A lost hospital, eye disease and an angry deity

In 1919 Alan William Stuart Sichel, a South African eye specialist, wrote a thesis titled “An Investigation into the incidence of conjunctivitis on Christmas Island, (Indian Ocean) with special reference to trachoma, its diagnosis and treatment”. Yes! another insidious scourge, apart from beriberi, that plagued the coolie workforce and created much suffering and in some instances, blindness. Trachoma is a bacterial infection and with repeated infections scarring develops under the eyelids. Untreated the eyelashes turn in and rub on the cornea eventually cause scarring. This leads to loss of vision and blindness. You can learn more about trachoma here.

Sichel’s thesis is an amazing document because it is so rich in detail. One of the most interesting of these is the location, description and photos of a long forgotten isolation hospital! It was built in 1913, (past Rocky Point and not far from the cemeteries) and closed 12 months later. There are other fantastic accompanying photographs in the thesis. We learn of the unhygienic practices of the coolies including an interesting method of eye massage. There is mention of using “carbolic dioxide snow” (we know this as “dry ice”!), in the form of pencils, which was the preferred treatment for trachoma. Sichel had his view on the cause of the 1912 epidemic but the coolies had their own idea about that and it involved a temple deity on the Island.

The thesis comprises of 162 pages and that is far too big for the scope of this page, so I have reproduced just some of the text and photographs. I have also included an original notice in Chinese with English translation and some charts. It is still a long page but a great read. If you would like to read the thesis in its entirety, it can be found on my “documents page“.

HISTORICAL.
The first reference to the existence of Conjunctivitis on Christmas Island appears in the medical report for May 1904. From 1901 until the time of this report the entries in the hospital register are very incomplete but there appears to have been no epidemic and what cases occurred were of a sporadic nature. In September, 1904, 49 cases were admitted to hospital and from this time onward they seem to have increased in number, for in December of the same year 111 patients were admitted.

At that time the medical officer spoke of the condition as “granular or purulent conjunctivitis” and further describes it as having been due to an “infective micro-organism which is readily discernible by the microscope and present in great numbers”. In a later report, April 1905, he alludes to this organism as being the bacillus of Koch-Weeks which he regarded as the causative agent. He definitely states that the cases were not due to gonorrhoeal infection and further, that the disease was spread by the practice, in vogue among the Chinese, of “cleaning out the eyes” by means of pieces of wood, each piece being used by several men, and also by the use of dirty towels and cloths for wiping the eyes.

The number of admissions for Conjunctivitis was maintained for the greater part of the year 1905, averaging 55 per month, but in November there was a distinct fall and the cases steadily diminished in number during 1906 so that the total admissions for that year were only 262 as compared with 616 in 1905. From these facts it will be seen that conjunctivitis, which previously had occurred sporadically, assumed epidemic form during the latter half of 1904 and that there was a marked exacerbation in December of that year. This epidemic subsided gradually and by the end of 1907 the disease existed once again in its usual sporadic form.

In his annual report for 1907 the medical officer remarks that all the cases which occurred during that year were simple, that is to say the purulent type had died out and the cases seen were merely the aftermath of the epidemic.

From 1908 to 1911 inclusive, the yearly incidence of the disease was small, averaging from .8 to 6 per 1000 of the population. Only occasional references to the subject are found in the medical reports during this period and it was pointed out that the few cases that occurred were of a mild nature and were admitted to hospital as a precautionary measure.

In the medical report for June, 1912, attention is drawn to the dry and dusty weather then being experienced as the cause of 20 cases being admitted during the month. This was followed in July by a violent outbreak of Conjunctivitis, the severity of which may be gathered from the fact that 196 cases occurred, 132 per 1000 of the population, and that in the course of a weak or two, 20 men were rendered blind. In August 170 cases were admitted and the disease continued severe until March, 1913, after which a steady decline set in and continued to the end of the year, since when Conjunctivitis, even in sporadic form, practically ceased to exist on Christmas Island. This satisfactory state of affairs was achieved as the result of measures taken to stamp out the disease and prevent its recurrence. One of the aims of this thesis is to describe these measures which will be considered in detail later.

The foregoing sketch of the incidence of Conjunctivitis on Christmas Island during the period 1901-15 reveals the fact that two great epidemics took place, one in the latter part of the year 1904, the other in 1912. The epidemic of 1904 began more gradually, was spread over a longer period and shewed a protracted decline whereas that of 1912 flared up with the greatest virulence and subsided rapidly.

