favoured with several valuable remarks on this subject, by Captain
Caldwell, an officer of great humanity and experience. Among other
remarks, he observes, that the different articles of clothing supplied
to sailors are, in general, too slight, and of too small a size, which
renders them expensive and inconvenient to large men. The trowsers, he
observes, should be much thicker, and larger, as the least shower goes
through them; and, in a cold climate, those made of _fear-nought_[84],
which do not cost more than the others, should also be allowed. What
a situation are men in when topsails are reefing in the winter season
while it rains, when cold and wet, with their trowsers sticking to
them, (which would not be the case if they were of flannel) and it is
not practicable that they should have change of clothing for every time
they are obliged to be wet? Thick, double-milled caps are much wanted
in bad weather to cover the head and ears. Dutch caps do not keep out
the weather, and will not stay on the head. It is commonly remarked
that the men who wear the thickest linen shirts are the most healthy.
Men, upon first entering into the service, are allowed the advance of
two months wages, in order to provide necessaries: but this, inadequate
as it is for a long voyage, is not extended to pressed men. It is also
argued against making large stoppages in seamen’s wages; that, by
diminishing what they have to receive when paid off, a discouragement
is thereby given to the service. But as we see men deserting from men
of war when several years wages are due to them, the most reasonable
and effectual encouragement seems to be to render their lives as
comfortable and healthy as possible.
But why might not most of the articles mentioned be supplied
gratuitously? In favour of which Captain Caldwell makes use of an
argument frequently inculcated in this work, viz. that so much
advantage would accrue to Government by preserving the health and lives
of men, and so much would be saved in hospitals, as would much more
than reimburse the extraordinary expence[85].
CHAP. IV.
Of EXERCISE.
It commonly happens in a ship of war that a great proportion of the
hands is landsmen; for, besides the men required to navigate the ship,
a great number is necessary to fight the guns, as well as for other
duties, and their health may be affected by the want of exercise.
It has been observed before, that one use of frequent reviews and
musters in a numerous crew is, to call forth men that would otherwise
be overlooked, to oblige them to come into the open air, to keep
themselves clean, and to prevent them from indulging in filth and
laziness. It is observed, that seamen are in general less subject
to scurvy than marines and landsmen, which seems to be owing to the
greater activity of their life and alacrity of their minds.
There is an essay on the causes of the pestilence, by an anonymous
author, published at Edinburgh in 1759, in which this disease is said
to be entirely the offspring of idleness, and he illustrates this by
its being more apt to arise in besieged towns than any other situation;
and he alledges that a false alarm of the plague will actually produce
it by throwing people idle, as was the case, he affirms, when the
plague was last at Messina.
There are always numbers who have been pressed into the service, to
whom a sea life is new, and who are therefore prone to indolence, low
spirits, and self-neglect. Men of this description are by far the most
apt to fall into the scurvy; and next to the quality of the food,
there is nothing contributes more to promote the scurvy than such a
disposition. It is indeed both a cause and a symptom of this disease,
and therefore idleness and _skulking_ should be rigidly discouraged,
unless the complaint is so far advanced as to render it cruel and even
impossible to force men to take exercise.
The Conqueror, of 74 guns, one of our squadron in the last year of the
war, was an instance of a ship in which only the prime seamen were
attacked with the scurvy, and this is to be accounted for upon the same
principle, for it proceeded from their having been exempted from the
duty of pumping, in which the inferior classes of men were constantly
employed, owing to the leaky state of the ship.
As low spirits and indolence have such an unfavourable effect upon
health, it would be wise, as well as benevolent, to promote whatever
produces jollity, contentment, and good humour, so far as is consistent
with sobriety and regularity. There are certain rough sports which are
now almost in disuse; and whoever would revive and encourage them,
would perform a useful office to the service.
A sea life frequently demands violent temporary exertions, from the
uncertainty of the weather, and other incidents; so that men are more
exposed to extreme fatigue and sudden calls of duty in this than in
any other situation of life. Nothing tends more to shorten life than
excessive bodily labour and watching; and it is for this reason that
seamen in general are short lived, and that their countenance and
general appearance make them appear older than they really are by
several years. This is remarkably the case when a seaman comes to be
upwards of forty and it has been mentioned before, that a person not
acquainted with this circumstance will make a mistake of ten years in
guessing at the age of a seaman from his looks.
Fatigue being therefore frequently the means of bringing on disease
and breaking the constitution, as much tenderness is due to men as is
consistent with the necessary duties of service. This is a circumstance
in which young officers are apt to forget themselves; and they should
take care how they _call all hands_ wantonly, and oblige men to make
exertions beyond their strength, especially as this will be submitted
to more readily by sailors than any other set of men, from the
generous alacrity of their nature.
It would be well if it could be rendered convenient at all times,
except in cases of danger or emergency, to put the men at three watches
instead of watch and watch. By the former arrangement they have eight
hours sleep and rest; by the latter only four hours are allowed, which
is not sufficient for refreshment, nor is there time for them to get
dry, in case they have been exposed to wet.
It would be a good rule to have as few men as possible out of bed in
the night-time, unless where active service renders it necessary; for,
if unoccupied, they lie about the decks, fall asleep, and catch cold.
In such situations, might not all the topmen but one remain on the
forecastle, where they might take exercise, which they could not do
aloft? I am indebted for this remark to the Rev. Mr. Ramsay, who joins
to a great knowledge of the sea service a warm and disinterested zeal
for its prosperity, and has been so good in several other instances as
to communicate to me the results of his experience and observation.
The good effects resulting from the indulgent treatment of men are,
that it encourages them to enter into the service, and to do their duty
with cheerfulness and resolution. There is something more daunting to
the mind of man to see his companions suffering under oppression and
languishing in disease, or perishing miserably from sores or sickness,
than in the terrors of fire and sword, which, as we have seen, make
the least part of the calamities of war. The good treatment of seamen,
in so far as it regards their health, is by no means incompatible with
strict discipline. Indeed strictness and even severity is necessary
with seamen; for it is observed with regard to men who are used to
arbitrary government, that they cannot bear indulgence and relaxation.
But the steady enforcement of discipline and regularity is so far from
being akin to cruelty, that it tends to prevent both sickness and
the commission of crimes, consequently rendering the infliction of
punishment less frequent and necessary. The chief excellence in the
character of an officer seems to consist in uniting strict discipline
with indulgence and humanity.
CONCLUSION.
The subject of the preceding remarks has been the prevention of
diseases and it has appeared that the means of this are not so much in
the province of the medical profession as of those who are entrusted
with the direction of the navy in a civil or military capacity; and
that with regard to cure and recovery also, a great deal depends upon
them, by their having it in their power to make a suitable provision
of proper diet and cordials. The great importance of the subject will
plead my excuse for again calling to mind, that such attentions are
not only dictated by humanity, but would be the greatest wisdom in an
œconomical and national light, considering how expensive it is to
_replace_ men and to support invalids, not to mention that it is upon
the health and lives of men that every public exertion essentially
depends, and upon which may depend not only the character of officers,
but the national character in the day of battle.
It must be confessed, that though there is still room for improvement,
the navy is now on a better footing with regard to the health and
comfort of seamen than it appears to have been in former times. The
victuals were in general in the late war of excellent quality; the
civil branch has shewn in many instances a readiness to adopt the means
and to furnish the articles that were recommended for the health of the
men[86]; and most of the commanders whom I have the honour to know are
humane, attentive, and intelligent.
To conclude; there is no situation of life in which there is room for
more virtues, more conduct and address, than that of a sea officer.
The men are thrown upon his humanity and attention in more views than
one: they are subject to a more arbitrary exertion of power than the
constitution of the date authorities in civil life, Englishmen giving
up into his hands, from considerations of public expediency, that which
they hold most dear, and of which they are most jealous, their LIBERTY.
It is the character of seamen to be thoughtless and neglectful of
their own interest and welfare, requiring to be tended like children;
but from their bravery, utility, and other good qualities, they seem
entitled to a degree of _parental_ tenderness and attention from the
state they protect and the officers they obey.
APPENDIX TO PART II.
In order to exhibit a concise view of the most material observations
contained in this part of the Work, a Memorial, delivered to the Board
of Admiralty in October, 1781, is here subjoined.
MEMORIAL,
Proposing Means for preventing the Sickness and Mortality prevailing
among His Majesty’s Seamen in the West Indies.
I have for the two last years attended a squadron, consisting seldom
of less than twenty ships of the line, in quality of physician to the
fleet at Barbadoes and the Leeward Islands. I received, by the order of
the Commander in Chief, a monthly return from the surgeon of each ship,
setting forth the diseases, deaths, and other circumstances of the
respective ships companies. I also superintended the hospital of the
place where the fleet happened to lie when in port. These advantages
have afforded me an intimate knowledge of the nature and causes of the
sickness and mortality among the seamen, both on board of their ships
and in hospitals.
It appears by my returns, that there died in the course of the twelve
months preceding July last, on board of ships, seven hundred and
fifteen seamen and marines, of whom only fifty-nine died in battle
and of wounds. There died in the same time in hospitals eight hundred
and sixty-two: so that out of twelve thousand one hundred and nine
men, which is the sum total of the complement of twenty ships of the
line, there have perished in one year one thousand five hundred and
seventy-seven, that is nearly every seventh man.
There were also sent to England in the same year, three hundred and
fifty men, disabled by lameness and chronic complaints, the greater
part of whom will be for ever lost to the service.
The degree of sickness is very different at different times; but it
appears by the returns, that, at a medium, there has been one man in
fifteen on the sick list.
Having employed all the attention of which I was capable to find out
the causes of this sickness and mortality, in order, if possible, to
point out the means of prevention, I flatter myself with being able to
assign the most general causes, and to propose some effectual remedies.
When it is considered that sickness is almost entirely confined to
ships of two and three decks, and that some of these are as healthy
as frigates and merchant ships, though in the same circumstances of
service with others that are extremely sickly, we are led from hence to
infer, that sickness is not in its own nature unavoidable, and we are
encouraged to hope, that the attainment of general health is within
the compass of human management.
I humbly and earnestly solicit attention to some of the most material
observations and conclusions which have occurred in the course of a
service, which, though short, has been extensive; and whatever is here
proposed has this recommendation, that it is easily practicable, and is
no addition to the public charges.
First, I hardly ever knew a ship’s company become sickly which was well
regulated in point of cleanliness and dryness. It is the custom in some
ships to divide the crew into squads or divisions under the inspection
of respective officers, who make a weekly review of their persons and
clothing, and are answerable for the cleanliness and regularity of
their several allotments. This ought to be an indispensable duty in
ships of two or three decks; and when it has been practised, and at
the same time ventilation, cleanliness, and dryness below and between
decks, have been attended to, I have never known seamen more unhealthy
than other men. The neglect of such attentions is a never-failing cause
of sickness.
I would, therefore, with all becoming deference, suggest, that such
a regulation, instead of being left to the discretion of officers,
should be made a part of the public instructions. From some commanders,
who already practise these rules, the advantage of them comes to be
known; and would not a public sanction not only render them general
and permanent, but facilitate the duty of the officer, by making such
a regulation appear a matter of legal necessity, instead of his own
arbitrary act?
