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grene of the extremities of a child, in which the bloodvessels were found free from disease, is, in this respect, well worthy of consideration.

You will wish to hear a few additional particulars regarding J. B———. She had lost four sisters and a brother from phthisis, but enjoyed good health till two years since, when she suffered from menorrhagia for thirteen weeks. The catamenia ceased a year since, when she became affected with cough, and began to lose flesh. Four months before her admission into the hospital, and on a few occasions subsequently, her expectoration was streaked with blood, but it consisted chiefly of green, consistent, viscid matter. Although only fifty-two years of age, she appeared more than sixty. Hair and irides grey; arcus senilis remarkably apparent, especially on the right cornea; fingers clubbed; nails curved. She suffered occasionally from flatulent distension and from diarrhoea; this latter symptom was relieved by bismuth. She inhaled chlorine with relief to her cough, and for the same object also derived some advantage from lozenges, prepared according to the original formula of Sydenham :-sugar candy, two pounds and a half, boil in a sufficient quantity of pump-water till it sticks to the end of the fingers; then add liquorice powder, elecampane, aniseed, angelica-seed, each half an ounce; orris powder, flowers of brimstone, each two drachms; essential oil of anise, two scruples; make lozenges according to art. These lozenges sometimes relieve, but cannot be expected to be so useful to the consumptive as Sydenham found them in common catarrhal cough.

We will now proceed to consider a symptom very

frequent in pulmonary consumption, and one which is apt to occasion considerable alarm in the minds of patients and their friends. I refer to spitting of blood. In proof of its frequency, I may mention that it has occurred in nineteen out of the twenty-six cases of confirmed phthisis at present under my care in the hospital-that is, in seventy-three per cent.; of the seven exceptions, five are in the first stage. This proportion is not very different from that which calculations on a larger scale supply; and when spitting of blood occurs, unconnected with disease of the heart, or mechanical injuries, or suppressed catamenia, it is, perhaps, the most significant of any single symptom of phthisis. You will observe that in the case of S. C. there is a murmur near the apex of the heart, accompanying, not superseding, the first sound, whence you conclude that there is disease of the mitral valve, not perhaps very considerable, but sufficient to occasion regurgitation into the left auricle, and we trace the disease to rheumatism. Hæmoptysis in this patient was preceded by a severe blow. We may fairly assume that in this case the hæmoptysis is probably unconnected with pulmonary disease; for, not to mention other reasons, rheumatic affections of the heart do not often co-exist with phthisis.

It is a popular opinion that "breaking a blood-vessel” often produces consumption, and even in medical writings you will sometimes find it implied that hæmoptysis often precedes phthisis. Is this opinion correct? Here is a table of the last twenty-four patients in whom I have observed hæmoptysis: it may assist your judgment on this question :

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In fourteen of the twenty-four, other symptoms, such as loss of flesh or strength, or changes of respiratory sound, which could not be conveniently entered in the table, preceded the hæmoptysis. In six patients one or the other of these symptoms, and the spitting of blood, were believed to commence together. In only four are we without evidence of the pre-existence of disturbed function. Even in these four it is highly probable that a careful examination, prior to the occurrence of the symptom in question, would have detected some change of respiration. Here is a young woman (M. W.) who has never had hæmoptysis, nor suppressed catamenia; her cough is only occasional, but her tongue is often loaded; there are fits of dyspepsia, with severe frontal headache, not referable to any peculiarities of diet. The catamenia are not interrupted. Her impaired health probably depends on tubercular cachexy; still, if she were not under medical observation, no circumstance would be recorded as indicative of phthisis. Listen to her breathing: in the left subclavicular region the inspiratory murmur is interrupted, the air seems to enter the corresponding portion of the lungs by a succession of waves, instead of in a continuous stream. This sign, as I may hereafter prove to you, when isolated, is not a proof of tubercular deposition, but it is a somewhat ominous symptom, especially when associated with other changes, such as prolonged expiratory murmur, which in this patient exists at the apex of the opposite lung. To my mind we have evidence of tubercular deposit, but as yet no hæmoptysis has occurred. As respects treatment, you will observe an issue under the left clavicle, produced

by galvanism; plates of zinc and silver being connected together, and the zinc plate moistened with a saline solution applied to the skin. Various alterative and tonic medicines having been used, with a few to relieve the headache and dyspepsia, with only a temporary advantage, I determined to try the effect of a tablespoonful of yeast three times a day. This substance, originally introduced into medical use by a clergyman named Cartwright, has been considered beneficial in typhus. It often gives relief as a gargle to the sore-throat of scarlatina; and its remarkable power of separating sugar from its combinations, and altering its character, might lead us to anticipate its possessing properties competent to influence favourably the digestive process, and thus to check the mal-assimilation by which tubercular conditions affect the blood. Some observations by my friend, Mr. Sampson, have contributed to make me hopeful in this respect, and this patient seems to have derived benefit from the medicine in question.

But to return to the subject of hæmoptysis. When this symptom is considerable, great alarm is generally experienced by the patients and their friends, and the danger of sudden death is supposed to be considerable. Is such an event common? By no means, In men it is very rare, and many practitioners in the course of many years have never witnessed such an event in women. Such a catastrophe, however, is possible; it occurred, for example, in the patient from whose lung Dr. Carswell took this delineation, which I exhibit to you, in which a large irregular ulcer in the left bronchus near the bifurcation of the trachea, effected a communication with the pulmonary artery.

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