No. 749.

LONDON, SATURDAY, JANUARY 6, 1838. [1837-38.

LECTURESON THE

THEORY AND PRACTICEOF MEDICINE;

NOW IN COURSE OF DELIVERY AT THE

THEATRE OF ANATOMY AND MEDICINE,WEBB-STREET, SOUTHWARK.

BY

MARSHALL HALL, M.D.,F.R.S. L.&E.,&c., &c.

THE EFFECTS OF Loss or. BLOOD :&mdash;T/ty harebeen often confounded with !)ta<MMM<Or!/affections, Theil’ distinction into 1’remoteand immediate effects. Organic changesprodzzced du1’&Igrave;ng the state of sinking. Theimmediate e.ffects of loss of blood; Ulustm-tions drazcri from venesection, pUC1’pe1’al hce-ino)-rha,e,4-c. The reaction whicla succeedsp1’ofuse loss of blood ; examples d1’au’n from1n’actice, Syncope and coma. Exhaustionfollowed by excessave reaction; its distinc-tire characters. Reaction a1’ising frorn acontinued drain of blood. Effects of long-continued epistaxis. Consequences of freebloodletting in certain cases of threatenedapoplexy.Gr.TLEMEN:&mdash;I must now beg your atten-

tion to another subject equally importantand practical with intestinal irritation, and,I trust I may add, equally indebted to myown investigations.The question of the morbid effects of loss

of blood appears to me not to have suf-ficiently engaged the attention either of thephysiologist or of the practical physician;yet to both they offer objects of inquiry ofgreat interest and importance.To the physiologist the phenomena of

syncope, of reaction, and of sinking, presentinnumerable objects for his consideration, ofthe very deepest interest. The influence ofsyncope on the functions of the brain, of theheart, of the capillary vessels, of the lungs,of the stomach, &c. ; the phenomena of re-action, excessive or defective, but especiallythe phenomena and influence of the sinking

state, or state of failure and decline of thevital powers, in their relation both to thenervous, the circulating, and the organicsystems, severally present objects for ourinvestigation, in a physiological point ofview, at once of much novelty and of thehighest utility.To the physician the symptoms of reaction,

so similar to those of some inflammatoryaffections of the head and of the heart, andthe phenomena of the sinking state, so

similar to those of some other affections ofthe head, and to those of some morbid affec-tions within the chest and abdomen, presentsubjects for his observation of the utmostmoment in actual practice. The diagnosisof these cases is most important; the pmg’"nosis and the treatment alike depend upon it.The morbid effects of loss of blood may

be divided into the immediate and into themore remote. Besides syncope, from itsslightest to its fatal form,the former includedelirium, convulsions, and coma. The lattercomprise the states of excessive reaction, ofdefective reaction, of the gradual failure ofthe vital powers, and of more rapid or sud-den sinking or dissolution. The former, thedifferent forms of syncope at least, are com-paratively well known. The latter appearto me not to have received the degree ofattention due to them. No author has de-scribed with accuracy the secondary or

tnore remote effects of loss of blood, underthe various circumstances of repetition, orcontinued flow, in which it may occur.And yet when we reflect how constantlybloodletting is employed as a remedy, andhow frequently haemorrhage occurs as a

disease, it must evidently be of great momentto trace the symptoms and effects of a dimi-nished quantity of blood upon the differentfunctions of the human body.This inquiry possesses a still higher in-

terest in a practical point of view, for, asI shall immediately explain, some of themore obvious and striking eflects of loss ofblood, or those of reaction, are such as tosuggest the idea of increased power and

energy of the system, and of increased actionin some of its organs, and to lead to an eri-o-neous and dangerous employment or repe-tition of the lancet when a directly opposite

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mode of treatment is required; while thestate of actual but protracted sinking fre-quently resembles a state of oppression ofthe brain, or of congestion of the lungs, soaccurately as to prompt the unwary prac-titioner to a still more suddenly fatal use ofthe lancet.There is another point of view in which

the eflects of loss of blood become interest-ing in the practice of physic. I have already Istated that the symptoms of reaction fromloss of blood accurately resemble those ofpower in the system, and of morbidly in-creased action of the encephalon, and thatfrom these causes the case is very apt to bemistaken, and mistreated by the further ab-straction of blood. The result of this treat-ment is in itself again apt further to mis-lead us, for all the previous symptoms arepromptly and completely relieved ; and thisrelief, in its turn, again suggests the reneweduse of the lancet. In this manner the lastbloodletting may prove suddenly and un-expectedly fatal.The next point for our consideration is

