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ficiently early to cut short the disease, it prevented or mitigated the symptoms of increased determination to the chest, or head, so apt to supervene.
In the Trusty, the treatment deemed the most successful was, where the patient lost within the first week or ten days between sixty and eighty ounces of blood, by taking away from sixteen to twenty four ounces at a time. When the fever was violent, a larger quantity was abstracted in a shorter period; but it was not often necessary to exceed thirty-six ounces in twenty-four hours, at two or three bleedings. After the tenth day it was not often considered proper to bleed, or only in smaller quantities, when indicated by symptoms of pressure upon any par ticular organ, or by the appearance or renewal of inflammation. When this remedy had been neglected at the beginning, or the patient was admitted on an uncertain day of the distemper, small bleedings of six or eight ounces, repeated according to the effect, were found safer than larger ones, which might have proved too debilitating, and were serviceable in preventing or moderating the consequences of inflammation and congestion. An able physician, Dr Parry, in his Elements of Pathology, page 317, thinks it is probable that subsultus tendinum, convulsive motions of the limbs, and hiccup, which often concur with delirium in various fevers, arise from long or violent irritation of the brain by sanguineous impulse." It is certainly in favour of this idea that effusions of blood or serum were generally found in the brain of those who died with these symptoms about the 18th day; and that, in some patients where small bleedings, graduated by the pulse, were tried even as late as this, when delirium, subsultus, startings, and coma, indicated an oppressed or irritated state of the sensorium, these symptoms were diminished, the respiration became freer, and the intellect more distinct after its employment. Under this treatment some apparently hopeless cases assuredly recovered; but it oftener failed. It is allowed that the presence of fever is most certainly detected by the state of the animal functions, and of the pulse; but to the latter there are many exceptions. I need not here adduce the many authorities that might be quoted in support of my own observation, to shew that the pulse, in many cases, has been found little affected in the worst fevers; that it is often little, if any, quicker than natural; and that it is sometimes preternaturally slow. But I believe it to be unnecessary to dwell upon its fallaciousness, or on the little information it often affords as to the propriety or quantity of blood to be taken, particularly where the head is much affected. In the early stage of disease it is often small, low, feeble, and irregular, previous to
considerable reaction; but, when the accession of this state is characterized by increased heat, hard, full, and frequent pulse, throbbing of the carotids, and other symptoms of excessive de termination, the indication is sufficiently manifest. This state of increased action, however, does not always follow, but the pulse continues low and contracted, or labouring and oppressed, until relieved by evacuations, when it rises, becomes fuller, and more equal ;- an effect which, with correspondent improvement in the intellectual powers, I have often seen produced by purgatives, as well as by venesection, in tropical fevers.
In this depressed state, the employment of a remedy, by no means passive, requires nice discrimination; for it is necessary to distinguish between that period of diminished energy preceding reaction, where it would prove injurious, and that in which, to use the language of Sydenham, all the symptoms of weakness proceed from nature's being in a manner oppressed, and overcome by the first attack of the disease, so as not to be able to raise regular symptoms adequate to the violence of the fever," until it could disengage and shew itself" by bleeding. Vol. II. p. 351.
It is impossible, therefore, from the state of the circulation, to lay down any infallible criterion for the employment of bloodletting in fever. The safest is the hardness of the pulse, and a white tongue, as indicating inflammatory action; and, upon the whole, it was generally considered at least safe to bleed in the early stage, where the heat was increased, and the pulse above 100.
The degree of resistance of the artery against the finger was considered a better guide than the size of the pulse; if it was firm and equal, bleeding was generally proper; if easily compressed, soft, or undulating, the contrary; if it felt tense, or corded, or the stroke was described as sharp, harsh, jerking, or rebounding, it was considered indispensable; but, in using such terms, we must be aware how difficult it is to attach precise and determinate meanings to words, and that the same pulse will be described very differently by different reporters.
In speaking of the fallacy of the pulse, I ought not to omit noticing the unequal distribution and power of the circulation which not unfrequently obtain in fever, as another source of error, if we judge of its force, in the vessels near the heart, by those of the extremities; for it may be strong and bounding in the central, yet weak and languid in the distant ar teries. Some marked examples of this kind occurred from exposure to severe cold for several hours in boats after depletion; in consequence of which, I grounded my applica
tion of the necessity of having a decked vessel to convey the sick to the hospital-ships. These patients, notwithstanding the application of warm blankets, &c. continued to complain of an extreme sense of chilliness, with coldness, and a sunk languid pulse in the extremities, while the face was hot and flushed, and the large vessels of the neck and head were greatly excited, indicating what Mr Hunter calls action without power. and shewing the danger, in such a case, of appretiating the state of the internal circulation by that of the radial artery. This unequal and partial distribution of heat, which seems to have engaged the attention of the ancients much more than the pulse, is very unfavourable in fever; and the same is the case whenever the actual condition of the patient and his feelings are much at variance; as, for example, when he complains of a much greater degree of either heat or cold than is indicated by the touch or by the thermometer.
