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greatly to be influenced by treatment; but it will be useful to notice the effects on the system generally, and on the lung locally, of moderate hæmorrhage. To many patients its occurrence seems beneficial rather than otherwise, for the congestion is thus relieved, and the system not materially weakened by the loss of blood. The effusion of blood into the smallest bronchi and air-cells does not necessarily cause any general irritation; for after hæmoptysis the presence of blood in the air-vessels may often be detected by physical signs; but these may disappear in a few hours or days, and no results follow. On the other hand, in some instances its presence irritates the lung considerably, giving rise to bronchitis and even catarrhal pneumonia. A rise takes place in the temperature; and sometimes while the hæmoptysis is going on, the pulse becomes more frequent, the breathing more rapid, and the cough more troublesome. Crepitation is heard in the lower lobes of one or both lungs, intermingled with a good deal of sibilant rhonchus, and the case becomes one of pneumonia. Fresh consolidation of the lung may even arise in this way, but according to our experience it is seldom permanent, being reabsorbed. Why the effusion. of blood into the smaller bronchi should be in some cases followed by bronchitis and pneumonia, and should give rise to no symptoms whatever in others, it is difficult to say, but we are inclined to ascribe the inflammatory consequences to a previous congestion, not sufficiently relieved by the hæmorrhage, rather than to the mechanical irritation caused by the blood-clots in the bronchi, which is the cause assigned by Niemeyer. The occurrence of hæmorrhage is generally preceded by violent exertion, sudden change of temperature, or something which produces pulmonary congestion. If the hæmorrhage removes this congestion, no inflammation follows; but if not, the injury of the ruptured vessels, and the reaction, after the

hæmorrhage or its cause, may convert the congestion into inflammation; hence the bronchitis and pneumonia. It may still be admitted that clots of blood plugging the bronchi add to the congestion of the lobules supplied by them, by depriving them of the air necessary for free circulation.

The first case given below, illustrates well some of the bad effects of hæmoptysis, pneumonia being set up by it. In the second case, the general effects were more marked, the patient dying of pyæmia.

CASE 25.-A French valet, aged 34, was seen by Dr. Theodore Williams, January 28, 1871. He stated that six years ago, whilst waiting on a gentleman, he had brought up some ounces of blood, and that since that time he had had two attacks, one two years ago, in which only a slight amount was expectorated, and the other three months ago, when he brought up a pint. He had been subject to cough off and on, and has lost some flesh since the second attack two years ago, but was never laid up or discontinued his work till two days ago, when he was again attacked with hæmoptysis, and brought up a pint; and to-day about an ounce. Is now expectorating bloody mucus. Pulse 68; temperature 978; respiration normal. Has gained flesh in the last three months through taking cod-liver oil. Deficiency of expansion and tubular sounds in upper part of right front chest. Some bronchophony above the scapula.

The patient continued to spit up blood for a week, the amount at a time varying from a teaspoonful to upwards of a pint; various styptics were used, and generally checked the flow of blood, but if omitted, the hæmorrhage returned. There was no rise of temperature or pulse, but the breathing became slightly more hurried, and the cough worse. On February 6 the physical signs were dulness, tubular sounds in upper right chest, some crepitation audible in mammary region. Harsh tubular sounds scattered over both lungs.

He improved on tonics and cod-liver oil for ten days, but on February 16 got excited about the war taking place in his country, and copious hæmorrhage came on. Bowels costive. Cough very troublesome. Temperature 998; pulse 80. Ergot of rye and a blister were ordered.

17th.-Blister rose well, and cough better. No more hæmoptysis has occurred, Bowels still costive; pulse 90; temperature 101.2. Crepitation audible in lower right lung.

18th. Bowels freely open with medicine. Patient very irritable, and has wandered much in his mind, and has had some slight return of the hæmorrhage. Pulse 92; temperature 99-2; respiration 30.

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19th.-Worse. Aspect blanched; breathing embarrassed. Crepitation audible in lower left lung as well as in right. Pulse 108; temperature 1016; respiration 32. A blister was applied to the left side.

20th.-Blister rose well, and patient was relieved as to breathing and cough; but, after severe fit of coughing, slight hæmoptysis came on, and now cough and other symptoms are worse. Pulse 108; temperature 101-2; respiration 36.-Ordered oil again.

22nd. Slight hæmoptysis, and cough has increased. Pulse 100; temperature 1011; respiration 28.

March 3rd.-Patient was very restless, cough very troublesome, and breath very short till a few days ago, when he expectorated largely of thick mucopurulent matter and some frothy mucus, and since then his aspect is much brighter. Crepitation in lower left chest. Rhonchus and crepitation (scattered) over whole right side.—Quinine, in two-grain doses twice a day, was ordered to be combined with the oil, and patient took it for two days, and then refused to take any more.

