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into a town diphtheria may become epidemic, and be dis-seminated by precisely the same channels as typhoidfever ; that the infection may be conveyed into any houseby sewer gas, or otherwise, altogether irrespective ofdampness of structure, but that its endemic breeding-grounds are to be found in certain well-defined spots inrural districts, where it is constantly liable to break out asif de novo, and that the constant condition of these localitiesis structural dampness of habitation.

ON THE

SELECTION OF THE MOST APPROPRIATETIME FOR OPERATING IN CASES OF

CONVERGENT STRABISMUS INCHILDREN.

BY JAMES E. ADAMS, F.R.C.S.,SURGEON TO THE LONDON HOSPITAL ; ASSISTANT-SURGEON, ROYAL

LONDON OPHTHALMIC HOSPITAL, MOORFIELDS.

THERE can, I think, be little doubt that when childrenbegin to squint, the question as to when they shall be sub-mitted to operation, and how they should be managed pre-viously to it, has often to be put to persons in practice whoare not specialists, and, judging from my own experience,does not always receive the consideration which it merits.Much uncertainty seems to me to prevail in the professiongenerally on this subject, and the text books do not put thematter very clearly. All of them explain the theory andthe method of the operation well enough, but they afford noinformation as to when it becomes essential to do the opera-tion, and when it may be done most advantageously to thepatient.The importance of this subject does not rest on the ques-

tion of appearance, but on the maintenance of a normalstandard of visual acuity in both eyes; and it is mostgrievous to have to operate on so many cases as we do inwhich the acuteness of vision of the squinting eye hasgreatly fallen off. One cannot too strongly insist that thesquinting eye is disused, and must, unless the squint isalternating or proper precautions be taken, become ambly-opic. It must be understood that I am speaking only of theconcomitant convergent strabismus of hypermetrupic child-ren. Now the cure of this condition does not consist inremoving the deformity so as to be no longer visible ; butour object is to restore binocular vision for all distances, andwe can make no certainty of doing this unless the two eyeshave at least nearly an equal acuteness of vision. When ithappens that we have to deal with a case of alternating stra-bismus (in which the two eyes with equal use remain equallygood), we may predict with certainty that, after correctingthe hypermetropia with glasses, the-squint will diminish, andthat a subsequent tenotomy will produce a complete result.But when one eye is amblyopic the case is quite different;the deformity may be removed, but the result is at best imper-fect and uncertain, because, as is well known, the perfectingof the operation depends on the fusion of double images byinstinctive co-ordination on the part of the patient.The answer to the question as to 1J)hen the operation

should be performed should, in my opinion, be as follows :-It should be postponed until the child is old enough to wearglasses, provacled that the acuteness of the deviating eye canbe maintained by regular daily exercise at reading &c., thesound eye being completely excltcclecl for half the day. Inpractice it will be found that this rule is not applicable tochildren of all ages, but applies well to those between fourand seven, provided that those in charge of them carry outthe instructions to the letter. When the young hyper-metropes do not commence to squint till they are seven oreight years old, it generally happens that their educationhas so far advanced that we can judge of their acuteness ofvision, and thev are usually brought to us before this hasdeteriorated. They can be trusted with glasses, which, eitherwith or without tenotomy, suffice to effect a cure. Thesepatients should therefore be thoroughly atropised, the errorsof refraction corrected, and proper glasses given to them forsome weeks before the operation is decided upon. Butwith children younger than this-say from three to sevenyears old-the wearing of glasses is attended with many

obvious drawbacks, and it is for children about this agethat I especially advocate the education of the deviatingeye as above suggested.

