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belly, occasional tenesmus, frequent costiveness, followed by spontaneous diarrhea and discharges of blood, attended with frequent prolapsus ani and difficult micturition.
In conducting the cure, very delicate management was requisite; in fact the disease required rather to be led than driven. A regulated diet, and the use of flannel next the skin, were of the highest consequence. At the same time, the patient was put under a gentle and gradual course of calomel, taking two or three grains morning and evening, and rubbing in a portion of mercurial ointment on the belly and right side. Laxatives and astringents were employed occasionally, but, above all, the greatest use was made of opium, both internally and locally, per anum, and it really effected most conspicuous benefit. Sulphate of zinc I now and then tried, but from the nausea which it excited, even in three-grain pills, morning and evening, and from its apparent inefficacy in the disease, I should scarcely, in future, be tempted to give it farther trials. The tonic power of Peruvian hark was very useful-both as an astringent to the bowels and as a restorative to the whole system. When the mouth was recovered from the first gentle mercurial course, if the complaint had not yielded, I did not hesi. tate to use calomel again in the same gradual manner, till the gums were slightly affected, and then gave tonics as before. This assiduous perseverance, and the patient attention which it implied, I am happy to say, were well rewarded. Many patients were thus recovered from a state, not hopeless indeed, but very precarious, and were re-established in firm health.
I have been thus minute on the subject of dysentery, seeing it was the principal disease by which we suffered. The prac, tice above detailed was not merely my own, but was pursued, though perhaps with minute variations, by most of the medical officers of my acquaintance on this expedition.
I have before mentioned, that, besides dysentery, many cases of intermittent fever and scurvy occurred; in truth, the latter diathesis was often very conspicuous in the patients affected with dysentery. Of the intermittents I need not speak, as nothing remarkable took place in their symptoms, and they were all easily cured by the usual means. Of scurvy, however, from the great number of the cases, and the fatality of some of them, it is necessary that I should give some account. Besides the customary symptoms of livid blotches, bleeding gums, a d a slow healing of the small cuts or scratches accidentally inflicted, phlegmonic inflammation and suppuration sometimes occurred spontaneously on the leg, followed, when the abscess burst or was opened, by sphacelation of the cellular substance. Often, too, trivial sores would change, in a night, and take on ulcerative action, with extensive sloughing of the integuments and muscles, and a most profuse ill-conditioned discharge. When the mere loss of parts was so considerable as to render it impossible to save the limb, and the resource of amputation was called for, the case did not often end well; for the stump, after doing apparently well, degenerated without any evident cause, and was seized with sloughing, a black thin fetid discharge, and a general melting away of the muscles, until they were insufficient to cover the bone. Hectic fever and exhaustion gave the patient his last release.
In this formidable complaint, which may be denominated sloughing scorbutic ulcer,” many remedies were employed, both internally and externally. The internal ones were limejuice, bark-mixture, and mineral acid; but it would appear that the former, though adequate to correct a mere proclivity to scurvy, has little or no power in these more advanced and serious states of the disease. In fact, it was not to be so corrected; it was not merely vegetable acid, but esculent vegetables, fruits, refreshments, and repose, that were necessary. It was purely from the want of these that the people had suffered; for neither crowding, impure air, nor filth, had any existence in situations where this form of scurvy often appeared.
Equal parts of basilicon and oil of turpentine (melted and applied warm to the ulcer), mixtures of lime-juice, or rum and water, charcoal cataplasms, common poultices, bark decoctions, or bark in powder, were employed as outward applications to a sore; but though they kept it cleaner, they were often of no avail to arrest the sloughing process. A solution of two drachms of alum, in about a quart of water, was, upon the whole, an admirable local remedy, and seemed to possess
wonderful powers in stopping the ravages of sphacelus, and giving a healing tendency to spreading ulcers. For the knowledge of this application, which is not more simple than efficacious, I am indebted to the liberality of Mr. Boyd, surgeon of the Gorgon Hospital-ship, a gentleman of uncommon ability and experience in every department of the profession.*
The detail of this season of peril and pressure closes here. It commenced about the middle of January, and its painful duration was upwards of two months. During the last week of March and first week of April, the main part of the expedition finally left those shores; therefore the observations I am about to make on fever, apply less to the armament in general, than to the force (chiefly naval) that was obliged to remain in the gulf of Mexico for several weeks after the rest had proceeded home.
