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by the mouth, by atoxyl, and others by antimonyinjections. Native cases of chronic infection showedthe necessity for care in claiming cures. No untreatedcase among Europeans had recovered, althoughnatives might survive for a considerable time. Hehesitated to express an opinion in the presence of thepatient attending the meeting, but candidly he didnot regard his cure as certain and beyond doubt.He believed that it was premature to regard Dr.Marshall’s method of treatment by one injection ofserum as a so-called cure. The macroscopical evidenceof infection of the central nervous system providedby pachymeningitis was not to be considered as thesole proof of cerebral invasion by the trypanosome,for it was by no means uncommon to find suchevidence only after microscopical examination ofthe meninges. He found it difficult to understandtrypanolytic action of the serum suggested by Dr.Marshall, and why the serum injected intravenouslyfailed, but when given intrathecally succeeded in

killing the trypanosomes in the cerebro-spinal fluid.Lieut.-Colonel R. H. ELLIOT pleaded for full

opportunity to be given to the trial of Dr. Marshall’snew line of treatment, and suggested a movementappealing to the Colonial Office to take up thematter with a view to thorough investigation.

Sir HUGH CLIFFORD, Governor of the UnitedProvinces of Nigeria, in the course of his remarks,drew attention to the huge area covered by Nigeria,535,000 square miles in extent, occupied by 17million inhabitants, with only one political officerfor every 64,000 population. He described the import-ance to be attached to the provision of a soundmethod of treatment as inestimable in dealing withsleeping sickness, a disease so crippling to the com-mercial prosperity of our African colonies. He drewa vivid picture of the insect-ridden condition whichfrom time immemorial had dominated and mouldedthe character of inhabitants of the tropics, and soseriously influenced trade and productivity intropical Africa. The tropical side of medicine wasone which called for careful study by all thosecoming to live in the tropics, and should be en-

couraged in every possible way. Colonel Elliot’sappeal touched him very intimately, and he wouldpersonally urge the Colonial Secretary to provideopportunity for Dr. Marshall’s important discoveryto be thoroughly tried and investigated.

Dr. E. T. JENSEN referred to the financial assist-ance alluded to by Colonel Elliot as a substantialsum likely to be forthcoming to advance the meansof treatment set on foot by Dr. Marshall’s valuablework. He brought forward as a formal motion thatevery facility should be given to Dr. Marshall’s workbeing carried further with a view to its beingthoroughly tested in the treatment of sleeping sick-ness, and that representation to that effect shouldbe submitted to the Colonial Office by the societv.-This proposal was seconded by Lieut.-ColonelELLIOT, and when put to the meeting was unani-mously carried.

Dr. W. T. PROUT hoped the new line of treatmentwould meet with every encouragement and trial.He laid stress on the point that Dr. Marshall] hadmade no claim of a complete and final cure in thecase of the patient present at the meeting, whocertainly looked in the best of health. His resultsso far had been most promising, and he would availhimself of an early opportunity of representing thesubject to the Colonial Office.

Dr. C. F. HARFORD avoided the technical aspectof the question of treatment, for it was 31 yearssince he had been in touch with sleeping sick-ness. He suggested that a difference existed betweenthe cases treated in the country of origin and thosetreated here, which might account for points appa-rently at variance. In infected countries the greateropportunities, which were offered than in this country,of obtaining light on the problems of the diseasemight be one cause of difference in the results ofobservation. He much hoped the Colonial Officewould take up the matter, which on account of its

great practical interest and importance should beprobed to the bottom.

Dr. MAHSHAMj in his reply expressed his gratitudeto the society for the reception given to his paper,particularly to Prof. Halliburton for his account ofthe choroid plexus, and to his Excellency Sir HughClifford for his very kind remarks. Dr. Manson-Bahr and Dr. Low had made comparison betweenthe uncertainty’of treatment in sleeping sickness andthat of malaria and syphilis. Because in some casesquinine and salvarsan respectively had no effect oneither of the two latter diseases, was no reason whythey should not be tried in ordinary routine cases ;the same argument surely applied to trypanosomiasisand its remedy. The European had a higher re-

sistance to trypanosome infection than the native.If cases in natives had gone on for two years withouttreatment and remained well, it was a sign they hadimproved even if they had not been cured.A cordial vote of thanks to Dr. Marshall for his

paper was unanimously carried.

