of blood-letting. Mr. White informs us, in the History of the Bilious
Fever which has lately prevailed at Bath, that bleeding, in many cases in
which this appearance of the blood took place, was useless or hurtful. In
some of the fevers of our own country, we sometimes see sizy blood
followed by symptoms which forbid the repeated use of the lancet, but
which yield to other depleting remedies, or to such as are of a cordial
nature. I have seen the same kind of blood, a few hours before death, in
a pulmonary consumption, and three days after a discharge of a gallon and
a half of blood from the stomach by vomiting.
11. Even a tense pulse does not always call for the repeated use of the
lancet. I have mentioned one case, viz. on the third or fourth days of a
malignant fever, in which it is improper. There are instances of
incurable consumptions from tubercles and ulcers in the lungs, in which
the pulse cannot be made to feel the least diminution of tension by
either copious or frequent bleedings. There are likewise cases of hepatic
fever, in which the pulse cannot be subdued by this remedy. This tense
state of the pulse is the effect of a suppurative process in the liver.
If a sufficient quantity of blood has been drawn in the first stage of
this disease, there is little danger from leaving the pulse to reduce or
wear itself down by a sudden or gradual discharge of the hepatic
congestion. The recovery in this case is slow, but it is for the most
part certain. I have once known a dropsy and death induced by the
contrary practice.
12. and lastly. There is sometimes a tension in the pulse in hæmorrhages,
that will not yield to the lancet. The man whose blood was sizy, three
days after losing a gallon and a half of it from his stomach, had a tense
pulse the day before he died; and I once perceived its last strokes to be
tense, in a patient whom I lost in a yellow fever by a hæmorrhage from
the nose. The only circumstance that can justify bleeding in these cases
is extreme pain, in which case, the loss of a few ounces of blood is a
more safe and effectual remedy than opium.
I shall now add a few remarks upon the efficacy of blood-letting, in
diseases which are not supposed to belong to the class of fevers, and
which have not been included in the preceding volumes.
I. The philosophers, in describing the humble origin of man, say that he
is formed "inter stercus et urinam." The divines say that he is
"conceived in sin, and shapen in iniquity." I believe it to be equally
true, and alike humiliating, that he is conceived and brought forth in
disease.
This disease appears in pregnancy and parturition. I shall first
endeavour to prove this to be the case, and afterwards mention the
benefits of blood-letting in relieving it, in both cases.
In pregnancy, the uterus is always affected with that grade of morbid
action which I formerly called inflammation. This is evident from its
exhibiting all its usual phænomena in other parts of the body. These are,
1. Swelling, or enlargement.
2. Hæmorrhage. The lochia are nothing but a slow and spontaneous bleeding
performed by nature, and intended to cure the inflammation of the uterus
after parturition.
3. Abscesses, schirri, and cancers. It is true, those disorders sometimes
occur in women that have never borne children. In these cases, they are
the effects of the inflammation excited by the menstrual disease.
4. A full, quick, and tense or frequent pulse; pain; want of
appetite[63]; sickness at stomach; puking; syncope; and sometimes
convulsions in every part of the body.
[63] Dr. Hunter used to teach, in his lectures, that the final cause of
the want of appetite, during the first months of pregnancy, was to
obviate plethora, which disposed to abortion. This plethora should
have been called an inflammatory disease, in which abstinence is
useful.
5. Sizy blood. This occurs almost uniformly in pregnancy.
6. A membrane. Dr. Scarpa has proved the membrana decidua, which is
formed during pregnancy, to be in every respect the same in its
properties with the membrane which is formed upon other inflamed
surfaces, particularly the trachea, the pleura, and the inside of the
bowels. Thus we see all the common and most characteristic symptoms and
effects of inflammation, in other parts of the body, are exhibited by the
uterus in pregnancy.
