Observations on the Diseases of Seamen

by Sir Gilbert Blane

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].