Part III. chap. vii.

In _February_ 1761, three Patients in the Decline of this Fever had Buboes formed in the Groin, which proved critical. At first, on observing them, I suspected them to be venereal; but on examining the Patients, they obstinately denied their having any Reason to suspect any such Cause; and the favourable Manner in which they healed without the Appearance of any other venereal Symptom, made me believe what they asserted to be true; especially as such People are not shy in owning Complaints of that Kind. The first Patient I saw who had a Bubo in the Decline of one of these Malignant Fevers, was a Woman, Wife to a Soldier of the thirty-seventh Regiment of Foot; she had a Child at her Breast, and her Husband was living with her at the Time she was taken ill of the Fever, and neither of them had the least venereal Complaint. In a few Days afterwards, two Soldiers in other Hospitals, towards the Decline of very bad Petechial Fevers, had likewise Buboes formed in the Groin, without any Suspicion of a venereal Taint. Except in these three, I did not see any critical Buboes appear in this Fever while I was with the Troops in _Germany_; tho' Mr. _Lovet_, who served as a Mate to the Hospitals, and who was at _Hoxter_, where we had another Hospital established, while I was at _Paderborn_, told me, that, in the Beginning of the Year 1761, they had several Men in the Hospital ill of this Fever, who had critical Buboes formed in the Groins and Armpits[21].

[21] This Symptom of Buboes is taken Notice of by Authors, but does not seem to be so frequent as many of them would make us believe. Neither Dr. _Huxham_ nor Dr. _Pringle_ mention their having seen such Buboes; and Dr. _Lind_ says, that he never saw them till the Beginning of the Year 1763.

About the same Time that these Buboes appeared, severals towards the Decline of this Fever complained of a Pain all along the Spermatic Chord; and soon after a Swelling of the Testicle appeared[22]. However, this Complaint was not peculiar to those who had the Fever; for others recovering from Fluxes, and other Disorders, were likewise affected with such Swellings. I did not observe any Symptom of this Kind in Fevers while I was with the Troops in _Germany_, except in _January_, _February_, _March_, and _April_ 1761. By Bleeding, and applying emollient Fomentations and Cataplasms, and bathing the Parts with _spiritus mindereri_ on the first Attack of the Pain, the Swelling of the Testicle was prevented; but where no Mention was made of this Pain till the Swelling had already begun, it commonly ended in a Suppuration of the Scrotum or Testicle, which healed very kindly. We had no Reason to suspect any venereal Taint in any of them.

[22] _Hippocrates_ takes Notice of Swellings of the Testicles in Fevers. He tells us, that a Man from Alcibiades had his left Testicle swell before the Crisis of a Fever. _See his Second Book on Epidemics_, sect. ii. And he mentions this Symptom as a Crisis in the ardent Fever. _See his Book on Crises_, sect. xi.--And Dr. _Antonio Lizzari_, in a Treatise which he published on the _Acute Diseases which were frequent at Venice, and all over Italy, in the Years 1761, 62_, tells us, that Abscesses of the Scrotum and Testicles frequently followed the Measles.

Many, while recovering from this Fever, were seized with an Ophthalmia, or Inflammation of the Eye; for the most part of one Eye only, sometimes of both. When the Patients were strong, they were blooded, and had Blisters applied behind the Ears; and sometimes, where the Pain was great, had Poultices of Bread and Milk applied to the inflamed Eye; which, with the Assistance of some cooling Physick, commonly removed this Complaint; tho' in some obstinate Cases we were obliged to repeat the Evacuations, to apply Leeches to the Temples; and after the acute State of the Disorder was passed, to order the Eye to be washed frequently with the Collyrium vitriolicum, or Collyrium Saturninum, before we got the better of this Complaint. However, it ought to be observed, that if these astringent Collyria were used too soon, they did hurt. When these Ophthalmias were neglected in the Beginning, the Inflammation frequently rose to a great Height, and left an Obscurity or Philm over the Cornea, which remained an Impediment to the Sight not to be removed.

Towards the Decline of these Fevers, and very often during the Course of them, many complained of Pains in their Feet and Toes, which sometimes ended in Mortifications, especially where the Patients lay in very cold Wards. For the most Part, the Mortification extended no further than the Ends of the Toes, tho' in some it spread over the Feet, and in two or three advanced up the Leg. Several lost one or more Toes; and in _February_ 1761, one Man lost Half of each Foot; another lost both Feet, and Part of each Leg. Both got the better of the Fever, tho' the Man who lost both Feet languished a long time afterwards. These Pains of the Feet and Toes, and the Mortifications which followed, were for the most part owing to the Patients being exposed to too much Cold while they were very weak, the Circulation languid, and the Juices vitiated by a putrid Distemper; by which means the Vessels were rendered incapable of carrying on the Circulation in their extreme Branches[23].

[23] These Pains and Mortifications of the Feet and Toes were not confined to those who were brought low by malignant Fevers; for, during the very hard Frost in the Beginning of the Year 1763, many of the Patients who lay in very large open Wards in the Hospital at _Osnabruck_, were affected in the same Way. One Man had both Feet, and Part of each Leg, compleatly mortified, and died in about nine Days after the first Appearance of the Mortification. One lost half of one Foot, and some Toes of the other; and the third lost the first Joint of some of his Toes, and the Ends of others.

As soon as the Sick began to complain of these Pains of the Toes and Feet, I found the best Remedy to be, the Bathing of the Feet in warm Water, or in warm aromatic Fomentations; and, after keeping the Feet for some time in these warm Liquors, to dry them well, and then rub them with the _linimentum saponaceum_, or _linimentum volatile_, and wrap them up in Flannel. And if ever any Lividness or Redness appeared on the Parts, we gave plentifully of the Cortex and Cordials, if not contra-indicated by the other Symptoms. When Vesicles arose on the Part, and a Gangrene formed, we directed the Parts to be scarified, and proper Dressings to be applied, while warm aromatic Fomentations and Cataplasms were used.

In _January_ 1762, one Patient, ill of the Petechial Fever at _Bremen_, had a Lividness and Blackness, threatning a Mortification, which appeared at the End of his Nose. I expected for some Days, that, if he recovered, he would lose Part of his Nose; but, by giving him large and repeated Doses of the _cortex_ and _confectio cardiaca_, in a Mindereri Mixture, and allowing him the free Use of Wine, its further Progress was prevented; and as the Patient got clear of the Fever, the Nose recovered its natural Colour, and only the scarf Skin peeled off from the End of it.

When the Fever continued long, and reduced the Patients low, it was very common for the Back, and Parts on which the Weight of the Body rested, to mortify. As soon as any thing of this Kind was observed, we ordered such Parts to be covered with proper Dressings, and gave the Bark and Cordials freely; and took care to make the Patient change his Posture; and by Pillows prevented as much as possible the Weight of the Body from resting on that Part. By this Treatment, many recovered, where the Fever was on the Decline, and the Strength not too much exhausted; even tho' a very large Surface of the Skin had mortified; but where the Patients were very low, and the Fever still continued, or where it was complicated with a Flux, which kept them perpetually nasty, and exhausted the Strength, it generally proved fatal.

Patients, who were reduced very low by this Fever, or by repeated Relapses, were subject to oedematous Swellings; especially of the Feet, towards the Evening, after sitting up all the Day. These Swellings generally went away as the Sick recovered their Strength; but in some Cases they continued obstinate, and ascended towards the Thighs; and in some spread all over the Body, and terminated in an universal Anasarca.

When these Swellings were recent, and confined to the Feet and Legs, commonly the Bark joined to the lixivial Salts, or the Oxymel of Squills, or other Diuretics, and a Purgative once or twice a Week, removed them. In some, an Infusion of Horse-radish had a good Effect; in others, Sweats brought out by means of _Dover_'s Powder, or of the _guttæ antimoniales anodynæ_.

Sometimes these Swellings were very obstinate, and resisted the Force of all internal Remedies. In such Cases, Punctures made in the Feet, or lower Part of the Legs, which furnished a Drain for the Water, had a good Effect. Blisters applied to the Legs were of Service to some. When the Punctures were made, or the Blisters applied, before the Patient's Strength was exhausted, provided that he laboured under no other Disorder but these oedematous Swellings, which proceeded from Weakness, I never observed any bad Effects from them; tho' I used them both repeatedly in a Variety of Cases. But if the Patient was very weak; or had a Hectic Fever or Purging; or other Disorders, and the oedematous Swellings large; then oftentimes the great Discharge exhausted his Strength, and a Gangrene and Death were the Consequence.

One of the most remarkable Instances of the good Effects of Blisters, was in the Case of a Soldier at _Paderborn_; _Thomas Hope_, of the Second Regiment of Foot Guards, after a Fever of this Kind, was swelled all over, especially about the Face and Neck, and had a Difficulty of Breathing: after having tried Variety of Medicines for this Complaint, without any Effect, he had a large Blister applied to his Back, and took the Cortex in a Mixture, with the Oxymel of Squills. As soon as the Blister began to discharge, the Swellings decreased; and were afterwards entirely removed by the Help of one or two Doses of Physic, and the continued Use of the Medicines before prescribed. Three other Men in the Hospital at _Osnabruck_, in _May_ 1761, having oedematous Swellings of the Feet and Legs, which yielded to no internal Remedies, had Blisters applied to their Legs, used the Cortex, with the lixivial Salts, two or three Times a Day, and a Purge every fourth Day; which removed the Swellings in a short Time.

Some of the Soldiers, who had repeated Hospital Fevers, had their Blood so much broke down, as to be subject to profuse Hæmorrhages from the Nose; and some of them passed Blood likewise by Stool; which reduced them to a very low State, sometimes attended with imminent Danger. In such Cases we found nothing to answer so well as to give freely of the Bark; to acidulate their Drinks with the _spiritus vitrioli_; to allow them as much Red Wine as the Strength and present Circumstances could bear; and at the same Time to support the Patient's Strength by a mild Diet, of light Digestion; as Water or Rice Gruel, Panado, weak Broth, and the like. When there was a Tendency to a Diarrhoea, we were obliged to add some of the _electuarium diascordii_ to the Cortex, and frequently to give an Opiate in the Evening. One Case, where this Method of Cure had a very remarkable good Effect, I had under my Care at _Paderborn_. A Soldier who lay in one of the lower Wards of the Jesuits Hospital, after a Malignant Fever, attended with a Flux, used to bleed at the Nose, to four, five, or six Ounces at a Time; and once or twice lost near a Pint of Blood, of a dark Colour, very thin and watery, and of so loose a Texture, that the grumous Part scarcely coagulated. This Evacuation brought him so low, that he could scarce turn himself in Bed; and his Pulse might be said rather to flutter than beat: By the continued Use of the Bark, and of Cordials, and Drinks acidulated with _spiritus vitrioli_, and some Spoonfulls of mulled Red Wine every two or three Hours, he was restored to Health and Strength. The only Accident which happened during the Cure, was a Threatening of a Looseness, and the Return of his Flux; which however was stopt by a Dose of the _tinctura rhei_; by joining some of the _electuarium diascordii_ with the Bark, and giving an Opiate in the Evening.

* * * * *

Putrid Malignant Fevers, attended with Eruptions, are taken Notice of by _Hippocrates_[24], and other antient Authors[25]; but whether they meant that particular Sort of Eruption which we now call Petechiæ, is uncertain; as their Descriptions are not clear enough to distinguish it from the Miliary and other Kinds. But since the Year 1500, we have had many accurate Accounts of Fevers of this Kind, which have appeared in different Parts of the World: from all which it appears that such Fevers generally take their Rise either from some antecedent Acrimony of the Blood; or, what is more frequent, from some Source of Corruption or Contagion; from the Use of putrescent animal Food, and a Want of fresh Vegetables and acescent Liquors; from the putrid Steams of corrupted animal Substances; from the moist putrid Vapour of low marshy Places in Summer, where there is stagnating Water, which corrupts by the Heat; from the foul Air of crowded Hospitals, Jails, and Ships; and from such like Causes[26].

[24] _Hippocrat._ lib ii. popul. sect. iii. text. 2.

[25] _Aetius Tetrab._ ii. sect. i. cap. 129. _Actuar._ lib. i. cap. 23.

[26] See these Causes mentioned by _Riverius_, and since more fully explained by Dr. _Pringle_, _Observations on the Diseases of the Army_, part iii. chap. vii.

When once this Fever begins, it is observed to be of a contagious Nature, and (if proper Care is not taken) to affect those who attend the Sick, or who live in the same Room, and breathe the same Air with them.

Many Authors have reckoned the Malignant, Petechial, and Pestilential, to be distinct Species of Fevers; and have treated each of them under a particular Head. But _Riverius_[27] has very justly observed, that they all belong to the same pestilential Tribe, and only differ from one another in the Degree of Infection, and the Violence of the Symptoms[28]; and that they are to be cured by the same general Treatment, and the same Medicines.

[27] _River. Prax. Med._ lib. xvi. sect. iii. Præfat.

[28] The Malignant or Hospital Fever, and Petechial, seemed to me to be entirely the same Disorder, and the Petechial Spots to be only a Symptom which appeared sometimes, but not always. And _Riverius_ says, the Petechiæ do not always appear; but when they do, it is a most certain Sign of a Pestilential Fever. See his _Prax. Med._ cap. xvi. sect. iii.

OF THE DYSENTERY.

The Dysentery generally began to appear soon after the Army took the Field; and became frequent about the End of _July_, and continued so till the Army went into Winter-Quarters; and through the Winter, many of those, who had this Disorder in Autumn, relapsed, upon returning to their Duty; or by drinking too freely of spirituous Liquors, and being irregular in their Living.

It is now generally agreed upon, that this Disorder is entirely produced by such Causes as make the Juices become too putrescent, and turn the Flow of Humours to the Bowels; and in the Camp it seemed to arise principally from an obstructed Perspiration caused by the Men's lying in the Field, and doing the necessary Military Duties in all Sorts of Weather; at the same Time being often exposed to the putrid Steams of dead Horses, of the Privies, and of other corrupted Animal or Vegetable Substances[29], after their Juices had been highly exalted by the Heat of Summer.

[29] The Dysentery has been long alledged to arise from a putrescent Cause in Camps; from the Smell of corrupted dead Animals, and of Excrements, during the Heat of Summer. _Ramazini_, in his Chapter on Camp-Diseases, informs us, that Dr. G. _Erric Barnstorff_, Physician to the Duke of _Brunswick_, who served five Campaigns with the _Brunswick_ and _Lunenburg_ Troops in _Hungary_, told him, that the Camp Diseases, particularly the Malignant Fever and Dysentery, took their Rise from the Troops remaining long encamped on the same Ground, and being exposed to the corrupted Steams of the Bodies of dead Men, Horses, and other Animals, which lay unburied; and of Excrements, which were not covered with Earth. And these Causes have since been particularly taken notice of by Dr. _Pringle_, in his _Observation on the Diseases of the Army_.

Many have imputed the Cause of this Disorder to the eating of Fruit in excess, because it generally appears about the Middle of Summer, the Time the Fruit begins to be in Season, and continues through the Autumn. But from later Observations this should seem to be a vulgar Error. Dr. _Pringle_ (part i. ch. iii. p. 20.) tells us, that, in the Year 1743, this Sickness began and raged before any Fruit was in Season, except Strawberries, (which from their high Price the Men never tasted) and ended about the Time the Grapes were ripe; which growing in open Vineyards were freely eat by every body. And Dr. _Tissot_, in a Treatise which he published, called _Avis au Peuple sur la Santé_, in his Chapter on the _Dysentery_, § 320, says, that ripe Fruit, especially the Summer-Fruits, are so far from being the Cause of the Disorder, that they are the great Preservatives against it: he says, that, in the Years which the Fruit is most plentiful, the Dysentery is least frequent; and he relates several Instances where the Use of ripe Grapes proved a Cure for the Disorder. Eleven People were attacked by the Dysentery, nine eat Fruit, and all recovered; the other two, a Grandmother and Child, from Prejudice, eat none, and both died. A Regiment of _Swiss_ Soldiers, in Garrison in the South of _France_, had the Dysentery very frequent among them. The Captains purchased some Acres of a Vineyard, and carried the sick Soldiers to the Field, and gave them the Grapes to eat; and ordered the Men in Health to live upon them chiefly. After this not one Person died, nor was any one seized with the Distemper.--In an Account of a Treatise on the Dysentery, published at _Hamburg_ in 1753, which was epidemical the Year before, in _August_ and _September_, we are told, that it did not proceed, as is commonly believed, from the eating of Fruit; for it was observed, that those who eat Fruit freely escaped better than those who abstained from it altogether. _Vide Comment. de Rebus in Hist. Nat. & Medecin. Gestis_, vol. II. par. iv. sect. v.

Generally in _August_ and _September_ we have People admitted into _St. George_'s Hospital for the Dysentery; who have certainly not catched the Disorder from eating of Fruit, but from working in the Fields, and being exposed to Causes similar to those which produce the Dysentery in Camps.

At the Time the Petechial Fever was frequent at _Paderborn_ in _January_, _February_, and _March_ 1761, the Flux frequently accompanied it; and we had in the Hospitals likewise a Number of old Cases of this Kind, the Remains of the preceding Campaign about _Warbourg_; besides some Men who had relapsed during the Winter, and were sent to us when the Troops marched, upon the Winter-Expedition, into the Country of _Hesse_. In _May_ and _June_, what Fluxes we had at _Osnabruck_, were the remaining old Cases of the Hospitals of _Munster_, _Paderborn_, _Hoxter_, and _Niehms_. Some few recent ones were sent to _Bilifield_ about the End of _June_, and above 300 to _Munster_, in _July_ and _August_. Those sent to _Bremen_, in _November_ and _December_, had continued for some time before they reached us; but a good many of the Soldiers in the Garrison were taken ill of this Disorder, and sent immediately to the Hospital. In the Beginning of _May_ we had but four ill of this Complaint in the Hospital I attended; and there were not above six or seven, among the Sick sent down from the Army, in the Middle of this Month. In _June_ there were but two sent to the Hospital at _Minden_; and not above ten among the Sick sent to _Natzungen_ in the Beginning of _July_; tho' towards the Middle of this Month they began to be more frequent; and continued to be more so in _August_ and _September_; and in the Hospital at _Osnabruck_ we had not above five or six ill of this Disorder, in _December_ 1762, and in _January_, _February_ and _March_ 1763.

The Dysentery commonly begun with Sickness and Gripes, succeeded by a Purging, and attended with more or less Fever. Very soon the Gripes became more severe, attended with a Flatulency in the Bowels, and often with a Tenesmus. The Stools were chiefly composed of Mucus, mixed with Bile, and more or less Blood: tho' sometimes no Blood could be observed in them; and then the Soldiers used to say they had the White Flux.

After eight, ten, or twelve, Days, if the Disorder was not complicated with any other, there remained little or no Fever, unless where some Accident supervened; tho' in Cases which terminated fatally, towards the latter End came on a Fever of a low malignant Kind, attended with black fetid Stools, Lientery, Hiccup, Stupor, and other bad Symptoms.

It often happened, that, after the Dysentery had continued for some Time, the Sick complained for a Day or two of severe Gripes; and then discharged along with the Stools little Pieces of hardened Excrements; at other Times, tho' more rarely, little Pieces of white Stuff like Tallow or Suet: Frequently small Filaments, and little Pieces of Membranes, were found floating in the Stools; and it was very common for the Sick to vomit up Worms of the round Kind, or discharge them by Stool[30].

[30] Most Authors, who treat of the Dysentery, mention this Symptom of Worms; and Dr. _Huxham_ tells us, that, in some Seasons, he has seen round Worms in the Stools of most of the Dysenteric Patients. _De Aere_, vol. II. p. 98.

In the Course of the Disorder, the Men often complained of a violent Pain of the Rectum, near the Fundament, which was most excruciating when they went to Stool; it continued for some Days, sometimes for a Week or more; and then they passed more or less of a Yellow Pus with their Excrements, and the violent Pain ceased. Mr. _A. Tough_, one of the Apothecaries to the Military Hospital in _Germany_, was the first who told me that I should find Pus mixed with the Stools: on my mentioning a Case of this Kind, which had been relieved by Bleeding, and Clysters often repeated; he told me he had observed it frequently at _Gibraltar_; and was at a Loss to understand the Nature of the Symptom, till he observed the Matter in the Stools; which at once shewed him that it had been originally an acute Inflammation of the Part, and pointed out to him the proper Method of Cure.

Oftentimes the Bilious and Malignant Fevers terminated in the Dysentery; or were accompanied with it, when it might be looked upon as a Symptom of these Fevers.

The Appearances we found after Death in the Bodies of some Patients, who died of old Fluxes at _Bremen_, were: In all of them the Rectum was inflamed, and partly gangrened, especially the internal Coat. In two the lower Part of the Colon was inflamed, and there were several livid Spots on its great Arcade. In one whose Body was much emaciated, and who had been seized with a violent Pain of the Bowels two Days before his Death, all the small Guts were red and inflamed; and in another there were livid gangrened Spots on the Stomach[31].

[31] From the Accounts we have in Authors, of the Dissection of the Bodies of Persons who died of the Dysentery, it would appear; that there is no Part of the alimentary Canal which has not some time or other been found inflamed, or in a state of Suppuration or Gangrene; and the Liver, Spleen, and other Viscera, have likewise been found diseased, but the Rectum and Colon have almost in all been more or less affected. The following Account I had, in the Year 1748, from the late Dr. _L. Fraser_, who afterwards practised in the Island of _Nevis_, two Days after the Patient died. _Mary Reid_, a Woman thirty Years of Age, was taken ill of a Dysentery, which in Three Weeks Time killed her. In her Life-time she complained, more than ordinary, of Gripes in her Belly, especially in her Left Side. Her Body was opened in Presence of Dr. _Dundas_, who had attended her, during her Illness. All the Intestines and Mesentery were inflamed, especially the Colon and Rectum; the internal Side of which was quite in a mortified State, and contained little Vesicles full of a putrid fetid Liquor, Numbers of which she had evacuated by Stool some Days before her Death.

There was no Disorder we were more successful in the Cure of, than recent Fluxes; but after they had continued for Weeks, and were become in a manner chronic, they often foiled all our Endeavours, and a great Number died[32].

[32] While this Sheet was in the Press, I received Dr. _Pringle_'s 4th Edition of his _Observations on the Diseases of the Army_, and Dr. _Baker_'s Treatise on the _Dysentery which was epidemic in London in the Year 1762_. Both these Gentlemen give an Account of the Dissection of the Bodies of some People who died of the Dysentery; where, besides the common Appearances of the inner Surface of the Rectum and Colon being covered with a bloody Slime, and their internal Coats being inflamed, gangrened, or in a putrid State, there were observed on the Inside of the lower Part of the Colon, and upper Part of the Rectum, a Number of little Tubercles, or Excrescences, which resembled the Small Pox, of a flat Sort at the Height of the Disorder; but differed from them in this, that they were of a firm Consistence, without any Cavity: they were believed to take their Rise from the cellular Membrane, which lies immediately above the villous Coat. Perhaps such Tubercles might have been found in the Colon and Rectum of those Bodies we opened; but not looking for them, they may have passed unobserved.

_Morgagni_, in his Book lately published, _de Sede & Causis Morborum_, epist. xxxi. is of Opinion, that the Filaments, and Pieces of Membranes, which are frequently observed in the Stools, are often formed of inspissated Mucus and Lymph, and other Liquors; and not the Fibres, or Pieces of the villous Coat of the Intestines, as alledged by many Authors.