These remarks being premised, I proceed to remark, that blood-letting is
indicated, in certain states of pregnancy, by all the arguments that have
been used in favour of it in any other inflammatory disease. The degree
of inflammation in the womb, manifested by the pulse, pain, and other
signs of disease, should determine the quantity of blood to be drawn. Low
diet, gentle purges, and constant exercise, are excellent substitutes for
it, but where they are not submitted to, blood-letting should be employed
as a substitute for them. In that disposition to abortion, which occurs
about the third month of pregnancy, small and frequent bleedings should
be preferred to all other modes of depletion. I can assert, from
experience, that they prevent abortion, nearly with as much certainty as
they prevent a hæmorrhage from the lungs: for what is an abortion but a
hæmoptysis (if I may be allowed the expression) from the uterus? During
the last month of pregnancy, the loss of from twelve to twenty ounces of
blood has the most beneficial effects, in lessening the pains and danger
of child-birth, and in preventing its subsequent diseases.
The doctrine I have aimed to establish leads, not only to the use of
blood-letting in the disease of pregnancy, when required, but to a more
copious use of it, when combined with other diseases, than in those
diseases in a simple state. This remark applies, in a particular manner,
to those spasms and convulsions which sometimes occur in the latter
months of pregnancy. Without bleeding, they are always fatal. By copious
bleeding, amounting in some instances to 80 and 100 ounces, they are
generally cured.
Let it not be supposed that blood-letting is alike proper and useful in
every state of pregnancy. There are what are called slow or chronic
inflammations, in which the diseased action of the blood-vessels not only
forbids it, but calls for cordial and stimulating remedies. The same
feeble state of inflammation sometimes takes place in the pregnant
uterus. In these cases cordials and stimulants should be preferred to the
lancet.
_Parturition_ is a higher grade of disease than that which takes place in
pregnancy. It consists of convulsive or clonic spasms in the uterus,
supervening its inflammation, and is accompanied with chills, heat,
thirst, a quick, full, tense, or a frequent and depressed pulse, and
great pain. By some divines these symptoms, and particularly pain, have
been considered as a standing and unchangeable punishment of the original
disobedience of woman, and, by some physicians, as indispensably
necessary to enable the uterus to relieve itself of its burden. By
contemplating the numerous instances in which it has pleased God to bless
the labours and ingenuity of man, in lessening or destroying the effects
of the curse inflicting upon the earth, and by attending to the histories
of the total exemption from pain in child-bearing that are recorded of
the women in the Brasils, Calabria, and some parts of Africa, and of the
small degrees of it which are felt by the Turkish women, who reduce their
systems by frequent purges of sweet oil during pregnancy, I was induced
to believe pain does not accompany child-bearing by an immutable decree
of Heaven. By recollecting further how effectually blood-letting relieves
many other spasmodic and painful diseases, and how suddenly it relaxes
rigidity in the muscles, I was led, in the year 1795, to suppose it might
be equally effectual in lessening the violence of the disease and pains
of parturition. I was encouraged still more to expect this advantage from
it, by having repeatedly observed the advantages of copious bleeding for
inflammatory fevers, just before delivery, in mitigating its pains, and
shortening its duration. Upon my mentioning these reflections and facts
to Dr. Dewees, I was much gratified in being informed, that he had been
in the practice, for several years before his removal from Abingdon to
Philadelphia, of drawing _large_ quantities of blood during parturition,
and with all the happy effects I had expected from it. The practice has
been strongly inculcated by the doctor in his lectures upon midwifery,
and has been ably defended and supported by a number of recent facts, in
an ingenious inaugural dissertation, published by Dr. Peter Miller, in
the year 1804. It has been generally adopted by the practitioners of
midwifery, of both sexes, in Philadelphia.
I do not mean to insinuate that bleeding is a new remedy in parturition.
It has long ago been advised and used in France, and even by the midwives
of Genoa, in Italy, but never, in any country, in the large quantities
that have been recommended by Dr. Dewees, that is, from 20 to 80 ounces,
or until signs of fainting are induced, nor under the influence of the
theory of parturition, being a violent disease.
