Leave as little as possible to his judgment.

And if it is a

serious case see that every instruction for the conduct of the case is set down in detail, in the form of an absolute order, to go into effect at a definitely stated hour, and in a definitely stated way.

The practice of medicine has reached that stage where we may define it as the scientific application of the laws of Nature and common sense to the regulation of the life and habits of the individual. The successful outcome of a case depends on the strict and absolute adherence to the details of the treatment as outlined by the physician. This being true, then we, as physicians, know that of more importance than the adherence to instructions regarding medication is the matter of adherence to instructions relating to the diet and hygiene. This is impossible of comprehension by the laity. The matter of the treatment of disease still stands surrounded in their minds with a glimmering of the same awe held by their distant ancestors for the machinations of the tribal "witch doctor." The majority at heart still cling to the idea that the physician with a wonderful remedy produces a more wonderful cure. With this fact in mind the physician must, or should, come to realize that it is only the instructions pertaining to the administration of medicine that produce a profound enough effect upon the mind of the patient to give even the probability of their being remembered and carried out where given verbally, and the assurance that even these will be understood and correctly followed is never positive.

Methods for examination of cases and likewise the suggested outlines for instructions to patients cannot be set down in the abstract, so no attempt has been made to do so. The methods and outlines used must be worked out by the individual physician along those lines which to him seem best. But that every physician should work out and evolve some system for the conduct and management of his cases-both as regards methods of examination and of treatment-would seem unquestionable. System does not complicate work-it simplifies it, it saves time, it saves energy, it saves worry, and what is of more importance, it will save lives that irregular, hap-hazard work would lose.

CLINICAL REPORTS.

Large Congenital Umbilical Hernia, with Report of Case. *By E. L DELANNEY, M. D., South Omaha.

SYNONYM-Hernia Fenicute Umbilicalis.

Congenital Hernia of the Umbilical cord may be in size from a small tumor the size of a marble to a large tumor the size of a childs head and may contain from a single loup of intestine to the whole abdominal viscera, including the liver.

The abdominal opening may be so small as to barely permit the introduction of the little finger, to a complete atresia of the abdominal wall, by the failure of the ventral linia to meet in the median line. The opening may be round and as large as two inches in diameter.

The opening is covered by the amnion which is a continuation of the covering of the umbilical cord. It is thin and transparent and when the hernia is large the intestinal coils can be plainly seen through the thin, bluish membrane. When the hernia is small a small loup of intestine can be easily caught up and ligated and severed at the same time with the cord. The sac may be fusiform or pedunculated, depending on the size of the opening and quantity of its content.

If left alone and the child lives, the sac becomes opaque, symptoms of inflammation follow and the amniotic covering sloughs at the skin margin, leaving the visceral content exposed without covering. If the opening is very small granulation may follow and the opening close. If, however, the opening is of any size, the abdominal viscera protrude and peritonitis ensues, shortly followed by death. The cord is usually attached to lower part. In very large hernia and with difficult deliveries, the amniotic covering may become ruptured and the intestines squeezed out during delivery.

Etiology:

Failure of intestinal coils, which are normally present in the cord in the second or third foetal month, to return in the abdominal caviety. (Oken-Ahlfeldt). This, however, would not explain those conditions in which the liver is found in the sac.

Ahlfeldt attributes the cause to a failure in atrophy of the Ductus Omphalomesentericus, the process of atrophy is retarded and the opening does not close around the vessels of the cord and Urachus.

*Read before the Nebraska State Medical Association, Omaha, May 2, 3 and 4, 1911.

Aschoff doubts this theory but does not offer a better one.

As neither the theory of Oken, Ahlfeldt or Aschoff seems to fit our particular case, we will have to formulate our own theory on the findings of this particular case, seeing, however, how the above might hold good in other cases.

Treatment:

Where small, an antiseptic pad to hold intestines in place after the fall of amniotic covering and waiting for granulation, might be justifiable. When the opening is large, however, the procedure is entirely surgical.

