velopment, its most uncertain, but its most fearfully interesting stage. An individual is suspected to be phthisical: he has some fever, some acceleration of pulse, some emaciation, and some cough; all inconsiderable in degree, yet all abiding; but no expectoration. In a patient thus suspected to be phthisical, auscultation may discover no more than this; that beneath the clavicle and about the scapula the respiratory murmur is less clear on one side than on the other, and that, where the murmur is defective, there too, the chest is less resonant to percussion. Now if, after repeated examinations, auscultation comes always to this result, no doubt can remain that tubercles are already formed in the upper lobe of one lung. But here is no unnatural sound, only the natural sound is in part defective; and this must arise from some impediment to the passage of air through that portion of the lungs. Now impediment may arise from the deposition of lymph, or any of the common products of inflammation, as well as from tubercular matter. But inflammation is very unapt to take place, and its products to be effused into the apex of an upper lobe, while every other part of the lungs remains unaffected by it. It may ultimately reach this situation, but seldom, very seldom, begins in it. On the other hand, it belongs to phthisical disease to deposit tubercles in the upper lobes first, and thence gradually to scatter them over the rest of the lungs. Always bear in mind that there are no auscultatory signs which expressly bespeak tubercles. You are left to get at the knowledge of their existence by that sort of evidence which has been called circumstantial; auscultation, however, having an important share in the result. As thus, auscultation finds the respiratory murmur defective at a certain part of the lungs; and hence we infer its obstruction by the deposition of some kind of matter or other. But the part is that which nature chooses, above all others, for the deposition of tubercular matter; and hence we further infer that the matter is tubercular in this particular instance. But, moreover, the constitutional symptoms are such as are wont to accompany phthisical disease; and hence we finally infer almost a certainty that tubercles are deposited at the upper part of one lung. We conclude that the thing must be, because it can be nothing else. Circumstantial evidence, it is acknowledged, may be as infallible as the evidence which bears direct attestation to the simple fact.'pp. 233-235.

When the mass of solid tubercle is about to soften and be converted into an abscess, a sharp sound ('click') is heard in those points under the collar-bone, which hitherto had been dull and impervious to air. That the ear may not be deceived by an accidental sound, the patient should be directed to cough, in order to dislodge any tough piece of phlegm which might have caused the noise. If, after repeated examination under varying circumstances, the ringing sharp sound is heard, it is the most authentic sign of a fatal change. That the circumstances cannot be too widely varied before the physician comes to a decided opinion, the following admirable example of Dr. Latham's own acumen will show :

'Some

'Some time ago I was desired to pronounce upon the nature of the disease, in a gentleman who was affected in this manner :-He had suffered a long and abiding hectic, and had reached a state of extreme emaciation, but had a very slight cough, and expectorated only one large globule of yellow heavy matter once a day, immediately after he woke in the morning. His little cough, his little expectoration, and his ability to inflate his lungs freely and deeply, encouraged a hope that he still might not have consumption, his abiding hectic and his extreme emaciation notwithstanding. I examined the chest, and found the respiratory murmur clear and loud, and vesicular. In the act of breathing there was no unnatural sound, either cavernous or gurgling, anywhere. Having learnt thus much, or, rather having puzzled myself thus far, I was interrupted in my further examination by some accident, and I postponed it until the next day. The next day I could get no more information from the mere breathing, except that, upon the whole, the air entered more freely into one lung than the other; the other, however, not wanting the vesicular murmur in any part. Neither from the voice could I get more information; it was neither cavernous nor pectoriloquous. Percussion elicited a somewhat different sound from the space between the clavicle and mamma on one side and the other. But the sound was dull on neither side. What, however, neither the respiration nor the voice could declare by any authentic sign, was made clear and manifest by the act of coughing; viz. that there was a large cavity, full of fluid, occupying a space in one lung between the clavicle and the mamma. For when I desired the patient to make as deep an inspiration as he could, and then to cough with all the force he was able, instantly there came plash after plash against my ear from the whole of this space; a sound which could only result from the agitation of fluid in a large cavity.

