RESEARCHES 
PRINCIPALLY RELATIVE 
TO THE 
« 
MORBID AND CURATIVE EFFECTS 
OP 
LOSS OF BLOOD. 
BY 
MARSHALL HALL, M.D. F.R. S. E. M. R. I. M. Z. S. &c. &c. 
SECOND AMERICAN EDITION. 
PHILADELPHIA: 
E. L, CAREY & A. HART, 
1835. TO \ 
ROBERT HAMILTON, M. D. F. R. S. E. &c. &c. 
OF EDINBURGH ; 
THIS LITTLE WORK IS INSCRIBED 
* * 
IN TESTIMONY OF 
A MOST SINCERE REGARD AND AFFECTION, 
» BY 
THE AUTHOR. ADVERTISEMENT. 
The principal object of the present work is to apprize the in- 
experienced of some unexpected phenomena arising from loss of 
blood, of the remarkable difference in the degree of tolerance or 
intolerance of loss of blood in different diseases, of the equal 
danger of an inefficient and undue use of the lancet, and of a 
rule which may be adopted to obviate this danger. 
Another fibject has been to establish, beyond the reach of con- 
troversy, a distinction between two classes of morbid affections, 
that of inflammations, and that irritations. 
Each of these points will be found to be of the utmost moment 
in the daily practice of physic. 
I first published some observations on the subjects of the 
present volume, in 1820. Since that period I have been en- 
abled to add, not only many interesting facts from my own ob- 
servation, but the testimony of many respectable authors, to the 
facts and principles formerly detailed. Dr. Abercrombie, Dr. 
Kellie, and Dr. Copeland, Mr. Travers, Mr. Brodie, and Mr. 
Cooke, have severally added some interesting observations on 
the effects of loss of blood, a subject by no means understood 
until very recently. 
As it has been my wish, in the following pages, to adduce the 
testimony of others relative to the morbid and curative effects of 
loss of blood, rather than to cite cases which have merely come 
under my own observation, I have eagerly inserted the facts sup- 
plied me by my friends; such facts afford not only an additional ADVERTISEMENT. 
but an unbiassed testimony to the truth of the general principles 
which I have laid down. 
I hope hereafter to adduce a series of well-marked cases in 
illustration of the application of these principles in practice; and 
especially of the limits, exceptions, and corrections which it may 
be necessary to point out, in reference to the rule for blood- 
letting, which I have proposed. 
This point might be illustrated, in some degree, by an ex- 
amination of the records of medicine. The general result of 
such an examination will be found to accord with the principles 
which I have laid down. But few particular instances could 
be adduced, on account of the almost universal neglect of 
attention to the position of the patient, in which bloodletting 
has been instituted. CONTENTS. 
PART FIRST. 
ON THE MORBID EFFECTS OF LOSS OF BLOOD. 
Page 
Chap. i. Introductory observations - 9 
II. Of the immediate effects of loss of blood - 14 
1. Of Syncope - - - 14 
2. Of Convulsion - - - - 20 
3. Of Delirium - - - - 21 
4. Of Coma - - - - - 25 
5. Of Sudden Dissolution ... 26 
III. Of the more remote effects of loss of blood, or 
exhaustion - - - - 30 
1. Of Exhaustion with excessive reaction - 30 
2. Of Exhaustion with defective reaction - 42 
3. Of Exhaustion with Sinking - - 43 
4. Of Exhaustion with Delirium - - 54 
5. Of Exhaustion with Coma v - 57 
6. Of Exhaustion with Amaurosis - - 63 
IV. Of the effects of further loss of blood in cases of 
exhaustion .... 66 
1. Of the substitution of Syncope for reaction - 66 
2. Of Sinking, or more sudden Dissolution 71 
V. Of the influence of various circumstances on the 
effects of loss of blood - - - 78 
VI. Of the effects of loss of blood on the internal organs 82 
VII. Of the treatment of the various effects of loss of blood 95 
APPENDICES TO PART FIRST. 
Appendix I. Of the similarity between the effects of loss 
of blood and the bloodlessness of Chlorosis. 101 
IT. Of a hydrencephaloid affection of infants 
arising from exhaustion - - 105 Page 
III. Of exhaustion arising from other sources 
besides loss of blood - - 136 
IV. Of the exhaustion arising from abstinence 137 
V. Of the state of sinking - - - 140 
PART SECOND. 
THE CURATIVE EFFECTS OF LOSS OF BLOOD. 
4 
Chap. I. Introductory observations - - 149 
II. Of some diseases in their relation to loss Of blood 166 
1. Of Fever .... 166 
2. Of Inflammation - 170 
3. Of Irritation - - - - 178 
4. Of Accidents and Operations - - 204 
III. Of the due institution of Bloodletting - 210 
1. Of early Bloodletting - - - 225 
2. Of a first Bloodletting - - - 227 
3. Of the repetition of the Bloodletting - - 233 
4. Of Bloodletting as a preventive of Inflammation 237 
5. Of late Bloodletting - - - 239 
6. Of local Bloodletting .... 240 
IV. Of Bloodletting in infancy and childhood - 243 
Conclusion - - - - - - 250 
APPENDIX TO PART SECOND. 
Cursory observations on the use of purgatives, opium, 
brandy, etc. - - - * 252 
CONTENTS. PART FIRST. 
ON THE MORBID EFFECTS OF LOSS OF BLOOD. 
C H A P T E R I. 
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 vessels, of the 
lungs, of the stomach, &c.; the phenomena of reac- 
tion, excessive or defective; but especially the phe- 
nomena and influence of the sinking state, or state of 
failure and decline of vital powers, in their relation 
both to the nervous, the circulating, and the organic 10 
ON THE MORBID EFFECTS 
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 some other affec- 
tions of the head, and to those of some morbid affec- 
tions within the chest and abdomen, present subjects 
for his observation of the utmost moment in actual 
practice. The diagnosis of these cases is most im- 
portant ; 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 tt.e states of excessive reaction, of defective 
reaction, of the gradual failure of the vital powers, 
and of a 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 con- 
tinued flow, in which it may, occur. And yet when 
we reflect how constantly blood-letting is employed 
as a remedy, and how frequently haemorrhage occurs OF LOSS OF BLOOD. 
11 
as a disease, it must evidently be of great moment to 
trace the symptoms and effects of a diminished quan- 
tity of blood upon the different functions of the human 
body. 
Th is 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 di- 
rectly 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 those 
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 12 
suggests the renewed use of the lancet. In this man- 
ner 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 
no reaction. At other times the reaction is exces- 
sive 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 ge- 
neral it may be said that reaction is principally ob- 
served in connexion with strength of system; in 
infancy and in old age reaction is slight; exhaustion 
from loss of blood is then most apt to show 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 induc- 
ing in the system, resistance or susceptibility in re- 
gard to the effects of loss of blood. The discussion 
of this subject, and its application to practice, are re- 
served for the second part of this work. 
The next point for our consideration in the inquiry 
ON THE MORBID EFFECTS OF LOSS OF BLOOD. 
13 
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 cavi- 
ties of the serous membranes, in the bronchia, in the 
lungs, and in the track of the alimentary canal, un- 
der the forms of effusion, oedema, and tympanitis. 
We must consider, in the last place, the proper 
mode of treating the effects of loss of blood, both con- 
stitutional 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. 14 
OX THE MORBID EFFECTS 
CHAPTER II. 
i 
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 the posture, and the first 
sensation and appearances of the patient, in this state, 
appear to denote that the brain is the organ the func- 
tion of which is first impaired ; the respiration suf- 
fers 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 sus- 
pended until the painful sensation produced rouses the 
patient to draw deep and repeated sighs, and then OF LOSS OF BLOOD. 
15 
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 
del irium, yawning, and a return of consciousness ; 
irregular sighing breathing; and a gradual return of 
the pulse. 
In cases of profuse hsemorfhagy 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 impercep- 
tible, and then there are irregular sighs, the pulse is 
slow, feeble, cr not to be distinguished, the extremi- 
ties 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 
* The respiration is carried on chiefly, if not exclusively, by the dia- 
phragm, in some other states of the system. I have witnessed this in 
hysteria. The patient is then scarcely observed to breathe. Mr. Hun- 
ter 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, 8v. Edit. 1812. V. 2. p. 44. 16 
ON THE MORBID EFFECTS 
may also he observed lhat 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 syn- 
cope increases until it induces sickness ; or whether 
the stomach be nauseated by the ingesta usually ad- 
ministered, 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 haemorrhagy there are none of 
these ameliorations. The symptoms gradually and 
progressively assume a more and a more frightful as- 
pect: the countenance does not improve but becomes 
more and more pale and sunk ; the consciousness 
sometimes remains until at last there is some deli- 
rium ; but everything 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 ex- 
tremely 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. OF LOSS OF BLOOD. 
17 
From the state of syncope the system usually re- 
covers itself spontaneously, if the cause by which 
the syncope was induced, be discontinued. The 
principle by means of which this recovery is effected, 
may, without involving any hypothesis, be denomi- 
nated 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 condi- 
tion of the vital powers, or sinking, or to dissolution, 
each state leading to a corresponding series of phe- 
nomena. The description of these varied phenomena 
is reserved for the ensuing chapter. 
2. Of Convulsions. 
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 observa- 
tion as old as Hippocrates, who observes <f*ustu>s ymrat 
r] vnfo irXsjpwa’ios, fj xsvutfiog. This remark applies not only 
to convulsive movements of the voluntary muscles, 
but to those of the respiratory system. In this man- 
ner, indeed, I believe, an affection resembling croup 18 
ON THE MORBID EFFECTS 
is sometimes induced, which is very apt to be mis- 
taken and mistreated for croup itself. 
The general principle of the affection of the brain 
from a state of inanition or exhaustion of the vas- 
cular 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 connexion 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. 
Convulsions 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. In such 
cases much blood usually flows before syncope is ob - 
served, 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. OF LOSS OF BLOOD. 
19 
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 al- 
lowed to flow until thirty-four ounces were taken. 
He then suddenly fell upon the floor violently con- 
vulsed ; 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 ef- 
fects 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 re- 
store it. A very intelligent surgeon in the neigh- 
bourhood 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 not- 
withstanding frequent recourse to brandy, continued 
long apprehensive for the patient’s life. He repre- 
sented the convulsions, which returned in paroxysms, 
as resembling the puerperal in their severest form. 20 
ON THE MORBID EFFECTS 
There has been reason to believe that the loss of 
blood in operations in which haemorrhage 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 some- 
times prove fatal, especially to children. I have 
known an infant die of convulsions on the day 
after the removal of a nsevus from the scalp, of no 
extraordinary size, and without any after hacmor- 
,rhage.”f 
Convulsion from loss of blood constitutes one 
species of puerperal convulsion, and should be accu- 
rately 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. 
* On Constitutional Irritation, p. 501, 
f Ibid. p. 401. OF LOSS OF BLOOD. 
21 
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 syncope; 
instead of laying him recumbent, his ignorant friends 
kept him in the erect position during an hour and a 
half, and thus protracted the state of deliquium du- 
ring the whole of this period. He was found per- 
fectly 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 sub- 
sided, and he regained a degree of warmth under the 
influence of brandy and fomentations. 
To these phenomena succeeded severe rigor, fol- 
lowed 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 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. 22 
ON the morbid effects 
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 \*is 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, delirium, 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. , miscarried on the third month of her 
pregnancy. There was considerable flooding. On 
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 af- 
fected 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 frequently 
occurs as an immediate effect of htemorrhagy during OF LOSS OF BLOOD. 
23 
parturition. Still more frequently mania occurs as a 
remote effect of loss of blood. 
It is important to remark that delirium 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 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. , aged 40, had been, for some time, un- 
der medical treatment for a small tumour in the 
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. had also passed 
five nights totally without sleep, although on the 
evening of the second day she had taken twenty-five 
minims of the tincture opii. 
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 ammonim aromaticus. 
1 saw Mrs. again in four hours ; the delirium 
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 be- 24 
ON THE MORBID EFFECTS 
fore. 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 perspira- 
tion. 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 pro- 
cured sleep. 
From this time there was no recurrence of deli- 
rium. The perspiration kept profuse for some days, 
but gradually subsided; the pulse became gradually 
slower and stronger. There was afterwards a pro- 
tracted affection of the chest. 
Puerperal mania from hsemorrhagy is rather to be 
ranked amongst the secondary effects of loss of blood, 
and will be slightly discussed in its proper place. OF LOSS OF BLOOD. 
25 
4. Of Coma. 
We may be called to patients so perfectly coma- 
tose, immediately after blood-letting or haemorrhage, 
that vve may be in doubt for a-time whether the case 
be not apoplexy. The history, the state of the coun- 
tenance, 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 the 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 cut 
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.”* 
* Surgical Observations, Part iii. page 335. 26 
ON THE MORBID EFFECTS 
5. Of Sudden Dissolution. 
I have pointed out, pages 10—13, some 'circum- 
stances in which blood-letting has led to sudden 
dissolution, and I have recorded in a recent work,* 
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 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 dis- 
covered to be fractured near their angles. Their 
fractured ends having been pushed inward, through 
the intercostal muscles, pleura costalis, the pulmonalis, 
into the substance of the lungs, the air had conse- 
quently 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 a considerable tightness of the chest, 
with pain chiefly in the situation of the fractures. 
* Commentaries on some Diseases of Females, p. 286. OF LOSS OF BLOOD. 
27 
His inspiration was somewhat short and rapid ; the 
pulse was at first weak and contracted, hut 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 band- 
age applied closely. 
The blood drawn yesterday had a decidedly in- 
flammatory character, and after the abstraction of it, 
the patient expressed himself relieved. Pie has pass- 
ed 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. 
He passed a good night, and this morning we find 
him capable of talking cheerfully with a friend. Ex- 
presses himself free from all pain. Emphysema just 28 
ON THE MORBID EFFECTS 
the same ; expectorates freely ; pulse small and jerk- 
ing, but very compressible. The blood drawn yester- 
day has not the slightest appearance of inflammation. 
Mr. Lloyd ordered the patient to lose eighteen 
ounces of the blood, considering, as we suppose, the 
state of the pulse as indicative of inflammation, and 
not as resulting from loss of blood, haemorrhagic irri- 
tion, 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 ftie 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 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 extrava- 
sated air, and presented a tuft-like appearance. 
The vessels about the heart were quite empty, 
neither was there any fibrine found in the ventricles, OF LOSS OF BLOOD. 
29 
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.” 30 
ON THE MORBID EFFECTS 
CHAPTER III. 
OF THE MORE REMOTE EFFECTS OF LOSS OF BLOOD, 
OR EXHAUSTION. 
1. Of Exhaustion with excessive reaction. 
Exhaustion may assume several different cha- 
racters. It may be attended with excessive or with 
defective reaction, or with actual sinking of the vital 
powers; its prominent symptoms 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. OF LOSS OF BLOOD. 
31 
The phenomena are very different, if, instead of 
one full bleeding to syncope, or of a profuse haemor- 
rhagy, and even protracted syncope, the person be 
subjected to repeated blood-lettings or to a continued 
drain. In this case, within certain limits, the pulse, 
instead of being slow and feeble, acquires a morbid 
frequency and the throbbing beat, and there are, 
in some instances, all the symptoms of excessive 
reaction. 
This state of excessive reaction is formed gradu- 
ally, and consists, at first, in forcible beating of the 
pulse, of the carotids, and of the heart, accompanied 
by a sense of throbbing in the head, of palpitation of 
the heart, and eventually perhaps of beating or 
throbbing in the scrobiculus cordis, and in the course 
of the aorta. This state of reaction is augmented 
occasionally by a turbulent dream, mental agitation, 
or bodily exertion. At other times it is modified by 
a temporary faintness or syncope. There is also 
sometimes irregularity of the beat of the heart and of 
the pulse. 
In the more exquisite cases of excessive reaction, 
the symptoms are still more strongly marked, and 
demand a fuller description. 
The beating of the temples is at length accom- 
panied by a throbbing pain of the head, and the en- 
ergies and sensibilities of the brain are morbidly aug- 
mented ; sometimes there is intolerance of light, but 
still more frequently intolerance of noise and of dis- 32 
OX THE MORBID EFFECTS 
turbance of any kind, requiring stillness to be strictly 
enjoined, the knockers to be tied, and straw to be 
strewed along the pavement; the sleep is agitated 
and disturbed by fearful dreams, and the patient is 
liable to awake or to be awoke in a state of great 
hurry of mind, sometimes almost approaching to 
delirium ; sometimes there is slight delirium, and oc- 
casionally even continued delirium ; more frequently 
there are great noises in the head as of singing, of 
crackers, of a storm, or a cataract; in’some 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 palpitation, and visible 
throbbings of the carotids, and sometimes even of the 
abdominal aorta, augmented to a still greater degree, 
by every cause of hurry of mind or exertion of the 
body, by sudden noises or hurried dreams or wakings; 
the patient is often greatly alarmed and impressed 
with the feeling of approaching dissolution ; the state 
of palpitation and throbbing are apt to be changed, 
at different times, to a feeling of syncope ; the effect 
of sleep is in some instances very extraordinary, 
sometimes palpitation, at other times a degree of 
syncope, or an overwhelming feeling of dissolution ; 
the pulse varies from 100 to 120 or 130, and is attended with a forcible jerk of bounding of the 
artery. 
The respiration is apt to be frequent and hurried, 
and attended with alternate panting and sighing ; the 
movement of expiration is sometimes obviously and 
singularly blended with a movement communicated 
by the beat of the heart; the patient requires the 
smelling-bottle, the fan, and the fresh air. 
The skin is sometimes hot; and there are fre- 
quently general hurry and restlessness. 
in this state of exhaustion, sudden dissolution has 
sometimes been the immediate consequence of mus- 
cular effort on the part of the patient, or of his being 
too suddenly raised from the recumbent into the erect 
position. 
The following case strikingly illustrates the phe- 
nomena of reaction from a continued drain or loss of 
blood. 
Mrs. aged 28, of a stout constitution. After 
delivery there was uterine haemorrhagy, which con- 
tinued to recur for the twelve subsequent months. It 
was then discovered that Mrs. laboured under 
polypus uteri; a ligature was applied, purgative 
medicines given, and the patient recovered. The 
effects of this loss of blood followed, however, and 
there were, 1. beating of the temples, a sense of vio- 
lent ‘ knocking’ in the head, pain, vertigo, dimness 
of sight, and singing in the ears, terrific dreams, and 
starting from sleep; 2. frequency of the pulse, pul- 
OF LOSS OF BLOOD. 
33 34 
sation of the carotids and aorta, fluttering and beating 
of the heart, faintishness, and a sense and fear ot 
dissolution ;—the palpitation of the heart was some- 
times such on awaking as even to move.the bed- 
clothes, the bed, and, it is said, even the door; 3. 
the breathing was short and hurried, sometimes with 
panting, sometimes with sighing; 4. there were ur- 
gent calls for air, for opened windows, and the 
smelling bottle, and the nostrils and temples were 
required to be bathed with sal volatile or vinegar. 
The countenance, prolabia, and tongue were pal- 
lid ; the legs somewhat oedematous; the bowels 
were irregular, the secretions morbid ; once there 
was obstinate constipation; frequently the bowels 
were merely confined, sometimes with sickness, but 
always with an increase of all the symptoms. 
The state of reaction as an effect of repeated loss 
of blood is interestingly pourtrayed in the follow- 
ing case, for which I am indebted to a friend. 
“ Mrs. a delicate, married person, aged 24, 
a week or ten days after her confinement of a still- 
born child, was seized with pain at the lower part of 
the abdomen, extending to the liver, and other symp- 
toms which indicated inflammation of the os uteri, 
together with much constitutional disturbance ; the 
case seems to have been mistaken in the beginning, 
so that it was allowed to become somewhat inveterate 
before the appropriate treatment was adopted. It 
was at this stage treated with leeches to the hypogas- 
ON THE MORBID EFFECTS OF LOSS OF BLOOD. 
35 
trium, cupping low in the loins, the hip-bath, aperient 
medicines, strict abstinence, &c. 
“ The benefit accruing from cupping over the sa- 
crum was observed to be so decided, that recourse 
was had to this remedy twice or thrice a week regu- 
larly. The disease seemed to be thus yielding in the 
most favourable manner, when the patient became 
suddenly and quite unexpectedly, affected with 
the effects of loss of blood, in a most violent form. 
The quantity of blood taken by the cupping had 
frequently been twenty ounces; and too exclusive 
attention had been paid to the disease, the state of 
the constitution not being sufficiently watched. In 
this manner, the patient became affected, all at once, 
after being cupped, with sudden and alarming syn- 
cope ; she gasped, and became convulsed, and after- 
wards slightly delirious. The admission of the cold 
air, and the administration of brandy, gradually re- 
stored the patient to sensibility, but she remained 
extremely feeble. 
“On the next morning, Mrs. was affected 
with extreme pain of the head, violent throbbing of 
the temples, slight delirium, and sickness; the street 
was found covered with straw. 
“ During this day, the pain of the head, the throb- 
bing, and the intolerance of light and of sound, had 
increased so much, with sickness, feverishness, and a 
frequent strong pulse, that it was apprehended that 
inflammation had taken place in the brain. The 36 
ON THE MORBID EFFECTS 
arm was actually tied up for blood-letting; but the 
remonstrances of the patient, the history of the attack, 
and the recollection of some remarks on the effects 
of loss of blood read some years before, happily led 
to the abandonment of this measure.57 
My friend candidly observes, u fortunately both for 
my patient and for myself, her repugnance to general 
bleeding prevented me from using the lancet, and so 
saved her life; I prescribed leeches to the temples, a 
blister to the nape of the neck, and a cold lotion to 
the head; opiates and the effervescing medicines 
were immediately rejected. My patient became 
much better. She earnestly requested to be allowed 
a little brandy ; I gave it her ; it obviously afforded 
much relief, and I began clearly to see the nature of 
the case.55 From this time light cordials, a mild diet, 
rest, quietude, a strict attention to the state of the 
bowels, constituted the treatment, and it was follow- 
ed by a gradual and progressive amendment. 
Some of the symptoms remained, however, for 
some time. The pain of the head continued very 
troublesome for many weeks, and a pulsatory move- 
ment in the side of the neck harassed the patient 
for several years. My friend adds, “ in this case the 
effects of loss of blood on the constitution stole al- 
most imperceptibly on me, and I was not then aware 
that such symptoms as you have detailed in your 
work would arise. This case also has made me 
attend very much to the prejudices of a patient ever 37 
since, and carefully examine whether they be well- 
founded. In this instance I really believe my yield- 
ing to them saved the life of my patient.” 
Since my first publication on this subject, in 1820, 
I have seen several allusions to it in various works, 
and one especially by Mr. Cooke, in his useful and 
'able abridgment of Morgagni. The observations of 
this author are indeed highly valuable, and they have 
been fully confirmed by Dr. Kellie. Mr. Coke re- 
marks, “ After uterine haemorrhage, and also after 
copious depletion on account of pulmonary and 
other inflammations, I have frequently observed the 
symptoms of cerebral congestion ; and which has 
generally appeared to arise from the excitement oc- 
casioned by some mental effort, though occasionally 
it has arisen without an evident cause. Whilst the 
other parts of the body appear comparatively blood- 
less, the vessels of the head throb violently ; there 
is severe pain ; confusion of intellect, sometimes to 
such a degree as to threaten delirium ; the pulse at 
the wrist is usually small and vibrating, and the 
countenance distressed. When I first observed these 
symptoms I was led to abstract blood, from an ap- 
prehension of phrenitis : but I did harm ; for if the 
urgency of symptoms was diminished, the suscepti- 
bility to a recurrence was increased, and restoration 
to health was protracted. The liability to this form 
of cerebral plethora has appeared to me to be pro- 
portionate to the preceding haemorrhage, and the 
OF LOSS OF BLOOD. 38 
ON THE MORBID EFFECTS 
consequent debility. If in this condition an intrusive 
visitor be admitted to converse, though but for a short 
time, with the patient—or if the patient attempt to 
read, or in any other way to employ the mental 
faculties beyond what is perfectly easy—or if the 
mind be agitated, this state of the head will almost 
inevitably be induced. It may, however, be brought 
on by all those causes which tend to destroy the 
equilibrium or circulation; and none are more likely 
in this condition of the patient, than noise in the 
room, deficiency of sleep, improper food, a consti- 
pated state of the bowels, or a morbid state of the se- 
cretions into them. This susceptibility to local con- 
gestion after excessive loss of blood, I presume 
depends upon the want of that due balance which, 
in a state of health, subsists between the nervous and 
vascular systems; but I am jealous of hypothesis in 
medicine, and to pursue them in the present work 
would be unwarrantable.’7 Vol. I. p. 73. 
“ From the peculiarity of the conformation of the 
nose, epistaxis is sometimes a most uncontrollable 
form of haemorrhage. I have recently seen two 
cases in which if it were not absolutely the occasion 
of death, it certainly accelerated that event. The 
first was in a gentlemen who laboured under hydro- 
cephalus. He was a susceptible man and would not 
endure a plug in the nostril. The haemorrhage fre- 
quently recurred; and when he had become ex- 
ceedingly pallid from loss of blood, it was curious to OF LOSS OF BLOOD. 
39 
observe to what an extent the irritative haemorrhagic 
action was propagated. At first he only distinguished 
pulsation in and about the nose, but as his strength 
decreased, and his anxiety and susceptibility were 
heightened, the carotids could be seen throbbing 
vehemently, and a corresponding action was percep- 
tible to the patient through their ramifications. The 
second case was in an old arthritic sufferer, who had 
been seized with cynanche parotidaea. The more 
acute inflammation had subsided, but the gland was 
much enlarged and indurated, and the jaw nearly 
rigid. In this state he was attacked with bleeding 
from the nose. It occurred sometimes when he was 
asleep, on which occasions he w'as threatened with 
suffocation from the formation of coagula in the 
fauces, which he removed with the utmost difficulty, 
in consequence of being unable to open his mouth. 
The haemorrhage commenced in the nasal cavity 
nearest to the enlarged gland, but it afterwards took 
place from both nostrils. He was excessively afflict- 
ed with gout, and had indications of hepatic disor-. 
ganization ; but the immediate cause of death was 
the repeated effusion of blood. The haemorrhagic 
action was not so extensively manifest as in the pre- 
ceding case; but when there was feebleness in the 
radial artery, and the extremities were cold, the 
patient was conscious of a strongly irritative throb- 
bing in the arteries ramifying through the nose and 
the circumjacent parts.” Vol. I. p. 191. 40 
More recently I find several interesting cases of 
this kind in the late admirable work of Dr. Aber- 
crombie. 
“ A gentleman, aged about 40, had been for some 
time losing considerable quantities of blood by arte- 
rial haemorrhage from the rectum. Considering it 
as merely haemocidail, he had paid little attention to 
it until his friends became alarmed by his altered 
appearance. From being strong and rather plethoric, 
he had become weak, exhausted, pale, and haggard. 
He had an asarca of his legs; his pulse frequent and 
feeble, and much excited by the least exertion. Along 
with these symptoms, he was liable to strong and 
irregular action of the heart, and complained of gid- 
diness, tinnitus aurium, violent throbbing in the head, 
and frequently of throbbing head-ache. On exam- 
ining his rectum, a fungous tumour was found within 
the sphincter, on the apex of which a small artery was 
bleeding, per sultrum. This was tied and there was 
no return of the haemorrhage ; and under the use of 
nourishing diet, and a liberal allowance of wine, all 
his other complaints disappeared. He made up so 
rapidly in flesh and blood, that not long after appre- 
hensions were entertained that he was becoming too 
plethoric, and it became necessary to reduce his regi- 
men, but under these circumstances he had no return 
of the symptoms in the head. 
“A lady, aged 25, had been frequently bled on 
account of symptoms in the head which had super- 
ON the morbid effects OF LOSS OF BLOOD. 
41 
vened upon an injury. Considerable relief had fol- 
lowed each bleeding; but the symptoms had soon 
returned so as to lead to a repetition of the bleeding 
at short intervals, and this had been going on for 
several months. When I saw her she was stretched 
upon a couch, her face of the most death-like pale- 
ness, or rather of the paleness of a stucco figure, her 
pulse very rapid and as small as a thread, her general 
weakness extreme. The mass of blood appeared to 
be reduced to the lowest point that was compatible 
with life, but she still complained of frequent head- 
ache, violent throbbing in the head, confusi<?h and 
giddiness. It was evident that evacuation could be 
carried no further, and in consultation with a very 
intelligent medical man who had the charge of her, 
it was agreed as a last experiment, to make a trial of 
the opposite system, nourishing diet and tonics. 
In a fortnight she was restored to a very tolerable 
health. 
i( I have been repeatedly consulted under the fol- 
lowing circumstances. A gentleman accustomed to 
very full living, is seized with an apoplectic attack, 
or with symptoms indicating the most urgent danger 
of apoplexy ; he is saved by bleeding and other free 
evacuations, and is kept for some time upon a very 
spare diet.' His complaints are relieved, and as long 
as he keeps quietly at home, he goes on without any 
uneasy feeling. But when he begins to go about, 
he becomes liable to attacks of giddiness and confu- 42 
ON THE MORBID EFFECTS 
sion, generally accompanied by palpitation of the 
heart, and an uneasy feeling about the praecordia. 
His pulse is now soft and rather weak, and his gene- 
ral appearance indicates the reverse of plethora, and 
these symptoms are removed by a cautious improve- 
ment of his regimen. This curious fact I have re- 
peatedly had occasion to attend to in the treatment 
of cases of this kind, and it has always appeared to 
me to be of a very great interest in reference to the 
pathology of the brain,77* 
2. Of Exhaustion with defective reaction. 
The phenomena of excessive reaction are most 
observed in young persons of a robust constitution, 
who have been subjected to repeated blood-letting. 
In infants, in feeble persons, and in rather advanced 
years, reaction after loss of blood is apt to be defec- 
tive. In this case the patient remains long pale, thin 
and feeble, and becomes faint on the slightest occa- 
sions; there are deafness and dozing, from which the 
patient is apt to be startled by sudden loud noises; 
the pulse is frequent, but feeble and perhaps irregular, 
and we shall look in vain for the throbbing and pal- 
pitation observed in the young and robust. This 
state either gradually yields to returning strength, or 
subsides into the state of sinking. In the study of 
* Researches on Diseases of the Brain, pp. 308—310. OF LOSS OF BLOOD. 
43 
the effects of loss of blood it is particularly necessary 
to bear in mind this difference of the phenomena aris- 
ing out of the state of the constitution, of vigour, or 
of feebleness of the patient. 
3. On Exhaustion with Sinking. 
The symptoms of exhaustion with excessive reac- 
tion. may gradually subside and leave the patient 
feeble but with returning health; or they may yield 
to the state of sinking. This term is adopted not 
to express a state of negative weakness merely, which 
may continue long and issue in eventual recovery, 
but to denote a state of positive and progressive fail- 
ure of the vital powers, attended by its peculiar 
effects, and by a set of phenomena very different from 
those of exhaustion with reaction. 
If in the latter the energies of the system were 
augmented, in the former functions of the brain, the 
lungs, and the heart are singularly impaired. The 
sensibilities of the brain subside, and the patient is 
no longer affected by noises as before; there is, on 
the contrary, a tendency to dozing, and gradually 
some of those effects on the muscular system which 
denote a diminished sensibility of the brain super- 
vene, as snoring, stertor, blowing up of the cheeks in 
breathing, &c.; instead of the hurry and alarm on 
awaking as observed in the case of excessive reac- 
tion, the patient in the state of sinking, requires a 44 
moment to recollect himself and recover his con- 
sciousness, is perhaps affected with slight delirium, 
and he is apt to forget the circumstances of his situa- 
tion, and, inattentive to the objects around him, to fall 
again into a state of dozing. 
Not less remarkable is the effect of the state of 
exhaustion with sinking on the function of the lungs ; 
indeed the very first indication of this state is, 1 be- 
lieve to be found in the supervention of a crepitus in 
the respiration, only to be heard at first on the most 
attentive listening ; this crepitus gradually becomes 
more audible and passes into slight ruttling, heard in 
the situation of the bronchia and trachea; there is 
also a degree of labour or oppression, sighing, hurry, 
blowing, in the breathing, inducing acuteness in the 
nostrils, which are dilated below and drawn in above 
the lobes at each inspiration ; in some cases there 
is besides, a peculiar catching, laryngal cough, which 
is especially apt to come on during sleep, and awakes 
or imperfectly awakes the patient. 
The heart has at the same time, lost its violent beat 
and palpitation, and the pulse and arteries their bound- 
ing or throbbing. 
The stomach and bowels become disordered and 
flatulent, and tympanitic, and the command over the 
sphincters is impaired. 
The last stage of sinking is denoted by a pale and 
sunk countenance, inquietude, jactitation, delirium, 
and coldness of the extremities. 
ON THE MORBID EFFECTS 45 
The symptoms of exhaustion first met with reac- 
tion, but gradually passing into the state of sinking, 
are exemplified in a remarkable manner in the fol- 
lowing case, the circumstances of which were the 
more accurately noticed as they occurred in the 
person of a much respected friend and intelligent 
member of the profession, and principally under my 
own roof.—Mr. , aged 40, of an extremely mus- 
cular and robust make, was returning from Notting- 
ham into the country on the 3rd of October, 1821, 
when his horse reared, fell backwards upon him, and 
fractured the third and fourth ribs of the left side of 
the chest; he was taken to an inn, and I saw him 
with a surgeon, early on the following morning. He 
then suffered extreme pain of the side, there was a 
distinct crepitus, but no emphysema ; the face was 
somewhat bruised and swollen and ecchymosed ; the 
pulse was 100 and strong. Sixteen ounces of blood 
were taken from the arm, and a dozen leeches were 
applied to the temples and the same number over the 
fracture of the ribs; the motions of the chest were 
restrained by a tight bandage, and calomel and purg- 
ing medicine were freely given. At noon sixteen 
ounces of blood were again drawn from the arm, and 
a surcingle was applied round the chest.—During 
the wdiole of the 5th of October, or second day after 
the accident, Mr. appeared to be.going on well, 
but at night a violent attack of pain of the side in- 
duced him to bleed himself; this was done to syncope, 
OF LOSS OF BLOOD. 46 
ON THE MORBID EFFECTS 
and as a large wash-hand basin was used to receive 
the blood, its quantity was not known but must have 
been very considerable ; seventeen leeches were then 
applied to the side and shoulder; great relief was 
obtained, and the surcingle which had been removed, 
was re-applied, and the mercury and purgatives were 
continued.—Early on the morning of the third day, 
there was another violent attack of pain of the side 
with dyspnoea ; a messenger was despatched for the 
medical attendants, but before their arrival Mr. 
had again bled himself, and taken sixteen ounces of 
blood, being unable to endure the pain ; in another 
hour eight ounces more blood were drawn, the patient 
sitting upright; this was followed by syncope and 
great relief from the pain. 
On the fourth day Mr. was removed a dis- 
tance of about one mile to my house, and bore the 
journey on a litter extremely well, having previously 
lost a teacupful of blood ; he expressed himself as 
feeling better than at any time since the accident. 
In the evening an increase of pain took place and 
about seven ounces of blood were taken with great 
relief. 
In all it would appear that Mr. lost at least 
120 ounces of blood. 
On the fifth day we were joined in consultation by 
an eminent physician and surgeon. There was much 
pain of the side ; and it was at first proposed to take 
away more blood. But as I had observed some of OF LOSS OF BLOOD. 
47 
the symptoms which I knew to indicate reaction from 
exhaustion, the venesection was omitted, and the 
application of leeches only was proposed ; the symp- 
toms, however, increased, and the leeches were not 
applied. 
