in different countries. For instance any one who will read the recent brochure by Macallen on Trachoma in Egypt, will see that there, it differs in many ways from what we know as trachoma, here.

He says the disease is found in very young children and is frequently ushered in by acute conjunctivitis. Furthermore that recent researches seem to show that trachoma of the genital passages occur, and that trachoma of the newly born is present as a result of infection in this way. He further says that in the acute conjunctival inflammation going with this, are found gonococci, as well as the Morax-Axenfeld diplo-bacillus, the Koch Weeks bacillus and various other organisms. In other words it is a mixed infetcion.

I think in this country we rarely see trachoma originate as an acute condition. In fact, the symptoms are often so slight that the sufferer never consults a physician until the hypertrophic stage is well advanced and the presence of corneal involvement forces the subject to seek relief. Yet on inquiry we find that the patient has had sensitive, weak eyes, when used. for some time. They water and get red in school work.

Boldt says that much confusion has originated because in the early study of the disease each investigator used not only a different name for the same thing but a different meaning for the same word to describe a similar condition, and not until Saemisch in 1876 made a sharp distinction between trachoma and follicular conjunctivitis were the two diseases studied with reference to their different pathology, etiology and course.

It is useless for me to trace the early knowledge of this disease farther than to say that most English and Continental writers regard its origin as following the Napoleonic campaign in Egypt. It has been known to exist there for centuries. It was, however, so confused with other forms of what, until modern times, was known as contagious ophthalmia that we have little of value save in a clinical way.

That trachoma is contagious has been admitted from the remotest time, notwithstanding the special organism that propagates it has not, up to the present, been discovered. In fact, no bacteriolagical studies made by competent observers have succeded in discovering and experimentally demonstrating the presence of the micro-organism producing trachoma.

In 1882, Sattler announced the discovery of a diplococcus resembling the gonococcus of Neisser. This was followed by many others. Of those in which numerous inoculative experiments were made not one has been able to stand the test of inoculation. The more recent work of Halherstaedter and Von Prowa

zek with the so-called "cell inclusion" have likewise failed in the crucial test. Notwithstanding all this, it has been conclusively shown that if a piece of trachomatous tissue be introduced into the healthy human conjunctiva there will be excited an acute conjunctivitis, which in a few months is followed by all the characteristics of true trachoma. Farther it has been shown that if the trachomatous material be filtered through a Berkefeld filter, that is thought to remove all known organisms, the juice remaining is still infectious if placed in the cul-de-sac of either man or the higher species of monkey.

FOLLICULOSIS, SO-CALLED FOLLICULAR CONJUNCTIVITIS.

There is found scattered through certain parts of the conjunctiva immediately underlying the epithelium numerous minute collections of lymph cells. In structure they do not differ from solitary follicles in the mucous membrane in other parts. Under normal conditions and most frequently during the growth of the child, that is from three to twelve years of age, these cells aggregate into lymph follicles. As a result of this the condition has been likened to adenoid and ton sil development, since they are frequently associated, and if no infection occurs, follow the same retrogression. Parsons says they are pathologically allied conditions.

They give rise to no symptoms calling for examination of the eyes and if the child has no other intercurrent eye disease, may never be noticed. That they are found in from ten to twenty-five per cent of all children in institutions I can vouch for. I presume the reason for this is that in such places the eyes are more often examined.

Stephenson says, "In my own mind I have no doubt that the follicular condition is in many instances natural to the conjunctiva of young subjects. " He farther says of 14,797 school children that he examined. 13.908 showed follicles in different degrees of intensity and none of these were in parochial schools.

I have had under my observation for twentv five years or more two institutions with children from five to fourteen years of age, and so-called follicular conjunctivitis has been the most common eye condition found. I have only treated the cases when an acute infection was engrafted onto the follicles.

This condition of folliculosis rarely gives rise to symptoms and if no acute infection supervenes the child passes to the age when, like tonsils and adenoids. they retrograde. leaving a perfectly healthy conjunctival membrane, with no disturbance of the lid and no cicatrization.

Axenfeld, probably the widest known oph

thalmic pathologist and bacteriologist says simple, harmless, conjunctical follicles, such as are so often found in school children may give rise to the impression of trachoma but only when associated with an acute catarrh are they contagious.

