Chapter XVII: Part III: Description and Treatment (3)

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.

The next cause that was mentioned of the long continuation of fluxes, was a lienteric state of the bowels. This consists in a great irritability of the whole alimentary canal, whereby all the _ingesta_ are transmitted so fast, that there is no time for assimilation. Liquid aliment, such as broth, is particularly subject to this inconvenience. There are few cases of long-protracted fluxes in the West Indies, without this symptom in some degree.

The remedies that are here found of most service are such as counteract irritability or relaxation. It is in cases where this is the prevalent symptom that opium may be most freely used. Frequent and small doses of the compound officinals, such as theriaca, pulvis e bolo compositus, or diascordium, have been found of service. Though the relaxation would seem here to indicate the Peruvian bark, yet I have hardly ever known it employed in any form in this or any other stage of the disease, without being hurtful. But there are other bitters not only safe but useful in restoring the tone of the bowels; of this kind are simaruba, quassia, and chamomile flowers. The first has been reckoned a specific in this sort of flux; but though its powers are undeniable, it will be found frequently to fail[117]. I have also used, with advantage, a tincture of gentian and cinnamon in Port wine. Something aromatic has a good effect when added to the bitter, being adapted to prevent or obviate flatulence, which is a common and troublesome symptom in this complaint.

That class of remedies which may be called pure astringents, might seem at first sight well calculated for cases of this kind. Of this sort are the _terra Japonica_ and _extractum campechense_; but though I have seen evident benefit from this last, there are few cases in which such medicines are found by experience to be of material service. Where the cause consists in simple relaxation, they will effect a cure; but it more frequently happens that the disease is kept up by a vitiated state of the secretions, or a depraved action of the bowels.

The absorbent earths are a more useful remedy in this form of the disease. They have, perhaps, a restringent effect independent of their power of absorbing acid. It is certain, however, that great part of their use consists in the destruction of acid, which is very apt to be generated in that depraved state of digestion which takes place in advanced fluxes, particularly in this lienteric state of the bowels. In the early and acute state the vegetable purgatives, such as cream of tartar, tamarinds, and manna, are proper; but in this advanced stage they are hurtful by the acidity and flatulence which they produce, and both the food and medicines should be so calculated as to avert and correct those inconveniencies. There is something in vegetable acids extremely unfriendly to a weak state of the bowels in general, tending to bring on spasmodic gripings, and preventing a healthy digestion and assimilation, as we know in the case of heartburn, and of those who make use of vinegar to check corpulency, by preventing the formation of blood. Vegetable acids, however, are admissible where there is a redundancy of bile, or where the excrements are putrid; and Dr. Zimmerman recommends tamarinds as a useful medicine in what he calls the putrid dysentery.

Lime water has been recommended in old flaxes, and I tried it in several cases; but, except in one, I could not perceive any benefit from it.

Absorbents may very properly be combined in prescription with some of the compound-officinal opiates, and a medicine will thereby be formed, which will have at once the advantage of an anodyne, a bitter, an astringent, a carminative, and absorbent. As these earths have little or no taste, they may also be added, with propriety, to the common drink, as in the form of the chalk julep, or _decoctum album_. It may be thought that here and elsewhere I have not been so particular as I ought to be concerning the forms and doses of medicines; but circumstances, such as age, constitution, and symptoms, make these, in a great measure, discretionary; and any one who is sufficiently conversant with physic to be entrusted with the charge of the sick, will have sufficient judgement to vary his practice accordingly. It has, therefore been my object rather to give the general principles of treatment than the particular forms of medicines.

A proper regulation of diet, as well as medicine, is of the utmost consequence in this disease. A free indulgence of animal food is pernicious, particularly in the first stage of it. In the chronic state, a moderate use of it is allowable, and in the lienteric state it answers better in a solid form than that of broth, which is apt to gripe and to run quickly through the bowels. The best general articles of diet are farinaceous bodies; and these are greatly improved by being toasted brown before they are used. It was observed, in a former part of this work, that the flux was supposed to have been prevented, in the fleet commanded by Sir Charles Saunders, by throwing burnt biscuit into the water used by the crews of the ships. It is a good practice to put a well-burnt toast into all that the patient drinks, and toasted bread, or panada made of toasted bread or biscuit, is one of the best articles of diet. Brackish water ought to be avoided, as it ruffles the bowels when in so delicate a state. Fermented liquors are improper, except when the disease is advanced, and where weakness and relaxation are the prevailing symptoms. Malt liquor will hardly ever agree, on account of its acidity and flatulence. Of wines, Port is to be preferred as the most strengthening; Madeira as the least subject to acidity; and, for the common men, no drink of the fermented kind is safer than a moderate quantity of spirits diluted with water.

