CONSUMPTION OF THE LUNGS. 237 



inspiration, retains its normal convexity, the percussion-sound over it, 

 however, being dull and flat, we may infer the existence of an extensive 

 solidification of the lung, which is most probably a pneumonic infiltra- 

 tion. A feeble respiratory movement at a point where the percussion- 

 sound, instead of being dull, is normal, or somewhat hollow and tym- 

 panitic, is a suspicious sign of tubercle, but not a conclusive one, as 

 small scattered spots of lobular pneumonia may also weaken the move- 

 ments of respiration without causing any dulness upon percussion. 



There is often an unusually wide extension of the shock of the car- 

 diac impulse, and an outward dislocation of the apex of the heart, when 

 the upper lobe of the left lung is indurated and contracted, thus laying 

 bare the pericardium and drawing the heart to the left. This symp- 

 tom, like depression of the thoracic wall, denotes a partial recovery 

 from the pneumonic process, and a patient is not to be pronounced 

 consumptive unless it be accompanied by fever, loss of flesh, or other 

 sign of inflammatory or tubercular destruction of the lung. 



Palpation, besides being serviceable in estimating the movements 

 cf respiration, and the degree of dislocation of the apex of the heart, 

 often exhibits abnormity of the pectoral fremitus in phthisis. Over 

 large cavities, containing air, and communicating with an open bron- 

 chus, the fremitus generally is intensified. It is also rendered stronger 

 by lobular infiltration and by extensive tuberculosis, which has occa- 

 sioned a relaxation of the pulmonary tissue. According to Seitz, how- 

 ever, for whose opinion I have great respect, the vocal resonance is of 

 little diagnostic value in consumption. 



Percussion furnishes several diagnostic points of the utmost im- 

 portance. 



Since Seitz first caused me to observe that it was easy to mark out 

 the upper boundary of the lungs, and that this was easier to do in 

 front than behind, and when the mouth is open than when shut (since 

 the tympanitic sound of the trachea is then more definitely distinguish- 

 able from the non-tympanitic sound of the apex), I never neglect this 

 mode of examination of patients with chronic pulmonary affections. I 

 can assert that the height of the pulmonary apex, which, under normal 

 conditions, is equal upon each side, and which extends from three to 

 five centimetres beyond the collar bone, is often found to be much 

 lower, especially upon one side, when the lungs are in a state of 

 chronic disease. A depression of the upper boundary, therefore, like 

 the depression of the supra and infra-clavicular regions indicates indu- 

 ration and contraction of the apex of the lung. 



A dulness upon percussion, in the supra and infra-clavicular region, 

 extending over the clavicle itself, and posteriorly over the supra- 

 scapular and supra-spinatus regions, is recognized even by many of 



