put up carelessly by the apothecaries, or from its having been taken
contrary to the printed directions, by many people. If it did harm in any
one case (which I do not believe) from the former of the above causes the
fault is not mine. Twenty men employed constantly in putting up this
medicine would not have been sufficient to have complied with all the
demands which were made of me for it. Hundreds who were in health called
or sent for it as well as the sick, in order to have it in readiness in
case they should be surprised by the disease in the night, or at a
distance from a physician.
In all the cases in which this purge was supposed to have been hurtful,
when given on the first or second day of the disease, I believe it was
because it was not followed by repeated doses of the same, or of some
other purge, or because it was not aided by blood-letting. I am led to
make this assertion, not only from the authority of Dr. Sydenham, who
often mentions the good effects of bleeding in moderating or checking a
diarrh[oe]a, but by having heard no complaints of patients being purged
to death by this medicine, after blood-letting was universally adopted by
all the physicians in the city.
It was remarked that the demand for this purging powder continued to
increase under all opposition, and that the sale of it by the
apothecaries was greatest towards the close of the disease. I shall
hereafter say that this was not the case with the West-India remedies.
It is possible that this purge sometimes proved hurtful when it was given
on the fifth day of the disease, but it was seldom given for the _first_
time after the third day, and when it was, the patient was generally in
such a situation that nothing did him either good or harm.
I derived great pleasure from hearing, after the fever had left the city,
that calomel had been given with success as a purge in bilious fevers in
other parts of the union besides Philadelphia. Dr. Lawrence informed me
that he had cured many patients by it of the yellow fever which prevailed
in New-York, in the year 1791, and the New-York papers have told us that
several practitioners had been in the habit of giving it in the autumnal
fevers, with great success, in the western parts of that state. They had
probably learned the use of it from Dr. Young, who formerly practised in
that part of the United States, and who lost no opportunity of making its
praises public wherever he went.
I have only to add to my account of that purging medicine, that, under an
expectation that the yellow fever would mingle some of its bilious
symptoms with the common inflammatory fevers of the winter and first
spring months, I gave that purge in the form of pills, in every case of
inflammatory fever to which I was called. The fatal issue of several
fevers in the city, during the winter, in which this precaution had been
neglected, convinced me that my practice was proper and useful.
It is to be lamented that all new remedies are forced to pass through a
fiery ordeal. Opium and bark were long the objects of terror and
invective in the schools of medicine. They were administered only by
physicians for many years, and that too with all the solemnity of a
religious ceremony. This error, with respect to those medicines, has at
last passed away. It will, I hope, soon be succeeded by a time when the
prejudices against _ten_ and _ten_, or _ten_ and _fifteen_, will sleep
with the vulgar fears which were formerly entertained of the bark
producing diseases and death, years after it had been taken, by "lying in
the bones."
OF BLOOD-LETTING.
The theory of this fever which led me to administer purges, determined me
to use blood-letting, as soon as it should be indicated. I am disposed to
believe that I was tardy in the use of this remedy, and I shall long
regret the loss of three patients, who might probably have been saved by
it. I cannot blame myself for not having used it earlier, for the immense
number of patients which poured in upon me, in the first week of
September, prevented my attending so much to each of them, as was
necessary to determine upon the propriety of this evacuation. I was in
the situation of a surgeon in a battle, who runs to every call, and only
stays long enough with each soldier to stop the bleeding of his wound,
while the increase of the wounded, and the unexpected length of the
battle, leave his original patients to suffer from the want of more
suitable dressings. The reasons which determined me to bleed were,
1. The state of the pulse, which became more tense, in proportion as the
weather became cool.
2. The appearance of a moist and _white_ tongue, on the first day of the
disease, a certain sign of an inflammatory fever.
3. The frequency of hæmorrhages from every part of the body, and the
perfect relief given in some cases by them.
4. The symptoms of congestion in the brain, resembling those which occur
in the first stage of hydrocephalus internus, a disease in which I had
lately used bleeding with success.
