Observations on the Diseases of Seamen

He makes the following computation of the additional expence for each man in some of the articles that have been mentioned:

84

See Part I.

85

Had I then known the salutary effects of porter and spruce beer, of which I have since been convinced, I should have proposed them as substitutes for rum.

86

The authenticity of this fact, as well as every other assertion in this work relating to the mortality in the fleet, may be proved from the ship’s books, deposited at the Navy Office.

87

I fancied that my reasoning on this subject was in a great measure new; but I lately met with the following passages in Celsus and Hippocrates, which seem to be illustrative of the same idea: – Quibus causa doloris, neque sensus ejus est, his mens laborat. Celsus, Lib. ii. cap. vii. which is nearly a translation of the following aphorism of Hippocrates: – [Greek hOkosoi poneontes ti tou sômatos, ta polla tôn ponôn ouk a sthanontai, touteoisin hê gnômê noseei]. Hippoc. Aphor. Lib. ii. Aphor. 6.

The same principle is ingeniously explained by Mr. Hunter in his Lectures.

88

See page 181 (#Page_181).

89

See pages 125 and 126 (#Page_125).

90

The form of administering this medicine was to add twenty drops of thebaic tincture, from half a grain to a grain of emetic tartar, and from five to ten grains of nitre, to two ounces of water or camphorated julep, of which one half was given about two hours before the common hour of rest, and the remainder at that hour. If spiritus Mindereri is preferred to the nitre, it may be given from two drachms to half an ounce for a dose, and it is better to administer it separately; for if it should not be exactly neutralized, it may decompose the antimonial, and render it inactive.

91

Since the publication of the first edition of this work, there has appeared a small tract on the treatment of low fevers, by Dr. Wall, of Oxford, and as his ingenuity and learning give him a just claim to the high rank he holds in his profession, attention is due to what he advances. The principal scope of the work is to recommend, from his own observation, the early use of opiates in those fevers, and the Doctor’s authority, as well as my own experience, convince me of the propriety of this practice in many cases occurring in this country, particularly among the lower sort of people, for whom spare diet and hard labour render evacuations less necessary than among the better sort. The inferior class of people are also more subject to this sort of fever from their houses and persons being less clean, and their apartments being worse ventilated; so that practice in these, as well as other cases, is to be varied according to the constitution and previous habits of life.

92

I first learned this, as well as many other useful and practical facts, from Mr. Farquhar, Surgeon in London, who has laid me under the greatest obligations by communicating many of his observations, derived from the most extensive experience and a truly penetrating sagacity.

93

I owe this piece of instruction, as well as many others, to Dr. Cullen’s Lectures.

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In a review of Haslar hospital made in person by that excellent officer, Vice-admiral Barrington, in 1780, it was very judiciously proposed, among other salutary improvements, that there should be two apartments for the reception of the sick upon their first landing; one wherein they should be stripped of their dirty clothes, and another in which they should go into the warm bath, and put on the hospital dress, that they might not carry infection into the wards.

95

The following is the form of it, and it was first introduced by Mr. Whitfield, apothecary to the hospital, under the name of Bolus Sedativus: – ℞. Confection. Damorat. [dram]ss. Castor. Russic. pulv. [scruple]ss. Tinct. Thebaic. gtt. iv. Syr. sim. q.s. Fiat bolus sexta quaque hora sumendus.

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Great nicety is required in all cases with regard to the times and doses of cordials; for it by no means follows that these should be in proportion to the lowness and loss of strength. This is well illustrated by Mr. Hunter in his Lectures, where he explains the distinction between the powers of the body and its actions. There must be a certain degree of strength to bear the excitement occasioned by stimulating and strengthening medicines or diet; for nothing is more pernicious, or even fatal, than that any part or function should make exertions beyond its strength; and there is the more danger in ill-timed remedies of this kind, as a state of weakness is generally a state of irritability.