Now, the differential diagnosis between this condition and trachoma is the one absorbing topic in school inspection of children's eyes, and on its proper recognition, depends the question of the prevalence of contagious eye diseases, to any large extent, in our public

schools.

The local appearance in each disease as I have seen it is about as follows:

In trachoma the conjunctival membrane throughout its extent is thickened; the socalled trachoma follicles seem to be more or less imbedded in thickened conjunctiva: no isolated blood vessels can be seen; the follicles appear anywhere on the conjunctiva but usually more abundant in the upper cul-de-sac, but always more or less on the tarsal conjunctiva, with it there is thickening of the lid substance. This condition is often found where the patient has not complained of eye discomfort. It may occur at any age but is more commonly seen in adults.

Folliculosis is found in children, seldom after fourteen years. It is rarely accompanied by symptoms unless there is added an infect ion; the conjunctiva retains its translucency; when the lid is pulled down a mass of follicles roll into view, usually more or less symmnetrically arranged in rows; there are well-defined spaces between the follicles, where the conjunctiva often appears normal and blood vessels can be seen. These follicles are sometimes seen in the upper cul-de-sac and occasionally as round semi-transparent isolated nodules, that do not coalesce on the conjunctiva of the upper lid and around the caruncle and semilunar folds. With this in uncomplicated cases the remainder of the conjunctiva has its normal appearance and the blood vessels can be distinctly defined; the lid substance is not thickened and the unaffected portion of the conjunctiva is shiny and glazy.

So much for these points in differentiation. I will admit there are often cases when from one examination: the diagnosis cannot be certainly made. This is most often in folliculosis with an added infection but if the case be watched for a few weeks the diagnosis can be positively made.

In the crusade started several years ago in New York against contagions eye diseases, the question as to what was true trachoma came to the front and I am personally informed by one of the ophthalmologists acting as consultant to the health department that the majority of cases submitted to operation were cases

In the discussion of this paper Drs. Reese and Wooten were strongly of the opinion that so-called follicular conjunctivitis never terminates in cicatrization or corneal involvement, yet they both stated that in cases of folliculosis which had been operated upon, often the scar tissue resulting from the operation produced corneal involvement, and damaged eyes resulted.

I desire to submit the following propositions that to me seem tenable.

Trachoma is a specific infectious inflammation of the conjunctiva.

It appears at all ages from the cradle to the grave.

No country is exempt, yet certain individuals and certain races present a certain immunity.

It is contagious by direct transmission only of the secretion from an infected eye to a healthy eye of another.

The activity of the contagion depends largely upon the presence of a secretion.

Trachoma, if untreated. leads in time to serious secondary changes, so-called sequellae. These are characteristic and pathognomonic.

No known treatment and no operative interference is sure to promptly cure the case at any stage of its career. and it is subject to relapses.

Trachoma being a specific infection due to a micro-organism cannot arise de novo and cannot result from the gradual evolution of any other conjunctival condition.

Folliculosis or follicular conjunctivitis, is a condition found in children.

It is often associated with the so-called lymphatic diathesis, tonsils and adenoids, and disappears in time without treatment and with a normal conjunctiva remaining.

It cannot be the first stage of a trachoma development since it has been known to disappear without treatment, and of all the different organisms that have been claimed as the specific agent in trachoma, no observer has found them in any number of cases known to be of the follicular type.

Folliculosis develops in the eyes of children as the result of local irritation and bad by

gienic surroundings, and can be produced in the eyes of susceptible adults by local applications, such as is seen after long use of atropine, eserine and other local agents.

If these conclusions are true there is no ground for the alarming statement as to the great amount of trachoma in the schools. There has been simply revealed many cases of a harmless condition of which the patient was unaware. These children are not threatened by any life long disability or blindness and I would emphasize the statement that it is unscientific and harmful to the best interests of both the profession and the laity to create a fear as to the existence of a disease the danger from which are largely imaginary.

