Dr. Nathan Smith married Sally Chase, Jonathan's daughter,
and built a thriving medical practice based in Cornish. There were probably very few doctors in the
Upper Valley, but even fewer who had been educated at Harvard. Nathan graduated from Harvard in 1790,
married Sally in 1791. Their first son, David Solon Chase Hall Smith, was born
about 9 months later.
Nathan
quickly became well known on both sides of the Connecticut River. In 1798, Typhus Fever hit the Upper Valley
and as Nathan traveled throughout the area treating patients, he was able to
track the appearance of the disease from one place to another. He tried to
figure out how the disease was transmitted and also how to treat it. His “Medical and Surgical Memoirs” published
after his death, contains an essay that describes his experiences treating
typhus.
In the
essay, he states that he believes that typhus is a contagious disease. He did not believe it is caused by “miasma”,
poisonous vapor coming off of swamps, for the simple reason that the cases typhoid fever that he treated did not happen
in families living near swamps, nor did the families living in the backwaters
of the Connecticut River seem more likely to contract the disease.
He believed
Typhus was contagious because it was possible to track its spread as families
became sick. It always amazes me how far
people traveled in those days, even though transportation was limited to
horseback or stagecoach. Dr Smith
treated many people in Thetford who came down with Typhus. The outbreak started when a woman from
Thetford went to Chelsea to take care of her sister who was sick with the
disease. The sister died, the woman came
home, got sick and died, and then her whole family came down with it. In the end, 40 people in Thetford died of
Typhus.
In his
essay, he tells the story of a young man from Plainfield who went to Western
New York State for a while, then returned home.
On the way home, he became sick and when he arrived home he was
diagnosed with Typhus. Soon after he was diagnosed, 9 more members of his
family came down with it. He does say that although there is some evidence of
contagion, some people get sick with the disease without any clear evidence of
their having caught it from someone else who had it. Another reason he gives
for it being a contagious disease is that if a patient got Typhus and
recovered, they couldn't get it again, which was the case with other contagious
diseases like mumps, measles, smallpox and whooping cough.
In his
essay, Nathan laments the lack of knowledge the medical profession has about
how contagion works. He says, “Contagion may be considered as the antecedent to
all which follows its application and without it no effect would be
produced. But how this cause operates on
the system, or on what part it makes its first impression, or how this first
impression produces the ultimate effects, we are wholly ignorant.”
By the time
he was summoned to Dartmouth College, where there were 50 or 60 students sick
with Typhus, Dr. Smith treated them and only one died. Possibly this was
because of his “cutting edge” treatment, or because Dartmouth students were
great candidates for surviving a serious disease. They were all young, and because
they were mostly from well-to-do families, they would have been raised
well-fed. The fact that they were at
college presupposes that they were healthy to begin with, because young men who
were sick would not have been at school.
Nevertheless,
by the time Typhus appeared at Dartmouth, Nathan had some definite ideas about
how to treat it. He admits that “I have
never been satisfied that I have cut short a single case of typhus, but have
been able to enable the patient to live through it more comfortably. Like smallpox, measles and whooping cough, it
must run its course. Powerful medicines
can make a person worse.”
One of the
medicines he listed was tartrite of antimony, which apparently contained some
amount of potash. This was used to make
a patient throw up. At the time, people
believed that if you were sick, it was because your body was full of toxins,
and if a doctor could cause you to lose bodily fluids, some of the toxins would
be lost with the fluids, thus you would have less of them in your system.
Medicine that makes people throw up is called an emetic. If you threw up, you would lose some fluid
and thus some of the toxin that was making you sick. In his essay, Dr. Smith said that the only
thing accomplished by giving a patient an emetic was to make him sicker.
thumb lancet
Another way
doctors tried to get rid of the poison in a patients' systems is by
bloodletting. Bloodletting, or bleeding the patient, involved making a cut in
the patients forearm and letting some blood drain out.
Again, bleeding was viewed as a way to get
some liquid out of a patient, and along with it, the poison that was making the
patient sick. Often patients lost so much blood during bloodletting that the
procedure weakened them enough to kill them. In their webpage
Red Gold, the
Epic Story of Blood, PBS reprinted the article “Bloodletting Over the
Centuries” by Gilbert Siegworth, MD, first published in the New York State
Journal of Medicine in 1980. In the article, Siegworth
describes how a thumb
lancet was used to bleed a patient
.
