been paid to this point in the history, an exciting cause would have been traced in many more cases. Of the 72 instances of hæmorrhagic phthisis, we subjoin a few examples :

CASE 19.—A clergyman, aged 34, first consulted Dr. Williams on July 17, 1848. After hard duty fourteen months ago he had hæmoptysis to the amount of two ounces, and in smaller quantity a week or two afterwards. Was much reduced by treatment, and wintered in Madeira with great benefit, and was well enough to ascend the Peak of Teneriffe without difficulty about six weeks ago; but has had cold and cough ever since. Dulness and tubular expiration in upper right chest. Bronchophony and mucous rhonchus below right clavicle.-Ordered iodide of potassium and carbonate of potash, and a croton-oil liniment,

In August he had hæmoptysis in church at Brighton to the amount of an ounce and a half, which ceased under acetate of lead with a daily aperient draught. After this he took oil, and got much better.

July 18, 1849.-Well till last few weeks, when he had temporary cough.

July 9, 1852.-Was well and doing double duty till a year ago, when he caught severe cold, and had hæmoptysis to the amount of three ounces; for which he was leeched, and much lowered. Has lost much flesh and strength, has night-sweats, and, expectoration has become yellow. Dulness and loud tubular sounds in the left mammary region.-Ordered oil in tonic of nitric and hydrocyanic acids, with tinctures of hop and

orange.

July 22. Had hæmoptysis (four ounces), yielding to treatment as

before.

In 1854 he went to Madeira, and passed a second winter with benefit. Married in 1856.

March, 1868.--Heard that he was quite well, with a family of six

children.

May, 1871.-Continues well. Since last visit he has had two or three attacks of hæmoptysis, and some years ago severe bronchitis and congestion of the lungs. At present he is in excellent health, doing parish duty, which he has not omitted for more than two months at a time for the last twelve years. Upwards of twenty-four years have elapsed since this patient's first symptoms.

CASE 20.-A clergyman, aged 42, first consulted Dr. Williams on Aug. 15, 1850. Nine months ago, after over-exertion, he lost his voice, and had cough, accompanied by some wasting and failure of strength, but continued to take three services every Sunday all the winter. After more exertion a month ago, for four days his morning expectoration was streaked with blood.

CASES OF RECOVERY.

159

Slight dulness; moist crepitation, with slight tubular sounds below left clavicle, more marked above; slight dulness and tubular voice in right interscapular region.-Ordered oil in a tonic of nitric and hydrocyanic acids, with the tinctures of hop and orange, and a liniment of acetum cantharidis.

September 16.-Much improved, under the oil, in flesh, strength, and breath, and able to walk fast and up-hill. Came from Hastings to-day, and after much talking, on lying down at night, expectorated blood to the amount of two ounces, with irritating cough. Is in too much tremor from fear to bear examination; pulse 90. Ordered gallic acid, with syrup of poppy, followed by an aperient draught of sulphate of magnesia and sulphuric acid.

21. No return of hæmorrhage; dulness, with crepitus above left scapula.

30.—Hæmoptysis to a pint and a half in last two days, and cough still troublesome. Ordered a blister and a morphia linctus, together with the gallic acid.

April 17, 1851.-Has wintered at Hastings, taking oil regularly, and gradually recovered from a state of great weakness; moderate cough and only slight expectoration. Has so much improved that now he can walk for five or six hours daily. Physical signs diminished.

May 4, 1854. Has taken oil regularly, and been quite well all the winter, without cough or expectoration; but has lately had neuralgia of the eye and occasional flushes of blood to the head; urine thick, with lithates; very little dulness or tubular sounds, but breath obscure above left, scapula, and whiffy in left scapular region; tubular voice above right scapula.— Ordered oil in nitric acid and tincture of orange, and an occasional effervescing saline.

January 21, 1858.-Has done duty well since. Only occasional cough, but always some mucous expectoration. Is strong and active, although of late has been much worried by a lawsuit. Signs diminished.

