NATIONAL LIBRARY OF MEDICINE Bethesda, Maryland OBSERVATIONS ON THE DISEASES OF THE ARMY. BY SIR JOHN PRINGLE, BART. Late Physician extraordinary to the King, and Physician in ordinary to the Queen of Great Britain. FIRST AMERICAN EDITION. WITH NOTES, BY BENJAMIN RUSH, M. D. Professor of the Institutes and Practice of Medicine in the University of Pennsylvania. PUBLISHED BY EDWARD EARLE, PHILADELPHIA. ALSO BY D. Maltory & Co., Boston; P. H. Nicklin & Co., Baltimore; and J. W. Campbell. Petersburgh. Fry and Kammerer, Printers. 1810. District of Pennsylvania, to wit: ***#**** be if REMEMBERED, That on the seventeenth day of * Seal * October, in the thirty fifth year of the Independence of the Uni- ******** ted States of America, A. D. 1810, Edward Earle, of the said dis- trict, hath deposited in this office, the title of a book the right whereof he claims as proprietor in the words following, to wit: " Observations on the Diseases of the Army. By Sir John Pringle, Baronet. Late Physician extraordinary to the King, and Physician in ordinary to the Queen of Great Britain. First American Edition. With Notes, by Benjamin Rush, M. D. Professor of the Institutes and Practice of Medicine in the University of Pennsylvania." In conformity to the act of congress of the United States, intituled, " An act for the encouragement of learning by securing the copies of maps, charts, and books, to the authors and proprietors of such copies during the times therein mentioned." And also to the act, entitled " An act supplementary to an act, entitled, " An act for the encouragement of learning, by securing the copies of maps, charts, and books, to the authors and proprietors of such copies during the time therein mentioned," and extending the benefits thereof to the arts of designing, engraving, and etching historical and other prints." D. CALDWELL, Clerk of the District of Pennsylvania DEDICATION. to The STUDENTS OF MEDICINE IN THE UNIVERSITY OF PENNSYLVANIA. BEHOLD! gentlemen, another attempt by your pre- ceptor to transplant a vigorous and fruitful European 9 plant into the soil of our country; or, in other words, >» behold, in the following American edition of sir John ^ Pringle's Observations upon the Diseases of the Bri- 3 tish Army, an attempt to increase and diffuse medical sj knowledge in the United States from a source to which _, physicians and learned societies have done homage in every part of the world. The opinions of the illustri- ous author, with a few exceptions, which are pointed out in the notes by the editor, accord with modern the- ories of medicine, and his practice is the result of ex- tensive and accurate observations in a climate nearly similar to that in which we live. Permit me to recom- mend this work to your frequent perusal, and to as- sure you that the more you know of acute diseases, the more you will perceive the truth of the Observa- tions, and the value of the precepts contained in it. iv DEDICATION. I have not added any notes to the appendix. The only remark I shall make upon the experiments of the author, as far as they relate to antiseptics, is, that no inference can be made from them to favour a belief of their acting in the same way upon a living body, and that the changes they induce in the fluids when taken into the stomach, are to be ascribed to their primary action upon irritable solids. The notes of the editor are distinguished from those of the author, by being designated by means of nume- rical characters. The account of the life of sir John Pringle, which succeeds this address to you, is extracted from Dr. Hutchison's Biographia Medica. You will perceive in it, among many interesting matters, the rewards which await talents honestly and industriously devoted to the service of science and humanity, in extensive business, public honours, royal patronage and affluent circum- stances. With sincere wishes for your happiness, I am, gentlemen, very respectfully, your friend, BENJAMIN RUSH. October, 1810. AN ACCOUNT OF THE LIFE OF THE AUTHOR. SlR JOHN PRINGLE, baronet, the late worthy President of the Royal Society, was born at Stichel- house, in the county of Roxburgh, North Britain, April 10, 1707. His father was sir John Pringle, of Stichel, baronet, and his mother, whose name was Magdalen Elliot, was sister to sir Gilbert Elliot, of Stobs, baronet. Both the families from which he de- scended were very ancient and honourable ones in the South of Scotland, and were in great esteem for their attachment to the religion and liberties of their own country, and for their piety and virtue in private life. He was the youngest of several sons, three of whom, besides himself, arrived to the years of maturity. His grammatical education he received at home, under a private tutor; and after having made such a progress as qualified him for academical studies, he was re- moved to the university of St. Andrew's, where he was put under the immediate care of Mr. Francis Pringle, professor of Greek in the college, and a near relation of his father. Having continued there some years, he went to Edinburgh in October 1727, for the purpose of studying physic, that being the profes- sion he now determined to follow. At Edinburgh however he stayed only one year, the reason of which was, that he was desirous of going to vi LIFE OF THE AUTHOR. Leyden, at that time the most celebrated school of medicine in Europe. Dr. Boerhaave, who had brought that university into reputation, was considerably ad- vanced in years, and Mr. Pringle was unwilling, by delay to expose himself to the danger of losing the benefit of that great man's lectures. For Boerhaave he had a high and just respect; but it was not his disposi- tion and character to become the implicit and syste- matic follower of any man, however able and distin- guished. Whilst he studied at Leyden, he contracted an intimate friendship with Van Swieten, who after- wards became so famous at Vienna, both by his prac- tice and writings. Van Swieten was not only Mr. Pringie's acquaintance and fellow-student at the uni- versity, but also his physician when he happened to be seized there with a fit of sickness. Nevertheless, he did not owe his recovery to his friend's advice; for Van Swieten having refused to give him the bark, another prescribed it, and Mr. Pringle was cured. When he had gone through his proper course of studies a; Leyden, he was admitted, July 20, 1730, to the doctor of physic's degree. His inaugural disserta- tion, " De Marcore senile," was printed. Upon quit- ting Leyden, Dr. Pringle settled as a physician at Edinburgh, where he gained the esteem of the magis- trates of the city, and of the professors of the college, by his abilities and good conduct: and such was his known acquaintance with ethical subjects, that, March 28, 1734, he was appointed by the magistrates and council of the city of Edinburgh to be joint-professor of pneumatics and moral philosophy with Mr. Scott, during the said Mr. Scott's life, and sole professor thereof after his decease; and, in consequence of this appointment, Dr. Pringle was admitted, on the same day, a member of the university. In discharging the LIFE OF THE AUTHOR. vii duties of this new employment, his text-book was " Puffendorff de Officio Hominiset Civis;" agreeably to the method he pursued through life of making fact and experiment the basis of science. Dr. Pringle con- tinued in the practice of physic at Edinburgh, and in performing the obligations of his professorship till 1742; when he was appointed physician to the earl of Stair, who then commanded the British army. For this appointment he was chiefly indebted to his friend Dr. Stevenson, an eminent physician at Edinburgh, who had an intimate acquaintance with lord Stair. By the interest of this nobleman, Dr. Pringle was consti- tuted, August 24, 1742, physician to the military hos- pital in Flanders; and it was provided in the commis- sion, that he should receive a salary of twenty shillings a day, and be entitled to half pay for life. He did not, on this occasion, resign his professorship of moral phi- losophy; the university permitted him to retain it, and Messrs. Muirhead and Cleghorn were allowed to teach in his absence, as long as he continued to request it. The eminent attention which Dr. Pringle paid to his duty as an army physician, is a matter that requires no enlargement on in this place, and is apparent from every page of his Treatise on the Diseases of the Army. One thing, however, deserves particularly to be men- tioned, as it is highly probable that it was owing to his suggestion. It had hitherto been usual for the se- curity of the sick, when the enemy was near, to re- move them a great way from the camp; the conse- quence of which was, that many were lost before they came under the care of the physicians. The earl of Stair being sensible of this evil, proposed to the duke de Noailles, when the army was encamped at Aschaf- fenburgh in 1743, that the hospitals on both sides should be considered as sanctuaries for the sick, and viii LIFE OF THE AUTHOR. mutually protected. The French general, who was distinguished for his humanity, readily agreed to the proposal, and took the first opportunity of showing a proper regard to the agreement. At the battle of Det- tingen, Dr. Pringle was in the coach with lord Car- teret during the whole time of the engagement, and the situation in which they were placed was dangerous. They had been taken at unawares, and were kept be- twixt the fire of the line in front, a French battery on the left, and a wood full of hussars on the right. The coach was occasionally moved to avoid being in the eye of the battery. Soon after this event, Dr. Pringle met with no small affliction in the retirement of his great friend, the earl of Stair, from the army. He of- fered to resign with his noble patron, but was not per- mitted. He,-therefore, contented himself with testify- ing his respect and gratitude to his lordship by accom- panying him forty miles on his return to England; after which he took leave of him with the utmost regret. But though Dr. Pringle was thus deprived of the immediate protection of a nobleman, who knew and highly esteemed his worth, his conduct in the duties of his station procured him effectual support. He at- tended the army in Flanders through the campaign of 1744; and so powerfully recommended himself to the duke of Cumberland, that in the spring following, March 11, he had a commission from his royal high- ness, appointing him physician general to his majesty's forces in the Low Countries, and parts beyond the seas: and on the next day, he received a second commis- sion from the duke, by which he was constituted phy- sician to the royal hospitals in the same countries. On March 5, he resigned his professorship, in conse- quence of these promotions. In 1745, he was with the LIFE OF THE AUTHOR. ix army in Flanders, but was recalled from that country in the latter end of the year, to attend the forces which were to be sent against the rebels in Scotland. At this time he had the honour of being chosen Fellow of the Royal Society. The election took place October 30, and the society had reason to be pleased with the ad- dition of such a member. Dr. Pringle, at the beginning of 1746, accompanied in his official capacity, the duke of Cumberland in his expedition against the rebels, and remained with the forces after the battle of Culloden, till their return to England in the middle of August. We do not find that he was in Flanders during any part of that year. In 1747 and 1748, he again attended the army abroad, and in the autumn of 1748, he embarked with the forces for England upon the conclusion of the treaty of Aix-la-Chapelle. From that time he principally re- sided in London, where, from his known skill and ex- perience, and the reputation he had acquired, he might reasonably expect to succeed as a physician. In April 1749, Dr. Pringle was appointed physician to his royal highness the duke of Cumberland. In 1750 he published, in a letter to Dr. Mead, " Observations on the Jail or Hospital-Fever." This piece, which passed through two editions, and was oc- casioned by the jail distemper that broke out at that time in the city of London, was well received by the medical world, though he himself afterwards consider- ed it as having been hastily written. After supplying some things that were omitted, and rectifying a few mistakes that were made in it, he included it in his grand work on the " Diseases of the Army," where it constitutes the seventh chapter of the third part of that treatise. b X LIFE OE THE AUTHOR. It was in the same year that Dr. Pringle began to communicate to the royal society his famous " Expe- riments upon septic and antiseptic substances, with remarks relating to their use in the theory of medi- cine." These experiments, which comprehended se- veral papers, were read at different meetings of the society; the first in June, and the next two in the No- vember follow*ing; three more in the course of the year 1751; and the last in February 1752. Only the first three numbers were printed in the " Philosophical Transactions," as Dr. Pringle had subjoined the whole by way of appendix to his " Observations on the Dis- eases of the Army." The experiments made upon sep- tic and antiseptic substances, which have accompanied every edition of the treatise just mentioned, procured for our ingenious physician the honour of sir Godfrey Copley's gold medal. Besides this, they gained him a high and just reputation as an experimental philoso- pher. In February 1753, he presented to the royal society " An Account of several persons seized with the Jail Fever by working in Newgate: and of the manner by which infection was communicated to one entire family." This was a very curious paper; and it was deemed of such importance by the excellent Dr. Ste- phen Hales, that he requested the author's permission to have it published, for the common good of the king- dom, in the " Gentleman's Magazine," where it was accordingly printed, previous to its appearance in the li Transactions." Dr. Pringle's next communication was "A remark- able Case of Fragility, Flexibility, and Dissolution of the Bones." In the 49th volume of the " Transac- tions" we meet with an account, which he had given of an earthquake felt at Brussels; of another at Glas- LIFE OF THE AUTHOR. Xl gow and Dunbarton; and of the agitation of the waters* November 1, 1756, in Scotland and at Hamburgh. The 50th volume contains observations by him on the case of lord Walpole of Woolterton, and a relation of the virtues of soap in dissolving the stone, as expe- rienced by the rev. Mr. Matthew Simpson. The next volume is enriched with two of the doctor's articles, of considerable length as well as value. In the first he has collected and related the different accounts, that had been given of a very extraordinary fiery meteor, which appeared on Saturday, the 26th of November 1758, between eight and nine o'clock at night, and in a se- cond, he has made a variety of remarks upon the whole, wherein is displayed no small degree of philosophical sagacity. It would be tedious to mention the various papers, which, both before and after he became presi- dent of the royal society, were transmitted through his hands. Besides his communications in the " Philoso- phical Transactions," he wrote in the " Edinburgh Medical Essays," volume fifth, an " Account of the success of the vitrum ceratum antimonii." April 14, 1752, Dr. Pringle married Charlotte, the second daughter of Dr. Oliver, an eminent physician at Bath, and who had long been at the head of his pro- fession in that city. This connexion did not last long, that lady dying in the space of a few years. Nearly about the time of his marriage, Dr. Pringle gave to the public the first edition of his " Observa- tions on the Diseases of the Army." It was reprinted in the year following, with some additions. To the third edition, which was greatly improved from the farther experience the author had gained by attending the camps for three seasons in England, an appendix was annexed in answer to some remarks, which pro- xii LIFE OF THE AUTHOR. fessor De Haen, of Vienna, and M. Gaber of Turin, had made on the work. The like attention was paid to the improvement of the treatise, in every subsequent edition. The work is divided into three parts: the first of which, being principally historical, may be read with pleasure by every gentleman. The latter parts lie more within the province of physicians, they alone are the best judges of the merits of the performance, and to its merit the most decisive and ample testimonies have been given. It has gone through seven editions at home; and abroad it has been translated into the French, the German, and the Italian languages. Scarce- ly any medical writer has mentioned it without some tribute of applause. Ludwig, in the second volume of his " Commentarii de Rebus in Scientia naturali et Medicina gestis," speaks of it highly; and gives an ac- count of it which comprehends sixteen pages. The celebrated and eminent baron Von Haller, in his " Bi- bliotheca Anatomica," with a particular reference to the treatise of which we are speaking, styles the au- thor " Vir illustris de omnibus bonis testibus bene " meritus." It is allowed to be a classical book, and has placed the writer of it in rank with the famous Syden- ham. Like Sydenham too, he became eminent, not by the quantity, but by the value of his productions; and has afforded a happy instance of the great and deserved fame, which may sometimes arise from a single performance. The reputation, that Dr. Pringle gained by his " Observations on the Diseases of the Army," was not of a kind which is ever likely to dimi- nish. The utility of the work, however, was of still greater importance than its reputation. From the time that he was appointed physician to the army, it seems to have been his grand object to lessen, as far as lay in his power, the calamities of war; and he was LIFE OF THE AUTHOR. xiii not without considerable success in his noble and be- nevolent design, The benefits, which may be derived from our author's grand work, are not solely confined to medical men. General Melville, a gentleman who unites with his military abilities the spirit of philoso- phy and humanity, was enabled, when governor of the neutral islands, to be singularly useful, in consequence of the instructions he had received from Dr. Pringle's book, and from personal conversation with him. By taking care to have his men always lodged in large, open, and airy apartments, and by never permitting his forces to remain long enough in swampy places to be injured by noxious airs, the general was the happy instrument of saving the lives of several hundred sol- diers. In 1753, Dr. Pringle was chosen one of the council of the royal society. Though he had not for some years been called abroad, he still held his place as phy- sician to the army; and, in the war which commenced in 1755, attended the camps in England during three seasons. This enabled him, from farther experience, to correct some of his former observations, and to give additional perfection to the third edition of his work. In 1758, he entirely quitted the service of the army, and being determined to fix now wholly in London, he was admitted a licentiate of the college of physi- cians, July 5th, in the same year. The reason, why this matter was so long delayed, might probably be his not having hitherto come to a final resolution with regard to his settlement in the metropolis. After the accession of his present majesty to the throne of Great-Britain, Dr. Pringle was appointed, in 1761, physician to the queen's household; and this honour was succeeded by his being constituted, in 1763, physician extraordinary to her majesty. April xiv LIFE OF THE AUTHOR. 12th, in the same year, he had been chosen a member of the academy of sciences at Haerlem; and in Jtfne fol- lowing, he was elected a fellow of the royal college of physicians, London. In the succeeding November, he was returned on the ballot, a second time, one of the council of the royal society; and in 1764, on the de- cease of Dr. Wollaston, he was made physician in ordi- nary to the queen. February 14, 1766, he was elected a foreign member, in the physical line, of the royal society of sciences at Gottingen; and on the 5th of June in that year, his majesty was graciously pleased to testify his sense of Dr. Pringle's abilities and merit, by raising him to the dignity of a baronet of Great Britain. July 18, 1768, sir John Pringle was appointed physician in ordinary to her late royal highness the princess dowa- ger of Wales, to which office a salary was annexed of one hundred pounds a year. In 1770, he was chosen, a third time, into the council of the royal society; as he was likewise, a fourth time, for the year 1772; and Nov. 30, in that year, in consequence of the death of James West, esq. he was elected president of that il- lustrious and learned body. His election to this high station, though he had so respectable a character as the late sir James Porter for his opponent, was carried by a very considerable ma- jority. This was undoubtedly the highest honour sir John Pringle ever received; an honour w ith which his other literary distinctions could not be compared. It was at a very auspicious time, that sir John Pringle was call- ed upon to preside over the royal society. A wonderful ardour for philosophical science, and for the advance- ment of natural knowledge, had of late years displayed itself through Europe, and had appeared with particu- lar advantage in our own country. He endeavoured to cherish it by all the methods that were in his power; and LIFE OF THE AUTHOR. xv he happily struck upon a new way to distinction and usefulness, by the discourses which he delivered on the annual assignment of sir Godfrey Copley's medal. This gentleman had originally bequeathed five gui- neas, to be given at each anniversary meeting of the royal society, by the determination of the president and council, to the person who had been the author of the best paper of experimental observations for the year past. In process of time, this pecuniary reward, which could never be an important consideration to a man of an enlarged and philosophical mind, however narrow his circumstances might be, was changed into the more liberal form of a gold medal; in which form it is become a truly honourable mark of distinction, and a just and laudable object of ambition. It was, no doubt, always usual with the president on the delivery of the medal, to pay some compliment to the gentle- man on whom it was bestowed; but the custom of making a set speech on the occasion, and of entering into the history of that part of philosophy to which the experiments related, was first introduced by Mr. Martin Folkes. The discourses, however, which he and his successors delivered, were very short, and were only inserted in the minute-books of the society. None of them had ever been printed before sir John Pringle was raised to the chair. The first speech that was made by him being much more elaborate and ex- tended than usual, the publication of it was desired, and with this request, it is said, he was more ready to comply, as an absurd account of what he had delivered had appeared in a newspaper. Sir John Pringle was very happy in the subject of his primary discourse. The discoveries in magnetism and electricity had been succeeded by the inquiries into the various species of air. In these inquiries Dr. Priestly, who had already xvi LIFE OF THE AUTHOR. distinguished himself by his electrical experiments, and his other philosophical pursuits and labours, took the principal lead. A paper of his, entitled,." Obser- vations on different kinds of air," having been read be- fore the society in March 1772, was adjudged to be deserving of the gold medal; and sir John Pringle em- braced with pleasure the occasion of celebrating the important communications of his friend, and of relat- ing with accuracy and fidelity what had previously been discovered on the subject. At the close1 of the speech, he earnestly requested Dr. Priestly to continue his liberal and valuable inquiries; and we need not say how minently the doctor has fulfilled this request. It was not intended, we believe, when sir John Prin- gle's first speech was printed, that the example should be followed; but the second discourse was so well receiv- ed by the royal society, that the publication of it was unanimously requested. Both the discourse itself, and the subject on which it was delivered, merited such a distinction. The composition of the second speech is evidently superior to that of the former; sir John hav- ing probably been animated by the favourable recep- tion of his first effort. His account of the torpedo, and of Mr. Walsh's ingenious and admirable experiments, relative to the electrical properties of that extraordi- nary fish, is singularly curious. The whole discourse abor.jids '.vith ancient and modern learning, and exhi- bits sir John Pringle's knowledge in natural history, as well as in medicine, to great advantage. The third time that he was called upon to display his abilities at the delivery of sir Godfrey Copley's medal, was on an eminently beautiful and important occasion: This was no less than Dr. Maskelyne's suc- cessful attempt, completely to establish sir Isaac New- ton's system of the universe, by his " Observations LIFE OF THE AUTHOR. Xvii '- made on the mountain Schehallien, for finding its " attraction." Sir John Pringle laid hold of this oppor- tunity, to give a perspicuous and accurate relation of the several hypotheses of the ancients, with regard to the revolutions of the heavenly bodies, and of the no- ble discoveries with which Copernicus enriched the as- tronomical world. He then traces the progress of the grand principle of gravitation clown to sir Isaac's il- lustrious confirmation of it; to which he adds a concise narrative of Messrs. Bouguer's and Condamine's ex- periment at Chimboraco, and of Dr. Maskelyne's at Schehallien. If any doubts still remained with respect to the truth of the Newtonian system, they were now totally removed. Sir John Pringle had reason to be peculiarly satis- fied with the subject of his fourth discourse; it being perfectly congenial to his disposition and studies. His own life had been much employed in pointing out the means, which tended not only to cure, but to prevent the diseases of mankind; and it is probable, from his intimate friendship with captain Cook, that he might suggest to that sagacious commander some of the rules, which he followed, in order to preserve the health of the crew of his majesty's ship the Resolution, during her voyage round the world. Whether this were the case, or whether the method pursued by the captain, to attain so salutary an end, were the result of his own reflections alone, the success of it was astonishing; and this famous voyager seemed well entitled to every honour that could be bestowed. To him the society assigned their gold medal, but he was not present to receive the honour. He was gone out upon the voy- age from which he never returned. In this last voyage he continued equally successful in maintaining the health of his men. c xviii LIFE OF THE AUTHOR. In his next annual dissertation, the president had an opportunity of displaying his knowledge in a way, in which it had not hitherto appeared. The discourse took its rise from the prize-medal's being adjudged to Mr. Mudge, then an eminent surgeon at Plymouth, upon account of his valuable paper containing " Directions for making the best Compositions for the Metals of Reflecting Telescopes; together with a Description of the Process for grinding, polishing, and giving the great Speculum the true parabolic form." Sir John accurately related a variety of particulars con- cerning the invention of reflecting telescopes, the sub- sequent improvements of these instruments, and the state in which Mr. Mudge found them, when he first set about working them to.greater perfection, till he had truly realized the expectation of sir Isaac Newton; who, above a hundred years ago, presaged, that the public would one day possess a parabolic speculum not accomplished by mathematical rules, but by me- chanical devices. Sir John Pringle's sixth discourse, to which he was led by the assignment of the gold medal to Mr. (now Dr.) Hutton, on account of his curious paper, enti- tled, " The force of fired Gun-powder, and the ini- tial velocity of Cannon-balls determined by experi- ments," was on the theory of gunnery. Though sir John had so long attended the army, this was pro- bably a subject to which he had heretofore paid very little attention. We cannot, however, help admiring with what perspicuity and judgment he has stated the progress that was made, from time to time, in the knowledge of projectiles, and the scientific perfection to which his friend Dr. Hutton had advanced this knowledge. As sir John Pringle was not one of those who delighted in war, and in the shedding of human LIFE OF THE AUTHOR. xix blood, he was happy in being able to show, that even the study of artillery might be useful to mankind; and therefore this is a topic, which he has not forgotten to mention. Here ended our author's discourses upon the delivery of sir Godfrey Copley's medal. If he had continued to preside in the chair of the royal society, he would, no doubt, have found other occasions of dis- playing his acquaintance with the history of philoso- phy. But the opportunities which he had of signali- zing himself in this respect were important in them- selves, happily varied, and sufficient to gain him a solid and permanent reputation. Several marks of literary distinction had been con- ferred upon sir John Pringle, before he was raised to the president's chair. But after that event they were bestowed upon him in great abundance: and to pre- vent our resuming the subject, we shall here collect them together. Previously, however, to these honours, except his having been chosen a fellow of the society of antiquaries of London, he received the last promo- tion, that was given him in his medical capacity, which was his being appointed November 4, 1774, physician extraordinary to his Majesty. In the year 1776, he was enrolled in the list of the members of no less than four learned bodies. These were the royal academy of sciences at Madrid, the society at Am- sterdam for the promotion of agriculture; the royal academy of medical correspondence at Paris; and the imperial academy of sciences at St. Petersburgh. The dates of sir John Pringle's election into these eminent societies, according to the order in which we have mentioned them, were on the 12th February, in the month of September, and on the 28th and 29th of December. July 5, 1777, sir John Pringle was nomi- nated, by his serene highness the landgrave of Hesse, XX LIFE OF THE AUTHOR. an honorary member of the society of antiquaries at Cassel. In 1778, he succeeded the celebrated Linnasus, as one of the foreign members of the royal academy of sciences at Paris. This honour is extended by that illustrious body to eight persons only, on which ac- count it is justly esteemed a very eminent mark of dis- tinction; and we believe there have been few or no in- stances, wherein it has been conferred on any other than men of great and acknowledged abilities and re- putation. October 11th, in the same year, our author was chosen a member of the medical society at Hanau. In the succeeding year, March 29th, he was elected a foreign member of the royal academy of sciences and belles lettres at Naples. The last testimony of respect in this way, which was bestowed upon sir John, was his being admitted, in 1781, into the number of the fellows of the newly instituted society of antiquaries at Edinburgh. The particular design of this society was to investigate the history and antiquities of Scot- land; and from the known characters and literature of the gentlemen who compose it, there can be little doubt but that the end they have in view will be suc- cessfully accomplished. Sir John Pringle was in his sixty-sixth year, when he was elected president of the royal society. Consi- dering, therefore, the extreme attention that was paid by him to the various and important duties of his office, and the great pains he took in the preparation of his discourses, it was natural to expect, that the burden of his honourable station should grow heavy upon him in course of time. This burden was increased not only by the weight of years, but by the accident of a fall in the area in the back part of his house, from which he received considerable hurt, and which, in consequence, affected his health and weakened his LIFE OF THE AUTHOR. xxi spirits. Such being the state of his body and mind, he began to entertain thoughts of resigning the president's chair. It has been also said and believed, that he was much hurt by the disputes introduced into the society concerning the question, whether pointed or blunt electrical conductors be the most efficacious in pre- serving buildings from the pernicious effects of light- ning. Perhaps sir John Pringle's declining years, and the general state of his health, will form sufficient reasons for his resignation. His intention, however, was disagreeable to many of his friends, and to many distinguished members of the royal society. Accord- ingly, they earnestly solicited him to continue in the chair; but his resolution being fixed, he resigned it at the anniversary meeting in 1778. The present worthy president, sir Joseph Banks, then Joseph Banks, esq. was unanimously elected to succeed him; a gentleman in the prime and vigour of his life, who had eminently distinguished himself by his acquaintance with natu- ral history; who had sailed round the globe, and per- formed other voyages in pursuit of that branch of science; and who has amply justified the choice that was made of him, by his attention to every part of his duty, and his assiduous concern to promote the inter- est and honour of the society. Though sir John Pringle quitted his particular re- lation to the royal society, and did not attend its meet- ings so constantly as he had formerly done, he still re- tained his literary connexions in general. His house continued to be the resort of ingenious and philosophi- cal men, whether from his own country or from abroad; and he was frequent in his visits to his friends. He was held in particular esteem by eminent and learned foreigners, none of whom came to England without waiting upon him, and paying him the greates res- xxii LIFE OF THE AUTHOR. pect. He treated them in return with distinguished civility and regard. When a number of gentlemen met at his table, foreigners were usually a part of the company. Sir John Pringle's infirmities increasing, he hoped that he might receive an advantage from an excursion to Scotland, and spending the summer there, which he did in 1780; and principally at Edinburgh. He had pro- bably then formed some design of fixing his residence in that city. However this may have been, he was so well pleased with a place, to which he had been habituated in his younger days, and with the respect shown him by his friends, that he purchased a house there, whi- ther he intended to return in the 'following spring. When he came back to London, he set about prepar- ing to put his scheme into execution. Accordingly, having first disposed of the greater part of his library, he sold his house in Pali-Mall, in April 1781, and some few days after he removed to Edinburgh. In this city he was treated by persons of all ranks with every mark of distinction. But Edinburgh was not now to him what it had been in early life. The viva- city of spirits, which in the days of youth spreads such a charm on the objects that surround us, was fled. Many, if not most, of Sir John Pringle's old friends and contemporaries were dead; and though some of thf:m remained, they could not meet together with the same strength of constitution, the same ardour of pursuit, the same animation of hope, which they had formerly possessed. The younger men of eminence paid him the sincerest testimony of esteem and regard; but it was too late in life for him to form new habits 01 close and intimate friendship. He found also the air of Edinburgh too sharp and cold for his frame, which had long been peculiarly sensible to severities LIFE OF THE AUTHOR. xxm; of weather. These evils were exaggerated by his in- creasing infirmities, and perhaps by that restlessness of mind, which, in the midst of bodily complaints, is still hoping to derive some benefit from a change of place. He determined, therefore, to return once more to London, where he arrived in the beginning of Sep- tember. Before sir John Pringle entirely quitted Edinburgh, he requested his friend, Dr. John Hope, to present ten volumes, folio, of " Medical and physical Observa- tions," in manuscript, to the royal college of physi- cians in that city. This benefaction was conferred on two conditions: first, that the observations should not be published; and secondly, that they should not be lent out of the library on any pretence whatever. A meeting of the college being summoned upon the oc- casion, sir John's donation was accepted with much gratitude, and a resolution passed to comply with the terms on which it was bestowed. He was at the same time preparing two other volumes to be given to the university, containing the formulae referred to in his annotations. Sir John Pringle, upon his arrival at the metropolis, found his spirits somewhat revived. He was greatly pleased with revisiting his London friends, and he was received by them with equal cordiality and affection. His Sunday evenings' conversations were honoured with the attendance of many respectable men; and on the other nights of the week, he had the pleasure of spending a couple of hours with his friends, at a soci- ety that had long been established, and which had met, for some time past, at Mr. Watson's, a grocer in the strand. Sir John's connexion with this society, and his constant attendance upon it, formed to the last, one of his principal entertainments. The morning was chiefly xxiv LIFE OF THE AUTHOR. employed by him in receiving and returning the visits of his various acquaintance, and he had frequently a small and select party to dine with him at his apart- ments in King-street, St. James's square. All this while, his strength declined with a rapidity which did not permit his friends to hope, that his life would long be continued. On Monday evening, Jan. 14, 1782, being with the society at Watson's, he was seized with a fit, from which he never recovered. He was accompanied home by Dr. Saunders, for whom he had the highest regard, and in whom he had, in every respect, justly placed the most unreserved con- fidence. The doctor afterwards attended him with un- wearied assiduity, but, as to any medical purpose, en- tirely in vain; for he departed this life on the Friday fol- lowing, in the seventy fifth year of his age, and the ac- count of his death was received every where, in a man- ner which showed the high sense that was entertained of his merit. On the 7th of February, he was interred in St. James's church, with great funeral solemnity, and with a very honourable attendance of eminent and re- spectable friends. As a testimony of regard to his me- mory, at the first meeting of the college of physicians at Edinburgh, after his decease, all the members ap- peared in deep mourning. Our author had acquired, by his long practice, a handsome fortune, which he disposed of with great pruder.-.e and propriety. The bulk of it, as might na- turally and reasonably be expected, he bequeathed to his worthy nephew and heir, sir James Pringle, of Stichel, bart. whom he appointed his sole executor. But the whole was not immediately to come to sir James; for a sum equal, we believe, to seven hundred pounds per annum was appropriated to annuities, re- vertible to that gentleman at the decease of the annui- LIFE OF THE AUTHOR. xxv tants. By these means sir John exhibited an impor- tant proof of his regard and affection for several of his valuable relations and friends. Sir John Pringle's em- inent character as a practical physician, as well as a medical author, is so well known, and so universally acknowledged, that an enlargement upon it cannot be necessary. In the exercise of his profession he was not rapacious; being ready, on various occasions, to give his advice without pecuniary views. The turn of sir John Pringle's mind led him chiefly to the love of sci- ence, which he built on the firm basis of fact. With regard to philosophy in general, he was as averse to theory, unsupported by experiments, as he was with respect to medicine in particular. Lord Bacon was his favourite author; and to the method of investigation recommended by that great man he steadily adhered. Such being his intellectual character, it will not be thought surprising, that he had a dislike to Plato. To metaphysical disquisitions he lost all regard in the lat- ter part of his life; and though some of his most valued friends had engaged in discussions of this kind, with very different views of things, he did not choose to revert to the studies of his youth, but contented him- self with the opinions he had then formed. Sir John Pringle had not much fondness for poetry. He had not even any distinguished relish for the im- mortal Shakspeare; at least, he seemed too highly sen- sible of the defects of that illustrious bard, to give him the proper degree of estimation. Sir John Pringle had not, in his youth neglected philological inquiries; and after having omitted them for a time, he returned to them again; so far, at least, as to endeavour to obtain a more exact knowledge of the Greek tongue, proba- blv with a view to the better understanding the New Testament. He paid great attention to the French lan- d xxvi LIFE OF THE AUTHOR, guage; and it is said, that he was fond of Voltaire's critical writings. How far this might contribute to the honour of sir John's taste, we shall not decide. How- ever just that eminent Frenchman's observations may have been on some subjects of criticism, the truly in- genious and excellent Mrs. Montagu has amply shown that he was absolutely unequal to the task of determin- ing concerning the merit of Shakspeare. Among all his other pursuits, sir John Pringle never forgot the study of the English language. This he regarded as a matter of so much consequence, that he took uncommon pains with respect to the style of his compositions; and it cannot be denied, that he excels in perspicuity, cor- rectness, and propriety of expression. Though our au- thor was not fond of poetry, there was a sister art for which he had a great affection; and that was music. Of this art he was not merely an admirer, but became so far a practitioner in it, as to be a performer on the violoncello, at a weekly concert given by a society of gentlemen at Edinburgh. Beside a close application to medical and philosophical science, sir John Pringle, during the latter part of his life, devoted much time to the study of divinity. This was with him a very fa- vourite and interesting object. He corresponded frequently with Michaelis on theological subjects; and that celebrated professor addressed to him some letters on " Daniel's prophecy of the seven weeks," which sir John thought worthy of being published in this country. Accordingly he was at considerable pains, and some expense, in the publication, which appeared in 1773, under the following title: Johannis Davidis Michaelis, Prof. Ordin. Philos. et Soc. Reg. Scient. Goettingensis Collegia; Epistolae, de lxx Hebdoma- dibus Danielis, ad D. Johannem Pringle, Baronettum; prime- privatim missal, nunc verb utriusque consensu LIFE OF THE AUTHOR. xxvii publice editas," 8vo. Sir John Pringle was likewise a diligent and frequent reader of sermons. If from the intellectual we pass on to the moral char- acter of sir John Pringle, we shall find, that the ruling feature of it was integrity. By this principle he was uniformly actuated in the whole of his behaviour. All his acquaintance will with one voice agree, that there never was an honester man. He was equally distin- guished for his sobriety. He told Mr. James Boswell, that he had never in his life been intoxicated with liquor, which must be allowed to have been a very laudable proof of the circumspection maintained by him, in the variety of company that he had kept, both at home and abroad. In his friendships, Sir John Prin- gle was ardent and steady. The intimacies which were formed by him, in the early part of his life at Edin- burgh, continued unbroken to the decease of the gen- tlemen with whom they were made; and were kept up by a regular correspondence, and by all the good offices that lay in his power. With relation to sir John Prin- gle's external manner of deportment, he paid a very respectful attention to those who were honoured with his friendship and esteem, and to such strangers as came to him well recommended. Foreigners, in par- ticular, had great reason to be satisfied with the un- common pains, which he took to show them every mark of civility and regard. He had however, at times, somewhat of a dryness and reserve in his behaviour, which had the appearance of coldness; and this was the case, when he was not perfectly pleased with the persons who were introduced to him, or who happen- ed to be in his company. His sense of integrity and dignity would not permit him to adopt that false and superficial politeness, which treats all men alike, though ever so different in point of real estimation and xxviii LIFE OF THE AUTHOR. merit, with the same show of cordiality and kindness. He was above assuming the professions, without the reality of respect. Dr Johnson, in his " Life of Pope," has recorded of that poet, that when he wanted to sleep, he " nodded in company;" and that he once slumber- ed at his own table, while the prince of Wales was talking of poetry. Sir John Pringle had this infirmity, especially in the latter part of his life. Nor is it sur- prising, when we consider, that he had for many years been so remarkably troubled for want of rest, that there was scarcely a single night, in which he did not lie awake for several hours. On the religious character of sir John Pringle, it will be necessary more particularly to enlarge; because such is the temper of the present age, that what is the greatest glory of any man is often imputed to him as a weakness. The principles of piety and virtue, which were early instilled into our author by a strict educa- tion, do not appear ever to have lost their influence upon the general conduct of his life. Nevertheless, when he travelled abroad in the world, his belief of the christian revelation was so far unsettled, that he be- came a sceptic with regard to it, if not a professed deist. But it was not in the disposition of sir John Pringle to rest satisfied in his doubts and difficulties, with res- pect to a matter of such high importance. He was too great a lover of truth, not to make religion the object of his serious inquiry. As he scorned to be an implicit believer, he was equally averse to being, an implicit unbeliever; which is the case of large numbers, who reject Christianity with as little knowledge, and as little examination, as the most determined bigots embrace the absurdest system that ever was invented. The re- sult of his investigation was a full conviction of the divine original and authority of the gospel. The evi- LIFE OF THE AUTHOR. xxix dence of revelation appeared to him to be solid and in- vincible; and the nature of it to be such as demanded his warmest acceptance. Sir John Pringle's literary and other connexions were so very numerous, that we cannot pretend to enu- merate them. Of his acquaintance in England it would not be easy to give a detail. If such a detail were at- tempted, it would include a large number of the most worthy and eminent characters of all professions. His conversation was not confined to medical gentlemen, though his intercourse with them was very great, but extended to many persons of rank and consequence, as well as merit. It would be impossible for us to do full justice to sir John Pringle's connexions with foreigners. There were no persons who visited Eng- land, if they had any taste for philosophical science, that were not recommended to him, and did not cul- tivate his acquaintance. Besides this, he corresponded with many eminent philosophers and physicians whom he had never seen. Such having been the character and eminence of sir John Pringle, it was highly pro- per, that his name should be recorded among the worthies of Westminster Abbey. Accordingly, under the direction, and at the expense of his nephew and heir, a monument has been erected, of which Mr. Nollekens was the sculptor, and on which an English inscription appears. If it had been determined to have had a Latin inscription, there was one, written by a gentleman of the first classical knowledge and taste, which would undoubtedly have had the preference. It contained an elegant and honourable testimony to his memory. PREFACE BY THE AUTHOR. 1 HE diseases of the army, as far as it appears, have been treated of by none of the ancient physicians; nor have we any information about them from the histori- ans, unless when some uncommon or very fatal dis- temper attended an expedition. Xenophon, in his re- lation of the famous retreat of the Greeks, observes, that they were liable to the fames canina, to blindness, and to a mortification of the extremities, from the snow and excessive cold to which they were exposed on their march. Pliny is the first who takes notice of the stoma'cace, the distemper now called the scurvy, which afflicted the Roman army in Germany, after it had continued two years in that country.* We likewise find the Romans under a necessity of shifting their camps, on account of the noxious vapours from the adjacent marshes. Plutarch observes, that Demetrius, in his last expedition, lost above eight thousand men by a sickness which followed a scarcity of provisions. Livy mentions a pestilential distemper, that seized both the Romans and the Carthaginians in Sicily. And Di- odorus describes another pestilence, attended with a * Ancient Germany included the northern parts of the Nether- lands; and it seems to be that marshy country which Pliny means; for he subjoins these words, trans Rfunum mantimo tractu, which agrees with the account that Tacitus gives of the expedition un- der Germanicus. xxxii PREFACE. flux of blood, which almost utterly destroyed the lat- ter at the siege of Syracuse; and though he refers the final cause of this calamity to the Gods, incensed against that people on account of their impiety, yet he explains the natural causes in a more full and satis- factory manner, than is usually done by historians on like occasions. But excepting in these and a few more instances, there remains no account of the diseases incident to the armies of the ancients. It may seem strange, that Vegetius should write a chapter containing directions how to preserve the health of soldiers, and yet not mention any disorder to which they were particularly subject; and that he should speak of the physicians at- tending the camp, without taking notice of their man- ner of disposing of the sick, whether in hospitals or otherwise. The silence of the ancients upon this arti- cle is the more to be regretted, because, as war was their study, it might be expected, that the orders, re- lating to the care of the sick, were good in proportion to their skill in the other branches of the military art. And indeed, as their troops were almost constantly in the field, and employed in different climates, the phy- sicians of those days had it much in their power to furnish posterity with many useful observations on the nature and causes of camp-diseases, and or ae proper method of treating them. Nor, when I was first em- ployed in the army, had this defect been supplied by any of the moderns whom I had read, unless by such as had either little, or not at all, attended the service, at least the military hospitals. So that after all, this branch of medicine, which ought long ago to have been complete, seemed to be still in a manner new: so little is a military life consistent with that state of tran- quillity requisite for study and observation. PREFACE. Xxxhi Perceiving therefore the little assistance I was to expect from books, I began to mark such observa- tions as occurred, in hopes of finding them afterwards useful in practice. And having continued this method to the end of the former war, I was induced to put those materials into order, and, with as much clear- ness and concisenes as I could, to endeavour from my own experience to supply to others, in some measure, what I thought so much wanting on this subject. I have divided the work into three parts. In the first, after a short account of the air and diseases more pe- culiar to the Low-Countries (so often the seat of our wars) I give an abridgment of the medical journal which I had kept of the several campaigns. In this I mention the epidemics, that is, the more frequent dis- eases of our troops, in the order in which they occur- red; our embarkations, marches, encampments, can- tonments, winter-quarters; the seasons, the changes of the weather, and, in a word, all the circumstances that seemed to me most likely to affect the health of an ar- my. In this part I have entered but little into the de- scription of diseases, much less have I touched upon their cure, reserving both those subjects to be treated of afterwards. My chief intention here, was to collect materials for tracing the more evident causes of mili- tary distempers, in order that whatever depended upon officers in command, and was consistent with the ser- vice, might be clearly stated, so as to suggest mea- sures, either for preventing, or for lessening such causes in any future war. And I have been the more studious of exactness in this account, as I foresaw, that in whatever manner the whole was to be received, this part at least would be acceptable, as being a narra- tion of facts, by one who was present and employed all the time. My inferences are few and short, as a full e xxxiv PREFACE. discussion of those points would have too much inter- rupted the series of incidents, that were to be present- ed in this place at one view. I have therefore thrown most of the reasoning, re- sulting from the first part, into the second; in which, after having divided and classed the diseases common to a military life, I inquire into the causes of them, such, I mean, as depend upon the air, the diet, and other circumstances, usually comprehended under the appellation of non-naturals. And here I have ventured to assign some sources of disorders, very differently from other writers upon this subject. I have also shown, how little instrumental some other causes are, which have been hitherto thought to be the most productive pf military distempers. Nor will this liberty, I hope, be condemned, when the opportunities, which I have had beyond others to make such remarks, are attended to; and when it is considered, that as natural know- ledge is daily improving, those who write last on sub- jects connected with it are most likely to be in the right. Among the chief causes of sickness and mortality in an army, the reader will little expect that I should rank (what are intended for its health and preserva- tion) the hospitals themselves, and that on account of the bad air, and other inconveniencies attending them. However, during the former war, one considerable step was made towards their improvement. Till then it had been usual, for the security of the sick (when the enemy was near) to remove them a great way from the camp, whereby many were actually lost before they came under the care of physicians; or, which was at- tended with equally bad consequences, if the hospitals were nigh, they were, for the same reason, frequently shifted, according to the motions of the army. But the PREFACE. XXXV earl of Stair, my illustrious patron, being sensible of this hardship, when the army was encamped, at As- chaffenburg, proposed to the duke de Noailles (of whose humanity he was Well assured) that the hospi- tals on both sides should be considered as sanctuaries for the sick, and mutually protected. This was readily agreed to by the French general, who took the first opportunity to show a particular regard to his engage- ment. For when our hospital was at Feckenheim, a village upon the Maine, at a distance from the camp, the duke de Noailles having occasion to send a detach- ment to another village upon the opposite bank, and apprehending that this might alarm our sick, he sent to acquaint them, that as he knew the British hospital was there, he had given express orders to his troops not to disturb them. This agreement was strictly ob- served on both sides during that campaign, and though it has been since neglected, yet it is still to be hoped, that on future occasions the contending parties will made it a precedent. After having explained the general causes of sick- ness in armies, I proceed to point out the means of removing some of those causes, and rendering others less dangerous; for without this addition, the former observations could have been of little use. But it is easy to conceive, that the prevention of diseases cannot depend on the use of medicines, nor upon any thing which a soldier shall have in his power to neglect, but upon such orders as he himself shall not think unrea- sonable, and such as he must necessarily obey. I conclude the second part with comparing the num- ber of the sick at different seasons, that the commander may know, with some degree of certainty, what force he may at any time rely upon for service; the effects of short or long campaigns upon the health; the dif- xxxvi PREFACE. ference between taking the field early, and going late into winter-quarters; with other calculations founded upon such materials as were furnished by the war. The data are perhaps too few to deduce certain conse- quences from them, but as I found no other which I could depend upon, I was obliged to make the best use of these, which at least will serve for a specimen of what may be done in this way upon further experi- ence. These two parts being intended for the use of offi- cers as well as physicians, I have endeavoured to re- late the facts and draw my inferences in the plainest manner, and with as few scientific terms as was con- sistent with the nature of the subject; and, I hope, w ith perspicuity enough to be understood by any reader not unacquainted with the common principles of natu- ral knowledge. But the third part, containing the practice, is de- signed for those of my own profession only, as it could neither be properly explained, nor be made instructive to others. In composing this from my notes, I was long in doubt how to proceed, whether wholly to omit such things as were commonly known, or to treat all the disorders, mentioned there, in a full and regular manner. But at last I determined upon the following course. I suppose the diseases, to which an army is most subject, to be divisible into two classes; one com- prehending those which are also common in Britain; and the other, such as more peculiar to a different cli- mate, or to the condition of a soldier. Now, as the first have been fully treated of by several learned authors, in the hands of every physician, and also occur in daily practice, I pass them cursorily over, being satisfied with laying down my general method of proceeding, and marking the difference, if any, to be observed in PREFACE. xxxvii prescribing in military hospitals. But with regard to the other class; including what are usually called the bilious fevers, and what I have denominated the jail or hospital-fever, and the dysentery, as they are disor- ders less frequent in this country, I thought proper to handle them more at length, and indeed in so full a manner, as I hoped might instruct those who had been little conversant with them before. My observations on the jail or hospital-fever were first published in the year 1750, in a letter to Dr. Mead. But as that piece was hastily written, occasioned by the jail-distemper breaking out at that time in London, some things were omitted, and some mistakes were made, which I have since endeavoured to supply and rectify in this work, wherein that dissertation is includ- ed.* To this account of the jail or hospital-fever, as well as that of the bilious fevers, and the dysentery, I have subjoined some conjectures about their internal and more latent causes, though I am aware, that an attempt of this kind may tend rather to weaken than confirm the credit of my observations; as we too often see the judgment influenced and perverted by such specula- tions. But the reader may be assured, that not only the descriptions, but the treatment of all these disor- * In the year 1722, a treatise was published here, intitled, A Rational Inquiry into the Nature of the Plague, drawn from His- torical Remarks; by John Pringle, M. D. As the subject was si- milar to mine, and as the author was of the same name, the wri- ter of the index to M. de Haller's edition of Boerhaave's Metho- dus Studii Medici has referred that piece, my letter to Dr. Mead, and my Inaugural Dissertation (at Leyden, in the year 1730) de Marcore Senilis to one person. In justice therefore to the worthy author of that Inquiry, I take this opportunity of informing the public of the mistake, which indeed it was very natural for a fo- reigner to fall into. xxxviii PREFACE. ders, were in a good measure fixed before I thought of assigning those causes, and which indeed were some- times first suggested by the effects of the medicines. Yet a just theory would often be useful; not only for discovering more powerful remedies, but for varying those we are already acquainted with, when the judg- ment cannot be assisted either by mere empiricism, or even by analogy from other diseases. In reasoning upon the nature of these distempers, I have so much recourse to the septic principle, that the reader may imagine, I have considered it as a more universal cause than I really think it; but excepting these, and one or two more I have alluded to in this work, I have hitherto referred no other disorder to that origin. As to the reality of such a principle, though I think I have sufficiently ascertained it in these sheets, yet to some it may be satisfactory to know, that the corruption of the humours, as the cause of certain dis- eases, was first hinted at by Hippocrates, further taken notice of by Galen, and still more fully treated of, and applied to medicine in later times, as appears by the Aphorisms of Sanctorius, and other noted works of his age. And though it was afterwards sunk in the systems of Sylvius and of Willis, as well as in that of the first mechanic writers in our art, yet it was revived by Hoffman and Boerhaave; and especially by the lat- ter, who, under the article of alkalis, comprehended all that he thought septic or putrid. But as that celebrated physician had not time to ascertain every part of his doctrine from his own experience, it was no wonder that some mistakes were made, and that the extent of this principle was not fully understood. Two things induced me to prosecute this subject; the great number of putrid cases that were under my care in the hospitals abroad, and the authority of Lord Bacon, who offers good reasons for considering, the knowledge of what brings on, and what retards putre- faction, as most likely to account for some of the more abstruse operations of nature. My papers on this sub- ject being read at the several meetings of the royal soci- ety, the three first were published in the Transactions; but while the rest were still in the hands of the secretary, in order likewise to be inserted there, finding it neces- sary to make frequent references to those experiments, I thought it proper to annex the whole to this work, in the same order wherein they were presented, with the addition of some notes, to explain what might not have been fully or clearly enough expressed before, and by way of connecting those facts with the preceding Observations. This book was first published in the year 1752, and reprinted in the year following with some additions. In the third edition I corrected some of my observa- tions, from further experience in the camps which I attended in England for three seasons in the beginning of the last war, before I quitted the service. But as I found the diseases of those hospitals similar to what had occurred during the former war, though milder on account of the nature of the climate, and from the soldiers not suffering the hardships, to which troops are exposed in sight of an enemy, I judged it unne- cessary to give any account of those easy campaigns. In the two subsequent editions, as well as in the present, I have revised the whole, and from more ma- ture reflection, from my private practice, and from conversing with others who had been employed in the hospitals abroad, in different climates, during the late war, I have had an opportunity of making further im- provements, by expressing with more confidence some of my former remarks, and by omitting others which xl PREFACE. I had advanced without sufficient foundation. I have likewise added some new observations to most of the articles in the third part, and especially to the chapter on the dysentery, having had more experience in that distemper, which, though uncommon in this place, was frequent in the autumn of 1762. I am sensible, however, that notwithstanding all my eare and attention, both in making the observations and the experiments, and the repeated opportunities that I have had of revising and correcting this work, not only many inaccuracies but mistakes have escaped me, which those will most readily excuse, who, hav- ing themselves made researches of this kind, are not unacquainted with the difficulties attending their pub- lication. Yet, however imperfect these sheets may be, I have the satisfaction to find, that they have served as a foundation for others to build upon, who, by making improvements on these subjects, have concurred with me, in attempting to draw, even from the calamities of war, some benefit to mankind. London, 18th January, 1768. CONTENTS. PART I. CHAPTER I. PAGE OF the air and diseases of the Low-Countries........ 1 CHAPTER II. A general account of the garrison diseases of the British troops, in Flanders, and in the cantonments in Germany, in the years 1742, and 1743................. 10 CHAPTER III. A general account of the diseases of the British troops, dur- ing the campaign in Germany, in the year 1743, and in the ensuing winter in Flanders............... 16 CHAPTER IV. A general account of the diseases of the campaign in Flan- ders, in the year 1744.................... 27 CHAPTER V. A general account of the diseases of the campaign in Flan- ders, in the year 1745.................... 32 CHAPTER VI. A general account of the diseases of the campaign in Great Britain, 1745 and 1746.................... 36 CHAPTER VII. A general account of the diseases of the campaigns in Dutch Brabant, in the years 1746 and 1747............ 48 CHAPTER VIII. A general account of the diseases of the campaign in Dutch Brabant, in the year 1748.................. 54 f xlii CONTENTS. PAGE PART II. CHAPTER I. Of the division of the diseases most incident to an an army. 64 CHAPTER II. Of the causes of the diseases most incident to an army. . . 70 Section I. Of the diseases occasioned by heat, and by cold. ib. Section II. Of the diseases occasioned by moisture. ... 72 Section III. Of diseases arising from putrid air....... 74 Section IV. Of diseases arising from errors in diet. ... 76 Section V. Of diseases arising from excess of rest, and motion; of sleeping, and watching; and from a want of cleanliness........................... 84 CHAPTER III. Of the general means of preventing diseases in an army. . 8.3 Section I. How to prevent diseases arising from heat, and cold............................... ib. Section II. How to prevent diseases arising from moisture. 85 Section III. How to prevent diseases arising Irom putrid air............................... 88 Section IV. How to prevent diseases arising from im- proper diet.......................... 98 Section V. How to prevent diseases arising from errors in exercise............................ 101 CHAPTER IV. The seasons compared, with regard to the health of an army.............................. 103 PART III. CHAPTER I. Observations on colds, and inflammatory fevers in general. 110 CHAPTER II. Observations on particular inflammations. t ......... n 9 CONTENTS. xliii Section I. Of the inflammation of the brain......... 