OPHTHALMOLOGICAL SOCIETY OF THEUNITED KINGDOM.

THE ANNUAL CONGRESS.(Concluded from p. 1136.)

Mr. E. TREACHER COLMNS delivered the BowmanLecture, taking as his subject Changes in the VisualOrgans. Correlated with the Adoption of ArborealLife and the Assumption of the Erect Posture.

Treatment of Manifest Corzconaitant Strabismus.A discussion on this subject was held on Friday

morning. It was opened by Mr. CLAUDE WORTH.He said the matters to be considered in the treatmentof convergent squint were : (1) prevention or cure ofamblyopia exanopsia ; (2) correction of refractiveerror ; (3) fusion training ; (4) operation. If a con-stant unilateral squint had lasted a considerableproportion of the child’s life, in the absence ofefficient treatment, the deviating eye would be foundto be more or less blind ; and it was the prevalentview that the amblyopia was usually the result ofdisuse. The younger the child the more rapid wasthe loss of sight ; one who began to squint cQnstantlyat one year of age might lose central fixation in threeto four months. The child must be forced to use thedeviating eye ; this was far more important than allthe rest of the treatment of squint. In a case ofrecent squint, in order to prevent amblyopia or tocure low degrees of it, the fixing eye should be keptunder atropine until it became the deviating eye.The child should then be seen again after the effectof the atropine had passed off. After this the devia-tion must be kept alternating, one or other eye beingatropised occasionally, if necessary. If centralfixation in the deviating eye was absent or unsteady,the atropine treatment was not sufficient : then thefixing eye should be continuously occluded. Withregard to the correction of refractive error, he saidno child was too young to wear glasses if they wererequired. In regard to fusion training, certain prin-ciples must apply to all methods. The child must beyoung, preferably under 6 years of age, and the sightof the deviating eye must be good. The mostdifficult step was to overcome the suppression.Most surgeons were now agreed that the essential causeof squint was a defect of the fusion sense. The objectof fusion training was. not to correct deviation-except in small degrees-but to enable the patientto see binocularly when the visual axes shall havebeen restored to approximately their normal relativedirections. Discussing the question of operation,he said that if measurements showed that the angleof deviation was not decreasing, operation becamenecessary. If there was no hope of binocular vision,it was not his custom to operate until the seventh oreighth year. He frequently, at an earlier date in hiscareer, performed tenotomy of the internal rectus in

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combination with advancement of the external inhigh degrees of convergent squint ; but he abandonedthe practice in 1905, and had since relied on advance-ment alone. Except in very small deviations, bothexterni were advanced. There were, he said,practically unavoidable failures in squint operations ;the result attained was a measure of the skill andexperience of the surgeon.Mr. A. J. BALLANTYNE dealt with the subject of

concomitant convergent squint, based upon his ownexperience. The first step should be an estimationof the refraction, and the prescription of suitableglasses to be worn constantly. In many cases thewearing of these, with training if necessary, sufficed.With one exception, his cases were aged 7 years orunder. The largest degree of squint corrected was40°, in a patient 18 months old, whose squint hadlasted two weeks. In most of his cases the angle was15° or less. In a number the eye was alreadyamblyopic. In most cases, he thought, the amblyopiawas the result of the squint, hence there was all themore encouragement to attempt to restore vision inthe squinting eye. He applied atropine more or lesscontinuously to the sound eye. He was now inclinedto operate at an earlier age than formerly. Advance-ment alone in many cases would bring about an Iapproximately straight position of the eyes ; he had Inever seen over-correction caused by advancementor muscle-folding, hence he would not hesitate tooperate at any age. He preferred muscle-folding inthe youngest children. He rarely did tenotomy of theinternal rectus, and never as the sole means ofcorrecting the squint. In children it was wise to dotoo little, rather than too much ; and if tenotomywas performed, it should be as a last resort. Casesin young children often suggested the existence of astate of excitability and instability of the accommoda-tion and convergence centres, and in these cases theoperative treatment of the strabismus was apt to bevery disappointing. Failure in these cases was notdue to slipping of the stitches, but to looking for aremedy of a mechanical kind for what was really afunctional error. His results from training offusion had been disappointing. We were, apparently,born with a certain racially-acquired degree ofbinocular equilibrium, but the finer coordination ofthe eyes necessary for binocular vision required to belearned, like the act of walking, by each individual,and the most useful line of inquiry would be alongthe evolution of binocular vision in the youngchild.Mr. E. E. MADDOX referred to the numerous cases