Kelly, in "Surgical Diseases of Children," says (page 534) "Closure by approximation of margins and suture, is indicated and may succeed, but often fails.'

Pfaundler and Schlossman recommend the radical operation first performed by Lindford in 1882, i. e., open hernial sac, freshening skin margins and suturing.

Ollshausen recommends extraperitoneal method, i. e., separating peritoneal covering from amniotic covering, freshening edges and suturing.

C. Breus recommends employment of percutaneous sutures, but owing to the large size of the opening in our particular case and other conditions, to be herewith quoted, none of the above methods were considered advisable.

We will now describe a case, herewith illustrated:

History:

Child, male, full term, labor easy, lasting about four hours. Large quantity of amniotic fluid. Paternal history negative, save that the father is quite a heavy drinker.

Maternal history, age 39, German, married twice. Five children with first husband, all living and well. Five children with second husband, one died of enteritis at 18 months. Others all well. One set of twins in second set.

Grand parents on both sides very old. No history of any deformity anywhere along the line.

Case:

On tying the cord a large tumor, as large as a fist was found at foetal extremity and connected to the child's abdomen. It was covered with a thin, bluish membrane, a dilatation of the amnion covering the cord. The membrane was transparent and the dark loups of intestines could be seen within the hernia. A large opening in the umbilical region connected the sac with

the visceral cavity. The bowels could be easily replaced but when released found their way back into the amniotic covering.

It was seen that as soon as the cord separted the visceral content would be exposed to the outside world, so the next morning, nine hours after the child was born, it was removed to the South Omaha Hospital, where we found the following condition:

Male child, well nourished, normal, with the exception of abdomen, which presented a peculiar appearance, on which I want to lay special stress. The abdomen was very large and flacid and when the child was on its back seemed to "run over,' so to speak, a fall on each side of the flanks, just as a large dropsical abdomen on an emaciated person looks, after it has been tapped and a large quantity of fluid withdrawn.

In accompanying illustration, the nurse is seen holding up the folds of abdomen so it will show in the picture.

In the center of the flaccid abdomen was a large umbilical hernia in the cord, containing loups of intestine, containing dark colored meconium. The peristaltic motion and passing of the meconium forward could plainly be seen. The shape of the abdomen lead us to believe that in this particular case, the failure to close, of the abdominal ring, had been due to some intraabdominal pressure, probably a foetal hydrops and subsequent findings seem to confirm our belief.

Assisted by Dr. R. E. Schindel and with Dr. A. A. Fricks as anesthetist, whom I want to mention here for a great part of the success of the case was no doubt due to the manner in which the anesthetic was given, we prepared the abdomen in the usual way and with the usual surgical proceedure.

Without an anesthetic the amniotic covering was dissected from the true skin, from which it was sharply defined. The two umbilical arteries, which were found in lower left hand side of opening, were clamped and tied with No. 2 Zonas gut. The umbilical vein, which was found in the upper left hand side, was treated the same way. This left an opening about two inches in diameter. From the peritoneal cavity, about a cupful of thin straw colored fluid flowed out, corroborating, in a way our theory of prenatal intra-abdominal fluid.

The hernial opening, above mentioned, was found surrounded by a tough cartilage like ring, which no amount of freshening up, short of a complete dissection, would have permitted of union if the parts had been so united. To overcome this condition and make a stronger union, we determined to split the ring in two, thus making two flaps, an internal and an external flap, as described by Mayo in his operation for the radical cure of umbilical hernia.

A few drops of ether was now given, just enough to numb, but not enough to put the child totally asleep. The cartilagenous ring was split and it was a surprise to us to find how tough the ring had become and it was at least half an inch thick. After splitting, two flaps were dissected apart for about one and a half inches, the remainder of the operation was done just. as in the Mayo for adults, i. e., the inside flap was overlapped with the upper flap overlapping the lower flap by about one inch and sewed with No. 2 Zonas Cat Gut, the line of sutures running crosswise. The outside flap was sewn with Silkworm gut with the line of suture up and down. The child was under the in