TREATMENT OF TABES MESENTERICA. 669 vegetable tonics are well borne. The ferro-citrate of quinine, or the citrate of iron, are the preparations which it will generally be desirable to employ in the first instance; and even their effect should be watched attentively. When well borne, the cod-liver oil is, I think, more useful in this than in any other form of the tuberculous cachexia in early life. The cases in which it causes nausea or diarrhoea are comparatively few, and its effects in fattening children who were greatly emaciated are sometimes very remarkable. In conclusion, I need hardly mention the importance of change of air, and the benefits likely to arise from a sojourn on the sea-coast; for you know how much more powerful nature's remedies are in diseases of this kind than the remedies of man's devising, LECTURE XXXIX. INTESTINAL WORMS-their varieties, symptoms, and treatment. DISEASES OF THE URINARY ORGANS-Inflammation of the kidneys-Albuminous nephritis-generally follows one of the eruptive fevers, oftenest scarlatina—its symptoms-modes in which it proves fatal-condition of the urine-appearances after death--essential nature of the changes in the kidneys.-Treatment. Calculous disorders-frequent in early life-deposits in the urine in childhood almost always consist of the lithates.-Other causes of dysuria besides gravel and calculus-Treatment of dysuria in early life-Lithic acid deposits connected with chronic rheumatism in children-symptoms of ill-health associated with them-importance of not overlooking them. Diabetes-true saccharine diabetes very rare in early life-simple diuresis less uncommon-symptoms of disordered health that attend both affections.-Treatment. Incontinence of urine-circumstances in which it occurs.-Treatment. OUR study of the diseases of the digestive organs would be incomplete if we took no notice of those parasitic animals which frequently inhabit the alimentary canal in children. It will not, indeed, be necessary to say much respecting them; for we know that the older medical writers greatly overrated their frequency and importance, when they saw the proofs of their existence in almost every variety of gastric and intestinal disorder, and even commonly attributed to their presence many forms of serious disturbance of the nervous system. Still, they are in many instances the occasion of considerable discomfort; they often aggravate, or even give rise to disorder of the digestive organs, while the irritation excited by their presence being propagated to the spinal cord, sometimes produces convulsions or other formidable nervous symptoms. Although intestinal worms are much more common in early life than in adult age; yet no species of them is peculiar to the child, but they belong to one or other of the five sorts ordinarily met with in the grown person." * * The work of Dr. Küchenmeister, Die Parasiten, etc. 8vo., Leipsig, 1855, contains the fullest details concerning the anatomy and physiology of intestinal worms, and particularly all those ingenious observations by which the development of the trenia from the cysticercus cellulosæ has been established. Its translation by the Sydenham Society has rendered the book accessible to all readers. SYMPTOMS OF INTESTINAL WORMS. 671 The ascaris vermicularis, or small thread-worm, which lives principally in the rectum, is by far the most common of all these entozoa, and is very troublesome, from the local irritation which it excites. The long thread-worm, the tricocephalus dispar, appears much less frequently in the evacuations: it inhabits the upper end of the large intestines, and in some cases coexists with the presence of ascarides in the rectum. When it is present alone, I am not aware that it gives rise to any unpleasant symptoms. The ascaris lumbricoides, or round worm, is of much less common occurrence than the small thread-worm, though observed more frequently than the tricocephalus : it dwells in the small intestines, and sometimes, entering the stomach, is rejected by vomiting. Occasionally only one of these worms is present, and though there are oftener several, yet it is but seldom that they exist in the child in very considerable numbers. The tape-worm, of which there are two kinds, the taenia solium and tania lata, is much the rarest of these entozoa in early life, and is seldom met with in children under seven years of age, though once or twice I have known it to exist in infants who were still in part nourished at the breast; and I apprehend it is altogether more frequent in early life in this country than in France,* or at least than in Paris. Various symptoms have been said to indicate the presence of worms in the intestines, but most of them are of small value: and nothing short of actually seeing the worms can be regarded as affording conclusive evidence of their existence. No one who is at all familiar with the disorders of early life will be disposed to attach much weight to symptoms such as the altered hue of the face, the appearance of a livid circle around the eyes, the loss of appetite, or its becoming irregular or capricious. Many causes besides the presence of worms give rise to a tumid state of the abdomen, to colicky pains, and to occasional sickness and vomiting; and itching of the nose or anus, though often present when the intestinal canal is infested with worms, yet is sometimes the occasion of much annoyance independently of their existence. An irregular or intermittent pulse, widely dilated pupils, occasional drowsiness, with uneasy rest at night, and starting during sleep, are evidences * MM. Rilliet and Barthez, Op. cit. 2nd ed. vol. iii. p. 862, pass over tape-worm without notice, on account of its extreme rarity in early life. At Geneva, however, M. Rilliet states that he has seen it several times, even in an infant of fifteen months, while, though I have kept no exact account of the instances of it which have come under my notice, the occurrence of tape-worm in children from five to ten years old is far from having been extremely uncommon. 