believed the weak and low pulse which I had observed in this fever, to be
the effect of debility from a depressed state of the system, but the
unsuccessful issue of purging, and even of a spontaneous diarrh[oe]a, in
a patient of Dr. Hutchinson, had led me not only to doubt of, but to
dread its effects. My fears from this evacuation were confirmed, by the
communications I had received from Dr. Stevens. I had been accustomed to
raising a weak and low pulse in pneumony and apoplexy, by means of
blood-letting, but I had attended less to the effects of purging in
producing this change in the pulse. Dr. Mitchell in a moment dissipated
my ignorance and fears upon this subject. I adopted his theory and
practice, and resolved to follow them. It remained now only to fix upon a
suitable purge to answer the purpose of discharging the contents of the
bowels. I have before described the state of the bile in the gall-bladder
and duodenum, in an extract from the history of a dissection made by Dr.
Mitchell. I suspected that my want of success in discharging this bile,
in several of the cases in which I attempted the cure by purging, was
owing the feebleness of my purges. I had been in the habit of
occasionally purging with calomel in bilious and inflammatory fevers, and
had recommended the practice the year before in my lectures, not only
from my own experience, but upon the authority of Dr. Clark. I had,
moreover, other precedents for its use in the practice of sir John
Pringle, Dr. Cleghorn, and Dr. Balfour, in diseases of the same class
with the yellow fever. But these were not all my vouchers for the safety
and efficacy of calomel. In my attendance upon the military hospitals
during the late war, I had seen it given combined with jalap in the
bilious fever by Dr. Thomas Young, a senior surgeon in the hospitals. His
usual dose was ten grains of each of them. This was given once or twice a
day until it procured large evacuations from the bowels. For a while I
remonstrated with the doctor against this purge, as being disproportioned
to the violence and danger of the fever; but I was soon satisfied that it
was as safe as cremor tartar or glauber's salts. It was adopted by
several of the surgeons of the hospital, and was universally known, and
sometimes prescribed, by the simple name of _ten_ and _ten_. This mode
of giving calomel occurred to me in preference to any other. The jalap
appeared to be a necessary addition to it, in order to quicken its
passage through the bowels; for calomel is slow in its operation, more
especially when it is given in large doses. I resolved, after mature
deliberation, to prescribe this purge. Finding ten grains of jalap
insufficient to carry the calomel through the bowels in the rapid manner
I wished, I added fifteen grains of the former to ten of the latter; but
even this dose was slow and uncertain in its operation. I then issued
three doses, each consisting of fifteen grains of jalap and ten of
calomel; one to be given every six hours until they procured four or five
large evacuations. The effects of this powder not only answered, but far
exceeded my expectations. It perfectly cured four out of the first five
patients to whom I gave it, notwithstanding some of them were advanced
several days in the disease. Mr. Richard Spain, a block-maker, in
Third-street, took eighty grains of calomel, and rather more of rhubarb
and jalap mixed with it, on the two last days of August, and on the first
day of September. He had passed twelve hours, before I began to give him
this medicine, without a pulse, and with a cold sweat on all his limbs.
His relations had given him over, and one of his neighbours complained to
me of my neglecting to advise them to make immediate preparations for
his funeral. But in this situation I did not despair of his recovery, Dr.
Mitchell's account of the effects of purging in raising the pulse,
exciting a hope that he might be saved, provided his bowels could be
opened. I now committed the exhibition of the purging medicine to Mr.
Stall, one of my pupils, who mixed it, and gave it with his own hand,
three or four times a day. At length it operated, and produced two
copious, f[oe]tid stools. His pulse rose immediately afterwards, and a
universal moisture on his skin succeeded the cold sweat on his limbs. In
a few days he was out of danger, and soon afterwards appeared in the
streets in good health, as the first fruits of the efficacy of mercurial
purges in the yellow fever.
After such a pledge of the safety and success of my new medicine, I gave
it afterwards with confidence. I communicated the prescription to such of
the practitioners as I met in the streets. Some of them I found had been
in the use of calomel for several days, but as they had given it in small
and single doses only, and had followed it by large doses of bark, wine,
and laudanum, they had done little or no good with it. I imparted the
prescription to the college of physicians, on the third of September, and
endeavoured to remove the fears of my fellow-citizens, by assuring them
that the disease was no longer incurable. Mr. Lewis, the lawyer, Dr.
