the rectum may possibly be confounded, are dysentery, hæmorrhoids, and prolapsus of the rectum.

From dysentery it may readily be distinguished by the absence of the glairy matter in the stools, of abdominal pain, of fever, and, in fact of every symptom of the latter disease, excepting the presence of blood in the evacuations, and, perhaps, frequent ineffectual calls to evacuate the bowels.

From hæmorrhoids it may be distinguished by the color and general appearance of the tumor, and its place of insertion: the age of the patient will also serve as a diagnostic mark.

A careful examination will, as we have already remarked, very readily enable the practitioner to distinguish a protruding polypus of the rectum from a prolapsus of the intestines."

In the application of the ligature for the removal of these polypous tumors, Dr. Gigon directs the child to be placed on his stomach, and made to strain, so as to protrude the tumor beyond the anus; it is then to be seized with a pair of forceps and drawn out still farther, so as to get at the pedicle, which is readily effected in consequence of the lax condition of the mucous membrane in children. It is often somewhat difficult to distinguish where the pedicle ends and the mucous membrane commences, in consequence of the color of both being the same. It is necessary, however, to pay some attention to this, in order that as little as possible of the mucous membrane may be included in the ligature. A waxed ligature is to be passed around the pedicle, but not drawn too tightly, for fear of rupturing it. It is better, after the ligature is properly applied, to return the whole into the rectum, without dividing the pedicle, as in one case, which fell under the notice of Dr. Gigon, in which excision was practised, a troublesome hemorrhage followed. The tumor, in general, comes away on the second or third day after the operation, which is unattended with pain, and, when properly performed, is not liable to be followed by any accident.

Dr. James Syme (London and Edinburgh Journ. of Med. Science, July, 1845) describes a form of polypus of the rectum, of which he has met with only one case in children beyond the age of nine or ten years. It is extremely soft and vascular, of a florid red color, and either of a cylindrical form, two to four inches in length, or resembling somewhat a strawberry, with a connecting footstalk, two or three inches long. It seldom protrudes except when the bowels are evacuated, and then admits of ready replacement, though not without occasional hemorrhage, which may be considerable in amount. A somewhat similar form of the disease is described by Dr. Bourgeois in the Bulletin Général Thérapeutique Méd. et Chirurg., and by Perrin in the Revue Médico-Chirurgicale, 1845.

In the removal of the tumor, Dr. Syme has always employed the ligature, and though the soft texture readily gives way when the thread is drawn, bleeding has never occurred in a single instance, nor any other symptom in the least degree disagreeable.

In a case which occurred in a female child, two years and a half old, Perrin (Revue Médico-Chirurg.) extracted the polypus by rup

turing its pedicle with his nails. It was of the size of a raspberry. A few drops of blood only followed the separation of the polypus. The next day during a stool the child discharged a clot of black blood of the size of a small nut, indicating a hemorrhage from the remaining portion of the pedicle.

6. Invagination of the Intestines.

Intestinal invagination or intussusception, that is, the passage of one portion of the intestine within that above or below it, is often met with in children who have died of various diseases, and appears in such cases to take place in the act of dying, from some convulsive or irregular movement of the muscular fibres of the intestinal canal. In these instances of invagination no symptoms are present during the lifetime of the patient to denote their existence, and after death they are reducible with perfect ease.

Occasionally, however, invagination of the intestines occurs in children during life, and then gives rise to symptoms of the most serious character, and, in the great majority of cases, more or less speedily destroys the life of the patient.

The symptoms are obstinate costiveness, or an abundant serous or bilious diarrhoea, progressive tumefaction of the abdomen, with tenderness upon pressure, often repeated paroxysms of acute pain, discharges of blood per anum, and subsequently of fecal matter, a peculiar distressed expression of countenance, with coldness of the extremities, and a feeble, scarcely perceptible pulse.

Dr. Gorham lays great stress on "the passing of blood per anum in various degrees of purity, never, indeed, contaminated with feculent matter, but chiefly with mucus," as a diagnostic sign in this affection. To this may be added constipation, vomiting, and constant straining as if a motion were about to occur, nothing, however, passing but blood, from a few drops to a copious hemorrhage.

