cavity. Ipecacuanha is useful when the hæmorrhage is of moderate quantity, and when its locale is recognised by comparative dulness and moist râles. Hamamelis I believe to be specially suited to hæmorrhages from the mucous membrane of the bronchi, and I believe that it is from its value in these cases that this remedy takes its high stand amongst us.

There are two points, however, which it is very necessary to remember in the treatment of hæmoptysis; first, that relapses after the first apparent check of the bleeding are very common, and very alarming to the patient and attendants; second, that the effusion of even a small quantity of blood into the bronchial tubes and air-cells may set up pulmonary irritation which may end in destructive tissue change. I believe, therefore, that it is good practice, and our duty to our patient and ourselves, after that we have selected and exhibited the remedy best indicated, to leave a reserve in the way of a thoroughgoing styptic to be used should occasion demand it. And this is all the more necessary and desirable, seeing that precise means of ready differential diagnosis are generally wanting.

IV. In the fourth section I would place those cases of hæmorrhage which arise from what is called "breaking a blood-vessel." They may be caused by the slow process of ulceration through the walls of an artery during the formation or increase of a cavity; or the blood may be poured out from several small vessels which have been ruptured by the movements of some calcareous fragment, or a weakened and exposed artery may be ruptured by some sudden exertion or emotion. In all such cases we get a profuse hæmorrhage, rapidly occurring often to the extent of half a pint or a pint in a few minutes, followed by a cessation thereof as soon as a clot forms round the vessel; often, however, to be renewed so soon as a fit of coughing removes the clot from its position. Generally speaking there will have been a previous knowledge of such a patient's condition, and therefore the diagnosis can be readily effected.

I do not consider the treatment of these cases to fall within the homoeopathic law; we have to all intents a wounded vessel pouring out blood into the lung. We cannot cut down upon it or tie it, we can only influence it indirectly. This can be done either by a medicine like Secale, which contracts in full doses the calibre of the vessel through the vaso-motor system; or by Gallic acid, which in full doses has a similar effect by acting directly on it through the blood itself. It is very difficult to estimate the precise value of these two remedies; in the slighter cases they do appear to act successfully and well, while in the severer cases they either or both may fail decidedly, and the hæmorrhage at last cease without any special cause whatever. In one most anxious case that I attended four years ago the attacks were most alarming, occurring once or twice in the twenty-four hours, scarcely ever to a less amount than half a pint, and they continued for ten days, and then when all hope was apparently gone they ceased entirely and the patient rallied.

I believe the Secale, to be fairly tested, should be given in 20 or 40 drops of the mother tincture, and the Gallic acid in 10 or 20 grain doses, stirred up in water.

There are several remedies mentioned in our repertories and manuals as valuable in hæmoptysis which I have not yet touched upon., Arnica would be useful in the third class, when the exciting cause was muscular exertion. Bryonia is reputed to be valuable in vicarious hæmoptysis, but I should rather suggest its sphere of action to be that of a valuable controller of the circulation, at the same time that it prevents lung irritation from the inspired blood. Millefolium I cannot say that I have derived any marked value from, though I notice it is spoken very highly of by our colleague Dr. Richard Hughes. Aconite and Ant. tart. are medicines that I prefer not giving in hæmoptysis, even when the case is slight and other symptoms may seem to call for them; I have seen them apparently in several instances occasion a recurrence of the bleeding.

Styptic sprays I have at times used, but I have for some time given up their use; they doubtless do restrain

hæmorrhage, but they do it by coagulating a considerable amount of effused blood in the lung, aud the consequences of this proceeding are decidedly mischievous. A kind of catarrhal pneumonia is set up; the alveoli and bronchioles are blocked with a cheesy effusion, and destruction of lung tissue may ensue with considerable rapidity.

Discussion on Dr. Herbert Nankivell's paper.

Dr. RANSFORD feels obliged to differ from Dr. Herbert Nankivell that large hæmorrhages do not come under the homoeopathic law, because the so-called rupture of a blood-vessel is generally caused by pulmonary disease, which must therefore be treated by the appropriate remedies. He is sure that greater success can be obtained by these means than by styptics only. He speaks not from personal experience alone, but also remembers the treatment pursued by some of the most eminent practitioners with whom he was associated in early life, such as the late Drs. Abercrombie, Begbie, and Davidson, of Edinburgh. He and they were then allopaths, and he contrasted their results with his own and other homœopaths. About three years ago he attended a young unmarried lady, who with her sister had a highly respectable ladies' school, in which his patient taught singing. She had thrown up just before his first visit about a breakfast-cupful of bright red blood. Having for some weeks before suffered from cough attended with loss of flesh he prescribed Arnica 1, Ipecacuanha and Phosphorus 3. She had no return until eighteen months afterwards, when a second attack occurred. He then gave Hamamelis virginica, Phosphorus 3, and also applied cold compresses to the chest. He forbade any vocal exertion, enjoined absolute rest and nourishing diet. He gave also Cod-liver oil. The patient has continued free from attacks since. A small cavity existed under the left clavicle. He has found Tinct. Ferri acetatis useful, and this is the only so-called styptic that he has used. He feels great confidence in the homeopathic treatment of these cases. A friend used Terebinthina with advantage in one severe case of hæmoptysis, but he also applied a blister to the chest. The ultimate result of this case he has never been able to ascertain. He would do anything to save a patient, but has never yet felt obliged to have recourse to Gallic acid. He thinks that by attending closely to the juvantia and avoiding the lædentia these hæmorrhages will often spontaneously cease.

