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Treatment by galvano-cautery has been brought prominently forward by Samelson, Hirschmann (1875), De Wecker and Masselon (1882), Unterharnscheidt (1883), Dehenne (1884), Wickerkiewicz and Frolich (1886), Fieuzal (1887), Reiech (1888), and by Hans Adler (1890). The method has been strongly opposed by Just and by Korn.
Kasaurow, in 1883, Cecchini, in 1885, and Peunow, in 1888, advocated scraping away the diseased tissue by means of a sharp curette ; while a similar treatment has lately been recommended by N. C. Macnamara, 1*- in this country, and by Blubaugh in America. Dr. Felix Lagrange 178 has invented a special instrument, one side of which resembles a Volkmann's spoon, while the other is furnished with a series of sharp steel teeth. The prominent granulations are removed by the spoon, and the others are attacked by la herse métallique. One may note, in passing, that Lagrange's instrument has a good deal to recommend it.
Mandelstamm (1883), Hotz (1886), Barton Pitts, Webster, Karwetsky, Wadsinsky, Standish, Noyes, Sattler (1891), Jaesche (1892), advocated “expression ” of the morbid material from the conjunctiva by means of the fingers or by the aid of special forceps.
Three further procedures attract attention, more, perhaps, by reason of their complicated character than by their practical utility: I refer to the operations introduced by Noiszewski, Darier, and Lindsay Johnson respectively.
Noiszewski, 179 of Dunaburg, treats intractable cases of trachoma by excising a piece of the diseased conjunctiva from the upper lid, and into the wound thus produced he transplants mucous membrane taken from the patient's lip. The transplanted membrane—which is of rectangular shape, 5 mm. long, 7 or 8 to 1 mm. broad-is retained in place by four sutures. Noiszewski has performed this operation on eight patients, but the results do not appear to have been strikingly successful. Indeed, it is difficult to understand the rationale of any procedure that leaves untouched the superior cul-de-sac, a structure regarded by the best authorities as the principal focus of trachoma. There seems little likelihood, therefore, that Noiszewski's operation will commend itself to the sober judgment of practical surgeons.
Darier,180 in 1890, brought under the notice of the Paris Ophthalmological Society a complicated surgical operation, which had suggested itself to him after witnessing the method adopted for trachoma by Herrenheisser, of Prague. His operation-invariably done under general anesthesia-consisted of the following stages (1) enlargement of the palpebral aperture by means of an incision at the external angle of the lids; (2) complete eversion of the palpebræ, so as to expose the whole of the conjunctiva ; (3) deep scarifications into the infiltrated tissues, made either with a small double-edged bistoury or by means of a Luer's three-bladed knife; (4) energetic brushing of the scarified surface by means of a stiff-bristled brush soaked in a solution of mercuric chloride (1 in 500). “These different steps constitute," to quote Darier's words, “a long, tedious, and very bloody operation ; but what does that matter if the result be good, and it is.” The after-treatment comprises cold compresses for the first forty-eight hours, while on the third day the lids are everted and washed with sublimate solution. At the end of a fortnight a majority of the patients, so it is said, are cured.
This severe and radical operation is recommended by its inventor in the worst cases of trachoma--that is, those rebellious to the ordinary methods of treatment; it is claimed that, after its performance, pannus and corneal ulcers rapidly heal. In the discussion that followed the reading of Darier's paper, Abadie expressed his opinion that the foregoing operation should be performed in all cases of trachoma that resisted two or three months of the customary escharotic treatment.
Darier's operation has been praised by Fourrey and by a few other surgeons. It is not, however, devoid of risks. For example, it has been followed by symblepharon, by entropion, and by ulceration and even perforation of the cornea.
The third proposal comes from an English surgeon, Mr. G. L. Johnson.181 That gentleman treats trachoma by scarifying the conjunctiva of the lids and fornices with a specially designed scalpel,