In conclusion I wish to state that true trachoma, has been known to exist in certain localities or districts in this state for many years. In 1894 I wrote the late Dr. Swan Burnett on this point as follows: There is prevalent in certain localities in this state a form of trachoma frequently non-inflammatory in its early stages but eventually produeing enormous thickening of the lids, great corneal vascularity and much deformity from conjunctival cicatrization. In fact this condition, I am told, was so well recognized in Cincinnati that it had been styled "Kentucky

Trachoma."

DISCUSSION.

J. McMullen: I wish to thank this society for the privilege of being present this evening and hearing the splendid paper read by Dr. Ray, to which I bave listened with great interest.

The emyist evidently recognizes the numerous difficulties sometimes encountered in both the diagnosis and treatment of trachoma. In examining the eyes of emigrants on Ellis Island, where I was stationed for seven or eight years, it was a very serious matter to report that the individual had trachoma. as this disease carried with it the sentence of dismissal from the country. Trachoma is one of the mandatorily deportable maladies. In justice to the individual, therefore, we always endeavored to differentiate between true trachoma and the various conjunetival diseases which sometimes simulate it so closely. In my present work in the Kentucky mountains I have also attempted in all cases to differentiate between folliculosis and trachoma.

It is most unfortunate that at present the diagnosis of trachoma must be based absolutely upon the observed clinical manifestations plus the personal opinion of the examiner. This is the cause of much of the existing confusion, because the etiology of the disease is unknown and every man is entitled to his opinion whatever it may be. Trachoma is presumed to be due to a specific bacterium, but unfortunately it has not yet been isolated and described; and until the etiology is definitely understood confusion and discussion

will necessarily continue as to what is and what is not true trachoma. In this part of the country it seems to me if the disease be treated and cured, whether it be follicular conjunctivitis or trachoma matters little from the standpoint of the patient, so long as proper relief is obtained. On Ellis Island, however, the diagnosis of trachoma makes considerable difference to the individual who is an alien knocking for admittance, and it was my habit while there to keep the patient under observation in the hospital for several days or weeks in order to settle the question of diagnosis if possible.

As we all know simple conjunctivitis will ordinarily disappear in a short time under appropriate treatment. The most puzzling cases are those where an acute conjunctiva is engrafted upon trachoma, so to speak; but by the institution of proper treatment the conjunctival hypertrophy may to a certain extent be reduced. and we are then able to determine whether th underlying trouble is trachoma.

It has always seemed to me that where it can be accomplished without the infliction of sufficient traumatism to produce cicatrization and subsequent corneal complications, aggravated cases of follicular conjunctivitis might be advantageously accorded treatment somewhat similar to that ap

plied in true trachoma, viz; some form of operation. Such treatment, carefully applied could do the patient no harm, and if the disease really be trachoma much good may be accomplished, although a cure may not result from the first operation.

All of us who are familiar with trachoma have doubtless observed extreme cases in which the condition of the patient was most pathetic from corneal complications, deformity of the lids, photophobia and practical blindness. The potentialities of trachoma are so great that we are certainly not justified in withholding treatment in any case where we even suspect it, because we know the disease is not only destructive to the vision of the individual but is also communicable from one person to another. In the campaign I am conducting against trachoma in this State it is my desire that the people know that the malady is dangeruos, I prefer to have them alarmed so they will return for treatment, otherwise they are prone not to do so. Adults would only seek treatment when they became unable to longer work in the fields, and would bring their children only when they were in such condition that they could no longer attend school. I am sure Dr. Ray fully appreciates the difficulty in curing trachoma where there is extensive hypertrophy with deep-seated granulations and an abundance of cicatrization such as occurs in the late cases. It has been my experience that follicular conjunetivitis is not followed by cicatrization nor corneal involvement unless these complications are caused by unwise methods of treatment.

