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would have a particularly bad effect upon the heart,and that the violent convulsions would put a con-siderable strain upon the heart. Setting aside statusepilepticus, however, this does not seem to be the case.The cardiac condition of a patient, after having hadseveral fits in a week, has not appeared to me to bematerially worse than it was before. On the other hand.that abnormalities of the circulatory system can giverise to epileptiform convulsions there can be no doubt.We know, for instance, that in such conditions asStokes-Adams’s disease, where the bundle of Hishas been damaged, frequent epileptiform convulsionsoccur, as they also do in advanced cases of aorticstenosis and even in cases of arterio-sclerosis. Butthese, of course, are not cases of genuine idiopathicepilepsy, and the question for consideration is whether,when true idiopathic epilepsy is found associatedwith a valvular lesion of ordinary endocarditis, theassociation may not be more than an accidental one.Even if there is no direct causal connexion between

epilepsy and heart disease it does not follow that thetwo diseases are uninfluenced by one another ; and,indeed, there seems reason to suppose that epilepsy,when associated with cardiac disease, exhibits somephenomena which are not quite like those of ordinaryepilepsy. Thus the classical onset of a fit with a cry,a fall, loss of consciousness, and convulsions is notcommon with the cardiac epileptics, whose attacksare characterised rather by giddiness, fits of absenceof mind, and transient intellectual troubles—in a

word, by psychic epilepsy. The aura, too, in thesecardiac cases often takes the form of palpitations,precordial pain, the feeling of a wave of blood whichrises up into the head, and produces dizziness. Asa rule, this condition lasts longer than the ordinaryepileptic aura ; it develops slowly, giving the patienttime to sit down, and at times the aura constitutesthe whole of the attack without giving rise to con-vulsions or loss of consciousness. The fits in cardiaccases are usually infrequent and less severe than inuncomplicated epilepsy. Some of my cases haveexhibited circulatory disturbances as an aura, suchas palpitations, feeling of numbness in the hands,severe pain in the cardiac region, pulsation of thecervical arteries, sensation of rapid beating of theheart with the face becoming hot prior to theepileptic fit.. Another feature of cardiac epilepsy is that the attacksusually occur at night ; this fact has been emphasisedby Lemoine,4 who considers that in mitral cases theattacks are caused by cerebral congestion, andstates that they may cease when the patient sits

up in bed, whereas in aortic cases the attacks aredue to cerebral anaemia and are cut short by thehorizontal posture.Though I have met with a few cases of idiopathic

epilepsy associated with aortic regurgitation, the mostcommon cardiac lesion in my experience in thisconnexion has been mitral stenosis.

It would, perhaps, seem over-fanciful to suggestthat in the case above recorded the epileptic seizureswere at the outset due to the previously existingmitral stenosis ; yet Dr. A. E. Bussell, in his mostsuggestive Goulstonian lecture (1905)/ 5 considersthat there is strong evidence for an epileptic fitowing its origin to some disturbance of the circulation.and regards cerebral anaemia as the fundamentalfactor which underlies epileptic fits. Gowers, too,adduces cases 6 which present strong evidence ofthe influence of repeated cardiac syncope in disposingto epilepsy. _________

4 Revue de Médecine, 1887.5 THE LANCET, 1909, i., 965 and seq.

6 Borderland of Epilepsy, p. 8.

ROYAL FREE HOSPITAL.—At the festival dinnerlast week it was reported that 700 patients are treated daily,and Lord Riddell stated that there was an overdraft of.620,000 as well as a large debit balance. Ah anonymousgift of oB5000 was announced, and Lord Riddell added thathe would give a similar sum.

THE LOSS OF ORIENTATION IN INSUREDWORKMEN:

ITS ECONOMIC ASPECT.

BY PERCY DUNN, F.R.C.S. ENG.,CONSULTING OPHTHALMIC SURGEON, WEST LONDON HOSPITAL;

LATE LECTURER ON OPHTHALMOLOGY, WEST LONDONPOST-GRADUATE COLLEGE.

