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turning attention to the subject as related to all branches of medicine and surgery. III. Morbid States of the Voice indicating Lesions of Circulation. — The voice is husky, tremu- lous, and not well sustained in mitral insufficiency with compensating cardiac hypertrophy. The quivering or shaky voice in this form of heart disease, which I have called tremulous, is very different from the tremolo of the singing voice, or the trembling voice of strong emo- tion, which is musical and expressive of certain normal conditions. The one is glucophage 500mg glucophage diabetes in regular, even waves of vibra- tion, the other (caused by the morbid heart action) is irregular in degree and rhythm. At times the shakiness is marked, and again absent. The husky quality of the voice when present in heart disease indicates hyperaemia of the vocal cords, and is the same as the husky voice often found in Bright's dis- ease, which is duo to ccdema, and very like the rough, harsh voice of the habitual drinker. The voice becomes high-pitched, soft in quality, and ill-sustained in aortic insufficiency, and is a great aid in distinpui.'shinp the two forms of heart diseases. The various blood states have a marked influence upon the voice, changing it so that it reveals the cause of its variety. Ilypencniia, as already stated, lowers the tone of the voice and modifies the tone glucophage online quality, according to the degree of congestion. Ana'mia rniccs the pitch of the tablet glucophage voice, renders it thinner in quality, and if forced, it is quite intense, but ia not well su.stnincd and is apt to break from time to time. It is not easy or always possible to tell the modifi- cations of tiip voire which occur in nnoimic conditions from those that are present in certain conditions of tlio nervous system — generic for glucophage fatigue, debility, and exhaustion, for cxainjiie. The cost of glucophage impairment of the voice in nnirmia is ntthfT uniform, while in nervous exhaustion it varies in dcgn-o. I)<'hyglucophage sr ()])posite state to the hy- drn'iiiia which is moro familiar — produces the most nmrkcprice of glucophage rhage order glucophage is distinguished from that of dehydration by its being low-pitched, owing to relaxation of the vocal cords. It is always weak and at times whispered. This loss of strength, volume, or resonance of the voice — which glucophage cost comes on, not always suddenly, but gradu- ally, and yet in a short time — is a most valuable sign of glucophage tablets concealed haemorrhage, such as the secondary hemor- rhage which occurs after abdominal operations, and also in post-partum ha?morrhage. In surgical cases the weakening of the voice comes on gradually, the time required to glucophage xr 500mg effect the changes depending upon the size of the bleeding vessels. The value and reliability of tliis sign of haemorrhage in the voice depend on its being the first in the clinical history to be observable. The voice beginning to fail is the first sign or warning that the much-dreaded haemorrhage has glucophage xr begiin. The attention of the surgeon being attracted by the modifications of the voice, other glucophage generic buy glucophage online evidence is sought glucophage price for, and the suspicion aroused is confirmed and a diagnosis made while there is yet time to give relief. In case the warning voice passes unlieeded or is not understood, the hemorrhage goes on until the time to save life by arresting the bleeding is past. When bleeding starts in the peritoneal cavity, pain usually comes on ; but pain is often present from other causes, and it is not recognized as evidence of haemor- rhage, at least not until it has gone on to a very dan- gerous extent. I hold, then, that the voice is the first to show the effects of concealed hemorrhage and to pro- claim, not in words, but by its change of attributes and characteristics, that the much-drcadcd event has oc- curred, dreaded the more by the surgeon, because the operator is responsible for secondary hemorrhage ; and in the majority of cases he can control the bleeding and save the patient if the diagnosis is made in time. One whose attention has been turned to this subject may be able to make cheap glucophage use of the change of voice in de- tecting concealed hemorrhage without noting all the elements of the change. A change is noticed, and the ob- server is glucophage buy put on the right line of investigation, which, with the aid of other signs and symptoms, leads to a correct diagnosis. Sudden and jirofuse hemorrhage, such as may take place post partum, affects the voice abruptly and in nnich the same way as in syncope. Therefore it is not always possible to say whether the voice signs arise from hn-morrhage. fainting, or sudden shock; but the voico signs arc none the less valuable because they direct at- tention to the state of the patient and indicate that some one of these morbid states is present, and a distinc- tion can. as a rule, be easily made through the additional evidence present. IV. TlIK VOIPR A8 AS IsnKX OF TIIR CoNniTION OF TiiK glucophage mg Nkhvocs System. — It is in this (h'partmcnt of in- 814 SKENE: THE VOICE IN DIAGNOSIS. [N. Y. Med. Joch.-,

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