Secondly, Scurvy is one of the principal diseases with which seamen
are afflicted, and this may be infallibly prevented, or cured, by
vegetables and fruit, particularly oranges, lemons, or limes. These
might be supplied by employing one or more small vessels to collect
them at different islands, and such an expedient would prevent much
sickness, and save many lives. I am well convinced that more men would
be saved by such a purveyance of fruit and vegetables, than could
be raised by double the expence and trouble employed on the imprest
service; so that policy, as well as humanity, concur in recommending
it. Every fifty oranges or lemons might be considered as a hand to the
fleet, inasmuch as the health, and perhaps the life, of a man would
thereby be saved.
Thirdly, The use of wine, in place of rum, has been found extremely
conducive to health. In the course of my observation I have met with
the most unquestionable proofs of the benefit that would arise from
this substitution. It is a farther reason for such a change, that good
rum is seldom or never supplied in the West Indies.
Fourthly, The necessaries provided for the sick by the present
establishment are not at all adequate, especially on a distant station,
where the supply is not regular, and the quantity at best is such as
can contribute but little to their comfort and recovery. An ample
provision might be made for the sick, without any additional expence,
in the following manner:
It is a rule in the service, that though men are sick, their ordinary
allowance of salt meat and other victuals is nevertheless served out,
and is either used by the other seamen, who stand in no need of it, or
is wasted. Now, if the pursers were instructed to provide themselves
with certain species of necessaries, such as Madeira wine, sugar, rice,
and dried fruits, to serve to the sick, in place of rum, and the common
provisions of the ship, such a regulation would be productive of the
very best effects, in recovering the health, and preserving the lives
of those men who have the misfortune to be taken ill in a situation
necessarily destitute of most of the comforts that can alleviate their
sufferings. I cannot help here applauding a late regulation, by which
melasses are substituted for part of the oatmeal; for the quantity of
the latter heretofore legally allowed was so much greater than what was
necessary, that one half of it has commonly been wasted.
It is to be observed, in general, with regard to the West Indies, that
ships on service are to be considered, in a great measure, in the light
of ships constantly at sea; for, excepting the island of Barbadoes,
there is no other port in which fresh meat and vegetables can be
procured in any quantity, and therefore sour krout, melasses, and such
other articles of antiscorbutic diet as can be supplied on board, are
absolutely necessary. Fleets could hardly exist here, were it not that
a warm climate is naturally more unfavourable to the scurvy than a cold
one.
Fifthly, Though the health of a ship’s company depends chiefly on
diet, and that discipline and order which is the business of officers,
yet much depends also on the medical art, particularly in the West
Indies; and as surgeons frequently cannot do justice to the men without
wronging themselves, in a country where the price of every thing is
exorbitant, and medicines often unsound, Government would find its
account in supplying gratuitously some of the most costly articles,
particularly Peruvian bark in a fresh state, from time to time, from
England.
Sixthly, It is now the general custom to send every sick person on
shore to an hospital, where there is frequently worse air and worse
accommodation than on board, from overcrowding the apartments.
Contagious diseases, though not so common as in Europe, are here
often mixed with those that are not so, whereby numbers are infected
and carried off; and, besides this, the land air is infinitely more
unwholesome in the West Indies than the air at sea or in a road. The
scurvy is perhaps not at all contagious, nor is it very difficult of
cure; but a number of cases of it terminate fatally from the flux
or fever, caught either by contagion in hospitals, by the noxious
influence of land vapours, or by intemperance. I beg leave, therefore,
humbly to suggest, that as few sick as possible of any disease, but
what is contagious, be sent to hospitals, and that some method be
established for the supply of vegetables and other refreshments to the
sick on board of their ships.
Seventhly, Crowding, filth, and the mixture of diseases, are the great
causes of mortality in hospitals. There should be a space of five
hundred cubic feet allowed for each man; and in general the sick had
better remain on board than be crowded beyond that degree; or relief
should be provided to the hospital by an hospital ship, which, for
reasons already given, is preferable to any accommodation on shore; and
such an institution would be more particularly proper for the reception
of convalescent men.
I would beg leave, therefore, earnestly to recommend that cleanliness,
the separation of diseases, and a competent space, be regularly
enjoined and strictly enforced in hospitals; and in order to make this
more practicable in the great scale of service now going on, I would
farther propose that hospital ships be established for the reception
of the sick or recovering. I know from extensive experience and close
observation, that these circumstances are more essential than even
medicine and diet.
These are a few remarks extracted from a series of observations, and
derived from great opportunities of experience. Many other remarks
would suggest themselves; but I purposely confine myself to what is
highly important, and easily practicable, with little or no addition to
the public expence. Some of the improvements recommended are indeed an
immediate, and all of them will be an eventual, saving to the public.
The alterations that have been proposed are,
1st, The establishment of a certain method and discipline, in order
to secure regularity and cleanliness among the men, and to render the
ships clean and dry.
2dly, The supply of fruit and other vegetables for the cure of the
scurvy.
3dly, The substitution of wine[87] for rum.
4thly, The provision of an adequate quantity of necessaries for the
sick.
5thly, The gratuitous supply of certain medicines.
6thly, The curing of certain diseases on board instead of sending them
to hospitals; and,
Lastly, The preventing of filth, crowding, and the mixture of diseases
in hospitals, by proper regulations, and by establishing hospital ships.
I beg leave again to call to mind, that 1518 deaths from disease,
besides 350 invalids, in 12,109 men, in the course of one year, is an
alarming waste of British seamen, being a number that would man three
of His Majesty’s ships of the line; and what I advance is from a real
conviction that a due attention to the above-mentioned propositions
would save more than two thirds of the seamen that would otherwise die
in that climate. It was to set this in a proper light that I requested
leave to quit my duty during the absence of the greater part of the
squadron in the hurricane months; and should any thing I propose meet
with public approbation, and be carried into effect, I should esteem it
a recompence far above any other gratification I can derive from the
service.
LONDON,
October 13, 1781.
To the Right Hon. the Lords Commissioners
of the Admiralty.
* * * * *
Next year the following Supplement to the preceding Memorial was sent
to the Board of Admiralty:
SUPPLEMENT to the MEMORIAL delivered last Year to the Board of
Admiralty.
Since my return to my duty on this station, additional experience has
afforded me farther practical confirmation of the utility of the former
proposals.
The great squadron employed on this station has, by the attention of
the Commissioners of Victualling, and also of the Commander in Chief,
been supplied with most of the articles recommended, in such quantities
as to prove their efficacy; and indeed the small degree of mortality in
comparison of former times, is a sufficient demonstration of this.
I beg leave to give an instance in the Formidable of the great and
salutary effects of the proposed improvements. This ship left England,
furnished not only with sour krout and melasses, in common with most
others in the squadron, but what was peculiar to herself was, an entire
supply of good wine in place of spirits; and an experiment has been
made in this instance, under my own eye, to ascertain what degree of
health it was possible to attain in a great ship in this climate. With
the above advantages, together with good discipline and medical care,
no man[88] died of disease from December, 1781, to May, 1782, and
only thirteen were sent to hospitals, whose complaints were small pox
and ulcers. In the months of May and June last, when at Jamaica, there
died of disease in this ship, three men, and seventeen were sent to the
hospital, most of whom had contracted their sickness on board of French
prizes.
In the rest of the fleet the health was in proportion to the wine and
other refreshments, and the cleanliness, good order, and discipline
observed.
In the squadron I attended the last five months, which seldom
consisted, during the last three months of that time, of less than
forty ships of the line, there have died of disease about 350 men,
and about 1000 have been sent to hospitals; a degree of sickness and
mortality which, though not greater than what frequently prevails
in Europe, I am persuaded would have been still less, had the
improvements proposed been complied with in a manner more extensive and
complete, and had the general rules of discipline and cleanliness been
kept up with due and equal strictness throughout the fleet.
This last article, which, being the most important, I have placed
first in the preceding memorial, it is only in the power of supreme
authority to enforce; and my additional experience and observation have
so far confirmed me in the opinion of the utility of this, as well as
the other articles, that I hope to be again pardoned for repeating my
humble and earnest solicitations that these regulations may be farther
extended and enforced.
FORMIDABLE,
At Port Royal, Jamaica,
July 16, 1782.
PART III.
DESCRIPTION AND TREATMENT
OF THE
DISEASES
MOST COMMONLY OCCURRING IN
FLEETS IN HOT CLIMATES.
It was mentioned in the Introduction to this work, that though my
opportunities of experience were extensive, several obstacles had
prevented me from making observations so accurately as could have been
wished. These were chiefly the bad accommodation of the sick at some
of the hospitals, and the shortness of our stay at any one place,
which seldom exceeded six weeks or two months, and prevented me from
completing such observations as I have happened to be engaged in.
But having practised among great numbers, observations necessarily
arose from the comparison of so many cases; and amidst the variety of
situations connected with the emergencies and hardships of war, nature
is seen in certain portions and under certain trials which are not
met with in common life. I shall therefore describe the diseases such
as they occurred, and shall add such remarks on practice as I could
ascertain.
The following observations shall be confined chiefly to what I have
called the sea epidemics, viz. Fevers, Fluxes, and the Scurvy.
CHAP. I.
Of FEVERS.
Though it is impossible to refer every particular case of fever to a
distinct class, on account of the mixed and anomalous symptoms that
arise, yet there are certain distinguishing features which afford
sufficient ground for dividing them into different kinds, and such a
division will at least serve to facilitate description, and to afford
room for laying down the outlines of practice.
The fevers which occurred most frequently on board of ships, and
at naval hospitals belonging to the fleet in which I was employed,
were the infectious ship fever, (which is the same with the jail and
hospital fever) the bilious remitting fever, and the malignant yellow
fever.
1. Of the infectious SHIP FEVER.
This does not occur so frequently in hot as in cold climates, both
because it is the disease of ships newly fitted out, which they seldom
are in the West Indies, and because there is something in the warmth
of a climate which prevents the production of contagion, as has been
formerly remarked. But as great fleets arrived from time to time in
the West Indies from Europe, with numbers of men labouring under this
fever, there were sufficient opportunities of making observations upon
it.
It has been so well described by Sir John Pringle, Dr. Lind, and other
writers, that it is unnecessary to enter into a minute detail of all
its different appearances in its several stages; and I shall content
myself with recounting some of the most distinguishing symptoms, and
with marking the peculiarities that arose from the influence of the
climate.
This fever is extremely various in its symptoms and in its degree of
malignity and fatality. We are told in some of the histories of the
jail distemper, that, upon its first attack, few escaped that were
seized with it; but that afterwards it grew more mild; and it has been
already observed, that the contagious poison of fever differs from that
of small pox and other specific infections, by varying in its degrees
of virulence.
There are, however, certain characteristic symptoms pretty constant in
this fever in all its forms.
One of the most remarkable of these is a greater degree of muscular
debility than what takes place in other fevers, and it deserves to
be mentioned first, as being one of the most constant. It is also a
tolerably true index of the degree of malignity, the danger being
in proportion to this symptom. In the more advanced stages of the
fever, a tremor of the hands, and of the tongue when put out, is a
constant symptom, and seems to be connected with this weak state of the
muscular fibres. I have seen, however, extreme debility without tremor
in cases too of the greatest danger, and it was observable in these
that there was little or no delirium.