the influence of the age, the strength, andthe varied constitution of the patient, inmodifying the effects of loss of blood. Onthese greatly depends the tendency to de-fective or to excessive reaction, and to thestate of sinking. So that the effects do notcorrespond with the measure, or even a com-parative measure, of loss of blood in difre-rent subjects. Sometimes there is no reac-tion. At other times the reaction is exces-sive, and even violent. In a third instance,we may be surprised by the sudden acces-sion of a sinking state, or even of the symp-toms of immediate dissolution. I think thewhole of these varied and even opposite phe-nomena admit of a ready explanation. Ingeneral it may be said that reaction is prin-cipally observed in connection with strengthof system ; in infancy and in old age reac-tion is slight ; exhaustion from loss of bloodis then most apt to show itself in the formof failure or sinking of the vital powers.But a question still more interesting even

than this, is that of the influence of differentdiseases in inducing in the system resistanceor susceptibility in regard to the effects ofloss of blood. The discussion of this sub-ject, and its application to practice, are rc-served for another occasion.

The next point for our consideration inthe inquiry into the morbid effects of lossof blood, is that of the organic changes in-duced during the state of sinking. Theseare chiefly observed in the brain, in thecavities of the serous membranes, in thebrouchia, in the lungs, and in the track ofthe alimentary canal, under the forms ofeffusion, oedema, and tympanitis.We must consider, in the last place, the

proper mode of treating the effects of loss ofblood, both constitutional and local. This

discussion will involve many very interest-

ing questions,The effects of loss of blood then require

to be traced successively in their relationboth to the central and to the ultimate partsboth of the nervous and vascular systems.They involve questions of the deepest in-terest in regard to physiology, pathology, andtreatment.

I. 01- THE InIhI.DIA1L: 1;H’I’I?GTS OF LossOF BLOOD.

1. Of 8yncope,-The most familiar of theefiects of loss of blood is syncope. Theinfluence of posture, and the first sensationsand appearances of the patient, in this state,appear to denote that the brain is the organ,the function of which is first impaired; therespiration suffers as an immediate conse-quence ; and the action of the heart becomesenfeebled, as an effect of the defect of sti-mulus, first from a deficient quantity ofblood, and, secondly, from its deficient arte-rialisatiou; the capillary circulation alsosuffers ; and if the state of syncope be

long-continued, the stomach becomes liffect-ed with sickness, and the bowels are eva-cuated.

In ordinary syncope from loss of bloodthe patient first experiences a degree ofvertigo, to which loss of consciousness stic-ceeds ; the respiration is affected in propor-tion to the degree of insensibility, being sus-pended until the painful sensation producedrouses the patient to draw deep and repeat-ed sighs, and then suspended as before ; the

beat of the heart and of the pulse is slowand weak: the face and seneral surface be-come pale, cool, and bedewed with perspi-ration ; the stomach is apt to be affectedwith eructation or sickness. On recoverythere is perhaps a momentary delirium,yawning, and a return of consciousness; ir-regular sighing breathing; and a gradualreturn of the pulse.

In cases of profuse haemorrhage the stateof the patient varies : there is at one momenta greater or less degree of syncope, then adegree of recovery. During the syncopethe countenance is extremely pallid, there ismore or less insensibility, the respiratorymovements of the thorax are at one periodimperceptible, and then there are irregularsighs ; the pulse is slow, feeble, or not to bedistinguished, the extremities are apt to becold, and the stomach is frequently affectedwith sickness. There are several phenomenaobserved in this state particularly worthy ofattention. I have remarked that when themovements of the chest have been impercep-tible, or nearly so, in the interval between thesighs, the respiration has still been carried onby means of the diaphragm. It may also be

observed, that the state of syncope is oftenrelieved, for a time, by an attack of sicknessand vomiting, immediately after .whiBt1 thepatient expresses herself as feeling better

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and the conntenaece is somewhat improved,the breathing more natural, and the pulsestronger and more frequent. It may be a

question in this case, whether the state ofsyncope increases until it induces sickcess ;or whether the stomach be nauseated by theingesta usually administered, and the syn-cope be, in part, an effect of this state of thestomach. In any case the efforts to vomitare succeeded, for a time, by an amelioratedstate of the patient.

