Chapter XV: Part III: Description and Treatment (1)

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 death[89]. 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 malignancy[90].

Thirdly, It happened in some ships[91] 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 Mindereri_[92]. I tried pure opiates in the early stage of this, fever, but found them not to answer; though in the low[93] 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 poppies[94]. 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 stupes[95]. 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 [96]warm 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.

It is an important question to what circumstances of this fever the Peruvian bark is adapted. An early and indiscriminate use of it is recommended in some late publications, upon the authority of which I tried it without regard to the stages or symptoms, and without any prejudice either for or against the practice; but I found that this powerful remedy was in danger of doing much harm, unless great attention was paid to circumstances, in order to ascertain the proper seasons for giving it. The symptoms that forbid the use of bark are chiefly foul bowels, hard pulse, sizy blood, great delirium, dry tongue, a hot and dry skin, and inflammatory affections of the viscera. It was found extremely pernicious in an early stage of the disease previous to evacuations; and the object of practice at this time should be to relieve the habit by means of these, in order to produce a general relaxation of the secretions, and to render the skin cool and soft, thereby paving the way for the bark.

It is not necessary, however, especially in the advanced stages of the disease in this climate, to wait for an absolute remission, in order to administer the bark. In a cold or temperate climate it will seldom be found advisable to give it in any period of this fever; but in a hot climate it is sometimes admissible where there are symptoms of general debility, such as a small pulse and muscular weakness, even though the frequency of the pulse, delirium, and a dry skin and tongue, should indicate some degree of fever. It may be remarked, by the bye, that a dry tongue is a fallacious symptom, for it may happen in consequence of the patient’s breathing through the mouth instead of the nose, without any fault in the secretions of the _fauces_. The symptom which forbids the use of the bark more absolutely than any other is an inflammatory or dysenteric state of the bowels, in which cases it seems to be invariably pernicious.

Where it happens that we are extremely anxious to throw in the bark, as we usually are in the West Indies, where fevers are very rapid and dangerous, and yet the symptoms seem hardly to admit its use, it was very commonly tried either in conjunction with some antimonial medicine or neutral salt, or these were given alternately with it, in order to soften and qualify its effects by preventing it from heating or otherwise aggravating the symptoms. Antimonial wine or _Spiritus Mindereri_ were conveniently employed with this intention.

With regard to the quantity of bark to be given, it may be proper in doubtful cases of this kind to begin with small doses, in order to feel how far it agrees or not; but in general it may be laid down as a rule with regard to this medicine, that, where it is really proper, and the medicine to be depended on, it is to be given in as large doses and as frequently as the stomach will easily bear it.

The next remedy mentioned was opium. It is a medicine more admissible and useful in this than any other kind of fever. The same cautions nearly apply in the administration of it as have been given with regard to the Peruvian bark. The caution with regard to foul bowels is particularly necessary in a hot climate, where an over secretion of bile is so apt to take place. When, the Boreas frigate arrived from England in March, 1783, there was a very bad fever of the infectious kind on board, some cases of which being sent to the hospital at St. Lucia, were treated unsuccessfully with bark and opium, which I had been induced to try upon the authority of the authors above alluded to. I attributed this want of success to the neglect of previous evacuation; for, upon inspecting the bodies, the intestines were found full of bilious _feces_. I profited from this, and was more successful in the other cases. It were to be wished that physicians could oftener bring themselves to confess their errors in practice, and their writings would be more instructive; for it is of consequence to know what we are to avoid as well as what we are to follow.

