persons who had been cured by copious blood-letting, have been ascribed
to it. This is so far from being true that the reverse of it has occurred
in many cases. Mr. Mierken worked in his sugar-house, in good health,
nine days after his last bleeding; and Mr. Gribble and Mr. George seemed,
by their appearance, to have derived fresh vigour from their evacuations.
I could mention the names of many people who assured me their
constitutions had been improved by the use of those remedies; and I know
several persons in whom they have carried off habitual complaints. Mr.
Richard Wells attributed his relief from a chronic rheumatism to the
copious bleeding and purging which were used to cure him of the yellow
fever; and Mr. William Young, the bookseller, was relieved of a chronic
pain in his side, by means of the same remedies.
3. It was said, that blood-letting was prescribed indiscriminately in all
cases, without any regard to age, constitution, or the force of the
disease. This is not true, as far as it relates to my practice. In my
prescriptions for patients whom I was unable to visit, I advised them,
when they were incapable of judging of the state of the pulse, to be
guided in the use of bleeding, by the degrees of pain they felt,
particularly in the head; and I seldom advised it for the _first_ time,
after the second or third day of the disease.
In pneumonies which affect whole neighbourhoods in the spring of the
year, bleeding is the universal remedy. Why should it not be equally so,
in a fever which is of a more uniform inflammatory nature, and which
tends more rapidly to effusions, in parts of the body much more vital
than the lungs?
I have before remarked, that the debility which occurs in the beginning
of the yellow fever, arises from a depressed state of the system. The
debility in the plague is of the same nature. It has long been known that
debility from the sudden abstraction of stimuli is to be removed by the
_gradual_ application of stimuli, but it has been less observed, that the
excess of stimulus in the system is best removed in a _gradual_ manner,
and that too in proportion to the degrees of depression, which exist in
the system.
This principle in the animal economy has been acknowledged by the
practice of occasionally stopping the discharge of water from a canula in
tapping, and of blood from a vein, in order to prevent fainting.
Child-birth induces fainting, and sometimes death, only by the _sudden_
abstraction of the stimulus of distention and pain.
In all those cases where purging or bleeding have produced death in the
yellow fever or plague, when they have been used on the first or second
day of those diseases, I suspect that it was occasioned by the quantity
of the stimulus abstracted being disproportioned to the degrees of
depression in the system. The following facts will I hope throw light
upon this subject.
1. Dr. Hodges informs us, that "although blood could not be drawn in the
plague, even in the smallest quantity without danger, yet a _hundred_
times the quantity of fluids was discharged in pus from buboes without
inconvenience[79]."
[79] Page 114.
2. Pareus, after condemning bleeding in the plague, immediately adds an
account of a patient, who was saved by a hæmorrhage from the nose, which
continued _two_ days[80].
[80] Skenkius, lib. vi. p. 881.
3. I have before remarked that bleeding proved fatal in three cases in
the yellow fever, in the month of August; but at that time I saw one, and
heard of another case, in which death seemed to have been prevented by a
bleeding at the nose. Perhaps the uniform good effects which were
observed to follow a spontaneous hæmorrhage from an orifice in the arm,
arose wholly from the _gradual_ manner in which the stimulus of the blood
was in this way abstracted from the body. Dr. Williams relates a case of
the recovery of a gentleman from the yellow fever, by means of small
hæmorrhages, which continued three days, from wounds in his shoulders
made by being cupped. He likewise mentions several other recoveries by
hæmorrhages from the nose, after "a vomiting of black humours and a
hiccup had taken place[81]."
[81] Essay on the Bilious or Yellow Fever of Jamaica, p. 40.
4. There is a disease in North-Carolina, known among the common people by
the name of the "pleurisy in the head." It occurs in the winter, after a
sickly autumn, and seems to be an evanescent symptom of a bilious
remitting fever. The cure of it has been attempted by bleeding, in the
common way, but generally without success. It has, however, yielded to
this remedy in another form, that is, to the discharge of a few ounces of
blood obtained by thrusting a piece of quill up the nose.
