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a prophylactic dose of serum. The evidence went to showthat 500 U.S.A. units was an adequate prophylactic dosein ordinary cases, since it is known to be enough toprotect a horse. 1000 units might be safer in a

severe and very foul wound, or one in which a

considerable time had elapsed since its infliction. He con-sidered it right to give serum in a suspicious wound, eventhough two or three weeks had passed since the infliction ofthe injury. As regards the treatment of the declared diseaseProfessor Andrewes expressed himself in favour, on theoreticalgrounds, of amputation or free excision of the wound, wherethis was possible. The route of administration of antitoxinwhich he advocated was the intrathecal one, as being betterthan the subcutaneous or intravenous routes and safer thanthe intracerebral one. Statistics showed clearly that, whenemployed, antitoxin should be given in large doses-15,000 or20,000 U.S.A. units repeated as necessary. As an adjuvantto keeping up a high concentration of antitoxin in the centralnervous system, large doses should also be given sub-cutaneously. More, however, could not be expected fromantitoxin than that it should turn the scale in doubtful cases.In the use of sedatives for the palliation of pain and othersymptoms it must be remembered that death was often dueto respiratory complications, and that such drugs as morphiamight in some circumstances be dangerous.

Dr. JOHN EYRE said that he was quite in accord withwhat Professor Andrewes had said with regard to the valueof finding Gram-positive organisms resembling B. aerogenescapsulatus in the discharge from an infected wound, but hehad met with several cases of tetanus in which they werenot found. Inoculation of a mouse caused tetanus after twoor three days. It was clear, therefore, that a decision as totreatment must depend mainly upon the surgical aspect ofthe case. Badly lacerated, contused, or deeply incisedwounds were those which should be chosen for prophylactictreatment against tetanus. Referring to treatment withcarbolic acid, he pointed out that the spore was not theentity which gave rise to the toxin, but the bacillus,which was very susceptible to the influence of carbolicacid. The site of production of the toxin should,in his opinion, be dealt with as soon as possible.With regard to the prophylactic dose, 500 units i

probably afforded good protection if they could be usedimmediately. The amount required, however, increasedrapidly with delay, and at the end of 24 hours frominfection 20 or 30 times as much was needed. The serumconferred immunity for about a week, and at the end of thattime a second dose was necessary. When tetanus hadbecome established, though on theoretical grounds, it waswell to get rid of the site of manufacture of the toxin, ir.

experimental work infection did not remain localised to thefocus of inoculation. He thought that intracerebral injec-tions, in view of the grave lesions produced, should only beused as a last resort, though they sometimes seemed to turnthe scale. The intrathecal route was the most important andefficient. In his own experience cases treated thus had usuallyrecovered, whilst those only receiving subcutaneous injectionshad usually died. Thecerebro-spinal fluid was often under con-siderable pressure and ran freely away, so that a considerabledose of serum could be given. Intravenous inoculation actedquickly and subcutaneous slowly, but the latter kept up apersistent dosage. He advised that all three methods shouldbe employed simultaneously.

Lieutenant R. B. BLAIR, R.A.M.C., said that he hadtreated 17 cases of tetanus at the Herbert Hospital,Woolwich; 6 had died, 9 recovered, and 2 were stillunder treatment. Ten cases were very acute. The woundswere mostly severe and all very dirty. They were

generally gunshot wounds, not shrapnel. In 4, prophy-lactic doses of serum had been given before they enteredthe hospital ; 3 of these had died, and it would seem thatthe doses they had had were small and not given earlyenough. He thought that unless the patients were seen

within two days 4000 units should be given intra-

spinously. The treatment which he had employed at thehospital for the cases of established tetanus was intrathecalinjection of 4000 units daily. No difficulty had been expe-rienced using a light anaesthesia. The cerebro-spinal fluidwas under very great pressure; it was allowed to run untilit began to drop slowly and then the serum was injected,the volume introduced being less than that which ran away.The hypnotics used were morphia, chloral and bromide

(60 grains of each 2 or 3 times in the 24 hours), andchloretone (40 grains in 2 ounces of olive oil, 2 or 3times daily, per rectum). When the chloretone was re-

tained it relieved the spasms for several hours, but it wasoften rejected. Stimulants might be necessary if exhaustionappeared. It was seldom necessary to amputate the limbduring the attack of tetanus ; in the few cases in whichthis had been done all but one succumbed. The total

quantity of serum given varied greatly, 62,000 units beingthe maximum amount which had been employed.

Dr. CARL H. BROWNING said that one point was clear, thatthe amount of serum required grew enormously with thelapse of time from infection. Consequently, the earliestsymptoms of tetanus must be carefully watched for. The

danger of anaphylaxis might probably be avoided by theprevious injection of dilute solution of antitoxin, and ananti-anaphylaxis thus produced. The blood pressure couldbe used as an indication of the amount of serum to be

injected intrathecally. If there was a fall of blood pressurein an average adult of 40 mm. of Hg the limit of dosage hadbeen reached.

WEST LONDON MEDICO-CHIRURGICALSOCIETY.

The Cure of Squint.A MEETING of this society was held on Dec. 4th, Mr.

