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able constitutional depression or infection. Thus it will be seen that I include in the term the conditions usually defined as " incipient phthisis" and " first fake viagra sale stage of consumption." Concerning the importance of an early diagnosis there can be no dispute. Of the curability of con- sumption there is no longer a doubt. As in every dis- ease, there comes a time in the progress of the case when viagra tablet indications death is inevitable. The earlier the diagnosis is made, fake viagra sale the greater the change of recovery. There- fore an early diagnosis is of the utmost importance to the patient. viagra tablet indications It is also of importance to others. That the disease is communicable is settled beyond fake viagra sale ques- tion. A patient should not, and generally will not. go about spreading the germs of the disease broadcast if he is properly instructed after a diagnosis is made. Therefore an early diagnosis is of vast importance to the community. And here, as a corollary to the abi n let me say: whenever we find that a patient has con- sumption he should be told the truth. Knowing the truth he will much more effectually co-operate, both in efforts directed toward his own recovery and i . those directed to the prevention of the spread of the disease. Notwithstanding the vast importance of an early diagnosis, and notwithstanding the great prevalence of the disease, an early recognition of phthisis is the exception. I am speaking well within bounds when I say that not one case in twenty is diagnosed while yet in an early stage. This is largely due to the fact that many patients do not consult a doctor till the disease has made seri- ous inroads. But it is also due to the failure of the profession generally to recognize the disease when they are consulted. This statement is an unpleasant, and it may be fake viagra sale an unpopular one to make, but it is cer- tainly true. Not long since I asked the supervising examiner of an insurance company how many of his local examiners he could trust to recognize an early phthisis. His answer was " Not one in twenty-five." I could sustain this statement by further quotations from many eminent diagnosticians, but I forbear. This failure of the profession is partly clue to want of skill, but largely to erroneous teachings of the past and to carelessness and want of thorough investiga- tion. When there is any reason to suspect phthisis, nothing short of a thorough, searching, exhaustive ex- amination is justifiable. Method is essential to thorough work in any line, 1896. Read before the Upper Cumberland .Medical Society, May and as an aid to systematic work it is well to make a record of every examination. Family History. A careful questioning as to fam- ily history is first in order. While the disease is rarely inherited directly, vet beyond doubt certain families are more susceptible than others, and a his- tory of a considerable number of cases of phthisis, scrofula, joint disease, or chronic diarrhoea should have viagra tablet indications weight in deciding an otherwise doubtful fake viagra sale case. But the tendency of the profession is to attach too much importance to family history. This is the re- sult of former erroneous fake viagra sale teachings of heredity. An absence of tuberculous' history in the family bv no means precludes the viagra tablet indications possibility of the disease in the individual, and should never keep us from a careful personal examination. Personal History After learning the history of the family, question as to the personal history should be made. A history of joint disease, scrofula, chronic cough, or any other tuberculous disease, increases the probability of phthisis; but the absence of any such disease, or of any previous sickness, fake viagra sale does not exclude it. I was taught when a viagra tablet indications student that previous to phthisis there always exists a condition of ill-health a pre-tuberculous stage. This was an error. Not only may the personal history of the patient viagra tablet indications have been good, but he may be in fair general health at present. and still have phthisis. For it is true that a consider- able amount of tuberculous deposit may coexist with fair or even good general health. Briefly, while a bad family and personal history and present condition increase the probability of phthisis, *he reverse does not exclude it. Nor does age exclude .t. Phthisis is much more frequent in childhood and old age than is generally supposed. In considering the present condition of the patient, the height and past and present weight should be learned; the appetite, the digestion, the appearance of the tongue, the condition of bowels and kidneys, the amount and quality of sleep should all be investigated; and especially should we make a note of the quality and rate of the pulse, of the temperature, respiration, presence or absence of cough, expectoration, hemor- fake viagra sale rhage or spitting of blood, and of pains in the chest. With such a record, carefully made and intelligently considered, a correct diagnosis of phthisis can often be made, even without a physical examination. We will return to a discussion of the rational symp- toms after a review of the physical signs of early phthisis. Physical Examination. Before beginning a phys- ical exploration of the chest, the patient should be stripped to fake viagra sale the waist. I make this an inviolable rule. In an advanced stage the coarse rales, gurgles, caver- nous respiration, etc., can often be detected through some clothing; but in early phthisis we have to deal with slight changes and slight differences, and even an undershirt is inexcusable. With the patient thus stripped, he is directed to stand fake viagra sale or sit erect and naturally. The chest is then measured about the nipples both at full inspiration and complete expiration; the opposite sides are measured