Upon my first being employed in the Military Hospitals in _Germany_, I was surprised to see so many of the old Dysenteric Cases end fatally; and imagined I had not fallen upon the Right Method of treating them: but upon consulting the other Physical People[33] employed in the same Service, I found them as unsuccessful, as myself, after having tried a Variety of Remedies: And at last, I was convinced, that when once the Flux had continued long, and injured the Structure of the Intestines to a certain Length, a Gangrene will often form by slow Degrees; and the Disorder end fatally, notwithstanding the Use of what are esteemed the most efficacious Remedies; and that, when this Disorder is violent, the Cure principally depends upon an early and speedy Application of proper Remedies, before the Strength be exhausted, or the Structure of the Bowels too much hurt. The bad Success we had in treating these old Cases, may perhaps surprise those who have never practised except in healthful Cities, where the Disease is commonly mild, and People apply soon for Advice. But all those Gentlemen who have had the Care of Military Hospitals, where the Dysentery has been frequent, and where the Sick have been often sent a great Way, before they reached the Hospitals, must be convinced of the Truth of what is here asserted.

[33] Mr. _Cleghorn_, in his _Account of the Diseases of the Island of Minorca_, says, "That almost all the Dysenteries which fell under my Observation, unless they were speedily cured in the Beginning, at best proved obstinate, and too frequently fatal, in spite of the many boasted Specificks for this Distemper." chap. v. p. 228.--The physical Gentlemen employed on the _American_ Service have told me, that the old Flux Cases were as fatal in _America_, as we found them in _Germany_. I would not from thence have it believed, that every old Flux was to be looked on as a lost Case; and for that Reason given up, and no Attempts be made to cure it; for many, by great Care, and Strength of Constitution, have gradually surmounted the Disorder, and recovered their Health; especially when they got over the Winter, and lived till the warm Weather began.

In the Treatment of this Disorder, as well as of the Malignant Fever, nothing contributed more to the Cure, than keeping the Sick as clean as possible, and in large airy Wards.

Most of the recent Fluxes, which I saw, were at first attended with a good deal of Fever, and Pain in the Bowels; and required more or less Blood to be taken away, according to the Strength of the Patient, and the Violence of the Symptoms.

When the Patients were strong, and complained of sharp Pain of the Bowels, attended with a Fever, we used the Lancet freely, nor were we discouraged from bleeding in the Beginning by the low quick Pulse which often attended the Disorder; and we frequently found the Pulse rise as the Blood flowed from the Vein. But when the Sick were low and weak, without much Pain or Fever, and the Pulse was soft, we were more sparing of the vital Fluid[34].

[34] Although Bleeding, in the Beginning, has been recommended by _Sydenham_, _Huxham_, _Pringle_, and other Practitioners; yet it has been reckoned unnecessary in this Disorder by some late Authors. But in most of the recent Cases I saw, it was extremely necessary, and contributed greatly to the Relief as well as the Cure of the Patient; indeed where the Disorder had already continued some time, and the Fever was gone off before the Patient was sent to us; and the Disorder had become in a manner chronic, and the Patient low, then bleeding was unnecessary, and would have probably done Hurt. Mr. _Francis Russel_ told me, that when the Dysentery was epidemical at _Gibraltar_, in Summer 1756, he found that by bleeding such Patients as he met with at the first coming on of the Symptoms, and by giving them immediately a Vomit, and afterwards a sudorific Draught, the Disorder was rendered mild, and few of those died.

As the Disorder was for the most part attended with Sickness in the Beginning, we gave a Vomit after bleeding; which not only discharged the Contents of the Stomach, and a Quantity of Bile, but relieved the Sickness, and frequently threw the Patient into a breathing Sweat; and made the Purgatives which were given next Day operate more freely, and with more evident good Effects than where no Vomit had been administered.--If in the Course of the Disease the Sickness returned, the Emetic was repeated; and we often observed, when the Flux was obstinate, that well-timed Vomits greatly promoted the Cure.--The Vomit we commonly employed was the Powder of Ipecacuana, which we gave from ten to twenty Grains; and where the Patient was strong, and we wanted to make a free Evacuation, we added one, two, or three Grains of the Tartar Emetic; which encreased the Strength of the Vomit, and commonly operated likewise by Stool[35], as Dr. _Pringle_ has observed.

[35] Mr. _W. Russel_, who was with the Hospital at _Martinico_, told me, that, when he was there, he found the Vomit with the Tartar Emetic to be far preferable to any other, in all Cases where there was much putrid Bile lodged in the alimentary Canal; as it speedily carried off those corrupt Humours, which were often productive of the greatest Mischiefs, if they remained, but for a short Time, pent up within the Bowels.

Next Day we ordered a Purge to empty the other Parts of the alimentary Canal. The Purgative, that at first was most employed for this Purpose, was Rhubarb; but upon repeated Trials we did not find, that, in general, it answered so well, in this first Stage of the Disorder, as the _sal catharticum amarum_, with Manna and Oil; which operated without griping or disturbing the Patient, procured a freer Evacuation, and gave greater Relief than any other purgative Medicine we tried. Mr. _Francis Russel_, Surgeon to the _British_ Military Hospital in _America_, who was formerly Surgeon to the Island of _Minorca_, was the first Person who informed me (in the Year 1757) of the Use of the _sal catharticum amarum_ in the Dysentery; he told me, that the Year before (1756) the Dysentery had been very frequent and very fatal at _Gibraltar_; and, after trying Variety of Medicines, he had found nothing give more Relief, or contribute more to the Cure, than repeated Doses of these Salts.

As a great Part of the Cure depended on the frequent Use of gentle Purges[36] in the Beginning, to carry off the corrupted Humours; the Purgative was repeated every second, third, or fourth Day, as the Case required; the Operation of the former Purge, and the Symptoms, determining the Frequency of the Repetition. It was surprising with how little Loss of Strength the Sick bore the Operation of these Purges; I have sometimes given them to strong People every Day, for two, three, or four Days successively; and observed that the Patient, instead of being weakened, seemed stronger, and more brisk and lively, after the Operation of each, from the Relief it gave; by evacuating those putrid, corrupted Humours, which kept him perpetually sick and uneasy, while they remained within the Bowels.

[36] Variety of Medicines have been recommended to answer this Purpose.

The _vitrum ceratum antimonii_ proved often too rough a Medicine, and therefore we laid it almost entirely aside.

Repeated small Doses of the Ipecacuana, from four to six Grains, operated both as an Emetic, and kept up a Purging; but they made the Men so sick, that we could not prevail upon them to continue their Use. Mr. _Francis Russel_ told me, that, in the Year 1756, he found a few Grains of Rhubarb added to each Dose, made it operate more as a Purgative, and did not make the Men so sick.--Dr. _Akenside_ proposes giving the Ipecacuana in so small Doses as one or two Grains every six Hours, in a Draught made of Mint-water, and Half a Drachm of _confectio cardiaca_; and, after bleeding and vomiting once, seems to depend almost entirely on the Use of this Medicine for the Cure of the Dysentery. See his _Comment. de Dysenteria_, cap. 2.

The watery Tincture of Rhubarb, recommended by _Degnerus_, we tried in some Cases at Bremen; and found it to be a good mild Purge, but not to answer so well as the Salts and Manna in recent Cases. Mr. _William Russel_ told me that they found this watery Tincture of Rhubarb to answer better in _America_ than any other of the Preparations of Rhubarb.

Calomel has been recommended by many as a Purge in Dysenteries; and Dr. _Huxham_ (_de Aere_, Vol. II. P. 100) assures us, that he has often experienced the good Effects of it, especially when the Patient at the same time had Worms; in such Cases we joined it to Rhubarb as mentioned in the Text, or gave a Calomel Bolus over Night, and a Purge next Morning. Dr. _Duncan_, Physician to his Majesty, told me, that he found the following Method of Cure always successful in the Dysentery, which was epidemic in _London_ in the Year 1762.

If the Patient was Plethoric, or had much Fever, he ordered more or less Blood to be taken away; and then gave four Ounces of the following Julep, every Half Hour, till it both vomited and purged. Rx _Tartar. emetic. gr._ iij _Mannæ elect. Unc._ ij _solve in Aq. hordeat. Lib._ 1.--The next Day, and for five or six Days more, the Patient took so much of a Decoction, of Manna, Tamarinds, and soluble Tartar, as kept up a free Discharge by Stool.--If the Irritation and Griping were severe, he found that a Solution of Manna, in the common Almond Emulsion, was sufficient.

When the Pain, or Tenesmus, was violent, a Clyster, of Chicken Broth, or of an Infusion of Linseed, with an Ounce or two of Oil of sweet Almonds dissolved in the Yolk of an Egg, injected once or twice a Day, was of great Use.

Upon the whole, he was always pleased when he saw large excrementitious Stools come away; and when that could be procured by a gentle Method, he was the more pleased.

This Disorder was very often cured in a few Days, and in that Case he dropt the further Use of Medicines; but when it exceeded the Period of six or seven Days, he then added thirty or forty Drops of the _tinctura thebaica_ to the Clysters; and ordered a Scruple of the Extract of the Logwood to be taken thrice a Day in some proper Vehicle.

The Patient's Diet was Rice-Gruel, Sago, Panado, and such like; no Animal Food, not so much as Chicken-Broth, was allowed in the Beginning of the Distemper, nor even Oil, Butter, or Fat of any Kind. The common Drink was Almond Emulsion, Rice-Water, or Barley-Water with Gum Arabic.

Dr. _Duncan_ lost but one Patient out of Eighty, whom he had under his Care that Season; and he was delirious, had a high Fever, and a _subsultus tendinum_ before the Doctor was called to him, and he died the next Day.

The late Dr. _Young_, of _Edinburgh_, seems to have had a very just Notion of this Disorder, and of the proper Method of treating it; for, in his Treatise on Opium, sect. vii. he says, "I am convinced from Experience, that most of the Dysenteries I have hitherto met with, might have been cured by purging mildly, but constantly; and at the same time abating the Acrimony in the great Guts by emollient Clysters, and in the small ones by Plenty of Absorbents, and a Diet of Chicken Broth: But it must be observed with regard to Purgatives, that Manna agrees best with some, Rhubarb with others, Jalap, Mercury, and toasted Rhubarb with others; while others are sooner cured by emollient Clysters. I use Opium only when the Disease is mild, or after its Violence is abated by Evacuants and Emollients."

Scammony, Aloes, and the other strong resinous and hydragogue Purges, are hurtful, and occasion Pain. I always observed, that those Purges answered best which made the freest Evacuation, and acted with the greatest Ease to the Patient; of which the Salts and Manna answered best of any I have hitherto used.

Though Rhubarb did not answer so well in the Beginning as the saline Purges; yet afterwards in the Course of the Distemper, when the Patient did not complain much of Gripes, half a Drachm of Rhubarb, either by itself or in a saline Draught, proved a good gentle Purge; and given with six or seven Grains of Calomel, was found to be a good Medicine, when the Disorder was attended with Worms.

In the Evening, after the Operation of the Purge, we gave an Opiate; and repeated it at Nights, in the Intervals between the Purges; but were obliged to be very sparing of the Dose, while the Disorder continued in its acute State; the Opiate was only given in a Quantity sufficient to mitigate the Pain, and to procure Rest, but never so as to stupify the Patient, or prevent a due Discharge by Stool; though we were often obliged to encrease the Dose, as Use made it familiar to the Patient.

In the Intervals between the Purges, we gave in the Day, the Mindereri Draughts with the Mithridate; or the saline Draughts with the Addition of four Drops of the _tinctura thebaica_; or some such mild diaphoretic, every four or six Hours; which helped to keep up a free Perspiration, without any Danger of stopping the Purging; and for the most part answered much better than the Diascord, or Philonium, or other strong Astringents and Opiates commonly prescribed for this Purpose; which were always liable to check the Purging too much, and bring on severe Gripes attended with Heat and Fever[37]; and therefore we seldom made Use of them in this first Stage of the Disorder.

[37] _Sydenham_, _Huxham_, and all good Practitioners, have taken Notice of the bad Effects of the too free Use of Astringents, and given Cautions against it.

If the Patient was attacked with severe Gripes[38], and a Tenesmus, which the Purgatives and gentle Opiates did not relieve, we ordered the Abdomen to be fomented with warm Stupes; and the Patient to drink freely of warm Barley or Rice-water, or of weak Broth[39], or an Infusion of Camomile Flowers, as recommended by Dr. _Pringle_; and ordered first Clysters of large Quantities of the plain emollient Decoction to be given; and if the Gripes still continued, to be repeated in small Quantities, with the Addition of a Drachm or two of the _tinctura thebaica_; for we observed that Opiate Clysters often gave more Relief, than Anodynes administered in any other Way; and sometimes, when a Tenesmus was very troublesome, the common oily Clyster, with a little Diascord, and _tinctura thebaica_, or the Starch Clyster, gave more Ease than any other.--In some Cases, where the Pain was sharp, attended with a Fever, we were obliged to take away more or less Blood; and sometimes also to apply a Blister to that Part of the Abdomen where the Patient felt most Pain.

[38] If the Patient was suddenly attacked with sharp Pain of the Bowels and Gripes, on a Day in which he had not Physic, a Dose of the Salts and Manna was commonly given immediately, to empty thoroughly the first Passages.

[39] Mr. _W. Russel_ told me, that he and Dr. _Huck_ found the free Use of the following Emulsion, made of Bees Wax, to be of great Use after Evacuations, where there was much Pain of the Bowels, in recent Cases of Fluxes in the Hospitals in _America_. Rx. Ceræ alb. vel flavæ drachmes tres. Sapon. alb. Hispan. drachmam unam. Aquæ fontanæ, unciam unam, liquefiant super ignem in vase ferreo, agitando spatula, & dein infunde in mortarium marmoreum, & adde paulatim aq. fontanæ, libras duas syrupi sacchari. spiritus vini gallici tenuis, vel aquæ alicujus spirituosæ ana unciam unam, terendo optime ut fiat emulsio.

This Method of dissolving Bees Wax, in a Watery Liquor, is entirely new; for before this we knew of no Way of making it miscible with Water.

During this Course, the Patients used the common low Diet of the Hospital; when they loathed the Rice-Gruel, they had Panado with a little Red Wine and Sugar; or Water-gruel, when it could be got, in its Place.--Their common Drink was Barley or Rice-water; of which it was recommended to them to drink plentifully; as nothing contributed more to the Cure than the free Use of such Liquors, to dilute and blunt the Acrimony of the Fluids[40]. In some Cases, when the Purging was violent, and not accompanied with the malignant Fever, the _decoctum album_ was found to be a good Drink; and we added occasionally a few Drops of the _tinctura thebaica_.

[40] Dr. _Huxham_ (_de Aere_, Vol. II. p. 107.) says, there is no Disorder in which a diluting, sweetening Drink is more necessary than in this; that he has done great Service among the Poor by luke-warm Water; that, after emptying the Bowels thoroughly, he has sometimes cured this Disorder by the Use of pure Water, and a small Quantity of Opium. And _Baglivi_ (_Prax. Med._ lib. i.) tells us, that the drinking of common Whey, and throwing up frequent Clysters of it, had cured many, and that this was looked upon as a Specific, and kept a Secret by some.

Such were the chief Remedies we used in the first Stage of this Disorder; but after some Weeks, when the Fever had abated, and free Evacuations had been made, and the Complaint become in a manner chronic, we were obliged to try other Methods; and found that the best Way of treating this Disorder, was, to endeavour to brace and restore the Tone of the Intestines, by means of the corroborating and gentle astringent Medicines, mixed with Opiates; while mild Purgatives were given at proper Intervals.

The Patients were kept to the same low Diet as before, with the Addition of a little Wine or Brandy. They were allowed from a Gill to a Pint of red Wine _per_ Day, which was commonly mulled before it was given them; when the Wine griped them, which it frequently did, they took in its Stead Half a Gill or a Gill of Brandy, mixed with a Pint or a Quart of Barley or Rice-water, or of the _decoctum album_.

In this Stage of the Disorder we found, that the same Medicines would not answer with all, and therefore we were obliged to try Variety[41]; and indeed, unless where the Violence of the Disorder had abated by the Use of Evacuations, the Event was always very doubtful; for when the Complaint had continued long and become chronic, and the Structure of the Intestines was much hurt, before the Sick were sent to us; or when it continued obstinate, and yielded but little to Evacuations, and the other Methods used in the first Stage, even Remedies esteemed the most efficacious oftentimes proved unsuccessful, and at length the Patient died.

[41] Dr. _Pringle_, in the _fourth Edition of his Observations_, just published, in treating of the third or last Stage of the Dysentery, remarks, that this is the Time for Astringents, which ought not to be given sooner, or at least very sparingly. And he tells us, that, in the former Editions of his Work, he mentioned those Compositions which he had most frequently used, but that he had now laid most of them aside; and at present trusts to Vomits, and to a Milk Diet, for the perfect Cure.

He says, "Whenever therefore the Patient is in this State, and especially when his Pulse is quick, and he complains of inward Heat, I began with giving him a Scruple of Ipecacuana; and the next Day I put him upon the Milk-Diet; which I continue till all the hectic Symptoms are gone, and till the Bowels have recovered their Tone. During this Course I have seldom had Occasion for any other Medicine, excepting the Chalk Julep mentioned before, which I use for correcting that strong Acid so incident to relaxed Stomachs. Sometimes also I add an Opiate to procure Rest at Night; but after a few Days these are likewise laid aside. All that I require (which indeed is often hard to obtain) is a strict Perseverance in the low Diet: and now and then a Repetition of the Vomit, upon any new Disorder of the Stomach, or great Laxity of the Bowels.

"Whilst the Patient continues in this Course, I forbid all animal Food and fermented Liquors; and besides Milk, I allow only the Preparations of Grain, Sago and Salop." See Part iii. ch. vi. p. 289, 290.

A Spoonful of the _mixtura fracastorii_, taken after every loose Stool; and an anodyne Draught at Night, had a good Effect with some--Repeated Doses of the _philonium Londinense_ answered better with others, who were low, and required a Remedy that was warm and cordial--And others found more Benefit from the Mindereri Draughts, with Mithridate, or the _confectio cardiaca_, or the Theriac anodyne Boluses.

The _mixtura Campechensis_, both alone and with _tinctura thebaica_, checked the Purging, and gave Relief sometimes; and the Addition of some of the Extract of Bark and Tincture of Cinnamon, seemed to encrease its Efficacy in one or two old Cases, at _Bremen_; but it afterwards occasioned such Sickness, that we did not continue its Use.

In other inveterate Dysenteries, where we thought that a strong Astringent was wanted, we added a small Proportion of Allum to the _Campechense_ Julep, which on first using seemed to be serviceable; but at other Times it occasioned a Tenesmus and Gripes; and therefore we were obliged to be very cautious how we used it.

Equal Parts of the _electuarium diascordii_ and _electuarium corticis_, taken in the Quantity of a Drachm twice or thrice a Day, was of Use in many old Fluxes[42], though it made other Patients so sick, that they were obliged to lay it aside.

[42] I had lately a very remarkable Instance of the Effects of this Medicine, in the Case of one _Gilchrist_, a middle-aged Man, by Trade a Taylor; who was admitted into _St. George_'s Hospital the 20th of _July_, 1763, for an old Flux, which had continued above six Months, and reduced him very low: He had taken a great many Medicines without any Effect. After giving him a Vomit and two Doses of Tincture of Rhubarb, I gave him four Grains of the Powder of Ipecacuana with Opium three Times a Day; but that having no Effect, after using it for above a Fortnight, I ordered him the Electuary of Diascord and Cortex; from the Time he began to use this Medicine, he mended daily; and was dismissed in good Health the 26th of _September_.

We tried likewise in this Stage of the Disorder, repeated small Doses of the Ipecacuana; but it occasioned such Sickness, that we did not persist in its Use.

In other Cases, we gave from two to five Grains of the Ipecacuana, mixed with Opium, in different Proportions (from three Grains to ten of the Ipecacuana to one of the Opium), every four or six Hours; it gave sometimes a little present Ease, at other Times it occasioned Sickness; we often continued its Use for ten, twelve, or fourteen Days; but it seldom produced any remarkable Change for the better, and we were obliged to have Recourse to other Remedies.

_Dover_'s Powder was given in large Doses, from one Scruple to two; and proved a good Sudorific and Anodyne in some Cases; though in others it made the Patients sick, without producing any good Effect.--It commonly answered better, when used occasionally as a Sudorific, than when constantly continued.

During the Use of these Remedies, it was necessary to repeat the Purgatives from Time to Time; or to mix them occasionally with the other Medicines, in order to carry off any corrupted Humours, or Excrements that might be lodged In the Cavity of the Intestines; for when this was neglected, the Patients were often seized with Sickness and Gripes, and a more violent Purging than before:--And if at any Time they complained of Gripes, and passed little Pieces of hardened Excrements, it was mostly a certain Sign that a Purge was indicated; and, on such Occasions, it generally gave Relief; and when attended with Sickness, a Vomit was given before the Purge.--Clysters were used as in recent Cases, where the Sick were low, or had much Pain of the Bowels[43], or complained of a Tenesmus.

[43] On the 21st of _November_, 1759, _Hanah Meredith_, a middle-aged Woman, was admitted into _St. George_'s Hospital for a Flux, which she had six or seven Weeks; she had no Fever, but complained much of Sickness and Gripes, and her Disorder had reduced her very low. During the two first Weeks of her being in the Hospital, she had two Vomits of Ipecacuana and four Doses of Rhubarb; and in the Intervals anodyne and astringent Medicines, which made no Alteration in her Complaints. On the 2d of _December_, she told me, that two Years before she had had a Flux for above three Months, which had yielded to no Remedies till she was ordered repeated Clysters, and that they had made a Cure in a short Time. I then ordered an emollient Clyster with a drachm of the _electuarium diascordii_, and a Scruple of the _tinctura thebaica_, to be given twice a Day, which gave her almost immediate Relief; and with the Assistance of some Doses of Rhubarb, and one or two Vomits and occasional Opiates, removed her Disorder by the Middle of _January_; though she remained long weak, and troubled at Times with Gripes; but these Complaints were at last got the better of by her taking some Doses of Rhubarb, and drinking daily a Pint of Lime Water mixed with Half a Pint of Milk.

_Sarah Spencer_, a middle-aged Woman, was admitted into _St. George_'s Hospital the 9th of _November_, 1763, for a Flux, which had continued for two Months, and reduced her very low. She complained much of Sickness and Gripes; her Stools were mostly composed of Mucus and Blood; her Pulse was low, and she had no Fever, but a Whiteness of the Tongue, and complained of Thirst.--The first Day she had a Vomit, and next Day a Dose of the purging saline oily Draught.--She was ordered to have an emollient Clyster, with a Drachm of Diascord, and as much _tinctura thebaica_, given her every Evening; and to have a Dose of the saline oily Purge twice a Week, and Opiates occasionally; by following this Course, and drinking at Times the Chalk Julep, her Disorder was removed, and she was discharged the Hospital on the 30th of the same Month.