119 Section II. Of the inflammation of the eyes........121 Section III. Of the inflammation of the throat....... 123 Section IV. Of the pleurisy and inflammation of the lungs. 125 Section V. Of the inflammation of the liver........ 130 Section VI. Of the inflammation of the stomach and intes- tines........................ j3j Section VII. Of the rheumatism............... 139 CHAPTER III. Observations on coughs, and the phthisis fiulmonalis..... 146 CHAPTER IV. Observations on the fevers called bilious, or the autumnal remitting, and intermitting fevers of an army.......151 Section I. Of the symptoms of the remitting, and inter- mitting fevers of the camp.................. 152 Section II. Of the symptoms of the remitting, and inter- mitting fevers in low and marshy countries........155 Section III. Of the causes of the remitting, and intermit- ting fevers of the camp, and those of low and marshy countries...........................164 Section IV. The remitting, and intermitting fever of the camp and cantonments compared with the summer and autumnal fevers of other places............... 167 Secti in V. Of the cure of the remitting, and intermitting fevers of the camp, and of those of low and marshy coun- tries.............................. 178 CHAPTER V. Observations on the obstructions consequent on the remit- ting, and intermitting fevers of the camp, and those of marshy countries....................... 191 CHAPTER VI. Observations on the camp-dysentery............. 194 Section I A description of the camp-dysentery...... ib. Section II. Of the dissections................212 Section III. Of the causes of the dysentery......... 223 Section IV. Of the cure of the dysentery.........230 xliv CONTENTS. PAGE CHAPTER VII. Observations on the jail or hospital-fever...........254 Section I. Of the rise of the jail or hospital-fever, and the manner of the infection................... lb" Section II. Of the symptoms................2j6 Section III. Of the prognostics...............264 Section IV. Of the dissections................265 Section V. Of the cure..................■ • 269 Section. VI. Of the causes of malignant or pestilential fevers. ............................281 CHAPTER VIII. Observations on the Itch..................■ • 2" CONTENTS. xlv APPENDIX. PAPER I. PAGE EXPERIMENTS showing that putrid substances are not to be called alkaline; that neither the volatile nor the fixed alkaline salts tend naturally to promote putrefaction with- in the body, being of themselves antiseptic. That the com- bination of two antiseptics may produce a third weaker than either. Experiments upon the comparative powers of some neutral salts in resisting putrefaction. And of the strong antiseptic qualities of myrrh, camphire, snake- root, camomile-flowers, and the Peruvian bark......307 PAPER II. A continuation of the experiments and remarks upon anti- septic substances. A table of the comparative powers of salts in resisting putrefaction. Of the antiseptic quality of several resins, gums, flowers, roots, and leaves of ve- getables, compared with common salt. Attempts to sweeten corrupted animal substances by means of camo- mile-flowers, and the Peruvian bark. A conjecture about the cause of intermitting fevers; and about the action of the bark in curing them...................316 PAPER III. Experiments on substances resisting the putrefaction of animal humours, with their use in medicine. Astringents always antiseptics, but antiseptics have not always a ma- nifest astriction. Of the use of putrefaction in general, and particularly in the animal economy. Of the different means of inducing putrefaction. Some substances reput- ed septics have a contrary quality. And the real septics are some of those very substances which have been the least suspected to be of that nature, viz. chalk; the testa- cea, and common salt- ...................326 xlvi CONTENTS. PAPER IV. A continuation of the experiments upon septics. Conjec- tures about the causes of the decline of putrid diseases. Of the difference between the effects of the testacea and lime-water. An account of a power discovered in putrid animal substances of exciting a vinous fermentation in vegetables. Of what use the saliva is in that process. And the application of these experiments to the theory of di- gestion............................337 PAPER V. Experiments and remarks on the fermentation of vegeta- bles, by means of putrid animal substances, continued. An austere acid produced by such fermentations. The probability that most vegetables are fermentable; not ex- cepting the acrid, antiscorbutic or alkalescent class. Of the fermentation of milk. How far the aliment ferments in the stomach. Of the use of the saliva in alimentary fer- mentation. Of various causes of indigestion. Of the cause and cure of the heart-burn. And from what cause a sour- ness of the stomach proceeds................347 PAPER VI. Experiments upon substances, hastening, retarding, in- creasing and diminishing alimentary fermentation, with rejnarks upon their use in explaining the action of diges- tion, and showing how that may be occasionally assisted by acids, bitters, aromatics, wine, &x. What substances come nearest to the saliva in its digestive quality, and how these are to be varied according to ihe habit. Of the diffe- rence between the action of the bile and that of common bitters. Sea-salt,-in different quantities, either promotes, or retards alimentary fermentation; but the other septic always hasten that process. In what properties the testa- cea, lime-water, and the fixed alkaline salts agree, and dif- fer. What aliments are the easiest, and what the hardest of digestion......................... 357 PAPER VII. Experiments and remarks upon the putrefaction of blood, and other animal substances. Of the nature of the in- CONTENTS. xiv„ flammatory crust or the sizy part of the blood. Of the foecal acid. Uses drawn from observing the colours of cor- rupted blood. Of the nature of purulent matter. The resolution of the blood, the relaxation of the fibres, and the emission of air, are the consequences of putrefac- tion: hence several symptoms of putrid diseases ac- counted for. The marrow not soon corruptible. The blood may become sensibly putrid whilst the animal lives. The different effects of alkaline salts, and of putrid substances, upon the nerves. That there is properly but one species of the true scurvy; and that this arises from putrefaction. 365 An answer to the learned professor de Haen, and M. Guber, concerning some remarks made by them on the pre- ceding work...................,......382 OBSERVATIONS ON THE DISEASES OF THE ARMY. PART I. CHAPTER I. Of the Air and Diseases of the Low Countries. 1 HE river Lis rising in Artois, and joining the Scheld at Ghent, separates the high and dry part of Flanders from the low and wet. Between this line and the sea the country is flat, marshy and unhealthful, in- cluding several barrier towns belonging to the Dutch, the French, and the Austrians; of all which Furnus and Sluys are the most sickly. But the other part of Flanders being higher, is, as well as the rest of the Austrian Netherlands, a dry and healthful country. Great part of the United Provinces, with Dutch Brabant, from Grave downwards along the Maes, being likewise low and wet, is subject to the same distempers with the flat part of Flanders. But the air is worst in Zealand, as that province is not only low and watery, but surrounded with the oozy beaches of the eastern and western Scheld, and the most marshy parts of the country; so that almost every wind, ex- cept from the sea, adds to its native moist and unwhole- some exhalations. A 2 Of the Air and Diseases Part I. All this tract of the Netherlands being little higher than the level of the sea, or the rivers that pass through it, was once so much exposed to inundations from floods^ and high tides, that till dykes and drains were made, it was one large morass; and even now, after in- credible labour, the country is liable to be overflowed by extraordinary floods and other casual inlets of water. By the evaporation of this water, as well as by that of the numerous canals and ditches, in which various plants and insects die and rot, the atmosphere, during the latter part of summer and autumn, is filled with moisture, and with putrid and insanitary vapours. A second, but less obvious source of humidity, is from the water under ground, which in that country lies so near the surface, that a dry ditch is seldom seen; and as the soil is light, the moisture easily tran- spires, and in summer loads the air with vapour, even where no water is visible. This is the condition of most of Dutch Brabant, where the people are more or less subject to intermitting fevers, in proportion to the distance of this water from the surface; so that by looking into their wells, one may form a judgment of the comparative healthfulness of the several villages: for these wells being fed by the subterraneous water, with which they are on a level, and sinking in propor- tion to the droughts of summer, are a proof of the constant exhalation of this concealed moisture, through the pores of the earth, by the heat of the sun. (1) (1) The history of the intermitting fevers of Brabant would have been considered as an exception to the general remark, that bilious fevers are derived from putrid exhalations, had not the secret cause of them been pointed out by our author. A fever of great malignity appeared at Berbice, which, between the months of July 1804, and May 1805, carried off five hundred persons. The ground at this time was uncommonly dry, in consequence Chap. I. of the Low Countries. 3 In Zealand and upon the coast of Flanders and Bra- bant opposite to that province, is observed a peculiar kind of damp, rising at low water from a beach that is covered with slime and mud, and which is perhaps the more apt to corrupt on account of the mixture of the fresh with the salt water.*(2) In those parts the people are sickly; but at Ostend, which is situated upon the ocean, and where there are no marshy grounds very near, the inhabitants are in general healthy. Another cause of the humidity and corruption of the atmosphere, is an imperfect ventilation. There are no hills to direct the wind in streams upon the lower grounds; hence the air is apt to stagnate; and the more so by reason of the large plantations made for pleasure, inclosure, or fuel. The farms and smaller villages are crowded with trees, which not only confine but moisten the air by their transpiration. But in the towns, in which there is less of this kind of moisture, where the houses and pavement of the streets in a great measure prevent the rising of the damps, and where are con- tinual fires, the aquatic diseases are both milder and less frequent. To these causes of fevers in flat and marshy coun- tries, may be added the impurity of the water in com- mon use; which being either collected from rains, prer served in cisterns, or drawn from shallow wells, is in hot and dry seasons soon corrupted. This being the case, the general tendency to putrefaction must be in- of the absence of rain. It is most probable, this fever originated from subterraneous exhalation, such as takes place at Brabant. * Lancis. de Nox. Palud. Effluv. lib. i. p. i. c. v. (2) In every part of .the United States? the exhalations from a mixture of salt and fresh water, from marshy grounds, are at- tended with the same effects. 4 Of the Air and Diseases Part I. creased by the use of such water, as well as by the meats, which in a close, hot and moist air are easily tainted. (3) Several circumstances therefore in that country concur in summer, not. only to relax the solids, but to dispose the humours to putrefaction; and as the combination of heat and moisture is the great cause of the speedy corruption of animal substances, so it is observed in every place to produce fevers, and other distempers of a putrid kind, similar to those that occur in the low and marshy parts of the Netherlands. This is the nature of the country. But according to the various degrees of heat and moisture of the season, the epidemic diseases begin earlier or later, are of longer or shorter duration, and are attended with milder or more alarming symptoms. When the heats come on soon, and continue throughout autumn, not moderated by winds and rains, the season proves sickly, the distempers appear early and are dangerous. But when the summer is late, or tempered by frequent showers and winds, or if the autumnal colds begin early, the diseases are few, their symptoms mild, and their cure easy.*(4) And here it may be proper to distinguish between the moist and the rainy seasons; for in marshy grounds, intense and continued heats, even without rain, occa- (3) There can be no doubt of the predisposition to fevers be- ing increased by the use of impure water. This has often ap- peared in Philadelphia, before the general use of the water of the Schuylkill. The soil upon which the city is built, favours in many places the mixture of the unwholesome materials of many manufactories, and in some instances of the contents of privies, with pump water. * All this is agreeable to the register of the weather and dis- eases, kept for several years by Dr. Stocke physician at Middel- burg in Zealand. (4) This is equally true in the middle states of America. Chap. I. of the Low Countries. 5 sion the greatest moisture, by the exhalation which they raise and support in the atmosphere; whereas frequent showers, during the hot season, cool the air, check the rise of the vapours, dilute and refresh the corrupted water, and precipitate the putrid and noxi- ous effluvia.{5) But if heavy rains fall in the beginning of summer, and are followed by great and uninter- rupted heats, then the water collected by the rain, stagnating in the lower grounds and corrupting there, furnishes matter for more exhalation, and thereby renders the season more sickly, and the diseases more fatal. It ought also to be remarked, that the sickness never begins till the heats have continued long enough to give time for the putrefaction and evaporation of the water. The epidemics of this country may therefore be generally dated from the end of July, or the begin- ning of August, under the canicular heats; their sen- sible decline, about the first foiling of the leaf; and their end, when the frosts begin: the rest of the year is much less disposed to produce any disease.(6) Again, we are to observe, that though in the month of September the greatest heat of the season is past, yet the distempers continue, from the greater variations of heat and cold; for the days are still warm, but the nights are cold and damp, and often foggy; and it is by such interchanges that the perspiration is checked, (5) This remark has too generally escaped notice, hence we confound a moist, with a rainy season. A wind often brings a moisture with it, which discovers itself in producing more ob- vious effects upon metals, and papers, and even wood, than a heavy rain. It likewise disposes the miasmata which produce bilious fevers to be more general, and more active in their effects upon the body. (6) This remark applies to the bilious fevers of the middle slates of America. 6 Of the Air and Diseases Part I. and the more putrescent parts of the blood retained in the body, where they produce either a fever or a flux.(7) It is also to be remembered, that the sum- mers are hotter on the continent than in Britain; and that in the Netherlands the heats are more stifling than in hilly countries. The epidemic of autumn, and prevailing distemper of this and other marshy countries, is a fever of an intermitting nature, commonly of a tertian form, but of a bad kind; which, in the dampest places, and worst seasons, appears as a double tertian, a remitting, a con- tinued putrid, or even an ardent fever.* All which, however varying in their appearance, according to the difference of constitution and other circumstances, yet are of a similar nature. For though in the beginning of the epidemic, when the heats are greatest, the fevers assume an ardent and a remitting form, yet by the end of autumn they usually terminate in regular intermittents.(8) In Zealand, where the air is worst, this fever is called the gall sickness; and indeed both the redundance and depravation of the gall in this distemper are some- times so great, that it was natural to refer the im- mediate cause to the corruption and overflowing of that humour.(9) But whatever be the immediate cause, (7) The same thing has uniformly taken place in all those years, in which the bilious yellow fever has prevailed in Phila- delphia, since the year 1793. * An ardent fever is defined, part iii. ch. iv. § ii. (8) The author in this paragraph, justly decides in favour of the unity of the cause of the bilious fever, in all its grades and forms. (9) The bilious yellow fever, received the name of" gall sick- ness" from the Germans, when it first made its appearance in Philadelphia in 1793, probably from the similarity of the dis- Chap. I. of the Low Countries. 7 the disease may be continued, and the symptoms ag- - gravated, by an increased secretion and putrefaction of the bile, occasioned by the fever. There may be in this, as in other disorders, a first cause producing an effect, and that effect producing new symptoms. In proportion to the coolness of the season, to the height and dryness of the grounds, this feyer is milder, remits or intermits more freely, and recedes further from the nature of a continued putrid, or an ardent fever. But to judge from its worse state, must we not refer most of the symptoms to a septic cause? since these fevers are commonly attended with intense heat and drought, foulness of the tongue, bitterness in the mouth, desire of acids, nausea, aversion to animal food, offensive vomitings, oppression about the stomach; sometimes with livid spots, and the like indications of corrupted humours. And as, with such symptoms, the disease still puts on an intermitting or a remitting form, it should seem, as if even the more benign inter- mittents and remittents of the season were owing, in some degree, to the same cause. The cholera and the dysentery, though seldom epidemic, yet are the frequent diseases of the moister countries. They appear in the same season with the fevers, and seem to be particular determinations of the vitiated humours; to which, if the first passages give vent, a cholera, or a flux, ensues; but if they are re- tained, and carried into the blood, they produce an intermitting or a remitting fever. (10) Both fevers and fluxes are often accompanied with worms, which are not to be considered as the cause of charges from the gall bladder, with the fever described by our author. (10) The unity of cholera morbus, with remitting fever, K justly admitted by our author in this sentence. 8 Of the Air and Diseases Parti. either, but as a sign of the bad state of the bowels, of the corruption of the aliment, and of the weakness of the fibres of the intestines, owing to the heat, the moisture, and the putrid state of the air.(ll) These are the acute diseases of the marshy parts of the Netherlands. The chief chronical disorder is a scurvy, incident to those chiefly who live in a moist and corrupted air, and especially if they use salted meats: this, though of a milder nature, yet, as it agrees so nearly with the sea-scurvy, may be accounted the same disease. The exhalations of the canals and marshes, in hot weather, act like the steams of a foul and crowded ship; they corrupt the blood, and stop perspiration. The sea air is not the cause of the scurvy; for on board a ship, on the longest voyages, there are preservatives against the marine scurvy; and upon the sea coast, it is not in the dry and elevated parts, but in the flat and marshy, where the inhabitants suffer by that distemper.* In general, it is the higher ranks of people who are least liable to the diseases of the marshes. For such countries require dry houses, apartments raised above the ground, moderate exercise without labour in the sun, or in the evening damps, a just quantity of fer- mented liquors, and victuals of good nourishment. (11) The discharge of worms in these diseases, is the effect of the increased heat of the body, or of the want of aliment, or of the offensive nature of the medicines taken for the cure of the disease, or of all the three causes that have been mentioned. The worms are sometimes ejected by puking, as well as dis- charged from the lower bowels. They appear to exist inoffen- sively in many people, and perhapsj necessarily; hence we ob- serve them in fevers that had been preceded for months and even years, with good health. * The nature of the scurvy is more fully explained in the Appendix, Paper vii. under experiment xlviii. Chap. I. of the Low Countries. 9 Without such helps, not only strangers but the natives themselves are sickly, especially after hot and close summers. The hardiest constitutions are little more exempted than others, and therefore the British sol- diers have always been subject to these fevers and fluxes in the Netherlands; not indeed to the scurvy, as their stay in the moister parts of the country has never been long enough to contract that disease. Now, though in the marshy parts of Flanders and Holland, the summer and autumnal distempers are frequent and violent, yet there are few countries, how ■ ever dry, that are totally exempted from them. For the heats, if great, relax the solids and tend to corrupt the humours; under which circumstances, if the body be exposed to fogs and nocturnal damps, to any stop- page of perspiration, or receives improper food, the same kind of disorders, though less characterized and less frequent, will be incident to dry as well as to marshy countries. Hence, even in the driest camps, after great and continued heats, these summer and au- tumnal fevers and fluxes are more or less common: for besides the natural moisture of a tent, the men will either by duty or by misconduct often suffer from wet ground, wet clothes, nocturnal damps and colds. And the danger of their falling into these diseases is the greater, as the variations of heat and cold are more sensible and frequent in the field than in quarters. But a sudden stoppage of perspiration, coming upon relaxed fibres, and a putrescent state of the blood aris- ing from a constant exposition to the sun, if not timely remedied, will generally occasion a remitting or an in- termitting fever, a cholera, or a flux; so that these dis- tempers may be considered almost as incident to a camp as to a low and marshy country. B 10 Of the Garrison Diseases Part I. CHAPTER II. ) At Newcastle, an hospital was made for the sick that landed there; and theTiouses, taken for that pur- pose, receiving also those who fell ill in the army com- manded by Marshal Wade, were so much crowded, that the air was soo>> corrupted. The fever became so contagious, that most of the nurses and medical at- tendants were seized with it; insomuch that three of the apothecaries of that place, with four of their ap- prentices and two journeymen employed in the hospi- tal, died of it. Ligonier's and Price's regiments landed in Holy- (26) This fact deserves attention. A common remittent from koinomiasmatic exhalations, when it puts on a chronic form, as- sumes the nature of an idiomiasmatic fever, and becomes as certainly contagious as the hospital or jail-fever, from its usual cause. Chap. VI. Campaign in Britain. 37 island. Both had embarked in good health, after leav- ing their sick at Antwerp; but by the time they arriv- ed, they were in no better condition than those who came to Newcastle. Their distress was unforeseen and unprovided for. Of 97 men taken out of the ships, ill of the jail-fever, 40 died: and the people of the place receiving the infection, in a few weeks buried 50, the sixth part of the inhabitants of that island. The same fever was carried into Berwick by the soldiers who landed there; but the sick being fewer, the distemper did not spread. In the beginning of December, a body of troops consisting of 12 battalions and 3 regiments of cavalry, under the command of his royal highness the Duke of Cumberland, assembled at Litchfield. The Quakers had n-ade a present of flannel under-waistcoats to the soldiers, which was a seasonable provision for a winter-campaign.(27) The march was dry; the army encamped at Packington for three days only; at Stone, the men lay for one night upon their arms: but at all other times lying in houses, and having plenty of straw, fuel, and provisions, they were more healthy than could be expected in a campaign at that time of the year. Towards the end of December, most of the infantry were sent into quarters, whilst the cavalry and 1000 foot advanced to Carlisle. The few who fell ill on the march were left in the towns on the road to the care of the country surgeons, and were well treated. (27) The utility of flannel waistcoats worn next to the skin. was obvious in several instances in the revolutionary army of the United States. No one of the officers who were thus clad was in- disposed at the siege of Savannah, and no one of them escaped sickness who was not provided with this internal covering. The troops from Wyoming in Pennsylvania who wore flannel shirts next their skins, were rarely seen in a military hospital. 38 Of the Diseases of the Part I. But the troops having continued several days at Litchfield, a greater number of sick was left in that place than in any other. On this account the work- house was fitted up for an hospital, where too many being admitted, the air was corrupted, and the com- mon inflammatory fever changed into one of the jail kind, of which several died. (28) But at all other places where the soldiers were taken ill, and where there was no common hospital, this hospital or jail- fever was unknown. The autumnal remitting fever, disguised with many symptoms of cold, could be traced in the troops that came over from Flanders, till the frosts in December put an end to it. But the prevailing disorders were hard coughs, stitches, pleuritic and rheumatic pains, with a few fluxes, the usual consequences of the men being exposed to colds and rains on duty, or to wet feet on the march. There were some intermittents besides, but all with such a mixture of coughs and infarctions of the lungs, as made bleeding the most necessary remedy. In general, bleeding was so requi- site, that in every town through which the troops past, and where the sick were to be left behind, the physician of the army believed the surgeons and apo- thecaries of the place more than half instructed about the cure of the patients committed to them, when he had inculcated the necessity of large and repeated (28) Uncommon mortality took place among the soldiers of the American army in the spring of 1777, from the same cause, in the house of employment in Philadelphia, which was then made use of as a military hospital. All the surgeons who attended it sickened, and three of them died from the contagion of the fever, generated wholly by too many patients being crowded to- gether in the same wards. Chap. VI. Campaign in Britain. 39 bleedings; for the men were at this time well fed, and from taking cold, their blood was soon inflamed. Carlisle was invested in the beginning of January, and taken in a few days. The shortness of the time, the mildness of the weather for the season, and the good cover which the troops found near the works, made the sickness so inconsiderable, that only one man died there. And during the whole expedition this body did not lose above 40 men, though there had been in all between 600 and 700 ill. On the 10th of February, the army, under the com- mand of his Royal Highness the Duke, marched from Edinburgh to Perth. It consisted of 14 battalions of foot and 3 regiments of cavalry, which being too large a number to be all billeted in the private houses of that town, two battalions were quartered in the churches. Provisions were in plenty, but the quarters were generally cold; so that many fell ill of the com- mon inflammatory disorders of winter. The hard coughs, in particular, with pleurises and peripneumo- nies were most frequent. In the beginning of March, the troops advanced from Perth to Montrose, and from thence to Aberdeen, leaving 300 sick behind, who were well accommodated in the corporation halls, or in the private houses of those towns. Till the end of March, the whole infantry was quartered in Aberdeen; but afterwards 9 battalions were cantoned at Inverurie and Strathbogie: at this time, one battalion more landed at Aberdeen and joined the army. The weather being all this time sharp, with frost, snow, and easterly winds, the inflammatory diseases continued. But whilst the men suffered by cold beds, guards, or out-duties, or by their own mismanage- 40 Of the Diseases of the Parti. ment, the officers escaped, having warm quarters, and being less exposed to cold: only in the beginning of March, when the weather was very cold, a few were seized with the gout. (29) The sick were well lodged in the town-hospital and in other large houses, where having a free air, they were preserved from the hospital-fever. Including those at Inverurie and Strathbogie, about 400 were left behind when the army moved; but of this number a small proportion died. On the 23d of April, the army first encamped at Cullen; the next day, we passed the Spey; and on the 27th, after the battle of Culloden, we advanced to Inverness, and encamped on the south side of the town. At Strathbogie and Inverurie, the duty had been constant to guard against a surprize; one day's march had been long and rainy, the encampment had been early, and colds had been taken by wading the rivers: these circumstances concurred to occasion some sick- ness. Before we reached Inverness, about 70 men being taken ill, were left in towns by the way. After our arrival, the inflammatory diseases still increased, and were the more severe, as the climate was cold, and the camp exposed in an open country to piercing (29) We have here a striking instance of the debility which predisposes to the gout, attracting all the morbid excitement induced in the system by the exciting causes of other diseases. This law of the animal economy in its morbid state, was often exemplified during the prevalence of the yellow fever in Phila- delphia, in which the usual seats of arthritic gout sometimes saved the system from the violence of the fever, but it oftener combined its symptoms with it, and thereby increased its danger and mortalitv. Chap. VI. Campaign in Britain. 41 winds. The pleurisies and peripneumonies were par- ticularly alarming, as tending quickly to suppuration. At Inverness, two malt-barns received the wounded; in all 270. There were several who had cuts of the broadsword, till then uncommon wounds in our hos- pitals; but these were easily healed, as the openings were large in proportion to the depth, as they bled much at first, and as there were no contusions and eschars, as i > gunshot wounds, to obstruct a good digestion. Besides these barns, two well aired houses were prepared for the sick. The regimental surgeons had also orders to provide quarters for their men when they were taken ill, with the liberty of sending to the general hospital such a proportion of the worst cases as would not crowd it. By this dispersion of the sick, and the preservation of a pure air in the wards, it was hoped that any contagion might be moderated, if not prevented; though it was more than ever to be appre- hended, from the smallness of the town, the jails filled with prisoners, many of them wounded, the prospect of a long encampment and camp diseases, the crowds and filth of a place where the markets of an army were kept; and lastly, a morbid state of air from the measles and small-pox, which had prevailed in the town before the arrival of the army. These circumstances concurred to put us more upon our guard, and therefore greater care was taken to di- vide the sick, and to keep the wards clean. An order was likewise given to clean the jails every day, to re- move speedily the bodies of those who died in them; and to lessen the crowd, part of the prisoners were put on board some ships that were lying in the road, with a liberty of coining upon deck for the air. In this manner the month of May passed without F 42 Of the Diseases of the Part I. any infection; and the weather, for the climate, being unusually dry and warm, the inflammatory sickness in the camp had visibly declined, when an unforeseen accident rendered the infectious fever more general and fatal than had been at first apprehended. For about the end of that month, Houghton's regiment, which with three more had been sent as a reinforcement, landed at Nairn and joined the army. A few days after, twelve men of that corps were sent to the hos- pital with fevers, and were bled largely upon admis- ion. But next day, not observing the coughs, stitches, and rheumatic pains, the common symptoms of the fever at that time prevailing in the camp, and finding that the bleeding had sunk the pulse, and that some had an uncommon stupor, the physician immediately referred this fever to the contagious kind; concluding it had taken its rise from the confinement and bad air in the ships during the voyage; yet he did not under- stand how this battalion, and none of the rest, who sailed with it, should be so sickly. But upon further inquiry, he was informed, that this fever came directly by infection from the true jail- distemper, communicated in the following manner. Not long before, a French ship had been taken on the coast of England, on board of which some troops had been sent to assist the rebels, and amongst them a few English soldiers, who in Flanders had gone over to the enemy. These deserters, upon being taken, were thrown into jails in England, where they were kept till the opportunity offered of sending them by the transports, to be tried by a court-martial at Inverness. They were 36 in number, and having brought with them the jail-fever, gave it to this battalion with which they happened to be embarked. In three days after coming on shore, 6 of the Chap. VI. Campaign in Britain. 43 officers were seized with it, and the regiment, in the few days they were quartered at Nairn, left about 80 sick; in the ten following, while in camp at Inverness, they sent to the hospital about 120 ill of the same fever: and though the virulence of the distemper diminished afterwards in their march to Fort-Augustus, and from thence to Fort-William, yet that corps remained for some time sickly. The symptoms of the jail-fever were in every point so like those of the hospital-fever, that, as they were formerly only conjectured to be the same distemper, they were now proved to be so. Being thus introdu- ced, it soon spread, not only in the hospitals but among the inhabitants of the town; whilst the ordi- nary camp diseases, after the beginning of May, sen- sibly declined both in violence and number. The weather being all the month of May not only dry, but warm for the climate, the camp at this time was sub- ject to no other diseases than such as usually attend the beginning of a campaign: there were perhaps fewer agues, and more diarrhoeas. For a looseness accompanied most of the disorders, but was slight, and seemed not to be so much the effect of colds as of the river-water, which comes out of Loch-Ness, and has generally been accounted laxative to people unaccustomed to it. This looseness ceased without medicines, or soon yielded to astringents. On the 3d of June, 4 battalions were left at Inver- ness, and 9, with a regiment of horse, marched to Fort-Augustus, leaving in the hospital about 600 sick, besides the wounded. The new encampment was close by the fort at the end of Loch-Ness, in a valley surrounded by moun- tains, except where it opens upon the water. This lake is a large body of fresh water, twenty-four miles 44 Of the Diseases of the Part I. in length, somewhat more than a mile broad, lying between two parallel and straight ridges of mountains, and affording the prospect of a vast canal. It is curi- ous on account of its great depth, and its never freez- ing. The common soundings are from 116 to 120 fathoms, and in one place they run to 135. The water is soft and sweet, and readily bears soap; yet to some it proves laxative, and is generally diuretic. The peo- ple of the country recommend it for the scurvy; and indeed from these qualities, there is reason to believe it may be proper in some species of that distemper.* A great many small but heavy stones, of the marca- site kind, are found upon the beach; and it is not im- probable that the bottom may be covered with the like. But whether the water is preserved from freez- ing by some mineral principle, by its vast depth, or by some hot springs, has not been determined.f As * Viz. In scurfs, tetters, and lesser degrees of the lepra, which are commonly, but improperly, supposed to proceed from a scorbutic humour. See part in. ch. vii. t It is probable, that the not freezing of this lake is owing to its great depth; for Count Marsilli observes {hist. Phys. de la Mer) that the sea, from 10 to 120 fathoms, is of the same degree of heat from December to the beginning of April; and he con- jectures that it remains so for the rest of the year with little variation. Now, it is reasonable to believe, that the great depths in fresh water will be little more affected, than those of the sea, with the heat and coldness of the air; and therefore that the sur- face of Loch-Ness may be kept from freezing by the vast body of water underneath, of a degree of heat considerably greater than that of the freezing point. Another circumstance may con- cur: there is never any perfect calm on the lake, and the wind, blowing always from one end to the other, makes such an undu- lation as must much obstruct the freezing of the water. This account seems to be confirmed by an observation commonly made in the neighbourhood, which is, that when the water is taken out of the lake and kept without motion, it then freezes as soon a's any Other. Chap. VI. Campaign in Britain. 4£, it is stored with good fish, and is without any parti- cular taste, it should seem to be little, if at all, im- pregnated with any mineral. And besides being always cool, there is the less reason to suppose any hot springs at the bottom, as none of that kind are found any where else in the country. This lake is fed by several small rivers, which are all liable to have ice, and empties itself by the Ness, a large clear river, which after a course of six miles runs into the Frith of Murry at Inverness, and, like its source, was never known to freeze. Fort-Augustus has always been a healthy garrison; but Fort-William, which lies towards the west coast, at the distance of twenty-eight miles from the other, has ever been sickly, and in particular subject to agues and to the bloody-flux. On the west coast there are continual rains, and the fort stands in a narrow and moist valley surrounded by mountains; so that there is not only a greater fall of rain, but a slower evapora- tion in that part than in any other of the country. There being no straw at Fort-Augustus, the men were ordered to cut the heath for bedding; and it was observable, that such as were most careful in provid- ing themselves with a due quantity, and renewing it often, were least sickly. (30) The weather, for the last half of May and begin- ning of June, had been uncommonly dry and warm, but afterwards it grew cold and rainy. Upon this change, the dysentery began to be more frequent; but there being constant winds, which kept the ground tolera- (30) The same advantage in defending the body from the dampness of the earth, has often been experienced by travellers in new and uncultivated countries, by covering the ground upon which they slept with dry leaves or with broken twigs of d«cayp«i trees. 46 Of the Diseases of the Part I. bly dry, the increase of the distemper by contagion seemed to be thereby prevented. The flux, and other diseases of this encampment, being attended with sizy blood, and other marks of inflammation, we found that large and repeated bleed- ings were more necessary here than in a warmer cli- mate. But vomits were not so efficacious as they had been abroad, though at this time they were of more service than in the spring; as if, even in this latitude, some degree of corruption of the humours could be traced in summer. Besides the dysentery, there were fluxes of a milder kind among the soldiers, proceeding either from er- rors in diet, wet feet, or wet clothes, or accompany- ing fevers, when, from the want of sufficient cover- ing, the sick could not freely perspire. The inflammatory fevers, in proportion as the summer advanced, appeared with less violent symptoms, and unless from extraordinary expositions to cold, had not so often the form of a peripneumony, pleurisy, acute rheumatism, or the like, but were chiefly distinguish- able by the sizyness of the blood. The intermittents partook both of a putrid and inflam- matory nature, and therefore required both bleeding, and evacuations of the prima vice. But they were not numerous; as the constant winds prevented a stagnation of the air, and soon dried the ground after rain. In this camp, we had no other accommodation for the sick than a few huts in the neighbourhood; appre- hending therefore bad air, we sent as many as could be transported to Inverness, and by this precaution the hospital-fever was retarded but not prevented. For when the sick multiplied, these infirmary-huts were much crowded, the air was vitiated, the hospital- fever broke out and beeame fatal: when this was Chap. VI. Campaign in Britain. 43 joined to a common inflammatory disorder, a mixture of the two arose which produced some perplexing cases, from the indications of cure being so contradic- tory. In the middle of August, the camp broke up, leav- ing at Fort-Augustus between 300 and 400 sick, who were afterwards carried to Inverness. By this time the hospital-fever was frequent among the inhabitants of that town, but was milder than usual, from the cool- ness of the weather and the open situation of the place. From the middle of February, when the army crossed the Forth, to the end of the campaign, there had been in hospitals upwards of 2000 men, including the wounded; of which number near 300 died, and mostly of this contagious fever. / 48 Of the Diseases of the Part I. CHAPTER VII. A general account of the Diseases of the Campaign in Dutch Brabant, in the years 1746 and 1747. 1746.] T HIS was the state of the health of the troops in Britain. In the Low-Countries, from the beginning of this campaign, there had been only 3 battalions of foot and 9 squadrons British. In August, 4 battalions were sent from Scotland to join the army, which land- ing at Willemstad, and remaining some time in that low and marshy ground during the height of the sick- ly season, were soon afflicted with the remitting, and intermitting fevers of the country; so that before they moved, they were obliged to send many sick to the hospital at Oosterhout. The campaign abroad being attended with several fatiguing and wet marches in autumn, after a hot summer, and continuing late, proved sickly. For at breaking up, exclusive of the wounded from the bat- tle of Rocoux, about 1500 of our men were in hos- pitals, which made at that time nearly a fourth part of our whole number. But there was nothing uncom- mon in the diseases, being such as regularly occur in the course of every campaign*. 1747.] In the ensuing spring, 1747, the army took the field on the 23d of April, encamping first at Gilsen near Breda. Our troops consisted at first of 15 battal- ions of foot and 14 squadrons; and some time after, 7 battalions more arrived from England; but 4 of these * As the author attended the army in Scotland during this campaign, he could not give a more particular account of the diseases of the troops employed in the Low Countries. Chap. VII. Campaign in Dutch Brabant. 49 being employed in Zealand, and 3 in the lines of Ber- gen-op-Zoom, these 7 never joined the army. The first days of the encampment were cold, then the weather grew mild, and continued so till the be- ginning of June, when it became hot From taking the field, till towards the end of June, there was little rain, and all the camp grounds were dry. In the first six weeks, about 250 \v*ere sent into hospitals; a moderate number, considering how early the troops had left their quarters. The distempers took their usual course, that is, were mostly inflamma- tory. The battle of Laffeld was on the 2d of July, and from about that time till towards the end of the month, there fell a good deal of rain; which cooled the air. About 800 wounded were brought from the field into Maestricht, where, among other places, a large church was employed for an hospital, which not only held a considerable number, but by its spaciousness prevent- ed the jail-fever, though many lay in it, during the season, who were ill of fluxes and other putrid dis- eases. After the battle, we crossed the Maes and encamp- ed at Richolt. In a few days we moved to Richel, and afterwards to Argenteau, still keeping in the neigh- bourhood of Maestricht. The situation of these camps was dry and airy, and there being at first no extraor- dinary night duty, the diseases were few and but little inflammatory. The dysentery did not as yet appear, unless among the guards, which at Richolt encamped on a low ground then a little wet with the rains; but the cases were few and the symptoms mild. From the 20th of July till the 10th of September, the weather was sultry, and till the middle of August the nights were nearly as hot as the days. During all G 50 Of the Diseases of the Parti. that time the camp was healthy, but the wounded suffered; for the great heat either brought on slow fevers, or by relaxing the fibres, or rendering the humours acrid, sometimes kept the wounds from closing, and at other times disposed them, when heal- ed, to break out afresh. About the middle of August, though the days were still hot, yet the nights began to grow cool* and the dews to fall; and from these interchanges, to which the men in camp were most exposed, the dysentery took its rise; as it usually happens upon the perspiration being checked by cold and damps, after the blood has received some taint by continued heats. Above half the soldiers had the distemper more or less, and it was also more frequent among the officers than had been hitherto known. The contagion ran through the neighbouring villages, and was mortal among the peasants, who either wanted medicine altogether, or used what they had better been without. But Maestricht suffered little, though it had a constant intercourse with the camp; for this town standing on a large river, in an open country, is particularly well aired and clean. Notwithstanding the violence and frequency of the flux, few of our people died of it; for the sick were more dispersed, the hospitals were better aired than usual, and the regimental surgeons having been taught by experience, either cured the men in their field-hos- pital, or made some necessary evacuations before they sent them to the general hospital at Maestricht. In the beginning of October, we had much rain, and those who happened to be exposed to it were seized with the dysentery; but to the army in general, this rain was a favourable circumstance, as it cooled the Chap. VII. Campaign in Dutch Brabant. 51 air, and thereby the sooner put an end to the dis- ease. (31) About this time the autumnal remitting fever, which had first appeared about the end of August, was frequent, but with nothing new either in the symptoms or cure. In a few days after the rains, the army moved to- wards Breda; and as the weather began then to be cold, coughs, pleuritic stitches and rheumatic pains became common, either alone or joined to the remit- ting fever. On the 12th of November, all the British got into winter-quarters. Although there had been much sickness in the great camp during the campaign, there was little mor- tality; and at breaking up, considering how late in the season it was, the numbers sent from the main body into the hospital were moderate. But in Zealand, the sickness was great among the 4 battalions which had continued there since the begin- ning of the campaign. These men, partly in camp and partly in cantonments, lay in South Beveland and in the island of Walcheren, two districts of that pro- vince, and both in the field and in quarters were so very sickly, that at the height of the epidemic some of these corps had but 100 men fit for duty; which was less than the seventh part of a complete battalion. The Royal, in particular, at the end of the campaign, had but four men that never had been ill. Now, the nature of the air in Zealand, and its effects in produc- ing remitting, and intermitting fevers, and fluxes hav- (31) The rain in this case not only cooled, but washed the air, and destroyed the putrid matters which furnished the exhala- tions that produced the fever. 52 Of the Diseases of the Part I. ing been already shown, it will be sufficient to refer to that place for a general account of those distem- pers*; and for a more particular one, to the third part of this work.f I shall only observe here, that the epidemic fever, by reason of the great heats of the season, not only began more early in Zealand than usual, but was more severe, and fully as fatal to the natives as to us. Our officers there were also sick- ly; (32) though by more timely and greater care, their fevers were attended with less ardent and alarming symptoms than those among the common men. But commodore Mitchel's squadron, which lay all this time at anchor in the channel between South-Beve- land and the island of Walcheren, in both which places the distemper raged, was neither afflicted with the fever nor the flux, but amidst all that sickness enjoyed perfect health; a proof, that the moist and putrid air of the marshes was dissipated, or corrected, before it could reach them; and, that a situation open to the wind is one of the best preservatives against the diseases of a neighbouring low and marshy country. In proportion as the autumn grew cool, the fever abated of its ardour, and changed more easily into an intermittent, though irregular, and of a bad kind. The dysentery was never general, but not uncom- mon; and it was observable, that those who were seized with it, usually escaped the fever; or, if any man had both, it was alternately; so that when the flux began, his fever ceased, and when the former * Chap. i. f Ch. iv. § ii. (32) This remark was often verified in the revolutionary army of the United States. Officers recovered from the same grade of fever which proved fatal to soldiers, from their being better ac- commodated and attended in private houses. Chap. VII. Campaign in Dutch Brabant. 53 was stopped, the other returned: hence it appeared, that though the two distempers were of a different form, yet they proceeded from a like cause. (33) As to the three other battalions which were sent to Bergen-op-Zoom, they encamped in the lines of that place, and remained there during the campaign. The town itself stands on a small eminence, but the country around being in some parts marshy, the air, though not so moist as in Zealand, was less dry than about Maestricht. The sickness was in the same pro- portion, being, both in kind and violence, of a middle degree between what prevailed in these two places; that is, the fevers were as much below the rage of those in Zealand, as they were above the mildness of the remitting ones of the great camp. And if the dysentery was more frequent in the lines of Bergen- op-Zoom than in Zealand, the reason was, that the men in the lines doing more duty, were oftener expos- ed to rain, and by being in a fixed camp had the dis- temper more by contagion. At the end of the campaign, we had in hospitals, from the main body of the British troops and all de- tachments, exclusive of the wounded, above 4000, which was somewhat more than a fifth part of our whole number. But it is to be remarked, that the 4 Zealand battalions furnished near the half; so that when those corps went into winter-quarters, their sick, in proportion to their men fit for duty, were nearly as four to one. (33) The truth of this paragraph, can be attested by all the physicians who have seen the autumnal diseases of the last seventeen years in Philadelphia. Where fevers do not inter- mit after the coming on of cold weather, they often assume a chronic and inflammatory form with a diminution of bilious dis- charges. 54 Of the Diseases of the Part I. CHAPTER VIII. A general account of the Diseases of the Campaign in Dutch Brabant, in the year 1748. 1748.] j[ HIS campaign, which was the last, opened early. For upon the 8th of April, the army encamped at Hillenraet near Roermond with 15 battalions and 14 squadrons British. From the time of our taking the field till the beginning of May, the weather was cold, with some snow, high winds, and rain; but the duty was easy, and the ground naturally dry. On the 12th of May, the army left Hillenraet, and in a few days came to Nistleroy, where we encamped for the last time, leaving in the hospital at Cuick about 500, and those, as usual, mostly ill of inflammatory diseases. There was indeed an uncommon proportion of intermittents, which were not all recent cases, but for the most part relapses in such, as during the pre- ceding campaign had been seized with fevers in Zea- land, or in the lines of Bergen-op-Zoom. These relapses were also, from the coldness of the season, attended with some degree of inflammation. In this camp the British were augmented by 7 bat- talions from England. The weather was now warm, and the days often hot; but some seasonable rains, with thunder and lighting, seemed to prevent any sultry heats, and to purify the air of what was most insalutary. For it has been remarked of thunder, that as it is most frequent in close and marshy countries, it may have for a final cause, the cooling the air, and correcting the putres- cency of the vapours when the heats are most intern- Chap. VIII. Campaign in Dutch Brabant. 55 perate.* The ground was also dry, and the camp airy; so that the sickness was inconsiderable while the troops kept the field. From this good state of health, the 4 battalions, which had been in Zealand the last campaign, were an exception, as being subject to a relapse into irregular agues terminating in dropsies; so that their sick being numerous, and crowding the regimental infirmaries (which were in the cottages near the line) they soon bred the contagious fever, which they carried to the general hospital, then at Ravenstein. But there, the wards being spacious and well aired, though several of the sick were brought in with petechial spots, the infection spread no further. On the 9th of July, the camp broke up and the troops went into cantonments. The head-quarters were at Eyndhoven, with the 3 battalions of guards; the rest of the foot were quartered in the adjacent vil- lages, and the cavalry near Bois-le-duc. At this time, we had only about 1000 in all the hospitals, including such as had remained from the last winter and the preceding campaign; but in a few days after leaving the field, a fever appeared, which soon became as frequent as any that had hitherto afflicted the army. It was thus accounted for. This part of Brabant is nearly as flat as any of the Netherlands; the only inequalities being some sand- hills and insensible risings, which give the advantage of a few feet in height to some of the villages. The soil is a barren sand, and so little water is seen, that at first sight the country might seem to be dry and healthful. But the appearance is deceitful; for water is every where to be found at the depth of two or * Musschenbroek Instit. Phys. cap. xl. 56 Of the Diseases of the Part I. three feet; and in proportion to its distance from the surface, the inhabitants are free from diseases. The country bordering upon the lower part of the Maes is not only unheaithful on this account, but, by reason of floods from the smaller rivers, lies all the winter under water, and continues damp throughout the summer. The moisture and corruption of the air were much increased by the inundations (which had been made about the fortified towns since the com- mencement of the war) and sensibly became more noxious upon letting off part of the water, in the be- ginning of summer, after the preliminary articles of the peace were signed. For these grounds, which were once entirely covered, being now half drained and marshy, filled the air with moist and putrid exha- lations. The States of Holland being made sensible of this, by the sickness which raged at Breda and in the neighbouring villages, gave orders to let in the water again, and to keep it up till winter. (34) This sickness was much greater near Breda and Bois-le-duc than at Eyndhoven, which lay at a greater distance from the inundations and from other marshy grounds. The moisture therefore in most of the can- tonments arose principally from the subterraneous water which exhaled through the sand.* There were two villages near Eyndhoven, called Lind and Zelst, the one 10 and the other 14 feet above the surface of the water (an extraordinary height in that country) and it was observable, how much better the soldiers (34) This wise practice should be imitated in all countries where it is practicable, in order to destroy by liquidity, the bane- ful effect of moisture upon grounds covered with matters capa- ble of putrefaction. * Chap. i. p. 2. Chap. VIII. Cantonments in Dutch Brabant. 57 kept their health in both these places than in any other of the cantonments. At Eyndhoven, two battalions of the guards were quartered in the town, and the third in the peasants' houses in the country; all within the compass of a mile; yet, it was remarkable, that the battalion, which lay out of the town, had always three times more sick in their returns than either of the other two, though one of them had been sickly the year before in Zea- land. Now, the height of the ground being alike to all, the difference in point of health could be ascribed to nothing but to the greater moisture of,the cot- tages;* for in other respects these corps were equal, viz. as to diet, duty and exercise. A similar case oc- curred in the cantonment of a regiment of foot, whereof one company being quartered in houses that stood upon a heath, enjoyed a tolerable degree of health, while the rest, that dwelt in a wood, were very sickly. And, as a further proof how prejudicial it is to confine the air by plantations, in a moist coun- try, it was observable that the Dutch camp at Gilsen, bordering on our cantonments, but lying upon an open heath, preserved a good share of health while we were at the worst. (35) Thus far an account of our situation; we shall next see how much the weather concurred in forming this epidemic. The summer had been hitherto warm, but through- out July and August, whilst the sickness was greatest, the weather was fair, close and sultry. Near the inun- dations, the nocturnal fogs were thick and foetid. * Chap. i. p. 3. (35) Our author deserves our gratitude for his reiterated notices of the bad effects of moisture, in inducing camp diseases either as a remote, or an exciting cause. H 58 Of the Diseases of the Part I. The heats abated in the beginning of September, and the distempers in proportion; but till the 20th of Oc- tober, the season was never cold. About that time we had some days of rain and high winds, and to- wards the end of the month, some nights of hard frost; then the weather grew milder, and continued so while the troops remained in that country. The first and worst appearance of the epidemic was in the form of an ardent fever. The men were sud denly seized with a violent headach, and frequently with a delirium. If sensible, they complained also of grievous pains in their back and loins, of intense thirst, and a burning heat, with sickness and oppres- sion at the stomach, or with retchings, and vomiting of bile. Others had an evacuation of the bile by stool, with a tenesmus, and pains in the bowels. This fever generally remitted from the beginning, especially upon bleeding, and evacuations of the prima vice; but if these precautions were omitted, the disease went on in almost a continued form. Such was the tendency to putrefaction, that some had spots and blotches, and even mortifications, almost always fatal. (36) With these and such other symptoms, most of the cases were accompanied, during the first rage of the distemper, in the cantonments next to the inundations; but those who lay further from the water, and were only annoyed with the natural moisture of the coun- try and the heat of the season, had fewer and milder fevers. Thus, though the sickness was general, those who were near the marshes suffered by far the most, both (36) The fever described in this paragraph, accords with the second grade of bilious fever in the United States, commonly called the inflammatory bilious fever. Chap. VIII. Cantonments in Dutch Brabant. 59 in the number and violence of the symptoms. The Greys, cantoned at Vucht (a village within a league of Bois-le-duc, surrounded with meadows either then under water, or but lately drained) were the most sickly. For the first fortnight, they had no sick; but after continuing five weeks in that situation, they re- turned about 150; after two months, 260, which was above half the regiment; and at the end of the cam- paign, they had in all but 30 men who had never been ill. Rothes's and Rich's dragoons, who also lay near the inundation, were likewise very sickly. Johnson's regiment of foot at Nieuland, where the meadows had been floated all winter, and were but just drained, returned sometimes above half their number. And the Scotch Fuzileers at Dinther, though lying at a greater distance from the inundations, yet being quartered in a low and moist village, had above 300 ill at one time. But it was remarkable, that a regiment of dragoons, cantoned at Helvoirt (a vil- lage lying only half a league southwest of Vucht) were in a good measure exempted from the distress of their neighbours, having remitting and intermitting fevers of a more favourable kind, and in a much smaller number. Such was the advantage of that dis- tance from the marshes, of the wind blowing mostly from the dry grounds, and of a situation upon an open heath, somewhat higher than the rest. (37) Thus the troops had scarce been a month in the cantonments, when the returns of the whole were in- creased by 2000; and afterwards they rose much higher. For the sickness continued throughout Au- (37) The same diversity of grades appeared in the bilious fever of Philadelphia in the year 1803. It receded gradually in vio- lence from a yellow fever in Water-street, to a mild intermit- tant about Tenth and Eleventh-streets from the Delaware. 60 Of the Diseases of the Part I. gust, and only abated with the heats, in the middle of September. Then indeed the fevers began to de- crease in number as well as in violence; the remis- sions were also more free; so that insensibly, with the coolness of the weather, this raging fever dwindled into a regular intermittent, and intirely ceased upon the approach of winter. It was curious to observe how these agues declined proportionally to the wither- ing and fall of the leaf. At that time less moisture ascends, and by the shedding of the leaves, the vil- lages become more open and perflated, and of course more dry and healthful. Throughout all the cantonments, the officers were remarkably less sickly than the common men; an ad- vantage they owed to good beds, dry rooms, and a better diet.(38) The peasants were great sufferers, particularly those near Breda and Bois-le-duc; but in the towns, there was less sickness, and fewer in proportion died.* In general, the fever was most frequent among the poorer sort, who lay on ground-floors, fared ill, and wanted medicine: for without artificial evacuations, nature was able either to make no cures, or but slow and imper- fect ones.(39) This country had not known so much distress for a number of years; as two such causes had not concurred; I mean the inundations, with a hot and close summer and autumn. All this while the dysentery was little frequent; a circumstance which seems to require some attention, * This is accounted for, page 3. (38) This was equally true in the American army, during the revolutionary war. (39) This testimony against the power of nature, to cure acute diseases, is worthy of being placed as a motto in the title pages of all practical treatises upon medicine. Chap. VIII. Cantonments in Dutch Brabant. 61 when we consider the corruption of the humours, and their disposition to affect the intestines. It may be re- membered, that the flux was said to appear, when after great heats the perspiration was suddenly stopped by wet clothes, wet ground, or night-fogs and dewsj'tyit these, though common occurrences in a camp, are rare in quarters. Add, that the spreading of the dysentery is not owing so directly to the season, wet clothes, or other accidents, as to the contagion arising from the putrid excrements of those that happen to fall first ill of that distemper. Now, in the canton- ments, the men were not only less liable to have their clothes wet, but when any were actually taken ill from such a cause, they were so much dispersed, that their excrements could not spread the infection.(40) About the middle of November, the peace being concluded, the troops moved from their cantonments to Willemstad, and there embarked for England; but the wind being contrary, several of the ships lay above a month at anchor, and, after all, meeting with a tedious and stormy passage (during which the men kept mostly below deck) the air was corrupted, and produced the jail or hospital fever. This distemper was worst in the ships which trans- ported the sick from the general hospital (at Ooster- hout) to Ipswich; for, from some seeds of the disease already among them, but chiefly from the men being crowded in the hold, where they were confined for three weeks, most of them were seized with this fever, either on board or soon after they landed. It was ob- (40) The numerous facts related by our author, of the bad effects of the effluvia from human ordure, in inducing dysentery, whether from privies, or when exposed to the air, suggest an important lesson to the inhabitants of cities, to armies, and to private families, to guard against their morbid effects. 