On the sixth day the following circumstances were 
noticed. There was some degree of dyspnoea and of 
pain in the side; and the patient had removed the 
surcingle in the hope of obtaining relief; the mouth 
was affected with ptyalism. The pulse was 100, and 
had acquired a peculiar jerk; there were violent throb- 
bings of the .carotids, a pulsatory pain of the head, 
and intolerance of noise, and, in a slight degree, of 
light; at one time in the morning of this day great 
agitation had been induced by a knock at the door. 
On account of the intolerance of sound, it was direct- 
ed that the pavement should be strewed with straw', 
and that the ringing of the bells of the adjacent 
church should be avoided. The bowels w'ere freely 
moved; a draught with tinctura opii, and spiritus 
ammonise aromaticus was given, with broth, arrow- 
root, sago, &c. 
Seventh day. The patient was rather better 
towards yesterday evening. All the symptoms of 
strong reaction continued as before. The head has 
been much relieved by the application of a cold 
lotion. 
On the succeeding day the pulse was only 84, and 
had lost, in some degree, its peculiar jerk; the caro- 48 
ON THE MORBID EFFECTS 
tids beat less violently ; the head was so much better 
as to render the lotion unnecessary ; there was more 
tranquillity and some hilarity of mind. The aperients, 
the anodyne, and the nourishments were continued. 
I saw my patient about 3 A. M. on the 
ninth day, and I then heard the slightest degree of 
that crepitus in the breathing, which I have already 
noticed as one of the first symptoms of sinking. The 
medical gentlemen met at nine, and the general 
symptoms were then so little changed, that no de- 
gree of alarm was excited in their minds. I men- 
tioned my fears, and the ground on which they were 
formed. At this meeting cupping was proposed ; 
but the changes in the patient were afterwards so 
rapid that in the evening brandy was recommended. 
The pulse was 110 in the middle of the day, unat- 
tended with its previous force and jerk, and easily 
compressible ; the beating of the carotids had subsi- 
ded ; a slight degree of stupor was observed ; on 
being left undisturbed, the patient fell asleep and 
snored ; there was some labour in the respiration, and 
a troublesome, dry, laryngal cough ; and, although 
the bandage was loose, there was no pain of the side 
of the chest: the countenance was anxious. 
The symptoms gradually assumed a more and 
more alarming form during this day ; at night there 
was considerable stupor, and when the patient was 
roused there was sometimes a degree of delirium ; 
during this sleep there were much snoring and puffing OF LOSS OF BLOOD. 
49 
up of the cheeks in expiration, something like the 
symptom which the French writers call “fumerla 
pipe on awaking, he would feel greatly concerned 
that he should have appeared to blow in your face ; 
there was much flatulence : the motions were ex- 
tremely offensive, and passed at each attempt to void 
urine. 
After midnight he could scarcely be roused ; but if 
awakened, he would speak collectedly, but in a hur- 
ried manner, and said he felt “ such a dying feel 
the pulse was about 120. I saw my patient at 3 
o’clock, A. M. there was little change in the pulse or 
other symptoms; but, in a minute or two, the pulse 
became slow, feeble, and irregular, he altered rapidly, 
and I found that he was moribund ; within a few mi- 
nutes more he expired. 
dtt dissection, the pleura was found morbidly red 
in the vicinity of the fracture, but not wounded ; 
there was some effusion of lymph in its cavity. The 
right lung was found united to its contiguous pleura 
by old adhesions. 
For the following valuable case illustrative of so 
many of the effects of exhaustion from loss of blood 
extracted from the Acta Physico-Medica Academiae 
Naturae Curiosorum ; 4to. Norimberg. 1737. Vol. 
iv. 535, 536, I am indebted to my friend, Dr. 
Stroud. 
“ Obs: 136 ; Dom. D. Christopheri Jacobi Trew. 
De Cephalalgia saevissima, venaesectionem justo lar~ 50 
ON THE MORBID EFFECTS 
giorem sequuta : postea que amaurosin, et denique 
cerebri hydropem producente. 
Mulier mediocris habitus, sanguineo-cholerica, 
aliquot annorum spatio cephalalgia laborare coepit 
periodica, et saepius recurrente; nullum, tanern, 
typum servante, nec causam manifestante; contra 
quam auxiliam in venaesectione, bis quotannis nunc in 
pede nunc in brachio repetita, quaesivit atque invenit. 
Hac, vero, anno aetatis ejus quadragesimo secundo, 
in brachio iterem administrata, accidit ut chirurgus, 
dum sanguis flueret cum adstandibus confabulatus, 
quantitatem sanguinis profusi tunc demum animad- 
verteret postquam pelvin satis capacem repleverat, et 
afflicta, ex subitaneo dolore acutissimo caput quasi 
perforante exclamans, ilium advocaverat. Clamorem 
editum illico sequebatur, gravis lipothymia ; qua dis- 
sipata, eodem momento cephalalgia non solum re- 
cruduit vehementissima, verum etiam dies noctesque 
saeviit, eademque vehementia tres integros annos 
continuavit, miseramque lecto penitus affixit. Longus 
foret sermo instituendus, si omnes quas aegra interea 
passa est calamitates, quasque contra illas periclitata 
est medicinas, exponendae essent. Nobis sufficet 
annotare medelam semper frustra expectatem, quere- 
las, vero, solum de intolerabilibus ictibus afque 
pulsationibus caput ferentibus effusas esse ; cseteroquin 
vires permansisse invictas, omnesque corporis func- 
tiones naturales, ipso tributo lunari et appetitu integro 
non excepto, legitime successisse; tandemque, in OF LOSS OF BLOOD. 
51 
miseriae complementum, tertia ante obitum hebdo- 
made, tristissimam subito supervenisse csecitatem ex 
vera amaurosi plenariam ; his omnibus, autem, anno 
aetatis quadragesimo quinto, subitaneam mortem 
fecisse finem. 
Sectio defuncti corporis concessa nullum alium 
manifestavit statum morbosum quam hjdropem cere- 
bri, seu lympham flavam, non solum sub pia matre, 
per universum ejus ambitum, et quidem in singulis 
vasorum areolis seorsim collectam, sed, etiam, onmes 
ipsius cerebri cavitates seu ventriculos replentem. 
Quae, tamen, ljmphae extravasatio, sine dubio, effec- 
tus potius quam causa phoenomenorum, si mortem 
excipias repentinam, dici meretur. 
• 
It would, perhaps, be difficult to offer any obser- 
vations on the nature and cause of excessive reaction : 
but it is plain that the state of sinking involves a 
greatly impaired state of the functions of all the vital 
organs, and especially of the brain, from defective 
stimulus. The tendency to dozing, the snoring and 
stertor, the imperfect respiration, the impaired action 
of the sphincters, the defective action of the lungs, 
and the accumulation of the secretions of the bronchia, 
the feeble and hurried beat of the heart and pulse, the 
disordered state of the secretions of the stomach and 
bowels, and the evolution of flatus, all denote an 
impaired condition of the nervous energy. The state 
of sinking may, indeed, in certain points of view, be 
compared with the state of the functions in apoplexy : 52 
and to the effects observed on abstracting the influ- 
ence of the brain and spinal chord by dividing the 
eighth pair of nerves, or by destroying the lower por- 
tion of the chord.* 
There are many very interesting though cursory 
notices of the subject under discussion, in the recent 
work of M. Andral, entitled, ‘ Precis d’ Anatomie 
Pathologique,’ under the head of ‘Anemic,’ confir- 
matory of the views which I have laid before the 
profession. 
At the 81st page of his first volume, M. Andral 
observes, ,, Lorsque Peconomie -vient a perdre, en un 
court espace de temps, une tres-grande quantite de 
sang, Paction de plusieurs organes est singulierement 
troublee : ainsi Pon observe de graves desordres dans 
le systeme nerveux: non seulement il y a des lipothy- 
mies, des defaillances; mais, au milieu de la diminu- 
tion reelle des forces qu’a produite la soustraction du 
sang, appraissent des phenomenes qui sembleraient 
ne devoir resulter que de la sur-excitation des centres 
nerveux: du delire survien't, des convulsions se 
manifestent; le coeur devient le siege de palpitations; 
la respiration est difficile, comme dans les cas de 
congestion pulmonaire ; dans ce dernier cas, il y a 
dyspnee, parce qu’il y a trop de sang relativement a 
Pair, qui entre dans les bronches: dans le cas d’ane- 
mie, il y a aussi dyspnee, mais par une cause con- 
ON THE MORBID EFFECTS 
* See Dr. Philip’s work on “ Tlie Vital Functions” passim. OF LOSS OF BLOOD. 
53 
traire; parce qu’il a trop cl’air relativement au sang 
que Fair doit vivifier; c?est comme lorsqu’on place 
un animal sous une cloche remplie d’oxigene pur. 
La digestion est aussi troublee : car, pour son ac- 
complissement normal, il faut que Festomac, qui a 
Faliment, deviennele siege d’un certain degrede 
congestion sanguine, qui, chez les individus, anemi- 
ques, ne peut plus avoir lieu. A mesure que le sang 
se refait, ces differens phenomenes morbides dis- 
paraissent.” 
At the 769th page of volume the second he adds : 
“ L’anemie des centres nerveux se produit sous Fin- 
fluence des meraes causes que celles que nous avons 
assignees en general a toute anemie (tome I). El le 
peut etre bornee au cerveau, ou coincider, avec un 
etat d’anemie de tout le corps. Elle s’observe, soit 
dans les maladies chroniques, soit dans certaines 
maladies aigues ou les sjmptdmes semblaient annon- 
cer un etat d’irritation du cerveau, et ou Fon iFest 
pas peu etonne de trouver, au contraire, cet orgaine 
d?une paleur remarquable. Nous avons deja eu 
occasion de nous arreter sur ces faits, que nous nous 
bornerons ici a rappeler.” 
But the most interesting remark of this writer oc- 
curs at page 46 of volume the first. Speaking of the 
sinking state generally, M. Andral confirms, in almost 
the same terms, the remark which I had made so 
long before, in regard to sinking from loss of blood, 
and other causes, that the lungs are “ comme ils le 54 
ON THE MORBID EFFECTS 
sont chez les animaux dont les nerfs pneumogas- 
triques ont ete coupes, ou chez les individus frappes 
d’ apoplexie.”* 
4. Of Exhaustion with Delirium. 
It has already been seen that delirium is a frequent 
result of exhaustion from loss of blood. It occurred 
in the cases detailed pp. 19—21. The following 
case, with which I have been favoured by Dr. Aber- 
crombie, is, as that gentleman observes, in all its cir- 
cumstances one of considerable interest. 
I 
“ A lady aged about 35, after delivery of her fifth 
or sixth child, recovered favourably for a fortnight, 
when she became affected with pain and deep-seated 
hardness in the right side of the pelvis, painful to the 
touch, and accompanied by a considerable degree of 
fever. After repeated topical bleeding, and various 
other remedies, the febrile state subsided, the swell- 
ing lost its tenderness, and it seemed to be gradually 
diminishing in size; but its progress was slow; and, 
after three or four weeks from the time of its appear- 
ance, she was still confined to bed, and was suffering 
a good deal of uneasiness : her pulse was now' calm, 
but she was considerably reduced in strength. At 
this time she was one day alarmed and agitated by 
some family occurrence of a trifling nature, and im- 
* See p. 50 of this volume ; and the “ Medical Essays p. 56. OF LOSS OF BLOOD. 
55 
mediately began to talk wildly and incoherently ; 
and, after a restless night, she was found next day in 
the highest state of excitement, talking incessantly, 
screaming, and struggling, with a wild expression of 
countenance, and a small rapid pulse. She was now 
treated by leeches to the temples, cold applications 
to the head, purgatives, &c. but with little or no bene* 
fit; and, on visiting her next day, 1 found her sitting 
up in bed, with a look of extreme wildness, both her 
hands in constant motion; she was talking incessantly, 
loudly, and wildly, and I learnt that she had not 
ceased talking in this manner for one instant for the 
last twelve hours. Her pulse was rapid and feeble, 
and her countenance expressive of exhaustion. This 
wTas a state which I had repeatedly seen fatal under 
various modes of treatment, and I certainly expected 
no good of the case. But in consultation with a 
highly respectable medical friend who had charge of 
it, I proposed to try a treatment purely stimulant. A 
full glass of white wine was accordingly given, and 
ordered to be repeated every hour. On visiting her 
at the end of the fourth hour, I found her composed 
and rational ; her pulse 90 and of good strength ; and 
from this time there was no return of the symptoms. 
The tumour in the right side increased in size, sup- 
purated, was opened, and healed favourably ; and she 
is now in perfect health. 
Dr. Abercrombie adds, “ I have several times seen a 
state resembling mania take place after large bleeding 56 
OX THE MORBID EFFECTS 
in inflammatory diseases, and subside gradually as 
the patients recovered strength. The most remarka- 
ble of these, that I recollect at present, were after 
pneumonia, and acute rheumatism. Many years 
ago, I saw a man who was seized with bleeding from 
the nose to such an extent, that, at last, it became 
necessary to arrest it by pieces of sponge carried up 
from the fauces. Next day he was without com- 
plaint except great weakness ; on the third day he 
became highly maniacal: pulse generally from 90 to 
100, and soft. After various treatment with little 
benefit, for eight or ten days, an emetic was given ; 
he vomited smartly, and, in doing so, the plugs were 
forced out of his nose. Very soon after this he fell 
asleep, and, after a long sleep, awoke quite rational, 
and continued so.” 
I am persuaded that loss of blood is by far the 
most frequent and influential source of delirium or 
mania occurring in the puerperal state. It would 
lead me into too long a discussion to treat of this 
point in this place. Besides, I purpose making it 
the subject of distinct consideration at some future 
period. Meantime, I would beg to refer my readers 
to my work on some Diseases of Females, pp. 251 — 
256 ; and to* Dr. Gooch’s recent Account of some 
Diseases peculiar to Women, chap. ii. and especially 
pages 144, 145. OF LOSS OF BLOOD. 
57 
5. Of Exhaustion with Coma. 
It has already been stated that exhaustion from 
loss of blood is apt to induce a state of coma. This 
effect is most obvious in the case of infants and 
children.* But it is not confined to this early period 
of life. Next to childhood, the feeble state of old 
age appears most prone to this form of exhaustion, 
as I think youth and vigour are to delirium. Coma 
occurred, however, in its most marked form in the 
interesting case given pp. 45—49. 
Dr. Abercrombie observes, “In the last stage of 
diseases of exhaustion, patients frequently fall into a 
state resembling coma, a considerable time before 
death, and while the pulse can still be felt'distinctly; 
and I have many times seen children lie for a day or 
two in this kind of stupor, and recover under the use 
of wine and nourishment. It is often scarcely to be 
distinguished from the coma which accompanies dis- 
eases of the brain. It attacks them after some conti- 
nuance of exhausting diseases, such as tedious and 
neglected diarrhoea; and the*patients lie in a state of 
insensibility ; the pupils dilated, the eyes open and in- 
sensible, the face pale, and the pulse feeble. It may 
continue for a day or two, and terminate favourably, 
or it may be fatal. This affection appears to corre- 
* See Appendix. 58 
ON THE MORBID EFFECTS 
spond with the apoplexia ex inanitione of the older 
writers. It differs from syncope, in corning on gra- 
dually, and in continuing a considerable time, perhaps 
a day or two ; and it is not, like syncope, induced 
by sudden and temporary causes, but by causes 
of gradual exhaustion going on for a consider- 
able time it differs from mere exhaustion, in the 
complete abolition of sense and motion, while the 
pulse can be felt distinctly, and is, in some cases, of 
tolerable strength. I have seen in adults the same 
affection, though it is perhaps more uncommon than 
in children. A man, considerably advanced in life, 
in consequence of a neglected diarrhoea, fell into a 
state closely resembling coma; his face pale and 
collapsed, but his pulse of tolerable strength. An 
elderly lady, from the same cause, had loss of me- 
mory and squinting. Both these cases recovered by 
wine and opiates : in the former, blistering on the 
neck was also employed. Richter states that amau- 
rosis has been produced by haemorrhage, cholera, 
and tedious diarrhoea ; and he mentions particularly 
a dropsical woman who became blind when the 
fluid was evacuated from her abdomen by tapping. 
“ On this interesting subject I shall at present only 
add the following remarkable illustration from an 
affection of hearing. A gentleman, about thirty 
years of age, came to Edinburgh from a distance, for 
advice in regard to an obscure affection, referred 
chiefly to the stomach, which had reduced him to a OF LOSS OF BLOOD. 
59 
state of extreme weakness and emaciation. As the 
debility had advanced, he had become considerably 
deaf; and, when I saw him, he was affected in the 
following manner. He was very deaf while sitting 
erect or standing; but, when he lay horizontally 
with his head very low, he heard perfectly. If, when 
standing, he stooped forward, so as to produce flush- 
ing of his face, his hearing w7as perfect; and, upon 
raising himself again into the erect posture, he con- 
tinued to hear distinctly as long as the flushing con- 
tinued ; as this went off, the deafness returned. 
“Upon the whole, it seems highly probable that 
a certain balance of the circulation of the brain is 
necessary for the healthy condition of its functions; 
that they are equally impeded by the interruption 
which takes place in apoplexy, and the diminished 
impulse which occurs in these opposite conditions. 
What, indeed, is syncope but an abolition of sense 
and motion ? It is preceded by giddiness, tinnitus 
aurium, and impaired vision ; and is accompanied 
by blindness, dilated pupil, perfect insensibility, and 
not unfrequently passes into convulsion. It differs 
then from apoplexy, chiefly or entirely in the state of 
the general circulation, the symptoms accompanying 
the two affections being remarkably similar, and the 
effect upon the sensorial functions almost entirely the 
same.”* 
* On Diseases of the Brain, pp. 310—312. 60 
ON THE MORBID EFFECTS 
For the following most interesting case of coma, 
and finally of sudden sinking, from exhaustion, I am 
greatly indebted to a medical friend. 
(l An opulent farmer, nearly 60 years of age, tall 
and well-formed, of active habits in the early part of 
life, mostly of the sanguineous temperament, and of 
the bilious diathesis, was affected with hereditary 
gout at an early period of life, and had continued to 
be a martyr to that disease. He had, for many 
years, been occasionally affected with internal spasm 
in the cardiac region, attended with urgent sickness 
and giddiness, that form of complaint, namely, which 
is commonly called gouty spasm of the stomach. The 
biliary system was sometimes so much deranged as 
to give rise to jaundice. He had more than once 
been attacked with pneumonia, which was always 
sufficiently active to require one or more general 
bleedings. 
“ About five months before the fatal event which I 
have to describe, he was seized with apoplectic symp- 
toms. He was saved from death by prompt treat- 
ment by bleeding and purgatives. From this time, 
however, his health became wholly unsettled, and 
his frame evidently enfeebled. In the beginning of 
summer he was occasionally affected with sub-acute 
gout, both in the upper and lower limbs, and also 
with lumbago. Cramps and jactitations prevailed 
much in these attacks; the depression of his spirits OF LOSS OF BLOOD. 
61 
was extreme; the tone of the nervous system was in 
every way reduced. 
“ After exposure in an open carriage, on one fine 
day with the wind in the east, he was suddenly at- 
tacked with a severe pain in the abdomen, chiefly in 
the right hypochondrium and towards the stomach, 
the respiration being at the same time exceedingly 
painful and laboured. His medical attendant viewed 
the diseases as acute hepatitis, and bled him profusely 
from the arm, and with immediate relief, which was 
rendered more complete by the free action of purga- 
tive medicines. There was a slight recurrence of 
the symptoms in the course of forty-eight hours, and 
large depletion from the vessels was again practised, 
so that at the end of three days, nearly seventy 
ounces of blood had been abstracted by means of the 
lancet, cupping, and leeches. 
(i When the reporter of this case first saw this 
patient, the state of the vital powers was seriously 
depressed. The patient appeared bloodless, and 
cadaverously pale. The.superficial veins everywhere 
had the look of being quite empty. The tongue was 
pale, and coated with brown fur, the saliva was 
abundant, but extremely viscid; the eyes were 
glassy, the pupils dilated, the sight imperfect, the 
voice was very feeble ; there was much subsultus 
tendinum; the senses occasionally wandered, there 
was a lethargic state without any refreshing sleep; 
on the contrary, there was much restlessness; the 62 
jactitation of the limbs was considerable, the respira- 
tion, when the eyes were closed, was noisy, and 
distinguished in a great degree by puffing, as a smo- 
ker puffs out the smoke from his pipe. The pulse 
ranged from 100 to 120, and was truly the irritable 
pulse: it was throbbing, and also attended with a 
jerk. His pulse, in health, was known to be 
about 66. 
“ The treatment had in every way been strictly 
antiphlogostic; the diet being confined to gruel, 
barley water, and tea. At this juncture it appeared 
imperative to change the regimen. The patient had 
a frequent disposition to faint, and actually appeared 
to be sinking into death. Cordial nourishment, as 
gruel and brandy, eggs, wine, beef-tea, &c. were ad- 
ministered with caution. The former fluids had 
been rejected from the stomach, but the cordials just 
mentioned, were retained. Cordial medicines were 
also given; in the first instance a volatile saline 
draught with cordial confection; and due attention 
was paid to the bowels. 
“ The powers of the patient were soon revived, 
and in a few days acquired a remarkable degree of 
improvement. After a short time, he was enabled to 
take airings in a carriage daily, but still there was no 
promising convalescence. The pulse never fell be- 
low 90, and continued bounding; there was an un- 
ceasing lethargy, and in sleep the respiration was 
ON THE MORBID EFFECTS OF LOSS OF BLOOD. 
63 
attended with the puffing. Subsultus tendinum 
continued to prevail. 
“ At the end of a month from the time of the first 
attack, the unfortunate patient became suddenly 
seized with stertorous breathing, while in the act of 
taking some nourishment. The muscles of the face 
were distorted, all the superficial vessels of the head 
and neck were instantly distended, and in less than 
two minutes death closed the scene. 
“ No examination of the body was permitted.” 
6. Of Exhaustion with Amaurosis. 
It sometimes happens that the most prominent 
symptom in exhaustion from loss of blood, and indeed 
from some other causes, is a state of amaurosis. 
Upon this point I cannot do better than insert the 
following interesting observations of Mr. Travers.* 
“ A loss of balance in the sanguiferous system, oc- 
casioning an undue determination of blood to the 
head, often exists, distinct from general plethora, and 
is aggravated by loss of blood. The following case is 
an example : 
“ A young medical man came to me one morning 
from the country in extreme anxiety, with an earnest 
solicitation that I would instantly apply a ligature to 
his carotid artery. This gentleman, aged 25, was of 
* Synopsis of the Diseases of the Eye, Ed. 1. pp. 158—160. 64 
ON THE MORBID EFFECTS 
short stature, and constitutionally healthy. His pu- 
pils were large, and his countenance was suffused, 
and bore the appearance of preternatural determina- 
tion of blood to the head. He had been the subject 
of two attacks of inflammation; one in April, the other 
in October of the same year; during which he lost up- 
wards of an hundred ounces of blood. He had now a 
constant heavy pain in the head, chiefly over the coro- 
nal suture, and in the direction of the sinuses, with 
tinnitus of the left ear. After stooping, the giddiness 
was extreme, and a golden-coloured spot, edged with 
black, appeared floating before the eye. He had been 
troubled with muscse in excess, for a year and a half 
past; he had now fire sparks flashing before the sight, 
and saw a pulse in the choroid synchronous with 
that of the w’rist. When looking at near objects he 
was not troubled with muscse, but they were always 
numerous, in proportion as the object was remote. 
He did not complain of much dimness. His com- 
plaints were not relieved by topical blood-letting. 
He recovered gradually, but perfectly, under a regu- 
lated diet, and a course of the blue pill with saline 
aperients. 
“The amaurosis, from depletion, is sometimes 
mistaken for its opposite, viz. that from plethoric 
congestion ; this is owing to the coincidence of a 
dilated and immoveable pupil, muscse, and a deep- 
seated pain in the head, with occasional vertigo; and 
its occurrence in a corpulent habit. It succeeds OF LOSS OF BLOOD. 
65 
somewhat abruptly to uterine floodings, and large and 
sudden depletion for acute diseases. The pain is not 
confined to the region of the orbit, though it affects 
chiefly, if not exclusively, the same side of the head ; 
it is that peculiar nervous pain to which women are 
subject after uterine haemorrhage, attended with a 
sense of defined pressure, as of an iron finger on the 
brain ; and sometimes a distressing jarring noise like 
that of a mill or threshing-floor, or the rattling of the 
shingles as a heavy wave of the sea recedes. It is 
perhaps connected with an imperfect injection of the 
medullary substance. By a cautious use of tonics it 
is relieved ; by whatever lowers or stimulates, whe- 
ther diet or medicine, it is decidedly aggravated. The 
vision in this form of amaurosis is further enfeebled 
by the loss of as much blood as flows from two or 
three leech-bites. This is not imaginary ; I have 
seen distinctly marked cases of it, in which large and 
copious venesection was still urged as the only re- 
source of art. This I consider to be a fatal mistake.” 
Amaurosis occurred in the very interesting case 
given, p. 45; and it had been here noticed by Rich- 
- / 
ter; see p. 58. 66 
ON THE MORBID EFFECTS 
CHAPTER IV. 
OF THE EFFECTS OF FURTHER LOSS OF BLOOD IN 
CASES OF EXHAUSTION. 
1. Of the substitution of Syncope for Reaction. 
The symptoms of exhaustion with reaction have, 
I am persuaded, frequently been mistaken for those 
of inflammation or other disease of the head or of the 
heart. Under this impression recourse has frequently 
been had to the further detraction of blood by the 
lancet. And the effect of this practice is such as 
greatly to impose upon the inexperienced,—for all 
the symptoms are perhaps greatly relieved. 
It was some time before I could fully comprehend 
the nature of this fact. I had satisfied myself that, 
in certain cases the symptoms were those of loss of 
blood ; and yet it appeared no less certain that those 
very symptoms were relieved by the lancet. At 
length I discovered, by a careful observation, that the 
symptoms which were relieved were those of reaction; 
and that the mode of relief was by the substitution of 
syncope; that the relief endured as long as the 
state of faintishuess continued, but returned as this OF LOSS OF BLOOD. 
67 
state gave way to the allaying and reaction ol the 
vital powers. 
Another circumstance equally interesting and cu- 
rious was, that within certain limits, the remedy 
which relieved for a time, eventually only added to 
the severity of the malady, for this was apt to return 
after a certain period, in a still more aggravated form. 
It is natural, indeed, to suppose, that, unless there 
was a tendency to the failure of the vital powers, the 
reaction of the system and the painful circumstances 
attending it, would be greater after a third or fourth 
loss of blood, than after a first or second ; indeed 
there are seldom the symptoms of reaction after one 
flow of blood, however great or profuse; it is the re- 
petition or protraction of the cause which, as I have 
already observed, is essential to produce this effect. 
It is observable too that in cases of exhaustion with 
reaction, syncope is very soon produced by the further 
loss of blood. This fact is of importance, because it 
may be regarded as a sign of the state of exhaustion, 
when this is observed by the reaction of the system, 
and as a warning voice against the further and incon- 
siderate use of the lancet. # 
Mrs. , aged 21, and of a rather feeble con- 
stitution, was confined of her first child ; the bowels 
had been constipated, and were moved several times 
by a dose of castor oil, but becoming again confined 
she became much indisposed on the fifth day, with 
flushing of the countenance, noise in the ears as 68 
of a rushing wind or the explosion of crackers, 
flashes of light on lying down, beating of the caro- 
tids, &c. the pulse being 120 in a minute. Fourteen 
ounces of blood were taken from the arm, which in- 
duced deliquium with relief to the symptoms.—About 
seven hours afterwards the noises in the head had 
returned and the pulse was 120; twelve ounces of 
blood were again drawn and the patient again fainted, 
and was again relieved. Eight ounces of blood 
were taken the next day. On the succeeding day 
the medical attendant was called early in the morn- 
ing ; there had been little sleep, but much lowness 
for several hours, the patient then complained of vio- 
lent beating in the head ; the pulse was 120. A 
teacupful of blood was taken which induced faint- 
ishness and abated the beating of the head.—By 
noon, she was again flushed and the beating had re- 
turned in an aggravated degree.—From this period 
the patient was bled no more ; but recovered under 
the influence of aperient and anodyne remedies. 
Mrs. , aged 35, was confined in June, 1811 ; 
the expulsion of the placenta was followed by much 
hsemorrhagy, which induced great exhaustion. On 
the tenth day she was seized with severe shivering, 
heat, throbbing pain of the head, and intolerance of 
light and sound ; ten ounces of blood were taken 
from the arm, about 10 o’clock A. M., which in- 
duced faintishness and relief. At 7 o’clock in the 
evening, the pain of the head was as severe as ever; 
ON THE MORBID EFFECTS OF LOSS OF BLOOD. 
69 
twelve ounces of blood were taken from the arm ; 
this was followed by such dreadful faintness and 
gasping breathing, as even to lead to the apprehen- 
sion of dissolution ; on recovering, the pain and in- 
tolerance of light and of sound returned as before. 
This patient became affected with all the symptoms 
of exhaustion with reaction, but gradually recovered 
without further blood-letting. 
It gives me great pleasure to add, in this place, the 
further testimony of Mr. Brodie to the facts and 
principles which I have published in relation to this 
interesting question. 
“In taking a view of the*various satisfactory 
reasons which may be urged in favour of a particular 
plan of treatment in cases of concussion of the brain, 
we must not overlook the circumstance that this 
treatment may be carried too far : and we must en- 
deavour to avoid the error which I have known some 
surgeons fall into, of resorting to a too free use of 
the lancet. At first when the reaction of the heart 
has taken place, it may be right that the patient 
should lose a considerable quantity of blood, so as 
completely to subdue the force of the circulation. 
Afterwards, for the most part, it is only an occasional 
blood-letting that is required, and that to a moderate 
extent. It has appeared to me that this mode of 
proceeding has usually done more, both towards re- 
lieving the present symptoms, and preventing subse- 
quent inflammation, than a more active system of 70 
ON THE MORBID EFFECTS 
depletion ; and where very large quantities of blood 
have been already taken away, if inflammation should 
show itself, our resources are comparatively limited, 
and we are not able to meet it with that energy and 
vigour which the circumstances of the case require. 
“ Where bleeding has been carried to a great extent, 
symptoms frequently occur which in reality arise 
from the loss of blood, but which a superficial ob- 
server will be led to attribute to the injury itself, and 
concerning which indeed it is sometimes difficult, 
even for the most experienced surgeon to pronounce 
in the first instance to which of these two causes they 
are to be referred. Repeated copious blood-letting 
is of itself adequate to produce a hardness of the 
pulse, which we shall in vain endeavour to subdue 
by persevering in the same system of treatment. In 
many individuals it will produce headache and con- 
fusion of mind, not very different from what the 
injury itself had previously occasioned. These things 
may be observed especially in young females who 
are disposed to hysteria, and whom I have often 
known to suffer from a continued aggravation of 
such symptoms as I have described, while the system 
of depletion has been continued, recovering imme- 
diately on the use of the lancet being laid aside, and 
on their being allowed to take solid nourishment, 
with occasional doses of carbonate of ammonia. Dr. 
Marshall Hall has published in the thirteenth volume 
of the Medico-Chirurgical Transactions, some excel- OF LOSS OF BLOOD. 
71 
lent practical observations on the effects of copious 
blood-letting, many of which are applicable to the 
cases mentioned above.”* 
2. Of Sinking, or more Sudden Dissolution. 
If the loss of blood be repeated still farther, not 
only syncope, but a state of sinking is induced; the 
effects of reaction are of course in this case, perma- 
nently relieved whilst a different series of phenomena, 
already fully described, is established. This transi- 
tion of reaction into sinking may either be sponta- 
neous, as in the case of Mr. , detailed in the 
preceding section, p. 45, or it may be the effect of a 
last blood-letting, the state of syncope scarcely ceas- 
ing, no reaction following, but the total though gra- 
dual failure of the vital powers. 
When the last bleeding has been considerable, it 
has, in some cases, been followed by the most dread- 
ful gaspings and other convulsive motions, and death. 
It should be observed that between the most gradual 
sinking and the most sudden dissolution, as the effects 
of blood-letting, there is every intermediate shade, 
with the phenomena of which it is of the utmost im- 
portance to be acquainted. These varied phenomena 
may, I think, be collected from the observations 
whicji have been made in this and the preceding sec- 
* Medico-Chirurgical Transactions, Vol. xiv. pp. 381, 382, 72 
ON THE MORBID EFFECTS 
lions. They are further illustrated by the following 
cases which exemplify the fatal effects of loss of 
blood, as supervening more and less gradually upon 
the use of the lancet. 
Mrs. , aged 30, had been affected with what 
appeared to be a slight attack of influenza ; she was 
seized with rigor and soon afterwards the pains of 
labour came on and issued in delivery in about fifteen 
hours, at nine o’clock A. M.; this was followed by 
much fever, the countenance being flushed, the pulse 
frequent, and the breathing difficult with incessant 
cough; these symptoms increased towards evening 
and in the night, and about forty ounces of blood 
were drawn from the arm at two blood-lettings, and 
the next morning twelve leeches were applied to 
the chest, with great relief. In the evening a blister 
was applied.—The night was passed more comforta- 
bly ; she dozed a little and was cheerful, and con- 
tinued relieved in the morning. As a preventive 
against a relapse, however, three teacupsful of blood 
were taken. The patient became faint during the flow 
of the blood, sank from that time, and never again ral- 
lied ; she became extremely feeble, and could scarcely 
articulate, and from being cheerful the day before, 
was now impressed with the conviction of approach- 
ing dissolution, and expressed herself as unable to 
recover from the last blood-letting. During this.day, 
Saturday, and during the two succeeding days OF LOSS OF BLOOD. 
73 
there was a state of extreme exhaustion,—and still a 
sense of load at the chest, and pain of the side. 
On the succeeding Tuesday the countenance was 
observed sometimes to flush to a deep scarlet, and 
then to become quite pallid, and a profuse perspira- 
tion frequently ran down the face; the pulse was 
extremely frequent, and the pain severe on coughing ; 
there was no delirium though she a-woke hurried 
from sleeps which she described as ‘just like death.7 
During the four following days there was little ob- 
vious change ; distressing faintings usually came on 
about two or three o’clock, P. M.- On the Sunday, 
she became drowsy, and evidently more sinking ; this 
state continued to increase, and she died in the even- 
ing of the following day. 
The last blood-letting, in the case just given, was 
obviously though rather gradually fatal. In the 
present case, the fatal event supervened imme- 
diately on the use of the lancet. Mrs. was 
of a pale and sallow complexion and weakly con- 
stitution. Six days before her confinement of her 
first child, she was awoke in the night by severe 
pain of the head confined to one spot. This pain 
continued several hours, when Mrs. applied to 
her medical man ; she was completely relieved by 
losing sixteen ounces of blood, followed by purgative 
medicine, and she continued well.—Mrs. ’s 
labour occurred on the 1st of September, 1817, and 
was rather tedious, but natural, and she had no com- 74 
ON THE MORBID EFFECTS 
plaint until the second day, when she experienced a 
second attack of pain in the head, but less violent 
than the previous one. She was seen six hours after 
this attack ; she then complained of pain and beating 
of the head, about the anterior part of the right pa- 
rietal bone; the skin was hot, and the pulse frequent 
and strong. Sixteen ounces of blood were taken 
from the arm, leeches were ordered to be applied to 
the temples, and an enema and purgative medicine 
were prescribed. In three hours’ time Mrs. 
was again visited, and it was deemed necessary to 
abstract more blood :—six or eight ounces were there- 
fore taken ; faintishness was induced, and the symp- 
toms were abated. 
