The slighter hemoptysis, which comes on in the progress of consumption, seldom demands constitutional bleeding: it will in general be checked by acetate of lead, nitre, digitalis, conserve of roses, acidulated drinks, &c. When the frequency of hemoptysis in an individual not naturally predisposed to phthisis leads us to connect its cause with some obscure condition of the capillary vessels of the organ exhibiting itself in either active or passive hemorrhage, we have to treat it as an idiopathic disease, and not, as before, as a symptom whose treatment was modified by that of the disease upon which it depended. The character of the hemorrhage, whether active or passive, alone regulates our attention: we are, therefore, relieved from the caution with respect to bleeding which tied up our hands in the management of this morbid phenomenon in phthisis. It was this kind of habitual hemoptysis to which we before alluded, as deriving so much benefit from small bleedings often repeated; a practice which seems to us entitled to a decided preference over large bleedings which cannot be repeated: for the efficacy of bleeding in these cases depends not so much upon the quantity of blood drawn, as upon the revulsive effect of the operation; the opening in the vein solicits the blood to it, and so diverts it from the source of the hemoptysis. The older physicians appreciated this point of practice, and accomplished it by closing the opening during the operation. When we reflect how comparatively independent of the general circulation the capillary system is, we see reason to expect more advantage from means which have more of a local operation, as cupping, leeching the chest, &c. We shalĺ find nothing to exercise such a salutary control over this kind of hemoptysis as change of air, adapting the temperature to the character of the discharge; if it be active, removing to a warmer climate; if passive, to a colder and more bracing. This hemorrhage is much influenced by moral causes; moral management contitutes an important part of its treatment: the writer has known it to cease immediately upon hearing agreeable news. TUBERCLES and PHTHISIS, to which we refer not often required in such a habit; we only for more detailed information upon them. We question its propriety as a preventive measure. would only observe that the causes which call a tubercular diathesis into active operation are such as have the effect, either directly or indirectly, of debilitating the energies of the constitution; and that therefore, though hemoptysis be a complication with which we cannot tamper, but which we must meet with decision, we cannot but regret the dilemma in which we are placed by a symptom requiring a mode of treatment which we have reason to apprehend may have the effect of increasing that condition of the system which has given rise to the original disease. We would convey our opinion respecting bleeding in phthisis in the words of Laennec, who observes that as bleeding can neither prevent the development of tubercles, nor cure them when they are formed, it should not be employed in the treatment of phthisis, except with a view to subdue an inflammatory complication or acute sanguineous congestion; beyond this it is a gratuitous waste of the patient's strength, and may be superseded by medicines, which have the effect of reducing the powers of the circulation without producing permanent prostration, such as digitalis, tartar emetic, &c. We would here express our decided conviction that phthisis, of which hemoptysis is so frequent a symptom, would be treated with much more success if physicians were not continually haunted with the apprehension of exciting or keeping up inflammation; a feeling which, within due limits, should ever be present, but still when pushed too far, and acted upon too rigorously, it deprives the system of its remaining stamina, and unfits it for bearing the exhausting effects of a wasting disease. A gentleman in Scotland (Dr. Stewart), who has now ceased to be a member of the medical profession, long since ventured to deviate from the routine of practice in this disease, and pursued a mode of treatment which has had most encouraging success: the principle of this treatment was to strengthen the constitution. He argued, that when the tubercles softened and the expectoration became purulent, the treatment should be the same as that required by the formation of matter in other parts of the body, when we have no other view than that of supporting the system. To fulfil this intention he treated the disease with tonic medicines cautiously exhibited, but placed his chief reliance upon cold bathing, exercise, and nourishing diet. His plan with respect to cold bathing consisted in making the patient sponge the entire body in the morning, and the neck, chest, and shoulders at night, with tepid vinegar and water, whose temperature was reduced each day till it was quite cold: this sponging was followed by rubbing for half an hour with flannels, and then with a flesh-brush. By degrees, as the feverishness subsided, the vinegar was laid aside. This was a preparation for cold bathing, and afterwards for sea-bathing. We do not mean to affirm that tubercles do not often form in an inflammatory habit, and that bleeding is Pulmonary apoplexy demands full depletion. Bleeding should be carried to the extent of producing fainting; and should the hemoptysis still continue, we must adopt every other means calculated either directly or indirectly to lower the energies of the circulation. For this purpose we would employ small doses of ipecacuanha often repeated, so as to keep up a continual nausea. Purgatives are a valuble resource. Laennec has not found tartar emetic as beneficial in this form of disease as in inflammation. Astringents should not anticipate the chronic stage of the disease. Hemoptysis dependent upon gangrene of the lungs requires a mode of treatment adapted to the vitiated constitution