high Degree as in the confirmed State of that Disorder; and commonly
in the Beginning the Pulse continued rather quick, in the Intervals
between the Paroxysms; and the Patients complained of some Degree of
Sickness for the first two or three Days. With those the Bark always
disagreed, till the Feverishness between the aguish Paroxysms was
gone; and we found, that the best Method of treating them, was to
bleed in the Beginning, if there was much Fever; and then to give a
Vomit and Purge, and to repeat them, if necessary; and where there was
no Purging, to give the saline Draughts, and other cooling Medicines;
and to add a few Grains of Rhubarb, or to give so much of the _pilulæ
saponacæ cum rheo_, daily, as procured one or two loose Stools.
After the Ague had regular Intermissions, and the Patient was quite
cool, and without Fever in the Intervals, if the Disorder did not
yield to the above Treatment, which it seldom did, we then gave the
Bark freely; even though the slight icteric Symptoms still remained;
and it put an End to the Ague, and removed the Jaundice at the same
Time, without the least Inconvenience to the Patient. In such Cases,
we generally used to add a few Grains of Rhubarb to the first Doses of
the Bark; or gave the Bark made up into Pills with Soap, and added
occasionally a few Grains of Rhubarb.
Several of those who had the icteric Symptoms along with the Ague, had
bilious Vomitings in the Time of the cold Fit; they found themselves
sick, with a bitter Taste in their Mouth, before the Approach of the
aguish Paroxysm; and many of them, though they took Emetics, which
operated freely at this Time, yet did not vomit up the Bile; but the
Sickness and bitter Taste continued till the cold Fit came on, when
they vomited Bile in large Quantities. In such Cases, after the Use of
Emetics and Purges, and the Ague was brought to have regular
Paroxysms, with free Intermissions, the Bark, given as just now
mentioned, removed the Ague and icteric Symptoms, without the least
bad Consequences.
Many Practitioners of great Repute have been prejudiced against the
Bark; and tell us, that the free Use of this Medicine often lays the
Foundation of Obstructions in the abdominal Viscera, especially when
it has been given where there was an icteritious Colour in the Eyes
and Countenance; and that, in such Cases, we ought not to give the
Bark till these Icteric Symptoms are gone. At first, I was very
cautious of giving it under such Circumstances; till meeting with some
Cases where the Paroxysms were severe, and became more frequent, while
the Patient was so low, as to be in Danger of sinking under the
Disorder, I gave the Bark freely, as the only Remedy capable of
preserving Life; which not only stopt the Ague, but carried off the
icteritious Symptoms[84], and restored the Patients to perfect Health.
[84] This agrees with what Mr. _Cleghorn_ remarks of Tertian
Fevers in his _Observations on the epidemic Diseases of the
Island of Minorca_, who says, "where there is an icteritious
Colour of the Eyes, we are likewise told, that the Cortex
should not be administered; though, in my Opinion, it is for
the most part dangerous to delay it, after the first
Appearance of that Symptom." Chap. iii. 2d edit. p. 205.
After this I gave it freely, in the Manner above mentioned, to some
Hundreds, with great Success; and I never saw any Mischief follow from
using it: Indeed sometimes, where it was given rather too soon, it did
not sit easy on the Stomach; and made the Patients hot and restless;
but, by laying it aside, these Effects immediately ceased; and
generally, after a little Time, the Paroxysms became milder and more
distinct, when the Bark was again administered, agreed with the
Stomach, and put an End to the Disorder; and I am now convinced, from
Experience, that the Cases in which the Bark has done Mischief, or
given Rise to Obstructions of the abdomenal Viscera, are but very
rare; and that these Mischiefs mostly arise from the Obstinacy of the
Disorder, and not from the Use of this Drug; for I have oftener
observed these Obstructions where little or no Bark had been used,
than where it was given freely[85]. What probably has given Rise to
the Belief of the Bark's doing so much Mischief, is, that in
_Holland_, and other low fenny Countries, where Agues are endemic,
they are oftentimes extremely obstinate, and yield hardly to any
Remedies; and if they are stopt by the Bark, they often return soon
after, and by their long Continuance give Rise to Obstructions of the
abdomenal _viscera_, which have been attributed to the Use of this
Specific.
[85] Dr. _Pringle_ takes Notice, that these Obstructions
happened as often without as with the Bark; and therefore
seemed to depend on the long Continuance and Obstinacy of the
Intermittent. _Observ._ part iii. chap. iv. sect. 2. p. 179.
3d Edit.
