Observations on the Diseases of Seamen

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.

The eye in a few hours takes a yellow tinge, which soon after extends more or less over the face and whole skin. This is a symptom so striking and constant, that it gives name to the disease, though it is not absolutely either peculiar or essential to it. There is something contagious in this symptom, which seems somewhat singular, and difficult to be accounted for. It was observed in the Royal Oak and Alcide to extend to men who were but slightly indisposed; and at the hospital it spread to men in the adjoining beds, without imparting any malignity to their diseases.

There is something very peculiar in the countenances of those who are seized with it, discernible from the beginning by those who are accustomed to see it. This appearance consists in a yellow or dingy flushing or fullness of the face and neck, particularly about the parotid glands, where the yellow colour of the skin is commonly first perceived. There is also in the eye and muscles of the countenance a remarkable expression of dejection and distress.

One of the most constant and distinguishing symptoms of this fever is an obstinate, unremitting, and painful pervigilium, which is the more tormenting, as the patient is extremely desirous of sleep. It is seldom that even a delirium comes to his relief to make him forget himself for a moment; but he continues broad awake, night and day, with his reason and senses sound, in a state of the most uneasy agitation.

But the most distinguishing symptom, and that which is expressive of the greatest danger, is, an unconquerable irritability in the stomach, which can be brought to bear nothing. An almost incessant retching takes place, which commonly, on the third day, ends in what is called the black vomit, the most hopeless of all the symptoms attending it. When this is examined, the colour is found to be owing to small dark flakes, resembling the grounds of coffee, and seems to be blood which had oozed from the surface of the stomach, a little altered. Indeed pure blood is sometimes thrown up, and we know that the red globules enter the smaller order of vessels, and issue by them; for bleeding at the nose is a common symptom about this time; and some relate that it also escapes by the ears and pores of the skin, which I never saw, but can readily believe it. At the same time, the stools grow black, and the urine is frequently of a very dark colour, which seem to be owing to the same cause. I never remember to have seen any one recover after these symptoms came on.

There seems to be a general error loci of the more tenacious and globular parts of the blood into the smaller order of vessels, to which the yellow colour is in a great measure owing; and when any part of the skin is ever so little pressed upon, a damask red colour remains for some time, the small vessels readily admitting the red globules. It is certain that a yellow colour of the skin may be produced by such an error loci, without any suspicion of the presence of bile. We have an illustration of this in the ecchymosis which follows upon an external contusion. In this case the red part of the blood is mechanically forced either into the smaller order of vessels, or into the cellular membrane, which occasions a livid appearance, and in the course of the recovery the same parts become yellow, probably in consequence of some of the gluten of the blood assuming this colour after the red parts have been removed by absorption or otherwise.

In the worst form of this disease there is all along an uncommonly distressing sensation of universal anguish, particularly about the stomach, where there is a sense of burning heat, which, as the miserable sufferers themselves express it, becomes unspeakable torture.

A sense of weight at the breast, deep and frequent sighing, and a great failure of muscular strength, are dangerous symptoms in all stages of the disease.

Upon the first attack the skin is extremely hot and dry, and the pulse hard and frequent; but the external heat soon becomes very little different from the usual standard of health, and the skin feels soft and moist. There sometimes happens an eruption of small pustules, with white heads, on the trunk of the body, which is a favourable sign; and I have seen a head-ach disappear upon this breaking out. The pulse does not serve as an index of danger; for, after the hurry of the first attack, it becomes very moderate in point of frequency, varying from eighty to a hundred pulsations in a minute, and is natural in point of regularity and strength.

In these circumstances this fever differs from that which was last described; and it also differs from it in being attended with little delirium. I have seen cases in which the senses were not affected from beginning to end; and I never observed that violent and incessant delirium which attends other dangerous fevers.

The state of the fauces is also different from that of most other fevers, for there is no excessive thirst. The tongue is somewhat white and foul; but I do not remember ever to have seen it black and dry.

A want of action in the bowels, and an insensibility to purgative medicines, indicate great danger; and, next to the black slimy stools, one of the most unfavourable symptoms is, when the feces are like white clay, as I have seen in some cases that ran out to the length of a week before they proved fatal. When the black vomit and stools occur, death commonly happens on the third or fourth day. A bilious diarrhœa spontaneously coming on, is a very favourable symptom.