But the advantages of this remedy are not confined to lessening the pains
of delivery. It prevents after pains; favours the easy and healthy
secretion of milk; prevents sore breasts, swelled legs, puerperile fever,
and all the distressing train of anomalous complaints that often follow
child-bearing. Dr. Hunter informed his pupils, in his lectures upon
midwifery, in the year 1769, that he had often observed the most rapid
recoveries to succeed the most severe labours. The severity of the pains
in these cases created a disease, which prevented internal congestions in
the womb. Bleeding, by depleting the uterus, obviates at once both
disease and congestion. Its efficacy is much aided by means of glysters,
which, by emptying the lower bowels, lessen the pressure upon the uterus.
Let it not be inferred, from what has been said in favour of
blood-letting in parturition, that it is proper in all cases. Where there
has been great previous inanition, and where there are marks of languor,
and feeble morbid action in the system, the remedies should be of an
opposite nature. Opium and other cordials are indicated in these cases.
Their salutary effects in exciting the action of the uterus, and
expediting delivery, are too well known to be mentioned.
I have expressed a hope in another place[64], that a medicine would be
discovered that should suspend sensibility altogether, and leave
irritability, or the powers of motion, unimpaired, and thereby destroy
labour pains altogether. I was encouraged to cherish this hope, by having
known delivery to take place, in one instance, during a paroxysm of
epilepsy, and having heard of another, during a fit of drunkenness, in a
woman attended by Dr. Church, in both of which there was neither
consciousness, nor recollection of pain.
[64] Medical Repository, vol. vi.
2. During the period in which the menses are said to dodge, and for a
year or two after they cease to flow, there is a morbid fulness and
excitement in the blood-vessels, which are often followed by head-ach,
cough, dropsy, hæmorrhages, glandular obstructions, and cancers. They may
all be prevented by frequent and moderate bleedings.
3. It has been proved, by many facts, that opium, when taken in an
excessive dose, acts by inducing a similar state of the system with that
which is induced by the miasmata which bring on malignant and
inflammatory fevers. The remedy for the disease produced by it (where a
vomiting cannot be excited to discharge the opium) has been found to be
copious blood-letting. Of its efficacy, the reader will find an account
in four cases, published in the fifth volume of the New-York Medical
Repository.
4. It is probable, from the uniformly stimulating manner in which poisons
of all kinds act upon the human body, that bleeding would be useful in
obviating their baneful effects. Dr. John Dorsey has lately proved its
efficacy, in the case of a child that was affected with convulsions, in
consequence of eating the leaves of the datura stramonium.
5. It has been the misfortune of diabetes to be considered by physicians
as exclusively a local disease of weak morbid action, or as the effect of
simple debility in the kidneys; and hence stimulating and tonic medicines
have been exclusively prescribed for it. This opinion is not a correct
one. It often affects the whole arterial system, more especially in its
first stage, with great morbid action. In two cases of it, where this
state of the blood-vessels took place, I have used blood-letting with
success, joined with the common remedies for inflammatory diseases.
6. In dislocated bones which resist both skill and force, it has been
suggested, that bleeding, till fainting is induced, would probably induce
such a relaxation in the muscles as to favour their reduction. This
principle was happily applied, in the winter of 1795, by Dr. Physick, in
the Pennsylvania hospital, in a case of dislocated humerus of two months
continuance. The doctor bled his patient till he fainted, and then
reduced his shoulder in less than a minute, and with very little exertion
of force. The practice has since become general in Philadelphia, in
luxations of large bones, where they resist the common degrees of
strength employed to reduce them.
In contemplating the prejudices against blood-letting, which formerly
prevailed so generally in our country, I have been led to ascribe them to
a cause wholly political. We are descended chiefly from Great-Britain,
and have been for many years under the influence of English habits upon
all subjects. Some of these habits, as far as they relate to government,
have been partly changed; but in dress, arts, manufactures, manners, and
science, we are still governed by our early associations. Britain and
France have been, for many centuries, hereditary enemies. The hostility
of the former to the latter nation, extends to every thing that belongs
to their character. It discovers itself, in an eminent degree, in diet
and medicine. Do the French love soups? the English prefer solid flesh.
