CHAP. XVIII. nurse. The health of the child is also concerned in the question; for, although the mother may have an abundant supply of milk, it is seldom of a nutritive quality, and the infant wastes from want of proper food. That the germs of tubercular disease (already hereditary in this case) may thus be increased is self-evident, as Children such children generally die early. die early. do not Many consumptive mothers date the commencement of their illness from the weaning period. In the above cases, 16 out of 189 did so, and doubtless this is a time of grave peril. In such cases, the catamenia never Catamenia return, or one or two changes only may take place. return. The prognosis is bad, the disease is generally of the Prognosis rapid, intractable form, the fever continuous, and the bad. local disease without limit. There is, perhaps, more severe hectic in this class of patients than in any other. The ages of persons tion are given below. affected by pregnancy or lacta- Age. From 25 to 40 is the prevalent period; but, as a large number of marriages are contracted in this country between those ages, the table has not much value as bearing on phthisis. CHAPTER XIX. HÆMOPTYSIS. XIX. CHAP. To assign a special value to each individual symptom of consumption would be to adopt rather an empirical Symptoms. than a rational view of the disease. Regarding the affection as a constitutional disorder, rather than the manifestation of a merely local alteration in the organs in which it is seated, we must look further than to such symptoms as are dependent on structural disarCannot be rangement. All the knowledge which can be gathered regarded alone. from physical changes is to be added to and compared with the evidence of systemic variations from the standard of health. The sum of the two sets of observations is an indication of the present state of the patient, and an application of our acquaintance with the higher problems of the laws of vital phenomena to this ascertained condition, forms the basis on which we are to construct a rational prognosis. But there is also a certain knowledge of the nature and bearing of particular symptoms, always demanded by the patient, which is of real importance in the formation of a True value prognosis. We cannot sever these symptoms from general vital conditions, but we can assign to them a peculiar value, and are often enabled, if truly informed as to their meaning, to relieve apprehensions on the part of the sick, or to strengthen our own views as to the nature and probable course of the affection. Remembering that these hold a position of subordinate relative. XIX. importance to the signs which are of a more general CHAP. character and have their chief value as interpreters of systemic disorder, their study will be found valuable in practice, and a perfect knowledge of their meaning will greatly assist us in estimating the progress of any given case. In this relation, an examination of the most prominent will be found interesting. It is proposed to record the result of many observations on hæmoptysis, and on alterations in the digestive system, as among the chief of this class of symptoms. ptysis most common in 1st and 3rd stages. Hæmoptysis is common to all stages of phthisis, but Hämoespecially remarkable in two. In a great number of cases it marks the very beginning of tubercular disease in the lung, and it is a very ordinary symptom of the third or stage of cavity. Again, in many instances it is present in a slight form throughout the whole course of the affection, or it marks the period when softening begins, indicating the passage of the disease from the first to the second stage. stage due Its course, and therefore its import, is different in In first each of these instances. In the first or earliest stage, to congeswhen a deposit of tubercle is taking place, and before tion. local injury to either blood-vessels or the bronchial membrane, it seems to be a congestion resembling local pulmonary apoplexy, and generally consists in a sudden rather profuse effusion, to the amount of some ounces of pure florid blood, and is accompanied by flushing, dyspnoea, pain in the chest, and hard rapid pulse. A careful observer will be able to detect dulness of the percussion note of the clavicular region of one side, while much harshness of the respiration murmur, and a fine crepitus caused by blood in the smaller air-tubes will be manifest.* The hæmoptysis caused by excavation of the lung is Much physical examination of the chest at this period is inadmissible. It will be well to abstain from percussion. CHAP. In 3rd stage. also not unfrequently profuse, and of all the forms is alone ever fatal 'per se,' an event which is due partly to the effusion proceeding directly from a tolerably large vessel, and also from the already exhausted condition of the patient, whose general strength is much less tolerant of the loss of blood, owing to the impoverishment of the system from the blood disease, and to the emaciation of all the tissues, including the muscular structure of the heart itself. It is manifest that these two cases of loss of blood differ materially. The first is, or resembles, a congestion, occurring before the constitution has suffered from the wasting effects of disease, and is felt by the system as a relief, evidenced by the subsidence of dyspnoea, and of pain, which commonly follows its appearance; the latter is a hæmorrhage mainly due to mechanical local causes, and is only a further drain on a system already weakened by profuse expectoration, sweating, and alterations in the nutritive qualities of the blood itself. The import of the first is the invasion of a formidable local disease, accompanied by congestion; of the latter, the already advanced stage of an affection which has ulcerated large vessels, and, it may be, impaired the coagulability of the vital fluid, and certainly the conTreatment tractility of the arterial and venous structures. The treatment indicated by these considerations is manifest. The occurrence of hæmoptysis in the early stage must be met by local depletion, of which the best form is leeching, after which a cupping-glass may be applied; and further, by cooling, saline medicines, the most perfect quiet, abstinence from all mental or physical excitants, and by the use of iced drinks. The hæmoptysis of the later period demands styptics of the stimulant kind, as turpentine, as the system will not tolerate the loss of an additional ounce of blood; on the contrary, support must be given; and while rest is enjoined, a diet of an invigorating kind may be indicated. given with advantage. Many lives have been shortened by the opposite or depleting method carried out with vigour, when the patient was already in the advanced stage of an exhausting malady. The condition to be combated is a hæmorrhage from open vessels permeating a diseased and ill-vitalised portion of a highly vascular organ, the system already reduced, the blood itself vitiated and altered, and the vital contractility of the vessels lowered. If this state be contrasted with that of a congestive hæmorrhage from an organ irritated by the early invasion of disease, with a system, vascular and nervous, working at nearly full powers, the mode of its occurrence will be more readily appreciated, while its treatment will be conducted on the rational principle of meeting the actual requirements of each case. CHAP. XIX. hæmor The third case of hæmorrhage from the lungs in Frequent tubercle is that of frequently repeated slight losses. It slight is due to causes partly mechanical, partly vital. The rhages. vessels are themselves weak and impaired in structure, and the smaller branches frequently give way; the circulating fluid has been impoverished and altered, and the force of the general circulation weakened. The import of this form of hæmoptysis is not important; it is never dangerous, often indicative of some slight and temporary congestion of the diseased portion of the lung, or of simple slow extension of the softening process. The prognostic import of the two former cases demands attention, and our tables furnish evidence that indications of value may be derived from the period of the disease in which the hæmoptysis occurs, its amount, and the frequency of its recurrence. Those who rely on this symptom as pathognomonic Hæmoof phthisis must often, however, be greatly deceived in without ptysis their diagnosis, and their prognosis may be found not tubercle. unfrequently in error. Out of 446 cases occurring in |