In some few Cases a Purging accompanied these icteric Symptoms, which
we treated much in the same Manner as when the Ague was complicated
with the Flux; we gave Emetics and Purgatives; and the mindereri
Draughts with Mithridate, throughout the Day, and Opiates at Night, if
the Purging was violent; if it continued, accompanied with regular
aguish Fits, the Bark, with Astringents, generally removed both.
In the latter Part of the Year 1761, and during Spring 1762, we had
at _Bremen_ many Patients in Agues of all Sorts; as Quotidians,
Tertians, Quartans, and irregular Agues of a very obstinate Nature.
The Town of _Bremen_ is large and well built, situated in a low sandy
Plain, with the _Weser_ dividing the old from the new Town; generally
a considerable Part of the Environs is covered with Water in the
Winter, and frequently the _Weser_ breaks down some of the Dikes, and
overflows all the Country round; and every Time the River overflows
its Banks, the Cellars of all the new Town, and of that Part of the
old Town next the River, are filled with Water. All the Year round, on
digging two or three Feet deep into the Ground, you come at Water.
Agues are endemic in this Place, and great Numbers of the lower Class
of People are afflicted with them at all Times of the Year, especially
in Spring and Autumn.
Some of the Sick sent down from the Army were bad of Agues; but the
greatest Number we had in Hospitals was composed of such as took it
in Town; either from doing Duty on the Ramparts, or from lying in bad
Quarters, or getting drunk and exposing themselves to Wet and Cold;
and many Men of the invalid Companies who had come from _Embden_
brought with them old inveterate tertian and quartan Agues.
Most of the recent Cases were easily cured by the Methods already
mentioned; though they often continued longer, required a greater
Quantity of the Bark to stop them, and a longer Continuance of its Use
to make a Cure, than at other Places, which were more dry, and higher
situated.
The most obstinate of the recent Cases were the irregular
Intermittents, which had regular Paroxysms, but where the Pulse was
not settled in the Intervals; which we were obliged to treat as
Remitting Fevers till the Paroxysms became quite distinct, and the
Patient was cool and free from any Fever in the Intervals; after which
they commonly yielded to the Bark.
But many of those Agues which had continued for some Time, especially
with those Invalids who came from _Embden_, or who had brought on
frequent Relapses by their own Irregularities, were very obstinate.
With many the Bark had no Effect; and its Use persisted in seeming
rather to exasperate the Paroxysms, and to do Hurt. Nor had almost any
Remedy we tried a better Effect. We gave the following Medicines to
divers Patients; the saline Draughts and cooling Medicines; Infusions
of Camomile Flowers and of other Bitters; Dr. _Morton_'s Powders of
Camomile Flowers, Salt of Wormwood, and diaphoretic Antimony; Dr.
_Mead_'s Powders of Camomile Flowers, Salt of Wormwood, Myrrh, and
Alum; Alum and Nutmeg; large Doses of _sal ammoniac_; large Quantities
of Spirits of Hartshorn; the antimonial Drops and Powders; to some we
gave Emetics, both in the Intervals and immediately before the Fits.
In some we tried to promote Sweats before the Approach of the Fits, by
making them drink freely of warm Liquors while they kept in Bed, and
took diaphoretic Medicines; and to others we applied Blisters.--But
all did not put a Stop to some of those Agues.
With some the Disorder continued till it broke down the Crasis of the
Blood, and brought on a general Relaxation of the Fibres; and the
Patients became cachectic, and fell into Dropsies, or were seized with
Diarrhoeas, of which they died. Some had Obstructions formed in the
Liver or Spleen, or other _viscera_, and fell into the Jaundice and
Dropsies, which carried them off.--In the Bodies, of several whom we
opened, we found Indurations of the Liver and Spleen--in two of them
Suppurations of the Liver--and in one, who had had the Ague at
_Embden_, and had long complained of one of those Swellings towards
the left Side of the _abdomen_, called the _Ague Cake_[86], the Spleen
was so much enlarged as to weigh above four Pounds.
[86] I have seen the dead Bodies of four People opened, who
had those Swellings of the left Side, commonly called the
_Ague Cake_, which had come after Agues; and in all the
Swelling was owing to an Enlargement of the Spleen.
Some, whose Constitutions were worn out by these obstinate Agues, fell
into Consumptions and other pulmonic Disorders in the Winter, of which
they died. One Man died in the cold Fit[87].
[87] The cold Fit is the most dangerous Time of the Paroxysm,
and the greatest Part of those who die of Agues die at this
Time; one or two Instances of which I saw in the Military
Hospital at _Edinburgh_ in the Year 1746.--_Van Swieten_ says
he has seen the trembling and shaking so great in the Time of
the cold Fit of Quartans, that the Teeth have dropt out of
the Head. _Comment. in sect._ 749. _Aphorism. Boerhaav._ vol.
