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of supply and demand. Good nurses are not forthcoming atthe wages and conditions offered. The Metropolitan AsylumsBoard was confronted with the same difficulty in its

fever hospitals. It solved the difficulty by offering higherwages and better conditions of service and the Local Govern-

ment Board would be well advised to adopt similar means.In the interests alike of the medical profession, the public,and the Poor-law nursing service we feel bound to enter

our protest at the earliest moment against a retrograde pro-posal. A large section of the public is becoming impatient,at the non-solution of this important question of workhouse

nursing. The constitution of this departmental committeewas unsatisfactory, its recommendations carry but little

weight, and the time has come for a Royal Commission tobe appointed in order thoroughly to investigate the matter.

The Treatment of Intussusception.A TRULY remarkable series of cases of intussusception

- was recently met with at the London Hospital, where withinnine days seven cases of this condition were admitted intothe wards. They were all under the care of Mr. HUGH M.RIGBY who contributed a detailed account of them to

THE LANCET of Feb. 7th (p. 364). One of the seven

patients was in a moribund condition when admitted and

died four hours later, and therefore we need hardly con-sider that case, but the remaining six patients were

submitted to operation and of these five recovered. The

one fatal case required resection of a portion of the boweland this complication of the operation for intussusceptionis universally recognised as of the gravest prognosis.Within recent years the whole question of the treatment

of intussusception has undergone a great change and

an examination of the reasons for the adoption of

the present methods should be by no means devoid of

interest.

Not long after the pathology of intussusception was

investigated the idea of forcing back the invaginated bowel

by fluid pressure arose. The earlier attempts were madewith air which was forced in by means of a syringe ; laterliquids were employed, water being chiefly used, thougholive oil has been advocated. Hydrogen and carbonic acidgas have also had their supporters, there is a very obvious

limitation to the action of both inflation and injection andthis is imposed by the ileo-cascal valve. Any intussuscep-tion limited to the small bowel cannot be affected by thedistension of the large intestine, for distension of the caecumcloses the valve firmly. It is true that it has been demon-

strated that in excessive distension of the caecum some of

the contents may escape upwards through the valve, but

this can only happen to a slight extent and when the

distending force is very great. Therefore these methods are

possible only in some forms of intussusception. The treat.

ment by inflation, and especially by injection, did certainlysucceed in reducing some intussusceptions, and this was so,not only in slight cases, but even in extensive cases, as

in one recorded by Dr. E. MANSEL SYMPSON, where severalinches of bowel protruded from the anus. In what pro-

portion of cases methods of distension succeed cannot

definitely be stated, but the statistics collected by Dr.

F. HOLME WiGGIN of New York, which give the per-

centage of successes as 25, may be considered as not under-

estimating the beneficial results of the treatment. Dis-

tension of the colon, too, is not without danger, for numerouscases are on record in which rupture of the bowel has

occurred. Mr. R. LAWFORD KNAGGS has collected seven

cases in which this accident was encountered and no

wonder need be felt at the rupture of the bowel under theconditions in which distension is usually performed, for

in most cases no attempt is made to gauge the pressureexerted by the distending fluid. A syringe is usuallyemployed and the pressure exerted by the hand on the

syringe is a very poor index to the pressure in the bowel. A

curious fact is here of great importance, and that is that thesmaller the syringe employed the greater is the distendingforce. The quantity of the liquid injected is an equallyfallacious test of the pressure in the bowel, for Mr. D’DARCYPOWER has shown that the capacity of the colon varies

greatly in different children. Indeed, in one of the fatal

cases of rupture of the bowel only nine ounces of

water had been injected. The process of distension mayalso be very exhausting to the child, especially if it

has to be repeated, as is necessary sometimes when

this is the sole method of treatment employed. In some

cases the process has been repeated four or five times.

An important objection to the treatment by distension is

that it is often very difficult for the surgeon to be certain

that the reduction is complete, for so small a portionof bowel may remain invaginated that nothing can be felt

through the abdominal wall and yet a fatal issue may

follow. On the other hand, the surgeon may feel a

small swelling after distension has been practised and

may think that reduction has not been complete, thoughthe mass felt is only cedematous bowel.For these and other reasons there has been of recent years

a growing tendency to resort to abdominal section at an

early stage of a case of intussusception. Even in the pasta laparotomy frequently followed unsuccessful attempts at

distension, but these unsuccessful attempts had been oftenso energetic and persistent that the severe exhaustion

that had been induced entirely precluded the possibilityof a successful result following the abdominal section.

Mr. JONATHAN HuTCHINSON’S case recorded in the fifty-seventh volume of the Medico-Chirargieal Transactions

appears to have been the first successful case in this

country, though one had occurred in France towards the

end of the eighteenth century. Since Mr. HUTCHINSON’S

case in 1871 many others have been recorded ; still failures

far outnumbered successes and, indeed, laparotomy for

intussusception had fallen into a certain degree of dis-

repute. With the development of abdominal surgery the con-fidence of the surgeon in the comparative harmlessness of a

laparotomy developed, and the abdomen was opened for thetreatment of this condition with less and less hesitation.

