tumor be equal, yet how infinitely more dangerous is the treatment advocated by Mr. Bryant than that of a properly administered injection.

His method adds to the possibility of lacerating the intestine the certain danger of death from peritonitis or shock arising from the abdominal incisions and manipulations. The latter danger is not a slight one by any means. The abdominal cavity, in children at least, cannot be opened with impunity. Treves' tables show that after laparotomy the death-rate in children, even though the invagination was "easily reduced," is 43 per cent.

What is this high death-rate due to? Not to the reduction of the invagination, for that was "easily reduced.”

It must be mainly due to the abdominal section. It will be said that delay in operating and consequent exhaustion of the patient is the cause of the fatal result. It may be said in reply that, had a properly given injection reduced the tumor without opening the abdomen, the patient, however weak and collapsed, would in the very large majority of these cases have quickly rallied and recovered. Numerous cases are reported where the prostration and collapse was profound and had continued for days, and yet when the invagination was reduced without opening the abdomen the patient quickly recovered. In fact, I can find no case on record where the patient died after the tumor was once reduced by insufflation or injection.

But we need to ask here, if the reduction of the invagination was "easy," why was the operation of laparotomy necessary at all?

It would seem, from the nature of the problem, that any case of invagination in the large intestine that can be easily reduced by the surgeon's fingers might have been safely reduced by the direct pressure of liquid injected into the colon.

The force thus exerted ought to be as safe and effective in untwisting and pushing back the intestinal tumor as the pulling and pushing by the surgeon's fingers after the abdomen is opened.

Surely, then, the grave operation of laparotomy should be reserved for cases that cannot be reduced by the simple operation of giving a forcible injection.

Now, what have been the results of laparotomy for intussusception in children where the invagination " was reduced with

difficulty or was irreducible"? According to the statistics of Leichtenstern, of Treves, and of Schramm, who have collected by far the largest number of these cases of any authors, the death-rate after laparotomy "where the invagination was difficult or irreducible" was just 100 per cent; not a single case recovered. Laparotomy has succeeded in 57 per cent of the cases where it was not indicated at all, where simpler, and less dangerous methods would have succeeded far better; and, according to statistics, has failed in every case where laparotomy was really indicated. These conclusions only apply to children under 12 or 15 years of age.

Spontaneous Cure. The second course open in an obstinate case is to leave it to nature. What are the statistics of operations by sloughing of the invaginated portion of the intestine, and how do these compare with laparotomy?

In the infant, spontaneous elimination takes place in only 2 per cent of the cases, and even these do not recover. In the second to the fifth year of age, spontaneous elimination takes place in only 6 per cent of the cases, and most of these die. Hence, up to the sixth year of age nature fails to cure these cases because the child's strength gives out before the slough can be thrown off.

Between the sixth and eleventh year, however, spontaneous elimination takes place in 38 per cent of the cases; and recovery takes place in 42 per cent of those that undergo spontaneous elimination. In other words, 22 per cent of all cases of intussusception that occur between 6 and 10 years of age recover by nature's operation.

We may suppose those cases of spontaneous elimination cases "difficult or impossible to reduce"-at least they never were reduced, although in most of them attempts were made to do so. When we compare nature's results in these cases with those of laparotomy in "difficult" cases, we are struck by the advantage of nature's method over that of the surgeon.

In children over 10 years of age, nature's operation gives still better results.

Hence it does not follow that, if one cannot reduce an invagination in all cases by an injection, he should, of course, call in a surgeon to open the abdomen.

This depends, among other things, on the age of the patient. Forcible Injections. The third course open in any case that

resists an injection given with a safe degree of force (six or seven pounds pressure to the square inch) is to resort to still greater force, say nine or ten pounds pressure to the square inch. This cannot be done without danger of rupturing the intestine, and thus causing the death of the patient.

But it must be borne in mind that these cases are dangerous ones, at the best, and-whether we leave them to nature, or resort to laparotomy-the death rate must be very high in any case.

In children under 6 years of age, either laparotomy or nature's operation is almost always fatal; hence we would be justified in running some risk in giving a forcible injection in these cases.

Not to draw this out too far, let me state in a few words the course I would recommend in all cases of intussusception in children.

