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.

There are few diseases in which a prudent employment of art is more useful, or in which early means of relief are more requisite than in this[114].

Where the dysentery is the original disease, and when the patient is robust and plethoric, with acute pain and a strong pulse, blood-letting may be practised with advantage in the beginning of the complaint. But there is no part of the practice in this disease in which the climate and manner of life makes a greater difference than in this; for in a temperate climate it frequently happens that repeated blood-letting is necessary; but in a hot climate, where the fibres are relaxed, and in the constitutions of seamen, whom we seldom or never find plethoric, the inflammatory symptoms requiring this evacuation do not run so high, nor continue so long.

It is in all cases of the utmost consequence to administer as early as possible a brisk saline purgative. An ounce and a half or two ounces of purging salts may be dissolved in a quart of barley water or water gruel, and given warm in cupfuls, at small intervals, till a free and copious evacuation is produced. If there should be much fever, or sickness at stomach, two grains of emetic tartar will be a great improvement of this medicine; and there will be this farther advantage from its use, that if the stomach should be loaded with bile, in which state it is more irritable, an evacuation upwards will also be excited to the great relief of the patient.

This early and seasonable measure will, in many cases, put a stop to the disease, especially if the patient is thrown into a sweat immediately after the bowels have been thus thoroughly evacuated. It is of great service in this disease to promote free perspiration, and even a plentiful sweat, which may be effected with great advantage by giving, at bed time, a medicine composed of opium, ipecacuana, and a little neutral salt, accompanying it with plentiful warm dilution. Nothing tends more to relieve griping and tenesmus than a general, warm moisture on the skin. The ipecacuana, which is an ingredient in this medicine, is one of the best anti-dysenteric remedies we know; the opium procures rest; and this, joined to the sudorific effect of the whole, not only gives a temporary relief, but tends to carry off the disease. It is most properly given in the evening; for there would be this inconvenience in constantly encouraging a sweat, that if the tenesmus should return, it would either be checked by the patient getting frequently out of bed, or there would be danger of his catching cold. I am well aware that we cannot be too cautious with regard to the use of opium in the beginning of this disease; but it is admissible more early in a hot climate than a cold one, as the inflammatory symptoms are less violent and can be sooner subdued; besides, it becomes an entirely different medicine when conjoined with the other ingredients that have been mentioned.

The best medicine in the day time we found to be small doses of ipecacuana alone twice or thrice a day; and if there should be fresh collections of bile, small doses of the saline purgative will be necessary. Ipecacuana in this intention, may be given in the dose of two grains in athletic constitutions, such as those of seamen; but in the more delicate constitutions, such as are commonly met with in private practice, one grain is a sufficient dose. I have found manna and tamarinds a good addition to this medicine in the earlier stages of the disease, where there was much bile; but in a more advanced stage of it they are apt to produce gripings and flatulence.

The marks of a redundance of bile are, a sickness at stomach, a sense of scalding at the anus when the stools are passing, and the yellow or green colour of the stools themselves. It is apt also to excite symptoms of fever, such as a foul tongue, a hot and dry skin, with thirst. When collections of it are suspected in this disease, it is best to evacuate it by vomiting, for it is thereby prevented from irritating the bowels, and from arriving at the inflamed parts with, perhaps, increased acrimony, acquired in passing through the whole length of the intestines.

Some gentlemen of the fleet informed me that they found oil of almonds a useful addition to the purgative. Others as well as myself made a practical comparison of the saline purgative with that composed of rhubarb and calomel, as recommended by Sir John Pringle, and we gave the preference to the former, as more easy, speedy, and effectual in its operation, especially in the first stage. Cases may occur, however, in which the other may be more advisable; for where there is a sense of weight about the stomach, which most probably arises from the biliary organs being clogged with bile, and where emetics have failed to remove it, or the weakness of the patient may render them improper, then calomel has the best effect: for it was formerly observed, that it tends to loosen the secretions, and to stimulate the more distant excretories, such as the biliary ducts.

It is very important to caution young practitioners concerning the employment of opium in all stages of this disease, but especially in the beginning; for though it is an excellent remedy when seasonably and judiciously employed, it is very liable to abuse, particularly in the hands of the inexperienced, who may be tempted to give it improperly from an anxiety to relieve; but as more harm may arise from an unseasonable administration of it than could be compensated by the best-timed use of it, it is best to err on the side of caution and omission. The principal caution to be observed with regard to this remedy is, to premise suitable evacuation, such as blood-letting, if necessary, but more especially purging. It is always pernicious to give it in its pure state during the _tormina_, so common in the first days. By these I mean the abdominal gripings, which denote inflammation, and are entirely different from the _tenesmus_, which is a more constant and characteristic symptom of the disease, and seems to arise from irritation and spasms of the rectum and colon.

It was in this disease that I first observed the good effects of a small quantity of neutral salt in taking off the inconveniencies attending opium, such as the feverish heat and confusion of the head, which it is apt to produce in many constitutions; and as the administration of the anodyne coincided with the evening dose of ipecacuana, I was led to adopt a form similar to that of Dover’s powder, but with only half the quantity of opium; or, it was given in a liquid form, by combining twenty drops of thebaic tincture and a drachm of ipecacuana wine, with nitre from five to ten grains, in any simple vehicle in form of a draught. There is a very observable difference, in some cases, between opium given in a liquid and in a solid form; and the former is much more certain in its effect when the intention is to procure speedy and effectual ease.

I have observed great benefit from the use of external remedies in dysentery, and these have, perhaps, been too much neglected by authors and practitioners. The warm bath is of great service, especially where the gripes and tenesmus are severe, and where the fever has been taken off by previous evacuation. Fomentations or warm applications of any kind to the abdomen give temporary relief; and it will be found of advantage to keep those parts, at all times, well defended from the cold air. Blisters to the abdomen were also found of use, and likewise acrid liniments, composed of oil, volatile spirits, and tincture of cantharides. Where the stomach has been much affected, I have perceived relief from fomenting it with stupes, upon which thebaic tincture and camphorated spirits were sprinkled, as recommended by Dr. Lind. I was once affected with a bad dysentery in the West Indies, and I thought myself much relieved by the warm bath and a blister. Strangury is not an uncommon symptom in this disease, independent of cantharides, and the most sensible and effectual relief is derived from fomentations to the pubis and perinæum, as I also experienced in my own case.

What has been hitherto said regards chiefly the acute dysentery; but the most frequent and troublesome complaint that occurred at the hospital, was the same disease in what may be called its chronic state.