of squint in which the child was unable to fix itsattention. Attention had a great effect, especiallyon the fusion faculty, and the defect in many childrenwas. not the absence of the fusion faculty, but thelack of a stimulus to action. To correct hyper-metropia, some occupation on near objects should beprovided. Squinting children should be kept fromreading early, and their parents should let them uselarge objects. Moreover, they should be encouragedto look upwards, as that produced a lessened tendencyto convergence. He considered that the amblyoscopewas very valuable in diagnosis.

Mr. T. HABRISON BUTLER said he could recall onlyone case in which he had had success with the fusiontest ; and in that, the case of a boy, he relapsed in ayear. Fusion training must only be done in childrenunder 6 years of age, but these were very difficult toeducate in such a scientific procedure. He had notmet with a patient who came and said he wantedbinocular vision. Most operations for squint. wereasked for on cosmetic grounds. Eight he regarded asthe most suitable age for operation, and he did notoperate when the squint was no more than 25°.Mr. M. S. MAYOU said that if a patient had good

vision in both eyes and some attempt at fusion, heoperated as early as possible, provided the patienthad worn glasses a year without improvement. Inconvergent strabismus up to 15° he did tenotomy ofthe internal rectus ; but in young children 20° couldoften be corrected by it. When the degree of con-

vergent squint was from 15° to 45° he did an advance-ment-i.e., tenectomy associated with tenotomy.He preferred a shortening of the tendon and usingthe stump of the muscle attached to the globe forholding the sutures.

Mr. N. BiSHOP HARMAN said the determiningfactors in squint could be grouped under three heads (1) defects of the eyes, (2) defects of the muscles ;(3) toxic influences. Among 368 infants in a higher-grade school, only 8 had emmetropic eyes. Theothers had errors of refraction, mainly hypermetropia,and in 126 the errors were considerable. Toxiccauses did not claim a high place. The chief causewas defective muscle-balance, but it was not suf-ficiently recognised, and had not its due place inschemes of treatment. He referred to the recentestablishment, in the Belgrave Hospital, of an

operative clinic for squint. The method employedthere was shortening of one muscle by sub-con-junctival reefing, with lengthening of the antagonistby tenoplasty.

Mr. A. L. WHITEHEAD (Leeds) said his experiencewas that squint was much more prevalent in hospitalthan in private practice. He attached great impor-tance to the full correction of the squinting eye, eventhough it were amblyopic and the results on thesquint had been marked. The treatment should becarried on during from six to 12 months. It must notbe forgotten that many cases showed a tendency tospontaneous cure. He liked tenectomy with teno-tomy when operating, as Mr. Mayou did. He hadnever over-corrected when doing this.

Mr. BROOKSBANK JAMES did not regard theamblyoscope as of much use in the matter of training,but it was useful for detecting the presence or absenceof the fusion faculty. He did not think squints.could be wholly corrected by the reefing operation.He corrected refraction in children of the youngestage, but no adequate training could be done in achild under 4 or 5 years old. In operating, hepreferred to do a central tenotomy, then wait.afterwards doing an advancement. He never didboth at the same time.