62 Of the Diseases, &c. Part I. servable, that the greatest number, and the worst cases, were in one of the ships, in which there hap- pened to lie two men with mortified limbs: this accident was not only the means of spreading the infection at sea, but also in the wards in which they lay after they were put ashore. (41) The hospital, prepared at Ipswich for the reception of the sick from Oosterhout only, was obliged to ad- mit several more from the other transports, which by stress of weather put in on that coast; so that in all, we had about 400, and most of them ill of this con- tagious fever. As so many were brought from the hospital-ships in the last extremity, the infection and mortality were at first considerable; but by the large- ness of the. wards, and by billeting in the town every man as soon as he recovered (thereby removing him from new contagion, and gaining more room for those who were still sick) the air was daily purified, and the distemper abated sooner than could have been ex- pected. The hospital then broke up, after it had con- tinued about three months in England. (41) This fact shows the necessity of separating persons with mortifications or even foul ulcers, from patients in other diseases in hospitals. OBSERVATIONS ON THE DISEASES OF THE ARMY. m PART II. IN the first part, I have given a general account of the more frequent diseases of the army, as they occur- red in the course of the war. But for particular de- scriptions, for the causes, preservatives, and cures, since they must have too much interrupted the series of facts that were proper to be presented in one view, I reserved them for different parts of this work, and shall therefore proceed in this, I. To divide the diseases into their several classes; II. To inquire into the causes, as far as they de- pend upon the air, diet, and other of the nonnaturals; III. To propose some means of prevention; IV. To compare the seasons, with regard to health and sickness, in order to compute what number of men may be relied on for service, at different times of the year. 64 Division of Diseases Part II. CHAPTER I. Of the Division of the Diseases most incident to an Army. 1 HE circumstances of soldiers, in time of war, are different from those of other people, in their being more exposed to t^e injuries of the weather, and always crowded together in camps, barracks, and hospitals: therefore the most general division of their distempers may be, into such as arise from the intem- perance of the weather, from bad air, and from infec- tion. Military diseases depending on the weather are re- ducible to two sorts, viz. to those of summer, and to those of winter; or, which is the same, to those of the tamp, and to those of garrisons. But as expositions to cold are unavoidable upon the first encampment, as also for some time before an army usually leaves the field, the winter-diseases, beginning about the end of autumn, do not intirely cease before the summer is well advanced; and on the other hand, as the heats of summer and the damps of autumn dispose the body to sickness, the camp-disorders do not cease intirely, but continue sometime after the troops return into winter-quarters: so that whenever we mention diseases as belonging to summer, or winter, to the camp, or garrison, they are to be understood as protracted in this manner. If the more general diseases of an army are not to be defined by the seasons, but by the state of the body that accompanies them, we may divide them into the inflammatory, and the bilious or putrid; the inflam- matory being the same with those of winter, and of Chap. I. incident to an Army. 65 the first encampment; and the bilious or putrid, the same with those of summer and autumn, and with part of those which are carried from the field into winter- quarters. The most frequent winter or inflammatory disorders are coughs, pleurisies, peripneumonies, acute rheum- atisms, inflammations of the brain, of the bowels, and of other parts, attended with a fever; lesser inflamma- tions, with little fever; and fevers of an inflammatory kind, where no part is so sensibly affected as to give a name to the disease. To the same class may also be referred such of the chronic ailments as arise from in- flammations; whereof the chief are old coughs, con- sumptions, and the rheumatism without fever. Now, all these distempers come originally from colds, which are supposed to occasion a suppression of perspiration, at a time when the fibres are most braced, the blood condensed, and the pores of the skin and lungs most contracted. But the diseases of summer and autumn are of a different nature. During these seasons, the fibres are relaxed, the fluids are more rarified, and more dis- posed to putrefaction; in which state, if any stoppage happen to perspiration, or to any of the excretions, designed to carry off the more volatile or putrid parts of the blood, a fever is raised, which, according to the seat of the humours, their acrimony, or the vent given them, appears in the form of a remitting, or intermit- ting fever, a cholera, or a dysentery. ]rlippocrates as, cribed distempers of this nature to a redundance of the bile; and most authors, to a corruption of that hu- mour; so that these summer and autumnal epidemics have been both early and generally called bilious.* * Putrid would be more proper; but I have retained the an- cient term bilious. I 66 Division of Diseases Part II. In effect, in all hot countries, and in camps, where men are so much exposed to the sun, the gall, if not more abundant, is at this time more disposed to cor- ruption than usual; and this circumstance, though probably not the first cause of the fever, yet seems to be the attendant of it, and of most of the summer and autumnal disorders, and concurs to make them worse. But when the same causes operate more slowly, or when the diseases last mentioned are but imperfectly cured, the viscera may be obstructed, or affected in such a manner as to give rise to various chronic com- plaints: so that considering not only the variety, but the frequency of disorders appearing at this time, we shall find the ancient maxim that held, " the summer and autumn to be the most sickly seasons,"* not only verified with respect to the warmer climates, but also to a camp, where men are so much exposed to heat and moisture, the great cause of putrid and contagious diseases. Having laid down this general difference between the summer and winter diseases, it may be proper to distinguish the parts of both these seasons, in order to see their influence upon the health, according as either is more or less advanced. When the winter begins, the men being thinly clad, get coughs, pleurisies, peripneumonies, and other inflammatory complaints, from colds. The same continue throughout the spring; but as the weather is then milder, the sickness is con- siderably less; so that this season is of all the year the most healthful to an army. But as soon as the troops take the field, though no earlier than the first, or mid- dle of May, by that change the winter distempers * Saluberrimum ver est; proxime deinde ab hoc, hyems; pe- riculosior aestas; autumnus longe periculosissimus. Cels. (ex Hipp. Aphor.) lib. ii. cap., i. Chap. I. incident to an Army. 67 recur, with several intermittents and fluxes of an in- flammatory kind. In the beginning of June, most of the inflammatory or winter diseases disappear, and what remain are of a milder nature: on this account, and because the autumnal epidemics have yet made no progress, this commonly proves the most healthful month of the campaign. July is likewise favourable, when the summer till that month has not been hot; and when the men have not lain in wet clothes, nor on wet ground; accidents that mostly give rise to the dysentery. But in temperate years, and upon dry ground, the diseases being milder, the remitting fevers, and fluxes begin only about the middle, or end of August, at the time when the days are still hot, but when the cool nights bring on dews and fogs. The dysentery declines with autumn, but the remitting fevers continue as long as the encampment, and never intirely cease till the frosts begin. Lastly, towards the end of the campaign, the cold weather renews many of the inflammatory symptoms; which, sometimes by themselves, but oftener combined with the remitting fever, make the first diseases of the winter. Although this be the common course, yet we may observe, that neither the inflammatory nor the autum- nal disorders are so strictly confined to their seasons, but that by various accidents they may sometimes be seen out of their place. In these matters, though there can be no precision, it is of use to know what ofienest occurs. In the year 1746, when the troops encamped in the north of Scotland, the inflammatory diseases, from the coldness of the climate, continued throughout summer; and the autumnal were either not seen, or were attended with so much inflamma- tion, that bleeding made the greatest part of the cure. It is to be further remarked, that as the two seasons 68 Division of Diseases Part II. run insensibly into one another, there will be a mixture and confusion of the two kinds of diseases. Thus, in the end of June, or beginning of July, whilst the in- flammatory symptoms recede, the bilious* are advanc- ing; so that whatever*causes bring on an illness, it may be either mildly inflammatory, or bilious, or have a mixture of the two. In the same manner, towards the decline of autumn, the bilious fevers begin to have additional coughs, stitches, rheumatic pains, or some other symptoms of the winter inflammations.(42) Lastly, it is to be observed, that the diseases of the winter, and those of the summer differ considerably as to their cure. Thus, in all winter or inflammatory disorders, the principal intentions are to diminish the force of the blood, to relax the fibres, and to make a revulsion from the parts inflamed; on which account the lancet and blisters are the chief remedies. But in summer and autumn, while the humours are in a putrescent state, and the solids too much relaxed, such medicines are wanted as clear the first passages, cor- rect, or expel the more corrupted parts of the fluids, and brace the fibres; hence vomits, purges, acids, and the bark are at that time of most service. Thus far we may class the diseases depending upon the seasons, or the weather. It remains to consider such as proceed from foul air, and from contagion. The most fatal are the dysentery and the hospital- * By this term bilious, I would all along mean nothing more than the remitting and intermitting fevers, and the dysentery, which are commonly attended with some corruption of the bile, without referring the first cause of these disorders to that hu- mour. (42) The same combination of the symptoms of winter diseases has often appeared with the autumnal bilious fever in Philadel- phia. Chap. I. incident to an Army. 69 fever, which, though arising from other causes, spread most by infection. As to the small-pox and measles, they were never general, and therefore I shall not rank them among the epidemics of an army. The lues Venerea and the itch are infections of a different kind. The first, not being more incident to soldiers than to other men, I shall likewise pass over; but the latter, being so frequent in camps, barracks and hospitals, may be reckoned one of the military diseases, and as such shall be treated of in its proper place. 70 Of the Causes of Diseases Part II. CHAPTER II. Of the Causes of Diseases most incident to an Army. IT appears from the first part, that the most frequent diseases of an army are owing either to the sensible changes in the air, and so have revolutions and periods like the seasons on which they depend; or to such ac- cidents as are almost unavoidable in a military life: It will therefore be proper to have a thorough knowledge of both these causes, in order to find out the means for lessening their influence. SECTION I. Of the Diseases occasioned by Heat, and by Cold. GREAT heats are never so much the immediate as the remoter cause of a general sickness, by relaxing the fibres and disposing the humours to putrefaction, whilst the men are the whole day exposed to the sun.* This was the case in every campaign, where it was observable, that no epidemic ever ensued upon the greatest heats till the perspiration was stopped by wet clothes, wet beds, dews or fogs, and then some bilious or putrid distemper was the consequence. In the * Soldiers in a camp suffer much from heat, by being con- stantly exposed to the sun, either without any shade at all, or only covered by a thin tent; and where the air being so much confined, the heat is often more insupportable than without, in the sun. This circumstance, joined to the damps of a camp, seems to be the cause that the summer and autumnal diseases of an army, even in a northern latitude, resemble so much the epidemics of southern countries, especially of those with a moist air. Chap. II. incident to an Army. 71 campaign of 1743, though the weather continued long hot, yet we had no great sickness till the men lay wet after the battle of Dettingen, when the dysentery im- mediately appeared.* Again, in the year 1747, the summer was likewise hot, but without any bad effects till towards the end of August, when the nights grow- ing cool, the dews and night-fogs, occasioning a stop- page of perspiration, brought on the same distemper.! And in the last campaign, though the heats were great, yet they were the cause of little sickness, till the troops were cantoned in the marshes; where a consi- derable degree of putrefaction and moisture being joined, the ardent, remitting, and intermitting fevers, and fluxes, were only the remoter effects of that heat.J Nevertheless we must allow, that the heats have been sometimes so great as to prove the more imme- diate cause of particular disorders; as when centinels were placed without cover, or frequent reliefs, in a scorching sun; or when the troops marched, or were exercised in the heat of the day; or when the men im- prudently lay down and fell asleep in the sun; all which circumstances were apt to bring on distempers vary- ing according to the season. In the beginning of sum- mer, such errors produce inflammatory fevers; and in the end of it, or in the beginning of autumn, a remit- ting fever, or a dysentery. But cold is oftener the more immediate cause of diseases, and is hurtful two ways; either when pure, or attended with moisture; of which, the last is the worst. The disorders arising from cold weather are all of the inflammatory kind, viz. coughs, pleurisies, peripneumonies, rheumatic pains, and the like; together with consumptions, which in the army are almost * Parti, chap. iii. t Part i. chap. vii. J Part i. chap. viii. 72 Of the Causes of Diseases Part II. always owing to neglected colds. The mildness of our winters, and the little duty of our troops in time of peace, make expositions to cold less frequent at home. But in war, it is to be remembered what a change a soldier undergoes, from warm beds, and the landlord's fireside in England, to cold barracks, scanty fuel, and sharp winters in the Netherlands; and all this without any addition of clothes. Now, how liable our men were to take cold, was seen in the account of the first gar- rison sickness, and of the diseases in the beginning and end of every campaign. SECTION II. Of Diseases occasioned by Moisture. MOISTURE is one of the most frequent causes of sickness. In the account of the diseases of the first winter, we observed how much the men suffered by damp barracks, especially at Bruges. The same remark was repeated in the next winter, and in the campaign of 1745. But soldiers are most liable to damps in their tents, where the air can never be thoroughly dry, by reason of a constant exhalation, and is often very moist from rains. These damps are common to all camps, and particularly to those in the lower and wetter parts of the Netherlands. But observe, that neither canals, nor even large inundations, where the water is deep, are nearly so dangerous, or exhale so much noxious vapours, as marshy grounds, or meadows that have been once floated and but lately drained; and that fields, though dry in appearance, may yet be moist by the transpiration of subterraneous water. (43) (43) This remark is confirmed by the facts mentioned in page 2d, and should never be overlooked in our researches into the remote causex>f bilious fevers. Chap. II. incident to an Army. 73 The moisture of a season is commonly estimated by the quantity of rain, whereas it depends more on the constancy of moist winds, whether they bring great rains or none at all;* but most of all upon close weather, especially in low and woody countries. In one case, rains will cause a dangerous moisture of the air, when the water stagnates and corrupts in low grounds after land-floods; but, otherwise, in the flat- test countries, if provided with drains, frequent sum- mer showers have a salutary effect, by tempering the heat, refreshing the stagnating water, and precipitating all putrid exhalations.f It is remarkable, that pestilen- tial diseases have frequently occurred in dry and hot summers;% and agreeably to this, I have observed that the most sickly seasons in the field have been attended with the greatest heat, and the least rain. (44) But it will be proper to add, that though rains in summer may be generally conducive to health, yet they have a different effect when the men are obliged to march in them, or lie upon the ground whilst it is wet with them. * I made no experiments on the dryness and moisture of dif- ferent winds in the Netherlands, but trusted to the accounts of others. Musschenbroek reckons all their northerly winds drying, but the east and northeast the dryest, and the west and south- west the moistest. Institut. Physic, cap. xliii. Compare Ld. Ba- con's JVat. Hist. cent. viii. exp. 786. t See part i. ch. i. %\A. Bacon's Nat. Hist. cent. iv. exp. 383. Diemerbr. de Pest. lib. i. cap. viii. and of this work, part iii. chap. iv. § iv. (44) The histories of pestilential fevers in all countries prove the truth of this remark. The air in these cases is generally stagnant, or without motion. It is possible the remote cause of the fever may exist in some new mode of aggregation, or in a change of the proportions of the component parts of the atmos- phere. Protracted calms at sea induce fevers, and probably from a similar cause. K 74 Of the Causes of Diseases Part II. Cold and moist air affecting the body, in winter produced many inflammatory disorders, and relapses into such distempers as the men had been first seized with in autumn; and this effect was still more manifest in the spring and beginning of summer, upon our first taking the field. But the consequences of moist air, after great heats of the weather and rarefaction of the blood, are more dangerous. For moisture relaxes the fibres, as well as stops perspiration; and when the humours are so much disposed to corruption by the heat^it is not surprising that the dysentery and the bilious fever, both putrid diseases, should ensue. The too great dryness of the air has likewise been mentioned by authors as the cause of epidemic dis- eases, but, I imagine, without reason. (45) For whether in winter-quarters, or in camps, the soldiers are gene- rally exposed to too much moisture: and as for the great droughts in summer, we are not thence to infer an over dryness of the air; for as long as there are vegetables to perspire, the air will scarce ever want humidity sufficient for health; so that perhaps it is in the sandy deserts only we can learn what distempers are incident to men breathing in too dry an atmos- phere. SECTION III. Of the Diseases arising from Putrid Air. I SHALL next consider the putrefaction of the air, which of all the causes of sickness is perhaps the most fatal and the least understood. This bad air so hurtful (45) A dry air, even when warm, is never unhealthy when it is changed by constant breezes. It is the « aer sine aura" of Hippocrates that produces disease. Chap. II. incident to an Army. 75 to an army may be divided into four kinds: the first, arising from the corrupted water of marshes; the second, from human excrements lying about the camp, in hot weather, when the dysentery is frequent; the third, from straw rotting in the tents; and the fourth kind, is that which is breathed in hospitals crowded with men ill of putrid distempers. Of this sort also, but in a lesser degree, is the air of full barracks not kept clean; and of transport-ships, when the men have little room, and are long on board. As to the first kind of bad air, it may be observed, that during the late war the whole army never hap- pened to encamp so near the marshes as to receive any sensible harm thereby; but detachments have suffered from this cause; as one did in Zealand, another in the lines of Bergen-op-Zoom;* and in the last year of the war, a great part of the troops, being cantoned near the inundation of Bois-le-duc, became extremely sickly.t Now, as the exhalations from marshes do not consist of watery vapours only, but also of putrid effluvia arising from innumerable vegetables and insects that die and rot in them, it is no wonder that the distempers incident to those who breathe such air, should be of so malignant a nature; and that bilious fevers and fluxes should be so frequent, infectious and dangerous in those countries.| Next to marshes, the worst encampments are on low grounds close beset with trees; for the air is then not only moist and hurtful in itself, but by stagnating becomes (from the filth of the camp) more susceptible of corruption. The second and third kinds of bad air are owing to the privies of a camp, and to rotten straw. Both these * Part i. ch. vii. t Part i. ch. viii. i Part i. ch. vii. and viii. 76 Of the Causes of Diseases Part II. are always offensive; but while the bloody flux pre- vails, as they contain the putrid excrements and efflu- via of the sick, they are then more infectious and dangerous. At certain seasons, the most healthy have some disposition to the dysentery, which might go easily off, were it not for those destructive steams, that work like a ferment and ripen the disease. The last source is from hospitals, barracks, trans- port-ships, and in a word from every crowded place; where the air is so pent up as not only to lose part of its vital principle by frequent respiration, but also to be subject to corruption, from the perspirable matter, which, as it is the most volatile part of the humours, it is also the most putrescent. Hence it is, that in pro- portion to the nastiness of such places, to the number of dysenteries, of foul sores, and especially of mortifi- cations, the contagious fever is frequent and mortal.* SECTION IV. Of Diseases arising from Errors in Diet. IRREGULARITIES in diet are commonly, but unjustly, supposed to have the greatest share in pro- ducing military diseases. Were this the case, the changes in the weather and seasons would not so sen- sibly affect the health of soldiers; the soberest and most regular corps would not be so sickly; different nations in the same camp, living variously, would not be afflicted with the same distempers: nor would there be such an inequality in the numbers of the sick in different years, were the greatest part of the diseases owing to any other causes, than what have been already * This subject of diseases arising from putrid air will be more fully treated in part iii. chap. vii. § 6. Chap. II. incident to an Army. 77 assigned. All therefore that can be admitted on this article, is, that there may be rules of diet established, by which, soldiers may be made somewhat less liable to sickness; but none can be proposed that will make any considerable exemption, if the weather, ground for encampment, and other circumstances do not con- cur to fayour them.* A soldier, in time of war, by the smallness of his pay, is secured against excess in eating, the most common error in diet. The danger is on the other hand; for when all are not obliged to eat in messes, some will be apt to spend their money upon strong liquors, and to squander away in one day their whole maintenance for a week. But when every man is ob- liged to contribute his share to a mess, we may be assured there can be no errors in diet of any conse- quence, whilst almost the whole pay is bestowed upon common food. For as to the abuse of spirits, and of fruit, and drinking bad water, however generally they have been accused, I will venture to affirm, that these three causes together never occasioned the tenth part of the sickness in the army, in any of our campaigns. First, as to spirits, it is to be observed, that even when drunk to excess, they tend more to weaken the constitution than to produce any of the common camp diseases; or if some actually fall ill after drink- ing, we may be assured that many more are preserv- ed by taking these liquors in moderation. Let us not confound the necessary use of spirits in a camp, with the vice of indulging them at home, but consider that soldiers are often to struggle with the extremes of * This article upon diet is only to be understood as relating to men in health, and not to the sick, who ought to be under the strictest regulations of diet, depending on the hospital, and not left to themselves, or to their nurses. 78 Of the Causes of Diseases Part II. heat and cold, with moist and bad air, long marches, wet clothes, and scanty provisions. Now, to enable them to undergo these hardships, it is proper that they should drink something stronger than water, or even than small-beer, which is commonly new and bad in camps, and even there too dear for their common use, And as to fruit, another supposed cause of the camp-fever and dysentery, it must be still more inno- cent; since these disorders being either of an inflam- matory, or a putrid nature, cannot be owing to what is acid. Were the dysentery the effect of eating too much fruit, should we not find it more common among children? Nor indeed are the soldiers over- fond of it; or if they were, have they means to pur- chase it. We can scarce imagine, when the daily pay, after stoppages, can but just procure a pound of good meat,that a man will bestow any part of it upon fruit. A few disorderly men may rob orchards; but the dysentery and camp-fevers are diseases to which the most regular are equally subject. It may be further remarked, that our worst flux began in the end of June*, when there was no other fruit but strawber- ries, which the soldiers never tasted; and that the same distemper intirely ceased about the first of Octo- ber, when the grapes were ripe, and so plentiful, in open vineyards, that the men eat what quantity they pleased. To these arguments, add the authority of Sydenham, who never mentions fruit as the cause of the dysenteries which were epidemic in London in his timef; and Degner, another diligent observer, and the author of a good treatise on this disease, expressly * Part i. ch. iii. f Op. § iv. cap. iii. Chap. II. incident to an Army. 79 says, that fruit had no share in producing that flux which raged some years ago at Nimeguen*. This point being then so plain, it may seem strange how a contrary opinion should have so generally gained belief, if it be not thus accounted for. The bloody flux usually coincides with that season in which fruit is in the greatest plenty; and as fruit is laxative and apt to gripe, it was natural to assign no other cause for the dysentery, than eating it immoderately; and the rather as the true cause was so little obvious. (46) But besides that strong people are little subject to a looseness from eating fruit, we may observe how dif- ferent the camp-dysentery is from a common diarrhaa, in symptoms, danger, and cure. It may be allowed, that eating too much fruit disposes the body to agues, especially in a moist country; but the remitting fever of the camp is not only of a more putrid nature, but is mostly attended with a sensible inflammation. But granting that fruit is capable of producing both fevers and fluxes, such as prevail in an army, yet in some hundreds which have been under my care for these distempers, as I never, upon the strictest in- quiry, could discover this*to be the cause, I must conclude that it so rarely takes place, that we may omit it in the account. At the same time it will be proper to observe, that whoever is actually under the cure of a flux, or but lately recovered, should be cautious with regard to fruit; for though the acid may * Hist. Dysent. cap. ii. § xxx. (46) Accidental coincidence is a fruitful source of error in medicine, as well as in other things. The arrival of two or three vessels from the West Indies in the month of August, and the appearance of the yellow fever, at the same time, have thus been combined, as cause and effect, in several of the seaports of the United States. They are as unrelated as the ripe summer fruits and dysentery in the cases mentioned by our author. 80 Of the Causes of Diseases Part II. be good for correcting the disposition to putrefaction, yet the bowels may be too much relaxed, and in too tender a state to bear any sharp, cold, or flatulent ali- ment. For the same reason, those who have lately recovered of intermittents must forbear eating it, or use it moderately. Nor should the most healthy person eat freely of it in close and marshy countries; because whatever is of so cooling and relaxing a nature, may too much weaken the habit, and thereby check per- spiration; by which means fruit, though in itself antiseptic, may yet lay the foundation of some putrid disease. Lastly, that many diseases are owing to bad water, has been an ancient and prevailing opinion; and even Hippocrates refers various disorders to this cause. But without entering into an inquiry about the justness of those notions, I shall only remark, that we are not to apply what is said of the water in the country where that author practised, to what our army commonly drank, which was plentiful and good. The only ex- ception worth notice was in Zealand, where the water being indeed less pure, it might concur with other causes in making the sickness more general in that province.* But in all other places our water was blameless, and particularly in the two seasons during which the bloody-flux was most epidemic, f To conclude, whoever will peruse the account of the several campaigns, will see such an uniformity in the rise and periods of the diseases, and that so much connected with the state of the air, as will be sufficient to convince him, that neither the abuse of spirits, nor of fruit, nor* drinking bad water, could have any con- siderable share in producing them. * Part i. chap. i. and vii. t Viz. In the camp at Hanau, in the year 1743; and at Maes- tricht, 1747. See part i. chap. iii. and vii. Chap. II. incident to an Army. 81 SECTION V. Of Diseases arising from excess of Rest, and Motion; of Sleep- ing, and Watching; and from want of Cleanliness. THE life of a foot-soldier is divided between the two extremes of labour and inactivity. Sometimes he is ready to sink under fatigue, when having his arms, accoutrements and knapsack to carry, he is obliged to make long marches, especially in hot or rainy weather; though the most frequent errors of men of that rank are on the side of rest. But the cavalry lead a more uniform life, having little fatigue by marches, and a constant but easy exercise, both in the field and in quarters, in the care of their horses; one reason for their better health. Sometimes the service requires such frequent re- turns of duty, that the men have not time to sleep; but such occurrences are rare, and generally when soldiers are off duty they sleep too much, which enervates the body, and renders it more subject to diseases. It is well known how necessary it is to keep up the perspiration; and also, how much the uncleanliness of the person will concur with other things to frustrate that intention. I have observed in the hospitals, that when men were brought in from the camp with fevers, nothing so much promoted a diaphoresis, as washing their feet and hands, and sometimes their whole body, with warm water and vinegar, and giving them clean linen. So that officers judge rightly with respect to the health of the men, as well as to their appearance, when they strictly require cleanness in their persons and clothes. L 82 Of the Causes of Diseases Part II. Under this head, it will be proper to mention the itch, the most general distemper among soldiers. The itch spreads so easily by the contact of the foul per- son, or of his clothes, that one in the same tent, mess, or barrack, will often communicate it to the rest: this circumstance, joined to the little attention which men of that rank have to cleanliness, makes it difficult to keep it under, though the cure of each individual be generally easy. Chap. III. incident to an Army. 83 CHAPTER III. Of the General Means of preventing Diseases in an Army. ALTHOUGH most of the causes of diseases above enumerated, viz. excess of heat and cold, too much moisture in the air, a putrid state of the air, great fa- tigue, wet clothes, and other circumstances which can > hardly be avoided, in times of actual service; yet as these only dispose men to sickness, and do not neces- sarily bring it on, it is incumbent on those who have the command, to make such provision as shall enable the soldier to withstand most of the hardships incident to a military life. It is almost needless to add, that the preservatives from diseases are not to depend on me- dicines, nor on any thing which a soldier shall have in his power to neglect; but upon such orders only, as, at the same time that they do not appear unreasonable to him, he shall be obliged to obey. We shall therefore inquire into the means of preser- vation from sickness in the order of its causes before- mentioned;* and as the chief depends on the air, we shall consider the proper precautions to be used in re- gard to it; and shall next propose some regulations about the diet, and other points that may fall under the direction of the officers. SECTION I. How to prevent Diseases arising from Heat, and Cold. TO palliate the effects of intemperate heat, com- manders have found it expedient so to direct the • Chap, ii 84 Means of preventing Part II. marches, that the men should come to their ground before the heat of the day; and to give orders, that none of them sleep out of their tents,(47) which in fixed encampments may be covered with boughs; to shade them from the sun.* It is a rule of some im- portance, to have the soldiers early out, and exercised before the cool of the morning is passed; for by that means not only the sultry heats are avoided, but the blood being cooled, and the fibres braced, the body will be better prepared to bear the heat of the day. Lastly, in hot weather, it will be found proper to shorten the centinel-duty, whenever the men are to stand without any shade. The preservatives from cold consist of clothes, bed- ding, and fuel. The experience which we have had of the use of under waistcoats, during the winter-cam- paign in Great-Britain,f should teach us to make the same provision for the whole army in any future war. None of the foreign soldiers are without this necessa- ry part of clothing; and indeed no man of the meanest condition abroad. Under-waistcoats would not only be useful in winter-quarters, but greatly so, on first taking the field, and towards the end of the campaign. How much likewise watch-coats were wanted for cen- tinel-duty, appeared from the general account of the diseases during the first winter. Another article, is the provision of strong shoes; for it is well known how easily men catch cold by wet feet. (47) For reasons given in a former note, it has been found that soldiers suffer less from sleeping in the open air, than in tents with the usual number of persons allotted to each of them. * Ne aridis, et sine opacitatearborum, campis aut collibus, ne sine tentoriis sestate, milites commorentur. Veget. de Re Milit lib. iii. cap. ii. t Part i. chap. vi. Chap. III. Diseases in an Army. 83 The second means of preservation mentioned was bedding, by which is understood, a blanket for every tent of the infantry. This provision, regarded by other nations, has generally been neglected both by the French and our army. We have observed of what ad- vantage the cloaks were to the cavalry; how useful therefore blankets must be in preserving the health of the foot, in the beginning and end of a campaign, is obvious. The only point to be considered, is, whether the expense, and impediment of so much baggage, will overbalance that advantage.* The last preservative was fuel. Of this our soldiers might require a greater supply, as being of military people the least inured to cold; but, as bearing some degree of it in winter quarters may tend to harden them against an early campaign, all that is requisite, is to give them enough for dressing their victuals, cor- recting the dampness of their barracks, and the rigour of a severe winter; and to trust rather to their warmer clothes, and exercises, than to fire, for preventing dis- eases arising from cold. We find these two articles of clothes and fuel particularly recommended to the care of commanding officers by Vegetius, an ancient who has given one of the fullest accounts of the Roman discipline.f SECTION II. How to prevent Diseases arising from Moisture. WHEN troops are to go into garrison, it is the bu- siness of the quarter-masters to examine every bar- * Since the first edition of this work, all our foot upon service have been provided with blankets. t Non lignorum patiantur (milites) inopiam, aut minor illis vestium suppetat copia; nee sanitati enim nee expeditioni ido- neus miles est, qui algere compellitur. De Re Milit. lib. iii. cap. ii. 86 Means of preventing Part II. rack offered by the magistrates of the place, and to refuse the ground-floors in houses, which either have been uninhabited, or have any signs of moisture. (48) We had an instance of the comparative dryness of upper stories,* which are always preferable, and par- ticularly in the Netherlands, where the houses are without drains. But if dry habitations cannot be pro- cured, the chief prevention of sickness from moisture will then depend upon fuel. In the field, the best security is by making trenches around the tents; by which means not only the natu- ral moisture of the ground is lessened, but the rain- water is intercepted and carried off without wetting the straw. This is necessary though the camp be to remain but for a few days in the same place. It is of much importance to allow soldiers plenty of straw, and to have it often renewed; for a dry and fresh bedding is not only comfortable, but a preserva- tive against diseases, and one reason of the better health which an army enjoys upon shifting ground, as the damp, or rotten straw is then left behind. But in fixed camps, when the straw is not often enough changed, it will be proper to have the tents opened every day for some hours, and once in a few days, to have all the straw taken out and well aired: without this precaution it will not only grow damp, but soon rot and prove unwholesome. (48) It is possible this remark may be correct in the damp countries, in which our author exercised his profession; but in the United States, ground floors were found to be uniformly more healthy, especially for hospitals, than any others. The fact is taken notice of by count Saxe in his reveries, and was men- tioned by col. Ward of the Massachussett's troops to Dr. Tilton, who applied it with great success to the construction of military hospitals for the revolutionary army of the United States. * Part i. chap. ii. Chap. III. Diseases in an Army. 87 It will also be necessary for the officers to air their tents daily; if this be not attended to, every thing will contract moisture. They are further to be advised, not to lay their matrass upon the grass, but to raise their bedding from the ground, or to use a bedstead. Oil-cloths spread on the ground of the tent, and kept dry, intercept much of the rising vapour. Towards the end of the season, when the weather grows cold and damp, it will be found useful to burn spirits in the evening, in order to warm and correct the air in the tent. But at no time are the officers to confine the air too much, not even in cold weather, and especially when sick; taking it for a rule, that there is more danger in lying in a moist atmosphere, loaded with their own effluvia, than with the curtains of the tent open, under a close marquise. Soldiers are unavoidably exposed to rain on marches and out-duty, and upon getting wet clothes are liable to fall sick, unless they be allowed to cut down wood to burn in the rear of the camp; an indulgence which I have observed to be necessary on those occasions. Where the grounds are equally dry, the camps are most healthful on the banks of large rivers; because in the hot season, those situations have the advantage of fresh air from the water, to carry off both the moist and putrid exhalations. And in cantonments, we are not only to seek villages removed from marshy grounds, but such as are least shut up with trees, and stand highest above the subterraneous water. In moist countries, towns are preferable to villages, and to single dwellings, for the reasons already given.* * Part i. chap. i. and viii. 88 Means of preventing Part II. SECTION III. How to prevent Diseases arising from Putrid Air. HAVING in the last chapter enumerated the com- mon sources of putrid air which affect an army, I shall now offer a few considerations upon the means for removing, or lessening each in particular. First, with regard to the putrid air of marshes and other stagnating water, the preservatives mentioned under the article of moist air are in a good measure applicable here. If the military operations shall oblige an army to continue long upon such ground, the best expedient will be to make frequent removes;* for by shifting, the straw will be changed, the men will have more exercise, and the old privies will be left behind, which in camps are particularly noxious on account of the frequency of the dysentery. As to cantonments in marshy grounds, if the troops must remain there in the dangerous season, it will be better to float the fields intirely, than to leave them half dry; for the shallower the water is, the more it will corrupt, and the evaporation will be grea- ter in proportion. (49) The regiment at Helvoirt, which lay off the inundation about half a league only, was an instance how near troops may be to marshes * Si autumnali sestivoque tempore diutius in iisdem locis mi- litum multitudo consistat, ex contagione aquarum et odoris ipsius ibeditate, vitiatis haustibus, et aere corrupto, perniciosissimus nascitur morbus, qui prohiberi aliter non potest nisi frequenti mutatione castrorum. Veget. de Re Milit. lib. iii. cap. ii. (49) The practice here recommended is wise, and should be followed in all cases where it is practicable. The certainty of its good effects is evinced by those low countries in the United States, which are sickly in ordinary seasons, being uncommonly healthy in those seasons in which the low or marshy grounds are covered by an unusual quantity of rain. Chap. III. Diseases in the Army. 89 without any remarkable sickness;* at least if the wind should carry the vapours a different way. Com- modore Mitchel's squadron in Zealand, and the healthy cantonments at Eyndhoven, Lind and Zelst, in a sickly neighbourhood, afford more instances of the same nature.f Nay it has been observed that in Rome, the sphere of noxious vapours, from the ad- jacent marshes, has extended to those streets only which lay nearest them, occasioning bad fevers there, whilst the rest of the city was healthful.:}: Thus, some- times a small remove from the marshes may prevent a general sickness. But if moving be inconsistent with the service, as it happened in the campaign 1747, when some battalions were sent to Zealand, and in the summer following, when our troops were canton- ed among the inundations, we must be content to lessen those evils which cannot wholly be avoided. As this is chiefly to be done by diet and exercise, we shall propose the rules when we come to treat of those articles. Whenever the dysentery begins to spread, the best means of preserving health are to leave the ground, with the privies, foul straw and other filth of the camp; which method is to be repeated once or twice more, or oftner, if consistent with the military opera- tions; or at least till the middle of September, when the danger is in a great measure at an end. The first campaign furnished a good argument for this practice; for the long continuance on the same ground, at Hanau, kept up the rage of the dysentery, which, * Part i. chap. viii. t Part i. chap. vii. and chap. viii. \ Lancis. de Nox. Palud. Effluv. lib. ii. epid. i. cap. iii*. M 90 Means of preventing Part II. upon decamping, suddenly abated.* And in the year 1745, the flux was milder than ever we have known it, which we impute not only to the coolness of the season, but also to the frequent removes, during the time that the army was most liable to the disease.f But if any circumstance should make it improper to change the ground when the dysentery begins to spread, other methods must be taken to check its progress. In order therefore to preserve a purity of air in the dysenteric season, let there be some slight penalty, but strictly inflicted, upon every man that shall ease himself any where about the camp, but in the privies. Further, from the middle of July, or upon the appear- ance of a spreading flux, let the privies be made deeper than usual, and once a day a thick layer of earth thrown into them, till the pits are full, which are then to be well covered, and supplied by others. It may also be proper to order the pits to be made either in the front or rear, as the reigning wind of the season may best carry off their effluvia from the camp. Moreover it will be necessary, frequently to change the straw, as not only apt to rot, but to retain the in- fectious steams of those who have fallen ill of the disease. But if fresh straw cannot be procured, more care must be taken in airing the tents and the old straw, as before directed. (50) Lastly, when the dysentery begins to be frequent, * Part i. chap. iii. f Part i. chap. v. (50) The whole of this paragraph merits attention. The im- portant advice contained in it will never produce its full effects upon the health of armies, until the commanders of them make a physician a part of their families, and regulate their encamp- ments, as well as every thing else connected with health, wholly by their advice. Chap. III. Diseases in the Army. 91 the sick should not be sent to one common hospital; at least not in such numbers as may vitiate the air so as not only to communicate the infection to others, but to keep it up among themselves. This rule will be much enforced by attending to the facts mentioned in the account of the German campaign,* compared with what passed in the summer 1747.f Therefore when the dysentery prevails, the regimental surgeons are to treat the slighter cases in the camp itself; and as many of the rest as they can conveniently attend or accommodate, in the regimental hospitals, which are then particularly to be chosen spacious and airy. Barns, (51) granaries, and the like places, wilj. allow the steams to disperse, without any danger from cold, as the weather is usually warm during that time. As to the general hospital, let it receive such only as the regimental hospitals cannot accommodate, and the sick that cannot be moved with the army. Without this dispersion of the men, the great hospi- tal may, in sickly times, be charged with some thou- sands, who cannot be well attended, but by a greater number of physicians than has hitherto been employ- ed by the public. .But were this objection removed, it would be still unadvisable to have but one general hospital, on account of the mortality that usually en- sues upon crowding together a number of putrid and contagious diseases. Having, in the account of almost every campaign, mentioned the frequency of the hospital-fever, I need not now urge the necessity of using precautions against it. Without entering upon a particular account * Part i. chap. iii. f Ibid. chap. vii. (51) The editor can testify from experience to the advantages of barns, for military summer hospitals, in preference to any other buildings. 92 Means of preventing Part "• of its nature, which is reserved for the third part of this work, I shall at present only propose the means where- by this disease may be kept either from appearing at all, or, at least, with so much contagion and danger. These means shall be considered under two heads; one, relating to the choice of hospitals; and the other, to the management of the air therein. In treating of the bloody-flux, the most airy and spacious houses, to be procured in the neighbourhood of the camp, were recommended, for the better re- covery of the sick, and for guarding against infection. Now the same means will also tend to prevent the hospital-fever, as the dysentery is so apt to breed it.* On these occasions, it is common to look out for close and warn) houses, and therefore to prefer a pea- sant's house to his barn; but experience has convinced us, that air more than warmth is requisite. For this reason, not only barns, stables, granaries and other out-houses, but, above all, churches make the best hospitals, from the beginning of June till October. Of this there was an instance in the campaign of 1747, when a large church at Maestricht was applied to that use; and where, notwithstanding .above 100 lay in it, with foul sores, fluxes, and other putrid diseases, for three months together (during the greatest part of which time the weather was hot) this fever never ap- * The putrid effluvia of the dysenteric feces are not only apt to propagate the dysentery, but likewise "to breed the jail or hos- pital-fever, with, or without bloody stools. (52) (52) This remark proves that the exhalations from dysenteric faeces do not act specifically in inducing dysentery, but that they are upon a footing with exhalations from other putrid matters. It is probable the original fever thus produced by them was the bilious fever, and that the jail or hospital-fever was combined with it. Chap. III. Diseases in the Army. 93 peared.* (53) Therefore we may lay it down for a maxim, that the more fresh air we let into hospitals, the less danger there will be of breeding the conta- gious distemper. Another point to be observed in a fixed camp, is to have the regimental hospitals scattered, and not crowded into one village. And for the same reason, if it should be necessary for the general hospital to admit a great number at a time (which must fre- quently be the case, upon the motion of an army after a long encampment) it will be proper to have the sick dispersed into two or three villages, rather than kept in one; though a narrower compass may be more for the economy of the hospital, and the easier attendance on the men. The want of pure and wholesome air cannot be compensated by diet or medicine: hence appears the expediency of carrying, at all times, as many of the sick along with their regiments as can easily be transported. It may be proper to make the following distinction. In the first part of a campaign, when inflammatory distempers prevail, those who are taken ill are to be left behind; as such cases least admit of motion, and at the same time are not infectious. But those who fall ill from the end of summer to the decline of autumn, as having diseases of a putrid kind, but which bear motion, and generally mend upon a change of air, are rather to be carried with their regiments * Part i. chap. vii. (53) Churches, in common with barns, owe their advantages for military hospitals to the height of their cielings. The latter are cooler than churches, from having no windows in them, and currents of air are conveyed through them more directly and more easily to the bunks of the sick. 94 Means of preventing Part II. and dispersed, than collected into one place, to breed and propagate the infection. (54) As these regimental hospitals are of such conse- quence, it would be proper to supply them with blankets and medicines from the public stores, with an allowance also for nurses and other necessaries. Nor is this care requisite in the field only, but also in winter-quarters; as there will generally be more. sick. on the camp breaking up, than can be well attended by the physicians upon the establishment. In the campaign 1743, about 3000 were left in the general hospitals; and in the year 1747, upon going into winter-quarters, the returns of the sick amounted to 4000. In the course of the former war one physician has had the charge of 700 at a time; in which case, though the hospital might be said to have a physician, it could reap little advantage from his attendance. But suppose that a sufficient number of physicians were employed, yet the crowds, by corrupting the air, would render most of their care ineffectual. This may easily be conceived from what has really hap- pened; for passing over the pestilential mortality in the hospitals of the first campaign, and taking the rest since at a medium, there has been commonly such a degree of bad air in them, as to render the practice but little successful; insomuch, that upon the most favourable computation, I have found that 1 in 10 died of all that were admitted. Besides the better chance for good air, there is a further advantage attending the (54) This remark should be qualified. It is true, soldiers ill with the hospital-fever are generally benefitted by being gently removed in wagons in warm weather, but great mortality uni- formly followed the removal of such patients in cool or cold weather in the same vehicles, in the revolutionary army of the United States. Chap. III. Diseases in an Army.' 95 regimental infirmaries, which is, that the several sur- geons are best acquainted with the constitution and disposition of their patients, as well as with all the circumstances of their distempers. And as the physi- cian is still to be resorted to in any case of difficulty, or is to make regular visits, there can be no objection made to this method of treating the sick; which, as often as it has been tried, I have observed to have been more successful than that in the large and gene- ral hospitals. To enable the surgeons the better to do their duty to their own regiments, it will be necessary, in time of war, to give each an additional mate; as it must often happen, that the sick will be too numerous to be properly attended by themselves and one mate only: besides, in sickly times, one of them may fall ill, or possibly both. We shall next consider the general hospitals, which are of two kinds, viz. the flying hospital, at- tending the camp at some convenient distance, and the stationary hospital, which is fixed to a place. In the choice of both, those who have the direction should take care to provide large and airy wards, remember- ing that warmth is not wanting in summer, and that in winter it is chiefly to be procured by fires. It would also be proper to have those places in towns rather than in villages, as in the former we are likely to find larger rooms, besides other conveniencies. As to the disposition of hospitals, with regard to preserving the purity of the air, the best rule is, to ad- mit so few patients into each ward, that any one un- acquainted with the danger of bad air, might imagine there was room to take in double or triple the num- ber. (55) It will also be found a good expedient, when (5 5) This is an excellent rule, and should be carefully'attend- cd to by physicians who have the charge of military hospitals. The 96 Means of preventing Part II. the cielings are low, to remove some part of them, and to open the garret-story to the tiles. It is surprising in how few days the air will be corrupted in close and crowded wards; and what makes it hard to remedy the evil, is the difficulty of convincing either the nurses, or the sick themselves, of the necessity of opening the doors or windows at any time for air. I have generally found those rooms the most healthful, where, by broken windows and other wants of repaid the air could not be excluded. It is therefore probable, that when fire-places are wanting, a preservative would be found in the se of the ventilators of my worthy friend Dr. Hales, where- of some might be made for the hospitals small enough to be easily carried about. By such an invention we might hope for a considerable purification of the air in every ward; and the working them might be a good exercise for the convalescents. As these ventilators must be of a smaller size, for the convenience of car- riage, the same might be likewise used on board the transport ships.* The neglect of it deprived the United States of 6everal thousand soldiers during the revolutionary war. * I was favoured with the following paper of directions from the celebrated inventor, whom I consulted on this occasion, but his method was never put in practice. " Some considerations about means to draw the foul air out of '* the sick-rooms of occasional army-hospitals, in private houses " in towns. " As it seems improper to draw the air out of these rooms, by " small moveable ventilators placed in the passages between " the rooms, because the foul air that is drawn out will soon re- " turn from those passages into the sick rooms; so the most " likely means that occur to me for doing it, is to have a board " screwed fast, and not nailed, because of the noise, to the upper " part of a window on the outside of each room. This board is to " have a round hole in it, and also the glass opposite to it, of a Chap. III. Diseases in an Army. 97 In winter-hospitals, chimneys only should be used, and stoves never; for though the latter may warm a large ward better and at less expense, yet by scarce making any draught of air, they will be apt to promote its corruption; whereas a fire in a chimney acts like a constant ventilator.(56) " size to receive a trunk of a sufficient length to reach from the " window to a small ventilator on the ground through which the " foul air is to be drawn out of each room, the fresh air entering " in at the door: this is to be repeated as often in a day as shall " bethought proper. " It will be requisite to have the holes both in the board fixed " over the windows, and in the side of the ventilator, made round, " to receive the corresponding round orifices of the trunk; by " which means the same trunk may serve for windows of differ- " ent heights, by being placed more or less obliquely, thus: viz. •l x, the end at the window; z, the end fixed to the ventilator. " There may be trunks of different lengths, and made to join " into each other, for the higher windows. As these trunks are " to be made of thin fir-boards, about five inches broad, they " need not be nailed together in the form of a trunk till they " are to be used, and may therefore lie in a small compass. " A very small ventilator will be sufficient for this purpose; " about five feet long, and twenty inches wide and deep, such as " described in my ventilator-book, fig. 6." (56) A strict regard ought to be had to this direction. Dr. Tilton combined warmth and ventilation very happily in the log N 98 Means of preventing Part II. If ventilators are used, other precautions will be the less necessary; but if they are not, we must have re- course to such other means as may help to purify the air. Among these, the most common is burning of frankincense, the wood or berries of juniper, or some other resinous or antiseptic vegetable. The steams of vinegar have been recommended on these occasions, and probably would best answer the purpose; but being not so commodiously diffused as other things that burn, they have hitherto been less tried. The burning of sulphur, or gunpowder, is also men- tioned by authors as proper in such cases; and from the acidity of their steams they seem likely to suc- ceed. SECTION IV. How to prevent Diseases arising from improper Diet. WE are to observe, that no orders will be able to restrain soldiers from eating and drinking what they like, if they have money to purchase it. Therefore a fundamental rule, and indeed almost the only needful, is to oblige the men to eat in messes; by which means, we may be assured the best part of their pay will be bestowed on wholesome food, in as much as what is agreeable to the majority has the best chance for an- military hospitals, constructed by him in Morris county, New Jersey, by making the fires in a hollow, in the centre of the hospitals, and leaving an opening in the roof in a perpendicular direction to them, through which the smoke was discharged. The bunks surrounded the fireplace. After kindling the fire, the patients suffered no inconvenience from the smoke. Their short and transient sufferings from this cause, were overbalanced by its salutary effects, for it has been proved by Dr. Clark in his treatise upon the diseases incident to long sea-voyages that smoke, checks the propagation of fever from morbid exhalations. Chap. III. Diseases in an Army. 9l> swering that character. And it will be sufficient to leave the choice to their taste and experience, without searching too scrupulously into the nature of particu- lar aliments, which even with more delicate people seldom offend so much in kind as in quantity. The greatest impediments to messing are the wives and children, who must often be maintained on the pay of the men: in such circumstances, it is not improper food, but the want of it that may endanger a soldier's health. This method being established, it only re- mains to take care that the men be supplied with good bread; and that the markets be so regulated that the traders have encouragement to come to the camp, and the messes have good provisions at a moderate price, vegetables in particular, which during the hot weather ought to make the greatest part of their diet. Though the pay of a British soldier is better than that of other troops abroad, yet his economy is less; so that after giving in his proportion to the mess, there is little danger of his having wherewithal to make a debauch. How far some quantity of strong liquors is useful, has been already shown.* As the heats of summer tend to produce diseases in autumn, by disposing the humours to corruption, it were to be wished that during the hot season, the diet were so ordered that this tendency might in some measure be corrected. It may deserve our notice, that the Romans considered vinegar as one of the most necessary provisions of an army.f Now, whether this was only used by way of seasoning to their victuals, or mixed with water, and drunk whilst they were hot * Part ii. chap. ii. § 4. t Hyeme lignorum et pabuli, aestate aquarum vitanda est diffi- cultas. F.-umenti vero, vini, aceti, nee non etiam salis omni tempore vitanda necessitas. Veget. de Re Milii. lib. iii. cap. iii. 100 Means of preventing Part II. or feverish, it must have had a good effect in correct- ing the too great putrescency of the blood during the summer. Vinegar-whey, already known in the hos- pital, is a cooling medicine in inflammatory fevers, and was liked by the patients. But the surest way of mak- ing soldiers take vinegar, or any other acid by way of preservative, is by mixing it with such a proportion of spirits as may be thought a proper quantity for each man; and especially when troops are sent into Zealand, or the more marshy parts of Brabant or Flanders, during the sickly season in those countries. Pork has sometimes been forbidden in camps, be- ing considered as unwholesome. Sanctorius observes that it checks perspiration; and as it corrupts sooner than beef or mutton, it may be presumed to afford a less proper nourishment than either, when there is danger from putrefaction. It is also believed, that in camps the meat in general is too little bled, and thereby becoming sooner tainted, cooperates with the other causes in breeding putrid diseases.(57) In establishing the messes some regulations might be made with regard to an allowance of spirits, whether by stoppages on the pay or otherwise. This is already practised in the navy, and probably for the same reason for which it might sometimes be proper here; since, in ships, men are also liable to distempers arising from moist and corrupted air. The officers, whether in camp, or in cantonments, in a moist country, are exposed, though in a less de- gree than the common men, to the same diseases of the season and climate. Their chief rule in diet, in sickly times, is to eat moderately avoiding surfeits (57) This remark applies chiefly to fresh pork. Salted pork was found to be a preservative of the health of the revolutionary army of the United States. Chap. III. Diseases in an Army. 101 and indigestion.* Wine is necessary; but excess in every thing is at this time dangerous. I shall conclude with that prudent rule of Celsus for preserving men against distempers arising from a moist and corrupted state of the air: Turn vitare oportet fatigationem, cru- ditatem,frigus, calorem, libidinem.\ SECTION V. How to prevent Diseases arising from Errors in Exercise. THE greatest fatigue which a soldier undergoes, is in making long marches, especially in hot or rainy weather. When the service requires it, such hardships must be endured; but they will be attended with less sickness, if care be taken to supply good provisions and plenty of dry straw. At other times, when despatch is not necessary, short marches before the heat of the day, with proper halts, are so far from harassing the troops, that nothing can be more conducive to the preservation of their health. In fixed camps, as there is always more sickness from inactivity than from fatigue, it would not be amiss to make proper regulations about the exercise at such times; and the rather, as our soldiers left to themselves are naturally too indolent to use what is fit for them. The exercise of a soldier may be considered under three heads; the first relates to his duty; the second, to his living more commodiously^ and the third, to his diversions. The first, consisting chiefly in the exercise of his arms, will be no less the means of preserving his health * Si qua intemperantia subest, tutior est in potione quam in osca. Celsus de Med. lib. i. cap. ii. t Lib. i. cap. x. 102 Means of preventing, fcfc. Part II. than of making him expert in his duty;* and frequent returns of this, early and before the sun grows hot, will be more advantageous than repeating it seldom, and staying too long out at a time: for a camp afford- ing little convenience for refreshment, all unnecessary fatigue is to be avoided. As to the second article, cutting boughs for shading their tents, making trenches around them for carrying off the water, airing the straw, cleaning their clothes and accoutrements, and assisting in the business of the mess, are all things which, as they must be strictly executed by orders, ought to be no disagreeable ex- ercise to the men for some part of the day. Lastly, as to diversions, since nothing of that sort can be enforced by orders, the men must be encou- raged to them, either by the example of their officers, or by small premiums to those who shall excel in any kind of sports, which shall be judged most proper for answering this purpose. But herein some caution is necessary with regard to excess; because our common people generally observe no medium between their love of ease, and pursuing the most violent exercise. And however necessary motion may be to troops in fixed camps, we are to beware, on the other hand, of giving them too much fatigue, especially in hot weather, and in times of sickness; and above all, of exposing them to wet clothes, which, as has been fully set forth, is one of the most frequent causes of camp-diseases. * Rei militaris periti, plus quotidiana armorum exercitia ad sanitatem militum putaverunt prodesse, quam medicos—ex quo intelligitur quanto studiosius armorum artem docendus sit sem- per exercitus, cum ei laboris consuetudo et in castris sanitatem, et in confiictu possit praestare victoriam. Veget. de Re Milit. lib. iii. cap. ii. Chap. IV. The Seasons compared, Sfc. 103 CHAPTER IV. The Seasons compared, with regard to the Health of an Army. IN the beginning of every campaign we are to ex- pect for the first month at least, that the returns will be considerably higher than if the men had remained in quarters. The earliest encampment began on the 8th of April,* and produced such a number of sick, that in a month's time the returns amounted to Tfth part of the whole. In the year 1745, the campaign was opened on the 25th of April; and in 1747, on the 23d of the same month; both in the Low-Countries: but in the year 1746, the troops encamped on the 23d of April, in the north of Scotland, which considering the latitude,.may be reckoned of all, the earliest campaign during the war. And from all these instances there is reason to believe, that the first proportion mentioned will generally hold, when the army takes the field in Flanders, in the first or second week of April. But if the troops are to continue in quarters till the middle of May, the sickness of the first month will be considerably less, though perhaps not so much as might be expected. Thus, in the first campaign, the British encamping on the 17th of May,f had in the hospital, after the first month, about rs part of the whole num- ber; a proportion, however, which we cannot offer as a general one, because the men had then made a long march, and it was their first campaign. The next year, when the troops marched out on the 13th of May, af * Part i. chap. viii. t Part i. chap, iii. 104 The Seasons compared, Part II. ter a month's encampment, there was found in the hos- pitals about ^th part only; but as the weather was then mild, and other circumstances favourable, the proportion may perhaps be reduced in common years to oreth: so that, cceteris paribus, the number of the sick will be after the first month about ^th greater when the army encamps in the middle of April, than when it takes the field a month later. After the first fortnight or three weeks of the en- campment, the sickness daily decreases; as the most infirm are already in the hospital, the rest more har- dened, and as the weather is growing daily warmer. This healthy state continues throughout the summer,* unless by some extraordinary exposition to rain, the men get wet clothes, or lie wet; in which case, in pro- portion to the preceding heats, the dysentery will be more or less frequent. The great sickness commonly begins about the middle or end of August, whilst the days are still hot, but the nights cool and damp, with fogs and dews; then, if not sooner, the dysentery prevails, and though its violence abates by the beginning of October, yet the remitting fever gaining ground, continues through- out the rest of the campaign, and never entirely ceases, even in quarters, till the frosts begin. The sickness in the beginning of the campaign is so uniform, that the number may be nearly predicted; but for the rest of the season, as the diseases are then of a contagious nature, and depend so much upon the heats of the summer, we cannot foresee how many may fall sick from the beginning to the end of autumn. At the end of the campaign in Germany, the number in the hospitals was to the men in health as 3 to 13. * That is, until the middle of August Chap. IV. with regard to Health. 