paroxysms of coughing which, although productive, has a brassy clang. The pupils are equal and react to light; the conjunctivæ are pale. His hearing is normal. Mouth and tongue are normal. His neck muscles are disproportionately well developed. In coughing his neck below the larynx is seen to widen perceptibly. This is also true on swallowing and there are two muscular movements in deglutition. After swallowing a glass of milk regurgitation occurs in which mouthfuls are either expectorated or reswallowed. The neck bulges a little mesial to the right sterno-cleido-mastoid muscles after taking a glass of milk. Pressure on this area will force milk back into the pharynx with a gurgling sound. Sounds or bougies can be passed easily to a distance of eight or nine inches from the incisors, where they are stopped short. A sound could never be passed into the stomach. To exclude a diverticulus or oesophageo-tracheal fistula the patient was given a glass of carmin stained milk. Careful observation showed that the sputum coughed up during the next few hours floated in the milk, but the milk was not incorporated in the sputum at all, which would have been the case had there been a fistula. Repeated examinations of the sputum failed to reveal tubercle bacilli. Blood is occasionally present-usually associated with the decomposed food material.

Lungs-The left apex is retracted. There is an area of dull tympany extending posteriorly at the level of the 2-3-4 dorsal spines to the scapula. The breath sounds over this area are bronchial and there are numerous medium sized moist rales. Bronchophony and whispered pectoriloquy are present. Except for some sonorous rales the lungs are otherwise clear.

Heart-The size and sounds are noraml. The aorta is not enlarged nor is it palpable in the suprasternal notch. The resonance under the first piece of the sternum is impaired. The examinations of the abdomen, feces, urine and central nervous system are negative. Blood examination: Reed 4,800,000; hemoglobin 70 per cent (Dare) whites 9,600.

Bismuth mush was given. The X-ray showed a shadow arising at the level of the cricoid cartilage and extending just below the suprasternal notch. The shadow is a little more to the right than to the left.

Diagnosis: Pulsion diverticulum of the oesophagus, arising posteriorly and to the right at the level of the cricoid cartilage and extending to the manubrium sterni; ulceration in the diverticulum. Bronchiectasis and chronic peribronchial indurative pneumonia at the root of and extending into the left upper lobe. Chronic diffuse bronchitis.

There was no blood in the stools. Gentle efforts toward introducing various types of oesophageal bougies were unsuccessful.

The surgical removal seemed to be the only therapeutic course left to follow, because of inability to pass the diverticulum with catheter or stomach tube for the purpose of temporarily improving the nourishment of the patient.

Guided by the cream of wheat and bismuth skiagraph the incision was made along the anterior border of the right sterno cleidomastoid, the muscles and vessels were retracted to the right and the trachea and larynx slightly to the left, the diverticulum was readily reached and freed from surrounding tissues by blunt dissection, after the fashion used in dealing with a hernial sac, when it was grasped at its base with two gynecological forceps paralleling one another.

The pouch was removed upon the distal side of the distal clamp. The object being to remove the distal clamp and afford the operator an opportunity to sterilize the edges of the oesophageal wound and also have sufficient projection of the edges of the wound to allow the introduction of the first two layers of sutures. The first, including the mucosa, being "O" plain, with intestinal needle, and the second "O" chromic, including the muscular coat, after which the second or proximal clamp was removed, following which silk was used for approximating of the adentitia.

Drainage was employed, although the wound healed without complications, and for five days the patient was fed through a large Naelaton catheter which was introduced toward the close of the operation while the oesophagus was still exposed.

The condition of the patient improved daily, and he was upon liberal soft diet at the end of the week, gaining 17 lbs. in 8 weeks.

Enterostomy.

By J. P. LORD, M. D., Omaha.

A recent success from enterostomy for paralytic ileus, due to post operative peritonitis, prompts the writer to renew his efforts to popularize this procedure which he believes to be too infrequently resorted to in cases otherwise doomed.

The first presenting loop of bowel is incised. The primary incision and drainage of the bowel is now preferred over the

*Transaction Western Surgical Association, 1908-9-11.

former method of introducing sutures in the distended bowel, which practice was too often accompanied by needle punctures, leakage and soiling. Three purse-string sutures of 00 catgut are introduced in circles about the small incision in the gut. A firm smooth rubber tube or a number 14 to 20 catheter American scale may be used. The fenestrum in a catheter is usually too small and the end should therefore be cut off. I make a practice of cutting two or three openings and thereby reduce the liability of occlusion. This, however, has seriously interfered but once in eighteen cases. The apex of the cone of bowel collapses sufficiently to prevent leakage in the majority of cases upon removal of the tube about the third day. None have required subsequent operation for closure of the fistula. Two cases closed after silver nitrate injections of needle sized fistulae. Six cases are now known to be living. One recovered and disappeared, one has since died from puerperal sepsis complicated by a presumable return of obstruction. The remaining who died were of a most extreme type, it having been considered justifiable to afford patients doomed to die of obstruction the last remaining chance for life. The recovered cases were all of the last resort class, their lives having been undoubtedly saved by interruption of an otherwise fatal toxemia.

