side. Since this occurrence, moreover, the patient has not recovered his speech; and at present, although the leg has recovered its action, the articulation of the smallest monosyllable is still impossible. Now, adds our young colleague, may not I ask, whether, if facts of this kind were numerous, would they not present a certain degree of accusatory evidence against the employment of bloodletting? And when, as impartial witnesses, we observe their development, do we not feel inclined to say, with the relatives of M. Cruveilhier's patient: "it was the lancet that did the mischief."

He then endeavours to account for these exceptional facts, and the explanation which he gives of them is not without some value.

What takes place in some pneumonia cases after depletion? Does not the pulse, which before the bleeding was small and compressed, become full, firm, and developed after it? Do not we, in fact, observe what is called reaction (of the vital power,) and do we not generally consider that just then new determination of blood takes place towards the lung ?-probably. It is also, probably, to counteract, by blood-letting, the accidents of bloodletting itself, that M. Bouillaud recommends repeated bleedings; in other words, that the amount of depletion is more efficacious in several bleedings than in a single

one.

If it were so for the brain, how could we be surprised at it? How could we wonder that this organ, contained in an inextensible cavity, subjected to slight movements, tumified as it is by the great quantity of blood which congests it, should resist for a time to hemorrhage, and that afterwards it should suddenly give way, when, after bloodletting, the circulation became more active in it, and its own movements more extensive? In other words, and to express our thoughts more completely, are there not two distinct elements concerned in the production of cerebral hemorrhage: on the one hand, the mass of the blood, and, on the other, the force with which it is moved? And

does not it appear that the first cannot be diminished without the second being increased?

To diminish the first without increasing the second ought to be the aim of the physician.

It is with the view of attaining such a result that we, for our part, fully intend never to open a vein without having first placed the head of the patient in an elevated position, repelled the blood from that organ by means of cold applications (a bladder filled with ice), without having, on the contrary, drawn it towards the lower extremities by means of sinapisms or foot-baths, and caused the patient to take a sedative potion with a few drops of digitalis. (Extracted from the Revue Medico-chirurgicale de Paris.

The Revue Thérapeutique Medico-Chirurgicale of the 15th February, 1854, in reproducing the passages which have just been read, follows them up with the comments and observations which I will quote literally.

M. Voillot has observed, as well as the practitioners mentioned in the preceding paragraph, the evil effects of blood-letting in certain cases; but he does not admit the explanation given by M. Aussaguel, and still less the conclusions which the latter seems to base upon them,namely, the necessity of insisting more upon depletion. These are the expressions of our colleague on the subject, whom we shall now allow to speak for himself.

The indication for bleeding in apoplexy or cerebral hemorrhage is one of those which appears the best established in pathology, the brain being an organ, the functions of which cannot be impeded in their exercise without immediate danger for life. If it be compressed in some way or another, in whole or in part, it loses its power, or a part of its power, and the agents of volition become powerless. Now, if the blood flow to it in too large a quantity, or if it do not return from it with sufficient facility, compression takes place, and apoplexy is imminent. Observation of the appearances in the dead body and the symptoms in the living seem to indicate

clearly the measures which ought to be adopted: blood must be drawn. But, then, what happens next? It is, that the depletion has transformed a simple threat, or the commencement, of paralysis into complete paralysis; there is the evidence, the effects are too well marked, too immediate, to allow of any misapprehension as to their cause.

After this, how can we account for facts so contrary to the theory of depletion? Was not it sufficiently copious? Yes, for it was repeated and even carried until syncope supervened. Why, then, was not the congestion removed? Why did not the circulation resume its usual course? Why, on the other hand, did the evil, which it was sought to avoid by its means, speedily result from it? Can it be that, as it has been surmised, the attraction (raptus) of the blood, towards the brain, must have been greater after than before the bleeding? But, in that case, why did the hemiplegia come on during the syncope, when, as it is well known, the circulation is interrupted?-(M. Aussaguel's thesis.) As for us, far from seeing in this case the effects of a more active circulation or of reaction, we should rather consider it as the result of the weakening of the tissues, occasioned or increased by the depletion, which, in most cases of this kind, is freely made-hence the sanguineous extravasations or the serous exudations.

Be this as it may, it is sufficient that observation has ascertained the accidents which may supervene upon blood-letting, to render it incumbent on us to proceed with great circumspection before we decide upon applying it. We have several times witnessed similar accidents, and we may state, without going very far back into our past experience, that, at present, we have under our observation a fact of this kind. Mr. J-, aged sixty-six, of a temperament highly sanguineous, was suddenly seized with difficulty in articulating his speech. When we were called in, he was standing and walking about his room -we at once prepared to bleed him. We had scarcely closed the vein, when he was seized with hemiplegia on the left side and with loss of speech. Since that time,

which is some years ago, and after employing the waters of Bourbonne, as well as several other means, the hemiplegia has continued just as it was at the outset; he drags his leg considerably as he walks, and can only pronounce one monosyllable, which obliges him to converse by signs.

In opposition to this fact, we think it right to mention two persons whose illness is more recent, for it originated in the course of the present year. Those two persons, of an apoplectic temperament, and about the age of the patient just mentioned (sixty and odd years), were suddenly seized with difficulty of articulation and hemiplegia, likewise on the left side; neither of them was bled or leeched; the first, a woman, recovered almost entirely at the end of a fortnight, she scarcely experiences any difficulty in walking, the movements of the tongue are comparatively free, but the arm remains paralysed. As to the other patient, although the improvement has not been so satisfactory, he has, nevertheless, recovered the free use of his speech and the use of his leg, which, however, is still somewhat stiff when walking. But the arm is still in a paralytic state.

What would have happened if we had bled these two patients? Could any one say, with reason, that we might have restored to them the complete use of the paralysed muscles, which is a rare event with or without bleeding? We believe, on the contrary, that we should have made a depletion not only useless, but perhaps adverse to the recovery, however incomplete, which they obtained.

Should we, on that account, say that we must, in similar circumstances, always abstain from bleeding? We have not arrived at so decided a conclusion. We believe we have sometimes derived good effects from blood-letting. Even recently, a person, aged seventy-two, of a sanguineous temperament, was suddenly seized with muttering speech; the mouth was drawn to one side, the tongue deviated. Having been called to him in the night we bled him largely; three days after this the symptoms had

disappeared, and the patient was restored to his usual state of health. We ought, however, to state, that after the bleeding, we prescribed for our patient infusions of arnica, a purgative draught, and a blister on the nape of the neck.

Ought we to ascribe to the bleeding the whole agency in the case? It is a question which it would be difficult to solve; the only thing that we can affirm, is, that it was not injurious, as it has been in other cases similar to this one. Beyond this we are without precise indications; for, although we ascertain that we have to deal with impending apoplexy or with a beginning of paralysis, we are not sure that blood-letting will not produce an effect exactly the contrary of that which is desired; or, at the very least, that it will not be an obstacle to an amelioration which may take place without it.

It is, no doubt, on account of this uncertainty that some practitioners discard blood-letting in all cases. As for us, we think that we ought to abstain from bleeding when the patient is above sixty years of age, the period of life when paralysis is most frequent,-when his step is awkward and heavy, when there is, in his case, a presumption of softening of the brain, and, finally, when it has progressed slowly and steadily towards paralysis. In a case of this kind we would prescribe, in preference, stimulants of the circulation, and arnica especially; drastic purgatives and blisters either on the nape of the neck or on the paralysed limbs.

We may state, in conclusion, that, in apoplexy, the usefulness of blood-letting is doubtful, and that we cannot affirm that it will not be injurious.

(To be continued.)