105 In 1747, when the troops left the field, the sick made about £th part of the whole number: but if we consi- der by itself the detachment sent that year into Zea- land, this proportion was just inverted; for the men in health were to the diseased, only as 1 to 4. Upon closing the campaign in 1744, though half of the army were new men, we had but one in 17 sick; and in the. year following, which was remarkable for health, there was not above 1 in 26 ill: but in both these years the troops returned into winter-quarters sooner than usual. I have observed, that the last fortnight of a cam- paign, if continued till the beginning of November, is attended with more sickness than the first two months of the encampment. If campaigns are therefore to last six months, it imports much as to health, whether they begin early, or late. For though it may be thought safer for troops to delay encamping till the beginning of May, and stay out till the end of October, yet experience shows it is better to go out a fortnight sooner, in order to return so much the earlier into winter-quarters. (58) We have already observed, that the remitting fever does not always terminate with the campaign, but continues in quarters till the frosts begin; and that there are no other acute distempers, excepting such as are occasioned by great colds,* from that period till the next encampment. But of chronic diseases, since the autumn has laid so large a foundation for them, a variety will always occur, and those generally arising from obstructed viscera. Yet upon the whole, the re- (58) This is good advice. Autumn is usually an unfriendly season to the health of man in middle latitudes. * Part ii. chap. i. and ii. o 106 The Seasons compared, Part II. turns of the sick will so much decrease, that if the troops are but tolerably accommodated, and the fore- going autumn has not been unusually' bad, they will probably next spring take the field without leaving above one man in 40 behind. Winter expeditions, though severe in appearance, are attended with little sickness, if the men have good shoes, quarters, fuel and provisions. Of this, we had one proof in the march into Germany; and another, in that to the North in the year of the rebellion. (59) But long marches in summer are not without danger, unless they are made in the night, or so early in the morning as to be finished before the heat of the day. Those who fall ill in the camp (especially in the decline of summer) so as to be confined for some time to the hospital, are during that season not to be relied upon for service; for being weakened by their sick- ness and lying warm while under cure, they will be liable to relapse as soon as they return to the field. It would therefore be proper to employ the convalescents in garrisons for the remainder of the campaign, or at least till they have full time to recover; for which end hospitals have neither accommodation nor air. It would also tend much to prevent diseases, if the sickly, or unseasoned corps, were sent a fortnight earlier than (59) The American revolutionary war furnished a memorable instance of the truth of this remark. Of nearly 2000 Philadel- phia militia troops, whom general Cadwallader commanded on the Delaware in the winter of 1776 and 7, and to whom the edi- tor acted as physician general, there was but one death, and not more than half a dozen sick in the course of six weeks, notwith- standing the greatest part of them slept in tents, or in the open air before fires, or upon barn or kitchen floors, during the whole of that time. Chap. IV. with regard to Health. 107 the rest into winter-quarters, whenever that is consist- ent with the service. Having mentioned the seasoning of troops, it may be proper to add the following caution, as a mistake here may be made so easily. By well seasoned troops are commonly understood, such as having gone through much fatigue are thereiore supposed best qualified to bear more. But in this we may be deceived; because such corps as have been rendered sickly by service, will never afterwards be strong, or fit for new labour, till all the infirm are dead or dismissed. For as sol- diers in time of war are not only subject to violent disorders, but have little time or convenience for re- covery, if once they fall ill it is odds but their con- stitution will be so weakened, as to make them ever after more liable to sickness. I shall mention two in- stances. In the year before the war, our troops having encamped on Lexden-heath near Colchester, and staid out late, returned sickly into quarters. Now, it was observable, that those who recovered and went to Flanders were the first sick in the garrisons; and that the same men, with others who were taken ill in the Low-Countries, were also most ailing in the canton- ments, and afterwards in the camps in Germany. So that these corps were never healthy till they lost all their weak men; which indeed in a great measure hap- pened during the course of the first campaign. The second instance is of those detachments in Zealand, and at Bergen-op-Zoom, which suffering greatly by the bad air of the country, the same battalions, in the beginning of the next campaign, were remarkably more sickly than any of the rest,* But as the first campaign in Flanders (though succeeding the sickly * Part i. chap, vii and viii. 108 The Seasons compared, Part II. one in Germany) was healthful,t and the next was still more so,$ some may thence infer, that troops are only liable to suffer in the first year, and being then seasoned will afterwards undergo the usual military fatigues unhurt. But besides that the weather was most favourable during the second and third cam- paigns, and that the camp broke up early in both, it must be remembered, that all the corps which had been in Germany had lost almost all their sickly men there; so that those who took the field, in the next year, were either old soldiers, who had never been ill, or recruits, additionals, or regiments which had come fresh from England: these therefore holding out well, were rather a proof of what is advanced above. And if the third campaign was still more healthful than the second, it is to be observed, that the army hap- pened then to be in its best state; consisting chiefly of fresh soldiers, or of men who never had been ill, or of those who were properly seasoned, by having made a short campaign in moderate weather. As a further proof that the health and hardiness of troops is not to be measured by the time they have served, in the two last years of the war, the sick were in pro- portion as numerous as they had been in the two first; and what happened in the cantonments in Dutch Bra- bant, during the last campaign, shows that no season- ing can avail against the influence of the moist and corrupted air of marshes. (60) / t Part i. chap. iv. i Chap. v. (60) There is no contradiction in this remark to one made by our auihor in the thirtieth page. Habit, so universal in its effects in protecting soldiers from the common diseases incident to the military life, exerts no influence over the system in defending it from autumnal fevers in climates alternately hot and cold. The Chap. IV. with regard to Health. 109 The whole amounts to this. Considering all the hardships, and expositions to cold attending the easi- est service, those troops will be best seasoned to un- dergo the fatigues of a second campaign, whose con- stitution has been least weakened in the first. same remark applies to all other classes of people inhabiting similar climates. OBSERVATIONS ON THE DISEASES OF THE ARMY. PART III. CHAPTER I. Observations on Colds, and Inflammatory Fevers in general. .HAVING laid down the division of the diseases most incident to an army, with the remoter causes and means of prevention, I shall proceed in this part to offer some practical observations upon each distem- per, in the order in which they were proposed;* and therefore shall begin with such as depend upon inflam- mation only. But as inflammatory disorders are every where common, and are treated of by so many authors, I shall not enter into a particular account of any, but make a few remarks on such as most frequently occur in military hospitals. Upon first taking the field, as well as during the winter, pleurisies and peripneu monies are the most common forms of the inflammatory fever; and next to them, fevers attended with rheumatic pains. The * Part ii. chap. i. Chap. I. Observations, &c. Ill inflammation turns also upon the brain, liver, stomach, and other viscera. Universally, the fever taking its rise from a stoppage of perspiration (or from what- ever is the primary effect of cold) by first inflaming any of these parts seems afterwards to be kept up by that inflammation. Sometimes we can perceive no part more affected than another, and only some general inflammatory symptoms. The distemper is then called simply an inflammatory fever, although probably some of the more indolent parts may at this time be affected with inflammation. This fever is most common after the weather begins to be warm. But inflammatory fevers are seldom seen single in the end of summer, or in autumn; for at such times expositions to cold, or moisture, produce fevers and fluxes of a putrid kind, where the inflammation seems to be often the least part of the disease. For after the summer solstice, the fevers tend most- ly to remit, and are attended with less sizy and more putrescent blood. But towards the end of the cam- paign, when the weather grows cold, more inflamma- tory symptoms are joined; so that the fevers may be said, at that time, to depend on two different causes. Among the mixed inflammatory fevers may be likewise reckoned the vernal intermittents, which upon the first encampment not only seize those who have had agues in the preceding autumn, but others who never had any. These are the more carefully to be distinguished from true intermittents, as they are to be treated chiefly by bleeding and other antiphlogis- tic remedies. When the bark has been given whilst the blood was inflamed, or before there was a proper intermission, I have observed that the distemper. 112 Observations on Part III. would either change into a continued fever, or stop for a while to recur with worse symptoms. The inflammatory fevers of an army differ from others, only in being more violent, and perhaps more frequently^ attended with a diarrhcea. The severities of the weather, to which a soldier is so much expos- ed, his backwardness to complain of the first symp- toms, his rough lying when first taken ill, or his be- ing carried to an hospital at a distance in a wagon, when already in a fever, account sufficiently for the first; and it is the stoppage of perspiration by lying cold, or by drinking improper liquors when first seiz- ed, that is the cause of the looseness. As bleeding is the principal remedy in the cure of inflammatory disorders, the delaying it too long, or not repeating it often enough in the beginning of bad colds, is the chief cause of their ending in dangerous inflammatory fevers, in rheumatisms, or consump- tions; and as a soldier applies first to the surgeon of his regiment, on him it chiefly depends to prevent many deaths, by the timely use of the lancet. In general, young practitioners are too sparing in letting blood, and delay it too long. But the surgeon may be assur- ed that soldiers will seldom complain of a cough, or pains with inflammatory symptoms, wherein immedi- ate bleeding is not proper; and from the continuance of the complaints, he is to judge of the necessity of repeating the evacuation, which, in the case of a stitch or difficult breathing, is never to be omitted in some quantity, even in the advanced state of the fever. I have generally ordered from twelve to sixteen ounces, to be let at the first or second bleeding, but less at all the rest. Here it may be proper to follow Celsus's rule, in observing the colour and consistence of the blood whilst it flows; that is, when it is thickish and Chap. I. Inflammatory Fevers in general. 113 of a dark cast (which it is in difficult breathing and great inflammations) to take it away more freely.*(61) When large quantities are necessary, it is best to bleed the patient lying, in order to prevent his fainting be- fore enough be drawn: otherwise, in all inflammatory pains, the animi deliquium, upon the loss of blood, is reckoned a favourable circumstance. Another prevention consists in an early sweat; for which one of the best medicines is a draught of vine- gar-whey with some spirits of hartshorn, at bed-timef. It has been usual to give the theriaca for this purpose; but all such drugs increase the fever if they do not procure a sweat, whereas this saline mixture operates without heating. The theriaca is rendered more su- dorific by adding to half a drachm some grains of the salt of hartshorn, and by encouraging the sweat with vinegar-whey, or thin water-gruel acidulated with vin- egar. But as to preventing fevers, that falls more in the way of the regimental surgeons than of the physician attending the hospital, who rarely sees the patient till either the fever be quite formed, or at least so far ad- vanced as not to be removed by sweating. (62) If therefore the feverish disorder or cold has been of two or three days' standing, it is to be treated by * De Med. lib. ii. cap. x. „ (61) The editor has borne testimony to the truth of this remark in his defence of bloodletting. He infers the existence of great inflammation, from the colour of the blood, resembling claret, while it is flowing. t Or give at bed-time two scruples of the salt of hartshorn, sa- turated with about three spoonfuls of common vinegar, in one draught, and promote the diaphoresis with some warm diluting liquor. (62) It is in the forming state of violent fevers only, that arti- ficial sweats are useful. After they are completely formed, they are generally hurtful when excited by stimulating remedies, V 114 . Observations on Part III. bleeding, and such medicines as are not heating, and yet tend to remove the inflammatory obstruction and promote perspiration. Some have thought nothing so efficacious for this intention as the spiritus Mindereri;* the internal use of which was first mentioned by the celebrated Boerhaave, and afterwards introduced into practice, at Edinburgh, by the late Dr. John Clerk, a physician of eminence in that city.f But during the former war I followed the common method of joining the testacea to nitre, without any particular attention at first to the effects of the former; but as I have since discovered a septic quality in those substances by ex- periments out of the body, it seems natural to con- clude that they exert a like power when taken by way * Pharmacop. Edinburg. But it is to be observed, that as to the names and compositions of medicines, unless where it is ex- pressed otherwise, as here, I follow the last edition of the Lon- don Dispensatory, viz. that of the year 1746. t As it may give satisfaction to the reader, to have Doctor Clerk's observations upon the effects of this medicine in vari- ous cases, I shall subjoin his own account, in the following ex- tract of a letter which he favoured me with on this subject. " In relation to the spiritus Mindereri, I never gave above " half an ounce for a dose. When I intend to promote a diure- " sis, I give that quantity twice a day, mixed with an equal pro- " portion of syrupus de althcea, and find it seldom fail. But in a " dropsy, I more commonly make use of the julapium diureti- " cum Pharmacopceix Pauperum Edinburgensis. I have some- " times added the sal succini, when I was sure of its being genu- " ine; but that is rarely to be found. For that reason it is left out " of the Pharmacopoeia Pauperum. and the spirit put in its place; " which has the same ratio to the salt, that the spirit of hartshorn " has to its salt; though formerly not being in use, it was thrown " away as of no value. When I give the spiritus Mindereri to " promote a diaphoresis, I always add a small quantity of sal cor- " nu cervi to give it the alcaline cast, as in the haustus diaphore- " iicus Pharmacopoeia Pauperum. When I design to bring on a " plentiful sweating, as in rheumatic diseases, I use the julapi- Chap. I. Inflammatory Fevers in general. 115 of medicine.* And this perhaps would be more fre- quently seen, were it not for the .quantity of acids usually given in acute diseases; in which case not only the septic nature of the testacea may be destroyed, but the acid neutralized, and thereby rendered more dia- phoretic. The putrefying quality of these powders is " urn diafihoreticum {Pharmacop. Pauper.) two spoonfuls every " hour, or hour and half, till the sweat breaks out: repeating it "pro re nata, when warm diluting liquors are not'sufficient to ". keep it up. I have given of the spirit in this manner about two " ounces, and ten grains of the sal cornu cervi in the space of " four and twenty hours. In topical inflammations, I give the " acid cast by mixing with it an equal quantity of acetum scilliti- " cum. I have often given it so in pleurisies and peripneumonies. " I understand that some of my brethren use this form only. Of " all neutrals, I take the sal ammoniacum crudum to come nearest " the spiritus Mindereri. I use sometimes the bolus diaphoreticus »' Pharmacopoeia Pauperum, but I do not find it nearly so effica- " cious as the julep." Some doubts arising, since Dr. Clerk's death, about the dose of his squill-mixture, I consulted his son Dr. David Clerk, one of the physicians to the Royal Infirmary at Edinburgh, who informed me, that he believed there was a mistake in his father's letter, of acetum scilliticum for syrupus acilliticus; and that his father did not give the spiritus Minde- reri-mixture in the same quantity with and without the syru- pus scilliticus. He added, that he had found in the liber memoria- lis of his father the following receipt: R Aqua hyssopi (yd cinna- momi sine vino) spiritus Mindereri syrupi scillitici aa zij. misce. Drntur cochlearia ij. bis die. That this was his common dose of all his julapia scillitica; but when the stomach could not bear so much in the morning, he then gave but one spoonful. That he himself did not particularly remember, how much of this mix- ture his father gave in the pleurisy and peripneumony, but be- lieved, that the quantity did not exceed four or five spoonluis in the day. He concluded with remarking, that considering the dif- ferent manner of making the vinegar of squills at London, and at Edinburgh, the London preparation was likely to be much stronger than the other. ' Append. Paper iii. exp. xxiii. * 116 Observations on Part III. also corrected by the contrayerva-root, and by the camphire which was added to them. The common dose was a scruple of the pulvis contrayervce composi- tus, with ten grains of nitre, and three grains of cam- phire reduced to a powder, and given four times a day. These powders were given partly to promote a dia- phoresis, when nature seemed to be pointing that way, and partly to abate spasms, as the head was so apt to be affected: upon the whole it was a medicine which had little sensible effect, and therefore I laid the less stress upon it. We may observe, that in fevers in dif- ferent countries and different ages, besides those remedies which have a manifest action, physicians have used others, which though operating impercep- tibly have yet been imagined to be of some efficacy towards conquering the disease. But as their practice was founded on the theory then prevailing, when that changed, so did the medicine; and this will probably be the case till the nature of a fever be better under- stood. My first practice in every inflammatory fever was to blister, and especially in the advanced state when I believed that the patient could not bear any farther loss of blood. But afterwards, when I found that a solution of the fever was not to be procured by such means, I confined the use of blisters to those states of the disease in which I could be the most assured of their efficacy. Such was that of a headach, when not removed by the first bleeding and by opening the body; in this case a blister between the shoulders sel- dom failed of giving ease. To the same place, though not with equal certainty of relief, a blister was applied, when the patient had a cough (which he generally had) or any other sign of inflammation in the lungs: but when he complained Chap. I. Inflammatory Fevers in general. 117 of a stitch in his side, the plaster was laid on the part affected. In these circumstances I likewise ordered some pectoral drink, and an oily mixture which shall be mentioned when I come to the pleurisy. In a deli- rium, I followed that course which shall be laid down in the next chapter. If the body was bound, I opened it (after the first bleeding) with some lenient physic; but throughout the course of the fever I found it sufficient to prevent costiveness by daily clysters,* if the patient had not otherwise regular stools. After recovery, some mild purge was often requisite, in order to prevent the too hasty repletion of the convalescents, upon indulging their appetite: cathartics at that time seemed other- wise unnecessary. But if the fever in the beginning was attended with gripes and a looseness, after bleed- ing 1 gave some rhubarb; and if the purging still con- tinued, 1 endeavoured to check it by the chalk-julep only; and afterwards proceeded in the method as above. Towards the crisis, or in the decline of the fever, a little wine was added to the panada, or given in some other shape, as the best cordial; and in great sinkings, I preferred some drops of spirit of hartshorn, in a teacupful of white wine whey, to every other medi- cine of that intention. After showing that so much depends on early and repeated bleedings in the beginning of these fevers, and on blisters, I can offer no remark more useful than what relates to opiates, which otherwise one might be too apt to have recourse to, amidst so many complaints of pain, looseness, and want of rest. With • A motion or two daily, procured in this way, I have observed :o be one of the best and most general remedies in fevers. 118 Observations on Part III. regard to the two first, I have already proposed what I found sufficient for the cure; but as to the watchful- ness, I shall observe, that opiates ought only to be used in the advanced state of the disease, when the inflammatory symptoms are much abated, when the head is not affected, and when the patient after long watching believes he should be well enough if he could but sleep. At such times, and especially at the crisis, and after it, I have usually given two scruples of the confectio Damocratis at bed-time, and with good effects. If the paregoric be continued, costiveness must be prevented by clysters or some mild laxative. In these, as in other fevers, thirst was moderated by acidulating the barley water with vinegar, or by balm tea with lemon juice. And as to diet, the patient was always kept upon the lowest, such as panada, watergruel, and the like, without allowing any broth till after a breaking and a sediment in the urine: when that happened, a decoction of the bark, or the elixir of vitriol, completed the cure. Chap. II. particular Inflammatory. 119 CHAPTER II. Observations on particular Inflammations. SECTION I. Of the Inflammation of the Brain. 1 HE phrenitis or inflammation of the brain, consi- dered as an original inflammation, is properly a sum- mer disease, when men are exposed to the ardour of the sun; and especially whilst asleep and in liquor. But a symptomatic phrenitis or delirium: is one of the most general inflammatory symptoms, is confined to no season, and happens indifferently in the bilious, malignant, or inflammatory fever. It is more common in military hospitals than elsewhere, on account of the violence done to all fevers when the sick are car- ried in wagons from the camp to an hospital, where the very noise, or light alone, would be sufficient with more delicate natures to raise a frenzy. (63) An original inflammation of the brain, requires im- mediate, large and repeated bleedings; and the relief is thought to be the more certain if the blood be (63) The editor has frequently seen this remark verified. The removal of patients in the first, or violent stage of all fevers, whether in wagons, coaches, or single horse chairs, often in- duces, not only delirium, but precipitates death. Many of the patients ill with the yellow fever, who were brought to the city hospital on the Schuylkill in the year 1798, died a few hours after they were admitted in it. One instance occurred of a pa- tient being taken out of a chair dead, when he arrived at the door of the hospital. It is to be lamented that a mode of convey- ing patients to hospitals has not been devised more consistent with the dictates of medical science and christian humanity. 120 Observations on Part III. taken from the jugular. I have never advised cutting the temporal artery, finding so much relief from ap- plying three or four leeches to each temple after bleeding in the arm.* The benefit thence arising may be compared to the effects of an hcemorrhage by the nose. The rest of the cure consists in the medicines common to all inflammatory fevers. The symptomatic phrenitis is also treated by open- ing a vein, if the pulse can bear it; but if this cannot be done by reason of lowness, the cure is to be at- tempted by leeches and blisters. It is usual in blister- ing to begin with the head, but in military hospitals I found it convenient to leave that to the last; (64) because barbers are careless, and in cutting the skin expose the patient more to a strangury.f The com- mon internal medicine was the diaphoretic powder mentioned in the last chapter. A phrenitis is often brought on, or increased, in * I have sometimes applied six to each temple. (64) Other reasons may be given for not applying blisters to the head in the early stage of phrenitis, besides that given by our author. In the highly excited state of the brain, they are either inactive or hurtful. By applying blisters to the limbs an epispastic disease is created, which abstracts morbid excitement from the brain, if not wholly, yet to such a degree as to render blisters to the head afterwards both safe and useful. Care should be taken not to apply blisters even to the limbs, until the disease in the brain has been loosened, or reduced by means of depleting remedies to such a degree as to be translated to the extremities of the body. The same reasonings apply to the cure of all other violent diseases of the brain. t Upon reading this passage in the first edition, Dr. Whytt, professor of medicine in the university of Edinburgh, wrote to me, he had observed, that by shaving the head twelve or fifteen hours before the application of the blister, a strangury was gene- rally prevented. Sometimes I have found the brain sensibly relieved by cutting off the hair and shaving the head, though no Chap. II. particular Inflammations. 121 the hospitals of an army, by the want of due perspi- ration, and of warmth in the extremities. Therefore, as soon as a soldier is brought into the house with feverish symptoms, his hands and feet should be washed with warm vinegar and water. And I would likewise recommend for the hospitals, what I have sometimes since in a phrenitis successfully used in my private practice, a fomentation to the feet and lower part of the legs with double flannels wrung out of water (with a seventh of vinegar) made agreeably warm, and repeated often for an hour or two at a time.(66) SECTION II. Of the Inflammation of the Eyes. SOLDIERS are subject to an ophthalmia or inflam- mation of the eyes, not only from winter colds, but from their frequent exposition to the sun and dust during the campaign. The slighter cases may be cured without bleeding; but if any degree of fever be joined, or the inflammation be considerable, this evacuation plaster was applied; (65) and since the first edition, I have in such cases, out of the hospital, given the sal sedativum of Hom- berg, to the quantity of 25 grains every four hours, and, as I have imagined, with good effect; but as I never trusted to that medicine singly, I cannot speak of it with certainty. (65) This practice recommended by Dr. Whytt has been found to be extremely useful, not only in the acute diseases of the head, but in many of its chronic diseases. Headach has often been cured by it. The connexion of the hair with diseases is evident from its burning crip, losing its curls, and even becom- ing erect, in their forming state. (66) These fomentations, like blisters to the limbs in phrenitis, produce the best effects after the partial reduction of the morbiU excitement of the brain by depleting remedies. Q 122 Observations on Part 111. ought not to be omitted. The greater inflammations are not to be cured without large bleeding, unless we can make a derivation from the part affected with- out draining the whole body. For this purpose, blis- ters are usefully applied behind the ears, especially if they are continued for two or three days, and if the sores are afterwards kept running. This part of the cure is sufficiently known. But what I have observed to be sometimes more efficacious, though less gene- rally practised, is bleeding by leeches; when two or more are applied to the lower part of the orbit, or near the external angle of the eye, and the wounds allowed to ooze till they stop of themselves. Therefore in all greater inflammations, after bleeding in the arm or ju- gular, I have used this method, and repeated it more than once if required. The practice is no less proper in an inflammation of the eyes from a hurt or blow: only in great fluxions, some blood is to be first taken from the arm, and immediately after, a revulsion is to be made by a brisk purge. But though these means are proper in the common ophthlamia, they are not to be relied on when the disease arises from a scrofulous, or a venereal cause.* In all cases, we are to look often and narrowly into the inflamed eyes; since the inflammation may either be occasioned, or kept up by moats, or by hairs * There are also inflammations and ulcers of the eye-lids, which are often mistaken for disorders of the eye itself, but are not to be cured by the common ophthalmic medicines. The fol- lowing liniment, communicated to me by a friend who had given particular attention to this branch of medicine, I once found effi- cacious: R Unguenti albi 5 v. sacchari Saturni ^i. quibus super por- fihyrite simul tritis instillentur balsami traumatici 9ij. Hujus paululum, linteo exceptum, oculo dolenti omni nocteim- ponatur. Chap. II. particular Inflammations. 123 of the cilia falling in, or growing inwards, so as to cause a constant irritation. The slighter inflammations from the dust, or the sun, were removed by fomenting with warm milk and water, adding a small proportion of brandy; and by anointing the eyes with the unguentum tutice, or the like, at night. But in bad cases, after the inflam- mation had yielded a little to evacuations, I found the coagulum aluminosum of the London Dispensatory, spread on lint and applied at bed-time, the best ex- ternal remedy. Till then the patient is to use a solu- tion of white vitriol: or, in violent pains, to foment frequently with a decoction of white poppy heads. SECTION III. Of the Inflammation of the Throat. THE inflammatory angina is most frequent and dangerous upon the first encampment. Its tendency to bring on a suffocation requires speedy and large bleedings, purging and blistering; but the method of using all these being so well laid down by Sydenham, I shall only mention another remedy which I have sometimes found useful. Let a piece of thick flannel, moistened with two parts of common sweet oil and one of spirit of hartshorn (or in such a proportion as the skin will bear) be applied to the throat, and renew- ed once in four of five hours.* By this means the neck, and sometimes the whole body, is put into a sweat; which, after bleeding, either carries off or lessens the inflammation. The formula is new but not the whole intention; for the ancients applied warm oil * This medicine I had from the late Dr. Young, physician at Edinburgh. 124 Observations on Part III. with a spunge, and warm bags with salt;* and some later writers have recommended poultices made of the dung of animals,! which seems to be only a coarse and an offensive way of using the volatiles. I observed little benefit from common gargles; for at that time I did not think of injecting them with a syringe, which I now constantly do. By this method, the patient brings away a great deal of tough phlegm, and generally finds some immediate relief, from clear- ing the glands of the fauces. My composition is thir- teen ounces of barley-water (or sage tea) with two ounces of mel rosarum and one ounce of vinegar; sometimes I have added a spoonful of mustard for a greater stimulus. The bleedings, the laxatives, the blisters, and this gargle are all the medicines I now find necessary. And even in the angina maligna or ul- cerous sore throat, I lay the chief stress of the cure upon gargling in this manner. In all cases, I direct five or six syringefuls to be injected, one after ano- ther, as far into the throat as the patient can bear, and the medicine to be repeated three times a day.J * Cels. lib. iv. cap. iv. t Etmuller. cap. de angina. \ In later practice, besides a blister to the back, in bad cases I have laid one across the throat: at other times I have appli- ed 7 or 8 leeches under the fauces; and when the patient has been brought low by the loss of much blood from the arm, I have opened one of the veins under the tongue, and taken away two or three spoonfuls: all these methods at times have had a good effect. But when an abscess is formed, which the lancet cannot reach, its breaking will be hastened by a common vomit. Chap. II. particular Inflammations. 125 SECTION IV. Of the Pleurisy and Inflammation of the Lungs. THE pleurisy and peripneumony are the most fre- quent forms of our inflammatory fever. It is to be re- membered, that in these disorders the pain may be felt in any part of the chest, behind or before, as well as in the sides; and sometimes so low down, as to be mista- ken for an inflammation of some of the abdominal viscera, such as the liver, spleen, or kidneys. Without entering scrupulously into the distinction, which most authors have made, between a pleurisy and peripneumony, I shall mention those remedies, which I used with most success in such pains of the breast, sharp or obtuse, as were attended with diffi- culty in breathing, almost always with a cough, and never were without some fever. For we are not to con- found these inflammatory pains, and difficulties in breathing, with some spasmodic stitches (which seiz- ing the muscles of respiration are not accompanied with a fever, and may be removed by externals only) nor with certain flatulent pains of the side, if I may so call them, to which hypochondriacal and hysterical persons are most subject. Such cases indeed came seldom into our hospitals. But to the same kind of fla- tulent stitches every person is liable, when brought low by sickness, and especially by any disorder of the bowels. These pains may be owing to wind confined, or to excrements pent up in that part of the colon next the diaphragm. They generally strike from the breast to the back, or from side to side, affect the breathinsr, and are sometimes attended with a short and frequent cough. But the fever a«d siziness of the blood, with other marks of a true pleurisy are wanting. Bleeding 126 Observations on Part III. may do harm, but qarminative laxatives, with warm applications to the part, give ease. A blister perhaps is the only remedy common to both. Although we cannot admit the critical days, yet we must observe with the ancients certain states of those inflammations of the breast, which are attended with different symptoms, and require a different method of cure. The sick are often brought into the hospital when the inflammation has spread upon the lungs, and gone too far to yield to evacuations. Now, however improper it would be at this time to commit the whole to nature, yet if the sputum appears, as described by Hippocrates, we are to consider it as the chief remedy, and are not to divert it by bleeding or purging; as I have found upon trial. With these cautions we are to proceed, letting blood freely for the first three or four days of the disease; but, if in that time the spitting begins, the bleeding must either be wholly omitted, or so moderated as to relieve the breast, without impairing the strength or checking the expectoration. Whh regard to the quantity, and repetitions of bleed- -ing, no precise rule can be given. Sydenham has spe- cified forty ounces for the whole quantity which men may, at a medium, lose in a pleurisy; but this, in our circumstances, would have been too little had it not been for blisters, which not only shortened the cure but prevented the loss of a great deal of blood. A pleurisy, taken in the beginning, will often be cured by one large bleeding, and a blister laid on the side affected. The objection to this practice is founded on the stimulating quality of the cantharides; but the relief is so certain, that theory ought only to be em- ployed here in accounting for the resolution of an m- Chap. II. particular Inflammations. 127 ternal spasm, or obstruction, by such a stimulus upon the skin.(67) This method of blistering the side is ancient, and was performed by sinapisms;* but now only cantha- rides are used, and the practice is become common in Britain. Some difficulty remains about the time of ap- plication, whether it is best to apply the blister in the beginning, or to wait till the pulse be softened by fre- quent bleeding. The experience which I have had in- duces me to prefer the former; for in treating great numbers in the hospitals, I found no inconvenience from using the blister immediately after the first bleed- ing, but, on the contrary, a more sudden and certain relief. Nay frequently, when the surgeon was not at hand, I have had the plaster put directly to the side, and the patient bled afterwards; being satisfied if the vein was opened before the flies had time to stimulate. These lateral blisters, as well as those for the back, were made as large as the palm of the hand with the fingers; a size unusual any where but in this country. Although the symptoms may vanish upon blistering, it will be more secure to bleed again, unless a sweat comes on with a relief from pain, and makes this and other remedies unnecessary. But, if the lungs are much inflamed the cure cannot be speedy; for though the first bleeding and blister should give ease, yet repeti- tions of both will be needful. Sometimes the stitch re- turns and fixes in the other side; but this being treat- ed as the first, will also give wayr. (67) Experience proves this practice to be successful, nor is it contrary to reason, for the depletion obtained by it, counteracts the less evil of a transient stimulus from the blister. The skin of the side moreover possesses but a feeble sympathy with the blood-vessels of the whole body. * Cels. lib. iv. cap. vi. 1 128 Observations on , Part III. A distinction has commonly been made between the pleurisy and peripneumony, which I likewise fol- lowed in the former editions. But having since read the dissections and remarks of those celebrated authors De Haller* and Morgagnif relating to this subject, I am convinced that we ought to consider these two distempers as one, in which the lungs are always inflamed, and often without the pleura; but the pleura never, without the lungs. (68) Wherever the pain is, I apply a large blister to the part; and if there is no particular stitch, but only a general oppression, I lay the plaster between the shoulders; and afterwards, if the disease is obstinate, first to one side and then to the other. Blisters, not only when applied to the chest but also to the extremities, tend to relieve the breast, and to promote expectoration; whereas bleeding must be used cautiously, if at all, after the sputum appears. Not only during the height of the inflammation, but throughout the state of expectoration, I give the patient from hour to hour a small teacupful of a pectoral infusion warm,| and once in five or six hours, four spoonfuls of an oily mixture. § But when the expectoration flags, instead of this last medicine, I order as much of the oxymel scilliticum as the patient * Opuscul. Pathol, obs. xiii. xiv. t De Sed. & Caus. Morb. ep. xx. et xxi. (68) Dissections confirm this remark. The editor has followed the author's practice with advantage, in applying blisters first between the shoulders in general affections of the lungs without local pain. \ Vis. An infusion made of the ingredients of the decoctum pectorale; to a quart of which, add an ounce of the simple Oxy- mel. § R Mellis (yel syrupi ex allhaa) 3vi. gummi Arabici in pulve- rem contriti Ji. aqua rosarum 3ii. accurate subactis admisce invi- cem ok? amygf'darrnn dulcium 5iss. et aqua pur a 5vi. Chap. II. particular Inflammations. 129 can take without sickness, or purging. Or, what I have often found more effectual, four spoonfuls once in six or eight hours of a solution of gum Ammonia- cum.* I' have likewise observed good effects from making the patient breathe over the steam of hot water: a practice recommended by Boerhaave and the Baron van Swieten, and confirmed to me by the re- peated trials of Dr. Huck, who found it more benefi- cial when the phlegm was viscid, as well as more grateful to the patient, by adding a small portion of vinegar. (69) This is my present practice. In the hospital, when the patient, was reduced byr repeated bleedings, I found the salcornu cervi joined to sperma ceti not only proper for raising the pulse but for pro- moting expectoration.f If notwithstanding this discharge, the patient com- plains much of a stitch, or labour in breathing, it is still necessary to bleed. But in this case there is dan- ger of falling into one of these extremes; either of suffering the lungs to be overpowered, by omitting to bleed; or of hazarding the suppression of the sputum, by bleeding too freely. Trillerus, Huxham, and the Baron van Swieten have delivered the rules how to proceed here. But, with regard to blisters, there need be no caution at such a juncture, as they * R Spermatis ceti {ex vitello ovi quantum satis est soluti) Jij. lactis Ammoniaci %vii. syrufii croci 3vi. misce. (69) Too much cannot be said in favour of this simple and powerful remedy. The editor has seen patients snatched from the jaws of death by it. Where a prompt effect is wished for, water should be poured upon a heated shovel. The vapour in this case is poured in a stream into the lungs. t This is the formula which I have generally used: R Spermatis ceti {ex vitello ovi soluti) 3iii. aqua pur a ?vii. salts cornu cervi 3i. syrupi balsamici 5i. misce. R 130 Observations on Part III. are always seasonable, whether for raising the pulse or relieving the breast. In the course of expectoration, a vomit has some- times contributed to discharge the viscid phlegm.(70) Sometimes opiates may be given, but with caution; for, as long as the pulse is hard, or the breathing difficult, or when watchfulness is owing to the fever, they do harm. But when the fever has ceased, and sleep is only prevented by a thin rheum falling on the fauces, or lungs, opiates, and especially if joined to squills, will both give rest and promote expectoration. SECTION V. Of the Inflammation of the Liver. THE liver is a part not only liable to original in- flammations, but also to suffer by translations of mat- ter. I have found by several dissections that this vis- cus, next to the lungs, is most subject to suppuration; but I have known one case only cured after an abscess. In this, the matter pointing was let out, and the patient soon after recovered. Another case occurred, remarkable for the situation of the abscess, which was entirely on the left side of the linea alba. The incision was nevertheless made, and a large quantity of pus was evacuated. The patient was relieved, but the operation having been delayed perhaps too long, he died soon after. Upon opening the body, the incision was found to have passed into the liver, but to have been too small for discharging all the matter. A third case was singular for the flatness of the (70) The editor can subscribe to the benefits of this practice, and he believes with Dr. Huxham, that patients when very weak in acute diseases, bear depletion by puking, much better than by bleeding, purging, or sweating. Chap. II. particular Inflammations. 131 tumour, and an unusual difficulty in breathing; for the man could not lie extended, but for the most part rested in a prone posture upon his knees and hands. He had frequent retchings to vomit, with a constant and un- common pain at his stomach and sickness; and two days before his death he grew yellow, and was seized with a hiccup. The body being opened, the liver was found wholly scirrhous, or purulent. The thick and posterior lobe was suppurated; and another large abscess rose from the concave part, which thrust the stomach outwards in such a manner, that had an inci- sion been made before death, as in the former case, it must have passed through the stomach before it came to the bag. As to the cure of an inflammation of the liver, I have made no remark that deserves notice; unless that with plentiful bleeding, one of the best remedies is a large blister laid over the part affected. SECTION VI. Of the Inflammation of the Stomach and Intestines. THE same method has been practised in the in- flammation of the stomach and intestines; nor have I known these local blisters attended with any bad con- sequences, though applied early in the disease. In particular, they were useful in the ileus or inflamma- , tory colic; and often answered in fixed pains of the bowels from spasms, without evident marks of inflam- mation. To this observation relating to the effects of blisters in pains of the abdomen, I shall subjoin a few remarks upon the inflammation of the bowels, which have oc- curred upon further reflection, and more experience. The eiAeoV, ileus (improperly rendered volvulus) ac- 132 Observations on Part III. cording to Galen, " is an inflammation of the intes- " tines attended with violent gripes, and such a con- " striction as to allow no passage for either the feces " or flatulence."* This definition, where vomiting is not named, is nevertheless agreeable to the description of the ileus by Hippocrates,! who mentions both a bilious and a stercoraceous vomiting, but which he considers as additional symptoms when the distemper rises to a height. For in the Aphorisms, J Hippocrates observes, that " in the ileus, vomiting is a bad sign;" which seems to imply, that there may be an ileus with- out any vomiting at all. And Aretaeus,^ who of all the ancients has given us the fullest and most satisfactory account of the disease, takes notice of three degrees of it; one, in which the stomach is oppressed, without vomiting; another, in which the patient brings up phlegm and gall; and the third and fatal one, when he voids his excrements by the mouth. From this it ap- pears, that whenever there are acute pains of the bowels, attended with an oppression at the stomach, great costiveness, and (if I may add from Hippocrates) a tension of the belly, of all perhaps the most constant symptom, without regarding whether there is vomit- ing or not, we may freely determine the case to be the ileus of the ancients; and from them draw what lights they can furnish with regard to the cure. But if, in con- formity with some of the best of the moderns, we should only call that an iliac passion, in which the peristaltic motion is wholly inverted, our practice can receive no assistance from the Greeks, who supposed that state of the ileus to be incurable. Thus Sydenham, when to the above symptoms even a vomiting of the food is joined, allows no other * Lib. de Definit. f De Morb. lib. iii. \ Sect. vii. aph. x. § Acut. Morb. lib. ii. cap. vi. Chap. II. particular Inflammations. 133 name to the disorder than that of the passio iliaca notha,* as supposing in that case only a partial inver- sion of the peristaltic motion; and he considers the rendering of clysters by the mouth as the mark of a total inversion, and therefore a pathognomonic symp- tom of the true iliac passion: quando liquet ex clyste- ribusper os ejectis et aliis signis verum esse ileum, fcfc.t This ileus verus of Sydenham I never saw but once (the patient died) and I should imagine, that it has been but rarely seen in our times by those in the greatest practice, and seldom or never cured:(71) so that it may seem extraordinary, that in his days it should occur so often, as to satisfy him about the certainty of his method of cure; and the more, as the remedies which he used would now appear inadequate to much milder degrees of the disease. But that ex- cellent author appears to have been afterwards sensible of the insufficiency of his former practice; for in the Processus Integri (his posthumous work) he omits part of it, and adds some more powerful remedies, which still perhaps, in other hands, would prove in- effectual. As to all the lesser degrees of the ileus, we must look in Sydenham for their description and cure, under the title of colica biliosa; which we may be the more certain is the same distemper with the ileus, as the author himself says, that if this colic was not timely remedied, it terminated in the iliac passion.%{72) But it is to be wished that Sydenham had not given the name of bilious colic to the ileus, nor considered it in the light he has done; because upon his authority * Sect. i. cap. vi. t Ibid. (71) The editor has seen one recovery, he does not say cure, after this symptom had taken place. \ Sect. iv. cap. vii. (72) There would be the same propriety in giving as many 134 Observations on Part III, many have been led to correct, and to evacuate the bile (perhaps faultless) without sufficiently attending to the inflammation, as he does not mention it. Syden- ham bleeds but once; from which circumstance alone we may judge, that he had never inquired how the bowels of those who died of the distemper appeared after death, nor apprehended any danger from a mor- tification, which from numerous dissections we are now assured is always threatened. Having had these reasons to diviate from Syden- ham's practice, I followed the more ancient one, of bleeding largely and often, as long as the violence of the symptoms remained, or whilst the strength per- mitted. If after the first bleeding, the patient was not sensibly better, in a few hours the vein was opened a second time, and immediately after, a blister (as large as the palm of the hand with the fingers) was applied over that part of the belly which was most affected. As I have more than once known the patient relieved in his bowels as soon as he felt the burning of his skin, and at the same time have stools by a purge or clyster, which had been given before without effect, we have reason to believe that the blister acts more as an an- tispasmodic than an evacuant. This was my common method in the hospital; and if since that time I have made less use of these blisters, it is'not from having seen bad consequences from them, but from finding, in private practice, a greater reluctance in the patient to have them upon a part where they are not com- monly applied; and also, from their somewhat inter- names to the rheumatism, as it affects joints, as to give different names to the different diseases of the intestines, from their dif- ferent seats. This error would be of little consequence did it not lead to a peculiar and different mode of treating diseases accord- ing as they were seated in the small or large intestines, or in their internal or external coats. Chap. II. particular Inflammations. 135 fering with the warm bath, which though a material article in the cure, was generally wanting in the hos- pitals of the army. Next to bleeding, the principal part of the cure depends upon opening the body, which formerly I at- tempted by clysters, and by giving every hour a pill of aloes, soap and calomel; but afterwards I changed that practice for the more lenient medicines. In this intention, I have given every hour, the size of a nut- meg of an electuary compounded of half an ounce of the electarium lenitivum, two drachms of the flowers of sulphur, and one drachm of the creme of tar- tar, with some syrup. (73) But of late, I have kept more to the use of the sal catharticus amarus, recommended to me by Dr. Heberden, who had had several proofs of its good effects in small but repeated doses. Two ounces of this salt being therefore dissolved in a pint of water, I give two spoonfuls every half hour; or one spoonful at shorter intervals, as long as the patient's stomach will bear it, or till he has had two motions. Although this medicine has a disagreeable taste, yet as Dr. Heberden remarked, the stomach will often retain it when more grateful liquors are rejected: a circumstance which might incline one to believe, what has been said of other neutral salts, that they possess some degree of a sedative, as well as a laxa- tive quality. Whether I direct the electuary or this solution to be given, I order a clyster, purely loosen- ing, for assisting the operation: for I never could un- derstand, how parts lying in the center of animal heat, and naturally in a moist state, should be fomented by (73) The late Dr. Cadwallader of Philadelphia, introduced the use of cream of tartar into general practice in obstinate obstruc- tions of the bowels with great success, in preference to more active purges. 136 Observations on Part III. any fluid, in a clyster no warmer than themselves. When I suspect that the obstruction is owing to hardened feces, at first I only use clysters of oil, but at all other times, the following: R Decocti communis pro clystere 5x. elcctarii lenitivi, old olivarum, singulorum 5ii. misce. But when the stomach is so much disordered as to throw up either of the above laxatives, I then join some opium to a stimulating purge; a practice which has been long in use here and followed by Dr. Mead.* R Extracti cathartici gr. xxv. extracti Thebaici gr. iss. mercurii dulcis sublimatigr. v. misce, Jiantpilula x. These are for one dose, to be given at some interval when the patient, after vomiting, complains of the least sickness. The smaller the pills are, they will have the better chance of being retained. About twelve hours after this, or when the force of the opium begins to go off, I endeavour to promote the opera- tion of the purge by the solution of the salt as before; and in a few hours more, still continuing the solution, I repeat the clyster. After procuring stools, most of the danger being over, I follow pretty nearly Sydenham's method, in regard to the rest of the disease; giving laudanum at bed-time; and in the morning, as much of the solution, or of some other laxative, as is sufficient to open the body freely till the hazard of a relapse is past. Sydenham, in the ileus (as he defines it) recom- mends for the vomiting a scruple of salt of worm- wood in a spoonful of lemon-juice, to be given in the act of effervescence; which practice I remember to have tried more than once successfully in iliacal cases, where the patient only vomited bile; but with this * Monit. et Prsecept. Medic, p. 114. Chap. II. particular Inflammations. 137 difference, that instead of giving the draught twice a day, I gave it every hour. (74) With regard to the causes of the ileus, it is well known that those who have ruptures are most liable to it; but such cases are not common in the army. As to the other causes, there were too few instances to satisfy me about the most frequent. Not but that among soldiers the bowels are often inflamed; but every inflammation there does not tend to an ileus; for by falling upon the larger intestines it generally occasions a flux, as will appear by the dissections of those who died of the dysentery. A few examples may be found of the ileus from an inflammation of the colon; but I imagine that in most of them, some har- dened feces, or some tumour, have concurred to straiten the passage and prevent stools. Upon the whole, I have met with this disease more in my prac- tice at home, than abroad in the army. Children and those who are delicate are perhaps more liable to it than men in the vigour of life; besides such as have ruptures are not inlisted. A gouty humour may often be the cause among people of higher rank, but sel- dom among soldiers. I remember to have had two patients in the ileus attended with vomiting; one a young gentleman of two and twenty (who had lived intemperately) whose disorder went off with a fit of the gout; and the other a man of fifty, who in a few days after a second attack was likewise seized with the gout, and afterwards had no complaint in his bowels. Neither of these persons had been troubled with the gout before. But whoever desires to pursue this inquiry farther, may consult the Sepulchretum (74) A substitute for this mixture has been discovered in the seriated alkaline julep, and in artificial seltzer water. S 138 Observations on Part IIL Atiatotnicum, Ruysch's anatomical and chirurgical ob- servations,* and the late excellent work of Morgagni, de Sedibus et Causis Morborum.\ I shall conclude with one remark, which though it has been made before, yet has not been so generally received as to render any further testimony unneces- sary. The ileus is for the most part attended with a sensible degree of fever, and with all the other symp- toms related as above; but besides that there are cases, in which there is no vomiting (as shown from the ancients) there are others in which the fever is scarce perceptible, when the patient feels little pain, and is not altogether costive. I say there are such cases of inflammation; because, when with symptoms so little alarming the patient has died, the bowels have been found not less mortified than after the most distinguishing marks of the disease. This, so far as I know, was first taken notice of by Dr. Simson, whose observation is quoted and confirmed by the Baron van Swieten,% and lately by Morgagni,§ who observes, that in such circumstances, the only presages of dan- ger are to be taken from the tension of the belly, and a dull pain upon pressing it, from the lowness and inequality of the pulse, and from a change in the countenance. What he says upon this subject well deserves attention. (75) * Obs. xci. t Ep. xxxiv. and xxxv. \ Comm. in Boerh. Aphor. § 371. § De Sed. et Caus. Morb. ep. xxxv. 22. (75) A fact of great consequence is here mentioned, and that is, there may be inflammation in the bowels without a sympathy being excited between them and the pulse. In all such cases, whether the inflammation exist in the bowels or in other parts of the body, indications of cure should be sought for from other symptoms, and happily they are seldom absent during the quies- cent or passive state of the pulse. Chap. II. particular Inflammations. 139 SECTION VII. Of the Rheumatism. THE ancients seem to have imperfectly distinguish- ed the gout from the distemper now called the rheu- matism, by giving the name of arthritis to the affection of all the joints, whether the pain arose from a rheu- matic inflammation, or a gouty humour. If not all, but some particular joint suffered, the distemper was denominated from the part; hence the terms chiragra, podagra, isahias, fcfc. all which they considered as species of the arthritis. But as some arthritic pains were observed to be of a different nature from others, they distinguished them according to the different humours which they supposed to be the cause of the disease. Thus, one kind they believed depended on the blood, therefore bleeding was recommended as the chief remedy, and in plethoric habits they bled more than once. Although by making this distinction, the ancients might sometimes treat in a proper manner that dis- temper now called a rheumatism, yet as names are so apt to impose upon the understanding, it is to be ima- gined that the different kinds of the arthritis were often confounded, and consequently often unskilfully managed. Accordingly we find, that in later times the physicians came to consider all pains of the joints as the effects of a rheum or catarrh. But this change of theory had a worse consequence; for, all catarrhous humours being supposed to be of a cold nature, bleeding was forbidden, and the cure of an acute rheumatism, as well as of the gout, was then attemp- ted without opening a vein. Boiallus seems to have been the first who opposed that practice, and distin- 140 Observations on Part III. guishing the inflammatory species of the catarrh (or what we now call a rheumatism) from the rest, de- clared that repeated bleeding was necessary for the cure.* But Ballonius is the first whom I find using the term rheumatism, to denominate this inflammatory species of the arthritis, which he also conceived to be different from either a gout, or a catarrh.f The same author is also the first who has described the disease in a proper manner, and who has recommended re- peated bleeding for the cure. This method has been since followed by the best practical writers, and in particular by Riverius and Sydenham. How frequently rheumatisms occurred, especially in the beginning of a campaign, was seen in the gene- ral account;J but we must add, that though this dis- temper scnetimes appeared with all the severity mentioned by Ballonius and Sydenham, it was gene- rally of a milder kind. In a high degree of an acute rheumatism the joints are considerably swelled and inflamed, but in our fevers with rheumatic pains that was seldom the case, and therefore the cure was commonly completed in a few days, by twice or thrice bleeding, and by promoting a diaphoresis with the cooler medicines, particularly with vinegar-whey. But if the rheumatism was attended with acute pains, or swelling of the joints, the cure was chiefly to be ob- tained by repeated and almost daily bleedings, till the feverish heat and the pains were intirely removed or * De Curat, per Sang. Miss. cap. xii. t We meet with the word ptvpccturftos in Galen, but in the lax sense of rheum or fluxion, and not, so far as I know, to denomi- nate any particular distemper. Ballonius begins his treatise upon the rheumatism by calling it affectus pane «va>vvp.»s apud antiquos. | Part i. chap. iii. and chap. iv. Chap. II. particular Inflammations. 141 made much easier. And in this course we may pro- ceed the more safely, as those who are subject to this kind of rheumatism are generally in the vigour of life, and are either plethoric, or able to bear such eva- cuations. Add, that frequent bleedings weaken the body less perhaps in this disease than in any other. (76) If the pain and swelling of the joints remain after the fever is abated by frequent bleedings, apply three or four leeches to the part where the inflammation and humour are the greatest, and let the blood ooze till it stops of itself. As the relief hereby obtained is some- times immediate, and the evacuation but small, the repetitions need not be limited.* Ballonius also men- tions this practice; and I have had sufficient experience to recommend it to others. But we are to expect little benefit from leeches in such pains of the joints as are not attended with both inflammation and swelling.(77) In the acute rheumatism internal medicines avail little. In such cases I have commonly given camphire, but not so as to force a sweat.f As to diet, it must be of the lowest kind, as Sydenham well advises. (76) There is no doubt of the truth of this assertion. * I have sometimes, since, successfully used twelve leeches every day for three days together, and I make the application as soon as the parts begin to swell. (77) In soldiers and sailors there is generally but little swel- ling in the joints affected with rheumatism, probably from the parts being too much debilitated to produce that reaction which ena- bles the blood vessels to relieve themselves by a copious dis- charge of serum. In these cases local bleeding cannot reach the seat of the disease. t Although we are not to force a sweat, it will be proper to keep up a gentle moisture on the skin; for which end I have used the camphire in this manner: R Camphor a grana xii. amygdalas dulces, demptis pclliculis, ij. eontritis paulatim adjice aqua pur a ^viiss. ut fiat emulsio, cujus 142 Observations on Part III. Ballonius mentions paregorics, but without defining the kind, or the times most proper for giving them. Sydenham condemns opiates, as fixing the disease; and, so far as I have observed, justly. Outward appli- cations, excepting leeches, are also to be omitted as long as any fever or inflammation remains. The spi- rituous and volatile liniments inflame; and the emol- lient fomentations, though they give ease for a time, do harm by relaxing. (78) But the chronic rheumatism is one of the most obstinate disorders of the hospitals; being either the remains of a rheumatic fever, or the continuation of pains that proceed at first from neglected colds. In complaints of this kind, if the blood be not sizy, we may suspect that the soldier either pretends indisposi- tion, or that his pains are of another nature.* Syden- colatura admisce spiritus volatilis aromatici guttas xl. syrupi croci 5ss. Dentur quarta vel quinta quaque hora cochlearia iv. During the feverish heat, I order a laxative clyster daily; but when the fever is off, or much on the decline, I give every night at bed-time a scruple of gum guaiacum dissolved with the yolk of an egg, in a draught of plain water sweetened with sugar; by which means the patient has generally one or two loose mo- tions next day. This method I continue, after leaving off the camphire, till he gets well. To the guaiacum draught I some- times add a few grains of salt of hartshorn to keep up a perspira- tion, without weakening its laxative quality. (78) Where there is much pain with or without swelling, the editor has found the application of cabbage leaves as recom- mended by Dr. Sydenham to afford great relief, and never to do any harm. * In our hospitals, the rheumatic pains were always attended with sizy blood. This mark however of a rheumatism is not constant; as I have since seen persons with the same complaints, under no temptation to deceive, without any visible alteration in their blood. Chap. II. particular Inflammations. 143 ham has also described this species, wherein, though there be no fever, he recommends bleeding; which practice I followed, and often found efficacious. The patient therefore once in eight or ten days lost about eight ounces of blood, as long as it was sizy, or his complaints remained. Between whiles, I purged him with a solution of gum guaiacum in a larger dose than in the formula above; and on the intermediate days I gave him twice or thrice in the day 50 or 60 drops of the spirit of hartshorn in a draught of water. The tincture of guaiacum of the dispensatory contains so little of the gum, that we must ascribe most of its virtue to the volatile salt. (79) This was my practice in the hospital; but since that time having seen great good effects from the gum guaiacum used only as a laxative, in these cases therefore I give it in solution, with five grains of salt of hartshorn, every night at bed-time; and bleed or not as I see occasion. When the joints are swelled and inflamed, leeches are to be used as before; but when there is no inflam- mation, the aching parts are to be covered with flannel. In general I have found little benefit from any other external application, except leeches or blisters. After the patient has continued some time in this course, his recovery will be quickened by the use of the cold bath, or the bark;*(80) and to those who can afford it, riding is a specific remedy. (79) There is a chronic rheumatism common to sailors, in which there is no heat nor swelling in the joints, but which yeilds only to small and frequent bleedings. The editor has cal- led it rheumaticula, to distinguish it from that torpid state of the joints which has obtained ihe name of rheumaitigia. * Some physicians have given the bark in acute rheumatisms (after plentiful bleeding) as soon as a sediment appeared in the 144 Observations on Part III. By this method I have found many cured: but I must acknowledge, that several slight cases in appear- ance, have withstood these and all other methods which I could think of. Sometimes venereal pains may be mistaken for rheumatic; at other times the two may be joined. A salivation does not cure a chronic rheumatism; but there are cases which will yield sooner, if once or twice a week we give a large dose of calomel over night, and purge it off the next morning.