The cause of the obstruction to the onward passage of the feces in cases of invagination, as well as of the other symptoms by which they are ordinarily attended, is, unquestionably, the occurrence of inflammation in the intestine, at the part where the invagination has occurred, and a consequent adhesion of the peritoneal surfaces that are brought into contact, producing not only a narrowing of the caliber of the intestine, but impeding or destroying its regular peristaltic action.

Invagination may take place in any part of the intestinal canal, but is most generally seated near the termination of the ileum. Cases are related in which the invaginated portion has sloughed off, and been discharged by the rectum; this seldom occurs, however, in children.

It is always the superior portion of the intestine which introduces itself into the inferior, and the extent of the invagination varies from three to six, twelve, or even eighteen inches.

According to Rilliet the intestinal invagination is always accomplished at the expense of the large intestine, invagination of the

small intestine never taking place. The inaccuracy of this statement is, however, pointed out by Bouchut, who has observed invagination of the small intestine into the adjacent inferior part. Taylor reports a case of this kind in a child twenty months old who died after an attack of acute peritonitis. Marage has seen another case in a child thirteen months old, who recovered after voiding the invaginated portion. Two other cases are reported, one by Trevor and the other by Thomas.-(Amer. Journal, 1852-Amer. Mel. Recorder, 1823.)

The disease is very generally fatal. In no instance, that has fallen within our own observation, has a favorable termination taken place in any case in which symptoms indicative of invagination were present. It must be confessed, however, that the more grave form of the disease seldom occurs in the small intestines, or in children under one or two years. Nevertheless there are a number of cases on record in which sloughing and expulsion of the invaginated portion of intestine was followed by entire recovery.

From an analysis, made by Dr. J. L. Smith, of New York, of 47 cases of intussusception, in which the ages are given, it appears that the disease occurs most frequently between the third and sixth months of infancy, and that more cases are met with in children

under one year of age than between one and twelve years.

The cases reported show that the disease occurs most frequently in males, in the proportion of two to one female.

Cases in which the intestine is strangulated are fatal within eight days. If the intestine continues pervious, and its circulation unobstructed, the child may live for many weeks, or even recover. An early death is often preceded by convulsions. (Amer. Journ. Med. Sciences, Jan. 1862.)

The appearances exhibited upon dissection, are those of inflam mation of the mucous membrane of the intestines, and often of their peritoneal coat. At the invaginated portion, the mucous surface is often highly inflamed, of a dark-red color, thickened, and covered, frequently, with a dark-red effusion, intermixed with portions resembling coagulable lymph; the two serous surfaces in contact are likewise inflamed, with exudation and adhesion.

In the treatment of invagination, such remedies should be employed as are calculated to prevent or reduce inflammation, and to restore the natural action of the intestines;-the warm bath, frequently repeated-leeches and warm fomentations to the abdomen, and abstinence from food and drinks.

The forcible injection of large quantities of warm water, or of air, by the rectum, has been strongly advised in cases of invagination, with the view of restoring the natural condition of the intestine, previous to the occurrence of inflammation. We know of no instance, however, in which this means has been crowned with success; after the occurrence of inflammation, it will necessarily fail, and may even be productive of mischievous effects.

In cases in which the invagination has been preceded by costiveness of the bowels, the injection of a large quantity of warm milk

and water, through a long elastic tube passed into the sigmoid flexure of the colon, may do good, by removing from the intestines any hardened and impacted feces, the retention of which we have reason to believe is occasionally a cause of invagination.

7.- Intestinal Worms.

At one period, and that a comparatively recent one, nearly all the diseases of infancy and early childhood were ascribed to the presence of worms in the intestines. A better acquaintance with the pathology of the diseases of early life, especially those of the digestive organs, has, however, shown that intestinal worms play a much less important part in their production than was supposed; and yet it is still a matter of dispute to what extent worms are to be considered as the causes of certain phenomena very generally, but by no means constantly, associated with their presence.

