These seem to arise in the same circumstances, and to be owing to the same general causes, as fevers. They may, in some sense, be considered as fevers, attended with peculiar symptoms in consequence of a determination to the bowels, just as fevers in cold climates are sometimes attended with rheumatism and catarrh. We have seen, in the first part of this work, that the dysentery arose chiefly in those ships which had been subject to fevers.

This determination to the bowels is owing to a variety of causes, but is chiefly connected with external heat; for it is most common in hot climates, and towards the end of summer or in the autumns of cold climates, owing probably to a greater acrimony of the secretions of the intestines, and particularly of the bile. Dysenteries arise in camps also at the same seasons, and in the same circumstances as bilious fevers113.

Besides climate and season, the other circumstances determining to the one disease more than the other are, 1. A difference in the constitutions of different men; for in the same ship it sometimes happens that both diseases prevail equally, though all the men are using the same diet and breathing the same air. 2. The nature of the occasional cause. A dysentery, for instance, is more likely to arise from an irregularity in eating or drinking; a fever from being exposed to the weather, particularly marsh effluvia. 3. The particular species of infection that may happen to be introduced. Suppose, for example, that a ship’s company is predisposed to acute distempers, and one man or more ill of the dysentery should be brought on board, this will become the prevailing disease, as happened in the Torbay in August, 1780. If the like number of fevers should be introduced, then fevers will be the prevailing disease.

These two diseases may therefore be considered as vicarious, the one substituting itself for the other according to particular accidents, and both proceeding from the same general causes; and this is no new idea of mine, but seems to have been Dr. Sydenham’s, when he calls the dysentery a febris introversa. It may be farther added, that dysentery is the latest form in which this cause, which is common to both, can exert itself; for it is a disease more within the reach of art; and some of the most dangerous symptoms attending fevers, particularly delirium, seldom occur in dysentery. When it proves fatal, it is in consequence of violent local affection, and that in general after it has taken a chronic form. When an incipient fever turns into a dysentery, all the symptoms, and particularly the head-ach, delirium, and coma, if there should be any, are immediately relieved. And the most favourable cases of the yellow fever are those in which a bilious diarrhoea comes on, while the most fatal are those in which the bowels are so torpid as to be insensible to any stimulus either from their own contents or from medicine.

I shall not enter into a minute description of this disease in all its stages, as this has been so ably executed by Sir John Pringle, Sir George Baker, and other authors, but shall only give a sketch of some of the most remarkable symptoms, particularly such as are peculiar to the climate and manner of life, so as to explain the varieties that may be necessary in the mode of treatment.

The fluxes that arose in the fleet were either what may be called the acute idiopathic dysenteries, or a dysenteric state of the bowels from neglected diarrhoeas, which was most apt to occur in the convalescent state of fevers, or in men labouring under the scurvy. The body is more susceptible of infection in a state of weakness from these or any other causes; and in hot climates the dysentery seems to be more infectious than fevers; for at hospitals it was so frequently communicated to men who were ill of other complaints, that it was in these the principal cause of mortality. For this reason, I was at more pains with regard to this disease than any other, in keeping those who were ill of it in a separate ward.

I have met with some violent and untractable cases which proved fatal in the acute state; but, in general, this disease draws out to a chronic form in this climate, and does not prove mortal for many weeks. The usual cause of death appears, from the inspection of the bodies, to be an ulceration of the great intestines, particularly of the descending colon and the rectum. This part of the intestinal tube is most affected from its being the receptacle of all the acrid secretions from the rest of the canal; and it is naturally more subject to congestions of the fluids and incurable ulcers, as appears from the rectum being so liable to the hÆmorrhoids and the fistula. This ulceration of the great intestines is so common, that, out of eight cases which I inspected after death, seven had this appearance. The case in which there was none was not so much a case of dysentery as of inflamed bowels, brought on by the man having drank to excess of spirits while he was recovering from a dysentery. The acute tormina which always occur in the first days of the disease seem owing to an inflammation, which terminates in ulcers; and these being constantly irritated by the sharp humours, produce the tenesmus, which is the symptom most essential to dysentery in the after part of the disease. Any diarrhoea may in this manner become dysenteric. During the acute griping at the beginning, the stools are loose and copious; but as soon as the tenesmus takes place, they are scanty, which is most probably owing to the spasmodic strictures in the great intestines, in consequence of irritation upon their excoriated surface. The inflammatory state is more lasting and violent in a cold than a hot climate, the gripings are more severe, and the danger is also greater in this stage of it.

