at all, the help of glasses is absolutely required. It may be neces sary in those cases to completely paralyze the accommodation for some weeks by the instillation of atropine, simply for the purpose of resting the eye.

For the selection of glasses, I generally determine the amount of manifest hypermetropia, by permitting the patient to look at large print at a distance of fifteen to twenty feet, or where an emmetropic eye would see it with distinctness. Then I find the lowest convex glass through which he can read the print, and this determines the degree of manifest hypermetropia. In the great majority of cases of asthenopia, the convex glass will be about thirty-six or forty inches. Having determined this point, I prescribe, if the hyperme tropia is thirty-six, a convex glass of thirty-inch focus; if it is fifty, glasses of about forty-inch focus, and so on. Wecker advises that the manifest and about one-fourth of the latent hypermetropia should be corrected by the first glasses presented. I notice, in looking over my records of quite a large number of cases of asthenopia, glasses of thirty-inch focus are prescribed oftener than any other; and the cases occur almost invariably in persons from fifteen to thirty years of age. I find nearly twice as many cases in females as in males; but this is probably not owing to a preponderance of hypermetropia in females, but rather to the fact that their occupation in general, and especially by artificial light in the evening, requires greater exertion of the accommodative power of the eye than that of males. Collegians and accountants, among the latter, are frequent sufferers.

It will often be necessary to change the glasses, after a few weeks, for those of greater refractive power, in order to cure the asthenopia. Sometimes, in asthenopia due to facultative hypermetropia, the glasses, after having served to cure the asthenopic symptoms, may be discarded. The patient should be particularly enjoined to use invariably his spectacles for near vision, and, whenever in any occupation his eyes seem fatigued, to rest a few minutes. In looking at distant objects, although he is obliged to accommodate, it is only momentarily as a rule, and need not, if discretion is used. fatigue the eye much.

Besides the asthenopia, we have also to treat the hyperemia

which frequently accompanies it. This is spoken of elsewhere. There are occasionally also those symptoms of general debility noticed at the commencement of this article. These are of course to be removed as speedily as possible by internal medication, generous as well as prudent dietetic regulations, and change of air, if necessary. I know of no remedies so useful internally in helping to remove the irritability of the eye in these cases as Macrot., Spigel, and Gelsem., when other symptoms pertaining to the general health do not forbid their use. When there is irritability of the sympathetic, nervous dyspepsia, irritation of the uterus or kidneys, and sensitiveness of the brain and nervous system generally, these remedies are applicable. I do not know any particular subjective symptoms which would lead me to select one of these remedies in preference to the others, unless it be perhaps the single one of want of appetite, or simply an indifference to food. This points invariably to Macrotin in these cases. When the hypermetropia is very slight, and the asthenopic symptoms are evidently dependent on diminished energy of the muscular system generally, we may frequently omit the prescription of spectacles altogether, and depend wholly upon the restoration of vigorous health for the cure of the affection.

Muscular asthenopia and asthenopic symptoms due to irritability of the retina are noticed elsewhere.

STRANGULATED UMBILICAL HERNIA.

Mortification and Removal of Fifty-eight Inches of Intestine. — Recovery.

BY G. D. BEEBE, M.D., CHICAGO.

ON July 10, 1869, I was called to see Mrs. J. B. Childs, of Lee Centre, Ill., who was temporarily in our city for a visit. While at the house of a friend she was taken with most violent pain in an umbilical hernia from which she had suffered since the birth of a child seven years previously.

On reaching the patient's bedside I found a large tumor at the umbilicus, the thin integumental coverings of which were greatly discolored, and were on the point of yielding to the pressure of a

considerable quantity of fluid within. The patient had vomited for two or three days; during the twelve hours preceding my visit the vomiting had been stercoraceous, with frequent hiccough. The skin and pulse did not indicate any marked peritoneal inflammation, but there seemed no apology for further delay in ascertaining the condition of the hernial mass.

A careful incision into the integuments liberated a quantity of dark, bloody serum, and revealed a mass of gangrenous intestine. With a grooved director the hernial sack was freely laid open, when I was startled to find so much of the intestine involved, and the entire mass was not only quite black, but at points was yielding and allowing the escape of focal matter. The situation was unprecedented, but a moment's reflection satisfied me that the patient's chances for life lay in removing the devitalized tissue, and pursuing such further steps as would subject her to the least hazard possible.

