letter I received from Dr. Davidson, dated November 4th, 1794. "Being

ordered (says the doctor) up to Barbadoes, last November, upon service, I found that the troops had suffered considerably by that formidable scourge, the yellow fever. The season had been remarkably dry. It was observed, a rainy season contributed to make the season healthier, excepting at Constitution-Hill, where the sixth regiment was stationed, and where a heavy shower of rain seldom failed to bring back the fever, after it had ceased for some time. I found the barrack, where this regiment was, surrounded by a pond of brackish water, which, being but imperfectly drained by the continuance of the drought, the surface was covered with a green scum, which prevented the exhalation of marshy putrefaction. After a heavy shower of rain, this scum was broken, and the miasmata evolved, and acted with double force, according to the time of their secretion."

[35] Clarke on the Diseases of Long Voyages to Hot Climates, p. 116.

[36] Diseases of Minorca, p. 8.

4. It is completely destroyed by frost. As neither rains nor frosts act in sick rooms, nor affect the bodies of sick people, they must annihilate the disease by acting exclusively upon the atmosphere. Very different in their nature are the small-pox and measles, which are propagated by specific contagion. They do not wait for the suns of July or August, nor do they require an impure atmosphere, or an exciting cause, to give them activity. They spread in the winter and spring, as well as in the summer and autumnal months: wet and dry weather do not arrest their progress, and frost (so fatal to the yellow fever), by rendering it necessary to exclude cold air from sick rooms, increases the force of their contagion, and thereby propagates them more certainly through a country.

5. It is likewise destroyed, by intense heat, and high winds. The latter, we are sure, like heavy rains and frost, do not produce that salutary effect by acting upon the bodies, or in the rooms of sick people.

It is worthy of notice, that while the activity of miasmata is destroyed by cold, when it descends to frost; by heat, when it is so intense as to dry up all the sources of putrid exhalation; by heavy rains, when they are succeeded by cool weather; and by high winds, when they are not succeeded by warm weather; they are rendered more active by cool, warm, and damp weather, and by light winds. The influence of damp weather, in retaining and propagating miasmata, will be readily admitted, by recollecting how much more easily hounds track their prey, and how much more extensively odours of all kinds pervade the atmosphere, when it is charged with moisture, than in dry weather.

It has been asked, if putrid matters produce malignant bilious fevers in our cities, why do they not produce them in Lisbon, and in several other of the filthiest cities in the south of Europe? To this I answer, that filth and dirt are two distinct things. The streets of a city may be very _dirty_, that is, covered with mud composed of inoffensive clay, sand, or lime, and, at the same time, be perfectly free from those _filthy_ vegetable and animal matters which, by putrefaction, contaminate the air. But, admitting the streets of those cities to abound with the filthy matters that produce pestilential diseases in other countries, it is possible the exhalations from them may be so _constant_, and so _powerful_, in their impressions upon the bodies of the inhabitants, as to produce, from habit, no morbid effects, or but feeble diseases, as was remarked formerly, is the case in the natives and old settlers in the East and West-Indies. But if this explanation be not satisfactory, it may be resolved into a partial absence of an inflammatory constitution of the air, which, I shall say presently, must concur in producing pestilential diseases. Such deviations from uniformity in the works of Nature are universal. In the present instances, they no more invalidate the general proposition of malignant fevers being every where of domestic origin, than the exemption of Ireland from venomous reptiles, proves they are not generated in other countries, or that the pleurisy and rheumatism are not the effects of the alternate action of cold and heat upon the body, because hundreds, who have been exposed to them under equal circumstances, have not been affected by those diseases. There may be other parts of the world in which putrid matters do not produce bilious malignant diseases from the causes that have been mentioned, or from some unknown cause, but I am safe in repeating, there never was a bilious epidemic yellow fever that could not be traced to putrid exhalation.

It has been asked, if the yellow fever be not imported, why does it make its first appearance among sailors, and near the docks and wharves of our cities? I answer, this is far from being true. The disease has as often appeared first at a distance from the shores of our cities as near them, but, from its connection with a ship not being discovered, it has been called by another name. But where the first cases of it occur in sailors, I believe the seeds of it are always previously received by them from our filthy docks and wharves, or from the foul air which is discharged with the cargoes of the ships in which they have arrived, which seeds are readily excited in them by hard labour, or intemperance, so as to produce the disease. That this is the case, is further evident from its appearing in them, only in those months in which the bilious fever prevails in our cities.

It has been asked further, why were not these bilious malignant fevers more common before the years 1791, 1792, and 1793? To this I answer, by repeating what was mentioned in another place[37], that our climate has been gradually undergoing a change. The summers are more alternated by hot and cool, and wet and dry weather, than in former years. The winters are likewise less uniformly cold. Grass is two or three weeks later in the spring in affording pasture to cattle than it was within the memory of many thousand people. Above all, the summer has encroached upon the autumn, and hence the frequent accounts we read in our newspapers of trees blossoming, of full grown strawberries and raspberries being gathered, and of cherries and apples, of a considerable size, being seen, in the months of October and November, in all the middle states. By means of this protraction of the heat of summer, more time is given for the generation of putrid exhalations, and possibly for their greater concentration and activity in producing malignant bilious diseases.

[37] Account of the Climate of Pennsylvania, vol i.

It has been asked again, why do not the putrid matters which produce the yellow fever in some years produce it _every_ year? This question might be answered by asking two others. 1st. Why, if the yellow fever be derived from the We st-Indies, was it not imported every year before 1791, and before the existence, or during the feeble and partial operation of quarantine laws? It is no answer to this question to say, that a war is necessary to generate the disease in the islands, for it exists in some of them at all times, and the seasons of its prevalence in our cities have, in many instances, had no connection with war, nor with the presence of European armies in those and in other sickly parts of the globe. During the seven years revolutionary war it was unknown as an epidemic in the United States, and yet sailors arrived in all our cities daily from sickly islands, in small and crowded vessels, and sometimes covered with the rags they had worn in the yellow fever, in British hospitals and jails. I ask, 2dly, why does the dysentery (which is certainly a domestic disease) rise up in our country, and spread sickness and death through whole families and villages, and disappear from the same places for fifteen or twenty years afterwards?

The want of uniformity in the exhalations of our country in producing those diseases depends upon their being combined with more or less heat or moisture; upon the surface of the earth being completely dry, or completely covered with water[38]; upon different currents of winds, or the total absence of wind; upon the disproportion of the temperature of the air in the day and night; upon the quantity of dew; upon the early or late appearance of warm or cold weather; and upon the predisposition of the body to disease, derived from the quality of the aliments of the season. A similar want of uniformity in the annual operations of our climate appears in the size and quality of grain, fruits, and vegetables of all kinds.

[38] In the Account of the Yellow Fever of 1793, the different and opposite effects of a dry and rainy season in producing bilious fevers are mentioned from Dr. Dazilles. In the autumn of 1804, I have elsewhere remarked, after a summer in which there had fallen an unusual quantity of rain, the bilious fevers appeared chiefly on the high grounds in Pennsylvania, which were in a state of moisture, while scarcely a case of them appeared in the neighbourhood of marshes, or low grounds, owing to their being so completely covered with water, as to be incapable of generating, by putrefaction, the miasmata which produce those forms of disease.

But the greater violence and mortality of our bilious fevers, than in former years, must be sought for chiefly in an inflammatory or malignant constitution of the atmosphere, the effects of which have been no less obvious upon the small-pox, measles, and the intercurrent fevers of Dr. Sydenham, than they are upon the summer and autumnal disease that has been mentioned.

This malignant state of the air has been noticed, under different names, by all the writers upon epidemics, from Hippocrates down to the present day. It was ascribed, by the venerable father of physic, to a "divine something" in the atmosphere. Dr. Sydenham, whose works abound with references to it, supposes it to be derived from a mineral exhalation from the bowels of the earth. From numerous other testimonies of a belief in the influence of the insensible qualities of the air, altering the character of epidemics, I shall select the following:

"It is certain (says Dr. Mosely) that diseases undergo changes and revolutions. Some continue for a succession of years, and vanish when they have exhausted the temporary, but secret cause which produced them. Others have appeared and disappeared suddenly; and others have their periodical returns."

The doctor ascribes a malignant fever among the dogs in Jamaica (improperly called, from one of its symptoms, hydrophobia), to a change in the atmosphere, in the year 1783. It was said to have been imported, but experience, he says, proved the fact to be otherwise[39].

[39] Treatise upon Tropical Diseases, p. 43, 44.

"This latent malignity in the atmosphere (says Baron Vansweiten) is known only by its effects, and cannot easily be reduced to any known species of acrimony." In another place he says, "It seems certain that this unknown matter disposes all the humours to a sudden and bad putrefaction[40]."

[40] Commentaries on Boerhaave's Aphorisms, vol. v. p. 226, 230.

Dr. John Stedman has related many facts, in his Essay upon Insalutary Constitutions of the Air, which prove, that diseases are influenced by a quality in it, which, he says, "is productive of corruption," but which has hitherto eluded the researches of physicians[41].

[41] Page 135.

Mr. Lempriere, after mentioning the unusual mortality occasioned by the yellow fever, within the last five or six years, in the island of Jamaica, ascribes it wholly "to that particular constitution of atmosphere upon which the existence of epidemics, at one period rather than another, depend[42]."

[42] Vol. ii. p. 31.

Not only diseases bear testimony to a change in the atmosphere, but the whole vegetable and animal creation concur in it, proofs of which were mentioned in another place. Three things are remarkable with respect to this inflammatory constitution of the air.

1. It is sometimes of a local nature, and influences the diseases of a city, or country, while adjoining cities and countries are exempted from it.

2. It much oftener pervades a great extent of country. This was evident in the years 1793 and 1794, in the United States. During the same years, the yellow fever prevailed in most of the West-India islands. Many of the epidemics mentioned by Dr. Sims, in the first volume of the Medical Memoirs, affected, in the same years, the most remote parts of the continent of Europe. Even the ocean partakes of a morbid constitution of its atmosphere, and diseases at sea sympathise in violence with those of the land, at an immense distance from each other. This appears in a letter from a surgeon, on board a British ship of war, to Mr. Gooch, published in the third volume of his Medical and Surgical Observations.

3. The predisposing state of the atmosphere to induce malignant diseases continues for several years, under all the circumstances of wet and dry, and of hot and cold weather. This will appear, from attending to the accounts which have been given of the weather, in all the years in which the yellow fever has prevailed in Philadelphia since 1792[43]. The remark is confirmed by all the records of malignant epidemics.

[43] Vol. iii. and iv.

It is to no purpose to say, the presence of the peculiar matter which constitutes an inflammatory or malignant state of the air has not been detected by any chemical agents. The same thing has been justly said of the exhalations which produce the bilious intermitting, remitting, and yellow fever. No experiment that has yet been made, has discovered their presence in the air. The eudiometer has been used in vain for this purpose. In one experiment made by Dr. Gattani, the air from a marsh at the mouth of the river Vateline was found to be apparently purer by two degrees than the air on a neighbouring mountain, which was 2880 feet higher than the sea. The inhabitants of the mountain were notwithstanding healthy, while those who lived in the neighbourhood of the marsh were annually afflicted with bilious and intermitting fevers[44]. The contagions of the small-pox and measles consist of matter, and yet who has ever discovered this matter in the air? We infer the existence of those remote causes of diseases in the atmosphere only from their effects. Of the existence of putrid exhalations in it, there are other evidences besides bilious and yellow fevers. They are sometimes the objects of the sense of smelling. We see them in the pale or sallow complexions of the inhabitants of the countries which generate them, and we observe them occasionally in the diseases of several domestic animals. The most frequent of these diseases are inflammation, tubercles, and ulcers in the liver. Dr. Cleghorn describes a diseased state of that viscus in cattle, in an unhealthy part of the island of Minorca. Dr. Grainger takes notice of several morbid appearances in the livers of domestic animals in Holland, in the year 1743. But the United States have furnished facts to illustrate the truth of this remark. Mr. James Wardrobe, near Richmond, in Virginia, informed me, that in August, 1794, at a time when bilious fevers were prevalent in his neighbourhood, his cattle were seized with a disease, which, I said formerly, is known by the name of the yellow water, and which appears to be a true yellow fever. They were attacked with a staggering. Their eyes were muddy, or ferocious. A costiveness attended in all cases. It killed in two days. Fifty-two of his cattle perished by it. Upon opening the bodies of several of them, he found the liver swelled and ulcerated. The blood was dissolved in the veins. In the bladder of one of them, he found thirteen pints of blood and water. Similar appearances were observed in the livers of sheep in the neighbourhood of Cadiz, in the year 1799, during the prevalence of the yellow fever in that city. They were considered as such unequivocal marks of an unwholesome atmosphere among the ancients, that they examined the livers of domestic animals, in order to determine on the healthy or unhealthy situation of the spot on which they wished to live.