Another striking character of this fever is the delirium of a
particular kind which usually attends it. Sensation and reason are
here in a state uncommonly depraved; and it is in this sort of fever
oftener than any other that we find a total deprivation of them in the
symptom called _coma_. The delirium is seldom of a wild, ungovernable
kind, such as occurs in inflammatory continued fevers, in the violent
paroxysms of intermitting and remitting fevers, or in inflammations
of the brain. It is, however, connected with great suffering; and
this consists in anguish rather than pain, shewing itself by outward
tremor, agitation, and what is called the _floccorum collectio_; also
by sighing, mumbling, and moaning, symptoms always indicating danger.
Delirium is a symptom, to the nature and appearances of which I have
been particularly attentive, in consequence of a painful and diligent
attendance upon some cases in which I was particularly interested from
friendship and affection, and in which this was a remarkable symptom.
It seems chiefly to consist in a false reference of our sensations,
whether external or internal; and this is in no sort of fever more
evident than in this. When any painful impression, for instance, is
made by an external body, the patient, if in a state of delirium, does
not refer it justly to the part affected; but the general agitation and
incoherence of sentiments will be aggravated for the time. I have known
a degree of heat applied to the extremities sufficient to blister them,
yet the part did not shrink, though the raving and general uneasiness
were increased. In like manner, with regard to internal sensations,
when an irritation is excited to expel the urine or _feces_, the mind
does not recognize it as such, but from a sense of uneasiness, probably
mistaken for something else, an effort is made to relieve nature,
which is done without a proper consciousness, and certain symptoms
are produced which are well-known marks of danger in this fever. In
watching those who have been under the influence of delirium, I have
observed it increase when any particular want of nature urged, and
this would continue for some time, the patient being incapable of
procuring himself immediate relief on account of the false reference
of sensation that has been mentioned; but he would become calm after
voiding the urine or _feces_, or after receiving something to drink,
according to the particular want that was present at the time. So
great is the disorder in the common course of sensation in this fever,
that a person ill of it has been even unconscious of inflammations of
vital parts, which, in the natural state of the nerves, would have
excited the most acute pain, and would have been distinctly referred
to the part affected, but were not discovered nor suspected till
inspection after death[89]. I remember one case in which there were
found large erosions, and even holes in the intestines, without any
preceding complaint that could have led to suspect such an appearance.
It would appear that the motions excited in the brain and nerves in
such cases, instead of producing the sensations naturally belonging to
them, serve to excite disagreeable emotions of a different kind, in
which delirium consists. It seems to be from the same depraved state
of sensation, that when a phthisical person is seized with this sort
of fever, his cough is for the time suspended. I have seen the same
circumstance occur in a maniacal case. From a like cause it sometimes
happens in dangerous cases of fever, that in the height of delirium the
_epiglottis_ loses its natural irritability, so that liquids in the
act of swallowing are apt to get into the windpipe, so as to excite
coughing and threaten suffocation, as I have observed in some cases
that came under my care.
All these different forms of delirium are signs of a body extremely
disordered in its functions, and forbode great danger.
The next symptom I shall mention as most characteristic of this sort
of fever is, the spots known by the name of _petechiæ_ and _vibices_,
which, though far from being constant, are, perhaps, more peculiar to
it than any other symptom. They occur only in the latter stages of
the disease, and in cases of considerable danger. The common opinion
concerning their cause is, that the blood is in such a dissolved state,
that the red part of it is effused into the cellular membrane. The
appearance in such bodies as I have inspected, seems to favour this
opinion; for there was hardly any coagulation of the blood in the great
vessels, and instead of those firm substances, called _polypi_, in
the heart, there were only soft grumous bodies, which were so tender
in their consistence, that, upon being handled, they, as it were,
dissolved. Since the improved method of treating these fevers has been
generally adopted, this symptom seldom occurs; for in most cases it may
be called an artificial symptom, chiefly arising from close apartments
and the heat of bed clothes.
It may be considered as a peculiarity of this fever, that it is more
indefinite in its crisis than most others. In continued fevers of the
inflammatory kind, there are frequent attempts at remission, there are
certain periodical exacerbations, and there is generally a distinct
crisis marked by a freedom of the secretions and turbid urine: but in
the fever of which we are treating, though the patient is generally
somewhat worse towards the evening and during the night, its course is
more equable, and the transition from sickness to health is insensible
and gradual, being seldom marked with any perceptible crisis.
The symptom next to be taken notice of, though a minute one, is very
constant and characteristic in this sort of fever. It is a peculiar
heat in the skin, communicated to the hand of another person. It is
usual to grasp the wrist of the patient after feeling his pulse, in
order to examine the state of the skin in point of heat and moisture;
and in doing this a glow of heat is impressed on the palm of the hand,
which lasts for some hours, if one should neglect so long to wash the
hands. I have never met with this symptom in any of the sporadic fevers
of England, though I am informed it sometimes occurs in these.
The fever we are treating of differs also from the sporadic nervous
fever of England, and from most others of the continued kind, in
being attended with a more copious secretion of bile, which, when
thrown up, is generally green, or, as it is otherwise called, of a
porraceous colour. This symptom takes place in all climates; but is
more remarkable in a hot climate, as might be expected.
These are the chief characteristic symptoms of this fever. I shall next
point out such modifications of it as occurred in the West Indies from
the influence of climate.
In the first place, when this fever prevailed on board of any ship
that arrived from a northern climate, it was soon after succeeded by,
or, as it were, converted into, a dysentery; for those ships that
arrived either from England or North America with the greatest stock of
feverish infection, were the most subject to fluxes, after being two or
three months in the West Indies. This was formerly made use of as an
argument, to prove that the dysentery proceeds from the same cause with
fever, taking a different determination, from circumstances of climate
and constitution.
Secondly, It sometimes happens that men, under the influence of this
infection, are more apt than others to be affected with symptoms
peculiar to the climate upon their first arrival. A very striking
instance of this has been mentioned in the case of men that were
pressed into the Formidable at New York, some of whom had the common
ship fever on the passage; others, upon our arrival at Barbadoes, were
seized with the yellow fever, and were the only men in the fleet who
had it at that time. There was another instance in the recruits brought
from England by the Anson, who were seized with a fever on board of
the Royal Oak; and in this fever the skin and eyes were yellow, though
without any symptoms of malignancy[90].
Thirdly, It happened in some ships[91] that the infection was kept up
for several months after arriving in the climate, from a neglect of
cleanliness, or the want of an opportunity of removing those who were
infected to an hospital. It did not in these take a dysenteric turn, as
in most of the other ships, but differed from the ship fever of colder
climates, as above described, in some particulars, which I shall here
enumerate. All the symptoms were milder: it was more protracted, and
less dangerous. In the beginning there was but little difference, only
the symptoms were less violent; but in the succeeding period of the
disease the pulse deviated very little from the natural standard, and
the skin felt cold and clammy. The tongue was white; and this did not
seem so much owing to any fur covering it, as to its being itself of
a pale, lifeless colour, as well as the face, and it appeared larger
in size than natural. The teeth were clogged with a white fur. Those
affected with this fever were subject to faintings, and had a constant
uncomfortable languor and listlessness. Most of them had a deep-seated
pain in the occiput, and an oppression at the stomach, but without any
inclination to vomit. The unfavourable symptoms were _coma_, _delirium_
and a yellowness of the skin. I never remember to have seen _petechiæ_
in any of them. The favourable symptoms were a warm moisture, or a
miliary eruption on the skin, and a gentle _diarrhœa_, which, however,
if neglected, was in danger of degenerating into an incurable flux.
A great number were seized with this fever in the Alcide, in July,
1783, and what is remarkable, most of them had the tape worm, as I
was informed by Mr. Telford, the surgeon of that ship, who frequently
obliged me with valuable remarks; and he observed also, that it
was evidently infectious, and that the skin communicated the same
disagreeable feeling to the hand as was mentioned above.
Though the inflammatory fever does not often occur in hot climates,
yet, as it is of great consequence to distinguish it in all cases from
the infectious fever of which we are treating, it may not be improper,
nor uninstructive, here to point out the most remarkable differences.
There is more resemblance in their symptoms, especially towards the
beginning, than might at first be supposed; and as it is very material
to avoid error with regard to the practice, which, in these two sorts
of fevers, ought to be very different, and even opposite, I have taken
particular pains to discriminate them.
The continued inflammatory fever is very uncommon in the West Indies;
but in the form in which I have met with it in North America and
England, there are cases in which the blood is sizy during the whole
course of the disease, even without local affection, though, in
general, there is more or less rheumatism, or pulmonic inflammation.
The symptoms which chiefly distinguish such cases from the fever before
described are, a greater degree of muscular strength, a more violent
delirium, pale urine, a more parched tongue and skin, greater heat
and thirst, and a pulse more frequent and strong, with a particular
sharpness. There is another symptom sometimes occurring, which I
consider as strongly characteristic of a fever of an inflammatory
nature. This is a watery diarrhœa, without _fæces_ and without gripes,
the stools consisting chiefly of the drink as it was taken in. There
seems here to be a suspension of the power of absorption as well as
secretion in the bowels, in consequence of a general spasm on the
extreme vessels; for there is hardly even bile or mucus in the stools.
There is also a particular appearance of the mouth connected with this
type of fever, which is better learned by the eye than by description.
It consists chiefly in a want of moisture on the lips, and a dryness
and shining appearance of the teeth. With these symptoms, it will be
found that the patient will bear the lancet in very advanced stages of
the disease. These fevers seldom occur but in a sporadic way, unless
when there is some peculiarity of season, as at New York in autumn,
1782. They are also more frequent among the better than the lower sort
of people.
By comparing these symptoms with those of the infectious fever above
described, there will appear an obvious difference in their nature, and
evident reasons for varying their treatment.
TREATMENT of the SHIP FEVER.
When the body is thrown into disorder by an attack of fever, the first
step to be taken is to clear the stomach and bowels of their crude and
acrid contents, consisting either of the food imperfectly digested,
or the depraved natural secretions. So great is the disturbance
produced by such offending matter, that, when nature is freed from
this embarrassment, the functions of the body are frequently by this
alone restored to their proper exercise, and a remission produced. It
seems probable also, that this evacuation proves salutary not only
by removing the morbid stimulus, but by preventing the absorption of
corrupted or ill-concocted juices into the mass of blood, which would
tend still farther to derange the functions of life. But perhaps
the circumstance that first suggested the utility of evacuating the
stomach, as the first step in the cure of fevers, was the nausea so
common in the beginning of them, which may be considered as a natural
indication of this practice. It farther appears rational, that, as
acute diseases generally come on suddenly, and find the body in a
state of repletion from the recent _ingesta_, the most obvious means
of relief should be to free the bowels, and particularly the stomach,
from what is foreign and oppressive to it. It seems also probable, that
the _nausea_ and the act of vomiting have a salutary effect independent
of evacuation; for I have seen relief produced from these when nothing
was evacuated. Such, indeed, is the great and universal influence and
sympathy of the stomach, that the operation of vomiting affects every
fibre of the body, and has been known to resolve tumours in the most
distant parts. An early administration of an emetic is therefore the
first step to be taken in the treatment of this as well as most other
fevers.
If it is given in small divided doses, it will most probably evacuate
the bowels downwards; and the most convenient form for this purpose is
a solution of emetic tartar. If it should not have this effect, some
brisk purgative medicine should be given soon after the operation of it.
I mention these evacuations before blood letting; for though this ought
to be first in those cases in which it is proper, it is here seldom
necessary, and we may pronounce it to be a remedy very ill adapted
to this sort of fever, particularly in a hot climate. It sometimes
happens, however, that there is violent head-ach, pain of the back
and limbs, with a throbbing pulse; and these symptoms may in the very
beginning not only justify, but require the losing some blood before
the administration of the emetic or purgative.