M'Ilvaine, Mrs. Bethel, her two sons, and a servant maid, and Mr. Peter
Baynton's whole family (nine in number), were some of the first trophies
of this new remedy. The credit it acquired, brought me an immense
accession of business. It still continued to be almost uniformly
effectual in all those which I was able to attend, either in person, or
by my pupils. Dr. Griffitts, Dr. Say, Dr. Pennington, and my former
pupils who had settled in the city, viz. Dr. Leib, Dr. Porter, Dr. Annan,
Dr. Woodhouse, and Dr. Mease, were among the first physicians who adopted
it. I can never forget the transport with which Dr. Pennington ran across
Third-street to inform me, a few days after he began to give strong
purges, that the disease yielded to them in every case. But I did not
rely upon purging alone to cure the disease. The theory of it which I had
adopted led me to use other remedies to abstract excess of stimulus from
the system. These were _blood-letting_, _cool air_, _cold drinks_, _low
diet_, and _applications of cold water_ to the body. I had bled Mrs.
Bradford, Mrs. Leaming, and one of Mrs. Palmer's sons with success, early
in the month of August. But I had witnessed the bad effects of bleeding
in the first week in September, in two of my patients who had been bled
without my knowledge, and who appeared to have died in consequence of
it. I had, moreover, heard of a man who had been bled on the first day of
the disease, who died in twelve hours afterwards. These cases produced
caution, but they did not deter me from bleeding as soon as I found the
disease to change its type, and instead of tending to a crisis on the
third, to protract itself to a later day. I began by drawing a small
quantity at a time. The appearance of the blood, and its effects upon the
system, satisfied me of its safety and efficacy. Never before did I
experience such sublime joy as I now felt in contemplating the success of
my remedies. It repaid me for all the toils and studies of my life. The
conquest of this formidable disease was not the effect of accident, nor
of the application of a single remedy; but it was the triumph of a
principle in medicine. The reader will not wonder at this joyful state of
my mind when I add a short extract from my note book, dated the 10th of
September. "Thank God! out of one hundred patients, whom I have visited
or prescribed for this day, I have lost none."
Being unable to comply with the numerous demands which were made upon me
for the purging powders, notwithstanding I had requested my sister, and
two other persons to assist my pupils in putting them up; and, finding
myself unable to attend all the persons who sent for me, I furnished the
apothecaries with the recipe for the mercurial purges, together with
printed directions for giving them, and for the treatment of the disease.
Hitherto there had been great harmony among the physicians of the city,
although there was a diversity of sentiment as to the nature and cure of
the prevailing fever. But this diversity of sentiment and practice was
daily lessening, and would probably have ceased altogether in a few days,
had it not been prevented by two publications, the one by Dr. Kuhn, and
the other by Dr. Stevens, in which they recommended bark, wine, and other
cordials, and the cold bath, as the proper remedies for the disease. The
latter dissuaded from the use of evacuations of all kinds. This method of
cure was supported by a letter from Alexander Hamilton, Esq. then
secretary of the treasury of the United States, to the college of
physicians, in which he ascribed his recovery from the fever to the use
of those remedies, administered by the hand of Dr. Stevens. The
respectable characters of those two physicians procured an immediate
adoption of the mode of practice recommended by them, by most of the
physicians of the city, and a general confidence in it by all classes of
citizens. Had I consulted my interest, or regarded the certain
consequences of opposing the use of remedies rendered suddenly popular by
the names that were connected with them, I should silently have pursued
my own plans of cure, with my old patients who still confided in them;
but I felt, at this season of universal distress, my professional
obligations to _all_ the citizens of Philadelphia to be superior to
private and personal considerations, and therefore determined at every
hazard to do every thing in my power to save their lives. Under the
influence of this disposition, I addressed a letter to the college of
physicians, in which I stated my objections to Dr. Kuhn and Dr. Stevens's
remedies, and defended those I had recommended. I likewise defended them
in the public papers against the attacks that were made upon them by
several of the physicians of the city, and occasionally addressed such
advice to the citizens as experience had suggested to be useful to
_prevent_ the disease, particularly low diet, gentle doses of laxative
physic, avoiding its exciting causes, and prompt applications for medical
aid. In none of the recommendations of my remedies did I claim the credit
of their discovery. On the contrary, I constantly endeavoured to enforce
their adoption, by mentioning precedents in favour of their efficacy,
from the highest authorities in medicine. This controversy with my
brethren, with whom I had long lived in friendly intercourse, carried on
amidst the most distressing labours, was extremely painful to me, and was
submitted to only to prevent the greater evil of the depopulation of our
city by the use of remedies which had been prescribed by myself, as well
as others, not only without effect, but with evident injury to the sick.