Still, however, the mortality continued high, and it was seenthat no small share of the blame was to be attributed to the

exhaustion produced by the previous attempts at reduction.Abdominal section was therefore gradually performed at anearlier stage, until it was found that the best results were

obtainable in those cases where little or no previous attemptsat distension had been made, and at the present time recourse

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to injection or inflation is gradually falling into disuse, andtheir place is being taken by laparotomy. The results

justify the change and the series of cases recently treated atthe London Hospital, to which we have already referred,clearly demonstrate the value of a primary abdominal sectionin intussusception. It is essential to distinguish in pre-

paring statistics between secondary laparotomy, where thecase has been previously treated by distension, and primarylaparotomy, in which no other remedial measures have been

employed. A confusion of these two classes will utterlyvitiate the conclusions from any series of cases. The ease

with which the invaginated gut can generally be with-

drawn after the abdomen has been opened is trulymarvellous, but in this, as in all other forms of acute in-

testinal obstruction, much depends on the duration of the

symptoms and the tightness of the constriction. If several

days have elapsed and the inclosed bowel is tightlynipped, peritoneal adhesions will have fixed it, and it

may be impossible to withdraw it. In such circumstances

the prognosis cannot fail to be very grave whatever

method of treatment be adopted. Fortunately these com-

plications are exceptional, especially in cases treated early,and therefore we may hope for even better results with a

growing recognition on the part of the public of the

importance of early treatment.

May it then be said that distension should never be

attempted ? The treatment of an analogous condition,

strangulated hernia, will furnish the answer. Formerlywhen a hernia became strangulated severe and protractedtaxis was frequently employed for its reduction with

disastrous results to the patient ; now the routine treat-

ment is an immediate herniotomy, but this may harm-

lessly be preceded by a single gentle attempt at reduc-tion if the strangulation is recent. So is it too with

intussusception. Laparotomy is the best method by whichto treat this condition, but a single gentle attempt atdistension in recent cases which are confined to the largeintestine and not of an acute type may be performed with

impunity. One condition, however, is essential. The

pressure in the colon must be absolutely under control, andthis can only be effected by employing a liquid as the dis-

tending agent and using a funnel and rubber tube to intro.duce it. If the funnel be raised not more than two feet

above the level of the patient the pressure will not exceedone pound on the square inch, and this pressure is probablyperfectly safe. The attempt should be made under an

anaesthetic and should it fail laparotomy can be immediatelyproceeded with, while the surgeon will feel sure that he hasnot by this gentle distension impaired the chance of successof his operative procedure.

The Royal Dental Hospital andits Anæsthetists.

THE entire staff of anassthetists of the Royal Dental

Hospital of London have been dismissed from their postsin circumstances which require consideration from us, andwe think that our readers will agree that the circumstances

also require more consideration than they have apparentlyreceived from the committee of management of the well-known hospital in Leicester-square. The story is briefly as

follows:-At the Royal Dental Hospital of London there

has lately been appointed an officer-and doubtless he hasproved a very useful officer-who is known as the dental

superintendent. His duty we find in a recent report of

the medical committee of the hospital defined as being"to supervise and direct the work of the demonstrators,the house surgeons, the curators, students, and pupils,and in the unavoidable absence of the anaesthetists to act as

their deputy " ; and the same report adds that his appoint-ment has proved an unmixed benefit to the hospital. In

October of last year the dental superintendent presented areport to the committee of management of the hospitalwhich is not in our hands, but which appears to have

attributed want of regularity and punctuality in the exerciseof their duties to some of the dental staff and some of the

administrators of anaesthetics attached to the hospital.This report was referred to and read at a meeting of

the medical committee without any special notice of its

contents being sent to the anaesthetists, who are, however,members of the medical committee; and as a result a

sub-committee was elected upon the suggestion of the

medical committee to consider the dental superintendent’sreport. The sub-committee was composed jointly of membersof the medical committee and members of the committee

of management, and reported to the committee of manage-ment ’’ that having regard to the enormous increase in thenumber of gas cases the sub-committee is of opinion thatthe best way of dealing efficiently with the problem is bythe appointment of two paid anaesthetists in place of thepresent honorary anaesthetic staff." " The report also definedthe hours of attendance of the medical staff and concluded

thus :-"that the members of the anaesthetic staff be thanked

for their services and be made honorary governors of the

hospital and that the two seniors be elected consultinganesthetists to the institution." This last clause amount,in our view, to dismissal of the anaesthetists of the hospitaland, it may be noted, without any marked expressionof gratitude for past services. The report was adoptedby resolution of the committee of management without

being submitted to the medical committee, and was at onceembodied in a circular letter and despatched to the anæs-

thetists of the hospital, the majority of whom received it

with complete surprise. Perhaps the anaesthetists may havebeen, as the sub-committee’s report comically calls them, an"anajsthetic staff " not to suspect what was in the wind, but

they did not. Some two years ago, at the time, we believe,that the dental superintendent was appointed, dissatisfactionwas expressed with the way in which the anaesthetists

rendered their services, but this had not prepared them for adismissal en bloc, with only a formal word of thanks and no

regretful phrase.Such is the story. There are several points of a personal

nature which may arise in the discussion of this unfortunate

affair, but we intend to do our best to consider the

matter wholly on the broad grounds of the good of the

public and of the dignity of the medical profession. The

committee of management proposes to make an immediatealteration in the regulations of the hospital which we arequite ready to believe is intended as a measure of reform,but which seems to us to constitute a possible danger to thepublic and to display scant respect for an important body of