Volume 4 — A DEFENCE OF BLOOD-LETTING AS A REMEDY FOR CERTAIN DISEASES.

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.