Angina Pectoris.

vaded, almost constantly, while he was sitting after dinner; now and then he was seized with it in the morning, when walking a little faster than usual: and was then obliged to stop, and rest on any object at hand. Once or twice it came on in bed; but did not oblige him to sit up, as it was then attended with no great difficulty in breathing. In the afternoon fits, his greatest ease was from a supine posture; in which he used to continue motionless for some hours, until quite spent and worn out with anguish, he dropt into a slumber. In the intervals between these attacks, which at length grew so frequent as to return every fourth or fifth day, he was, to appearance, in perfect health.

Thus matters continued for more than two years; and various antipathodies were ineffectually tried for his relief. In 1769, there supervened a very sharp constrictory pain at the upper part of the sternum, stretching equally on each side, attended with the former symptoms of anxiety, dyspnoea, choking, &c., and with an excruciating cramp, as he called it, that could be covered with a crown-piece, in each of his arms, between the elbow and the wrist, exactly at the insertion of the pronator teres; the rest of the limb was quite free. The fits were sometimes brought on, and always exasperated, by any agitation of mind or body. He once attempted to ride on horseback during the paroxysm; but the experiment was near proving fatal to him. The difference of season or weather made no impression upon him. Still, in the intervals, his health was perfectly good; except that his eyes, which before his illness were remarkably strong and clear, were now grown extremely tender: and that his sight was much impaired. He had no flatulence of stomach, and his bowels were regular.

In this situation, February 22, 1770, he applied to me for assistance. I had seen, I believe, eight or ten of these frightful cases before. Two of the patients dropt dead suddenly. They were men between 40 and 50 years of age, and of a make somewhat fleshy. The fate of the others I was not informed of; or, at least cannot now recollect.

Having found the total inefficacy of blisters and the whole class of nervous medicines in the treatment of this anomalous spasms, I thought it right to attempt the correcting or draining off of the irritating fluid in the case now before us. To this purpose, I ordered a mixture of lime-water with a little of the compound juniper-water, and an alternative proportion of Huxham's antimonial wine: I put the patient on a plain, light, perspirable diet; and refrained him from all viscid, flatulent, and acrimonious articles. By pursuing this course, he was soon apparently mended; but after he had persisted regularly in it for at least two months, he kept for some time at a stand. I then ordered a large issue to be opened on each of his thighs. Only one was made. However, as soon as it began to discharge, his amendment manifestly increased. The frequency and severity of the fits abated considerably; and he continued improving gradually, until, at the end of 18 months he was restored to perfect health: which he has enjoyed, without the least interruption, till now, except when he has been tempted (perhaps once in a twelvemonth) to transgress rules, by making a large meal on salted meat, or indulging himself in ale or rum-punch, each of which never failed to disorder him from the beginning of his illness: and even on these occasions, he has felt no more than the slightest motion of his former sufferings; insomuch that he would despise the attack, if it did not appear to be of the same stock with his old complaint. No other cause has had the least ill effect on him.

Though rum was constantly hurtful, yet punch made with a maceration of black currants in our vulgar corn-spirit, is a liquor that agrees remarkably well with him.

He never took any medicine after the issue began to discharge; and I have directed that it shall be kept open as long as he lives. The inflammations of his throat have disappeared for five years past; he has recovered the strength and clearness of his sight; and his health seems now to be entirely re-established."

Dr Macbride, in a letter to Dr Duncan, published in the Edinburgh Medical Commentaries, gives the following additional observations on this disease.

Within these few weeks I have, at the desire of Dr Smyth, visited, three or four times, a very ingenious man who keeps an academy in this city, of about 34 years of age, who applied to the doctor for his advice in January last.

I shall give you his symptoms as I had them from his own mouth, which appear to me to mark his case to be an angina pectoris, and as deplorable as any that I have read of. It was strongly distinguished by the exquisite constrictory pain of the sternum, extending to each of his arms as far as the insertion of the deltoid muscles, extreme anxiety, laborious breathing, strangling, and violent palpitation of the heart, with a most irregular pulse. The paroxysms were so frequent, that he scarcely ever elapsed a day, for six or seven years, without one. They were usually excited by any agitation of mind or body, though slight. He had clear intervals of health between the fits. The difference seems hereditary in him, as he says his father was affected in the same manner some years previous to his death. He has a strong gouty taint, which never showed itself in his limbs; and he has led a life of uncommon sedentariness, from intense application to mathematical studies, attention of mind, and passion, even from his boyish years. These circumstances may, perhaps, account for his having been taken with this disease at so early an age as 17.

A large issue was immediately opened in each of his thighs. In a month afterwards he began to mend, and has gone on improving gradually. He can now run up stairs briskly, as I saw him do no later than yesterday, without hurt; can bear agitation of mind; and has no complaint, excepting a slight oppression of the breast, under the sternum, which he feels sometimes in a morning, immediately after dressing himself, and which he thinks is brought on by the motion used in putting on his clothes; though for a complete week preceding the day on which I saw him last, he told me that he had been entirely free from all uneasiness, and was exulting that he had not had such an interval of ease for these last seven years.

Doctor Smyth also showed me, in his adverfaria, the case of a gentleman who had been under his care in 1760, which he had forgotten when my book went. went to the press, and which he was reminded of the other day by a visit from his patient. It was a genuine angina pectoris, brought on by a very sedentary life, and great vexation of mind, clearly marked by the exquisite pain under the sternum, that extended acutely to the upper extremities, particularly along the left arm, together with the other symptoms of dyspnoea, anxiety, palpitation of the heart, &c., recited in the case above. The disorder went off in 1762, by large spontaneous discharges from the piles, but returned upon him feverishly in 1765. Issues in his thighs were then recommended to him, but not made. But, whether it was by the persuasion of some friend, or of his own accord, he went into a course of James's powder, in small alternative doses, combined with a little castor and aloes. This he persisted in for about six weeks; in the meanwhile, he had large acrimonious gleecings from the scrotum and a plentiful discharge of ichor from the anus.—From this time he began to find his complaints grow less and less distressing, and he has now been totally free from them for six years past."

The PUERPERAL, or Childbed Fever.

This species of fever, as its name imports, is peculiar to women in childbed; and is usually the most fatal of all the disorders to which the sex is liable. But, notwithstanding the prevalence of it in all ages, its real nature has remained, to the present time, a subject of much dispute and uncertainty. The critical period of its invasion, when febrile commotions are apt to be excited by various accidents, and the equivocal symptoms which accompany it, have even afforded room for questioning whether it be a primary or a secondary disease. Some writers have considered it as proceeding entirely from an inflammation of the uterus; others have imagined it to be the consequence of an obstruction to the secretion of the milk; while the greater number has been inclined, for reasons equally if not more plausible, to impute it to a suppression of the lochia. If we examine this fever attentively, however, according to its natural course, and independently of all the accidental concomitant symptoms with which it is not essentially connected, we may safely pronounce it to be a primary disease of a particular nature, and perhaps not the necessary consequence of any of the causes above mentioned.

This fever is most generally incident to women within 48 hours after delivery, though it may supervene on the fourth or fifth day, and sometimes considerably later. It is preceded, like other fevers, by a rigor, which is commonly violent; and, when happening during the time of labour, may be confounded with the pains of parturienty. In its earlier stage it is attended with the signs of inflammation. A great pain is felt in the back, hips, and the region of the uterus; which, in the part last mentioned, is accompanied with the sense of heat and throbbing. A sudden change in the quality or quantity of the lochia now also takes place; the patient is frequently troubled with a tenesmus; and the urine, which is very high-coloured, is discharged in small quantity and with pain. At the first attack of the fever, the woman is generally seized with a vomiting of porraceous matter, as in the cholera morbus, to which disease it then bears a strong resemblance.—Puerperal Fever.

But instead of this symptom, there is sometimes only a nausea, or loathing at the stomach, with a disagreeable taste in the mouth. The belly swells to a considerable bulk, and becomes susceptible of painful sensations from the slightest impression. The tongue is generally dry, though sometimes moist, and covered with a thick brownish fur. When the fever has continued a few days, the symptoms of inflammation usually subside, and the disease acquires a more putrid form. At this period, if not at the very beginning of the disorder, a bilious or putrid diarrhoea, of a dangerous and obstinate nature, supervenes, and accompanies it through all its future progress; each motion to stool being preceded by a temporary increase, and followed by an alleviation of pain. The patient usually nauseates all kind of food and drink, except what is cold and acidulated. A brown or blackish froth, the consequence of putrid exhalations, adheres to the edges of the teeth; a troublesome hiccup is at length produced, which greatly exacerbates the pains of the abdomen; petechiae or vibices also appear, with sometimes a miliary eruption, but which produces no mitigation of the disease. Through the whole course of the fever, the patient is affected with great anxiety and dejection of spirits.

