provision is made for multiple small drains of folded rubber tissue, to permit of the egress of oil. Adhesive straps are so applied as to remove the danger of undue tension on the superficial sutures caused by the lateral sagging of the fat of the abdominal wall. The aseptic technic must be faultless.

In so small a series of cases, the absence of the recurrence or a fatality is surely well within the limits of good fortune.

A discussion of diastasis of the recti or hernia of the linea alba, while closely associated with the consideration of umbilical hernia, is purposely omitted for the sake of brevity, and to focus attention upon the plea that umbilical hernia may be accorded the same thoughtful consideration which is bestowed upon other herniae; that the futility of palliative measures be recognized; that the small umbilical hernia be surgically repaired before it shall have attained extraordinary dimensions; and that the patient afflicted with a large umbilical hernia be encouraged to seek surgical counsel and to expect relief.

DISCUSSION.

DR. SULLIVAN (New London): I cannot add anything to Dr. Ludington's paper, but I wish to emphasize the importance of surgical intervention in these cases. Everyone recognizes the danger of strangulation in both the femoral and the inguinal types of hernia. To me this element is just as great in the umbilical hernia, together with the added elements of malignant degeneration and abscess formation in the omental contents of the hernial sac. To insure success in this operation, primary union,— union without serum,-is of very great importance. I believe we can obtain this in a greater number of cases if-assuming that our asepsis is perfect, we will do more cutting with a good sharp knife close to the sac and less tearing with our fingers. A good many doctors refuse to recommend operation to their patients because they have no confidence that the condition will not recur. A good many more say that the patient will not submit to operation. If we remember, most of the cases that come to us come complaining of discomfort from the hernia, and we tell them that if the operation is successful they will be relieved of this discomfort; but we fail to tell them of the other dangers that are lurking in that sac, and they go away from us in the frame of mind that I heard a sailor express this morning. Two sailors sat before me on the train and from their conversation I gather that both had been in the hospital and both had been operated upon. One said: "I asked the doctor what

my chances were, and he said: 'Well, you might live a month, you might live a year, and you might drop off any minute'-and I said, 'Hell, doctor, I knew that before!'"

DR. GOMPERTZ (New Haven): There is a medical aspect to umbilical hernia which should be considered. Patients with this condition give a history of vague digestive disturbances, such as discomfort and distress coming on two or more hours after eating. They may also complain of nausea and vomiting. Constipation is generally present. The term "umbilical dyspepsia" has been used to describe this condition, when a hernia is present. Frequently these cases are confounded with duodenal ulcer, as the patients tell us their pain is relieved by assuming a horizontal position. However, if the patient's abdomen is carefully examined, a small umbilical hernia may be found. In many cases I have tried the medical treatment of strapping the hernia and the fitting of a proper bandage, but I believe it a waste of time to try the so-called medical treatment, and if you want to cure the hernia, these cases should be referred to the surgeon for operative treatment.

Hiccough-Complicating Medical and Surgical

Conditions.

DR. ORIN R. WITTER, Hartford.

We must consider hiccough as a symptom of disease rather than as a disease in itself, clinically observed as an intermittent inspiratory spasm of the diaphragm with or without a sudden closure of the epiglottis.

The mechanism is well described by Osler as-"being complex, the afferent nerve impressions to the respiratory center may be peripheral or central, the efferent are distributed through the phrenic nerve to the diaphragm, causing the intermittent spasm, and through the laryngeal branches of the vagus to the glottis, causing sudden closure as the air is rapidly inspired"-and from my own observation I consider that the efferent impulses through the gastric branches also of the vagus nerve cause increased peristalsis of the stomach with pyloric spasm, the complex sympathetic system being a great factor in continuing the reflex.

We have usually associated hiccough with very severe and definitely diagnosed medical or surgical disease, the patient being critically ill or often in the terminal stage of the disease; as such may be mentioned pneumonia, influenza, pleurisy (especially diaphragmatic pleurisy) empyema, peritonitis (especially of upper abdominal infections), inflammation of the liver, kidneys, pancreas, stomach and bowels, particularly typhoid,-these examples representing cases presenting severe toxaemias; intestinal obstruction, ileus, strangulated hernia, over-distended urinary bladder, operative manipulation in the upper abdomen producing shock, kidney insufficiency or suppression of urine following surgery of the genito-urinary tract, these examples representing cases presenting prostration, shock, or collapse. The cases just named may all be grouped as severe cases, and the hiccough but an annoying symptom in the clinical picture, the management of the case and treatment being mainly the treatment of the original condition.

Compared with these severe cases with hiccough, frequently there have come under my observation, during the past year, cases in which the hiccough has been the chief symptom in the clinical picture. Many of the patients have been physically, mentally, or nervously fatigued, while mild affections of the respiratory or gastro-intestinal tracts have often been the exciting cause. The attacks of hiccough have varied in severity from that of a mild degree, duration less than one day, to that of a desperate degree lasting up to eight days, the patient's condition becoming critical from the exhaustion and prostration.

Five of such cases may be given to illustrate this condition of severe hiccough complicating what was apparently a minor illness.

I.

Salesman; age 40. Physically strong until a mild attack of influenza two months previously, after which he failed to regain strength and evidenced nerve fatigue. Patient developed mild pharyngitis and tonsilitis, complicated by severe hiccough with pyloric spasm for three days, causing great prostration and some alarm. Condition relieved by full doses of strychnia and small doses of bromide.

2. Physician; age 50. Extreme fatigue from heavy obstetrical and gynecological practice; without evident cause other than fatigue, hiccough persisted for three days and was relieved by rest and a gastric carminative. 3. Infant. Severe hiccough the first symptom; mild acidosis with

pyloric spasm; relieved by regulation of the diet.

4. Man; age 36; music teacher. Nervous temperament; mild gastric and intestinal indigestion; fatigue from overwork. Patient developed severe hiccough lasting eight days, with pyloric spasm and occasional vomiting lasting three days, prostration. Not relieved by nerve and gastric sedatives, but yielded to full doses of strychnia.

5. Physician of middle life, overworked by hard country practice during the influenza epidemic, with the usual irregularity of meals and loss. of sleep, possibly himself a victim of a mild influenza with little temperature and extreme fatigue. Developed hiccough with pyloric spasm and vomiting; condition soon became critical, the hiccough nearly constant, whether asleep under opiates and sedatives or awake, projectile vomiting, visible peristalsis of stomach, pyloric spasm, progressive weakness with cardiac embarrassment; the question was raised of kidney insufficiency, pyloric obstruction, or both. Examination: lungs negative; heart organically negative but irregular as to rhythm and force; urine negative and kidney function within normal limits; X-ray proving pyloric spasm with dilated stomach. Rectal salines were given. Various mechanical stunts