*(81) Some of the more obstinate pains may be of that kind which Sydenham calls the scorbutic rheumatism; or others, more properly, the arthritis vaga, or flying gout. For though the common men, and especially at their time of life, very rarely have the true gout; yet, by irregularities, or diseases, the humours may tend water; though some degree of fever remained, and the pains were still considerable. 1 have had some success myself in giv- ing it so early, but have not seen cases enough to recommend the practice to others. (80) It is possible the bark may be given with advantage in the feeble acute rheumatisms of soldiers and in others previously worn down to a state of great debility by labour. The editor has used it, always with safety, and sometimes with advantage in the convalescence from the acute rheumatisms which occur in the United States. * In obstinate cases, without fever, Riverius recommends large and repeated doses of calomel joined to a purgative. Prax. lib. xvi. cap. iii. isf Observat. cent. iii. obs. xli. And others have found the same preparation answer, in alterative doses, continued for some weeks. But as the venereal pains are so often con- founded with the rheumatic, it is perhaps chiefly in the former that the mercurials have been found so efficacious. (81) Let not the languid state of the pulse be considered as an objection to occasional purging in a chronic rheumatism. The purges are not intended in these cases to reduce the system, but to invite the disease from the joints to the bowels by induc- ing in them an artificial debility. Chap. II. particular Inflammations. 145 that way without producing any regular fit. Of what kind those pains may be that are sometimes felt after ill formed and obstinate intermittents, I cannot deter- mine. Sydenham believes them to be owing to the bark; but they were certainly taken notice of by Bal- lonius before the use of that medicine. The sciatica of our hospitals is almost always of the rheumatic kind; and therefore, if recent, yields to bleeding, blistering upon the part, and the guaiacum. But if the distemper is of a long standing, or the cause gouty, the matter will lie too deep for a blister, or any of the common medicines. I remember two cases in the hospital, in which the pain was exquisite and con- stant, and nothing gave relief; so that the men, after growing hectic, and long pining, died in agony.*(82) The late Dr. J. Clerk of Edinburgh acquainted me, that he had known obstinate sciaticas, both of the rheumatic and arthritic kind, cured by a long con- tinuance of soap taken to the quantity of four or six drachms daily.f * From other cases which I have seen since, I am induced to think that these men had a suppuration about the hip joint. (82) The editor has seen a fatal hectic fever from rheuma- tism in the knee joint, where there was no appearance nor sus- picion of suppuration. t Since the two first editions of these observations, I have used in the rheumatism (when there was no fever) Dr. Dover's pow- der, giving for some nights about 20 or 25 grains of it at bed- time, with plenty of some warm diluting liquor, and laying the patient in blankets; for the composition, see the treatise called The Ancient Physician's Legacy to his Country. T 146 Observations on Coughs, Part III. CHAPTER III. Observations on Coughs, and the Phthisis Pulmonalis-. W ITHOUT entering into the general consideration of these disorders, I shall only take notice of such cases as I have found most frequent in the army. Coughs and consumptions are properly annexed to inflammatory diseases. For, a recent cough from cold may be considered as the lowest degree of a peripneu- mony; and an old and neglected cough as the begin- ning of a consumption. Obstructions of the lungs are succeeded by tuber- cles and ulcerations. In the bodies which I dissected of those who died of the phthisis pulmonalis, I found the lungs adhering to the pleura, and full both of tu: bercles and ulcers. We ought therefore to be careful in removing colds in the beginning. But this part belongs to the regi- mental surgeon, who is first applied to, and who may be assured that a cough is bad indeed when a soldier complains of it. The disease being of an inflammatory nature, bleeding is the chief remedy, which alone wil frequently cure bad colds, whilst all other medicines may be ineffectual without it. Recent coughs, after bleeding, are softened by a mucilage of linseed, by sperma ceti, or by any common sweet oil.* * I observed that the oils had a better effect when joined to a pretty large quantity of a volatile alkali: R Halis cornu cervi JfJ. solve ex aqua pura olei olivarum (yel amygdalarum dulcium) Sumantur ter^quatcrve die cochlearia iv. agitata prius phiala. Besides dein admisce sacchari albi Chap. III. and the Phthisis Pulmonalis. 147 When the obstruction is of a long standing, oily medicines are not only useless, but by relaxing the stomach may increase the disorder. In older and more stubborn coughs, or in the first stage of a consumption, when the patient complains of pains in his side, constriction at the breast, or of hot and restless nights, I have trusted most to small but repeated bleedings, to setons, and to a low and cooling diet. I have found these small bleedings not only benefi- cial in old coughs threatening consumptions, but- also after hectic symptoms have appeared. The quantity of blood drawn was from four to seven ounces, once in eight or ten days, and sometimes a vein was opened after shorter intervals. It was observable that the pa- tients seldom found themselves so much relieved on the first, as on the second or third night after bleeding. (83) The blood was constantly sizy; but if it had been found in a resolved state, to have insisted upon taking away more would have been improper. Nor would I recom- mend this method for common practice without making great allowance for the strength of soldiers, nor without suiting the quantity of blood to be let to the condition of weaker patients. In habits naturally weak, or scro- Besides this the patient, if disturbed by his cough at night, took 6 or 7 grains of the pilules Mat thai at bed-time; but since that time I have generally, in a draught at bed-time, joined to 15 or 20 drops of laudanum about 2 drachms of the oxymel scilliti- cum, or half a drachm of gum Ammoniacum (according to the de- gree of heat, or to the stomach of the patient) in order to correct the binding qualities of the opium. The former of these compo- sitions was communicated to me by the late Dr. J. Clerk of Edin- burgh: the latter, by Dr. Simson of St. Andrews. (83) This remark should be deeply imprinted upon the minds of young physicians, otherwise they will be deterred from using, and repeating the bleeding, and at a time when it is the only effec- tual remedy in arresting the progress of consumption. 148 Observations on Coughs, Part III. fulous, or when the patient has been long in a decay, bleeding, like all other means, will be ineffectual. But I can more freely recommend from repeated trials the use of a seton, made in the side upon the part most affected. In thirst, heat and other symptoms, the signs of a putrid state of the humours, the ptisan is to be acidu- lated, and the aliments ought then to be all of the ace- scent kind. Buttermilk is particularly good. And, if possible the patient ought to be confined to a milk and vegetable diet. 1 have found nothing diminish the hectic fits so much as small bleedings and a cooling diet. (84) Col- liquative sweats arc sometimes checked by lime water, and sometimes by the elixir of vitriol. (85) In the advanced state of a consumption, we may distinguish two sorts of coughs, one caused by the ulcers, and the other by a thin rheum falling upon the fauces and trachea; which parts being then deprived of their mucus become sensible of any irritation: and this last kind is perhaps the most painful and teazing: to the patient. The same medicines are not proper for both: For the first sort I have used the balsam of Peru, but did not find it more efficacious than the capyvi. Of this last I commonly gave about ten drops, twice a day, in a bolus of conserve of roses. * (84) Experience has confirmed the truth of this assertion in many hundred instances. (85) The Editor has used lime water with advantage in re- straining the distressing night sweats which attend the hectic stage of pulmonary consumption. He has likewise advised a small teaspoonful of the fine powder of calcined oyster shells, and a few grains of the powder of agaric to be taken at bed-time with tem- porary benefit. He has once known them checked by promoting a large discharge of urine by the patient's eating plentifully of watermelons. * Having since the former editions of this work, been so often Chap. III. and the Phthisis Pulmonalis. 149 The other kind of cough can only be palliated by incrassants, and for that purpose I have commonly used the conserve of roses, and opium. The former is always safe, and otherwise well adapted to the nature of the disease, but of weak virtues; the latter is the most efficacious; but is to be given with caution, con- sidering how apt it is to affect the head, to bind the body, and to obstruct expectoration. However, as these bad qualities are in some measure to be corrected by squills, as soon as the patient begins to complain of restless nights from coughing, I have usually prescri- bed a draught with a drachm and a half of the oxymel scilliticum and fifteen drops of the tinctura Thebaica, to be given at bed-time; and have increased the dose of each ingredient when there seemed to be occasion for it. I never gave the bark in any stage of the consump- tion, unless in the convalescent state, when the lungs seemed to be free from obstruction.* disappointed in the effects of such balsams in this distemper, I have laid them all aside, and trust chiefly to small but repeated bleedings (when the patients can bear the loss of blood), to a total milk or vegetable diet, to a seton in the affected side, to country air and riding, and to the free use of acids when they complain of thirst and hectic heats. (86) (86) This summary mode of treating pulmonary consumption, should be confined only to its inflammatory state. In its typhus state, not only balsams of all kinds, but the most cordial aliments and drinks, the latter, in such quantities as to keep up a tendency to intoxication, have been used with success. The records of the Pennsylvania hospital contain a number of cures performed by these stimulating remedies. * I have frequently, since, given three or four spoonfuls once or twice a day of a decoction or an infusion of the bark, without observing it to heat or obstruct the breathing; but on the contrary, to have a good effect when the patient has complained of low 150 Observations on the Part III. Riding and asses milk, the two common resources, are wanting in military hospitals: what is still worse, the air of such places, or of full barracks, is con- trary to the cure. Hence it happens, that though these means may often succeed with men better ac- commodated, they will generally be frustrated by the foul steams the sick breathe there: and though a sol- dier may chance to escape their bad effects and recover, it is odds but he relapses, by being exposed to colds as soon as he returns to his duty. In this manner I have treated the phthisis pulmona- lis. I have likewise observed much benefit to arise from small and frequently repeated bleedings in the cure of wounds, when matter has been absorbed, and a hectic fever brought on. (87) spirits and weakness, and has not been in the last stage of the distemper. (87) To the remedies mentioned by our author for consump- tion, modern physicians have added a salivation. It has succeed- ed in all its states, but chiefly after the inflammatory diathesis of the system has been reduced by bleeding and other depleting re- medies. Chap. IV. Bilious Fevers. 151 CHAPTER IV. Observations on the Fevers ca//«/Bilious, or the autum- nal remitting and intermitting fevers of the army. I COME now to consider those putrid diseases, com- monly though perhaps improperly called bilious,* which being the most common and fatal to an army, and least known, shall therefore be treated of in a more full and regular manner than the preceding. The bilious disorders begin about the decline of summer, and become epidemic in autumn, appearing earlier, more general, and with worse symptoms, in proportion to the heat of the season, and to the mois- ture of the ground and climate. Although of different forms they are of a like nature, and may be reduced to two heads, viz. fevers and fluxes. Beginning with the fevers, I shall first describe that which is frequent in every camp; next, that which seems more peculiar to the marshes; in the third place, I shall inquire into the cause of both; and then com- pare them with those of other places in the like cir- cumstances: lastly, I shall propose the method of cure which I followed both in the fevers of the camp, and in those which occurred in the marshy parts of the Netherlands. In the next chapter I shall mention such remedies as I found most successful in removing the obstructions occasioned by these distempers. * Why so called, see part ii. ch. i. part iii. chap. iv. § 3. 152 Observations on the Part III. SECTION I. Of the Symptoms of the Remitting, and Intermitting Fevers of the camp. IN the month of June, the fevers in the camp are fewer and less inflammatory than upon first taking the field; and as the season advances they are attended with still less inflammation, but with more disorder of the stomach and bowels, and with pains in the head; and they have all a sensible remission. This change, just perceptible after the solstice, becomes manifest by the end of summer, or the beginning of autumn. This epidemic differs according to the nature of the ground, and therefore I shall distinguish it into two species; one, incident to an army on dry ground; and the other, infesting it in damp and marshy countries. I shall first describe the former. The bilious or remitting fever of the camp begins with chilliness, lassitude, pains of the head and bones, and a disorder at the stomach. At night the fever runs high, the heat and thirst are great, the tongue is parched, the head aches violently, the patient gets no rest, and often becomes delirious; but generally in the morning, an imperfect sweat brings on a remission of all the symptoms. In the evening, the paroxysm re- turns, but without any cold fit, and is commonly worse than the former: next morning it remits as be- fore. These periods go on daily till the fever if ne- glected, changes insensibly into a continued form. Sometimes loose stools carry off the fit and supply the place of sweats. Although this fever in many particulars resembles an intermittent, yet it is somewhat of a different nature, as shall be more fully shown when we come to the cure. Chap. IV. Bilious Fevers. 153 In the camp we seldom meet with a regular intermit- tent either in a tertian or quartan form, unless in the case of a man who was ill of one before he took the field. The remissions usually appear from the beginning, and especially if the patient is bled on the first attack: sometimes they are little perceptible for the first two or three days. Haemorrhages of the nose, at the height of the paroxysm, generally bring on the re- mission sooner and make it more complete. Vomiting or purging have the like effects. But I remember no natural evacuation making a cure at once, unless when a cholera supervened, that- is, a violent discharge both ways of the corrupted humours which seemed to be the cause of the disease. The fits are seldom preceded by shiverings, or any sense of cold, after the first attack. The pulse is full and quick during the paroxysms, and in the remis- sions it still indicates some degree of fever. The blood is florid, the crassamentum is firm, in a large quantity, and sinks in the serum. The blood shows no great sign of inflammation in the beginning of the epidemic, but towards the end of the campaign it acquires a sizy crust; for by that time, to the other symptoms are joined either stitches, rheumatic pains, or a cough.(88) Whilst the weather continues warm, the marks of a foulness in the prima vice are most frequent; but as winter approaches, the inflammatory symptoms pre- vail. The urine is high coloured and crude till some eva- (88) Our author errs in estimating the violence of a fever by a sizy crust upon the blood. Its florid colour, and the crassamen- tum sinking in the serum, indicate a higher grade of disease, and call for a more prompt use of the lancet than the sizy crust* u 154 Observations on the Part HI. cuations have been made, and then it begins to break. What is voided by vomiting, or by stool, is generally of a bilious and corrupted nature. Costiveness not only often precedes but accompanies the disease, and when that happens the belly feels hard, and the pa- tient complains of wind. Although all do not vomit yet every one feels a disorder at the stomach, espe- cially during the hot weather. Worms come away frequently by stool, sometimes by vomiting. They are of the round kind, and those who are troubled with them have more obstinate grip- ings, or sickness at the stomach. In such cases, stitches are frequent; but these being often of the flatulent kind are not always relieved by bleeding. Some grow yellow as in the jaundice. This colour was observed to be more frequent during the first campaign than afterwards: it was an unfavourable, but not a mortal sign. One of the regimental surgeons told me, that he had opened the body of one of his men who died with this symptom, but had discovered no calculus, nor any kind of obstruction in the gall- bladder or in the biliary ducts. The infantry were more subject to the fever than the cavalry; and these last, more than the officers: this seemed to be owing to the difference of clothing and accommodations.* There were no critical days, nor any certain dura- tion of the distemper, which was longer or shorter, according to the manner of treating it.(89) It could not be called dangerous, when timely and proper means were used; but this fever is often fatal to an * Part i. chap. iii. (89) The power of nature over the system in producing criti- cal days, appears to have been destroyed by the habits of a sol- dier's life. Chap. IV. Bilious Fevers. 155 armv, when so many are seized at once as cannot be properly attended; or when it changes into a continued or malignant form, either by neglect at first, or by crowding too many who are ill of it into the same hospital. This remitting fever attended every campaign, and was most frequent and fatal after the hot summers of the years 1743, and 1747; but in the campaigns 1744, and 1745, the seasons being temperate, fewer were seized, and the cases were milder. SECTION II. Of the Symptoms of the Remitting, and Intermitting Fevers in low and marshy countries. THIS species of the putrid fever was mentioned in the general account of the diseases, most incident to the Netherlands,* and also in the account of those which occurred during the two last campaigns;! but the full description was reserved for this place. We are first to observe, that though all moist coun- tries are subject to intermittents, yet if the moisture is pure, and the summers are not close and hot, the fevers will mostly appear in a regular tertian form and be easily cured. (90) But if the moisture arises from stagnating water, in which plants, fish, and in- sects die and rot, then the damps being of a putrid nature not only occasion more frequent but more dangerous fevers, which oftener appear in the form of quotidians, or double tertians, than in that of single ones. These marsh-fevers are not only apt to begin with little remission, but after intermitting for some * Part i. ch. i. t Part l- ch- vii- and viii" (90) There can be no doubt of moisture alone being one of the remote causes of fever. 156 Observations on the Part III. days, to change again into continual fevers of a putrid and malignant nature. It is remarkable how much they vary with the season; for however frequent, vio- lent or dangerous^ they have been in the decline of summer, or beginning of autumn, when the putrefac- tion is at the height, yet before winter they are redu- . ced to a small number, become mild, and generally assume a regular tertian form. The first kind were observed to prevail near the inundations in Dutch Brabant;* the next, were those of Zealand; f of the third degree, were those in the lines of Bergen-op-Zoom;% and the mildest sort, were such as were'most frequent in the cantonments around Eyndhoven,$ in villages rendered moist by planta- tions, and subterraneous water, but not putrid. I shall describe the first and worst kind, from which it will be easy to judge of the nature of the rest. In the end of July 174 ', when the troops had been a fortnight or three weeks in the cantonments, whilst the days were sultry, but the nights cool and foggy,|| several of the men (of those regiments which lay nearest the inundations) were seized at once with a burning heat and a violent head-ach; some feeling a short and slight chilliness before the attack, others mentioning no preceding disorder. They also com- plained of intense thirst, aching of the bones, a pain of the back, great lassitude and inquietude, frequently of a nausea, sickness, or a pain about the pit of the stomach, and sometimes they vomited green or yel- low bile of an offensive smell. The pulse upon the first attack was generally depressed, but rose upon bleeding. There were some instances of the head * Part i. ch. viii. % Ibid. ch. viii. t Ibid. ch. vii. \\ Ibid. ch. viii. \ Ibid. ch. vii. Chap. IV. Bilious Fevers. 157 being so suddenly and violently affected, that without any previous complaint the men ran about in a wild manner, and were believed to be mad, till the solution of the fit by a sweat, and its periodic returns, disco- vered the true nature of their delirium. (91) Some time after, Dr. Stedman, then surgeon to the Greys, acquainted me: " That two of the men " who were first taken ill were seized at once with " symptoms of an ardent fever, and though they were " speedily and plentifully bled, yet in an hour after, " both were in a high delirium, which continued for " some hours and then went off with a profuse sweat, " under which all the other symptoms either abated " or vanished. That next day about the same hour " the paroxysm returned, and in six or seven hours " ran the same course. That in this manner the fever " affected many of that corps, whilst some of them " had less distinct paroxysms, the hot fits longer, and " those followed by imperfect sweats with little relief. " That sometimes the remissions were so impercep- " tible, that the disease appeared almost in a continued " form. That the nearer it approached to this last state " it was the more intractable; but that when the parox- " ysms were distinct, with an intermission of some " hours between them, the patients for the most part " did well, however great the delirium was during " the fever. That a few returns of the paroxysms re- " duced their strongest men to so low a condition as " to disable them from standing. That some became " at once delirious without any previous complaint, " and would have thrown themselves out of the win- " dows, or into the water, if not prevented; that their (91) Fever, when accompanied with this symptom, has beeu called the maniacal state of fever, it is very properly distinguished from mania by paroxysms which terminated in sweats. 158 Observations on the Part III. " frenzy continued for some hours, after which fal- " ling into a profound sleep, they awaked quite sen- " sible but with a violent head-ach. That others, " whose fever appeared in a continued or remitting " form, had critical sweats about the ninth day, and " afterwards regular paroxysms and intermissions. " That a few had a crisis by stool or urine. That " there were some who were ill about three weeks " without any sensible remission, after which the " fever ended with some quotidian paroxysms, and " that these men during their illness had gentle " sweats, or rather a continual moisture upon the skin. " That many upon being first taken ill had bilious " vomitings; and that several voided round worms " both ways. That the profuse sweats had always a " putrid smell; and that the discharge from the blis- " ters was so offensive, that the nurses declined dres- " sing them. What was most remarkable, a few of " those who died were observed to have a regular "pulse, though very near their end. (92) That all " those who died had a cadaverous smell (93) for " some days before death, and immediately after, " livid spots and other signs of a mortification." Dr. Stedman concluded with observing, that " the same " distemper was also common among the peasants of " the cantonments in the neighbourhood, and that a " great number of them died." This account of the beginning of the epidemic being so full and distinct, I need only add, that it agreed with the observations of all the other regimen- tal surgeons in the like situation, allowing for some (92) A regular pulse attended the last stage of the yellow fever in Philadelphia in many instances. (93) The editor has known but one instance of a recovery from a malignant fever, in which this cadaverous smell took place. Chap. IV. Bilious Fevers. 159 variation according to the different circumstances of those corps. Thus Mr. Lauder, surgeon to the Ini- skilling regiment, then Lord Rothes's, informed me, " that most of the men were first taken ill upon their " return from forage: for, the regiment being canton- " ed upon the right and left of St. Michel's Gestel " (their principal quarters) close upon the inunda- " tions,* and many of the quarters being above two " leagues from Bois-le-duc where the magazines were " kept, the men were obliged to set out about four in " the morning, in order to get back before the greatest " heat of the day. That at this early hour the mea- " dows and marshes on each side of the road were " covered with a thick fog of an offensive smell, " which he considered as the chief cause of the sick- " ness. For though the party generally returned be- " fore noon, that several among them were already in " a fever, and some actually delirious; nay, that a few " on their way home were so suddenly taken with a " frenzy, as to throw themselves from their trusses " into the water, imagining they were to swim to their "quarters. That from the first attack, as many of " them as were sensible complained of a violent head- " ach, thirst, and burning heat; and that all of them, " attempting to sit up, were ready to faint away with " a giddiness, sickness at stomach, and retching to " vomit. That these fevers were for some days of a " continued form, or at most had slight remissions; " after which they either remitted more plainly, or " thoroughly intermitted. That at first the pulse was " small and depressed (though the patient was then " delirious) but that it always rose upon bleeding." Mr. Lauder told me, about three years after this sick- * Part i. chap. viii. 160 Observations on the Part III. ness, that two of those men, who were so suddenly taken with a frenzy on their return from foraging, though they recovered of their fever, had ever since been epileptic; and that all the rest, who had been ill, were still liable to returns of an intermitting fever. The condition of the foot was somewhat different, for few of them being cantoned near the inundations, their fevers though frequent were generally of a milder nature; yet some of those corps had the sickness also in a high degree, occasioned by the moist and corrupted air of their quarters. The village of Dinther* lay low, and was surrounded with ditches and thick plantations. Mr. Tough, surgeon to the battalion there, observed: " That the meadows were every evening overspread " with a fog, which continued till next morning after " sun rise, and which had the offensive smell of a foul " ditch newly drained. That the men were commonly " taken ill in the night-time with a shuddering or sense " of cold, which was soon followed by a violent head- " ach, intense heat, and other feverish symptoms.f " That at this time the pulse was so small and de- " pressed, that if a vein was opened the blood at first " would scarce run out, but that after some vent it " flowed briskly, and then the pulse rose. That a " profuse sweat succeeded the heat, and with that a " remission, or intermission of the fever. That the " paroxysms returned every evening, and if care were " not soon taken to stop the fever, it was apt to charnge " into a continued form with malignant symptoms. " That in three cases he observed petechial spots; * Part i. ch. viii. t It is to be remarked, that the dragoons having better pay generally hired beds of their landlords, or at least lay warm in their cloaks: but that the foot soldiers wanting these advantages, lay in barns and other damp places without any covering. Chap. IV. Bilious Fevers. 161 " and in a fourth, a mortification under the left breast, " which however was cured by the bark. Lastly, that " there was one instance of a man, who being sud: " denly seized with the usual headach, and not imme- " diately bled, got out of his quarters and ran about " the fields like one distracted." In the greatest heat of the weather and rage of the distemper, most of these fevers answered the descrip- tion of the Koiveog or ardent fever of the ancients, which Hippocrates does not rank with the inflammatory dis- eases of the winter and spring, but with the bilious epidemics of summer and autumn,* though later writers have applied this term to all fevers attended with great inflammation. But it was observable, that even in the worst parts of that country, as soon as the weather cooled in the decline of autumn, the fevers began to assume a milder form; and in the end of the season, differed little from the common intermittents of other places. There were but few quartans, and those did not appear till late, nor were they hard to cure unless when they succeeded to some other form of this fever, which had already produced obstructions in the viscera. When the sickness was at the worst many voided round worms, which were not the cause of the fevers, * Aphor. lib. iii. The ardent fever of the ancients was either continued, or re- mittent; of which last Gorraeus gives the following description: " Est o xuvo-of tertiana febri ifAoyivin, ut qui ab iisdem causis, eodem anni tempore Is? iisdem corporibus firovenit, a quibus is? tertiana febres excit'ari solent. In tertiana intermittente prii»u;r rigor, deinde clKijp%i* est: verum ardentis exaccrbationcs nullc cum ri- gore flunt, nee unquam intcgre solvuntur, sed modice tantum rcmittuntur." Definit. in voce ¥.S,vith. X 162 Observations on the Part III. but, as we observed before, concurred with other circumstances to retard the cure. At the height of the epidemic it appeared, that both intermittents and remittents, by extending or doubling their paroxysms, frequently changed into a continued, putrid and dangerous form, and that most of those whom we lost died in this way. These men, as we remarked, had a corrupted smell for a day or two before their death, and soon after it their bodies mor- tified. Some had petechial spots, though the place where they lay was neither crowded with sick, nor too close; and to these spots were added some other symptoms, the same with those of the hospital-fever. But in general, the mortality was not in proportion to the number of the sick, nor to the alarming nature >pf the symptoms. Although the distemper was violent, yet it yielded to medicine, and no kind of acute dis- order seemed to require it more; for a great number of the country people perished for want of it, whilst most of our men recovered by the care of their regi- mental surgeons. Of the Greys and Rothes's dragoons, who were the most sickly, 31 died in all; which will not appear a considerable number, if we reflect what a multitude of bad cases there were (and those much dispersed) and how few to attend them.*(94) One of the most unfavourable circumstances was the proneness to a relapse, the danger of which was greatest during the hot weather, less in the decline of autumn, and least of all after the frosts began. But in the following spring, relapses became so frequent, that * Part i. chap. viii. (94) Let sceptics in medicine, and the advocates for the heal- ing powers of nature be dumb, after reading the different issue of the bilious fever, described by our author in the two preceding paragraphs. I Chap. IV. Bilious Fevers. 163 those regiments, who had served in Zealand in the preceding autumn, had in the next campaign above four times more sick than any other corps in the line. Frequent relapses brought on visceral obstructions, which made the intermittents more obstinate and irregular, and terminate in a dropsy, or jaundice. In this bad state of the viscera, a hard tumour was fre- quently felt on the left side of the belly, lower than the false ribs, called by the common men the ague- cake. But as none of those who died with this tumour were opened, the part affected could not be ascertain- ed. I conjectured it to be the spleen. It was often accompanied with swelled legs, a distension of the whole belly, or with some other hydropical symptom; and whilst it lemained, the fits could not be safely stopped by the bark. It was a bad but not a mortal sign, since many who had it recovered. I likewise met with a few cases of the tympanites, a distemper which I suspected to be chiefly owing to a premature use of the bark before proper evacuations. But as to other obstructions, and in particular those which brought on the ascites, I observed that they happened as often without, as with the bark, and therefore seemed generally to depend on the long continuance and obstinacy of the intermittent. It was remarkable, that whilst the sickness raged among the common men, it appeared in a mild degree among the officers, who seldom had the fever in a continued form, or attended with malignant symp- toms, but in the shape of single and double tertians, or of quotidian remittents. The reason seemed to be, that they were less exposed to the sun and fogs, that they had drier quarters, better diet, and the use of wine. 164 Observations on the Part III. SECTION III. Of the Causes of the Remitting and Intermitting Fevers of the camp, and those of low and marshy countries. THE heat and moisture of the air appear to be the chief remote and external cause of these fevers; and this cause is most prevalent not only in proportion to the warmth and closeness of the weather, but to the quantity of vapour with which the air is loaded in the drought of summer. Rains in general lessen the mois- ture of the air by draining it of so much water: and by descending from a colder region, they not only refresh the atmosphere but the earth also, and thereby check immoderate exhalations. The most healthful campaigns have therefore been those in which the heat and moisture of the air were moderated by fre- quent showers. But if the air in its greatest heat receives not only the aqueous, but the putrid effluvia from marshy grounds, or from any large surface of corrupted water, the remote and external cause of sickness will be aggravated, the diseases will be more numerous and attended with more alarming symp- toms. The relaxation of the fibres and greater tendency in the humours to putrefy, consequent on this state of the atmosphere, may be considered as the internal and predisposing cause of these fevers: for, a hot and moist air unbraces the solids, resolves the blood, and obstructs perspiration. When the air is filled with vapour, it admits the perspirable matter with diffi- culty; and when part of that is retained, the blood not only thereby receives a septic ferment, but is more heated by having less evaporation. Nor can the want of a free perspiration be supplied by sweating, aS Chap. IV. Bilious Fevers. 165 sweating tends to weaken the body and render it more subject to disorders. Although these two causes may be sufficient of themselves to produce this fever, yet for the most part a third is wanting to bring on the disease: this is called the exciting or occasional cause, which always arises from some error in the non-naturals; such as heating the blood by fatigue, intemperance, or insolation; or by suddenly checking the perspiration by improper food, wet clothes, lying on wet ground, &c. To these last errors in regimen Sanctorius must allude, when he refers the causes of the autumnal tertian fevers to a stoppage of perspiration; and we can scarce doubt of the justness of that observation, though from Keil's Tables it would seem, that this excretion may not only be diminished, tout for some time wholly suppressed, without any injury to the health.(95) But we are not to compare the ordinary checks given to perspiration in this country (where the weather is sel- dom close and hot for any considerable time) with what happens in other climates subject to such intem- perature, where the inhabitants having in summer and autumn long and uninterrupted heats (and by thatmeans blood of a more putrescent nature) require a more con- stant evacuation of what is recrementitious. Sancto- rius himself says, " that such a stoppage of perspira- " tion as in summer might occasion a malignant fe- " ver, will in winter scarce affect the health,"* (95) In a vigorous constitution the perspiration when obstruct- ed is conveyed out o^ the body by urine, stool, or an incre-sed exhalation from the lungs. It is only when the body is debilitat- ed that the perspiration is retained, ant! disease thereby induced. * Adiapneustia. qnse restate maiignam febrem, hyeme vix mi- nimam alterationem efficere potest: corpora enim acriori perspi- rabili sestate referta sunt quam hyeme. Med. Stat. sect. ii. aphor. xxxv. 166 Observations on the Part III. Thus far we have endeavoured to trace the remote, the predisposing, and 'he occasional causes of these fevers, and it were to be wished that with the same probability we could explain rheir causa proxima or immediate cause, that is, could show how these vitiated humours act upon the vital principle, so as to excite a fever of a remitting or intermitting form, accompa- nied with such symptoms as were mentioned above. But in these researches, as so much depends upon the action of parts which have laws peculiar to themselves and are imperfectly known, it seems better not to form an hypothesis at present, but to wait till further dis- coveries be made in the animal economy. These fevers have been long called putrid, and not without foundation; since, from what we have observ- ed, there seems at this time to be such a disposition in the humours to putrefaction. They have still more an- ciently been distinguished by the name of bilious, but with a more disputable propriety; as the first authors did not confine that term to the appearances only, but extended it likewise to the cause of the disease. Yet it was no wonder that the ancients should believe that these fevers arose from bile, when they observed that nature cured them by a cholera or violent discharge of the gall both ways; and that physicians could also suc- ceed, in the same manner, by a vomit and a purge. But after all, the bile seems to be more the effect than the cause; for whenever these fevers come to fair intermissions they give way to the bark, a medicine which so far as we know has no direct influence upon that humour. All therefore that can be said in favour of the ancient doctrine is, that though the bile be not the first cause, yet, from its redundance and deprava* tion, owing perhaps to the fever, it frequently be- 4 Chap. IV. Bilious Fevers 167 comes a secondary cause of irritation and supports the disease.(96) I should now proceed to the cure, but as it may be proper to examine these principles, by considering what form the summer and autumnal disorders as- sume in other places, under the influence of a warm, moist, and putrid air, I shall produce a few instances for this purpose from such authors as seem to have made the proper observations. SECTION IV. The Remitting and Intermitting Fever of the Camp and Cantonments compared with the Summer and Autumnal Fevers of other places. I SHALL begin with the morbus Hungaricus, a dis- ease frequently mentioned by authors, but, as I ima- gine, not thoroughly known. It is described as a ma- lignant fever, attended with sickness at the stomach, a pain and hardness about the epigastric region, great thirst, a parched tongue, and a constant headach end- ing in a delirium. These were the common symptoms, to which were generally added petechial spots, or blotches. This distemper was contagious and mortal, though it usually run out from 14 to 20 days. It was first* taken notice of in the year 1566, in the imperial army in Hungary, and from thence it spread over a great part of Europe. As I have read no author who was an eye-witness, I shall take the liberty to infer from this account, which we have from Sennertus,* that the Hungarian disease was a compound of the bi- (96) This remark is correct, nor is this the only instance in which a disease is increased by its effects. Sometimes the effects of a disease, become the cause of many other diseases. * De morbo Hungarico. 168 Observations on the Part III. lious and hospital-fever, taking its rise in the camp, but acquiring that high degree of malignity from the foul air of the places in which the sick were crowd- ed.(97) It appears that the climate there is one of the worst for an army in the field; which is easily under- stood, from the cold and damp nights that succeed the sultry days in a marshy country.* And since the au- (97) There can be no doubt of the miasmata which produce the bilious and hospital fevers, acting at the same time upon the body Dr. Monroe & Lempriere mention instances of it. A fe- ver thus formed, *ias sometimes become contagious, which Lem- ' priere says has led to the erroneous belief that the bilious yellow fever spreads by contagion. * The moisture of that country is to be understood only of such low parts of it as lying upon the great rivers, particularly the Danube andDrave. are exposed to frequent inundations. For, the land-floods form marshes, and these corrupting begin to in- fect the air about the end of summer. The rest of Hungary is said to be dry and healthful: but the campaigns being always made near those, rivers, the troops on that account have been generally sickly. Dr. Brady, physician-general to the Austrian army, who served three campaigns in Hungary, informed me, that upon the drying up of the inundations, he has seen large tracts of those grounds swarming with aquatic insects; and he confirmed the above ac- count of the moisture of the air, and of the remarkable difference between its temperature by day and by night. Now, the sudden changes from heat to cold are not only to be ascribed to the damps (the air after sun-set being always colder in proportion to its moisture) but, according to that gentleman, to the winds blow- ing from the Carpathian mountains, which are some of the high- est in Europe and constantly covered with snow. These lying at so great a distance, he supposed that the stream of air from that quarter was in the day-time thoroughly heated before it could reach the camp, but which could not happen after sun-set. Dr. Brady also told me, that the description here given of the bilious fevers of the marshes agreed with the observations which he had made of the autumnal fever incident to the queen's troops in Hungary, not only with regard to the symptoms, but to i's cure by the bark, which he, the first of any Austrian physician, Chap. IV. Bilious Fevers. 169 tumnal fevers and fluxes are more frequent and worse in Hungary than elsewhere, in order therefore to ac- count for the great mortality and pestilential nature of this epidemic, we need only suppose that the weather in that year was more than ordinarily unwholesome throughout Europe, that the sick were crowded toge- ther, and that the dead frequently lay unburied.* But these reflections will be better understood after consi- dering the nature of the jail or hospital-fever, to which class this disease may in part be referred. We shall therefore proceed to examine some other epidemics of a less doubtful nature. At Copenhagen, in the year 1652, a fever began in autumn after an unusually hot and dry summer.f That city is situated in a low and moist country. The fever was accompanied either with quotidian or tertian paroxysms, with bilious vomitings, a burning heat, violent fiead-achs, often with a delirium, and with pete- chial spots which came out in the fits and disappeared in the remissions. These spots, with an extraordinary de- bility, showed the malignant nature of the disease, which was further ascertained by the fever's ending in profuse sweats, abscesses, a diarrhoea, or dysente- ry. The author of this account, Thomas Bartholine, upon dissecting the bodies, and finding the stomach had given in that distemper-. And he added, that the course of the other military diseases, both there and in Bohemia, had been si- milar to what he found (by reading the first edition of these Ob- servations) had occurred in our campaigns in Germany and in the Low-Countries. * This very circumstance is mentioned by Sennertus. Fid. loc. cit. f Bartholin, Histor. Anatomic. Rar. cent. ii. hist. lvi. Y 170 Observations on th& Part III. and duodenum always inflamed or mortified, assigns to these parts the seat of all malignant fevers.(98) In the year 1669, a like fever raged at Leyden, de- scribed by professor Sylvius de le Boe,* who lived at the time, and practised there. The situation of this place is also low and damp. The spring and beginning of summer were cold, but the remainder of summer, and the autumn were unusually hot, with little or no rain, and with a constant calm or stagnation of the air. The water of the canals and ditches were highly cor- rupted, and the more so, as the author observes, byr an inlet of salt water mixing with the fresh, f The air being thereby rendered more impure brought on an epidemic fever of a remitting, or intermitting form, and very fatal. Besides a disorder of the stomach, great anxiety, bilious vomitings, quotidian or tertian paroxysms, and other symptoms the constant attend- ants of this illness, he mentions spots, oozing of blood from the nose and hemorrhoidal veins, dysenteric stools, putrid urine, great debility, aphthae, and other appearances which argued an uncommon resolution and putrefaction of the blood. And yet, which is strange, Sylvius ascribed the cause to a prevailing acid,! and treated the distemper accordingly:(99) so that we cannot help remarking, that the great mortality (98) We see in the history of this fever its sameness in its causes, symptoms, and in the appearance of the stomach after death, with the American yellow fever. * Prax. Med. append, tract, x. t The reasons of this may be learned from the experiments in the Appendix, paper iii. and iv. \ Sylv. Prax. loc. cit. dcxxvii. (99)The same opinion has been revived inthis country.Happily however, it has not led to the exclusive use of the same remedies for the cure of the fever, which has been supposed to arise from this morbid acid. Chap. IV. Bilious Fevers. 171 among the principal inhabitants of that city (of which he says, two thirds died) might have been owing, in some measure, to the method of cure by absorbents, and other medicines, agreeably to the notion which that ingenious and learned man and his followers enter- tained of its cause. These and other instances of the same kind may confirm what was observed before, of the danger arising from hot and dry summers to' moist and low countrie..* But the putrid diseases are still more frequent and fatal in the marshy countries of the south, where the heats are longer and more intense. In some parts of Italy, and in other tracts of the same latitude, these fevers have appeared with such dangerous and putrid symptoms, as not only to have been called pestilential, but confounded with. the plague itself. In this sense we are to understand Celsus,f in the terms pestilentia and febris pes^ilentialis, which he describes as peculiar to the grave* anni tempus and the graves regiones. His meaning is, that the bilious and malignant fever is the disease of the latter part of summer and of autumn, when the air is thickest and most foggy, and that it is most frequent in low and marshy countries. Rome was always liable to these fevers. Galen calls the hemitritcca the epidemic of that city, and speaks of its moist air. J Nay, in the beginning of the republic, before the Romans seem to have been aware of the noxious effects of stagnating water, or at least before they knew how to let it off, that place appears to have been so very sickly, that from the beginning of the state to the year U. C. 459, I find fifteen plagues * Part i. ch. i. Part ii. ch. i. § 2. f Cels. de Medicin. lib. i. cap. x. lib. iii. cap. viii. t De Temperam.lib. ii. 172 Observations on the Part III. mentioned by Livy,* which yet, from other circum- stances, appear to have been only so many malignant and destructive epidemics occasioned by the putrid effluvia from the neighbouring marshes. But when drains and common sewers were made, Rome became more healthful, and then only the low and wetter places of Latium remained sickly. Afterwards, when the city fell into the hands of the Goths, the drains being stopped and the aqueducts cut, the Roman ter- ritory became one continued marsh, which for a series of years occasioned an incredible desolation, f And though these evils have been since remedied, yet still, by neglecting to draw off the stagnating and corrupted water (after inundations of the Tyber succeeded by great heats) the malignant remitting, and intermitting fevers become both general and fatal. The dissections made by Lancisius, added to his excellent account of those epidemics, are a full proof of their putrid nature. J <» Although it does not appear that the*countries in which Hippocrates practised were either marshy or subject to inundations, yet we find him frequently mentioning these fevers as common in summer and autumn, and as prevailing most when wet springs with southerly winds were succeeded by hot and close summers. A remarkable constitution of this kind is described in his epidemics, § at which time the diseases were ardent, remitting, and intermitting fevers of a bad kind, attended with fluxes, parotids, and eruptions of a pestilential nature. Prosper Alpinus observes, that the stagnating canals * Lancisius reckons up several more from the same author. Vid. Dissert, de Advent. Rom. Cceli Qualit. cap. iii. t Id. loc. cit. | De Nox. Palud. Effluv. lib. ii. epid. i. cap. vi. § Lib. iii. § 3. Chap. IV. Bilious Fevers. 173 at Grand Cairo breed every year a malignant kind of smallpox, as also the putrid and pestilential fevers that prevail in March, April and May, which the southerly winds make the hottest months in that country.* He also remarks, that the pestilential fevers are both epidemic and fatal at Alexandria in autumn after the recess of the Nile. They begin with a nausea, great sickness at the stomach, extraordinary inquietude, and a vomiting of an acrid bile;f and many have bilious and putrid stools. Now, as these distempers rage in both those cities every year, it is not surprising, if in seasons uncom- monly hot and moist they should be raised to a true plague. For, though the learned author asserts, that the true plague is not properly indigenous in Egypt, but is brought thither from Greece, Syria, or the more southern parts of Africa, yet he thinks that it may sometimes begin there after extraordinary inundations of the Nile, when the water, extending itself beyond the usual drains, stagnates and forms some large putrid marshes.:}: Java, lying between 5 and 10 degrees of south latitude, is so near the line, that the seasons are not so properly divided into summer and winter, as into the dry and the rainy. The rains begin in November and continue till May, in which time an immense quantity falls. There are also a great number of marshes and canals with stagnating water at Batavia, and by their exhalation the air is rendered moist, foggy and un- healthful. Bontius observes, that at this time the humidity is great, and that even in the dry months the metals rust,$ and the clothes rot in that country * De Med. J£gypt. lib. i. cap. xiv. t The author's phrase is bills virulenta. \ Ibid. cap. xv. § The rusting of metals is perhaps only an ambiguous sign of moisture in any place near the sea within the tropics. For I have 174 Observations on the Part III. sooner than.in any part of Europe. Nevertheless, the plague is unknown in Java, though from these cir- cumstances one might expect that this island should be greatly exposed to it. (100) But we are to consider, that when the sun is most vertical in that country, it is also most clouded; by which circumstance, and the continual interchanges of the sea and land breezes, the heat of the air is moderated, and its stagnation in a great measure prevented. The distempers are the cholera, flux, and a continued putrid fever. This last comes on suddenly with a delirium, and is attended with constant watchfulness, a vomiting of bile of various colours, but chiefly green. The extremities grow cold, whilst the inward parts burn, and the thirst is excessive; but the fever comes soon to a crisis. The evacuation of the first passages is the principal part of the cure; and next to that, the author recommends saffron,* a powerful antiseptic as well as a cordial medicine.f The British settlements on the Gold-coast, in Gui- nea, are as near the line on one side as Java is on the other. In that country, the rainy season begins about the end of April and continues till past the middle of been told by a gentleman, who made the experiment in Jamaica, that though ironrustsvery soon in that island, yet that salt of tartar seemed to attract moisture from the air more slowly there than in Britian. I imagine therefore that the speedy rusting of metals, in hot climates, near the ocean, is owing to the great exhalation of the spirit of salt, which flies off from the sea-water by means of the heat. (100) The fever of Batavia is derived from the same causes as the yellow fever, in the United States and the plague in Egypt. The trifling difference in their symptoms is produced wholly by a difference of climate. * Bont. Method. Medend. cap. xiv. f Append. Paper, ii. exp. xi. Pap. iii. exp. xVi. Chap. IV. Bilious Fevers. 175 June; from that time the weather is cold for the cli- mate, and the air very moist, from the exhalation of so much rain. During this cold season remitting, and inn rmitting fevers with quotidian paroxysms are epi- demic. These fevers are accompanied with great thirst, with a nausea and inquietude, and frequently with a vomiting and purging of putrid bile; nor do they usually abate till that is evacuated. If a discharge of that humour is not made in time, the distemper assumes a continued and nialignant form, the pulse sinks, and a delirium comes on, which is generally fa- tal. Fluxes are likewise frequent at this season; and both fever and flux are not less common on board the ships lying off the coast, than on shore, but do not af- fect such as keep out at sea beyond the limits of the foggy air. The sea and land breezes here, with the haziness of the weather during the hot season, seem to be of the same use as at Java for preventing pesti- lential diseases.* Nor do the bilious fevers of the West-Indies, though of a putrid nature, ever turn to a plague; because the same kind of breezes prevailing there, may prevent that degree of stagnation and corruption of the air which is necessary to produce it. But the heats being great, and the atmosphere loaded with vapours, fevers of remitting and intermitting forms, with bilious vo- mitings, become epidemic throughout June, July and August (April and May are always rainy months in Jamaica) and rage most after the wettest seasons. These fevers are incident to the natives as well as to strangers. But the new comers are liable to a more putrid and a more dangerous fever, or rather to a * This account of Guinea, I had from persons of observation, who had lived some years in that country. 176 Observations on the Part III. higher degree of this bilious disorder, which, though not confined to any certain time of the year, mostly coincides with the former. This last is distinguished by vomitings of matter, sometimes green or yellow, at other times black and bloody, but chiefly by the yellowness of the skin, which gives it the name of the yellow-fever. The blood is so much resolved, that be- fore death it enters the smallest vessels and tinges the saliva, and the serum discharged by a blister.* * Dr. Warren (in his treatise concerning the malignant fe- ver in Barbadoes) mentions several other symptoms indicating putrefaction of the humours, and nervous spasms consequent thereupon. This ingenious author appears however to have mis- taken the nature of the yellow-fever, by referring it to the pes- tilential class of diseases: but though he died young, we are in- formed that he was sensible of his error, and had he lived longer, would have corrected it. By Dr. Hillary's account, we can see a similarity in the symptoms, and in the treatment, with the bilious fevers of other hot climates. But, upon this article I re- ceived the most satisfaction from Dr. Huck, who having been upon the expeditions to the French and Spanish islands, in the late war, made the following remark upon the paragraph above: " Even in the most ardent and worst kinds of the yellow-fever, " I think a paroxysm may generally be perceived once in four " and twenty hours; for the patient is commonly worse towards " the evening, or at night. And if the yellow-fever was to be dis- M tinguished, in its beginning, from the common remitting or « intermitting fever which was so fatal to our army, it was only " by all the symptoms running higher, and by a greater degree " of the fever when one might have expected freer remissions. " Both fevers began with nearly the same symptoms; sometimes, " though rarely, with a shivering. But whenever the fever ran " high with burning heat, violent pains of the head and loins, " profuse sweats without relief, redness and burning pains of the «* eyes, inflamed countenance, watchfulness, anxiety, oppression, " and burning pains about the pracordia, frequent vomitings of " green or yellow bile, or (what I think was rather worse) a con- " stant retching to vomit without bringing up any thing, or vo- '• miting the drinks only, one might then almost certainly fore- Chap. IV. Bilious Fevers. 177 The result of the whole is: Wherever the greatest causes of putrefaction exist, there also will be seen the greatest number of remitting, intermitting, or bil- ious and putrid fevers. Before I conclude, it may be proper to take notice, that we have also fevers of a bilious kind in Britain; and that both our remitting and intermitting fevers, and dysenteries, seem no less owing to a putrid cause than those of other countries. But I must add, that such is the dryness of the soil, and its freedom from marshes, the constant perflation and the moderate and interrupted heats of our summers, that unless in extraordinary hot and close seasons, and in marshy places, these distempers are mild, and scarce ever epidemic. In fine, during the latter part of summer, or through- " tel the yellowness; and if this appeared on the second, third, " or fourth day, the disease was generally mortal. I have often " seen patients labouring under most of these symptoms imme- " diately relieved by early evacuations, and the fever brought to " intermit. Nay, I have more than once seen this fever with all " these symptoms carried off by bleeding and exhibiting, within " a few hours from the first attack of the disease, a medicine " which operated pretty briskly both by vomit and stool; and I " have known some of these very patients, who were so well as " to go abroad on the second or third day after, and who contiri- " ued well for four or five days, but on committing some error, " such as exposing themselves too much to the sun, were again " seized with the same symptoms, and died on the fourth or fifth " day, with their skin tinged of a deep yellow or copper-colour. " Hence I am apt to think that these are different degrees of " the same disease, and that it sometimes depends upon the " manner in which the patient is treated in the beginning, whe- " ther he shall have the yellow, or only a remitting or intermit- " ting fever."( 101) (101) There can be no doubt of the truth of this opinion quo- ted from Dr. Huck, a physician whose talents for observation and discrimination were well known to the editor. z 178 Observations on the Part III out autumn, there seems to be in most places a ten- dency, more or less, to these remitting, and intermit- ting fevers, or to some disorders of the first passages, connected with a resolution of both the fluid and fi- brous parts of the body. And this holds chiefly in hot and moist countries, and in all camps, for the reasons already given.* SECTION V. Of the Cure of the Remitting and Intermitting Fevers of the camp, and of those of low and marshy countries. I COME now to the cure, in treating of which I shall observe the following method. In the first place I shall distinguish the two sorts of fevers as before, and then I shall mention such remedies as I have found most successful in them. The cure of the camp-fever depends chiefly upon evacuations and a low diet; neutral salts and diluting acid liquorsf are assistants; and the bark is useful when there are complete intermissions. I found it necessary to begin with opening a vein, and to repeat .the bleeding according to the urgency of the symptoms. The vernal and latter autumnal re- mitting fevers are accompanied with pleuritic and rheumatic pains, from the coldness of the weather, and on that account require more bleeding. A person un- acquainted with the nature of this disorder, and at- tending chiefly to the paroxysms and remissions, would be apt to omit this evacuation, and to give the bark prematurely; which might bring on a continued * Part i. ch. i. Part ii. ch. ii. § 2. f The barley-water was acidulated with a little vinegar; and in the convalescent state we assisted the bark with the elixir of vitriol. Chap. IV. Bilious Fevers. 179 inflammatory fever. A vein may be safely opened either during the remission, or in the height of a par- oxysm. For, besides that I have observed the remis- sion to come sooner and fuller after an haemorrhage, I have repeated experience of the safety of bleeding in the hot fits; and not only in this, but in the marsh- fever, even after it had come to almost regular inter- missions. In order therefore to make Celsus's maximf consistent with this practice, we must interpret his term impetus febris in the sense of that chilliness or cold fit which preceded the hot one in the fevers which he describes; for then bleeding would indeed be impro- per. But as the paroxysms of our fever, after the first at- tack, were without any coldness, his caution was not to be minded; nor any other except the common one, of not bleeding during the sweat. Since the first two editions of this work, having had more opportunities of seeing these fevers, I found it the best course to give a purge, at any time of the day, immediately after bleeding, and the rather as the patient was then generally costive: R Infusi sena communis 5iii. electariilenitivi Zfi. nitripuri 3L tinctures sena 3vi. misce. The half only was taken at once, and if it did not move him twice in four hours, which generally7 it did not, he then took the remainder. This potion agreed with the stomach, purged plentifully and with ease, and therefore was a more useful than elegant compo- sition. Next morning (when there was almost always a remission) I gave one grain of tartar emetic, rubbed to a powder with 12 grains of crabs-eyes, and re- t Quod si vehemens febris urget, in ipso impetu ejus sangui- nem mittere, hominem jugulare est. Lib. ii. cap. x. 180 Observations on the Part III. peated the dose in two hours, if the first had little or no effect; at any rate in four hours. This medicine not only votnitted, but generally opened the body and raised a sweat. By these evacuations, the fever gene- rally became easier, and was sometimes quite remov- ed. Some of the regimental surgeons had made the first trials with the small doses of the emetic tartar; but having seen the operation, as they gave it with diaphoretic antimony, prove too rough, I changed that part of the composition for the crabs-eyes. For- merly, instead of this powder, I gave in the first re- mission after seeing the patient, a scruple of ipecacu- anha with two grains of emetic tartar in one dose. But though this often succeeded, yet upon compari- son I preferred the method above mentioned, viz. first purging, and then clearing the primes vies with small doses of the antimonial preparation. This medicine I usually repeated next day, or the day following; if not, I opened the body with some mild laxative or a clyster, and continued this method till the fever went gradu- ally off, or intermitted. I have been since confirmed in my good opinion of this practice, by the account which Dr. Huck gave me of his success in such fevers, both in North-Amer- ica and the West-Indies, by a method similar to mine. In the beginning, he let blood; and in the first remis- sion, gave four or five grains of ipecacuanha, with from half a grain to two grains of emetic tartar: this powder he repeated in two hours, taking care that the patient should not drink before the second dose; for then the medicine more readily passed into the bow- els 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 car- Chap. IV. Bilious Fevers. 181 rying off the bile; and then the fever either went quite off, or intermitted so far as to yield to the bark. On the continent, he found little difficulty after the in- termission; but in the West-Indies, unless he gave the bark upon the first intermission, though imperfect, the fever was apt to assume a continued and danger- ous form. Dr. Huck never varied this method, ex- cept from a stronger indication to purge than to vo- mit; 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.* As I did not begin to use the emetic tartar, in small and repeated doses, till the late war (and then only during three encampments in England) I had in those easy campaigns too few opportunities of trying this practice, so as fully to satisfy me that it was the best; but partly from what I saw myself, and heard from the regimental surgeons, I imagined it was most like- ly" to succeed, even before Dr. Huck communicated * Since the last edition of this work, Dr. Huck told me, " That in the highly bilious or yellow-fever of the West-Indies " (where the stronger vomits, if not administered very early in " the disease, are thought to be hurtful, but where nevertheless " it seems necessary to clear the prima via) he preferred this " medicine. For, that though the first or second dose of it gene- " rally excited some degree of vomiting, yet in three or four " hours it also purged; and that this last operation he endeavour- " ed to keep up, by giving from time to time two or three spoon- " fuls more, until an evident remission appeared, which was " usually on the fourth or fifth day from the beginning of this « disease. That he watched attentively for this remission, and " upon its first appearance began to give a decoction of the bark, " in as large and as frequently repeated doses as the stomach « could bear." 182 Observations on the Part III. his observations. I have been informed since, that in other countries, in such fevers, the chief medicine af- ter bleeding is this antimonial preparation, given from a quarter to half a grain, three or four times a day, throughout the disease; in which dose it is not intend- ed to puke, but to evacuate the bile by stool, and which it does with more certainty when assisted by clysters. The neutral salts were given after the evacuations, in order to bring the fever sooner to a crisis, or to re- gular intermissions. The saline draughts made with lemon-juice being too costly for common hospital- practice, instead of that acid, we saturated the salt with the spirit of vitriol; but since that time, for the same intention, I have preferred the elixir vitrioli aci- dum, as in this formula: R Salis absinthii %{. elixiris vitrioli acidi 31J. ~vel quod satis sit ad satuxationem, aqua pur a 5vi. aqua cinnamomi simplicis 5i. syrupi e corticibus aurantiorum 5$. misce. Dentur quinquies vel sexies die cochlearia iv. I come next to the bark, and shall observe, that these fevers have often such fair remissions, and even with a breaking in the water, as might persuade a phy- sician unacquainted with their nature, that they would always yield to that medicine; but he would be often disappointed. (102) Whether it be that some inflam- mation hinders the bark from taking effect, or that these quotidians are not true intermittents (as not be- ing of a tertian or quartan form) certain it is, that they (102) In the bilious remittents of the United States, of the first, second, and sometimes of the third grade, the bark is equal- ly ineffectual in curing them. Indeed it is generally offensive to the stomach. Chap. IV. Bilious Fevers. 