in which it occurs. Tonics constitute our principal remedial agents, while we seek to allay the irritation of the cough by opium, hyoscyamus, conium, &c. When hemoptysis proceeds from the larynx or trachea, and seems to be produced by an excessive exercise of voice, the first thing required is the repose of the organ; nor, in general, is this enough; as the local affection is merely the index of constitutional relaxation, the object of the means we employ must be to restore the tone of the system by exercise, showerbaths, sulphate of quinine, &c. To this we would add sponging the throat with vinegar and water. For further information on this subject we would refer to the articles ApoPLEXY PULMONARY; PHTHISIS PULMONALIS; LUNGS, GANGRENE OF THE, &c. &c. (Robert Law.) HEMORRHAGE, (aiμoppayía, from alua, sanguis, and phywu, rumpo,) loss of blood. The purpose of this article is to present a summary view of the knowledge we possess, and of the doctrines now generally received, concerning internal hemorrhage. The term is here employed in its most comprehensive sense, as signifying the passage of the blood beyond its natural channels-beyond or out of the vessels that are appointed to contain and convey it in the healthy living body. Under this definition it is indifferent whether the extravasated blood remains pent up within the body or not. The epithet internal is however prefixed, in order to limit the subject to those forms of hemorrhage which fall within the province of the physician, and to exclude all consideration of those cases which, whether they are the result of disease, or of accidental injury, or of surgical operation, are capable of relief by mechanical expedients only. These latter cases are sometimes, though not perhaps with much propriety of language, comprised under the general title of surgical hemorrhage, in contradistinction to the former, which are then classed as being medical. In what has been called surgical hemorrhage the blood proceeds from some large vessel, situated within the reach of the eye and the finger. The principles upon which the loss of blood in such cases is arrested or prevented are well understood; and in no part of the rapid progress of modern surgery has the union of well contrived observation with sound reasoning been productive of more admirable results. With a few remarkable exceptions, such as the protection afforded against small-pox by vaccination, or against sea-scurvy by the use of lemon-juice, there is not perhaps any single improvement in the art of healing by which so many lives are saved, and so much human suffering is relieved or averted, as by the scientific application of the ligature upon the larger blood vessels. That kind of hemorrhage which falls to the care of the physician is less perfectly understood, and is controllable with less certainty. It comprehends, however, a large and very formidable class of diseases. In some of these the effusion of blood is an accidental symptom only; of many it forms the principal sign or circumstance; and there are others in which it may be considered, in reference to our united means of investigation, as constituting the whole disease. The accidental injuries to which the animal frame is continually exposed must have furnished mankind, from the earliest times, with frequent illustrations of the striking fact that the mere loss of blood, when it exceeds a certain amount, implies also the loss of life. They who had seen their fellow-men bleed rapidly to death from external wounds would be strongly impressed with the great importance of the fluid, the removal of which from the body led to an event so appalling; and they would look with interest and alarm upon the rarer instances which might occur of bleeding from internal and unseen parts. A natural but deceptive analogy, uncorrected by pathological knowledge, would almost unavoidably lead them to this further inference, that all hemorrhage hemorrhage, the source of which they could not see, as well as that the source of which they were able to examine and appreciate,-proceeded from an opening in the sides of some one (or more) considerable bloodvessel. It is true that some hemorrhages, of which the origin is, during life, beyond our vision and means of inquiry, do result from the rupture of vessels of a certain magnitude; but it is no less true that in the greater number of instances of bleeding from the interior of the body, there is no lesion, capable of being detected by dissection, either of the veins or the arteries; but the blood is poured out by what is called exhalation, and proceeds from those ultimate ramifications of the minuter bloodvessels which constitute the capillary system. This remarkable and important piece of knowledge was ascertained long since by Morgagni; it was more formally and completely demonstrated by Bichat; and it has been so amply illustrated by subsequent observation that it may seem to be a fact almost too trite to dwell upon. Yet, judging from the writings and language even of medical men, it does not appear to be so generally known or acknowledged as it ought to be among them; and among unprofessional persons the old errors upon this subject prevail almost universally. To break or burst a bloodvessel, in the most literal meaning of those words, is thought by the public, and by some at least of the profession, to be a misfortune of very common occurrence; yet relatively to the frequency of hemorrhage, it is certainly a very rare one. Bichat explicitly propounds the doctrine that in certain hemorrhages the blood escapes from the capillary vessels by a process which, in pursuance of his example, and to avoid circumlocution, we shall call that of exhalation. He rests this opinion upon several distinct considerations, some of which are perhaps more curious than conclusive. Thus he states that if the uterus of a female who has died during the menstrual period, be carefully examined, no erosion of its inner