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.
[56] Vol. iii.
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]."
[57] Elementa Physiologiæ, vol. iv. p. 45.
[58] Vol. i. p. 131.
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?
[59] Account of the Yellow Fever in 1793.
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.
[60] Remarks on the Constitution of the Medical Department of the
British Army.
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.
[61] Asiatic Essays.
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.
[62] Vol. iii.
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.