183 can be seldom safely stopped by it. For, though the paroxysms have disappeared under its use, yet having so often seen the breast affected, or a lurking fever re- main after giving the febrifuge, at last I made it a rule to attempt the cure without it; or at least to delay giv- ing any, till in the convalescent state the patient re- quired it only as a strengthener. And indeed there seems to be the less occasion for the bark here, as by bleeding once or twice, clearing the primce vice by the purge and the emetic, and afterwards by keeping the body open, the paroxysms commonly lessen daily till they quite disappear. But whenever I found that the distemper was not likely to take that turn, but that in spite of the evacuations, the fits became worse (which was often the case in the marsh-fever) I then had re- course to the bark; and when it was most wanted, I have generally had the satisfaction of seeing it most effectual. As the intervals between the end of the swreats and the beginning of the subsequent paroxysms were very short, in order to have the more time to give the bark, I began to administer it two or three hours before the sweat ended. In general, we may consider the feverish paroxysm as over, when the thirst and heat have ceased, and the patient finds him- self in a profuse and easy sweat. But if ever the fever appeared in a tertian or quartan form, after the usual evacuations the bark was a sure remedy. The bark answered best in substance with Rhenish wine, after standing a night in infusion; but for com- mon use it was made into an electuary, in which, to each ounce of the powder a drachm of sal ammoniacus was sometimes added. This was the practice in the beginning of the fever, and also in its remitting and intermitting state. But if the disease was neglected in the first stage, or if after 184 Observations on the Part 111. remissions or intermissions it changed into a continu- ed fever, a vein was opened, if the pulse could bear it; but at any rate, if the head was affected with pain or delirium, leeches were applied to the temples, and a large blister was laid between the shoulders. At this time, neither strong vomits nor cathartics were given; but gentle pukes, repeated clysters, or some lenient purges were administered: the chief rule to be ob- served was to clear the prima vice. But though a sweat was then the proper crisis, we abstained from the serpentaria, volatiles, and other warm medicines, unless when the pulse sunk, and the petechia or the like bad symptoms appeared; in which case it was necessary to use some of the warmer alex- ipharmacs, and to treat the disease like, what it was in effect, a malignant fever.* Sometimes the fever changed into a dysentery, which was treated in the manner directed in the fol- lowing chapter. But if a diarrhoea came on, though that was never to be stopped suddenly, yet it was of- ten found proper to restrain it gradually, and to pro- mote a diaphoresis.-\ Although a looseness was not the * Chap. vii. t If the first passages have not been sufficiently cleared in the beginning, and the body kept open during the course of the fe- ver, we can expect no other crisis than by a looseness; which therefore is not to be stopped as long as there is strength to bear it. But if there has been no omission at first, with regard to the evacuations by emetics and cathartics, or if the patient is too much weakened by the flux, after some rhubarb, let him take twice a day the following bolus: R Theriaca Andromachi J^i. radicis ipecacuanha in pulverem contrita gr. ii. vel iii. creta preparata quantum satis est: misce. This medicine, with the proportion of the ingredients varied oc- casionally, I have known effectual in checking the purging, and Chap. IV. Bilious Fevers. 1&5 common crisis, yet if nature pointed that way (by cholic-pains, or a tension of the belly, attended with a dryness of the skin) it was necessary to procure fre- quent stools by clysters, or some mild laxative (such as an infusion of rhubarb with manna) repeated as of- ten as the patient could bear the evacuation. II. The camp and marsh-fevers are not more alike in their symptoms than in their cure. The rules therefore laid down in the preceding paragraphs being applica- ble to both, I shall only offer a few cautions concern- ing those points wherein they seem most /to differ. When the fever of the marshes is of an ardent kind, it may seem to require large bleeding; but in general as the humours have here a more putrid tendency than common, this disease admits of less bleeding than the camp fever, in which, by great and frequent colds, the blood becomes more inflamed. However^ in most cases it was necessary to open a vein, either upon the first attack, or the next day, if there was no intermission. But repeated bleedings, unless upon evident marks of a fixed inflammation, were so far from producing the desired effect, that they seemed to render the fever more obstinate. It ought also to be remarked, that the rule about bleeding regards the soldiers only, and not the natives, whose constitutions were different from those of our men, who were not bringing a salutary moisture upon the skin. But when the loose- ness could not be moderated by it, I then ordered the following mixture: R Extracti Thebaici grana ii. solvantur in julepi e creta 5xvi. Dentur post alternas sedes liquidas cochlearia iv. This is my common astringent mixture, which, upon compar- ison, I have observed to be fully as efficacious as that with the electarium e tco?-dio, and more agreeable to the taste and the sto- mach, 2A 186 Observations on the Part 111. only young, but robust and sanguine. And even amongst the soldiers, bleeding was seldom necessary upon a relapse, or after the weather grew cool; as the fever then appeared without inflammation, and as a regular intermittent. I observed, that vomits were still more efficacious in the marshes than in the camp; in so much, that when a large quantity of bile was evacuated by an emetic, the fever would often be removed at once. But this was not to be obtained by the ipecacuanha alone, which I have seen have a contrary effect, in making the subsequent paroxysms longer and more violent than the preceding; whether that was by acting weakly, and sending more of the corrupted humours into the blood than it discharged from the prima vice, or from some other cause, is uncertain:* for this rea- son I added two grains of the emetic tartar. (103) The marsh-fever, during the hot season, being more apt to run into double paroxysms, or to change into a continued form, than to remain regularly intermit- tent, it was necessary, after due preparation, to stop it in the first fair intermission. And for this purpose the bark was found to be no less specific in those parts than at home. But I must add, that though large quantities were given, relapses were not only frequent but certain, if the medicine was not repeated more fre- quently than the soldiers could generally be prevailed * I had twice experience of this effect of the ipecacuanha by itself in my own case. • (103) It is a common objection to many remedies, that they i-ire worse than the disease they are given to cure. It is necessary this should be the case in order to their producing a salutary effect. The emetic tartar succeeded better than ipecacuanha in ihis fever, only because its stimulus transcended the force of the disease, and thus induced anew and healthy action in the system. Chap. IV. Bilious Fevers. 187 upon to take it: so that upon the whole, the bark was less useful than might have been expected. But ob- serve, that no bad consequence arose from repeating it often. For, the visceral obstructions, which suc- ceeded to these fevers, were not to be imputed to that medicine, but to a long continuance of the dis- ease, or to frequent relapses; against which there was no security, unless the patient took an ounce of the powder once every ten or twelve1 days, throughout the autumn. The most effectual way to make a sol- dier continue the use of the bark, is to mix it with equal parts of brandy and water.* (104) The next means of prevention depend on a proper diet. The convalescents must eat moderately, especi- ally of greens and of fruit, and are to abstain from new small-beer, and whatever is flatulent or tends to relax. In general, whatever produces such effects disposes the stomach to indigestions, and thereby to a corruption of the humours; and, on the other hand, whatever braces proves antiseptic. A moderate use of spirits is at this time necessary; but as a soldier's pay is insufficient for providing both wholesome food and strong liquor, the public- should make, on such occasions, an allowance of spirits to the army, as it does to the navy, though perhaps half that quantity- might be sufficient. For the round worms, which so often accompany * I have since observed, that the surest way of preventing a relapse in those who unwillingly return to the use of the bark, is to give four or five ounces in powder, as fast as the patient can be prevailed upon to take it: this quantity he may finish in six or seven days. (104) The French physicians found a wateiy infusion of roasted and ground coffee with the bark to be agreeable to the soldiers in the fevers of Egypt. The less patients are accustomed to spi- ritous medicines, or to the use of medicines in spirits the better 188 Observations on the Part III. these fevers, I commonly gave half a drachm of rhubarb, with twelve grains of calomel, without observing any inconvenience from so large a dose of mercury, which with us was always duly prepared. Such anthelmin- tics as act slowly, and do not purge, seemed to have little chance for doing service here, as the symptoms were generally so urgent as to require some quicker remedy. For, though these animals will sometimes lie long in the bowels, without creating much unea- siness to a person otherwise well, yet in a fever, espe- cially one of a putrid kind, the worms being annoyed by the increase of the heat, and the corruption of the humours in the prima via (consequent on the fever) begin to move about and struggle to get out. Lan- cisius, who makes this remark, adds, that some of the bodies being opened of those who (at Rome) had diqd of such a bilious fever, they found wounds in the intestines made by the biting of the worms: nay, that some of them had even pierced through the coats of the guts, and lay in the cavity of the abdomen. In our hospitals, no dissection of that kind was made, but I have known many cases in which the worms escaped by the patient's mouth, though there had been no previous retching to bring them up. But, without advancing so far, they will occasion some very alarming symptoms. I remember, a soldier was brought to the hospital, about the end of summer, ill of one of these fevers, but with more than usual dis- order in his stomach and bowels, not yielding to the common evacuations; the muscles of his face were strangely convulsed, and he was so restless that he could not lie for a minute in the same posture. At first I did not suspect worms, but in a day or two after, the patient having voided a round one by stool, I then gave him the powder above mentioned, which Chap. IV. Bilious Fevers. IgQ either upon the first or second dose, brought away several more: after this, the extraordinary symptoms ceased, and he soon got well. I shall conclude this subject with an extract of a letter which I received from Dr. de Monchy of Rot- terdam, who, during the time of my service, was phy- sician to the Dutch troops which then made part of the allied army. This gentleman, after perusing one of the former editions of this work, favoured me with some remarks upon it; and among others, with what follows, upon the bilious fevers. This was the more acceptable, as my learned friend had not only had the same opportunities with me of seeing thdSe distem- pers in the camp, but also in his private practice, both before and since the war, in his own country, where they are more numerous and of a worse kind than in Britain. These are his words: Sic cetera observations mea a tuis parum vel nihil differunt, nisi forte quod venam secandi {raro saltern) ' non tantam infebribus biliosis necessitatem invenerim; imo naturam imitando, pracedente emetico, subinde vomitum excitando {prout magis minusve ad superiora materia turgeret) et levem, sed per dies aliquot pro- tractam diarrhceam eccoproticis efflciendo, feliciter, sine ulla alia notabili critica evacuatione, centenos ourave- rim; et adhuc quotannis, tempore autumnali, optimo cum successu et brevi curem. Qitoad tempus vomitorio utendi Boerhaavium aliosque practicos secutus sum, dando illud tribus vel quatuor horis ante paroxysmum, in ea continuo permanens opi- nione, quod major tunc sit materia morbosa accumulatio et activitas; et postea major subactio, et facilior per urinam evacuatio. Simplex hac fuit mea semper me- thodus curandi febres biliosas cum oris amaritie, nan- 190 Observations, &?c. Part III. sea, vomitu, &fc. dum agri adhuc in primo initio morbi versabantur. Quantocyus in continuis, vel parum tantum remit- tentibus, aque tempore vespertino quam matutino pra- scribebam vomitorium ex pulveris ipecacuanha scru- pulis ij, et tartari emetici granis ij; et statim hora post hujus remedii flnitam operationem, ut purgans, cremo- rem tartari ad unciam i. ex lacte ebutyrato assumerent agri sedulo curabam. Hac postero die, si eadem fomitis adessent signa in primis viis, imo et tertio die iterabam. Si vero febrem, ut et pleraque ejus symptomata immu nuta videbam, alvum tantum laxam servare conabar simplici decocto hordei et tamarindorum cum nitro. Chap. V. Observations, &?c. 191 CHAPTER V. Observations on the Obstructions consequent on the Remitting, and Intermitting Fevers of the camp, and those of marshy countries. J\. LONG continuance of these fevers, or frequent relapses into them, brought on visceral obstructions ending in a dropsy, or a jaundice. The dropsies seemed to be chiefly owing to obstruc- tions of the liver and spleen, in which case the watery swelling generally began at the feet and rose gradually to the belly. But when the belly alone was swelled, and that suddenly, after the unseasonable use of opiates in the dysentery, or of the bark in intermittents, the colon then became distended with air, and the distemper was a true tympanites. Such cases indeed did not often occur; but when they did, they yielded to the following remedies. If there was any degree of fever, I began with bleeding, and gave the common saline mixture,* with rhubarb; but if there was no fever, a few grains of the species aromatica were joined to the laxative; and the patient drank some strong camomile tea. Every night at bed-time, till the tumour disap- peared, I gave fifteen grains of rhubarb, or as much as was sufficient to procure one or two stools the next day. When the swelling gave way, if the pulse was slow, and if there was no thirst, without omitting the rhubarb, I endeavoured to strengthen the bowels, cy- an electuary of camomile flowers and ginger, with a small proportion of steel. * See page 182. 192 Observations, &c. Part III. All strong purging medicines, and carminatives without laxatives were hurtful. A man who had been some weeks ill of this distem- per and was feverish, died suddenly in the night time, upon his belly subsiding all at once, after three or four loose stools occasioned by taking, some squills. The body being opened, neither air nor water were found in the cavity of the abdomen; but the colon was so large and relaxed, that it seemed to have contained air enough to have been the cause of the tumour. This case suggested the use of a swathe in such disorders; as the patient may thereby always make a compres- sion suitable to the decrease of the air in his bowels. The ascites comes on more slowly, and is generally attended with anasarcous swellings, and a paucity and thickness of urine. Sometimes the intermittent goes off when the swelling begins; at other times it continues, or comes and goes in an irregular manner. I observed that these dropsies were not to be cured by purging alone, nor by soap, nor mercurials; but chiefly by the lixivial salts, either in the form of broom-ashes, salt of wormwood, or salt of tartar. The common method was this: about forty grains of salt of wormwood (or of tartar) were dissolved in about ten ounces of an infusion of the absinthium vulgare, to which were added about two ounces of the spirit called Holland-Gin; and this mixture was taken at three draughts and repeated daily. The patient had no other medicine, except, once in four or five days, half a dram of pilula ex colocynthide cum aloe for a purge; and in the decline of the disease, some common chaly- beate. Sometimes the diuresis was promoted by swal- Chap. V. Observations, &?c. 193 lowing garlic, (105) or mustard-seed. Although the ascites was accompanied with the hard swelling for- merly mentioned,* nothing was further done, except fomenting the part, or covering it with a warm plaster. Some irregular and obstinate agues were removed by the same medicines; or if they returned after the cure of the dropsy, they were then successfully treated with the bark.f The jaundice, without fever, was likewise cured by the lixivial salts, and the same purge; and both in that distemper and in the dropsy, I have observed good effects from antimonial vomits. (105) Dr. Sydenham mentions cures of dropsy being perform- ed by the use of garlic. * Part iii. ch. iv. § 2. t Since that time, I have given in cases of irregular agues, where I suspected obstructions of the viscera, the following mix- ture (little different from that mentioned above) for a continuance, and with good effects: R Florum chamameli 5fJ. aqua pur a bullientis 5viii. mac era per dimidium hora et colatura admisce spiritus vini Gallici ?ii. salts absinthii 3Ji. Dentur quater, guotidie, cochlearia iv. 2B 194 Observations on the Part III. CHAPTER VI. Observations on the Camp-dysentery. 1 HE bilious disorders of the camp were divided into fevers and fluxes; * and therefore as I have fully treated of the former, I shall now come to the latter, but confine myself to that species called the dysentery, as it is the least known out of the field, and is often general and fatal there. I shall first describe the dis- ease; then give an account of the dissections of some who died of it; after which, I shall inquire into its cause; and lastly, propose what I have observed to be most successful in the cure. SECTION I. A Description of the Camp-dysentery. SOME dysenteries appear upon first taking the field; but the cases are never so bad, nor nearly so fre- quent as towards the end of summer, or in the begin- ning of autumn. At that time they become epidemic and contagious, prevail for about six weeks or two months, and then cease. (106) They are always most numerous and worst after hot and close summers, espe- cially in fixed camps, or when the men lie wet after a march in warm weather. The diagnostics of the dysentery, besides some feverish symptoms, are a disorder at the stomach and wind in the bowels, small, but frequent stools of a * Part ii. ch. i. (106) The contagiousness of dysentery is denied by nearly all thinking physicians. When epidemic, it spreads like the yellow fever, only from an impure atmosphere. Chap. VI. Dysentery. 195 slimy and frothy matter, a tenesmus, and gripes. Blood mixed with the faces is a common, but not a constant symptom; for, many have all the other marks without this, at least in the beginning, and others have blood in their stools from various causes without a dysentery: but as this disorder is mostly attended with blood, for that reason it has been called the bloody flux. These may be called the pathognomonic symptoms, and as such may distinguish this illness from a diarr- hoea, an hemorrhoidal, and all other fluxes. Agreeably to this description, Sydenham and Willis use the term dysentery, and apply it to every case of that flux which raged at London in the year 1670; though Sydenham says, that some of his patients voided no blood; * and Willis observes, that those whom he attended, for the most part, had none but watery stools: f the name is one of the few particulars in which those celebrated authors agree in their account of that disease. The learned Morgagni mentioning that epidemic, takes notice of the propriety with which Willis applies the word dysenteria to a flux with the symptoms above- mentioned, though without blood, but adds, that, for the more distinctness, he would call such the dysente- ria incruenta. % It may be remarked, that, in confining this appella- tion to such symptoms, I have departed from the an- cients, and for that reason may be the more blame- able, as, upon a former occasion, I found fault with others for the like freedom. \ But in the case of the ileus, which I allude to, Sydenham had made an un- necessary change, by giving different names to two * ftforb. Acut. sec. iv. cap. iii. t Pharm. Rat. sec. iii. cap. iii. \ De Sed. et Caus. Morb. epist. xxxi. § 11 et 13. § See part iii. ch. ii. § 6. 196 Observations on the Part III.% stages of the same disease; whilst here, the ancients having used a term, either in so lax a sense, as to in- clude several ailments of a different nature, or, in so confined a sense, as not to comprehend all the varie- ties of the same distemper, I was forced to leave them, and take the definition from those who seem to have treated these disorders of the bowels with more preci- sion. Thus, the word dysentery, in the original Greek, im- porting a disorder of the bowels in general, we find Hippocrates using it, not only to signify all ulcera- tions, but all hemorrhages of the intestines (even those which are critical and salutary) and likewise every kind of flux, with, or without blood.* It would seem however, that after his time some of the other Greek authors, whose works are lost, were sensible of this want of precision, and therefore restricted the meaning of the term to an ulceration of the bowels, attended with gripes and tenesmus, and with mucous and bloody stools. For a disease with these symptoms Celsus calls tormina, and'says, it is the Jveevrefl* of the Greeks;t and Caelius Aurelianus, retaining the Greek name, describes the dysentery much in the same manner with Celsus.! Yet Galen returns to the looser acceptation of the * Dysenteria est exulceratio intestinorum—Alii vero, inter quos ipse Hippocrates est, dysenteriam interdum appellant non ipsam modo exulcerationem intestinorum, verum omnem etiam cruoris perintestina vacuationem. Gorraeus, in voce Lwntipi*. Ejus etiam dysenteriae, quae plerunque morbos plurimos sal- utariter ac judicatorie solvit, meminisse videtur Hippocrates (Prorrh. 2.) Av non muta- bantur; eos vero relictis sedibus, media nocte, potus superficiem petere, ubi ad horam usque decimam a. m. pastum quaerebant, dum priora loca repetebant, crebra tandem investigatione inve- nit. Exemptis acaris orbiculo humectato impositis, quam parum, variis adfusis liquoribus, irritarentur, et quod per oleum ipsum salvi transirent, animadvertit. A spiritu vini laedebantur, maxime vero a tinctura rhabarbari, quod imprimis notatu dignum; quum autem rhabarbarum dysenteriae sit specificum, lapathumque acu- tum ei valde cognatum, et quotodiana scabiei medicina, afhnita- tem invenimus et analogiam. Vasi, ter licet aqua calida abluto, adhaerebant. Illos in aliis etiam locis quaerebat, inque vasis potus acidi, 8c sub doliorum obturamentis saepius reperiebat. Dysente- ria quae Scanioe territorium Gyinge quotannis fere, tempore mes- sis, vexat, aeque ac ea, quae in castris est vulgaris, ex iisdem aca- ris, in potu acido latentibus, qui inde per secessus propagantur, et contagium generant, originem suam fortassis traxerit. Chap. VI. 'Dysentery. 229 ducing this flux,* or indeed any of the military dis- eases, I need not repeat them here. But with regard to the gall, as I have called the dysentery one of the bi- lious disorders, some reason may be expected for my taking no notice of that humour upon this occasion. It may be remembered, that I have always used the term bilious more in compliance with the ancients, to dis- tinguish a certain class of diseases, than from an opi- nion that they are really occasioned by the bile. In this light I consider the autumnal remitting and intermit- ting fevers, which I often call bilious. And as to the dysentery, I shall observe, that though at first, from the sickness of the stomach and vomiting, the gall may seem to be concerned, yet in the advanced state of the disease it must be wholly acquitted; since upon dis- section, the liver and smaller intestines are generally found in a natural state, though these parts ought to be the most liable to be affected by disorders of the bile. And as to the bile itself, do we not see it some- times here in a large, sometimes in a small quantity, sometimes of one colour, sometimes of another, some- times thick, sometimes thin, and at other times of a natural consistence? Now had it any share in bringing on, or supporting this disease, should we not find a greater uniformity in its appearance? Nay, I have even imagined, that such medicines as could procure a more copious secretion of the bile would often prove useful, having observed the patient most relieved, whenever an evacuant acted in such a manner as to carry down with it much of that humour. * Part i. ch. iii. Part ii. sh. ii. § 4, 23© Observations on the Part III. SECTION IV. Of the Cure oj'the Dysentery. THERE are few acute distempers less beholden to nature for a cure, or attended with more deceitful in- dications. The hemorrhage seems to require repeated bleedings; the flux, strong astringents; the pain of the bowels, constant opiates; and yet unless these remedies are used with caution, they tend more to confirm than to remove the disease. On the other hand, emetics and purges have been either wholly condemned, or too sparingly used: yet later experience shows them to be the chief means of the cure. But setting aside for the present all indications (which, from our imperfect knowledge of the animal economy, we are seldom ena- bled to form) I shall proceed to offer the result of my experience, and add some observations from others whom I could most rely on, and who have likewise been much conversant with this flux. With these fur- ther lights the nature of the disorder being more clear- ly seen, the reader may perhaps be directed to some more certain method of cure than what has yet been practised. In order to proceed with more clearness, I shall distinguish the dysentery into three states: viz. the first, whilst it is recent, or whilst the sick can easily bear evacuations; the second, when the distemper is of a bad kind, or has continued long, and has much impaired the strength, inflamed the intestines, and brought on a hectic fever; and the third state, when the patient, though recovering, is kept low by a tenes- mus, or some other remains of the disease; or becomes subject to frequent returns of a looseness, from the weakness of his bowels. Chap. VI. Dysentery. 531 I. In the first state, I begin with a moderate bleed- ing; though it may be true that a dysentery of itself does not require that evacuation;* but as this disorder is partly of the inflammatory kind, and is often accom- panied with a fulness of blood, bleeding is sometimes indispensable, and indeed is generally conducive to the cure. Yet unless the fever be kept up by some inflam- mation not peculiar to the disease (as it frequently happens in the winter and vernal cases) repeated bleed- ings are either unnecessary or hurtful, as may be ob- served in most distempers arising from a putrid cause. In weakly habits, and where there are few feverish symptoms, I wholly omit that evacuation. In the evening of the same day I give an emetic. In the beginning of my practice in the army, I used the vitrum ceratum antimonii, which I had formerly observed to be the best medicine in this case for re- lieving both the stomach and the bowels. But as the virtues of that antimonial preparation have been fully set forth elsewhere,f I shall say nothing of them here, and only observe, that though I was convinced of its being a powerful remedy (by seeing it often succeed when other things had failed) yet the roughness of its operation, and the prejudice conceived against the glass of antimony, as a medicine, having deterred the other physicians of the army, and the regimental sur- geons from using it, I also desisted, being desirous of ascertaining the efficacy of some other method that was less exceptionable. Instead therefore of this pre- paration, I ordered a scruple of ipecacuanha; and for the common men, I generally added one grain or two of emetic tartar. Whether 1 gave the weaker or the * Dysenteria qua dysenteria venaesectionem nunquam indicat. Barbette Prax. lib. iv. cap. v. f Med. Essays, vol. v. Mem. de 1'Acad. des Sc. A. 1745. 232 Observations on the Part III. stronger vomit, I observed it to be most successful when it likewise operated by stool. This effect was the more certain, when instead of the usual quantity of ipecacuanha, five grains only were given at once, and repeated at an hour's distance, twice or thrice, till a purging was brought on, which usually hap- pened soon after the third dose. Fifteen grains exhi- bited in this manner were commonly sufficient. Piso, who first described this root, and recommended it in the dysentery, appears to have relied chiefly on its purgative quality, though he adds, that it still had a better effect when it vomited also.* When the sto- mach is chiefly affected, I give the ipecacuanha, either by itself, or with the tartar emetic, in the dose above mentioned; but when the person complains more of gripes than sickness, I direct the root to be divided as above, with a view to its more certain operation * Perhaps the medicine is more cathartic while fresh than after long keeping; and better in decoction, or infusion, than in substance. We may observe, that Piso recommends the second and third decoction for weak patients, as less cathartic and more astringent. The following is the principal passage which relates to the use of this specific: Dehinc ad radicem ipecacuanha tan- quam ad sacram anchoram confugiendum, qua nullum praes- tantius aut tutius, cum in hoc, turn in plerisque aliis, cum, vel sine sanguine, fluxibus compescendis, natura excogitavit reme- dium. Quippe praeterquam quod tuto et efficaciter tenacissimos quosque humores per ipsam alvum, saepissime autem per vomi- tum ejiciat, et a parte affecta derivet, vim quoque astrictivam post se relinquit.—IUud vero hoc modo perficitur: Drachmae duae radicis ipecacuanha in 5iv. liquoris appropriati coctae vel per noctem maceratae, cujus infusum cum, vel sine oxymellis 5j exhibetur. Postridie semel atque iterum, pro re nata, secunda imo tertia ejus decoctio repetenda; tarn quod aegri debiliores earn facilius ferant, quam quod astrictoria ejus vis tunc magis efficax appareat. Gul. Pison. Hist. Nat. et Med. Indiae Occident, lib. ii. cap. ix. Chap. VI. Dysentery. 233 upon the bowels. In one or other of these forms, I give the emetic on the first day of my seeing the pa- tient, whether he has been bled or not. If the full quantity be given, the operation is assisted, in the common way, with repeated draughts of camomile tea. But if the small doses be used, he ought to drink nothing till the medicine works downwards, and then he may take some water-gruel to promote its effect. When the stools are large and bilious, and the pa- tient fatigued with the operation, I give no medicine on the following day; but if he has taken the emetic all at once, so as only to clear his stomach, or if the divided doses have wrought weakly by stool, I order a purge next morning, viz. five grains of calomel, with five and twenty or thirty of rhubarb, which in ordinary constitutions is a moderate, or rather a small dose. At first I gave the rhubarb without any calo- mel, and usually about half a drachm; but afterwards I found it necessary either to double that quantity, or to join calomel to that, or to a smaller dose, in order to procure a thorough passage. I have remarked in the former editions of this work, that " we are to at- " tend less to the dose than to the effects, which are " not to be judged of by the frequency, but by the " copiousness of the stools, and the relief which the " patient finds from the gripes and tenesmus after the " operation; and that as on the one hand the physi- " cian ought to avoid all the rough and stimulating " purges, so on the other he is not to spare those of a " lenient kind, especially rhubarb, which is commonly " under-dosed." This is still my opinion, except that with regard to rhubarb, I have not seen it in this flux have so good an effect as when joined with well pre- pared calomel, by which means it becomes more le- nient, that is, easier in its operation. 2 G 234 Observations on the Part III. At night, after the purge, I usually give for the first time an opiate, viz. ten grains of the pilula sapo- nacea, with two, or sometimes with three grains of ipecacuanha, either in a bolus or in a draught: for ever since I found that some common soap pills had passed undissolved, I have disused that form in all weaknesses of the intestines. Formerly I joined to the opiate a small quantity of the vitrum ceratum antimo- nii, in order to promote perspiration; but when I drop- ped that medicine as an emetic, for the reasons al- ready given, I omitted it here also, and supplied its place with the Indian root. Here I must observe with regard to opiates in the dysentery, that it were better perhaps that they were never given at all, than used before the first passages are cleared. For though from the beginning they are sure to give some immediate relief, yet by confining the wind and the corrupted humours, they tend to fix the cause, and to render the distemper more obstinate in the end. This is the result of my experience, which I am sorry to find does not exactly correspond with that of Sydenham. For though that excellent physi- cian did not omit purging when the dysentery was most epidemic, yet at all other times it appears that he trusted to laudanum alone. Now, whatever was the nature of those fluxes which he treated in that manner, I must believe that such as are most incident to an army are of a less tractable nature, and in general are not to be cured without repeated evacuations. As to the best kind of opiate, I have made no particular ob- servation; and therefore if 1 have here specified the pilula saponacea, it was only because I preferred that composition to the simple extractum Thebaicum, as there was less hazard of an error in the weight. It is Chap. VL Dysentery. 235 well known that ten grains of these pills are equal to one of pure opium. If the two first days have been employed in the man- ner described, I order no medicine on the third, un- less the patient still complains of gripes; in which case the opiate is repeated at night. But on the fourth day, if any bad symptoms remain, I direct the ipeca- cuanha to be given once more in divided doses; or, if the patient should express great aversion to a drug which made him sick before, I repeat the purge, and that in a larger dose if the former has not operated sufficiently. The largest of this kind, which in such cases I have used, consisted of thirty grains of rhu- barb with eight of calomel. By this time most of the dysenteric cases give way, and sometimes sooner. But if some fomes of the dis- temper still remains, or if the patient has committed any error in diet, or has exposed himself to oold, so as to relapse, I have recourse to the same remedies, that is, either to the purge, or to the ipecacuanha, accord- ing as the one or the other has agreed with him be- fore. In fine, these evacuants are the chief medicines which I trust to in this stage of the disease. This method was nearly followed in the last war by the other physicians of the army, and in particular by Dr. Huck, who having been in constant service either in North-America, or in the West-Indies, had the best opportunities of seeing the dysentery in all its forms. He acquainted me that, notwithstanding the difference of climates, the distemper, when epidemic among the troops, appeared with much the same symptoms every where, and when cureable yielded to the same medicines. Believing it will be acceptable to the read- er, I here subjoin a short account of Dr. Huck's prac- tice in his own words. 236 Observations on the Part III. " When the patient is feverish, or plethoric, I al- " ways begin with bleeding; and if the fixed pains " and the fever seem to indicate a considerable inflam- " mation, I repeat it. I have thought, that giving four " or five grains of ipecacuanha with one grain of " emetic tartar, without drinking after this dose, but " suffering it of itself to work off, and repeating it in " two hours, with orders to the patient to wash his " stomach with camomile tea, was the best method of " clearing the first passages. Sickness at the stomach, " bad taste in the mouth, giddiness, heart-burn, and " severe gripes were reasons for repeating the vomit " on any of the following days. If the stomach did " not seem much disordered after it, I used to purge " with two ounces of manna and one ounce of Glau- " ber's salt dissolved in a quart of water, whereof a " quarter of a pint was drunjta every half hour till it " procured two or three copious stools. This I prefer- " red to rhubarb and to every other cathartic, espe- " cially in the beginning, repeating it every third or " fourth day till the gripes, &c. abated, and giving an " opiate every night, after the first or second doge of " the physic. But I never knew an opiate of use wMkt " the fever, the thirst, the gripes, and tenesmus were " considerable. If astringents were useful, it was only " when a laxity of the bowels remained after the dis- " ease." By this account, we find that Dr. Hnck not only divided the ipecacuanha, but to each of the doses added some emetic tartar, which upon a comparative trial was found to improve the medicine. And indeed for the future, I should prefer his method, as I have- reason to believe, from my own observations upon the bilious fevers, that this antimonial preparation may be of service in removing some feverish spasms, which, Chap. VI. Dysentery. 237 though not the original cause, may yet concur with it in supporting the disease. We may likewise observe, that Dr. Huck thought the salts and manna a better purge than rhubarb, in the beginning of the dysentery; but in talking with him on this subject, I found, that though lie had fre- quently given rhubarb by itself, yet he had never given it with calomel, and therefore that he could not deter- mine whether his purge or mine were the best in this state of the distemper. (117) I likewise understand, that most of our physicians employed in Germany, during the late war, preferred salts and manna (to which they frequently added some oil) to rhubarb alone; and that after bleeding and vo- miting, they usually kept the body open with that mix- ture.* Possibly there may be better ways of giving the rhubarb than with calomel. Degner praises a tinc- ture of it in a watery menstruum, of which he gave small but frequent doses; but as I never saw his trea- tise till after the conclusion of the former war, I have (117) That active purges are rendered more certain and gentle in their operation, when given with such as are of a mild nature, than when given alone, was first noticed by Dr. Sydenham. It is equally true that many of those articles in the materia medica which have obtained the title of " heroic" medicines, are render- ed more safe, and more useful by being combined with medicines of a more gentle nature: * Dr. Monro, one of the physicians on that service, told me, that he had commonly given in the dysentery a purge in this manner: R Manna 5jg vitelli ovi 5i« contritis simul, in mortario lapideo, admisce paulatim olei olivarum Jvi. salis cathartici amari {aqua pur a 5iij. soluti) ?j. This was the dose for a strong person, but to the weakly pa- tients he gave a smaller quantity. Dr. Armstrong and Dr. Tur- ner, who werife likewise of the army in Germany, also informed me, that they had used much the same composition. 238 Observations on the Part III. since that time met with too few rebellious cases, to induce me to compare his preparations with those remedies which I had used before, with tolerable success. * After clearing the first passages, in the manner des- cribed, I have generally endeavoured to finish the cure by combining purges with opiates, in such a manner as to keep the body open, and at the same time to ap- pease the gripes, but I have not always succeeded to my wish. In the year 1760, the brigade of guards arriving in Germany, about the end of July, in a rainy season, and when there was a scarcity of straw for the tents, such numbers of the men were taken ill, and for the most part with the dysentery, that when the camp broke up, in the month of December, above half of that corps were unfit for duty. Mr. Paterson (one of the master-surgeons to the hospital, then a mate in the guards) who gave me this information, told me, that he had been generally successful, by treating those of his battalion, who had been ill of the flux, in the fol- lowing manner: " If the patient was of a plethoric " habit and very feverish, he began with bleeding; " then gave a vomit of ipecacuanha; and besides that, " if he had seen the sick person early in the day, a * It may seem strange, that authors have not yet agreed about the proper purge to be used in the dysentery; but we ought to consider that different constitutions require different laxatives. A physician, in his first practice, not attending to this, and meet- ing with a dysenteric patient, with whom rhubarb, for instance, agrees, and sena or salts disagree, will be afterwards apt to ad- here to the first and condemn the other; and vice versa. But as to the use of purges in this disorder, and the variety of them oc- casionally to be employed, according to the difference of consti- tutions, we have such full and just reflexions in Young's Trea- tise on Opium (in the section on the dysentery) that I shall not fcirther insist on the subject, but refer the reader to those judi- cious observations. Chap. VI. Dysentery. 239 " drachm of rhubarb at night; if not, the next morn- " ing. In the evening of the second day, after the ope- " ration of the purge, he gave about twenty drops of " laudanum, or about ten grains of the pilula sapo- " nacea. After that, if the disease continued, he for- " med a mass of theriaca and rhubarb into the consist- " ence of pills, and of this administered half a drachm " morning and evening, and sometimes thrice a day." Mr. Paterson added, " That, the next year, when he " himself was seized with the bloody-flux, he had " followed the same method of cure; that it was near " three weeks before he recovered, being constantly " kept in camp, frequently marching, and being ex- " posed to cold, wet, and other hardships in the course " of his duty; but that during all the time, he had " found the greatest benefit from the medicine above " mentioned. That about half an hour after every dose " the tenesmus abated, and the stools became more " copious and less frequent for three or four hours " following. That on this account, for the last seven " or eight days, he took half a drachm of the above " composition thrice a day, which amounted to about " one drachm of theriaca and half a drachm of rhu- " barb in twenty-four hours." If by the means above mentioned, or by other me- thods, the disease is so far changed that the patient complains less of gripes and tenesmus, and begins to have stools, though loose, yet of a natural colour, with less slime and more faces, he being then in a fair way of recovery, his case shall be further considered when I come to treat of the third state of the disease. At present I am to treat of those who have gone through the first state, and who either have had no medicine at all, or received little or no benefit from it; and when 240 Observations on the Part III- their stools are as small, as frequent, as slimy, and as painful as ever. II. In the second state, though there be often more of a hectic fever than at first, and though a mortifica- tion be threatened by the retention of the putrid mat- ter and the continuance of the inflammation, yet, so far as I have observed, bleeding is not the remedy, but lax- atives (such as have little irritation, and yet are suffi- cient to prevent an accumulation of the sharp hu- mours) and those medicines which either sheathe the bowels against the acrimony, or procure a respite from pain and spasms till nature acquires force sufficient for the cure. Here for the first time I used the sal cathar- ticus amarus alone, though probaby7 it might have been more effectual with oil and manna, or given not at once but in small and repeated doses, as in the ileus.* In this state I once gave, to a young woman, five grains of ipecacuanha with twelve of rhubarb, which first making her sick, and then working down- wards, brought away some faces of a natural colour, and gave a favourable turn to the disease. But as this person was one of my latest patients in a dysentery, I have had no opportunity of repeating that medicine. At this period of the flux, finding emollient and anodyne clysters to be of considerable benefit, I therefore used a decoction of linseed, or of starch, or fat mutton broth, from four to eight ounces, ac- cording as a smaller or larger quantity could be re- tained. When the motions were so frequent, that the patient could not keep these clysters, I added to each from twenty to fifty drops of laudanum, or as much as was necessary for abating the stimulus, without too much affecting the head. As the patient must * See page 135. Chap. VI. Dysentery. 241 use opiates, this will probably be found the best way of giving them; for thus they are applied directly to the rectum, where the irritation is the greatest. But in bad cases the motions are generally so frequent, that, notwithstanding the laudanum, one clyster given in the evening may be insufficient for composing the patient throughout the night; and if so, he must either take another, or the common opiate. Although the advantage of clysters be visible, yet we cannot avail ourselves of them in the hospital so often as could be wished, partly through the neglect of the nurses, and partly through the reluctance of the men to use them: even in private practice, we must often desist from clysters on account of the tenderness of the parts. For mitigating the gripes and expelling the wind, we are not to use the warmer carminatives; at least I have never known them to answer. Opiates give im- mediate relief, but they only palliate, and often aug- ment the cause. I have met with no remedy that re- markably answered this intention: the best, was fomenting the belly, and drinking camomile tea. The infusion of these flowers was first thought of on ac- v count of their antispasmodic and bracing qualities, but having found them a powerful antiseptic, I am in- clined to think that some of their effects may be owing to that principle. The fomentations were made of the common herbs, with the addition of some spirits; but as they required frequent repetitions, they were less use* by the soldiers than by the officers, who were better attended. The flatulent pains would sometimes affect the side, as in a pleurisy; but a laxative medi- cine, or the fomentations just mentioned, removed them without bleeding. When the patient complained of a heart-bum, and of every thing turning sour on his stomach, I ordered 2H 242 Observations on the Part III. from time to time four spoonfuls of the julepum e creta; and when at the same time the gripes and incessant motions required some palliative, I dissolved two grains of extractum Thebaicum in a pint of that julep, and gave it in the manner mentioned before.* At other times, when there was no complaint of an acid, but of gripes and frequent motions, I endeavour- ed to blunt the acrimony, and in some degree to sheath the bowels against the irritation, by food of a mucilaginous quality (which shall be mentioned hereafter) and by giving for drink a decoction of starch with gum-arabic, seasoned with some simple cinnamon water and sugar. A pint of this liquor com- monly contained three drachms of starch with half an ounce of the gum. For the same intention, a solution of wax was used in the hospitals in North-America, and, as Dr. Huck informed me, often with good effects.f Preparations of wax have been long in repute for their virtues in this disorder: Bates recommends a solution of it in spirits;% and Diemerbroeck gives instances of its extraordinary effects, when dissolved in milk, and mentions some authors who praise this medicine for the dysentery.^ (118) *Page 185. t R Ceraflava rasa 5*1$ • saponis Hispani duri rasi ^i. aqua pura 5i. liquescant leni igne, et assidue agitentur donee in unum coeant; dein effunde materiam in mortarium lapideum, eique paulatim admisce aqua pur a 5 viij. aqua nucis moschata 5Ej. et sacchari albi quod satis sit ad gratum saporem. This makes a smooth mixture of no disagreeable taste, whereof the patient takes as much, at proper intervals, as to consume the whole quantity in a day; which is then to be renewed. The soap is only used as a dissolvent of the wax. \ Pharmacop. Batean. in formula Butyrum Cera. § Observat. et Curat. Med. obs. xxviii. (118) From some trials that have been made with beeswax in Chap. VI. Dysentery. 243 When the flux continues till the strength is much impaired, and the pulse sinks whilst the hectic heat remains, the danger is great; though there are still hopes, as long as there are neither involuntary stools, nor aphtha, nor a hiccup, and when the patient does not complain of great lowness, and the anxietaspra- cordiorum: then the case is bad indeed, and scarcely admits of palliatives; since opiates have but little effect, either in easing the pain, or checking the frequency of the stools. Sometimes the disease is complicated with the hospital-fever; in which case few recover. But when there is room for medicine, I have commonly used a decoction of the bark with snakeroot (describ- ed in the next chapter) to which I added a few drops v of laudanum. At other times, and especially when the pulse was sunk, I have experienced the good effects of the following decoction, of which four spoonfuls were given every four or five hours: R Radicis serpentaria Virginiana 3iij. coque ex aqua fontana xij. ad 5viij. abjecta sub finem coctionis theriaca Andro- machi 3j- cola. In the year 1760, Dr. Whytt wrote to me: " That " in this bad state of the dysentery, when the mouth il and alimentary canal were threatened with aphtha, "and even sometimes after they appeared, he had chronic dysenteries and diarrhoeas, I am disposed to ascribe its efficacy in restraining them, wholly to the powerful and ineffec- tual efforts of the stomach to digest it, whereby the excitement is attracted from the intestines, and their morbid peristaltic motion thus diminished. This opinion is rendered probable by its having done most service when it was given in a simple state, in which case it was discharged in some experiments made by Dr. Vandyke, in the same form in which it was taken. It is prob- able, mutton-suet, and milk, and many other medicines, supposed to be demulcents, and astringents, act in the same way in curing chronic fluxes from the bowels. 244 Observations on the Part III. " successfully given the bark; having first made such " evacuations as the case required, or the patients " could bear, by bleeding, vomiting with ipecacuanha, " and purging with rhubarb. That to a pint of a " strong decoction of the bark, he added three " drachms, or half an ounce of confectio Japonica (a " composition of the Edinburgh Dispensatory, of the " same intention with diascordium, but simpler) and " ordered two spoonfuls of it every four hours, with- " out any other medicine, except some laudanum at " bed-time. That when, by the continued use of this, " the body became costive, he then gave rhubarb; and " after that, went on with the decoction of the bark, " but with less of the confectio Japonica, or even " without it." At this time, supposing that the rectum, from the irritation occasioned by the incessant motions, tend- ed to a mortification, I endeavoured to quiet the spasms by repeated anodyne clysters, but without any antiseptic ingredient. Something however of that kind has been tried by others. For Mr. Hunter, one of the master-surgeons on the expedition to Portugal, told me, that he had frequently used antiseptic clysters with good effect, when the patient was worn down wjth continual motions and a tenesmus. His first trial was with four ounces of a strong decoction of the bark, in which he dissolved some grains of opium; and afterwards, he found that a decoction either of the tormentil-root, or of oak-bark with opium, an- swered the same purpose. He added, that these clys- ters were repeated often, and especially if they came soon away without having the desired effect. Hitherto I have said nothing of the diet; which was nearly the same in both these states of the disease. It consisted chiefly of rice or barley-gruel, sago, panada, Chap. VI. Dysentery. 245 and some puddings; and to those who were but a little feverish, some mutton broth was allowed: but this last article was omitted afterwards, as I observed that in general animal food was improper. For drink, I or- dered rice or barley water, toast and water, or the de- coction of calcined hartshorn. During the former war, we used no salep in the hospital. Although that root has been accounted specific in the distemper, yet from my own experience I can say nothing particularly in its commendation. Mr. Triquet, surgeon-major to the second regiment of guards, informed me (at the camp in the isle of Wight, in the year 1758) that in his regimental hospital, no kind of diet had agreed so well with his men who were ill of fluxes, as a mess made of flour boiled in milk, sweetened with sugar, and taken for breakfast and supper. But though all these substances are of the softest and least heating kind of food, yet I have observed, that for the most part the patient could not eat any of them, nor swallow any of the liquors mentioned above, nor indeed any other, except plain warm water, without being sick or griped immediately after. It was therefore natural to con- clude, that until the stomach and bowels were able to bear some stronger nourishment without pain or sick- ness, nothing but water should be given for the whole diet. In this notion I was confirmed by some curious observations on the dysentery, communicated to me by M. de Senac, who, during my service in the Low- Countries, in the former war, was physician-general to the French army. That learned person informed me, that having had good evidence for believing that several had been cured by taking nothing but large quantities of warm water, for five or six days together, he had successfully made the experiment upon him- self, and upon fourteen more who submitted to that 246 Observations on the Part III. regiment He added, that after having tried other me- thods, without being satisfied with them, he had at last fixed upon the following, by which he had made num- berless cures. This, after evacuating by bleeding, and by a vomit of emetic tartar, consisted chiefly in giving one grain of that antimonial preparation, dissolved in a pint of common whey, or chicken water, in divided draughts, every day, for all food, drink, and medicine till the patient recovered. His intention, he said, was to keep a free passage from the stomach to the rectum by the mildest laxative, which he found was best an- swered by that minute quantity of the emetic* In case the gripes proved more obstinate than usual, notwithstanding the evacuations, he then endeavoured to quiet them, by giving some syrup of white-poppies at bed time. But though this course (in which the lowness of the diet is a material circumstance) was not only agreeable to my sentiments upon the nature of the disease, but was recommended to me by a physi- cian, in whose judgment and veracity I had intire con- fidence, yet I have never been able to avail myself of the communication, on account of the difficulty, I may say the impossibility, of making the people of this country submit to so low a diet, even for a few days. (119) * As the emetic tartar is not every where made to the same standard, it is easily understood that the laxative dose must vary according to the preparation of that medicine. (119) There can be no doubt of the efficacy of this practice in dysenteries of a moderate grade of diseased excitement. It is a chronic mode of depletion, but it should not be relied upon ex- clusively in the violent dysenteries of the full-fed, and high-toned citizens of the United States. Redi mentions a fact, much in favour of the practice advised by M. de Senac for the cure of dysentery. He says that he found the intestines of all the animals he dissected that had died of famine, not only free of excrement, Chap. VI. Dysentery. 247 Under the article of diet, I must not omit a caution with regard to the kettles of the hospital, which are all made of copper tinned; but as the tinning soon wears off, the metal is corroded by every thing that is salt or acid; and we may well imagine how apt the nurses will be to let such things stand long in those vessels, and to neglect cleaning them before they are again used. I suspect that this may be often the cause of mischief, especially during the dysenteric season, when the sto- mach and bowels are otherwise so much disposed to be out of order. It would therefore be an advantage to military hospitals, to have a brazier constantly at- tending them. III. I come now to the third state of the disease, in which the patient, though seemingly recovering, is kept low by a tenesmus, almost his only complaint; or by frequent returns of a looseness, through the weak- ness of his bowels. The tenesmus is not always owing to one cause: sometimes I have known it occasioned by the hard scybala formerly mentioned, which coming away in small parcels, for several days together, have made a constant irritation. The discharge of these I have hastened by an -ounce of Glauber's salt, dissolved in half a pint of water, and given at different draughts in a morning. If one or two such doses had no effect, I imputed the continuance of the tenesmus to an ex- coriation, or some sore of the rectum, by which the part becomes so tender as to be irritated by the hu- mours of the intestines, though these humours may now, perhaps, be sound. For medicine, if the tenes- but perfectly clean and of a white colour. Considering how much the secretions in the bowels are altered by disease in their qual- ity, it is natural to expect that diluting drinks by obviating their acrimony, may contribute to the cure of dysentery. 248 Observations on the Part III. mus was great, and the motions frequent, I had still recourse to opiates, and especially to the anodyne clysters first mentioned.* In every case of great irri- tation, during this state of the disease, I used formerly to give the decoction of starch with gum-arabic, de- scribed above; f but of late I have more frequently prescribed mutton-suet, prepared according to the fol- lowing receipt, which for some time has been in use here; " Take two ounces of fresh suet, and a pint of " new milk, set them over a slow fire, and let them " be stirred till they boil, then add a heaped spoonful " of starch finely powdered, and mixing it well with " the rest, let them boil a little together." This pre- paration may be sweetened, or not, according to the taste: and this quantity, or even the double (if the stomach will bear it) may be consumed in a day, and it will have the better effect if the patient takes no other food. I have sometimes attempted to give this medicine in the first and second state of the disease, but it never answered; for at that time the stomach was too much disordered to bear it. (120). Sydenham has said, that the tenesmus, at the end of a dysentery, is never occasioned by an ulcer in the rectum; in which he is corrected by Morgagni, who mentions one case to the contrary, that had occurred in his own practice;| but by quoting that case only, it appears that Morgagni knew but of few exceptions to Sydenham's rule; which indeed, from my own ob- servation, I should reckon a pretty general one. As to the frequent returns of purging, we are not, * See above, page 239. f Page 242. (120) The editor has often relieved a tenesmus by applying a piece of cotton dipped in equal parts of laudanum and sweet oil to the part affected. i De Sed. et Caus. Morb. ep. xxxi. § 27, 28. Chap. VI. Dysentery. 249 as I observed before, to consider them so much as re- lapses into the dysentery, as into a diarrhoea or white- flux, owing to the weak state of the bowels. Whenever therefore the patient is in this condition, I begin with a scruple of ipecacuanha, and the next day I put him upon a course of those medicines, which, from their effects in stopping a looseness, have been called astringents. For this purpose, during the former war, I commonly used the following mixture: R Extracti ligni Campechensis (ex aqua cinnamomi spirituosa ij[5 triti) 3nj- aqua fontana 5vij. tinctura Japonica 31J. misce. Of this the patient took two spoonfuls once in four or five hours, and sometimes also an opiate at bed-time. I understand, that in one of the hospitals of this city, where thisjbrmula is used for old and obstinate diar- rhoeas, and for dysenteries not yielding to the com- mon methods, they order, at the same time, a bolus to be taken every night, consisting of a scruple of phi- Ionium Londinense and two grains of ipecacuanha, and that with these two medicines they have been gene- rally successful. Since that war, having read the account which Deg- ner and others have given of the virtues of the sima- ruba, 1 made a few trials of that medicine, and which were mostly in its favour. Degner not only recom- mends it as a mild astringent, but as a corrector of the bile; for according to his theory, the depravation of that humour was the cause of the epidemic flux which he treats of. On that account he gave it early in the disease, whilst the gripes and tenesmus continued, and whilst blood was yet found in the stools. But from my experiments, I could discover none of the salutary effects of the simaruba before the third state. Dr. Huck, who had used it often in North-America, told 21 250 Observations on the Part III. me, that he had never seen it answer in the beginning, nor even in the advanced state of the dysentery, till the gripes and tenesmus had in a great measure ceased, and till the blood had disappeared in the stools; but that when only a looseness remained, he had often found it succeed. This was his formula: R Corticis radicis simaruba "Z\y. vel iij. coque ex aqua fontana sesquilibra ad libram, et cola. This quantity was given every day in several draughts. He began with the weakest decoction, and when the stomach of the patient could easily bear it, he then ordered him the strongest. Dr. Huck observed, that unless the sick found themselves sensibly better with- in three days from the time they began the medicine, they seldom afterwards received any benefit from it. Dr. Mitchell, who formerly practised in Virginia, where the dysentery is frequent, also informed me, that he had likewise used this vegetable; but not with success, except when the patient either voided an im- moderate quantity of blood during the height of the disorder, or had a diarrhoea after the inflammatory state was passed. He added, that he had usually made a stronger decoction than that which Degner prescrib- ed; who probably was led to gfve the simaruba with more caution, as the bowels were so much inflamed when he began it. I have also known good effects of small doses of ipecacuanha joined to an opiate, such as two grains of that powder with fifteen of the philonium Londinense, taken twice a day. Others have received benefit from ipecacuanha alone. Dr. Huck observed, that a sol- dier, after getting over the inflammatory state of the dysentery, was much reduced by a white-flux of the lienteric kind, and that after giving him several astrin- gents without effect, he had at last succeeded, by or- Chap. VI. Dysentery. 251 dering him six grains of ipecacuanha in powder, to be taken every morning fasting; that this man was puked by the medicine for the first three or four days only, and that he afterwards took it without complaining that it made him sick. During this astringent course, the men are still to be attentive to their diet, abstaining from greens, fruit, malt-liquor and acids. In this state I have allowed them some flesh meat; and for drink, water mixed with a little rum or brandy: to the officers and private patients, I have given some wine when they were very desirous of it. But from further experience, lam con- vinced, that, at this period of the disease, the cures would be both more frequent and speedy, could we prevail upon our patients to abstain altogether from animal food, and from vinous and spirituous liquors: for when no astringents have availed, I have frequently known the cure obtained by a milk and vegetable diet, without them. Therefore when the astringents fail, and especially when the pulse is quick, and the patient complains of inward heat, I first give a vomit of ipecacuanha, and then begin that low regimen, which I continue till the hectic symptoms have ceased, and the bowels have recovered their tone. During this course, I have sel- dom had occasion for medicines, excepting the chalk- julep mentioned before, which I use for correcting that strong acid so incident to relaxed stomachs. Sometimes I add an opiate at night in order to pro- cure rest; but after a few days I generally lay both aside. All that I require (which indeed is often hard to obtain) is a strict perseverance in the diet; and now and then a repetition of the vomit, upon any new disorder of the stomach, or greater laxity of the bowels. Whilst the patient continues in this state, I forbid "252 Observations on the Part III. all animal food; and besides milk, I allow only the -preparation of grain, sago, and salep. In large hospi- tals, the soldiers cannot be fully supplied with milk; but in such circumstances they must be contented with less, and with the other parts of diet here prescribed; •without eating cheese, eggs, or other things which are heavy or heating to men in their condition. Although gn ens and fruit may seem to favour the general inten- tion of cooling, yet, as they are mostly loosening, I have thought that the use of them, at this time, was less proper; but it is possible, that, upon further experience, we may find some kinds both of the one and the other conducive to the cure. And I am the rather inclined to this opinion, from having observed, in one of the latest cases, that when the patient drank butter-milk (indeed none of the sourest) he received more benefit than could have been expected from sweet milk; though the former, from an acidity, like that of some fruits, might be supposed to be contrary to the nature of the disease. In this regimen, I allow of neither fermented liquors, nor spirits. The chief drinks are the decoctions of barley, of rice, or of calcined hartshorn, toast and wa- ter, or milk and water. Having observed, in my pri- vate practice, that some were better for drinking Bristol water, not only at the spring but at a distance, I desired one of my patients (who had come from the Havannah) to observe, whether he found any differ- ence between drinking the river water, and the pump- water in this city; and, after some trials, he assured me that he was less liable to a return of his flux when he used the latter. Now, Bristol water and most of the pump water in London agree in not lathering with soap; that is, in being in reality hard, however soft they may be to the taste. But I would not from thence Chap. VI. Dysentery. , 253 infer, that this mineral water has- no other advantage than hardness, when drunk warm at the spring; con- sidering how long it has been in repute for its efficacy in cases of this kind, especially when hectic heats are joined. Pure air being of such consequence in the cure, the physician can scarce be successful in full hospitals unless the wards be uncommonly well aired. The best expedient, in the dysenteric season, is to divide the sick, and to lay them in churches, or in barns, or in ruinous houses only, where neither they nor their nurses can confine the air. Not, but that expositions to cold are hurtful, and that a constant free perspira- tion is favourable to the cure; but when warmth is not to be had with a purity of air, we must chiefly regard the latter. Not only in the camp, but in the hospitals, the privies should be covered every day with a layer of earth; and at these times, particularly, the wards should be fumigated and kept clean. Such men as have long languished in the.hospital^under a hectic, and a laxity of the bowels, have been surprisingly restored, by cantoning them in the country, for the benefit of drinking milk, and breathing the fresh air. . Lastly, as conducive to the cure, and as a preserva- tive against a relapse, especially when the weather be- gins to grow cold, the convalescents ought to be pro- vided with under-waistcoats: some of the officers; who had been subject to relapses, have informed me, that they had found benefit from wearing a flannel waistcoat next their skin. 254 Observations on the Part III. CHAPTER VII. Observations on the Jail, or Hospital-Fever. 