Blood-letting, as a remedy for fevers,
and certain other diseases, having lately been
the subject of much discussion, and many objections
having been made to it, which appear to be
founded in error and fear, I have considered that a
defence of it, by removing those objections, might
render it more generally useful, in every part of
the United States.
I shall begin this subject by remarking, that
blood-letting is indicated, in fevers of great morbid
excitement,
1. By the sudden suppression or diminution of
the natural discharges by the pores, bowels, and
kidneys, whereby a plethora is induced in the system.
2. By the habits of the persons who are most
subject to such fevers.
3. By the theory of fever. I have attempted to
prove that the higher grades of fever depend upon
morbid and excessive action in the blood-vessels.
It is connected, of course, with preternatural sensibility
in their muscular fibres. The blood is the
most powerful irritant which acts upon them. By
abstracting a part of it, we lessen the principal
cause of the fever. The effect of blood-letting is
as immediate and natural in removing fever, as
the abstraction of a particle of sand is, to cure an
inflammation of the eye, when it arises from that
cause.
4. By the symptoms of the first stage of violent
fevers, such as a sleepiness and an oppressed pulse,
or by delirium, with a throbbing pulse, and great
pains in every part of the body.
5. By the rupture of the blood-vessels, which
takes place from the quantity or impetus of the
blood in fevers of great morbid action. Let no
one call bleeding a cruel or unnatural remedy. It
is one of the specifics of nature; but in the use of
it she seldom affords much relief. She frequently
pours the stimulating and oppressing mass of blood
into the lungs and brain; and when she finds an
outlet for it through the nose, it is discharged either
in such a deficient or excessive quantity, as to be
useless or hurtful. By artificial blood-letting, we
can choose the time and place of drawing blood, and
we may regulate its quantity by the degrees of action
in the blood-vessels. The disposition of nature
to cure violent morbid action by depletion, is
further manifested by her substituting, in the room
of blood-letting, large, but less safe and less beneficial,
evacuations from the stomach and bowels.
6. By the relief which is obtained in fevers of
violent action by remedies of less efficacy (to be
mentioned hereafter), which act indirectly in reducing
the force of the sanguiferous system.
7. By the immense advantages which have attended
the use of blood-letting in violent fevers,
when used at a proper time, and in a quantity suited
to the force of the disease. I shall briefly enumerate
these advantages.
1. It frequently strangles a fever, when used in
its forming state, and thereby saves much pain,
time, and expence to a patient.
2. It imparts strength to the body, by removing
the depression which is induced by the remote
cause of the fever. It moreover obviates a disposition
to faint, which arises from this state of the
system.
3. It reduces the uncommon frequency of the
pulse. The loss of ten ounces of blood reduced
Miss Sally Eyre's pulse from 176 strokes to 140,
in a few minutes, in the fever of the year 1794.
Dr. Gordon mentions many similar instances of
its reducing the frequency of the pulse, in the puerperile
fever.
4. It renders the pulse more frequent when it is
preternaturally slow.
5. It checks the nausea and vomiting, which attend
the malignant state of fever. Of this I saw
many instances in the year 1794. Dr. Poissonnier
Desperrieres confirms this remark, in his Account
of the Fevers of St. Domingo; and adds further,
that it prevents, when sufficiently copious, the
troublesome vomiting which often occurs on the
fifth day of the yellow fever[48]. It has the same effect
in preventing the diarrhœa in the measles.
6. It renders the bowels, when costive, more
easily moved by purging physic.
7. It renders the action of mercury more speedy
and more certain, in exciting a salivation.
8. It disposes the body to sweat spontaneously,
or renders diluting and diaphoretic medicines more
effectual for that purpose.
9. It suddenly removes a dryness, and gradually
a blackness, from the tongue. Of the former effect
of bleeding, I saw two instances, and of the latter,
one, during the autumn of 1794.
10. It removes or lessens pain in every part of
the body, and more especially in the head.
11. It removes or lessens the burning heat of
the skin, and the burning heat in the stomach, so
common and so distressing in the yellow fever.
12. It removes a constant chilliness, which
sometimes continues for several days, and which
will neither yield to cordial drinks, nor warm bed-clothes.
13. It checks such sweats as are profuse without
affording relief, and renders such as are partial
and moderate, universal and salutary.
14. It sometimes checks a diarrhœa and tenesmus,
after astringent medicines have been given to
no purpose. This has often been observed in the
measles.
15. It suddenly cures the intolerance of light
which accompanies many of the inflammatory states
of fever.
16. It removes coma. Mr. Henry Clymer
was suddenly relieved of this alarming symptom,
in the fever of 1794, by the loss of twelve ounces
of blood.
17. It induces sleep. This effect of bleeding is
so uniform, that it obtained, in the year 1794, the
name of an anodyne in several families. Sleep
sometimes stole upon the patient while the blood
was flowing.
18. It prevents effusions of serum and blood.
Hæmorrhages seldom occur, where bleeding has
been sufficiently copious.
19. It belongs to this remedy to prevent the
chronic diseases of cough, consumption, jaundice,
abscess in the liver, and all the different states of
dropsy which so often follow autumnal fevers.
My amiable friend, Mrs. Lenox, furnished an exception
to this remark, in the year 1794. After
having been cured of the yellow fever by seven
bleedings, she was affected, in consequence of taking
a ride, with a slight return of fever, accompanied
by an acute pain in the head, and some of the
symptoms of a dropsy of the brain. As her pulse
was tense and quick, I advised repeated bleedings
to remove it. This prescription, for reasons which
it is unnecessary to relate, was not followed at the
time, or in the manner, in which it was recommended.