It is, hoowever, surprising how difficult it is to make thosein charge of the child understand the importance and theobject of this plan, even in the case of people in good posi-tion, and it seems as though it were impossible to eradicatethe idea that this method is intended to cure the squint.Last year I had a case of a boy at four, who had squintedfor about six months, and who had V. 18 in R., and -H inL., Hm. and for whom I adopted the above plan. Atthe expiration of ten ,months he was brought to me again,with the statement "that he is no better," and I foundupon inquiry that the exclusion of the non-squinting eye hadbeen very imperfectly carried out, the result being that thevision of the squinting eye had come down to -is.Notwithstanding this example of the difficulties of the

plan, I still maintain that this is the best method of dealingwith these cases. Unfortunately it happens frequently thatchildren begin to squint earlier even than this, often withinthe first twelve months, and here we cannot expect thistreatment to-be- carried out. It therefore becomes necessaryhere to operate as -soon as the squint has become confirmed,unless it happen to be an alternating squint, and even thenit must be proved that ORe eye is used as much s the other.We must operate with the hypermetropia uncorrected andthe vision undetermined, rather than leave the one eye to acertainty of deterioration.In my suggestions as to the ages at which the plan above

proposed is to be adopted of course I do not wish to beunderstood literally, but discretion is to be used accordingto the character of the particular child in question.Finsbury-circus.

ERGOT IN THE TREATMENT OF ANGIO-PARALYTIC MEGRIM.

BY DR. SCHUMACHER.

OF the numerous theories proposed to explain the peculiarsymptoms of megrim, that which attributes this to an affec-tion of the cervical sympathetic appears to be the most

plausible. Du Bois-Reymond and Brunner, themselvessubject to the disease, assume as its immediate cause atetanic contraction of the cerebral vessels due to an irritationof the vaso-motor nerves, whereas Mollendorf holds that it

proceeds from dilatation of the vessels in consequence of aparalysis of those nerves. Both views seem correct, andthere is every reason to believe in the existence of two formsof megrim, an angio-tetanic and an angio-paralytic.

It follows, therefore, that the treatment of megrim mustvary according to the nature of each case. For while theangio-tetanic form of the disease would be relieved bynitrite of amyl, the angio-paralytic can be benefited onlyby such remedies as serve to contract the cerebral blood-vessels. Upon this ground Eulenburg recommended ergotof rye in the treatment of the latter form, and the favour-able results obtained.from the exhibition of that drug havebeen confirmed in America, England, and Germany. Asthere are, however, but few cases on record showing thebenefit to be derived from ergot in angio-paralytic megrim,I think the following may not be uninteresting, dis-tinguished as it is by its long duration and its greatresistance to all other methods of treatment

Mrs. S-, of Aix-la-Chapelle, aged forty-nine, of arather feeble constitution, and affected with kypho-scoliosisfor the last fifteen years, enjoyed tolerably good health untilthe end of 1S73. At that time the menses ceased, and shebegan to suffer from intermittent but violent palpitation,usually occurring at night, and accompanied by painfuloppression of the chest-symptoms resembling those ofangina pectoris. There was ’no history of either gout orrheumatism. The kidneys were healthy, but the heart wasenlarged in its transverse diameter, inasmuch as the cardiacdulness exceeded the right sternal border and also the nippleline for about one centimetre in each direction. The heart-= sounds were normal; the pulse was 80, and rather weak. Iconcluded at the time that the case was one of dilatation ofthe heart in consequence of the kypho-scoliosis and the com-pression of the lungs.

