PULMONARY HEMORRHAGE.

Two forms of pulmonary hemorrhage are recognized: 1. Broncho-pulmonary hemorrhage, or bronchorrhagia, in which condition the blood is poured into the bronchi and is expectorated; 2. Pulmonary apoplexy, or pneumorrhagia, in which disease the hemorrhage occurs into the substance of the lung.

BRONCHO-PULMONARY HEMORRHAGE, OR HÆMOPTYSIS. There is a variety of causes giving rise to this condition. (a) Pulmonary tuberculosis is the most common cause, and it should always be suspected, even if neither symptoms nor physical signs be present. Small repeated hemorrhages in the earlier stages are due to bronchial congestion or ulceration. Large hemorrhages in the later stages arise in cavities from erosion of a branch of the pulmonary artery or from rupture of an aneurysmal dilatation of the same.

(b) Hemorrhages may occur in young people without assignable cause, although in some cases they may follow excitement or severe muscular exertion, especially in high altitudes.

(c) Anæmic hysterical women may raise a little blood from time to time without apparent reason. Deception must always be suspected in such cases, however.

(d) Severe injuries and contusions of the chest are often. followed by hemorrhage.

(e) Patients with emphysema and bronchitis may occasionally raise small quantities of blood.

(f) Hemorrhage may result from certain diseases of the lung, the initial stage of pneumonia, cancer, gangrene, abscess, or bronchiectatic cavities.

(g) Vicarious hæmoptysis may occur with interrupted menstruation. It has been known to follow removal of both ovaries.

(h) Small repeated hemorrhages are common with the pulmonary congestion of heart disease, especially with lesions of the mitral valve.

(i) With aneurysms small quantities of blood may be raised

from congestion of the bronchi from pressure or by leakage through a small perforation. Large and fatal hemorrhage results from rupture of the sac into the trachea or into a bronchus.

(j) Any ulcerative process in the larynx, the trachea, or the bronchus may cause small repeated hemorrhages.

(k) Sir Andrew Clark describes a form of hæmoptysis, seen in elderly people, which he calls "arthritic hæmoptysis." It occurs in those of the arthritic diathesis; it is due to minute structural alterations in the terminal bloodvessels of the lung. The prognosis in these cases is usually good.

(7) Hæmoptysis occurs with extensive blood-alterations. of malignant fevers, as hemorrhagic variola, and with purpura hæmorrhagica.

(m) In Japan and China occurs an endemic hæmoptysis due to the presence of the Distoma Ringeri in the bronchi.

Symptoms.-There may be a preceding feeling of oppression in the chest, but usually the first symptoms are a warm, mawkish taste in the mouth, nausea and faintness, and the appearance of the blood. The quantity of blood ejected varies from a dram to a pint or more.

Anæmic symptoms-faintness, syncope, dyspnoea, "airhunger," and pallor--depend on the quantity of blood lost. Large hemorrhages may be fatal from anæmia or from the filling of the bronchi with blood, but usually danger is not imminent. There is generally but little effort in raising the blood. Should the quantity be large, a certain amount may be swallowed, to be vomited later or passed with the stools. Blood from the lungs has certain characteristics which distinguish it from blood from the stomach. scarlet in color, of an alkaline reaction, frothy, and mixed with mucus. In the clots air-bubbles can usually be seen. After a hemorrhage the sputa are usually blood-stained, of a dark crimson or brown color, and frequently clots like bronchial casts are raised. Vomited blood is dark brownish, contains no air, but is mixed with stomach-contents and is of an acid reaction. Blood coming from the pharynx or the nares is usually hawked up, and on inspection blood

streaks can almost always be seen descending from the naso-pharynx.

Large hemorrhages, leading even to a fatal issue, can take place into extensive pulmonary cavities without blood being coughed up at all. The hemorrhage may continue for several hours or even days, and attacks may be repeated from time to time. They may be induced by exertion, by over-indulgence in stimulants, or by excitement, but in some cases they occur without apparent cause, even while the patient is resting quietly at night.

Anæmic symptoms follow large hemorrhages, but after small hemoptyses the patients frequently feel much relieved in their pulmonary or cardiac symptoms.

Treatment. For the large hemorrhages arising from erosion of an artery or from rupture of an aneurysm treatment is unavailing. The patient should be kept absolutely quiet and secluded, and small doses of opium should be given to relieve the restlessness and steady the heart. Fainting is nature's measure of tranquillizing the circulation and inducing firm thrombosis.