The pain, in the mean time, became
more alarming. In this situation, two physicians
were proposed by her friends to consult with me.
I objected to them both, because I knew their principles
and modes of practice to be contrary to mine,
and that they were proposed only with a view of
wresting the lancet from my hand. From this desire
of avoiding a controversy with my brethren,
where conviction was impossible on either side, as
well as to obviate all cause of complaint by my patient's
friends, I offered to take my leave of her,
and to resign her wholly to the care of the two gentlemen
who were proposed to attend her with me.
To this she objected in a decided manner. But
that I might not be suspected of an undue reliance
upon my own judgment, I proposed to call upon
Dr. Griffitts or Dr. Physick to assist me in my attendance
upon her. Both these physicians had renounced
the prejudices of the schools in which
they had been educated, and had conformed their
principles and practice to the present improving
state of medical science. My patient preferred Dr.
Griffitts, who, in his first visit to her, as soon as
he felt her pulse, proposed more bleeding. The
operation was performed by the doctor himself, and
repeated daily for five days afterwards. From an
apprehension that the disease was so fixed as to require
some aid to blood-letting, we gave her calomel
in such large doses as to excite a salivation.
By the use of these remedies she recovered slowly,
but so perfectly as to enjoy her usual health.
20. Bleeding prevents the termination of malignant,
in the gangrenous state of fever. This effect
of blood-letting will enable us to understand some
things in the writings of Dr. Morton and Dr. Sydenham,
which at first sight appear to be unintelligible.
Dr. Morton describes what he calls a putrid
fever, which was epidemic and fatal, in the
year 1678. Dr. Sydenham, who practised in London
at the same time, takes no notice of this fever.
The reason of his silence is obvious. By copious
bleeding, he prevented the fever of that year from
running on to the gangrenous state, while Dr.
Morton, by neglecting to bleed, created the supposed
putrid fevers which he has described.
It has been common to charge the friends of
blood-letting with temerity in their practice. From
this view which has been given of it, it appears,
that it would be more proper to ascribe timidity
to them, for they bleed to prevent the offensive and
distressing consequences of neglecting it, which
have been mentioned.
21. It cures, without permitting a fever to put
on those alarming symptoms, which excite constant
apprehensions of danger and death, in the
minds of patients and their friends. It is because
these alarming symptoms are prevented, by bleeding,
that patients are sometimes unwilling to believe
they have been cured by it, of a malignant fever.
Thus, the Syrian leper of old, viewed the water of
Jordan as too simple and too common to cure a
formidable disease, without recollecting that the remedies
for the greatest evils of life are all simple,
and within the power of the greatest part of mankind.
22. It prepares the way for the successful use of
the bark and other tonic remedies, by destroying,
or so far weakening, a morbid action in the blood-vessels,
that a medicine of a moderate stimulus afterwards
exceeds it in force, and thereby restores
equable and healthy action to the system.
23. Bleeding prevents relapses. It, moreover,
prevents that predisposition to the intermitting and
pleuritic states of fever, which so frequently attack
persons in the spring, who have had the bilious remitting
fever in the preceding autumn.
But great and numerous as the advantages of
blood-letting are in fevers, there have been many
objections to it. I shall briefly enumerate, and endeavour
to refute the errors upon this subject.
Blood-letting has been forbidden by physicians,
by the following circumstances, and states of the
system.
1. By warm weather. Galen bled in a plague,
and Aræteus in a bilious fever, in a warm climate.
Dr. Sydenham and Dr. Hillary inform us, that
the most inflammatory fevers occur in, and succeed
hot weather. Dr. Cleghorn prescribed it
copiously in the warm months, in Minorca. Dr.
Mosely cured the yellow fever by this remedy, in
Jamaica. Dr. Broadbelt, and Dr. Weston, in the
same island, have lately adopted his successful practice.
Dr. Desportes speaks in the highest terms
of it in all the inflammatory diseases of St. Domingo.
He complains of the neglect of it in the rheumatism,
in consequence of which, he says, the disease
produces abscesses in the lungs[49]. I have never,
in any year of my practice, been restrained
by the heat of summer in the use of the lancet,
where the pulse has indicated it to be necessary,
and have always found the same advantages from
it, as when I have prescribed it in the winter or
spring months.
In thus deciding in favour of bleeding in warm
weather, I do not mean to defend its use to the
same extent, as to diseases, or to quantity, in the
native and long settled inhabitants of hot climates,
as in persons who have recently migrated to them,
or who live in climates alternately hot and cold.
2. Being born, and having lived in a warm climate.
This is so far from being an objection to
blood-letting in an inflammatory disease, that it renders
it more necessary. I think I have lost several
West-India patients from the influence of this
error.