Such in general is the course of the puerperal fever; the symptoms of which, however, may be often varied, according to the constitution of the patient, the degree of the disease, and its earlier or later invasion. When the woman is naturally weak, or her strength has been greatly reduced by immoderate evacuations after delivery; when the disease is violent, and immediately follows that period; its progress and termination are proportionably rapid and fatal. In such unfortunate circumstances, many have been known to expire within 24 hours from the first attack of the disease; nay, there are some instances where the rigor has concluded the scene. The catastrophe, however, is most generally suspended for some days; and the number of these is variable, though the 11th from the commencement of the fever may justly be fixed as the period which is usually decisive. In whatever stage of the disease an unfavourable termination may happen, it would seem as if the commencement of the patient's recovery were not marked by any critical revolution of the fever, as depending on an alteration of the humours; but that the cure is gradually effected, either by a spontaneous vomiting, or a long-continued discharge by stool of that porraceous matter, the existence of which in the stomach is usually evinced at the first attack of the disease. The most unfavourable prognostic, therefore, arises from such a weakness of the patient as renders her unable to support so tedious an evacuation as that by which the fever is overcome. When the lochia return to their former state, when the swelling and tenderness of the abdomen abate, and there is a moisture on the skin, we have reason to hope for a happy termination of the disease.

Though the puerperal fever may generally be ascertained from the description which has been given, and chiefly by that remarkable tenderness of the abdomen which particularly distinguishes it: yet, as some of its symptoms may be confounded with those arising from other diseases, and which require a different method of Appendix.

Puergal Fever.

of cure, it will be proper to mention here the circum- stances by which it may be known with greater cer- tainty.

The pains of the abdomen, attending the childbed fever, may be distinguished from those called after- pains, by their uninterrupted continuance through the course of the disease, though sometimes they suffer exacerbations; whereas, in the latter, they often to- tally intermit. They are also distinguishable by the ab- sence of fever with concomitant symptoms in the one, and their evident existence in the other.

Many circumstances evince a dissimilarity between the puerperal and miliary fevers, notwithstanding the symptoms of anxiety and oppression are common to both; inasmuch that the nature of the approaching dis- ease may be ascertained at the very commencement of its attack. In the puerperal fever the rigor is more violent, of longer duration, and not interrupted, as it is in the other. The pulse is fuller and stronger; the skin is more hot; and the tongue, whether moist or dry, though generally the latter, is not of a white, but brownish appearance; and the urine is also higher col- oured. Eruptions, which are critical in miliary fevers, procure no mitigation of the puerperal fever, and cordials generally increase it.

When the original attack of the puerperal fever hap- pens to coincide with the febrile convulsion which is excited in childbed women by the milk, the na- ture of it may at first be misapprehended; but the concomitant symptoms, and greater violence of the disease, must in a short time dispel such an error.

From all the most accurate accounts of this disease, and from the period at which it generally commences, there seems reason to conclude, that it owes its rise more immediately to accidents after delivery. For it is allowed that it may follow a labour under the best and most favourable circumstances, though endeavours to dilate the os internum are supposed frequently to produce it. The more immediate causes generally af- firmed by authors are a stoppage of periphraxis, the too free use of spices, and the neglect of procuring food after delivery; sudden frights, too hasty a sepa- ration of the placenta, and binding the abdomen too tight. The putrid appearance, however, which this disease so soon assumes, affords ground to suspect that the predisposing cause of it is a vitiated state of the humours; for it is generally observed to be most pre- valent in an unhealthy season, and among women of a weakly and scrofulous constitution. But from its pre- valence in some particular hospitals, while others in the same city are entirely free from it, there can be little doubt that it is often communicated by contagion from one female to another. This opinion is corroborated also by many other circumstances; particularly by the means by which it has been removed from hospitals. It would seem, however, that this contagion does not act on the female system without a certain predisposition, and that this predisposition is induced by those changes to which the female habit is subjected in consequence of delivery.

Within these few years this fever has been treated of by several writers, most of whom have differed from each other in their sentiments of the nature of the dis- ease. The first in the order of publication is Dr Denman, who seems to be of opinion, that it may de- rive its origin either from a redundancy or too great acrimony of the bile, the secretion of which appears to be much interrupted in the time of gestation. In Dr Manning's treatise on this fever, he mentions its being highly probable that such a cause contributes greatly to produce the disease, especially where the putrid tendency of the humours is increased by un- wholesome air and diet.

It has likewise been the fate of the puerperal fever, that no disease has more divided the sentiments of phy- sicians in regard to the method of cure. The appa- rent indications and contra-indications of bleeding, and other remedies, arising from the complication of inflammatory and putrid symptoms; the equivocal ap- pearance of the vomiting and purging, as whether they be critical or symptomatic; and the different causes whence symptoms similar to each other may arise in pregnant women; all these circumstances con- cur to involve the subject in great obscurity and inde- cision. If we carefully attend to the several charac- teristics of the disease, however, so as to be able to di- stinguish it from every other puerperal complaint, and observe at the same time the usual manner of its de- cension, our judgement may be guided in the method of cure by the salutary efforts of nature. But, in order to obtain a clearer view of the genuine indica- tions, it will be proper to consider them under the sev- eral lights in which they have been generally agitated by authors.

One of the most essential points to be ascertained in the cure of the childbed fever, respects the pro- priety of bleeding. A free use of the lancet has been generally regarded as the most successful expedient in practice; and there are some instances of critical haemorrhages which would seem to confirm its util- ity. But Dr Denman thinks we may safely affirm from experience, that for one who will be benefited by large bleeding, a much greater number will be inju- red, and that even almost irretrievably. Nor can this seem surprising, when we consider the situation of childbed women. In fact, the evacuations conse- quent upon delivery are sufficient to diminish any un- due superabundance of the fluids; and if, as frequent- ly happens, the disease be produced by too hasty a se- paration of the placenta, the consequence of which is generally a very copious discharge of blood, we can never suppose that nature will be assisted in overcoming the febrile convulsion, by the farther evacuation of the vital fluid, through the defect of which she is now rendered unequal even to the ordinary support of the animal economy. We may appeal to every practical physician, how much he has known the pulse to sink, and what a train of nervous symptoms he has observed to succeed an excess of the discharge above mentioned. Besides, it is an axiom in physic, that a remedy which cures any disorder, will always prove sufficient to pre- vent it; and therefore, if bleeding were the proper cure in the childbed fever, the disease ought to have been prevented by a large evacuation of blood, when that happened previous to its attack. Experience, how- ever, in this, as in all other diseases, is the only uner- ring guide we can follow; and whoever regulates his practice by fact and observation, will be convinced that bleeding, especially in a larger quantity, is, in general, very far from being attended with success. Bleeding is seldom proper, except in women of plethoric constitutions, and in whom the signs of inflammation rise high. Nor even in such patients ought it to be repeated without great caution, and the existence of strong indications. Bleeding, when used in proper circumstances, may unquestionably palliate the fever; but that it often shortens the duration of it, appears to be a matter of much doubt. On this account the practice becomes still more suspicious and exceptionable, when we consider that by venesection improperly used the patient's strength may be so far reduced as not to support the tedious loofenels by which the disease is generally carried off. Though bleeding, however, ought in general to be used with great caution, there are certainly many cases in which it is both necessary and advantageous.

The genuine nature and effects of the loofenels in this disease, is another controverted point of the highest importance, and which merits the most attentive inquiry. Physicians, observing that women who die of the puerperal fever are generally molested with that evacuation, have been induced to consider this symptom as of the most dangerous and fatal tendency; and what, therefore, we should endeavour by every means to restrain. In this opinion, however, they would seem to have been governed by too partial an observation of facts. For experience certainly authorizes the assertion, that more women appear to have recovered of the childbed fever, through the intervention of a diarrhoea, than have been destroyed by that cause. If it also be considered, that purging is usually almost the only sensible evacuation in the more advanced state of the disease, and is that which accompanies it to its latest period, we shall have the strongest reason to think that it is critical rather than symptomatical, and ought therefore to be moderately supported, instead of being unwarily restrained. Nay, the advantage which is found to attend vomiting as well as purging, in the earlier stage of the disease, would seem to evince that the matter discharged by these evacuations is what chiefly foments the disease. Emetics and purgatives, therefore, in the opinion of Dr Manning, are the only medicines on which any rational dependence is to be placed in this fever; at least, they are certainly such as are found the most successful. It is an established rule in practice, to prefer the vomit at the beginning of every fever attended with any nausea or loathing of the stomach, and where there is not any reason to apprehend an inflammation of that organ. Nor does the state of childbed women afford the smallest ground for prohibiting our recourse to the same expedient in answering a similar indication.

