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

[72] Dr. Pringle takes Notice of this yellow Colour or Jaundice. He says, "some grow yellow, as in the Jaundice. This was found more frequent during the first Campaign than afterwards; it was an unfavourable, but not a mortal Symptom." Observ. part iii. ch. 4.—Hippocrates mentions the Jaundice occurring in Fevers, Aphor. iv. Sec. 62 & 64; and he reckons it a favourable Symptom in ardent Fevers, where it happens on the seventh Day. See Book on Crises's, sect. 3.

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

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

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

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

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

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

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

Dr. Hillary's Purge was: Rx. Mannae sescunc. vel unc. ij. Tamarind. cond. unc. i. Tartar vitriolat. gr. x. solve in seri lactis praeparat. cum Vin. Maderiens. unc. vi. Colaturae adde Tinct. Senae unciam dimidiam. Divide in Partes quatuor, & capt. aeger unam omni hora donec laxetur alvus.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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



OF THE Intermitting Fever, or Ague.

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

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

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

[78] See Van Swieten, Vol. II. p. 537.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Some Agues were accompanied with the Jaundice, though not in such a high Degree as in the confirmed State of that Disorder; and commonly in the Beginning the Pulse continued rather quick, in the Intervals between the Paroxysms; and the Patients complained of some Degree of Sickness for the first two or three Days. With those the Bark always disagreed, till the Feverishness between the aguish Paroxysms was gone; and we found, that the best Method of treating them, was to bleed in the Beginning, if there was much Fever; and then to give a Vomit and Purge, and to repeat them, if necessary; and where there was no Purging, to give the saline Draughts, and other cooling Medicines; and to add a few Grains of Rhubarb, or to give so much of the pilulae saponacae 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 cascarillae, or eleutheriae, 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 Haemorrhages from the Nose; and two had like to have died of them before the Bleeding was stopped. The Haemorrhages 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 pilulae saponaceae cum rheo daily as kept the Body open; or the saline Draughts with five or six Grains of Rhubarb in each, or such a Quantity as answered the same Purpose as the Pills; and from Time to Time repeated the Emetic[93] and Purge.

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

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

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

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

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

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

Dr. Russel greatly recommends the Use of Sea Water along with the saponaceous Medicines. See his Treatise on the Use of Sea Water.

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



OF TUMOURS of the BREAST.

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

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

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

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



OF PARALYTIC COMPLAINTS.

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

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

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

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

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



OF AN INCONTINENCY of URINE.

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

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

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

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

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

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



OF A STOPPAGE of URINE.

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

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

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

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

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

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