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EXPRESSION 
IN THE 
TREATMENT OF TRACHOMA. 
BY 
A. E. PRINCES, Al. 13., 
JACKSONVILLE, ILL. 
Read at the meeting of the Illinois State Medical Society, at Jacksonville, May 23-25,1889. 
Mr. President and Gentlemen: 
It is my pleasure in this paper to call your attention to a method 
employed in the treatment of chronic follicular trachoma, which has 
found its way into few of the journals and none of the text-books, 
which, in my opinion, takes the lead among the remedies employed 
against this intractable disease. This process is the expression or enucle- 
ation of the follicular contents. 
The first reference to this subject which is to be found in literature 
occurs in Graefe’s Archive fur Ophthalmologie 1883, in which Mandel- 
stamm, a Russian oculist, speaks of the efficacy of squeezing, in the treat- 
ment of trachoma, by means of the thumbs. “The lid being everted and 
held by the thumb of the left hand, the nail of the right thumb is placed 
in the retrotarsal fold. The two thumbs are now pressed against one 
another, including the lid and part of the reflected mucous membrane, 
thereby squeezing out the follicular contents and breaking down their 
walls.” This announcement of Mandelstamm made little if any impression 
and the idea might still have remained dormant but for an accidental 
discovery made by Dr. F. C. Hotz, of Chicago, two years before the 
appearance of the publication of Mandelstamm. He published his obser- 
vation in the following words, in Knapp’s Archives of Ophthalmology, 
June, 1886, “At this time,” he says, “an exceedingly nervous patient 
with follicular trachoma and acute pannus came under my care. A vio- 
lent spasm of the orbicularis set in when I turned the upper eyelid, and 
as I pushed the everted lid upward in order to obtain a better viewr of the 
retrotarsal portion, I observed that the contents of the numerous trachoma follicles were squeezed out by the pressure of the orbicularis, in the form 
of gelatinous plugs, and by assisting this pressure a little with the thumb, 
I succeeded in thoroughly emptying all the follicles. The next day I 
was actually surprised by the remarkable improvement. All acute irri- 
tation was gone, the photophobia and the heavy pressure of the lids had 
disappeared; the eyes were opened without discomfort, and in a few 
weeks the patient was discharged as cured.” 
This article appealed so forcibly, as both rational and practical, that 
I was led to adopt it at once and have subjected the method to three 
years of almost daily trial and in the various stages of trachoma. 
To appreciate the indications for squeezing in the treatment of 
trachoma, it will be well to bear in mind the natural history of the dis- 
ease. Though the lines are not closely drawn, in the course of the disease 
may be recognized three over-lapping stages. 
2d—The Follicular. 
3d—The Cicatricial. 
1st—The Inflammatory. 
In the first the epithelial structures are principally affected and the 
enlargement of the pappillse has led to the term, papillary hypertrophy. 
In this stage, it is my opinion, that squeezing is contraindicated. 
The inflammation, is acute, and the treatment has not been found to 
shorten the disease. With the subsidence of the acute process, which 
may be shortened by sacrification and astringents, one is able to observe 
the characteristic of the second stage. 
The hypertrophied pappillse may be seen interspersed with the 
follicles, which, by their color and increasing prominence, lead to no pos- 
sible mistake in the diagnosis. With the further progress of the disease 
they become the ruling factor of the process. They infiltrate the hyper- 
trophied pappillie and may be seen in masses or folds corresponding to 
those of the conjunctiva. They may be more or less extensive, in one 
case being limited to a few follicles and in another omnipresent with the 
conjunctival area, resembling the ovary of the fish. Lying beneath the 
epithelial surface they are by it protected against their rational caustic 
treatment which has so often been seen to result in the deplorable 
destruction of the tarsal and retrotarsal mucous surface, resulting 
in ptosis, entropion and blepharo-phimosis. The poisonous contents 
of these follicles, rather than the roughened surface, is to be held account- 
able for the recurrent ulcers of the cornea, which result from the corneal 
invasion of septic agents. 
The presence of the follicles in the tissue stimulate the secretion 
of a protective exudate, the organization of which results in the cicatri- 
zation, which characterizes the third stage. 
