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In January, 1904, she again broke down, and the eye symptoms, insomnia and dyspepsia returned. She had some hæmatemesis, and the papular rash on the right side of her face became pretechial in patches. Occasionally she had an evanescent urticarial rash all over the body,

June 6th, 1904.-Slight conjunctival injection. Slight spasm of orbicularis. Pupil reflexes normal. Media and fundi normal.

No numbness or tingling of the extremities. Knee jerks marked.

R.V.= c + '50 D and J 40.

L.V.=4C + 1, J, at 25 c.m. to 30 c.m. Visual fields contracted for white and all colours. The field for colours was distinctly inverted in the right eyethat for red being the largest, and that for blue, which is normally the largest, being the smallest. At times she was unable to distinguish blue at all with the right eye. The red field is also slightly larger than the blue in the left eye. .

Case 11.Thomas L., aet 27, a collier. On the 2nd April, 1902, he was struck by a piece of rock on the external angular process on the left side. He stated that he was unconscious for half-an-hour after the accident, and that the stone was extracted from the wound in the skin by a fellow-workman. There was a scar to be seen at the external angular process. He was attended for this accident at a neighbouring hospital. Some time later he sought advice at the Birmingham Eye Hospital, but of this attendance there is no documentary evidence. Being unable to get a ticket to come again, he went to another eye hospital, where he said the surgeon wanted to remove his eye. Whether this was suggested or not, it was not carried out. On January 31st, 1903, he came again to the Birmingham Eye Hospital, and was anxious to have his left eye removed because it was painful and useless.

Right eye: Some congestion of the conjunctiva. Pupils active but somewhat small. Media clear. Optic disc slightly hyperæmic.

R.V.=Counts fingers at i foot.

Left eye: Much congestion of the conjunctival and ciliary vessels. Blepharospasm and lachrymation. Pupil active and small. Media clear. Optic disc hyperæmic.

L.V.=No perception of light. R. Visual field contracted. The left field, of course, could not be taken. He was treated with

Gutt. Coc. c Adrencelin.

Mist. Potass Brom. c Valerian. Galvanism.
February 10th.—Left eye in statu quo, except that

L.V.=Perception of light only.
Right eye-by retinoscopy showed a myopia of — 4:5.

R V.= C - 4 D.
This refraction suggested spasm of accommodation, and

R.V.= c + 1 D.
L.V.=Perception of light (not improved by any glass).

On March 13th refraction, vision and field as on February 10th. I have not been able to trace this case any further, as he has left the district.

These two cases—particularly that of the female patient, whose prolonged attendance gave me time and opportunity to make more careful notes—are fairly representative of ocular hysteria as described by Parinaud, Borelt and others. I have confined my attention to cases of traumatic origin as they appear to me to be somewhat rarer and of slightly different character from the ordinary non-traumatic cases. Compared with the latter, traumatic cases seem to show a preponderance of vasomotor changes—flushings, congestions, erythematous rashes and localised sweatings—whilst the nontraumatic cases, which I have observed, have shown more of the paralytic symptoms-ptosis (non-spastic), paralysis of accommodation, and external ocular muscles, anæsthesia of the cornea and skin areas.

A marked failure of vision is always present, but though this was bilateral in these two cases, it has been my experience to find it unilateral in non-traumatic cases. The fields of vision are practically always markedly and more or less concentrically contracted, both for white and colours. The

* Norris and Oliver, System of Diseases of the Eye.
Annales d'oculistique, Jan. and April, 1900.

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, e.g., 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 HERNIÆ.

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.

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