Imatges de pÓgina

my authorities, or given their meaning, as found in my notebook, than quoted their precise words. In ships recently and hastily fitted out, fever is so frequent an occurrence, that it would be superfluous to dwell upon the rise and progress of that in question, by explaining the consequences attendant upon the equipment of a large fleet, with the utmost dispatch, manned chiefly with landsmen, necessarily subjected to great changes in their diet, habits, &c. and unaccustomed to the privations and exposure incident to their new mode of life. During the voyage to England, sickness increased rapidly in Vice-Admiral Crown's squadron, which had been longer at sea, having sailed from Archangel to join the division at Cronstadt; and, by the time the fleet arrived in the Medway, fever had made so alarming a progress, that it became necessary to appropriate hospital-ships to receive the sick, which were immediately crowded with patients; several of whom were in a dying state, and many in the advanced stage of typhus.

To the previous exertions, and judicious arrangements, of Dr Weir, inspector of hospitals, I found myself greatly indebted upon my arrival, some time afterwards.

To the fleet, which, under the command of his Excellency Admiral Tate, consisted of fifteen sail of the line, and eight frigates, &c. were then attached twelve British medical officers,The services of whom, and of those appointed on subsequent occasions, were of great assistance to me, and advantageous to the squadron. Exclusively of the milder cases, treated by them on board, the hospital and convalescent ships contained, at that time, about 300 patients; but, as shewing the prevalence of the disease, and the result of the treatment employed, it will be better to give the total number, by premising that, between the 18th of December 1812 and the 24th of April 1813, there were received by the Argonaut and Trusty 802 cases; and, again, between the 25th of September 1813 and the 3d of March 1814, were admitted 1006 cases; making in the whole 1808 patients in hospital, generally labouring under fever. Of this number, including convalescents at the time of my arrival, above twothirds were under cure, and 109 died, during the periods of my inspection, comprehending seven months, which is nearly one man in eleven. The antecedent mortality had been double this proportion, which may be accounted for, by many, at the commencement, having been received in the last stage of the disease, whereas, afterwards, they were generally sent early;-by the greater malignity of the first attacks;-and also by the greater confidence and freedom with which the depletory system was resorted to, in proportion to its success. This, it may

be presumed, would have been still greater, if the patients, in all cases, could have been sent to the hospital-ships at once; but, notwithstanding every injunction to this effect, owing to their distance from the fleet, the state of the tide and weather, and their frequently not complaining immediately, the fever had often made considerable progress before it was detected.

I ought here to observe, that the above dates (in both cases commencing with the reception of the sick into the hospitalships, and ending when my appointment ceased, on the fever being subdued) comprehend two distinct periods of sickness; the ships having remained perfectly healthy from April 1813 till the following September, when fever was revived in the fleet by a large reinforcement of recruits having arrived in crowded transports; but as the disease and the treatment were the same, I have thought it best to give the aggregate result, and to state that my remarks apply to both periods; though in the former, the disorder had attained a higher degree of malignancy before it was controlled. Many of the first and worst cases, as already stated, were admitted in the last stage of typhus, with low muttering delirium, picking at the bed-clothes, subsultus tendinum, hiccup, squinting, and involuntary exertions,-and some with a vomiting of dark-coloured fluid, gangrene of the toes, &c.

When I joined the fleet, the fever, in both instances, had become less typhoid; it was reported to me to be "synochus, frequently terminating in typhus, and death, if copious evacuations had not been had recourse to at an early period of the disease."

It is highly important, here, to contrast the difference of symptoms under this practice, even in unfavourable cases, with those of the patients first received, which had not been controlled by depletion. The tongue was often parched, but not black; there was delirium, but not of the low muttering kind; subsultus tendinum, but without great nervous tremor; seldom involuntary discharges, and no strabismus, nor those appearances of putrescency which mark the close of malignant fever. It appears to me, therefore, an inevitable conclusion, that, by those remedies which repress inflammatory action at the commencement, those graver, or eminently typhoid symptoms, which characterize the advanced stage of such fevers, were prevented. But I am not anxious to designate the di-order, since it has been but too common to connect with the name peculiar ideas of a disease, modifying the treatment, which ought alone to be regulated by a knowledge of its nature and tendency, aided by the pathological light of dissection.

In proof of the highly infectious nature of this fever, in the

first instance, particularly in the hospital-ships, where so much disease was concentrated, it will be sufficient to mention, that nine out of eleven medical officers, attached to the sickly division, and to the hospitals, were attacked in the course of a few weeks. It proved fatal to one surgeon and an assistant; and two assistant-surgeons belonging to the Trusty died of the consequences. I was one of the last taken ill, after having been exposed for little more than ten days; which may be readily accounted for, when the powerful exciting causes inseparable from visiting a distant, detached, and sickly squadron, in the middle of winter, are taken into consideration.

The contagion appears to have been particularly powerful in the Trusty, which ship had received the first, and consequently the worst cases; as not only the surgeon, and other medical officers, suffered severely, but twelve out of sixteen attendants, accustomed to the duty of waiting upon the sick, were seized with fever, four of whom died.

