Post-mortem, 12 hours.--Body little emaciated. Blood generally fluid. External jugulars distended with it. Left lung adherent by dense membrane at posterior part of apex, and in separating it a cavity was torn open of size of hen's egg, containing frothy blood, and a few dark clots, one of which partially plugged an opening into a large blood-vessel. Walls of cavity irregular, with broken grey matter, and several large veins containing fluid blood. Anterior part of lung pretty healthy, but a few grey solid masses below the cavity, and a few tubercles scattered through both lungs. A larger mass at the right apex, in some points opaque and softening, in others, intersected by dense bands. Bronchi contained much frothy blood and bloody mucus. Bronchial glands much enlarged, with pinkish and grey deposit. Blood-vessels of the lung very large the veins more than double the size of their accompanying bronchi. Heart rather large, without increased thickness of walls. Aorta somewhat dilated. Kidneys large and much congested. Liver very much enlarged, rather pale; substance fragile. Although considerable disease must have existed before the hæmorrhage, it had not attracted much attention. There was no material loss of flesh, and he continued his work, and probably his habit of drinking freely of porter. This filled the blood-vessels, and led to the hæmorrhage, which in the post-mortem was traced to ruptured vessels. The following is an example of hæmoptysis occurring during the second stage : CASE 17.-A medical man, aged 45, was seen by Dr. Williams, June 2, 1863. He had been long in India, where he had suffered from fever and dysentery; and during last winter a cough had come on, which had often been hard. In the last few days he had brought up a quantity (according to his own account pints) of blood. Dulness, obstruction and crepitation sounds in upper right chest, crepitation being coarse in parts. Under doses of bitartrate of potash and gallic acid, followed by occasional draughts of sulphate of magnesia and sulphuric acid, the hæmoptysis was checked, and the cough lessened, but the hæmorrhage recurred several times. September 29, 1865.-Wintered at Bournemouth, but was confined to the house, and had hæmoptysis to the amount of several ounces several times. Cough troublesome, and expectoration increased, but patient is by no means thin, and looks well. Dulness and crepitation in upper right chest, most marked in the front. Subcrepitus and tubular sounds audible above left scapula. This patient died in the spring of 1868, having lived nearly 6 years after his first symptoms. The following is a good example of hæmoptysis accompanying the first stage, in which the patient remained well for many years, though eventually excavation of the lung took place : CASE 18. A gentleman, aged 36, of strong, large frame, consulted Dr. Williams first on June 19, 1850. Had been in good health, with no cough; but after much exertion in May he expectorated half a pint of blood, and yesterday about the same quantity. Had been bled and leeched on the right chest, with diminution of the dulness; signs of congestion were found in the right lung. Pulse quiet; no cough; bowels confined.Ordered gallic and nitric acids, and digitalis; an aperient of sulphate of magnesia with sulphuric acid. June 24. Hæmorrhage returned slightly next day, but not since. Dulness and tubular sounds in the upper right front and back.-A blister to the scapula; nitric and hydrocyanic acid mixture. July 20.-No return of hæmorrhage; cough slight. Has taken cod-liver oil with acid mixture a fortnight. Less dulness, but still large tubular expiration in the upper right front and back. September 26.-At Norwood. Taking oil, &c., regularly. Much improved in flesh and strength. Cough and expectoration slight. Dulness and tubular expiration less marked. June 21, 1851.-Wintered in Madeira. Well, but frequent colds from damp weather. Continued oil and acids till the last three months. Breath harsh and loud below right clavicle; little dulness and less tubular sounds in right back. September 25, 1852.-Has continued well. November 24, 1853.-Passed last winter with only one attack of cold and cough, when the sputa were discoloured. Has been pretty well since; but has had an occasional feeling of oppression in the right lung, and three weeks ago, after much exertion of voice, brought up four ounces of blood, and some on the following days, when it was checked by gallic acid. Still much cough and wheezing. Urine scanty, red, and turbid. General wheezing rhonchi in right lung: little dulness or tubular sounds.--Ordered iodide of potassium, carbonate of potash, squills, stramonium, and liquorice, and a croton-oil liniment. Under this treatment he soon got the better of this illness, and continued in good health, except occasional attacks of the same kind; more wheezy and asthmatic than phthisical. He continued active in business, and often gave lectures and spoke at public meetings, although warned against doing so. February 13, 1863.-Three months before had coughed up four ounces of blood, and about the same quantity three days ago. Breath had been shorter since, with more expectoration. Feels the cold more, but voice and HÆMORRHAGIC VARIETY. 155 muscular strength good. Urine often thick.-Dulness and tubular sound at and above right scapula; moist crepitus and mucous rhonchus above and below. To take oil, with sulphuric acid, calumba, &c.; saline at night. June 18. Several times hæmoptysis this year; now about half an ounce daily, five days. Physical signs the same. December 27, 1864.