Monday, April 18, 2011

Dr. Elihu H. Smith's patients

After graduating from Yale in 1786, when he was 15 years old, Elihu Hubbard Smith wrote poetry and edited one of the first collections of American poems. Then he got his medical degree at the University of Pennsylvania, and, inspired by the lectures of Dr. Benjamin Rush, moved to New York City to start his medical practice. He found that difficult and wavered in his resolve, contemplating instead starting a literary magazine or joining his father who was a pharmacist in Litchfield, Connecticut. In the meantime he wrote a libretto for an opera produced in New York. He followed the yellow fever epidemic of 1793 from afar, siding with his old mentor as Rush defended his regimen of bleeding and purging to treat yellow fever.

In 1795, Dr. Amasa Dingley, another young doctor, invited Smith to join him in treating patients with yellow fever as New York City suffered an epidemic. Smith left a copious diary of his life then which, while it didn't describe cases in great detail, does show the idealism with which he fought the epidemic and his methods of treatment. He dedicated himself to proving the superiority of Rush's methods.

"Do I not see ignorance, pride, stupidity, carelessness, & a superstitious veneration for foreign writers, & a mean jealousy of an illustrious writer of our own country, go hand in hand, & as it were, conspire, against the lives of men?" he asked himself in his journal. "I think I do. I think I have had sufficient opportunity to determine that his principles & practice are equally & certainly sound. I think I should apply them, in nearly all their extent."

Smith soon had first hand experience of the efficacy of Rush's methods. He saw Dingley draw two pounds of blood from a man in two days, "with great advantage." Then when one of his own patients had a serious relapse with feeble pulse and severe fever, Smith brought out his lancet. "I determined to bleed him," he wrote in his journal. "He tottered out to a chair in the yard. I took away 18 oz. He rose, & walked, with a steady step, to the end of the yard; & after a discharge, returned; went down stairs, & returned to his room."

Then Smith joined Dingley in trying to cure the apothecary Nathan Webb with bleeding and purges. Their patient suffered one of the worst side effects of bleeding. "We were near an hour employed in attempting to stop a bleeding which took place from a vein which had been opened before," Smith wrote in his diary. "The blood was entirely destroyed in its texture; the man stupidly insane; the house deserted; a negro nurse only remaining; except a drunken relation of the landlord, who with oaths & imprecations, refused to allow our moving the sick man, from an apartment five feet wide by twelve long, into an unoccupied, airy room. We did it however - & exerted every thing in our power to restore sensibility & hope to a man, thus forlorn, & without relation or friend near him, to yield any assistance."

They returned the next day and found Webb dead.

His experience in the epidemic convinced Smith to remain a doctor. He applied his literary talents to the creation and editing of America's first scientific journal, The Medical Repository

He focused his own research on finding the cause of yellow fever and wrote a long monograph on 1795 epidemic in New York City in which he endorsed Rush's view that the disease was caused by a filthy environment. Ironically, in his diary, he frequently noted how bad mosquitoes were in the late summer and early fall of 1795. While treating patients in the early days of New York's 1798 epidemic, he contracted the disease and died on September 19. That will be the subject of another blog post.

Here are excerpts from his monograph on the causes of the fever, in which he does mention mosquitoes but only blames them for predisposing people to get the fever not with causing it:

Excerpts from "Letters From Dr. E. H. Smith to Dr. W. Buel" in Noah Webster's A Collection of Papers on the Subject of Bilious Fever, Prevalent in the United States for a Few Years Past. 1796

[66]....Though the fever continued to extend itself, to the last, yet it never became general over the city; and, for a large time, was mostly confined to a particular district. As the season advanced, the peculiarities of this district may be supposed to have become common to a larger portion of the city; and this extension to the whole part only prevented by the letting in of winter. To the district alluded to, the East river, from Long-Island ferry to Mr. Rutger's [67] forms the eastern boundary; the northern reaches from thence to Division-street; thence westerly, down Division-street, Chatham-street, the extremity of Pearl-street, into William-street, to Franckfort-street, down this last to Gold-street, through that to Beekman-street, along which the line proceeds to Pearl street, as far as the Market, down which it should be continued to the river. - The space included in these bounds, is all over which the fever, according to the best of my remembrance, exerted any power, till after it had reached its height; when it extended down Water-street, a little below Wall-street, and proved very mortal. It is true that there were a few persons affected in various other parts of the town; but during the great part of the prevalence of the fever it was principally active in the north-eastern and middle parts of the district comprehended as above; and, as a thorough knowledge of the peculiarities of this portion of our city is, in my opinion, indispensable to the history of the disease which afflicted it, I cannot doubt your patience with the minute description I think it necessary to give.