[44] Alibert's Dissertation sur les Fievres Pernicieuses et Attaxiques Intermittentes, p. 185.

The advocates for the yellow fever being a specific disease, and propagated only by contagion, will gain nothing by denying an inflammatory constitution of the atmosphere (the cause of which is unknown to us) to be necessary to raise common remittents to that grade in which they become malignant yellow fevers; for they are obliged to have recourse to an unknown quality in the air, every time they are called upon to account for the disease prevailing chiefly in our cities, and not spreading when it is carried from them into the country. The same reference to an occult quality in the air is had by all the writers upon the plague, in accounting for its immediate and total extinction, when it is carried into a foreign port.

In speaking of the influence of an inflammatory constitution of the atmosphere in raising common bilious, to malignant yellow fevers, I wish not to have it supposed, that its concurrence is necessary to produce sporadic cases of that, or any other malignant disease. Strong exciting causes, combined with highly volatilized and active miasmata, I believe, will produce a yellow fever at any time. I have seen one or more such cases almost every year since I settled in Philadelphia, and particularly when my business was confined chiefly to that class of people who live near the wharves, and in the suburbs, and who are still the first, and frequently the only victims of the yellow fever.

It has been said, exultingly, that the opinion of the importation of the yellow fever is of great antiquity in our country, and that it has lately been admitted by the most respectable physicians in Britain and France, and sanctioned by the laws of several of the governments in Europe. Had antiquity, numbers, rank, and power been just arguments in favour of existing opinions, a thousand truths would have perished in their birth, which have diffused light and happiness over every part of our globe. In favour of the ancient and general belief of the importation of the yellow fever, there are several obvious reasons. The idea is produced by a single act of the mind. It requires neither comparison nor reasoning to adopt it, and therefore accords with the natural indolence of man. It, moreover, flatters his avarice and pride, by throwing the origin of a mortal disease from his property and country. The principle of thus referring the origin of the evils of life from ourselves to others is universal. It began in paradise, and has ever since been an essential feature in the character of our species. It has constantly led individuals and nations to consider loathsome and dangerous diseases as of foreign extraction. The venereal disease and the leprosy have no native country, if we believe all the authors who have written upon them. Prosper Alpinus derives the plagues of Cairo from Syria, and the physicians of Alexandria import them from Smyrna or Constantinople. The yellow fever is said to have been first brought from Siam (where there are proofs it never existed) to the West-Indies, whence it is believed to be imported into the cities of the United States. From them, Frenchmen and Spaniards say it has been re-shipped, directly or indirectly, to St. Domingo, Havanna, Malaga, Cadiz, and other parts of the world. Weak and absurd credulity! the causes of the ferocious and mortal disease which we thus thrust from our respective ports, like the sin of Cain, "lie exclusively at our own doors."

Lastly, it has been asserted, if we admit the yellow fever to be an indigenous disease of our cities, we shall destroy their commerce, and the value of property in them, by disseminating a belief, that the cause of our disease is fixed in our climate, and that it is out of the power of human means to remove it. The reverse of this supposition is true. If it be an imported disease, our case is without a remedy; for if, with all the advantages of quarantine laws enforced by severe penalties, and executed in the most despotic manner, the disease has existed annually, in most of our cities, as an epidemic, or in sporadic cases, ever since the year 1791, it will be in vain to expect, from similar measures, a future exemption from it. Nothing but a belief in its domestic origin, and the adoption of means founded upon that belief, can restore the character of our climate, and save our commercial cities from destruction. Those means are cheap, practicable, and certain. They have succeeded, as I shall say presently, in other countries.

From the account that has been given of the different ways in which this disease is communicated from one person to another, and from the facts which establish its propagation exclusively through the medium of the atmosphere, when it becomes epidemic, we may explain several things which belong to its history, that are inexplicable upon the principle of its specific contagion.

1. We learn the reason why, in some instances, the fever does not spread from a person who sickens or dies at sea, who had carried the seeds of it in his body from a sickly shore. It is because no febrile miasmata exist in the bodies of the rest of the crew to be excited into action by any peculiar smell from the disease, or by fear or fatigue, and because no morbid excretions are generated by the person who dies. The fever which prevailed on board the Nottingham East-Indiaman, in the year 1766, affected those forty men only, who had slept on shore on the island of Joanna twenty days before. Had the whole crew been on shore, the disease would probably have affected them all, and been ascribed to contagion generated by the first persons who were confined by it[45]. A Danish ship, in the year 1768, sent twelve of her crew on shore for water. They were all seized after their return to the ship with malignant fever, and died without infecting any person on board, and from the same causes which preserved the crew of the Nottingham Indiaman[46].

[45] Observations on the Bilious Fevers usual in voyages to the East-Indies, by James Badinach, M. D. Medical Observations and Inquiries, vol. iv.

[46] Clarke on the Diseases of Long Voyages to Hot Climates, p. 123, 125.

2. We learn the reason why the disease sometimes spreads through a whole ship's crew, apparently from one or more affected persons. It is either because they have been confined to small and close berths by bad weather, or because the fever has been protracted to a typhus or chronic state, or because the bodies of the whole crew are impregnated with morbid miasmata, and thus predisposed to have the disease excited in the manner that has been mentioned. In the last way it was excited in most of the crew of the United States frigate, in the Delaware, opposite to the city of Philadelphia, in the year 1797. It appears to have spread, from a similar cause, from a few sailors, on board the Grenville Indiaman, after touching at Batavia. The whole crew had been predisposed to the disease by inhaling the noxious air of that island.

The same reasons account for the fever expiring in a healthy village or country; also for its spreading when carried to those towns which are seated upon creeks or rivers, and in the neighbourhood of marsh exhalations. It has uniformly perished in the high and healthy village of Germantown, when carried from Philadelphia, and has three times appeared to be contagious near the muddy shores of the creeks which flow through Wilmington and Chester.

3. From the facts that have been mentioned, we are taught to disbelieve the possibility of the disease being imported in the masts and sails of a ship, by a contagious matter secreted by a sailor who may have sickened or died on board her, on a passage from a West-India island. The death in most of the cases supposed to be imported, in this way, occurs within a few days after the ship leaves her West-India port, or within a few days after her arrival. In the former case, the disease is derived from West-India miasmata; in the latter, it is derived, as was before remarked, either from the foul air of the hold of the ship, or of the dock or wharf to which the ship is moored.

Many other facts might be adduced to show the yellow fever not to be an imported disease. It has often prevailed among the Indians remote from the sea coast, and many hundred cases of it have occurred, since the year 1793, on the inland waters of the United States, from the Hudson and Susquehannah, to the rivers of the Mississippi. In South-America, Baron Humboldt assured me, it is every where believed to be an endemic of that country.

These simple and connected facts, in which all the physicians in the United States who derive the yellow fever from domestic causes have agreed, will receive fresh support by comparing them with the different and contrary opinions of the physicians who maintain its importation. Some of them have asserted it to be a specific disease, and derived it from the East and West-Indies; others derive it from Beulam, on the coast of Africa; a third sect have called it a ship fever; a fourth have ascribed it to a mixture of imported contagion with the foul air of our cities; while a fifth, who believed it to be imported in 1793, have supposed it to be the offspring of a contagion left by the disease of that year, revived by the heat of our summers, and disseminated, ever since, through the different cities of our country. The number of these opinions, clearly proves, that no one of them is tenable.

A belief in the non-contagion of the yellow fever, or of its being incommunicable except in one of the five ways that have been mentioned, is calculated to produce the following good effects:

1. It will deliver the states which have sea-ports from four-fifths of the expences of their present quarantine laws and lazarettoes. A very small apparatus, in laws and officers, would be sufficient to prevent the landing of persons affected by the ship fever in our cities, and the more dangerous practice, of ships pouring streams of pestilential air, from their holds, upon the citizens who live near our docks and wharves.

2. It will deliver our merchants from the losses incurred by the delays of their ships, by long and unnecessary quarantines. It will, moreover, tend to procure the immediate admission of our ships into foreign ports, by removing that belief in the contagious nature of the yellow fever, which originated in our country, and which has been spread, by the public acts of our legislatures and boards of health, throughout the globe.

3. It will deliver our citizens from the danger to which they are exposed, by spending the time of the quarantine, on board of vessels in the neighbourhood of the marshes, which form the shores of the rivers or coasts of quarantine roads. This danger is much increased by idleness, and by the vexation which is excited, by sailors and passengers being detained, unnecessarily, fifteen or twenty days from their business and friends.

4. It will lead us to a speedy removal of all the excretions, and a constant ventilation of the rooms of patients in the yellow fever, and thereby to prevent the accumulation, and further putrefaction of those exhalations which may reproduce it.

5. It is calculated to prevent the desertion of patients in the yellow fever, by their friends and families, and to produce caution in them to prevent the excitement of the disease in their own bodies, by means of low diet and gentle physic, proportioned to the impurity of the air, and to the anxiety and fatigue to which they are exposed in attending the sick.

6. It will put an end to the cruel practice of quieting the groundless fears of a whole neighbourhood, by removing the poor who are affected by the fever, from their houses, and conveying them, half dead with disease and terror, to a solitary or crowded hospital, or of nailing a yellow flag upon the doors of others, or of fixing a guard before them, both of which have been practised in Philadelphia, not only without any good effect, but to the great injury of the sick.

7. By deriving the fever from our own climate and atmosphere, we shall be able to foresee its approach in the increased violence of common diseases, in the morbid state of vegetation, in the course of the winds, in the diseases of certain brute animals, and in the increase of common, or the appearance of uncommon insects.

8. A belief in the non-contagion of the yellow fever, and its general prevalence from putrid animal and vegetable matters _only_, is calculated to lead us to drain or cover marshy grounds, and to remove from our cities all the sources of impure air, whether they exist in the holds of ships, in docks, gutters, and common sewers, or in privies, gardens, yards, and cellars, more especially during the existence of the signs of a malignant constitution of the air. A fever, the same in its causes, and similar to it in many of its symptoms, that is, the plague, has been extirpated, by extraordinary degrees of cleanliness, from the cities of Holland, Great-Britain, and several other parts of Europe.

The reader will perceive, from these facts and reasonings, that I have relinquished the opinion published in my account of the yellow fever in the years 1793, 1794, and 1797, respecting its contagious nature. I was misled by Dr. Lining, and several West-India writers, in ascribing a much greater extent to the excreted matters in producing the disease, than I have since discovered to be correct, and by Bianchi, Lind, Clark, and Cleghorn, in admitting even the common bilious fever to be contagious. The reader will perceive, likewise, that I have changed my opinion respecting one of the modes in which the plague is propagated. I once believed, upon the authorities of travellers, physicians, and schools of medicine, that it was a highly contagious disease. I am now satisfied this is not the case; but, from the greater number of people who are depressed and debilitated by poverty and famine, and who live in small and filthy huts[47] in the cities of the east, than in the cities of the United States, I still believe it to be more frequently communicated from an intercourse with sick people by the morbid excretions of the body, than the yellow fever is in our country. For the change of my opinion upon this subject, I am indebted to Dr. Caldwell's and Mr. Webster's publications upon pestilential diseases, and to the travels of Mariti and Sonnini into Syria and Egypt. I reject, of course, with the contagious quality of the plague, the idea of its ever being imported into any country so as to become epidemic, by means of a knife-case, a piece of cotton, or a bale of silks, with the same decision that I do all the improbable and contradictory reports of an epidemic yellow fever being imported in a sailor's jacket, or in the timbers and sails of a ship that had been washed by the salt water, and fanned by the pure air of the ocean, for several weeks, on her passage from the West-Indies to the United States.

