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minimum of intelligent cooperation on the part of the

patient.The application of these rules to the various muscle

paralyses taken in detail is as follows - ,

Given a diplopia which increases in one direction we

have-A.—HORIZONTAL DIPLOPIA.

1. Increasing towards the right :—(a) Image formed by the right eye further to the right:

Right External Rectus.(b) Image formed by the left eye to the right:

Left Internal Rectus.2. Increasing to the left :-

(c) Image formed by the left eye to the left:Left External Rectus.

(d) Image formed bv the right eye to the left:Right Internal Rectus.

B.-VERTICAL DIPLOPIAS.

’Separation increasing upwards.1. Right eye’s image above :-An elevator of the right eye affected.

(e) Vertical separation greater up and to the right than up and tothe left: Right Superior Rectus.

(f) Separation greater up and to the left than up and to theright: Right Inferior ObUque.

2. Left eye’s image above :-An elevator of the left eye affected,

(g) Separation greater up and to the left than up and to theright: Left Superior Rectus.

(h) Separation greater up and to the right than up and to theleft: Left Inferior ObUque.

Separation increasing downwards.1. Right eye’s image below :-A depressor of the right eye affected.

(i) Separation greater down and to the right than down and tothe left: Right Inferior Rectus.

(j) Separation greater down and to the left than down and tothe right: Right Superior Oblique.

2. Left eye’s image below :-A depressor of the left eye affected.

(k) Separation greater down and to the left than down and tothe right : Lejt Inferior Rectus.

(1) Separation greater down and to the right than down and tothe left: Left Superior Oblique.

New Cavendish-street,’W.

Medical Societies.ROYAL SOCIETY OF MEDICINE.

SURGICAL SECTION.

Benign Twmo2crs (Fibroma, lJIyolll4, Lipoma) Enaapsuled inthe TVall of the 8tomaah.-Solnf Cases of G-astrw Surgery.A MEETING of this section was held on June 8th, Mr.

J. WARRINGTON HAWARD, the President, being in thechair.

Mr. WALTER G. SPENCER read a paper on Benign Tumours(Fibroma, Myoma, and Lipoma) Encapsuled in the Wall ofthe Stomach. He said the connective-tissue tumours of thestomach were commonly sarcomata. There were, however,exceptions to that general statement: a benign encapsuledgrowth, a fibroma, myoma, or lipoma, might increase to aconsiderable tumour, and yet could be removed withoutdamage to the stomach. These benign growths hadbeen mistaken for sarcomata and an excessive operationhad been done ; when left alone, such tumours hadcaused death by pyloric obstruction, or by ultimatelybecoming malignant. A case under Mr. Spencer whichoccurred in a female, aged 46 years, was similar to a

tumour of the stomach described by Morgagni. The patientwas first seen by Mr. H. G. Barling, who discovered thetumour and distinguished it from the kidneys, which were bothmoveable in the horizontal plane. When drawn out throughthe abdominal incision the appearance was that of a per-fectly normal stomach containing a soft body of the size andshape of a large kidney. The stomach cavity was quitenormal, but the mucous membrane of the posterior wall waspushed forwards, yet was freely moveable over the tumour,which had grown in the submucous tissue. The tumour was

easily shelled out and proved to be a dense fibroma of theshape and size of a large kidney, weighing 200 grammes, or7 ounces. The patient recovered well, and three and ahalf months after was fit to resume her occupation. Mr.

Spencer also showed a museum specimen of a precisely,

similar tumour, only smaller, the size and shape of a

small sausage. But it was placed in exactly the sameposition, with the convexity downwards and the con-

cavity close to the lesser curvature. It also during lifeformed a freely moveable abdominal tumour which the

surgeon took for an intussusception and cut out the tumouralong with the middle part of the woman’s stomach. Findingout what he had done, he had to reopen the abdomen tocorrect the suturing, but the patient died. The tumour wasshown in situ and was seen to be situated in the submucous

layer, encapsuled and separable from the mucous andmuscular coats. Under the microscope it had the structureof a myoma or fibromyoma. Reference was made to othercases of encapsuled and pedunculated benign tumours of thestomach; also to specimens in the Museum of the RoyalCollege of Surgeons of England from the horse and cod-fish.Mr. Spencer, in conclusion, said that although it was impos-sible to diagnose such tumours except at the time of opera-tion, yet benign tumours, either sessile or encapsuled, or ped-unculated and easily detached, could be successfully removedwithout excising any portion of the stomach.-Mr. L. A.BIDWELL said it was interesting to note that a tumour of thestomach might be mistaken for a moveable kidney anddescribed a case in point. He raised the question whetherbenign tumours ever became malignant.-Dr. H. MAC-NAUGHTON JONES remarked that malignant degeneration wasobserved in uterine myomata.-The PRESIDENT suggested thatbenign tumours became malignant, not from degenerationbut from invasion from without.-Mr. SPENCER, in replying,pointed out that the question of benign tumours becomingmalignant really resolved itself into a question of terms. Atumour that from an ordinary surgical point of view might bedescribed as benign, might, if submitted to minute histo-logical examination, be found to contain malignant features.

