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The Family Physician.

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SIR JAMES PAGET. Bart., F.R.C.S., F.R.S

By permission of Mr. H. R. Barraud , London.

THE

FAMILY PHYSICIAN.

Q iWanual of domestic iHetnnne,

BY PHYSICIANS AND SURGEONS OF THE PRINCIPAL

LONDON HOSPITALS.

TO WHICH IS ADDED

THE LADIES’ PHYSICIAN.

S UBSCRIETION E n l T l O A'.

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CASSELL & COMPANY, Limited:

LONDON, PARIS, NEW YORK A- MELBOURNE.

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VOMITING.

577

about right ; for older children the milk may be increased to a half or two-thirds. Should even this fail, and the vomiting continue, one might try milk diluted with three or even four times its quantity of vei-y thin arrowroot-water ; or the child might be fed on cream and water only — one part of cream to three or four of water.

In the distressing morning vomiting of drunkards, arsenic will effect a cure with almost unfailing certainty, and will simultaneously improve the state of the stomach, and restore both appetite and digestion. The vomit in these cases is generally intensely bitter and sour, and of a green colour. It is usually accom- panied by great straining and distress, and generally very little or nothing is ejected, and then it is called “dry vomiting.” The arsenic mixture (Pr. 40) may be employed, a tea-spoonful being taken four times a day, and the first dose half an hour before rising. Ipecacuanha will sometimes succeed in these cases, but arsenic acts far more certainly.

In that form of vomiting to which we have referred as coming on suddenly and without pain or nausea, arsenic employed as above will nearly always succeed ; ipecacuanha will prove almost equally efficacious. Should there be constipation it will be as well to get the bowels thoroughly open by some mild aperient before com- mencing treatment.

The vomiting of cancer and ulcer of the stomach may yield to ipecacuanha, but sometimes this fails, and then arsenic may be employed. Sometimes the arsenic mixture (Pr. 40) succeeds when almost everything else has been employed in vain.

Alum in from six to ten grain doses, dissolved in half an ounce of water, some- times checks obstinate vomiting occurring in consumptive patients, especially when it is brought on by the cough.

We have by no means exhausted our list of remedies for vomiting. In the treatment of this complaint bismuth has long enjoyed a deservedly high reputation. It is commonly given in combination with hydrocyanic acid ; three drops of dilute hydrocyanic acid may be added to each dose of the bismuth mixture (Pr. 18). We have already insisted on the necessity of giving bismuth before meals and not after. Chloroform may be used for the same purpose, two or three drops being given in a wine-glassful of water. Creasote will sometimes succeed when other remedies have failed. The dose is three drops, which any chemist will make into a pill for you. It should be given either three times a day or every four hours, about half an hour before meals. Often enough ten drops of laudanum in a little water, or a hypo- dermic injection of morphia, will succeed better than anything. Sometimes an effervescing mixture will speedily allay the irritability of the stomach. In many cases simple soda-water, with or without brandy, answers admirably. A bag of ice or a blister applied to the pit of the stomach often succeeds, and small pieces of ice slowdy swallowed are useful. The spinal ice-bag does good in sea-sickness {see Sea- sickness), and might be used in other forms of vomiting, as, for example, the vomiting of pregnancy. Dry champagne is often retained when everything else is rejected. Wyeth’s Soda Mint or Neutralising Tablets are useful.

But after all, the regulation of the diet, both as regards quantity and quality, is the great thing to be aimed at. In illustration of this fact we cannot do better than quote a most striking and instructive case recorded by the celebrated Dr.

37

578

THE TREATMENT OF DISEASES.

William Hunter. “ Many years ago,” he says, “a gentleman came to me from the eastern part of the city with his son, about eight or nine years old, to ask my advice for him. dhe complaint was great pain in the stomach, frequent and violent vomiting, great weakness, and wasting of flesh. I think I hardly ever saw a human creature more emaciated or with a look more expressive of being near the end of all the miseries of life. The disorder was of some months’ standing, and from the beginning to that time had been daily growing more desperate. He was at school when first taken ill, and concealed his disorder for some time ; but grow- ing much worse he was compelled to complain, and was brought home to be more carefully attended. From his sickly look, his total loss of appetite, besides what he said of the pain which he suffered, but especially from his vomiting up almost every- thing which he swallowed, it was evident that his disorder was very serious.