The present work is based on the experience gained during the investigation of the latter outbreak and hence this epidemic and its effect on the industry of the Island must first of all be described in order that the gravity of the situation may be appreciated, as wall as the importance of having to deal with the disease in a vigorous manner with a view to its ultimate eradication.

The Christmas Island Phosphate Company drew its labour force, as far as the production of phosphate is concerned, entirely from China. The contractor for labour employed by the Company obtained coolies from Southern China whence they were shipped to Singapore. Whenever additional labour was-needed coolies were dispatched from the depot, at Singapore to the Island. These men were indentured for one year, after which they were free to return to China via Singapore or to remain at work on the Island. In order to keep the labour force up to the necessary strength, a varying number of indentured coolies were from time to time required to replace those who had left on expiration of their contracts, of whom there was a more or less constant number every month.

In December, 1912, as the result of the numerous cases of Conjunctivitis that had occurred, the Straits Settlements Government addressed a letter to the manager of the Company in which information as to the cause and extent of the epidemic was sought. In reply a report by the medical officer explained that the epidemic was due to an outbreak of infectious Conjunctivitis and that, owing to the existing dry weather, the condition of the eyes had been aggravated by dust and glare. It further stated that infection had spread rapidly owing to the dirty habits of the coolies and to the escape of patients from hospital who mixed with others in the coolie houses.

In March, 1913, a report by the medical officer giving full details of the epidemic and the means already taken to deal with the disease was submitted to the medical authorities in Singapore and their advice sought. A coolie whose eyes were affected was at the same time sent for examination and in due course pronounced to be a case of “Acute” Trachoma. The medical authorities in reply offered suggestions as to the steps to be taken to limit the spread of the disease. During the same month, at a conference held in Singapore between the Company’s agents and certain medical men, rigorous segregation of all affected coolies was urged and it was further suggested that treatment by Carbonic Oxide Snow should be given a trial.

A consultation was also held at which the Company’s agents met representatives of the Government who expressed their emphatic refusal to allow coolies suffering from the disease to be landed at Singapore. In May, 1913, the Government extended the restrictions by forbidding further importation to the Island of Chinese labour. This was a serious blow to the Company who at the time were under obligations to fulfil important contracts. As the result of this intervention of the Government they were not only faced by a shortage of labour but placed in the position of being unable to deport affected coolies whose contracts had expired.

In placing restrictions on the movements of coolies between the Island and Singapore, the Government acted on the erroneous assumption that Trachoma had never hitherto existed and was not found in the Straits Settlements and they were naturally afraid therefore of the possible introduction of such a loathsome disease. So serious a view of the existing state of affairs was taken by the Government that it formed the subject of a discussion at a meeting of the Legislative Council held on 6th June, 1913. Here it was insisted that a special isolation hospital should be erected on the Island by the Company and that the services of a medical officer with special knowledge of eye diseases should be obtained from England. It was also arranged that the Government Bacteriologist should be sent to investigate and report on the epidemic. This was done during July, 1913, and a report submitted embodying the following conclusions.

1. That a considerable number of coolies on Christmas Island are suffering from Trachoma.
2. That the epidemic reached its height in the latter part of 1912.
3. That the exact cause of the exacerbation is difficult to demonstrate. Flies appear to play no part.
4. That the infection is now endemic as it is in Singapore and other parts of the Malay Peninsula.
5. That as it is endemic in China, certain cases of Class I probably arrived in that condition.
6. That isolation and disinfection in a regular systematic way will tend greatly to diminish its further dissemination.
7. That the disease was probably transmitted by the indiscriminate use of infected towels, etc.
8. That in view of the fact that the epidemic is on the decline, there is only a slight risk of fresh arrivals becoming infected should the ordinary sanitary measures be effectively carried out.

The new Isolation Hospital was opened on 16th July, 1913. It was situated on the coast road running north from Flying Fish Cove about half a mile beyond the old Hospital and consisted of two main buildings, the larger being 150 feet in length, 46 feet in breadth and 15 feet in height, while the smaller was 80 feet in length but similar in height and breadth.

These buildings were constructed of wood, roofed with corrugated iron and built up on piles to a height of several feet from the ground. There were also provided quarters for attendants, a dispensary, laboratory and the usual out-houses. In order to ensure absolute segregation the Hospital was surrounded by a barbed wire fence and guarded by a detachment of 12 Sikh police provided by the Government for the purpose.