In some old Dysenteries, where the villous Coat of the Intestines was much injured, I gave the Cordial Draughts, with the Addition of Half a Drachm of the _balsamum copaivi_, a Scruple of the Extract of the Bark, and five Drops of the _tinctura thebaica_, three Times a Day. At first, this Medicine seemed to promise much, particularly in the Case of an old Invalid, _William Brookes_; who had been long ill of a Flux, attended with Gripes and a Tenesmus. He had used Variety of Remedies, without receiving any Benefit. For the first Fortnight, after he began the Use of this Medicine, he rested well, and found great Relief; and seemed to be in a fair Way of doing well. But the Disorder being too far advanced before he began to use it, he relapsed, and died. On opening his Body, the inner Coats of the Rectum and the lower Part of the Colon seemed to be reduced almost to a gelatinous Substance, and the other Coats were black, approaching to a Gangrene.--The same Medicine gave Relief in other Cases, but they were too far advanced before it was administered. In these Cases, when the villous Coat of the Intestines was inflamed and very irritable, the mucilaginous Medicines, the _pulvis e tragacantha_, and such others, were of Service; and frequently Starch Clysters and Anodynes gave Relief, when other Remedies had little Effect. Flower, boiled with Milk, and sweetened with Sugar, and given for Breakfast, as mentioned by Dr. _Pringle_, proved a good Palliative to some; and the Starch and Gum Arabic, dissolved in Water, a good Drink to others.--Lime Water and Milk, drank to the Quantity of a Pint or a Quart a Day, was of use to a few, though it did not agree with all.

It was very common for Patients bad in the malignant Fever to be seized likewise with the Flux. Such Cases were always extremely dangerous; and when the Fever was bad, we were often obliged to neglect the Flux, and only attend to the Fever.--When the Purging was violent, and appeared very early in the Fever, it often sunk the Patients, and soon carried them off: but where it was moderate, and did not appear till towards the Height or the Decline of the Fever, it often proved a Crisis to the Disorder.

When such Fluxes appeared early attended with sharp Pain of the Bowels, and Signs of Inflammation; if the Patient was strong, we began the Cure with opening a Vein, which the Patient bore easily, and it gave Relief; but when the Symptoms were mild, without any acute Pain, the Bleeding was omitted.--Commonly the Bowels were loaded with corrupted Humours, when this Symptom appeared; and, therefore, we found it of Advantage to give a Dose of the Salts with Manna and Oil, or some other gentle Purge, to carry them off; and in the Evening an Opiate to ease the Pain and procure the Patient Rest.

After this we gave the Mindereri Draughts with Mithridate; and as soon as the Petechiæ appeared, or we observed any Remissions in the Fever, the Patient took every four or six Hours, a Drachm of an Electuary, composed of equal Parts of the _electuarium corticis_ and the _electuarium diascordii_[44]; or Half a Drachm of the Powder of the Bark, or a Scruple of the Extract, in the Mindereri Draughts, with four or five Drops of the _tinctura thebaica_; and we repeated the Opiate in the Evening, always proportioning the Quantity of it to the Effects of the former Dose, and the Violence of the Purging.

[44] This Practice of giving the Cortex with Opiates in the Dysentery is not new; for Dr. R. _Morton_, in his Appendix to his second Exercise on the Fevers, which appeared from 1658 to 1691, observes, that after the Plague of 1666 had ceased, a Fever from a milder Poison, attended with Gripes and Dysentery, began to make its Appearance. As the common Methods of Cure proved unsuccessful, and Dr. _Morton_ observed Exacerbations and Remissions, he resolved to give the Bark mixed with Laudanum; and found it answer his Expectation. The first Patient to whom he gave it, was a man in _Long Lane_, who laboured under a Tertian Dysentery; upon observing a Remission, he ordered a Drachm of the Bark, mixed with a Grain of Opium, to be given every four Hours for six Times; and this removed both the Fever and Dysentery.--He says, he afterwards gave it, with equal Success, in the Quotidian Dysenteries, where he observed Exacerbations or Remissions; and he adds, that he does not doubt but that it will answer as well in Epidemical Diarrhoea's, and Camp Fevers attended with such Symptoms.

Dr. _Whytt_ of _Edinburgh_ has given with Success a strong Decoction of the Bark, mixed with the _confectio japonica_ of the _Edinburgh_ Dispensatory, in the bad State of the Dysentery, when the Mouth and alimentary Canal were threatened with Aphthæ, and even sometimes after they had appeared. And Dr. _Pringle_ mentions his having given the Decoction of the Bark, with Snake-Root and some Drops of Laudanum, in the Dysentery complicated with the malignant Fever. See _Note to Page 245 of his third Edition on the Diseases of the Army_.

On the second or third Day, we repeated the Purge; or, if the Patient was weak, ordered a Clyster to be administered in its Place; in order to prevent the putrid Fluids and Excrements from being accumulated in the Bowels:--In other respects we treated it as when the Disorder was not complicated with the malignant Fever.

This Method, though it did not succeed with all, yet it answered better than any other I tried;--and it ought to be remarked, that although it had such a good Effect in Cases attended with the malignant Fever, or where the Fever inclined to the intermittent Kind, it did not answer so well in other recent Cases, but often made the Patient sick.

In military Hospitals, Fluxes are liable to be complicated with other Disorders, as well as with the malignant Fever; especially with Coughs, and pleuritic and peripneumonic Symptoms, when the Weather begins to be cold, in _October_ and _November_.--In such Cases, when the Patients were strong, we were often obliged to bleed freely, to apply Blisters, and in the Beginning treat the Disorder as inflammatory; having at the same Time an Eye towards the Flux, in the other Medicines we prescribed.

Patients, who have had the Flux long, are apt to have their Legs swell at Nights; or to swell all over as soon as the Flux has stopped. Such oedematous or anasarcous Swellings, we treated nearly in the same Manner as those which followed the petechial Fever; only that we durst not at first be so free with the Use of Purgatives; for as the Bowels remained weak and easily irritated, such Medicines were apt to bring back the Flux; and therefore, in the Beginning, we were for the most part obliged to attempt the Cure by Diuretics and Diaphoretics; and to be sparing of the Use of Purgatives, especially of those of the hydragogue Kind; though if the Swellings continued for some Time after the Flux was gone off, and the Patients were strong, we then ventured to give Purges at proper Intervals:--And Blisters and Scarifications removed them in several Instances both at _Paderborn_ and _Osnabruck_.

In _December_, 1761, we had a Case of this Kind where the _oxymel scilliticum_ was of remarkable Service. A Soldier, belonging to the Guards, after a Flux, swelled all over, and made but a very small Quantity of Water. He took Medicines of different Sorts for some Weeks, but received no Benefit till we gave him the Oxymel Mixture; after taking a few Doses he made Water very freely, and in large Quantities, and the Swellings of his Body and Scrotum began immediately to subside; and by continuing its Use for a Fortnight, the Swellings entirely disappeared, and he recovered his Health and Strength.--The Oxymel, at the same Time that it promoted a Flow of Urine, kept his Body gently open, but did not occasion any Return of the Flux.

At the Beginning of _January_, 1762, one _Carter_, a Soldier of the Eleventh Regiment of Foot, laboured under an universal Anasarca; which about two Months before had succeeded a Flux. He made but very little Water, and that of a high red Colour. He took Variety of Medicines, as Purges, Vomits, _Dover_'s Powder, lixivial and neutral Salts with Opiates, Infusions of Horse-Radish, all without Effect; till he was ordered small Doses of Calomel, three Grains Morning and Evening. After the third Dose he began to make Water freely; and by the 24th of _January_ the Swellings were all gone, and he was shipped off for _England_ the 8th of _February_; having been discharged from his Regiment. The Ship, he went aboard of, was detained in the River _Weser_ for above six Weeks, and the malignant Fever broke out aboard the Transport: He took the Distemper, and got well of it; but towards the Decline was seized with a Return of the Flux, which carried him off.

When these oedematous Swellings came after the Purging was stopt, if the Patient's Strength was not much exhausted, and he laboured under no other Disorder, he commonly got the better of it:--But when the Strength was gone before the Swellings appeared, the Disorder often ended in a confirmed Dropsy, and at last in Death; and when the Swellings were universal over the Body, while the Flux yet continued, it was a Sign of great Weakness, and they did not survive it long[45].

[45] Many other Medicines have been used for the Cure of old Dysenteries,--The _Conessi Bark_, recommended as a Specific in Diarrhoeas, cured a Dysentery which had yielded nothing to a Variety of Medicines. _Edinburgh Medical Essays_, _Vol._ III. _Art._ iv.--The _cortex eleutheriæ vel cascarillæ_ is much recommended for the Cure of Dysenteries in the _Memoir. de L'Academie des Sciences a Paris_ 1719, and is still in great Repute among the _Germans_.--The Decoction of the _semiruba_ Bark was found to have a good Effect in the Dysentery, where the Patient continued to void Blood with his Stools; and when the Stools were only liquid, without a Mixture of Blood, some of the Cascarilla added to the Decoction encreased its Efficacy. See _Degnerus_'s Treatise _de Dysenteria_, _cap._ iii. _sect._ 55. These and many other Remedies have been tried in obstinate Dysenteries.

From what I have observed myself, and from the Accounts of others, I am now convinced, that such Cases as are not already too far gone, are most likely to be cured,

1. By keeping the Patients on a low Diet, composed principally of Milk, Sago, Rice, Salop, and such other Things as are recommended by Dr. _Pringle_; allowing weak Broths, and a small Quantity of white Meat, as they recover their Strength. The common Drink to be Barley or Rice-Water, Toast and Water, _Bristol_ Water, Almond Emulsion, and such like.--By making them wear some additional Cloathing, and guarding carefully against catching cold.--Errors of Diet and Exposure to Cold being the most frequent Causes of Relapses into this Disorder.

2. By giving from Time to Time a Dose of some mild Purge; such as a little Manna and Salts; a Solution of Manna in Almond Emulsion; twenty or thirty Grains of Rhubarb, in a saline Draught, or such like; and occasionally gentle Emetics.

3. By the Use of some of the mild Astringents and Corroborants.--The Bark, with Astringents and Opiates, agreeing best with some--Decoctions of the Semiruba with others--Chalk in Electuaries, or Juleps, with others--anodyne and astringent Clysters with others--while others receive more Benefit from other Remedies--and severals find themselves better when they use no Medicines of this Kind.

4. And by the occasional Use of Opiates, and a free Air: And by moderate Exercise on Horseback, or in a Machine in the convalescent State.

I ought not to omit mentioning, that I have seen some Cases where Evacuations had been used in the Beginning, which, after they had continued for some Time, were cured by a regular Diet of Broths, and white Meats; riding daily on Horseback; and drinking a generous good Claret Wine. However, it ought to be remarked, that this Method only succeeded where the Disorder was mild, and its Violence had abated by previous Evacuations.

OF THE CHOLERA MORBUS.

The Cholera Morbus, or a sudden and violent Vomiting and Purging, was very frequent in _July_ and _August_ 1701; and several were attacked with it at _Munster_.--It was attended with great Sickness, with Pain, and Inflation of the Abdomen, Thirst, and a small quick Pulse: Some had it in a pretty violent Degree, but in general it was mild; and although the Sickness, Vomiting, and Purging, continued, in one or two Cases, for above a Day; yet none of those died whom I saw.

This Disorder weakens the Patient much, in a short Space of Time; and sometimes, when violent, kills in less than twenty-four Hours. It is always most frequent in Summer and the Beginning of Autumn; and is taken Notice of by _Hippocrates_, _Aretæus_, _Celsus_, and other antient Authors; and is very accurately described by many of them.--It is of the bilious Kind; and the Cure principally depends upon the free Use of warm mild Liquors in the Beginning; to dilute and blunt the Acrimony of the Bile, and other Fluids, and to promote their Discharge; and afterwards of gentle Cordials to support the Strength; and warm Fomentations to allay the Pain when violent; and mild Opiates to procure Rest; and if the Sickness or Griping remains next Day after the Cholera is stopt, to give a Dose of Physic and an Opiate in the Evening.

An Officer, who had been wounded on the 15th of _July_, at the Battle of _Fillinghausen_, began afterwards to live very freely, and was on the 4th of _August_ seized in the Night with the Cholera.--About ten o'Clock next Day I was sent for; and found him in violent Agony, with sharp Pain in the Bowels, Reachings, and Strainings to Vomit, and Spasms and Cramps in the Bowels, Legs, and Arms.--He had large red Blotches on his Extremities, and no Pulse was to be felt at the Wrist, and rather a Fluttering than a Beating at the Heart.--He had vomited and purged much in the Night before I saw him, but the Purging had begun to abate.--I immediately ordered him an emollient Clyster, and a saline Draught, with the _confectio cardiaca_, and five Drops of liquid Laudanum; which, if he vomited up, was to be repeated soon after; if not, only once in four Hours: And he was directed to drink freely of weak Chicken Broth, warm.--Two Hours afterwards we found him in the same Situation; still no Pulse to be felt, which prevented us from bleeding him; and the violent Pain of the Stomach and Bowels, and the Cramps, continued. We then ordered Flannels, dipped in a warm emollient Decoction, to be kept constantly applied to his Belly, dipping them in the warm Decoction as soon as they began to grow cool; his Clyster to be repeated with the Addition of a Drachm of the _electuarium e baccis lauri_, and Half a Drachm of the _tinctura thebaica_; a Scruple of Castor, and Half a Drachm of Spirit of Lavender, to be added to each of his Draughts; and a Blister to be prepared, in case these Medicines gave no Relief.--Soon after, beginning to use the Fomentations, the Cramps and Pains began to abate; about four o'Clock in the Afternoon we could perceive a Fluttering of the Pulse at the Wrist, and all the Pains and Cramps were much easier; so that there was no occasion for the Blister.--Next Morning he was very easy, but low, and inclined to be sick; for which his Cordial Draughts were repeated every six Hours.--The third Day, as he complained of a little Griping in the Bowels, we ordered him a Dose of Tincture of Rhubarb, and an Opiate in the Evening, which entirely removed these Complaints, and he was abroad and well next Day.

One Soldier, who had a good deal of Fever, and complained of acute Pain in the Bowels, along with the Vomiting and Purging, was blooded; and drank freely of warm Barley-Water while the Vomiting continued.--After throwing up a Quantity of green bilious Matter, the Vomiting ceased; and the Gripes and Purging became less violent.--In an Hour after, being able to retain some very weak Broth in his Stomach, he drank plentifully of it through the Day; and the Purging being abated towards Night, he took an anodyne Draught; and next Day, having still a little Sickness remaining, had a Dose of Physic and an Opiate at Night, which removed all his Complaints.

The Rest, who were attacked with the Cholera at _Munster_, were treated much in the same Way; only as they had not such acute Pain and Fever as this Man, it was thought unnecessary to bleed them.

The Antients[46] recommended drinking freely of warm Water in the Beginning, and the Use of both cold and hot Fomentations of the Stomach and Belly;--and in the low State, the Use of Wine, mixed with Water, and Polenta[47]; and to apply Rue, with Vinegar, and other strong smelling Things, to the Nostrils; besides Variety of other Remedies.--When Convulsions happen, _Celsus_[48] advises to anoint the Belly with warm Oil; and if that does not remove them, to apply Cupping-Glasses or Mustard to the Stomach; and, after sleeping, to abstain the second Day from Drink; and the third, to go into the Bath; and if any thing of a Fever remains after the Cholera is suppressed, to give a Purge.

[46] See _Aretæus_, Lib. ii. Cap. 4. and _Celsus_, Lib. iv. Cap. 11.

[47] The Polenta seems to have been nothing but toasted Barley Meal. See _Plinii Hist. Natural._ Lib. xxii. Cap. 25.

[48] _Celsus loco citato._

Dr. _Sydenham_[49] trusts principally to drinking freely of Chicken Broth, and throwing up Clysters of the same, and afterwards giving Opiates.

[49] _Processus integ. de Cholera._

Dr. _Ayton Douglas_, in the sixth Volume of the _Edinburgh_ Medical Essays[50], recommends a Decoction of Oat Bread, baked without Leaven or Yest, and carefully toasted as brown as Coffee, but not burnt; as a Remedy very grateful to the Stomach, and useful in stopping the Vomiting, and sometimes the Purging too: And he relates several Cases where it had a good Effect. After the Vomiting was stopped, he added the Use of mild Opiates; and, where the Patient was low, Wine and other Cordials.

[50] Art. 65.

OF THE INFLAMMATORY FEVER.

On the Return of the Troops from the Winter Expedition into the Country of _Hesse_, in the Year 1761, we had several Men seized with Inflammatory Fevers without any topical Inflammation; and at the Opening of each Campaign had always Numbers sent to the Hospitals ill of this Disorder. Towards the End of the Campaigns, and throughout the Winter, many were seized with Inflammatory Fevers; but these were mostly complicated, with pleuritic, or peripneumonic Symptoms, or other topical Inflammations, or with rheumatic Complaints.

In the Inflammatory Fever, the Sick were seized at first with cold and hot Fits, succeeded by Pain in the Head and all over the Body. The Pulse was strong and quick, and the Blood sizy; attended with other Appearances commonly observed in such Fevers.

As the Summer advanced, this Fever was often accompanied with bilious Symptoms, with Sickness, and vomiting of bilious Matter, and very frequently with a Purging: Towards the End of Summer it ceased, and was succeeded by the bilious remittent Fever.--And it was no uncommon Thing to see those Fevers, which originally were entirely of an inflammatory Nature, after the sick had been some Days in a crowded Hospital, partake a good deal of the Nature of the Malignant Fever, or be changed entirely into it.

We treated these Fevers in the common antiphlogistic Method.--We blooded freely in the Beginning; gave the saline Draughts with Nitre and other cooling Medicines; and made the Patients drink plentifully of small Liquors:--And when they were inclined to be costive, gave mild Purges, or emollient laxative Clysters. We afterwards applied Blisters; and if the Pulse began to sink, gave Cordials, Wine, and other Remedies commonly employed in such Cases;--and towards the Decline of the Fever endeavoured to promote such Evacuations as were pointed out by Nature, and likely to prove critical.

When the Case was complicated with bilious Symptoms in the Beginning, we were obliged to have particular Regard to the first Passages. If the Patient complained much of Sickness, we gave a gentle Vomit in the Evening, after bleeding; and a Purge next Day, to carry off any bilious or corrupted Humours that might be lodged in the Stomach or Intestines; and we found that these Evacuations gave Relief, and generally mitigated all the Symptoms.

If at any Time during the Fever a Looseness came on, especially when attended with Gripes, we gave a Dose of some gentle Physic, which made a free Evacuation; and an Opiate in the Evening after its Operation; and afterwards we found it answer better to attempt rather to moderate, than wholly stop the Purging by strong Astringents, and Opiates; unless where the Evacuation by Stool was so great as to be in Danger of sinking the Patient.

The _pulvis antimonialis_, composed of ten Parts of the _pulvis e chelis_, and one Part of the Tartar emetic, given in small Doses, was serviceable in many of these Fevers, after free Evacuations had been made.

Two Patients, one a Soldier of the Twentieth Regiment, the other a _German_ Waggoner, were taken ill of this Fever about the 25th of _December_, 1762: They were both blooded freely, and had a Dose of Physic in the Beginning; and the saline Draughts with Nitre and other cooling Remedies; and had Blisters applied without producing any considerable Change in their Disorder.--On the 5th of _January_, 1763, they both complained much of Thirst, and were inclined to be costive; their Tongues were parched, their Pulses quick and small, and their Skins dry; they were restless at Nights, and the Soldier had a slight Delirium.--I ordered each of them four Grains of the _pulvis antimonialis_ every four Hours.

6th. Next Day the Soldier told me, he had had four loose Stools; his Senses were much clearer, the Pulse calmer and slower, and he said he found himself lighter and easier, and less feverish, than he had been since he was first taken ill. The Medicine was continued, with the Addition of an anodyne Draught at Night.--7th. I found him in a fine breathing Sweat, and he told me he had slept well in the Night: p.--8th. The Sweat continued till this Morning, and on going off his Urine let fall a copious white Sediment, and left him free from the Fever; after which he mended daily.

The Waggoner, after taking the third Dose of the Powders, had a warm Moisture upon the Skin.--On the 6th was cooler and without much Fever, and had had one Stool.--7th. The warm Moisture ended in a profuse Sweat, which carried off the Fever, and he continued to recover daily.

OF THE ANGINA; OR, SORE THROAT.

Many of the Soldiers during the Campaign were seized with Inflammations of the Throat, especially when the Nights were cold and moist after warm Days; and when they did Duty in cold wet Nights in the Winter Season.--All of them I saw in _Germany_ were of the inflammatory Kind; I did not observe any that were malignant.

They were treated in the antiphlogistic Method.--The Patients were blooded liberally in the Beginning--took the cooling nitrous and saline Medicines--gentle Diaphoretics and Purgatives--and used frequent Gargarisms.

Sometimes a Flannel rubbed with camphorated Oil, or the _linimentum volatile_, and applied round the Neck, was of Service.--And frequently after bleeding sufficiently, where the Breathing or Swallowing was difficult, the Application of a large Blister to the Neck gave speedy Relief.

OF THE PLEURISY.

The Pleurisy, or an acute Inflammation of the Side, was most frequent among the Soldiers towards the latter End of the Campaigns; though some were attacked with it at all Times of the Year, from doing Duty in all Sorts of Weather.

We followed the antiphlogistic Method of Cure; and ordered plentiful Bleeding in the Beginning, till the Violence of the Pain began to abate, or the Patient grew faint;--and the Side to be fomented with Flannels dipped in warm emollient Decoctions, and afterwards rubbed with volatile Liniments: At the same Time the Patient drank freely of warm diluting Liquors, as Barley Water, the pectoral Decoction, and such like; and took the saline and other cooling Medicines, mixed occasionally with Sperma Ceti, or some other soft Pectorals, if there was a tickling Cough.--When the Patient was costive, we gave a Dose of Salts, or some other mild Physic, or laxative Clysters.

If the Pain continued very acute, we repeated the Bleeding as often as Necessity seemed to require, and the Pulse could bear; and immediately after the second Bleeding ordered a large Blister to be applied to the Part affected.

Physicians formerly used to forbid Bleeding after the fourth Day, if it had been omitted so long; but when no Symptoms of Suppuration had already appeared, on whatever Day of the Disorder it happened, I ordered plentiful Bleeding, the same as in recent Cases; and never found any Disadvantage, but often great Service from this Practice.

When the Sharpness of the Pain was gone, and the Pulse became soft, very often a dull Pain remained for some Time in the Part.--In some Cases a brisk Purge removed it;--in others, cupping above the Part, and afterwards rubbing it with the volatile Liniments, did Service;--in others, gentle Opiates at Night, especially where there was a tickling Cough;--and in one or two Cases, this Pain did not go away, till the Patient was ordered to drink every Day for some Time, a Quart of the Decoction of Sarsaparilla with the antimonial Wine.

In the Course of this Disorder, if a kindly Moisture broke out on the Skin, which gave Relief, this was encouraged by the Use of mild warm Liquors; or if the Patient began to spit up a viscid or yellowish Mucus, we endeavoured to keep up the Expectoration by the Use of mild Pectorals; and if a Purging came on, we were careful not to check it too soon, unless it was so violent as to be in Danger of sinking the Patient.

When an Inflammation of the Side came to Suppuration, which happened in one or two Cases at _Osnabruck_, in _May_ 1761; as soon as a Fluctuation of Matter was to be felt, an Incision was was made in the Part, and the Matter discharged; after which the Sore healed kindly, and the Patients recovered[51]. I am persuaded, was this Operation oftener performed, many would recover who die consumptive.

[51] Dr. _Mead_ advises, where the Lungs and Pleura grow together, and an Abscess forms, to open it with Caustic; and afterwards to keep the Ulcer open during the Patient's Life: For he says, he has often seen, where such Sores were healed up, that the Patient died soon after by an Efflux of Matter upon the Breast. _Monita Medica_, Cap. i. Sect. 7.

OF THE PERIPNEUMONY.

