may induce the habit of masturbation. In the female, a purulent discharge from the vagina is by no means uncommon. Worms of any kind are liable to occasion a mucous diarrhoea, associated with a good deal of tenesmus. Tape worms give rise to fewer local symptoms, but they are more often associated with progressive and even marked emaciation. The symptoms of worms are, as I have said, none of them pathognomonic, so that it is impossible to make a diagnosis off-hand. Supposing that a child is emaciating slowly, has a frequent cough, occasional diarrhoea, perhaps febrile attacks, and sleeps badly at night, it might equally well be suffering from commencing tuberculosis as from worms. It is indeed only by observation that the question can be settled. In all cases of doubt an aperient should be given, and the evacuations carefully examined. Treatment of this kind should in most cases, we may hope, enable us to clear up the difficulty. Treatment.-Worms, like tinea, usually accompany a state of health which, if it cannot be called bad, is yet below a normal standard; and, for one child in whom nothing but health can be detected, there will be many who are pale, thin and unkempt. Possibly in the case of tape worm the feeble health may in part be due to the presence of the parasite, but this can hardly be the case for other forms of worms, and, like tinea, therefore, the existence of any form of intestinal parasite may be considered an evidence of the need of tonic treatment and better hygiene. As a general prophylactic, salt is to be commended, and I am of opinion that this is a necessary article of diet, which is much neglected in feeding children. But general principles of this kind must be associated with special treatment directed to the death and expulsion of the worm, and this will vary for the different species. Thread worms should be attacked locally by means of enemata. A drachm of sulphate of iron may be added to a pint of infusion of quassia, and a third part of it injected on alternate mornings. Simple salt and water is recommended by some, lime-water by others. Enemata of this kind may be continued as long as may be necessary, and are moderately certain of success. But mothers and nurses often bungle over their administration, and either frighten the child so much that repetition of the treatment is impossible, or the fluid is allowed to run away again as soon as it is injected, when naturally enough a failure results. The lower bowel should be first emptied by an injection of warm soap and water. The child should lie upon a bed with its buttocks elevated, and the tube of the syringe should be passed gently within the inner sphincter. The fluid, previously warmed, must be injected with some little force, that it may be lodged in the upper part of the rectum, otherwise expulsive efforts will be immediately excited, the fluid will not reach its destination, and the desired end may not be secured. Even in such case, however, by compressing the anus between the buttocks, or by a firm pad, the expulsive effort may be overcome, and the enemata retained. If the enemata be not given at bedtime, the child should be kept on the bed for an hour or so after its administration. Attention to details of this kind determines the success of the treatment. Compared with it other measures are very inefficient. Brisk purgatives, such as calomel with jalap (F. 33), will cause the expulsion of many worms, but their action is not radical, and it is better therefore to trust if possible to enemata. They may be combined with an internal treatment of sulphate of iron and compound decoction of aloes (F. 34); and iron in some form should be continued for some time after the extermination of the worms. The irritation about the rectum is best re lieved by smearing the parts with a combination of mercurial ointment and glycerinum acidi carbolici in equal portions. The round worm is best treated by santonine, which may be given in doses of one or two grains three times a day, either disguised in bread and honey, or in a teaspoonful of confection of sulphur or confection of senna. After two days of this treatment some purgative should be administered, 3 ss of castor oil mixture (F. 3), or two grains of jalap resin in milk, being as good as any. A tonic treatment of iron is to be continued for some time after the dislodgement of the worms. [Other remedies are fluid extract of senna and spigelia and oil of chenopodium. With the first it is not necessary to give a purgative. The second may be given dropped upon a lump of sugar, three times a day; the third dose being followed by a brisk cathartic, or, it may be, administered in the form of an emulsion with castor oil, thus: S.-One teaspoonful three times daily, for a child of two years.] Many drugs have been proposed for the destruction of tape worms, pomegranate root bark, turpentine, cusso, and male fern being most prominently supported. But with children, as with adults, although it is advisable to have many strings to the bow, the oil of male fern is the one remedy in almost exclusive use. It is a drug which is apparently harmless even in doses of considerable size. drachm to a drachm and a half of the liquid extract is a proper dose. It may be given as an emulsion with 3ss of pulv. tragacanth. co.* either in milk or in any sweetened aromatic water that may be pleasant to the child. The anthelmintic must be given after a fast, and with the intestine previously emptied of its contents by castor-oil. After an early tea the castor-oil should be given, and early the next morning-as early as possible so as to avoid too prolonged a fast-the oil of male fern; the child lies quiet in bed the while, and two or three hours later a second dose of oil is given, after which food may be given when required. Should this treatment fail, turpentine should be given-twenty drops of oil of turpentine three times a day-the food being confined to liquids. The turpentine may be given as in formula 31, and must be followed up by a purgative every day or two. [Powdered kameela, given in syrup, and pumpkin-seeds, beaten up with sugar into an electuary, are also used. These are sometimes more successful than male fern. The dose of kameela is twenty grains to a drachm; of pumpkin-seed, from one to two drachms; each to be followed by a purge.] * Pulvis's Tragacanthæ Compositus, Br .P., contains: Tragacanth, in powder, Starch, in powder, Refined sugar, in powder, I ounce. 3 ounces.-ED. CHAPTER IX. INTUSSUSCEPTION. Intussusception is where one piece of intestine passes into a piece immediately continuous with it, the intussusception being the tumor so formed. In the common kind the ileocæcal valve and the lower part of the ileum are received into the colon, and the tumor is composed of the colon externally (ensheathing layer), the ileo-cæcal valve and cæcum within this (returning layer), and the lower part of the ileum, internally (entering layer). In this form, therefore, the ileo-cæcal valve is always the lowest part, and supposing, as is often the case, that the intussusception passes into the rectum, it is that part which is felt by the finger within, or which protrudes from the anus. Much more rarely a piece of the ileum passes through the ileo-cæcal valve; or some other part of the large or small intestine is affected away from the valve. Further, as might be expected, the direction of the intussusception is almost invariably from above downwards; although one or two cases are on record in which the reverse direction has obtained, and a piece from below has passed into that which lies above it. Pathology. It would not be difficult to occupy a good deal of space in discussing this question, but not much good would be gained thereby. I shall, therefore, be content with insisting upon one or two facts which seem to be allimportant in their bearing upon it. And first, let it be noticed that by far the larger number of cases of intussusception occur in infants under two years of age-most of them under a year; secondly, that small intussusceptions in the |