So long as the follicles remain to excite irritation, the cicatrization 
continues. The second stage may thus be seen to lap over the third, 
which is often prolonged months or years by the presence of more or less 
follicles which being situated deep in the tarsus or concealed in the 
retrotarsal fold, resist the efforts of nature or elude the vigilance of art. 
The curative method of nature is that of siege and many cases of trachoma result in spontaneous recovery, but with a loss of a large portion of the 
mucous surface which has been transformed into cicatricial tissue. The 
caustic method of the past has imitated the method of nature and secured 
the end in a shorter time by artificially destroying the epithelium and 
hastening the cicatrization. This irrational proceedure has been pushed 
still further by some of the prominent French surgeons who have advo- 
cated the excission of the retrotarsal folds maintaining that the disease 
is not cured until the whole area of trachoma development is destroyed. 
The mycological development of the last decade has changed all 
this. After the primary stage of epithelial inflammation, the diseased 
germs infest the follicles, and the problem is, therefore, to remove them 
as they develope with the least possible destruction of the mucous 
membrane. 
By mechanically squeezing the area, underlying which the follicles 
may be seen, the pressure causes a rupture of the surface permitting the 
extrusion of the follicular contents and is followed by healing with no loss 
of tissue. In the secondary stage this may require repetition one or 
more times, because there are often numerous small follicles which are 
not sufficiently developed to permit of their removal. But if the case is 
seen in the cicatricial stage, when the battle of supremacy is being 
waged by the two contending forces, a single squeezing is often sufficient 
to reverse the balance of power and effect a permanent cure. 
The method of effecting this deserves some comment. 
The failure of Mandelstamm’s suggestion to obtain recognition was 
probably due to its narrow limit of availability. Squeezing between the 
thumbs is not applicable to the lower lid and available in the treatment of 
the upper lid in only a small proportion of very chronic cases. Hotz, in 
his article, speaks of having used an old-fashioned iris forceps. 
For the first two years of my experience with the method, a curved 
clot forceps was employed, but so often was it found ineffectual in re- 
moving the concealed follicle that an attempt has been made to supply a 
need, which it is believed exists. 
In the construction of an efficient trachoma forceps three qualities 
have been deemed essential: First, that the shape should render accessi- 
ble every point of the conjunctural surface; second, that sufficient 
strength should be possessed to express the follicular contents when 
occurring beneath the tarsus; third, that the terminal extremity should 
be of round or oval wire to prevent laceration of the mucous membrane 
which is always delicate and often atrophied. 
These requirements have been communicated to Geo. Tiemann & Co., 
who has produced this forceps which has been found to meet the demand. 
Since receiving it a few months ago I have effected a cure in a number 
of chronic cases wdiich had resisted treatment, in which the follicles were wholly inaccessible by means of the thumbs or any forceps in my posses- 
sion. By means of this instrument it has been found possible to reach 
the commisural angles of the retrotarsal folds, carruncle, plica-semilu- 
naris, and besides to remove the granulations from under the bulbur 
conjunctiva though extending to the limbus corneae. 
The hemorrhage in these operations is generally slight and believed 
to exert a favorable influence on the disease. The pain, in considerable 
measure, may be controlled by 8 per cent, solution of cocoaine muriate, 
and still more effectually by the use of bromide of ethyl, which, when 
properly administered, secures anaesthesia in from thirty to sixty seconds, 
which lasts but from one to two minutes and seldom leaves so much as a 
headache. 
It must not be understood that squeezing is considered a substi- 
tute for all other treatment. Many cases of this persistent disease 
will test the patience of the patient and the tact of the physician in con- 
ducting the disease through the second stage until there are no new 
crops of follicles to be squeezed out. It will be found necessary to exer- 
cise intelligence in the selection of agents to control the inflammatory 
conditions of the lids as well as the complications of the cornea and iris 
which may exist. 
Attention to the general health must not he overlooked; neither 
must the condition of the lachrymal drainage be ignored. The surgical in- 
dications furnished by entropion and blepharo-phimosis must also receive 
efficient and prompt attention, for the eye is hut an organ of the physical 
economy and is dependent upon the general condition as well as the 
local environment for the successful operation of its special function.