THE CLAVICULAR REGION - § 1. With marked dulness on one side.
A. When that dulness is due to interstitial deposit we may have any of the interrupted sounds, from fine crepitation to gur gling and metallic noises. In the greater number of eases, inter stitial deposit at the apex is tubercular, and any superadded sound serves only to show the particular stage of the disease ; but when its character is that of fine crepitation, when the breath-sound ,has a loud, diffuse, blowing character, and the voice a brassy resonance, we must look to the general symptoms to see whether we have not to deal with pneumonia. Clicking and squeaking sounds, with suppressed or blowing breathing, and loud vocal resonance, exist from the commencement of tubercular softening; but with the marked dulness now under consideration we are more in cases of phthisis, to meet with abundant coarse moist sounds and gurgling, indicating the existence of cavities; the character of the breathing may scarcely be distinguishable, because it is thus superseded, but when heard, it is harsh and blowing, and the voice is always loud. When the superadded sound has a metallic character, it indicates the existence of a cavity of some size, and then the breath-sound will have some thing of amphoric blowing provided the fluid which causes the bubbling does not oppose the free ingress of air into the cavity: the voice-sound becomes painfully loud under such circumstances. Friction-sound may accompany both forms of interstitial deposit, but in phthisis it is generally peculiarly creaking.
B. With fluid in the pleura. The entire absence of superadded sound, when the breathing is blowing, and the voice ringing, is of itself a very important point in diagnosis, naturally suggesting the absence of deposit in the lung, and leading to an examination of its lower and back part. Friction sound is sometimes heard just under the clavicle, but more commonly, when audible, it is to be found somewhat lower down.
c. In the case of deep-seated tumor, while the breathing is weak, and the voice probably unchanged, there are also generally no superadded sounds ; at least there are none which belong to it as a tumor, and those in the lung are only the result of bronchial irritation : if it be an aneurism, there will be others connected with the circulation.
§ 2. With marked resonance on one side.
A. When the cause of this is the presence of air in the pleura, we shall have our diagnosis greatly confirmed by the absence of gurgling or metallic noises in the clavicular region; this fact, even when metallic tinkling or plashing are not heard behind, assists in distinguishing the case from one in which a large cavity presents characters of breath and voice-sound, which equally de serve the name " amphoric." B. When the resonance i8 due to emphysema, we find that if severe bronchitis exist, moist sounds are audible in various parts of the chest, but rarely under the clavicle : with any degree what ever of bronchitis, sonorous and sibilant sounds are heard there : with no bronchitis, emphysema gives rise to no superadded sound.
§ 3. When the dulness is not so marked.
A. In cases of consolidation of the lung from pneumonia, the dulness is generally distinct; but though this sign be wanting, the existence of fine crepitation with whiffing breathing, and brassy voice, is sufficient to cause further inquiry. The consolidation is more commonly tubercular : crepitation of a coarser kind, with prolonged expiration and diffuse exaggerated voice-sound, accom panies the rapid development of tuberculosis; a certain amount of chronic pneumonia is probably coincident with it in these cir cumstances, but the crepitation is not so fine, the breathing is not whiffing, and the voice is not brassy, as they are in the simple inflammation of the upper lobe. In the more ordinary develop ment of tubercles fine moist sounds often occur early with some suppression of the breathing, but with increase of the voice-sound; towards the end of the first stage, the breathing becomes louder and more blowing, clicking or squeaking sounds are heard : the coarsest rounds are only found with decided dulness.