Warm clothing is of the utmost consequence in this disease, and external warmth of the abdomen tends greatly to sooth the bowels. I have seen good effects from a warm gum plaster constantly worn on that part. Though cold is in general hurtful and unsafe, I have nevertheless known the sailors, who, by their habits of life, are commonly heedless, bathe in the sea when labouring under what they call the white flux, without any bad effects.

It sometimes happens that this disease baffles every effort both of medicine and diet, so that a change of climate becomes the only resource.

The last cause of habitual flux that was mentioned was the retention of _scybala_, which keep up the irritation and tenesmus. It is very natural to neglect purgative medicines when there seems already to be too great a discharge by the bowels; but there is this inconvenience from omitting them for a length of time, that those hard lumps of feces, called _scybala_, are apt to collect in the cæcum and cells of the colon, as I have seen upon inspecting the dead bodies; and the fibres of the intestines being weakened, their natural strength is not sufficient to expel them without being stimulated by a purgative. It is therefore necessary to give some evacuant medicine from time to time, even though there should be no griping nor any marks of acrimony in the intestines. Rhubarb is allowed to be one of the best medicines for this purpose; and I have also known a combination of salts and sena have a good effect after a long neglect of purgative medicines. It is probable, from the durable effects produced, that these do not operate merely by the expulsion of _scybala_; and we can conceive that they may be of service by the removal of certain depraved fluid secretions, or that they may stimulate the vessels to a more healthy action and a more natural secretion. Be this as it will, experience teaches that in all fluxes it is of advantage to interpose from time to time some purgative medicine.

From the preceding view of the variety of causes which tend to keep up this disease, it will appear that great judgement and discrimination are necessary in varying the practice according to circumstances; and there is no disease in which there is room for more attention and nicety in adapting the different remedies to the different symptoms. We can hereby also account for the various characters that different remedies have had, some having been extolled by one practitioner while they have been pronounced insignificant by another; for no one remedy will suit all the various cases of this disease. As it is of the greatest consequence to distinguish these cases, I have been more particular and diffuse on this article than any other; and having laboured under this complaint myself, I was naturally led to take a greater interest in its treatment, and had also thereby a better opportunity of making observations on it.

CHAP. III.

Of the SCURVY.

I shall not be so minute either in the description or treatment of the scurvy, as of the preceding diseases. A detail of this kind would lead to unnecessary prolixity and repetition; for the prevention and cure of it consisting in diet rather than medicine, have been fully handled in the former parts of this work; and the subject, in the descriptive as well as the practical part, has, in a manner, been exhausted by Dr. Lind. With regard to the theoretical part, I refer the reader to the ingenious treatise lately published by Dr. Milman.

It has appeared that the principal source of scurvy is a vitiated or scanty diet, and that it is very much promoted by cold, moisture, filth, sloth, and dejection of mind. Hard labour has been assigned by some as a cause; but this is not conformable to my observation in general, and what has been related to have happened in the Conqueror[118], more particularly led me to be of a contrary opinion.

The principal differences of the symptoms of the scurvy in hot and cold climates, so far as I have observed, are, that in the former the livid hardness on the extremities is an earlier symptom, and in the latter the gums are sooner affected, and the difficulty of breathing is a more frequent and more uneasy symptom. This difficulty of breathing is one of the most fatal symptoms, and is most frequent in those cases in which there are the fewest external marks of the disease, and is probably that form of the complaint which attacks a vital part by a sort of translation from the extremities.

There is a remarkable symptom sometimes attendant on this disease which has escaped authors, and is mentioned in Mr. Telford’s Report, page 23. This is the _nyctalopia_, or weakness of the eye-sight, which was also common in the garrison of Gibraltar[119], among those who were affected with the scurvy, a disease that prevailed much during the late siege of that place.

With regard to the cure, enough has been said in the preceding parts of this work to prove that fresh vegetables are the most effectual antiscorbutics. I shall here mention a fact farther in proof of this, which has not before been taken notice of. When the fleet arrived at Barbadoes in May, 1781, part of the soldiers, who served as marines, were affected with the scurvy, and being sent to the army hospital, where, at that time, no fresh animal food was allowed, they recovered much faster by being confined to vegetable articles, than the seamen who were fed upon fresh animal food without any fresh vegetables.