The Soldiers were subject at all Times to the Peripneumony, or Inflammation of the Lungs, from doing Duty in cold wet Weather, and from their irregular Way of living; but more particularly towards the End of the Campaigns, and in Winter.

This Disorder was much more dangerous and fatal than the Pleurisy, especially when neglected in the Beginning; for then Bleeding had seldom any Effect; the Difficulty of Breathing encreased, the Patient was seized with an Orthopnea, and such an Anxiety and Sense of Suffocation, that he could not sleep; and the Pulse sunk; and in these Cases Death only afforded Relief. This we experienced in many Men who had lain neglected in Quarters, for two, three, four, or five Days, before they were brought to the Hospital.

In most of the Bodies of those who died of this Disorder, and were opened after Death; we found the Lungs violently inflamed, with livid or gangrenous Spots on their Surface; and more or less of a watery Serum extravasated into the Cavity of the Chest.

Three had Suppurations in the Lungs. In one, who had lain sick in Quarters for ten Days or upwards, before he was sent to the Hospital, the right Cavity of the Thorax was found full of a watery Serum; and the Lobes of the Lungs on the same Side almost entirely wasted; and what remained seemed as it were composed of thickened Membranes, resembling those formed by the coagulable Lymph, or what is called by some (though improperly) the fibrous Part of the Blood. The Lobes in the left Side seemed to be in a sound State, or at most but slightly inflamed. From the right Lobes of the Lungs being so much wasted, I suspected that the Patient had probably laboured long under some Disorder of the Breast; but I could not from Enquiry obtain any Information in this Particular; nor did he ever mention such a Thing during the few Days he lived after being brought into the Hospital; he said, he had only been ill for eight or ten Days before; but Soldiers afflicted with chronic Distempers, when they are seized with violent Symptoms, or acute Diseases, are apt to reckon the Beginning of their Disorder, only from the Time they are taken ill in a violent Manner; and never to take any Notice of their former Complaints.

Another Soldier, about the Middle of _February_, 1762, remained in Quarters five Days after being taken ill with a Pain of the Breast, and a Difficulty of Breathing; the sixth Day he was brought to the Hospital in the Morning, and I saw him about eleven o'Clock; he then had all the Symptoms of the true Peripneumony, attended with a strong hard Pulse. He was immediately blooded as freely as his Pulse would bear, had Blisters applied, and other Remedies used; notwithstanding which, on the eighth Day from that Time, he began to throw up a purulent Matter in great Quantity, attended with a constant hectic Heat, and Fever; which sunk him so fast, that he died the tenth Day, after he first began to expectorate.

On the 2d of _March_, a Soldier, of the Fifty-first Regiment of Foot, was brought to the Hospital, with a violent Pain in the left Side, and a great Difficulty of Breathing. Upon examining him, he told me, that about two Years before he had had a violent Stitch in his left Side, towards the lower Part of the Thorax; that ever since he had been subject to a Difficulty of Breathing; and at Times to a Pain in the Side; but that he had only been seized with the violent Pain and Difficulty of Breathing he then complained of, about five Days before, occasioned by catching Cold, on being billeted in a low, cold, and damp House.--His Pulse was quick, the Pain of his Side and Difficulty of Breathing so great, that he could not sleep, nor lie down, but was obliged to sit constantly in an erect Posture; his Tongue was white and furred, and he had had no Stools for three Days: He was ordered to be blooded immediately; and to take a Dose of Salts; and his Side to be rubbed with the _linimentum volatile_. 3d. His Breathing and Pain of the Side were easier; he had slept a little in the Night, and could lie on his right side, but not on his left. He was ordered the Squill Mixture. 4th. His Breathing was worse; he was blooded a second Time; had a large Blister applied to his Side, and was ordered to continue the Use of the Squill Mixture. On the 5th, 6th, and 7th, he seemed easier, though the Breathing was still much affected, and his Pulse quick and low, attended with a hectic Heat. On the 8th, he told me that his left Side was swelled: On examining, I observed a Fullness in that Side of the Thorax; and on pressing with my Fingers between the Ribs, I thought I felt an obscure Fluctuation of a deep-seated Fluid. From these Appearances, and the History of the Case, I judged that there was a Collection of some Fluid within the Cavity of the Chest; and that the only Means left to give Relief, was to make an Opening into the Cavity, and so evacuate the Fluid. I therefore proposed to him the Operation of the Empyema, to be performed immediately; which he several Times obstinately refused to submit to: He allowed a Seton to be put in his Side, but that did not answer the End proposed: He languished six Days longer; and died the 14th of _March_. Next Day an Opening was made in the Thorax, in the Part where the Operation was proposed to have been performed; as soon as the Pleura was cut through, some Quarts of Water rushed out. We then opened the Thorax, and found still some Water in the left Cavity. The Pericardium was thickened, and slightly inflamed, and adhered to the Diaphragm; which was likewise a little thickened and inflamed in the adhering Part; the Lungs on that Side were much compressed, and contracted by the Pressure of the Water; but on being inflated and cut, seemed in a sound State, except that they were slightly inflamed. The Lungs of the left Side adhered every-where firmly to the Thorax, but seemed otherwise sound; having no Tubercles, Suppuration, or other Disorder, that we could observe in cutting them. The Heart and Blood Vessels were sound, and no other polypous Concretions were observed within their Cavities, but such as we find in most dead Bodies; which seem to be formed of the coagulable Lymph in _articulo mortis_. The Viscera of the Abdomen were in a sound State.

We treated the Peripneumony nearly as the Pleurisy. We bled freely in the Beginning, till the Breathing became easier, or the Pulse began to sink; taking Care not to be deceived by a low oppressive Pulse, which generally rose upon Bleeding. We applied large Blisters; gave the mild Pectorals freely, and plenty of warm diluting Liquors, Barley Water, the pectoral Decoction, and such like; which afforded more Relief than any other Medicines. We gave too saline Purges, and laxative Clysters occasionally; and in some Cases ordered the Steams of warm emollient Decoctions with Vinegar to be drawn into the Lungs.

By this Treatment most of them, who applied early for Relief, got the better of the Disorder.

When the Expectoration began, the Patient continued the free Use of the mild Pectorals, and diluting Liquors; and no Medicines were given that might in the least tend to stop it; other Evacuations were omitted, unless where the Pain of the Breast, or the Difficulty of Breathing increased; in which Case, if the Pulse kept up, I ordered a Vein to be opened, and a suitable Quantity of Blood to be taken away; no other Remedy affording any Relief, till this Evacuation was made. Where the Patient was costive, we frequently ordered laxative Clysters, or a mild Purge, and found them beneficial: But where no such Symptoms occurred, it was best, for the most part, to omit all Evacuations of this Kind, after a free Expectoration had begun, and to trust to it for carrying off the Disorder.

In some Cases, where the Expectoration stopt suddenly after bleeding, we gave with Advantage a gentle Vomit, as recommended by Dr. _Huxham_[52].

[52] Some late Authors seem to look upon the _Pleurisy_ and _Peripneumony_ as the same Disorder: However, though it be true, that when the _Pleura_ is inflamed, the Surface of the contiguous Lungs is generally in the same State; and that, when the _Lungs_ are inflamed, the Pleura is often affected; yet as I have frequently seen the true Peripneumony without that sharp Pain of the Side which characterizes the Pleurisy; and upon opening the Bodies of People who have died of the Peripneumony, have found the Lungs violently inflamed and livid, and so filled with Blood as to sink in Water, without the Pleura being much diseased; and upon opening the Thorax of others who died of the Pleurisy, have found the intercostal Muscles and Pleura violently inflamed with livid Spots, and only a small Portion of the Surface of the contiguous Lungs affected; I cannot help still looking upon them as distinct Disorders; though they require nearly the same Treatment, and are often complicated together.

OF THE COUGH and CONSUMPTION.

Coughs were very frequent during the Winter, and when the Weather was wet and cold. They were often accompanied with Pains of the Breast; and, when neglected, Obstructions, Tubercles, and Suppurations, were apt to form in the Lungs, and the Disease to end in a Consumption, or _Phthisis Pulmonalis_.

When Coughs were slight, guarding against further Cold, and the Use of mild Pectorals and warm Drinks, removed them. But when the Patient complained of a Pain and Tightness about the Breast, it was always necessary to take away more or less Blood; and after Bleeding to give some of the mild Pectorals, such as the Sperma Ceti or oily Mixtures; and, if a Fever attended, to join the Use of Nitre, or of the saline or mindereri Draughts; and, if a tickling Cough was troublesome, to give frequently a Tea Spoonful of the oily Linctus, acidulated either with the Spirit of Vitriol, or the _oxymel scilliticum_. The mild Diaphoretics, such as the mindereri Draughts, given along with warm Drinks, to promote a free Perspiration, or Sweat, were used with Advantage; when the Patients kept in Bed, and lay in Wards which had Stoves in them.

If the Cough and Pain of the Breast were not relieved by these Means, the Patient was bled a second Time, and a Blister applied to the Side immediately after; which often removed most of the Complaints. When it did not, we gave the pectoral Decoction for common Drink; and if there was a Shortness or Difficulty of Breathing, the squill Mixture, or _lac ammoniacum_, with Oxymel; and occasionally gentle Purges: And if at any Time of the Disorder the Tightness and Pain of the Breast returned violent, we took away some Blood, no other Remedy affording Relief.

When there was little or no Fever, and a thin Rheum kept up a tickling Cough, nothing had a better Effect than to add some Drops of the _tinctura thebaica_, or some of the _elixir paregoricum_, to the oleagenous or squill Mixtures; or to give an Opiate Draught or Pill at Bed-Time, which eased the Cough, and procured the Patient Rest.

At all Times it was necessary, when the Cough was violent, attended with Pains of the Breast, to keep the Patients on low Diet; and in as free and pure Air as the Nature of the Hospitals would admit of; for we often found that those Men who had laboured long under obstinate Coughs, which threatened Consumptions in small crowded Wards, recovered surprisingly on being removed to a freer Air; of which we had a remarkable Instance in the Hospital at _Bremen_, in _January_ 1762; upon removing some Men, afflicted with very bad Coughs, out of small Wards, which were damp, into one large one, which was dry and airy.

When the Weather was good, we made the Patients walk out a little in the Day-Time; for we observed, that remaining always in the Hospital, and breathing nothing but a foul Air, helped to encrease the Disorder.--When we knew the Men to be sober, and not apt to commit Irregularities, we used to procure them good Billets, and make them come daily to the Hospital for their Medicines.

Equal Parts of Lime-Water and Milk, drank to the Quantity of a Quart a Day, was of Use to some; and the _infusum amarum_, and other gentle Bitters, taken to the Quantity of an Ounce or two, Morning and Evening, to others[53].

[53] Asses Milk, and _Bristol_ and _Seltzer_ Waters, which are found so serviceable in pulmonic Disorders, could not be had in the military Hospitals; and riding on Horseback was too expensive a Remedy for a Soldier.

In chronic Cases, where we suspect Obstructions and Tubercles to be formed in the Lungs, which have not already come to Suppuration, Dr. _Russel_ recommends the Use of Sea Water for resolving them; but we were at too great a Distance from the Sea to try this Remedy. See his _Treatise on Sea Water_, Page 17.

A Decoction of the Cortex removed some Coughs which had continued for a considerable Time. In one or two of these Cases, slight hectic Symptoms had already appeared[54]. However, for the most part, where-ever Obstructions of the Lungs were confirmed, or there were evident hectic Symptoms without a free Discharge of purulent Matter, the Bark did no Service; but rather heated and increased the Fever, and made the Sick more restless and uneasy.--It was of most Use where there seemed to be no confirmed Obstructions, but the Vessels much relaxed; which we judged to be the Case from the Patients having no fixed Pain, nor the Breathing much affected. If the Sick were plethoric, or in the least feverish, we ordered a little Blood to be taken away, before we began the Use of this Medicine.

[54] _Mary Shepperd_, a Woman twenty-six Years of Age, was admitted into _St. George_'s Hospital the 6th of _June_, 1759, for a Cough; attended with a constant hectic Fever and Night Sweats, which had begun in the Month of _April_, after the Measles. She complained likewise of having the _fluor albus_, and she had been blooded more than once before she came to the Hospital.--I at first gave her some of the mild Pectorals; and a Solution of White Vitriol in Water, _utenda pro inject. uterina_. After a Week, finding no Alteration in her Complaints, I advised her to become an Out-patient; and to go down to her Friends in the Country, to live upon a Milk Diet; to take gentle Exercise, and continue the Use of her Medicines; which she did, but without any Alteration in her Disorder, till the 6th of _July_, when I ordered her to take thrice a Day two Ounces of the Decoction of the Cortex, along with a saline Draught. Immediately, on beginning to use this Medicine, her Disorder began to take a favourable Turn; her Fever and Night Sweats left her, her Cough became easier, and she recovered Health and Strength daily. She came to the Hospital the 15th of _August_, seemingly in good Health, to return Thanks for her Cure.

In similar Cases, I have sometimes observed good Effects from the Use of the Balsam _Copaivy_, or _Peru_; given either in Juleps or made up into an Electuary, as in the _electuarium e spermate ceti cum balsamo_; but in whatever Form they were given, if there were confirmed Obstructions of the Lungs, they rather heated and inflamed, than did any real Service.

When Coughs continued long, attended with Pain in the Side, Difficulty of Breathing, and Hectic Fever and Night Sweats, we always had Reason to suspect, that the Disorder would terminate in a confirmed Consumption. When this was threatened, we found, that the principal Thing to be done, was to keep the Patients cool; and to endeavour to allay the hectic Heat and Fever; and to retard, as much as possible, the Progress of the Disorder. When the Case was recent, we were sometimes so lucky as to make a Cure; but after it was confirmed, it for the most part ended fatally.

We kept the Patients upon a low Diet; and where-ever Milk was to be got easily, we allowed them a Pint a Day[55]; which was either mixed with Water and given for Drink, or they took it to Breakfast or Supper.--Their common Drink was either Barley Water or the pectoral Decoction; which was occasionally acidulated with a few Drops of Spirit of Vitriol; and we gave at the same Time the cooling Medicines, such as Nitre, the saline or mindereri Draughts, mixed at Times with Sperma Ceti, or some other of the mild Pectorals.

[55] In private Practice, at this Stage of the Disorder, the Use of Asses Milk, and drinking the _Bristol_ Water at the _Bristol_ Wells, and riding on Horseback daily, are justly ranked amongst the most efficacious Remedies; and going into the more southern Climates, as the South of _France_, _Portugal_, or _Italy_, where the Air is warmer, more constant, and dry, than in _England_, has often been found to produce good Effects.

The opening a Vein, and taking away from four to eight Ounces of Blood[56], whenever the Pain of the Breast was troublesome, or the Patient was hot and restless at Nights from the Hectic Fever, gave the greatest Relief of any Thing we tried; and these repeated small Bleedings were so far from wasting the Patient's Strength, that they rather seemed to prevent its being exhausted so fast as otherwise it would have been, by allaying the Force of the Hectic Fever.

[56] This Practice has been strongly recommended by Dr. _Mead_, in his _Monita Medica_, Sect. x. and by an anonymous Author in the _Edinburgh Medical Essays_, Vol. IV. Art. 28. and Dr. _Mead_ says, when Things have not been quite desperate, he has seen good Success from it.

At this Stage of the Disorder, we put in Setons, or ordered Issues, to serve as a Drain to carry off the Matter, and found them of Advantage in some Cases. When the Patients complained of any fixed Pain, we always made the Issues as near the Part affected as possible[57]. On the 5th of _May_, 1762, a Man, belonging to the Eighty-eighth Regiment of Foot, was sent to the Hospital at _Bremen_ for an Hæmoptoe, attended with a constant hectic Heat and Fever.--After being blooded, and using the cooling Remedies without Success, he had four Pea Issues made in his Back; and had a slight Decoction of the Cortex, acidulated with Spirit of Vitriol. As soon as the Issues began to discharge freely, the hectic Heat, Fever, and Spitting of Blood, diminished daily; and he recovered his Health and Strength in a short Time. However, it ought to be observed, that although these Drains are sometimes efficacious, yet, when the Disease is far advanced, the Mischief is generally too deep rooted for them to be of any Service.

[57] In _June_, 1748, a Servant Girl came to ask my Advice for a Cough, attended with a constant Hectic Fever and Night Sweats, which had begun some Months before, on catching Cold. The Matter she spit up was yellow, and had the Appearance of Pus; and she complained of a Pain in the left Side of the Thorax. I ordered her the saline Mixture with Sperma Ceti to be taken thrice a Day, to lose a little Blood, to drink an Infusion of Linseed sweetened with Honey, and to have a Seton put in her Side at the Part where she complained of Pain; advising her to go home to her Father, who was a Farmer in the Country, and to live upon a Milk and Vegetable Diet, and ride on Horseback whenever she could conveniently. She seemed so far gone in a Consumption, that I scarce expected to see her again; but, in the Month of _December_, she came to return me Thanks for her Cure, seeming then to be in good Health. She told me, that, as soon as the Seton began to discharge freely, she found Relief; and mended afterwards daily, by following the Directions I had given her.

The Bark, and natural Balsams, for the most part were prejudicial, and encreased the Hectic Heat and Fever; except in one or two Cases, where the Disorder seemed to depend on a Vomica of the Lungs, and the Patient coughed up the Matter freely.--In one Case they were of considerable Service; the Patient was very low, and had the Night Sweats, but coughed up the Matter freely: On using the Decoction of the Bark, and the _electuarium e spermate ceti cum balsamo_, the Matter expectorated became thicker, and of a more balmy Consistence, without any Increase of Heat or Fever; after which the Symptoms became gradually milder, and the Patient recovered.

In the Course of this Disorder the Patients often became very hot and restless, and were troubled with Gripes, succeeded by a Purging: These Symptoms were most readily removed by a Dose of Rhubarb, or of some other mild Purge; for they generally proceeded from corrupted Humours lodged in the Intestines. In the Evening, after the Operation of the Purge, we gave an Opiate to procure the Patient Rest.--When the first Dose of Physic did not stop the Purging, we repeated the Opiates at Nights, and in a Day or two gave another Purge; and if there was much Sickness, or Load at the Stomach, gave likewise a gentle Emetic.

If the Purging still continued, we were obliged to join the Use of Astringents along with the Opiates. In some Cases, I found good Effects from equal Parts of Milk and Water boiled with Rose Leaves, Pomegranate Bark, Balaustine Flowers, and Cinnamon, as recommended by Dr. _Mead_ in his _Monita Medica_[58]; it served both for Food and Medicine.--When Opiates and Astringents were given to stop the Purging at its first Appearance, before the Bowels were emptied, they always did Mischief; and increased the Heat and Fever: And although they stopt the Purging for a few Hours, it always broke out with greater Violence afterwards.

[58] _Sect._ x. _de Febrib. lentis sive Hecticis._

When the Sick were attacked with a Shortness and Difficulty of Breathing, which was not relieved by Evacuations, and the Use of cooling Medicines, and Pectorals, and Blisters, nothing gave so much Ease, or had such a good Effect, as a gentle Vomit; for it often removed the immediate Oppression from the Breast, and helped to pump up the Matter from the Lungs.

In the advanced State of the Consumption, the Cough was always very troublesome; and the Sick found no Relief but from Opiate Medicines, which, in such Cases, cannot be expected to do more than give a little present Ease.--As they were apt to obstruct the free Expectoration, we generally mixed them with some _oxymel scilliticum_, or _tinctura foetida_, which took off a good deal of their suffocating Quality.

Dr. _Barry_[59] advises for the Cure of a Consumption, to make an Incision or Aperture into the Side; where-ever there is a fixed Pain attended with a Weight, a Hectic Fever, and other Symptoms of an evident Suppuration: He says the Pleura is thickened, and the Lungs adhere at the Part where they are exulcerated; and that by the Operation the Pus may be evacuated, and a Cure made; and he gives several Instances of the Success of the Operation, when performed in Time.

[59] _Treatise on the Digestions_, p. 410.

OF THE Epidemical CATARRHAL FEVER Of APRIL, 1762; CALLED, THE INFLUENZA.

After a very cold severe Winter at _Bremen_, the Weather, from being very cold, became of a sudden extremely hot, about the 10th of _April_. In a few Days after, many People were seized with a violent Catarrhal Disorder. It often began with such a Cold and Shivering, that many imagined at first that they were going to have Agues; but soon after they were attacked with a Cough, and a Difficulty of Breathing, and Pain of the Breast, with a Head-Ach, and Pains all over the Body, especially in the Limbs.--The first Nights they commonly had profuse Sweats.--In several, it had the Appearance of a remitting Fever, for the two or three first Days.--Many had a slight Inflammation of the Throat, and a Hoarseness. In all it was attended with an acute Fever in the Beginning, and the Urine was of a high Colour; and when the Disorder had put on the Appearance of a Remittent Fever in the Beginning, it dropt a Sediment towards Morning after the second Day; and did the same in all, when the Disorder was going off.--Some had a Purging, but the greater Number were rather inclined to be costive.--The Cough in many was very violent; and the Patients, after each Fit of Coughing, had Reachings, or Strainings to vomit, exactly resembling those which come after violent Fits of the Hooping Cough.--At first the Patients spit up only a little Phlegm; but in the Decline of the Disorder, they expectorated freely.--The violent Cough and Feverishness generally continued for four, five, or six Days; with others it continued longer; and some had a Cough for two or three Weeks after the Fever left them.

This Catarrhal Fever seized most of the People of the Town of _Bremen_; and there were very few of the _British_ who escaped it; at the same Time, it was epidemical in most Countries in _Europe_.

We treated it entirely as an inflammatory Disorder, and none died who applied early for Relief.--Most People recovered by one plentiful Bleeding, and taking the mild cooling Medicines, such as the _mixtura e spermate ceti cum nitro_, the saline or mindereri Draughts, or such like. When the Fever and Difficulty of Breathing continued after the first Bleeding, in a Day or two a Vein was opened a second Time; and immediately after a Blister was applied to the Back, which commonly removed the Fever, and relieved the Breathing.--When the Patients were inclined to be costive, a Dose of Physic was of Service.

None of the _British_ died, except one or two of the Soldiers, who remained in Quarters after being taken ill; and, instead of bleeding and living low, indulged in the Use of spirituous Liquors; and were not brought to the Hospital, till they were in the last Stage of a Peripneumony.--Many of the Inhabitants of the Town died of this Disorder, which was probably owing to Want of Care.

OF THE RHEUMATISM.

The Rheumatism is one of the Disorders most generally to be met with in military Hospitals. There were at all Times some Men in our Hospitals labouring under Rheumatic Fevers, or other rheumatic Complaints; though we never had at any one Time a great Number; owing probably to the Weather being very favourable in both the Campaigns of 1761 and 1762.--It was always most frequent when the Weather was wet and cold; both during the Campaign, and when we were in Winter Quarters.

It commonly began either, 1. With an acute Fever, and Pains all over their Body: or, 2. With Pains in particular Parts, as the Shoulders, Legs, Arms, Knees, and sometimes of the Side, attended with some Degree of a Fever.--The first was the most common Form it assumed, when Men were attacked with it in the Field or in Garrison; owing to their doing Duty in cold wet Weather.--The other Causes generally took place when they had been formerly subject to rheumatic Complaints, and had caught Cold; or after they had been weakened and reduced low by Fevers, Fluxes, or other Disorders.

We had but very few Rheumatisms accompanied with Swelling, Pain, and Inflammation of the Joints of the Knees and Wrists, &c. which are so common in our Hospitals about _London_. I did not meet with above a Dozen Cases, of this Kind, whilst in _Germany_ with the Army.