It has been mentioned that the best effects arise from the conjunction of an antimonial with an opiate; but, in this sort of fever, antimonials, and even most of the neutral salts, are hurtful after the first stage, and opiates may after this be given alone or combined with camphor. With regard to the precise period of leaving off antimonials, it must be left to discretion, and the constitution of the patient is the best guide. There is so great a difference in patients in this respect, that all practical precepts should be qualified by a due discrimination of constitutions. Absolute and dogmatical rules are so far from applying in the practice of physic, that there are some cases of the same disease that require a treatment even opposite to what is in general most adviseable. This may be very aptly illustrated by the small pox, of which there are cases that ought to be treated very differently from the general method laid down by Sydenham, and in which cordial medicines are highly proper and necessary. This difference in diseases themselves seems to be one great cause of the difference of opinion among physicians on practical points, each party finding some countenance in experience for their general doctrine, do not make allowance for the varieties that exist in nature; so that, in one sense, both may be said to be in the right. If the patient is not very much sunk, and if there are bilious symptoms, or an obstinate dryness in the skin, a few grains of James’s powder may be given with advantage even in an advanced period of the disease. If a hot and dry skin should at this period be the only troublesome symptom, it will be more safely and effectually removed by camphor combined with something opiate and the _Spiritus Mindereri_, which is the only neutral now admissible, than by antimonials, which, at this time, would be in danger either of ruffling the patient by their operation on his stomach and bowels, or of weakening him too much either in this way, or by exciting profuse sweats. Evacuant medicines of every kind being then improper, clysters are the only laxatives to be employed in case the state of the bowels require them.

Having mentioned camphor, it may be proper here to remark, that it is a medicine of which I have found it extremely difficult to ascertain the virtues and effects; and in consequence of this ambiguity, I believe there are few articles of the materia medica more abused in practice. In all inflammatory affections, and in the beginning of all fevers where there is much heat and thirst, I think I have observed it to aggravate the symptoms. It seems in no case to be more proper than at certain periods of this fever, and especially when there happens to be spasmodic pains of the stomach, or tremors and cramps in the extremities.

In this advanced stage of the fever, in which the most common symptoms are weakness, restlessness, tremors, and low delirium, no medicine was found so much to be trusted to as opium, which here acts as a cordial as well as an anodyne and antispasmodic. It may be given, in the camphorated julep, in the form of tincture, from five to ten drops every six or eight hours, or some of the officinal compounds, such as the theriaca or mithridate, may be employed with advantage. I have thought also, that, at this period, castor conjoined with opium seemed to improve its virtue. This was first suggested to me by Mr. Crudie, an ingenious German surgeon, whom I employed as an assistant at the hospital at St. Lucia; and since I have been physician to St. Thomas’s hospital, I have found the most pleasing effects, in similar cases, from a composition used there, the principal ingredients of which are opium and castor[97].

In this state of the fever I have also used with advantage the decoction of Peruvian bark and serpentary, as recommended by Sir John Pringle; and when the skin is cold and the circulation is very languid, as is sometimes the case, volatile salts and powder of serpentary may very properly be employed.

But in the advanced state, and in the worst forms of this disease, there is perhaps no medicine superior to wine. This was given either pure, or diluted with water for common drink, and sometimes to the quantity of a quart in twenty-four hours. In delicate people, such as we meet with in private practice, the quantity ought to be less.

There is this caution necessary with regard to the use of wine, that when the fever is gone off, and only extreme debility remains, the free use of it is not safe nor proper; for, in a weak and exhausted state, a person is more apt to be [98]heated and intoxicated by any fermented liquor, than in health, or even in the preternatural and disturbed state of actual disease, such as occurs in this fever.

After the disease is removed, a long state of weakness is apt to succeed, especially in a warm climate. The most proper remedies, then, are bitters, such as decoctions of Peruvian bark, infusions of quassia bark, gentian, or camomile flowers. These answer better than the bark in substance, which is now apt to nauseate and load the stomach, and the patient is apt to take an aversion to this and whatever else he took in a state of sickness. The best strengthening medicines are such as comfort the stomach and create appetite; and we may mention Huxham’s tincture of bark, in small doses, and a moderate use of wine, as the most proper for these purposes. Where colliquative sweats take place, elixir of vitriol is serviceable, and with this intention I have joined it, with evident advantage, to the evening anodyne, which, without such a corrector, tends rather to aggravate this symptom. I have known assafœtida prove a useful stimulus to the stomach at this time, and it may even be used while the fever subsists, especially where the secretions of the fauces are scanty. This medicine is recommended by Sir John Pringle in the same circumstances. But I consider the prudent use of opiates, particularly at bedtime, as the most effectual cordial and strengthening medicine in this convalescent state.