It would appear that the combined designation

follicular-trachoma is distinctly misleading and should be abandoned, unless by this expression we actually mean trachoma, because the word trachoma implies so much more than follicular conjunctivitis. Although I may be accused of being biased, I believe trachoma is an exceedingly serious affection, and is not to be compared with follicular conjunctivitis. In the mountains where I have been working for the last year or two, and where hundreds of cases of trachoma have been seen and treated, these fine points in diagnosis do not bother us very much. Of course we all recognize that in typical advanced cases there is no difficulty in making accurate diagnosis of trachoma, but it is frequently difficult to effect a

cure.

an

Two years ago, I examined the school children of seven or eight mountain counties, I remember in one school the teacher had undoubted trachoma, and several of his children were suffering from the same disease. When I returned to the mountains last winter to establish the hospital at Jackson, Ky., I saw a patient who said he had been waiting a long time for us to build that hospital because he wanted to be treated. I found that he had a very severe case of trachoma, with pannus and marked photophobia. A local physician, well acquainted with the patient, told me the trachomatous school teacher I saw two years before had died, and this man married his widow and had since lived with this trachomatous family. The doctor assured me that the patient had absolutely no evidence of trachoma nor even two or three a conjuncticitis previously, that weeks after marrying the widow he began to have eye trouble which had rapidly developed. There was first noted a "watering of the eyes," the secretion soon becoming profuse and semi-purulent, and was followed by photophobia and corneal development.

It seems to me this affords a very good illustration of the beginning of trachoma. We are frequently asked how trachoma begins. Personally, I believe it always commences with symptoms not unlike those of acute conjunctivitis. There must certainly be an acute stage, i.e., it does not begin as a chronic affection. I believe, however, that trachoma is essentially a separate and distinct disease. These may be speculations not based upon anything particularly scientific, but they are in strict accord with my clinical observations. Trachoma is seen in various stages, from its inception to the sclerotic stage with corneal involvement, ectropion, entropion, etc., the condition of the patient being pathetic in the extreme. In my opinion there is but one kind of trachoma, and while Fuchs and others describe two or three varieties, viz., granular, papillary and cicatricial, they are one and the same thing observed in the different stages.

My work in the mountains is to me so extremeily interesting that I hope I may be pardoned for further allusion thereto: Two years ago at the

request and with the co-operation of the State Board of Health, I examined about 4000 people in Eastern Kentucky, the majority of them school children, and 500, or 12 1-2 per cent. had undoubted trachoma according te my diagnosis. These were all cases that I believe would be accepted as trachoma by anyone familiar with the disease. Quite recently my assistant has examined nearly 9000 people in eight or ten other counties in the southeastern section of the State. Of 7356 school children examined he found that 370 had trachoma, or about 5 per cent. Of 593 people examined outside the schools he found 91 had trachoma or about 16 per cent. In making these examinations outside the schools, the people get the impression that an "eye doctor is coming around," and only those with eye symptoms come to be examined, which of course gives a larger percentage of trachoma in other people than in school children. For instance, in one of the bluegrass counties I recently examined 409 school children and found that 10 had trachoma, or 2.4 per cent; of 55 people examined outside the schools in the same county 27 per cent had trachoma.

The reason for the increase of trachoma in Kentucky is not difficult to understand. Railroad facilities are being constantly extended, and the trachomatous native thus finding an outlet migrate to other places where the disease finds virgin soil. I wish to emphasize the statement that the people of the mountain counties of Kentucky are splendid people, being honest, upright, and intelligent. I ought to be in position to know, since I have practically lived with them for two years. I regret to say, however, that some of them continue to live in an unsanitary way, using the same towels, etc., and trachoma is thus disseminated.

The U. S. Public Health Service now has three hospitals in the Kentucky mountain regions, one located at Jackson, one at Hindman, and one at Hyden. Satisfactory results are being secured in the treatment of trachoma in all of these hospitals, and a cordial invitation is extended to every member of this society to visit any one or all of them. If notified in advance I shall be pleased to arrange a special clinic for that day. I think I will be able to show you patients illustrating every stage of trachoma, and in whom there is absolutely no question as to the correctness of the diagnosis. Of course we see a great deal more trachoma in the mountains than you gentlemen do in Louisville, although I am sure Dr. Ray and others here have seen and treated many such cases. At a recent meeting of the Virginia Medical Society I was rather surprised to hear the majority of the eye men present say they saw practically no cases of trachoma in their practice in Virginia. I am quite sure the disease is prevalent in the southwestern part of the state, but it may be uncommon around Richmond.

S. G. Dabney: I have enjoyed Dr. Ray's paper

very much, and have little to add. While our opinions may sometimes be at variance in regard to the early diagnosis of trachoma, there is rarely any difference in the contagious stage of the dis

ease.

