Chapter VII: Front Matter (7)

I have mentioned, among the _apparent_ bad effects of bleeding, that it sometimes changes a soft into a tense pulse. Of this I saw a remarkable instance in Captain John Barry, in the autumn of 1795. After the loss of 130 ounces of blood in a malignant yellow fever, his pulse became so soft as to indicate no more bleeding. In this situation he remained for three days, but without mending as rapidly as I expected from the state of his pulse. On the fourth day he had a hæmorrhage from his bowels, from which he lost above a pint of blood. His pulse now suddenly became tense, and continued so for two or three days. I ascribed this change in his pulse to the vessels of the bowels, which had been oppressed by congestion, being so much relieved by the hæmorrhage, as to resume an inflammatory action. I have observed a similar change to take place in the pulse, after a third bleeding, in a case of hæmorrhoidal fever, which came under my notice in the month of January, 1803. It is thus we see the blood-vessels, in a common phlegmon, travel back again, from a tendency to mortification, to the red colour and pain of common inflammation.

From a review of the commotions excited in the system by bleeding, a reason may be given why the physicians, who do not bleed in the depressed state of the pulse, have so few patients in what they call malignant fevers, compared with those who use a contrary practice. The disease, in such cases, being locked up, is not permitted to unfold its true character; and hence patients are said to die of apoplexy, lethargy, cholera, dysentery, or nervous fever, who, under a different treatment, would have exhibited all the marks of an ordinary malignant fever.

In obviating the objections to blood-letting from its apparent evils, I have said nothing of the apparent bad effects of other remedies. A nausea is often rendered worse by an emetic, and pains in the bowels are increased by a purge. But these remedies notwithstanding maintain, and justly too, a high character among physicians.

19. Bleeding has been accused of bringing on a nervous, or the chronic state of fever. The use of this remedy, in a degree so moderate as to obviate the putrid or gangrenous state of fever only, may induce the chronic state of fever; for it is the effect, in this case, of the remains of inflammatory diathesis in the blood-vessels; but when blood is drawn proportioned to the morbid action in the system, it is impossible for a chronic fever to be produced by it. Even the excessive use of blood-letting, however injurious it may be in other respects, cannot produce a chronic fever, for it destroys morbid action altogether in the blood-vessels.

20. Bleeding has been charged with being a weakening remedy. I grant that it is so, and in this, its merit chiefly consists. The excessive morbid action of the blood-vessels must be subdued in part, in a fever, before stimulating remedies can be given with safety or advantage. Now this is usually attempted by depleting medicines, to be mentioned hereafter, or it is left to time and nature, all of which are frequently either deficient, or excessive in their operations; whereas bleeding, by suddenly reducing the morbid action of the blood-vessels to a wished-for point of debility, saves a great and unnecessary waste of excitability, and thus prepares the body for the exhibition of such cordial remedies as are proper to remove the debility which predisposed to the fever.

21. It has been said that bleeding renders the habitual use of it necessary to health and life. This objection to blood-letting is founded upon an ignorance of the difference between the healthy, and morbid action of the blood-vessels. Where blood is drawn in health, such a relaxation is induced in the blood-vessels, as to favour the formation of plethora, which may require habitual bleeding to remove it; but where blood is drawn only in the inflammatory state of fever, the blood-vessels are reduced from a morbid degree of strength to that which is natural, in which state no predisposition to plethora is created, and no foundation laid for periodical blood-letting. But there are cases which require even this evil, to prevent a greater. Thus we cure a strangulated hernia, when no fever attends, by the most profuse bleeding. The plethora and predisposition to disease which follow it are trifling, compared with preventing certain and sudden death.

22. Bleeding has been accused of bringing on an intermitting fever. This is so far from being an objection to it, that it should be considered as a new argument in its favour; for when it produces that state of fever, it converts a latent, and perhaps a dangerous disease, into one that is obvious to the senses, and under the dominion of medicine. Nor is it an objection to blood-letting, that, when used in an inflammatory intermittent, it sometimes changes it into a continual fever. An instance of the good effects of this change occurred in the Pennsylvania hospital, in an obstinate tertian, in the year 1804. The continual fever, which followed the loss of blood, was cured in a few days, and by the most simple remedies.

23. It has been said that bleeding, more especially where it is copious, predisposes to effusions of serum in the lungs, chest, bowels, limbs, and brain. In replying to this objection to bleeding, in my public lectures, I have addressed my pupils in the following language: "Ask the poor patients who come panting to the door of our hospital, with swelled legs and hard bellies, every fall, whether they have been too copiously bled, and they will all tell you, that no lancet has come near their arms. Ask the parents who still mourn the loss of children who have died, in our city, of the internal dropsy of the brain, whether they were destroyed by excessive blood-letting? If the remembrance of the acute sufferings which accompanied their sickness and death will permit these parents to speak, they will tell you, that every medicine, except bleeding, had been tried to no purpose in their children's diseases. Go to those families in which I have practised for many years, and inquire, whether there is a living or a dead instance of dropsy having followed, in any one of them, the use of my lancet? Let the undertakers and grave-diggers bear witness against me, if I have ever, in the course of my practice, conveyed the body of a single dropsical patient into their hands, by excessive blood-letting? No. Dropsies, like abscesses and gangrenous eruptions upon the skin, arise, in most cases, from the _want_ of sufficient bleeding in inflammatory diseases. Debility, whether induced by action or abstraction, seldom disposes to effusion. Who ever heard of dropsy succeeding famine? And how rarely do we see it accompany the extreme debility of old age?"