Other steps taken by the Company in conformity with the suggestions made by the Government Bacteriologist during his visit were, the provision of a steam steriliser for the routine disinfection of face cloths, a distribution of new towels to the coolies and the disinfection and white-washing of all coolie houses both in the Settlement Lines and on Phosphate Hill. Notices in Chinese were posted at various points informing the coolies of the nature of the disease and of the steps to be taken to avoid infection, (vide Appendix XIV). As a further precaution all affected coolies were transferred from the Hill to the Settlement Lines, leaving at the former place only those apparently free from disease.

During July 1913, 40 coolies, after thorough examination for Trachoma in Singapore, were allowed to proceed to the Island for work on the new railway, the construction of which was then about to be commenced, on the strict understanding that they were to live in a new camp on the railway and work only in that vicinity, and further, that they were to be inspected and a report rendered as to the state of their eyes every three weeks.

In September the Government at length agreed to the proposal that new coolies should be allowed to live in the Hill Lines from which place, as has already been pointed out, all affected individuals had been removed, and in due course a draft of 50 coolies arrived on the Island and were quartered on the Hill. Permission was also obtained for “passive” cases of Trachoma and unaffected coolies desirous of leaving the Island to be sent to Singapore provided a medical certificate was rendered as to their condition.

The writer reached Christmas Island towards the end of August 1913. The position of affairs on the Island at that time was as follows. All coolies showing signs of Trachoma were quartered in the Settlement Lines. The coolies occupying the Hill Lines had previously been examined and all affected men transferred to the Settlement which left the Hill Lines free from the disease. Construction of the new railway had just been begun and the 40 coolies who had arrived in July were quartered at Camp 540 on the railway. In this way all the Trachomatous coolies were segregated as regards dwelling houses. Arrangements were made for all the coolies living at the Settlement, i.e. affected men, to work in the upper part of the quarries whereas those living on the Hill worked in the lower part, also known as No.3 Quarry. These quarries are situated on the slopes of Phosphate Hill and the two portions referred to are separated by a difference in altitude amounting to nearly 200 feet, (vide Sketch
plan, Chart I).

The coolies quartered on the Railway were employed exclusively on that work. Thus coolies suffering from Trachoma were kept apart from the remainder while at work as well as in their quarters, but it must be pointed out that this method of segregation was not absolute, it being impossible to prevent individual coolies from visiting their friends in the evenings; but short of fenced-in compounds no better means of segregation could have been devised.

At the end of August the Isolation Hospital had been in occupation for some six weeks and there were about 90 cases under treatment. These for the most part consisted of coolies who had suffered acutely during the height of the epidemic and who had been receiving treatment for a considerable period. The nature of the treatment had been varied from time to time. During the acute stage of the disease frequent douching with antiseptic lotions and sedative drops were in use, at a later stage Nitrate of Silver while in the preceding two months the application of Carbonic Oxide Snow had been commenced and was still being carried out by the resident medical officer. Each case had by this time received from 3 to 8 applications but though improvement in the condition of the eyes was noticeable, progress was slow.

On taking charge of the Isolation Hospital I in the first place tried the effect of Copper Sulphate in selected cases, at the same time continuing the routine treatment with Carbonic Oxide Snow on the remainder. As the majority of the cases were now in a suitable condition for the operation of Expression it was decided to carry this out in conjunction with the application of Snow. Owing to the patients having been in hospital for several months and being naturally desirous of returning to work or leaving the Island, it was deemed advisable to adopt a form of treatment which promised a more rapid cure than could otherwise be expected. It was also important from the Company’s point of view, to utilise the services of these coolies especially as further importation of labour was subject to severe restrictions. When the patients were informed that operative treatment would be carried out they objected, stating that they were afraid of being made blind or dying under the anaesthetic. All arguments to the contrary being unsuccessful, resort was had to strategy. It was proposed that two coolies should submit to the operation and if they died or became blind, the remaining coolies would not be so dealt with; if, however, they were “cured” and discharged to work within three weeks all the other patients would have to be operated upon. It is well known that the Chinese are prone to bargaining and this proposal appealed to them so strongly that they chose two of their number to submit to the ordeal. These cases were operated upon in due course under chloroform and Expression satisfactorily carried out. On recovering from the effects of the operation 2 applications of Snow at an interval of one week were made, following which the conjunctivae were found to be quite smooth and scarring. At the end of three weeks as agreed upon, although there was still a slight discharge from their eyes, both these coolies were allowed to leave hospital and resume work. The immediate effect of this was that the remaining patients clamoured for the same treatment so that they too could be cured, and thereafter operative measures were carried out daily without the least trouble on the part of the coolies until all the suitable cases in hospital had been “expressed”.

