[Reprinted from The Medical News, April 13, 1895.] 
A CASE OF ACCIDENTAL S P 0 N G E- G R A FT / N G OF 
THE CONJUNCTIVA OF EIGHTEEN MONTHS' 
DURATION, WITH SOME SUGGESTIONS 
UPON SPONGE-GRAFTING IN 
EYE-SURGERY. 
By A. G. THOMSON, M.D., 
OF PHILADELPHIA ; 
DEMONSTRATOR OF OPHTHALMOLOGY IN THE PHILADELPHIA POLYCLINIC, 
AND OPHTHALMIC SURGEON TO BETHANY DISPENSARY AND TO THE 
DISPENSARY OF THE CHILDREN'S HOSPITAL. 
The case herewith reported presents two interesting 
features: 
I. The conditions under which the foreign material 
was introduced and the length of time it remained at- 
tached to the conjunctiva. 
II. A beautiful illustration of the so-called process of 
sponge-grafting, which may suggest for it some further 
uses in eye-surgery. 
The case was that of a colored girl, sixteen years old, 
who came to Wills’ Hospital, complaining that there 
had been something growing in her right eye for the pre- 
ceding eighteen months. On examining the eye I found 
a small swelling on the outer portion of the lower lid, 
giving the appearance of a fair-sized chalazion. As I 
drew down the lower lid to expose the palpebral con- 
junctiva a small mass protruded, yellowish in color, from 
which exuded a thin, purulent discharge, and resembling 
a papillomatous growth in appearance. Subsequent ques- 
tioning showed that the girl had been an inmate of the 
House of Correction, having been discharged from that 
institution last August, after two years’ confinement, and 2 
that six months after admission she noticed one morning 
this growth in the eyelid. She consulted one of the 
female attendants, and was told to bathe the eye in hot 
water. After two weeks of this treatment and the growth 
not disappearing, the attendant resorted to surgical 
means and attempted to remove it with a pair of forceps. 
This time she was more successful, securing a portion 
of the sponge and with it some of the conjunctival tissue, 
and causing some bleeding from the lid. 
As I could not account for the presence of the growth, 
and also as it resembled sponge in character, I directed 
my questions with that object in view. The girl then 
stated that all the girls in her department washed them- 
selves with one large sponge several times a week, and 
that often after washing she had noticed small particles 
of sponge adhering to her skin. With this history I 
then examined a piece of the mass microscopically, and 
found it to be indeed sponge. The photograph taken did 
not turn out well, so I cannot show the position and relation 
of the sponge in the conjunctival sac. On examining 
the lid more closely I found the sponge firmly implanted 
in the palpebral conjunctiva toward the outer side of the 
lid, yellowish in color, oval in shape, and with ragged 
edges; it was 8 mm. long, 7 mm. wide, and 3.5 mm. 
high. As for the remaining portions of the eye, they 
were apparently normal, with the exception of that por- 
tion of the ocular conjunctiva that came in contact with 
the sponge when the eyelid was closed. Here the ves- 
sels were somewhat enlarged and the conjunctiva slightly 
hyperemic. ■* 
It would seem improbable that a foreign material the 
size of the piece of sponge stated, consisting of a sub- 
stance subject to very septic surroundings (2. e., a sponge 
used in the House of Correction on all kinds of people 
until it became so rotten that it was falling to pieces), 
could remain so long in the conjunctival sac without 
causing the slightest discomfort and only a very little 3 
irritation ; but I think, if we look into the condition more 
closely, the absence of symptoms can be accounted for, 
as the sponge, being of soft animal tissue, becoming 
attached to the conjunctiva, the granulations springing 
up in the interstices of the sponge virtually made it a 
part of the lid itself, and it therefore caused no more irri- 
tation than any other small piece of granulation-tissue 
in the same position. 
As a case of sponge-grafting, the formation of new 
tissue, as seen in the sketch of the section, shows it to be 
a perfect success. 
Fig. i. 