The next means of relief I shall mention, and also the most probable
means of cutting short the disease, is to excite universal sweat.
This being an imitation of nature, is founded on reason as well as
experience; for it is by sweating that the fit of an intermittent
is relieved and terminated; and continued fevers in general, if not
always, begin with a fit of the same kind. A dry skin, accompanied
with heat, is one of the most constant as well as troublesome and
uneasy symptoms in all fevers; and it would appear from the peculiar
heat of the skin in this sort of fever, that there is either a more
than common acrimony of the matter of perspiration, or something
peculiar in the mode of circulation on the surface of the body.
Sweating does not seem to operate entirely by the evacuation of
acrimony, for no relief is procured by it if it is partial; and it
is evident from a number of facts that the state of the brain and
_viscera_ depends on that of the external surface of the body; for a
free state of the pores of the skin, provided it is general, tends more
than any other circumstance to relieve internal pain, and also to take
off delirium. The good effect of sweating seems, therefore, chiefly to
depend on a general relaxed state of the small vessels on the surface
of the body; and it ought to be effected, if possible, by gentle,
soothing means, and not by such regimen and medicines as heat the body
and accelerate the circulation. This intention is best answered in the
beginning by moderate doses of antimonial medicines, and either James’s
powder or tartar emetic may be employed. The first is a more certain
sudorific, being less apt than the other to run off by the bowels;
and its effect will be still more certain, if accompanied with a mild
opiate, rendered diaphoretic by _Spiritus Mindereri_, which will both
prevent the antimonial from acting roughly, and will determine its
operation to the skin. A sweat kept up by these means, together with
plentiful warm dilution, from twelve to twenty-four hours, is the most
probable means of bringing about a complete remission of the fever;
and in this case a fresh accession is to be prevented by the immediate
administration of the bark.
These are the means proper for stopping the fever in the beginning,
or tending to render its future progress more safe; and though, with
this view, free evacuations have been recommended, yet, if the fever
should go on, great caution is necessary in this respect in the future
treatment, debility being the symptom chiefly to be guarded against.
Purgatives may, indeed, be occasionally necessary, in consequence of
accumulations of bile taking place; but, in general, the evacuations by
stool should not be more frequent than in health; and some of the cases
which were most unmanageable and fatal, were those in which there was
a spontaneous _diarrhœa_. With regard to blood letting, it is always
hurtful after the first two days, unless some inflammatory affection of
a vital part should arise.
The natural evacuation, which may with most safety and advantage be
solicited and encouraged in this disease, is, that by perspiration;
and it is observable, that in those cases for which nature does most,
there is a universal warm sweat, which has generally a very offensive
smell, and seems to be a salutary effort of the constitution to cure
the disease. Where this takes place, little medical assistance is
necessary, except to keep it up chiefly by warm dilution; and there is
no circumstance in which the judgement of a physician is shewn more
than in discerning those cases in which his chief business is to look
on, where nature, being equal to the task, ought not to be disturbed by
the active and officious interposition of art. We should not, however,
aim at producing a profuse sweat, except with a view to effect a
remission immediately after the first evacuations. In the course of the
disease, it is only necessary to keep up a gentle moisture or softness
of the skin.
The head being particularly affected in this sort of fever, the patient
is extremely restless and delirious, especially at night; and there is
a medicine which has a most pleasing effect in procuring both rest and
perspiration. This is a combination of an opiate with an antimonial
medicine, which was administered in the evening with great success;
and the sudorific effect is rendered more certain by the addition of
some saline neutral, especially _Spiritus Mindereri_[92]. I tried
pure opiates in the early stage of this, fever, but found them not to
answer; though in the low[93] fevers of England, and in the advanced
stages and convalescent state of this fever, they are extremely safe
and useful. Pure laudanum is also given by Dr. Lind, at Haslar, with
great success in the height of the disease; but in the West Indies
there is a greater tendency to acrid excretions, and the effect of pure
opium in causing a retention of these, seems to be the cause of its
disagreeing in that climate in the first stage of this fever.
It may here be observed, that the addition of a little neutral salt
alone will sometimes so qualify the operation of opium, as to prevent
its bad effects, such as the increase of febrile heat and delirium, and
the stupor and head-ach which, when given alone, it frequently induces
the following day. I have generally employed nitre with this intention;
but this does not seem so well adapted to this disease as some other
neutral salts, as it tends too much to lower the powers of life.
But with a view to perspiration, the _Spiritus Mindereri_ is the most
effectual neutral medicine when conjoined with an opiate, and there
is not, perhaps, a more safe and pleasing diaphoretic known than a
combination of it with syrup of poppies[94]. There is some neutral salt
in Dover’s powder, and this has more effect than could be expected
from so small a quantity of an inert medicine; for I know from trials
of my own, as well as those of others, that ipecacuanha and opium
given together, in the proportions prescribed in that powder, will
not have the same effect as when joined with the neutral salt. This
is an instance of those useful combinations of medicines which can be
discovered only by experience, but which every physician ought gladly
to adopt in practice upon good testimony and fair trial, though he may
not be able to account for their effects, nor to explain their mode of
operation.
There is nothing more important than plentiful warm dilution; and the
infusion of sauge, or any such light aromatic, is rather more proper
than farinaceous decoctions, or any compositions in which there is wine
or spirits. Success in this, as well as other diseases, depends on
attention to nursing as much as upon medicine; for what would it avail
here to administer medicines for promoting perspiration, unless they
were assisted with fluids to allay thirst, to dilute the acrimony in
the first passages and in the vessels, and to furnish the materials of
free perspiration?
But however desirable it may be to procure sweat, this is not to be
attempted by close rooms and bed clothes, nor by hot medicines, such
as volatile salts, serpentary, spirituous tinctures, or aromatics.
These, according to the testimony of Sydenham, tend to increase the
heat and delirium, and to produce _petechiæ_, miliary eruptions, or
local inflammations. In the intervals of the anodyne diaphoretic above
described, _Spiritus Mindereri_ and small doses of camphor, with
proper dilution, may be safely employed to procure a soft skin.
The only other means I shall mention with this view is, the application
of warm moisture to the surface of the body, which may be done by
soaking the feet and hands in warm water, or by fomenting the feet and
legs with stupes[95]. These operations have the effect of bringing on
a general relaxation on the skin, thereby taking off febrile agitation
and delirium, and inducing sleep. I sometimes, with seeming benefit,
ordered cataplasms to be applied to the feet, merely of the emollient
kind, without mustard or any other acrid substance, being intended to
relax, and not to stimulate.
In the use of pediluvia and fomentations, there is a difference worth
attending to between the practice in this fever, and that in the
inflammatory fever before described, for they are as hurtful in the
latter as they are beneficial in the former. I have observed, in
general, that they have a bad effect in all cases where there is sizy
blood, particularly where the breast is affected.
Delirium is one of the most constant and alarming symptoms in this
disease, and the removing of it depends much upon the attendants as
well as the physician. It has been said before, that it depended on
a false apprehension of the impressions or natural sensations. When
a person, for example, labours under delirium, and is affected with
thirst, the minds is either so agitated with other objects, that
this sensation is overlooked, or, instead of producing a craving for
drink, it excites some other disagreeable emotion in consequence of
the disordered state of _sensorium_. This last seems to be probable
from the cessation of delirium, which will take place upon any natural
want being satisfied; I have seen a temporary stop put to the patients
raving by making him drink, or upon his discharging his urine or
_feces_; for he is then unconscious of thirst and other natural wants,
is therefore ignorant of the means of satisfying them; and when he
does so, he fancies he is about something else which is the subject of
his delirious thoughts. This observation leads to a material practical
purpose; for it follows from it, that unremitting attention should be
given to the patient’s feelings and all his possible wants, as those
natural notices and instinctive cravings which occur in health are now
wanting, in consequence of the depraved state of sensation.
Most of the remarks that have hitherto been made apply to the earlier
stages of the disease. The principal remedies applicable in the more
advanced stages are, blisters, Peruvian bark, opium, and wine.
I have found what Dr. Lind says concerning the efficacy of blisters
confirmed by my own experience, especially in those fevers in which
there was great delirium, _coma_, and head-ach; but I have not
experience enough to say whether they were as useful in the beginning
of the disease in the West Indies as he found them to be in England.
The men that were brought from the ships to the hospitals were affected
with the disease in various stages; but as we had in general a very
inaccurate history of the several cases, the method of treatment
upon their first admission was pretty nearly the same in all; and it
consisted, in the first place, in washing their face, hands, feet, and
legs, with warm water and vinegar, from which they derived the greatest
comfort, being commonly very dirty. There ought to be a [96]warm bath
at every naval hospital kept in constant readiness; for there are so
few conveniences on board of a ship for preserving bodily cleanliness
among the sick, that the surface of the body becomes loaded with
filth, so that the operation of the warm bath could not fail to be
highly comfortable and salutary as the first step to their cure when
brought on shore. We had generally very indistinct information about
the state of their bowels, as well as other circumstances, on account
of their delirium; but it was at any rate useful, or at least safe,
to give them a clyster. They were enjoined plentiful dilution; and if
they were low, some wine and water was allowed. In the evening, the
anodyne diaphoretic medicine was administered, and a blister applied
to some part of the body. In consequence of this method, we seldom
failed to find the patients better next morning; and it was tried in
such numbers, that the efficacy of it was sufficiently ascertained. It
happened in some cases, that these means were omitted, and a comparison
of these with the others served to ascertain the true efficacy of the
medicines; the stationary state of the symptoms, when the disease
was thus left to itself, sufficiently proving the propriety of the
treatment above described.
It is an important question to what circumstances of this fever the
Peruvian bark is adapted. An early and indiscriminate use of it is
recommended in some late publications, upon the authority of which
I tried it without regard to the stages or symptoms, and without
any prejudice either for or against the practice; but I found that
this powerful remedy was in danger of doing much harm, unless great
attention was paid to circumstances, in order to ascertain the proper
seasons for giving it. The symptoms that forbid the use of bark are
chiefly foul bowels, hard pulse, sizy blood, great delirium, dry
tongue, a hot and dry skin, and inflammatory affections of the viscera.
It was found extremely pernicious in an early stage of the disease
previous to evacuations; and the object of practice at this time should
be to relieve the habit by means of these, in order to produce a
general relaxation of the secretions, and to render the skin cool and
soft, thereby paving the way for the bark.
It is not necessary, however, especially in the advanced stages of the
disease in this climate, to wait for an absolute remission, in order to
administer the bark. In a cold or temperate climate it will seldom be
found advisable to give it in any period of this fever; but in a hot
climate it is sometimes admissible where there are symptoms of general
debility, such as a small pulse and muscular weakness, even though the
frequency of the pulse, delirium, and a dry skin and tongue, should
indicate some degree of fever. It may be remarked, by the bye, that a
dry tongue is a fallacious symptom, for it may happen in consequence of
the patient’s breathing through the mouth instead of the nose, without
any fault in the secretions of the _fauces_. The symptom which forbids
the use of the bark more absolutely than any other is an inflammatory
or dysenteric state of the bowels, in which cases it seems to be
invariably pernicious.
