CHAPTER XXXV.

HÆMOPTYSIS.

THE treatment of hæmoptysis in phthisis always demands careful consideration and preliminary investigation, and the ordinary habit of repressing it by styptics is often fraught with much danger.

In the majority of cases the amount of bleeding is so small as not to attract much attention, and in such any special treatment for its arrest would be unnecessary; but even in other instances in which it is more profuse, its importance really lies in indicating a condition of the circulating system, or some other part of the body, than any mischief to which it may give rise.

The first duty on the occurrence of hæmoptysis is to examine the chest and the fauces. If there be evidences of congestion of the lungs as a whole, such as may be proved by diminished resonance and lessened respiration, with a sense of constriction or dyspnoea, and with more or less disturbance of the general system, or if there be similar evidences restricted to a part of the lung, whether at the base or apex, and shown more particularly after a certain amount of effusion has occurred by crepitation or indistinct moist rales, the

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proper course will be to relieve the bowels, to determine to the skin, and to enforce the maintenance of the horizontal posture. Unless the discharge be considerable, it is not advisable to employ cold, either by ice or cold and comfortless food, or exposure to cold air, since the aim is not repressent, but derivative. The use of hot foot-baths and saline diaphoretics, the application of blisters between the shoulders, or the use of the croton oil liniment to a large part of the chest, will be the proper course; and unless active inflammation should follow, the hæmorrhage will soon be arrested.

When there is evidence of inflammatory action the case assumes a character which cannot be treated of here, and the severity of the antiphlogistic regimen must depend upon the circumstances of the case.

When the hæmorrhage can be traced from enlarged vessels in the pharynx, the case may be left to general treatment, unless it be urgent, when the local application of a solution of nitrate of silver (30 grs. to an ounce) by the aid of a large camel's hair brush, or of the solid caustic, to any particular vessels which may be seen, will be proper. The use of styptic gargles, as those of alum, borax, and tincture of the sesquichloride of iron diluted with water, may be employed in continuance of treatment.

There are, however, many instances in which it is necessary to act upon the blood, either from the condition of that fluid, or the fact of the hæmorrhage being probably a transudation through the membrane, or from a vessel bursting into a cavity in the lungs beyond

our reach. In all of these cases we have found great benefit from the use of an aqueous or a spirituous solution of the perchloride of iron, made in the proportion of 5 drachms of the salt to 6 ounces of water or proof spirit, and given in doses of twenty to thirty drops in water six times a day. Warren's styptic, made by the addition of 2 drachms of turpentine and alcohol each to 5 drachms Acidi Sulph. Fort., and then filtered through sand, is also a most efficient remedy, and the dose may be 15 to 30 drops in water. The employment of 1 scruple to half-drachm doses of turpentine in mucilage is an old and very valuable remedy, and to these may be added the employment of gallic, tannic, and dilute sulphuric acids, in doses of 3 grains of the two former, or 1 scruple to half-drachm of the latter. The use of ice gradually dissolved in the mouth is very valuable.

We meet also occasionally with cases in which the hæmoptysis is clearly associated with the menstrual function, and is erroneously considered vicarious. In such cases the menses are greatly reduced in quantity, and not infrequently changed in quality, and the hæmoptysis occurs either at the period of their occurrence, or at the usual monthly period when they are absent. We have seen numerous instances of the former, in which there was much uneasiness at the stomach for two or three days preceding, and on the day of the occurrence of the insufficient menstrual discharge, so that the cases assumed rather the features of ulceration of the stomach, until the periodicity and the relation to the menses had been clearly established.

It is always very difficult to decide upon the direct plan of treatment in these cases, since the discharge gives no relief, is attended by suffering, and occurs in enfeebled persons, and yet there is no indication which would justify the employment of styptics. The only safe plan is to enforce the horizontal posture, to give mild diluents as food, to regulate the general functions, to use the mustard foot-baths, and to apply a mustardplaster to the lumbar region of the spine.

Hence, on a review of this subject, we venture to affirm the following general rules:

1. That commonly the hæmoptysis is unimportant,

except as indicating a condition of the general system, or of the pharynx or of some portions of the lung.

2. That its repression by direct means is often highly

prejudicial, and tends to further advance in the disease of the lungs, and that in no case is it justifiable without a careful examination of those

organs.

3. That ordinarily the plan of treatment is tonic and derivative.

CHAPTER XXXVI.

MUSCULAR PAINS.

THE myalgia to which we have already referred as a pre-existent and concomitant condition of early phthisis, is that of the muscles about the chest, some of which are connected simply with the arm, and others with the acts of inspiration and expiration. The former induce distress, and therefore demand alleviation, but the latter limit the respiratory motions, and thereby all the vital and mechanical actions which attend them, and more or less induce danger to health. The indications for treatment are various, and include the removal of any mechanical or vital cause, the improvement of the general tone of the system, and the use of local derivatives.

As the weight of the arm is borne by the muscles attached to the neighbourhood of the shoulder, there is a constant tendency in these muscles to the condition known as weariness, and in order to avert or relieve this, we direct that the arm be artificially supported, as when leaning upon a table. But there are engagements as those of a sempstress, in which, whilst one arm may be thus supported, the other must remain free for motion, and hence there is a cause of inequality