country cure their inflammatory fevers without it. To relieve myself from
the distressing obloquy to which my use of this remedy formerly exposed
me, I have carefully sought for, and examined their remedies for those
fevers, with a sincere desire to adopt them; but my inquiries have
convinced me, that they are not only disproportioned to the habits and
diseases of civilized life, but that they are far less successful than
blood-letting, in curing the inflammatory fevers which occur among the
Indians themselves.
25. Evacuating remedies of another kind have been said to be more safe
than bleeding, and equally effectual, in reducing the inflammatory state
of fever. I shall enumerate each of these evacuating remedies, and then
draw a comparative view of their effects with blood-letting. They are,
I. Vomits.
II. Purges.
III. Sweats.
IV. Salivation. And,
V. Blisters.
I. Vomits have often been effectual in curing fevers of a mild character.
They discharge offensive and irritating matters from the stomach; they
lessen the fulness of the blood-vessels, by determining the serum of the
blood through the pores; and they equalize the excitement of the system,
by inviting its excessive degrees from the blood-vessels to the stomach
and muscles. But they are,
1. Uncertain in their operation, from the torpor induced by the fever
upon the stomach.
2. They are unsafe in many conditions of the system, as in pregnancy, and
a disposition to apoplexy and ruptures. Life has sometimes been destroyed
by their inducing cramp, hæmorrhage, and inflammation in the stomach.
3. They are not subject to the controul of a physician, often operating
more, or less than was intended by him, or indicated by the disease.
4. They are often ineffectual in mild, and always so in fevers of great
morbid action.
II. Purges are useful in discharging acrid fæces and bile from the bowels
in fevers. They act, moreover, by creating an artificial weak part, and
thus invite morbid excitement from the blood-vessels to the bowels. They
likewise lessen the quantity of blood, by preventing fresh accessions of
chyle being added to it; but like vomits they are,
1. Uncertain in their operation; and from the same cause. Many ounces of
salts and castor oil, and whole drachms of calomel and jalap, have often
been given, without effect, to remove the costiveness which is connected
with the malignant state of fever.
2. They are not subject to the direction of a physician, with respect to
the time of their operation, or the quantity or quality of matter they
are intended to discharge from the bowels.
3. They are unsafe in the advanced stage of fevers. Dr. Physick informed
me, that three patients died in the water-closet, under the operation of
purges, in St. George's hospital, during his attendance upon it. I have
seen death, in several instances, succeed a plentiful spontaneous stool
in debilitated habits.
III. Sweating was introduced into practice at a time when morbific matter
was supposed to be the proximate cause of fever. It acts, not by
expelling any thing exclusively morbid from the blood, but by
abstracting a portion of its fluid parts, and thus reducing the action of
the blood-vessels. This mode of curing fever is still fashionable in
genteel life. It excites no fear, and offends no sense. The sweating
remedies have been numerous, and fashion has reigned as much among them,
as in other things. Alexipharmic waters, and powders, and all the train
of sudorific medicines, have lately yielded to the different preparations
of antimony, particularly to James's powder. I object to them all,
1. Because they are uncertain; large and repeated doses of them being
often given to no purpose.
2. Because they are slow, and disagreeable, where they succeed in curing
fever.
3. Because, like vomits and purges, they are not under the direction of a
physician, with respect to the quantity of fluid discharged by them.
4. Because they are sometimes, even when most profuse, ineffectual in the
cure of fever.
5. The preparations of antimony, lately employed for the purpose of
exciting sweats, are by no means safe. They sometimes convulse the
system by a violent puking. Even the boasted James's powder has done
great mischief. Dr. Goldsmith and Mr. Howard, it is said, were destroyed
by it.
None of these objections to sweating remedies are intended to dissuade
from their use, when nature shows a disposition to throw off a fever by
the pores of the skin; but, even then, they often require the aid of
bleeding to render them effectual for that purpose.