In cases of fatal haemorrhage there are noameliorations. The symptoms graduallyand progressively assume a more and morefrightful aspect: the countenance does notimprove, but becomes more and more paleand sunk ; the consciousness sometimes re-mains, until, at last, there is some delirium;but everything denotes an impaired state ofthe energies of the brain ; the breathing be-comes stertorous, and, at length, affected byterrible gasping; there may be no effortsto vomit; the pulse is extremely feeble, oreven imperceptible ; the animal heat fails,and the extremities become colder andcolder in spite of every kind of externalwarmth ; the voice may be strong, and thereare constant restlessness and jacitation ; atlength the strength fails, and the patientsinks, gasps, and expires. ’

From the state of syncope the system ’,usually recovers itself spontaneously, if thecause by which the syncope was induced be discontinued. The principle by meansof which this recovery is effected, may,without involving any hypothesis, be deno-minated reaciion.This reaction of the system may, under

different circumstances, be excessive or de-fective, or it may be destroyed altogether,and yield to an opposite condition of thevital powers, or sinking,&mdash;or to dissolution,- each state leading to a correspondingseries of phenomena.

2. Of Convulsion.&mdash;Convulsion is, after

syncope, the most familiar of the immediateeffects of loss of blood. It is most apt tooccur in children, and in cases of slow andexcessive detraction of blood.Convulsion obviously arises from an affec-

tion of the brain. It is that phenomenonwhich denotes most distinctly that the brainmay be similarly affected in opposite statesof the general system; an observation asdld as Hippocrates. This remark appliesnot only to convulsive movements of the vo-luntary muscles, but to those of the respi-ratory system. In this manner, indeed, Ibelieve an affection resembling croup issometimes induced, which is very apt to bemistaken and mistreated for croup itself.The general principle of the affection of

the brain, from a state of inanition or ex-haustion of the vascular system, is one towhich I shall have occasion repeatedly toadvert. It is also one of the utmost inte-rest-in physiology, and of the utmost mo-

ment in practice. Iu the case of convulsion,as an immediate effect of loss of blood,their connection and relation are obvious;hut, in some other instances, it requires muchattention to trace them. In every case ofconvulsion the local treatment must besimilar in principle though very differentin degree ; whilst the constitutional treat-

ment, of course, be of a directly oppositekind, in the two cases of repletion and ofexhaustion of the general system.

Convulsion occurring from bloodletting,must, I think, be generally considered as de-noting that the remedy has been used beyondthe safe degree. It is most apt to occur incases in which the patient has been freelybled in a more or less recumbent position,in which the blood has flowed slowly, or inwhich time has been lost during the opera-tion. In such cases much blood usuallyflows before syncope is observed-too muchto be safe ; in such circumstances we should,therefore, be very cautious how we bleed todeliquium. The following case, given to meby a friend, was one in which, for a shorttime, some alarm was felt lest the patientmight not rally at all.A physician, aged thirty-four, became

affected with inflammation of the larynx.He was bled freely on two successive morn-ings at his own instance. In the afternoonof the second day, the disease being unsub-dued, he was bled a third time, placed in arather inclined position upon a sofa. Theblood was allowed to flow until thirty-fourounces were taken. He then suddenly fellupon the floor violently convulsed; and heremained for some time afterwards in sucha state of syncope as to render his recoveryvery doubtful ; being carried to bed, how-ever, and, cordials being administered, heslowly recovered. He did not afterwardssuffer from the secondary effects of loss ofblood.’ A similar case is given by Mr. Travers.This gentleman observes :-&laquo; Some patientscannot bear the loss of blood ; it gives riseto prostration, attended with convulsions,in which the circulation fails so alarminglyas to require watching for several hours,and the repeated administration of stimu-lauts to restore it. A very intelligent sur-geon, in the neighbourhood of London, inbleeding a clergyman to the extent of twentyounces, whose idiosyncracy, in this respect,was not known, was compelled to remainwith him during the whole of that day; and,notwithstanding frequent recourse to brandy,continued long apprehensive for the patient’slife. He represented the convulsions, whichreturned in paroxysms, as resembling thepuerperal in their severest form. There hasbeen reason to believe that the loss of bloodin operations in which haemorrhage was un-avoidable, has sometime induced this state;this, however, in the present advanced stateof surgery, is rare.

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The same author observes :&mdash;" The un-avoidable effusion of blood in operations,though insufficient to create alarm for thepatient’s safety, on that score, obviouslypredisposes to the convulsions which some-times prove fatal, especially to children. Ihave known an infant die of convulsions onthe day after the removal of a naevus fromthe scalp of no extraordinary size, and with-out any after-haemorrhage.

Convulsion from loss of blood constitutesone species of puerperal convulsion, andshould be accurately distinguished fromother forms of this affection, arising from ’,intestinal or uterine irritation, and an imma-diate disease of the head.