"If ever bleeding kills," says Botallus, either directly or indirectly, through the instrumentality of other diseases, "it is not from its excess, but because it is not drawn in a sufficient quantity, or at a proper time[53]." And, again, says this excellent writer, "One hundred thousand men perish from the want of blood-letting, or from its being used out of time, to one who perishes from too much bleeding, prescribed by a physician[54]."

[53] Cap. viii. § 4.

[54] Cap. xxxvi. § 4.

It is remarkable, that the dread of producing a dropsy by bleeding, is confined chiefly to its use in malignant fevers; for the men who urge this objection to it, do not hesitate to draw four or five quarts of blood in the cure of the pleurisy. The habitual association of the lancet with this disease, has often caused me to rejoice when I have heard a patient complain of a pain in his side, in a malignant fever. It insured to me his consent to the frequent use of the lancet, and it protected me, when it was used unsuccessfully, from the clamours of the public, for few people censure copious bleeding in a pleurisy.

24. Against blood-letting it has been urged, that the Indians of our country cure their inflammatory fevers without it. To relieve myself from the distressing obloquy to which my use of this remedy formerly exposed me, I have carefully sought for, and examined their remedies for those fevers, with a sincere desire to adopt them; but my inquiries have convinced me, that they are not only disproportioned to the habits and diseases of civilized life, but that they are far less successful than blood-letting, in curing the inflammatory fevers which occur among the Indians themselves.

25. Evacuating remedies of another kind have been said to be more safe than bleeding, and equally effectual, in reducing the inflammatory state of fever. I shall enumerate each of these evacuating remedies, and then draw a comparative view of their effects with blood-letting. They are,

I. Vomits.

II. Purges.

III. Sweats.

IV. Salivation. And,

V. Blisters.

I. Vomits have often been effectual in curing fevers of a mild character. They discharge offensive and irritating matters from the stomach; they lessen the fulness of the blood-vessels, by determining the serum of the blood through the pores; and they equalize the excitement of the system, by inviting its excessive degrees from the blood-vessels to the stomach and muscles. But they are,

1. Uncertain in their operation, from the torpor induced by the fever upon the stomach.

2. They are unsafe in many conditions of the system, as in pregnancy, and a disposition to apoplexy and ruptures. Life has sometimes been destroyed by their inducing cramp, hæmorrhage, and inflammation in the stomach.

3. They are not subject to the controul of a physician, often operating more, or less than was intended by him, or indicated by the disease.

4. They are often ineffectual in mild, and always so in fevers of great morbid action.

II. Purges are useful in discharging acrid fæces and bile from the bowels in fevers. They act, moreover, by creating an artificial weak part, and thus invite morbid excitement from the blood-vessels to the bowels. They likewise lessen the quantity of blood, by preventing fresh accessions of chyle being added to it; but like vomits they are,

1. Uncertain in their operation; and from the same cause. Many ounces of salts and castor oil, and whole drachms of calomel and jalap, have often been given, without effect, to remove the costiveness which is connected with the malignant state of fever.

2. They are not subject to the direction of a physician, with respect to the time of their operation, or the quantity or quality of matter they are intended to discharge from the bowels.

3. They are unsafe in the advanced stage of fevers. Dr. Physick informed me, that three patients died in the water-closet, under the operation of purges, in St. George's hospital, during his attendance upon it. I have seen death, in several instances, succeed a plentiful spontaneous stool in debilitated habits.

III. Sweating was introduced into practice at a time when morbific matter was supposed to be the proximate cause of fever. It acts, not by expelling any thing exclusively morbid from the blood, but by abstracting a portion of its fluid parts, and thus reducing the action of the blood-vessels. This mode of curing fever is still fashionable in genteel life. It excites no fear, and offends no sense. The sweating remedies have been numerous, and fashion has reigned as much among them, as in other things. Alexipharmic waters, and powders, and all the train of sudorific medicines, have lately yielded to the different preparations of antimony, particularly to James's powder. I object to them all,

1. Because they are uncertain; large and repeated doses of them being often given to no purpose.

2. Because they are slow, and disagreeable, where they succeed in curing fever.

3. Because, like vomits and purges, they are not under the direction of a physician, with respect to the quantity of fluid discharged by them.

4. Because they are sometimes, even when most profuse, ineffectual in the cure of fever.

5. The preparations of antimony, lately employed for the purpose of exciting sweats, are by no means safe. They sometimes convulse the system by a violent puking. Even the boasted James's powder has done great mischief. Dr. Goldsmith and Mr. Howard, it is said, were destroyed by it.

