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and a note is made of the result. Next, he is inspected carefully, and then, in order, palpation, percussion, 8.W MEDICAL RECORD. [June 13, 1S96 and auscultation are practised. The presence of any scars indicating former glandular trouble about the neck is noted while inspecting, also the degree of muscular development, amount of adipose tissue, and the symmetry of chinese viagra 200mg the chest. When palpating, corre- sponding regions should be compared. It is well to do this also when percussing. But not too much stress is to be put upon comparison, as both sides are often equally involved. An expert ear viagra sale real must recognize the quality of the normal percussion note. The finger or plessimeter chinese viagra 200mg should be applied firmly in percussion, and the stroke adapted to the viagra sale real condition of the parts. Just how much force should be given the stroke can only be learned by experience. The use of hammer or plessimeter is a matter of individ- ual choice; one can be as accurate without as with them. But in auscultation the stethoscope should al- ways be used. Accuracy is impossible without it. Initial lesions are sometimes found in all parts of chinese viagra 200mg the chest, and all parts should be investigated; yet it is in the chinese viagra 200mg apices that the earliest infiltrations usually occur, and they should receive especial attention. I make it a rule to begin percussion at the neck, and to first determine the height to which the lungs extend on each side. The height and outline of the apices are surprisingly similar in normal chinese viagra 200mg chests and even a slight lack of symmetry is to be regarded with sus- picion. The height of the apices can lie readily seen by marking with ink or pencil the change from the dull note of the muscle, or the "band-box v note of the larynx, to the note of underlying lung tissue.' Pathology. The pathological conditions of early phthisis are briefly as follows: In its incipiency there is more or less deposit or infiltration and no general symptoms are present. We viagra sale real do not often see a patient in this condition except accidentally, as in insurance ex- minations. Sometimes this deposit becomes consider- able, as I have said before, without giving rise to symp- toms or in any degree impairing the general health. On the other hand, even a slight deposit will sometimes produce a localized bronchitis, a lobular pneumonia, or a circumscribed pleuritis. Before the area of infil- tration becomes very large it usually does produce some one, or two, or all three of these complications. The bronchitis of early phthisis is usually of the smaller tubes. There may or may not be some hem- orrhage from the first deposit. This depends upon whether or not there is much obstruction to the blood- vessels, and whether or not the vascular walls share in the tuberculous process. As the degree of consolida- tion becomes greater the tissues begin to break down and ulcers or small cavities form. This marks the beginning of an advanced stage. But sometimes this destructive process begins while the area of infection is yet small, and it may then be fairly included within the pathology of early phthisis, especially if the gen- eral health is not much affected. Usually the lung tissue is involved in the morbid process, but occasion- ally a tuberculous deposit forms on the walls of a bron- chial tube and goes on to destruction with little or no involvement of the surrounding lung. Physical Signs From this review of the pathol- we can readily see what physical signs to expect. With but slight consolidation we will learn nothing by inspection, mensuration, or pal])ation. and only a trained ear can detect the changed percussion note slightly duller, slightly higher. It takes but little infiltration to weaken the air-cells and impair their elasticity. As a result we have the murmur lessened in intensity, and with a slightly higher viagra sale real pitch. From some cause I believe because of 1 This method of determining tin.- height of the apex, and the importance of. it. were pointed out by Professor von /.iemssen in 1867. Vet it is scarcely mentioned by writers. It seems to : ~ as value is not appreciated. nerve involvement of the affected area we frequently have a jerky or cog-wheel character of respiration Of course the amount of infiltration may be so slight or it may chinese viagra 200mg be buried so deeply under normal chinese viagra 200mg tissue that even expert ears fail to detect any modification.! One symptom worth something in the detection ol early infiltrations, yet not often mentioned, is thel transference of heart sounds. If with the stethoscope) applied to the posterior apex, the heart sounds are heard with viagra sale real more than usual distinctness, we may well suspect chinese viagra 200mg a diseased condition of the intervening lung.| Of chinese viagra 200mg course allowance must be made for violent hearli action. Even with considerable deposit we may learn noth- ing from inspection. Or we may, if one side is nor- mal, notice lessened movement upon the affected side.l Sometimes, too, there is noticeable flattening about the apex or apices, an appearance as if the neck rose straight from the flattened shoulders. Palpation will now give us noticeable increase of vocal fremitus. Sometimes the increased sense of resistance when pressing upon the apex or between the ribs is viagra sale real marked. The percussion note is decidedly duller and chinese viagra 200mg higher, and by auscultation we find the murmur not lessened but decidedly increased in intensity, higher in pitch, and harsher in quality a broncho-vesicular murmur. If there is a bronchitis we find fine or coarse rales, ac- cording to the size of the tubes involved. With a lob- ; ular pneumonia, crepitant rales are heard. If there are circumscribed pleurisies, grating, creaking, or rub- bing sounds may be heard. Pleuritic friction sounds