The Lancet

The Lancet

The abuse of regular medicines, the administration of too much opium, the misuse of medicines that alter bodily functions, and the use of the lancet to induce bleeding are specific steps taken by physicians like Ricketson to make the patient healthier.  Ricketson tries to redefine these parts of the patient care process in the last section of his book.  In addition to the singlemost problem he sees being practiced by physicians, the abuse and mishandling of drugs, he briefly reviews the rules for administering mercurials, opium, emetics, cathartics, bitters, astringents, aromatics, stimulants, and the lancet.  Ricketson’s discussion of the use of the Lancet in particular is of interest because it demonstrates the early nature of a feeling amongst some physicians of the uncertainty that existed about this particular therapeutic practice.  Even though it had a fairly solid theory or philosophy for its use, with a long history to back up this tradition’s claims, some physicians had limitation to their use of this specific medical tool.  Ricketson tries to make sense of this particular paractice based on his own practice of bloodletting and his experiences wtih other physicians performing the same sorts of medical care.  Due to nature of this part of traditional regular medicine and the Quakerian perspective of such, this section of Ricketson’s book is included here in its entirety (if necessary, please click on this pdf to enlarge and read):

Ricketson prescribes bloodletting just for the treatment of “all acute febrile diseases, of an inflammatory nature, accompanied by giddiness, head-ache, a full hard pulse, and acute pain.”   Febrile diseases lacking this complete list of symptoms, and fevers of a nervous or putrid nature, should be treated with tonics and strengtheners.  Medical conditions that produce some sort of visibly stressful state of the body, such as onset of sanguinous (red) temperament  (flushing , hot tempered, hyperexcitement, etc.) may also require bleeding.   Bleeding is administered before a return of regular periodic pains or bleeding, to prevent such events from recurring.   (Terminology note: ‘plethory’ refers to increase in blood bulk or volume in the body.)

Apoplexy as an Example

In Thomas’s Modern Practice of Physic (Charleston, 1810, p. 248-9), the description of apoplexy describes it much like the modern description of a stroke, with the exception that the description is based totally on appearances, not actually known cerebrovascular states.   This is because apoplexy could occur, around 1800 to 1810, without a real stroke happening.  It was a condition of the body characterized by the results of “compression on the brain” of excessive amounts of blood.   It is the kind of disease that most often afflict people “at an advanced period in life, and most usually on those who are of a corpulent habit, with a short neck and large head, and who lead an inactive life, make use of a full diet, or drink to excess.”  In essence, this is the result of morbid obesity.  With morbid obesity, Thomas notes how and why one develops the sanguinous state Ricketson referred to, which Thomson calls “sanguinous apoplexy”: 

“The immediate cause of apoplexy in most generally a compression on the brain, produced either by an accumulation of blood in the vessles of the head, and distending them to such  degree as to compress the medullary portion of the brain; or by an effusion of the blood from the red vessels, or from serum of the exhalates, which fluids are accumulated in such a quantity as to occasion compression.”

The causes for this are “over-distention and effusion” of the head and brain can range from “fits of passion”, great exertions of muscular strength, severe exercise, wearing any thing too tight around the neck, overloading the stomach, stooping down for any length of time, long exposure to intense cold or a vertical sun, the sudden supression of any long-term evacuation, the applications of the fumes of certain narcotic and metallic substances, such as opium, alcohol, mercury, etc. . . ”  Following a post-mortum autopsy, Thomas notes that the findings suggest that these events occur due to “a loss of vitality in the brain”, suggested by a lack of the typical exudation, extravasation and effusion signs (what today we consider signs of stroke such as a ruptured blood vessel, a blockage of cerebral vessels, or the like).  In sum, the causes for sanguinous apoplexy qaccording to Thomas are “a full and luxurious mode of living, with but little exercise, a sanguine temperament, a full habit, middle age, short neck, suppressed evacuations, and warm weather.”

Thomas’s second form of apoplexy is serous apoplexy, in which a “phlegmatic temperament” prevails, i.e. “the face is pale and tumid, the veins are depressed, the pulse is small, weak, irregular, and intermittent, respiration is impeded and stertorous, and the extremities are cold and flaccid.”  These patients may also suffer vertigo, torpor, loss of sense and motion, hemiplegia, semipalsy states, loss of speech and a failed memory.  These weakening conditions ultimately lead to fatality through some for of total weakening event such as a death brought on by diarrhea, hemorrhage, hemorrhoids, and sometimes fever and loss of an ability to speak. 

