lence be applied by some hard, heavy, sharp-pointed instrument or substance which either punctures or rends the abdominal wall. That when a hernia is already present, violence which might in the sound, whole individual, be borne with impunity may, if accidentally applied over viscera which have escaped from the abdominal cavity, cause very painful or mortal consequences. Hence, the herniated is not a whole perfect being, so that a comparatively trivial force, which in the normally developed would make no impression, might with him be followed by serious results."

In his recent Atlas and Epitome of Abdominal Hernias, Sultan writes: "In the critical examination of a causal relation between hernia and accident we must remember, first of all, that a hernia complete in all its parts, can never arise at the moment of an accident or by a single augmentation of the intra-abdominal tension, be it ever so great.

"If the hernia first appears at the time of an accident, we may certainly suppose that the hernial sac was either congenital, or gradually formed."

The object of this paper is to elicit by discussion, based on the experience and observation of the members of the association, just how much of a factor traumatism is in the production of hernia.

If it is a frequent cause, we ought to know it, and thus be qualified to emphasize its importance and to appreciate its dangers.

On the other hand, if violence plays no part in the cau sation of hernia, we, as seekers of scientific knowledge, should know the truth so as to prevent wrongly attributing to some severe or slight injury what is due entirely to antecedent conditions. My own study of the question leads me to the opinion that traumatism is occasionally a true cause of hernia, but only by direct violence.

That is, the force producing the hernia must be applie to that part of the abdominal wall at which the hernia ap

pears, and then, by some hard instrument with sufficient force to rupture the wall.

Whether the rupture follows the natural openings in the abdomen, or creates a new passageway, is immaterial to

our purpose.

Hernia as the result of injury can and does occur. How frequently I am not prepared to say, but from a careful study of the statistics on the subject, would suggest that one case in every ten thousand would be a liberal estimate. In a very great majority of all the cases of the so-calle traumatic hernias, there was, in my judgment, without doubt, a pre-existent weakness at the hernial opening, and a preformed sac, which would in all probability have resulted in a rupture at no distant date if no injury had been received.

It may be said with emphasis and certainty that indirect injury whenever and however applied is never the cause of a hernia.

No concussive force, however severe, or single increase of intra-abdominal pressure can ever be satisfactorily demonstrated as the primary and sole factor in the produc tion of any form of abdominal hernia.

If the limits of my paper would permit, I could cite from my practice and the hospital records a number of cases to prove the correctness of this proposition. Indeed, I' can not think it would require any evidence in corroboration, for I feel sure, that where anything like a careful examination has been made, the experience and observation of every surgeon in the land will overwhelmingly confirm it. There is no doubt that violence direct or indirect, may greatly aggravate an already existing hernia, and in some cases produce strangulation, but this is very far from admitting that ordinary or indirect traumatism can produce hernia under normal conditions. When a hernia appears, after the application of ordinary force, it can always be

demonstrated that it had previously existed, the injury being in no sense the cause, but an incident only in its evolution.

Congenital hernia is never the result of traumatism, but of structural defects. In acquired hernias, various factors have been considered. In general terms, without going into particulars, it may be said, that any condition which weakens the abdominal wall predisposes to rupture.

Muscular relaxation from ill health or old age, repeated pregnancies, the removal of a large abdominal tumor, abcesses, and wounds of the abdominal wall, the constant lifting of heavy weights, and the diminished resistance of certain parts of the abdominal wall, all predispose to the development of hernia. In fact, any long-continued force requiring strong muscular effort, straining at stool from chronic constipation, or from an old urethral stricture, violent efforts in coughing, etc., by prolonged, constantly repeated, increased abdominal pressure, are one and all true factors in the causation of acquired hernia.

Under their influence, the parietal peritoneum yields slowly more and more to the increased intra-abdominal pressure at the weak place in the abdominal wall, and finally a protrusion is formed here, into which the viscera gradually but surely pass.

The supposed sudden appearance of an acquired hernia is in my opinion always dependent upon a mistake in observation.

The preformed hernial sac is present but empty, or the hernia so small at the time of the injury as to have escaped previous notice.

To sum up:

1. I think it is established by experience, and a preponderance of testimony from our best authorities, that indirect violence of any character can never be regarded as the cause of hernia.

2. Severe direct injury can not be considered a causative factor except where the muscular wall of the abdomen is ruptured by the injury and the hernia appears at the point of the injury.

3. It is highly probable, if not absolutely sure, that in all cases of so-called traumatic hernia, where ordinary force only is applied, the true cause will be found in congenital defects and not as a result of the trauma.

HEMORRHAGIC TYPHOID IN A CHILD-RE

COVERY.

By M. McH. HULL, M.D., ATLANTA.

No subject is of more interest to the practitioner of medicine than that of typhoid fever, so universal is it in its distribution over the country and so impartial in its choic of its victims. While formerly considered a disease of youth and adolescence, it has been observed in old age, and recent years have demonstrated the fact that there are a great many children who are attacked by the bacillus of Eberth, the youngest case reported being but four and one half months of age.

It is also of interest because of the various forms that the disease assumes in different individuals, giving us the abdominal type, the pneumonic type, the neurotic type, etc. Recently there came under my care a child that was suffering from a rather rare type of the affection, a history of whose case I desire to make a record both on account of the rarity of the type and also on account of the unusual termination of this type of the disease. The case is as follows:

J. V. D., Jr., male, four years old, the youngest child of a large family, previously in the best of health; surroundings healthful. Family history good.

On March 16th the patient was taken ill with a severe headache and abdominal pain, followed by fever and stupor. He was given some medicine to act on his liver, and on March 20th when I saw him first in the late evening,