It is well known that infancy is extremelyprone to convulsions from various causes.This is particularly observed in relation toloss of blood.

In Dr. Kellie’s interesting experimentsupon dogs and sheep, convulsions werefound to be a frequent consequence of thevascular exhaustion. I have proved theeffect to be dependant on the spinal marrow,and not, as formerly supposed, on the brain.

3. Of Delirium.-Delirium occurs as animmediate, as mania occurs as a more re-mote, effect of loss of blood.A young man, aged thirty, had lost much

blood from the arm, and by leeches, andunder the influence of a brisk purgative, fellinto complete syncope ; instead of layinghim recumbent, his ignorant friends kepthim in the erect position during an hour anda half, and thus protracted the state of deli-quium during the whole of this period. Hewas found perfectly colourless and senseless,and affected with rattling in the breathing.Being laid down, he made a convulsiveeffort to expectorate, and the blood rushedinto his cheeks ; in half an hour he beganto recover, opened his eyes, and complainedof deafness ; the pulse was frequent. Therattling gradually subsided, and he regaineda degree of warmth under the influence ofbrandy and fomentations.To these phenomena succeeded severe

rigor, followed by great heat of skiu, con-stant delirium, with continued, though di-minished, deafness. The delirium did notcease during the night. On the followingmorning it was only occasional, and thedeafness slight.This state was followed by numbness of

the feet and legs, and a great fear of choak-ing on going to sleep.The patient gradually recovered.Another patient fell and hurt his back.

On three successive days he was freely bledfrom the arm and by cupping, and purged.On the evening of the third day he wasagain bled. This was followed by faint-ness, sickness, and retching, and muchaffection of the head.

I saw this patient very early on the fol-lowing morning. There were great pallor,

tinnitus aUl’him, with extreme intoleranceof noises, and of the light, and sighingbreathing. To these symptoms succeededgreat hurry and alarm of mind, with extra-ordinary noises and visions, delirium, weep-ing, and sighing. At length continued deli.rium supervened, and finally wore out thepatient. He died, in fact, a maniac.The following case is remarkable as com-

bining convulsion with delirium :-’ Mrs. -- miscarried on the third monthof her pregnancy. There was considerableflooding. On unthinkingly getting out ofbed for some purpose, there was a suddenprofuse gush of blood. She turned pale andnearly fainted. She was promptly carriedand laid upon the bed, but soon becameaffected with convulsion. This was snc-

ceeded by delirium, which continued duringtwo hours. A little brandy and water wasgiven. She recovered in a few days.As might have been anticipated, delirium

frequently occurs as an immediate effect of

haemorrhage during parturition. Still morefrequently mania occurs as a remote effectof loss of blood.

It is important to remark, that deliriummay occur even from the loss of a verysmall quantity of blood, in those cases inwhich there is what I have ventured to termintolerance of loss of blood, or, in otherwords, great susceptibility to its effects, asubject which will be fully discussed here-after.Mrs. , aged 40, had been, for some

time, under medical treatment for a smalltumour in the mamma. She was seized withrubeola ; on the first and second days of therash she was purged freely, too freely ; onthe third she was bled to eight ounces, andsix leeches were applied to the chest, for a

slight oppression felt there. Mrs.had also passed five nights totally withoutsleep, although on the evening of the secondday she had taken twenty-five minims of thetinctura opii.Under the influence of these circum-

stances, Mrs. was seized with deli-rium. I saw her on the fourth day; therewere constant delirium, a profuse perspira-tion, a trifling rash, and a feeble pulse of120. I gave fifty drops of tinctura opii,and one drachm of the spiritus ammoniaearomaticus.

I saw Mrs. again in four hours;the delirium had subsided into a state of ob-stinate silence, the patient sitting up in bed,refusing to answer questions, and havinghad no sleep ; the skin and pulse as before.I directed one ounce of brandy to be givenevery 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 hadbeen taken during the night, and that there

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had been much qniet sleep. I found thepatient collected, the pulse 108, and lessfeeble ; the skin still in a state of perspira-tion. The brandy was directed to be givenevery second hour. In the evening therewas still further amendment. The bowelsnot having been moved, an aperient draughtwas 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 forsome days, but gradually subsided; the

pulse became gradually slower and stronger;there was afterwards a protracted affectionof the chest.

Puerperal mania from haemorrhage is ra-ther to be ranked amongst the secondaryeffects of loss of blood, and will be discuss-ed in its proper place.

