Chapter IV: Part III: chap. vii (3)

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.