zation, the result of inflammation provoked by the constant irritation of a cavity above; in others, and these are more common, it is due to a conjoint state of hepatization, crude tubercles, more or less numerous, and more or less advanced, and to very considerable congestion, and sanguineous and serous infiltration. This reduction of respiration in the third stage of phthisis is a progressive sign. Once commenced, it remains, or more or less rapidly increases until nothing is heard except a very little coarse bronchial respiration sound, or an occasional sibilus or sonorous rhonchus. Its course is slow, and unattended for the most part with that sudden development and almost as sudden declension observed in respect of the abolition or reduction of respiration due to empyema. The gradual development also greatly differs from the instantaneous abolition of ordinary respiration sounds, in some examples of pneumothorax, attendant upon phthisis.

THE ABOLITION OF RESPIRATION SOUNDS.-The total abolition of respiration sounds at some parts, and occasionally over almost the whole of one side of the chest, takes place when copious effusion is poured into the cavity of the pleura. This effusion depending upon inflammation occasionally takes place in the third or cavity stage of phthisis, as a direct consequence of that disease, and it is more commonly observed in this stage than in either of the two preceding ones. The abolition of respiration also is due, in a very few examples of phthisis at this period, to serous effusion depending upon an anæmic state, or a dropsy-forming condition of the blood, often dependent upon co-existent disease of the kidney and albuminuria, now and then combined with tubercle in that organ. It is also by no means unfrequently due to a very different condition, viz., the interposition of atmospheric air between the lungs and the thoracic walls causing collapse and compression of the lung. But this condition of air in the cavity of the pleura depending upon perforation I have decided to treat as constituting a later and concluding stage of phthisis.

Another cause of the abolition of respiration sounds in the third stage of phthisis is occasionally found in the enlarged and fatty degenerated liver which occasionally accompanies pulmonary tuberculosis. The liver occasionally, too, presents the lardaceous character. Total abolition in consequence of the enlarged liver is found to exist on the right side of the chest only. No respiratory or vocal sound whatever is heard in some cases below the level of the nipple. The lung is

pushed up beyond that level, and its place is occupied by the encroaching liver. During the last five years I have noted this state of things, or an approach to it, in some half dozen post-mortem examinations made at the Hospital for Consumption. A man named John Carr died in the hospital in 1856 under Dr. Cotton. The apices of both lungs were excavated. The liver weighed 123lbs. A soldier named John Mann, also under the care of Dr. Cotton, died in 1857, and presented a very large encroaching liver. It weighed 11lbs.loz. Both the lungs at their apices were excavated. Such cases are generally associated with jaundice, and the liver is felt large in the abdomen.

The abolition of respiration sounds due to the seropurulent liquid of empyema, begins at the bottom of the chest, and slowly and gradually proceeds upwards, i. e. when the patient occupies the erect posture. It is common for it to reach to the angle of the scapula or a little above it, and to stop there. It sometimes rises higher, and I have in several examples, perhaps half a dozen, found this abolition as high as the level of the second rib in front. The abolition ascends gradually and equally, perhaps half or a whole inch, or even more in the twenty-four hours. It is accompanied with very considerable dyspnoea, sometimes very great dyspnoea, and occasionally with only moderate distress, the dyspnoea in general being in proportion to the extent and rapidity of accession of the abolition of respiration sounds. I have seen much distress from little effusion, and in a few cases I have heard the patient say, that his breathing was easy when one side of the chest has presented no respiration sound, except above the second rib. The suddenness or slowness of the effusion, and the healthy or unhealthy state of the opposite lung, have explained these anomalies.

The abolition of respiration sound in the case of the empyema of phthisis in the third stage is confined to one side at least I have always found it so.

The percussion under these circumstances is absolutely dull. The voice at the clavicle is usually loud or cavernous; at the base it is absent. When the effusion has reached the angle of the scapula the voice becomes ægophonic, a character whose singular properties and mechanism I have already described. When the abolition of respiratory sound ascends to the spine of the scapula, ægophony is lost.

The dimensions of the chest increase: the semi-diameter increases, and the excess may reach from one to two inches. The intercostal spaces bulge in an undue manner. The side

remains little affected in shape and movement at different periods or stages of the respiratory acts. When the patient at an early period of the abolition of sound is placed upon his abdomen, some sound is occasionally heard posteriorly, the liquid falling to the anterior and now lower part of the chest.

After a time abolition of sound from empyema is marked by remarkable changes. The line of absolute dulness falls, ægophony returns, and as absorption of the liquid proceeds finally disappears.

