from a person who sickens or dies at sea, who had carried the seeds of it
in his body from a sickly shore. It is because no febrile miasmata exist
in the bodies of the rest of the crew to be excited into action by any
peculiar smell from the disease, or by fear or fatigue, and because no
morbid excretions are generated by the person who dies. The fever which
prevailed on board the Nottingham East-Indiaman, in the year 1766,
affected those forty men only, who had slept on shore on the island of
Joanna twenty days before. Had the whole crew been on shore, the disease
would probably have affected them all, and been ascribed to contagion
generated by the first persons who were confined by it[45]. A Danish
ship, in the year 1768, sent twelve of her crew on shore for water. They
were all seized after their return to the ship with malignant fever, and
died without infecting any person on board, and from the same causes
which preserved the crew of the Nottingham Indiaman[46].
[45] Observations on the Bilious Fevers usual in voyages to the
East-Indies, by James Badinach, M. D. Medical Observations and
Inquiries, vol. iv.
[46] Clarke on the Diseases of Long Voyages to Hot Climates, p. 123,
125.
2. We learn the reason why the disease sometimes spreads through a whole
ship's crew, apparently from one or more affected persons. It is either
because they have been confined to small and close berths by bad weather,
or because the fever has been protracted to a typhus or chronic state, or
because the bodies of the whole crew are impregnated with morbid
miasmata, and thus predisposed to have the disease excited in the manner
that has been mentioned. In the last way it was excited in most of the
crew of the United States frigate, in the Delaware, opposite to the city
of Philadelphia, in the year 1797. It appears to have spread, from a
similar cause, from a few sailors, on board the Grenville Indiaman, after
touching at Batavia. The whole crew had been predisposed to the disease
by inhaling the noxious air of that island.
The same reasons account for the fever expiring in a healthy village or
country; also for its spreading when carried to those towns which are
seated upon creeks or rivers, and in the neighbourhood of marsh
exhalations. It has uniformly perished in the high and healthy village of
Germantown, when carried from Philadelphia, and has three times appeared
to be contagious near the muddy shores of the creeks which flow through
Wilmington and Chester.
3. From the facts that have been mentioned, we are taught to disbelieve
the possibility of the disease being imported in the masts and sails of a
ship, by a contagious matter secreted by a sailor who may have sickened
or died on board her, on a passage from a West-India island. The death in
most of the cases supposed to be imported, in this way, occurs within a
few days after the ship leaves her West-India port, or within a few days
after her arrival. In the former case, the disease is derived from
West-India miasmata; in the latter, it is derived, as was before
remarked, either from the foul air of the hold of the ship, or of the
dock or wharf to which the ship is moored.
Many other facts might be adduced to show the yellow fever not to be an
imported disease. It has often prevailed among the Indians remote from
the sea coast, and many hundred cases of it have occurred, since the year
1793, on the inland waters of the United States, from the Hudson and
Susquehannah, to the rivers of the Mississippi. In South-America, Baron
Humboldt assured me, it is every where believed to be an endemic of that
country.
These simple and connected facts, in which all the physicians in the
United States who derive the yellow fever from domestic causes have
agreed, will receive fresh support by comparing them with the different
and contrary opinions of the physicians who maintain its importation.
Some of them have asserted it to be a specific disease, and derived it
from the East and West-Indies; others derive it from Beulam, on the coast
of Africa; a third sect have called it a ship fever; a fourth have
ascribed it to a mixture of imported contagion with the foul air of our
cities; while a fifth, who believed it to be imported in 1793, have
supposed it to be the offspring of a contagion left by the disease of
that year, revived by the heat of our summers, and disseminated, ever
since, through the different cities of our country. The number of these
opinions, clearly proves, that no one of them is tenable.
A belief in the non-contagion of the yellow fever, or of its being
incommunicable except in one of the five ways that have been mentioned,
is calculated to produce the following good effects:
1. It will deliver the states which have sea-ports from four-fifths of
the expences of their present quarantine laws and lazarettoes. A very
small apparatus, in laws and officers, would be sufficient to prevent the
landing of persons affected by the ship fever in our cities, and the more
dangerous practice, of ships pouring streams of pestilential air, from
their holds, upon the citizens who live near our docks and wharves.
