as far as the internal ring, a curved needle is then pushed through the sac of the hernia and skin, then the concave covering is screwed down, a cork placed over the end of the needle. This apparatus is allowed to remain about a week, then the cover is gradually loosened. The patient is kept on his back and bowels confined. One hundred and forty cases. by Rothmond gave 117 cures, four benefited, six not benefited, thirteen relapsed. Rothmond states that many cases were lost sight of. Otto Weber of Bonn, says that Wutzer did not cure one out of fourteen cases operated on by himself.

Agnew's modification of Wutzer's operation substitutes an instrument with two grooves and uses a wire in place of a needle, and inserts three horizontal sutures between the blades of the instrument. The instrument used is much like a bivalve speculum. The wire holds the stricture invaginated and is twisted over a roller bandage. Prof. Wood's subcutaneous wire operation consists of an oblique incision over the fundus of the sac. With the handle of the scalpel the tissues beneath the skin are separated for about an inch all around the incision. The index finger raises the external oblique and conjoined tendon. Pass a needle along the finger, pierce the muscle and tendon, and push the skin inward, insert the silver wire in the needle and withdraw it. Pierce the external pillar in a similar way, and draw the skin outward so that only one puncture will be made in the skin. Insert the wire in the needle and withdraw. Pass the needle behind the sac, thread the inner wire. Draw the loop down until it reaches the skin, twist the wire down into the wound. Leave the ends of the wire long. Draw up the loop and make the ends of the wire into a hook. Hook this over a roller. You now have the sac invaginated. Sew up the incision. This operation might succeed in small recent herniæ. Prof. Wood claims 70 per cent. of cures out of 225 cases. In other hands the operation has been far less brilliant. Dr. Cheever reports three cases permanently cured, three much relieved, two died, fourteen failures.

To say the least the operation is not scientific. You all know how little force it takes to separate two pieces of string that are pulled upon by each hand, if the force that is to sep

arate them is applied in the middle. This is what Prof. Wood aims to do in the wire and pin operation.

In January, 1886, Charles Wilson was sent to the Marine Hospital at Wilmington, N. C., from Savannah, Ga. He had an incomplete hernia, and any pressure over the inguinal canal gave him intense pain. This patient was a petulant, contrary man. I advised him to have an operation performed. He consented. I then canvassed the literature for a suitable operation. The one that commended itself to me was Gross' direct method. This operation consisted in cutting down upon the sac, suturing it, cutting away the surplus, and returning the remainder. After refreshing the edges of the pillars I drew them into apposition with sutures. Knowing that sterilized silver wire caused almost no irritation, I decided to use it. I passed silver wire through strong nitric acid, then put it into alcohol till I used it. While inserting the sutures I endeavored to do it in such a way as to restore the obliquity of the canal. One stitch internal to the cord, and two external did this quite effectually. I twisted the wire so as to leave the cord freely movable, yet, so as to bring the pillars into close apposition. The ends of the wire were turned down and made smooth. The wound was sutured with carbolized silk and a drainage tube inserted at the lower angle. This operation and the dressing was performed under strict antiseptic rules. The wound healed by first intention except where the drainage tube was. This also healed two days after removal. The temperature never rose above 99.5° which it reached on the third day. A graduated compress was placed over the canal and internal ring while he was in bed. He was discharged with an easy spring truss, about four weeks after the operation. Dr. Vaughn wrote me from Boston in May, 1887, stating that the man was in the hospital for diarrhoea. There was not the slightest evidence of hernia. He was without a truss. He still wears the sutures. So far as I know this is the only case where the wire was allowed to remain and be covered with granulation and connective tissue. This operation closely resembles that performed by Dr. H. O. Marcy. He uses the shoemaker's stitch.

A hernia that is irreducible and remains so, and is not ad.

herent, should be returned to the abdomen by an operation. If however it is irreducible, is large, and there are firm adhesions, it should be left, and be prevented from becoming larger by an accurately fitting bag. Dr. J. C. Warren's apparatus is often of much value in reducing herniæ that have long been irreducible. It consists of three important parts, an elastic sac, inside of and separate from an outer inelastic sac, and a collar to be adjusted to the neck of the hernia. The space between may be filled with air or water and exert gradual compression. An ordinary fountain syringe may be used to exert the pressure needed.