Do the French love their meats well cooked? the English prefer their
meats but half roasted. Do the French sip coffee after dinner? the
English spend their afternoons in drinking Port and Madeira wines. Do the
French physicians prescribe purges and glysters to cleanse the bowels?
the English physicians prescribe vomits for the same purpose. Above all,
do the French physicians advise bleeding in fevers? the English
physicians forbid it, in most fevers, and substitute sweating in the room
of it. Here then we discover the source of the former prejudices and
errors of our country-men, upon the subject of blood-letting. They are of
British origin. They have been inculcated in British universities, and in
British books; and they accord as ill with our climate and state of
society, as the Dutch foot stoves did with the temperate climate of the
Cape of Good Hope[65].
[65] I have frequently been surprised, in visiting English patients, to
hear them say, when I have prescribed bleeding, that their
physicians in England had charged them never to be bled. This
advice excluded all regard to the changes which climate, diet, new
employments, and age might induce upon the system. I am disposed
to believe that many lives are lost, and numerous chronic diseases
created in Great-Britain, by the neglect of bleeding in fevers. My
former pupil, Dr. Fisher, in a letter from the university of
Edinburgh, dated in the winter of 1795, assured me, that he had
cured several of his fellow-students of fevers (contrary to
general prejudice) by early bleeding, in as easy and summary a way
as he had been accustomed to see them cured in Philadelphia, by
the use of the same remedy. Dr. Gordon, of Scotland, and several
other physicians in Great-Britain, have lately revived the lancet,
and applied it with great judgment and success to the cure of
fevers.
It is probable the bad consequences which have followed the
indiscriminate use of the lancet France, and some other countries, may
have contributed in some degree to create the prejudices against it,
which are entertained by the physicians in Great-Britain. Bleeding, like
opium, has lost its character, in many cases, by being prescribed for the
_name_ of a disease. It is still used, Mr. Townsend tells us, in this
empirical way in Spain, where a physician, when sent for to a patient,
orders him to be bled before he visits him. The late just theory of the
manner in which opium acts upon the body, has restrained its mischief,
and added greatly to its usefulness. In like manner, may we not hope,
that just theories of diseases, and proper ideas of the manner in which
bleeding acts in curing them, will prevent a relapse into the evils which
formerly accompanied this remedy, and render it a great and universal
blessing to mankind?
AN INQUIRY
INTO THE
_Comparative State of Medicine_,
IN PHILADELPHIA,
BETWEEN THE YEARS 1760 AND 1766,
AND THE YEAR 1805.
In estimating the progress and utility of medicine, important advantages
may be derived from taking a view of its ancient, and comparing it with
its present state. To do this upon an extensive scale, would be
difficult, and foreign to the design of this inquiry. I shall therefore
limit it, to the history of the diseases and medical opinions which
prevailed, and of the remedies which were in use, in the city of
Philadelphia, between the years 1760 and 1766, and of the diseases,
medical opinions, and remedies of the year 1805. The result of a
comparative view of each of them, will determine whether medicine has
declined or improved, in that interval of time, in this part of the
world.
To derive all the benefits that are possible from such an inquiry, it
will be proper to detail the causes, which, by acting upon the human
body, influence the subjects that have been mentioned, in those two
remote periods of time.
Those causes divide themselves into climate, diet, dress, and certain
peculiar customs; on each of which I shall make a few remarks.
After what has been said, in the history of the Climate of Pennsylvania,
in the first volume of these Inquiries, it will only be necessary in this
place briefly to mention, that the winters in Philadelphia, between the
years 1760 and 1766, were almost uniformly cold. The ground was generally
covered with snow, and the Delaware frozen, from the first or second week
in December, to the last week in February, or the first week in March.
Thaws were rare during the winter months, and seldom of longer duration
than three or four days. The springs began in May. The summers were
generally warm, and the air seldom refreshed by cool north-west winds.
Rains were frequent and heavy, and for the most part accompanied with
thunder and lightning. The autumns began in October, and were gradually
succeeded by cool and cold weather.