When the Rheumatism began with Pains all over the Body, attended with a High Fever, we treated it at first entirely as an Inflammatory Fever[60]. We blooded freely, and repeated this Evacuation often[61], if the Blood continued sizy, and the Pains violent; provided the Pulse was strong. When the Pleura, the Lungs, or any other of the Viscera were affected, we blooded as freely as we should have done in acute Inflammations of these Parts: We gave the saline Draughts with Nitre[62]; and Plenty of Barley Water and other weak diluting Liquors; and gentle Physic once or twice a Week; and afterwards applied Blisters, which often relieved both the Pains and Fever.

[60] _Sydenham_, in treating of this Disease, orders Bleeding, and that to be repeated next Day; and afterwards every other Day, two, three, or four Times, or more, as the Patients Strength can bear it; and on the intermediate Days to give a purgative Clyster. But in young People, and those who have lived regularly, he says, that a very low Diet will cure as effectually as Bleeding and Medicines; That the Patients must live four Days on Whey alone, but after this may eat Bread for Dinner; and on the last Days for Supper also; and when the Symptoms begin to abate, he allows them to eat boiled Chicken, or other light Food; but says they must live every third Day on Whey, till their Strength returns. _Precess. Integr. de Rheumatismo_.

[61] A Remark of Dr. _Huxham_'s deserves to be taken Notice of here: He tells us, that there are some Kinds of Rheumatisms, _viz._ those which come from a sharp serous Rheum, which do not bear the free Use of the Lancet; that plentiful Bleeding does more Hurt than Good; and that, in such Cases, the Medicines which bring out breathing Sweats, and at the same Time correct the Acrimony of the Blood, joined with gentle Opiates, have a much better Effect. _De Aere_, Vol. II. p. 185.

[62] Dr. _Brocklesby_, in his _Observations on military Diseases_, recommends the Use of large Quantities of Nitre dissolved in Water Gruel, or Sage Tea, (in the Proportion of two Drachms of the Nitre to a Quart of the Liquor) in acute Rheumatisms. He says, "I am assured from numberless Instances, that in stout young Men, by taking six hundred Grains (ten Drachms) daily, for four or five Days successively, and diluting plentifully, as before recommended, plain Nitre proves the most powerful and best Sudorific, in such Complaints, that I have ever tried; and this Quantity, and even more, may be retained in the Stomach, and pass through the Course of the Circulation, by only diluting properly with those thin attenuating Beverages as before recommended. Such Quantities, in three or four Days, seldom failed wonderfully to relieve the Patient, and very often to cure him entirely, by the most plentiful and profuse Sweats." _See from p. 116, to p. 124._

I have never hitherto given Nitre in such large Quantities as here recommended by Dr. _Brocklesby_.

After some Days, if the Pains still remained, we continued the saline Draughts with Nitre throughout the Day; and in the Evening endeavoured to promote a free Perspiration by Means of the mild Diaphoretics, such as the mindereri Draughts with Mithridate, in Doses frequently repeated; at the same Time, the Patient kept in Bed, and drank freely of mild diluting Liquors. Sometimes we gave twenty, thirty, or forty Drops of Spirits of Hartshorn, in repeated Draughts of warm Barley Water: or a like Quantity of the Antimonial Wine, used in the same Manner: or from sixty to a hundred Drops of the Antimonial Wine, mixed with one-fourth Part of the _tinctura thebaica_, in a large Draught of some warm Liquor; which I have observed, in many Cases, to have a better Effect, than most other Medicines used for this Purpose; as it acts both as an Opiate in easing the Pain, and procuring Rest; at the same Time that it promotes a free Perspiration, or gentle Sweat, to carry off the Distemper.

But it should be observed, that, in the Beginning of Rheumatic Fevers, forced Sweats generally did Hurt, and often increased both the Pain and Fever; and that in general we had greater Success, and made speedier Cures, when we did not attempt to promote Sweating, till after other Evacuations had been sufficiently made, and the Fever had begun to abate; and that in this Fever, when we did attempt to procure Sweats, the milder Diaphoretics, with Plenty of weak diluting Liquors, answered better than those of a more heating Nature; though after the Fever was gone, and the Pains still continued, sometimes the stronger Sudorifics, such as G. Guaiac, and its volatile Tincture, _Dover_'s Powder, and the like, best answered the Purpose, and carried off the Distemper, when the milder ones had little Effect.

I have often observed, where Sweating made no Change in the Distemper, that keeping up a free Perspiration by Means of the Decoction of the Sarsaparilla with the Antimonial Wine, or small Doses of the _pulvis antimonialis_ (_gr._ v.), given twice or thrice a Day, removed Rheumatisms, which had resisted the Force of other Remedies.

Sometimes the cold Bath[63] removed Pains which had not yielded to internal Medicines; but it ought to be observed, that when Patients went into the cold Bath while the Feverishness still remained, and the Blood continued sizy, or before free Evacuations had been made, oftentimes, instead of giving Relief, it made the Disorder worse, and more obstinate[64].

[63] I have frequently ordered the warm Bath with Advantage in Rheumatic Cases in _St. George_'s Hospital; but we had no Convenience of this Kind with the flying Hospital in _Germany_.

[64] This I have seen many Instances of, particularly in the Case of _Ann Walker_, a Woman of twenty three Years of Age, who was under my Care in _St. George_'s Hospital, in _May_, 1759. Before she came to the Hospital, she had been blooded, and had gone into the cold Bath four Times, which, she told me, had increased her Pains to a violent Degree; in which State she had continued for some Weeks before she came to the Hospital; but by being blooded, and taking the cooling saline Medicines, with gentle Purges, and mild Diaphoretics, she got well in a Month's Time.

When the Rheumatism was confined to a particular Part, attended with Fever, we treated it as the acute Rheumatism. Fomenting the Part with warm emollient Decoctions, and rubbing it afterwards with the volatile, or saponaceous Liniments, often gave Ease; and the Application of Cupping-Glasses and Blisters frequently removed the Disorder. In some Cases, where the first Blister did not relieve, the Application of a second, and afterwards keeping up a Discharge from the Part by Means of the Epispastic Ointment, carried off the Pain. In others, where the mild Diaphoretics were ineffectual, Sweating, with the G. Guaiac, or _Dover_'s Powder, and such other Medicines, after the Fever was gone, removed the Complaints[65].

[65] Warm Water, pumped upon the Part, often removes such rheumatic Pains as have resisted the Force of internal and other Remedies. On the 29th of _August_, 1759, _Mary Ward_ was admitted into _St. George_'s Hospital for rheumatic Pains of the Arms, Legs, and Knees, attended with Fever, which all yielded to Evacuations, and the Use of cooling Medicines, mild Diaphoretics, and of the warm Bath, except the Pain of the Knee; which, after it had resisted the Course above-mentioned, was at last removed by pumping warm Water on the Part, three Times a Week; joined to the Use of Fomentations and volatile Liniments.

When the Rheumatism was attended with Inflammation and Swelling of the Joints, we blooded freely, gave cooling Purges, and the saline Draughts with Nitre, along with Plenty of weak diluting Liquors, and prescribed a cool low Diet.

After the Violence of the Fever and Inflammation was abated, fomenting the Parts, and rubbing them with the saponaceous or volatile Liniments, sometimes hastened the Discussion of the Swelling; as did likewise the Application of Blisters[66], after the Inflammation was entirely gone; but it ought to be noticed, that if volatile Liniments or Blisters are used too soon, they will sometimes occasion violent Inflammation and Pain[67].

[66] _Ann Ragen_, a Woman about thirty-three Years of Age, was admitted into _St. George_'s Hospital the 17th of _January_, 1759, for rheumatic Pains of her Legs and Arms, and a Swelling of her right Knee. Free Evacuations, and the Use of cooling Medicines, and mild Diaphoretics, removed all her other Complaints, except the Swelling of the Knee, by the Middle of _February_, when I ordered a Blister to be applied to it; after which the Swelling gradually decreased, and she was discharged, cured, the 20th of _March_.--_Rachael Hyde_, a Woman twenty-four Years of Age, was admitted into _St. George_'s Hospital the 9th of _May_, 1759, for similar Complaints, which were removed by the same Means, all except the Swelling of the Knee. A Blister was applied, and most of the Swelling went away, but returned soon after: It was at last removed by the Use of the warm Pump three Times a Week, and drinking a Pint of the Guaiac Decoction daily.

[67] I have sometimes ordered Leetches to be applied to such Swellings (as recommended by Dr. _Pringle_), and found them to be of Service; and, at other Times, I have applied emollient Fomentations and Poultices, which have given great Ease to the Patient.--I have seen Setons or Issues, made near the Part affected, afford considerable Relief.

Rheumatic Cases of this Kind are often very obstinate, and require a considerable Length of Time before they are got the better of; and frequently more or less of the Swelling, especially of the Wrists and Joints of the Fingers, remains ever after; and Patients, who have once had the Rheumatism in this violent Degree, are always subject to Relapses; as are even those who have had the Rheumatism but slightly.

Mercury[68] has been recommended in the Cure of Rheumatisms; but I never found it do any Service by itself, except in Cases complicated with venereal Symptoms; though I have often given it, and even sometimes gone so far as to raise a Salivation, where the Pains were most severe in the Night; and the Patient, at the same Time, thought he had some Reason to suspect a venereal Taint, though no external Symptom appeared. However, many good Practitioners have recommended small Doses of Calomel to be given at Nights, and next Morning a Purge; in which Way, I think, I have observed good Effects from its Use.

[68] Dr. _Musgrave_, in his Treatise _de Arthritide Symptomat._ p. 30, cap. ii. sect. 10, says, he has known a Salivation, raised by Mercury, cure the Rheumatism.

The Bark was frequently of Use in restoring the Strength, and removing those rheumatic Pains which remained after Fevers, and other Disorders; but, in other Cases, it had little Effect.

When the Rheumatism continues long, and has taken deep Root, _Sydenham_[69] advises to bleed from Time to Time, at some Weeks Distance; which, he says, will either entirely remove the Disease, or bring it to that Condition, that the Remains of it will be easily extirpated by an Issue; and giving some of the volatile Salts in _Canary_ Wine, Morning and Evening. I have always observed in rheumatic Cases, which continued long, that, after free Evacuations, the Patients received more Benefit from a mild low Diet, continued for some Time, and the Use of diluting Decoctions with mild Diaphoretics, while they took gentle Purges once or twice a Week, than from any other Remedies.

[69] Vide _Sydenham. Opera._ sect. vi. cap. 5.

I have given Half an Ounce of Soap a Day, for a considerable Time, in some old rheumatic Cases, in the Manner recommended by the late Dr. _John Clerk_ of _Edinburgh_, as mentioned by Dr. _Pringle_; and, I think, with Advantage; but have not had sufficient Trials to ascertain the Merits of this Medicine.

Dr. _Sydenham_, in treating of the Rheumatism, which he calls scorbutic, says; that after it had resisted Bleeding, Purging, low Diet, and other Remedies, he has cured it by giving thrice a Day two Drachms of an Electuary made of _conserv. cochlear. horten. recent. unc._ ij. _lujul. unc._ i. _pulv. ar. comp. drachm_ vi. _cum syrup. aurant._ q. s. drinking after it three Ounces of a Water drawn from _Brunswick_ Beer, and some of the antiscorbutic Plants.

There is no Disorder which Soldiers are so apt to counterfeit as the Rheumatism, when ever the Duty in the Field is severe; but while there is no Fever or Size in the Blood, or other evident Marks of the Distemper, and the Men look healthy, there is always Reason to suspect Imposture.

OF THE Autumnal Remitting Fever.

The Remitting Autumnal Fever, called by the Antients [Greek: synechês], was also one of the most frequent Disorders during the Campaign.

This Fever is observed in most Countries, after the Juices have been highly exalted by the Heat of Summer; and People are exposed to the Heats of Mid-Day, and to the cold Damps of the Night. We observe it every Year in the Neighbourhood of _London_, especially among the labouring People, who work in the Fields, towards the End of Summer, and in Autumn; but it is generally in a milder Degree than in Armies, where Men are more exposed to the Vicissitudes of the Weather.

As we go further towards the South, this, as well as other bilious Disorders, becomes more frequent.

This Fever is reckoned the endemic Distemper of the _West Indies_, of the Coast of _Guinea_, and other Places in the Torrid Zone; but in those warm Countries it appears in a more violent Degree; makes a much more rapid Progress; and proves far more fatal than in our cooler and more temperate Climate. And it is observed to be always most frequent and most fatal where a Country is covered with Wood, or is marshy; and where there are frequent Fogs, and much stagnating Water, which corrupts by the Heat of Summer.

In _January_, _February_, and _March_ 1761, we had none of those Remitting Fevers at _Paderborn_. In _April_, some few of the Soldiers, on their Return from the Winter-Expedition into _Hesse-Cassel_, had Fevers attended with bilious Symptoms; but they were rather of the continued, inflammatory Kind, and tending to malignant, than such as could be called remitting.

The first Time that I saw much of this Fever, was among the Sick sent to _Bilifield_ in the End of _June_ 1761; soon after the Army took the Field. The Remissions were short, and it partook much of the Nature of the common Inflammatory Fever; and most of them were cured by the antiphlogistic Method. A Day or two before we left this Place, it began to change into the Malignant Hospital Fever, from the Sick being too much crowded.

In the Middle of _July_, about Twelve Hundred Sick were sent to the Hospital at _Munster_; and about one-third Part were ill of this Remitting Fever. It did not partake near so much of the inflammatory Nature as at _Bilifield_; the Remissions became much more evident; and it was attended much oftener in the Beginning with bilious Vomiting and Purging; and in some few the Disorder turned to a Dysentery. About eight or nine had it changed into the Hospital Fever, from the Wards in one of the Hospitals being too much crowded; and in some few the Disorder terminated in regular Agues. In _November_ severals were taken ill of it in the Garrison of _Bremen_, which mostly ended in a regular Intermittent, the endemic Distemper of the Place. Towards the End of _December_ we had none of these Remitting Fevers, the Disorders turning more to the inflammatory Kind.

In _June_ 1762, this Fever began to appear again among the Sick, sent from the Army, to the Hospital at _Natzungen_; and it continued to be frequent through the Summer and Autumn; and the greatest Part of these Fevers this Year terminated in regular Agues, mostly in Tertians, and were cured by the Bark; whereas the Year before very few terminated this Way.

This Disorder in the Beginning had commonly the Appearance of a continued Fever; and many had a Sickness and Vomiting, and threw up a Quantity of yellow Bile, mixed with the Contents of the Stomach. In a few Days, especially after Bleeding, the Remissions became clear; tho' on its first Appearance in _June_ 1761 they were short, and rather obscure; and it seemed still to partake a good deal of the Nature of the common Inflammatory Fever, the Blood being very sizy; but as the Season advanced, the Remissions became more evident, and the Paroxysms more like those of an Ague; and the Blood less sizy, tho' at all Seasons of the Year it had some Appearance of an inflammatory Buff in this Disorder. The Sick were restless and uneasy at Night; but commonly felt themselves cooler and lighter in the Day-Time: and although they had no cold Fit, as the Fever came on at Nights, and many of them no Breathing Sweat, as they became cooler and freer from the Fever in the Morning; yet the Fits were so remarkable, that many of the Patients used to say they had a regular Fit of an Ague every Night, or towards the Morning; and some few, that they had the Fit every second Night. As the Season advanced, the Remissions appeared more distinct. However, there was always a good Number in whom the Fever went on in a continued Form, through its whole Course, without any Signs of Remission; tho' they had all the other Symptoms of this Fever. In a few Instances the Fever, after it came to remit, changed again into a continued Form.

The Heat in the Time of the Paroxysms rose high, and several were delirious during its Continuance[70]; but were quite sensible in the Intervals, though never wholly without the Fever.

[70] I did not see the Delirium rise so high, nor the Paroxysms so severe, as in the Marsh Fever described by Dr. _Pringle_.

At the End of _July_ 1761, four or five were attacked with a Bleeding at the Nose, in the Time of the Paroxysms, and became cooler afterwards; but it did not prove a Crisis in any of them.

The Urine in the Beginning was commonly of a high Colour, though sometimes it was pale and limpid: At first it deposited no Sediment; but when the Fever came to remit, there was often a small Sediment after each Paroxysm; and as the Fever was going off, it let fall a Sediment in all[71].

[71] Dr. _Hillary_ says the Symptoms of this Fever in _Barbadoes_ were much the same as those of the [Greek: synechês], or continued Remitting Fever in England; except only that the Urine in this hot Climate never deposits any lateritious Sediment, nor very rarely in any intermitting or any other Fever, except when a Crisis happens that Way. _Observations on the Diseases of Barbadoes_, p. 23.

Some at first were inclined to be costive; others had a Sickness and Purging; and several of those who were costive in the Beginning, were in the Course of the Disorder attacked with a Purging; and others, after some previous Complaint of the Stomach, were seized with both Vomiting and Purging. In general, after the Sick continued some Days in the Hospital, they were inclined to be loose; which was a favourable Circumstance, when this Evacuation was not so great as to be in Danger of sinking the Patient. Some were attacked with a Dysentery.

In this, as well as in most other Fevers, the Sick frequently passed by Stool Worms of the round Kind; and sometimes they vomited them up, or the Worms came up into their Mouth or Nostrils while they lay asleep in Bed; and some towards the Height were afflicted with Deafness, which was commonly a favourable Symptom.

Most of those ill of this Disorder had a yellowish Colour of the Countenance, which went off with the Fever. It was more observable in some than in others; in general, it was slight; some few became yellow all over[72]; particularly one Man, in the Hospital at _Munster_, who, after being seized with violent Vomiting and Purging, Convulsions, and Twitchings of the Tendons, and Hiccup, became yellow, as in the deepest Jaundice. This Symptom of Yellowness arises from a Redundancy and Absorption of Bile; and is sometimes observed in other Fevers as well as this[73]; for while we were at _Paderborn_ in _February_ 1761, two Men were brought to the Hospital in Fevers, attended with this Symptom. They were both delirious, with parched dry Tongues, slight Twitchings of the Tendons, and other bad Symptoms; and one of them had a continual Vomiting and Purging. They both died, and the Body of him who had the Purging was opened. All the Bowels, especially the Colon, were tinged with a yellow Bile, and had a slight Degree of Inflammation all over their Surface; the Gall-Bladder was distended with a very dark-coloured Bile; but no Concretions were found in its Cavity, or in the bilious Ducts; nor Mucus, or any other Thing obstructing these Passages. The Surface of the Lungs seemed slightly inflamed; and there was a small Quantity of greenish Serum in the Cavities of the Thorax. I could not learn the Histories of these two Mens Disorders, before they were brought to the Hospital; but, from the Symptoms, was inclined to believe, that the Fevers had been of the malignant or petechial Kind; and that the yellow Colour was only an accidental Symptom of it; for on one of the Men we could perceive obscure Traces of dun petechial Spots on his Breast and Arms; and the malignant Fever was frequent at this Time among the Troops, and the bilious autumnal Fevers had ceased long before.

[72] Dr. _Pringle_ takes Notice of this yellow Colour or Jaundice. He says, "some grow yellow, as in the Jaundice. This was found more frequent during the first Campaign than afterwards; it was an unfavourable, but not a mortal Symptom." _Observ._ part iii. ch. 4.--_Hippocrates_ mentions the Jaundice occurring in Fevers, _Aphor._ iv. § 62 & 64; and he reckons it a favourable Symptom in ardent Fevers, where it happens on the seventh Day. See _Book on Crises_'s, sect. 3.

[73] Does this Fever, when accompanied with this universal Yellowness of the Skin, approach to the Nature of the yellow Fever of the _West Indies_? As I had so few Cases of this Kind under my Care, I cannot determine any thing about it from my own Experience; but, from the Accounts of others, I should believe them to be very different Disorders.--In the yellow Fever of the _West Indies_, the Blood appears quite loose and dissolved, without the least Appearance of Size, even on the first Day; and the general Yellowness appears on the third or fourth, with Signs of a total Dissolution, and gangrenous Diathesis of the Blood: Whereas, in the Remitting Fever of _Jamaica_, Mr. _Nasmith_ tells us, (See Dr. _Lind_'s first Paper on Fevers), there is always an inflammatory Diathesis of the Blood. The Yellowness in both depends on a Redundancy and Absorption of Bile; but in the yellow Fever of the _West Indies_, the Bile is in a much more putrescent State, and a great Part of the Cure depends on the early and speedy Evacuation of it.--In the yellow Fevers which appeared in _Haslar_ Hospital, which are taken Notice of by Dr. _Lind_, in his _Two Papers on Fevers_, the Blood was in quite a different State from what it is in the Yellow Fever of the _West Indies_; the Blood drawn from two of these Patients became covered with a thick yellow Gluten, and the Serum was of the Consistence of a thin Syrup, and of a deep yellow Tinge, and tasted bitter; and in another who was bled two Days before his Death, it threw up the same thick yellow Gluten, tho' the red Part below was quite loose.

I could not observe any certain critical Days, or Periods, when this Disorder terminated.--Some, who had it slightly, got well in a few Days; with others, it continued longer: Some continued long feverish, and would seem cooler and freer from Fever for a Day or two, and then grow worse again; and many had repeated Relapses.

Neither could I observe any regular Crisis in this Fever. Sweat was the Discharge which oftenest proved critical. Many seemed to be relieved by a Purging; but as the greater Part had a Looseness after some Days, which continued often through the Disorder, without producing any very sudden Change in the Symptoms, it seemed to be a favourable Circumstance; though it seldom carried off the Fever so suddenly as to be manifestly critical. The Urine broke, and dropt a Sediment, for the most part, as the Fever took a favourable Turn.

When this Fever proved mortal, it commonly assumed a continued Form; the Tongue became parched and dry, the Patient delirious, with Twitchings of the Tendons, Hiccup, and other fatal Presages; while others were seized with a violent Diarrhoea, or Dysentery, which sunk them irrecoverably.

In the Beginning, it was absolutely necessary to bleed the Patients freely; and frequently to repeat the Evacuation, where the Symptoms required it. The Blood was of a florid Colour, and commonly threw up more or less of an inflammatory Buff.

In these Fevers, we were obliged to have particular Regard to the first Passages, especially in the Beginning of the Disorder; for they were generally loaded with bilious Humours[74]; which, if suffered to remain in the Bowels; were either absorbed, and increased the Heat and Fever, or brought on a violent Diarrhoea; and therefore, after Bleeding, we gave a Vomit in the Evening, and next Day a Dose of some gentle Purge, as Rhubarb or Salts; to carry off these putrid, bilious Humours: And afterwards, in the Course of the Disorder, if the Patient was costive, and grew hot, restless, and uneasy, we either repeated the Purge, or gave laxative Clysters, which generally removed these Symptoms.--Frequently after the Operation of the Emetic, the Patient had some loose Stools, from the Gall Bladder's being emptied in the Strainings to vomit. Such Stools were always bilious, as were commonly those procured by purgative Medicines.