With respect to the comparative advantages of large or of frequently-repeated small bleedings, in early fever, both plans were employed here, and with various results; the latter may be often useful and safe, where the former would be inadmissible. But, at the commencement of the attack, or where some important viscus is threatened with inflammation, I must give a decided preference to the large and sudden abstraction of blood, while there is yet any chance of anticipating or removing congestion, or of cutting short the fever. The one will, of course, be preferable while we have these objects in view; the other may be useful in mitigating symptoms where the expectation of crushing the disease can be no longer indulged. It is also evident, that the occurrence or renewal of inflammation later in fever may justify a cautious and limited detraction of blood, when the loss of a larger quantity could not be borne.
The same advantages were derived from venesection in cases of relapse. Mr Sheppard, who was surgeon of the convalescent ship, upon whose judgment I place great reliance, remarks: "From cautious experience of the advantages of blood-letting, the activity of fever often induced me to bleed largely, occasionally twice or thrice within the first twenty-four hours of the relapse. Nothing short of experience of decided benefit from this remedy could have justified the practice in that state of disease." He further observes: "Notwithstanding the advantages resulting from depletion, the blood drawn exhibited no inflammatory character."
The total amount of blood most frequently abstracted in the course of this disease has been already stated; but in some few extremely plethoric and robust constitutions, from 100 to
150 ounces, and upwards, were taken away, with both successful and unsuccessful results. In one case of extremely violent fever in the fleet before my arrival, and where extravasation was afterwards found in the brain, I was informed that 200 ounces of blood had been withdrawn; but there are very few, if any, instances where the propriety of so large an evacuation may not be held questionable.
Like the pulse, the appearance of the blood was not a faithful index of the expediency of venesection. Though frequently, it did not generally exhibit the buffy coat; and, in many cases where it was soft and florid at first, it became firm and buffy under subsequent bleedings. However, if there was a large proportion of crassamentum, this remedy was not deemed less
In many instances the coagulum seemed soft, and as if dissolved in the serum; while, in others, the surface appeared like half-warmed jelly. In blood drawn late in the disease, or examined afterwards, the serum was often found of a firm gelatinous consistence, and of a straw colour, with not an eighth part of crassamentum, and that of a very loose texture, and of the appearance of currant-jelly. The presence of petechia did not prevent early depletion in this disease. On the contrary, they were obviously connected with increased excitement, and determination to the surface, and very often disappeared after, though they were not always prevented by the detraction of blood. It is, however, necessary to discriminate between petechiæ occurring at an early, and those which sometimes appear in the last stage of fever, when the circulation is languid, and the vital powers are failing.
In estimating the general value of phlebotomy, considerable allowance ought, no doubt, to be made for circumstances, such as the season of the year, and the robust habits of the Russians; but it was also practised upon the attendants and others with similar good effects, and, the reports add, upon the old as well as the young;-an observation which I should feel considerable hesitation in receiving, without explaining that there were very few with aged or debilitated constitutions.
In a typhous fever which afterwards prevailed among the Danish and American prisoners of war, and in which a glossy and turgid appearance of the eye was often the first indication of the disease, Dr Dobson of the Trusty informed me, that he found venesection attended with the same success as in the Russians; but, while he is firmly of belief that no other plan was equally successful, he candidly acknowledges that, in many cases, his expectations from the lancet were altogether disap
pointed, while, in others again, it seemed to save several who were studded with petechiae,-a symptom that often manifested itself within thirty-six hours of the attack. After reverting to the failure of the lancet in cases where he had reason to expect success, he concludes,-" But these failures by no means argue against the propriety of the practice, where no other measure was equally successful; inflammation was still present, and to its consequences death was, in every case, clearly proved by dissection."
In endeavouring to account for this contrariety of result in cases seemingly analogous, the operation of moral and physical causes, and particularly the varying influence of confinement and mental depression on different constitutions, with many other considerations, ought not to be overlooked.
To those who would infer that, if fever and inflammation be so frequently connected, and follow each other in the relation of cause and effect, blood-letting ought to be more uniformly proper and successful in fever, it may be answered, that, even could its existence be always immediately ascertained, yet such is the variety in the kind and degree of inflammation, according to the seat, nature, and period of the disease, as greatly to modify the result; for, in fact, with the exception of greater fulness of the vessels of the part, owing to the peculiarity of structure and the mutability of the animal powers, very different, and even opposite conditions, have been comprehended under this general term. It therefore by no means follows, that this operation should be indiscriminately resorted to; or, even setting aside its injudicious employment as to time or quantity, that it should be expected to prove uniformly successful in fever; for we know that this is far from being the case even in the purer phlegmasiæ, and that the diseases of this order neither always admit, nor can they be always arrested by extensive depletion. Upon the whole, however, I am inclined to think that the results were more favourable in the Russian than in the later fever; and, after making all deductions, that they were amply sufficient to prove the great superiority of this mode of treatment. The whole of the medical reports, and particularly those of Dr Douglas, concurred to substantiate the efficacy of early and decided blood-letting; and, when the many bad cases admitted into both establishments are taken into consideration, I think it may be fairly concluded, that the success was fully as great as could be expected in a disease so complicated as fever, and so often attended with dangerous congestions. Farther than I have above stated, I cannot pretend to lay down any precise directions for the employment of venesection.