In preparing patients for the anaesthetic the customary steps were taken, including the administration of an enema previous to operation. Shortly before leaving the Island in October, 1915, by which time the “eye trouble” had totally subsided, it came to the writer’s knowledge that he had achieved a great reputation among the coolies. They regarded him in the light of a wizard for, so they said, he employed a wonderful cure, namely, washing the disease out of the eyes by injecting water into the rectum.

In addition to the more effectual treatment adopted for the cases in hospital, other measures for the better handling of the whole Eye Trouble were put into force. The chief of these was an examination of the eyes of all coolies on the Island which was done for the purpose of obtaining a complete record of the distribution and nature of the disease, and in order to compile a register of all affected men. This examination was made during the period 24th October to 11th November, 1913, and took a considerable time relative to the number of individuals examined, owing to the fact that the only way to ensure every man being seen was to inspect the various gangs at work, which meant visiting different localities scattered over the Island. Extreme caution had to be exercised in a matter of this kind owing to the objection on the part of the coolies to having their eyes examined with the possibility of being sent to hospital, and the necessity of avoiding a general strike. It must be remembered that on account of the isolated nature of the Island the Company were more or less powerless in the event of the coolies refusing to work and there was the danger of a serious situation arising as previous experience had proved.

The details of this examination are tabulated in Appendix VII but the results may be briefly summarised as follows – 786 coolies, including 88 in hospital, were examined and 291 found to be suffering from Trachoma, i.e. 37% of the total seen, or a little over 19% of the total population of Christmas Island at that date.

… In addition to this examination periodic inspections of the eyes of all coolies living in the Hill Lines and on the Railway, i.e. in non-Trachomatous localities, were instituted to be held every three weeks. Any man found to be affected was immediately transferred to the Settlement Lines. It is noteworthy that during the course of these inspections not more than 3 cases had to be transferred to the Trachomatous section of the community and these may very well have been overlooked at the time of the original separation owing to the early stage of the disease when first seen.

Another measure taken was the provision of shaded goggles which were issued free of cost to every coolie for the purpose of protecting the eyes from dust and glare while at work in the quarries. The coolies, however, regarded their goggles more as articles of adornment than as a means of preventing inflammation of the eyes, and it was no unusual occurrence for them to be seen at work in the heat of the day with goggles tied on top of their straw hats while in the cool of the evening, after a bath and the donning of their best clothes, they would promenade along the coolie lines proudly wearing their glasses. Nevertheless, foremen and supervisors were instructed to see that the goggles were worn by the coolies while at work and this was done as far as possible.

Two towels or face cloths were issued to every man, one to be in use while the other was collected for washing and sterilisation, a measure which was carried out weekly.

When all the patients who were in the Isolation Hospital at the date of its opening, and others subsequently admitted, had been satisfactorily treated, they were in the majority of cases discharged to work or, if they so preferred, allowed to return to China in which event they proceeded from hospital direct to the ship. In the case of coolies discharged to work it was deemed inadvisable for them to be quartered in the Settlement, i.e. a Trachomatous area, for fear of the disease lighting up again, and, on the other hand it was equally objectionable for them to mix with others who were unaffected. To meet this difficulty the Company, on my suggestion, erected special quarters for these discharged men at No.3 Quarry and arranged for them to work as a separate party away from all other coolies.

During the latter part of November, 1913, a start was made to admit to hospital for treatment all coolies remaining on the Island who suffered from Trachoma. About 12 of those whose names were on the register which had been prepared, were admitted and treatment commenced when this arrangement came to an abrupt end. The coolies whose names had been taken, about 200 in number, together with their friends, paraded one morning to interview the Manager. They asserted that their eyes were not “sore” and that, as they were perfectly well and willing to work, they would not go to hospital. In spite of all argument and advice they maintained their attitude so that, fearing trouble, the Manager decided not to press the matter. Thus no further cases were obtainable for treatment.

In December, 1913, four months after arrival on the Island, I submitted a lengthy report on the Eye Question to the Manager of the Company, dealing with the origin and nature of the recent epidemic and suggesting measures for preventing a recurrence. It was emphasised that misunderstanding existed with regard to the nature of the epidemic, that it was primarily due to Purulent Conjunctivitis occurring in coolies affected with Trachoma, that these coolies had come from China in that condition; further, that there was no reason why coolies suffering from Trachoma should be debarred from proceeding to Singapore as long as hundreds of Trachomatous men were arriving there every week from China without examination of any kind.