By one party, the existence of worms is deemed invariably detri mental to health; by another they are regarded as always the effect, and not the cause of disease; while a third, with Dr. Rush, consider their presence as altogether innoxious, if not, to a certain extent, beneficial. It is at least certain that there is no single symptom, or combination of symptoms, which indicates positively the existence of worms in the intestines, excepting their presence in the evacuations. They have repeatedly been discharged during life or discovered after death in cases in which their presence was not suspected. One species, in fact, the tricocephalus, Bremser has met with in nearly every body he has opened, and we have seldom failed, in any instance, to detect it. In cases in which the most unequivocal indications of the existence of worms were supposed to be present, a careful examination of the evacuations gave no evidence of their discharge during the lifetime of the patient, and not a single trace of them could be discovered in the intestinal canal after death.

Worms are certainly of very common occurrence in the intestines of children, and may, it is true, under certain circumstances, become a cause of severe irritation; but much less frequently than is generally supposed. It is important to recollect, that even in cases where the presence of worms is established beyond doubt, by their appearance in the discharges, the symptoms of disease under which the patient labors may be produced by causes totally independent of them, and continue, or even augment in violence, though we should succeed in effecting the complete expulsion or destruction of the worms.

The worms that infest the intestines are, the tricocephalus dispar, the oxyuris vermicularis, the ascaris lumbricoides, and the bothriocephalus latus.

The tricocephalus dispar-the trichuris or long threadworm of some writers-is commonly from an inch and a half to two inches in length. The anterior two-thirds of its body is slender, like a hair, while the remaining third is much thicker. It is white, or of the color of the substances it has swallowed. The sexes are in different

individuals.

The mouth is at the capillary extremity, which is always found adhering to the surface of the intestine. This worm is met with in the large intestines-most commonly in the cœcumwhich seems to be its natural locality. Frequently there is but a single individual; and in almost every instance a very small number. It is the worm most universally met with.

The oxyuris vermicularis-the ascaris of Rudolphi and most writers -popularly the maw, or threadworm-is from a line to four or five lines long, white, slender, and elastic, blunt at the interior end, and with a rounded mouth. It is found in the large intestines, and particularly in the rectum of children. This worm generally exists in great numbers; often in the form of a ball, thickly coated or invested with mucus.

The ascaris lumbricoides.-This is the worm most commonly met. with in the small intestines of children. It sometimes exists in great numbers; occasionally congregated in the form of a ball. The lumbricoides is usually from three to twelve inches in length and varying in diameter from a line to two or three. Its usual color is white, but changes with that of the substance it swallows. When dead, it becomes perfectly stiff. This worm frequently finds its way into the stomach, and may be discharged by the mouth or through the nostrils.

The bothriocephalus latus-the tænia lata, or broad tapeworm of many writers-is thinner, and generally wider than the common tænia. It is often twenty feet long, and may greatly exceed this length, reaching in some cases, it is said, to sixty, and in others to upwards of a hundred feet. (Bremser, Robin, Frank, Geoze, Sibbargarrde.) It is of a dirty white color, becoming grayish when immersed in alcohol. It has a large head, with two lateral grooves, which are considered by Rudolphi to be the organs for the absorption of nourishment. It is found in the small intestines. It is seldom met with in the United States, either in children or in adults, but is said to be common in Poland, Russia, Switzerland, and in some parts of France.

The tænia solium, or common tapeworm, is of a white color, and of a flat form; the posterior extremity is rounded, and the anterior long and slender, terminating in an extremely narrow neck, with a minute head, armed with four suckers, between which there may sometimes be discovered a small mouth, surrounded by a circle of five hooks. The joints that separate from the posterior extremity of the tænia solium have received the denomination of cucurbitani. This worm inhabits the small intestines, and sometimes attains an enormous length. Several tænia are occasionally found in the same individual, and according to Rosen, in conjunction with other species of worms. The fact of the head, or smaller extremity of the tænia solium not being discovered in the fecal discharges is no evidence, as Bremser remarks, that the entire destruction of the worm has not been effected, as it is extremely easy to overlook so diminutive an object in such a medium. The tania is very seldom met with in children under five years of age; it has, nevertheless, been found in