“ Three of the most eminent physicians of the time attended him in succession, and tried a variety of medicines without the least good. They had all, as the father told me, after sufficient trial, given the patient up, having nothing further to propose. The last prescription was a pill of solid opium, for in the fluid state, though at first the opiate had stayed some time upon his stomach, and brought a temporary relief, it failed at length, and, like food, drink, and every medicine which had been given, was presently brought up again by vomiting. The opiate pill was therefore given in hopes that it would elude the expulsive efforts of the stomach. It did so for a time, but after a little use, that likewise brought on vomiting. Then it was that his physician was consulted for the last time, who said that he had nothing further to propose.

“ Though at first the boy professed that he could assign no cause for his complaint, being strictly interrogated by his father if he had ever swallowed anything that could hurt his stomach, or received any injury by a blow or otherwise, he confessed that the usher in the school had grasped him by the waistcoat at the pit of the stomach, in a peevish fit, and shaken him rudely, for not having come up to the usher’s expectation in a school exercise; that, though it was not very painful at the time, the disorder came on soon after. This account disposed the father to suspect that the rude grasp and shake had hurt the stomach. With that idea he brought him to me, as an anatomist, that an accurate examination might, if possible, discover the cause or nature of the disorder.

“ He was stripped before the fire, and examined with attention in various situations and postures, but no fulness, hardness, or tumour whatever could be discovered ; on the contrary, he appeared everywhere like a skeleton covered with a mere skin, and the abdomen was as flat, or rather as much drawn inwards, as if it had not contained half the usual quantity of bowels.

“ Having received all the information I could expect, and reflected some little time upon the case, I wished to speak with the father in another room, and, to give my patient some employment as well as refreshment, asked him to take a little milk in the meantime. But his father begged that taking anything into his stomach might be put off till he got home, because he was certain that it would make him sick. ‘Just before we set out,’ said he, ‘1 gave him a little milk, but

VOMITING.

579

he was sick and brought it all up in the coach, before we had got many paces from the house.’

“In the adjacent room I said to the father, ‘This case, sir, appears to me so desperate that I could not tell you my thoughts before your son. I think it most probable, no doubt, that he will sink under it 5 I believe that no human sagacity or experience could pretend to ascertain the cause of his complaint, and without supposing a particular or specific cause, there is hardly anything to be aimed at in the way of a cure. Yet, dreadful as this language must be to your ear, I think you are not to be without hope. As we do not know the cause, it may happen to be of a temporary nature, and may of itself take a favourable turn; we see such wonderful changes every day in cases that appear the most desperate, and especially in young people. In them the resources of nature are astonishing.’

“ Then he asked me if I could communicate any rules or directions for givkig him a better chance of getting that cure from nature which he saw he must despair of from art.

“ I told him that there were two things which I would recommend. The first was not so important, indeed, yet I thought it might be useful, and certainly could do no harm. It was to have his son well rubbed for half an hour together with warm oil and a warm hand, before a fire, over and all round his stomach, every morning and evening. The oil, perhaps, would do little more than make the friction harmless, as well as easy, and the friction would both soothe pain, and be a healthful exercise to a weak body.

