On the other hand the cough may become so violent that vomiting is caused at the same time. Nevertheless many consumptives describe their cough as very unimportant on account of their innate sorrowless nature, and they will not even be discouraged by the gravest symptoms. Often however it is fear that induces the patients to make light of their coughing, their spitting blood, their losing flesh and to place but little importance on these circumstances. A _hoarse_ cough is a sure sign of a diseased _larynx_. Many consumptives complain of cutting pains between the shoulderblades, under the clavicles or in the side; but these are rarely intense and are often entirely wanting. Unfortunately it is unknown to the average layman that the internal organs may suffer extensive tearing down without an indication of pain. The _Expectoration_ of consumptives which is thrown out by coughing with great exertion, is but scant in the beginning, as a rule phlegmy, glassy transparent and sticky. It is one of the suspicious symptoms of developing pulmonary consumption if this lasts for any greater length of time. Sometimes sharply defined, yellowish stripes, at times branching, appear in the same. Later on the expectoration becomes more purulent, and of greenish-yellow or greenish-gray color. Still later the patients throw out rounded lumps of greenish yellow or yellowish green color, which flatten out like a coin in the spittoon. They sink in water which is a sign of forboding evil. _Blood_ appears in different quantities in the sputum of consumptives. Bloody streaks are of no importance; they may appear with every violent cough. On the other hand the casting out of _pure blood_ is indeed serious. The _quantity_ of blood thrown out during an attack may be very different, varying from a few drops hardly a teaspoonful, to hundreds of grammes, even more than a liter. It is generally light red, filled with airbubbles, foamy, and is largely coughed out in coagulated lumps. The coughing of blood is sometimes preceded by a feeling of oppression, rushing of blood to the head and palpitation. Some patients experience a sweet taste in the mouth even before the bleeding. In many cases all preceding symptoms are missing and the patient is suddenly attacked by blood coughing during some more vigorous movement, during the exertion of coughing or even without any direct cause. _Blood coughing_ seems to appear somewhat more frequently with the _female_ sex than with the male and has with them unmistakable relations to menstruation, as with the sick it often sets in before, often after or even during the same and at such times more frequently than at others.