97

See a method proposed for obviating this, page 358 (#Page_358).

98

Page 381 (#Page_381) et seq.

99

Sailor’s fever.

100

See pages 161 (#Page_161), 181 (#Page_181), and 380-1 (#Page_380).

101

I have in the whole of this work been extremely cautious in reasoning concerning causes, from an opinion that they are very obscure, and that the theoretical part of physic is very imperfect and fallacious. This is perhaps in no instance more remarkable than in those opinions that prevail concerning the nature and influence of bile in producing diseases. An increased secretion of bile commonly attends the feverish complaints of hot climates, and those of the hot seasons of temperate and cold climates. It is not unnatural, therefore, to impute the disease then prevailing to this redundancy of bile: but, upon considering the matter more closely, it will appear to be rather a concomitant symptom, or effect, than a cause of those fevers; for, in the first place, in those cases in which there is the greatest secretion of bile, as in the cholera morbus, there is no fever. The only danger in this disease arises from the violent irritation produced in the bowels by such an extraordinary quantity of this secretion which commonly passes downwards; though I have seen it prove fatal when it flowed into the stomach, and produced perpetual retching and excoriation of the fauces; but in this case also without any fever. Secondly, in the most fatal of all fevers, in the West Indies, there are no marks of an increased secretion of bile, but, on the contrary, a preternatural defect of it, as appears by its not being evacuated either by stool or vomiting, by the white stools which sometimes attend the yellow fever, and by its not appearing in the first passages, nor in its own receptacles after death. Perhaps also that state of the bowels which renders it so difficult to procure stools may be in part owing to the want of this natural stimulus. It is nevertheless true, that in the intermitting and remitting fevers of hot climates and seasons there is perhaps always an accumulation of bile at the beginning, and an increased secretion of it during their course. It is farther true, that this adds to the patient’s uneasiness, and aggravates the symptoms, and that the cure consists partly in the evacuation of the bile. But it is also true, that in the very worst sort of fevers in hot climates it is a favourable symptom where the secretion of the liver is restored and increased, a bilious diarrhœa being one of the most auspicious symptoms that can occur in a yellow fever; and in those that are protracted and afford hopes of recovery, there is generally a gush of bile from time to time. – We may therefore lay down the following positions: 1. That in cases in which bile is most freely and copiously secreted no fever exists, as in cholera morbus. 2. That in the worst sort of fevers there is no preternatural secretion of bile, but, on the contrary, a defect of it. 3. That nevertheless there is an uncommon quantity of bile secreted in most of the fevers of hot climates, and that part of the cure consists in evacuating it.

