responded to the yellow fever crisis by having directions for the
treatment of the fever printed in the newspapers. Dr. Adam Kuhn,
the "A.K." of the first letter, was one of the city's
most prominent practitioners and also taught at the medical
school. Dr. Edward Stevens was
new to the city, but gained immediate prominence because
Alexander Hamilton credited him for curing his fever. Dr. Benjamin Rush's letter was also printed as a handbill.
Kuhn was out of the city when his letter was printed, and Stevens
about to leave the city. Since historians so often accuse Rush of
suiting his therapy to his medical theories, I have highlighted
the portions of Kuhn's and Stevens' letters which pertain to
medical theory. Rush at this time consciously avoided mention of
EXTRACT OF A LETTER
Philadelphia Sept. 7, 1793
I received your letter to day and shall with pleasure give you every information in my power respecting the malignant fever, which proves so fatal among us. As I consider debility and putrification the alarming circumstances to be attended to, and to be abbreviated from the earliest commencement of the disease, my method treatment is instituted accordingly and has generally been successful. I do not administer any emetic, neither do I give a laxative unless indicated by the costiveness, when I recommend cream. of tartar or castor oil, but prefer a clyster of either. In case of nausea I order a few bowls of camomile tea to be taken; if the nausea continues, it is to be relieved with the continuous saline draught in a state of effervesence, elixir of vitriol, and, if necessary, laudanum. The sickness of the stomach may also be alleviated by applying mint, cloves, or any other spice with wine or spirits to the pit of the stomach. The stomach being composed, 20 drops of elixir of vitriol are to be taken every 2 hours in a cup full of strong cold camomile tea, and if bark can be obtained, two drachms of the best pale bark in substance are to be taken given 2 hours, alternately with the elixir of vitriol. When an ounce of bark has been administered in this manner, the dose is to be diminished to one drachm every two hours, as the continuance of large doses might disorder the stomach or bowels. Should the bark prove purgative it will be necessary to give 10 or 15 drops of laudanum after every stool. But if the bark cannot be retained on the stomach, 20 drops of elixir of vitriol are to be taken every hour, and recourse must be had to bark clysters.
Two ounces of bark are to be put into three half pints of boiling water and be boiled down to a pint; the decoction to be strained and to 4 ounces of the decoction we add from two to four drachms of finely powdered bark and fifty drops of laudanum. This mixture is to be injected every 4 hours or oftener if the symptoms are violent. One or two glasses of Madeira wine may be added to each injection where the debility is great. Wine is to be given from the beginning; at first weaker wines, such as claret and Rhenish; it these cannot be had, Lisbon or Madeira diluted with rich lemonade. The quantity is to be determined by the effects it produces and by the state of debility which prevails, guarding against its occasioning or encreasing the heat, restlessness or delirium. I prefer pale bark from a conviction that most of the red bark offered for sale is adulterated. But I place the greatest dependence for the cure to the disease, on throwing cool water twice a day over the naked body. The patient is to be placed in a large empty tub, and two buckets full of water, of the temperature 75 or 80 degrees Fahrenheit's thermometer, according to the state of the atmosphere, are to be thrown on him.
He is then to be wiped dry and put to bed, it is commonly followed by an easy perspiration & is always attended with great refreshment to the patient. The remedy however must be applied from the earliest attacks of the disease and continued regularly through the whole course of it. Of regimen it is needless to say much to you: ripe fruits, sago with wine, and rich wine-whey are the most proper. A spacious chamber with a free circulation of air and repeatedly changing the bed and body linen are highly necessary. If the bark clysters should bring on costiveness the laudanum may occasionally be omitted; if this is not attended with the desired consequences, we have recourse to a common injection. Sprinkling the chamber with vinegar, washing the face, neck, hands and feet with it and then wiping them dry, will have their use. The fumes of vinegar and of nitre will contribute much to sweeten the air of the chamber.
I am, & c,
N.B. The practice of applying the cold bath to fevers is not new. In a malignant fever which prevailed in Breslau in Silesia and proved extremely fatal, yielding to none of the usual remedies, DR. DE HAEHN a physician of the place had recourse to this remedy and found it effectual. It also had been used with advantage in England with putrid fevers. In many of the West India islands it is generally employed in their malignant fevers. DR. STEVENS, a gentleman of high character in this profession who is now in this city, assures me that in the island of St. Croix where he practiced medicine many years, it has been found more effectual than any method heretofor practiced.
