If the brain be the seat of determination of blood, in a morbid sense, there will be throbbing of the carotids and their superficial branches, restlessness, more or less intolerance of light and sound, diminution of the power of attention and application, dreamy and disturbed sleep, irritability of temper, attacks of giddiness, &c. The face and eyes are apt to be flushed, and the feet cold. The uneasy sensations about the head are increased by stooping, or the recumbent posture. The kidney, in cases of acute anasarca, manifests an excellent example of morbid hyperæmia. It is enlarged and turgid with blood, but its texture is not apparently altered. Its secretion is scanty, loaded with albumen, and with fibrinous concretions, and epithelium of the tubes. No doubt can exist that its functional energy is gravely impaired. In active menorrhagia we have a third instance in which, from various causes, a morbid hyperæmia of a hollow organ lined by a secreting mucous membrane is induced, the results being pain and uneasiness in the region of the affected part, increased sensation of heat, tension and throbbing, which are relieved by the discharge of a fluid more completely sanguineous than the natural secretion; in fact, by an almost real hemorrhage. In such an instance, it is not only the mucous lining of the uterus that becomes hyperæ mic, but the whole organ, with its thick muscular walls. Their tissue is loosened up and swollen by the quantity of blood admitted, so that the size of the organ is increased; and if this hyperæmia should not in great degree subside, the result may be a permanent enlargement and congested state of the uterus. The foregoing examples, taken from different organs, will serve as sufficient illustrations of the effects of active hyperæmia. It seems, however, desirable to allude, somewhat more in detail than has yet been done, to hemorrhage, flux, and dropsy, considered as results of hyperæmia in general.

These may be regarded as the effusions of hyperæmia, as distinguished from inflammation. No doubt they do also occur in cases where inflammatory action is proceeding; but still they are not the special and characteristic products of this state.

Hemorrhage implies the effusion of blood in mass, not merely of some of its constituents; exudations, therefore, which are only colored by hæmatin, do not constitute hemorrhage. The best character of an hemorrhagic effusion is the presence of large masses of blood-globules imbedded in fibrinous coagula. Such may be found either from an opening in a vessel of some magnitude, or from numerous capillaries. In every case where blood is effused in any quantity, the walls of the vessels must have given way; and perhaps this is the case in every instance where a blood-globule escapes from its channel, though it is not, to our minds, absolutely certain that there is no such thing as the hemorrhage by exhalation of the older writers. Hemorrhage may take place either in solid parenchymatous organs, or in those that inclose cavities and form canals. In the first case, the substance of the organ undergoes more injury than in the latter. An effusion of blood into the brain is a most serious thing; on the surface of the Schneiderian membrane it is a mere trifle. When a large quantity of blood is suddenly extravasated in a solid organ, it ploughs up and disorganizes the

tissue, and forms therein a cavity for itself, where it lies like a mass of black currant jelly: the walls of the cavity are usually ragged, and soon become stained to some depth by altered coloring matter. But the extravasation may occur in a very different manner, affecting a great number of points at once, and having the appearance of a multitude of red dots scattered about, or of minute streaks. This is termed capillary apoplexy, to distinguish it from the other form ("apoplect. herd" of Rokitansky). It is often seen in the gray matter of the cerebral hemispheres after death, from concussion of the brain.