The state which the great intestines fall into in old dysenteries seems to have something in it peculiar to itself: the several coats become thick and spongy; their texture is obliterated and destroyed; and they become of a black or very dark purple colour. This, however, cannot be called mortification; for the fibres of the gut do not lose their tenacity, nor is there that putrid and dissolved state in which gangrene consists; but it advances in time to such an extreme state of disease as to be entirely incapable of recovering its natural appearance and functions, and proves therefore the cause of death.

The greater frequency and obstinacy of these chronic fluxes in hot than in cold climates seems to be owing to the same weakening of the powers of life which make recovery in general so tedious, and particularly that of wounds and ulcers. The greater quantity of acrid bile will also tend to keep up the ulceration. Dysenteries have this disadvantage, that the Peruvian bark, which is the most powerful restorative in other complaints of this climate, is here found to be inadmissible on account of the heat, thirst, and other febrile symptoms, which it seldom fails to induce in all stages of this disease.

Treatment of Fluxes.

There are few diseases in which a prudent employment of art is more useful, or in which early means of relief are more requisite than in this114.

Where the dysentery is the original disease, and when the patient is robust and plethoric, with acute pain and a strong pulse, blood-letting may be practised with advantage in the beginning of the complaint. But there is no part of the practice in this disease in which the climate and manner of life makes a greater difference than in this; for in a temperate climate it frequently happens that repeated blood-letting is necessary; but in a hot climate, where the fibres are relaxed, and in the constitutions of seamen, whom we seldom or never find plethoric, the inflammatory symptoms requiring this evacuation do not run so high, nor continue so long.

It is in all cases of the utmost consequence to administer as early as possible a brisk saline purgative. An ounce and a half or two ounces of purging salts may be dissolved in a quart of barley water or water gruel, and given warm in cupfuls, at small intervals, till a free and copious evacuation is produced. If there should be much fever, or sickness at stomach, two grains of emetic tartar will be a great improvement of this medicine; and there will be this farther advantage from its use, that if the stomach should be loaded with bile, in which state it is more irritable, an evacuation upwards will also be excited to the great relief of the patient.

This early and seasonable measure will, in many cases, put a stop to the disease, especially if the patient is thrown into a sweat immediately after the bowels have been thus thoroughly evacuated. It is of great service in this disease to promote free perspiration, and even a plentiful sweat, which may be effected with great advantage by giving, at bed time, a medicine composed of opium, ipecacuana, and a little neutral salt, accompanying it with plentiful warm dilution. Nothing tends more to relieve griping and tenesmus than a general, warm moisture on the skin. The ipecacuana, which is an ingredient in this medicine, is one of the best anti-dysenteric remedies we know; the opium procures rest; and this, joined to the sudorific effect of the whole, not only gives a temporary relief, but tends to carry off the disease. It is most properly given in the evening; for there would be this inconvenience in constantly encouraging a sweat, that if the tenesmus should return, it would either be checked by the patient getting frequently out of bed, or there would be danger of his catching cold. I am well aware that we cannot be too cautious with regard to the use of opium in the beginning of this disease; but it is admissible more early in a hot climate than a cold one, as the inflammatory symptoms are less violent and can be sooner subdued; besides, it becomes an entirely different medicine when conjoined with the other ingredients that have been mentioned.