But with regard to the management of the sick at this time, as much depends on diet as medicine. Nothing has been said concerning this in the acute state of fever, because no nourishment is then necessary. In that state there is a loathing of all food, and the powers of digestion and assimilation seem to be then suspended, so that alimentary substances become not only an useless load, but offensive and hurtful by turning acid or putrid. It is likewise evident from fact, as well as reason, that nature, in this situation, does not require sustenance; for we frequently see people labouring under fevers who do well and recover, though they have been entirely without nourishment for a length of time in which the like abstinence in a state of health would have proved fatal. The friends and attendants of the sick, from a prejudice not unnatural, but not considering the difference between health and that state of derangement which takes place in fever, are for ever wishing to supply the patient with nourishment, and every physician meets with trouble in counteracting this officiousness. Nevertheless, when the fever draws out to a considerable length, and the principal symptom is that state of weakness which, in low fevers, runs insensibly into that of convalescence, then it is necessary to pay the utmost attention to nourishment, and nothing tends more to insure and hasten recovery than the assiduous administration of light and nourishing food, the same cautions being observed which have just been mentioned with regard to cordials. One of the greatest hardships of a sea life is the want of those articles of diet that are suitable to a recovering state, and many lives are lost from this circumstance, after the force of the disease has been subdued[99].

With regard to the peculiar form, before described[100], which this fever assumes a few months after ships have been in a hot climate, we found camphor, volatile salts, and serpentary, the best remedies. As there was a remarkable coldness of the skin, I was induced in one case to try the hot bath, and with good effect, from which it seems probable that a short stay in a bath, of a heat from 96° to 100°, so as to have its warming and stimulating, without its relaxing effects, would answer well in fevers of this kind.

2. Of the BILIOUS REMITTING FEVER.

This is peculiar to tropical climates, and arises in the same situations in which intermitting fevers arise in temperate and cold climates. It seldom arises at sea, unless where there has been previous exposure on shore, of which some examples have been mentioned in the first part of the work. It may generally be traced to the air of woods or marshes; and in our fleet hardly any men were attacked with it but those who were employed in the duties of wooding and watering.

The most distinguishing symptom is a copious secretion of bile which attends it. Its course, in general, is shorter than that of the fever before described; and though the symptoms are more violent, they are not so equal and steady, owing to the tendency there is to remission. The symptoms are particularly violent at the beginning, in so much that some of the men, after being exposed upon duty to the heat of the sun and the air of marshes and woods, would become frantic, being seized almost instantaneously with _delirium_ resembling madness. This fever, when it arises merely from the effluvia of woods and marshes, has a natural tendency to remit; nay, some fevers at St. Lucia, proceeding from this cause, were of the pure intermitting form from the beginning. But in many of those that arose at Jamaica little or no remission was to be perceived; and it was distinguished from the ship fever by the bilious vomits and stools, more violent delirium, and head-ach, and by being attended with less debility. The greater tendency to the continued form at this time was probably owing to this circumstance, that the men who were exposed to the land air in wooding and watering, were then exposed also to such causes as naturally produce continued fevers, such as infection, the foul air of the French prizes, intemperance, and hard labour. There was in some cases a yellowness of the eye, and even of the whole skin, but without the other symptoms that characterise the yellow fever, properly so called.

In cases that proved fatal, the symptoms, for some time before death, resembled very much those of the fever before described at the same stage. There was either _coma_ or constant delirium, great seeming anguish, the mouth and tongue very dry, or with only a little ropy slime, a black crust on the teeth, picking of the clothes, and involuntary stools.

TREATMENT OF THE BILIOUS REMITTING FEVER.