3. Great apparent weakness. This, in acute
and violent fevers, is always from a depressed state
of the system. It resembles, in so many particulars,
that weakness which is the effect of the abstraction
of stimulus, that it is no wonder they have
been confounded by physicians. This sameness
of symptoms from opposite states of the system is
taken notice of by Hippocrates. He describes convulsions,
and particularly a hiccup, as occurring
equally from repletion and inanition, which answer
to the terms of depression, and debility from action
and abstraction. The natural remedy for the former
is depletion, and no mode of depleting is so
effectual or safe as blood-letting. But the great
objection to this remedy is, when a fever of great
morbid excitement affects persons of delicate constitutions,
and such as have long been subject to
debility of the chronic kind. In this state of the
system there is the same morbid and preternatural
action in the blood-vessels, that there is in persons
of robust habits, and the same remedy is necessary
to subdue it in both cases. It is sometimes indicated
in a larger quantity in weakly than in robust
people, by the plethora which is more easily induced
in their relaxed and yielding blood-vessels, and by
the greater facility with which ruptures and effusions
take place in their viscera. Thus it is more
necessary to throw overboard a large part of the
cargo of an old and leaky vessel in a storm, than of
a new and strong one. I know that vomits, purges,
sweats, and other evacuating remedies, are preferred
to bleeding in weakly constitutions, but I hope
to show hereafter, that bleeding is not only more
effectual, but more safe in such habits, than any
other depleting remedy.
4. Infancy and childhood. This is so far from
being an objection to bleeding, that the excitable
state of the blood-vessels in those periods of life,
renders it peculiarly necessary in their inflammatory
diseases. Dr. Sydenham bled children in the
hooping cough, and in dentition. I have followed
his practice, and bled as freely in the violent states
of fever in infancy as in middle life. I bled my
eldest daughter when she was but six weeks old,
for convulsions brought on by an excessive dose of
laudanum given to her by her nurse; and I bled
one of my sons twice, before he was two months
old, for an acute fever which fell upon his lungs
and bowels. In both cases, life appeared to be
saved by this remedy.
5. Old age. The increase of appetite in old
people, their inability to use sufficient exercise,
whereby their blood-vessels become relaxed, plethoric,
and excitable, and above all, the translation
of the strength of the muscles to the arteries, and
of plethora to the veins, all indicate bleeding to be
more necessary (in equal circumstances) in old,
than in middle aged people. My practice in the
diseases of old people has long been regulated by
the above facts. I bled Mrs. Fullarton twice in a
pleurisy in January, 1804, in the 84th year of her
age, and thereby cured her disease. I am not the
author of this practice. Botallus left a testimony
in favour of it nearly 200 years ago[50], and it has
since been confirmed by the experience of Hoffman,
and many other physicians. An ignorance of,
or inattention to this change in the state of the
blood-vessels, in persons in the decline of life, and
the neglect of the only remedy indicated by it, is
probably the reason why diseases often prove fatal
to them, which in early or middle life cured themselves,
or yielded to a single dose of physic, or a
few ounces of bark.
6. The time of menstruation. The uterus, during
this period, is in an inflamed state, and the whole
system is plethoric and excitable, and of course
disposed to a violent degree of fever, from all the
causes which excite it. Bleeding, therefore, is
more indicated, in fever of great morbid action, at
this time, than at any other. Formerly the natural
discharge from the uterus was trusted to, to remove
a fever contracted during the time of menstruation;
but what relief can the discharge of four or five
ounces of blood from the uterus afford, in a fever
which requires the loss of 50, or perhaps of 100
ounces to cure it?
7. Pregnancy. The inflammation and distention
induced upon the uterus directly, and indirectly
upon the whole system by pregnancy, render bleeding,
in the acute states of fever, more necessary than
at other times. I have elsewhere mentioned the
advantages of bleeding pregnant women, in the yellow
fever. I did not learn the advantages of the
practice in that disease. I bled Mrs. Philler 11
times in seven days, in a pleurisy during her pregnancy,
in the month of March, 1783. Mrs. Fiss
was bled 13 times in the spring of 1783; and Mrs.
Kirby 16 times in the same condition, by my orders,
in the winter of 1786, in a similar disease.
All these women recovered, and the children they
carried during their illness, are at this time alive,
and in good health.
8. Fainting after bleeding. This symptom is
accidental in many people. No inference can be
drawn from it against blood-letting. It often occurs
after the first and second bleedings in a fever,
but in no subsequent bleeding, though it be repeated
a dozen times. Of this I saw several instances,
in the yellow fever of 1794. The pulse,
during the fainting, is often tense and full.
9. Coldness of the extremities, and of the whole
body. This cold state of fever when it occurs
early, yields more readily to bleeding, than to the
most cordial medicines.
10. Sweats are supposed to forbid blood-letting.
I have seen two instances of death, from leaving a
paroxysm of malignant fever to terminate itself by
sweating. Dr. Sydenham has taught a contrary
practice in the following case. “While this constitution
(says the doctor) prevailed, I was called to
Dr. Morice, who then practised in London. He
had this fever, attended with profuse sweats, and
numerous petechiæ. By the consent of some other
physicians, our joint friends, he was blooded, and
rose from his bed, his body being first wiped dry.
He found immediate relief from the use of a cooling
diet and medicines, the dangerous symptoms
soon going off; and by continuing this method he
recovered in a few days[51].” In the same fever, the
doctor adds further, “For though one might expect
great advantages in pursuing an indication
taken from what generally proves serviceable (viz.
sweating), yet I have found, by constant experience,
that the patient not only finds no relief, but, contrariwise,
is more heated thereby; so that frequently
a delirium, petechiæ, and other very dangerous
symptoms immediately succeed such sweats[52].”
Morgagni describes a malignant fever which prevailed
in Italy, in which the patients died in profuse
sweats, while their physicians were looking for
a crisis from them. Bleeding would probably have
checked these sweats, and cured the fever.