Dr. COOPER.-There are two most important particulars in reference to hæmoptysis I would like to see worked out. One is, the connection between it and enlargement of the heart due to overexertion, and the other is the relationship that exists between it and cessation of the menstrual flow. My own observations

lead to the conclusion that enlargement of the heart is a lesion of very common occurrence, especially in housemaids and "general servants;" it has often surprised me how frequently one meets with symptoms due to cardiac hypertrophy in this class of patients. Their muscular systems are generally feeble and illadapted to the amount of strain their duties require, and hence the heart becomes hypertrophied from the undue tension brought to bear upon it. Such cases I have frequently prescribed for upon the supposition that the hæmoptysis was due to obstruction caused by the enlarged heart, and have given Iodium in the 3rd or 6th decimal dilution with singular benefit. In one case particularly, where a young girl doing housemaid's work was seized with most copious hæmoptysis after overexerting herself, the patient made a good recovery after Iodium was given. Arnica is certainly most useful in some of these cases, but it has not answered my expectations like Iodium. As to the connection between it and menstrual cessation my impression has always been that in suppressing the menses nature was adopting her own means of husbanding the resources of the economy in order to cope with the diseased process going on in the lungs. However, in reading Scanzoni's Diseases of Women the other day my attention was struck with a case given by Professor Gardner, the translator, that goes far to upset any such supposition; the case was one in which haemoptysis and general phthisical condition ceased after re-establishment of the menstrual flow. ("In one case of scanty menstruation and pulmonary hæmorrhage supposed from tuberculosis, the attempt to dilate a stricture of the cervix, and its final complete division with the knife, resulted in reestablishing the accustomed quantity of the menses, the entire arrest of the pulmonary hæmorrhage, the subclavicular tenderness and dulness on percussion, and the general health of the patient, with no trace of phthisis remaining.-Scanzoni, Diseases of Women, p. 337, translator's note). As regards the general question of the treatment of hæmoptysis, I am quite sure that the simpler our treatment of this and other diseases the better. I do not see why we should not begin the treatment of an ordinary case of sudden and profuse hæmoptysis by administering a solution of common salt in water; it has long been a household remedy, and has especially been referred to by Graves. Surely it has never proved inferior to Gallic acid, Muriated tincture of Iron, Secale cornutum, and the many other styptics now so frequently in vogue. Again, I would be inclined to try, before resorting to the administration of more violent remedies, the inhalation of powdered Gum Arabic. The styptic properties of pulverized Gum Arabic are most marked. I remember one case of violent epistaxis in a syphilitic patient where, after failure of the local application of the Muriated tincture of Iron and a plugging of the anterior and posterior nares, the simple introduction into the nostril of powdered Gum Arabic upon cotton wool completely arrested the

flow, and, I have every reason to believe, was the means of saving the patient's life.

Dr. DUDGEON said the subject of hæmoptysis was too extensive to be discussed completely at one meeting. He would limit himself to speaking of dangerous hæmorrhage from the lungs, and how it could be stopped. Dr. Nankivell had enumerated many remedies, but had omitted to mention an important means of stopping hæmorrhage from the lungs, viz. a ligature tied round the arms so as to stop the venous incubation. Temperature too was important. The application of a heated spinal bag between the shoulders, according to Chapman's plan, had been frequently found of use. Secale was a remedy which he had employed with success in some cases of hæmoptysis, one or two drops of the tincture for a dose. A very severe case came under his notice lately, which was treated by Gull and others by the hypodermic injection of Ergotin.

Dr. BAYES wished to say a few words on the first, second, and fourth classes of Dr. Nankivell's interesting cases. With regard to the first class, where there is expectoration of dark changed blood occurring in women early in the morning, with deficient menstrual flow at the periods, he had generally found this accompanied with functional irregularities of the kidneys, either with a large flow of pale watery urine or with a deficient excretion altogether, and in either case there is a want of free excretion of urates from the system. In such cases Cantharis, 3rd, 6th, or 3x, will very rapidly cure. He (Dr. Bayes) had met with many such cases, and he would say they are readily and invariably (or nearly so) cured by this medicine. "Bloody expectoration after short cough is one of the larynx symptoms of Cantharis. In the treatment of the second class, in which there is an excess of menstrual flow, his (Dr. Bayes') experience did not coincide with Dr. Nankivell's, for in his hands Aconite had proved very serviceable in such cases, but it must be given in from the 3rd to the 12th or even higher dilutions. In the treatment of that active hæmoptysis called " rupture of a blood-vessel," he (Dr. Bayes) had had no experience of large doses of Secale, but in his former allopathic practice he had much experience in the use of Gallic acid in such cases, although he never used quite such large doses as those named by Dr. Nankivell. His own method had been to make a saturated solution of the Gallic acid in boiling water; when this cools down the solution contains about 100 grains to the ounce. Of this solution he used to give a dessert-spoonful every quarter or half hour till the hæmoptysis ceased or until the blood became dark or blackish; when this occurs the hæmorrhage usually ceases. He never saw any evil results from this treatment, but an overdose of Gallic acid gives a sense of great tightness in the head and ringing in the ears.

Dr. DRURY said, that, while giving the author due credit for the care bestowed on his paper and for the interesting matter contained in it, he thought that for the purposes of treatment some