The measures proper to be taken in the beginning of all fevers are pretty nearly the same. There is little difference in the first treatment of this from that of the ship fever, except that blood letting is here more frequently proper, and that a more free evacuation of the bowels is necessary on account of the more copious secretion of bile.

In full and athletic habits the disease very commonly begins with pains in the limbs, back, and head, with a strong throbbing pulse; in which case it is proper first of all to let blood at the arm. This is also highly proper and necessary in those cases mentioned above, in which the patient becomes suddenly frantic. But though the cases requiring blood-letting are more frequent in this sort of fever than that already treated of, yet great caution and nice discernment are necessary with regard to it, in all cases, in a hot climate. As fevers in such a climate run their course faster, the symptoms succeeding each other in a more close and hurried manner, greater expedition, as well as discernment, are required in timing the different remedies than what are necessary in a cold climate. Blood letting unseasonably and injudiciously employed either endangers life, or has a very remarkable effect in protracting recovery, by the irrecoverable weakness it induces.

With regard to the evacuation by the bowels, it has already been mentioned in another part of the work, when on the subject of prevention, that, before the fever comes on, there is a languor and general feeling of indisposition, and that then an emetic and a purgative, followed by some doses of the bark, were the most likely means of preventing the attack of the disease. If the fever has properly begun, which is announced by a _rigor_ taking place, then no time is to be lost in procuring evacuation; and, after blood letting, if the symptoms should require it, the best medicine is tartar emetic, which, if given in small divided doses, at short intervals, will most probably evacuate the whole intestines by vomiting and purging, and may even prove sudorific. But it will nevertheless be proper to administer a purgative medicine soon after; and what we found to operate with most ease, expedition, and effect, was, a solution of purging salts and manna, either in an infusion of sena, or in common water, or barley water, with some tincture of sena added to it.

The next step towards procuring a remission is, to open the pores of the skin, which is best done by small doses of James’s powder or emetic tartar, assisted by the common saline draughts, which will be given with most advantage in the act of effervescence, or by _Spiritus Mindereri,_ together with plentiful warm dilution. I once, by way of comparison, tried the two antimonial preparations above mentioned in a number of men ill of this fever, who were sent to the hospital at one time, giving emetic tartar to one half, and James’s powder to the other, and their effects were so similar, that I could perceive no reason for preferring the one to the other. Antimonial medicines seem better adapted to this than any other sort of fever, and may be more freely given in it.

These are the most likely means of bringing about a remission; and if this is effected, nothing remains to be done but to throw in as much Peruvian bark as the stomach will bear.

But whether from a fresh accumulation of bile, or some other circumstance, it may happen that the fever is kept up; and in this case there is commonly a sense of weight or uneasiness about the _hypochondria_, which seems to indicate that the redundant bile is in the gall bladder or ducts of the liver. In this case a repetition of evacuants is necessary, and calomel will be found to answer remarkably well as a purgative, its stimulus being so extensive as to loosen and bring away bile when the saline purgatives, such as that above mentioned, had failed of having that effect. I have known these to pass through the intestines without relieving the uneasy sensation about the stomach as calomel is found to do; and it will be still more effectual for this purpose, if given alone in a dose, from five to ten grains, and followed some hours afterwards by some other purgative. After this, antimonial medicines are again to be had recourse to; and these, as well as purgative and neutral medicines, are safe and useful in a more advanced stage of this fever than they are in the ship fever; for the strength is not so apt to sink, and the state of the bowels requires them more. Antimonials, however, are to be used sparingly and cautiously as the fever advances; for I have known them, when given only a few days after the first attack, to have the effect, in some constitutions, of making the stomach swell, and of producing a general sense of heat and uneasiness.

After the evacuations of the bowels, the anodyne diaphoretic may be very seasonably given in the manner formerly mentioned; for it will not only tend to sooth and procure sleep after the commotion that has been excited, but by its gentle sudorific effect will assist in completing the remission.