Where it happens that we are extremely anxious to throw in the bark,
as we usually are in the West Indies, where fevers are very rapid
and dangerous, and yet the symptoms seem hardly to admit its use, it
was very commonly tried either in conjunction with some antimonial
medicine or neutral salt, or these were given alternately with it, in
order to soften and qualify its effects by preventing it from heating
or otherwise aggravating the symptoms. Antimonial wine or _Spiritus
Mindereri_ were conveniently employed with this intention.
With regard to the quantity of bark to be given, it may be proper in
doubtful cases of this kind to begin with small doses, in order to feel
how far it agrees or not; but in general it may be laid down as a rule
with regard to this medicine, that, where it is really proper, and the
medicine to be depended on, it is to be given in as large doses and as
frequently as the stomach will easily bear it.
The next remedy mentioned was opium. It is a medicine more admissible
and useful in this than any other kind of fever. The same cautions
nearly apply in the administration of it as have been given with
regard to the Peruvian bark. The caution with regard to foul bowels is
particularly necessary in a hot climate, where an over secretion of
bile is so apt to take place. When, the Boreas frigate arrived from
England in March, 1783, there was a very bad fever of the infectious
kind on board, some cases of which being sent to the hospital at St.
Lucia, were treated unsuccessfully with bark and opium, which I had
been induced to try upon the authority of the authors above alluded
to. I attributed this want of success to the neglect of previous
evacuation; for, upon inspecting the bodies, the intestines were found
full of bilious _feces_. I profited from this, and was more successful
in the other cases. It were to be wished that physicians could oftener
bring themselves to confess their errors in practice, and their
writings would be more instructive; for it is of consequence to know
what we are to avoid as well as what we are to follow.
It has been mentioned that the best effects arise from the conjunction
of an antimonial with an opiate; but, in this sort of fever,
antimonials, and even most of the neutral salts, are hurtful after the
first stage, and opiates may after this be given alone or combined with
camphor. With regard to the precise period of leaving off antimonials,
it must be left to discretion, and the constitution of the patient is
the best guide. There is so great a difference in patients in this
respect, that all practical precepts should be qualified by a due
discrimination of constitutions. Absolute and dogmatical rules are so
far from applying in the practice of physic, that there are some cases
of the same disease that require a treatment even opposite to what
is in general most adviseable. This may be very aptly illustrated by
the small pox, of which there are cases that ought to be treated very
differently from the general method laid down by Sydenham, and in which
cordial medicines are highly proper and necessary. This difference
in diseases themselves seems to be one great cause of the difference
of opinion among physicians on practical points, each party finding
some countenance in experience for their general doctrine, do not
make allowance for the varieties that exist in nature; so that, in one
sense, both may be said to be in the right. If the patient is not very
much sunk, and if there are bilious symptoms, or an obstinate dryness
in the skin, a few grains of James’s powder may be given with advantage
even in an advanced period of the disease. If a hot and dry skin should
at this period be the only troublesome symptom, it will be more safely
and effectually removed by camphor combined with something opiate and
the _Spiritus Mindereri_, which is the only neutral now admissible,
than by antimonials, which, at this time, would be in danger either of
ruffling the patient by their operation on his stomach and bowels, or
of weakening him too much either in this way, or by exciting profuse
sweats. Evacuant medicines of every kind being then improper, clysters
are the only laxatives to be employed in case the state of the bowels
require them.
Having mentioned camphor, it may be proper here to remark, that it is
a medicine of which I have found it extremely difficult to ascertain
the virtues and effects; and in consequence of this ambiguity, I
believe there are few articles of the materia medica more abused in
practice. In all inflammatory affections, and in the beginning of all
fevers where there is much heat and thirst, I think I have observed it
to aggravate the symptoms. It seems in no case to be more proper than
at certain periods of this fever, and especially when there happens
to be spasmodic pains of the stomach, or tremors and cramps in the
extremities.
In this advanced stage of the fever, in which the most common symptoms
are weakness, restlessness, tremors, and low delirium, no medicine
was found so much to be trusted to as opium, which here acts as a
cordial as well as an anodyne and antispasmodic. It may be given, in
the camphorated julep, in the form of tincture, from five to ten drops
every six or eight hours, or some of the officinal compounds, such as
the theriaca or mithridate, may be employed with advantage. I have
thought also, that, at this period, castor conjoined with opium seemed
to improve its virtue. This was first suggested to me by Mr. Crudie,
an ingenious German surgeon, whom I employed as an assistant at the
hospital at St. Lucia; and since I have been physician to St. Thomas’s
hospital, I have found the most pleasing effects, in similar cases,
from a composition used there, the principal ingredients of which are
opium and castor[97].
In this state of the fever I have also used with advantage the
decoction of Peruvian bark and serpentary, as recommended by Sir John
Pringle; and when the skin is cold and the circulation is very languid,
as is sometimes the case, volatile salts and powder of serpentary may
very properly be employed.
But in the advanced state, and in the worst forms of this disease,
there is perhaps no medicine superior to wine. This was given either
pure, or diluted with water for common drink, and sometimes to the
quantity of a quart in twenty-four hours. In delicate people, such as
we meet with in private practice, the quantity ought to be less.
There is this caution necessary with regard to the use of wine, that
when the fever is gone off, and only extreme debility remains, the free
use of it is not safe nor proper; for, in a weak and exhausted state,
a person is more apt to be [98]heated and intoxicated by any fermented
liquor, than in health, or even in the preternatural and disturbed
state of actual disease, such as occurs in this fever.
After the disease is removed, a long state of weakness is apt to
succeed, especially in a warm climate. The most proper remedies,
then, are bitters, such as decoctions of Peruvian bark, infusions
of quassia bark, gentian, or camomile flowers. These answer better
than the bark in substance, which is now apt to nauseate and load
the stomach, and the patient is apt to take an aversion to this and
whatever else he took in a state of sickness. The best strengthening
medicines are such as comfort the stomach and create appetite; and we
may mention Huxham’s tincture of bark, in small doses, and a moderate
use of wine, as the most proper for these purposes. Where colliquative
sweats take place, elixir of vitriol is serviceable, and with this
intention I have joined it, with evident advantage, to the evening
anodyne, which, without such a corrector, tends rather to aggravate
this symptom. I have known assafœtida prove a useful stimulus to the
stomach at this time, and it may even be used while the fever subsists,
especially where the secretions of the fauces are scanty. This medicine
is recommended by Sir John Pringle in the same circumstances. But I
consider the prudent use of opiates, particularly at bedtime, as the
most effectual cordial and strengthening medicine in this convalescent
state.
But with regard to the management of the sick at this time, as much
depends on diet as medicine. Nothing has been said concerning this in
the acute state of fever, because no nourishment is then necessary. In
that state there is a loathing of all food, and the powers of digestion
and assimilation seem to be then suspended, so that alimentary
substances become not only an useless load, but offensive and hurtful
by turning acid or putrid. It is likewise evident from fact, as well
as reason, that nature, in this situation, does not require sustenance;
for we frequently see people labouring under fevers who do well and
recover, though they have been entirely without nourishment for a
length of time in which the like abstinence in a state of health would
have proved fatal. The friends and attendants of the sick, from a
prejudice not unnatural, but not considering the difference between
health and that state of derangement which takes place in fever, are
for ever wishing to supply the patient with nourishment, and every
physician meets with trouble in counteracting this officiousness.
Nevertheless, when the fever draws out to a considerable length, and
the principal symptom is that state of weakness which, in low fevers,
runs insensibly into that of convalescence, then it is necessary to pay
the utmost attention to nourishment, and nothing tends more to insure
and hasten recovery than the assiduous administration of light and
nourishing food, the same cautions being observed which have just been
mentioned with regard to cordials. One of the greatest hardships of a
sea life is the want of those articles of diet that are suitable to a
recovering state, and many lives are lost from this circumstance, after
the force of the disease has been subdued[99].
With regard to the peculiar form, before described[100], which this
fever assumes a few months after ships have been in a hot climate, we
found camphor, volatile salts, and serpentary, the best remedies. As
there was a remarkable coldness of the skin, I was induced in one case
to try the hot bath, and with good effect, from which it seems probable
that a short stay in a bath, of a heat from 96° to 100°, so as to have
its warming and stimulating, without its relaxing effects, would answer
well in fevers of this kind.
2. Of the BILIOUS REMITTING FEVER.
This is peculiar to tropical climates, and arises in the same
situations in which intermitting fevers arise in temperate and cold
climates. It seldom arises at sea, unless where there has been previous
exposure on shore, of which some examples have been mentioned in the
first part of the work. It may generally be traced to the air of woods
or marshes; and in our fleet hardly any men were attacked with it but
those who were employed in the duties of wooding and watering.
The most distinguishing symptom is a copious secretion of bile which
attends it. Its course, in general, is shorter than that of the fever
before described; and though the symptoms are more violent, they are
not so equal and steady, owing to the tendency there is to remission.
The symptoms are particularly violent at the beginning, in so much
that some of the men, after being exposed upon duty to the heat of
the sun and the air of marshes and woods, would become frantic, being
seized almost instantaneously with _delirium_ resembling madness. This
fever, when it arises merely from the effluvia of woods and marshes,
has a natural tendency to remit; nay, some fevers at St. Lucia,
proceeding from this cause, were of the pure intermitting form from
the beginning. But in many of those that arose at Jamaica little or
no remission was to be perceived; and it was distinguished from the
ship fever by the bilious vomits and stools, more violent delirium,
and head-ach, and by being attended with less debility. The greater
tendency to the continued form at this time was probably owing to this
circumstance, that the men who were exposed to the land air in wooding
and watering, were then exposed also to such causes as naturally
produce continued fevers, such as infection, the foul air of the
French prizes, intemperance, and hard labour. There was in some cases
a yellowness of the eye, and even of the whole skin, but without the
other symptoms that characterise the yellow fever, properly so called.
In cases that proved fatal, the symptoms, for some time before death,
resembled very much those of the fever before described at the same
stage. There was either _coma_ or constant delirium, great seeming
anguish, the mouth and tongue very dry, or with only a little ropy
slime, a black crust on the teeth, picking of the clothes, and
involuntary stools.
TREATMENT OF THE BILIOUS REMITTING FEVER.
The measures proper to be taken in the beginning of all fevers are
pretty nearly the same. There is little difference in the first
treatment of this from that of the ship fever, except that blood
letting is here more frequently proper, and that a more free evacuation
of the bowels is necessary on account of the more copious secretion of
bile.
In full and athletic habits the disease very commonly begins with
pains in the limbs, back, and head, with a strong throbbing pulse; in
which case it is proper first of all to let blood at the arm. This
is also highly proper and necessary in those cases mentioned above,
in which the patient becomes suddenly frantic. But though the cases
requiring blood-letting are more frequent in this sort of fever than
that already treated of, yet great caution and nice discernment are
necessary with regard to it, in all cases, in a hot climate. As fevers
in such a climate run their course faster, the symptoms succeeding each
other in a more close and hurried manner, greater expedition, as well
as discernment, are required in timing the different remedies than
what are necessary in a cold climate. Blood letting unseasonably and
injudiciously employed either endangers life, or has a very remarkable
effect in protracting recovery, by the irrecoverable weakness it
induces.