5. Riverius describes a pestilential fever which prevailed at
Montpellier, in the year 1623, which carried off one half of all who were
affected by it[82]. After many unsuccessful attempts to cure it, this
judicious physician prescribed the loss of _two_ or _three_ ounces of
blood. The pulse rose with this small evacuation. Three or four hours
afterwards he drew six ounces of blood from his patients, and with the
same good effect. The next day he gave a purge, which, he says, rescued
his patients from the grave. All whom he treated in this manner
recovered. The whole history of this epidemic is highly interesting, from
its agreeing with our late epidemic in so many of its symptoms, more
especially as they appeared in the different states of the pulse.
[82] De Febre Pestilenti, vol. ii. p. 145, 146, and 147.
An old and intelligent citizen of Philadelphia, who remembers the yellow
fever of 1741, says that when it first made its appearance bleeding was
attended with fatal consequences. It was laid aside afterwards, and the
disease prevailed with great mortality until it was checked by the cold
weather. Had blood been drawn in the manner mentioned by Riverius, or had
it been drawn in the usual way, after the abstraction of the stimulus of
heat by the cool weather, the disease might probably have been subdued,
and the remedy of blood-letting thereby have recovered its character.
Dr. Hodges has another remark, in his account of the plague in London in
the year 1665, which is still more to our purpose than the one which I
have quoted from it upon this subject. He says that "bleeding, as a
preventive of the plague, was only safe and useful when the blood was
drawn by a _small_ orifice, and a _small_ quantity taken at _different_
times[83]."
[83] Page 209.
I have remarked, in the history of this fever, that it was often cured on
the first or second day by a copious sweat. The Rev. Mr. Ustick was one
among many whom I could mention, who were saved from a violent attack of
the fever by this evacuation. It would be absurd to suppose that the
miasmata which produced the disease were discharged in this manner from
the body. The sweat seemed to cure the fever only by lessening the
quantity of the fluids, and thus _gradually_ removing the depression of
the system. The profuse sweats which sometimes cure the plague, as well
as the disease which is brought on by the bite of poisonous snakes, seem
to act in the same way.
The system, in certain states of malignant fever, resembles a man
struggling beneath a load of two hundred weight, who is able to lift but
one hundred and seventy-five. In order to assist him it will be to no
purpose to attempt to infuse additional vigour into his muscles by the
use of a whip or of strong drink. Every exertion will serve only to
waste his strength. In this situation (supposing it impossible to divide
the weight which confines him to the ground) let the pockets of this man
be emptied of their contents, and let him be stripped of so much of his
clothing as to reduce his weight five and twenty or thirty pounds. In
this situation he will rise from the ground; but if the weights be
abstracted suddenly, while he is in an act of exertion, he will rise with
a spring that will endanger a second fall, and probably produce a
temporary convulsion in his system. By abstracting the weights from his
body more gradually, he will rise by degrees from the ground, and the
system will accommodate itself in such a manner to the diminution of its
pressure, as to resume its erect form, without the least deviation from
the natural order of its appearance and motions.
It has been said that the stimulating remedies of bark, wine, and the
cold bath, were proper in our late epidemic in August, and in the
beginning of September, but that they were improper afterwards. If my
theory be just, they were more improper in August and the beginning of
September, than they were after the disease put on the outward and common
signs of inflammatory diathesis. The reason why a few strong purges cured
the disease at its first appearance, was, because they abstracted in a
_gradual_ manner some of the immense portion of stimulus under which the
arterial system laboured, and thus gradually relieved it from its low and
weakening degrees of depression. Bleeding was fatal in these cases,
probably because it removed this depression in too sudden a manner.
The principle of the gradual abstraction, as well as of the gradual
application of stimuli to the body, opens a wide field for the
improvement of medicine. Perhaps all the discoveries of future ages will
consist more in a new application of established principles, and in new
modes of exhibiting old medicines, than in the discovery of new theories,
or of new articles of the materia medica.