“ The second thing I had to propose I imagined to be of the utmost consequence. It was something which I had particularly attended to in the disorders of the stomach, especially vomitings. It was carefully to avoid offending a very weak stomach, either with the quantity or quality, of what is taken down, and yet to get enough retained for supporting life. ‘ I need not tell you, sir,’ said I, * that your son cannot live long without taking some nourishment ; he must be supported to allow of any chance in his favour. You think that for some time he has kept nothing of what he swallowed, but a small part must have remained, else he could not have lived till now. Do you not think, then, that it would have been better for him if he had only taken the very small quantity which remained with him, and was con- verted to nourishment 1 It would have answered the end of supporting life as well, and perhaps have saved him such constant distress of being sick, and of vomiting. The nourishment which he takes should not only be in very small quantity at a time, but in quality the most inoffensive to a weak stomach that can be found. Milk is that kind of nourishment ; it is what Providence has contrived for supporting animals in the most tender stage of life. Take your son home, and as soon as he has rested a little, give him one spoonful of milk ; if he keeps it some time without sickness or vomiting, repeat the meal, and so on. If he vomits it, after a little rest try him with a small quantity, viz., with a dessert or even a tea-spoonful. If he can but bear the smallest quantity you will be sure of being able to give him nourishment. Let it be the sole business of one person to feed him. If you succeed in the beginning, persevere with great caution, and proceed very gradually to a

580

THE TREATMENT OF DISEASES

greater quantity, and to other fluid food, especially to what his own fancy may in- vite him, such as smooth gruel or panada, milk boiled with a little flour of wheat or rice, thin chocolate and milk, any broth without fat or with a little jelly or rice or barley in it, ike. &c.’ We then went in to our patient again, and that he might be encouraged with hope and act his part with resolution, I repeated the directions with an air of being confident of success. The plan was simple, and perfectly understood. They left me. I heard nothing of the case till, I believe, between two and three months after. His father came to me with a most joyful countenance;, and with kind expressions of gratitude told me that the plan had been pursued with scrupulous exactness, and with astonishing success ; that his son had never vomited since I had seen him ; that he was daily gaining flesh, and strength, and colour, and spirits, and now grew very importunate to have more substantial food. I recom- mended a change to be made by degrees. He recovered completely, and many years ago he was a healthy and very strong young man.”

WARTS.

Warts are closely allied to corns. They occur most frequently on the hands or fingers of young people. They may be met with either singly or in large numbers. They are occasionally hereditary, and in these cases they not uncommonly correspond in number and position with those existing in one of the parents. In the majority or cases, however, warts exhibit a considerable degree of capriciousness in their appearance, period of duration, and disappearance. From their frequent occurrence on the hands of those often engaged in the examination of dead bodies, it would seem probable that the poison of decomposing animal matter is, under certain jircumstances, capable of favouring their growth.

It is a common belief that the blood from a wart is capable of producing other warts on people with whose skin it may happen to come in contact ; but the evidence on this point is, to say the least, inconclusive. It is even doubtful whether the ordinary warts which occur on the hands can be inoculated.

The arsenic treatment, to which we referred when speaking of corns, is well adapted for warts. The top of the wart should either be sliced off with a sharp knife, cut off with a pair of scissors, or destroyed with a drop of some caustic, such as nitric acid. It is then to be painted with the arsenic solution two or three times a day. In a short time it undergoes a change, and appears to break up into a number of pieces. It may then be removed or turned out without the slightest pain or difficulty.

There are several other means of getting rid of warts. Their vitality is low, and they are usually readily destroyed by the application of a caustic or astringent. The strong acetic acid known as the “ glacial ” acetic acid is often used for this pur- pose. It should be applied with a glass rod until the wart is pretty well sodden with the acid. It may have to be applied more than once, and care should be taken to prevent it from coming in contact with the surrounding skin, or it may cause a blister. Small warts occurring in numbers may usually be got rid of cer- tainly and painlessly by keeping them constantly moist with a lotion made, by adding

WASTING PALSY.

5bi

two drachms of dilute nitric acid to a pint of water. Lunar caustic is sometimes used for warts, but its action is. as a rule, too superficial to be of much service.