If the hemorrhage, though taking place in the same way, be more abundant, the spots and streaks approach closer together, the tissue becomes more swollen, and, at last, may become thoroughly red, the blood having penetrated completely between and among the elements of the parts. Rokitansky enumerates the following exciting causes of hemorrhage: (1.) Hyperæmia of very great intensity, of whatever kind. This may occur in various conditions of the system, but of course the local strain will be most severe when a state of plethora exists at the same time, and the action of the heart is powerful. We have seen considerable hæmoptysis take place in a healthy person after very severe exertion. This might be considered as an instance of hemorrhage from intense active hyperæmia. The large evacuations of blood that are poured out from hæmorrhoids, exemplify the same result from passive hyperæmia, as also do cases of passive menorrhagia. (2.) The hyperæmia that takes place in some kinds of inflammation which have been hence named hemorrhagic. This tendency is materially promoted by the delicacy and laxity of the tissue affected. The lungs are scarce ever inflamed without some amount of hemorrhagic exudation taking place, viz: the rusty sputa of pneumonia. Where scurvy is prevalent, hemorrhage seems more prone to accompany inflammations, as might, indeed, be expected. A form of pericarditis has recently been described by Dr. Kyber, which he terms "pericarditis scorbutica," in which, after death, large quantities of bloody coagula, together with effusions of lymph, are found in the serous cavity. Hemorrhage from this cause is apt to attack morbid growths, especially the softer varieties of cancer. (3.) The vessels may rupture and pour out blood in consequence of the tissue surrounding them becoming more spongy and lax, so that they are not adequately supported. This appears to be the cause of hemorrhage from the decrepit uterus of the aged. (4.) Textural disease of an organ, rendering it more brittle or soft than natural. The most marked instance of this is the fatty, degenerated heart, which has often undergone spontaneous rupture. (5.) Alterations of consistence of the coats of the vessels, such as take place in atheromatous disease or in chronic inflammation; this may affect the smallest vessels or the largest trunks, but is almost confined to the arteries, and may be accompanied with dilatation (aneurismal) or not. (6.) Ulceration of the surrounding tissues may give rise to hemorrhage, by involving some of the vessels. Severe, or even fatal, hæmatemesis, from ulcers of the walls of the stomach, is not uncommon. The hyperemia which issues in hemorrhage, may be occasioned by obstruction to the venous current, as in hæmorrhoids from diseased liver, and pulmonary apoplexy from

obstructive disease of the heart; or it may be caused by intense irritation, as when bloody discharges are occasioned by drastic purgatives, or hæmaturia by stimulant diuretics. Posture may prove the cause of hemorrhage when the tonicity of the vessels is very low. Thus, stooping has been known to occasion cerebral, and the erect posture uterine, hemorrhage. The influence of malaria and cold has been before noticed. There seems to be a kind of hemorrhagic diathesis; at least, Dr. Copland states that hemorrhages are more common in the offspring of parents who have suffered from them than in others, and that the tendency is observed in several members of the same family. Hemorrhage from the rectum, urinary organs, and uterus, is said by Chomel to occur oftener in cold than in warm seasons, and epistaxis and hæmoptysis to be more frequent in summer than in winter. Dr. Prout observed a peculiar tendency to renal hemorrhage during the time that cholera was prevalent. Age seems to have an influence in determining the seat of hemorrhage. Epistaxis is most common in children, hæmoptysis in the early period of life, and hæmorrhoidal discharge in the aged. The blood, when effused, may remain in a liquid state for some time, or quickly coagulate. When it is poured out into the substance of a part, it undergoes, after a time, the changes which are commonly observed when a superficial part has been bruised. These consist in alteration of the color of the hæmatin, which passes "from a dark red into a blue, then into a brown, and lastly, into a yellow color, before it entirely disappears." At the same time the blood-globules, at least in many cases, undergo peculiar changes; they become massed together, and sometimes included in a kind of cellular envelop; they waste and shrink up, until there remain at last only minute yellow or orange-red granules, which evidently consist chiefly of pigment. Such are not unfrequently found in the straight tubuli of kidneys affected with M. Brightii; they are the undoubted records of former hemorrhage. In some cases the

altered hæmatin takes the form of crystalloid, elongated, rectangular tablets, which vary very much in size, and are colored more or less deeply by red matter. The formation of these seems to be promoted by the addition of water. They were extremely well seen in a case which we witnessed of cystic disease of the kidney, in which several large dark clots were contained in a cyst of extraordinary magnitude. The

