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vary considerably in quality and intensity even with the same amount of pleuritis. Physical signs are rnodified somewhat in different parts of the same chest and by the different conditions of the chest walls in different individuals. Thin chest walls give more vocal fremitus, a percussion note more intense, and a respiratory murmur more distinct than chest walls overlaid with considerable muscular or adipose tissue. In the right subclavicular region the vocal fremitus is usually more marked, the percussion note duller and higher, and the respiratory murmur harsher than on the left side. The gland and muscles obscure the sounds in the mammary regions and the scapula in the scapular regions. The value of the physical signs is very great. It is true that there are morbid conditions not of tuberculous origin which give some or all of these signs, but, excepting pneumonia, such conditions are rare, and croupous pneumonia is so easily differentiated as to need only to be mentioned. The other conditions, such as cancerous and benign tumors, hydatids, and syphilitic generic viagra contact growths, may, so far as physical signs go, deceive the most expert. But there is usually some clew to the true cause, as for instance the locality. Hydatids are most frequent at the base of the lung. Cancer usually begins at the mediastinum. Syph- ilitic growths occur in the lower and middle lobe and even in the lower part of the upper lobe, but almost never in the apex. We may in some cases have t rely upon the personal history buy viagra vardenafil or finally upon the ex- ploring buy viagra vardenafil needle and microscope. But any and all of these causes of consolidation are rare compared to tu- berculous deposit, and, given evidence of more or less consolidation of lung tissue, it is safe to assume phthisis unless we can prove the contrary. The same may be said generic viagra contact of moist rales, evidence of bronchitis. A buy viagra vardenafil chronic localized bronchitis x>i other than tubercu- lous buy viagra vardenafil origin is possible, but is very rare. Expert work in physical diagnosis requires skill that can come only after considerable training. The ear must be familiar with all the normal chest sounds, and trained to detect the slightest variations, even as the musician must be familiar with his instrument and trained to detect the slightest jar or discord. It June 13, 1896] MEDICAL RECORD. 831 is different, however, as to a correct interpretation of the general symptoms. This is not a matter of skill, but of knowledge and generic viagra contact judgment alone, and is within reach of all. buy viagra vardenafil I do not mean to state that a positive diagnosis can always be made in this way. Even an expert, combining physical signs with general symp- toms, will often refuse to speak positively without the confirmation of the microscope. But the general prac- titioner who has a thorough knowledge of the patho- logical conditions of phthisis, and of its varying clinical history, ought to recognize the very probable existence of the disease at a much earlier stage than is now usual. Symptoms and Complications. Pulmonary tuber- culosis occurs as a very acute disease, as well as a very chronic one, and with all intermediate grades; and cases in the same grade as to chronicity vary greatly as to symptoms and complications. An accu- rate description of the symptoms of one case will rarely fit another. No buy viagra vardenafil one symptom is always present in early phthisis, but there are not often lacking some two or three out of the group to indicate clearly their cause. Cough. As we should expect from the pathology of phthisis, cough is generic viagra contact usually the first symptom to attract attention. Rarely, yet not so rarely but that buy viagra vardenafil every practitioner must meet them, cases advance quite far with practically no generic viagra contact cough, deceiving the patient and his friends, who think there can be nothing the matter with the lungs of one who does not cough. The onset of the cough is as a rule very insidious, so that the patient does not know when it begins. Its character and course are very variable jn different cases. It often begins as a slight hawking and clearing of the throat buy viagra vardenafil in the morning only. Gradually it becomes more frequent, and the throat clearing buy viagra vardenafil is noticeable during the day and night. Sometimes the local irri- tation of the nerves early produces severe and harsh cough. Again, a bronchitis occurs early and there is a viscid, glairy sputum with the cough. In other cases there is very early breaking down of the tub culous area, and buy viagra vardenafil there is then early expectoration of a purulent or muco-purulent sputum. Oftener, however, the cough is for a long time of a dry, hacking char- acter. It may at first be noticeable only when the patient is about to speak, and sounds like a short, jerky laugh preceding the words. This hacking cough may continue for weeks and months, or it may disap- pear entirely at times, to reappear now and then for a year or two. After a longer or shorter time expectora- tion begins. generic viagra contact Sometimes the history of a cough begins with a "severe cold" or an attack of "grippe." In many of these cases, a slight cough preceding the acute attack has probably been forgotten or has not been noticed. In others, the so-called cold was really an acute exacer- bation of the early phthisis, and doubtless in some an attack of grippe has lighted up a dormant tuberculous deposit. In all of these cases the cough continues very persistent. The patient says he cannot get rid of his "cold." He may improve some, but the cough per sists in spite of cough syrups and what-nots, and after a few weeks or months he consults a doctor. Cases with such a history are frequently diagnosed chronic bronchitis, but the microscope has shown us that they are almost always of tuberculous origin. Even the absence of the physical signs of some degree of