Most of these special symptoms will be referred to in describing the particular symptoms produced by the several species of worm. It may, however, be stated in this place, that every variety of nervous symptom, from headache, and other disorders of sensation, to spasm, paralysis, and convulsions, has been found associated with the presence of worms in the alimentary canal. Some of these have been looked upon as pathogno monic. Thus, Dr. Underwood held that an attack of convulsions, accom panied by small pulse and hiccough, was an almost certain sign of worms. Monro was of opinion that unequal dilatation of the pupils pointed posi tively to the same conclusion. Others have relied upon the rapidity and irregularity of the pulse as furnishing sufficient grounds for the diagnosis. It cannot be denied that these symptoms may be noticed in children suf fering from intestinal worms, and may possibly be produced by them ; but similar symptoms are found in cases where careful observation fails to dis cover any sign of the creatures or their ova in the stools.
There is one symptom which, although not positively distinctive of the irritation of worms in the bowel, renders the presence of the parasites highly probable. This symptom is a peculiar appearance of the tongue. In all cases where the bowels are the seat of a mucous flux, the tongue gives evidence of this condition. It is flabby, and indented at the edges by the teeth. The increased secretion of mucus in the mouth gives to the tongue a slimy, gummy appearance. The lingual surface is covered with a thin coating of gray fur, and the fungiform papillae at the sides of the dorsum peer through the fur as round or oval spots, which are more or less red, according to the degree of irritability of the stomach. In cases where worms are present, I have often remarked a peculiar fawn colour of the fur covering the dorsum, and the slimy appearance of the organ has been especially noticeable.
A child may be infested by more than one variety of worm at the same time. It is not uncommon to find round-worms together with thread worms ; and sometimes round-worms and tape-worms are present at the same time in the same subject. Thus, a little boy, aged one year and eight months, was under my care for tape-worm, from which he had been suffer ing for three months. This child, on one occasion, passed a large round worm and many joints of the tmnia in the same stool.
In the case of thread-worms, the patient seldom complains of abdominal pain, but the irritation set up in the rectum by the presence of the entozoa gives rise to a troublesome itching of the fundament, which in sensitive children may cause an extreme degree of suffering. This irritation comes on towards the evening, and at night may be so distressing that sleep is greatly interfered with. In some cases, in addition to the itching, shoot
ing pains may be complained of in the same part. Catarrh of the rectum is not uncommon in such subjects. There may be looseness of the bowels, and the evacuations are often discharged with straining efforts. They may be followed by prolapse of the rectum. The stools often contain glairy mucus; and sometimes blood in streaks, or even clots of considerable size. Difficulty in emptying the bladder may be a consequence of the irritation, and the child sometimes holds his water for many hours together. Itch ing of the nose, a leaden tint of the lower eyelid, and swelling of the upper lip, are also very common symptoms when thread-worms are present.
The worms are readily detected as white moving threads in the stools, and may be seen in the folds of mucous membrane about the anus. They may pass or be conveyed into the vagina in little girls ; and can often be discovered in the bed-clothes. A microscopic examination of the stools usually discovers a multitude of ova.
The lumbricus, on account of its large size and its habits of nocturnal activity, is a cause of considerable irritation. This worm is said frequently to give rise to nervous disorders in the child ; and cases have been recorded in which severe headache, photophobia, choreic movements, convulsions, and even profound coma have ceased on the expulsion of a number of these creatures. It is difficult to say what share the worms take in the produc tion of such symptoms. Probably some additional cause is in operation, for in rickety children, whose tendency to convulsions and other forms of nervous disturbance is one of the most characteristic consequences of that phase of general malnutrition, I have not noticed that the presence of the long round-worm is especially liable to be accompanied by eclamptic seiz ures. Probably, in most cases where nervous symptoms are associated with intestinal worms, the nervous disturbance is quite independent of any irri tation produced by the worms in the bowels. It is common enough for children who are suffering from undoubted disease of the nervous centres to be infested with lumbrici. Thus, in cases of tubercular meningitis, one or more long worms are often expelled by the action of aperients ; but it is needless to say that in such a case no amelioration in the symptoms fol lows the expulsion of the parasites. So, also, children under my care suf fering from chorea have passed lumbrici, but I cannot call to mind a single case where any improvement in the disease has directly followed the ap pearance of the worm in the stools.