On the succeeding morning, September the 4th, 
the symptoms still remained the same ; the surface 
was hot; the bowels had been purged and the 
evacuations were natural. The saline mixture was 
ordered. At noon the symptoms remaining as before, 
the purgative medicine was repeated and a blister 
was applied.—In the evening, the evacuation of the 
bowels was satisfactory, and the pain of the head 
was not severe, but there was much beating 
and a rushing noise; and there was restlessness, 
and a teasing, irritative cough. A draught with 
thirty drops of the tinctura opii was administered. 
On the morning of September the 5th, Mrs. 
expressed herself as being much better from having 
enjoyed comfortable sleep. The surface was still OF LOSS OF BLOOD. 
75 
hot, and the head still affected as before. In the 
evening, there was a degree of tenderness in the 
region of the uterus. She dreaded the idea of being 
bled, from the faintishness she had before experi- 
enced from it, and said it would certainly kill her. 
On the morning of the 6th, the pain in the re- 
gion of the uterus was relieved, the head was affect- 
ed as before, the window was kept open for want of 
air. In the evening Mrs. complained of being 
faint and low. A mixture with camphor and sul- 
phuric aether was prescribed. 
On the 7th, the irritative cough again occurred; 
the pulse was frequent, from 120 to 130; and the 
other symptoms remained unabated. A physician 
was consulted. Sixteen ounces of blood were directed 
to be taken from the arm; a grain of calomel was 
given every three hours, and the effervescing medi- 
cine was ordered. 
On the morning of the 8th, Mrs. appeared 
to be relieved in every respect; the heat of the sur- 
face and the pain of the head were diminished ; the 
blood presented the buffy coat. It was thought 
proper, however, to abstract more blood. Four 
teacupsful were taken ; the most dreadful fainting 
followed, with gasping, open mouth, a convulsive 
action of the diaphragm, and in an hour or two death 
closed the scene. 
The following case forwarded to me by a medical 76 
friend is not, I think, unworthy of a niche in this 
little volume. 
l( A gentleman nearly seventy years of age, the 
subject of frequent gouty paroxysms, whose con- 
stitution was broken down, and who was of a pallid 
complexion, was suddenly seized with severe pain in 
the side, hot skin, quick full pulse, and difficulty in 
breathing. A physician was consulted, who re- 
commended the abstraction of six ounces of blood. 
The arm was tied up accordingly, the patient being 
in bed ; before two ounces were taken away his 
pulse sunk, and heavy perspiration came on, with 
faintness. The patient was placed horizontally 
in bed, and it was some length of time before 
his medical attendant deemed it prudent to leave 
the house. 
“ The blood taken away, manifested the usual 
character of inflammation, but the pain in the side 
was not removed. On the following morning he was 
again visited by his physician, who finding that the 
pain and other symptoms detailed were not relieved, 
directed the bleeding to be repeated to six ounces ; 
this was again attempted, but before one ounce 
escaped, he became so alarmingly faint, that he fell 
back in the bed, the circulation being suspended for 
a length of time, and his dissolution expected to take 
place. Stimuli of every description which could 
at the moment be brought forward, were resorted 
to; after a considerable lapse of time, the heart’s 
ON THE MORBID EFFECTS action was feebly renewed, but its power was never 
again restored ; and the pain in his side was not 
relieved. From this time he progressively sank, and 
in a short time expired. 
OF LOSS OF BLOOD. 
77 78 
ON THE MORBID EFFECTS 
CHAPTER V. 
ON THE INFLUENCE OF VARIOUS CIRCUMSTANCES ON 
THE EFFECTS OF LOSS OF BLOOD. 
The question of the influence of various circum- 
stances in opposing or inducing the phenomena of 
exhaustion, in cases of loss of blood, is especially 
reserved for the second part of this work. I shall 
therefore make but a few very cursory remarks upon 
this point in this place. 
“ The first and principal circumstance which modi- 
fies the effects of loss of blood, is that which relates 
to the strength of the patient. Ceteris paribus, the 
degree of reaction is proportionate to the degree of 
strength. In infancy, in declining years, and in the 
feeble in constitution, there is defective reaction after 
loss of blood, the phenomena of which have been 
already detailed ; the state of syncope is a state of 
danger ; and a second or a third blood-letting is borne 
with difficulty. In youth, and in the vigorous and 
robust, on the contrary, the reaction is strong, and 
especially marked after repeated venesection. 
In the strong, the state of sinking is ever preceded 
by that of great reaction, unless indeed the strength OF LOSS OF BLOOD. 
79 
be overwhelmed by the degree or early repetition 
of the evacuation ; in the feeble it steals on in- 
sidiously and gradually, unmarked by reaction of the 
system. 
The other circumstances which exert an influence 
on the effects of loss of blood, are certain states of 
disorder or disease. And I must in this place par- 
ticularly remark, that the state of intestinal irritation 
is particularly apt to lead to those effects of blood-let- 
ting which I have described as exhaustion ; while 
that of inflammation seems to protect the system 
from the effects of loss of blood ;—in the former case 
throbbing is soon induced, unless, indeed, it be pre- 
vented by a state more nearly allied to syncope ; in 
the latter, blood-letting is followed by little of reaction 
until the state of inflammation be subdued, and the 
system be freely exposed to the uncontroled influence 
of loss of blood ; in the former there is danger from 
full depletion ; in the latter, this measure is provi- 
dentially not less safe than necessary. 
The patient whose case is detailed, page 45, would 
certainly not have fallen a sacrifice to the loss of one 
hundred and twenty ounces of blood only, had there 
been inflammation, and especially inflammation of a 
serous membrane. Indeed one of the most impor- 
tant remarks which I have to make, and which will 
lead to one of the most important improvements in 
surgery, is that we are not to treat the patient im- 80 
ON THE MORBID EFFECTS 
mediately after an accident, or an operation, as one 
affected with inflammation. 
Inflammation may, nay, in the course of events 
will, often supervene; but before this event takes 
place, the case is to be treated as different from in- 
flammation. Blood-letting is not well borne. It may, 
if unwarily practised, prove fatal even. Whereas it 
is the remedy and the only remedy for inflammation. 
The phenomena of reaction seem readily to assimi- 
late with the constitutional effects of intestinal irri- 
tation, as is distinctly apparent in some of the cases 
given in the last section; they are, on the contrary, 
to a certain degree incompatible with those of inflam- 
mation; so that, during the existence of acute and 
active inflammation, the symptoms of exhaustion are 
seldom observed; but they are very apt to display 
themselves immediately on the active state of inflam- 
mation being subdued ; whereas exhaustion and in- 
testinal irritation appear to co-operate in inducing a 
state of reaction in the system. 
In all cases, we are only to expect the phenomena 
of reaction when a certain quantity of blood has been 
lost: one blood-letting, although large, and even a 
continued drain, if not considerable, will not induce 
exhaustion; the powers of the system are sufficiently 
great to recruit and to restrain its actions. But ex- 
haustion is sooner induced under circumstances of 
intestinal irritation, and less so under those of inflam- 
mation, than in health; and reaction is the conse- OF LOSS OF BLOOD. 
81 
quence, unless the strength of the patient be low, and 
then the reaction is defective, or even gives way to 
a state of positive sinking. 
There are seldom the symptoms* of reaction after 
one flow of blood, however great or profuse ; it is 
the repetition or protraction of the cause, which, as I 
have already observed, is essential to produce this 
effect. 
Each successive blood-letting, is of course attended 
with increased risk. There is considerable danger 
where the reaction is strong ; still greater when it is 
feeble. A large blood-letting in such cases may be 
followed by sudden death. There is greater danger 
when fainting has been several times induced, and 
when there is the least tendency to 1 want air.? 82 
ON THE MORBID EFFECTS 
CHAPTER VI. 
ON THE EFFECTS OF LOSS OF BLOOD ON THE INTERNAL 
ORGANS. 
We are altogether in want of a series of observa- 
tions on the effects of loss of blood on the internal 
organs. 
There is, I think, reason to suppose that a state of 
exhaustion from loss of blood, may lead to effusion 
into the ventricles of the brain ; and a case published 
by the late Dr. Denman sufficiently proves that such 
a state of exhaustion is no protection against an at- 
tack of sanguineous apoplexy. 
This patient had suffered from hsemorrhagy from 
a fungous growth from the uterus, which many at- 
tempts were made to restrain by ligature during the. 
long interval of time between 1802 and 1809. Dr. 
Denman concludes this interesting case thus:— 
“ In February, and in May, 1809, two fruitless 
attempts were made to pass the ligature. Mr. Croft 
and myself then agreed to fill a small pair of denti- 
culated forceps, not unlike those used in lithotomy, 
firmly on the stem, with the intention of occasioning 
the whole to decay, and of destroying, if it were OF LOSS OF BLOOD. 
83 
possible, the regenerative power. But while we are 
preparing for this, the patient, after passing the day 
without any usual complaint, went to bed in good 
spirits, but was found the next morning in a state of 
insensibility, with stertor. In this state she remained 
about twenty-four hours, and then expired. Leave 
was given to inspect the body, which indeed she had 
often expressed a wish might be done. 
“ The head was the first part examined. Nothing 
particular was observed about the membranes or 
surface of the brain ; but in the ventricles were found 
about four ounces of blood, separated into coagular 
and serum. This extravasation was clearly the im- 
mediate cause of her death, little as it might have 
been expected, on account of the daily profuse dis- 
charge, to which she had for so many years been 
subject. It had often been remarked, that, although 
this patient was become much paler than she had 
formerly been, she was not comparatively thin in 
her person ; and many who visited her, could hardly 
be convinced that she laboured under any dangerous 
disease.”* 
There is an interesting case which illustrates the 
fact of a tendency to congestion of the brain, in cir- 
cumstances of exhaustion from loss of blood, in Mr. 
Hey’s work upon puerperal fever. There had been 
* Transactions of a Society for the Improvement of Medical and 
Surgical Knowledge, Vol. III. page 315. 84 
ON THE MORBID EFFECTS 
hsemorrhagy after delivery, and the patient had been 
twice bled to seven ounces, for abdominal tenderness. 
On the morning of the third day it was repeated. 
She had passed the night without any pain, not- 
withstanding which she had slept but little. Pulse 
at 110, and very strong. No more stools: clyster 
repeated. 
The author proceeds, “ Having augured favourably 
of this case from the gradual and complete cessation 
of pain, it was with no less surprise than regret, 
that, in the evening, I found an entire new train of 
symptoms. The patient having been affected through- 
out the day with an irresistible propensity to sleep, 
from which she got no refreshment, awoke in the 
evening with pain in her head, accompanied with 
giddiness and ringing at the ears. Her face was 
flushed ; her pulse at 132 and strong. She had had 
three loose stools, and had parted with a large quan- 
tity of urine. Some leeches were ordered to be ap- 
plied to the temples; but finding, on a second visit, 
that they had not been procured,! took three ounces 
of blood from the temporal artery. The saline draughts 
were directed to be made without decoct, cinchonse, 
and a blister to be applied to the nape of the neck. 
Just before the bleeding the pulse was at 120, after 
it at 112. 
“ 24th. I found the patient sitting up in bed to 
take some refreshment. She had slept several hours 
in the night. Her countenance was good. It was OP LOSS OP BLOOD. 
85 
rather singular, that the left side of the head, from 
which the blood had been taken, was easy, but the 
opposite side painful. The crassamentum, as before 
was extremely firm. Pulse 126. I took three ounces 
of blood from the temporal artery of the right side, 
and the evacuation greatly diminished the pain. 
“ In the evening she experienced a seizure some- 
what similar to that of the preceding day. Having 
been visited by several friends, who had inconsider- 
ately talked and read a good deal to her, she was 
suddenly affected with a sense of great confusion and 
noise in the head, accompanied with much heat and 
flushing of the face. Pulse 140. In consequence 
of the relief before experienced, she was very desi- 
rous to lose some more blood from the temples, 
and therefore, though the pulse appeared less 
strong, I took an ounce and a half from the temporal 
artery. 
“ The case having become more alarming from 
this relapse, a consultation was requested ; and a 
physician who had attended several of these melan- 
choly cases with me, was called in ; my father also 
visited the patient with us. The pulse had come 
down to 120, and was evidently fuller since the 
bleeding. The crassamentum was as firm as be- 
fore. It was agreed, that the saline draughts should 
be continued, that a blister should be applied to the 
head, and temples and forehead be frequently bathed 
with cold vinegar and water. 86 
ON THE MORBID EFFECTS 
“ 25th, Eight, A. M. She had had no sleep in the 
night, but the head was rather more composed, and 
she was free from heat. Pulse 116. Some indica- 
tions of a paralytic affection were now apparent. She 
faltered in her speech, and her tongue, when put out, 
was drawn to one side. At noon the pulse got up 
to 140, she took little notice, and, though she some- 
times spoke coherently, an answer to any question 
could scarcely be obtained from her; her mind also 
appeared much agitated. 
“ At four, P. M. the physician met us : it was 
agreed that a little wine whey should be given 
frequently, and the following medicine was pre- 
scribed ; 
R. Spt. aether, comp. gutt. xxx. 
Spt. ammon. comp. gutt. x. 
Aq. purse M. 
fiat haustus tertia qu&que hora sumendus. 
A draught with fifteen drops of tinct. opii was also 
directed to be taken at bed-time. 
“ 26th. The night had again been passed almost 
without sleep ; but the head was free from pain, 
confusion, and the sense of ringing. Pulse 116. 
“Two, P. M. After three hours, comfortable sleep, 
the head was not so well. The bowels were open, 
and the stools natural. Pulse 120. 
“ 27th. 1 was not able to see the patient myself  OP LOSS OF BLOOD. 
87 
on this clay, and 1 neglected to minute any account 
of its occurrences. 
“ 28th. She had had no sleep in the night, and 
was very restless, with some degree of delirium. We 
found her incessantly talking, but could procure no 
answer from her to any question that was proposed. 
She refused all medicine. Pulse 120. 
u In the course of the day the abdomen became 
tumid from flatus confined in the bowels ; the tume- 
faction was unattended by pain or soreness, and en- 
tirely subsided as soon as evacuations were procured 
by an injection. 
“ Ten, P. M. She was in all respects, w7orse. 
Her urine came away involuntarily ; she had some 
rattling in her breathing, and appeared to be sink- 
ing. Pulse 132. Thirty drops of spt. aether sulph. 
were ordered to be given now and then as a grateful 
cordial. 
“ 29th. We were agreeably surprised to find our 
patient much better. During the night she had been 
able to retain her urine, and had made a large quan- 
tity with proper intervals. She was quite sensible, 
and more composed ; and had regained the power 
of putting out her tongue, which before she had lost. 
The pulse was at 106, and the tongue continued 
clean. Ordered to take at regular intervals a 
draught of infus. rosce made with decoct, cinchona;, 
and to have occasionally a little Madeira wine. 
These favourable symptoms did not long continue. 88 
In the evening the pulse had got up to 120, and the 
heat had increased. 
“From this time the patient became gradually 
weaker, her pulse was accelerated more and more, 
and her urine was again discharged involuntarily. 
She lived two days in a state of great anxiety, and 
increasing restlessness, and died on Sunday night the 
first of July.” 
It is impossible to imagine a more interesting and 
instructive train of events. Nothing but a careful 
examination is wanting to make it complete as an 
illustration of the effects of the extreme loss of blood 
upon the brain, lungs, and other organs of the 
body. 
I am indebted for the cursory sketch which fol- 
lows, to my friend Dr. Tweedie. “ Mrs. , aged 
about 27, of spare habit, and the mother of two 
children, was frequently affected, during her last 
pregnancy, with uneasiness about her head, very often 
amounting to pain. There was great irritability of 
mind, so that trifling matters annoyed her. 
“ During the latter months of her pregnancy there 
was frequent profuse flooding. This, in spite of rest 
and antiphlogistic measures, went on, and ended in 
premature labour. 
u She had a slow recovery ; and when first permit- 
ted to sit out of bed, she suddenly lost the power of 
speech, and, on her husband coming to her, she was 
found to be affected with paralysis of the right side. 
ON THE MORBID EFFECTS OF LOSS OF BLOOD. 
89 
She was moderately treated, ancfr the paralysis was 
slowly removed. 
“ She was then removed to Brighton, but during 
the journey she one morning started up suddenly in 
bed, in a state of insanityP 
The following case, for which I am indebted to 
Mr. Hammond, of Brixton, is one of the most in- 
teresting kind, both in the mode of its accession and 
removal. 
“ Mrs. , a delicate thin woman, was confined 
on the 20th Dec. 1827. The labour was natural, but, 
after the expulsion of the placenta, she lost about 
three pints of blood. This produced faintness, which 
continued for nearly an hour, after which she re- 
covered. The night was passed free from any pain 
or disturbance, but she was watchful, and could get 
no sleep. On the following day, however, she was 
cheerful, the lochia natural, the milk beginning to be 
secreted, the pulse 110, the bowels not relieved. She 
complained of a slight headache, but attached no im- 
portance to it, as in her usual health she was more or 
less troubled with it. O 
“ On the 22d Mrs. took half an ounce of 
castor oil, w’hich opened the bowels but once ; but 
this produced fainting, which continued for some 
time. The headache continued, but was not in- 
creased in violence. She repeated the castor oil at 
8 o’clock in the evening. 90 
ON THE MORBID EFFECTS 
“ Onv the 23d, tUe bowels were not relieved ; but 
they were freely on the 24th, when considerable 
faintness followed, and the headache became more 
severe. Twelve leeches were applied to the temples; 
the lochia and milk flowed abundantly. In the even- 
ing the headache was found to be much relieved; 
she took some mild support, and expressed herself as 
considerably better. The pulse as yesterday. 
“ On the 25th it was reported that Mrs. had 
passed a more comfortable night: but the headache 
had returned with increased severity ; she was bled 
to twenty-four ounces, which produced slight faint- 
ishness, but the headache was not relieved. The 
bowels were open ; the pulse 120, sharp and wiry ; 
the secretions went on well. At one o’clock headache 
was as acute as in the early part of the morning. 
The bleeding was repeated and carried to deliquium ; 
she lost about 20 ounces, and then became strongly 
convulsed. The blood was cupped and sizy. The 
tinctura opii was given in camphor mixture. At half 
after six o’clock a physician was called in consulta- 
tion. The headache was relieved, but she appeared 
much exhausted ; the countenance was blanched to 
an ivory whiteness; the pulse 115, and soft. The in- 
fusum digitalis with liquor ammonia) acetatis was 
directed to be given every four hours. 
“ On the 26th Mrs. was found to have had 
a tolerable night, having slept four hours, but she 
again complained of headache. Twelve leeches OF LOSS OF BLOOD. 
91 
were applied to the temples, and afforded relief. The 
bowels were regularly attended to ; the lochia were 
less in quantity ; the milk abundant; the pulse 115; 
the tongue moist. 
“On the 27th, 28th, and 29th Mrs. was bet- 
ter in every respect. 
i£ On the 30th the headache returned, and she was 
restless. Six leeches were applied to the temples 
In other respects she was the same. 
“ On the 31st, at 10, A. M., it was reported that 
she had passed a tranquil night, and was in every 
respect better. At 6, P. M. the medical attendant 
was called suddenly to her, and fo und her in a state of 
extreme depression, the right arm paralyzed, the leg 
partially so, the speech much altered, and the deglu- 
tition difficult; the countenance was blanched, and 
the pulse feeble. Eight leeches were ordered to be 
applied to the side of the neck, and a blister 
to the nape, with pills of camphor, and camphor 
draughts. 
“On January the first, the paralytic affection was 
better, though the arm remained still powerless. Mrs. 
complained of much exhaustion. In the even- 
ing it was found that there was considerable diarrhoea, 
which produced faintness; the pulse was feeble; the 
skin natural. The mistura cretae with tinctura opii 
was given with mild support. 
“ On the 2d of January, the diarrhoea was still 
very urgent; the countenance was sunken and 92 
OIV THE MORBID EFFECTS 
anxious; thfe pulse extremely weak, indeed scarcely 
perceptible. Broth with isinglass and rice, and mild 
support, were directed to be given frequently. The 
paralysis was subsiding. The lochia had nearly dis- 
appeared ; the milk was abundant. 
“ On the 3d of January, the diarrhoea was begin- 
ning to decline, but the patient remained in a very 
exhausted state. The headache was nearly gone ; the 
pulse was stronger; a nd the general appearance 
improved. Nourishment had been taken freely. 
From this time Mrs. continued to improve, 
the symptoms gradually subsiding ; and at the end of 
the month she became quite convalescent; and she 
has continued in good health.” 
Mr. Travers mentions a case of pneumonia, in 
which a stroke of palsy, fatal the same evening, took 
place in the act of blood-letting.* It is to be regret- 
ted that it is not mentioned what quantity of blood 
had flowed before this event occurred ; but as it is 
given’ to illustrate tbe effects of loss of blood, it is 
to be presumed that it was considerable. 
Paralysis has occurred in a state of exhaustion 
from other causes, as undue lactation, and in various 
circumstances of debility, as in cases of disorder of 
the general health, with sallowness and pallor, and a 
loaded tongue and breath. Of the former case Dr. 
Davis mentions an instance in his correspondence 
* On Constitutional Irritations, p. 501, OF LOSS OF BLOOD. 
93 
with Dr. Musgrave. Of the latter, I witnessed an 
example in a very near relative. Amaurosis is not 
unfrequent in similar circumstances. 
Effusion into the ventricles is doubtless a frequent 
effect of the extreme state of vascular exhaustion. 
An example of this kind has already been given p. 
49. The experiments of Dr- Seeds and Dr. Kellie 
confirm the same fact. 
After the brain, it becomes necessary to examine 
the condition of the lungs under the influence of ex- 
cessive loss of blood. I have already compared this 
state to that observed in the experiment of dividing 
the eighth pair of nerves, or otherwise subtracting 
the nervous energy, p. 52. Still there is a difference: 
instead of hepatization with destruction of the texture 
of the lungs, there is oedema with a clogged condition 
of the bronchia. 
It is by the stethoscope, indeed, that the very first 
symptoms of sinking from loss of blood will be dis- 
covered, although a very early one is that rattle which 
I have already described as being audible without the 
immediate or mediate application of the ear. 
The bronchia first become clogged, the lungs be- 
come oedematous and the arterialization of the blood 
is defective. 
In two patients, who died of haemorrhagy, exam- 
ined by Dr. Hodgkin, the lungs were found decidedly 
oedematous; in one, there was effusion into both 
cavities of the pleura and pericardium ; in the other 94 
ON THE MORBID EFFECTS 
there were adhesions. In one the head'was examined, 
and no morbid appearances found.. A similar illus- 
tration of the effects of exhaustion from loss of blood, 
was detailed to me some years ago by Mr. Jowett, 
of Nottingham. 
The state of flatulency, sometimes almost amount- 
ing to tympanitis, and the foetid evacuations of the 
intestines, sufficiently denote the morbid condition of 
this internal organ. 
There is also in extreme cases of exhaustion, a 
general tendency to serous effusion, both into the 
internal cavities and into the cellular membrane. This 
effect of the loss of blood has been very long remarked 
bv medical writers. 
As I have carefully avoided, in this work, the 
statement of any circumstances which I did not think 
amply substantiated by well-observed facts, I shall 
leave this part of my subject to be elucidated by fu- 
ture observation. 
I still have it in view to investigate the organic 
effects, and especially the remedies, of loss of blood 
by a series of experiments. OP LOSS OF BLOOD. 
95 
CHAPTER VII. 
OF THE TREATMENT OF THE VARIOUS EFFECTS OF 
LOSS OF BLOOD. 
The treatment of the effects of loss of blood must 
be resolved into that which is general or constitutional, 
and that which is local; and it must vary according 
to the peculiar state or stage of these effects. Syn- 
cope, reaction, and sinking, each, require their appro- 
priate treatment. 
The constitutional treatment must be stimulant in 
syncope, sedative and soothing in the state of reac- 
tion, and restorative in that of sinking. The local 
treatment must vary with the organ chiefly affected, 
and with the mode in which it is affected. 
When syncope assumes a dangerous form, the 
principal remedies are, attention to the posture of the 
patient, stimulants, and chiefly brandy, and the trans- 
fusion of blood. 
The effect of posture is not, even now fully known. 
It would be easy to allow the patient to lie over the 
edge of the bed, the head low upon the floor, 
and the feet greatly raised. In this manner such 96 
ON THE MORBID EFFECTS 
pressure would be restored to the encephalon as 
would in many cases support life, until, other reme- 
dies being administered, the patient might be placed 
out of immediate danger. 
I need not, in this place, notice the importance of 
a regulated mode of giving brandy and nourishment. 
I think it is frequently given in such quantities as 
actually to induce sickness, and its own rejection 
from the stomach, and so as to frustrate the object of 
the physician completely. The effects should be 
carefully watched. The physician ought not, of 
course, in such a case, to leave the patient for a 
moment. 
The next remedy is transfusion. Unfortunately it 
has too frequently happened that the proper period 
of adopting this measure has been allowed to pass 
by. Not only the vascular system is exhausted, but, 
after a time, the functions of the nervous system have 
begun to fail. It might be a question, therefore, 
whether galvanism might not be usefully conjoined 
with transfusion. 
It is an important point to determine how large a 
quantity of blood the system will bear to receive 
under various circumstances of exhaustion. Too 
much may overwhelm. Too little may be inade- 
quate to the accomplishment of the object in view. 
It is also an important question whether the opera- 
tion should be done at once, or at twice, or thrice, 
and with what intervals. As the system cannot OF LOSS OF BLOOD. 
97 
bear a sudden reduction of the quantity of blood, 
so it may not be enabled to bear its too sudden re- 
storation. 
It is almost needless to add, that a due attention 
must be constantly paid to assist the arterialization 
of the blood, by the admission of fresh air; and to 
sustain the animal heat by proper clothing, and espe- 
cially warm applications to the feet. 
If there should be convulsions, delirium, or coma, 
it may be necessary to apply a sinapism to the nape 
of the neck ; and in the two former cases, some 
mild sedative, as the tinctura hyoscyami, may be of 
advantage. 
In the case of excessive reaction, the remedies 
appear to be, first, extreme quiet of the body and of 
mind ; then, the mildest sedatives, especially the hy- 
osciamis ; thirdly, the mildest nutriments ; and lastly, 
and above all, time. 
The pain and throbbings in the head, the intole- 
rance of noises, the general susceptibility to dis- 
turbance, the palpitations of the heart, alike demand 
the utmost quiet, to which everything soothing in 
the manner and treatment must be added. The 
tinctura hyoscyami is, I think, the kindliest anodyne 
and sedative in these cases. The cause and other 
circumstances of the case, point out the necessity for 98 
ON THE MORBID EFFECTS 
mild nutriment, to which perhaps the minutest quan- 
tities of brandy may be added. 
It may be necessary to subdue the throbbing action 
of the head, by local blood-letting even ; and it is most 
remarkable how small a quantity of blood being 
taken, will relieve. An interesting example of this 
kind is given at page 83. Two or three leeches are 
frequently quite sufficient. 
But the most unequivocal remedy is a cold spiritu- 
ous lotion applied all over the head, by means of a 
cap consisting of one fold of stocking. 
In exhaustion with delirium, the tinctura hyoscyami 
should be conjoined, in full doses, with the other 
remedies. The morbid susceptibility, not only of 
the brain, but of the heart, is greatly assuaged by 
this remedy. 
In cases of exhaustion with sinking, stimulants 
must be administered abundantly. Cataplasms of 
mustard may be applied to the nape of the neck, and 
to the feet. It is difficult to imagine what would be 
the effect of the transfusion of blood ; I have no 
doubt that galvanism would prolong life; and I 
should think the two remedies might be conjoined 
with advantage. 
In all cases of exhaustion the functions of the 
bowels suffer. Constipation and flatulency are the 
usual consequences. These are best relieved by the 
warm water enema, which must, however, of course, OF LOSS OF BLOOD. 
99 
be administered with due precaution, to prevent fur- 
ther exhaustion. 
It is interesting to observe the blunted sensibilities 
in syncope and in sinking, and to compare them with 
the morbidly acute sensibilities of the state of reac- 
tion. Sinapisms to rouse, and the tinctura hyoscyami 
to lull them, are, in their respective places, remedies 
of the greatest value. 
Sinapisms may tend to save or prolong life, in the 
sinking state, on the principle of exciting inflamma- 
tion. For it will be seen shortly, that during a 
state of inflammation, the system is far less susceptible 
of the effects of loss of blood generally, than in 
health. 
After the due administration of blood-letting, there 
are three other remedies, the use and abuse of which 
still offer matter of interesting inquiry to the practi- 
cal physician, both in their relation to the morbid 
effects of loss of blood, and to other diseases. These 
are, purgative medicines, brandy, and opium. 
Aperients must be given, yet guardedly given, in 
cases of debility or exhaustion. The bowels become 
disordered, and must be gently relieved ; but the 
more active operation of an aperient would add to 
the exhaustion. 
The powers must be recruited and sustained, and 
for this purpose brandy must be administered, yet 
cautiously. Too much stimulus would hurry the 100 
ON THE MORBID EFFECTS, &C. 
action of the heart. The proper criterion for the use 
of brandy is, on the contrary, that it should allay the 
morbidly increased action of this organ. 
Opium, if properly given, allays the morbid sensi- 
bilities and actions of the system. But if it be ad- 
ministered in an undue dose, it is apt, 1 am persuaded, 
to lower the powers of life, by directly subduing the 
energies of the nervous system, or rather, by inducing 
an impaired condition of the respiration. The undue 
action of opium resembles, in fact, the case of sub- 
stracted nervous energy by the division of the eighth 
pair of nerves, with the superadded influence of im- 
paired respiratory movements. 
I may pursue the inquiry into the action, use, and 
abuse of these three important remedies at some 
future period. APPENDICES TO PART THE FIRST. 
APPENDIX I. 
ON THE SIMILARITY BETWEEN LOSS OF BLOOD, AND 
THE BLOODLESSNESS OF CHLOROSIS. 
There is a remarkable similarity between the 
effects of loss of blood, and the state of bloodlessness 
which obtains in chlorosis. The general symptoms; 
—the tendency to affections of the head resembling 
arachnitis, and to affections of the heart resembling- 
organic affections of this organ ;—the condition of the 
general surface, and of the capillary and larger 
circulations;—the proneness to oedema and serous 
effusions generally, are, indeed, identical in both 
these conditions. 
These two affections not only agree in the many 
particulars enumerated, but also in two others of 
great interest; first, in their tendency, in their last 
stages, to induce effusion into the cavities of the 102 
brain, pleura, pericardium, and peritonaeum; and 
secondly, in their involving a danger of issuing in the 
slate of sinking, or even of sudden death. 
From both these circumstances it is plain that the 
capillary and the general circulation are alike in a 
very analogous condition in these two morbid states ; 
and from both these circumstances the morbid anato- 
my is found to be very similar. 
The differences which do exist between these two 
morbid states arise from the different modes of their 
accession, loss of blood being a simple event, while 
the bloodlessness of chlorosis is the gradual effect of 
a previous state of complicated disorder. In the 
former, as there are none of the peculiar appearances 
of the tongue and internal mouth observed in chloro- 
sis, so there is an absence of some internal changes, 
especially of the liver, which, as I have observed else- 
where,* is very apt to become affected with simple 
enlargement in cases of protracted disorder of the 
general health. 
I have met with two cases of chlorosis in which 
the whole of these observations were fully exempli- 
fied,—the only cases of this affection which have 
been fatal within the scope of my observation. In 
the first, the patient sank exhausted into a state of 
coma and death. In the second, death occurred, 
suddenly, the patient after being confined to bed a 
RLOODLESSNESS IIV CHLOROSIS. 
* Commentaries, &c. p. 45. BLOODLESSNESS IN CHLOROSIS. 
103 
few days, and immediately after being in better 
spirits than usual, having sat up for a quarter of an 
hour, became faint, gasped, and expired. 
The former of these cases was one of pure chloro- 
sis. The latter, chlorosis with a degree of the icterode 
complexion. Of the former case no examination 
was permitted. In the latter, the following morbid 
appearances were observed ; There was some effu- 
sion into the ventricles of the brain, the pericardium, 
and the left cavity of the pleura, the right being 
obliterated by adhesion; the lungs were gorged with 
serum ; the heart was large ; the liver much enlarg- 
ed : the hand was of the colour of ivory there was 
plenty of adipose substance ; the ancles were a little 
(edematous. 
Some years ago a patient, after excessive bleed- 
ing, was doing well, but got up in bed to empty 
the bladder,—sank down, and suddenly expired. 
The event in this example of chlorosis was pre- 
cisely similar. It has already been stated, that, 
in exhaustion from excessive loss of blood, the 
patient is apt to sink into coma ; such a case is 
parallel with that of the case of chlorosis first 
mentioned. 
In a word, there is, in exhaustion, loss of blood 
without previous disorder or disease, while in 
chlorosis, there is bloodlessness as an effect of 
previous disorder, and frequently as a complication 104 
BLOODLESSNESS IN CHLOROSIS. 
of organic disease. In both there is the same ten- 
dency to oedema from failure of the capillary circula- 
tion, and to sinking or sudden dissolution from 
failure of the circulation in the larger vessels. APPENDIX II. 
ON A HYDRENCEPHALOID AFFECTION OF INFANTS 
ARISING FROM EXHAUSTION. 
I have watched, with peculiar care, many cases 
of a morbid affection incident to infancy, which ge- 
nerally arises from circumstances of exhaustion, but 
resembles, in many of its symptoms, the earlier and 
especially the later stages of hydrencephalus. As 
this affection has not been noticed by practical 
writers as it deserves, I think the following brief 
account of it cannot prove uninteresting to the pro- 
fession. 
I first gave a cursory sketch of this morbid affec- 
tion in a little volume of “ Medical Essay” published 
in 1835, but now out of print. It has since been 
briefly noticed by Dr. Abercrombie in his valuable 
“ Researches on Diseases of the Brain and Spinal 
Chord,” published in 1828. The present essay was 
read to the Medico-Chirurgical Society, on the ninth 
of December, 1828. Lastly, Dr. Gooch has treated 
of this affection in his excellent “ Account of some 
Diseases peculiar to Women,” just published. These 
arre all the notices I have hitherto seen of this singu- 
lar and interesting disorder. 106 
ON A MORBID 
The diseases of children best understood, are 
those which arise from irritation, and principally 
irritation in the stomach and bowels, and the irrita- 
tion of teething, and inflammation. But there is 
another source of disorder in infancy, less frequent 
perhaps in its operation, but not less important in its 
consequence, and far less understood by medical 
men, in exhaustion. This exhaustion has its origin 
in early infancy, chiefly in diarrhoea or catharsis; 
in the later periods of infancy, in the loss of blood, 
with or without the relaxed or evacuated condition 
of the bowels. 
The state of diarrhoea has generally depended 
upon improper food. It has very frequently succeed- 
ed to weaning, or to other changes in the diet. The 
catharsis has followed the administration of an aperient 
medicine, which, at such a moment of disorder of the 
stomach and bowels, is apt to act excessively. The 
exhaustion from loss of blood generally follows the 
inappropriate or undue application of leeches or use 
the lancet. 
1 may observe, indeed, in this place, that of the whole 
number of fatal cases of disease in infancy, a great 
proportion occur from this inappropriate or undue 
application of exhausting remedies. This observa- 
tion may have a salutary effect in checking the ar- 
dour of many young practitioners, who are apt to 
think that if they have only bled, and purged, and 
given calomel enough, they have done their duty ; AFFECTION OF INFANCY. 