4. Of Coma.-We may be called to pa-tients so perfectly comatose, immediatelyafter bloodletting, or haemorrhage, that wemay be in doubt for a time whether the casebe not apoplexy. The history, the state ofthe countenance, of the pulse, and of theextremities, and the other symptoms will,after a little watching, make the case clearto us.

I do not find that I have preserved thenotes of any case of this kind in adults;but I have known such a morbid state occur-ring in infants and children.Mr. C. Bell observes,-" When a man

who has cut his throat is brought into thehospital, he is in a state very much resem-bling that which some authors have describ-ed as accompanying severe wounds. Thoughsensible he is cold, pale, taciturn, and veryoften, although such men are desirous ofliving, they sink within twenty-four hours ;this appears at first to proceed from a strongimpression on the mind ; that is, I believe,the consequence of loss of blood, and theshock thus given to their powe7S of life."

5. Of S’udden Dissolution.-I have pointedout some circumstances in which bloodlet-ting has led to sudden dissolution, and Ihave recorded in a recent work several in-stances of this kind; to these I must referyou. The subject will be again mentionedin the course of these lectures, in which thecases in which this sad event is most apt tooccur, will be accurately pointed out.

II. OF THE MORE REMOTE EFFECTS OF LossOF BLOOD, OR EXHAUSTION.

1. Of Exhaustion with excessive Reaction.- Exhaustion may assume several differentcharacters ; it may be attended with exces-sive or defective reaction, or with actualsinking of the vital powers ; its most promi-nent symptom may be delirium, or coma.With each of these it is very important thatthe physician should be accurately acquaint-

ed. I proceed to describe that form of ex-haustion which is attended with excessivereaction.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 fre-quency. In cases of profuse loss of blood,on the contrary, the recovery is not quite souniform, and the pulse acquires and retainsa morbid frequency for a certain length oftime ; this frequency of the pulse may gra-dually subside, however, and be unattendedby any other symptom of indisposition of anyconsequence.The phenomena are very different if, in-

stead of one full bleeding to syncope, or ofa profuse h&aelig;morrhage, and even protractedsyncope, the person be subjected to repeatedbloodlettings, or to a continued drain. Inthis case, within certain limits, the pulse,instead of being slow and feeble, acquires amorbid frequency and a throbbing beat, andthere are, in some instances, all the symp-toms of excessive reaction.

This state of excessive reaction is formedgradually, and consists, at first, in forciblebeating of the pulse, of the carotids, and ofthe heart, accompanied by a sense of throb-bing in the head, of palpitation of the heart,and eventually, perhaps, of beating or

throbbing in the scrobiculus cordis, and inthe course of the aorta. This state of re-action is augmented occasionally by a tur.bulent dream, mental agitation, or bodilyexertion. At other times it is modified by atemporary faintness, or syncope; there isalso, sometimes, irregularity of the beat ofthe heart and of the pulse.

In the more exquisite cases of excessivereaction the symptoms are still more stronglymarked, and demand a fuller description.The beating of the temples is at length ac-companied by a throbbing pain of the head,and the energies and sensibilities of thebrain are morbidly augmented ; sometimesthere is intolerance of light, but still morefrequently intolerance of noise and of dis-turbance of any kind, requiring stillness tobe strictly enjoined, the knockers to be

tied, and straw to be strewed along thepavement; the sleep is agitated and dis-turbed by fearful dreams, and the patient isliable to awake or to be awoke in a state ofgreat hurry of mind, sometimes almost ap-proaching to delirium ; sometimes there isslight delirium, and occasionally even con-tinued delirium; more frequently there aregreat noises in the head, as of singing, ofcrackers, of a storm, or of a cataract ; insome instances there are flashes of light ;sometimes there is a sense of great pressure,or tightness, in one part, or round the head,as if the skull were pressed by an iron nail,or bound by an iron hoop.The action of the heart and arteries is

