the blood previously extravasated would have escaped, and no ruptured vessel would have been detected. A similar action takes place in the stomach; ecchymosis is produced, but the action of the gastric juice prevents our observing the changes with the same facility as in the intestine. There is little doubt that the capillaries thus become over distended, and then ruptured in the ordinary form of hæmatemesis, when no ulceration has taken place.

In reference to the oozing of blood from the stomach, which often precedes death, it is doubtful whether obstruction on the right side of the heart, with antemortem coagulation, and consequent distension of the branches of the vena portæ and gastric vessels, is not associated in some cases with increased action of the gastric juice, so that the solution of the mucous membrane, which often follows death, actually precedes it.

The symptoms, which precede hæmatemesis, are a sense of faintness, followed by weight at the scrobiculus cordis; the countenance becomes pallid, the pulse compressible and failing, the extremities cold, and sometimes actual syncope takes place; vomiting is then produced, and several pints, or even quarts, of half coagulated blood are rejected; the patient becomes faint, blanched, and the bleeding is checked. After a few days or hours there may be return of hæmorrhage, till at last, in some cases, the patient appears almost

drained of blood. The subsequent symptoms are especially due to this loss, as found in other instances of anomia; severe headache, noise in the ears, disturbed vision, dilated pupil, palpitation or irregular action of the heart, with a sharp but compressible pulse, are present. If a large vessel have been divided the first attack may, as we have before remarked, lead to fatal syncope. This sudden termination, is, however, unusual; the patients generally slowly rally, and after a few hours the black pitchy discharge of altered blood takes place from the bowels.

The character of the disease which has led to the hæmorrhage must necessarily modify the preceding, as well as the general symptoms and their termination. Thus in ulceration of the stomach, and in cancerous disease, the peculiar symptoms of those maladies are present. In aneurism a pulsating tumour may sometimes be felt, and severe local pain, or pain in the course of the spinal nerves, may be experienced. In congested portal system the signs are those of engorged liver, as shown by pain in the right side, dyspepsia, a sallow or semi-jaundiced complexion, furred tongue, occasional nausea or vomiting, impaired appetite, spasmodic pain at the stomach or in the region of the colon, constipation of the bowels, disturbed sleep, and pain in the head; enlargement of the liver and hæmorrhoids are also frequently present.

In vicarious menstruation, local congestion of the

mucous membrane, or of the edges of a pre-existing ulcer, as we sometimes find in an ulcer on the leg, leads to the effusion of blood. We may have very slight symptoms, as absence of the proper menstrual discharge, pain in the side, and periodical vomiting of blood, without constitutional disturbance, and without the blanched countenance that we find in hæmorrhage from other causes. With this vicarious discharge we not unfrequently find hysteria, neuralgic pains, and leucorrhoea, &c.

In purpura hæmorrhagica there is a blanched countenance, faintness, &c.; but we have indication of the cause in the changed character of the blood, and its effusion from other mucous membranes as well as into the skin. The hæmatine is probably acted upon, and the corpuscles broken down, so that actual exosmosis of coloured serum takes place.

During the course of fever hæmorrhage from the bowels, apparently of a critical character, occasionally takes place. The patient, who may be in a state of great prostration, with a dry and brown tongue, rapidly amends, and hence the discharge of blood has been regarded by some as indicating a "crisis" in the disease. In the cases of profuse hæmorrhage during fever, which have come under our own observation, the effusion of blood has probably taken place from ulcerated surfaces. In one instance, minute ulcers were found in the stomach, from which a profuse and fatal hæmorrhage

took place. In another instance, a young woman, whilst prostrate from typhoid fever, suffered from hæmorrhage from the bowels to a great extent; the patient became blanched, the pulse for many hours could scarcely be felt, but very slowly she completely recovered.

When blood is poured out from the oesophagus or mouth, it is regurgitated or rejected without effort, rather than vomited, and we generally find either dysphagia or ulceration of the throat.

Blood from the lungs is sometimes so retained in a vomica or dilated bronchus, that it loses its frothy appearance and florid colour, and the patient is often scarcely able to tell us whether he vomited or coughed it up.. No actual cough may be produced, for the blood is easily brought up into the throat, and then spat out, or it may be swallowed and then vomited, or discharged by the bowels. In these cases, we attach much importance to the general signs of disease, and to the physical examination of the lungs and heart.

As to the prognosis in hæmorrhage from the stomach, we must bear in mind that it is rare for a patient to die from simple hæmatemesis, although such cases do occur. Patients often appear to be almost bloodless, but steadily convalesce. Still the cause of the symptom must be our guide as to its termination; sudden and large bleedings after symptoms of organic disease should always be regarded with alarm, for ulceration often

extends into the larger arteries, and the dense fibrous tissue prevents contraction of the vessels, and thus the hæmorrhage persists unchecked.

The treatment of the bleeding must be according to the cause of the disease. When it takes place from ulceration or cancerous disease, the use of styptics is advisable, alum with dilute sulphuric acid, acetate of lead, gallic acid, catechu, tincture of iron, oil of turpentine, or Ruspini's styptic may be used. But in cases where it arises from congestion of the liver, I have generally looked upon the hæmatemesis as to a great extent curative, and prescribed remedies calculated to relieve the congested liver, as a grain or two of blue pill with conium and magnesia mixture, so as to remove the effused blood from the intestines.

Ice and cold drinks are grateful to the patient, and beneficial in producing contraction of bleeding vessels; but food should be abstained from, because coagula may be removed by it from divided vessels, and hæmorrhage be again produced. After a short time, fluid demulcent nourishment may be given, but it should be in a nearly cold condition; and when there is the evidence of a cessation of the hæmorrhage, solid substances, easy of digestion, may be taken in small quantities. Vegetable tonics with mineral acids, and the milder preparations of steel will then be found of service; but we shall be often much disappointed by the various astringents, as gallic acid, alum, &c., which afford only partial relief.