2. It will deliver our merchants from the losses incurred by the delays
of their ships, by long and unnecessary quarantines. It will, moreover,
tend to procure the immediate admission of our ships into foreign ports,
by removing that belief in the contagious nature of the yellow fever,
which originated in our country, and which has been spread, by the public
acts of our legislatures and boards of health, throughout the globe.
3. It will deliver our citizens from the danger to which they are
exposed, by spending the time of the quarantine, on board of vessels in
the neighbourhood of the marshes, which form the shores of the rivers or
coasts of quarantine roads. This danger is much increased by idleness,
and by the vexation which is excited, by sailors and passengers being
detained, unnecessarily, fifteen or twenty days from their business and
friends.
4. It will lead us to a speedy removal of all the excretions, and a
constant ventilation of the rooms of patients in the yellow fever, and
thereby to prevent the accumulation, and further putrefaction of those
exhalations which may reproduce it.
5. It is calculated to prevent the desertion of patients in the yellow
fever, by their friends and families, and to produce caution in them to
prevent the excitement of the disease in their own bodies, by means of
low diet and gentle physic, proportioned to the impurity of the air, and
to the anxiety and fatigue to which they are exposed in attending the
sick.
6. It will put an end to the cruel practice of quieting the groundless
fears of a whole neighbourhood, by removing the poor who are affected by
the fever, from their houses, and conveying them, half dead with disease
and terror, to a solitary or crowded hospital, or of nailing a yellow
flag upon the doors of others, or of fixing a guard before them, both of
which have been practised in Philadelphia, not only without any good
effect, but to the great injury of the sick.
7. By deriving the fever from our own climate and atmosphere, we shall be
able to foresee its approach in the increased violence of common
diseases, in the morbid state of vegetation, in the course of the winds,
in the diseases of certain brute animals, and in the increase of common,
or the appearance of uncommon insects.
8. A belief in the non-contagion of the yellow fever, and its general
prevalence from putrid animal and vegetable matters _only_, is calculated
to lead us to drain or cover marshy grounds, and to remove from our
cities all the sources of impure air, whether they exist in the holds of
ships, in docks, gutters, and common sewers, or in privies, gardens,
yards, and cellars, more especially during the existence of the signs of
a malignant constitution of the air. A fever, the same in its causes, and
similar to it in many of its symptoms, that is, the plague, has been
extirpated, by extraordinary degrees of cleanliness, from the cities of
Holland, Great-Britain, and several other parts of Europe.
The reader will perceive, from these facts and reasonings, that I have
relinquished the opinion published in my account of the yellow fever in
the years 1793, 1794, and 1797, respecting its contagious nature. I was
misled by Dr. Lining, and several West-India writers, in ascribing a much
greater extent to the excreted matters in producing the disease, than I
have since discovered to be correct, and by Bianchi, Lind, Clark, and
Cleghorn, in admitting even the common bilious fever to be contagious.
The reader will perceive, likewise, that I have changed my opinion
respecting one of the modes in which the plague is propagated. I once
believed, upon the authorities of travellers, physicians, and schools of
medicine, that it was a highly contagious disease. I am now satisfied
this is not the case; but, from the greater number of people who are
depressed and debilitated by poverty and famine, and who live in small
and filthy huts[47] in the cities of the east, than in the cities of the
United States, I still believe it to be more frequently communicated from
an intercourse with sick people by the morbid excretions of the body,
than the yellow fever is in our country. For the change of my opinion
upon this subject, I am indebted to Dr. Caldwell's and Mr. Webster's
publications upon pestilential diseases, and to the travels of Mariti and
Sonnini into Syria and Egypt. I reject, of course, with the contagious
quality of the plague, the idea of its ever being imported into any
country so as to become epidemic, by means of a knife-case, a piece of
cotton, or a bale of silks, with the same decision that I do all the
improbable and contradictory reports of an epidemic yellow fever being
imported in a sailor's jacket, or in the timbers and sails of a ship that
had been washed by the salt water, and fanned by the pure air of the
ocean, for several weeks, on her passage from the West-Indies to the
United States.