[47] M. Savary, in his Travels, says, two hundred persons live in Cairo within a compass that accommodates but thirty persons in Paris.

It gives me pleasure to find this unpopular opinion of the non-contagion of the plague is not a new one. It was held by the Faculty of Medicine in Paris, in the beginning of the eighteenth century, and it has since been defended by Dr. Stoll, of Vienna, Dr. Samoilowitz, of Russia, and several other eminent physicians. Dr. Herberden has lately called in question the truth of all the stories that are upon record of the plague having been imported into England in the last century, and the researches of Sir Robert Wilson of the British army, and of Assellini, and several other French physicians, have produced the most satisfactory proofs of its not being a contagious disease in its native country. A discovery more pregnant with blessings to mankind has seldom been made. Pyramids of error, the works of successive ages and nations, must fall before it, and rivers of tears must be dried up by it. It is impossible fully to appreciate the immense benefits which await this mighty achievement of our science upon the affairs of the globe. Large cities shall no longer be the hot-beds of disease and death. Marshy grounds, teeming with pestilential exhalations, shall become the healthy abodes of men. A powerful source of repulsion between nations shall be removed, and commerce shall shake off the fetters which have been imposed upon it by expensive and vexatious quarantines. A red or a yellow eye shall no longer be the signal to desert a friend or a brother to perish alone in a garret or a barn, nor to expel the stranger from our houses, to seek an asylum in a public hospital, to avoid dying in the street. The number of diseases shall be lessened, and the most mortal of them shall be struck out of the list of human evils. To accelerate these events, it is incumbent upon the physicians of the United States to second the discoveries of their European brethren. It becomes them constantly to recollect, that we are the centinels of the health and lives of our fellow-citizens, and that there is a grade of benevolence in our profession much higher than that which arises from the cure of diseases. It consists in exterminating their causes.

A DEFENCE

OF

_BLOOD-LETTING_,

AS A

REMEDY FOR CERTAIN DISEASES.

Blood-letting, as a remedy for fevers, and certain other diseases, having lately been the subject of much discussion, and many objections having been made to it, which appear to be founded in error and fear, I have considered that a defence of it, by removing those objections, might render it more generally useful, in every part of the United States.

I shall begin this subject by remarking, that blood-letting is indicated, in fevers of great morbid excitement,

1. By the sudden suppression or diminution of the natural discharges by the pores, bowels, and kidneys, whereby a plethora is induced in the system.

2. By the habits of the persons who are most subject to such fevers.

3. By the theory of fever. I have attempted to prove that the higher grades of fever depend upon morbid and excessive action in the blood-vessels. It is connected, of course, with preternatural sensibility in their muscular fibres. The blood is the most powerful irritant which acts upon them. By abstracting a part of it, we lessen the principal cause of the fever. The effect of blood-letting is as immediate and natural in removing fever, as the abstraction of a particle of sand is, to cure an inflammation of the eye, when it arises from that cause.

4. By the symptoms of the first stage of violent fevers, such as a sleepiness and an oppressed pulse, or by delirium, with a throbbing pulse, and great pains in every part of the body.

5. By the rupture of the blood-vessels, which takes place from the quantity or impetus of the blood in fevers of great morbid action. Let no one call bleeding a cruel or unnatural remedy. It is one of the specifics of nature; but in the use of it she seldom affords much relief. She frequently pours the stimulating and oppressing mass of blood into the lungs and brain; and when she finds an outlet for it through the nose, it is discharged either in such a deficient or excessive quantity, as to be useless or hurtful. By artificial blood-letting, we can choose the _time_ and _place_ of drawing blood, and we may regulate its quantity by the degrees of action in the blood-vessels. The disposition of nature to cure violent morbid action by depletion, is further manifested by her substituting, in the room of blood-letting, large, but less safe and less beneficial, evacuations from the stomach and bowels.

6. By the relief which is obtained in fevers of violent action by remedies of less efficacy (to be mentioned hereafter), which act indirectly in reducing the force of the sanguiferous system.

7. By the immense advantages which have attended the use of blood-letting in violent fevers, when used at a proper time, and in a quantity suited to the force of the disease. I shall briefly enumerate these advantages.

1. It frequently strangles a fever, when used in its forming state, and thereby saves much pain, time, and expence to a patient.

2. It imparts strength to the body, by removing the depression which is induced by the remote cause of the fever. It moreover obviates a disposition to faint, which arises from this state of the system.

3. It reduces the uncommon frequency of the pulse. The loss of ten ounces of blood reduced Miss Sally Eyre's pulse from 176 strokes to 140, in a few minutes, in the fever of the year 1794. Dr. Gordon mentions many similar instances of its reducing the frequency of the pulse, in the puerperile fever.

4. It renders the pulse more frequent when it is preternaturally slow.

5. It checks the nausea and vomiting, which attend the malignant state of fever. Of this I saw many instances in the year 1794. Dr. Poissonnier Desperrieres confirms this remark, in his Account of the Fevers of St. Domingo; and adds further, that it prevents, when sufficiently copious, the troublesome vomiting which often occurs on the fifth day of the yellow fever[48]. It has the same effect in preventing the diarrh[oe]a in the measles.

[48] Traite des Fievres de l'Isle de St. Domingue, vol. ii. p. 76.

6. It renders the bowels, when costive, more easily moved by purging physic.

7. It renders the action of mercury more speedy and more certain, in exciting a salivation.

8. It disposes the body to sweat spontaneously, or renders diluting and diaphoretic medicines more effectual for that purpose.

9. It _suddenly_ removes a dryness, and _gradually_ a blackness, from the tongue. Of the former effect of bleeding, I saw two instances, and of the latter, one, during the autumn of 1794.

10. It removes or lessens pain in every part of the body, and more especially in the head.

11. It removes or lessens the burning heat of the skin, and the burning heat in the stomach, so common and so distressing in the yellow fever.

12. It removes a constant chilliness, which sometimes continues for several days, and which will neither yield to cordial drinks, nor warm bed-clothes.

13. It checks such sweats as are profuse without affording relief, and renders such as are partial and moderate, universal and salutary.

14. It sometimes checks a diarrh[oe]a and tenesmus, after astringent medicines have been given to no purpose. This has often been observed in the measles.

15. It suddenly cures the intolerance of light which accompanies many of the inflammatory states of fever.

16. It removes coma. Mr. Henry Clymer was suddenly relieved of this alarming symptom, in the fever of 1794, by the loss of twelve ounces of blood.

17. It induces sleep. This effect of bleeding is so uniform, that it obtained, in the year 1794, the name of an anodyne in several families. Sleep sometimes stole upon the patient while the blood was flowing.

18. It prevents effusions of serum and blood. Hæmorrhages seldom occur, where bleeding has been sufficiently copious.

19. It belongs to this remedy to prevent the chronic diseases of cough, consumption, jaundice, abscess in the liver, and all the different states of dropsy which so often follow autumnal fevers.

My amiable friend, Mrs. Lenox, furnished an exception to this remark, in the year 1794. After having been cured of the yellow fever by seven bleedings, she was affected, in consequence of taking a ride, with a slight return of fever, accompanied by an acute pain in the head, and some of the symptoms of a dropsy of the brain. As her pulse was tense and quick, I advised repeated bleedings to remove it. This prescription, for reasons which it is unnecessary to relate, was not followed at the time, or in the manner, in which it was recommended. The pain, in the mean time, became more alarming. In this situation, two physicians were proposed by her friends to consult with me. I objected to them both, because I knew their principles and modes of practice to be contrary to mine, and that they were proposed only with a view of wresting the lancet from my hand. From this desire of avoiding a controversy with my brethren, where conviction was impossible on either side, as well as to obviate all cause of complaint by my patient's friends, I offered to take my leave of her, and to resign her wholly to the care of the two gentlemen who were proposed to attend her with me. To this she objected in a decided manner. But that I might not be suspected of an undue reliance upon my own judgment, I proposed to call upon Dr. Griffitts or Dr. Physick to assist me in my attendance upon her. Both these physicians had renounced the prejudices of the schools in which they had been educated, and had conformed their principles and practice to the present improving state of medical science. My patient preferred Dr. Griffitts, who, in his first visit to her, as soon as he felt her pulse, proposed more bleeding. The operation was performed by the doctor himself, and repeated daily for five days afterwards. From an apprehension that the disease was so fixed as to require some aid to blood-letting, we gave her calomel in such large doses as to excite a salivation. By the use of these remedies she recovered slowly, but so perfectly as to enjoy her usual health.

20. Bleeding prevents the termination of malignant, in the gangrenous state of fever. This effect of blood-letting will enable us to understand some things in the writings of Dr. Morton and Dr. Sydenham, which at first sight appear to be unintelligible. Dr. Morton describes what he calls a putrid fever, which was epidemic and fatal, in the year 1678. Dr. Sydenham, who practised in London at the same time, takes no notice of this fever. The reason of his silence is obvious. By copious bleeding, he prevented the fever of that year from running on to the gangrenous state, while Dr. Morton, by neglecting to bleed, created the supposed putrid fevers which he has described.

It has been common to charge the friends of blood-letting with _temerity_ in their practice. From this view which has been given of it, it appears, that it would be more proper to ascribe _timidity_ to them, for they bleed to prevent the offensive and distressing consequences of neglecting it, which have been mentioned.

21. It cures, without permitting a fever to put on those alarming symptoms, which excite constant apprehensions of danger and death, in the minds of patients and their friends. It is because these alarming symptoms are prevented, by bleeding, that patients are sometimes unwilling to believe they have been cured by it, of a malignant fever. Thus, the Syrian leper of old, viewed the water of Jordan as too simple and too common to cure a formidable disease, without recollecting that the remedies for the greatest evils of life are all simple, and within the power of the greatest part of mankind.

22. It prepares the way for the successful use of the bark and other tonic remedies, by destroying, or so far weakening, a morbid action in the blood-vessels, that a medicine of a moderate stimulus afterwards exceeds it in force, and thereby restores equable and healthy action to the system.

23. Bleeding prevents relapses. It, moreover, prevents that predisposition to the intermitting and pleuritic states of fever, which so frequently attack persons in the spring, who have had the bilious remitting fever in the preceding autumn.

But great and numerous as the advantages of blood-letting are in fevers, there have been many objections to it. I shall briefly enumerate, and endeavour to refute the errors upon this subject.

Blood-letting has been forbidden by physicians, by the following circumstances, and states of the system.

1. By warm weather. Galen bled in a plague, and Aræteus in a bilious fever, in a warm climate. Dr. Sydenham and Dr. Hillary inform us, that the most inflammatory fevers occur in, and succeed hot weather. Dr. Cleghorn prescribed it copiously in the warm months, in Minorca. Dr. Mosely cured the yellow fever by this remedy, in Jamaica. Dr. Broadbelt, and Dr. Weston, in the same island, have lately adopted his successful practice. Dr. Desportes speaks in the highest terms of it in all the inflammatory diseases of St. Domingo. He complains of the neglect of it in the rheumatism, in consequence of which, he says, the disease produces abscesses in the lungs[49]. I have never, in any year of my practice, been restrained by the heat of summer in the use of the lancet, where the pulse has indicated it to be necessary, and have always found the same advantages from it, as when I have prescribed it in the winter or spring months.

[49] Page 35.

In thus deciding in favour of bleeding in warm weather, I do not mean to defend its use to the same extent, as to diseases, or to quantity, in the native and long settled inhabitants of hot climates, as in persons who have recently migrated to them, or who live in climates alternately hot and cold.

2. Being born, and having lived in a warm climate. This is so far from being an objection to blood-letting in an inflammatory disease, that it renders it more necessary. I think I have lost several West-India patients from the influence of this error.