II. p. 511.
Where-ever the Ague continued long, and the Bark had no Effect, we
were obliged to lay it aside, and to try other Remedies adapted to the
present Circumstances of the Patient.
The mild Methods succeeded best; giving the saline Draughts and gentle
cooling Medicines to such as were strong and plethoric, and had the
aguish Paroxysms violent; and the gentle Aromatics and Bitters, or
Chalybeats, to those of a weakly Habit, or whose Fibres had been much
relaxed, and their Constitutions greatly injured by this or any other
preceding Disorder.
During these Courses, we gave at Times gentle Emetics; and if the
Patient complained of Gripes and Purging, which they frequently did,
in the Course of this Disorder, we gave a Dose of Rhubarb, or of some
other mild Purge; and after it other Medicines proper for this
Complaint.
By these Methods frequently the aguish Paroxysms became gradually
milder, and at last vanished. At other Times, after they had continued
for five or six Weeks, we again gave the Bark, and found it to have
the proper Effect. With others they continued thro' the Winter, and
went off of themselves in the Spring. With others they still
continued; and as no Medicines nor Time seemed to have any Effect in
that Country, we recommended their being sent over to _England_ for
Change of Air, as the only Means likely to remove the Disorder.
Two Agues which had resisted the Use of the Bark were cured by Powder
of Camomile-Flowers, Salt of Wormwood, and diaphoretic Antimony; and
one by the Use of the aluminous Powders, with Myrrh.--One Invalid, who
had long been ill of an obstinate Tertian, on catching Cold, was
seized with an Inflammation of his Throat, for which he was blooded,
and took a mild Purge; next Day there appeared a Swelling of one of
the parotid Glands, which we endeavoured to bring to Maturation, by
the Application of emollient Cataplasms; after some Days it went
entirely away, without coming to Suppuration; but as there remained
still a Confusion of the Head, and a Quickness of the Pulse, a large
Blister was applied to the Back, which continued running for some
Days; after it dried up he fell into a Fit resembling that of an
Epilepsy, and next Day had another Fit of the same kind; from the Time
the Swelling first appeared till the Time he had the first Fit, he had
no Ague, but it returned the second Day after the second epileptic
Fit; another Blister was applied, and he had no Return of the
epileptic Fits, though his Ague continued obstinate till _March_, at
which Time he was sent to _England_[88].--About the same Time the
aguish Fits of two others were stopt by the Application of Blisters,
though they returned in both soon after.
[88] On the 29th of _August_ 1759, a Man (_Murdoch Brinnen_)
about thirty Years of Age, was admitted into _St. George_'s
Hospital for a very large Swelling of the parotid Glands and
neighbouring Parts, which had come three Days before, after a
Fit of the Tertian Ague, which did not return afterwards. The
Swelling was discussed by the Application of emollient
Cataplasms, which were intended to have brought it to
Suppuration. He had no Return of the Ague, nor did any bad
Consequence follow the Discussion of the Tumour, and the Cure
was completed by a few Doses of Physic, and a Decoction of
the Bark, which restored him to his Strength, and carried off
the little Heat and Feverishness which remained.
Excepting in these few Cases, I found no Medicines effectual in
stopping those Agues, which had resisted the Bark when properly given,
though we tried a vast Variety in different Cases. The _cortex
cascarillæ_, or _eleutheriæ_, was given freely, both in Decoction and
Substance, in four Cases, which had not yielded to the Bark, but
without producing any good Effect; we had not an Opportunity of
trying this Bark in more Cases of this kind, nor in Fluxes, the small
Quantity of it which had come from _England_ being all expended.
A Soldier of one of the Regiments of Guards, who was admitted into the
Hospital for oedematous Legs, and the Remains of a very bad Flux, which
he had had ever since the preceding Autumn; after being cured of the
Flux, and most of the oedematous Swellings, was seized with an
intermitting Complaint in _February_. He had no regular hot and cold
Fits; but every second Day, after a slight Shivering and Cold, he was
seized with Gripes and a Purging. In one or two of the Fits his Pulse
was very quick, and the Pain of the Bowels very acute and severe;
which obliged us to blood him, and give him a Dose of the saline oily
Purge; after which we treated the Disorder as a Flux complicated with
the Ague, and gave the Bark mixed with Diascord, and gentle Opiates at
Nights, and at Times gentle Purgatives; the Ague and Diarrhoea stopt
very soon, and in a few Weeks he got free of all Complaints, though he
still continued weak, till he was sent to _England_, about the
Beginning of _April_.
