imitated by striking the second phalanx of the forefinger of the left hand with the forefinger of the right. The struck finger is held free in the air. It is due to complete solidification or effusion in the pleura.

Some physicians have, in a few instances, believed that they have heard the sound termed by the French bruit de pot felé, or, by the English, cracked-pot sound, in the first stage of phthisis. I have never heard this sound at this stage of the disease; and I feel assured that the sound, in its true and full characters, has never been emitted by a chest in the first stage of phthisis only. A sound, which may be called a quasi-cracked pot sound, it is true, is occasionally heard. It is a sound, loud, not dull, prolonged, with a metallic-like slight chink; but the peculiar dull, loud, jarring, short duration, cavity clink is different from it, and by the practised and careful physician may be readily distinguished from it. This quasi-cracked pot sound will be considered more, and contrasted fully with the true sign, at later parts of this work. The quasi-cracked pot sound is heard most frequently in the case of children; and whether the contents of the chest be healthy or unhealthy seems to have little influence in its manifestation according to some of the most copious writers on the subject. It is of no value whatever as a sign of the first stage of phthisis.

CHAP. XII.

FIRST STAGE-continued.

Position and Form of the Chest. - Forward Inclination of Thorax.-Rounding of Back.-Elevation of Clavicles and Scapula.- Double-flattened Chest. Single-flattened Chest. Depression of the Thoracic Cone.-Angular Con

ditions of the Front of the Thorax.-Varieties of Chest in reference to Induction of Phthisis.

CONSIDERABLY before any appreciable alteration in the position of the chest in phthisis can be discovered, the auscultatory signs and alterations of the percussion note which have been already described, are manifested in a sensible and reliable degree in almost every example of the disease. But ere much time has passed from the accession of dullness on percussion, the position of the chest undergoes a change in a large proportion of cases. I am inclined to say that not less a proportion than one half of patients in the first stage of

phthisis in whom a reliable degree of alteration in the percussion sound is procured, evince, in an amount sufficiently great to be appreciated, a change in the position of the chest in respect of the perpendicular. The thoracic cone is bent forward at an abnormal angle. The axis of the thorax is no longer a continuation of the axis of the abdomen, or nearly so, as in health, but is inclined forward to a sensible extent. This is obvious to the eye. The shoulders are carried forward with the thorax. If one limb of the chest goniometer (an instrument to be afterwards described) be applied to the lumbar vertebræ, and the other be applied to the dorsal vertebræ, or in the direction of these bones, the arrow of the index will point not to 180°, the normal point, viz. that of a straight line, but to 175° or 160° upon the arc.

The dorsal vertebræ, from a comparatively straight line, deviate to a curve constantly increasing with the progression of the disease. This may be measured with the chest goniometer. We take the tangents to the curve. A portion of the vertebral curve is taken about equal to the length of the two extended arms of the instrument, this being divided into two equal parts, the two limbs respectively placed upon these parts give the tangents to the curve, and by looking at the index on the arc, we find that the angle formed by the meeting of the two tangents is that of 180°, or even 150°. Thus we measure the amount of the curve, and consequently the amount of deviation from the normal line or form. In this way we have a mathematical and exact demonstration that the curve of the dorsal vertebræ is materially increased. The back is become rounder. It will be found, however, at a future part of this work, that the increased curve of the first stage of phthisis is replaced in most examples of the disease, and more particularly in chronic cases with excess of dyspnoea, by a very great increase of roundness in the third stage of the disease. It appears to be scarcely necessary to say that this undue curving of the dorsal vertebræ occurs in other diseases, and in cases of mere general debility long continued.

Concurrent with the rounding of the dorsal vertebral line, the clavicles and scapulæ are wont to be unduly raised, but to a very small amount in the first stage of phthisis. This holds only in perhaps fewer examples than the rounding of the spine, and it is remarked most when the first stage is considerably advanced, and when both sides of the chest are affected; or when in addition to the apex or apices being tuberculated, one or both bases are congested, or have their

finer bronchial tubes obstructed with thickening of the mucous membrane, or with excessive secretion. In such cases an explanation of the greater frequency of this alteration in the shape of the thorax is found in the presence of more than usual dyspnoea. The elevation of the clavicle and scapula is moderate, and much less extensive, and less frequent than in asthma.