With regard to the evacuation by the bowels, it has already been
mentioned in another part of the work, when on the subject of
prevention, that, before the fever comes on, there is a languor and
general feeling of indisposition, and that then an emetic and a
purgative, followed by some doses of the bark, were the most likely
means of preventing the attack of the disease. If the fever has
properly begun, which is announced by a _rigor_ taking place, then no
time is to be lost in procuring evacuation; and, after blood letting,
if the symptoms should require it, the best medicine is tartar emetic,
which, if given in small divided doses, at short intervals, will most
probably evacuate the whole intestines by vomiting and purging, and may
even prove sudorific. But it will nevertheless be proper to administer
a purgative medicine soon after; and what we found to operate with most
ease, expedition, and effect, was, a solution of purging salts and
manna, either in an infusion of sena, or in common water, or barley
water, with some tincture of sena added to it.
The next step towards procuring a remission is, to open the pores
of the skin, which is best done by small doses of James’s powder or
emetic tartar, assisted by the common saline draughts, which will be
given with most advantage in the act of effervescence, or by _Spiritus
Mindereri,_ together with plentiful warm dilution. I once, by way of
comparison, tried the two antimonial preparations above mentioned in
a number of men ill of this fever, who were sent to the hospital at
one time, giving emetic tartar to one half, and James’s powder to the
other, and their effects were so similar, that I could perceive no
reason for preferring the one to the other. Antimonial medicines seem
better adapted to this than any other sort of fever, and may be more
freely given in it.
These are the most likely means of bringing about a remission; and if
this is effected, nothing remains to be done but to throw in as much
Peruvian bark as the stomach will bear.
But whether from a fresh accumulation of bile, or some other
circumstance, it may happen that the fever is kept up; and in this
case there is commonly a sense of weight or uneasiness about the
_hypochondria_, which seems to indicate that the redundant bile is in
the gall bladder or ducts of the liver. In this case a repetition of
evacuants is necessary, and calomel will be found to answer remarkably
well as a purgative, its stimulus being so extensive as to loosen
and bring away bile when the saline purgatives, such as that above
mentioned, had failed of having that effect. I have known these to
pass through the intestines without relieving the uneasy sensation
about the stomach as calomel is found to do; and it will be still more
effectual for this purpose, if given alone in a dose, from five to ten
grains, and followed some hours afterwards by some other purgative.
After this, antimonial medicines are again to be had recourse to; and
these, as well as purgative and neutral medicines, are safe and useful
in a more advanced stage of this fever than they are in the ship fever;
for the strength is not so apt to sink, and the state of the bowels
requires them more. Antimonials, however, are to be used sparingly and
cautiously as the fever advances; for I have known them, when given
only a few days after the first attack, to have the effect, in some
constitutions, of making the stomach swell, and of producing a general
sense of heat and uneasiness.
After the evacuations of the bowels, the anodyne diaphoretic may be
very seasonably given in the manner formerly mentioned; for it will not
only tend to sooth and procure sleep after the commotion that has been
excited, but by its gentle sudorific effect will assist in completing
the remission.
The principal point of management in the fevers of this climate is, to
throw in the Peruvian bark in proper season. I formerly took occasion
to differ from the opinion of those who alledge that little or no
discrimination is necessary with regard to the circumstances in which
bark is proper in continued fevers. I made fair and unprejudiced trials
of this, but always found that some sort of remission, especially
towards the beginning of the disease, was necessary, in order to make
the use of this medicine safe and proper. The greatest vigilance is
indeed required that the administration of it be not omitted when
it is at all adviseable, as the course of fevers is very quick and
critical in this climate. I have watched many nights with some friends
in whose health I was particularly interested, to catch the hour when
it might be allowable to give it; and where the propriety of it was
somewhat ambiguous, it was usual to qualify it either by conjoining
some antimonial or neutral salt with the first doses, or by giving them
alternately with it, as has been formerly mentioned.
Under the use of these means, the favourable symptoms are, a warm moist
skin, a strong steady pulse, with the pulsations under a hundred in a
minute, a natural countenance, and being free from delirium. But if the
fever should not yield during the first week, but takes an unfavourable
turn, the pulse then becomes more small and frequent, there is a
general agitation, the tongue is tremulous when put out, there is great
thirst and delirium, with a dry and hot skin. In these circumstances,
besides the continuation of the antimonials in smaller doses, with the
anodyne diaphoretic, and the occasional use of purgatives, blisters
now become proper; and we found also camphor combined with nitre an
excellent medicine at this period of the disease.
Should the patient survive to the end of the second week, the treatment
then comes to resemble more and more that of the infectious fever
already described. Bark may be given, though there should be no proper
remission, and cordials and opiates may be more freely used. Attention
to the state of the bowels will still be necessary, since repeated
accumulations of bile are apt to occur even in the most advanced
stage, and gentle emetics of ipecacuana, as well as laxatives, may
be necessary. For the same reason also, greater caution is requisite
in the use of pure opiates than in the infectious ship fever before
treated of. In order to keep the bowels soluble, it was a very usual
practice, and found very useful, to conjoin a few grains of rhubarb
with each dose of the bark.
3. Of the YELLOW FEVER.
The fever last treated of may be said to be peculiar to a hot climate;
but the hot seasons of temperate climates produce something resembling
it. That now to be described never occurs, so far as I know, except
under the influence of tropical heats. Such a fever is indeed known
without the tropics; for it is very common in Carolina in the hot
season; but there the heat is even greater than that of the West
Indies. In order to produce it, there must be, for some length of
time, a heat seldom falling below seventy-five degrees on Fahrenheit’s
thermometer.
Though it differs from the fever last described, both in its causes and
symptoms, it is not meant to say that it is so distinct as to form a
separate species of disease, like the measles and small pox. Unless the
characters of fevers are strongly marked, it is difficult, and even
impossible, to refer them to any particular species; and the different
concurrence of causes and constitutions is so various, that great
numbers of ambiguous cases occur.
With regard to the cause of the yellow fever, it differs from the
bilious remittent in this, that the air of woods and marshes is not
necessary to produce it; for it most commonly arose from intemperance
or too much exercise in the heat of the sun. It was observable,
however, that it was more apt to arise when, besides these causes,
men were exposed to unwholesome air, particularly the foul air of
ships, whether from infectious effluvia, or proceeding merely from the
putrefaction that takes place in neglected holds.
It is also remarkable with regard to it, that it is confined almost
entirely to those who are newly come from a cold or temperate climate.
The same remark is made by the French, who therefore call it _fievre
de matelot_[101], considering it as peculiarly incident to those who
have newly arrived from a long voyage. It would appear also, from what
has been formerly mentioned[102] that those men, who have been exposed
to that sort of infection that prevails in ships in cold climates are
more particularly the subjects of the yellow fever when they arrive in
a hot climate. It is farther in proof of the same opinion, that there
are medical gentlemen, natives of the West Indies, who have hardly
ever seen it, their practice lying at a distance from any sea-port
town where strangers usually arrive. Of these strangers, those who are
young, fat, and plethoric, are most apt to be attacked; and more of our
officers in proportion were seized with it than common men.
It has been said, that it never attacks either the female sex or
blacks. This is in general, though not absolutely, true; for I knew
a black woman, who acted as nurse to some men ill of this fever at
Barbadoes, who died with every symptom of it.
This fever assumes various forms, according to the peculiar
constitutions of different men, and other circumstances; but
in the following description I shall enumerate the most common
appearances:--In general it begins with short alternate chills and
flushes of heat, seldom with those rigors which constitute the regular
cold fit, and with which most other fevers begin. These are immediately
succeeded by violent head-ach, pain in the back, universal debility,
sickness, and anguish at the stomach. There is commonly, in the
beginning, a good deal of bile on the stomach, which is thrown off by
vomiting, either natural or excited by an emetic. Those men who were
taken ill of this fever in the Alcide, in the end of the year 1781, had
a sore throat in the beginning; but this is not a common symptom.
In the course of this disease there is by no means a free secretion
of bile, and least of all in those cases that are most violent, and
prove the soonest fatal. In cases that are more protracted, and less
desperate, there are frequent accumulations of it, as appears by the
vomits and stools[103].
The eye in a few hours takes a yellow tinge, which soon after extends
more or less over the face and whole skin. This is a symptom so
striking and constant, that it gives name to the disease, though
it is not absolutely either peculiar or essential to it. There is
something contagious in this symptom, which seems somewhat singular,
and difficult to be accounted for. It was observed in the Royal Oak
and Alcide to extend to men who were but slightly indisposed; and at
the hospital it spread to men in the adjoining beds, without imparting
any malignity to their diseases.
There is something very peculiar in the countenances of those who
are seized with it, discernible from the beginning by those who are
accustomed to see it. This appearance consists in a yellow or dingy
flushing or fullness of the face and neck, particularly about the
parotid glands, where the yellow colour of the skin is commonly first
perceived. There is also in the eye and muscles of the countenance a
remarkable expression of dejection and distress.
One of the most constant and distinguishing symptoms of this fever is
an obstinate, unremitting, and painful _pervigilium_, which is the more
tormenting, as the patient is extremely desirous of sleep. It is seldom
that even a _delirium_ comes to his relief to make him forget himself
for a moment; but he continues broad awake, night and day, with his
reason and senses sound, in a state of the most uneasy agitation.
But the most distinguishing symptom, and that which is expressive of
the greatest danger, is, an unconquerable irritability in the stomach,
which can be brought to bear nothing. An almost incessant retching
takes place, which commonly, on the third day, ends in what is called
the _black vomit_, the most hopeless of all the symptoms attending it.
When this is examined, the colour is found to be owing to small dark
flakes, resembling the grounds of coffee, and seems to be blood which
had oozed from the surface of the stomach, a little altered. Indeed
pure blood is sometimes thrown up, and we know that the red globules
enter the smaller order of vessels, and issue by them; for bleeding at
the nose is a common symptom about this time; and some relate that it
also escapes by the ears and pores of the skin, which I never saw, but
can readily believe it. At the same time, the stools grow black, and
the urine is frequently of a very dark colour, which seem to be owing
to the same cause. I never remember to have seen any one recover after
these symptoms came on.
There seems to be a general _error loci_ of the more tenacious and
globular parts of the blood into the smaller order of vessels, to which
the yellow colour is in a great measure owing; and when any part of the
skin is ever so little pressed upon, a damask red colour remains for
some time, the small vessels readily admitting the red globules. It
is certain that a yellow colour of the skin may be produced by such an
_error loci_, without any suspicion of the presence of bile. We have an
illustration of this in the ecchymosis which follows upon an external
contusion. In this case the red part of the blood is mechanically
forced either into the smaller order of vessels, or into the cellular
membrane, which occasions a livid appearance, and in the course of the
recovery the same parts become yellow, probably in consequence of some
of the gluten of the blood assuming this colour after the red parts
have been removed by absorption or otherwise.
In the worst form of this disease there is all along an uncommonly
distressing sensation of universal anguish, particularly about the
stomach, where there is a sense of burning heat, which, as the
miserable sufferers themselves express it, becomes unspeakable torture.
A sense of weight at the breast, deep and frequent sighing, and a great
failure of muscular strength, are dangerous symptoms in all stages of
the disease.
Upon the first attack the skin is extremely hot and dry, and the pulse
hard and frequent; but the external heat soon becomes very little
different from the usual standard of health, and the skin feels soft
and moist. There sometimes happens an eruption of small pustules, with
white heads, on the trunk of the body, which is a favourable sign; and
I have seen a head-ach disappear upon this breaking out. The pulse does
not serve as an index of danger; for, after the hurry of the first
attack, it becomes very moderate in point of frequency, varying from
eighty to a hundred pulsations in a minute, and is natural in point of
regularity and strength.