The repeated and numerous instances of their inefficacy, in some of the
most opulent families in the city, and the almost uniform success of the
depleting remedies, happily restored the public mind, after a while, from
its distracted state, and procured submission to the latter from nearly
all the persons who were affected by the fever.
Besides the two modes of practice which have been described, there were
two others: the one consisted of _moderate_ purging with calomel only,
and moderate bleeding, on the first or second day of the fever, and
afterwards by the copious use of bark, wine, laudanum, and aromatic
tonics. This practice was supported by an opinion, that the fever was
inflammatory in its first, and putrid in its second stage. The other mode
referred to was peculiar to the French physicians, several of whom had
arrived in the city from the West-Indies, just before the disease made
its appearance. Their remedies were various. Some of them prescribed
nitre, cremor tartar, camphor, centaury tea, the warm bath, glysters, and
moderate bleeding, while a few used lenient purges, and large quantities
of tamarind water, and other diluting drinks. The dissentions of the
American physicians threw a great number of patients into the hands of
these French physicians. They were moreover supposed to be better
acquainted with the disease than the physicians of the city, most of
whom, it was well known, had never seen it before.
I shall hereafter inquire into the relative success of each of the four
modes of practice which have been mentioned.
Having delivered a general account of the remedies which I used in this
disease, I shall now proceed to make a few remarks upon each of them. I
shall afterwards mention the effects of the remedies used by other
physicians.
OF PURGING.
I have already mentioned my reasons for promoting this evacuation, and
the medicine I preferred for that purpose. It had many advantages over
any other purge. It was detergent to the bile and mucus which lined the
bowels. It probably acted in a peculiar manner upon the biliary ducts,
and it was rapid in its operation. One dose was sometimes sufficient to
open the bowels; but from two to six doses were often necessary for that
purpose; more especially as part of them was frequently rejected by the
stomach. I did not observe any inconvenience from the vomiting which was
excited by the jalap. It was always without that straining which was
produced by emetics; and it served to discharge bile when it was lodged
in the stomach. Nor did I rest the discharge of the contents of the
bowels on the issue of one cleansing on the first day. There is, in all
bilious fevers, a reproduction of morbid bile as fast as it is
discharged. I therefore gave a purge every day while the fever
continued. I used castor oil, salts, cremor tartar, and rhubarb (after
the mercurial purges had performed their office), according to the
inclinations of my patients, in all those cases where the bowels were
easily moved; but where this was not the case, I gave a single dose of
calomel and jalap every day. Strong as this purge may be supposed to be,
it was often ineffectual; more especially after the 20th of September,
when the bowels became more obstinately constipated. To supply the place
of the jalap, I now added gamboge to the calomel. Two grains and a half
of each, made into a pill, were given to an adult every six hours, until
they procured four or five stools. I had other designs in giving a purge
every day, besides discharging the re-accumulated bile. I had observed
the fever to fall with its principal force upon such parts of the body as
had been previously weakened by any former disease. By creating an
artificial weak part in the bowels, I diverted the force of the fever to
them, and thereby saved the liver and brain from fatal or dangerous
congestions. The practice was further justified by the beneficial effects
of a plentiful spontaneous diarrh[oe]a in the beginning of the
disease[66]; by hæmorrhages from the bowels, when they occurred from no
other parts of the body, and by the difficulty or impracticability of
reducing the system by means of plentiful sweats. The purges seldom
answered the intentions for which they were given, unless they produced
four or five stools a day. As the fever showed no regard to day or night
in the hours of its exacerbations, it became necessary to observe the
same disregard to time in the exhibition of purges: I therefore
prescribed them in the evening, at all times when the patient had passed
a day without two or three plentiful stools. When purges were rejected,
or slow in their operation, I always directed opening glysters to be
given every two hours. The effects of purging were as follow:
1. It raised the pulse when low, and reduced it when it was
preternaturally tense or full.
2. It revived and strengthened the patient. This was evident in many
cases, in the facility with which patients who had staggered to a
close-stool, walked back again to their beds after a copious evacuation.
Dr. Sydenham takes notice of a similar increase of strength after a
plentiful sweat in the plague. They both acted by abstracting excess of
stimulus, and thereby removing the depression of the system.