There is a considerable variety of symptoms in all the stages of this disease, but particularly in the more advanced or chronic state, so that a corresponding variety is necessary in the modes of treatment, and there are few diseases in which there is more room for exercising the judgement.

In all stages of it an accurate discernment is necessary with regard to the use of opiates, and great part of the practice here consists in timing these well. They are least admissible in the beginning, where evacuation is the principal object; but as the disease advances they become more and more allowable and useful. The principal cautions necessary in their administration are, 1. To premise sufficient evacuation, so that the intestines may not be loaded with bile, _scybala_, or any other irritating matter at the time of giving the opiate. 2. To obviate the effects which an anodyne has of causing a retention of the contents of the intestines. This may be done, either by giving something purgative along with it, or after it has produced its quieting effect. The former method seems preferable; for as soon as the effect of the opiate is over, the purgative is ready to act; and in this way it is so far favourable to the operation of the purgative that large feculent stools will be discharged: whereas, had the purgative been given alone, it would have been more apt to produce scanty griping stools, attended with tenesmus. Rhubarb answers well in such cases, and may be given in a dose from twelve to twenty grains, according to the age and constitution. 3. To prevent feverish heat and delirium. This was proposed to be done in the first stage of the disease, by combining it with ipecacuana and a little neutral salt. With the same intention, it may now be joined with a few grains of Dr. James’s powder, or _vitrum ceratum antimonii_, in which form it would not be so strongly sudorific, an effect not so much required in the chronic as in the acute state.

The principal causes that keep up the flux, and render it so obstinate, are, 1. A too great secretion of bile, either continual or frequently recurring. 2. Ulcers in the great intestines. 3. A lienteric state of the bowels. 4. A retention of _scybala_.

The first cause is much less frequent than might be expected by those who fancy that every disease of this climate proceeds from bile. When there does occur a redundancy of bile, there is more occasion for the employment of evacuant medicines, and more need of caution in that of opiates. A medicine that will dispose the liver, or the circulating system in general, to form less bile, is a _desideratum_ in physic; but, in case of an excessive flow of it, emetics and mercurial purgatives, as has been already mentioned, are the best means of evacuating it; and care should be taken that it be discharged before it accumulates too much, or becomes acrid by too long retention.

In order to obviate that irritation in which tenesmus consists, some benefit was found from the injection of emollient and anodyne clysters, to wash off and dilute the acrimony, and to sooth and heal the parts. A strong infusion or decoction of linseed or starch may first be given to the quantity of near a pint, to be evacuated after a short retention, and then a few ounces of the same, with thirty or forty drops of laudanum, to be retained for a length of time, in order to procure rest. Instead of this last, I have known a small quantity of warm milk, with syrup of poppies, used with advantage in private practice.

I was at first tempted to think that a very frequent injection of such clysters would be very useful, by washing and healing the colon and rectum, and preventing farther exulceration. But besides the objection arising from the tenderness of the parts, which, in some cases, renders the operation itself painful, I found that if they were given oftener than once a day, they rather increased the uneasiness, and made the patient feel languid and exhausted; so true it is that no practical rule can be established from reason alone without being brought to the test of experience. The rectum seems to have a peculiar sensibility, and a remarkable consent with the whole system; for a stool will induce syncope, or even death, in a state of great debility. Clysters may be pernicious, even though they produce no evacuation of _feces_; and Sydenham has remarked, with respect to other diseases, that their unseasonable or too frequent use greatly debilitates and disturbs the patient. When not abused, however, they are of the most eminent service in this and other complaints.

Certain medicines, which have been called _sheathing_, have been recommended to be taken by the mouth. Of this kind are mucilage, oil, and wax. I have made trial of mucilage, such as starch, without any sensible effect, probably because it loses its qualities by the powers of digestion before it reaches the part upon which it is intended to act. With regard to oil, I have hardly enough of experience of my own to decide; but some of the surgeons of the fleet informed me that they found advantage from combining it with the purgatives. I was discouraged from using it by finding that it was apt, in the West Indies, to become rancid on the stomach, and, for this reason, I seldom, in any case, employed the castor oil, which, though produced in that climate, seems to answer better as a medicine in Europe. But since my return to England I have used, with great benefit, at St. Thomas’s hospital, a medicine, composed of tincture of rhubarb and oil, in old dysenteries, attended with discharges of blood. I took the hint of this from finding it of great service in deep-seated piles, as recommended by Dr. Griffith[115]. It is necessary to combine something purgative with the oil, otherwise it might be altered by digestion, or absorbed, or might become rancid by too long retention in the first passages. Wax is a body not changeable by digestion, and seems therefore well suited for the purpose of sheathing the bowels; and I have found advantage from the preparation of it recommended by Sir John Pringle[116], on the authority of Dr. Huck. I have also seen some advantage in old fluxes, in St. Thomas’s hospital, from the use of spermaceti, given with an equal quantity of conserve of roses and half as much absorbent powder, agreeably to a form in use at that hospital.

The climate has a great influence in preventing these ulcers from healing, upon the same principle that it prevents the cure of external sores and wounds, so that there are cases that admit of no cure but from a change of climate. I have seen in some cases of old dysentery, small, round, ill-conditioned ulcers break out on the surface of the body, which seemed to proceed from the same general habit that produced those of the intestines. There was something peculiar in the appearance of those external sores, being like small round pits, as if a part of the skin had been removed by caustic, and with little or no discharge. In a case of this kind, which proved fatal, I found the whole surface of the great intestines beset with small ulcers, not unlike those on the skin.

Since the first edition of this work was published, I have met with a pamphlet, written by Dr. Houlston, of Liverpool, in which the friction of mercurial ointment on the abdomen is recommended as a cure for old fluxes; and I have tried this practice in some very obstinate cases in St. Thomas’s hospital with evident success. In these cases it is probable the disease is kept up by a vitiated state of some of the various secretions belonging to the intestinal canal, which the mercurial alternative tends to correct.

The next cause that was mentioned of the long continuation of fluxes, was a lienteric state of the bowels. This consists in a great irritability of the whole alimentary canal, whereby all the _ingesta_ are transmitted so fast, that there is no time for assimilation. Liquid aliment, such as broth, is particularly subject to this inconvenience. There are few cases of long-protracted fluxes in the West Indies, without this symptom in some degree.