When warts cr warty growths occur on the nose, lips, or any part besides the hands, chromic acid may be used. The solution is made by dissolving a hundred grains of crystallised chromic acid in an ounce of water. The solution is best applied by the aid of a pointed glass rod, or when a large quantity is required by means of a small glass tube drawn to a point. Only so much should be applied as will saturate the diseased growth, and it should not be brought in contact with the surrounding tissues. Any superfluous acid is to be removed by a piece of blotting- paper or wet lint. The application usually produces only a little temporary smarting, unless indeed, the part is ulcerated, when the pain is more severe and of longer duration. After the application of the chromic acid, it is a good plan to dress the part with lint dipped in lead lotion, as it relieves the soreness and restrains the inflammation. Under the influence of this treatment the growth usually rapidly wastes, in some cases being thrown off altogether, and in othei’S undergoing a partial though distinct diminution in size. In the majority of cases one application suffices, the cure being complete in from four to eight days. When, however, the warts are very large, repeated applications may be necessary.

The application of a few drops of tincture of steel daily for several days will often cure a wart. It is best adapted to those forms which are moist and secreting.

Thuja occidentalis, a product of the evergreen known as arbor vitce, is a good remedy for warts. Each wart should be painted three or four times a day with the tincture of thuja, small doses being also given internally.

When warts are provided with a little stalk or peduncle, as they are sometimes, they may be removed by the application of an elastic ligature. A small elastic ring, or a thin india-rubber thread such as may be drawn out of an old brace, may be applied to the base of the growth so as to constrict it pretty tightly, though not painfully. The continuous constriction will, in a few days, cause the wart to dry up and fall off.

WASTING PALSY PROGRESSIVE MUSCULAR ATROPHY.

This curious disorder has only been recognised as a distinct affection since the year 1853. It is essentially characterised by a wasting of the muscles, there being no diminution of intelligence or of the sensibility of any part of the body. It occur* most frequently in young adults, and in middle-aged individuals, but even children are sometimes attacked. Men are more liable to it than women, and this probablv depends on the greater and more sustained muscular exertion which men’s occupations demand, and on their more frequent exposure to cold and wet. The influence of consanguinity in the production of this complaint is often well marked. In many instances the subjects of wasting palsy have been persons of good physical development, and not unfrequently they have been remarkable for their strength and activity. In the majority of cases the immediate cause of the disease is either excessive muscular exertion or exposure to cold. Many patients have attributed the onset of their symptoms to wearing damp apparel, to the immersion of the

582

THE TREATMENT OF DISEASES.

limbs in cold water, to standing or sitting in a draught when hot, or to exposure to inclement weather. Particular sets of muscles which are of necessity in long continued action in persons following certain mechanical trades, as, for example, masons, milliners, shoemakers, and smiths, are those which are most frequently involved, and in these cases the wasting may be permanently limited to these parts. It has occasionally happened that the disease has followed a severe blow on the back, or some injury to the spine. Thus in the case of a boy of fifteen wasting of the muscles of the trunk and upper limbs followed a playful blow with the fist of one of his companions between the shoulders. In another instance the first symptoms of wasting of the muscles of the ball of the thumb occurred six months after the fall of a bale of cotton cloth on the nape of the neck. A curious case is recorded of a gentleman aged fifty-four, who suffered what he considered a slight injury. In jumping across a flower-bed for a wager, he came down heavily on his heels, and then fell backwards on his head. He was stunned for a time, but gradually recovered, and after some days’ confinement to his bed appeared to be quite well again. It was, however, soon perceived that a great change had taken place in his habits. Having been extremely fond of manly sports and exercises — rowing, cricketing, riding, and the like — he discontinued to take part in any of these, although he continued to go every autumn to the Scotch moors for the purpose of shooting grouse. Five years after the accident, whilst engaged in the last-named sport, he perceived that his right leg had lost a part of its usual strength, and from that time the ordinary symptoms of wasting palsy developed themselves.