Many, especially those whose Constitution had been shaken by this or
some other Disorder, complained of flatulent Swellings of the Stomach
and Bowels, which affected them either while the Ague continued, or
soon after it was stopped, and were very troublesome and uneasy. For
the most part, these Swellings were removed by the Use of cordial
Medicines mixed with the Bark, or a Course of Bitters, and some Doses
of Rhubarb given at proper Intervals. In some Cases, where they were
attended with Sickness, and the Stomach seemed to be loaded, a Vomit
gave Relief. Very often these Symptoms continued for Weeks after the
Ague had left them, and did not go entirely off, till the Patient
recovered his Strength.
In _February_, _March_, and _April_, 1761, severals of the Soldiers in
the Hospital at _Paderborn_ complained of periodical Head-Achs, which
returned in most, every Day; in others, only every second; and
afterwards Cases of this Kind occurred at different Times as long as
the Army continued in _Germany_. These Head-Achs generally began in
the Forenoon, were very violent while they lasted, and confined the
Patient to his Bed for some Hours. During the Pain, the Pulse was
quick; but in the Intervals the Patients were quite cool, and without
Fever. Sometimes, tho' not always, the Urine deposited a little
Sediment as the Head-Ach was going off. Commonly the Pain was all over
the Head, but most severe in the Forehead; though sometimes it was
confined to one Side only.
These Head-Achs we treated entirely as Agues of the same Type. When
the Patient was strong, some Blood was taken away, and afterwards we
prescribed an Emetic and Purge, and then gave the Bark liberally,
which generally put an End to the Complaint, without any bad
Consequences attending.
OF THE JAUNDICE.
The Jaundice, or a yellow Colour of the Eyes and Skin, occasioned by
an Absorption of Bile into the Blood, was another Distemper which
appeared towards the End of each Campaign.
This Disorder, for the most part, takes its Rise[89] from Calculi
lodged in the biliary Ducts[90]; and sometimes from a viscid Mucus or
Pituita obstructing those Passages[91]; and it may be brought on by a
Tumour, or any other Cause[92], compressing these Ducts, so as to
prevent the free Flow of the Bile into the Cavity of the Intestines.
[89] Obstructions and Scirrhi of the Liver have been assigned
as the Cause of the Jaundice; but as we have so many Cases of
this Kind related where no Jaundice appeared, it is now much
doubted, whether such Obstructions, which do not affect the
Ducts, are capable of producing this Disorder.
[90] We have numerous Cases in _Bonetus_, and other physical
Observations, where Calculi have been found in the Gall
Bladder, and Ducts of People who have died of the Jaundice;
and I have frequently found two, three, and sometimes twelve,
fifteen, or twenty, such bilious Calculi in these Cavities.
[91] Viscid Mucus or Pituita, or viscid Bile, has been
observed frequently to obstruct the Ducts. Dr. _Coe_ says,
sometimes icteric Patients discharge very thick Bile, almost
as viscid as Bird-Lime. See his _Treatise on biliary
Concretions_, chap. ii. where he has collected a great Number
of icteric Cases, in which the Bile has been found quite
viscid after Death.
[92] See the Case of a Jaundice in _Bonetus's Sepulchretum
Anatomicum_, tom. II. p. 326, where the Sides of the common
biliary Duct were compressed by an Enlargement of the Glands
about the _vena portarum_; and we sometimes meet with a
Jaundice in pregnant Women which goes off after Delivery, and
seems to have been caused by the Pressure of the Uterus and
indurated Foeces in the Colon. _Van Swieten_ says, he has seen
this very frequently, vol. III. sect. 918, p. 95.
The yellow Colour, or Jaundice, observed in the Ague, and some other
bilious Disorders, seems to arise sometimes from Spasms of the Ducts;
or from too great a Quantity of Bile secreted and absorbed into the
Blood, which seems evidently to be the Case where large Quantities of
Bile are either vomited or discharged by Stool; a Proof that the
biliary Ducts are clear, and free from Obstructions.
In the End of the Campaign of 1760, after a continued Rain for many
Weeks, the Jaundice had been very frequent, and in a Manner
epidemical, among the Troops, for some Time before they left the
Field; and in passing thro' _Munster_, about the End of _December_, I
observed several ill of that Distemper in Hospitals, and met with a
few Cases of this Kind in the Hospitals at _Paderborn_ in _January_
1761; but during the Spring and Summer, we had only one or two now and
then sent to the Hospitals for this Complaint; though towards the End
of the Campaign it became more frequent, and several were sent down to
_Bremen_; and some of the Garrison were likewise affected with it.
