doses of tartarized antimony, or of ipecacuanha, are, by some had recourse to from the first; but the practice is one of which I have little experience. Tartarized antimony, it is affirmed on high clinical authority, has actually caused death under these circumstances: however, it does not necessarily increase bleeding even though it causes vomiting, this I have seen in the practice of others. The bowels should be freely opened with cooling saline purgatives, and watery evacuations, if possible, be kept up for a day or two.

Ligature of the limbs, so as to prevent the free return of blood through the veins, has proved a useful adjunct occasionally. Raising the arms over the head unquestionably stops epistaxis sometimes; I know not what effect the position may have in hemoptysis. Free circulation of cool air, light bedclothes, a hard bed, quietude, and silence are essential aids. Large pieces of Wenham Lake ice should be allowed to dissolve in the mouth; and the cautious application of ice in bags to the spine or over the heart I have repeatedly seen (hence I do not value the speculative objections to the practice) almost instantaneously arrest the flow of blood. Heat may at the same time be applied to the extremities.

Among remedies, controlling the action of the heart, digitalis, aconite, and prussic acid claim attention; if the heart be irritable, and the hæmoptysis moderate, the first-mentioned medicine is valuable. Refrigerants, such as nitrate of potass, sulphuric acid, &c., may be employed as adjuvants.

(b.) The medicines belonging to the astringent class, in which I place most confidence, are the acetate of lead, given in doses of two grains with dilute acetic acid and laudanum, every halfhour, hour, or two hours, according to the urgency of the case; gallic acid (grains, three to six, as a dose;) alum; ergot of rye (not so valuable, however, as an epistaxis) and matico. If there be excessive anæmia, the tincture of the sesqui-chloride of iron, or sulphate of iron with gallic acid (making a gallate of iron) may be given from the first. In various other astringents, krameria, logwood, kino, catechu, sulphates of zinc and copper, little trust is to be reposed; nor, useful as it is in some hemorrhages, have I ever seen turpentine distinctly beneficial in hæmoptysis. Drachm doses of kitchen salt, either in powder or dissolved in water, appear sometimes (I have seen the fact in three instances) to arrest hæmoptysis very rapidly, and this, whether they produce emesis or not. Five or six drachms may

be given at intervals,-and, as the agent is always at hand, it may at once be used, while other means are in preparation. The treatment of hemorrhagic reaction and of sinking is the same in the case of hæmoptysis as of all hemorrhages.

Are there any means of preventing the tendency to frequent hæmoptysis in the course of tuberculous disease? I believe not. Cheyne, of Dublin, it is true, had great faith in the prophylactic virtues of small and repeated bleedings; but I confess that the case cited from his practice by Sir James Clark hardly makes me a convert. Hemorrhage was clearly not prevented in this instance (though a weekly venesection was performed for a year,) for the bleedings recurred again and again; and blood-letting seems eventually to have failed even to control the seizures, when actually present. I fully agree with Sir James Clark, that the remedy was relied on too exclusively; nor can I believe that this patient's case was the type of a class, for, instead of becoming spanæmic and emaciated, as the mass of men would under such treatment, he appears to have grown in flesh and regained strength.

ALTERATIONS OF SECRETION.

CEDEMA OF THE LUNG.

Edema of the lung, or serous infiltration of its parenchyma, is in the immense majority of cases a secondary state, occurring either as a part of general dropsy, as a dependence on disease of the heart, as a sequence of congestive conditions of the lung (as after continued fever,) of acute and chronic bronchitis, or of pneumonia. Laennec taught, however, that it may occur as a primary and idiopathic condition, and that the suffocative orthopnoea which sometimes cuts off children after measles, arises from such oedema. Even as a secondary condition it is rare at least, it is rarely demonstrable post mortem.

Disturbance of respiration from a slight to an intense degree, slight cough, watery, or sometimes rather tenacious, expectoration, sensation of weight and heaviness within the chest, constitute its symptoms--a combination any thing but distinctive; neither are the physical signs conclusive. Inspection discloses nothing sufficiently marked to be trusted to; the vocal fremitus

may be slightly intensified; the percussion-sound is duller than natural; the parietal resistance increased; the vocal resonance varies in character; the respiration is weak, and harsh, or even blowing, and mingled with liquid subcrepitant rhonchus: the last-mentioned, when well marked, is the most distinctive, sign.

In congestion of the lung the subcrepitant rhonchus is drier than in cedema, the expectoration more viscid, and there are no dropsical symptoms. Hydrothorax is unattended with rhonchus, and the dulness, caused by the pleural fluid, changes its seat with the posture of the patient. Pleural pseudo-rhonchus, unless care be taken, may be confounded with the subcrepitant rhonchus cedema (vid. p. 126;) the rhonchus of capillary bronchitis is rather to be distinguished, it must be confessed, by co-existent evidence of bronchial inflammation, than by its own characters.

Edema, occurring after pneumonia, furnishes an indication for the use of gentle tonics. If it form a part of general dropsy, it is mainly to be relieved by means calculated to lessen the latter. But dry-cupping and a succession of flying blisters to the chest, sometimes exercise a distinctly beneficial local effect.