It has farther appeared, that there is something in a particular class of fruit of the lemon and orange kind, which far surpasses every other remedy, whether dietetic or medicinal. Numberless instances have occurred, in the preceding part of this work, of men having recovered at sea from using the juice of this fruit alone, even under all the inconveniences of a sea diet. When the juice is intended to be kept for a length of time, it should be expressed and bottled, a small quantity of spirits being added to preserve it for if fire is used in preparing it, as in the form of a rob, I know for certain that its virtues will be thereby very much impaired. It is very difficult to say upon what principle these fruits act, for no sensible effects are produced by them except a small increase of some of the secretions.

It ought to be mentioned here as a fact of great consequence, though very little known, and never, I believe, published before, that the juice of limes and lemons is the best detergent of any external application that has yet been tried in scorbutic ulcers. Nothing was found so effectual in preventing these from spreading, and in disposing them to heal, as an emollient poultice with[120] lemon or lime juice sprinkled on its surface; or it was applied by soaking in it the lint with which the sore was dressed, and also as a lotion, in which case it was used diluted with two or three times its quantity of water; for if used pure, it was found too irritating, and was apt to bring on a fungous disposition. This precaution is particularly necessary with regard to limes, the juice of which is a much more concentrated acid than that of lemons. Mr. Lucas, surgeon of the Conqueror, favoured me with several valuable remarks in proof of this practice. A poultice was always found a good application in these cases, by its power of absorbing the acrimonious discharge, which would otherwise irritate the neighbouring parts. I have been informed by a navy surgeon, who served in the former war, that he has known the most obstinate ulcers cured by applying a paste of oatmeal and water, the surface of which was sprinkled with Goulard’s preparation of lead.

The fleet was furnished with essence of malt; but its powers were so inconsiderable, that some of the surgeons denied that it had any. In trials, however, that were made in an early state of the disease, it was found to have a sensible effect in checking and removing it. It was also found of evident use in the bad ulcers so apt to arise in scorbutic habits, and in this intention was superior to the Peruvian bark as an internal alterative. Indeed, in those ulcers that were truly scorbutic, the bark was found to be of very little use; and, next to what has been already mentioned, joined to the advantages of diet, opium was found of the greatest service in disposing these, as well as all other ill-conditioned sores of hot climates, to heal.

I have mentioned the scorbutic habit as distinguished from the scurvy, but there seems to be no difference except in degree; for a person may be laid to labour under the disease before it betrays itself by any obvious symptom, and it must have gathered a certain degree of force before visible symptoms are produced. The chief mark of this latent and incipient stage of the disease is that incurable state of ulcers that has been mentioned, whether they appear spontaneously or in consequence of slight accidents. There is another mark of this scorbutic habit which is not mentioned in any description of the disease I have ever seen. It is a soft, indolent tumour which arises under the skin on a part which has received a small blow, or contusion, so slight as not to break the skin. It most commonly appears about the elbow or fore-arm, and generally disappears without any inconvenience, what it contains being absorbed. A surgeon, who opened one of them, (a practice, however, not to be approved of) informed me that it consisted of fluid blood. We may also reckon a languor, or sense of weight, as one of those marks of scurvy which occur before the more obvious symptoms appear.

In this state of the disease, the articles of lesser powers, such as malt and melasses, may be of service by preventing its farther progress, or the appearance of actual symptoms, and by restoring the constitution.

In some of the early stages of this disease the effervescing mixture of acids with fixed alkali may probably also be of use. I never could perceive any sensible benefit in those cases in which I tried it, though some of the gentlemen of the fleet reported to me that they thought it of service.

There is no article of the _Materia Medica_ yet known that possesses any considerable power over this disease without the assistance of proper diet. With this assistance, however, it is found, that whatever tends to increase the fluid secretions, hastens very much the recovery of the scorbutic patient. I have observed a very striking instance of this in the effects of a spontaneous diarrhoea; for I have seen those hard livid swellings on the legs, that form one of the most constant symptoms of this disease, almost disappear, and the hams, from being contracted, become flexible in the course of twelve hours after the purging came on. I have endeavoured to imitate this with purgatives, but never with the same effects as the natural looseness. A free flow of urine is also found to promote the recovery, and vinegar of squills is one of the most effectual medicines in this intention. It is likewise of singular service to excite sweat; for an obstruction of perspiration seems to be one of the principal constituents of the disease. The goose skin, which is an early and constant symptom of this disease, seems to be owing to a constriction of the exhaling vessels. Dover’s powder has been employed with advantage as a sudorific, with decoction of the woods drank warm, and plentiful warm dilution. Camphor, combined with nitre, has been found one of the best remedies, and it acts both as a diaphoretic and diuretic.