107 
when, in fact, in subduing a former, they have ex- 
cited a new disease, which they have not understood, 
and which has led to the fatal result. 
This question, and that of the effects of exhaustion 
in infants and children, open a new field for inves- 
tigation. Almost all our works on infantile diseases 
are silent on the subject; and yet without an accu- 
rate knowledge of it, I regard it as totally impossible 
that we should be prepared to watch and treat the 
morbid affections of this young and tender age. The 
subject must be taken up and investigated anew. 
All the affections which may arise from exhaustion, 
must be accurately observed, distinguished from 
similar affections arising from other causes, and 
traced back to their origin, and forward in relation 
to their remedies. In this manner some hydrence- 
phaloid, convulsive, and even croupy affections will 
be viewed in a new aspect; and we shall be pre- 
served from some painful dilemmas into which we 
should assuredly fall without this knowledge of the 
effects of exhaustion. 
But in this essay I purpose to confine my obser- 
vations to one of the forms of disorder which arise 
from this cause,—the hydrencephaloid. It may be 
divided into two stages, the first that of irritability, 
the second that of torpor ; in the former there appears 
to be a feeble attempt at reaction, in the latter the 
nervous powers appear to be more prostrate. These 108 
ON A MORBJU 
two stages resemble, in many of their symptoms, 
the first and second stages of hydrencephalus re- 
spectively. 
This morbid affection has, as I have stated, usually 
been first induced by some change in the diet, by 
which the stomach has been loaded or disordered, 
and the bowels perhaps affected with diarrhoea; and 
this latter state has frequently been exasperated by 
the untimely administration of an aperient medicine. 
The infant becomes irritable, restless, and feverish ; 
the face flushed, the surface hot, the pulse frequent; 
there is an undue sensitiveness of the nerves of feel- 
ing, and the little patient starts on being touched, or 
from any sudden noise ; there are sighing, moaning 
during the sleep, and screaming; the bowels are 
flatulent and loose, and the evacuations are mucous 
and disordered. 
If, through an erroneous notion as to the nature of 
this affection, nourishments and cordials be not given ; 
or if the diarrhoea continue, either spontaneously, or 
from the administration of medicine, the exhaustion 
which ensues is apt to lead to a very different train 
of symptoms. Ihe countenance becomes pale, and 
the cheeks cool or cold; the eye-lids are half-closed, 
the eyes are unfixed, and unattracted by any object 
placed before them, the pupils unmoved on the ap- 
proach of light; the breathing, from being quick, 
becomes irregular and affected by sighs; the voice AFFECTION OF INFANCY. 
109 
becomes husky, and there is sometimes a husky 
teasing cough; and, eventually, if the strength of the 
little patient continue to decline, there is crepitus or 
rattling in the breathing ; the evacuations are usually 
green ; the feet are apt to be cold. 
A similar train of symptoms occurs in other cases, 
in which the strength of the little patient has been 
subdued, and the vascular system exhausted by the 
abstraction of blood. In both cases, leeches are 
sometimes again applied to subdue this new form of 
disease, under the erroneous notion of a primary 
cerebral affection. This measure infallibly plunges 
the little patient into imminent, if not irretrievable 
danger. 
Sometimes the sinking state goes on in spite of 
every appropriate remedy. 
Stimuli, if efficacious, reduce the frequency of the 
pulse, and restore the wonted warmth, colour, ex- 
pression, and smiles to the countenance. 
The condition of the cheeks, in regard to colour 
and warmth, may be considered as the pulse of very 
young infants, indicating the degree of remaining 
power, or of exhaustion. In the present case espe- 
cially, there is no symptom so important, so distinc- 
tive. It is from the condition of the cheeks, in 
conjunction w7ith a due consideration of the history, 
that the diagnosis of this morbid state, and the 
indications of the appropriate remedies are chiefly to 
be deduced. The general surface, and especially the 110 
ON A MORBID 
hands and feet, also afford important sources of infor- 
mation as to the condition of the nervous or vital 
powers. Next to these, the degree of frequency of 
the pulse, and the character of the breathing, are 
points of the greatest importance; during the stage 
of irritability the breathing is quick ; during that of 
torpor, it is slower, irregular, suspirious, and finally 
crepitous ; the pulse changes in its beat, from being 
full becoming smaller, but retaining, perhaps, its for- 
mer frequency. 
We should be especially upon our guard not to 
mistake the stupor or coma, into which the state of 
irritability is apt to subside, for the natural sleep, 
and for an indication of returning health. The pallor 
and coldness of the cheeks, the half-closed eye-lid, 
and the irregular breathing, will sufficiently distin- 
guish the two cases. It is equally important to 
dintinguish this state from a hydrencephaloid affec- 
tion arising from derangement of the alimentary 
canal, and from the coma of hydrencephalus itself. 
This is to be done chiefly by observing the condition 
of the countenance, and by tracing the history and 
cause of the affection. 
The following remarks are copied from my 
“Medical Essays.7’ They present a sketch of a mor- 
bid affection, of which 1 have since the period of 
their publication, seen sufficient to enable me to de- 
scribe it more distinctly. 
“ The state of exhaustion is very apt to be in- AFFECTION OF INFANCY. 
111 
duced in early infancy, and as the reaction is feeble at 
this period of life, the case soon assumes the charac- 
ter of sinking. I have frequently been consulted 
when the original disease has been subdued, perhaps, 
and the chief complaint of the little sufferers was a 
state of exhaustion which a truce from remedies and 
medicines, and a proper supply of nourishment and 
perhaps stimulus have removed. 
“ This state of things is often mistaken for inflam- 
mation of the brain, or hydrencephalus. And it may 
be difficult to state the grounds for a just diagnosis 
between the two affections. It will, however, be of 
great assistance to be fully aware of the nature and 
character of exhaustion, and to conjoin with this 
knowledge a due retrospect of the history of the case, 
and a due consideration of the effects of the various 
remedies which may have been employed. 
“ The state of exhaustion in infants is little marked 
by the symptoms of reaction. At first there are 
great restlessness and irritability of temper, whilst 
the countenance is pale and expressive of great 
anxiety, and there is great frequency of the pulse ; 
afterwards the temper and restlessness appear sub- 
dued, there are some dozing and other false and decep- 
tive appearances of amendment, but the pulse is still 
more frequent, the face pale and sunk, and the cheeks 
and extremities are cold: the voice is apt to be 
husky, and attended with a husky, hacking, and dis- 
tressing cough.” 112 
ON A MORBID 
“ When a child has been rather long ill, when 
active remedies have been employed, when the form 
of the disease has perhaps changed in some degree, 
and paleness of the cheeks is attended with irritability 
and restlessness, we should carefully consider whether 
the symptoms may not be those of exhaustion. I 
am persuaded that by relinquishing all lowering 
remedies, and adopting a cordial and soothing plan of 
treatment, I have seen some children recover who 
would soon have sunk under the continuance of 
remedies calculated to subdue a supposed state of 
inflammation. 
In these cases, the idea that the original disease, 
and the remedies, had worn out the little patient, 
and led to a state of exhaustion, had apparently never 
occurred to the practitioner. It is impossible to do 
justice to this subject in a short section of a short 
essay; but I am satisfied that the hints here offered, 
will, if carefully considered and cautiously acted 
upon, be of great assistance to the young physician 
in his treatment of some of the diseases of infants.”* 
Dr. Abercrombie observes,—“ in the last stage of 
diseases of exhaustion, patients frequently fall into a 
state resembling coma, a considerable time before 
death, and while the pulse can still be felt distinctly; 
I have many times seen children lie for a day or 
two in this kind of stupor, and recover under the 
* Pp. 72—76. 113 
use of wine and nourishment. It is often scarcely 
to be distinguished from the coma which accom- 
panies diseases of the brain. It attacks them after 
some continuance of exhausting diseases, such as 
tedious or neglected diarrhoea ; and the patients lie 
in a state of insensibility, the pupils dilated, the eyes 
open and insensible, the face pale, and the pulse 
feeble. It may continue for a day or two and ter- 
minate favourably, or it may prove fatal. This 
affection seems to correspond with the apoplexia ex 
inanitione of the older writers. It differs from syn- 
cope in coming on gradually, and in continuing a 
considerable time, perhaps a day or two; and it is 
not, like syncope, induced by sudden and temporary 
causes, but by causes of gradual exhaustion going 
on for a considerable time. It differs from mere ex- 
haustion, in the complete abolition of sense and mo- 
tion, while the pulse can be felt distinctly, and is, in 
some cases, of tolerable strength. I have seen in 
adults the same affection, though it is perhaps more 
uncommon than in children.’7* In a letter which I 
had the honour to receive from Dr. Abercrombie, 
that gentleman observes, “ the state of infants which 
1 have referred to, is a state of pure coma, scarcely 
distinguishable, at first sight, from the perfect stupor 
of the very last stage of hydrocephalus, the child 
lying with the eyes open, or half open, the pupils 
AFFECTION OF INFANCY. 
* Researches, &c. pp. 310, 311. 114 
ON A MORBID 
dilated, the face pale. It is difficult to describe dis- 
tinctly the appearance, but it is one which conveys 
the expression of coma, rather than of sinking; and 
I remember the first time I met with the affection, 
the circumstance which arrested my attention, and 
led me to suppose the disease was not hydrocephalus, 
and the state somewhat different from coma, was 
finding on further inquiry, that it came on after 
diarrhoea and not with any symptoms indicating an 
affection of the head. The child recovered under 
the use of wine and nourishment.77* 
Dr. Gooch observes,—“ 1 am anxious to call 
the attention of medical men to a disorder of children 
which I find invariably attributed to, and treated as, 
congestion or inflammation of the brain, but which 
I am convinced often depends on, or is connected 
with, the opposite state of circulation. It is chiefly 
indicated by heaviness of head and drowsiness: the 
age of the little patients whom I have seen in this 
state has been from a few months to two or three 
years; they have been rather small of their age, and 
of delicate health, or they have been exposed to de- 
bilitating causes. The physician finds the child lying 
on its nurse’s lap, unable or unwilling to raise its head, 
half asleep, one moment opening its eyes, and the 
* Effects somewhat similar are apt to follow operations on very young 
children. The reader may consult Mr. Travers’ late interesting work 
upon “Constitutional Irritation,” pp. 139—141, published in 1826. AFFECTION OF INFANCY. 
115 
next closing them again with a remarkable expression 
of languor. The tongue is slightly white, the skin 
is not hot, at times the nurse remarks that it is colder 
than natural ; in some cases there is at times a slight 
and transient flush : the bowels I have always seen 
already disturbed by purgatives, so that I can scarce- 
ly say what they are when left to themselves; thus 
the state which I am describing is marked by heavi- 
ness of the head and drowsiness, without any signs 
of pain, great languor, and a total absence of all ac- 
tive febrile symptoms. The cases which I have 
seen have been invariably attributed to congestion of 
the brain, and the remedies employed have been 
leeches and cold lotions to the head, and purgatives, 
especially calomel. Under this treatment they have 
gradually become worse, the languor has increased, 
the deficiency of heat has become greater and more 
permanent, the pulse quicker and weaker, and at 
the end of a few days, or a week, or sometimes 
longer, the little patients have died with symptoms 
apparently of exhaustion. In two cases, however, 
I have seen, during the last few hours, symptoms of 
oppressed brain, as coma, stertorous breathing, and 
dilated and motionless pupil.75* 
But although this morbid affection is scarcely de- 
scribed by former writers, it is, I find, sufficiently 
familiar to many observing practitioners, on recalling 
* Account &c., pp. 357, 358. 116 
ON A MORBID 
to their minds the circumstances of the singular 
and interesting state of things attending it, and I am 
indebted to several friends for notices of cases of this 
kind. 
The remedies for this morbid affection, are such 
as will check the diarrhoea, and afterwards regulate 
the bowels, and restore and sustain the strength of 
the little patient. With the first objects it may be 
necessary to give the tinctura opii, and chalk, and 
afterwards the pilula hydrargyri, rhubarb, and mag- 
nesia ; with the second, sal volatile, but especially 
brandy, and proper nourishment are to be given ac- 
cording to circumstances. But, in this, as in so 
many cases of infantile disorders, the young milk of 
of a young and healthy-nurse, is the remedy of most 
importance,—in the absence of which, ass’s milk 
may be tried, but certainly not with the same confi- 
dent hope of benefit. 
Five or ten drops of the sal volatile may be given 
every three or four hours; and twice or thrice in 
the interval, five or ten drops of brandy may be given 
in arrowroot done in water. As the diarrhoea and 
the appearance of exhaustion subside, these remedies 
are to be subtracted ; the bowels are to be watched 
and regulated, and the strength is to be continually 
sustained by the nurse’s or ass’s milk. The brandy 
has sometimes appeared to induce pain ; sal volatile is 
then to be substituted for it; a dose of magnesia has 
also appeared to do good. AFFECTION OF INFANCY. 
117 
For the state of irritability, the warm bath is a 
remedy of great efficacy. For the coma a small 
blister or sinapism should be applied to the nape of 
the neck. A state of exhaustion of the general sys- 
tem, as I have observed elsewhere,* by no means 
precludes the possibility of real congestion of the 
brain. It rather implies it. In extreme cases these 
are not only the symptoms of cerebral congestion 
during life, but effusion of serum into the ventricles 
of the brain is found on examination after death. 
In every case the extremities are to be kept warm 
by flannel, and the circulation should be promoted in 
them by assiduous frictions. It is of the utmost im- 
portance carefully to avoid putting the little patient 
into the erect posture. A free current of air is a re- 
storative of the greatest efficacy. 
I proceed to exemplify this description and the 
appropriate treatment, by adducing several cases. 
The first I give from the li Medical Essays 
Case I.—“ A little girl aged four months was 
seized with a bowel complaint; the usual medical 
attendant prescribed an aperient, which acted too 
freely. When I saw it on the second or third day 
of the disorder, the countenance was pale and sunk, 
and the cheeks cool; it started on being touched ; 
there was a peculiar huskiness of the voice, and the 
pulse beat from 144 to 150. By giving brandy, the 
* Commentaries on Diseases of Females, passim. 118 
pulse was found on the succeeding day reduced to 120. 
and there was some apparent amendment, although 
a degree of ruttling in the breathing or on coughing, 
was now added to the huskiness of the voice. By 
continuing the brandy the cheeks became warm, 
and at length somewhat flushed, and the pulse rose 
to 140. The quantity of brandy was diminished and 
cautiously regulated, and the pulse very gradually 
fell to the natural standard. 
“ In this case the pallidness and coldness of the 
cheeks, and the state of the voice and breathing, 
indicated almost a fatal degree of exhaustion ; the 
frequency of the pulse arising from this cause, was 
reduced by the brandy; but it was afterwards again 
increased as the effect, not of the exhaustion, but of 
the stimulus, and the cheeks recovered their warmth, 
and sometimes even became flushed. In another 
case precisely similar, the state of sinking continued 
in spite of every remedy, and the little infant 
lingered and then expired. I have known such 
a state of lingering to be continued for several 
days.” 
Case II.—On Saturday the 21st of March, I was 
called to an infant three months old, under the fol- 
lowing circumstances. It had been weaned a fort- 
night ; during this period it had been fed with milk 
and barley water, and once a day with the addi- 
tion of bread. It remained well until the Thursday 
before my visit, when it became affected with fever, 
ON A MORBID AFFECTION OF INFANCY. 
119 
restlessness, crying, and moaning in its sleep, and 
with diarrhoea, passing several undigested and mu- 
cous stools. A dose of calomel was given, which 
induced sickness. A second dose was then ad- 
ministered which in the course of that and the suc- 
ceeding day, Friday, was followed by sixteen evac- 
uations. 
During Friday night, there was. much heat, inter- 
rupted sleep, and griping pains, followed by offensive 
evacuations. On the following morning, there was 
some degree of dozing of coma, the eyes were 
imperfectly closed, the tunica albuginea alone being 
visible, and the mouth was open. This inanimate 
state, attended by coldness of the cheeks, hands and 
feet, would continue for ten minutes, and then there 
would be some degree of reaction. 
This state of things continued during the whole of 
Saturday, the dozing assuming the character of more 
settled coma. I saw the little patient late in the 
evening. The cheeks were then pale and cold ; the 
eyes were half open, and unfixed, and unexcited by 
any external object however brilliant, and the pupils 
were moderately dilated, and unmoved on the ap- 
proach of light; the pulse was 132: the breathing 
irregular and sighing ; the general surface pale, and 
the hands and feet cold. 
There were thus the usual symptoms of the comatose 
stage of hydrencephalus. The condition of the coun- 
tenance, general surface, and extremities, and the his- 120 
ON A MORBID 
tory of the case, however, led me to view it as one of 
exhaustion, and not of inflammation and effusion with- 
in the head. I therefore prescribed five drops of 
brandy, and three of sal volatile, to be given alter- 
nately every hour; and I' directed the little patient 
to be put once in the interval of the two hours, 
to the breast of a young and heatyhy nurse. 
Under this discipline there was a gradual but not 
unchequered amendment. The stupor began to al- 
ternate with restlessness, and there were frequent 
startings; more than once the restlessness was so 
great as to require the use of a warm bath, by which 
it was greatly relieved, and quiet and sleep induced. 
The countenance gradually assumed a more natural 
and animated appearance and expression, with an 
occasional smile. The bowels were moved four 
times on the succeeding day, the evacuations being 
green. 
On Monday morning, a little magnesia and rhubarb 
were given, the other remedies having been and 
being still continued. The little patient started 
much less on this day, and slept quietly, and there 
was no return of restlessness to require the warm 
bath. 
On the succeeding days there was an obvious 
and progressive amendment. The brandy and sal 
volatile were gradually abstracted, the breast being 
continued. 
Case III.—I was called a short time ago, to see AFFECTION OF INFANCY. 
121 
a little girl, aged two years and three quarters, who 
had laboured under an attack of influenza. The 
affection of the chest had been severe and protracted, 
and sixteen leeches had been applied, besides the ad- 
ministration of other depletory measures, before it 
had subsided. 
The symptoms of affection of the chest were, 
however, subdued at last; but the little patient was 
left extremely exhausted, and in this state a new 
train of symptoms supervened, not less alarming, and 
more puzzling, than the first. The child fell into a 
dozing state, and lay with its eyelids but half closed; 
it moaned when any attempt was made to rouse it; 
the eyes were unfixed on any external object, the 
pupils were dilated, yet partially contractile on the 
influx of light; the pulse was 140. 
On withdrawing into an adjoining room, the medi- 
cal gentleman whom I had the pleasure of meeting, 
observed, “ hydrencephalus has now supervened, and 
we must administer calomel.” I replied that I took 
a different view of the case,—that it resembled hy- 
drencephalus indeed, but arose from exhaustion, and 
that brandy, not calomel, could alone save the little 
patient’s life. I referred to the history of the case 
for sufficient sources of exhaustion ; and to the facts 
detailed in the preceding part of this paper, for the 
actual occurrence of such cases in practice. 
We administered brandy, directing thirty drops to 
be given every two hours, with barley-water in the 122 
ON A MORBID 
intervals, and a quarter of a pint of ass’s milk twice 
in the twenty-fours. The bowels were relieved by 
magnesia and the warm water injection. 
This plan of treatment lowered the number of the 
pulse, and gradually diminished the severity of the 
other symptoms. Still the eyes were not to be fixed 
by presenting any bright object before them ; the 
pupils remaining dilated ; the tunicae conjuctivae be- 
came inflamed from exposure, between the partially 
closed eyelids: and once or twice the faeces were 
passed involuntarily in bed. 
The brandy having occasioned pain in the bowels, 
an effect which I have several times observed, it was 
given alternately with the spiritus aromaticus. The 
rest of the plan was pursued with unexampled as- 
siduity by a most tender mother, who did not once 
undress or leave her little patient, until she saw it 
out of all danger. This task was the severer, be- 
cause, although the symptons which had been detailed 
subsided gradually and favourably, they were suc- 
ceeded by an equally severe and sadly protracted 
aphthous affection. 
The first symptom of amendment was a diminished 
frequency of the pulse; the next a restored suscepti- 
bility of the pupils to light; then the eyes became 
attracted and fixed by external objects, and a smile 
began to play upon the little patient’s countenance ; 
the eyelids closed more and more perfectly during 
sleep, and the conjunctivae lost their inflamed, in- AFFECTION OF INFANCY. 
123 
jected appearance ; the knees were drawn np, and 
the posture on the side began to be assumed sponta- 
neously. 
I have notes of two other cases of this kind, but 
they are so precisely similar to those which I have 
given, that it appears needless to add to the length 
of this little paper, by relating them in detail. I shall 
rather adduce the further evidence contained in the 
following paragraph of a letter written to me by my 
friend, Mr. Heming, Surgeon, of Kentish Town, 
than whom I know not a more intelligent and ob- 
serving practitioner: 
“ The two little children of whom I spoke to you, 
became affected with bowel complaint, and the usual 
medical attendant gave them some aperient medicine. 
As they continued to get worse, Dr. Blegborough 
was consulted. I saw them on December the 10th, 
1826. The youngest, an infant aged nine months, 
was suffering with aphthous diarrhoea, was very pale, 
and much emaciated, and appeared to be dying. It 
lingered for two or three days with the symptoms of 
sinking, which you have described, and then expired. 
The eldest child, a girl aged three years, the princi- 
pal subject of the short account which I am enabled 
to give you, had had leeches applied to the temples, 
and had taken calomel and jalap, and its mother was, 
at the time I saw it, applying a cold spirituous lotion 
to the head. Dr. JBlegborough had given it as his 
opinion, that the case was hydrencephalus, and of 124 
ON A MORBID 
course hopeless, and in truth I thought he was right, 
for the child was completely insensible to sound or 
light, the eyes were half closed, and affected with 
strabismus, and the pupil dilated ; its head fell from 
side to side, and the faeces were passed involuntarily ; 
the skin was blanched, and there was great emacia- 
tion. 1 recommended sinapisms to be applied to the 
feet; and, if the child should become capable of 
swallowing, which I did not expect, to give it ass’s 
milk, and to omit all medicine. 
“When I called on the 12th, I was greatly and 
agreeably surprised to find this little patient much 
better. The ass’s milk had been taken and seemed 
to agree. As the bowels were still moved frequently 
and involuntarily, and as I did not now think the symp- 
toms depended upon effusion into the brain, though l 
confess I was much puzzled to know to what cause 
they were to be assigned, 1 recommended small doses 
of laudanum to be given until the diarrhoea should 
be checked. On the 14th, the motions were less 
frequent, and the little patient was better in every 
respect. On the 18th, although very pale, the child 
was still further improved. It was sent into the 
country, and a few months after, it was perfectly 
well.” 
For the following case I am indebted to my intelli- 
gent friend Dr. Tweedie : 
“ In September last, I was requested by a respecta- 
ble medical practitioner to visit an infant which he AFFECTION OF INFANCY. 
125 
suspected to be dying from effusion into the brain. 
On reaching the house, I found a little child about 
four months old, lying in a state of complete coma, 
from which it could not be roused. On raising the 
eyelids, the pupils were found natural though the 
eye was dull. The pulse was rapid and feeble, the 
breathing frequent, and occasionally interrupted and 
suspirious, and the bowels were loose, the evacuations 
consisting chiefly of mucus. 
“ On inquiring into the previous history, I was 
informed that the mother having accepted the situa- 
tion of wet nurse in a family, had placed this child, 
which was then in perfect health, under the care of 
another nurse who had just weaned her own child at 
the age of nine months ; that very soon afterwards it 
began to be sick, and the bowels became relaxed, 
and as it did not get better, it was removed to the 
house of a relation, who attempted to rear it by spoon 
diet. It was soon observed to rally under this 
change; but the diarrhoea continued in spite of 
remedies administered with the view of checking it. 
Ten days afterwards it became again fretful and un- 
easy, the bowels being still purged ; then coma gra- 
dually supervened, and it died nine days afterwards, 
within twelve hours of my visit. 
“Permission could not be obtained to examine the 
body.” 
It is since this paper was read to the Medico- 
Chirurgical Society, that I have had the satisfaction 126 
ON A MORBID 
of seeing the recent publication of Dr. Gooch, in 
which that acute physician has given cases similar to 
those just detailed. I cannot but be sensible of the 
flattering manner in which he has alluded to my 
observations. 
As the cases and remarks of Dr. Gooch contain 
the only additional information upon the present 
subject which I have found in medical writings, I 
think it important to add some of them to those which 
I have already deduced from my own observation, 
and that of the gentlemen already quoted : 
“ A little girl, about two years old, small of her 
age, and very delicate, was taken ill with the symp- 
toms which I have above described. She lay dozing, 
languid, with a cold skin, and a pulse rather weak, 
but not much quicker than natural. She had no 
disposition to take nourishment. Her sister hav- 
ing died only, a week before of an illness which began 
exactly in the same way, and which was treated by 
leeches and purgatives ; and some doubts having been 
entertained by the medical attendant of the propriety 
of the treatment, leeches were withheld, but the child 
not being better at the end of two days, the parents, 
naturally anxious about their only surviving child con- 
sulted another practitioner. The case was immediately 
decided to be one of cerebral congestion, and three 
leeches were ordered to be applied to the head. As 
the nurse was going to apply them, and during the 
absence of the medical attendants, a friend called in AFFECTION OF INFANCY. 
127 
who had been educated for physic, but had never 
practised it, and who had great influence with the 
family : he saw the child, said that the doctors were 
not sufficiently active, and advised the number of 
leeches to be doubled. Six, therefore, were applied ; 
they bled copiously ; but wTien the medical attend- 
ants assembled in the evening, they found the aspect 
of the case totally altered, and that for the worse: 
the child was deadly pale, it had scarcely any pulse, 
its skin was cold, the pupils were dilated and mo- 
tionless when light was allowed to fall on them, and 
when a watch was held to its' eyes it seemed not to 
see ; there was no squinting. Did this state of vi- 
sion depend on the pressure of a fluid effused into 
the brain since the bleeding, and during this exhaust- 
ed and feeble state of circulation, or did it depend on 
the circulation of the brain being too languid to sup- 
port the sensibility of the retina? It is well known 
that large losses of blood enfeeble vision. I saw a 
striking instance of this in a lady who had flooded to 
death. When I entered the chamber she had no 
pulse, and she was tossing about in that restless state 
which is so fatal a sign in these terrific cases. She 
could still speak, asked whether I was come, (she 
knew I had been sent for, and said, “ Am I in any 
danger?—How dark the room is!—I can’t see.” 
The shutters were open, the blind up, and the light 
from the window facing the bed fell strong on her 
face. I had the curiosity to lift the lid, and observe 128 
ON A MORBID 
the state of the eye; the pupil was completely di- 
lated, and perfectly motionless, though the light fell 
strong on it. Who can doubt that here the insensi- 
bility of the retina depended on the deficiency of its 
circulation ? But to return to the little patient. The 
next day she had vomited her food several times ; it 
was therefore directed that she should take no other 
nutriment than a desert spoonful of ass’s milk every 
hour, and this was strictly obeyed, and continued 
for several days. The child wasted, her features 
grew sharp, and every now and then she looked 
fretful, and uttered a faint squeaking cry ; the eye- 
balls became sunk in the socket, like those of a 
corpse that had been dead a month ; the skin con- 
tinued cool, and often cold, and the pulse weak, 
tremulous, and sometimes scarcely to be felt. Under 
this regimen, and in this way, she continued to go on 
for several days. At times she revived a little, so as to 
induce those who prescribed this treatment to believe 
confidently that she would recover, and she clearly 
regained her sight, for if a watch was held up to her 
she would follow it with her eyes. She lived longer 
than I expected ; a full week, and then died with 
the symptoms of exhaustion, not with those of op- 
pressed brain. The head was opened by a surgeon 
accustomed to anatomical examinations, and nothing 
was found but a little more serum than is usual in 
the ventricles. 
i( If the reader has perused the foregoing case at- AFFECTION OF INFANCY. 
129 
tentively, and has reflected on it, he will of course 
draw his own inferences. I can draw no others than 
these, that the heaviness of head and drowsiness, 
which were attributed to congestion in the brain, 
really depended on a deficiency of nervous energy; 
that the bleeding and scanty diet aggravated this 
state, and insured the death of the child; also, that 
the state of the eye which so speedily followed the 
loss of blood, and which resembled that occasioned 
by effusion, did in reality depend on a deficiency in 
the circulation of the brain, a fact of considerable 
curiosity and importance. 
“ I will now relate a case similar in the symptoms, 
but very different in the treatment and result. I 
was going out of town one afternoon, last summer, 
when a gentleman drove up to my door in a coach, 
and entreated me to go and see his child, which he 
said had something the matter with its head, and that 
the medical gentleman of the family was in the house, 
just going to apply leeches. I went with him im- 
mediately, and when I entered the nursery, I found 
a child, ten months old, lying on its nurse’s lap, ex- 
actly in the state which I have already described ; 
the same unwillingness to hold its head up, the same 
drowsiness, languor, absence of heat and all symp- 
toms of fever. The child was not small of its age, 
and had not been weak, but it had been weaned 
about two months, since which it had never thriven. 
The leeches had not been put on. 1 took the medi- 130 
ON A MORBID 
cal gentleman into another room, related to him the 
foregoing case, and several similar to it, which had 
been treated in the same way, and had died in the 
same way. Then I related to him a similar case, 
which I had seen in the neighbouring square, which 
had been treated with ammonia in decoction of bark, 
and good diet, which had recovered; not slowly, so 
as to make it doubtful whether the treatment was the 
cause of the recovery, but so speedily that at the 
third visit I took my leave. He consented to post- 
pone the leeches, and to pursue the plan which I 
recommended. We directed the gruel diet to be left 
off, and no other to be given than ass’s milk, of 
which the child was to take, at least a pint and a 
half, and at most a quart in the twenty-four hours. 
Its medicine was ten minims of the aromatic spirit of 
ammonia in a small draught every four hours. When 
we met the next day, the appearance of the child 
proved that our measures had been right; the nurse 
was walking about the nursery with it upright in 
her arms. It looked happy and laughing: the same 
plan was continued another day ; the next day it 
was so well that I took my leave, merely directing 
the ammonia to be given at longer intervals, and thus 
gradually withdrawn, the ass’s milk to be continued, 
which kept the bowels sufficiently open, without 
aperient medicine. 
“So inveterate is the dispositon to attribute drowsi 
ness in children to congestion of the brain, and to AFFECTION OF INFANCY. 
131 
treat it so, that I have seen an infant, four months 
old, half dead from the diarrhoea produced by artifi- 
cial food, and capable of being saved only by cordials 
aromatics, and a breast of milk; but because it lay 
dozing on its nurse’s lap, two leeches had been put 
on the temples, and this by a practitioner of more 
than average sense and knowledge. I took off the 
leeches, stopped the bleeding of the bites, and at- 
tempted nothing but to restrain the diarrhoea, and get 
in plenty of nature’s nutriment, and as I succeeded 
in this, the drowsiness went off, and the child revived. 
If it could have reasoned and spoken it would have 
told this practitioner how wrong he was; any one, 
who from long defect in the organs of nutrition, is 
reduced so that he has neither flesh on his body, nor 
blood in his veins, well knows what it is to lay down 
his head and doze away half the day without any 
congestion or inflammation of his brain. This error, 
although I have specified it only in a particular com- 
plaint of children, may be observed in our notions 
and treatment of other diseases, and at other periods 
of life. If a woman has a profuse haemorrhage after 
delivery, she will probably have a distressing head- 
ache, with throbbing in the head, noises in the ears, 
a colourless complexion, and a quick, weak, often- 
thrilling pulse, all which symptoms are greatly in- 
creased by any exertion. I have seen this state treated 
in various ways, by small opiates, gentle aperients, 
and unstimulating nourishment, with no relief. I 132 
ON A MORBID 
have seeu blood taken away from the head, and it 
has afforded relief for a few hours, but then the 
head ache, throbbing, and noises, have returned worse 
than ever; the truth is, that this is the acute state of 
what in a minor degree, and in a more chronic form 
occurs in chlorosis, by which I mean pale-faced 
amenorrhoea, whether at puberty or in after-life. It 
may be called acute chlorosis, and like that disease 
is best cured by steel, given at first in small doses, 
gradually increased, merely obviating constipation by 
aloetic experiments. 
“ I shall not encumber this paper with a multiplicity 
of cases, but state that the above are only specimens 
of a class of which I have seen enough to convince 
me that they deserve the attention of the profession. 
If I had any doubt about this, this doubt would be 
removed the fact that Dr. Marshall Hall has 
already recognized them, and described them in a 
paper which has been read at the Medico-Chirurgical 
Society. He has therefore anticipated me in an- 
nouncing them.” t( The only difference between 
our experience seems to be this—that he attributes 
the state which I have been describing to the diarrhoea 
produced by weaning, or to the application of leeches 
for some previous complaint. In most of the cases 
I have seen, however, the child has had no previous 
illness, and leeches have been applied subsequent to 
the drowsiness, and as a remedy for it.”* 
Pp. 358—367. AFFECTION OF INFANCY. 
133 
In regard to the difference in the experience of 
Dr. Gooch and myself, I would observe that that of 
Dr. Abercrombie plainly concurs with mine, and 
that, in all the cases seen by Dr. Gooch himself, the 
bowels had already been disturbed by purgatives, so 
that a source of exhaustion had existed in them. All 
the cases which I have seen, or heard of, and those of 
Mr. Heming and of Dr. Tweedie, alike involved a 
state of exhaustion. 
The first stage of the affection which has been 
described, or that of irritability, may, indeed, depend 
on a previous disordered conditon of the stomach and 
bowels; but the state of torpor is obviously the 
result of exhaustion. 
The rest of Dr. Gooch’s observations are highly 
interesting. 
Since the preceding pages were written, I have 
had the satisfaction of having attended a most inter- 
esting case of this affection, in conjunction with Dr. 
James Johnson, and Mr. Balderson, of Poland Street, 
Oxford Street. 
ft 
The patient, a little child two years and three 
quarters old, had taken a purgative medicine inten- 
ded for an elder child, consisting of eight grains of 
scammony, and two and a half of calomel, which 
had acted excessively. It was first seen on August 
the 30th, affected with sickness and purging, with 
fever, restlessness, and a frequent small pulse. An 134 
OIV A MORBID 
effervescing medicine with the tinctura cardamomi 
composita was prescribed for the sickness. 
In the evening the stomach and bowels were found 
to be quieted ; but there were now flushing, a fuller 
pulse, and some cough and dyspnoea. Two leeches 
were directed to be applied to the chest, and the mix- 
ture to be continued, omitting the tincture of carda- 
moms ; small doses of the hydrargyri submurias and 
of ipecacuanha were prescribed. 
Aperients, saline, and the vinum antimonii w'ere 
given, and on September the 2d, two more leeches 
were applied to the chest. 
On the morning of the 3d, a dose of the oleum 
ricini was prescribed, and a blister was applied to the 
chest. In the evening Mr. Balderson began to suspect 
that effusion had taken place into the brain ; the 
skin was hot and dry, the tongue furred, the pupils 
dilated and incontractile on the approach of light; 
there was stupor, and the pulse was lower though 
full. A cold lotion was applied to the head, and the 
doses of calomel were increased from one fourth to 
one half of a grain every four hours. 
On the 4th, Dr. Johnson saw the little patient with 
Mr. Balderson, and prescribed nearly similar reme- 
dies. There was continued stupor. 
On the 5th, the patient was insensible to all around 
her. I was requested to join Dr. Johnson and Mr. 
Balderson, in consultation. It really did not appear 
that sufficient cause of exhaustion existed to account AFFECTION OF INFANCY. 