ASLETT BALDWIN, the President, being in the chair.Mr. N. BISHOP HARMAN read a paper on the Cure of

Squint. Squint was the loss of the finest function of thehuman eyes-binocular vision. Confining his attention tofixed squints in children, he said that in a school of 1000children no less than 18 were squinters, and that girls werenearly twice as much affected as boys. In 1400 childrenseen at a children clinic on account of poor vision 199were squinters. The incidence in these cases was from 100in the years 4 and 5, to 5 in the fourteenth year. Of these199 cases 166 were fixed convergent squints, 16 alternatingconvergent, 8 divergent, and the rest were associated withdisease of the eyes. After quoting from ancient authors toshow that squint was held to have an evil moral significance,he proceeded to trace the evolution of the binocular vision,and the profound effect it had had on the form of man ; hemaintained that the upright position and ’’ his fair largefront " were directly associated with the evolution of vision.The effect on the brain was similar, for the area of visualcortex was incomparably greater in the hunting animals thanin the hunted, and greatest of all in man. The control of theeyes he likened to that of the driver of a four-in-hand. A gooddriver would master a poor team, but the best team wasdefective without a driver. So the balance of the eyes wasmaintained by the fusion faculty of the brain; if that were

poor then squint would ensue, even though the eyes weregood. Defects of the eyes were adjuvant factors. In not afew cases there was a strongly hereditary tendency tosquint. Treatment could be put into three grades.1. Balancing the vision of the eyes. First there mustbe correction of any error of refraction by retinoscopy, nextexercise of the vision of the squinting eye. 2. The

awakening of the fusion faculty. This had been firstattempted by Erasmus Darwin in 1778, and modern practicewas of the utmost value in ascertaining the power of thebrain to resume control under favourable condition.3. Operation. The rationale of this step lay in the factthat squint of any duration was associated with changesin the tendons, and that these acted as insuperableobstacles to the resumption of brain control. In con-

vergent squint the internus tendon was shortened andthickened, the externus thinned and lengthened. If a truecure was to be effected-i.e., the restoration of binocularvision-then if Stages 1 and 2 of the treatment failed toeffect a speedy cure operation should be done before timehad stereotyped the vicious effects of the squint. If thattime had passed then they were no more than beauty doctorsintent on removing an ugly cast. The advocate of early andregular operation must be prepared to present an operativeprocedure which was both expeditious and reliable. And inthis connexion Mr. Harman showed photographs of the stepsof his combined operation for lengthening the contractedtendon and shortening the stretched tendon. He main-tained that effects could only be secure when both the

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affected tendons were adjusted ; indeed, it was the onlymethod whereby the full mobility of the eye could besecured without subsequent deformity. His operationfor shortening a tendon, "subconjunctival reefing andadvancement," was performed as follows. The tendon wasnot cut or exposed to view. The upper and lower edgeswere cleared by two buttonholes cut through the conjunctivaand capsule. The tendon was freshened oy a rasp. Specialforceps of simple design were then passed into the button-holes to secure the tendon. The movement of the forcepsfolded the tendon. The reef was sewn up or advanced asthe case indicated, and then the antagonist was lengthenedby a graduated partial tenotomy. The steps of the reefingadvancement were as follows: (1) The eye was securedwith an anchor stitch placed at the limbus in the axis ofthe tendon to be shortened ; (2) the position of the tendonwas noted-it was pointed out that there were well-definedsurface markings and colour differences ; (3) the button-holes were cut above and below the tendon close to thecanthus; (4) the tendon was lifted and both surfaces raspedwith the instrument provided ; (5) reefing forceps wereapplied, adjusted to the extent of the shortening required,and rotated ; (6) the reef was sewn up by a double over-and-over stitch ; and (7) the reef was advanced by fixing thestitches into the limbus. Then the antagonist was length-

ened by the "jigsaw" operation. The tendon was exposed,secured in " director-forceps " which checked bleeding andgave a guide to the incisions. Three cuts were made-athwart,the tendon, the middle extending two-thirds from one edge,and the lateral each one-half across from the other edge. Thetendon thereon extended lengthwise without loosing its attach-ments or alignment. Mr. Harman showed how the cuts couldbe varied to secure vertical deviation also. Results: Of thefirst 100 serial cases, including the early experimental opera-tions, the results obtained after the average interval of ninemonths were : Binocular vision, 4 ; straight, 36 ; error less’than 3°, 22 ; less than 5°, 23 (these make 85 per cent.successes) ; error 10° (since corrected), 9 ; over that, 4 ;relapsed six months after operation during severe keratitis,1 ; and over-correction found six months after operation, 1.He had now almost completed the second hundred cases, andthe percentages of successes were still higher. One of theadvantages of this combined operation was the power fornice regulation of effects. This was of the utmost import-ance when operation had to be done early to save thebinocular vision, for at an early age a general anaestheticwas commonly needed, and the operator was entirelydependent on his own judgment and technique.

ROYAL ACADEMY OF MEDICINE INIRELAND.

SECTION OF SURGERY.

Treatment of Perforating Gastric and IJzbodenal Ulcers.-Exhibition of Cases.-Intestinal Stasis.