morbidly increased, and there are great pal-

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pitation, and visible throbbings of the caro- with-sickness, but always with an increasetids, and sometimes even of the abdominal of all the symptoms.aorta, augmented to a still greater degree, The state of reaction, as an effect of re-by every cause of hurry of mind or exertion peated loss of blood, is interestingly pour-of the body, by sudden noises, or hurried trayed in the following case, for which I amdreams or wakings ; the patient is often indebted to a friend :-greatly alarmed and impressed with the " Mrs. --, a delicate married person,feeling of approaching dissolution ; the state aged 24, a week or ten days after her con-of palpitation and throbbing are apt to be fitiement of a still-born child, was seizedchanged, at different times, to a feeling of with pain at the lower part of the abdomen,syncope ; the effect of sleep is, in some in- extending to the liver, and other symptomsstances, very extraordinary, sometimes pal- which indicated inflammation of the os uteri,pitation, at other times a degree of syncope, together with much constitutional disturb-or an overwhelming feeling of dissolution; ance. The case seems to have been mis-the pulse varies from 100 to 120 or 130, and taken in the beginning, so that it was al-is attended with a forcible jerk, or bounding lowed to become somewhat inveterate beforeof the artery, the appropriate treatment was adopted. ItThe respiration is apt to be frequent and was at this stage treated with leeches to

hurried, and attended with alternate pant- the hypogastrium, cupping low in the loins,ing and sighing; the movement of expira- the hip-bath, aperient medicines, strict ab-tion is sometimes obviously and singularly stinence, &c.blended with a movement communicated by " The benefit accruing from cupping overthe beat of the heart ; the patient requires the sacrum was observed to be so decided,the smelling-bottle, the fan, and the fresh that recourse was had to this remedy twiceair. The skin is sometimes hot, and there or thrice a week regularly. The diseaseare frequently general hurry and restless- seemed to be thus yielding in the most fa-ness. vourable manner, when the patient becameIn this state of exhaustion, sudden disso- suddenly, and quite unexpectedly, affected

lution has sometimes been the immediate with the effects of loss of blood, in a mostconsequence of muscular effort on the part violent fnrm. The quantity of blood takenof the patient, or of his being too suddenly by the cupping had frequently been twentyraised from the recumbent into the erect ounces, and too exclusive attention had beenposition. paid to the disease, the state of the consti-The following case strikingly illustrates tution not being sufficiently watched. In

the phenomena of reaction from a continued this manner the patient became affected, alldrain, or loss of blood :- at once, after being cupped, with suddenMrs. , aged 28, of a stout constitu- and alarming syncope ; slae gasped, and

tioa. After delivery there was uterine became convulsed, and afterwards slightlyhsemorrhage, which continued to recur for delirious. The admission of the cold air, andthe twelve subsequent months. It was then the administration of brandy, gradually re-discovered that Mrs. &mdash;&mdash;&mdash;&mdash; laboured under stored the patient to sensibility, but shepolypus uteri; a ligature was applied, pur- remained extremely feeble.gative medicines given, and the patient re- " On the next morning Mrs. - wascovered. The effects of this loss of blood affected with extreme pain of the head,followed, however, and there were,-I. violent throbbing of the temples, slight deli-beating of the temples, a sense of violent rium, aud sickness ; the street was found" knocking in the head, pain, vertigo, dim- covered with straw. During this day theness of sight, and singing in the ears, ter- pain of the head, the throbbing, and the in-rific dreams, and starting from sleep ; 2. fre- tolerance of light and of sound, had increas-quency of the pulse, pulsation of the caro- ed so much, with sickness, feverishness,tids and aorta, fluttering and beating of the and a frequent strong pulse, that it was ap-heart, faintishness, and a sense and fear of prehended that inflammation had taken placedissolution : the palpitation of the heart was in the brain. The arm was actually tied upsometimes such, on awaking, as even to for blood-letting; but the remonstrances ofmove the bed-clothes, the bed, and, it is the patient, the history of the attack, andsaid, even the door; 3. the breathing was the recollection of some remarks on theshort and hurried, sometimes with panting, effects of loss of blood, read some years be-sometimes with sighing ; 4. there were ur- fore, happily led to the abandonment of thisgent calls for air, for opened windows, and measure."the smelling hottle, and the nostrils and My friend candidly observes,-&laquo; Fortu-temples were required to be bathed with nately both for my patient and for myself,sal volatile or vinegar. The countenance, her repugnance to general bleeding pre-prolabia, and tongue were pallid; the legs vented me from using the lancet, and so

somewhat oodematous; the bowels were ir- saved her life. I prescribed leeches to theregular, the secretions morbid; once there temples, a blister to the nape of the neck,was obstinate constipation; frequently the and a cold lotion to the head ; opiates andbowels were merely confined, sometimes the effervescing medicines were immediately