Such external applications as relax the skin are found also to forward the cure. The contraction of the hams and the livid hardness of the calves of the legs are relieved by emollient cataplasms. Burying the legs in the earth, which has a sensible good effect, seems to act on the same principle, for it makes the parts sweat profusely.

There can be no doubt that in the scurvy there takes place in certain parts of the body a stagnation of the humours in the small vessels, particularly of the lower extremities, and that it is to this circumstance that the livid hardness of the fleshy parts of the legs is owing. The effect of medicine in removing this, must be to restore the action of those torpid vessels, so as to bring the stagnated fluids again into circulation[121] Purgatives seem to act upon it as they do in the dropsy, by exciting absorption. The irritation of the bowels and their increased secretion thus affecting the minute vessels in all parts of the body, is the result of that sympathy or balance established between every part of the system, in order to support the harmony and effect the purposes of the animal œconomy.

It has long appeared to me, that the scurvy is owing rather to a defect of nourishment than to a vitiated state of it. In fact, that sort of food which is supposed most commonly to induce the scurvy, is, in most cases, not putrid, but is in an unnatural and depraved state by being drained of its juices, which run off in brine; and perhaps some of the more subtile and nutritious parts are wasted by evaporation. It is not found that salt of itself has any effect in inducing the scurvy, and indeed it can be induced under a state of diet in which there is no salt, as we know from some instances quoted by Dr. Lind; and some cases are related by Dr. Monro and Dr. Milman, in the Medical Transactions, which are in proof of the same opinion. But the case most in point to prove that it depends on a defect of aliment, is that of Dr. Stark, who, by way of experiment on himself, reduced his diet to the least quantity he could subsist upon, and was thereupon affected with the symptoms of the sea scurvy. I have also known some symptoms of it arise in old people in consequence of long abstinence, owing to the want of appetite.

It would appear that the aliment we take in acts in two ways in increasing the vigour of the body. First, by assimilation, whereby it affords the matter of which the solids of the body are made, in order to carry on growth in youth; and to repair the waste of parts in adult age. A very small quantity of matter is necessary for these purposes; and as a proof of it, we see people supported equally well with very different quantities and qualities of food. Secondly, Food is necessary as a stimulus, either by a power it has of soothing the nerves of the stomach, and the other surfaces to which it is applied, or by its volume in distending the intestines and blood vessels. It is upon this principle that luxury renders the great quantities of food we take in necessary; and those species of food which satisfy most by their stimulus are by no means such as are the most nutritious. It is also upon this principle, that in cases of accidental hardship from want of food, or in barren and inclement countries where food is scarce, the body is supported, in some measure, by what contains little or no nutritious matter, such as pure water, or the bark of trees powdered and kneaded into a sort of bread, as we are told of the inhabitants of Lapland.

There are other familiar and well-established facts, which prove, that either from the influence of disease, from habits of life, or the nature of particular animals, life can go on for a length of time with little or no aliment. This is the case in fevers, in sea-sickness, in certain singular cases that have been recorded[122], in torpid animals, and in animals of cold blood. Though a man in health will die if deprived of food for a very few days, it does not follow that this is owing to the want of matter to repair the waste of the body. The craving for food, and the faintness from long abstinence, arise from the want of the accustomed stimulus, especially in those who are used to live well; and a person feels himself most refreshed by food and drink when newly taken in, and before it can be applied to the purpose of nutrition.

As there is a continual waste and decay, however, both of our fluids and solids, some degree of reparation is absolutely necessary, especially to animals of warm blood; and such _ingesta_ as would give the stimulus of food, without being possessed of any nutritious principle, would indeed continue life for a certain time; but disease would ensue. The provision used at sea answers, in a great measure, to this description; for unless the powers of digestion and assimilation are remarkably strong, salt beef and biscuit, which have been long kept, do not contain much more nourishment than saw-dust, or the bark of a tree, and the disease induced by this diet is the scurvy.

