sions; the voice is often lost, and the act of swallowing rendered so painful that death ensues from actual starvation.

The pathological changes in the diseased structures determine, in a great measure, the amount of distress experienced by the sufferer. The mucous membrane may be thickened, softened, or ulcerated; but it is impossible to tell its precise condition during the patient's lifetime. Ulceration is nearly sure to exist where the symptoms have been severe and long-continued, and it may involve not only the mucous membrane, but extend also to the cartilages of the larynx or trachea.

Chronic laryngitis, arising from other causes than phthisis, is comparatively rare. Simple inflammation of a subacute or chronic form, ending in loss of voice, irritable cough, and uneasiness about the throat, now and then follows exposure to cold, and is also met with in persons who habituate themselves to an undue exercise of the voice. Malignant disease sometimes appears in the upper part of the respiratory passages; and syphilis is well known to be productive of structural changes in the same region. It is, however, generally easy to distinguish these diseases from laryngeal phthisis, not only on account of the very different aspect which their history and symptoms present, but also from the circumstance that the tubercular affection is invariably accompanied by a similar condition of the pulmonary organs.

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CHAP. IV.

PHYSICAL SIGNS.

THE general symptoms of early phthisis are of themselves insufficient to declare, with any degree of certainty, the nature of the disease; and even at a later period, however unequivocal they may be, they are incapable of accurately pointing out the precise stage at which the disease has arrived. Under no circumstances, therefore, can a physical ✓ examination of the chest be deemed unnecessary; and a diagnosis should never be attempted without its assistance.

First Stage.-A small amount of tubercle may✓ exist in the lung, without immediately effecting any sensible alteration, either in the symmetry or respiratory movement of the thoracic walls. After a time, however,—which is determined by the increase or otherwise of the tubercular deposit, and its effect upon the neighbouring pulmonary tissue, -the form of the chest becomes changed, and its action impaired. There is often at first a slight bulging of the infra-clavicular region of the affected side, in consequence of the tubercle being sufficient in quantity to distend the pulmonary cells,

or of its having become surrounded by a temporary hypertrophy or emphysema of a portion of the lung. This, however, soon disappears, the thoracic parietes over the morbid deposit invariably falling more or less inwards as the disease advances, owing either to atrophy of some of the air-cells, or to contraction of the pulmonary tissue from secondary inflammation.

But the regions about the clavicles are not the only parts to exhibit the effect of pulmonary tuberculosis. The whole contour of the chest soon becomes altered; the shoulders are gradually drawn forward, and the back is rounded, causing the patient to lose permanently in height.

The change of respiratory movement bears a direct proportion to that of the thoracic walls, and commences simultaneously with it. Until there is some depression, however, the alteration is so small, and, as it appears to me, so irregular and uncertain, as scarcely to claim any great attention. But no sooner have the parietes of the chest over the diseased parts fallen the least inwards, than the action of the thoracic walls is sensibly altered: there is less expansion of one side than of the other, especially during forced breathing, the swelling movement so characteristic of health being no longer observed. This becomes more and more marked as the case advances, until at length the anteroposterior diameter of the upper part of the chest is almost incapable of enlargement, and every effort at deep inspiration is attended with a

peculiar forced elevation of the shoulders at once indicative of pulmonary obstruction.

For a very accurate estimation of these changes in the respiratory movement, the chest-measurer is a useful instrument; but I cannot help thinking that the practised eye and the properly applied hand are capable of affording every information which is worthy of influencing the diagnosis.

So soon as there is any amount of tubercle in the lung, the percussion-sound over the diseased part is less clear than upon the corresponding portion of the other side; and is attended with a feeling of resistance, very different to the elasticity so invariably existing in a healthy chest. No dependence, however, should be placed upon slight differences, unless corroborated by other signs, since they are not only met with in other diseases, but also occur now and then in healthy persons.

The respiration is, at the same time, morbidly affected; and in many cases this is evident, even before there is any manifest alteration in the form or movement of the thoracic parietes. Either it is louder than natural, or it is weak, harsh, jerking, or even bronchial; or, there is a change in the relative duration of the two respiratory murmurs.

An increased loudness is occasionally met with; but it is only temporary, disappearing as the tubercle becomes more abundant, or the lung begins to contract. Weakness of respiration is a more common and more lasting condition; and the same may

N

be said of harshness, both which are often combined. Jerking breathing is limited to the inspiration, and is a very frequent attendant upon the first stage, especially at its commencement. Bronchial respiration, on the other hand, is scarcely ever the first deviation from health, but is a sequel to one of the preceding, and an indication of a somewhat advanced period of tubercular formation. A prolongation of the expiratory murmur is, perhaps, one of the earliest and most common alterations, and generally easy of recognition.

None of these changes from healthy breathing are, however, of themselves a proof of phthisis, as they show nothing more than functional derangement of the lung, which, it is obvious, may depend upon a great variety of causes; it is only when they are strictly limited to the upper part of the chest, especially on one side, and are confirmed by other symptoms, that they can be looked upon as evidence of the lungs being tubercular.

After the first stage has existed some little time, one, two, or more dry clicks or dry crackling rhonchi, as they are termed, are heard with the inspiration; and, as they never happen from any other cause than tubercle, are at once characteristic of phthisis. As the second stage begins they become less dry and more abundant, and may attend both respiratory murmurs, until they pass into the humid click, which is the distinctive mark of tubercular softening. These rhonchi are, fortu