The first and most obvious remark, on the greater parft of the district, just pointed out, is, that it is the lowest, flattest, and most sunken part of the whole city. Some places are much more sunken than other; but the whole space is evidently so, compared with the adjacent ground; and appears to have an inclination, more of less observable, in different streets, to the East river. This inclination is very considerable in Dover-street; a street which is said always to have suffered from fevers of this kind, during the hot season. From the division of Pearl and Cherry-streets, down the latter, the descent is rapid, to somewhere near James's-street; about which is the lowest part of the street, and from whence it is nearly level [68] to the northern boundary. Beyond this bound, the ground rises again; and the made ground, by the river side, is also somewhat elevated: so likewise, is the whole ground over which the westerly line passes - through Division, Chatham, & c. streets. Thus you will perceive, that the part of the city where the fever was most active, for the longest period, forms, as it were, a basin, having its side, nearest the water, a little inclined. Within this basin, there are several smaller cavities; one of which, in particular, will require a further description. Those streets, also, which are no included in this hollow, but which lie along the river, will require some attention; which shall be given them.

The extreme irregularity in the disposition of the streets, and the narrowness of the greater number of them, are great obstacles to a free ventilation of this city. This misfortune, common to every part of it, falls with peculiar heaviness on that district which has just been spoken of. The comparatively high and neighboring lands of Morrissania and Long-Island, receive almost solely the benefit of breezes from the north-east and east: The Sound, which divides them from the city, being too narrow to add much force and freshness to a breeze nearly spent on their heights. North, the island rises into little hills, from which the wind passes on to the high parts of the city; rarely visiting the low and intervening space; unless it may be the topmost rooms of the houses: and, as the houses are generally low, the effects of a wind from this quarter must be inconsiderable. - North-westerly, there is somewhat more of an opening; but even this is small. West, south west, and south, the other parts of the town, which are higher and thickly settled, break the force of the gales from these points. So that, thus situated, this quarter of [69] the city, though it were perfectly well laid out, would have but little chance for a free ventilation: irregularly disposed and narrow as the streets are, we must be convinced of the impossibility of its receiving the necessary supply of fresh air. You will understand me speaking of a thorough ventilation, and in the sultry season, when it is most necessary: a partial supply of air, equal to the support of a feverish existence, it undoubtedly obtains.

Much of the ground, in the northern part of this district is swampy, and abounds with little pools and puddles of stagnant water. This was especially true last summer and autumn; there being great rains, and no adequate means for conducting off the water. Indeed, so flat are some of the paved streets, in this quarter, that the rains did not run down the gutters, but continued in little puddles, and were evaporated from the places where they fell. In the new streets, which are unpaved, and without any gutters, numerous imperfect ditches assisted the disposition of water to stagnate. These places were often muddy, when the southern part of the town was dry; and the streams from them very offensive, when the dry streets, towards the North river, were perfectly sweet.

Several of the paved streets, and indeed the greater number, in the district of which I am speaking, are narrow and crooked; some with neither side walks nor gutters, and by far the largest portion of them miserably built. Most of those which are unpaved, are, in all respects, still worse; the buildings chiefly wooden, and placed on the ground; the old ones falling to decay; the new, but imperfectly finished. Of them all, it may be remarked, that they are much exposed, some of them more than others, to the full [70] influence of the docks, whatever that may be, and it cannot be salutary; or to that of a boiling sun, from early in the morning, till the middle of the afternoon; and some of them to both.

So much for the streets, generally: a few particulars, concerning some of them, are necessary to the formation of a perfect idea of this district.

A line, drawn from the corner of Ferry and Pearl streets, up the latter, to where William street enters it; then down William to Franckfort, and through that, a part of Gold and Ferry-streets, to Pearl-street again, will form the ridge of a new cavity (included in the principal boundaries above mentioned) which seems contrived, by art, for the dwelling place of fever. This court-yard of the palace of death, is divided by several dismal lanes, courteously denominated streets; such as Vanderwater, Rose and Jacob-streets, & c. which form the borders to innumerable tan-vats. The whole is one vast tan-yard, the firm parts of which seem to have been constructed by art in the midst of an extensive quagmire. To this place as far as I can discover, there is no outlet. Think what must be the condition of it, in the months of August and September! - Yet human beings live here; and habit renders its noxious exhalations, in some sort, harmless ot them. It is remarkable that few persons, regularly inhabiting this hollow, died of the fever last year. To those, whose evil destiny led them to seek a new dwelling place there, it proved highly pestilential.

Dover-street is a short, narrow street, running from the beginning of Cherry-street, down to the East-river; and contains near twenty buildings -[71] ... rapid. As the exposure is nearly to the east, it receives the whole effect of the sun, from 6 a.m. to 3 p.m. in the summer. The descent makes it easy to keep the surface of the street clean; though it prevents a free ventilation. But it has been raised, several feet, since the buildings, which are mostly low, were erected; so that the road is, in many instances, up to the middle of the lower story windows; leaving the cellars to the houses, and cellar kitchens, without a communication with the street. The yards remaining as before, are, of consequence, much lower than the street; without vent; and, of necessity, all the water, and filth of every kind, which gathers in them, must there stagnate, ferment and putrify. Add to this, some of these yards are capacious, and contain little, decayed, wooden huts; sometimes built directly on the ground; and containing, oftentimes, several families.