None of these objections to sweating remedies are intended to dissuade from their use, when nature shows a disposition to throw off a fever by the pores of the skin; but, even then, they often require the aid of bleeding to render them effectual for that purpose.

IV. Mercury, the Sampson of the materia medica, after having subdued the venereal disease, the tetanus, and many other formidable diseases, has lately added to its triumphs and reputation, by overcoming the inflammatory and malignant state of fever. I shall confine myself, in this place, to its depleting operation, when it acts by exciting a salivation. From half a pound to two pounds of fluid are discharged by it in a day. The depletion in this way is gradual, whereby fainting is prevented. By exciting and inflaming the glands of the mouth and throat, excitement and inflammation are abstracted from more vital parts. In morbid congestion and excitement in the brain, a salivation is of eminent service, from the proximity of the discharge to the part affected. But I object to it, as an exclusive evacuant in the cure of fever,

1. Because it is sometimes impossible, by the largest doses of mercury, to excite it, when the exigences of the system render it most necessary.

2. Because it is not so quick in its operation, as to be proportioned to the rapid progress of the malignant state of fever.

3. Because it is at all times a disagreeable, and frequently a painful remedy, more especially where the teeth are decayed.

4. Because it cannot be proportioned in its duration, or in the quantity of fluid discharged by it, to the violence or changes in the fever.

Dr. Chisholm relied, for the cure of the Beullam fever at Grenada, chiefly upon this evacuation. I have mentioned the ratio of success which attended it.

V. Blisters are useful in depleting from those parts which are the seats of topical inflammation. The relief obtained by them in this way more than balances their stimulus upon the whole system need hardly say, that their effects in reducing the morbid and excessive action of the blood-vessels are very feeble. To depend upon them in cases of great inflammatory action, is as unwise as it would be to attempt to bale the water from a leaky and sinking ship by the hollow of the hand, instead of discharging it by two or three pumps.

VI. Abstemious diet has sometimes been prescribed as a remedy for fever. It acts directly by the abstraction of the stimulus of food from the stomach, and indirectly by lessening the quantity of blood. It can bear no proportion, in its effects, to the rapidity and violence of an inflammatory fever. In chronic fever, such as occurs in the pulmonary consumption, it has often been tried to no purpose. Long before it reduces the pulse, it often induces such a relaxation of the tone of the stomach and bowels as to accelerate death. To depend upon it therefore in the cure of inflammatory fever, whether acute or chronic, is like trusting to the rays of the sun to exhale the water of an overflowing tide, instead of draining it off immediately, by digging a hole in the ground. But there are cases in which the blood-vessels become so insolated, that they refuse to yield their morbid excitement to depletion from any outlet, except from themselves. I attended a sailor, in the Pennsylvania hospital, in 1799, who was affected with deafness, attended with a full and tense pulse. I prescribed for it, purging, blisters, and low diet, but without any effect. Perceiving no change in his pulse, nor in his disease, from those remedies, I ordered him to lose ten ounces of blood. The relief obtained by this evacuation induced me to repeat it. By means of six bleedings he was perfectly cured, without the aid of any other remedy.

Bleeding has great advantages over every mode of depleting that has been mentioned.

1. It abstracts one of the exciting causes, viz. the stimulus of the blood, from the seat of fever. I have formerly illustrated this advantage of blood-letting, by comparing it to the abstraction of a grain of sand from the eye to cure an opthalmia. The other depleting remedies are as indirect and circuitous in their operation in curing fever, as vomits and purges would be to remove an inflammation in the eye, while the grain of sand continued to irritate it.

2. Blood-letting is quick in its operation, and may be accommodated to the rapidity of fever, when it manifests itself in apoplexy, palsy, and syncope.

3. It is under the command of a physician. He may bleed _when_ and _where_ he pleases, and may suit the _quantity_ of blood he draws, exactly to the condition of his patient's system.

4. It may be performed with the least attendance of nurses or friends. This is of great importance to the poor at all times, and to the rich during the prevalence of mortal epidemics.

5. It disturbs the system much less than any of the other modes of depleting, and therefore is best accommodated to that state of the system, in which patients are in danger of fainting or dying upon being moved.

6. It is a more delicate depleting remedy than most of those which have been mentioned, particularly vomits, purges, and a salivation.

7. There is no immediate danger to life from its use. Patients have sometimes died under the operation of vomits and purges, but I never saw nor heard an instance of a patient's dying in a fainty fit, brought on by bleeding.

8. It is less weakening, when used to the extent that is necessary to cure, than the same degrees of vomiting, purging, and sweating.

9. Convalescence is more rapid and more perfect after bleeding, than after the successful use of any of the other evacuating remedies.

By making use of blood-letting in fevers, we are not precluded from the benefits of the other evacuating remedies. Some of them are rendered more certain and more effectual by it, and there are cases of fever, in which the combined or successive application of them all is barely sufficient to save life.

To rely upon any one evacuating remedy, to the exclusion of the others, is like trusting to a pair of oars in a sea voyage, instead of spreading every sail of a ship.