5. The character of the diseases which had preceded the yellow fever.
They were all more or less inflammatory. Even the scarlatina anginosa had
partaken so much of that diathesis, as to require bleeding to subdue it.
6. The warm and dry weather which had likewise preceded the fever. Dr.
Sydenham attributes a highly inflammatory state of the small-pox to a
previously hot and dry summer; and I have since observed, that Dr.
Hillary takes notice of inflammatory fevers having frequently succeeded
hot and dry weather in Barbadoes[74]. He informs us further, that the
yellow fever is always most acute and inflammatory after a very hot
season[75].
[74] Diseases of Barbadoes, p. 16, 43, 46, 48, 52, 122.
[75] Page 147.
7. The authority of Dr. Mosely had great weight with me in advising the
loss of blood, more especially as his ideas of the highly inflammatory
nature of the fever accorded so perfectly with my own.
8. I was induced to prescribe blood-letting by recollecting its good
effects in Mrs. Palmer's son, whom I bled on the 20th of August, and who
appeared to have been recovered by it.
Having begun to bleed, I was encouraged to continue it by the appearance
of the blood, and by the obvious and very great relief my patients
derived from it.
The following is a short account of the appearances of the blood drawn
from a vein in this disease.
1. It was, in the greatest number of cases, without any separation into
crassamentum and serum, and of a scarlet colour.
2. There was in many cases a separation of the blood into crassamentum
and _yellow_ serum.
3. There were a few cases in which this separation took place, and the
serum was of a _natural_ colour.
4. There were many cases in which the blood was as sizy as in pneumony
and rheumatism.
5. The blood was in some instances covered above with blue pellicle of
sizy lymph, while the part which lay in the bottom of the bowl was
dissolved. The lymph was in two cases mixed with green streaks.
6. It was in a few instances of a dark colour, and as fluid as molasses.
I saw this kind of blood in a man who walked about his house during the
whole of his sickness, and who finally recovered. Both this, and the
fifth kind of blood which has been mentioned, occurred chiefly where
bleeding had been omitted altogether, or used too sparingly in the
beginning of the disease.
7. In some patients the blood, in the course of the disease, exhibited
nearly _all_ the appearances which have been mentioned. They were varied
by the time in which the blood was drawn, and by the nature and force of
the remedies which had been used in the disease.
The effects of blood-letting upon the system were as follow:
1. It raised the pulse when depressed, and quickened it, when it was
preternaturally slow, or subject to intermissions.
2. It reduced its force and frequency.
3. It checked in many cases the vomiting which occurred in the beginning
of the disease, and thereby enabled the stomach to retain the purging
medicine. It likewise assisted the purge in preventing the dangerous or
fatal vomiting which came on about the fifth day.
4. It lessened the difficulty of opening the bowels. Upon this account,
in one of my addresses to the citizens of Philadelphia, I advised
bleeding to be used _before_, as well as after taking the mercurial
purge. Dr. Woodhouse informed me that he had several times seen patients
call for the close-stool while the blood was flowing from the vein.
5. It removed delirium, coma, and obstinate wakefulness. It also
prevented or checked hæmorrhages; hence perhaps another reason why not a
single instance of abortion occurred in such of my female patients as
were pregnant.
6. It disposed, in some cases, to a gentle perspiration.
7. It lessened the sensible debility of the system; hence patients
frequently rose from their beds, and walked across their rooms, in a few
hours after the operation had been performed.
8. The redness of the eyes frequently disappeared in a few hours after
bleeding. Mr. Coxe observed a dilated pupil to contract to its natural
size within a few minutes after he had bound up the arm of his patient. I
remarked, in the former part of this work, that blindness in many
instances attended or followed this fever. But two such cases occurred
among my patients. In one of them it was of short continuance, and in the
other it was probably occasioned by the want of sufficient bleeding. In
every case of blindness that came to my knowledge bleeding had been
omitted, or used only in a very moderate degree.
9. It eased _pain_. Thousands can testify this effect of blood-letting.
Many of my patients whom I bled with my own hand acknowledged to me,
while the blood was flowing, that they were better; and some of them
declared, that all their pains had left them before I had completely
bound up their arms.