Anæmic symptoms are treated by elevation of the foot of the bed, by ligating the extremities, and by hypodermic. injections (hypodermoclysis) or arterial transfusion of sterilized saline solutions, which may also be given by the rectum. Internal hæmostatics are useless.

In less serious hemorrhages the patient may be given ice to swallow and may drink small quantities of aromatic sulphuric acid in water. Theoretically, measures to reduce the frequency of the heart-beats and reduce the blood-pressure in the pulmonary circulation are indicated, but our knowledge as to how this latter indication can be fulfilled is very meagre. Rest should be enforced, and opium be given to quiet the patient. The diet should be light, and stimulants should not be employed. Digitalis is contraindicated. Aconite may be given with benefit if there be vascular excitement. Acid drinks and cracked ice may be given. Ergot, gallic acid, acetate of lead, hydrastis, and krameria are used. as routine measures, but are of doubtful utility. Ice applied to the chest is recommended, and in some cases it seems

to do good. Free purgation is indicated to reduce bloodpressure; it should be resorted to in all protracted cases.

PULMONARY APOPLEXY; HEMORRHAGIC INFARCT. Hemorrhage into the substance of the lung, with rupture. of its tissue, may occur with severe contusions, with penetrating wounds, and with rupture of an aneurysm. Aside from these cases, so-called "hemorrhagic infarcts result from embolism or thombosis of a branch of the pulmonary artery, resulting in the stoppage of its circulation. As these are "terminal" arteries, without anastomotic branches, the blood in the vessels beyond the obstruction is in a condition of stasis, and congestion occurs from a backward pressure into the shut-off region. The vascular walls lose their consistency and allow the escape of blood into the surrounding structures.

The hemorrhagic area is red and solid, resembling a bloodclot, becoming reddish-brown in time from pigment-changes. It is of a wedge shape with the base out; the pleura covering it is usually inflamed. It is usually situated toward the base, and it varies in size from a walnut to that of an orange. There may be a surrounding zone of pneumonia. Such an infarction may be absorbed if small, but it usually becomes changed to a pigmented, puckered cicatrix. In rarer cases it may undergo sloughing or gangrene. Abscess results if the cause be an infectious embolus containing suppurative micrococci, as may occur in pyæmia or in malignant endocarditis.

Symptoms.-There is usually pain in the side, sudden dyspnoea, oppression in the chest, and bloody expectoration, in some cases amounting to a fair-sized hæmoptysis. Physical examination yields over the hemorrhagic area, if it be of sufficient size, dulness, bronchial voice and breathing, and pleuritic and bronchial râles. Large hemorrhagic infarcts may be followed by sudden death. It must be remembered that obstruction of a large branch of the pulmonary artery can occur without the formation of a hemorrhagic infarct.

The treatment is practically that of pneumonia.

LOBAR PNEUMONIA.

Definition and Synonyms.-Lobar pneumonia is an infectious disease due to the diplococcus pneumoniæ; it is characterized by an inflammation of the lung with constitutional symptoms. Synonyms: Croupous or Fibrinous. Pneumonia; Pneumonitis.

Etiology. The diplococcus pneumonia of Fränkel, commonly known as the "pneumococcus," is the specific germ of the disease. It is an ovoid coccus, or, more properly speaking, a bacillus, usually occurring in pairs, and more often encapsulated. It is found in the nasal and buccal secretions of 20 per cent. of healthy people, and after an attack of pneumonia it is often found in the mouth for months; hence there must be conditions giving the germ at times more intense pathogenic properties, or conditions ren

FIG. 26.-Fränkel's pneumonia coccus, bred from the expectoration. (Prepared by Prof. Gärtner. Oil-immersion lens: eye-piece No. 4.)

dering the individual susceptible to the infection. Among these causes may be mentioned exposure to hardship and cold; consequently the disease is more frequent in men. than in women. It frequently follows immersion in cold water. Traumatisms of the chest-wall produce the so-called "contusion-pneumonia." Alcoholism, chronic Bright's disease, and any condition of bodily weakness predispose to the disease. Repeated attacks may occur; they are explained by auto-infection from the persistence of diplococci in the buccal and nasal secretions. The disease is more common in the months from February to May, although it may occur at any time. It occurs in all temperate climates, but it is unknown north of Labrador. It is more frequent in