ECTROPION.

Ectropion is said to occur as a complication of trachoma, but as I have never observed it personally, there will be no necessity to describe its treatment in this place.

SYMBLEPHARON POSTERIUS.

Symblepharon posterius in some degree forms a sequel to almost every case of severe trachoma. During the cicatricial stage of the malady the retro-tarsal folds-whether superior or inferior-shrink, and become adherent to each other, so that the conjunctival sinus is obliterated to a greater or less extent. The earliest signs of this condition will be found on everting the lower lid, when one or more vertical folds will be seen connecting that structure with the eyeball. Should symblepharon increase, similar folds may be noticed uniting the upper lid to the globe; while, at a later stage, the culs-de-sac may be altogether effaced, or represented merely by shallow grooves.

In the worst cases, the foregoing may pass by insensible gradations into ZEROPHTHALMUS, a melancholy condition, in which the conjunctiva has lost all power of moistening the eyeball, while the corneal epithelium has become dry, scaly, and opaque, so that sight is hopelessly lost. Zerophthalmus is not a common sequel of trachoma.

With regard to the treatment of symblepharon and zerophthalmus nothing need be said, for the sufficient reason that they lie beyond the resources of surgical art.

THE TREATMENT OF FOLLICULAR

CONJUNCTIVITIS.

FROM a former essay it will have been gathered that, in my opinion, trachoma and follicular conjunctivitis are two distinct affections. Indeed, the points of contrast between them are so marked that it is difficult to understand how they could have been confounded together for so long a period. Trachoma, on the one hand, is contagious, and never arises apart from contagion. It drags a tedious course over many years, and invariably terminates in scarring of the conjunctiva. The malady often entails damage to sight, and is perhaps the commonest cause of trichiasis and entropion. Its cure demands prolonged isolation and systematic treatment. Follicular conjunctivitis, on the other hand, may arise from defective sanitary environment. In the absence of discharge from the eye it is not contagious, while it tends to terminate in speedy and spontaneous cure. It is not associated with pannus or ulcers of the cornea. It never gives rise to serious sequelæ; and, lastly, it soon yields to treatment of a proper kind.

In dealing with follicular disease it is necessary, from a therapeutic standpoint, to distinguish between (a) cases without, and (b) cases with catarrhal symptoms.

The main features of the first, or non-catarrhal, class may be thus briefly sketched out. The palpebral conjunctiva is not appreciably thickened. It is studded with few or many vesiculo-grains, transparent, rounded or oval in shape, often lying in rows, and seldom exceeding 1 mm. in diameter. As a rule, the membrane is pale, but at times it is reddened by the presence of arborescent vessels. While this latter condition is more or less common, especially as regards the lower lid, it is important to note that diffuse congestion

is never present; nor is there any discharge from the eye. It would be impossible to adopt a better name for this non-catarrhal class than that proposed by Adamiuk, viz. :—Folliculosis.

The catarrhal cases are distinguished by secretion, which may be either mucous or muco-purulent. In the slighter forms there is no discharge during the day time, but enquiry will elicit the fact that the lids are glued together, or, in common parlance, “stuck," by dried secretion in the morning when the patient first awakes. In severer forms, dried particles of discharge may be observed in the canthi and about the cilia, or strings of a similiar material may be lying in the culs-de-sac. The palpebral conjunctiva contains vesiculograins, which are generally larger and more numerous, as well as more opaque, than is the case in simple folliculosis. The membrane may be somewhat thickened, and is always injected; that is to say, redness will be present which may be best described as uniform or diffuse in its distribution. A common appearance is that of small white spots upon the tarsal conjunctiva of the upper lid. These are in reality vesiculo-grains, flattened by the pressure to which their position exposes them. The term "follicular conjunctivitis" should, strictly speaking, be reserved exclusively for this catarrhal class.

It is obvious, then, that follicular conjunctivitis is merely folliculosis, plus catarrhal symptoms. Both are more or less chronic conditions, which affect children in preference to adults. The changes are always more marked in the lower than in the upper lids. Treatment may be described under two heads-general and special.

