แ

A CLINICAL ENQUIRY INTO THE PREVALENCE AND SIGNIFICANCE OF THE FOLLICULAR GRANULATION OF THE CONJUNCTIVA.

UNDER the names of follicular, vesicular, or sago-grain granulations are included a series of conjunctival changes, the study of which is still involved in considerable confusion. Thus, we find no less than three widely divergent theories regarding their origin. The first is that the vesicles are outward and visible signs of the specific affection, trachoma; a second traces the follicles to the direct influence of unhealthy surroundings; while a third distinguishes between the true granulation of trachoma and the false granulation, which is a sign of a much less serious malady, namely, follicular conjunctivitis.

In illustration of the foregoing propositions, the views of some of the authors who have from time to time interested themselves in the subject may be briefly quoted.

The knowledge possessed by the ancients concerning granulations of the conjunctiva was, practically speaking, disregarded until the early part of the present century, when the prevalence of epidemic ophthalmia among soldiers once more directed attention to the subject. John Cunningham Saunders 99 appears to have been one of the first—in this country at least―to recognise the frequency and importance of an accompanying chronic granular condition of the eyelids. O'Halloran,100 also a British surgeon, gave in 1824 a good account of the growths. "In every large body of men," he wrote, persons are to be found whose eyelids are overspread by villous flocculencies or fungous productions analogous to what have been

denominated granulations, notwithstanding that from youth they may have enjoyed health, or absolute immunity from the affection under notice" (i.e., chronic ophthalmia).

Some years later, Löffler 106—the surgeon to a Prussian regiment— found that many of the soldiers, whose conjunctiva showed the vesicular granulations, became affected later on with acute ophthalmia. He consequently looked upon those growths as a predisposing cause of the acute disease.

So long ago as 1834, Canstatt 101 published some important statements concerning palpebral granulations. He pointed out that the growths were not exclusively confined to cases of military ophthalmia, but were also observed as a sequel to other forms of conjunctivitis, provided that they had been of long duration, or had relapsed frequently. He was of opinion, moreover, that in the latter cases the granulation was secondary and accidental, whereas it formed a primary and invariable sign of military ophthalmia.

Decondé,102 writing in the year 1849, divided palpebral granulations into two forms, viz., the vesicular and the fleshy. The former (granulations vésiculeuses), which were found only in the retro-tarsal folds, commenced as small projecting points. When the growths had attained their full development, they were, according to this writer, semi-transparent, as large as a millet seed, and easily ruptured by slight pressure. They were disposed in one or several rows, separated from each other by furrows, in which enlarged vessels were situated. The fleshy granulations (granulations charnues), on the other hand, were small, and placed closely side by side on the tarsal conjunctiva of the lids, more especially of the upper one. They bled readily on the slightest touch. Decondé regarded the vesicular granulation as characteristic of military ophthalmia, but he looked upon the fleshy growth as a secondary phenomenon by no means pathognomonic of that malady.

Hairion-who wrote in 1850, and again in 1870-applied the term "granulations" to all alterations in the conjunctiva capable of giving to that membrane an uneven and rugose appearance. He regarded the first stage of trachoma as constituted by the vesicular granulation,

which he described as follows:-"The palpebral conjunctiva is smooth, white, and of a pearly aspect, as in the normal state. Arrived at their full development, the granulations are as large as a millet seed, transparent, pellucid, discrete, and disseminated over the palpebral conjunctiva in the neighbourhood of the external commissure." In the second stage of trachoma, the conjunctiva was represented as becoming red and infiltrated by inflammatory exudations, especially around the vesicles, which by that time had become gelatinous and semi-transparent. In the third stage, the gelatinous mass had undergone fatty degeneration, and become absorbed, while the inflammatory exudation had become converted into cicatricial tissue. Red and fleshy growths were not infrequently observed. According to Hairion, the various stages of trachoma outlined above were infectious as well as contagious.

