patients cannot bear the loss of blood; it gives rise to prostration, attended with convulsions, in which the circulation fails so alarmingly as to require watching for several hours and the repeated administration of stimulants to restore it. A very intelligent surgeon in the neighbourhood of London, in bleeding a clergyman to the extent of twenty ounces, whose idiosyncracy in this respect was not known, was compelled to remain with him during the whole of that day; and notwithstanding frequent recourse to brandy, continued long apprehensive for the patient's life. He represented the convulsions, which returned in parox. ysms, as resembling the puerperal in their severest form. There has been reason to believe that the loss of blood in operations in which hemorrhage was unavoidable, has sometimes induced this state; this however, in the present advanced state of surgery is rare.'" 16.

3. Delirium. This occurs as an immediate effect of loss of blood, whereas mania is a more remote effect. Dr. Hall mentions the case of a young man who had lost much blood from the arm and by leeches, besides being briskly purged. He fell into complete syncope. Instead of laying him recumbent, they kept him erect, and thus protracted the deliquium for an hour and a half. He was found colourless and senseless, affected with rattling in the breathing. On being laid down the blood began to come to his face, and animation to increase. The pulse was quick, and he complained of deafness. To these phenomena succeeded severe rigor, great heat of skin, and delirium. These symptoms gradually subsided, and the patient recovered. Several other cases of an analogous nature are adduced as exemplifications of the injurious effects of inordinate loss of blood.

"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 affected with convulsion. This was succeeded by delirium, which continued during two hours. A little brandy and water was given. She recovered in a few days.

“As might have been anticipated, delirium frequently occurs as an immediate effect of hæmorrhagy during 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 of blood, or in other words, great susceptibility to its effects, a subject which will be fully discussed in the second part of this work.

“Mrs. —————, aged 40, had been, for some time, under 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 tinctura 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 ammoniæ aromaticus.

"I 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 before. I directed one ounce of brandy to be given every hour, with beef tea.

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

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

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

"From this time there was no recurrence of delirium. The perspiration kept profuse for some days, but gradually subsided; the pulse became gradually slower and stronger. There was afterwards a protracted affection of the chest." 22.

4. Coma. We are sometimes called to patients who are perfectly comatose after bleeding, and we are in doubt whether the case be or be not apoplexy. The history, the countenance, the pulse, the state of the extremities, and other symptoms, will help to guide us, after a little careful reflexion.

5. Sudden Dissolution. For examples of this the reader is referred to Dr. Hall's Commentaries on the Diseases of Females.

In the second chapter, the author treats of the more remote effects of loss of blood, or exhaustion-and first of exhaustion 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.

"The phenomena are very different, if, instead of one full bleeding to syncope, or of a profuse hæmorrhage, 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 a throbbing beat, and there are, in some instances, all the symptoms of excessive reaction.

"This state of excessive reaction is formed gradually, 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 accompanied by a throbbing pain of the head, and the energies and sensibilities of the brain are morbidly aug mented; sometimes there is intolerance of light, but still more frequently into lerance of noise and of disturbance 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 occasionally even continued delirium; more frequently there are great noises in the head as of singing, of crackers, of a storm, or of 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 or bounding of the artery." 31.

The respiration is apt to be hurried, and attended with alternate panting and sighing" the movement of expiration being sometimes obviously blended with a movement communicated by the beat of the heart." The skin is sometimes hot, and hurry and restlessness prevail. In this state of exhaustion, sudden dissolution is sometimes the immediate consequence of any muscular exertion, or even of being raised from the horizontal posture. The following case exemplifies some of the effects of loss of blood in a striking manner.

"Mrs. - -, aged 28, of a stout constitution. After delivery there was uterine hæmorrhagy, which continued 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 violent 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, pulsation of the carotids and aorta, fluttering and beating of the heart, faintishness, and a sense and fear of dissolution;-the palpitation of the heart was sometimes 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 urgent 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 pallid; 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." 33.

Exhaustion with defective reaction is the next subject of consideration. The opposite phenomena are mostly observed in young people of robust constitution, who have been subjected to repeated blood-letting. In infants, feeble persons, and persons of advanced age, reaction, after loss of blood, is apt to be defective. In this case the patient remains long pale, thin, and feeble, becoming faint on the slightest occasions. The pulse is frequent, but feeble, and perhaps irregular; and we have not the throbbing and palpitation so common in the opposite circumstances.

EXHAUSTION WITH SINKING.

"The symptoms of exhaustion with excessive reaction 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 failure 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 the 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 supervene, 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 reaction, the patient in the state of sinking, requires a moment to recollect himself and recover his consciousness, is perhaps affected with slight delirium, and he is apt to forget the circumstances of his situation 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, I believe, 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 rattling, 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, laryngeal 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 bounding 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." 46.

EXHAUSTION WITH DELIRIUM.

This section contains only a case communicated to the author by Dr. Abercrombie.

We conceive that it was neither more nor less than a case of puerperal mania, and had little or nothing to do with the leechings which had been employed for the topical affection. As the case is short, we shall here give it.

"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 swelling 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 appearance, 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 immediately 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 benefit; and, on visiting her next day, I 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 was 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, suppurated, was opened, and healed favourably; and she is now in perfect health.” 60.

EXHAUSTION, WITH COMA.

The following case was communicated to Dr. Hall by a friend. An opulent farmer, 60 years of age, tall and well formed, of active habits in the early part of life, and of sanguineous temperament, had suffered severely from gout, and for many years had suffered from spasms about the cardiac region, attended with urgent sickness and giddiness-in fact, "gout in the stomach." The biliary system was much deranged and jaundice had occurred. He had more than once been attacked with pneumonia, requiring one or more general bleedings. About five months before the fatal event, he suffered an apoplectic seizure, and his life was saved by active depletion. From that time his health became unsettled and his whole frame enfeebled. Depression of spirits was extreme, and he was harrassed with cramps and sub-acute gout.

"After exposure in an open carriage, on one fine day, with the wind in the east, he was suddenly attacked 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 disease as acute hepatitis, and bled him profusely from the arm, and with immediate relief, which was rendered more complete by the free action of purgative 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." 67.

This active work, in an old and enfeebled man, soon depressed the vital powers. The patient appeared bloodless and cadaverously pallid. The tongue was pale, the pupils dilated, the sight imperfect, the eyes glassy. There was subsultus tendinum, jactitation of the limbs, suspirious respiration, pulse 100 to 120, irritable and throbbing. Cordials were exhibited, the powers of life revived, and the patient recovered so far as to be able to take airings in his carriage. But complete convalescence was never re-established, and in the course of a month he died suddenly. No examination of the body was obtained.

Amaurosis sometimes becomes the prominent symptom in exhaustion from loss of blood, of which Mr. Travers gives some good examples in his Synopsis of Diseases of the Eye. The following is an interesting case, No. XXV. FASCIC. II. F