It is to seldom a physician is called during the rigor preceding the puerperal fever, that he has few opportunities of trying the effects of remedies in that early stage of the disease. When such occur, however, we should endeavour as much as possible to abate and shorten that period, as the succeeding fever is generally found to bear a proportion to the violence and duration of it. For this purpose, warm diluting drinks should be plentifully used, with a small quantity of volatile spirits or brandy. When Dr. Manning apprehended such an accident, he sometimes ordered the nurse to give immediately a dish or two of warm sack-whey; taking care that it was not too strong, which is a caution that ought always to be remembered: for though a free use of the more cordial and spirituous kinds of liquors might perhaps soon abate the rigor, there is danger to be feared from their influence on the approaching fever, especially in women of a strong and healthy constitution. In all cases, warm applications to the extremities, such as heated bricks, towels, or toasted grains in a linen bag, may be used with perfect safety, and some advantage.

When the hot fit is advanced, the first thing Dr Manning orders is some emollient injection, as chicken-water, or water and milk, which ought to be frequently repeated through the course of the disease. These prove beneficial, not only by promoting the discharge from the intestines, which seems in fact to be the solution of the disease; but also by acting as a kindly fomentation to the uterus and adjacent parts. With this intention they are particularly serviceable when the lochia are suppressed. Great care, however, is requisite in administering them, on account of the tenacious and inflammatory disposition, which at that time render the parts in the pelvis extremely susceptible of pain.

The next step in the method of cure ought to be to promote the discharge of the morbid matter both by the stomach and intestines. This intention may be answered by a remedy prescribed by Dr Denman—Two grains of tartaric acid rubbed up with a scruple of the powder of lapilli cancrorum.

Of a powder thus prepared, Dr Denman gives from two to six grains, and repeats it as circumstances require. If the first dose do not procure any sensible operation, he repeats it in an increased quantity at the end of two hours, and proceeds in that manner; not expecting any benefit but from its sensible evacuation.

Should the disease be abated, but not removed, (which sometimes happens), by the effect of the first dose, the same medicine must be repeated, but in a less quantity, till all danger be over. But if any alarming symptoms remain, he does not hesitate one moment to repeat the powder, in the same quantity as first given; though this be seldom necessary, if the first dose operates properly.

It is to be observed, says Dr Denman, that as the certainty of cure depends upon the proper repetition of the medicine, the method of giving it at stated hours does not appear eligible. If the first dose produce any considerable effect by vomiting, procuring stools, or plentifully sweating, a repetition of the medicine in a less quantity will seldom fail to answer our expectations; but great judgement is required in adapting the quantity first given to the strength of the patient and other circumstances. We are not to expect that a disease which from the first formation carries so evident marks of danger, should instantly cease, even though a great part of the cause be removed.

Frequent doses of the saline draughts ought also to be given, which not only promote the evacuation by the intestines, but likewise increase the salutary discharges of urine and perspiration. These medicines are particularly serviceable in subduing the remains of the fever, after its violence has been broken by the more efficacious remedies above mentioned; but when they are used even in the decline of the disease, gentle laxatives of rhubarb and magnesia, as advised by Dr Denman, Although the discharge by the intestines appears to have the most salutary effect in this disease; yet when the stomach has not been properly unloaded of offensive matter, though a great nausea and sickness had indicated the expediency of such an evacuation at the beginning of the fever, the continuance of the loofenels is sometimes too long protracted as in the end to prove fatal. In this alarming state of the disease, when the stools are very frequent and involuntary, and all appearances threaten danger, Dr Denman says, that a clyster of chicken-water injected every one, two, or three hours, or as often as possible without fatiguing the patient too much, with a cordial diaphoretic draught taken every six hours, has produced better effects than could be expected.

While these medicines are employed, we should endeavour to mitigate the pains of the belly by relaxing applications. During the course of the disease, the patient ought to drink freely of diluting liquors, and abstain from every thing of a heating quality, unless great faintness should indicate the use of a small quantity of some cordial medicine.

Such is the practice recommended in this disease by Dr Denman. We shall now take a cursory view of the sentiments of succeeding writers on this subject.

According to Dr Hulme, the proximate cause of the puerperal fever is an inflammation of the intestines and omentum; for the confirmation of which opinion he appeals to dissections. He supposes the chief predisposing cause of the disease to be the pressure of the gravid uterus against the parts above mentioned. The omentum, says he, in the latter stage of pregnancy, must either be flat, which is its natural situation, or be rumpled or carried up by the gravid uterus in folds or doublings. When the latter is the case, which he observes is probably not seldom, the danger of a strangulated circulation will be greater.

Mr White, who has also written on this disease, judiciously remarks, that were Dr Hulme's hypothesis well founded, the disorder ought rather to take place before delivery, and be immediately removed at that period: That it would likewise most generally happen to women at their first labour, when the abdominal muscles are least yielding, and the pains more violent; the contrary of which is most frequently experienced to be the case.

It also deserves to be remarked, that, upon Dr Hulme's supposition, we cannot account for the disease being more common and fatal in large towns and in hospitals, than in the country and private practice, while other inflammatory disorders are more endemic among those who live in the latter than the former situation. Even admitting the friction of the intestines and omentum against the uterus to be as violent as Dr Hulme supposes, is it not highly improbable, that any inflammation could be occasioned by the pressure of such soft substances upon each other? Or, were this effect really produced, ought not the puerperal fever to be more common and fatal after the most laborious deliveries? But this observation is not supported by experience.

Dr Hulme, in favour of his own hypothesis, alleges that it gives a satisfactory answer to the question, "Why all lying-in women have been, and ever will be, subject to this disease?" In this proposition, however, the doctor supposes such an universality of the disease as is not confirmed by observation. It is affirmed upon undoubted authority, that in many parts of Britain the puerperal fever is hardly known; whereas, were it really produced by the causes he assigns, it would be equally general and unavoidable.

But how peculiar forever this author's sentiments are in respect of the proximate cause of this disease, they have not led him to any method of cure different from the established practice. On this subject Dr Hulme divides his observations into two parts, comprehending under the former the more simple method of treatment, and under the latter the more complex. He sets out with remarking, that the patient being generally colicky at the beginning of the disease, an emollient opening clyster will often give immediate relief; but if this should not prove effectual, recourse must be had to cathartics. Those which he found answer his purpose best, were the sal catharticus amarus, the oleum ricini, emetic tartar, and antimonial wine. When the bowels have been sufficiently cleared and the pain abates, he advises encouraging a gentle diaphoresis by medicines which neither bind the body nor are heating; such as small doses of ipecacuan, emetic tartar, and antimonial wine, combined with an opiate in a moderate dose, and given once or twice in the course of 24 hours; administering the saline draughts in the intermediate spaces. If preceding or during this course, a sickness at stomach or vomiting attend, he advises assiting the efforts of nature, by drinking plentifully of chamomile tea, warm water, or any other diluting liquor. He concludes with recommending a cooling regimen, rest of body, and tranquillity of mind; prohibiting all kinds of bandage upon the abdomen, and enjoining particular attention to the state of the bowels, which ought to be kept gently open for some time, even after the disorder seems to be gone off, till the patient be quite out of danger.

So much for the simple treatment: we now proceed to the second part, where he describes the method of practice when the disease is in its more irregular and complicated state.

When a diarrhoea accompanies the disease, he observes that it ought by no means to be checked, but supported, by ordering the patient to drink plentifully of mild aperient liquors. If the pain of the hypogastric region be attended with stitches in the sides or over the pit of the stomach, and a pulse that reliefs the finger pretty strongly, he remarks that bleeding would then be highly necessary; declaring, however, his opinion, that, in the puerperal fever, bleeding is to be considered only as a secondary means of relief, though the first in point of time; that it ought to be advised with great caution; and that the greatest dependence is always to be placed upon evacuations by stool.

Mr White imputes the puerperal fever to a putrefactive disposition of the humours, contracted during pregnancy, and fomented by the hot regimen commonly used by women in childbirth. In conformity to this opinion, the chief means which he recommends for preventing the disease is a cool regimen and free circula- Puerperal Fever, which he evinces to be of the greatest importance. In respect of bleeding, he informs us, that upon the strictest inquiry, he cannot find that those who have bled the most copiously have had the greatest success, either in private or hospital practice. He even seems to question the propriety of this evacuation in any case; but approves of emetics, cathartics, and clysters, for cleansing the prime vice, and likewise of such medicines and diet as will correct the putrid humours: adding, that an upright posture and free ventilation are at all times useful, and absolutely necessary, both for the prevention and cure of the disease.

Another writer who treats of the childbed fever is Dr Leake, who has published the result of his observations on this disease from April 1768 to the autumn of the year 1770; but chiefly from December 1769 to May 1770, during which period the childbed fever prevailed much about London.