A MAN after convalescence from the enucleation ofan eye is puzzled by a symptom which is new to him.At first it amuses him, and save on inquiry he nevermentions it while under examination. He finds onpouring out a cup of tea that instead of the teafalling into the cup much of it falls outside. Briefly,for the time being he has lost the faculty of orienta-tion. When normal binocular vision is presentcorrect orientation is secured by the balanced actionof the ocular muscles. But with the loss of an eyeand the change to monocular vision the disturbanceof the muscular equilibrium is reflected in thetemporary arrest of accurate orientation. Theduration of the disability is generally a question ofage. It usually varies between three and sixweeks in young adults. In older men the period islonger.As a matter of expediency no one-eyed man should

be permitted to resume his employment until accurateorientation has been re-established. For example,a bricklayer, unconscious of his mistake, will laybricks out of line ; if he has to ascend or descenda ladder he is liable to make a false step, with therisk of serious consequences. He is aware thatsomething is wrong with his sight, but is naturallyignorant of the cause. Moreover, a man in thiscondition can become a positive danger to his fellowworkmen ; if called upon to wield a hammer forthe purpose, say, of striking a rivet, the retinalimage of the rivet may be displaced while strikingthe blow, and injury may be inflicted upon the manwho is assisting him. -

The Position of Insurance Companies.Two points present themselves for consideration in

this connexion. First the economic one, secondlythe position in which the insurance companies findthemselves. From the economic aspect the workmanas long as the loss of orientation continues is con-fronted with an impairment. of his earning capacity,apart from the loss of an eye. He can no moredepend upon the accuracy of his work than can hisemployer. A bricklayer is of no use if he cannotgo up or down a ladder without risk, nor is he of anyuse if he cannot lay bricks in line. What then,under the circumstances, is the position of theinsurance companies ? Inevitably the weekly wagecompensation must be continued until correct orienta-tion has been restored. It must be admitted that thedisability has arisen indirectly, as the result of anaccident in the course of employment. -

Cases of the kind are, nevertheless, rare, as

experience shows, owing to the gradual recoveryfrom the disability. But that is not all that canbe said of the matter. If it should happen that theloss of orientation becomes permanent the insurancecompany concerned will find itself in an unenviableposition. Although the form vision may be adequatefor resuming some occupation (and apparentlycounty court judges are satisfied when this amountsto 6/12, with or without correction in the remainingeye), a workman may demand an exorbitant sum forthe settlement of his case, and if it be refused, maytake his case into court, basing his claim upon thefact that owing to the loss of his eye, a defect hasdeveloped in the other one which prevents him fromdefining objects clearly. He emphasises that an

object at first appears to him plain and distinct, butafterwards becomes blurred and unsteady. Conse-

quently he is unable to define clearly, for example,

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the markings on a measuring gauge. With sucha complaint the court is at once impressed in hisfavour and the difficulty arises of finding an answerto the question for what kind of work is such a manfitted, having due regard to his possible earningcapacity. The judge requires to be satisfied on thispoint; he weighs the suggestions placed before him,and if he rejects them as being against the man’sinterests, the workman may become a pensioner forlife of the insurance company concerned. It is truethat the company has the power of reopening thecase should it be found that the man is afterwardscapable of undertaking remunerative employment.But there is little inducement for him to imperilan arrangement so greatly in his favour. Some work-men on the dole will not work if they can live withoutdoing so. Similarly, an elderly man, with only oneeye and a loss of orientation which has becomepermanent, is well aware that the labour market ispractically closed to him.

Uniocular Heterophoria.Loss of orientation, or heterophoria, in an insured

workman with only one eye cannot be excluded asa factor of importance under the Workmen’s Com-pensation Act. If permanent as a disability, revealedby the accident, it adds to the claim in the settlementfor the loss of an eye, inasmuch as it reduces theworking capacity and the earning capacity of theworkman concerned, apart from the abolition ofbinocular vision.The conditions under which it may assume a

permanent form may now be considered. Whilebinocular vision is present heterophoria in one eyecommonly exists as a latent form of disturbance ofmuscular equilibrium such as occurs in anisometropia,where the refraction in one eye is better than that inthe other. In a general sense, the better eye becomesthe working eye while the more defective one functionsin a state of latent heterophoria, without, however,causing any disturbance to the vision. When, on theother hand, the working eye has been removed, withabolition of binocular vision, the latent heterophoriain the remaining eye becomes manifest with theconsequent loss of the power of accurate fixation,and the possible continuance of this as a permanentdefect. In all cases in which a workman losesan eye in the course of his employment thiscontingency arises, and the only consolation to bederived from its consideration is the rarity of itsoccurrence.