135 
for the symptoms upon this principle, so that I con- 
curred in the propriety of the measure already 
adopted, and of the application of two leeches to the 
temples. 
On the 6th, there was too obviously danger of 
sinking; the cheeks and hands were cold, and the 
pulse extremely feeble; and I could no longer doubt 
that the symptoms were induced, not by encephalic 
effusion, but by exhaustion of the general system. 
Yet there were dozing, unwillingness to move, and 
other symptoms of hydrencephalus. There was, 
however, none of the contracted brow of hydrence- 
phalus, no grating of the teeth, no screaming, no 
convulsive affection. Thirty drops of brandy were 
now given in ass’s milk every four hours. 
The amendment was so obvious, from this change 
of plan, that the brandy and ass’s milk were directed, 
to be given more frequently at our next visit,—indeed 
every hour. 
Under this discipline our little patient very gradu- 
ally recovered her sensibility, warmth, and natural 
disposition, and all the symptoms threatening effusion 
vanished, together with the restlessness and unwill- 
ingness to move. 
This case is peculiarly instructive. It teaches us 
to watch the hydrencephaloid affections of young 
children, and to suspect exhaustion even when but 
little blood has been drawn, if the case were merely 
bronchial, or not really inflammatory. The sad 136 
ON A MORBID 
effects of the application of the two last leeches, 
contrasted with those of brandy and nourishment, 
were too striking not to be at once obvious to all. 
It is also highly important to remember, that one 
over dose of a cathartic medicine may induce the state 
of exhaustion with its irritability or its coma. 
APPENDIX III. 
OF EXHAUSTION ARISING FROM OTHER SOURCES 
BESIDES LOSS OF BLOOD. 
I shduld have inserted in this place an account 
of exhaustion as it arises from other causes than loss 
of blood, chiefly undue lactation, leucorrhoea, 
haemorrhoids, &c. had I not already published my 
observations on this interesting subject in another 
work,* to the third and fourth chapters of Part III. 
of which, I must beg to refer my readers. 
It will be readily conceived that hypercatharsis 
and diarrhoea may induce the symptoms of exhaus- 
tion in adults as well as in children. In some cases 
of great susceptibility to exhaustion, this event is 
very remarkable, and occurs when from the degree 
and measure of its cause it could scarcely have been 
suspected. 
* Commentaries on some Diseases of Females. APPENDIX IV. 
OF THE EXHAUSTION ARISING FROM ABSTINENCE. 
A further illustration of the principles detailed in 
the preceding pages, is afforded by the phenomena 
of exhaustion arising from abstinence. It would be 
foreign to the objects of this work to notice this 
subject except in the most cursory manner. The 
reader may consult the well known details of the 
sufferings of Captain Blythe, Captain Franklin, and 
the crew of the Meduse, and may perhaps turn for a 
moment to “ The Prisoners of Chillon.” 
One of the best accounts of the effects of absti- 
nence, is that of a fatal case of this nature by the 
late Dr. Willan.* It is defective for want of the 
* 
morbid appearances after death. In this case, great 
imbecility of mind was replaced by continued raving, 
and this by sullenness. 
An illustration of the effects of starvation, on a 
larger scale, is presented to us in Dr. P. M. Latham’s 
interesting account of the epidemic at the Milbank 
Penitentiary. In the extreme stage of weakness in 
th&se cases, the head frequently became affected with 
* Miscellaneous Works, edited by Dr. Ashby Smith, 1821, p. 437. 138 
EXHAUSTION FROM ABSTINENCE. 
pain, vertigo, delirium, convulsions, apoplexy, mania. 
There was early fainting from bloodletting. On 
examination after death, increased vascularity was 
observed in the brain, with effusion between its mem - 
branes and into its ventricles. In a word, there 
were the usual appearances in cases of exhaustion. 
I must conclude this subject by the following brief 
but interesting extract from M. Andral.* 
Au moment oii j’ecris ces Iignes, je lis dans un 
Journal de medecine un fait qui confirme trop pleine- 
ment d’autres faits que j?ai cites ailleurs, pour que je 
ne le rapporte pas ici. Ce fait me parait tres-bien 
faire ressortir jusqu’a quel point, en privant le cer- 
veau de ses exc.itans accoutumes, on peut produire 
precisement les menies effets que ceux auxquels on 
donnerait lieu en augmentant la quantite de ces 
excitans. 
“ Un homme tres-adonne a Fivrognerie, fut jete 
en prison pour cause de vol, et reduit tout-a-coup au 
regime du pain et de Feau. Des les premieres 
semaines de ce nouveau genre de vie, on observe du 
trouble dans les facultes intellectuelles du prisonnier; 
son embonpoint et ses forces declinent, sa figure palit 
et exprime Fabatfement: il passe les nuits dans 
Finsomnie; plus tard, il survient un delire, qui,d’abord 
tranquille, devient ensuite de plus en [)lus furieux ; 
il croit voir des figures horribles qui le jettent dans 
* Anatomic Pathologique, Tom. ii. p. 769. EXHAUSTION FROM ABSTINENCE. 
139 
des angoisses continuelles ;-iI pousse des cris penmans. 
Le docteur Hausbrandt, appele a examiner le malade, 
apprend quelles etaient ses habitudes avant son entree 
en prison, et que Fentiere abstinence des 
liqueurs alcooliques est la cause de son deperissement 
et de sa manie. En consequence, il prescrit Fadmin- 
istration deux fois par jour d’une petite qtiantite 
d’eau-de-vie ; les accidens cerebraux ne tardent pas 
pas a se dissiper, Fembonpoint et les forces reviennent 
ensuite peu-a-peu, le malade recouvre enfin sa pre- 
miere sante, et la conserve pendant tout le temps de 
sa detention.” APPENDIX V. 
OF THE STATE OF SINKING. 
Of the state of sinking, little is to be found in 
medical writings, and it is, 1 think, seldom under- 
stood in practice, in its earliest stages. Yet it is of 
the utmost importance to distinguish this state, both 
on account of the prognosis and treatment. 
Amongst the first effects of the sinking state, is 
frequently the subsidence of some painful symptom, 
as delirium, cough, or even pain itself, into a state of 
ease and perhaps of dozing. This event is continu- 
ally mistaken by the patient and his friends for a 
favourable alleviation of the disease ; the physician 
himself even, may leave his patient in hope, may 
raise the hopes of relatives, and may even propose to 
postpone his succeeding visit, under this false im- 
pression, when the patient is dozing perhaps to awake 
no more, or only to a state of obvious but irremedia- 
ble sinking. This point has been treated of expressly 
by Sir Henry Halford, in a paper, not duly estimated 
by the profession, in the sixth volume of the Trans- 
actions of the College of Physicians, page 398, and 
entitled, “ On the necessity of caution in the estima- 
tion of symptoms in the last stages of some diseases.” OF THE STATE OF SINKING. 
141 
The fatal event is occasionally still more sudden, 
perhaps following immediately upon some sudden 
exertion or effort. 
In this case, as in those of intestinal irritation and 
loss of blood, there are, when life is protracted, local 
affections of particular organs, peculiar to itself. The 
head becomes affected with delirium, or with dozing 
or slight coma, and there is a half-closed eyelid, 
restlessness, and moaning; and there is a tendency 
to effusion into the brain. There is frequently, as a 
first sign of sinking, a slight crepitus or rattle heard 
in the breathing, perhaps with a restless cough, or 
dyspnoea requiring the erect position, and the lungs 
become affected with oedema, or disorganized as if 
by inflammation. The pulse is frequent and feeble. 
The nose and extremities are apt to be cold and livid. 
The bowels become distended from an excessive 
evolution of flatus. 
The whole of this matter is little understood. 
Having made it an object of investigation for some 
time, however, 1 can speak with confidence of the 
statements which I have made. As I can, in this 
place, only give a sketch of the subject, I will refer 
my readers to such works as contain observations 
bearing upon it. Mr. John Hunter has written a 
chapter, in his work on Inflammation, “ on Dissolu- 
tion,” which contains many interesting remarks upon 
the sinking state. I have already quoted a paper by 
Sir Henry Halford ; that physician has also published 142 
OF THE STATE OF SIN'KIN'G. 
another paper, in the fourth volume of the same 
work, page 316, “On the Climacteric Disease,” 
which is, merely the sinking state of old age. Laen- 
nec has some scattered but interesting remarks upon 
a condition of the lungs, which he denominates in 
one place u peripneumonie des vieillards,” and in 
another, “ peripneumonie des agonisans,” and which 
I recognize to be an affection of the lungs induced 
during the sinking state. The same observation 
may be made in regard to some cases of oedema of 
the lungs. On the present subject the reader may 
further consult the first volume of the last edition of 
the celebrated work of this author, pages 97, 284, 
351, 481, &c. I can only insert here, a passage 
from page 284, “ Mais de meme que Pon observe 
quelquefois des taches violettes tres-etendues sur Ies 
parties posterieures du corps un ou deux jours avant 
la mort, chez les malades dont les forces sont tres~ 
abattues, et particulierement dans fievres graves, de 
meme aussi Pengorgement sanguin ou sereux des 
parties posterieures des poumons commence souvent 
quelques heures avant la mort. La crainte de tour- 
menter inutilement des moribonds nfa empeche de 
verifier habituellement ce fait ; mais je Pai rencontre 
presque chaque fois que je Pai cherche. Un rale 
sous-crepitant et muqueux dans les parties inferieurs 
du dose et a la racine des poumons, accompagne 
presque constamment Pagonie et le rale tracheal. 
Ainsi Poppression que Pon observe chez la plupart OF THE STATE OF SINKING. 
143 
ties mourans, lors meme que les organes respiratoires 
ont ete parfaitement intacts pendant tout le temps de 
la maladie, s’explique par le meme fait.7’ 
There are also some remarks not irrelevant to this 
subject in the “ Clinique Medicale,” and in the 
u Anatomie Pathologique,” of M. Andral. 
It is plain from these observations that the mere 
observations of the morbid anatomy, unconnected 
with that of the symptoms, not only of the disease, 
but also of the final sinking state, must have led to 
innumerable errors. The morbid appearances are 
frequently not the effects of the disease, but of the 
state of sinking, if that has been protracted; but 
in what work are these distinguished from each 
other. 
The sinkingstate obviously differs with its various 
causes. In the case of sinking from exhaustion, there 
appears to be a failure of the powers of the whole 
nervous and secretory systems simultaneously, ma- 
nifested by its effects on the functions of the brain, 
heart, lungs, and intestinal canal. When the state of 
sinking occurs from oppression of the brain, the 
mechanism of respiration and. the functions of the 
lungs are first and chiefly affected ; when on the 
contrary, sinking arises from a clogged state of the 
bronchia and of the air cells, there is a manifestly 
defective arterialization of the blood ; and lastly, 
when sinking takes place in certain affections of 
the stomach or bowels, as gastritis, enteritis, dysen- 144 
OF THE STATE OF SINKING. 
tery, &lc. there is great and often sudden failure of 
the circulation, indicated by an extremely small pulse, 
and of the animal heat, with a cessation of the pain 
—events which have frequently led to the erroneous 
idea of gangrene. These differences in the state of 
sinking, as well as that state itself, require to be still 
further traced ; the investigation will doubtless lead 
to many interesting observations in pathology. 
It does not appear probable that this state, or 
disease, as Mr. Hunter terms it, will admit of reme- 
dy. I would merely suggest that there is, in some 
cases of sinking, an obvious analogy to the state 
induced in animals by the division of the eighth pair 
of nerves, or the destruction of a part of the spinal 
marrow, as observed by Dr. Philip,* and that it is 
probable that the life might be protracted by means 
of galvanism. 
Still it is chiefly with the view to the prognosis 
that the study of this subject becomes important. 
And I would particularly notice, in relation to this 
point, the crepitous rattle of which I have already 
spoken. From the moment this peculiar symptom 
is observed, it may, as far as our present means ex- 
tend, be regarded as of fatal omen. Let us be particu- 
larly on our guard against mistaking a state of sink- 
ing, for one of amendment. And let us not be taken 
* On the Vital Functions, third edition, Chap, vii, and the Philosophi- 
cal Transactions, for 1827. OF THE STATE OF SINKING. 
145 
by surprise by those still more sudden terminations of 
the case of sinking, which occasionally occur from 
effort or exertion. 
Several other symptoms besides the crepitus heard 
in the breathing, are of sad, not to say fatal import. 
These are a state of inflammation of the conjunctiva, 
arising, I believe, from the eyes being for a long time 
only imperfectly closed; great and irregular fre- 
quency, and a feebly vibrating character of the 
pulse; dozing; sighing in the breathing; difficult 
digestion ; a tympanitic tumidity of the bowels; 
retention of the urine; and involuntary evacuations. 
The sinking state is often early denoted by al- 
tered secretions, especially foetid evacuations from 
the bowels; and by an ungovernable frequent 
pulse. 
Mr. Travers has given a very interesting account 
of the state of sinking in burns :— 
“ The complaint of pain in the fatal cases is re- 
markably disproportionate to the mischief, or at least, 
it disappears early ; and it is a favourable sign, 
where the continuance of it seems to demand the use 
of opiates; the early subsidence of complaint, un- 
willingness to be disturbed, apathy approaching to 
stupor, as if the scale of sensibility had shrunk below 
the point of pain, is invariably a fatal symptom. 
Continued shivering is an ill omen. The failure of 
the pulse and consequent coldness of the extremities, 
with a livid hue of the transparent skin of the cheeks 146 
and lips from congestion in the capillaries, drowsi- 
ness, with occasional muscular catchings, are sure 
prognostics of death. The disposition to coma is 
characteristic, and invariably occurs in a marked 
degree, even if no opium be given. The respiration 
is light, scarcely audible, until the pulmonary circu- 
lation failing from the diminished power of the heart, 
congestion takes place in the capillaries of the lungs; 
but this does not happen until long after the same state 
has pervaded the system. Finally, laborious breath- 
ing and stertor ensue, and the patient expires in an 
apoplectic coma, with or without convulsions.’7* 
The state of sinking is, in effect, a new disease, 
supervening upon, perhaps occasioned by, a previous 
one, or induced, by agents which exhaust the system 
more directly. It occurs sooner than is suspected, 
and may be divided into two stages; the concealed, 
and the open. The former is only detected by great 
care: it is denoted by a little disturbing cough, and 
by applying the ear or the stethoscope to the chest, and 
thus detecting a crepitous rattle. This state must 
not be confounded with pneumonia, or bronchitis ; 
the history will distinguish them. The second stage 
is accompanied by the external and more obvious 
signs of the sinking or dying state, as the tracheal 
rattle, with the other symptoms already detailed. 
Dr. Philip’s observations on the order in which the 
OF THE STATE OF SINKING. 
* On Constitutional Irritation, pp. 106, 107. OF THE STATE OF SINKING. 
147 
functions cease in dying, do not appear to apply to 
the sinking state, but to the very article of death 
itself. ' 
I have thus briefly sketched the symptoms and 
appearances in the sinking state, as far as they ap- 
pear to me to be interesting to the physician. In a 
physiological point of view, the sinking state is 
equally interesting, and I purpose to pursue the in- 
quiry, under that aspect, on some future occasion. PART SECOND. 
THE CURATIVE EFFECTS OF LOSS OF BLOOD. 
CHAPTER I. 
INTRODUCTORY OBSERVATIONS. 
It is one of the most remarkable facts in physic, 
that if several patients of similar strength and con- 
stitution, but affected by dissimilar diseases, be 
respectively placed in the erect position and bled to 
deliquium, they will be found to have lost very va- 
rious quantities of blood. I have known a patient 
not apparently very feeble, faint on losing four ounces 
of blood ; and I have known patients bear to lose 
fifty, sixty, and even seventy ounces of blood without 
syncope. 
This fact, plain and simple as it is, with its ra- 
tionale and practical applications, has, I think, been 
greatly overlooked. 
Its rationale is to be found, 1 believe, in con- 150 
ON THE CURATIVE EFFECTS 
nexion with an equally interesting fact, that different 
diseases induce in the constitution different powers 
or susceptibilities in regard to the effects of loss of 
blood. Each disease appears, indeed, to possess its 
own peculiar and intrinsic virtue in this respect. This 
is determined by placing the patient perfectly erect, 
and bleeding to incipient syncope; the quantity of 
blood which flows is the measure of the protective 
influence of the disease in one class of cases, and of 
its influence in superinducing a susceptibility to the 
effects of loss of blood in the other. 
An interesting scale of diseases may be formed 
representing these properties. It would begin with 
congestion of the head, or tendency to apoplexy ; 
inflammation of the serous membranes, and of the 
parenchymatous substance of various organs, would 
follow ; then acute anasarca and lastly, inflamma- 
tion of the mucous membranes. This part of the 
scale would be divided from the next by the condi- 
tion of the system in health. Below this would be 
arranged fever, the effects of intestinal irritation, some 
cases of delirium, reaction from loss of blood, and 
disorders of the same class with hysteria, dyspepsia, 
chlorosis, and cholera morbus. 
Persons in health and of moderate strength, will 
generally faint if bled in the erect posture, on taking 
fifteen ounces of blood. I have known seventy 
ounces to be taken in the sitting posture, in the ten- 
dency to apoplexy, without syncope ; but the case is OF LOSS OF BLOOD. 
151 
an extreme one. Patients with pleuritis or pneumo- 
nia frequently lose thirty-five ounces of blood without 
fainting. In bronchitis little more is borne to be lost 
than in health. A stout person in fever will fre- 
quently faint on losing ten, twelve, or fourteen ounces 
of blood. In intestinal irritation, with urgent symptoms 
even, the abstraction of nine or ten ounces of blood 
will generally induce deliquium. In delirium tremens, 
or puerperal delirium, the patient soon faints from loss 
of blood. The same thing is still more observed in 
those cases of violent reaction, which arise from loss 
of blood itself. In dyspepsia, hysteria, and chlorosis, 
the susceptibility to syncope from loss of blood is 
very great* And I have known a patient, of good 
strength, affected with cholera, faint on taking four 
ounces of blood, although she had shortly before 
borne to lose nearly twenty ounces without faintish- 
ness, under the influence of inflamed mamma. 
I imagine that the rationale of this fact will be 
found in the obvious difference in the nature of these 
diseases. In all thofb cases in which the circulation 
of the heart and larger arteries alone is affected, and 
especially in such as involve irritation, or exhaustion, 
there is early syncope on taking blood. But in such 
cases as consist in an affection of the capillary circu- 
lation, and especially such of these as affect the head, 
it requires the abstraction of much blood, to induce 
.deliquium. Syncope is prevented by the influence 
exerted by this slate of the capillary circulation over 152 
ON THE CURATIVE EFFECTS 
that of the heart and larger arteries, and over the 
whole system, and especially over the circulation 
within the brain ; and it does not entirely subdue the 
morbid action of the capillary vessels even when in- 
duced. To induce syncope in pure fever, we have 
then but to subdue the state of reaction in the heart 
and larger arteries. In inflammation, we have not 
only to do this, but to overcome the influence of a 
permanent morbid action of the capillaries; this is 
especially observed in inflammation of the serous 
membranes and within the head. 
The practical application of this fact, consists 
chiefly in its affording a rule for bloodletting in all 
cases in which this measure is required to be fully 
instituted; a guard against undue bloodletting, 
both in this and some other cases ; and a source of 
diagnosis. 
The quantity of blood which flows when a patient 
requiring full bloodletting is placed upright and 
bled to deliquium, seems accurately proportionate to 
the exigencies of the case. In inflammation much 
blood should be taken ; and much blood will flow 
before deliquium is induced : in irritation, little blood 
should be drawn ; and there is early syncope from 
bloodletting. The quantities are even accurately 
suited, not only to the exigencies of the disease, but 
to the powers of the system ; at least so it appears to 
me from considerable experience. 
The rule is suited also to the degree and the du- OF LOSS OF BLOOD. 
153 
ration of the disease, for, with each of these, its 
influence in inducing tolerance or intolerance of loss 
blood is respectively augmented. 
It is not less adapted to those most frequent of all 
events, mixed cases. Inflammation, and irritation 
may be conjoined. For example, there may be mere 
nephralgia, or absolute nephritis, from calculus, or a 
mixed case involving both. There may be mingled 
intestinal irritation, and inflammation. In each of 
these circumstances, the rule for bloodletting which 
I have proposed, adapts itself accurately to the 
demands of these various morbid affections, and to 
the actual strength and condition of the general 
system. 
It is difficult to say whether more injury has been 
done by an undue or by an inefficient use of the 
lancet. In inflammation we must bleed fully. In 
irritation we must bleed cautiously. Inefficient blood- 
letting in the former disease, and undue bloodletting 
in the latter, are alike dangerous or even fatal to the 
patient; from both extremes we are guarded by the 
rule which I propose. By directing the patient to 
be placed in the erect position, and bled to deliquium, 
we often take much more blood than we should have 
ventured to prescribe in inflammation, and very much 
less than we might be disposed to direct in irritation ; 
and in both these cases the rule conducts us to the 
only safe mode of treatment. 
An important question relates to the due repetitions 154 
ON THE CURATIVE EFFECTS 
of bloodletting. This should, in general, be the 
more prompt, the greater the tolerance of loss of blootl 
in the previous bloodlettings. 
A further practical application of this fact, flows 
from the adoption of the rule. In doubtful cases it 
furnishes us with a fresh means of diagnosis. If 
much blood has flowed before syncope occurred, we 
must suspect inflammation ; if little, we must suspect 
that, however similar the symptoms, the case is in 
fact of a different nature,—perhaps irritation, perhaps 
exhaustion. 
I have also found that in every case in which early 
syncope occurs from bloodletting, the more remote 
effects of loss of blood, as reaction, or sinking, are 
also very liable to occur; and it is in these cases 
that sudden dissolution has followed the use of the 
lancet. There is, in every point of view, intolerance 
of loss of blood. The reverse of all this obtains in 
inflammation, which seems to be incompatible, to a 
certain degree, with the effects of loss of blood, which 
are, however, very apt to supervene, as the inflam- 
matory action subsides. 
It is by the multitude of facts alone, that the pro- 
positions which have been stated can be established 
or corrected. With the view of obtaining these facts, 
I would now propose, that in every case in which 
full bloodletting is to be instituted, the patient should 
be placed perfectly erect in a chair or in bed, and 
bled to the very first appearance of deliquium: the OF LOSS OF RLOOD. 
155 
quantity of blood taken is then to be noted, and ac- 
curately registered in a table. The same thing is to 
be observed on each repetition of the bloodletting. 
And that nothing may be left unattended to which 
may throw additional light on the subject, to this 
point I would add, 1. the appearances of the blood, 
and 2. the effects of its abstraction upon the disease. 
These various facts I propose to register in the 
following manner: 
Age and 
strength 
of the pa- 
tient.. 
Disease, 
its stage 
and com- 
plications. 
Quantity 
of blood 
taken. 
Effects on 
the patienl 
ind dis- 
ease. 
Appear- 
ances of 
the blood. 
Repeti- 
tions of 
the blood- 
letting. 
Effects. 
It is obvious that none but the most unequivocal 
cases should be thus registered. Cases, the diagno- 
sis of which was not perfectly clear, would only add 
their own obscurity to the investigation. 
It is equally obvious that the investigation pro- 
posed can only add useful facts, which will in their 
turn become useful guides to the physician. It is 
still true, as Celsus has observed,—“ nulla perpetua 
prcBcepta medicina recipitTo the young practi- 
tioner, however, I think the practice proposed will 156 
ON THE CURATIVE EFFECTS 
prove of great assistance ; and if it preserve one from 
the bitter reflection, which some have experienced, of 
having done too much, or too little, l shall not esteem 
that my labour has been in vain. 
I would observe in conclusion, that I do not think 
it safe, in any case to bleed to deliquium in the re- 
cumbent posture. But there are few cases, if any, 
in which, if it be proper to bleed fully, danger can 
accrue from bleeding to the most incipient syncope 
in the perfectly upright position. Besides the remedy 
is at hand. It consists simply in laying the patient 
recumbent, and, if necessary, raising the ,feet and 
depressing the head. 
It may become a question whether the patient may, 
in a little time, be again placed erect so as to re- 
produce a state of slight deliquium, and thus to add 
to the power of the previous bloodletting in subduing 
the disease. But I do not think a state of continued 
syncope free from danger. I have known it lead to 
delirium. 
On the other hand, the influence of an opposite 
position, the head being placed extremely low, and 
the lower part of the body being very much raised, 
has not been sufficiently traced in the various cases 
of the immediate or remoter effects of loss of blood. 
Amongst the other objects of this inquiry, should 
be that of collecting any modifications or exceptions, 
in regard to the rule which I have laid down. It 
cannot be imagined that it should be without excep- OF LOSS OF BLOOD. 
157 
tions. It is as important that these should be pointed 
out, as that the rule itself should be established. 
There are two exceptions to the rule which I have 
proposed, which I would briefly mention. In some 
cases of fever requiring bloodletting, the patient can- 
not support the erect position : in such a case, the 
arm should be first prepared, and then the patient 
should be gently raised and supported in the upright 
position, carefully avoiding all muscular effort; the 
vein should then be promptly opened.—On the other 
hand, in the case of congestion of the brain from ex- 
haustion, there is not such early syncope from blood- 
letting as might be expected ; and yet it is obvious 
that the system cannot bear the loss of blood: I have 
known this to obtain in exhaustion from undue lac- 
tation. 
It will also be an interesting question whether this 
rule, in its repetitions, besides excluding undue 
bloodletting on one hand, and inefficient bloodletting 
on the other, does not secure the cure of the dis- 
ease, with the least possible expenditure of the vital 
fluid. 
The appearances of the blood, the effects of its 
abstraction upon the disease and many other ques- 
tions will naturally come to be included in the far- 
ther prosecution of the inquiry into the effects of 
bloodletting. 
Lastly, the effects and due application of the local 158 
ON THE CURATIVE EFFECTS 
abstraction of blood, by cupping or leeches, will 
constitute another interesting object of inquiry. This 
is frequently peculiarly appropriate when general 
depletion would be totally inadmissible. 
I cannot conclude this chapter better, than by 
adding the following extract from a paper by Mr. 
Heming, whom I have already had occasion to men- 
tion in this work, and than whom I know of no one 
who enters better into the true spirit of inquiry, 
whether it be in regard to points suggested by his 
own mind or that of others. In a letter addressed to 
the Editor of the Medical Gazette, No. 93, this gen- 
tleman observes, 
“ I was present during the course of the last win- 
ter, at the reading of Dr. Marshall Hall’s paper on 
bloodletting, before the Medico-Chirurgical Society; 
and I afterwards read the report of that paper, and 
the additional remarks of the author, in your journal, 
Nos. 34 and 57. I took a deep interest in the prin- 
ciples detailed, and determined to submit them to 
the test of experiment and observation. 
“ The result of my attention to the subject, I beg 
to lay before your numerous readers. It may induce 
them to pursue the inquiry for themselves, and to 
follow my example in submitting the facts they may 
observe to the profession. 
“ The first thing I did was to look over various 
medical writings, with the view of ascertaining OF LOSS OF BLOOD, 
159 
whether there were already any facts upon record 
bearing upon the question. I soon found, upon 
your own pages, many cases in point; and first, the 
very interesting one of Dr. Badeley, in your 13th 
number, for March, 1828, page 368 ; my attention 
was next excited by the account of a case by Mr. 
Smith, which almost immediately follows your re- 
port of Dr. Hall’s paper, in* your 54th number, page 
63; and again by the case which immediately fol- 
lows Dr. Hall's own communication, in your 57th 
number, page 158, by Mr. Darby. Dr. Badeley’s 
and Dr. Darby’s cases are given expressly to show 
how much blood may be borne to be lost under some 
circumstances, and they are both cases of pleuritis. 
In Mr. Smith’s case, the patient never “ rallied after 
the bloodletting,” and it is a case of delirium tre- 
mens. My attention is once more forcibly drawn 
to this subject by a paper in your number for August 
the 8th, page 300, by Mr. Newstead, entitled, “ Re- 
marks on a peculiar class of disease's resembling in- 
flammation.” Mr. Newstead observes, “ I was as- 
tonished at the small quantity of blood which com- 
monly flowed before syncope was produced,”* &c. 
Lastly, my attention has been drawn to this subject 
more forcibly than ever, by the perusal of Dr. 
* “I would remark, that Mr. Newstead’s observations, however in- 
teresting, are entirely anticipated by Dr. Hall, in his remarks on intesti- 
nal irritation, &c.; and rather denote the propriety of some new and 
appropriate denomination for this class of cases.”. 160 
ON THE CURATIVE EFFECTS 
Gooch’s recent work, entitled, “ An Account of 
some of the most important Diseases peculiar to 
Women.” In this work two kinds of puerperal 
disease are described : the first is inflammatory, and 
bears bloodletting; the second is different from 
inflammation; and in these bloodletting led to 
early syncope, and if injudiciously used or repeated, 
to a fatal termination. 
“ The general result of this cursory glance, chiefly 
over your own pages, is, that some diseases bear 
bloodletting remarkably well; others remarkably 
ill. But it may be said that this has been long 
known. This may be true; but has the principle 
ever been so accurately stated—has it been made of 
any practical utility—has it been made available as 
a guide for the use and measure of bloodletting, 
and as a diagnostic ? I venture to say that it has 
not; and to add, that those who will take the pains, 
which I have done, to possess themselves of the facts 
involved in this inquiry, will find themselves richly 
rewarded by the confidence with which they will 
thenceforth prescribe or adopt the measure of blood- 
letting, in cases in which they might otherwise have 
been long held in doubt and suspense. 
“ I will now proceed to the detail of my own ex- 
perience since I adopted the mode of bloodletting 
proposed by Dr. Marshall Hall. 
“ I bled a stout man, aged 35, on the eleventh day 
of fever: he was flushed, his skin hot, and his pulse OF LOSS OF BLOOD. 
161 
120; he fainted on losing 3'iv. of blood. On the 
next day I found him much better, indeed convales- 
cent.* In another case, not dissimilar, fviii. of blood 
flowed, and syncope occurred. 
“ Four cases were unattended by any inflammatory 
affection, and in each there was considerable dis- 
order of the stomach and bowels, indicated by the 
alvine evacuations being discoloured, offensive, and 
scybalous; the tongue loaded, particularly at the 
back part and middle; and the breath offensive. 
The average quantity of blood lost in all these cases 
was very small; and in one, although a strong young 
man, complete syncope was produced by the loss of 
3xv. and the fainting returned for some hours, when- 
ever the body was raised up. 
“Four cases were instances of inflammation of 
the mucous membranes, and in these it will be ob- 
served that the average quantity of blood lost was 
about fxv. 
“ With the exception of one, a case of convulsions, 
occurring in a child with hooping-cough, all the 
others were those of inflammation of serous mem- 
branes or parenchymatous substance; in these the 
quantity of blood lost was very large, generally up- 
wards of fxxx. 
“ In a case of peritonitis, in a girl only nine years 
* “Six months afterwards this same patient was bled under the influ- 
ence of lumbago; he lost § xvi. of blood without experiencing the least 
disposition to syncope,” 162 
ON THE CURATIVE EFFECTS 
of age, not remarkably strong, the quantity of blood 
lost was particularly great; she had been affected 
two months before with measles, which was succeeded 
by general anasarca; the latter complaint was re- 
moved by purgatives, and ten days afterwards she 
had an attack of peritonitis. I saw her eighteen 
hours after the commencement of pain ; she was lying 
on her back, with her knees drawn up, her breathing 
quick and painful, and her belly swollen, and so ten- 
der, that she cried out upon the slightest touch ; f xx. 
of blood flowed before there was the slightest dispo- 
sition to faintness; when syncope did come on, it did 
not occur to an excessive degree ; and upon recover- 
ing from this state, she had lost her pain and tender- 
ness, which never returned. It is remarkable that 
from the loss of so large a quantity of blood she sus- 
tained but little inconvenience, and was well in a 
short time.* 
“ One patient had suffered from tenderness about 
the region of the liver, with hardness and enlarge- 
ment at the part for some months; but at the time I 
bled her, her complaint assumed more an acute cha- 
racter than formerly, being attended with considera- 
ble pain. The pain was relieved, but there was still 
remaining some tenderness and enlargement. She 
lost Ixxxix. of blood, and fainted. 
* “ Tliere is scarcely a case on record in which so much blood was 
drawn at this early age.” OF LOSS OF BLOOD. 
163 
“ In one case, in which, from the age, habit, and 
symptoms, I supposed the patient to be threatened 
with apoplexy, the loss ofblood was considerable, for 
the age of the patient, without producing the least 
disposition to syncope. Another was a case of slight 
paralysis, occurring in a man of strong constitution 
and florid countenance ; and the loss of blood which 
he sustained before fainting was equal to that which 
was borne by some of the patients who had inflam- 
mation of a serous membrane. 
“ One case of affection of the head, arising from 
other causes than inflammation, yet attended by 
many of the symptoms of phrenitis, I witnessed 
in a near relative; syncope was induced by with- 
drawing Six. of blood. I was called to what I con- 
sidered a similar case, and sent my assistant to bleed 
her, and stated before he returned that there would 
be early syncope; he abstracted Sxl. of blood ! I 
was surprised at the result; but on inquiry and re- 
flection, it was perfectly accounted for. The patient 
had bled ill, and much time was lost in taking the 
blood; in such circumstances I would remark that 
more blood may be taken, even if the patient be 
erect, than he may be able to bear. But besides this, 
there tvas a state of chronic inflammation of the hip- 
joint, which I did not think of at the moment: this 
enabled her to bear the loss of a large quantity of 
blood. 
“ I bled a young person, aged 21, of moderate 164 
OF THE CURATIVE EFFECTS 
strength, and affected with fluor albus, two months 
ago, and again a fortnight ago, at her own request. 
She had been accustomed to this kind of discipline. 
She fainted each time on losing gxij. I saw this pa- 
tient yesterday, labouring under rubeola, with an in- 
flammatory affection of the chest. I bled her in the 
same manner to slight syncope, and she lost sxxxij ! 
To-day she is greatly relieved, and doing well. So 
obvious is the protective power of inflammation, and 
so practical and diagnostic is the mode of bloodlet- 
ting. 
“ On two different occasions I bled the same pa- 
tient, with inflammation of the mamma, and after- 
wards in cholera morbus. In the former case she 
lost §xx. of blood; in the latter she fainted just 
when giv. had flowed ! 
£i I must also add, that the proper mode of per- 
forming the operation of bloodletting is, first to pre- 
pare the arm; then gently to raise and support the 
patient; and then to make a free opening into the 
vein. If the blood flows well, I think the rule is 
safe; if it flows slowly, too much might be taken, 
and especially if it become necessary to open an- 
other vein. I have observed that if syncope be 
allowed to take place under a slow detraction of 
blood, convulsions are more apt to occur than when 
the flow of blood is prompt and rapid. 
“ The general results of these cases, and my own 
experience, coincide entirely with the statements OF LOSS OF BLOOD. 
165 
made by Dr. Hall. Some diseases enable the sys- 
tem to bear bloodletting; others render it incapable 
of bearing loss of blood. The former are, congestion 
or inflammation within the head, inflammation gene- 
rally, but chiefly of the serous membranes and paren- 
■chymatous substance, at least that of the mucous 
surfaces ; the latter are, some cases of delirium, and 
of variously seated pains and tenderness unattended 
by inflammation, but connected with intestinal dis- 
order, previous loss of blood, and what must still, I 
fear, be termed a nervous condition of the system.” 