In January, 1874 Mrs. S- began to complain of severe

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headache on the right side. Without any known cause itgenerally came on after midnight, when she was roused byit from her sleep, and then kept awake for several hours.Bicarbonate of soda, rhubarb, and small doses of morphia,gave her immediate, but only temporary, relief. Aboutthe end of January the palpitations ceased altogether, butthe nocturnal headache increased in violence. The head-ache now regularly returned every night between twoand half-past two o’clock. It was mainly situated inthe right occiput and thence spreading to the fore-head. There was a feeling as of a heavy pressure upon theeyes, a forcible pulsation of the right temporal arteries, anda distinct rise of temperature on the affected side of from0’3° to 0’4° C. Gradually the pains subsided towards themorning. At my morning visits I found the patient greatlyfatigued, and, as the sole objective symptom, an injectionof the vessels of the right sclerotic, which, however, disap- z,peared in the course of the day. As the attacks seemed tobe of a typical recurrence, I therefore ordered large doses ofquinine, but without any benefit. Caffein not only gaveno relief, put produced also nausea and sickness. The in-duced current also failed, but the treatment by means of theconstant current (stable current of from six to eight elementsapplied for from eight to ten minutes) seemed to be, for atime at least, most successful. During three weeks theelectricity was applied about twelve times, and theintensity of the pain greatly diminished ; no attack ap-peared in the nights following the days on which electricityhad been used, and the intervals between the attacks alsoincreased from three to four days. The treatment, however,was unfortunately interrupted, whereupon the headachereturned with its former violence. Again the patient wasroused between two and half-past two o’clock; again thepain started from the right occiput, radiated to severalbranches of the trigeminus, accompanied by a hummingnoise in the right ear, beating of the arteries, and rise oftemperature on the right side. Again the constant currentwas applied, without, however, producing the same favour-able results as before. Iodide of potassium and the nervinetonics were then tried, but they failed to relieve the dis-tressing symptoms.Upon the supposition that the case was an affection of the

sympathetic nerve, and that the headache was due to a

paralysis of the arteries, I had in February, 1874, begun togive the ergotine de Bonjean, but the doses were small andthe results not at all satisfactory. Meanwhile Eulenburghad recorded (Bed. Ktin. Wochensch., 15, 1873) a case ofintermittent headache with disturbance of circulation -

cephalalgia vasomotoria-which was completely cured bylarge doses of ergotine. As the symptoms of that case re-sembled those of the one just described, six grains ofergotine were at one time given per diem, and this quantitywas gradually increased to twelve grains. The exhibitionof one drachm and a half in the course of two weeks wasfollowed by an abatement of the symptoms ; for though theheadache returned every night, it was less violent thanbefore. From the 15th of April, 1874, the daily quantity ofergotine was increased to fifteen grains, and after the patienthad thus consumed two drachms more of the drug theattacks had a much shorter duration and were much lesssevere. The above dose of fifteen grains was continued forone month. During that time the ergotine produced nodisturbance of the general health, while the headache gra-dually subsided, so that towards the middle of May thepatient was discharged as cured. She had taken not less thanseven drachms of ergotine in a very short time, and has eversince been free from any of the angio-paralytic symptoms.

Aix-la,Chapelle.

CONTRIBUTIONS TO PLASTIC SURGERY.BY SURGEON-MAJOR J. M. FLEMING, M.D.,

BENGAL MEDICAL DEPARTMENT.

(Concluded from p. 179.)

CASE 7. Pestoration of the Chin. and Lower Lip. -Harju, aged thirty, a hill-man, employed as a jhampan-bearer, was brought to the Simla Dispensary on the eveningof Oct. 2nd, 1877, on account of a very severe gunshot injuryof the face. The lower jaw was smashed, and the soft partscovering it, including the right half of the lower lip, werecompletely torn off. The tongue had escaped uninjured,

but, from want of support, hung down on the neck, amidstshreds of muscles and integument and fragments of theshattered bone.The comminuted fragments of bone having been removed,

the remains of the lip were brought together with a twistedsuture, and an endeavour made to close the wound as far aspossible. Sloughing, however, ensued, and a hideous gapresulted.

Fig. 8 shows the appearance on Oct. 18th, sixteen daysafter the accident. On that date a plastic operation was

resolved on, which was divided into two stages : (a) restora-tion of lip; (b) complete closure of wound. The followingare the details.On Oct. 18th, 1877, healthy granulation having been esta-

blished, the patient was placed under chloroform, and, theremains of the lower jaw being found necrosed as far as theangle on the right side and the socket of the first molar toothon the left, the bone was removed to that extent with sawand forceps. The cut extremities of the lower lip, havingbeen pared, were then brought together with a harelip pinand two silver sutures, and the wound strapped with courtplaster.

Oct. 23rd.-Outer bandages changed ; strapping on lip notinterfered with.

26th (eight days after operation).—Strapping removed forthe first time. Complete adhesion of the lip has taken place.

Harelip pin, being loose, was removed. Sutures allowed toremain.31st.-Sutures removed. The lower lip has completely