In a remarkable example of the abolition of respiration due to empyema and connected with pulmonary tuberculosis (Bird), I believe, in the third stage, a fistulous opening existed at the right subclavicular region near the sternum, which evacuated much fetid pus and respiratory air. The patient also expectorated much of the same liquid. Humid crepitation had been observed some time, and latterly liquid cavernulous sounds became audible under the right clavicle at its humeral extremity. Absolute dulness prevailed from the base close up to the clavicle. This patient died. I have in other examples of phthisis found fistulous openings discharging pus from the pleural cavity, but they have been under the fifth rib.

The abolition of sound due to serous effusion is slow in its development. It is usually very partial, and confined to the very base of the chest. It is commonly found on both sides of the thorax. It seldom rises high. There may be bronchophony, but ægophony is seldom heard, if I may decide by my own experience. The countenance and white colour of the skin, the oedematous feet, &c., usually point out the true nature of this form of abolition of respiration sounds. PUERILE OR AUGMENTED RESPIRATION OF THE LUNG ON THE HEALTHY SIDE OF THE CAVITY LUNG. - This is a very common occurrence. It is most observed at the upper parts of the side. It serves by contrast to mark well the deficiency of the opposite side. In such cases the expiration is usually somewhat prolonged.

This

INCREASE OF RESPIRATION AT BASE OF DISEASED LUNG. condition I have not unfrequently noted in cavity cases. The loudness and fulness have been such as to eclipse the healthy sounds of the healthy base, when I have employed the differential stethoscope. In such cases the base is compensating by excessive action for the deficiency of its apex.

Excessive loudness, too, of the respiration sounds of the base of the unhealthy lung is occasionally established, and after

the manner noticed above eclipses the weaker sound of the healthy base. This loudness depends upon the resisted respiration due to the presence of crude tubercle. It is analogous to the harsh and loud respiration sounds of the first stage of the disease. The circles express these acoustic results. The black circle denotes sound heard, the dotted circle sensorial silence.

Auscultation of Heart and great Vessels.-Loudness and Nearness of Sounds at upper Interspaces. Arterial Blowing from Pressure, influenced by respiratory Acts.-Arterial Murmurs from intrinsic Disease.-Adventitious Heart Sounds: pure and mixed.-Venous Murmur.

THE auscultation of the heart and great vessels, in the third stage of phthisis, is very important, and reveals in a very large number of cases abnormal signs very useful in the diagnosis of this disease. Even when these signs are of little value in a diagnostic point of view, or are superfluous, from the decisive character of other signs, it is very important to note them; for such anomalies, as they really are, prove highly interesting, and present points for study which may afford a reflected light upon the pathology of these parts and of various diseases. To omit the remarkable alterations in the locale, impulse and sounds of the heart, and the arterial and venous sounds which are sometimes established, would be to write the signs of phthisis in an exceedingly imperfect manner; and for the physician to pass them over unnoticed and unthought of, would argue a style of treatment furnishing little accurate information.

Although the auscultatory signs of the heart, &c., compared with percussion, &c., are less valuable, I prefer treating of them in this place, because I shall thus be enabled to conclude the subject of auscultation in this stage; and by so

NEARNESS AND DISPLACEMENT OF SOUNDS.

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doing I am enabled to keep together all the auscultation signs of the period, an arrangement which will be convenient for reference to this branch of inquiry.

One of the most remarkable signs connected with the heart's sounds, in the third stage of phthisis, is a striking loudness and nearness to the ear, under the clavicle. The heart's sounds reach the ear, as if that organ lay, which in many cases it really does, under the second intercostal space and the second rib, and as if the whole, or nearly the whole, lung structure which formerly and in health covered it were destroyed and obliterated. The point of greatest loudness is changed; the greatest intensity is translated; the loudness is greater at the second interspace than it is at the fifth. When the cavity is situated on the left side, this sign is most developed; when the cavity is situated on the right side, the sounds of the heart are still greatly augmented, but the increase is less than when the disease is upon the left side. I have often found the sounds of the heart upon the right side at the second interspace more loud than at the fifth interspace on the left side, and under the nipple: this occurs invariably when, by reason of contracting adhesions, the heart, as is often the case, is drawn upwards and to the right. So decidedly are the sounds of the heart louder at the second and third interspaces, the cavity being on the left side, than at the fifth interspace, the point of greatest normal intensity, that when the two limbs of the differential stethoscope are placed upon these points respectively, the sounds are heard at the first-named places only, and not at all at the point of normal greatest intensity. The acoustic circles will serve to illustrate these facts. The black represents sound, the blank silence.

Second Interspace.

Fifth Interspace.

The abnormally-heightened intensity of heart-sounds at the parts indicated, due to the presence of a cavity, is in character somewhat different from the increased loudness of solidification,whether that be of hepatization, tubercle, or cancer. The loudness of cavity has a character of nearness and directness; the loudness of solidification has a character of comparative distance, and of transmission through a solid conductor that