In strangulated hernia taxis is often practiced too long. If the hernia is not replaced in ten minutes without an anæsthetic, an anesthetic ought to be given, the pelvis elevated, and taxis again tried. The longer the hernia has been strangulated, the greater must be the care in taxis not to tear the intestine by manipulation. If taxis fail, and in the majority of instances it will, if the strangulation has lasted twelve hours, proceed to operate. Cut through the skin and on down to the sac. To know when you are near the sac, pinch up the tissue. If you get the sensation of the double fold, as you do when you pick up your drawers and trousers with your thumb and finger, you have not entered the sac. Relieve the constriction by cutting upward and outward to avoid the epigastric artery. When the gut is exposed and the constriction relieved, cover the bowel, if it is dark brown in color, with a towel wet with a warm bichloride solution 1-10000. If a healthy color returns you may return it to the abdomen; if not, and the constricted portion seems likely to slough, resect the dead portion, and a portion of the mesentery. Use Senn's decalcified bone plates as a splint for the intestine, or what will be more convenient, four or five strands of carbolized gut, wound with fine gut to hold the divided ends of intestine in close apposition. Here as in the operation for reducible hernia, the aim should be to restore the obliquity of the inguinal canal. If the hernia is a direct one the incision for relieving the constriction should not be upward and outward, but upward and inward.

HYPERMETROPIC ASTIGMATISM,

And its Relation to “Nervous Sick Headache," with Report of a Case.

D. BALDWIN WYLIE, M.D.

The intimate relation existing between errors of refraction and numerous nervous manifestations, notably the so-called "nervous sick headache," has been recognized for some time, and is acknowledged by all scientific men who are thrown much in contact with eye troubles.

Of all the forms of refractive error, hypermetropic astigmatism probably stands at the head in this respect. The amount of trouble that a seemingly insignificant error of this kind may generate is well shown by the following case.

Gertrude B., aged thirteen, of German parentage, and of vigorous constitution, entered my clinic in the "out department" of the Illinois Charitable Eye and Ear Infirmary, June 5, 1889. She was at the time afflicted with a marginal blepharitis which was the immediate cause of her seeking aid from a specialist. Upon inquiry I learned that she had for some time been a sufferer from "nervous sick headache" which had baffled the skill of the family physician.

There was considerable conjunctival injection and hyperlachrymation.

Ophthalmoscopic examination discovered a normal fundus, save for a slight hyperemia of the disk and retina. The refraction however was much at fault, showing a marked compound hypermetropic astigmatism of the right eye, and a smaller amount of apparently simple hypermetropia of the left. Upon testing the vision I found a manifest compound hypermetropic astigmatism of the right eye of 0.75 dioptres in all meridians and 1.00 dioptry additional in the vertical meridian. The vision was which was rendered by placing the xx proper lenses before the eye. In the left eye I found a manifest hypermetropia of 0.50 dioptres with vision xxv which was rendered by the proper lens. The patient was then put under atropine for one week, and on the 12th was again tested with the following result: R. E. Vision,= 20 and with +2.75 D. combined with + 1.00 D. cylinder axis 180° vision = showing a latent hypermetropia of 2.00 dioptres. L. E.

20

XX

20

20

XL

20

20 XXV

=

LX

XX

XX

20

vision and with+2.25 D. sphere vision =x. A week was allowed for the restoration of accomodation, when on the 19th, patient accepted + 2.00 D. combined with +1.00 D. cylinder axis 180° and read with the right eye, + 1.75 D. sphere and read with the left eye. This combination was prescribed. Patient returned on the 28th, and reported much improvement, being able to study for a long time without the fatigue previously complained of, but that the headache, although less, was still quite troublesome. I directed her to wear the glasses constantly, and report again in two weeks. On July 15th patient again presented herself, stating that the headache still continued, and that she was altogether about as when last seen. I searched carefully for some other cause, but finding none, I made up my mind that some portion of the error had been undiscovered and left uncorrected. An extended and careful examination of the fundus showed nothing new, but upon the use of the shadow test I discovered a very slight degree of astigmatism in the left eye. The patient was again put under the mydriatic, and a most careful test made. The right eye was found to present exactly the same error as on the previous examination. The left eye however upon a very careful test, showed 0.25 D. of astigmatism and no more could be brought out by any means. A week was allowed for restoration of accomodation, and on the 22nd she accepted the same correction as before with the addition of +0.25 D. cylinder with the axis in the 90th meridian in the left eye. This change was made in the lens, and when the patient again presented herself on the 2nd of August, she was highly delighted, she could now read for hours without fatigue, and all the headache had vanished. She was directed to wear the correction constantly, and to pursue her usual habits of life, and report again in two weeks. I next saw her on the 19th, at which time she was as much elated as before, having had no fatigue on reading, nor the least show of headache. I did not see the patient again until Dec. 23rd, when her gratitude brought her to the clinic with a Christmas offering, at which time she reported everything as being well. Had had no more headache nor fatigue on reading, and was feeling much improved in every way.