511

rejected. My patient became much better. the equilibrium of circulation ; and noneShe earnestly requested to be allowed a lit- are more likely, in this condition of the pa-tle brandy; I gave it her; it obviously ticnt, than noise in the room, deficiency ofafforded much relief, and I began clearly to sleep, improper food, a constipated state ofsee the nature of the case." From this time the bowels, or a morbid state of the secre-light cordials, a mild diet, rest, quietude, a tions into them. This susceptibility to localstrict attention to the state of the bowels, congestion, after excessive loss of blood, Iconstituted the treatment, and it was fol- presume depends upon the want of that duelowed by a gradual and progressive amend- balance which, in a state of health, subsistsment. between the nervous and vascular systems ;

Some of the symptoms remained, however, but I am jealous of hypothesis in medicine,for some time. The pain of the head con- and to pursue them in the present worktinued very troublesome for many weeks, would be unwarrantable."&mdash;Vol. i. p, 73.and a pulsatory movement in the side of the " From the peculiarity of the conforma-neck harassed the patient for several years. tion of the nose, epistaxis is sometimes aMy friend adds,-" In this case the effects most uncontrollable form of haemorrhage.of loss of blood on the constitution stole I have recently seen two cases in which, ifalmost imperceptibly on me, and I was not it were not absolutely the occasion of death,then aware that such symptoms as you have it certainly accelerated that event. Thedetailed in your work would arise. This first was in a gentleman who laboured undercase also has made me attend very much to hydrocephalus ; he was a susceptible man,the prejudices of a patient ever since, and and would not endure a plug in the nostril.carefully examine whether they be well- The haemorrhage frequently recurred; andfounded. In this instance I really believe when he had become excessively pallid frommy yielding to them saved the life of my loss of blood, it was curious to observe topatient." what an extent the irritative haemorrhagic

Since my first publication on this subject, action was propagated. At first he onlyin 1820, I have seen several allusions to it distinguished pulsation in and about thein various works, and one especially by nose, but as his strength decreased, and hisMr. Cooke, in his useful and able abridg- anxiety and susceptibility were heightened,ment of Morgagni. The observations of this the carotids could be seen throbbing vehe..author are indeed highly valuable, and they mently, and a corresponding action washave been fully confirmed by Dr. Kellie. perceptible to the patient through their ra-Mr. Cooke remarks,-" After uterine hae- mitications. The second case was in an oldmorrhage, and also after copious depletion arthritic sufferer, who had been seized withon account of pulmonary and other inflam- cynanche parotidasa. The more acute in-mations, I have frequently observed the flammation had subsided, but the gland wassymptoms of cerebral congestion; and which much enlarged and indurated, and the jawhas generally appeared to arise from the nearly rigid. In this state he was attackedexcitement occasioned by some mental ef- with bleeding from the nose. It occurredfort, though occasionally it has arisen with- sometimes when he was asleep, on whichout an evident cause. Whilst the other parts occasions he was threatened with suffoca-of the body appear comparatively bloodless, tion from the formation of coagula in thethe vessels of the head throb violently; fauces, which he removed with the utmostthere is severe pain; confusion of intellect, difficulty, in consequence of being unable tosometimes to such a degree as to threaten open his mouth. The haemorrhage com-delirium ; the pulse at the wrist is usually menced in the nasal cavity nearest to thesmall and vibrating, and the countenance enlarged gland, but it afterwards took placedistressed. When I first observed these from both nostrils. He was excessivelysymptoms I was led to abstract blood, from afflicted with gout, and had indications ofan apprehension of phrenitis ; but I did hepatic disorganization ; but the immediateharm, for if the urgency of symptoms was cause of death was the repeated effusion ofdiminished, the susceptibility to a recur- blood. The haemorrhagic action was not sorence was increased, and restoration to extensively manifest as in the precedinghealth was protracted. The liability to this case ; but when there was feebleness in theform of cerebral plethora has appeared to radial artery, and the extremities were cold,me to be proportionate to the preceding the patient was conscious of a strongly irri-h&aelig;morrhage, and the consequent debility. tative throbbing in the arteries ramifyingIf in this condition an intrusive visitor be through the nose and the circumjacent parts.admitted to converse, though but fur a short Vol. i. p. 191.time, with the patient; or if the patient More recently I find several interestingattempt to read, or in any other way to cases of this kind in the late admirableemploy the mental faculties beyond what work of Dr. Abercrombie.is perfectly easy ; or if the mind be agitated, " A gentleman, aged about 40, had beenthis state of the head will almost inevitably for some time losing considerable quantitiesbe induced. It may, however, be brought of blood by arterial haemorrhage from theon by all those causes vvhich tend to destroy rectum. Considering it as merely haemor&middot;

