Observations on the Diseases of Seamen

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[102 - I have been very cautious of admitting any theory into this work; but I cannot help adopting the doctrine of my much-valued master, Dr. Cullen, on this point, viz. that a great part of the symptoms of fever arise from reaction, or that effort which nature makes to overcome the morbid cause. I am happy in any opportunity of acknowledging my obligations to this learned professor, to whom the medical world in general is so much indebted, as well for the rational views of the animal œconomy, which he teaches, as for that spirit of study and inquiry which he infuses into the minds of his pupils.]. 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[103 - M. Desportes, who wrote a treatise on the diseases of St. Domingo.], 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[104 - There is a difference in the appearance of the blood when sizy, perhaps not sufficiently insisted on by practical writers; for though there should even be a very thick buff, yet, if the surface is flat, and the crassamentum tender, no great inflammation is indicated, in comparison of that state of the blood wherein the surface is cupped, the crassamentum contracted so as to afford the appearance of a large portion of serum, and where it feels firm and tenacious, though perhaps but thinly covered with buff. This is a distinction well worth attending to in practice; for it is in these last circumstances that blood-letting gives most relief, and where the patient will bear the repetition of it with most advantage.].

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[105 - See the same observation in Mr. Hume’s Essay on this Disease, published by Dr. Donald Monro.] 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[106 - The state of the stomach is very much affected by that of the external surface of the body; and it is sagaciously observed by Sydenham, that the stomach being commonly very irritable in the plague, the most effectual means of making it retain what was administered internally was to excite a sweat.].

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[107 - The red bark was brought to England in a Spanish prize in the year 1781, and a very accurate account of its medical and chemical properties was published the year after by Dr. William Saunders, of Guy’s hospital. None of it had been brought to the West Indies before the peace, so that I had no opportunity of trying it in that climate.].

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[108 - Mr. Telford related to me, that he had cured several intermittents that had baffled the bark, by means of white vitriol, whilst he was surgeon of the Yarmouth in 1779. He gave it in doses of five grains every four hours in the intermission, and was successful in every case except two, in which the patients were far advanced in the dropsy.He met with several cases of the same kind in the Alcide, in 1782, in which he was successful with the flowers of zinc, after having given large quantities of bark to no purpose. He preferred, however, the white vitriol, as being milder in its operation, and less apt to disagree with the patient’s stomach.He did not employ either of them in the recent state of the disease, nor does he assert that they are universal or infallible remedies; but only alledges, that he has experienced the most evident good effects from them in an advanced stage of the disease, and a reduced state of the patient, where the common remedy had failed.] 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[109 - Dr. Huck Saunders, whose recent loss the world has reason to regret on account of his experience and sagacity as a physician, as well as his virtues as a man, communicated to me, in conversation, some observations on the cure of obstinate intermittents, which deserve to be mentioned here. When he was physician to the army at the Havannah he cured a number of agues which had resisted the bark, by giving two ounces of the vinous tincture of rhubarb and six drams of the tincture of sena seven or eight hours before the fit. This being repeated two or three times, carried off the disease. He also informed me, that he had met with agues in England which did not yield to the bark; but, upon leaving it off, and putting the patients on a course of mercury, they were cured upon returning to the use of the bark.Arsenic has also been found to be an effectual remedy in intermittent fevers. I was informed by Dr. Huck Saunders, that when he was in North America, in the war before the last, there was an expedition undertaken against the Cherokee Indians, whose country is extremely subject to agues; and as an adequate quantity of bark would have been very cumbersome where light service was necessary, Mr. Russel, who had the medical management of the expedition, provided a great number of pills, containing each one eighth part of a grain of arsenic, by the proper use of which he was enabled to cure the intermittent fevers with which the troops were seized.I shall here mention another unusual remedy in intermitting fevers; and though I can bring only one instance in proof of its efficacy, yet this is so strong as to make it deserve farther trial. A man, on board of the Sandwich, had an obstinate intermittent which had resisted the bark, and was stopped by applying to the stomach a plaster, composed of gum plaster, epispastic plaster, and opium, in proportions which I do not now recollect.].

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[110 - Sir John Pringle on the Diseases of the Army.].