1 COME now to the last fatal distemper, inci- dent to an army, namely, the hospital-fever. In treat- ing of this, I shall, 1. describe its rise, and the man- ner of the infection; 2. the symptoms; 3. the prog- nostics; 4. the dissections of some of those who died of it; 5. the method of cure: and lastly, from these and other materials, I shall inquire into the causes of such fevers. SECTION I. Of the Rise of the jfail or Hospital-Fever, and the manner of the Infection. THE hospitals of an army, when crowded with sick, or when the distempers are of a putrid nature, or at any time when the air is confined, especially in hot weather, produce a fever of a malignant kind, and of- ten mortal.* I have observed the same sort to arise in full and crowded barracks; and in transport-ships, when filled beyond a due number, and detained long by contrary winds; or when the men have been long kept at sea under close hatches, in stormy weather. Hospital-ships, for distant expeditions, have for this reason been generally destructive both to the sick and their attendants. As soon as I became acquainted with this fever in the hospitals abroad, I suspected it to be the same with what is called here the jail-distemper, which I had * Part i. ch. ii. iii. iv. viii. Part ii. ch. iii. § 3. Chap. VII. Jail or Hospital-Fever. 255 never seen; and I was confirmed in my opinion, by hav- ing an opportunity of comparing them, furnished byr an accident mentioned in the first part of these obser- vations.* This disorder is incident to every place ill-aired and kept dirty, that is, filled with animal steams from foul or diseased bodies. And upon this account, jails and military hospitals are most exposed to this kind of pestilential infection; as the first are in a con- stant state of filth and impurity, and the latter are so much filled with the poisonous effluvia of sores, mor- tifications, dysenteric and other putrid excrements. I have seen instances of its beginning in a ward, when there was no other cause but one of the men having a mortified limb. Nay, there is reason to apprehend, that when a single person is taken ill of any putrid dis- ease (such as the small-pox, dysentery, or the like) and lies in a small and close apartment, he may fall into this malignant fever. (121) This I have actually known to happen in camp, when any one has been seized with such a disorder, and kept his tent too close. But ex- cepting on a few of those occasions, this fever is not properly one of the camp-diseases, though it be uni- versally accounted such; for being frequently seen in camp-hospitals, it is therefore erroneously supposed to come from the field. (122) * Page 42. (121) Many facts prove that persons may produce and infect themselves with what is called the jail fever, by means of con- finement, impure air, foul linen, and unwholesome food. It is equally true that persons may thus generate the contagion of the jail-fever, and communicate it to others, without being infected by it themselves. (122) Our author is correct in this remark. During the whole time in which the Editor acted in a medical capacity in the revo- lutionary army of the United States, he rarely saw an instance of 256 Observations on the Part III. I have observed some instances of a high degree of contagion attending it; but the common course of the infection is slow, and catching to those chiefly who are constantly confined to the bad air; such as the sick in hospitals and their nurses, and prisoners in jails. But when there is no great quantity of infectious mat- ter, or when a person has not breathed long in such dangerous steams, or when they are not particularly virulent, he will either escape altogether, or fall ill so slowly, as to give time for stopping the fever before it be quite formed. Much will also depend on the con- stitution: some will have the disorder hanging about them for some days before it confines them to their bed; others will complain for weeks of the same symp- toms, without any regular fever; and others, after leav- ing the infectious place, without the fever, will after- wards be seized with it.* SECTION II. Of the Symptoms. WHEN the distemper comes on slowly* the first complaints are small interchanges of heat and cold, a trembling of the hands, sometimes a sense of numb- ness in the arms, weakness of the limbs, loss of appe- tite: and the disorder being greater at night, the body is hot, the sleep interrupted and not refreshing. With these symptoms, for the most part there is some pain, or confusion of the head. The pulse at first is a little quicker than natural, the tongue is white, but the a hospital fever in the camp. It was generally the offspring of too much crowding, filth, negligence, and something worse, in the military hospitals. The camp diseases were bilious fevers and dysenteries, rheumatisms, pleurisies, and catarrhs. * Part i. ch. vi. p. 43. Chap. VII. Jailor Hospital-Fever. 257 drought is inconsiderable. Those who are thus affect- ed find themselves too much indisposed to go about business, but too well to be wholly confined. In this state, sometimes a vomit, sometimes a change j>f air, will remove the disorder, sometimes a sweat: 1 have had experience of the two last methods of prevention in my own case.(123) The disease, in the beginning, is not easily to be dis- tinguished from any common fever.* I have observed the tremor of the hands to be one of the most constant signs: but in order to form our diagnostics we must take other circumstances into consideration. We are to inquire whether the person has been exposed to the usual causes of fevers, or to foul air and infection; as also, if he has been bled, whether he has been relieved by the evacuation; because, in inflammatory fevers, bleeding generally moderates all the symptoms, but in this it seldom has that effect. When the fever advances, the symptoms already mentioned are in a higher degree, and in particular the patient complains of great lassitude, of a nausea, pains in the back, a more constant pain and confusion in the head; and then we perceive an uncommon dejection of spirits. At this time, the pulse is never sunk, but beats quick, and often varies, in the same day, both as to strength and fulness. It is little affected by bleeding (123) Such was the reliance of the Editor while in the Ameri- can army upon an emetic in curing this fever in its forming state, that he made it a practice to carry a number of doses of tartar emetic in his pocket, which he gave to such of the officers and soldiers as complained of the premonitory signs of the fever, and always with the happiest effects. * Febres malignas in principio statim cognoscere difficile est, cum malignitas sacpe diu lateat, et non nisi ubi vires sum sit sese prodat. Sennert. Epit.de Febrib. lib.iv. chap, x 2K 258 Observations on the Part III. once, if a moderate quantity of blood be taken away; but if the evacuation is large, and especially if repeat- ed, to answer a false indication of inflammation, the pulse, increasing in frequency, is apt to sink in force, and often irrecoverably, whilst the patient becomes de- lirious. But withal we must observe, that in every case, independent of evacuations, the pulse sooner or later sinks, and gives then certain intelligence of the ma- lignity of the disease. The appearance of the blood is various; for though it is commonly little altered, yet sometimes it will be sizy, not only on the first attack, but after the fever is formed. The worst appearance is when the crassamen- tum is resolved; though this does not happen till the advanced state of the disease: but indeed as the blood has then been so seldom taken away, I cannot say whe- ther this be a frequent occurrence or not. The urine is also various. Sometimes it is of a red- dish or flame colour, which it preserves a long time; but it is oftener pale, and changes from time to time in colour as well as crudity, being sometimes clear, sometimes clouded: towards the end, upon a favoura- ble crisis, it becomes thick, but does not always de- posit a sediment. If the sick lie warm, and have had no preceding flux, the body is generally bound; but when they lie cold, as they often do in field-hospitals, the pores of the skin being shut, a diarrhoea is a common symptom, but is not critical. In the worst cases, a flux appears in the last stage; then the stools are involuntary, colliquative, ichorous, or bloody, and have a cadaverous smell; the effects of a mortification of the bowels, and the sign of approaching death. When the hospitals are filled with dysenteries, some of the nurses will be infected Chap. VII. Jailor Hospital-Fever. 259 with the flux only, and others with this malignant fe- ver, ending in these bloody and gangrenous stools. (124) In the beginning, the heat is moderate; even in the advanced state, on first touching the skin, it seems in- considerable; but upon feeling the pulse for some time, I have been sensible of an uncommon ardour, leaving an unpleasant sensation on my fingers, for a few minutes after.* The first time I observed this, I referred it to the force of imagination; but I was as- sured of the reality by repeated experiments, and by the testimony of others, who, without knowing of my observation, had made the same remark. A day or two before death, if care be not taken, the extremities be- come cold, and the pulse is then hardly to be felt. The skin is generally dry and parched, though some- times there are shorter or longer sweats, especially in the beginning. Such as are produced by medicine are of no use, except on the first attack, at which time they will often remove the fever; but such as are na- tural are never critical till the distemper begins to de- cline. These last are rarely profuse, but gentle, conti- nued, and equally diffused over the body: sometimes the disease will terminate by an almost imperceptible moisture of the skin. The sweats are usually foetid, and even offensive to the patient himself. The tongue is mostly7 dry, and without constant care (124) Another proof of the dysentery and hospital-fever ori- ginating from the same cause. * Galen, describing the autumnal remitting fevers, makes the same remark about the heat: Febrium, quae a putredine oriuntur, maximum indicium est mordacitas et acrimonia caloris; quae pe- rinde ac fumus nares et oculos, sic ipsa crodere tactum videtur. —Non statim ea qualitas, admota manu, discernitur, at per mo- ram prsedicta caliditatis species effertur ex penitioribus partibus Lacun. Epit. Galen, de Differ. Febr. lib. i. cap. vii. 260 Observations on the Part III. of the nurse, becomes hard and brown, with deep chops: but this symptom is common to most fevers. It may be particular to this, that sometimes the tongue will be soft and moist to the last, but with a mixture of a greenish, or yellowish colour. (125) The drought is sometimes great, but more frequently moderate. In the advanced state, the breath is offensive, and a black- ish furring gathers about the roots of the teeth. Some are never delirious, but all are under a stupor or confusion. Few retain their senses till death; many- lose them early, and from two causes; either from im- moderate bleeding, or the premature use of warm and spirituous medicines. They rarely sleep, and, unless delirious, have more of a dejected and thoughtful look than what is commonly seen in other fevers. The face is late in acquiring either a ghastly, or a very morbid appearance; yet the eyes are always muddy, and gene- rally the white is of a reddish cast, as if inflamed. The confusion of the head often rises to a delirium, espe- cially at night; but unless by an unseasonable hot re- gimen, it seldom turns to rage, or to those high flights of imagination frequent in other fevers. When the de- lirium rises to that height, the face is flushed, the eyes are red, the voice becomes quick, and the patient strug- gles to get up. But when that disorder is owing to large evacuations, or only to the advanced state of the disease, the face appears meagre, the eye-lids in slurn,- bers are only half shut, and the voice, which is com- monly slow and low, sinks to a degree scarce to be heard. From the beginning, there is generally a great dejection of mind, and a failure of strength. (125) We sometimes observe the tongue after being dry in this fever, suddenly to become moist, and yet the patient notwith- standing sinks under the disease. Chap. VII. Jailor Hospital-Fever. 261 A tremor of the hands is more common than a start- ing of the tendons; or if the subsultus occurs, it is in a lesser degree than in many other fevers. In every stage of the disease, as the pulse sinks, the delirium and tre- mor increase; and in proportion as the pulse rises, the head and spirits are relieved. Sometimes, even from the beginning, the patient grows dull of hearing, and at last becomes almost deaf. When the fever is protracted, with a slow and low voice, the sick have a particular craving for something cordial; and nothing is so acceptable and so cordial as wine. They long for no food, yet willingly take a little panada if wine be added. But such as are delirious, with a quick voice, wild looks, a subsultus tendinum, or violent actions, though their pulse be sunk, yet bear neither hot medicines, wine, nor the common cordials. Vomiting, and complaints of a load and sickness afr the stomach, though usual symptoms, are not essen- tial to the disease; nor are pleuritic stitches, difficulty in breathing, or flying pains to be referred to it, so much as to the constitution of the patient, or to a pre- ceding cold. There is a certain eruption, which is the frequent, but not inseparable attendant of the fever. This is a petechial efflorescence,* which is sometimes of a * It is doubtful whether the ancients knew any thing of these » spots, and the fever which they accompany; but among the mo- derns, they were, so far as I know, first described by Fracasto- rius, under the names of Lenticulae, Puncticula, or Peticulse; for by all these, both the fever and the spots were commonly called in his time. Sunt et alise febres, quae mediae quodammodo sunt inter vere pestilentes et non pestilentes—quales illse fuere quae annis 1505, et 1528, in Italia primum apparuere aetate nostra non prius notse, certis vero regionibus familiares; ut Cypro, et vicinis insulis, majoribus etiam nostris cognitae, vulgus Lenticulas, aut 262 Observations on the Part III. brighter, or paler red, at other times of a livid colour, but never rises above the skin.* The spots are small, but generally so confluent, that at a little distance the skin appears only somewhat redder than ordinary, as if the colour were uniform; but upon a nearer inspection there are interstices seen. For the most part this erup- tion is so little conspicuous, that unless looked for attentively, it may escape notice. The spots appear thickest on the breast and the back, less on the legs and arms; and I do not remember to have observed any upon the face. I have sometimes seen them as early as the fourth, or fifth day, and at other times as late as the fourteenth. They are never critical, nor are they reckoned among the mortal symptoms, but only concur with other signs to ascertain the nature of the disease. The nearer they approach to a purple, the more they are to be dreaded. In a few cases, instead of spots, I have observed purple streaks and blotches, which perhaps are still a worse symptom. The pete- chia will sometimes not appear till after death; f and we had a case in the hospital, in which, upon bleed- ing, these spots were seen on the arm, below the liga- ture, and no where else on the skin. This fever, though of the continued kind, yet has generally sensible exacerbations at night, with remis- sions and often partial sweats in the day; and after a Puncticula appellat, quod maculas proferant lenticulis, aut punc- turis pulicum similes. Quidam mutatis Uteris Peticulas dicunt. Fracast. de Morb. Contag. lib. ii. cap. vi. * For this reason they are not to be referred to any of the ec- thymata of the ancients, which denote pustules or eruptions higher than the skin, as in miliary fevers, with which this fever is not to be confounded. t A circumstance incident to the plague. Fid. Diemerbroeck de Peste, lib. iv. hist. v. Chap. VII. Jail or Hospital-Fever. 263 long continuance, it is apt to change into a hectic, a remitting, or an intermitting form. The length of the disease is uncertain: I have known it end either in death or recovery in seven days; but in the hospitals it generally continued from fourteen to twenty days;* and some died or recovered, after four weeks' illness. From the time of the sinking of the pulse till death, or a favourable crisis, there is per- haps less change to be seen from day to day in this, than in any other fever not of the malignant kind. When the course is long, it sometimes terminates in suppurations of the parotid,! or axillary glands; and when these do not appear, it is probable that the fever is kept up by the formation of some internal abscess. Many, after the crisis, complain of a pain in their limbs and want of rest; and almost all of them men- tion great weakness, confusion in their head, vertigo, and a noise in their ears. Having now related the most distinguishing marks of this fever, I shall only add, that there are some- times slight degeees of it hardly to be described, and which can only be discovered in full hospitals, by ob- serving the men to languish, though the nature of the illness, for which they came in, should seem to admit of a speedier cure. In such cases, they have a whitish tongue, they complain of slight headachs, of want of appetite, and other inconsiderable feverish symptoms. * Dr. Clephane observed, that the most sensible change to the better was generally upon the 17th day, from the time the pa- tient found himself so ill as to keep his bed. The common pe- riod of the fever is the more diligently to be attended to, as we seldom have a crisis before that time, excepting upon a relapse, and then I have observed the course to be commonly shorter. t I remember one instance of both parotids swelling, without any previous indisposition, when the person, not suspecting the 264 Observations on the Part III. SECTION III. $ Of the Prognostics. MEN who have been weakened by distempers, or other accidents (as those who have undergone a sali- vation) are more susceptible of the infection than the strong and vigorous, and run more risk. Those who are taken into crowded hospitals, with the small-pox, however good the sort may be, and however well they may pass the height, fall readily into this fever, and die. One who has recovered is not less subject to a relapse, than he was to the distemper at first; but it has not been observed, whether such as have had ab- scesses are as liable to relapse as others. The second fever is attended with double danger, as the patient has been so much weakened by the first. A sure sign of the corruption of the air in an hospital, is, when many of the nurses fall* sick. We cannot draw a prognostic from any sign by itself, and all of them together are more fallible per- haps in these fevers than in others. Generally, the fol- lowing are good: to have little delirium; the strength little impaired; turbid urine in the decline of the dis- ease; and at that time, a gentle sweat or moisture dif- fused over the body; or even the skin soft, and the tongue moist; or to have then bilious stools succeeded by a diaphoresis; the pulse to rise by wine or cordials, with an abatement of the stupor, tremor, and other nervous symptoms. Deafness is rather a good sign. A sediment in the urine, without other changes to the cause, and applying discutient cataplasms, was, upon the tumours subsiding, seized with the hospital-fever. This happened to Mr. Forbes, surgeon to the second troop of horse-guards, then a mate in the hospital. Chap. VII. Jail or Hospital-Fever. 265 better, is no sure mark of recovery; and some have recovered in whose water I had seen no sediment. The bad signs are, a subsultus tendinum; the eyes much inflamed and staring; the speech quick, and the sound of the voice altered; a high delirium; constant watchfulness; sickness at the stomach, and vomitings; frequent stools with a sinking pulse, and the disorder of the head increased; involuntary faces; coldness of the extremities; and a tremulous motion of the tongue. It is observed to be among the worst signs, when the patient complains of blindness; when he swallows with difficulty; or cannot put out his tongue when desired to do it; when he can lie on his back only, and pulls up his knees; or when insensible, he endeavours to uncover his breast; or makes frequent attempts to get out of bed. If to any of these are added ichorous, ca- daverous and involuntary stools, it is a sign of a mor- tification of the bowels and approaching death. It will not seem strange to find most of these prog- nostics common to the advanced state of other fevers, when we consider, that from whatever cause fevers begin, by a long continuance the humours are cor- rupted, and the brain and nerves affected much in the same manner as in those which arise from infection, SECTION IV. Of the Dissections. THE dissections of those who died of the common hospital-fever, or of Houghton's regiment, which had the distemper from the jails, were in all ten. In some of the bodies, all the cavities were opened; in others, either the brain alone was seen, or the bowels. These imperfections of this part I thought proper to mention, that the accounts here given might not be considered 2L 266 Observations on the Part III, as complete, or prevent others from pursuing the inquiry further. The most unexpected appearances, were abscesses of the brain; of which therefore I shall take more par- ticular notice. The first I saw of this kind was at Ghent; but the man being brought into the hospital from the barracks, no more than two days before he died, I could only conjecture from the symptoms, and the imperfect account I had of him, that his death was owing to a fever of this kind, after lingering near a month in it. I found about three ounces of purulent matter in the ventricles of his brain; and observed that the whole cortical and medullary substance was un- commonly flaccid and tender. Nay, some of the same kind of matter was found in the substance of the upper part of the cerebellum: yet this person, with somerfM- por and deafness, had his senses till the night before he died, so far at least, that he answered distinctly when roused and spoken to; but about that time the muscles of his face began to be convulsed. Of two other instances of men, who undoubtedly died of this fever, in one the brain was suppurated; in the other, the cerebellum. In the former case, the pa- tient was under a stupor, with deafness, from the be- ginning, but was never delirious, nor altogether insen- sible. His pulse sunk early; and about ten days before he died, his head began to swell, and continued very large till within two days of his death, when it subsided a little. For several days before his end he would taste nothing but cold water; and during his illness he lay constantly on his right side. The head being opened, an abscess as large as an egg was found in the sub- stance of the fore part of the right hemisphere of the brain, full of thin matter like whey. At that time five more, ill of the same fever, had the like swelling of Chap. VII. Jail or Hospital-Fever. 267 their heads, but recovered.* This extraordinary symptom I never observed before nor since. In the other case, the abscess in the cerebellum was about the size of a small pigeon's egg, and contained also a thin ichorous matter: nor had this patient been ever so thoroughly insensible, as not to answer reasonably when spoken to. Two days before he died, his urine turned pale. Both these bodies were opened by Mr. Breach, apothecary in Southwark, then a mate in the hospital. But suppurations in the brain were not constant; for another who died about this time, and had been ill about the same number of days, with the like symp- toms, the pale water excepted, had no abscess either in the brain or cerebellum. And two were opened af- terwards, in whom the cortical substance of the brain had an inflammatosy appearance, but no suppuration. In one of them, the large intestines were corrupted: that man went oft with a looseness; and just before his death he had a discharge of an ichorous matter from his nose. In the military hospital at Ipswich, one who unexpectedly died of this fever, after having been once in a fair way, had no suppuration in his brain. And about that time Dr. Clephane informed me, that he had seen the head of another opened, who died after an abscess in each of the orbits; that he had found the brain flaccid, and about two ounces of a thin serum in the ventricles; but that neither of these two bodies had been further inspected. I shall not enter into a description of other particu- lars in these dissections; for though I have them writ- ten at length, it may be sufficient from what has been said to draw the following conclusions. * This happened at Inverness, and all, or most of these men, were of Houghton's regiment. See page 42. 268 Observations on the Part III. That, as there is the greatest tendency to putrefac- tion through the whole course of the illness; it gene- rally terminates, when it proves fatal, either in an actual mortification of some part, or in an abscess of the brain, often ichorous; that the intestines more particu- larly are disposed to mortify, as few die without ca- daverous and involuntary stools; and from an obser- vation which we made, of the petechia not appearing till after death, it seems reasonable to conclude, that those spots are owing to a resolution and a corruption of the blood. The putrid sweats and smell of the body, before death, are a further argument for what is now advanced. And as to the abscesses, so often found in the brain, the ichorous kind may be considered as a species of mortification proper to parts of that texture; and from the preceding cases, it seems probable, that these suppurations are not rare occurrences in this fever.* From the inflammatory appearance of the brain, without suppuration, we may account for the same remedies having sometimes opposite effects. For though in the advanced state, wine and cordials are often the best medicines, yet there are some who can- not take them without increasing the delirium: such therefore have probably some more than usual inflam- mation about the brain. The last observation which I shall make upon the dissections, is, that the great tendency of this fever to putrefaction reduces it to the pestilential class of diseases; as all of that kind are remarkable for a pros- tration of strength, sunk pulse, dejection of spirits, * From the numerous dissections of those who died of the last plague at Marseilles, it appeared that some of the viscera were always mortified and inflamed, and that the brain and lungs were most frequently affected in that manner. Traite de la Peste, part i. Chap. VII. Jailor Hospital-Fever. 269 putrid sweats and stools, petechia, livid blotches, and the like symptoms. These are the inferences which we may reasonably draw from the dissection of the bodies. But from thence to ascertain the first morbific matter, where the effects only are seen; or to account for all the va- rieties of this fever, would be too great an attempt from such materials. Nor would it be just to propose our method of cure as deduced from the inspection of the dead bodies, since the most successful part of it was taken from the experience of others, or from trials of my own preceding most of these dissections. SECTION V. Of the Cure. IN the cure of this fever, as in others, I varied my method according to the state of the disease. Distin- guishing it therefore into three states, in each I shall propose those remedies which from experience I found to be the best. Let us suppose the first to continue as long as the person is able to go about; the second to begin with his confinement, when the fever is man- ifest, the head in some degree affected, but the pulse still full; and the third, when the pulse sinks, and a stupor comes on, with the other symptoms already described. I. In the first state, as well as in all the rest, the fun- damental part of the cure is to remove the patient out of the foul air. When that cannot be done, the room or ward is to be purified, by making a succession of air by means of fires, or letting it in by doors and win- dows, diffusing the steams of vinegar, or the like; for whatever medicines are given while the corruption of the air continues, or indeed increases by the effluvia 270 Observations on the Part III. of the sick, there can be little hopes of recovery. Therefore in every stage, though the patient should breathe no other infectious air but that of his own at- mosphere, it will be necessary if the bed has curtains, to keep them open, and use all other means to procure a free ventilation. On the strict observation of this rule, the cure will much depend.(126) For the next article of prevention, I gave a vomit; and after its operation, half a drachm of theriaca with ten grains of sal cornu cervi, and some draughts of vinegar whey; and I repeated the same, without the vomit, the following night. Sometimes I have used the sudorific medicine alone; and by both methods I have seen those symptoms removed, which I appre- hended to be the forerunner of this fever received by contagion. I must not omit to observe, what may appear a mi- nute circumstance, that as the prevention depended so much upon a free diaphoresis, I found it conducive to that end, especially with the less cleanly sort, to have their feet and hands washed with warm vinegar and water. After sweating, if the patient was to remain in the foul air, I used as a preservative a decoction of the bark and snake-root, which I shall treat of after- wards. II. But in the second state, when the fever was ma- nifest, if the pulse was full, I generally took away some blood, if that had not been done before.(127) When (126) Besides elevating, or taking down curtains, the bed should be removed from the walls of a room, and when it can be done conveniently, placed in the middle of i-.. By this means the late Dr. Beardsley of Connecticut, checked the mortality of the dysentery in the American army, during the revolutiona- ry war. (127) There were now and then cases in which the loss of a few ounces of blood was found to be useful in the military hospitals of the United States. Chap. VII. Jailor Hospital-Fever. 271 the symptoms run high, a plentiful evacuation of this kind seemed indicated, yet I observed, that large bleedings generally proved fatal, by sinking the pulse and bringing on a delirium. Nor was a moderate bleeding to be repeated without caution; for as several circumstances in this fever were different from those of common fevers, so experience showed, that even those whose blood was sizy, unless their lungs were inflamed, were the worse for a second bleeding. If the head only suffered, I judged it safer to bleed by leeches at the temples, than to open a vein in the arm. But in the delirium, with a sunk pulse, even leeches did no good, sometimes, I imagined, did harm, and therefore phlebotomy was not to be tried. Many re- covered without bleeding, but few who lost much blood. Vomits are also to be used cautiously. Before the disease is formed, one was recommended for preven- tion; and even if the stomach was foul, as is usual in autumn, an emetic was believed to be proper in the beginning of the second period also, in order to re- lieve the stomach, and dispose to perspiration. In au- tumn 1757, when our troops returned from the expe- dition to the Rade de Basque, several of the soldiers were brought into the hospital, at Portsmouth, ill of a disorder compounded of the bilious and jail-fever. For when those men, upon being seized with the common fever of the season, were confined to the holds of the crowded transports, their distemper assumed a malig- nant form. All those who were not in the lowest state, but complained of a headach, of costiveness, and a dis- order at their stomach, I first bled, then purged; and af- terwards, proceeding with them in the manner describ- ed in the cure of the bilious fevers,* I gave them * Page 179 et seq. 272 Observations on the Part III. twice a day a grain of emetic tartar, which commonly not only puked, and opened the body, but brought on a diaphoresis. All those who were treated in this man- ner recovered. But in the advanced state of the hospi- tal-fever, when the patient has all along complained of a sickness at his stomach, I judge emetics to be un- safe, from having, in two instances, seen the disease take suddenly a worse turn, when in that circumstance I had given a vomit of ipecacuanha. Nor can I recom- mend any other method as sufficiently ascertained by my experience for this symptom; but in other fevers, which I have treated since, and which, by a constant nausea, showed some similarity to this, Ihave frequent- ly been able to conquer that complaint by giving the saline draughts of Riverius,f in the act of eflerve- t Huic symptomati (scil vomitui) gravissimo statim medetur, quasi miraculo, sal absinthii ad ~z.i. in succi limonum recentis cochleari exhibitum, ut experientia didici. River, in cap. de Feb. Pestilent. The manner in which this operates may perhaps be de- duced from the Append, paper vii. exp. xliv. I find the quantity, of a drachm of the salt, in Riverius's draught, marked in two editions of the original; but which must be a typographical error for a scruple, if the author meant there should be no more salt than is sufficient to saturate the acid, and if the salt which he used was of the same strength with ours. This last circumstance however may be doubted, considering that formerly the sal absinthii was frequently prepared with sulphur, and by means of the acid there, it became a much weaker alkali than that which is now kept in the shops. In those days recourse was had to this salt, in several disorders of the stomach, from a notion that it possessed the vir- tues of the original plant; and the acid seems chiefly to have been added to make it more grateful to the stomach. But now we find, that the lixivial salt of every plant will answer as well as that of wormwood; and that the lemon-juice, or some other acid is ne- cessary for producing an effervescence, with an evolution of some fixed air, upon which the virtue of that medicine so much de- pends. See Append, paper vii. exp. xliv. Chap. VII. Jailor Hospital-Fever. 273 i scence, but repeated oftener than what is commonly practised by others. This is my formula: R Sails absinthii 9iv. sacchari albi Jij- solve ex aqua pur a ?iv. et admisce aqua cinnamomi simplicis 5ij. Dentur omni hora cochlearia iij. cum cochleari uno succi limo- num, donee ager nauseare desierit. Previously to this medicine, I have sometimes made the patient clear his stomach by drinking some camo- mile-tea; at other times, I have omitted that infusion; but, when costive, I have generally begun with a laxa- tive clyster, and caused it to be repeated every day, or frequently, if the patient had not otherwise stools. My next care was to promote a perspiration, which in this state of the fever, was only attempted by the cooler diaphoretics; and for that purpose the spiritus Mindereri was chiefly used. But at this time of the disease, the morbific cause was generally too much fixed to be expelled by the pores of the skin; and therefore unless a sweat came easily, and with relief to the patient, it Was never insisted on; nay, if voluntary and profuse, with a low and quick pulse, I judged it proper to check it. Then the fever began to elude the force of blisters, alexipharmacs, and sudorifics, until the usual time of its decline. Of this I have seen ma- ny instances, but shall only mention one: Mr. Annesly, one of the mates, was seized with the hospital-fever, and after being confined to his bed, for four or five days, and blistered, he took several doses of musk, of five and twenty grains each, which opened his body, raised his pulse, and brought out a thorough sweat; yet the fever continued till about the seventeenth day, and then went ofFwith a gentle moisture of the skin, and turbid urine.( 128) " (128) The hospital fever in spite of the power of medicine will run its protracted course. Sweats, whether natural or obtained 2 M 274 Observations on the Part III. As soon therefore as the fever was confirmed, I gave such medicines only as were recommended above, in the cure of inflammatory fevers,* viz. the contrayerva- powders with nitre and camphire, and barley-water acidulated with vinegar. Although costiveness was prevented by clysters (lest an accumulation of the faces should prove anew fomcs of corruption) yet a looseness was not encou- raged, on account of the great weakness attending this illness. About this time I have used blisters, but without success. Nay, upon the first attack, the whole head has been blistered, and the oozing kept up for some days; but without relieving the head, or preventing any of the usual symptoms. III. I come now to the third, and longest state, in which the pulse sinks, the stupor is great, a delirium is threatened, and petechia often appear. This change begins in three or four days after the fever is formed, often later, according to the treatment and other cir- cumstances. But, what is observable, if the patient has been once or twice largely bled, on the first symp- toms, he will sometimes pass over the second stage, and from a condition little removed from health, his pulse will be apt to sink, and he suddenly become de- lirious. Now, whether this change was occasioned byr misconduct, or came in the course of the disease, I found it necessary to vary the method, and to have for by art, generally do harm not only during its course, but at its crisis. It is strange, that physicians who very properly object to bleeding in this typhus state of fever, should forget that sweating is another and more unsafe mode of depleting in it. Those reco- veries are most certain in which the fever terminates in a gene- ral moisture or softness of the skin. * Part iii. ch. i. Chap VII. Jail or Hospital-Fever. 275 my principal intention, the support of the vis vita, es- pecially towards the decline of the fever; but which could not be answered without some warmer medi- cines than those which have yet been mentioned. Therefore as soon as the pulse began to sink, and the urine to turn pale, I left out the nitre in the diaphore- tic powders,* and substituted 10 grains of the radix serpentaria Virginiana. Sometimes I have given a plain decoction of that root, adding a small quantity of some spirituous li- quor; at other times, I have prescribed the same in substance, from two scruples to a drachm every day, and with good effects; but at last an accident was the occasion of my adding the bark. A man ill of this fe- ver, with petechial spots, having a blister applied to his back, the part mortified; but a strong decoction of the bark, together with some of the tincture being given, and continued for some days, with the usual cordials, the sore began to suppurate, and the case took so favourable a turn, that there was little doubt of the patient's recovery, till nauseating the medicine, he left it off, and then the gangrene recurring he died. From this case however, I was induced to join the de- coction of the bark to the snake-root in the advanced and sunk state of the fever. The first nine recovered who took this compound medicine, though four of them had the petechia; and of thirty-nine cases, which were under my care during that season, I lost only four. But it will be just to add, that the places in which the sick lay were uncommonly well aired, and that the fever was not attended with such bad symptoms as I have seen at other times. For at Ipswich, where the kind was worse, and where the air was so much vi- * Part iii.ch. i. 276 Observations on the Part III. tiated in the hospital, that most of the nurses were in- fected, as well as the men who were admitted for other distempers, I imagine (for I kept no exact account) that I might lose about double that proportion. When I joined the bark to the serpentaria in ordi- nary cases, I began with a much smaller quantity of the former than what I had used for the gangrene, in- tending to increase it by degrees; but finding that smaller quantity answer so well, I seldom altered it. This is now my receipt: Ii Corticis Peruviani in pulvercm contrili 5uj. cogue ex aqua fontana 5xvj.crf ^viij. adjectis subfinem coctionis radicisser- pentaria Virginiana contusa Jij. stent per horam, dein colatu- ra admisce aqua alexiteria spirituose cum aceto 5ij. sacchari albi^Q. Of this my common dose was four spoonfuls every six hours; but if the patient seemed to be heated by it, he took only three. If he was lower than usual I gave the larger quantity once in four hours; thus giv- ing the medicine at shorter or longer intervals, ac- cording to the circumstances: sometimes I have les- sened the proportion of the serpentaria when I ima- gined it heated too much. In one case the fever terminated in a suppuration of one of the parotids, which was opened and healed dur- ing the use of the same remedy. Besides this medicine, I found it sometimes proper to give a volatile cordial, in this manner: R Aqua fontana 2vj. aqua nucis moschata ±j. confectionis car- diaca 3i$. sails cornu cervi 3$. syrupi croci tQ. misce. Dentur subinde in languoribus cochlearia ij. vel iij. This quantity was commonly consumed in 24 hours. But in cases out of the hospital, and where wine was to be had in plenty, I either omitted this mixture, or used it more sparingly. In general, it agreed well with the low state of these fevers; and in great sinkings, Chap. VII. Jail or Hospital-Fever. 277 » which either came after unseasonable bleedings, or long want of nourishment, it was, next to wine, the best resource. For, as a grateful and efficacious cor- dial at this time, there was nothing comparable to wine, of which the common men had an allowance from a quarter to half a pint in a day, of a strong kind, made into whey, or added to panada, which was their only food. But to others but of the hospital, I commonly prescribed Rhenish, or a small French wine, whereof some have consumed near a quart a day, and part of that undiluted. And indeed so great is the virtue of wine in this stage of the fever, that I have known se- veral recover from the lowest condition, when refus- ing the decoction, on account of its taste, they took nothing but a little panada with wine, and the volatile mixture, every two or three hours, by turns. Perhaps there is no rule more necessary, than not to let the pa- tient, when low, remain long without taking something cordial or nourishing; as I have seen men, once in a promising condition, sunk past recovery, by being suffered to pass a whole night without any support, about the time of the crisis. In the advanced state of this fever, the sick are remarkably low, and therefore Hoffman rightly advises, in such cases, that they should be kept constantly in bed, and not permitted even to sit up in it. In the last stage of thisMisease, as well as in that of the sea-scurvy, it should seem, that the force of the heart is too small to convey the blood to the brain, except when the body is in an horizontal posture.* (129) * See the description of the sea-scurvy in Lord Anson's voy- age. (129) Many soldiers perished with this fever in the military hospitals of the United States during the revolutionary war from passing whole nights without food or drink, and some of them fell dead in attempting to walk to or from a close stool. Opium 278 Observations on the Part III. But however necessary wine, and the decoction above mentioned, are in the low state of the fever, we are to remember, that throughout this long stage, these remedies are to be administered only as antisep- tics, and supporters of the vis vita; without aiming at thoroughly raising the pulse, or thoroughly relieving the head, or at forcing a sweat by them, before nature points that way; which I have seldom seen happen be- fore the fourteenth day. For though the patient may die before that period, if he has been largely bled, or if the cordial medicines have been given him too freely, yet such remedies as I have used have not been powerful enough to bring on a crisis sooner. We have seen how inseparable a stupor was from this fever, particularly in its low state, and how apt this stupor was to turn to a slight delirium in the even- ing. If this was all, as being in the common course, nothing was done. But if the delirium increased upon using wine, if the eyes looked wild, or the voice be- came quick, there was reason to apprehend a phrenitis; and accordingly I have often observed, that at such times all internal heating medicines aggravated the symptoms; whilst blisters, before useless, became then of service: in those circumstances therefore, I began to apply them as in the inflammatory fevers. I have had no opportunity of trying, in the delirium of these fevers, the fomentations of warm water and vinegar for the feet, which since the war I found effi- cacious in other fevers;* but I am inclined to believe, that in this case also, they would answer better than either sinapisms or blisters, provided they be long enough and often enough applied. In the inflamma- in frequent, and sometimes in large doses, was more useful than wine in many instances in the low state of the fever in the Ame- rican military hospitals. * Part iii. ch. ii. § I. Chap. VII. Jail or Hospital-Fever. 279 tory fevers, I have known these fomentations have little effect for the first hour, and yet succeed after- wards. For internal medicine, I omitted the decoction for some time, but continued the acid drink,* and gave camphire with the pulvis contrayerva compositus and nitre, as before. If the delirium was with a slow voice, and without violent motions, the decoction, and wine were given, without any other medicine; for in no instance was this symptom quite removed till the usual time of the crisis. I have observed that a delirium would arise from two opposite errors; one, from large and repeated bleedings; and the other, from wine and the cordial medicines being given too early. It appears therefore how nice the principles are that regard the cure: thus neither a hot, nor a cool regimen, will answer with every patient, nor with every state of the disease. (130) If a diarrhoea came on in the decline of the fever, it was moderated (but not suppressed) by adding a few drops of the tinctura Thebaica to the full quantity of the alexipharmac decoction; or by giving some spoon- fuls of the chalk-julep with opium, mentioned before.f For though the looseness may be considered as criti- cal, yet as the sick are too low to bear great evacua- tions, it must in some measure be restrained; and I have often observed, that when it has been treated in this manner, about the usual time of the crisis, the patient has fallen into a breathing sweat, which has carried * Viz. Barley-water with vinegar. (130) It is equally true, delirium may be cured by the opposite remedies of depletion, and stimulants, according to the state of the system. t Page 185. In order to check the purging and promote a diaphoresis, I should now prefer the bolus of theriaca with ipeca- cuanha, likewise mentioned in that page. 280 Observations on the Part III. off the disease. In the worst cases of this fever, and especially when it coincides with the dysentery, the stools are frequently bloody; in which dangerous state if any thing could be done, it was attempted by the same medicines. In proportion to the putrid nature of the stools, opiates and astringents were used with the greater caution. We shall next consider the state of the patient after the fever has ceased, or changed into another form. If the disease terminates in a suppuration of the parotid glands, we are to open the abscess, without waiting for a fluctuation, or a thoroughvsoftness of the tumour, which may never happen; the pus being often here so viscid, that after it is ripe, the part will feel nearly as hard as if the suppuration had not begun.* Almost every patient, after the fever, complained of want of rest, frequently of a vertigo, or confusion of the head, of a continuation of the deafness, or other symptoms, which are commonly called nervous. I then gave an .opiate at night, and in the day, some strengthening medicines, such as the bark, and the elixir of vitriol. I found that in these cases the bark was not only the best strengthener but the surest preservative against a return of the fever. For this last intention, I gave the convalescent about three drachms a day, for six or seven days together; and afterwards, if he re- mained longer in the hospital, some smaller quantity daily. When the pulse was slow, a few grains of asa- * This may be the reason why these tumours have not always proved critical. For Riverius, after the swelling of the glands, was obliged to make other evacuations, perhaps from not making timely incisions. Fid. cap. de Feb. Pestilent. Mr. Girle, formerly surgeon at St. Thomas's, observed to me, that such critical tumours, after malignant fevers, were not to be ripened by poul- tices of bread and milk (which by growing cold are more apt to r: pel them) but by some of the warm gum-plasters. Chap. VII. Jail or Hospital-Fever. 281 fcetida, given twice a day, have had a good effect. But if there was any appearance of a hectic fever, from an inward abscess, the case was treated accordingly. Upon comparing some of the remaining symptoms of those who recovered, with the condition of the brain in such as died, and were opened, I have been induced to think, that some part even of that substance might suppurate, and yet the person recover. Sometimes the patient falls into an irregular inter- mittent, which, if not of a hectic nature, from an in- ternal abscess, may proceed from neglecting to clear the prima via. For it is easy to conceive, that after a long fever of so putrid a nature, often attended with a languor of the bowels, the faces may be so much accumulated, and so corrupted, as to occasion new disorders. In such circumstances, after proper evacu- ation by a purge, the bark was almost a sure remedy. SECTION VI. Of the Causes of Malignant or Pestilential Fevers, IT is evident from the preceding account, that this distemper is of a truly pestilential nature; as appears by the manner in which the head is affected, by the dejection of the spirits, debility, sunk pulse, the sup- puration of the parotid and axillary glands, the putrid sweats, petechial spots, mortifications, and contagion. For though all these symptoms are not found together in one person, yet they are common to the disease; and it is well known that in the plague itself, the symp- toms are various, according to the degree of virulence, and the constitution of the person infected. It would be unnecessary to show the difference be- tween a malignant or pestilential fever, and the true plague, as that distinction, perhaps not clearly com- prehended by the ancients, has been well ascertained by some of the later writers on that subject: and therer 2N 282 Observations on the Part III. fore I shall only remark, that though the hospital-fever may differ in specie from the true plague, yet it may be accounted of the same genus; as it seems to pro- ceed from a like cause, and is attended with similar symptoms (131) The malignant or pestilential fevers are various, ac- cording to the virulence of the miasma or putrid fer- ment received into the blood; but all seem to depend upon some internal or external fomes of corruption, whether owing to a putrid habit, or to exhalations from corrupted animal, or vegetable substances. I shall first treat of the remote and external causes, and next of the internal and immediate. I. The hospital and jail-fever are to be considered as the same disease, and little, if at all, different from such as have arisen after battles, when the bodies of the slain have been left unburied to rot upon the field. This Galen notes as one of the causes of pestilential fevers,* and is supported by the testimony of other authors, in particular by Forestus, who was eyewit- ness to a distemper of this kind (which indeed he calls a plague) owing to the same cause, attended with bu- boes and a high degree of contagion.f The same au- thor also gives an account of a malignant fever break- ing out at Egmont in North Holland, occasioned by the rotting of a whale, that had been left upon the shore.J We have a like observation of a feve"r affecting (131) The editor dissents from the author in supposing the plague to arise from idomiasmatie exhalations. It is produced by the same exhalations as bilious fevers. In small and filthy huts both kinds of exhalation may combine, in which case it is probable the plague may become contagious, but in a very fee- ble and limited degree. * Epit. Galen. De Feb. Differ, lib. i. cap. iv. t Observat. lib. vi. obs. xxvi. \ Obs. ix.schol. Paraeus observes, that in his time the like hap- pened on the coast of Tuscany. De Peste. cap. iii. Chap. VII. Jail or Hospital-Fever. 283 the crew of a French ship, upon the putrefaction of some cattle, which they had killed in the island of Ne- vis in the West-Indiesf. These men were seized with a pain in their head and loins, great weakness, and a disorder of the stomach, accompanied with a fever; some had carbuncles; and on others, purple spots appeared after death. Hippocrates describes a pestilential constitution, and imputes it to a southern, humid and close state of the airf. The putrid effluvia of lakes and marshes are mentioned by Galen as having the same effect. $ One of the most memorable distempers incident to an army is recorded by Diodorus, the historian, || which broke out among the Carthaginians, in Sicily, at the siege of Syracuse. That author not only relates some of the most distinguishing symptoms, but reasons well about the cause. He observes, that pains' in the back, and eruptionsT[ were common; that some had bloody stools; and that others were suddenly seized with a delirium, so as to run about and beat all that came in their way;** that they died on the fifth, or at furthest on the sixth day; that the physicians knew no cure; and that it was the more fatal as the sick were abandoned by every body, on account of the conta- gion. As to the cause, the author takes notice, of the multitude of people confined within a narrow compass; of the situation of the camp, in a low and wet ground; of the scorching heats in the middle of the day, suc- ceeded by the cold and damp air from the marshes in t Traite de la Peste. $ Epidem. lib. iii. sect. iii. § Epit. Galen, de Feb. Differ, lib. i. cap. iv. || Biblioth. Hist. lib. xiv. cap. lxx. lxxi. IT In the original, QXwroiuicti. ** This circumstance of a sudden delirium agrees with what was mentioned in the description of the marsh-fever, in the can- tonments near Bois-le-duc. Part iii. ch. iv. § 2. 284 Observations on the Part III. the night-time:* he adds, the putrid steams arising first from the marshes, and afterwards from the bodies of those who lay unburied. I observed, that I had found the first full account of malignant epidemic fevers, attended with petechia, in Fracastorius. One of those appeared in the year 1505; another, three and twenty years after, and both in Italy. That author omits the cause of the former; but the latter he ascribes to an extraordinary .inunda- tion of the Po, which happening in the spring left marshes, and these corrupting infected the air through- out the summer. Forestus remarks, that from the putrefaction of the water only, the city of Delft, where he practised, was scarce ten years together free from the plague, or some pestilential distemper.f In the year 1694, a fever broke out at Rochfort in France, which, on account of the malignant symptoms and great mortality, was at first believed to be the true plague.| But M. Chirac, who was sent by the court to inquire into its nature, found the cause to arise from some marshes that had been made by an inundation of the sea; and observed, that the corrupted steams, which smelled like gun-pow- der, were carried to the town by the wind, that had long blown from that quarter. About two thirds of those who were taken ill died.ij This fever raged in * This is said to be the principal cause of the malignant camp- diseases in Hungary. See pages 168, 169. f Observat. lib. vi. He adds, that the magistrates, upon his re- presentation of the cause, erected a wind-mill for moving ^ind refreshing the water. At that time Holland was more liable to inundations, and to the stagnation of water, than at present. $ Traite des Fievres Malignes. Oeuvres Posthumes de M. Chirax. Eloge de M. Chirax par M. de Fontenelle. § In those who were opened, the brain was found either in- flamed, or loaded with blood; the fibres of the body were remark- ably tender, and the bowels were either suppurated, or mortified. Chap. VII. Jailor Hospital-Fever. 285 June, July, and August, and then ended upon a great fall of rain; which purified the air, and refreshed the stagnating water. I might adduce many instances of malignant fevers, occasioned by the putrid effluvia of marshes, from other authors; but as these already mentioned seem sufficient to prove what has been advanced, I shall observe upon the whole, that the bilious or remitting, and intermitting fever of low and wet countries, whe,n at the worst, may be considered as a species of the malignant or pestilential fever; since they have been seen with all the virulent symptoms peculiar to that class of diseases.* In general, it may be remarked, that the putrefac- tion of animal or vegetable substances, in a dry air, is most apt to produce a malignant fever of a more con- tinued form; whereas putrid effluvia, in a moist at- mosphere, have a greater tendency to bring on parox- ysms and remissions. But the steams of corrupted blood seem to dispose more to a flux than to any other disorder; for though some will be seized with the hos- pital-fever by the contagion of bloody stools, yet I have observed, that for the most part this infection produces the dysentery, f From this view of the causes of malignant fevers and fluxes, it is easy to conceive how incident they must be, not only to all marshy countries after hot seasons, but to all populous cities, low and ill aired; unprovi- ded with common sewers; or where the streets are narrow and foul; or the houses dirty; where fresh water is scarce; Where jails and hospitals are crowded, and not ventilated, or kept clean; when in sickly times, the burials are within the walls,$ and the bodies not laid deep; when slaughter-houses are likewise within *Part iii. ch. iv. § 2, 3. t Part iii. ch. vi. § 3. \ Secreta dte Feb. Castrens. Malign. 286 Observations on the Part III. the walls; or when dead animals and offals are left to rot in the kennels, or on dunghills; when drains are not provided to carry off any large body of stagnating or corrupted water in the neighbourhood; when flesh meats make the greatest part of the diet, without a proper mixture of bread, greens, wine or other fer- mented liquors; when the grain is old and mouldy, or has been damaged by a wet season; or when the fibres are relaxed by immoderate warm bathing. I say, in proportion to the number of these or the like causes concurring, a city will be more or less subject to pes- tilential diseases, or to receive the leven of a true plague, when brought into it by any merchandize. I shall add a few instances to confirm these observations. Constantinople is not only liable to frequent returns of the true plague, but to an annual pestilential fever, which may be considered as the endemic distemper of that place.* But, that this is not owing to the climate, appears from its healthful state during the Greek em- pire, and from observing, that even now, such as live in the suburbs, and keep out of the way of infection, are secure. Nor is the cause to be referred only to the crowds, and to the narrowness and nastiness of the streets; since some of the foreigners are less subject to the sickness than the Turks themselves.f It must therefore be attributed to something peculiar to that people, or rather to such as profess their religion. For, besides that pestilential distempers are frequent in all the cities of the Levant, they prevail in Egypt;! where * See Timoni's account of the plague at Constantinople. Phil. Trans, n. 364. Abridg. vol. vi. part iii. ch. ii. sec. xxi. t Although Timoni observes that strangers in general run a greater hazard than the citizen, yet he adds, Armeni omnium nationum minime ad pestem sunt dispositi; observo illos paucis- simis uti carnibus; cepis, porris, alliis, vinoque maxime utuntur. t Vid. Prosp. Alpin. de Med. iEgypt. Chap. VII. Jail or Hospital-Fever. 287 the inundations are not solely to be blamed; as that country was more healthful before it became a province of the Ottoman empire. And in Sennar, where Ma- hometanism is likewise established, pestilential fevers are destructive; though they seldom visit the Abyssi- nians, who border on that knigdom, and live in a hot- ter climate, but are Christians.* Now, for this differ- ence, the following causes may be assigned. The re- ligion of the Turks enjoins constant ablutions; their luxury is in their baths; and it is well known how much warm bathing, by relaxing the fibres, may dis- pose the body to putrid diseases, j- Add to this, their abstinence from wine and all fermented liquors, the great antidotes to putrefaction; J the principle of fata- lism, which keeps them from avoiding infection; and their ignorance of the learned arts, by which they might know to prevent or cure the plague. In the account of the epidemic malignant fever of Cork, we find the cause ascribed by the author to a concurrence of these circumstances: the moisture of the air, the impurity of the water, the infection of an uncommon number of slaughter-houses, and the offals left to corrupt in the streets; joined to the immoderate quantity of flesh-meats, eaten by the poorest people, * Lettres Edifiantes et Curieuses, recueil iv. t Therefore Celsus forbids bathing in time of the pestilentia; that is, as was shown before, during the season in which malig- nant or pestilential fevers prevail. De Med. lib. 1. cap. x. \ We have the following singular observation in Forestus, on occasion of a pestilential fever that raged in his time: Quicunque aquam obingentem calorem febrilem bibissent (ut villicus quidam, ad quern curandum alio morbo affectum, accitus essem, mihi narravit) correpti intra duos dies moriebantur. Qui vero cerevi- siam bibebant, utpote potum magis huic nostrae regioni consue- tum, iis morbus protrahebatur. Dr. Rogers observes, that" such as riot on animal food, and drink water only, are subject to pu- trid and slow fevers." 288 Observations on the Part HI, without bread or fermented liquors, during the victual- ling season.* Forestus informs us of a pestilential fever, which raged at Venice in his time, produced by the corrup- tion of a small kind of fish in that part of the Adri- atic! (132) And the same author quotes Montanus for a description of the pestilential endemic fever at Famagusta, in Cyprus, arising, in summer, from the corruption of a lake in the neighbourhood of that city. This very distemper we find taken notice of by Fra- castorius, and allowed to be the same with what he calls the lenticula or puncticula, since known by the name of the petechial fever. History abounds with examples of pestilential fevers added to the other miseries of a siege; nay there is scarce any instance of a town being long invested, without some distemper of this kind. Sometimes it may be owing to the filth of a place, crowded with people, and cattle, brought in for shelter, as it formerly happened both at AthensJ and at Rome;& at other times the sickness has been occasioned by corrupted grain; || and by meats long salted, becoming putrid. Although the putrefaction of vegetables is not so * See Dr. Rogers's Essay on Epidemic Diseases. In this book we have a full account of the rise of a malignant fever and small- pox, deduced from a putrefaction in the air, peculiar to the city of Cork, from August to January. That place is noted for the great number of cattle killed for the use of the shipping, which is said to amount to above 120,000 head in the year. t Observat. lib. vi. obs. ix. schol. (132), The first cases of yellow fever which occurred in New- York in the year 1798 were induced by the effluvia of some salted beef in a state of putrefaction. t Diodor. Biblioth. Hist. lib. xii. cap. xlv. § Tit. Liv. anno U. C. ccxci. || Caesar de Bell. Civ. lib. ii. viz. in his account of the siege of Marseilles. Chap. VII. Jail or Hospital-Fever. 289 noxious as that of animals, it is not however without bad effects; for vegetables rotting in a close place yield a cadaverous smell; and we have instances of malig- nant fevers occasioned by the effluvia of putrid cab- bages,* as well as of plants in marshes. (133) Forestus imputes the plague at Delft, in the year 1557, to the eating of mouldy grain, which had been long kept up by the merchants, in a time of scarcity-! And I have heard it remarked, that in this island the dysentery is observed to be more frequent among the common people, in those parts where they live mostly on grain, when the preceding crop has been damaged in a rainy season, or kept in damp granaries. Jails have been often the cause of malignant fevers; and perhaps no where oftener than in this country. Lord Bacon makes the following observation: " The " most pernicious infection, next the plague, is the " smell of the jail, when the prisoners have been long, " and close, and nastily kept; whereof we have had, " in our time, experience twice or thrice; when both " the judges that sat upon the jail,J and numbers of " those who attended the business, or were present, " sickened upon it and died. Therefore it were good " wisdom, that in such cases the jail were aired before "they be brought forth."§ It is probable that one of the times, pointed at by this noble author, was at the fatal assizes held in the year 1577; of which we have a more particular account in Stowe's Chronicle, in these words: " On the 4th, 5th and 6th days of July were " the assizes held at Oxon, where was arraigned and * Dr. Rogers's Essay on Epidemic Diseases, p. 41. (133) Putrid vegetables more uniformly induce bilious fevers, than putrid animal substances. f Observat. lib. vi. obs. ix. \ That is, upon the prisoners from the jail. % Nat. Hist. exp. dccccxiv. 