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ones that most frequently coexist with pulmonary tu- berculosis. Given an eaual number of the morbid conditions that cause hemorrhage, and phthisis is the one most likely to do it. But it is more frequent than any of the others. It is, as Flint says, " the cause of the hemorrhage in an overwhelming number of cases." Spitting blood during the menstrual period vica- rious buy viagra ontario menstruation affords just ground for suspicion of tuberculosis. I have watched three such cases for several years and two of them have already developed unmistakable phthisis. Before making a diagnosis of pulmonary hemor- rhage the throat should be excluded as the source of viagra prescription buy the blood. This is easily done by inspection during the bleeding. It is not so easy buy viagra ontario a matter after the subsidence of the hemorrhage, but the presence or ab- viagra prescription buy sent t- of morbid conditions affords ground for a prob- able diagnosis. Hemorrhage from the larynx is rare: from the vault of the pharynx it is commoner, but from that locality at least part of the blood will pass through the nostrils. The appearance of the blood, whether clotted or not, does not help. The patient referred to above, whose doctor had excluded phthisis because there was no cough, had spit up buy viagra ontario blood, which, because it was somewhat clotted and dark, the doctor said came from buy viagra ontario the throat. Yet his throat is normal, and there is no reason to believe it would bleed. But there is dulness over the right upper lobe, with a harshened murmur, and the temperature rises even- evening to 99 ' I. Such a condition of things, the rise of temperature, the evidences of infiltration, and the hemorrhage make buy viagra ontario a diagnosis of phthisis almost positive even without the microscope. Pleuritic Pains. Pleuritic pains occurring about the upper parts of the chest or beneath the scapula are significant of phthisis. They are symptomatic of the circumscribed dry pleurisies that may occur at any stage of the disease. These pains differ in cliar.u t( 1. Usually sharp and definitely located, the stitch pain. they at other times give a sense of soreness or of aching, and spread oxer a considerable area. While pleurith pains frequently occur during early phthisis, they arc by no viagra prescription buy means constant. Some cases pass through this stage with no pain whatever. Thus the absence of pain lias little weight. And the diagnostic value of its presence depends largely upon the coinci- dence of other symptoms. Considered alone, a pain in the chest lias no such significance as a hemorrhage or a chronic cough, for the pain occurs much more frequently from other causes than do the other symp- toms. The neoplasms already mentioned as some- times producing cough and hemorrhage, may also pro- duce pain. More frequent causes of pain in the chest are intercostal neuralgia and pleurodynia. The pain and tenderness of intercostal neuralgia are usually lo- cated at three points near the exit of the nerve from the cord, in the axillary region, and near the sternum. Pleurodynia more closely resembles pleurisy, but usu- allv occurs in those subject to rheumatism in other parts of the body also. I have found intercostal neuralgia frequent in the phthisical and suggest it as of some value as an early symptom. The Temperature. The study of the temperature in phthisis is always very interesting. It has a va- riety of causes and shows all grades of intensity. The principal causes are, first, the absorption of the toxic products of the tubercle bacilli; second, the reactive inflammation of the lung tissue; third, the absorption of the septic products after infection by pyogenic germs. The first is the most frequent cause of fever in early phthisis, the second often uniting with it, but the third or septic cause is only added after the tis- sues begin to break down. Thus, the high tempera- ture with chills, very marked remission, and profuse sweating so characteristic of advanced phthisis, never occur in the first stage. There are exceptional cases of phthisis in which the inflammatory reaction is so slight, and the bacillary advance so slow, that the sys- tem becomes accustomed to the toxins and no fever results until destruction and septic absorption take place. This oftenest occurs in the so-called fibroid phthisis. Absence of fever, therefore, denotes a slow advance or entire arrest viagra prescription buy of the disease. Periods of arrest are frequent during early phthisis and a di- agnosis that excludes phthisis because of a normal temperature may lie at fault. There are very few cases, however, in which there is not more or less rise of temperature at times during the first stage. Even in the very chronic conditions and during periods of arrest, the presence of tuberculous trouble is quite sure to cause some fever after physical or mental fa- tigue or buy viagra ontario worn - . It is a good plan, in buy viagra ontario otherwise doubt- ful cases, to keep buy viagra ontario a record of the temperature taken at intervals of two hours, for ten or twelve days, and to require exercise to the point of fatigue several times during this record making. A rise in temperature of one or two degrees following this exercise, even though normal at other times, is, other viagra prescription buy diseases excluded, a reliable indication of incipient phthisis. buy viagra ontario A daily fever, though ever so slight, denotes prog- buy viagra ontario ress of the disease, and it is at such a time that the patient most frequently consults a doctor. And fortu- nately diagnosis is then easiest, as other symptoms are more pronounced. In the great majority of cases there is a slight but persistent fever. The temperature rises only a degree or a degree and a half above normal, but stays there day after day, week after week, even month after month, with a steadiness not equalled in any other disease. There is some daily remission, usually in the morning. The amount of the remission viagra prescription buy varies in different cases. The range may be only buy viagra ontario from 99 to 99 ' j I'., or 100" F., or at times it may go somewhat below normal in the early morning, to surely rise again in the viagra prescription buy evening. Accompanying the fever there is more or less loss of appetite, coated tongue, slow but progressive loss of weight, a feeling of languor, and general malaise. Sleep is broken and restless. The patient rises even more worn and haggard than upon retiring, and looks with dread upon the day's duties. Sometimes there