We doubtless all agree that conjunctival inflammation attended with little or no secretion is non-contagious and non-communicable. Conjunctival inflammation with insufficient secretion to case adhesion of the eyelids in the morning is common, and no one could reasonably claim that such cases are contagious. Fortunately border

line cases, about which men of equal experience oftentimes differ as to the diagnosis, are generally those in which the disease is least likely to be conveyed from one person to another.

The members of this society are familiar with my views upon this subject. I am decidedly "on the fence" concerning our ability to make an accurate diagnosis in all stages of trachoma, although like Dr. Ray for many years I thought the diagnosis was easy. Since talking with Dr. Moore, on his first visit to Louisville in connection with the trachoma investigation, my thoughts have been directed along different channels; I have never ceased thinking, and the more I consider the matter the more doubtful I am about our ability to make an accurate diagnosis in the early stages of trachoma. It is no proof that the disease is not trachoma, because spontaneous recovery occurs in certain cases, as that is true of every disease. Allusion is made to this fact by May in his book issued this year, and similar statements are made in other books on the subject.

Like the gentleman who preceded me. I have for some time believed that the ultimate solution of the diagnosis of trachoma must rest with the laboratory. However, I am sometimes a little skeptical about laboratory diagnosis, and do not believe they should be invariably accepted as final without giving due consideration to the clinical history. Until the etiology of trachoma is known, that is until the micro-organism has been isolated and we know the cause of the disease we are going to continue to blunder in our diagnosis.

It has semed to me that perhaps the wisest plan would be to treat doubtful cases as trachema, but there are serious objections to this method especially in private practice. Patients in moderate circumstances cannot afford to enter the hospital for operation, and seriously object to doing so unless it becomes absolutely necessary and they should not be made to incur needless expense in doubtful non-contagious cases. Since our last discussion I have seen several cases of what might be considered doubtful trachoma, and the patients all improved under conservative treatment. I have operated in only one doubtful but in my opinion, non-contagious case, the patient being a school boy less than ten years of age. I do not believe he had trachoma and the only excuse for operating upon him was that he

had been taken out of school and removal of adenoids and diseased tonsils was necessary and I thought it wise at the same time to "roll" the eyelids. There was no conjunctival secretion, and if the boy had trachoma it was not in my opinion in the communicable stage.

Another case seemed to be one of very mild follicular conjunctivitis, I called my office neighbor, Dr. Levi, in to see it. To him also it seemed not at all like what we generally call trachoma, but it is a very significant fact that this patient a little girl of about ten, had an older sister with typical severe trachoma with pannus and corneal ulcers.

Remembering Dr. Moore's remarks on just this line of cases I cannot but wonder whether long observation would not find the little girl developing a genuine trachoma like her older sister. As Dr. McMullen has said the diagnosis of trachoma, at present, can only be a matter of personal opinion.

It will not surprise me if in the future, when the etiology of this disease has been discovered, we shall find it necessary to rewrite this whole chapter. To my mind we will probably find that cases of trachoma may at one stage be communicable and at another free from this danger; that some cases will recover with little or no treatment and others will develop into very serious complications possibly resulting in blindness.

We will hope then to have positive knowledge as to when the disease is actually cured-a knowledge which we sadly lack just now.

It will not surprise me too if, when that time comes we find that follicular conjunctivitis and trachoma are one and the same disease of different types and in different stages, but having the same underlying cause and practically the same pathology. No more convincing proof of the present unsettled state of mind as to this question can be found than in the diagnosis of the children exhibited here to-night. On one side we will find several gentlemen, of large experience and wide reading, positive that these children have not trachoma. On the other side, we will find others of equally large experience and who have devoted long and special study to this disease, of the opinion that these children have trachoma.

I. Lederman: As I have been working in conjunction with Dr. Ray, and making the same observations he has, quite naturally I agree fully in the conclusion he has formulated.

A marked distinction should be made between the work of public health men who visit us for a day or two and hurriedly make the diagnosis of trachoma, and the physicians who keep the patients under observation for a considerable length of time. While there are many border line cases, I think those of us who watch the patients for an extended period are in better position to make an accurate diagnosis than a man who only sees the patient once.