Observations on blood-letting. Founded upon researches on the morbid and curative effects of loss of blood ...

CHAPTER I. PAGE INTRODUCTORY OBSERVATIONS : i CHAPTER II

OF THE IMMEDIATE EFFECTS OF LOSS OF BLOOD - - - - - 9 1. Of Syncope - ee : - 9 2. Of Convulsion - - - - - 13 3. Of Delirium — - - - - - 17 4. Of Coma - - SEA - 22 5. Of Sudden Dissolution - vi

OF

OF

OF

OF

CONTENTS.

Chapter III. The More Remote Effects Of Loss

OF BLOOD, OR EXHAUSTION = 1. Of Hxhaustion with excessive Reaction 2. Of Exhaustion with defective Reaction 3. Of Exhaustion with Sinking < -

4. Of Exhaustion with Delirium or Mania

». Of Exhaustion with Coma - : 6. Of Exhaustion with Amaurosis - -

Chapter II. Of Some Diseases In Their- Relation To

LOSS OF BLOOD : - =- 196 I. Of Fever - - - fs - 196 2. Of Inflammation - - - - 201 3. Of Irritation - - - - = LO 4. Of Accidents and Operations — - -- 243

Chapter III. Of The Due Institution Of Blood-letting 250

1. Of early Blood-letting - - - 269 2. Of a first Blood-letting — - - ah. Te 3. Of the Repetition of the Blood-letting - 279 4. Of Blood-letting as a Preventive of Inflammation - - - - 284 ». Of late Blood-letiing - - - 287

Of Local Biood-letting - - Week

Os :

vill CONTENTS.

Chapter IV

OF BLOOD-LETTING IN INFANCY AND CHILD- HOOD - ~ = a = OT CONCLUSION’ ~- = 299 POSTSCRIPT.

TABLE of the Degree of Tolerance, or Intolerance, of Loss of Blood in different

Diseases - - - - a ee Sc. §C.

AN ESSAY P

ON A HYDRENCEPHALOID AFFECTION IN INFANTS’ ARISING FROM EXHAUSTION.

; A eae wen ae ete ee et ead

REGISTER OF CASES OF BLOODLETTING.

No. and|, 48eand | Di Quantity E ; a Ges streneth of th isease, its stage ee ffects on Pr initials. ten t | - and complications. of blood the patient and Appearances of the Repetitions of the ip ee i, d . taken. on the disease blood. bloodletting. a pone aod ase ; " on the disease.

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Part First. ‘on The Morbid Effects Of Loss Of Blood

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Part First. On The Morbid Effects Of Loss Of Blood

CHAPTER L[.

INTRODUCTORY OBSERVATIONS.

THE question of the morbid effects of loss of blood appears to me not to have sufficiently engaged the attention either of the physiologist or of the practical physician; yet to both they offer objects of inquiry of great interest and importance.

To the physiologist the phenomena of syncope, of reaction, and of sinking, present innumerable objects for his consideration, of the very deepest interest. The influence of syncope on the functions of the brain, of the heart, of the capillary

B 2 vessels, of the lungs, of the stomach, &c.; the phenomena of reaction, excessive or defective ; but especially the phenomena and influence of the sinking state, or state of failure and decline of the vital powers, in their relation both to the nervous, the circulating, and the organic systems, severally present objects for our investigation, in a physiological point of view, at once of much novelty and of the highest utility.

To the physician the symptoms of reaction, so similar to those of some inflammatory affections of the head and of the heart, and the phenomena of the sinking state, so similar to those of eae other affections of the head, and to those of some morbid affections within the chest and abdomen, present subjects for his observation of the utmost moment in actual practice. The diagnosis of these cases is most important ; the prognosis and the treatment alike depend upon it.

The morbid effects of loss of blood may be divided into the immediate and into the more remote. Besides syncope, from its slightest to its fatal form, the former include delirium, convulsions, and coma. The latter comprise the

OF LOSS OF BLOOD. ~ oe states of excessive reaction, of defective reaction, of the gradual failure of the vital powers, and of more rapid or sudden sinking or dissolution. The former, the different forms of syncope at least, are comparatively well known. The latter appear to me not to have received the degree of attention due to them. No author has described with accuracy the secondary or more remote effects of loss of blood, under the various circumstances of repetition, or continued flow, in which it may occur. And yet when we reflect how constantly bloodletting is employed as a remedy, and how frequently hemorrhage occurs as a disease, it must evidently be of great moment to trace the symptoms and effects of a diminished quantity of blood upon the different functions of the human body.