IV. Mercury, the Sampson of the materia medica, after having subdued the
venereal disease, the tetanus, and many other formidable diseases, has
lately added to its triumphs and reputation, by overcoming the
inflammatory and malignant state of fever. I shall confine myself, in
this place, to its depleting operation, when it acts by exciting a
salivation. From half a pound to two pounds of fluid are discharged by it
in a day. The depletion in this way is gradual, whereby fainting is
prevented. By exciting and inflaming the glands of the mouth and throat,
excitement and inflammation are abstracted from more vital parts. In
morbid congestion and excitement in the brain, a salivation is of eminent
service, from the proximity of the discharge to the part affected. But I
object to it, as an exclusive evacuant in the cure of fever,
1. Because it is sometimes impossible, by the largest doses of mercury,
to excite it, when the exigences of the system render it most necessary.
2. Because it is not so quick in its operation, as to be proportioned to
the rapid progress of the malignant state of fever.
3. Because it is at all times a disagreeable, and frequently a painful
remedy, more especially where the teeth are decayed.
4. Because it cannot be proportioned in its duration, or in the quantity
of fluid discharged by it, to the violence or changes in the fever.
Dr. Chisholm relied, for the cure of the Beullam fever at Grenada,
chiefly upon this evacuation. I have mentioned the ratio of success which
attended it.
V. Blisters are useful in depleting from those parts which are the seats
of topical inflammation. The relief obtained by them in this way more
than balances their stimulus upon the whole system need hardly say, that
their effects in reducing the morbid and excessive action of the
blood-vessels are very feeble. To depend upon them in cases of great
inflammatory action, is as unwise as it would be to attempt to bale the
water from a leaky and sinking ship by the hollow of the hand, instead of
discharging it by two or three pumps.
VI. Abstemious diet has sometimes been prescribed as a remedy for fever.
It acts directly by the abstraction of the stimulus of food from the
stomach, and indirectly by lessening the quantity of blood. It can bear
no proportion, in its effects, to the rapidity and violence of an
inflammatory fever. In chronic fever, such as occurs in the pulmonary
consumption, it has often been tried to no purpose. Long before it
reduces the pulse, it often induces such a relaxation of the tone of the
stomach and bowels as to accelerate death. To depend upon it therefore in
the cure of inflammatory fever, whether acute or chronic, is like
trusting to the rays of the sun to exhale the water of an overflowing
tide, instead of draining it off immediately, by digging a hole in the
ground. But there are cases in which the blood-vessels become so
insolated, that they refuse to yield their morbid excitement to depletion
from any outlet, except from themselves. I attended a sailor, in the
Pennsylvania hospital, in 1799, who was affected with deafness, attended
with a full and tense pulse. I prescribed for it, purging, blisters, and
low diet, but without any effect. Perceiving no change in his pulse, nor
in his disease, from those remedies, I ordered him to lose ten ounces of
blood. The relief obtained by this evacuation induced me to repeat it. By
means of six bleedings he was perfectly cured, without the aid of any
other remedy.
Bleeding has great advantages over every mode of depleting that has been
mentioned.
1. It abstracts one of the exciting causes, viz. the stimulus of the
blood, from the seat of fever. I have formerly illustrated this advantage
of blood-letting, by comparing it to the abstraction of a grain of sand
from the eye to cure an opthalmia. The other depleting remedies are as
indirect and circuitous in their operation in curing fever, as vomits and
purges would be to remove an inflammation in the eye, while the grain of
sand continued to irritate it.
2. Blood-letting is quick in its operation, and may be accommodated to
the rapidity of fever, when it manifests itself in apoplexy, palsy, and
syncope.
3. It is under the command of a physician. He may bleed _when_ and
_where_ he pleases, and may suit the _quantity_ of blood he draws,
exactly to the condition of his patient's system.
4. It may be performed with the least attendance of nurses or friends.
This is of great importance to the poor at all times, and to the rich
during the prevalence of mortal epidemics.
5. It disturbs the system much less than any of the other modes of
depleting, and therefore is best accommodated to that state of the
system, in which patients are in danger of fainting or dying upon being
moved.
6. It is a more delicate depleting remedy than most of those which have
been mentioned, particularly vomits, purges, and a salivation.
7. There is no immediate danger to life from its use. Patients have
sometimes died under the operation of vomits and purges, but I never saw
nor heard an instance of a patient's dying in a fainty fit, brought on by
bleeding.
