Kitabı oku: «Observations on the Diseases of Seamen», sayfa 17

CHAP. IV.
Of the Wounds received in the Actions of April, 1782

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

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

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

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

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

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

Of those who died on board, fifteen¹²¹ were carried off with the Symptoms of the locked jaw; but of those sent to the hospital, only one. The reason that so few in proportion were affected with it in the hospital may have been, that none of the wounded were landed till near the end of the third week after the principal action. The danger of this symptom was then, in a great measure, past, though I have known it to take place in every period from the second or third day till the fourth week.

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

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

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

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

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

This accident affected some ships remarkably more than others, particularly the Barfleur and Bedford, though their wounds had nothing peculiar, nor were in a greater proportion than in the rest of the fleet. Four were carried off by it in each of these ships. It has formerly been observed, that great ships acquire peculiar habits, or dispositions, which incline the constitutions of the men to one disease more than another. This complaint took a run in some particular ships last year also after the battle of the Chesapeak; and I have known it prevail in some particular hospitals more than others. In the present instance, it may have been owing either to something peculiar in the constitution, or air of the ships; or we can conceive it to be owing to some sort of nervous sympathy, just as the epilepsy¹²² has been known to spread from one boy to another, at a school, in consequence of imitation, dread, horror, or some such delicate nervous or mental affection. We have in yawning an example of a spasmodic affection spreading from one person to another. If this is the case in the locked jaw, those affected by it should be removed from the presence of the other wounded men, lest the idea of the sufferings of others should be so fixed in their mind, or so impress them with the fear of the like, as to invite the attack of the same complaint.

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

The locked jaw from accident differs also from other cases of tetanus, in respect to its cure; for the latter has been successfully treated by cold bathing, as is related by Dr Wright¹²³ and Dr. Cochrane¹²⁴; but it is acknowledged by the latter that this treatment did not answer when the complaint proceeded from a wound.

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

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

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

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

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

It would be difficult to assign a satisfactory reason why this accident is more frequent in hot than in cold climates. The effect of external heat upon the living body is not to raise its temperature even when the heat of the air exceeds that of the body¹²⁵; so that we are to seek for the effects of it in some of those affections peculiar to animal life. And as the outward temperature of the air does not affect the general mass of the body, all the effects produced by it must depend on impressions made on the external surface of the body and lungs; and the skin, which may be considered as a large expanded tissue of nervous fibres endowed with universal sympathy and great sensibility, affects every organ and every function of the body, according to the state of the air in contact with it, whether cold or hot, moist or dry, pure or vitiated. This sympathetic sensibility of the skin is chiefly affected by the state of the perspiring pores on its surface; for it is only when these are open that the impression of the air on the skin produces catarrhs, rheumatisms, and internal inflammations in cold climates; and the external temperature in hot climates being such as to keep the pores almost always open, this seems to be a principal reason of that universal irritability prevailing there, and of the general sympathy that prevails between every part, particularly as connected with the organs of perspiration¹²⁶. This readiness of one part to be affected by another in hot climates is well illustrated by the sudden translation of certain diseases. I have seen, for instance, a catarrh cease, and be converted, as it were, into a diarrhœa, and this as quickly disappearing, a pain in the foot would arise, like an attack of the gout. All this would happen in the space of a few hours.

But, in cold climates, wounds are by no means exempt from the locked jaw; for it sometimes occurs in England, where I have seen it even in the winter season¹²⁷.

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

This eminent physician, in attending a case in which he was nearly interested, and in which his endeavours were rewarded with success, found the greatest benefit from opium and the warm bath. The opium was given in the form of tincture, in moderate, but pretty frequent, doses. The bath was composed of milk and water, and the addition of milk was, no doubt, an improvement; for there is something in this as well as oil extremely soothing to the human nerves. Dr. Warren had intended to make trial of a bath of oil in case this had failed. He mentioned the following observation, with regard to the external application of oil, which could only have been suggested by that anxious attention that was paid to the case. It was found, that the uneasiness arising from the spasm was allayed by constantly drawing a feather wetted with oil over the temples, which had an evident effect in lulling the pain and spasm; for when this operation was left off, there was an immediate recurrence of these symptoms¹²⁸.

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

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

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

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

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

There is a singular species of accident to which engagements at sea are liable, the WIND OF A BALL, as it is called. If a cannon ball in its flight passes close to any part of the body, it renders it livid and numb for some time¹²⁹. It is most dangerous when it approaches the stomach; and there was an instance of a man in the last battle, who, upon a ball passing close to his stomach, dropped down dead instantaneously, without the least visible marks of injury. Another, in consequence of a ball passing close to his belly, remained without sense or motion for some time, and a large livid tumor arose on the part, but he recovered. I attended a man at the hospital at Barbadoes, who had the buttons of his trowsers carried off by a cannon ball, without its having touched the body. The pubis was livid and swelled for some time after: he suffered exquisite pain from strangury, which seemed to proceed from a paralysis of the bladder, for he voided no water without a catheter for near three months, after which time he recovered. I know a brave young officer¹³⁰ in the army, who had his epaulette carried off by a cannon ball at Charlestown, in consequence of which the shoulder and adjacent parts of the neck were affected for some time. A like accident happened to a marine officer in one of the late engagements; but in neither of these was the head materially affected, nor is it so apt to be affected in this way as the stomach. I never knew death the consequence of the wind of a ball on the head; though an officer¹³¹ in the Sultan, at the battle of Grenada, was so stunned by a shot passing near his temple, as to be insensible for some time, but he recovered entirely in a few hours¹³².

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

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

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

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

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

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

THE END.