The nature and symptoms of the scurvy countenance this opinion: for as the means of renewing the animal matter of our bodies is withdrawn under this course of diet, nature, in consequence of an accommodating principle, observes a sort of frugality, and the animal œconomy adopts such measures as may be productive of the least possible waste and corruption of the fluids. Accordingly all the secretions become scanty; and, in particular, one of the first symptoms of this disease is a suppression of perspiration, as appears by the goose-skin that attends it. There is a paucity of urine. There is also a great languor in the circulation, which may be considered either as a means adopted by nature to prevent that vitiated and effete state of the fluids which a brisker action might induce; or it may happen from a want of that due supply of nourishment necessary to produce a vigorous action of all the functions.

We have a proof of this general languor not only from the great aversion to motion, and the great disposition to syncope, but from the inspection of the dead body, from which it appears that the whole circulating system, being more flaccid and less elastic, is subject to preternatural distention. The heart is accordingly found enlarged in bulk, the size of the cavities being increased; and in the extremities, where the circulation is naturally most languid, the small vessels carrying the colourless part of the blood, are so far enlarged as to admit the red part of it, as appears by the livid colour; and where this is the case, these vessels being unable to carry on the circulation, a stagnation ensues, as is evident in those livid appearances most common about the calves of the leg, which feel like a hard cake. I have examined those parts in the dead subject, and found a want of fluidity in the contents of the vessels, but could not discover any thing like _eechymosis_; from which I concluded that the colour was owing to an _error loci_, and the hardness to stagnation and coagulation of the fluids, and a want of action of the vessels.

The incurable state of ulcers, so common in this disease, is also what we might expect from the defect of fresh assimilated juices; for where a breach is made, either by nature or accident, in the solids, particularly of the extremities, the proper suppuration is prevented by the depraved state both of the fluids and vessels; and we cannot expect that renewal of solid parts in which healing consists, where both the instruments and materials of its formation are so defective.

I shall conclude what I have to say on this subject, by shortly considering whether or not this disease is ever contagious.

There is something in the nature and history of the scurvy that would lead us at once to pronounce that it is not infectious; for the external causes on which it depends are so obvious, and seem so adequate to account for its appearance and prevalence upon certain occasions, as at first sight to exclude every other external cause.

But it seems extremely unphilosophical to deny the reality or possibility of any thing in Nature, from our supposed knowledge of the means and causes she employs, particularly in a branch of science so obscure as the animal œconomy. Could we, therefore, prove the point as a matter of fact, it would be in vain to deny it, from our fancied acquaintance with Nature’s modes of operation.

The facts which give a suspicion of the scurvy being infectious are, 1st, What is related by Dr. Lind, that the sea scurvy spread at one time from the naval hospital to the people of the adjacent country. 2dly, There occurred several instances, in the first part of this work, of this disease prevailing to a much greater degree in some[123] particular ships than others, though upon the most accurate inquiry there was found no difference in the diet, or any other external or predisposing cause adequate to account for this. We can conceive, that those ships having accidentally a few men, whose constitutions were remarkably predisposed to this disease, might catch it earlier than in other ships, and communicate it to the rest of the crew.

The only practical inference that would lie from the establishment of this fact would be, that when the disease begins first to appear, the men affected should be separated from the rest; and this is a good practice, whether this opinion is true or not; for such men ought to be put in one mess, in order that they all may live upon the same antiscorbutic articles of diet, and that they may more easily be debarred from the use of their common provisions, of which this disease does not make them lose the relish.

CHAP. IV.

Of the WOUNDS received in the Actions of April, 1782.

Loss in the Battle and from Wounds--Fatality of the locked Jaw--Treatment of it--Some Ships more subject to it than others--Different from other Cases of Tetanus--It is not cured by the Removal of the Part--It may come on after the Part is cured--Effect of Climate in producing it--Accidents from the Wind of a Ball--Accidents from the Explosion of Gunpowder--Means of preventing them--General Observations on Sores and Wounds.

Though surgery was not properly in my department, yet, having had a fair opportunity of collecting facts concerning this branch of practice, I thought it my duty to pay some attention to it.

The whole number of men wounded in the actions of April, 1782, amounted to eight hundred and ten.

Of these, sixty died on board before the end of the month, five in the course of the following month, and two in June.

There were ninety-seven wounded men sent to the hospital at Port Royal, of whom there had died twenty-one when the fleet left Jamaica on the 17th of July.