Mr. INMAN thought none of the suggested explana-tions as to the cause of squint were adequate. Oftenthe owner of the squinting eye had deliberately takenon a squint. A child worked its fusion centre, andthen, at 3 or 4 years of age, a squint occurred. Ithad no reference to near work ; and at 6 or 7 years ofage it had become well developed, and its possessorwas an object of sympathy. He said he had foundthat an amazing proportion of squinters were left-handed persons, yet among the general populationthe left-handed persons were from 2 to 4 per cent.Some members of neurotic families were left-handed,some had a stammer, some had a squint. A childpractically never developed a divergent squint, thereason being that the convergent squint was theeasier. He suggested the close watching of cases

by members, and the subsequent comparison of

experiences.Mr. R. R. CRUISE showed a new form of amblyo-

scope which he had designed, in which ordinarystereoscopic pictures could be used. Those who usedit could fuse at their angle and enlarge the amplitudeof their fusion. In regard to operation, for manyyears he had not hesitated to tenotomise. The bogyof divergence, he considered, was greatly exaggerated,especially if one did an advancement first, thentenotomised, dissecting up the conjunctiva to thecaruncle. He described the method in detail.

Mr. E. H. STACK, discussing the operations forsquint, said he seldom did tenotomy of the externalrectus. He advocated a routine examination of theeyes of children before 4 years of age. Proper prismsor spectacles in these early years would probably dovery much to save those which could be corrected.Mr. ’Y ORTH and Mr. BALLANTYNE replied.

Clinical Meeting.On Friday afternoon members attended a demon-

stration of clinical cases and apparatus at St.

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Thomas’s Hospital. In the evening, at No. 1,Wimpole-street, further papers were read and dis-cussed.

The Iris-Prolapse Operation for Glaucoma.Lieutenant-Colonel H. HERBERT read a communi-

cation entitled, " A Justification of the Wide Iris-prolapse Operation for Glaucoma." He said thevalue of the treatment must be determined mainlyby the two vital questions : the completeness andpermanency of the relief of tension provided, and thesafety in the matter of late infection. In a few ofthe severer chronic glaucomas full relief fromabnormal tension was obtained by this method muchless quickly and less easily than by some otheriris-inclusion operations. But it was in the per-manency of relief of tension that iris-inclusionoperations in general stood out pre-eminently. This<could not be said of many iris-free leaking cicatrices.In the last two years he had come across 13 instances

- of a late return of tension after iris-free operations.With regard to safety in the matter of late infection,:subconjunctival prolapses could be divided intofour grades, and these he described. The object ofthe paper was to remove some of the prejudice with I,which the operation was viewed.-Several members discussed the paper.

The Rational Treatrraent of Glaucoma.Mr. T. HARRISON BUTLER read a paper on this

subject. He said there was still considerabledifference of opinion as to the significance of thechanges discovered in the glaucomatous eye. Exa-mination of the fields of vision both as to the peripheryand the centre was of extreme importance. Henow rarely operated upon patients for glaucoma inthe acute stage ; under suitable treatment most casesquieted down, and then the operation was muchsafer. His practice now was to do the so-called"trap-door iridectomy"&mdash;i.e., trephining with a

1.5 mm. instrument and leaving the disc with ahinge. He proceeded to discuss the non-operativetreatment of glaucoma, remarking that his ownexperience overwhelmingly favoured early operation- -i.e., as soon as loss of function was realised.

Mr. C. GouLmFrT read a paper by himself andMr. M. H. WHITING on Implantation Cyst of theSclera following an Operation for Squint, in whichthey discussed the general subject and gave clinicaland pathological particulars of cases.

Sir WILLIAM LISTER read papers on (1) SomeIntra-ocular Epithelial Cysts ; (2) Punctate Depositsin the Retina.On Saturday morning there were further papers.

Mr. P. G. DOYNE read one on observations with thescotometer, Sir ARNOLD LnwsorT on a case of orbitaltumour, which turned out to be a neuroma of thenasal branch of the fifth nerve ; MR. HAROLD GplMS-DALE on the Mechanism of the Stability of the Eye.