I suspect the disputes about the eligibility of the different remedies which have been mentioned, have arisen from an ignorance that they all belong to one class, and that they differ only in their force and manner of operation. Thus the physicians of the last century ascribed different virtues to salts of different names, which the chemists of the present day have taught us are exactly the same, and differ only in the manner of their being prepared.

Having replied to the principal objections to blood-letting, and stated its comparative advantages over other modes of depletion, I proceed next to mention the circumstances which should regulate the use of it. These are,

I. The state of the pulse.

The following states of the pulse indicate the necessity of bleeding.

1. A full, frequent, and tense pulse, such as occurs in the pulmonary, rheumatic, gouty, phrenitic, and maniacal states of fever.

2. A full, frequent, and jerking pulse, without tension, such as frequently occurs in the vertiginous, paralytic, apoplectic, and hydropic states of fever.

3. A small, frequent, but tense pulse, such as occurs in the chronic, pulmonary, and rheumatic states of fever.

4. A tense and _quick_ pulse, without much preternatural frequency. This state of the pulse is common in the yellow fever.

5. A slow but tense pulse, such as occurs in the apoplectic, hydrocephalic, and malignant states of fever, in which its strokes are from 60 to 90, in a minute.

6. An uncommonly frequent pulse, without much tension, beating from 120 to 170 or 180 strokes in a minute. This state of the pulse occurs likewise in the malignant states of fever.

7. A soft pulse, without much frequency or fulness. I have met with this state of the pulse in affections of the brain, and in that state of pulmonary fever which is known by the name of pneumonia notha. It sometimes, I have remarked, becomes tense after bleeding.

8. An intermitting pulse.

9. A depressed pulse.

10. An imperceptible pulse. The slow, intermitting, depressed, and imperceptible states of the pulse are supposed exclusively to indicate congestion in the brain. But they are all, I believe, occasioned likewise by great excess of stimulus acting upon the heart and arteries. A pulse more tense in one arm than in the other, I have generally found to attend a morbid state of the brain. Much yet remains to be known of the signs of a disease in the brain, by the states of the pulse; hence Mr. Hunter has justly remarked, that "In inflammation of the brain, the pulse varies more than in inflammations of any other part; and perhaps we are led to judge of inflammation there, more from _other_ symptoms than the pulse[55]."

[55] Treatise on Inflammation, chap. iii. 9.

The slow, uncommonly frequent, intermitting, and imperceptible states of the pulse, which require bleeding, may be distinguished from the same states of the pulse, which arise from an exhausted state of the system, and that forbid bleeding, by the following marks:

1. They occur in the beginning of a fever.

2. They occur in the paroxysms of fevers which have remissions and exacerbations.

3. They sometimes occur after blood-letting, from causes formerly mentioned.

4. They sometimes occur, and continue during the whole course of an inflammation of the stomach and bowels. And,

5. They occur in relapses, after the crisis of a fever.

The other states of the pulse indicate bleeding in every stage of fever, and in every condition of the system. I have taken notice, in another place, of the circumstances which render it proper in the advanced stage of chronic fever.

If all the states of pulse which have been enumerated indicate bleeding, it must be an affecting consideration to reflect, how many lives have been lost, by physicians limiting the use of the lancet only to the tense or full pulse!

I wish it comported with the proposed limits of this essay to illustrate and establish, by the recital of cases, the truth of these remarks upon the indications of bleeding from the pulse. It communicates much more knowledge of the state of the system than any other sign of disease. Its frequency (unconnected with its other states), being under the influence of diet, motion, and the passions of the mind, is of the least consequence. In counting the number of its strokes, we are apt to be diverted from attending to its irregularity and force; and in these, it should always be remembered, fever chiefly consists. The knowledge acquired by attending to these states of the pulse is so definite and useful, and the circumstances which seduce from a due attention to them are so erroneous in their indications, that I have sometimes wished the Chinese custom of prescribing, from feeling the pulse only, without seeing or conversing with the patient, were imposed upon all physicians.

To render the knowledge of the indications of blood-letting, from the state of the pulse, as definite and correct as possible, I shall add, for the benefit of young practitioners, the following directions for feeling it.

1. Let the arm be placed in a situation in which all the muscles which move it shall be completely relaxed; and let it, at the same time, be free from the pressure of the body upon it.

2. Feel the pulse, in all obscure or difficult cases, in both arms.

3. Apply all the fingers of one hand, when practicable, to the pulse. For this purpose, it will be most convenient to feel the pulse of the right hand with your left, and of the left hand with your right.

4. Do not decide upon blood-letting, in difficult cases, until you have felt the pulse for some time. The Chinese physicians never prescribe until they have counted 49 strokes.

5. Feel the pulse at the intervals of four or five minutes, when you suspect that its force has been varied by any circumstance not connected with the disease, such as emotions of the mind, exercise, eating, drinking, and the like.

6. Feel the pulsations of the arteries in the temples and in the neck, when the pulse is depressed or imperceptible in the wrists.

7. Request silence in a sick room, and close your eyes, in feeling a pulse in difficult cases. By so doing, you will concentrate the sensations of your ears and eyes, in your fingers.

