DIAGNOSIS.-The indications of this disease are, principally, dyspnoea or hurried respiration, the lungs but imperfectly filling with air at each inspiration; some degree of dullness on percussion, in consequence of the fullness of the congested lungs; and the existence of hæmoptysis or pulmonary hemorrhage.

This last symptom, when connected with active congestion, may be called tonic hemorrhage; but, when with passive congestion, atonic hemorrhage. Hemorrhage not unfrequently occurs in connection with the existence of phthisis, either at an early period, or more often at an advanced. But, in all these cases, it is to be regarded as a symptom of disease, rather than as disease itself. In phthisis, blood-vessels are invaded by the tubercular disease, and even laid open. In congestion, the case is very different. Sometimes, the smaller blood-vessels, it is true, are ruptured. This is evidently done when the hemorrhage suddenly follows a straining or violent effort; but, ordinarily, the discharge of blood is an effusion from the mucous membrane of the bronchial tubes. Whether the leakage be from the capillaries, or, as is more probable, from the smallest veins, it is from vessels lying near the mucous surface of the tubes, they being there congested. In active congestion, the blood is too violently forced into those vessels. In passive congestion, the vitalizing power of the blood itself is feeble, the coats of the vessels most often, are morbidly relaxed, and the mechanical pressure of the current within produces an effusion, while there is not sufficient power to force the blood in its proper channels. The existence of the blood in the larger and the medium-sized bronchi, before it is expectorated, causes the mucous and the sub-crepitant rales; but thinness of the liquid through which the air passes, renders the sound sharper and more snapping than is that of those rales when made in mucus or pus.

TREATMENT. If hemorrhage has occurred, the arrest of that is the first indication to be fulfilled. To effect that object, the internal use of astringents, or astringents combined with vegetable stimulants, is valuable. As astringents, cutechu, kino, tannin, trillium pendulum, and lycopus virginicus are all valuable. The last, most of all, has a special reputation as an astringent and a

styptic. Whatever article is relied on, liberal doses should be given and repeated every few minutes, till the hemorrhage ceases. The addition, in small quantity, of some simple vegetable stimulant, as capsicum baccatum, to the astringent, increases its efficacy. The best known styptic, however, to be employed, whether in hæmoptysis, or in other hemorrhages, is the chloride of sodium (common salt.) A saturated solution of this in water should be prepared; and the patient may drink from a fluid dram to a fluid ounce of the liquid, frequently repeating the dose, till relief is gained. The modus operandi of this remedy is not very fully understood. I suppose, however, it acts by means of the stimulating or energizing properties introduced into the blood by venous absorption. In connection with these means, soaking the feet in warm water, swallowing small pieces of ice, and other means of equalizing the circulation are useful. The blood should, as much as possible, be invited and impelled away from the part affected.

In regard to the removal of the congestion itself, and guarding against future hemorrhages, different means are required, according to the existing conditions and causes. If the hemorrhage is the result of violence, especially, if some of the vessels have been ruptured, rest or the most quiet condition possible should be peremptorily enjoined. The nervous system should be kept quite calm; and, if possible, all severity of coughing should be avoided. Should pulmonary pneumonitis occur, it must be treated accordingly. After this has subsided, if a weakness at the spot remains, gentle local stimulants, as strengthening plasters, may be of some service. But regard to the general health, in the use of simple restoratives, should give the leading feature to the treatment.

In the case of a sanguine and plethoric female, especially if there is menstrual suppression or a partial interruption of the menstrual function, the emmenagogue and depletive treatment is, to an extent, indicated. Hence, agents to produce uterine action and a hydragogue cathartic effect, such as macrotine, podophilline, and the like, are beneficial.

But, in the case of passive congestion, giving rise to atonic hemorrhage, a very different treatment must be adopted. The chlorotic or anæmic condition of the blood requires primary at

tention. The deficient corpuscles and fibrine must be restored, and thus more vitality be added to the system. Direct and effective emmenagogues used in this case, produce only evil. Agents adapted to produce a healthy uterine action, as the trillium pendulum, macrotine, and the like, will do no injury, but will be favoraqle; but all depleting measures must be avoided. Stimulating drafts applied to the feet, the tepid sitz bath occasionally, and friction to the surface, are beneficial. The vegetable stimulants and bitter tonics, to some extent, are indicated; but the most effective means of removing the disease are the use of iron, in some form, and such vegetable agents as directly improve the vital powers of the blood. Of the different preparations of iron, the iodide, the carbonate, and the sulphate are all valuable; but I prefer the last. Of the vegetable remedies indicated, the compound sirup of aralia nudicaulis and guaiacum wood are among the most efficacious.