[47] M. Savary, in his Travels, says, two hundred persons live in Cairo
within a compass that accommodates but thirty persons in Paris.
It gives me pleasure to find this unpopular opinion of the non-contagion
of the plague is not a new one. It was held by the Faculty of Medicine in
Paris, in the beginning of the eighteenth century, and it has since been
defended by Dr. Stoll, of Vienna, Dr. Samoilowitz, of Russia, and several
other eminent physicians. Dr. Herberden has lately called in question the
truth of all the stories that are upon record of the plague having been
imported into England in the last century, and the researches of Sir
Robert Wilson of the British army, and of Assellini, and several other
French physicians, have produced the most satisfactory proofs of its not
being a contagious disease in its native country. A discovery more
pregnant with blessings to mankind has seldom been made. Pyramids of
error, the works of successive ages and nations, must fall before it, and
rivers of tears must be dried up by it. It is impossible fully to
appreciate the immense benefits which await this mighty achievement of
our science upon the affairs of the globe. Large cities shall no longer
be the hot-beds of disease and death. Marshy grounds, teeming with
pestilential exhalations, shall become the healthy abodes of men. A
powerful source of repulsion between nations shall be removed, and
commerce shall shake off the fetters which have been imposed upon it by
expensive and vexatious quarantines. A red or a yellow eye shall no
longer be the signal to desert a friend or a brother to perish alone in a
garret or a barn, nor to expel the stranger from our houses, to seek an
asylum in a public hospital, to avoid dying in the street. The number of
diseases shall be lessened, and the most mortal of them shall be struck
out of the list of human evils. To accelerate these events, it is
incumbent upon the physicians of the United States to second the
discoveries of their European brethren. It becomes them constantly to
recollect, that we are the centinels of the health and lives of our
fellow-citizens, and that there is a grade of benevolence in our
profession much higher than that which arises from the cure of diseases.
It consists in exterminating their causes.
A DEFENCE
OF
_BLOOD-LETTING_,
AS A
REMEDY FOR CERTAIN DISEASES.
Blood-letting, as a remedy for fevers, and certain other diseases, having
lately been the subject of much discussion, and many objections having
been made to it, which appear to be founded in error and fear, I have
considered that a defence of it, by removing those objections, might
render it more generally useful, in every part of the United States.
I shall begin this subject by remarking, that blood-letting is indicated,
in fevers of great morbid excitement,
1. By the sudden suppression or diminution of the natural discharges by
the pores, bowels, and kidneys, whereby a plethora is induced in the
system.
2. By the habits of the persons who are most subject to such fevers.
3. By the theory of fever. I have attempted to prove that the higher
grades of fever depend upon morbid and excessive action in the
blood-vessels. It is connected, of course, with preternatural sensibility
in their muscular fibres. The blood is the most powerful irritant which
acts upon them. By abstracting a part of it, we lessen the principal
cause of the fever. The effect of blood-letting is as immediate and
natural in removing fever, as the abstraction of a particle of sand is,
to cure an inflammation of the eye, when it arises from that cause.
4. By the symptoms of the first stage of violent fevers, such as a
sleepiness and an oppressed pulse, or by delirium, with a throbbing
pulse, and great pains in every part of the body.
5. By the rupture of the blood-vessels, which takes place from the
quantity or impetus of the blood in fevers of great morbid action. Let no
one call bleeding a cruel or unnatural remedy. It is one of the specifics
of nature; but in the use of it she seldom affords much relief. She
frequently pours the stimulating and oppressing mass of blood into the
lungs and brain; and when she finds an outlet for it through the nose, it
is discharged either in such a deficient or excessive quantity, as to be
useless or hurtful. By artificial blood-letting, we can choose the _time_
and _place_ of drawing blood, and we may regulate its quantity by the
degrees of action in the blood-vessels. The disposition of nature to cure
violent morbid action by depletion, is further manifested by her
substituting, in the room of blood-letting, large, but less safe and less
beneficial, evacuations from the stomach and bowels.
6. By the relief which is obtained in fevers of violent action by
remedies of less efficacy (to be mentioned hereafter), which act
indirectly in reducing the force of the sanguiferous system.
