796

the instance before us, necessary for qualify-ing their graduates or licentiatiates for enter.ing on the practice of their profession, it isat least inconsistent, if not criminal in them,to send forth another grade of practitioners,with the scanty preparation made in threeyears, as in the case of the Bachelors ofMedicine of Trinity College ; while on theother hand if they deem this short periodsufficient for the purpose, they are equallycriminal and inconsistent in casting five

years more upon another class of their

diplomatists.With respect, therefore, to this question,

we conceive that there can be but one

opinion as to the propriety and expediencyof having but one class of graduates in themedical profession. If, at all events, we

are more certain of one thing than another,it is, that the capabilities of the Universityof Dublin cannot be brought into full ope-ration without the adoption of a radical re-form, and we are equally certain that this

will take place at some future day. Alreadyin that city a corporation has been com-

pelled to relinquish one of its darling reo

strictions,-against which we were the firstto concentrate the irresistible power of pub.lic opinion, and we do not despair of yet be-holding its now prostrate rival, rise to that

importance among the medical schools of

Europe, to which it is so justly entitled.

Researches principally relative to the Mor-bid and Curative effects of Loss of Blood.By MARSHALL HALL, M.D., &c.—Lon-don. Seeley and Burnside. 1830. 8vo.

pp. 343.

Researches principally relative to the Mor-bid and Curative effects of Loss of Blood.By MARSHALL HALT., M.D., &c.-Lon-don. Seeley and Burnside. 1830. 8vo.

pp.343.

ABOUT five years ago Dr. Hall publisheda small volume entitled 11 Medical Essays,"containing three papers ;-on the loss of

blood, on intestinal irritation, and on thestate ofsinking. The present work is com-

posed of the former of these, somewhat am-plified, though not much improved; of nearlythe whole of the other two ; of observationson a " Hydrencephaloid affection of In-

fancy;’’ and of nearly fieventy pages taken

from the works of other writers, togetherwith a number of letters and communica-tions from the author’s friends. The subjectof the work is one of very great interest and

importance ; and considering the time thathas elapsed since the first essay was pub-lished, it might have been expected that theauthor would now have adduced many new

facts, or at least have arranged his ideas

and his arguments with more order, andgreater perspicuity. Such, however, is by nomeans the case ; there are indeed a greaternumber of cases, and some additional obser.

vations, but there is little or nothing whichcan throw any further light on the subject,which can render the diagnosis less obscure,or which can lead to any better methods oftreatment.

The work is divided into two parts; onthe morbid, and on the curative effects ofthe loss of blood ; but each of them, as maybe readily imagined from what we have juststated, contains much that has little or noconnexion with either of these subjects.The immediate ill effects of loss of blood are

tolerably well described, though not betterthan has been done by many preceding wri-ters. Dr. Hall, however, seems to reckon

upon a very small degree of information inhis readers, when he thinks it necessary to

point out to them as " a phenomenon parti.cularly worthy of attention in the state of

syncope," that " when. the movements ofthe chest have been imperceptible, or neatlyso, in the interval between the sighs, therespiration is still carried on by means ofthe diaphragm/’The cases here are not very happily cho-

sen ; thus in one of the three, illustrative ofdelirium from bleeding, it appears much

more probable, that this affection was in-duced by the disease itself (rubeola), andby five sleepless nights, than by the abstrac-tion of eight ounces of blood, and the appli-cation of six leeches.

Among the " secondary, or more remoteeffects of loss of blood," two, especially, aretreated of at some length," exhaustion withexcessive reaction," and " exhaustion withsinking." The symptoms of the former,whichDr. H. very justly thinks is produced ratherby frequently-repeated bleedings, than bya single copious one, are described as a

quick, often irregular pulse, strong throb-bing of all the arteries, palpitation of the

797

heart, beating headacll, hurried respira-tion, &c. and, in very severe cases, morbid

sensibility to light and sound, flashes of

light, ringing in the ears, disturbance of theMnsorium, frightful dreams, violent palpi-tation of the heart, strong feeling of suffo-cation, and, " sometimes, a sense of greatpressure or tightness in one part of, or roundthe head, as if the scull were pressed by aniron nail, or bound by an iron hoop." Somewell-marked cases are given, two of themfrom Dr. Abercrombie’s work on diseases ofthe brain, but no allusion is made to the

very ingenious explanation, given by thatwriter, of the manner in which, in these

cases, the symptoms of cerebral congestionare produced.