Dr Leake tells us that this fever generally commenced the evening of the second or morning of the third day after delivery, with a rigor or shivering fit. Sometimes it invaded soon after delivery; and at other times, though rarely, it has seized so late as the fifth or sixth day. Now and then it seemed to be occasioned by catching cold, or by errors in diet; but oftener by anxiety of mind. Sometimes the thirst was great; though the tongue had, in general, a better appearance at the beginning than is common in other fevers. It was seldom ever black or very foul; but, as the disease advanced, became white and dry, with an increase of thirst; and at last was of a brownish colour towards the root, where it was slightly covered with an inflamed mucus. The loss of strength was so great and sudden, that few of the patients could turn in bed without assistance, even so early as the first or second day after the attack. The lochia, from first to last, were not obstructed, nor deficient in quantity; neither did the quality of this discharge seem to be in the least altered from its natural state; a presumption, says the author, that the uterus was not at all affected. Of this he was convinced by making a considerable pressure above the pubes with the hand, which did not occasion pain; but when the same degree of pressure was applied higher, between the stomach and umbilical region, it became almost intolerable. A perfect crisis seldom if ever happened in this fever, which he imputes to the great oppresion of the vital powers, whereby they were rendered unable to produce such an event. When the disease proved mortal, the patient generally died on the tenth or twelfth day from the first attack. In those who died of the fever, the omentum was found suppurated; an inflammation of which part, or of the intestines, Dr Leake concludes to be the proximate cause of the disease.

In consequence of this idea of the cause of the disease, Dr Leake affirms that venesection is the only remedy which can give the patient a chance for life. But, though it be the principal resource to be depended upon at the beginning of the fever, he observes that it will seldom prove of service after the second or third day; and, if directed yet later, will only weaken and exhaust the patient; when, matter having begun to form in the omentum, the progress of the disease can no longer be prevented by that evacuation. At this period the blood begins to be tainted by the absorption of the purulent fluid; and the fever, from being inflammatory, is changed into a putrid nature.

After bleeding in such a quantity as the symptoms require, he advises that the corrupted bile be evacuated and corrected as soon as possible; that the diarrhoea, when excessive, be restrained by emollient antidyse clysters and gentle sudorifics, or even by opiates and mild astringents, when the patient's strength begins to sink under the discharge; and, lastly, that where the signs of the putrefaction or intermition take place, antiseptics and the cinchona may be administered.

The great uniformity of the symptoms in all Dr Leake's patients might authorize an opinion, that the fever which he describes was in a great measure a disease sui generis, and depended much upon the constitution of the air preceding and during the period in which the fever prevailed.

Dr Kirkland has also made judicious observations on this subject. He rejects the opinion that the puerperal fever is a disease sui generis, and arises always from the same cause. The particular situation of childbed women, he acknowledges, occasions a similarity in the appearance of all the febrile symptoms; but he affirms that the same kind of fever may be produced by various causes; for instance, by an inflammation of the uterus or abdomen, by putrid blood or other matter, and putrid miasms. The symptoms, he observes, will vary according to the time of seizure. If the fever happen in three or four days after delivery, all the symptoms usual to the situation of the patient will make their appearance; but if it do not invade till the milk has been secreted, and the lochial discharge be nearly finished, the symptoms, if the breasts are properly drawn, will, for the most part, be those only which are common to that kind of disorder by which the fever has been produced.

With respect to the cure of puerperal fevers, Dr Kirkland advises the antiphlogistic method when they arise from inflammation; but when this method fails of success, and a diarrhoea supervenes, the disease has changed its nature, having become more or less putrid, and requires a very different treatment.

His observations relative to the management of the diarrhoea merit attention. No one, says he, would purge and bleed to cure the colligative fever arising from the aborption of matter in large wounds; and yet the only difference is, that in the puerperal fever the matter absorbed from the uterus, &c., acts with more violence, because the blood is commonly thinner and the habit in a more irritable state. We see, continues he, that absorbed matter purges as effectually as if any purging medicine had been given by the mouth; and may we not therefore do harm by additional purging, when there has been a large evacuation, especially as purges in this case are incapable of entirely removing the fomes morbi?

He considers cinchona as the principal remedy, as soon as the pulse sinks, the heat is lefened, and the stomach will bear it. If this increase the diarrhoea beyond moderation, he joins with it small doses of laudanum; but if the diarrhoea should entirely stop without the fever going off, in place of laudanum he advises a proper quantity of rhubarb. Should the diarrhoea, notwithstanding the use of the medicines proposed, become come so violent as to endanger the patient, he agrees with Mr White in recommending the columbo root, which is a warm cordial, and removes the irritability of the stomach and intestines more powerfully than any other bitter he knows.

Of this disease also, as it appeared in Derbyshire and some of the adjacent provinces, an account has been published by Dr Butter. Concerning the causes and nature of the disease, he observes, that pregnancy seems to add much to the natural sensibility of the female constitution; because at this period women are often subject to a train of nervous symptoms, which never molest them at other times. During gestation likewise, the appetite is for the most part keen, while the digestion appears to be impaired; and this weakness is increased not only by improper food, of which the woman is frequently delirious, but also by the inactivity attending her situation. To these circumstances, it is added, that the intestinal passage being interrupted by the uterine pressure, colic generally prevails. From the several observations here enumerated, Dr Butter concludes, that the proximate cause of the puerperal fever is a spasmodic affection of the first passages, with a morbid accumulation in their cavity; and upon this supposition he endeavours to account for the various symptoms of the disease.

In treating of the method of cure, he lays down two indications; the former of which is to promote two, three, or four stools daily, in a manner suited to the strength of the patient, till such time as they resume a natural appearance. The second indication is to relieve all uneasy symptoms, such as heat, thirst, headache, &c.

With respect to the opinion entertained by Dr Butter of the cause of the puerperal fever, it nearly coincides with that of Mr White. But however plausible it may appear, we are not entirely satisfied that a disease attended with so peculiar symptoms as the puerperal fever can depend principally upon an irritability, which is not restricted either to the pregnant or puerperal state.

The late Dr Thomas Young professor of midwifery in the university of Edinburgh, although he published nothing on the subject of the puerperal fever, wrote a very ingenious dissertation respecting it, which was read in the Philosophical Society of Edinburgh. In that dissertation, after giving a very accurate account of the symptoms of the disease, which coincides very nearly with the account given by others, he endeavours to show, that the puerperal fever, strictly so called, is in every instance the consequence of contagion; but he contends, that the contagious matter of this disease is capable only of producing its effect, in consequence of a peculiar predisposition given by delivery and its consequences. In support of this doctrine, he remarks, that for many years the disease was altogether unknown in the lying-in ward of the Royal Infirmary at Edinburgh; but that after it was once accidentally introduced into the hospital, almost every woman was in a short time after delivery attacked with it; although prior to her delivery, she may have lain, even for weeks together, not only in the same ward with the infected, but even in the very next bed. He remarks, that it was only eradicated from the hospital in consequence of the wards being entirely emptied, thoroughly ventilated, and new painted. After these precautions, puerperal females in the hospital remained as free from this disease as formerly. The puerperal fever, according to Dr Young, has very generally a strong tendency to the typhoid type; although he allows, that in the beginning it is not unfrequently attended with inflammatory symptoms, and even with topical inflammation, particularly in the intestinal canal. On this idea, he considers the puerperal fever as admitting of the same variety of treatment with other affections depending on contagion, in which sometimes an inflammatory, sometimes a putrefactive tendency, prevails; such, for example, as smallpox or erysipelas. But from the prevailing putrefactive tendency in this affection, he considers the free access of cool air, with the liberal use of antiseptics, as being very generally requisite.

It deserves to be remarked, that though the several writers who treat of this subject have conducted their method of cure conformably to their particular idea of the cause of the disease, respecting which their sentiments are very different, they seem to have been equally successful in the treatment of their patients. Indeed the several writers differ less from each other in their method of care than might be expected, where so great an opposition of theoretical sentiment prevails. For after endeavouring to establish indications correspondent to their particular systems, those who contend for the expediency of promoting the intestinal discharge, disfavour not having recourse to phlebotomy when the disease is attended with inflammatory symptoms; while, on the other hand, the most strenuous advocates for bleeding admit the utility of the former evacuation. It appears, therefore, that a due regulation of the alvine discharge is necessary through the whole course of the fever, but venefication only sometimes.

WORMS.

Those infesting the human body are chiefly of three kinds: the acarides, or small round and short white worms; the teres, or round and long worm; and the tania, or tape worm.

The acarides have usually their seat in the rectum.—The teres or lumbrici are about a span long, round and smooth: they are seated for the most part in the upper small intestines; but sometimes they are lodged also in the stomach, and in any part of the intestines, even to the rectum.—The tape-worms are from two to forty feet long, according to the testimony of Platerus; they generally infest the whole tract of the intestines, but especially the ileum: they very much resemble a tape in their appearance, whence the name of tape-worm: but another species of this genus, from the resemblance of each joint to a gourd seed, has the name of the gourd worm.