But why was there a vesicular murmur at this space? Probably because the cavity, large as it was, had a considerable stratum of healthy lung interposed between it and the walls of the chest. Why was there no pectoriloquy? These same conditions, the size of the cavity, and the intervention of healthy lung between it and the walls of the chest, were enough to prevent it. Besides, the cavity was full, and thus was unfavourable to pectoriloquy. And why, above all, was there no gargouillement, no gurgling sound in the respiration, and little or no expectoration? The air during ordinary respiration might not have free access to the cavity. The cavity was there, but there might be no considerable bronchus entering it. Or, what is most probable, a considerable bronchus or bronchi entered it, but were obstructed by some obstacle, from within or from without, before they reached it. Either hypothesis will furnish the explanation, how a large cavity full of pus can exist in the lungs, and yet not enough of air find its way into it, in ordinary breathing, to produce an audible agitation of its contents, and not enough of matter find its way out of it to furnish more than a scanty expectoration. In this case it took the whole night, and the continual oozing of pus by some narrow passage from the cavity into the bronchi, to accumulate half an ounce ready to be expectorated in the morning.'pp. 240-242. Although

Although the deposition of tubercle in the lung and its subsequent softening are the genuine characters of phthisis, yet there is great variety in the course of the malady. In some, the first or tuberculous stage is slow, and attended with such slight symptoms, as merely to fix the attention of the patient and his friends on a feeble and declining state of general health. Such an individual is said never to be ill and never to be well; he outlives many with whom he had been an object of pity-whose robust frames and capacities of active enjoyment he has envied. Perhaps a little bleeding from the lung may excite alarm, which, however, is soon allayed and then the usual hopes, and fears, and thoughts, and habits of his every day life run in their usual channels. If he be calm and placid, little will occur to break on his tranquillity; if tinctured with melancholy, he will run the gauntlet of medical inflictions, trying every name and system uppermost in the scum and froth of a metropolitan reputation.

Having stated what consumption really is as a malady of the lungs, and compared certain forms of phthisis with kindred forms of disease in external parts, Dr. Latham proceeds to follow out his great practical distinctions. These distinctions are new; but they are stated with the precision and simplicity of truth, and are the unquestionable results of the vast experience of a wise observer. He shows, that there is an unmixed phthisis and a mixed phthisis, and that each has its own auscultatory signs, marking all its stages, and suggesting its treatment, and determining the prognosis of the physician. Of the unmixed phthisis he describes two varieties—

Consumption is perpetually presenting itself to me in this form. An individual loses the complexion of health, and becomes thin; he coughs a little; but perhaps he has no notable fever, and no constant acceleration of pulse. I auscult his chest, and find a dulness beneath one or both clavicles, or about one or both scapula, and a free respiratory murmur through every other part of the lungs. Here there is no disease beyond tubercles; and while they occupy the upper lobe, the whole lungs besides are without a vestige of disease. This form of consumption may endure for years and years, the auscultatory signs continually denoting the same thing, and the patient getting neither a bit better nor a bit worse in the mean time. But he is a wretched invalid, and finds that there is something continually incapacitating him for the severer business of life.

To such a person it is a continual puzzle why he does not get well. He consults an infinite number of medical men; and it is remarkable that he gets no comfort or satisfaction from those who understand his disease the best, and the greatest comfort and satisfaction from those who understand nothing about it. Those, who know what it is, out of kindness do not tell him the truth, and they cannot asseverate a falsehood stoutly enough to carry any weight with it; whereas those who know nothing about it affirm boldly and unhesitatingly that it is all

stomach,

stomach, really believing that the whole and sole disorder is in the stomach, and that it is within the reach of an easy cure. Surely auscultation is so essential a help for arriving at the truth in such a case, that they who are skilled in the use of it always agree as to what the truth is and, indeed, there is no wonder in their agreement: the wonder is, that they who do not arrive at the truth should so constantly agree in adopting the same fallacy. I have been somewhat curious in my inquiries concerning this matter, and the constancy with which I have found the whole malady imputed to the stomach has appeared to me very strange. There is, however, a circumstance in the history of these cases which gives a colour of truth to this opinion. The state of the bowels is very frequently such as to demand the continual use of purgative medicine; and the cough often comes on, and with it a kind of asthmatic breathing, soon after dinner; and both continue as long as the stomach is distended with food.