In more unpromising cases the urine is scanty, and in the last stage of life it becomes of a very dark colour, as was mentioned before. A plentiful secretion of urine is a very favourable circumstance, and seems to be one of nature’s methods of curing the disease; for such cases are observed to terminate well. I remember one case in particular in which several quarts were made daily for several days together, and it was of a very dark saffron colour, but looked green where the surface was in contact with the side of the pot. I inspissated a small quantity of it, and found a large residuum, which was very deliquescent, and seemed to be all saline. In a hot climate the urine does not shew that separation and deposition which denote the crisis of fevers in cold climates, and this is perhaps owing to there being less mucilage and more alkali in the former, on account of the more putrescent state of the fluids. Upon adding a little vinegar to the urine in the case above mentioned, it became turbid like the critical urine of the fevers of Europe.

At the approach of death, cold clammy sweats come on; the pulse continues regular and of a certain degree of strength, but grows gradually slower. I have counted it at forty pulsations in a minute. The patient is frequently sensible to the last moment; nor does the countenance sink into what is called the Hippocratic appearance. In other cases I have seen, at this time, coma, and not infrequently convulsions. Broad livid spots sometimes also appear on the skin. Extreme muscular debility, a great difficulty of deglutition, and a dimness of the eye-sight, are likewise common symptoms in the last scene.

The different stages which lead to dissolution following each other thus rapidly, there is not that gradual failure of the powers of nature that usually give warning of approaching death; but the springs of life run down, as it were, at once, the wretched sufferer expires, and is happily delivered from the most extreme misery of which human nature is capable.

Such is the general train of symptoms in this fever, taken entirely from my own observation; but great varieties occur both in the symptoms and duration, so great indeed, that it is hardly recognisable for the same disease. I shall give specimens of such anomalous cases in two that occurred at Port Royal, on board of the Canada, in July, 1782.

A lieutenant of that ship had been subject, for four days, to fits of retching, without any bilious discharge or pain in the stomach; and, except a white tongue, he had no symptom of fever in that time, nor any thing to prevent him from doing his duty. On the fourth day, when I first saw him, he began to complain of a fixed pain in the pit of the stomach, which was not very violent, and about the same time a yellowness began to appear on the white of the eye. He took a laxative medicine, which had the desired effect, and some volatile spirits, with some drops of thebaic tincture in simple mint water, for the pain in his stomach. He had a good night. Next day the complaint of the stomach was better; but there was great muscular debility. He had several natural stools; and as there seemed little indication but debility, he took nothing that day except an infusion of some bitters and aromatics in wine. As he did not want for appetite, he eat some broth and chicken; and nothing to give any alarm happened this day, except a short qualm, in which he was faint, with a sense of cold, feeling to himself, as he said, as if he should have expired. In the afternoon he began to have black-coloured stools, which was the first symptom that clearly betrayed the nature of the disease. He was then ordered as much Peruvian bark as he could take with red wine, and these his stomach bore. Decoction of bark was also given him in clysters. He had a strong voice, and was quite sensible, but grew weaker and weaker with frequent returns of the qualms, and he expired that evening before ten o’clock.

I have not the least hesitation in ranking this case with the fevers last described, though so many of the usual symptoms were wanting. This gentleman, though of a lively, active disposition, was of a slender make, and of a dingy, doughy complection, and his case gave me the idea of a disease attacking a constitution which, not having powers to struggle with it, is overwhelmed without making resistance102. 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.

4. Of the Effects of Flowers of Zinc and White Vitriol in the Cure of obstinate Intermittent Fevers

It frequently happens in the West Indies that intermittent fevers are so obstinate as to resist the common means of cure by the Peruvian bark; so that these complaints become extremely distressing to the medical practitioner as well as to the patient. Indeed this was a difficulty that occurred so often, that I was sometimes tempted to think, either that the great reputation of this medicine is not so well founded as is commonly believed, or that the bark generally in use in these times is not of so good a quality as that employed by the physicians who first established its character.

But, in the first place, the experience upon which its reputation was first built was in a temperate climate, where very few agues are found to resist it when properly administered. In the next place, there is reason to believe that, in fact, the medicine itself now commonly in use is not equally powerful with what was first employed; and a species of it, called the Red Peruvian Bark, has lately been discovered, or rather, perhaps, revived, which is certainly of a superior quality, and has been found to cure intermittents in which the common sort had failed107.