purulent. If this be absent, no matter how red or how rough the conjunctiva may be, the condition is not a true conjunctivitis. Many of those who consult us with a complaint of "granulated eyelids" are not suffering from conjunctivitis at all. Inspection of the lining of the lids reveals a hyperemic injection and loss of transparency of the membrane, the surface of which is roughened by the engorgement of the papillæ, and in more chronic cases by their hypertrophy, into an appearance more or less suggestive of that of a piece of worn velvet. Eyes in this condition are naturally prone to attacks of true inflammation of the membrane, with its accompanying secretion; but the essential element in the condition, and the one which gives rise to the discomfort, and to the erroneous diagnosis, is the hyperemia, especially as it affects the papillæ. My experience is that in the large majority of cases this depends on an uncorrected, or improperly corrected error of refraction, and is only to be cured by optical treatment. Intercurrent conjunctivitis may require to be treated by the usual applications, and the hypertrophic results of a chronic hyperemia may have to be met after the removal of the cause; but the astringent treatment commonly adopted avails little, and may even increase the patient's distress, so long as the source of the irritation remains-foreign bodies, it may be, or meibomian concretions, or late hours in heated rooms, or irritating dust, or imperfect drainage of the conjunctival sac, but preeminently eye-strain.

Permit me merely to refer to two other affections of the conjunctiva, characterized by more or less nodular elevations, which may easily be mistaken for granular conjunctivitis; these are vernal catarrh, and warts of the conjunctiva, of each of which I have seen two examples in Los Angeles. The former, in addition to a peculiar recurrent thickening and vascularity of the circumcorneal limbus, is characterized by a hypertrophy and opacity of the conjunctiva overlying the tarsus, which makes it look as if it were smeared with milk, and an almost cartilaginous hypertrophy and hardening of the papillæ at the upper margin of the tarsus; which latter, if the other distinctive features of the disease be overlooked, may be easily mistaken for true granulations. Warts of the conjunctiva, when sessile, can sometimes be distinguished only by touch from half-buried trachoma nodules. I am the more inclined to condone a mistake in the diagnosis of these affections, as I have been myself deceived by them at first sight. Treatment of both seems to be useless; irritant applications only aggravate the conditions.

There is yet another condition of the conjunctiva, which is very commonly spoken of as granular conjunctivitis, and treated as such, but which etiology, prognosis and treatment alike demand that we should carefully distinguish. I refer to the affection commonly called "follicular conjunctivitis." And here let me say that I do not regard this condition as being primarily a conjunctivitis at all, but rather an adenopathy of the conjunctiva, and prefer to designate it as "folliculosis." For the ocular conjunctiva, like other mucous membranes, normally contains small isolated masses of adenoid tissue, in close relation to its lymphatic system. These, in individuals of a lymphatic diathesis, especially children, are liable to take on an hypertrophy, just as they do in the pharynx, and come into evidence as small, rounded, pinkish, more or less isolated masses, of about the size of a small pin-head, often arranged in rows like strings of beads, and occurring almost exclusively in the fornix of the lower lid, though a few are also to be found in the upper fornix over the ends of the tarsal cartilage. In typical cases there is no discharge of any kind from the conjunctiva, and the affection is accordingly not primarily a conjunctivitis. Indeed in most cases the condition is discovered accidentally, when the eyes are being searched for some

foreign body, and the discovery gives rise to needless alarm. For this affection is in most cases absolutely innocuous, and pursues a protracted course, eventually disappearing without leaving a trace of its existence, and in no case leading to cicatricial or atrophic changes in the conjunctiva. True, a conjunctiva affected with folliculosis is, like a pharyngeal mucous membrane in a similar condition, specially prone to catarrhal inflammation, with the usual accompanying mucous or mucopurulent discharge, acute or chronic, which must be treated on its own merits, and in the usual way. But I have repeatedly observed that a fairly acute conjunctivitis, carefully treated, may, I suppose by stimulating the lymphatic system of the conjunctiva, result in the disappearance of the adenoid prominences, and the restoration of the conjunctiva to a normal condition. Where the folliculosis is complicated by a chronic conjunctival catarrh, this tends to maintain the condition, and must be continuously treated till it is got rid of. In cases of this description, I am accustomed to rely on the use of boric acid solution, applied several times a day by means of the eye-bath, followed in the evening by the insertion of a small piece of a one or two or even three per cent. ointment of perfectly neutral subacetate of lead—a remedy which our fear of lead deposits in the cornea has needlessly driven out of fashion in cases where there is no corneal lesion. (The public still clings to it in the form of Thomson's Eye Water, which is used with material benefit in just the cases of which I am speaking.)