This inquiry possesses a still higher interest in a practical point of view; for, as I shall immediately explain, some of the more obvious and striking effects of loss of blood, or those of reaction, are such as to suggest the idea of increased power and energy of the system, and of increased action in some of its organs, and to lead to an erroneous and dangerous employment or repetition of the lancet, when a directly opposite mode of treatment is required ; while the state of actual but protracted sinking frequently resembles a state of oppression of the brain, or of congestion of the lungs, so accurately, as to prompt the unwary practitioner to a still more suddenly fatal use of the lancet.

There is another point of view in which the effects of loss of blood become interesting in the practice of physic. I have already stated that the symptoms of reaction from loss of blood, accurately resemble these of power in the system, and of morbidly increased action of the encephalon, and that from these causes the case is very apt to be mistaken, and mistreated by the further abstraction of blood. The result of this treatment is in itself again apt further to mislead us; for all the previous symptoms are promptly and completely relieved ; and this relief, in its turn, again suggests the renewed use of the lancet. In this manner the last blood-letting may prove suddenly and unexpectedly fatal.

The next point for our consideration is the influence of the age, the strength, and the varied constitution of the patient, in modifying the effects of loss of blood. On these greatly depends the tendency to defective or to excessive reaction, and to the state of sinking. So that the effects do not correspond with the measure, or even a comparative measure, of loss of blood, in different subjects. Sometimes there is no reaction. At other times the reaction is excessive and even violent. In a third instance we may be surprised by the sudden accession of a sinking state, or even of the symptoms of immediate dissolution. I think the whole of these varied and even opposite phenomena admit of a ready explanation. In general it may be said that reaction is principally observed in connection with strength of system ; in infancy and in old age reaction is slight ; exhaustion from loss of blood is then most apt to shew itself in the form of failure or sinking of the vital powers.

But a question still more interesting even than this, is that of the influence of different diseases in inducing in the system, resistance or susceptibility in regard to the effects of loss of blood. The discussion of this subject, and its application to practice, are reserved for the’

second part of this work.

The next point for our consideration in the inquiry into the morbid effects of loss of blood, is that of the organic changes induced during the state of sinking. These are chiefly observed in the brain, in the cavities of the serous membranes, in the bronchia, in the lungs, and in the track of the alimentary canal, under the forms of effusion, cedema, and tympanitis.

We must consider, in the last place, the proper mode of treating the effects of loss of blood, both constitutional and local. This discussion will involve many very interesting questions.

The effects of loss of blood then require to be traced successively in their relation both to the central and to the ultimate parts both of the nervous and vascular systems. They involve questions of the deepest interest in regard to the physiology, pathology, and treatment.

CHAPTER. II.

OF THE IMMEDIATE EFFECTS OF LOSS OF BLOOD.

1. Of Syncope.

THE most familiar of the effects of loss of blood is syncope. The influence of posture, and the first sensations and appearances of the patient, in this state, appear to denote that the brain is the organ the function of which is_ first impaired ; the respiration suffers as an immediate consequence ; and the action of the heart becomes enfeebled as an effect of the defect of stimulus, first from a deficient quantity of blood, and secondly from its deficient arterialization; the capillary circulation also suffers; and if the state of syncope be long continued, the stomach and bowels become variously affected.