-Hæmoptysis recurred every two or three weeks till August, when he went to Bournemouth; none since. Has regained some flesh and strength. More extensive dulness, obstruction, and coarse crepitus over greater part of right lung; cavernous sounds in scapular region; dulness and loud bronchophony now also at and above left scapula. These signs have been increasing during the last twelve months, with more constant cough, copious opaque flocculent expectoration, pulse 100, and loss of flesh and strength. A few months later the cavernous sound in the right lung became amphoric, with signs of increase in the left also. In the autumn of 1865 he went to Madeira, and died on the voyage back, early in 1866. From 1853 to 1863 the disease was so much arrested that he resumed active habits, and ceased to regard himself an invalid. The disease in consequence recommenced its activity, and ran its destructive course. While hæmoptysis may accompany all stages of consumption, and may vary considerably in amount, it may also be entirely absent throughout the whole course of the disease. In the acute forms, and particularly in acute tuberculosis, hæmoptysis rarely occurs, and the relief in the more chronic varieties of the malady often derived from a copious hæmorrhage has led some physicians to think that the great congestion noticeable in acute cases might be relieved by local or general bloodletting. Whilst the most rapid cases of phthisis are nearly free from hæmoptysis, there is a class of patients already alluded to in whom the amount of the disease is small, and large and repeated hæmorrhage the principal feature. We described a few of these cases three years ago under the term of the hæmorrhagic variety of consumption,' and it is no small satisfaction to us that so careful an observer as Dr. Peacock also recognised in them a sepa 1 Lancet, June, 1868. rate class, which he calls 'the hæmoptysical variety,'1 and he gives an excellent description of its chief features. As far as we ourselves have observed, the symptoms are as follows: The patient may have had a slight cough for some time, or shown signs of failing health, but very often this is not the case, and he may be in apparently fair health, when he is suddenly attacked with hæmoptysis, generally of a profuse character, lasting often many days, and causing much reduction in flesh and strength. Cough and expectoration follow, and a careful examination of the chest detects only slight physical signs, and these in the supra or interscapular regions, or else beneath the clavicle. The patient gradually improves, and will sometimes recover his strength and lose his cough before the hæmoptysis recurs, which it is pretty sure to do sooner or later. The period before its recurrence may vary from days to years, and with it, to a great extent, the prospect. of ultimate recovery, as the frequently recurring attacks considerably weaken the patient and soon usher in the train of symptoms usually attendant on active consumptive disease. The cough becomes persistent, the expectoration muco-purulent, when not sanguinolent, wasting and nightsweats appear, and the physical signs which first evidenced slight consolidation, and later the same in a greater degree, now show softening and excavation. This is, however, rare, for the changes in the lung are generally limited to increase in the amount of consolidation, and what appeared at first rather obscure and was even denied, now becomes unmistakeable. The blood brought up is generally florid, but occasionally dark in colour, and partially coagulated; the amount varies greatly, but it is usually large, and in one case under observation amounted to seven quarts at a time. But the quantity expectorated 1 St. Thomas's Hospital Reports, 1870. is no measure of the danger resulting to the patient, as in this form of the disease a large amount of blood may be brought up without fatal or even pernicious results. Our 1,000 tabulated cases furnish 72 instances of this form of phthisis, of whom 60 were males and 12 females, a proportion of 5 to 1 of the former to the latter, which forms a contrast to the proportionate numbers of the two sexes in all forms of consumption, which was as 2 to 1. Thus we see that males are far more liable than females to the hæmorrhagic form of phthisis, and this for a reason that will presently appear. The patients were attacked rather later in life than the generality of consumptives. The average age of attack for the males being 30 and for the females 27. Family predisposition was not usually present, appearing in only 25 instances, and perhaps this may account for the later age of attack. In 42 cases the hæmoptysis was preceded for a shorter or longer time by cough, but in the rest hæmorrhage was the first symptom. In 45 no exciting cause was recorded. In 27 an explanation was to be found either (1) in the patient having been subjected to some great bodily exertion, as preaching, lecturing, acting on the stage, rowing, climbing, or running; or (2) in his having been inhaling an atmosphere either mechanically or chemically irritating to the lungs, as that of a laboratory or workshop; or (3) in his having been exposed to decidedly depressing conditions, as chills from getting wet through, great mental worry, fasting, too close application to a sedentary occupation, severe attacks of certain lowering diseases, as dysentery, measles, and syphilis, the latter being in one case followed by mercurialization. We see, therefore, that in a large number of these cases the attack of hæmoptysis did not occur, without, as Dr. Peacock expresses it, some more or less decided exciting cause, and it is probable that had great attention |