Читать книгу An Account of the Diseases which were most frequent in the British military hospitals in Germany - Donald Monro - Страница 6

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

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

At the Time the Petechial Fever was frequent at Paderborn in January, February, and March 1761, the Flux frequently accompanied it; and we had in the Hospitals likewise a Number of old Cases of this Kind, the Remains of the preceding Campaign about Warbourg; besides some Men who had relapsed during the Winter, and were sent to us when the Troops marched, upon the Winter-Expedition, into the Country of Hesse. In May and June, what Fluxes we had at Osnabruck, were the remaining old Cases of the Hospitals of Munster, Paderborn, Hoxter, and Niehms. Some few recent ones were sent to Bilifield about the End of June, and above 300 to Munster, in July and August. Those sent to Bremen, in November and December, had continued for some time before they reached us; but a good many of the Soldiers in the Garrison were taken ill of this Disorder, and sent immediately to the Hospital. In the Beginning of May we had but four ill of this Complaint in the Hospital I attended; and there were not above six or seven, among the Sick sent down from the Army, in the Middle of this Month. In June there were but two sent to the Hospital at Minden; and not above ten among the Sick sent to Natzungen in the Beginning of July; tho’ towards the Middle of this Month they began to be more frequent; and continued to be more so in August and September; and in the Hospital at Osnabruck we had not above five or six ill of this Disorder, in December 1762, and in January, February and March 1763.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

A Spoonful of the mixtura fracastorii, taken after every loose Stool; and an anodyne Draught at Night, had a good Effect with some—Repeated Doses of the philonium Londinense answered better with others, who were low, and required a Remedy that was warm and cordial—And others found more Benefit from the Mindereri Draughts, with Mithridate, or the confectio cardiaca, or the Theriac anodyne Boluses.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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