sur face or of its blood vessels can be seen, nor any of those numerous cicatricula which, he argues, must have been formed, if each occurrence of the catamenial discharge had resulted from a rupture of those vessels. The rupture which he here supposes is the simultaneous laceration of numberless capillary blood vessels. Such laceration, if it took place, would indeed account for the discharge; and it has been assumed in explanation of some morbid hemorrhages. It is by no means certain, however, that it would give occasion, especially on a mucous surface, to visible scars. Punctures, even of the skin, made by fine needles which wound the blood vessels, do not, we imagine, however numerous they may be, leave any such traces of their former presence. He adds, that if we submit the same uterus to pressure, and mark closely what happens, we see minute drops of a red fluid exude from its inner surface; and if we then wipe these drops away, the membrane whence they proceeded appears to be perfectly entire. Whatever weight this argument may possess is strengthened by the actual observation of the process of menstruation in the living uterus. Dr. James Hamilton of Edinburgh is in the habit of relating, in his lectures, the case of a patient who was once under his care, and whose complaint appeared to him so instructive upon this very point, that he sent her into the clinical wards of the infirmary, that the students might have an opportunity of witnessing it. This woman was afflicted with enlargement and complete prolapsus of the uterus. The professor describes the inverted womb as having hung down between her thighs like a quart bottle; it could not be replaced; and it was tense and hard, except during the periods of menstruation, which took place regularly. At those times it became soft and flexible, and the menstrual discharge was seen, by numbers of medical men and of students, to issue guttatim from the exposed surface. As, however, the process of menstruation cannot be looked upon as a morbid process; as, in the unpregnant female, during a certain portion of her life, it is not only consistent with perfect health but actually essential to it; and as the fluid so poured out is not strictly blood; the analogical argument drawn from the preceding facts in favour of hemorrhage by exhalation, though it may afford a strong presumption, is not decisive. But the deficiency here noticed is supplied by what is observed in those cases (rare indeed, yet well authenticated) of actual cutaneous hemorrhage, where a dew of blood appears upon some portion of the skin, is wiped away, and reappears, with no perceptible alteration of the affected surface beyond some occasional variation in its colour. Another of the arguments advanced against the possibility of rupture or laceration in such cases is drawn from the well-known fact that the flow of blood, or of the catamenia, will sometimes continue for a few moments, then cease, and again recur; and that these alter nate changes may happen several times in the course of a single day; so that, upon the supposition against which Bichat is contending, the wounds of vessels must heal and re-open at every change. This reasoning is obviously both inconclusive and erroneous. We know that the cessation of hemorrhage from a torn vessel may and often does result from other causes than cicatrization; that even when the vessel is of considerable size, and the laceration extensive, the bleeding may occur, and pause, and occur again, and that repeatedly, within a short space of time. Bichat did not overlook that species of evidence by which alone, after all, the existence of hemorrhage, independent of any rupture of vessels, can be satisfactorily established. He states that he had frequently dissected the bodies of persons who had died from hemorrhage; that he had examined, according to the nature of the case, the surfaces of the bronchi, the stomach, the intestines, or the uterus; and that, although he took the precaution of washing them clean, and even of submitting them to maceration before he inspected them with a microscope, he never could detect the slightest appearance of erosion. Numerous and conclusive observations of the same kind have been accumulated by the zealous pursuit of morbid anatomy for which the present age is so remarkable; and in this way direct proof has been obtained, not only that internal hemorrhage may take place from the surfaces of membranes by exhalation, but that this is the mode in which it most commonly happens; that the effusion of blood by any of the natural outlets of the body can seldom, excepting in the cases of aneurismal disease, be explained by the detection of a broken bloodvessel. Where hemorrhage, for example, has occurred so profusely from the stomach or bowels that the death which ensued has been sufficiently accounted for by the mere loss of blood, the whole tract of the alimentary canal has been diligently scrutinized, and has exhibited no breach of surface, nor any perceptible alteration of texture. Sometimes its mucous membrane appears, here and there, of a red colour, and as it were charged with blood; sometimes it is pale and transparent, while the vascular network visible immediately beneath it is gorged and turgid; sometimes the whole is colourless, the same network of vessels having been completely emptied by the previous hemorrhage; and sometimes again (and this is very illustrative of the mode by which the blood has issued) vast numbers of small darkcoloured masses, like grains of fine sand, can be made to start from the surface of the membrane by slight pressure. There can be no doubt that these are minute portions of blood, which had remained and coagulated in the vessels or apertures forming the ultimate channels of the hemorrhage. These views receive an indirect but strong support and illustration from the well-known circumstance, that certain hemorrhages are pre ceded and followed by an increased