[74] According to Dr. _Hillary_'s Account of the Yellow Fever in the _West Indies_, which is attended with bilious Vomiting, it bears bleeding once or twice, but not a third Time, before the third Day, but not at all after that Time; and after Bleeding a great Part of the Cure depends on carrying off as much of the putrid Bile as expeditiously and safely as possible, which he says is to be done by making the Patients drink freely of warm Water (sometimes mixed with a little simple Oxymel or Green Tea) so as to vomit seven or eight Times; and then to give a grain, or a Grain and a half of Opium, to procure Rest, and to settle the Stomach; to make the Patient take nothing for two Hours after; and then, if he has not had a Stool, to give a laxative Clyster; after six Hours Rest, to give a gentle Purge, to carry off as much as possible of the bilious corrupted Humours; and in the Course of the Disorder to repeat the Purge, as often as the Patient is attacked with an Anxiety, and a painful burning Heat about the Præcordia; which almost always depend on bilious corrupted Humours pent up within the Bowels; and to endeavour to support the Patient's Strength, and stop the putrescent Diathesis of the Fluids by suitable Antiseptics, of which he found a watery Infusion of Snake Root, mixed with _Madeira_ Wine and Syrup of Poppies, to answer the best of any Thing he tried, and to sit easiest on the Stomach; and to this he added the Use of Cordials, and of strong Wine Whey as the Patient became lower.

Dr. _Hillary_'s Purge was: Rx. Mannæ sescunc. vel unc. ij. Tamarind. cond. unc. i. Tartar vitriolat. gr. x. solve in seri lactis præparat. cum Vin. Maderiens. unc. vi. Colaturæ adde Tinct. Senæ unciam dimidiam. Divide in Partes quatuor, & capt. æger unam omni hora donec laxetur alvus.

His Infusion of Snake-Root was prepared in the following Manner:

Rx. Rad. Serpent. Virgin. drachm. ij. Croci Angl. drachmam dimidiam, infunde per horam vase clauso in aq. bull. q. s. & dein unc. vi. Colaturæ, adde aq. Menth. simp. unc. ij. Vin. Maderiensis, unc. iv. Syrup. Croci vel Syr. e Mecon. unc. i. Elix. Vitriol. acid. q. s. ad gratum saporem M. capiat æger cochlear. ij. vel iij. omni hora vel secunda quaq; hora vel sæpius pro re nata.

The Stomach is so irritable in the Beginning of this Disorder, as to reject the saline Draughts, Nitre, and such other Medicines. Nor will the Bark, which might be judged a very proper Medicine in the second Stage of the Disorder, lie upon the Stomach, but is thrown up immediately, in whatever Form it is given. However, a Gentleman who had practised long in the _West Indies_ told me, that although the Patient could not retain it in his Stomach, yet that he had found great Service, after the Bowels were emptied, from the Bark used freely in Clysters.

Dr. _Hillary_ disapproves of the Use of Blisters in the advanced State of these Fevers.

After emptying the Bowels, we gave the cooling, and mild Diaphoretics, such as the saline and mindereri Draughts, joined occasionally with Nitre, or the Contrayerva Powders; while we made the Patient drink plentifully of warm diluting Liquors; which we found to answer in general better than any other Remedies: They brought the Remissions to be more evident, and the Paroxysms to be milder, at the same Time that they kept up a free Perspiration, as a Means to carry off the Distemper.

In some Cases we gave the Antimonial Powder, made of one Part of Tartar Emetic, and ten of the _pulvis e chelis_, in small Doses, from two to four Grains every four or six Hours. The first Doses of this Powder sometimes made the Patient sick, and acted as a Purgative, and kept up a free Perspiration; at other Times, it produced no visible Effect. In some Cases, where it was given early, it operated both by Stool, and as a Diaphoretic, and removed the Fever[75]; and it was of Use in others, towards the Decline of the Fever; but we were often obliged to lay it aside; for it either acted too roughly, or produced no visible Effect or Alteration in the Disorder.

[75] Dr. _Millar_, one of the Physicians to the Army, told me in _Germany_, that he had given this antimonial Powder with great Success in the Remitting Fever, while the Eighth Regiment of Foot (to which he was formerly Surgeon) lay in _England_.--Dr. _Pringle_, in his fourth Edition of his _Observations_, Part iii. ch. iv. tells us, that having given a mild Purge immediately after Bleeding, he next Morning, when there was almost always a Remission, gave a Grain of the Tartar Emetic, with twelve Grains of Crabs-Eyes, and repeated the Dose in two Hours, if the first had little or no Effect; at any Rate, in four Hours. This Medicine not only vomited, but generally opened the Body, and raised a Sweat. By these Evacuations, the Fever was sometimes quite removed, but always became easier.--This Medicine he usually repeated the second or third Day; if not, he opened the Body with some mild Laxative, or a Clyster; and continued this Medicine, till the Fever went gradually off, or intermitted.--Dr. _Pringle_ says, that Dr. _Huck_ treated this Fever in a Method similar to this, both in _North America_ and in the _West Indies_. In the Beginning he let Blood; and in the first Remission, gave four or five Grains of Ipecacuana, with Half a Grain of Tartar Emetic: This Medicine he repeated in two Hours, taking Care that the Patient should not drink before the second Dose; for by that Means the Medicine passed more readily into the Bowels, before it operated by vomiting. If, after two Hours more, the Operation either Way was small, he gave a third Dose; which commonly had a good Effect in carrying off the Bile; and then the Fever either went quite off, or intermitted so far as to admit the Bark. On the Continent he found no Difficulty after the Intermission; but in the Islands, unless he gave the Bark upon the first Intermission, though imperfect, the Fever was apt to assume a continual and dangerous Form. Dr. _Huck_ never varied this Method, but upon a stronger Indication to purge, than to vomit. In which Case he made an eight Ounce Decoction, with Half an Ounce of _Tamarinds_, two Ounces of _Manna_, and two Grains of _Emetic Tartar_; and dividing this into four Parts, he gave one every Hour, till the Medicine operated by Stool.

When the Fever came to remit, we were obliged, for the most part, to continue the Use of the mild Diaphoretics, as before; for, although the Disorder put on a remitting Form, the Bark had very little Effect in stopping it[76], unless where the Fever changed into a regular Quotidian or Tertian Ague.--In the Year 1761, very few of these Fevers turned to regular Intermittents; but, in the Year 1762, the greater Part of them terminated in regular Agues, and were cured by the Bark[77].

[76] Dr. _Hillary_, in mentioning the Remitting Fever of the Island of _Barbadoes_, says: In those who were blooded, and took an Emetic afterwards, and then the saline Draughts, the Fever was generally carried quite off by a critical Sweat on the seventh or ninth Day; in some few it came to intermit regularly after that Time; and was soon cured by the _cortex Peruviana_, given with the saline Draughts, and seldom effectually without them; though these irregular ingeminated Fevers often remitted, and sometimes seemed to intermit; yet if the _cortex Peruviana_ was given too soon in the Disease, before it intermitted regularly (as I have more than once seen, where it had been injudiciously given), it generally caused the Fever to become continual and malignant. _Observat. on the epidemic Diseases of Barbadoes_, p. 22.

[77] Mr. _Cleghorn_, after giving a very accurate Account of Tertian Fevers, as they appeared in their various Forms of true, of double, and triple Tertians, and of Semi-Tertians, in the Island of _Minorca_, tells us, that he first attempted the Cure by profuse Evacuations; but afterwards learnt from Experience, that they were unnecessary; and that Bleeding and Purging once or twice in the Beginning, was all that was in general requisite; and if on the fifth Day the third Revolution was not attended with more threatening Symptoms than the second, and the Patient bore it easily, he frequently trusted the whole Business to Nature; which commonly terminated the Fever about the fourth or fifth Revolution; and for the most part with an Increase of some natural Evacuation.--But if the Paroxysm on the fifth Day was the longest and most severe that happened, attended with any doubtful or dangerous Symptom, he ordered two Scruples of the Cortex to be given every two or three Hours; so that five or six Drachms may be taken before next Day at Noon; lest, if this Interval escaped, he should not have found a favourable Opportunity of giving a sufficient Quantity of the Medicine afterwards; as the Fits about this Period are wont to become double, subintrant, or continual.--This did not always put an immediate Stop to the Fever, but it invigorated the Powers of the Body, and prevented or removed the dangerous Symptoms. Having given the Bark on the fifth Day, if a Fit came on the sixth, and declined the same Evening, he gave some more Doses of the Bark to mitigate the Fit on the seventh; yet sometimes this Fit of the sixth united with that of the seventh, and the Patient had the Heat, Restlessness, Raving, and other Complaints, greatly augmented, and the Case seemed more desperate than ever; which, however, were more dangerous in Appearance than Reality, and went off with a profuse Sweat next Morning; after which he gave the Bark freely as before; and this either stopt the Fits, or made them so moderate, as that they yielded quickly to the same Sort of Management.--By this Method, when Assistance is called timely, Mr. _Cleghorn_ says, the most formidable Intermitting and Remitting Tertians, may be certainly and speedily brought to a happy Conclusion about the End of the first Week, or Beginning of the second. See _Observ. on the epidemic Diseases in Minorca_, chap. iii. p. 187, &c.

In the Year 1761, we tried the Bark in various Forms in many Cases, where the Patient had been blooded and purged in the Beginning, and used the cooling Medicines; and where the Remissions were very clear: Yet it had no Effect in removing the Disorder, except in two or three Cases at _Munster_, where the Paroxysms assumed a tertian Form; for the most part, it made the Patients more hot and feverish, and we were obliged to leave off using it, as it was in Danger of changing the remittent into a continued Fever. However, it was of Service after the Fever came to a Crisis, and was going off; and Dr. _Pringle_ has very justly observed, that it hastened the Recovery, and that those who used it were less subject to Relapses than such as did not; and therefore we commonly gave it in a convalescent State.--Before giving the Bark, I always found it of Advantage to give a Dose of Rhubarb, or of some other Purgative, or to mix some Rhubarb with the first Doses, so as to procure the Patient some loose Stools.

When either the Fever went on without Intermission, or changed into a continued Form, or the Patient continued hot and feverish through the Day, with a Head-Ach, and other feverish Symptoms, nothing answered better, after free Evacuations had been made, than to apply a large Blister to the Back; and to make the Patient drink freely of cooling diluting Liquors; which generally relieved the Head, and abated the Violence of the other Symptoms.

When a Purging came on in the Course of this Disorder, if there was much Fever, with a strong throbbing Pulse, Gripes and Pain of the Bowels, some Blood was taken away; and immediately after the Patient took a Dose of Salts and Manna, or of Rhubarb; and an Opiate in the Evening after its Operation: But if there was little or no Fever, or sharp Pain, Bleeding was omitted; and if the Patient complained of Sickness, a few Grains of Ipecacuana were given previous to the Purge.

After this, if the Purging was moderate, and did not sink the Patient, we did nothing to stop it; but if it was violent, we gave the mindereri Draughts with Mithridate, and the Chalk Julep in the Day, and an Opiate at going to Rest; and occasionally used the emollient and anodyne Clyster; and, if necessary, repeated the Emetic and Purge.

The Hiccup seldom appeared in this Fever till the Patient was reduced very low, and was commonly the Forerunner of Death. Some few, who had a Purging and Vomiting, were taken with a Hiccup, attended with Sickness, and Load at the Stomach, which seemed to depend on bilious Humours lodged in the Stomach and Bowels. This induced me to give a few Grains of the Ipecacuana; and to make the Patients drink an Infusion of Camomile Flowers till they vomited freely, and afterwards to take some mild Purge, or use laxative Clysters; after which they found themselves easier, and an anodyne Draught, with twenty or twenty-five Drops of the _tinctura thebaica_, put an End to the Hiccup. Others required the Use of Cordial Draughts, mixed with Opiates; and repeated Clysters and Fomentations, before they found Relief.--The Application of a Blister removed the Hiccup in one, after the above Remedies had proved ineffectual; as did the Musk Julep with Opium, and the Application of an aromatic Plaister to the Stomach, in another Patient.

Several of them complained of a burning Heat and Pain in making Water; which commonly went off by drinking freely of the Gum Arabic Decoction, with the dulcified Spirit of Nitre, and the Use of oily Draughts; though in some it required the Assistance of Opiates, and of Fomentations and Clysters, before it was got the better of.

The Symptom of Worms we were often obliged to neglect till the Fever was over, and then we treated it as formerly mentioned.

The Deafness, though not near so frequent in this as the Malignant Fever, was rather a favourable Symptom, and mostly went away of itself; though in a few Cases, where it continued long, we applied Blisters behind the Ears, or to the Neck, with Advantage.

Many, especially those who were brought low, complained, after the Crisis of the Fever, of Restlessness, and Want of Sleep; which, however, went off as their Strength returned: Where it fatigued them much, and kept them low, we gave a Cordial anodyne Draught at Night; and if that did not answer, commonly the Addition of a few Glasses of Wine in the Afternoon had the desired Effect.

Others, in their convalescent State, complained of such a Giddiness, and Lightness of the Head, that they could neither walk nor stand; others, of a Dimness of the Eyes. These Symptoms, for the most part, went off as the Patients gathered Strength: The Use of the Bark, with now and then a Glass of Wine, hastened the Cure; and in two or three Cases we were obliged to give a Dose or two of some gentle Physic, and to apply a Blister, before the Patient got the better of them.

As the Sick were recovering, it was common for them to complain of Pains of the Shoulders, Arms, and Legs, which also left them as they recovered their Strength; where they did not, the saline Draughts, and a low Diet, generally had a good Effect; and where it had not, we treated them as rheumatic Complaints.

When the yellowish Colour of the Countenance remained after the Fever, we kept the Patient on a low Diet; and his Body open by Means of the saline Draughts, with a few Grains of Rhubarb, or by giving Half a Drachm, or two Scruples of the Soap Pills with Rhubarb daily; which, for the most part, removed the Yellowness soon. Two only had a Jaundice remain after the Fever, and both were cured in a short Time.

In other Respects, the Treatment of this Fever, when it degenerated into a continued Form, had nothing particular in it; nor differed from the common Practice of giving cooling Medicines when the Fever was high, and supporting Nature by the Use of Cordials and Wine, and the Application of Blisters, &c. when low; and promoting such Evacuations as Nature pointed out for a Crisis.

OF THE Intermitting Fever, or Ague.

This Disorder belongs to the same Tribe of Diseases as the Remitting Fever. We call it an Intermitting Fever, or Ague, when the Paroxysms are distinct, begin with a cold and hot Fit, and go off with a Sweat; and the Patient is cool, and free from the Fever in the Intervals between the Fits.

Many have been the Causes alledged to produce this Disorder. The great Quantity of Bile that is often thrown up in the Fit, has caused it to be ranked among the bilious Diseases; and the Seasons of the Year in which it is most frequent, and the low moist Situation of the Places where it is endemic, have made Practitioners suspect, that an obstructed Perspiration, and a Tendency in the Juices to the Putrescent, are the Cause of it.

But whatever Cause we may suppose to give Rise to the first feverish Fit, it is difficult from hence to account for the regular Returns of the Paroxysms and Intermissions: For my own Part, after considering Intermittents, which observed a regular _Type_ in the Course of a Salivation[78]; their being so easily stopt by the Bark without any sensible Evacuation; their being sometimes put away by a Stimulus externally applied[79], or by a Fright, or sudden Plunge into cold Water[80]; their returning after slight Errors in Diet, and sometimes by the Operation of a Purge, or of Bleeding; their attacking sometimes only particular Parts, and many such Accidents in these Fevers, I must confess, that I am unable to form any Idea, either of their Origin, Seat, or Cause[81].

[78] See _Van Swieten_, Vol. II. p. 537.

[79] A Gentleman told me, that he was once cured of an Ague in the Country, by applying a Poultice of Garlic to his Wrists, and letting it lie on till it inflamed and blistered the Part.--I have seen Blisters cure an Ague.--In the _Edinburgh Med. Essays_, Vol. II. Art. v. we have an Account of Agues being cured by the Application of Poultices of recent Erigerum (Groundsel) applied to the Stomach on the Days free from the Paroxysm, which caused strong Vomiting.

[80] See an Account of an Ague being cured by the Patient being pushed into a Pool of Water without any previous Notice, and being much frightened, in _Mason's Account of Agues_, p. 222.

[81] The common Account given of the Cause of Agues, and of the regular Return of their Paroxysms, has been: That the Ague takes its Rise from some Sort of Matter, bilious, or whatever it may be, either mixed with the Blood, or lodged in the Bowels, or in some other Part of the Body; that a great Part of this Matter is thrown out of the Body, in the Time of the Paroxysm; but that so much remains as serves by Way of a Ferment to assimilate other Particles to its own Nature; which, when collected in a certain Quantity, produce a new Fit; and, according to the Time that it takes to produce this Quantity, the Disorder assumes the Form of a Quotidian, Tertian, or Quartan Ague.

The Soldiers were subject to this Disorder, particularly in Spring, if they took the Field soon, and in Autumn: The Frequency of it was in a great Measure determined by the Nature of the Ground on which they were encamped, or the Situation of the Garrison or Town in which they were quartered; for the lower and moister the Camp or Garrison, and the more moist the Season, the more subject an Army is to Agues; and the drier the Situation of the Camp or Garrison, and the finer and drier the Weather is, the freer they are from Disorders of this Kind.

In Winter 1761, we had but very few Agues in the Hospitals; but on the Return of the Troops from the Expedition into _Hesse-Cassel_, and during the Spring, some (though not many) were attacked with Quotidian and Tertian Agues, and but very few with Quartans.--In _July_ and _August_ they were more frequent, and accompanied with more bilious Symptoms. At _Bremen_, during the latter End of Autumn, and throughout the Winter and Spring 1762, we had Agues of all Sorts, and many inveterate Cases; and all this Spring, and during the Summer and Autumn, the Ague was the epidemic Disorder all over _Westphalia_, as well as among the Troops.

In Spring 1761, what Agues we had were mostly Tertian, some Quotidian, and but two or three of the Quartan Kind. They were, for the most part, mild, and yielded to the Bark.--Some of them began in the Form of a continued Fever; but after Bleeding, and the Use of the cooling Medicines for a few Days, they began to remit, and at last ended in regular Quotidian or Tertian Agues: Others, at first, appeared in Form of Remittent Fevers, attended with a strong throbbing Pulse; but changed to regular Intermittents by pursuing the antiphlogistic Method of Cure; and some from the Beginning assumed the Type of Quotidian or Tertian Agues, but often attended with a good deal of Fever, for the first two or three Days; and some had a slight Delirium in the Time of the Paroxysms, and the Pulse was not quite settled in the Intervals. In such Cases, where the Patient was strong, nothing answered so well as to take away some Blood; and to give the saline Draughts with Nitre till the Fever was moderated, before we gave the Bark.

In general, there is a Prejudice against bleeding in Agues, after they become regular; but I have always observed, both in _England_ and in _Germany_, that where Patients are strong and plethoric, and the Fever in the Paroxysms rises high, or the Pulse remains quick in the Intervals, that taking away more or less Blood, and giving the antiphlogistic Medicines in the Beginning, eased the Patient, moderated the Fever, and made it safer to give the Bark soon; and I never saw the least Inconvenience from the Practice; but, on the contrary, have seen several Intermittent Fevers change into continued ones from the Neglect of this Evacuation; and have seen Cases where the Bark, instead of stopping the Ague, rather increased the Fever, till the Patient was blooded, and had pursued the antiphlogistic Method for some Time; after which the Bark had its proper Effect, and put an End to the Disorder.

As soon as these Agues became regular, and the Patient was quite cool, and free from any Fever in the Intervals, we gave the Bark; which soon put a Stop to the Paroxysms, without the least bad Consequences; but, before giving the Bark, we always took Care to empty the first Passages by the Use of Emetics and Purgatives, where there was no Symptom to forbid their Use: In Cases where the Patient was weak, and the Fits so violent as to make it necessary to stop the Ague, before we had Time to administer Emetics or Purgatives, we added so much Rhubarb to the first Doses of the Bark as procured the Patient some loose Stools, as recommended by Dr. _Mead_[82]; which did not prevent its stopping the Ague, at the same Time that it answered the End proposed of carrying off any putrid Humours that might be lodged in the Intestines.

[82] Mr. _Cleghorn_, while at _Minorca_, after Evacuations, gave the Bark at the End of the third Period, as we observed before; but where the Fever had been neglected till about the third or fourth Period, or badly treated in the Beginning, and the Bowels were inflamed or overcharged with corrupted Gall, he was obliged to endeavour to palliate the most pressing Complaints, and to watch Evening, Night, and Morning for a Remission, and then immediately to fly to the Bark, as the only Remedy that could avert the Danger. If the Patient was strong, he gave Half an Ounce of the Bark, with six Drachms of the _sal catharticum amarum_, divided into four equal Parts, of which the Patient took one every two Hours; the Effect of which was, that the next Fit was mitigated, and an Intermission commonly ensued, in which the Bark was repeated without the Purgative, to finish the Cure.--But where the Patient was excessively feeble, and there was a manifest Risk of his dying in next Fit, he gave Cordials with the Bark, instead of the _sal catharticum_; and endeavoured to throw in six or seven Drachms in the Space of ten or twelve Hours; he having found by Experience, that if a smaller Quantity is given, the Paroxysms come on earlier than usual, and make all Attempts to preserve Life unsuccessful. See his _Account of the epidemic Diseases of Minorca_, cap. iii. 2d edit. p. 192.

In _England_, Vernal, Quotidian, and Tertian Agues, frequently go off after Bleeding, and taking some Emetics and Purges, and the saline Draughts, and cooling Medicines, for some Time, without the Use of the Bark; but in _Germany_ very few yielded to this Treatment, and we were obliged to give the Bark[83] before we could put a Stop to them.

[83] Sometimes, when Patients are reduced low by Agues, the Stomach becomes so squeamish as to reject the Bark in every Shape it can be given; in such Cases, when the Ague cannot be stopped by other Means, it may be administered with great Advantage in Clysters, of which the following is a very remarkable Instance.--_William Hadderell_, a Lad seventeen Years of Age, in the End of the Year 1761, was attacked with a severe Tertian Ague, in which a Mortification came on his left Foot, and one-half of it dropt off; notwithstanding, his Ague continued to attack him every second Day, and the Sore continued running on the 12th of _October_ 1763, when he was admitted into _St. George_'s Hospital. He was reduced extremely low; and the Sore of his Foot looked so bad, that it was at first imagined he must lose his Leg. He was ordered some Vomits, and a Purge, and cooling Medicines, and afterwards to take the Bark freely; but his Stomach rejected it, in whatever Form it was given. Other Means were then tried to stop his Ague, but with no Effect, till the 7th of _November_, that I ordered two Drachms of the Powder of the Bark to be given him twice a Day in an emollient Clyster, with Half a Drachm of the _tinctura thebaica_, which stopt his Ague in three Days; and he had had no Return of it on the 28th of _January_ 1764, and had recruited his Health and Strength, and the Sore of his Foot was greatly lessened. Dr. _Harvey_ (who teaches Midwifery in _London_) told me, that he has cured Children of Agues by Bark Clysters, after the Bark Waistcoats, and other Means used, had proved unsuccessful.

In the End of _July_, and Beginning of _August_, the aguish Cases we had at _Munster_ continued to be of the Quotidian or Tertian Kind. The greatest Part of them began in the Form of continued Fevers, tending more to the bilious Kind than the preceding Months, and many of the Sick had bilious Vomitings in the cold Fits; and the Agues we had in Spring, and during the Campaign 1762, were of the same Nature, and required the same Treatment.

Those Cases, which began in the Form of continued Fevers, were treated as such till they began to have regular Intermissions; they then yielded to the Bark.

Some were attended with the Dysentery; and the Purging and Gripes were most severe on the Days of the aguish Paroxysms. In such Cases, we were frequently obliged at first to neglect the Ague, and to treat the Disorder entirely as a Flux. Where there was much Fever, the Patient strong, and the Pains in the Bowels acute, we ordered Bleeding; and after it a gentle Emetic, and some Doses of the saline oily Purge, or of Rhubarb; and gentle Opiates in the Evening, and other Medicines proper in the Dysentery, till its Violence was abated, before we gave the Bark: though in some Cases, where the aguish Paroxysms were very severe, and helped to increase the Purging, and the Patient was in Danger of sinking, we gave the Bark, notwithstanding the Flux still continued; and the Method we followed was the same as that I formerly mentioned, where it was complicated with the Malignant Fever; which was to give the Bark, mixed with Diascord, and Opiates, or other Medicines proper for the Dysentery, in the Intervals between the Purges.