7. By the immense advantages which have attended the use of blood-letting
in violent fevers, when used at a proper time, and in a quantity suited
to the force of the disease. I shall briefly enumerate these advantages.
1. It frequently strangles a fever, when used in its forming state, and
thereby saves much pain, time, and expence to a patient.
2. It imparts strength to the body, by removing the depression which is
induced by the remote cause of the fever. It moreover obviates a
disposition to faint, which arises from this state of the system.
3. It reduces the uncommon frequency of the pulse. The loss of ten ounces
of blood reduced Miss Sally Eyre's pulse from 176 strokes to 140, in a
few minutes, in the fever of the year 1794. Dr. Gordon mentions many
similar instances of its reducing the frequency of the pulse, in the
puerperile fever.
4. It renders the pulse more frequent when it is preternaturally slow.
5. It checks the nausea and vomiting, which attend the malignant state of
fever. Of this I saw many instances in the year 1794. Dr. Poissonnier
Desperrieres confirms this remark, in his Account of the Fevers of St.
Domingo; and adds further, that it prevents, when sufficiently copious,
the troublesome vomiting which often occurs on the fifth day of the
yellow fever[48]. It has the same effect in preventing the diarrh[oe]a in
the measles.
[48] Traite des Fievres de l'Isle de St. Domingue, vol. ii. p. 76.
6. It renders the bowels, when costive, more easily moved by purging
physic.
7. It renders the action of mercury more speedy and more certain, in
exciting a salivation.
8. It disposes the body to sweat spontaneously, or renders diluting and
diaphoretic medicines more effectual for that purpose.
9. It _suddenly_ removes a dryness, and _gradually_ a blackness, from the
tongue. Of the former effect of bleeding, I saw two instances, and of the
latter, one, during the autumn of 1794.
10. It removes or lessens pain in every part of the body, and more
especially in the head.
11. It removes or lessens the burning heat of the skin, and the burning
heat in the stomach, so common and so distressing in the yellow fever.
12. It removes a constant chilliness, which sometimes continues for
several days, and which will neither yield to cordial drinks, nor warm
bed-clothes.
13. It checks such sweats as are profuse without affording relief, and
renders such as are partial and moderate, universal and salutary.
14. It sometimes checks a diarrh[oe]a and tenesmus, after astringent
medicines have been given to no purpose. This has often been observed in
the measles.
15. It suddenly cures the intolerance of light which accompanies many of
the inflammatory states of fever.
16. It removes coma. Mr. Henry Clymer was suddenly relieved of this
alarming symptom, in the fever of 1794, by the loss of twelve ounces of
blood.
17. It induces sleep. This effect of bleeding is so uniform, that it
obtained, in the year 1794, the name of an anodyne in several families.
Sleep sometimes stole upon the patient while the blood was flowing.
18. It prevents effusions of serum and blood. Hæmorrhages seldom occur,
where bleeding has been sufficiently copious.
19. It belongs to this remedy to prevent the chronic diseases of cough,
consumption, jaundice, abscess in the liver, and all the different states
of dropsy which so often follow autumnal fevers.
My amiable friend, Mrs. Lenox, furnished an exception to this remark, in
the year 1794. After having been cured of the yellow fever by seven
bleedings, she was affected, in consequence of taking a ride, with a
slight return of fever, accompanied by an acute pain in the head, and
some of the symptoms of a dropsy of the brain. As her pulse was tense and
quick, I advised repeated bleedings to remove it. This prescription, for
reasons which it is unnecessary to relate, was not followed at the time,
or in the manner, in which it was recommended. The pain, in the mean
time, became more alarming. In this situation, two physicians were
proposed by her friends to consult with me. I objected to them both,
because I knew their principles and modes of practice to be contrary to
mine, and that they were proposed only with a view of wresting the lancet
from my hand. From this desire of avoiding a controversy with my
brethren, where conviction was impossible on either side, as well as to
obviate all cause of complaint by my patient's friends, I offered to take
my leave of her, and to resign her wholly to the care of the two
gentlemen who were proposed to attend her with me. To this she objected
in a decided manner. But that I might not be suspected of an undue
reliance upon my own judgment, I proposed to call upon Dr. Griffitts or
Dr. Physick to assist me in my attendance upon her. Both these physicians
had renounced the prejudices of the schools in which they had been
educated, and had conformed their principles and practice to the present
improving state of medical science. My patient preferred Dr. Griffitts,
who, in his first visit to her, as soon as he felt her pulse, proposed
more bleeding. The operation was performed by the doctor himself, and
repeated daily for five days afterwards. From an apprehension that the
disease was so fixed as to require some aid to blood-letting, we gave her
calomel in such large doses as to excite a salivation. By the use of
these remedies she recovered slowly, but so perfectly as to enjoy her
usual health.