The frosts and cold rains which had lately prevailed on this coast were now at an end, and the weather rapidly mounted to the average standard of the torrid zone. During April and May, the thermometer was never below 80 degrees, and often indeed rose much higher. This greatly augmented temperature soon began to tell on the people, and gave rise to many cases of cholera and of ardent fever,—the latter entirely confined to those who had previously been serving on shore, or exposed much to the sun and night-dews while pulling in boats on the coast, or in the river of Apalachicola. Of the former disease, not one instance, so far as I know, proved fatal. Large doses of calomel, with opium, and plenty of mild diluents, constituted the whole of the treatment. In ardent fever, however, the success, though great, was by no means so uniform.
Of the treatment I come now to speak. Regarding this disease to be, to all practical intents and purposes, inflammatory, and the affection of the head to be primary and essential; which is evinced by headach, intolerantia lucis, and red eyes, occurring as the earliest symptoms (for the eye is here an index of the state of the brain, in the same manner as the tongue
* I trust Mr. B. will excuse this unauthorized citaticn of his name and authority.
is of the state of the stomach), I have never hesitated to push evacuations to the utmost. Bleeding from the arm or frontal branch of the temporal artery, was always my first step; and large and repeated bleeding during the early stage (the earlier the better) I consider the great palladium of the patient's safety. One cannot tell how many ounces ought to be taken; we ought to bleed to syncope, to break the morbid association of the symptoms, and induce a speedy remission; for I am convinced, that it is less by its unloading the vessels, than by the shock (I cannot express it in philosophical language) which it gives to the whole system, nervous as well as vascular, that blood-letting affords the magical relief I have so often witnessed. It is also by the inexplicable changes implied in the word shock, that cold affusion operates advantageously; for, in tropical climates, where the temperature of sea-water is generally from 80 to 82 degrees, its refrigerating power must be much abated.
The state of the pulse is less to be regarded than the urgency of the other symptoms; even when the former is thready or undulating, the latter often imperiously demand renewed depletion; and their demand must be complied with at all hazards. In a disease like this, where the danger is frequently imminent in twelve or twenty-four hours, it is amazing how much its apparent character may be altered by active depletion. From a fever of the highest grade, management will change its complexion to one of the second or third order. To secure every chance of such success, no attention must be spared; the patient ought to be seen every two hours; and, whenever the febrile symptoms get up anew, new exertions must forthwith be made to subdue them.
It is an Herculean disease, and, without that almost omnipotent remedy, the lancet, we might be said to encounter it unarmed; for all other means are but of secondary force. It requires all the vigour and activity imaginable, else it will gain ground on us with rapid strides. A practitioner who will not bleed largely in the onset, will soon feel himself in the melancholy predicament of the celebrated Julian the Apos. tate,* who was hurried into battle with an active and unrelenting enemy before he had buckled on his armour, or prepared himself for his defence. Like Julian, he will feel his vantageless condition when it is too late, and will pay dearly (if he has sensibility), or at least his patient will pay dearly, the forfeit of such neglect; for be it remembered, that, in medicine no less than in politics, “Quicquid delirant reges, plectuntur Achivi.”
In this disease, therefore, it is indispensable to bleed again and again:- It is the main stay,—the sheet-anchor of hope. Without it, many, very many mast infallibly be lost;—would that I could say that by it all are saved! But when it is recollected how often inflammation, even of parts not vital, foils all our exertions at resolution, it cannot be wondered at, if blood-letting is often incompetent to remove inflammation of the brain or abdominal viscera, organs endowed with high sensibility, extensive sympathy, and functions whose right performance is essential to life.
I cannot undertake to go minutely into all the happy resultst of this decisive practice; in fact, it is the less necessary for me to do so, as it obtains so generally amongst surgeons employed in the service of their country in tropical climates,
* For the death of Julian, and the manner of it, see the elegant narrative of Ammianu Marcellinus (Hist. Lib. xxx.), as also Mr. Gibbon's interesting account.
† It is remarked that patients who have been ill of fever are apt afterwards to die of dysentery or chronic complaints. Though thirty-seven of the crew of the frigate to which I belong laboured under ardent fever on the Jamaica station, and though the ship afterwards suffered a good deal from dysentery in the Gulf of Mexico, none of the thirty survivors died of that or any other subsequent disease. It is therefore another praise of the deple. tory practice, that it leaves no visceral obstructions to be a source of after danger.
I shall here mention a farther indirect advantage arising from this method. In the early stage of ardent fever there is often a torpor of the bowels, which renders them insensible to the stimulus of purgatives. When bleed. ing is practised, either while the blood flows, or immediately after recovering from syncope, the cathartic previously given produces urgent calls to the seat and full purging. Venæsection certainly renders the body more suscep. tible of the action of blisters also.