In the Medical Transactions, vol. 1st. Dr Heberden gives a very accurate account of the symptoms produced by the acarides, from an eminent physician who was troubled with them all his life. They brought on an uneasiness in the rectum, and an almost intolerable itching in the anus; which sensations most usually came on in the evening, and prevented sleep for several hours. They were attended with heat, sometimes so considerable as to produce a swelling in the rectum both both internally and externally; and if these symptoms were not soon relieved, a tenesmus was brought on, with a mucous dejection. Sometimes there was a gripping pain in the lower part of the abdomen, a little above the os pubis. If this pain was very severe, a bloody mucus followed, in which there were often found acarides alive. They were also sometimes suspected of occasioning disturbed sleep, and some degree of headache.

On this case Dr Heberden observes, that the general health of the patient did not seem to have suffered from the long continuance of the disease, nor the immediate inconveniences of the disorder itself to have increased. "It is (says he) perhaps universally true, that this kind of worms, though as difficult to be cured as any, yet is the least dangerous of all. They have been known to accompany a person through the whole of a long life, without any reason to suspect that they had halved its end. As in this case there was no remarkable sickness, indigestion, giddiness, pain of the stomach, nor itching of the nose, possibly these symptoms, where they have happened to be joined with the acarides, did not properly belong to them, but arose from some other causes. There is indeed no one sign of these worms, but what in some patients will be wanting."

The above mentioned patient used purging and irritating clysters with very little success. One dram and an half of tobacco was infused in six ounces of boiling water; and the strained liquor being given as a clyster, occasioned a violent pain in the lower part of the abdomen, with faintness and a cold sweat: this injection, though retained only one minute, acted as a smart purge, but did little or no good. Lime-water was also used as a clyster; which brought on a catarrh, but had no good effect. Six grains of salt of steel were dissolved in six ounces of water, and injected. This clyster in a few minutes occasioned an aching in the rectum, gripped a little without purging, and excited a tenesmus. Some few acarides were brought off with it; but all of them were alive. The uneasy sensation in the rectum did not abate till some warm milk was thrown up. Whenever the tenesmus or mucous stools were thought worth the taking notice of, warm milk and oil generally gave immediate relief. If purging was necessary, the lenient purges, such as manna with oil, were, in this particular case, made use of: rhubarb was found too stimulating.—But, in general, the most useful purge, and which therefore was most usually taken, was cinnamon and rhubarb, of each half a drachm: this powder seldom failed to bring away a mucus as transparent as the white of an egg, and in this many acarides were moving about. The cinnamon frequently adhered to this mucus, which did not come off in large quantities, when a purge was taken without cinnamon. Calomel did no more than any other purge which operates briskly would have done; that is, it brought away acarides, with a great deal of mucus. Oil given as a clyster sometimes brought off the animalcules: the oil swam on the surface of the mucus, and the acarides were alive and moving in the mucus itself, which probably hindered the oil from coming in contact with them and killing them.

Dr Heberden also observes, that mucus or slime is the proper nest of the acarides, in which they live, and is perhaps the food by which they are nourished; and it is this mucus which preserves them unhurt, though surrounded with many other liquors, the immediate touch of which would be fatal. It is hard to satisfy ourselves by what instinct they find it out in the human body, and by what means they get at it; but it is observable in many other parts of nature, as well as here, that where there is a fit soil for the hatching and growth of animals and vegetables, nature has taken sufficient care that their seeds should find the way thither. Worms are said to have been found in the intestines of still-born infants. Purges, by lessening this time, never fail to relieve the patient; and it is not unlikely, that the worms which are not forced away by this quickened motion of the intestines, may, for want of a proper quantity of it, languish, and at last die; for if the acarides are taken out of their mucus, and exposed to the open air, they become motionless, and apparently die in a very short time. Dr Heberden supposes that the kind of purge made use of is of some consequence in the cure of all other worms as well as acarides; the animals being always defended by the mucus from the immediate action of medicines; and that therefore those purges are the best which act briskly, and of which a repetition can be most easily borne. Purging waters are of this sort, and jalap especially for children; two or more grains of which, mixed with sugar, are most easily taken, and may be repeated daily.

From Dr Heberden's observations, we may easily see why it is so difficult to destroy these animals; and why anthelmintics, greatly celebrated for some kinds, are yet far from being specifics in the disease. As the worms which reside in the cavities of the human body are never exposed to the air, by which all living creatures are invigorated, it is evident, that in themselves they must be the most tender and easily destructible creatures imaginable, and much less will be requisite to kill them than any of our common insects. The most pernicious substances to any of the common insects are oil, caustic fixed alkali, lime, and lime-water. The oil operates upon them by shutting up the pores of their bodies; the lime-water, lime, and caustic alkali, by dissolving their very substance. In the case of intestinal worms, however, the oil can have very little effect upon them, as they are defended from it by the moisture and mucus of the intestines; the like happens with lime-water: and therefore it is necessary that the medicine should be of such a nature as to destroy both mucus and insects together; for which purpose the caustic fixed alkali is at once safe and efficacious; nor is it probable that any case of worms whatever could resist the proper use of this medicine. A very large dose of any salt indeed will also destroy the mucus and destroy the worms; but it is apt to inflame and excoriate the stomach and intestines, and thus to produce worse distempers than that which it was intended to cure. Dr Heberden gives the following remarkable case of a patient cured of worms by enormous doses of common salt, after trying many other remedies in vain. In February 1757, the patient was seized with uncommon pains in his stomach, attended with nausea, vomiting, and constipation of bowels, and an almost total loss of sleep and appetite: Worms. He soon became much emaciated, and could neither stand nor walk upright; his belly grew small and hard, and closely retracted, insomuch that the sternum covered the navel, and the latter could scarce be discovered or felt by the finger: his urine was always milky, and soon deposited a thick white sediment; his excrements were very hard and lumpy, resembling those of sheep, only of a brown colour; nor had he ever a stool without some medicine or other to procure it. In this situation he continued four years; during which time he had been in an infirmary, attended by eminent physicians, but was disguised as incurable. At last he was advised by a neighbour to drink salt and water, as he said he knew one cured by it who had for many years been afflicted with the same kind of pains in the belly and stomach. As his distemper was now almost inapplicable, he willingly tried the experiment. Two pounds of common salt were dissolved in as little water as possible, all which he drank in less than an hour. Soon afterwards he found himself greatly oppressed at the stomach, grew extremely sick, and vomited violently; on the fourth straining he brought up about half a pint of small worms, part acariides, and the rest resembling those worms which are called the botus, and frequently met with in the stomach of horses, but much smaller, and about the size of a grain of wheat. The salt soon began to operate downwards, and he had five or six very copious fetid stools, tinged with blood; and in them discharged near an equal quantity of the same kind of worms he had vomited. Being greatly fatigued with the violence of the operations, he fell into a calm sleep, which lasted two hours, during which he sweated profusely, and awoke much refreshed. Instead of his usual pains, he now only complained of a rawness and soreness of his gullet, stomach, and bowels, with an almost unquenchable thirst; to allay which, he drank large quantities of cold water, whey, butter-milk, or whatever he could get. The urine he now passed was small in quantity, and rendered with very great difficulty, being highly saturated with the salt, from whence arose a most troublesome dysuria and strangury. However, these symptoms gradually abated by a free use of the liquors above-mentioned; and on the third morning he was so well recovered, that he took two pounds more of salt, dissolved in the like quantity of water. The effects were nearly similar to the former; only that most of the worms were now burnt, and came away with a considerable quantity of lime and mucus. The drought, strangury, &c. returned with their former violence, but soon yielded to the old treatment. He sweated very copiously for three days, slept easily, and by that time could extend his body freely: on the fifth day he left his bed, and, though very weak, could walk upright; his strength and appetite soon returned, and he became robust and well.

The anthelmintic medicines which have been recommended by one person or other, are in a manner innumerable; but the principal are,

1. Quicksilver. This is very efficacious against all kinds of worms, either taken in the form of calomel or corrosive sublimate. Even the crude metal boiled in water, and the water drunk, has been recommended as an almost certain cure. But this, it is evident, can receive no impregnation from the mercury. If, therefore, it have any effect, it must be from some foreign and accidental impregnation. In most instances there can be no objection to mercury, but only that it is not endowed with any attenuating quality whereby the mucus in which these insects resides can be dissolved. It therefore fails in many cases, though it will most certainly destroy worms where it can get at them.

2. Powder of tin. This was for some time celebrated as a specific, and indeed we may reasonably expect good effects from it; as by its weight and grittiness it rubs off the mucus and worms it contains from the coats of the intestinal canal, in which case they are easily evacuated by purgatives. In order to produce any considerable effects, it must be given in a large dose.