HYDROTHORAX.

Hydrothorax, or dropsy of the pleura (serous fluid without inflammation-products,) occurs actively, passively, or mechanically. Of the former kind is the true hydrothorax, occasionally putting the close to existence in cancer of the mamma, and also occurring in certain cases of Bright's disease: on the whole, this variety is very rare. In the great majority of cases, hydrothorax is passive or mechanical, occurs as a part of general dropsy, or is produced by obstructed circulation through the lungs and heart,-especially the right side and tricuspid orifice.

In hydrothorax the pain and "stitch" of pleurisy are wanting, and there is no tenderness under pressure. There is less cough, and may actually be none. But the mechanical effects of hydrothorax are commonly more serious than those of pleuritic effusion, for the simple reasons, that hydrothorax is generally double, and sequential to more or less serious organic disease, already disturbing the respiration and circulation,-pleurisy, on the contrary, generally single and primary. Hence the dyspnoea may be excessive, with constant orthopnoea, and extreme lividity of the face, anxious countenance, clammy perspirations,

and coolness of the expired air. If the patient can lie down, he does so, on the back, with slight inclination now to one side, now to the other.

The physical signs agree with those of pleurisy in some, disagree in other points. Dulness under percussion, moveable in area, with the changed posture of the patient; distant, weak, or suppressed respiration; occasional ægophony; total loss of vocal fremitus, occasionally peripheric fluctuation, are common to the two affections. But in hydrothorax there is no frictionsound or fremitus, and both sides are commonly affected, while in pleurisy one only generally suffers. Dilatation of the side and flattening of the intercostal spaces exist in both diseases, but are carried habitually to a higher point in the inflammation than in the dropsy. The heart and mediastinum are but little displaced sidewards in hydrothorax, because the disease is generally double; the diaphragm may be very considerably depressed.

If the dropsy be of the irritative kind, moderate cupping (unless some contra-indications exist) is beneficial; under all circumstances, dry cupping is advisable. If there be no marked oedema of the walls, the chest should be blistered. Painting with caustic iodine, or ioduretted friction, sometimes obviously promote absorption. The internal remedies are diuretics and purgatives.

Inasmuch as hydrothorax is commonly a local manifestation of a general disease, little, as a rule, is to be expected from paracentesis, at least in the way of permanent cure. But great temporary relief, and even prolongation of life, may be secured in urgent cases by the operation; and, where asphyxia is threatened by double hydrothorax, it appears to me that puncture should at once be had recourse to.

PNEUMOTHORAX.

I. -Decomposition of solid or fluid materials within the pleura, and the secretion of gas by that membrane, are alleged causes of simple non-perforative pneumothorax. As already mentioned, I believe cases of pneumonia occur in which a local pneumothorax appears referrible to a process of secretion; of the other kinds of simple pneumothorax, I know nothing clinically. In the immense majority of cases, pneumothorax comes of injury to the walls of the chest, or of perforating disease of

the lung; and probably in 90 per cent. of the latter class of cases of perforation is tuberculous.*

II. Practically, then, the symptoms of invasion of pneumothorax (excluding traumatic cases) are equivalent to those of perforation of the lung, or, more correctly speaking, of the pulmonary pleura. And these are sudden sharp pain in the side, often of agonizing, overwhelming intensity, coupled occasionally with a sensation of something having given way internally, and of fluid escaping into the chest, and almost invariably most intense dyspnoea. If these three symptoms suddenly and unmistakeably appear in a phthisical person, the diagnosis of perforation would rarely be at fault; but I have known perforation occur, as proved by physical signs and inspection after death, without any one of the three announcing its occurrence. The physical signs are the only unfailing evidence. After a time, the sensation of dyspnoea may wear off; I have known a man's respirations 52 in the minute without his feeling any of the sufferings of difficult breathing.†

Air effused into the pleura acts as an irritant on the pleural surface; fluid is produced (often within twenty-four hours,) and the compound state of hydro-pneumothorax is established. The patient lies in various postures, but most commonly and steadily on the back, inclining to the sound side, with the head more or less raised: orthopnoea also occasionally exists. The pulse is. excessively frequent; but the respiration relatively more so; I have known the ratio perverted into one of 2.3 to 1. The countenance is pinched, anxious, and imploring; the lips, cheeks, and face generally more or less livid; the sleep consists of fitful dozes at rare intervals; the skin is moist, sometimes bathed in cool clammy perspiration. The voice habitually loses strength greatly, and almost complete aphonia has sometimes been observed. Edema of the affected side of the thorax is, at the least, very rare, before pneumothorax has been accompanied, and this for some time, with pleuritic effusion.

The perforation may either undergo closure by lymph, or remain pervious. I have seen two cases of the former kind, in

* Of 147 cases of pneumothorax collected by M. Saussier, 81 only were phthisical. But tuberculous perforation is an every-day affair, which passes unnoticed; perforations from gangrene, vesicular emphysema, hydatids, pulmonary apoplexy, abscess, &c., are greedily caught hold of, and recorded. The number of the latter published, consequently, gradually swells out of proportion with their real frequency.

Plimton, Clin. Lect., loc. cit., p. 575.