20 290 Observations on the Part III. " condemned Rowland Jenkins for a seditious tongue; " at which time there arose amidst the people such " a damp,* that almost all were smothered. Very few " escaped that were not taken. Here died in Oxon "three hundred persons; and sickened there, but died " in other places, two hundred and odd."t Of the same kind of infection, we have an unhappy instance, so fresh in our memory, that I needed not to have mentioned it here, had it not been to inform such as live at a distance, or those who are to come after us. In the year 1750, on the 11th of May, the sessions began at the Old-Bailey, and continued for some days; in which time there were more criminals tried, and a greater multitude was present in the court than usual. The hall in the Old-Bailey is a room of only about thirty feet square. Now, whether the air was most tainted from the bar by some of the prisoners, then ill of the jail-distemper, or by the general uncleanliness of such persons, is uncertain;^ but it is probable that both causes concurred. And we may easily conceive, how much it might have been vitiated by the foul steams of the Bail-dock, and of the two rooms open- ing into the court, in which the prisoners were the whole day crowded together till they were brought out to be tried. || It appeared afterwards that those * A damp, an old expression (still retained by the miners) sig- nifying bad air. t This account is confirmed by Camden. Annal. Elizabeth. § It has been the custom, some days before every sessions, to remove all the malefactors from the other jails into that of New- gate, already too much crowded. At such times three hundred have been confined within that narrow space; and it is well known how nastily both this and other prisons here are kept. || I have been informed, that at those sessions about a hundred were tried, who were all kept in those close places as long as the court sat; and that each room was but 14 feet by 1 l,.and 7 feet high. The Bail-dock is also a small room taken off one of the corners of the court, and left open at the top: in this, during the Chap. VII. Jailor Hospital-Fever. 29J places had not been cleaned for some years. The poi- sonous quality of the air was aggravated by the heat and closeness of the court, and by the perspirable matter of a number of people of all sorts, penned up for the most part of the day, without breathing the free air, or receiving any refreshment. The bench consisted of six persons,* whereof four died, together with two or three of the counsel, one of the under-sheriffs, se- veral of the Middlesex-jury, and others present, to the amount of above forty; without making allowance for those of a lower rank, whose death may not have been heard of; and without including any that did not sicken within a fortnight after the sessions. trials, are put some of the malefactors who have been under the closest confinement. * Viz. the Lord Mayor, three of the Judges, one of the Alder- men, and the Recorder. Of these died Sir Samuel Pennant, Lord Mayor; Sir Thomas Abney and Baron Clarke, Judges; and Sir Daniel Lambert, Alderman. It is remarkable, that the Lord Chief-Justice and the Recorder, who sat on the Lord Mayor's right hand, escaped, whilst he himself, with the rest of the bench, on his left, were seized with the infection; that the Middlesex- jury, on the left side of the court, lost many, whilst the London- jury, opposite to them, received no harm; and that of the whole multitude, but one or two, or, at most, a small number of those who were on the Lord Mayor's right hand, were taken ill. Some, unacquainted with the dangerous nature of putrid effluvia, have ascribed both this circumstance, and the sickness, in general, to a cold taken by opening a window; by which a stream of air was directed to the side of the court on the Lord Mayor's left hand. But it is to be observed, that the window was at the furthest end of the room from the bench, though the Judges suffered most. Nor could the kind of the fever, nor the mortality attending it, be attributed to a cold: it is therefore probable that the air from the window directed the putrid steams to that part of the court above mentioned. Indeed it must be granted, that septic parti- cles, passing into the blood, become more active and fatal if the infected person catches cold, or by any accident suffers a stop- page of perspiration; for a free perspiration seems to be the chief means by which the blood is purified from any infectious matter. 292 Observations on the Part III. It was said, that this fever in the beginning had an inflammatory appearance, but that after large evacua- tions the pulse sunk,* and was not to be raised by blisters, nor cordials; and the patients soon became delirious. Several had petechia; and all that were seiz- ed with the fever died, excepting two, or three at most. Some escaped without a fever, by a looseness coming on, which was easily cured. This sickness, as far as was known, spread no further; there being at that time no disposition in the air, nor other circum- stances, to propagate the infection. By Dr. Huxham's observations, we find that the same kind of fever had been frequent at Plymouth du- ring the former war, occasioned by the number of French prisoners, and by the hospitals and other places being crowded with men, taken out of our own ships, actually ill of the distemper.f It is remarkable how much the plague, pestilential fevers, putrid scurvies and dysenteries, have abated in Europe within this last century; a blessing which we can ascribe to no other second cause, than to our im- provement in every thing relating to cleanliness, and to the more general use of antiseptics. Felix Platerus, physician at Basil in Switzerland, gives an account of seven different pestilential fevers (he calls each pestis) which afflicted that city in the space of seventy years, all of them within his memory.J Thomas Bartholine mentions five that raged in Denmark in his time; and all from some foreign contagion. \ And other authors, their contemporaries, throughout Europe, are full of the like observations. Forestus remarks, that in his * See page 258. t Essay on Fevers, ch. v. viii. \ F. Plater. Observa . lib. ii. § Nostra memoria quinquies in Dania pestilentia grassata est, 1619, 1625, 1629, 1637, 1654, semper aliunde translata. Tho. Barthol. de Medicin. Danor. Domest. dissert, iv. Chap. VII. Jail or Hospital-Fever. 293 days the plague was most frequent at Cologne and Paris; and refers the cause to the multitude of the in- habitants, and the nastine6s of the streets;* yet both those cities are at present healthful, and not peculiarly subject to any putrid disease. Timoni takes notice, that at Constantinople the cleaner houses are less liable to be infected with the plague than the dirty.f As to diet, it may be observed, that hopped beer, wine, and vinous liquors, coming more into general use, have been some means of suppressing putrid dis- eases. Greens and fruit are likewise more universally eaten;| and salted meats make a much less part of our * Colonise, et Lutetiae Parisiorum, pestis frequentissima estob hominum frequentiam et sorditiem platearum. Observat. lib. vi. obs. v. schol. At that time, the streets not being paved, we may easily conceive how offensive they must have been in such large and populous cities. It will be proper to observe, that Forestus generally confounds the true plague with pestilential or malig- nant fevers, and therefore it is probable that he only means the latter; since those two cities have been little liable to the true plague, from their inland situation. fPhilos. Transact, n. 364. Abridg. vol. vi. part iii. ch.ii. sect. xxi. X Having asked Mr. Miller, keeper of the botanic garden at Chelsea, what he thought might be the proportion between the quantity of, greens and fruit consumed now, and a hundred years ago, he answered: " That in former times, he believed, the trades- " men and common people, about this city, scarce used any, and -' those of higher rank, but little. For that he had been assured by " old gardeners, and by others of his acquaintance, that so late " as seventy years ago, a cabbage sold at three-pence, which now " sells for a half-penny; and that most other greens and fruit were " proportionally dear; insomuch that those, who now eat garden- " vegetables every day, would then only use them on Sundays, " by way of dainty. From which circumstance, and the present " extent of ground laid out in kitchen-gardens, he inferred, that " there was at least six times more garden-stuff used now than " about the time of the revolution." Nor are we to think that this defect of greens and fruit was supplied by a greater consump- tion of the farinacea in bread, or in other forms; since at that 294 Observations on the Part III. diet than formerly. (134) To this, add the more gene- ral consumption of tea and sugar, which I have shown elsewhere to be no inconsiderable antiseptics. * How far these things may be abused, or become productive of other distempers, is not now the question. For so great a city, perhaps London at present is one of the least subject to pestilential fevers, to the dysentery, or other putrid diseases; with which how- ever it seems formerly to have been little less infested than others, notwithstanding the advantages of its situ- ation; viz. in a climate not liable to great heats, or close weather; on a gravelly soil; and on the banks of a large river, which not only supplies fresh water, but fresh air, by the constant motion of the tides. Add, that London stands in a wide plain, where the fields are kept pretty open. Even since the days of Sydenham, there appears to be a considerable alteration for the better; for besides that there has been no plague, we have known no malignant epidemic fever, or fatal dy- time bread was dearer in proportion to meat than it is now. Hence it seems reasonable to conclude, that formerly a greater quantity of flesh was eaten than at present; and it is well known how much more salted meats were then in common use. Let me add, with regard to the farinacea, that they do not seem so much disposed to resist putrefaction as greens or fruit; as appears by the cure of the sea-scurvy, and some experiments that I have made on that subject. See Append, paper iii. exp. xx. xxi. (134) It is possible salted meat without vegetables, may have been one of the causes of the greater frequency of malignant fevers in ancient, than in modern times, but salted meat when well prepared, and eaten with vegetables and fermented liquors, has been proved to be an excellent preventive of the bilious and hospital fevers and of diseases of the bowels. A sudden and ge- neral change was perceived in the health of the American army during the revolutionary war as soon as salted beef and pork with potatoes, became a part of the daily rations of the soldiers. The same aliments have often been found equally beneficial in other communities and in private families. * Append, paper iv. exp. xxvi. Chap. VII. Jailor Hospital-Fever. 295 sentery,* and few bilious fevers of a bad kind; or in- deed, excepting the small-pox and measles, any putrid distemper that could be called general. In some of the lowest, moistest and closest parts of the town, and amongst the poorer people, spotted fevers and dy- senteries are still to be seen; but which are seldom heard of among those of better rank, living in more airy situations. Although many things relating to health might be here better regulated, yet some of the main points have been well attended to; such as regard the privies, the common sewers, and the supplies of fresh water: add, that the people in general are very cleanly. The common dirt of the streets does not seem to affect the health of the inhabitants of great cities; and though the more offensive kind of it may concur with other things to render the air less healthful, yet it ap- pears to have little influence in producing pestilential diseases. (135) Stale urine abounds with a volatile alkaline salt that resists putrefaction;! and the com- mon faces are rendered less, if at all, infectious, by means of a strong acid united with the parts which are really corrupted.! The case is different in putrid dis- orders, and especially in the dysentery, where the faces, * In autumn 1762, the dysentery, though frequent, could not be called epidemic. It prevailed chiefly among the lower people, and in general was of a benign kind. See page 223. (135) There can be no doubt of the truth of this remark. There is a material difference between dirt, and filth. The former which usually covers the middle of the streets of cities, is composed of earth, and is incapable of putrefaction; the latter which consists of dead vegetable and animal matters, when putrid, is the source of febrile diseases. When perfectly dry, it is as inoffensive as dirt. t Append, paper i. exp. ii. iii. X Append, paper vii. exp. xliii. Add the experiments of M. Homberg sur la matiere fecale. Hist, de l'Acad. R. de Sciences, A. 1711. Hoffman, Med. Rat. Syst. torn. i. lib. i. sect. ii. cap. vii. 296 Observations on the Part III. as we have already shown, are in a state of corruption, and contagious.* I shall conclude this part of my subject with ob- serving, that whilst great cities furnish many materials for vitiating the air, they are provided with two consi- derable antidotes; the first arises from the circulation of the air, by means of the constant motion of the people and carriages, and of the draughts made by fires; the other from the quantity of an acid, produced by fuel, the strongest resister of putrefaction. II. Thus far the remote, and external causes of the hospital and other malignant fevers seem to be suffi- ciently ascertained. But in what manner these putrid effluvia act, and produce the various symptoms within the body, is not so easily determined, and therefore what follows is to be considered as conjectures only. I conceive that the miasma or septic ferment (con- sisting of the effluvia from putrid substances) being received into the blood, may have a power of corrupt- ing the whole mass.f The resolution of the blood, and sometimes even its smell in the advanced state of a jail-fever, the offensiveness of the sweats and other excretions, the livid spots, blotches, and mortifica- tions, incident to this distemper, seem to be proofs of what is here advanced.(136) The acrimony irritates * Part i. ch. iii. Part ii. ch. ii. § 3. Part iii. ch. vi. § 1. t See the Append, paper vii. exp. xlviii. (136) The miasmata which produce fevers do not act as putrid ferments upon the blood. It is incapable of putrefaction in a liv- ing animal. Of course there is no such disease as a putrid fever. The change in the blood in fevers, supposed to be putrid, is in- duced entirely by the violent or feeble action of the blood vessels, upon it. It is more consonant to modern pathology and to reason, to call such fevers gangrenous. They arise from the same causes which produce local gangrene, and the effects are the same in both cases. It is to be regretted that our author's practice was in- fluenced in several instances by his belief in a putrid diathesis m the blood in fevers. For example in pages 114 and 115 he rejects Chap. VII. Jail or Hospital-Fever. 297 the nerves and occasions various spasms; the pulse is quickened, at first raised, but soon depressed, from the heart not receiving enough of the vital principle, or from a resolution of its fibres, occasioned by putrefac- tion. I have elsewhere produced instances of the heart being so far relaxed, in the true plague, as to become uncommonly large, by the ordinary force of the blood.* Yet, were putrefaction the only change made in the body by contagion, it might be easy to cure such fe- vers by the use of acids only, or other antiseptics. But as the disease, when once formed, is not to be removed by such means alone, it would therefore seem that some part of the brain is inflamed early, and that the fever is chiefly kept up by that inflammation; f that to this circumstance most of the symptoms are owing; and that in the advanced state, a cure cannot be obtain- ed till the obstructing matter is resolved, or suppurated. That this may be the case, is not improbable, from observing some affinity between the symptoms of this fever, and those of the low and nervous kind, which carry marks of inflammation of some part of the brain, though the cause has not arisen from any apparent putrefaction. The sinking of the pulse, pale urine, sweats not critical, confusion of the head, decay of strength, dejection of spirits, subsultus tendinum, and tremor of the muscles, are common to both; and there- fore, considering the appearance of the brain in those who died of the hospital-fever, it seems not unreason- able to conclude, that some of these symptoms may a mixture of the testacea with nitre as a remedy for fevers lest they should act as septics upon the blood. Modern chemistry has taught us to expect antiseptic qualities from them upon the con- tents of the bowels, and modern practice has proved not only their safety, but their efficacy in fevers erroneously supposed to be of a putrid nature. * Append, paper vii. exp. xlvi. t See the dissections; 2P 298 Observations on the Part III. depend upon the inflammation, and others on the sup- puration of that organ. May not an argument for a septic ferment be also drawn from the cure? Thus, before the inflammation is fixed, are not the septic particles expelled by sweat- ing, and other discharges? After that period, is not the most effectual method, to support the strength, but so as not to increase the inflammation? Near the end of the last stage, the humours being resolved by putre- faction, is not the obstruction removed; and at that time have not the stronger antiseptic, and cordial me- dicines, place, in order to correct, and to enable na- ture to expel what is so much vitiated? In this low state, are not the volatiles sometimes useful for raising the pulse; is not wine the best cordial; and do not we find that not only wine, but camphire, serpentaria, and the bark, viz. the most efficacious medicines here, are considerable antiseptics?* Now these are the remarks which I have made on the nature, the cure, and the causes of malignant or pestilential fevers. In the description, I have endea- voured to distinguish them from all others, as far as I could do it in distempers whose symptoms are so much alike. The nervous fevers are frequently accompanied with miliary eruptions, which have no resemblance to the petechia; nor have I ever happened to see miliary eruptions in this malignant kind. The nervous fevers seem to belong to the inflammatory, and to what has been called, the bilious class of diseases, though inci- dent to those chiefly who are of a weak or lax habit. But whatever be the cause of nervous fevers, if they end in petechial spots, putrid sweats, or become con- tagious, we may from thence conclude, that by the long continuance of the disease, the humours are be- * Append, paper ii. exp. xi. xii. xiii. Chap. VIII. Itch. 299 come putrid; or, in other words, that the nervous fe- ver is changed into one of a malignant form, akin to that of hospitals and jails. CHAPTER VIII. Observations on the Itch. IN the division of the diseases most incident to an army, this was the last mentioned. Although it be of a contagious nature, yet the infection is communi- cated only by the contact of the diseased person, or by his clothes, bedding, £sfc. and not by effluvia, as in the dysentery and hospital-fever. It is confined to the skin, and seems best accounted for by Leeuwenhoek, from certain small insects which he discovered in the pustules by the microscope.* So that the fre- quency of the itch, in the army, is not to be ascribed to the change of air, or diet, that soldiers are exposed to upon expeditions, but to the infection propagated by a few (who happen to have it at first setting out) to others in the same ship, tent, or barrack.f But of all places the hospitals are most liable to this contagion, as receiving all sorts of patients. Hence I have observed, * Since the first edition was published, I found a paper in the Phil Transact, for the year 1730, called, An abstract of a Letter from Dr. Bonomo to Signor Redi, containing some observations concerning the worms of human bodies; by which accounty 1 find that Dr. Bonomo was the first who discovered these animalcula, and who likewise proposed curing the itch by external applica- tions only. t Part i. ch. ii. 300 Observations on the Part II I. that after the crisis of fevers the itch generally appear- ed, though the person was free from it when admitted. One therefore unacquainted with this disorder might be apt to mistake it for a miliary eruption, especially as these two bear a nearer resemblance to each other, than could be expected in two ailments of so different a nature. But those who know how seldom the milia- ry eruptions, and how frequently the other are seen in the army, will be less liable to fall into this error. The two may also be distinguished by the following marks: the miliary pustules, though not confined to the neck and breast, yet are most numerous and visi- ble there; whilst the itch infects mostly the parts be- tween the fingers, the inside of the wrists, the sides of the belly, and the hams. The miliary pustules ap- pear before the fever has ceased, they are attended with little itching, and go off of themselves; whereas the itch is not perceived till after the crisis, in the convalescent state, when it increases daily and becomes very trou- blesome. Although an army cannot be entirely freed from the itch, yet the cure of each individual is more certain in that than in most other distempers; and the remedy is so well known that I scarce need mention it. But I have seen this method oftener fail with the officers than with the private men; because the latter having no change of dress, what they wore was purified by the medicine, at the same time that they themselves were cured; whilst the former catching the itch, have some- times kept it longer, from the circulation of infection between their body and their clothes. Sulphur is the specific remedy of this disease, and is both more safe and more efficacious than mercury. For unless a mercurial ointment were to touch every part of the skin, there could be no dependence upon it: Chap. VIII. Itch. 301 whereas by a sulphurous application, a cure may be obtained by partial unctions only. It would seem as if these, as well as other insects, were killed by the steams of brimstone^ though only raised by the heat of the body. And as to the internal use of the mercury, which some have accounted specific, we have known several instances, in the hospital, of men undergoing a complete salivation for the cure of the lues Venerea without being cured of the itch. The ointment which I mostly used was made in this manner: R Sulphuria vivi praparati ^i. radicis hellebori albiinpulverem subtilissimum contrita 3ii. {vel salts Ammoniaci crudi 5j) ax- ungia porcina ^iif5« misce. This quantity served for four unctions; and the pa- tient was rubbed every night. But to prevent any dis- order that might arise from stopping too many pores at once, I commonly began with anointing only a fourth part of the body at a time. Some are said to cure this disease by rubbing the legs only; but that method I never tried, believing that the medicine would be more efficacious by touching the whole skin. Although the itch may be thus removed by one pot of ointment, yet it will be proper to renew the appli- cation, and to rub the parts most affected for some nights longer, till a second, or a third quantity be also exhausted. In some bad cases, we are obliged to con- tinue to anoint the whole body for several nights to- gether, and also to subjoin the internal use of sulphur; not with a view to purify the blood, but to diffuse the steams more certainly through the skin; as the animal- cula may sometimes lie too deep to be thoroughly de- stroyed by an external application only. As these fumes may heat the blood, at a time when the perspiration is so much impeded, it is proper that the patient should keep all the while to a cool diet, and 302 Observations on the Part III. guard against cold.(137) If he be of a full habit, or in any degree feverish, he should bleed and take a purge; (137) The Editor once saw the hospital fever induced in some soldiers by rubbing them with a composition of sulphur and hogs- lard for the cure of the itch. This fact shows the propriety of the advice given by the Author to avoid taking cold during the exter- nal use of a remedy so much disposed to obstruct perspiration. Our Author has recommended the use of ardent spirits by sol- diers in several places, in treating of the means of preventing their diseases. The Editor has reserved a few remarks upon this advice for the concluding part of his labours, in order, by giving them in a connected and concentrated state, to render them more impressive upon the minds of his readers. He does not think ar- dent spirits should form a part of the daily ration of the soldier. They induce a predisposition not only to camp, but to many chro- nic diseases. They likewise weaken the discipline of an army. Most of the punishments inflicted upon soldiers are for neglect of duty, or for crimes committed while they were under their influence. It is a vulgar error to suppose, that the fatigue arising from violent exercise or hard labour is relieved by the use of spirituous liquors. The principles of life are the same in a horse as in a man, and yet we find that noble animal undergoes the se- verest labour in the extremes of warm and cold weather, with no other liquor than simple water. Our country affords many in- stances, especially among the societies of friends and methodists, of the labours of the harvest being more easily sustained by the use of milk and water, or molasses and water, than by the tran- sient stimulus of rum and water. General Wolfe, whose genius embraced every thing that belonged to the health and comfort, as well as to the discipline and prowess of an army, never suffered a drop of ardent spirits to be issued to his soldiers except when they served as sentries, or upon fatigue duty in rainy weather. These are probably the only cases in which a small quantity of spirits may be useful. The substitutes for these destructive li- quors should be 1. Vinegarandwater, with or withouta little molasses. Vinegar and water constituted the only drink of the Roman armies in their long marches over burning sands with a weight of sixty pounds in military weapons attached to each soldier, and yet we read of scarcely any diseases among them. 2. Milk and water, or molasses and water. 3. As Chap. VIII. Itch. 303 otherwise neither of these evacuations seem to be ne- cessary. The nature of the itch has been often mistaken, whilst some have referred it to the leprous, and others to the scorbutic class of diseases; but it appears to be a distemper sui generis, or at least different from either of those two. The psora mentioned by the Greek wri- ters, and the scabies by the Latin, have been generally supposed to be this very eruption; but as this is not evident from the description which I have read of them,* I should conclude, that though other diseases of the skin seem to have been formerly no less frequent than at present, perhaps more, yet the itch was either altogether unknown, or at least uncommon among the ancients; since they take such particular notice of other cutaneous foulnesses, and omit this wholly. Further, it may be observed, that in the most marshy 3. As drink is often called for, rather to obviate fatigue than to allay thirst, certain cordial articles of aliment should be taken with it, or preferred to it. These should be onions, garlic, the dried fruits of our country, a piece of dried beef, a neat's tongue, a sausage, or a little sugar. The American Indians use no other cordial to support them in their long and fatiguing marches, than a few spoonsful of a mixture of the fine powder of green corn dried, and maple sugar, which they carry with them in baskets, mixed with a little water. The strength acquired by all these ar- ticles is of a durable nature, and is not followed, like that derived from the temporary effects of spirits upon the body, by languor, sickness, and a predisposition to camp diseases. The Editor cannot close his notes upon this excellent work without expressing his respect to the memory of its illustrious author, to whom he was introduced by Dr. Franklin in London in the winter of 1769, and who did him the honour to admit him, when a student of medicine, to a conversation party held at his house once a week, where he met with a number of the most re- spectable physicians of London, and from which he derived both pleasure and instruction. * Paulus, lib. iv. cap. ii. Celsus, lib. v. cap. xxviii. 304 Observations, fcrc. Part III. parts of the Low-Countries, where the true scurvy is so general and bad, the itch is scarce known; and that though both the scurvy and the itch may meet on board our ships, yet they are to be considered as two distinct ailments; the former, arising from foul air, bad water, corrupted provisions, and the want of vege- tables; the other, from contagion; each requiring a dif- ferent cure. Both the scabies, and the various kinds of the impetigo* of the ancients, seem at present to be confounded un- der the general, but improper, appellation of scorbutic eruptions.,f The former are chiefly distinguished by the hardness of the skin in one or more parts of the body, attended with a dry scurf, or pustules, or scabs; and generally with some degree of itching. But they are so far from being always curable by external applica- tions only, that it is sometimes dangerous to attempt to subdue them in that manner. There it is thought necessary to change the humours by a spare diet, fre- quent purges of the saline kind, or by mercurial or other medicines, which have little or no efficacy in curing the itch, and which rather increase than cure the true scurvy. * It would seem, that by the impetigo, Celsus means the lepra Gracorum. Vid. loc. cit. t The true scorbutic spots are of a livid colour, not commonly scurfy, or raised above the skin, and are attended with manifest signs of a lax state of the fibres, and a corruption of the blood. For a real scurvy imports a slow, but general resolution or putrefac- tion of the whole frame; whereas the scabies, impetigo or leprosy may be found to affect those of a very different constitution. APPENDIX, CONTAINING, I. EXPERIMENTS UPON SEPTIC AND ANTISEPTIC SUBSTANCES, WITH Remarks relating to their Use in the Theory of Medicine, in several Papers read before the Royal Society. AND II. AN ANSWER TO PROFESSOR DE HAEN AND M. GABER, CONCERNING Some Remarks made by them on the preceding Work. 2Q \ APPENDIX. PAPER I. Experiments showing that putrid substances are not to be called alkaline; that neither the volatile nor fixed alkaline salts tend naturally to promote putrefaction within the body, being of themselves antiseptic. That the combination of two antiseptics may produce a third weaker than either. Experiments upon the comparative powers of some neutral salts in resisting pu- trefaction. And of the antiseptic qualities of myrrh, camphire, snake-root, camomile-flowers, and the Peruvian bark. Read June 28, 1750. ALTHOUGH an inquiry into the manner how bo- dies are resolved by putrefaction, with the means of accelerating, or preventing that process, has been reck- oned not only curious but useful,* yet we find it little prosecuted in an experimental way; nor is it to be wondered at, considering how offensive such opera- tions are. But as I have been led to make some expe- riments and remarks on this subject, by my having had an uncommon number of putrid distempers un- der my care in the hospitals of the army, I shall ven- ture to lay before the society what I have found dif- ferent from the common opinion; as well as some facts, which, as far as I know, have not been mentioned be- fore. * Lord Bacon calls the inducing or accelerating putrefaction, " a subject of very universal inquiry;" and says, that "it is of an " excellent use to inquire into the means of preventing or stay- " ing putrefaction; which makes a great part of physic and sur- " gery." Mat. Hist. Cent. iv. 308 APPENDIX. Paper I. Finding it a received opinion, that bodies by putre- faction become highly alkaline, I made the following experiments to inquire how far this may be true. EXPERIMENT I. The serum of human blood putrefied made, with a solution of the corrosive sublimate, first a turbid mixture, and afterwards a precipitation. This is one of the tests of an alkali, but scarce to be admitted here; since the same thing was done with the recent urine of a person in health, which is not accounted alkaline. The same serum did not tinge the syrup of violets green, and showed no effervescence when the spirit of vitriol was poured upon it. I made the experiment twice with portions of a different serum, both highly putrid; and once with water in which corrupted flesh had been some time infused; yet the most I could find was, that having previously given the syrup a reddish cast with an acid, this colour was rendered fainter (which might be the effect of dilution) but was not de- stroyed by the putrid humours. And as to efferve- scence, having dropped some spirit of vitriol into those liquors singly, and also when diluted with water, the mixture was quiet, and only a few air-bubbles appear- ed on shaking the glasses. Upon the whole, though there were some marks of a latent alkali in the putrid serum, yet they were so faint, that a quantity of water equal to that of the putrid liquors, mixed with only- one drop of the spirit of hartshorn, being put to the same trial, discovered more of an alkaline nature.* * My conclusion from this experiment was too general, as will appear by a remark made by M. Gaber: see An Answer, isfc. at the end of the Appendix. Paper I. APPENDIX. 309 EXPERIMENT II. It has been a maxim, that all animal substances be- ing distilled after putrefaction, send forth a large quan- tity of volatile salt, in the first water; but Mr. Boyle found that this held good in urine only, and that in the distillation of the serum of human blood putrefied, the liquor which came first over had little strength; either as to its smell or taste, and did not at first effervesce with an acid.* And here it may be observed, that the chemists have frequently applied those properties which they discovered in urine to all the humours indifferently, whereas, in fact, there is a great diversi- ty. For some animal substances, 'such as the urine, the bile, and the crassamentum of the blood soon pu- trefy; the serum, the saliva, and the white of an egg, slowly. Yet those which soonest corrupt do not always arrive at the highest degree of putrefaction. Thus the bile is soon corrupted, but the rankness of it is sensi- bly less than that of flesh; and the white of an egg is not only less disposed to putrefy than the yolk, but when putrid yields a different and less offensive smell; and it seems peculiar to stale urine to contain an alk- aline salt, which, without distillation, makes a strong effervescence with acids; whilst most other animal hu- mours putrefied, though they have a more intolerable foetor, yet contain less volatile salt, less extricable, and scarce effervescing with acids. What makes the difference between stale urine and other putrid sub- stances still greater, is its inoffensiveness with regard to health; whilst the effluvia from other animal sub- stances have oftentimes been the cause of pestilential diseases. * Nat. Hist, of the human blood, vol. iv. page 178. fol. ed. 310 APPENDIX. Paper I. Now upon finding in urine a greater quantity of volatile salt, and that more easily separable than from any other humour, and that stale urine is the least noxious of putrid animal substances; so far from dreading the volatile alkali as the deleterious part of corrupted bodies, from this instance, we should rather infer it to be a sort of corrector of putrefaction. EXPERIMENT III. Daily experience shows how harmless the volatiles are, whether smelled to, or taken in substance; but still there remains a prejudice, as if these salts, being the produce of corruption, should therefore hasten putrefaction, not only in distempers where they are unwarily given, but also in experiments out of the body. As to the effects arising from the internal use of them, little can be said, unless the kind of the disor- der were precisely stated. For supposing, that by their nature they were disposed to promote putrefaction, yet if that be already begun, from a languid circula- tion, and obstruction, the volatiles may then, by their stimulating and aperient qualities, be the means of stopping its progress. And, on the other hand, though they were really antiseptic, yet if the humours are disposed to corruption, from excess of heat or mo- tion, these very salts, by adding to the cause, may augment the disease. So that upon the whole, it will be the fairest criterion of the nature of these volatiles, to find whether, out of the body, they accelerate, or retard putrefaction. 1. In order to decide this question, I made repeat- ed experiments of joining both the spirit, and the salt of hartshorn to various animal substances, and I con- Paper I. APPENDIX. 311 stantly found, that so far from promoting putrefaction they evidently prevented it, and that with a power pro- portioned to their quantity.* The trials were made with the serum of the blood, and also with the crassa- mentum, after it had been dried by keeping. I once separated the thick inflammatory crust of pleuritic blood from the rest of the mass, and having divided it, I put one portion into distilled vinegar, the other into the spirit of hartshorn; and after keeping the in- fusions above a month, in the middle of summer, I found the piece which lay in the alkaline spirit as sound as that in the acid. 2. Another time, I put into a four-ounce phial about an ounce and an half of an equal mixture of ox's gall and water, with 100 drops of spirit of harts- horn; and in another, as much of the gall and water, without any spirit. The phials being corked were set by a fire, so as to receive about the degree of animal heat, and in less than than two days, the mixture with- out the spirit became putrid; yet the other was not only then, but after two days longer, untainted. 2>. I afterwards infused two drachms of the lean of beef in two ounces of water, adding half a drachm of the salt of hartshorn; another phial contained as much flesh and water, with a double quantity of sea-salt; in a third were only the flesh and the water, by way of stand- ard: these phials were placed in a lamp furnace, in a heat varying between 94 and 103 degrees of Fahren- heit's scale. About eighteen hours after infusion, the contents of the phial, which served as a standard, were rank; and in a few hours more, that with the sea-salt * Mr. Boyle had already observed, that fine urinous spirits ad- ded to blood, warm from the vein, would make it appear more florid, keep it more fluid, and long preserve it from putrefaction. Phil. Transact, n. xxix. Abridg.vol. iii. ch. v. § viii. 312 APPENDIX. Paper I. were also putrid; but the flesh with the volatile alkali was sound, and so continued after standing four and twenty hours longer in the same degree of heat. And that the smell of the hartshorn might occasion no de- ception, the piece of flesh was washed from the salt, and still smelled sweet. 4. About the same time, I took three peices of fresh beef, of the same weight as above mentioned, and lay- ing two of them in gallypots, I covered one with saw dust, and the other with bran; but the third piece be- ing strewed with salt of hartshorn powdered, I put into a four ounce phial which had a glass stopper. They were all three placed on the outside of a window exposed to the sun, and the weather being warm, the flesh in the gallypots began to smell on the third day, and on the fourth was quite putrid. Next day the phial was examined, when the flesh was washed from the salt, and found perfectly sweet. It was then dried, and salted again with hartshorn; and having stood in the house for some weeks, in hot weather, it was inspect- ed a second time, and found to be as sound as before. Nor was the substance at all dissolved, but of such a consistence as might be expected after lying as long in common brine.* And lest it should be imagined that the flesh in the gallypots, by being more exposed to the air than that in the phial, became sooner putrid, I also inclosed flesh in phials, like that with the salt of hartshorn, and found the confinement rather hasten the putrefaction. Now finding, by these and many other experiments of the same kind, that volatile alkaline salts not only do not dispose animal substances to putrefaction, out of the body, but even prevent it, and that more pow- * The same piece, being kept a twelvemonth, continued un- tainted, and as firm as at first. Paper I. APPENDIX. 313 erfully than common sea-salt, we may presume that the same, taken by way of medicine, will cateris par- ibus prove antiseptic; at least we cannot justly sup- pose them corruptors of the humours, more than wine or spirits, which used in immoderate quantities may raise a fever, and thereby accidentally be the occasion of corruption. EXPERIMENT IV. I likewise made several experiments with the fixed alkaline salts, and found that they possessed little less antiseptic powers than the volatile. The trials were both with the ley of tartar and the salt of wormwood. But here we must not confound the disagreeable smell of such mixtures, with one that is really putrid; nor the power which these lixivials have of dissolving some animal substances, with putrefaction.* EXPERIMENT V. From these experiments it was natural to conclude, that since acids by themselves were amongst the most powerful antiseptics, and that the alkaline salts were likewise of that class, a mixture of the two, to satura- tion, would resist putrefaction little less than the acid alone. But in the trials, which I made upon flesh, with a spiritus Mindereri, composed of vinegar satur- ated with salt of hartshorn; and with lemon juice sa- turated with the salt of wormwood, I found the anti- septic virtue considerably less, than when either the acids or alkalies were used singly. * In the trials upon flesh, I observed that though the fixed al- kaline salts seemed at first to loosen the texture of fibrous animal substances, yet after infusion for some days, those peices not only were not dissolved, but were firmer than others which had lain in water only. 2R 314 APPENDIX. Paper I. EXPERIMENT VI. As to the comparative powers of these salts upon flesh, I observed that half an ounce of lemon juice sa- turated with a scruple of the salt of wormwood, resisted putrefaction nearly as much as fifteen grains of nitre; and when the trial was made with ox's gall, that two drachms of that mixture were more antiseptic than a scruple of nitre. Again, that nitre, compared with the dry neutral salts, weight for weight, was more antisep- tic in preserving flesh than any which I had tried. The sal Ammoniacus came next to it, and even exceeded it in the experiment with ox's gall. After these, the sal diureticus, tartarus solubilis, and tartarus vitriola- tus, seemed to have nearly the same antiseptic power. EXPERIMENT VII. Thus far I have examined the common neutral salts, which, however powerful in resisting putrefaction, are inferior to some resinous substances, and even to some plants that I have tried. For myrrh, in, a watery men- struum, was found at least twelve times more anti- septic than sea-salt. Two grains of camphire, mixed with water, preserved flesh better than sixty grains of sea-salt: and I imagine that could the camphire have been kept from flying off, or concreting to the sides of the phial, half a grain, or even less would have sufficed. An infusion of a few grains of Virginian snake-root, in powder, exceeded twelve times its weight of sea-salt. Camomile flowers have nearly the same quality. The Peruvian bark is also antiseptic; and if I have not found it so strong as the two substances last mention- ed, I impute that, in some measure, to my not having been able to extract all its embalming parts in water. Paper I. APPENDIX. 315 Now, the watery infusions of vegetables possessing this balsamic virtue are the more valuable, in that be- ing usually free of acrimony, they may be taken in greater quantities than either spirits, acids, the alka- line, or even the neutral salts. And as in the great variety of substances answering this purpose, there may be some other useful qualities annexed, it would not be amiss to review some part of the materia me- dica with this intention. I shall add, that besides this remarkable power in preserving bodies, I discovered in some of those sub- stances a sweetening or correcting quality, after pu- trefaction had actually begun. But those experiments I shall lay before the society at some other time, with a table of the comparative force of salts, and some further remarks upon the same subject. 316 APPENDIX. Paper II. PAPER II. A continuation of the experiments and remarks upon antiseptic substances. A table of the comparative powers of salts in re- sisting putrefaction. Of the antiseptic quality of several resins, gums, flowers, roots, and leaves of vegetables, compared with common salt. Attempts to sweeten corrupted animal sub- stances by means of camomile flowers, and the Peruvian bark. A conjecture about the cause of intermitting fevers; and about the action of the bark in curing them. Read November 21, 1750. OAVING in my last paper just mentioned the com- parative force of a few salts, and of other substances in resisting putrefaction, I shall now lay before the society a particular account of those experiments, and of some others which I have made on that subject. EXPERIMENT VIII. Three pieces of the lean of fresh beef, each weigh- ing two drachms, were put separately into wide mouthed phials. Two ounces of cistern water were added to each; in one, were dissolved thirty grains of sea-salt;* in another, sixty; but the third contained nothing but flesh and water. These phials were little more than half full, and being corked were placed in a lamp furnace regulated by a thermometer, and kept to the degree of heat of the human body. In about ten or twelve hours after, the contents of the phial without salt had a faint smell, and in two or three hours more became putrid.f In an hour or two * All these experiments were made with the white or boiled salt in common use here. t These pieces were intire. But when they are beaten to the Paper II. APPENDIX. 317 longer, the flesh with the least salt was tainted, but that which had most remained sweet above thirty hours af- ter infusion. This experiment was often repeated, and with the same result, allowance being made for some small variations in the degree of heat. The use of the experiment was for making stand- ards, whereby to judge of the septic or antiseptic strength of bodies. Thus, if water with any ingredient preserved flesh better than without it, or better than with the addition of the salt, that ingredient might be said to resist putrefaction more than water alone, or water with thirty, or sixty grains of sea-salt. But if, on the other hand, water with any addition brought on corruption faster than when pure, the substance added was to be reckoned a promoter of putrefaction. The following experiments were therefore all made in the same degree of heat, with the quantities of flesh, water, and air, above specified; together with such septic, or antiseptic substances as shall be afterwards mentioned, and were all compared with the standards. But as the smallest quantity of salt preserved flesh lit- tle longer than plain water, I have always compared the several antiseptic bodies with the largest quantity; so that whenever any substance is said to oppose putrefaction more than the standard, I mean, more than sixty grains of sea-salt dissolved in two ounces of water. EXPERIMENT IX. I then examined other salts, and compared them in the same quantity with the standard, which being of all the weakest resister of putrefaction, I shall suppose consistence of a pulp, with the same quantity of water, the putre- faction begins in less than half the time mentioned above. 318 APPENDIX. Paper II. it equal to unity, and express the proportional strength of the rest in higher numbers, as in the following table. A table of the comparative powers of salts in resisting putrefaction. Sea-salt - - - - - - 1 Sal gemma? - - - - 1 -f Tartarus vitriolatus - - - - 2 Spiritus Mindereri - - - - 2 Tartarus solubilis .... 2 Sal diureticus - - - - - 2 -f Sal Ammoniacus - - - - 3 Saline mixture - - - - 3 Nitre......4 + Salt of Hartshorn - - - 4 -f Salt of wormwood - - - 4 -f Borax - - - - - - 12 -f Salt of amber - - - - - 20 + Alum - - - - - 30 + In this table I have marked the proportions by in- tegral numbers, it being difficult, and perhaps unne- cessary, to bring this matter to more exactness; only to some I have added the sign +, to show, that those salts are stronger than the number in the table by some fraction; except in the three last, where the same sign imports that the salts may be stronger by some units.* * Five grains of borax was the smallest quantity compared with sixty grains of sea-salt; but from its holding out so much longer, I suspect that three grains would have been sufficient; in which case the force of this salt was to be estimated at 20: a singular instance of the strength of a salt, which so far from being acid, is rather alkaline, if we may judge by its urinous taste. One grain of alum was weaker than sixty grains of sea-salt, but two grains were stronger: the power therefore of alum lies between 30 and 60, but by the experiment, nearer the first of these numbers. Paper II. APPENDIX. 319 The vitriolated tartar is rated at 2, though more than thirty grains were taken to equal the standard; but as I perceived that all of it was not dissolved, an allow- ance was made accordingly. On the other hand, as part of the hartshorn flies off, its real force must be greater than is shown by the table. The salt of amber is little volatile; but as three grains thereof were found more preservative than sixty of the sea-salt, it must therefore be more than twenty times stronger. This is indeed an acid salt; but as the acid part, in so small a quantity, is inconsiderable, it should seem that the an- tiseptic power is owing to some other principle. The spiritus Mindereri was made of common vinegar and salt of hartshorn: the saline mixture, of salt of worm- wood saturated with lemon-juice.* The alkaline part in either of these mixtures, with water only, would have resisted with a power of 4 -f; so that the addi- tion of the acid rendered these salts less antiseptic; viz. the spiritus Mindereri, by one half; and the saline mix- ture, by a fourth part; which was an unexpected cir- cumstance. EXPERIMENT X. 1. I proceeded to try resins and gums, and began with myrrh. As part of that substance dissolves in wa- ter, eight grains were made into an emulsion; but most of it subsiding, I could not reckon on a solution of more than one or two grains, which nevertheless hav- ing preserved the flesh longer than the standard, we may account the soluble part of myrrh perhaps about thirty times stronger than sea-salt. * Both the spiritus Mindereri and the saline mixture being in a liquid form are compared with the dry salts, upon the quantity which they contain of the alkaline salt. 320 APPENDIX. Paper II. 2. Aloe, asafoztida, and terra Japonica, dissolved in the same manner as myrrh, like it subsided, and had the same antiseptic force. But gum Ammoniacum and sagapenum showed little of this virtue; whether it was, that they opposed putrefaction less, or that most of the antiseptic principle fell with the grosser parts to the bottom. Three grains of opium, dissolved in water, did not subside, and resisted putrefaction better than the standard. But I observed, that more air than us.ual was generated here, and that the flesh became more tender than with any of the stronger antiseptics. 3. Of all the resinous substances, I found cam- phire the strongest resister of putrefaction. Two grains dissolved in one drop of spirit of wine, five grains of sugar and two ounces of water, exceeded the. stand- ard; though during the infusion most of the camphire flew off, swam at the top, or stuck to the phial. If we suppose only the half lost, the remainder was at least sixty times stronger than sea-salt: but if, as I imagine, the water suspended not above a tenth part, then cam- phire will be three hundred times more antiseptic than sea-salt. That nothing might be ascribed to the minute portion of the spirit used in this experiment, I made another solution of camphire in a drop or two of oil, and found that mixture less perfect, but still beyond the standard. EXPERIMENT XI. 1. I made strong infusions of camomile-flowers, and of Virginian snake-root; and finding them both much beyond the standard, I gradually lessened the quantity of those materials, till I found five grains of either im- part a virtue to boiling water superior to the standard. Now, as we cannot suppose that these infusions con- tained half a grain of the embalming part of these ve- Paper II. APPENDIX. 321 getables, it follows, that this substance must be at least an hundred and twenty times more antiseptic than common salt. 2. I also made a strong decoction of the Peruvian bark, and infused a thin bit of flesh in two ounces of it strained; which flesh did not corrupt, though it re- mained two or three days in the furnace, after the standard was putrid. During this time, the decoction became gradually limpid, whilst the grosser parts sub- sided: by which it appears, that a most minute portion of the bark (perhaps less than of the snake-root or ca- momile-flowers) intimately mixed with water, is pos- sessed of a considerable antiseptic virtue. 3. Besides these, pepper, ginger, saffron, contray- erva-root, and galls, in the quantity of five grains each, as also ten grains of dried sage, of rhubarb, and of the root of wild valerian,* separately infused, exceeded sixty grains of salt. The leaves of mint, angelica, ground-ivy, senna, green tea and red roses; as also the tops of common wormwood, mustard-seed, and horse- radish-root were likewise severally infused, but in larger quantities, and proved more antiseptic than the standard. And as none of these can be supposed to yield in the water above a grain or two of the embalm- ing principle, we may look upon them all as powerful resisters of putrefaction. Further, I made a trial with the decoction of white poppy-heads, and another with the expressed juice of lettuce, and found them both above the standard. By these specimens we may now see how extensive antiseptics are; since, besides salts, vinous spirits, * Although the experiment was made with ten grains of the powder of this root only, yet, considering how long that quantity resisted putrefaction, we may reckon valerian-root among the stronger antiseptics. 2S 322 APPENDIX. Paper II. spices, and acids, commonly known to have this pro- perty, many resins, astringents, and refrigerants, are of the number; and even those plants called alkalescent, and supposed promoters of putrefaction; of which class horseradish is particularly antiseptic. And indeed after these trials I expected to find almost all substances endowed with some degree of this quality, till, upon further experiments, I perceived that some made no resistance to, and others promoted corruption. But before I enter upon that part of my subject, it will be proper to relate some other experiments more nearly connected with the preceding. EXPERIMENT XII. Having seen how much more antiseptic these infu- sions were than sea-salt, I then tried whether vegeta- bles would part with this virtue, without infusion. For this purpose, taking three small slices of the lean of beef, each not exceeding the thickness of half a crown, into one I rubbed the powder of the Peruvian bark, into another that of snake-root, and into a third that of camomile-flowers. It was in the heat of summer, y^et after keeping these pieces for several days, I found the flesh with the bark but little tainted, and the other two sweet. The substance of all the three was firm; in particular that piece with the camomile was so hard and dry that it seemed incorruptible. The reason why the bark had not altogether the same effect, depended probably on its closer texture. EXPERIMENT XIII. I have also made some attempts towards the sweet- ening of corrupted flesh by means of mild substances; Paper II. APPENDIX. 323 because distilled spirits, or strong acids, which might be supposed the most likely to answer this intention, are of too acrid and irritating a nature to be thorough!} useful when this correction is most wanted. And as to salts, besides their acrimony, it is well known that meat once tainted will not take salt. A piece of flesh weighing two drachms, which in a former experiment had become putrid (and was there- by made tender, spongy, and to float in water) was thrown into a few ounces of a strong infusion of camo- mile flowers, after expressing the air, in order to make it sink in the fluid. That liquor was renewed two or three times in as many days, when perceiving the fetor gone, I put the flesh into a clean phial with a fresh in- fusion: this I have kept all the summer, and have it still by me, sweet and of a firm texture.f In the like manner I have succeeded, in sweetening several thin pieces of corrupted flesh, by repeated infusions in a strong decoction of the bark, and I have constantly observed, that not only the offensive smell has been removed, but a firmness restored to the fibres. Now, since the bark parts with so much of its virtue in water, is it not reasonable to suppose, that it may yield still more in the body, when opened by the saliva and the bile, and therefore that in some mea- sure it operates by this antiseptic virtue? From this principle we may perhaps account for its success in gangrenes, and in the low state of malignant fevers when the humours are apparently corrupted. And as to intermitting fevers, in which the bark is most spe- cific, were we to judge of their nature from circum- stances attending them, in climates and in seasons most liable to the distemper, we should assign putre- t This piece I kept a twelvemonth after this paper was read at the Royal Society, and I found it then still firm and uncorrupted. 524 APPENDIX. Paper II. faction as one of the principal causes. They are the great epidemic of marshy countries, and prevail most after hot summers, with a close and moist state of the air. They begin about the end of summer, and con- tinue throughout autumn, being at the worst when the atmosphere is most loaded with the effluvia of stagna- ting water, rendered more putrid by vegetables and animals dying and rotting in it. At such times all meats are quickly tainted, and dysenteries, with other putrid disorders, coincide with these fevers. The heats dis- pose the blood to acrimony, the putrid effluvia are a ferment,* and the fogs and dews, so common in such situations, stopping perspiration, shut up the corrupt- ed humours, and bring on a fever. The more these causes prevail, the easier it is to trace this putrefac- tion. The nausea, thirst, bitter taste of the mouth, and frequent evacuations of corrupted bile are common symptoms, and arguments for what is advanced. We shall add, that in moist countries, and in bad seasons, the intermittents not only begin with symptoms of a putrid fever, but if unduly treated are easily changed into a malignant form, with livid spots or blotches on the skin, or a mortification of the bowels. At the same time it must be acknowledged, that such is the quick action of the bark in removing these fevers, that its febrifuge quality must be something different from its * It will be proper to remark, that when I use here (as in the preceding observations) the word ferment, to denote the cause that changes the humours, I mean only to express the assimila- ting power of all putrid animal substances over the fresh, as shall be explained more fully in the next paper, under experiment xviii. There seemed to be the more need for this caution, as in one of the subsequent papers I am to show, that putrid animal sub- stances become ferments in the strictest sense, that is, act like yeast, when joined to any vegetable substance capable of a vinous fermentation. See exper. xxviii. and the following. Paper II. APPENDIX. 325 antiseptic: and yet we may remark, that whatever me- dicines (besides evacuations and the bark) have been found useful in the cure of intermittents, they are mostly, so far as I know, powerful correctors of putre- faction, such as myrrh, camomile-flowers, wormwood, tincture of roses, alum with nutmeg, the vitriolic, or other strong mineral acids with aromatics. Thus far having recited my experiments upon flesh or the fibrous parts of animals, I shall proceed to show what effects the antiseptics have upon the humours. For though from analogy we might conclude, that whatever retards the corruption of the solids, or re- covers them after they are tainted, will act similarly upon the fluids, yet as this does not certainly follow, I judged it necessary to make some new trials, which, with some experiments on the promoters of putrefac- tion, the reverse of the former, shall be offered to the society at a future meeting. 326 APPENDIX. Paper III. PAPER III. Experiments on substances resisting the putrefaction of animal humours, with their use in medicine. Astringents always anti- septics, but antiseptics have not always a manifest astriction. Of the use of putrefaction in general, and particularly in the animal economy. Of the different means of inducing putrefac- tion. Some substances reputed septics have a contrary quality. And the real septics are some of those substances which have been the least suspected to be of that nature, viz. chalk, the testacea, and common salt. Read Nov. 1. 1750. JlIAVING given a full account of the manner in which I tried the power of antiseptics on the fibrous parts of animals, I shall but just mention the result of some experiments made with them upon the hu- mours.* EXPERIMENT XIV. Decoctions of wormwood, and of the Peruvian bark, also infusions of camomile-flowers, and of snake-root, preserved yolks of eggs several days longer not only than water did alone, but also when some sea-salt was added to it. I likewise found that salt of hartshorn preserved this substance better than four times its weight of sea-salt. EXPERIMENT XV. Ox?s gall was kept some time from putrefaction by small quantities of the ley of tartar, spirit of hartshorn, * All the following experiments, whether made in the lamp- furnace, or by the fire, were made in a degree of heat equal to that of the human blood, viz. about 100 degrees of Fahrenheit's scale. Paper III. APPENDIX. 337 sal Ammoniacus, and the saline mixture; and still lon- ger, by a decoction of wormwood, infusions of camo- mile-flowers, and of snake-root; by solutions of myrrh, camphire, and salt of amber: all these were separately mixed with gall, and found more antiseptic than sea- salt, and seemingly in proportion to their effects upon flesh. Only nitre failed, which though four times stronger than sea-salt in preserving flesh, yet is infe- rior to it in preserving gall, and much weaker than the sal Ammoniacus; which, again, is somewhat less pow- erful than nitre in keeping flesh sweet. The nitre was soon opened by the gall, and emitted much air, which rose as from a fermenting liquor; and when this hap- pened the gall had begun to putrefy.* But the saline mixture generated no air, and opposed the putrefac- tion of the gall more than it did that of the flesh. EXPERIMENT XVI. The last trial was with the serum of human blood, which was preserved by a decoction of the bark, and by an infusion of snake-root. But saffron and cam- phire were not here above a fourth part so antiseptic as before: whether it be that they are less preservative of this humour, or, as I suspect, that they were nrJt sufficiently mixed with it. Nitre acted nearly with its full force, being about four times stronger than sea- salt; and it generated some air, but less than it did with the gall. No other humour was tried: but from these specimens, added to the former experiments, we may conclude, that whatever is a preservative of flesh * Perhaps this may be the reason why, as I have observed, nitre disagrees with the stomach and bowels in cases of pntrid bile. 328 APPENDIX. Paper III. will be universally antiseptic, though perhaps not always with the same force. EXPERIMENT XVII. Having shown how putrid flesh mayr be sweetened, I shall conclude that part of my subject with a like trial made upon the yolk of an egg. A portion of this diluted with a little water, having stood till it was cor- rupted, a few drops of it were put into a phial with two ounces of pure water, and about twice as many drops were mixed with a strong infusion of camomile- flowers. At first both phials had some degree of a pu- trid smell, but being corked, and kept a few days near a fire, in about the degree of animal heat, the mixture with plain water contracted a foztor, whilst the other smelled only of the flowers. Thus far I have related my experiments made upon antiseptics, by which it appears, that besides spirits, acids, and salts, we are possessed of many powerful resisters of putrefaction, endowed with qualities of heating, and cooling, of volatility, astriction, &c. which make some substances more adapted than others to particular indications. In some putrid cases many cor- rectors are already known, in others they are wanting. We are yet at a loss how to correct the sanies of a cancerous sore; but in such a multitude of antiseptics, it is to be hoped that some will be found at last ade- quate to that intention. It may be further remarked, that as different dis- tempers, of the putrid kind, require different antisep- tics, so the same disease will not always yield to the same medicine. Thus, the bark will fail in a gangrene, if the vessels are too full, or the blood is too thick. But if the vessels are relaxed, and the blood resolved, Paper III. APPENDIX. 329 or disposed to putrefaction, either from a bad habit, or from the absorption of putrid matter, then the bark is specific. With the same caution are we to use it in wounds, viz. chiefly in the cases of absorbed matter, when it infects the humours and brings on a hectic fever. But when inflammatory symptoms prevail, the same medicine, by increasing the tension of the fibres (a state very different from the other) has such effects as may well be expected. From the success of the bark in various putrid dis- orders, it should seem that astriction had no small share in the cure;* and indeed does not the nature of putrefaction consist in a separation and disunion of parts? But as there are other cases in which astrin- gency is less wanted, we may find in the contrayerva- root, snake-root, camphire, and other substances, a considerable antiseptic power, with little or no appear- ance of astriction. And as several of these medicines are also diaphoretic, their operation, in this respect, may for that reason be the more successful. I come now to the second thing proposed, which was, to give an account of some experiments made on substances hastening or promoting putrefaction, and which I shall likewise venture to lay before the Society. For setting aside the offensive idea commonly annexed to the word putrefaction, we must acknow- ledge it to be one of the instruments of Nature, by which some great and salutary changes are brought about. With regard to medicine, we know that neither animal nor vegetable substances can become aliment without undergoing some degree of putrefaction. Some * Are not all astringents strong antiseptics; and have not all antiseptics some astringent quality, though not always manifest? 2T 330 APPENDIX. Paper III. distempers may proceed from a want of it;* the crisis of fevers seems to depend upon it;f and perhaps even animal heat, according to Dr. Stevenson's theory4 * Some learned authors mean the same thing, when they ex- press this by a defect of a due degree of alkalescence in the hu- mours; but I have shown in my first paper how liable that term is to objections. f It is observable that Hippocrates entertained the same idea, since he oftener than once uses the word signifying to putrefy, as synonymous to that which signifies to concoct. Thus, Foesius remarks, "Zfauv, quod est putrefacere, Hippocrati concoquere significat; ut et