So that the whole loss of men in the battles of April, and their consequences, is as follows:

Killed outright 266
Died of their wounds on board 67
Died of their wounds at the hospital 21
---
Total 354

Of those who died on board, fifteen[124] were carried off with the Symptoms of the locked jaw; but of those sent to the hospital, only one. The reason that so few in proportion were affected with it in the hospital may have been, that none of the wounded were landed till near the end of the third week after the principal action. The danger of this symptom was then, in a great measure, past, though I have known it to take place in every period from the second or third day till the fourth week.

Only three men in the whole fleet recovered from this alarming complaint; and as it is interesting to know every thing relating to so desperate a symptom, I shall give a short account of each.

The first was a seaman of the Montagu, who had his thigh wounded by a splinter which carried away part of the integuments and _membrana adiposa_, and lacerated in a small degree the _vastus externus_ muscle. The wound did extremely well till the 23d day, when the jaw became almost entirely fixed, and the whole muscles of the wounded side were thrown into frequent spasms. Mr. Young, the surgeon, who was always anxious and assiduous in his duty, consulted with me, and we had immediate recourse to the warm bath, which gave a degree of instantaneous relief, and was repeated twice a day for half an hour. He was sensibly better every time; in nine days was entirely free of the symptom, and continued afterwards to do well. The only other means taken for this man’s recovery, besides what were used with the other wounded men, were from three to five grains of opium, which he took every day, in divided doses.

The next was a seaman of thirty years of age, belonging to the Magnificent, who had the _humerus_ broken and shattered by a splinter which entered the deltoid muscle. Several large portions of bone were extracted, and the artery was laid bare on the inside. On the fifth day there came on a large ichorous discharge, with a low quick pulse and depressed spirits, and the jaws began to close, with pain and stricture on both sides about the articulation of the lower jaw. He had every day since the accident taken half an ounce of Peruvian bark, combined with opium or rhubarb, according as it made him loose or costive. This was continued, and the part externally was kept constantly moist all round with volatile liniment, to which a fourth part of _tinctura thebaica_ was added. Next day the jaw was almost entirely fixed, so that it was with difficulty that a little wine and water could be introduced with a spoon. Mr. Harris, the surgeon, now wisely determining to do something vigorous in this unpromising situation, beat up twelve ounces of opium moistened to the consistence of a cataplasm with the thebaic tincture, and applied one half to each side of the jaw. The patient this day swallowed a pint of the bark decoction with half an ounce of nitre, and took a diaphoretic draught of twenty drops of thebaic tincture and thirty of antimonial wine. He had also the smoke of tobacco thrown up his nostrils.

On the third day after the attack he could open his mouth half an inch. The cataplasms were taken off, beat up afresh with the tincture, and applied anew. The bark and other medicines were continued. On the fourth day the stricture and pain of the jaw went entirely off, but the cataplasm and volatile liniment were applied for three days longer. The wound produced a laudable discharge, every symptom became favourable, and he continued to recover.

The only other person who recovered from this symptom was a man in the Bedford. Several died of it on board of this ship; and as the same means of relief were skilfully employed in all the cases by Mr. Wickes, the surgeon, the success seemed owing more to something favourable in the man’s constitution, than any thing peculiar in the treatment, which consisted in the administration of the warm bath, opium and camphor, with mercurial friction on the jaw.

This accident affected some ships remarkably more than others, particularly the Barfleur and Bedford, though their wounds had nothing peculiar, nor were in a greater proportion than in the rest of the fleet. Four were carried off by it in each of these ships. It has formerly been observed, that great ships acquire peculiar habits, or dispositions, which incline the constitutions of the men to one disease more than another. This complaint took a run in some particular ships last year also after the battle of the Chesapeak; and I have known it prevail in some particular hospitals more than others. In the present instance, it may have been owing either to something peculiar in the constitution, or air of the ships; or we can conceive it to be owing to some sort of nervous sympathy, just as the _epilepsy_[125] has been known to spread from one boy to another, at a school, in consequence of imitation, dread, horror, or some such delicate nervous or mental affection. We have in yawning an example of a spasmodic affection spreading from one person to another. If this is the case in the locked jaw, those affected by it should be removed from the presence of the other wounded men, lest the idea of the sufferings of others should be so fixed in their mind, or so impress them with the fear of the like, as to invite the attack of the same complaint.