The general treatment both of folliculosis and of follicular catarrh is identical, and may be summed up by saying that the laws of healthy life must be carefully observed. Thus, the patient should dwell amid wholesome surroundings; many cases are speedily cured by the simple change from a damp, unhealthy site to one that is dry and bracing. Particular attention should be paid to ventilation, especially of sleeping apartments; ample floor space should be provided. Close confinement indoors is to be avoided, and outdoor exercise should be insisted upon. The dietary should be on a

liberal scale, and frequent variations are desirable, more particularly when dealing with the inmates of schools, parochial or otherwise. In children it is of importance that sufficient fat be given, if needful under the guise of cocoa or milk, butter or dripping. Schooling or other occupation must be carried on under good conditions of hygiene, while any work under artificial light should be discouraged. Clothing ought to be warm, and flannel next the skin is desirable. If the patient be the subject of any constitutional ailment as scrofula or rachitis-proper treatment must be enforced; and, in general terms, every care should be taken to build up tissue and increase nutrition by the administration of such drugs as codliver oil, iron, and bark. To sum up, the keynotes of a successful general treatment are an abundance of fresh air, ample and varied food, warm clothing, together with judicious occupation and exercise.

At one time and another, I have made a good many experiments in order to ascertain whether the so-called alterative drugs would benefit these follicular conditions. In this way, the mercurial preparations have had a fairly extensive trial, while iodide of potassium has been given in quantity amounting to 150 grains per diem. Arsenic, antimony, sulphur, and the hypophosphites have been also tried. In no case, however, have I had reason to believe that any good has been thereby effected.

The special treatment of the two ailments consists in the skilful and systematic use of various local remedies. That of folliculosis may be dismissed in few words. If vesiculo-grains be not specially numerous, if their size be small, and if their existence cause no discomfort, then no special medication should be adopted. The case, however, should be watched, and steps taken to notify the surgeon if discharge of any kind be observed.

When the palpebral overgrowths are large or numerous, the treatment will be similar to that for the catarrhal form now to be described.

The most useful treatment, in my experience, is by ointments containing lead. The sub-acetate salt is selected, and care must be

taken that it is thoroughly pulverised before compounding the ointment. If this precaution be neglected, coarse particles are liable to adhere to the conjunctiva, thereby giving rise to local ulceration and discomfort. It is surprising to notice the tenacity with which such morsels cling to the mucous membrane, and I have seen them remain attached for as long as six months. To resume, my usual plan is to commence the treatment with a I per cent. ointment, applied twice a day. It should be brought into contact with the conjunctiva of the everted lids by means of a small camel hair brush. After the lids have been allowed to return to their normal position, they should be gently rubbed with the pulp of the forefinger, so as to diffuse the ointment over the mucous membrane. A fortnight later, the strength of the remedy is increased to 2 per cent. If that does not suffice, it may be made still stronger, and occasionally it becomes necessary to employ a 5 per cent. proportion.

Under this treatment the vesiculo-grains become smaller, and now and then disappear completely. Congestion and discharge are at the same time reduced, and the conjunctiva gets into a condition that for all practical purposes may be regarded as healthy.

Another plan that sometimes succeeds equally well is to paint the everted conjunctiva once a day with liquor plumbi subacetatis, which need not be washed away with water. The cautions already given about lead, when speaking of trachoma, must, of course, be borne in mind in this connection (p. 189).

If the catarrhal symptoms preponderate over the structural changes in other words, if much discharge be present-it will be advisable to commence treatment by using, three to six times a day, a tepid solution of corrosive sublimate, 1 to 5,000. This lotion should be applied in the way already described (p. 192). A saturated solution of boracic acid is also useful, or, indeed, any of the lotions mentioned in the section on trachoma. Later, when the discharge. has been lessened, recourse may be had to lead ointment, the influence of which in promoting absorbtion of the growths is sometimes surprising.

Cupric sulphate in ointment form has been recommended by some