I am moreover indebted to Dr Stevens for the following observations: that laxatives are never employed but when the clysters are not attended with the desired effect of moving the bowels; that in violent attacks of the disease bark clysters are repeated every two hours, and the water is applied to the body every 6 or 8 hours and even more frequently; that when there is disposition to diarrhea the elixir of vitriol has a tendency to increase it, as is therefore laid aside and that the disease which he has seen in this country is of the same nature with the malignant fever of the West Indies.
If you are of the opinion, that the enclosed statement can have the least tendency to ally the apprehensions of the citizens, I beg you to make any use of it you may think proper.
I am with respect,
Your most humble servant,
Sept 13, 1793
Matthew Clarkson, Esq. Mayor of the city of Philadelphia
From the 23d, of August, the day on which I saw the first patient with yellow fever, to the 3d day of September, when I was myself confined with a remittent fever, I visited sixty persons, ill of various complaints. The greater part, were indisposed with the remittent and intermittent fever, which always prevail among us, at this season of the year, which all yielded readily to our usual mode of treating those diseases, except in one gentleman, who had been many years an invalid-Seven only of this number had the yellow fever; three of them were patients of other gentlemen of the faculty. Of these seven, I was called to four, in the early stages of the disease. Three of them are now well; the other was in the fourth day of the disease, when I became unwell myself. He had then, no unfavourable symptoms; but died on the 8th day, from the time he was seized.
DR RUSH'S DIRECTIONS
For Curing and Preventing the
As soon as you are affected (whether by night or day) with a pain in the head or back, sickness at stomach, chills or fever--more especially if those symptoms be accompanied by a redness or faint yellowness of the eyes, and dull or shooting pains about the region of the liver, take one of the powders* in a little sugar and water, every six hours, until they produce four or five large evacuations of the bowels--drink plentifully gruel, or barley water, or chicken water-or any other mild drink that is agreeable, assist the operation of the physic. It will be proper to lie in bed while the medicine is operating, by which means a plentiful sweat will more easily be brought on. After the bowels are thoroughly cleaned, if the pulse be full of tense, 8 or 10 ounces of blood should be taken form the arm, and more, if the tension or fulness of the pulse should continue. Balm tea, toast and water, lemonade, tamarind water, weak camomile tea, or barley water, should be drank during this state of the disorder--and the bowel should be kept continually open, either by another powder, or by small doses of cream of tartar, or cooling salts, or by common opening clyster; but if the pulse should become weak and low after the bowels are cleaned, infusions of camomile and snakeroot in water or in substance, may be administered in the intermission of the fever. Blisters may likewise be applied to the sides, neck, or head in this state of the disorder, and the lower limbs may be wrapped up in flannels wetted in hoe vinegar or water. The food shall consist of gruel, sago, panada, tapioca, tea, coffee, weak chocolate, wine whey, chicken broth, and the white meats, according to the weak or active state of the system. The fruits of the season may be eaten with advantage at all times.
Fresh air should be admitted into the room in all cases and cool air when the pulse is full and tense.--The floor should be sprinkled now and then with vinegar-and the discharges from the body removed as speedily as possible. The best preventatives of the disorder are a temperate diet, consisting chiefly of vegetables, great moderation in the exercises of the body and mind, warm cloathing cleanliness, and a gently open state of the bowels.
Sept. 10 1793.
* Each powder consisting of ten grains of Calomel, and fifteen grains of Jalap, for an adult.
FOR THE GENERAL ADVERTISER
FROM DR. E. STEVENS
DR. JOHN REDMAN
IN compliance with the request of the learned body over whom you preside, I now cheerfully transmit them a few brief and detached observations on the nature and treatment of the present and fatal disorder which prevails in the city. Their humane activity to ascertain the real character of the complaint and to establish some fixed and steady mode of cure for it are fresh proofs of their benevolence and clearly evinces that disinterested liberality for which they so eminently distinguished. I only regret that their application to me, has approached so near the moment of my departure that I have not sufficient leisure to elucidate the subject so amply and satisfactorily as the importance it deserves. Imperfect however as the enclosed sketch may be, I can with truth assure them that it is dictated soley by a philanthropic demise of desire of checking the ravages of the disease and of restoring tranquility to the dejected minds of the public.
