itching, burning and pain which extends to the genitals. In the evening and night, especially after the child has become warm in bed, the worms seem to be in their worst condition, and give rise to various symptoms. Frequently the symptoms return every night with regularity.

I had under my care a child whose temperature would go up slightly every night, and nervous symptoms of rolling the eyes, twitching of the extremities, would occur after having been in bed an hour or so. The child was treated first for malaria, but there being no improvement, worm treatment by mouth and rectum was given with most satisfactory results.

Aside from the nervous symptoms usually seen, the restless nights and boring of the nose, caused by the infection of the hands of the child from the anus, are the most prominent symptoms of seat worms, when a diagnosis of the trouble cannot be made from the actual observation of the animal.

Although there are really no dangerous conditions produced by the oxyuris, yet the condition is unpleasant and often very hard to treat successfully, and they cause very alarming and confusing symptoms.

In this disease, which is so obstinate and which often returns after apparent cure, it is necessary not only to treat promptly, but also to continue the treatment for some time. Although the treatment by injections which have for their purpose the destruction of the worms in the rectum, and due to which are most of the unpleasant symptoms is most important, yet it must not be forgotten that worms are constantly being added to from the small intestine, so it is well to give the same treatment by mouth as in the case of the round worms, and attack the oxyuris from above and below.

Cleanliness is an absolute necessity as a first step in the treatment of all cases, and to adopt methods to prevent reinfection. In a well pronounced case, where the symptoms have indicated, and the presence of seat worms confirmed the diagnosis, treatment twice or three times weekly with santonin and calomel, suitable to the age of the child, by mouth, followed by active purge, should be given. Daily the physician should then irrigate the colon by the means of a fountain syringe, and

long rubber catheter, first with a quart of luke warm water, to which may be added a small amount of salt or borax, in order to remove the mucus; when this has been discharged, half a pint of bichloride solution, 1-10,000 should be injected high into the bowel through a catheter, and retained as long as possible. Another most efficient injection is quassia, infusion two ounces to pint. This should be repeated every two or three nights; on other nights a simple saline injection of cool water may be employed by the mother. After each irrigation and after each stool, the parts about the anus should be bathed with a bichloride solution, I to 10,000 and a mercurial ointment applied to control the itching and preventing the escape of the worm from the bowels. Both in day and night dressing of the child the clothes should be so fastened that it will be impossible for the child to handle the afflicted parts. The hands of the child should be kept scrupulously clean, washing them with an antiseptic solution; while the nose is sprayed twice or three times daily. Good results have been obtained by different ones from injections of asafetida, lime water and aloes, while garlic by mouth and rectum seems to find much favor in obstinate cases. The above treatment, well carried out, will, I think, overcome the most obstinate ones.

The tape worm is never seen in nursing children where milk forms the exclusive diet. It is often met with from the age of five to fifteen years and is most common from fifteen to forty. Wanruch found in two hundred and six cases of tape worm, twenty-two in children. There are no symptoms which are absolutely diagnostic of the worm. There may be varied disturbance of digestion, irregular appetite, unpleasant sensations in the belly, which in young children may increase to colicky pains and gastralgia; weak children suffer much more from the parasite than do those who are strong and well nurished. There may be various nervous disturbances; children are often fretful, peevish and impatient; often there is a pain around the umbilicus, which radiates toward the epigastric region. Sometimes this pain returns at regular intervals and is generally quieted by eating. The appetite is irregular-sometimes poor and then may be increased to regular boulimia.

There is nothing pathognomonic about these symptoms. A combination of neurotic blushes, a tendency to colicky pains and an itching around the anus may lead one to suspect the presence of a tape worm, but a certain diagnosis can be made only by evidence of the segments.