In ordinary syncope from loss of blood, the patient first experiences a degree of vertigo, to which loss of consciousness succeeds ; the respiration is affected in proportion to the degree of insensibility, being suspended until the painful sensation produced rouses the patient to draw deep and repeated sighs, and then suspended as before; the beat of the heart and of the pulse is slow and weak; the face and general surface become pale, cool, and bedewed with perspiration; the stomach is apt to be affected with eructation or sickness. On recovery there is perhaps a momentary delirium, yawning, and a return of consciousness ; irregular sighing breathing ; and a gradual return of the pulse. In cases of profuse hemorrhagy the state of the patient varies: there is at one moment a greater or less degree of syncope, then a degree of recovery. During the syncope the countenance is extremely pallid, there is more or less insensibility, the respiratory movements of the thorax are at one period imperceptible and then there are irregular sighs, the pulse is slow, feeble, or not to be distinguished, the extremities are apt to be cold, and the stomach is frequently affected with sickness.—There are several phenomena observed in this state particularly worthy of attention. I have remarked that when the movements of the chest have been imperceptible or nearly so, in the interval between the sighs, the respiration has still been carried on by means of the diaphragm.* It may also be observed that the state of syncope is often relieved, for a time, by an attack of sickness and vomiting, immediately after which the patient expresses herself as feeling better, and the countenance is somewhat improved, the breathing more natural, and the pulse stronger and more frequent. It may be a question, in this case, whether the state of syncope increases until it induces sickness ; or whether the stomach be nauseated by the ingesta usually administered, and the syncope be, in part, an effect of this state of the stomach. In any case the efforts to vomit, are succeeded, for a time, by an ameliorated state of the patient. : In cases of fatal hemorrhagy there are none of these ameliorations. The symptoms gradually

* The respiration is carried on chiefly, if not exclusively, by the diaphragm, in some other states of the system. I have witnessed this in hysteria. The patient is then scarcely observed to breathe. Mr. Hunter observed in a dog poisoned by injecting emetic tartar into its veins, that “ it continued pretty easy for about three hours, but then became a little convulsed, which increased, and at last it became senseless, with little twitchings, hardly breathing, except with the diaphragm, and having a low, slow pulse.”—On Inflammation, 8vo. Edit. 1812. V. 2. p. 44.

and progressively assume a more and more frightful aspect: the countenance does not improve but becomes more and more pale and sunk; the consciousness sometimes remains until at last there is some delirium ; but every thing denotes an impaired state of the energies of the brain ; the breathing becomes stertorous and at length affected by terrible gasping ; there may be no efforts to vomit ; the pulse is extremely feeble or even imperceptible; the animal heat fails. and the extremities become colder and colder in spite of every kind of external warmth ; the voice may be strong, and there are constant restlessness and jactitation ; at length the strength fails, and the patient sinks, gasps, and expires. —

From the state of syncope the system usually recovers itself spontaneously, if the cause by which the syncope was induced, be discontinued. The principle by means of which this recovery is affected, may, without involving any hypothesis, be denominated reaction.

This reaction of the system may, under different circumstances, be excessive or defective, or it may be destroyed altogether and yield to an opposite condition of the vital powers, or sinking,—or to dissolution,—each state leading to a corresponding series of phenomena. The description of these varied phenomena is reserved for the ensuing chapter.

2. Of Convulsion.

Convulsion is, after syncope, the most familiar of the immediate effects of loss of blood. It is most apt to occur in children, and in cases of the slow and excessive detraction of blood.

Convulsion obviously arises from an affection of the brain. It is that phenomenon which denotes most distinctly that the brain may be similarly affected in opposite states of the general system; an observation as old as Hippocrates, who observes cracpos yiveras } tno wAnpwotos, 7) Kevwaotos. This remark applies not only to convulsive movements of the voluntary muscles, but to those of the respiratory system. In this manner, indeed, I believe, an affection resembling croup is sometimes induced, which is very apt to be mistaken and mistreated for croup itself.

The general principle of the affection of the brain from a state of inanition or exhaustion of the vascular system, is one to which I shall have occasion repeatedly to advert in this work. It is also one of the utmost interest in physiology, and of the utmost moment in practice. In the case of convulsion as an immediate effect of loss of blood, their connection and relation are obvious. But in some other instances it requires much attention to trace them. In every case of convulsion the local treatment must be similar in principle though very different in degree; whilst the constitutional treatment must of course be of a directly opposite kind, in the two cases of repletion and of exhaustion of the general system.

