COLONEL GEORGE E. BUSHNELL, M.C., U.S.A. 297 



apex above the clavicle anteriorly and to the third dorsal vertebra posteriorly. 

 The same signs at the extreme apex left side. 



"2. Same signs second interspace right anteriorly near sternum (proximity 

 of right main bronchus or trachea). 



"3. Increased vocal resonance, slightly harsh breathing immediately below 

 center of left clavicle. 



"4. Fine crepitations over sternum heard when stethoscope touches the 

 edge of that bone. 



"5. Clicks heard during strong respiration or after cough in the vicinity of 

 the sternocostal articulations. 



"6. The so-called atelectatic rales heard at the apex during the first inspira- 

 tion which follows a deeper breath than usual or cough. 



"7. Sounds resembling rales at base of lung (marginal sounds), especially 

 marked in right axilla, limited to inspiration. 



"8. Similar sounds heard at apex of heart on cough (lingula). 



"9. Slightly prolonged expiration at left base posteriorly. 



" 10. Very slight harshness of respiratory sounds with prolonged expiration 

 in the lower paravertebral regions of both lungs posteriorly, most marked at 

 about angle of scapula, disappearing a short distance above that point, equal 

 on both sides, or slightly more marked at the angle of one side, more frequently 

 the left." 



"Incipient tuberculosis of the apex is often erroneously diagnosticated: 



"i. On account of misinterpretation of normal signs. 



"2. Because the importance of minor differences between the two sides is 

 exaggerated. 



"3. Because signs of a healed lesion are considered to indicate an incipient 

 lesion." 



"The only trustworthy sign of activity of apical tuberculosis is the presence 

 of persistent moist rales." 



Concerning the diagnosis of acute lesions, the following are 

 striking sentences: 



"If small, this lesion is manifested by rales, with or without changes in 

 breath sounds, percussion note, and voice transmission. The more acute 

 the lesion the greater the probability that its presence will be indicated only 

 by rales. . . . Large acute lesions are rarely found in candidates for 

 enlistment and the small acute lesion is also comparatively rare. Tubercu- 

 losis as it presents itself to the Army examiner is usually of a chronic type." 



"An arrested chronic lesion is characterized by harshness of breath sounds 

 and prolongation of expiration, by increased vocal fremitus and resonance and 

 by more or less pronounced dullness on percussion." 



"An active chronic localized lesion is denoted by the presence of rales, 

 together with the other signs described under the arrested lesion. Rales do 

 not necessarily show that the lesion is extending nor that the activity is of 

 much clinical importance, but in military practice the presence of rales ac- 