In the latter, which is often a consequenceof the state just described--" The sensibilities of the brain subside,

and the patient is no longer affected bynoises as before ; there is, on the contrary,a tendency to dozing, and gradually some ofthose effects on the muscular system whichdenote a diminished sensibility of the brainsupervene, as snoring, stertor, blowing upof the cheeks iu breathing, &c.; instead ofthe hurry and alarm on awaking as observedin the case of excessive reaction, the patientin the state of sinking, requires a moment torecollect himself and recover his conscious-ness, is perhaps affected with slight deli-

rium, and he is apt to forget the circum-stances of his situation, and, inattentive to

the objects around him, to fall again into astate of dozing.

" Not less remarkable is the effect of thestate of exhaustion with sinking on thefunction of the lungs ; indeed the very firstindication of this state is, I believe, to befound in the supervention of a crepitus inthe respiration, only to be heard at first onthe most attentive listening; this crepitusgradually becomes more audible and passesinto slight rattling, heard in the situation ofthe bronchia and trachea ; there is also a

degree of labour or oppression, sighing,hurry, blowing in the breathing, inducingacutenea in the nostrils, which are dilatedbelow and drawn in above the lobes at eachitisj)ir-.tion ; in some cases there is besides,a peculiar catcliing, laryngal cough, whichis especially apt to come on during sleep,and awakes or imperfectly awakes the pa-tient.

" The heart has, at the same time, lost itsviolent beat and palpitation, and the pulseand arteries their bounding or throbbing." The stomach and bowels become disor-

dered and flatulent, and tympanitic, and thecommand over the sphincters is impaired.

" The last stage of sinking is denoted bya pale and sunk countenance, inquietude,jactitation, delirium, and coldness of theextremities."

The stethoscopic sign here mentioned,which the author attributes to oedema of the

lungs, and which corresponds with that ob-served by Laennec in many fatal diseases,a few hours before death, and denominatedby him ’ râle des agonisans," has not, webelieve, been noticed by any other writer,and is of considerable importance, as indi-cating the impending danger, while there isyet the possibility of obviating it. The sec-

tion on " Exhaustion with delirium," is

chiefly occupied by the very interesting casewhich we quoted in our review of the secondedition of Abercrombie’s work. Dr. H. does

not however seem aware that it has been

published, for he introduces it as-,, a casewith which I have been favoured by Dr.Abercrombie."When the symptoms of reaction are mis-

taken for those of inflammation, and bleed-ing is again had recourse to, a temporaryrelief is often produced, but after a shorttime they return with increased violence, ’.

and the patient is brought into a worse

state than before. The observations on this

subject were extracted, at length, in our re-view of the essays already spoken of (videLANCET, No. 123) ; and, notwithstandingtheir brevity, the difficulty of the diagnosis,and the importance of the subject, nothinghas now been added, except an extract froma paper by Mr. Brodie, in the Med. Chir.Transactions.Under the head of " Sinking, or more

sudden dissolution," three very strikingcases are given of the fatal effects of unne-cessarily repeated bleeding ; but we are in-clined to believe, that, independently of

any light which Dr. Hall may have thrownupon the subject, very few practitionerswould have continued to employ this reme-dy under the circumstances described. Inthe first case, especially, the abstraction of" three teacupfuls of blood as a preventiveagainst relapse," after the principal symp-toms had been subdued by bleeding to fortyounces, and the application of twelve

leeches, was a most injudicious, nay, unjus-tifiable measure.