The

Care must be used of remedies, especially in children, from the ease with which gastric disturbances may be set up. All tape worm remedies, especially the most efficacious, have the disadvantage that they are liable to upset the stomach. In general, it will be found more difficult to expel the worm in children than in adults, principally for the reason that the treatment directed against it as in the former cannot be so heroic. One of the difficulties in the way of treating children is that the medicines are so very unpleasant to take. An old remedy against the worm is the bark of the pomegranate. powdered bark, fresh as possible, should be macreated with an equal amount of water and this reduced by boiling to half the quantity. Very young children should be given half a teaspoonful of this decoction and those over ten years may be given a full teaspoonful, adding syrup of orange peel to prevent vomiting. The list of drugs used for the expulsion of the worm is a long one; probably the most satisfactory is the oleoresin of male fern, which should be given in capsule in fifteen minim doses to a child of ten years, four capsules administered at hourly intervals; the vermifuge should be preceded by several hours fasting and the bowels should be previously opened by a laxative. The following plan as given by Holt for administration has been found satisfactory. A light supper of milk, in the morning a saline laxative on rising-no breakfast; after the saline has acted, the capsules are to be given and following the last one, half an ounce of castor oil or some other active purge; only milk should be given that day. The fragments passed should be carefully examined to see if the head had been expelled. As the worm is very likely to be broken at the neck. If this occurs it will grow out again and in about three months segments will appear in the stool.

In conclusion this paper not claiming any originality in

idea, simply enters a plea for the general practitioner not to overlook, in his zeal for new diseases, the intestinal parasites and the symptoms they can cause in children and have even from the history of earliest times, and the necessity of remembering to always at least consider their presence in obscure cases of children's diseases.

ENDOMETRITIS.

BY DR. B. J. WETHERBY, WILKES-BARRE, PA.

READ MARCH 5, 1902.

Endometritis, or inflammation of the uterine mucosa, is of importance from its rather frequent occurrence among our gynecological patients and from its sometimes misleading symptoms which often cause us to make a wrong diagnosis and to treat organs that are not themselves at fault. Its classifications by different teachers are many and often confusing. Pozzi's classification is the following: acute interstitial, chronic interstitial, chronic glandular, and chronic polypoid. Winckle speaks of three varieties: glandular, interstitial and fungus, each of which may be acute or chronic. Montgomery's classification is acute inflammatory, hemorrhagic catarrhal and chronic painful; a very good classification and one that easily included all subdivisions. It may be limited to the cervix, to the fundus, or it may include the entire endometrium. In my own practice cervical endometritis has been most common. The pathogenic germ gains entrance to the endometrium and starts pathological changes. If it is soon cured there may be few evidences of the disease-perhaps a little leucorrhoea, menorrhagia, and some pelvic discomfort. If it is long continued or is very virulent in character the disease spreads to the deeper parts and may travel out into the tubes even to the ovaries, and destructive changes may take place. If it becomes chronic, granulations will spring up or there will be hyperplasia of the

mucosa with the development of polypii. The deeper glandular structures will become involved and there will be hyperplasia of the parenchyma of the uterus. Each of these conditions produces its own characteristic symptoms; and yet it is only different degrees of the same condition.

When we consider the vulnerability of the endometrium the wonder is that any woman escapes. Once a month for about thirty years the endometrium is in a state of congestion and is covered with blood which may be more or less decomposed. The vagina and external genitals are often dirty and foul during the entire menstrual period, thus extending a welcome to the whole family of cocci and bacilli. The cloth which receives the menstrual discharge is often worn until it becomes filthy and smells to heaven, while many of the less enlightened women wear no cloth at all and have a superstition against taking any sort of a bath until after the flow has ceased. Intercourse is often indulged in during menstruation, affording a splendid opportunity for the introduction of pathogenic germs. Think of the traumatism inflicted upon the endometrium at the time of every abortion or labor. Think of the sounds, clean and unclean, which are introduced into the uterus by bungling hands; of the bougies, quills, pencils, hairpins, etc., used by the laity and midwives for illegitimate purposes; of the festive, prolific, and almost omnipresent gonococci (for your gonococcus is a true expansionist); is it a wonder that endometritis. is not a rare disease? It is fortunate for women that the endometrium is so resistant; the normal menstrual fluid aseptic, and the vaginal secretions a poor medium for the growth and development of pathogenic germs.

The most frequent cause in the non-puerperal state, is the gonococcus, and in the puerperal state, the different pyogenic organisms, of which the most common is the streptococcus pyogenes. The staphylococcii, gonococci, and bacterium coli commune may also be the infecting agents after confinement. The gonococcus plays a very important part in this enlightened and most Christian nation, it being the etiological factor in thirty-five per cent. of all cases, according to good authority. Some good authorities place the per cent. even higher than this. In