with the peritoneal covering granular. An ovarian tumor was found on the left side. It had a long pedicle, which was wrapped about a portion of the sigmoid flexure of the colon. The tumor was removed and the intestine freed. A rubber tube passed through the anus relieved the distended intestines of an enormous quantity of fluid fecal matter and gas. The abdomen was closed without drainage. The patient's recovery was in every sense satisfactory.

Case 12. Strangulation from a Meckel's diverticulum. This occurred in a young man 16 years of age, who up to this illness had enjoyed good health. He had, however, been chronically constipated. His illness began with cramps in the abdomen in the region of the umbilicus, accompanied by vomiting. All foods or liquids administered by mouth were promptly rejected. Constipation was absolute, neither gas nor feces being passed. Persistent efforts to get the bowels to act were continued for six days, but without avail. During this time the pain was relieved by opiates. Enemata and purgatives though given again and again produced no effect. I saw the patient at the end of the sixth day. He was then in a state of collapse. His pulse was weak and 140 per minute; temperature 972°. The abdomen was only slightly distended and pain was not much complained of. Stimulation was being resorted to. As a forlorn hope, it was decided to submit the case to surgical treatment. A hurried section of the abdomen was made; strangulation by a Meckel's diverticulum was found. The strangulation was relieved but the patient died six hours later.

Case 13. Obstruction by stone. This patient was a woman nearly seventy years of age, who had not enjoyed good health

for several years. She had jaundice forty years ago. For

several weeks she had suffered with stenosis of the bowel which eventuated in its complete obstruction. When this occurred Dr. E. G. Wood, under whose care she was, referred her to me for surgical treatment. An abdominal section showed the small intestines very much distended and congested throughout. The peritoneal cavity contained much bloody fluid. The gall bladder

was buried in a mass of adhesions, which also involved the pyloric end of the stomach and the first part of the duodenum. About eleven inches from the ileo-cecal valve, the small intestine was blocked by a large stone. This was removed by opening the gut. The abdominal cavity was closed. The patient made a slow but complete recovery.

An analysis of these thirteen cases shows that eleven of them recovered, and that two died. One from pneumonia which existed at the time of the operation, and the other from the consequence of his disease. In neither case can we fairly charge the fatal result to the operation. In all of the uncomplicated cases operated upon early after the onset of the trouble the patients recovered.

In conclusion, it is fair to say

I. That opiates and purgatives have no place in the treatment of mechanical obstruction of the bowels, when the cause of the obstruction is external to the lumen of the gut.

2. That a high mortality is due to delay in adopting surgical treatment for these cases.

3. That early surgical treatment of bowel obstruction is not only safe, but is the one to be recommended.

BRONCHITIS AND BRONCHO-PNEUMONIA IN

CHILDREN.

BY WILLIAM A. WOOD, M. D., GALLATIN, MO.

AMONG the diseases of children at this season of the year none is more common or fatal than bronchitis and pneumonia. If anything we can say on this subject shall lead to a more careful study of these grave diseases in young children, our labor will not be in vain.

In dealing with this class of patients very many difficulties confront the physician. The infant can give him no information, and the child who is old enough to answer his questions intelligently very often refuses to come to his aid, hence subjective

symptoms are not available in reaching a diagnosis. The thermometer is an unreliable guide for the reason that in children the temperature fluctuates. It rises suddenly and falls just as suddenly without any ascertainable cause. The pulse is also unsafe as a guide in disease, because the physician has no means of knowing what it is in normal health. Under the influence of nervous excitement, anger or fright both the temperature and pulse are changeable and uncertain. When we add to these incidental influences the disturbing phenomena of disease, we begin to realize the embarrassments of the medical adviser.

The physician who is a close observer is, however, not without resources. He can get very much of the information he needs from the mother or nurse of the child and a patient study of the objective symptoms. There is a revelation in the cry of the child. The cry of pain is different from the cry of anger, or of hunger, or of exhaustion. He must note this difference. In pneumonia the cry is suppressed in consequence of its interference with respiration. The peculiarity of a cough must be studied. In ordinary bronchitis it does not cause pain. In pneumonia it is accompanied by more or less pain, which is plainly depicted on the face of the child. Physiognomy also teaches its lesson. Conditions of the countenance reveal the nature of disease. In sleep the face of a healthy child expresses repose. In pneumonia there is always a movement of the nostrils, indicative of difficult respiration. A chewing motion of the mouth denotes gastro-intestinal disturbance. It is said that the upper third of the face is changed in brain affections, the middle third in diseases of the chest, and the lower third in abdominal lesions. Contractions of the brows show pain in the head, and drawing of the upper lip, pain in the abdomen. A waxy color of the face indicates kidney disease, and a flush on the cheeks, inflammation of the lungs or pleura.

As bronchial pneumonia is usually secondary to bronchitis, it is not an easy matter to determine exactly when it begins, for its symptoms are often very obscure, and for this reason it is important to study all the objective symptoms which may aid in reaching a correct diagnosis.

Bronchitis is a very common disease of infancy and childhood. It is variable in extent and intensity. It begins with cough, hoarseness, difficulty of respiration and febrile excitement. There may be soreness of the throat, coryza, sneezing, and a watery condition of the eyes. It may be ushered in with a chill or a chilliness, with languor, exhaustion and drowsiness, followed later by more or less fever. The pulse becomes frequent, with a rise in the temperature. The cough may be slight at first, but increases in proportion to the extent and intensity of the inflammation. When it is frequent and severe it will be accompanied by more or less pain or soreness at the base of the sternum, but the face does not express the same degree of suffering as in the cough of pneumonia. The respiration in mild cases is but little accelerated, but in severe cases it is short, difficult and oppressed, and is attended by a wheezing or rattling sound, heard first in the throat but subsequently over the whole of the chest. The physical signs of acute, bronchitis in very young subjects are a combination of mucous and sibilant rhonchi. In older children these sounds are more marked, especially the mucous rhonchi. When the inflammation extends to the more minute ramifications of the bronchi the general symptoms are correspondingly aggravated. We have now the capillary bronchitis of the older writers, which is exceedingly dangerous, generally terminating in death, sometimes in a few hours.

Every case of bronchial catarrh should be regarded as the beginning of a pneumonia. In the commencement of an attack of bronchitis a small dose of calomel and Dovers's powder, followed with castor oil or salines, will be of service. Quinine now in small doses should be given at short intervals for about two days. Alternated with this, the following may be given:

M. Sig.

Take from one-half to one teaspoonful, according

to age.

The child should be kept warm with flannel next the skin, should remain in bed with the room at a uniform temperature of not less than 65° F., and should be given mucilaginous drinks or barley water with nourishment as will best meet the wants of the system. Fomentations or hot cloths applied to the chest will often be of service.

If there is much prostration the following prescription may be given:

R

Spts. ammon. arom.

Syrup senega

Tinct, scilla

Syr. prun. virg.

5 j 5 j

5 ss

3 ij

M. Sig. Take from one-half to a teaspoonful every two

hours.

In children of eight years and upward, the muriate of ammonia in small doses may be substituted for the spirits ammonia aromatic.

In case the inflammation has extended to the lung substance and broncho-pneumonia is developed, the chest should be enveloped in a jacket poultice of Antiphlogistine covered with oiled silk, and if there is high fever give as follows:

M. Sig. Give one-half to one teaspoonful every two hours.

If the cough is distressing, give the following:

M. Sig.

From one-half to one teaspoonful every two hours.