May 18, 1860.-Active and well till a month ago, when cough returned, with opaque expectoration, which has since improved. Still some dulness and tubular breath in both scapular regions, chiefly in left, and in left front.

September 26, 1866.-Wonderfully well, and generally does duty. Cough and expectoration very slight. Weighs twelve stone-heavier than ever.

This patient was alive and well in January, 1871, more than twenty years after his first visit, and more than twenty-one since his first symptoms; and for the last thirteen years has done duty regularly.

CASE 21.-A gentleman, aged 32, consulted Dr. Williams, Aug. 9, 1854. Two years ago he had hæmoptysis to the amount of half a pint, and afterwards every three months he continued to bring up a smaller amount, till June,

when he states, that in five days he brought up 14 pints! He has had a bad cough for the last month, and has lost much flesh. Bowels costive. Dulness, deficient breath, and tubular sound in upper right back. Obstructed breath and crepitation below. Tubular sounds above left scapula. Oil was ordered in a mixture of sulphuric, gallic, and hydrocyanic acids, with tinctures of hop and orange. Also, for a time, a morning aperient draught of sulphate of magnesia and sulphuric acid. Counter-irritation with a cantharides liniment.

November 9.-Has gained much flesh and strength, and only once had hæmoptysis, amounting to iii. Tubular sounds above right scapula, breath still obscure below, and mucous croak on deep breath.

December, 1867.-Heard that he got quite well, except that his breath has continued rather short. Only lately has had more cough and expectoration.

The subjoined case is remarkable on account of two brothers being affected with the same course of symptoms.

CASE 22.-Mr. M, aged 21, Oct. 9, 1865.-Paternal aunt died of hæmoptysis. Three years ago several times spit blood, and had since cough, with yellow expectoration, and short breath. Has taken oil in winter, and not lost much flesh.

Decided tubular sounds above both scapula, most left; where is also slight crepitus. Breath and percussion generally good.-To take oil, with phosphoric acid and quinine.

January 8, 1866.-Suffering from a cold and increased cough in the last month; and now from sickness and oppressed breathing.

More dulness, with crepitus, in upper right, most front.

Effervescing saline with opiate, and blistering with acetum cantharid. June 18, 1866.-Since February has been at Torquay, taking the oil and tonic regularly; and has much improved in strength; cough slight, but expectoration is still yellow, and breath short. Breath sound; still weak in right chest, with crepitus and tubular sounds above. Breath puerile in left lung.

May 30, 1867.-Last November was laid up with abscess of the rectum, which healed in a month; but left him weak; and being shut up all winter at home, he has lost much strength. Cough, however, is much better. Tubular sounds still above right scapula, and croaky crepitus below clavicle. Breath pretty clear elsewhere.

May, 1869.-Took oil with tonic steadily, and very much improved; spent next winter abroad; and finding himself so much better he remained last winter at home, attending to business, without suffering, till the middle of April, when, after exertion, he brought up a large quantity of blood, and sank in three weeks.

HÆMORRHAGIC CONSUMPTION.

161

A brother was attacked in 1866 with similar symptoms and signs, and expectorated large quantities of blood repeatedly, requiring gallic acid in full doses. He has been more careful of himself, has implicitly followed his instructions, and has been restored to health, unbroken when last heard of, 1870.

CASE 23.-An officer in the army, aged 20, was first seen by Dr. Williams March 12, 1860, and gave the following history:-He had been subject to cough in winter, but otherwise enjoyed good health till the previous September, when he had a chancre, followed in December by sore throat, and an eruption on the legs. Four weeks ago cough came on, and a week later he had hæmoptysis to the amount of three drachms. Feels much weakened. Slight dulness; tubular sounds in upper part of right chest.-Oil was ordered in a tonic of nitric acid; iodide of potassium and tincture of orange, and a night draught of iodide of potassium and bicarbonate of potash.