8. It is less weakening, when used to the extent that is necessary to
cure, than the same degrees of vomiting, purging, and sweating.
9. Convalescence is more rapid and more perfect after bleeding, than
after the successful use of any of the other evacuating remedies.
By making use of blood-letting in fevers, we are not precluded from the
benefits of the other evacuating remedies. Some of them are rendered more
certain and more effectual by it, and there are cases of fever, in which
the combined or successive application of them all is barely sufficient
to save life.
To rely upon any one evacuating remedy, to the exclusion of the others,
is like trusting to a pair of oars in a sea voyage, instead of spreading
every sail of a ship.
I suspect the disputes about the eligibility of the different remedies
which have been mentioned, have arisen from an ignorance that they all
belong to one class, and that they differ only in their force and manner
of operation. Thus the physicians of the last century ascribed different
virtues to salts of different names, which the chemists of the present
day have taught us are exactly the same, and differ only in the manner of
their being prepared.
Having replied to the principal objections to blood-letting, and stated
its comparative advantages over other modes of depletion, I proceed next
to mention the circumstances which should regulate the use of it. These
are,
I. The state of the pulse.
The following states of the pulse indicate the necessity of bleeding.
1. A full, frequent, and tense pulse, such as occurs in the pulmonary,
rheumatic, gouty, phrenitic, and maniacal states of fever.
2. A full, frequent, and jerking pulse, without tension, such as
frequently occurs in the vertiginous, paralytic, apoplectic, and hydropic
states of fever.
3. A small, frequent, but tense pulse, such as occurs in the chronic,
pulmonary, and rheumatic states of fever.
4. A tense and _quick_ pulse, without much preternatural frequency. This
state of the pulse is common in the yellow fever.
5. A slow but tense pulse, such as occurs in the apoplectic,
hydrocephalic, and malignant states of fever, in which its strokes are
from 60 to 90, in a minute.
6. An uncommonly frequent pulse, without much tension, beating from 120
to 170 or 180 strokes in a minute. This state of the pulse occurs
likewise in the malignant states of fever.
7. A soft pulse, without much frequency or fulness. I have met with this
state of the pulse in affections of the brain, and in that state of
pulmonary fever which is known by the name of pneumonia notha. It
sometimes, I have remarked, becomes tense after bleeding.
8. An intermitting pulse.
9. A depressed pulse.
10. An imperceptible pulse. The slow, intermitting, depressed, and
imperceptible states of the pulse are supposed exclusively to indicate
congestion in the brain. But they are all, I believe, occasioned likewise
by great excess of stimulus acting upon the heart and arteries. A pulse
more tense in one arm than in the other, I have generally found to attend
a morbid state of the brain. Much yet remains to be known of the signs of
a disease in the brain, by the states of the pulse; hence Mr. Hunter has
justly remarked, that "In inflammation of the brain, the pulse varies
more than in inflammations of any other part; and perhaps we are led to
judge of inflammation there, more from _other_ symptoms than the
pulse[55]."
[55] Treatise on Inflammation, chap. iii. 9.
The slow, uncommonly frequent, intermitting, and imperceptible states of
the pulse, which require bleeding, may be distinguished from the same
states of the pulse, which arise from an exhausted state of the system,
and that forbid bleeding, by the following marks:
1. They occur in the beginning of a fever.
2. They occur in the paroxysms of fevers which have remissions and
exacerbations.
3. They sometimes occur after blood-letting, from causes formerly
mentioned.
4. They sometimes occur, and continue during the whole course of an
inflammation of the stomach and bowels. And,
5. They occur in relapses, after the crisis of a fever.
The other states of the pulse indicate bleeding in every stage of fever,
and in every condition of the system. I have taken notice, in another
place, of the circumstances which render it proper in the advanced stage
of chronic fever.
If all the states of pulse which have been enumerated indicate bleeding,
it must be an affecting consideration to reflect, how many lives have
been lost, by physicians limiting the use of the lancet only to the tense
or full pulse!