CHAPTER VIII,

PULMONARY APOPLEXY,

I use this term for want of a better, though there is an etymological objection to its use. Apoplexy, in Greek aroλngia, is from the preposition anо from and the verb λnssw to strike,—to strike from, or strike down. The term is applied to a disease of the brain, under which a person falls suddenly down and lies in a comatose condition, the circulation and the respiration continuing, but the breathing being commonly stertorous. This disease, pathologically examined, was found to consist of a congestion of the blood vessels and an extravasation of blood upon the brain.

When, therefore, it was found that a certain pathological condition of the lungs consists in the extravasation or the effusion of blood into the areolar tissue or the parenchyma, and that the blood remains fixed there, as does that thrown out upon the brain in the cranium, the term apoplexy was, by an analogy not very remote, applied to that pathological condition, and it was called pulmonary apoplexy.

PATHOLOGY.-In this disease, there must necessarily be, at the outset, congestion of the blood-vessels, to a greater or less extent; but the hemorrhage which occurs is peculiar and characteristic. The blood, instead of passing into the bronchial tubes and being discharged by coughing, is lodged in the areolar tissue, and confined there, or is effused into the vesicles and the terminal bronchial tubes which are situated within the lobules. Sometimes the blood is evidently extravasated, and the pulmonary tissue is broken down or torn. In this disease, there is a clear resemblance between the injury and that which exists in the brain. when there is cerebral hemorrhage. Ordinarily, however, there is no such laceration; but the lobules are gorged with blood which has been somehow effused. Pathologists are not agreed to what extent the blood passes directly from the coats of the vessels into the areolar tissue, and to what extent it is poured into the air passages, at or near their terminations. Sometimes, with the induction of this disease, there is no hæmoptysis, though oftener there is, at least, some slight discharge of blood, in connection with coughing.

Now, if the blood is pent up in the areolar tissue, it of course cannot escape. The fact, that there is generally some hæmoptysis, proves that some blood does actually enter the air passages. If the blood mainly, or to any extent, is deposited in the air passages, why is it not thrown out by the cough which the irritation must produce? To this it is replied, that, in the compressed lobules, the nervous energy may be so deadened, by the pressure or other means, that no important degree of irritation is produced; or the bronchial outlet from each lobule may become compressed or blocked up with coagulated blood so as not to allow of an evacuation.

This disease, like the congestion already considered, has been very commonly referred to the effect of a contracted mitral orifice -not allowing the blood to return, from the lungs, with sufficient rapidity. But, though this will account for the congestion of the pulmonary apoplexy, except the ordinary pulmonary hemorrhage and hæmoptysis, yet if the blood is effused directly into the areolar tissue, the cause must be sought in the pulmonary parenchyma, and not in the heart; and, if the effusion is direct into the term

inal air passages, and yet there is little or no tendency to hæmoptysis, the cause of that peculiarity must be sought for in the lungs themselves. Some consider that the disease is connected with the capillaries rather than with the larger bloodvessels, and that it differs from inflammation mainly in the blood's lacking the phlogistic and reactive character of inflammation. It appears that there is a weakness in the vessels and the tissues concerned, by which the blood leaks or oozes into its place of deposit, and little or no vital reaction is established.

Dr. Thomas Watson thinks there is sufficient reason for considering the blood in pulmonary apoplexy to have been first poured into one or more of the larger branches of the bronchial tubes, and then to be driven backward into the pulmonary lobules by the convulsive efforts which the patient makes in respiring, or by paroxysms of coughing. He thinks that clots of blood found to exist in different and distinct parts of the lung, at the same time, are phenomena to be explained in this manner. When the texture in some of the lobules is lacerated, he thinks that the lesion happens through the violence of regurgitation on the part of the blood in the bronchi. In support of this view, he relies mainly on the fact that the body of a person who died of a rupture of the lingual branch of the carotid artery, while suffering from tonsillitis, exhibited, at the post mortem examination, hard, dark and small masses of blood, scattered through the parenchyma of the lungs, as well as clots about the trachea and glottis. The doctor takes it for granted that the blood forming these masses in the parenchyma passed there, from the lingual artery through the trachea and bronchi, and hence concludes, that all such masses are formed from blood received through the bronchi leading to the places of their existence. According to this theory, it might be inquired, how the engorged condition of the lung should take place, and yet no hæmoptysis whatever occur, as sometimes happens; but the subject is one on which, it seems to me, we need more light.

When the lung in the condition of pulmonary apoplexy is examined, there are generally found hard knots or compact masses, situated here and there, mainly in the lower lobe and towards its posterior surface. These knots are of a dark red or brown color,