During the Winter not above four or five were sent to the Hospitals I
attended, and but a few to the flying Hospital, during the Campaign
1762. It frequently appeared in dropsical Cases, depending on
obstructed Viscera.
Those in whom the Jaundice was the original Disorder, and not
complicated with any other, generally got well soon; but where it
appeared in dropsical Cases, depending on obstructed Viscera, it was
commonly fatal.
In the Beginning of this Disease, Patients usually complained of
Sickness, Heat, Thirst, and other feverish Symptoms; and some had a
Vomiting, and Pain of the Stomach, for a Day or two before the
Jaundice appeared; the Urine was always of a deep Colour from the
first; and about the second or third Day the Skin, and the Whites of
the Eyes, began to be tinged with a yellow Colour, attended with the
common Symptoms of this Disorder.
Such was the Manner in which the Jaundice began in those who were
taken ill in Garrison; but those sent us from the Army could seldom
give any accurate Account of their own Cases.
In the Course of this Disorder, the Sick were inclined to be costive,
though some few had a Diarrhoea; several, who had been reduced by
Fevers, or other Complaints, before the Jaundice appeared, were
attacked with violent Hæmorrhages from the Nose; and two had like to
have died of them before the Bleeding was stopped. The Hæmorrhages did
not prove critical, but seemed to depend on a dissolved State of the
Blood.
On the Patient's being first taken ill, if he was plethoric or
feverish, or complained of Pain, attended with Sickness and Vomiting,
some Blood was taken away. Next Day we gave twenty-five or thirty
Grains of Rhubarb in a saline Draught, and afterwards the common
saline and other cooling Medicines, till the Fever was abated. If the
Pain and Fever did not abate, a Vein was opened a second Time, and a
few Drops of the _tinctura thebaica_ were added to the saline
Draughts, while emollient Clysters were frequently administered, and
the Stomach and Belly fomented with Flannels dipped in warm emollient
Decoctions.
When the Pain and Fever were gone, we then gave a gentle Vomit in the
Evening, and next Day a Dose of Rhubarb; and afterwards so much of
the _pilulæ saponaceæ cum rheo_ daily as kept the Body open; or the
saline Draughts with five or six Grains of Rhubarb in each, or such a
Quantity as answered the same Purpose as the Pills; and from Time to
Time repeated the Emetic[93] and Purge.
[93] Vomits are reckoned amongst the most efficacious
Remedies in this Disorder, and I have often seen good Effects
follow their Use.--_Janet Crags_, a Woman thirty Years of
Age, was, on the 21st of _December_ 1758 admitted into _St.
George_'s Hospital for a Jaundice of some Months Continuance.
Her Eyes and Skin were not of the common icteric Colour, but
of a dark livid yellow, for which Reason both she and the
Nurses termed her Disorder the Black Jaundice. She at first
complained of a Difficulty of Breathing, and a Weight and
Oppression about the Region of the Liver, for which she was
blooded, took some Doses of Physick, and the Soap Pills with
Rhubarb; but these produced no Change in her Complaints. On
the 29th she had a Cough, and complained much of Sickness and
Difficulty of Breathing, for which she was ordered a Vomit,
and afterwards to take the Squill Draught Morning and
Evening, which occasioned a Purging and Gripes. On the 5th of
_January_ 1759, the Looseness still continuing, I ordered her
to leave off the Use of the Squill Draughts, and to take only
some Rhubarb in an oily Draught every Night at Bed-Time. On
the 8th, tho' the Purging had increased, I did not chuse to
check it, as I suspected it would prove a Crisis to the
Disorder, and therefore only ordered her the Cordial Draughts
and Wine to support her Strength. The Looseness continued
till the 15th, when most of the icteric Symptoms were gone,
and by the 30th they entirely disappeared. However, she
continued low, and subject to Flatulencies for some Months
afterwards, which were at last removed by the continued Use
of Cordials, gentle Bitters, a nourishing Diet, and repeated
Doses of Rhubarb; and on the 2d of _May_ she was discharged
in a firm State of Health.
Dr. _Coe_ says, "I have more Reason to be satisfied of the
Effect of Vomits in dislodging these Calculi, than of any
other, or indeed of all other Medicines." _Treatise on
biliary Concretions_, chap. ii. p. 253. Besides viscid
Humours, which Vomits bring away from the biliary Passages,
how often are Gall Stones likewise found in the Stools after
the Operation of a Vomit? _Ibid._ p. 256.