Van Roosbroeck, another Belgian oculist, gave in 1853 an account of his researches upon the subject of contagious ophthalmia. He found that the first stage-that of chronic blennorrhoea-caused no uneasiness to the patient. The lower lid he described as veined by branching vessels, and studded with vesicles or phlyctens, the contents of which could be readily evacuated by needle puncture. Roosbroeck made the important observation that these "phlyctens" were common enough among children and also in the peasantry, and that, after remaining unchanged for an indefinite period, they might ultimately disappear, and leave no trace of their previous existence. But if individuals thus affected entered the army, he noticed that, sooner or later, the congestion of the lids increased, the surface of the tarsal conjunctiva became villous, and larger granulations made their appearance in the retro-tarsal folds. At the same time, the caruncle became swollen, inflammation spread to the sclerotic conjunctiva, and the eyes began to discharge. The symptoms of the second stage were more severe. Thus, the palpebral conjunctiva became more and more swollen; the vesicles lost their transparency, increased in size, and no longer collapsed when punctured with a sharp needle; in other words, they had become solid. Pannus was often observed, together with ulcers of the cornea. An

abundance of muco-purulent discharge escaped from the eyes, and the patient was unable to endure light.

Warlomont 103 (1856) thought that palpebral granulations constituted the chronic stage of purulent ophthalmia, and that the vesicular became transformed into the fleshy variety. In the so-called sub-acute phase a muco-purulent secretion was present; the bulbar conjunctiva was swollen and red; and pain and photophobia were observed. In the third stage-namely, acute purulent ophthalmia-the lids were enormously swollen and of a livid colour, while an abundance of pus escaped whenever they were separated. Warlomont laid it down that patients whose eyes manifested granulations carried about with them the germ of mischief, which might at any time develop into the condition of purulent ophthalmia.

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Marston, who wrote in 1862, was of opinion that vesicles constituted the initial lesion of trachoma, and that they were not only contagious, but that they also predisposed to inflammatory affections of the conjunctiva. He was responsible, moreover, for the following generalisation, which has been adopted and repeated by many modern authors. "So certain do I feel," said Marston, "that the prevalence of vesicular disease of the lids is in direct ratio to the amount and degree of defective sanitary arrangements, that I conceive that the palpebral conjunctiva offers a delicate test and evidence as to the hygienic conditions of a regiment."

Although Marston may claim the credit of having been one of the first to enunciate concisely and clearly the significance of the follicular granulation from a sanitary standpoint, yet the grounds for his inference appear to have been founded upon the earlier investigations of Stromeyer. Furthermore, two years before the appearance of Marston's communication, much the same thing had been expressed by Philip Frank,104 when he stated that "the prevalence of granular conjunctivæ in a body of men may be regarded as indicating a contaminated state of the atmosphere in which they habitually sojourn." Frank's general views with regard to the vesicular granulation may be gathered from the following quotation :-"Innocent as

these primary lesions may appear, they gain in importance by the predisposition they engender to inflammatory attacks, and by the contagious nature of the secretion which, under such circumstances, is furnished by the affected conjunctiva. Exposure to atmospheric vicissitudes and other sources of irritation, which in a healthy conjunctiva would lead to an attack of catarrhal inflammation or ordinary conjunctivitis, commensurate in its intensity with the nature of the exciting cause, is prone to produce most obstinate structural changes in lids affected with vesicular granulations, on account of the tendency of those bodies to assume a more advanced structural development under the influence of inflammatory irritation."

A year after the appearance of Marston's paper, Assistant-Surgeon F. H. Welch 105 published an elaborate paper on the so-called vesicular bodies. His conclusions were as follows:

:

1st. That men may be carrying about a condition of the lids far removed from the healthy state, and yet to a casual observation not detectable.

2nd. That these "vesicles," or "sago grain bodies," whatever their nature may be, are caused by, or at least intimately dependent on, the impure state of the atmosphere in which the men live.

3rd. That the condition of the lids may be taken as a standard of the hygienic condition of the regimental quarters.

4th. That age exercises a great influence on the extent and severity of the affection.

5th. That the presence of these vesicles causes or predisposes to inflammatory attacks.

6th. That there is an intimate connection between "vesicular bodies" and "granular lids," the one being the primary stage of the other.

In 1873, we find Mr. Brudenell Carter 106 insisting upon the importance of the follicular granulation, and adopting the theories previously laid down by Frank, Marston, and Welch. After giving an excellent and graphic account of the naked eye and microscopic characters of the condition, he goes on to say:-"Although the