Convulsion occurring from blood-letting must, I think, be generally considered as denoting that the remedy has been used beyond the safe degree. It is most apt to occur in cases in which the patient has been freely bled in a more or less recumbent position, in which the blood has flowed slowly, or in which time has been lost during the operation. Jn such cases much blood usually flows before syncope is observed, too much to be safe; in such circumstances we should therefore be very cautious how we bleed to deliquium. The following case, given to me by a friend, was one in which for a short time some alarm was felt lest the patient might not rally at all.

A physician, aged thirty-four, became affected with inflammation of the larynx. He was bled freely on two successive mornings at his own instance. In the afternoon of the second day, the disease being unsubdued, he was bled a third time, placed in a rather inclined position upon a sofa. The blood was allowed to flow until thirty-four ounces were taken. He then suddenly fell upon the floor violently convulsed ; and he remained for some time afterwards in such a state of syncope as to render his recovery very doubtful; being carried to bed, however, and cordials being administered, he slowly recovered. He did not afterwards suffer from the secondary effects of loss of blood.

A similar case is given by Mr. Travers. This gentleman observes, ‘‘ Some patients cannot bear the loss of blood; it gives rise to prostration, attended with convulsions, in which the circulation fails so alarmingly as to require watching for several hours and the repeated administration of stimulants to restore it. A very intelligent surgeon in the neighbourhood of London, in bleeding a clergyman to the extent of twenty ounces, whose idiosyncracy in this respect was not known, was compelled to remain with him during the whole of that day ; and notwithstanding frequent recourse to brandy, continued long apprehensive for the patient’s life. He represented the convulsions, which returned in paroxysms, as resembling the puerperal in their severest form. There has been reason to believe that the loss of blood in operations in which hemorrhage was unavoidable, has sometimes induced this state ; this however, in the present advanced state of surgery is rare.” *

The same author observes, ‘‘ The unavoidable effusion of blood in operations, though insufficient to create alarm for the patient’s safety, on that _ score, obviously predisposes to the convulsions which sometimes prove fatal, especially to children. I have known an infant die of convulsions on the day after the removal of a nevus from the scalp,

* On Constitutional Irritation, p. 501.

of no extraordinary size, and without any after hemorrhage.” *

Convulsion from loss of blood constitutes one species of puerperal convulsion, and should be accurately distinguished from other forms of this affection, arising from intestinal or uterine irritation, and an immediate disease of the head.

It is well known that infancy is extremely prone to convulsion, from various causes. This is particularly observed in relation to loss of blood.

In Dr. Kellie’s interesting experiments upon dogs and sheep, convulsions were found to be a frequent consequence of the vascular exhaustion.

3. Of Delirium.

Delirium occurs as an immediate, as mania occurs as a more remote, effect of loss of blood. A young man, aged thirty, had lost much blood from the arm, and by leeches, and under the influence of a brisk purgative fell into complete syncope; instead of laying him recumbent,

-* On Constitutional Irritation, p. 141.

c his ignorant friends kept him in the erect position during an hour and a half, and thus protracted the state of deliquium during the whole of this period. He was found perfectly colourless and senseless, and affected with rattling in the breathing. Being laid down, he made a convulsive effort to expectorate, and the blood rushed into his cheeks ; in half an hour he began to recover, opened his eyes, and complained of deafness ; the pulse was frequent. The rattling gradually subsided, and he regained a degree of warmth under the influence of brandy and fomentations.

To these phenomena succeeded severe rigor, followed by great heat of skin, constant delirium, with continued though diminished deafness. The delirium did not cease during the night. On the following morning it was only occasional, and the deafness slight.

This state was followed by numbness of the feet and legs, and great fear of choaking on going to sleep.

The patient gradually recovered.

Another patient fell and hurt his back. On three successive days he was freely bled from the arm and by cupping, and purged. On the evening of the third day he was again bled. This was followed by faintness, sickness, and retching, and much affection of the head.

I saw this patient very early on the following morning. There were great pallor, tinnitus aurium, with extreme intolerance of noises, and of the light, and sighing breathing. To these symptoms succeeded great hurry and alarm of mind, with extraordinary noises and _ visions, delirtum, weeping, and sighing. At length continued delirium supervened, and finally wore out the patient. :

The following case is remarkable by combining convulsion with delirium :

Mrs. pregnancy. ‘There was considerable flooding. On

, miscarried on the third month of her unthinkingly getting out of bed for some purpose, there was a sudden profuse gush of blood. She turned pale and nearly fainted. She was promptly carried and laid upon the bed, but soon became affected with convulsion. This was succeeded by delirium, which continued during two hours. A little brandy and water was given. She recovered in a few days.