This interesting paper is accompanied by an 
equally interesting registry of thirty-one cases, illus- 
trative of the powers or susceptibilities of the system, 
in regard to bloodletting in different diseases, and 
confirmatory of the remarks I had made on the sub- 
ject. I know not a more interesting or important 
medical record. I may possibly subjoin it, with 
some additions and alterations, at the end of this 
volume. 166 
ON THE CURATIVE EFFECTS 
CHAPTER II. 
OF SOME DISEASES IN THEIR RELATION TO LOSS OF 
. BLOOD. 
In the preceding chapter I have given a cursory 
sketch of the very varied powers and susceptibilities 
of the system in regard to the effects of loss of blood, 
in various diseases. I purpose now to enter upon 
this question more particularly. 
I. Of Fever. 
The different forms and complications of fever 
and of inflammation, doubtless constitute the most 
frequent as well as the most important cases of acute 
diseases. In their intimate nature, and in their re- 
lation to the effects of loss of blood, pure fever and 
pure inflammation are widely different. 
There have been long disputes, indeed, whether 
fever ever be perfectly pure, that is, independent of 
inflammation. In a practical point of view, I think 
it the safest plan to regard fever as occasionally truly OF LOSS OF BLOOD. 
167 
idiopathic, but as extremely liable to be conjoined 
with inflammation. 
Whoever is imbued with an accurate knowledge 
of physiology will, I think, perceive in the phenome- 
na of fever, much that is to be distinctly referred to 
the state of the nervous system : the alternate chills 
and heat, the tendency to vertigo, the muscular tre- 
mors, the affection of the various secretions, are 
plainly of this character. With this, the vascular 
system soon participates. They form a whole 
which suffers together. 
Fever seems to differ from inflammation in being 
an affection of the whole nervous and vascular sys- 
tems ; in inflammation there is an affection of thjese 
systems in one part or organ. 
There is another difference between these two 
diseases: fever appears to consist in an affection of 
the nervous system and of the heart and larger ar- 
teries, the capillary vessels being only affected as an 
extension of this morbid state. In inflammation 
there is, according to the experiments of Dr. Wilson 
Philip, and Dr. Hastings, a primary affection of the 
capillary vessels, consisting in enlargement of their 
diameter and a slower movement of more numerous 
globules of the blood. A consequence which flows 
from this view of the subject is, that to subdue mo- 
mentarily the state of fever, we have only to subdue 
the augmented action of the heart and larger arte- 
ries ; but as the capillary circulation is less imme- 168 
ON THE CURATIVE EFFECTS 
diately under the influence of the heart, the action of 
the former may be subdued, whilst a morbid state of 
the latter may be continued with comparatively little 
change. 
It is upon this principle, I believe, that a fact is to 
be explained which will be frequently adverted to in 
this work, that syncope is more readily produced by 
the abstraction of blood, in pure fever, and in other 
diseases consisting alike in the state of the heart and 
larger arteries, than in pure inflammation, consisting 
in a peculiar condition of the capillary vessels, more 
permanent and less under the influence of the general 
circulation. 
In the former case, syncope is the simple effect of 
depriving the heart and arteries of their accustomed 
stimulus, and this probably under circumstances of 
augmented susceptibility of the nervous system to 
impressions of this kind; in the latter, although 
blood may be taken, and the action of the heart and 
arteries be thus subdued, yet from a less degree of 
susceptibility of the nervous system, and from the 
unsubdued morbid action of the capillaries, acting as 
it were as a permanent stimulus to the general sys- 
tem, syncope is not so soon induced by the abstrac- 
tion of blood. But whatever the explanation of this 
fact may be, the fact itself is, I think, established 
upon the sure ground of multiplied experiment. 
There are three circumstances in fever which 
should lead to the use of the lancet. The first is, or loss or BLOOD. 
169 
excessive reaction of the vascular system ; the 
second, much excitement of the nervous system, 
especially violent delirium ; and the third, and the 
most imperative, the existence of local inflammation. 
Each of these cases will require a few observations. 
In excessive vascular reaction, bloodletting is of 
the most essential service, especially early in the 
disease. The quantity of blood which should be 
taken must depend upon many circumstances, as the 
strength of the patient, the stage of the disease, the 
character of the epidemic. But the limit, beyond 
which it would be dangerous to go is, I think, clearly 
marked out by the degree of susceptibility to the 
effects of loss of blood, denoted by the tendency to 
syncope on abstracting blood pretty freely in the 
erect posture. v But as I shall recur to this question, 
I would only repeat, in the present place, that the 
susceptibility to the effects of blood, is far greater 
than in inflammation. I have known very stout per- 
sons in the strong reaction of fever, faint on with- 
drawing four, six, eight, ten, and twelve ounces of 
blood in the erect posture. 
The same observations may be made in regard to 
great nervous excitement denoted by delirium. To 
abstract a moderate quantity of blood does great 
good. But to bleed too freely is dangerously to 
depress the powers of life. In this case, as in the 
last, the patient may safely be placed in the erect 170 
ON THE CURATIVE EFFECTS’ 
posture, and bled to incipient syncope, if it be a first 
bloodletting and early in the disease. 
But the most marked difference in regard to the 
powers of supporting the loss of blood, is superin- 
duced by the addition of a local inflammatory affec- 
tion to the original disease. The patient immediately 
becomes less prone to faint on being bled. It will be 
obvious how important it would be to establish this 
point accurately by an ample collection of facts; and 
thus to trace it in its reference to practice. If. ap- 
pears to me, from what I have hitherto ascertained, 
that there is, in every instance, a strict alliance be- 
tween the degree of tolerance of loss of blood and 
the exigencies of the cure. 
2. Of Inflammation. 
My remarks must be veTy brief upon a subject, 
generally speaking, so well understood as inflamma- 
tion. I would observe, however, that this disease is 
not necessarily ushered in by rigor, or attended by 
heat of skin ; in the severest cases rigor does, how- 
ever, occur, and then a degree of heat of surface 
usually follows; but in the other cases in which 
these phenomena are observed, the rigor generally 
depends, I think, upon a superadded cause, existing 
in the state of the bowels, and the heat upon this 
cause, or upon the use of remedies. I have also 
observed that the pulse, in pure inflammation, is OF LOSS OF BLOOD. 
171 
frequently very little accelerated at first; it is so 
however in the severest cases, and it becomes so 
during the continuance of the disease, and of course 
of the remedies. In pure inflammation, except of 
the encephalon itself, the head is frequently very 
little affected, and there is neither headache nor 
vertigo; these symptoms may, however, eventually 
occur, together with delirium, as the result of deple- 
tion and exhaustion. 
Indeed it may be observed, in general, that the 
functions of the nervous system are little affected by 
pure inflammation, in its earlier stages, and in its 
more usual forms. Inflammation which is extreme 
in violence or diffusion, does indeed terribly affect 
the nervous powers ; and in its latter stages, it may 
doubtless produce the same effects ; but in this latter 
case, the circumstance of inflammation is usually 
combined yvith those of exhaustion, the result of the 
appropriate treatment; so that it may be considered 
as no longer a pure but as a mixed case. 
But the remark of greatest moment which I would 
make in this place, is, that pure inflammation induces 
a state of the system which protects it from the in- 
fluence and effects of loss of blood. A patient under 
the influence of pure inflammation, will bear to lose 
a far greater quantity of blood without experiencing 
syncope, than the same person in health. This fact 
is of the utmost interest and importance in a prac- 
tical point of view. 172 
ON THE CURATIVE EFFECTS 
Inflammation is a sort of concentrated and perma- 
nent stimulus, exciting and maintaining the powers 
of the system. Under its influence 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 bloodlet- 
ting and other remedies employed for it, leaving the 
system under the influence, greater or less, of those 
remedies. 
But whilst it does exist, it constitutes a stimulus 
and a protective power against the influence and ef- 
fects of loss of blood. Syncope even does not remove 
it; syncope merely subdues the constitutional effect 
of the stimulus of inflammation ; and except when 
that inflammation has been of recent origin, it is 
found still to exist on the reaction ; by inducing re- 
peated or excessive syncope, however, it may come 
to be perfectly subdued, and then it is usual for this 
reaction to be excessive, the stimulus which protected 
the system from the effects of loss of blood being re- 
moved. 
It is in this manner that inflammation differs in its 
protective influence from mere fever; in the latter 
syncope subdues all the actions; in the former those 
peculiar to the inflammation still subsist, being, in 
great measure, independent of the action of the 
heart. 
This fact obtains, according to my experience, in 
a more marked manner in inflammation of the ence- OF LOSS OF BLOOD. 
173 
phalon than in that of any other cavity of the human 
body ; and in inflammation of the serous membranes, 
and of the parenchymatous substance, than in that 
of the mucous membranes. Early in February I 
was called to a gentleman, forty years of age, and 
very far from robust, suffering from deep-seated pain 
in the forehead, slight intolerance of light, a degree 
of quickness in his mode of speaking, and wakeful- 
ness; the state of the skin and the pulse being natu- 
ral. He had been bled to eighteen ounces the day 
before, without its having induced either syncope or 
relief to the pain and other symptoms. I directed him 
to be placed in the erect posture, and bled from a 
moderate sized orifice, until syncope should be in- 
duced. This prescription was repeated on the two 
succeeding days. The quantities of blood taken 
were twenty-six, twenty-four, and twenty-two 
ounces respectively, leeches having been applied, 
and the most energetic purgatives having been 
administered. This case was obviously one of 
inflammation of the encephalon, not of the most 
violent character. The quantities of blood taken, 
on each of four successive days, were such as would 
not have been borne had not the tendency to syncope 
been far less than in health, by the peculiar and spe- 
cific influence of inflammation. 
I have drawn a similar inference from having ob- 
served the degree of resistance to syncope from loss 
of blood which has obtained in other cases of inflam- 174 
ON THE CURATIVE EFFECTS 
matioii, especially pleuritis and peritonitis. In these 
diseases the system bears the loss of blood almost as 
well as in arachnitis itself. It would be in vain to 
load this work with examples. Indeed such infe- 
rences are not to be drawn from a few cases, but 
must be the collective results from many. And I 
purpose to give in this place these results of my ex- 
perience and investigation of this interesting ques- 
tion, rather than to detail the numerous facts from 
which they have flowed. 
Inflammation of the bronchia, or of the mucous 
membrane lining the bowels, has not appeared to me 
to protect the constitution in an equal degree from 
the occurrence of syncope on the detraction of blood. 
Inflammation not only renders the system less 
susceptible of immediate syncope, but also of the 
remoter effects of loss of blood. Such effects indeed 
are very apt to supervene at the moment the state of 
inflammation has subsided, and ffs protective in- 
fluence, of course, been withdrawn. 
. The following case strikingly illustrates, first, the 
protecting powers of inflammation in regard to the 
effects of loss of blood; and, in the second place, 
these very effects when this peculiar influence of 
inflammation is withdrawn. 
Mrs. , aged 30, and of moderate strength, had 
suffered from pain in the right hypochondriac region 
for a month, when on the evening of the 14th of 
May, 1828, it became extremely acute. OP LOSS OF BLOOD. 
175 
On the morning of the 15th, it continued very 
severe, interrupting the respiration, and preventing 
the patient from assuming the recumbent position ; 
the pulse was 90, full and hard ; the surface hot. 
She was placed quite erect, and bled to syncope; this 
took place when thirty-nine ounces of blood had 
flowed, the pain being relieved but not entirely re- 
moved. Calomel and purgative medicines were 
given. In the evening the pain had increased, the 
pulse remained as in the morning, the medicines 
had acted well; Mrs. , *was again placed in 
the erect position and bled to syncope, and the 
same quantity of blood flowed as before; the pain 
being quite removed. A blister was applied, and 
the medicine repeated with colchicum. 
On the 16th, the pain continued relieved ; the 
countenance was pallid ; the pulse less frequent; the 
skin cooler. 
On the 19th, there was no pain of the side, the 
countenance was pallid, but apt to flush frequently; 
the pulse was 96, and throbbing; with much throb- 
bing of the head, ringing of the ears, and complaint 
of weakness. 
On the 20th, Mrs. was found subject to 
flushing, palpitation of the heart, and frightful 
dreams; the pulse was 90, but without throbbing; 
the respiration unattended by pain ; but there was 
still some degree of tenderness on pressure in the 
right hypochondrium. 176 
ON THE CURATIVE EFFECTS 
In another case the most active bloodletting had 
been employed to subdue peritonitis. An abscess 
formed, however, and burst into the bowels. At 
this moment the most acute symptoms of reaction 
from loss of blood were set up, and the patient suf- 
fered from the most violent throbbing pain of the 
head, intolerance of sound, palpitation, &c. In a 
third case detailed to me by Dr. Abercrombie, a 
similar tumor formed on the right side of the pelvis ; 
the inflammation of this tumor greatly subsided by 
the use of the ordinary remedies; but the patient 
became affected with delirium. Such cases having 
been fatal under other treatment, Dr. Abercrombie 
prescribed a glass of wine to be given every hour. 
After the fourth glass the patient w7as found com- 
posed. The tumor eventually suppurated externally, 
and the patient did well. 
Some gentlemen have objected to the induction of 
syncope, thinking it particularly apt to be followed 
by reaction. I would observe upon this point, that I 
do not recommend that the bloodletting should ever 
be carried to actual syncope, but only to the very 
first signs of approaching syncope, which is, in fact, 
to be prevented by immediately laying the patient in 
the recumbent position. In most of those cases in 
which much reaction has followed syncope, I believe 
that there either was not inflammation, or that the 
inflammation was completely subdued by the blood- 
letting. In each of these cases it has been seen, that OF LOSS OF BLOOD. 
177 
reaction is very apt to supervene upon bloodletting, 
whether syncope be or be not induced. In no case 
have I seen this reaction do any other injury than 
that of inducing its new and peculiar train of symp- 
toms ; it has never appeared to me to aggravate the 
original disease. 
But there is another remark of the utmost moment, 
which I must make, though cursorily, in this place, 
as it will require a more particular notice hereafter. 
It is, that at the very moment the protective influence 
of inflammation is withdrawn, further bloodletting 
is in the highest degree dangerous. I have known 
several instances of the fatal issue of bloodletting 
when this measure has been instituted as a preven- 
tive against the recurrence of symptoms of inflam- 
mation which had been subdued by previous blood- 
lettings. 
If I were to venture to state the average quantities 
of blood which would flow in the different cases and 
forms of inflammation, I should mention forty ounces 
for arachnitis, from thirty to thirty-five for pleuritis 
or pneumonia, and fifteen for bronchitis. This sim- 
ple statement cannot fail to strike the medical reader. 
It is impossible to foresee at once all the advantages 
which must flow in practice, from these important 
differences in the powers or susceptibilities of the 
system in regard to bloodletting in these different 
diseases. 
I think it important to mention, in a very especial 178 
ON THE CURATIVE EFFECTS 
manner, that in some forms of acute anasarca, there is 
great tolerance of loss of blood. 
3. Of Irritation. 
1 proceed to notice a morbid affection of very 
frequent occurrence, and with which the profession 
generally appear to me still to be totally unacquaint- 
ed. This statement will not be deemed too strong, 
if I am enabled to show that there is a series of 
cases not generally distinguished from certain inflam- 
mation, and yet. very different in their nature, and 
especially in their reference to the effects of loss of 
blood. 
The cases to which I allude, resemble, in their 
symptoms, the most acute forms of arachnitis, pleu- 
ritis, and peritonitis, but especially arachnitis. Yet 
instead of possessing the power of resisting the effects 
of loss of blood belonging to inflammation, there is 
the utmost degree of susceptibility to those effects. 
In the former cases thirty, forty, and even fifty 
ounces of blood may flow before the slightest de- 
liquium is observed; in the latter there is fre- 
quently the most perfect syncope on abstracting nine 
or ten ounces of blood! 
The irritation of a calculus in ureter, or in the 
hepatic duct, is well known to occasion a remarkable 
sympathetic affection of the stomach. The introduc- 
tion of a bougie into the urethra sometimes induces OF LOSS OF BLOOD. 
179 
rigor and a complete paroxysm of fever. Uterine 
irritation is not less frequently the cause of extraor- 
dinary effects upon the system generally and upon 
various organs. 
But of all the sources of sympathetic morbid af- 
fections, irritation in the stomach and bowels ap- 
pears to be the most common, and certainly not the 
least important. Indigestible substances taken, and 
disordered faeculent matter retained, are the frequent 
sources of that combined affection of the head and 
the stomach, termed sick headache. 
If such effects of local irritation upon distant 
organs, then, be universally known and admitted, it 
cannot be considered as extraordinary that others less 
recognized should exist. But such a point is to be 
established by facts, not by argument. I proceed 
therefore to detail some cases, which will, I doubt 
not, if perused with attention and without prejudice, 
fully convince the reader of the occurrence of a form 
of a disorder hitherto overlooked, or mistaken for 
other diseases, but very distinct, and very important 
to be distinguished. 
The most frequent cause of this affection is a dis- 
ordered state of the contents of the colon ; the next is, 
some indigestible substance taken into the stomach. 
But as the mere presence of a calculus in the ureter 
is not always sufficient alone to induce an attack of 
pain and vomiting, so a deranged condition of the 
intestinal contents will not, alone, induce an attack 180 
ON THE CURATIVE EFFECTS 
of the morbid affection which I am about to de- 
scribe ; in general some superadded cause, some 
shock sustained, or some effort made by the system, 
is necessary to rouse into activity the cause of irrita- 
tion otherwise dormant. In the same manner, indi- 
gestible substances may frequently be taken, when 
the health is unimpaired, with impunity; but if the 
system be under the influence of shock, or effort, or 
of nervous or vascular excitement or exhaustion, a 
cause of disorder which might have been inert in 
other circumstances, proves of frightful activity. 
The effects of intestinal or nervous irritation, are 
chilliness, varying from coldness of the extremities 
to extreme rigor, followed by great heat of the sur- 
face, and symptoms resembling those of arachnitis or 
peritonitis, singly or successively, in their most acute 
forms, but especially arachnitis ; more rarely there is 
pain resembling that of pleuritis : more rarely still, a 
peculiar pain passing along one side of the neck to 
the shoulders; and occasionally, generally after 
bloodletting, there is palpitation of the heart. 
It must be regarded as extraordinary that such 
marked affections have not been discriminated, and 
traced to their proper source. But I am persuaded 
that they are, to this day, confounded with inflam- 
mation of the organs chiefly affected, to the great 
injury, and even danger of the patient. It is indeed 
extraordinary how slow the human mind is to receive OF LOSS OF BLOOD. 
181 
new impressions, even of the truth, wedded as it 
usually is to first opinions. 
These observations apply particularly to that form 
of this affection which resembles arachnitis. There 
are few w7ho distinguish it from arachnitis itself. I 
have, however, witnessed some very interesting 
scenes, and not less interesting convictions of the 
truth of the views which I have taken of this subject, 
in cases which have occurred in the persons or in 
the families of medical gentlemen themselves. Two 
of these cases I propose to detail briefly ;* premising, 
that the mere fact of the most acute symptoms, re- 
sembling those of arachnitis or peritonitis, having 
yielded without the abstraction of blood altogether, 
or without a shadow of that degree of bloodletting 
which is absolutely necessary for the cure of these 
inflammatory diseases, is alone sufficient to convince 
us that there is a case of morbid affection resembling 
in its symptoms, but differing in its nature and treat- 
ment, from those diseases. 
Amongst the earlier cases of the effects of irri- 
tation which excited my attention, was that of Mrs. 
, a rather delicate, married woman, aged 35. 
When I was first called to this patient she appeared 
to labour under inflammation of the periotonaeum ; 
the symptoms of which were so severe as apparently 
to demand the repeated employment of the lancet, 
• See pp. 184, 185. 182 
ON THE CURATIVE EFFECTS 
and application of leeches, so that the patient lost 
about thirty-five or forty ounces of bowels 
were freely purged, the stools were very fetid. 
All the symptoms were removed on the third day, 
I only visited my patient once, and I had every hope 
of a speedy and secure convalescence. I was, how- 
ever, disappointed. Early on the succeeding day 
I received an urgent request to see her. She had 
been seized with severe pain of the head, especially 
over the eyebrows, attended by beating and throb- 
bing, and by the most urgent intolerance of light, so 
that the eyes could not be opened for a moment for 
examination; the pain was increased on attempting 
to sit up erect; the countenance was palish and sal- 
low; the pulse full and frequent; there was no 
faintness or sighing. 
As this case occurred very early in my investiga- 
tion of the effects of irritation, I hesitated in deter- 
mining whether the symptoms were such as I had 
already witnessed in one or two cases as arising from 
that cause, or were indicative of inflammation within 
the head. I prescribed a draught with thirty drops 
of the tinctura opii and of the spiritus ammoniae aro- 
maticus, and called again in an hour and a half, not 
without anxiety. I was greatly relieved to find my 
ptftient better in every respect, able to bear the light, 
suffering much less pain, and having enjoyed a com- 
fortable sleep after a night of wakefulness and dis- 
tress. Aperient medicine was administered, and, OF LOSS OF BLOOD. 
183 
after the full evacuation of the bowels, light nourish- 
ment, and a repetition of the draught with tinctura 
opii and spiritus ammoniee aromaticus, whilst a cold 
lotion was applied to the head. 
On the succeeding day Mrs. , was better in 
every respect, but complained of any noise. On the 
next day she was comparatively well, only suffering 
from vertigo on raising the head. 
From this time the recovery was progressive and 
uninterrupted, the utmost care being taken to regu- 
late the bowels and the diet. 
Mr. , aged 19, complained on Sunday even- 
ing, September t e 29th, of pain shooting through 
the region of the stomach to the back, recurring at 
intervals ; he took some ginger tea, was relieved, 
went to bed, rose in the morning, looking pale, but 
expressing himself better, went into the counting- 
house, and ate his dinner of cold roast beef as usual. 
About five o’clock in the afternoon of the 30th, he 
became affected with coldness of the hands and feet, 
slight flushing of the face, violent aud constant pain 
of the crown, or, as he said, of the bones of the head, 
numbness of the right hand and contraction of the 
right side of the lip, and slight incoherence of man- 
ner ; he answered hastily and sharply to any ques- 
tions, and experienced restlessness, and extreme 
intolerance of light or noise, and desired that the 
shutters might be accurately closed, and that the 
door should not be moved. About two hours after 184 
ON THE CURATIVE EFFECTS 
this attack, sickness came on, a great load was 
vomited, and he became more collected, but still 
complained of pain of the bones of his head, and of 
the slightest light or noise. In another hour he fell 
into an uneasy slumber, breathed hard through the 
nostrils, awoke in half an hour a little easier, his 
hands and feet becoming warmer. 
He took a cup of bohea tea, and a dose of calomel 
and jalap at ten o’clock P. M.; he lay more com- 
posed, then dozed at intervals, but always complained 
on awaking of pain of the head ; at two o’clock he 
slept more quietly; his medicine acted three times ; 
he rose in the morning much refreshed but looking 
dull and sallow. He continued to recover during the 
day, rode out, ate his dinner, but still looked ill. 
The next patient, an intelligent surgeon, tall and 
robust, had undergone a painful operation on the 
anus, and had suffered much for six days on passing 
the faeces and on dressing the wound ; he had kept 
himself low, and had passed restless nights as well 
as painful days. On the morning of the sixth day, 
after some exertion, the feet and legs became ex- 
tremely cold; the surface afterwards became gene- 
rally heated and the mouth clammy; the face was 
flushed, the skin sore, and the eye-balls particularly 
tender: the pulse rose to 96. In the afternoon the 
chillness returned, and was followed by heat, throb- 
bing in the temples, and pain in the head, with fly- 
ing stitches in the side ; the pulse was 112. Sixteen OF LOSS OF BLOOD. 
185 
ounces of blood were taken from the arm ; faintness 
and perspiration were induced, the throbbing ceased, 
but the pain continued, and the pulse was 116; the 
patient felt overcome, became restless, and affected 
with vertigo on moving, and frequent sighing. 
At night the head became distractingly painful; 
the faintness exceedingly distressing; I found my 
patient with wet cloths applied over the forehead and 
eyes. The question of further bloodletting or of the 
application of leeches was proposed to me. I was 
persuaded, however, that the affection of the head 
depended upon intestinal and nervous irritation. I 
therefore prescribed a large enema of gruel and oil; 
with sal volatile, and nourishment. 
The enema induced vomiting and a copious alvine 
evacuation. On the following day all symptoms of 
affection of the head had subsided. 
In this case the natural strength of the patient, the 
violence, and even urgency, of the symptoms, the 
recovery without further bloodletting, and the ex- 
treme susceptibility to the effects of loss of blood are 
all remarkably displayed, and form a striking con- 
trast with the characters of true arachnitis. 
The following case is not a v less interesting illus- 
tration of this morbid affection. 
Mrs. , aged 24, and of moderate strength, had 
suffered from an attack similar to the one about to 
be described, some months previously. She remain- 
ed well until excited to undue exertion by company 186 
ON THE CURATIVE EFFECTS 
and visiting. She then began to complain of pain of 
the head, of a sense of fatigue, and of being unre- 
freshed by her sleep. 
Two days afterwards the hands and feet became 
very cold alternately with great heat of the skin ; and 
the pain of the head had augmented. 
In two days more the symptoms had still further 
increased : the coldness of the extremities was at- 
tended by great pain, and succeeded by extreme 
dryness and intense heat; there was severe pain of 
the head and along the right side of the neck; the 
tongue was loaded, and oedematous; the stomach 
affected with nausea; the bowels disordered, and the 
faeces scybalous. 
During two other days these symptoms only aug- 
mented, the patient still attempting to remain up; 
the pain of the head increased and became attended 
with great intolerance of light, and throbbing, una- 
bated by aperient medicines, and by further rest. It 
was thought right to take a little blood. Mrs. 
was therefore put in the erect posture and the stream 
allowed to flow until faintishness took place; com- 
plete syncope was produced by abstracting ten ounces 
of blood. The distressing symptoms still however 
continued the next day, when medicines were ad- 
ministered which induced vomiting and free evacua- 
tions of scybalous and disordered faeces. 
From this time the recovery was gradual, but de- 
layed by a disposition to diarrhoea, and by a state of OF LOSS OF BLOOD. 
187 
prostration, paleness and thinness, highly peculiar 
and characteristic. 
In both these cases the symptoms of affection of 
the head persisted after the bloodletting, and were 
relieved by sickness and a free evacuation of the 
bowels. In both, the prostration from the bloodlet- 
ting was extraordinary. 
The next case is that of Mrs. , a young mar- 
ried lady, in the fourth month of pregnancy, habi- 
tually costive. The present attack came on after 
much fatigue in travelling; and she is stated to have 
experienced a similar one formerly. 
On the 7th of October, she complained of pain of 
the head, and leeches were applied to the temples. 
On the 8th the pain of the head was more violent 
and attended with much throbbing of the temples ; 
and to these symptoms pain of the right side under 
the breast, a sense of tightness across the chest, and 
hurry in breathing, were superadded. Twelve 
ounces of blood were drawn, and an efficient ape- 
rient medicine was given, and on the 9th and 10th 
she was much better ; and a saline medicine was 
prescribed. • 
On the 11th she was again taken worse, after im- 
prudently sitting up ; the beating of the temples, 
tightness across the chest, and difficulty in breathing 
returned, unattended by cough. Sixteen ounces of 
blood were taken from the arm, with great relief, and 
the aperient medicine was repeated. 188 
ON THE CURATIVE EFFECTS 
The patient was relieved, and continued better on 
the 12th. In the night of the 13th the medical at- 
tendant received an urgent message to visit his pa- 
tient, and found her affected with severe pain and 
beating of the head, great tightness and pain across 
the chest, and with violent palpitation of the heart. 
Twelve ounces of blood were taken, and calomel and 
other aperient medicines given, with considerable 
relief. 
On the 14th a physician was consulted, who pre- 
scribed the pil. hydrarg. with an aperient draught. 
In the night the apothecary was again sent for, all 
the symptoms having returned, and now, for the first 
time, with the addition of a slight cough. Eight 
ounces of blood being drawn, great relief was ob- 
tained. 
In the night of the 16th the medical attendant was 
again sent for; all the symptoms had returned in a 
still more aggravated form, the pain of the head, light- 
ness across the chest, palpitation, and cough being 
extremely severe. Eight ounces of blood were 
drawn without relief; the head was shaved, a cold 
lotion applied, and a blister ordered for the back of 
the neck. 
On the 17th I saw the patient for the first time: 
there were much pain and throbbing of the head, 
which felt benumbed and heavy as if she could not 
raise it from the pillow; there had been no sleep; 
the pupils were extremely small, with intolerance of OF LOSS OF BLOOD. 
189 
noise and disturbance of any kind ; there were palpi- 
tation of the heart and sometimes faintness and a 
feeling of sinking or dying; there were a sense of 
tightness across the chegt, oppression in the breath- 
ing, and a peculiar tracheal or laryngal cough ; some 
pain in the region of the uterus increased by pressure, 
but no vaginal discharge;—the countenance was 
usually pale, but sometimes flushed, the tongue ex- 
tremely loaded, and even black at the back part; the 
alvine evacuations, on giving purgative medicine, 
were still, at first, dark-coloured, offensive, and 
scybalous,and afterwards, offensive, and like yeast; 
the pulse was 120. 
I was forcibly struck by a general but marked re- 
semblance of this case, to those already given, and 
to others of the same nature which I had witnessed; 
the depleting plan already fully adopted and repeat- 
ed, had proved ineffectual in affording lasting relief; 
the purgatives hitherto given, were, I beloved, ineffi- 
cient. The plan I proposed was, to give efficient 
purgatives, to restrain their operation by draughts 
with tinctura opii and spiritus ammonise aromaticus, 
to support the strength by means of nourishment 
given every hour or oftener, to procure sleep by 
anodyne enemata, to guard against exertion or 
fatigue, noise or disturbance. The recovery was 
uniformly progressive; there was not even one 
recurrence of the painful attacks; the symptoms 
gradually disappeared, the pulse becoming natural, 190 
ON THE CURATIVE EFFECTS 
the pupils of the natural size, the head and chest re- 
lieved, and the bowels daily but fully moved ; quiet 
sleep, and a good appetite returned. 
In six days the patient was convalescent; shortly 
afterwards she bore a long journey home without any 
ill consequences, and at the proper time, had a safe 
delivery. 
Those forms of this morbid affection which resem- 
ble peritonitis and pleuritis are equally characterized 
and distinguished by alternate chill or rigor and heat, 
frequency of the pulse, and susceptibility to the effects 
of loss of blood. They do not occur so frequently 
or distinctly as the affection of the head. Such 
cases are, however, occasionally met with. M. 
Andral has noticed them in his “ Clinique Medi- 
cale,” Tom. i. pp. 51—54. 
The following case of supposed metastatic inflam- 
mation, taken from the Edinburgh Medical Journal, 
in fact the results from a varied character 
of this affection. 
Mrs. F. a young married lady, had felt unwell for 
some days in consequence of slight cold. Her medi- 
cal attendant, Mr. F. had bled her copiously the pre: 
ceding evening, apprehending symptoms of enteritis. 
She was of a spare and slender make, the mother of 
two children, generally healthy, but subject to severe 
and frequent constipation of the bowels, which seem- 
ed to form the ground-work of her present com- 
plaint. OF LOSS OF BLOOD. 
191 
“ On my visit/’ the writer observes, “ I found 
enteritis established in its most acute form, nor had 
the previous bleeding produced any mitigation of her 
sufferings. A vein was immediately opened, and 
she was bled ad deliquium ; the warm bath, calomel 
and nitre of each three grains every four hours, and 
a solution of manna in strong senna tea, (the only 
laxative that could remain on her stomach), were 
ordered. Next day the symptoms had remitted, but 
it was necessary to repeat the bleeding, and to apply 
many leeches to the abdomen. The bowels were 
now freely purged, the evacuations black and offen- 
sive to a degree 1 have seldom witnessed. On the 
third day the mouth was sore, the abdomen free from 
pain, all the symptoms favourable, except a quick- 
ness of the pulse, which, I thought, was attributable 
to the action of the mercury : I therefore consigned 
my charge to my medical friend ; but I was sur- 
prised, on the day but one succeeding, at being re- 
quested to see Mrs. F. again, and still more so, to 
find very marked symptoms of inflammation of the 
brain. These had come on in the course of the pre- 
vious afternoon, without any intelligible reason, (ex- 
cept that the bowels had become constipated.) I 
was certain, from the prudence of Mr. F., that no 
stimulant, either in food or drink had been given. 
The intolfcrantia soni et lucis was so great that she 
could not bear the slightest motion about her, not 
hardly permit me light enough to conduct my ex- 192 
ON THE CURATIVE EFFECTS 
animation. She complained of intolerable weight 
and oppression of the head, vivid flashes of light 
constantly before the eyes, urgent thirst, the tongue 
was coated, the pulse full and labouring, the skin 
hot, &c.; no delirium ; no pain upon pressure of any 
part of the abdomen ; the mouth still sore. Copious 
depletion was again had recourse to, a blister to the 
nape of the neck, the head wrapped in towels kept 
constantly wet with vinegar and water, large doses 
of ext. coloc. comp, with calomel twice a-day, as- 
sisted by the former mixture of senna and manna, 
and a mixture of antim. tart, et potass, nit. every 
four hours. The pressure of other engagements pre- 
vented my seeing her oftener than every other day, a 
circumstance I the less regretted, from the constant 
attendance of her brother-in-law. At every visit but 
my last, I was obliged to bleed ad deliquium, or until 
sensible relief was obtained, besides applying nume- 
rous leeches every day. She was never delirious, 
always protruding her arm for the lancet and ex- 
pressed the relief she felt while the blood was flow- 
ing: it never had a true bufly coat, but the crassa- 
mentum was remarkably firm and fibrous. After 
the second bleeding, the pain was confined to the 
right hemisphere, on which side a blister was applied 
and kept open till it formed a running sore. At my 
fourth visit the pain in the head was sensibly abated, 
but symptoms of abdominal inflammation had super- 
vened. This the bleeding of that day conquered. OF LOSS OF BLOOD. 
193 
The bowels, notwithstanding the large doses of pur- 
gatives, were with difficulty kept soluble, the disor- 
der sensibly yielding as the evacuations became more 
natural. The soreness of the mouth, which never 
amounted to ptyalism, subsided during the attack, 
and never again recurred. At my sixth visit, I 
took leave of my patient with sanguine hope of her 
permanent recovery ; yet within a week I was again 
called to her, in consequence of a severe attack of 
pleuritis. I understood that the pain in the head had 
returned a few days after I saw her, and that her 
brother had found it necessary to continue, in a 
modified degree, my plan of treatment. As she 
slowly recovered, difficulty of breathing, and pain in 
the side came on, and at length a very marked case 
of pleurisy wras established. Almost in despair, I 
again began the evacuating system, and at length had 
the pleasure of subduing this last attack, but not 
without repeated bleeding, leeching, and blistering. 
My patient was by this time terribly wore down, and 
in my opinion inflammation had nothing to fasten 
upon. However, a few weeks in the country soon 
restored her to her usual appearance.” 
I consider it quite certain that this case was not 
one of inflammation, but of intestinal irritation, and 
of its effects on several organs in succession. If so, 
I need not insist on the necessity of forming an ac- 
curate diagnosis of these two diseases in order to the 
adoption of an appropriate mode of treatment. The 194 
ON THE CURATIVE EFFECTS 
case itself, which I reprint, notwithstanding the dif- 
ferent view I take of it, with the approbation of its 
candid and liberal author, is indeed “ peculiarly in- 
teresting and affords ample scope for meditation.’7 
All of us, I think, have drawn similar conclusions 
from similar premises, and if those conclusions be in 
fact erroneous, it is of the utmost consequence that 
they should be corrected. 
