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.

6. Sizy blood, or blood covered with a buffy coat. The more the 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.

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].”

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?

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.

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.

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.

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.

10. There are cases in which sizy blood should not warrant a repetition 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.

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.

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].

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].

The yellow fever prevailed in the neighbourhood of Spruce-street wharf, and near a filthy stream of water which flowed through what is now called Dock-street, in the year 1762. Some cases of it appeared likewise in Southwark. It was scarcely known in the north and west parts of the city. No desertion of the citizens took place at this time, nor did the fear of contagion drive the friends of the sick from their bed-sides, nor prevent the usual marks of respect being paid to them after death, by following their bodies to the grave. A few sporadic cases of the same grade of fever appeared in the year 1763.

Pneumonies, rheumatisms, inflammatory sore throats, and catarrhs were frequent during the winter and spring months. The last disease was induced, not only by sudden changes in the weather, but often by exposure to the evening air, on porches in summer, and by the damp and cold air of places of public worship in winter.

The influenza was epidemic in the city in the spring of the year 1761.

The malignant sore throat proved fatal to a number of children in the winter of 1763.

The scarlet fever prevailed generally in the year 1764. It resembled the same disease, as described by Dr. Sydenham, in not being accompanied by a sore throat.

Death from convulsions in pregnant women, also front parturition, and the puerperile fever, were common between the years 1760 and 1766. Death was likewise common between the 50th and 60th years of life from gout, apoplexy, palsy, obstructed livers, and dropsies. A club, consisting of about a dozen of the first gentlemen in the city, all paid, for their intemperance, the forfeit of their lives between those ages, and most of them with some one, or more of the diseases that have been mentioned. I sat up with one of that club on the night of his death. Several of the members of it called at his house, the evening before he died, to inquire how he was. One of them, upon being informed of his extreme danger, spoke in high and pathetic terms of his convivial talents and virtues, and said, “he had spent 200 evenings a year with him, for the last twenty years of his life.” These evenings were all spent at public houses.

The colica pictonum, or dry gripes, was formerly a common disease in this city. It was sometimes followed by a palsy of the upper and lower extremities. Colics from crapulas were likewise very frequent, and now and then terminated in death.

Many children died of the cholera infantum, cynanche trachealis, and hydrocephalus internus. The last disease was generally ascribed to worms.

Fifteen or twenty deaths occurred, every summer, from drinking cold pump water, when the body was in a highly excitable state, from great beat and labour.

The small-pox, within the period alluded to, was sometimes epidemic, and carried off many citizens. In the year 1759, Dr. Barnet was invited from Elizabeth-town, in New-Jersey, to Philadelphia, to inoculate for the small-pox. The practice, though much opposed, soon became general. About that time, Dr. Redman published a short defence of it, and recommended the practice to his fellow-citizens in the most affectionate language. The success of inoculation was far from being universal. Subsequent improvements in the mode of preparing the body, and treating the eruptive fever, have led us to ascribe this want of success to the deep wound made in the arm, to the excessive quantity of mercury given to prepare the body, and to the use of a warm regimen in the eruptive fever.

The peculiar customs and the diseases which have been enumerated, by inducing general weakness, rendered the pulmonary consumption a frequent disease among both sexes.

Pains and diseases from decayed teeth were very common, between the years 1760 and 1766. At that time, the profession of a dentist was unknown in the city.

The practice of physic and surgery were united, during those years, in the same persons, and physicians were seldom employed as man-midwives, except in preternatural and tedious labours.

The practice of surgery was regulated by Mr. Sharp's treatise upon that branch of medicine.

Let us now take a view of the medical opinions which prevailed at the above period, and of the remedies which were employed to cure the diseases that have been mentioned.

The system of Dr. Boerhaave then governed the practice of every physician in Philadelphia. Of course diseases were ascribed to morbid acrimonies, and other matters in the blood, and the practice of those years was influenced by a belief in them. Medicines were prescribed to thin, and to incrassate the blood, and diet drinks were administered in large quantities, in order to alter its qualities. Great reliance was placed upon the powers of nature, and critical days were expected with solicitude, in order to observe the discharge of the morbid cause of fevers from the system. This matter was looked for chiefly in the urine, and glasses to retain it were a necessary part of the furniture of every sick room. To ensure the discharge of the supposed morbid matter of fevers through the pores, patients were confined to their beds, and fresh, with cool air, often excluded by close doors and curtains. The medicines to promote sweats were generally of a feeble nature. The spiritus mindereri, and the spirit of sweet nitre were in daily use for that purpose. In dangerous cases, saffron and Virginia snake-root were added to them.

Blood-letting was used plentifully in pleurisies and rheumatisms, but sparingly in all other diseases. Blood was often drawn from the feet, in order to excite a revulsion of disease from the superior parts of the body. It was considered as unsafe, at that time, to bleed during the monthly disease of the female sex.

Purges or vomits began the cure of all febrile diseases, but as the principal dependence was placed upon sweating medicines, those powerful remedies were seldom repeated in the subsequent stages of fevers. To this remark there was a general exception in the yellow fever of 1762. Small doses of glauber's salts were given every day after bleeding, so as to promote a gentle, but constant discharge from the bowels.

The bark was administered freely in intermittents. The prejudices against it at that time were so general among the common people, that it was often necessary to disguise it. An opinion prevailed among them, that it lay in their bones, and that it disposed them to take cold. It was seldom given in the low and gangrenous states of fever, when they were not attended with remissions.