. Several attendants in the Argonaut, two assistants, and ultimately the surgeon, were also attacked; but he informs me, that, with one exception, all recovered, in whom he had the adIt is vantage of combating the disease at its commencement. needless here to dwell upon the value of various prophylatic measures under the heads of separation, ventilation, dryness, cleanliness, better clothing, &c. to which my solicitude was chiefly directed, or the difficulties that opposed their execution. I may, however, remark, that the benefit was in proportion as they were practised, and that the disease gradually became milder, to which the decreasing severity of the weather, as the spring advanced, materially contributed. Indeed, although malignant cases still continued from time to time to occur, in the more general course of symptoms, such as I am about to describe, there was little remarkable; and without keeping in view the tendency to inflammation and disorganization which characterized the progress of the disease, there would have appeared little to warrant apprehension; but, as Dr Haygarth justly remarks, after describing the symptoms of Typhus mitior, sometimes even this mild typhus is fatal.

The invasion of this, like many other fevers, was generally preceded by listlessness, languor, and weariness, which, according to the old maxim, foretell disease. This state of indisposition to mental or bodily exertion, was followed by chilliness rarely increasing to rigor, prostration of strength, or a sense of general soreness and fatigue; pain of the head, back, &c.; anorexy, but seldom vomiting, and succeeded by increased heat, though the patient often complained of cold; frequent pulse, but

VOL. XII. NO. 46.


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varying in strength, white tongue, thirst, costiveness, and other symptoms of fever, which often continued for several days before any particular organ appeared to be attacked. In some cases, a higher degree of febrile action was early indicated by flushing of the face, sensibility and glossiness of the eyes, throb bing of the arteries of the neck and temples, with greater heat and anxiety of respiration; but though, in others, the accession was less strongly marked, and the patient made little complaint, except of headach at first, yet symptoms of increased determination to the breast, head, &c. supervened in a few days, unless anticipated; corroborating the observations of Riverius and Baglivi, as to the frequency of visceral inflammation in such fevers.

The features of fever are so infinitely modified, that I have no intention of delineating all the varieties in the present instance; but I trust I shall not be suspected of the less veneration for such great authorities as Dr Cullen, Fordyce, &c. if I notice here, that my observation has not tended to convince me of the propriety of holding forth an intermittent paroxysm as an epitome of continued fevers in general, or of considering them as merely a repetition of such paroxysms, more or less distinctly marked, with longer or shorter intervals.

I am, therefore, gratified by having since found that Dr Willan, in his reports for 1801, from close attention to the origin, symptoms, and termination of both, is of opinion, that no direct analogy subsists between an intermittent and a malignant fever, propagated by infection.

The most frequent occurrence in the disease under consideration was a sense of dyspnoea, and a cough supervening about the fifth day in some it assumed more the appearance of simple pulmonic inflammation; in others of pneumonia typhodes. It was occasionally attended also with symptoms of cynanche, and swellings of the parotid and submaxillary glands, which, in a few instances, terminated in mortification and death; and gelatinous-looking effusions were likewise sometimes found in the trachea and bronchial vessels; but these varieties were comparatively rare.

Delirium and coma were very constant attendants at a more advanced period, in unfavourable cases; and it is hardly necessary to remark, that the danger was in proportion to the degree of stupor, and the depraved or oppressed condition of the sensorial and respiratory functions; while, in the more obscure cases, it was better estimated by the countenance, posture, and answers of the patient, than by the pulse or other prominent symptoms. In a few instances in which they occurred, an un

pleasant cadaverous smell from the body, and much tremor of the hands and lips, indicating great depression of nervous energy, proved fatal symptoms. The same remark was particularly made to me in the Levant, as to tremor of the lips in the plague.

Some authors, as Sydenham, Huxham, &c. mention examples of spontaneous salivation proving critical in fever. Instances of increased determination to the salivary glands sometimes attended here, which could not be imputed to mercurial influence. In myself, without having taken any mercury at all, their action was excited by insensibly acquiring a habit of spitting frequently, until it amounted to complete ptyalism. It accompanied, and diminished with the disease in a remarkable degree on the seventeenth day, and had almost entirely ceased by the next morning.

It had always been considered a favourable omen, as indicating a less powerful character of fever, at least as far as relates to heat and vascular excitement; for in those of tropical climates, I have had but too many opportunities of observing that salivation could not be induced when there was a high temperature and strong inflammatory or febrile action; and I am therefore led to believe that its existence is incompatible with a rapid and ardent form of fever.

I may here add, that, as far as I may judge from personal recollection, the feelings which excited the greatest uneasiness and attention, were a throbbing of the temples for some nights preceding the attack, the headach in the first, and the cough in the latter stage of the disease, together with watchfulness, and a distressing sense of sinking, or extreme prostration, and a tendency to evening delirium, representing the presence of unpleasant objects; but generally so mild, that the mind became sensible of it when painful, and, by opening the eyes and fixing the attention, could be recalled from its alienation.

The duration of the fever was various, often protracted, and without any regular crisis. But, upon the whole, an amendment was, perhaps, most frequently observed on the eleventh day; though in numerous instances on the other odd days also, from the 7th to the 17th inclusive. Few recovered in whom a change for the better was not perceptible by the latter date, which is considered by Sir John Pringle as the most frequently critical. When the disease was prolonged, it generally left a troublesome cough behind, and an excessive degree of debility, from which the convalescence was extremely tedious, but when a crisis took place early the recovery was rapid.

Although I am not inclined to place much reliance on such

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