Extract of Cataract by S’uction.Mr. A. W. ORMOND communicated a note on a

Method of Extracting the Crystalline Lens in its

Capsule by " Suction." The method was introduced

to obviate the movement of the lens when incisingthe anterior surface of the lens with a sharp hook.He showed and demonstrated the apparatus used,which was on the same principle as the Bunsen-Sprengel pump.

Dr. GEORGE MACKAY (Edinburgh) sent a communi-cation explaining a mechanical contrivance for

trephining, and Mr. Traquair demonstrated it. Itis actuated by clockwork, and can be employedin using Newton’s colour top as devised by Mr.Percival.During the Congress an extensive optical exhibit,

by various well-known firms, was held in the building,and the optophone was demonstrated.The members dined together on Thursday evening,

and the attendance at all the sittings was wellmaintained.

Reviews and Notices of Books.BLOCK ANESTHESIA AND ALLIED SUBJECTS.

With Special Chapters on the Maxillary Sinus,the Tonsils, and Neuralgias of the Nervus Tri-geminus. By ARTHUR E. SMITH. D.D.S., M.D.London : Henry Kimpton. 1921. Pp. 895. 90s.

THIS large volume is intended for oral surgeons,dentists, laryngologists, rhinologists, otologists, andstudents, but it is to practitioners and studentsof dentistry that it will make its chief appeal as atext-book. The book opens with a history of

general and local anaesthesia and closes with a

consideration of post-operative complications andtheir treatment. The chapters of most importanceare those which describe in detail the technique oflocal anaesthesia of the branches of the fifth cranialnerve ; the methods of nerve-blocking each branchare discussed systematically and very fully undersuch headings as Topography of Anatomy, NeedleEmployed, Technic of Injecting Structures An&aelig;sthe-tised, &c.. with the object of enabling the practitionerto find at once full details of the particular part onwhich he is working. The numerous illustrationsof these sections are for the most part of considerablepractical value, and a great deal of labour has beenexpended on their preparation. There is a detailedand accurate account of the anatomy of the nervesof the face, mouth, and neighbouring regions.with excellent photographs of dissections anddiagrams which show every branch from severalaspects.The rest of the book gives a rather lengthy description

of a number of matters which are nearly or remotelyrelated to block anaesthesia, including such subjectsas a classification of the nervous system, intravenous,intra-arterial, and spinal methods of anaesthesia,and the chemistry of local anaesthetic drugs. Dr.Smith’s attempt to leave nothing unsaid is shown bythe devotion of some 70 pages to a description ofthe various drugs that have been used for localanaesthesia, and by the complicated armamentariumof syringes and other instruments that are describedand illustrated. The wisdom of giving so muchspace to allied subjects is open to question, and itmay be thought that such detailed accounts as thatof the surgery of the maxillary sinus are rather out ofplace ; on the other hand, the treatment of trigeminalneuralgia seems well within the province of the book.and the technique of alcoholic injection has receiveda full description which should prove of real value tosurgeons and neurologists. There are photographsand diagrams excellently reproduced ; those whichillustrate the anatomy and technique of block anees-thesia are of definite value, but the numerous picturesof simple instruments might well have been omitted.The statement in the " Foreword " that this is not

a book for the timid or for cowards is vary true, forthe mass of detail makes it rather difficult to read.It is the repetitions, illustrations, and minutedescriptions of matters, some of which have littlebearing on the main theme, that have made thevolume bulky and expensive, and to some extentmust counteract the real value of its more practicalportions ; the latter, however, should prove ofgreat use to the oral surgeon, and the book is likelyto be employed as a work of reference by thoseinterested in the many branches of surgery on whichit touches.

NIANUEL DE COPROLOGIE CLINIQUE.By R. GOIFFON. With a preface by Dr. J. CH.Roux. Paris : Masson et Cie. 1921. With 36figures and 2 coloured plates. Pp. 232. Fr.12.EXAMINATION of the faeces is probably more

neglected than any other aid to exact diagnosis,partly no doubt owing to the fact that the informationto be gained from a systematic analysis is not yetfully appreciated. Nothnagel, some 30 years ago,