The remedies that are here found of most service are such as counteract irritability or relaxation. It is in cases where this is the prevalent symptom that opium may be most freely used. Frequent and small doses of the compound officinals, such as theriaca, pulvis e bolo compositus, or diascordium, have been found of service. Though the relaxation would seem here to indicate the Peruvian bark, yet I have hardly ever known it employed in any form in this or any other stage of the disease, without being hurtful. But there are other bitters not only safe but useful in restoring the tone of the bowels; of this kind are simaruba, quassia, and chamomile flowers. The first has been reckoned a specific in this sort of flux; but though its powers are undeniable, it will be found frequently to fail[117]. I have also used, with advantage, a tincture of gentian and cinnamon in Port wine. Something aromatic has a good effect when added to the bitter, being adapted to prevent or obviate flatulence, which is a common and troublesome symptom in this complaint.

That class of remedies which may be called pure astringents, might seem at first sight well calculated for cases of this kind. Of this sort are the _terra Japonica_ and _extractum campechense_; but though I have seen evident benefit from this last, there are few cases in which such medicines are found by experience to be of material service. Where the cause consists in simple relaxation, they will effect a cure; but it more frequently happens that the disease is kept up by a vitiated state of the secretions, or a depraved action of the bowels.

The absorbent earths are a more useful remedy in this form of the disease. They have, perhaps, a restringent effect independent of their power of absorbing acid. It is certain, however, that great part of their use consists in the destruction of acid, which is very apt to be generated in that depraved state of digestion which takes place in advanced fluxes, particularly in this lienteric state of the bowels. In the early and acute state the vegetable purgatives, such as cream of tartar, tamarinds, and manna, are proper; but in this advanced stage they are hurtful by the acidity and flatulence which they produce, and both the food and medicines should be so calculated as to avert and correct those inconveniencies. There is something in vegetable acids extremely unfriendly to a weak state of the bowels in general, tending to bring on spasmodic gripings, and preventing a healthy digestion and assimilation, as we know in the case of heartburn, and of those who make use of vinegar to check corpulency, by preventing the formation of blood. Vegetable acids, however, are admissible where there is a redundancy of bile, or where the excrements are putrid; and Dr. Zimmerman recommends tamarinds as a useful medicine in what he calls the putrid dysentery.

Lime water has been recommended in old flaxes, and I tried it in several cases; but, except in one, I could not perceive any benefit from it.

Absorbents may very properly be combined in prescription with some of the compound-officinal opiates, and a medicine will thereby be formed, which will have at once the advantage of an anodyne, a bitter, an astringent, a carminative, and absorbent. As these earths have little or no taste, they may also be added, with propriety, to the common drink, as in the form of the chalk julep, or _decoctum album_. It may be thought that here and elsewhere I have not been so particular as I ought to be concerning the forms and doses of medicines; but circumstances, such as age, constitution, and symptoms, make these, in a great measure, discretionary; and any one who is sufficiently conversant with physic to be entrusted with the charge of the sick, will have sufficient judgement to vary his practice accordingly. It has, therefore been my object rather to give the general principles of treatment than the particular forms of medicines.

A proper regulation of diet, as well as medicine, is of the utmost consequence in this disease. A free indulgence of animal food is pernicious, particularly in the first stage of it. In the chronic state, a moderate use of it is allowable, and in the lienteric state it answers better in a solid form than that of broth, which is apt to gripe and to run quickly through the bowels. The best general articles of diet are farinaceous bodies; and these are greatly improved by being toasted brown before they are used. It was observed, in a former part of this work, that the flux was supposed to have been prevented, in the fleet commanded by Sir Charles Saunders, by throwing burnt biscuit into the water used by the crews of the ships. It is a good practice to put a well-burnt toast into all that the patient drinks, and toasted bread, or panada made of toasted bread or biscuit, is one of the best articles of diet. Brackish water ought to be avoided, as it ruffles the bowels when in so delicate a state. Fermented liquors are improper, except when the disease is advanced, and where weakness and relaxation are the prevailing symptoms. Malt liquor will hardly ever agree, on account of its acidity and flatulence. Of wines, Port is to be preferred as the most strengthening; Madeira as the least subject to acidity; and, for the common men, no drink of the fermented kind is safer than a moderate quantity of spirits diluted with water.

Warm clothing is of the utmost consequence in this disease, and external warmth of the abdomen tends greatly to sooth the bowels. I have seen good effects from a warm gum plaster constantly worn on that part. Though cold is in general hurtful and unsafe, I have nevertheless known the sailors, who, by their habits of life, are commonly heedless, bathe in the sea when labouring under what they call the white flux, without any bad effects.

It sometimes happens that this disease baffles every effort both of medicine and diet, so that a change of climate becomes the only resource.

The last cause of habitual flux that was mentioned was the retention of _scybala_, which keep up the irritation and tenesmus. It is very natural to neglect purgative medicines when there seems already to be too great a discharge by the bowels; but there is this inconvenience from omitting them for a length of time, that those hard lumps of feces, called _scybala_, are apt to collect in the cæcum and cells of the colon, as I have seen upon inspecting the dead bodies; and the fibres of the intestines being weakened, their natural strength is not sufficient to expel them without being stimulated by a purgative. It is therefore necessary to give some evacuant medicine from time to time, even though there should be no griping nor any marks of acrimony in the intestines. Rhubarb is allowed to be one of the best medicines for this purpose; and I have also known a combination of salts and sena have a good effect after a long neglect of purgative medicines. It is probable, from the durable effects produced, that these do not operate merely by the expulsion of _scybala_; and we can conceive that they may be of service by the removal of certain depraved fluid secretions, or that they may stimulate the vessels to a more healthy action and a more natural secretion. Be this as it will, experience teaches that in all fluxes it is of advantage to interpose from time to time some purgative medicine.

From the preceding view of the variety of causes which tend to keep up this disease, it will appear that great judgement and discrimination are necessary in varying the practice according to circumstances; and there is no disease in which there is room for more attention and nicety in adapting the different remedies to the different symptoms. We can hereby also account for the various characters that different remedies have had, some having been extolled by one practitioner while they have been pronounced insignificant by another; for no one remedy will suit all the various cases of this disease. As it is of the greatest consequence to distinguish these cases, I have been more particular and diffuse on this article than any other; and having laboured under this complaint myself, I was naturally led to take a greater interest in its treatment, and had also thereby a better opportunity of making observations on it.

CHAP. III.

Of the SCURVY.

I shall not be so minute either in the description or treatment of the scurvy, as of the preceding diseases. A detail of this kind would lead to unnecessary prolixity and repetition; for the prevention and cure of it consisting in diet rather than medicine, have been fully handled in the former parts of this work; and the subject, in the descriptive as well as the practical part, has, in a manner, been exhausted by Dr. Lind. With regard to the theoretical part, I refer the reader to the ingenious treatise lately published by Dr. Milman.