3. It abated the paroxysm of the fever. Hence arose the advantage of
giving a purge in some cases in the evening, when an attack of the fever
was expected in the course of the night.
4. It frequently produced sweats when given on the first or second day of
the fever, after the most powerful sudorifics had been taken to no
purpose.
5. It sometimes checked that vomiting which occurs in the beginning of
the disease, and it always assisted in preventing the more alarming
occurrence of that symptom about the 4th or 5th day.
6. It removed obstructions in the lymphatic system. I ascribe it wholly
to the action of mercury, that in no instance did any of the glandular
swellings, which I formerly mentioned, terminate in a suppuration.
7. By discharging the bile through the bowels as soon and as fast as it
was secreted, it prevented, in most cases, a yellowness of the skin.
[66] In some short manuscript notes upon Dr. Mitchell's account of the
yellow fever in Virginia, in the year 1741, made by the late Dr.
Kearsley, sen. of this city, he remarks, that in the yellow fever
which prevailed in the same year in Philadelphia, "some recovered
by an _early_ discharge of _black_ matter by stool." This
gentleman, Dr. Redman informed me, introduced purging with
glauber's salts in the yellow fever in our city. He was preceptor
to Dr. Redman in medicine.
However salutary the mercurial purge was, objections were made to it by
many of our physicians; and prejudices, equally weak and ill-founded,
were excited against it. I shall enumerate, and answer those objections.
1. It was said to be of too drastic a nature. It was compared to arsenic;
and it was called a dose for a horse. This objection was without
foundation. Hundreds who took it declared they had never taken so mild a
purge. I met with but one case in which it produced bloody stools; but I
saw the same effect from a dose of salts. It sometimes, it is true,
operated from twenty to thirty times in the course of twenty-four hours;
but I heard of an equal number of stools in two cases from salts and
cremor tartar. It is not an easy thing to affect life, or even subsequent
health, by copious or frequent purging. Dr. Kirkland mentions a
remarkable case of a gentleman who was cured of a rheumatism by a purge,
which gave him between 40 and 50 stools. This patient had been previously
affected by his disease 16 or 18 weeks[67]. Dr. Mosely not only proves
the safety, but establishes the efficacy of numerous and copious stools
in the yellow fever. Dr. Say probably owes his life to three and twenty
stools procured by a dose of calomel and gamboge, taken by my advice. Dr.
Redman was purged until he fainted, by a dose of the same medicine. This
venerable gentleman, in whom 70 years had not abated the ardour of
humanity, nor produced obstinacy of opinion, came forward from his
retirement, and boldly adopted the remedies of purging and bleeding, with
success in several families, before he was attacked by the disease. His
recovery was as rapid, as the medicine he had used was active in its
operation. Besides taking the above purge, he lost twenty ounces of blood
by two bleedings[68].
[67] Treatise on the Inflammatory Rheumatism, vol. i. p. 407.
[68] Dr. Redman was not the only instance furnished by the disease, in
which _reason_ got the better of the habits of old age, and of the
formalities of medicine. About the time the fever declined, I
received a letter from Dr. Shippen, sen. (then above 82 years of
age), dated Oxford Furnace, New-Jersey, October 13th, 1793, in
which, after approving in polite terms of my mode of practice, he
adds, "Desperate diseases require desperate remedies. I would only
propose some small addition to your present method. Suppose you
should substitute, in the room of the jalap, _six_ grains of
gamboge, to be mixed with ten or fifteen grains of calomel; and
after a dose or two, as occasion may require, you should bleed
your patients _almost_ to death, at least to _fainting_; and then
direct a plentiful supply of mallows tea, with fresh lemon juice,
and sugar and barley water, together with the most simple, _mild_,
and nutricious food." The doctor concludes his letter by
recommending to my perusal Dr. Dover's account of nearly a whole
ship's crew having been cured of a yellow fever, on the coast of
South-America, by being bled until they fainted.
But who can suppose that a dozen or twenty stools in a day could endanger
life, that has seen a diarrh[oe]a continue for several months, attended
with fifteen or twenty stools every day, without making even a material
breach in the constitution? Hence Dr. Hillary has justly remarked, that
"it rarely or never happens that the purging in this disease, though
violent, takes the patient off, but the fever and inflammation of the
bowels[69]." Dr. Clark in like manner remarks, that evacuations do not
destroy life in the dysentery, but the fever, with the emaciation and
mortification which attend and follow the disease[70].