This disorder arises from contagion. Its approaches are slow and insidious at the commencement. It is ushered in with a slight degree of languor and lassitude, loss of appetite, restlessness and disturbed dreams, depression of spirits and a want of inclination to perform the ordinary occupations of life. The patient does not consider himself sufficiently sick to complain or call in the assistance of a Physician. His feelings are rather unpleasant than alarming. This train of symptoms continue for 2 or 3 days and if not removed by timely aid is succeeded by a sharp pain in the head, anxiety and suppression about the Praecordia, a febrile surge pulse, great prostration of strength and a variety of morbid Phaenomena which are too well known to the faculty to need description. In the first stage of the disorder a little attention and well directed efforts of a skillful practitioner may generally prove successful in the mitigating the violence of future symptoms and preventing with much danger or long confinement. At the first appearance of languor, lassitude, &c. especially if the patient has been near the source of contagion, he should carefully avoid fatigue of the body and application of the mind. Everything can tend to debilitate should be carefully guarded against. He should remain at perfect rest. His diet should be fuller and more cordial than usual, and a few extraordinary glasses of Madeira may be allowed. He should take the cold bath every morning, and if his sleep is disturbed, a gentle opiate combined with a few grains of volatile salts and some grateful Aromatic may be administered at night. A few doses of good genuine bark may be taken in powder during the day and if the stomach should become afflicted with Nausea, a strong decoction of the same may be substituted. Great care should be taken to keep the mind of the patient calm and serene--neither to terrify it with needless apprehension, nor alarm it by the melancholy relation of the spreading mortality that surrounds him. It is at this stage of the complaint that the Physician may lay the foundation of future success. But unfortunately, it is the period of the disease which is commonly too much neglected by the patient. Gentleman of the faculty are rarely called in until the symptoms are more alarming and dangerous. But it is a matter of material consequence to the patient to know that by a little bit of attention at the commencement, and by carefully watching the approaches of the disease even though it should by contracted, it may be rendered mild and may terminate favourably . Its also of equal consequence for practitioners to attend to these particulars in laying down the prophylaxes to their patients.
When the disorder has gained ground and becomes violent and when the danger is imminent the most unremitted exertions should be made by the Physicians to mitigate the symptoms. The Nausea and vomiting may be relieved by an infusion of camomile flowers given frequently until the stomach is sufficiently emptied of all crude matter. Small doses of a cordial mixture composed of the oil of peppermint and compound spirits of lavender may then be taken until the sickness abates. If notwithstanding the instability of the stomach should continue, recourse must instantly had to the cold water bath which must be used every two hours or oftener if the urgency of the symptoms should require it. After each immersion, a glass of old Madeira or a little Brandy burnt with cinnamon may be administered. Flannel clothes wrung out of spirits or Wine impregnated with spices may be applied to the pit of the stomach and changed frequently.
An injection containing an ounce of powdered bark mixed with this sago to which a tea spoon full of Laudanum has been added should be administered. These injections may be continued every two hours omitting the laudanum after the first. As soon as the stomach can bear the medicine and nourishment in small doses; as much Madeira wine may be given as the patient can bear without affecting his head or heating him too much. All emetics and violent cathartics should be avoided. If the bowels should not be sufficiently open a laxative of clyster may be necessary of a few grains of powdered rhubarb added to each dose of bark until the desired effect is produced. If diarrhea should prevail it must be checked by a starch injection blended with laudanum, by the tincture of E. Kino yaponica or a decoction carcarilla. All drastic cathartics did injury when the disease is in its advanced stage. If stupor, coma, or delirium should come on a large blister be applied between the shoulders and small one to the thighs, stimulant cataplasms should also be applied to the feet; when haemorahagies appear the elixir of vitriol may be administered in conjunction with the bark. But great care should be taken to prevent it from affecting the bowels. If the pulse should be sunk, the prostrations of strength great and the subsultus teninium take place small doses of the liquor mineralis haffinanni of vitriolic aether diluted with water may be given. Musk and camphor in this stage of the disease have likewise proved effectual; upon the whole, sir, I may sum up this hasty outline by inculcting the use of the tonic plan in its fullest extent and by warning against the ill consequences of debilitating applications or profuse evacuations in every period of the disease; the cold water bath, bark and wine, a spacious and well ventilated room, frequent change of bed and body linens and attention to rest and quiet if properly persevered in will, in most cases prove successful and strip this formidable disease of its malignity, its terror and its danger.
The descriptions I have given of the disorder & the utility of the plan of cure I have laid down are confirmed by experience and coincides with our reason and the soundest theory; the cause producing the effect is strong debilitating power; the symptoms occasioned by its application indicate extreme debility in the animal functions and great derangement of the nervous system; ought not therefore the remedies adapted to the complaint, to be cordial stimulating and tonic? Should not violent evacuations which evidently weaken and relax be avoided? These are hints which it would be presumptuous to extend or dwell upon; Their superior judgement will I am convinced supply every deficiency and enable them to pursue that plan which is best adapted to public utility and the effectual removal of the present dreadful malady. If the few observations I have suggested be serviceable to the inhabitants of this city my intention will be fully answered and my feelings completely grateful.
I have the honor to be, Sir,
Your most obedient servant,