In judging of the states of the pulse which have been enumerated, it will be necessary always to remember the natural difference, in its frequency and force, in old people and children; also in the morning and evening, and in the sleeping and waking states of the system.

Much yet remains to be known upon this subject. I have mentioned the different states of the pulse, which call for bleeding, but it is more difficult to know when to prescribe it, when the pulse imparts no sign of disease. In general it may be remarked, where the disease is _recent_, the part affected important to life, and incapable of sustaining violent morbid action long, without danger of disorganization, where pain is great, and respiration difficult, the pulse may be disregarded in the use of the lancet.

But to return.

II. Regard should be had to the character of the reigning epidemic, in deciding upon blood-letting. If the prevailing fever be of a highly inflammatory nature, bleeding may be used with more safety, in cases where the indications of it from the pulse are somewhat doubtful. The character of a previous epidemic should likewise direct the use of the lancet. The pestilential fever which followed the plague in London, in 1665, Dr. Sydenham says, yielded only to blood-letting. It is equally necessary in all the febrile diseases which succeed malignant fevers.

III. Regard should be had to the weather and season of the year. Dr. Hillary and Dr. Huxham both say it is much more necessary in dry, than in wet weather, and, all physicians know, it is more copiously indicated in the spring and autumn, than in summer and winter.

IV. The constitution of a patient, and more especially his habits with respect to blood-letting, should be taken into consideration, in prescribing it. If he be plethoric, and accustomed to bleeding in former indispositions, it will be more necessary, than in opposite states and habits of the system. Nature will expect it.

V. The corpulency of a patient should regulate the use of the lancet. A butcher of great observation informed me, that a fat ox did not yield more than from one half, to one third of the quantity of blood of a lean one, of the same size of bone, and it is well known, that the loss of a small quantity of blood, after cutting off the head of a fowl, is always a sign of its being fit for the table. The pressure of fat upon the blood-vessels produces the same effects in the human species that it does in those animals; of course, less blood should be drawn from fat, than from lean people, under equal circumstances of disease.

VI. As persons have more or less blood in their vessels, according to their size, less blood should be drawn, under equal circumstances, from small than large people.

VII. Regard should be had to the age of adults in prescribing bleeding. In persons between fifty and sixty years of age, for reasons formerly mentioned, more blood may be drawn than in middle life, in similar diseases. In persons beyond 70, it will be necessary to regulate the quantity to be drawn by other signs than the pulse, or the appearances of the blood, the former being generally full, and sometimes tense, and the latter often putting on the sign of the second grade of morbid action formerly described.

VIII. Regard should be had to the country or place from which persons affected with fevers have arrived, in prescribing the loss of blood. Fevers, in America, are more inflammatory than fevers, in persons of equal rank, in Great-Britain. A French physician once said, it was safer to draw a hogs-head of wine from a Frenchman's veins, than a quarter of a hundred pounds of beef from an Englishman's, meaning to convey an idea of the difference in the grades of morbid or inflammatory action in the diseases of the inhabitants of France and England, and of the difference in the quantity of blood proper to be drawn in each of them. A similar difference exists between the grades of fever in Great-Britain and America. From a want of attention to this circumstance, I saw a common pleurisy end in an abscess of the lungs, in a sea captain, in the city of London, in the year 1769, who was attended by a physician of the first reputation in England. He was bled but once. His pulse and American constitution called for the loss of 50 or 60 ounces of blood.

IX. Regard should be had to the structure and situation of the parts diseased with febrile action. The brain, from its importance to all the functions of life, the rectum, the bladder, and the trachea, when inflamed, and the intestines, when strangulated, from their being removed so much out of the influence of the great circulation, all require more copious bleeding than the same degrees of disease in the lungs, and some other parts of the body.

X. After blood-letting has been performed, the appearances of the blood should be attended to, in order to judge of the propriety of repeating it. I shall briefly describe these appearances, and arrange them in the order in which they indicate the different degrees of inflammatory diathesis, beginning with the highest.

1. Dissolved blood. It occurs in the malignant states of fever. I have seen it several times in the pleurisy, and have once heard of it in a case of gout. I have ascribed this decomposition of the blood to such a violent degree of action in the blood-vessels, as to dispose them to a paralytic state. It is generally considered as a signal to lay aside the lancet. If it occur in the _first stage_ of a fever, it indicates a very opposite practice. By repeated bleedings, the vessels recover their natural action, and the blood becomes _reduced_ to its original texture. Of this I have had frequent experience, since the year 1793. It required three successive bleedings to restore the blood from a dissolved, to a coagulable state, in Mr. Benton. It afterwards became very sizy. If this dissolved blood appear towards the close of a malignant fever, no other benefit than the protraction of life for a day or two, or an easy death, can be expected from repeating the bleeding, even though it be indicated by a tense pulse; for the viscera are generally so much choaked by the continuance of violent action in the blood-vessels, that they are seldom able to discharge the blood which distends them, into the cavity in the vessels, which is created by the abstraction of blood from a vein. There is some variety in the appearance of this state of the blood, which indicates more or less violent pressure upon the blood-vessels. It threatens most danger to life when it resembles molasses in its consistence. The danger is less when the part which is dissolved occupies the bottom of the bowl, and when its surface is covered with a sizy pellicle or coat.