The reasons which induced me to prescribe purging and bleeding, in so
liberal a manner, naturally led me to recommend _cool_ and _fresh air_ to
my patients. The good effects of it were obvious in almost every case in
which it was applied. It was equally proper whether the arterial system
was depressed, or whether it discovered, in the pulse, a high degree of
morbid excitement. Dr. Griffitts furnished a remarkable instance of the
influence of cool air upon the fever. Upon my visiting him, on the
morning of the 8th of October, I found his pulse so full and tense as to
indicate bleeding, but after sitting a few minutes by his bed-side, I
perceived that the windows of his room had been shut in the night by his
nurse, on account of the coldness of the night air. I desired that they
might be opened. In ten minutes afterwards the doctor's pulse became so
much slower and weaker that I advised the postponement of the bleeding,
and recommended a purge instead of it. The bleeding notwithstanding
became necessary, and was used with great advantage in the afternoon of
the same day.
The cool air was improper only in those cases where a chilliness attended
the disease.
For the same reason that I advised cool air, I directed my patients to
use cold _drinks_. They consisted of lemonade, tamarind, jelly and raw
apple water, toast and water, and of weak balm, and camomile tea. The
subacid drinks were preferred in most cases, as being not only most
agreeable to the taste, but because they tended to compose the stomach.
All these drinks were taken in the early stage of the disease. Towards
the close of it, I permitted the use of porter and water, weak punch, and
when the stomach would bear it, weak wine-whey.
I forbade all cordial and stimulating food in the active state of the
arterial system. The less my patients ate, of even the mildest vegetable
food, the sooner they recovered. Weak coffee, which (as I have formerly
remarked) was almost universally agreeable, and weak tea were always
inoffensive. As the action of the pulse diminished, I indulged my
patients with weak chocolate; also with milk, to which roasted apples, or
minced peaches, and (where they were not to be had), bread or Indian mush
were added.
Towards the crisis, I advised the drinking of weak chicken, veal, or
mutton broth, and after the crisis had taken place, I permitted mild
animal food to be eaten in a small quantity, and to be increased
according to the waste of the excitability of the system. This strict
abstinence which I imposed upon my patients did not escape obloquy; but
the benefits they derived from it, and the ill effects which arose in
many cases from a contrary regimen, satisfied me that it was proper in
every case in which it was prescribed.
_Cold water_ was a most agreeable and powerful remedy in this disease. I
directed it to be applied by means of napkins to the head, and to be
injected into the bowels by way of glyster. It gave the same ease to
both, when in pain, which opium gives to pain from other causes. I
likewise advised the washing of the face and hands, and sometimes the
feet, with cold water, and always with advantage. It was by suffering the
body to lie for some time in a bed of cold water, that the inhabitants of
the island of Massuah cured the most violent bilious fevers[84]. When
applied in this way, it _gradually_ abstracts the heat from the body, and
thereby lessens the action of the system. It differs as much in its
effects upon the body from the cold bath, as rest in a cold room, differs
from exercise in the cold and open air.
[84] Bruce's Travels.
I was first led to the practice of the partial application of cold water
to the body, in fevers of too much force in the arterial system, by
observing its good effects in active hæmorrhages, and by recollecting the
effects of a partial application of warm water to the feet, in fevers of
an opposite character. Cold water when applied to the feet as certainly
reduces the pulse in force and frequency, as warm water, applied in the
same way, produces contrary effects upon it. In an experiment which was
made at my request, by one of my pupils, by placing his feet in cold pump
water for a few minutes, the pulse was reduced 24 strokes in a minute,
and became so small as hardly to be perceptible.
But this effect of cold water, in reducing the frequency of the pulse, is
not uniform. In weak and irritable habits, it increases its frequency.
This has been fully proved by a number of experiments, made by my former
pupil, Dr. Stock, of Bristol, in England, and published in his "Medical
Collections of the Effects of Cold, as a Remedy in certain Diseases[85]."
[85] Page 185.
In the use of the remedies which were necessary to overcome the
inflammatory action of the system, I was obliged to reduce it below its
natural point of excitement. In the present imperfect state of our
knowledge in medicine, perhaps no disease of too much action can be cured
without it.
Besides the remedies which have been mentioned, I was led to employ
another of great efficacy. I had observed a favourable issue of the
fever, in every case in which a spontaneous discharge took place from the
salivary glands. I had observed further, that all such of my patients
(one excepted) as were salivated by the mercurial purges recovered in a
few days. This early suggested an idea to me that the calomel might be
applied to other purposes than the discharging of bile from the bowels. I
ascribed its salutary effects, when it salivated in the first stage of
the disease, to the excitement of inflammation and effusion in the
throat, diverting them from more vital parts of the body. In the second
stage of the disease, I was led to prescribe it as a stimulant, and, with
a view of obtaining this operation from it, I aimed at exciting a
salivation, as speedily as possible, in all cases. Two precedents
encouraged me to make trial of this remedy.