The symptoms generally come on very gradually. The tailor finds that he cannot hold his needle, the shoemaker cannot thrust his awl, the mason fails to wield his hammer, the gentleman experiences a difficulty in writing, in taking out his pocket-handkerchief, or putting on his hat. Some such incident directs attention to the affected limb, which is then discovered to be wasted and shrunken. In most cases the change begins in the upper limbs, most frequently of all in the hand, in the ball of the thumb especially, and in the ball of the right much oftener than in that of the left thumb. Next to those of the hand, the muscles of the shoulders are apt to be the earliest affected ; sometimes those of the neck and face ; less often some of the muscles of the lower limbs are the first to suffer. There seems to be a kind of caprice as regards the starting-point, but the muscles of which we have just been speaking are those which are ordinarily most employed by working men — a fact in favour of the theory that the disorder is sometimes the result of over-work. As the disease progresses the natural rounded contour of the limbs is replaced by an unsightly flattening, the bones stand out with unnatural prominence, giving the member the appearance of a skeleton clothed in skin. This may be carried to such an extent that the hand looks more like a claw than anything else. When the shoulder is affected the whole limb dangles powerlessly at the side. Sometimes, as we have seen, the disease extends to other parts of the body, and when the face is involved it is veiled, as it were, by an impenetrable mask, no emotion changes its unvarying aspect, and the expression is always solemn, stolid, and immovable. Sometimes the muscles of the mouth and cheeks waste away, and then the saliva dribbles out over the lips. The complaint sometimes induces a change in the voice,

WASTING PALSY.

583

which loses its register, and is finally reduced to a monotone. In extreme cases absolute immobility of the limbs or affected parts may result, but more commonly the various movements are still capable of being performed, though with greatly diminished force. Occasionally during the progress of the disease the wasted muscles exhibit curious flickering or tremulous movements, which can be seen going on under the skin. They are not sufficiently powerful to move the limb, and they commonly pass unnoticed by the patient himself. They afford a proof that the muscle is not yet dead. In some cases the progress of the disease is accompanied by a good deal of pain of a neuralgic character. In a few instances agonising pain has been a marked feature of the case. The general health remains unaffected, the intelligence is unimpaired, and the ordinary functions are usually performed with their accustomed regularity.

With the view of conveying a clearer idea of this terrible, though interesting malady, we give an abstract of one of the earliest recorded cases. The patient was a mountebank, aged thirty-two. From his own account it appears that one cold September night he slept on the muddy pavement of the streets, and in the morning on awaking found his right side quite benumbed. The warmth of a tavern fire soon restored both sensation and motion, but three weeks afterwards he noticed a weakness of the right hand, and from that time was no longer able to play the cornet-a-piston. For a year the weakness was confined to the muscles of the hand ; he then passed another night in the cold and wet, and from that time felt a great weakness in his legs. This gradually progressed, and about a year later he was so weak that he had to come to the hospital. At the time of admission he could dress himself and walk, though with trouble, and could feed himself, and talk without difficulty. Speaking of his own condition, he said, “ I am not ill, but my strength is gone, and my weakness increases daily. There is a feeling of great hissitude in my limbs, which torments me every hour, but especially on awaking from sleep.” Still another year later and the unfortunate patient could not walk at all, neither had he the power to change his position without help. His food was given him, and he had to be put to bed just like a little child. His appetite was voracious, but he had the greatest difficulty in swallowing, and twice he was nearly choked by pieces of vegetable sticking in the throat. The only way to feed him was to place a spoon containing food right at the back of the throat ; consider- able efforts at swallowing on the spoon and its contents were then made, and the former being withdrawn, the food was in time swallowed. The saliva could not be got rid of, and constantly ran from the mouth. In trying to swallow liquids, the greater part was always returned. The power of articulation being lost, the wants were made known by nods, by the eyes, and by guttural, nasal sounds. The respiration was very incomplete, so that it seemed certain that the unhappy man, whose intelligence was unimpaired, was menaced every moment with suffoca- tion. Finally he was seized with the then prevailing influenza, and being unable to expectorate the phlegm, was one morning found quite dead. This, it must be remembered, was an unusually severe case.

The course of this disease is essentially chronic, and its duration uncertain. It often happens that after destroying a group of muscles, its course is permanently

584

THE TREATMENT OF DISEASES.

arrested. Even when progressive, its advance is seldom continuous, but is marked by repeated pauses and re-commencements, and the pauses may last for months or years at a time. Cases which can be traced to the effects of over-exercise usually do well.

WHITES.