Though the locked jaw, in consequence of wounds, resembles frequently in its symptoms the tetanus which arises without any external accident, yet there are many cases of the former which differ materially from the violent symptoms of the other, as described by authors. In most cases of the locked jaw from wounds the spasms are not so general, so violent, nor attended with such exquisite pain. It sometimes happens that the convulsive twitchings are even accompanied with a sort of pleasure, as in the case of a lieutenant of the Montagu, whose case was related to me by Mr. Young, the surgeon of that ship, a man of skill and observation in his profession, and upon whose fidelity and accuracy I could perfectly rely. This officer had been wounded in the elbow at the battle of St. Christopher’s by a splinter, whereby the capsular ligament of the joint was injured. On the ninth day, symptoms of the locked jaw came on, and soon after the whole muscles of the wounded side were affected with frequent convulsive twitchings, which, as he himself said, afforded a pleasant sensation, exciting laughing like an agreeable titillation. He died on the fourth day after it came on, and had no pain to the last.

The locked jaw from accident differs also from other cases of tetanus, in respect to its cure; for the latter has been successfully treated by cold bathing, as is related by Dr Wright[126] and Dr. Cochrane[127]; but it is acknowledged by the latter that this treatment did not answer when the complaint proceeded from a wound.

It is to be remarked, that the locked jaw did not take place in those cases in which the wounds had a foul and gangrenous appearance more than others; for those that digested and cicatrized favourably, were equally apt to be affected by it; and though amputations are most liable to this symptom, the slightest injuries, even a scratch, will sometimes bring it on.

It would be difficult, therefore, to establish any particular treatment that would tend to prevent accidents of this kind; but Mr. Bassan, surgeon of the Arrogant, one of the line-of-battle ships engaged on the 12th of April, mixed laudanum with the dressings of all the wounds, and no locked jaw occurred.

In the Bedford there occurred a curious circumstance concerning this complaint. In one of the cases that proved fatal, the symptoms did not come on till the wound was so far healed that all dressing had been laid aside.

Mr. Wood, surgeon of the hospital at Jamaica, informed me, that in cases of the locked jaw from injuries to small members, such as fingers, he had tried the effect of amputating the part after the symptoms had come on, but without any effect in putting a stop to them.

Would it not appear, from the two last mentioned facts, that this symptom is not kept up, nor even takes place in the first instance, from an immediate present irritation, but that the constitution comes to be so modified, or receives such an impulse, as it were, that the complaint runs its course independent of the presence of that _stimulus_ which excites it?

It would be difficult to assign a satisfactory reason why this accident is more frequent in hot than in cold climates. The effect of external heat upon the living body is not to raise its temperature even when the heat of the air exceeds that of the body[128]; so that we are to seek for the effects of it in some of those affections peculiar to animal life. And as the outward temperature of the air does not affect the general mass of the body, all the effects produced by it must depend on impressions made on the external surface of the body and lungs; and the skin, which may be considered as a large expanded tissue of nervous fibres endowed with universal sympathy and great sensibility, affects every organ and every function of the body, according to the state of the air in contact with it, whether cold or hot, moist or dry, pure or vitiated. This sympathetic sensibility of the skin is chiefly affected by the state of the perspiring pores on its surface; for it is only when these are open that the impression of the air on the skin produces catarrhs, rheumatisms, and internal inflammations in cold climates; and the external temperature in hot climates being such as to keep the pores almost always open, this seems to be a principal reason of that universal irritability prevailing there, and of the general sympathy that prevails between every part, particularly as connected with the organs of perspiration[129]. This readiness of one part to be affected by another in hot climates is well illustrated by the sudden translation of certain diseases. I have seen, for instance, a catarrh cease, and be converted, as it were, into a diarrhœa, and this as quickly disappearing, a pain in the foot would arise, like an attack of the gout. All this would happen in the space of a few hours.

But, in cold climates, wounds are by no means exempt from the locked jaw; for it sometimes occurs in England, where I have seen it even in the winter season[130].

Since my return to England I have received some new and useful information on this subject in conversing with Dr. Warren, physician to the King; and as any observations derived from so much acknowledged skill and sagacity must be valuable, I shall here relate what he was so kind as to communicate to me.

This eminent physician, in attending a case in which he was nearly interested, and in which his endeavours were rewarded with success, found the greatest benefit from opium and the warm bath. The opium was given in the form of tincture, in moderate, but pretty frequent, doses. The bath was composed of milk and water, and the addition of milk was, no doubt, an improvement; for there is something in this as well as oil extremely soothing to the human nerves. Dr. Warren had intended to make trial of a bath of oil in case this had failed. He mentioned the following observation, with regard to the external application of oil, which could only have been suggested by that anxious attention that was paid to the case. It was found, that the uneasiness arising from the spasm was allayed by constantly drawing a feather wetted with oil over the temples, which had an evident effect in lulling the pain and spasm; for when this operation was left off, there was an immediate recurrence of these symptoms[131].