I wish it comported with the proposed limits of this essay to illustrate
and establish, by the recital of cases, the truth of these remarks upon
the indications of bleeding from the pulse. It communicates much more
knowledge of the state of the system than any other sign of disease. Its
frequency (unconnected with its other states), being under the influence
of diet, motion, and the passions of the mind, is of the least
consequence. In counting the number of its strokes, we are apt to be
diverted from attending to its irregularity and force; and in these, it
should always be remembered, fever chiefly consists. The knowledge
acquired by attending to these states of the pulse is so definite and
useful, and the circumstances which seduce from a due attention to them
are so erroneous in their indications, that I have sometimes wished the
Chinese custom of prescribing, from feeling the pulse only, without
seeing or conversing with the patient, were imposed upon all physicians.
To render the knowledge of the indications of blood-letting, from the
state of the pulse, as definite and correct as possible, I shall add, for
the benefit of young practitioners, the following directions for feeling
it.
1. Let the arm be placed in a situation in which all the muscles which
move it shall be completely relaxed; and let it, at the same time, be
free from the pressure of the body upon it.
2. Feel the pulse, in all obscure or difficult cases, in both arms.
3. Apply all the fingers of one hand, when practicable, to the pulse. For
this purpose, it will be most convenient to feel the pulse of the right
hand with your left, and of the left hand with your right.
4. Do not decide upon blood-letting, in difficult cases, until you have
felt the pulse for some time. The Chinese physicians never prescribe
until they have counted 49 strokes.
5. Feel the pulse at the intervals of four or five minutes, when you
suspect that its force has been varied by any circumstance not connected
with the disease, such as emotions of the mind, exercise, eating,
drinking, and the like.
6. Feel the pulsations of the arteries in the temples and in the neck,
when the pulse is depressed or imperceptible in the wrists.
7. Request silence in a sick room, and close your eyes, in feeling a
pulse in difficult cases. By so doing, you will concentrate the
sensations of your ears and eyes, in your fingers.
In judging of the states of the pulse which have been enumerated, it will
be necessary always to remember the natural difference, in its frequency
and force, in old people and children; also in the morning and evening,
and in the sleeping and waking states of the system.
Much yet remains to be known upon this subject. I have mentioned the
different states of the pulse, which call for bleeding, but it is more
difficult to know when to prescribe it, when the pulse imparts no sign of
disease. In general it may be remarked, where the disease is _recent_,
the part affected important to life, and incapable of sustaining violent
morbid action long, without danger of disorganization, where pain is
great, and respiration difficult, the pulse may be disregarded in the use
of the lancet.
But to return.
II. Regard should be had to the character of the reigning epidemic, in
deciding upon blood-letting. If the prevailing fever be of a highly
inflammatory nature, bleeding may be used with more safety, in cases
where the indications of it from the pulse are somewhat doubtful. The
character of a previous epidemic should likewise direct the use of the
lancet. The pestilential fever which followed the plague in London, in
1665, Dr. Sydenham says, yielded only to blood-letting. It is equally
necessary in all the febrile diseases which succeed malignant fevers.
III. Regard should be had to the weather and season of the year. Dr.
Hillary and Dr. Huxham both say it is much more necessary in dry, than in
wet weather, and, all physicians know, it is more copiously indicated in
the spring and autumn, than in summer and winter.
IV. The constitution of a patient, and more especially his habits with
respect to blood-letting, should be taken into consideration, in
prescribing it. If he be plethoric, and accustomed to bleeding in former
indispositions, it will be more necessary, than in opposite states and
habits of the system. Nature will expect it.
V. The corpulency of a patient should regulate the use of the lancet. A
butcher of great observation informed me, that a fat ox did not yield
more than from one half, to one third of the quantity of blood of a lean
one, of the same size of bone, and it is well known, that the loss of a
small quantity of blood, after cutting off the head of a fowl, is always
a sign of its being fit for the table. The pressure of fat upon the
blood-vessels produces the same effects in the human species that it does
in those animals; of course, less blood should be drawn from fat, than
from lean people, under equal circumstances of disease.
VI. As persons have more or less blood in their vessels, according to
their size, less blood should be drawn, under equal circumstances, from
small than large people.