11. Dissolved blood, and an absence of an inflammatory
crust on its crassamentum. I shall
hereafter place dissolved blood at the highest point
of a scale, which is intended to mark the different
degrees of morbid action in the system. I have
mentioned, in the Outlines of a Theory of Fever,
that it is the effect of a tendency to a palsy, induced
by the violent force of impression upon the
blood-vessels. This appearance of the blood in
certain states of fever, instead of forbidding bleeding,
is the most vehement call of the system for it.
Nor is the absence of a crust on the crassamentum
of the blood, a proof of the absence of great morbid
diathesis, or a signal to lay aside the lancet.
On the contrary, I shall show hereafter, that there
are several appearances of the blood which indicate
more morbid action in the blood-vessels than
a sizy or inflammatory crust.
12. An undue proportion of serum to crassamentum
in the blood. This predominance of water
in the blood has often checked sufficient blood-letting.
But it should be constantly disregarded
while it is attended with those states of pulse (to be
mentioned hereafter) which require bleeding.
14. The presence of petechiæ on the skin.
These, I have elsewhere said, are the effects of the
gangrenous state of fever. Dr. Sydenham and Dr.
de Haen have taught the safety and advantage of
bleeding, when these spots are accompanied by an
active pulse. A boy of Mr. John Carrol owes
his recovery from the small-pox to the loss of fifty
ounces of blood, by five bleedings, at a time when
nearly every pock on his arms and legs had a purple
appearance. Louis XIV was bled five times
in the small-pox, when he was but thirteen years of
age, and thereby probably saved from the grave,
to the great honour and emolument of the single
physician who urged it against the advice of all the
other physicians of the court. Dr. Cleghorn mentions
a single case of the success of bleeding in the
petechial small-pox. His want of equal success
afterwards, in similar cases, was probably occasioned
by his bleeding too sparingly, that is, but three
or four times.
Abscesses and sore breasts, which accompany or
succeed fever, are no objections to blood-letting,
provided the pulse indicate the continuance of inflammatory
diathesis. They depend frequently upon
the same state of the system as livid effusions
on the skin.
14. The long duration of fever. Inflammatory
diathesis is often protracted for many weeks, in the
chronic state of fever. It, moreover, frequently revives
after having disappeared, from an accidental
irritant affecting some part of the body, particularly
the lungs and brain. I bled a young man of James
Cameron, in the autumn of 1794, four times between
the 20th and 30th days of a chronic fever,
in consequence of a pain in the side, accompanied
by a tense pulse, which suddenly came on after the
20th day of his disease. His blood was sizy. His
pain and tense pulse were subdued by the bleeding,
and he recovered. I bled the late Dr. Prowl
twelve times, in a fever which continued thirty days,
in the autumn of the year 1800. I wish these
cases to be attended to by young practitioners.
The pulmonary consumption is often the effect of
a chronic fever, terminating with fresh inflammatory
symptoms, by effusions in the lungs. It may
easily be prevented by forgetting the number of the
days of our patient's fever, and treating the pulmonary
affection as if it were a recent complaint.
15. Tremors and slight convulsions in the limbs.
Bark, wine, laudanum, and musk are generally prescribed
to remove these symptoms; but, to be effectual,
they should, in most cases, be preceded by
the loss of a few ounces of blood.
16. Bleeding is forbidden after the fifth or seventh
day in a pleurisy. This prohibition was introduced
into medicine at a time when a fear was
entertained of arresting the progress of nature in
preparing and expelling morbific matter from the
system. From repeated experience I can assert,
that bleeding is safe in every stage of pleurisy in
which there is pain, and a tense and oppressed
pulse; and that it has, when used for the first time
after the fifth and seventh days, saved many lives.
Bleeding has likewise been limited to a certain
number of ounces in several states of fever. Were
the force of the remote cause of a fever, its degrees
of violence, and the habits of the subject of it, always
the same, this rule would be a proper one;
but, this not being the case, we must be governed
wholly by the condition of the system, manifested
chiefly by the state of the pulse. To admit of copious
bleeding in one state of fever, and not in another,
under equal circumstances of morbid excitement,
is to prescribe for its name, and to forget
the changes which climate, season, and previous
habits create in all its different states.
17. The loss of a sufficient quantity of blood is
often prevented by patients being apparently worse,
after the first or second bleeding. This change for
the worse, shows itself in some one or more of the
following symptoms, viz. increase of heat, chills,
delirium, hæmorrhages, convulsions, nausea, vomiting,
faintness, coma, great weakness, pain, a tense,
after a soft pulse, and a reduction of it in force
and frequency. They are all occasioned by the
system rising suddenly from a state of extreme depression,
in consequence of the abstraction of the
pressure of the blood to a state of vigour and activity,
so great, in some instances, as to reproduce
a depression below what existed in the system before
a vein was opened; or it is occasioned by a
translation of morbid action from one part of the
body to another.
The chills which follow bleeding are the effects
of a change in the fever, from an uncommon to a
common state of malignity. They occur chiefly in
those violent cases of fever which come on without
a chilly fit.
The hæmorrhages produced by bleeding are
chiefly from the nose, hæmorrhoidal vessels, or uterus,
and of course are, for the most part, safe.