Judging from Dr. Hall’s other works andfrom some parts of the one before us, we

798

should be inclined to consider him as a manof considerable ability and powers of ob-

servation, but either his own ignorance oncertain points is very great, or he supposesthat that of his readers is so. The fol-

lowing sentence may serve as a specimen." One of the most important remarks

which I have to make, and which will leadto one of the most important improvementsin surgery, is, that we are not to treat the

patient immediately after an accident, or anoperation, as one affected with inflamma-tion."As well might he have announced as an

important improvement, that a limb was notto be amputated for aneurism, or that small-pox was not to be treated with blankets,confined air, and cordials.

In the sixth chapter, on the effects of lossof blood on the internal organs, we havelooked in vain for any details of morbid ana-

tomy. In one case, quoted from Dr. Den-man, where the patient died of sanguineous

apoplexy, after having suffered, during se-veral years, from uterine haemorrhage, theeffusion on the brain’alone is mentioned. Inanother, extracted from Hey on puerperalfever, no examination was made, and theremaining cases described did not provefatal. The author states, that " In two pa-tients who died of limmoirliagy, examinedby Dr. Hodgkin, the lungs were found de-cidedly redematous; in one, there was effu-sion into both cavities of the pleura and peAricardium; in the other there were adhe-sions. In one the head was examined, andno morbid appearances found ;" and that" A similar illustration of the effects of lossof blood was detailed to him, some yearsago, by -Air. Jowett, of Nottingham ;" buthe neither gives a single observation of hisown, nor alludes to any of the experimentsof modern physiologists, " leaving this partof the subject to be elucidated by future ob-servation."The treatment of the ill effects of bleed-

ing is, for the most part, judicious, but no-thing is recommended which is not generallyknown and employed. Transfusion is passedover very briefly. Dr. Hall thinks it wouldbe most efficacious, if combined with galva-nism, and that it has generally failed frombeing employed too late.

After this first part of the work, are noless than five appendices,of which one, alone,

occupies more than forty pages, and formsan entirely distinct essay ; it is on ’ a mor.bid affection of infancy," bearing a greatresemblance to hydrocephalus (wepresumehy. acutus is meant), owing in every case

to exhaustion, induced generally by purgingor diarrhoea, but sometimes by loss of blood.As this essay has but little connexion withthe proper subject of the work, it is unne.cessary for us to notice it very particularly.In the disease in question, as well as in allthe others of very young infants, thoughmore especially here, Dr. Hall thinks the

degree of colour in the cheeks a much bettercriterion than the state of the pulse. An.

other important symptom is, irritability,withrestlessness, immediately preceding a coma.tose state ; these, together with the historyof the case, and a knowledge of the treat-ment employed, will often, he thinks, suf-fice for the forming a correct diagnosis, andwhen this is once obtained, there will, ofcourse, be very little difficulty with regardto the treatment. The best stimuli he hasfound to be brandy and ammonia in verysmall but repeated doses.The fifth appendix, on the sinking state,

contains no new information, and is indeedalmost entirely made up of extracts fromother authors.The second part commences with some

observations on the manner in which bleed.

ing is borne in different diseases and in dif.ferent persons, apparently of equal healthand strength. With regard to the former,Dr. Hall observes,

" Each disease appears to possess its own

peculiar and intrinsic virtue III this respect.This is determined hv placing the patientperfectly erect, and bleeding to incipientsyncope ; the quantity of blood which flowsis the measure of the protective influence otthe disease in one class of cases, and of ininfluence in superinducing a susceptibilityto the effects of loss of blood in the other.

’° An interesting zn scale of diseases may b&formed representing these properties. Itwould begin with congestion of the head, ortendency to apoplexy ; inflammation of theserous membranes, and of the parenchyma.tous substance of various organs, would fill.low ; then acute anasarca; and, lastly, in-

flammation of the mucous membranes. Thispart of the scale would be divided from thenext by the condition of the system inhealth. Below this would be arrangedfever, the effects of intestinal irritation,some cases of delirium, reaction from loss of