It has appeared that the principal source of scurvy is a vitiated or scanty diet, and that it is very much promoted by cold, moisture, filth, sloth, and dejection of mind. Hard labour has been assigned by some as a cause; but this is not conformable to my observation in general, and what has been related to have happened in the Conqueror[118], more particularly led me to be of a contrary opinion.

The principal differences of the symptoms of the scurvy in hot and cold climates, so far as I have observed, are, that in the former the livid hardness on the extremities is an earlier symptom, and in the latter the gums are sooner affected, and the difficulty of breathing is a more frequent and more uneasy symptom. This difficulty of breathing is one of the most fatal symptoms, and is most frequent in those cases in which there are the fewest external marks of the disease, and is probably that form of the complaint which attacks a vital part by a sort of translation from the extremities.

There is a remarkable symptom sometimes attendant on this disease which has escaped authors, and is mentioned in Mr. Telford’s Report, page 23. This is the _nyctalopia_, or weakness of the eye-sight, which was also common in the garrison of Gibraltar[119], among those who were affected with the scurvy, a disease that prevailed much during the late siege of that place.

With regard to the cure, enough has been said in the preceding parts of this work to prove that fresh vegetables are the most effectual antiscorbutics. I shall here mention a fact farther in proof of this, which has not before been taken notice of. When the fleet arrived at Barbadoes in May, 1781, part of the soldiers, who served as marines, were affected with the scurvy, and being sent to the army hospital, where, at that time, no fresh animal food was allowed, they recovered much faster by being confined to vegetable articles, than the seamen who were fed upon fresh animal food without any fresh vegetables.

It has farther appeared, that there is something in a particular class of fruit of the lemon and orange kind, which far surpasses every other remedy, whether dietetic or medicinal. Numberless instances have occurred, in the preceding part of this work, of men having recovered at sea from using the juice of this fruit alone, even under all the inconveniences of a sea diet. When the juice is intended to be kept for a length of time, it should be expressed and bottled, a small quantity of spirits being added to preserve it for if fire is used in preparing it, as in the form of a rob, I know for certain that its virtues will be thereby very much impaired. It is very difficult to say upon what principle these fruits act, for no sensible effects are produced by them except a small increase of some of the secretions.

It ought to be mentioned here as a fact of great consequence, though very little known, and never, I believe, published before, that the juice of limes and lemons is the best detergent of any external application that has yet been tried in scorbutic ulcers. Nothing was found so effectual in preventing these from spreading, and in disposing them to heal, as an emollient poultice with[120] lemon or lime juice sprinkled on its surface; or it was applied by soaking in it the lint with which the sore was dressed, and also as a lotion, in which case it was used diluted with two or three times its quantity of water; for if used pure, it was found too irritating, and was apt to bring on a fungous disposition. This precaution is particularly necessary with regard to limes, the juice of which is a much more concentrated acid than that of lemons. Mr. Lucas, surgeon of the Conqueror, favoured me with several valuable remarks in proof of this practice. A poultice was always found a good application in these cases, by its power of absorbing the acrimonious discharge, which would otherwise irritate the neighbouring parts. I have been informed by a navy surgeon, who served in the former war, that he has known the most obstinate ulcers cured by applying a paste of oatmeal and water, the surface of which was sprinkled with Goulard’s preparation of lead.

The fleet was furnished with essence of malt; but its powers were so inconsiderable, that some of the surgeons denied that it had any. In trials, however, that were made in an early state of the disease, it was found to have a sensible effect in checking and removing it. It was also found of evident use in the bad ulcers so apt to arise in scorbutic habits, and in this intention was superior to the Peruvian bark as an internal alterative. Indeed, in those ulcers that were truly scorbutic, the bark was found to be of very little use; and, next to what has been already mentioned, joined to the advantages of diet, opium was found of the greatest service in disposing these, as well as all other ill-conditioned sores of hot climates, to heal.

I have mentioned the scorbutic habit as distinguished from the scurvy, but there seems to be no difference except in degree; for a person may be laid to labour under the disease before it betrays itself by any obvious symptom, and it must have gathered a certain degree of force before visible symptoms are produced. The chief mark of this latent and incipient stage of the disease is that incurable state of ulcers that has been mentioned, whether they appear spontaneously or in consequence of slight accidents. There is another mark of this scorbutic habit which is not mentioned in any description of the disease I have ever seen. It is a soft, indolent tumour which arises under the skin on a part which has received a small blow, or contusion, so slight as not to break the skin. It most commonly appears about the elbow or fore-arm, and generally disappears without any inconvenience, what it contains being absorbed. A surgeon, who opened one of them, (a practice, however, not to be approved of) informed me that it consisted of fluid blood. We may also reckon a languor, or sense of weight, as one of those marks of scurvy which occur before the more obvious symptoms appear.

In this state of the disease, the articles of lesser powers, such as malt and melasses, may be of service by preventing its farther progress, or the appearance of actual symptoms, and by restoring the constitution.

In some of the early stages of this disease the effervescing mixture of acids with fixed alkali may probably also be of use. I never could perceive any sensible benefit in those cases in which I tried it, though some of the gentlemen of the fleet reported to me that they thought it of service.

There is no article of the _Materia Medica_ yet known that possesses any considerable power over this disease without the assistance of proper diet. With this assistance, however, it is found, that whatever tends to increase the fluid secretions, hastens very much the recovery of the scorbutic patient. I have observed a very striking instance of this in the effects of a spontaneous diarrhoea; for I have seen those hard livid swellings on the legs, that form one of the most constant symptoms of this disease, almost disappear, and the hams, from being contracted, become flexible in the course of twelve hours after the purging came on. I have endeavoured to imitate this with purgatives, but never with the same effects as the natural looseness. A free flow of urine is also found to promote the recovery, and vinegar of squills is one of the most effectual medicines in this intention. It is likewise of singular service to excite sweat; for an obstruction of perspiration seems to be one of the principal constituents of the disease. The goose skin, which is an early and constant symptom of this disease, seems to be owing to a constriction of the exhaling vessels. Dover’s powder has been employed with advantage as a sudorific, with decoction of the woods drank warm, and plentiful warm dilution. Camphor, combined with nitre, has been found one of the best remedies, and it acts both as a diaphoretic and diuretic.