Uncommon weakness, succeeding blood-letting,
is the effect of sudden depression induced upon the
whole system, by the cause before-mentioned, or
of a sudden translation of the excitement of the
muscles into the blood-vessels, or some other part
of the body. These symptoms, together with all
the others which have been mentioned, are so far
from forbidding, that they all most forcibly indicate
a repetition of blood-letting.
I shall briefly illustrate, by the recital of three
cases, the good effects of bleeding, in removing
pain, and the preternatural slowness and weakness
of the pulse, when produced by the use of that remedy.
In the month of June of 1795, I visited Dr. Say
in a malignant fever, attended with pleuritic symptoms,
in consultation with Dr. Physick. An acute
pain in his head followed six successive bleedings.
After a seventh bleeding, he had no pain. His fever
soon afterwards left him. In thus persevering
in the use of a remedy, which, for several days,
appeared to do harm, we were guided wholly by
the state of his pulse, which uniformly indicated,
by its force, the necessity of more bleeding.
In the autumn of 1794, I was sent for to visit
Samuel Bradford, a young man of about 20 years
of age, son of Mr. Thomas Bradford, who was ill
with the reigning malignant epidemic. His pulse
was at 80. I drew about 12 ounces of blood from
him. Immediately after his arm was tied up, his
pulse fell to 60 strokes in a minute. I bled him a
second time, but more plentifully than before, and
thereby, in a few minutes, brought his pulse back
again to 80 strokes in a minute. A third bleeding
the next day, aided by the usual purging physic,
cured him in a few days.
In the month of March, 1795, Dr. Physick requested
me to visit, with him, Mrs. Fries, the wife
of Mr. John Fries, in a malignant fever. He had
bled her four times. After the fourth bleeding,
her pulse suddenly fell, so as scarcely to be perceptible.
I found her hands and feet cold, and her
countenance ghastly, as if she were in the last moments
of life. In this alarming situation, I suggested
nothing to Dr. Physick but to follow his
judgment, for I knew that he was master of that
law of the animal economy which resolved all her
symptoms into an oppressed state of the system.
The doctor decided in a moment in favour of more
bleeding. During the flowing of the blood, the
pulse rose. At the end of three, ten, and seventeen
hours it fell, and rose again by three successive
bleedings, in all of which she lost about thirty
ounces of sizy blood. So great was the vigour
acquired by the pulse, a few days after the paroxysms
of depression, which have been described,
were relieved, that it required seven more bleedings
to subdue it. I wish the history of these two cases
to be carefully attended to by the reader. I have
been thus minute in the detail of them, chiefly because
I have heard of practitioners who have lost
patients by attempting to raise a pulse that had
been depressed by bleeding, in a malignant fever,
by means of cordial medicines, instead of the repeated
use of the lancet. The practice is strictly
rational; for, in proportion as the blood-vessels are
weakened by pressure, the quantity of blood to be
moved should be proportioned to the diminution
of their strength.
This depressed state of the pulse, whether induced
by a paroxysm of fever, or by blood-letting,
is sometimes attended with a strong pulsation of the
arteries in the bowels and head.
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].”
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].”
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.
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].”
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?
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.
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.
I regret that the limits I have fixed to this Defence
of Blood-letting will not admit of my applying
the principles which have been delivered, to
all the inflammatory states of fever. In a future
essay, I hope to establish its efficacy in the maniacal
state of fever. I have said that madness is
the effect of a chronic inflammation in the brain.
Its remedy, of course, should be frequent and copious
blood-letting. Physical and moral evil are
subject to similar laws. The mad-shirt, and all
the common means of coercion, are as improper
substitutes for bleeding, in madness, as the whipping-post
and pillory are for solitary confinement
and labour, in the cure of vice. The pulse should
govern the use of the lancet in this, as well as in all
the ordinary states of fever. It is the dial-plate of
the system. But in the misplaced states of fever,
the pulse, like folly in old age, often points at a
different mark from nature. In all such cases, we
must conform our practice to that which has been
successful in the reigning epidemic. A single
bleeding, when indicated by this circumstance, often
converts a fever from a suffocated, or latent, to
a sensible state, and thus renders it a more simple
and manageable disease.
It is worthy of consideration here, how far local
diseases, which have been produced by fevers,
might be cured by re-exciting the fever. Sir
William Jones says, the physicians in Persia always
begin the cure of the leprosy by blood-letting[61].
Possibly this remedy diffuses the disease through
the blood-vessels, and thereby exposes it to be
more easily acted upon by other remedies.
Having mentioned the states of fever in which
blood-letting is indicated, and the manner in which
it should be performed, I shall conclude this inquiry
by pointing out the states of fever in which
it is forbidden, or in which it should be cautiously
or sparingly performed. This subject is of consequence,
and should be carefully attended to by all
who wish well to the usefulness and credit of the
lancet.
1. It is forbidden in that state of fever, as well
as in other diseases, in which there is reason to believe
the brain or viscera are engorged with blood,
and the whole system prostrated below the point of
re-action. I have suggested this caution in another
place[62]. The pulse in these cases is feeble,
and sometimes scarcely perceptible, occasioned by
the quantity of blood in the blood-vessels being
reduced, in consequence of the stagnation of large
portions of it in the viscera. By bleeding in these
cases, we deprive the blood-vessels of the feeble
remains of the stimulus which keep up their action,
and thus precipitate death. The remedies
here should be frictions, and stimulating applications
to the extremities, and gentle stimuli taken
by the mouth, or injected into the bowels. As
soon as the system is a little excited by these remedies,
blood may be drawn, but in small quantities
at a time, and perhaps only by means of cups or
leaches applied to the seats of the congestions of
the blood. After the vessels are excited by the
equable diffusion of the blood through all their
parts, it may with safety be drawn from the arm,
provided it be indicated by the pulse.