efflux of the fluids which belong to the surface concerned. In hemorrhages from the mucous membranes this succession of events is in some persons habitual. First there is an augmented flow of mucus alone, then of mucus tinged with blood, then of blood alone; and the hemorrhage ceases by a similar but inverse gradation towards a mucous drain, which itself at length decreases and disappears. In such cases (there being no manifest erosion or or ganic change) it is apparent that the blood proceeds from the same vessels or apertures, which in health pour out the natural fluids of the part-mucus, serum, or sweat. There seems no more necessity, under the action of disease, for a rupture of vessels to give exit to the blood than to give exit to these fluids. What the vessels or outlets to which we give the name of exhalents really are-how they are distributed and arranged-in what manner they are connected with the ordinary capillary circulation of red blood-or under what influences they are placed-are points concerning which we have little or no certain knowledge. We know indeed that such channels must exist, though we cannot demonstrate or see them; and that, whilst the health is entire, they do not allow the blood, as such, to pass through them. Several kinds of hemorrhage by exhalation have been enumerated by pathologists, according to the different morbid conditions with which the efflux of blood is associated. The chief distinctions of any importance may, however, be almost all comprised within the two general classes of idiopathic and symptomatic hemorrhage. Idiopathic hemorrhage is that which occurs without any discoverable change of texture, either in the part from which the blood proceeds, or in any other part capable of influencing the circulation in the former, by reason of some intelligible connexion of structure, or function, or mutual relation. The epistaxis of young persons affords an example of this kind of hemorrhage, to which the terms spontaneous and essential are also sometimes applied. Symptomatic hemorrhage, on the other hand, is that which depends upon some notable organic disease. It comprehends all cases of hemorrhage by exhalation not embraced by the definition just given of idiopathic hemorrhage. It may be said to be primary when the organic disease upon which it depends is situated in the very part which gives issue to the blood; secondary, when the organic disease is situated in some other part more or less distant from the former. We have instances of the primary species in hemorrhage from the stomach, or from the uterus, dependent upon incipient scirrhus of those organs; from the pleuræ or peritoneum, under violent inflammation; from the mucous membrane of the air-passages in intense bronchitis. Examples of the secondary species occur in hemorrhages from the bronchial membrane in consequence of the presence of crude tubercles in the lungs, or of organic disease of the heart; and in hemorrhages from the mucous membrane of the stomach and bowels in consequence of disease obstructing the circulation through the spleen or liver. The proximate cause (as it is called) of idiopathic hemorrhage-or the essential condition of the facts concerned in its production-is involved in much obscurity. There appears good reason for believing that it is different in different cases. It is certain that in very many instances the hemorrhage is preceded and accompanied by an unusual accumulation of blood in the capillary vessels of the part. In the secondary species of symptomatic hemorrhage this kind of sanguine congestion is also almost always present, and is then owing to some mechanical impediment of the venous circulation. The causes of such congestion antecedent to idiopathic hemorrhage are less obvious, especially when the congestion is partial. Since the time of Stahl and his disciples the existence of local plethora has been fully recognised as constituting a frequent element of disease. Some of the distinctions introduced by him were doubtless fanciful: it is certain, however, not only that local congestion is of common occurrence, but also that this unequal distribution of the blood in the capillary vessels may happen in several ways, and from various causes, easily distinguishable from each other. M. Andral, the most recent, and probably the most able writer on this subject, describes three different conditions under which local plethora (or, to use his own convenient though somewhat uncouth phraseology, hyperemia) may occur in the living body. One of these conditions has been already adverted to, that, namely, in which the return of the blood from the capillary vessels towards the heart is impeded by some mechanical obstacle. Hyperemia of this kind may be strictly local. It may be confined to a single limb when the principal venous trunk belonging to that limb is compressed, or otherwise diminished in size. If there be disease of the liver, of such a nature as to prevent a free passage of the blood through that organ, congestion will take place in all those parts of the capillary system from which the blood is conveyed by the veins that ultimately combine to form the vena porta. The force of gravity alone will be sufficient to induce venous congestion in parts of the body in which, under ordinary circumstances, the circulation through the veins is aided instead of being opposed by that force. If the head, for instance, be suffered to hang downwards for a certain time, we see the unequivocal signs of such congestion in the tumid condition and the purplish colour of the lips, cheeks, and eyelids. When an impediment to the free transmission of blood exists in the heart itself, a tendency to stagnation is produced, first in the venæ cavæ, then in the smaller ramifications by which these veins are fed, and at length in the general system of capillary vessels; and thus general hyperemia from a physical cause will ensue, the parts which are the most vascular being also