3. Geoffroa incrustis, or cabbage bark. This remedy is used by the inhabitants of Jamaica. The first account of it which appeared in this country was published in the Physical and Literary Essays, vol. ii., by Mr Duguid surgeon in that island. He acquaints us, that the inhabitants of Jamaica, young and old, white and black, are much infested with worms, especially the long round sort; the reason of which, he thinks, is the quantity of sweet viscid vegetables which they eat. On dissecting a child of seven months old, who died of vomiting and convulsions, twelve large worms were found; one of them filled the appendix vermiformis, and three of them were entwined in such a manner as to block up the valvula Tulpia, so that nothing could pass from the small to the great guts.—The cabbage bark, however, he tells us, is a safe and effectual remedy, and the most powerful vermifuge yet known; and that it frequently brings away as many worms by stool as would fill a large hat. He owns that it has sometimes violent effects; but this he attributes to the negroes who make the decoction (in which form the bark is used) too strong, and not to the remedy itself.

Mr Anderson, surgeon in Edinburgh, has also given an account of this bark and its operation, in a letter to Dr Duncan, published in the Edinburgh Medical Commentaries, volume iv. p. 84. From this account it appears, that there are two different kinds of cabbage bark; the one much paler than the other: the pale kind operates much more violently than the other. It often occasions loose stools, great nausea, and such like symptoms, attended with great uneasiness in the belly: in one or two instances it was suspected of inducing syncope. The darker coloured kind resembles the calca lignea, though it is of a much coarser texture. This kind, Mr Anderson thinks, may be exhibited in any case where an anthelmintic is necessary; the dangerous symptoms might have followed either from the use of the first kind, or from an over-dose of the second. The usual method of preparing the medicine is by boiling two ounces and a half of the bark in two quarts of water to a pint and a half. Of this a tea-spoonful may be given at first in the morning, gradually increasing the quantity till we come to four or five table-spoonfuls in a day. When exhibited in this manner, Mr Anderson informs us, that he never saw it produce any violent symptoms, and has experienced the best effects from it as an anthelmintic. After the use of this decoction for eight or nine mornings successively, a dose of jalap with calomel must be given, which seldom fails to bring away the worms, some dead, some alive. If at any time the decoction produce more than one or two loose stools, a few drops of liquid laudanum may be given; and, in general, Mr Anderson gave 15 or 20 drops of the spirit of lavender with each dose.

In a letter from Dr Ruth, professor of chemistry at Philadelphia, to Dr Duncan of Edinburgh, the following account is given of another preparation of this medicine. "It has long (says he) been a complaint among physicians, that we have no vermicide medicine which can be depended upon. Even calomel fails in many cases where there are the most pathognomonic signs of worms in the bowels. But this complaint, it is hoped, is now at an end. The physicians of Jamaica have lately found, that the cabbage bark, as it is called in the West Indies, made into a syrup with brown sugar, is an infallible antidote to them. I have used above 30 pounds of it, and have never found it fail in one instance. The syrup is pleasant; it sometimes pukes, and always purges, the first or second time it is given."

The most accurate botanical description of the geoffreana inermis, or the tree furnishing the worm bark, as it has often been called, is that which was published some years ago in the Philosophical Transactions by Dr Wright, formerly physician at Jamaica, now of Edinburgh, who also highly extols this remedy as an anthelmintic.

Notwithstanding these encomiums, however, the cabbage bark has not come into general use in Britain. But diseases from the tereter, or lumbrici as they are often called, the species of worm against which this bark is employed, much less frequently occur in Britain than in some other countries. When they do occur, in almost every instance they readily yield to more gentle and safe anthelmintics; and the worms may not only be expelled by calomel, but by the vegetable bitters; as the powder of the artemisia fantonica, or the like.

4. Couhage, or cow itch. This is the Dolichos serus or pruriens of Linnæus; and the principles on which it acts have been already explained under the article Dolichos. It is somewhat similar to the powder of tin, but bids fair for being more efficacious. It might at first appear to occur as objections to this medicine, that by the hairs of it entangling themselves with one another, calculi might be formed in the intestines, or obstructions equally bad; or if the sharp points and hooks with which it abounds were to adhere to the nervous coats of the intestines themselves, they might occasion a fatal irritation, which could not be removed by any means whatever. But from the experience of those who have employed it extensively in practice, it would appear, that these objections are entirely theoretical; and that it may be employed with perfect safety. The episcule, gently scraped off from a single pod, and mixed with syrup or molasses, are taken for a dose in the morning fasting. This dose is repeated in this manner for two or three days without any sensible operation; but even a very slight purgative taken afterwards has been found to discharge an almost incredible quantity of worms. And according to Dr Bancroft, who has given a very particular account of its use in his Natural History of Guiana, it is one of the safest and most certain anthelmintics yet discovered; but, as well as the bark of the Geoffrea, it has hitherto been very little used in Britain, probably from its not being necessary.

5. Indian pink. This plant, which is the Spigelia marilandica of Linnæus, is also an American plant, and was first recommended in the Edinburgh Physical and Literary Essays by Dr Gardiner of Charlestown in South Carolina. He is of opinion that a vomit ought always to precede the use of it; and informs us, that half a dram of it purges as briskly as the same quantity of rhubarb. At other times he has known it produce no effect on the belly though given in very large quantity: In such cases it becomes necessary to add a grain or two of sweet mercury, or some grains of rhubarb; but then it is less efficacious than when it proves purgative without addition. The use of it, however, in small doses, is by no means safe; as it frequently produces giddiness, dimness of sight, convulsions, &c. The addition of a purgative, indeed, prevents these effects; but at the same time, as already observed, it diminishes the virtue of the medicine. The doctor therefore recommends large doses, as from them he never knew any other effect than the medicine's proving emetic or violently cathartic. The dose is from 12 to 60 or 70 grains of the root in substance, or two, three, or four drams of the infusion, twice a day. This medicine has also had its day, and is now very far from being considered as a specific.

The long round worms seem to be the most dangerous which infest the human body, as they often pierce through the stomach and intestines, and thus bring on a miserable death. The common symptoms of them are nausea, vomiting, looseness, fainting, slender intermittent pulse, itching of the nose, and epileptic fits. By the consumption of the chyle they produce hunger, paleness, weakness, coliciveness, tumor of the abdomen, eructations, and rumbling of the intestines; but it is from the perforation of the intestines that the disease proves so frequently fatal. A child may be known to have worms from his cold temperament, paleness of the countenance, livid eyelids, hollow eyes, itching of the nose, voracity, startings, and grinding of the teeth, in sleep; and more especially by a very fetid breath. Very frequently, however, they are voided by the mouth and anus, in which case there is no room for doubt. In the Medical Commentaries, vol. ii., we have an account of the intestines being perforated by a worm, and yet the patient recovered. The patient was a woman troubled with an inflammation in the lower part of the abdomen. The pain was so violent, that for six days she slept none at all; the tumor then broke, discharged upwards of a pound of thin watery faeces, immediately after which the excrements followed. The next day she was extremely low; her pulse could scarcely be felt; the extremities were cold; and there was a considerable discharge from the wound, which had already begun to mortify. She got a decoction of cinchona with wine, which alleviated the symptoms; but in removing the mortified parts a worm was found among them nine inches long, and as thick as an eagle's quill. By proper applications, the discharge of excrements ceased, and she recovered perfect health. She was sensible of no accident giving rise to the Appendix.

Worms. The inflammation; so that in all probability it arose entirely from the worm itself.

The *tænia*, or *tape worm* as it is called, is one of those most difficult to be removed from the human body. It is of two kinds, *tænia folium* and *tænia lata*; for a description of which see the article *TÆNIA*. The reason of its being so difficult to cure is, that though portions of it are apt to break off and be discharged, it is endowed with a power of reproduction, so that the patient is little or nothing better. The symptoms occasioned by it are not different from those above described. A specific against the *tænia lata* has been lately so much celebrated in France, that the king thought proper to purchase it from the proprietor (Madame Nouffer), and the account of it has been translated into English by Dr Simmons. The patients are required to observe no particular regimen till the day before they take the specific. That day they are to take nothing after dinner till about 7 o'clock; after which, they are to take the following soup: "Take a pint and an half of water, two or three ounces of good fresh butter, and two ounces of bread cut into thin slices; add to this salt enough to season it, and then boil it to the consistence of panada." About a quarter of an hour after this, they take a biscuit and a glass of white wine, either pure or mixed with water; or even water alone, if they have not been accustomed to wine. If the patient has not been to stool that day, (which, however, is not usual with patients in this way), the following clyster is to be injected. "Take a small quantity of the leaves of mallows, and boil them in a sufficient quantity of water, mixing with it a little salt, and when strained off add two ounces of olive oil." Next morning, about eight or nine hours after the supper above mentioned, the specific is to be taken. This is no other than two or three drams of the root of male fern, *polypodium filix mas* of Linnaeus, gathered in autumn, and reduced to fine powder. It is to be taken in any distilled water, or in common water. This medicine is apt to occasion a nausea; to avoid which, Madame Nouffer allows her patients to chew anything that is agreeable, but forbids anything to be swallowed; or they may smell to vinegar, to check the sickness; but if notwithstanding this, the specific be thrown up, a fresh dose must be swallowed as soon as the sickness is gone off, and then they must try to sleep. About two hours after this the following bolus is to be taken. "Take of the pavacea of mercury 14 times sublimed, and select resin of scammony, each ten grains: of fresh and good gamboge six or seven grains: reduce each of these substances separately into powder, and then mix them with some conserve into a bolus." This composition is to be swallowed at two different times, washing it down with one or two dithers of weak green-tea, after which the patient must walk about his chamber. When the bolus begins to operate, he is to take a dish of the same tea occasionally, until the worm be expelled; then, and not before, Madame Nouffer gives him broth or soup, and he is directed to dine as is usual after taking physic. After dinner he may either lie down or walk out, taking care to conduct himself discreetly, to eat but little supper, and to avoid everything that is not of easy digestion.

