a thermal rise and of previous severe constitutional symptoms would exclude this. In concluding this short differentiation, I may say that a distinct diagnosis between a pulmonary embolus and a late uterine rupture was next to impossible in this case. In introducing the forceps, I must of necessity have passed them into the uterine cavity, and, by the continuous and powerful manipulation which I brought to bear, may have given rise to a deep lesion in the wall of the uterus, and in this way a seat for ulceration was started (Scanzoni, "Geburtshilfe "). It is my opinion that the case should not have been delivered in this way after the first application of the forceps. Had the case occurred in a woman with a roomy pelvis, the forceps would certainly have been indicated, and this on account of the child's condition. Three symptoms of all importance were present which indicated that fetal life was very much endangered, and I certainly know that if the forceps were more often applied when these symptoms presented themselves, more children would be saved. If the forceps were less applied for the fact that the mother was tired or sleepy, or the regulation one or two hours for the second stage were up, and more applied for the child's safety, a good deed would be done. The three symptoms which indicate danger to the fetus are:

I. Slowing of the heart's action between and during the pains, say a fetal heart of eighty, or a gradual sinking of the tones during each pain, or especially where the heart tones have been good and suddenly cease. If the sounds sink to eighty or seventy in a pain, but rise again to one hundred and twenty or one hundred and forty in the intervals, there is no danger to be apprehended. But if, in a given case, the heart tones should even be one hundred for a considerable time, the case should demand the entire attention of the physician, and even under these conditions, especially if the woman had previously borne dead children, it would be well to terminate the labor, providing the condition of the parts allowed it.

II. Escape of meconium is a symptom of great importance. It shows that there is a paralysis of the voluntary muscles, and especially the sphincter ani, from some cause, and most frequently this is carbonic gas poisoning. Should this symptom be present with a fetal heart of eighty, the most urgent symptoms are presented to the accoucheur for a speedy delivery. Time and time again have I noticed this, and it often was the only

cause for terminating a labor. I have yet to see the case in which the child was not to some degree asphyxiated where these two symptoms were present.

III. The umbilical souffle is a symptom, when present, not to be forgotten. It reminds one of a soft, blowing murmur, synchronous with the fetal heart. It is caused by the cord being subjected to pressure, either from being around the child's neck or around its body, or pressed against the uterine walls; therefore it should be found in every case where it is suspected that the cord is being pressed upon.

In the above case, we see a multipara with a contracted pelvic inlet in labor for over sixteen hours in the second stage, with good pains all this time, a very large fetus, a child in imminent danger. In such a case, the mother should be given a chance, especially after the forceps have been applied and have failed to deliver the child. Means should then be used to destroy the life of the fetus. What would have been simpler, and at the same time safer to the mother, in this case, than a perforation and the cranioclast? I feel almost certain that, had the child been destroyed, the mother's life would have been saved. As it was, both lost their lives.

INTUSSUSCEPTION IN CHILDREN.

BY

EDWARD B. BAYLISS, M.D.,

Newport, Ky.

THE article in the JOURNAL for July, under the above heading, has been of great interest to me, and perhaps to many others of my professional brethren. They, with me, will join in thanking Dr. Forest for supplementing our knowledge, combined as it is with a lack of ingenuity, by his readiness of resource.

I wish to give in this article a history of three cases, in one of which an error in diagnosis was made, by both my colleague and myself; the other two being simple cases, easily recognized, and by the use of Dr. Forest's apparatus, slightly changed,

treated readily and successfully. Before deciding to report case I., I looked up what references I had at hand in order to discover whether my error was on account of ignorance pure and simple, or whether others had made errors similar to mine. While I find no similar cases reported, the conclusion has not forced itself upon my mind that I am woefully ignorant, but rather that the case is a singular one. I give it in order to show how we may be misled, and with what results to our patients.

CASE I.-Bowman, æt. 5 years, male, was brought into the office April 28th, 1886, and was examined by my partner, Dr. Jenkins. At this time the mother gave him the history, subsequently repeated to me, that for three weeks preceding this time the child had colicky pains over the entire abdomen, so severe that he would cry out at intervals of a few minutes. Previous to bringing him to our office, she had consulted another physician, who, remarking that nothing was wrong, had ordered castor-oil. A further point in the history of the case was that the child never took the trouble to masticate his food, always swallowing it whole. There was no history of vomiting and the bowels were said to be regular. On examination of the abdomen, a long, hard, tumor-like swelling was found lying to the left and on a level with the umbilicus. Manipulation of this mass or swelling occasioned no pain to the child. The pulse, tongue, and temperature were normal. Supposing the presence of a mass of hardened feces, hydr. chl. mit., gr. iss. in twelve powders, was ordered, one powder to be given each two hours until the bowels moved freely. On April 30th, the tumor had disappeared and the patient felt and looked better and brighter. The mother stated that the child had passed five large pieces of banana which she remembered he had eaten about two weeks previously. There was now no trouble for several days, when a neighbor, in the goodness of her heart, gave the child several cubes of green rhubarb, which were bolted as usual. Soon the bowel pain reappeared, for which the mother gave several of the calomel powders, six having previously been given. The following morning the patient was brought to the office, at which time the symptoms were the same as before, still no constipation or vomiting. For the pain a solution of morph. bimeconate was ordered to be given each hour. In the evening the child was brought back, at which time I first saw the case. The abdomen was soft. There was not excessive pain, and no tenderness. The tumor was distinctly felt in the transverse colon over toward the left, and was about two inches long. The bimeconate solution was continued, and a poultice ordered to be retained till the patient was seen in the morning. In the morning the pain had almost entirely ceased, and the tumor appeared smaller and softer. Two days later, when seen again, the tumor was felt low down on the