I am aware that certain writers, chief among whom are Burnett, Wurdewann and Noyes in this country, regard this condition of folliculosis as a stepping-stone to true trachoma, holding that the one condition may pass over into the other; but after a very extensive experience of both, I am unable to detect any clinical evidence for the belief that the one condition has anything to do with the other, save this, that we occasionally meet with cases where, with unmistakable trachoma nodules in the upper lid, we find also equally unmistakable adenoid follicles in the lower lid. The latest authoritative work on the subject of Epidemic Ophthalmia, by Sidney Stephenson, maintains that the follicular granulation does not constitute the initial stage of the specific disease, trachoma; that it is not necessarily an immediate and direct outcome of an unhealthy environment; that in all likelihood it is an expression of what the author terms the "adenoid activity" of young subjects, being comparable to the follicular projection of the pharynx.

If then folliculosis of the conjunctiva be analogous to follicular affection of other mucous membranes, such as that of the pharynx, trachoma, it appears to me, is fairly comparable to the so-called adenoids. Microscopically all four consist of aggregations of lymphoid cells, which in limited amount are normal constituents of the mucous membranes. In the follicular affections these are isolated, encapsulated, and still active. In trachoma, as in the adenoid disease, in addition to the presence of non-encapsulated aggregations of the lymphoid cells, which are obsolete and degenerated, the whole of the surrounding mucous membrane is infiltrated with similar cells in a more or less active condition, many of which develop into spindle-shaped cells, and eventually into connective tissue fibres, which, by their organization and contraction, eventually lead to the cicatricial sequelæ, characteristic of the late stages of the affection. Trachoma seems to me to be simply conjunctival adenoids, in which the morbid growth is altered, and impressed with a distinctive character by the friction and pressure to which it is constantly subjected. The bacteriology of trachoma is still in an indeterminate state; but I should not be surprised if it were ultimately

purulent. If this be absent, no matter how red or how rough the conjunctiva may be, the condition is not a true conjunctivitis. Many of those who consult us with a complaint of "granulated eyelids" are not suffering from conjunctivitis at all. Inspection of the lining of the lids reveals a hyperemic injection and loss of transparency of the membrane, the surface of which is roughened by the engorgement of the papillæ, and in more chronic cases by their hypertrophy, into an appearance more or less suggestive of that of a piece of worn velvet. Eyes in this condition are naturally prone to attacks of true inflammation of the membrane, with its accompanying secretion; but the essential element in the condition, and the one which gives rise to the discomfort, and to the erroneous diagnosis, is the hyperemia, especially as it affects the papillæ. My experience is that in the large majority of cases this depends on an uncorrected, or improperly corrected error of refraction, and is only to be cured by optical treatment. Intercurrent conjunctivitis may require to be treated by the usual applications, and the hypertrophic results of a chronic hyperemia may have to be met after the removal of the cause; but the astringent treatment commonly adopted avails little, and may even increase the patient's distress, so long as the source of the irritation remains-foreign bodies, it may be, or meibomian concretions, or late hours in heated rooms, or irritating dust, or imperfect drainage of the conjunctival sac, but preeminently eye-strain.

