ter this is, the more as a rule will he cough. Sometimes the
position of the patient is of influence; if he lies mostly on the
diseased side the expectoration becomes more difficult and coughing
increases.

Coughing is generally that symptom which soonest attracts the attention
of the patient and his surroundings. For that very reason consumption is
in its beginning stages easily confounded with such other diseases as
are also accompanied by cough.

At the same time we know of exceptional cases where cough was entirely
absent in the first stages of the disease, or was at least so slight
that it was overlooked, and under such conditions the pale and poor
appearance and reduced strength is mistaken for chlorosis or some other
anaemic affection, also the existing febrile excitements are wrongly
judged, or on account of lack of appetite or light derangements of the
stomach a stomachic affection is surmised, until suddenly a hemorrhage
of the lungs clearly defines the true nature of the ailment.

On the other hand the cough may become so violent that vomiting is
caused at the same time. Nevertheless many consumptives describe their
cough as very unimportant on account of their innate sorrowless nature,
and they will not even be discouraged by the gravest symptoms. Often
however it is fear that induces the patients to make light of their
coughing, their spitting blood, their losing flesh and to place but
little importance on these circumstances. A _hoarse_ cough is a sure
sign of a diseased _larynx_.

Many consumptives complain of cutting pains between the shoulderblades,
under the clavicles or in the side; but these are rarely intense and are
often entirely wanting. Unfortunately it is unknown to the average
layman that the internal organs may suffer extensive tearing down
without an indication of pain.

The _Expectoration_ of consumptives which is thrown out by coughing with
great exertion, is but scant in the beginning, as a rule phlegmy, glassy
transparent and sticky. It is one of the suspicious symptoms of
developing pulmonary consumption if this lasts for any greater length of
time. Sometimes sharply defined, yellowish stripes, at times branching,
appear in the same. Later on the expectoration becomes more purulent,
and of greenish-yellow or greenish-gray color.

Still later the patients throw out rounded lumps of greenish yellow or
yellowish green color, which flatten out like a coin in the spittoon.
They sink i