Whites, or Leucorrhcea, a common complaint in women, may arise from a number of causes. A good injection may be made by dissolving a tea-spoonful of powdered alum in a pint of cold water. Gallic acid or tannic acid may be used in the same way. It is a good plan to combine the alum and tannic acid, dis- solving a tea-spoonful of the former and half a tea-spoonful of the latter in the pint of water. Another good injection is a tea-spoonful of bicarbonate of potash or bicarbonate of soda in a pint of water. Common lime-water may be used for the same purpose undiluted. The injection should be used three times a day, or, at least, night and morning. It does not matter much what form of inject- ing apparatus is used, but one worked by squeezing an india-rubber ball is generally preferred, and it is essential that it should have a good long nozzle that can be introduced for some distance. The small glass syringes ordinarily sold are of comparatively little use. The patient should lie on her back, and raise the hips by means of pillows. The injection should be retained for four or five minutes, and the syringing should be performed thoroughly.

Pulsatilla is a good remedy for leucorrhcea, as for many other complaints peculiar to women. A table-spoonful of the mixture (Pr. 43) may be taken four times a day, and an injection used made by adding two tea-spoonfuls of tinc- ture of pulsatilla to a pint of water. Hamamelis (Pr. 45) is also useful in this con- dition, and fifteen drops of Hazeline in a little water will often effect a speedy cure.

It must be remembered that leucorrhcea is not merely a local complaint, but depends on a relaxed condition of the system. It is often associated with anaemia (p. 92) and general debility (p. 207), and in these cases nothing does so much good as a course of quinine or iron. In the list of prescriptions we give several mixtures likely to prove of benefit; as, for example, Prs. 1, 2, 9, 11, and 63. When the ordinary preparations of iron disagree, there is nothing equal to Wyeth’s Dealysed Iron, or Burrough’s Beef and Iron Wine. Kepler’s Malt Extract, and the malt extract and cod-liver oil are most useful. For diseases incidental to women a visit to Limpley Stoke often proves highly beneficial. Out-door exercise and a good nourishing diet are essential.

WORMS.

The round-worm is the commonest form from which man suffers. It is very like an earth-worm, for which in former times it was generally mistaken. It is usually some five or six inches long, and is lighter in colour and more pointed at the extremities than the earth-worm. Sometimes young ones are met with measuring not more than an inch or an inch and a half. These worms occur most frequently in young people. They live in the bowels, but sometimes make their way into the stomach, and are then usually quickly got rid of by vomiting. As a rule, there are only one or two, but occasionally large numbers are met -with. A girl only eight years old

WORMS.

585

Fig. 10— ROUND- WORM, (a) A mouth enlarged.

voided upwards of 200 in the course of a week, and the case is lecoided of a soldier who passed 367 in six days. In another instance the patient got lid of 460 in a fortnight. This, however, is quite exceptional. The round-worm is met with

all the world over, but is more common in some countries than in others. In the Southern States of North America it attacks almost every one, young or old, and especially the negroes. In the West India Islands, Brazil, Finland, Green- land, in parts of Holland, Germany, and France, it is also very common. The rural population suffer more than the dwellers in towns, and the inhabitants of low and damp localities more than those who enjoy higher and drier abodes. The symptoms to which these worms give rise are, as a rule, not very decided ; often enough there are no discoverable symptoms. When large numbers occur in a person of delicate constitution they may cause thirst, disturbed sleep, with grinding of the teeth, moroseness, with low spirits, pallid countenance, fetid breath, swelling of the belly, shrunken limbs, depressed appetite, slimy stools, itching of the nose, straining, and irritation of the back passage. It must be understood that the occurrence of such marked symptoms is exceptional.

The indications for treatment are to relieve the irritation of the bowels when present, to improve the general nutrition where that has suffered, but above all to expel the worms. The best remedy for getting rid of the worm is santonine, the active principle of wormseed. From two to four grains of the santonine, according to age, are to be mixed with a tea-spoonful or more of castor oil, and taken early in the morning before breakfast, repeating the dose two or three mornings successively. Every stool should be examined for worms. As soon as the intruders are got rid of, attention should be directed to the improvement of the general health. Iron (1'rs. 3 and 4), quinine (Pr. 9), and cod-liver oil are likely to prove of advantage. Parrish’s Chemical Food is useful. Plenty of out-door exei’cise, with, if possible, change of air, is likely to do good.