2. It is seldom proper beyond the third day, in
a malignant fever, if it has not been used on the
days previous to it, and for the same reason that
has been given under the former head. Even the
tension of the pulse is not always a sufficient warrant
to bleed, for in three days, in a fever which
runs its course in five days, the disorganization of
the viscera is so complete, that a recovery is scarcely
to be expected from the lancet. The remedies
which give the only chance of relief in this case,
are purges, blisters, and a salivation.
3. Where fevers are attended with paroxysms,
bleeding should be omitted, or used with great
caution, in the close of those paroxysms. The
debility which accompanies the intermission of
the fever is often so much increased by the recent
loss of blood, as sometimes to endanger life.
4. Bleeding is forbidden, or should be used
cautiously in that malignant state of fever, in which
a weak morbid action, or what Dr. Darwin calls
a tendency to inirritability, takes place in the blood-vessels.
It is known by a weak and frequent
pulse, such as occurs in the typhus fever, and in
the plague in warm climates. I have often met
with it in the malignant sore throat, and occasionally
in the pleurisy and yellow fever. The remedies
here should be gentle vomits or purges, and
afterwards cordials. Should the pulse be too much
excited by them, bleeding may be used to reduce
it.
5. It should be used sparingly in the diseases of
habitual drunkards. The morbid action in such
persons, though often violent, is generally transient.
It may be compared to a soap-bubble. The arteries,
by being often overstretched by the stimulus
of strong drink, do not always contract with the diminution
of blood, and such patients often sink,
from this cause, from the excessive use of the lancet.
6. It has been forbidden after the suppurative
process has begun in local inflammation. It constantly
retards the suppuration, when begun, in
the angina tonsillaris, and thus protracts that disease.
To this rule there are frequent exceptions.
7. It should be omitted in pneumony, after copious
expectoration has taken place. This discharge
is local depletion, and, though slow in its
effects compared with bleeding, it serves the same
purpose in relieving the lungs. The lancet can
only be required where great pain in coughing,
and a tense pulse, attend this stage of the disease.
8. It may be omitted (except when the blood-vessels
are insulated) in those diseases in which
there is time to wait, without danger to life, or future
health, for the circuitous operation of purging
medicines, or abstemious diet.
9. It should be avoided, when it can be done
without great danger to life, where there is a
great and constitutional dread of the operation. In
such cases, it has sometimes done harm to the patient,
and injured the credit of the lancet.
10. There are cases in which sizy blood should
not warrant a repetition of blood-letting. Mr.
White informs us, in the History of the Bilious
Fever which has lately prevailed at Bath, that bleeding,
in many cases in which this appearance of the
blood took place, was useless or hurtful. In some
of the fevers of our own country, we sometimes see
sizy blood followed by symptoms which forbid the
repeated use of the lancet, but which yield to other
depleting remedies, or to such as are of a cordial
nature. I have seen the same kind of blood, a
few hours before death, in a pulmonary consumption,
and three days after a discharge of a gallon
and a half of blood from the stomach by vomiting.
11. Even a tense pulse does not always call for
the repeated use of the lancet. I have mentioned
one case, viz. on the third or fourth days of a malignant
fever, in which it is improper. There are
instances of incurable consumptions from tubercles
and ulcers in the lungs, in which the pulse cannot
be made to feel the least diminution of tension by
either copious or frequent bleedings. There are
likewise cases of hepatic fever, in which the pulse
cannot be subdued by this remedy. This tense
state of the pulse is the effect of a suppurative process
in the liver. If a sufficient quantity of blood
has been drawn in the first stage of this disease,
there is little danger from leaving the pulse to reduce
or wear itself down by a sudden or gradual
discharge of the hepatic congestion. The recovery
in this case is slow, but it is for the most part
certain. I have once known a dropsy and death
induced by the contrary practice.
12. and lastly. There is sometimes a tension in
the pulse in hæmorrhages, that will not yield to
the lancet. The man whose blood was sizy, three
days after losing a gallon and a half of it from his
stomach, had a tense pulse the day before he died;
and I once perceived its last strokes to be tense, in
a patient whom I lost in a yellow fever by a hæmorrhage
from the nose. The only circumstance
that can justify bleeding in these cases is extreme
pain, in which case, the loss of a few ounces
of blood is a more safe and effectual remedy than
opium.
I shall now add a few remarks upon the efficacy
of blood-letting, in diseases which are not supposed
to belong to the class of fevers, and which have
not been included in the preceding volumes.
I. The philosophers, in describing the humble
origin of man, say that he is formed “inter stercus
et urinam.” The divines say that he is “conceived
in sin, and shapen in iniquity.” I believe it
to be equally true, and alike humiliating, that he is
conceived and brought forth in disease.
This disease appears in pregnancy and parturition.
I shall first endeavour to prove this to be
the case, and afterwards mention the benefits of
blood-letting in relieving it, in both cases.
In pregnancy, the uterus is always affected with
that grade of morbid action which I formerly called
inflammation. This is evident from its exhibiting
all its usual phænomena in other parts of the
body. These are,
1. Swelling, or enlargement.
2. Hæmorrhage. The lochia are nothing but
a slow and spontaneous bleeding performed by nature,
and intended to cure the inflammation of the
uterus after parturition.