As a result of this report, which was forwarded to the Government, permission was at length obtained for all cases of “uncomplicated” Trachoma, i.e. Trachoma without superadded infection, to return to Singapore should they so desire. Recognising that the presence on the Island of coolies suffering from Trachoma was likely to be the basis of any future epidemic that might occur, a question that will be discussed when dealing with the all Trachomatous individuals to leave the Island, at the same time none but coolies with strictly healthy eyes being imported. In this way it was hoped that Trachoma would in course of time be entirely eliminated and with it the risk of future epidemics causing such serious interference to the industry.

In March, 1914, the Isolation Hospital was closed, no further cases being available for treatment, and thereafter attention was directed solely to the carrying out of preventative measures.

How the infection was spread

In investigating the means of spread there are several possible channels of infection which must be considered. What is probably the most important of these is to be found in the use of the face cloth or towel carried by every coolie and used by him while at work, for wiping the perspiration from his face. These towels are readily infected by being brought into contact with discharge from the eyes. When at work each coolie uses his own towel which as a rule is carried by being slung over the shoulder, but on returning to their quarters after work these towels are left lying about the hut in the general upheaval caused by a score of coolies rushing in to deposit their/their effects. In this way a certain amount of intermixing must occur, with the result that infected towels may be used by men to whom they do not belong.

In addition to being a means of conveying the actual infective agent, the face cloth also acts detrimentally by being used for rubbing the eyes which is vigorously done by the coolie whenever he feels the least irritation; thus, besides introducing infection it helps to prepare the soil by increasing the irritation.

The dirty habits of the coolies are another possible mode of transmitting infection. Men suffering from Conjunctivitis are wont to rub the discharge from their eyes with the fingers which in turn are smeared on the clothing; moreover, they have frequently been observed to convey the discharge in the same way to the woodwork of the hut, tables, bedsteads and other articles.

A common custom among the Chinese to which the spread of infection has been attributed (Falk) is that of massaging the eye lids. This is done by rolling the latter between two small wooden sticks which the masseur uses over and over again in successive ”sittings” without making any attempt to clean them. It is not likely that dust in capable of carrying infection although it has been regarded by some … as an important agent especially in Egypt and other places where dust abounds; but it undoubtedly plays a great part in the causation of Conjunctivitis by the irritation of the eyes to which it gives rise, i.e. a purely mechanical part, and, in the case of Christmas Island, the composition of the dust in the quarries entitles it to be regarded as a chemical irritant in addition; as such it has been repeatedly referred to in the present enquiry.

Flies are often accused of being carriers by direct transference of infective matter from one eye to another, but this has never been verified by scientific proof (MacCallan) and it is doubtful whether they play any part at all.

… The use of water for washing the face in common by several persons is another channel of infection frequently quoted and one on which stress is laid by Nettleship and Stephenson among British writers on the subject. On Christmas Island troughs of running water were provided in the bathing shed and the coolies washed themselves according to the Eastern custom of throwing the water over their bodies by means of pannikins dipped in these troughs; moreover, each coolie used his own basin for washing the face and was most particular in this respect.

… To sum up, the causation of the epidemic of 1912 must according to this view be explained by the employment of a large number of Trachomatous individuals under conditions which produced severe and continuous irritation of the eyes, thus giving the organisms normally present in the conjunctival sac an opportunity for multiplying and overcoming the resistance of tissues already diseased.

The coolie explanation of the epidemic

What the coolies thought about the cause of the epidemic eye disease is fascinating; and of course, their logical observations of the matter made perfect sense to them.

In this connection it is interesting to note the explanation given by the coolies themselves as to the cause of the epidemic. There was a Chinese temple or “Joss House” on the Island in which was housed an idol or “Joss” who rejoiced among other embellishments in the possession of gilded eyes. Soon after the outbreak of Conjunctivitis occurred, a particularly observant worshipper noticed that one of these orbs of gold was missing. To the simple minds of the coolies it was obvious that the Joss, in anger at the sacrilege committed, had caused this scourge to visit them. With all due haste a new eye, even more ornate than the lost one, was procured from Singapore and fixed in the empty socket of the deity. When the disease at length died down it was regarded as proof that the Joss had been appeased.