By this Treatment, very often both the Flux and Ague went off. However, it ought to be observed, that unless the aguish Paroxysms were severe, and in Danger of sinking the Patient, or that the Disorder had continued for some Time, and the Paroxysms were distinct, we seldom gave the Bark till the Violence of the Flux was abated: And where-ever much Griping and Pain in the Bowels attended the Flux and Ague, there Bleeding as well as Purgatives were necessary, before exhibiting the Bark; which seldom or ever agreed with them, till there was an evident _Apurexia_, or Absence of Fever in the Intervals between the Fits. Where these Cautions were neglected, the Bark generally made the Patients worse; and we were obliged to omit it, till the Violence of the Purging was over.

Some Agues were accompanied with the Jaundice, though not in such a high Degree as in the confirmed State of that Disorder; and commonly in the Beginning the Pulse continued rather quick, in the Intervals between the Paroxysms; and the Patients complained of some Degree of Sickness for the first two or three Days. With those the Bark always disagreed, till the Feverishness between the aguish Paroxysms was gone; and we found, that the best Method of treating them, was to bleed in the Beginning, if there was much Fever; and then to give a Vomit and Purge, and to repeat them, if necessary; and where there was no Purging, to give the saline Draughts, and other cooling Medicines; and to add a few Grains of Rhubarb, or to give so much of the _pilulæ saponacæ cum rheo_, daily, as procured one or two loose Stools.

After the Ague had regular Intermissions, and the Patient was quite cool, and without Fever in the Intervals, if the Disorder did not yield to the above Treatment, which it seldom did, we then gave the Bark freely; even though the slight icteric Symptoms still remained; and it put an End to the Ague, and removed the Jaundice at the same Time, without the least Inconvenience to the Patient. In such Cases, we generally used to add a few Grains of Rhubarb to the first Doses of the Bark; or gave the Bark made up into Pills with Soap, and added occasionally a few Grains of Rhubarb.

Several of those who had the icteric Symptoms along with the Ague, had bilious Vomitings in the Time of the cold Fit; they found themselves sick, with a bitter Taste in their Mouth, before the Approach of the aguish Paroxysm; and many of them, though they took Emetics, which operated freely at this Time, yet did not vomit up the Bile; but the Sickness and bitter Taste continued till the cold Fit came on, when they vomited Bile in large Quantities. In such Cases, after the Use of Emetics and Purges, and the Ague was brought to have regular Paroxysms, with free Intermissions, the Bark, given as just now mentioned, removed the Ague and icteric Symptoms, without the least bad Consequences.

Many Practitioners of great Repute have been prejudiced against the Bark; and tell us, that the free Use of this Medicine often lays the Foundation of Obstructions in the abdominal Viscera, especially when it has been given where there was an icteritious Colour in the Eyes and Countenance; and that, in such Cases, we ought not to give the Bark till these Icteric Symptoms are gone. At first, I was very cautious of giving it under such Circumstances; till meeting with some Cases where the Paroxysms were severe, and became more frequent, while the Patient was so low, as to be in Danger of sinking under the Disorder, I gave the Bark freely, as the only Remedy capable of preserving Life; which not only stopt the Ague, but carried off the icteritious Symptoms[84], and restored the Patients to perfect Health.

[84] This agrees with what Mr. _Cleghorn_ remarks of Tertian Fevers in his _Observations on the epidemic Diseases of the Island of Minorca_, who says, "where there is an icteritious Colour of the Eyes, we are likewise told, that the Cortex should not be administered; though, in my Opinion, it is for the most part dangerous to delay it, after the first Appearance of that Symptom." Chap. iii. 2d edit. p. 205.

After this I gave it freely, in the Manner above mentioned, to some Hundreds, with great Success; and I never saw any Mischief follow from using it: Indeed sometimes, where it was given rather too soon, it did not sit easy on the Stomach; and made the Patients hot and restless; but, by laying it aside, these Effects immediately ceased; and generally, after a little Time, the Paroxysms became milder and more distinct, when the Bark was again administered, agreed with the Stomach, and put an End to the Disorder; and I am now convinced, from Experience, that the Cases in which the Bark has done Mischief, or given Rise to Obstructions of the abdomenal Viscera, are but very rare; and that these Mischiefs mostly arise from the Obstinacy of the Disorder, and not from the Use of this Drug; for I have oftener observed these Obstructions where little or no Bark had been used, than where it was given freely[85]. What probably has given Rise to the Belief of the Bark's doing so much Mischief, is, that in _Holland_, and other low fenny Countries, where Agues are endemic, they are oftentimes extremely obstinate, and yield hardly to any Remedies; and if they are stopt by the Bark, they often return soon after, and by their long Continuance give Rise to Obstructions of the abdomenal _viscera_, which have been attributed to the Use of this Specific.

[85] Dr. _Pringle_ takes Notice, that these Obstructions happened as often without as with the Bark; and therefore seemed to depend on the long Continuance and Obstinacy of the Intermittent. _Observ._ part iii. chap. iv. sect. 2. p. 179. 3d Edit.

In some few Cases a Purging accompanied these icteric Symptoms, which we treated much in the same Manner as when the Ague was complicated with the Flux; we gave Emetics and Purgatives; and the mindereri Draughts with Mithridate, throughout the Day, and Opiates at Night, if the Purging was violent; if it continued, accompanied with regular aguish Fits, the Bark, with Astringents, generally removed both.

In the latter Part of the Year 1761, and during Spring 1762, we had at _Bremen_ many Patients in Agues of all Sorts; as Quotidians, Tertians, Quartans, and irregular Agues of a very obstinate Nature. The Town of _Bremen_ is large and well built, situated in a low sandy Plain, with the _Weser_ dividing the old from the new Town; generally a considerable Part of the Environs is covered with Water in the Winter, and frequently the _Weser_ breaks down some of the Dikes, and overflows all the Country round; and every Time the River overflows its Banks, the Cellars of all the new Town, and of that Part of the old Town next the River, are filled with Water. All the Year round, on digging two or three Feet deep into the Ground, you come at Water.

Agues are endemic in this Place, and great Numbers of the lower Class of People are afflicted with them at all Times of the Year, especially in Spring and Autumn.

Some of the Sick sent down from the Army were bad of Agues; but the greatest Number we had in Hospitals was composed of such as took it in Town; either from doing Duty on the Ramparts, or from lying in bad Quarters, or getting drunk and exposing themselves to Wet and Cold; and many Men of the invalid Companies who had come from _Embden_ brought with them old inveterate tertian and quartan Agues.

Most of the recent Cases were easily cured by the Methods already mentioned; though they often continued longer, required a greater Quantity of the Bark to stop them, and a longer Continuance of its Use to make a Cure, than at other Places, which were more dry, and higher situated.

The most obstinate of the recent Cases were the irregular Intermittents, which had regular Paroxysms, but where the Pulse was not settled in the Intervals; which we were obliged to treat as Remitting Fevers till the Paroxysms became quite distinct, and the Patient was cool and free from any Fever in the Intervals; after which they commonly yielded to the Bark.

But many of those Agues which had continued for some Time, especially with those Invalids who came from _Embden_, or who had brought on frequent Relapses by their own Irregularities, were very obstinate. With many the Bark had no Effect; and its Use persisted in seeming rather to exasperate the Paroxysms, and to do Hurt. Nor had almost any Remedy we tried a better Effect. We gave the following Medicines to divers Patients; the saline Draughts and cooling Medicines; Infusions of Camomile Flowers and of other Bitters; Dr. _Morton_'s Powders of Camomile Flowers, Salt of Wormwood, and diaphoretic Antimony; Dr. _Mead_'s Powders of Camomile Flowers, Salt of Wormwood, Myrrh, and Alum; Alum and Nutmeg; large Doses of _sal ammoniac_; large Quantities of Spirits of Hartshorn; the antimonial Drops and Powders; to some we gave Emetics, both in the Intervals and immediately before the Fits. In some we tried to promote Sweats before the Approach of the Fits, by making them drink freely of warm Liquors while they kept in Bed, and took diaphoretic Medicines; and to others we applied Blisters.--But all did not put a Stop to some of those Agues.

With some the Disorder continued till it broke down the Crasis of the Blood, and brought on a general Relaxation of the Fibres; and the Patients became cachectic, and fell into Dropsies, or were seized with Diarrhoeas, of which they died. Some had Obstructions formed in the Liver or Spleen, or other _viscera_, and fell into the Jaundice and Dropsies, which carried them off.--In the Bodies, of several whom we opened, we found Indurations of the Liver and Spleen--in two of them Suppurations of the Liver--and in one, who had had the Ague at _Embden_, and had long complained of one of those Swellings towards the left Side of the _abdomen_, called the _Ague Cake_[86], the Spleen was so much enlarged as to weigh above four Pounds.

[86] I have seen the dead Bodies of four People opened, who had those Swellings of the left Side, commonly called the _Ague Cake_, which had come after Agues; and in all the Swelling was owing to an Enlargement of the Spleen.

Some, whose Constitutions were worn out by these obstinate Agues, fell into Consumptions and other pulmonic Disorders in the Winter, of which they died. One Man died in the cold Fit[87].

[87] The cold Fit is the most dangerous Time of the Paroxysm, and the greatest Part of those who die of Agues die at this Time; one or two Instances of which I saw in the Military Hospital at _Edinburgh_ in the Year 1746.--_Van Swieten_ says he has seen the trembling and shaking so great in the Time of the cold Fit of Quartans, that the Teeth have dropt out of the Head. _Comment. in sect._ 749. _Aphorism. Boerhaav._ vol. II. p. 511.

Where-ever the Ague continued long, and the Bark had no Effect, we were obliged to lay it aside, and to try other Remedies adapted to the present Circumstances of the Patient.

The mild Methods succeeded best; giving the saline Draughts and gentle cooling Medicines to such as were strong and plethoric, and had the aguish Paroxysms violent; and the gentle Aromatics and Bitters, or Chalybeats, to those of a weakly Habit, or whose Fibres had been much relaxed, and their Constitutions greatly injured by this or any other preceding Disorder.

During these Courses, we gave at Times gentle Emetics; and if the Patient complained of Gripes and Purging, which they frequently did, in the Course of this Disorder, we gave a Dose of Rhubarb, or of some other mild Purge; and after it other Medicines proper for this Complaint.

By these Methods frequently the aguish Paroxysms became gradually milder, and at last vanished. At other Times, after they had continued for five or six Weeks, we again gave the Bark, and found it to have the proper Effect. With others they continued thro' the Winter, and went off of themselves in the Spring. With others they still continued; and as no Medicines nor Time seemed to have any Effect in that Country, we recommended their being sent over to _England_ for Change of Air, as the only Means likely to remove the Disorder.

Two Agues which had resisted the Use of the Bark were cured by Powder of Camomile-Flowers, Salt of Wormwood, and diaphoretic Antimony; and one by the Use of the aluminous Powders, with Myrrh.--One Invalid, who had long been ill of an obstinate Tertian, on catching Cold, was seized with an Inflammation of his Throat, for which he was blooded, and took a mild Purge; next Day there appeared a Swelling of one of the parotid Glands, which we endeavoured to bring to Maturation, by the Application of emollient Cataplasms; after some Days it went entirely away, without coming to Suppuration; but as there remained still a Confusion of the Head, and a Quickness of the Pulse, a large Blister was applied to the Back, which continued running for some Days; after it dried up he fell into a Fit resembling that of an Epilepsy, and next Day had another Fit of the same kind; from the Time the Swelling first appeared till the Time he had the first Fit, he had no Ague, but it returned the second Day after the second epileptic Fit; another Blister was applied, and he had no Return of the epileptic Fits, though his Ague continued obstinate till _March_, at which Time he was sent to _England_[88].--About the same Time the aguish Fits of two others were stopt by the Application of Blisters, though they returned in both soon after.

[88] On the 29th of _August_ 1759, a Man (_Murdoch Brinnen_) about thirty Years of Age, was admitted into _St. George_'s Hospital for a very large Swelling of the parotid Glands and neighbouring Parts, which had come three Days before, after a Fit of the Tertian Ague, which did not return afterwards. The Swelling was discussed by the Application of emollient Cataplasms, which were intended to have brought it to Suppuration. He had no Return of the Ague, nor did any bad Consequence follow the Discussion of the Tumour, and the Cure was completed by a few Doses of Physic, and a Decoction of the Bark, which restored him to his Strength, and carried off the little Heat and Feverishness which remained.

Excepting in these few Cases, I found no Medicines effectual in stopping those Agues, which had resisted the Bark when properly given, though we tried a vast Variety in different Cases. The _cortex cascarillæ_, or _eleutheriæ_, was given freely, both in Decoction and Substance, in four Cases, which had not yielded to the Bark, but without producing any good Effect; we had not an Opportunity of trying this Bark in more Cases of this kind, nor in Fluxes, the small Quantity of it which had come from _England_ being all expended.

A Soldier of one of the Regiments of Guards, who was admitted into the Hospital for oedematous Legs, and the Remains of a very bad Flux, which he had had ever since the preceding Autumn; after being cured of the Flux, and most of the oedematous Swellings, was seized with an intermitting Complaint in _February_. He had no regular hot and cold Fits; but every second Day, after a slight Shivering and Cold, he was seized with Gripes and a Purging. In one or two of the Fits his Pulse was very quick, and the Pain of the Bowels very acute and severe; which obliged us to blood him, and give him a Dose of the saline oily Purge; after which we treated the Disorder as a Flux complicated with the Ague, and gave the Bark mixed with Diascord, and gentle Opiates at Nights, and at Times gentle Purgatives; the Ague and Diarrhoea stopt very soon, and in a few Weeks he got free of all Complaints, though he still continued weak, till he was sent to _England_, about the Beginning of _April_.

Many, especially those whose Constitution had been shaken by this or some other Disorder, complained of flatulent Swellings of the Stomach and Bowels, which affected them either while the Ague continued, or soon after it was stopped, and were very troublesome and uneasy. For the most part, these Swellings were removed by the Use of cordial Medicines mixed with the Bark, or a Course of Bitters, and some Doses of Rhubarb given at proper Intervals. In some Cases, where they were attended with Sickness, and the Stomach seemed to be loaded, a Vomit gave Relief. Very often these Symptoms continued for Weeks after the Ague had left them, and did not go entirely off, till the Patient recovered his Strength.

In _February_, _March_, and _April_, 1761, severals of the Soldiers in the Hospital at _Paderborn_ complained of periodical Head-Achs, which returned in most, every Day; in others, only every second; and afterwards Cases of this Kind occurred at different Times as long as the Army continued in _Germany_. These Head-Achs generally began in the Forenoon, were very violent while they lasted, and confined the Patient to his Bed for some Hours. During the Pain, the Pulse was quick; but in the Intervals the Patients were quite cool, and without Fever. Sometimes, tho' not always, the Urine deposited a little Sediment as the Head-Ach was going off. Commonly the Pain was all over the Head, but most severe in the Forehead; though sometimes it was confined to one Side only.

These Head-Achs we treated entirely as Agues of the same Type. When the Patient was strong, some Blood was taken away, and afterwards we prescribed an Emetic and Purge, and then gave the Bark liberally, which generally put an End to the Complaint, without any bad Consequences attending.

OF THE JAUNDICE.

The Jaundice, or a yellow Colour of the Eyes and Skin, occasioned by an Absorption of Bile into the Blood, was another Distemper which appeared towards the End of each Campaign.

This Disorder, for the most part, takes its Rise[89] from Calculi lodged in the biliary Ducts[90]; and sometimes from a viscid Mucus or Pituita obstructing those Passages[91]; and it may be brought on by a Tumour, or any other Cause[92], compressing these Ducts, so as to prevent the free Flow of the Bile into the Cavity of the Intestines.

[89] Obstructions and Scirrhi of the Liver have been assigned as the Cause of the Jaundice; but as we have so many Cases of this Kind related where no Jaundice appeared, it is now much doubted, whether such Obstructions, which do not affect the Ducts, are capable of producing this Disorder.

[90] We have numerous Cases in _Bonetus_, and other physical Observations, where Calculi have been found in the Gall Bladder, and Ducts of People who have died of the Jaundice; and I have frequently found two, three, and sometimes twelve, fifteen, or twenty, such bilious Calculi in these Cavities.

[91] Viscid Mucus or Pituita, or viscid Bile, has been observed frequently to obstruct the Ducts. Dr. _Coe_ says, sometimes icteric Patients discharge very thick Bile, almost as viscid as Bird-Lime. See his _Treatise on biliary Concretions_, chap. ii. where he has collected a great Number of icteric Cases, in which the Bile has been found quite viscid after Death.

[92] See the Case of a Jaundice in _Bonetus's Sepulchretum Anatomicum_, tom. II. p. 326, where the Sides of the common biliary Duct were compressed by an Enlargement of the Glands about the _vena portarum_; and we sometimes meet with a Jaundice in pregnant Women which goes off after Delivery, and seems to have been caused by the Pressure of the Uterus and indurated Foeces in the Colon. _Van Swieten_ says, he has seen this very frequently, vol. III. sect. 918, p. 95.

The yellow Colour, or Jaundice, observed in the Ague, and some other bilious Disorders, seems to arise sometimes from Spasms of the Ducts; or from too great a Quantity of Bile secreted and absorbed into the Blood, which seems evidently to be the Case where large Quantities of Bile are either vomited or discharged by Stool; a Proof that the biliary Ducts are clear, and free from Obstructions.

In the End of the Campaign of 1760, after a continued Rain for many Weeks, the Jaundice had been very frequent, and in a Manner epidemical, among the Troops, for some Time before they left the Field; and in passing thro' _Munster_, about the End of _December_, I observed several ill of that Distemper in Hospitals, and met with a few Cases of this Kind in the Hospitals at _Paderborn_ in _January_ 1761; but during the Spring and Summer, we had only one or two now and then sent to the Hospitals for this Complaint; though towards the End of the Campaign it became more frequent, and several were sent down to _Bremen_; and some of the Garrison were likewise affected with it. During the Winter not above four or five were sent to the Hospitals I attended, and but a few to the flying Hospital, during the Campaign 1762. It frequently appeared in dropsical Cases, depending on obstructed Viscera.

Those in whom the Jaundice was the original Disorder, and not complicated with any other, generally got well soon; but where it appeared in dropsical Cases, depending on obstructed Viscera, it was commonly fatal.

In the Beginning of this Disease, Patients usually complained of Sickness, Heat, Thirst, and other feverish Symptoms; and some had a Vomiting, and Pain of the Stomach, for a Day or two before the Jaundice appeared; the Urine was always of a deep Colour from the first; and about the second or third Day the Skin, and the Whites of the Eyes, began to be tinged with a yellow Colour, attended with the common Symptoms of this Disorder.

Such was the Manner in which the Jaundice began in those who were taken ill in Garrison; but those sent us from the Army could seldom give any accurate Account of their own Cases.

In the Course of this Disorder, the Sick were inclined to be costive, though some few had a Diarrhoea; several, who had been reduced by Fevers, or other Complaints, before the Jaundice appeared, were attacked with violent Hæmorrhages from the Nose; and two had like to have died of them before the Bleeding was stopped. The Hæmorrhages did not prove critical, but seemed to depend on a dissolved State of the Blood.

On the Patient's being first taken ill, if he was plethoric or feverish, or complained of Pain, attended with Sickness and Vomiting, some Blood was taken away. Next Day we gave twenty-five or thirty Grains of Rhubarb in a saline Draught, and afterwards the common saline and other cooling Medicines, till the Fever was abated. If the Pain and Fever did not abate, a Vein was opened a second Time, and a few Drops of the _tinctura thebaica_ were added to the saline Draughts, while emollient Clysters were frequently administered, and the Stomach and Belly fomented with Flannels dipped in warm emollient Decoctions.

When the Pain and Fever were gone, we then gave a gentle Vomit in the Evening, and next Day a Dose of Rhubarb; and afterwards so much of the _pilulæ saponaceæ cum rheo_ daily as kept the Body open; or the saline Draughts with five or six Grains of Rhubarb in each, or such a Quantity as answered the same Purpose as the Pills; and from Time to Time repeated the Emetic[93] and Purge.

[93] Vomits are reckoned amongst the most efficacious Remedies in this Disorder, and I have often seen good Effects follow their Use.--_Janet Crags_, a Woman thirty Years of Age, was, on the 21st of _December_ 1758 admitted into _St. George_'s Hospital for a Jaundice of some Months Continuance. Her Eyes and Skin were not of the common icteric Colour, but of a dark livid yellow, for which Reason both she and the Nurses termed her Disorder the Black Jaundice. She at first complained of a Difficulty of Breathing, and a Weight and Oppression about the Region of the Liver, for which she was blooded, took some Doses of Physick, and the Soap Pills with Rhubarb; but these produced no Change in her Complaints. On the 29th she had a Cough, and complained much of Sickness and Difficulty of Breathing, for which she was ordered a Vomit, and afterwards to take the Squill Draught Morning and Evening, which occasioned a Purging and Gripes. On the 5th of _January_ 1759, the Looseness still continuing, I ordered her to leave off the Use of the Squill Draughts, and to take only some Rhubarb in an oily Draught every Night at Bed-Time. On the 8th, tho' the Purging had increased, I did not chuse to check it, as I suspected it would prove a Crisis to the Disorder, and therefore only ordered her the Cordial Draughts and Wine to support her Strength. The Looseness continued till the 15th, when most of the icteric Symptoms were gone, and by the 30th they entirely disappeared. However, she continued low, and subject to Flatulencies for some Months afterwards, which were at last removed by the continued Use of Cordials, gentle Bitters, a nourishing Diet, and repeated Doses of Rhubarb; and on the 2d of _May_ she was discharged in a firm State of Health.

Dr. _Coe_ says, "I have more Reason to be satisfied of the Effect of Vomits in dislodging these Calculi, than of any other, or indeed of all other Medicines." _Treatise on biliary Concretions_, chap. ii. p. 253. Besides viscid Humours, which Vomits bring away from the biliary Passages, how often are Gall Stones likewise found in the Stools after the Operation of a Vomit? _Ibid._ p. 256.

Most of the icteric Cases we had, which were not complicated with other Disorders, yielded to the above Treatment in about twelve or fourteen Days. Two or three remained obstinate for a longer Time. To one I ordered a Quart of the pectoral Decoction, made with Parsly Roots instead of the Linseed, to be drunk daily along with the Soap Pills; and the Jaundice disappeared in about eight or ten Days. One who had the Disease more obstinate than the rest, and complained for some Time of a Tension and Uneasiness about the Liver, was ordered to have the right Side fomented Morning and Evening, and to rub it for some Time after with the _linimentum saponaceum_ and to drink the Decoction of Sarsaparilla after the Soap Pills; and by continuing this Course for about three Weeks, the Disorder went off[94].