Does not the restoration of the blood from its disorganized state, by means of bleeding, suggest an idea of a similar change being practicable in the solids, when they are disorganized by disease? And are we not led hereby to an animating view of the extent and power of medicine?

2. Blood of a scarlet colour, without any separation into crassamentum or serum, indicates a second degree of morbid action. It occurs likewise in the malignant state of fever. It is called improperly dense blood. It occurs in old people.

3. Blood in which part of the crassamentum is dissolved in the serum, forming a resemblance to what is called the lotura carnium, or the washings of flesh in water.

4. Crassamentum sinking to the bottom of a bowl in yellow serum.

5. Crassamentum floating in serum, which is at first turbid, but which afterwards becomes yellow and transparent, by depositing certain red and fiery particles of the blood in the bottom of the bowl.

6. Sizy blood, or blood covered with a buffy coat. The more the crassamentum appears in the form of a cup, the more inflammatory action is said to be indicated by it. This appearance of the blood occurs in all the common states of inflammatory fever. It occurs too in the mild state of malignant fevers, and in the close of such of them as have been violent. It is not always confined to the common inflammatory state of the pulse, for I have observed it occasionally in most of the different states of the pulse which have been described. The appearance of this buffy coat on the blood in the yellow fever is always favourable. It shows the disease to be tending from an uncommon to a _common_ degree of inflammatory diathesis. It has been remarked, that blood which resembles claret in its colour, while flowing, generally puts on, when it cools, a sizy appearance.

It would seem, from these facts, that the power of coagulation in the blood was lessened in an exact ratio to the increase of action upon the blood-vessels, and that it was increased in proportion to the diminution of that action, to that degree of it which constitutes what I have called _common_ inflammatory action.

Here, as upon a former occasion, we may say with concern, if bleeding be indicated by all the appearances of the blood which have been enumerated, how many lives have been lost by physicians limiting the use of the lancet to those cases only, where the blood discovered an inflammatory crust!

These remarks upon the relative signs of inflammatory action in the blood-vessels, should be admitted with a recollection that they are all liable to be varied by a moderate, or violent exacerbation of fever, by the size of the stream of blood, and by the heat, coldness, and form of the cup into which the blood flows. Even blood drawn, under exactly equal circumstances, from both arms, exhibited, in a case of pleurisy communicated to me by Dr. Mitchell, of Kentucky, very different appearances. That which was taken from one arm was sizy, while that which was taken from the other was of a scarlet colour. That which is drawn from a vein in the arm, puts on, likewise, appearances very different from that which is discharged from the bowels, in a dysentery. These facts were alluded to in the Outlines of the Theory of Fever[56], in order to prove that unequal excitement takes place, not only in the different systems of the body, but in the same system, particularly in the blood-vessels. They likewise show us the necessity of attending to the state of the _pulse_ in both arms, as well as in other parts of the body, in prescribing blood-letting. When time, and more attention to that index of the state of the system in fevers, shall have brought to light all the knowledge that the pulse is capable of imparting, the appearances of the blood, in fevers, will be regarded as little as the appearances of the urine.

[56] Vol. iii.

XI. Blood-letting should always be copious where there is danger from sudden and great congestion or inflammation, in vital parts. This danger is indicated most commonly by pain; but there may be congestion in the lungs, liver, bowels, and even in the head, without pain. In these cases, the state of the pulse should always govern the use of the lancet.

XII. What quantity of blood may be taken, with safety, from a patient in an inflammatory fever? To answer this question it will be necessary to remark, 1. That, in a person of an ordinary size, there are supposed to be contained between 25 and 28 pounds of blood; and 2. That much more blood may be taken when the blood-vessels are in a state of morbid excitement and excitability, than at any other time. One of the uses of the blood is to stimulate the blood-vessels, and thereby to assist in originating and preserving animal life. In a healthy state of the vessels, the whole mass of the blood is necessary for this purpose; but in their state of morbid excitability, a much less quantity of blood than what is natural (perhaps in some cases four or five pounds) are sufficient to keep up an equal and vigorous circulation. Thus very small portions of light and sound are sufficient to excite vision and hearing in an inflamed, and highly excitable state of the eyes and ears. Thus too, a single glass of wine will often produce delirium in a fever in a man, who, when in health, is in the habit of drinking a bottle every day, without having his pulse quickened by it.

