the normal percussion outline must almost invariably be attended with auscultatory signs capable of ready recognition.

A pronounced disparity between the apical percussion boundaries upon the two sides may exist in the entire absence of tubercle deposit. Recently I have had occasion to note a conspicuous instance of apical shrinkage as determined upon percussion, which, without the aid of the x-ray, would have led to a deplorable error of diagnosis.

A man of twenty-five with an unfortunate family history of tuberculosis accompanied to Colorado, in the latter part of 1906, a sister in advanced phthisis. The patient speedily succumbed to the disease, and the survivor presented himself for examination and opinion before venturing to return permanently to an unfavorable climate. There were no symptoms suggestive of pulmonary involvement, and the physical examination was negative, save for a well-defined dissimilarity in the apical percussion boundaries. The extent of shrinkage at the right apex is shown in the accompanying photograph (Fig. 37). Upon x-ray

Fig. 37.-Disparity between the apical percussion outlines, suggesting a tuberculous involvement of the right apex, unconfirmed by x-ray examination. (See radiograph, Fig. 44.)

examination, however, it was found that a well-marked thickening of the right mediastinal pleura had taken place, resulting in pronounced traction upon the pulmonary tissues at the apex, without evidence of tubercle deposit. The skiagraph (Fig. 44) is presented upon p. 252. In this connection an interesting clinical phenomenon is shown in Fig. 38, which illustrates a very material apical shrinkage noted. upon inspection. The patient, aged twenty, was sent to Colorado January 17, 1907. In spite of a loss of seventeen pounds in weight, with persisting fever and slight cough, the physical and bacteriologic examinations failed to disclose the slightest evidences of tuberculous infection. The apical percussion borders were perfectly normal, despite the extreme visible retraction upon the right side. Another patient, aged twenty-seven, arrived in Colorado in the latter part of 1907 with distinct physical evidences of pulmonary tuberculosis. The shrinkage of apical percussion boundaries was pronounced at the right apex,

although the other physical signs pointed to an absence of tuberculous infection at this region. Signs of slight infiltration with moisture were detected, however, in the left lung, especially from the third rib to the

base. Upon x-ray examination it was found that the tuberculous process was limited solely to the left lung, without evidence of apical involvement upon either side. The extent of the dissimilarity of percussion outlines at the apex is shown in Fig. 39. In Fig. 6 are shown practically

Fig. 39. Pronounced shrinkage of the outline of percussion resonance at right apex, despite absence of tuberculous involvement in this region. Physical evidences of a tuberculous process perfectly defined in left lung. (Compare with radiograph, Fig. 53.)

uniform resonant boundaries at the two apices upon careful percussion. If anything, the area of resonance was slightly smaller at the right apex. Reference, however, to the skiagraph (Fig. 45) reveals an appreciable

shadow at the right apex, suggesting the likelihood of a greater difference in the percussion borders than was found to exist. A patient, aged twenty-eight, was sent to Colorado in October, 1907, for suspected pulmonary tuberculosis, presenting a history of pulmonary hemorrhage. Despite a well-marked shrinkage in the outline of percussion resonance at the left apex, physical examination of the chest was in other respects entirely negative. The bacteriologic findings were also negative. After several weeks a pronounced hemoptysis took place, apparently adding to the significance attaching to an unquestioned disparity in the apical outlines. The outlines of percussion resonance upon the two sides are shown in Fig. 40. As illustrative of the very pronounced unilateral apical shrinkage in connection with advanced tuberculous change the following case is of some interest. A young man came under my observation in the

summer of 1907, presenting physical evidences of rather extensive tuberculous involvement of the right lung, with slight infiltration in the upper left. The extent of visual unilateral retraction may be noted by reference to the accompanying photograph (Fig. 41). By comparing with Fig. 56, an explanation of the shrinkage is found in the destructive tuberculous change at the apex. In view of the experience afforded by the observation of the above and similar cases, it is apparent that the significance of the percussion outlines at the apices is subject to considerable variation.

The auscultatory signs of moderate infection are modifications of the normal respiratory murmur, adventitious sounds or râles, changes in the vocal resonance and in the whispered voice.

Modifications of the normal respiratory sounds partake of the general type of bronchovesicular respiration, which has been described.

True bronchial breathing is rarely observed in cases of partial consolidation, although the bronchial element may markedly predominate over the vesicular. The changes relating to intensity, pitch, duration, and quality of the inspiratory and expiratory sounds have been dwelt upon at such length in the preceding chapters that further description is unnecessary. It must be remembered that the recognition of bronchovesicular breathing at the right apex is possessed of far less significance than at the left, owing to the physiologic difference between the two apices.

The adventitious sounds or râles incident to this class of cases may assume the same general characteristics as those occurring in incipient stages, being of an explosive, crackling type and recognized at the end of inspiration following a cough. More frequently, however, they are distinctly moist and bubbling, exhibiting variations in size and easily appreciable without cough during expiration as well as inspiration.

The râles may be elevated in pitch and consonating in character, denoting their origin in bronchial tubes surrounded by indurated pulmonary tissue.

The physical signs pertaining to the spoken voice represent important changes in the vocal resonance over the partially solidified lung. The degree to which the voice-sounds are exaggerated in intensity and modified in pitch and quality, has been explained to vary materially according to the extent of consolidation. A very important sign is the intensification of the whispered voice in the presence of slightly consolidated lung. This increased transmission, together with a slight elevation of pitch and change of quality, antedates considerably the recognition of bronchovesicular breathing.

It is sometimes possible to detect an increased intensity of the normal heart-sounds on account of their conduction through solidified lung.

CHAPTER XXXVI

ADVANCED CASES

PATIENTS conforming to this group usually exhibit a striking combination of physical signs. Exploration of the chest is important not so much as a means of diagnosis as a matter of clinical exactitude and as a feature of prognosis. Although extensive cavity formation may be present in some individuals exhibiting every external evidence of health and vigor, yet in a large number of cases the general appearance of the patient is highly suggestive of the disease. Emaciation, pallor, dyspnea, and cyanosis are often pronounced. The skin of the body may be dry, harsh, or even scaly, and the hands thin, cold, and clammy. The fingers may be elongated, with tapering extremities and incurving nails, or the ends distinctly clubbed. The neck is thin and appears

Fig. 42. Illustrating an area of well-defined visual pulsation in a patient with extensive tuberculous involvement of the left lung, with marked fibrosis. Note the slight deflection of the tip of the sternum toward the unaffected side. (Compare with radiograph, Fig. 79.)

unduly long. The ears stand out prominently from the sides of the head, and are often waxy, bloodless, and almost transparent. The breathing is at times labored, with the action of the accessory muscles of respiration prominently displayed. The nose may be pinched, the eyes sharp and bright, the hair dry and lusterless, and the face pallid, cyanotic, or flushed. The complexion is sometimes remarkably pale and clear, exhibiting strikingly a delicate plexus of superficial veins. patient frequently assumes a pronounced stooping posture, the general attitude being that of marked debility. In addition to the drooping of the shoulders, the scapulæ are very conspicuous and suggest the oft-noted resemblance to wings. The changes noted upon inspection, with

The