fibrin, and other residue of the extravasation, together with broken-up fragments of the tissue, are gradually reabsorbed, the solid substances undergoing liquefaction, chiefly in the way of fatty transformation. further change may take place, not so much in the effused blood, as in the parts around it. These, which are at first ragged and torn, undergo more or less inflammation, which ends in the effusion of a solidifying blastema; this fibrillates, and passes into the state of more or less perfect fibrous or areolar tissue, and thus forms a capsule or cyst, inclosing the now more or less altered blood. Rokitansky describes the cyst as being lined by a colored, soft, gelatinous, loosely-adherent layer, formed from the coagulum, which, at a later period, by fibrillating, and even developing vessels, assumes very much the aspect of a delicate serous membrane. The contents of the cyst may be a gelatinous or serous fluid alone, or with more or less traces of a vascularized areolar tissue. In some cases absorption takes place completely, and the cavity is obliterated by the adhesion of the opposite sides, and the formation of a linear cicatrix. This, however, is not the most frequent issue, in consequence of the following impediments: (1) a large size of the cyst; (2) retraction of the surrounding tissue, depending partly on its atrophy, partly on its induration; (3) the deposition of the fibrin, either as a central lumpy mass, or as a thickish, peripheral, capsulating layer. The effused blood-mass may undergo a different kind of change, in consequence of absorption of its watery parts, and become, in this way, a kind of tumor, termed an hæmatoma. Dr. Walshe classes this along with other growths, but we think it better to consider it as a simple result of hemorrhage, and this for three reasons: (1) that it presents no higher structural character than that of fibrin; (2) that it is generally devoid of vessels; (3) that it does not appear to increase by growth in the proper sense of the term. Dr. Walshe describes an hæmatoma from the spinal meninges, which had been produced by a blow, as of the size of a walnut, of pale straw color, and of fine granular texture when closely inspected. "Such tumors exhibit, microscopically, the qualities of fibrin; fibrils gelatinizing with acetic acid, amorphous fragments, granules, and molecules." "Their chemical relations are those of fibrin." An epithelial investment covers the surface, and makes it smooth, but there is usually no enveloping cyst. Hæmatomata occur in serous and synovial cavities, beneath fibrous and mucous membranes, in parenchymatous organs, in muscular masses of the limbs, in the substance of certain new products, especially encephaloid cancers, in cavities accidentally formed in the tissues, as in tuberculous cavities of the lungs. An hæmatoma thus formed, and being essentially a fibrinous mass, may undergo certain other changes; saline earthy matter may be deposited in it, inducing a state which is more correctly named cretification, than ossification; melanic pigment may probably also form in it. It may, perhaps, undergo a development to the somewhat higher stage of fibrous tumor, and sometimes even true bone may be formed within it. A vascular plexus has been observed in several instances in tumors of this kind; and though it may be objected that this has been developed in superadded exudation-matter, yet it appears to us very much more probable that the persistent fibrin afforded. the developmental nidus from its own substance. One result of hemor

rhage, even in lesser degrees, may be the persistent discoloration of the tissues from the presence of brown or black pigment, which is dif fused among the elementary parts in a finely divided condition, as one of the transformations of the effused hæmatine. Hemorrhage, like the hyperæmia from which it results, may be active or passive, sthenic or asthenic. The former variety is associated with the same general condition of the system which characterizes active hyperæmia, the latter, in the same way, is connected with passive hyperæmia. Rokitansky says of the condition occasionally observed, in which hemorrhage takes place to an alarming amount, even from a slight cause, which he terms Hæmorrhophily, that it depends, as far as we know at present, on an unusually delicate construction and vulnerability of the vascular membrane, together with a thin, watery quality of the blood in general.

FLUX AND DROPSY.

We have already in part noticed these results of hyperæmia, more particularly of the passive variety, but it seems desirable on account of their great importance and frequency to review them separately. The term flux may be properly applied to a discharge of various kinds taking place from a mucous surface, or from a glandular organ connected therewith; the term dropsy to an effusion of fluid in serous or synovial cavities, or in the areolar tissue. Fluxes will be active or passive according to the kind of hyperemia which occasions them; the same can scarcely be said of dropsies; the very great majority of them are passive. It is necessary to fix some limitation to the kind of fluid that may be said to constitute flux or dropsy, as there are many exudations which require to be distinguished on account of their different nature. A sero-purulent effusion, on the secretion of a serous cyst, would not come under the present head. Perhaps we shall be nearly correct if we say that a fluid similar to, but more aqueous than the liquor sanguinis, mingled in the case of flux with a varying quantity of mucous secretion or desquamated epithelium, mature or immature, and if proceeding from a gland mingled with more or less of its secretion, is that which properly belongs to this kind of morbid action.

Of active fluxes we have a good example in miniature in a common sneeze; the peculiar sensation demanding the reflex expiratory contraction is no doubt occasioned by the turgid state of the bloodvessels of the Schneiderian membrane pressing upon the interwoven nerves; this hyperæmia quickly terminates in a muco-serous effusion which the blast expels, and after one or two such acts, all is quiet again. More considerable, and much more enduring is the hyperæmia in the state of coryza, and the serous flux is of course much more prolonged. In this instance we have an opportunity of observing a quality of the fluid of a serous flux which is very common, viz: that it is especially acrid and irritating, so that it will sometimes excoriate the parts over which it flows. What gives it this quality is not very apparent; it seems at least doubtful whether it is merely an excess of the natural saline ingredients of the blood. We should rather suppose it to be some organic acid salt