writers. It is used in strengths that range from per cent. to 3 per cent., applied twice or thrice in the twenty-four hours. For my own part, I have obtained no striking success from the method, which has often set up a considerable amount of irritation. It appears to me, therefore, inferior to the lead treatment.

The application of strong remedies in these cases is often attended with risk. In particular instances, it is true, they agree well, but I am bound to confess that I have never been able to discover any definite indication as to their use. There can be no doubt, however, that at times they are quite capable of giving rise to increased redness and thickening of the conjunctiva, in short, to a species of spurious trachoma. Bluestone, therefore, should be reserved for cases which refuse to yield to simpler plans. If its use be decided on, the escharotic should be lightly applied (as a general rule, not oftener than thrice a week), and whenever a decided impression has been made upon the vesiculo-grains, a milder remedy should be

substituted.

There is a special use of silver nitrate, however, that deserves a passing mention. I refer to the daily application of a per cent. solution, painted on the conjunctiva in the usual way. The action of the liquid should, as far as possible, be limited to the actual overgrowths, and it is generally advisable to soak up any surplus by means of absorbent wool. I have not infrequently seen obstinate cases yield to this method. But, for my own part, I avoid the stronger solutions, because they often seem to do more harm than good.

The operation of "expression" may be also employed, but only when the growths are of comparatively large size, and cannot be got rid of by lead ointment, or by the application of the antiseptic or astringent lotions already named. It is in these cases a simple matter to seize and crush each individual follicle with dissecting forceps, and if the growths be present in the upper retro-tarsal fold, the roller forceps may be lightly applied in a manner described when speaking of the surgical treatment of trachoma. Beyond this, nothing need be done in the majority of cases.

Another plan that may be adopted is to touch each individual follicle with the galvano-cautery, but the method should be reserved for cases where the growths are specially large and luxuriant. A few drops of a 2 per cent. cocaine solution are first applied, the lids everted, and their mucous membrane carefully dried by a morsel of absorbent wool. Next, the point of the glowing wire is brought into contact for two or three seconds with the most prominent growths, and made to penetrate into their substance. Anything like general cauterisation must be avoided. Two to five vesiculo-grains may be destroyed at each sitting, but the cautery should not be applied a second time until the irritation of the first operation has passed away, a process that generally occupies about a week. The procedure is practically painless, and no special instruments are needed beyond the galvano-cautery (Fig. 16). On an emergency, even that may be

b

FIG. 16.-A convenient form of galvano-cautery for destroying vesiculo-grains. It consists of a Schech's simple handle, a press button or key (a), wires (b, b) to connect to battery, and a platinum cautery burner of knife shape (c).

dispensed with, and a white-hot knitting needle used in its stead. It is worth while pointing out that any prolonged exposure of the conjunctiva makes the operation difficult, because the quickly resulting hyperæmia may obscure even large vesiculo-grains. In my own work, a thin layer of boric acid is sprinkled over the conjunctiva after the cauterisation, and the application is repeated daily until the inflammation has subsided.

One can hardly repeat too often, however, that these follicular conditions of the conjunctiva are of an innocent nature, and entail no serious consequences. It is only when they occur in marked form that they demand anything like active treatment.

Before leaving this subject, one further fact should be mentioned, viz., that an eruption of follicles now and then follows the application

of certain drugs to the eye, as for example, atropine, physostigmine, and cocaine. This occurs under two conditions. In the firstusually after the agents have been used for some days or weeks— an acute ophthalmia, resembling the muco-purulent form, sets in suddenly. On everting the lids, the palpebral conjunctiva is found to be strewn with closely set, non-transparent follicles, which vary in size and number in different cases. This form is not rare amongst children. In the second type-which may follow a single local application-the skin of the lids becomes dry, red, and sometimes looks almost erysipelatous. At the same time, an eruption of transparent follicles is observed, especially in the lower retro-tarsal fold. As a general rule, however, the ordinary symptoms of conjunctivitis are wanting. This second form, so far as I know, is confined to adults.

Without attempting to discuss the causes of the foregoing conditions, it may be pointed out that the chief reasons assigned for them are:-First, personal idiosyncracy; second, an impurity of the drug, either chemical or septic; third, infection from a diseased eye, the materies morbi being passed by a common use of the pipette, or in some similar way; fourth, paralysis of the vaso-motor nerves and consequent dilatation of the blood vessels of the conjunctiva (Glorieux 242).

The toxic inflammation is to be met by withdrawing the irritating agent at once, and by the application of a metallic astringent. The preparations of lead possess a special value in these conditions, and often succeed best in the form of hot compresses of the liquor plumbi subacetatis dilutus.

APPENDIX.

LAVATORY ARRANGEMENTS.

In an earlier part of this volume ophthalmia was shown to be often spread by imperfect washing arrangements, and an opinion was expressed that special precautions should be adopted in order to meet the danger. In the present appendix a short account will be given of the contrivances-mechanical and otherwise-which have been found useful for that purpose.

It will simplify matters if the subject be discussed under two heads first, washing and bathing; secondly, the management of accessories, such as towels, sponges, flannels, and soap.

WASHING AND BATHING.

It should be an absolute rule in every boarding school (or other institution where children have to wash their faces) for each scholar to have a washing utensil of his own, to be retained for his exclusive use. The bowls-which may be of earthenware or enamelled ironshould be marked or numbered in such a way as to be readily distinguished, and the scholars should be drilled into using them properly. In the case of small, good class schools, where expenditure is not limited, there would be no objection to fixed lavatory basins— "plug" or "tip-up”—as long as a sufficient number were provided to allow of each child having his own.

The provision of a separate bowl or basin, however, is in many instances impracticable, under which circumstances washing may be carried out at a stream of running water. The simplest way is to