| NOVEMBER, 1793. | ||||||||||||||
| Barom. | Ther. | Winds. | Weather. | |||||||||||
| Days. | 7 A. M. | 2 P. M. | 7 A. M. | 2 P. M. | 7 A. M. | 2 P. M. | 7 A. M. | 2 P. M. | ||||||
| 1 | 30 | 1 | 30 | 1 | 40 | 41 | NNE | NE | rain, | cloudy, | ||||
| 2 | 30 | 3 | 30 | 25 | 32 | 49 | NNE | NE | fair, | fair, | ||||
| 3 | 30 | 1 | 30 | 0 | 43 | 56 | calm | SW | cloudy, | cloudy, | ||||
| 4 | 29 | 8 | 29 | 9 | 55 | 67 | SW | SW | cloudy, | fair, | ||||
| 5 | 30 | 15 | 30 | 1 | 50 | 64 | NE | NE | rain, | rain, | ||||
| 6 | 29 | 8 | 29 | 65 | 63 | 67 | S | S | cloudy, | cloudy, | ||||
| 7 | 29 | 8 | 29 | 8 | 44 | 64 | calm | SW | fair, | fair, | ||||
| 8 | 29 | 8 | 29 | 85 | 43 | 56 | SSW | SW | fair, | fair, | ||||
| 9 | 29 | 9 | 29 | 95 | 42 | 65 | SW | SW | fair, | fair, | ||||
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.