An ignorance of the quantity of blood which has been drawn by design, or lost by accident, has contributed very much to encourage prejudices against blood-letting. Mr. Cline drew 320 ounces of blood in 20 days from a patient in St. Thomas's hospital, who laboured under a contusion of the head. But this quantity is small compared with the quantity lost by a number of persons, whose cases are recorded by Dr. Haller[57]. I shall mention a few of them. One person lost 9 pounds of blood, a second 12, a third 18, and a fourth 22, from the nose, at one time. A fifth lost 12 pounds by vomiting in one night, and a sixth 22 from the lungs. A gentleman at Angola lost between 3 and 4 pounds daily from his nose. To cure it, he was bled 97 times in one year. A young woman was bled 1020 times in 19 years, to cure her of plethora which disposed her to hysteria. Another young woman lost 125 ounces of blood, by a natural hæmorrhage, every month. To cure it, she was bled every day, and every other day, for 14 months. In none of these instances, was death the consequence of these great evacuations of blood. On the contrary, all the persons alluded to, recovered. Many similar instances of the safety, and even benefit of profuse discharges of blood, by nature and art, might be mentioned from other authors. I shall insert only one more, which shall be taken from Dr. Sydenham's account of the cure of the plague. "Among the other calamities of the civil war which afflicted this nation, the plague also raged in several places, and was brought by accident from another place to Dunstar Castle, in Somersetshire, where some of the soldiers dying suddenly, with an eruption of spots, it likewise seized several others. It happened at that time that a surgeon, who had travelled much in foreign parts, was in the service there, and applied to the governor for leave to assist his fellow-soldiers who were afflicted with this dreadful disease, in the best manner he was able; which being granted, he took so large a quantity of blood from every one at the beginning of the disease, and before any swelling was perceived, that they were ready to faint, and drop down, for he bled them all standing, and in the open air, and had no vessel to measure the blood, which falling on the ground, the quantity each person lost could not, of course, be known. The operation being over, he ordered them to lie in their tents; and though he gave no kind of remedy after bleeding, yet of the numbers that were thus treated, not a single person died. I had this relation from Colonel Francis Windham, a gentleman of great honour and veracity, and at this time governor of the castle[58]."

[57] Elementa Physiologiæ, vol. iv. p. 45.

[58] Vol. i. p. 131.

Again. An ignorance of the rapid manner in which blood is regenerated, when lost or drawn, has helped to keep up prejudices against blood-letting. A person (Dr. Haller says) lost five pounds of blood daily from the hæmorrhoidal vessels for 62 days, and another 75 pounds of blood in 10 days. The loss each day was supplied by fresh quantities of aliment.

These facts, I hope, will be sufficient to establish the safety and advantages of plentiful blood-letting, in cases of violent fever; also to show the fallacy and danger of that practice which attempts the cure of such cases of fever, by what is called _moderate_ bleeding. There are, it has been said, no half truths in government. It is equally true, that there are no half truths in medicine. This half-way practice of moderate bleeding, has kept up the mortality of pestilential fevers, in all ages, and in all countries. I have combated this practice elsewhere[59], and have asserted, upon the authority of Dr. Sydenham, that it is much better not to bleed at all, than to draw blood disproportioned in quantity to the violence of the fever. If the state of the pulse be our guide, the continuance of its inflammatory action, after the loss of even 100 ounces of blood, indicates the necessity of more bleeding, as much as it did the first time a vein was opened. In the use of this remedy it may be truly said, as in many of the enterprizes of life, that nothing is done, while any thing remains to be done. Bleeding should be repeated while the symptoms which first indicated it continue, should it be until four-fifths of the blood contained in the body are drawn away. In this manner we act in the use of other remedies. Who ever leaves off giving purges in a colic, attended with costiveness, before the bowels are opened? or who lays aside mercury as a useless medicine, because a few doses of it do not cure the venereal disease?

[59] Account of the Yellow Fever in 1793.

I shall only add under this head, that I have always observed the cure of a malignant fever to be most complete, and the convalescence to be most rapid, when the bleeding has been continued until a _paleness_ is induced in the face, and until the patient is able to sit up without being fainty. After these circumstances occur, a moderate degree of force in the pulse will gradually wear itself away, without doing any harm.

XIII. In drawing blood, the quantity should be large or small at a time, according to the state of the system. In cases where the pulse acts with force and freedom, from 10 to 20 ounces of blood may be taken at once; but in cases where the pulse is much depressed, it will be better to take away but a few ounces at a time, and to repeat it three or four times a day. By this means the blood-vessels more _gradually_ recover their vigour, and the apparent bad effects of bleeding are thereby prevented. Perhaps the same advantages might be derived, in many other cases, from the gradual abstraction of stimuli, that are derived from the gradual increase of their force and number, in their application to the body. For a number of facts in support of this practice, the reader is referred to the history of the yellow fever, in the year 1793. In an inflammatory fever, the character of which is not accurately known, it is safest to begin with moderate bleeding, and to increase it in quantity, according as the violence and duration of the disease shall make it necessary. In fevers, and other diseases, which run their courses in a few days or hours, and which threaten immediate dissolution, there can be no limits fixed to the quantity of blood which may be drawn at once, or in a short time. Botallus drew three, four, and five pints in a day, in such cases. Dr. Jackson drew fifty-six ounces of blood, at one time, from a Mr. Thompson, of the British hospitals, in a fever of great violence and danger. This patient was instantly relieved from what he styled "chains and horrors." In three or four hours he was out of danger, and in four days, the doctor adds, returned to his duty[60]. Dr. Physick drew ninety ounces, by weight, from Dr. Dewees, in a sudden attack of the apoplectic state of fever, at one bleeding, and thereby restored him so speedily to health, that he was able to attend to his business in three days afterwards. In chronic states of fever, of an inflammatory type, small and frequent bleedings, are to be preferred to large ones. We use mercury, antimony, and diet drinks as alteratives in many diseases with advantage. We do not expect to remove debility by two or three immersions in a cold bath. We persist with patience in prescribing all the above remedies for months and years, before we expect to reap the full benefits of them. Why should not blood-letting be used in the same way, and have the same chance of doing good? I have long ago adopted this _alterative_ mode of using it, and I can now look around me, and with pleasure behold a number of persons of both sexes who owe their lives to it. In many cases I have prescribed it once in two or three months, for several years, and in some I have advised it every two weeks, for several months.