The best medicine in the day time we found to be small doses of ipecacuana alone twice or thrice a day; and if there should be fresh collections of bile, small doses of the saline purgative will be necessary. Ipecacuana in this intention, may be given in the dose of two grains in athletic constitutions, such as those of seamen; but in the more delicate constitutions, such as are commonly met with in private practice, one grain is a sufficient dose. I have found manna and tamarinds a good addition to this medicine in the earlier stages of the disease, where there was much bile; but in a more advanced stage of it they are apt to produce gripings and flatulence.

The marks of a redundance of bile are, a sickness at stomach, a sense of scalding at the anus when the stools are passing, and the yellow or green colour of the stools themselves. It is apt also to excite symptoms of fever, such as a foul tongue, a hot and dry skin, with thirst. When collections of it are suspected in this disease, it is best to evacuate it by vomiting, for it is thereby prevented from irritating the bowels, and from arriving at the inflamed parts with, perhaps, increased acrimony, acquired in passing through the whole length of the intestines.

Some gentlemen of the fleet informed me that they found oil of almonds a useful addition to the purgative. Others as well as myself made a practical comparison of the saline purgative with that composed of rhubarb and calomel, as recommended by Sir John Pringle, and we gave the preference to the former, as more easy, speedy, and effectual in its operation, especially in the first stage. Cases may occur, however, in which the other may be more advisable; for where there is a sense of weight about the stomach, which most probably arises from the biliary organs being clogged with bile, and where emetics have failed to remove it, or the weakness of the patient may render them improper, then calomel has the best effect: for it was formerly observed, that it tends to loosen the secretions, and to stimulate the more distant excretories, such as the biliary ducts.

It is very important to caution young practitioners concerning the employment of opium in all stages of this disease, but especially in the beginning; for though it is an excellent remedy when seasonably and judiciously employed, it is very liable to abuse, particularly in the hands of the inexperienced, who may be tempted to give it improperly from an anxiety to relieve; but as more harm may arise from an unseasonable administration of it than could be compensated by the best-timed use of it, it is best to err on the side of caution and omission. The principal caution to be observed with regard to this remedy is, to premise suitable evacuation, such as blood-letting, if necessary, but more especially purging. It is always pernicious to give it in its pure state during the tormina, so common in the first days. By these I mean the abdominal gripings, which denote inflammation, and are entirely different from the tenesmus, which is a more constant and characteristic symptom of the disease, and seems to arise from irritation and spasms of the rectum and colon.

It was in this disease that I first observed the good effects of a small quantity of neutral salt in taking off the inconveniencies attending opium, such as the feverish heat and confusion of the head, which it is apt to produce in many constitutions; and as the administration of the anodyne coincided with the evening dose of ipecacuana, I was led to adopt a form similar to that of Dover’s powder, but with only half the quantity of opium; or, it was given in a liquid form, by combining twenty drops of thebaic tincture and a drachm of ipecacuana wine, with nitre from five to ten grains, in any simple vehicle in form of a draught. There is a very observable difference, in some cases, between opium given in a liquid and in a solid form; and the former is much more certain in its effect when the intention is to procure speedy and effectual ease.

I have observed great benefit from the use of external remedies in dysentery, and these have, perhaps, been too much neglected by authors and practitioners. The warm bath is of great service, especially where the gripes and tenesmus are severe, and where the fever has been taken off by previous evacuation. Fomentations or warm applications of any kind to the abdomen give temporary relief; and it will be found of advantage to keep those parts, at all times, well defended from the cold air. Blisters to the abdomen were also found of use, and likewise acrid liniments, composed of oil, volatile spirits, and tincture of cantharides. Where the stomach has been much affected, I have perceived relief from fomenting it with stupes, upon which thebaic tincture and camphorated spirits were sprinkled, as recommended by Dr. Lind. I was once affected with a bad dysentery in the West Indies, and I thought myself much relieved by the warm bath and a blister. Strangury is not an uncommon symptom in this disease, independent of cantharides, and the most sensible and effectual relief is derived from fomentations to the pubis and perinÆum, as I also experienced in my own case.

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. Griffith115. 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 Pringle116, 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 fail117. 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.