3. Abscesses, schirri, and cancers. It is true,
those disorders sometimes occur in women that
have never borne children. In these cases, they
are the effects of the inflammation excited by the
menstrual disease.
4. A full, quick, and tense or frequent pulse;
pain; want of appetite[63]; sickness at stomach;
puking; syncope; and sometimes convulsions in
every part of the body.
5. Sizy blood. This occurs almost uniformly
in pregnancy.
6. A membrane. Dr. Scarpa has proved the
membrana decidua, which is formed during pregnancy,
to be in every respect the same in its properties
with the membrane which is formed upon
other inflamed surfaces, particularly the trachea,
the pleura, and the inside of the bowels. Thus we
see all the common and most characteristic symptoms
and effects of inflammation, in other parts of
the body, are exhibited by the uterus in pregnancy.
These remarks being premised, I proceed to remark,
that blood-letting is indicated, in certain
states of pregnancy, by all the arguments that have
been used in favour of it in any other inflammatory
disease. The degree of inflammation in the womb,
manifested by the pulse, pain, and other signs of
disease, should determine the quantity of blood to
be drawn. Low diet, gentle purges, and constant
exercise, are excellent substitutes for it, but where
they are not submitted to, blood-letting should be
employed as a substitute for them. In that disposition
to abortion, which occurs about the third
month of pregnancy, small and frequent bleedings
should be preferred to all other modes of depletion.
I can assert, from experience, that they prevent
abortion, nearly with as much certainty as they prevent
a hæmorrhage from the lungs: for what is an
abortion but a hæmoptysis (if I may be allowed the
expression) from the uterus? During the last
month of pregnancy, the loss of from twelve to
twenty ounces of blood has the most beneficial effects,
in lessening the pains and danger of child-birth,
and in preventing its subsequent diseases.
The doctrine I have aimed to establish leads, not
only to the use of blood-letting in the disease of
pregnancy, when required, but to a more copious
use of it, when combined with other diseases, than
in those diseases in a simple state. This remark
applies, in a particular manner, to those spasms and
convulsions which sometimes occur in the latter
months of pregnancy. Without bleeding, they
are always fatal. By copious bleeding, amounting
in some instances to 80 and 100 ounces, they are
generally cured.
Let it not be supposed that blood-letting is alike
proper and useful in every state of pregnancy.
There are what are called slow or chronic inflammations,
in which the diseased action of the blood-vessels
not only forbids it, but calls for cordial and
stimulating remedies. The same feeble state of
inflammation sometimes takes place in the pregnant
uterus. In these cases cordials and stimulants
should be preferred to the lancet.
Parturition is a higher grade of disease than that
which takes place in pregnancy. It consists of
convulsive or clonic spasms in the uterus, supervening
its inflammation, and is accompanied with
chills, heat, thirst, a quick, full, tense, or a frequent
and depressed pulse, and great pain. By some
divines these symptoms, and particularly pain,
have been considered as a standing and unchangeable
punishment of the original disobedience of
woman, and, by some physicians, as indispensably
necessary to enable the uterus to relieve itself
of its burden. By contemplating the numerous
instances in which it has pleased God to bless the
labours and ingenuity of man, in lessening or destroying
the effects of the curse inflicting upon the
earth, and by attending to the histories of the total
exemption from pain in child-bearing that are recorded
of the women in the Brasils, Calabria, and
some parts of Africa, and of the small degrees of it
which are felt by the Turkish women, who reduce
their systems by frequent purges of sweet oil during
pregnancy, I was induced to believe pain does
not accompany child-bearing by an immutable decree
of Heaven. By recollecting further how
effectually blood-letting relieves many other spasmodic
and painful diseases, and how suddenly it
relaxes rigidity in the muscles, I was led, in the
year 1795, to suppose it might be equally effectual
in lessening the violence of the disease and pains
of parturition. I was encouraged still more to expect
this advantage from it, by having repeatedly
observed the advantages of copious bleeding
for inflammatory fevers, just before delivery, in
mitigating its pains, and shortening its duration.
Upon my mentioning these reflections and facts to
Dr. Dewees, I was much gratified in being informed,
that he had been in the practice, for several
years before his removal from Abingdon to
Philadelphia, of drawing large quantities of blood
during parturition, and with all the happy effects
I had expected from it. The practice has been
strongly inculcated by the doctor in his lectures
upon midwifery, and has been ably defended and
supported by a number of recent facts, in an ingenious
inaugural dissertation, published by Dr. Peter
Miller, in the year 1804. It has been generally
adopted by the practitioners of midwifery, of both
sexes, in Philadelphia.
I do not mean to insinuate that bleeding is a new
remedy in parturition. It has long ago been advised
and used in France, and even by the midwives
of Genoa, in Italy, but never, in any country,
in the large quantities that have been recommended
by Dr. Dewees, that is, from 20 to 80 ounces, or
until signs of fainting are induced, nor under the
influence of the theory of parturition, being a violent
disease.
But the advantages of this remedy are not confined
to lessening the pains of delivery. It prevents
after pains; favours the easy and healthy secretion
of milk; prevents sore breasts, swelled legs,
puerperile fever, and all the distressing train of
anomalous complaints that often follow child-bearing.
