An account of the bilious remitting yellow fever, as it appeared in the city of Philadelphia, in the year 1793. By Benjamin Rush, M.D. Professor of the institutes, and of clinical medicine, in the University of Pennsylvania.

OF PURGING.

I HAVE already mentioned my rea|sons for promoting this evacuation, and the medi|cine I preferred for that purpose. It had many advantages over any other purge. It was de|tergent 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 ope|ration. 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 is pro|duced by emetics; and it served to discharge bile when it was lodged in the stomach. I did not 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 pati|ents, in all those cases where the bowels were ea|sily 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 calo|mel. Two grains and an 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 de|signs 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 fe|ver

to them, and thereby saved the liver and brain from fatal or dangerous congestions. The prac|tice was further justified by the beneficial effects of a plentiful spontaneous diarrhoea in the begin|ning of the disorder* 1.1; by hemorrhagies from the bowels, when they occurred from no other parts of the body, and by the difficulty or impractica|bility of reducing the system by means of plen|tiful sweats. The purges seldom answered the in|tentions for which they were given, unless they produced four or five stools a day. As the fever shewed 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 even|ing 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 co|pious evacuation. Dr Sydenham takes notice of a similar encrease of strength after a plentiful sweat in the plague. They both acted by ab|stracting excess of stimulus, and thereby removing indirect debility.

3. It abated the paroxism 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 oc|curs in the beginning of the disorder; and it al|ways assisted in preventing the more alarming occur|rence of that symptom, about the 4th or 5th day.

6. It removed obstructions in the lymphatic sys|tem. I ascribe it wholly to the action of mer|cury, 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, ob|jections were made to it by many of our physi|cians; and prejudices, equally weak and ill-found|ed, 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 founda|tion. 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 some|times, 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 disorder 16 or 18 weeks* 1.2. Dr Mosely not only proves the safe|ty, but establishes the efficacy of numerous and copious stools in the yellow fever. Dr Say pro|bably owes his life to three-and-twenty stools pro|cured 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 ob|stinacy of opinion, came forward from his retire|ment, and boldly adopted the remedies of purg|ing and bleeding, with success in several families, before he was attacked by the disease. His reco|very 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† 1.3.

But who can suppose that a dozen or twenty stools in a day could endanger life, that has seen a diarrhoea 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* 1.4. Dr Clark in like manner remarks, that evacuations do not destroy life in the dysentery, but the fever with the emaciation or mortification which attend and follow the disease† 1.5.

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 previ|ously loose or decayed. The salivation was a tri|fling 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 ef|fect 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 men|tion those views under another head.

3. It was said that the mercurial purge, exco|riated 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 excori|ation 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* 1.6."

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 in|flamed, and lacerated the stomach and bowels. In support of this calumny, the inflamed and morti|fied appearances which those viscera exhibited upon dissection in a patient who died at the hos|pital 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 physi|cian, 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 inflamma|tion, and ulceration of the intestines, which are the chief causes of death, in this distemper* 1.7."

5. It was urged against this powerful and effi|cacious medicine, that it was prescribed indiscri|minately 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 Trea|surer 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 simi|lar 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 an hun|dred 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 mis|carried 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* 1.8." However diversified our fever was in some of its symptoms, it was in all cases accompa|nied 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 peo|ple. 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 con|stantly in putting up this medicine, would not have been sufficient to have complied with all the de|mands 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 disorder in the night, or at a distance from a physician.

In all the cases, in which this purge was sup|posed to have been hurtful, when given on the first or second day of the disorder, 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 diarrhoea, 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 remarkable that the demand for this purging powder continued to encrease under all opposition, and that the sale of it by the apothe|caries 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 after the 5th day of the disorder, but it was seldom given for the first time after the third day, and when it was, the pa|tient 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.

My pupil Mr Potter gave calomel and jalap in large doses, with great success in the bilious fever of Caroline county in Maryland, before he knew that I had adopted that purge in the cure of our epidemic. He had heard the history of its origin and use from me, some months before, in a con|versation upon bilious fevers in my shop.

I have only to add to my account of that purg|ing medicine, that under an expectation, that the yellow fever would mingle some of its bilious symp|toms, 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 inflam|matory fever to which I was called. The fatal issue of several fevers in the city, during the win|ter, in which this precaution had been neglected, satisfied 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 administer|ed only by physicians for many years, and that too with all the solemnity of a religious ceremony. This superstition 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 pro|ducing diseases and death, years after it had been taken, by "lying in the bones."

Notes

• * 1.1

  In some short manuscript notes upon Dr Mitchell's account of the yellow fever in Virginia, in the year 1741, made by the late Dr Kearsley, Sen. of this city, he remarks, that in the yellow fever which prevailed in the same year in Philadelphia "some recovered by an early discharge of black matter by stool." This gentleman, Dr Redman informed me, introduced purging with Glauber salts in the yellow fever in our city. He was preceptor to Dr Redman in medicine.
• * 1.2

  Treatise on the Inflammatory Rheumatism, vol. i. p. 407.
• † 1.3

  Dr Redman was not the only instance furnished by the disorder, in which reason got the better of the habits of old age, and of the formalities of medicine. About the time the fever declined, I received a letter from Dr Shippen, Sen. (then above 82 years of age) dated Oxford Furnace, New Jersey, October 13th, 1793, in which, after approving in polite terms of my mode of practice, he adds "Desperate diseases require desperate remedies. I would only propose some small addition to your present method. Suppose you should substitute, in the room of the jalap, six grains of gamboge, to be mixed with 10 or 15 grains of calomel; and after a dose or two as occasion may require, you should bleed your patients almost to death, at least to fainting; and then direct a plentiful supply of mallows tea, with fresh le|mon juice, and sugar and barley water, together with the most simple, mild, and nutritious food." The Doctor con|cludes his letter by recommending to my perusal Dr Do|ver's account of nearly a whole ship's crew having been cured of a yellow fever, on the coast of South America, by being bled until they fainted.
• * 1.4

  Diseases of Barbadoes, p. 212.
• † 1.5

  Diseases in Voyages to Hot Climates, vol. ii. p. 322.
• * 1.6

  Medical Inquiries and Observations, London edition, vol. i. p. 112.
• * 1.7

  Vol. ii. p. 342.
• * 1.8

  Vol. i. p. 9.