Kitabı oku: «Observations on the Diseases of Seamen», sayfa 12

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 death⁸⁷. 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 malignancy⁸⁸.

Thirdly, It happened in some ships⁸⁹ 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 Mindereri⁹⁰. I tried pure opiates in the early stage of this, fever, but found them not to answer; though in the low⁹¹ 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 poppies⁹². 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 stupes⁹³. 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 ⁹⁴warm 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.