Thomas’s treatments for apoplexy include leeches or bloodletting to the temples, scaring or cupping glasses to the occiput, a blistering of the head or neck, small blisters to the extremities, and cataplasms to the soles of the feet.  Interestingly, Thomas correctly notes that in cases where one side is more affected (true strokes in this case), that the opposite side of the head is where these treatments have to be practiced.  

For treating serous apoplexy, all of these steps are avoided, and attempts are made to improve the removal of serum from the brain, including an administration of warm purgatives, blisters to the head, back and extremities, and sinapisms (mustard plasters) on the soles of the feet.  Salts, elixirs and cordials are provided to increase this reduction in phlegmatic fluids in the body.  Cephalic and nervous medicines that perform in this way, and stomach purgatives,  are recommended to treat the Palsy. 

In all cases, treatments should work to increase fluid flows, without raising the heat of the body.  Ongoing use of gentle laxatives is recommended to prevent the onset of apoplexy, avoiding heat and cold whilst keeping the feet warm and dry, wearing the appropriate clothing–well-fitted about the neck, engaging in just moderate exercise, sleeping with the head above the chest.  this description on the prevention of apoplexy ends with:

“Nothing has a better effect in preventing apoplexy in those who are predisposed to its attacks, than a perpetual issue between the shoulders, or a seton in the neck; but great care must be taken to not allow them to dry up without opening some other drain in their stead.”

Comparing this with Ricketson’s treatments, it helps to note that Thomas’s book was published one year after Ricketson’s book (Thomas’s first edition of this book was published 1797, and contained much less detail; the above is from the 1813 second edition.)  So this was probably the standard of care at the time, and Ricketson’s statements were  not just a recapitulation of Thomas’s work.  Ricketson’s personal favorites are worth noting due to some of the differences his procedures had from Thomas, such as the recommendation of flannel clothing to prevent the cold from impacting one’s health, and the options he recommends to always relying upon blood-letting.   Ricketson allows for the setons, plasters, blistering, setons, leeches, cupping, etc., when simple bloodletting is not enough.  But he does not differentiate between the two types of apoplexy like Thomas.  More importantly, the bulk of Ricketson’s writing tends to steer the reader away from being bled too much, or on a regular basis, all for the wrong diagnostic reasons.   Ricketson’s two-page quote taken from physician and obstetrician Dr. John Leake (1729-1792), then of Westminster Lying-In Hospital, makes this point clear.  Like Leake, Ricketson recommends a healthy lifestyle to prevent the maladies that often require bleeding in the first place.  Bleeding should be performed only to meet a special need, and then just to serve as some means for treating acute problems, not for long term prevention.  He writes: 

“The best substitutes for bleeding are, moderate exercise, a spare diet, and gentle laxative; which, properly conducted, will often supply the place and defect of regular, habitual discharges of blood.”

Review

Summarizing Ricketson’s book, we learn a lot about his overall philosophy as a physician activity practicing both Medicine and Quakerism.  Still, this only tells us a little about his personal philosophy, more of which can be obtained from his writings that appear in the local medical journals.  A number of these writings are available for review and so are included in the next section.  These smaller details of Ricketson’s work and community efforts as a physician are representive of his religious standing as a whole, as well as representative of his take on health and disease as a person.  One of the more impressive things about Ricketson’s past is his devotion to his work at some community level, both with the professional community as well as with the immediately local community.  Ricketson also managed to have his own influences on the ongoing disputes about the various causes for disease then being generated by Samuel Mitchell and others working for the local trade journal Medical Repository, and teaching at the local New York City medical school.  Comparing Shadrach Ricketson with other physician living nearby in the valley who were published in the Respository, he was very much in tune with the popular notion that weather was a major factor contributing to or serving as a primary cause for disease.  Ricketson, however, fails to make any if any emphasis of another medical geography theme promoted by physicians, the medical topography theory of disease.  The closest he comes to supporting this notion pertains mostly to the pedological (soil-based) theories for disease then being established by medical topographers who would later become known as medical geologists in the 1860s.  The following demonstrate Ricketson’s activity as a multidiscplinary professional in both regular medicine and the related specialities of medical climatology and public health epidemiology.