In using a thumb lancet for
bloodletting, a practitioner followed a specific procedure. “ The arm of the
patient was bound above the elbow with a broad tape tight enough to compress
the vein, but not tight enough to diminish the arterial pulse. The blade of the
lancet was grasped between the thumb and forefinger, and the hand was steadied
by the other three fingers. The lancet was then introduced into the vein in an
oblique direction until blood rose up at the point. The front edge of the
lancet was then pulled up in as straight a line as possible to make the skin
wound the same size as that in the vein. The thumb of the left hand which was
compressing the vein distally was removed, and the blood was allowed to flow
into a bowl for measurement. Care was taken to avoid transfixation of the vein,
accidental arteriotomy, or injury to the nerve or tendon. The spurting blood
was caught in various types of vessels. Barber's shaving bowls were sometimes
used. (http://www.pbs.org/wnet/redgold/basics/bloodlettinghistory2.htm)
In his “Medical and Surgical Memoirs”, Nathan
doesn't say much one way or the other about bleeding the patient. He writes that there are some symptoms that
can be alleviated by bloodletting (when pain accompanies a sense of fullness in
the head or chest). He does not advocate
bloodletting as a standard procedure when treating Typhus.
He was
definitely against blistering, which was yet another way doctors tried to get
patients to lose fluid. Doctors would
apply poultices - wet rags – dripping
wet with scalding hot water onto a patients chest in order to burn them. This would raise blisters and when the
blisters broke, the patient would lose the fluid in the blisters and thus lose
a little of the poison in their system.
Nathan
recommends giving the patient as much as he wants to drink, keep cool air in
the sickroom by opening the windows when at all possible, and wet the patients
bedsheets with water to bring the fever down.
This may not seem like cutting edge medicine, but these were revolutionary
ideas at the dawn of the 19th century. People believed it was dangerous to leave the
windows open, and that night air was bad for you to breathe. They believed that the “miasma” from swamps
could come in through an open window and make you sick!
I have read several biographies of Dr Nathan
Smith that say that he believed in “watchful waiting” and emphasized the care
and comfort of the patient. I don't see
that in his “Surgical and Medical Memoirs”.
In fact, mention of patient comfort is striking in its absence. He cautions against using bloodletting as a
standard procedure, absolutely does not believe in blistering, and thinks that
emetics make the patient sicker. He believes that these things do not help the
patient get better, and may very well make sickness worse. He never mentions
that causing sick people to experience even more pain for no good reason is a
terrible idea because burning them, cutting them and making them throw up makes
them even more miserable than they already are.
He doesn't believe in performing these procedures because they may not
help and may make people worse, and may cause people to die rather than get
better.
Nathan's
focus was on survival, not patient comfort, not because he was heartless, cruel
and uncaring but because he really couldn't afford to focus on what his
patients were feeling. He was a
surgeon. One of the focuses of his
practice was surgery, and probably the most surgeries he performed were
amputations, and he did them without anesthesia! The only anesthesia available was
whiskey. By the time surgeries
progressed, the patient either passed out or went into shock, which caused them
to be somewhat senseless, but doctors in general and surgeons especially had to
have a certain amount of callousness toward their patients' pain.
Even when he
wrote about “enabling his patients to live through Typhus more comfortably”, I
wonder if he was really talking about lessened suffering. He could have meant “by a comfortable
margin”, meaning not snatching patients back from the brink of death by the
skin of their teeth, but treating patients in a way that assures they will
recover, where their survival is never in question. Other than that one
comment, he never mentions the comfort of his patients.
In
2014, we can look read Nathan's Medical and Surgical Memoirs and we know where
he was right and where he was sadly wrong.
Neither bloodletting, blistering or emetics help patients get better, so
he was right regarding all of that. He
was also right to treat Typhus fevers by keeping them hydrated and giving them
plenty of fresh air and doing everything possible to bring their temperature
down. There
are two types of Typhus, Typhus and Typhoid Fever. They are both called Typhus because both
diseases can cause delirium and temporary psychosis. Typhus is carried by fleas or lice. A person with Typhus has back pain, high
fever, a rash, joint pains and severe headache and muscle pains. Typhoid Fever is spread through the feces of
an infected person, and is usually
contracted through contaminated water. People who have Typhoid Fever start with
a low grade fever that gradually becomes worse.
Some Typhoid Fever patients can have severe diarrhea, but others can be constipated. Typhoid Fever can affect a patient's heart
and lungs, and can cause severe delirium. I believe the Typhoid essay in
Nathan's book addressed Typhoid Fever as opposed to the Typhus transmitted by
fleas, because he comments on the diarrhea and constipation. Because of vastly
improved sanitary practices and clean water supplies, Typhoid fever is very
rare in modern America,