Mr. E. STANMORE BISHOP read a paper entitled " On SomeCases of Gastric Surgery." He said that surgery, as appliedto gastric disease, had of late years attracted much atten-tion. The proposal to treat surgically gastric ulcer and itsresults was comparatively recent, and all records of casesso treated were valuable, whilst the outcome had been, as arule, so satisfactory that many previously looked upon asincurable or neurotic had been subjected to at least explora-tory operations with a view if suitable to more definite

procedures. Those explorations had resulted in the dis-

covery of some conditions which were to a certain extentunexpected but which had proved amenable to surgicalskill, such, for instance, as hour-glass stomach or earlycarcinoma, whilst experience had shown that gastric or

duodenal perforations were, if attended to without loss oftime, by no means the hopeless accidents they were onceconsidered. Of partial gastrectomy there had been sixcases. In all, operation was not sought until a well-markedmass was present which could be felt, and in two cases seen.The lump varied in size from a celluloid ball to a tangerineorange. The patients were two males and four females, theirages ranged from 38 to 57 years. All the patients were in verypoor condition and had become emaciated ; probably thataccounted in large measure for the mortality-four out of six.Two survived for a period of 10 and 12 months respectively,but died ultimately : from certain recurrence in one case andfrom exhaustion with probable recurrence in the other, butthat was not verified post mortem. The operation performed ineach case was that of Billroth with end-to-end union, and thatwas followed in two cases by leakage at the angle between thevertical and circular sutures. In all great difficulty was experi-enced with the clamps. The later method of closing bothopenings completely and finishing with gastro-enterostomyevidently yielded better results, and was the measure whichwould probably be adopted generally in future. In theÂnnals of Surgery last year Mayo called attention to a

triangular fold of peritoneum descending in certain casesfrom the duodeno-jejunal angle and losing itself on thejejunum and advised its removal. It would also be in thememory of all abdominal surgeons that a discussion arosesome months since as to the correct line of apposition betweenthe two viscera. Might it not be that that fold indicatedthe proper angle at which the united jejunum should lie, andthat so far from removal it should be welcomed as an addi-tional means of strengthening and protecting the line ofunion ? 1 In two of his cases it was observed and used forthat purpose. The result was good, and in the later casesthe angle so indicated had been followed as nearly as

1755

possible. Another point to which he had as yet seen no refer-ence was the peculiar naked-eye appearance of the first sevenor eight inches of the jejunum ; that gut, which was thepart desired for anastomosis, looked sodden, it had not thepolished surface of the rest of the small intestine and wascovered by a number of minute eminences ; it might containputty which had been compressed in places, so "moulded"

"

was it. Of course, the surgeon relied mainly upon the factof its emergence from the duodeno-jejunal opening, upon itsanatomical position in fact, to assure himself that it was thecoil required, but that was a confirmation which suppliedadditional certitude and was therefore welcome. He was notsure that that was always the case, but he had seen it in somany that he should confess to a feeling of doubt anduneasiness if it were not recognisable. Another point wasthe value of the symptom of hunger-pain as a differentiatorbetween gastric and duodenal ulcers. This symptom un-doubtedly had great significance, and was of much import-ance in the differential diagnosis, but he ventured to hintthat that differential value might be somewhat exagge-rated. In two or three of his cases in which duodenalulcer was demonstrated at the operation that symptom wasabsent, whilst in a case sent to him by a well-known physi-cian with a confident diagnosis of duodenal ulcer, based

upon its presence, no duodenal ulcer was found, but a typical ’,,saddle-shaped ulcer of the lesser curvature of the stomach Iwas present. The operation itself appeared to act verymuch in the same way with reference to the passage of food I

through the alimentary canal as perineal section did withregard to the passage of urine through the urethra when astricture was present ; the stricture in that case being at thepylorus, at first all the contents passed through the newopening; the stricture being thus allowed to rest, if not

cancerous, slowly yielded ; some content began to find itsway along the normal route, then more and more, less and Iless passing through the artificial opening, until at last thenormal route became again the only one. Whether the new Ifroute in cases of gastro-enterostomy became totally closed, ’Ias did the perineal opening, there did not so far appear to besufficient evidence to prove, but that matters tended in that Idirection, the x-ray evidence he had been able to obtainseemed to show very definitely.-After Mr. BIDWELL, Mr.C. P. CHILDE, and Mr. SPENCER had spoken, Mr. STANMOREBISHOP replied.

EDINBURGH MEDICO-CHIRURGICALSOCIETY.

- Be-MMM.—.PAtM’MM’Cy of Ergot.A MEETING of this society was held on June 2nd, Dr.