20. Bleeding prevents the termination of malignant, in the gangrenous
state of fever. This effect of blood-letting will enable us to understand
some things in the writings of Dr. Morton and Dr. Sydenham, which at
first sight appear to be unintelligible. Dr. Morton describes what he
calls a putrid fever, which was epidemic and fatal, in the year 1678. Dr.
Sydenham, who practised in London at the same time, takes no notice of
this fever. The reason of his silence is obvious. By copious bleeding, he
prevented the fever of that year from running on to the gangrenous state,
while Dr. Morton, by neglecting to bleed, created the supposed putrid
fevers which he has described.
It has been common to charge the friends of blood-letting with _temerity_
in their practice. From this view which has been given of it, it appears,
that it would be more proper to ascribe _timidity_ to them, for they
bleed to prevent the offensive and distressing consequences of neglecting
it, which have been mentioned.
21. It cures, without permitting a fever to put on those alarming
symptoms, which excite constant apprehensions of danger and death, in the
minds of patients and their friends. It is because these alarming
symptoms are prevented, by bleeding, that patients are sometimes
unwilling to believe they have been cured by it, of a malignant fever.
Thus, the Syrian leper of old, viewed the water of Jordan as too simple
and too common to cure a formidable disease, without recollecting that
the remedies for the greatest evils of life are all simple, and within
the power of the greatest part of mankind.
22. It prepares the way for the successful use of the bark and other
tonic remedies, by destroying, or so far weakening, a morbid action in
the blood-vessels, that a medicine of a moderate stimulus afterwards
exceeds it in force, and thereby restores equable and healthy action to
the system.
23. Bleeding prevents relapses. It, moreover, prevents that
predisposition to the intermitting and pleuritic states of fever, which
so frequently attack persons in the spring, who have had the bilious
remitting fever in the preceding autumn.
But great and numerous as the advantages of blood-letting are in fevers,
there have been many objections to it. I shall briefly enumerate, and
endeavour to refute the errors upon this subject.
Blood-letting has been forbidden by physicians, by the following
circumstances, and states of the system.
1. By warm weather. Galen bled in a plague, and Aræteus in a bilious
fever, in a warm climate. Dr. Sydenham and Dr. Hillary inform us, that
the most inflammatory fevers occur in, and succeed hot weather. Dr.
Cleghorn prescribed it copiously in the warm months, in Minorca. Dr.
Mosely cured the yellow fever by this remedy, in Jamaica. Dr. Broadbelt,
and Dr. Weston, in the same island, have lately adopted his successful
practice. Dr. Desportes speaks in the highest terms of it in all the
inflammatory diseases of St. Domingo. He complains of the neglect of it
in the rheumatism, in consequence of which, he says, the disease produces
abscesses in the lungs[49]. I have never, in any year of my practice,
been restrained by the heat of summer in the use of the lancet, where the
pulse has indicated it to be necessary, and have always found the same
advantages from it, as when I have prescribed it in the winter or spring
months.
[49] Page 35.
In thus deciding in favour of bleeding in warm weather, I do not mean to
defend its use to the same extent, as to diseases, or to quantity, in the
native and long settled inhabitants of hot climates, as in persons who
have recently migrated to them, or who live in climates alternately hot
and cold.
2. Being born, and having lived in a warm climate. This is so far from
being an objection to blood-letting in an inflammatory disease, that it
renders it more necessary. I think I have lost several West-India
patients from the influence of this error.