The cure then is complete; but it is not always effected with the same quickness in every subject. He who has not kept down the whole bolus, or who is not sufficiently purged by it, ought to take, four hours after it, from two to eight drams of Epsom salt dissolved in boiling water. The dose of this salt may be varied according to the temperament and other circumstances of the patient.

If the worm should not come away in a bundle, but in the form of a thread (which particularly happens when the worm is involved in much tenacious mucus), the patient must continue to sit upon the close stool without attempting to draw it away, drinking at the same time warm weak tea; sometimes this alone is not sufficient, and the patient is obliged to take another dose of purging salt, but without varying his position till the worm be wholly expelled.

It is unusual for patients who have kept down both the specific and purging dose, not to discharge the worm before dinner-time. This, however, sometimes happens when the dead worm remains in large bundles in the intestines, so that the faeces becoming more limpid towards the end of the purging, pass by it without drawing it with them. The patient may in this case eat his dinner; and it has been observed, that the food, joined to the use of a clyster, has brought about the expulsion of the worm.

Sometimes the worm is brought away by the action of the specific alone, before the patient has taken the purging bolus: when this happens, Madame Nouffer gives only two thirds of it, or substitutes the salt in its stead.

Patients must not be alarmed by any sensation of heat or uneasiness they may feel during the action of the remedy, either before or after a copious evacuation, or just as they are about to void the worm. These sensations are transitory, and go off spontaneously, or by the affluence of the vapour of vinegar drawn in at the nose.

They who have vomited both the specific and bolus, or who have kept down only a part of them, sometimes do not void the worm that day. Madame Nouffer therefore directs them to take again that night the soup, the wine and biscuit; and if circumstances require it, the clyster. If the worm do not come away during the night, she gives them early the next morning another dose of the specific, and, two hours afterwards, fix drams or an ounce of purging salt, repeating the whole process of the preceding day; excepting the bolus, which she suppresses.

She observes, that very hot weather diminishes in some degree the action of her remedy; she therefore prefers the month of September for administering it; but as she has not been always able to choose the season, and has been sometimes obliged to undertake the cure of patients in the hottest days of summer, she then gave her specific very early in the morning; and with this precaution she saw no difference in its effects.

On the day appointed for the trial of this medicine before the commissioners nominated by the king of France, it was exhibited to five different persons; but only one of them was certainly known to have the *tænia lata* by having discharged parts of it before. That person was cured; the second voided a portion of the *tænia folium*; the third some *africoides*, with a part of the *tænia folium*; the fourth and fifth voided no worms; but but the last considered much of the viscid slime he voided to be worms in a dissolved state.

This trial was thought sufficient to ascertain the efficacy of the medicine, and further trials were made by those to whom the secret was communicated. The first voided two tenia, after much vomiting and 18 or 20 stools; the second had no vomiting, but was as violently purged, and discharged two worms; the third had 20 copious stools during the night, and discharged the worm in the morning; and the fifth was affected in much the same manner. Some others who were not relieved, were supposed not to have a tenia.

This specific, however, is not to be considered as a new discovery; the efficacy of fern in cases of tenia having been known long ago. Theophrastus prescribes its root, in doses of four drams, given in water sweetened with honey, as useful in expelling flat worms.—Dioctorides orders it in the same dose, and adds, that its effects are more certain when it is mixed with four oboli (40 grains) of scammony or black hellebore; he particularly requires that garlic should be taken before hand. Pliny, Galen, Oribasius, and Aëtius, ascribe this same virtue to fern; and are followed in this by Avicenna, and the other Arabian physicians. Dorotheus, Valerius Cordus, Dodonaeus, Matthiolus, Delechampius, who commented on Dioctorides, or copied him in many things, all mention the fern-root as a specific against the tenia. Sennertus, and Burnet after him, recommended in similar cases an infusion of this plant, or a dram of its powder, for young persons, and three drams for adults. Simon Paulus, quoted by Ray and Geoffroy, confides it as the most efficacious of all poisons against the flat worm, and as being the basis of all the secret remedies extolled by empirics in that defense. Andry prefers distilled fern-water to the root in powder, or he employs it only in the form of an opiate, or mixed with other substances.

These are not the only authors who have mentioned the tenia; many others have described this worm, the symptoms it excites, and the treatment proper to expel it. Almost all of them mention the fern-root, but at the same time they point out other remedies as possessing equal efficacy. Amongst these we find the bark of the root of the mulberry-tree, the juice of the auricula marus, the roots of chamaeleon niger, ginger, zedoary; decoctions of mugwort, southernwood, wormwood, penny-royal, origanum, hyssop, and in general all bitter and aromatic plants, &c. Some of them direct the specific to be simply mixed and taken in wine or honey and water; others join to it the use of some purgative remedy, which they say adds to its efficacy. Oribasius, Sylvius, &c. distinguish the specific that kills the worm, from the purgative that evacuates it, and direct them to be given at different times. Sennertus gives a very satisfactory reason for adopting this method. If we give, says he, the purgative medicine and the specific at the same time, the latter will be hastily carried off before it can have exerted its powers on the worm; whereas, if we give the specific first, and thus weaken the worm, it will collect itself into a bundle, and, being brought away by means of the purge, the patient will be cured. The cure will be more speedy if the prime vice have been previously lubricated. These precautions are all of them essential to the success of the remedy, nor are they neglected by Madame Nouffer in her method of treatment. The panada and injection she prefers the night before, to lubricate the intestines, and prepare the prime vice. The fern root, taken in the morning, kills and detaches the worm; of this the patients are sensible by the cessation of the pain in the stomach, and by the weight that is felt in the lower belly. The purgative bolus administered two hours after this, procures a complete evacuation; it is composed of substances that are at once purgative and vermifuge, and which, even when administered alone, by different physicians, sometimes succeeded in expelling the worm. If this purgative appear to be too strong, the reader is desired to recollect, that it produced no ill effects in either of the cases that came under the observation of the physicians appointed to make the trials; and that in one of those cases, by diminishing the dose, they evidently retarded the evacuations.—Regard however, they observe, is to be had both to the age and the temperament of the patient, and the treatment should always be directed by a prudent and experienced physician, who may know how to vary the proportions of the dose as circumstances may require. If the purgative be not of sufficient strength, the worm, after being detached by the specific, remains too long a time in the intestines, and becoming soon corrupted, is brought away only in detached portions; on the other hand, if the purgative be too strong, it occasions too much irritation, and evacuations that cannot fail to be inconvenient.

Madame Nouffer's long experience has taught her to distinguish all these circumstances with singular adroitness.

This method of cure is, as we have seen, copied in a great measure from the ancients; it may be possible to produce the same effects by varying the remedies; but the manner of applying them is by no means indifferent: we shall be always more certain of success, if the intestines be previously evacuated, and if the specific be given some time before the purgative bolus. It is to this method that Madame Nouffer's constant success is attributed.

Her remedy has likewise some power over the tenia folium; but as the rings of this worm separate from each other more easily than those of the tenia lata, it is almost impossible for it to be expelled entire. It will be necessary therefore to repeat the treatment several times, till the patient cease to void any portions of worms. It must likewise be repeated, it, after the expulsion of one tenia folium, another should be generated in the intestinal canal. This last case is so rare, that it has been supposed that no person can have, more than one of these worms; and for this reason it has been named solitary worm, which, being once removed, could never be renewed or replaced by a second; but experience has proved, that this notion is an ill-founded prejudice; and we know that sometimes these worms succeed each other, and that sometimes several of them exist together. Two living teniae have frequently been expelled from the same patient. Dr De Haen relates an instance of a woman who voided 18 teniae at once. In these cases the symptoms are usually more alarming; and the appetite becomes excessive, because these worms derive all their nourishment from the chyle. If too austere and ill-judged a regimen deprives Appendix.