the most readily and the most completely gorged. The two other forms in which local plethora or hyperemia may present itself are called respectively active or sthenic hyperemia, and passive or asthenic. The first of these proceeds from some irritation or stimulus, either applied to the part itself, or influencing that portion of the nervous system by which the vital actions of the part are regulated. The irregular distributions of blood which fall under this head are not always morbid. In a certain degree and for a certain time they may consist with the most perfect health. The deep flushing of the cheeks and forehead under strong mental emotion, and the general redness of the skin produced by violent exercise, are familiar illustrations of this healthy congestion of capillary vessels. A similar congestion may be produced at will upon the surface of the body by mechanical or chemical stimuli-by friction for example, or the application of heat. If these causes of the local accumulation of blood be intense in degree, or continue to be applied for a certain time, the congestion is accompanied by disturbance of the functions of the part-by pain, or by other well-known changes. But local congestion of this active kind, and essentially morbid in its character, is of frequent occurrence in various organs of the body; and in many of these cases there is no obvious exciting cause of such an unequal distribution of the blood. We have evidence indeed, in the blush of shame or anger, and in the paleness of fear, that the capillary blood vessels may be filled to excess, or completely emptied, by causes operating through the brain and nerves; and it seems probable that morbid congestions, which are sometimes separated from those consistent with health by shades of difference not easily discriminated, may also be occasioned through the agency of the same nervous system. Local hyperemia of the active kind seems in many instances to form a part, or rather to be an effect, of a plethoric condition of the whole body. To understand precisely what is meant by a state of general plethora, it is necessary to remember the physiological doctrine that the whole vascular system is constantly distended beyond the size of the vessels when free from any distending force. When the arteries are in any way emptied of their contents, their diameter diminishes, and frequently they become even impervious. The general notion of plethora is that this state of distention is greater than what is ordinary or natural. It is easy to conceive that in persons who live fully, lead an inactive life, and sleep much, there should be a greater quantity of blood formed, and consequently a preternatural distention of the vessels. Fulness of habit and a florid complexion are marks of the existence of general plethora; of superfluous blood being partly expended in the formation of that substance which is the least necessary in the animal economy, namely, fat, the capillary vessels of the face partaking of the general fulness or vascular distention present in all parts of the system. We trace the existence of general plethora also in the character of the diseases most prevalent in those who are the subjects of it, in the tendency especially which they evince to hemorrhage and to inflammation. A state of general plethora is, however, by no means essential to the production of local congestion, which, on the contrary, is of frequent occurrence in persons who are pale, spare, and deficient in blood. Nay, a remarkable proclivity to an unequal distribution of blood in the capillaries, has been observed in those who, from accident or disease, have already lost large quantities of that fluid. The general symptoms, however, which accompany local hyperemia in these two opposite conditions of the system, undergo proportional modifications. The simple existence of local congestion of the active kind, and independent of any mechanical impediment, is sufficient to show that the blood, after it has entered the capillary system, is no longer under the sole influence of the heart's impulse; but that its subsequent motion is mainly determined by a power of contraction belonging to the smaller bloodvessels themselves. It is upon a supposed defect of such power-a diminished tonicity of the vessels, that the doctrine of asthenic or passive hyperemia is founded. The efficacy of the assigned cause in the production of hyperemia is perhaps less obvious here than in the cases which have just been considered. The following are some of the observed facts from which its actual operation has been presumed. In persons enfeebled by age or by disease, the lower parts of the legs, the ankles, and insteps, and the skin which forms the surface of old scars, are often habitually purplish or violetcoloured. This cannot be owing to the mere influence of gravity, because that remains constant at all ages and in all conditions of the system. The peculiar colour, denoting a sanguine congestion of the part in which it is visible, may indeed be diminished sometimes by placing the limb in the horizontal position, whereby the weight of the blood in opposing its own return from the capillary vessels being removed, the action of the vessels themselves again suffices for its propulsion. But the congestion in these cases often disappears upon the employment of friction, or of stimulating application, which would be powerless against any mechanical obstacle in the larger veins, and which would tend to increase the afflux and accumulation of blood in active hyperemia. In the same way the large, flabby, and livid granulations which often appear on the surface of indolent ulcers, are made to contract, and to assume a more healthy and florid hue by local stimulants, which quicken the previously languid circulation by exciting (it is supposed) the vital action of the minute blood vessels. There is no part of the body which affords more striking and unquestionable evidence that |