Subjoined are the brief notes of a case in point.A boilermaker, aged 61, in September, 1923, lost his right

eye through the penetration of a piece of steel. When seen inJanuary, 1925, four months later, the vision of the left eye was6/24, improved to 6/12 nearly, with +0-75 cyl. and +1 ;ph.Orientation was still unrestored. On Nov. 21st, 1925, hewas seen again. About a week previously he had resumedwork as a plater’s labourer." This required him to hammer inrivets. With the first use of the hammer he hit a man on thehead, rendering him unconscious He ascribed the accidentto his vision becoming hazy, so that he failed to see therivet clearly. The orientation was still defective, althoughhe admitted that a 2° prism base outwards enabled him tosee more clearly. After this he ceased to do any work.He was seen for the third time on Oct. 5th, 1925. Therewas no change in the condition, and on Jan. 22nd, 1926,the case was taken into the county court wtth the resultthat the man became a pensioner for life of the insurancecompany concerned.

WORKHOUSE STATISTICS. - Information recentlyelicited from the Minister of Health in the House ofCommons shows that the average number of personsmaintained in workhouses in England and Wales was

slightly smaller in the year 1924-25 than in the previousyear. The figure for 1923-24 was 207,346, and that for1925 204,895. On Jan. lst last 154,500 adults and 52,000children under 16 years of age were being maintained in thevarious classes of Poor-law institutions in England andWales. The average weekly cost per person maintainedwas 25s. 5d. in the year 1923-24 and 27s. led. in the year1924-25. The total expenditure in connexion with theinstitutions was 13,735,923 during the year 1923-24 and14,494,451 during the year 1924-25.

Medical Societics.LONDON ASSOCIATION OF THE MEDICAL

WOMEN’S FEDERATION.

1’Iae H ealik of the Professional Woman.A MEETING of this Association was held on June 8th

at the house of the British Medical Association, Dr.CHRISTINE MURRELL, the President, being in the chair.

Dr. LETITIA FAIRFIELD gave an address on theHealth of the Professional Woman, which was

published in full in THE LANCET of July 3rd. Adiscussion followed the paper.

Dr. ELEANOR LowRY suggested that the occupa-tional laryngitis might be caused by : 1. Bad voiceproduction. 2. Sinus trouble. 3. Excessive smoking.

Dr. JUSTINA WiLSON, from her experience of theNational Hospital for Diseases of the Heart, confirmedthe much greater incidence of rheumatic heart diseasein women. Heart disease following influenza appearedto be very deadly to the heart muscle.

Dr. MARY KIDD agreed that vegetables rather thanfruit were needed to prevent constipation. It wasunfortunate that vegetables were so expensive nowa-days, and also that considerable time had to be spentin cleaning and cooking them which the womanworker living alone could ill afford.

Dr. RUTH VERNEY deplored the lack of cheapinstitutions to which functional nervous disease casescould be sent, since many of these cases could only betreated away from the home circumstances whichmight have contributed to cause the breakdown.

Dr. MINA DOBBIE said that practitioners ought to;nquire how working women spent their leisure andholidays ; often it was found that they looked afteraged relatives from a sense of duty and were quitegrateful to practitioners who forbade them to do so.

Dr. E. L. ROBERTS suggested that a possible causeof neurosis in elderlv teachers was a sense of failure innot having advanced further in their profession anda lack of anything to look forward to.

Dr. C. M. PEAKE pointed out that the effects of themenopause might not be immediate-for example,flushings could occur long after the actual cessationof menstruation.

Dr. A. SHEPPARD thought that in some of the bankscompulsory retiring age for women was as early as 45.The PRESIDENT pointed out that the other duties

outside work performed by most professional womenwould account for some of the excess of functionalnervous disease. Neurasthenia in her opinion wasalwavs the result of emotional overstrain. Therewas a need for well-run nursing homes in psychologicalinstitutions where the practitioner could continue totreat the patient.-Dr. FAIRFIELD briefly replied.A social meeting of the Association was held at the

same place on June 18th, the PRESIDENT in the chair.A lecture, illustrated by lantern slides, was given

by Sir JAMES BERRY on the subject ofGreek Templcs in Sicily,

which Lady BERRY followed up by reminiscences oftravel in many lands.

Sir JAMES BERRY dealt in the first place with thehistorical side of his subject, sketching the mainevents which led to the formation of the colonies of"

Magna Graeca " in Southern Italy and Sicily. Hethen passed on to a consideration of the architectureof Greek temples in general, their arrangement, themodifications which they underwent during the

development of Greek culture, the influence of theearlier architecture of Egypt and the subsequentfate of the erections. In an enlightening series ofslides showing reconstructions of temples, temples inprocess of building, and the quarries from which thestone was hewn, the methods employed by theGreeks in fashioning and erecting such vast stoneedifices were exemplified and made clear.Lady BERRY then showed a series of photographs

which she had made during various holidays abroad