the bronchophony of the solid lung of the earlier stages, passes imperceptibly into pectoriloquy; and this again into the amphoric voice, should the vomica become very large. The sound of the cough is similarly modified; if the vomicæ are small, it may be only bronchial; if they are of moderate size, it is cavernous; and when they are of great extent, it is amphoric.

The rhonchus of cavities differs also with their size, and may be either cavernulous or cavernous. The former of these is only an exaggeration of the humid click, and is liquid, bubbling, and metallic. The cavernous rhonchus has many varieties, depending upon the amount and consistence of the secretion, and its intermixture with air: sometimes it is plashing, and seems as if the contents of the vomica were in a state of ebullition; sometimes it is metallic and clicking; sometimes it is like the agitation of a thick viscid substance; but however variable it may be, it is readily recognized by its liquidity and metallic hollowness.

The physical signs of a cavity always depend upon its contents; when there is but little secretion, cavernous respiration may alone be heard; when there is more, cavernous rhonchi may be associated with it; and when the mucous or purulent fluid is very abundant, nothing but the rhonchi may be distinguishable.

In addition to the more immediate signs of tubercular disease of the lungs, we have others

scarcely less valuable, arising out of the inflammatory process which is apt to occur. Thus, a pleural friction murmur, or fine crepitation at the apex of either lung, shows the existence of local pleurisy or pneumonia, which, in all probability, depends upon the irritation of tubercle. Subcrepitant rhonchus, also, when limited to the ordinary seat of tubercular matter, being indicative of a local capillary bronchitis, is equally and frequently a phthisical sign, and one which is very seldom deceptive. It is obvious, however, that all of these require corroborative evidence.

From the very beginning of tuberculosis of the lungs, there is no distinct line of separation between any of its physical signs; one passes insensibly into another; and although we are in the habit of speaking of different stages, these must not be regarded as steps in the disease, but merely as divisions for conveniently expressing its regular progression.

It is unnecessary that I should enter upon the physical signs of certain complications of phthisis, since they differ in no essential respect from those attending the same diseases when idiopathic. We may expect to find frequently, associated with the tubercular affection, more or less indication of general secondary bronchitis, and sometimes of pleurisy, or even pneumonia; and these will occasionally so mask the original disease as to render it difficult to determine,-until their more urgent

symptoms have considerably abated,-whether or not the patient is really phthisical.

The physical evidences of pneumothorax are as well marked as are its general symptoms. Bulging of the intercostal spaces; tympanitic resonance on percussion; and either weakness or deficiency of respiratory sound, or else amphoric breathing, are more or less evident; metallic tinkling may also exist, but it seldom appears quite at the commenceThe amphoric character of the respiration may be noticed from the very first, or it may become gradually developed; but in some cases it never exists, the breathing being, throughout, simply weak or even altogether absent,-differences depending upon the kind of opening formed into the pleural cavity.

ment.

Hydro-pneumothorax may be recognized by dulness of sound at the base of the chest, and morbid resonance above; the line of union of the two changing with the posture of the patient. Metallic tinkling is often, but not invariably, heard; and the plashing of the fluid is sometimes distinctly audible, both to the patient and the auscultator, by gently agitating the thorax.

It remains only that I should say a few words upon the physical diagnosis of laryngeal phthisis.

When the larynx, or the trachea, is inflamed, the sound produced by air passing through it is modified according to the deficiency or increase of the natural secretions; it is either harsh, dry,

and whistling, or accompanied by mucous rhonchi. Except in determining these points, the stethoscope affords no information, and fails to indicate, with any degree of certainty, whether or not ulceration is present. But we have the less reason to regret this imperfection in the physical signs of this disease, since its general symptoms are always very clearly marked.

The state of the larynx is sometimes an impediment to a proper examination of the thorax, either by obstructing the entrance of air into the chest, or by causing so harsh and loud a sound in its passage, that the more feeble respiratory murmur lower down becomes inaudible; but under such circumstances it usually happens that the general symptoms either of the pulmonary or the laryngeal disease, are sufficiently evident to render a minute physical examination of the chest the less necessary.

PART III.

THE TREATMENT OF CONSUMPTION.

CHAP. I.

PREVENTIVE

TREATMENT.

HAVING, in the preceding parts, endeavoured to show the many circumstances calculated to give rise to phthisis, as well as the different aspects which the disease assumes, it remains that I should now give them their practical application.

The well-known adage, claiming for prevention a higher place than cure, is nowhere better illustrated than in consumption, as it is much easier to keep this disease at bay, than to check or cure it in its progress. I propose, therefore, making a few observations upon what may be termed its preventive treatment; and as this must differ according to the healthiness or otherwise of the particular case, the subject is obviously divisible into two parts.

(1.) The method of guarding against Consumption in healthy persons.

The inheritance of health will not ensure its