A pressure of six pounds to the square inch having failed to reduce the tumor after a lengthened trial, I should cautiously raise the pressure to seven and eight pounds, and even nine pounds to the square inch, depending on the acuteness of the attack and the length of time the invagination had continued. This having failed, what course should then be followed?

If the child be under 2 years of age, open the abdomen at once and resect the intestine. The child will probably die; but, if left to nature, the case it absolutely hopeless.

If the child be between 2 and 5 years of age, and injections have failed, the chances of cure by sloughing or from laparotomy are about equal, and the surgeon will be justified in following either course. Remember that the invagination probably cannot be reduced even by traction, and the principal object in opening the abdomen is to resect the intestine, or to perform enterotomy.

If, however, the child be over five years of age, and the tumor has resisted a pressure of eight or nine or ten pounds to the square inch without being reduced, we must conclude that it is irreducible.

Now, according to statistics given above, the operation of laparotomy in these cases shows a greater death rate than the cure by sloughing, the "spontaneous cure;" therefore, nature's operation, nearly hopeless as it is, should be preferred to laparotomy.

29 WASHINGTON SQUARE, New York.

A NEW INSTRUMENT FOR INTRAUTERINE MEDICATION.

BY

EUGENE C. GEHRUNG, M.D.,

St. Louis, Mo.

IN consideration of the dangers accompanying the injection. of fluids into the undilated or even the dilated uterus, by all the means at present in use, I take pleasure in presenting to the profession a new instrument, based on a principle not before applied in the practice of medicine and surgery, by means of which I am enabled to wash out the undilated womb, and make applications of medicinal agents with absolute safety (if such an expression can ever be applied to any procedure in the practice of medicine) to this and other cavities.

FIG. 1-Represents the entire apparatus, one-third the natural size. The letters A and B are applied to corresponding parts in both engravings.

FIG. 2-Represents the canula cut open lengthwise, natural size.

The instrument is simple in construction and consists of a double canula. The outer canula A is made one-eighth of an inch in diameter; and is nine and six-eighths inches in length; the inner, G (Fig. 2), is about one-third this size and is oneeighth of an inch shorter. The outer canula has also an arm or branch B, to which a piece of rubber-tubing is attached, which dips into the vessel containing the fluid with which it is desired to inject the uterus. The inner canula has an enlargement at the

extremity П, which causes it to fit the outer canula closely at this point, and make an air-tight joint, it being retained in its place by friction only, which permits it to be readily withdrawn and replaced for the purpose of cleansing. The extremity II of the inner canula has a conical finish on its inner aspect to receive an aspirator point and provide an air-tight fitting. The distal extremity of the outer canula is provided with four rows of openings extending one and one-half inches back from the point. At I(Fig. 2), the inner canula is provided with a diaphragm or metal plug fitting closely into the outer tube, and screwed on the inner canula by a thread running down from its point to I.

The aspirator F terminates at its lower end in a screw point to which is attached the stop-cock arrangement, E (Fig. 1). This stop-cock is so arranged that, by placing the lever in the position as indicated in the cut, the aspirator is completely closed, while the canula A is in direct connection through the stop-cock with the outlet tube D. By moving it towards and in a line with the syringe, this and the canula A are connected; by turning it to a point opposite to E, the canula A is closed, and connection between the syringe and the tube D (Fig. 1) is established.

The principles applied are: 1st, the use of a vis a fronte instead of a vis a tergo, and 2d, that of causing the cavity to be injected to complete the connection between the two canula.

To better understand the modus operandi, suppose the point of the canula introduced into the cavity of the womb, the tubing attached to the arm B, and the aspirator, with the piston closed, attached to the canula at H, Fig. 2. By withdrawing the piston, a vacuum is formed in the apparatus, which is felt by the liquid into which the weighted end of the tubing is plunged. The atmospheric pressure being thus removed from a portion of the fluid, this will ascend through the tubing and canula B, course along the space between the inner and outer canula, till it reaches the lower holes in the walls of the latter, through which it flows into the cavity of the uterus until this is filled to the level of the holes nearest the point of the instrument. It re-enters the canula through these, and finds its way through the inner canula to the syringe, which, when full, can be emptied through the outflow tube D into a receiving vessel, without being detached from the apparatus, by turning the stop-cock so as to connect the syringe