10. But blood-letting had, in many cases, an effect the opposite of
_easing_ pain. It frequently increased it in every part of the body, more
especially in the head. It appeared to be the effect of the system rising
suddenly from a state of great depression, and of an increased action of
the blood-vessels which took place in consequence of it. I had frequently
seen complaints of the breast, and of the head, made worse by a single
bleeding, and from the same cause. It was in some cases an unfortunate
event in the yellow fever, for it prevented the blood-letting being
repeated, by exciting or strengthening the prejudices of patients and
physicians against it. In some instances the patients grew worse after a
second, and, in one, after a third bleeding. This was the case in Miss
Redman. Her pains increased after three bleedings, but yielded to the
fourth. Her father, Dr. Redman, concurred in this seemingly absurd
practice. It was at this time my old preceptor in medicine reminded me of
Dr. Sydenham's remark, that moderate bleeding did harm in the plague
where copious bleeding was indicated, and that in the cure of that
disease, we should leave nature wholly to herself, or take the cure
altogether out of her hands. The truth of this remark was very obvious.
By taking away as much blood as restored the blood-vessels to a morbid
degree of action, without reducing this action afterwards, pain,
congestion, and inflammation were frequently increased, all of which were
prevented, or occurred in a less degree, when the system rose gradually
from the state of depression which had been induced by the great force of
the disease. Under the influence of the facts and reasonings which have
been mentioned I bore the same testimony in acute cases, against what was
called _moderate_ bleeding that I did against bark, wine, and laudanum in
this fever.
11. Blood-letting, when used _early_ on the first day, frequently
strangled the disease in its birth, and generally rendered it more light,
and the convalescence more speedy and perfect. I am not sure that it ever
shortened the duration of the fever where it was not used within a few
hours of the time of its attack. Under every mode of treatment it seemed
disposed, after it was completely formed, to run its course. I was so
satisfied of this peculiarity in the fever, that I ventured in some cases
to predict the day on which it would terminate, notwithstanding I took
the cure entirely out of the hands of nature. I did not lose a patient on
the third, whom I bled on the first or second day of the disease.
12. In those cases which ended fatally, blood-letting restored, or
preserved the use of reason, rendered death easy, and retarded the
putrefaction of the body after death.
I shall now mention some of the circumstances which directed and
regulated the use of this remedy.
1. Where bleeding had been omitted for three days, in acute cases, it was
seldom useful. Where purging had been used, it was sometimes successful.
I recovered two patients who had taken the mercurial purges, whom I bled
for the first time on the seventh day. One of them was the daughter of
Mr. James Cresson, the other was a journeyman ship-carpenter at
Kensington. In those cases where bleeding had been used on the first day,
it was both safe and useful to repeat it every day afterwards, during the
continuance of the fever.
2. I preferred bleeding in the exacerbation of the fever. The remedy here
was applied when the disease was in its greatest force. A single paroxysm
was like a sudden squall to the system, and, unless abated by bleeding or
purging, often produced universal disorganization. I preferred the former
to the latter remedy in cases of great danger, because it was more
speedy, and more certain in its operation.
3. I bled in several instances in the remission of the fever, where the
pulse was tense and corded. It lessened the violence of the succeeding
paroxysm.
4. I bled in all those cases in which the pulse was preternaturally slow,
provided it was tense. Mr. Benj. W. Morris, Mr. Thomas Wharton, jun. and
Mr. Wm. Sansom, all owe their lives probably to their having been bled in
the above state of the pulse. I was led to use bleeding in this state of
the pulse, not only by the theory of the disease which I had adopted, but
by the success which had often attended this remedy, in a slow and
depressed state of the pulse in apoplexy and pneumony. I had moreover the
authority of Dr. Mosely in its favour, in the yellow fever, and of Dr.
Sydenham, in his account of a new fever, which appeared in the year 1685.