The use of opium was confined chiefly to ease pain, to compose a cough, and to restrain preternatural discharges from the body. Such were the prejudices against it, that it was often necessary to conceal it in other medicines. It was rarely taken without the advice of a physician.

Mercury was in general use in the years that have been mentioned. I have said it was given to prepare the body for the small-pox. It was administered by my first preceptor in medicine, Dr. Redman, in the same disease, when it appeared in the natural way, with malignant or inflammatory symptoms, in order to keep the salivary glands open and flowing, during the turn of the pock. He gave it likewise liberally in the dry gripes. In one case of that disease, I well remember the pleasure he expressed, in consequence of its having affected his patient's mouth.

But to Dr. Thomas Bond the city of Philadelphia is indebted for the introduction of mercury into general use, in the practice of medicine. He called it emphatically “a revolutionary remedy,” and prescribed it in all diseases which resisted the common modes of practice. He gave it liberally in the cynanche trachealis. He sometimes cured madness, by giving it in such quantities as to excite a salivation. He attempted to cure pulmonary consumption by it, but without success; for, at that time, the influence of the relative actions of different diseases and remedies, upon the human body, was not known, or, if known, no advantage was derived from it in the practice of medicine.

The dry gripes were cured, at that time, by a new and peculiar mode of practice, by Dr. Thomas Cadwallader. He kept the patient easy by gentle anodynes, and gave lenient purges, only in the beginning of the disease; nor did he ever assist the latter by injections till the fourth and fifth days, at which time the bowels discharged their contents in an easy manner. It was said this mode of cure prevented the paralytic symptoms, which sometimes follow that disease. It was afterwards adopted and highly commended by the late Dr. Warren, of London.

Blisters were in general use, but seldom applied before the latter stage of fevers. They were prescribed, for the first time, in hæmorrhages, and with great success, by Dr. George Glentworth.

Wine was given sparingly, even in the lowest stage of what were then called putrid and nervous fevers.

The warm and cold baths were but little used in private practice. The former was now and then employed in acute diseases. They were both used in the most liberal manner, together with the vapour and warm air baths, in the Pennsylvania hospital, by Dr. Thomas Bond. An attempt was made to erect warm and cold baths, in the neighbourhood of the city, and to connect them with a house of entertainment, by Dr. Lauchlin M'Clen, in the year 1761. The project was considered as unfriendly to morals, and petitions, from several religious societies, were addressed to the governor of the province, to prevent its execution. The enterprize was abandoned, and the doctor soon afterwards left the city.

Riding on horseback, the fresh air of the sea-shore, and long journies, were often prescribed to invalids, by all the physicians of that day.

I come now to mention the causes which influence the diseases, also the medical opinions and remedies of the present time. In this part of our discourse, I shall follow the order of the first part of our inquiry.

I have already taken notice of the changes which the climate of Philadelphia has undergone since the year 1766.

A change has of late years taken place in the dress of the inhabitants of Philadelphia. Wigs have generally been laid aside, and the hair worn cut and dressed in different ways. Round hats, with high crowns, have become fashionable. Umbrellas, which were formerly a part of female dress only, are now used in warm and wet weather, by men of all ranks in society; and flannel is worn next to the skin in winter, and muslin in summer, by many persons of both sexes. Tight dresses are uncommon, and stays are unknown among our women. It is to be lamented that the benefits to health which might have been derived from the disuse of that part of female dress, have been prevented by the fashion of wearing such light coverings over the breasts and limbs. The evils from this cause, shall be mentioned hereafter.

A revolution has taken place in the diet of our citizens. Relishes and suppers are generally abolished; bitters, to provoke a preternatural appetite, also meridian bowls of punch, are now scarcely known. Animal food is eaten only at dinner, and excess in the use of it is prevented, by a profusion of excellent summer and winter vegetables.

Malt liquors, or hydrant water, with a moderate quantity of wine, are usually taken with those simple and wholesome meals.

Clubs, for the exclusive purpose of feeding, are dissolved, and succeeded by family parties, collected for the more rational entertainments of conversation, dancing, music, and chess. Taverns and beer-houses are much less frequented than formerly, and drunkenness is rarely seen in genteel life. The tea table, in an evening, has now become the place of resort of both sexes, and the midnight serenade has taken place of the midnight revels of the young gentlemen of former years.

In doing justice to the temperance of the modern citizens of Philadelphia, I am sorry to admit, there is still a good deal of secret drinking among them. Physicians, who detect it by the diseases it produces, often lament the inefficacy of their remedies to remove them. In addition to intemperance from spiritous liquors, a new species of intoxication from opium has found its way into our city. I have known death, in one instance, induced by it.

The following circumstances have had a favourable influence upon the health of the present inhabitants of Philadelphia.

The improvements in the construction of modern houses, so as to render them cooler in summer, and warmer in winter.

The less frequent practice of sitting on porches, exposed to the dew, in summer evenings.

The universal use of stoves in places of public worship.

The abolition of the custom of obliging lying-in women to sit up for company.

The partial use of Schuylkill or hydrant water, for culinary and other purposes.

The enjoyment of pure air, in country seats, in the neighbourhood of the city. They not only preserve from sickness during the summer and autumn, but they render families less liable to diseases during the other seasons of the year.

And, lastly, the frequent use of private, and public warm and cold baths. For the establishment of the latter, the citizens of Philadelphia are indebted to Mr. Joseph Simons.

The following circumstances have an unfavourable influence upon the health of our citizens.

Ice creams taken in excess, or upon an empty stomach.

The continuance of the practice of attending funerals, under all the circumstances that were mentioned in describing the customs which prevailed in Philadelphia, between the years 1760 and 1766.