672 SYMPTOMS OF INTESTINAL WORMS. of disturbance of the nervous system, but do not specially indicate the presence of worms as the cause of such irritation. The small thread-worms, which are of all the most frequent, produce a most distressing itching and irritation about the anus, which always become more troublesome at night than they are in the daytime, and frequently prevent the child for hours from getting to sleep. Sometimes, too, they give rise to a troublesome diarrhoea, attended with considerable tenesmus, while in female children they occasionally creep up the vulva, and not merely cause much irritation there, but excite a leucorrhoeal discharge, which ceases on their expulsion. The round worms often give no evidence at all of their presence, so long as they are but few in number, and as the child affected by them is otherwise healthy; the discharge of a lumbricus by stool, or its expulsion by vomiting, being often the first indication of their existence. The common opinion, indeed, which associates inordinate appetite with the presence of lumbrici, is probably not devoid of truth, since these creatures appear to live on the contents of the intestines, not, as the tape-worm dòes, on the juices of the living structures themselves. The more marked symptoms of gastro-intestinal disorder are dependent either on the presence of a great number of these parasites (an occurrence which seems to be far rarer in this country than in many parts of the continent, especially in Italy), or on some circumstance exciting in them an unusual restlessness, and causing them to wander from one part of the intestines to another. According to the excitability of the patient, and according also to the course taken by the worm, the symptoms thus produced will be more or less formidable. The diarrhoea that sometimes attends the expulsion of lumbrici, is of all the accidents the least serious, or rather it is by the supervention of diarrhoea, or its artificial induction, that these intruders are most frequently got rid of. Much discomfort often precedes their expulsion by vomiting, though sometimes I have known a worm to be rejected almost without warning, and with very little difficulty or annoyance. Strange instances, indeed, are on record of these worms getting into the oesophagus, and thence passing out of the nostrils; and of death being produced by their entering the larynx; but such are wholly exceptional accidents, from which no inference can be deduced as to the ordinary consequences of their presence. Violent convulsions, and other cerebral symptoms, are alleged to be more frequently produced by the presence of lumbrici than of any other varieties of these entozoa. It chances, however, that SYMPTOMS OF INTESTINAL WORMS. 673 the most formidable convulsions which I ever observed to be excited by worms, were due to the presence of an immense number of small thread-worms, and ceased immediately on their expulsion. M. Legendre too has called attention to the great frequency of symptoms of disorder of the nervous system in connection with the presence of tape-worm; such symptoms having been present in twenty out of thirty-three cases. They consisted, in twelve instances, of more or less frequently repeated convulsive seizures, which eight times assumed the character of epilepsy, four times of hysteria; while on eight occasions the convulsive movements were partial, and affected either the face or one of the limbs.' It would seem, then, that the presence of worms of any kind, just like any other source of irritation, may excite convulsions, or may disturb in other ways the functions of the nervous system. In the symptoms themselves, there does not seem to be anything which could enable us at once to distinguish between convulsions produced by the presence of worms and those dependent on some other cause. In most instances, however, it will be found that the child has passed worms frequently before the cerebral symptoms made their appearance, while the absence of any other adequate cause for their occurrence should at once direct our attention to the possibility of their arising from this source; and an examination of the evacuations will seldom fail to discover evidence to justify our suspicions. The symptoms of tænia are not pathognomonic of that peculiar form of entozoon, but are common to it and to the lumbrici, with the exception, perhaps, that tape-worm is apt to produce a more decided impairment of the general health, and that from the difficulty in obtaining its complete expulsion its symptoms are usually more persistent. When once, however, our suspicions are excited, we are seldom long without receiving complete confirmation of them in the appearance of joints of the worm intermingled with the evacuations, since, when the creature has attained to maturity, the spontaneous detachment of portions of it from time to time is a purely physiological occurrence. The different varieties of worms are not to be got rid of by the same treatment; nor is the cure of all equally easily effected. In *Sur les symptomes nerveux que détermine le Tania:-tiré des Archives de Médecine, 1850, and a second paper in the Archives for December 1854. In this latter paper he gives the particulars of several cases of convulsions in children from the presence of tænia, and has collected statistics to show that the rarity of this worm in early life has been somewhat exaggerated. |