Having thus given several cases of this morbid af- 
fection, I proceed to the further detail of its symp- 
toms. 
It generally begins in the manner of a sudden at- 
tack. This attack is usually ushered in by rigor, 
indeed by a more distinct and decided rigor than is 
observed in many cases of inflammation; the rigor 
is usually soon followed by much heat of surface; 
with the heat the patient experiences some affection 
of head, chest, or abdomen, and, indeed, frequently 
of all; there are vertigo on raising the head, pain, 
and some morbid impression on the mind, panting in 
the breathing, fluttering about the heart, with gene- 
ral hurry, irritability, and restlessness; the tongue is 
white and loaded ; the alvine evacuations are mor- 
bid,— dark-coloured, foetid, and scybalous,—or yel- 
low like the yelk of egg,—or of the appearance of 
yeast; the urine is turbid and frequently deposits a 
copious sediment. 
The affection of the head consists of the most acute 
pain, the greatest intolerance of light and sound, and OF LOSS OF BLOOD. 
195 
the severest form of vertigo, wakefulness, and dis- 
tress, and sometimes even delirium, and the pupils of 
the eyes are often extremely contracted. 
The affection of the chest is denoted by severe 
and acute local pain, which is apt to vary its situa- 
tion, passing from one side to the other, or to the 
back, or occupying a situation higher up or lower 
down ; this pain checks a deep inspiration, and even 
the ordinary breathing, to which it imparts a charac- 
ter of difficulty and anxiety. 
When the abdomen is affected, there is acute pain, 
and great tenderness under pressure, in some part, or 
more or less generally diffused. The attack and 
situation of the pain is such, in some instances, that 
the case is with difficulty distinguished from gall- 
stones, though it more generally resembles perito- 
nitis. 
When the heart is the seat of this affection, there 
are violent and terrific attacks of palpitation, and the 
course of the carotids and even of the abdominal 
aorta, is sometimes the seat of violent pulsation or 
throbbing. 
All these affections are apt to occur in sudden at- 
tacks, and to recur in paroxysms,—perhaps varying 
their form,—and exciting great alarm in the patient 
and his friends, who usually despatch a hurrying 
message to the medical attendants. 
The preceding cases are sufficient to establish the 
fact that there are attacks which resemble inflamma- 196 
ON THE CURATIVE EFFECTS 
tion of the head, chest, or abdomen, and yet are 
totally different in their nature. This fact is, of it- 
self, highly important. And if I should fail in giving 
sufficient diagnostic marks of these morbid affections, 
it will still be of the utmost moment to know, that 
the distinction is absolutely essential to the adoption 
of an appropriate mode of treatment; and that whilst 
we appeal to future experience to render the diagnosis 
more complete, the peculiarities of each individual 
case must be carefully seized in order to supply the 
deficiency of general rules. 
I would first observe that the attack of irritation, 
b in general, more sudden than that of inflammation, 
which is usually formed somewhat more gradually. 
This circumstance must therefore be cautiously in- 
quired into, and may assist the diagnosis. 
I believe, too, that the seizure in the former case 
is attended by more distinct rigor, and afterwards by 
greater hear, than in the latter. 
The case of irritation affects, in a marked degree, 
more organs at once, than that of inflammation, 
which is usually confined, at first at least, to one. 
The state of the tongue and the condition of the 
alvine evacuations are far more marked by disorder, 
and the latter are far more offensive, in attacks from 
irritation than in cases of inflammation. 
The affection of the head from irritation comes on 
suddenly, is formed all at once, and is frequently at- 
tended by great restlessness, suffering, and distress, OF LOSS OF BLOOD. 
197 
and there is early syncope on taking blood. In 
arachnitis, the disease is usually formed somewhat 
more gradually ; the patient has been subject to pain 
of the head perhaps for some days or even longer; 
he complains less; or at least there is less urgent 
distress,—less distress of a general kind ; the pain 
may be very severe, although it is more frequently 
rather obscure; the intolerance of light and sound is 
less urgent; the rigor, and subsequent heat, and the 
attack in general is less marked; the patient is not 
so soon relieved by remedies, and the tongue and 
alvine evacuations are less morbid, and there is, espe- 
cially, great tolerance of loss of blood. In the attack 
of affection of the head from irritation, the patient is 
relieved perhaps completely if the lancet be employ- 
ed, but the attack soon recurs with equal or greater 
violence ; in arachnitis, the relief is seldom so com- 
plete, the interval of ease so long, or the return so 
marked ; the pain is diminished, perhaps, but gradu- 
ally resumes its former violence, unless active mea- 
sures be interposed. 
When the chest is affected from irritation, the pain 
is severe and acute, and perhaps increased by a full 
inspiration ; if the inspiration be repeated, however, 
a second and a third time, the increase of the pain is 
less and less ; the situation of the pain varies ; there 
is no cough, no crepitus on making a full expiration. 
In all these respects the case differs from inflamma- 
tion. The remarks already made respecting the re- 198 
ON THE CURATIVE EFFECTS 
lief from remedies, the effect of bloodletting, the 
tendency to a sudden recurrence of the pain, &c. in 
cases of affection of the head, apply equally here. 
I had long remarked that there might be both acute 
pain and tenderness under pressure, of the abdomen, 
without inflammation; this state of things is fre- 
quently the result of intestinal irritation. It is dis- 
tinguished from inflammation by the general symp- 
toms of this affection, the mode of attack, the effects 
of remedies. In inflammation, the surface is usually 
cool, the head unaffected, the patient remarkably 
quiet; in the case of irritation, on the contrary, there 
is generally much heat after rigor, the head is much 
affected, and the patient is restless and generally dis- 
tressed, the tongue loaded and perhaps swollen, the 
alvine evacuations extremely morbid, and great 
relief is obtained by the free operation of medicine. 
I now proceed to notice some points in the history 
of this morbid affection. In doing this it will be 
impossible to avoid some slight repetitions of what 
has been already stated. But 1 think it will be of 
sufficient importance to give a connected view of the 
course of the affection, to render such repetition par- 
donable. 
The attack generally takes place rather suddenly. 
It usually begins with severe rigor, which is succeed- 
ed by great heat of skin, and eventually by perspi- 
ration. With the rigor of heat, there is usually the 
accession of some severe local affection. 199 
The changes in the course of the disease are, like 
the first attack, generally sudden. The patient is 
better and worse, and the most urgent messages are 
sent, at different times, to the medical attendant. 
Generally the patient will be found to have been 
previously subject to disorders of the bowels ; after- 
wards he is apt to experience similar attacks unless 
he be attentive to diet and regimen and to the state 
of the alvine evacuation. 
Besides the circumstances already pointed out, 
there are some points of a very interesting nature 
which deserve to be particularly noticed in this 
place :— 
1st. It must have fallen to the lot of many phy- 
sicians to witness very severe morbid affections, im- 
mediately consequent upon causes which appeared 
totally inadequate to the production of such effects. 
A slight blow, or a trifling fall has appeared to in- 
duce serious and alarming indisposition. The truth 
is, that there was already a disordered and loaded 
state of the bowels,—dormant until roused into effect 
by the accident. A lady about fifty years of age, fell 
a few steps down stairs ; she got up however and 
walked to the sofa ; in a short time she was taken 
with chilliness, succeeded by heat of skin and the 
most intolerable pain of the head and sensibility to 
light, noise, &c. She soon recovered on taking 
active purges alternated with the ammoniacal ano- 
dyne draught. 
OF LOSS OF BLOOD. 200 
ON THE CURATIVE EFFECTS 
2ndly. Every physician must also have observed 
cases of apparent inflammation, which did not pursue 
the usual course of inflammation, probably yielding 
sooner than is generally observed, or receding alto- 
gether, and recurring in paroxysms, This course of 
the disorder is noticed in several of the cases given 
in this section. 
Srdly. The case is often relieved, perhaps, but 
obstinately refuses to yield to the lancet, recurring 
with great if not increased violence, in a manner not 
observed in cases of inflammation. 
4thly. In other instances the-local affection 
ceases,—perhaps for a day or two even,—and then 
recurs, only attacking some distant part. In these 
cases it has often been thought that there had been a 
metastasis of the former local affection, whilst, in 
fact, the cause of both remaining unremoved, has 
exerted its influence through a different channel of 
sympathy and upon another organ. 
5thly. In the same manner we sometimes ob- 
serve cases apparently involving inflammation of 
more vital organs than one, at the same time. Such 
cases may certainly occur. But it is my present ob- 
ject to show that appearances may be deceptive, and 
that the case may be different from inflammation, 
and dependent on a disorder remote from the parts 
affected. 
6thly. In the last place, there have been many 
cases in which the expected traces of morbid anatomy, OF LOSS OF BLOOD. 
201 
—the effects of inflammation within the head, chest, 
or abdomen,—have been absent altogether. This 
observation has been fully illustrated, in regard to 
the brain, in the recent works of MM. Parent Du- 
chatelet and Martinet,* and of M. Hebreart;f all these 
authors have noticed cases in which the symptoms of 
arachnitis existed, and yet not a trace of the effects 
of inflammation on dissection. The view which has 
been given of the effects of intestinal irritation may 
assist us in explaining an event which must have 
been witnessed by all who have in any degree pur- 
sued the study of morbid anatomy.J 
A most : interesting and useful paper might be 
compiled upon this very subject. 
The mode of treatment comprises the full evacua- 
tion of the stomach and of the bowels, soothing by 
anodynes, light nourishment, and certain local re- 
medies. 
Before I make a few observations on each of 
these measures, I wish, however, shortly to discuss 
the question,—ought we ever to have recourse to the 
lancet? If our diagnosis was early and certain, 
perhaps the lancet would never be required. But 
there are two reasons why it appears to me that, 
* De 1’Arachnitis, pp. 24, 25. 
f Aniiufiire Med. Chir. See Dr. Johnson’s Review, No. X. pp. 435, 
438 ; see also No. VIII. p. 731. 
\ See further the Transactions of the College of Physicians, Vol. V . 
pp. 199, 255 ; Laennec, Abercrombie ; and the Clinique Medicale of M 
Andral, Ed, I, Tom. IV, pp, 433, 442, 448, 457—459. 202 
ON THE CURATIVE EFFECTS 
whilst we must use this remedy with every pre- 
caution, it should not be entirely discarded, even in 
cases of intestinal irritation. First, that which was 
originally irritation merely, may doubtless lead to a 
state of inflammation ; the presence of much dis- 
ordered faeces in the bowels, may not only irritate, 
and induce pain of that, and of some remoter part, 
but may eventually induce inflammation, if long con- 
tinued. Secondly, in the case of intestinal irritation 
the diagnosis may not, until the symptoms of the 
affection be still further studied, be such as to remove 
all doubt as to the nature of the case. It will then 
be prudent to bleed for the sake of safety, whilst we 
enforce the other and more specific modes of treat- 
ment. 
Of the mode of using the lancet I propose to treat 
in the succeeding chapter. 
I would particularly remark that the free evacua- 
tion of the stomach by vomiting has, in very many 
instances, afforded the most prompt relief. This 
important fact naturally suggests the propriety of ad- 
ministering an emetic. 
The bowels must also be fully evacuated. 
This alone, however, will not remove the symp- 
toms of this distressing disorder, which appear to 
partly continue after the original cause is removed, 
from the irritation occasioned by the medicine, and 
from the state of purging themselves, and partly from 
the degree of lowness and exhaustion induced. To OF LOSS OF BLOOD. 
203 
remove these effects, the draught of tinctura opii and 
spiritus ammonias aromaticus, on one hand, and light 
and fluid nourishment, on the other, seem to be ab- 
solutely necessary. This remark is highly important, 
for I have frequently known the practitioner disap- 
pointed who depended upon any one of the remedies 
mentioned. It is by the judicious combination of all, 
that we must hope to subdue the present symptoms, 
and, what is of equal moment, to prevent their re- 
currence. 
The local applications are chiefly a cold lotion ap- 
plied to the head, a liniment applied to the chest, and 
a fomentation and liniment applied to the abdomen, 
when the pain occupies one or other of these parts. 
As it is my principal wish to be as brief as possible, 
I have not deemed it necessary to enter more into 
detail respecting the various remedies to be employ- 
ed. It is the objects which are to be attained which 
should be kept steadily in view. The same motive 
has especially induced me to give only such a number 
of cases as might be just sufficient to establish the 
facts and lead to reflection, whilst I reserve it for 
future opportunities to pursue the investigation. I 
shall have attained my object if I shall have impress- 
ed the profession with the truth that arachnitis, and 
other inflammations of important viscera, are some- 
times stimulated by intestinal irritation, and that an 
accurate diagnosis of these affections is still required 204 
OX THE CURATIVE EFFECTS 
in order that we may avoid dangerous measures, and 
adopt such as can alone cure the disease. 
4. Of Accidents and Operations. 
Another subject on which I would treat slightly 
in this place, is one of medical surgery, and relates 
to the treatment proper to be pursued after serious 
accidents and operations. 
'These cases must be considered at two distinct 
periods;—the first is that before, the second, that 
after, the accession of inflammation. 
The condition of a patient immediately after an 
accident or operation, may be compared to that which 
succeeds to a shock of any kind. During what I 
have denominated the first stage after an accident or 
operation, the state of the patient greatly resembles 
that of irritation. The patient becomes affected with 
febrile and nervous symptoms, and there is great in- 
tolerance of loss of blood. In some cases there are 
even all the symptoms of irritation with that affection 
of the head which resembles arachnitis. Such a case 
is the following one which I extract from a recent 
very interesting essay on Green Tea, by Mr. Newn- 
ham. 
“ I was requested to visit Mrs. Whicher, of Peters- 
field, about the middle of October, 1819. She had 
been thrown from a gig, on the 15th of that month, 
and had suffered concussion . of the brain, among OX LOSS OF BLOOD. 
205 
other serious, but less important injuries. She had 
remained in a state of insensibility for thirty-six 
fours, after which, delirium alternated with tran- 
sient and fitful gleams of approaching reason. I found 
her on the 18th, delirious, her pulse hard and con- 
tracted, with an occasional feeble stroke almost 
amounting to intermission, her tongue furred and dry, 
her skin hot, and her bowels rather costive ; she was 
suffering from great pain in the head, exquisite in- 
tolerance of light, contracted pupil, injected conjunc- 
tiva, swollen palpebrse, and disposition to be drowsy ; 
nausea and vomiting were also present, though less 
severely so, than for the first tw7o days after her ac- 
cident. She was largely bled, very freely purged, 
and, in the evening, a number of leeches were ap- 
plied. 
“ On the 19th, the appearance of the blood drawn 
on the preceding day, was huffy, and much cupped, 
with a proportionally large, and very firm crassa- 
mentum. Her pulse was hard, though more expand- 
ed than at my former visit; the pain of the head 
was still exquisite; there was the same intolerance 
of light, heat, of skin, thirst, &c.—-My patient was 
again bled largely ; faintness succeeded the operation, 
both on this, and on the former occasion. The blood 
drawn exhibited the same appearances, and she was 
continued upon a system of purgatives, and of the 
most rigid abstinence. 
“ On the 20th, Mrs. Whichei’s delirium had in- 206 
ON THE CURATIVE EFFECTS 
creased ; the pain in her head was still intense, hut 
her pulse was softer, and her skin rnoister; she had 
experienced less thirst, but, at intervals, since yester- 
day, had suffered a great deal from faintness. She 
was altogether in a very precarious state. She was 
now directed to take some strong green tea, with 
the view of arresting the inordinate action of the 
cerebral vessels, which still continued. 
“At my visit on the 21st, I found my patient 
better; her headache was less severe, and she had 
much less intolerance of light; she conversed with 
me more rationally than before; her pulse was 
broader, fuller, and firmer, her tongue cleaner, the 
pupil more dilated, the conjunctiva clearer, and alto- 
gether she was much improved. 1 shall not continue 
to transcribe farther my notes of this case:—suffice 
it only to say that my patient continued improving, 
and in a short time I had the satisfaction of seeing 
this most valuable lady restored to her family and 
friends. I ought not, however, to omit slating, that, 
during all this time, the process of gestation was 
going on.” 
I am persuaded that there never was inflammation 
in this case. The symptoms on the 20th were of 
the same nature as on the 18th and 19th, and yet 
they were subdued by the green tea without further 
depletion. This could not have been the case, had 
there really been arachnitis. The fact of syncope 
having occurred from each of the bloodlettings, al- OF LOSS OF BLOOD. 
207 
though the quantity of blood drawn, and the posture 
of the patient, are not mentioned, is worthy of re- 
mark ; as is also that of the conjunction of a con- 
tinued state of deliquium with the symptoms of 
arachnitis. 
Having laid this case with my opinion of it before 
an eminent surgeon in London, I was favoured with 
the following reply : “ 1 agree with you entirely in 
the opinion that Mrs. Whicher’s symptoms were en- 
tirely nervous, depending more on the state of the 
system before the accident, than on the accident it- 
self.” In fact this case is an interesting exempli- 
fication of the remark made, p. 199, that the cause of 
irritation is frequently dormant and inoperative, until 
it be excited into action by the occurrence of some 
shock to the system at large. 
Another form of morbid affection arising from ac- 
cidents or operations, is that of delirium. This state 
has been described by M. Dupuytren under the de- 
nomination of delirium traumaticum, and bears no 
slight analogy in its causes, symptoms, and means 
of cure, to some cases of puerperal delirium. 
Still more frequently, however, there are local 
pains with fever; and the question is whether the 
case be of the nature of irritation, or of inflammation. 
In the former case, bloodletting is neither required 
nor borne.; opiates, with a strict attention to the state 
of the bowels and the diet, are the most important 
remedies; in the latter, on the contrary, bloodletting 208 
ON THE CURATIVE EFFECTS 
in its appropriate modes of application, is our princi- 
pal means of cure. 
This distinction will, I am persuaded, lead to a 
most material improvement, in the medical treatment 
of many cases of surgery. That bloodletting is not 
the appropriate or the tolerated remedy in the early 
stage after accidents or operations, is proved by a 
multitude of facts,—and by none in a more interest- 
ing manner than by the case given, p. 26, and the 
case so fully detailed, pp. 45—48. Similar facts 
would be found in regard to the state of patients 
after lithotomy and the other great operations of sur- 
gery, if the records of the art were carefully searched. 
The facts to be borne in mind, are, that the imme- 
diate effect of an accident or operation is one of 
nervous exhaustion ; that a secondary effect is a state 
of irritation ; and that a third may be one of inflam- 
mation ;—that there is intolerance of bloodletting 
during the state of irritation ; and that bloodletting 
is not a preventive, although it be the cure of in- 
flammation. 
But it may be difficult to determine the limit be- 
tween irritation and inflammation, and to ascertain, 
in individual cases, whether there be the first, or the 
second, of these affections. In such circumstances 
of doubt the rule for bloodletting which I have pro- 
posed becomes of great utility. The patient may be 
placed upright and bo bled to incipient syncope. In 
mere irritation there is early syncope, and little blood OF LOSS OF BLOOD. 
209 
is lost, as little is required or would be borne to be 
lost; in inflammation, on the contrary, and precisely 
according to its degree, duration, severity, and ex- 
tent, much blood flows before deliquium is expe- 
rienced, and this is exactly what is required to sub- 
due the disease, and is well supported by the actual 
condition of the system. 210 
ON the curative effects 
CHAPTER III. 
ON THE DUE INSTITUTION OF BLOODLETTING. 
It would be difficult to determine whether greater 
injury has risen in the practice of physic, from un- 
due, or from inefficient bloodletting. To neglect the 
full use of this most important of our remedies, when 
it is required, or' to institute it when it is not so, is 
equally to endanger the safety of the patient. 
Much is said, in the present day, about bleeding 
boldly. This is frequently only another expression 
for bleeding rashly. Now, our modes of treatment 
should not be characterized by rashness, but by dis- 
crimination and by efficiency. Let us study the 
characters of diseases; and let us study the effects 
of loss of blood ; we shall then be prepared to pre- 
scribe bloodletting, at once with energy and with 
safety, and with proportionate success. 
It sometimes requires no little boldness to abstain 
from the use of the lancet. 
Bloodletting is not only the most powerful and im- 
portant, but the most generally used, of all our reme- 
dies. Scarcely a case of acute, or indeed of chronic 
disease, occurs, in which it does not become necessary 
to consider the propriety of having recourse to the OF LOSS OF BLOOD. 
211 
lancet, or to estimate the effects of bloodletting al- 
ready instituted. 
The question of the due institution of bloodletting, 
not only involves more serious consequences, but 
also more principles of the practice of physic, than 
any other. Every circumstance in the condition of 
the patient, in the nature of the disease, and in the 
effects of remedies, requires to be weighed with the 
utmost accuracy : for the neglect or misapplication 
of this remedy, or its inefficient or undue institution, 
or repetition, may allow the disease to acquire an 
overwhelming power, or plunge the patient into a 
hopeless state of exhaustion. 
But the extreme complexity of this last question 
can only be properly estimated by reflecting upon 
the varied, nay, the innumerable, modes in which 
the three circumstances of the condition of the pa- 
tient, the nature and character of the disease, and 
the effects of remedies, may be combined. 
The circumstances of the constitution of the pa- 
tient, and the effects of remedies being the same, 
each disease possesses, as I have already stated, its 
own peculiar power, or susceptibility, in regard to 
the effects of loss of blood, both immediate and re- 
mote. 
This power and this susceptibility of the system in 
regard to the effects of loss of blood, may generally 
be determined by placing the patient very erect, per- 
haps with the eyes turned towards the ceiling, and 212 
ON THE CURATIVE EFFECTS 
taking blood from a moderate sized orifice, until the 
first or slightest appearance of syncope be induced ; 
the quantity of blood which thus flows denotes that 
power or that susceptibility respectively. 
It then becomes a question whether the quantity 
of blood permitted to flow before the first appear- 
ance of approaching syncope is manifested, be the 
precise quantity which ought to be taken. I think 
it is so, with certain limitations, in the greatest num- 
ber of cases, the power of the system being exactly 
in proportion to the necessity for bloodletting, and its 
susceptibilities, to the caution required in the admi- 
nistration of this remedy. 
To trace these powers and susceptibilities of the 
system in regard to the effects of loss of blood, and 
to apply the facts so ascertained to the question of 
bloodletting in the cure of diseases, has been a prin- 
cipal object of investigation with me for a conside- 
rable period. I shall in this place, briefly illustrate 
these points by the cursory detail of three cases;— 
the first, a case of inflammation within the head ; the 
second, of irritation resembling inflammation of the 
brain ; and the third, of the latter affection in a 
patient labouring under disease of the hip-joint. 
In the first of these cases, there were not very 
violent symptoms of inflammation of the encephalon. 
It occurred in the person of a medical gentleman ; 
and the course of the disease, and the effects of the 
remedy, were remarked with great accuracy. The OF LOSS OF BLOOD. 
213 
symptoms were deep-seated pain, slight alteration of 
manner, slight intolerance of light, a natural pulse, a 
natural skin. I felt persuaded that there was in- 
flammation. Besides the administration of other 
appropriate remedies, he was ordered to be placed 
upright in bed, and bled to slight syncope, on four 
successive days. The quantities of blood taken were 
twenty-six, twenty-four, and twenty-two 
ounces respectively, leeches being applied in the in- 
tervals ; they appeared so large, that the gentleman 
who performed the operation was, at each time, in- 
duced to desist from taking more, although syncope 
was never induced. It was only on the last blood- 
letting that slight syncope was observed. The 
patient recovered favourably, and promptly, without 
any of the symptoms of the remote effects of loss of 
blood. 
The second case occurred in the wife of a medical 
friend, and was observed with equal accuracy and 
anxiety. The patient was a stouter person, and the 
symptoms far more violent, and so accurately re- 
sembled those of arachnitis as to lead to the con- 
clusion that that was indeed the disease; there were 
violent throbbing pain, the utmost intolerance of 
light, great heat of skin, a very frequent pulse. Still 
I was persuaded that the case was sympathetic of 
intestinal irritation, and not inflammation. As this 
opinion, however, involved great difference in the 
treatment, it was not until I proposed to place the 214 
ON THE CURATIVE EFFECTS 
patient upright and bleed to incipient syncope, that 
my friend’s mind could be quite reconciled. It was 
then very obvious that there was something peculiar 
in the case. Complete syncope followed the ab- 
straction of ten ounces of blood ! On recovering from 
this syncope, the patient suffered as much as before. 
Diarrhoea occurred. The recovery was progressive 
though slow and marked by much exhaustion, on 
pursuing the usual remedies of irritation. 
These simple facts prove the existence of two kinds 
of cases, similar in their symptoms, but altogether 
dissimilar in their nature and in their relation to the 
effects of loss of blood. Similar remarks may be 
made in regard to pleuritis and peritonitis, and affec- 
tions resembling them but dependent upon irritation. 
The first protect the system from the effects of loss 
of blood, the second render it more susceptible to its 
influence than it is in a state of health. These facts, 
well substantiated, cannot fail to throw much light 
both upon the nature of these diseases and upon the 
due administration of bloodletting. 
If irritation should supervene upon inflammation, 
the wonted susceptibility to the effects of loss of 
blood will, of course, be less observed. This fact is 
illustrated by the following case. 
Miss , aged 20, had been affected during four 
years with disease of the hip-joint ascribed to a fall, 
the effects of which, at the time, confined her in a 
hospital during eight months; she sometimes suffer- OF LOSS OF BLOOD. 
215 
ed severely from pain, for which leeches, fomenta- 
tions, &c. were applied; and she became pale and 
thin. During the last six months, there had also 
been attacks of pain in the region of her right kidney, 
which were usually relieved by passing gravel. In 
the midst of this state of things, Miss was, on 
March the 22nd, 1829, seized with pain of the head, 
and intolerance of light and of sound, together with 
more than usual pain of the hip and in the region 
of the kidney ; the skin was hot, the tongue furred, 
the pulse 97 ; there had been some degree of vomit- 
ing, and the alvine evacuations were dark and offen- 
sive. Aperients were given. 
These symptoms continued much the same on the 
23rd and 24th, but on the 25th the affection of the 
head was greatly aggravated. Miss was placed 
in the erect posture and bled to incipient syncope; 
some delay was occasioned by the necessity for open- 
ing a second vein ; it was found that forty ounces of 
blood had flowed. On the 26th? the headache and 
intolerance of light and noise were increased, and 
there was palpitation of the heart. These symptoms 
continued during the succeeding week. , 
I saw Miss , on the 3rd of April. It had 
been a question whether the case were inflammation 
within the head, or irritation. The symptoms were 
those of the latter; the quantity of blood which had 
flowed denoted the former. On a full examination 
of the case, I was persuaded, however, that the case 216 
ON THE CURATIVE EFFECTS 
was one of irritation, and that the disease of the 
hip had enabled the system to bear a degree of loss 
of blood altogether unusual in this morbid affection. 
The result of the case proved the correctness of this 
opinion. Recovery took place without further blood- 
letting. I prescribed three grains of the submurias 
hydrargyri to be followed by an aperient draught. 
On April the 4th and 5th, the pain of the head, 
and intolerance of light and sound, and the palpita- 
tion of the heart, were still very severe; the bowels 
had been moved, the evacuations being very black 
and lumpy ; the mouth affected; the pulse 108. 
On the 6th, Miss was better. On the 7th, 
she was still better, having less affection of the head 
and palpitation of the heart; the bowels had acted 
well, the evacuations improved in colour. A little 
pudding was taken. 
On the 8th, Miss was still better, and was 
allowed a little meat. ' 
On the 9th, it was found that Miss had im- 
prudently sat up three or four hours on the day be- 
fore, and she had become in every respect worse from 
this fatigue ; there were greater intolerance of light 
and sound, more pain of the head and back, and 
palpitation. The diet was restricted to arrow-root 
in water. Her bowels were moved, and rest and 
quiet enjoined. 
From this time Miss slowly recovered, losing 
the affection of the head, that of the hip remaining. OF LOSS OF BLOOD. 
217 
The bowels were obstinate; and there were much 
paleness and debility. 
There cannot be a more interesting illustration of 
the principle which I have laid down, than the fol- 
lowing case which I extract from Mr. Lawrence’s 
lecture on inflammation, as reported in the Lancet, 
No. 325, p. 270. It is given by that distinguished 
surgeon as an illustration of the advantage of one 
ample bloodletting, over several smaller ones. But 
it also illustrates, in the most striking manner, the 
influence of inflammation in rendering the system 
capable of bearing the loss of bloodletting. 
Mr. Lawrence observes, “ Some years ago I had 
occasion to attend a young female—a slender young 
girl, in a serious attack of inflammation in the chest. 
I bled her not very sparingly, and adopted other an- 
tiphlogistic treatment, but I found it necessary to 
repeat the bleeding several times; and after a con- 
siderable number of bleedings, the inflammation was 
not yet satisfactorily reduced. The symptoms of 
inflammatory disorder- in the chest continued, and I 
deemed the patient in danger. Still her circulation 
was reduced to that state in which I could not take 
more blood from her. I then resorted to the use of 
digitalis—nearly poisoned her with it, I believe— 
(laughter); however, through the means I used, or 
in consequence of her possessing a pretty good con- 
stitution, she recovered. It happened two or three 
years afterwards, that I had occasion to treat her 218 
ON THE CURATIVE EFFECTS 
again for a complaint of this kind. She was a ser- 
vant in a public institution with which I am connect- 
ed, and I was requested to see her, having been ac- 
cidentally at the establishment. I had previously 
seen her in the course of the week before this oc- 
curred. She had wanted a tooth taken out, which I 
removed for her, and that was attended with a great 
deal of swelling about the jaw and throat, so that 1 
found it necessary to apply leeches to the parts. By 
the end of the week, I was called to see her, and I 
found her labouring under symptoms of the highest 
degree of inflammation of the chest. Though she 
had been attacked only two or three hours when 1 
saw her, the symptoms were very severe; there was 
excessive pain, so that she could hardly command 
her breathing; flushing, and great heat over the 
whole body; white tongue, and a highly disturbed 
state of the pulse, full, strong, and very frequent; I 
never saw symptoms proceed to so great a degree in 
so short a time. The case was very favourable, I 
thought, for trying depletion to a great extent, I 
therefore bound up her arm and bled her; she was 
a rather slender weakish young woman, as I have 
already said. The blood spouted out most vigorously 
from the vein of the arm. I had got a good large 
vessel; it ran into it famously ; and really, in cases 
of inflammation, where the blood ruus freely out of 
the vein, I generally let it run on till it stops 
(laughter), for that seems to me to be the only OF LOSS OF LLOOD. 
219 
way of doing good, and 1 fully intended to have 
gone on till this young woman fainted; but to my 
astonishment, though I had taken away an enormous 
quantity, she did not faint, and still the blood ran 
out in a vigorous stream into the vessel, without 
touching the surface of the arm, to the last. In the 
end I stopped it, because the quantity did seem to 
me to be so very great. I had the blood weighed 
afterwards, and it weighed three pounds; that is 
eight and forty ounces ! I believe it was an ounce 
or two more; however, it was not less, and yet that 
evacuation did not make that young woman faint. 
Now, that single venesection cured her; she was 
well from that time; all the symptoms were re- 
moved ; she had no further symptoms whatever in- 
dicating inflammation of the chest. She kept very 
quiet for two or three days, took opening medicines, 
and was restricted to a low? diet; but really I may 
say she required no further treatment but that single 
venesection.7’ 
To this case I would add the following account 
of three others, by my friend Mr. Warry. 
The first is a case of pleuritis. The second il- 
lustrates the protective influence of laryngitis in re- 
gard to the effects of loss of blood; the Jthird, the 
contrary tendency of irritation. Laryngitis forms an 
exception to the rule relative to inflammation of 
mucous membranes. The case of irritation resem- 220 
ON THE CURATIVE EFFECTS 
bled peritonitis, but the patient bore bloodletting 
ill, and was not benefited by it. 
My dear Sir, 
Having read with much interest your paper 
on * The investigation of the due administration of 
Bloodlettingand knowing that you are at the pre- 
sent moment engaged in preparing for publication 
some further remarks on that interesting subject, I 
send you three cases selected from some which 
have come under my notice, which I think illus- 
trate the subject, and of which I beg you will make 
use in any way you may judge proper. 
I am, dear Sir, 
Sincerely yours, 
E. T. Warry. 
84, Gower-Street, Bedeorh-Shuare, 
Nov. 30, 1829. 
“ John Filser, aged 40, a short healthy country- 
man, applied for advice on the 27th of March, 1826; 
he complained of pain in the left side, which was 
increased on his attempting to inspire, said he has 
been subject to inflammation of the lungs, and had 
always been obliged to be bled for it. The symp- 
toms were not very urgent, I therefore took only 
fifteen ounces of blood, which afforded him very 
trifling relief; I gave him a purgative, and desired 
to hear from him on the following morning. OF LOSS OF BLOOD. 
221 
“ On the 28th, he was enabled to walk with the 
greatest difficulty about half a mile to see me; he 
said the pain was exceedingly increased, and he could 
not make the slightest attempt at inspiration. I again 
bled him, sitting in the upright posture in a chair, 
from a very large orifice ; forty-four ounces flowed 
before either relief or syncope was produced. The 
blood was drawn in seven different cups, each of 
which the patient held himself, during the operation ; 
by the time he had lost forty-eight ounces, he was 
in a state of syncope, from which, however, he soon 
recovered; the pain had entirely left him, and he was 
enabled to inspire as freely as usual; I did not see 
him again. The blood was lost in about three or 
four minutes, the last twenty ounces being conside- 
rably buffed and cupped, that first drawn not at all 
so.” 
“ I was sent for to see Henry Bawden, aged 50, 
on August 18th, 1825, at eleven a. m. On my ar- 
rival I found him in bed, lying on his back with his 
shoulders and head raised, breathing with great diffi- 
culty, and affected with an uneasy sensation of dry- 
ness in the larynx, with a voice extremely hoarse, 
and reduced to a scarcely audible whisper; his 
pulse was full and strong, and 86 in a minute; 
there was considerable thirst; added to the affection 
of the larynx, he complained of an obtuse pain at 
the scrobiculus cordis extending to the right side, 
which was much increased on making a full inspi- 222 
ON THE CURATIVE EFFECTS 
ration ; I immediately opened a vein in the right 
arm, and took thirty-five ounces of blood, the patient 
being in a recumbent position, receiving it in six dis- 
tinct tea-cups. This did not produce the least 
faintness; the blood was very much buffed and 
cupped. Saline medicine with the tartras antimonii 
was given every four hours. 
“ On the 18th, at seven p. m. I again saw him, 
and considered it necessary that the bleeding should 
be repeated ; this was accordingly done to the extent 
of twenty-five ounces without producing faintness. 
The same medicines were directed for him with an 
opiate at bed-time. 
“On the 19th, at 8 a. m. I again bled him; and 
when I had taken about fifteen ounces of blood he 
became and sick, a profuse perspiration broke 
out over the whole body, and for the first time com- 
\ 
plete syncope was produced. 
“ On the 20th, he was much better, twenty leeches 
were applied to his throat, and after them a blister; 
no further depletion was necessary; the patient did 
well, and recovered perfectly.” 
“ Elizabeth Smith, aged 18, having been much out 
of health during two months, was admitted into 
Bartholomew’s Hospital, on Oct. the 29th, 1826, 
complaining of violent pain across the abdomen, 
augmented on pressure; the breathing hurried, the 
pulse 110 and hard, the bowels confiued, the faeces 
dark and offensive. She was placed in bed and OP LOSS OF BLOOD. 
223 
bled from the arm, and although in the recumbent 
posture, she fainted when 3xii. of blood had been 
taken. 