The diet of the inhabitants of Philadelphia, during those years,
consisted chiefly of animal food. It was eaten, in some families, three
times, and in all, twice a day. A hot supper was a general meal. To two
and three meals of animal food in a day, many persons added what was then
called "a relish," about an hour before dinner. It consisted of a slice
of ham, a piece of salted fish, and now and then a beef-steak,
accompanied with large draughts of punch or toddy. Tea was taken in the
interval between dinner and supper.
In many companies, a glass of wine and bitters was taken a few minutes
before dinner, in order to increase the appetite.
The drinks, with dinner and supper, were punch and table beer.
Besides feeding thus plentifully in their families, many of the most
respectable citizens belonged to clubs, which met in the city in winter,
and in its vicinity, under sheds, or the shade of trees, in summer, once
and twice a week, and, in one instance, every night. They were drawn
together by suppers in winter, and dinners in summer. Their food was
simple, and taken chiefly in a solid form. The liquors used with it were
punch, London porter, and sound old Madeira wine.
Independently of these clubs, there were occasional meetings of citizens,
particularly of young men, at taverns, for convivial purposes. A house in
Water-street, known by the name of the Tun tavern, was devoted chiefly to
this kind of accidental meetings. They were often followed by midnight
sallies into the streets, and such acts of violence and indecency, as
frequently consigned the perpetrators of them afterwards into the hands
of the civil officers and physicians of the city.
Many citizens, particularly tradesmen, met every evening for the purpose
of drinking beer, at houses kept for that purpose. Instances of
drunkenness were rare at such places. The company generally parted at ten
o'clock, and retired in an orderly manner to their habitations. Morning
drams, consisting of cordials of different kinds, were common, both in
taverns and private houses, but they were confined chiefly to the lower
class of people.
From this general use of distilled and fermented liquors, drunkenness was
a common vice in all the different ranks of society.
The dresses of the men, in the years alluded to, were composed of cloth
in winter, and of thin woollen or silk stuffs in summer. Wigs composed
the covering of the head, after middle life, and cocked hats were
universally worn, except by the men who belonged to the society of
friends.
The dresses of the women, in the years before mentioned, consisted
chiefly of silks and calicoes. Stays were universal, and hoops were
generally worn by the ladies in genteel life. Long cloth or camblet
cloaks were common, in cold weather, among all classes of women.
The principal custom under this head, which influenced health and life,
was that which obliged women, after lying-in, "to sit up for company;"
that is, to dress themselves, every afternoon on the second week after
their confinement, and to sit for four or five hours, exposed to the
impure air of a crowded room, and sometimes to long and loud
conversations.
Porches were nearly universal appendages to houses, and it was common for
all the branches of a family to expose themselves upon them, to the
evening air. Stoves were not in use, at that time, in any places of
public worship.
Funerals were attended by a large concourse of citizens, who were thereby
often exposed to great heat and cold, and sometimes to standing, while
the funeral obsequies were performed, in a wet or damp church-yard.
The human mind, in this period of the history of our city, was in a
colonized state, and the passions acted but feebly and partially upon
literary and political subjects.
We come now to mention the diseases which prevailed in our city between
the years 1760 and 1766.
The cholera morbus was a frequent disease in the summer months.
Sporadic cases of dysentery were at that time common. I have never seen
that disease epidemic in Philadelphia.
The intermitting fever prevailed in the month of August, and in the
autumn, chiefly in the suburbs and neighbourhood of the city. In the year
1765, it was epidemic in Southwark, and was so general, at the same time,
as to affect two thirds of the inhabitants of the southern states. This
fact is mentioned by Dr. Bond, in a lecture preserved in the minutes of
the managers of the Pennsylvania hospital.
The slow chronic fever, called at that time the nervous fever, was very
common, in the autumnal months, in the thickly settled parts of the city.
The bilious fever prevailed, at the same time, in Southwark. The late Dr.
Clarkson, who began to practise medicine in that part of the city, in the
year 1761, upon hearing some of his medical brethren speak of the
appearance of bilious remittents in its middle and northern parts, about
the year 1778, said they had long been familiar to him, and that he had
met with them every year since his settlement in Philadelphia[66].