TIMID STAGE, OR THAT OF CAVITY FORMATION.—On inspection there is now seen superficial and rapid breathing and uneven expansion of the two sides of the chest; sinking in of the supra clavicular and infraclavicular spaces causes undue prominence of the cor responding clavicle. The auxiliary re spiratory muscles of the neck stand out prominently, owing to the general ema ciation and to the increased work thrown upon them. The angle of the scapula of the affected side, upon deep inspiration, lags behind its fellow, and fails to make the normal excursion. The intercostal spaces arc wider than usual, and the chest is frequently long and thin and the scapula winged.
Increased vocal fremitus is found over consolidated areas and over cavities, is much intensified, and is of considerable diagnostic value.
Often the heart's impulse is distinctly visible at some distance from the pa tient; the more the lung is contracted, the wider the area over which this im pulse can be seen.
It is not infrequent to hear, in patients having cavities, when they are asked to open the mouth and to breathe as gently as possible, a short puffing sound similar to that produced by blowing over the open mouth of a small bottle; it occurs with each heart-beat and is evidently produced by that organ acting as a plexor and the intervening tissue be tween it and the cavity-wall as the plex imeter. It might naturally be supposed that the nearer the heart to the cavity, the greater distinctness with which the sound would be heard; but in cavities at either apex the sound is heard with pe culiar loudness.
The dullness found on percussion in the second stage continues throughout the later stage of the disease and over cavities with their walls in open com munication with a bronchus; cracked pot resonance is obtained when the pa tient is directed to open the mouth and a quick sharp percussion-stroke is made.
On auscultation sharply-defined sub crepitant rides give way to moist, bub bling rides of all sizes, and when cava tion has occurred there will often be heard the metallic tinkle or mucous click.
Over the site of the cavity will be heard a blowing, cavernous, or amphoric breathing, while around about it will be heard tubular and bronchial breathing varying in intensity according to the density of the consolidation, and in some instances the bronchial breathing will vary in degree in different areas near or remote from the cavity.
Whisper-resonance is generally pres ent and is marked in character.
Myoidema as a diagnostic sign of pul monary tuberculosis. If a point on the chest-wall corresponding with the ela vieular origin of the pectoralis major be struck in a patient with advaifeed tuber culosis, a sulcus is formed which quickly travels to the origin and insertion of the muscle, where it is lost. In the nodular variety there is formed at the point struck a small, quivering tumor which, after oscillating backward and forward, as if uncertain of its position, for a sec ond or two, finally comes to rest, and after a few seconds gradually fades away. The initial pallor produced by the blow quickly gives way to redness, reminding one forcibly of "tactic cerebrate." The term "myoidema" was first made use of by Lawson Tait in 1872. He also be . lieved the sign to be diagnostic of pul monary tuberculosis. While it is also said to be obtainable in other wasting diseases, Jeansehne and Lermoyez claim ing even that it could be obtained in healthy individuals, the writer has never been able to obtain it in the latter. Sir William Broadbent finds it almost al ways present in early phtbisis, and Stokes claims that it is always most evi dent in the earlier periods. Walsham (Lancet, Jan. 27, IMO).