3. Great apparent weakness. This, in acute and violent fevers, is always from a depressed state of the system. It resembles, in so many particulars, that weakness which is the effect of the abstraction of stimulus, that it is no wonder they have been confounded by physicians. This sameness of symptoms from opposite states of the system is taken notice of by Hippocrates. He describes convulsions, and particularly a hiccup, as occurring equally from repletion and inanition, which answer to the terms of depression, and debility from action and abstraction. The natural remedy for the former is depletion, and no mode of depleting is so effectual or safe as blood-letting. But the great objection to this remedy is, when a fever of great morbid excitement affects persons of delicate constitutions, and such as have long been subject to debility of the chronic kind. In this state of the system there is the same morbid and preternatural action in the blood-vessels, that there is in persons of robust habits, and the same remedy is necessary to subdue it in both cases. It is sometimes indicated in a larger quantity in weakly than in robust people, by the plethora which is more easily induced in their relaxed and yielding blood-vessels, and by the greater facility with which ruptures and effusions take place in their viscera. Thus it is more necessary to throw overboard a large part of the cargo of an old and leaky vessel in a storm, than of a new and strong one. I know that vomits, purges, sweats, and other evacuating remedies, are preferred to bleeding in weakly constitutions, but I hope to show hereafter, that bleeding is not only more effectual, but more safe in such habits, than any other depleting remedy.

4. Infancy and childhood. This is so far from being an objection to bleeding, that the excitable state of the blood-vessels in those periods of life, renders it peculiarly necessary in their inflammatory diseases. Dr. Sydenham bled children in the hooping cough, and in dentition. I have followed his practice, and bled as freely in the violent states of fever in infancy as in middle life. I bled my eldest daughter when she was but six weeks old, for convulsions brought on by an excessive dose of laudanum given to her by her nurse; and I bled one of my sons twice, before he was two months old, for an acute fever which fell upon his lungs and bowels. In both cases, life appeared to be saved by this remedy.

5. Old age. The increase of appetite in old people, their inability to use sufficient exercise, whereby their blood-vessels become relaxed, plethoric, and excitable, and above all, the translation of the strength of the muscles to the arteries, and of plethora to the veins, all indicate bleeding to be more necessary (in equal circumstances) in old, than in middle aged people. My practice in the diseases of old people has long been regulated by the above facts. I bled Mrs. Fullarton twice in a pleurisy in January, 1804, in the 84th year of her age, and thereby cured her disease. I am not the author of this practice. Botallus left a testimony in favour of it nearly 200 years ago[50], and it has since been confirmed by the experience of Hoffman, and many other physicians. An ignorance of, or inattention to this change in the state of the blood-vessels, in persons in the decline of life, and the neglect of the only remedy indicated by it, is probably the reason why diseases often prove fatal to them, which in early or middle life cured themselves, or yielded to a single dose of physic, or a few ounces of bark.

[50] Magis esse adjuvandos senes, missione sanguinis dum morbus postulat, aut corpus eorum habitus malus est, quam ubi hæc (quod absonum videbitur) juvenibus contingunt. De Cur. per Sang. missionem, cap. 11. § 11.

6. The time of menstruation. The uterus, during this period, is in an inflamed state, and the whole system is plethoric and excitable, and of course disposed to a violent degree of fever, from all the causes which excite it. Bleeding, therefore, is more indicated, in fever of great morbid action, at this time, than at any other. Formerly the natural discharge from the uterus was trusted to, to remove a fever contracted during the time of menstruation; but what relief can the discharge of four or five ounces of blood from the uterus afford, in a fever which requires the loss of 50, or perhaps of 100 ounces to cure it?

7. Pregnancy. The inflammation and distention induced upon the uterus directly, and indirectly upon the whole system by pregnancy, render bleeding, in the acute states of fever, more necessary than at other times. I have elsewhere mentioned the advantages of bleeding pregnant women, in the yellow fever. I did not learn the advantages of the practice in that disease. I bled Mrs. Philler 11 times in seven days, in a pleurisy during her pregnancy, in the month of March, 1783. Mrs. Fiss was bled 13 times in the spring of 1783; and Mrs. Kirby 16 times in the same condition, by my orders, in the winter of 1786, in a similar disease. All these women recovered, and the children they carried during their illness, are at this time alive, and in good health.

8. Fainting after bleeding. This symptom is accidental in many people. No inference can be drawn from it against blood-letting. It often occurs after the first and second bleedings in a fever, but in no subsequent bleeding, though it be repeated a dozen times. Of this I saw several instances, in the yellow fever of 1794. The pulse, during the fainting, is often tense and full.

9. Coldness of the extremities, and of the whole body. This cold state of fever when it occurs early, yields more readily to bleeding, than to the most cordial medicines.

10. Sweats are supposed to forbid blood-letting. I have seen two instances of death, from leaving a paroxysm of malignant fever to terminate itself by sweating. Dr. Sydenham has taught a contrary practice in the following case. "While this constitution (says the doctor) prevailed, I was called to Dr. Morice, who then practised in London. He had this fever, attended with profuse sweats, and numerous petechiæ. By the consent of some other physicians, our joint friends, he was blooded, and rose from his bed, his body being first wiped dry. He found immediate relief from the use of a cooling diet and medicines, the dangerous symptoms soon going off; and by continuing this method he recovered in a few days[51]." In the same fever, the doctor adds further, "For though one might expect great advantages in pursuing an indication taken from what generally proves serviceable (viz. sweating), yet I have found, by constant experience, that the patient not only finds no relief, but, contrariwise, is more heated thereby; so that frequently a delirium, petechiæ, and other very dangerous symptoms immediately succeed such _sweats_[52]."

[51] Wallis's edition, vol. i. p. 210.

[52] Vol. i. p. 208.

Morgagni describes a malignant fever which prevailed in Italy, in which the patients died in profuse sweats, while their physicians were looking for a crisis from them. Bleeding would probably have checked these sweats, and cured the fever.

11. Dissolved blood, and an absence of an inflammatory crust on its crassamentum. I shall hereafter place dissolved blood at the highest point of a scale, which is intended to mark the different degrees of morbid action in the system. I have mentioned, in the Outlines of a Theory of Fever, that it is the effect of a tendency to a palsy, induced by the violent force of impression upon the blood-vessels. This appearance of the blood in certain states of fever, instead of forbidding bleeding, is the most vehement call of the system for it. Nor is the absence of a crust on the crassamentum of the blood, a proof of the absence of great morbid diathesis, or a signal to lay aside the lancet. On the contrary, I shall show hereafter, that there are several appearances of the blood which indicate more morbid action in the blood-vessels than a sizy or inflammatory crust.

12. An undue proportion of serum to crassamentum in the blood. This predominance of water in the blood has often checked sufficient blood-letting. But it should be constantly disregarded while it is attended with those states of pulse (to be mentioned hereafter) which require bleeding.

14. The presence of petechiæ on the skin. These, I have elsewhere said, are the effects of the gangrenous state of fever. Dr. Sydenham and Dr. de Haen have taught the safety and advantage of bleeding, when these spots are accompanied by an active pulse. A boy of Mr. John Carrol owes his recovery from the small-pox to the loss of fifty ounces of blood, by five bleedings, at a time when nearly every pock on his arms and legs had a purple appearance. Louis XIV was bled five times in the small-pox, when he was but thirteen years of age, and thereby probably saved from the grave, to the great honour and emolument of the single physician who urged it against the advice of all the other physicians of the court. Dr. Cleghorn mentions a single case of the success of bleeding in the petechial small-pox. His want of equal success afterwards, in similar cases, was probably occasioned by his bleeding too sparingly, that is, but three or four times.

Abscesses and sore breasts, which accompany or succeed fever, are no objections to blood-letting, provided the pulse indicate the continuance of inflammatory diathesis. They depend frequently upon the same state of the system as livid effusions on the skin.

14. The long duration of fever. Inflammatory diathesis is often protracted for many weeks, in the chronic state of fever. It, moreover, frequently revives after having disappeared, from an accidental irritant affecting some part of the body, particularly the lungs and brain. I bled a young man of James Cameron, in the autumn of 1794, four times between the 20th and 30th days of a chronic fever, in consequence of a pain in the side, accompanied by a tense pulse, which suddenly came on after the 20th day of his disease. His blood was sizy. His pain and tense pulse were subdued by the bleeding, and he recovered. I bled the late Dr. Prowl twelve times, in a fever which continued thirty days, in the autumn of the year 1800. I wish these cases to be attended to by young practitioners. The pulmonary consumption is often the effect of a chronic fever, terminating with fresh inflammatory symptoms, by effusions in the lungs. It may easily be prevented by forgetting the number of the days of our patient's fever, and treating the pulmonary affection as if it were a recent complaint.

15. Tremors and slight convulsions in the limbs. Bark, wine, laudanum, and musk are generally prescribed to remove these symptoms; but, to be effectual, they should, in most cases, be preceded by the loss of a few ounces of blood.

16. Bleeding is forbidden after the fifth or seventh day in a pleurisy. This prohibition was introduced into medicine at a time when a fear was entertained of arresting the progress of nature in preparing and expelling morbific matter from the system. From repeated experience I can assert, that bleeding is safe in every stage of pleurisy in which there is pain, and a tense and oppressed pulse; and that it has, when used for the first time after the fifth and seventh days, saved many lives. Bleeding has likewise been limited to a certain number of ounces in several states of fever. Were the force of the remote cause of a fever, its degrees of violence, and the habits of the subject of it, always the same, this rule would be a proper one; but, this not being the case, we must be governed wholly by the condition of the system, manifested chiefly by the state of the pulse. To admit of copious bleeding in one state of fever, and not in another, under equal circumstances of morbid excitement, is to prescribe for its name, and to forget the changes which climate, season, and previous habits create in all its different states.

17. The loss of a sufficient quantity of blood is often prevented by patients being apparently _worse_, after the first or second bleeding. This change for the worse, shows itself in some one or more of the following symptoms, viz. increase of heat, chills, delirium, hæmorrhages, convulsions, nausea, vomiting, faintness, coma, great weakness, pain, a tense, after a soft pulse, and a reduction of it in force and frequency. They are all occasioned by the system rising suddenly from a state of extreme depression, in consequence of the abstraction of the pressure of the blood to a state of vigour and activity, so great, in some instances, as to reproduce a depression below what existed in the system before a vein was opened; or it is occasioned by a translation of morbid action from one part of the body to another.

The chills which follow bleeding are the effects of a change in the fever, from an uncommon to a common state of malignity. They occur chiefly in those violent cases of fever which come on without a chilly fit.

The hæmorrhages produced by bleeding are chiefly from the nose, hæmorrhoidal vessels, or uterus, and of course are, for the most part, safe.

Uncommon weakness, succeeding blood-letting, is the effect of sudden depression induced upon the whole system, by the cause before-mentioned, or of a sudden translation of the excitement of the muscles into the blood-vessels, or some other part of the body. These symptoms, together with all the others which have been mentioned, are so far from forbidding, that they all most forcibly indicate a repetition of blood-letting.

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.

20. Bleeding has been charged with being a weakening remedy. I grant that it is so, and in this, its merit chiefly consists. The excessive morbid action of the blood-vessels must be subdued in part, in a fever, before stimulating remedies can be given with safety or advantage. Now this is usually attempted by depleting medicines, to be mentioned hereafter, or it is left to time and nature, all of which are frequently either deficient, or excessive in their operations; whereas bleeding, by suddenly reducing the morbid action of the blood-vessels to a wished-for point of debility, saves a great and unnecessary waste of excitability, and thus prepares the body for the exhibition of such cordial remedies as are proper to remove the debility which predisposed to the fever.

21. It has been said that bleeding renders the habitual use of it necessary to health and life. This objection to blood-letting is founded upon an ignorance of the difference between the healthy, and morbid action of the blood-vessels. Where blood is drawn in health, such a relaxation is induced in the blood-vessels, as to favour the formation of plethora, which may require habitual bleeding to remove it; but where blood is drawn only in the inflammatory state of fever, the blood-vessels are reduced from a morbid degree of strength to that which is natural, in which state no predisposition to plethora is created, and no foundation laid for periodical blood-letting. But there are cases which require even this evil, to prevent a greater. Thus we cure a strangulated hernia, when no fever attends, by the most profuse bleeding. The plethora and predisposition to disease which follow it are trifling, compared with preventing certain and sudden death.

