244 Epidemics. 



and elimination, leaving one or more vomicse to mark the 

 presence of common consumption. 



During this time the lower half of the lung appears 

 frequently to improve, only to take upon it a new phase, 

 and before the fatal result tubercle and vomicse have found 

 a place in the lower half of the first affected lung. 



If tubercle does not appear, the chronic congestion appears 

 to gradually extend upward ; constant, slight, and, now and 

 then, sharp pleuritic pains are felt ; and the continuous dull 

 surface, with distant crepitation, announces the presence of 

 pleuritic effusion, and with it the constant desire of the 

 patient to be raised in bed. 



Neither does the evil end here, for mostly the left lung 

 becomes involved in the same congestion, and, in rare cases, 

 there is effusion into the pericardium, but rarely announced 

 by distinct pericarditis ; there is a dull, slow, and oppressed 

 movement of the heart for perhaps a fortnight to a month 

 before it appears, and a tendency to faint from any exertion, 

 but the heart remains of natural size and rhythmical ; at 

 times a case will present itself without any valvular affec- 

 tion, and yet be very unrhythmical. The effusion shows 

 itself by increased difficulty of breathing, a feebler pulse 

 and beat of the heart, and a most distinctly-wider surface 

 over which the palpations of the heart can be felt, which 

 percussion more precisely defines. Dropsy, of course, in 

 such cases, ushers in the last phase of this disease. 



It is deserving of the most careful consideration that in 

 the earlier stages of congestion, strange as it may appear, 

 percussion gives an amount of resonance totally unaccount- 

 able ; but in two months later no complaint upon this head 

 can be made, as it is dull enough. 



How, then, is it recognized at all ? It is rather singular. 

 Upon examining the lungs from above downwards, the 

 intensity of the sound by auscultation gradually diminishes 