In this form of chronic consumption spittings of blood are apt to take place occasionally; and, when they do, they must give fearful intimations of disease of the lungs to those who are not yet assured of it by auscultation. But I have known them also imputed to the stomach. In this form of 'chronic consumption abscesses are apt to occur by the side of the rectum, and to degenerate into fistulous sinuses. But in this form of consumption vomicæ are not postponed indefinitely: they at length are formed, and from that time the patient sinks rapidly. Often, when a fistulous sinus has been cured by an operation, and the long abiding discharge from it abolished, an expectoration of pus will occur for the first time, and never afterwards cease. From the first formation of vomica the patient sinks rapidly. In pulmonary consumption, characterized by the length of its tubercular stage (if I may so call it), and by a seeming reluctance to pass on to the formation of vomicæ, when, after several years, vomica do ultimately take place, it is often in great numbers simultaneously, or in very quick succession; so much so, that a lung which two or three weeks ago was, in a great part, dull to percussion, and yielded no sound to the ear but bronchial breathing or bronchophony, will now give the clearest auscultatory signs that it is literally riddled with cavities; and not only so, but, if the patient survive a little longer, that many cavities have run together, and a multitude become one. The same simultaneous gurgling when the patient breathes, and the same simultaneous plash when he coughs, will reach the ear from half one side of the chest.

'It is remarkable how to the very last the sounds are often properly and exclusively those of phthisical disease, or rather those which it belongs to the essential conditions of phthisical disease in the lungs alone to produce, and those sounds only. There are cavernous breathing, or gurgling breathing and gurgling cough, or pectoriloquy; and in whatever parts of the lungs you have not these, if you have any sound at all, it is the vesicular murmur of health. Nothing is more common, upon dissection, than to find the lungs most largely beset with tubercles and vomicæ; and at the same time every part of them, which a tubercle or a vomica does not absolutely occupy, altogether healthy.

'Such is one form of pulmonary consumption; and it would seem to

be,

be, in many striking circumstances, distinguishable from others. I may fairly wish that I had a less accurate knowledge of it; for that knowledge first came to me from observing its symptoms in two of my most valued friends, and from watching in them, year after year, the sure but hesitating approaches of death.

But consumption is perpetually presenting itself to me under a different character. The patient will live as long as he whose disease is slow to advance beyond the stage of mere tubercles. His condition, however, is different; and that condition varies more from time to time; he will spit for a while considerable quantities of pus, and then cease from expectorating altogether. He will suffer hectic fever, and then throw it off, and then suffer it again; lose his flesh, and recover it, and then lose it again. Here, if you auscult the chest, you will find cavernous respiration or pectoriloquy, a gurgling respiration or a gurgling cough at the apex of one or both lungs, and at every other part a clear vesicular murmur. These are the cases in which pulmonary tubercles excite around themselves just enough of inflammation and suppuration to procure their own solution or evacuation, and no more. The phthisical disease is carrying on its own specific processes within its own specific limits. It is depositing tubercular matter, and then maturating, and softening, and evacuating it; and the result is the formation of a vomica. But, except in the seat of the vomica, the whole lung still remains healthy.

A very dear friend of my own was twelve years dying of consumption; and another individual was twenty. They had expectoration, and hectic fever, coming and going during twelve and twenty years; but they died before the days of auscultation, and, therefore, the exact condition of the lungs at different periods during the progress of their disease was not known. I know a man, now living, who occasionally spits blood and pus, and who has occasionally spit blood and pus during the last twenty years. At various times during the last four years, auscultation has discovered a vomica or vomicæ at the apex of one lung, but, withal, a satisfactory vesicular murmur in other parts. This individual, in what regards eating and drinking, has lived a life of abstinence, but a life of great toil in what regards exertion of body and mind. Sometimes his friends are full of apprehension about him; his hectic fever, his emaciation, his cough, and expectoration, seem preludes to the worst event; but again he rallies, and his mind and his body recover, or seem to recover, their wonted powers.

But in this form of pulmonary consumption, a time arrives at which there is no more resumption of the appearance or reality of health, no more pausing between (as it would seem) the formation of one vomica and another. The hectic, the cough, the expectoration, continue; the emaciation increases; the strength declines; and auscultation has no longer to seek the gargouillement, the cavernous breathing, or the pectoriloquy, in one spot, but finds them at all times anywhere between the clavicle and the mamma, or anywhere about the scapula on one or both sides. Here, too, however, it is remarkable, as in the other form of consumption, that the vesicular murmur of health is often heard

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