In these circumstances this fever differs from that which was last
described; and it also differs from it in being attended with little
delirium. I have seen cases in which the senses were not affected from
beginning to end; and I never observed that violent and incessant
delirium which attends other dangerous fevers.
The state of the _fauces_ is also different from that of most other
fevers, for there is no excessive thirst. The tongue is somewhat white
and foul; but I do not remember ever to have seen it black and dry.
A want of action in the bowels, and an insensibility to purgative
medicines, indicate great danger; and, next to the black slimy stools,
one of the most unfavourable symptoms is, when the _feces_ are like
white clay, as I have seen in some cases that ran out to the length of
a week before they proved fatal. When the black vomit and stools occur,
death commonly happens on the third or fourth day. A bilious diarrhœa
spontaneously coming on, is a very favourable symptom.
In more unpromising cases the urine is scanty, and in the last stage
of life it becomes of a very dark colour, as was mentioned before. A
plentiful secretion of urine is a very favourable circumstance, and
seems to be one of nature’s methods of curing the disease; for such
cases are observed to terminate well. I remember one case in particular
in which several quarts were made daily for several days together,
and it was of a very dark saffron colour, but looked green where
the surface was in contact with the side of the pot. I inspissated
a small quantity of it, and found a large residuum, which was very
deliquescent, and seemed to be all saline. In a hot climate the urine
does not shew that separation and deposition which denote the crisis
of fevers in cold climates, and this is perhaps owing to there being
less mucilage and more alkali in the former, on account of the more
putrescent state of the fluids. Upon adding a little vinegar to the
urine in the case above mentioned, it became turbid like the critical
urine of the fevers of Europe.
At the approach of death, cold clammy sweats come on; the pulse
continues regular and of a certain degree of strength, but grows
gradually slower. I have counted it at forty pulsations in a minute.
The patient is frequently sensible to the last moment; nor does the
countenance sink into what is called the _Hippocratic_ appearance. In
other cases I have seen, at this time, _coma_, and not infrequently
convulsions. Broad livid spots sometimes also appear on the skin.
Extreme muscular debility, a great difficulty of deglutition, and a
dimness of the eye-sight, are likewise common symptoms in the last
scene.
The different stages which lead to dissolution following each other
thus rapidly, there is not that gradual failure of the powers of nature
that usually give warning of approaching death; but the springs of life
run down, as it were, at once, the wretched sufferer expires, and is
happily delivered from the most extreme misery of which human nature is
capable.
Such is the general train of symptoms in this fever, taken entirely
from my own observation; but great varieties occur both in the symptoms
and duration, so great indeed, that it is hardly recognisable for the
same disease. I shall give specimens of such anomalous cases in two
that occurred at Port Royal, on board of the Canada, in July, 1782.
A lieutenant of that ship had been subject, for four days, to fits of
retching, without any bilious discharge or pain in the stomach; and,
except a white tongue, he had no symptom of fever in that time, nor
any thing to prevent him from doing his duty. On the fourth day, when
I first saw him, he began to complain of a fixed pain in the pit of
the stomach, which was not very violent, and about the same time a
yellowness began to appear on the white of the eye. He took a laxative
medicine, which had the desired effect, and some volatile spirits, with
some drops of thebaic tincture in simple mint water, for the pain in
his stomach. He had a good night. Next day the complaint of the stomach
was better; but there was great muscular debility. He had several
natural stools; and as there seemed little indication but debility,
he took nothing that day except an infusion of some bitters and
aromatics in wine. As he did not want for appetite, he eat some broth
and chicken; and nothing to give any alarm happened this day, except a
short qualm, in which he was faint, with a sense of cold, feeling to
himself, as he said, as if he should have expired. In the afternoon he
began to have black-coloured stools, which was the first symptom that
clearly betrayed the nature of the disease. He was then ordered as much
Peruvian bark as he could take with red wine, and these his stomach
bore. Decoction of bark was also given him in clysters. He had a strong
voice, and was quite sensible, but grew weaker and weaker with frequent
returns of the qualms, and he expired that evening before ten o’clock.
I have not the least hesitation in ranking this case with the fevers
last described, though so many of the usual symptoms were wanting. This
gentleman, though of a lively, active disposition, was of a slender
make, and of a dingy, doughy complection, and his case gave me the
idea of a disease attacking a constitution which, not having powers
to struggle with it, is overwhelmed without making resistance[105].
In those robust, plethoric habits, which are most commonly attacked,
there is a sufficient degree of strength to excite the violent symptoms
before enumerated.
A few days after this gentleman’s death, another officer of the same
ship was taken ill with the same sort of fever, and it was also
attended with several unusual symptoms. Neither his skin nor eyes were
yellow; the skin was hot and dry throughout the disease, and during
the three first days there was a diarrhœa, which was neither bilious,
putrid, nor mucous, but consisted in watery stools. There were no
gripes, nor any local pains whatever; but I never remember to have
seen more suffering from that general anguish, particularly about the
stomach, which attends this sort of fever. On the third night he began
to vomit and purge blood, which soon terminated in that dark-coloured
discharge which is a symptom so characteristic and fatal in this
disease. He continued sensible till within eight hours of his death,
which happened on the fourth night. The pulse was full and pretty
strong during the whole course of the disease; but there was all along
great debility and frequent sighing, symptoms that ought always to
create alarm.
TREATMENT OF THE YELLOW FEVER.
I feel this as the most painful and discouraging part of this work, the
yellow fever being one of the most fatal diseases to which the human
body is subject, and in which human art is the most unavailing.
It seems hardly to admit of a doubt that there are particular instances
of disease, in their own nature, _determinedly fatal_, that is, in
which the animal functions are from the beginning so deranged, that
there are no possible means in nature capable of controlling that
series of morbid motions which lead to dissolution. Of this kind
appear to be the greatest number of cases of the plague, many of the
malignant small pox, and some of fevers, particularly of that kind
now under consideration. It is extremely difficult to ascertain such
cases from observation; and it may be said that the opinion of the
existence of them is favourable to ignorance and indolence. But, on the
other hand, it may be questioned if more harm is not likely to arise
in medicine by being too sanguine and officious, than by a diffidence
of art and trusting to the powers of unassisted nature? Were we
thoroughly acquainted with the animal œconomy, we should perceive _à
priori_ in what instances the seeds of disease would either operate
so as necessarily to terminate in death, or when they were within the
command of art. But we can derive little or no information from this
source, on account of our great ignorance of the secret operations
of the living body; so that the only grounds of judging are our
observation and experience concerning the usual event of disease, and
the effects of remedies. Though these are circumstances attended with
great uncertainty and ambiguity, yet I believe it will be admitted as
the opinion of the most chaste and experienced observers, that there
do really exist diseases whose course cannot be diverted by any means
that can be employed. This opinion, I have said, is, in one view,
extremely discouraging; yet, to the mind of a feeling and conscientious
practitioner, who must often find his best endeavours baffled in many
diseases as well as this, and who might be apt to look back and accuse
himself of some fault or omission, it affords this satisfaction to
his reflections, that the want of success may have been owing to
something in the nature of the disease, and not to his want of skill
and attention.
But though the fatality of this disease is discouraging, let us not
despond, but rather redouble our diligence in observing what assistance
and relief nature may admit of.
It is proper in this as in every other fever of this climate, to begin
the cure by cleansing the first passages. This does not produce the
same relief as in the common bilious fever, probably because there is
a less free secretion of bile, and therefore less oppression from the
collection of it.
With regard to blood-letting, the most that can be said in its favour
is, that if there should be a hard throbbing pulse, with violent pain
in the head and back, it is _safe_ in the first twelve hours. This
limitation is necessary, at least with regard to common seamen, who do
not bear evacuations so well as officers and others, who are used to
a better diet, and to whom the loss of blood has, in some cases, been
found useful in the early stage of this fever. It is, however, in all
cases extremely dangerous, except in the circumstances mentioned above.
The blood is said to shew a buff in the beginning of the disease, but
in the second stage, it is mentioned by a French author[106], that it
hardly coagulates or separates. But even the appearance of a buff,
without considering other circumstances, does not always argue the
propriety of blood-letting[107].
The great object in the cure of this fever is, to bring the stomach to
bear the bark. There are here wanting most of the circumstances that
in the other cases forbid the use of it; for there is no preternatural
quantity of bile in the stomach and intestines, nor is there a hot and
dry skin, nor violent delirium. The only obstacle to its administration
is the great irritability of the stomach, which is the most fatal
symptom of the disease; and the principal part of the management
of the patient consists in the prevention or removal of this. The
stomach is to be treated with the utmost tenderness and attention. One
gentle emetic at the beginning is all that is allowable; and as fresh
collections of bile are less apt to occur, the repetition of it is less
necessary.
It is best to abstain altogether from antimonial medicines, and to
render every thing, whether food, drink, or medicine, as grateful as
possible. The liquid most apt to stay upon the stomach is the juice of
the acid fruits of the climate, such as[108] oranges and lemons. It
happens frequently, however, that acids come to be loathed extremely,
so as to nauseate the stomach and to encourage retching. In this case
I have found a composition of wine and water with lemon juice and
nutmeg, sweetened with sugar, and given warm, to be a very grateful
and salutary drink. The patient sometimes prefers the decoction of
farinaceous substances to every other liquid; and in one case in
particular, which did well, the patient was led by taste to prefer warm
water gruel to every thing else, and the great quantity he drank seemed
to have a considerable share in his recovery, by keeping up a warm
moist skin and producing a great flow of urine.
In order to check vomiting, the saline draught, in the act of
effervescence, has been employed with evident advantage; but in most
cases this symptom is so obstinate as to discourage all attempts to
remove it. I have known magnesia in mint water have a visible effect in
soothing the stomach, particularly when given immediately after some
acid beverage.
I was informed by Dr. Young, physician to the army, that he found
an infusion of chamæmile flowers one of the best medicines in this
vomiting; and a surgeon of one of the line-of-battle ships informed
me, that he also found advantage from it in alleviating this symptom.
The French author above mentioned affirms, that milk, boiled with
some flour or bread, given in the quantity of a spoonful at a time,
and frequently repeated, had more effect than any thing he tried in
stopping the vomiting in this fever. I have seen this symptom relieved
by fomenting the stomach with stupes wrung from the decoction of bark,
and sprinkled with camphorated spirits and tincture of bark[109].
But nothing I have ever seen tried had so great an effect in removing
this irritability of stomach as a blister applied to it externally;
and it is a remedy which, so far as I know, has not been hitherto
recommended. In other fevers, when the head was not particularly
affected, I preferred this part for the application of a blister, for
it is in some respects more convenient than between the shoulders, and
the stomach is the part more affected perhaps than any other in all
fevers. But in this fever I was led to apply it to this part, both
from its being affected in an uncommon degree, and from observing,
upon inspecting the bodies of those who died, that the only morbid
appearance that could be discovered was an inflammatory suffusion on
the inner membranes of the stomach.
I have employed opiates both externally and internally to allay this
symptom, but without the effect that might have been expected from so
powerful a sedative.
As the stomach will seldom, even in the most favourable cases, bear
such a quantity of bark as to subdue the disease, it must be exhibited
in every other way that can be thought of, such as by clyster and by
external fomentation, both of which I have employed with good effect. I
used to order a pint of decoction of bark to be injected every three or
four hours, and the fomentation to be employed nearly as often. I have
heard of the decoction of bark being used as a warm bath with success;
but I cannot decide concerning this practice from my own experience.