As might have been anticipated, delirium fre-

C2 quently occurs as an immediate effect of heemorrhagy during parturition. Still more frequently mania occurs as a remote effect of loss of blood.

It is important to remark that delirtum may occur even from the loss of a very small quantity of blood, in those cases in which there is: what I have ventured to term intolerance of loss of blood, or in other words, great susceptibility to its: effects, a subject which will be fully discussed in the Second Part of this work.

Mrs.

under medical treatment for a small tumor in the

, aged 40, had been, for some time, mamma. She was seized with rubeola; on the first and second days of the rash she was purged freely, too freely ; on the third she was bled to eight ounces, and six leeches were applied to the chest, for a slight oppression felt there. Mrs. without sleep, although on the evening of the

, had also passed five nights totally second day she had taken twenty-five minims of the tinctura opi.

Under the influence of these circumstances, Mrs. ——, was seized with delirium. I saw her on the fourth day; there were constant delirium, a profuse perspiration, a trifling. rash, and a feeble pulse of 120. I gave fifty drops of tinctura opii, and one dram of the spiritus ammoniz aromaticus.

I saw Mrs. ——, again in four hours; the delirrum had subsided into a state of obstinate silence, the patient sitting up in bed, refusing to answer questions, and having had no sleep; the skin and pulse as before. I directed one ounce of brandy to be given every hour, with beef tea.

The first dose of brandy had produced sleep. It was directed to be continued every hour, at my visit in the morning.

On the morning of the second day I was informed that eight ounces of brandy had been taken during the night ; and that there had been much quiet sleep. I found the patient collected, the pulse 108, and less feeble ; the skin still in a state of perspiration. The brandy was directed to be given every second hour. In the evening there was still further amendment. The bowels not having been moved, an aperient draught was prescribed to be taken early in the morning.

This draught acted thrice. The delirium returned, and was removed by the brandy, which again procured sleep.

From this time there was no recurrence of delirium. The perspiration kept profuse for some days, but gradually subsided; the pulse became gradually slower and stronger. There was afterwards a protracted affection of the chest.

Puerperal mania from hemorrhagy is rather to be ranked amongst the secondary effects of loss of blood, and will be slightly discussed in its proper place.

4. Of Coma.

We may be called to patients so perfectly comatose, immediately after blood-letting or hemorrhage, that we may be in doubt for a time whether the case be not apoplexy. The history, the state of the countenance, of the pulse, and of the extremities, and the other symptoms will, after a little watching, make the case clear to us.

I do not find that I have preserved the notes of any case of this kind in adults ; but the reader will find in an appendix to this volume a rather minute account of such a morbid state occurring in infants and children.

Mr. C. Bell observes, ‘‘ when a man who has eut his throat is brought into the hospital, he is in a state very much resembling that which some authors have described as accompanying severe wounds. Though sensible, he is cold, pale, taciturn, and very often, although such men are desirous of living, they sink within twenty-four hours. This appears at first to proceed from a strong impression on the mind; that is, I believe, the consequence of loss of blood, and the shock thus given to their powers of life.’ *

5. Of Sudden Dissolution.

I have pointed out, page 6, some circumstances in which blood-letting has led to sudden dissolution, and I have recorded in a recent work, fT several instances of this kind. ‘To these I must refer the reader. The subject will be again mentioned in the second part of this volume, in which the cases in which this sad event

* Surgical Observations, Part iil. page 335. + Commentaries on some Diseases of Females, p. 286.

is most apt to occur, will be accurately pointed out.