The words of the latter physician are so apposite to the cases which have
been mentioned, that I hope I shall be excused for inserting them in this
place. "All the symptoms of weakness (says our author) proceed from
nature's being in a manner oppressed and overcome by the first attack of
the disease, so as not to be able to raise regular symptoms adequate to
the violence of the fever. I remember to have met with a remarkable
instance of this, several years ago, in a young man I then attended; for
though he seemed in a manner expiring, yet the outward parts felt so
cool, that I could not persuade the attendants he had a fever, which
could not disengage, and show itself clearly, because the vessels were so
full as to obstruct the motion of the blood. However, I said, that they
would soon find the fever rise high enough upon bleeding him.
Accordingly, after taking away a large quantity of blood, as violent a
fever appeared as ever I met with, and did not go off till bleeding had
been used three or four times[76]."
[76] Vol. ii. p. 351.
5. I bled in those cases in which the fever appeared in a tertian form,
provided the pulse was full and tense. I well recollect the surprise with
which Mr. Van Berkel heard this prescription from me, at a time when he
was able to walk and ride out on the intermediate days of a tertian
fever. The event which followed this prescription showed that it was not
disproportioned to the violence of his disease, for it soon put on such
acute and inflammatory symptoms as to require six subsequent bleedings to
subdue it.
6. I bled in those cases where patients were able to walk about, provided
the pulse was the same as has been mentioned under the fourth head. I was
determined as to the propriety of bleeding in these two supposed mild
forms of the fever, by having observed each of them, when left to
themselves, frequently to terminate in death.
7. I paid no regard to the dissolved state of the blood, when it appeared
on the first or second day of the disease, but repeated the bleedings
afterwards in every case, where the pulse continued to indicate it. It
was common to see sizy blood succeed that which was dissolved. This
occurred in Mr. Josiah Coates, and Mr. Samuel Powel. Had I believed that
this dissolved state of the blood arose from its putrefaction, I should
have laid aside my lancet as soon as I saw it; but I had long ago parted
with all ideas of putrefaction in bilious fevers. The refutation of this
doctrine was the object of one of my papers in the Medical Society of
Edinburgh, in the year 1767. The dissolved appearance of the blood, I
suppose to be the effect of a certain action of the blood-vessels upon
it. It occurs in fevers which depend upon the sensible qualities of the
air, and in which no putrid or foreign matter has been introduced into
the system.
8. The presence of petechiæ did not deter me from repeating
blood-letting, where the pulse retained its fulness or tension. I
prescribed it with success in the cases of Dr. Mease, and of Mrs. Gebler,
in Dock-street, in each of whom petechiæ had appeared. Bleeding was
equally effectual in the case of the Rev. Mr. Keating, at a time when his
arms were spotted with that species of eruptions which I have compared to
moscheto-bites. I had precedents in Dr. De Haen[77] and Dr.
Sydenham[78], in favour of this practice. So far from viewing these
eruptions as signs of putrefaction, I considered them as marks of the
highest possible inflammatory diathesis. They disappeared in each of the
above cases after bleeding.
[77] Ratio Medendi, vol. ii. p. 162. vol. iv. p. 172.
[78] Vol. i. p. 210, and 264.
9. In determining the quantity of blood to be drawn, I was governed by
the state of the pulse, and by the temperature of the weather. In the
beginning of September, I found one or two moderate bleedings sufficient
to subdue the fever; but in proportion as the system rose by the
diminution of the stimulus of heat, and the fever put on more _visible_
signs of inflammatory diathesis, more frequent bleedings became
necessary. I bled many patients twice, and a few three times a day. I
preferred frequent and small, to large bleedings, in the beginning of
September; but towards the height and close of the epidemic, I saw no
inconvenience from the loss of a pint, and even twenty ounces of blood at
a time. I drew from many persons seventy and eighty ounces in five days;
and from a few, a much larger quantity. Mr. Gribble, cedar-cooper, in
Front-street, lost by ten bleedings a hundred ounces of blood; Mr.