I have no other internal remedy to recommend; for whatever power of
retention the stomach may have should be employed in taking bark. If it
should become tolerably retentive, camphor will be found of service;
and if given in the evening with an opiate, perspiration and sleep will
probably be procured, by which the patient will be greatly relieved.
Blisters to the thighs and legs seemed to coincide with the general
intention of cure, and they appeared to be of advantage in the cases in
which they were tried.
4. Of the Effects of Flowers of Zinc and White Vitriol in the Cure of
obstinate INTERMITTENT FEVERS.
It frequently happens in the West Indies that intermittent fevers are
so obstinate as to resist the common means of cure by the Peruvian
bark; so that these complaints become extremely distressing to the
medical practitioner as well as to the patient. Indeed this was a
difficulty that occurred so often, that I was sometimes tempted to
think, either that the great reputation of this medicine is not so
well founded as is commonly believed, or that the bark generally in
use in these times is not of so good a quality as that employed by the
physicians who first established its character.
But, in the first place, the experience upon which its reputation was
first built was in a temperate climate, where very few agues are found
to resist it when properly administered. In the next place, there is
reason to believe that, in fact, the medicine itself now commonly in
use is not equally powerful with what was first employed; and a species
of it, called the Red Peruvian Bark, has lately been discovered, or
rather, perhaps, revived, which is certainly of a superior quality,
and has been found to cure intermittents in which the common sort had
failed[110].
However this may be, it is an undoubted fact that obstinate agues are
much more frequent in the West Indies than in Europe; and something to
supply the insufficiency of the bark seemed to be a _desideratum_.
I was informed by Dr. Hendy, of Barbadoes, that he had found the
flowers of zinc to answer in cases of intermittent fever, in which
even the bark and every other remedy and mode of treatment had failed.
It was found very successful in the like cases, both in my own trials
at the hospitals, and by the surgeons of the men of war to whom I
recommended the use of it. In order to judge what may be expected
from it, I shall give a specimen of its success in some cases, at the
hospital at St. Lucia, of which I kept an accurate account, in the
months of February and March, 1783.
About the time the fleet arrived there, six cases of intermittent
fevers were sent to the hospital from different ships. One was of six
weeks continuance, and had been some times of the tertian, sometimes of
the quartan type. Two were quartans; one of which was of two months,
the other of eight months duration. Two were regular tertians; of which
one had only had two fits, but was a relapse after a week’s exemption
from an attack of several weeks. The other was of three months
continuance, attended with an eruption on the hands and arms. The
sixth case was a quotidian of three weeks, attended with a cough of the
same standing, and joined with sea scurvy.
In all of them the bark had been given at some period or other; and the
flowers of zinc were now tried in all, except the last. In three out
of the five this medicine had the most visible good effects. In one
the disease was so speedily removed, that there was only one fit after
the first day of taking this medicine, and the other two had recovered
perfectly after it had been used for seven days.
In these cases there can be little or no ambiguity with regard to the
real efficacy of the medicine, as the disease had lasted from two
to six months, and there was no other circumstance of change in the
situation or treatment of the patients that could account for their
recovery.
Of the two cases in which it failed, one was the tertian of three
months, attended with the eruption; the other was the relapsed tertian
of three days.
With regard to the dose, I began with giving it in the quantity of two
grains thrice a day, which, in some, produced the desired effect, and
without the least sensible operation on the stomach or bowels. If this
dose did not stop the fits after a few days trial, it was increased to
three grains, which, in some, would produce a little sickness. I found
that four grains ruffled the stomach a good deal; but if the patient is
gradually habituated to it, even more than this may be given without
inconvenience.
In those cases in which it was successful it was not found necessary to
give more than two grains at a dose, except in one of them, in which
three were given the day before the fit ceased. In the two unsuccessful
cases the medicine had a fair trial for a fortnight; but one of them
getting no better, and the other seeming to get worse, it was left off.
The cases to which this medicine is adapted are those that have
extremely distinct remissions, with no symptoms of bile nor any local
affection. When agues come to be long protracted, they are frequently
what may be called nervous; that is, consisting of certain morbid
motions that seem to be induced by habit, after the original cause is
removed, and with a tolerable enjoyment of appetite, sleep, and all the
functions of life, during the intermission.
The two cases in which the zinc failed recovered by the use of the
bark. This had been unsuccessfully tried before, and its good effects
now might either depend on its having been left off for some time,
whereby the body recovered its sensibility to its virtues, or it might
be in consequence of administering it in ardent spirits with a few
grains of capsicum and ginger, additions which I found to improve its
effects in other cases, and is a mode of giving it well suited to this
climate.
The zinc was not tried in the sixth case, on account of the local
affection and the remission being short and imperfect.
The white vitriol, being a salt of zinc, might be supposed to possess
the same virtues; and it would appear to do so from some facts[111]
that were reported to me in the West Indies, and also from some trials
made by me at St. Thomas’s hospital since I came to England.
Though this is a medicine of very considerable powers, I do not mean to
put it in competition with the bark, by proposing it as a substitute
for it, or by representing it as superior to it in all circumstances;
but only to propose it as a valuable subsidiary in particular cases.
The account I have given is faithfully extracted from a diary of
my practice; and were I to say more in its favour than the future
experience of others may warrant, I should do more harm than service
to its reputation. Many good medicines have had their characters hurt
by being over-rated by the first proposers of them, who are naturally
sanguine and partial, without, perhaps, intending to deceive. But
when others find that their virtues do not come up to what has been
asserted, they are apt to run into the other extreme, and explode them
altogether; so that what was given out as good for every thing, is now
found to be good for nothing[112].
CHAP. II.
Of FLUXES.
These seem to arise in the same circumstances, and to be owing to
the same general causes, as fevers. They may, in some sense, be
considered as fevers, attended with peculiar symptoms in consequence
of a determination to the bowels, just as fevers in cold climates are
sometimes attended with rheumatism and catarrh. We have seen, in the
first part of this work, that the dysentery arose chiefly in those
ships which had been subject to fevers.
This determination to the bowels is owing to a variety of causes, but
is chiefly connected with external heat; for it is most common in hot
climates, and towards the end of summer or in the autumns of cold
climates, owing probably to a greater acrimony of the secretions of the
intestines, and particularly of the bile. Dysenteries arise in camps
also at the same seasons, and in the same circumstances as bilious
fevers[113].
Besides climate and season, the other circumstances determining to
the one disease more than the other are, 1. A difference in the
constitutions of different men; for in the same ship it sometimes
happens that both diseases prevail equally, though all the men are
using the same diet and breathing the same air. 2. The nature of the
occasional cause. A dysentery, for instance, is more likely to arise
from an irregularity in eating or drinking; a fever from being exposed
to the weather, particularly marsh effluvia. 3. The particular species
of infection that may happen to be introduced. Suppose, for example,
that a ship’s company is predisposed to acute distempers, and one man
or more ill of the dysentery should be brought on board, this will
become the prevailing disease, as happened in the Torbay in August,
1780. If the like number of fevers should be introduced, then fevers
will be the prevailing disease.
These two diseases may therefore be considered as _vicarious_,
the one substituting itself for the other according to particular
accidents, and both proceeding from the same general causes; and
this is no new idea of mine, but seems to have been Dr. Sydenham’s,
when he calls the dysentery a _febris introversa_. It may be farther
added, that dysentery is the latest form in which this cause, which
is common to both, can exert itself; for it is a disease more within
the reach of art; and some of the most dangerous symptoms attending
fevers, particularly _delirium_, seldom occur in dysentery. When it
proves fatal, it is in consequence of violent local affection, and
that in general after it has taken a chronic form. When an incipient
fever turns into a dysentery, all the symptoms, and particularly the
head-ach, delirium, and _coma_, if there should be any, are immediately
relieved. And the most favourable cases of the yellow fever are those
in which a bilious diarrhœa comes on, while the most fatal are those
in which the bowels are so torpid as to be insensible to any stimulus
either from their own contents or from medicine.
I shall not enter into a minute description of this disease in all its
stages, as this has been so ably executed by Sir John Pringle, Sir
George Baker, and other authors, but shall only give a sketch of some
of the most remarkable symptoms, particularly such as are peculiar to
the climate and manner of life, so as to explain the varieties that may
be necessary in the mode of treatment.
The fluxes that arose in the fleet were either what may be called the
acute idiopathic dysenteries, or a dysenteric state of the bowels from
neglected diarrhœas, which was most apt to occur in the convalescent
state of fevers, or in men labouring under the scurvy. The body is more
susceptible of infection in a state of weakness from these or any other
causes; and in hot climates the dysentery seems to be more infectious
than fevers; for at hospitals it was so frequently communicated to men
who were ill of other complaints, that it was in these the principal
cause of mortality. For this reason, I was at more pains with regard to
this disease than any other, in keeping those who were ill of it in a
separate ward.
I have met with some violent and untractable cases which proved
fatal in the acute state; but, in general, this disease draws out to
a chronic form in this climate, and does not prove mortal for many
weeks. The usual cause of death appears, from the inspection of the
bodies, to be an ulceration of the great intestines, particularly
of the descending colon and the rectum. This part of the intestinal
tube is most affected from its being the receptacle of all the acrid
secretions from the rest of the canal; and it is naturally more subject
to congestions of the fluids and incurable ulcers, as appears from
the rectum being so liable to the hæmorrhoids and the _fistula_. This
ulceration of the great intestines is so common, that, out of eight
cases which I inspected after death, seven had this appearance. The
case in which there was none was not so much a case of dysentery as
of inflamed bowels, brought on by the man having drank to excess of
spirits while he was recovering from a dysentery. The acute _tormina_
which always occur in the first days of the disease seem owing to an
inflammation, which terminates in ulcers; and these being constantly
irritated by the sharp humours, produce the _tenesmus_, which is the
symptom most essential to dysentery in the after part of the disease.
Any diarrhœa may in this manner become dysenteric. During the acute
griping at the beginning, the stools are loose and copious; but as
soon as the tenesmus takes place, they are scanty, which is most
probably owing to the spasmodic strictures in the great intestines,
in consequence of irritation upon their excoriated surface. The
inflammatory state is more lasting and violent in a cold than a hot
climate, the gripings are more severe, and the danger is also greater
in this stage of it.
The state which the great intestines fall into in old dysenteries
seems to have something in it peculiar to itself: the several coats
become thick and spongy; their texture is obliterated and destroyed;
and they become of a black or very dark purple colour. This, however,
cannot be called mortification; for the fibres of the gut do not lose
their tenacity, nor is there that putrid and dissolved state in which
gangrene consists; but it advances in time to such an extreme state
of disease as to be entirely incapable of recovering its natural
appearance and functions, and proves therefore the cause of death.
The greater frequency and obstinacy of these chronic fluxes in hot than
in cold climates seems to be owing to the same weakening of the powers
of life which make recovery in general so tedious, and particularly
that of wounds and ulcers. The greater quantity of acrid bile will also
tend to keep up the ulceration. Dysenteries have this disadvantage,
that the Peruvian bark, which is the most powerful restorative in other
complaints of this climate, is here found to be inadmissible on account
of the heat, thirst, and other febrile symptoms, which it seldom fails
to induce in all stages of this disease.
TREATMENT of FLUXES.