6th.-Worse; much paler; tongue, which has been generally slightly furred, is now glossy and red. Pulse 120; temperature 100; respiration 32.-Ordered sulphurous acid with tincture of orange, to be taken with the oil.

9th.-Aspect much brighter; tongue cleaner and moister; appetite improved; and patient gets up for some hours in the day. Cough only at night and in the morning, and expectoration frothy. Crepitation in right lung has diminished. Pulse 100; temperature 99.2; respiration 28.

March 28th.-Has steadily improved in the last three weeks, and gaining in flesh and strength. Oil and sulphurous acid have been taken the whole time. Breath remains short. Some dulness above the right scapula, with increased vocal fremitus, and slight crepitation in the upper front; some crepitation at the posterior base of both lungs. Harsh tubular expiration throughout the left lung. Pulse 96; temperature 981; respiration 28.-Ordered oil, with diluted nitro-hydrochloric acid.

April 21st.-Now walks about, though finds breath rather short. Cough only in fits. Has taken oil regularly. Pulse 80; temperature 98·4; respiration 24. In right chest slight dulness and crepitation to third rib. Some scattered crepitus behind. In left chest crepitation has quite disappeared, but harsh tubular sounds are audible in parts.

In this case hæmoptysis occurred several times without giving rise to any inflammatory symptoms; but at length after an attack, pneumonia was set up, which was happily ended in resolution.

The following is a remarkable instance of hæmoptysis, ending in fatal suppuration.

CASE 26.-A nobleman, aged 48, of a gouty family, first consulted Dr. Williams, July 18, 1855. He had suffered from gout more or less for years,

and in order to escape the attacks he had been to the West Indies, and two winters ago to Italy. In the following spring he passed blood by the bowels, and in the summer had hæmoptysis to an ounce, which continued to a less degree in spite of cupping and leeching, but was stopped by gallic acid. Passed the last winter well, and free from cough, in Egypt, until chilled by a ride to Damascus; and in May, while in Paris, brought up an ounce and a half of blood. Cough returned and increased on reaching London in June. Slight dulness, slightly louder breath, with some tubular sound in upper left back. More tubular voice and obscure breath in upper right.---Ordered oil in tonic of nitric and hydrocyanic acids, with tinctures of hop and orange, and counter-irritation.

August 2nd.-Takes the oil well, and with benefit. Dulness and tubular sounds, mostly in upper back, with slight crepitation.

October 5th. Two months ago, after feeling much better and attending quarter sessions, had a cold; and a few days later slight hæmoptysis, and a sensation of weight at the sternum. Gallic acid and acetate of lead were given. On the 2nd and 3rd of October, without effort, he spouted up altogether two quarts of blood, and became very faint. Yesterday and to-day (Oct. 5th) he brought up only a few ounces. A draught of infusion of roses and sulphuric acid, with morphia, was given every four hours. Bowels not open for three days. Patient almost free from cough. Pulse 90. Breath clear and puerile in left front; much obstruction, with obscure crepitation in right front. Too weak to bear examination in the back.—Ordered an aperient draught of sulphate of magnesia and sulphuric acid, and a mixture of gallic and sulphuric acids, &c. The patient continued in an extremely weak state, with frequent pulse and respiration, hot skin, and low fever; expectorating bloody pus in increasing quantities. A few days later symptoms of pyæmia came on; tongue became dry and brown; pulse very rapid and running. Slight delirium ensued, and the patient died within a week.

What influence does the occurrence of hæmoptysis exercise on the duration of phthisis? Does it tend to curtail it? Reliable information on this important point will be acceptable to both physician and patient, affording fair grounds of prognosis to the one and holding out comforting hopes to the other. Our 1000 tabulated cases include 63 fatal ones, where the patients had hæmoptysis of an ounce and upwards on one or more occasions. Among these the average duration was 7 years 6 months; an average only differing by a few months from that of the total deaths. Again, in 220 living cases of

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similarly extensive hæmoptysis, the average was 8 years 3.23 months-about the same as that of the living cases generally. These facts certainly do not indicate that hæmoptysis exercises any curtailing influence over phthisis viewed as a whole. When, however, we classify the deaths according to the stages the patients were in when the hæmorrhage took place, we perceive the significance which attaches to the state of lung at the time of its

We here see that hæmoptysis occurring in the second or third stages is more likely to curtail the duration of the disease than in the first; and in the first, as in phthisical cases generally, it is comparatively unimportant.