June 8. Has been at Pau since. The cough is better; but he has had occasional hæmoptysis to the amount of a drachm; and he still has syphilitic eruption and pains. Submaxillary glands swollen.

November 12.-Has been living in Ireland, and was better till he caught cold in the camp, and fresh cough came on, with increased expectoration, and occasional hæmoptysis to the amount of several ounces. Dulness and tubular breath and voice above right scapula. Crepitation, and obstruction sounds in the upper third of left chest.-To continue oil in acid tonic, and winter at Torquay.

September 18, 1861.-Wintered well at Torquay till April, when he brought up 4 ounces of blood, and continued spitting some blood for 10 days. He remained well till 18 days ago, when hæmoptysis recurred to the amount of four ounces, and he discovered he had recent syphilitic symptoms. Dulness and deficient breathing and some croaky sounds in upper left chest.

July, 1862.-Wintered in Madeira, and remained well, and married there; but after some exertion he brought up an ounce of blood, and some slight amount since. There is still dulness, with rough breath in upper left chest, harsh behind. Dulness increased above right scapula.

October 2, 1863.-Passed winter travelling in Italy, Sicily, Spain, and Egypt, with little cough, and only hæmorrhage to amount of half an ounce. Took oil pretty regularly. In the summer went to Turkey and Malta, and enjoyed the heat. Still dulness above right scapula, and croak on deep breath.

December 28, 1864.-Was last winter at Bonchurch, and able to walk 12 miles a day, and lost cough. Lately has been in Edinburgh, and tolerably well, except occasional colds and pain in the side. Oil omitted from May till November. Weak breath, and some friction sounds in left back.

June 2, 1868.-Remained well, living in Hampshire till last summer. When in Paris spit half an ounce of blood, and in November brought up

M

half a pint. Has had cough ever since. He lived low and lost flesh; but has regained lately with better fare. Throat sore and tonsils enlarged. Tubular sounds at and within left scapula, and below left clavicle.—To resume the oil, and take every night 10 grains of iodide of potassium.

May 22, 1869.-Has returned to oil, and passed winter in Hampshire, hunting; with slight cough, and gained 4lbs. Deficient and tubular breath in the upper portions of both lungs-most in the left, where slight crepitus. January 6, 1870.-Has been pretty well, except occasional colds and cough; and once had hæmoptysis, a drachm, which relieved cough; and again later half an ounce. Has suffered chiefly lately from enlarged tonsils.

Weak breath and whiffy sounds audible in upper left lung.

June, 1870.-In the spring following had an attack of diphtheria, followed by pneumonia of right lung; but recovered well with tonics and oil, and is now stronger than before the attack. Only tubular sounds and harsh breathing at left apex.

The lung affection in this case probably originated from syphilis, traces of which were perceptible in several parts of its course.

CASE 24.- A gentleman, aged 35, was seen by Dr. Williams, June 20, 1862. He had lived freely, but had been fairly well, and only suffered from occasional giddiness before the end of November, when he was wetted and chilled. Hæmoptysis came on, and in ten days he brought up three pints, and was much reduced.

Three months before the attack he had a cough, which gradually diminished, but had not quite disappeared, and was accompanied by yeilow expectoration. At present his breath is good, and he is free from cough, and has been taking cod-liver oil and gaining flesh. Slight dulness; tubular voice and breath in left interscapular region, and to a less degree below the spine of right scapula.

January 17, 1866.-Remained quite well, except in November, 1863, after fifty-four miles hunting, brought up 3vi. of blood, for which was bled, and soon recovered. At present has no cough or short breath. Physical signs-still bronchophony can be detected at and above the left scapula.

Let us now consider the effects of hæmoptysis, both general and local, on the course of phthisis, and the complications it gives rise to. We know that a very profuse attack may cause immediate death by exhaustion, as in some of the cases already given; or by suffocation; or it may prove fatal in a short period through the supervention of pyæmia, as in the very remarkable instance we give further on. These, however, exceptionally severe cases of hæmoptysis, are of rare occurrence, and probably not