"Your husband does not knock you about as he used to do, eh?" "No, sir.'

"I am delighted to hear it. After all, his heart is in the right place.'

"Oh, yes, sir-and the rest of his body, too. He is in jail!"

Denver, Colo.-"Hello, papa!" These words, uttered by a three weeks' old baby, startled not only the parents of the child, but the doctor and a nurse, and the doctor, T. Mitchell Burns, is busy perusing his scientific works trying to account for the case, which is the most unusual that has ever come to his notice.

The baby is Helen Marie, daughter of William Wagner, a former policeman. She is developed physically and mentally far beyond her age, and is one of the most beautiful babies ever attended by the physician. Ability to utter understandable words at her tender age is her most remarkable accomplishment.

ABSTRACTS.

Air Sickness.

Air sickness in aviation is described by Dr. R. Cruchet as analogous to mountain sickness, and as due to sudden changes in the atmospheric pressure. Aviators are said to be often affected, at altitudes above three thousand feet, with quickened respiration and heart beat, headache and nausea. In the descent, after partial and temporary adaptation to a more rarified tmosphere, the conditions are reversed and the rapid increase of pressure leads to palpitation, suffocation, tinnitus, vertigo and somnolence. Cruchet believes that some of the fatal accidents have been due to the aviators becoming momentarily unconscious from these physiological phenomena and thereby losing control of the machine.

The Cost of Children.

"The Cost of Children" is discussed in the February 10th Outlook by Martha Bensley Bruere. The doctor's bill plays an important part in the cost, and, under certain circumstances, the nurse's. A priori, it does not seem right that a government should permit the birth of a citizen to tax the parents. Again we find ourselves becoming convinced that physicians should be paid as the police-or the army, if the comparison is liked better-are paid. The services, growing more and more prophylactic as intelligence and education increased, of an efficient medical or surgical specialist should be rendered to rich and poor alike, whenever required and at the general expense. As disease refuses to respect state lines, this must with us become a federal concern.

Iodine In Smallpox.

Rockhill has, during the past year, used a ten per cent iodine and ninety per cent glycerine solution, painting it over the pustules two or three times a day. The results are drying of the pustule, the absorption of the toxine, and arrest of destruction of the tissue; therefore, the disfiguring due to pock marks has been prevented. The stay at the hospital has been shortened from twenty-five to thirty days under the old treatment to from eight to fifteen days. The pustules on the face may be opened with a sterile instrument and touched up with tincture of iodine. Desquamation is frequently completed in

from four to six days, except a few pustules on the palms and soles. These may be opened, touched with tincture of iodine, and the patient then discharged. The author has treated eighty-five patients by this method during the past year, with 100 per cent recoveries, and with an average stay in hospital of twelve days. The favorable action of the iodine depends upon its valuable antiseptic properties.

Acute Tonsilitis.

In considering the prophylaxis and treatment, Schonemann (Practitioner, August, 1911), holds that the tonsils represent lymphatic glands of the neck, draining the pharyngeal mucous membrane. The normal function of the tonsils is the same as that of all lymphatic glands. Tonsilitis is, therefore, nothing more than an inflammation set up by infection brought by the lymphatics. Infection of the tonsils by way of the surface is very rare; the origin of the lymphatic vessels which end in the tonsils is to be found in the nasal mucous membrane. And it is possible that every cold in the nose may set up tonsilitis, although such need not necessarily occur. Upon such bases Schonemann has now discontinued all local treatment of inflamed tonsils. Instead he gives plenty of salicylate internally -gr. xlv of asperin in a quarter of an hour, with a large quantity of tea in order to promote sweating. The interior of the nose must be examined, and if any hypertophy is found, all such must be removed surgically-not by electric cautery. For disinfection of the nasal mucosa, Schonemann instills a 2 per cent callargol solution.

Oil of Camphor In Purulent Peritonitis.

Notwithstanding the great progress which modern surgery has made in the treatment of abdominal disease and the prophylaxis of peritoneal infection, purulent peritonitis remains, when once established, a very deadly malady. It is especially when acute disease of the vermiform appendix has been treated with insufficient promptness that this fatal complication remains familiar to the surgeon. Hence suggestions are heard from time to time urging the use of chemical agents, as well as saline irrigation and flushing of the peritoneum, which so often proves insufficient. Dr. Krecke, of Munich, recommends oil of camphor for this purpose and claims excellent results. He treated with complete success eleven cases of acute general purulent peritonitis, all resulting from perforation of a slough