22. Bleeding has been accused of bringing on an intermitting fever. This is so far from being an objection to it, that it should be considered as a new argument in its favour; for when it produces that state of fever, it converts a latent, and perhaps a dangerous disease, into one that is obvious to the senses, and under the dominion of medicine. Nor is it an objection to blood-letting, that, when used in an inflammatory intermittent, it sometimes changes it into a continual fever. An instance of the good effects of this change occurred in the Pennsylvania hospital, in an obstinate tertian, in the year 1804. The continual fever, which followed the loss of blood, was cured in a few days, and by the most simple remedies.

23. It has been said that bleeding, more especially where it is copious, predisposes to effusions of serum in the lungs, chest, bowels, limbs, and brain. In replying to this objection to bleeding, in my public lectures, I have addressed my pupils in the following language: "Ask the poor patients who come panting to the door of our hospital, with swelled legs and hard bellies, every fall, whether they have been too copiously bled, and they will all tell you, that no lancet has come near their arms. Ask the parents who still mourn the loss of children who have died, in our city, of the internal dropsy of the brain, whether they were destroyed by excessive blood-letting? If the remembrance of the acute sufferings which accompanied their sickness and death will permit these parents to speak, they will tell you, that every medicine, except bleeding, had been tried to no purpose in their children's diseases. Go to those families in which I have practised for many years, and inquire, whether there is a living or a dead instance of dropsy having followed, in any one of them, the use of my lancet? Let the undertakers and grave-diggers bear witness against me, if I have ever, in the course of my practice, conveyed the body of a single dropsical patient into their hands, by excessive blood-letting? No. Dropsies, like abscesses and gangrenous eruptions upon the skin, arise, in most cases, from the _want_ of sufficient bleeding in inflammatory diseases. Debility, whether induced by action or abstraction, seldom disposes to effusion. Who ever heard of dropsy succeeding famine? And how rarely do we see it accompany the extreme debility of old age?"

"If ever bleeding kills," says Botallus, either directly or indirectly, through the instrumentality of other diseases, "it is not from its excess, but because it is not drawn in a sufficient quantity, or at a proper time[53]." And, again, says this excellent writer, "One hundred thousand men perish from the want of blood-letting, or from its being used out of time, to one who perishes from too much bleeding, prescribed by a physician[54]."

[53] Cap. viii. § 4.

[54] Cap. xxxvi. § 4.

It is remarkable, that the dread of producing a dropsy by bleeding, is confined chiefly to its use in malignant fevers; for the men who urge this objection to it, do not hesitate to draw four or five quarts of blood in the cure of the pleurisy. The habitual association of the lancet with this disease, has often caused me to rejoice when I have heard a patient complain of a pain in his side, in a malignant fever. It insured to me his consent to the frequent use of the lancet, and it protected me, when it was used unsuccessfully, from the clamours of the public, for few people censure copious bleeding in a pleurisy.

24. Against blood-letting it has been urged, that the Indians of our country cure their inflammatory fevers without it. To relieve myself from the distressing obloquy to which my use of this remedy formerly exposed me, I have carefully sought for, and examined their remedies for those fevers, with a sincere desire to adopt them; but my inquiries have convinced me, that they are not only disproportioned to the habits and diseases of civilized life, but that they are far less successful than blood-letting, in curing the inflammatory fevers which occur among the Indians themselves.

25. Evacuating remedies of another kind have been said to be more safe than bleeding, and equally effectual, in reducing the inflammatory state of fever. I shall enumerate each of these evacuating remedies, and then draw a comparative view of their effects with blood-letting. They are,

I. Vomits.

II. Purges.

III. Sweats.

IV. Salivation. And,

V. Blisters.

I. Vomits have often been effectual in curing fevers of a mild character. They discharge offensive and irritating matters from the stomach; they lessen the fulness of the blood-vessels, by determining the serum of the blood through the pores; and they equalize the excitement of the system, by inviting its excessive degrees from the blood-vessels to the stomach and muscles. But they are,

1. Uncertain in their operation, from the torpor induced by the fever upon the stomach.

2. They are unsafe in many conditions of the system, as in pregnancy, and a disposition to apoplexy and ruptures. Life has sometimes been destroyed by their inducing cramp, hæmorrhage, and inflammation in the stomach.

3. They are not subject to the controul of a physician, often operating more, or less than was intended by him, or indicated by the disease.

4. They are often ineffectual in mild, and always so in fevers of great morbid action.

II. Purges are useful in discharging acrid fæces and bile from the bowels in fevers. They act, moreover, by creating an artificial weak part, and thus invite morbid excitement from the blood-vessels to the bowels. They likewise lessen the quantity of blood, by preventing fresh accessions of chyle being added to it; but like vomits they are,

1. Uncertain in their operation; and from the same cause. Many ounces of salts and castor oil, and whole drachms of calomel and jalap, have often been given, without effect, to remove the costiveness which is connected with the malignant state of fever.

2. They are not subject to the direction of a physician, with respect to the time of their operation, or the quantity or quality of matter they are intended to discharge from the bowels.

3. They are unsafe in the advanced stage of fevers. Dr. Physick informed me, that three patients died in the water-closet, under the operation of purges, in St. George's hospital, during his attendance upon it. I have seen death, in several instances, succeed a plentiful spontaneous stool in debilitated habits.

III. Sweating was introduced into practice at a time when morbific matter was supposed to be the proximate cause of fever. It acts, not by expelling any thing exclusively morbid from the blood, but by abstracting a portion of its fluid parts, and thus reducing the action of the blood-vessels. This mode of curing fever is still fashionable in genteel life. It excites no fear, and offends no sense. The sweating remedies have been numerous, and fashion has reigned as much among them, as in other things. Alexipharmic waters, and powders, and all the train of sudorific medicines, have lately yielded to the different preparations of antimony, particularly to James's powder. I object to them all,

1. Because they are uncertain; large and repeated doses of them being often given to no purpose.

2. Because they are slow, and disagreeable, where they succeed in curing fever.

3. Because, like vomits and purges, they are not under the direction of a physician, with respect to the quantity of fluid discharged by them.

4. Because they are sometimes, even when most profuse, ineffectual in the cure of fever.

5. The preparations of antimony, lately employed for the purpose of exciting sweats, are by no means safe. They sometimes convulse the system by a violent puking. Even the boasted James's powder has done great mischief. Dr. Goldsmith and Mr. Howard, it is said, were destroyed by it.

None of these objections to sweating remedies are intended to dissuade from their use, when nature shows a disposition to throw off a fever by the pores of the skin; but, even then, they often require the aid of bleeding to render them effectual for that purpose.

IV. Mercury, the Sampson of the materia medica, after having subdued the venereal disease, the tetanus, and many other formidable diseases, has lately added to its triumphs and reputation, by overcoming the inflammatory and malignant state of fever. I shall confine myself, in this place, to its depleting operation, when it acts by exciting a salivation. From half a pound to two pounds of fluid are discharged by it in a day. The depletion in this way is gradual, whereby fainting is prevented. By exciting and inflaming the glands of the mouth and throat, excitement and inflammation are abstracted from more vital parts. In morbid congestion and excitement in the brain, a salivation is of eminent service, from the proximity of the discharge to the part affected. But I object to it, as an exclusive evacuant in the cure of fever,

1. Because it is sometimes impossible, by the largest doses of mercury, to excite it, when the exigences of the system render it most necessary.

2. Because it is not so quick in its operation, as to be proportioned to the rapid progress of the malignant state of fever.

3. Because it is at all times a disagreeable, and frequently a painful remedy, more especially where the teeth are decayed.

4. Because it cannot be proportioned in its duration, or in the quantity of fluid discharged by it, to the violence or changes in the fever.

Dr. Chisholm relied, for the cure of the Beullam fever at Grenada, chiefly upon this evacuation. I have mentioned the ratio of success which attended it.

V. Blisters are useful in depleting from those parts which are the seats of topical inflammation. The relief obtained by them in this way more than balances their stimulus upon the whole system need hardly say, that their effects in reducing the morbid and excessive action of the blood-vessels are very feeble. To depend upon them in cases of great inflammatory action, is as unwise as it would be to attempt to bale the water from a leaky and sinking ship by the hollow of the hand, instead of discharging it by two or three pumps.

VI. Abstemious diet has sometimes been prescribed as a remedy for fever. It acts directly by the abstraction of the stimulus of food from the stomach, and indirectly by lessening the quantity of blood. It can bear no proportion, in its effects, to the rapidity and violence of an inflammatory fever. In chronic fever, such as occurs in the pulmonary consumption, it has often been tried to no purpose. Long before it reduces the pulse, it often induces such a relaxation of the tone of the stomach and bowels as to accelerate death. To depend upon it therefore in the cure of inflammatory fever, whether acute or chronic, is like trusting to the rays of the sun to exhale the water of an overflowing tide, instead of draining it off immediately, by digging a hole in the ground. But there are cases in which the blood-vessels become so insolated, that they refuse to yield their morbid excitement to depletion from any outlet, except from themselves. I attended a sailor, in the Pennsylvania hospital, in 1799, who was affected with deafness, attended with a full and tense pulse. I prescribed for it, purging, blisters, and low diet, but without any effect. Perceiving no change in his pulse, nor in his disease, from those remedies, I ordered him to lose ten ounces of blood. The relief obtained by this evacuation induced me to repeat it. By means of six bleedings he was perfectly cured, without the aid of any other remedy.

Bleeding has great advantages over every mode of depleting that has been mentioned.

1. It abstracts one of the exciting causes, viz. the stimulus of the blood, from the seat of fever. I have formerly illustrated this advantage of blood-letting, by comparing it to the abstraction of a grain of sand from the eye to cure an opthalmia. The other depleting remedies are as indirect and circuitous in their operation in curing fever, as vomits and purges would be to remove an inflammation in the eye, while the grain of sand continued to irritate it.

2. Blood-letting is quick in its operation, and may be accommodated to the rapidity of fever, when it manifests itself in apoplexy, palsy, and syncope.

3. It is under the command of a physician. He may bleed _when_ and _where_ he pleases, and may suit the _quantity_ of blood he draws, exactly to the condition of his patient's system.

4. It may be performed with the least attendance of nurses or friends. This is of great importance to the poor at all times, and to the rich during the prevalence of mortal epidemics.

5. It disturbs the system much less than any of the other modes of depleting, and therefore is best accommodated to that state of the system, in which patients are in danger of fainting or dying upon being moved.

6. It is a more delicate depleting remedy than most of those which have been mentioned, particularly vomits, purges, and a salivation.

7. There is no immediate danger to life from its use. Patients have sometimes died under the operation of vomits and purges, but I never saw nor heard an instance of a patient's dying in a fainty fit, brought on by bleeding.

8. It is less weakening, when used to the extent that is necessary to cure, than the same degrees of vomiting, purging, and sweating.

9. Convalescence is more rapid and more perfect after bleeding, than after the successful use of any of the other evacuating remedies.

By making use of blood-letting in fevers, we are not precluded from the benefits of the other evacuating remedies. Some of them are rendered more certain and more effectual by it, and there are cases of fever, in which the combined or successive application of them all is barely sufficient to save life.

To rely upon any one evacuating remedy, to the exclusion of the others, is like trusting to a pair of oars in a sea voyage, instead of spreading every sail of a ship.

I suspect the disputes about the eligibility of the different remedies which have been mentioned, have arisen from an ignorance that they all belong to one class, and that they differ only in their force and manner of operation. Thus the physicians of the last century ascribed different virtues to salts of different names, which the chemists of the present day have taught us are exactly the same, and differ only in the manner of their being prepared.

Having replied to the principal objections to blood-letting, and stated its comparative advantages over other modes of depletion, I proceed next to mention the circumstances which should regulate the use of it. These are,

I. The state of the pulse.

The following states of the pulse indicate the necessity of bleeding.

1. A full, frequent, and tense pulse, such as occurs in the pulmonary, rheumatic, gouty, phrenitic, and maniacal states of fever.

2. A full, frequent, and jerking pulse, without tension, such as frequently occurs in the vertiginous, paralytic, apoplectic, and hydropic states of fever.

3. A small, frequent, but tense pulse, such as occurs in the chronic, pulmonary, and rheumatic states of fever.

4. A tense and _quick_ pulse, without much preternatural frequency. This state of the pulse is common in the yellow fever.

5. A slow but tense pulse, such as occurs in the apoplectic, hydrocephalic, and malignant states of fever, in which its strokes are from 60 to 90, in a minute.