Water-street, above Dover-street, is chiefly composed of low, decayed and dirty wooden buildings. This street being either made-ground entirely, or raised like Dover-street, the same is true of the situation of the houses and yards. And, lest any of the filth, or water, should drain off, from any of the yards, the western side of Water-street has been kindly converted, by the enlightened zeal of the directors of these affairs, into a perfect dyke; which answers its design, most completely, by preventing even the slightest leakage. Beside, as this street lies directly on the water, it has the benefit of the whole force of the sun, the greater part of the day; and of the exhalations from the docks; which are here in great number, and in the highest state of their perfection. There is, however, a better opportunity for fresh air, in this, than in some other streets. Yet even this is an advantage which the rage for [72] improvement threatens to transfer to a new street, still further out in the river; which, if completed, may form another dyke, to the increased pleasantness and health of this quarter of the town.

Of Roosevelt, Catharine, James, Oliver, &c. Streets, nearly the same remarks are true as of Dover and the upper part of Water-street: for though they are somewhat wider, straighter, and have more good and new buildings in them, yet they are raised in the same manner, have sunken yards, and under-ground apartments; and Roosevelt street has an open sink, where the drippings of the tea-water pump, after having gently collected all the filth in their way, are received; and being just enough to wash the gutter, or the sewer, the stench is most intolerable, during the sultry months,.

Tio many other of these streets the same remarks will apply; and to some with aggravated force: but what has been said, will, perhaps, be sufficient to air your imagination in the conception of a just idea of their condition: I mean of their necessity and unavoidable condition.

Of the Docks, it may be enough to mention, generally, that they are badly contrived in every part of the town; and worst of all, in their part; being broken up into numerous little wharves, thus forming narrow slip, where the ground is left bare at ebb tide; and where vegetable, animal, and excrementitious matters, being thrown in, at all times, instead o being cast into the stream, ferment, putrify, and render the stench truly pestiferous. Indeed, this is so much the case, with all of them, in the summer, that, except to persons habituated to their exhalations, [73] they are absolutely intolerable; exciting, in persons of a delicate make, immediate vomiting; and in othrs nausea, indigestion, head-ache, or some temporary illness, when exposed to hem but a short time.

In addition to the above-related facts, concerning the condition of the streets, in that part of the city where care was most needed, it may be remarked that, at no time was there ever so great an apparent inattention to preserving them clean. Besides the impediments which the level nature of the streets, in many parts of the town, presented to the draining off of the filth which is constantly accumulating in large towns like this, artificial impediments were permitted; as if death were not sufficiently active, and needed the aid of the magistrate. In all the streets where buildings were going forward, the workmen were allowed to restrain the course of the water, in the gutters, by forming little dams, for their convenience in making their morter. The effect of this stoppage of water was so great, that even in Broadway, one of the streets the best calculated of any in the city for free ventilation, in that part of it where the new Tontine Tavern was building, the stench was exceedingly offensive. And in this condition it was allowed to remain for near two months; though it was almost under the windows of the principal magistrate of the city. If this were true of the widest, and one of the best aired and cleanest streets, of New-York, whay think you was the state of those narrow, crooked, flat, unpaved, muddy alleys, mentioned above? No one can form even a faint idea who has not walked through them, in the middle of some one of those deadly, suffocative days, which experienced in September last.

[74] But this is not all: beside those masses of semi-putrid vegetable and animal matters - cabbage, turnips, the heads and entrails of fish, & c. which, at all times of the year, out of compassion to men who might be usefully employed as scavengers to the city, are allowed to complete the putrefactive process, undisturbed, in the middle of the streets - the sight and smell were shocked, at every turn, by dead rats, fowls, cats, dogs and pigs. So remarkably was this the case, that I question whether there could have been found a single street, alley, or even bye-lane, of any tolerable length, which did not lend its aid to render this exhibition full and frequent.

.... p 76 Flies were very numerous and troublesome, in every part of the city, in the beginning of summer; but they suddenly disappeared, about the middle of July, from the more airy parts of the town, and succeeded, every where, by clouds of musketoes, incredibly large and distressing; and these continued to afflict us, long after the time when they commonly depart. Almost every person suffered exceedingly from the bites of these insects; and foreigners especially. In some they occasioned universal swellings, and eruption, somewhat like Pemphigus and in other numerous little ulcers. These last, a physician of my acquaintance, saw even in a native American. The irritation, restlessness, and consequent watchfulness and fatigue, occasioned by these animals, no doubt predisposed the well to be affected by the fever; while they extremely harassed the sick, and retarded their recovery.

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