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.
[50] Magis esse adjuvandos senes, missione sanguinis dum morbus
postulat, aut corpus eorum habitus malus est, quam ubi hæc (quod
absonum videbitur) juvenibus contingunt.
De Cur. per Sang. missionem, cap. 11. § 11.
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]."
[51] Wallis's edition, vol. i. p. 210.
[52] Vol. i. p. 208.
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]."
[53] Cap. viii. § 4.
[54] Cap. xxxvi. § 4.
It is remarkable, that the dread of producing a dropsy by bleeding, is
confined chiefly to its use in malignant fevers; for the men who urge
this objection to it, do not hesitate to draw four or five quarts of
blood in the cure of the pleurisy. The habitual association of the lancet
with this disease, has often caused me to rejoice when I have heard a
patient complain of a pain in his side, in a malignant fever. It insured
to me his consent to the frequent use of the lancet, and it protected me,
when it was used unsuccessfully, from the clamours of the public, for few
people censure copious bleeding in a pleurisy.