6. An uncommonly frequent pulse, without much tension, beating from 120 to 170 or 180 strokes in a minute. This state of the pulse occurs likewise in the malignant states of fever.

7. A soft pulse, without much frequency or fulness. I have met with this state of the pulse in affections of the brain, and in that state of pulmonary fever which is known by the name of pneumonia notha. It sometimes, I have remarked, becomes tense after bleeding.

8. An intermitting pulse.

9. A depressed pulse.

10. An imperceptible pulse. The slow, intermitting, depressed, and imperceptible states of the pulse are supposed exclusively to indicate congestion in the brain. But they are all, I believe, occasioned likewise by great excess of stimulus acting upon the heart and arteries. A pulse more tense in one arm than in the other, I have generally found to attend a morbid state of the brain. Much yet remains to be known of the signs of a disease in the brain, by the states of the pulse; hence Mr. Hunter has justly remarked, that "In inflammation of the brain, the pulse varies more than in inflammations of any other part; and perhaps we are led to judge of inflammation there, more from _other_ symptoms than the pulse[55]."

[55] Treatise on Inflammation, chap. iii. 9.

The slow, uncommonly frequent, intermitting, and imperceptible states of the pulse, which require bleeding, may be distinguished from the same states of the pulse, which arise from an exhausted state of the system, and that forbid bleeding, by the following marks:

1. They occur in the beginning of a fever.

2. They occur in the paroxysms of fevers which have remissions and exacerbations.

3. They sometimes occur after blood-letting, from causes formerly mentioned.

4. They sometimes occur, and continue during the whole course of an inflammation of the stomach and bowels. And,

5. They occur in relapses, after the crisis of a fever.

The other states of the pulse indicate bleeding in every stage of fever, and in every condition of the system. I have taken notice, in another place, of the circumstances which render it proper in the advanced stage of chronic fever.

If all the states of pulse which have been enumerated indicate bleeding, it must be an affecting consideration to reflect, how many lives have been lost, by physicians limiting the use of the lancet only to the tense or full pulse!

I wish it comported with the proposed limits of this essay to illustrate and establish, by the recital of cases, the truth of these remarks upon the indications of bleeding from the pulse. It communicates much more knowledge of the state of the system than any other sign of disease. Its frequency (unconnected with its other states), being under the influence of diet, motion, and the passions of the mind, is of the least consequence. In counting the number of its strokes, we are apt to be diverted from attending to its irregularity and force; and in these, it should always be remembered, fever chiefly consists. The knowledge acquired by attending to these states of the pulse is so definite and useful, and the circumstances which seduce from a due attention to them are so erroneous in their indications, that I have sometimes wished the Chinese custom of prescribing, from feeling the pulse only, without seeing or conversing with the patient, were imposed upon all physicians.

To render the knowledge of the indications of blood-letting, from the state of the pulse, as definite and correct as possible, I shall add, for the benefit of young practitioners, the following directions for feeling it.

1. Let the arm be placed in a situation in which all the muscles which move it shall be completely relaxed; and let it, at the same time, be free from the pressure of the body upon it.

2. Feel the pulse, in all obscure or difficult cases, in both arms.

3. Apply all the fingers of one hand, when practicable, to the pulse. For this purpose, it will be most convenient to feel the pulse of the right hand with your left, and of the left hand with your right.

4. Do not decide upon blood-letting, in difficult cases, until you have felt the pulse for some time. The Chinese physicians never prescribe until they have counted 49 strokes.

5. Feel the pulse at the intervals of four or five minutes, when you suspect that its force has been varied by any circumstance not connected with the disease, such as emotions of the mind, exercise, eating, drinking, and the like.

6. Feel the pulsations of the arteries in the temples and in the neck, when the pulse is depressed or imperceptible in the wrists.

7. Request silence in a sick room, and close your eyes, in feeling a pulse in difficult cases. By so doing, you will concentrate the sensations of your ears and eyes, in your fingers.

In judging of the states of the pulse which have been enumerated, it will be necessary always to remember the natural difference, in its frequency and force, in old people and children; also in the morning and evening, and in the sleeping and waking states of the system.

Much yet remains to be known upon this subject. I have mentioned the different states of the pulse, which call for bleeding, but it is more difficult to know when to prescribe it, when the pulse imparts no sign of disease. In general it may be remarked, where the disease is _recent_, the part affected important to life, and incapable of sustaining violent morbid action long, without danger of disorganization, where pain is great, and respiration difficult, the pulse may be disregarded in the use of the lancet.

But to return.

II. Regard should be had to the character of the reigning epidemic, in deciding upon blood-letting. If the prevailing fever be of a highly inflammatory nature, bleeding may be used with more safety, in cases where the indications of it from the pulse are somewhat doubtful. The character of a previous epidemic should likewise direct the use of the lancet. The pestilential fever which followed the plague in London, in 1665, Dr. Sydenham says, yielded only to blood-letting. It is equally necessary in all the febrile diseases which succeed malignant fevers.

III. Regard should be had to the weather and season of the year. Dr. Hillary and Dr. Huxham both say it is much more necessary in dry, than in wet weather, and, all physicians know, it is more copiously indicated in the spring and autumn, than in summer and winter.

IV. The constitution of a patient, and more especially his habits with respect to blood-letting, should be taken into consideration, in prescribing it. If he be plethoric, and accustomed to bleeding in former indispositions, it will be more necessary, than in opposite states and habits of the system. Nature will expect it.

V. The corpulency of a patient should regulate the use of the lancet. A butcher of great observation informed me, that a fat ox did not yield more than from one half, to one third of the quantity of blood of a lean one, of the same size of bone, and it is well known, that the loss of a small quantity of blood, after cutting off the head of a fowl, is always a sign of its being fit for the table. The pressure of fat upon the blood-vessels produces the same effects in the human species that it does in those animals; of course, less blood should be drawn from fat, than from lean people, under equal circumstances of disease.

VI. As persons have more or less blood in their vessels, according to their size, less blood should be drawn, under equal circumstances, from small than large people.

VII. Regard should be had to the age of adults in prescribing bleeding. In persons between fifty and sixty years of age, for reasons formerly mentioned, more blood may be drawn than in middle life, in similar diseases. In persons beyond 70, it will be necessary to regulate the quantity to be drawn by other signs than the pulse, or the appearances of the blood, the former being generally full, and sometimes tense, and the latter often putting on the sign of the second grade of morbid action formerly described.

VIII. Regard should be had to the country or place from which persons affected with fevers have arrived, in prescribing the loss of blood. Fevers, in America, are more inflammatory than fevers, in persons of equal rank, in Great-Britain. A French physician once said, it was safer to draw a hogs-head of wine from a Frenchman's veins, than a quarter of a hundred pounds of beef from an Englishman's, meaning to convey an idea of the difference in the grades of morbid or inflammatory action in the diseases of the inhabitants of France and England, and of the difference in the quantity of blood proper to be drawn in each of them. A similar difference exists between the grades of fever in Great-Britain and America. From a want of attention to this circumstance, I saw a common pleurisy end in an abscess of the lungs, in a sea captain, in the city of London, in the year 1769, who was attended by a physician of the first reputation in England. He was bled but once. His pulse and American constitution called for the loss of 50 or 60 ounces of blood.

IX. Regard should be had to the structure and situation of the parts diseased with febrile action. The brain, from its importance to all the functions of life, the rectum, the bladder, and the trachea, when inflamed, and the intestines, when strangulated, from their being removed so much out of the influence of the great circulation, all require more copious bleeding than the same degrees of disease in the lungs, and some other parts of the body.

X. After blood-letting has been performed, the appearances of the blood should be attended to, in order to judge of the propriety of repeating it. I shall briefly describe these appearances, and arrange them in the order in which they indicate the different degrees of inflammatory diathesis, beginning with the highest.

1. Dissolved blood. It occurs in the malignant states of fever. I have seen it several times in the pleurisy, and have once heard of it in a case of gout. I have ascribed this decomposition of the blood to such a violent degree of action in the blood-vessels, as to dispose them to a paralytic state. It is generally considered as a signal to lay aside the lancet. If it occur in the _first stage_ of a fever, it indicates a very opposite practice. By repeated bleedings, the vessels recover their natural action, and the blood becomes _reduced_ to its original texture. Of this I have had frequent experience, since the year 1793. It required three successive bleedings to restore the blood from a dissolved, to a coagulable state, in Mr. Benton. It afterwards became very sizy. If this dissolved blood appear towards the close of a malignant fever, no other benefit than the protraction of life for a day or two, or an easy death, can be expected from repeating the bleeding, even though it be indicated by a tense pulse; for the viscera are generally so much choaked by the continuance of violent action in the blood-vessels, that they are seldom able to discharge the blood which distends them, into the cavity in the vessels, which is created by the abstraction of blood from a vein. There is some variety in the appearance of this state of the blood, which indicates more or less violent pressure upon the blood-vessels. It threatens most danger to life when it resembles molasses in its consistence. The danger is less when the part which is dissolved occupies the bottom of the bowl, and when its surface is covered with a sizy pellicle or coat.

Does not the restoration of the blood from its disorganized state, by means of bleeding, suggest an idea of a similar change being practicable in the solids, when they are disorganized by disease? And are we not led hereby to an animating view of the extent and power of medicine?

2. Blood of a scarlet colour, without any separation into crassamentum or serum, indicates a second degree of morbid action. It occurs likewise in the malignant state of fever. It is called improperly dense blood. It occurs in old people.

3. Blood in which part of the crassamentum is dissolved in the serum, forming a resemblance to what is called the lotura carnium, or the washings of flesh in water.

4. Crassamentum sinking to the bottom of a bowl in yellow serum.

5. Crassamentum floating in serum, which is at first turbid, but which afterwards becomes yellow and transparent, by depositing certain red and fiery particles of the blood in the bottom of the bowl.

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.

[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.

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.

[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].

[66] From the early knowledge this excellent physician and worthy man had thus acquired of the bilious remitting fever, he was very successful in the treatment of it. It was by instruction conveyed by him to me with peculiar delicacy, that I was first taught the advantages of copious evacuations from the bowels in that disease. I had been called, when a young practitioner, to visit a gentleman with him in a bilious pleurisy. A third or fourth bleeding, which I advised, cured him. The doctor was much pleased with its effect, and said to me afterwards, "Doctor, you and I have each a great fault in our practice; I do not bleed enough, you do not purge enough."

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.

The combined influence of great heat and intemperance in drinking, acting upon passions unusually excited by public objects, on the 4th of July, every year.

The general and inordinate use of segars.

The want of sufficient force in the water which falls into the common sewers to convey their contents into the Delaware, renders each of their apertures a source of sickly exhalations to the neighbouring streets and squares.

The compact manner in which the gutters are now formed, by preventing the descent of water into the earth, has contributed very much to retain the filth of the city, in those seasons in which they are not washed by rain, nor by the waste water of the pumps and hydrants.

The timbers of many of the wharves of the city have gone to decay. The docks have not been cleaned since the year 1774, and many of them expose large surfaces to the action of the sun at low water. The buildings have increased in Water-street, and with them there has been a great increase of that kind of filth which is generated in all houses; the stores in this street often contain matters which putrify; from all which there is, in warm weather, a constant emission of such a f[oe]tid odour, as to render a walk through that street, by a person who does not reside there, extremely disagreeable, and sometimes to produce sickness and vomiting.

In many parts of the vicinity of the city are to be seen pools of stagnating water, from which there are exhaled large quantities of unhealthy vapours, during the summer and autumnal months.

The privies have become so numerous, and are often so full, as to become offensive in most of the compact parts of the city, more especially in damp weather.

The pump water is impregnated with many saline and aërial matters of an offensive nature.

While these causes exert an unfriendly influence upon the bodies of the citizens of Philadelphia, the extreme elevation or depression of their passions, by the different issues of their political contests (now far surpassing, in their magnitude, the contests of former years), together with their many new and fortuitous modes of suddenly acquiring and losing property, predispose them to many diseases of the mind.

The present diseases of Philadelphia come next under our consideration.