In the month of October, 1789, I attended a gentleman in a bilious fever,
which ended in many of the symptoms of a typhus mitior. In the lowest
state of his fever, he complained of a pain in his right side, for which
I ordered half an ounce of mercurial ointment to be rubbed on the part
affected. The next day, he complained of a sore mouth, and, in the course
of four and twenty hours, he was in a moderate salivation. From this time
his pulse became full and slow, and his skin moist; his sleep and
appetite suddenly returned, and in a day or two he was out of danger. The
second precedent for a salivation in a fever, which occurred to me, was
in Dr. Haller's short account of the works of Dr. Cramer[86]. The
practice was moreover justified, in point of safety, as well as the
probability of success, by the accounts which Dr. Clark has lately given
of the effects of a salivation in the dysentery[87]. I began by
prescribing the calomel in small doses, at short intervals, and
afterwards I directed large quantities of the ointment to be rubbed upon
the limbs. The effects of it, in every case in which it affected the
mouth, were salutary. Dr. Woodhouse improved upon my method of exciting
the salivation, by rubbing the gums with calomel, in the manner directed
by Mr. Clare. It was more speedy in its operation in this way than in any
other, and equally effectual. Several persons appeared to be benefited by
the mercury introduced into the system in the form of an ointment, where
it did _not_ produce a salivation. Among these, were the Rev. Dr.
Blackwell, and Mr. John Davis.
[86] Bibliotheca Medicinæ Practicæ, vol. iii. p. 491.
[87] Diseases of Long Voyages to Hot Climates, vol. ii. p. 334.
Soon after the above account was written of the good effects of a
mercurial salivation in this fever, I had great satisfaction in
discovering that it had been prescribed with equal, and even greater
success, by Dr. Wade in Bengal, in the year 1791, and by Dr. Chisholm in
the island of Granada, in the cure of bilious yellow fevers[88]. Dr. Wade
did not lose one, and Dr. Chisholm lost only one out of forty-eight
patients in whom the mercury affected the salivary glands. The latter
gave 150 grains of calomel, and applied the strongest mercurial ointment
below the groin of each side, in some cases. He adds further, that not a
single instance of a relapse occurred, where the disease was cured by
salivation.
[88] Medical Commentaries, vol. xviii. p. 209, 288.
After the reduction of the system, _blisters_ were applied with great
advantage to every part of the body. They did most service when they were
applied to the crown of the head. I did not see a single case, in which a
mortification followed the sore, which was created by a blister.
Brandy and water, or porter and water, when agreeable to the stomach,
with now and then a cup of chicken broth, were the drinks I prescribed to
assist in restoring the tone of the system.
In some cases I directed the limbs to be wrapped in flannels dipped in
warm spirits, and cataplasms of bruised garlic to be applied to the feet.
But my principal dependence, next to the use of mercurial medicines, for
exciting a healthy action in the arterial system, was upon mild and
gently stimulating food. This consisted of rich broths, the flesh of
poultry, oysters, thick gruel, mush and milk, and chocolate. I directed
my patients to eat or drink a portion of some of the above articles of
diet every hour or two during the day, and in cases of great debility,
from an exhausted state of the system, I advised their being waked for
the same purpose two or three times in the night. The appetite frequently
craved more savoury articles of food, such as beef-stakes and sausages;
but they were permitted with great caution, and never till the system had
been prepared for them by a less stimulating diet.
There were several _symptoms_ which were very distressing in this
disease, and which required a specific treatment.