Such external applications as relax the skin are found also to forward the cure. The contraction of the hams and the livid hardness of the calves of the legs are relieved by emollient cataplasms. Burying the legs in the earth, which has a sensible good effect, seems to act on the same principle, for it makes the parts sweat profusely.

There can be no doubt that in the scurvy there takes place in certain parts of the body a stagnation of the humours in the small vessels, particularly of the lower extremities, and that it is to this circumstance that the livid hardness of the fleshy parts of the legs is owing. The effect of medicine in removing this, must be to restore the action of those torpid vessels, so as to bring the stagnated fluids again into circulation[121] Purgatives seem to act upon it as they do in the dropsy, by exciting absorption. The irritation of the bowels and their increased secretion thus affecting the minute vessels in all parts of the body, is the result of that sympathy or balance established between every part of the system, in order to support the harmony and effect the purposes of the animal œconomy.

It has long appeared to me, that the scurvy is owing rather to a defect of nourishment than to a vitiated state of it. In fact, that sort of food which is supposed most commonly to induce the scurvy, is, in most cases, not putrid, but is in an unnatural and depraved state by being drained of its juices, which run off in brine; and perhaps some of the more subtile and nutritious parts are wasted by evaporation. It is not found that salt of itself has any effect in inducing the scurvy, and indeed it can be induced under a state of diet in which there is no salt, as we know from some instances quoted by Dr. Lind; and some cases are related by Dr. Monro and Dr. Milman, in the Medical Transactions, which are in proof of the same opinion. But the case most in point to prove that it depends on a defect of aliment, is that of Dr. Stark, who, by way of experiment on himself, reduced his diet to the least quantity he could subsist upon, and was thereupon affected with the symptoms of the sea scurvy. I have also known some symptoms of it arise in old people in consequence of long abstinence, owing to the want of appetite.

It would appear that the aliment we take in acts in two ways in increasing the vigour of the body. First, by assimilation, whereby it affords the matter of which the solids of the body are made, in order to carry on growth in youth; and to repair the waste of parts in adult age. A very small quantity of matter is necessary for these purposes; and as a proof of it, we see people supported equally well with very different quantities and qualities of food. Secondly, Food is necessary as a stimulus, either by a power it has of soothing the nerves of the stomach, and the other surfaces to which it is applied, or by its volume in distending the intestines and blood vessels. It is upon this principle that luxury renders the great quantities of food we take in necessary; and those species of food which satisfy most by their stimulus are by no means such as are the most nutritious. It is also upon this principle, that in cases of accidental hardship from want of food, or in barren and inclement countries where food is scarce, the body is supported, in some measure, by what contains little or no nutritious matter, such as pure water, or the bark of trees powdered and kneaded into a sort of bread, as we are told of the inhabitants of Lapland.

There are other familiar and well-established facts, which prove, that either from the influence of disease, from habits of life, or the nature of particular animals, life can go on for a length of time with little or no aliment. This is the case in fevers, in sea-sickness, in certain singular cases that have been recorded[122], in torpid animals, and in animals of cold blood. Though a man in health will die if deprived of food for a very few days, it does not follow that this is owing to the want of matter to repair the waste of the body. The craving for food, and the faintness from long abstinence, arise from the want of the accustomed stimulus, especially in those who are used to live well; and a person feels himself most refreshed by food and drink when newly taken in, and before it can be applied to the purpose of nutrition.

As there is a continual waste and decay, however, both of our fluids and solids, some degree of reparation is absolutely necessary, especially to animals of warm blood; and such _ingesta_ as would give the stimulus of food, without being possessed of any nutritious principle, would indeed continue life for a certain time; but disease would ensue. The provision used at sea answers, in a great measure, to this description; for unless the powers of digestion and assimilation are remarkably strong, salt beef and biscuit, which have been long kept, do not contain much more nourishment than saw-dust, or the bark of a tree, and the disease induced by this diet is the scurvy.

The nature and symptoms of the scurvy countenance this opinion: for as the means of renewing the animal matter of our bodies is withdrawn under this course of diet, nature, in consequence of an accommodating principle, observes a sort of frugality, and the animal œconomy adopts such measures as may be productive of the least possible waste and corruption of the fluids. Accordingly all the secretions become scanty; and, in particular, one of the first symptoms of this disease is a suppression of perspiration, as appears by the goose-skin that attends it. There is a paucity of urine. There is also a great languor in the circulation, which may be considered either as a means adopted by nature to prevent that vitiated and effete state of the fluids which a brisker action might induce; or it may happen from a want of that due supply of nourishment necessary to produce a vigorous action of all the functions.

We have a proof of this general languor not only from the great aversion to motion, and the great disposition to syncope, but from the inspection of the dead body, from which it appears that the whole circulating system, being more flaccid and less elastic, is subject to preternatural distention. The heart is accordingly found enlarged in bulk, the size of the cavities being increased; and in the extremities, where the circulation is naturally most languid, the small vessels carrying the colourless part of the blood, are so far enlarged as to admit the red part of it, as appears by the livid colour; and where this is the case, these vessels being unable to carry on the circulation, a stagnation ensues, as is evident in those livid appearances most common about the calves of the leg, which feel like a hard cake. I have examined those parts in the dead subject, and found a want of fluidity in the contents of the vessels, but could not discover any thing like _eechymosis_; from which I concluded that the colour was owing to an _error loci_, and the hardness to stagnation and coagulation of the fluids, and a want of action of the vessels.

The incurable state of ulcers, so common in this disease, is also what we might expect from the defect of fresh assimilated juices; for where a breach is made, either by nature or accident, in the solids, particularly of the extremities, the proper suppuration is prevented by the depraved state both of the fluids and vessels; and we cannot expect that renewal of solid parts in which healing consists, where both the instruments and materials of its formation are so defective.

I shall conclude what I have to say on this subject, by shortly considering whether or not this disease is ever contagious.

There is something in the nature and history of the scurvy that would lead us at once to pronounce that it is not infectious; for the external causes on which it depends are so obvious, and seem so adequate to account for its appearance and prevalence upon certain occasions, as at first sight to exclude every other external cause.

But it seems extremely unphilosophical to deny the reality or possibility of any thing in Nature, from our supposed knowledge of the means and causes she employs, particularly in a branch of science so obscure as the animal œconomy. Could we, therefore, prove the point as a matter of fact, it would be in vain to deny it, from our fancied acquaintance with Nature’s modes of operation.

