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 diarrhœa 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.
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].
But who can suppose that a dozen or twenty stools in a day could endanger life, that has seen a diarrhœa 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].
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].”
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].”
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.
Much has been said of the bad effects of this purge from its having been put up carelessly by the apothecaries, or from its having been taken contrary to the printed directions, by many people. If it did harm in any one case (which I do not believe) from the former of the above causes the fault is not mine. Twenty men employed constantly in putting up this medicine would not have been sufficient to have complied with all the demands which were made of me for it. Hundreds who were in health called or sent for it as well as the sick, in order to have it in readiness in case they should be surprised by the disease in the night, or at a distance from a physician.
In all the cases in which this purge was supposed to have been hurtful, when given on the first or second day of the disease, I believe it was because it was not followed by repeated doses of the same, or of some other purge, or because it was not aided by blood-letting. I am led to make this assertion, not only from the authority of Dr. Sydenham, who often mentions the good effects of bleeding in moderating or checking a diarrhœa, but by having heard no complaints of patients being purged to death by this medicine, after blood-letting was universally adopted by all the physicians in the city.
It was remarked that the demand for this purging powder continued to increase under all opposition, and that the sale of it by the apothecaries was greatest towards the close of the disease. I shall hereafter say that this was not the case with the West-India remedies.
It is possible that this purge sometimes proved hurtful when it was given on the fifth day of the disease, but it was seldom given for the first time after the third day, and when it was, the patient was generally in such a situation that nothing did him either good or harm.
I derived great pleasure from hearing, after the fever had left the city, that calomel had been given with success as a purge in bilious fevers in other parts of the union besides Philadelphia. Dr. Lawrence informed me that he had cured many patients by it of the yellow fever which prevailed in New-York, in the year 1791, and the New-York papers have told us that several practitioners had been in the habit of giving it in the autumnal fevers, with great success, in the western parts of that state. They had probably learned the use of it from Dr. Young, who formerly practised in that part of the United States, and who lost no opportunity of making its praises public wherever he went.
I have only to add to my account of that purging medicine, that, under an expectation that the yellow fever would mingle some of its bilious symptoms with the common inflammatory fevers of the winter and first spring months, I gave that purge in the form of pills, in every case of inflammatory fever to which I was called. The fatal issue of several fevers in the city, during the winter, in which this precaution had been neglected, convinced me that my practice was proper and useful.
It is to be lamented that all new remedies are forced to pass through a fiery ordeal. Opium and bark were long the objects of terror and invective in the schools of medicine. They were administered only by physicians for many years, and that too with all the solemnity of a religious ceremony. This error, with respect to those medicines, has at last passed away. It will, I hope, soon be succeeded by a time when the prejudices against ten and ten, or ten and fifteen, will sleep with the vulgar fears which were formerly entertained of the bark producing diseases and death, years after it had been taken, by “lying in the bones.”