A MEETING of this section was held on Nov. 13th,Dr. F. CONWAY DwYER, the President, being in the chair.The PRESIDENT read an address on the Treatment of Per-

forating Gastric and Duodenal Ulcers. For many years hehad given up lavage, which he believed to be extremelyharmful and responsible for many untoward results. Heremoved the septic fluid with large swabs and relied on

pelvic drains for getting rid of any fluid left behind.

Formerly he was of opinion that gastro-enterostomy shouldbe done if the patient’s condition permitted it, but in the12 cases he described he had performed it only in one

instance, and then only because the perforation was so largeand the edges so friable that when the rent was sewn up hefeared the lumen of the bowel was too much narrowed.

Eight of the 12 cases made a complete recovery, three didnot survive operation more than a few days, and one died afortnight after operation from pneumonia.

Mr. H. STORES showed a case of Regeneration of RupturedSciatic Nerve. The case was one of arthritis of the hip-joint accompanied by intense pain. Operation was per-formed for excision of the hip-joint, in the course of whichthe sciatic nerve was accidentally ruptured. The injury tothe nerve was not discovered for two or three weeks. Twoand a half years had elapsed since the operation, and the

patient was shown to demonstrate the amount of regenera-tion that had taken place. The suturing of the nerve wasdone about three weeks after the excision. The small loss ofsensation now present in the case was remarkable.-ThePRESIDENT considered the absence of wasting in the limbastonishing.

Mr. W. C. STEVENSON showed cases treated by RadiumEmanation Needles. From the first patient a malignantpolypus was removed by Mr. Graham in May last. It

subsequently grew again, and the whole of the anterior wallof the antrum had to be removed, but again the tumourbegan to grow. The patient came under Mr. Stevenson’scare in the end of June with a large gland on one side and asmaller one on the other, accompanied by considerable

proptosis. He inserted six needles into the gland, andtwo or three days afterwards six more needles were put in,and left in for 24 hours. After six weeks the tumour gotsmaller and redder. When the needles had been insertedfour times the tumour showed considerable diminution. Arecurrence of the swelling having taken place six weeksafter the first application further needles were applied,and the patient showed the effects of the radiation. He hadput on a considerable amount of weight. Although he hadto take hypnotics regularly before, since the radiationwas started he was able to get on without them.Another patient shown had been pronounced by ProfessorMcWeeney to be suffering from epithelioma of the palate.The condition seemed to be much improved, and the ulcernow seen was only about half its original size. -ThePRESIDENT said that he had no experience of the applicationof radium except what he had gained from a short visit tothe Middlesex Hospital, where Sir Alfred Pearce Gould hadunder treatment a large number of cases. In some of themwhat would seem to have been an almost miraculous curewas brought about. Sir A. Pearce Gould informed him, how-ever, that some of the cases disimproved with extreme

rapidity after radium, and that it was wholly impossible tosay whether in any particular case a cure would be broughtabout or whether the patient would be made worse.

Mr. A. J. M. BLAYNEY read a paper on Intestinal Stasis,but the discussion on it was postponed to the next meetingof the section.

aeSCULAPIAN SOCIETY.-A meeting of thissociety was held at the Metropolitan Hospital on Dec. 4th,Dr. David Ross, a past President, being in the chair.--Dr.Anthony Feiling read a paper on Acute Paraplegia, of whichthe following is an abstract. The question of prognosismust always be important in acute paraplegia, or paralysis ofthe lower limbs of rapid onset. Accurate diagnosis is essentialbefore any prognosis could be given. Hence a knowledge ofthe various pathological processes which may cause thiscondition is necessary. These are chiefly three: (1) polio-myelitis ; (2)acute myelitis ; (3) acute peripheral neuritis ortoxic polyneuritis. Poliomyelitis is, of course, identical withinfantile paralysis, and is an acute inflammatory disease of thecentral nervous system; the spinal cord, however, suffered mostfrequently and most severely. The majority of cases of acutemyelitis are in reality syphilitic in origin, the pathologicalprocess being a double one, a gummatous meningitis and asoftening of the cord following thrombosis of the vesselsfrom endarteritis. The introduction of the Wassermannreaction and the characteristic changes in the cerebro-spinalfluid have confirmed the opinion previously held as to thesyphilitic origin of the majority of these cases. The

pathology of toxic polyneuritis is less certainly under-

stood ; alcohol is very often the etiological factor. Theclinical features of these three conditions are oftencharacteristic. The patient’s age is an important pointof distinction. In poliomyelitis the characteristicfeatures are a day or two of constitutional disturb-ance, followed by the abrupt onset of paralysis ; painwas often a marked feature ; objective sensory loss was veryrare, and the sphincters were not affected; hypotonia was aprominent feature of the paralysis. The residual paralysisis always less extensive than that present at the beginningof the disease. The patient with acute syphilitic myelitis isgenerally older. After a few days, in which prodromalsymptoms, such as tingling and numbness, may be felt, theparalysis sets in rapidly, and in the course of a few days isusually complete. At first flaccid, it later becomes spasticwith exaggeration of the deep reflexes and extensor