Fevers have assumed several new forms since the year 1766. The mild bilious fever has gradually spread over every part of the city. It followed the filth which was left by the British army in the year 1778. In the year 1780, it prevailed, as an epidemic, in Southwark, and in Water and Front-streets, below Market-street[67]. In the years 1791 and 1792, it assumed an inflammatory appearance, and was accompanied, in many cases, with hepatic affections. The connection of our subject requires that I should barely repeat, that it appeared in 1793 as an epidemic, in the form of what is called yellow fever, in which form it has appeared, in sporadic cases, or as an epidemic, every year since. During the reign of this high grade of bilious fever, mild intermittents and remittents, and the chronic or nervous forms of the summer and autumnal fever, have nearly disappeared.

[67] It appears, from the account given by Mr. White of the bilious fever of Bath, that it prevailed several years in its suburbs, before it became general in that city. It is remarkable, that Southwark was nearly the exclusive seat, not only of the bilious or break-bone fever of 1780, but of the intermitting fever in 1765, taken notice of by Dr. Bond, and of the yellow fever of 1805.

Inflammations and obstructions of the liver have been more frequent than in former years, and even the pneumonies, catarrhs, intercurrent, and other fevers of the winter and spring months, have all partaken more or less of the inflammatory and malignant nature of the yellow fever.

The pulmonary consumption continues to be a common disease among both sexes.

The cynanche trachealis, the scarlatina anginosa, the hydrocephalus internus, and cholera infantum, are likewise common diseases in Philadelphia.

Madness, and several other diseases of the mind, have increased since the year 1766, from causes which have been mentioned.

Several of the different forms of gout are still common among both sexes.

Apoplexy and palsy have considerably diminished in our city. It is true, the bills of mortality still record a number of deaths from the former, every year; but this statement is incorrect, if it mean a disease of the brain only, for sudden deaths from all their causes are returned exclusively under the name of apoplexy. The less frequent occurrence of this disease, also of palsy, is probably occasioned by the less consumption of animal food, and of distilled and fermented liquors, by that class of citizens who are most subject to them, than in former years. Perhaps the round hat, and the general use of umbrellas, may have contributed to lessen those diseases of the brain.

The dropsy is now a rare disease, and seldom seen even in our hospital.

The colica pictonum, or dry gripes, is scarcely known in Philadelphia. I have ascribed this to the use of flannel next to the skin as a part of dress, and to the general disuse of punch as a common drink.

The natural small-pox is nearly extirpated, and the puerperile fever is rarely met with in Philadelphia. The scrophula is much less frequent than in former years. It is confined chiefly to persons in humble life.

I proceed, in the order that was proposed, to take notice of the present medical opinions which prevail among the physicians of Philadelphia. The system of Dr. Boerhaave long ago ceased to regulate the practice of physic. It was succeeded by the system of Dr. Cullen. In the year 1790, Dr. Brown's system of medicine was introduced and taught by Dr. Gibbon. It captivated a few young men for a while, but it soon fell into disrepute. Perhaps the high-toned diseases of our city exposed the fallacy and danger of the remedies inculcated by it, and afforded it a shorter life than it has had in many other countries. In the year 1790, the author of this inquiry promulgated some new principles in medicine, suggested by the peculiar phænomena of the diseases of the United States. These principles have been so much enlarged and improved by the successive observations and reasonings of many gentlemen in all the states, as to form an American system of medicine. This system rejects the nosological arrangement of diseases, and places all their numerous forms in morbid excitement, induced by irritants acting upon previous debility. It rejects, likewise, all prescriptions for the names of diseases, and, by directing their applications wholly to the forming and fluctuating states of diseases, and the system, derives from a few active medicines all the advantages which have been in vain expected from the numerous articles which compose European treatises upon the materia medica. This system has been adopted by a part of the physicians of Philadelphia, but a respectable number of them are still attached to the system of Dr. Cullen.

A great change has taken place in the remedies which are now in common use in Philadelphia. I shall briefly mention such of them as are new, and then take notice of the new and different modes of exhibiting such as were in use between the years 1760 and 1766.

Vaccination has been generally adopted in our city, in preference to inoculation with variolous matter.

Digitalis, lead, zinc, and arsenic are now common remedies in the hands of most of our practitioners.

Cold air, cold water, and ice are among the new remedies of modern practice in Philadelphia.

Blood-letting is now used in nearly all diseases of violent excitement, not only in the blood-vessels, but in other parts of the body. Its use is not, as in former times, limited to ounces in specific diseases, but regulated by their force, and the importance of the parts affected to health and life; nor is it forbidden, as formerly, in infancy, in extreme old age, in the summer months, nor in the period of menstruation, where symptoms of a violent, or of a suffocated disease, manifested by an active or a feeble pulse, indicate it to be necessary.

Leeches are now in general use in diseases which are removed, by their seat or local nature, beyond the influence of the lancet. For the introduction of this excellent remedy into our city we are indebted to Mr. John Cunitz.

Opium and bark, which were formerly given in disguise, or with a trembling hand, are now, not only prescribed by physicians, but often purchased, and taken without their advice, by many of the citizens of Philadelphia. They even occupy a shelf in the closets of many families.

The use of mercury has been revived, and a salivation has been extended; with great improvements and success, to nearly all violent and obstinate diseases. Nor has the influence of reason over ignorance and prejudice, with respect to that noble medicine, stopped here. Cold water, once supposed to be incompatible with its use, is now applied to the body, in malignant fevers, in order to insure and accelerate its operation upon the salivary glands.

Wine is given in large quantities, when indicated, without the least fear of producing intoxication.

The warm and cold baths, which were formerly confined chiefly to patients in the Pennsylvania hospital, are now common prescriptions in private practice.

Exercise, country air, and the sea shore, are now universally recommended in chronic diseases, and in the debility which precedes and follows them.

Great pains are now taken to regulate the quantity and quality of aliments and drinks, by the peculiar state of the system.

Let us now inquire into the influence of the new opinions in medicine, and the new remedies which have been mentioned, upon human life.

The small-pox, once the most fatal and universal of all diseases, has nearly ceased to occupy a place in our bills of mortality, by the introduction of vaccination in our city. For the prompt adoption of this great discovery, the citizens of Philadelphia owe a large debt of gratitude to Dr. Coxe, and Mr. John Vaughan.

Fevers, from all their causes, and in all their forms, with the exception of the bilious yellow fever, now yield to medicine. Even that most malignant form of febrile diseases is treated with more success in Philadelphia than in other countries. It would probably seldom prove mortal, did a belief in its being derived from an impure atmosphere, and of its exclusive influence upon the body, while it prevailed as an epidemic, obtain universally among the physicians and citizens of Philadelphia.

The pulmonary consumption has been prevented, in many hundred instances, by meeting its premonitory signs, in weakness and feeble morbid excitement in the whole system, by country air, gentle exercise, and gently stimulating remedies. Even when formed, and tending rapidly to its last stage, it has been cured by small and frequent bleedings, digitalis, and a mercurial salivation.

The hydrocephalus internus, the cynanche trachealis, and cholera infantum, once so fatal to the children of our city, now yield to medicine in their early stages. The two former are cured by copious bleeding, aided by remedies formerly employed in them without success. The last is cured by moderate bleeding, calomel, laudanum, and country air.

The gout has been torn from its ancient sanctuary in error and prejudice, and its acute paroxysms now yield with as much certainty to the lancet, as the most simple inflammatory diseases.

The dropsy is cured by renouncing the unfortunate association of specific remedies with its name, and accommodating them to the degrees of excitement in the blood-vessels.

The tetanus from wounds is now prevented, in most cases, by inflaming the injured parts, and thereby compelling them to defend the whole system, by a local disease. Where this preventing remedy has been neglected, and where tetanus arises from other causes than wounds, it has often been cured by adding to the diffusible stimulus of opium, the durable stimuli of bark and wine.

Death from drinking cold water, in the heated state of the body, is now obviated by previously wetting the hands or feet with the water; and when this precaution is neglected, the disease induced by it is generally cured by large doses of liquid laudanum.

Madness, which formerly doomed its miserable subjects to cells or chains for life, has yielded to bleeding, low diet, mercury, the warm and cold baths, fresh air, gentle exercise, and mild treatment, since its seat has been discovered to be in the blood-vessels of the brain.

The last achievement of our science in Philadelphia, that I shall mention, consists in the discovery and observation of the premonitory signs of violent and mortal diseases, and in subduing them by simple remedies, in their forming state. By this means, death has been despoiled of his prey, in many hundred instances.

In this successful conflict of medicine with disease and death, midwifery and surgery have borne a distinguished part. They derive their claims to the gratitude of the citizens of Philadelphia from the practice of each of them being more confined, than formerly, to a few members of our profession. It is in consequence of the former being exercised only by physicians of regular and extensive educations, that death from pregnancy and parturition is a rare occurrence in Philadelphia.

I should greatly exceed the limits prescribed to this inquiry, should I mention how much pain and misery have been relieved, and how often death has been baffled in his attempts upon human life, by several late improvements in old, and the discovery of new remedies in surgery. I shall briefly name a few of them.

In cases of blindness, from a partial opacity of the cornea, or from a closure of the natural pupil, a new pupil has been made; and where the cornea has been partially opaque, the opening through the iris has been formed, opposite to any part of it, which retained its transparency.

The cure of fractures has been accelerated by blood-letting, and, where the union of a broken bone has not taken place from a defect of bony matter, it has been produced by passing a seton between the fractured ends of the bone, and effecting a union thereby between them. Luxations, which have long resisted both force and art, have been reduced in a few minutes, and without pain, by bleeding at deliquium animi.

Old sores have been speedily healed, by destroying their surfaces, and thereby placing them in the condition of recent accidents.

The fruitless application of the trepan, in concussions of the brain, has been prevented by copious bleeding, and a salivation.

A suppression of urine has been cured, by the addition of a piece of a bougie to a flexible catheter.

Strictures in the urethra have been removed by means of a caustic, also, in a more expeditious way, by dividing them with a lancet.

Hydrocele has been cured by a small puncture, and afterwards exciting inflammation and adhesion by an injection of wine into the tunica vaginalis testis.

The popliteal aneurism and varicose veins have both been removed by operations that were unknown a few years ago.

For the introduction of several of those new surgical remedies, and for the discovery and improvement of others, the citizens of Philadelphia are indebted to Dr. Physick. They are likewise indebted to him and Dr. Griffitts for many of the new and successful modes of practice, in the diseases that have been mentioned. Even the few remedies that have been suggested by the author of these inquiries, owe their adoption and usefulness chiefly to the influence of those two respectable and popular physicians.

Before I dismiss this part of our subject, I have only to add, that since the cure and extraction of the teeth have become a distinct branch of the profession of medicine, several diseases which have arisen from them, when decayed, have been detected and cured[68].

[68] The late Mr. Andrew Spence was the first regular bred dentist that settled in Philadelphia. There are now several well educated gentlemen in the city of that profession.

We have thus taken a comparative view of the medical theories and remedies of former and modern times, and of their different influence upon human life. To exhibit the advantages of the latter over the former, I shall mention the difference in the number of deaths in three successive years, at a time when the population of the city and suburbs was supposed to amount to 30,000 souls, and in three years, after the population exceeded double that number.

Between the 25th of December, 1771, and the 25th of December, 1772, there died 1291 persons.

Between the same days of the same months, in 1772 and 1773, there died 1344 persons.

Within the same period of time, between 1773 and 1774, the deaths amounted to 1021, making in all 3,656. I regret that I have not been able to procure the returns of deaths in years prior to those which have been mentioned. During the three years that have been selected, no unusually mortal diseases prevailed in the city. The measles were epidemic in 1771, but were not more fatal than in common years.

Between the 25th of December, 1799, and the 25th of December, 1800, there died 1525 persons.

Between the same days of the same months, in the years 1801 and 1802, there died 1362 persons.

Within the same period of time, between 1802 and 1803, the deaths amounted to 1796, making in all 4,883.

Upon these returns it will be proper to remark, that several hundreds of the deaths, in 1802 and 1803, were from the yellow fever, and that many of them were of strangers. Of 68 persons, who were interred in the Swedes' church-yard alone, one half were of that description of people. Deducting 500 from both those causes of extra-mortality in the three years, between 1799 and 1803, the increase of deaths above what they were in the years 1771 and 1774 is but 727. Had diseases continued to be as mortal as they were thirty years ago, considering the present state of our population, the number of deaths would have been more than 7,312.