With the assistance of two or three of my colleagues whom I could hastily summon to my aid, I traced the gut to the hernial ring; finding sound tissue there, I divided it, and by a strong suture secured the sound extremity to the margin of the incision. Then with a pair of scissors I cut the intestine away from the mesentery throughout its extent until sound intestine was found at the opposite side. Here it was again divided, and the sound extremity secured as before. The mesenteric vessels, which were very numerous, as may be supposed, were closed by torsion; ice was applied until all hæmorrhage had ceased. This was the most protracted part of the operation. Then the hernia knife was brought to bear on the ring, which was freely enlarged. Making sure that the bleeding would not recur on the removal of the pressure maintained by the ring, the parts were now returned within the abdomen, leaving the two divided ends of intestine protruding from the abdomen, and lying side by side where they were secured to the integumental margin in such manner as to form an artificial anus.

The day following the operation the pulse rose to one hundred and twenty, and there was some disposition to singultus; but the cathartics, which had been administered by my predecessor in the case, were producing free discharges at the artificial anus, and in two days the irritation began to subside, and the digestive func

tions became tolerably well re-established. An examination of the intestine removed proved it to be a portion of the jejunum, measuring four feet and ten inches.

As soon as I could feel some assurance of the patient's surviving the first operation, I began to prepare for the second, viz, the cure of the artificial anus. There were not wanting those in the profession who wisely shook their heads, and thought this operation should have been postponed for several months to enable the patient to regain strength, etc., and influences were brought to bear upon the patient to that end. But she seemed willing to rest her case in my hands; and, so soon as my instrument-maker could prepare the instruments from drawings furnished him, I was ready to proceed. A few days' delay was asked by the patient's husband on account of business.

On July 31, a clamp was introduced, the blades of which were oval, one inch and a fourth in length and three-fourths of an inch in width. They were fenestrated, leaving serrated jaws one-eighth of an inch wide. One blade was passed into each end of intestine until fully within the abdomen; great care was exercised that only the intervening walls of these intestines should be embraced by the clamp, and the blades were then approximated by a set screw in the handles until slight pain was occasioned. Instructions were given that, if nausea and vomiting occurred, the clamp should be loosened; otherwise it should be very gradually tightened during the next two days. On the third day, the presumption being that adhesive inflammation had united the two intestines, firm pressure was applied by the clamp so that the parts embraced might be caused to slough; and a free incision was made from one intestine into the other, through the fenestral opening in the blades. On the fourth day the clamp was gradually loosened and removed, and from that time the focal matter passed freely into the lower bowels and regular evacuations occurred in the natural manner.

A digital exploration revealed the smooth, rounded edges of the opening made by the clamp, and it now only remained to close the integumental opening. This was done by deeply-set quill sutures, on the eighth of August, and the patient departed for her home in the central part of the State, leaving my cabinet enriched by a pathological specimen, which is as highly valued as it is rare.

It is no less amazing than gratifying to witness the happy effects of homœopathic remedies in controlling the constitutional disturbances consequent upon grave surgical operations; and seldom have I seen those effects more happy in my hands than in the present case, where Aconite and Arsenicum played so important a part in controlling the inflammation, and preventing peritonitis and enteritis.

A CASE.

BY CARROLL DUNHAM, M.D., NEW YORK.

ON October 10, 1864, I was requested to visit Mrs. C .E. N., aged about thirty-eight years. She gave me the following history: She had been always in good health, married ten years, but never pregnant. While travelling in France in 1854, she was attacked with what was then called acute peritonitis. She was confined to her bed several years. Partially recovering, she consulted Trousseau, who discovered the right ovary inflamed and somewhat enlarged. From this time, she was more or less unable to walk, and suffered much from a tumor, which gradually developed in the pelvis, between the uterus and the rectum, and which was pronounced by Trousseau to be an enlarged and prolapsed ovary.

In 1863 she came to New York, and placed herself under one of our most experienced gynecologists, who confirmed Trousseau's diagnosis, pronounced the case incurable, and advised a sparing resort to anodynes to mitigate severe suffering. I found Mrs. H. confined to her sofa; she had not left her room for a year. A firm, elastic tumor occupied the space between the uterus and vagina anteriorly and the rectum posteriorly, completely occluding the vagina, and rendering defecation very difficult. It seemed not to be adherent to the walls of either passage. Attempts at walking induced paroxysms of acute pain across the hypogastrium, in the sacral region, and around the right hip-joint; from here the pains extended down the groin and along the femoral nerve. The pain was relieved by flexing the thigh upon the pelvis; and always induced or aggravated by extending the thigh. Even without the provocation of motion there were frequent and severe paroxysms