[69] Diseases of Barbadoes, p. 212.
[70] Diseases in Voyages to Hot Climates, vol. ii. p. 322.
2. A second objection to this mercurial purge was, that it excited a
salivation, and sometimes loosened the teeth. I met with but two cases
in which there was a loss of teeth from the use of this medicine, and in
both the teeth were previously loose or decayed. The salivation was a
trifling evil, compared with the benefit which was derived from it. I
lost only one patient in whom it occurred. I was taught, by this
accidental effect of mercury, to administer it with other views than
merely to cleanse the bowels, and with a success which added much to my
confidence in the power of medicine over this disease. I shall mention
those views under another head.
3. It was said that the mercurial purge excoriated the rectum, and
produced the symptoms of pain and inflammation in that part, which were
formerly mentioned.
To refute this charge, it will be sufficient to remark that the bile
produces the same excoriation and pain in the rectum in the bilious and
yellow fever, where no mercury has been given to discharge it. In the
bilious remitting fever which prevailed in Philadelphia in 1780, we find
the bile which was discharged by "gentle doses of salts, and cream of
tartar, or the butternut pill, was so acrid as to excoriate the rectum,
and so offensive as to occasion, in some cases, sickness and faintness
both in the patients, and in their attendants[71]."
[71] Vol. i.
Dr. Hume says further upon this subject, that the rectum was so much
excoriated by the natural discharge of bile in the yellow fever, as to
render it impossible to introduce a glyster pipe into it.
4. It was objected to this purge, that it inflamed and lacerated the
stomach and bowels. In support of this calumny, the inflamed and
mortified appearances, which those viscera exhibited upon dissection in a
patient who died at the hospital at Bush-hill, were spoken of with horror
in some parts of the city. To refute this objection it will only be
necessary to review the account formerly given of the state of the
stomach and bowels after death from the yellow fever, in cases in which
no mercury had been given. I have before taken notice that sir John
Pringle and Dr. Cleghorn had prescribed mercurial purges with success in
the dysentery, a disease in which the bowels are affected with more
irritation and inflammation than in the yellow fever. Dr. Clark informs
us that he had adopted this practice. I shall insert the eulogium of this
excellent physician upon the use of mercury in the dysentery in his own
words. "For several years past, when the dysentery has resisted the
common mode of practice, I have administered mercury with the greatest
success; and am thoroughly persuaded that it is possessed of powers to
_remove inflammation_ and _ulceration_ of the intestines, which are the
chief causes of death in this distemper[72]."
[72] Vol. ii. p. 342.
5. It was urged against this powerful and efficacious medicine, that it
was prescribed indiscriminately in all cases, and that it did harm in all
weak habits. To this I answer, that there was no person so weak by
constitution or a previous disease, as to be injured by a single dose of
this medicine. Mrs. Meredith, the wife of the treasurer of the United
States, a lady of uncommon delicacy of constitution, took two doses of
the powder in the course of twelve hours, not only without any
inconvenience, but with an evident increase of strength soon afterwards.
Many similar cases might be mentioned. Even children took two or three
doses of it with perfect safety. This will not surprise those physicians
who have been in the practice of giving from ten to twenty grains of
mercury, with an equal quantity of jalap as a worm purge, and from fifty
to a hundred grains of calomel, in the course of four or five days, in
the internal dropsy of the brain. But I am happy in being able to add
further, that many women took it in every stage of pregnancy without
suffering the least inconvenience from it. Out of a great number of
pregnant women whom I attended in this fever I did not lose one to whom I
gave this medicine, nor did any of them suffer an abortion. One of them
had twice miscarried in the course of the two or three last years of her
life. She bore a healthy child three months after her recovery from the
yellow fever.
No one has ever objected to the _indiscriminate_ mode of preparing the
body for the small-pox by purging medicines. The _uniform_ inflammatory
diathesis of that disease justifies the practice, in a certain degree, in
all habits. The yellow fever admits of a sameness of cure much more than
the small-pox, for it is _more_ uniformly and more highly inflammatory.
An observation of Dr. Sydenham upon epidemics applies, in its utmost
extent, to our late fever. "Now it must be observed (says this most acute
physician) that some epidemic diseases, in some years, are uniformly and
constantly the same[73]." However diversified our fever was in some of
its symptoms, it was in all cases accompanied by more or less
inflammatory diathesis, and by a morbid state of the alimentary canal.
[73] Vol. i. p. 9.