VII. Regard should be had to the age of adults in prescribing bleeding.
In persons between fifty and sixty years of age, for reasons formerly
mentioned, more blood may be drawn than in middle life, in similar
diseases. In persons beyond 70, it will be necessary to regulate the
quantity to be drawn by other signs than the pulse, or the appearances of
the blood, the former being generally full, and sometimes tense, and the
latter often putting on the sign of the second grade of morbid action
formerly described.
VIII. Regard should be had to the country or place from which persons
affected with fevers have arrived, in prescribing the loss of blood.
Fevers, in America, are more inflammatory than fevers, in persons of
equal rank, in Great-Britain. A French physician once said, it was safer
to draw a hogs-head of wine from a Frenchman's veins, than a quarter of a
hundred pounds of beef from an Englishman's, meaning to convey an idea of
the difference in the grades of morbid or inflammatory action in the
diseases of the inhabitants of France and England, and of the difference
in the quantity of blood proper to be drawn in each of them. A similar
difference exists between the grades of fever in Great-Britain and
America. From a want of attention to this circumstance, I saw a common
pleurisy end in an abscess of the lungs, in a sea captain, in the city of
London, in the year 1769, who was attended by a physician of the first
reputation in England. He was bled but once. His pulse and American
constitution called for the loss of 50 or 60 ounces of blood.
IX. Regard should be had to the structure and situation of the parts
diseased with febrile action. The brain, from its importance to all the
functions of life, the rectum, the bladder, and the trachea, when
inflamed, and the intestines, when strangulated, from their being removed
so much out of the influence of the great circulation, all require more
copious bleeding than the same degrees of disease in the lungs, and some
other parts of the body.
X. After blood-letting has been performed, the appearances of the blood
should be attended to, in order to judge of the propriety of repeating
it. I shall briefly describe these appearances, and arrange them in the
order in which they indicate the different degrees of inflammatory
diathesis, beginning with the highest.
1. Dissolved blood. It occurs in the malignant states of fever. I have
seen it several times in the pleurisy, and have once heard of it in a
case of gout. I have ascribed this decomposition of the blood to such a
violent degree of action in the blood-vessels, as to dispose them to a
paralytic state. It is generally considered as a signal to lay aside the
lancet. If it occur in the _first stage_ of a fever, it indicates a very
opposite practice. By repeated bleedings, the vessels recover their
natural action, and the blood becomes _reduced_ to its original texture.
Of this I have had frequent experience, since the year 1793. It required
three successive bleedings to restore the blood from a dissolved, to a
coagulable state, in Mr. Benton. It afterwards became very sizy. If this
dissolved blood appear towards the close of a malignant fever, no other
benefit than the protraction of life for a day or two, or an easy death,
can be expected from repeating the bleeding, even though it be indicated
by a tense pulse; for the viscera are generally so much choaked by the
continuance of violent action in the blood-vessels, that they are seldom
able to discharge the blood which distends them, into the cavity in the
vessels, which is created by the abstraction of blood from a vein. There
is some variety in the appearance of this state of the blood, which
indicates more or less violent pressure upon the blood-vessels. It
threatens most danger to life when it resembles molasses in its
consistence. The danger is less when the part which is dissolved occupies
the bottom of the bowl, and when its surface is covered with a sizy
pellicle or coat.
Does not the restoration of the blood from its disorganized state, by
means of bleeding, suggest an idea of a similar change being practicable
in the solids, when they are disorganized by disease? And are we not led
hereby to an animating view of the extent and power of medicine?
2. Blood of a scarlet colour, without any separation into crassamentum or
serum, indicates a second degree of morbid action. It occurs likewise in
the malignant state of fever. It is called improperly dense blood. It
occurs in old people.
3. Blood in which part of the crassamentum is dissolved in the serum,
forming a resemblance to what is called the lotura carnium, or the
washings of flesh in water.
4. Crassamentum sinking to the bottom of a bowl in yellow serum.
5. Crassamentum floating in serum, which is at first turbid, but which
afterwards becomes yellow and transparent, by depositing certain red and
fiery particles of the blood in the bottom of the bowl.