Could the temple or “Joss House” referred to above be the Tai Pak Kong temple in Settlement? Sichel did identify the temple in the photograph at the top of the page. On an early map I have also seen this temple referred to as the “Chinese Joss House”. Regardless, I wonder if there is idol, with odd golden eyes, still in a temple on Christmas Island?

The (painful) treatment

At a time before antibiotics, the treatment of trachoma on Christmas Island was difficult. There appears to be some trial and error with regards to the treatment. The errors lead to blindness. But there were successes. Even today, antibiotic treatment alone is only useful in the early stages of the disease.

The application of Carbonic Oxide Snow is made thus.-
Standing behind the patient who is seated on a stool, the surgeon, having everted the upper lid, holds it in position with the fore-finger of the left hand. An assistant, standing in front of the patient, inserts a flat ivory or bone ruler between the everted lid and the globe for the double purpose of protecting the latter and providing a firm basis against which pressure may be directed. [First step] A piece of lint is wound round a pencil of the Snow which the surgeon holds pen-wise between the thumb and fingers of the right hand, bringing the shaped surface into contact with the everted tarsal surface of the lid. [Step 2] Moderately firm pressure is then applied for 10 seconds or longer, the effect varying with the length of the application and pressure used.

Separate applications, using the point of the pencil, are made in each canthus and finally the retro-tarsal fold is dealt with by inserting the stick between the ruler and the everted lid and applying pressure in- an upward direction. The second eye is treated in a similar manner. After the applications some Cocain ointment may be smeared over the inner surface’of the lids but this is not essential.

The immediate effect of the application is to freeze the conjunctiva which becomes hard and exhibits the same appearance as does the skin after local anaesthesia by the Ethyl Chloride spray. This passes off in a few seconds and is succeeded by a brief stage of pallor after which the conjunctiva becomes congested and of a dusky red colour. This stage of hyperaemia usually lasts for 24 to 36 hours, by which time a supercial eschar in the shape of a grey film is formed and thrown off in the course of the next day or two. The density and extent of this sloughing depend on the intensity of the application. By the third or fourth day after treatment congestion has disappeared and the actual condition of the conjunctiva can be ascertained. In a few cases petechial haemorrhages occur in the palpebral conjunctiva and may persist for a few days, likewise sub-conjunctival haemorrhage in the bulbar region may be caused and usually takes a week or 10 days to be absorbed. As the frozen lid thaws severe pain is experienced by the patient but does not usually last longer than 5 to 10 minutes. A certain amount of discomfort may persist for several hours but by the following day there is as a rule no complaint. The initial pain is more severe but the total discomfort considerably less than is the case after the use of Copper Sulphate.

The therapeutic action of Carbonic Oxide snow depends on its physical properties in virtue of which it is to be regarded as an escharotic; it is doubtful whether it has any chemical action.

In the earlier cases in which the Snow was used the procedure adopted was to make applications at intervals of one week extending over a long period, the duration of treatment depending on the progress of the case. Further, the amount of pressure employed and length of application were increased at each successive sitting; for example, on the first occasion Snow was applied for 10 seconds with light pressure, a week later for 15 seconds with firmer pressure, then for 20 seconds with still more pressure until a maximum of 30 seconds was reached and continued at subsequent sittings.

After progress of these cases was watched, it was apparent that this procedure was too vigorous and resulted in excessive scarring of the lids. Harston advocates repeated applications of 30 seconds duration each, and denies that excessive scarring is caused thereby, but the progress of my earlier cases was not in accordance with his view. As the result of the experience thus gained I was led to modify my methods considerably and in the later cases only 2, or at most 3, applications were made at intervals of one week; moreover, they were made with moderate pressure and in no case exceeded 10 seconds in duration.

In cases treated with Snow after Expression the interval between the operation and the first application was reduced from a week or 10 days in the earlier ones to 4 days, the Snow in the latter cases being applied before the effects of the operation had passed off.

The application of Carbonic Oxide Snow to the lids appears to initiate a process of resolution and absorption of the Trachomatous matter which then proceeds uninterruptedly until a “cure” is attained. Expression by wholesale removal of the follicles so far prepares the ground as it were that only a short course of Snow treatment is required and for this reason the combined method reduces the total period of treatment very considerably.

All text in quotes © Alan William Stuart Sichel. University of Edinburgh, Edinburgh Medical School thesis and dissertation collection 1919. Used with permission. CC-BY-NC-SA 4.0