[60] Remarks on the Constitution of the Medical Department of the
British Army.

There is a state of fever in which an excess in the action of the blood-vessels is barely perceptible, but which often threatens immediate danger to life, by a determination of blood to a vital part. In this case I have frequently seen the scale turn in favour of life, by the loss of but four or five ounces of blood. The pressure of this, and even of a much less quantity of blood in the close of a fever, I believe, as effectually destroys life as the excess of several pounds does in its beginning.

In cases where bleeding does not cure, it may be used with advantage as a _palliative_ remedy. Many diseases induce death in a full and highly excited state of the system. Here opium does harm, while bleeding affords certain relief. It belongs to this remedy, in such cases, to ease pain, to prevent convulsions, to compose the mind, to protract the use of reason, to induce sleep, and thus to smooth the passage out of life.

XIV. Bleeding from an artery, commonly called arteriotomy, would probably have many advantages over venesection, could it be performed at all times with ease and safety. Blood discharged by hæmorrhages affords more relief, in fevers, than an equal quantity drawn from a vein, chiefly because it is poured forth, in the former case, from a ruptured artery. I mentioned formerly, that Dr. Mitchell had found blood drawn from an artery to be what is called dense, at a time when that which was drawn from a vein, in the same persons, was dissolved. This fact may possibly admit of some application. In the close of malignant fevers, where bleeding has been omitted in the beginning of the disease, blood drawn from a vein is generally so dissolved, as to be beyond the reach of repeated bleedings to restore it to its natural texture. In this case, arteriotomy might probably be performed with advantage. The arteries, which retain their capacity of life longer than the veins, by being relieved from the immediate pressure of blood upon them, might be enabled so to act upon the torpid veins, as to restore their natural action, and thereby to arrest departing life. Arteriotomy might further be used with advantage in children, in whom it is difficult, and sometimes impracticable to open a vein.

XV. Much has been said about the proper place from whence blood should be drawn. Bleeding in the foot was much used formerly, in order to excite a revulsion from the head and breast; but our present ideas of the circulation of the blood have taught us, that it may be drawn from the arm with equal advantage in nearly all cases. To bleeding in the foot there are the following objections: 1. The difficulty of placing a patient in a situation favourable to it. 2. The greater danger of wounding a tendon in the foot than in the arm, And, 3. The impossibility of examining the blood after it is drawn; for, in this mode of bleeding, the blood generally flows into a basin or pail of water.

Under this head I shall decide upon the method of drawing blood by means of cups and leeches, in the inflammatory state of fever. Where an inflammatory fever arises from local affection, or from contusion in the head or breast, or from a morbid excitement in those, above other parts of the arterial system, they may be useful; but where local affection is a symptom of general and equable fever only, it can seldom be necessary, except where bleeding from the arm has been omitted, or used too sparingly, in the beginning of a fever; by which means such fixed congestion often takes place, as will not yield to general bleeding.

XVI. Much has been said likewise about the proper time for bleeding in fevers. It may be used at all times, when indicated by the pulse and other circumstances, in continual fevers; but it should be used chiefly in the paroxysms of such as intermit. I have conceived this practice to be of so much consequence, that, when I expect a return of the fever in the night, I request one of my pupils to sit up with my patients all night, in order to meet the paroxysm, if necessary, with the lancet. But I derive another advantage from fixing a centinel over a patient in a malignant fever. When a paroxysm goes off in the night, it often leaves the system in a state of such extreme debility, as to endanger life. In this case, from five to ten drops of laudanum, exhibited by a person who is a judge of the pulse, obviate this alarming debility, and often induce easy and refreshing sleep. By treating the human body like a corded instrument, in thus occasionally relaxing or bracing the system, according to the excess or deficiency of stimulus, in those hours in which death most frequently occurs, I think I have been the means of saving several valuable lives.

XVII. The different positions of the body influence the greater or less degrees of relief which are obtained by blood-letting. Where there is a great disposition to syncope, and where it is attended with alarming and distressing circumstances, blood should be drawn in a recumbent posture, but where there is no apprehension or dread of fainting, it may be taken in a sitting posture. The relief will be more certain if the patient be able to stand while he is bled. A small quantity of blood, drawn in this posture, brings on fainting, and the good effects which are often derived from it. It should therefore be preferred, where patients object to copious or frequent bleedings. The history of the success of this practice in the British army, recently mentioned from Dr. Sydenham, furnishes a strong argument in its favour.