Permit me merely to refer to two other affections of the conjunctiva, characterized by more or less nodular elevations, which may easily be mistaken for granular conjunctivitis; these are vernal catarrh, and warts of the conjunctiva, of each of which I have seen two examples in Los Angeles. The former, in addition to a peculiar recurrent thickening and vascularity of the circumcorneal limbus, is characterized by a hypertrophy and opacity of the conjunctiva overlying the tarsus, which makes it look as if it were smeared with milk, and an almost cartilaginous hypertrophy and hardening of the papillæ at the upper margin of the tarsus; which latter, if the other distinctive features of the disease be overlooked, may be easily mistaken for true granulations. Warts of the conjunctiva, when sessile, can sometimes be distinguished only by touch from half-buried trachoma nodules. I am the more inclined to condone a mistake in the diagnosis of these affections, as I have been myself deceived by them at first sight. Treatment of both seems to be useless; irritant applications only aggravate the conditions.

There is yet another condition of the conjunctiva, which is very commonly spoken of as granular conjunctivitis, and treated as such, but which etiology, prognosis and treatment alike demand that we should carefully distinguish. I refer to the affection commonly called "follicular conjunctivitis." And here let me say that I do not regard this condition as being primarily a conjunctivitis at all, but rather an adenopathy of the conjunctiva, and prefer to designate it as "folliculosis." For the ocular conjunctiva, like other mucous membranes, normally contains small isolated masses of adenoid tissue, in close relation to its lymphatic system. These, in individuals of a lymphatic diathesis, especially children, are liable to take on an hypertrophy, just as they do in the pharynx, and come into evidence as small, rounded, pinkish, more or less isolated masses, of about the size of a small pin-head, often arranged in rows like strings of beads, and occurring almost exclusively in the fornix of the lower lid, though a few are also to be found in the upper fornix over the ends of the tarsal cartilage. In typical cases there is no discharge of any kind from the conjunctiva, and the affection is accordingly not primarily a conjunctivitis. Indeed in most cases the condition is discovered accidentally, when the eyes are being searched for some

foreign body, and the discovery gives rise to needless alarm. For this affection is in most cases absolutely innocuous, and pursues a protracted course, eventually disappearing without leaving a trace of its existence, and in no case leading to cicatricial or atrophic changes in the conjunctiva. True, a conjunctiva affected with folliculosis is, like a pharyngeal mucous membrane in a similar condition, specially prone to catarrhal inflammation, with the usual accompanying mucous or mucopurulent discharge, acute or chronic, which must be treated on its own merits, and in the usual way. But I have repeatedly observed that a fairly acute conjunctivitis, carefully treated, may, I suppose by stimulating the lymphatic system of the conjunctiva, result in the disappearance of the adenoid prominences, and the restoration of the conjunctiva to a normal condition. Where the folliculosis is complicated by a chronic conjunctival catarrh, this tends to maintain the condition, and must be continuously treated till it is got rid of. In cases of this description, I am accustomed to rely on the use of boric acid solution, applied several times a day by means of the eye-bath, followed in the evening by the insertion of a small piece of a one or two or even three per cent. ointment of perfectly neutral subacetate of lead-a remedy which our fear of lead deposits in the cornea has needlessly driven out of fashion in cases where there is no corneal lesion. (The public still clings to it in the form of Thomson's Eye Water, which is used with material benefit in just the cases of which I am speaking.)

I am aware that certain writers, chief among whom are Burnett, Wurdemann and Noyes in this country, regard this condition of folliculosis as a stepping-stone to true trachoma, holding that the one condition may pass over into the other; but after a very extensive experience of both, I am unable to detect any clinical evidence for the belief that the one condition has anything to do with the other, save this, that we occasionally meet with cases where, with unmistakable trachoma nodules in the upper lid, we find also equally unmistakable adenoid follicles in the lower lid. The latest authoritative work on the subject of Epidemic Ophthalmia, by Sidney Stephenson, maintains that the follicular granulation does not constitute the initial stage of the specific disease, trachoma; that it is not necessarily an immediate and direct outcome of an unhealthy environment; that in all likelihood it is an expression of what the author terms the "adenoid activity" of young subjects, being comparable to the follicular projection of the pharynx.