The facts which give a suspicion of the scurvy being infectious are, 1st, What is related by Dr. Lind, that the sea scurvy spread at one time from the naval hospital to the people of the adjacent country. 2dly, There occurred several instances, in the first part of this work, of this disease prevailing to a much greater degree in some[123] particular ships than others, though upon the most accurate inquiry there was found no difference in the diet, or any other external or predisposing cause adequate to account for this. We can conceive, that those ships having accidentally a few men, whose constitutions were remarkably predisposed to this disease, might catch it earlier than in other ships, and communicate it to the rest of the crew.

The only practical inference that would lie from the establishment of this fact would be, that when the disease begins first to appear, the men affected should be separated from the rest; and this is a good practice, whether this opinion is true or not; for such men ought to be put in one mess, in order that they all may live upon the same antiscorbutic articles of diet, and that they may more easily be debarred from the use of their common provisions, of which this disease does not make them lose the relish.

CHAP. IV.

Of the WOUNDS received in the Actions of April, 1782.

Loss in the Battle and from Wounds--Fatality of the locked Jaw--Treatment of it--Some Ships more subject to it than others--Different from other Cases of Tetanus--It is not cured by the Removal of the Part--It may come on after the Part is cured--Effect of Climate in producing it--Accidents from the Wind of a Ball--Accidents from the Explosion of Gunpowder--Means of preventing them--General Observations on Sores and Wounds.

Though surgery was not properly in my department, yet, having had a fair opportunity of collecting facts concerning this branch of practice, I thought it my duty to pay some attention to it.

The whole number of men wounded in the actions of April, 1782, amounted to eight hundred and ten.

Of these, sixty died on board before the end of the month, five in the course of the following month, and two in June.

There were ninety-seven wounded men sent to the hospital at Port Royal, of whom there had died twenty-one when the fleet left Jamaica on the 17th of July.

So that the whole loss of men in the battles of April, and their consequences, is as follows:

Killed outright 266 Died of their wounds on board 67 Died of their wounds at the hospital 21 --- Total 354

Of those who died on board, fifteen[124] were carried off with the Symptoms of the locked jaw; but of those sent to the hospital, only one. The reason that so few in proportion were affected with it in the hospital may have been, that none of the wounded were landed till near the end of the third week after the principal action. The danger of this symptom was then, in a great measure, past, though I have known it to take place in every period from the second or third day till the fourth week.

Only three men in the whole fleet recovered from this alarming complaint; and as it is interesting to know every thing relating to so desperate a symptom, I shall give a short account of each.

The first was a seaman of the Montagu, who had his thigh wounded by a splinter which carried away part of the integuments and _membrana adiposa_, and lacerated in a small degree the _vastus externus_ muscle. The wound did extremely well till the 23d day, when the jaw became almost entirely fixed, and the whole muscles of the wounded side were thrown into frequent spasms. Mr. Young, the surgeon, who was always anxious and assiduous in his duty, consulted with me, and we had immediate recourse to the warm bath, which gave a degree of instantaneous relief, and was repeated twice a day for half an hour. He was sensibly better every time; in nine days was entirely free of the symptom, and continued afterwards to do well. The only other means taken for this man’s recovery, besides what were used with the other wounded men, were from three to five grains of opium, which he took every day, in divided doses.

The next was a seaman of thirty years of age, belonging to the Magnificent, who had the _humerus_ broken and shattered by a splinter which entered the deltoid muscle. Several large portions of bone were extracted, and the artery was laid bare on the inside. On the fifth day there came on a large ichorous discharge, with a low quick pulse and depressed spirits, and the jaws began to close, with pain and stricture on both sides about the articulation of the lower jaw. He had every day since the accident taken half an ounce of Peruvian bark, combined with opium or rhubarb, according as it made him loose or costive. This was continued, and the part externally was kept constantly moist all round with volatile liniment, to which a fourth part of _tinctura thebaica_ was added. Next day the jaw was almost entirely fixed, so that it was with difficulty that a little wine and water could be introduced with a spoon. Mr. Harris, the surgeon, now wisely determining to do something vigorous in this unpromising situation, beat up twelve ounces of opium moistened to the consistence of a cataplasm with the thebaic tincture, and applied one half to each side of the jaw. The patient this day swallowed a pint of the bark decoction with half an ounce of nitre, and took a diaphoretic draught of twenty drops of thebaic tincture and thirty of antimonial wine. He had also the smoke of tobacco thrown up his nostrils.

On the third day after the attack he could open his mouth half an inch. The cataplasms were taken off, beat up afresh with the tincture, and applied anew. The bark and other medicines were continued. On the fourth day the stricture and pain of the jaw went entirely off, but the cataplasm and volatile liniment were applied for three days longer. The wound produced a laudable discharge, every symptom became favourable, and he continued to recover.

The only other person who recovered from this symptom was a man in the Bedford. Several died of it on board of this ship; and as the same means of relief were skilfully employed in all the cases by Mr. Wickes, the surgeon, the success seemed owing more to something favourable in the man’s constitution, than any thing peculiar in the treatment, which consisted in the administration of the warm bath, opium and camphor, with mercurial friction on the jaw.

This accident affected some ships remarkably more than others, particularly the Barfleur and Bedford, though their wounds had nothing peculiar, nor were in a greater proportion than in the rest of the fleet. Four were carried off by it in each of these ships. It has formerly been observed, that great ships acquire peculiar habits, or dispositions, which incline the constitutions of the men to one disease more than another. This complaint took a run in some particular ships last year also after the battle of the Chesapeak; and I have known it prevail in some particular hospitals more than others. In the present instance, it may have been owing either to something peculiar in the constitution, or air of the ships; or we can conceive it to be owing to some sort of nervous sympathy, just as the _epilepsy_[125] has been known to spread from one boy to another, at a school, in consequence of imitation, dread, horror, or some such delicate nervous or mental affection. We have in yawning an example of a spasmodic affection spreading from one person to another. If this is the case in the locked jaw, those affected by it should be removed from the presence of the other wounded men, lest the idea of the sufferings of others should be so fixed in their mind, or so impress them with the fear of the like, as to invite the attack of the same complaint.

Though the locked jaw, in consequence of wounds, resembles frequently in its symptoms the tetanus which arises without any external accident, yet there are many cases of the former which differ materially from the violent symptoms of the other, as described by authors. In most cases of the locked jaw from wounds the spasms are not so general, so violent, nor attended with such exquisite pain. It sometimes happens that the convulsive twitchings are even accompanied with a sort of pleasure, as in the case of a lieutenant of the Montagu, whose case was related to me by Mr. Young, the surgeon of that ship, a man of skill and observation in his profession, and upon whose fidelity and accuracy I could perfectly rely. This officer had been wounded in the elbow at the battle of St. Christopher’s by a splinter, whereby the capsular ligament of the joint was injured. On the ninth day, symptoms of the locked jaw came on, and soon after the whole muscles of the wounded side were affected with frequent convulsive twitchings, which, as he himself said, afforded a pleasant sensation, exciting laughing like an agreeable titillation. He died on the fourth day after it came on, and had no pain to the last.

