1 32 THOMPSON YATES LABORATORIES REPORT 
or a catarrh would eventually terminate in trachoma. But, owing to the opportunities 
of observing children with eye inflammations in the Workhouse Infirmary, it has 
been noticed that many children admitted with simple muco-purulent catarrh have 
returned at some period after their discharge suffering from granular lids. 
In some instances, all the members of a large family have been inmates of the 
infirmary at the same time, some suffering from muco-purulent catarrh, others 
from granular lids. 
Old cases of trachoma, although possessing some bacteriological interest, are 
useless for the purpose of ascertaining the primary cause of the condition, inasmuch 
as the organism initiating the disease has probably long since disappeared. 
The bacteriology of granular conjunctivitis has been described in three 
sub-divisions : — 
(a) Early cases showing very small granules scattered over the whole 
surface of the upper conjunctiva. 
(I?) Later cases with large granules. 
(Y) Old chronic cases with no characteristic granules but a large amount 
of cicatricial contraction. 
In the first series of cases there may or may not be discharge ; the discharge 
is usually not abundant, and many most pronounced granular lids have only a little 
discharge ' gumming ' the lids in the morning. 
In a few instances the small granules, when treatment has been neglected, 
have been observed to increase in size and merge into the second group. 
In addition to the large granules the upper lid often shows a certain amount 
of new formation of fibrous tissue, causing slight thickening of the lid and alteration 
in the contour of the palpebral fissure. 
The last stage of the disease is marked by the total disappearance of the 
granules, distortion of the upper lid with dense fibrous tissue, contraction of the con- 
junctival sac, pannus and other corneal complications. 
Probably all cases of trachoma have commenced with the formation of small 
granules. The majority of adults with classical trachomatous lids state that they have 
had the complaint 5 ever since childhood.' 
The disease is often so insidious in its onset, and its symptoms so slight, that 
a whole school may be affected without any suspicion of its presence until a few 
children have discharge from the eyes. 
As a result of this insidious onset many cases are not seen until the disease 
is well advanced and the granules large. It is sometimes difficult to obtain a history 
long enough to account for the presence of large granules. They occasionally grow 
remarkably quickly and form mushroom-like elevations on the conjunctiva similar to 
the warty growths of gonorrhoea in the urethra. 