If then folliculosis of the conjunctiva be analogous to follicular affection of other mucous membranes, such as that of the pharynx, trachoma, it appears to me, is fairly comparable to the so-called adenoids. Microscopically all four consist of aggregations of lymphoid cells, which in limited amount are normal constituents of the mucous membranes. In the follicular affections these are isolated, encapsulated, and still active. In trachoma, as in the adenoid disease, in addition to the presence of non-encapsulated aggregations of the lymphoid cells, which are obsolete and degenerated, the whole of the surrounding mucous membrane is infiltrated with similar cells in a more or less active condition, many of which develop into spindle-shaped cells, and eventually into connective tissue fibres, which, by their organization and contraction, eventually lead to the cicatricial sequelæ, characteristic of the late stages of the affection. Trachoma seems to me to be simply conjunctival adenoids, in which the morbid growth is altered, and impressed with a distinctive character by the friction and pressure to which it is constantly subjected. The bacteriology of trachoma is still in an indeterminate state; but I should not be surprised if it were ultimately

discovered that trachoma and adenoids have not only, as we already know, a com mon diathetic foundation, but also a common bacterial cause.

I have said above that conjunctival folliculosis is not essentially a conjunctivitis at all, though it is often complicated by true inflammatory trouble. With regard to the so-called granular conjunctivitis, I should be inclined to hazard the same statement. The essential feature in the affection is the trachoma nodule, or granule, if we prefer to call it so; the element of conjunctivitis is secondary, and almost, we may say, accidental. Nothing is more striking than the variety displayed by undeniable cases of this affection. In many the most striking feature is a papillary hypertrophy, sometimes exceedingly coarse and exuberant, of the conjunctiva lining the tarsal portions of the lids, in which the trachoma nodules are buried out of sight. They can always be found, however, in the retrotarsal folds, which should be exposed by a double eversion of the cocainized lid. As a rule, the greater the papillary hypertrophy, the more abundant the secretion. Cases occur, however I have seen them often-in which the progress of the affection has been so insidious that there has been absolutely nothing to call attention to it, save, it may be, a certain heaviness and appearance of languor in the upper lid; and yet, on everting this, we find in its sulcus a well-marked deposit of trachoma nodules, and even deeply seated nodules in the tarsal conjunctiva. Notwithstanding the absence of conjunctivitis, these cases are as truly "granular" as any that we meet with, and if neglected will pursue a typical course; so that we are warranted in saying that the conjunctivitis is a variable and accidental element in the condition—the granule, or trachoma nodule the essential element.

Occasionally we meet with cases—those I have seen have been chiefly in the form of an epidemic-in which the disease at its first onset is accompanied by an exceedingly acute conjunctivitis, of a blenorrhagic character; in these the essential trachomatous nodules are easily overlooked, because obscured by the swollen conjunctiva. Careful inspection will always discover them, if present, when once the violence of the inflammation has somewhat abated.

The typical course of trachoma is so graphically depicted in the standard textbooks, that I need hardly describe it here. What I wish especially to emphasize is the vitally important distinction between this disease and the spurious granulations of folliculosis, which are so often confounded with it.

I. As to its mode of origin. Folliculosis is due to a dyscrasia; trachoma is propagated by contagion, and calls for the most rigid precautions against the communication of infection. I formerly had to deal with hundreds of cases of trachoma every year, and I give it as the result of careful inquiry that I have almost always been able to trace intimate association with an infected individual. I have seen an epidemic of acute trachoma, with unmistakable "granules,' introduced into a school by one child affected with an apparently mild form, the spread of which was only arrested by the isolation and treatment of ten who had become infected, and by the enforcement of proper sanitary precautions, especially with regard to face-cloths and towels. The catarrhal conjunctivitis which often accompanies folliculosis is as infectious as other forms of catarrhal conjunctivitis, but gives rise to nothing specific or distinctive.

2. As to its clinical features. I am far from maintaining that the two affectious are always easily distinguishable. Difficulty arises especially where folliculosis is accompanied by an acute or subacute conjunctivitis, in which the conjunctiva as a whole is thickened and fleshy. One feels inclined sometimes in such a case to suspend judgment, and treat the catarrh, in the hope that the subsidence of the swelling may reveal the true nature of the case. Still, even here, the