showed no preference for one side over the other. He will often sit upright in bed, bending his shoulders greatly forward, for an hour or two, or until exhausted with the necessary effort.

Some patients will lie exclusively on the diseased side for a length of time. All at once they then manifest a preference for the diseased side. Latterly, the patient Perry lay and slept exclusively upon the diseased side; and a day or two before her death Farrell turned on the diseased side and died upon it. This change occurs when liquid forms. The patient now seeks the posture of empyema.

EXTERNAL SOUNDS.-I deem it right to mention a curious phenomenon which I have noted in connection with the auscultation of the perforated side. Loud, sonorous, external noises have been heard by me, when using the stethoscope, to come with much resonance from the air-filled side. The external vibrations have affected the side and caused it to consonate.

HYDRO-PNEUMOTHORAX.-The addition of liquid to air in the pleura has been spoken of already. This compound condition is called hydro-pneumothorax. Effusion may or may not occur in the perforation stage. It is true that the effusion of liquid tends to take place after perforation.

Hydro-pneumothorax is found in nearly all cases of perforation of above some weeks' duration. It is signalized by dulness on percussion at the very lowest part of the thorax, and when that is the abdominal end of the cavity, directed more to the abdomen than to the thorax where the air is confined, the air somewhat counteracting the dulling tendency of liquid. Splashing is to be evoked. Metallic tinkle is heard, but not more than in cases of simple perforation. The dimensions of the side are increased. The chest is rounder, and the intercostal spaces are more than usually prominent. Displacements of the heart and lungs of the opposite side are common and to a more marked extent than in simple pneumothorax. Egophony, the characteristic of pure empyema, I have never heard in hydro-pneumothorax, the result of perforation in phthisis. In cases of hydropneumothorax, fœtid pus or sero-purulent fluid may be passed through the fistulous opening and expectorated.

I append a table of seven cases of perforation seen by me lately. Six were my patients. One was Dr. Cotton's. From this table, as far as it goes, it appears that both sexes are equal sufferers, and that both sides are equally liable to perforation:

DURATION. The duration of the signs of perforation is short. The average is about one month or six weeks. But like the signs of most diseased actions to which man is subject, those of perforation vary much in duration. When we consider the varying conditions under which perforation takes place, the various events which arise, and the varying powers of the patients, we need not wonder that the average is not nearly reached in some cases, and that it is greatly exceeded in others.

1. My patient Farrell died about two weeks after the first discovery of perforation signs.

2. D. died one month after detection.

3. W. died a month after detection.

4. P. died six weeks after.

5. C. died a few days after.

6. died six weeks after.

7. R. died eighteen months after.

8. A. died two months after.

But it is to be observed, that the period between detection and death is an imperfect measure of duration. The signs probably existed a considerable time before their discovery.

VITAL CAPACITY.-The vital capacity must be very low in the stage of perforation. One lung will hold scarcely any air; but we must remember, however, that though the lung holds little or nothing, the pleural cavity both receives and discharges air. Pleural respiration, so to speak, still goes on, though this is truly in small amount.

I am not aware that physicians have actually ascertained by experiment the lung capacity of perforation patients. For my own part, I have scrupled to test my patients in this way. Their exhaustion and distress make it a point of duty in general to omit this inquiry.

The cough of perforation is peculiar. It is extremely short, consisting, for the most part, of one or two short quick forcible expirations. In some cases this is repeated almost incessantly, the patient having scarcely time to utter a word or two without being interrupted. It closely resembles the cough of pleurisy. But in addition to this peculiar cough the loud, sonorous, moist, and deep and protracted cough of the third stage is experienced from time to time.

The sputum is perhaps more scanty than during the third stage. I have seen it reduced to a small amount of thin, frothy, gummy-looking liquid. I have never seen blood in the sputum.

The voice is with difficulty formed in bad cases. It is a low voice, and feebly and painfully uttered.

The mouth and pharynx, &c., are much the same as in the third stage. I have seen the tongue as clean as in health.

THE EXAMINATION OF THE PATIENT.

297

PART II.

CHAP. XL.

PRACTICAL DIRECTIONS.

Necessity of early Exploration.-Thorough Examination.-The Room.-Temperature.-Light.-Silence. Posture.-Inspection.

In the preceding part of this work the results of the examination of the phthisical patient have been fully given, but it remains for me to say how these results are best obtained, so that, by the employment of the most approved methods, the patient's disease may be most clearly made out, and the instruction of the student be consulted.

FULNESS OF EXAMINATION. When a patient comes before the physician, under circumstances rendering it reasonably probable that his symptoms are due to the presence of pulmonary consumption, however early, whether these circumstances be the actual symptoms of thoracic disease, whether it be that the patient is himself suspicious and anxious, whether relatives desire an opinion, whether an insurance company seek information, or whether a brother practitioner desires a second opinion, in respect of this disease, it is most important and it is imperative that a sufficient examination should be made, and that at as early a period as possible.

The very fact that a patient seeks advice on his own account, or that he is sent to us whether by professional or non-professional parties, should constitute in our minds a warrant for full examination. This should hold in even apparently trivial cases, for it often happens that apparently very trivial cases are really very serious ones. How often has a patient been deprived of suitable medical treatment; how often and how long has he been exposed to injurious agencies; how often has a patient entered into long engagements of a ruinous character, because he was never to see the end of them; how often has he taken social steps injurious

to himself and others,-simply because this rule has been disregarded? Again, how often has the kind, and even the skilful and deserving, medical man been the almost innocent sufferer in his reputation by his too great confidence that no physical examination was required?—and again, how often has the consulting physician and "the second opinion" obtained great, and perhaps not undeserved, credit and reputation by instituting that inquiry which the first, and perhaps equally well-informed physician had, from too great ease of mind, from dilatoriness, or from modesty, neglected to carry out, but which he was perfectly competent to institute.

Take, again, the case of the patient in extremis, even in articulo mortis; we are bound to make a sufficient examination. A few minutes well employed, no pain, no inconvenience to the patient being involved,-we are enabled to pronounce positively on the nature of the disease, to specify its stage, its seat, and its chief local characters. This is a satisfaction of great price to relatives and to the physician; it may be, too, to the patient himself, who is yet called upon to make some important and immediate decision.

Yet again, let us imagine a case, by no means very rare, of a patient greatly reduced in flesh, very ill, and in daily expectation of death. Such a patient has many of the symptoms which consumption produces, but which, in this particular case depend upon other conditions of a comparatively unimportant nature. To examine such a patient, to discover only healthy respiration sounds, and to give a corresponding report, is surely a service of immense value.

The examination of a patient suspected of phthisis should be undertaken at an early period. If possible, it should be made at the first interview. If, however, time and circumstances will not permit of a tolerably full examination, it is better not to undertake it at all at the time, but to postpone it to another opportunity, giving in the mean time an opinion on the symptoms only, reserving a decided statement on the nature of the disease, and prescribing for urgent symptoms and offering some safe rules for regimen. It will sometimes happen that the patient is too ill at the first interview to submit to a full and protracted examination. In this case, the discovery of some of the more important signs should be attempted, such as gurgling, liquid crepitation, and very dull local or general tympanitic percussion sound. Such conditions as these signs reveal will afford prima facie grounds for an opinion and indications for treatment. In the case of very nervous and very timid persons, it is sometimes neces