We cannot speak very confidently of the prevention of round- worm, because we are not certain how it enters our bodies. Probablv, however, the careful cooking of all our food would prove a good safeguard, even in those countries and districts

where the pest most abounds.

Tape-worm occurs most frequently where much pigs’ flesh is consumed, and indi- viduals who do not eat this meat are peculiarly exempt from the complaint. It is frequently observed among those who in their occupations are in the habit of putting knives used for cutting raw meat into their mouths ; also among those who indulge in raw or very under-done meat. There can be no doubt that in this country tape- worm is often communicated by eating raw or imperfectly cooked beef. We need not enter into any detailed description of the tape-worm, for it is not likely to be mistaken for any other kind. It may vary in length from a yard to twenty feet. The head is at the part that tapers to a point. Usually small pieces or joints an inch or so in length are passed in the motions.

586

THE TREATMENT OF DISEASES.

There can be no question that a large proportion of persons infested with tape- worm are unconscious of any departure from the state ot perfect health, but there is as little doubt that in some instances func- tional derangements occur which are referable to the irritation it produces. Such are various uncomfortable sensations in the abdomen ; pains resembling colic, sometimes felt when the stomach is empty, at others after certain articles of food ; variable appetite, now excessive, now failing entirely ; slight diarrhoea or constipation, and so on. Sometimes there is a constant craving for food, debility, irritability of the bladder, giddiness, noises in the ears, attacks of faintness, restlessness, wasting, and itching at the nose and back passage. This somewhat grave list of symptoms really contains nothing that is at all characteristic, and the only positive proof of the existence of the worm is the pas- sage of the joints.

We will now consider the different remedies that may be employed for the expulsion of the worm.

The male shield-fern (. Aspidium felix mas ) is perhaps the oldest and most widely-known vermifuge. The patient must eat a very light tea, but no supper, and just before bed- time should swallow two table-spoonfuls of castor oil. On the following morning after the oil has acted he is to take either Pr. 35 or a tea-spoonful of the liquid extract of male shield-fem in a little milk. No food is to be taken until the bowels have freely acted, when the worm is usually expelled. The head should be carefully looked for.

The bark of the pomegranate root ( Punica granatuvi ) is also an ancient and extensively used remedy. Two ounces of the bruised bark, of the fresh root if possible, are to be macerated for twenty-four hours in two pints of water, to be then boiled down to a half, strained, and divided into three doses, one of which is to be taken at half-hourly intervals. The medicine is to be taken on an empty stomach, and must be repeated daily for four or five days. It is very desirable that the root from which the bark is obtained should be fresh.

Kousso — the flowers and tops of a plant known as Brayera anthelmintica — is a quick and good vermifuge, an especial favourite in Abyssinia, where tape-worm is veiy prevalent. The dose is half an ounce suspended in water, and it must be taken fasting. An objection to its use is that it is somewhat costly, but it might be tried vn obstinate cases when other measures have failed.

It must be admitted that in some cases tape-worm proves extremely obstinate, but still persistence in treatment nearly always succeeds in getting rid of it at last.

Fig. 11.— JOINTS OF TAPE-WORM.

A. Head ( a ), and a number of joints of lx>d.v.

B. Microscopical structure of portions of three joints.

writers’ cramp

587

It is sometimes a good plan to give ten-drop doses of the liquid extract of male shield- fern three or four times a day for a week or more.

The best way of avoiding tape-worm is to make sure that your meat is always well done. Pork infested with “ measles ” should never be sold for food. Cooks and butchers should learn not to put their knives in their mouths, for it is a dangerous practice in more ways than one. Every one suffering from tape-worm — and for the matter of that any kind of worm — should disinfect every motion as soon as it is passed by pouring over it strong carbolic acid. This should be done not only for his own sake, but for the safety of others.