799

blood, and disorders of the same class, withhysteria, dyspepsia, chlorosis, and choleramorbus."These differences, especially that between

fever and inflammation, he attempts to ex-

plain, by stating that in the one, the heartand larger arteries alone, in the other the

capillaries also, of some particular part, areaffected ; and that in the latter the irritationis kept up by this condition of the minute

vessels, which are much less easily actedupon by general bleeding. Without pretend- I

ing to determine whether this explanation Ibe a just one or not, we will only observethat, so long as we are ignorant of the im-mediate cause of syncope, it will be impos-sible to discover with any certainty why itis more readily produced in one case than inanother. The practical application of thefact is much more satisfactory and less liableto objection ; it is, that bleeding should al-ways be performed with the patient in anerect or sitting posture, and that the quan-tity of blood ’to be taken should not be de-termined previously, but only by the effectswhich its abstraction produces ; for in al-most every instance the tolerance of bleed-

ing will be in a rlirect ratio with the necessityfor it; and, as Dr. H. most justly observes,"At the very moment that the protectiveinfluence of inflammation is withdrawn, fur-ther bloodletting is in the highest degreedangerous." It is not, however, recom-

mended, that bloodletting should ever becarried to actual syncope, but only to thevery first signs of approaching syncope,which is, in fact, to be prevented by imme-diately laying the patient in a recumbentposition."Although there are separate sections on

fever and inflammation, in their relation toloss of blood, little is to be learnt from thembeyond what we have already stated. Theauthoi’s view of these diseases appears insome measure to coincide with that of Dr. S.

Smith, which we shall shortly have occasionto notice." Fever," says he, " seems to differ from

inflammation, in being an affection of thewhole nervous and vascular system; in in-flammation there is au affection of these svs-tems iu one part or organ: ’ And again, " in-flammation is a sort ot eoncentrated and per-manent stimulus, exciting and maintainutgthe powers of the system. Under its influ-ence bloodletting is fully borne. It may at

length exhaust the powers of the system, and,then the state of sinking supervenes. Or it.

may be subdued by the bloodletting and otherremedies employed for it, leaving the system)under the influence, greater or less, of those

remedies."I Jn this part of the book is inserted the

essay on intestinal irritation, already alludedto, and which was reviewed by us at some

length : we have nothing now to add to ourformer observations, but we cannot abstainfrom expressing our surprise at the igno-rance or assurance of Dr. H. in continuingto state that " the profession are still totallyunacquainted with this morbid affection."We repeat, that in spite of the new and veryindefinite term which he has chosen to applyto it, it is a disease observed and described

by many ancient as well as modern writers.The whole essay, indeed, appears to have

been inserted with little alteration and no

improvement.The section on " accidents and opera-

tions," contains nothing original worthy ofnotice, and is equally out of place with thepreceding: if at all admissible in the work,’it should have been placed in the first, andnot in the second part.The first part of the third chapter tends

to show how much better bleeding is bornein inflammation than in irritation, but is vervlittle more than a repetition (not a recapi-tulation) of what had been said previously,’sometimes even twice or three times over,and very nearly in the same words. Thelatter part of it, on the indications for and’

against bleeding, and on the comparativenecessity, under different circumstances, forits repetition, is more to the purpose, andcontains some judicious and instructive ob-servations, but certainly displays neither

acute reasoning nor extensive research.’, In the fourth and last chapter, on blood-letting in infancy and childhood, a subject ofconsiderable interest, we find absolatt-ly no-thing worth notice, except perhaps a " pro-test against the usual plan of applying leechesin infancy (to infants) and allowing the bites.to continue to bleed," a practice which is,certainly, as the author contends, " repletewith danger." Having thus gone throughthe work, it is scarcely necessary for us togive any summary of its merits. Had the.author, instead of thi owing together a num-ber of loose-papers and unconnected obser-

800

ration!), taken the trouble of digesting andarranging the whole, and rejecting the ex-

traneous matter, the book would certainlyhave been much reduced in size, but it wouldhave been greatly increased in value. As

it is, the labour of perusing it will scarcelybe adequately rewarded by a knowledge ofthe scattered information which it contains.

TREATMENT OF SNAKE BITES.

By J. HANCOCK, M.D., London.