The locked jaw from accident differs also from other cases of tetanus, in respect to its cure; for the latter has been successfully treated by cold bathing, as is related by Dr Wright[126] and Dr. Cochrane[127]; but it is acknowledged by the latter that this treatment did not answer when the complaint proceeded from a wound.

It is to be remarked, that the locked jaw did not take place in those cases in which the wounds had a foul and gangrenous appearance more than others; for those that digested and cicatrized favourably, were equally apt to be affected by it; and though amputations are most liable to this symptom, the slightest injuries, even a scratch, will sometimes bring it on.

It would be difficult, therefore, to establish any particular treatment that would tend to prevent accidents of this kind; but Mr. Bassan, surgeon of the Arrogant, one of the line-of-battle ships engaged on the 12th of April, mixed laudanum with the dressings of all the wounds, and no locked jaw occurred.

In the Bedford there occurred a curious circumstance concerning this complaint. In one of the cases that proved fatal, the symptoms did not come on till the wound was so far healed that all dressing had been laid aside.

Mr. Wood, surgeon of the hospital at Jamaica, informed me, that in cases of the locked jaw from injuries to small members, such as fingers, he had tried the effect of amputating the part after the symptoms had come on, but without any effect in putting a stop to them.

Would it not appear, from the two last mentioned facts, that this symptom is not kept up, nor even takes place in the first instance, from an immediate present irritation, but that the constitution comes to be so modified, or receives such an impulse, as it were, that the complaint runs its course independent of the presence of that _stimulus_ which excites it?

It would be difficult to assign a satisfactory reason why this accident is more frequent in hot than in cold climates. The effect of external heat upon the living body is not to raise its temperature even when the heat of the air exceeds that of the body[128]; so that we are to seek for the effects of it in some of those affections peculiar to animal life. And as the outward temperature of the air does not affect the general mass of the body, all the effects produced by it must depend on impressions made on the external surface of the body and lungs; and the skin, which may be considered as a large expanded tissue of nervous fibres endowed with universal sympathy and great sensibility, affects every organ and every function of the body, according to the state of the air in contact with it, whether cold or hot, moist or dry, pure or vitiated. This sympathetic sensibility of the skin is chiefly affected by the state of the perspiring pores on its surface; for it is only when these are open that the impression of the air on the skin produces catarrhs, rheumatisms, and internal inflammations in cold climates; and the external temperature in hot climates being such as to keep the pores almost always open, this seems to be a principal reason of that universal irritability prevailing there, and of the general sympathy that prevails between every part, particularly as connected with the organs of perspiration[129]. This readiness of one part to be affected by another in hot climates is well illustrated by the sudden translation of certain diseases. I have seen, for instance, a catarrh cease, and be converted, as it were, into a diarrhœa, and this as quickly disappearing, a pain in the foot would arise, like an attack of the gout. All this would happen in the space of a few hours.

But, in cold climates, wounds are by no means exempt from the locked jaw; for it sometimes occurs in England, where I have seen it even in the winter season[130].

Since my return to England I have received some new and useful information on this subject in conversing with Dr. Warren, physician to the King; and as any observations derived from so much acknowledged skill and sagacity must be valuable, I shall here relate what he was so kind as to communicate to me.

This eminent physician, in attending a case in which he was nearly interested, and in which his endeavours were rewarded with success, found the greatest benefit from opium and the warm bath. The opium was given in the form of tincture, in moderate, but pretty frequent, doses. The bath was composed of milk and water, and the addition of milk was, no doubt, an improvement; for there is something in this as well as oil extremely soothing to the human nerves. Dr. Warren had intended to make trial of a bath of oil in case this had failed. He mentioned the following observation, with regard to the external application of oil, which could only have been suggested by that anxious attention that was paid to the case. It was found, that the uneasiness arising from the spasm was allayed by constantly drawing a feather wetted with oil over the temples, which had an evident effect in lulling the pain and spasm; for when this operation was left off, there was an immediate recurrence of these symptoms[131].

It would appear, therefore, from this as well as the former cases, that opium and the warm bath are the only remedies yet known which are of service in this complaint, and much will depend on the judicious management of them. The method of administering the opium, recommended by Dr. Warren, seems to be the most judicious, especially in constitutions not habituated to this medicine.

There is a certain medium in giving opium, by which its best effects are obtained, for in an under dose it will produce disturbance instead of rest; and when it is given in large quantities it frequently defeats the very end for which it is given, by throwing the body into convulsions which terminate in death. The rule for judging of the proper limits of this dose is, by its effect in inducing that stupor or insensibility which renders the senses incapable of irritation; for in this, as well as in every other case of disease, the cure seems ultimately to be the work of nature, the effect of medicine being only a secondary operation, by which it removes some obstacle to the natural efforts of the constitution. Though a dose of opium greater than ordinary is required to produce this insensibility in cases of spasm, and though the constitution in that situation will bear more, yet even here it may be given to excess; and by beginning with small quantities, and giving it in frequent rather than large doses, the constitution will thereby be better reconciled to it, and it will also with more convenience admit of that gradual increase which is peculiarly necessary with this medicine. These ideas were suggested to me by Dr. Warren; and it may be farther added, in recommendation of his method, that the liquid form is preferable to the solid, as the effects of it will sooner be seen, and a better judgement can be formed how far it is proper to push it.

Great attention is also necessary in regulating the heat of the bath; for if it is not sufficiently warm, it will not have the effect of producing a due relaxation; and if it should be too hot, it will stimulate too much, and will have the farther inconvenience of making the patient very faint in a short time. It cannot be well regulated without a thermometer, and 93° upon Fahrenheit’s scale is perhaps the best temperature. I have kept a patient in a bath of that heat for six hours, which he could not have endured for half an hour had the heat been three or four degrees higher.

