Observations on the Diseases of Seamen

by Sir Gilbert Blane

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].