To the Editor of THE LANCET.

Srn,-Upon reading in the -last number ofTUE LANCET, the interesting statements givenby Alr. I)uncan (at a meeting of the West-minster Society), respecting the Munghoos,and the antidotes to the bites of venomousserpents in India, I was so struck with itsanalogy or coincidence with what has beenrelated to me in South America, in parts sodistant, as opposite as the antipodes, I couldnot forbear offering you the following ac-

count from my manuscript, which possiblyyou may deem worthy of attention, especiallyas the subject of antidotes is so little under-stood, and the treatment of course so vacil-lating and effete.

I am, Sir,Your very obedient Servant,

J. HANCOCK.London, 24th Feb., 1830.

J. HANCOCK.

IN South America, where I resided fortwenty-five years, and where venomous ser-pents are very numerous, a free use of theguaco infused in rum or other spirit, is

generally esteemed as the best remedy forthe bites of poisonous serpents, taken in.wardly and applied to the wound. It doubt-less is one of the most potent usually at

hand. It must be noticed, however, that theguaco here alluded to is not the composite,micl1râa guaco of Mutis and Humboldt, aplant nearly insipid, but a species, or ratherseveral species, of strong aromatic bitteraristolochias which grow in Orinoko, and invarious parts of Guiana.Don Ventura Gomez (a great savanero)

related to me, at Angostura, in 1816, an in-stance he had witnessed of a man (one Ibad just attended in fever), whom he sawwith his own eyes, as he expressed it, takeup a cascabel or rattle-snake, and put it inhis bosom, catching it while irritated and ina most savage state. The serpent, on beingtaken up by this man, seemed in a half tor-pid or lethargic state, made feeble attempts

i to bite, and did bite his hand slightly whilewreatliing about his arm.*

He had been told previous to this, byDon Andreas Condi, ot the ability or strange

talent of this man, who was prepared with the; guaco by.-a Doctor in Santa Fe.

Dr. Irabila also gave me Ihe same account

of this man (named Marcos). " This man,"says the Rev. Doctor, " was inoculatedwith the guaco, by a brother of the cele-brated Mutis of Santa Fe." He explained

the term inoculado in this way, that the mandrank a smali possim of the guaco for ninemornings, observing apare and rigid diet,premising purges.The Doctor related a most extraordinary

feat performed by this man upon a serpent,which he saw himself, it was a rattle-snake.I should have passed this unnoticed, had I

not known the character of my informer.He met Mareos at the door of Condi, at

Angostura, and observed by the side of him,a wild and ferocious rattle-snake, whichMarcos immediately took up, wound abouthis hand, and afterwards put into his ho-som. He pretended at first it, was done bysome mysterious prayers and incantations;but the Dr. treating it as folly and affirm.ing the effect of guaco, he afterwards con.fessed it to be true. He stated that he wascured, as he termed it, in the manner beforerelated,-that he was young, and his fatherbeing under cure with guaco, caused him toenter on the same, for it is a most common

practice in those parts of Santa Fe and

Caraccas, to " cure," or prepare those whoare to be exposed to the bites of venomousserpents. Some estates in Caraccas, 1was told, have all theit negroes, and eventheir horses and cattle, so prepared. This

serpent would spring with violence at anyone else ; but with Marcos seemed torpidand lethargic. At length he let the snakeloose in the yard ; but it soon died, as ofthe poison he had imbibed from his master.

The Doctor saw the man also handle awater snake, Culebra de Agua (a boa, andof course not poisonous), at Tocoma in a

surprising manner, allowing it to wreathearound his arms and body, for the snake beobserved was three varas, or nine feet in

length. This, as well as the rattle-snake,made, he says, slight efforts to bite, butwithout any effect ; and an Englishman pre-sent, seeing how Marcos managed the mon.ster, was bold enough to make a trial of it

himself ; but the snake seized him by thethumb which he split asunder, and he (tlieDr.) assisted to pick the eves out of themonster’s head, before he could be made tolet go.

* I remarked that, perhaps the fang3were drawn, but he most positively assertedthe contrary.