I am extremely diffident, as I have said, in all matters depending on our supposed knowledge of the animal œconomy; but the preceding circumstances seem to countenance the following reasoning: – The bile, according to Dr. Maclurg, who has given one of the best dissertations on its nature and properties, is composed of two parts; the gross part, which is coagulable by acids, and that part in which the bitter principle resides. The first constitutes the principal part in point of quantity, and seems to be that portion of the mass of fluids which loses the property of sound healthy blood, by a tendency to putrefaction, and is thrown out by this secretion. I will not undertake to vouch for the truth of this, but shall assume it as true in the following reasoning: – According to this theory, therefore, the greater part of the bile is what may be called the effete part of the circulating mass, or perhaps only of the red globules or gluten, the watery and saline part, which passes off by urine being the corrupted part of the serum. This part of the bile being very liable to putrefaction, the bitter part is considered by Dr. Maclurg as intended to correct this, and also to answer some good purpose in digestion. One of the effects of the bile in this operation is to extinguish acidity, whether proceeding from substances taken in, or generated in the stomach. The blood in all climates, and in all situations of life, is subject to have part of it thus corrupted, which, being separated from the common mass by the liver, is mingled and discharged with the common feces; but external heat continued for any length of time tends to augment this corruption of the fluids, and therefore to increase the secretion of bile; and it has been observed both by myself and others, that the bile found in those bodies that have been inspected after death, in consequence of fevers in hot climates, is less bitter, and not so penetrating to the fingers, being therefore deficient in the antiseptic principle. But since external heat makes no alteration in the degree of temperature of the fluids themselves, this effect must take place through the medium of the solids, in consequence of that general languor and want of energy which too much external heat induces in the functions, particularly in that power by which the living body preserves itself from putrefaction. Now if this portion of the blood, thus altered and depraved, is readily secreted and speedily thrown out, as in cholera morbus, no harm befals the constitution, nor any inconvenience but what arises from the irritation of the primæ viæ. But this may not take place if the body should be otherwise deranged; for the removal of this noxious matter from the mass of blood depends upon a due irritability of the blood vessels, the liver, and the bowels, whereby they are stimulated to contract, and thereby expel it. According to the principle of Mr. John Hunter, (whose deep and industrious researches into the animal œconomy place him high in the list of those few on whom nature has bestowed real genius, and who are capable of adding something new to the stock of human knowledge,) there is in a state of health a relative habitude or mutual harmony existing between the solids and fluids, whereby they stimulate and produce actions in each other, in which the healthy state of the functions consists, whether employed in the formation of what is found, or the expulsion of what is noxious: so that where it happens that the solids have a morbid insensibility to the impressions of corrupted and acrimonious fluids, the retention of these adds still more to the general derangement. To illustrate this, it may be observed, that the stomach and bowels, when they are endowed, as it were, with their natural perception, immediately expel any preternatural accumulations of bile that may take place; but when they are insensible to this stimulus through disease, no effort is made to relieve nature till it is excited by medicine. The same reasoning may be applied to the various vessels and ducts. Thus when we see the liver gorged with bile, without any free excretion of it into the gall bladder, as I have sometimes found to be the case upon inspecting the body in some of the worst cases of fever, would it not appear that the gall ducts have lost that natural irritability whereby the bile is expelled? Or, in consequence of a depraved state of action, connected with febrile affection, may it not happen that the absorbents, which, in their natural state, only absorb particular substances, and in a given quantity, will suffer a change in this natural action, and absorb whatever happens to be applied to their orifices? In case of jaundice, the bile, which is perhaps not at all absorbed in a state of health, is taken up in large quantities, and mingled with the mass of blood, which proves a seasonable relief in the state of accumulation and distension occasioned by the obstruction. This may happen in cases of fever, not indeed as a relief to nature, but from a depraved state of irritability in the lymphatics, induced by disease. Though no increased quantity of bile, therefore, is found in the gall bladder, there may have been an increased excretion of it, a preternatural absorption having been excited. So that it may admit of a question whether the colour of the skin, in the yellow fever, is owing to this, or if the idea of it given in the text[159 - See page 437-8 (#Page_437).] is more just; but in either case it seems probable that the extreme tendency to putrefaction in the whole body is owing either to the presence of bile, in consequence of absorption, or the retention of something in the blood from a defect of its secretion.

This reasoning concerning the bile in hot climates may, in some sort, be illustrated by what happens to the urine in cold climates. The urine is the vehicle of an excrementitious part of the blood, of which an increased proportion is generated in certain fevers, and if it is thrown out in the form of high-coloured, turbid urine, the fever will most probably be slight and short; but if it becomes pellucid, or crude, as it is called, the general derangement will be increased, the fever will be more violent and dangerous, and the first sign of returning health will be a turbid appearance and sediment.

If the reasoning in the above discussion should appear to some readers unsatisfactory, or ill connected, I can only say that if it is deserving of this character, I am willing to have it considered not only as an illustration, but an example of the nicety and fallacy of theoretical disquisitions.

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.

103

M. Desportes, who wrote a treatise on the diseases of St. Domingo.

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.

105

See the same observation in Mr. Hume’s Essay on this Disease, published by Dr. Donald Monro.

106