Worms deprives them of this, they may be expected to attack even the membranes of the intestines themselves. This evil is to be avoided by eating frequently.

Such are the precautions indicated in this disease. The ordinary vermifuge remedies commonly procured only a palliative cure, perhaps because they were too often improperly administered. But the efficacy of the present remedy, in the opinion of the French physicians, seems to be sufficiently confirmed by experience. To the above account, however, it seems proper to subjoin the following observations by Dr Simmons.

"A Swiss physician, of the name of Herrenschwand, more than 20 years ago, acquired no little celebrity by distributing a composition of which he styled himself the inventor, and which was probably of the same nature as Madame Nouffer's. Several very eminent men, as Tronchin, Hovius, Bonnet, Cramer, and others, have written concerning the effects of this remedy. It seems that Dr Herrenschwand used to give a powder by way of preparation, the night before he administered his specific. Nothing could be said with certainty concerning the composition either of one or the other. The treatment was said sometimes to produce most violent effects, and to leave the patients in a valetudinary state. Dr De Haen was dissuaded by his friends from using it, because it disordered the patients too much. It will be readily conceived, now that we are acquainted with Madame Nouffer's method, that these effects were occasioned wholly by the purgative bolus. It is not strange, that resin of scammony or jalap, combined with mercurius dulcis and gamboge, all of them in strong doses, should in many subjects occasion the greatest disorders. It seems likely, however, that much of the success of the remedy depends on the use of a drastic purge. Some of the ancients who were acquainted with the virtues of the fern root, observed that its efficacy was increased by scammony. Refinuous purges, especially when combined with mercury, have often been given with success in cases of tenia. Dr De Haen saw a worm of this sort five ells long expelled by the resin of jalap alone. Dr Gaubius knew a woman who had taken a variety of anthelmintic remedies without any effect, though she had voided a portion of tenia an ell and a half long previous to the use of these medicines; but at length, after taking a purge of singular strength, she voided the worm entire. Many other instances of the same kind are to be met with in authors. Other remedies have occasionally been given with success. In Sweden, it has been a practice to drink several gallons of cold water, and then to take some drastic purge. Boerhaave says, that he himself saw a tenia measuring 300 ells expelled from a Russian by means of the sulphate of iron.

From some late accounts, there is reason to believe that Dr Herrenschwand's remedy for tenia does not so exactly agree with that of Madame Nouffer as Dr Simmons seems to imagine. According to the account given us by a gentleman who had his information from Dr Herrenschwand himself, it consists entirely of gamboge and fixed vegetable alkali.

Of Poisons.

Of many poisons we have already treated, but there are some of which nothing has hitherto been said. Among the most fatal of these are the bites and stings of serpents, scorpions, &c. According to Dr Mead, the symptoms which follow the bite of a viper are, an acute pain in the place wounded, with a swelling, at first red, but afterwards livid, which by degrees spreads farther to the neighbouring parts; with great faintness, and a quick, low, and sometimes interrupted pulse; great sickness at stomach, with bilious convulsive vomitings, cold sweats, and sometimes pains about the navel. Frequently a foamy liquor runs from the small wound, and little pustules are raised about it: the colour of the whole skin in less than an hour is changed yellow, as if the patient had the jaundice. These symptoms are very frequently followed by death, especially if the climate be hot, and the animal of a large size. This is not, however, the case with all kinds of serpents. Some, we are assured, kill by a fatal sleep; others are said to produce an universal hemorrhage and diffusion of the blood; and others an unquenchable thirst. But of all the species of serpents hitherto known, there is none whose bite is more expeditiously fatal than that of the rattlesnake. Dr Mead tells us, that the bite of a large serpent of this kind killed a dog in a quarter of a minute; and to the human species they are almost equally fatal. Of this serpent it is said, that the bite makes the person's skin become spotted all over like the skin of the serpent; and that it has such a motion as if there were innumerable living serpents below it. But this is probably nothing more than a diffusion of the blood, by which the skin becomes spotted as in petechial fevers, at the same time that the muscles may be convulsed as in the distemper called hieroglyphos, which was formerly thought to be the effect of evil spirits; but it is even not improbable that observers have been somewhat aided by fancy and superstition when they thought that they detected such appearances.

It has justly appeared surprising to philosophers, how such an inconsiderable quantity of matter as the poison emitted by a viper at the time of biting should produce such violent effects. But all inquiries into this matter must necessarily be uncertain; neither can they contribute anything towards the cure. It is certain that the poison produces a gangrenous disposition of the part itself, and likewise seemingly of the rest of the body; and that the original quantity of poison continues some time before it exerts all its power on the patient, as it is known that removing part of the poisonous matter by suction will alleviate the symptoms. The indications of cure then are three: 1. To remove the poisonous matter from the body: Or, 2. If this cannot be done, to change its destructive nature by some powerful and penetrating application to the wound: And, 3. To counteract the effects of that portion already received into the system.

The poisonous matter can only be removed from the body by sucking the wound either by the mouth, or by means of a cupping glass; but the former is probably the more efficacious, as the saliva will in some measure dilute and perhaps obviate the poison. Dr Mead directs the person who sucks the wound to hold warm oil in his mouth, to prevent inflammation of the lips and tongue: but as bites of this kind are most likely to happen in the fields, and at a distance from houses, the want of oil ought by no means to retard the operation, as the delay of a few minutes might prove of the most fatal consequence; and it appears from Dr Mead's experiments, that the taking the poison of a viper into the mouth undiluted, is attended with no worse consequences than that of raising a slight inflammation. A quick excision of the part might also be of very great service.

The only way of answering the second indication is, by destroying the poisoned part by a red-hot iron, or the application of alkaline salts, which have the power of immediately altering the texture of all animal substances to which they are applied, provided they are not covered by the skin; and as long as the poison is not totally absorbed into the system, these must certainly be of use.

To answer the third indication, Dr Mead recommends a vomit of ipecacuanha, encouraged in the working with oil and warm water. The good effects of this, he says, are owing to the shake which it gives to the nerves, whereby the irregular spasms into which their whole system might be drawn are prevented. After this the patient must go to bed, and a sweat must be procured by cordial medicines; by which the remaining effects of the poison will be carried off.

It has been confidently asserted by many, that the American Indians are possessed of some specific remedy by which they can easily cure the bite of a rattlesnake. But Mr Cateby, who must have had many opportunities of knowing this, positively denies that they have any such medicine. They make applications indeed, and sometimes the patient recovers; but these recoveries he ascribes to the strength of nature overcoming the poison, more than to the remedies made use of. He says, they are very acute in their prognostics whether a person that is bit will die or not; and when they happen to receive a bite in certain parts of the body, when the teeth of the animal enter a large vein, for instance, they quietly resign themselves to their fate, without attempting anything for their own relief. Indeed, so violent and quick is the operation of this poison, that unless the antidote be instantly applied, the person will die before he can get to a house. It would seem therefore eligible for those who are in danger of such bites, to carry along with them some strong alkaline ley, or dry alkaline salt, or both, which could be instantly clapt on the wound, and by its dissolving power would destroy both the poison and the infected parts. Strong cordials also, such as ardent spirits, volatile alkali, &c., might possibly excite the languid powers of nature, and enable her to expel the enemy, which would otherwise prove too powerful. This seems to be somewhat confirmed from the account we have in the Philosophical Transactions of a gentleman bit by a rattlesnake, who was more relieved by a poultice of vinegar and vine-ashes put to his wound than any thing else. The vine ashes being of an alkaline nature, must have saturated the vinegar, so that no part of the cure could be attributed to it; on the other hand, the ashes themselves could not have been saturated by the small quantity of acid necessary to form them into a poultice; of consequence they must have operated by their alkaline quality.—Soap ley, therefore, or very strong salt of tartar, may reasonably be thought to be the best external applica-

tion, not only for the bites of vipers, but of every venomous creature; and in fact we find dry salt universally recommended both in the bites of serpents and of mad dogs. Dr Mead recommends the fat of vipers immediately rubbed into the wound; but owns that it is not safe to trust to this remedy alone.

Some years ago the volatile alkali was strongly recommended by M. Sage of the French academy, as a powerful remedy against the bite of the viper; and, by a letter from a gentleman in Bengal to Dr Wright, it would appear that this article, under the form of the eau de luce, which is very little if any thing different from the spiritus ammoniae succinatus of the London Pharmacopoeia, has been employed with very great success against this affection in the East Indies; but from the trials made with it by the abbé Fontana, published in his Treatise on the Poison of the Viper, it would appear that it by no means answered his expectation; and the efficacy of this, as well as of the snake pills mentioned under the article HYDROPHOBIA, still requires to be confirmed by further experience.

MELÆNE.