An interesting account of a case of this kind is given in the Lancet, vol. xi. p. 94. . Arthur P., a stout muscular man, about 57 years of age, was brought to the hospital, early on Friday morning, in consequence of a fall from a scaffold a few minutes previously. On examining into the nature of the accident, the fourth, fifth, and sixth ribs were discovered to be fractured near their angles. Their fractured ends having been pushed inward, through the intercostal muscles, pleura costalis, and pulmonalis, into the substance of the lungs, the air had consequently escaped into the thorax, and through the pleura and lacerated muscles into the cellular tissue on the outside of the chest. The patient at this time complained of considerable tightness of the chest, with pain chiefly in the situation of the fractures. His inspiration was somewhat short and rapid ; the pulse was at first weak and contracted, but in a very short time became full and hard. In addition to these symptoms he had cough, attended with expectoration, as well as severe pain in the head. The crepitation was for the most part confined to the integuments covering the left side of the thorax. He was bled by the dresser to eighteen ounces, and at noon he was ordered to. lose twenty ounces more, to take a dose of house medicine occasionally, and to have a bandage applied loosely.

The blood drawn yesterday had a decidedly inflammatory character, and after the abstraction of it, the patient expressed himself relieved. He has passed an indifferent night, and is much annoyed by a troublesome cough. Pulse quick ; tongue slightly coated ; bowels open; ordered to be bled to eighteen ounces, and to take common linctus for the cough.

Noon.—Still complains of pain about the seat of the injury, but in a much less degree than before ; the emphysema has not extended beyond its former boundaries ; free from pain in his head, and on the whole expresses himself better. Pulse 90, full, and rather jerking; tongue moist. Ordered to lose eighteen ounces of blood immediately, and a similar quantity in the evening.

Has passed a good night, and this morning we find him eapable of talking cheerfully with a friend. Expresses himself free from all pain.

Emphysema just the same; expectorates freely ; pulse small and jerking, but very compressible. The blood drawn yesterday has not the slightest appearance of inflammation.

Mr. Lloyd ordered the patient to lose eighteen ounces of blood, considering, as we suppose, the state of the pulse as indicative of inflammation, and not as resulting from loss of blood, hemorrhagic irritation, as this state has been called. The dresser, however, perceiving what effect even the loss of a few ounces had, desisted from drawing any more. About two hours subsequently, Mr. Lawrence saw the patient, and concurred with Mr. Lloyd, as to the propriety of the further abstraction of blood; they therefore directed twenty ounces of blood more to be drawn. The pulse after this time became a mere flutter, and the man only survived a few hours.

On examination the fourth, fifth, and sixth ribs were found to be fractured near to their angles; the left lung was considerably torn and collapsed, and into the left cavity about a pint of bloody fluid was found effused. The right lung was quite healthy, but appeared very light coloured from the almost total absence of blood

OF LOSS OF BLOOD. - ae in it. The left lung sank on being placed in water ; it appeared going into a state of hepatization. Here and there the pleura pulmonalis was detached from the lung by means of. the extravasated air, and presented a tuft-like appearance.

The vessels about the heart were quite empty, neither was there any fibrine found in the ventricles, the whole organ being of a very pale colour. The right cavities bore no proportion to the left, the former being considerably larger, and the coats thinner than the latter. The liver was of a very light colour. The spleen was found to be particularly tinged with blood. On removing the skull cap the dura mater presented a vascular appearance; but the pia mater and the substance of the brain were almost colourless. The man was observed to have a reducible inguinal hernia on the right side. On examining the contents of sac, it was found to be omentum.”

CHAPTER III.

OF THE MORE REMOTE EFFECTS OF LOSS OF BLOOD, OR EXHAUSTION.

1. Of Exhaustion with excessive reaction.

EXHAUSTION may assume several different characters. It may be attended with excessive or with defective reaction, or with actual sinking of the vital powers ; its most prominent symptom may be delirium, or coma. With each of these it is very important that the physician should be accurately acquainted. I proceed to describe that form of exhaustion which is attended with excessive reaction.

The reaction or recovery from ordinary syncope is generally a simple return to a healthy state of the functions, or nearly so, the pulse not passing beyond its natural frequency. In cases of profuse loss of blood, on the contrary, the recovery is not quite so uniform, and the pulse acquires and retains a morbid frequency for a certain length of time; this frequency of the pulse may gradually subside, however, and be unattended by any other symptom of indisposition of any consequence.