Clinical tuberculosis . possible by studyingthe effects of the motor and trophic reflexes on the muscles andsubcutaneous tissues, the movements of the chest wall, the flat-tenings and bulgings of the bony thorax when these are pres-ent, and the position of the heart l)cnt, to determine with sur-prising accuracy the nature and extent of the i^athologicalchanges within. Inspection reveals more in advanced tubercu-losis than in early. Inspection calls for Hie closest powers of observation and the INSPECTION 465 keenest analysis of data. It is not only necessary to note de-paitures from the normal
Clinical tuberculosis . possible by studyingthe effects of the motor and trophic reflexes on the muscles andsubcutaneous tissues, the movements of the chest wall, the flat-tenings and bulgings of the bony thorax when these are pres-ent, and the position of the heart l)cnt, to determine with sur-prising accuracy the nature and extent of the i^athologicalchanges within. Inspection reveals more in advanced tubercu-losis than in early. Inspection calls for Hie closest powers of observation and the INSPECTION 465 keenest analysis of data. It is not only necessary to note de-paitures from the normal, but suck departures must be assignedto their cause. They nuist be dealt with as being expressions ofdefinite pathological changes. The skin should be inspected,noting cyanosis, edema, enlarged vessels, atrophies or any otherdeparture from the normal. Any enlargement of the lymphaticglands or tlie tliyroid should be noted. Atrophy and lower position of the breast upon the thorax isoften to be seen on the affected A B c Fig. 94.—Phthisical chest. .4, anterior view; B, lateral view; C, posterior view. (West.) The form of the chest should be observed. Much has been writ-ten about the phthisical chest (Fig. 94, A, B, C) which is char-acterized as being long, flattened, particularly above, with acutecostal angle, winged scapuhv, wide intercostal spaces, cuppedsupraclavicular fosste, a drooping forward of the shoulders anda poorly developed musculature. This type of chest has beenhanded down through the ages as belonging to a group of in-dividuals which is specially predisposed to tuberculosis. Some ofthese characteristics belong to two different conditions, the so-called jilitliisiciis liahitus and astlicnia congenita lutbitiis must be looked \;pon as being a result of tubercu- 460 PHYSICAL EXAMINATION IN PULMONARY TUBERCULOSIS lous infection, instead of a predisposing cause, wliile astheniacongenita itniversalis with its long chest, wide intercostal
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