Showing granulation-tissue intersected by sponge-fibers. X 30°' 
This method of using sponge to replace lost tissue was 
first suggested by Prof. D. J. Hamilton, of Edinburgh, 
in 1881, who recognized the fact that in the organization 
of tissue the blood-clot or fibrinous lymph plays only a 
mechanical and passive part in any situation in which the 4 
organized tissue becomes replaced by a fibrous cicatrix. 
This being the case, he hit upon the idea of using sponge 
as a substitute, as the interstices of the sponge resembled 
the fibrinous network in a blood-clot or in fibrinous 
lymph, and at the same time being an animal tissue it 
would undergo tissue-digestion. 
The process that occurs when a piece of sponge is 
placed in contact with an exposed surface and remains 
long enough is that a quantity of fibrinous lymph is 
effused into the sponge ; this lymph becomes organized, 
and then is replaced by granulation-tissue, which ex- 
tends and fills the interstices of the sponge, with, finally, 
a total absorption of the sponge-skeleton itself, leaving 
only a mass of cicatricial tissue. 
The girl refused to allow me to remove the entire 
sponge at that time, but agreed to the removal of a small 
portion. This was excised, with a small piece of the sur- 
rounding tissue, which was cut and mounted by Dr. 
Charles W. Burr. In hardening the section the free por- 
tion of the sponge, that part not being infiltrated by new 
tissue, was detached from the remainder of the graft. 
This accident is almost impossible of avoidance, owing 
to the destructive effect of the hardening fluid on the 
sponge. I am, therefore, unable to show all the stages 
from the deep granulation-tissue to the lymph in free 
sponge. 
The section presented the following appearance: A 
mass of granulation-tissue in different stages of develop- 
ment intersected in all directions by a network of yel- 
lowish bands that represent the sponge-skeleton. The 
base of the new growth is composed of embryonic, more 
or less developed, connective tissue, which in the deeper 
layers has quite replaced the sponge-fibers. Above the 
deep part, gradually shading from it and filling the in- 
terstices of the sponge, is the new tissue, which consists 
of new granulation-tissue, blood-cells, leukocytes, giant- 
cells, etc. 5 
The evidence of tissue-growth by aid of sponge-graft 
is clear, but the mode of absorption or disappearance of 
the sponge-skeleton is as yet unknown, although this 
undoubtedly occurs, as we find in the deeper layers that 
the sponge skeleton is more reduced in size and the 
fibers are fewer in number. 
It is commonly believed, although the section does not 
show it, that absorption is due to an eroding influence of 
the giant-cells analogous to the action of the osteoclasts 
in bone-formation, as they are found in great numbers 
closely adhering to sponge-fiber. 
Fig. 2. 
Showing absorption of sponge-fibers. X 450. 
In my sections there are several places showing giant- 
cells in close contact with the fibers, but I cannot see 
any evidence of absorption from this cause. I find, also, 
that these giant-cells are numerous in only the super- 
ficial portions of the graft, where we would not as yet 
look for absorption, and are extremely rare in deeper 
portions where the absorption takes place. My own 
opinion is that absorption is more probably due to a 
softening or separation of the fiber of a laminated struc- 
ture by the pressure of the densely packed surrounding 6 
granulation-tissue, and, finally, absorption by the juices 
of the tissues, as the disappearance of the sponge is seen 
in only the deeper layers and apparently affecting the 
whole fiber at the same time. 
So far as I can learn, this is the first instance in which 
sponge has been grafted, either intentionally or acci- 
dentally, on the conjunctiva. From the undoubted evi- 
dence of formation of new tissue, from the non-irritating 
properties of the sponge as seen, from the means under 
which it was introduced and the length of time it re- 
mained in the conjunctival sac, and from the microscopic 
proof of its final absorption, we have every reason to 
believe that sponge-grafting is a valuable means of re- 
placing tissue lost by burns or injuries to the eyelids, 
which are eventually followed by ectropion, entropion, 
symblepharon, etc., and from the disfigurement caused 
by shrinking cicatrices.