George, a carter in Ninth-street, lost about the same quantity by five
bleedings; and Mr. Peter Mierken, one hundred and fourteen ounces in five
days. In the last of the above persons the quantity taken was determined
by weight. Mr. Toy, blacksmith near Dock-street, was eight times bled in
the course of seven days. The quantity taken from him was about a hundred
ounces. The blood in all these cases was dense, and in the last, very
sizy. They were all attended in the month of October, and chiefly by my
pupil, Mr. Fisher; and they were all, years afterwards, living and
healthy instances of the efficacy of copious blood-letting, and of the
intrepidity and judgment of their young physician. Children, and even old
people, bore the loss of much more blood in this fever than in common
inflammatory fevers. I took above thirty ounces, in five bleedings, from
a daughter of Mr. Robert Bridges, who was then in the 9th year of her
age. Even great debility, whether natural or brought on by previous
diseases, did not, in those few cases in which it yielded to the fever,
deprive it of the uniformity of its inflammatory character. The following
letter from Dr. Griffitts, written soon after his recovery from a third
attack of the fever, and just before he went into the country for the
re-establishment of his health, will furnish a striking illustration of
the truth of the above observation.
"I cannot leave town without a parting adieu to my kind friend, and
sincere prayers for his preservation.
"I am sorry to find that the use of the lancet is still so much dreaded
by too many of our physicians; and, while lamenting the death of a
valuable friend this morning, I was told that he was bled but _once_
during his disease. Now if my poor frame, reduced by previous sickness,
great anxiety, and fatigue, and a very low diet, could bear_ seven_
bleedings in five days, besides purging, and no diet but toast and water,
what shall we say of physicians who bleed but once?
"_October 19th, 1793._"
I have compared a paroxysm of this fever to a sudden squall; but the
disease in its whole course was like a tedious equinoctial gale acting
upon a ship at sea; its destructive force was only to be opposed by
handing every sail, and leaving the system to float, as it were, under
bare poles. Such was the fragility (if I may be allowed the expression)
of the blood-vessels, that it was necessary to unload them of their
contents, in order to prevent the system sinking from hæmorrhages, or
from effusions in the viscera, particularly the brain.
9. Such was the indomitable nature of the pulse, in some patients, that
it did not lose its force after numerous and copious bleedings. In all
such cases I considered the diminution of its frequency, and the absence
of a vomiting, as signals to lay aside the lancet. The continuance of
this preternatural force in the pulse appeared to be owing to the
miasmata, which were universally diffused in the air, acting upon the
arterial system in the same manner that it did in persons who were in
apparent good health.
Thus have I mentioned the principal circumstances which were connected
with blood-letting in the cure of the yellow fever. I shall now consider
the objections that were made to it at the time, and since the prevalence
of the fever.
It was said that the bleeding was unnecessarily copious; and that many
had been destroyed by it. To this I answer, that I did not lose a single
patient whom I bled seven times or more in this fever. As a further proof
that I did not draw an ounce of blood too much it will only be necessary
to add, that hæmorrhages frequently occurred after a third, a fourth, and
in one instance (in the only son of Mr. William Hall) after a sixth
bleeding had been used; and further, that not a single death occurred
from natural hæmorrhages in the first stage of the disease. A woman, who
had been bled by my advice, awoke the night following in a bath of her
blood, which had flowed from the orifice in her arm. The next day she was
free from pain and fever. There were many recoveries in the city from
similar accidents. There were likewise some recoveries from copious
natural hæmorrhages in the more advanced stages of the disease,
particularly when they occurred from the stomach and bowels. I left a
servant maid of Mrs. Morris's, in Walnut-street, who had discharged at
least four pounds of blood from her stomach, without a pulse, and with
scarcely a symptom that encouraged a hope of her life; but the next day I
had the pleasure of finding her out of danger.
It was remarked that fainting was much less common after bleeding in this
fever than in common inflammatory fevers. This circumstance was observed
by Dr. Griffitts, as well as myself. It has since been confirmed to me by
three of the principal bleeders in the city, who performed the operation
upwards of four thousand times. It occurred chiefly in those cases where
it was used for the first time on the third or fourth day of the disease.
A swelling of the legs, moreover, so common after plentiful bleeding in
pneumony and rheumatism, rarely succeeded the use of this remedy in the
yellow fever.