The circumstance next in consequence, in the cure of this complaint, is the keeping up a moisture on the skin, and guarding the surface of the body from the access of the air. This is particularly necessary with regard to the part itself, which should be constantly enveloped in warm, anodyne, and emollient applications. The good effects of this is particularly exemplified in the case which recovered under the care of Mr. Harris, who gave the diaphoretic medicine, composed of antimonial wine and laudanum, and applied the anodyne cataplasm to the external _fauces_. It was remarked, that the locked jaw was most incident to those wounded men who lay in parts of the hospital where they were exposed to a current of air; and the cases of tetanus that most usually occur in the West Indies, independent of wounds, are those of slaves who fall asleep in the night-time in the open air.

Since the first edition of this work, there has appeared an Essay on the Locked Jaw by Dr. Rush, physician to the American army in the late war, in which he recommends, from his own observation, Peruvian bark, wine, and blisters, and to dress the wounds with mercurial ointment, in the cure of this complaint. From some trials I have since made of the bark in St. Thomas’s hospital, I have reason to think well of it as a remedy in this disease.

There is a singular species of accident to which engagements at sea are liable, the WIND OF A BALL, as it is called. If a cannon ball in its flight passes close to any part of the body, it renders it livid and numb for some time[132]. It is most dangerous when it approaches the stomach; and there was an instance of a man in the last battle, who, upon a ball passing close to his stomach, dropped down dead instantaneously, without the least visible marks of injury. Another, in consequence of a ball passing close to his belly, remained without sense or motion for some time, and a large livid tumor arose on the part, but he recovered. I attended a man at the hospital at Barbadoes, who had the buttons of his trowsers carried off by a cannon ball, without its having touched the body. The _pubis_ was livid and swelled for some time after: he suffered exquisite pain from strangury, which seemed to proceed from a _paralysis_ of the bladder, for he voided no water without a catheter for near three months, after which time he recovered. I know a brave young officer[133] in the army, who had his epaulette carried off by a cannon ball at Charlestown, in consequence of which the shoulder and adjacent parts of the neck were affected for some time. A like accident happened to a marine officer in one of the late engagements; but in neither of these was the head materially affected, nor is it so apt to be affected in this way as the stomach. I never knew death the consequence of the wind of a ball on the head; though an officer[134] in the Sultan, at the battle of Grenada, was so stunned by a shot passing near his temple, as to be insensible for some time, but he recovered entirely in a few hours[135].

The class of wounds most peculiar to a sea engagement are scorches from the accidental explosion of gunpowder; and in most of the campaigns in which I have served they have been very frequent and fatal. Few accidents, however, of this kind happened in the late engagements; so that we had but little experience of this sort of wounds in April, 1782. But on former occasions they were very frequent, and the best application to the burnt parts was found to be linseed oil, which some of the surgeons mixed with lime water, others with cerusse, and both compositions answered well. Opium was found of great use in alleviating pain and procuring rest, care being taken to guard against costiveness by the use of clysters. In the battles of 1780 and 1781, one-fourth part of the whole killed and wounded was from this sort of accident; but on the 9th and 12th of April, 1782, only two accidental explosions of gunpowder happened in the whole fleet, by one of which one life was lost, by the other, two. This difference was owing partly to greater experience and habits of caution acquired in the course of the war, and partly to certain improved methods in working the artillery introduced by Sir Charles Douglas, which, like all his other valuable improvements, tend to give facility and expedition, as well as to save the lives of men. The circumstances which tend to prevent explosions are, 1st, The wetting of the wads, which prevents their inflaming and blowing back when they fight the weather side of the ship; a circumstance which, without this precaution, gives occasion to a number of accidents by the burning parts catching the loose powder, or setting fire to the cartridges. 2dly, The use of goose-quill tubes and small priming boxes, made of tin, instead of the large horns formerly in use, whereby great quantities of powder were scattered about and exposed to accidental fire. 3dly, The use of locks, which was practised with great success in several ships, and was found to make the operation both more safe and more expeditious.

It frequently happens that men bleed to death before assistance can be procured, or lose so much blood as not to be able to go through an operation. In order to prevent this, it has been proposed, and on some occasions practised, to make each man carry about him a garter, or piece of rope-yarn, in order to bind up a limb in case of profuse bleeding. If it should be objected, that this, from its solemnity, may be apt to intimidate common men, officers at least should make use of some such precaution, especially as many of them, and those of the highest rank, are stationed on the quarter deck, which is one of the most exposed situations, and far removed from the cockpit, where the surgeon and his assistants are placed. This was the cause of the death of Captain Bayne, of the Alfred, who, having had his knee so shattered with a round shot, that it was necessary to amputate the limb, expired under the operation, in consequence of the weakness induced by loss of blood in carrying him so far. As the Admiral, on these occasions, allowed me the honour of being at his side, I carried in my pocket several tourniquets of a simple construction, in case accidents to any person on the quarter deck should have required their use.

It sometimes happens, however, that no hæmorrhage arises from a limb being carried off by a ball. The surgeon of the Fame related to me an instance of this, in which the thigh was cut through by a shot near its upper part, all except a little flesh and skin, and yet not the least hæmorrhage followed. This may have been owing to the limb being entirely severed, or nearly so, whereby the vessels contracted more easily than if they had been partially divided. All that was done for this man was to remove the limb, and to saw off the jagged end of the bone. He survived six days, still without bleeding, and died of the locked jaw.

I was informed by several of the surgeons, that the method of taking up the vessels by the _tenaculum_ was found to answer extremely well; and many of them imagined that the locked jaw was not so apt to be brought on by this mode of operation as by that of the needle. But it is hardly to be attempted in time of action, for want of steadiness and a good light, and it was chiefly at the hospitals that this practice was found so successful.

Mr. Alanson’s method of amputation by a great retraction of the muscles, so that the fleshy parts shall meet over the bone and unite in the first intention, was attended with great success in the West Indies, particularly at the hospital at St. Lucia, under the care of Mr. Bulcock.

It may be remarked, that though all sores and wounds in the foot and leg are difficult of cure in a hot climate, I have observed, that, where the constitution is good, those in the thighs, arms, trunk, and head, are rather more easy of cure than in Europe, and that parts divided by incision very readily unite by the first intention. In reasoning upon this, it may be said, that as healing depends on a certain degree of vigour in the powers of life, this should not err either on the side of excess or defect. If it is too great, as in the case of a hale, plethoric constitution in a cold climate, too much inflammation is apt to be excited; and if too feeble, as happens in a hot climate, in the lower extremities, which are far removed from the source of life and circulation, the salutary effort is not strong enough to generate new organised parts. But in the trunk of the body, in such a climate, the powers of the animal œconomy are in that just medium which is most favourable to this operation of nature.

THE END.

APPENDIX

TO