The most common alteration of the configuration of the thorax, in the early part of the first stage of phthisis is a flattening of the anterior surface. The flattening involves the sternum down to the ensiform cartilage, and the cartilages of the first four or five upper ribs on both sides of the chest. The sternum, instead of presenting a projecting line as it descends, tends to become perpendicular, or it may even incline inwards as it passes down. If the joint at the middle of the chest goniometer be placed at the upper border of the sternum, and one limb be directed upwards, but in the perpendicular, and the other, or as it will now be the inferior, limb be placed upon the sternum, the index on the arc will point to 180°, or, so to speak, to the angle of a straight line or to a smaller, viz. 175° while in health the angle indicated would be 190° or 200°, the latter indicating a well projecting sternum. The cartilages of the ribs are flattened laterally, the normal rounded figure of health is lost. The angle of the tangents to the curve will frequently be found 178°; or within two degrees of a straight line, while it is to be remembered that the normal angle in most adult chests is about 170°. But it is not laterally only that the flattening is remarked, or that this holds with single cartilages only; the same alteration is visible vertically or from above downwards in reference to the line formed by the aggregated cartilages. In health the line which represents the cartilages from above downwards is rounded or curved and the angle of its tangents most commonly is about 170°, while in the first stage of phthisis it often becomes straight or perpendicular, or it may even be directed inwards towards the spine as it descends, being the reverse of the natural direction. The angle to its tangents is often 178° or only two degrees different from a straight line. The second, third, and fourth cartilages suffer more flattening than the first and the lower cartilages, and hence the inclination to the straight line which we observe. When the sternum has assumed the perpendicular direction, and the costal cartilages on both sides of the chest have became flattened, I have designated this abnormal alteration

the double flattened chest. This deviation from the natural configuration of the thorax is very common in the first stage of phthisis. It has been observed by me in a large percentage of examples of phthisis at this period. It is peculiarly the deviation of the more early period of the first stage of the disease. Of sixty-six examples of this alteration occurring in phthisis of which I took particular notice, fortynine were associated with the first stage, twelve with the second stage, and five with the third stage. It is a comparatively rare occurrence in other diseases. Of seventyfour examples, as many as sixty-six occurred in phthisis, and only two occurred in bronchial disease, one in dyspnoea and two in heart disease. To account for the comparative rarity of this deviation in the advanced stages of phthisis, it is to be remarked that this is not due to a subsequent rising of the sternum and rounding of the costal cartilages, but to the fact that more remarkable and striking deviations of a restricted extent occur in these stages and take the place, so to speak, of the double flattened chest, these deviations being single flattening and undue angularity of the articulations of the sternum and cartilages, and of the cartilages and the ribs. The double flattened chest has been more frequently observed by me in females than in males. The rate per cent in males has been only 39.1 per cent., while in females it has been 60-8. This preponderance amongst females is due perhaps to the greater delicacy and feebleness of this sex, which tend to habits of stooping, to early yielding of the ribs and cartilages to the injurious influences of the disease, and also to the fact, of which I have no doubt, that phthisis in females is less frequently than in males the result of active accidental causes, and more frequently the product of constitutional errors, slow in operation, and therefore more likely to be attended with general debility. The disease for the same reasons is more likely to be diffused over both sides of the chest and to lead to a corresponding flattening. This deviation from the natural configuration of the chest occurs at all ages, but is remarked in a larger proportion of cases in young subjects than in old. I have observed that the proportion of examples is excessive in girls under fifteen years of age. The greater ratio of cases in the young than in the old probably depends upon the more yielding consistence of the bones and cartilages in them than in adults.

The double flattened chest is not confined to phthisis affecting both lungs. It is seen occasionally when the physical signs reveal, by reliable evidence, the presence of tubercle in one

lung only. I have seen double flattening nine times in single phthisis out of forty-nine examples of this deviation in the first stage of phthisis. In the other forty examples the tubercle was diffused over both lungs, though it is true in some cases the deposit preponderated much on one side over the other.

The double-flattened chest owes its development to the reduced bulk of the lung. Although the weight of the lung in phthisis increases materially by the deposition of tubercle, yet its bulk, under the inspiratory effort, is very considerably reduced, The accession of fresh and adventitious material interferes with the normal inflation of the vesicular structure; an amount of air is prevented entering, greater in bulk than the obstructing tubercle that is added; and the result is a decided diminution in the bulk of the lung, even during inspiration. The normal quantity of retained air is likewise reduced by the presence of tubercle, and consequently the bulk of the lung, even after expiration, is also diminished. As soon as the lung is inflated to that degree that cannot be exceeded without pain, distress, or laceration, or undue distension of dilatable parts, the inspiratory muscles which elevate the chest, including the sternum and the ribs with their cartilages, in inspiration, cease to act. This point or limit of easy inspiration must be reached sooner when the lung is solidified by tubercle, than when it is fully inflatable as in health; and therefore the chest will rise less in this disease than in health. As the sternum is less raised, it will, of course, project less, and as the cartilages are seldom elevated, interstitial absorption will soon remove these curves and impart the flattened appearance which is under consideration. To this cause is frequently super-added another, viz. the presence of contracting tissue in the lung, underneath the upper cartilages. Plastic tissue, either in the lung or at the pulmonary pleura, by contracting very much, destroys the vesicular structure, and compresses it to a great extent. Over this part, of course, the chest cannot rise without the occurrence of a very unlikely amount of compensatory dilatation in other parts, or of laceration. If to such plastic material there be added fibrinous exudation, binding the pleura pulmonalis with the pleura costalis immediately under the cartilages of the upper ribs, a great addition is made to the means by which flattening is produced. This fibrinous bond is observed in many examples of phthisis in the first stage, but much more frequently in the latter part of it than in the first. Soon after its formation, it contracts, and by a process of