right side and was not giving any pain. From this time for a week or more the patient was better and worse, alternately, and under the use of magnesia sulph. in broken doses, the tumor appeared to be smaller and the stools were fecal in character. Then the tumor appeared to enlarge and to ascend into the transverse colon, going as far as the sigmoid flexure, where it would lodge. At times there would be severe pain, and at times none. The stools being soft and feculent, with no blood or slime, still put us off our guard. At one time the tumor was four inches long, while at others it was very small. It also appeared to change its position, so much so that we were led to discuss the possibility of a tumor with a long pedicle, or a floating kidney. Besides this, the tumor was of two parts, with a distinct sulcus between them. On questioning the mother, we found that the child had eaten prunes, swallowing seeds and all. These seeds, we thought, might form a beginning for the tumor, and the fecal stools could then be accounted for by the openings between the stones allowing of their passage. The pain also could be accounted for by the sharp points of the seeds bruising the bowel. Acting on this idea, we inserted the rectal tube so much and sarcastically written about, and succeeded in filling the bowel. This had the effect of bringing away hard, black lumps, as the mother described them, and also a ring which she assured us was of fecal matter. After this the tumor appeared smaller, and a second washing out had much the same effect. Shortly after this, a quantity of pus was discharged, after which the child appeared easier. The tumor appeared the same as before, but the pain was not as great, in fact the child was very comfortable, with stools as before; no straining or vomiting. A solution of morphia gr. i. to aqua menth. pip. 3 i. was left to be given as needed, but very little of it was used. The patient was eating fairly well, and was on hydroleine as well, when whooping-cough set in. Still he appeared to be doing well, but coughed very hard. After a very severe spasm, he sat up and said he felt weak, then fell back dead, having had hardly any pain for some days.

About eight hours after death, a post-mortem examination was made by Dr. Jenkins and myself. The tumor, as felt through the abdominal walls, was long, reaching entirely across the abdomen in the region of the transverse colon; abdominal wall flat, never had been tympanitic. On examination of the intestines, they were found to be somewhat injected, especially the transverse colon, which was also covered with newly-formed lymph. It was also felt to be remarkably thickened, giving one the idea of a large sausage. Following the tumor over to the right, we found a portion of the ileum extending into a sulcus in the tumor immediately under the liver. Then we knew that we had to deal with an intussusception. We removed the specimen, and after washing, split it longitudinally. The walls of the transverse colon were much thickened, and the cecum was lying in the first curve of the sigmoid flexure. It was gangrenous, as were the

parts around. The ileo-cecal valve was patulous, and where the vermiform appendix had probably been, was an ulceration extending clear through the bowel, so large that at the first glance it was taken to be the valve itself. No adhesions had formed at any point, and no peritonitis was present. No other portions were examined.

A post-mortem diagnosis is easy, but looking back over this case with its history, I am unable to see anything that I could have put my hands on, and said this is conclusive and the case is clear. In Smith, Steiner, and Pepper's System the symptoms laid down are much the same. In all of them the vomiting and constipation, with straining, and perhaps passage of blood are relied on for a diagnosis. In this case we had none of these symptoms; on the contrary, there was a surprising regularity in all the bodily functions. In no case that I have found, was there a history of a tumor that disappeared on the passage of articles as large as pieces of banana, but reappeared on ingestion of pieces as nearly conforming in size to the original cause as this. Neither is there any history of a case of intussusception developing as slowly as did this. Smith speaks of cases remaining pervious, and finally dying of exhaustion; this was evidently one of that kind. This perviousness is explained, I think, by the position of the ileocecal valve, being, as it was, nearly at the apex of the cone formed by the inverted eecum. The question naturally arises, whether, if the case had been understood in the start, it could have been successfully treated, and whether an operation at the last stage would have been of any use. We were of the opinion that, had the whooping-cough not come in as a complicating factor, the child would have recovered. Judging from the lack of adhesions after so long sickness, we were not far wrong. We were deprived of the diagnostic benefit derived from the tumor felt in the rectum or extending beyond it, probably by the fact that the cecum was too large to pass the sigmoid flexure. I should say, however, that the tumor, as felt by the hand ante mortem, was never so far over as it was found post mortem, due probably to the tumor having been forced over by spasmodic action of the diaphragm during the attacks of pertussis. The question as to what might have been done if the true nature of the case had been early discovered, and how much the intercurrent pertussis would have affected the result, had any been obtained, I must leave undecided. In a similar case, how