Chapter V: Part III: chap. vii (4)

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 _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.

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. §. 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 Hæmorrhage 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 Perinæum, 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 _vesiculæ seminales_ and Rectum, the
other between the _vesiculæ_ 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.