JAMES RITCHIE, the President, being in the chair.Mr. GEORGE A. BERRY opened a discussion in a com-

munication entitled Critical Remarks on the Symptomato-logy and Causes of so-called Eye-strain." " After referringto the vagueness of the term he said that popularlyI I weakness " might be any symptom such as readily watering,intolerance of light, defective sight or discomfort, and frontalheadache induced by reading. ’’ Eye-strain," on the otherhand, was a term originated by the medical professionand he did not know of it as distinct from asthenopia ;indeed, he preferred the latter term as it was associatedwith a generic diagnosis. - He thought that the bearingwhich eye conditions had in causing headache had beenexaggerated. When there was hypermetropia, or astig-matism, or an absence of complete lateral parallelismof the axes of the two eyes, it did not follow thatthe deviations from the normal accounted for the patient’scomplaints as they were too readily assumed to do.

Speaking generally, the symptoms which in his opinionindicated eye-strain were due either to irritations of the

superficial nerves in the conjunctiva and cornea or to the useof the eyes under conditions which called for a strainedrelationship between associated impulses as between accom-modation and convergence. In the case of superficial irritationit was the summation of minute, long-continued stimuli whichcaused the actual pain referred elsewhere than to the eyesalone. In other cases the headache might be looked upon moreas the effect of the cerebral effort which was required to dis-sociate nerve impulses. In almost all cases of eye-strainthere was also an individually variable element to be con-sidered-namely, the neurotic element. Equal sources of

irritation produced different degrees of pain in differentindividuals or in the same individual at different times.Thus, in health an effort might be made without the con-scious appreciation of its being an effort, while in ill healthit might be associated with asthenopia. Thus often duringconvalescence from acute illness, discomfort or pain in the"eyes or headache might be experienced for the first time.The most frequent causes of conjunctival and corneal irrita-tion were lid pressure, exposure to strong illumination, andgout. Lid pressure was very often induced by astigmatism,especially if this was one in which the horizontal meridianof the cornea was the most highly curved (as happened in 20per cent. of astigmatic eyes), when an unconscious effort wasmade to correct it by pressing the lids on the e5e. Generallythis could only be done by frowning. The pressure inducedirritation of the cornea leading by summation to the sensa-tion of frontal strain and headache. Most people who havewalked in the glare of the sun have experienced this head-ache as a result of the frowning and semiclosure of the eyes.Many astigmatics have found out that their vision can beimproved by pressing the finger-tip on the eyeball. The

ophthalmometer revealed in many cases the change whichlid pressure produced on the cornea. The headache in-duced by lid pressure arose mainly when the eyeswere focussed on near objects. Lid pressure was onlyresorted to in the lower degree of astigmatism becauseheadaches did not accompany the higher degrees of thisaffection. Asthenopic symptoms from the superficial irrita-tion caused by strong illumination were very common andwere due to the effect of the ultra-violet rays. The eyeswere usually protected from such rays by being directed tothe green of grass or trees which absorbed the rays. Thesymptom set up by such strong light as sunlight, reflectionfrom white paper, incandescent gas or electric light wasnot generally headache but smarting of the eyes when

reading and inability to continue reading for long. The

symptoms quickly disappeared when the patient was kept ina darkened room, but such treatment was both unnecessarilyirksome and even hurtful. All that was necessary was toprotect the eyes from the rays by special glasses, the best ofwhich was called" euphos," but "London smoke" glassesafforded a sufficient protection and allowed the patient tolive in sunlight. When there was astigmatism the use of cylin-drical glasses became necessary but they were only requiredfor reading or other near work if headaches were present.Another form of eye-strain was technically called asthenopiaaccommodativa. The most frequent cause of this kind ofheadache was hypermetropia and it was aggravated by read-ing with insufficient light. Reading in bed was often hurtfulbecause the illumination was obtained from a single feeblecandle. Myopic conditions were easily recognised, andhence the symptoms complained of could be treated. Earlyand full correction for reading until after the age of fungrowth was now generally recognised to be right. Inwhat has been called asthenopia nervosa the patientswere, in fact, hysterical and treatment by suggestion wasadvisable. Mr. Berry had found the subcutaneous injec-tion of sterilised water over the eyebrows was most

efficacious, and the use of dark glasses must be forbidden.Not more than three or four injections should be given.-Dr. GEORGE MACKAY said that the personal equation in

eye-strain was remarkable. Some individuals with verymarked errors of refraction never suffered, from headache,while in other cases with very slight errors the disabilityowing to headache was intense. The employment of a veryweak prism often afforded remarkable relief.-Dr. W. G.SYM said that an endless number of diseases, includingsterility, diabetes, and appendicitis, were supposed by someto be due to eye-strain. He thought that Mr. Berry hadmade too much of the lid-pressure theory.

Dr. ALEXANDER GOODALL read a paper entitled A

Pharmacological Estimate of the Value of Commercial

Samples of the Liquid Extract of Ergot with Notes on ErgotStandardisation." He said that in the case of some drugswhose active principle was recognisable a chemical standardwas laid down by the British FharmacopoBia, but in caseswhere no chemical assay was possible that official publica-tion gave no guidance. It had been found, however, bymany firms of manufacturing chemists that it was in theirinterest to employ a pharmacological test for some of theirproducts, and in the case of certain substances there nowexisted ample data to afford standards. Well-known examples