[94] Sometimes the warm Bath has a good Effect after other Remedies have afforded no Relief. In the Year 1743, a young Gentleman, a Student of Physic at _Edinburgh_, had a Jaundice for which he had taken Variety of Medicines, and rode daily on Horseback for some Weeks, without receiving any Benefit: At last, by my Father's Advice, he took a brisk Dose of Physic, and before it began to operate had a large Quantity of warm Whey thrown up by way of a Clyster, and went immediately into the warm Bath. In the Bath he was taken with a violent Inclination to go to Stool; and after coming out, had a great Number of bilious Stools that Day, and next Morning was still inclined to be loose; and in a few Days all the icteric Symptoms vanished. On the 20th of _July_ 1763, a middle aged Woman, _Elizabeth Hosier_, was admitted into _St. George_'s Hospital for a Jaundice, which came about a Fortnight before. She had been blooded, and had taken some Medicines, before I saw her. I ordered her a Vomit and Purge, and to take too Scruples of the Soap Pills and Rhubarb daily; and four Days afterwards the Vomit and Purge were repeated, but without making any Change in her Disorder. On the 29th she went into the warm Bath, and took a Vomit immediately on coming out. After the Vomit she had some loose Stools, and the icteric Symptoms went all off in a few Days. She continued well for some Months; but I have been told, that she has since relapsed.

When the Jaundice continues obstinate, there is hardly any Thing has often a better Effect than the continued Use of Decoctions of the Juices of succulent Plants, of Whey in the Spring, Soap, and such like Medicines. The Baron _Van Swieten_ tells us, that he has cured many obstinate Jaundices by making the Patients drink daily a Pint or two Pints of a Decoction of Grass, Dandelion, Fumaria, Succory, and such like, prepared in Whey; to each Pint of which he added Half an Ounce of _sal polychrest_, and an Ounce or two of Syrup of the five aperient Roots; and by ordering them to drink the Spa Water in Summer, and take freely of Soap, along with a Decoction of the aperient Roots, in Winter. In those who were cured by these Remedies, he says, Stones, or a kind of a grumous calculous Matter, were always found in the Stools, as the Jaundice was going off. He relates one very particular Case of a Lady of sixty Years of Age, who had had a black Jaundice for twelve Years, and was cured by continuing the Use of these Medicines for eighteen Months; during the last six Months of which she had a Looseness, and constantly discharged by Stool a fetid granulated Matter of the Colour of Clay;--and another singular Case of a Man who was cured by living mostly upon Grass, and a Decoction of it, for two Years together. The Man came at last to devour such Quantities of it, and could distinguish the good Sort from the bad so well, that the Farmers often used to drive him out of their Fields. Vol. III. §. 950.

_Glisson_ tells us, that Cattle are subject to bilious Concretions in Winter, which are dissolved and evacuated in the Spring, when they begin to move much about, and to eat the new Grass, which purges them. _Oper._ vol. II. _Anat. Hepat._ chap. vii. p. 104.

Dr. _Russel_ greatly recommends the Use of Sea Water along with the saponaceous Medicines. See his _Treatise on the Use of Sea Water_.

The Hæmorrhage from the Nose commonly stopped soon. Where it was violent, we kept the Patient cool, and applied Cloths dipped in Vinegar and Water to the Nose.--In two Cases, one at _Munster_, the other at _Bremen_, the Patients were hot and feverish, and a Vein was opened, and eight or ten Ounces of Blood taken away; and in one Case nothing took Effect till we gave repeated Doses of the _tinctura saturnina_ in a common acid Julep.

OF TUMOURS of the BREAST.

In _May_ 1761, a great many of the Patients, who had been in Hospitals the preceding Winter, had Tumours formed on the external Part of the Breast, which they shewed me at _Osnabruck_. They began in the Form of indolent Tumours, and came slowly to Suppuration. For the most part, the Suppuration was only partial, and the Tumour, on being opened, discharged a very small Quantity of Matter. Some of them, though they felt soft, and seemed to contain Matter, yet, upon being opened, discharged only a small Quantity of black Blood. None of them melted down entirely into Pus, or came fully to Suppuration, and healed kindly as Abscesses which succeed acute Inflammations. But after a small Quantity of Matter was discharged, for the most part, there still remained a hard Tumour, which felt as if it was a Swelling of the Bone, or Cartilage below; and in some the Surface of the Bone was found rough at the Bottom of the Abscess.

These Tumours seldom rose high, and were most of them situated at the lower Part of the Sternum, or a little to one Side of it, commonly on the left Side, above the _cartilago ensiformis_. Some Patients had only one, others two, and some three such Tumours. The first of them I saw was on the left Side, which, on being felt, gave exactly the same Sensation as when the Cartilages of the Sternum are begun to be raised by an Aneurism of the Aorta; only no Pulsation was to be perceived; and most of them had the same Appearance.

The Patients, who had such Tumours, commonly complained of Pains of their Breast. One or two, after these Tumours came to Suppuration, seemed to recover their Health, and to feel no Uneasiness, tho' some of the Swelling remained: But many of them were inclined to be hectic, and seemed likely to grow consumptive.

Being ordered up to the flying Hospital in _June_, and the Sick going down to _Bremen_, I had no Opportunity of seeing the Event of these Tumours, or of examining the Bodies of those who died with them. One I accidentally met with the following Winter at _Bremen_, who died of a Consumption and Diarrhoea. He had a large Abscess, which penetrated into the Cavity of the Chest, and discharged a great Quantity of very fetid Matter, at the Part where one of these Tumours had been seated, and the Sternum and Ribs were carious all round the Abscess.

OF PARALYTIC COMPLAINTS.

Some of the Soldiers, from lying out in the Nights on the wet Ground, and from doing Duty in cold rainy Weather, were seized with a Pain and Numbness all over, and lost the Use of their Limbs, which in some was succeeded with a Palsy of these Parts: But the greatest Number of those afflicted with Paralytic Symptoms were seized with them either in Fevers, or after feverish and other Disorders. The Number, who were attacked with Complaints of this Kind, were but few.

When Men were suddenly taken with Pain and Numbness all over, we found that the best Method of treating them was to put them to Bed, and give them Plenty of mild warm diluting Liquors for Drink; and if there was much of a Fever, to open a Vein, to give the cooling antiphlogistic Medicines, and apply Blisters; and if these Complaints still remained, to endeavour to promote a breathing Sweat, by means of Diaphoretics and warm Drinks. Several who were brought to the Hospital, soon after being seized in this Manner, got well; but in some few, one or other of the Limbs would begin to waste, and remain paralytic afterwards.

Those who had the true confirmed Palsy seldom remained long enough with us to be cured. Two or three received Benefit from Blisters applied to the Parts, and from Issues; drinking at the same time the Decoction of the Woods, or of Sarsaparilla, and taking the volatile Tincture of Guaiac or Valerian[95], and being sweated by the Use of _Dover_'s Powder, or other Diaphoretics.

[95] On _Wednesday_ the 1st of _February_ 1764, _Margaret Julion_, a Woman between fifty and sixty Years of Age, was admitted into _St. George_'s Hospital for an entire Loss of Speech, which seemed to depend on a paralytic Disorder of the Parts about the Larynx. The Account her Friends who came with her to the Hospital gave of her Case was, that she had been for five Months troubled at Times with Pains of her Bowels, and a Purging; that on _Sunday_ se'night before coming to the Hospital, she had suddenly lost the Use of her Speech, and had not spoke since that Time, though she seemed to hear and understand whatever was said to her. I asked her some Questions, which she answered distinctly by Signs. She had no paralytic Complaint of her Face, Arms, Legs, or any other Part of her Body, and swallowed both Fluids and Solids with Ease. She had no Fever, and seemed to complain of nothing but the Loss of Speech.--A Blister was applied to her Neck, and she was ordered the saline Draughts, with a Scruple of Powder of Valerian in each, to be taken three Times a-day, and a Dose of sacred Tincture, to be taken twice a-Week. She followed this Course for a Fortnight, when another Blister was applied to the Fore-part of the Neck, and the Powder of Valerian in the Draughts was changed for two Drachms of the _tinctura valeriana volatilis_. At the End of three Weeks she could pronounce the two Words _Why_, _What_. She continued the same Course till this Day, the 16th of _March_, and can now pronounce many Words and short Sentences.

One Man of the 51st Regiment of Foot, after doing Duty in very cold wet Weather, in the Beginning of the Year 1762, was seized with a Palsy of one Side of his Face, which prevented him from speaking distinctly, and was an Impediment to his eating. He mended much after being blooded, and having a large Blister to his Neck, kept open for some time by means of the epispastic Ointment.

OF AN INCONTINENCY of URINE.

An Incontinency of Urine was another Complaint frequent among the Soldiers; but it seemed to me to be counterfeited by many. All, who had it, said that they had received some Hurt[96] or Sprain of the Back, or a Kick from a Horse, or that a Carriage had run over them.

[96] A Soldier in the Hospital at _Paderborn_ used to discharge his Water involuntarily, and mixed with Pus, which came from some violent Blows he had received on the Back.

_John Pearce_, a young Man about eighteen Years of Age, was admitted into _St. George_'s Hospital, the 10th of _April_ 1759, for a Pain of his Side, and a Complaint of the Bladder. The Account which he gave of his own Case was, that, some Months before, he had received a violent Blow with a Cricket-Bat on the left Side, on the Region of the Kidney; and that ever since he had had a sharp Pain in that Part, and sometimes had a Stoppage of Urine, and at other Times it came away insensibly. His Pulse was rather quick, but low, and he had a feverish Heat. He at first took some cooling Medicines; but on the 20th, being low and faint, he had some of the foetid Julep. On the 23d he was attacked with a sharp Pain in the Belly and Side, had a Stoppage in making Water, a quick and full Pulse, and most of the Symptoms of the Stone. He was ordered to be blooded immediately, to take the saline Draughts every four Hours; and as he was inclined to be costive, to take as much lenitive Electuary as to procure him a loose Stool; and it was recommended that he should be sounded as soon as the Violence of the Fever was over. On the 25th he continued much in the same Way, and had made some Water, which was intolerably foetid. Half a Drachm of the dulcified Spirit of Nitre, and five Drops of the _tinctura thebaica_, were added to each of his Draughts, as the Pain and Difficulty of making Water had increased. On the 26th his Pulse rose, and became very hard and quick; the Pain in his Side, and the Dysuria, became more violent; and about Twelve o'Clock he had a convulsive Fit, resembling that of an Epilepsy; after coming out of the Fit, as the Fever and Pain had increased, he was blooded; the Belly was fomented and embrocated, and he took the oily Draughts four Times a-Day; his Blood immediately threw up a very thick Buff. He remained pretty easy the rest of the Day; but about the same Time next Day, he had another convulsive Fit, and died.

On opening his Body, we found about two or three Pints of a dark-coloured foetid Water in the Abdomen; on cutting through, and squeezing the right Kidney, there came out a thin purulent Matter every where from its Substance, though it appeared sound; on raising and cutting through the Peritoneum, covering the left Kidney, there was a Discharge of about a Pint of black and very foetid Water, which had every where surrounded this Kidney; and there were six mortified Spots on its Surface, as large as the End of one's Finger, with a Depression in each about a Quarter or Half an Inch deep; most of the Substance of this Kidney seemed diseased, and it was full of Suppurations. The Bladder was contracted and thickened, and contained a rough Stone, which weighed three Ounces. The rest of the _viscera_ were sound. This Stone had certainly been in the Bladder long before the young Fellow received the Blow with the Cricket-Bat; but the Injury done the Kidney had probably aggravated the Symptoms.

I do not remember ever to have seen convulsive Fits, such as this young Man had, in acute Diseases, except in one Case of a slow Fever, which came by taking Cold after a Salivation, and which I attended, along with Dr. _Pringle_. The Gentleman had three Fits exactly of the same kind as this young Man, at twenty-four Hours Distance from one another, and he died of the third.

Those who really had the Disorder seemed to have received such an Injury of the Bladder, or Kidneys as required a considerable Space of Time to get the better of; and by reason of the short Time we had them under our Care at the flying Hospital, they seldom received much Benefit. One or two thought they grew better on taking the Bark and Balsam of _Peru_; at the same Time they bathed Morning and Evening the lower Part of the Abdomen and Perinæum, with Flannels dipped in gentle astringent Liquors, applied cold. Blisters applied to the _os sacrum_ had no Effect.

OF A STOPPAGE of URINE.

We formerly mentioned, that in acute Diseases many complained of a Stoppage or Difficulty of making Water; and others had this Complaint from Strictures of the Urethra, or Disorders of the Bladder or Kidneys[97].

[97] It is often very difficult to judge of the Cause, or to be able to determine exactly the Seat of these Disorders before Death; as the following Cases will shew.

_John Waden_, a middle-aged Man, was admitted into _St. George_'s Hospital the 10th of _April_ 1759, for a Swelling of the Abdomen, and a Difficulty of making Water, which he said begun about two Months before, with a violent Pain in his Back and Belly, occasioned by his being employed in making of Cyder in a very cold Cellar. He had not had a Stool for some Days: at first he took a Dose of Physic, and some of the saline Draughts; but in a Day or two complained that his Belly had grown to a monstrous Size, and that he had not made Water for above twenty-four Hours; on examining, we found the Bladder so much distended as to reach up to the Navel; and upon a Catheter's being introduced, above two Quarts of Water were drawn off, and the Swelling immediately subsided; but in the Afternoon was as large as before, the Bladder seeming to be in a paralytic State. During the Months of _May_ and _June_, his Water was drawn off twice a-Day; he had his Belly fomented with emollient, astringent, and other Decoctions, and embrocated with Liniments; was blooded once when feverish, took Cordials, the Bark, Myrrh, and a Variety of Medicines, without any Effect. On the 3d of _July_, a flexible Catheter was introduced into the Bladder, and left there, in order that the Urine might drain away as fast as it was secreted, and the Bladder be allowed to contract, and recover its Tone. The Catheter gave him no Pain, and he thought himself much easier by the Bladder's never being too much stretched; but on taking out the Catheter some Days after, he had the same Stoppage of Water as before. On consulting with Dr. _Batt_ and the other Physicians, it was agreed to give two Grains of the Powder of Cantharides, with three Grains of Camphor and ten of Sugar, rubbed well together in a Mortar, twice a-Day; and to continue the Use of the flexible Catheter. He found no Uneasiness or Strangury from the Use of the Cantharides, and thought he passed his Water more freely, when the Catheter was taken out; but after fourteen Days, finding no Change for the better, and being free from any Fever, he was ordered into the cold Bath; the two first Days he found himself more lively and brisk; but the third Day was chilly and cold after coming out of it, and therefore was desired to leave it off; some Days after he became hectic, and I observed Pus in his Water, which he said he had passed with his Urine for above three Months; after this he languished for near a Month, and died upon the 25th of _August_.--Upon examining his Body next Day, we found the thoracic Viscera in a sound State, except that the Lungs adhered a little on the right Side. Both Kidneys were diseased; they were inflamed, and seemed enlarged; and on cutting them, had Tubercles dispersed every where through their Substance, which had come to Suppuration, and contained a good deal of Matter; the lower Part of the left Kidney was mortified, and contained two or three Ounces of a black foetid Liquor. The Bladder of Urine was contracted, and its Coats greatly thickened, and the internal Coat much inflamed; and there was a Cyst full of Matter, about Half the Size of a Walnut, between the muscular and villous Coats, towards the lower Part of the right Side of the Bladder; and there were two large Cysts, containing a small Quantity of Matter, though capable of containing near two Ounces each; one situated between the _vesiculæ seminales_ and Rectum, the other between the _vesiculæ_ and Bladder, which opened into the Urethra by one common Orifice, capable of admitting a large Quill, at the Side of the _caput galinaginis_. The rest of the Viscera were in a sound State.

_Mary Hibbard_, a Woman twenty-four Years of Age, was admitted into _St. George_'s Hospital, the 6th _June_ 1759, for a Complaint of her Bladder. The Account she gave of herself was, that, about _Christmas_ 1758, she had parted with some Gravel; and about fourteen Days before coming to the Hospital, she was seized with a violent Pain in her Back and Loins, attended with a Sickness and Nausea; and very soon after complained of a violent Pain in the lower Part of her Belly, and with a perpetual Inclination to make Water, though she felt a sharp Pain and Difficulty in doing it; and that these Complaints still remained. Her Pulse was quick and strong, and she was inclined to be costive. She was immediately blooded, took the oily Draughts three Times a-Day, the _decoctum furfuris_ for common Drink, and so much lenitive Electuary as procured her a Stool next Day. As there was a strong Suspicion of her having a Stone, she was sounded; but nothing at all was to be felt in the Bladder. Her Medicines eased her Pain in making Water, but not the Pain in her Back. On the 16th her Water was thick and turbid, and deposited a brown Sediment; and the Difficulty in making Water still remained; instead of the lenitive Electuary she was ordered the Rhubarb oily Draught to be taken every Night. On the 18th, there being no Change in her Disorder, she had Draughts made of an Ounce and a Half of simple Mint Water, Half a Drachm of the dulcified Spirit of Nitre, and five Drops of the _tinctura thebaica_, and Syrup three Times a-Day; but on the 22d she complained, that since she left off the oily Medicines, her Pain and Difficulty in making Water had grown worse; she was therefore ordered the saline and oily Draughts alternately, and to take the Rhubarb oily Draught occasionally when costive, which removed these Complaints; and they did not return while she remained in the House; but on the 4th of _July_, the Day before she was to have been discharged as cured, she was attacked with a sharp Pain in her Hip and Loins, and about the _os coccygis_; which increased till the 9th, and extended itself all along the Outside of the right Thigh; it was most acute about the _os coccygis_; but on examining, nothing was to be observed externally: This Pain continued more or less all that Month, and till the End of the next, and so obstinate as not to be altered by bleeding, and the Use of Liniments, Blisters, cooling Medicines, Opiates, warm Baths, and other Remedies. On the 20th of _August_, a strengthening Plaister was applied to her Back, which gave immediate Relief, and she was discharged cured the 29th. She continued well till _October_, when she was attacked with a violent Fever at _Hounslow_, and was brought to the Hospital on the 24th of that Month, and the tenth Day of the Fever. She died the 3d of _November_. During the Course of the Fever, she only complained once of a Difficulty of making Water.--After Death I had her Body opened, when the only Thing particular which we could observe, was the urinary Bladder about four times the natural Size; it seemed to be flaccid, and in a State of Relaxation; the Kidneys were sound, and no Signs of any Distemper could be observed about the Uterus or Rectum, or near the _os coccygis_.--When she was first in the Hospital, I desired her always to examine her Urine; but she never observed that she passed any Sand, Gravel, or any thing of that kind.

_Thomas Jacey_, an elderly Man, was admitted into _St. George_'s Hospital the 14th of _March_ 1759, for a Pain in his Back, and a Difficulty and Pain in making Water, which was often mixed with grumous Blood; but he had never observed any Sand or Gravel in it. His Pulse was quick and full, attended with Heat and Thirst; and he was inclined to be costive; he was at first blooded, and took a Dose of laxative Mixture, and two Ounces of the Tincture of Roses, four Times a Day, and the _decoctum malvæ_ for common Drink. At first he seemed relieved, and passed no grumous Blood for some Days; but on the 26th, as he complained much of a Pain in making Water, the Tincture of Roses was changed for the oily Draughts, and he was ordered the Rhubarb oily Draught occasionally. On the 9th of _April_ he fell suddenly into a comatose Way, and remained so till the 12th, when he died, notwithstanding the Use of divers Remedies.--Upon examining his Body, both Kidneys were found in a sound State; the Intestines covered with slight inflammatory Spots, the Bladder of Urine quite contracted, schirrhous, and greatly thickened; and its internal Surface rough and eroded, with one or two black Spots on it, and some grumous Blood lying on its Surface. The other viscera were sound.

In Ulcers of these Organs, the natural Balsams, mixed with soft Things, are often of great Service; of which the following Case is an Example.--_William Lumley_, a Boy nine Years of Age, was admitted into _St. George_'s Hospital, the 6th of _September_ 1759, for a Pain in the Bladder, and a Difficulty in making Water, which was always more or less mixed with Matter. At first there was a Suspicion of his having the Stone; but on sounding, none was to be found. From the Symptoms, it appeared as if there was an Ulcer in the Bladder near to its Neck; the Boy had a Cough, was very low, and inclined to be costive; at first he took three Spoonfuls of the Sperma Ceti Mixture four Times a-Day, and a Dose of Physic; but the Symptoms still remaining, on the 2d of _October_ he was ordered to take a Scruple of the _electuarium e spermate ceti_ three or four Times a Day, and to have the Gum-Arabic Decoction for his common Drink. By continuing the Use of these Things, and taking some opiate and laxative Medicines occasionally, he mended by slow Degrees, and all his Symptoms went off; and he recovered his Health and Strength, and returned Thanks for his Cure the 18th of _January_ 1760.

The following Account of a remarkable Suppression of Urine I had in a Letter, dated the 25th of _November_ 1757, from Mr. _Pearson_, one of the Surgeons to his Majesty's Military Hospitals, who then served as a Mate.

_James Ruffendal_, aged Twenty, of a delicate Habit, was, in the Middle of _July_ last, seized with a violent Pain in both Kidneys, which extended along the Ureters to the Bladder, and remained in the same Situation for about three Weeks; during which Period his Urine began to decrease in Quantity, and the voiding of it was attended with acute Pain about the Neck of the Bladder. The Secretion then totally stopt; he remained for upwards of five Weeks in the Hospital at _Dorchester_, and made no Water; at the End of which Time I first visited him along with Mr. _Adair_. He complained then of a slight Pain in his Kidneys, and told us he had a tolerable Appetite, sweated little, and voided every Day four or five Liquid Stools. He was ordered Boluses of Camphor, and _sal. vol. c. cervi_, and every Night a Dose of _tinctura cantharidum_; which he continued to take for a Fortnight without receiving the least Benefit. I then blooded him to the Quantity of ten Ounces, and gave him an Emetic of six Drachms of the _vinum ipecacoanhæ_, and two Ounces of the Oxymel of Squills, which operated very well; and afterwards ordered him to take one of the following Boluses every four Hours. Rx Sapon. dur. Hispan. drachm. i. Sal. Absynth. gr. vi. Calc. Viv. gr. x. Balsam. Peruv. q. s. ut fiat Bolus. These he continued to take for twelve Days. On the Morning of the 14th of _October_, he was suddenly seized with an acute Pain in both Kidneys, and about Noon voided upwards of Half a Pint of straw-coloured Urine, which let fall a clay-coloured Sediment. As he was feverish, I took away twelve Ounces of Blood, and ordered him Barley-Water with Nitre for Drink. He was easy in the Night, and made upwards of two Pints of Urine, which deposited a Sediment of a gelatinous Consistence. Next Morning the Pain increased, especially in his Right Side, and ten Ounces more of Blood was taken away. This lowered the Pulse, and considerably abated the Pain. Both this and the Blood taken away the Day before threw up an inflammatory Buff. He was ordered to continue the Use of the Barley Water with Nitre, and to take three Spoonfuls of a Mixture with _spiritus mindereri_ every two Hours. He had an easy Night, and was next Day free from Fever; but complained of an Uneasiness in his Stomach and Nausea. He was ordered a Scruple of the Powder of Ipecacoanha, which vomited him, and procured him a Stool. He was easy in the Night; but in the Morning was hot, and complained of a Pain in his Right Kidney, and all over his Bones, as he expressed it. I then gave him a Mixture, with _spiritus mindereri_, and the _pulvis contrayerva comp._ of which I desired him to take some Spoonfuls frequently. This procured him a plentiful Sweat, which removed the Fever and Pain: these Symptoms returned next Day, but were removed by the same Means. I remained at _Dorchester_ for a Week after, and he recovered his Strength and Appetite as much as could be expected in so short a Time; but he still complained of Pain in his Right Kidney, tho' he made Water freely. By a