Thread-worms are of very common occurrence in children. They are little things looking just like a thread. They not unfrequently occur in immense numbers. They reside in quite the lower part of the bowel, from which circumstance they are

often known as seat-worms. When only a few are present, they give rise to no inconvenience, and are usually only accidentally discovered in the stools. When they are numerous, they often cause itching or tickling of the back passage, which is sometimes very distressing, especially towards night.

A capital mode of treatment is to inject into the back passage a pint of cold water containing a table-spoonful of tincture of steel. This may be repeated once or twice a day until the worms have disappeared. An injection of infusion of quassia, or of salt and water, answers equally well. It is very desirable to pay attention to the general health, and steel wine, Parrish’s Chemical Food, or cod-liver oil may be advantageously administered.

The patient should avoid touching the neighbourhood of the back passage, and should be scrupulously clean in person and clothing. The common Hindoo custom of washing after every act of defecation should be adopted. People suffering from worms should sleep alone. The food should be well cooked, and the hands should be thoroughly washed before and after every meal.

Fig. 12. — THREAD-WORMS, (n) A mouth enlarged.

WRITERS5 CRAMP.

The term writers’ cramp is not a happy one, for the affection is by no means confined to those who wield the pen. It— or a practically identical disorder — may be found in the artist, and may prevent him from painting in oils ; or it may occur in the violinist or the pianist, and hinder the musical performances of either ; it may be met with in the seamstress, or the smith, or the milkmaid, and may limit or destroy their powers of work. In fact, analogous conditions occur in almost all avocations. Of late years it has been met with in those female stage-dancers who are accustomed to balance themselves on the tips of their toes.

It is usually a chronic and slowly-developed disease. A difficulty is experienced in executing a particular movement, such as that of writing, or playing on a musical

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THE TREATMENT OF DISEASES.

instrument, other movements of the same limb being perfectly easy of performance, lhe patient experiences at tirst a sense of stiffness or weariness after unusually pro- longed exertion. The author or copyist finds that his pen no longer readily obeys the mandates of the will, it will not move as it ought to, and the writing is altered in character and looks unnatural. The pianist makes blunders in striking the chords, the fingers falling on the keys they were intended to avoid. The move- ments, which from years of constant practice had become almost involuntary — a kind of second nature — are now performed with effort and difficulty. The violinist can no longer control the movements of his left hand, and his fingers feel cramped and stiff. The poor needlewoman can no longer ply her needle, she pricks her fingers in her now bungling efforts, and the stitches are irregular and the work badly done. The premiere danseuse is seized with severe pain or cramp in the calves of her legs, and is temporarily obliged to desist from her efforts.

The disturbances of movement which render writing or similar acts difficult or impracticable are highly characteristic. Such disturbances are in the first instance slight, and are only perceived when the effort has been long continued, being then felt as a sensation of extreme weariness. By degrees the symptoms become more and more marked, and make their appearance very soon after the commence- ment of the exertion, and ultimately directly the pen is taken in the hand, or even when the hand is merely placed in the required position. At first the difficulty may be overcome by a vigorous effort, but soon no amount of determination will enable the sufferer to perform the desired act. Other things are done without trouble, but that combination of movements, the performance of which is necessary for the patient to obtain a livelihood, resists every effort. In a fully developed case of writers’ cramp, the patient may be unable to write a dozen lines to save his life, and yet he may be able to paint, or play the pianoforte, or carve without the slightest difficulty. So long as he refrains from attempting to perform the special act, whatever it may be, he differs in no respect from a healthy man ; immediately he attempts to follow his pursuit he is reduced to a condition of perfect helplessness. The moment he abandons his effort and desists from the attempt he is all right again, and feels nothing abnormal. After a time, prolonged effort to perform the desired act brings on distinct cramp, or a jerking or shaking of the part. The cramp movements, which are at first limited to the thumb and fingers, are some- times temporarily avoided by the writer, who adopts some mechanical device which