Dr. Hunter informed his pupils, in his lectures
upon midwifery, in the year 1769, that he
had often observed the most rapid recoveries to
succeed the most severe labours. The severity
of the pains in these cases created a disease, which
prevented internal congestions in the womb.
Bleeding, by depleting the uterus, obviates at once
both disease and congestion. Its efficacy is much
aided by means of glysters, which, by emptying
the lower bowels, lessen the pressure upon the
uterus.
Let it not be inferred, from what has been said in
favour of blood-letting in parturition, that it is proper
in all cases. Where there has been great previous
inanition, and where there are marks of languor,
and feeble morbid action in the system, the remedies
should be of an opposite nature. Opium and
other cordials are indicated in these cases. Their
salutary effects in exciting the action of the uterus,
and expediting delivery, are too well known to be
mentioned.
I have expressed a hope in another place[64], that
a medicine would be discovered that should suspend
sensibility altogether, and leave irritability, or
the powers of motion, unimpaired, and thereby
destroy labour pains altogether. I was encouraged
to cherish this hope, by having known delivery to
take place, in one instance, during a paroxysm of
epilepsy, and having heard of another, during a fit
of drunkenness, in a woman attended by Dr.
Church, in both of which there was neither consciousness,
nor recollection of pain.
2. During the period in which the menses are
said to dodge, and for a year or two after they cease
to flow, there is a morbid fulness and excitement
in the blood-vessels, which are often followed by
head-ach, cough, dropsy, hæmorrhages, glandular
obstructions, and cancers. They may all be prevented
by frequent and moderate bleedings.
3. It has been proved, by many facts, that opium,
when taken in an excessive dose, acts by inducing
a similar state of the system with that which is
induced by the miasmata which bring on malignant
and inflammatory fevers. The remedy for the disease
produced by it (where a vomiting cannot be
excited to discharge the opium) has been found to
be copious blood-letting. Of its efficacy, the reader
will find an account in four cases, published in the
fifth volume of the New-York Medical Repository.
4. It is probable, from the uniformly stimulating
manner in which poisons of all kinds act upon the
human body, that bleeding would be useful in obviating
their baneful effects. Dr. John Dorsey has
lately proved its efficacy, in the case of a child that
was affected with convulsions, in consequence of
eating the leaves of the datura stramonium.
5. It has been the misfortune of diabetes to be
considered by physicians as exclusively a local disease
of weak morbid action, or as the effect of simple
debility in the kidneys; and hence stimulating
and tonic medicines have been exclusively prescribed
for it. This opinion is not a correct one.
It often affects the whole arterial system, more especially
in its first stage, with great morbid action.
In two cases of it, where this state of the blood-vessels
took place, I have used blood-letting with
success, joined with the common remedies for inflammatory
diseases.
6. In dislocated bones which resist both skill
and force, it has been suggested, that bleeding,
till fainting is induced, would probably induce
such a relaxation in the muscles as to favour
their reduction. This principle was happily applied,
in the winter of 1795, by Dr. Physick, in
the Pennsylvania hospital, in a case of dislocated
humerus of two months continuance. The doctor
bled his patient till he fainted, and then reduced
his shoulder in less than a minute, and with very
little exertion of force. The practice has since become
general in Philadelphia, in luxations of large
bones, where they resist the common degrees of
strength employed to reduce them.
In contemplating the prejudices against blood-letting,
which formerly prevailed so generally in
our country, I have been led to ascribe them to a
cause wholly political. We are descended chiefly
from Great-Britain, and have been for many years
under the influence of English habits upon all subjects.
Some of these habits, as far as they relate
to government, have been partly changed; but in
dress, arts, manufactures, manners, and science,
we are still governed by our early associations.
Britain and France have been, for many centuries,
hereditary enemies. The hostility of the former to
the latter nation, extends to every thing that belongs
to their character. It discovers itself, in an
eminent degree, in diet and medicine. Do the
French love soups? the English prefer solid flesh.
Do the French love their meats well cooked? the
English prefer their meats but half roasted. Do
the French sip coffee after dinner? the English
spend their afternoons in drinking Port and Madeira
wines. Do the French physicians prescribe
purges and glysters to cleanse the bowels? the English
physicians prescribe vomits for the same purpose.
Above all, do the French physicians advise
bleeding in fevers? the English physicians forbid
it, in most fevers, and substitute sweating in the
room of it. Here then we discover the source of
the former prejudices and errors of our country-men,
upon the subject of blood-letting. They are
of British origin. They have been inculcated
in British universities, and in British books; and
they accord as ill with our climate and state of
society, as the Dutch foot stoves did with the temperate
climate of the Cape of Good Hope[65].
It is probable the bad consequences which have
followed the indiscriminate use of the lancet
France, and some other countries, may have contributed
in some degree to create the prejudices
against it, which are entertained by the physicians
in Great-Britain. Bleeding, like opium, has lost
its character, in many cases, by being prescribed
for the name of a disease. It is still used, Mr.
Townsend tells us, in this empirical way in Spain,
where a physician, when sent for to a patient, orders
him to be bled before he visits him. The
late just theory of the manner in which opium acts
upon the body, has restrained its mischief, and added
greatly to its usefulness. In like manner, may
we not hope, that just theories of diseases, and
proper ideas of the manner in which bleeding acts
in curing them, will prevent a relapse into the evils
which formerly accompanied this remedy, and render
it a great and universal blessing to mankind?