I shall briefly illustrate, by the recital of three cases, the good effects of bleeding, in removing pain, and the preternatural slowness and weakness of the pulse, when produced by the use of that remedy.
In the month of June of 1795, I visited Dr. Say in a malignant fever, attended with pleuritic symptoms, in consultation with Dr. Physick. An acute pain in his head followed six successive bleedings. After a seventh bleeding, he had no pain. His fever soon afterwards left him. In thus persevering in the use of a remedy, which, for several days, appeared to do harm, we were guided wholly by the state of his pulse, which uniformly indicated, by its force, the necessity of more bleeding.
In the autumn of 1794, I was sent for to visit Samuel Bradford, a young man of about 20 years of age, son of Mr. Thomas Bradford, who was ill with the reigning malignant epidemic. His pulse was at 80. I drew about 12 ounces of blood from him. Immediately after his arm was tied up, his pulse fell to 60 strokes in a minute. I bled him a second time, but more plentifully than before, and thereby, in a few minutes, brought his pulse back again to 80 strokes in a minute. A third bleeding the next day, aided by the usual purging physic, cured him in a few days.
In the month of March, 1795, Dr. Physick requested me to visit, with him, Mrs. Fries, the wife of Mr. John Fries, in a malignant fever. He had bled her four times. After the fourth bleeding, her pulse suddenly fell, so as scarcely to be perceptible. I found her hands and feet cold, and her countenance ghastly, as if she were in the last moments of life. In this alarming situation, I suggested nothing to Dr. Physick but to follow his judgment, for I knew that he was master of that law of the animal economy which resolved all her symptoms into an oppressed state of the system. The doctor decided in a moment in favour of more bleeding. During the flowing of the blood, the pulse rose. At the end of three, ten, and seventeen hours it fell, and rose again by three successive bleedings, in all of which she lost about thirty ounces of sizy blood. So great was the vigour acquired by the pulse, a few days after the paroxysms of depression, which have been described, were relieved, that it required seven more bleedings to subdue it. I wish the history of these two cases to be carefully attended to by the reader. I have been thus minute in the detail of them, chiefly because I have heard of practitioners who have lost patients by attempting to raise a pulse that had been depressed by bleeding, in a malignant fever, by means of cordial medicines, instead of the repeated use of the lancet. The practice is strictly rational; for, in proportion as the blood-vessels are weakened by pressure, the quantity of blood to be moved should be proportioned to the diminution of their strength.
This depressed state of the pulse, whether induced by a paroxysm of fever, or by blood-letting, is sometimes attended with a strong pulsation of the arteries in the bowels and head.
I have mentioned, among the apparent bad effects of bleeding, that it sometimes changes a soft into a tense pulse. Of this I saw a remarkable instance in Captain John Barry, in the autumn of 1795. After the loss of 130 ounces of blood in a malignant yellow fever, his pulse became so soft as to indicate no more bleeding. In this situation he remained for three days, but without mending as rapidly as I expected from the state of his pulse. On the fourth day he had a hæmorrhage from his bowels, from which he lost above a pint of blood. His pulse now suddenly became tense, and continued so for two or three days. I ascribed this change in his pulse to the vessels of the bowels, which had been oppressed by congestion, being so much relieved by the hæmorrhage, as to resume an inflammatory action. I have observed a similar change to take place in the pulse, after a third bleeding, in a case of hæmorrhoidal fever, which came under my notice in the month of January, 1803. It is thus we see the blood-vessels, in a common phlegmon, travel back again, from a tendency to mortification, to the red colour and pain of common inflammation.
From a review of the commotions excited in the system by bleeding, a reason may be given why the physicians, who do not bleed in the depressed state of the pulse, have so few patients in what they call malignant fevers, compared with those who use a contrary practice. The disease, in such cases, being locked up, is not permitted to unfold its true character; and hence patients are said to die of apoplexy, lethargy, cholera, dysentery, or nervous fever, who, under a different treatment, would have exhibited all the marks of an ordinary malignant fever.
In obviating the objections to blood-letting from its apparent evils, I have said nothing of the apparent bad effects of other remedies. A nausea is often rendered worse by an emetic, and pains in the bowels are increased by a purge. But these remedies notwithstanding maintain, and justly too, a high character among physicians.
19. Bleeding has been accused of bringing on a nervous, or the chronic state of fever. The use of this remedy, in a degree so moderate as to obviate the putrid or gangrenous state of fever only, may induce the chronic state of fever; for it is the effect, in this case, of the remains of inflammatory diathesis in the blood-vessels; but when blood is drawn proportioned to the morbid action in the system, it is impossible for a chronic fever to be produced by it. Even the excessive use of blood-letting, however injurious it may be in other respects, cannot produce a chronic fever, for it destroys morbid action altogether in the blood-vessels.