. Physical diagnosis . olidification at both apices when only one is affected. Since solidification is usually accompanied by retraction in theaffected lung in very advanced cases, the chest falls in to a greater 1 Unless senile emphysema masks it. Fibroid phthisis (vide infra) mayshow no dulness. Remember that gastric tympany may be transmitted to theleft lung and mask dulness there. 312 PHYSICAL DIAGNOSIS. or less extent over the affected area, and the respiratory excursionis much diminished, as shown by ordinary inspection and by thediminution or disappearance of the excursion of the diaphr
. Physical diagnosis . olidification at both apices when only one is affected. Since solidification is usually accompanied by retraction in theaffected lung in very advanced cases, the chest falls in to a greater 1 Unless senile emphysema masks it. Fibroid phthisis (vide infra) mayshow no dulness. Remember that gastric tympany may be transmitted to theleft lung and mask dulness there. 312 PHYSICAL DIAGNOSIS. or less extent over the affected area, and the respiratory excursionis much diminished, as shown by ordinary inspection and by thediminution or disappearance of the excursion of the diaphragmshadow. The intensity of the tubular breathing depends on theproximity of the solidified portions to the chest wall and to thelarge bronchi, as well as on the presence or absence of pleuriticthickening. It is rare to find a whole lung solidified. The process, begin-ning at the apex or just below, extends down as far as the fourth Bronchial breath-ing, dulness. Increased fremitus. Increased voicesounds. Rales. Fig. 163.—To Illustrate Progress of Signs in Pulmonary Tuberculosis. rib in front, , through the upper lobe, in a relatively short time,but below that point its progress is comparatively slow and thelower lobes may be but little affected up to the time of death. Onthe relatively sound side the exaggerated (compensatory) resonancemay mask the dulness of a beginning solidification there, whichsooner or later is almost sure to occur. It is exceedingly rare forthe disease to extend far in one lung without involving the other. About the time that the tuberculous process invades the previ-ously sound lung it is apt to show itself at the apex of the lower lobe BRONCHITIS, PNEUMONIA, TUBERCULOSIS. 313 of the lung first affected. Consonating rales appear posteriorly alongthe line which the vertebral border of the scapula makes when thearm is raised over the shoulder. These points are illustrated inFig. 163. Cavity Formation. Cavities of greater or lesser extent are
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