uniformity of the contraction, according to V. Reuss,* distinguishes the hysterical field of vision from that in neurasthenia where the field generally takes the form of a spiral owing to the gradual exhaustion of the retina during the time the field. is being taken.

Another peculiar feature of the hysterical field is brought out in the first case, i.e., the inversion of the colour fields. The natural order of the fields in order of magnitude is white, blue, red, green. In my patient's case it was white, red, green blue in the affected eye, and unless the field was taken quickly blue was not visible at all. In the supposed sound eye the field for red was slightly larger than that for blue. I have called these cases "hysteria" because the hysterical symptoms. are predominant, but the absence of convulsive seizures and the presence of insomnia and some evidence of nervous exhaustion indicate an element of neurasthenia.

The symptoms recorded are those which the patients directly complained of. In the case of the woman other symptoms, eg., monocular diplopia, erythropsia and micropsia, could be elicited by leading questions; but as these might be the result of suggestion they have not been included. The most discouraging features of the cases are the bad prognosis and the ineffectiveness of treatment. It is worthy of note that neither of these cases belonged to that class (of which much is heard of in the law courts) which expect substantial damages for the injury received, and who are supposed to recover immediately the money has been received. The woman willingly accepted £10 as compensation eight weeks after the injury, but this did not in the least improve her physical and mental state. The man had forfeited all claims to compensation as he did not apply in time for it. As far as can be judged from these cases, it is not just to assume that cases of traumatic neuroses are sure to recover from their troubles when litigation is over.

The treatment employed cannot be said to have been very effectual. It is true that the patients improved considerably for short periods of time, but only to relapse again. Smoked

*Ophthalmic Review, December, 1902.

glasses gave considerable relief from the photophobia, whilst atropine, cocaine and suprarenal drops allayed spasm, pain and congestion. Probably the bromides and tonics such as iron, strychnine and arsenic did something towards the general improvement. Large doses of bromide of potassium were certainly effectual in relieving the insomnia.

Hypnotic suggestion is supposed to be very efficacious in these cases, but my attempts at this form of treatment were not successful.

PRACTICAL THERAPEUTICS.

THE APPLICATION OF TRUSSES TO
REDUCIBLE INGUINAL HERNIE.

By LEONARD GAMGEE, F.R.C.S.

A truss, to be efficient, must not only adequately keep up the hernia, but must do so without causing any discomfort to the wearer. Unless a truss fulfils these two conditions, it may be taken for granted that either (1) the truss itself is faulty, either as regards the spring or the pad; (2) the truss, though itself of proper size and shape, is not worn in the proper position; or (3) the truss is not of the pattern best suited to the particular variety of hernia from which the patient suffers.

Attention must be paid to the following points in connection with the truss-spring:

(1.) It may be too strong, and, therefore, exert too much pressure. When a truss fails to keep up an inguinal hernia, it is far more probable that the fault is in the shape or the position of the pad than that the spring is too weak. The pressure of the truss-spring as supplied by the instrument maker is more often too great than too small.

(2.) In most people there are distinct bony projections at the back of the pelvis over the posterior borders of the blades of the ilia. If the patient is stout, these projections are not well marked, and will not cause trouble. If, on the contrary, the patient is thin, the projections are marked, and it is necessary to allow for them in shaping the truss-spring.

(3.) Less commonly, there is a projection over the middle line of the sacrum, just where the spring crosses the bone. This, being uncommon, is often overlooked in fitting a truss. When it is present, it also requires the spring to be shaped, so as to allow for it.

(4.) Pain is often caused by the pressure of the spring, just where it turns inwards beneath the anterior superior iliac spine. If this is the case, the spring may require to be sharply bent inwards at this point.

(5.) Care must be taken that the spring is so shaped that the pressure is exerted equally by the whole breadth of the spring; otherwise the upper or lower border, as the case may be, exerts an undue amount of pressure, and so causes pain.

These remarks as to the spring refer to all inguinal trusses, no matter what variety of pad is used. For a bubonocele or a light scrotal hernia, a pad of the ordinary shape keeps the hernia up, but there are several points to which attention must be paid regarding the adjustment of the pad. Firstly, the pad must exert the whole of its pressure over the position of the external ring and the inguinal canal, and should under no circumstances press upon the pubic bone. Pressure on the bone is the cause of two evils—(a) It causes pain, and (b) the pressure is borne by the bone and not by the anterior wall of the inguinal canal; hence, while the hernia may not be able to escape through the external ring, it is still able to pass through the internal ring and so enter the canal. It is hardly necessary to lay stress on the danger of such a state of affairs. Secondly, if the patient has an overhanging abdominal wall, the pad must be so adjusted as to look upwards and backwards, instead of directly backwards. If this is not done, the upper border of the pad exerts far too much pressure, while the hernia escapes beneath the lower border. For a heavy scrotal hernia, and indeed for many light ones as well, the so-called "rat-tail" pad is necessary. This pad is larger than the ordinary one, and is continued downwards over the pubes by a triangular prolongation, which gradually narrows into a strap, which is carried over the perineum to be attached to the spring posteriorly. It is most important that the tail of the pad should be made of strapping only and that it should not contain any metal. Hence the metal part of the rat-tail pad must be the same shape as that of the ordinary pad, though it should be slightly larger; as in the case of a scrotal hernia

the canal and rings are more dilated than in the case of a bubonocele. It can easily be seen that if, as is often the case, the metal is continued into the tail, then pain is caused by pressure on the pubic bone, while the wall of the inguinal canal is not supported in the proper manner.

Even with the use of a rat-tail pad, a heavy scrotal hernia will sometimes escape to the inner side of the pad. To prevent this the "fork-tongue" pad is useful. This is the same as the rat-tail pad, with the addition of a projection inwards towards the middle line The metal of the pad is continued into the projection, to which a strap is attached and fastened at its other end to the spring on the opposite side.

Whatever the shape of the pad used, many scrotal herniæ are difficult to keep up. If the hernia at first comes down, while the truss is on, the patient should be instructed to reduce the hernia each time it escapes, and to wear the truss night and day. If these directions are followed, then, in a few weeks, the hernia becomes easily manageable. If it does not, then another careful examination should be made, so as to make quite sure that there is not an irreducible string of omentum adherent to the bottom of the sac.

In the Child-In treating an inguinal hernia in a young child by means of a truss, it must be borne in mind—(1) That the hernia is seldom so heavy as to make its proper keeping-up by a truss a difficult matter, and (2) that it is generally considered possible to cure an inguinal hernia in a young child by means of a truss. As regards the weight and size of the hernia in a child, the above statement generally holds true; but, certainly, cases are occasionally met with in which the hernia is so heavy and large that no form of truss is really efficient.

In treating a hernia in an infant by means of a truss, it is most important to pay special attention to the child's digestion and nutrition-to the former, so as to prevent distention of the abdomen, due to accumulation of intestinal gas, and also to prevent straining due to constipation; and to the latter, in order to render the abdominal muscles strong, for on their