Kitabı oku: «Observations on the Diseases of Seamen», sayfa 14

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 matelot⁹⁹, considering it as peculiarly incident to those who have newly arrived from a long voyage. It would appear also, from what has been formerly mentioned¹⁰⁰ 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 stools¹⁰¹ 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. 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 author¹⁰³, 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-letting¹⁰⁴.

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 as¹⁰⁵ 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 bark¹⁰⁶.

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.