CLAVICULAR REGION - the evidence derived from this region is by far the most valua ble portion of that which serves to indicate disease of the upper lobe; changes of structure seldom exist on its posterior aspect of sufficient amount to give rise to distinct auscultatory phenomena through the scapula, without also causing perceptible change in front; corroborative signs are generally found behind, and, pos sibly, disease which seems of small extent when we examine in front, is far advanced in the scapular region. Still the first and the most correct knowledge of its existence usually comes from the clavicular region, and it is a good rule that it should be the first examined.
§ 1. Percussion notes a marked difference between the two sides of the chest, and one has a dull, dead resonance, with a sense of resistance. , A. The breathing is louder on the duller side ; there is a very evident prolongation of the expiratory murmur ; it has acquired an unnatural harshness, and a blowing sound; the voice-sound is also louder, and probably changed in character, as compared with the other side of the chest. There can be no doubt that the dis ease is on the duller side, and of some form associated with con solidation. In this region we meet with tubercular deposit, fibrin ous deposit, and retraction of the lung, consequent on effusion into the cavity of the pleura.
B. The breathing is weaker on the duller side.
a. It is entirely superseded by superadded sound ; the voice sound is loud and harsh; the sound of the breathing is manifestly obstructed by some extraneous fluid mixed with the air contained in the lung, and in addition to this we feel sure, from the de,ad ness of the percussion-stroke and the loudness of the voice, thlit there is some form of consolidation present, generally the tuber cular. (See next Chapter, Div. I., § 1, A.) b. The dulness and deadness of the percussion-stroke are most complete, and are evidently not confined to the clavicular region, but extend throughout every part of the chest on the affected side; the rhythm of the breathing, if any can be heard at all, is altered by disproportionate length of the expiration, and the voice-sound has a loud ringing character. The chest is probably full of fluid
on that side, but the existence of this condition is to be decided from a consideration of the signs appertaining to the remainder of the chest.
c. The sound on percussion varies according to the force of the stroke ; a gentle tap brincrs out imperfect superficial resonance, a firmer stroke distinct anedecided dulness; the breathing is weak, and not otherwise altered in rhythm or quality ; but in addition to the vesicular murmur, there may be he,ard a sound of distant blowing. This would point out some solid mass occupying a central position with reference to the lung.
d. There is local swelling wader the clavicle, and the breath ing is entirely suppressed. Here we have no doubt of the exist ence cf tumor, aneurism, or solid growth, as the case may be.
§ 2. Percussion notes a decided difference with exaggeration of resonance on one side of the chest.
A. The breathing is louder on the more resonant side.
a. The percussion sound is tympanitic, while there is a sensa tion of wooden resistance to the stroke; the breath-sound is heard as if one were blowing into a large empty jar; the voice-sound. has the same character, called amphoric. These signs may be caused either by air in the pleura (pneumothorax), with an opening com municating between the lung and the pleural sac, somewhere near the clavicle, or by a cavity of very large size ; in the one case the tympanitic resonance is general, in the other local.
b. The percussion-sound is less distinctly tympanitic, and there is no resistance; the breath-sound has a blowing character ; the voice-sound is ringing. This condition is often met with in the first stage of pleuritic effusion ; its true nature is only revealed by exploring the remainder of the chest.