Observations on the Diseases of Seamen

by Sir Gilbert Blane

What has been hitherto said regards chiefly the acute dysentery; but the most frequent and troublesome complaint that occurred at the hospital, was the same disease in what may be called its chronic state.

There is a considerable variety of symptoms in all the stages of this disease, but particularly in the more advanced or chronic state, so that a corresponding variety is necessary in the modes of treatment, and there are few diseases in which there is more room for exercising the judgement.

In all stages of it an accurate discernment is necessary with regard to the use of opiates, and great part of the practice here consists in timing these well. They are least admissible in the beginning, where evacuation is the principal object; but as the disease advances they become more and more allowable and useful. The principal cautions necessary in their administration are, 1. To premise sufficient evacuation, so that the intestines may not be loaded with bile, scybala, or any other irritating matter at the time of giving the opiate. 2. To obviate the effects which an anodyne has of causing a retention of the contents of the intestines. This may be done, either by giving something purgative along with it, or after it has produced its quieting effect. The former method seems preferable; for as soon as the effect of the opiate is over, the purgative is ready to act; and in this way it is so far favourable to the operation of the purgative that large feculent stools will be discharged: whereas, had the purgative been given alone, it would have been more apt to produce scanty griping stools, attended with tenesmus. Rhubarb answers well in such cases, and may be given in a dose from twelve to twenty grains, according to the age and constitution. 3. To prevent feverish heat and delirium. This was proposed to be done in the first stage of the disease, by combining it with ipecacuana and a little neutral salt. With the same intention, it may now be joined with a few grains of Dr. James’s powder, or vitrum ceratum antimonii, in which form it would not be so strongly sudorific, an effect not so much required in the chronic as in the acute state.

The principal causes that keep up the flux, and render it so obstinate, are, 1. A too great secretion of bile, either continual or frequently recurring. 2. Ulcers in the great intestines. 3. A lienteric state of the bowels. 4. A retention of scybala.

The first cause is much less frequent than might be expected by those who fancy that every disease of this climate proceeds from bile. When there does occur a redundancy of bile, there is more occasion for the employment of evacuant medicines, and more need of caution in that of opiates. A medicine that will dispose the liver, or the circulating system in general, to form less bile, is a desideratum in physic; but, in case of an excessive flow of it, emetics and mercurial purgatives, as has been already mentioned, are the best means of evacuating it; and care should be taken that it be discharged before it accumulates too much, or becomes acrid by too long retention.

In order to obviate that irritation in which tenesmus consists, some benefit was found from the injection of emollient and anodyne clysters, to wash off and dilute the acrimony, and to sooth and heal the parts. A strong infusion or decoction of linseed or starch may first be given to the quantity of near a pint, to be evacuated after a short retention, and then a few ounces of the same, with thirty or forty drops of laudanum, to be retained for a length of time, in order to procure rest. Instead of this last, I have known a small quantity of warm milk, with syrup of poppies, used with advantage in private practice.

I was at first tempted to think that a very frequent injection of such clysters would be very useful, by washing and healing the colon and rectum, and preventing farther exulceration. But besides the objection arising from the tenderness of the parts, which, in some cases, renders the operation itself painful, I found that if they were given oftener than once a day, they rather increased the uneasiness, and made the patient feel languid and exhausted; so true it is that no practical rule can be established from reason alone without being brought to the test of experience. The rectum seems to have a peculiar sensibility, and a remarkable consent with the whole system; for a stool will induce syncope, or even death, in a state of great debility. Clysters may be pernicious, even though they produce no evacuation of feces; and Sydenham has remarked, with respect to other diseases, that their unseasonable or too frequent use greatly debilitates and disturbs the patient. When not abused, however, they are of the most eminent service in this and other complaints.

Certain medicines, which have been called sheathing, have been recommended to be taken by the mouth. Of this kind are mucilage, oil, and wax. I have made trial of mucilage, such as starch, without any sensible effect, probably because it loses its qualities by the powers of digestion before it reaches the part upon which it is intended to act. With regard to oil, I have hardly enough of experience of my own to decide; but some of the surgeons of the fleet informed me that they found advantage from combining it with the purgatives. I was discouraged from using it by finding that it was apt, in the West Indies, to become rancid on the stomach, and, for this reason, I seldom, in any case, employed the castor oil, which, though produced in that climate, seems to answer better as a medicine in Europe. But since my return to England I have used, with great benefit, at St. Thomas’s hospital, a medicine, composed of tincture of rhubarb and oil, in old dysenteries, attended with discharges of blood. I took the hint of this from finding it of great service in deep-seated piles, as recommended by Dr. Griffith[115]. It is necessary to combine something purgative with the oil, otherwise it might be altered by digestion, or absorbed, or might become rancid by too long retention in the first passages. Wax is a body not changeable by digestion, and seems therefore well suited for the purpose of sheathing the bowels; and I have found advantage from the preparation of it recommended by Sir John Pringle[116], on the authority of Dr. Huck. I have also seen some advantage in old fluxes, in St. Thomas’s hospital, from the use of spermaceti, given with an equal quantity of conserve of roses and half as much absorbent powder, agreeably to a form in use at that hospital.

The climate has a great influence in preventing these ulcers from healing, upon the same principle that it prevents the cure of external sores and wounds, so that there are cases that admit of no cure but from a change of climate. I have seen in some cases of old dysentery, small, round, ill-conditioned ulcers break out on the surface of the body, which seemed to proceed from the same general habit that produced those of the intestines. There was something peculiar in the appearance of those external sores, being like small round pits, as if a part of the skin had been removed by caustic, and with little or no discharge. In a case of this kind, which proved fatal, I found the whole surface of the great intestines beset with small ulcers, not unlike those on the skin.

Since the first edition of this work was published, I have met with a pamphlet, written by Dr. Houlston, of Liverpool, in which the friction of mercurial ointment on the abdomen is recommended as a cure for old fluxes; and I have tried this practice in some very obstinate cases in St. Thomas’s hospital with evident success. In these cases it is probable the disease is kept up by a vitiated state of some of the various secretions belonging to the intestinal canal, which the mercurial alternative tends to correct.