For the vomiting, with a burning sensation in the stomach, which came on
about the fifth day, I found no remedy equal to a table spoonful of sweet
milk, taken every hour, or to small draughts of milk and water. I was
led to prescribe this simple medicine from having heard, from a
West-India practitioner, and afterwards read, in Dr. Hume's account of
the yellow fever, encomiums upon the milk of the cocoa-nut for this
troublesome symptom. Where sweet milk failed of giving relief, I
prescribed small doses of sweet oil, and in some cases a mixture of equal
parts of milk, sweet oil, and molasses. They were all intended to dilute
or blunt the acrimony of the humours, which were either effused or
generated in the stomach. Where they all failed of checking the vomiting,
I prescribed weak camomile tea, or porter, or cyder and water, with
advantage. In some of my patients the stomach rejected all the mixtures
and liquors which have been mentioned. In such cases I directed the
stomach to be left to itself for a few hours, after which it sometimes
received and retained the drinks that it had before rejected, provided
they were administered in a small quantity at a time.
The vomiting was sometimes stopped by a blister applied to the external
region of the stomach.
A mixture of liquid laudanum and sweet oil, applied to the same place,
gave relief where the stomach was affected by pain only, without a
vomiting.
I have formerly mentioned that a distressing _pain_ often seized the
lower part of the _bowels_. I was early taught that laudanum was not a
proper remedy for it. It yielded in almost every case to two or three
emollient glysters, or to the loss of a few ounces of blood.
The convalescence from this fever was in general rapid, but in some cases
it was very slow. I was more than usually struck by the great resemblance
which the system in the convalescence from this fever bore to the state
of the body and mind in old age. It appeared, 1. In the great weakness of
the body, more especially of the limbs. 2. In uncommon depression of
mind, and in a great aptitude to shed tears. 3. In the absence or short
continuance of sleep. 4. In the frequent occurrence of appetite, and, in
some cases, in its inordinate degrees. And 5. In the loss of the hair of
the head, or in its being suddenly changed in some cases to a grey
colour.
Pure air, gentle exercise, and agreeable society removed the debility
both of body and mind of this premature and temporary old age. I met with
a few cases, in which the yellow colour continued for several weeks
after the patient's recovery from all the other symptoms of the fever. It
was removed most speedily and effectually by two or three moderate doses
of calomel and rhubarb.
A feeble and irregular intermittent was very troublesome in some people,
after an acute attack of the fever. It yielded gradually to camomile or
snake-root tea, and country air.
In a publication, dated the 16th of September, I recommended a diet of
milk and vegetables, and cooling purges to be taken once or twice a week,
to the citizens of Philadelphia. This advice was the result of the theory
of the disease I had adopted, and of the successful practice which had
arisen from it. In my intercourse with my fellow-citizens, I advised this
regimen to be regulated by the degrees of fatigue and foul air to which
they were exposed. I likewise advised moderate blood-letting to all such
persons as were of a plethoric habit. To men whose minds were influenced
by the publications in favour of bark and wine, and who were unable at
that time to grasp the extent and force of the remote cause of this
terrible fever, the idea of dieting, purging, or bleeding the inhabitants
of a whole village or city appeared to be extravagant and absurd: but I
had not only the analogy of the regimen made use of to prepare the body
for the small-pox, but many precedents in favour of the advice. Dr.
Haller has given extracts from the histories of two plagues, in which the
action of the miasmata was prevented or mitigated by bleeding[89]. Dr.
Hodges confirms the utility of the same practice. The benefits of low
diet, as a preventive of the plague, were established by many authors,
long before they received the testimony of the benevolent Mr. Howard in
their favour. Socrates in Athens, and Justinian in Constantinople, were
preserved, by means of their abstemious modes of living, from the plagues
which occasionally ravaged those cities. By means of the low diet, gentle
physic, and occasional bleedings, which I thus publicly recommended, the
disease was prevented in many instances, or rendered mild where it was
taken. But my efforts to prevent the disease in my fellow-citizens did
not end here. I advised them, not only in the public papers, but in my
intercourse with them, to avoid heat, cold, labour, and every thing else
that could excite the miasmata (which I knew to be present in all their
bodies) into action. I forgot, upon this occasion, the usual laws which
regulate the intercourse of man with man in the streets, and upon the
public roads, in my excursions into the neighbourhood of the city. I
cautioned many persons, whom I saw walking or riding in an unsafe manner,
of the danger to which they exposed themselves; and thereby, I hope,
prevented an attack of the disease in many people.
[89] Bibliotheca Medicinæ Practicæ, vol. ii. p. 93. and 387.