment three days after the operation.

Despite repeated communications from Galezowski, excision of the

cul-de-sac does not appear to have gained much popularity among ophthalmic surgeons until the year 1882, when Brachet 184 published an account of a patient who eight years before had undergone the operation. The resulting condition was most satisfactory: the conjunctiva was scarred and smooth; the position of the eyelids normal; the movements of the globe not in the least hampered; and, last but not least, the "granulations" were completely cured, and the previously existing pannus cleared up.

185

Other surgeons hastened to confirm Brachet's experience. Thus, Despagnet examined some of Galezowski's patients twelve or fifteen years after operation, and found that the lids possessed a full range of movement, and were normal in other respects. Santos Fernandez,170 of Havana, found no untoward results, after a similar interval, in patients on whom he had operated. Voukchévitch,186 while fully confirming the statements of Galezowski and Brachet, published the clinical histories of a number of cases where excision of the cul-de-sac had been successful in curing trachoma. Schneller 187 was in the habit of removing the diseased folds with a knife, until an accident of a serious nature led him to substitute fenestrated forceps and blunt-pointed scissors for the scalpel. He practised the operation on an extensive scale, and spoke of its value in the highest terms.

One could hardly expect that so radical a method would escape criticism, and as a matter of fact we find that it was met by all kinds of objections. Hotz,188 for instance, asserted that recurrent inflammations of the conjunctiva and cornea followed as a direct result of the proceeding. He further maintained that removal of the folds must seriously impair the mobility of the eyelids; and said, in so many words, that the cure was worse than the disease. Jaesche 189 expressed a similar view in more temperate language. Lloret 190 condemned the operation, and believed that it was likely to produce entropion. In short, the belief was common that removal of the retro-tarsal folds, by reason of the resulting scar-changes, would give rise to ptosis or other malpositions of the eyelids.

Sattler 145 on the contrary, urged that the objections to the

operation were without foundation in fact, and his opinion was the more valuable, inasmuch as he had abandoned removal of the folds in favour of scraping with a sharp spoon.

While excision of the cul-de-sac has been advocated by many continental surgeons, its claims seem to have been overlooked by the majority of practitioners in this country.

For my own part, I have now performed excision of the upper fornix on upwards of seventy eyes, and many of my patients have been under observation during periods ranging from two to six years. Once only have I seen an untoward result follow the operation. In that case, unequal contraction took place in the scar, and for a time the inner surface of the upper lid showed a groove running down its centre. Seven weeks after the first operation, the cicatrix was dissected up, and a strip of conjunctiva obtained from a rabbit was placed between its cut surfaces. This simple expedient was successful in removing the deformity, which has not returned at the end of five years.

My results show that excision of the upper fornix, if properly carried out, is invariably followed by good results. The fact may be mentioned, however, that in the practice of a friend I once met with a difficulty in everting the upper lid after excision of the fornix. But in that particular case the operation had not been performed on the lines to be immediately described, and it was obvious that too much conjunctiva had been taken away. As regards my own patients, it is no exaggeration to say that in every instance the removal of the diseased folds had materially hastened the cure of the granular lids.

The condition of things after a successful excision may be thus described. On eversion of the upper lid, a transverse glistening line of scar-tissue marks the site of operation, and the cul-de-sac is represented by a shallow depression. The conjunctiva passes directly from the surface of the lid to that of the eyeball, their junction being formed by the cicatrix just mentioned. The globe is capable of movement in various directions without any obvious dragging upon the eyelid; and there is no ptosis, unless that condition was present before the operation. For that matter, I

have several times seen the ptosis of advanced trachoma actually benefited by excision of the fornix. In these cases, the removal of the swollen and loose conjunctiva seems to enable the levator muscle to act to better advantage, and in that way partly to counteract the drooping of the lid.

My operations upon the lower cul-de-sac have amounted to half-adozen only. The reasons that have led me to remove the upper

FIG. 1.-Excision of the upper cul-de-sac. The diagram represents the exposed cul-de-sac with its attached threads. The first incision is being made, and its course is indicated by the dotted line.

in preference to the lower fold may be thus epitomised. Owing to the fact that the superior fornix normally contains a relatively large amount of adenoid tissue, it is the rule to find the tracho matous process more advanced there than elsewhere. Further, the inaccessible position of the fold renders it a matter of considerable difficulty to apply local remedies efficiently to its surface. Hence, it often happens that, even after a long course of topical