It would appear, therefore, from this as well as the former cases, that opium and the warm bath are the only remedies yet known which are of service in this complaint, and much will depend on the judicious management of them. The method of administering the opium, recommended by Dr. Warren, seems to be the most judicious, especially in constitutions not habituated to this medicine.

There is a certain medium in giving opium, by which its best effects are obtained, for in an under dose it will produce disturbance instead of rest; and when it is given in large quantities it frequently defeats the very end for which it is given, by throwing the body into convulsions which terminate in death. The rule for judging of the proper limits of this dose is, by its effect in inducing that stupor or insensibility which renders the senses incapable of irritation; for in this, as well as in every other case of disease, the cure seems ultimately to be the work of nature, the effect of medicine being only a secondary operation, by which it removes some obstacle to the natural efforts of the constitution. Though a dose of opium greater than ordinary is required to produce this insensibility in cases of spasm, and though the constitution in that situation will bear more, yet even here it may be given to excess; and by beginning with small quantities, and giving it in frequent rather than large doses, the constitution will thereby be better reconciled to it, and it will also with more convenience admit of that gradual increase which is peculiarly necessary with this medicine. These ideas were suggested to me by Dr. Warren; and it may be farther added, in recommendation of his method, that the liquid form is preferable to the solid, as the effects of it will sooner be seen, and a better judgement can be formed how far it is proper to push it.

Great attention is also necessary in regulating the heat of the bath; for if it is not sufficiently warm, it will not have the effect of producing a due relaxation; and if it should be too hot, it will stimulate too much, and will have the farther inconvenience of making the patient very faint in a short time. It cannot be well regulated without a thermometer, and 93° upon Fahrenheit’s scale is perhaps the best temperature. I have kept a patient in a bath of that heat for six hours, which he could not have endured for half an hour had the heat been three or four degrees higher.

The circumstance next in consequence, in the cure of this complaint, is the keeping up a moisture on the skin, and guarding the surface of the body from the access of the air. This is particularly necessary with regard to the part itself, which should be constantly enveloped in warm, anodyne, and emollient applications. The good effects of this is particularly exemplified in the case which recovered under the care of Mr. Harris, who gave the diaphoretic medicine, composed of antimonial wine and laudanum, and applied the anodyne cataplasm to the external _fauces_. It was remarked, that the locked jaw was most incident to those wounded men who lay in parts of the hospital where they were exposed to a current of air; and the cases of tetanus that most usually occur in the West Indies, independent of wounds, are those of slaves who fall asleep in the night-time in the open air.

Since the first edition of this work, there has appeared an Essay on the Locked Jaw by Dr. Rush, physician to the American army in the late war, in which he recommends, from his own observation, Peruvian bark, wine, and blisters, and to dress the wounds with mercurial ointment, in the cure of this complaint. From some trials I have since made of the bark in St. Thomas’s hospital, I have reason to think well of it as a remedy in this disease.

There is a singular species of accident to which engagements at sea are liable, the WIND OF A BALL, as it is called. If a cannon ball in its flight passes close to any part of the body, it renders it livid and numb for some time[132]. It is most dangerous when it approaches the stomach; and there was an instance of a man in the last battle, who, upon a ball passing close to his stomach, dropped down dead instantaneously, without the least visible marks of injury. Another, in consequence of a ball passing close to his belly, remained without sense or motion for some time, and a large livid tumor arose on the part, but he recovered. I attended a man at the hospital at Barbadoes, who had the buttons of his trowsers carried off by a cannon ball, without its having touched the body. The _pubis_ was livid and swelled for some time after: he suffered exquisite pain from strangury, which seemed to proceed from a _paralysis_ of the bladder, for he voided no water without a catheter for near three months, after which time he recovered. I know a brave young officer[133] in the army, who had his epaulette carried off by a cannon ball at Charlestown, in consequence of which the shoulder and adjacent parts of the neck were affected for some time. A like accident happened to a marine officer in one of the late engagements; but in neither of these was the head materially affected, nor is it so apt to be affected in this way as the stomach. I never knew death the consequence of the wind of a ball on the head; though an officer[134] in the Sultan, at the battle of Grenada, was so stunned by a shot passing near his temple, as to be insensible for some time, but he recovered entirely in a few hours[135].