To render the circumstances of the statement of deaths that has been given perfectly equal, it will be necessary to add, that the measles prevailed in the city, in the year 1802, as generally as they did in 1771.

From the history that has been given, of the effects of the late improvements and discoveries in medicine upon human life, in Philadelphia, we are led to appreciate its importance and usefulness. It has been said, by its enemies, to move; but its motions have been asserted to be only in a circle. The facts that have been stated clearly prove, that it has moved, and rapidly too, within the last thirty years, in a straight line.

To encourage and regulate application and enterprize in medicine hereafter, let us inquire to what causes we are indebted for the late discoveries and improvements in our science, and for their happy effects in reducing the number of deaths so far below their former proportion to the inhabitants of Philadelphia.

The first cause I shall mention is the great physical changes which have taken place in the manners of our citizens in favour of health and life.

A second cause, is the assistance which has been afforded to the practice of physic, by the numerous and important discoveries that have lately been made in anatomy, natural history, and chemistry, all of which have been conveyed, from time to time, to the physicians of the city, by means of the Philadelphia and hospital libraries, and by the lectures upon those branches of science which are annually delivered in the university of Pennsylvania.

3. The application of reasoning to our science has contributed greatly to extend its success in the cure of diseases. Simply to observe and to remember, are the humblest operations of the human mind. Brutes do both. But to _theorize_, that is, to _think_, or, in other language, to compare facts, to reject counterfeits, to dissolve the seeming affinity of such as are not true, to combine those that are related, though found in remote situations from each other, and, finally, to deduce practical and useful inferences from them, are the high prerogatives and interest of man, in all his intellectual pursuits, and in none more, than in the profession of medicine.

4. The accommodation of remedies to the changes which are induced in diseases by the late revolutions in our climate, seasons, and manners, has had a sensible influence in improving the practice of medicine in our city. The same diseases, like the descendants of the same families, lose their resemblance to each other by the lapse of time; and the almanacks of 1803 might as well be consulted to inform us of the monthly phases of the moon of the present year, as the experience of former years, or the books of foreign countries, be relied upon to regulate the practice of physic at the present time, in any of the cities of the United States.

5. From the diffusion of medical knowledge among all classes of our citizens, by means of medical publications, and controversies, many people have been taught so much of the principles and practice of physic, as to be able to prescribe for themselves in the forming state of acute diseases, and thereby to prevent their fatal termination. It is to this self-acquired knowledge among the citizens of Philadelphia, that physicians are in part indebted for not being called out of their beds so frequently as in former years. There are few people who do not venture to administer laudanum in bowel complaints, and there are some persons in the city, who have cured the cynanche trachealis when it has occurred in the night, by vomits and bleeding, without the advice of a physician. The disuse of suppers is another cause why physicians enjoy more rest at night than formerly, for many of their midnight calls, were to relieve diseases brought on by that superfluous meal.

6. The dispensary instituted in our city, in the year 1786, for the medical relief of the poor, has assisted very much in promoting the empire of medicine over disease and death. Some lives have likewise been saved by the exertions of the humane society, by means of their printed directions to prevent sudden death; also, by the medical services which have lately been extended to out-patients, by order of the managers of the Pennsylvania hospital.

7thly and lastly. A change, favourable to successful practice in Philadelphia, has taken place in the conduct of physicians to their patients. A sick room has ceased to be the theatre of imposture in dress and manners, and prescriptions are no longer delivered with the pomp and authority of edicts. On the contrary, sick people are now instructed in the nature of their diseases, and informed of the names and design of their medicines, by which means faith and reason are made to co-operate in adding efficacy to them. Nor are patients left, as formerly, by their physicians, under the usual appearances of dissolution, without the aid of medicine. By thus disputing every inch of ground with death, many persons have been rescued from the grave, and lived, years afterwards, monuments of the power of the healing art.

From a review of what has been effected within the last nine and thirty years, in lessening the mortality of many diseases, we are led to look forward with confidence and pleasure to the future achievements of our science.

Could we lift the curtain of time which separates the year 1843 from our view, we should see cancers, pulmonary consumptions, apoplexies, palsies, epilepsy, and hydrophobia struck out of the list of mortal diseases, and many others which still retain an occasional power over life, rendered perfectly harmless, _provided_ the same number of discoveries and improvements shall be made in medicine in the intermediate years, that have been made since the year 1766.

But in vain will the avenues of death from those diseases be closed, while the more deadly yellow fever is permitted to supply their place, and to spread terror, distress, and poverty through the city, by destroying the lives of her citizens by hundreds or thousands every year. Dear cradle of liberty of conscience in the western world! nurse of industry and arts! and patron of pious and benevolent institutions! may this cease to be thy melancholy destiny! May Heaven dispel the errors and prejudices of thy citizens upon the cause and means of preventing their pestilential calamities! and may thy prosperity and happiness be revived, extended, and perpetuated for ages yet to come!

* * * * *

INDEX.

A

Anthelmintics, i. 228 Arsenic, a remedy for cancerous sores, i. 240 Army of the United States, diseases of, i. 269 ----, causes of, i. 272 ----, remedies for, i. ibid. Agriculture, the practice of, recommended to country physicians, i. 388 Age, old, observations on the state of the body and mind in, i. 427 ----, its diseases, i. 446 ----, ----, their remedies, i. 449 Air, cool, its good effects in the yellow fever of 1793, iii. 279 Association of ideas, its effects upon morals, ii. 45

B.

Barometer, its mean elevation in Philadelphia, i. 96 Blisters, their efficacy in obstinate intermittents, i. 179 ----, ----, in the bilious fever of 1780, i. 128 ----, ----, in the yellow fever of 1803, when applied in its early stage, iv. 141 Bed, lying in, useful in the bilious fever of 1780, i. 128 Bleeding, its efficacy in the cure of obstinate intermittents, i. 179 ----, ----, in the yellow fever of 1793, iii. 253 ----, reasons for the practice, iii. 254 ----, circumstances which regulated it, iii. 261 ----, objections to it answered, iii. 269 ----, gradual manner of abstracting blood recommended, iii. 273 Blood-letting, defence of it as a remedy for certain diseases, iv. 275 ----, indicated in fevers, iv. ibid. ----, its good effects in fevers, iv. 277 ----, objections to it answered, iv. 284 ----, its comparative advantages, iv. 313 ----, circumstances which should regulate its use, iv. 316 ----, appearances of the blood, iv. 326 ----, when forbidden, or to be used cautiously, iv. 344 ----, its advantages in pregnancy, iv. 349 ----, in parturition, iv. 353 ----, during the cessation of the menses, iv. 356 ----, in curing the disease induced by a large dose of opium, iv. 357 ----, in curing the disease induced by poison, iv. ibid. ----, in diabetes, iv. ibid. ----, in dislocated bones, iv. 358 Blood, quantity drawn from several persons in 1797, iv. 37 ----, appearances of it in 1793, iii. 256 ----, ----, in 1794, iii. 404

C.

Civilization, diseases derived from it, i. 32 ----, ----, not necessarily connected with it, i. 60 Climate of Pennsylvania, account of, i. 71 ----, its changes, i. 76 ----, its temperature, i. 78 ----, its effects upon health and life, i. 108 Calomel, useful joined with emetics in scarlatina anginosa, i. 144 ----, its effects as a purge, when combined with jalap, in the yellow fever, iii. 241 ----, objections to it answered, iii. 243 Contagious, the yellow fever not so, iv. 223 Cholera infantum described, i. 157 ----, a form of bilious fever, i. 158 ----, its remedies, i. 160 ----, means of preventing it, i. 164 Cynanche trachealis, its different names, i. 169 ----, appearances in the trachea after death, i. 170 ----, its different grades, i. 171 ----, its remedies in its forming state, i. ibid. ----, its remedies after it is formed, i. 172 ----, favourable and unfavourable signs of its issue, i. 174 Consumption, pulmonary, thoughts on, i. 199 ----, pulmonary, Indians, and persons who lead laborious lives, not subject to it, i. 200 ----, radical remedies for it in exercise, labour, and the hardships of a camp and naval life, i. 204 ----, its causes, ii. 62 ----, not contagious, ii. 79 ----, tracheal, described, ii. 84 ----, its remedies, ii. 87 ----, premonitory signs, ii. ibid. ----, of the remedies for its inflammatory state, ii. 89 ----, of blood-letting, ii. ibid. ----, of a vegetable diet, ii. 104 ----, of the remedies for its hectic state, ii. 107 ----, for its typhus state, ii. 108 ----, of its radical remedies, ii. 128 ----, of exercise, ii. ibid. ----, of travelling, ii. 137 ----, signs of its long or short duration, and of its issue in life and death, ii. 144 ----, its different ways of terminating in death, ii. 147 College of physicians, their letter to the citizens of Philadelphia, declaring the existence of the yellow fever in the city, &c. in 1793, iii. 82 ----, their letter to the governor of the state, on the origin of the yellow fever in 1793, iii. 197 ----, their opinion of the origin of the fever in 1799, iv. 100

D.

Diseases of the Indians, i. 16 ----, from civilization, i. 30 ----, produced by ardent spirits, i. 343 ----, of the military hospitals, during the revolutionary war between Great-Britain and the United States, i. 269 ----, of old age, i. 446 Drunkenness, a fit of it described, i. 338 ----, remedies for it, i. 374 Disease, summer and autumnal, its sources, iv. 163 ----, means of preventing it in its malignant forms, iv. 173 ----, in its mild forms, iv. 198 ----, in its intestinal forms, iv. 200 ----, of preserving cities and communities from them, iv. 202 ----, of exterminating them, iv. 210 ----, from drinking cold water, i. 186 ----, ----, how prevented, i. ibid. ----, ----, its cure, i. 185 Dropsies, their causes, ii. 151 ----, divided into inflammatory, and of weak morbid action in the blood-vessels, ii. 157 ----, remedies for the inflammatory state of, ii. 160 ----, ----, with weak morbid action in the blood-vessels, ii. 176 Dropsy of the brain, internal, ii. 192 ----, its history, ii. 195 ----, its causes, ii. 203 ----, its cure, ii. 210 Distress, familiarity with it, its moral effects, ii. 46 Death, its proximate cause, ii. 447

E.

Emetics, useful in the bilious fever of 1780, i. 186 ----, in the scarlatina anginosa of 1783 and 1784, i. 144 ----, in the yellow fever of 1798, iv. 79 ----, in the yellow fever of 1799, iv. 97 ----, hurtful in the yellow fever of 1797, iv. 44 Exhalations, putrid, their sources and effects in producing the summer and autumnal disease, iv. 163

F.

Faculty, moral, inquiry into the influence of physical causes on, ii. 3 Fruits, summer, useful in destroying worms, i. 229 Fever, bilious, history of it in 1780, i. 117 ----, outlines of a theory of, iii. 3 ----, its unity asserted, iii. 17 ----, unity of its exciting causes, iii. 16 ----, objections to a nosological arrangement of its different forms, iii. 33 ----, effects of, iii. 39 ----, different states of, enumerated, iii. 41 ----, objections to putrefaction in, iii. 43 ----, bilious yellow, history of, in 1793, iii. 69 ----, ----, its exciting causes, iii. 88 ----, ----, its premonitory signs, iii. 93 ----, ----, its first symptoms, iii. 95 ----, ----, symptoms of it in the blood-vessels, iii. 97 ----, ----, ----, in the liver, lungs, and brain, iii. 104 ----, ----, ----, in the stomach and bowels, iii. 108 ----, ----, ----, in the secretions and excretions, iii. 110 Fever, bilious yellow, symptoms of it, in the nervous system, iii. 116 ----, ----, ----, in the senses and appetites, iii. 122 ----, ----, ----, in the lymphatic and glandular system, iii. 124 ----, ----, ----, on the skin, iii. 125 ----, ----, ----, in the blood, iii. 128 ----, ----, nature of the black vomit, iii. 111 ----, ----, types of the, iii. 135 ----, ----, the empire of, over all other diseases, iii. 139 ----, ----, who most subject to it, iii. 148 ----, ----, negroes affected by it in common with white people,