“ On the 30th, the pain continued unabated ; she 
was again bled in the recumbent position; and syn- 
cope occurred when fxiv. had flowed* Forty drops 
of the tinctura opii were given immediately after the 
bleeding. 
“ On the 31st, Ixv. of blood were taken, in the 
same manner, and with the same effect, and twenty 
leeches were applied. On Nov. the 1st, thirty 
leeches were applied. On the 3rd, the pain and 
tenderness of the bowels were increased, the pulse 
hard and 115; ?xii. of blood were taken, and syn- 
cope was again produced; and Iviii. were drawn 
from the loins by cupping. Still the pain was un- 
abated on the 7th, and she had become extremely 
feeble; the pulse was 130; the retina had become 
acutely sensitive to light; the extremities cold, and 
the legs swollen ; and the urine was limpid, and 
sometimes passed involuntarily. 
“ She now took the extractum conii at bed-time, 
and with great relief, the pain of the bowels becoming 
greatly diminished. This relief continued for six 
or seven days. The pain then returned, and eventu- 
ally, the patient left the hospital little benefited.7’ 
There is a fact which calls for caution in reference 
to bloodletting in these cases. Many of the uneasy 
symptoms induced by the loss of blood are relieved by 224 
ON THE CURATIVE EFFECTS 
having recourse to the lancet, and we might thus be 
betrayed into a dangerous recurrence to this remedy.* 
Many of these symptoms are produced by the effort 
made by the system in its reaction; to take blood 
subdues the reaction for a time, substitutes a ten- 
dency to syncope in its place, and consequently re- 
lieves the uneasy symptoms; but the reaction re- 
curs with augmented violence, if the strength of 
the system be still good, or, it may be that a state 
of sinking, or even sudden death may be the issue. 
It would be proper in this place to adduce a 
series of observations on the effects and issue of 
bloodletting in different diseases. For the present, 
however, I must be content to present the reader 
with the general results of my investigation. It 
would require many years to collect such a series 
of facts as would be accurate and complete. But 
I hope, by continued attention to the subject, to 
effect this desirable object eventually. 
It is a remarkable fact, already noticed, that the 
diseases which most require the use of the lancet, 
are precisely those which best bear the loss of 
blood.They may be enumerated in the following 
order:—I. Diseases within the head, especially 
apoplexy, shortly before, and early after, the attack; 
and inflammation. II. Inflammation: 1. of the serous 
membranes; 2. of the parenchymatous substance of 
* See p. 66. 
f See p. 152. OF LOSS OF BLOOD. 
225 
various organs; 3. of .the mucous membranes. III. 
Fever, and its complications. IV. Irritation: 1. of 
the brain, resembling arachnitis ; 2. of the chest,— 
of the abdomen, &c. 
In the last class of morbid affections, in which it 
may be a question whether bloodletting be required 
or not, the loss of blood induces early syncope. 
And in those affections of the head and heart, which 
arise from loss of blood, in which further bloodletting 
would not be unattended by risk, there is still earlier 
deliquiutn on attempting to use the lancet. 
I may add that acute anasarca must be arranged 
with those diseases which require and bear large 
depletion ; whilst dyspepsia and chlorosis assimilate 
more with irritation and reaction from loss of blood. 
1. Of Early Bloodletting. 
Some medical writers have attempted to fix and 
to limit the dates at which it is proper to institute 
bloodletting. To do this really, is utterly impossible. 
Most diseases may, indeed, be divided into the 
stages, 1. of accession; 2. of full developement; 
3. of disorganization of the part or parts affected; 
and 4. of deterioration or failure of the powers of 
the general system. It is very essential to bear this 
view in mind, whenever we may be required to 
determine the question of bloodletting. It will guide 
us far better than days or dates. If the disease be 226 
ON THE CURATIVE EFFECTS 
formed, and not merely expected, the earlier the 
lancet is used the better. If it be fully developed, 
bloodletting is still more required, and even better 
borne. It is when disorganization is great, and the 
powers of the system are shaken, that it requires the 
utmost caution and skill to conduct the treatment of 
the case. 
Early in the disease, a single bloodletting to syn- 
cope will often prove sufficient for the cure. If this 
remedy be employed later, it will usually be neces- 
sary, and safe, to repeat it. 
The first stage of apoplexy is that which pre- 
cedes the attack. The attack itself is frequently one 
of disorganization. On this, failure of the functions 
and powers of life, speedily follows. In the first 
stage a single bloodletting to syncope, always a 
large one, perfectly relieves; in the second, blood- 
letting is neither so well borne nor so efficacious ; 
it must be repeated, and it must be conjoined with 
the local abstraction of blood and other remedies. 
In arachnitis an early bloodletting to syncope, also 
always a large one, is frequently equally efficacious ; 
but if the disease has become fixed by delay, it will 
always be necessary to repeat the remedy, perhaps 
several times. 
In pleuritis and pneumonia one early bloodletting 
to syncope frequently subdues the disease entirely. 
At a later period, it is usually necessary to repeat 
the bloodletting. OF LOSS OF BLOOD. 
227 
In peritonitis, especially if the intestines be involved 
in the disease, it is very essential to observe that the 
feet are warm before the rule respecting bloodletting 
is adopted ; otherwise syncope may take place be- 
fore the due quantity of blood is taken. 
In bronchitis and in dysentery, bloodletting is 
neither so well borne, nor so efficacious, although 
instituted early, as in pleuritis or peritonitis. La- 
ryngitis constitutes an exception to this remark as 
extended to the inflammation of the mucous mem- 
branes in general; in this case it is probable that 
the brain suffers from the impeded respiration. 
Early bloodletting is of the utmost service in 
fevers. It may be a question whether this remedy 
be proper in irritation, but I incline to recommend 
one early use of the lancet. In the reaction from 
loss of blood the topical application of leeches, or 
of cupping, is frequently of great service; general 
bloodletting is of course excluded. 
Having thus stated and illustrated the general 
principle proposed to guide us in the due use, 
measure, and limitation of bloodletting, I proceed 
to speak of this remedy in its first institution and in 
its repetitions. 
2. Of a First Bloodletting. 
The necessity and propriety of a first bloodletting 
must be determined by the diagnosis of the disease, 
and by a due estimation of the powers of the patient. 228 
ON THE CURATIVE EFFECTS 
In the case of inflammation no one would think 
of trusting the safety of the patient to any other 
remedy than bloodletting. And in the case of irri- 
tation, bloodletting although a subsidiary, may still 
be a useful remedy. 
The propriety of the measure having been thus 
determined, the next question is that of the due and 
proper mode of its administration. What quantity 
of blood should be taken ? This question must in- 
volve the consideration of the nature, stage, and 
degree of severity of the disease, and of the strength, 
and the greater or less power or susceptibility in re- 
gard to the effects of loss of blood, of the patient. 
How difficult must it frequently be, accurately to 
determine these points! This can only be done, in 
many cases, indeed, by watching the effects of the 
loss of blood as it flows. And yet the usual mode 
of proceeding, is to prescribe the quantity of blood 
to be drawn, and forthwith to leave the patient in 
the hands of one from whom, however competent, 
the right, or at least the freedom, of judgment is thus 
preposterously taken. 
It was with the view of accurately suiting the 
remedy to the individual case, that I was led to de- 
vise a rule for the administration of bloodletting, 
which should at once involve within itself a due 
regard to all the circumstances which I have men- 
tioned. This rule, as I have already observed, con- 
sists in placing the patient perfectly erect, in making OF LOSS OF BLOOD. 
229 
a moderate sized orifice into the vein, and in allow- 
ing the blood to flow until incipient syncope occurs. 
If the case be one of inflammation, much blood 
will flow without inducing syncope, and the quantity 
will be precisely in proportion to the degree of 
severity, and in relation to the seat of the disease; 
in a word, to the exigency of the case. 
If the case be one of irritation, the quantity of 
blood which will flow before syncope is perceived, 
will be, as it ought to be, very small. 
In the case of reaction from loss of blood, syncope 
will occur on the abstraction of a still smaller addi- 
tional quantity of the vital fluid. 
If the patient be robust, a proportionately greater 
quantity of blood will flow without inducing syncope, 
than if he be feeble. The same remark may be ex- 
tended to any peculiarities of constitution, as plethpra 
on one hand, or corpulency on the other; in the 
former case a greater, and in the latter, a less de-, 
traction of blood, will lead to a state of syncope. 
The administration of the remedy is thus accu- 
rately suited to the nature "and degree of severity of 
the disease, and to the powers or susceptibilities of 
the patient. 
And thus the quantity of blood which has flowred 
becomes, in its turn, accurately diagnostic of the 
nature of the morbid affection, demonstrative of the 
powers and susceptibilities of the patient, and, taken 
in conjunction with other circumstances, indicative 230 
ON THE CURATIVE EFFECTS 
of the propriety or safety of the further detraction of 
blood, but especially of the degree of necessity which 
exists for revisiting the patient very early. 
It is remarkable, too, that this rule is accurately 
adapted to those mixed cases, which, although un- 
noticed by nosologists, are by far the most frequent 
occurrences in actual practice. As inflammation pre- 
dominates over irritation, or irritation over inflam- 
mation ; or as exhaustion from loss of blood, or inci- 
pient failure of the powers of the system, may be 
supervening to either of these morbid states, so will 
the quantity of blood drawn be greater or less. 
It may be proper, in this place, to add a few words 
in regard to limitations and exceptions to the rule 
for bloodletting just proposed. 
In recommending the adoption of this rule, I must 
suppose that the case is such as to require, and the 
strength of the patient such as to bear, the full effect 
of the detraction of blood. In any other case, it 
may be proper, perhaps, to adopt some other mode 
of proceeding. 
The case of inflammation may be so mild as not 
to require a full bloodletting; or it may be chronic, 
and general bloodletting maybe inappropriate; or 
the powers of the patient may be so low that the 
mere assumption of the erect position may lead to 
syncope. How far general bloodletting is required 
in the case last mentioned I do not pretend to deter- OF LOSS OF BLOOD. 
231 
mine; but I confess that I think the topical remedy 
most appropriate. 
But in acute cases, in persons whose strength is 
not altogether impaired, I think nothing short of the 
plan I have proposed, can be esteemed efficient, or 
can be expected to be efficacious. 
One apparent exception to this rule exists where 
there is, besides the affection of the head, for instance, 
arising from irritation, inflammation of some part. 
An example of this kind, already detailed, p. 214, 
presented itself in the case of a young person affect- 
ed with chronic inflammation of the hip-joint. 
Symptoms of irritation, affecting the head chiefly, 
came on. She was bled, and lost a large quantity 
of blood before syncope was induced, although she 
was of a feeble constitution. 
I would in this place again caution the reader, in 
regard to the case of irritation, not to have un- 
necessary recourse to the'lancet. This caution is 
obviously still more necessary in regard to exhaustion 
from loss of blood. 
But a caution of this kind is peculiarly necessary 
in the case of sinking of the vital powers. This 
case is frequently very insidious in its accession and 
in its character. Bloodletting is sometimes suggested 
by a complaint of oppression in the breathing. The 
pulse does not indicate such extreme danger. In 
such a moment, the detraction of a small quantity of 232 
ON THE CURATIVE EFFECTS 
blood, an evacuation of the bowels, and even a trifling 
effort, has led to immediate dissolution. 
There are doubtless still many questions and 
cautions in regard to bloodletting, requiring renewed 
investigation, and the test of further experience. For 
example, is it ever, and in what cases, dangerous to 
place the patient upright, and bleed to incipient 
syncope, admitting that general bloodletting is re- 
quired at all ? Is it ever, and in what cases, right 
and safe to carry the bloodletting beyond the point 
of incipient syncope ? Is it ever, and in what cases, 
safe and proper to place the patient in a more or 
less recumbent posture, and bleed to syncope ? And, 
lastly, is it ever, and in what cases, advisable to make 
a less or greater orifice than that which I have 
denominated ‘ of a moderate size7 into the vein,—so 
as to allow more or less blood to flow before syn- 
cope is induced?—it is obvious that the orifice into 
the vein may be so large as to induce syncope be- 
fore the required quantity of blood has been taken ; 
or it may be so small as to act as a sort of drain, and 
allow of the flow of an undue quantity of blood. 
It has been observed by several writers that re- 
action is very apt to follow bloodletting which has 
been carried to syncope; and this fact has been urged 
as an argument against the practice. I am per- 
suaded, however, that this will rarely be observed 
in cases in which the precaution has been observed 
of bleeding the patient from a good sized orifice, and OF LOSS OF BLOOD. 
233 
in the erect position ; and that, even in the cases in 
which it does occur, it will be of little consequence, 
except as an indication against the further use of the 
lancet. 
I think, indeed, that there would be danger in 
bleeding to actual syncope in the case in which the 
blood flows very slowly ; and especially in that in 
which, from this cause, it becomes nqpessary to open 
a second vein. Much more blood flows in such a 
case before syncope is observed, than when the blood 
pours forth in an ample stream, and more, I think, 
than can always be borne with impunity or safety. 
Another circumstance requires attention. It must 
be carefully seen that the patient’s feet are warm. 
Otherwise less blood may flow in inducing syncope, 
than will be required to subdue the disease. 
3. Of the Repetition of the Bloodletting. 
In determining the question of the propriety of a 
repetition of bloodletting, many circumstances re- 
quire to be considered. But I would remark, in 
the first place, that if much blood have flowed at the 
first bloodletting, it must be taken as indicating the 
necessity for an early repetition of our visit at least; 
for it will also, unless the symptoms shall have been 
greatly subdued by it, indicate the necessity for a 
prompt repetition of the remedy. 
1 would take this opportunity of observing, that 234 
ON THE CURATIVE EFFECTS 
little reliance is, in my opinion, to be placed on the 
appearance of buff upon the blood. 1 have no doubt 
that this appearance is induced by inflammation ; but 
I am also convinced that it is induced by irritation, 
and even by the reaction which attends exhaustion 
from loss of blood. I knew one patient greatly in- 
jured, and another, I believe, destroyed, by confiding 
to this appearance of the blood, as an indication for 
the further use of bloodletting. 
If the quantity of blood taken has been great, if the 
symptoms of the disease are neither subdued nor de- 
clining, I cannot hesitate, judging from*much atten- 
tion to the subject, to recommend an early repeti- 
tion of the bloodletting, conducted precisely in the 
same manner as before. 
Of course the same observations will apply to a 
third, fourth, or fifth, or any subsequent repetition of 
the remedy. Generally speaking, as long as blood- 
letting is required, it can be borne; and as long as it 
can be borne, it is required. Nothing less than the 
most ample bloodletting can be trusted to for the 
cure of inflammation ; as long as there is inflamma- 
tion, much blood will flow before syncope is in- 
duced. Copious bloodletting is unsafe in irritation, 
and, a fortiori, in exhaustion from loss of blood, 
however great the reaction ; but in these cases syn- 
cope is early induced on opening a vein, the patient 
being raised into the erect posture. Indeed, this rule 
appears to me to be, in every case, most efficient, OF LOSS OF BLOOD. 
235 
most safe. And it has the advantage, not only of 
proportioning the quantity of blood taken to the pre- 
cise exigencies of the case and powers of the patient, 
and of denoting the necessity for its early repetition, 
for which objects it was first devised ; but by in- 
volving the circumstance of syncope itself, it implies 
the necessary superinduction of that state which 
constitutes a great part of its\efficacy. 
Thus the rule is as applicable to the case of repe- 
tition, as to that of the first institution of the blood- 
letting. If much blood have been already taken, 
proportionably less will flow, caeteris paribus, before 
fainting occurs. Yet if the disease shall, in the mean 
time, have become augmented in severity, it will re- 
quire the detraction of a proportionably greater 
quantity of blood to produce syncope. This principle 
frequently explains the fact, that a second, or even 
a third, bloodletting is frequently better borne than 
the first; the inflammatory action is become more 
established—influences the system more. 
In the cases in which the patient does bear a 
second bloodletting better than the first, it becomes 
an inquiry, whether this arises from there being less 
nervousness about the operation, or from the con- 
tinuance of the disease, or from other circumstances, 
as a different state of the feet, and of the surface 
generally, as to temperature. 
It is certainly true that the duration of inflamma- 
tion influences the system in its powers of bearing 236 
ON THE CURATIVE EFFECTS 
loss of blood; the longer the disease has subsisted, 
unless the morbid changes are great, or the strength 
has begun to be worn, the better bloodletttng is 
borne. 
A young farmer, aged twenty-one, was attacked 
with pneumonia. On the second day of the disease, 
it was proposed to bleed him. He was alarmed and 
agitated, and reluctantly consented to the operation. 
When four ounces of blood had flowed from the 
vein, he fainted completely. On each of the two 
succeeding days, he lost fifteen ounces of blood, 
sitting in the erect position, without the least ap- 
proach to syncope, and with effectual relief. 
My friend, Mr. Toogood, of Bridgewater, to whom 
I am indebted for this interesting case, observes, 
“ I have no doubt that the fainting on the first blood- 
letting was caused by apprehension. I have very 
frequently remarked, that patients have soon fainted 
on being bled for the first time, who have borne 
large and repeated bleedings very well afterwards.” 
I should imagine, too, that young and raw farmers 
were not the most likely persons to be brave and firm 
under a surgical operation however trifling. The 
following case is interesting in the same point of 
view. 
Ann , aged 22, complained for two years of 
pain in the hip, increased by pressure on the anterior 
part of the joint, or by striking the knee. There 
were also tenderness, fulness, and hardness, about OF LOSS OF BLOOD. 
237 
the region of the liver; the pulse being frequent, the 
tongue white, with its papillae raised and broad ; the 
bowels confined ; and the skin dry, and sometimes 
hot. 
She was bled in the erect position, and on losing 
about two ounces of blood she became frightened 
and pale, and fainted completely. She soon re- 
covered however, and the blood was then suffered to 
flow till she had lost about eighteen ounces of blood, 
and she did not faint a second time. 
4. Of Bloodletting as a Preventive of Inflammation. 
I now come to a point of the utmost moment. I 
will suppose that the preceding bloodletting, or 
bloodlettings, have subdued the symptoms of the 
disease. It has frequently been proposed to repeat 
the remedy by way of preventive and security against 
a return of these symptoms. Of all the cases in 
which bloodletting has been instituted, none is so re- 
plete with danger! 
In the first place, the powers of the patient have 
been subdued; in the second place, the case is one 
of pure exhaustion,—the state of inflammation which 
was before protective of the system against the effects 
of loss of blood, having been removed. At such a 
period the symptoms of exhaustion with or without 
reaction, are very apt to supervene without any 238 
ON THE CURATIVE EFFECTS 
further loss of blood. But actual bloodletting at 
such a moment, has often issued in an irremediable 
state of sinking.* 
There is thus extreme danger from further blood- 
letting in such a case. And indeed such instances 
of bloodletting constitute a considerable proportion 
of those disastrous events from the use of the lancet, 
of which ,we occasionally hear. 
1 may observe incidentally here, that the presence 
of inflammation has such a decided influence in 
enabling the system to support the loss of blood, 
that I have sometimes had an idea that, in the case 
of sinking, the patient might possibly be saved by 
inducing inflammation. But in fact, the state of 
sinking appears almost to preclude the existence of 
inflammation, as we may learn from observing the 
inaction of the strongest blisters applied in such cir- 
cumstances. So that a state of inflammation 
and of sinking, and I think I might say, of reaction 
from exhaustion, appear to be in a certain degree 
incompatible with each other. 
I have already noticed the peculiar condition of 
the system, soon after serious accidents or operations. 
Even in these cases bloodletting is not to be resorted 
to as a preventive of inflammation. This remedy is 
neither required nor well borne in such circumstances, 
and other remedies are imperatively called for, just 
* See the Commentaries on some Diseases of Females, p. 286. OF LOSS OF BLOOD. 
239 
as bloodletting is the remedy for inflammation actu- 
ally established. Symptoms of exhaustion, with or 
without reaction, are very apt to supervene without 
loss of blood, especially in the aged. This point has 
been noticed in an interesting manner by Mr. Law- 
rence, as reported in the Medical Gazette, No. 100, 
p. 159. But bloodletting in such a case has often 
issued in immediate sinking. 
Cases of lithotomy, and of fractured ribs are, in 
fact, for a certain length of time cases of irritation 
and not of inflammation. Afterwards they become 
cases of inflammation, but this morbid process is not 
set up instantaneously; and until this event do take 
place, very moderate bloodletting may be proper,— 
but remedies of a different class are imperatively 
required ; the bowels, and the diet must be regulated, 
and anodynes and frequently cordials must be ad- 
ministered. 
5. Of late Bloodletting. 
Of all the circumstances under which the physi- 
cian may be called to his patient, none is more dis- 
tressing, none more puzzling, than that of neglected 
inflammation. The morbid changes produced in the 
part affected, and the devastations in the powers of 
the system, may be so great, that bloodletting would 
be unavailing, if it could be borne, and could not be 
borne, if it would be availing. In such cases the 240 
ON THE CURATIVE EFFECTS 
powers are to be sustained whilst the disease is in- 
trusted to other remedies. 
6. Of Local Bloodletting. 
Local bloodletting is to be viewed in three points 
of light. ' First, it is useful as an auxiliary to general 
bloodletting, in cases of inflammation: secondly, it 
is proper in some cases of itritation, in which gene- 
ral bloodletting could not be borne: and, thirdly, it 
may be required in cases of exhaustion with reaction 
and affection of the head, in which general blood- 
letting would be injurious or even fatal. 
When, in cases of inflammation, syncope has been 
induced by general bloodletting, it may still be ne- 
cessary to employ cupping or leeches. These re- 
medies are especially and peculiarly efficacious in 
such a subdued state of the system, and their prompt 
and timely use, at this moment, may obviate the 
necessity for a repetition of the general bloodletting, 
and thus the powers of the system will be husbanded. 
But delay will deprive the local remedy of great 
part of its efficacy. Such delay will therefore only 
be proper, when very early syncope has been pro- 
duced by the general bloodletting, indicating a very 
low state of the disease, or of the vital powers. 
I think it will rarely be necessary to repeat the 
general bloodletting in cases of irritation. Topical 
bloodletting is, generally, both more appropriate and OF LOSS OF BLOOD. 
241 
more efficacious, if a first use of the lancet have not 
subdued the local affection. Indeed it may be a 
question whether the topical is not in most cases of 
this affection, to be preferred to the general remedy. 
For the symptoms of irritation are very apt to be 
superseded by those of exhaustion. 
But in the case of exhaustion from loss of blood 
itself, it may still be necessary to apply the topical 
remedy. It has already been noticed that such a 
state is not only not incompatible with repletion and 
a tendency to effusion within the head, but that it 
actually supposes that condition of the encephalon, 
if long protracted. In this case further general 
depletion would be obviously attended with great 
danger. Topical bloodletting, may, however, be 
required for the local congestion. 
It is remarkable, in this case, how small a quantity 
of blood taken, will relieve the patient. Two or 
three leeches, even, are sometimes sufficient; half a 
dozen are an ample number. If cupping be em- 
ployed, the early relief obtained will denote the 
proper quantity of blood which should be allowed 
to flow. In the interesting case of this kind given 
by Mr. Hey in his treatise on puerperal fever,* the 
abstraction of so small a quantity as three ounces of 
blood, from the temporal artery, on two successive 
days, afforded complete relief. 
* See above, p. 68. 242 
ON THE CURATIVE EFFECTS 
Together with topical bloodletting, such measures 
must frequently be adopted as may restore the powers 
of the general system. These remedies are by no 
means incompatible with each other. Each, alone, 
will relieve; but it is when duly combined, that their 
efficacy is most manifested. 
Before I finally dismiss the subject of topical 
bloodletting, I would just intimate, that I believe that 
the application of leeches to parts covered by the 
bed-clothes, and followed, as is not unusual, by that 
of a bread poultice, sometimes issues in the detrac- 
tion of a quantity of blood scarcely suspected. I 
have known the patient inundated by the blood thus 
flowing from a dozen leech-bites upon the abdomen, 
and affected by the most fearful symptoms of ex- 
haustion. OF LOSS OF BLOOD. 
243 
CHAPTER IV. 
OF BLOODLETTING IN INFANCY AND CHILDHOOD. 
Not the least interesting application of the rale 
which I have proposed, to guide and govern us in the 
use of bloodletting, is its use in the treatment of the 
diseases of infancy and childhood. This tender age 
is far more liable than later years, both to the in- 
sidious, and the sudden, fatal effects of loss of blood ; 
it therefore requires to be viewed with still greater 
care and watchfulness. 
The modes of general bloodletting employed in 
infancy and childhood are, leeching, cupping, and 
venesection. 
I must first, once for all, protest against the usual 
plan of applying leeches in infancy, and allowing 
the bites to continue to bleed. Nothing can be more 
indefinite—nothing more replete with danger. Most 
of all it is dangerous to apply leeches late at night; 
the bleeding may go on unobserved and unsuspected, 
and precipitate the little patient into a state of irre- 
mediable sinking. 
The proper mode of abstracting blood in infants 
or children, whether by leeches, cupping, or vene- 244 
ON THE CURATIVE EFFECTS 
secti&n, is to place the little patient upright, and watch 
the countenance. On the very first indication of 
pallor, or faintishness, the flow of blood must be 
stopped.* For this purpose the leeches, or the cup- 
ping-glasses, are to be removed, or the vein secured. 
The effect of exhaustion in infants and children 
are seen chiefly under three forms; 1. that of irrita- 
bility ; 2. that of stupor; and 3. that of convulsions. 
Of the state of irritability the following case, 
though too briefly sketched, presents an interesting 
example. 
A little patient was reduced by too copious and 
repeated bleeding for croup. There supervened a 
state of irritability of temper, so that, when greatly 
exhausted, it made great efforts to bite, scratch, and 
beat its attendant. This state of agitation continued 
until the powers of life were gradually exhausted. 
The state of irritability frequently, though not 
always, leads to that of stupor. Of the latter I 
have given so many instances in Appendix II. to 
Part First, that it appears unnecessary to add more 
here. Yet I cannot refrain from inserting the fol- 
lowing interesting account from my friend Mr. Cox, 
Surgeon, Montague-Square, relating as it does, not 
only to the symptoms of exhaustion, but to the use 
of bloodletting. 
* This may be done in the case of a leech-bite, or of venesection, if ne- 
cessary, by taking up a small portion of the integuments by a mere stitch 
with a needle and silk. OP LOSS OF BLOOD. 
245 
My dear Sir, 
The subject you are now illustrating is of so 
important and interesting a character, and the ex- 
amples you have already given in your tract are so 
striking, that it hardly needs any fresh case to confirm 
the truth of your statements. The state of ex- 
haustion from loss of blood was most strongly mark- 
ed in the case of my little boy. At five months old 
he was one of the strongest and most vigorous 
infants I ever saw ; between that and the age of 
six months, he was attacked on a Sunday with 
croup of a highly inflammatory character, which 
was relieved by the application of six leeches to the 
throat, and calomel and ipecacuanha given every 
three hours. On the succeeding day (Monday) he 
was so much better that I had the greatest hopes 
that the disease was vanquished ; but in the night of 
Monday he was attacked with symptoms of inflam- 
mation of the lungs of the most violent character, 
which were relieved only by the application of 
leeches, repeated with the interval of a few hours 
only, till faintness was produced ; this was sustained 
by frequent doses of the tinctures of colchium and 
squill; the symptoms of inflammation of the chest 
w7ere thus relieved, but I need scarcely tell you, that 
these were succeeded by a state of exhaustion, which 
was extreme, and resembled hydrencephalus in many 
of its characteristics. There was a quick irritable 
pulse, dilated pupil, insensibility, &c. &c. Although 246 
ON THE CURATIVE EFFECTS 
the inflammation had been of so serious a character, 
that it appeared to my friend Dr. Bernard, of Clifton, 
and myself, that, none but the most active means 
would save the life of the child ; yet they were 
employed by myself, anxiously watching for an im- 
pression on the disease, and as soon as the breathing 
became less distressing, and faintness was produced, 
and the pulse was less strong, hard and vibrating, the 
depleting means were gradually withdrawn* The 
state of exhaustion I have described supervened, 
and although many symptoms stimulated an affection 
of the head, I was enabled to remove them by gentle 
stimulants. Had the symptoms of oppression of 
the brain been met by further depletion, I can have 
no doubt that the result would have been fatal. He 
had repeated attacks of croup and inflammation of 
the lungs during dentition, but he is now a strong 
healthy boy. 
I am, 
My dear Sir, 
Yours, very faithfully, 
J. C. Cox. 
.33, MONTAGUE-SdUARE, 
November 21, 1829. 
On the subject of convulsions as arising from ex- 
haustion, I cannot do better than refer to various 
parts of the interesting treatise on this subject by OF LOSS OF BLOOD. 
247 
Mr. North,* but especially to pp. 101, et seq. and pp. 
202, et seq. Mr. North observes, at p. 101—“A 
plethoric state of constitution increases the natural 
aptitude of the child for convulsions. But we must 
guard against being influenced by an erroneous 
opinion which is very general. There are many 
practitioners, and some of no mean celebrity, who 
assume, that in every case of convulsions there is 
either a local or general increase of the actions of 
the arterial system, which demands for its relief the 
abstraction of blood. It is, therefore, the more ne- 
cessary to insist upon the frequent occurrence of con- 
vulsions from debilitating causes, and from a state of 
nervous irritability without any vascular excitement 
either local or general.” And at p. 280,—“ I aijj 
also of opinion that children are not unfrequently 
bled and purged for the purpose of relieving great 
irritability, when much advantage might be gained 
by the judicious application of sedatives, under re- 
strictions to which I have before adverted.” Mr. 
North’s work is full of remarks of the same character, 
and of the utmost importance and practical utility. 
Similar remarks apply to children and adults, in 
regard to the various powers and susceptibilities of 
the system to the effects of loss of blood, under the 
influence of different diseases. In affections of the 
head, in inflammatory affections, there is great power; 
* Practical Observations on the Convulsions of Infants; by John North, 
1826. 248 
ON THE CURATIVE EFFECTS 
in cases of irritation, and, still more, of exhaustion, 
there is great susceptibility. 
It will be obvious from this remark, that the 
various attempts to state the quantities of blood, 
which may be taken from children, in their several 
ages, must have proceeded upon the most vague con- 
jectures. This is further proved by the very various 
statements made upon this very point by various 
writers. In fact, were such a scale made, it must be 
made distinctly for every disease, in reference to 
every age. Something of this kind, I hope to effect, 
with the other objects already pointed out, in the 
course of my continued investigation of the effects 
of loss of blood. But it will be obvious that this can 
only be done by long and uninterrupted attention to 
the subject. 
I have, however, already observed sufficiently to 
be enabled to recommend that, in every case of 
general bloodletting, whether by leeches, cupping, or 
% 
the lancet, the little patient be supported in the erect 
position, its countenance carefully watched, and the 
flow of blood arrested on the very first appearance 
of pallor. * 
The quantity of blood which thus flows will vary 
with the character of the disease, precisely as I have 
described in relation to adults; 
The boundary which it would be dangerous to 
pass, is accurately fixed ; OF LOSS OF BLOOD. 
249 
And the result observed becomes accurately diag- 
nostic of the character of the disease. 
It will be observed that 1 esteem the application 
of leeches and of cupping, in infancy, as a mode of 
general bloodletting, as well as the use of the lancet. 
The precise number of leeches applied will regulate 
the rapidity of the detraction of the blood; their 
prompt removal, and the immediate closure of the 
leech-bites, must be effected, on observing that the 
system is brought under the influence of loss of 
blood. The same observation applies to cupping, 
and, a fortiori, to the lancet. 
1 am persuaded that this view of the subject, 
simple as it is, will reflect a new and important light 
upon the whole subject of the nature and treatment 
of the diseases of infants and children. CONCLUSION. 
By the Table, inserted at page 155, and by the 
aid of my medical friends, I hope to collect, in a 
moderate space of time, a body of valuable facts, 
to confirm the practical safety and utility of the 
rule for bloodletting which I have proposed, or 
to ascertain the various exceptions and limitations 
to it which may occur in practice. Meantime, 
1 trust the rule itself will prove that guide and guard 
in the use of the lancet which has been so long, 
and I think, particularly lately, so imperatively re- 
quired. 
There are, 1 am’ persuaded, few cases in which, 
if the measure be proper at all, bloodletting will be 
carried too far if the rule proposed be strictly 
adopted ; whilst the fullest effect upon the system 
is effectually and safely secured, and, in the case of 
absolute syncope suddenly supervening, the remedy 
is at hand, in the immediate change of posture from 
the erect to the recumbent. 
I would still add one further remark. It is that 
the effect of bloodletting may, in some cases, be 
beneficially renewed, without the further abstraction CONCLUSION. 
251 
of blood, by mere change of posture. If the per- 
fectly erect posture be resumed, syncope will fre- 
quently recur, and this state may, in some cases, be 
advantageously prolonged. 
On the other hand, the full effect of an opposite 
kind of posture, in the various cases of exhaustion, 
have not, I think, been sufficiently investigated. 
There are various modes of almost inverting the 
natural posture of the body, without subjecting the 
patient to much fatigue. And this principle may be 
variously enforced in some protracted, as well as 
sudden, cases of exhaustion. APPENDIX TO PART SECOND. 
CURSORS OBSERVATIONS ON THE USE OF PURGA- 
TIVES, OPIUM, BRANDY, ETC. 
I have repeatedly observed the assimilation of 
the effects of irritation and of loss of blood. I 
would now remark that the effects of exhaustion 
are frequently seen, and that in their most severe 
forms, where the loss of but a small quantity of 
blood has followed upon the undue action of pur- 
gative medicine. This fact is exemplified both in 
regard to adult age and infancy, p. 23, and Ap- 
pendix ii, p. 135. 
In many cases, especially of irritation, I have found 
it of the utmost advantage to give a cordial purga- 
tive, and even to repeat the cordial at the moment of 
the evacuation of the bowels. The purgative, may 
in this manner, be prescribed in an efficient dose, 
its exhausting influence being obviated. 
1 have repeatedly known the affection of the head 
so apt to arise from irritation, or at least a similar 
affection, to be perpetuated by the exhaustion induced 
by an active purgative, although the first cause were 
removed by it. This frequently constitutes a very APPENDIX. 
253 
puzzling state of things. It is obviated by some kind 
of cordial in medicine or diet. 
Of opium I would repeat, that it does harm in 
cases of exhaustion, when it does more than allay 
irritability, and especially when it induces stupor. 
One of the best modes of exhibiting opium is 
certainly that of introducing it within the rectum, 
besides the additional advantage afforded by its ad- 
mitting of being washed away by injection, if its 
operation should be too powerful or continued. 
The proper operation of opium as a remedy against 
exhaustion is by allaying reaction; whilst its undue 
action seems to add to exhaustion, by impairing 
various functions, but especially that of the act and 
function of respiration. 
This remark is important, because I believe opium 
to be very frequently, not so much untimely, as un- 
duly, employed, as a remedy for the effects of loss of 
blood. 
Brandy, the sheet anchor against exhaustion, may 
also be unduly employed. It is so when it quickens, 
instead of lowering, the pulse, and when it excites 
sickness and vomiting. In prescribing this remedy, 
it is therefore highly important to keep within the 
limits beyond which these effects would be produced. 
Next to brandy, as the remedy for exhaustion, 
must rank various articles of diet. On this subject, 
however, I have but one remark to add. It is, that 254 
APPENDIX. 
the sickness, which frequently attends exhaustion, 
is often allayed by giving a little solid food, when 
other remedies had been tried in vain. 
We still want a treatise on the morbid and cura- 
tive effects of remedies in general. 
THE END.