OF THE Intermitting Fever, or Ague.
Reading edition
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].
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.
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.
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.
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.
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 Diarrhœas, 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.
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].
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.
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 œdematous 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 œdematous 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 Diarrhœa 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.