512

rhoidal, he had paid little attention to it untilhis friends became alarmed by his alteredappearance. From being strong and ratherplethoric, lie had become weak, exhausted,pale, and haggard. He had anasarca of hislegs ; his pulse was frequent and feeble,and much excited by the least exertion.Along with these symptoms, he was liableto strong and irregular action of the heart,and complained of giddiness, tinnitus au-rium, violent throbbing in the head, andfrequently of throbbing headach. On ex-amining his rectum, a fungous tumour wasfound within the sphincter, on the apex ofwhich a small artery was bleeding, per sal-turn. This was tied, and there was no re-turn of the haemorrhage ; and under the useof nourishing diet, and a liberal allowanceof wine, all his other complaints disappear-ed. He made up so rapidly in flesh andblood, that [not long after apprehensionswere entertained that he was becoming tooplethoric, and it became necessary to reducehis regimen, but under these circumstanceshe had no return of the symptoms in thehead." A lady, aged 25, had been frequently

bled on account of symptoms in the headwhich had supervened upon an injury. Con-siderable relief had followed each bleeding ;but the symptoms had soon returned so as

to lead to a repetition of the bleeding atshort intervals, and this had been going onfor several months. When I saw her shewas stretched upon a couch, her face of themost death-like paleness, or rather of thepaleness of a stucco figure, her pulse veryrapid and as small as a thread, her generalweakness extreme. The mass of blood ap-peared to be reduced to the lowest pointthat was compatible with life, but she still

complained of frequent headach, violentthrobbing in the head, confusion, and gid-diness. It was evident that evacuation couldbe carried no further, and in consultationwith a very intelligent medical man whohad the charge of her, it was agreed, as alast experiment, to make trial of the oppo-site system, nourishing diet and tonics. Ina fortnight she was restored to very toler-able health." I have been repeatedly consulted under

the following circumstances :-A gentleman,accustomed to very full living, is seizedwith an apoplectic attack, or with symptomsindicating the most urgent danger of apo-plexy ; he is saved by bleeding and otherfree evacuations, and is kept for some timeupon a very spare diet. His complaints arerelieved, and as long as he keeps quietlyat home, he goes on without any uneasyfeeling ; but when he begins to go about,he becomes liable to attacks of giddinessand confusion, generally accompanied bypalpitation of the heart and an uneasy feel-ing about the praocordia. His pulse is nowsoft and rather weak, and his general ap-

pearance indicates the reverse of plethora,and these symptoms are removed by a cau-tious improvement of his regimen. Thiscurious fact I have repeatedly had occasionto attend to in the treatment of cases of this

kind, and it has always appeared to me tobe of very great interest in reference to thepathology of the brain."

LECTURESON

MATERIA MEDICA AND

THERAPEUTICS;NOW IN COURSE OF DELIVERY

AT THE

WINDMILL-STREET SCHOOL OF MEDICINE.BY

GEORGE G. SIGMOND, M.D.

CINCIIONA :&mdash;Distinguishing characters of thegenus; ; its various species; locality ofgrowth. The varieties of bark found incommerce. Effects of cinchona in firers,in hyponchondria, &c. Enlargement of thespleen in intermittent fevers. Cinchonaefficacious in most periodic affections. Pre-eazctions to be used in the cinployineizt ofcautions to be used in the employement ofcinchona. The treatment of intermittentsby bleeding. . Tinctures of cinchona. Infu-sion of the bark. Sydenham’s electuary.GENTLUNTEN :-The genus cinchona is

marked by certain distinguishing characters,which have undergone much botanical exa-mination. It is formed of several species,all of which are trees with round branches,excepting at the top, where they are ob-scurely four cornered; the flowering branchesare alternately compressed, with simple en-tire opposite leaves; the inflorescence is

varied, but, in general, paniculate. Thecalyx is adherent to the germen, one-leafed,five-toothed, and permanent; the corollais synpetalous, funnel-shaped, five-cleft ;there are five stamina, the filaments are inthe middle of the tube ; the anthers are two-celled, and dehiscent longitudinally byvalves; the germen is inferior, formed oftwo or four connate carpels ; the style is ofthe length of the stamina; the stigma thick,bi1id, or entire. The fruit is capsular, bra-ceate, or drupaceous, two-celled, some-

times with more cells ; the valves parallelto the partitions, opening inwardly. Theseeds are many, oblong, compressed; thealbumen is large, fleshy, or horny ; the em-bryo small, the radicle is turned towardsthe hilum, the cotyledons thin and folia-ceous.

The modern genus cinchona is limited toabout sixteen species; some, which wereformerly included, are found very different