Medical Inquiries and Observations, Vol. 3 / The Second Edition, Revised and Enlarged by the Author

by Benjamin Rush

OF THE METHOD OF CURE.

In the introduction to the history of the fever, I mentioned the remedies which I used with success, in several cases which occurred in the beginning of August. I had seen, and recorded in my note book, the efficacy of gentle purges in the yellow fever of 1762; but finding them unsuccessful after the 20th of August, and observing the disease to assume uncommon symptoms of great prostration of strength, I laid them aside, and had recourse to a gentle vomit of ipecacuanha, on the first day of the fever, and to the usual remedies for exciting the action of the sanguiferous system. I gave bark in all its usual forms of infusion, powder, and tincture. I joined wine, brandy, and aromatics with it. I applied blisters to the limbs, neck, and head. Finding them all ineffectual, I attempted to rouse the system by wrapping the whole body, agreeably to Dr. Hume's practice, in blankets dipped in warm vinegar. To these remedies I added one more: I rubbed the right side with mercurial ointment, with a view of exciting the action of the vessels in the whole system, through the medium of the liver, which I then supposed to be principally, though symptomatically, affected by the disease. None of these remedies appeared to be of any service; for although three out of thirteen recovered, of those to whom they were applied, yet I have reason to believe that they would have recovered much sooner had the cure been trusted to nature. Perplexed and distressed by my want of success in the treatment of this fever, I waited upon Dr. Stephens, an eminent and worthy physician from St. Croix, who happened then to be in our city, and asked for such advice and information upon the subject of the disease, as his extensive practice in the West-Indies would naturally suggest. He politely informed me, that he had long ago laid aside evacuations of all kinds in the yellow fever; that they had been found to be hurtful, and that the disease yielded more readily to bark, wine, and, above all, to the use of the cold bath. He advised the bark to be given in large quantities by way of glyster, as well as in the usual way; and he informed me of the manner in which the cold bath should be used, so as to derive the greatest benefit from it. This mode of treating the yellow fever appeared to be reasonable. I had used bark, in the manner he recommended it, in several cases of sporadic yellow fever, with success, in former years. I had, moreover, the authority of several other physicians of reputation in its favour. Dr. Cleghorn tells us, that “he sometimes gave the bark when the bowels were full of vicious humours. These humours (he says) are produced by the fault of the circulation. The bark, by bracing the solids, enables them to throw off the excrementitious fluids, by the proper emunctories[65].”

I began the use of each of Dr. Stevens's remedies the next day after my interview with him, with great confidence of their success. I prescribed bark in large quantities: in one case I ordered it to be injected into the bowels every four hours. I directed buckets full of cold water to be thrown frequently upon my patients. The bark was offensive to the stomach, or rejected by it, in every case in which I prescribed it. The cold bath was grateful, and produced relief in several cases, by inducing a moisture on the skin. For a while I had hopes of benefit to my patients from the use of these remedies, but, in a few days, I was distressed to find they were not more effectual than those I had previously used. Three out of four of my patients died, to whom the cold bath was administered, in addition to the tonic remedies before-mentioned.

Baffled in every attempt to stop the ravages of this fever, I anticipated all the numerous and complicated distresses in our city, which pestilential diseases have so often produced in other countries. The fever had a malignity and an obstinacy which I had never before observed in any disease, and it spread with a rapidity and mortality far beyond what it did in the year 1762. Heaven alone bore witness to the anguish of my soul in this awful situation. But I did not abandon a hope that the disease might yet be cured. I had long believed that good was commensurate with evil, and that there does not exist a disease for which the goodness of Providence has not provided a remedy. Under the impression of this belief I applied myself with fresh ardour to the investigation of the disease before me. I ransacked my library, and pored over every book that treated of the yellow fever. The result of my researches for a while was fruitless. The accounts of the symptoms and cure of the disease by the authors I consulted were contradictory, and none of them appeared altogether applicable to the prevailing epidemic. Before I desisted from the inquiry to which I had devoted myself, I recollected that I had, among some old papers, a manuscript account of the yellow fever as it prevailed in Virginia in the year 1741, which had been put into my hands by Dr. Franklin, a short time before his death. I had read it formerly, and made extracts from it into my lectures upon that disease. I now read it a second time. I paused upon every sentence; even words in some places arrested and fixed my attention. In reading the history of the method of cure I was much struck with the following passages.

“It must be remarked, that this evacuation (meaning by purges) is more necessary in this than in most other fevers. The abdominal viscera are the parts principally affected in this disease, but by this timely evacuation their feculent corruptible contents are discharged, before they corrupt and produce any ill effects, and their various emunctories and secerning vessels are set open, so as to allow a free discharge of their contents, and consequently a security to the parts themselves, during the course of the disease. By this evacuation the very minera of the disease, proceeding from the putrid miasmata fermenting with the salivary, bilious, and other inquiline humours of the body, is sometimes eradicated by timely emptying the abdominal viscera, on which it first fixes, after which a gentle sweat does as it were nip it in its bud. Where the primæ viæ, but especially the stomach, is loaded with an offensive matter, or contracted and convulsed with the irritation of its stimulus, there is no procuring a laudable sweat till that is removed; after which a necessary quantity of sweat breaks out of its own accord, these parts promoting it when by an absterging medicine they are eased of the burden or stimulus which oppresses them.”

“All these acute putrid fevers ever require some evacuation to bring them to a perfect crisis and solution, and that even by stools, which must be promoted by art, where nature does not do the business herself. On this account an ill-timed scrupulousness about the weakness of the body is of bad consequence in these urging circumstances; for it is that which seems chiefly to make evacuations necessary, which nature ever attempts, after the humours are fit to be expelled, but is not able to accomplish for the most part in this disease; and I can affirm that I have given a purge in this case, when the pulse has been so low, that it could hardly be felt, and the debility extreme, yet both one and the other have been restored by it.”

“This evacuation must be procured by lenitive chologoque purges.”

Here I paused. A new train of ideas suddenly broke in upon my mind. I 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 diarrhœa, 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, fœtid 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.