blended with the mucous secretion, and not merely seen upon its surface; and when it flows into the mouth in a pure form, without cough or effort on the part of the patient. I have never met with the latter form of hæmoptysis except in tubercular cases. It is necessary to say a few words upon the other diseases in which hæmoptysis may occur, and which, on this account, might be mistaken for phthisis. Streaky hæmoptysis may happen at any period of chronic bronchitis, as well as in inflammatory and congestive attacks of the mucous membrane about the fauces; and, in either case, is to be distinguished from that of phthisis by no other means than by a careful examination of the chest, and attention to the patient's history. Blood, in a somewhat larger quantity, either pure or intermixed with mucous or salivary secretion, may proceed from the throat or gums; but in such cases, the absence of other suspicious symptoms, together with an examination of the mouth, will scarcely allow its real source to be mistaken. Hæmoptysis may occur at any stage of acute bronchitis, but it is not very common, and is seldom seen, except in plethoric patients. It is also met with in simple plethora, in which case it is compatible with the most robust health, and even, in many instances, essential to its preservation. It is sometimes vicarious to certain natural or diseased secretions: thus, it may take place in females whose uterine functions are irregular; and it will occasionally be found alternating with the bleeding of hæmorrhoids, or even of varicose veins. Expectoration of blood is likewise a symptom of obstructive diseases of the heart, in which cases it is not so often pure, as intermixed with bronchial secretion. It is manifest, therefore, that the entire value of hæmoptysis depends upon its association with other symptoms. It should, consequently, be never considered apart, but ought carefully to be compared with attendant indications; and if these should present at all a phthisical character, there will be little chance of error in pronouncing its tubercular origin. Dyspnoea. -Shortness of breath, particularly during unusual exertion, may present itself as one of the earliest symptoms of phthisis, and long continue to be the chief source of discomfort to the patient. But there is much uncertainty in its occurrence, persons being met with, even in the last stage of the disease, in whom it has neither been frequent nor urgent, whilst there are some whom it has never troubled. It may occur, however, at any stage of consumption, and from causes very opposite in their nature. In many instances there is difficulty of breathing simply in consequence of mechanical obstruction produced by the tubercular deposit. The lungs, however, exhibit in so remarkable a manner that compensative power observable in nearly every organ of the body-of readily accommodating themselves to the presence of foreign substances, provided they be slowly deposited, that dyspnea of this character is chiefly noticed at the commencement of the pulmonary disease, and upon the occasion of any rapid or extensive addition of fresh tubercle. The sudden accession of this symptom becomes, therefore, in some measure, a guide to the first onset of the tubercular disease, as well as at a subsequent period an indication of its increase. It often happens, however, that the dyspnoea of phthisis bears no proportion either to the amount or rapidity of the developement of tubercle, but proceeds from secondary bronchitis, pneumonia, or pleurisy. This may be observed at any stage of the primary disease, but never more frequently than after softening has taken place, at which time the sudden accession of difficult respiration is often attributable either to bronchial or pleuritic inflammation. Dyspnoea may likewise arise in consequence of obstruction in the bronchial tubes, either from an excessive amount of secretion, or a want of power on the part of the patient to expectorate sufficiently. In some instances it is purely a nervous affection, and connected with general hysteria. It is evident, therefore, that dyspnoea may be a most formidable, or a comparatively unimportant symptom, according to the particular conditions K But as there is upon which it may depend. nothing in the character of phthisical dyspnoea which serves to distinguish it from that of asthma, obstructive diseases of the air-passages, or even simple hysteria, it has no separate value as a diagnostic sign. Pain plays a most capricious part in phthisis, and bears no necessary relationship either to the state of the lungs or the stage of the disease; being frequently severe at a time when there is but little pulmonary tubercle, and, on the other hand, very often absent when the lungs are extensively tubercular. In some cases it is scarcely felt during the whole course of the malady; in others it is an early and very troublesome symptom; and, in many instances, it disappears and returns almost indefinitely; it would be difficult, perhaps, to find two cases strictly alike in these particulars. Most frequently it is referred to the regions between the scapulæ, and above and beneath the clavicles, or to the shoulders; but it may occur in any part of the chest however remote from the situation of the tubercle, and is often complained of solely at the epigastrium. Sometimes it is deeply seated; at others, the skin and superficial parts are chiefly affected, and there is such morbid sensibility of the cutaneous surface, that even the most gentle percussion is productive of distress. Thus it is evident, that although pain is very often felt in the parts actually diseased, it is in many instances of a reflex nature. The character of the pain is quite as variable as its situation; most commonly, it is spoken of as being heavy, dragging, or gnawing; occasionally it is rather an uneasiness than actual pain; but, in some cases, it is acute and tearing. These different qualities serve, in some degree, as guides to the pathological state of the lungs. When the pain is heavy and dragging, it is probably due to pulmonary congestion; when distant from the seat of the tubercle, or when the cutaneous surface is principally involved, it is likely to be either a reflex action, or to be nervous or hysterical; but when acute and lancinating, there is greater reason for attributing it to pleuritic inflammation. It often happens that pain is experienced only during unusual exertion, and is not felt when the patient is at rest; but, on the other hand, persons are frequently to be met with, even in the latter stages of consumption, so little inconvenienced in this way, that they are able to follow laborious occupations. It may, indeed, be said of pain, in its relationship to phthisis, that there is nothing certain about it, except its variableness. The many and anomalous pains experienced about the chest in the course of other diseases, are a frequent source both of anxiety to the patient and embarrassment to the physician, in consequence of their close resemblance, in many important particulars, to those which are often met with in phthisical cases. Rheumatic pain of the thoracic |